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Volume 21, Number 1—January 2015

Health Care Response to CCHF in US Soldier and Nosocomial Transmission to Health Care Providers, Germany, 2009

Nicholas G. CongerComments to Author , Kristopher M. Paolino, Erik C. Osborn, Janice M. Rusnak, Stephan Günther, Jane Pool, Pierre E. Rollin, Patrick F. Allan, Jonas Schmidt-Chanasit, Toni Rieger, and Mark G. Kortepeter1
Author affiliations: Landstuhl Regional Medical Center, Landstuhl, Germany (N.G. Conger, E.C. Osborn, J. Pool, P.F. Allan); Walter Reed Army Institute of Research, Silver Spring, Maryland, USA (K.M. Paolino); Force Health Protection, Fort Detrick, Maryland, USA (J.M. Rusnak); Bernard Nocht Institute, Hamburg, Germany (S. Günther, J. Schmidt-Chanasit, T. Rieger); Centers for Disease Control and Prevention, Atlanta, Georgia, USA (P. Rollin); Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA (M.G. Kortepeter)

Main Article

Table 2

Isolation, infection control, PPE, and decontamination procedures used by a health care center during treatment of a US soldier infected with Crimean–Congo hemorrhagic fever virus, Germany, 2009*

Placed in AIIR with an anteroom. Restricted visitation; sign-in sheet to track personnel entry. Entry required wearing of fluid-resistant gown and gloves (gloves pulled over edge of gown sleeve cuff), fit-tested N95 respirator, eye protection/face shield, and shoe coverings; disposal of PPE in anteroom before exiting. IPaC staff performed hands-on refresher training sessions for proper donning and doffing of PPE and for respiratory procedures (i.e., suctioning). Biohazard suits with PAPRs worn during bronchoscopies and chest tube placement.
Labeling of ventilators used on patient; IPaC staff–observed cleaning to ensure proper decontamination/terminal disinfection before use on another patient. Bleach 10% solution used to clean ventilators; bellows replaced; circuits discarded; internal removable parts were removed, bagged, and sterilized (viral desiccation).
Two dedicated bronchoscopes, equipment, and bronchoscope tower (labeled restricted use); IPaC staff–observed cleaning to ensure proper decontamination/terminal disinfection. Cleaning/decontamination of endoscope performed after each procedure: endoscope soaked in enzymatic detergent to remove soils (to reduce risk of splashing, no scrubbing performed); decontaminated endoscope placed in AER with a biologic indicator testing (to ensure proper decontamination/cleaning); each endoscope load underwent 2 cycles in the AER before reuse.
Medical waste
All medical waste placed in RMW bags located inside patient’s room, sprayed, and then placed in a rigid plastic container (labeled biohazard/RMW) before disposal and incineration, following Germany’s regulations for handling infectious biohazardous wastes. Disposable sharps placed in sharps containers, autoclaved, and contained in protected location until disposal/decontamination (incineration). Suctioned containers holding blood-contaminated fluids, oral and respiratory secretions, bronchoscopy drainage fluids, or other drainage from patient snapped closed and contained/stored/labeled as biohazard/RMW before disposal/incineration.
All linen (disposable isolation gowns of HCWs, sheets and gowns of patient) placed in labeled regulated medical waste bags and sealed. When full, these RMW bags were then stored in larger (50 gallon) RMW containers and secured in a RMW holding area (another AIIR in the ICU that was labeled and secured as a RMW holding area) until transport for incineration. The outside of all RMW bags/containers wiped down with a 10% bleach solution before transport.
Medical laboratory
Phlebotomy/laboratory tests limited to most critical samples; performed by a single laboratory technician. All specimens placed in a plastic zip-locking bag that was placed inside a rigid plastic container and then inside a second similar (but larger) plastic container with lid taped to the container (biohazard/RMW labels). All specimens directly transported to the laboratory.
Except for blood and urine samples for diagnostic tests, specimens not pretreated with polyethylene glycol p-tert-octylphenyl ether under a laminar flow hood to reduce viral load before shipment to Bernard Nocht Institute because of concern treatment may interfere with validity of laboratory tests (but will be recommended in future cases). PPE for laboratory workers included gown, gloves, and N95 respirators (N95 respirators worn because specimens with a high viral load were tested in analyzers outside the BSC). Centrifugation of specimens performed within a Class II BSC.
Chemical disinfection of instruments/equipment performed immediately after each use with 10% bleach solution (or per manufacturer’s recommendation). All specimens and nonreusable equipment autoclaved before disposal, then incinerated per Germany’s regulatory requirements.
Terminal decontamination
Bleach 10% solution or standard hospital-grade disinfectants used for terminal cleaning of all surfaces and equipment, of patient’s room, and of aero-evacuation airplane. Terminal cleaning of ICU room overseen by IPaC staff.
Body sprayed with 10% bleach, placed in a body bag that was then decontaminated with 10% bleach solution, and then in a second sealed body bag that was decontaminated with 10% bleach solution before transfer to morgue. Embalming performed (generally not recommended due to exposure risk) by personnel wearing biohazard suits with hood, full face respirators, and double gloves overlapping sleeves of biohazard suit (duct-taped at wrists). Embalming procedures observed by IPaC staff. Body maintained in room at 1.1°–3.3°C. Daily RT-PCR of serum samples and RT-PCR of deep tissue samples on days 1 and 6 after embalming (confirmed negative). Chemical disinfection of nonsurgical instruments and equipment; surgical instruments also sterilized. Terminal decontamination of room.
*AER, automatic endoscope reprocessor; AIIR, airborne-infection isolation room; BSC, Class II biosafety cabinet; HCWs, health care workers; ICU, intensive care unit; IPaC, infection prevention and control; PAPRs, powered air-purifying respirators; PPE, personal protective equipment; RMW, regulated medical waste; RT-PCR, reverse transcription PCR.

Main Article

1Preliminary results from this study were presented at the Annual Meeting of the Armed Forces Infectious Disease Society; May 23, 2010, San Antonio, Texas, USA; NATO Biomedical Advisory; May 27, 2010, Munich, Germany; and Asian Pacific Military Medicine Conference, May 3, 2011, Sydney, New South Wales, Australia.

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