Guidance

Risk assessment and immediate management of viral haemorrhagic fevers (contact high consequence infectious diseases) in acute hospitals

Updated 23 October 2024

Executive summary

This document provides guidance on the risk assessment and management of patients in the UK in whom infection with a viral haemorrhagic fever (VHF) should be considered or is confirmed. This guidance aims to eliminate or minimise the risk of transmission to healthcare workers and others coming into contact with an infected patient or their samples. This guidance replaces the previous Advisory Committee on Dangerous Pathogens (ACDP) publication ‘Management and Control of Viral Haemorrhagic Fevers’ published in 2015.

VHFs are severe and life-threatening viral diseases that have been reported in parts of Africa, South America, the Middle East and parts of Europe. VHFs are of particular public health importance because they can spread within a hospital setting and in the community, have a high case-fatality rate and are difficult to recognise. Environmental conditions in the UK do not support the natural reservoirs or vectors of any of the haemorrhagic fever viruses, and all but 3 recorded cases of VHF in the UK have been acquired abroad^{[footnote 1]}.

In preparing this guidance, ACDP undertook a new assessment of the risks of transmission of VHF infection. Evidence from outbreaks strongly indicates that the main routes of transmission of VHF infection are direct contact (through broken skin or mucous membrane) 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, but there is uncertainty about the risk to healthcare workers from aerosol generating procedures (AGPs) and a precautionary approach is taken.

Following the revised risk assessment, this guidance recommends control options for the isolation of VHF patients in the UK. In most cases, infectious patients with confirmed VHF infection will receive care within a specialist high level isolation unit (HLIU), but if this is not possible then alternative infection control options are outlined. An important emphasis in this guidance reflects the increasing data to show that a substantial proportion of patients with VHF do not have fever at presentation. For this reason, patients who have a relevant travel history or epidemiological exposure within 21 days and an acute illness with a history of feverishness, should undergo risk assessment for VHF, even if there is no measured fever.

Section 1: introduction

Overview

All recorded cases of VHF in the UK have been acquired abroad, except for a research laboratory worker who sustained a needle-stick injury in 1976 and contracted Ebola virus disease^{[footnote 2]}. Additionally, a woman developed Lassa fever during late pregnancy in 2022, with secondary transmission to her baby in utero, following close contact with her husband who had been infected during a visit to Mali^{[footnote 3]}.

The following criteria are used to define a high consequence infectious disease (HCID), which includes some VHFs:

• acute infectious disease
• typically has a high case-fatality rate
• may not have effective prophylaxis or treatment
• often difficult to recognise and detect rapidly
• ability to spread in the community and within healthcare settings
• requires an enhanced individual, population and system response to ensure it is managed effectively, efficiently and safely

Contact HCIDs are usually spread by direct contact with an infected patient or infected fluids, tissues and other materials, or by indirect contact with contaminated materials and fomites.

This guidance only covers those VHFs that fulfil the criteria to be classified as contact HCIDs. Other diseases with haemorrhagic manifestations such as dengue, yellow fever, leptospirosis, Rift Valley fever and hantaviruses are not covered by this guidance because they are not spread by person-to-person transmission.

In preparing this guidance, ACDP undertook an assessment of the risks of transmission of VHF infection. Evidence from outbreaks strongly indicates that the main routes of transmission of VHF infection are direct contact (through broken skin or mucous membrane) 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 an airborne transmission risk from VHF patients in terms of natural transmission in the community. In the healthcare setting, extra precautions need to be taken due to the potential risk of aerosolised virus, for example from patients undergoing medical AGPs.

Following the revised risk assessment, this guidance recommends infection control options for the isolation of VHF patients in the UK. These options include flexibility in the isolation of a patient with a confirmed VHF infection within a specialist HLIU, with guidance if transfer to the preferred option of an HLIU is not feasible. The most common reasons where transfer to a HLIU may not be feasible are:

• the patient is expected to die imminently, before transfer can be arranged - this is on the basis that acceptable HCID infection prevention and control (IPC) precautions can be applied at the local hospital, with external support and advice from the UK Health Security Agency (UKHSA), NHS England and the NHS England Contact HCID Network if required
• the patient is no longer considered to be highly infectious and any remaining, low risk of transmission can be managed outside an HLIU setting

Who this guidance is for

This UK guidance is for:

• healthcare staff in emergency departments, infectious disease departments, infection control, microbiology or virology and acute medical units
• ambulance staff, who may be required to transport a patient in whom VHF is suspected or confirmed
• those working in laboratories dealing with specimens from patients in whom VHF is suspected or confirmed
• public health professionals, including those in port health authorities, who may be required to carry out public health actions associated with a VHF case
• mortuary and funeral personnel, who may need to deal with a VHF case

Section 2: patient risk assessment

Risk assessment is a legal obligation.

You should:

• know who is your lead for risk assessment and be familiar with local risk assessment arrangements
• use the VHF risk assessment algorithm published alongside this guidance to determine whether an acutely unwell patient with a travel or exposure history within 21 days may have a VHF infection

The patient’s risk assessment determines the level of staff protection and the management of the patient.

The risk to staff may change over time, depending on the patient’s symptoms, the results of diagnostic tests and/or information from other sources. Patients with VHF can deteriorate rapidly.

Why a risk assessment is necessary

The Control of Substances Hazardous to Health Regulations 2002 requires employers to assess risk to their employees in the workplace. This includes assessing the risk of acquiring a VHF infection in a healthcare setting or other workplace. The purpose of risk assessment is to enable decisions to be made about the actions needed to control the risk and prevent spread of infection. Risk assessment therefore embraces both assessment of the patient for the possibility of VHF and assessment of associated risks to staff. Measures to control any risks include implementation of practical infection control measures, information provision, training and health surveillance where the assessment shows that these are required.

In the UK, only persons who have one or more of the following risk factors are at risk of infection with VHFs:

• travelled to an area where VHFs occur
• been exposed to the blood, body fluid or tissues of a person or animal infected with VHF
• worked in a laboratory with the infectious agents of VHFs

There have been rare cases of sexual transmission from male survivors of VHFs - for Ebola virus disease, this includes cases of sexual transmission up to 5 years after the original infection and illness episode.

How to conduct the patient risk assessment

The patient risk assessment should be led by a senior member of the medical team responsible for the acute care of patients, for example the emergency care senior physician, emergency department consultant or admitting team consultant. An infectious disease physician, microbiologist or virologist should also be involved.

If a person with possible VHF is identified in the community, for example at a GP surgery, the doctor who has identified the potential risk for VHF should telephone their local infection consultant (infectious disease, microbiology or virology) for a preliminary risk assessment based on the available information. Similarly, if Health Protection Team (HPT) staff are informed of a patient with possible VHF in the community, they should refer the caller to the local infection consultant for the risk assessment rather than undertaking it themselves. If appropriate, the infection consultant should arrange for the patient to be transferred to the relevant assessment centre for further clinical and risk assessment.

For any patient who has a relevant travel history or epidemiological exposure within 21 days and has an acute illness with a history of feverishness, follow the major steps in the pathway from identification to diagnosis in the patient risk assessment algorithm. This will establish the patient’s VHF risk category, which determines the subsequent management of the patient and the level of protection for staff. Further information is provided in the subsequent sections of this guidance.

The algorithm deals with the management of the patient, diagnostic testing and the level of staff protection, all of which are dependent on the risk of VHF infection and the patient’s symptoms.

Application of standard infection prevention and control precautions (SICPs) and transmission based precautions (TBPs) are paramount to ensure members of staff are not put at risk while the initial risk assessment is carried out. It is assumed throughout this guidance that staff will be following and applying these infection control precautions. If these measures are not already in place, they must be introduced immediately when dealing with a patient in whom VHF is being considered.

The patient’s VHF risk category can change depending on the patient’s symptoms and/or the results of diagnostic tests. It is important to note that a patient with a VHF infection can deteriorate rapidly.

The patient’s VHF risk category

The questions in the algorithm are designed to assess thoroughly the risk of VHF infection. Following the questions, the patient will be categorised as one of the following:

• ‘minimal risk of VHF’ (see Section 3, below)
• ‘at risk of VHF’ (see Section 4, below)

Patients who are unwell are highly unlikely to have a VHF infection if:

• the onset of their illness was more than 21 days after caring for or coming into contact with the bodily fluids of, or handling clinical specimens from, a live or dead individual or animal known or strongly suspected to have a VHF
• the onset of their illness was more than 21 days after visiting a VHF endemic area
• their UK malaria screen is positive and they respond appropriately to malaria treatment

For more information, see:

• Viral haemorrhagic fevers: epidemiology, characteristics, diagnosis and management - a collection of guidance from UKHSA
• High consequence infectious disease: country specific risk - for detailed information on geographic distribution
• High consequence infectious diseases: monthly summaries - for details of recent VHF outbreaks

Section 3: management of a patient categorised as ‘minimal risk of VHF’

Infection prevention and control measures

An unwell patient categorised as ‘minimal risk of VHF’ should be isolated in a single side room to limit contact until the possibility of transmissible infection has been ruled out. The side room should have dedicated en-suite facilities or at least a dedicated commode.

All staff should be using SICPs. Additional precautions (TBPs) should be added for splash-inducing procedures and AGPs.

The medical procedures that are considered to be aerosol generating and associated with an increased risk of respiratory transmission are listed in NHS England’s ‘National Infection Prevention and Control manual for England (NIPCM)’ as:

• awake bronchoscopy (including awake tracheal intubation)
• awake ear, nose and throat (ENT) airway procedures that involve respiratory suctioning
• awake upper gastro-intestinal endoscopy
• dental procedures (using high speed or high frequency devices, for example ultrasonic scalers or high speed drills)
• induction of sputum
• respiratory tract suctioning
• surgery or post-mortem procedures (like high speed cutting or drilling) likely to produce aerosol from the respiratory tract (upper or lower) or sinuses
• tracheostomy procedures (insertion or removal)

Note that:

• ‘awake’ includes ‘conscious’ sedation (excluding anaesthetised patients with secured airway)
• the available evidence relating to respiratory tract suctioning is associated with ventilation. In line with a precautionary approach, open suctioning of the respiratory tract, regardless of association with ventilation, has been incorporated into the current AGP list. Only open suctioning beyond the oro-pharynx is currently considered an AGP. Oral or pharyngeal suctioning is not considered an AGP

Table 1: infection prevention and control measures for ‘minimal risk of VHF’

Staff protection	Measures
Standard infection control precautions	Hand hygiene, gloves, plastic apron
Additional precautions (TBPs) for splash-inducing procedures	Fluid repellent surgical facemask, eye protection
Additional precautions for potential aerosol generating procedures	FFP3 respirator or EN certified equivalent, eye protection

Diagnostic investigations

All samples from patients in the ‘minimal risk of VHF’ category can be handled as standard samples and laboratories are not required to take additional precautions. Investigations required will include urgent malaria investigations. Other investigations, as locally appropriate, may include full blood count, urea and electrolytes, liver function tests, glucose, C-reactive proteins, coagulation studies, urine, stool and blood cultures and chest X-ray.

Malaria investigation results

If the malaria result is positive, the patient may be re-categorised as ‘VHF unlikely’ and treatment for malaria should begin immediately. Up-to-date UK malaria treatment guidelines (published in the Journal of Infection in 2016) are available online. However, IPC precautions (see Table 1, above) must be maintained until a negative PCR result has been received, or an agreement with the imported fever service (IFS) (see Appendix 1) has been made that PCR for VHF is no longer indicated. If a patient fails to respond appropriately to antimalarial therapy, or if there is the development of further features suggestive of VHF, they should be re-evaluated for the possibility of VHF and investigated accordingly. In this case, the patient should be re-classified as ‘at risk’ and managed appropriately, in particular following all appropriate infection control measures (Section 4). If the patient has returned from an area currently affected by a VHF outbreak, see also below in ‘diagnostic investigations’.

If the malaria result is negative, the patient remains unwell and no diagnosis has been made, the case should be further discussed with a local infection consultant (infectious disease, microbiology or virology). The infection consultant should consider discussing VHF testing with the IFS (0844 778 8990). See Appendix 1 for details of the VHF testing process.

Section 4: management of a patient categorised as ‘at risk of VHF’

Where a patient is categorised as ‘at risk of VHF’:

• the lead clinician who is responsible for the acute care of the patient should be a senior member of the medical team
• the patient should be isolated in a single side room immediately
• enhanced infection control measures, as set out below, should be put in place
• an urgent malaria screen and local diagnostic investigations should be carried out as appropriate (see Appendix 6)
• if a malaria test is negative, liaise with local infection consultant (infectious disease, microbiology or virology). Infection consultant to discuss VHF testing with the IFS
• if the patient’s VHF test is positive, the responsible physician should contact the NHS England emergency preparedness, resilience and response (EPRR) duty officer (0333 200 5022, option NHS05) and launch full public health actions
• if a malaria test is positive and the patient has returned from a country affected by a current VHF outbreak, then dual infection should be considered and be discussed with the local infection consultant (infectious disease, microbiology or virology)

Infection prevention and control measures

A unified personal protective equipment (PPE) ensemble for the clinical care of HCID patients - both suspected and if subsequently confirmed - has been published in the National Infection Prevention and Control manual (NIPCM) (Chapter 2: Transmission based precautions (TBPs)). It is recommended that this ‘HCID assessment PPE’ will be worn by staff in contact with a patient assessed as ‘at risk of VHF’ or a confirmed VHF patient prior to transfer to an HLIU or where transfer to an HLIU may not be feasible. Components of HCID assessment PPE ensemble are specified in the NIPCM addendum on HCID PPE. It is recommended that the NIPCM addendum should be read in parallel with this guidance.

Specifications are provided for each component in the NIPCM addendum, together with details of the order and process for putting on and removing this ensemble. It is essential that all clinical staff who may be required to wear this PPE are trained, practised and competent in using it.

The patient should be isolated in a single side room immediately to limit contact. The side room should have dedicated en-suite facilities or at least a dedicated commode. Spaces should be dedicated for putting on and removing PPE.

Patient movement within the hospital should be minimised, but the patient may need to be moved to an appropriate isolation facility. Staff wearing HCID assessment PPE should accompany the patient during transfer and contact with other patients, hospital staff or visitors should be avoided during transfer. The route to be taken by the patient should be identified in advance and cleared of other people. Ambulant and continent patients who are well enough can walk - they should perform hand hygiene prior to transfer and should be instructed to avoid touching anything during transfer. Other patients should be transferred on a bed, which is then left in the isolation room. Staff accompanying the patient should be prepared to manage any body fluid spills (see Appendix 8) and therefore carry a spill kit during the transfer.

Relatives and visitors are not allowed into the patient room. If absolutely necessary, one parent or guardian of a child patient may stay in the room after the risks have been explained - ideally this should be a parent or guardian who has been caring for the child prior to admission. The parent or guardian should wear an apron and gloves and be instructed in hand hygiene.

The number of staff in contact with the patient should be restricted.

Only staff who are trained and competent in the use of HCID assessment PPE should enter the patient room and this PPE should be worn at all times while in the patient room. It follows that any clinical site that could reasonably be expected to encounter such patients (especially emergency departments) should have a team of staff available who are trained and competent in the use of HCID assessment PPE, in order to be able to assess the patient and provide acute care.

The hospital IPC team should be informed according to local policy. Guidance on decontamination, disinfection, waste and laundry is provided in Appendices 8 and 9.

Communication with staff about potential infection risks is paramount. Only staff who are trained and competent in the use of HCID assessment PPE should provide clinical care.

A list must be kept of all individuals who enter the patient room. This will be needed for follow up if the VHF test is positive.

Diagnostic investigations

Investigations required will include:

• urgent malaria test
• full blood count
• urea and electrolytes
• liver function tests
• clotting screen
• C-reactive proteins
• glucose
• blood cultures

Appendix 5 provides guidance on collecting specimens from a patient categorised as ‘at risk of VHF’.

These tests should be performed using containment level 2 laboratory procedures (see Appendix 6). Analysis of specimens should not be delayed while waiting for the results of VHF tests.

If on clinical assessment a respiratory viral illness (such as influenza) may be part of the differential diagnosis, respiratory virus PCR testing may be considered (see Appendix 6).

For waste disposal purposes, the laboratory should be informed that specimens are to be retained until VHF status is known.

If the malaria screen is negative, the case should be discussed promptly with the local infection consultant (infectious disease, microbiology or virology). The infection consultant should contact the IFS (0844 778 8990) to discuss urgent VHF testing (see Appendix 1).

If the malaria screen is positive and the patient has returned from an area affected by a current VHF outbreak, then dual infection should be considered and discussed with the local infection consultant (infectious disease, microbiology or virology).

VHF test results and subsequent patient management

If the VHF test is negative, then VHF is unlikely. The patient can be managed locally. If there is further clinical concern, the patient should be discussed with the IFS.

If the VHF test is positive, a number of urgent actions are required - see the following section for details.

Section 5: management of an unwell patient with confirmed VHF

Where a patient has had a positive VHF test result:

• they should be managed in an HLIU, unless exceptional circumstances prevent transfer of the patient
• full public health actions should be launched
• once the patient has been transferred, testing of specimens should be carried out in the dedicated laboratory at the HLIU

If a patient has confirmed VHF, the following urgent actions are required:

• restrict the number of staff in contact with the patient, ensure that only staff who are trained and competent in the use of HCID assessment PPE enter the patient room and compile a list of all staff who have been in direct contact with the patient
• arrange immediate transfer to an HLIU - the lead clinician should discuss this urgently with the NHS England EPRR duty officer (see Appendix 4 for transfer information)
• notify the IPC team of the positive VHF test result
• launch full public health actions (see Section 6)

If, after discussion with the HLIU, it is judged that the condition of the patient precludes transfer to the HLIU, an immediate discussion with the local lead for infection control should take place regarding local risk assessment and control measures. Discussions with the Health and Safety Executive (HSE), the relevant national public health agency and experts at the HLIU are also necessary. Advice on managing a VHF positive patient in a non-HLIU environment is provided in Appendix 3.

If further laboratory samples are required from the patient prior to transfer, or if the patient is unable to be transferred, testing of specimens should be carried out in accordance with the procedures set out in Appendix 6.

Section 6: public health actions

VHF is a notifiable disease. The registered medical practitioner attending the patient must therefore notify a confirmed case according to the local regulations.

Identification of contacts

It is the responsibility of the healthcare facility caring for a patient with VHF to maintain a list of all staff who have had contact with the patient, regardless of whether appropriate IPC precautions were or are in place during contact with the patient.

It is the responsibility of the relevant public health agency to:

• identify community contacts of a confirmed case of VHF
• assess and categorise all contacts (hospital and community) of a patient with VHF
• ensure the appropriate monitoring of higher risk contacts
• arrange further evaluation for contacts who develop an illness within 21 days of the last possible exposure
• consider post exposure prophylaxis and arrange as necessary

Potential contacts need to be categorised by their likelihood of exposure. As an example, see the risk categorisations for Ebola virus disease in Ebola: public health recommendations for asymptomatic contacts.

A contact is defined as a person who has been exposed to an infected person or their blood and body fluids, excretions or tissues following the onset of their illness. This may include contacts that are not in the UK. Staff who have been caring for the patient while wearing appropriate PPE would be considered low risk contacts. For management of staff accidentally exposed, see Appendix 7.

Appendix 1: VHF testing

Imported fever service (IFS)

To discuss a case assessed as being ‘at risk of VHF’, telephone the imported fever service (IFS) on 0844 778 8990 (24 hours). In the unlikely event that this number is unobtainable, please contact the Rare and Imported Pathogens Laboratory (RIPL) consultant on 07789 031672. Do not use the RIPL consultant number unless the IFS 0844 number is unavailable.

Note that if, following discussion with the IFS, the patient is re-categorised as ‘minimal risk of VHF’, then VHF testing will not be required and the patient can be de-escalated from the ‘at risk of VHF’ pathway with immediate effect.

VHF testing

If the malaria result is negative on a patient categorised as ‘at risk of VHF’, the case should be further discussed with a local infection consultant (infectious diseases, microbiology or virology). The infection consultant should discuss VHF testing with the IFS (0844 778 8990). The IFS doctor will require full details of the patient’s travel history, possible exposure activities, clinical presentation, investigation results and clinical management to date. The differential diagnosis, the appropriate samples to send (usually EDTA and clotted blood, with or without a urine sample), the necessary sample transport arrangements (category A or category B courier) as appropriate to the likelihood that the sample contains a HG4 pathogen, and anticipated test turnaround times will be discussed.

If a VHF test is being considered, the infection consultant must contact the IFS prior to sending any samples. If IFS confirms that the patient is ‘at risk of VHF’ and agrees that VHF testing should be carried, samples will usually be directed to the Rare and Imported Pathogens Laboratory (RIPL) at UKHSA Porton at the address provided below. (Samples taken in Scotland will usually be directed to the Scottish National VHF Testing Service laboratory in Edinburgh - see below.) Results are usually available within 6 to 8 hours following receipt of the specimen. In the meantime, basic diagnostic investigations and local management should continue. RIPL will normally test in parallel for other agents likely to cause similar presentations that occur in the country of origin, for example Dengue fever, rickettsial infections, leptospirosis.

VHF test results

If the VHF test is negative, in most cases HCID assessment PPE is no longer required, unless there is a strong clinical suspicion and RIPL or the IFS consider that repeat testing may be appropriate.

If the VHF test is positive, a number of urgent actions are required - see Section 5 for details.

Specialist VHF testing laboratories

Rare and Imported Pathogens Laboratory (RIPL)
UKHSA Porton
Porton Down
Salisbury
Wiltshire
SP4 0JG
Tel: 01980 612100 (24 hours)

Scottish National VHF Testing Service (SNVTS)
Laboratory Medicine, the Royal Infirmary of Edinburgh
Little France
Edinburgh
EH16 4SA
Tel: 0131 536 1000 (RIE switchboard)

Appendix 2: contact details for HLIUs

There are 2 principal HLIUs in England:

Royal Free London NHS Foundation Trust
London
Tel: 020 7794 0500 (24 hours, ask for infectious disease consultant on call)

Newcastle upon Tyne Hospitals NHS Foundation Trust
Newcastle
Tel: 0191 233 6161 (24 hours, ask for infectious disease consultant on call)

Note: the registered medical practitioner must notify a confirmed case to the NHS England EPRR duty officer in the first instance. The NHS England Contact HCID Network will then be convened and will decide on patient transfer and placement. This applies to cases in all 4 nations of the UK.

Appendix 3: principles for the isolation of patients with confirmed VHF

Patients with confirmed VHF infection should be managed in a specialist HLIU.

In exceptional circumstances it may not be appropriate to transfer patients to an HLIU. This appendix does not give advice on the clinical management of such patients.

Clinical management of a patient infected with VHF is undertaken by specialist infectious disease clinicians in commissioned contact HCID treatment centres, on a case-by-case basis and is not discussed further here.

Patient isolation requirements

Experts agree that there is no circumstantial or epidemiological evidence of an airborne transmission risk from VHF patients. A theoretical risk has been postulated. Evidence from outbreaks strongly indicates that the main routes of transmission of VHF infection are direct contact (through broken skin or mucous membrane) with blood or body fluids and indirect contact with environments contaminated with splashes or droplets of blood or body fluids.

Avoiding contact with a patient’s body fluids, minimising contamination of the environment and safely containing contaminated fluids and materials is paramount to protecting staff and the wider public against infection risks.

Following a revised assessment of the risks for the transmission of VHF by the ACDP, this guidance recommends 2 infection control options for the containment and isolation of unwell, infectious VHF patients in the UK. These 2 infection control options provide flexibility in the isolation of a patient with a VHF infection within an HLIU. The particular option used for a patient is decided by the NHS England Contact HCID Network.

Option 1: default option for unwell adult patients

VHF patients can be completely isolated using a negative pressure patient bed isolator within a negative pressure isolation suite. Exhaust air from the bed isolator is HEPA (high efficiency particulate air) filtered, as is the exhaust air from the isolation suite, providing additional protection. Staff are protected due to their physical separation from the patient by a flexible film barrier and an air barrier. Access to the patient is via built-in access portholes within the flexible film. The patient isolator will contain all body fluids so that contamination of the isolation suite is minimised. Staff will normally wear theatre scrubs and gloves where necessary and should not require additional PPE if this option is used.

Option 2: preferred option for younger children and certain patient groups, or when option 1 is not feasible

VHF patients can be isolated within a negative pressure isolation suite that has an appropriately designed ventilation system without utilising a bed isolator. Due to the potential for greater exposure to blood and body fluids as a result of ongoing long-term patient management of a confirmed case, staff protection must be provided through the use of PPE that is recommended within the HCID network for the care of patients with confirmed HCIDs. Only staff who are trained and competent in the use of this PPE should be allowed to care for the patient.

High level isolation units (HLIUs)

Designated HLIUs for the management of VHF have been commissioned by NHS England in the Royal Free Hospital, London and the Royal Victoria Infirmary, Newcastle; their design and use are set out in the NHS England commissioning specifications. The operation of these units is defined in local operational policies. Further support for managing confirmed contact HCID cases is provided by the Royal Liverpool Hospital and the Royal Hallamshire Hospital, Sheffield.

Managing a VHF positive patient in a non-HLIU environment

In exceptional circumstances it may not be appropriate to transfer an unwell, infectious patient to an HLIU. In this case, it is important that advice is sought from HLIU specialist staff and the relevant public health agency (for example, UKHSA for a patient in England). The patient must be housed in a single occupation infectious disease unit side room (‘enhanced single room’), preferably with a ventilated lobby (isolation suite), with en-suite sanitary facilities and where complete physical separation from other patients can be achieved.

Enhanced single rooms will have extract ventilation and operate at negative pressure relative to the rest of the unit. In isolation suites with a ventilated lobby, the lobby will be at positive pressure to ensure that air from the corridor does not enter the isolation room, and that air from the room does not escape into the corridor. This design enables these suites to be used for both source and protective isolation. Although this does not adhere to the stepped negative pressure approach applied in HLIUs, it provides acceptable containment under exceptional circumstances. Further specialist advice may need to be sought.

There must be a clear segregation and gradation of clean and potentially contaminated areas. PPE should be put on in the lobby of isolation suites or nearest the door in enhanced single rooms without a lobby.

An operational policy must be created, documented and agreed with all staff involved. Only specialist staff who are trained and competent in the use of HCID assessment PPE, as specified in the NIPCM addendum, should be allowed to care for the patient.

A segregated holding area for contaminated material must be designated as near as possible to the side room, with procedures in place for transfer of material to that area with minimum potential for cross-contamination.

Procedures must be put in place for disinfection, decontamination and terminal cleaning as soon as possible following transfer of the patient out of the isolation suite. For further details on cleaning and decontamination, see Appendix 8.

Procedures must also be put in place for safe transfer of waste from the holding area to where it will be inactivated. For further details, see Appendix 9.

Appendix 4: transfer of a patient

Transfer of a patient within the UK

Transfer of a patient with confirmed VHF will be co-ordinated by the NHS England EPRR duty officer in collaboration with the National Ambulance Resilience Unit.

If appropriate, the NHS England HCID Contact Network will make a recommendation to the senior clinician with responsibility for the patient to transfer the patient to the designated HLIU. Only patients with confirmed VHF should be transferred to the HLIU, except in exceptional circumstances when patients may be transferred before the diagnosis is confirmed (for example, for a symptomatic close contact of a confirmed case where VHF is considered to be highly likely but testing has not been performed yet).

Transfer by air within the UK

Although road transfer is preferable, air transfer may be necessary in some circumstances. If necessary, the NHS England EPRR duty officer will arrange this.

Appendix 5: specimen collection

Specimens collected from patients categorised as ‘minimal risk of VHF’

The main risk of infection to the healthcare worker when collecting the specimens is direct contact with blood or body fluids from the patient. The risk of exposure to VHF when collecting specimens from patients categorised as ‘minimal risk’ is small, as an alternative diagnosis such as malaria is usually found. There are therefore no additional precautions to be taken for these specimens, above those already in place under standard infection control precautions. It is not necessary for the managing doctors to warn the laboratory, as the risk to laboratory staff is extremely low.

Healthcare waste generated as a result of specimen collection from patients categorised as ‘minimal risk of VHF’ must be treated as category B infectious waste.

Specimens collected from patients categorised as ‘at risk of VHF’

It is important to inform the laboratory that the patient has been categorised as ‘at risk of VHF’ to ensure that:

• the appropriate laboratory containment (containment level 2) is in place for specimen handling
• correct waste disposal procedures are followed

Waste should be securely stored pending laboratory results. In the event that VHF infection is confirmed, this would require disposal as category A waste, otherwise it can be disposed of as category B.

Specimens must be transported to the laboratory in suitably sealed containers. Specimens must not be transported in a pneumatic tube system.

Healthcare waste generated as a result of specimen collection from patients categorised as ‘at risk of VHF’ must be securely stored pending laboratory results. In the event that VHF infection is confirmed, this would require disposal as category A infectious waste, otherwise it can be treated as category B waste.

Specimens from patients with confirmed VHF

There are potential risks of infection to the healthcare worker associated with collecting and handling specimens from patients with confirmed VHF. The main risk of infection when collecting and handling specimens is direct contact with blood or body fluids from the patient, for example by accidental inoculation (needle-stick) or contact with broken skin or mucous membranes.

In patients with confirmed VHF, specimens taken for laboratory analysis should be kept to the minimum necessary for patient management and diagnostic evaluation. Specimens should be discussed in advance between clinicians and the appropriate specialist for each laboratory area.

Healthcare waste generated as a result of specimen collection from patients with confirmed VHF must be treated as category A infectious waste. Waste should be dealt with according to the guidance set out in NHS England’s ‘Safe management of healthcare waste (HTM 07-01)’ (see Appendix 9).

To ensure safe transfer of these specimens to the laboratory, the specimens should be carried in suitably sealed containers.

Appendix 6: laboratory procedures

There are potential risks of infection to laboratory staff associated with handling specimens from all types of patient. Patients suspected of VHF infection are categorised into one of the following categories:

• minimal risk of VHF infection
• at risk of VHF infection
• confirmed VHF infection

For specimens from all patients in whom VHF is being considered, appropriate risk assessments, together with local codes of practice, must be in place. This information can be used to ensure that the risks are effectively managed and that relevant facilities are in place and are managed properly. The risk assessment should include evaluation of the risks associated with each analytical technique and the application of appropriate control measures.

Respiratory virus infection is common in returning travellers. The use of respiratory virus nucleic acid amplification tests (NAATs), such as PCR, may be considered in these patients if a local risk assessment can show that they can be performed safely. A suitable and sufficient assessment of the risks when handling these samples must be undertaken prior to the work starting. This risk assessment must consider the potential presence of a hazard group 4 virus in the samples, in addition to the presence of any respiratory pathogens. Particular attention should be paid to the use of inactivating viral transport media, safe ways of working and the use of suitable disinfectants. In the event of the detection of a respiratory virus, consideration should be given to the potential of co-infection with a viral haemorrhagic fever virus. De-escalation of HCID infection prevention and control measures should only be done after consultation with an infection expert and, where appropriate, the IFS.

Autoanalysers used to process laboratory samples are considered to pose minimal risk to laboratory staff. Routine processing of samples for each of the above categories therefore pose no greater likelihood of exposure than samples containing hepatitis B, hepatitis C, HIV and other blood-borne viruses. To ensure a safe system of work, protocols for machine decontamination, maintenance, management of spillages and waste disposal must be in place and followed, taking into consideration manufacturers’ recommendations. Autoanalysers should be disinfected following local procedures after sample processing and before scheduled maintenance.

Autoanalysers and standard infection control precautions should remain the preferred method for processing specimens. In certain circumstances the use of discrete analysers could be considered, for example to maintain work flow of standard specimen processing. However, this is not considered to be a safer option than using autoanalysers and would require risk assessment for manual processing of the specimen, for example pipetting.

Point of care (POC) blood gas analysers present a risk of splashing and should only be used in exceptional circumstances and in a controlled environment - that is, limited for use in the patient room by appropriately trained staff.

Specimens from a patient categorised as ‘minimal risk of VHF’

The overall risk to laboratory workers from specimens from these patients is considered to be minimal, and specimens may be processed at containment level 2. Routine laboratory tests should be carried out where possible in autoanalysers using standard practices and procedures at containment level 2.

Specimens from a patient categorised as ‘at risk of VHF’

The overall risk to laboratory workers from specimens from this category of patient is also considered to be low, and specimens may continue to be processed (for a restricted list of investigations - see the patient risk assessment algorithm) at containment level 2 in routine autoanalysers. Effluent waste from these autoanalysers is not considered to pose a significant risk because of the small sample size and dilution step and will therefore require no special waste disposal precautions. Procedures must be in place for the effective management of spillages (see Appendix 8). A sealed centrifuge bucket or rotor should be used for centrifugation procedures that are being undertaken manually - that is, not within an autoanalyser.

For specimens categorised as ‘at risk of VHF’ laboratory staff should be informed so that original patient specimens can be retained and provision made for disposal as category A waste in the event that VHF is subsequently confirmed (see Appendix 9).

When preparing blood film slides for malaria testing, consideration should be given to the potential for splash and therefore should be carried out in a microbiological safety cabinet, or alternatively facial protection should be used. Blood film slides should be disposed of in a dedicated sharps bin, which should be retained and processed as category A waste in the event that VHF is subsequently confirmed in any of the samples. After use, the work surfaces should be treated with 1,000 parts per million (ppm) available chlorine (see Appendix 8).

Specimens from a patient with confirmed VHF

The number of patients with a positive VHF test in the UK is very low (about 1 to 2 cases every 2 years). In most cases, patients with a positive VHF test will be transferred to an HLIU and specimens will be analysed at the dedicated HLIU laboratory. However, where transfer is delayed or considered inadvisable, the specimens may be processed in a containment level 2 laboratory using routine autoanalysers, provided that the additional precautions outlined below are followed:

• experienced laboratory staff should be available to manage the co-ordination of testing and liaise where appropriate with other laboratories
• specimen cuvettes from routine autoanalysers should be safely disposed of as category A waste
• a risk assessment should be carried out for test protocols not undertaken in routine autoanalysers that are likely to result in the production of splashes or aerosols. Where appropriate, these tests should be undertaken in a microbiological safety cabinet or other equipment providing a similar level of protection
• for manual centrifugation procedures, a sealed centrifuge bucket or rotor must be used
• patient samples that are not for immediate disposal should be packed in rigid containers, which should be surface decontaminated and retained within the laboratory awaiting safe disposal
• disinfection and decontamination procedures, validated as effective against blood-borne viruses, must be in place
• autoanalyser disinfection procedure should be carried out following sample processing and before scheduled maintenance
• retained specimens must be disposed of as category A waste
• blood film slides should be disposed of in a dedicated sharps bin, which must be processed as category A waste
• work surfaces should be treated with 1,000 ppm available chlorine (see Appendix 8)

Specific instructions for speciality areas

Automated instruments can be used to process blood cultures for microbiological analysis. Blood cultures should be maintained in a closed system until a VHF test result is known. If the VHF test is positive, specialist advice about any further handling of the specimens should be sought from the IFS.

If a member of staff has handled VHF-positive specimens, with or without PPE, they should liaise with their occupational health provider so as to be identified as a contact for categorisation purposes (see Appendix 7).

Paediatrics and neonatal units

Given the possible small volumes associated with this patient group, which may require manual uncapping and manipulation, a risk assessment should be carried out for test protocols not undertaken in routine autoanalysers that are likely to result in the production of splashes or aerosols for samples from patients classified as ‘at risk’ and ‘confirmed’. Where appropriate, these tests should be undertaken in a microbiological safety cabinet or other equipment providing a similar level of protection.

Appendix 7: management of staff accidentally exposed to potentially infectious material

Procedures must be in place to deal with any accidental exposure of staff to blood or body fluids from at risk or confirmed cases of VHF.

Accidental exposures that need to be dealt with promptly are:

• percutaneous injury, for example needle-stick injuries: immediately wash the affected part with soap and water, and encourage bleeding via gentle squeezing
• contact with unprotected intact or broken skin: immediately wash the affected part with soap and water
• contact with mucous membranes (eyes, nose or mouth): immediately irrigate the area with emergency wash bottles, which should be accessible in case of such an emergency

In all cases, the incident will need to be reported immediately to the local clinical virologist, clinical microbiologist or infectious diseases physician.

For a source case classified as ‘at risk of VHF’ for whom VHF testing has not been completed, the local clinical virologist, clinical microbiologist or infectious diseases physician to whom the incident has been reported should immediately discuss it with the duty RIPL physician, contacted by telephoning the IFS on 0844 778 8990.

For a source case in which VHF infection has been confirmed by laboratory testing, the local clinical virologist, clinical microbiologist or infectious diseases physician to whom the incident has been reported should immediately discuss it with the duty infectious diseases physician at the Royal Free Hospital (020 7794 0500).

In the event that VHF infection in the source patient is excluded by laboratory testing, the recipient of the body fluids exposure incident may still require the appropriate follow-up for possible blood-borne virus (HIV, hepatitis B virus, hepatitis C virus) exposure, including with their local occupational health provider.

In Great Britain, under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (‘RIDDOR’), an incident may need to be reported to HSE. In Northern Ireland, it may need to be reported under RIDDOR (NI) to the Health and Safety Executive for Northern Ireland (HSENI). Under RIDDOR, a definite exposure would be reported as a dangerous occurrence, whereas if the staff member actually acquired an infection it would need to be reported under the occupational disease category.

Appendix 8: cleaning and decontamination

VHFs are enveloped viruses. These types of virus have been shown to be susceptible to a broad range of disinfectants including chlorine and alcohol, and to thermal inactivation (one hour at 58 to 60 degrees Celsius, or 30 minutes at 75 degrees Celsius). There is no evidence to suggest that they have any greater resistance to inactivation than other enveloped or blood-borne viruses such as HIV. Therefore, it can be assumed that decontamination methods used against blood-borne viruses will be effective.

Survival of viruses outside the body is dependent on several factors. For example, Ebola virus survival on different surfaces is dependent on a number of environmental factors (for example, type of surface, humidity, light, concentration of virus present). It can survive for several hours when dried onto surfaces such as doorknobs and worktops and up to several days in body fluids such as blood at room temperature. However, it is easily inactivated at higher temperatures and by soap and water.  

For patients categorised as ‘minimal risk of VHF’, standard infection control precautions, cleaning and decontaminating procedures apply.

Materials or equipment requiring decontamination may be segregated and stored while waiting for VHF test results if facilities are available to do so safely. If results confirm the patient as negative for VHF, waste can then be treated using standard infection control precautions. However, if it is not practicable to segregate and store materials pending VHF results, then materials from at risk cases must be decontaminated in the same way as confirmed cases, as outlined in the rest of this appendix.

Staff should ensure that areas and equipment used for the care of patients who have been categorised as ‘at risk of VHF’ (with testing not yet completed) or have been confirmed with VHF infection are decontaminated and cleaned following the procedures in this appendix. Decontamination and cleaning must be conducted wearing appropriate HCID assessment PPE.

It is important to ensure that products used in the decontamination procedure have been validated as effective against blood-borne viruses.

Bleach, hypochlorite and chlorine releasing agents

In various protocols and guidance, reference will be made to bleach or hypochlorite solution. To clarify:

• the active disinfectant component of bleach is sodium hypochlorite (NaOCl)
• typical household bleach is a solution of sodium hypochlorite generally containing 50,000 ppm (5%) available chlorine
• it is important to check the concentration in the formulation before use, as it is likely to require dilution
• the strength of the bleach may reduce with long-term storage
• typical in-use concentrations are 10,000 ppm (1%; 1 in 5 dilution of typical bleach) for the disinfection of blood spills and 1,000 ppm (0.1%; 1 in 50 dilution of typical bleach) for general environmental cleaning
• sodium dichloroisocyanurate (NaDCC) may be used as an alternative to NaOCl. This is also available in granule form, which may be practical to absorb, contain and disinfect spills - refer to suppliers’ instructions for in-use concentrations
• there is a minimum contact time for chlorine-based absorbent granules - this contact time is usually 2 minutes but may vary from product to product
• gloves should be suitable for use and inspected before they are put on to ensure that they are intact. Where the task involves using chemicals such as chlorine-based products, the gloves should be certified as suitable for chemical resistance and comply with the PPE directive (refer to the healthcare cleaning manual)
• ensure adequate ventilation when disinfecting areas with chlorine-based products - for example, open windows or doors where necessary

Recommended procedures when there has been no obvious contamination by blood and/or body fluids

Standard washing and cleaning methods can adequately treat areas and equipment, which have not been contaminated with blood, body fluids or laboratory specimens. This includes surface cleaning of an impervious mattress when there has been no obvious contamination by blood or body fluids.

Recommended procedures when there has been contamination by blood and/or body fluids

VHF viruses have been known to survive for 2 weeks or even longer on contaminated fabrics and equipment. Persons carrying out decontamination and cleaning procedures must wear appropriate HCID assessment PPE and use suitable disinfectant products determined by a robust risk assessment. For information on handling spillages of blood and body fluids, see ‘Spillages of blood or body fluids from a confirmed case of VHF’ below.

It is difficult to provide assurance that a mattress contaminated by blood or body fluids is decontaminated. For this reason, a contaminated mattress should be segregated and safely stored while waiting for VHF test results if facilities are available. However, if it is not practicable to segregate and store a mattress pending the VHF test result, then it must be bagged for disposal in line with the guidance in Appendix 9.

Terminal disinfection of rooms used to care for patients with confirmed VHF

Rooms used to house confirmed VHF patients in a non-specialist unit will need to be decontaminated via fumigation. This procedure will need to be carried out following a thorough risk assessment and in consultation with the local infection control team. Vaporised hydrogen peroxide is known to be effective against VHFs. Whichever method is chosen, it should be validated to ensure it has been effective.

Spillages of blood or body fluids from a confirmed case of VHF

Staff dealing with spillages must be trained and competent in the use of HCID assessment PPE and must wear it at all times while dealing with the spill.

For small spots of blood or small spills:

• contamination should be mopped up with absorbent material (for example disposable paper towels, gel preparations), which are then disposed of through the correct waste stream
• the area should then be disinfected with freshly prepared hypochlorite solution containing 10,000 ppm available chlorine (1%; 1 in 5 dilution of typical bleach) ensuring a contact time of 2 minutes before wiping up with disposable paper towels
• the surface should then be washed with warm water and detergent
• all waste, including gloves and paper towels, should be disposed of as category A waste

For larger spills, the procedure followed should be the same as for small spills - however, the following additional measures may be required:

• where possible, allow any potential aerosols to settle out
• towels, gloves, disposable overshoes and any contaminated clothing should be disposed of as category A waste

Appendix 9: waste treatment and disposal

NHS England’s Safe and sustainable management of healthcare waste (HTM 07-01) contains comprehensive, best practice guidance on the management of all types of healthcare waste in the UK, including waste that is highly infectious.

All waste from patients classified as ‘minimal risk of VHF’ infection should be treated as category B infectious waste.

Waste from patients classified as ‘at risk of VHF’ may be segregated and safely stored while waiting for VHF test results if facilities are available. However, if it is not practicable to segregate and store pending VHF test results then waste from ‘at risk’ cases must be treated as category A. If VHF test results subsequently confirm the patient as negative for VHF, waste can then be treated as category B.

All waste from patients with a confirmed VHF infection is classified as category A infectious waste, on the basis that it is known or reasonably expected to be contaminated with pathogens presenting the most severe risk of infection. All treatment, disposal and transport of waste should therefore follow the guidance for category A infectious waste.

Inactivation of waste on-site

Waste water can be safely disposed of through sanitary sewers without the need for additional water treatment on the basis that the volume of effluent will be small and the survival time of the virus in the sewerage system is likely to be short.

Any liquid effluent that does not go into a lavatory plumbed into the sewerage system should, however, be stored in a sealed, leak-proof container and disposed of as category A waste. If possible, contents should be solidified with high absorbency gel.

Inactivation of waste off-site

Where it is not possible to inactivate waste on site from patients categorised as ‘at risk’ or ‘confirmed’, a risk assessment must be undertaken for off-site waste disposal with advice from the on-site transport of dangerous goods advisor. This should include:

• consideration of the volume of waste generated
• availability of UN-approved containers for storage and transportation of category A waste
• provision of safe and secure on site storage prior to transfer
• liaison with a licensed category A waste contractor to ensure safe collection, transport and disposal compliant with the European Agreement concerning the International Carriage of Dangerous Goods by Road (ADR)

Crockery and cutlery

Disposable crockery and cutlery should be used where possible for those patients categorised as ‘at risk’ or ‘confirmed’ VHF. They should be disposed of as category A waste, or stored safely until the VHF result is known. If the VHF test is negative they can be disposed of normally.

Toilets

Toilets or commodes may be used by patients categorised as ‘at risk’ or ‘confirmed’ for VHF infection. Where commodes are employed, a dedicated commode should be used with a disposable bowl. After use, the contents should be solidified with high-absorbency gel. The commode waste should be treated as category A waste. Toilets and commodes should be disinfected with hypochlorite containing 10,000 ppm available chlorine at least daily, preferably after each use and upon patient discharge. For non-ambulant patients, disposable bedpans should be used and the contents should be solidified with high-absorbency gel then disposed of as category A waste. Excreta in disposable bed pans, bowls or urine bottles must never be placed into sluice macerators.

Use and treatment of disposable linen

The use of disposable linen should always be considered when appropriate, in particular when caring for a patient at risk of or with confirmed VHF infection. This linen should be treated and disposed of as category A waste or stored pending the VHF test result. If negative, it can be disposed of as category B waste.

Use and treatment of non-disposable linen

All re-usable linen from patients classified as ‘at risk’ may be segregated and safely stored while waiting for VHF test results if facilities are available. If VHF results subsequently confirm the patient as negative for VHF, re-usable linen can then be treated as for any other linen contaminated with infectious body fluids. However, if it is not practicable to segregate and store pending VHF results then waste from ‘at risk’ cases must be treated as category A.

All re-usable linen from patients with a confirmed VHF infection must be treated and disposed of as category A waste.

A mattress contaminated with body fluids of a patient with confirmed VHF infection must be bagged up for disposal as category A waste, or after discussion with the local infection prevention and control team, decontaminated by a validated procedure and then disposed of as category B waste.

Laboratory waste

The infectious component of laboratory waste can be classified as either category A (specimens from patients confirmed to have VHF infection) or category B (specimens from patients classed as ‘minimal risk of VHF’ or from patients classed as ‘at risk of VHF’ that have been confirmed as negative for VHF) as set out in NHS England’s ‘Safe and sustainable management of healthcare waste (HTM 07-01)’.

Waste from autoanalysers is not considered to pose a significant risk because of the small sample size and dilution step and will therefore require no special waste disposal precautions.

Appendix 10: after death care

Post-mortem examination

A post-mortem examination on a person known to have died of VHF exposes staff to unwarranted risk and should not be performed.

Where a patient suspected of having VHF dies prior to a definitive diagnosis, it may be necessary on public health grounds to undertake some diagnostic tests to either establish or eliminate the diagnosis of VHF or to provide an alternative diagnosis including, for example, malaria. Consultation with appropriate specialists may help to determine the extent of the limited amount of sampling that will enable such an assessment and how to perform this sampling safely.

Personnel undertaking diagnostic sampling post-mortem must wear appropriate PPE following the guidance for safe collection and transport of specimens. Where the deceased is in a bed isolator, the specimens should be taken before transferring the body to a leak-proof body bag. Where the results of such tests have found the deceased to be negative for VHF then a post-mortem examination may be required.

Disposal of the deceased

Where a confirmed VHF case has died while being cared for in a bed isolator, the body should be removed according to the local operational policy.

Where the body of a confirmed or suspected VHF patient is not in an isolator, staff wearing suitable PPE should place the body in a double body bag. Absorbent material should be placed between each bag and the bag sealed and disinfected with 1000 ppm available chlorine or other appropriate disinfectant. The bag should be labelled as high risk of infection and placed in a robust coffin with sealed joints.

The national public health agency, UKHSA, should be contacted.

Public health and controlling the risk of exposure

Under public health law, every person having the charge or control of premises in which is lying the body of a person who has died while suffering from a notifiable disease such as VHF must take such steps as may be reasonably practicable to prevent persons coming unnecessarily into contact with, or proximity to, the body.

In England the Health Protection (Local Authority Powers) Regulations 2010 and in Wales the Health Protection (Local Authority Powers, Wales) Regulations 2010 grant discretionary powers to local authorities to restrict contact with, and access to, an infected dead body where necessary.

In Scotland, part 6 (Protection of public from risks arising from bodies) of the Public Health etc. (Scotland) Act 2008 grants powers to health boards to restrict the release of infected bodies from hospitals.

In Northern Ireland the Public Health Act (Northern Ireland) 1967 grants powers to the Director of Public Health to prohibit persons coming into contact with a body of a person who has died while suffering from a notifiable disease.

Funeral directors and embalmers

Funeral directors will need to be consulted beforehand and provided with sufficient information of the infection risk normally provided by an infection control notification sheet. Further guidance is available in HSE’s Managing infection risks when handling the deceased.

It is recognised that in most other circumstances in this country, bodies often receive some form of hygienic preparation or are fully embalmed as a means of delaying putrefaction (for example, when the funeral is delayed or for transportation over long distances within the UK or internationally). However, in the case of confirmed VHF cases, embalming or hygienic preparation of bodies presents an unacceptably high risk and should not be undertaken.

Religious or ritual preparations, viewing of the deceased and funeral arrangements

Particular handling of a deceased person may be necessary for other safety reasons. For example, as it is not possible to remove pacemakers and other implants safely for cremation, patients with these implants who die from confirmed VHF disease must be buried.

As far as is reasonably practicable, the needs and wishes of the deceased’s family should be respected. However, the serious nature of this infection and the associated occupational and public health risks necessarily impose significant limitations and constraints, which aim to limit contact with the body by the next of kin. Due to the unusual circumstances, there will be a need to communicate sensitively that the following will need to be avoided with respect to the deceased:

• religious or ritual preparation of the body
• washing
• dressing
• viewing
• touching or kissing

It is advised that the funeral director discusses appropriate infection control procedures, use of PPE and waste disposal arrangements with specialists (communicable disease control and HLIU consultants) if additional advice is needed.

Repatriation or expatriation of the deceased’s remains

In general, the transportation of human remains to or from the UK is governed by a number of authorities:

• the receiving country (normally regarded as being the body of law that controls how the remains should be handled as regards control of infection)
• the country of origin
• the carrier - whose requirements will be governed by the International Air Transport Association (IATA) Dangerous Goods Regulations (DGR), under which human remains need to be accompanied by a notification of infection form or ‘free from infection’ certificate (for further information, see the Shipping dangerous goods guidance)

VHF-infected bodies should not be embalmed on grounds of risk (see above) - therefore both for this reason and because of the consequent difficulty there would be in achieving full compliance with IATA requirements, the transportation of bodies out of the country is not recommended. However, following cremation, ashes may be transported safely.

In the unlikely event of a VHF-infected body being embalmed abroad and transported back to the UK, it would need to be contained within a sealed, zinc-lined transport coffin in accordance with IATA requirements. Upon arrival in the UK a change of coffins is to be avoided and this may dictate the options for burial or cremation, which should be arranged promptly.

Appendix 11: relevant health and safety legislation and guidance

The legislation framework in the UK

This appendix summarises the UK health and safety legislation and guidance relevant to working in healthcare with patients infected with VHF, or in laboratories with specimens potentially contaminated by haemorrhagic fever viruses.

The Health and Safety at Work etc. Act 1974 (‘the HSW Act’) is the primary piece of legislation covering occupational health and safety in the UK and places duties on employers and others, where the risks from exposure to biological agents may arise from work activities. It also places duties on employees to co-operate with their employer, so far as is necessary, to enable them to comply with their health and safety duties as set down under the HSW Act and under relevant legislation.

The Control of Substances Hazardous to Health Regulations 2002 (‘COSHH’) provides a framework of actions designed to control the risk from a range of hazardous substances including biological agents.

Under the Management of Health and Safety at Work Regulations 1999 and COSHH, once a risk assessment has been completed, methods must be chosen to adequately control the identified risks following a hierarchical approach of:

• eliminating risk
• controlling risk at source or by safer design
• using physical engineering controls and safeguards

This should be supported by:

• safe systems of work
• the use of PPE

These regulations require employers to assess the risk of infection for both their employees and others who may be affected by the work, for example, waste disposal workers, service engineers and members of the public. When a risk has been identified, there is a duty to select and apply appropriate prevention or control measures. Engineering controls used, such as microbiological safety cabinets, must be regularly maintained. PPE must be properly stored, cleaned, maintained and, if found to be defective, repaired or replaced.

COSHH requires that employers take all reasonable steps to ensure that the control measures they provide are used, which includes provision of information and training, as well as appropriate supervision of employees. Risk assessments must be reviewed regularly and revised when conditions change, an incident occurs, a deficiency is noted or if for any other reason it is suspected that the assessment is no longer valid. In addition, employees must receive suitable and sufficient information, instruction and training about the risks they may encounter at work. Subject to assessment, there may also be the need to provide health surveillance for employees and offer them vaccines.

Other health and safety regulations may apply, for example equipment provided must be suitable, safe for use and safely maintained in line with the requirements of the Provision and Use of Work Equipment Regulations 1998. In this context, ‘equipment’ also includes needles. Laboratory equipment such as autoclaves must comply with the Pressure Equipment Regulations 2016 and the Pressure Systems Safety Regulations 2000.

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR 2013) requires employers to report all diseases and any acute illness caused by an occupational exposure to a biological agent (see HSE’s Exposure to carcinogens, mutagens and biological agents).

The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2009 (as amended) stipulates requirements for secure packaging and clear hazard labelling for the safe transfer of specimens and waste contaminated and potentially contaminated by haemorrhagic fever viruses.

Further HSE guidance relevant to working in healthcare with patients infected with VHF, or in laboratories with specimens potentially contaminated by haemorrhagic fever viruses, can be found in:

• Management and operation of microbiological containment laboratories

• Blood-borne viruses (BBV) - guidance for employers and employees

• Managing infection risks when handling the deceased - guidance for the mortuary, post-mortem room and funeral premises and during exhumation

Summary of responsibilities for health and safety

The employer will need to:

• ensure the organisation has the necessary management framework to protect the health and safety of staff and to provide a safe working environment
• have access to competent help in applying the provision of health and safety law
• consult with employees’ safety representatives on health and safety matters
• establish procedures to be followed by any worker if situations presenting serious and imminent danger arise
• co-operate and co-ordinate where 2 or more employers or self-employed persons share a workplace
• make health and safety policy and local codes of practice freely accessible either by putting them on display or by individual issue, and ensure all staff, including all newcomers and temporary workers, are aware of them
• manage and follow up recognised dangerous occurrences, accidents or incidents at work which could result in the release of a biological agent likely to cause severe human illness or infection, for example, sharps injuries during surgical and needle-related procedures, including reporting under RIDDOR
• keep health records in relation to work involving risk of exposure to VHF

Specifically, for VHF this should include information on:

• whether employees could be exposed to VHF and how
• the risks posed by this exposure
• the main findings of any risk assessment
• the precautions employees should take to protect themselves and other employees, contract staff or visitors
• how they should use and dispose of any PPE that is provided
• what procedures they should follow in the event of an emergency

The employee will need to:

• comply with agreed risk assessments following the COSHH hierarchy
• adhere to agreed safe systems of work, for example, laboratory rules, sharps and waste disposal polices, decontamination and disinfection procedures
• properly use the control measures provided by their employers, including personal PPE and report any problems with them
• bring to the attention of their employers any instances of dangerous occurrences, accidents or incidents arising out of their work which could result in the release of a biological agent likely to cause severe human illness or infection, or a sharps injury involving a known VHF-infected source so that necessary remedial or preventative actions can be taken, including reporting under RIDDOR

If a patient refuses to be admitted, or an admitted patient voluntarily leaves hospital, where infection poses a risk to others in the community the consultant in communicable disease control or consultant in public health should be contacted to make a decision on applying for a part 2A order under The Health Protection (Notification) Regulations 2010.

Appendix 12: glossary

Aerosols

Aerosols are very small particles (of respirable size) that may contain infectious agents. They can remain in the air for extended periods of time and can be carried over long distances by air currents. Aerosols can be released during aerosol generating procedures (see below).

Aerosol generating procedure (AGP)

This is a medical procedure that can result in the release of aerosols from the respiratory tract. The criteria for an AGP are a high risk of aerosol generation and increased risk of transmission (from patients with a known or suspected respiratory infection).

Airborne transmission

Airborne transmission refers to the spread of infection from one individual to another by airborne particles (aerosols) containing infectious agents. Airborne particles are very small particles that may contain infectious agents. They can remain in the air for long periods of time and can be carried over long distances by air currents. Airborne particles can be released when an individual coughs or sneezes and during AGPs. ‘Droplet nuclei’ are aerosols formed from the evaporation of larger droplet particles (see droplet transmission). Aerosols formed from droplet particles in this way behave as other aerosols. Airborne precautions are measures used to prevent and control infection spread without necessarily having close patient contact via aerosols from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Aerosols can penetrate the respiratory system to the alveolar level.

Autoanalyser

An autoanalyser is an automated analysis machine, where specimens are uploaded and remain within the system during analysis, therefore greatly reducing or preventing the risk of infection to laboratory staff through contact with the specimen.

Autoclave

An autoclave is a strong, pressurised, steam-heated vessel for sterilisation.

Available chlorine

This is the measurement of the oxidising capacity of a hypochlorite solution.

Category A infectious waste

Category A infectious waste is waste that is known or reasonably expected to be contaminated with pathogens presenting the most severe risk. A list of such pathogens can be found in NHS England’s ‘Safe and sustainable management of healthcare waste (HTM 07-01)’.

Category B infectious waste

Category B infectious waste is waste that is known or reasonably believed to be contaminated with pathogens not listed for inclusion into category A waste - see NHS England’s ‘Safe and sustainable management of healthcare waste (HTM 07-01)’.

Centrifugation

Centrifugation is a technique that uses a mechanical centrifuge to separate different components of a sample, such as blood, based on their relative densities.

Containment level 2 laboratory

A containment level 2 laboratory is a aboratory that is generally used for working with hazard group 2 biological agents.

Droplets

This refers to a small indefinite quantity (usually of liquid). Droplets are larger than aerosols, although the cut-off size between droplets and aerosols are often debated between 5 and 10μm.

Dual infection

Dual infection means the patient is infected with more than one infectious agent - for example, Plasmodium falciparum and Ebola virus.

Endemic

Endemic means occurring in a particular region or population.

Hazard

Hazard, in relation to a substance, means the intrinsic property of that substance which has the potential to cause harm to the health of a person - in the context of this guidance, this means an infectious biological agent.

Hazard group (for biological agents)

This refers to the classification of a biological agent based on its ability to cause disease by infection, based on whether the agent is pathogenic for humans, whether the agent is a hazard to employees, whether the agent is transmissible to the community and whether there is effective treatment or prophylaxis available.

Healthcare worker

This refers to clinical and other staff, including:

• those in primary care, who have regular, clinical contact with patients - laboratory and other staff for example
• mortuary staff, who have direct contact with potentially infectious specimens
• non-clinical ancillary staff who may have social contact with patients, but not usually of prolonged or close nature

Host

A host is an organism that is infected with or is fed upon by a parasitic or pathogenic organism, for example, a virus. The host does not benefit and is often harmed by the association.

Respirator

A respirator is a protective mask with a filter that protects the face and lungs against harmful aerosols.

Respiratory protective equipment

Respiratory protective equipment is respiratory protection that is worn over the nose and mouth designed to protect the wearer from inhaling hazardous substances, including airborne particles (aerosols). There are 2 types of respiratory protection that can be used: tight-fitting disposable FFP respirators and loose-fitting powered respirator hoods (TH2). 

FFP stands for ‘filtering face piece’. There are 3 categories of FFP respirator: FFP1, FFP2 and FFP3. FFP3 and loose-fitting powered respirator hoods provide the highest level of protection and are recommended when caring for patients in areas where high-risk AGPs are being performed.

Risk

Risk refers to the likelihood that the potential for harm to the health of a person will be attained under the conditions of use and exposure and also the extent of that harm - in the context of this guidance, the likelihood of exposure and the consequential infection and disease.

Risk assessment

Risk assessment is a process that describes and quantifies the risk associated with a hazard.

Standard infection control precautions (SICPs)

SICPs are the basic IPC measures necessary to reduce the risk of transmitting infectious agents from both recognised and unrecognised sources of infection. Sources of (potential) infection include blood and other body fluids secretions or excretions (excluding sweat), non-intact skin or mucous membranes and any equipment or items in the care environment that could have become contaminated.

Terminal clean

A terminal clean is defined as a procedure required to ensure that an area has been cleaned and decontaminated following transfer or discharge of a patient suspected or confirmed to be infected or colonised with an infectious pathogen (that is, alert organism or communicable disease) to ensure a safe environment for the next patient.

Vector

Any agent (living or inanimate) that acts as an intermediate carrier or alternative host for a pathogenic organism and transmits it to a susceptible host.

VHF test

Testing of a patient’s sample for the presence or absence of VHF genetic material via PCR analysis.

1. There has been the exception of one research laboratory worker who sustained a needle-stick injury in 1976, and 2 secondary cases in 2022, both of whom were family members of a primary case who acquired Lassa in Mali. ↩

2. Emond RT, Evans B, Bowen ET, Lloyd G. A case of Ebola virus infection. British Medical Journal (1977) 2:541-514. ↩

3. Disease Outbreak News; Lassa fever - United Kingdom of Great Britain and Northern Ireland, published by the World Health Organization (2022). ↩