Viral Hemorrhagic Fevers and PPE

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On a recent episode of Transmission Interrupted, NETEC hosts Jill Morgan and Trish Tennill go back to the basics of viral hemorrhagic fevers and personal protective equipment (PPE). 

Virus Families That Cause Viral Hemorrhagic Fevers 

Viral hemorrhagic fevers (VHFs) are a group of infectious diseases caused by four viral families, including Filoviridae (e.g., Ebola, Marburg) (CDC, https://www.cdc.gov/vhf/virus-families/filoviridae.html, Accessed 9/21/2022), Arenaviridae (e.g., Lassa) (CDC, https://www.cdc.gov/vhf/virus-families/arenaviridae.html, Accessed 9/21/2022), Bunyavirales (e.g., Crimean Congo Hemorrhagic Fever) (CDC, https://www.cdc.gov/vhf/virus-families/bunyaviridae.html, Accessed 9/21/2022) and Flaviviridae (e.g., Yellow Fever) (CDC, https://www.cdc.gov/vhf/virus-families/flaviviridae.html, Accessed 9/21/2022). 

Common Characteristics 

Viral hemorrhagic fevers and the four viral families they derive from have the following common characteristics.  

• They are ribonucleic acid (RNA) viruses, which can replicated and mutate quickly, making these viruses among the most common cause of emerging disease in people. 

• They are lipid envelope viruses that can be easily killed on surfaces by physical (heat, sunlight, etc.) or chemical (detergent, bleach, etc.) methods. 

• They are zoonotic diseases that spread from animal or insect hosts to humans.  

• They can spread to people when a person encounters an infected animal or insect host or an area that they may have contaminated. Some viral hemorrhagic fevers only spread from a host species, while others can be transmitted person-to-person. 

• Their presenting symptoms are likely to be nausea, vomiting, diarrhea, fever, muscle, joint pain, and headache—the kind of symptoms emergency departments and clinics see all the time. Bleeding or hemorrhaging isn’t always an early sign. 

Four Viral Hemorrhagic Fevers 

Of the diseases caused by the four viral families, Ebola Virus Disease (EVD), Marburg Virus Disease (MVD), Lassa Fever, and Crimean-Congo Hemorrhagic Fever (CCHF) are among those with person to person spread and the potential to cause serious and life-threatening disease. NETEC focuses most of its efforts on educating and preparing health care workers on how to respond to possible outbreaks of these diseases in the U.S. 

How to Evaluate a Patient  

Early recognition of viral hemorrhagic fevers (VHFs) is critical for infection control. But how do you separate the everyday illness from a VHF?  

Start with symptom screening

Symptoms include a fever > 38°C/100.4°F and one or more of the following clinical criteria:  

• severe headache 

• muscle pain 

• erythematous maculopapular rash on the trunk with fine desquamation 3–4 days after rash onset 

• vomiting 

• diarrhea 

• abdominal pain 

• bleeding not related to injury 

• thrombocytopenia 

• pharyngitis (Arenaviruses only) 

• proteinuria (Arenaviruses only) 

• retrosternal chest pain (Arenaviruses only) 

Next ask about the patient’s travel history

Ask the patient if have they traveled outside of the country in the last month.  

• If they recently traveled to a region endemic for a VHF or experiencing an outbreak, and are symptomatic, isolate them in a negative pressure room and notify staff and the public health department.  

If you are in an emergency department or other triage space and a patient presents with symptoms, take steps to minimize your exposure and follow precautions commensurate with the risks. For example, you could: 

• Put the patient in a room and finish the screening from the doorway or over the phone. 

• Place the patient in a room and don appropriate PPE if the patient needs help. 

• Always alert the next caregiver. 

See the CDC’s CALM algorithm for Emergency Room clinicians (CDC, https://www.cdc.gov/vhf/abroad/assessing-vhf-returning-traveler.html, Accessed 9/21/2022) in assessing a patient with signs, symptoms, and/or diagnostic findings concerning for a possible viral hemorrhagic fever (VHF). 

See the CDC Case Definition for Viral Hemorrhagic Fevers. 

PPE and Precautions for VHFs 

As soon as you identify a patient with symptoms and travel history consistent with a viral hemorrhagic fever, isolate them and determine your personal protective equipment (PPE). 

Choose your PPE in conjunction with engineering and administrative controls; consider the potential infectious agent, patient condition, your level of interaction, and tasks to be performed. 

NETEC has developed a matrix identifying the personal protective equipment (PPE) and precautions necessary for different viral hemorrhagic fevers. 

The most important aspect to any PPE ensemble is whether you can wear it and take it off safely. The time to figure whether your PPE meets this criteria is not when you have a patient, but before you need to use it!