THE OUTBREAK MANUAL 2006
Private Bag X11285 1200 Nelspruit Mpumalanga South Africa Tel: 0137663411 Fax: 0137663473
Mpumalanga Communicable Diseases Control Email: info@cdcmpumalanga.net Outbreak Hotline in Mpumalanga: 0137663411
ISBN # 0-620-26961-8 April 2006 This is an updated version of The Outbreak Manual originally produced in June 1998, in hard copy in June 1999 and as an electronic version and in 2000. The Outbreak Manual is available on line at http://www.cdcmpumalanga.net/outbreakmanual.htm This manual prepared through the expertise and tireless efforts of Drs Kobus Hugo and Gerhard Swart
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Table of Contents INTRODUCTION
11
Keys to effective epidemic response ................................................ 12
CONDITIONS REQUIRING IMMEDIATE RESPONSE ON CLINICAL PRESENTATION ALONE
13
ACUTE FLACCID PARALYSIS (POLIOMYELITIS)
14
CASE DEFINITION................................................................................ 14 CONFIRMATION ................................................................................... 14 INFORMATION ...................................................................................... 15 Clinical picture ................................................................................... 15 Infectious agent ................................................................................. 15 Reservoir ........................................................................................... 15 Incubation period .............................................................................. 16 Period of infectiousness .................................................................... 16 PREVENTION........................................................................................ 16 RESPONSE ........................................................................................... 17 Infection Control Precautions ............................................................ 17 Treatment .......................................................................................... 17 Specimens ........................................................................................ 17 Reporting .......................................................................................... 17 Treatment of Contacts ...................................................................... 18
DIARRHOEA OUTBREAKS (>10 CASES LINKED BY PERSON, PLACE AND TIME)
19
CASE DEFINITION................................................................................ 19 CONFIRMATION ................................................................................... 19 INFORMATION ...................................................................................... 19 Clinical picture ................................................................................... 19 Infectious agent ................................................................................. 19 Reservoir ........................................................................................... 20 Transmission ..................................................................................... 20 Incubation period .............................................................................. 20 Period of infectiousness ..................................................................... 20 PREVENTION........................................................................................ 20 RESPONSE ........................................................................................... 21 Treatment .......................................................................................... 21
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Specimens ........................................................................................ 21 Reporting .......................................................................................... 22 Treatment of Contacts ...................................................................... 22
DYSENTERY OUTBREAKS (>10 CASES LINKED BY PERSON, PLACE AND TIME)
23
CASE DEFINITION................................................................................ 23 CONFIRMATION ................................................................................... 23 INFORMATION ...................................................................................... 23 Clinical picture ................................................................................... 23 Infectious agent ................................................................................. 24 Reservoir ........................................................................................... 24 Transmission ..................................................................................... 24 Incubation period .............................................................................. 24 PREVENTION........................................................................................ 24 Response .............................................................................................. 25 Infection Control Precautions ............................................................ 25 Treatment .......................................................................................... 25 Specimens ........................................................................................ 25 Reporting .......................................................................................... 26 Treatment of Contacts ...................................................................... 26
FEBRILE DISEASE WITH NON-BLISTERING GENERALIZED SKIN RASH (MEASELS) 27 CASE DEFINITION................................................................................ 27 CONFIRMATION ................................................................................... 27 INFORMATION ...................................................................................... 27 Clinical picture ................................................................................... 27 Infectious agent ................................................................................. 29 Reservoir ........................................................................................... 29 Transmission ..................................................................................... 29 Incubation period .............................................................................. 29 Period of infectiousness .................................................................... 29 PREVENTION........................................................................................ 29 RESPONSE ........................................................................................... 30 Infection Control Precautions ............................................................ 30 Treatment .......................................................................................... 30 Specimens ........................................................................................ 31 Reporting .......................................................................................... 31 Treatment of Contacts ...................................................................... 32
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FEBRILE DISEASE WITH SUPPURATIVE LYMPHADENOPATHY (PLAGUE)
34
CASE DEFINITION................................................................................ 34 CONFIRMATION ................................................................................... 34 INFORMATION ...................................................................................... 34 Clinical picture ................................................................................... 34 Infectious agent ................................................................................. 35 Reservoir ........................................................................................... 35 Transmission ..................................................................................... 35 Incubation period .............................................................................. 35 PREVENTION........................................................................................ 36 RESPONSE ........................................................................................... 36 Infection Control Precautions ............................................................ 36 Treatment .......................................................................................... 36 Specimens ........................................................................................ 36 Reporting .......................................................................................... 37 Treatment of Contacts ...................................................................... 37
H5N1 AVIAN INFLUENZA (BIRD FLU)
38
CASE DEFINITION................................................................................ 38 Criteria A - Clinical criteria ............................................................... 38 Criteria B - Epidemiological risk factors - travel............................... 39 Criteria C - Epidemiological risk factors - local ................................ 39 CONFIRMATION ................................................................................... 39 INFORMATION ...................................................................................... 40 Clinical picture in humans ................................................................. 40 Infectious agent ................................................................................. 40 Reservoir ........................................................................................... 40 Transmission ..................................................................................... 40 Incubation period .............................................................................. 41 Period of infectiousness .................................................................... 41 PREVENTION........................................................................................ 41 RESPONSE ........................................................................................... 42 Infection Control Precautions ............................................................ 42 Treatment .......................................................................................... 42 Specimens ........................................................................................ 42 Reporting .......................................................................................... 43 Treatment of Contacts ...................................................................... 43
HAEMORRHAGIC FEVER (VIRAL HAEMORRHAGIC FEVER)44 CASE DEFINITION................................................................................ 44
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CONFIRMATION ................................................................................... 44 INFORMATION ...................................................................................... 44 Clinical picture ................................................................................... 44 Infectious agent ................................................................................. 45 Reservoir ........................................................................................... 45 Transmission ..................................................................................... 45 Incubation period .............................................................................. 46 Period of infectiousness .................................................................... 46 PREVENTION........................................................................................ 46 RESPONSE ........................................................................................... 46 Infection Control Precautions ............................................................ 46 Treatment .......................................................................................... 46 Specimens ........................................................................................ 47 Reporting .......................................................................................... 47 Treatment of Contacts ...................................................................... 47
HAEMORRHAGIC FEVER WITH JAUNDICE (YELLOW FEVER)
49
CASE DEFINITION................................................................................ 49 CONFIRMATION ................................................................................... 49 INFORMATION ...................................................................................... 49 Clinical picture ................................................................................... 49 Infectious agent ................................................................................. 49 Reservoir ........................................................................................... 50 Transmission ..................................................................................... 50 Incubation period .............................................................................. 50 Period of infectiousness .................................................................... 50 PREVENTION........................................................................................ 50 RESPONSE ........................................................................................... 50 Infection Control Precautions ............................................................ 50 Treatment .......................................................................................... 51 Specimens ........................................................................................ 51 Reporting .......................................................................................... 51 Treatment of Contacts ...................................................................... 51
MENINGOCOCCAL MENINGITIS
53
CASE DEFINITION................................................................................ 53 CONFIRMATION ................................................................................... 53 INFORMATION ...................................................................................... 54 Clinical picture ................................................................................... 54 Infectious agent ................................................................................. 54 Reservoir ........................................................................................... 54
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Transmission ..................................................................................... 55 Incubation period .............................................................................. 55 Period of infectiousness .................................................................... 55 PREVENTION........................................................................................ 55 RESPONSE ........................................................................................... 55 Infection Control Precautions ............................................................ 55 Treatment .......................................................................................... 55 Specimens ........................................................................................ 56 Reporting .......................................................................................... 56 Treatment of Contacts ...................................................................... 57
PROFUSE WATERY DIARRHOEA (CHOLERA)
59
CASE DEFINITION................................................................................ 59 CONFIRMATION ................................................................................... 59 INFORMATION ...................................................................................... 59 Clinical picture ................................................................................... 59 Infectious agent ................................................................................. 60 Reservoir ........................................................................................... 61 Transmission ..................................................................................... 61 Incubation period .............................................................................. 61 Period of infectiousness .................................................................... 61 PREVENTION........................................................................................ 61 RESPONSE ........................................................................................... 62 Infection Control Precautions ............................................................ 62 Treatment .......................................................................................... 62 Specimens ........................................................................................ 63 Reporting .......................................................................................... 63 Treatment of Contacts ...................................................................... 63
RABIES
64
INFORMATION ...................................................................................... 64 Clinical picture ................................................................................... 64 Infectious agent ................................................................................. 64 Major Vectors .................................................................................... 65 Transmission ..................................................................................... 65 Incubation Period .............................................................................. 66 Pathogenisis ..................................................................................... 66 Period of Infectiousness ................................................................... 66 PREVENTION........................................................................................ 66 CONFIRMATION ................................................................................... 67 RESPONSE ........................................................................................... 68 Treatment .......................................................................................... 68
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Infection Control Precautions ............................................................ 70 Specimens ........................................................................................ 70 Reporting .......................................................................................... 71
SYSTEMIC FEBRILE DISEASE (>10 CASES LINKED BY PERSON, PLACE AND TIME)
73
CONDITIONS REQUIRING REPORTING AND RESPONSE WITHIN 24 HOURS OF POSITIVE LABORATORY RESULTS .............................. 74 ANTHRAX ............................................................................................. 74 DIPHTHERIA ......................................................................................... 75 HEPATITIS, VIRAL A and E ................................................................. 75 Treatment of Hepatitis A contacts:.................................................... 76 LEGIONELLOSIS (LEGIONNAIRE’S DISEASE) ................................. 77 PERTUSSIS........................................................................................... 77 TYPHOID FEVER .................................................................................. 78 CASE DEFINITION ........................................................................... 78 CONFIRMATION .............................................................................. 78 INFORMATION ................................................................................. 78 PREVENTION ................................................................................... 80 RESPONSE ...................................................................................... 81
APPENDIX A STANDARD AND ADDITIONAL PRECAUTIONS85 Standard Precautions .......................................................................... 85 Hand-washing ................................................................................... 85 Gloves ............................................................................................... 85 Mask, Eye Protection, Face Shield ................................................... 86 Gown (or plastic apron) .................................................................... 86 Patient-Care Equipment ................................................................... 86 Environmental Control ...................................................................... 86 Linen ................................................................................................. 87 Occupational Health and Blood-borne Pathogens ........................... 87 Airborne Precautions .......................................................................... 87 Patient Placement ............................................................................. 87 Respiratory Protection ...................................................................... 88 Patient Transport .............................................................................. 88 Droplet Precautions ............................................................................. 88 Patient Placement ............................................................................. 88 Mask.................................................................................................. 89 Patient Transport .............................................................................. 89 Contact Precautions ............................................................................ 89 Patient Placement: ............................................................................ 89 Gloves and Hand-washing ................................................................ 89
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Gown (or plastic apron) .................................................................... 89 Patient Transport .............................................................................. 90 Patient-care Equipment .................................................................... 90
APPENDIX B KEY MESSAGES
91
APPENDIX C PACKING AND SHIPPING PROCEDURES
93
Storage and transport for avian influenza ........................................ 94
GLOSSARY
96
EXAMPLE OF A LINE LIST
99
CONTACT DETAILS
100
ACKNOWLEDGEMENTS
101
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INTRODUCTION An infectious disease epidemic requires an immediate and effective response. You should: 1. Familiarise yourself with the case definitions in The Outbreak Manual. The infectious diseases included are those which, when they occur more frequently than usual, pose a serious threat to the public’s health. 2. Be alert and look for cases meeting the case definition. 3. Immediately respond as indicated. An immediate correct response will limit the extent of an epidemic. 4. Always remember that the Mpumalanga Outbreak Response Team is there to provide you with epidemiological, micro-biological and logistical support during outbreaks. Contact numbers:
The Mpumalanga Outbreak Response Team (MJOC) during office hours at 013 7663411
or
The district Communicable Disease Control Manager.
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Keys to effective epidemic response 1. Know the case definitions 2. Vigilantly look for cases 3. Rapidly implement the recommended response i.
Report case to district CDC Manager
ii.
Activate MJOC
iii.
Send correct specimens to confirm pathogen
iv.
Case investigation within 24 hours after reporting
4. Contact the Provincial Team for assistance at 013 7663411 5. Implement control measures 6. Evaluation of response
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CONDITIONS REQUIRING IMMEDIATE RESPONSE ON CLINICAL PRESENTATION ALONE
Acute Flaccid Paralysis (Poliomyelitis)
Diarrhoea Outbreaks (>10 cases linked by person, place and time)
Dysentery Outbreaks (>10 cases linked by person, place and time)
Febrile Disease with Non-blistering Generalized Skin Rash (Measles)
Febrile Disease with Suppurative Lymphadenopathy (Plague)
Haemorrhagic Fever (Viral Haemorrhagic Fevers)
Haemorrhagic Fever with Jaundice (Yellow Fever)
Meningococcal Meningitis
Profuse Watery Diarrhoea (Cholera)
Outbreaks of Systemic Febrile Disease (>10 cases linked by person, place and time)
Febrile Disease with respiratory symptoms and history suggestive of Avian Influenza virus contact.
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ACUTE FLACCID PARALYSIS (POLIOMYELITIS) CASE DEFINITION Any case of acute flaccid paralysis, including Guillain-Barré Syndrome, in a child less than 15 years of age for which no other cause is apparent, or a patient of any age diagnosed as polio by a medical officer.
CONFIRMATION When the clinical case definition is met and:
Polio virus is found in the stool
Confirmation of probable case:
the clinical case definition is met
and The patient has residual paralysis at 60 days or The patient dies or The patient was lost to follow-up.
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INFORMATION Polio is targeted for global eradication.
Clinical picture 99% of infections are asymptomatic or non-specific febrile illness. Paralytic cases may begin with fever, malaise, headache and nausea, followed by muscle pain or stiffness and then lameness in one or more limbs. There are decreased or absent tendon reflexes in the affected limbs and no sensory loss. Onset is usually sudden and paralysis is asymmetrical (compared to Guillain-BarrĂŠ Syndrome where paralysis is usually symmetrical). Up to 10% of paralytic cases in an epidemic die, usually due to paralysis of respiratory muscles.
Infectious agent Polio virus 1, 2 and 3. All types cause paralysis. Type 1 is responsible for most outbreaks caused by wild virus while Type 2 or 3 cause most vaccine-associated disease.
Reservoir People, particularly those who are asymptomatic. There is no long term carrier state. Transmission Faecal-oral transmission is most important, particularly in areas of poor sanitation. Where sanitation is good, transmission by coughing and sneezing has been implicated in certain outbreaks.
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Incubation period Normally 7-14 days, but can vary from two days to a month.
Period of infectiousness Virus can be found in the throat for about a week and in faeces for up to 6 weeks, but cases are most infectious a few days before and after the start of symptoms
PREVENTION 1. Encourage your local community to practice good personal hygiene (See Key Messages Appendix B). 2. Immunise all children with Trivalent Oral Polio Vaccine (TOPV) and maintain the Cold Chain as TOPV is destroyed by heat. 3. Schedule: Birth 6, 10 & 14 weeks 18 months 5 years 4. All supplementary activities to increase polio vaccination coverage should reach the maximum number of target age-group children.
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RESPONSE Infection Control Precautions
Standard precautions (see Appendix A)
Where patient is in diapers or incontinent – Add Contact Precautions (see Appendix A)
Treatment
Hospitalise as soon as possible
Specimens
5 – 10 g of fresh stool from the case (a “thumb nail” quantity), or a rectal swab may be taken.
2 specimens should be sent, 24-48 hours apart, within 14 days of paralysis onset.
Use plastic screw-top container and refrigerate.
Follow standard packing and shipping procedure (Appendix C). Maintaining the cold chain (0 8°C) is essential.
Contact the local SAIMR/NHLS laboratory for collection and indicate that specimen is for the National Institute of Communicable Diseases (NICD, Virology) and from a suspected AFP case (refrigerate while you await collection).
Reporting
Any syndrome of acute flaccid paralysis in a child less than 15 years of age needs to be reported irrespective of diagnosis
Phone 013 7663411 (Provincial Outbreak Response Team) immediately to report a suspected case of AFP.
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Phone the National Institute for Communicable Diseases at Tel: 27-11-386 6000 Fax: 27-11-882 0596 and let the virologist-on-call know that the specimen has been sent.
Complete the official AFP Case Investigation Form and fax to 013 7664473.
AFP and polio are statutory notifiable conditions.
Treatment of Contacts
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Where deemed necessary by the Provincial EPI coordinator, on epidemiological grounds or where polio virus is isolated from an AFP case’s stool, all children below five years of age in the affected area should receive two drops of TOPV, regardless of their immunisation status. Occasionally the age group for immunisation will be extended by the Provincial EPI Coordinator.
If polio virus is isolated, then a second round of TOPV immunisation should be performed four weeks after the first round.
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DIARRHOEA OUTBREAKS (>10 cases linked by person, place and time) CASE DEFINITION More than 10 cases of diarrhoea (>3 three unformed stools in a 24 hour period or self-reported diarrhoea) which can be linked by place, person and time.
CONFIRMATION By laboratory examination of stool specimen to identify the causative organism. This is most successful when the stool specimen reaches the laboratory within 2 hours, and on ice.
INFORMATION Clinical picture Clinical presentation depends on the organism responsible but common symptoms are diarrhoea, vomiting, abdominal cramps and fever.
Infectious agent A large number of different organisms (viruses, bacteria and protozoa) and chemical substances can cause diarrhoeal outbreaks. Some are mainly food-borne, like Salmonella, Campylobacter, Clostridium perfringens (all three having an animal reservoir) and some types of E. coli, while other organisms are mainly waterborne, particularly enterotoxigenic
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E. coli. Where vomiting is a major symptom then viral gastroenteritis or food poisoning caused by staphylococci, Bacillus cereus, Clostridium perfringens or Vibrio parahaemolyticus should be suspected. The short incubation period of food poisoning usually allows incrimination of a specific food item and tracing of other victims.
Reservoir Important examples are: poultry (Campylobacter, Salmonella species), shellfish (Vibrio parahaemolyticus), and people (Staphylococcus aureus, Rota and Norwalk viruses, Giardia lamblia).
Transmission Hand (contaminated by infected faeces) to mouth is the most common mode of transmission of infectious agents but contaminated food is also often implicated, like poultry (Campylobacter, Salmonella species), raw sea-food (Vibrio parahaemolyticus), contaminated flash-fried rice (Bacillus cereus), contaminated warmed-up left overs (Clostridium perfringens) and faecally contaminated water (ETEC, Giardia lamblia) also plays an important role.
Incubation period From hours (Staphylococcus aureus) to 3 weeks (Giardia lamblia).
Period of infectiousness Usually only while symptomatic or for a short time after symptoms cease.
PREVENTION Clinics should be the source of clear messages on effective food hygiene, like the “Ten Golden Rules for Safe Food Preparation�.
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1. Choose food that is safely processed 2. Cook food properly 3. Eat cooked food immediately 4. Protect food after cooking 5. Reheat cooked food thoroughly 6. Wash hands repeatedly 7. Avoid contact between cooked and raw food 8. Use safe water 9. Keep all working surfaces very clean 10. Protect food from insects, rodents and other animals
RESPONSE Infection Control Precautions
Standard precautions (see Appendix A)
Where patient is in diapers or incontinent – Add Contact precautions (see Appendix A)
Treatment
Only adequate fluid replacement should be used while awaiting laboratory results. A decision on specific therapy, if any, can then be made in consultation with the Provincial Outbreak Response Team (MJOC) or when a specific organism is isolated.
Specimens
5-10g of fresh stool (faeces) in a plastic screwtop container and refrigerate.
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Follow standard packing and shipping procedure (see Appendix C) in less than 2 hours. Otherwise send on Cary-Blair medium. It is important to maintain the cold chain.
Vomitus can be submitted if staphylococcal toxin poisoning is suspected.
Suspected candidate food or water should also be submitted, following the same procedure.
Reporting
Phone the Provincial Outbreak Response Team (MJOC) at 013 7663411 immediately when >10 cases of diarrhoea are suspected to be linked by person, place or time.
Proven food poisoning (outbreaks of more than three persons) is a notifiable condition.
Begin a line-listing of cases (see end of Manual).
Treatment of Contacts
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Where food or drink is implicated, get a complete list of candidate foods (including milk and water supply) and store all foods still available under refrigeration. Enquire about the origin, preparation and storage of suspected food and examine food handlers where indicated. Submit suspected left-over food for laboratory examination.
Antimicrobial prophylaxis is not indicated.
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DYSENTERY OUTBREAKS (>10 cases linked by person, place and time) CASE DEFINITION More than 10 cases of diarrhoea where there is visible blood in the stool, which can be linked by place, person and time.
CONFIRMATION Laboratory identification of organism in stool specimen is necessary to identify the causative organism.
INFORMATION Clinical picture Severity of disease is variable, from asymptomatic to prominent diarrhoea containing blood, pus and mucus. Fever, nausea, vomiting and abdominal cramps may also be present. A variety of other systemic signs/symptoms may also occur depending on the specific agent, like toxic megacolon and haemolytic-uraemic syndrome (Shigella dysenteriae 1), haemolytic-uraemic syndrome (Enterohaemorragic E. coli), arthritis and convulsions (Campylobacter jejuni), and systemic abscesses (amoebiasis).
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Infectious agent Bacteria (certain strains of Escherichia coli, Shigella dysenteriae 1, Campylobacter jejuni) and a protozoan (Entamoeba histolytica).
Reservoir
People – Enteroinvasive E. coli, Shigella species, amoebiasis
Cattle – Enterohaemorragic E. coli, Campylobacter
Domestic pets and poultry – Campylobacter
Transmission Faecal-oral transmission is important, either through direct contact or by contaminated food. Occasionally Entamoeba histolytica is responsible for large water-borne outbreaks and it has also been transmitted by sexual intercourse.
Incubation period From a few hours in Shigella, to many months in amoebiasis but usually days to weeks.
PREVENTION 1. Similar to diarrhoea prevention. As most causes of dysentery require only relatively few organisms to produce disease, strict personal hygiene, particularly of food handlers, is essential. 2. Careful food preparation and storage, and pasteurisation of milk are effective in preventing dysentery caused by Campylobacter.
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Response Infection Control Precautions
Standard precautions (see Appendix A)
Where patient is in diapers or incontinent – Add Contact precautions (see Appendix A)
Treatment
Assess hydration, and adequate fluid replacement should be instituted while awaiting laboratory results. Antibiotic therapy is always indicated in cases of dysentery and the recommended antibiotic is nalidixic acid. Adaptations will depend on the organism responsible for the outbreak and its susceptibility profile, which should be discussed with the Provincial Outbreak Response Team (MJOC).
Nalidixic acid (Adults = 1 g qid for 5 days; children = 15 mg/kg qid for 5 days).
Alternatively for adults and non-pregnant women: Ciprofloxin 500mg bd for 7 days
Amoebic dysentery caused by Entamoeba hystolitica: Metronidazole 800mg every 8 hours for 5 days in acute cases.
Where there is a high fever (>39°C), Paracetamol may be used (10 mg/kg every 4 – 6 hours).
Specimens
5-10g of fresh stool (faeces) in a plastic screwtop container and refrigerate.
Follow standard packing and shipping procedure (see Appendix C). Delays should be limited,
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preferable to less than 2 hours. Otherwise send in Cary-Blair medium. It is important to maintain the cold chain.
Suspected candidate food or water should also be submitted following the same procedure.
Reporting
Phone Provincial Outbreak Response Team (MJOC) at 013 7663411 immediately when >10 cases of dysentery are suspected to be linked by person, place or time.
Begin a line-listing of cases (see end of Manual).
Treatment of Contacts
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Antimicrobial prophylaxis is not indicated.
Risk of dysentery can be reduced by good sanitation and water purification practices (see Appendix B).
Where food or drink is implicated get a complete list of candidate foods (including milk and water supply) and embargo under refrigeration all foods still available. Enquire about the origin, preparation and storage of suspected food and examine food handlers where indicated. Submit suspected left-over food for laboratory examination.
Mpumalanga Outbreak Control Manual
FEBRILE DISEASE WITH NONBLISTERING GENERALIZED SKIN RASH (MEASELS) CASE DEFINITION Febrile disease with non-blistering generalized skin rash.
CONFIRMATION
Laboratory confirmed
Meeting the clinical case definition and linked to a laboratory confirmed case.
or
INFORMATION Measles is the disease targeted for eradication after polio eradication.
Clinical picture A highly contagious infectious disease characterised by the following clinical features:
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a generalised non-blistering maculopapular rash which usually appears on the third to seventh day of illness and which lasts for >3 days. The rash usually starts on the face and spreads to the trunk in the next 2-4 days.
Koplik spots may appear by day 3 on the buccal mucosa.
A temperature of 38.3 degrees Centigrade; and cough, or coryza, or conjunctivitis.
Koplik spots on the buccal mucosa
Malnourished children may develop severe disease, with haemorrhagic rash, protein-losing enteropathy and blindness, and up to 10% of malnourished children will die.
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Infectious agent Measles virus
Reservoir People
Transmission Droplet spread, either air-borne or through contaminated articles.
Incubation period Usually 10 days (ranging from 1 – 3 weeks).
Period of infectiousness From just before the prodrome to 4 days after the appearance of rash. The virus is present in blood, urine, respiratory excretions, conjunctivae, from onset of symptoms until about the 4th day of the rash.
PREVENTION 1. Live attenuated measles vaccine is given IM to all children at 9 and 18 months of age. It is important to protect the vaccine from heat and light. 2. All supplementary activities to increase measles coverage should reach the maximum number of target age-group children. 3. The immunisation status of all children admitted to hospital must be checked in their Road-toHealth Cards and catch-up immunisation offered to those who are not fully immunized
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4. All children admitted to a Hospital or children’s home should receive the 6 months measles dose only in the event of a measles outbreak. Please note that the 6 months measles dose is an additional dose and this does not replace the 9 months routine measles dose. It should ideally be recorded on the Road to Health Card in the clinical note, diagnosis and treatment space and not where the nine-month measles dose is usually recorded, as this could lead to the 9month measles dose then not being recorded as intended. Furthermore, this policy will be applied as temporary measure, only until the outbreak has subsided.
RESPONSE Infection Control Precautions
Standard and Airborne precautions (see Appendix A).
Treatment
Case should be considered highly infectious for 4 days after appearance of rash and preferably isolated, or at least restricted from contact with groups of people.
Patients with complications should be hospitalized and treated accordingly.
A child hospitalised with fever and rash should be isolated on admission. All children between 6 months and 9 years of age, without proof of measles immunisation, should be immunised against measles.
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Vitamin A should be given to each suspected case of measles (<1 year = 100 000 IU Vit A p.o. once, >1 year = 200 000 IU Vit A p.o. once).
Mpumalanga Outbreak Control Manual
Paracetamol may be given for fever and discomfort (10 mg/kg every 4 – 6 hours).
Specimens
Blood should be taken (one red-top tube) if within 30 days of rash onset. This specimen should be refrigerated and standard packing and shipping procedure should be followed (Appendix C), and marked for the National Institute for Communicable Diseases at Tel: 2711-386 6000 Fax: 27-11-882 0596.
Urine (plastic screw-top container) should be collected if within 7 days of rash onset, and refrigerated. Similar packing and shipping procedure should be followed (Appendix C). The specimens will be tested for proof of recent measles or rubella infection.
During an outbreak it is usually only necessary to send specimens from the first 5 – 10 cases of fever and rash.
Reporting
Phone the Provincial Outbreak Response Team (MJOC) at 013 7663411 when a patient meeting the case definition is discovered. Provincial Outbreak Response Team (MJOC) will authorise request for measles IgM and rubella IgM determination in the blood specimen.
Phone the National Institute for Communicable Diseases at Tel: 27-11-386 6000 Fax: 27-11-882 0596 and let the virologist on call know that the specimen has been sent.
Complete the official Measles Line-listing Form for suspected outbreaks of measles and fax to 013 7663473.
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A confirmed measles case should be notified on an official notification form.
Treatment of Contacts
Where deemed necessary by the Provincial EPI Coordinator, on epidemiological grounds, a focused campaign of measles immunisation may be conducted in an affected area. The agegroup targeted will depend on the scale of the outbreak, the age-group affected and the immunisation status of local children. A single dose of measles vaccine will be given to the target group, irrespective of immunisation status.
Any measles outbreak should be used as an opportunity to promote catch-up immunisation of unimmunised children in the affected district.
Measles
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No the similarities between this Roseola rash and measles
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Postauricular lymph nodes in Rubella
Rubella
Typical
Scarlet fever strawberry tongue
scarlet fever rash
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FEBRILE DISEASE WITH SUPPURATIVE LYMPHADENOPATHY (PLAGUE) CASE DEFINITION Febrile disease with suppurative lymphadenopathy.
CONFIRMATION 1. The clinical case definition is met and the plague bacillus, Yersinia pestis is cultured from bubo aspirate or 2. A person presents with a septicaemia or 3. pneumonia and the plague bacillus is cultured from blood, CSF or sputum.
INFORMATION Clinical picture Plague usually presents as a febrile disease with regional lymphadenitis (bubonic plague), particularly of the inguinal area. It may however present as a septicaemia without an evident bubo (septicaemic plague), or as plague pneumonia, resulting from haematogenous spread in bubonic or septicaemic cases (secondary plague pneumonia) or inhalation of infectious droplets (primary plague pneumonia).
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A more uncommon presentation is pharyngeal plague where there is pharyngitis and cervical lymphadenitis resulting from exposure to larger infectious droplets or ingestion of infected tissue.
Note bubo in armpit of patient with plague
Infectious agent Yersinia pestis bacteria
Reservoir Wild rodents
Transmission Plague is transmitted to humans by infected fleas or by direct exposure to infected tissue or respiratory droplets from pneumonic plague cases.
Incubation period 2 â&#x20AC;&#x201C; 6 days but as short as one day with pneumonic plague.
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PREVENTION 1. Rodent control should be practiced near human habitation, including proper storage and disposal of food, garbage and refuse. 2. Prevent direct contact with wild rodents and immediately report large-scale rodent deaths to the National Institute for Communicable Diseases at Tel: 27-11-386 6000 Fax: 27-11-882 0596. 3. Periodic surveys of wild rodents and dogs for plague markers by suitably trained and equipped teams.
RESPONSE Infection Control Precautions 1. Bubonic plague - Standard precautions (see Appendix A). 2. Plague pneumonia - Standard and Droplet precautions (see Appendix A).
Treatment
Hospitalise as soon as possible.
Begin treatment immediately after sending blood specimens.
Intramuscular streptomycin (30mg/kg per day) for ten days. This may be modified when sensitivity results are available.
Specimens
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One tube of clotted blood – for serology (antiplague IgM & IgG).
Blood culture bottles – for culture and sensitivity.
Mpumalanga Outbreak Control Manual
When an aspirate is taken from a bubo (affected lymph gland) be very careful, using a mask and gloves, and carefully inject aspirate into a sterile screw-top plastic container. Follow standard packing and shipping procedure (Appendix C), and carefully mark “suspected plague” and send to SAIMR/NHLS laboratory. As sputum collection is dangerous in cases of plague pneumonia, the patient should be advised how to produce sputum and the health worker should leave while the patient produces sputum.
Reporting
Phone the Provincial Outbreak Response Team (MJOC) at 013 7663411 immediately to report all cases of febrile disease with suppurative lymphadenopathy or laboratory proven cases of bubonic, septicaemic or pneumonic plague.
Phone SAIMR/NHLS laboratory to alert them that specimens have been sent.
Laboratory proven plague in humans is a statutory notifiable condition.
Treatment of Contacts
Close contacts of patients with proven plague should be provided with chemoprophylaxis and placed under active surveillance for 6 days after last contact. Doxycycline (100 mg daily) is the usual prophylaxis for the duration of exposure. This is of particular importance for close contacts of patients with pneumonic plague (household members, kissing contacts, medical and field personnel).
Prophylaxis for children under 9 years or pregnant women should be discussed with the Provincial Outbreak Response Team. Mpumalanga Outbreak Control Manual
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H5N1 AVIAN INFLUENZA (BIRD FLU) CASE DEFINITION Patients meeting the following criteria should be considered for diagnostic testing: NOTE: the clinical features of human infection with avian influenza are non-specific and each individual must meet both clinical AND epidemiological criteria (see below).
Any individual with: Criteria A PLUS Criteria B OR Criteria A PLUS Criteria C
Criteria A - Clinical criteria Clinical signs and symptoms specifically suggestive of avian influenza (H5N1) infection in humans: Fever ≥380C and ≥1 of the following:
Symptoms/signs of lower respiratory tract infection including viral pneumonia
Watery diarrhoea, vomiting, abdominal pain
AND
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Criteria B - Epidemiological risk factors - travel
History of travel within 8 days prior to onset of symptoms to an area currently affected by avian influenza (H5N1): AND
Had close contact (within 1 meter) with live or dead domestic fowl, wild birds or pigs in any environment including poultry markets OR
has been in close contact (touching/speaking distance) with a case of severe respiratory illness/unexplained death in one of the affected areas.
OR Meets Criteria A AND at least ONE of the following:
Criteria C - Epidemiological risk factors - local
Individual is a health care worker who has treated the above or is part of a cluster of unexplained respiratory illness
Individual is a laboratory worker who has potential exposure to influenza A (H5N1)
Individual is working in a veterinary/agriculture team that is directly involved in conducting surveillance for avian influenza in birds
CONFIRMATION
Laboratory confirmation
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or
Meets the clinical case definition and is linked to a laboratory confirmed case
INFORMATION Clinical picture in humans
Fever, cough, sore throat and muscle pains
Eye infections and pneumonia,
Severe breathing problems and other life-threatening diseases
Fever, cough, sore throat and muscle pains are common symptoms of other infections, so confirmation must be sought from the local health facility
Infectious agent H5N1 subtype (avian influenza)
Reservoir Wild waterfowl are considered the natural Ventilation of a 15-month-old girl with avian influenza reservoir of all influenza A viruses. Considerable circumstantial evidence suggests that migratory birds can introduce low pathogenic H5 and H7 viruses to poultry flocks, which then mutate to the highly pathogenic form.
Transmission
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Through direct contact with infected poultry (chickens, ducks, turkeys)
Through surfaces contaminated with secretions and droppings from infected birds Mpumalanga Outbreak Control Manual
Incubation period Current data for H5N1 infection indicate an incubation period ranging from two to eight days and possibly as long as 17 days.
Period of infectiousness 3-7 days
PREVENTION
Always wash hands with soap and water or ash before and after handling food
Avoid close contact with birds
Poultry must not be brought indoors
If birds must be kept indoors, keep them away from where the family eats and sleeps
Keep children away from poultry and all birds, and from collecting eggs.
Children must be told to always wash their hands before eating.
Children must report all sick or dead birds seen to adults immediately
Avoid contact with pet birds unless they are always kept indoors
Wash or disinfect shoes, clothes and the wheels of bicycles after visiting farms or poultry markets, especially before going indoors
If a person feels sick after touching sick or dead birds, contact the nearest health post immediately
If it is suspected that someone in the family may have contacted the disease, the person must be taken to the nearest health post.
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If the Bird Flu is confirmed or suspected in the area, avoid going to gatherings as people may spread the disease even before they feel sick
Many families in Mpumalanga keep domestic chickens and other birds. Many people also buy live chickens from the market. Potentially, therefore, everyone is at risk. People must observe good hygiene practices like always washing hands with soap and water after touching birds
RESPONSE Infection Control Precautions
Standard, airborne and droplet precautions (see Appendix A).
Treatment Antiviral therapy. Contact Provincial Communicable Diseases Control Program for recommended treatment.
Specimens All cases meeting the case definition must be discussed with the National Institute for Communicable Diseases prior to submission of specimens
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A swab collected from each nostril, and a throat swab pooled into the same container of viral transport medium is the specimen of choice.
These specimens are suitable for testing by polymerase chain reaction (PCR) which is a rapid, sensitive laboratory test.
An acute-phase serum specimen (7-10 ml of whole blood) should be taken soon after onset of clinical symptoms and not later than seven days after onset.
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A convalescent-phase serum specimen should be collected 14 days after the onset of symptoms.
Where patients are near death, a second antemortem specimen should be collected even if 14 days have not elapsed.
Throat, nasal, nasopharyngeal swabs or aspirates should be placed in a vial of virus transport medium.
The virus transport medium should be stored and transported at 4°C.
Blood should be collected in the usual manner for serum samples, transported at 4°C and delivered promptly to the laboratory.
Reporting
When a case meets the case definition criteria it should be reported to the Provincial Outbreak Response Team (MJOC) at 013 7663411 immediately.
Treatment of Contacts Contact the Communicable Diseases Control manager at 013 7663411 for recommendations.
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HAEMORRHAGIC FEVER (VIRAL HAEMORRHAGIC FEVER) CASE DEFINITION Acute onset of febrile disease with hemorrhaging into skin, mucosa or internal organs.
CONFIRMATION ď&#x201A;ˇ
A clinically compatible illness is supported by serology (a rising anti-body titre is demonstrated on paired sera or a positive IgM anti-body test is found); or
ď&#x201A;ˇ
Virus is isolated in the laboratory.
INFORMATION Clinical picture An acute febrile illness characterized by severe headache, muscle and joint pain, petechial rash and haemorrhagic signs, like nose bleeds, vomiting blood or blood in stools. In Lassa Fever there is often accompanying tinnitus and early sore throat with a white exudate and ulceration. CongoCrimean Fever is distinguished by prominent early nausea and vomiting, and prominent bleeding from needle puncture sites or large confluent ecchymoses under the skin. Marburg and Ebola Fever are both accompanied by early profuse watery diarrhoea, and by a high mortality rate from profound haemorrhage and myocarditis. Rift Valley Fever is most often
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a milder disease with an influenza-like illness or loss of visual acuity but it can be fatal in older people, and those with underlying liver disease. Other infectious (like malaria, meningococcal septicaemia) and non-infectious (drug reactions) diseases may mimic VHF.
Infectious agent Lassa, Congo-Crimean, Marburg, Ebola and Rift Valley Fever Viruses.
Reservoir
Lassa – rodents especially multi-mammate mouse
Congo-Crimean – small mammals, like hares, and livestock (sheep and cattle)
Marburg and Ebola – unknown
Rift Valley – sheep and cattle
Transmission
Lassa – Contamination of food and dust by urine of rodent reservoir; direct contact with the infected body fluids or tissue of patients.
Congo-Crimean – Bite of infected bont-legged tick (Hyalomma spp.) or exposure to the infected tissue, blood and secretions of livestock or patients.
Marburg and Ebola – Primary transmission is still unknown but secondary transmission from the body fluids and tissue of infected patients is well described and there may be prolonged excretion in body fluids eg. semen, tears.
Rift Valley – By exposure to infected tissue during large outbreaks in livestock or by bites of infected mosquitoes.
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Incubation period From as short as 2 days to 3 weeks.
Period of infectiousness Primarily during stage of clinical illness, but may be prolonged in body fluids, particularly in Marburg infection.
PREVENTION
Avoid exposure to animals and arthropod vectors in areas where they play a role in transmission. In South Africa, especially in the Free State and Northern Cape (Congo-Crimean fever).
Agricultural produce should be protected from contamination by rodent excreta and rodent control measures should be strictly implemented.
Barrier nursing of suspected and proven cases.
RESPONSE Infection Control Precautions
Standard and Contact precautions (see Appendix A).
Treatment
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Hospitalise and isolate suspected case as soon as possible.
Always consider more common reasons for this syndrome, like meningococcal septicaemia, malaria, typhoid fever and tick bite fever.
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Specimens
One tube of EDTA blood (purple top)
One full tube of clotted blood (red top) – for serology
Blood culture bottles – for culture (3 aerobic and 3 anaerobic)
Where a patient with suspected VHF has died prior to diagnosis, a liver biopsy may be submitted to the National Institute for Communicable Diseases at Tel: 27-11-386 6000 Fax: 27-11-882 0596
Carefully adhere to standard packing and shipping procedure (see Appendix C).
Reporting
Phone Provincial Outbreak Response Team (MJOC) at 013 7663411 immediately to report any suspected case of haemorrhagic fever.
Phone National Institute for Communicable Diseases at Tel: 27-11-386 6000 Fax: 27-11-882 0596 to let the virologist-on-call know that the specimens have been sent.
Complete an official notification form for all cases of laboratory proven viral haemorrhagic fever.
Treatment of Contacts
Active surveillance for at least 10 days of all close contacts of haemorrhagic cases, especially for fever.
When cases of Ebola/Marburg Fever survive, sexual intercourse should be restricted until semen has been demonstrated to be free of
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virus. This can take up to 6 months in certain cases.
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Haemorrhagic fever with jaundice (yellow fever) CASE DEFINITION A viral haemorrhagic fever picture accompanied by jaundice.
CONFIRMATION ď&#x201A;ˇ
Laboratory isolation of virus
or ď&#x201A;ˇ
Demonstration of viral antigen in the blood.
INFORMATION Clinical picture An acute febrile illness characterized by severe headache, muscle pain, chills, nausea and vomiting of variable severity. Often the pulse is slow in spite of high fever. Classically fever disappears for a few days and then recurs. It may then be accompanied by haemorrhagic signs like melena, epistaxis and ground-coffee coloured vomit. Jaundice gets more intense with time. During an epidemic 50% of cases may die.
Infectious agent Yellow fever virus
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Reservoir Aedes mosquitoes
Transmission By the bite of infected mosquitoes
Incubation period 3 – 6 days
Period of infectiousness Patient’s blood is infective to mosquitoes for the first few days of the illness and once infected, mosquitoes remain infective for life.
PREVENTION 1. All South Africans visiting areas where yellow fever is endemic should be vaccinated subcutaneously with the 17D Yellow Fever vaccine at least 10 days before departure. A Yellow Fever certificate is valid for 10 years. Children can be immunised from 9 months of age or older. 2. Visitors to South Africa from endemic zones should have a valid Yellow Fever certificate.
RESPONSE Infection Control Precautions
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Standard and Contact precautions (see Appendix A).
In addition, room should be screened against mosquitoes and a knock-down insecticide used.
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Treatment
Hospitalise as soon as possible.
Always consider other causes of this syndrome like; viral hepatitis, malaria, Gram negative septicaemia, typhoid fever.
Specimens
One tube of EDTA blood (purple top).
One full tube of clotted blood (red top) - for serology.
Blood culture bottles – culture (3 aerobic and 3 anearobic).
Carefully follow standard packing and shipping procedure (Appendix C).
Reporting
Phone Provincial Outbreak Response Team (MJOC) at 013 7663411 immediately to report any case of haemorrhagic fever with jaundice.
Phone National Institute for Communicable Diseases at Tel: 27-11-386 6000 Fax: 27-11-882 0596 to let the virologist know that the specimen has been sent.
All cases of yellow fever (laboratory confirmed) should be notified on an official notification form.
Treatment of Contacts
Inquire about all places visited by patient in the 3 – 6 days prior to onset of disease.
Where outbreaks affecting more than one individual occur, targeted yellow fever vaccination campaigns may be considered, in
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consultation with the Provincial Outbreak Response Team
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MENINGOCOCCAL MENINGITIS CASE DEFINITION Sudden onset of febrile disease with intense headache and/or stiff neck, with or without a petechial rash.
CONFIRMATION
When there is a positive antigen test or culture of Neisseria meningitidis from cerebrospinal fluid (CSF)
Clinical fulminant disease is confirmed on blood culture
Gram negative diplococci are present in serum from skin lesions.
or
or
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INFORMATION Clinical picture Acute disease with fever, nausea, vomiting, intense headache and stiff neck. Often there is a petechial rash which may blister. Progression to coma and shock may be rapid. Some infections are asymptomatic or present as a respiratory / pneumonic picture. Occasionally there is only a septicaemia with petechia. If untreated, 50% of cases die. With prompt diagnosis and therapy less than 10% will die although permanent neurological damage is common.
Menigococcal septicemia
Infectious agent Neisseria meningitidis bacteria. The groups that cause disease are A, B, C, W135, X & Y.
Reservoir People, asymptomatic nasal carriers are common.
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Transmission Respiratory droplets
Incubation period 3 – 5 days (ranging from 1 – 10 days)
Period of infectiousness The bacteria remain in the nasal and pharyngeal discharges for an extended period unless treated with appropriate antibiotics.
PREVENTION Overcrowding of young people and children in schools, barracks and colleges should be reduced.
RESPONSE Infection Control Precautions
Standard and Droplet precautions (see Appendix A).
Strict Droplet precautions for at least 24 hours after starting adequate intravenous treatment with Penicillin.
Treatment
Do not wait for the results of the lumbar puncture before beginning antibiotic therapy (Penicillin 4 million units every four hours i.v. for adults). This may be adapted following
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sensitivity results. Where resistance has previously been demonstrated in an area, treatment should be initiated with Ceftriaxone (4g/day in 12 hourly doses).
Hospitalise and isolate all suspected cases as soon as possible.
Patients treated with penicillin during hospitalisation should receive the prophylactic treatment as specified (under contacts) on hospital discharge to eradicate the organism from the nasopharynx.
Specimens
All patients meeting the clinical description should immediately have a lumber puncture (CSF) performed by careful aseptic technique after excluding signs of increased intracranial pressure by performing either a CT scan or fundoscopy.
Blood cultures (3 aerobic and 3 anaerobic bottles).
CSF and blood cultures from all proven cases should be submitted to SAIMR/NHLS for typing – clearly marked meningococcal disease (see Appendix C).
Reporting
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Phone the Provincial Outbreak Response Team (MJOC) at 013 7663411 immediately to report any case
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meeting the case definition or where gram negative diplococci are seen in CSF or any laboratory proven case of Neisseria meningitidis meningitis or septicaemia.
All laboratory proven cases of meningococcal disease should be notified on the official notification form.
Treatment of Contacts
Close surveillance of household and other intimate contacts, particularly for the onset of fever.
Close contacts are treated with chemoprophylactic antibiotics Examples of close contacts are:
o
Household contacts
o
People in hostels sharing the same sleeping space
o
Persons sharing the same eating utensils
o
Close friends at school but not the whole class
o
All the children in a day care center class of the index case
o
Health personnel who came into contact with nasopharyngeal secretions of the patient eg. mouth-to-mouth resuscitation.
Ciprofloxacin treatment is given to all close contacts (> 18 years of age and non-pregnant women) 500 mg po stat or alternatively Ceftriaxone may be used for close contacts and
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pregnant women (250mg im stat-adults; 125mg im stat-children)
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Rifampicin may be used as an alternative to the above treatment regimes (for adults – 600 mg b.d. p.o. for two days, for children >one month – 10mg/kg and for children <one month – 5mg/kg) and for all confirmed meningococcal patients before discharge.
On rare occasions, particularly outbreaks in highly congested environments or with particularly virulent strains, the Provincial Outbreak Response Team may decide to initiate a targeted immunisation campaign with meningococcal vaccine.
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PROFUSE WATERY DIARRHOEA (CHOLERA) CASE DEFINITION Sudden onset of profuse painless watery stools with rapid dehydration in a person 5 years of age or older.
CONFIRMATION
Vibrio cholerae is cultured from a stool sample
or
Meets the clinical case definition and is linked to a laboratory confirmed case.
INFORMATION Clinical picture Most cases (up to 80%) are asymptomatic or have mild diarrhoea. In severe cases there is acute onset of profuse painless diarrhoea (rice water stools), occasional vomiting, rapid dehydration and circulatory collapse. Patients may lose up to 30 liters of fluid per day in stools. Severe cases can develop symptoms of shock within 2
Rice water stools
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hours. Where severe cases are incorrectly treated more than half may die, usually within a few hours. For every 1 symptomatic case there are 40 asymptomatic cases/carriers in the community. The asymptomatic carriers can test positive for cholera for a few weeks after contracting the infection.
Washer Woman Hand sign in dehydration due to Cholera
Infectious agent Vibrio cholerae 01 (two types, either Classical or EI Tor) and 0139 release a powerful toxin after binding to the gut wall that stimulates the release of large volumes of water. A high infective dose is necessary for severe clinical disease. Vibrio cholerae non-01 has been associated with sporadic cases and small outbreaks of gastroenteritis.
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Reservoir V. cholerae is an environmental bacteria found in water bodies at low numbers with amplification in humans during epidemics. Shellfish may serve as reservoirs.
Transmission Ingestion of water contaminated with faeces or vomit from patients or carriers. Occasionally food contaminated by faeces, transferred by hands or flies, is the source.
Incubation period Usually 2 â&#x20AC;&#x201C; 3 days (from hours to a week).
Period of infectiousness Usually only while diarrhoea lasts and for a few days after symptoms cease, but occasionally for a couple of months (carriers)
PREVENTION 1. Health education should stress the use of safe water for domestic purposes (drinking, cooking, and washing hands and eating utensils). Tap water that is laboratory monitored is usually safe. Where there is doubt about water quality it should be boiled (rolling boil for 3 minutes) or chlorinated (5ml of bleach (JIK) in 20 litres of water that has at least been filtered through a clean cloth), well mixed and then allowed to stand for 20 minutes before use. Protect this water from contamination. 2. Hand-washing is important especially by foodhandlers, and those caring for patients and young children.
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3. Sanitary faeces disposal in fly proof latrines is important to prevent contamination of the environment. Sufficient toilet paper should be available to prevent contamination of fingers. 4. Fly breeding should be prevented by regular refuse disposal and improved sanitation. 5. Boil all shellfish for at least 10 minutes before serving.
RESPONSE Infection Control Precautions
Standard precautions (see Appendix A).
Where patient is in diapers or incontinent, add Contact precautions (see Appendix A).
Treatment
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Admit patient to a treatment centre, where possible.
Immediate rehydration. Eighty to ninety percent of patients can be successfully treated by oral rehydration (8 teaspoons of sugar and ½ teaspoon of salt in 1 liter of safe water. If dehydration is more severe, intravenous fluids should be administered (<12 years = Half Darrows with 5% glucose; ≥12 years of age = Ringers lactate).
Ensure that all lost fluids are replaced either orally or intravenously to prevent dehydration
Antibiotics are not routinely prescribed for the treatment of cholera.
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Specimens
A freshly – passed stool (less than 2 hours old) should be collected in a screw-top bottle.
Standard packing and shipping procedure must be followed (see Appendix C).
Specimen should preferably reach the laboratory within 2 hours, otherwise alkaline peptone water (2-7 hours) or Cary-Blair transport medium should be used if delay of more than 7 hours is expected.
Reporting
Symptoms corresponding to the case definition should be reported to the Provincial Outbreak Response Team (MJOC) at 013 7663411 immediately or a case of profuse watery diarrhoea where Vibrio cholerae has been isolated by the laboratory.
Begin a line-listing of cases (see end of Manual).
Confirmed cases of cholera should be notified on an official notification form.
Treatment of Contacts
The affected community can markedly reduce their risk of infection by good sanitation and water purification practices (see Appendix B).
Vaccination is not recommended as it is not effective in controlling cholera.
Mass chemoprophlaxis is ineffective in controlling the spread of cholera.
Close contacts of a proven case should be placed under active surveillance for 5 days for development of diarrhoea.
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RABIES INFORMATION Clinical picture
Non specific prodromal features (1-4 days) o
Fever, headache, malaise
o
Intense pruritis, paraesthesia or pain around bite site
o
Neuro psychiatric symptoms/irritability/anxiety
Neurological signs and behaviour symptoms (1-6 days) o
Paralysis /dysphagia
o
Hallucinations
o
Hydrophobia / hypersalivation / dysarthria
o
Manic behaviour
o
Generalised convulsions
Death imminent after 5-10 days
Infectious agent
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o
RNA virus
o
Genus: Lyssavirus
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Major Vectors Limpopo
Black-backed jackal
KZN
Dogs
Mpumalanga
Dogs
Yellow mongoose
Northern Cape
Bat eared fox
Yellow mongoose
North West, Free State and Gauteng Provinces
Yellow mongoose
Transmission
Transmitted through saliva
Wounds caused by bites
Contamination of mucous membranes o
Mouth
o
Eyes
o
Nasal passage
Aerosol transmission (described in laboratory workers and humans visiting bat caves)
The virus cannot be transmitted by eating the meat of a rabid animal
The virus does NOT penetrate intact skin
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Incubation Period
9 days to 19 years in one instance
Only 14% are longer than 90 days
Average 20-60 days in South Africa
Factors affecting incubation period:
Bite site (close proximity to the brain)
Depth or severity of bites with higher viral introduction
Direct introduction into neural tissue
Pathogenisis
Local viral proliferation in non neural tissue at site of entry
Followed by viral attachment to nerve cell receptors and entry into peripheral nerve endings.
Virus then transported along afferent axons eventually reaching the CNS
Followed by widespread distribution of the virus throughout the brain and spinal cord
Period of Infectiousness In dogs and cats, usually for 3-7 days before onset of clinical signs (rarely over 4 days) and throughout the course of the disease.
PREVENTION Avoid contact with animals that display sudden unusual behavior with neurological symptoms and signs. Usually tame animals become wild and wild animals become tame.
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When encountering such an animal, contact the State veterinarian or closest veterinarian facility to report the animal. Occupational risk e.g. veterinary staff can be immunized with initial 3 doses of vaccine.
Day 0, 7, 28
Boosters every 1 to 3 years
CONFIRMATION
History of exposure
Clinical signs suggestive of rabies
Laboratory confirmation
Hydrophobia due to inability to swallow
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RESPONSE Treatment
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A. ANIMAL ASSESSMENT The following aspects must be considered: 1. Vaccination: tangible proof of current rabies vaccination status (dog or cat) must be obtained. 2. Behavioral changes: all aspects must be considered 3. Possible exposure: any known incident during the previous few months 4. Rabies endemicity: entire RSA is rabies endemic but current incidence and prevalence are important 5. Provocation: was the animalâ&#x20AC;&#x2122;s reaction due to provocation? 6. Stray (unsupervised animals): this history may be unreliable B. CATEGORIES OF RABIES EXPOSURE Risk Cat.
Type of Exposure
Action to be Taken
1
Touching/feeding animal Licking of intact skin
Note if case history is reliable If history is not reliable, treat as for Category 2
2
Touching/feeding animal Licking of broken skin
Apply wound treatment Administer vaccine Do not administer anti-rabies immunoglobulin Stop vaccination if animal is rabies negative on laboratory test or remains healthy after 10 days of observation
3
Bites/scratches which penetrate the skin and draw blood Licking of mucus membranes
Apply wound treatment Administer vaccine Administer anti-rabies immunoglobulin Stop vaccination if animal is rabies negative on laboratory test or remains healthy after 10 days of observation
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C. WOUND TREATMENT 1. Wash wound thoroughly under running water with soap, or saline or chlorhexidine, or cetrimide, for 5 minutes 2. Apply disinfectant, e.g. Betadine or aqueous iodine (Zepharin) 3. Do not suture or apply compressive bandages 4. Administer anti-tetanus treatment and antibiotics if necessary D. ANTIRABIES TREATMENT (CATEGORY 3) 1. Unimmunised patient: inject single dose vaccine into deltoid muscle on days 0, 3, 7, 14 and 28. Infiltrate immunoglobulin (20 IU/kg) on day 0 into and around wound, with remainder into the other deltoid muscle. 2. Previously immunised patient: inject single dose vaccine into deltoid muscle on days 0 and 3
Infection Control Precautions Standard and Droplet precautions (see Appendix A).
Specimens Laboratory confirmation
No vireamia –cannot detect virus in blood o
Antibodies in CSF means active disease
o
Nuchal skin biopsy
Corneal impressions
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Refrigerate skin biopsies without preservatives.
Require only air drying
CSF PCR
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Corneal impressions False negative results are common
Reporting ď&#x201A;ˇ
Suspicious and confirmed rabid animals should be reported to the State Veterinarian immediately.
ď&#x201A;ˇ
Incidents where people have been in contact with a suspected rabid animal should be reported to the Provincial Outbreak Response Team (MJOC) at 013 7663411 immediately. Mpumalanga Outbreak Control Manual
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ď&#x201A;ˇ
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Treatment should commence immediately.
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SYSTEMIC FEBRILE DISEASE (>10 cases linked by person, place and time) A large variety of other infectious agents may cause epidemics of acute or sub-acute febrile disease. Fever may be accompanied by non-specific signs like rigors (e.g. malaria, influenza, septicaemia) or organ-specific signs like jaundice (e.g. hepatitis A and E, leptospirosis), respiratory signs (e.g. Legionnaires disease, influenza), central nervous system signs (e.g. viral encephalitis, typhoid), arthritis (e.g. arboviruses) or skin manifestations (typhus, relapsing fever, monkey-pox). Recently many new agents have been described as the cause of outbreaks (e.g. Lyme disease, Legionella pneumophila, Hanta virus). This trend will continue and may become more common. Large-scale global travel and climatic changes are resulting in extension of the distribution of many diseases. It is therefore essential that all health workers remain on the alert for clusters of systemic febrile disease. Where outbreaks of >10 cases of febrile disease, prove to be due to any of the under-mentioned notifiable conditions, or where other advice is needed, phone the Provincial Outbreak Response Team (MJOC) at 013 7663411 to report the incident.
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CONDITIONS REQUIRING REPORTING AND RESPONSE WITHIN 24 HOURS OF POSITIVE LABORATORY RESULTS
Anthrax
Diphtheria
Hepatitis A and E
Legionellosis
Typhoid fever
Whooping cough
ANTHRAX An illness with acute onset characterised by several distinct clinical forms including:
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Cutaneous (a skin lesion evolving over 2 to 6 days from a papule, through a vesicular stage, to a depressed black eschar).
Inhalation (a brief prodrome resembling a viral respiratory illness followed by development of
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hypoxia and dyspnea, with x-ray evidence of mediastinal widening). ď&#x201A;ˇ
Intestinal (severe abdominal distress followed by fever and signs of septicaemia).
ď&#x201A;ˇ
Oropharyngeal (mucosal lesion in the oral cavity or oropharynx, cervical adenopathy and edema, and fever).
Confirmation A clinically compatible illness that is laboratory confirmed.
DIPHTHERIA An upper respiratory tract illness characterised by sore throat, low-grade fever, and an adherent membrane on the tonsil (s), pharynx, and/or nasal mucosa, and occasional cardiac or neurological signs, without other apparent cause. Confirmation The clinical case definition is met and the disease is either laboratory confirmed or linked to a laboratory-confirmed case.
HEPATITIS, VIRAL A and E An illness with acute onset of symptoms and jaundice or elevated serum aminotransferase levels. Confirmation A case that meets the clinical case definition and is laboratory confirmed.
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Treatment of Hepatitis A contacts: Hepatitis A Viral vaccine should be used for preventing secondary cases and outbreaks provided that:
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Patients Jaundice due to Hepatitis A are informed that vaccine should be given as close to the time of exposure as possible and the latest time that the vaccine is likely to be effective in preventing disease is probably 7 days from onset of disease in the primary case. Use of vaccine after this time may be considered to prevent tertiary infections.
Specimens from suspected cases are collected, processed and reported urgently.
Arrangements are in place for early reporting by microbiologists of IgM confirmed cases of acute HAV infection to the Provincial Communicable Disease Control Program.
Same- or next-day vaccination is given to family and household contacts considered at risk from exposure to the primary case.
The patient information leaflet included with HAV vaccine is given to each recipient and/or parent so that they are informed about the advantages and disadvantages of vaccine.
Arrangements are in place for surveillance of secondary cases and vaccine failures so that the policy and practice can be properly audited.
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Human Normal Immunoglobulin (HNIG) should be offered in addition or in preference to vaccine if the following applies:
The exposed person is at particular risk of adverse outcome of HAV infection, e.g. is more than 50 years old, has liver cirrhosis, or has pre-existing Hepatitis B or C virus infection.
To protect close contacts who are identified too late to be protected by vaccine (8 days or more from exposure).
The window of opportunity for HNIG to prevent a secondary case is 14 days post-exposure, but HNIG may modify disease severity if given after 14 days. In general it is probably not worth considering much after 28 days from exposure.
The patient information leaflet included with HNIG has been given to the person to ensure they are informed about the advantages and disadvantages of HNIG.
LEGIONELLOSIS (LEGIONNAIRE’S DISEASE) An illness with acute onset, commonly characterised by fever, cough and pneumonia that is confirmed by chest radiograph. Encephalopathy and diarrhoea may also be present. Confirmation A case that is laboratory confirmed.
PERTUSSIS A coughing illness lasting at least 2 weeks with one of the following: paroxysms of coughing, inspiratory “whoop”, or post-tussive vomiting – and without other apparent cause. Confirmation
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A clinically compatible case that is laboratory confirmed or linked to a laboratoryâ&#x20AC;&#x201C;confirmed case.
TYPHOID FEVER CASE DEFINITION Confirmed case A patient with fever (38 C and above) that has lasted for at least 3 days, with a laboratory confirmed positive culture (blood, bone marrow, bowel fluid) of S. typhi Probable case of typhoid fever A patient with fever (38 C and above) that has lasted for at least three days, with a positive sero-diagnosis or antigen detection test but without S. typhi isolation
CONFIRMATION ď&#x201A;ˇ
Salmonella typhi is cultured from blood, stool, urine or bone marrow
INFORMATION Clinical picture Usually insidious onset of fever, severe headache, malaise, loss of appetite, an enlarged spleen, non-productive cough and gastro-intestinal upset, more commonly constipation than diarrhoea. Often the pulse is unusually slow when compared to what would be expected with the fever (relative bradycardia). Mild and atypical infections may occur, but, if disease is not treated, it progresses and may result in perforation of the ileum with an acute abdomen or progressive neurological disease and death. With correct treatment the fatality rate can be reduced from 20% to < 1%. Occasionally, after treatment, relapses occur.
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Rose spots on the trunk of a typhoid patient Infectious agent Salmonella typhi. Reservoir The reservoir is humans. Some people become chronic carriers with intermittent excretion of bacteria in faeces and less often urine. Carriers frequently have biliary tract abnormalities including gallstones. The chronic urinary carrier state occurs in those with schistosome (bilharzia) infections. Transmission Transmission occurs through food and water contaminated by the faeces or urine of patients and carriers. Contaminated shellfish, raw vegetables or fruit, and milk have all caused outbreaks. Food-handlers who are carriers of typhoid bacteria pose a major risk in the transmission of the disease. Flies can also transmit bacteria from faeces onto food.
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Incubation period From 3-30 days, usually 8-14 days. Period of infectiousness Usually from the first week throughout convalescence. About 10% of untreated typhoid fever patients will discharge typhoid bacteria for 3 months after onset of symptoms. Up to 5% of infected people may become chronic carriers.
PREVENTION 1. Routine administration of Typhoid vaccines is of limited value. 2. Special circumstances exist where it can be considered. 3. Health education should stress the use of safe water for domestic purposes (drinking, cooking, and washing hands and eating utensils). Tap water that is laboratory monitored is usually safe. Where there is doubt about water quality it should be boiled (rolling boil for 3 minutes) or chlorinated (5ml of bleach (JIK) in 20 litres of water that has at least been filtered through a clean cloth), well mixed and then allowed to stand for 20 minutes before use. Protect this water from contamination. 4. Hand-washing is important especially by foodhandlers, and those caring for patients and young children. 5. Sanitary faeces disposal in fly proof latrines is important to prevent contamination of the environment. Sufficient toilet paper should be available to prevent contamination of fingers. 6. Fly breeding should be prevented by regular refuse disposal and improved sanitation.
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7. Boil all shellfish for at least 10 minutes before serving.
RESPONSE Infection Control Precautions
Standard precautions (see Appendix A).
Where patient is in diapers or incontinent, add Contact precautions (see Appendix A).
Treatment All suspected cases of typhoid should be hospitalised as soon as possible. Assess hydration, and institute adequate fluid replacement. Ciprofloxacin have several advantages and would be the drug of choice for treatment of ALL non-pregnant individuals Drug of choice in all age groups – uncomplicated disease
Drug of choice in all age groups with complicated disease (septic shock, acidosis) or patients who are vomiting
Oral ciprofloxacin for 7 days
Ceftriaxone for 7 days
Paediatric cases: 15mg/kg/day given in 2 divided doses
Paediatric cases: 50-75mg/kg/day given in 1-2 divided doses
Adults 500-750mg BD
Adult dose: 2-4g daily (up to 2g BD in severe disease)
In pregnancy:
Alternative:
Ceftriaxone for 7 days
Adults: ciprofloxacin 400mg 12hrly ivi
Adult dose: 2-4g daily (up to 2g BD in severe disease) Alternative: Amoxicillin for 14 days 75-100mg/kg/day usually given in 3 divided doses
Once patients have clinically improved, treatment can be completed with oral ciprofloxacin
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Where there is a high fever (>39°C), paracetamol may be used (10 mg/kg every 4 – 6 hours). Management of carriers
Up to 5% of typhoid cases may become chronic carriers
Treat Bilharzia
Ciprobay 750mg bd po for 28 days (80% clearance)
Amoxil 23mg/kg for children po per day for 6 weeks
Bactrim 160 to 800mg bd po for 6 weeks
When discharged
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Three negative stool cultures (and urine in patients with Bilharzia) 24 hours apart 48 hrs after antimicrobials
If any of these are positive
Repeat cultures at intervals of one month as above (3 negative stool cultures)Specimens
Avoid doing typhoid serology testing (WIDAL) due to false positive results
During acute illness blood cultures should be performed on patients to confirm the diagnosis.
Alternatively stool samples may yield a positive result from week 2-3 of illness.
Stool specimens should immediately be sent to the laboratory in appropriate containers, while blood should be sent to the laboratory in blood culture bottles.
Refrigerate 5-10g of fresh stool in a plastic screw top container and send to the laboratory for typhoid investigation.
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Follow stated packing and shipping procedure
If stool specimen transport delays are expected: o
longer than 4 hours: use alkaline peptone water as medium
o
Carey Blair medium can be used if longer delays are expected
Cold chain must be maintained
Suspected source of food or water should also be submitted for investigation
Blood culture, aseptically collected:
o
adults: 5-10ml of blood should be collected in an aerobic culture bottle
o
children: 3 ml of blood into paediatric aerobic culture bottle.
The presence of clinical symptoms and/or an antibody response is suggestive of the diagnosis but not confirmatory. The mainstay of laboratory diagnosis is the blood culture. Stool cultures may only be positive after the first week of illness and a positive stool culture can occur in carriers as well as cases. Antibody testing using the WIDAL, and stool cultures in the acute phase of the disease are not routinely recommended.
Reporting
Contact the Provincial Outbreak Response Team (MJOC) at 013 7663411 immediately when typhoid is confirmed by laboratory or case definition in 2 or more cases that are epidemiologically linked.
Begin a line-listing of cases (see end of Manual).
Confirmed cases of typhoid should be notified on an official notification form.
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Treatment of Contacts
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Anti-microbial prophylaxis is not indicated.
Close contacts should be alerted to the symptoms of typhoid and be advised to present to the health service should they develop symptoms.
The risk of typhoid can be reduced by adequate sanitation, good food hygiene and boiling water before consumption.
Household and close contacts should not be employed in sensitive occupations (e.g. food handling) until at least 2 negative stool and urine cultures 24 hours apart are obtained.
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APPENDIX A STANDARD AND ADDITIONAL PRECAUTIONS Standard Precautions (All body fluids, except sweat, are regarded as potentially infectious)
Hand-washing
Wash hands after touching blood, body fluids, secretions and contaminated items, whether or not gloves are worn.
Wash hands immediately after gloves are removed, between patient contacts and when working on different areas of the same patient if there is potential to transfer micro organisms from a contaminated site to a cleaner susceptible site.
-antimicrobial) soap for routine hand-washing.
Gloves
Wear gloves (clean, non-sterile) when touching blood, body fluids, secretions, excretions, contaminated items, mucous membranes and non-intact skin.
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ď&#x201A;ˇ
Change gloves between tasks on the same patient after contact with material which may have a high concentration of micro-organisms. Remove gloves promptly after use without touching non-contaminated surfaces and before going to another patient and wash hands immediately.
Mask, Eye Protection, Face Shield Wear mask and eye protection or a face shield during procedures that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions.
Gown (or plastic apron) Wear a gown (clean, non-sterile) or plastic apron during procedures that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. Remove as promptly as possible and wash hands immediately.
Patient-Care Equipment If soiled with blood, body fluids, secretions and excretions, prevent skin and mucous membrane exposures, contamination of clothing, and transfer of micro-organisms to other patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed. Ensure that single-use items are discarded properly.
Environmental Control Routine cleaning of environmental surfaces is adequate unless there has been significant soiling by potentially infectious body fluids when disinfection is required.
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Linen excretions, handle, transport and process in a manner that prevents skin and mucous membrane exposure and contamination of clothing, so that transfer of microorganisms to other patients and environments is prevented.
Occupational Health and Blood-borne Pathogens ď&#x201A;ˇ
Take care to prevent injuries when using needles, scalpels and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments; and when disposing of used needles. Never recap used needles. Do not bend, break or otherwise manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture resistant containers, which are located as close as practical to the area where the items are used.
ď&#x201A;ˇ
Use mouth pieces, resuscitation bags or other ventilation devices as an alternative to mouth-tomouth resuscitation methods where the need for resuscitation is predictable.
Airborne Precautions Use with Standard Precautions:
Patient Placement ď&#x201A;ˇ
Ideally, place the patient in a private room that has o
(i) monitored negative air pressure in relation to the surrounding areas
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ď&#x201A;ˇ
o
(ii) 6 to 12 air changes per hour, and
o
(iii) discharge of air outdoors.
A room with a simple extraction fan providing at least 6 air changes per hour, or, at worst, just an open window, is probably more realistic. Keep the room doors closed and the patient in the room. When a private room is not available, place the patient in a room with a patient who has active infection with the same microorganism, but with no other infection.
Respiratory Protection Susceptible persons should not enter the room of patients known or suspected to have measles, if other immune care givers are available. If they must enter the room, they should wear respiratory protection. Immune persons need not wear respiratory protection. Face masks do not protect against aerosols but are a barrier to splashes and larger droplets.
Patient Transport Limit the movement and transport of the patient from the room to essential purposes only and then place a mask on the patient.
Droplet Precautions Use with Standard Precautions.
Patient Placement A private room. If not available, place the patient in a room with a patient(s) who has active infection with the same micro-organisms but with no other infection. If not possible, maintain spatial separation of at least one meter between the infected patient and other patients or visitors. Door may remain open. Page 88
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Mask Wear a mask when working within one meter of the patient.
Patient Transport Limit the movement or transport of the patient from the room to essential purposes only. If movement is necessary, mask the patient, where possible.
Contact Precautions Use with Standard Precautions.
Patient Placement: Place the patient in a private room. When a private room is not available, place the patient in a room with a patient(s) who has active infection with the same microorganisms but with no other infection.
Gloves and Hand-washing Wear gloves when entering the room. Change gloves after having contact with infectious material that may contain high concentrations of microorganisms (faecal material and wound drainage). Remove gloves before leaving the patientâ&#x20AC;&#x2122;s environment and wash hands immediately with an antimicrobial agent or waterless antiseptic. Afterwards ensure that hands do not touch potentially contaminated environments, to avoid transfer of microorganisms to other patients or environments.
Gown (or plastic apron) Wear a gown or plastic apron (a clean, non-sterile gown is adequate) on entering the room, when you anticipate that your clothing will have substantial contact with the patient or environment. Remove the gown before leaving the patientâ&#x20AC;&#x2122;s environment.
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After removal, ensure that clothing does not contact potentially contaminated surfaces. The gown should not be re used before being autoclaved. All disposable protective equipment should be safely sealed in a secure bag in the isolation area and then incinerated.
Patient Transport ď&#x201A;ˇ
Limit the movement and transport of the patient from the room to essential purposes. If transported, minimise the risk of transmission.
Patient-care Equipment When possible, dedicate the use of non-critical patientcare equipment to a single patient (or cohort with the same pathogen). If equipment is shared, then adequately clean and disinfect.
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APPENDIX B KEY MESSAGES
Drink only water from a safe source or water that has been disinfected: o
(boiled for 3 minutes
or o
chlorinated – 5ml of bleach in 20 litres of filtered water, mixed well and allowed to stand for at least 20 minutes).
Dispose of human excreta promptly and safely.
Wash hands after contact with excreta and before preparing or eating food.
Cook food or reheat it thoroughly, and eat it while still hot.
Avoid uncooked food unless it can be peeled or shelled.
Ten Golden Rules for Safe Food Preparation 1. Choose food that is safely processed 2. Cook food properly 3. Eat cooked food immediately 4. Protect food after cooking 5. Reheat cooked food thoroughly 6. Wash hands repeatedly
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7. Avoid contact between cooked and raw food 8. Use safe water 9. Keep all working surfaces very clean 10. Protect food from insects, rodents and other animals (from WHO Golden Rules)
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APPENDIX C PACKING AND SHIPPING PROCEDURES All specimens should be handled in such a way as to minimise the risk of transmitting pathogens during transport and handling. Measures include:
Do not contaminate the environment when obtaining and packing a specimen.
Practice meticulous hand washing with soap.
Carefully observe all other relevant infection control measures for the particular condition (see Appendix A); like always using disposable gloves.
Specimens should be collected in correct, safe containers (e.g. well-fitting screwtop containers or well-sealed blood specimen bottles).
Always place specimen container in a plastic bag that is tied off with a rubber band (if it is not a self-sealing bag). Then place this bag, with a request form, in a separate plastic bag which is also sealed.
Always boldly mark (preferably in bold red) with the suspected epidemic condition.
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Follow recommended procedure for packing cold box.
Check that the cold box seal is intact and that there is no crack in the cold box. If the box is broken, it should be replaced.
Ice-packs should be frozen solid before use.
You need enough ice-packs to line the bottom, sides and top of the cold box.
Seal the box with tape or string.
Notify the receiving laboratory.
Laboratory confirmation is usually only necessary for the first 10 – 20 cases.
Storage and transport for avian influenza Specimen collection poses a risk of aerosol production and recommended precautions should be followed closely. Specimens should be packaged and transported as per standard recommendations for infectious substances. It is essential that the laboratory receiving the sample is aware that it comes from a potential avian influenza case and that it has the facilities required to safely handle the sample. Please package as follows: 1) USE APPOPRIATE PRECAUTIONS AT ALL TIMES WHEN HANDLING BLOOD OR OTHER BODY FLUIDS. 2) Wrap blood specimen tubes and viral transport medium (containing the swabs) separately in absorbent material e.g.: cotton wool. 3) Then place the specimens in a secondary container, preferably sturdy plastic or stainless steel with a well fitting lid. 4) Wrap them again in absorbent material and place in another container.
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5) Put the patient details on the OUTSIDE of this container including: a. Patient Name and hospital number b. Doctor and contact no. c. Lab Name and contact person. d. Clinical details. d. Results of any tests already performed. 6) Address as follows: National Institute for Communicable Diseases (NICD) 1 Moddertontein Road Sandringham Johannesburg
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GLOSSARY Active surveillance
frequent follow-up for signs or symptoms in a human contact
Attenuated
the process in which a potentially dangerous organism is made less dangerous in order to provide immunity
Bubo
inflamed swelling of a gland, usually in the groin or arm pit
Cary-Blair medium
a material which allows the growth of certain bacteria
Case definition
the signs and symptoms which are typical of a disease or condition
Ecchymoses
bleeding into the superficial layer of the skin
EHEC
Entero Haemorrhagic E. coli â&#x20AC;&#x201C; a bacteria which causes bleeding in the bowel
EIEC
Entero Invasive E. coli â&#x20AC;&#x201C; a sub type of the E. coli bacteria
Encephalopathy
generalised brain dysfunction
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Exudate
the fluid that oozes out of a wound, sore or injury
Gullian-BarrĂŠ syndrome
a specific disease associated with symmetrical paralysis usually beginning in the lower limbs
Haematogenous spread
blood spread
Haemolytic-uraemic syndrome
a syndrome of bleeding tendency and renal failure most often associated with infection
Incubation period
period of time between initial infection and onset of first symptoms
Infectious agent
any agent that can cause infection, it may be a virus, bacteria, fungus, protozoan or worm
Lymphadenopathy
pathology of lymph nodes with an increase in size
Maculopapular
skin rash where there is colour change (macule) which is raised above the normal surface of the skin
Myocarditis
inflammation of the heart muscle
Outbreak
increase in cases of a disease in a particular area during a specific time period beyond what would normally be expected.
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Period of infectiousness
time in which an infected person can spread an infection to another person
Protein-losing enteropathy
condition of the gut, usually after toxin damage, where there is excessive protein loss
Reservoir of infection
the natural environment of an infectious agent from where it can spread to a host
SAIMR/NHLS
South African Institute for Medical Research/National Health Laboratory Service
Suppurative
profuse pus
Tinnitus
ringing in the ears
Toxic megacolon
a condition where toxins damage the large gut wall and cause it to expand in size
Toxin
poison formed in the body by pathogenic organisms, like some bacteria
Transmission
refers to how an infectious agent is spread
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Example of a line list
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CONTACT DETAILS For further information on a) The Outbreak Manual â&#x20AC;&#x201C; Update 2006 or b) Training CDs on each of the communicable diseases Contact the Provincial Communicable Diseases Control Office at 013-7663411 Or visit the Mpumalanga Communicable Diseases Control Web site at http://www.cdcmpumalanga.net
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Acknowledgements We would like to acknowledge the following contributors:
Professor Dave Dürrheim
Dr. Bernice Harris
Dr. Kelvin Billinghurst
Professor Ggoyega Ogunbanjo
Associate Professor Rick Speare
The NICD Staff
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