S5E1: Viral Haemorrhagic Fever and The National High Level Isolation Unit - Infectious Diseases
And we’re back!
Welcome to Season 5 of TheCase.Report! What better a way to endure the cold and wet autumnal evenings than kicking back and listening to TCR? We’re kicking off the new season with a spicy infectious diseases case to get your brains ticking!
Many thanks as always to IAEM who make this podcast possible - at our heart, we are a community of learning and it is humbling to see how the podcast has evolved over time, including our international collaboration with EM Cases in season 4 - and we’ve only just begun. But enough of the updates, we’ve got a case to run!
With a new and improved National Isolation Unit (NIU) now under construction in the Mater Misericordiae University Hospital, and the development of the two-bedded National High Level Isolation Unit (NHLIU/HLIU), what better way to remind ourselves of the pertinence of a succinct history and exam, and the importance of utilising national resources than with a TCR case?
Joining us on the case this month are our NCHDs Conor O’Gara, Leah Flanagan and Ralph Hurley O’Dwyer, who treat us to a comprehensive run through of this case of Viral Haemorrhagic Fever.
For our bonus segment, we are honoured to be joined by Dr Catherine Uhomoibhi and Dr Deirdre Morley, co-leads of the National Isolation Unit, who share their infectious diseases mastermind expertise with us. They have also run multiple simulations in preparation for the opening of the NHLIU, including an international simulation involving 3 different countries, simulating the transfer of a patient with a high consequence infectious disease internationally by air!
You can click on these links to download the infographics on Travel History and Fever in the Returning Traveller, or in the notes below.
Don’t forget to follow us on our socials instagram, X and facebook to keep track of our latest releases, sneak previews of our fifth season and access to our bonus episodes!
Right, enough of the teasers. Are you ready to take the history of a returned traveller?
Ah yes, I saw a case of this one time… in a book!
Fever in the returning traveller is a salient case, and although we may not see it very often, it is super important to get a handle on it quickly. Early recognition and isolation are key aspects to the care of these patients and are instrumental in garnering good patient outcomes and also keeping healthcare staff safe.
Early suspicion
As early as the first few sentences in triage, a fever in a returned traveller should raise suspicion immediately. The pertinence of early isolation in a single room is stressed in this episode, with excellent recognition from the triage nurses. As always, it is easier to de-escalate the isolation and PPE precautions, therefore, prompt isolation where possible is incredibly helpful. Notwithstanding this, it is still important to carry out a full and thorough clinical history and exam - but this aids the process from the outset.
TCR Top Tip: Fever in a traveller from a malarial zone IS malaria until proven otherwise.
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Mapping out a strict timeline of time abroad
Exact locations visited (names of villages, town, cities)
Duration in each visited region
Public transport or mode of transport used
Accommodation in each region
Any freshwater swimming?
Drinking water origin?
Any new diet or foods?
Any known sick contacts?
Any high-risk areas visited?
Any animal or insect bites?
Malaria prophylaxis?
Type? Compliance? Any missed medication? When commenced and discontinued?
Any new sexual contacts?
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Any sick contacts?
Working in healthcare specifically: any breach of PPE or exposure without PPE or NSI?
Recreational drugs
Approach to the VHF Patient
With all investigations sent to local or national labs from the isolated patient, a call to the microbiologist on-call or the lab is imperative.
This ensures the safety of lab workers and ensures you’re sending the right test, in the right bottle, to the right place at the right time.
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Glucose
LFT’s
Renal profile
FBC
APTT
CRP
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Get it to the lab within 1hr!
EDTA blood specimen for blood smear
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2 sets of cultures
30 mins apart
Separate venepuncture sites
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Testing for all of our favourite VHFs including
Filoviruses (Ebola group viruses and Marburg virus)
Crimean Congo Haemorrhagic Fever Virus
Lassa Virus
Orthopox viruses
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Don’t forget to outrule other causes of sepsis in addition to your VHF investigations.
SEPSIS SIX
High-flow oxygen therapy
Blood cultures
IV Abx
Fluid challenge
Measure urine output
Get a lactate
Think urinary / pulmonary causes
CXR & MSU to outrule other possible causes
COVID-19 / Influenza swabs
As was stressed in the case, a thorough clinical assessment ensuring an in-depth travel history is essential for the management of VHF. Given there’s a spectrum of how sick these patients present, supportive care and management will vary depending on the individual patient. Involvement of ICU colleagues might be necessary so don’t forget to include them early on!
Differential Diagnoses
Remember: Fever in a returned traveller from a malarial zone IS malaria until proven otherwise!
Malaria
Sepsis
Leptospirosis
Dengue Fever
Arboviral Disease
And…
Don’t forget about horses even if it does look and sound like a zebra this time…
Common things are common, and even if the patient’s symptomology and history is suggestive of a VHF or is a case of fever in a returned traveller, you should still rule out other causes of infection and sepsis alongside your VHF investigations.
Perform the sepsis six
Think urinary / pulmonary causes
CXR & MSU to outrule other possible causes
COVID-19 / Influenza swabs
*TOP TIP*: Consult the travel medicine bible - The CDC’s Yellow Book of differentials is not to be missed!
So what exactly is Viral Haemorrhagic Fever?
VHF agents are zoonotic diseases that may cause a haemorrhagic syndrome in humans. These illnesses are caused by 4 distinct families of viruses: the adenoviruses, bunyaviruses, filoviruses and flaviviruses. Some well known VHFs that can spread person to person include Ebola, Marburg, Lassa and Crimean Congo haemorrhagic fever. VHFs tend to be found in tropical and subtropical areas such as Africa, South America and the Middle East [1].
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Pyrexic >37.5
Returned from VHF endemic region within last 21 days
Contact with probable or confirmed case of VHF within 21 days
Headache
Myalgia
Prostration
Any signs of bleeding (from minor to major bleeding) from any organ
Petechial rash
Ecchymoses
Hypotensive shock
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Fluid repellent full-sleeved gown
Gloves
FFP2 / FFP3
Face shield / eye protection
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Consult local microbiology and infectious disease guidelines and don’t forget that call to the lab to inform them you’re coming! Samples should travel separately to the rest of the emergency department and appropriate safety information should be given to the staff delivering specimens.
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Ring your local Infectious Disease / Microbiology team and the National Isolation Unit (Mater Switch 01-803 2000) for specialist advice.
Conor seemed to enjoy the hold music while waiting to be transferred during the case!
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Depending on the case, the National Emergency Operations Centre (NEOC) may be involved in organising transport of the patient.
If the NIU has accepted the patient and there are beds / transport available, a decision will be made on the safest way to transfer the patient
Listen in to the bonus segment for more on the logistics of transfer and the EpiShuttle
Public health
The Health Protection Surveillance Centre (HPSC) provides thorough, detailed and easy-to-use guidelines on the approach to VHF.
Check out the specific HSPC algorithm we highlighted in the case
Remember to ring your local Public Health unit for advice and to notify them if you have suspicion of a VHF case!
If there is a confirmed case, Public Health will aid in contact tracing and further management.
Resources from the case:
ProMED International Society for Infectious Diseases
Bonus segment! Behind the scenes at the National Isolation Unit…
In the second half of the show we get to hear some incredible insights into the behind the scenes work at the NIU from its very co-leads, Dr Deirdre Morley, Consultant in Infectious Diseases and Intensive Care at the Mater Misericordiae Hospital, Dublin, and Dr Catherine Uhomoibhi, Infectious Diseases Specialist Registrar.
The key to success
In Dr Morley’s eyes, the key to success in running a high-level NIU is the merging of the Infectious Diseases and Intensive Care departments. These patients can deteriorate quite quickly, requiring input from both specialities.
Infrastructure
We hear about the basic and essential infrastructure required to run such a facility including unfilow, autoclave for waste, decontamination showers and having an on-site biosafety level 3 lab just to name a few - all based upon recognised international standards, and on learnings from France and Germany. The focus behind the infrastructure is to provide the highest standard of care to patients, while offering the highest level of protection to staff.
When to activate the National Isolation Unit?
The NIU is for high-consequence infectious diseases (HCIDs) which can be either airborne or contact. MERS is an example of an airborne HCID, while contact HCIDs can include the VHFs, such as Marburg, Ebola, Lassa and Crimean Congo to name but a few.
Dr Morley reminds us that ideally a diagnosis would be confirmed prior to transfer to the NIU due to the cost and the resource intensive nature of running it. However, the NIU may be activated in certain situations before a diagnosis is confirmed, and can be stepped down if there is a negative result. Early discussion with the NIU consultant is always advised in cases where there is a high suspicion.
Fail to prepare, prepare to fail.
Most excitingly we discuss the importance of running high fidelity simulations for these high-acuity, low-occurrence events. We walk step by step through two local, and one mind-bogglingly complex international high fidelity simulation involving 3 different countries and a simulated air transfer of a patien!. The importance of doing a good debriefing and enabling feedback from everyone involved cannot be stressed enough!
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Running an international simulation takes the meaning of an MDT to a whole other dimension - involving a military level of cooperation, communication and teamwork between the various groups as large and diverse as:
Irish Defence Forces
National Ambulance Service (NAS)
HSE Health Protection Surveillance Centre (HPSC)
Department of Health
National Emergency Operations Centre (NEOC)
An Garda Síochána
European Response Coordination Centre (ERCC)
Norwegian rescEU Jet Air Ambulance for the Transport of Infectious Patients (NOJAHIP)
And many many more acronyms…
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Simulation provides the perfect opportunity to assess protocols and identify problems in real time, facilitating staff learning while also testing transport and communication between all the different MDT members as described above.
And as Catherine stresses, above all, these simulations build strong links, broaden our communities and deepen our connections with other organisations around the globe. They strengthen our ability to work together and prepare us for an increasingly more global future.
“Ní neart go cur le chéile”.
And on the topic of debriefing…
That’s a wrap for the first episode of season 5! Our massive thanks to our two Adults in the Room, Dr Deirdre Morley and Dr Catherine Uhomoibhi for their fascinating insights into the NIU, simulation, and the protocols we can expect to have in place when the NIU opens. This may be the first case we’ve ever had where our Adult in the Room has had nothing further to add to the case, so we’ve set our standards high for season 5!
If you’re an ED NCHD and enjoyed this case, and think you would like to try your hand at creating an episode, we’d love to hear from you!
We’re looking for teams from every ED in Ireland and beyond to contribute content this season, and want to explore the breadth of knowledge that we know is just waiting to be shared on TCR! Our Production Team are passionate about FOAMed, and will guide you through the whole process of bringing your primitive case idea to life! Sound interesting? Give us a buzz at info@thecase.report, and we’ll be thrilled to get you started on your episode.
We’ve got some incredible content coming to you over the next couple of months, and our fantastic new TCR Innovation Team are creating wonderful educational adjuncts to make your learning easier, and dare we say… fun?!
Don’t forget to follow us on our socials instagram, X and facebook to keep track of our latest releases, sneak previews of our fifth season and access to our bonus episodes!
If you didn’t get a chance to listen, we released a pre-season bonus a couple of weeks ago focused on pre-hospital system design which you can listen along to with the show notes.
That’s it for this month’s episode. The next episode will be released on Monday the 4th of November 2024. Until next time, may your coffee be strong, and your rounds grand. TCR, out.
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Laboratory Diagnosis of Viral Haemorrhagic Fever Viruses. Health Protection Surveillance Centre, VHF Guidance Chapters. Available at URL: https://www.hpsc.ie/a-z/vectorborne/viralhaemorrhagicfever/guidance/vhfguidancechapters/Chp%204_Laboratory_finalweb.pdf
[accessed 02/10/24]
Overview of Viral Haemorrhagic Fevers. Health Protection Surveillance Centre, VHF Guidance Chapters. Available at URL: https://www.hpsc.ie/a-z/vectorborne/viralhaemorrhagicfever/guidance/vhfguidancechapters/Chp%201_Introduction_finalweb.pdf
[accessed 02/10/24]
Viral Haemorrhagic Fevers, Centres for Disease Control and Prevention Yellow Book 2024. Available at URL: https://wwwnc.cdc.gov/travel/yellowbook/2024/infections-diseases/viral-hemorrhagic-fevers
[accessed 02/10/24]
The Management of Viral Haemorrhagic Fevers in Ireland, National Disease Surveillance Centre. Available at URL: https://www.hpsc.ie/a-z/vectorborne/viralhaemorrhagicfever/publications/File,4638,en.pdf
[accessed 02/10/24]
Article on Road Closure for the international simulation https://www.dublinlive.ie/news/dublin-news/mater-hospital-cordoned-gardai-part-28894795
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Main Case:
Dr Leah Flanagan
Dr Conor O'Gara
Dr Ralph Hurley O’Dwyer
Adult in the Room/Bonus segment guests
Dr Catherine Uhomoibhi
Dr Deirdre Morley
TCR Innovation Team - Show notes / infographics / website design / social media
Dr Johnny Collins
Ms Sinéad Kelly
Dr Genevieve Callander
Dr Liam Loughrey
