VHF Preparedness Questions and Answers
Q1. What is Ebola?
A. Ebola virus disease (previously known as Ebola haemorrhagic fever) is a rare but severe disease which is caused by the Ebola virus. It belongs to the group of diseases called Viral Haemorrhagic Fevers (VHFs). It can result in uncontrolled bleeding, causing damage to the patient’s vital organs. It was first recognised in 1976 and has caused sporadic outbreaks since then in several African countries.
The virus is initially transmitted to people from wild animals and spreads in the human population through human-to-human transmission through contact with blood and body fluids.
A. VHFs start with non-specific symptoms including fever, headache and muscle weakness. Later in the course of the illness patients can develop vomiting, diarrhoea, bruising and bleeding.
The two most important factors when assessing patients for risk of VHF are fever or history of fever in past 24 hours; and history of travel to a VHF endemic country in the past 21 days.
There are other illnesses which are much more common than Ebola (such as flu, typhoid fever and malaria) that have similar symptoms in the early stages, so proper medical assessment is really important to ensure you get the right diagnosis and treatment.
A. The risk of a returning traveller bringing Ebola into the country remains very low. For Ebola to be transmitted from one person to another, contact with blood or other body fluids is needed. It is important to remember that there is no evidence for respiratory spread of VHF. As such, even in the highly unlikely event of an imported case, the risk to the general Scottish population remains very low.
A. General information on Ebola and other viral haemorrhagic fevers is available on the ebola page of the NHS Inform website.
A. If Ebola or another VHF is suspected, the patient must be discussed immediately with a senior clinician at the site where the patient has presented. VHF risk assessment should then be carried out using the NHS GGC VHF algorithm.
If, by using the algorithm, the patient is deemed high risk for VHF they must be discussed immediately with the on call ID Consultant, available via switchboard.
Viral haemorrhagic fever (including Ebola virus disease) is only one of a number of potential causes for a fever in travellers returning from Africa. Other infections such as malaria are more likely and therefore any febrile traveller from Africa should be discussed with/referred to Infectious Diseases.
A. The responsibility for transfer of patients who are at high risk of VHF lies with the Scottish Ambulance Service Special Operations Response Team (SORT), who are fully equipped for transfer of such cases. Attendance of the SORT can be arranged following discussion with the on-call Consultant ID physician.
A. Patients at high risk of VHF should be kept in Emergency Departments for as little time as possible, pending transfer to specialist infectious disease services. Suspected VHF cases are specifically exempted from waiting time targets.
A. Each emergency department will identify an area to be used for assessment of possible cases. The level of PPE required will be determined by careful travel history determining risk and the clinical condition of the patient. It is important to remember that there is no evidence for respiratory spread of VHF and the illness is spread by contact with infectious body fluids, most notably vomit, diarrhoea and blood.
A. NHSGGC will comply with all PPE for high risk / confirmed VHF patients as recommended by the National VHF Steering Group and HPS. Staff in ED’s will be trained in the use of this PPE and have a supply made available to them.
A. FFP3 masks are also used as part of the infection control procedures for patients who have, or are suspected to have some other infections. Departments are expected to ensure a regular programme of fit-testing for staff. Additional fit-testing training is being provided to support departments in providing this service. For further information and advice, departments should contact Health and Safety.
It is important to remember that VHFs, including ebola, are not airborne, and the principle purpose of the PPE is to prevent splash/exposure to body fluids.
A. The use of a buddy is standard practice when using high-level PPE. The details on doning and doffing of the PPE is included in training to ED departments that is being rolled out.
A. The key items of PPE when assessing patients are gloves and plastic apron, (with surgical mask and goggles if there is a risk of splashing of blood and or body fluids. ) which are part of standard infection control procedures, and should be available in all areas of the hospital. If following assessment the patient is considered as high risk for VHF, then they should be discussed with the on-call ID consultant, who will advise further.
A. During the initial presentation of a feverish returning traveller, for example in an emergency department, this can be a suitably senior staff member able to perform the risk assessment, who should use standard infection control precautions. If the patient is assessed as high risk on basis of the algorithm, only those staff trained in appropriate PPE should provide care until transfer to specialist ID unit.
A. Returning travellers with a fever are far more likely to have an alternative diagnosis – such as malaria – than a VHF.
GPs should be prepared to perform the initial history taking and risk assessment using the VHF algorithm. Preferably this should be over the telephone
Dependent on the result of risk assessment the patient should either be managed by the GP as normal, or discussed with the ID unit. If a patient is assessed as ‘high risk’ by the GP, the GP should contact the on-call ID Consultant via the Gartnavel General switchboard immediately.
If a feverish returning traveller attends the practice, the receptionist should direct them to a single room, and immediately alert senior clinical staff. The patient should not be asked to sit in the general waiting area. The GP carrying out the risk assessment should use standard infection control procedures (hand hygiene, gloves, plastic apron). Unless the patient has vomiting, diarrhoea, or active bleeding, whilst in the practice, the risk of transmission of any infection is low.
A. Adult patients who are suspected of having Ebola can be discussed with the on-call consultant infectious disease physician, who can be contacted via switchboard. The Consultant ID physician will advise on arrangement of transport, which will be performed by the Scottish Ambulance Service SORT team.
Similarly, paediatric patients should be discussed with the on-call paediatric infectious diseases consultant, who can provide further information and advice.
A. If a patient is deemed high risk for VHF as per the algorithm, it is important that they do not have blood samples taken until they have been discussed with the on call Infectious Diseases Consultant.
The laboratories in NHSGGC have agreed to perform some blood tests on high risk patients including malaria tests, FBC, Coagulation, U&Es and LFTs.
Specific procedures are in place to analyse blood from high risk patients. The laboratories must be informed of the patient prior to sending samples, and samples should be packaged appropriately. More details are available in the NHSGGC VHF protocol or on discussion with the on call ID Consultant. The necessary containers are held at the Brownlee Centre and at A&E departments in NHSGGC.
A. In the first instance suspected cases should be discussed with the on-call infectious diseases consultant, who can be contacted via switchboard. If transfer to the ID unit is arranged, then the ID consultant will contact the on-call Consultant in Public Health Medicine. . They can also be reached via switchboard. Both infectious diseases and public health have a 24 hour on-call system.
A. There is national guidance for the disposal of clinical waste from high risk or confirmed VHF patients. The Clinical Waste Officer (Health and Safety) will provide detailed advice.
A. If, following detailed risk assessment by senior staff member, the patient is considred to be ‘no risk’ or ‘low risk’ for VHF, the room can be cleaned using standard cleaning protocols.
The cleaning/decontamination of rooms used by patients considered ‘high risk’ of VHF or who are confirmed as having VHF, should be discussed with the infection control team.
A. A webinar, produced by NES/HPS and presented by Dr Alisdair MacConnachie, is available via the following link:
A. NHS GGC is guided by advice and national policy produced by the National VHF group, Health Protection Scotland (HPS) and the Scottish Government. Experts from NHS GGC are fully involved in discussions on patient protocols, including membership of the National VHF group.
A. Email PHPU during office hours for non-urgent queries. For urgent queries regarding a specific patient contact the oncall ID Consultant or CPHM.