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GUIDELINES FOR MANAGEMENT OF DECEASED WITH SUSPECTED EBOLA CASES
ABOUT EBOLA VIRUS DISEASE Ebola virus disease (Ebola; formerly known as Ebola Haemorrhagic Fever) is a severe, often fatal illness with a death rate of up to 90%. The illness affects humans and non-human primates: monkeys, gorillas and chimpanzees (WHO, July 8, 2014). Ebola viruses are part of the family of Filoviridae which also includes Marburg virus. Five species of Ebola virus have been identified: Zaire, Sudan, Reston, Tai Forest and Bundibugyo (Commonwealth of Australia Department of Health, 2014). The origin of the virus is unknown but fruit bats (Pteropodidae) are considered the likely host of the Ebola virus, based on available evidence (WHO, July 8, 2014). TRANSMISSION OF EBOLA VIRUS DISEASE Ebola virus disease is introduced into the human population through close contact with secretions, organs, blood or other body fluids of host species or infected animals. In Africa, infection has occurred through the handling of infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead in the rain forest. It is important to reduce contact with high risk animals (e.g. fruit bats, monkeys or apes), such as not picking up dead animals or handling their raw meat (WHO, July 8, 2014). Airborne transmission, as occurs for measles or smallpox, has never been documented (Commonwealth of Australia Department of Health, 2014). Once a person is infected, Ebola virus can spread to others from direct contact with the infected person's blood or other body fluids or secretions (stool, urine, saliva, semen) through broken skin or intact mucous membranes. Infection can also occur if broken skin or intact mucous membranes of a healthy person come into contact with objects such as soiled clothing, bed linen or used needles contaminated with an Ebola patient's infectious fluids (WHO, July 8, 2014). CASE FATALITY RATE Ebola first appeared in 1976 in two simultaneous outbreaks, one in a village near the Ebola River in the Democratic Republic of the Congo, and the other in a remote area of Sudan. (WHO, July 8, 2014) Between September 1 and October 24, 1976, 318 cases of acute viral haemorrhagic fever occurred in northern Zaire (now known as. There were 280 deaths and only 38 serologically confirmed survivors. The index case was treated initially by injection of chloroquine for presumed malaria. Within a week, several others who had received injections were found to be suffering from Ebola, and all subsequent cases had either received injections at the hospital or had close contact with another case. The hospital was closed within four weeks of the outbreak, by which time 11 of its 17 staff had died. It was not possible to identify a direct link between the two areas of outbreak. Although they are separated by about 4 days travel, it was thought likely that an infected person had made the journey. Ebola virus antibodies were found in five people who were not ill and had not had contact with the infected villages or the hospital. This suggested that the virus may be endemic (WHO, 1978). The incubation period (time from infection to onset of symptoms) varies from 2 to 21 days. Patients are contagious only after the development of symptoms, i.e., people are not contagious during the incubation period. The typical symptoms and signs are: sudden onset of fever, intense weakness, muscle pain, headache and sore throat. These are followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases both external and internal bleeding. The management of Ebola virus disease is by intense supportive care. Patients are frequently dehydrated and need intravenous fluids and electrolytes. There is no specific curative treatment. Recommendations from the Commonwealth of Australia Department of Health for patients with symptoms compatible with Ebola, who have a history of travel or residence in affected areas in the 21 days prior to the onset of symptoms, or contact with a known probable or confirmed case in the 21 days before onset include:  Care for the patient in a single room and transmission-based precautions implemented (contact and droplet) using personal protective equipment (PPE) (including routine use of a surgical mask, disposable gown, gloves, and eye protection). P2 (N95) respirators should be used when aerosol-generating procedures are performed. Close attention to hand hygiene is important  Blood and other samples should be collected for Ebola virus testing and other investigations, but because of the highly infectious nature of the fluids, routine testing should be minimized Primary diagnostic testing is detection of Ebola virus by PCR in serum, plasma, a throat swab or urine. Serology is also available. In Australia, testing is conducted in a Physical Containment level 4 laboratory (VIDRL, Peter Doherty Institute, Victoria). NECESSITY FOR INSTITUTIONAL RESPONSE In view of the incubation period and availability of air travel, it is possible that travellers who have been in affected areas of West Africa, or have been in close contact with others who have been will arrive in Australia and become ill. It is likely that these patients will be identified clinically, and in the event of their death, arrangements made which do not involve forensic services. However, a death could be referred to the Coroner/VIFM especially in cases of uncertainty about the diagnosis, or if a person from the affected region dies suddenly and unexpectedly. Reference to this document can serve to advice about the handling of the deceased. In case of an outbreak in Australia a new protocol would be developed based on the core principles of this protocol. In general, the new protocol would follow the approach of the International Committee for the Red Cross for management of dead bodies after disasters. VIFM are responsible for contingency planning required for management of a multiple casualty event in their jurisdiction. This planning can be adapted to manage deaths due to a pandemic in which hospital mortuaries may be overwhelmed. VIFM are best equipped to manage multiple deaths. As government facilities, VIFM may also be requested to manage bodies when other mortuaries are not prepared to store or transport the bodies. This situation could occur in cases of Ebola. COORDINATED RESPONSE REQUIRED – FORENSIC PATHOLOGY AND DEPARTMENT OF HEALTH In Victoria, Australia, suspected or known cases of Ebola virus require immediate notification to the Victorian Department of Health on 1300651160 and formal notification within 5 days. The director of VIFM will also notify the Chief Medical Officer and the State Coroner immediately. VIFM will work closely with the Department of Health in their response. MANAGEMENT OF A DEAD BODY WITH PROVEN OR SUSPECTED EBOLA VIRUS DISEASE INTRODUCTION- WHO GUIDELINES WHO has guidelines for the "Movement and burial of human remains", as follows: The handling of human remains should be kept to a minimum. The following recommendations should be adhered to in principle, but may need some adaptation to take account of cultural and religious concerns:  Remains should not be sprayed, washed or embalmed  Only trained personnel should handle remains during the outbreak  Personnel handling remains should wear PPE (gloves, gowns, apron, surgical masks, eye protection) and closed shoes  Protective equipment is not required for individuals driving or riding in a vehicle to collect human  Protective equipment should be put on at the site of collection of human remains and worn during the process of collection and placement in a body bag  PPE should be removed and placed in an infectious bag immediately after the remains have been placed in a body bag and transferred to a transport coffin. The infectious bag should also be placed in the coffin.  The coffin should be wrapped in sealed, leak proof material and should be cremated or buried (WHO, March 2008) RESPONSE TO A NOTIFICATION BY POLICE/HEATH PROFESSIONAL OF A DECEASED SUSPECTED OF HAVING EBOLA VIRUS DISEASE The CAE/Initial Coronial reporting office has a role in monitoring reports of death and alerting the VIFM/Department of Health when a death has occurred in a person who has recently travelled to the African nations. If the deceased was reported to have flu like symptoms, the on-call pathologist is to be notified. Police are to be notified to secure the scene and await further advice. The on-call pathologist, in consultation with Director VIFM will make the decision to either treat the deceased as "suspected EBOLA" or a normal case. The Department of Health should also be contacted on 1300651160 as they may be able to provide details whether the deceased is a known high risk. ACTIONS FOLLOWING DECISION THAT NOTIFIED DEATH IS TO BE MANAGED AS POSSIBLE/ SUSPECTED EBOLA If the decision to treat the deceased as ‘suspected ebola" the deceased is to remain in situ and the Victorian Police DVI/CBR unit will attend to provide advice and assist in the process. A VIFM Forensic Pathologist with appropriate PPE including tyvek suits will attend the scene and collect a blood sample for testing at VIDRL. Only the Department of Health can authorise EVD testing and will make the initial contact with VIDRL. The
Forensic Pathologist will notify the Department by calling 1300 651 160 to obtain authorisation for EVD
testing.
The sample is to be double bagged and transported by VIFM staff or DVI/CBR unit direct to VIDRL. If the test is positive, a risk assessment will take place in conjunction with the forensic pathologist to determine the level of PPE. If the scene is contaminated with large amounts of body fluids or severe trauma Level A fully encapsulated suits may be required to move the deceased. If there are no body fluids present Level C may be used. The police will treat the scene as a "hot zone". The trained police/fire brigade/ forensic pathologist will attend the deceased and take overall photos. The deceased is to be transferred to a heavy duty leak proof body bag. This bag is placed a second bag in the "Warm zone". The outside of the bag is to be decontaminated with a disinfectant solution. An example of an effective disinfectant is sodium hypochlorite at 0.05%, 500 ppm available chlorine (i.e. 1:100 dilution of household bleach at initial concentration of 5%). (WHO 2008) The secured decontaminated body bags may then be transferred to VIFM mortuary by the normal funeral director arrangements with an escort. ACTIONS TAKEN FOR THE MANAGEMENT OF DECEASED SUSPECTED TO HAVE EBOLA AT VIFM/FSCC Component
Protocol
 All persons required to remove/transport or examine deceased should wear at o Tyvek suit or similar (fluid/biological hazard resistant or impermeable) Personal Protective o Eye protection (goggles or face shield) o Disposable shoe covers Component
Protocol
 Mortuary staff are to be alerted by the Coronial Admissions and Enquiries of suspected Ebola cases  Prior to arrival the CT scanner room is to be prepared with a white disposable (fluid impermeable) sheet, all labels are to be ready and solutions of disinfectant available  Staff are to wear four pairs of gloves.  Only two staff are to be present in the CT scanning room. One staff is to remain clean and act as a monitor and ensure safe procedures are followed.  Each staff member is to monitor and check each other to ensure correct PPE is  External surface of the bag is to be wiped with disinfectant.  Transfer the deceased using the body lift. Clean staff member to operate the  Once transfer is complete remove outermost pair of gloves  The body bag is not to be opened.  An external label is placed on the bag  A disposable infectious disease waste bag is to be placed on the trolley for all disposable gloves and PPE as they are removed  The deceased is transferred to the CT room. The doors should open automatically. If buttons need to be pushed, clean towels are to be used and immediately disposed in infectious waste bag on trolley  A disposable white plastic sheet is to be placed on the CT Scan couch  Deceased is to be transferred to the couch via the body lift.  Two staff members are to leave the room and wait without touching any other surface until the CT scan is complete  A third staff member will operate the CT scanner from a separate room  On completion of the CT scan the deceased is transferred back to the original trolley. The disposable white sheet to be placed in the infectious bag.  Deceased should be stored in isolated (homicide) refrigerator.  Once the deceased is placed in the fridge, the two staff members remove all PPE in a safe manner and place in the disposable infectious bag which remains with the deceased. Storage of deceased  Hand hygiene procedures should take place.  Only authorised personnel are to enter the fridge.  A log of all persons accessing the deceased should be maintained. Cleaning of the CT  The same staff are to don full PPE and clean the couch and the straps of the Component
Protocol
body lift with disinfectant solution.  PPE is to be removed safely, placed in infectious waste bags and stored with  Examinations should take place in the special autopsy suite  Minimal staff should be present  All examinations should take place with the body remaining in the body bag  Limit the use of needles and other sharps as much as possible  All needles and sharps should be handled with extreme care and disposed of in puncture-proof, sealed containers. This container should remain with the deceased.  Specimen to obtain: blood by precordial stab  A minimum volume of 4mL whole blood preserved with EDTA, clot activator, sodium polyanethol sulfonate (SPS), or citrate in plastic collection tubes can be
submitted (www.cdc.gov)
 Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is paramount, as blood, sweat, vomit, faeces and other body secretions represent potentially infectious materials  Staff performing environmental cleaning and disinfection should wear full PPE Post examination (described above)  The external surface of the body bag is to be wiped down using hypochlorite solution, prior to returning to the refrigerator  PPE is to be removed safely and placed in the infectious disease waste bag and stored with the deceased ACTIONS FOLLOWING CONFIRMATION DECEASED HAS TESTED POSITIVE TO EBOLA  The nominated funeral director is to be contacted as soon as possible to arrange burial.  Mortuary staff are to don full PPE and prepare the body bag for transfer to coffin  All waste is to be enclosed within the body bag  The funeral directors are to deliver a coffin and mortuary staff will transfer the deceased directly into  Once transfer is complete, the staff are to clean lifting equipment and wipe down any external surface of the coffin that came in contact with the body bag  Staff are to remove PPE safely.  PPE to be placed in an infectious bag in the coffin  Coffin is to be sealed and transferred for burial MANAGEMENT OF EXIGENT CIRCUMSTANCES SUCH AS AN OUTBREAK OF EBOLA VIRUS DISEASE It is anticipated that, once an outbreak has been established, the majority of cases will not require medicolegal death investigation. However, it may be necessary to store bodies at VIFM. The protocol described above would be used. Unusual circumstances would include the homicide of an Ebola patient. The necessity for and extent of the post mortem examination would be determined on a case-by-case basis in consultation with the Crown prosecution service and/or Coroner. COMMUNICATION WITH STAFF VIFM will undertake a training session for staff with information about Ebola and protective measures. OMM AT O WITH FAMILIES AND EXTERNAL STAKEHOLDERS VIFM will manage all communications with families and stakeholders according to standard procedures. SUSPECTED INJURY OR EXPOSURE OF STAFF MEMBER Staff with percutaneous or mucocutaneous exposures to blood, body fluids, secretions, or excretions from a deceased with suspected Ebola, or asymptomatic staff members who have been exposed to a deceased with Ebola, would be immediately referred for appropriate medical care and monitoring, in accordance with jurisdictional health policies. 1. World Health Organisation. Frequently asked questions on Ebola virus disease. 8 July, 2014 Bulletin of the World Health Organisation, 56 (2): 271-293 (1978) Ebola haemorrhagic fever in Zaire, 1976. Report of an International Commission 2. Commonwealth of Australia. Department of Health. 18 July 2014. Ebola virus disease (EVD) outbreaks in Western Africa. Important information for clinicians in secondary or tertiary care. 3. WHO. March 2008. Interim Infection Control Recommendations for Care of Patients with Suspected or Confirmed Filovirus (Ebola, Marburg) Haemorrhagic Fever 4. Public Health Ontario, Viral haemorrhagic fever: Update for clinicians. 2014-07-16 5. Public Health Ontario, Viral Haemorrhagic Fevers (VHFs) – Sample collection and submission guide. 2014- 6. International Committee for the Red Cross, Management of dead bodies after disasters: a field manual for first responders. 10-04-2009 Publication Ref. 0880

Source: http://afda.org.au/app/webroot/media/member/ViFM%20Local%20Guidelines%20for%20management%20of%20supected%20EBOLA%20CASES.pdf