Purpose
Introduction
This chapter focuses on the approach to a returning traveler who may be infected with a "viral special pathogen," defined here as a virus which: can spread person-to-person; frequently causes illness resulting in severe morbidity or death; and has no, or limited, medical countermeasures. The most significant of these are filoviruses, arenaviruses, nairoviruses, henipaviruses, and highly pathogenic coronaviruses, and they will be the focus of this chapter (Table 10.7.1). Avian influenza is covered elsewhere. Find epidemiology information in the Influenza chapter and patient management advice can be found at this clinical brief.
Care of a person suspected of having an infection with a viral special pathogen (i.e., a "suspected case") presents challenges, including identifying potential risk factors, determining appropriate testing, and safeguarding healthcare professionals and the public while providing medical care. The idiom "Identify, Isolate, and Inform" is used to describe the initial process of identifying ill travelers with risk factors for a viral special pathogen, isolating the potentially infectious patient to protect healthcare professionals and the community, and informing appropriate authorities. This chapter reviews these steps and incorporates how to initiate medical care for a patient suspected of having infection with a viral special pathogen.
Table 10.7.1: Viral special pathogens, endemicity and animal reservoirs
| Virus | Endemicity1 | Reservoir |
|---|---|---|
| Ebola virus | The Democratic Republic of the Congo, Gabon, Guinea, Republic of the Congo | Likely bats (species unknown, fruit or insectivorous bat) |
| Sudan virus | South Sudan, Uganda | |
| Bundibugyo virus | The Democratic Republic of the Congo, Uganda | |
| Taï Forest virus | Côte d’Ivoire | |
| Marburg virus | Angola, The Democratic Republic of the Congo, Equatorial Guinea, Ghana, Guinea, Kenya, Tanzania, Uganda, Zimbabwe | Egyptian fruit bat (Rousettus aegyptiacus) |
| Ravn virus | The Democratic Republic of the Congo, Kenya, Uganda | Egyptian fruit bat (Rousettus aegyptiacus) |
| Lassa fever virus | Benin, Burkina Faso, Côte d’Ivoire, Ghana, Guinea, Liberia, Mali, Nigeria, Sierra Leone, Togo | Multimammate rat (Mastomys natalensis) |
| Lujo virus | Zambia | Unknown reservoir, likely rodents |
| Junin virus | Argentina | Drylands vesper mouse (Calomys musculinus) |
| Chapare virus | Bolivia | Small-eared pygmy rice rats (Oligoryzomys microtis) |
| Sabia virus | Brazil | Unknown reservoir, likely rodents |
| Machupo virus | Bolivia | Large vesper mouse (Calomys callosus) |
| Guanarito virus | Venezuela | Short-tailed cane mouse (Zygodontomys brevicauda) |
| Crimean-Congo hemorrhagic fever virus | Eastern and southern Europe through Central Asia, all of Africa, Middle East | Ixodid (hard) ticks are both reservoir and vector |
| Nipah virus | Parts of southern and southeastern Asia, primarily Bangladesh, India, and Malaysia | Fruit bats of the genus Pteropus (flying foxes) |
| Middle East respiratory syndrome coronavirus (MERS-CoV) | Countries considered in or near the Arabian Peninsula include: Bahrain; Iraq; Iran; Israel, the West Bank and Gaza; Jordan; Kuwait; Lebanon; Oman; Qatar; Saudi Arabia; Syria; the United Arab Emirates; and Yemen; because the risk for MERS-CoV transmission from camels in North, West, and East Africa is not yet fully understood, consider MERS evaluation for travelers coming from these regions who develop severe respiratory illness within 14 days of direct physical camel contact | Dromedaries (camels) |
Notes
1Defined as countries where the known or suspected reservoir host is found and where human cases have been reported.
Presentation of a suspected case
The speed of international air travel, combined with increasing interactions among people, domestic and wild animals, and their environments, create opportunities for the emergence and re-emergence and spread of known and unrecognized viral special pathogens in the United States. Additionally, advance notification of an ill traveler with a known exposure to a viral special pathogen to a healthcare facility in the United States is unlikely.
Healthcare facilities and public health agencies should maintain situational awareness about ongoing outbreaks worldwide, as well as countries where these diseases are endemic, to rapidly identify and isolate acutely ill travelers arriving unannounced to a healthcare facility. This requires maintaining a strategy of rapid and appropriate risk assessments that include taking a thorough travel history for all patients with possible acute infectious illness to identify those who might have been exposed during international travel (see Post-Travel Evaluation of the Ill Traveler chapter). All travelers from endemic or outbreak areas with a possible acute infectious illness should be assessed to determine epidemiologic risk factors for a viral special pathogen infection and to assure the provision of appropriate and safe patient care, including basic laboratory testing, medical stabilization, and empiric therapy, while awaiting definitive viral special pathogen testing if indicated based on the clinical and epidemiologic assessment.
Assessment of epidemiologic and clinical risk factors for a viral special pathogen (Identify)
No single sign or symptom is pathognomonic for diseases caused by viral special pathogens. The decision to test is primarily driven by assessing epidemiologic risk factors and ruling out more common causes of illness (Figure 10.7.1; see Post-Travel Evaluation of the Ill Traveler chapter). Because none of the viral special pathogens described in this chapter are endemic to the United States, eliciting travel-associated exposures is critical. Besides the standard medical questions, all patients presenting with a possible acute infectious illness should be screened for travel and occupational history to identify epidemiologic risk factors for a viral special pathogen (Table 10.7.1; Table 10.7.2). While evaluating signs and symptoms, consideration of common diseases, both locally acquired and travel-associated, such as malaria, influenza, and sexually transmitted diseases, should not be forgotten (Table 10.7.3).
Figure 10.7.1
Table 10.7.2: Risk factors for animal to human transmission of viral special pathogens in endemic countries
| Risk factors for animal to human transmission | Virus |
|---|---|
|
Working or spending time in a cave or mine; contact with bats, bat guano, or bat urine; handling or consumption of raw meat or other animal products harvested from forest animals (non-human primates, duiker, and other antelope) Occupations at risk: hunters and miners |
Ebola virus Sudan virus Bundibugyo virus Taï Forest virus Marburg virus Ravn virus |
|
Contact with rodents, rodent dropping, rodent urine, or rodent nests; rodent bites; inhaling virus shed in aerosolized secretions or excretions of infected rodents; consumption of food contaminated with rodent droppings or urine Occupations at risk: agricultural workers |
Lassa fever virus Lujo virus Junin virus Chapare virus Sabia virus Machupo virus Guanarito virus |
|
Tick bites; contact with infected animal blood or products Occupations at risk: animal herders, livestock workers, and slaughterhouse workers |
Crimean-Congo hemorrhagic fever virus |
|
Contact with bats, bat guano, or bat urine; contact with pigs; consumption of raw date palm sap Occupations at risk: pig farmers |
Nipah virus |
|
Exposures to dromedary camels Occupations at risk: those working in close contact with camels in endemic areas, including camel handlers and slaughterhouse workers |
Middle East respiratory syndrome coronavirus (MERS-CoV) |
Table 10.7.3: Special pathogens, clinical presentation
| Virus | Incubation period | Signs and symptoms |
|---|---|---|
| Chapare virus | 4–21 days |
Syndrome of fever, malaise, headache for 5–7 days followed by encephalitis, renal failure, hemorrhage, and hypotension Cytopenias, especially thrombocytopenia Neurologic involvement, severe gingival hemorrhage |
| Crimean-Congo hemorrhagic fever virus | 1–14 days |
Initial non-specific febrile illness with fever, headache, myalgias, gastrointestinal symptoms, progressing to hemorrhagic findings and multi-organ system failure Symptoms may also include jaundice, or, in severe cases, changes in mood and sensory perception As the illness progresses, extensive hematomas/ecchymoses/injection site bleeding |
|
Ebola virus Bundibugyo virus Marburg virus Ravn virus Sudan virus Taï Forest virus |
2–21 days |
Non-specific “flu-like” initially: fever, fatigue, headache, chills, myalgias, anorexia Symptoms may include sore throat, vomiting, diarrhea (which may be severe), conjunctivitis, rash, hiccups, cough Severe disease: persistent bleeding, bruising, hemorrhage, prostration, altered mental status, multi-organ system failure |
| Guanarito virus | 3–19 days |
Syndrome of fever, malaise, headache for 5–7 days followed by encephalitis, renal failure, hemorrhage, and hypotension Cytopenias, especially thrombocytopenia |
| Junin virus | 6–14 days |
Syndrome of fever, malaise, headache for 5–7 days followed by encephalitis, renal failure, hemorrhage, and hypotension Cytopenias, especially thrombocytopenia |
| Lassa fever virus | 2–21 days |
Mild asymptomatic or flu-like symptoms occur in 80% of infections; severe infections are similar to Ebola disease Symptoms may include facial swelling, pharyngitis, respiratory distress, renal failure, (especially in Nigeria) Deafness may occur during acute disease or recovery |
| Lujo virus | 7–13 days |
Syndrome of fever, headache, myalgia, sore throat, diarrhea, rash, face edema, and neck edema Bleeding not a prominent feature |
| Machupo virus | 3–16 days |
Syndrome of fever, malaise, headache for 5–7 days followed by encephalitis, renal failure, hemorrhage, and hypotension Cytopenias, especially thrombocytopenia |
| Middle East respiratory syndrome coronavirus (MERS-CoV) | 2–14 days |
Symptoms may include fever, chills, rigors, headache, non-productive cough, dyspnea, myalgia Less common: sore throat, coryza, sputum production, dizziness, nausea, vomiting, diarrhea, abdominal pain Severe disease: pneumonia and acute respiratory distress syndrome; multiple organ dysfunction syndrome |
| Nipah virus | 5–14 days |
Initial non-specific flu-like illness with fever, myalgia, vomiting, malaise Headache and altered mental status may present early and progress rapidly to encephalitis and neurologic symptoms Respiratory symptoms, including copious secretions, shortness of breath, acute respiratory distress syndrome Rare late or relapsing neurologic presentations |
| Sabia virus | 6–21 days |
Syndrome of fever, malaise, headache for 5–7 days followed by encephalitis, renal failure, hemorrhage, and hypotension Cytopenias, especially thrombocytopenia Pharyngitis, nausea, vomiting |
Infection prevention and control considerations (Isolate)
While evaluating a patient for a viral special pathogen, it is critical to maintain a posture of strict infection prevention and control in the healthcare facility while providing effective care (Figure 10.7.1). Principles of infection prevention and control include engineering and administrative controls such as: patient placement; transport pathways; healthcare team selection, management, and training; and adapting clinical practices to a high-containment environment. The selection and use of PPE, although highly visible, is the last and least effective layer of protection.
Patients with suspected viral special pathogen infections should immediately be placed in a private room with a door and private bathroom or covered bedside commode. For patients presenting with respiratory symptoms and epidemiologic risk factors, consider placement in a negative pressure isolation room, if available. The pathway to the evaluation area should be selected to reduce exposure to other individuals and allow for efficient cleaning after passage, as required. If an anteroom is not available, use portable, industrial-grade high efficiency particulate air filters in the patient's room to provide additional air changes to remove airborne particulates. If a private room is not available, a separate enclosed area with a private bathroom or covered bedside commode is acceptable. Where possible, the interior of the patient's room should be visible to healthcare professionals outside the room (e.g., window). If tolerated, patients should wear a surgical mask whenever others are in the room.
To minimize transmission risk, limit the number of healthcare personnel entering the patient's room. Only trained essential personnel with designated roles should evaluate and provide care for the patient. In addition, healthcare facilities should maintain a log of all people entering the patient's room. Consider posting hospital personnel at the patient's door to ensure all personnel entering the room are recorded in the log and to prevent unauthorized people from entering. Tasks should be planned, and all necessary supplies should be brought into the patient's room to reduce the need to break containment.
Where appropriate, consider using methods of communicating with the patient that do not require entry into the patient's room. For a medically stable patient, consider collecting the history via mobile phone, electronic tablet, or nursing call intercom. The use of dedicated medical equipment (preferably disposable) is strongly recommended for the provision of patient care. All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to the manufacturer's instructions and hospital policies. Specific modes of disease transmission will impact patient placement, practices, and PPE selection (Table 10.7.4). Learn more about infection prevention and control recommendations for selected viral hemorrhagic fevers or MERS.
Table 10.7.4: Special pathogens, patient placement, and personal protective equipment considerations for healthcare workers
| Virus | Patient placement | Recommended personal protective equipment |
|---|---|---|
|
Bundibugyo virus Chapare virus Crimean-Congo hemorrhagic fever virus Ebola virus Guanarito virus Junin virus Lassa fever virus Lujo virus Machupo virus Marburg virus Ravn virus Sabia virus Sudan virus Taï Forest virus
|
Single-patient room (containing a private bathroom) with the door closed There should be adequate space for donning and doffing PPE Avoid AGPs if possible; conduct AGP procedures in a private room and ideally in an airborne infection isolation room when feasible; room doors should be kept closed during the procedure except when entering or leaving the room, and entry and exit should be minimized during and shortly after the procedure |
For patients with suspected infection who are clinically stable and do not have bleeding, vomiting, or diarrhea, healthcare professionals should, at a minimum, wear:
For patients with confirmed infection and patients with suspected infection who are clinically unstable or have bleeding, vomiting, or diarrhea, healthcare workers should, at a minimum, wear:
|
| Nipah virus | Airborne isolation room |
For patients with suspected infection who are clinically stable, healthcare professionals should, at a minimum, wear:
For patients with suspected infection who are clinically unstable (e.g., hemodynamic instability, vomiting) or who are confirmed to have Nipah virus infection regardless of clinical stability, healthcare workers should, at a minimum, wear:
|
| Middle East respiratory syndrome coronavirus (MERS-CoV) | Airborne isolation room |
For patients with suspected or confirmed infection, regardless of clinical stability, healthcare workers should, at a minimum, wear:
|
Notes
Abbreviations: AGP, aerosol-generating procedure; NIOSH, National Institute for Occupational Safety and Health; PAPR, powered air-purifying respirator; PPE, personal protective equipment.
Initial notification (Inform)
Healthcare professionals should first contact their state, tribal, local, or territorial (STLT) public health department for assistance in determining whether a symptomatic traveler's illness and exposure history meets the suspected case definition. The determination that a patient is potentially infected with a special pathogen drives the decision to test and should not be made lightly. All interactions with patients with suspected infection must be performed under strict isolation precautions in a healthcare facility until the viral special pathogen is ruled out, which may take several days. Precautions and patient management should be applied uniformly and should not be adjusted based on further gradations of risk. While necessary, these measures may create barriers to a patient's access to care, especially if a facility is not prepared for such situations. For patients for whom a viral special pathogen is a serious consideration, consultation with CDC is highly recommended and would be coordinated by the STLT public health department. CDC can leverage national and international resources to provide context around the patient's travel and activities to identify potential epidemiologic risk factors. This consultation provides a forum to weigh the pros and cons of testing, discuss the need to maintain a strict infection control posture, and collectively make decisions that are in the best interest of the patient and public health. CDC's disease-specific experts can be reached at 770-488-7100.
Table 10.7.5: Criteria for diagnostic testing for Middle East respiratory syndrome (MERS) in the United States
| Clinical features | And | Epidemiologic risk |
|---|---|---|
| Severe illness: Patient has fever and pneumonia1 or fever and acute respiratory distress syndrome with no other more likely alternative diagnosis | AND ≥1 of the following epidemiologic risk factors | Within 14 days before symptom onset, a history of travel from countries in or near the Arabian Peninsula2 OR Within 14 days before symptom onset, history of close contact with a person who themselves developed fever and acute respiratory illness within 14 days of travel to countries in or near the Arabian Peninsula OR Within 14 days before symptom onset, a history of direct physical camel contact3 in North, West, or East Africa4 OR Is a member of a cluster of patients with severe acute respiratory illness of unknown etiology OR High-risk occupational exposure to MERS-CoV as laboratory or research personnel5 |
| Milder illness: Patient has fever or symptoms of respiratory illness6 (e.g., cough or shortness of breath) with no other more likely alternative diagnosis | AND ≥1 of the following epidemiologic risk factors | Within 14 days of symptom onset, a history of being in a healthcare facility (as a patient, worker, or visitor) in a country or territory in or near the Arabian Peninsula where recent healthcare associated cases of MERS have been identified OR Within 14 days of symptom onset, a history of direct physical camel contact3 in or near the Arabian Peninsula OR Within 14 days of symptom onset, a history of close contact7 with a person with confirmed MERS-CoV infection while that person was ill OR High-risk occupational exposure to MERS-CoV as laboratory or research personnel5 |
Notes
1Pneumonia diagnosis may be based on clinical and/or radiographic evidence. Pneumonia may be severe (requiring hospitalization).
2Countries considered in or near the Arabian Peninsula include Bahrain; Iraq; Iran; Israel, the West Bank and Gaza; Jordan; Kuwait; Oman; Qatar; Saudi Arabia; United Arab Emirates; and Yemen.
3Direct physical contact could include touching, riding, hugging, kissing, grooming, or exposure to respiratory secretions but does not include consumption of cooked camel meat.
4Because the risk for MERS-CoV transmission from camels is not yet fully understood, consider MERS evaluation for travelers from these regions who develop severe respiratory illness within 14 days of direct camel contact.
5Diagnostic and research facilities that handle MERS-CoV should have established procedures instructing their staff in how to prevent and respond to occupational exposures. Laboratory exposures may occur through contact with infected animals and viral specimens without proper precautions and personal protective equipment.
6Symptoms of respiratory illness may include but are not limited to cough, shortness of breath, sore throat and/or trouble breathing. Some people also get diarrhea, nausea, and vomiting in addition to respiratory symptoms. Contact your state, tribal, local, or territorial public health department if you have further patient questions.
7Close contact is defined as: a) being within approximately 2 m (6 ft) or within the room or care area of a patient confirmed to have MERS-CoV infection for a prolonged period of time (such as caring for, living with, visiting, or sharing a healthcare waiting area or room with a patient confirmed to have MERS) while not wearing recommended protective equipment (e.g., gowns, certified disposable N95 respirator, eye protection) or b) having direct contact with infectious secretions of a patient confirmed to have MERS (e.g., being coughed on) while not wearing recommended personal protective equipment.
Initial management (care of the patient with suspected infection)
As with all ill patients, focus the initial physical examination on ascertaining hemodynamic stability and hydration status. Patients may be dehydrated, even without obvious fluid losses, due to decreased appetite and intake, as well as increased insensible losses due to fever or tachypnea. Immediately initiate volume support if there is any evidence of hypotension or dehydration. Offer oral rehydration solution if there is a delay in obtaining intravenous access. Once intravenous access is established, initiate hydration with Ringer's lactate solution or normal saline. Frequent monitoring of the patient's volume status, including fluid shifts, is important because many diseases, including those caused by viral special pathogens, may present with significant capillary leak syndrome, leading to pulmonary edema and anasarca in the setting of overly aggressive hydration.
Respiratory failure may occur due to overhydration, accumulation of fluid in the interstitial space (associated with severe sepsis), or pulmonary pathology. Supplemental oxygen delivered by nasal cannula is an immediately accessible first-line therapy. Use of high-flow devices or non-invasive mechanical ventilation (such as BiPAP) may increase the risk of aerosolization of infectious viral particles, requiring implementation of airborne isolation precautions, and should be balanced against the option of elective intubation. Consideration of intubation should include discussions of appropriate infection prevention and control precautions, training of available operators, and availability of support staff. If possible, avoid emergent intubation. Once the patient is intubated, aerosolization risk is diminished except in the setting of open suctioning or bronchoscopy procedures.
Severe hypoglycemia has been a complicating factor in recent Ebola disease outbreaks and can also be seen in severe malaria and bacterial sepsis. Therefore, perform point-of-care glucose testing early and repeat regularly until stable. If glucose supplementation is necessary and the patient also requires volume support, provide glucose in a manner that does not compromise the restoration of intravascular volume.
Electrolyte disturbances including hypokalemia and hyperkalemia have been reported and may be secondary to volume loss due to gastrointestinal losses (vomiting, diarrhea) or acute kidney injury secondary to dehydration or sepsis. Anemia, thrombocytopenia, or coagulopathy may also be present.
Laboratory testing
Routine diagnostic testing
Routine laboratory testing to monitor the patient's clinical status and diagnostic testing for other potential causes of illness should be pursued while viral special pathogen testing is underway. Considering that the risk of viral special pathogen transmission in a clinical laboratory is the same as other bloodborne pathogens (e.g., HIV, hepatitis B virus, hepatitis C virus), it is important for clinicians and laboratory professionals to know they can safely and effectively perform other diagnostic testing on clinical specimens collected from these patients.
Adhering to standard procedures for testing, any unknown specimen should be handled assuming it could contain a dangerous pathogen. Site- and activity-specific risk assessments should be performed to evaluate a specimen's path through the healthcare facility, through the laboratory, and during all work processes. The assessment should include factors related to specimen management and transport, such as: the use of sharps and their disposal; the potential for splashing, spraying, spattering, or generating droplets; equipment hazards; biosafety cabinet (BSC) certification and operation; and safe work practices. Additionally, decontamination procedures should be assessed prior to laboratory testing, including procedures related to: methods for surface and equipment decontamination; infectious waste management; and PPE selection and use.
As is standard procedure for all bloodborne pathogens, consider using equipment with closed tube systems in which the specimen container stays capped during testing (e.g., vacutainer tube). Centrifugation poses the risk of aerosolization; therefore, if centrifugation is necessary for testing, centrifuges should have sealed buckets or sealed rotors. The rotors and buckets should be loaded in a BSC. After centrifugation, open the sealed buckets or rotors inside a BSC or enclosed hood. Blood culture instruments (automated and benchtop) have been used successfully after careful evaluation through a risk assessment. Subculture of any positive blood culture bottles (whether from automated, benchtop, or manual procedures) should be performed within a BSC. Learn more about the management of routine laboratory testing.
Malaria (see Malaria chapter) is the leading cause of travel-related hospitalization and death. Consider malaria in any patient with a febrile illness who recently returned from a malaria-endemic country (see Yellow Fever Vaccine and Malaria Prevention Information, by Country chapter), irrespective of adherence to antimalarial medications. Immediate blood smears with same-day results for malaria testing is ideal; thin smears can be inactivated with methanol and safely read. If timely blood smears are not available, a rapid diagnostic test can be performed. Glucometry and rapid tests for influenza, COVID-19, respiratory syncytial virus, and group A Streptococcus can also be performed. Biospecimens can be obtained and held pending preparation of appropriate laboratory space and staff for handling them. If the healthcare facility elects to run specimens on point-of-care instruments, they should be set up in a dedicated space outside of the patient's room.
Viral special pathogen testing
Decisions about testing for most viral special pathogens will be managed by the STLT public health department in coordination with the clinical team and CDC. For many pathogens, testing is only available at CDC or select laboratories within the Laboratory Response Network. The STLT public health department will determine to which facility a diagnostic specimen should be sent. The process should be discussed prior to obtaining a diagnostic specimen to ensure appropriate handling and packaging. Learn more about the guidelines for the handling and packaging of viral special pathogen specimens and laboratory testing for MERS.
Treatment
The patient's clinical features and epidemiologic risk factors should be used to guide empiric treatment. Broad spectrum antimicrobial therapy is reasonable for an ill patient, ideally with prior collection of biospecimens for culture even if laboratory capacity has not yet been determined. If testing for malaria is delayed, empiric antimalarial therapy may be appropriate, as is initiation of doxycycline if a rickettsial disease is suspected. Antivirals used for influenza and COVID-19 are also available and have good safety profiles.
Convalescent-phase plasma is effective in treating Argentine hemorrhagic fever, but it is available only in Argentina. Ribavirin has been used to treat Lassa fever and other Old World arenavirus infections, New World arenavirus infections, and Crimean Congo hemorrhagic fever, but it is not approved for use by the U.S. Food and Drug Administration (FDA) for these indications. Clinicians can initiate requests for the compassionate use of intravenous ribavirin by contacting CDC's Viral Special Pathogens Branch (770-488-7100). Although not FDA-approved for such use, remdesivir is easily available in most U.S. healthcare facilities and has some activity against filoviruses. Two FDA-approved treatments, Ebanga (single monoclonal antibody) and Inmazeb (triple monoclonal antibody cocktail) are available for treating Ebola virus (species Orthoebolavirus zairense) infection in adult and pediatric patients. Without treatment, the mortality rate due to Ebola virus infection can be up to 90%. In a randomized clinical control trial in the Democratic Republic of the Congo, Ebanga and Inmazeb reduced mortality rates to 35% and 33%, respectively. Both drugs particularly reduced deaths in patients with low viral loads: mortality rates in patients treated with Ebanga were 9.9% and those treated with Inmazeb were 11.2%. Clinicians can initiate requests for Ebanga or Inmazeb by contacting CDC's Viral Special Pathogens Branch (770-488-7100). Monoclonal antibody products are in development for other filoviruses, and their use may be possible under investigational protocols. Consultation with CDC is recommended prior to initiation of any non-approved therapeutics for viral special pathogens.
Communications
The importance of internal and external communications regarding a patient suspected of infection with a viral special pathogen cannot be overstated. These are high-profile events and, if not handled properly, can result in violation of patient privacy, loss of confidence in the affected hospital, and anxiety in the community. Hospitals should have, and follow, their own internal communication protocols for notification. At a minimum, these protocols should include infection control preventionists, infectious disease specialists, hospital administration, and the press or communications office. Healthcare facilities should have plans in place that identify if, and when, the hospital incident command system should be activated.
Close coordination and cooperation between the healthcare system and public health authorities is essential to properly respond to a disease caused by a viral special pathogen. Even the suspicion of a patient infected with 1 of these viruses should trigger a report to the STLT public health department. Coordination with public health experts may result in improved: clinical and epidemiologic risk assessments; access to specialized testing for viruses for which there is no commercial testing option; consultation and recommendations on appropriate infection control; coordination with subject matter experts at CDC or other medical facilities; and harmonization of messaging to manage potential public concern.
If necessary, public health authorities can require and enforce patient isolation for certain viral special pathogens and may begin conducting contact tracing with symptom monitoring or quarantine of contacts. If the patient is confirmed to be infected with a viral special pathogen, engagement with local, state, and federal public health agencies is required to determine where the patient will be isolated, whether the patient will need to be transported to another facility, and, if so, how they will be transported. If a patient might be transferred to a special pathogen treatment unit, the clinical care team there should be included early in discussions of patient management to contribute expertise and to assure maximal facility preparation.
Prior to media release, STLT public health departments should coordinate with CDC and other federal partners on public messaging about a confirmed viral special pathogen case. It is essential that patient privacy be maintained; therefore, careful consideration to avoid releasing any identifying patient information is vital. Data elements that are considered "identifying" varies by location, and prior planning can streamline this process.
Concerns have been expressed regarding the public relations impact on a healthcare facility's overall operations if it is publicly known that they are caring for a patient possibly infected with a viral special pathogen. However, there is value in transparency. Facility and public health authorities speaking with confidence and providing a unified message can reassure communities. To prepare for a patient with a possible viral special pathogen infection, healthcare facilities should work with their STLT public health departments to understand roles and responsibilities. STLT public health departments are encouraged to work with their healthcare facilities and special pathogen treatment centers to offer training and preparedness planning activities. A list of online resources can be found in Table 10.7.6.
Table 10.7.6: Online resources
- Ang, B. S. P., Lim, T. C. C., & Wang, L. (2018). Nipah Virus Infection. Journal of Clinical Microbiology, 56(6). https://www.doi.org/10.1128/JCM.01875-17
- Bah, E. I., Lamah, M. C., Fletcher, T., Jacob, S. T., Brett-Major, D. M., Sall, A. A., ... Fowler, R.A. (2015). Clinical Presentation of Patients with Ebola Virus Disease in Conakry, Guinea. The New England Journal of Medicine, 372(1), 40–47. https://www.doi.org/10.1056/NEJMoa1411249
- Choi, M. J., Cossaboom, C. M., Whitesell, A. N., Dyal, J. W., Joyce, A., Morgan, R. L., ... Frey, S. E. (2021). Use of Ebola Vaccine: Recommendations of the Advisory Committee on Immunization Practices, United States, 2020. MMWR Recommendations and Reports, 70(1), 1–12. https://www.doi.org/10.15585/mmwr.rr7001a1
- Croser, E. L., & Marsh, G. A. (2013). The changing face of the henipaviruses. Veterinary Microbiology, 167(1-2), 151–158. https://www.doi.org/10.1016/j.vetmic.2013.08.002
- Günther, S., & Lenz, O. (2004). Lassa virus. Critical Reviews in Clinical Laboratory Sciences, 41(4), 339–390. https://www.doi.org/10.1080/10408360490497456
- Henao-Restrepo, A. M., Camacho, A., Longini, I. M., Watson, C. H., Edmunds, W. J., Egger, M., ... Kieny, M. (2017). Efficacy and effectiveness of an rVSV-vectored vaccine in preventing Ebola virus disease: final results from the Guinea ring vaccination, open-label, cluster-randomised trial (Ebola Ça Suffit!). The Lancet, 389(10068), 505–518. https://www.doi.org/10.1016/S0140-6736(16)32621-6
- Mulangu, S., Dodd, L. E., Davey, R. T., Jr, Tshiani Mbaya, O., Proschan, M., Mukadi, D., ... Muyembe-Tamfum, J. (2019). A Randomized, Controlled Trial of Ebola Virus Disease Therapeutics. The New England Journal of Medicine, 381(24), 2293–2303. https://www.doi.org/10.1056/NEJMoa1910993
- Oh, M., Park, W. B., Park, S., Choe, P. G., Bang, J. H., Song, K., ... Kim, N. J. (2018). Middle East respiratory syndrome: what we learned from the 2015 outbreak in the Republic of Korea. The Korean Journal of Internal Medicine, 33(2), 233–246. https://www.doi.org/10.3904/kjim.2018.031
- Ozkurt, Z., Kiki, I., Erol, S., Erdem, F., Yilmaz, N., Parlak, M., ... Tasyaran, M. (2006). Crimean-Congo hemorrhagic fever in Eastern Turkey: clinical features, risk factors and efficacy of ribavirin therapy. Journal of Infection, 52(3), 207–215. https://www.doi.org/10.1016/j.jinf.2005.05.003
- Weatherman, S., Feldmann, H., & de Wit, E. (2018). Transmission of henipaviruses. Current Opinion in Virology, 28, 7–11. https://www.doi.org/10.1016/j.coviro.2017.09.004