WORLD HEALTH ORGANIZATION CDS/80.1

ORGANISATION MONDIALE DE LA SANTÉ ORIGINAL: ENGLISH

PROCEDURES FOR THE SURVEILLANCE AND MANAGEMENT OF MONKEYPOX AND VIRAL HAEMORRHAGIC FEVERS (YELLOW FEVER, LASSA FEVER, EBOLA AND MARBURG VIRUS DISEASES)

These procedures for the surveillance and management of monkeypox and viral haemorrhagic fevers were developed at a Seminar on the Surveillance of Monkeypox and Viral Haemorrhagic Fevers, held at the WHO Regional Office for Africa, Brazzaville, from 28 April - 2 May 1980 (AFRO Document AFR/EPID/42). The Seminar was co-sponsored by the WHO Regional Offices for Africa and the Eastern Mediterranean and by WHO Headquarters.

The issue of this document does not constitute Ce document ne constitue pas une publication. formal publication. It should not be reviewed, Il ne doit faire l'objet d'aucun compte rendu ou abstracted or quoted without the agreement of résumé ni d'aucune citation sans l'autorisation de the World Health Organization. Authors alone l'Organisation Mondiale de la Santé. Les opinions are responsible for views expressed in signed exprimées dans les articles signés n'engagent articles. que leurs auteurs. CDS^0.1 page 2

CONTENTS

' Page

PREFACE 5

1. INTRODUCTION '-''.v^

1.1 Need 5 1.2 Objectives 5

1.2.1 Monkeypox 5

1.2.2 Viral haemorrhagic fevers 6

1.3 Criteria for strengthening the surveillance system 6

2. SURVEILLANCE SYSTEMS

2.1 Definition of epidemiological surveillance 6 2.2 Methods of surveillance 6 2.2.1 General 6

2.2.1.1 Hospital-based surveillance 7

2.2.1.2 Village surveillance 7

2.3 Monkeypox surveillance 7

2.3.1 In areas of known occurrence 7

2.3.1.1 Hospital-based surveillance 7 2.3.1.2 Continuous village surveillance 8

2.3.1.3 Intermittent village surveillance 8

2.3.2 In areas of unknown but suspected occurrence 8

2.3.2.1 Hospital-based surveillance 9 2.3.2.2 Area surveillance 9 2.3.2.3 Seroprevalence surveys 9

2.4 Haemorrhagic fever surveillance 9

2.4.1 In areas of known occurrence 9

2.4.1.1 Hospital-based surveillance 9 2.4.1.2 Continuous village surveillance 9

2.4.1.3 Intermittent village surveillance 9

2.4.2 In areas of unknown but suspected occurrence 9

2.4.2.1 Hospital or dispensary surveillance 9 2.4.2.2 Area surveillance 9

2.4.2.3 Seroprevalence survey 9

2.5 Organization and promotion of surveillance systems lO

2.5.1 Personnel, training and support 2.0 2.5.2 Notification 10 CDS/SO.1 page 3

Page

2.6 Epidemiologic investigations 10

2.6.1 Monkeypox 11

2.6.1.1 Criteria for case suspicion and reporting 11 2.6.1.2 Criteria for a more complete follow-up investigation 11 2.6.1.3 Actions during the complete follow-up investigation 11

2.6.1.3.1 Interviews 11 2.6.1.3.2 Facial pockmark surveys 12 2.6.1.3.3 Serum collection from contacts 12 2.6.1.3.4 Animal studies 12

2.6.2 Haemorrhagic fevers 12

2.6.2.1 Criteria for case suspicion and reporting (including yellow fever) 12 .'.I , 2.6.2.2 Criteria for a more complete follow-up investigation (excluding yellow fever) 12 2.6.2.3 Actions during the investigation 12

2.6.2.3.1 Interviews 12 . . 2.6.2.3.2 Serum collection from contacts 13 > - . . ; 2.6.2.3.3 Large scale serosurveys 13 2.6.2.3.4 Animal studies 13

2.6.3 Yellow fever 13

3. MANAGEMENT OF CASES :. ^, . .• -,.h nofJ* '

3.1 Initial considerations including burial 14 3.2 Protection of personnel 15 •ri: 3.3 Patient isolation 16 3.4 Patient care and management 17 3.5 Room decontamination 18

COLLECTING AND SHIPPING DANGEROUS PATHOGENS

4.1 Personal protection •. 18 4.2 Sample collection - procedures 18 4.3 Local field and laboratory procedures 19 4.4 Post-mortem procedures 19

5. SHIPMENT OF INFECTIOUS AGENTS AND DIAGNOSTIC SPECIMENS

5.1 Packaging 20 5.2 Centres to send specimens for diagnosis 20

5.2.1 Monkeypox 20 5.2.2 Yellow fever 20 5.2.3 Lassa fever, Ebola virus disease, Marburg virus disease, other haemorrhagic fevers 21

5.3 Responsibility of the sender . 5.4 Responsibility of the receiver 5.5 Shipping documents and forms . 5.6 Contingency planning CDs/80.1 ! page 4

ANNEXES

Page

1. Diseases

A. Monkeypox 23 B. Yellow fever 24 C. Lassa fever 26 D. Marburg and Ebola virus diseases 28

2. Forms

A. Clinical history 30 B. Specimen collection 33 C. Epidemiological investigation, including serological surveys 35

3. Instructions for collection, storage and shipping of specimens 39

4. Registers

A. Deaths '^2 B. Patients suspected of having monkeypox or viral haemorrhagic fevers ... 43

5. Decontaminat ion .,:

A. Disinfectants, sterilization, decontamination 44

B. Space decontamination 46

6. Protective material maintained at WHO headquarters 47

7. Selection, care and decontamination of protective material and clothing 48

8. Packaging Instructions 52

9. Shipper's certificate for restricted articles (2) 54

10. Infectious substance label 56

11. Photographs 1-4 57 CDS/SO.I page 5

PREFACE

This manual of procedures is designed to offer some guidelines for health personnel or epidemiologists concerned with developing surveillance and managing outbreaks of monkeypox and haemorrhagic fevers. Just as the geographic distribution, frequency, source and trans­ mission pattern of cases of human monkeypox need to be known, so the same is needed for haemorrhagic fevers, including yellow fever. The procedures are based on the substantial knowledge and data gathered from experience, field investigations and laboratory findings, but they reflect the limited understanding of the transmission, etiology and risk associated with these diseases.

The reason that monkeypox and haemorrhagic fevers are considered together is that, apart from their geographic overlap, many of the methods used to detect and manage cases are similar. There are other important reasons for combining the surveillance of these diseases. Animal specimens from monkeypox écologie studies may well contain one of the haemorrhagic fever viruses - all such specimens must be tested in a laboratory having adequate containment faci­ lities, and with the capability to detect haemorrhagic fever antigen or antibody. Furthermore, specimens obtained from ill persons suspected to suffer monkeypox infection in these areas could contain one of the haemorrhagic fever viruses, with risk of infection among laboratory i workers who might carry out investigations for monkeypox in a laboratory without adequate safety features. This latter risk may be relatively small and such an infection has never occurred during the past ten years' surveillance of monkeypox.

As for any work of this sort, there will certainly be weaknesses, resulting from our incomplete knowledge of and experience with these diseases. The procedures, therefore, require constant correction and modification as information increases, particularly when these procedures have been applied in the field. In this respect, your proposals or sugges­ tions for future editions of the procedures are important and will be most welcome. Such comments should be addressed to the Director, Disease Prevention and Control, World Health Organization Regional Office for Africa, P.O. Box No. 6, Brazzaville, Congo, with a copy to the Director, Division of Communicable Diseases, World Health Organization, 1211 Geneva 27, Switzerland. . , •

1- INTRODUCTION : . •J-.'U:^ - • • • .:m;. ; ' i i "'

1.1 Need • ' • •

The diseases considered in this manual (Annexes lA-lD) are, with the exception of yellow fever, recently described. All of these diseases have been associated with outbreaks having high case-fatality rates. Many of these outbreaks have disrupted the health and administra­ tive services when quarantine, hospital closure and large-scale diversion of local, national and international resources occurred.

Early detection of outbreaks of disease with epidemic potential allows prompt and effec­ tive control. More complete knowledge of the clinical, epidemiological and écologie features of these diseases is essential for devising methods to control them and for developing long- term public health policies.

While the diseases mentioned above are the major interest of this programme, the surveil­ lance systems described herein can be adapted to detect such important public health problems as Rift Valley fever, Crimean-Congo haemorrhagic fever, dengue haemorrhagic fever, etc.

1-2 Objectives

•'••2.1 Monkeypox

In accordance with the recommendation of the Global Commission for the Certification of Smallpox Eradication, surveillance for human monkeypox should continue to 1985, at least. More ata are needed on the distribution, frequency, transmissibility and natural history of monkey­ pox virus, including identification of the reservoir of this virus. In 1985, if data thus CDS/SO.I page 6

collected confirm the conclusion of the Global Commission that monkeypox would not pose a threat to the achievement of smallpox eradication, the special surveillance procedures for monkeypox may be incorporated into the framework of national surveillance.

1.2.2 Viral haemorrhagic fevers

The objectives are to identify promptly cases of Lassa fever, Ebola virus disease, and Marburg virus disease, describe their epidemiology more completely and design better treatment and control measures for illness and outbreaks caused by these agents. For Ebola and Marburg virus diseases an objective will be to describe their natural history, including the reservoir of the agents causing these diseases.

As pertains to yellow fever, the techniques described in this document should be used to detect individual "sporadic" cases or the first case of a yellow fever epidemic if the diag­ nosis is otherwise uncertain. When the diagnosis of yellow fever is made the methods used for surveys and management of cases are different from those used for the other haemorrhagic fevers (see sections 2.6.3 and 3).

1.3 Criteria for strengthening the surveillance system - :

The basis for developing a more sensitive and responsive surveillance system depends on ;,, epidemiological and administrative factors.

Surveillance should be strengthened: in areas where cases have occurred or areas where the écologie milieu is similar to that where cases have occurred; in countries which express strong interest in surveillance activities: when there are adequate resources from national, WHO and other collaborating agencies in terms of personnel, transportation and other forms of material support.

2. SURVEILLANCE SYSTEMS ' . /• \' ' , • - , ' . • ^

2.1 Definition of epidemiological surveillance

Epidemiological surveillance is the process of collection, interpretation and distribution of information on rates of occurrence of a particular disease to estimate the variation of incidence and prevalence in order to take appropriate action for the control or eradication of the disease.

Hence, four key words summarize the use of information in any surveillance system:

COLLECTION - INTERPRETATION - DISTRIBUTION - ACTION r-., ,.

2 .2 Methods of surveillance

2.2.1 General I ..^i.: ''r..-,

Resources are limited in the areas where surveillance of these diseases should be developed. Therefore, whilst efforts should be made to develop a general surveillance capability in terms of awareness of health personnel of the need to report suspected cases of these diseases, priority should be given to implementation of just a few surveillance methods in a small area of great epidemiological importance. This approach would get optimal results using the relatively limited resources. With this in view, hospital-based surveillance deserves high priority, since a large proportion of patients with monkeypox and haemorrhagic fevers came to hospitals or got their disease there.

For the development and use of the special surveillance methods described below, there are two important points. Firstly, each method would be first used at specially designated health units or areas to study whether the proposed system is realistic and functions well. If practical, the system will be expanded. Secondly, the method, if requiring special sampling methods or laboratory investigations, such as a serological survey, should be reviewed by a national surveillance officer in consultation with WHO. Upon request WHO will make the necessary arrangements including laboratory back-up. CDS/80.1 page 7

2.2.1.1 Hospital-based surveillance

This is the first component of the surveillance system which should be established. The purpose of this type of surveillance in an endemic area is (1) to define more precisely the frequency of the disease; (2) to find fresh cases for study of secondary spread and for possible epidemiologic clues regarding the natural source; and (3) to identify specific areas or villages where more detailed studies of prevalence of antibodies and incidence of infection can be carried out.

2.2.1.2 Village surveillance : . :

Village surveillance can be either continuous or intermittent. This is an optional surveillance method which should be looked on as a more focused and special technique designed to gather more details about the epidemiology and ecology of a disease than are available from hospital surveillance alone. It should be established only after careful consideration of available resources and only in villages where the disease is known to occur. ,,

2.3 Monkeypox surveillance -• ' .,•

2.3.1 In areas of known occurrence

The strategy for these areas is designed to quantitate the frequency of occurrence, the transmission pattern and the clinical spectrum of disease.

2.3.1.1 Hospital-based surveillance ' . .loJL.-Jsf!. w.. i . - r -^M- • <

To establish an effective hospital- or dispensary-based system, the hospital personnel must be contacted, become interested and motivated and be trained to detect suspected cases. They must be able to register and report the specific needed information and to collect the required specimens. A reward system can be established; rewards can be paid to members of the public and/or health staff who properly report and investigate cases of rash disease or for reporting a case of monkeypox which is confirmed.

For the hospitals or dispensaries designated to participate in the programme, one or more persons at the facility must be trained to carry out the following steps:

- observe patients, especially children under the age of 10, for rash illness with a papular, vesicular or pustular eruption;

- take a history and fill out the information form provided (see Form 2A, Annex 2A) ;

- procure a lesion specimen (Annex 3), either a crust or a swab specimen,and fill out the specimen collection form (see Form 2B, Annex 2B);

- obtain specimens of skin lesions in the event of death;

- obtain an acute serum specimen (Annex 3). This is to be collected, allowed to clot, the serum decanted and stored at A^C or -20°C (if available); with each specimen a separate form (2B) must be completed;

- send the information and specimens to the surveillance officer or save for regular pick-up ;

- obtain a follow-up examination and serum specimen after three weeks.

The length of time for the report to reach the local surveillance officer should not be more than about three weeks. Highly suspect cases, particularly patients who are severely ill, should be reported immediately to the local surveillance officer and investigated in collabora­ tion with the national surveillance officer without awaiting laboratory confirmation of the etiology. Under the national surveillance officer's supervision, a full-scale investigation of family members as well as a control family should ensue, with serum specimens and more detailed epidemiologic information (see Form 2C, Annex 2C). CDS/SO.I page 8

Regular visits at least every three months by the national surveillance officer and close supervision will be required in order to make this system function. The local surveillance officer should work in close collaboration with the primary health care units in the area.

2.3.1.2 Continuous village surveillance

This technique requires someone stationed in a village to carry out daily surveillance for rash illness. If a resident surveillance officer is impractical, frequent visits can be made by a non-resident officer. Either the whole village or a cohort will be randomly chosen and a serum sample taken (Form 2C). Carefully done, this type of surveillance will describe the illness-to-infection ratio, in addition to other clinical and epidemiological features. .

Each household will be visited at an appropriate frequency, ideally at least once per week, to check for illness with fever and rash. Where the monkeypox and haemorrhagic fever surveillance actions are combined, the household visits should ideally occur at least three times per week. When an illness is identified, the patient is followed-up and a blood specimen is taken two weeks after recovery. In the case of a rash illness, a lesion specimen is obtained, in addition to acute and convalescent sera.

The entire cohort is re-bled approximately every six months (Form 2C), depending on resources and circumstances. Serum specimens are preferable, but filter-paper bloods can be used if handled properly; coordination with the laboratory is necessary.

Support and supervision are mandatory. To encourage participation, vitamins and iron pills can be distributed in the villages at the time of the mass serosurveys. The success of repeat serological surveys can be facilitated by offering some curative services when fever surveillance is being done.

Aspirin and chloroquine can be given to eliminate malaria as a cause of the fever. These systems always require the cooperation and support of a strong headman or chief, A village member who is designated for continuous surveillance should be properly trained and compensated.

2.3.1.3 Intermittent village surveillance with periodic serosurveys of the entire village population, or at least a cohort.

The objectives here are to detect the rate of seroconversion and determine a rough idea of the illness-to-infection ratio. Carrying out this type of surveillance will also require the cooperation of the village, especially of the headman or chief.

An entire village or at least a cohort of about 500 people should be chosen with sound statistical and epidemiological reasoning. They should be bled and followed-up with periodic visits and then re-bled at s ix-month intervals for one to two years. The repeated bleedings will allow calculation of a seroconversion rate. Periodic visits with identifica­ tion of severe rash illness will give a rough approximation of the illness-to-infection ratio. Clustering of seroconversion within families can be observed if it occurs.

The rates of seroconversion can be had by comparing prevalence of antibody by age, smallpox vaccination scars and pockmarks with results of previous serosurveys.

Nomads or other mobile populations will require special surveillance procedures using the same principles described in this manual. This may include visits to nomad camps, watering holes, periodic markets, etc. The periodic point prevalence survey is a good method for dealing with these populations.

2.3.2 In areas of unknown but suspected occurrence

The purpose of this method in these areas is to document the occurrence of sporadic cases, thus showing that the disease is endemic in the area under surveillance. CDS/SO.I page 9

2.3.2.1 Hospital-based surveillance

The system is to be set up as described in section 2.3.1.1. This is probably the most efficient way to set up surveillance for sporadic cases, but it must be supervised carefully.

2.3.2.2 Area surveillance

A technique which can be used in remote areas with no health infrastructure and where the occurrence of disease is uncertain, is village-to-village surveillance by a person on a bicycle or small motorcycle. The person would visit selected villages or compounds regularly, asking about rash illness (or other disease syndromes if surveillance is combined), collecting appropriate information and specimens where required. Only a limited number of areas can be covered in these surveys.

2.3.2.3 Seroprevalence survey '

A one time seroprevalence survey (Form 2C) can be done quickly in an area highly suspect for sporadic disease. The level of antibody titres by age-group can be very helpful in giving clues as to endemicity when compared to rates of vaccination scar and/or facial pock- marking.

2.4 Haemorrhagic fever surveillance ' '

The haemorrhagic fevers tan no longer be regarded as just strange and exotic diseases with little real impact on the population at risk. They have become important disease problems not only to the local population but to referral hospitals and other facilities in cities where such patients may be brought. Increased knowledge about the distribution, transmission and ecology of these diseases is needed in order to deal with them rationally and effectively. Despite differences in some epidemiological features and measures used for control of these diseases, the expense, the scarce resources available and the enormous difficulty in carrying out surveillance programmes in these areas justify some integration of surveillance methods for the haemorrhagic fevers with those used for human monkeypox.

The technique and rationale to be used are essentially those outlined under monkeypox surveillance, namely:

2.4.1 In areas of known occurrence

2.4.1.1 Hospital-based surveillance is used to identify cases for epidemiologic investigation and areas for more complete village surveillance and for possible écologie study (see section 2.3.1.1) .

2.4.1.2 Continuous village surveillance for studying the actual incidence of disease, the illness-to-infection ratio, and seroprevalence in various populations by age (see section 2.3.1.2) .

2.4.1.3 Intermittent village surveillance for studying seroconversion and clustering within families and villages (see section 2.3.1.3).

2.4.2 In areas of unknown but suspected occurrence

2.4.2.1 Hospital or dispensary surveillance - possibly a more efficient way to document sporadic cases if facilities are available. For details see section 2.3.1.1.

2.4.2.2 Area surveillance in remote areas without medical facilities where disease occurrence is uncertain. This is to document sporadic cases of haemorrhagic disease and define better the boundaries of endemic disease (see section 2.3.2.2).

2.4.2.3 Seroprevalence survey - see section 2.3.2.3 for details. CDS/SO.I page 10

2 .5 Organization and promotion of surveillance systems

2.5.1 Personnel, training and support , ,

A national health authority responsible for the detection and control of infectious diseases should be designated to direct surveillance for monkeypox and viral haemorrhagic ; ' fevers; he or she should be an epidemiologist qualified in medicine or a related field. Day-to-day surveillance operations should be the responsibility of a trained epidemiologist who works full-time on this activity. At least two health officers (nurse, health inspector, technician, etc.), trained in epidemiology and surveillance of these diseases, should be assigned at the national level for integrating surveillance of these diseases into the health care system in priority areas.

The existing epidemiological infrastructure should be used in countries where there have been no cases of these diseases or where resources are not available to have a special programme

Two vehicles, a secretary, office space and adequate financial and other administrative support should be assigned to this project at the national level. Where available and indi­ cated, existing personnel and resources should be used.

A local health officer at the regional and district level should be designated and trained to coordinate surveillance for these diseases in the area under his or her jurisdiction; this person may be responsible for surveillance of other diseases. Each hospital and health care unit in priority areas should have one person designated and trairted to do surveillance. In areas where village surveillance is done, a village surveillance officer should be designated and trained. The appointment of a specific person assigns responsibility and accountability; these are important elements in the management of a successful surveillance programme.

All persons working in the surveillance network will need special training and be provided with specimen collection kits, forms, visual aids and other materials. To stimulate reporting on these diseases, technical information should be distributed to peripheral health and admini­ strative authorities. _ , .i m ,. -v • . v,:,: . . . •.

At the hospital and health units and in the participating villages a register listing all of the deaths will be kept (Annex 4A). Another register will indicate persons with signs and symptoms of disease possibly due to monkeypox or viral haemorrhagic fever (Annex 4B). sï i 2.5.2 Notification

Countries should strongly consider making these diseases "officially notifiable", thereby including them in their routine reporting forms (weekly, monthly, etc.). A periodic feed­ back surveillance bulletin (monthly, quarterly) with information on these diseases would be a strong stimulus for reporting.

In the past a reward system has been used successfully to promote detection and reporting of monkeypox cases. Countries may wish to consider this method of stimulating local interest.

2.6 Epidemiologic investigations

Active surveillance is critical for the identification of new cases of monkeypox or haemorrhagic fevers. However, the epidemiologic investigation of each new case is equally important in order to identify the risk factors associated with person-to-person spread, to describe adequately the clinical and epidemiologic features of the illness in different areas, and to gather clues regarding the natural reservoir of these diseases.

Clearly not every suspect case of illness can or should be followed by intensive investi­ gation. In order to make efficient use of resources, criteria must be established for immediate and eventual epidemiologic investigation of a suspect case. Furthermore, specific procedures must be established for doing the epidemiologic investigation so that data collected by different groups in different areas at different times are comparable. CDS/SO.I page 11

If there is doubt about whether a patient fits case criteria for monkeypox or haemorr­ hagic fever, specimens should be collected, an investigation should begin, and data recorded. A decision on the extent of further investigations can be made on the basis of laboratory results.

2.6.1 Monkeypox • -,

Criteria for case suspicion and reporting from village or dispensary to intermediate level health unit (hospital). Suspicion of monkeypox will be evoked by:

- any unvaccinated person, particularly children, coming from tropical rain forest areas to the hospital with a febrile illness and a vesicular or crusting skin rash ' for which a diagnosis cannot be determined;

- patients dying with a diagnosis of chickenpox or having a severe atypical rash thought due to chickenpox or another eruptive disease (especially if hospitalized);

- persons having five or more facial pockmarks due to disease occurring since small­ pox was eradicated in the area and not due to another disease.

Particular care must be taken to assess and accurately describe the clinical picture and to fill out the clinical form. Whenever possible, questions should be asked in the patient's native language. A serum specimen is to be obtained along with lesion specimens (see instruc­ tions and Forms 2A, B and C). The patient's movements and contacts with humans and animals prior to disease onset should be carefully listed (see forms). A second blood specimen must ' be obtained two to three weeks after the specimen taken during the initial illness to deter- ' mine if there has been a rise in antibody titre indicating an acute infection. '•

2.6.1.2 Criteria for a more complete follow-up investigation to include interviews with family and village contacts. Contact to be made with national health authorities.

- A patient with severe illness clinically resembling monkeypox or smallpox (Annex lA) should be reported to the national surveillance officer to be investigated immediately.

- A patient with a mild or moderate illness clinically like monkeypox or smallpox should be investigated without waiting for laboratory confirmation.

- All laboratory-confirmed monkeypox cases, regardless of clinical presentation, must be investigated. •• i: '

When there are several patients requiring follow-up, priority must be given to those most nearly fitting the suspect case criteria for monkeypox. -

2.6.1.3 Actions during the complete follow-up investigation

2.6.1.3.1 Interviews will be conducted with household members and other persons who might have been in contact with the patient, both before and after the onset of illness, to determine if the monkeypox virus has spread, and to aid in finding the human (or animal) source of this or related diseases. Each individual household member and close contact must be interviewed. Information on household matters, on other close contacts of the patients, and village members should be recorded as shown on Form 2C. Since all but one human'monkeypox case has occurred in small villages of less than 1000 persons, this should not be too difficult for monkeypox cases. The following are recorded: relationship and degree of contact with the index patient, the smallpox vaccination status, recent illness (note specific signs and symptoms) and exposure to local animals and insects. Information should be sought on recent deaths in the village due to diseases which might fit the criteria for monkeypox. These include those thought due to chickenpox and other eruptive disease. House-to-house visits are usually necessary to identify all cases in villages known or suspected to have had monkev pox cases. .^juivcy- CDs/80.1 page 12

2.6.1.3.2 Facial pockmark surveys. Experience has shown that most patients recovering from smallpox-like disease are left with at least five facial scars of 1 mm or more in diameter. While these should be carefully looked for, it should be remembered that it is possible that scarring from monkeypox may be less severe and that facial pockmarks may not be present; if the clinical history is compatible with monkeypox, a serum should be taken. If five or more pockmark-like scars are present but are determined to have been caused by another disease, this should be noted. Persons found with facial pockmarks possibly due to smallpox-like disease but having onset since smallpox was eradicated should be investigated using Forms 2A-C and a serum sample taken for study of poxvirus antibody.

2.6.1.3.3 Serum collection from contacts. During the course of the investigation, serum specimens should be taken from all family members, irrespective of vaccination scar status, and other close contacts. Additionally, serum specimens should be taken from 40 to 50 persons in the village who had no direct contact with the patient during the illness and matched for age, sex and vaccination history with sera from those who did have contact. This is required in order to assess the role of close contact in the spread of disease. Information should be entered on Form 2C.

2.6.1.3.4 Animal studies. Data on possible natural sources of these illnesses may be obtaine by questioning persons about recent domestic or wild animal deaths in the area, especially thos species which may have come in contact with the patient. Special efforts should be made to find animals with skin eruptions or those dying from unexplained causes. Animal names in the local language should be used when asking about the animals and recorded along with the English or French name. Photos are useful in identifying local species and these should be available to investigative teams. Under most circumstances the capture of animals for identification and for virological and serological studies requires the collaboration of a specialized mammo-. logy team. Ecological studies should not be undertaken without prior consultation. WHO wil]^ coordinate these investigations upon request.

2.6.2 Haemorrhagic fevers ..... • .' -

2.6.2.1 Criteria for case suspicion and reporting (including yellow fever) - • '

Clinical criteria for suspecting a case of viral haemorrhagic fever are prolonged fever (three days or more) often to 39 or 40°C, severe prostration, with bleeding and/or jaundice. Clinical data are to be collected and entered on the clinical form (2A). An acute serum specimen must be obtained using appropriate precautions. If the patient survives, a follow-up blood specimen must be obtained after two to three weeks. In the event of death, a post­ mortem liver biopsy and heart blood must be obtained according to the methods described under specimen collection (Annex 3).

Two unexplained deaths in one week, linked in time and place, in patients having signs and symptoms compatible with these diseases, should trigger an immediate investigation.

2.6.2.2 Criteria for a more complete follow-up investigation (excluding yellow fever)

- A patient with severe febrile illness and bleeding leading to death must be followed up immediately.

- A patient with prolonged fever, abnormal bleeding, but who does not die should be investigated without waiting for laboratory confirmation.

_ p^ii laboratory-confirmed cases, regardless of symptoms, must be followed-up with an investigation.

2.6.2.3 Actions during the investigation

2 6 2 3 1 Interviews will be conducted with household members and other persons who might have been in contact with the patient to determine if a virus causing haemorrhagic fever has spread and to aid in finding the human (or animal) source of this or related diseases. CDS/SO.I page 13

Each individual household member and close contact must be interviewed. Information on house­ hold members, on other close contacts of the patient, and village members should be recorded as shown on the appropriate form (2A-C). Stress is placed on the relationship and degree of con­ tact with the index patient, recent illness with specific signs and symptoms, and exposure to local animals and insects. Data should be gathered on recent deaths in the village due to diseases which might fit the criteria for haemorrhagic disease.

2.6.2.3.2 Serum collection from contacts. During the course of the investigation, sei_.. îrum specimens should be taken from all family members and other close contacts to find if spread has occurred (Form 2C). Additionally, serum specimens should be taken from persons in the village who had no direct contact with the patient during the illness and matched for age and sex with sera from those who did have contact, using appropriate epidemiologic methods. This is required in order to assess the role of close contact in the spread of disease.

In the event of a confirmed or highly likely case, village serosurveys should be done in addition to the serological study of secondary transmission.

2.5.2.3.3 Large-scale serosurveys

The selection of specific areas for establishing the initial surveillance system for ' ' monkeypox and haemorrhagic fevers will be based on proven occurrence, or écologie similarity to other areas of known disease occurrence.

Once the area has been defined, a list of villages or other individual administrative units should be made and six of these should be chosen at random for performing serosurveys. The six villages are chosen on the basis of logistical considerations. However, before a serosurvey is begun contact should be made with the laboratory and other needed advisers to ensure that appropriate tests can be done promptly and that the survey method is the most desirable. Each village is visited before the bleeding activities begin, to gain the coopera­ tion of the chief or headman, A map of the village, numbering each house, will be made, and a rough census performed. In order to do the census, 10 or 15 houses, or roughly 10% of the number of houses in the village, will be chosen for contacting and collecting exact information on the number of people and age-distribution in each of the households. Based on this infor­ mation, a random selection of houses will be made such that the total number of people in each desired group to be bled will be approximately 200. Data forms will be completed (Form 2C) and serum specimens collected from each member of the household chosen for study. To promote monkeypox surveillance concurrently, in the "6 village survey" about 200 children below 10 years of age and without vaccination scars will be bled and included in the study group.

Members of the surveillance team must be specifically trained to take serum specimens from children. This training may best be accomplished at a hospital. Specimens are to be collected and processed according to procedures outlined in the specimen collection protocol. After the team has gained experience in two villages, no more than four to five days should be required to carry out such a serosurvey.

2.6.2.3.4 Animal studies. As for monkeypox, data on possible natural sources of these ill­ nesses may be obtained by questioning persons about recent domestic or wild animal deaths In the area, especially those species which may have come in contact with the patient. Animal names in the local language should be used when asking about the animals and recorded along with the English or French name. Photos should be used in identifying local species.

2.6.3 Yellow fever

Surveillance and investigations should follow the principles utilizing hospital/health unit based surveillance, proper collection of specimens, and notification to higher authorities. Special methods for investigations should utilize the following documents as a guide:

- Technical guide for a system of yellow fever surveillance, WHO Weekly-Epidem--" oloeical Record, No. 49, 1971, pp. 493 - 500. CDS/SO.I page 14

- Note on yellow fever in Africa, (1) Virological aspect, (2) Entomological aspect, VIR/79.1, 1979 (available from Virus Diseases unit, WHO, Geneva).

- Working papers No. 2 - Investigation of Yellow Fever Outbreaks, and No. 3 - Yellow Fever: Epidemiology and Entomological Surveillance; presented at the Seminar on Surveillance of Monkeypox and Viral Haemorrhagic Fevers, 28 April - 2 May 1980, Brazzaville.

3. MANAGEMENT OF CASES

3 .1 Initial considerations including burial

Management of the patient depends to a certain extent upon the location of the patient when the disease is first diagnosed. As soon as the diagnosis of monkeypox, Lassa fever, Marburg or Ebola virus infection, or any other dangerous pathogen, is suspected the patient must be isolated to prevent secondary infection; if the patient is suspected of having yellow fever an effective mosquito net should be employed.

The patient should be isolated and barrier nursing techniques using available persons, equipment, clothing and materials must be instituted immediately if Marburg or Ebola virus infection. Lassa fever or any other dangerous pathogen is suspected. Persons investigating and caring for monkeypox patients should have been successfully vaccinated or revaccinated against smallpox within the previous three years; only those staff caring for the patient need to be vaccinated against smallpox. Persons investigating and caring for possible yellow fever cases should have been immunized against yellow fever within the previous 10 years.

If the patient is diagnosed at home, consideration should be given to providing treatment at this site unless better care could be given at a health unit. When a patient is kept at home, those in contact should take every precaution to prevent their contracting the disease. They should be separated from others in the village to prevent community spread. Barrier nursing techniques and other procedures described later (sections 3.1.2, 3.1.3) should be adapted to this situation. If the diagnosis is made at a rural clinic or health centre, the patient should be given treatment at this site rather than transporting the patient to a hospital. Carefully controlled barrier nursing should be established in part of the facility and no other activity should take place there. , .!.;>:,: . ; ; .

The transport of persons suspected of having one of the haemorrhagic fevers requires con­ siderable care during the trip and preparations must be made at the receiving institution. Travel stress to a severely ill person can be detrimental. During epidemics of haemorrhagic fevers in rural areas, or even cities, however, it is often desirable to quarantine patients at a local hospital or medical facility. This will decrease the likelihood of further cases occurring in the family, a major risk if the patient is cared for at home. In order for the patient to be transferred, adequate transport must be available, and trained medical staff must be present in order to properly care for the patient. Patients with suspected or proven yellow fever should not be moved out of the infected zone.

It is very unlikely that a special high security plastic "transport isolator" will be available for such transport. If not, an open pick-up truck or the back of any other vehicle should be used; the patient is placed on a stretcher in the rear. Two persons should attend the patient. Both should wear a disposable gown (if available) or cloth gown. Shoes with coverings (cloth will do) are important. The attendants should wear rubber gloves, masks and goggles or glasses. Respiratory masks are desirable if available. However, experience strongly suggests that a surgical mask made of cloth or heavy paper will suffice. The driver of the vehicle need wear only a mask and gloves and should not come in contact with the patient

When the patient is removed from the vehicle, the bed of the vehicle should be sprayed with 2% formaldehyde or a hypochlorite solution (10% household bleach) and then thoroughly rinsed with copious amounts of water to prevent harm to the truck bed (see Annex 5A). The protective clothes of the attendants are then destroyed if they are disposable, or disinfec­ ted by soaking in a formaldehyde or hypochlorite solution and then washing in water (Annex 5A). CDS/80.1 page 15

Decontamination of spaces is discussed in Annex 5B. Experience has shown that in certain areas some people are unwilling to reveal cases of haemorrhagic fever in their family because they believe that if patients are transported to the hospital and die they may not return home for burial. The same safety precautions can be used for transporting the body of a person who died of haemorrhagic fever back to his home for burial.

Corpses should be wrapped in two thicknesses of absorbent sheeting soaked with a disinfec­ tant (Annex 5A) and then further wrapped in a plastic sheet. Burial should be brief and limited to only essential family members. When a patient dies at the hospital, public health authorities should assure that contact with the corpse is restricted only to those wrapping the body. It is advisable that staff from the health unit attend the burial to assist in handling the body to minimize risk of infection of family members during the burial rites.

Under some circumstances, such as a large epidemic, or where no transport or medical facility is available, patients may remain in their village. In the village the same safety procedures should be used. The risk of close contact with the patient should be explained to the family and contacts should be minimized, as persons caring for such a patient may become infected. In order to minimize this risk the person caring for the patient should be given instructions on how to reduce direct contact, both with the patient and the patient's poten­ tially infection excretions and blood. Simple protective clothing such as a gown, gloves and mask and some disinfectant should be supplied. A guard may be posted to limit the patient's contact to a single person or two persons who will be caring for him. Wherever possible a member of the health staff should assist in all aspects of the burial.

3.2 Protection of personnel , • •

All hospital staff (including staff in the laundry, janitors, repair men, etc.) must take every precaution to prevent direct contact with the patients, their body discharges and diag­ nostic samples. Patient contact with non-essential personnel must be kept to a minimum. This does not mean that the patient cannot and should not receive every element of normal medical care, however. It simply means that the procedures must be carried out with care. For this reason protective clothing should be worn at all times.

There are several options which can be taken in supplying protective clothing to hospital personnel: ideally, a disposable gown, full-face respirator equipped with high efficiency particulate air (HEPA) filter, disposable gloves, trousers, head and shoe covers, all of waterproofed material, are desirable, if available.

In the event that disposable clothing and protective gear are not available, improvisation is required. If full-face masks with HEPA filters are not available, then half-face masks with HEPA filters may be used. Eyes can be protected by a full-face plastic visor or shield. If respirators with air filters are not available, the next best protection is provided by the disposable paper surgical mask. Care must be taken to ensure that the mask fits tightly around the entire peripheral surface of the face; a wet surgical mask loses its effectiveness and should be changed as frequently as possible. Goggles, glasses or a face shield should be worn for face protection. However, field experience has shown that use of surgical masks, gowns and gloves in conjunction with proper technique has offered satisfactory protection.

Washable "scrub-suits" and surgical gowns can be substituted for the disposable protec­ tive clothing. A rubber or plastic apron should be worn over the gown. Effective protection can also be provided by improvising water-resistant garb from large plastic bags. Hoods can be improvised in the same manner. Smaller plastic bags can also be substituted for boots and, if necessary, for rubber or plastic gloves. In improvising protective clothing one must carefully ensure that an effective physical barrier is provided between the patient-care staff (nurses, laboratory workers, cleaners, laundry workers, etc.) and the patient, his/her excre­ tions and secretions. CDS/80.1 page 16

Personnel entering the isolation rooni(s) should, if possible, wear protective clothing of the disposable type which is used only once (see Annexes 6 and 7). After use it is discarded into a covered receptacle lined with a large plastic bag at the exit from the isolation facility If disposable protective clothing is not available, multi-use garments should be used only once and then sterilized and laundered with caution to avoid contamination of laundry personnel or equipment prior to reuse. Where supplies of protective clothing are limited, modification of procedures may be necessary, but potentially contaminated items should be removed from the facility in well-closed plastic bags and taken for sterilization by autoclaving or boiling or for incineration.

Special attention must be paid to the correct method of removing protective clothing so that potentially contaminated surfaces never touch the wearer's bare hands, face or uncontamina- ted materials and equipment. Gloved hands are first rinsed in a disinfectant solution (sodium hypochlorite containing 5000 ppm available chlorine - Annex 5A). The apron, head and shoe covers are then removed and discarded into a plastic bag designated for decontamination and/or sterilization or incineration. The gown and gloves are next removed in one single operation taking care to fold the gown inside out in the motion. Wearing a fresh pair of gloves, the trousers are removed and placed in the bag with the other discarded clothing. The respirator is next removed and sponged off with the sodium hypochlorite solution and replaced in its con­ tainer. The second pair of gloves is removed and placed in the discarded bag. As a last step, the hands are washed with soap and water.

Extensive experience with Lassa fever and more limited experience with Ebola virus has shown that the careful use of reusable gowns, gloves and masks can be effective in preventing transmission to hospital personnel. Masks, caps and gowns can be made from inexpensive cotton cloth. While surgical gloves are desirable, thinner latex gloves can be used if checked carefully for cuts and cracks.

After the patient is examined the gloved hands are rinsed in hypochlorite or formaldehyde solution and then mask and cap are removed and placed in a container with one of the two disin­ fectants. If the gown is not wet it can be removed and hung up for multiple use during the day. The gloves are then rinsed again in disinfectant, removed and placed in a container of water to prevent rapid deterioration of the gloves. The masks, gloves and caps are then washed in soap and water, rinsed and dried for reuse. Gowns should be rinsed in disinfectant washed in soap and water, rinsed and dried at the end of each day. If the gown becomes wet during patient care, it should be removed and disinfected and the area of clothes or skin underneath should also be disinfected.

Health personnel caring for the patient should be under medical supervision. A written record should include daily temperature and presence or absence of any signs or symptoms. These people should not have widespread contact with the community. Restriction of their movements should be related to the degree of contact with patients.

3.3 Patient isolation '' '

In the event that special isolation units are not locally available the patient(s) should be isolated in a separate building, room or ward to ensure complete isolation from other patient areas. If there is a suitable private room which contains an entry anteroom it should be used Anterooms should have handwashing facilities and contain supplies for the patient, protective clothing for the medical staff and facilities for preparing materials for disposal which are taken from the patient's room. If there is no anteroom the area within the room adjacent to the entrance door should be separated from the rest of the room by furniture, curtains or other- physical barriers to form a temporary anteroom. The anteroom enforces proper procedures and provides for handwashing facilities, the storage of supplies, protective clothing and medical equipment, and is a "dirty" area for preparing materials for removal. A system of separating patients by separate rooms or areas into those suspected and known to have the disease should be established. CDs/80.1 page 17

Access to the isolation room or area must be strictly controlled. It should be located so that there is no hospital traffic passing the room door. The door is to be kept closed. The management of the patient(s) should be organized as to limit the number of persons in and out of the room. There should be no cross-circulation of personnel or materials from other hospital areas. The room should have good ventilation through screened windows and doors. Any mechani­ cal ventilation system which recirculates the air throughout the hospital should not be used. Fans which may raise and circulate dust and droplets should not be used unless absolutely required for the patient's welfare.

3.4 Patient care and management

The guiding principle for care and treatment is that the patient must not be abandoned. It has been shown that care can be given with minimal risk to the hospital personnel if certain basic supportive measures are kept in mind.

The minimum number of staff should care for the patient. This should be at least three in a 24-hour period, allowing at least one person responsible for the patient at all times. ' ' The treatment area should be isolated from the rest of the hospital. Family members and other persons should not have contact with the patient until recovery. (A recovered patient is defined as having absence of fever for at least five days.)

The fever must be treated. Sponging the patient with water and use of acetominophen (Tylenol) (not aspirin, because it can cause bleeding) is recommended to decrease the tempera­ ture. This will reduce the tendency towards dehydration. Preventing dehydration is a key element in the treatment of the disease. Oral rehydration should be used as much as possible. Intravenous fluids should be used when oral rehydration is not possible. With severe gastro­ enteritis the use of potassium and bicarbonate in oral or intravenous fluids is important.

Exsanguination is unusual. However, transfusion with whole blood may be needed, particu­ larly after the rehydration of an initially dehydrated anaemic patient. Death usually follows a profound drop in blood pressure which does not seem to be attributable to simple hypovolemic shock. Nevertheless, attention must be given to maintaining the blood pressure while not causing congestive heart failure.

Specific immune plasma may be of value in treating cases of haemorrhagic fever which come to the hospital within five days of onset of illness. If plasma is administered, serial daily serum specimens are to be collected, and careful clinical information recorded, in order to better assess the value of plasma therapy. The effectiveness of specific immune plasma for Lassa fever, Ebola and Marburg diseases has not been proven. A research protocol should dictate the use of plasma. Plasma should only be collected from patients proven to have recovered from these diseases. WHO should collaborate in activities related to plasma collection and use.

As described above, hands should always be washed after contact with the patient or contami­ nated material. The disinfectant and washing facilities should be conveniently placed at the entrance of the anteroom. Hands may be rinsed in a disinfectant and then washed in soap and water. Mechanical soap dispensers and disposable paper towels are highly recommended. If a sewage disposal system is not available the washing water can be disposed of in latrines.

Each patient should have an individual thermometer labelled with his/her name and kept in a receptacle containing a disinfectant (alcohol/iodine solution) at the bedside. This equip­ ment can be decontaminated between use by rinsing in a disinfectant solution (sodium hypo- ' chlorite containing 5000 ppm available chlorine). Other reusable instruments should be placed, ' after use, in a disinfectant solution and regularly removed from the isolation area for steam * sterilization or boiling. Used equipment and materials leaving the room must be placed in watertight plastic bags for transport to the sterilization or disposal facilities.

Bedding and other linen must be placed in plastic bags and removed for sterilization by autoclaving or boiling before being laundered. The use of disposable bed linen is recommended if available. CDS/SO.I page 18

All body secretions and excretions should be treated with sodium hypochlorite (5000 ppm available chlorine) before being removed from the isolation room. The patient should use a chemical toilet, bedside commode or bedpan in lieu of toilet facilities which may be provided within the isolation area. If bedpans are used they should be labelled with the patient's name and not used by other patients until after being sterilized. Used bedpans must not be left in isolation facilities but be immediately filled with the sodium hypochlorite solution (5000 ppm available chlorine) and placed in a plastic bag. After allowing time for the disinfectant to act the bedpan can be removed (inside the plastic bag) and emptied into a toilet or latrine either inside the isolation area or in some area of the facility separate from other patient areas. The bag and bedpan should be thoroughly rinsed with the disinfec­ tant and returned to the isolation area. The bag should not be reused but be placed in a discard receptacle for incineration. When available, disposable bedpans which can be incinerated following each use should be used. Used containers for vomit, urine or other potentially contaminated materials should receive the same treatment.

The hospital should arrange to supply food and drink for patients in the isolation facility. All eating utensils should be used only by the patient. They must be washed and treated with the disinfectant solution within the isolation area. Uneaten food is to be regarded as infectious and disposed of accordingly.

3.5 Room decontamination

All spaces with which the patient has come in contact should be decontaminated. Known or potentially contaminated surfaces of transport and isolation equipment, hospital rooms and conveyances can be decontaminated by applying the sodium hypochlorite (5000 ppm available chlorine) solution. Interior spaces that are known or suspected of being contaminated can be decontaminated by fumigation with formaldehyde gas (Annex 5B).

4. COLLECTING AND SHIPPING DANGEROUS PATHOGENS

4.1 Personal protection ' ' '

Laboratory and/or other staff entering the isolation area, collecting samples and working with the patient(s) must conform to the same degree of personal protection as described above, Extreme care must be exercised to avoid self-inoculation with needles and other sharp instru­ ments .

4.2 Sample collection - procedures . .' • - ''''

Contingency planning should provide for an ample supply of equipment for sampling and shipment of specimens. These include sterile vacutainers, sterile disposable needles and syringes, screw-cap containers, sterile thick-wall glass phials for collecting and trans­ porting specimens. Blood is obtained by aseptic venipuncture in sufficient quantity for serology, haematology, blood chemistry and blood culture examination (40-50 ml). Extreme care must be exercised to avoid self-inoculation with needles and other sharp instruments. Used syringes and needles and vacutainer sleeves should be discarded into a covered deep pan containing a sodium hypochlorite solution (5000 ppm available chlorine); the solution should cover the materials immersed in it.

All collection equipment must be effectively decontaminated prior to disposal or reuse (Annexes 5A and 7). When disposable equipment is not available then reusable materials must be used with extreme caution. All reusable materials, i.e. needles, syringes, etc., must be sterilized between each use. The outside of each specimen container should be swabbed with the sodium hypochlorite solution, be placed in a double plastic bag and then the bag should be immersed in the sodium hypochlorite solution when it is removed from the isolation area.

Procedures for specimen collection, including liver biopsy, are in Annex 3. CDS/SO.I page 19

4.3 Local field and laboratory procedures

Attempts at isolation and identification of viral haemorrhagic fever agents and other suspected dangerous pathogens must be carried out in maximum containment laboratories.

In an emergency, essential laboratory procedures such as (a) complete blood count, including differential count of white blood cells; (b) platelet count; (c) blood smear for malaria parasites; (d) urinalysis; (e) blood culture for enteric fevers; (f) slide test for infectious mononucleosis; (g) throat swab cultures; and (h) stool and urine cultures if required, and other investigations in clinical chemistry and haematology may be needed. Because of the emergency situation they must necessarily be carried out at the local laboratory. In these instances the person performing the laboratory examinations should isolate the equipment necessary for the performance of the examination in a separate room or building.

These specimens can only be handled safely on the open bench or in the field in such circumstances: if the technician is suitably garbed (minimum: gown, surgical gloves and full-face respirator with HEPA filter) and uses correct laboratory techniques. However, it is strongly advised that the tests be done in a laboratory equipped with a biological safety cabinet where the technician wears protective clothing of the same standard as that recommended for nursing and medical care of the patient. If these standards cannot be met it should be considered to submit specimens to a suitably equipped laboratory to which their transfer is feasible.

Care must be taken to minimize potentially hazardous procedures such as ones that produce aerosols. The laboratory equipment used to process such specimens from patients should be thoroughly decontaminated before being returned to routine use. Surfaces in contact with potentially contaminated fluids may be effectively decontaminated by flushing with a sodium hypochlorite solution (5000 ppm available chlorine). Items such as complex instruments that may have been contaminated with aerosols and cannot be effectively treated with hypochlorite can be decontaminated with ethylene oxide or formaldehyde (Annex 5A). Disposable components and excess specimens should be placed in a 5000 ppm available chlorine sodium hypochlorite solution and autoclaved prior to their disposal (Annex 5A). It may further be desired to decontaminate the laboratory space in which the examinations were performed. This may be accomplished by the method described in Annex 5B.

Persons working with specimens from patients with suspected haemorrhagic fevers should be under daily medical surveillance. This should include, as a minimum, recording of tempera­ ture twice daily and immediate reporting of any illness to his/her supervisor. He/she should take antimalarials if in an area endemic for malaria.

4.4 Post-mortem procedures ,,

If a post-mortem is carried out extreme precaution must be observed. The pathologist and anyone else assisting in the room should wear protective clothing as previously described. As there is a serious risk of contamination by aerosols a full-face respirator with HEPA filter should be used as it will provide more protection than a surgical mask and goggles or visor. Washing of body cavities or rinsing of tissues should be avoided. Body fluids should be absorbed on suitable material which should be left in body cavities. Pieces of tissue removed for histological examination should be immediately immersed in a fixative such as formalin. Specimens for virological studies should be put directly into a sterile screw- cap container which should then be rinsed in formalin and immediately removed from the room When the post-mortem has been completed the room should be thoroughly washed with the 5000 ppm available chlorine sodium hypochlorite solution and left unused for three days with maximum ventilation. CDS/SO.I page 20

5. SHIPMENT OF INFECTIOUS AGENTS AND DIAGNOSTIC SPECIMENS

5.1 Packaging

A special kit is available from WHO (Smallpox Eradication unit, WHO, 1211 Geneva 27 Switzerland) for collection of specimens from suspected monkeypox patients (see Annex II photograph 2). If this kit is not immediately available, local materials can be improvised following recommended packaging procedures.

Packaging specifications for infectious agents and diagnostic specimens have been formulated by the World Health Organization, the International Air Transport Association (lATA), and the Universal Postal Union (UPU). The specifications have been developed to maintain the specimen's suitability for laboratory examination, prevent cross-contamination and to safeguard personnel handling the package and the public in the event of damage to the package. Specific packing instructions and procedures are provided in Annex 8. To conform to the requirements the packaging is in three layers: (1) a primary watertight receptacle containing the specimen; (2) a secondary watertight receptacle enclosing enough absorptive material between it and the primary receptacle to absorb all of the fluid in the specimen in case of leakage; and (3) an outer package which is intended to protect the secondary package from outside influences such as physical damage and water while in transit.

It is important to securely tape on the outside of the secondary container one copy of the specimen data forms, letters and other information which identify or describe the specimen (Another copy should be sent by airmail to the receiving laboratory and a third copy retained by the sender.) In this manner the receiving laboratory can identify the specimen and make the decision regarding safe internal handling and examination.

5.2 Centres to send specimens for diagnosis

5.2.1 Monkeypox ' '

For suspected monkeypox cases all specimens should be sent to the following address where all arrangements will be made for onforwarding and notification of results to the sender- Chief, Smallpox Eradication unit World Health Organization 1211 Geneva 27 Switzerland

The following WHO Collaborating Centres will then receive the specimens after being con­ tacted by WHO:

Chief, Viral Exanthems Branch or Chief, Smallpox Prophylaxis Department Bureau of Laboratories Research Institute of Virus Preparations Center for Disease Control 1st Dubrovskaya ul. 15 Atlanta, Georgia 30333 Moscow United States of America Union of Soviet Socialist Republics

5.2.2 Yellow fever

Specimens should be sent to:

Institut Pasteur de Dakar or Institut Pasteur d'Abidjan 36 avenue Pasteur Boîte postale 490 Boîte postale 220 Abidjan Dakar Ivory Coast Senegal

The WHO Regional Office or the Virus Diseases unit, Geneva, can advise on the availability of other research centres to do rapid diagnosis and collaborate in research activities. CDS/SO.I page 21

5.2.3 Lassa fever, Ebola virus disease, Marburg virus disease, other haemorrhagic fevers

Specimens should be sent to: . .. ,

Chief, Special Viral Pathogens or Director, Special Pathogens Reference Bureau of Laboratories Laboratory Center for Disease Control PHLS Centre for Applied Microbiology Atlanta, Georgia 30333 _ . and Research United States of America Porton Down ' • ' - • Salisbury , Wiltshire England '

The WHO Regional Office or the Virus Diseases unit, Geneva, can advise on the availability of other research centres to do rapid diagnosis and collaborate in research activities.

5.3 Responsibility of the sender • .-i - •'•

The key to getting prompt specimen testing results is good coordination between the sender and the laboratory. WHO can facilitate this coordination; both the regional office and the appropriate technical unit at WHO, Geneva, should be contacted.

Transportation of infectious substances requires coordination between the sender, carrier and receiver to secure safe transport and arrival on time and in proper condition. This requires the following actions by the sender;

- advance arrangements between sender, carrier and receiver to assure specimens will be accepted and promptly tested; this should be done by telephone and/or cable;

- preparation of dispatch of documents; :-.^ ' 't: >'r: i • n to;- iOOa

- routing;

- timely notification of all transportation data by the sender to the receiver;

No dispatch of infectious substances is to be made before advance arrangements have taken place between sender, carrier and receiver, or before the receiver has confirmed with his national authorities that the substance can be imported legally and that no delay will be incurred in the delivery of the consignment to its destination.

5.4 Responsibility of the receiver ,;jT-i; ^ ; i ; •: -, A-.-.-' ,

It is the responsibility of the receiver to obtain the necessary authorization from national authorities for the importation of infectious substances. The receiver must provide' to the sender the required importation permits, letters of authorization or other documents required by national authorities where the specimens originate.

Upon receipt of known or suspected high-risk infectious substances of human or animal origin, the receiver should immediately acknowledge receipt to the sender.

5.5 Shipping documents and forms

The sender must provide the carrier with signed certification that the substance is properly packed and can be legally accepted by the receiver. The lATA Shipper's Certifica­ tion for Restricted Articles is suggested as a model (Annex 9).

In order to secure transmission without hindrance it is necessary to prepare all dispatch documents, i.e. waybills, shipper's certification for restricted articles and/or other docu­ ments that may be required, in strict accordance with rules governing the acceptance of materials to be dispatched (Annexes 9 and 10). The following sentence should be quoted on waybills: "Infectious substance for diagnostic, research and scientific purposes only - no commercial value - do not delay - do not open in transit". If the substance is perishable. CDS/SO.I page 22 warnings must also appear on the waybill; for instance: "Keep cool +2/+4°C" or "Keep frozen" or "Do not freeze". The full address of the receiver must be shown on the waybill, together with the name of a responsible person and his telephone number.

In the case of shipment by air, dispatch should be made whenever possible on direct flights. When transfers are necessary, precautions should be taken to ensure expeditious handling. lATA regulations require that packages containing infectious substances should not be consolidated with other consignments. Waybills should show air transport flight numbers with data and designation of any airport(s) of transit.

The sender must notify the receiver in advance of shipping details, such as type and number of specimens, means of transport, flight number(s), waybill number, date and hour of expected arrival at the point of destination so that the consignment can be collected promptly. Advance telegraph and telephone communication must always be used for this notification. The same information should be transmitted by mail. The article number, proper shipping name of the article, the class and packing note and special handling information must meet requirements of the current lATA regulations. The annexed "Infectious Substance" label (Annex 10) must also be attached to the package. ?: .JÏ.: J. • • > v

Shipper's certification forms (Annex 9) are available from most air carriers. This form and the Infectious Substance label can be purchased from:

(1) Bartsch Verlag KG . Tel: (089) 601 3031 P.O. Box Telex: 522 123 D-8012 Ottobrun-Munich fj; Federal Republic of Germany " ' ^ •^'^ .. ' - 5,-oD ' ' • >• •' • (2) Labelmaster Tel: (312) 973 4944

6001 North Clark Street • ' ^ .. -••.-r • . Chicago, Illinois 60660 United States of America • •• ' ' ^

(3) International Aeradio Limited Tel: (01) 574 2411 :. ' : Hayes Road Telex: 24114 Southall, Middlesex UB2 5NJ . . , ^,,. , .ii,c^'t- England

5.6 Contingency planning '"'^ "' " '"' ' ' '•

It is most important that discussions be held long in advance and agreements reached with customs, air transport and postal authorities for the eventual possible shipment of infectious substances to outside laboratories. Such pre-planning is necessary to ensure prompt, expedi­ tious handling of specimens if an emergency occurs. Contingency planning must also ensure an adequate supply of shipping containers, the lATA Shipper's Certification and the Infectious Substance labels, as they may not be locally available. CDS/SO.I page 23

ANNEX lA

MONKEYPOX (resume)^

1. Introduction

Human monkeypox is an acute exanthematous disease caused by monkeypox virus, a member of the orthopoxvirus group of poxviruses. Because the disease resembles smallpox, each suspected case merits a complete investigation.

2. Clinical features -. : ; - -

The signs and symptoms of monkeypox are similar to smallpjx. Following a seven to 15 day incubation period, there is a two to three day prodrome with fever, muscle and back pains and extreme fatigue. The various stages of the rash develop over the face and body at about the same time; evolution of macules, to papules, vesicles, pustules and finally scabs takes about 10 days. Desquamation of scabs may take up to three weeks. Lesions are generally more concentrated on the extremities. The mucous membranes and cornea have been affected. -?>•;:. Eight (167o) of the 50 reported cases have died. The differential diagnosis includes most commonly chickenpox, measles, bacterial skin infections, scabies, drug eruptions and syphilis.

3. Laboratory diagnosis

Virus is considered to be present in the skin lesions. The virus is relatively stable even in scabs. Laboratory confirmation requires that adequate material from virus-containing lesions be taken (see instructions for specimen collection). Electron microscopy will show orthopoxvirus particles but cannot distinguish between the members of the group. Culture on chorioallantoic membrane of chicken eggs can give a precise virus diagnosis. Acute and convalescent sera help in the diagnosis if there is a titre rise; antibodies^ to specific orthopoxvirus can be detected by special testing. i • ^^1- ^.''^^ r ^

4. EpidemioloRical features ...

Since 1970, when the first case was found in Zaire, 50 cases of human monkeypox have been reported. All have been detected in the tropical rainforest areas of central and western Africa. Children less than 10 years of age have comprised more than 80% of cases. Five persons appear to have contracted the disease from an index case. The secondary transmission rate of human monkeypox to susceptible persons is 10% in close family contacts, and less than 5% for all susceptible contacts; this is much less than that of smallpox. Smallpox - vaccination appears to protect against monkeypox. Although monkeys in the wild have had monkeypox antibodies, the natural reservoir of human monkeypox is unknown.

5. Treatment

There is no specific treatment against monkeypox virus. Attention should be given to adequate nourishment and hydration and to keeping the skin clean and dry. Antibiotics should be given to prevent secondary bacterial infection.

6. Prevention

Patients should be isolated in the village or hospital. Persons caring for the patient should have been successfully vaccinated against smallpox within the previous three years. A small group of health personnel in areas where monkeypox cases have occurred should be vaccinated and given the responsibility for investigating and caring for patients with monkeypox. Vaccination of the general population is not indicated due to the infrequency of the disease.

^ For a more complete description, see Breman, J. G. et al. (1980) Human Monkeypox, 1970-1979, Bull. Wld Hlth Org., 58, 165-182 CDS/SO.I page 24

ANNEX IB

YELLOW FEVER (resume)^

1. Introduction

Cases of yellow fever originate in tropical areas of Africa and the Americas, where the disease can be transmitted in the vicinity of the forest by mosquitos which have bitten infected monkeys. Secondary transmission from a human case to non-vaccinated persons occurs vis à vis the bite of certain species of mosquitos, the most efficient of which is Aedes aegypti which is most frequently found in villages and towns. The blood and organs of patients are a source of virus and those exposed to this type of contact should have been vaccinated at least 10 days before.

2. Immediate clinical diagnosis

The incubation period is from six to 12 days. Mild forms consist of only a febrile syndrome or of an influenza-like or dengue-like illness. The severe form offers a classical three-phase evolution:

- a "congestive (red) phase: sudden onset with high temperature, headache, backache, nausea, vomiting;

- a remission phase of short duration, less than 24 hours;

- a "toxic" phase with liver impairment: icterus and haemorrhagic symptoms such as bleeding from the gingiva, nose and intestinal tract (haematemesis, melaena), renal impairment (oliguria, proteinuria, elevated blood urea nitrogen), coma and terminal hypothermic shock. The case fatality rate of severe forms may reach 80%.

3. Laboratory diagnosis , •>

3.1 For fatal cases, the quickest laboratory diagnosis is obtained through the examination of a liver specimen. The histopathological diagnosis is based on mid-lobular zonal necrosis with microvacuoles and Councilman bodies. However, the differential diagnosis may be difficult as other viral haemorrhagic fevers may cause foci of liver necrosis (but less well localized to the mid-zone of the lobule) and Councilman-like bodies, -

3.2 During the acute phase, the virus can be isolated from the blood but the chances of successful virus isolation decrease after the fifth day of illness. There is no rapid method at present to visualize or identify the virus directly in the blood. The diagnosis depends on inoculation of the blood into cell culture, mosquitos or suckling mice. Isolation on cell culture may be the fastest technique but two methods should be used, preferably simultaneously. Identification of the virus is carried out by the immunofluorescence or complement fixation tests with a specific reference serum applied on the third day, and following days on inoculated cells and mouse brain. Isolation in mosquitos is longer. Electron microscopy examination of liver fragments does not readily show yellow fever virions.

3.3 A serological diagnosis is often difficult to interpret as the serum may be broadly reactive with several antigens of Casals group B (Flaviviruses) as a consequence of multiple infections with these viruses. However, the picture is sometimes clearer when there are yellow fever specific antibodies in persons with primary infections, A rise of antibodies between acute and convalescent phase specimens taken at least 14 days apart has diagnostic value,

^ For a more complete description see WHO Expert Committee on Yellow Fever, third report, Wld Hlth Org, techn. Rep, Ser., No. 479, Geneva 1971. CDS/SO.I page 25

Annex IB

3.4 In the face of an epidemic, single serum specimens taken from a convalescent group compared by the complement fixation tests to serum specimens of normal controls of the same age and similar occupations may show a significant difference in the prevalence of yellow fever antibodies. Carefully interpreted, this investigation may provide a rapid clue as to the possible etiology of the outbreak. However, complement fixing antibodies can also be elicited by a recent immunization with the 17D yellow fever vaccine in persons with past infections with other flaviviruses.

4. Prevention and public health

4.1 Contagiousness: no direct person to person transmission but precautions are necessary while handling laboratory and necropsy specimens. The blood of patients with acute disease is infectious.

4.2 Isolation of individuals: patients should be protected from vector mosquitos by mosquito nets. _ , -.. -, , , ..

4.3 The patient can be transported if under protection from mosquitos but movement is not advised during the severe phase of illness. As a general rule, patients should not be moved out of infected zones.

4.4 Transmission factors: presence of a susceptible population and high density of Aedes aegypti in a domestic environment or contact with sylvatic mosquitos carrying the virus.

4.5 Prevention and control: immunization with 17D vaccines. A delay of at least 10 days is needed for antibodies to develop.

Vector control measures: ground and/or air spraying of insecticides to decrease adult Ji populations; larviciding can be used to reduce mosquito populations at the breeding source.;";

4.6 Contingency planning: in endemic zones it is advisable to have ready a reserve of •JI' vaccine, syringes and needles, needleless injectors, insecticides, spraying machines and to arrange for rapid laboratory diagnosis of suspect cases. CDS/SO.I page 26

ANNEX IC

LASSA FEVER (résumé)^

1. Introduction

Lassa fever is a febrile illness caused by infection with Lassa virus. This virus is a member of a group of viruses called arenaviruses, many of whose members cause haemorrhagic fever in various parts of the world. Lassa virus was first discovered in 1969 when it was isolated from a stricken missionary from northern Nigeria. It was found in 1972 that a rodent, Mastomys natalensis, was the reservoir of the virus. This rodent is one of the most common in Africa, and is often the predominant rodent infestation of houses in parts of Africa

2. Clinical features .

Lassa fever usually has its onset from six to 15 days after infection. It begins with a fever, malaise and headache during the first 24-48 hours. By the second to fourth day of illness frequent symptoms are abdominal pain, retrosternal or epigastric pain, sore throat and often vomiting or diarrhoea. Physical examination often shows some conjunctivitis, pharyngeal exudate, and abdominal tenderness. Laboratory findings are non-specific and may include a normal to low white blood cell count, proteinuria and granular urinary casts.

The fever is usually rather high, up to 40°C in severe cases, and may last for 10-14 days and sometimes longer, before settling to normal. In the typical hospitalized case, prolonged weakness, malaise and postural hypotension are the rule. The sore throat, epigastric pain and back pain generally subside about the same time as does the fever. In severe cases an encephalopathic or meningitic picture may occur; the virus has been isolated on several occasions from spinal fluid. Lassa cases who die frequently display bleeding symptoms (50%), usually from the bowel, vagina or oral mucosa. Not all of those who have bleeding manifestations will die. A harbinger of death is usually a sudden and profound drop in blood pressure. Death usually ensues within 12-24 hours after such a drop despite vigorous efforts in stabilizing vascular volume with intravenous fluids including protein. The cause of this sudden hypotension is not known.

The differential diagnoses of Lassa fever are numerous. They include typhoid fever, malaria and non-specific viral illness in the absence of sore throat, influenza and other respiratory viral infections, streptococcal sore throat, non-icteric yellow fever, various other arboviral illnesses and finally other haemorrhagic fevers such as Crimean-Congo virus, Ebola and Marburg disease.

3. Laboratory features

The laboratory diagnosis of Lassa fever is most frequently made by means of an indirect fluorescent antibody test performed on acute and convalescent sera taken from patients suspected of having Lassa fever. The test is rapid and reliable and can be performed in the field by an experienced person with a fluorescent microscope.

The diagnosis can also be made by isolating the virus from clinical specimens, usually from serum or whole blood, in tissue culture. This method is not practical in the field because of the relatively sophisticated laboratory which is required.

A third method of diagnosis, though not completely specific, is by a formalin fixed post­ mortem liver biopsy. Such a specimen can be taken within one or two hours of death, put into 10% formalin and shipped in the mail without fear of communication of the virus. The typical finding of non-inflammatory focal liver necrosis associated with a compatible clinical illness would lead to a presumptive diagnosis of Lassa fever. This method cannot reliably separate Lassa fever from Ebola or Marburg disease; however, differentiation can be made by electron microscopy as typical viral particles may be seen.

For a more complete description, see Monath, T. P. (1975) Lassa fever: review of epidemiology and epizootiology, Bull. Wld Hlth Org., 52, 577-592 CDS/SO.I page 27

Annex IC

4. Epidemiology of Lassa

Lassa virus is found in nature in the blood, urine and tissues of the rodent Mastomys natalensis. This rodent is one of the most common found in sub-Saharan Africa, It is found both in villages and in the bush depending on the subspecies of the rodent and the terrain. Thus far, evidence of Lassa virus has been found in many countries of West Africa as well as the Central African Republic. In addition a new strain of Lassa has been isolated from Mastomys in Mozambique and in Rhodesia. Antibody to this new strain has been found in humans but it is not known whether it causes illness.

Although it is believed that most human Lassa infections occur as a result of virus transmission from infected Mastomys, it is also known that some infection occurs as a result of transmission from person to person. This is based on the hospital transmission which occurred during Lassa epidemics in Nigeria and Liberia.

Among village Mastomys populations in certain parts of Sierra Leone, as many as 151 have had Lassa virus in the blood, and another 15-2070 had antibody, meaning they were at one time infected with the virus. Further studies identifying endemic areas are continuing. CDS/SO.I page 28

ANNEX ID

MARBURG VIRUS DISEASE AND EBOLA VIRUS DISEASE (résumé)^

1, Introduction

Although the area of prevalence of these diseases is not yet well defined, it may be assumed that many areas of Africa south of the Sahara constitute an enzootic-endemic zone. The animal source of infection is still unknown, but there is ample evidence of man-to-man transmission of these diseases. Transmission is particularly enhanced either through contact with contaminated organs, blood, secretions or excretions, by close personal contact or by injections with unsterile needles. The clinical symptoms of these diseases are identical but the viruses, although morphologically similar as shown by electron microscopy, present some degree of antigenic differences. This point has to be considered before use of immune plasma

2, Clinical ' ^ •'• ••• • ^

The incubation period for Marburg virus disease ranges from three to nine days whereas in the far larger epidemics of Ebola virus disease, the incubation period ranges from four to 16 days with an average of seven days.

The onset is abrupt with severe frontal and temporal headache and extreme malaise. Generalized aching pains, particularly in the lumbar region, are common and the eyes are very sensitive and painful on pressure. There is high fever by the second day of illness and the patient becomes increasingly debilitated. A severe watery diarrhoea, abdominal pain and cramping, nausea and vomiting are early symptoms. There may be knife-like chest or pleuritic pains, sore throat and cough; the throat discomfort can be sufficiently severe to prevent eating or drinking. A measles-like maculopapular rash appears between days 5 and 7 involving the whole body. It lasts four to five days, is not itchy and is followed by a fine desquamation. On black skin the rash may not be so obvious, and is often recognized later with the appearance of desquamation. A pronounced non-purulent conjunctivitis may occur. There is often an enanthem of the palate accompanied by "tapioca-like" lesions on the tonsils. A pharyngitis may be present and the throat is often extremely dry. There may be fissuring and open sores in the tongue and lips. Many patients on admission to hospital may have "ghost-like" drawn features, deep-set eyes, expressionless faces and extreme lethargy. The patient is anxious and often sullen. Rapid cachexia and dehydration may occur. There may be a relative bradycardia.

A high proportion of cases develop severe haemorrhagic manifestations between days 5 and 7 Fatal cases always have some form of bleeding, often from multiple sites. The gastrointestinal tract and lungs are more frequently affected. Haematemesis, melaena and sometimes the passage of fresh blood in the stools may be accompanied by bleeding from the nose, gums and vagina; sub-conjunctival haemorrhages are common. Petechiae, haematuria and bleeding from needle puncture sites are frequently seen. Death, when it occurs, is usually between seven and 16 days and is preceded by severe blood loss and shock.

Involvement of the central nervous system may be apparent with paraesthesia, lethargy, confusion, irritability, aggression and signs of meningeal irritation. Oliguria, oedema, pancreatitis, myocarditis and orchitis may be present.

Death may occur in up to 907o of patients in hospital outbreaks but in endemic areas the fatality ratio is probably much lower.

3. Laboratory diagnosis

Testing mentioned below should be performed in a maximum containment laboratory unless specified otherwise.

^ For a more complete description, see Pattyn, S. E., ed. (1978) Ebola virus haemmorrha^ic fever: Proceedings of an International Colloquium on Ebola Virus Infection and other Haemorrhagic Fevers held in Antwerp, Belgium, 6-8 December 1977, 436 pp. Elsevier/North Holland Biomedical Press, Amsterdam, New York, 1978. CDs/80,1 page 29

Annex ID

3.1 Laboratory diagnosis and collection of specimens and transport must be carried out with safety precautions. The high virus content of the blood and organs during the acute phase enables a rapid diagnosis by electron microscopy examination of blood centrifugation sediments and organ suspensions. If a specific serum is available, the indirect fluorescent method may be utilized to identify virus particles; with the necessary precautions, this can be done by experienced teams in the field. However, an antigenic difference between strains might be encountered which would result in a false negative result if this difference is wide enough. Post-mortem histopathological examination of liver sections may also provide a rapid diagnosis with a high presumptive value resulting from the presence of characteristic inclusions in liver cells in addition to the non-systematic cell necrosis and Councilman-like bodies which are common to other viral haemorrhagic fevers. Detection of virus by electron microscopy of liver sections is a rapid diagnostic method.

3.2 Isolation of the virus must be attempted only where a maximum containment laboratory is available. Cultivation of virus may be obtained in four days or more in several cell systems or signs of infection in five to seven days in guinea-pigs. Excretion of the virus in urine may be prolonged (a patient with uveitis yielded Marburg virus from her eye after 80 days and evidence of sexual transmission occurred after the same period in another episode).

3.3 A rapid serological diagnosis using the immunofluorescent test may show antibodies in blood of patients, sometimes as early as the fifth day (whereas virus may still be present). This is possible by adding the patient's serum to spots of inactivated infected cells on slides and further addition of an anti-immunoglobulin (possible IgM) labelled serum.

4. Preventive and public health

4.1 Contagiousness: although less transmissible and with lower death rates than formerly estimated, the disease is still considered very dangerous. Close personal contact, accidental parenteral introduction, contamination with blood and excreta, and aerosol transmission may occur. Although the risk of transmission may be less in the first two to three days, the appropriate precautions must be observed.

4.2 Isolation of individuals: strict isolation. Barrier nursing is required. Consider putting patients in negative pressure isolator.

4.3 Transportation: transport required under adequate security with maintenance of patient isolation precautions: additional travel stress for an already ill person is inadvisable.

4.4 Transmission factors: intra-hospital disease transmission opportunities. Touching the body at funerals and person-to-person contact within households promotes transmission.

4.5 Prevention and control: protective clothing, sanitary cordon, incinceration or boiling and other methods of sterilization of all contaminated material, one-time use of disposable syringes. Mechanical transmission by mosquitos and other arthropods is conceivable because of the very high blood virus titre but has not been proved. . .,,,

4.6 Immunization protection: no vaccine presently available. Development of a vaccine is •

desirable. ^ .riv-^;'-<>- •

4.7 Contingency planning: • ^ . • ;

- Maximum containment laboratory requirement. - High security patient isolation accommodation. - Stockpile of protective clothing and respiratory apparatus - Rapid laboratory diagnostic means, prior to administration of immune plasma. - International coordination through WHO. CDs/80.1 page 30

ANNEX 2A

' • INSTRUCTION FOR COMPLETING DATA FORMS FOR MONKEYPOX AND HAEMORRHAGIC FEVER CLINICAL CASE . .. ,

General and clinical information form ' ' ^,

1. Print the name clearly,allowing one letter per space. Put last name first. , •

2. Field number - each person must have a unique number.

3. Country: 01 = Benin 02 = Cameroon 03 = Congo 04 = Ghana 05 = Ivory Coast

06 = Kenya 07 = Liberia 08 = Mozambique 09 = Nigeria

-i; r • '10 = Sierra Leone 11 = Sudan 12 = Uganda 13 = Zaire

(Write name of country in parentheses) •. • • ; •/* :, •

4. Write region or province in parentheses. All provinces or regions of a particular country should be given a code number.

5. Zone or district name to be written. Zones or districts in surveillance area to be

coded. Same for locality, chiefdora, village and tribe,and village where illness began.

6. Age: (a) If person is over 11 months of age then put 1 in the first space followed

by number of years (Ex: If child 6 years old put 10 6)

•• ' P^'^^o'^ between 28 days and 1 year put 2 in the first space and the

number of months of age (Ex: A 5 month old child put 2 0 5)

" (c) If person is between 1 to 28 days then put 3 in the first space and

then the number of days of age (Ex: A 15 day old child put 3 1 5)

(If exact age is not known then estimate) » • -j ' '• «

7. Sex: 1 = Male; 2 = Female; 9 = Unknown

8. Hospitalized: 0 = No; l=Yes, 9 = Unknown ^roK :«r:-.;:

9. Dates: Put day in first two spaces, month in third and fourth spaces and year

in fifth and sixth spaces.

10. Outcome: 0 = Died; 1 = Lived; 9 = Unknown.

11. Clinical diagnosis: This is the working diagnosis after patient is initially seen

by the nurse or doctor.

Monkeypox = 01; Ebola = 02; Lassa = 03; Marburg = 04; Yellow fever = 05;

Congo Haemorrhagic Fever = 06; Rift Valley Fever = 07; Varicella = 08;

Measles = 09; Impetigo = 10; Hepatitis = 11;

12. Final diagnosis: Diagnosis after appropriate laboratory work finished.

Clinical Data

13. Day of illness of interview: How many days has the person been ill at time of

interview? Onset of illness is defined as onset of fever. CDS/SO.I page 31

Annex 2A

14. Fever: 0 = No fever during illness; 1 = Has fever; 2 = Had fever but none at ' time of examination and interview; 9 = unknown.

15. Rash: Day of illness: write number of days after fever onset that rash began.

16. Rash characteristics: 0 = Not present; 1 = Present, 9 = unknown.

17. Lesions (number): Lesions are to be counted and number written.

18. Palms and soles affected: 0 = No; 1 = Yes ; 9 = unknown. ' '

19. Vaccination scar: 0 = No; 1 = Yes; 9 = unknown.

20. Symptoms: After careful questioning about each symptom the day of illness .: on which the particular symptom began is written. The first day of illness is the first day of fever.

21. Signs: same as above. Day of illness will correspond with day of illness of interview.

S ; f i ; For bleeding location and lymphadenitis: 0 = Absent; 1 = Present; 9 = unknown. CDS/80.1 page 32

Annex 2A FORM 2A

GENERAL AND CLINICAL INFORMATION ON CLINICAL CASES OF MONKEYPOX AND HAEMORRHAGIC FEVER

General Data Clinical Data (continued)

Name (Day of illness of interview) -•.-.AH

Field No. -— Lesions (number): On face Country ( On trunk Region or Province ( Palms and soles affected _ Zone or district ( .~ Vaccination scar _ Year Locality or chiefdom ( Symptoms: Day illness began* ' ' Village ( Muscle pain , . . Tribe ( Joint pain Reason for investigation ( Back pain Village where illness began Abdominal pain ( •t Vît Chest pain Age Cough Sex _ Vomiting Hospitalized _ Diarrhoea Date •Hi Signs: Bleeding Discharge date Rectal Outcome _ Oral Clinical diagnosis Nasal Final diagnosis Vaginal Clinical Data: Other Day of illness of interview Pharyngitis Fever _ Rales Date onset Abdominal tenderness Before rash _ Liver enlargement Rash _ Spleen enlargement Date onset Lymphadenitis Day of illness Cervical Characteristics: Haemorrhagic _ Axillary Confluent _ Inguinal Discrete _ Jaundice Same stage _ Oedema

Different stage *First day illness = first day of fever or rash Unsure NOTES: Total on body

Name of informer: Title: Date: INSTRUCTIONS FOR CO^^PLETING SPECIMEN FORM FOR MONKEYPOX OR VIRAL HAEMORRHAGIC FEVER SPECIMENS

Name: write in full name of case, last name first.

Field number - same number as on case form.

Country - same code as case form.

Speciraen series number: lifhen more than one specimen is collected, each is given a separate series number and each requires a specimen form: Ex: A suspect monkeypox case has 3 specimens taken. Acute serum specimen gets specimen series 01, a scab-lesion specimen gets 02 and a convalescent serum specimen gets 03. Further specimens are labelled 04, 05 etc as they are taken.

Specimen type: 01 = serum 02 = scab-lesion 03 = urine 04 = throat swab 05 = liver biopsy

Clinical diagnosis -• see code for clinical

Age, sex - as on other forms

Vaccination scar - 0 = no, 1 = yes, 9 = unknown

Illness outcome - 0 = died, 1 = serious, 9 = unknown

Complete address of person who submitted form and person to whom results are to be sent. CDS/SO.I page 34

Annex 2B

, ...... , " FORM 2B .

FORM TO ACCOMPANY SPECIMENS FROM ACUTE SUSPECTED MONKEYPOX OR HAEMORRHAGIC FEVER PATIENTS

Name

Field number

Country

Specimen series number

Date collected Day of illness collected

Specimens type

Clinical diagnosis ( >

Age Sex •

Vaccination scar (Year )

Illness outcome

Submitted by

Address

Results to be sent to

Address ' ':

For laboratory use

Method Agent Re s u 11 CDS/SO.I page 35

ANNEX 2C

INSTRUCTIONS FOR COMPLETING THE CASE INVESTIGATION SEROLOGICAL SURVEY FORM

1. Case name - If case investigation, print name and field number of index case. Field number should be from list of predetermined numbers. 2. Reason for investigation:

1 = Investigation of proven case

2 = Investigation of suspect case

3 = Serosurvey

3. Case or control family

1 = Proven monkeypox case family

2 = Suspect monkeypox case family

3 = Proven haemorrhagic fever case

4 = Suspect haemorrhagic fever case family ' 5 = Control family .''--nr h^.-iar- ire-^ : !. . : ; .

6 = Serosurvey family

4. Date of visit: Date family is visited and information is collected. Village data ' ' '

5. Population of village is entered. b • • rii^nc^--' ":c. u .;r;.: rui

6. Terrain: 1 = High forest f;-- 1 h. -"^ 2 = Secondary forest K;. • v-.iv:;-.^^ ei n-.^naq

3 = Savannah [,:. vf.i. 'i :.. .."O Tsacsnr n<ïrfT

4 = Coastal . i :-ii.:nï'i^'i s;-.?;" -.vmn-A ar is& +J !

5 = other n,maAnu " K ••!'rr.,--î - 1 • : ^K^;

7. Season: 1 = Dry; 2 = Wet; 3 = Transitional ^ * ;-!'H;-:>:,'; ,:-c

8. Village accessibility: 1 = On motor road; 2 = Four wheel drive only; ' '

3 = Footpath only; 9 = Unknown - ''-t! bo>i-::ir:

9. Water source: 1 = Stream; 2 = Well; 3 = Swamps; 4 = Rain; 7 = Other; 9 = Unknown.

10. Number of sleeping houses - Total number of village houses used for sleeping. '

Family and house data '• • ' • '"ïft.î 1. Head of household - Print full name. - '''' -•'•!:'••:•'•> ^

2. Family number - This is same as field number of head of household. ' '

3. Number of persons in family - Family defined as those living under same roof or in same compound if more than one house. Write number of

persons, then number of males, and number of females. ' ''^ - • :

b;io! d , Ci. I ''-•s • •• CDS/80.1 page 36

Annex 2C

4. Number of rooms in house: Write in total rooms including cooking room if

attached to sleeping house. 5. Persons/Room: Divide persons in family/rooms in house. 6. Location of house in village: 1 = Centre; 2 = Between centre and edge; 3 = Very edge next to bush. 7. Wall construction: 1 = Mud; 2 = Mud + Cement; 3 = Cement; 4 = Brick; 5 = Wood. 8. Roof construction: 1 = Thatch; 2 = Tin; 7 = Other. 9. Floor construction: 1 = Dirt; 2 = Cement; 3 = Wood; 4 = Tile; 7 = Other. 10. Windows: 0 = None; 1 = Open; 2 = Shutters; 3 = Screens; 4 = Glass; 7 = Other. 11. Ceiling: 0 = None; 1 = Mat; 2 = Wood; 3 = Tin; 7 = Other. .... 12. Latrine: 0 = None; 1 = Bucket; 2 = Pit; 3 = Flush; 7 = Other.

13. Field number: From preassigned numbers. 14. Age: (a) If person is over 11 months of age then put 1 in the first space followed by number of years ( Ex: If child 6 years old put ^ 6^) (b) If person is between 28 days and 1 year put 2 in the first space and the number of months of age (Ex: A 5 month old I child, put _2 0 ^) (c) If person is between 1 to 28 days then put 3 in the first space and then the number of days of age (Ex: A 15 day old child, put 3^ _1 5^). (If exact age is not known then estimate). 15. Sex: 1 = Male; 2 = Female; 2 = unknown. 16. Bedroom number: A diagram of each house is to be drawn with each room numbered. The number of the room where each individual sleeps is then entered in the square marked bedroom number. 17. Years in village: Enter number of years person has lived in village. •

18. Illness past month: Febrile: 0 = No; 1 = Yes Ti. loT - smu- •' ' • Rash : 0 = No; 1 = Yes 19. Date of onset illness: Put in date illness listed above began. 20. Physical contact with indey case: 0 = None; 1 = Casual physical contact not to include caring for person when ill or sleeping; 2 = Close physical contact (sleeping with) but not nursing ill patient.

21. Cared for index case: 0 = No; 1 = Yes 22. Handled secretion, blood or excretions of index case: 0 = No; 1 = Yes. 23. Date smallpox vaccination: Enter date if known. If unknown enter 99 in

last 2 spaces. 24. Vaccination scar: 0 = No; 1 = Yes; 9 = Unknown.

25. Facial pockmarks: 0 = No; 1 = Yes; 9 = Unknown. CDS/SO.1 page 37

Annex 2C

26, Contact with wild animal past month: 0 = No; 1 = Yes; 9 = Unknown. (Write name of animal in note section - use local name and English and French name if possible). , . 27. Skinned animal and prepared for food: 0 = No; 1 = Yes. -. ' ^'

28. Serum specimen taken from person: 0 = No; 1 = Serum; 2 = Filter paper, 29. Result: For laboratory to fill in. , : , >,

? Ï ~ ? «i

3 i i- -4-

•- f. CDS/80.1 page 38

Annex 2C CooHiient s 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 I I 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Result s 1 S' ci g 1 1 1 1 1 1 1 1 1 1 en

1 1 1 1 1 1 1 1 1 1 1 an d fo r foo d prepare d Skinne d

1 1 1 1 1 1 1 1 1 1 Trappe d • animal s

1 1 1 1 1 1 1 1 • 1 pas t mont h wil d ! wit h animal s Contac t •

1 1 1 1 1 1 1 1 1 1 si Facia l 1 pock - mark s

U l-i u « 1 1 1 1 1 1 1 1 1 1 so U > CO

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 i 1 I 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 smallpo x § Dat e o f 1 1 1 1 1 1 1 1 1 1 1 vaccinatio n

1 1 1 1 1 1 1 1 1 1 cas e tio n inde x : secre ­ bloo d 1 Handle d

1 1 1 1 1 1 1 1 1 1 fo r 11 1 inde x cas e Care d

1 1 1 1 1 1 1 1 1 1 ca l tac t cas e 1 con - j Physi ­ , wit h 1 inde x | 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 onse t

illnes s 1 1 1 1 1 1 Dat e o f 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1

mont h 1 1 1 1 1 1 1 1 1 1 Illnes s pas t Febril e ras h

1 1 1 1 1 1 1 1 1 1

lag e 1 1 1 1 1 1 1 1 1 ' Year s 1 i n j vil ­ < E ' •O 0 0 1 1 1 1 I 1 1 1 1 1 OJ o c ta u 1 1 1 1 1 1 1 1 1 1

•K 1 1 1 1 1 1 1 1 1 1

« 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 < 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Fiel d 1 numbe r 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Nam e Inde x cas e | Hea d a f househol j CDS/SO.I page 39 ANNEX 3 THE COLLECTION, STORAGE AND SHIPPING OF SPECIMENS FROM HUMANS FOR STUDIES ON MONKEYPOX AND VIRAL HAEMORRHAGIC FEVER

!• Serum specimens - routine serosurveys

1.1 All serum specimens should be collected by means of vacuum blood-collecting tubes whenever possible as this is a closed sterile system. For adults and children a standard-size 10 ml vacuum tube will be used with a 21 or 22 gauge vacutainer needle. While the vacutainer system is preferred, individual syringes and needles can be used. At least 5 cc of blood will be collected by venipuncture, the tubes will be labelled and allowed to sit at room tempera­ ture for one hour or until a clot is formed. After the clot is formed the tube should be placed in the cold at 4°C (not frozen) for at least four hours in order to allow clot retrac­ tion to occur. If refrigeration is not available, room temperature is acceptable. Blood tubes may be left overnight under refrigerated conditions. After thorough clot retraction, as much serum as possible, without the introduction of red blood cells (RBC) , will be collected and placed in a plastic screw-cap phial for long-term storage. The phial will be labelled with the appropriate number and placed at -20°C (frozen) or 4''C for storage prior to shipment.

1.2 In the event of technical difficulties which do not allow a venous specimen to be'taken, a capillary specimen may be taken from the patient, either from the finger tip or the ear lobe. For this purpose, a special capillary tube will be used which will allow the collec­ tion of approximately 0.2 cc whole blood, which will yield about 0.1 cc of serum. The serum is then separated and placed in 0.9 cc of diluent for storage at 4°C or -20°C.

1-3 Filter-paper. Under certain circumstances, serosurveys may be accomplished by use of filter-papers. Each filter-paper has two circles imprinted on it, and each circle is designed to absorb a specified amount of blood. Whencollecting blood with these filter-papers, the finger or ear lobe is pricked and the filter-paper is touched to the bleeding area until each of the two circles is completely filled with blood on both sides of the filter-paper. Two such filter-papers, or a total of four circles of whole blood, will be collected from each person. The filter-papers are then placed in a drying oven or out in the sun for thorough drying. Following this, the filter-papers are placed in a sealed container with sodium silicate in order to ensure their dryness during storage and transportation. For long-term storage, the filter-papers must be placed at 4°C or -20°C.

1.4 Shipping

All serum specimens will be placed in double sealed metal containers and shipped on dry ice when available (following International Air Transport Association (lATA) recommendations). With proper care, serum specimens for serology can be shipped on wet ice or without refrigera­ tion if the duration of travel does not exceed three or four days.

Filter-papers may be shipped via airmail or air freight at room temperature, provided the shipping time is not prolonged and they are packed with silicone gel desiccant.

2. Acute serum specimens from suspected cases

2.1 Designated members of the national surveillance team, or designated and specifically trained persons at the surveillance hospitals, may collect acute serum specimens for the diagnosis of monkeypox and haemorrhagic fevers. The persons so designated will be trained in the specific techniques and precautions required to collect and safely store such speci­ mens. The person taking the specimen will wear a gown, surgical gloves, and mask to protect him/her from infection with haemorrhagic fevers. The specimen to be drawn will be collected in a vacuum tube. After use the needle, needle holder, and the outside of the vacuum tube will be immersed in 1% hypochlorite solution or formaldehyde solution for decontamination The specimen will be allowed to clot and the clot to retract as with any ordinary serum ' specimen. Wearing gloves and a mask, the person responsible will then transfer about 2 cc of serum to a screw-cap plastic tube. The vacuum tube and pipette will then be immersed i a solution of hypochlorite or formaldehyde for decontamination. The specimen will then b^" stored inside a shipping container or other similar container at -20 °C for nrpr,=.r-of. • ^ shipping. preparation for CDS ^80.1 page 40 Aanex 3

2,2 Acute serum specimens will be shipped on dry ice which will be made available on a regular basis for shipping to a previously designated and informed laboratory or WHO.

3. Lesion specimens. All suspect cases of monkeypox will have specimens taken from lesions for virus isolation and for electron microscopy examination,

3.1 Vesiculo-pustular stage

3.1.1 Swab collection

Open the vesicles or pustules with the lancet in the specimen collection kit. Take the sterile swab and absorb the vesicular or pustular fluid from at least six lesions. Place the swab and lancet in the plastic specimen collection container and screw the top on securely. Place the container in the metal tin. Fill out the specimen collection form. Place the metal tin and the form in the outer cardboard container which can be shipped to the laboratory

3.1.2 Capillary tubes -

Fill at least four plastic capillary tubes with vesicular fluid and seal the ends with plasticine. Put the capillary tubes in a test-tube and pack with cotton-wool.

3.1.3 Smear on slides

If plastic capillary tubes are not available, use clean cut swabs with wooden applicators (Q-tips). The contents of three or four vesicles should be put on a glass microscope slide Two slides should be made in this manner. Label the slide, and pack in a shipping container All specimens should be maintained at 4°C if possible until shipped.

3.2 Crusting stage. With the lancet, take off as many crusts as possible. A minimum of six should be put in the plastic screw-top bottle. Use the lancet to scrape the base of the lesion and put this material in the bottle also. Close the bottle with sticking plaster and label the tube. Pack the container and fill out the form as described above. Collect serum from patients in the acute phase and from convalescents as described in section 1.

3.3 Scarring or recovery stage. Serum is to be collected from such patients and kept in a freezer or refrigerator as described in section 1.

4. Post-mortem liver biopsy

4,1 Collection and storage. Liver biopsies are to be taken within six hours of death from patients with severe febrile illness, and bleeding, and/or severe jaundice. The biopsy is to be taken using a 10 cc syringe with 1 cc of sterile saline in the barrel. The person taking the biopsy should wear surgical gloves, a mask, and a gown, A 10- or 12-gauge liver biopsy needle with trocar is pushed through the skin, but not into the liver. The trocar is removed and the syringe with saline is attached to the biopsy needle and the biopsy needle then thrust into the liver. The needle is then extracted from the liver and the material in the needle is then expelled into a phial of 10% buffered formalin. A piece of liver approxi­ mately 3 or 4 cm should be obtained by this procedure. Repeat the procedure a second time to get a second piece of liver, which should go into the same phial of formalin. The formalin phial should then be closed and sealed with tape.

The biopsy procedure should again be repeated without saline and at least two cotes of liver should be placed in a dry sterile container for culture. The container should be sealed.

The needle and syringe and any other materials used for the procedure should be placed into a 1% hypochlorite solution or VL formaldehyde solution. This disinfectant solution should be sucked up into the needle and the bail of the syringe in order to decontaminate the interior of these instruments. CDS/80.1 page 41 Annex 3

The phial containing the formaldehyde-liver preparation should be kept at room tempera- Under no circumstances must it be frozen. In order to prepare the specimens for shipping the outside of the phial must be washed with hypochlorite solution or formaldehyde. The phial IS then placed into the inner compartment of a shipping cylinder, which is then placed into the aluminium outer shipping container. This material can then be shipped by airmail or air freight to the laboratory or WHO. Under no circumstances must this material ^^.ï'PPf r specimens in dry ice or wet ice. Specimens for culture should be kept at -iO C and shipped in dry ice.

5 All instruments and other materials used in collection of monkeypox specimens should be flamed, submerged in hypochlorite or formaldehyde solution prior to washing with soap and water and autoclaving or boiling in water for 20 minutes.

6. Lesion specimens should be shipped with dry ice whenever possible, but can be shipped in an expeditious manner, without refrigeration. '

Bottles and tubes containing lesion specimens will be packed in a manner described for acute specimens from haemorrhagic fever patients. The containers will be placed in inner screw-cap cylindrical cans. The empty spaces of this can will then be filled with absorbent material. The can will then be placed in a watertight aluminium can with a screw cap. This aluminium can will then be placed, along with any other aluminium cans in the case of multiple specimens, in a refrigeration box. Empty spaces at the bottom, sides and top of the box will then be filled with an absorbent material. All data forms and patient information forms per­ taining to the specimens shipped must be included in a sealed plastic envelope inside the shipping box. CDS/SO.I page 42

ANNEX 4A CDS/80.1 page 43

ANNEX 4B

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ANNEX 5A

DISINFECTANTS, STERILIZATION, DECONTAMINATION

I. CHEMICAL DISINFECTANTS

1. Chlorine - Sodium hypochlorite

Chlorine is a universal disinfectant active against all microorganisms. It is a strong oxidizing agent, corrosive to metals. Chlorine solutions will gradually lose strength so that fresh solutions must be prepared frequently, thus it is advisable to prepare solutions from a powdered form of sodium hypochlorite if possible. Liquid sodium hypochlorite is commonly available as a household bleach and in varying strength for medical purposes.

Sodium hypochlorite at the strength of 4000-5000 ppm available chlorine is currently recommended as the disinfectant of choice in emergency situations involving suspected cases of Lassa fever and Marburg-Ebola infections.

Care must be exercised in following recommendations on dilutions or per cent, solutions of sodium hypochlorite (and other disinfectants) because of the varying strength of the base product.

In the United States of America household or laundry bleach contains 5.257» available chlorine (52 500 ppm). Diluted 1:100, the solution contains 525 ppm available chlorine. Current Center for Disease Control (CDC) recommendations are for a 107» aqueous solution of household bleach for general decontamination purposes. This provides a solution containing 5250 ppm available chlorine.

In many parts of the world, household or laundry bleach is known as eau de javel. The amount of available chlorine is not always known or stated on the container. If this is the only available disinfectant, use as directed - normally a 1:8 dilution. A field check of concentration should be a strong chlorine odour, a "slippery feel", but not strong enough to "burn" the fingers. If large quantities of this product are used for a prolonged period, the strength, if in doubt, should be checked at a laboratory. ; ;i: -

In the United Kingdom "commercial" hypochlorite usually contains 100 000 ppm of available chlorine. Diluted 1:100, the solution contains 1000 ppm of available chlorine. The "Code of Practice for the Prevention of Infection in Clinical Laboratories and Post-Mortem Rooms" (Howie Code) recommends a 10:1000 dilution (10 000 ppm available chlorine) for disinfection of blood spillage, etc. Other references from the United Kingdom recommend dilutions from 1 to 47o for general decontamination purposes (1000-4000 ppm of available chlorine). The stronger solutions are used in the presence of gross organic matters.

2. Phenol - Phenolic compounds . i i ' i ? ' ^ ; ' '

Phenol as phenol is not often used as a disinfectant. However, many of the phenolic compounds are basic to a number of common disinfectants. They exhibit variable results against the viruses, but literature indicates their effectiveness and use where Lassa fever and the Marburg-Ebola viruses are concerned. CDC recommends the use of "Lysol" as a substitute for chlorine if chlorine is not available. All of the phenolic compounds should be used at the manufacturer's recommended use dilutions.

3. Iodine - lodophors

One of the most popular groups of disinfectants are the iodine compounds known as lodophors. Their action is similar to that of the chlorines. Clean surfaces or clear water can be effectively treated by 75 ppm available iodine but difficulties may be experienced if any appreciable amount of protein is present. For washing hands or as a sporicide, the lodophors may be diluted in ethyl alcohol. Literature concerning its use with the Lassa fever and Marburg-Ebola viruses indicates effective disinfection at 450 ppm available iodine. CDS/SO.I page 45 Annex 5^

4, Formaldehyde - Formalin

Formaldehyde for use as a disinfectant is usually marketed at about 37% concentration of the gas in water solution referred to as formalin. Formaldehyde in a concentration of 57» active ingredient is an effective liquid disinfectant. Formaldehyde at 0.2-0.47, is often used to inactivate viruses in the preparation of vaccines. Formaldehyde vapour generated from formaldehyde solution is an effective space disinfectant for sterilizing rooms or buildings. Literature concerning Marburg-Ebola virus indicates use of formalin at a 27» solution.

II. STERILIZATION '

1. Autoclaving - • " .:- •. !

Moist steam under pressure is the most effective means of accomplishing sterilization and is normally achieved by the use of the autoclave. Autoclaves should be operated at 121°C (250°F) at 15 Ib/in^ of steam pressure for minimum exposure time of 15 minutes.

2. Pressure cooker

Sterilization by moist heat can be accomplished in a common household pressure cooker, the 15 lb or 20 lb gauge must be used and the exposure time extended beyond 15 minutes to provide a safety factor.

3. Boiling : -• ' ! "•

The use of boiling water as a sterilant is not to be discounted. Immersion in water at a "rolling boil" for 20 minutes is effective. ,

III. DECONTAMINATION • . , .

All equipment, supplies, refuse, clothing and laundry - in effect any article - which leaves the isolation area or is in contact with the patient must be decontaminated prior to processing for reuse or disposal. This is most easily accomplished by soaking the material in the disinfectant solution.

Paper, clothing (disposable and reusable) and bedding need to be "wetted-down" with the disinfectant after being placed in bags for removal from the isolation area. Reusable clothing and bedding must be boiled or autoclaved prior to washing for reuse.

Instruments and other reusable equipment should be boiled or autoclaved in the disinfectant solution prior to processing for reuse.

Heat sensitive laboratory equipment and similar apparatus may be decontaminated by exposure to formaldehyde vapour from formalin. One method of accomplishing this is to seal the equipment in a plastic bag with a pledget of cotton soaked with formalin. A small open container of water is also sealed in the bag. An exposure time of at least eight hours should be observed. CDS/80.1 page 46

ANNEX 5B

SPACE DECONTAMINATION

Decontamination of furniture, isolation rooms and areas, transport and bed isolation units and equipment and conveyances other than aircraft (ambulances, for example) requires a combination of liquid chemical disinfectants and gaseous fumigants.

1. Surfaces

Known or potentially contaminated surfaces of transport and isolation equipment, rooms furniture and conveyances can be effectively deccntaminated by applying a 5000 ppm available chlorine solution of sodium hypochloriff or other disinfectant known to be virucidal

2. Spaces -

Interior spaces of rooms, isolation equipment ant' conveyances can be decontaminated by- fumigation with formaldehyde gas which may be generated by heating formalin (0.5 ml per cubic foot of space). All openings in the space (i.e. windows, doors, etc) to be decontaminated should be sealed with masking or similar tape before the gas is generated. Ideally, the fumigation should be conducted at an ambient temperature of at least 21°C (70°F) at a relative humidity of 60".. The gas should remain in contact with the space overnight - or for eight hours. After fumigation the area must be thoroughly ventilated before personnel are allowed to enter. Appropriate respirators must be worn if personnel have to enter the space prior to ventilation.

Surfaces of the space to be fumigated should be dry as formaldehyde is soluble in water and will be rapidly taken up. The use of air circulating fans is recommended to provide thorough mixing of the gas throughout the space.

Where electricity is not available formaldehyde may be generated by reacting formalin with potassium permanganate. Formalin is placed in a small open container. This small container is placed in a larger container that will hold all of the mixture that boils over. ' A ratio of 40% K>fn04 to 60Z formalin by weight volume is recommended. All preparations for" evacuation should be made before mixing these compounds as the reaction is immediat°.

3. Aircraft : ^iv- • : .:.:n:)r::j

Space decontamination of aircraft is not to be carried out because of chemical reactions between all currently known space fumigants and sensitive aircraft controls and equipment. Therefore, air transport of infected patients should be via special isolators designed for the purpose. If such equipment is not available, the aircraft should be dedicated to the evacuation effort. Personnel involved should be protected by isolation clothing. The patient and his equipment, excretions and secretions should be treated as if in a hospital isolation room. CDS/80.1 page 47

ANNEX 6

PROTECTIVE MATERIAL MAINTAINED AT WHO HEADQUARTERS

Protective clothins (any equipment which can be decontaminated in the field should be

(a) for nursing

plasticized paper gowns, disposable

plastic aprons

- paper masks, disposable ; v • - ^!

- plastic "visor" masks

paper hoods, disposable J ..

- gloves (rubber or plastic) . . , -

plastici'ed paper boots, disposable > ;

(b) for autopsies, laboratory work and other high risk work ' ' • ''' - ' ^""E

overalls with hoods, disposable

plasticized paper boots, disposable :nn ..i £ : •>:,

gloves (rubber and plastic) , T

plastic "visor" masks and paper masks . asii < '

respirators (full-face rubber masks) with microbiological filters

.. . , . -. ,. • : : : • ,vi';-'.-j .•;;ï! i ^;?- j'To'jî -.f:. .:-^b--i-

(c) general ' "" ' ' ' ' . , ' • :

- plastic bags (small and large)

- plastic sheeting J ""., •; i • ^ •

- waterproof cardboard bowls, disposable ' '

- waterproof cardboard bedpans, covers (disposable) and plastic supports. CD s/so, 1 page 48

ANNEX 7

SELECTION, CARE AND DECONTAÎIINATION OF PROTECTIVE EQUIPIŒNT AND CLOTHING

I. RESPIRATORY, FACE AND EYE PROTECTION EQUIPMENT

1. Introduction

In caring for patients, the collecting of specimens and the conduct of laboratory procedures involving dangerous pathogens it is most important to provide for respiratory, face and eye protection. Following is information on available equipment with supplementary notes on use, care and disinfection.

2, Equipment • •• '

2-1 Air_su22lied_hood;res2irators (self-contained). These devices provide the most positive protection. They consist of lightweight hoods of clear poly- vinylchloride or other materials with a clear faceplate which covers the head, neck and shoulders. Air is supplied under pressure, normally from the back of the head and it is dispersed around the face and neck, being expelled from under the collar of the hood, ^ .,

The most useful hood-respirator of this type obtains source of air from a small battery powered blower unit which filters the air through high efficiency particulate air (HEPA) filters. Fully charged batteries should provide six to seven hours running time,

Other hood-respirators of this type receive air from portable oxygen cylinders or from air lines connected to externally located air compressors. The typesusing portable oxygen cylinders are limited in that they provide for only 15 to 30 minutes of use,

2.2 Full-face_mask-res2irators. This equipment provides good positive protection covering the major portion of the face, eyes and respiratory tract. They may contain both a biological filter and a chemical cartridge. If the respirator is to be used only for patient-care and biological laboratory work the chemical cartridge is not required. The biological filter must be a high efficiency particulate air (HEPA) filter. In selecting a mask-respirator of this type location of the filters is important for visual purposes. Units with filters placed on the side of the mask provide better vision than units with the filter located in front of, or below, the mouth.

The effectiveness of the full-face mask-respirator is dependent upon such factors as the resistance it presents to breathing, the comfort when worn for long periods and the peripheral seal of the device. A good peripheral seal of the mask to the face is important because without it inhaled air will bypass the filter element and provide poor or no protection. A clean shaven face is required if a mask-respirator is to provide a good face seal. In wearing the mask-respirator it is important that proper tension exists on the respirator headband as there is a direct relationship between strap tightness and seal. Also, care must be exercised that the mask is worn properly to protect the peripheral seal between mask and face.

Head covers (preferably of the disposable type) should be worn with this mask-respirator. CDS/80.1 page 49 Annex 7

.^•^ SiM;li£i=2§sk-resgirator. This equipment is to be used only when an air supplied hood-respirator or the full-face mask-respirator is not available. Half-face mask-respirators do not protect the eyes, but protect only against entry through the nose and mouth. They may contain both a biological filter and a chemical cartridge. If the respirator is to be used only for patient-care and biological laboratory work the chemical cartridge IS not required. The biological filter must be a high efficiency particulate air (HEPA) filter. In selecting a mask-respirator of this type location of the filters is important for visual purposes. Units with the filters placed on the side of the mask provide for better vision than units with the filter located in front of, or below, the mouth.

The effectiveness of the half-face mask-respirator is dependent upon such factors as the resistance it presents to breathing, the comfort when worn for long periods and the peripheral seal of the device. The good peripheral seal of the mask to the face is important because without it inhaled air will bypass the filter element and provide poor or no protection. A clean shaven face is required if a mask-respirator is to provide a good face seal. In wearing the mask-respirator it is important that proper tension exists on the respirator headband as there is a direct relationship between strap tightness and seal. Also, care must be exercised that the mask is worn properly to protect the peripheral seal between mask and face. , ,^ .

There are two major problems to guard against with the half-face mask- respirator other than for the provision of eye protection. There is no universal size of this mask, therefore several varying sizes must be available; it is also more difficult to get a good peripheral seal between the mask-respirator and the face. .. , „

It is necessary to provide separate eye protection when the half-face mask-respirator is used. It is preferable to use a full-face plastic visor or shield if one can be obtained which will fit over the respirator. Otherwise, tight fitting goggles are recommended. . i - . : a

Head covers (preferably of the disposable type) should be worn with this mask-respirator.

^•^ ll§yrsi£êi;"_!!!5sks. Thickpaper (high efficiency) surgical masks can be used when biological mask-respirators are not available. Several manufacturers produce such masks made of high efficiency filter paper. These should be purchased whenever possible.

Care must be taken to assure that the mask fits tightly around the enLire periphery (contact) surface between mask and skin, otherwise the filter effect of the mask is negated. Masks should be worn only once and changed frequently as they become ineffective when they become moist.

It is necessary to provide eye protection with this type of mask. It is preferable to use a full-face plastic visor or shield. If such a visor or shield is not available tight fitting goggles are recommended.

Head covers (preferably of the disposable type) should be worn with this mask. 2-5 Face_shie2ds_and_hoods_j^_goggles. Full-face shields and hoods provide the optimum face and eye protection when microbial airborne infection is not of concern. Shields should be of such design that they cover the entire face, permit tipping back to clear the face if desired and are easily removable in the event of an accident. Goggles, if used, should be tight fitting around the eyes.

Protection of the eyes is extremely important as infection can occur through the conjunctiva of the eyes. Further, chemicals used in microbiology and virology laboratories, i.e. disinfectants, which may be splashed in the eye in the course of preparing use dilutions, can cause blindness.

UTien biological protection is of importance face mask-respirators and head coverings must also be worn.

3. Care and Decontamination ' ' •' • " '

Full-face and half-face mask-respirators should be assigned to individuals whenever possible. This provides for better fitting of the equipment and reduces the opportunity of cross-infection between individuals.

Where personnel have been working in an area that has resulted in overt contamination of the reusable respiratory protective equipment, ethylene oxide (ETO) should be used to assure complete penetration of the decontaminant. The facepiere, however, must be aerated fnr 24 hnurs before reuse, because if there is insufficient aeration chemical burns can be inflicted on the user.

Respirators may also be decontaminated in the field by exposure to formaldehyde gas. Techniques described in Annex_2 are appropriate. The ' biological filters, however, will not be internally decontaminated unless the gas is moved through the filter in an air stream. Therefore, consideration should be given to replacing filters at the termination of continuous use.

These decontamination processes will have an adverse effect on any charcoal filter element, and, therefore, any cartridge or canister that contains this absorbent as a component of the overall mask should be replaced following sterilization. Autoclaving should not be used, as it has a deleterious effect on some of tlie compounds used to seal the filter material to the edge of the canister or cartridge.

Personnel using respiratory protection devices should wipe down their equipment with a chemical disinfectant every time protective clothing is removed. A damp cloth tliat has been soaked in disinfectant and the excess squeezed out should be used for the wipe-down process of the facepiece. A hypochlorite solution (500 ppm) with a wetting agent, or alcohol 85%, would be satisfactory. In any wipe-down process, it is extremely important to reach all crevices. Following the wipe-down procedure, the protective equipment should be thoroughly rinsed with clean, warm water and then exposed to free-flowing air for at least 30 nins. before rouse. Valves, headstraps and other parts should be checked. Replace them with new parts, if defective. Insert new filters, cartridges, or canisters, if required; ascertain that the seal is tight. Place in plastic bag or container for storage.

When applied frequently to equipment, several of the disinfectants will cause corrosion of metal surfaces and require that parts of a mask be replaced from time to time. CDS/80.1 page 51 Annex 7

For those situations in which personal hygiene is the only consideration, all rubber and plastic face masks and respirators should be scrubbed with a liquid detergent solution and decontaminated with a suitable disinfectant. Wipe off the decontaminated respiratory device with warm water to remove any residual disinfectant so as to avoid any possible dermatitis. Following this procedure, half-face masks can be stored in plastic bags until required again. Full-face masks or other types of respirators should be stored in cartons or carrying cases specifically fabricated for the protective equipment.

II. PROTECTIVE CLOTHING -, , ; V -^^^ v.:

A variety of disposable protective clothing in several sizes, including extra large, should be stocked at centers for emergency use. Clothing of synthetic polyethylene fiber is particularly good as of high strength (wet or dry) and presents a good barrier (wet or dry) to movement of particles through it while retaining reasonable "breathability" for comfort.

Protective clothing should include:

1. Gowns - solid front, wrap around, long sleeves with close fitting ' ''' cuffs and closures.

2. Head covering - hood or cap which covers the complete head (with exception of the face) and forms a collar over the neck and shoulders. : 3. Trousers - long enough to be tucked into shoe coverings. 4. Shoe covers - long enough to extend over trouser legs and which can j . be securely fastened at the top. .,-,„ -,, ,. .-.-^ ,-.. r -• ^ 5. Gloves - long enough to enclose cuffs of gowns. .; ^ - • K;,-. •LI^ 00-.

•' 6. Aprons - water proof. „ . 'r 7,_ . :

•- Instead of providing gowns and trousers, one-piece coveralls with or without hoods are available. Waterproof boots or overshoes may be substituted for shoe covers, but must be decontaminated with a disinfectant after each use. CDS/80,1 page 52

ANNEX 8

PACKING INSTRUCTIONS

Diagnostic Specimens and Infectious Substances

1. Volume less than 50 ml ,:. -, , (;

Place the material in a securely closed, watertight container /primary container (test tube, vial, etc.)^/- Place the primary container in a second, durable watertight container (secondary container). Several primary containers may be enclosed in a single secondary container if the total volume of all the primary containers so enclosed does not exceed 50 ml. Fill the space at the top, bottom, and sides between the primary and secondary containers with ' ""* " sufficient nonparticulate absorbent material to absorb the entire contents of the primary container(s) in case of breakage or leakage. Then enclose each set of primary and secondary containers in an outer shipping container constructed of corrugated fiberboard, cardboard, wood, or other material of equivalent strength.

If dry ice is used as a refrigerant, it must be placed outside the secondary container(s), , , , . ,>,.,..; ,•

2, Volumes of 50 ml or greater

Place the material in a securely closed, watertight container (primary container). Enclose this container in a second, durable watertight container (secondary container). Single primary containers are not to contain more than 500 ml of material. However, two or more primary containers whose combined volumes do not exceed 500 ml may be placed in a single secondary container. Fill the space at the top, bottom, and sides between the primary and secondary containers with sufficient nonparticulate absorbent material to absorb the entire contents of the primary container(s) in case of breakage or leakage. Then enclose each set of primary and secondary containers in an outer shipping container con­ structed of corrugated fiberboard, cardboard, wood, or other material of equivalent strength. Also place a shock-absorbent material, in volume at least equal to that of the absorbent material, between the primary and secondary containers at the top, bottom and sides, between the secondary container and the outer shipping container, (The maximum amount of materials that may be enclosed within a single outer shipping container should not exceed 4000 ml.)

If dry ice is used as a refrigerant, it must be placed outside the secondary container(s). If dry ice is used between the secondary container and the outer shipping container, the shock-absorbent material is to be placed so that the secondary container does not become loose inside the outer shipping container as the dry ice sublimates.

The attached diagram shows the elements of packaging for infectious substances and diagnostic specimens. CDS/80.1 page 53 Annex 8

Diagram showing the elements of packaging for Infectious Substances and Diagnostic Specimens

Ampoule containing the specimen: screw-capped vial (illustrated) with a Primary nontoxic rubber line and taped shut, or flame-sealed glass ampoule. receptacle Absorptive material - e.g. tissue paper or absorbent cotton wool - sufficient to absorb all the specimen should leakage occur I Secondary ) packaging Plastic bag, heat-sealed or taped over (not stapled). ) Shock-absorbing padding - e.g. loosely packed paper or absorbed cotton wool. Outer Rigid waterproof outer container. packaging Tight-fitting lid e.g. screw-on or push-on (paint-can type) - taped shut or clipped. CDS/80.1 page 54 SHIPPER'S CERTIFICATION FOR RESTRICTED ARTICLES S amp le 1 ANNEX 9 (excluding radioactive materials) For packages 50 ml or les ATTESTATION DE L'EXPEDITEUR POUR ARTICLES REGLEMENTES (à l'exclusion des matières radioactives)

Two completed anà signed copifs of this certification stnall be handed lo the earner. I Use block lettersl

Deux exemplaires complétés et signes (te cettf; Attestation seront remis au rransoorteur. lEcrire en Capitales)

WARNING Failure to comply m all respects with the lATA Restricted Articles Regulations may be a breach of the applicable law, subtect to legal penalties This certification shall in no circumstance be signed by an lATA Cargo Agent, consolidator or a forwarder

AVERTISSEfVlENT Le non respect sur quelque point que ce soit de la Réglementation lATA pour le Transport des Articles Réglementes peut constituer une infraction aux lois en vigueur punissable par la loi Ce certificat ne peut en aucun cas être signe par une agence messageries lATA, un groupeur ou un transitaire

This constgnmf.'nt is wiîhin the limitations p'esc^ib'd *or (mark OPPI

Cf.'T envoi est dans les limites autorisées sur (Marquer d'une cro ir]

both passenger and cargo aircra'T only cargo aircaft avions passagers et cargo dvion cargo uniquement

Nun^ijer [Article NumtïerjPropcr shipping name of Article as sho'wn m Class lATA Padsiiig iNet Quantity! Flash point of jisee section IV iSection IV of lATA Restricted Articles Note No. ioer Paci

Special Handling Infoi ir!r;ti

I hereby certify that the contents of this consign ment are fully and accurately described above by pro per shipping name and aie classified packed marked, labelled and m proper condition for carriage by air according to tfte current edition of the lATA Restricted Articles Regulations and all applicable Garner and Governmental regulations I acknowledge ihat I may be liable for damages resulting from any misstatement or omission, and I furtfier agree that any air Carrier involved in the shipment of this Consignment may rely upon this Certification

Je soussigné certifie par lu présente que le contenu de cet envoi est désigne complement et correctement par son nom et est classe emballe, marque et étiquete et en bon état pour le transport aérien conformément à la dernière edition fie la Réglementation lATA pour le Transport des Articles Réglementes et a tous les règlements des Etats et des transporteurs Je reconnais pou von être tenu responsable de dommages resultant de fausse declaration et d omission et lereconnisd autre part que 10ut Transporteur assurant le transport de cet envoi pourra s appuyer sur cette Attestation

.uidi ess ol S'i ippi \ame an.' Mie or person siqn,nLj Certif cation ' lie l'expéilileui ^on-- et titre la ^'ersonne Signant \ Attestation

Sionatiiie oî the Sh.ppei isee IVARNING abCvel J Signature de l'Eypéj'teur ivoii AVERTISSEMENT plus haut' A

Au po( t of Dep*if lui e * Ail 00' t of Desîiridt on " 1 P A" W.Hhîll No Aéroport do destination W Nil lie l. eitrp (If Tf.visport Aenen A^ioport d 0' 'UiMp

1 ' T his txiy is opt lonal f or complet ion tiy isSLimq c.if MLM . 1 Cette (,,ïst' est tjcultativp pour le transporuuîf d cingme. CDS/80.1 page 55 SHIPPER'S CERTIFICATION FOR RESTRICTED ARTICLES Annex 9 (excluding radioactive materials) Sample 2 ATTESTATION DE L'EXPEDITEUR POUR ARTICLES REGLEMENTES for packages o (à l'exclusion des matières radioactives) ^° ^ litre

Two completed and signed copies of this certification shall be handed to the carrier. (Use hlock letters) Deux exemplaires complétés el signés de cette Attestation seront remis au transporteur. lEcrire en Capitales)

WARNirjG Failure to comply in all respects with the lATA Restricted Articles Regulations may be a breach of the applicable law, subiect to legal penalties This certification shall in no circumstance be signed by an lATA Cargo Agent consolidator or a forwarder

AVERTISSEMENT Le non respect sur quelque point que ce soit de la Réglementation lATA pour le Transport des Articles Réglementes peut constituer une infraction aux lois en vigueur, punissable par la loi Ce certificat ne peut en aucun cas être signe par une agence messageries lATA. un groupeur ou un transitaire

This consignment is withm the limitations prescribed for Imark one)

Cet envoi est dans les limites autorisées sur (Marquer d'urne croix)

r-\ both passenger and cargo aircraft only cargo aircraft avions passagers et cargo avion cargo uniquement

Mumber Article Numt^er Proper shipping name of Article as shown in Class I lATA Packing Net Quantity Flash-point of Isee section IV Section IV of lATA Restricted Articles Note No. per Package (closed cup) packages lATA Regul.l Regulations. Specify each article separately. I applied ! for flammable liquids Point d'éclair (cuvette Nombre No. d'article jDésignation exacte du produit scion Chapitre IV Classe N° Note Quantité fermée) pour liquides de Icf Chapitre IV Re'glementation lATA j d'Emballage nette I inflammables Colis Réglem. lATA) Désigner séparément chaque article. ! utilisé par colis I oc OF

736 INFECTIOUS SUBSTANCE 696

Special Handling Information: Informations spéciales concernant la manutention: Infectious Substance for Diagnostic, re.search and scientific purposes only - no commercial value - do not delay do not open in transit I hereby certify that the contents of this consignment are fully and accurately described above by proper sfiipping name and are classified packed marked, labelled and in proper condition for carriage by air according to tfia current edition of the lATA Restricted Articles Regulations and all applicable Carrier and Governmental regulations I acknowledge that I may be liable for damages resulting from any misstatement or omission, and I further agree that any air Carrier involved in the shipment of this Consignment may rely upon tfiis Certification

Je soussigné certifie par la présente que le contenu de cet envoi est désigne complément et correctement par son nom. et est classe emballe, marque et étiquete et en bon état pour le transport aérien conformément à la dernière edition de la Réglementation lATA pour le Transport des Articles Réglementes et à tous les règlements des Etats et des transporteurs Je reconnais pouvoir être tenu responsable de dommages resultant de fausse derlaiation et d omission, etiereconnisd autrepart que tout Transporteur assurant le transport de cet envoi pourra s appuyer sur cette Attestation

Name jntl lull address of Shipper Name and title of person signing CertificatiO'i Nom et adresse de l'expédiieui Nom et titre de la personne signant l'Attestation

Date I Signature of the Shipper Isee WARNING above) Signature de l'Expétliteur (voir AVERTISSEMENT plus hauti

Aw Waybill No Airport of Departure Airport of Destination • No ife Lettre de Transport Aérien Aéroport d'origine Aéroport de destination

'This bOH IS optional for completion by issuing carr ler. I Cette case est facultative pour le transporteur d engine.| CDS/80.1 page 56

ANNEX 10

INFECTIOUS SUBSTANCE LABEL

I-, CDS/so.I page 57 CDS/80.1 pago 5a Annux 11 CDS/ftO. I page S9 Anne» Il

SpeciMit collection kit u«ed for «u«p«cted monkeypox cases (see Annex 3, iti 3)

1. Uncet 2. Sterile svabs 3. Plastic speciaen collection container

k. Hetal tin 5. Outer cardboard nailing container. HateriAls ii*cd to inkf sixTlmcn» from persons suspected of h.ivinx viral tvaraorrhaglc fevers;

1. l.iver biop»v needle .tssewbly S. Variitninor nt-odlcs (for cuff) 2. Spociwcn n Jars ffor llvrr biopsy) 6. Vacutainer iubc« (for blt>od drawing) Î Formol solution for Jars (for liver biopsy) 7. SeruB collection tubes i* Vacutainer cuff 8. Tourniquet COS/so.1 page 61 Annex 11

A. Technician wearing washable plaitic B. Technician wearing plasticisad one apron, gloves, surgical cloth mask piece uniform and full-face biological and face visor over plastic gown. respirator.

Disposable bedpans patient care.