Infection Control for

Viral Haemorrhagic Fevers

in the African

Health Care

Setting

World Health Organization

U.S. DEPARTMENT

Public

OF

Health

HEALTH

Service

& HUMAN SERVICES CDC

CENTERS FOR DISEASE CONTROL

AND PREVENTION
C. J. Peters, M.D., Chief 

Special Pathogens Branch 

Division of Viral and Rickettsial Diseases 

National Center for Infectious Diseases 

Centers for Disease Control and Prevention 

Guenael Rodier, M.D., Chief 

Epidemiological Surveillance and Epidemic Response 

Division of Emerging and Other Communicable Diseases 

World Health Organization 

Developed and written by: 

Ethleen Lloyd, M.S., C.H.E.S., Health Communication Specialist


Special Pathogens Branch (CDC)


Helen Perry, M.A., Educational Design Specialist


Special Pathogens Branch (CDC)


Layout and design by: 

Lilien Yang, M.S., Visiting Fellow


Special Pathogens Branch (CDC)


Illustrations by: 

Willie Richardson, A.A., Visual Information Specialist


Division of Media and Training Services, Public Health Program Practice Office (CDC)


The material in this manual is in the public domain. It may be used and reprinted without permission. The

source should be acknowledged. Suggested citation: Centers for Disease Control and Prevention and World

Health Organization. Infection Control for Viral Haemorrhagic Fevers in the African Health Care Setting.

Atlanta, Centers for Disease Control and Prevention, 1998: 1-198.
Infection Control


for Viral Haemorrhagic Fevers


in the African Health Care Setting 

December 1998 

This manual was prepared by: 

Centers for Disease Control and Prevention: National Center for Infectious Diseases, 

Division of Viral and Rickettsial Diseases, Special Pathogens Branch, WHO Collaborating 

Centre for Viral Haemorrhagic Fevers 

and 

World Health Organization: Division of Emerging and Other Communicable Diseases -­

Surveillance and Control 
Acknowledgements 

The contributions of the following organizations to the preparation and review of this 

document are gratefully acknowledged: 

Centers for Disease Control and Prevention 

Hospital Infections Program 

Office of Health and Safety 

World Health Organization 

WHO Regional Office for Africa 

WHO Country Programmes in Kenya and Gabon 

Centre International de Recherches Médicales de Franceville, Gabon 

Communicable Disease Surveillance Centre, United Kingdom 

Dr. Kalongi and the staff of Clinique Bondeko, République Démocratique du Congo 

École de Médecine, Université de Kinshasa, République Démocratique du Congo 

Épicentre, France 

Fogarty International, USA 

Hôpital Général de Kikwit, République Démocratique du Congo 

Institut de Médecine Tropicale, Belgium 

Institut de Recherche Biologique Appliquée de Guinée 

Institut Pasteur à Paris, France 

Institute of Virology, Germany 

Johns Hopkins School of Public Health, USA 

Lassa Fever Research Projects, Guinea, Sierra Leone 

Medical Emergency Relief International, United Kingdom 

Médecins Sans Frontières, Belgium 

National Institute of Virology, South Africa 

Participants attending the CDC WHO VHF Isolation Precautions workshops held 

at Mumias, Kenya, and Booué, Gabon 

Swedish Institute for Infectious Diseases, Sweden 

Tulane University, USA 

United States Army Medical Research Institute of Infectious Diseases, USA 

Virus Research Centre, Kenya Medical Research Institute, Kenya 

Yale University, USA 
Table of Contents 

Introduction 1


Viral Haemorrhagic Fevers: An Overview 3


How VHF Is Transmitted in the Health Care Setting 4


What Is in This Manual 5


Who the Manual Is For 5


Objectives 5


How to Use the Manual 6


Glossary for Use with This Manual	 8


Section 1 Use Standard Precautions with All Patients	 9


1.1	 Use Standard Precautions 11


1.2	 Establish and Maintain a Minimum Level of Standard


Precautions 12


1.3	 Establish Routine Handwashing 12


1.4	 Handle and Dispose of Sharp Instruments Safely 14


1.5	 Disinfect Reusable Needles and Syringes Safely 15


1.6	 Disinfect Disposable Needles and Syringes That Must Be


Reused 15


1.7	 Use VHF Isolation Precautions 16


1.8	 Select a VHF Coordinator 18


Section 2 Identify Suspected Cases of VHF	 19


2.1	 Use Information from Previous Outbreaks to Suspect a VHF 22


2.2	 Begin VHF Isolation Precautions 25


2.3	 Alert Health Facility Staff about Specific Risk for VHF


Transmission 25

2.4	 Report the Suspected Case to the Health Authorities 27


2.5	 Identify Patient’s Contacts and Travel History 28


Section 3 Isolate the Patient	 29


3.1	 Select Site for the Isolation Area 31


3.2	 Plan How to Arrange the Isolation Area 32


3.3	 Gather Recommended Supplies 34


3.3.1	 Plan Disinfection for VHF-Contaminated Items 34


3.3.2	 Gather Supplies for the Patient Area 35


3.3.3	 Gather Supplies for the Changing Room 36


3.3.4	 Arrange for Storing of Supplies Outside the Changing


Room 36


3.4	 Set Up Changing Rooms 37


3.5	 Place Security Barrier Around Isolation Area 37


3.6 Consult Family Members about Patient Care 39


Check List: Supplies for a Changing Room 41


Check List: Supplies for Patient Area 42


Section 4 Wear Protective Clothing	 43


4.1 Specify Who Should Wear Protective Clothing	 45


4.2 Gather a Supply of Protective Clothing	 46


4.3 Put On Protective Clothing	 53


4.4 Take Off Protective Clothing	 57


Section 5 Disinfect Reusable Supplies and Equipment	 65


5.1	 Prepare Bleach Solutions 68


5.2	 Prepare Supply of Soapy Water 72


5.3	 Disinfect Gloved Hands between Patients 73


5.4	 Disinfect Used Gloves before Reuse 74

5.5	 Disinfect Reusable Medical Instruments 75


5.6	 Disinfect Bedpan or Waste Bucket 76


5.7	 Disinfect Patient’s Utensils 76


5.8	 Disinfect Spills of Infectious Body Fluids 77


5.9	 Disinfect Infectious Waste and Non-Reusable Supplies for


Burning 78


5.10	 Clean and Disinfect Protective Clothing 79


5.11	 Clean and Disinfect Boots 79


5.12	 Clean and Disinfect Patient’s Bedding 80


5.13	 Give First Aid for Accidental Exposures 81


Section 6 Dispose of Waste Safely	 83


6.1 What Needs Disposal	 85


6.2 Select Staff to Supervise Waste Disposal and Burning	 87


6.3 Train and Supervise Staff to Carry Out Waste Disposal	 87


6.4	 Select Site for Burning VHF-Contaminated Waste 89


6.5	 Use Incinerator to Burn VHF-Contaminated Waste 89


6.6	 Use Pit to Burn VHF-Contaminated Waste 92


6.7	 Take Steps to Ensure Security of Burning Site 93


Section 7 Use Safe Burial Practices	 95


7.1	 Prepare the Body Safely 97


7.2	 Transport the Body Safely 98


7.3	 Prepare Burial Site 98


7.4	 Disinfect the Vehicle after Transporting the Body 99

Section 8	 Mobilize Community Resources and Conduct Community


Education 101


8.1 Identify Key Community Resources	 104


8.2 Meet with Community Leaders and Assess the Current Situation 106


8.3 Describe the Target Population	 108


8.4	 Describe Problems Contributing to Transmission Risk 108


8.5	 Identify Changes or Actions Required 108


8.6	 Identify Barriers to Carrying Out Recommended Changes or


Actions 109


8.7	 Develop Specific Messages 109


8.8	 Select Activities for Communicating Messages 110


8.9	 Assign Tasks and Carry Out Activities 110


8.10	 Evaluate Activities 111


8.11	 Obtain Community Feedback 112


8.12	 Meet Regularly with the Mobilization Committee 112


Section 9	 Make Advance Preparations to Use VHF Isolation Precautions 113


9.1	 Identify a VHF Coordinator to Oversee Preparations 115


9.2	 Assess Current Readiness for VHF Isolation Precautions 116


9.2.1	 Monitor Routine Handwashing Practices 116


9.2.2	 Assess Readiness for Identifying Suspected VHF Cases 117


9.2.3	 Assess Readiness for Setting Up a VHF Isolation Area 117


9.2.4	 Assess Readiness for Medical, Laboratory, and Cleaning


Staff 117


9.3 Train Health Facility Staff in VHF Isolation Precautions 118


9.4 Plan for Community Mobilization	 121


9.5 Assess Current Supplies and Equipment	 122


9.6 Periodically Reassess Supplies	 122


VHF Isolation Precautions Supplies 123 
Annex 1 Standard Precautions for Hospital Infection Control 133


Annex 2 Specific Features of VHFs 135


Annex 3 Planning and Setting Up the Isolation Area 141


Annex 4 Adapting VHF Isolation Precautions for a Large Number of


Patients 145


Annex 5 Making Protective Clothing 149


Annex 6 Requirements for Purchasing Protective Clothing 153


Annex 7 Disinfecting Water for Drinking, Cooking and Cleaning 157


Annex 8 Preparing Disinfectant Solutions by Using Other Chlorine


Products 161


Annex 9 Making Supplies: Sharps Container, Incinerator, and Boot


Remover 163


Annex 10 Sample Job-Aids and Posters for Use in the Health Facility 165


Annex 11 Laboratory Testing for VHFs 171


Annex 12 Skin Biopsy on Fatal Cases for Diagnosis of Ebola 173


Annex 13 Community Education Materials 181


Annex 14 Conducting In-Service Training for VHF Isolation Precautions 185


Annex 15 Local Resources for Community Mobilization and Education 187


Annex 16 International and Regional Contacts 189


References 193


Index 197

Figure List 

Figure 1 Epidemiological graph of the Ebola hemorrhagic fever outbreak in 

Kikwit, 1995 3


Figure 2 An example of a handwashing station 13


Figure 3 Parts of hands that are often missed during handwashing 13


Figure 4 Standard sharps container 14


Figure 5 Using plastic bottle to dispose of used needles 14


Figure 6 Placing the disposable needle and syringe in soapy water 15


Figure 7 An example of VHF Isolation Precautions poster 26


Figure 8 A sample layout of an isolation area 32


Figure 9 A sample layout for a single patient 33


Figure 10 A sample layout for several patients 33


Figure 11 A security barrier and sign 37


Figure 12 An example of a sign-in sheet 38


Figure 13 Inner layer of clothing 46


Figure 14 Thin gloves 46


Figure 15 Using plastic bags as boots 47


Figure 16 Storing boots 47


Figure 17 Gown with ties 48


Figure 18 Wearing a plastic apron 48


Figure 19 Thick gloves 49


Figure 20 Using plastic bags as gloves 49


Figure 21 HEPA-filter mask 50


Figure 22 Surgical mask 51

Figure 23 Cotton mask 51


Figure 24 Head covering 51


Figure 25 Wearing clear eyeglasses or goggles 52


Figure 26 Scrub suit 53


Figure 27 Putting on boots 53


Figure 28 Putting on the first pair of gloves 54


Figure 29 Putting on the outer gown 54


Figure 30 Putting on a plastic apron 55


Figure 31 Proper way to put on the second pair of gloves 55


Figure 32 Putting on mask 55


Figure 33 Putting on head cover 56


Figure 34 Putting on eyewear 56


Figure 35 Disinfecting the boots 57


Figure 36 Disinfecting / disposing of used gloves 58


Figure 37 Removing the apron 59


Figure 38 Removing the gown 59


Figure 39 Washing the gloved hands 59


Figure 40 Removing the eyewear 60


Figure 41 Removing the head cover 60


Figure 42 Removing the mask 60


Figure 43 A boot remover 61


Figure 44 Removing the inner gloves 61


Figure 45 Marking container for mixing 1:10 bleach solution 69


Figure 46 Preparing bleach solutions 70

Figure 47 Preparing bleach solutions during an outbreak 71


Figure 48 Small piece of cake soap 72


Figure 49 Checking gloves for holes 74


Figure 50 Disinfecting a spill on the floor 77


Figure 51 Disinfecting a spill on the wall 78


Figure 52 Transferring laundry to the cleaning area 79


Figure 53 Cleaning patient’s bedding 80


Figure 54 A 220-litre drum 89


Figure 55 Making an incinerator 90


Figure 56 Making an incinerator 90


Figure 57 A completed incinerator 91


Figure 58 Disinfecting the vehicle after transporting the body 99


Figure 59 Meeting community leaders 107

Introduction 

African countries (shaded areas) where viral haemorrhagic fevers have been 

documented in the past 
2 
Non he alth c are w orke rs

He alth c are w orke rs

Viral Haemorrhagic Fevers: An Overview 

In Africa, viral haemorrhagic fevers (VHFs) include Lassa fever, Rift 

Valley fever, Marburg and Ebola haemorrhagic fevers, 

Crimean-Congo haemorrhagic fever (CCHF) and yellow fever. 

Humans initially contract an infection with a haemorrhagic fever 

virus through exposure to rodents or insects (for Ebola and 

Marburg VHFs, the natural reservoir is unknown). 

Person-to-person transmission of Lassa, Ebola, Marburg and CCHF 

viruses can occur through direct contact with VHF-infected 

material. 

Typically, during the course of a VHF, the blood vessels and many 

organ systems are damaged. VHFs are often accompanied by 

bleeding, reflecting the widespread presence of the virus 

throughout the patient’s body. As a result, the blood, urine, 

vomitus, pus, stool, semen and saliva from the VHF patient are 

infectious. This is why VHFs pose a serious risk to caregivers in 

the health care setting and in the community. 

The transmission risk of VHFs in the health care and laboratory 

setting is well documented. During the 1995 Ebola haemorrhagic 

fever outbreak in Kikwit (former Zaire, and now the Democratic 

Republic of the Congo), one fourth of the cases were in health care 

workers with a history of recent patient care.1 After barrier nursing 

practices (such as wearing protective clothing) were implemented, 

the risk of transmission was reduced. No new cases were reported 

among health care workers who used these practices. (Fig.1) 

Health staff began 

using VHF Isolation Numbe r o f deaths 12 Precautions 

10

Health care workers 

Non health care workers 

8

6

4

2

0

31- 4- 8- 12- 16- 20- 24- 28- 2- 6- 10- 14- 18- 22- 26- 30- 3- 7- 11- 15- 19­

Mar Apr Apr Apr Apr Apr Apr Apr May May May May May May May May Jun Jun Jun Jun Jun

Date o f ons et o f s ymptoms

Fig. 1. The number of infected health care workers declined after barrier nursing practices

were begun during the Ebola haemorrhagic fever outbreak at Kikwit, 1995. One case

resulted from an inappropriate use of barrier nursing practices.

Khan AS et al. The Reemergence of Ebola Hemorrhagic Fever, Journal of Infectious Diseases, in press, 

1998. 

3


1 
How VHF Is Transmitted in the Health Care Setting


The virus enters the health facility in the body


fluids of a VHF patient


All health care staff, laboratory staff, cleaning 

staff, other patients and visitors to the health 

facility are at risk for exposure to VHF. 

The virus is transmitted during direct, 

unprotected contact with a VHF patient OR with 

a deceased VHF patient. 

The virus is also transmitted during unprotected


contact with VHF infectious body fluids


OR


contaminated medical equipment and supplies


OR


as a result of an accidental needlestick or


accidental exposure to infectious body fluids.


The exposed person carries the virus back to the 

community. Transmission continues if there is 

direct person-to-person contact OR any 

unprotected contact with infectious body fluids. 

4

Introduction

What Is in This Manual 

This manual describes a system for using VHF Isolation 

Precautions to reduce the risk of transmission of VHF in the health 

care setting. The VHF Isolation Precautions described in the 

manual make use of common low-cost supplies, such as 

household bleach, water, cotton cloth, and plastic sheeting. 

Although the information and recommendations are intended for 

health facilities in rural areas in the developing world, they are 

appropriate for any health facility with limited resources. 

Who the Manual Is For 

The manual is intended primarily for health officers who 

implement infection control in the health care setting, and for: 

•	 Health facility administrators 

•	 Hospital outbreak coordinators 

•	 Chief medical officers 

•	 Chief nursing officers 

•	 Medical and nursing staff 

•	 Medical and nursing educators 

•	 Public health officers and programme administrators. 

Objectives 

The information in this manual will help health facility staff to: 

1.	 Understand what VHF Isolation Precautions are and how to 

use them to prevent secondary transmission of VHF in the 

health facility. 

2.	 Know when to begin using VHF Isolation Precautions in the 

health care setting. 

3.	 Apply VHF Isolation Precautions in a large-scale outbreak. 

(When a VHF occurs, initially as many as 10 cases may 

appear at the same time in the health facility.) 

5 
4.	 Make advance preparations for implementing VHF Isolation 

Precautions. 

5.	 Identify practical, low-cost solutions when recommended 

supplies for VHF Isolation Precautions are not available or 

are in limited supply. 

6.	 Stimulate creative thinking about implementing VHF 

Isolation Precautions in an emergency situation. 

7.	 Know how to mobilize community resources and conduct 

community education. 

How to Use the Manual 

This manual can be used as a rapid reference when one or two 

cases of a VHF appear in a health facility and no previous 

preparations for VHF Isolation Precautions have been done. 

Administrators or hospital outbreak coordinators can use the 

information and instructions to set up an isolation area quickly and 

make adaptations from local materials so that an effective system 

of infection control can be implemented as soon as possible. 

The manual can also be used for planning and carrying out 

in-service training aimed at strengthening VHF Isolation 

Precautions. It can be accompanied by workshop activities, in 

which participants discuss and practice the recommendations 

made in this manual. 

The manual should be used to help health facilities make advance 

preparations for responding with appropriate precautions when a 

VHF case is suspected. 

6

Introduction

This manual consists of nine sections:


Section 1 Use Standard Precautions with All Patients describes how to establish 

routine precautions for infection control. The section emphasizes the 

importance of using Standard Precautions consistently, especially 

handwashing before and after examining patients with fever. 

Section 2 Identify Suspected Cases of VHF lists common signs and symptoms of 

VHF and the immediate precautions to take when a VHF is suspected. 

Section 3 Isolate the Patient lists recommended supplies and describes how to set 

up an isolation area. It includes checklists that can be used in an 

emergency situation and practical suggestions for alternate equipment 

when recommended items are not available. 

Section 4 Wear Protective Clothing describes the protective clothing that should be 

worn when VHF is present in the health facility. It also provides 

information about selecting appropriate items when recommended 

clothing is not available. 

Section 5 Disinfect Reusable Supplies and Equipment describes the use of VHF 

Isolation Precautions during patient care and when disinfecting and 

cleaning contaminated surfaces, supplies and equipment. This section 

also presents recommended first aid for accidental exposures. 

Section 6 Dispose of Waste Safely describes step-by-step procedures for disposing 

of VHF-contaminated waste. It also lists detailed instructions for building 

an incinerator from available material. 

Section 7 Use Safe Burial Practices describes how to prepare bodies of deceased 

VHF patients safely for burial and how to prevent disease transmission 

through contact with the deceased patient. 

Section 8 Mobilize the Community and Conduct Community Education provides 

guidance for involving the community in disease prevention and control 

activities when VHF is suspected. It also describes how to choose a VHF 

Coordinator. 

Section 9 Make Advanced Preparations to Use VHF Isolation Precautions lists 

steps for preparing in advance to use VHF Isolation Precautions. If 

advance preparations have been carried out, and a VHF is suspected, the 

supplies are ready and health facility staff are trained in recommended 

practices. When advance preparations are not possible, VHF Isolation 

Precautions must be implemented in an emergency situation.


The Annexes provide additional details about specific topics described in the manual.


7

Glossary for Use with This Manual Glossary for Use with This Manual

Changing room	 Changing room Area next to isolation ward where health workers dress in protective
 Area next to isolation ward where health workers dress in protective

clothing, disinfect hands and gloves, and dispose of soiled and
 clothing, disinfect hands and gloves, and dispose of soiled and

contaminated protective contaminated clothing.
 protective clothing.

Cleaning	 Cleaning Removal of any soiling or other material on equipment or surfaces
 Removal of any soiling or other material on equipment or surfaces

before disinfection or sterilization.
 before disinfection or sterilization.

Contamination	 Contamination Presence of infectious agent in blood and other body fluids, on body Presence of infectious agent in blood and other body fluids, on body

surfaces and medical equipment, clothing and supplies. Contact with surfaces and medical equipment, clothing and supplies. Contact with

contaminated body fluids or items is a risk for disease transmission. contaminated body fluids or items is a risk for disease transmission.

Disinfection	 Disinfection Elimination of Elimination of most microorganisms from a surface, making it safe for microorganisms from a surface, making it safe for

reuse. “Sterilization” means eliminating reuse. “Sterilization” means eliminating all microorganisms.

Health care worker	 Health care worker Any person trained to provide patient care (medical, nursing,
 Any person trained to provide patient care (medical, nursing,

paramedical, emergency room nurses, community health workers).
 paramedical, emergency room nurses, community health workers).

Health facility	 Health facility Any hospital, health centre or clinic with inpatient facilities. Also any Any hospital, health centre or clinic with inpatient facilities. Also any

facility providing emergency or first-service care. facility providing emergency or first-service care.

Health facility staff	 Health facility staff All patient care, laboratory, cleaning, disposal, reception, and All patient care, laboratory, cleaning, disposal, reception, and

administrative staff who are likely to have contact with suspected VHF administrative staff who are likely to have contact with suspected VHF

cases, VHF infectious body fluids, and infectious waste. cases, VHF infectious body fluids, and infectious waste.

Isolation area/ward	 Isolation area/ward The area in the health facility used for housing suspected VHF
 The area in the health facility used for housing suspected VHF

patients. It includes the patient's room or area, isolated latrine or
 patients. It includes the patient's room or area, isolated latrine or

toilet, family entrance, and changing room.
 toilet, family entrance, and changing room.

Protective clothing	 Protective clothing Masks, gloves, gowns, eyeglasses, caps, aprons, and boots. Provides Masks, gloves, gowns, eyeglasses, caps, aprons, and boots. Provides

protection against splashes or spills of infectious material when protection against splashes or spills of infectious material when

examining suspected VHF cases or handling infectious waste and examining suspected VHF cases or handling infectious waste and

laundry.laundry.

Sharps container	 Sharps container Puncture-resistant container for collecting used needles and syringes. Puncture-resistant container for collecting used needles and syringes.

Standard Precautions	 Standard Precautions Practices for limiting or preventing disease transmission in the health
 Practices for limiting or preventing disease transmission in the health

care setting.
 care setting.

Sterilization	 Sterilization Elimination of all microorganisms (viral, bacteria, and fungal) through Elimination of all microorganisms (viral, bacteria, and fungal) through

heat, using an autoclave or steam sterilizer, or other appropriate heat, using an autoclave or steam sterilizer, or other appropriate

methods.methods.

VHF Coordinator	 VHF Coordinator Designated health officer who coordinates infection control and Designated health officer who coordinates infection control and

outbreak response, and provides liaison with the community and other outbreak response, and provides liaison with the community and other

agencies involved in outbreak control. agencies involved in outbreak control.

VHF Isolation VHF Isolation Barrier nursing and other infection control practices for preventing Barrier nursing and other infection control practices for preventing

Precautions Precautions contact between VHF infectious body fluids and non-infected persons. contact between VHF infectious body fluids and non-infected persons.

8

Section 1 

Use Standard Precautions with 

All Patients 

This section describes how to: 

•	 Identify a minimum level of Standard Precautions for use 

with all patients regardless of their infection status. 

•	 Establish routine handwashing practices. 

•	 Establish safe handling and disposal of used needles and 

syringes. 

•	 Be prepared to intensify Standard Precautions and include 

VHF Isolation Precautions. 

•	 Identify a VHF Coordinator to oversee and coordinate 

activities associated with VHF Isolation Precautions. 
Section 1


10 
Section 1 Use Standard Precautions with All Patients 

1.1	 Use Standard Precautions 

Health workers throughout the world are aware of the risks for 

transmitting human immunodeficiency virus (HIV) and hepatitis 

viruses in the health care setting. Many use precautions (such as 

wearing gloves) for preventing contact with infected blood. 

Other dangerous diseases are also transmitted through contact with 

blood or other body fluids and pose a significant risk in the health 

care setting. For instance, a patient with a VHF may come to the 

health facility at any point in his or her illness, 

•	 When the possibility of exposure is often highest, and 

•	 Before the specific cause of the patient’s illness is known. 

Because a health worker cannot always know when a patient’s 

body fluids are infectious, Standard Precautions2 should be used 

with all patients in the health care setting, regardless of their 

infection status. 

Standard Precautions are designed to prevent unprotected contact 

between the health care worker and 

•	 Blood and all body fluids whether or not they contain 

blood 

•	 Mucous membranes. 

When a specific diagnosis is made, additional precautions are 

taken, based on how the disease is transmitted.3 

2	 See Annex 1 for more information about Standard Precautions. 

3	 This manual describes the Isolation Precautions to use when a patient is known to have or suspected of 

having a VHF. Annex 1 describes other precautions for various modes of disease transmission. 

11

Section 1


1.2	 Establish and Maintain a Minimum Level of 

Standard Precautions 

Limited supplies and resources may prevent a health facility from 

using all the Standard Precautions all the time. However, health 

facilities should establish and maintain a basic, practical level of 

Standard Precautions that can be used routinely with patients in 

their health facility. 

At a minimum, consider the services in the health facility that 

present a risk of disease transmission due to potential contact with 

blood and all body fluids, broken skin or mucous membranes. 

For health facility staff who work in such areas, establish at least: 

•	 A source of clean water (Please see Annex 7) 

•	 Routine handwashing before and after any contact with a 

patient who has fever 

•	 Safe handling and disposal of sharp instruments and 

equipment, including needles and syringes. 

1.3	 Establish Routine Handwashing 

Handwashing is the most important precaution for the

prevention of infections.

Handwashing before and after contact with a patient who has fever 

should be a routine practice in the health facility — even when 

VHF is not present. Washing hands with soap and water 

eliminates microorganisms from the skin and hands. This provides 

some protection against transmission of VHF and other diseases. 

In services where health care workers see patients with fever, 

provide at least: 

•	 Cake soap cut into small pieces 

•	 Soap dishes. Microorganisms grow and multiply in 

humidity and standing water. If cake soap is used, provide 

soap dishes with openings that allow water to drain away. 

•	 Running water, or a bucket kept full with clean water 

12 
Use Standard Precautions with All Patients

•	 A bucket for collecting rinse water and a ladle for dipping, 

if running water is not available 

•	 One-use towels. Sharing towels can result in 

contamination. Use paper towels. If they are not available, 

provide cloth towels that can be used once and then 

laundered. If towels are not available, health care workers 

and health facility staff can air-dry their hands. 

Fig. 2. An example of a handwashing station

Make sure health facility staff know the steps of handwashing: 

1.	 Place a piece of soap in the palm of one hand. 

2.	 Wash the opposite hand and forearm. Rub the surfaces 

vigorously for at least 10 seconds. Move soap to the 

opposite hand and repeat. 

3.	 Use clean water to rinse both hands and then the forearms. 

If running water is not available, pour clean water from a 

bucket over the soapy hands and forearms. The rinse water 

should drain into 

another bucket. 

4.	 Dry the hands and 

forearms with a clean, 

one-use towel. First 

dry the hands and then Back

the forearms. Or let 

rinsed hands and 

forearms air-dry. 

Front

Fig. 3. The shading shows the parts of hands that are

often missed during handwashing. Make sure to wash

all parts of your hands: front, back, between the

fingers and under nails.

13

Section 1


1.4 Handle and Dispose of Sharp Instruments Safely 

Disease transmission can occur through accidental needlestick 

injuries. Make sure health facility staff always handle sharp 

instruments safely. Do not recap needles after use. 

Limit invasive procedures to reduce the number of injectable 

medications. This will limit the opportunities for accidental 

needlestick injuries. 

When an injection is necessary, always 

use a sterile needle and sterile syringe 

for each injection. 

To discard disposable needles and

syringes safely: Disposable needles 

and syringes should be used only once. 

Discard the used disposable needle 

and syringe in a puncture-resistant 

container. Then burn the container in 

an incinerator or pit for burning. 

Instructions for using incinerators and 

pits for burning are described in 

Section 6. 

If puncture-resistant containers are not 

available, use empty water, oil, or 

bleach bottles made with plastic or 

other burnable material. Adapt them 

for use as puncture-resistant 

containers. 

Detailed instructions for making a 

puncture-resistant container are listed 

in Annex 9. 

Fig. 4. Standard sharps container

Fig. 5. Using plastic bottle to

dispose of used needles

14

Use Standard Precautions with All Patients

1.5	 Disinfect Reusable Needles and Syringes Safely 

Reusable needles and syringes are not recommended. If reusable 

needles and syringes are used, clean, disinfect and sterilize them 

before reuse, according to your hospital’s policy. 

Note: Needles and syringes used with VHF patients require 

special care. Cleaning staff should wear two pairs of gloves when 

handling needles and syringes used with any patient with a known 

or suspected VHF. See the recommendations for wearing 

protective clothing when handling contaminated supplies in 

Section 4. 

1.6	 Disinfect Disposable Needles and Syringes That 

Must Be Reused 

Remember! Whenever possible, use disposable needles and

syringes only once and then discard them safely.

In situations when disposable needles and syringes must be 

reused, make sure they are cleaned and disinfected after each use. 

Disinfection with bleach will reduce the risk of transmission of 

VHF and blood-borne diseases, such as HIV infection and viral 

hepatitis. 

1.	 Obtain a jar or pan. Clean and disinfect it. Use it in Step 8 

to store the disinfected needles and syringes. 

2.	 Place the disposable 

needle and syringe in a 

pan of soapy water after 

use. Fill the needle and 

syringe with soapy water. 

Leave them to soak until 

they are cleaned. 

3.	 Take the soaking needles 

and syringes to the 

cleaning area. 

4.	 Clean them very carefully 

in soap and water. 

Remove any blood or 

other biological waste, especially from the area around the 

syringe fittings. Blood or other biological products may 

collect in these small openings. 

15 

Fig. 6. Placing the disposable needle

and syringe in soapy water
Section 1


5.	 Draw full-strength bleach into the needle and syringe. 

6.	 Soak for 30 seconds, and then expel bleach into a container 

for contaminated waste. 

7.	 Soak again by once more drawing full-strength bleach into 

the needle and syringe. Soak for 30 seconds, and then 

expel bleach into the container for contaminated waste. 

8.	 Let the disinfected needle and syringe air-dry. Store them 

in a clean jar or pan that has been disinfected. 

1.7	 Use VHF Isolation Precautions 

Section 2 of this manual describes how to identify a suspected case 

of VHF so that relevant health facility staff can begin using VHF 

Isolation Precautions. When a VHF is suspected, those health 

facility staff who will have contact with the patient or with the 

patient’s blood or other body fluids should intensify Standard 

Precautions and use VHF Isolation Precautions. 

VHF Isolation Precautions: The VHF Isolation Precautions 

described in this manual have been shown to be effective in 

reducing the transmission of VHFs in the health care setting. 

As soon as a case of VHF is suspected in the health facility, alert 

authorities and start VHF Isolation Precautions. 

16

Use Standard Precautions with All Patients

To reduce the risk of VHF transmission in a health care 

setting: 

USE VHF ISOLATION PRECAUTIONS 

1.	 Isolate the patient. 

2.	 Wear protective clothing in the isolation area, in the 

cleaning and laundry areas and in the laboratory. 

Wear a scrub suit, gown, apron, two pairs of gloves, 

mask, headcover, eyewear, and rubber boots. 

3.	 Clean and disinfect spills, waste, and reusable 

equipment safely. 

4.	 Clean and disinfect soiled linens and laundry safely. 

5.	 Use safe disposal methods for non-reusable supplies 

and infectious waste. 

6.	 Provide information about the risk of VHF 

transmission to health facility staff. Reinforce use of 

VHF Isolation Precautions with all health facility staff. 

7.	 Provide information to families and the community 

about prevention of VHFs and care of patients. 

Regular in-service training will strengthen skills for using VHF 

Isolation Precautions. When a VHF is suspected, efforts will have 

to be focused on providing care. There will not be enough time or 

opportunity to provide initial training in skills for VHF Isolation 

Precautions. 

If health facility staff already know how to use VHF Isolation 

Precautions when a VHF is suspected, authorities can be alerted 

and VHF Isolation Precautions started without delay. 

If health facility staff do not know how to use VHF Isolation 

Precautions when a VHF case is suspected, training will need to 

take place immediately. 

17

Section 1


1.8	 Select a VHF Coordinator 

Being prepared for an emergency situation can save lives. In 

addition to using a basic level of Standard Precautions with all 

patients, health facilities can also prepare in advance for situations 

when protective clothing, disinfection materials, and isolation 

procedures are needed urgently. 

Many health facilities already have an emergency coordinator or 

emergency team who could assume the role of a “VHF 

Coordinator.” The “VHF Coordinator” will: 

•	 Oversee advance preparations and ensure that health 

facility staff are prepared to use VHF Isolation Precautions. 

•	 Serve as the focal point and coordinate activities when a 

VHF case is suspected. 

•	 Take the lead in mobilizing the community when an urgent 

situation occurs. 

Once a staff person is identified to serve as the VHF Coordinator, 

he or she can review the recommendations in this manual and 

begin the preparations described in Section 9. The VHF 

Coordinator can also encourage efforts to strengthen and reinforce 

the routine practice of a basic level of Standard Precautions with 

all patients. 

Remember! Using a minimum level of Standard Precautions

routinely will prevent transmission of contagious diseases, such

as HIV infection, viral hepatitis and VHF.

18

Section 2 

Identify Suspected Cases of VHF 

This section describes how to: 

•	 In a non-outbreak situation, suspect VHF in patients with 

fever, severe illness, and signs of unexplained bleeding. 

•	 Alert relevant health facility staff and begin VHF Isolation 

Precautions as soon as VHF is suspected. 

•	 Report the suspected case to designated health authorities. 
Section 2


20 
Section 2 Identify Suspected Cases of VHF 

In an outbreak situation, several cases occur around the same time. 

They may be grouped together, and there may be person-to-person 

transmission. An initial diagnosis of a VHF can be made based on 

the signs and symptoms of the specific VHF. 

Suspecting a VHF during a non-outbreak situation in a single case 

is more difficult. The early symptoms of a VHF include high fever 

and headache. These are also symptoms for many infections seen 

at the health facility. 

Most patients who present with fever do not have a VHF. Their 

fever is more often caused by malaria, typhoid fever, dysentery, 

severe bacterial infection or other fever-producing illnesses usually 

seen in the area. 

The health worker probably will not suspect a VHF until more 

severe signs develop and the patient does not respond to 

recommended treatment for other illnesses. 

However, health workers should be aware of the possibility for 

suspecting a VHF in a non-outbreak situation. As soon as a VHF is 

suspected, VHF Isolation Precautions should begin. This will help 

reduce the number of people exposed to the VHF. 

21

Section 2


2.1	 Use Information from Previous Outbreaks to 

Suspect a VHF 

When a patient presents with fever, use the available diagnostic 

tools in your health facility to identify or exclude the cause of 

fever. For example, do a malaria smear or take a stool culture as 

soon as possible. 

•	 Treat the most likely cause of the fever according to the 

appropriate treatment guidelines. 

•	 If the fever continues after 3 days of recommended 

treatment, and if the patient has signs such as bleeding or 

shock, consider a VHF. 

•	 Review the patient’s history for any contact with someone 

who was ill with fever and bleeding or who died from an 

unexplained illness with fever and bleeding. 

•	 If no other cause is found for the patient’s signs and 

symptoms, suspect a VHF. Begin VHF Isolation 

Precautions. 

The flowchart on the next page shows how to 

•	 Suspect a VHF and 

•	 Decide to use VHF Isolation Precautions. 

The flowchart applies to a non-outbreak situation. Annex 4 gives 

examples of VHF case definitions in outbreak situations. 

22

Identify Suspected Cases of VHF

Use Isolation Precautions for Suspected VHF Cases


• Severe illness with weakness and 

fatigue 

• Measured fever (38.5oC or 101oF) 

for more than 72 hours and less 

than 2 weeks 

Diagnose and treat for likely cause of 

fever in area (such as malaria, 

typhoid fever, dysentery, severe 

bacterial infection) 

If no response to


antimalarial and


antibiotic treatment


Does patient have one or more of the following? 

*	 Unexplained bleeding from 

–	 mucous membranes (gum, nose or vagina) 

–	 skin (puncture sites, petechiae) 

–	 conjunctiva (red eyes due to swollen blood 

vessels) 

–	 gastrointestinal system (vomiting blood; dark 

or bloody stools) 

*	 Shock: blood pressure <90mm Hg or rapid, 

weak pulse 

*	 Contact in the 3 weeks prior to onset of illness 

with anyone who had an unexplained illness 

with fever and bleeding or who died after an 

unexplained severe illness with fever 

Suspect a VHF 

and 

Begin VHF Isolation Precautions 

23

Section 2


If VHFs have occurred in the area before:

Talk with the district or national surveillance officer about VHFs 

that have been reported in your area.4 Use the information when 

making a diagnosis of a suspected VHF case. 

Record here the case definitions for VHFs that have been reported 

in your area: 

VHF Case Definition 

4 Annex 2 provides more information about VHFs seen in the area of your health facility. 

24 
Identify Suspected Cases of VHF

2.2	 Begin VHF Isolation Precautions 

Every health facility has its own procedures for responding to an 

urgent situation. Adapt VHF Isolation Precautions as needed. 

Designate the health officer who will coordinate VHF Isolation 

Precautions. How to select a VHF Coordinator is described in 

Section 9.1. As soon as a health care worker suspects a VHF, he 

or she should notify the health facility administrator and the VHF 

Coordinator who will: 

•	 Refer the patient to the isolation area and take the necessary 

steps to begin VHF Isolation Precautions (See Section 3). 

•	 Limit the number of health facility staff and visitors in the 

patient’s room. 

•	 Limit the use of invasive procedures and reduce the number 

of injectable medications. 

Important! Between the time when VHF is suspected and when 

the patient is received in the isolation area, there is a risk for 

disease transmission from the patient’s blood and other body fluids 

(stool, urine, vomit). Prevent disease transmission to other 

patients, visitors and health staff in the waiting area by placing the 

suspected VHF patient apart from other patients. Make every effort 

to reduce this waiting time. 

2.3	 Alert Health Facility Staff about Specific Risks for 

VHF Transmission 

As soon as a VHF is suspected, alert the relevant health staff who 

should begin using VHF Isolation Precautions, especially: 

•	 Doctors or nurses providing direct patient care 

•	 Cleaning, laundry, and waste disposal staff who clean and 

disinfect contaminated material and supplies 

•	 Laboratory staff who handle samples from the suspected 

VHF cases 

•	 Medical or support staff who prepare or handle deceased 

VHF patients. 

25 
Section 2


Explain how VHF transmission can occur in the health facility and 

the risks to health facility staff.5 Remind the staff that VHF is a 

highly infectious disease. They must use VHF Isolation 

Precautions whenever they have contact with the VHF patient, the 

patient’s blood or other body fluids, or contaminated supplies and 

equipment. 

Fig. 7. An example of VHF Isolation Precautions poster.

5 The chart on page 4 of the Introduction summarizes the risk of VHF transmission in the health care 

setting. 

26 
Identify Suspected Cases of VHF

2.4	 Report the Suspected Case to the Health 

Authorities 

Report suspected cases of VHF according to national level 

surveillance guidelines. 

If your district is conducting special surveillance activities for a 

VHF, the district officer will provide specific information about 

whom you should contact and how. If serum samples are needed, 

the contact person will give you special instructions for collecting 

and shipping serum samples. The table below can be used to 

record information about whom to contact if a VHF is suspected. 

Contact 

Person Agency 

Telephone 

and/or Fax 

Number 

Information to 

Report 

Samples 

to 

Collect 

27

Section 2


2.5 Identify Patient’s Contacts and Travel History 

Ask the patient (or a family member who can answer for the 

patient): 

• Where do you live? 

• When did the symptoms begin? 

• Who else is sick in your family (or village)? 

• Where have you travelled recently? 

Use the answers to identify others who had contact with the 

patient. Provide them with information about VHF and when to 

seek care. 

Section 8 describes the steps for giving information to the 

community about VHF and preventing VHF transmission. 

28

Section 3 

Isolate the Patient 

This section describes how to: 

•	 Gather supplies to set up an isolation area. 

•	 Make a substitute item from available materials whenever a 

recommended item is not available. 

•	 Select a site for the VHF isolation area and set up: 

—	 The patient’s room 

—	 A changing room for health care workers to use 

when changing clothes 

—	 A changing room for other health facility staff to use 

near their work area 

—	 A family entrance, if necessary 

—	 A security barrier around the entire isolation area. 

•	 Counsel family members about patient care. 
Section 3


30 
Section 3 Isolate The Patient 

Isolating the VHF patient will: 

•	 Restrict patient access to health facility staff trained to use 

VHF Isolation Precautions. 

•	 Establish a barrier between the VHF patient and uninfected 

patients, other health facility staff, and visitors. 

3.1	 Select Site for the Isolation Area 

Ideally, an isolation area should already be available to admit 

patients requiring isolation. 

If an isolation area is not available or if advance preparations have 

not been done, and VHF is suspected, immediately identify and set 

aside: 

•	 A single room with an adjoining toilet or latrine. 

If a single room is not available, select one of the following in 

order of preference: 

•	 A separate building or ward that can be used with VHF 

patients only (especially if Ebola haemorrhagic fever is 

suspected, or if there is a large number of patients) 

•	 An area in a larger ward that is separate and far away from 

other patients in the ward 

•	 An uncrowded corner of a large room or hall 

•	 Any area that can be separated from the rest of the health 

facility (TB rooms, isolation ward for infectious diseases, 

private or semiprivate rooms). 

31

Section 3


Make sure the selected site has: 

1.	 An isolated toilet: If a toilet is not next to the patient's 

room, select and isolate a toilet near the isolation area. Use 

it to receive the patient’s disinfected waste and other liquid 

waste. 

If a toilet is not available, prepare a latrine for disposal of 

the patient’s and other liquid waste. 

2.	 Adequate ventilation: The isolation room should have 

adequate ventilation because chlorine disinfectants will be 

used. To prevent airborne or droplet transmission of 

infectious agents, avoid rooms with air conditioning. 

3.	 Screened windows: If windows are left open for cooling, 

screen them to prevent transmission of mosquito- and other 

insect-borne diseases. 

Restrict access. Tie a rope or line around the area outside the 

window to restrict the area and prevent entry through the window. 

3.2	 Plan How to Arrange the Isolation Area 

Make use of the available space and design of the health facility to 

arrange the isolation area. The diagram below shows an ideal 

arrangement for an isolation area. The next page shows examples 

for a single patient’s room and for a ward with several patients. 

Patient’s room Toilet 

Changing room 12 11 1

10 2

9 3

8 4

7 5 6

Fig. 8. A sample layout of an isolation area

32

Isolate the Patient

Toilet Patient’s room Changing room


Bed 

Bedside 

table 

Storage 

shelf 

Disinfection 

station 

Disinfection station Disinfection station 

Hooks 

Storage 

shelf 

Fig. 9. A sample layout for a single patient

Screens between beds Disinfection station 

Bed Bed 

Bed Bed Bed 

Toilet 

Bed 

Changing room 

Disinfection station 

Hooks 

Storage 

shelf 

Storage 

shelf 

Table for medical supplies and equipment; 

disinfection and handwashing stations 

Fig. 10. A sample layout for several patients

33

Section 3


3.3 Gather Recommended Supplies 

Ideally, supplies should be available to begin VHF Isolation 

Precautions. If a separate emergency supply is not available when 

a VHF case is suspected, use supplies from other services in the 

health facility. 

If a recommended item is not available, or if the quantity is

limited, make a substitute item from available materials. For 

example, the manual recommends using plastic sheeting to cover 

mattresses. If plastic sheeting is not available, use plastic cloth 

normally used to cover kitchen tables. This is usually available in 

the local market. 

3.3.1 Plan Disinfection for VHF-Contaminated Items 

Ordinary household bleach, soap and water are useful 

disinfectants against viruses causing VHF.6 They are low in cost 

and commonly available. 

Ordinary Household Bleach: The viruses causing VHF are 

very sensitive to bleach solution. This manual describes a 

low-cost disinfection system using two bleach solutions: a 

solution of 1:10 and a solution of 1:100. Detailed 

instructions for preparing the solutions are in Section 5.1. 

Soap and Clean Water: Scrubbing with soap and water 

before disinfection removes infectious body fluids and other 

foreign matter from contaminated items. This makes bleach 

solutions more effective. Detailed instructions for preparing 

solutions of soapy water are in Section 5.2. 

Sterilization: Heat sterilization requires special equipment, 

such as an autoclave or steam sterilizer. When this 

equipment is not working or is not available, boiling 

heat-resilient items in water for 20 minutes will kill VHF 

viruses. 

6 VHF viruses are lipid enveloped, and this feature makes them sensitive to destruction by detergent 

solutions. 

34

Isolate the Patient

3.3.2 Gather Supplies for the Patient Area 

Obtain the following items for use in the patient’s room: 

Bed and mattress or sleeping mat for each patient. 

Plastic sheeting to cover the mattress or sleeping mat. This is strongly 

recommended. Plastic sheeting will protect the mattress from contamination. It 

can be easily cleaned and disinfected if it becomes contaminated with infectious 

body fluids. 

Bedding for each bed -- at least 1 blanket and a bottom sheet. If necessary, the 

patient or the patient's family can bring the bedding from home. 

One thermometer, one stethoscope, and one blood-pressure cuff per patient. 

Keep them in the isolation area for reuse with the same patient. 

If there is not enough equipment to supply one each of these items per patient, 

assign one piece of equipment for use only with the patients in the isolation area. 

Covered container for alcohol or bleach solution used to disinfect thermometer 

and stethoscope after use with each patient. 

Puncture-resistant container for collecting used disposable needles, syringes and 

other sharp instruments. 

Puncture-resistant tray with soapy water for collecting reusable needles, 

syringes and instruments. 

Bedside table or shelf on which to place medical instruments, puncture-resistant 

container, and so on. 

Large wall clock with a second hand for measuring respiration rates and pulse. 

Bedpan for each patient. 

Screens or other barriers to place around the VHF patients' beds. This will 

prevent patient-to-patient transmission through spills or splashes of infectious 

body fluids or from aerosol routes. 

If screens are not available, stretch ropes or lines from one end of the patient 

area to the other. Hang sheets from the ropes. 

Disinfection station with buckets, sprayer, bleach solutions, soap and water, 

mop, and a supply of one-use towels. It is preferable to dispose of gloves after 

each use. However, the reuse of gloves in many health facilities is a common 

practice. Disinfect gloved hands between patients if there are not enough gloves 

for health care workers to dispose of after each patient. 

Container with soapy water for collecting discarded outer gloves. 

35 
Section 3


Boot sprayer for disinfecting the boots before leaving the patient’s room. 

Extra supply of gowns and gloves.

3.3.3 Gather Supplies for the Changing Room 

Hooks, nails, or hangers for hanging reusable protective clothing.


Roll of plastic tape for taping cuffs and trousers of protective clothing.


Disinfection station with bleach solution for disinfecting gloved hands.


Handwashing station with bucket, soap, soap dish, clean water, and supply of


one-use towels.


Containers with soapy water for collecting:


• Discarded gloves 

• Used instruments to be sterilized.


Containers for collecting:


• Reusable protective clothing to be laundered 

• Infectious waste to be burned. 

3.3.4 Arrange for Storing of Supplies Outside the Changing Room 

Shelf or box with a lock for storing clean protective clothing.


Supply of clean protective clothing.

Container for collecting non-infectious waste.


Covered shelf (or plastic bags which can be closed) to store disinfected boots


and keep them dry. 

The checklists at the end of this section can be used to gather supplies for the isolation 

area. 

36

Isolate the Patient

3.4 Set Up Changing Rooms 

For patient-care staff:

One changing room is needed outside the patient isolation area. 

This area is where health care workers will put on protective 

clothing to protect them from spills or splashes of infectious body 

fluids while they are in the patient’s room. After leaving the 

patient's room, they will reenter the changing room and remove 

the protective clothing. They will hang it for reuse or dispose of it 

appropriately. 

Contaminated clothing and supplies remain in the changing room 

until cleaning staff trained to use VHF Isolation Precautions take 

the VHF-contaminated items to the laundry or disposal site. 

For laboratory, cleaning, laundry, and waste disposal staff:

Set up changing rooms near the work areas for other health facility 

staff who will handle laboratory specimens and who will clean 

launder, or dispose of contaminated items. They will also need to 

wear protective clothing during any contact they have with body 

fluids or VHF-contaminated items. 

The stations in the changing room should be set up so that traffic 

flow is from the least to most contaminated area. 

3.5 Place Security Barrier Around Isolation Area 

Restrict access to the isolation

area: Place signs around the 

isolation area clearly stating 

that access is restricted. Or tie 

lines or ropes around the 

isolation area and hang plastic 

sheets from them. 

Fig. 11. A security barrier and sign

37

Section 3


Prepare a list of health facility staff and family members

authorized to enter the isolation area: List the medical, nursing, 

laboratory, cleaning staff, and, if appropriate, those family 

members who are trained in the use of VHF Isolation 

Precautions. If an accidental exposure or incident occurs, the list 

can help in the prompt identification of possible contacts. 

When there is a large number of patients, station a guard at the

entry to the isolation area: In a large scale outbreak, station a 

security guard at the door of the patient isolation area outside the 

changing room. The guard will limit access to authorized health 

facility staff and family members only. This is critical for 

maintaining strict isolation and protecting the community. 

Provide the guard with the list of authorized persons and a sign-in 

sheet. The guard can record who comes into the isolation area 

and note the time of entry and departure. 

Date Name Service Time In Time Out 

13.6.98 Dr. Nsango Infectious

Diseases 10:15 11:30

13.6.98 Nurse

Bandari

Intensive

Care 10:00 11:30

13.6.98 Nurse

Ninakazi

Intensive

Care 11:00 13:30

13.6.98 Masika Cleaning 11:10 11:45

13.6.98 Madunda

Family

member 11:15

Fig. 12. An example of a sign-in sheet

38 
Isolate the Patient

3.6	 Consult Family Members about Patient Care 

Talk with family members and explain why the patient is being 

isolated. Tell them about the risk of transmission for VHF and why 

protective clothing is needed. Answer any questions they have. 

When there is a large outbreak (more than one or two cases), 

identify a person to serve as a liaison between health facility staff 

and the patients’ families. Select a health staff member, an 

experienced community member, or a convalescent patient. 

If it is the custom for family members to provide cleaning and 

washing of the patient while the patient is in the health facility, 

help the family to select a caregiver. Select as caregiver the family 

member who has already had the most contact with the patient. 

Also select a second person who can do the patient care activities 

when the other caregiver is resting. 

In areas where family members participate in patient care, they are 

likely to help the patient with: 

•	 Feeding and giving water 

•	 Washing the hospital gown or pyjama with soap and water 

•	 Getting up or moving around. 

When a VHF is suspected, it is likely that health care workers 

trained in VHF Isolation Precautions will do most of the direct 

patient care tasks. However, if there are family members who will 

assist with direct patient care, give them information and training 

about: 

•	 The risk of VHF transmission and the reason for protective 

clothing 

•	 How to wear gloves, gowns, and a mask 

•	 How to take off gloves, gowns, and mask and store or 

dispose of them safely. 

Make sure there is a changing room for family members to use that 

is separate from the changing room for health care workers. 

Provide a set of protective clothing for the family members to wear 

in the isolation room. At a minimum, make sure that the family 

members wear at least a pair of gloves. 

39 
Section 3


Provide in the family members’ changing room: 

•	 A shelf or table to store a supply of clean gloves to be worn 

by the family member 

•	 Hooks to hang a set of protective clothing 

•	 A bucket with soapy water for collecting discarded gloves 

after leaving the isolation area 

• A handwashing station.


Arrange to monitor family members for signs of illness.


Assist family members with:


•	 Coordination of other family members who bring food for 

the patient and for the family member providing care 

•	 Location of an area for family members to stay in while 

providing care that includes cooking, washing and sleeping 

facilities. 

Note: When a breast-feeding mother has a suspected case of VHF, 

the child's breast-feeding should not be interrupted. Help the 

family to decide how to continue the child’s breast-feeding when 

the mother is too ill to do so. 

40

Isolate the Patient

Checklist: Supplies for a Changing Room 

Storage Outside the Changing Room: 

1.	 Shelf or cabinet with lock 

2.	 Supply of clean scrub suits, gowns, aprons, 

gloves, masks, headcovering, and eyewear 

3.	 Covered shelf for storing disinfected boots 

4.	 Bucket for collecting non-infectious waste 

Inside the Changing Room: 

1.	 Hooks, nails, or hangers for hanging reusable 

gowns, scrub suits 

2.	 Roll of plastic tape 

3.	 Handwashing supplies: bucket or pan, clean 

water, soap, one-use towels 

4.	 Bucket or pan, 1:100 bleach solution for 

disinfecting gloved hands 

5.	 Container with soapy water for collecting 

discarded gloves 

6.	 Container with soapy water for collecting used 

instruments to be sterilized* 

7.	 Container with soapy water for collecting 

reusable gowns, masks, sheets to launder* 

*Place outside the changing room if the changing room 

is too small 

If large amounts of waste on floor: 

Sprayer, bucket or shallow pan with 1:100 bleach 

solution for disinfecting boots 

41

Section 3


Checklist: Supplies for Patient Area


1.	 1 bed with clean mattress or sleeping mat and at 

least a bottom sheet and blanket for each bed 

2.	 Plastic sheeting to cover mattress or sleeping mat 

3.	 1 thermometer, 1 stethoscope, and 1 blood 

pressure cuff for each patient or for each patient 

area 

4.	 1 puncture-resistant container for collecting 

non-reusable needles, syringes, and discarded 

sharp instruments 

5.	 1 bedside table or shelf 

6.	 1 large wall clock with a second hand 

7.	 Pan with 1:100 bleach solution or alcohol and 

one-use towels for disinfecting the thermometer 

and stethoscope between use with each patient 

8.	 Bucket or pan, 1:100 bleach solution, one-use 

towels for disinfecting gloved hands between 

patients 

9.	 Supplies for disinfecting patient excreta (bedpan, 

urinal, 1:10 bleach solution) 

10.	 Sprayer, 1:100 bleach solution, clear water, and 

mop for disinfecting spills on floor and walls 

11.	 Container with soapy water for collecting 

discarded gloves 

12.	 Screens (or sheets hung from ropes or lines) 

placed between VHF patients’ beds 

13.	 Extra supply of gowns and gloves 

14.	 Container for collecting infectious waste to be 

burned 

42 
Section 4 

Wear Protective Clothing 

This section describes how to: 

•	 Prepare a supply of protective clothing for use with VHF 

Isolation Precautions. 

•	 Make adaptations from locally available materials when an 

item is not available, or if the supply is limited. 

•	 Put on and take off protective clothing in the changing 

room. 
Section 4


44 
Section 4 Wear Protective Clothing 

4.1	 Specify Who Should Wear Protective Clothing 

•	 All doctors, nurses, and health care workers who provide 

direct patient care to suspected VHF patients. 

•	 All support staff who clean the isolation room, handle 

contaminated supplies and equipment, launder reusable 

supplies, and collect and dispose of infectious waste from 

VHF patients. 

•	 All laboratory staff who handle patient specimens and body 

fluids from suspected VHF cases. 

•	 Laboratory support staff who clean and disinfect laboratory 

equipment used to test VHF specimens. 

•	 Burial teams who remove bodies of deceased VHF patients 

and prepare them for burial. 

•	 Family members who care for VHF patients. 

When a VHF case is suspected in the health facility, the following 

protective clothing should be worn in the isolation area: 

•	 A scrub suit or inner layer of clothing (an old shirt and 

trousers brought from home) 

•	 A pair of thin gloves 

•	 Rubber boots or overshoes (only if the floor is soiled) 

•	 A gown or outer layer of clothing (surgical or disposable 

gown with long sleeves and cuffs) 

•	 A plastic apron worn over both layers of clothes 

•	 A second pair of thin or thick gloves. Wearing a second 

pair of gloves provides an added measure of safety during 

patient care and when handling contaminated supplies 

•	 A HEPA-filter (high-efficiency particulate air respirator) or 

other biosafety mask (or surgical mask if HEPA-filter or 

other biosafety mask is not available) 

45 
Section 4


• Cotton head covering 

• Clear eyeglasses or non-fogging goggles. 

Note: When protective clothing is not available or is in short

supply, adaptations must be made and used.

4.2 Gather a Supply of Protective Clothing 

Obtain and store the following items 

outside the changing room or in a 

storage cabinet inside the changing 

room. 

Scrub suit or inner layer: Wear a 

scrub suit or a set of old clothes 

brought from home (such as a 

loose-fitting shirt and trousers). 

Avoid wearing long skirts to prevent 

contact between clothing and spills 

of infectious waste on the floor. 

Thin gloves: These permit 

fine-motor function when 

examining or caring for patients. 

They can be latex, vinyl, or 

surgical gloves; they do not need 

to be sterile. The gloves must 

reach well above the wrist, 

preferably 10 cm to 15 cm long (4 

inches to 6 inches), measuring 

from the wrist up along the arm. 

46 

Fig. 13. Inner layer of clothing

Fig. 14. Thin gloves
Wear Protective Clothing

Boots: Boots or overboots must be worn over street shoes when 

infectious waste is on the floor. Common rubber boots are 

recommended. The sides of the boots should be at least 30 cm 

(12 inches) high and have textured soles. 

If boots are not available, wear two layers of plastic bags. 

Fig. 15. Using plastic bags as boots

Assign those staff who are entering the isolation area their own 

pairs of boots. Staff members will be responsible for storing their 

boots in a covered shelf or in a plastic sack between each use. 

Fig. 16. Storing boots

Gown or Outer Layer: Wear a disposable surgical gown or a 

cotton gown over the first layer of clothes. 

Disposable surgical gowns can be reused by the same staff 

member if they are not contaminated and are not obviously dirty 

and torn. 

When the supply of disposable gowns is limited, wear a cotton 

surgical gown that can be washed and reused. 

47 
Section 4


The gown should: 

•	 Open at the back and close with ties at the neck and waist. 

•	 Be knee-length with collar wraps around the neck and 

elastic bands to close the gown around the wrist. If elastic 

bands are not used, sew on cotton loops. They can be 

hooked around the thumb to hold the sleeve in place. 

front	 back 

Fig. 17. Illustration of gown with ties

If the supply of cotton surgical gowns is limited, make additional 

gowns from local cotton fabric. Instructions for making cotton 

gowns are listed in Annex 5. Specifications for ordering gowns 

and other pieces of recommended clothing are listed in Annex 6. 

Plastic Aprons: Wear a plastic apron over the outer gown. The 

apron prevents contact with infectious body fluids that may soak 

through protective clothing when the 

patient bleeds, coughs or vomits. 

Plastic aprons should be worn by 

anyone who has direct contact with a 

suspected VHF case or infectious 

body fluids. These aprons are strongly 

recommended for: 

•	 Nurses 

•	 Laboratory staff 

•	 Cleaning staff 

•	 Staff who perform autopsies or 

prepare bodies for burial. 

Fig. 18. Wearing a plastic apron

48

Wear Protective Clothing

When a supply of commercial plastic aprons is not available, make 

aprons from plastic sheeting, rubber, or plastic cloth normally used 

to cover kitchen tables. 

The apron should: 

•	 Have hooks or ties that fasten around the neck. 

•	 Have ties at the waist that reach around and tie at the back. 

•	 Be long enough to cover the top of the boots and provide 

additional protection from spills running inside the boots. 

Thick gloves: These are worn over an inner pair of thin or latex 

gloves. They are worn to clean spills, launder reusable protective 

clothing and patient bedding, handle disposable waste, and 

conduct autopsies and burial preparations. 

Fig. 19. Thick gloves

The gloves can be made of neoprene or thick rubber. They should 

reach well above the wrist, about 30 cm (12 inches) up the arm. 

When thick rubber gloves are not available, use normal kitchen 

gloves as the outer layer of gloves. 

If the supply of gloves is limited, wear one pair of gloves. 

Disinfect them after each contact with the VHF patient or with 

infectious body fluids and contaminated material. How to 

disinfect and clean gloves during patient care and for reuse is 

described in Sections 5.3 and 5.4. 

If gloves are not available, use plastic bags to cover the hands. 

Fig. 20. Using plastic bags as gloves

49

Section 4


If nothing is available to serve as a glove or hand covering, make 

sure health facility staff wash their hands with soap and water 

immediately: 

• After every contact with the VHF patient 

• Before leaving the patient’s room 

• After any contact with infectious body fluids 

• After contact with any contaminated material. 

How to set up handwashing stations is described in Section 1.3. 

Mask: Masks protect the health care worker's face from contact 

with blood or droplets of infectious body fluids. Use masks that 

cover the mouth and nose. Use a HEPA-filter or other biosafety 

mask, a surgical mask, or a cotton mask made locally. 

HEPA-filter or biosafety mask: A HEPA-filter mask filters 

the air to prevent breathing in small particles and harmful 

microorganisms. It provides protection from airborne 

transmission of microorganisms. 

Fig. 21. HEPA-filter mask

A HEPA-filter or biosafety mask is lightweight and easy to 

use. It can be reused by the same health care worker as 

long as it continues to fit comfortably and the mask does 

not become contaminated, crushed, or splattered with body 

fluids. 

Do not touch the mask after it has been put on. The mask 

may become contaminated once it is touched. To avoid 

the necessity for touching the mask, make sure it fits 

comfortably before entering the patient’s room. 

When handling a reused mask, hold it by the strings. Be 

careful that the outside surface does not touch the health 

care worker’s face. 

50 
Wear Protective Clothing

Surgical mask: If HEPA-filter or 

other biosafety masks are not 

available, use surgical masks. 

Surgical masks will not filter out 

small particles, but they will 

protect the health care worker 

from droplets or splashing of 

body fluids. 

A surgical mask can be reused by the same health care 

worker as long as it is not contaminated and not obviously 

dirty and torn. 

Cotton mask: If surgical masks are not available, use cotton 

masks made from four or five layers of cotton cloth sewn 

together. 

• Use a different colour for 

each side of the mask. 

This will help health care 

workers quickly identify 

which side should be 

worn inside. 

• The mask should have 

ties that are long enough 

to reach behind the head. 

Cotton masks will not provide protection from breathing in 

particles, but they will provide protection against splashes 

and other droplet contact with infectious body fluids. A 

cotton mask can be reused by the same health care worker 

as long as it is not contaminated and not obviously dirty 

and torn. 

Head covering: A head covering or cap protects the hair and head 

against splashes from the patient's vomit, blood, or other body 

fluids. 

Use disposable or cotton 

caps. If disposable caps are 

not available, make cotton 

caps from locally available 

cotton fabric. Include ties so 

the cap does not fall off when 

the health care worker bends 

over a patient. 

51 

Fig. 22. Surgical mask

Fig. 23. Cotton mask

Fig. 24. Head covering
Section 4


If cotton caps are not available: 

•	 Use a scarf, bandanna, or large piece of cloth. 

•	 Fold the scarf, bandanna, or cloth and wrap it around the 

head. 

Eyewear: Wear clear eyeglasses or non-fogging goggles to protect 

the eyes from splashes or spills of infectious body fluids. 

Obtain clear eyeglasses from a local 

eyeglass shop or in the market. 

Place ties on the ear holders. Tie the 

eyeglasses around the back of the 

head so they will not fall off when a 

health care worker bends over a 

patient. If available, wear 

commercial non-fogging goggles 

instead of eyeglasses. 

Fig. 25. Wearing clear eyeglasses or

goggles

52

Wear Protective Clothing

4.3	 Put On Protective Clothing 

Make sure the changing room (and the changing area for cleaning 

and other staff) contains a supply of protective clothing. Section 

3.4 describes how to set up a changing room. 

1.	 Before entering the changing room, remove jewelry, wallets 

and other valuables. Store them safely outside the changing 

room. 

2.	 Remove street clothes and 

hang them on a hook. Put on 

the scrub suit or set of old 

clothes. 

3.	 Enter the changing room. 

4.	 Put on rubber boots. 

Put on each boot and tuck 

the trouser leg inside the 

boot. If overboots are used, 

tape the top of the boot to 

the leg with plastic tape. 

This will help prevent spills 

from running inside the 

boots. 

Fig. 26. Scrub suit: the first layer of

clothing

Fig. 27. Putting on boots

53

Section 4


5.	 Put on the first pair of gloves. 

•	 Look at your hands for cut or broken skin. If the skin 

is cut or broken, refrain from direct patient contact. 

•	 Put on one glove at


a time. If the scrub


suit or set of old


clothes has long


sleeves, place the


edge of each glove


under the cuff.


•	 When only one pair


of gloves is worn,


place the edge of


the glove over the


cuff or gown.


•	 If gloves are not available, use plastic bags. Put on 

one layer now. Attach and close the first layer with 

tape or elastic bands. 

6.	 Put on the outer gown. 

•	 Pick up the gown


from the inside.


This is especially


important if the


gown is being


reused.


•	 Place arms


through the


armholes.


Fig. 28. Putting on the first pair of

gloves

Fig. 29. Putting on the outer gown

•	 Tie the gown in 

back. Or, ask 

another health 

care worker to tie the gown. 

54

Wear Protective Clothing

7. Put on the plastic or rubber 

apron. 

Fig. 30. Putting on a plastic apron

8.	 Put on the second pair of gloves. 

•	 Place the edge of the


second pair of gloves


over the cuff of the


gown.


•	 If using plastic bags,


place the second layer


of plastic bags over the


first. Close ends of the


bags with plastic tape or


elastic bands.


•	 Health facility staff who 

do cleaning, laundering, disinfecting, waste disposal 

or handling the body should wear thick gloves as the 

second pair of gloves. 

9.	 Put on the mask. Tie it at the back of the neck and towards 

the top of the head. 

Fig. 31. Proper way to put on the

second pair of gloves

Fig. 32. Putting on mask

55 
Section 4


10. Put on a head cover.


Fig. 33. Putting on head cover

11.	 Put on the protective 

eyewear. Attach the 

eyeglasses or goggles 

behind the head with 

string or cord to prevent 

the eyewear from falling 

off when working with 

patients in the isolation 

ward. 

Fig. 34. Putting on eyewear

Remember! Make sure the mask, head cover and eyewear fit 

comfortably. Once gloved hands have touched a patient, do not 

touch the mask, headcover and eyewear. 

Plan ahead to bring everything into the isolation area for 

examining the patient. Once protective clothing has been put on, 

do not re-enter the general health facility. In an emergency, ask 

the guard or a health assistant to go and obtain any needed items 

from other parts of the health facility. 

56

Wear Protective Clothing

4.4	 Take Off Protective Clothing 

The steps for removing protective clothing include disinfection 

with bleach solutions and washing hands with soap and water. 

How to set up supplies for disinfection is described in Section 3.3. 

How to prepare the bleach solutions is described in Section 5.1. 

Outer gloves and boots are likely to have the most contact with 

infectious body fluids during patient care. 

Before leaving the patient’s room: 

1.	 Disinfect the outer pair of gloves. 

•	 Wash the gloved hands in soap and water. 

•	 Dip the gloved hands in 1:100 bleach solution for 1 

minute. 

2.	 Disinfect the apron. Spray or wipe it with 1:100 bleach 

solution. 

3.	 Disinfect the boots. 

Note: The soles of rubber boots are difficult to clean 

because they are textured. Disinfect them carefully and 

make sure to reach all surfaces of the textured soles. 

•	 Use a sprayer


containing 1:100


bleach solution to


spray boots


OR 

•	 Hold the foot over


a pan or basin and


ask another health


worker to pour


1:100 bleach


solution over the


boots


OR 

Fig. 35. Disinfecting the boots

•	 Step into a shallow pan containing 1:100 bleach 

solution and wipe boots on a bleach-drenched cloth. 

57 
Section 4


4.	 Remove the outer pair of gloves. 

If two pairs of gloves are worn: 

•	 Pull the edge of the glove back over the gloved hand 

so that the glove turns inside out as it is being pulled 

back. 

•	 If gloves will be reused, place the glove in a bucket 

containing soapy water. 

Fig. 36.

Disinfecting used

gloves in soapy

water for reuse or

disposing of them

in waste bucket

•	 If gloves will not be reused, discard them in a bucket 

for disposal of contaminated waste. 

• Remove the other glove in the same way. 

If only one pair of gloves is worn: 

•	 Do not remove the gloves now. 

•	 Rinse the gloved hands in 1:100 bleach solution for 

1 minute before leaving the patient’s room. 

After disinfecting the boots and removing the outer gloves, go into 

the changing room. 

58

Wear Protective Clothing

5. Remove the apron and outer gown.


•	 Put the apron in a 

laundry container or 

hang it for reuse (if it will 

be reused). 

Fig. 37. Removing the apron

•	 Remove the outer 

gown. Hang it on a 

hook for reuse. Make 

sure it is hung inside 

out. If the gown needs 

laundering, place it in 

the laundry container. 

Fig. 38. Removing the gown

6.	 Disinfect the gloved hands 

after contact with apron and outer gown. 

• Rinse the gloved hands in 

1:100 bleach solution. 

Then wash them in soap 

and water. 

•	 Dry the gloved hands 

with a one-use towel. 

•	 If bleach is not available, 

wash the gloved hands 

with soap and water. 

Fig. 39. Washing the gloved hands

59

Section 4


7.	 Remove the eyewear, head 

cover and mask. 

•	 If eyewear is heavily 

soiled, wash the 

eyeglasses in soapy 

water and wipe them 

clean. Store them in a 

drawer or shelf with 

the clean supply of 

eyeglasses. 

•	 Remove the head 

cover and, if unsoiled, 

store it with the 

cleaned eyewear. If it 

is soiled, place it in the 

laundry container or 

discard it in the bucket 

for disposal of 

contaminated waste. 

•	 Remove the mask and 

hang it on a hook or 

store it for reuse. 

•	 A HEPA-filter or other 

biosafety mask can be 

reused by the same 

health care worker as 

long as it is not soiled. 

If the HEPA-filter or 

other biosafety mask is 

soiled, discard it in a 

bucket for disposal of 

contaminated waste. 

Fig. 40. Removing the eyewear

Fig. 41. Removing the head cover

Fig. 42. Removing the mask

•	 A locally made cotton mask can be reused as long as 

it is not obviously dirty and torn. 

If it is soiled, place it in the laundry container. 

60 
Wear Protective Clothing

8.	 Remove the boots. 

•	 Place a towel that has been soaked in 1:100 bleach 

solution on the floor for health facility staff to stand 

on when removing boots. 

•	 Use a boot remover to take off the rubber boots. 

Avoid touching the boots with bare or gloved hands. 

Fig. 43. A boot remover

•	 Store boots safely until next use. For example, store 

them in a plastic sack or on a covered shelf. 

9.	 Remove the inner pair of gloves. 

If gloves will be discarded: 

•	 Remove the first glove 

with the other gloved 

hand. Pull the edge 

of the first glove back 

over the gloved hand 

so that the glove turns 

inside out as it is 

being pulled back. 

•	 Place the inside-out 

glove in the palm of 

the gloved hand. 

•	 Reach inside the glove to a clean area. Pull the 

glove back over the hand so that only the inside of 

the glove is exposed and covers the glove held in 

the palm. Discard the gloves in a bucket for 

disposal of contaminated waste. 

•	 Wash ungloved hands with soap and water. 

61 

Fig. 44. Removing the inner gloves
Section 4


If gloves will be reused: 

•	 Reach inside the first glove to a clean area. Pull the 

glove back over the hand so the glove turns inside 

out as it is pulled back. Place the glove in a bucket 

of soapy water. 

•	 Remove the second glove in the same way. 

•	 Place the second glove in soapy water. 

•	 Immediately wash ungloved hands with soap and 

water. 

10.	 Remove inner layer of clothes and dress in street clothes. 

•	 If the inner layer is not soiled, store the clothing for 

reuse. 

•	 If soiled, place the clothing in the laundry container. 

•	 If personal shower facilities are available, shower 

before dressing in street clothes. 

•	 If skin has contact with soiled material, follow 

guidelines for accidental exposure in Section 5.13. 

•	 Put on street clothes. 

11.	 Wash hands with soap and clean water before leaving the 

changing room. 

62

Wear Protective Clothing

Note: 

When gloves are in limited supply, use one pair of gloves only. 

Modify the order for removing protective clothing as follows: 

1.	 Rinse gloved hands in 1:100 bleach solution 

upon leaving the patient isolation room. 

2.	 Remove apron and outer gown as described in 

Section 4.4. 

3.	 Remove the gloves. 

4.	 Wash ungloved hands in soap and water. 

5.	 Remove the inner gown or scrub suit, mask, 

head cover and eyewear. 

6.	 Wash hands again. 

63

Section 4


64 
Section 5 

Disinfect Reusable Supplies 

and Equipment 

This section describes how to: 

•	 Prepare disinfectants. 

•	 Clean and disinfect used gloves before reuse. 

•	 Clean and disinfect used medical instruments and supplies. 

•	 Disinfect patient waste and spills of infectious body fluids. 

•	 Disinfect and discard infectious waste and non-reusable 

supplies. 

•	 Clean and disinfect protective clothing, boots, and patients’ 

sheets. 

•	 Give first aid for accidental exposures. 
Section 5


66 
Section 5 Disinfect Reusable Supplies and Equipment 

What to Disinfect: Disinfection kills almost all bacteria, fungi, 

viruses, and protozoa. It reduces the number of microorganisms to 

make equipment and surfaces safer for use. When VHF is 

suspected in the health facility, all medical, nursing, laboratory 

and cleaning staff should disinfect: 

•	 Hands and skin after contact with a VHF patient or 

infectious body fluids 

•	 Gloved hands after contact with each VHF patient or after 

contact with infectious body fluids (when gloves cannot be 

changed) 

•	 Thermometers, stethoscopes and other medical instruments 

after use with each VHF patient 

•	 Spills of infectious body fluids on the walls and floors 

•	 Patient excreta and containers contaminated by patient 

excreta 

•	 Reusable supplies such as protective clothing and patient 

bedding 

•	 Used needles and syringes. 

Note: All health facility staff — including cleaning, waste disposal, 

and laundry staff — who handle, disinfect, or clean 

VHF-contaminated supplies and equipment should wear the same

protective clothing as health care workers who provide direct

patient care. Wear thick gloves for the second pair of gloves. 

Follow the steps in Section 4 for putting on and taking off 

protective clothing. 

67

Section 5


5.1 Prepare Bleach Solutions


In a central place in the health facility, prepare two solutions of 

ordinary household bleach. Normally, ordinary household bleach 

has a 5.0% chlorine concentration.7 

•	 1:10 bleach solution8 is a strong solution used to disinfect 

excreta and bodies. It is also used to prepare the 1:100 

bleach solution. 

•	 1:100 bleach solution9 is used to disinfect: 

—	 Surfaces 

—	 Medical equipment 

—	 Patient bedding 

— Reusable protective clothing before it is laundered. 

It is also recommended for: 

—	 Rinsing gloves between contact with each patient 

—	 Rinsing gloves, apron, and boots before leaving the 

patient’s room 

—	 Disinfecting contaminated waste for disposal. 

Bleach solutions must be prepared daily. They lose their strength 

after 24 hours. Anytime the odour of chlorine is not present, 

discard the solution. 

Note: 1:10 bleach solution is caustic. Avoid direct contact with 

skin and eyes. Prepare the bleach solutions in a well-ventilated 

area. 

7 The recommendations in this section assume ordinary bleach solution has a 5% chlorine concentration. 

Annex 8 contains a table describing quantities to use when preparing chlorine solutions from other 

chlorine products. 

8 This is a solution with 0.5% chlorine concentration. 

9 This is a solution with 0.05% chlorine concentration. 

68

Disinfect Reusable Supplies and Equipment

To prepare the bleach solutions 

1.	 Gather the necessary supplies: 

•	 1 container that holds 10 measures (for example, 10 

litres) to make the base 1:10 bleach solution 

•	 1 large or several smaller containers (1 for each 

station) with covers or lids to hold the 1:100 bleach 

solutions. These containers should be a different 

colour than the container holding the 1:10 bleach 

solution, or they should be clearly labelled “1:100.” 

•	 Chlorine bleach (for example, 1 litre of Javel) 

•	 Clean water 

•	 A measuring cup or other container (for example, a 

bottle that holds 1 litre). 

2.	 To prepare the containers for mixing the bleach solutions, 

determine where to mark the measurements for “9 parts” 

and “1 part” on each container. 

•	 Pour 9 measures of water


into the container. Mark


a line where “9 parts”


Mark inside the has filled the container. 

container to show For example, use a nail 

where 9 parts of to scratch a line on a 

metal or plastic bucket. water should be 

•	 Add 1 measure of water 

to the first 9 parts. 

9 parts 

Mark the level when 

Using a nail, mark a bleach is added 

line at the point where 

the total volume has Fig. 45. Marking container for mixing 1:10

filled the container. bleach solutions

3.	 To prepare 1:10 bleach solution: 

•	 Fill the marked container with water up to the mark 

for 9 parts. 

•	 Then pour the ordinary household bleach into the


container up to the top mark.


69 
Section 5 

4.	 To prepare 1:100 bleach solution: 

•	 Measure and pour 9 parts of water into the large 

container. Then measure and pour 1 part of 1:10 

bleach solution into the water to make 1:100 bleach 

solution. 

9 parts water	 9 parts water 

1 part bleach	 1 part 1:10 bleach 

1:10	 1:100 

Fig. 46. Preparing bleach solutions

•	 Distribute a container to each station. 

•	 Fill the container at each station in the isolation area 

with the 1:100 bleach solution as shown in Section 

3.2. 

•	 Place the remaining 1:10 bleach solution in the 

isolation area to disinfect spills and excreta. 

•	 When there is a large outbreak, make larger 

quantities of bleach solutions. Prepare the 

disinfectants daily and distribute them as described 

in Section 3. 

•	 Remove the disinfectants everyday or whenever the

solutions become cloudy or bloody. Replace the 

solution with a fresh supply. Safe disposal of bleach 

solutions is described in Section 6.1. 

70 
Disinfect Reusable Supplies and Equipment

•	 If you cannot smell chlorine in the bleach solution,

the concentration is no longer strong enough for

disinfection. Replace the solution with a fresh 

supply. 

•	 Make a schedule for the cleaning staff so they know 

when to bring a fresh solution into the isolation area, 

when to change them, and when to remove them. 

1:100 

1:10 

Fig. 47. Preparing bleach solutions during an outbreak

71

Section 5


5.2	 Prepare Supply of Soapy Water 

Prepare a daily supply of soapy water. 

1.	 Gather the necessary supplies: 

•	 Ordinary cake soap or powdered laundry detergent 

•	 Supply of clean water 

•	 Large bucket 

•	 Container for measuring 1 litre. 

2.	 Cut a small piece of cake soap. 

2.5cm 

2.5cm 

2.5cm 

Fig. 48. Small piece of cake soap

3.	 Mix one piece of cake soap with 4 litres (1 gallon) of water. 

4.	 Make sure the soap is well mixed with the water so there 

are suds. Pour into pan or bucket for use in cleaning (see 

Section 3.3). 

OR 

5.	 Mix powdered laundry detergent according to instructions 

on packet. 

72

Disinfect Reusable Supplies and Equipment

5.3	 Disinfect Gloved Hands between Patients 

Health care workers should change outer gloves between each 

patient. 

If there are not enough gloves to allow health care workers to 

change to a new pair of outer gloves after examining or treating 

each patient, disinfect gloved hands in 1:100 bleach solution after 

working with each patient. 

To disinfect gloved hands:

1.	 Place a bucket of 1:100 bleach solution in the isolation 

room. 

2.	 If gloved hands are visibly soiled, wash them first in soap 

and water. 

3.	 Dip the gloved hands into the 1:100 bleach solution for 1 

minute. 

4.	 Dry the gloved hands with a one-use (or paper) towel, or let 

the gloved hands air-dry. 

5.	 If a bleach solution is not available, wash gloved hands 

with soap and water. 

6.	 After several rinses in bleach solution, the gloves may 

become sticky and will need to be changed. 

7.	 If gloves will be reused, place gloves in a bucket of soapy 

water. See Section 5.4 for instructions about washing used 

gloves. 

If gloves are not going to be reused, discard them in the 

container for disposable infectious waste. 

73

Section 5


5.4	 Disinfect Used Gloves before Reuse 

Reusing gloves is not recommended. If it is necessary to reuse 

gloves because the supply in the health facility is limited, clean 

and disinfect them. Also check them for holes. 

When cleaning staff handle contaminated supplies, make sure they 

wear the same protective clothing as health care workers. They 

should wear thick gloves as the second pair of gloves. 

To clean and disinfect gloves for reuse:

1.	 Take the bucket with soaking gloves to the VHF laundry 

area. Carefully move the gloves to a bucket with fresh 

soapy water. 

2.	 Gently rub the gloves to remove visible soiling and cover 

with water. 

3.	 Soak them overnight. 

4.	 Wearing at least an apron 

and thick gloves, rinse the 

gloves in clean water. To 

check for holes, fill each 

glove with rinse water. If 

any water squirts out, there 

is a hole in the glove. 

Discard any gloves with 

holes. 

5.	 Air-dry the remaining 

gloves. 

6.	 If available, put talcum 

powder in dry gloves. 

7.	 Return clean gloves to the 

storage shelf in the entry to the isolation area. 

Fig. 49. Checking gloves for holes

74

Disinfect Reusable Supplies and Equipment

5.5	 Disinfect Reusable Medical Instruments 

In the isolation room, each time health care workers wash their 

hands between patients, they should also disinfect thermometers 

and stethoscopes they have used to examine the patient. 

To disinfect thermometers and stethoscopes with alcohol: 

1.	 Use rubbing alcohol (70% isopropyl). 

2.	 Place the alcohol in a covered container and put it in the 

patient’s room. Change the alcohol at least once a week. 

3.	 Use a clean cloth or paper towel and dip it in the alcohol 

solution. 

4.	 Carefully wipe the thermometer with the alcohol solution 

and hold the cloth around it for 30 seconds. Discard the 

cloth. Let the thermometer air-dry. 

5.	 Use another clean cloth and dip it in the alcohol solution. 

6.	 Carefully wipe the metal part of the stethoscope and hold 

the cloth against the surface for 30 seconds. Let it air-dry. 

7.	 Discard the cloth in the laundry container. Discard paper 

towels in the bucket for waste to be burned. 

To disinfect thermometers and stethoscopes with bleach solution:

1.	 Place a covered container of 1:100 bleach solution in the 

isolation room. Change the bleach solution each day. 

2.	 Use a clean cloth or paper towel and dip it in the bleach 

solution. Never dip a soiled cloth back into the bleach 

solution. Use a cup or dipper to pour the bleach solution 

on a soiled cloth. 

3.	 Wipe the thermometer with the cloth soaked in bleach 

solution. Or, soak the thermometer for 10 minutes in the 

bleach solution. Let the thermometer air-dry. 

4.	 Use a clean cloth or new paper towel and dip it in the 

bleach solution. 

5.	 Wipe the metal part of the stethoscope with 1:100 bleach 

solution. Let it air-dry. 

75 
Section 5


6.	 Discard the cloth in the laundry container. Discard paper 

towels in the bucket for waste to be burned. 

How to disinfect and dispose of used needles and syringes is 

described in Sections 1.4 through 1.6. 

5.6	 Disinfect Bedpan or Waste Bucket 

1.	 Cover the contents with 1:10 bleach. Empty the bedpan 

contents directly into the isolated toilet or latrine. 

2.	 Clean the bedpan with soap and water to remove solid 

waste. Pour into toilet or latrine. Rinse the bedpan in 

1:100 bleach solution and return it to patient's room. 

If a family member is responsible for carrying out this task, make 

sure the family member wears protective clothing. 

5.7	 Disinfect Patient’s Utensils 

If families will assist with patient care, provide 1:100 bleach 

solution and soap and water so the family member can wash the 

patient’s eating utensils. After washing the utensils, rinse them in 

1:100 bleach solution, and let them air-dry. 

76

Disinfect Reusable Supplies and Equipment

Fig. 50. Disinfecting a spill on the

floor

5.8	 Disinfect Spills of Infectious Body Fluids 

Place a bucket containing 1:100 bleach solution in the isolation 

area. 

To disinfect spills of infectious body fluids:

1.	 Use a cup or dipper to pour 

bleach solution on spills. 

Cover the spill completely 

with 1:100 bleach 

solution. If the spill is heavy 

or dense, cover with 1:10 

bleach solution. Take care 

to prevent drops or splashes 

of the contaminated body 

fluid from reaching anyone 

when pouring bleach 

solution on the spill. 

2.	 Soak the spill for at least 15 

minutes. 

3.	 Remove the disinfected blood or spilled material with a 

cloth soaked with 1:100 bleach solution. 

4.	 Discard any waste in the container for collecting disposable 

infectious waste or in the isolated latrine or toilet. 

5.	 Wash area as usual with soap and clean water. 

77

Section 5


Fig. 51. Disinfecting a spill on the

wall

To clean the walls or other surfaces:

Surfaces such as tabletops, sinks, 

walls and floors are not generally 

involved in disease transmission. 

However, in a VHF patient’s room, 

if walls are visibly soiled with blood 

or other body fluids, clean them as 

follows:10 

1.	 Use a sprayer or mop to wash 

the walls with 1:100 bleach 

solution. Rinse the mop in a 

fresh supply of 1:100 bleach 

solution. (If using a sprayer, 

apply the spray close to the surface to minimize splashing 

and aerosols.) 

2.	 Wash the wall as usual with soap and clean water to 

remove visible soil. 

3.	 Discard any waste in container for collecting infectious 

waste or in the isolated latrine or toilet. 

5.9	 Disinfect Infectious Waste and Non-Reusable 

Supplies for Burning 

Place a bucket or other container containing 1:100 bleach solution 

in the patient’s room. Use it to collect infectious waste, 

contaminated items, and non-reusable supplies that will be 

burned. 

How to carry out safe waste disposal is described in Section 6. 

10	 Favero, MS, and Bond, WW. Sterilization, disinfection, and antisepsis in the hospital. In: Murray PR ed. 

Manual of Clinical Microbiology. Washinton, D.C.: American Society for Microbiology. pp. 183-200, 

1991 

78

Disinfect Reusable Supplies and Equipment

Fig. 52. Transferring laundry to the

cleaning area

5.10 Clean and Disinfect Protective Clothing 

Set aside a special part of the laundry or cleaning area for laundry 

from suspected VHF patients. Make sure health facility staff who 

handle contaminated laundry wear protective clothing, including 

thick gloves as the second pair of gloves. 

1.	 Transfer laundry as soon as 

possible to area set aside for 

VHF laundry. 

2.	 Carefully move the laundry to 

a bucket with fresh 1:100 

bleach solution. 

3.	 Soak laundry in 1:100 bleach 

solution for 30 minutes. Be 

sure that all items are 

completely soaked. 

4.	 Remove items from the bleach 

solution and place in soapy 

water. 

5.	 Soak overnight in soapy water. 

6.	 Scrub thoroughly to remove stains. Rinse and line-dry. 

7.	 Use a needle and thread to repair any holes or torn areas. 

8.	 The clean clothing is now ready for use. It can be ironed 

although this is not necessary. (It is not necessary to wear 

protective clothing when ironing cleaned clothing.) 

Items that are very worn out should be discarded or used as 

cleaning rags. 

5.11	 Clean and Disinfect Boots 

Place a sprayer or pan with 1:100 bleach solution at the exit of the 

patient's room. Change the pan often. Steps for disinfecting boots 

are described in Section 4.4. 

79

Section 5


5.12	 Clean and Disinfect Patient’s Bedding 

For plastic sheeting:

1.	 If the plastic sheeting becomes soiled during its use with the 

same patient, remove liquid or solid waste with absorbent 

towels. Discard them in the container for collecting 

infectious waste for burning. Then, wash the plastic 

sheeting with 1:100 bleach solution. 

2.	 Change the plastic sheeting between patients. 

3.	 If the plastic sheeting cannot be changed between patients, 

wash it with 1:100 bleach solution after each patient. 

Fig. 53. Cleaning patient’s bedding

For patient’s sheets:

1.	 Remove sheets from bed. Put them in a container (plastic 

bag or bucket) in the patient’s room. 

2.	 Take the container directly to the laundry area. 

3.	 Soak in 1:100 bleach solution for 30 minutes. Be sure all 

items are completely soaked. 

4.	 Remove items from the bleach solution and place them in 

soapy water. Soak overnight. 

5.	 Scrub thoroughly to remove stains. Rinse and line-dry. 

80

Disinfect Reusable Supplies and Equipment

Mattresses:

If a mattress is heavily soiled, remove it from the isolation area to 

the outdoors and burn it. Make sure health facility staff wear 

protective clothing and gloves when touching and carrying the 

soiled mattress. 

If mattresses must be reused: 

1.	 Pour 1:10 bleach solution directly on the mattress. Let the 

solution soak through completely to the other side. 

2.	 Flood the soiled area with soapy water and rinse with clean 

water. 

3.	 Let the mattress dry in the sun for several days. 

4.	 Turn the mattress often so it dries on both sides. 

5.13	 Give First Aid for Accidental Exposures 

Accidental needlestick injury: Assume any needlestick injury is a 

suspected contact for VHF whether or not a break in the skin can 

be seen. If an accidental needlestick injury occurs, treat the 

exposure site. 

1.	 Immerse the exposed site in 70% alcohol for 20 to 30 

seconds, and wash with soap and clean water. 

2.	 Flush the site in running water for 20 to 30 seconds. 

3.	 If needed, cover with a dressing. 

4.	 Report the incident to a supervisor or the 

physician-in-charge. 

The purpose of notifying the physician-in-charge is: 

•	 To identify what caused the problem 

•	 To take corrective action to solve the problem and prevent 

accidental transmission 

•	 To provide appropriate care for the possible case of VHF. 

81

Section 5


Remind the health facility staff that accidents do happen even 

when every precaution to prevent them has been taken. Reassure 

health facility staff that reporting the accidental exposure will have 

no negative consequences. Explain that reporting the accidental 

exposure is essential for protecting themselves, their families, other 

health workers and patients. 

Accidental contact with infectious body fluids: An accidental 

contact can occur if there is unprotected contact between 

infectious body fluids and broken skin or the mouth, nose or eye. 

For example, vomit may run under a glove, a patient might cough 

blood which runs into the health care worker's eye, or coughed 

blood may run underneath a health care worker's mask and get 

into the mouth. Treat any accidental contact as a suspected 

contact with VHF. As soon as the contact occurs: 

1.	 Flush the area in the most appropriate manner with soap 

and clean water. If a splash occurs in the eye, flush it with 

clean water. 

2.	 Leave the isolation area and remove the protective clothing 

as recommended. 

3.	 Take a shower and put on street clothes. 

4.	 Report the exposure to a supervisor or the 

physician-in-charge. Complete the necessary forms. 

Follow up accidental exposures:

1.	 Monitor the condition of the health facility staff. Take a 

measured temperature two times per day. 

2.	 If a fever occurs -- temperature is 38.5oC (101oF) or higher -­

the health facility staff should not do patient care activities. 

Treat as a suspected case of VHF if the health facility staff’s 

signs and symptoms meet the case definition (Please see 

page 23 and Annex 4). 

82

Section 6 

Dispose of Waste Safely 

This section describes how to: 

•	 Dispose of liquid waste and patient excreta in an isolated 

latrine or toilet. 

•	 Use an incinerator to burn contaminated waste. 

•	 Use a pit to burn contaminated waste. 

•	 Maintain security of the disposal site. 
Section 6


84 
Section 6 Dispose of Waste Safely 

Direct, unprotected contact during disposal of infectious waste can 

result in accidental transmission of VHF. For this reason, all 

contaminated waste produced in the care of the VHF patient must 

be disposed of safely. All non-reusable items should be destroyed 

so they cannot be used again. Burning should be carried out at 

least daily. 

6.1	 What Needs Disposal 

When VHF is suspected, disinfect and dispose of: 

•	 Infectious blood and other body fluids such as urine, faeces, 

and vomitus 

•	 Disposable needles and syringes and disposable or 

non-reusable protective clothing 

•	 Treatment materials and dressings 

•	 Non-reusable gloves 

•	 Laboratory supplies and biological samples 

•	 Used disinfectants. 

Recommended Disposal Methods: Liquid waste, including patient 

excreta, can be disposed of in an isolated latrine or toilet set aside 

for VHF cases. Burning is the recommended method for disposal 

of other VHF-contaminated waste. A safe and inexpensive 

disposal system can be made by using an incinerator or a pit for 

burning. 

•	 A latrine or toilet that joins the patient's isolation room can 

be used to receive the disinfected bedpan contents from the 

VHF patient. The latrine or toilet should be isolated. 

Access should be restricted to health facility staff trained to 

work in the VHF isolation area. Isolating the patient area is 

described in Section 3.5. 

85 
Section 6


•	 Incinerators are containers with holes for ventilation to 

allow air to enter and exit the container. This allows the 

fire to reach temperatures high enough to completely 

destroy all biological materials. Use flammable fuel (such 

as diesel fuel) to speed the burning process and keep the 

temperatures high. 

Incineration is recommended for disposal of: 

—	 Needles and syringes 

—	 Used treatment materials and dressings 

—	 Non-reusable protective clothing 

—	 Laboratory supplies. 

•	 When an incinerator is not available, burn waste in a pit. 

Use fuel to accelerate the burning and ensure that all waste 

is completely destroyed. 

Use a pit to dispose of: 

—	 Disinfected body fluids such as urine, faeces, and 

vomitus when no designated latrine or toilet is 

available. 

—	 Used disinfectants. If it is not possible to dispose of 

used disinfectants in a latrine or toilet, burn the used 

disinfectant together with flammable items 

(disposable gowns or masks, for example). Burning 

with the flammable items will help keep the 

temperature of the fire hot enough to boil off the 

liquids. 

Note: All staff who are likely to handle infectious material should 

know and use VHF Isolation Precautions. Reinforce with all health 

facility staff the importance of handling infectious waste safely. 

86

Dispose of Waste Safely

6.2	 Select Staff to Supervise Waste Disposal and 

Burning 

Select a person with authority who will: 

•	 Oversee all the disposal procedures, including preparation 

of the incinerator and pit. 

•	 Train and supervise the staff who carry out waste disposal. 

•	 Make a schedule for collecting and burning disposable 

waste. 

•	 Supervise the collection and burning to make sure it is 

carried out safely. 

6.3	 Train and Supervise Staff to Carry Out Waste 

Disposal 

The cleaning staff who do the disposal tasks should understand the 

purpose of safe disposal, know how to wear protective clothing, 

and know clearly how to carry out waste disposal safely. 

After the cleaning staff is selected: 

1.	 Describe the risks of VHF transmission. Explain that health 

facility staff who carry out waste disposal should wear 

protective clothing including a plastic apron and at least 

two pairs of gloves. Wear thick gloves as the outer pair of 

gloves. 

2.	 Describe the disposal procedures that cleaning staff will 

carry out: 

•	 Bring the containers of infectious waste from the 

isolation and cleaning areas to the disposal site. 

Discard the items in the incinerator or burning pit. 

•	 Pour fuel on the waste in the incinerator or over the 

pit. Light the fire. 

87 
Section 6


•	 Watch the burning carefully. 

—	 Move waste frequently as it burns to be sure 

all items burn completely. 

—	 If any items remain, repeat the burning 

procedures. 

•	 When burning ends, remove ashes from incinerator 

and bury them in a pit. 

•	 When the pit is nearly full of ash, cover it with soil. 

Waste should not be near the surface. It should take 

about half a meter of soil to close the pit. 

•	 Build a new pit when the old pit is full. 

3.	 Show the cleaning staff how to: 

•	 Wear protective clothing with one pair of thick or 

kitchen gloves over an inner pair of thin gloves. 

•	 Collect and carry the buckets of infectious waste 

from the isolation area to the disposal area. 

•	 Collect and dispose of liquid waste in an isolated 

latrine or toilet. If no latrine or toilet can be isolated, 

burn the liquid waste in the pit. 

•	 Place the infectious waste in the incinerator or pit for 

burning. 

•	 Dowse the infectious waste with fuel (such as diesel 

fuel) and burn it. 

•	 Watch the burning from beginning to end to make 

sure all the waste items are burned before letting the 

fire go out. 

88

Dispose of Waste Safely

6.4	 Select Site for Burning VHF-Contaminated Waste 

Select a burning site on the health facility grounds. It should be 

located away from the normal traffic flow. To help maintain 

security and prevent unauthorized access, the site should not be in 

public view or in an area where it will attract a crowd. The ash 

from the burning is not infectious, and it can be placed in a pit and 

buried. 

6.5	 Use Incinerator to Burn VHF-Contaminated 

Waste 

If an incinerator is available on the health facility’s grounds, and it 

can be set aside for VHF-contaminated waste, use diesel fuel 

during burning to make sure all the waste is completely destroyed. 

If no incinerator is available, make one from an empty 220-litre 

(55-gallon) oil or fuel drum. 

1.	 Gather the following supplies: 

•	 220-litre (55-gallon)


drum


•	 Chisel or other sharp


instrument (an awl, for


example) to cut metal


•	 Hammer 

•	 0.5 mm or 1.0 mm metal


wire


Fig. 54. A 220-litre drum

•	 The piece cut out from


the top of the drum or a


wire screen or grill about 1 cm thick


•	 Metal rods or bars 4 cm or 5 cm x 2 cm. 

2.	 Cut open the drum by removing the top in one piece. Save 

the top cutaway piece. 

3.	 Hammer the edges of the drum so they are not sharp. 

4.	 Cut three half-moon openings just below the open end of 

the drum. 

89 
Section 6


5.	 Turn the drum and put the 

open end on the ground. The 

bottom of the drum is now the 

top. 

6.	 Cut four holes on the sides of 

the drum. These holes are for 

threading the two metal rods 

through the drum so that they 

form an X or cross inside the 

drum. The crossed rods will 

support a platform used for 

holding the infectious material 

to be burned.	 Fig. 55. Turn the drum and put the

open end on the ground

To cut the holes for the rods:


Just above the half moon


openings (about one-third of the


height of the drum), cut a hole


the same size as the diameter of


the metal rod. Directly across


from the hole, on the other side


of the drum, cut a second hole


so that a rod can be threaded


through the two holes. Repeat


the steps and make two more
 Fig. 56. Place the rods across the holes on opposite sides of the drum

drum. Thread each rod through


the holes to make an X or cross.


7.	 Use the top piece of the drum that was cut away in step 2 

to make the platform. It will rest on the crossed rods and 

hold the infectious material to be burned. The platform 

also lets air come in from the bottom of the drum so that 

the temperatures at the bottom are high enough to 

completely burn the material. 

To make the platform: Punch holes in the cutaway top 

piece of the drum. Make enough holes so it looks like a 

sieve. Save the platform to use in Step 10. 

8.	 Pierce a series of holes (about 0.5 cm in diameter) on the 

sides of the drum and above the crossed rods to improve 

the draw of the fire. 

half-moon 

openings 

90

Dispose of Waste Safely

9.	 Cut away half of the bottom of the drum (which is now the 

top of the incinerator and is facing up). Attach the wire 

loops to the cutaway half. Attach another loop for a handle 

to open the trap door. Items to be burned will be put in the 

incinerator through this door. 

10.	 Place the platform you made in Step 7 inside the drum on 

top of the rods. Replace the incinerator if, as a result of the 

heat, large holes appear in the sides. 

metal rods 

half-moon 

openings Fig. 57. A completed incinerator

platform 

To burn waste in the incinerator:

1.	 Place the infectious waste inside the top of the drum. Soak 

the waste in one litre of fuel. 

2.	 Light the fire carefully. 

3.	 Watch the fire and frequently mix the waste with the metal 

bars to be sure all of the waste is burned. 

4.	 When the fire has gone out, empty the ashes into a pit. 

91

Section 6


6.6	 Use Pit to Burn VHF-Contaminated Waste 

If an incinerator is not available, make a pit for burning infectious 

waste. 

1.	 Locate the pit far from the normal traffic flow of the health 

facility. 

2.	 Dig a pit that is 2 meters deep. It should be wide enough 

to hold all contaminated waste material, including 

discarded liquids. 

To burn waste in the pit:

1.	 Place the disinfected waste in the pit, including disinfected 

liquid waste that was not discarded in an isolated latrine or 

toilet. 

2.	 Pour fuel (such as diesel fuel) on the waste. Carefully start 

the fire. 

3.	 Watch the burning to make sure all the waste is completely 

destroyed. 

4.	 When the fire has gone out, if any waste remains, repeat 

the steps for burning. 

5.	 When no waste remains and the fire goes out, cover the 

ashes with soil. 

6.	 Before the pit becomes completely full, cover it with soil so 

that no pieces of waste are visible or are too close to the 

surface. The pit should be closed when it can be covered 

by one-half meter of soil. 

7.	 Dig a new pit. 

92

Dispose of Waste Safely

6.7 Take Steps to Ensure Security of Burning Site 

Maintain the security of the burning site to limit access to 

contaminated items. This is important since children could be 

tempted to pick up the interesting waste materials and use them for 

toys. Dogs, cats, and other animals may carry items beyond the 

health facility boundaries. 

Tie a rope around the disposal area. Hang warning signs from the 

rope that tell people this is a dangerous area. Also station a guard 

to prevent unauthorized access to the disposal area. 

Never leave unburned waste in the incinerator or the pit. 

93

Section 6


94 
Section 7 

Use Safe Burial Practices 

This section describes how to: 

• Prepare bodies of deceased VHF patients. 

• Transport the body safely to the burial site. 

• Disinfect the vehicle after transporting bodies. 
Section 7


96 
Section 7 Use Safe Burial Practices 

There is risk of transmission in the health facility when a VHF 

patient dies because the bodies and body fluids of deceased VHF 

patients remain contagious for several days after death. Family 

and community members are also at risk if burial practices involve 

touching and washing the body. 

7.1	 Prepare the Body Safely 

Burial should take place as soon as possible after the body is 

prepared in the health facility. Health facility staff should: 

•	 Prepare the body safely. 

•	 Be aware of the family’s cultural practices and religious 

beliefs. Help the family understand why some practices 

cannot be done because they place the family or others at 

risk for exposure. 

•	 Counsel the family about why special steps need to be 

taken to protect the family and community from illness. If 

the body is prepared without giving information and 

support to the family and the community, they may not 

want to bring other family members to the health facility in 

the future. They may think that if the patient dies, the body 

will not be returned to them. 

•	 Identify a family member who has influence with the rest of 

the family and who can make sure family members avoid 

dangerous practices such as washing or touching the body. 

To prepare the body in the health facility: 

1.	 Wear protective clothing as recommended for staff in the 

patient isolation area. Use thick rubber gloves as the 

second pair (or outer layer) of gloves. 

2.	 Spray the body and the area around it with 1:10 bleach 

solution. 

3.	 Place the body in a “body bag” (mortuary sack) and close it 

securely. Spray the body bag with 1:10 bleach solution. 

97 
Section 7


4.	 If body bags are not available, wrap the body in two 

thickness of cotton cloth and soak with 1:10 bleach 

solution. Then wrap the body in plastic sheeting. Seal the 

wrapping with plastic tape. Spray the body bag as in 

Step 3. Place the body in a coffin if one is available. 

5.	 Transport the body to the burial site as soon as possible. 

Assign a health officer or health facility staff person to 

accompany the body to ensure that the safety precautions 

remain secure during the journey. 

7.2	 Transport the Body Safely 

VHF Isolation Precautions should remain in force when the body is 

being transported to the burial site. 

1.	 Plan to take the shortest route possible for security purposes 

and to limit any possibility of disease transmission through 

accidental contact. 

2.	 Any health facility staff who must touch or carry the body 

during transport should wear the same protective clothing 

as is worn in the isolation area. Note: The driver does not

need to wear protective clothing if there is no contact

with the body.

3.	 Take a closed container or sprayer with 1:10 bleach 

solution in the event of any accidental contact with the 

body or infectious body fluids. Also use it to clean up spills 

in the transport vehicle. 

7.3	 Prepare Burial Site 

1.	 The grave should be at least 2 meters deep. 

2.	 Explain to the family that viewing the body is not possible. 

Help them to understand the reason for limiting the burial 

ceremony to family only. 

98 
Use Safe Burial Practices

7.4	 Disinfect the Vehicle after Transporting the Body 

1.	 The staff person who disinfects the vehicle must wear 

protective clothing. 

2.	 Rinse the interior of the vehicle where the body was carried 

with 1:10 bleach solution. 

3.	 Let it soak for 10 minutes. 

4.	 Rinse well with clean water and let the vehicle air-dry. Be 

sure to rinse well because the solution is corrosive to the 

vehicle. 

Fig. 58. Disinfecting the vehicle after transporting the body

99

Section 7


100

Section 8 

Mobilize Community Resources 

and Conduct Community 

Education 

This section describes how to: 

•	 Organize community resources to develop and provide 

information about prevention and control of VHF in the 

community. 

•	 Identify key messages and communication channels. 

•	 Evaluate communication activities and take action to 

improve them as needed. 
Section 8


102

Section 8 Mobilize Community Resources and 

Conduct Community Education 

When VHF is suspected: 

•	 Make sure that the community knows about the VHF 

outbreak and how it is transmitted. 

•	 Involve the community in identifying the source of the 

epidemic and controlling it. 

• Reduce fear and rumours in the population. 

To develop community education in an urgent situation: 

•	 Describe the extent of the current health problem. 

•	 Identify and mobilize key community members who will 

plan and lead the education efforts. 

•	 Describe the target population and develop health 

messages. 

•	 Plan and conduct activities to communicate messages. 

•	 Conduct ongoing evaluation of the activities and make 

improvements as needed. 

103

Section 8


8.1	 Identify Key Community Resources 

Identify key community organizations who already know the 

community and have access to it. Describe their expertise and 

available resources that could be useful in responding to the 

outbreak. Consider organizations such as: 

•	 Local governments 

•	 Local non-governmental organizations (NGOs) 

•	 Religious groups (missions, churches, mosques, temples) 

•	 Businesses 

•	 Schools 

•	 Sports clubs and other recreational clubs 

•	 Service organizations 

• Volunteer organizations and community service groups. 

For each organization, gather and record information about: 

•	 The organization's expertise 

•	 The representative or leader to be contacted 

•	 Available human resources 

•	 Available material resources (such as vehicles, office 

supplies, and communication equipment). 

104

Mobilize Community Resources and Conduct Community Education

Record the information on a chart such as the one below. Use it for planning and refer 

to it when VHF cases occur. 

Organization 

or Group 

Expertise Representative 

or Leader and 

Locating 

Information 

Human Resources Available 

Equipment 

Contacted? Tasks 

Assigned 

Red Cross Emergency 

response; 

Disaster relief 

Amadu Barrie 

House next to 

hotel 

35 trained 

volunteers 

2 pickup 

trucks 

Catholic 

Mission of St. 

Francis 

Teaching 

Child care 

Sister Frances 

Use 

short-wave 

radio at the 

Catholic 

Mission 

6 sisters 

4 novices 

165 students 

residing 

1 Land Cruiser 

1 storage 

room 

1 photocopy 

machine 

1 short-wave 

radio 

Merchants 

Association 

Marketing & 

community 

relations 

Kira Talitha 

General store 

on main road 

12 members well 

known in 

community 

41 delivery 

workers with 

knowledge of 

customers' 

residence 

Wagon 

Supplies of 

fabric, plastic 

cloth, buckets, 

household 

bleach 

Farmers 

Cooperative 

Organization 

Economic 

development 

Daoudou 

Maliki 

Government 

Centre 

Building 

Telephone: 

21246 

2 workers fluent 

in language of 

rural population 

1 short-wave 

radio 

1 car 

office supplies 

105

Section 8


8.2	 Meet with Community Leaders and Assess the 

Current Situation 

Invite representatives from each organization to a meeting. 

Explain that the goal is to develop a Mobilization Committee that 

will help halt an outbreak. Together with the VHF Coordinator 

and health facility staff, the Mobilization Committee will: 

•	 Plan and describe how communication will take place 

between the Mobilization Committee and the VHF 

Coordinator. The purpose is to keep the health staff 

informed about the outbreak status in the community. 

•	 Make sure the community leaders understand: 

—	 The signs and symptoms of a VHF. 

—	 How the disease is spread. 

—	 Personal precautions to use to prevent contact with 

infectious material and body fluids. 

—	 The person to notify when a VHF is suspected (for 

example, station a Red Cross volunteer at the health 

facility to take reports from community members 

about unexplained deaths or suspected VHF cases). 

—	 The importance of handwashing, decontamination of 

surfaces, careful laundering of clothes, bedding, and 

other home infection control measures such as trying 

to keep the sick person in a separate corner of the 

house. 

—	 Careful decontamination of the bedding and room 

where the patient has died. 

—	 The need for limited contact between the sick 

person and other family and community members. 

—	 The need to follow up family or community 

members who have had contact with the sick 

person. The duration of the follow up will vary 

according to the incubation period for the VHF. 

106 
Mobilize Community Resources and Conduct Community Education

—	 When to send a sick person to the hospital. The 

VHF Coordinator, community liaison person, or Red 

Cross volunteer can facilitate this move if the 

community has been adequately prepared. For 

example, they can assist in transporting the patient 

safely to the health facility, help disinfect the area 

where the patient was cared for at home. 

—	 How to care for VHF patients at home before they 

have been diagnosed and also after they have been 

released from the health facility. 

—	 What is expected of families when the patient is in 

the hospital. 

—	 Why burial practices may need to be changed 

during the outbreak. 

•	 Deliver health messages using a variety of communication 

methods that will reach as many people as possible in the 

community. 

•	 Conduct community surveillance including reporting 

deaths, conducting case finding activities and planning case 

follow-up. 

Fig. 59. Meeting with community leaders

107

Section 8


8.3	 Describe the Target Population 

To prepare a complete description of the target population, gather 

and present information about: 

•	 Maps of the town 

•	 The size of the population 

•	 Major ethnic groups in the town 

•	 Locations of any special populations such as refugees or 

squatter settlements where the risk of disease transmission 

may be particularly high 

•	 How many people may be affected by the outbreak 

•	 The populations at greatest risk. 

Ask the members of the Mobilization Committee for any additional 

information they might have about the target population. For 

example, they may know about nearby villages and recent travel 

by the local population to other areas. 

8.4	 Describe Problems Contributing to Transmission 

Risk 

Identify the likely transmission risks for this community. 

For example, does the community know how disease is 

transmitted and how it can be prevented? Is it customary to visit 

the sick in their homes? During mourning, are individuals 

expected to lay hands on the body or touch the body to show their 

grief? Are there new skills to teach? Is bleach available? 

8.5	 Identify Changes or Actions Required 

Specify the behaviour changes and actions that are required to 

solve the problems. For example, if traditional burial practices 

involve touching or washing the body, the community will need to 

adapt burial practices. 

108

Mobilize Community Resources and Conduct Community Education

8.6	 Identify Barriers to Carrying Out Recommended 

Changes or Actions 

Talk with members of the Mobilization Committee about what 

could prevent individuals from doing the recommended changes 

or actions. Discuss, for example, if individuals: 

•	 Know about the relevant VHF precautions and how to 

follow them? 

•	 Have the skills to do the recommended changes or actions? 

•	 Have the correct resources to carry out the recommended 

changes or actions? 

•	 Understand that some caretaking and burial practices must 

change during the outbreak even though they involve 

traditional beliefs or cultural practices? 

8.7	 Develop Specific Messages 

Review the information collected by the Mobilization Committee. 

Select messages that match the specific risks for transmission of 

VHF. Consider how to solve the obstacles that might prevent 

individuals from taking the recommended precautions. 

For example, the custom in the community may be to visit the sick 

when they are at home. Plan a message about limiting visitors. 

Also include information about how diseases are transmitted. This 

will help the community understand why they must change their 

customary practice. 

After selecting the messages, decide if some activities should take 

place before others. 

For example, give basic information about VHF and its 

transmission before telling the community about not touching the 

body of a relative who has died. 

In addition, the community may have heard rumours that everyone 

in the hospital is dying. To reduce fear and rumours, give 

information as soon as possible about VHF transmission. Discuss 

the precautions being taken in the hospital to protect the patients, 

the health facility staff, and the community. 

109 
Section 8


8.8	 Select Activities for Communicating Messages 

List all available methods of communicating with the community. 

More than one method should be used to reach the maximum 

population with the necessary information. For instance, consider: 

•	 Existing communication channels in the community 

(church, mosque, temples and other religious networks; 

traditional healers, personal communication) 

•	 Door-to-door campaigns 

•	 Radio messages 

•	 Short-wave radio to reach outlying areas 

•	 Banners and posters. 

Contact the person responsible for each communication method. 

Ask for their support and availability. 

8.9	 Assign Tasks and Carry Out Activities 

Look at the list of community resources prepared in Section 8.1. 

Determine who should undertake which activity. For example: 

•	 Religious leaders will make announcements in their 

services. They can also prepare messages to deliver to 

small groups and in personal communications. 

•	 The Red Cross will be trained to evacuate the bodies and 

safely perform burials. 

•	 The Red Cross volunteers and student volunteers will be 

trained by a member of the health facility staff skilled in 

VHF Isolation Precautions. A training schedule will be set 

up and the Mobilization Committee will work out the 

information needed. 

•	 The governor or village chief can make public 

announcements with a loudspeaker to tell people to stay 

calm, to listen to the information, and to attend information 

sessions. 

•	 Student clubs will make banners to put across the road to 

give a specific message, design leaflets, pass out leaflets, 

and go door to door and answer questions. 

110 
Mobilize Community Resources and Conduct Community Education

Elicit ideas from the Mobilization Committee about possible 

problems and creative solutions. Describe the problems that have 

occurred in previous outbreaks or that might occur in a future 

outbreak. Explain that meetings with the group will continue 

throughout the outbreak and new problems will be discussed as 

they arise. 

If funding and human resources are limited, set priorities. Select 

specific activities that will make the most impact. Work with the 

Mobilization Committee to coordinate and communicate with all 

the resources in the community. There may be ways to 

accomplish all the activities if groups can be mobilized and 

understand the need. 

Use the community information sheet to organize the specific tasks 

and assign organizations to do them. 

8.10 Evaluate Activities 

Evaluation of the community education efforts should be ongoing. 

Keep records of activities accomplished, any problems, and their 

solutions. Use the evaluation results to make improvements. 

When problems occur, find out why and solve them. Develop 

new solutions to identified problems and implement these 

solutions. 

For example, in the 1995 Ebola haemorrhagic fever outbreak in 

Kikwit, community education was a key element in halting the 

epidemic. However, no one predicted that survivors would not be 

accepted when they returned into the community. Community 

members believed survivors still carried the disease. A new 

education activity had to be developed so that the survivors and 

surviving children would not be abandoned. 

111

Section 8


8.11 Obtain Community Feedback 

The Mobilization Committee should identify a representative from 

the community or from each area of the community (for example, 

a representative from each neighbourhood or quartier) to attend 

community meetings and obtain feedback from the community. 

Explain to the community the purpose of the Mobilization 

Committee. Describe the activities that have been planned or that 

are already being done. Reinforce the critical role of the 

community representatives in providing information from the 

Mobilization Committee to their own communities. Community 

representatives are also important sources of information about 

possible transmission risks and prevention activities. 

Be alert to feedback from the community that can affect the 

outcome of the community education efforts. For example, are 

there areas where health messages do not reach community 

members? 

8.12 Meet Regularly with the Mobilization Committee 

Set up regular meetings with the Mobilization Committee. Keep 

them well informed of what is happening. Encourage and support 

them to help continue enthusiasm for the efforts. Provide new 

messages and information they need. Work together to identify 

new problems and plan solutions. 

112

Section 9 

Make Advance Preparations to 

Use VHF Isolation Precautions 

This section describes how to: 

•	 Identify health facility staff person to coordinate VHF 

activities. 

•	 Assess current readiness for VHF Isolation Precautions. 

•	 Identify and train key staff who will work with VHF cases. 

•	 Plan for community mobilization. 

•	 Assess current supplies and obtain what is needed for VHF 

Isolation Precautions. 

•	 Use substitutions when supplies are limited or not 

available. 
Section 9


114

Section 9 Make Advance Preparations to Use 

VHF Isolationtion Precautions 

When a VHF case is suspected, VHF Isolation Precautions must 

begin immediately. All efforts must be focused on meeting 

patients’ needs. There is no time to give initial training in VHF 

Isolation Precautions. 

Being prepared for an emergency can ultimately save lives. Health 

care workers will know how to use VHF Isolation Precautions, and 

adequate supplies will already be available. Disease prevention in 

the health facility setting will be more effective. 

This section describes how to prepare for VHF Isolation 

Precautions. 

9.1	 Identify a VHF Coordinator to Oversee 

Preparations 

Someone in the health facility may already serve as a coordinator 

for emergency situations. This person can also serve as the VHF 

Coordinator. If the emergency coordinator cannot assume the 

VHF activities, select a staff person with authority who can serve as 

VHF Coordinator. Discuss the tasks the coordinator will need to 

do for VHF activities: 

•	 Oversee all the preparations for VHF Isolation Precautions. 

•	 Serve as the focal point for information and leadership 

when a VHF case is suspected. 

•	 Inform all health facility staff about VHFs and the risks 

associated with them. 

•	 Organize training in VHF Isolation Precautions for medical, 

nursing, and laboratory staff who will work directly with 

VHF patients or infectious body fluids. 

•	 Assign responsibility to medical, laboratory, and cleaning 

staff for ensuring that all the necessary precautions, 

treatment protocols and cleanup procedures are carried out 

within their areas. 

115 
Section 9


•	 Hire or reassign and train additional cleaning staff for work 

with disinfection of waste, clothing, and equipment. 

•	 Make sure that teams are trained to prepare and transport 

bodies for burial. 

9.2	 Assess Current Readiness for VHF Isolation 

Precautions 

Be prepared to use VHF Isolation Precautions by identifying 

problems and actions to solve them. Make sure relevant staff 

know how to suspect a VHF, especially those who: 

•	 See patients when they arrive at the health facility and 

decide where they are next seen 

•	 Work in the outpatient department 

•	 Work in the emergency room. 

9.2.1	 Monitor Routine Handwashing Practices 

Routine handwashing practices should be part of the minimum 

level of Standard Precautions used with all patients in the health 

facility. 

To reinforce consistent handwashing practices, regularly monitor 

the practices and improve them as needed. For example: 

•	 Has handwashing been identified as a routine practice in 

the health facility? 

•	 Do all staff wash their hands after contact with each patient, 

especially new patients with fever? 

•	 Are there reliable supplies of soap and running water or 

buckets with clean water available in areas where health 

workers should use them? 

•	 Are posters reminding health workers to wash their hands 

placed in areas where health workers can see them? 

116

Make Advance Preparations to Use VHF Isolation Precautions

9.2.2	 Assess Readiness for Identifying Suspected VHF Cases 

Assess the need for training your health staff to suspect a VHF. For 

example: 

•	 Do health care workers know the case definition for 

identifying VHF cases that have occurred in your area? 

•	 Do health care workers know the procedure for informing 

the emergency or VHF Coordinator when a VHF is 

suspected? 

•	 Do health care workers in the relevant areas know the level 

of Standard Precautions identified for the health facility? 

Do they use them all the time to prevent health facility 

transmission of VHFs and other contagious diseases such as 

HIV and hepatitis B? 

9.2.3	 Assess Readiness for Setting Up a VHF Isolation Area 

•	 Has an area been selected for VHF isolation that meets the 

criteria described in Section 3.1? 

•	 Has a map been drawn showing where to locate the 

changing room, the patient room, the changing room for 

the cleaning staff, and a changing room for family members 

(if needed)? 

A map that is prepared in advance can be used as a 

reference for setting up a VHF isolation area in an urgent 

situation. 

9.2.4	 Assess Readiness of Medical, Laboratory, and Cleaning 

Staff 

Key staff should be identified and informed about what will be 

expected of them when a VHF case is suspected. For example: 

•	 Is there a family liaison officer who will: 

—	 Provide information and help families to care for the 

patient 

—	 Help families find a place near the hospital where 

cooking, sleeping, and sanitary facilities are 

available 

—	 Talk with family members about their concerns? 

117 
Section 9


• Have the health care workers who will have access to the 

isolation area if a VHF case is suspected been identified? 

While all health facility staff should know and use Standard 

Precautions consistently, identify the health care workers 

who must also know how and when to use VHF Isolation 

Precautions. 

• Have laboratory staff been designated to work with VHF 

samples? Laboratory staff are at particular risk of disease 

transmission because they handle biological samples. They 

do not see the patients and cannot know if the sample is 

infected with a dangerous disease. When a VHF case 

occurs, limit work on VHF samples to one laboratory staff 

person who will do all testing of body fluids from VHF 

patients. Make sure the designated person knows when 

and how to use protective clothing and safely disinfect 

spills and waste. 

• Have cleaning staff been selected and trained to use VHF 

Isolation Precautions? Cleaning staff have close contact 

with infectious spills and equipment. They are at high risk 

of transmission if VHF Isolation Precautions are not used. 

Select the cleaning staff who will be responsible for 

cleaning in VHF isolation areas, laundry areas, and the 

body preparation area. 

• Have body disposal teams been identified and trained to 

use VHF Isolation Precautions? The health facility staff or 

Red Cross volunteers who prepare corpses before families 

claim them are at risk for VHF. The VHF patient is still 

contagious for several days after death. 

The VHF Coordinator should also meet with each group to explain 

the risk of health facility transmission and the training schedules 

and to answer any questions they have. 

9.3	 Train Health Facility Staff in VHF Isolation 

Precautions 

Learning to use a new skill takes time and practice. Health facility 

staff who do not know how to use VHF Isolation Precautions will 

need information about the new tasks, see them demonstrated and 

practice doing them. Staff who are not familiar with protective 

clothing should practice putting them on and working in them 

before a VHF case presents. 

118 
Make Advance Preparations to Use VHF Isolation Precautions

Include information about VHFs and using VHF Isolation 

Precautions during in-service training.11 Discuss topics such as: 

General information about VHFs:

•	 A VHF can be caused by several different viruses, which are 

transmitted to humans by animals or arthropods. 

•	 Each virus causes a different disease, but all attack the small 

blood vessels that carry blood through the body. 

•	 The virus is usually in all organs and can cause bleeding 

from the nose, mouth, and intestine, as well as under the 

skin. 

•	 Common presenting complaints are fever, body aches, 

weakness persisting after rehydration, diarrhoea, muscle 

pain and back pain. 

•	 Clinical examination may reveal only conjunctival injection 

(red eyes), mild hypotension (low blood pressure), flushing, 

and haemorrhages. 

•	 The course of VHF leads to shock, generalized mucous 

membrane bleeding, reduced sensitivity to pain, and signs 

involving the nervous system. 

•	 Examples of VHFs include: 

Africa: Lassa fever, Rift Valley fever, Marburg and Ebola 

haemorrhagic fevers, Crimean-Congo haemorrhagic 

fever, and yellow fever. 

South America: Argentine haemorrhagic fever, Bolivian 

haemorrhagic fever, Venezuelan haemorrhagic 

fever, haemorrhagic fever with renal syndrome 

(rare), yellow fever, and dengue haemorrhagic fever. 

Asia: Haemorrhagic fever with renal syndrome and 

dengue haemorrhagic fever.12 

11 Annex 14 contains a suggested agenda for training during in-service meetings. It can be adapted by 

individual health facilities. 

12 See Annex 2 for more information about VHFs reported in your area. 

119

Section 9


VHF Transmission Risk in the Health Facility:

Give information about VHF, its transmission, and previous 

outbreaks in the area listed in the Introduction and Section 2 of 

this manual. Explain that: 

•	 The virus is present in the patient's body fluids. 

•	 It is transmitted through unprotected contact between an 

infectious patient or their body fluids and a non-infected 

person. 

•	 While VHF is not a common diagnosis, it is a dangerous 

disease and poses significant risks in the health care setting. 

VHF Isolation Precautions: 

When a VHF case is suspected, the health facility will immediately 

take steps to limit its transmission. These include steps to: 

•	 Create an isolation room for VHF patients. 

•	 Limit contact with VHF patients to a small number of 

specially trained staff and, in some areas, a family member 

who has received information and training in VHF Isolation 

Precautions. 

•	 Limit the use of invasive procedures as much as possible in 

treatment of VHF patients. 

•	 Use protective clothing for all staff who have contact with 

VHF patients or their body fluids. 

•	 Use safe disinfection and waste-disposal methods. 

Procedures for Accidental Exposures:

Provide information about how to respond when accidental 

exposures occur. These procedures are detailed in Section 5.13 of 

this manual. 

120

Make Advance Preparations to Use VHF Isolation Precautions

9.4	 Plan for Community Mobilization 

Section 8 describes how to mobilize the community in an urgent 

situation. However, community mobilization will be easier and 

occur quickly if it is planned in advance. 

Now is the best time to establish a Mobilization Committee. The 

following steps can be done in advance. 

•	 Identify key community resources. 

—	 Identify key organizations and record them on the 

Community Information Sheet (page 105). 

—	 Identify the representative or leader for each 

organization. 

—	 Contact the representative or leader for an initial 

meeting. 

•	 Meet with identified community leaders. 

—	 Give information and educate them on VHFs. 

—	 Explain the purpose for a Mobilization Committee. 

—	 Discuss and clarify each organization’s expertise. 

—	 Discuss and clarify the human resources available 

from each organization. 

—	 Discuss and clarify equipment available from each 

organization. 

—	 Establish methods for communicating between the 

Mobilization Committee and the VHF Coordinator. 

—	 Record the relevant information on the Community 

Information Sheet. 

•	 Annually update the information on the Community 

Information Sheet. 

Then, when a VHF case is suspected, the committee can meet and 

take action to mobilize resources and carry out community 

education. 

121 
Section 9


9.5 Assess Current Supplies and Equipment 

Use the checklist at the end of this section to assess which supplies 

are already available in the health facility. If these supplies are 

available, can they be set aside for use when VHF Isolation 

Precautions are needed? If they are not available, could they be 

borrowed from another service if an outbreak occurred? 

If the supply is limited or unavailable, identify practical, low-cost 

substitute items. When an item or equipment is not available, 

consider what could be used in its place that will serve the same 

function. Obtain the substitute item now. Set it aside for use 

when VHF Isolation Precautions are needed. 

For example, assess the present system for waste disposal. Find 

out what is needed to carry out safe waste disposal when a VHF 

case is suspected. Ask health facility staff to prepare an incinerator 

(if none is available) so it is ready in advance. Let health facility 

staff practice using it before cases occur. 

The checklist that starts on the next page lists the necessary items 

and recommended quantities. Use it to assess whether an item is 

available. Also list what needs to be done to be prepared for VHF 

Isolation Precautions. 

9.6 Periodically Reassess Supplies 

Periodically, for example, every 4 months, make sure the supplies 

are dry, clean, and ready to be used. 

122

123


VHF Isolation Precautions Supplies: Standard Precautions 

Recommendations for handwashing and safe disposal of sharps* 

Recommended Item Recommended Amount Amount 

Available 

Amount to 

Obtain 

Lo

Source of clean water prepared as needed Container for daily supply of water for handwashing (if running water is not available) 

1 or 2 large containers 

Ladle several Bucket or pan for use with handwashing 1 for each location in the health facility where 

handwashing is required 

Pieces of soap several bars cut in pieces Soap dishes 1 for each handwashing station One-use towels 1 roll per health worker per week Sharps containers 1 for each location where sharp instruments are used Pans with soapy water to collect needles and syringes to be cleaned and disinfected for reuse 

1 for each location where sharp instruments are used 

Pans with full-strength bleach 1 for cleaning area Supply of clean water for rinsing needles and syringes 

1 - 5 litres 

Clean and disinfected jar for storing disinfected needles and syringes 

1 for each patient isolation area 

* This is a recommended minimum level of Standard Precautions for use with all patients regardless of their infectious status. 
124


VHF Isolation Precautions Supplies: Patient Isolation 

Recommended Item Recommended Amount Amount 

Available 

Amount to 

Obtain 

Lo

Bed 1 per patient Mattress or sleeping mat 1 per patient Plastic sheet to cover mattress 1 per bed Bedding: bottom sheet and blanket 1 each per patient Thermometer 1 per patient isolation area (1 per patient if available) Stethoscope 1 per patient isolation area Blood pressure cuff 1 per patient isolation area Covered container for alcohol or bleach solution used to disinfect thermometer and stethoscope after use with each patient 

1 per patient isolation area 

Sharps container or plastic pan with bleach solution in it for disposal of used needles and syringes 

1 per patient isolation area 

Bedside table or shelf 1 per patient Large wall clock with a second hand 1 per patient isolation room 
VHF Isolation Precautions Supplies: Patient Isolation 

Recommended Item Recommended Amount Amount 

Available 

Amount to 

Obtain 

Lo

One-use towels 1 roll per patient per week or stay Bed pan 1 per patient Screens (or sheets hung from ropes or lines) placed between VHF patients’ beds 

enough length to go around isolation area 

Signs saying “Isolation Area: No Access” 10 Poster describing Isolation Precautions 1 

125

126


VHF Isolation Precautions Supplies: Protective Clothing* 

Recommended Item Recommended Amount Amount 

Available 

Amount to 

Obtain 

Lo

Scrub suits 1 - 2 reusable scrub suits per health staff Surgical gowns 3 reusable gowns per health staff 

4 disposable gowns per health staff per week 

Plastic aprons 1 reusable apron for each health staff who needs one 

3 disposable aprons per health staff per week 

Thin gloves 3 dozen disposable pairs per health staff per week Thick or heavy-duty kitchen gloves 2 pairs per health staff HEPA-filter or other bio-safety mask 1 - 2 per health staff who needs one Cotton mask 3 - 4 per health staff Rubber boots 1 pair per health staff Headcovering 1 - 2 per health staff who needs one Eyewear 1 pair of goggles or clear spectacles per health staff in 

isolation area 

Shelf or cabinet with lock 1 outside the changing room 
127


VHF Isolation Precautions Supplies: Protective Clothing* 

Recommended Item Recommended Amount Amount 

Available 

Amount to 

Obtain 

Lo

Covered shelf for storing disinfected boots 

1 outside the changing room 

Hooks, nails or hangers for hanging reusable gowns and scrub suits 

1 for each health staff 

Boot remover 1 per changing room Rolls of plastic tape 1 per changing room Extra supply of clean protective clothing (for patient isolation area) 

1 - 3 sets (depending on staffing) 

Extra supply of clean protective clothing (for the changing room) 

1 - 3 sets 

* All health facility staff -- including cleaning, waste disposal, and laundry staff -- who handle, disinfect or clean VHF-contaminated supp

protective clothing as health care workers who provide direct patient care. 
128


VHF Isolation Precautions Supplies: Disinfection 

Recommended Item Recommended Amount Amount 

Available 

Amount to 

Obtain 

Lo

Supplies for preparing disinfectants Plastic bucket with lid or cover for preparing 1:10 bleach solution 

1 

Containers for preparing 1:100 bleach solution 

1 large container or several small ones 

Measuring cup 1 with measurments marked on it Bleach 1 litre bleach yields 100 litres of 1:100 bleach 

solution 

Supplies for disinfection station (changing room and patient room) Pan or bucket with 1:10 bleach solution 1 per each disinfection station Pan or bucket with 1:100 bleach solution 1 per each disinfection station Pan or bucket with 1:100 bleach solution for collecting reusable gloves 

1 per changing room 

Bucket or bag for collecting contaminated, reusable protective clothing 

1 per changing room 

Bucket or bag for collecting patient’s contaminated laundry 

1 per patient isolation area 

Pan with soapy water for collecting used needles and syringes 

1 per patient isolation area 
129


VHF Isolation Precautions Supplies: Disinfection 

Recommended Item Recommended Amount Amount 

Available 

Amount to 

Obtain 

Lo

Sprayer, bucket or shallow pan with 1:100 bleach solution for disinfecting boots 

1 for the disinfection station in patient room 

Sprayer, 1:100 bleach solution, clean water for disinfecting spills on floor or wall 

1 per each disinfection station 

Mop 1 per each disinfection station Supplies for laundry Bucket with 1:10 bleach solution Buckets with 1:100 bleach solution 2 - 3 (10 - 30 litres of bleach solution is needed daily) Buckets with soapy water 2 - 3 (10 - 30 litres of soapy water is needed daily) Source of clean water for rinsing the laundry 

10 - 30 litres/day 

Needles and thread for repairing holes in protective clothing 

5 spools and 5 needles 

Talcum powder to put in washed gloves 1 tin Line to air-dry reusable clothes 
VHF Isolation Precautions Supplies: Waste Disposal 

Recommended Item Recommended Amount Amount 

Available 

Amount to 

Obtain 

Lo

Containers with 1:100 bleach solution for collecting infectious waste 

1 per patient isolation area 

Pit or incinerator for burning infectious waste* 

1 per facility, pit should be 2 meters deep 

Kerosene or petrol 1 litre per week Wood for burning Rope to make barrier around the waste disposal site 

enough length to go around the waste disposal site 

130


* If no incinerator is available, make one from an empty 220-litre (55-gallon) oil or fuel drum. 
131


VHF Isolation Precautions Supplies: Safe Burial Practices 

Recommended Item Recommended Amount Amount 

Available 

Amount to 

Obtain 

Lo

Supply of 1:10 bleach solution prepared as needed Sprayer 1 Body bags (cotton cloth, plastic sheeting, plastic tape) 

as needed 

VHF Infection Control Supplies: Others 

Recommended Item Recommended Amount Amount 

Available 

Amount to 

Obtain 

Lo

Supply checklist as needed Patient record forms as needed Accidental exposure record forms as needed Training materials for staff training in VHF Isolation Precautions 

as needed 
132

ANNEX 1	 Standard Precautions for Hospital Infection 

Control13 

Standard Precautions aim to reduce the risk of disease transmission in the health 

care setting, even when the source of infection is not known. Standard 

Precautions are designed for use with all patients who present in the health care 

setting and apply to: 

• Blood and most body fluids whether or not they contain blood 

• Broken skin 

• Mucous membranes. 

To reduce the risk of disease transmission in the health care setting, use the 

following Standard Precautions. 

1.	 Wash hands immediately with soap and water before and after examining 

patients and after any contact with blood, body fluids and contaminated 

items — whether or not gloves were worn. Soaps containing an 

antimicrobial agent are recommended. 

2.	 Wear clean, ordinary thin gloves anytime there is contact with blood, body 

fluids, mucous membrane, and broken skin. Change gloves between tasks 

or procedures on the same patient. Before going to another patient, 

remove gloves promptly and wash hands immediately, and then put on 

new gloves. 

3.	 Wear a mask, protective eyewear and gown during any patient-care activity 

when splashes or sprays of body fluids are likely. Remove the soiled gown 

as soon as possible and wash hands. 

4.	 Handle needles and other sharp instruments safely. Do not recap needles. 

Make sure contaminated equipment is not reused with another patient until 

it has been cleaned, disinfected, and sterilized properly. Dispose of 

non-reusable needles, syringes, and other sharp patient-care instruments in 

puncture-resistant containers. 

5.	 Routinely clean and disinfect frequently touched surfaces including beds, 

bed rails, patient examination tables and bedside tables. 

6.	 Clean and disinfect soiled linens and launder them safely. Avoid direct 

contact with items soiled with blood and body fluids. 

13	 Adapted from Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for Isolation

Precautions In Hospitals, January 1996. Centers for Disease Control and Prevention, Public Health Service, US 

Department of Health and Human Services, Atlanta, Georgia. 

133 
Annex 1


7.	 Place a patient whose blood or body fluids are likely to contaminate 

surfaces or other patients in an isolation room or area. 

8.	 Minimize the use of invasive procedures to avoid the potential for injury 

and accidental exposure. Use oral rather than injectable medications 

whenever possible. 

When a specific diagnosis is made, find out how the disease is transmitted. Use 

precautions according to the transmission risk. 

•	 If airborne transmission:

1.	 Place the patient in an isolation room that is not air-conditioned or 

where air is not circulated to the rest of the health facility. Make 

sure the room has a door that can be closed. 

2.	 Wear a HEPA or other biosafety mask when working with the 

patient and in the patient’s room. 

3.	 Limit movement of the patient from the room to other areas. Place a 

surgical mask on the patient who must be moved. 

•	 If droplet transmission:

1.	 Place the patient in an isolation room. 

2.	 Wear a HEPA or other biosafety mask when working with the 

patient. 

3.	 Limit movement of the patient from the room to other areas. If 

patient must be moved, place a surgical mask on the patient. 

•	 If contact transmission:

1.	 Place the patient in an isolation room and limit access. 

2.	 Wear gloves during contact with patient and with infectious body 

fluids or contaminated items. Reinforce handwashing throughout 

the health facility. 

3.	 Wear two layers of protective clothing. 

4.	 Limit movement of the patient from the isolation room to other 

areas. 

5.	 Avoid sharing equipment between patients. Designate equipment 

for each patient, if supplies allow. If sharing equipment is 

unavoidable, clean and disinfect it before use with the next patient. 

134 
ANNEX 2 Specific Features of VHFs14 

Geographical and epidemiological characteristics of VHFs 

Disease Geography Vector/Reservoir Human I

• Africa • Tick bites. Crimean Congo HF Ticks. Tick-mammal-tick • Balkans maintenance. • Squashing ticks. 

• China (Western) • Exposure to aerosols or fomites from s

animals do not show evidence of illne

• Former Soviet transported to market or when held in 

Union (Southern) 

• Nosocomial epidemics have occurred

• Middle East 

Dengue HF, Dengue All Tropic and Aedes aegypti mosquitoes. Increased world-wide distribution of the 

Shock Syndrome subtropical Regions Mosquito-human-mosquito viruses in travellers is increasing the area

(DHF/DSS) maintenance. Transmission occurs 

with the frequent geographic transport of viruses by travellers. 

• Virus is spread by close contact with a

Ebola HF and Africa Unknown. 

Marburg HF • Route of infection of the first case is u

• Infected non-human primates sometim• Aerosol transmission is suspected in so• Transmitted by aerosols from rodent to 

Lassa Fever West Africa Mice. The Mastomys genus of the 

mouse. • Direct contact with infected rodents o

• Person-to-person contact. Note: The reservoir rodent is very commcause of severe febrile illness in West Afr

14 Peters CJ, Zaki SR, Rollin PE. Viral Hemorrhagic Fevers, Chapter 10 in Atlas of Infectious Diseases, vol 8, vol ed Robert Fekety, bo

Churchill Livingstone. 1997: pp10.1-10.26. 

135

Geographical and epidemiological characteristics of VHFs 

Disease Geography Vector/Reservoir Human I

Rift Valley Fever Sub-Saharan Africa Floodwater mosquitoes. 

Maintained between mosquitoes and domestic animals, particularly sheep and cattle. 

• Mosquito bite. • Contact with blood of infected sheep, • Aerosols generated from infected dom• No person-to-person transmission obs

Yellow Fever • Africa 

• South America 

Aedes aegypti mosquitoes. 

Mosquito-monkey-mosquito maintenance. Occasional human infection occurs when unvaccinated humans enter forest. In an urban outbreak, virus maintained in infected Aedes aegypti mosquitoes and humans. 

• Mosquito bite. • In epidemics, mosquitoes amplify tran• Fully developed cases cease to be vire

transmission is not believed to be a prinfectious (including aerosols) in the la

136

137


Common clinical features of VHFs 

Disease Incubation Period Case Fatality Characteris

Crimean Congo HF 3-12 days 15% - 30% Most severe bleeding and ecchymoses (

coming from a vessel into the skin) of al

Ebola HF and Marburg HF 

2-21 days 25% - 90% • Most fatal of all HF. • Weight loss. 

• Exhaustion and loss of strength. • A maculopapular (a lesion with a bro• Post infection events have included h

Lassa Fever 5-16 days Approximately 15% • Exhaustion and loss of strength. • Shock. 

• Deafness develops during recovery in 

Rift Valley Fever 2-5 days (uncomplicated 

disease; incubation for HF may differ) 

50% of severe cases (about 1.5% of all infections) 

• Shock. • Bleeding. • Reduced or no urine production. • Jaundice. • Inflammation of the brain. • Inflammation of the blood vessels in t

Yellow Fever 3-6 days 20% • Acute febrile period followed by a br

• Toxic phase follows remission with ja
Specific clinical findings in different VHFs 

Disease haemorrhage Thrombocytopenia1 leukocyte count 2 rash icterus 3 renal disease pulmonary disease tremor4 , dysarthria5 encep

pat

Crimean Congo HF 

+++ +++ ↓↓ ranging 

to ↑ 

++ + + 

Ebola HF and Marburg HF 

+ + + + + data not 

available 

+ + + + + + + + 

Lassa Fever + ranging to 

S 

+ no change + + + + + ran

to S 

Rift Valley Fever 

+ + + + + + data not 

available 

+ + + data not 

available 

E 

Yellow Fever + + + + + no change 

ranging to ↓↓ 

+++ ++ + + + 

138


1 abnormally low number of platelets in the circulating + occasional or mild 

blood 

2 white blood cell count 

++ commonly seen and may be +++ characteristic 

3 jaundice 

S characteristic and seen in sev

4 shaking 5 difficulty speaking and pronouncing words due to 

↑ occasionally or mildly increa

problems with the muscles used for speaking ↓↓ commonly decreased 

6 disease of the brain E May develop true encephalit
139


A summary of prevention and treatment of VHFs 

Disease Prevention T

Crimean Congo HF • Tick avoidance. • Avoid contact with acutely infected animals, especially slaughtering. 

• Use VHF Isolation Precautions when a case is suspected. 

• Ribavirin is effective in red• Ribavirin should be used b

limited South African expe

Dengue HF, Dengue Shock Syndrome (DHF/DSS) 

• Mosquito control of Aedes aegypti. • Vaccines currently under investigation for probable use in travellers but unlikely to be a solution to hyperendemic dengue transmission that leads to dengue HF. 

• Supportive care. It is effec

Ebola HF and Marburg HF 

• Standard Precautions including needle sterilization in African hospitals are particularly important. • Use VHF Isolation Precautions when a case is suspected. • Avoid unprotected contact with suspected patients or infectious body fluids. • Avoid contact with monkeys and apes. 

• None other than supportiv• Antiviral therapies urgently 

Lassa Fever • Rodent control. 

• Use VHF Isolation Precautions when a case is suspected. 

• Ribavirin is effective in red• Use Ribavirin in higher ris

aminotransferase (AST) is g

Rift Valley Fever • Vaccination of domestic livestock prevents epidemics in livestock but not sporadic, endemic infections of humans. 

• Human vaccine safe and effective, but in limited supply. • Veterinarians and virology workers in sub-Saharan Africa are candidates for vaccine. 

• Supportive care. • Use Ribavirin in haemorrh

experimental animals). 

Yellow Fever • Mosquito control of Aedes aegypti would eliminate urban transmission but forest transmission remains. 

• Vaccine is probably the safest and most effective in the world. 

• Supportive care. 
Annex 2


History of Viral 

Haemorrhagic Fevers 

Seen in Your Area 

Major Signs and Symptoms Transmission Route 

140

ANNEX 3	 Planning and Setting Up the Isolation 

Area 

Checklist: Supplies for a Changing Room 

Storage Outside the Changing Room: 

1.	 Shelf or cabinet with lock 

2.	 Supply of clean scrub suits, gowns, aprons, gloves, masks, 

headcovering, and eyewear 

3.	 Covered shelf for storing disinfected boots 

4.	 Bucket for collecting non-infectious waste 

Inside the Changing Room: 

1.	 Hooks, nails, or hangers for hanging reusable gowns, scrub 

suits 

2.	 Roll of plastic tape 

3.	 Handwashing supplies: bucket or pan, clean water, soap, 

one-use towels 

4.	 Bucket or pan, 1:100 bleach solution for disinfecting 

gloved hands 

5.	 Container with soapy water for collecting discarded gloves 

6.	 Container with soapy water for collecting used instruments 

to be sterilized* 

7.	 Container with soapy water for collecting reusable gowns, 

masks, sheets to launder* 

*Place outside the changing room if the changing room is too small 

If large amounts of waste on floor: 

Sprayer, bucket or shallow pan with 1:100 bleach solution for 

disinfecting boots 

141

Annex 3


Checklist: Supplies for Patient Area


1.	 1 bed with clean mattress or sleeping mat and at least a 

bottom sheet and blanket for each bed 

2.	 Plastic sheeting to cover mattress or sleeping mat 

3.	 1 thermometer, 1 stethoscope, and 1 blood pressure cuff for 

each patient or for each patient area 

4.	 1 puncture-resistant container for collecting non-reusable 

needles, syringes, and discarded sharp instruments 

5.	 1 bedside table or shelf 

6.	 1 large wall clock with a second hand 

7.	 Pan with 1:100 bleach solution or alcohol and one-use towels 

for disinfecting the thermometer and stethoscope between 

use with each patient 

8.	 Bucket or pan, 1:100 bleach solution, one-use towels for 

disinfecting gloved hands between patients 

9.	 Supplies for disinfecting patient excreta (bedpan, urinal, 1:10 

bleach solution) 

10.	 Sprayer, 1:100 bleach solution, clear water, and mop for 

disinfecting spills on floor and walls 

11.	 Container with soapy water for collecting discarded gloves 

12.	 Screens (or sheets hung from ropes or lines) placed between 

VHF patients’ beds 

13.	 Extra supply of gowns and gloves 

14.	 Container for collecting infectious waste to be burned 

142

Planning and Setting Up the Isolation Area

Use the grid on the next page to draw the layout of an isolation area in your own 

health facility. Be sure to include: 

•	 Area for patient isolation 

•	 Changing room for health care workers to use for changing clothes 

•	 Area for cleaning and laundering VHF-contaminated supplies 

•	 Changing area for cleaning staff who handle VHF-contaminated waste but 

who do not do direct patient-care activities. 

143

Annex 3


Planning Grid: Layout for Isolation Area in Your Health Facility


144

ANNEX 4	 Adapting VHF Isolation Precautions for a 

Large Number of Patients 

The recommendations in this manual assume 1 or 2 VHF cases have occurred in a 

non-outbreak situation. When more than 1 or 2 VHF patients present in the 

health facility, additional precautions need to be taken. When Ebola 

haemorrhagic fever occurs, initially there may be as many as 10 cases. 

When a VHF is suspected, develop a case definition based on the VHF that has 

occurred. Use it to identify new cases during the outbreak. For example, the 

current case definition for suspecting Ebola haemorrhagic fever (EHF) is: 

Anyone presenting with fever and signs of bleeding such as: 

• Bleeding of the gums 

• Bleeding from the nose 

• Red eyes 

• Bleeding into the skin (purple coloured patches in the skin) 

• Bloody or dark stools 

• Vomiting blood 

• Other unexplained signs of bleeding


Whether or not there is a history of contact with a suspected case of EHF.


OR 

Anyone living or deceased with: 

• Contact with a suspected case of EHF AND 

• A history of fever, with or without signs of bleeding. 

OR


Anyone living or deceased with a history of fever AND 3 of the following symptoms:


• Headache 

• Vomiting 

• Loss of appetite 

• Diarrhoea 

• Weakness or severe fatigue 

• Abdominal pain 

• Generalized muscle or joint pain 

• Difficulty swallowing 

• Difficulty breathing 

• Hiccups 

OR 

Any unexplained death in an area with suspected cases of EHF. 

145

Annex 4


The current case definition for suspecting Lassa fever is:


Unexplained fever at least 38oC or 100.4oF for one week 

or more. 

And 1 of the following: 

—	 No response to standard treatment for most 

likely cause of fever (malaria, typhoid fever) 

—	 Readmitted within 3 weeks of inpatient care 

for an illness with fever 

And 1 of the following: 

—	 Edema or bleeding 

—	 Sore throat and retrosternal pain/vomiting 

—	 Spontaneous abortion following fever 

—	 Hearing loss following fever 

Prepare Your Health Facility 

If there are more than 2 suspected VHF patients, take steps immediately to adapt 

the VHF Isolation Precautions for a large number of patients. 

1.	 Reinforce the use of Standard Precautions — especially handwashing — 

throughout the health facility. Make sure there is a reliable supply of soap 

and clean water in areas where health facility staff have contact with 

patients suspected as having a VHF. 

2.	 Make sure adequate supplies of protective clothing are available. 

3.	 Set up a temporary area that is separate from the rest of the facility where 

febrile patients can wait to be seen by a health care worker. Also use this 

area for patients who have been seen by a health care worker and who are 

waiting to go to the isolation area. 

Make sure the temporary admission area contains a supply of protective 

clothing, buckets with disinfectants in them for collecting disposable waste, 

and disinfectants for cleaning and disinfecting spills of infectious materials. 

146

Adapting VHF Isolation Precautions for a Large Number of Patients

4.	 Identify a family liaison person from the health facility staff who can spend 

time with families to answer questions, provide information about the VHF 

and its transmission. If family members help provide care when relatives 

are in hospital, make sure they know how to use protective clothing when 

they are with the patient in the isolation area. Help families with 

arrangements for cooking, washing and sleeping. 

5.	 Designate a separate building or ward for placing patients with the same 

disease together in a single isolation area. Select and isolate a toilet or 

latrine for disposal of disinfected patient waste and other liquid waste. 

6.	 Restrict access to the building or ward set aside as the isolation area. Set 

up walkways from the temporary area to the isolation area by tying ropes 

along the walkway and hanging plastic sheets from them. 

7.	 Prepare a list of health facility staff authorized to enter the isolation area. 

Station a guard at the entry to the isolation area, and provide the guard 

with the list of authorized persons. The guard will use the list to limit 

access to the isolation area to authorized health facility staff and, if 

necessary, the caregiving family member. 

8.	 Provide the guard with a sign-in sheet for recording who goes into the 

isolation area and the time of entry and departure. 

9.	 Prepare a large quantity of disinfectant solutions each day (bleach solutions 

and detergent solutions). Store the disinfectants in large containers. Ask 

cleaning staff to change the disinfectants when they become bloody or 

cloudy or when the chlorine odour is no longer detectable. 

10.	 Obtain additional patient supplies. Make sure each patient has a bed and 

mattress or sleeping mat. Designate medical equipment for use with each 

VHF patient (for example, a thermometer, a stethoscope, and a 

blood-pressure cuff for each patient). If there are not enough items 

available to provide one per patient, be sure to clean and disinfect the 

items before use with the next patient. 

11.	 Make sure schedules are carried out as planned for collecting, transporting 

and burning infectious waste daily. Make sure that burning is supervised 

and that security of the burning site is maintained. 

12.	 Initiate community education activities. 

147

Annex 4


148

ANNEX 5 Making Protective Clothing 

Instruction on Making Headwear 

Materials needed:


Elastic 3⁄4 meter


Cotton cloth 51 cm2 (20 square inches)


A homemade head cover

46 to 50 cm 

(18 to 20 inches) 

18 cm 

(7 inches ) 

1. Cut a round piece of cotton cloth that is 

46 to 50 cm (18 to 20 inches) in diameter. 

2. Sew elastic on the edge and shape a circle 

18 cm (7 inches) in diameter. 

149

64 cm


(25 inches)


20 cm 

(7.5 inches) 

Placing the tie away 

from the edge allows 

for overlap so the 

back of the gown can 

be closed. 

Hole for threading 

the lower tie. 

108 cm


(42 inches)


long


148 to 158 cm


(58 to 62 inches)


Annex 5


Instruction on Making Gown 

Materials needed: 

1.5 meters cotton cloth to make one gown 

150

46 cm (18-inch) loop


or 2 long ties


25 - 30 cm 


(10 to 12 inches)


41 cm 

(16 inches) 

66 to 71 cm


(26 to 28 inches ) wide


100 cm 

(40 inches ) long 

66 to 71 cm


(26 to 28 inches) wide


Placing the tie away 

from the edge allows 

for overlap so the 

back of the gown can 

be closed. 

Fold cloth to make 

ties or use sewing 

tape; about 91 cm 

(36 inches) long 

Making Protective Clothing

Instruction on Making Aprons 

Materials needed (to make 2 aprons):


11⁄4 meters plastic sheeting or plastic cloth used for covering tables


91 cm (36 inches) sewing tape


151

Annex 5


Instruction on Making a Cotton Mask 

1 meter cotton cloth to make at least 2 masks 

50 cm in second colour to make the inside of the masks 

1. Cut 4 pieces of 

cotton cloth to the 

size shown. 

2. Cut 1 piece from a 

different colour. 

Use it as the inside 

of the mask. 

3. Sew the 5 pieces 

together and gather 

or pleat the vertical 

sides to 13 cm (5 

inches) long. Sew 

all pieces in place. 

4. Sew on ties. 

28 to 30 cm 

(11 to 12 inches) 

20 cm 

(8 inches) 

13 cm 

(5 inches) 

152

ANNEX 6 Requirements for Purchasing Protective 

Clothing 

Specifications for Items of Protective Clothing: 

This list describes the generic requirements for ordering or purchasing protective 

clothing from commercial vendors. Record the amounts needed on this list of 

specifications. The list can be photocopied and provided to donors to make sure 

that vendor specifications match the recommended specifications. Determine the 

quantities needed from the recommendations on the chart in Section 9. 

Gowns 

Requirements Made from cotton cloth, cotton blend, or disposable fabric. The requirements 

are the same for both disposable and reusable gowns. 

Gowns should have the following requirements: 

— Open at the back with ties at the neck, waist and middle of the back. 

— Ribbed or elasticized cuffs. 

— Be long enough to reach the knees. 

— If only large size is available, larger size can be cut and altered to fit 

smaller people. 

If elasticized or ribbed cuffs are not available, attach thumb hooks to the end 

of the gown's sleeves. The thumb hooks can then be covered with the long 

wrist-sleeve of the gloves. 

Quantity 

needed 

Number of disposable gowns _______ Number of reusable gowns _______ 

Apron 

Requirements Aprons are worn if there is risk of direct exposure to body fluids. The aprons 

are worn by physicians, nurses, corpse carriers, and cleaners. The 

requirements for the apron are the same for disposable or reusable models. 

Aprons should have the following requirements: 

— Rubber or plastic apron with hooks or ties around the neck and with ties at 

the back. 

— Made from disposable plastic or heavy plastic which can be disinfected for 

reuse. 

— Able to fit over gown. 

Quantity 

needed 

Number of disposable aprons _______ Number of reusable aprons _______ 

153

Annex 6


Caps 

Requirements To prevent contamination of hair and head from patient's vomit or blood: 

— Use disposable caps. 

— If disposable caps are not available, use cotton caps that can be 

laundered and reused. 

Quantity 

needed 

Number of disposable caps ______ Number of cotton caps ______ 

Masks 

Requirements Worn to protect mouth and nose from splashes or droplets of patient's body 

fluids. 

Masks should offer appropriate protection. 

1. 3M HEPA or N Series Mask: 

— Has preferable exhalation valve 

— Lightweight 

— Easy to use 

2. Biosafety mask that limits 0.3-μm particles 

3. Dust-mist masks 

4. Surgical masks only protect from droplets splashed in the face. They 

are not HEPA rated. 

Quantity 

needed HEPA mask _______ Biosafety mask _______ Dust-mist mask _______ 

Thin gloves 

Requirements Thin gloves to permit fine motor function. They can be surgical glove quality 

but do not need to be sterile. 

— Must reach well above the wrist, preferably 10 to 15 cm (4" to 6") long, 

measuring from the wrist up along the arm. 

— Should be tested for pinholes. 

— May be powdered or non-powdered. 

Quantity 

needed 

Number of pairs _______ 

154

Requirements for Purchasing Protective Clothing

Thick gloves 

Requirements Thick gloves for handling bodies, disinfection, and disposal of infectious 

waste. 

— Should be made from neoprene or other thick rubber material. 

— Must reach well above the wrist, preferably about 30 cm (12”), measuring 

from wrist up along the arm. 

Quantity 

needed 

Number of pairs _______ 

Boots or overboots 

Requirements The requirements are the same for both latex overboots which can stretch over 

street shoes, and regular rubber boots 

— Should be 30 cm (12") high and have textured soles. 

— Provide several sizes to meet size requirements of anyone who might use 

them (for example, obtain pairs of boots in sizes medium, and large). 

Overboots are preferable to regular boots. They take up less space, fewer 

sizes are needed, and they are less expensive. 

Quantity 

needed 

Total number of pairs of overboots _______ (medium _____ large _____) 

Total number of pairs of rubber boots ______ (medium _____ large _____) 

Protective eyewear 

Requirements 1. Use non-fogging goggles that are vented at the sides. 

2. If non-fogging goggles are not available, purchase clear spectacles locally. 

— Should have ties extending from ear holders that can be tied around the 

back of the head so glasses will not fall off when health care worker leans 

over patient. 

Quantity 

needed 

Number of pairs of non-fogging goggles _______ 

Number of pairs of clear spectacles _______ 

155

Annex 6


Other recommended equipment Quantity 

needed 

Sprayers: backpack style with hose to use for cleaning and disinfecting spills, 

rinsing boots, and other decontamination procedures. 

Plastic sheets for mattresses and barriers: can be purchased locally. 

Waterproof mattresses 

Front lamps: to fit over the physician's head to provide light when physician is 

examining patients. 

Kerosene lamps 

Body bags 

156

ANNEX 7	 Disinfecting Water for Drinking, Cooking and 

Cleaning 

The Standard Precautions and VHF Isolation Precautions described in this manual 

recommend using a source of clean water. In an emergency situation, health 

facility staff may not have access to clean running water. For example, if the 

power supply is cut off, water cannot be pumped to the health facility. Other 

sources of water could be contaminated. 

This Annex describes how to use household bleach to disinfect water when clean 

running water is not available in the health facility. 

Adding a small amount of full strength household bleach to water will disinfect it 

enough so that it can be safely used for drinking, cooking, and cleaning.15 

1.	 Locate several containers for storing the disinfected water. They should 

have: 

•	 A narrow mouth (to prevent hands being put


into the water)


•	 A screw top or attached lid 

•	 A spigot, if possible. 

Examples include jerry cans, large plastic jugs, or


buckets with spigots and lids that can be firmly


closed.


An example of a water

container

2.	 Make available: 

•	 At least 1 litre of full strength household bleach. Use the 

instructions on the package to prepare a full-strength concentration. 

•	 Pieces of bar soap or powdered soap. 

3.	 Clean and disinfect the containers. To disinfect the containers, wash them 

with soap and water, or rinse them with 1:100 bleach solution. 

4.	 Collect water from the available source (for example, a river, stream, or 

well used by the village). 

15 World Health Organisation: Cholera and other diarrhoeal diseases control -- technical cards on 

environmental sanitation. Document WHO/EMC/DIS/97.6. Geneva: 1997. 

157

Annex 7


5. Place the water into the disinfected containers, and add 3 drops of full 

strength household bleach per litre of water. 

Preparing drinking water

6.	 Mix the water and bleach drops together. 

Let the water stand for 30 minutes. This water is now safe to drink and to 

use for preparing meals. Clearly label the containers so that the health 

facility staff will know that the water is for drinking and is available for use. 

Use a marking pen to write DRINKING WATER on the container, or put a sign 

on it that says DRINKING WATER. 

7.	 Provide clean water for the: 

—	 Handwashing stations in


areas where health workers


are likely to have contact


with patients who have fever


or with infectious body


fluids.


—	 Disinfection station where


reusable needles and


syringes are cleaned and


disinfected.


Using stored clean water for handwashing

158

Disinfecting Water for Drinking, Cooking and Cleaning

8.	 Assign the job of collecting and disinfecting water to a specific health 

facility staff person. Give the health staff person information about how to 

do the task and why it is important. Make a schedule for collecting and 

disinfecting water routinely. 

To disinfect a large quantity of water: 

1.	 Determine how many litres the container holds. 

Example: 25 litres 

2.	 Calculate the amount of bleach that is needed to disinfect the specified 

quantity of water. 

Example:	 Use 3 drops of bleach per litre of clear water.


3 drops x 25 litres = 75 drops.


3.	 Find a spoon, cup or bleach bottle cap that can be used to measure the 

required amount of bleach. Count the number of drops that the measuring 

spoon, cup or bottle cap will hold. 

Example:	 75 drops of bleach = 1 teaspoon 

4.	 Use the measuring spoon or cup to measure the amount of bleach each 

time the large quantity of water is disinfected. 

159

Annex 7


160

ANNEX 8	 Preparing Disinfectant Solutions by Using 

Other Chlorine Products 

The disinfectants recommended in this manual are made with household bleach. 

This table describes how to make 1:10 and 1:100 chlorine solutions from other 

chlorine products. 

Preparation and Use of Chlorine Disinfectants 

Use a chlorine product 

to make : 

1:10 solution 

For disinfecting: 

• Excreta 

• Cadavers 

• Spills 

1:100 solution 

For disinfecting: 

• Gloved hands 

• Bare hands and skin 

• Floors 

• Clothing 

• Equipment 

• Bedding 

Household bleach 

5% active chlorine 

1 litre bleach per 10 litres 

of water 

100 ml per 10 litres of 

water or 

1 litre 1:10 bleach 

solution per 9 litres of 

water 

Calcium hypochlorite 

powder or granules 70% 

(HTH) 

7 grams or 1⁄2 tablespoon 

per 1 litre of water 

7 grams or 1⁄2 

tablespoon per 10 

litres of water 

Household bleach 

30% active chlorine 

16 grams or 1 tablespoon 

per 1 litre of water 

16 grams or 1 

tablespoon per 10 

litres of water 

161

Annex 8


162

ANNEX 9	 Making Supplies: Sharps Container, 

Incinerator, and Boot Remover 

Making a Sharps Container:

If a puncture-resistant container is not available for collecting used disposable 

needles, syringes and other sharp instruments that have penetrated the patient’s 

skin, make a container using these instructions. 

Materials: 

•	 Plastic bottle or container made from burnable material (empty 

plastic water bottles, for example) 

•	 Cardboard box to serve as a stand for holding the plastic bottle 

•	 Plastic tape. 

1.	 Gather several plastic bottles and boxes made from cardboard or other 

sturdy, burnable material. 

2.	 Tape the sides and lid of the cardboard box together so the top side is 

closed. 

3.	 Draw a circle on the top of the box that is the same diameter as the plastic 

bottle. 

4.	 Cut out the circle and leave a hole in 

the top of the box. 

5.	 Place the bottle inside the hole. Fill 

the bottle 1/3 full with 1:10 bleach 

solution. 

6.	 Place the bottle with its stand in the 

patient’s room or where disposable 

skin-piercing equipment is used. 

7.	 At the end of the day, when disposable 

waste is collected, carry the bottle and 

its stand to the site for burning 

infectious waste. Place the bottle and 

box in the pit for burning. 

163 

An adapted sharps container
Annex 9


Making an incinerator: See Annex 10. 

Making a boot remover:

33 cm 

(13 inches) 19 cm 

(8 inches) 

52 cm 

(21 inches) 

Please bring this picture to the local carpenter.


164

ANNEX 10	 Sample Job-Aids and Posters for Use in 

the Health Facility 

This section includes a series of sample posters that can be photocopied or 

hand-copied for use in health facilities. The sample posters and job-aids are 

pictorial explanations of how to do the steps described in various sections of this 

manual. For example, posters will remind health workers about: 

• Using VHF Isolation Precautions 

• How to put on and take off protective clothing 

• How to build an incinerator. 

165

Viral Haemorrhagic Fevers Isolation Precautions

Wash handsas needed

Isolatethepatient

Wearprotectiveclothing

Disposeof needles and syringes safely

Disposeof waste safely

Usesafe burial practices
Steps for Putting On Protective Clothing 

1	 Wear scrub suit 

as the first layer 

of protective 

clothing. 

2	 Put on rubber 

boots. 

3	 Put on the 

first pair of 

gloves. 

4	 Put on the 

outer gown. 

5	 Put on the plastic 

apron. 

6	 Put on the second 

pair of gloves. 

Place the edge of 

gloves over the cuff 

of the gown. 

7	 Put on the 

mask. 

8	 Put on a 

head 

cover. 

9	 Put on the 

protective 

eyewear. 
Steps for Taking Off Protective Clothing


1 Disinfect the outer 

pair of gloves. 7 Remove the 

eyewear. 

2	 Disinfect the apron 

and the boots. 

3	 Remove the outer 

pair of gloves. 

4	 Remove the apron. 

5	 Remove the outer 

gown. 

8	 Remove the head 

cover. 

9	 Remove the mask. 

10	 Remove the 

boots. 

11	 Remove the 

inner pair of 

gloves. 

6 Disinfect the 

gloved hands. 12 Wash hands with 

soap and clean 

water. 
Steps for Building an Incinerator


1	 Find a 220-litre 

(55-gallon) 

drum. 

2	 Cut open the 

drum. Remove 

and save the top 

cutaway piece. 

3	 Hammer the edges of the drum so they 

are not sharp. 

4	 Cut 3 half-moon 

openings just 

above the top end 

of the drum. 

5	 Turn the drum 

upside down. 

The bottom of 

the drum now is 

the top. 

6	 Cut 4 holes on 

the sides of the 

drum. Thread 2 

metal rods 

through these 

holes so that they 

cross inside the 

drum. 

7	 Punch holes in the 

top cutaway piece 

to make a platform. 

8	 Pierce a series of 

holes on the side 

of the drum and 

above the crossed 

rods to improve 

the draw of the 

fire. 

9	 Cut away half of 

the top. Attach the 

wire loops to the 

cutaway half to 

make a trap door. 

Attach another 

loop for a handle 

to open the trap 

door. 

10	 Place the platform 

inside the drum 

on top of the 

rods. 
Annex 10


170

ANNEX 11 Laboratory Testing for VHFs 

Always wear protective clothing when handling specimens from suspected VHF 

cases. Label all tubes carefully with name, date of collection and hospital 

number. Provide a patient summary or fill out a clinical signs and symptoms form 

(Annex 12). Contact your district officer for special instructions about collecting 

and shipping specimens. 

Diagnostic

Test Samplesrequired Preparation &Storage Shipping Viruses to be confirmed 

ELISA (Serology) Whole blood* Freeze or Frozen on dry ice Ebola 

Detects: 

—Viral antigen 

Serum or plasma refrigerate 

(as cold as 

possible) 

or ice packs or 

both**** Lassa 

CCHF 

—IgM and IgG Acute and Rift Valley 

antibody convalescent** Marburg 

Yellow fever 

PCR Whole blood or Refrigerate or Frozen on dry ice Ebola 

Detects: clot*** freeze or ice packs or 

both**** Lassa 

DNA, RNA CCHF 

(genetic material) 

from virus 

Tissues 

(fresh frozen) 

Freeze Rift Valley 

Marburg 

Serum/plasma Yellow fever 

Immunohisto- Liver biopsy from Fix in formalin Room Ebola 

chemistry fatal cases (can be stored up temperature Lassa 

(liver) to 6 weeks) (Do not freeze) CCHF 

Detects: Rift Valley 

Viral antigen in 

cells Marburg 

Yellow fever 

Immunohisto- Skin biopsy from Fix in formalin Room Ebola 

chemistry fatal cases (can be stored up temperature Lassa 

(skin) to 6 weeks) (Do not freeze) 

Detects: (any site) 

Viral antigen in 

cells 

Immunohisto- Tissue biopsy Fix in formalin Room Possible

chemistry 

(other tissues) 

from fatal cases (can be stored up 

to 6 weeks) 

temperature 

(Do not freeze) 

detection of 

Ebola, Lassa, 

CCHF, Rift 

Detects: (other tissues, Valley, Marburg, 

Viral antigen in 

cells 

spleen, lung, 

heart, kidney) 

Yellow Fever 

171

Annex 11


*	 Whole blood can be used for enzyme-linked immunosorbent assay (ELISA) 

and may be frozen. Do not centrifuge suspected VHF specimens because 

this increases risk to the lab worker. If serum specimens have already been 

prepared these can be used. Place specimens in plastic tubes for shipping 

and storage and be sure that the tubes are sealed and properly labelled. 

**	 Collect acute-phase specimen when patient is admitted to hospital or 

diagnosed as suspected case and collect convalescent-phase specimen at 

death or when discharged from the hospital. 

***	 Whole blood or tissue is preferred, although serum or plasma may provide 

results. 

****	 Use both ice packs and dry ice to provide best results. If dry ice or ice 

packs are not available, sample may be shipped at room temperature and 

still provide valid results in most cases. 

172

ANNEX 12	 Skin Biopsy on Fatal Cases for Diagnosis of 

Ebola 

Ebola virus can be detected in fatal cases from a skin specimen using an 

immunohistochemistry test developed by the Centers for Disease Control and 

Prevention (CDC) Infectious Diseases Pathology Activity. The skin specimen is 

fixed in formalin which kills the virus. The specimen is no longer infectious once 

it is placed in formalin and the outside of the vial has been decontaminated. This 

vial can be shipped by mail or hand carried to the lab without risk. Results are 

available within a week after the specimen arrives at the CDC. 

CDC provides Skin Biopsy Kits for the collection of skin samples in formalin. If 

these are available in your area, follow the simple instructions that are provided in 

the kit. An example of the instructions is on the following pages. 

If a kit is not available, the biopsy can still be collected and sent for diagnosis to: 

Dr. Sherif Zaki 

Centers for Disease Control and Prevention 

Infectious Diseases Pathology G-32 

1600 Clifton Road, NE 

Atlanta, GA 30329-4018 

173

Annex 12


174

 

 

 

Check the list of equipment and make sure everything is in place before beginning. 

Kit Equipment List: Other items needed: 

1. Instruction sheet 1. 1 or 2 buckets for disinfectant 

2. Selection criteria and surveillance forms and handwashing 

3. (1) box powdered bleach 2. Gowns or plastic aprons 

4. (2) pairs latex gloves 3. 10 litres water 

5. (1) pair heavy-duty gloves 4. VHF Infection Control Manual 

6. (2) masks 

7. (1) face shield 

8. (1) tweezers and scissors set 

9. (1) vial with formalin 

10. (1) vial with chaotrope 

11. (1) piece hand soap 

12. (2) pieces of parafilm 

13. (1) mailing tube 

14. (1) set mailing labels 

Shipping Instructions: 

Be sure to fill out the forms with the name of the patient on each page. Number the vial and put 

the number on the form. This is very important, especially if you have more than one specimen to 

send. Use a pencil to write on the lid of the vial. 

The formalin- and chaotrope-fixed specimens are not infectious. The vial can be sent by 

normal mail or carried on a plane without risk to the carrier. 

Put the forms and the vial containing the specimen into the mailing tube. Close the lid tightly and 

seal with tape if available. Put the label on the tube and send it to CDC by the post office. It can 

be mailed in your country or if someone carries it to the United States, it can be placed in any 

U.S. mailbox. 

Please remember to put stamps on the mailing tube. 
Surveillance for Viral Hemorrhagic Fever 

INSTRUCTION FOR USING THE SKIN BIOPSY KIT 

IMPORTANT: The instruments used in the biopsy are for one use only, must not be reused, and 

should be disinfected and incinerated after the biopsy. Reusing could result in contamination of 

subsequent samples. 

See the “Infection Control for Viral Haemorrhagic Fevers” manual for detailed information on how 

to properly put on and take off protective clothing and how to make an incinerator. 

1. Fill out the patient forms with 

the patient’s information. 

Include your address for sending 

the results. Check the 

equipment and make sure you 

have everything you need. 

8. Place the remaining sample in 

the formalin. See example sample 

size. Close the cap tightly to 

prevent leaks. 

2. Prepare the disinfectant 

solution. Mix the contents of the 

box of bleach in 10 liters of water. 

9. Dip the vials in the disinfectant 

for 1 minute. Set them aside to dry. 

3. Put on the protective clothing. Begin 

with the gown, next the latex gloves, 

then the kitchen gloves, then the mask, 

and finally the face shield or eye 

protection. Use a plastic apron if one is 

available. See the “Infection Control for 

Viral Haemorrhagic Fevers” manual for 

detailed information on protective 

clothing. 

10. Place the rest of the 

equipment in the bucket and leave 

it for 30 minutes. If you need to 

move the cadaver, do so while you 

have the protective clothing on. 

When you are finished, rinse your 

exterior gloves in the disinfectant, 

remove them, and drop them in the 

bucket. 

4. Take the equipment to the work 

site. Label vials with patient name 

and date. Open the vials of 

formalin and chaotrope.* Open the 

instruments: the scissors and the 

tweezers. Arrange them for use 

near the body. 

11. Wearing the interior gloves, pour 

excess bleach solution out at the base 

of the incinerator (without pouring out 

equipment). Empty equipment from 

bucket by dumping directly into the 

incinerator. Remove interior gloves 

and place them in the incinerator. 

Using caution, light the incinerator. 

5. Gently turn the head of 

the cadaver to expose the 

side of the neck. 

12. Wash your hands with soap 

and water. The specimen is not 

infectious after it is placed in 

formalin and chaotrope, and the 

outside of the vial is disinfected. 

6. With the tweezers and 

scissors, cut a piece of skin 

approximately 1.5 cm in size 

from the neck and remove. 

13. Stretch a piece of parafilm 

around the closure of each vial to 

provide an extra seal. This will 

help prevent leakage during transit. 

Be sure that both vials are properly 

labeled. 

7. From the piece of skin, cut a smaller sample 

(about the size of a rice grain) and place it in the 

chaotrope. See example sample size. Close the 

cap tightly to prevent leaks. 

14. Place the vials and the 

patient forms in the mailing 

tube and send to CDC 

Atlanta. Do not freeze the 

sample. 

* Chaotrope is a skin irritant and may be harmful if swallowed or splashed in the eye. Use caution when handling open containers of chaotrope. 

In case of contact on skin, wash with soap and water. In case of contact in eyes, flush with water or saline. Get medical attention immediately. 

For safety data about formalin, see label on container. 
Hemorrhagic Fever Surveillance Form 

Vial Number: 

Name and location of Health Center: 

Name of physician or nurse:

Contact address (Important: to receive results, give a very specific contact address):

Telephone/Fax number: 

Patient data 

Name: 

Age: 

Sex: Male Female 

Address: 

Hospital Number: 

Profession or occupation: 

Date of first symptoms: 

Date of death: 

Date of admittance: 

Date of biopsy: 

If patient was not hospitalized, who cared for the patient? 

Are any other family members ill? If yes, relationship: 

Symptoms of family member: 

If the patient was hospitalized, use the table attached to mark the 

symptoms you observed and any other important observations. 
Clinical Signs and Symptoms Form 

Name of Patient: 

Symptoms (Check each one 

present) 

Date of appearance: 

Fever 

Diarrhea 

Extreme weakness after 

rehydration 

Nausea 

Vomiting 

Sore Throat 

Headache 

Loss of appetite 

Muscle pain 

Joint pain 

Hiccups 

Cough 

Conjunctivitis 

Chest pain 

Rapid respiration 

Recent loss of hearing 

Burning sensations of the skin 

Bleeding, specify below: Date of appearance: 

Black or bloody vomit 

Black or bloody stool 

Mouth 

Nose 

Urine 

Skin or puncture site 

Other bleeding: (specify) 

Other Observations:(specify) 
Selection criteria for testing of suspected 

viral hemorrhagic fever (VHF) 

Patient’s last name, first name: 

When to obtain a skin biopsy sample for testing: 

The patient had the following symptoms within 2 weeks preceding death: 

Fever and 

Diarrhea and 

One of the following signs: 

Headache 

Intense weakness after rehydration 

Muscle pains 

Joint pains 

Back pains 

Treatment was given with antibiotics and 

antimalarials for a minimum of 3 days. 

The patient failed to respond to treatment with no definitive diagnosis and died 

with at least 3 of the following: 

Sore throat or difficulty in swallowing 

Red eyes 

Skin eruptions 

Hiccups 

Burning sensation of the skin 

Bleeding: nose, mouth, urine, stools (black or bloody), or vomit (black 

or bloody) 

Rapid respiration 

Patient reports another similar death in the family within last 10 days* 

* Measures should be taken to put the family and contacts under surveillance. 

Obtain a skin biopsy sample , following the instructions given in this document.

The biopsy sample is not infectious once in formalin or chaotrope.

Send it to CDC for testing at the following address: 

Special Pathogens Branch, CDC 

1600 Clifton Rd., MS G-14 

Atlanta, GA 30333, USA 

Telephone: (404) 639-1115 

TELEX 549571CDCATL 
ANNEX 13 Community Education Materials 

Examples of posters used to provide information to family members of Ebola 

patients. Kikwit, 1995. 

Avoid contact with the patient’s 

blood, urine, and vomit. 

Do not touch or wash the 

bodies of deceased patients. 

Burn needles and syringes 

immediately after use. 

Use gloves to handle the 

patient’s clothing. Boil soiled 

clothing before washing it. 

181

Examples of posters or


teaching aids for viral


haemorrhagic fevers


Protect yourself. 

Never touch urine, blood, vomit from a patient 

with fever. 

Wash spills with bleach solution or soap and water. 

To prevent transmission of Lassa fever, wear 

a gown, gloves and mask. 

Wash your hands if you take care of a 

patient with fever. 
You can get Lassa fever by touching 

the blood, urine, or vomitus of 

another person with Lassa fever. 

In addition to fever, Lassa fever patient may 

have: sore throat, back pain, cough, 

headache, red eyes, vomiting, or chest pain. 

To prevent Lassa fever, keep your 

food and water covered. 
You can get Lassa fever by touching, playing 

with, or cutting up a rat’s dead body. 

There is no injection or vaccine to prevent 

Lassa fever. To prevent Lassa fever, we must 

prevent its spread by rats. 
ANNEX 14	 Conducting In-Service Training for VHF 

Isolation Precautions 

In-service training for VHF Isolation Precautions should be ongoing. Provide 

training about VHF Isolation Precautions during supervisory visits, staff meetings 

or conferences. Also use other channels such as newsletters, bulletins and 

job-aids to provide health facility staff with information and reinforce the use of 

VHF Isolation Precautions. 

Training in skills is most effective if health staff receive information, see examples, 

and have an opportunity to practice the skills they are learning. Make sure that 

training sessions for each topic include relevant examples and opportunities for 

meaningful practice. 

Conduct training sessions in small groups with each category of health worker. 

•	 Present information with charts, pictures, posters or information written on 

a flipchart or chalkboard. Use drawings from this manual to illustrate the 

topic you are presenting. 

•	 Give examples of the skills you would like the health staff to use. For 

example, demonstrate the steps for handwashing as you explain aloud 

what you are doing. 

•	 Provide the materials and supplies that health staff need to practice the 

skill. For example, provide two buckets of clean water, soap and clean, 

one-use towels. Ask health workers one at a time to practice washing their 

hands. Ask for feedback from the rest of the group about what was done 

well and where improvement is needed. 

•	 Provide feedback to the health staff and answer questions. Conclude the 

training by summarizing the steps presented in the session. Provide a 

job-aid or handout to tape on a wall to remind health facility staff about the 

skills they learned in the session. 

•	 Routinely monitor supplies and equipment to make sure that the supplies 

for doing the desired skill are available. During supervisory visits, be sure 

to acknowledge when you see health staff using the skills well. When 

problems occur, find out what has caused them, and take steps to solve 

them so that health staff can continue to use the practices consistently. 

The following is a sample agenda for in-service training. It describes how to 

include topics about VHF Isolation Precautions during monthly staff meetings. 

Adapt it to the schedule for your health facility. 

185 
Annex 14


Month VHF Isolation Precautions Topic 

January 1. 

2. 

3. 

4. 

Disease Transmission in the Health Care Setting 

Identifying Viral Haemorrhagic Fevers: When to Suspect a VHF 

General Information about Standard Precautions 

Handwashing 

February 1. 

2. 

Recommended Protective Clothing for VHF 

Practice Putting On and Taking Off Protective Clothing 

March 1. 

2. 

Preparing Disinfectants 

Using Disinfectants 

April 1. 

2. 

Selecting Disposal Sites and Planning Security Barriers 

Building an Incinerator 

May 1. 

2. 

Maintaining an Incinerator 

Preparing a Pit for Burning Infectious Waste 

June 1. 

2. 

Safe Use and Disposal of Sharp Instruments 

Making a Sharps Container 

July 1. 

2. 

Assessing Inventory of Protective Clothing 

Identifying Items to Use When Recommended Protective Clothing is not 

Available 

August 1. 

2. 

Sites for Isolation Area (Patient Room and Changing Room); Security Barriers 

Planning to Set Up an Isolation Area 

September 1. 

2. 

Assessing Available Supplies for Isolation Area 

Identifying Items to Use When Recommended Supplies are not Available 

October 1. Selecting and Training Caregiving Family Members: VHF, Protective Clothing 

November 1. 

2. 

3. 

Using VHF Isolation Precautions during Patient Care 

Disinfecting Thermometers, Stethoscopes and Blood Pressure Cuffs 

Disinfecting Used Needles and Syringes 

December 1. 

2. 

Procedures for Responding to Accidental Exposures 

Standard Precautions -- Especially Handwashing after Examining Patients with 

Fever 

186

ANNEX 15 Local Resources for Community 

Mobilization and Education 

Section 8 of this manual describes how to develop community education in an 

urgent situation. The first step is to identify key community resources such as 

groups who know the community and already have access to it. Information 

about each key community resource can be recorded on the following chart. Use 

the chart as a reference to identify appropriate community resources that can be 

called upon when a VHF occurs. 

187

Annex 15


Local Resources for Community Mobilization and Education


Organization 

or Group Expertise 

Representative or 

Leader and 

Locating 

Information 

Human 

Resources 

Available 

Equipment Contacted? Task Assigned 

188

ANNEX 16 International and Regional Contacts


SWITZERLAND World Health Organization (WHO) 

Division of Emerging and other Communicable Diseases Surveillance 

and Control (EMC) 

Dr David L. Heymann 

20 Avenue Appia, CH-1211 Genève 27, Switzerland 

Tel: 41-22-791-2660/41-22-791-2661 

Fax: 41-22-791-4198 

E-mail: HEYMANND@WHO.CH 

ZIMBABWE WHO Regional Office for Africa 

Dr D. Barakamfitiye 

Director, Prevention and Control of Diseases 

Medical School, C Ward, Parirenyatwa Hospital, Mazoe Street 

P.O.Box BE 773, Belvedere, Harare, Zimbabwe 

Tel: 1-407-733-9236 

Fax: 1-407-733-9360 

E-mail: BARAKAMFITIYED@HTSD.COM at INET 

Dr A. Ndikuyeze, Regional Adviser, Prevention and Control of Diseases 

Medical School, C Ward, Parirenyatwa Hospital, Mazoe Street 

P.O.Box BE 773, Belvedere, Harare, Zimbabwe 

Tel: 1-407-733-9240 

Fax: 263-479-1214 

E-mail: NDIKUYEZEA@SERVER.WHOAFR.ORG 

WHO Collaborating Centres for Viral Haemorrhagic Fevers 

UNITED STATES OF 

AMERICA 

Centers for Disease Control and Prevention (CDC) 

National Center for Infectious Diseases 

Division of Viral and Rickettsial Diseases 

Special Pathogens Branch 

1600 Clifton Road, MS G-14 

Atlanta, Georgia 30329-4018, USA 

Telephone: 1-404-639-1115 

Fax: 1-404-639-1118 

E-Mail: CJP0@CDC.GOV 

189

Annex 16


UNITED STATES OF 

AMERICA 

US Army Medical Research Institute of Infectious Diseases 

(USAMRIID) 

Fort Detrick, Maryland 21702-5011, USA 

Telephone: 1-301-619-4608 

Fax: 1-301-619-4625 

CENTRAL AFRICAN 

REPUBLIC 

Institut Pasteur de Bangui 

Boite Postale 923 

Bangui, Central African Republic 

Telephone: 236-614-576 

Fax: 236-610-109 

FINLAND University of Helsinki 

Haartman Institute 

Department of Virology 

P.O.Box 21 

SF-Helsinki, Finland 

Telephone: 358-0-434-6490 

Fax: 358-0-434-6491 

FRANCE Institut Pasteur à Paris 

28, rue du Dr Roux 

75724 Paris Cedex 15, France 

Telephone: 33-1-4061-3088 

Fax: 33-1-4061-3151 

GERMANY Philipps-University 

Institute of Virology 

Robert-Koch-Str. 17 

D-35037 Marburg, Germany 

Telephone: 49-6421-28-6253 

Fax: 49-6421-28-8962 

KENYA Kenya Medical Research Institute 

Mbagathi Road 

P.O.Box 54628 

Nairobi, Kenya 

Telephone: 254-2-722-541 

Fax: 254-2-725-950 

190

International and Regional Contacts

NIGERIA University of Ibadan 

College of Medicine 

Department of Virology 

Ibadan, Nigeria 

SOUTH AFRICA National Institute for Virology 

Special Pathogens Unit 

Private Bag X4 

Sandringham 2131, Zaloska 4 

Republic of South Africa 

Telephone: 27-11-882-9910 

Fax: 27-11-882-0596 

SWEDEN Swedish Institute for Infectious Disease Control 

S-105 21 Stockholm, Sweden 

Telephone: 46-8-735-1300 

Fax: 46-8-735-6615 

UNITED KINGDOM Centre for Applied Microbiology and Research 

Division of Pathology 

Porton Down, Salisbury, United Kingdom 

Telephone: 44-198-061-2224 

Fax: 44-198-061-2731 

191

Annex 16


192

193 

References 

Viral haemorrhagic fevers 

Baron RC, McCormick JB, and OA Zubier. Ebola virus disease in southern Sudan: 

hospital dissemination and spread. Bull WHO: 61: 997-1003, 1983 

Centers for Disease Control and Prevention. Update: Outbreak of Ebola viral 

hemorrhagic fever, Zaire, 1995. MMWR: 44: 468-469, 475, 1995 

Feldmann H, Klenk HD, and A Sanchez. Molecular biology and evolution of 

filoviruses. Archives of Virology: 7suppl: 81-100, 1993 

Gear JH. Clinical aspects of African viral hemorrhagic fevers. Reviews of

Infectious Diseases: 11suppl: s777-s782, 1989 

Gear JS, Cassel GA, Gear AJ, Trappler B, Clausen L, Myers AM, Kew MC, 

Bothwell TH, Sher R, Miller GB, Schneider J, Koornhoh HJ, Gomperts ED, 

Isaacson M, and JH Gear. Outbreak of Marburg virus disease in Johannesburg. 

British Medical Journal: 4: 489-493, 1975 

Johnson KM. African hemorrhagic fevers caused by Marburg and Ebola viruses. 

In: Evans AS, ed. Viral Infections of Humans, Epidemiology and Control. New 

York: Plenum Medical Book Company. pp. 95-103, 1989 

Khan AS, et al. The reemergence of Ebola hemorrhagic fever. Journal of

Infectious Diseases: 1998, in press. 

Peters CJ, Sanchez A, Feldmann H, Rollin PE, Nichol S, and TG Ksiazek. 

Filoviruses as emerging pathogens. Seminars in Virology: 5: 147-154, 1994 

Peters CJ, Johnson ED, Jahrling PB, Ksiazek TG, Rollin PE, White J, Hall W, Trotter 

R, and N Jaxx. Filoviruses. In: Morse SS, ed. Emerging Viruses. New York: 

Oxford University Press. pp. 159-175, 1991 

Peters CJ, Zaki SR, and PE Rollin. Viral hemorrhagic fevers. In: Fekety R, vol. ed. 

Mandell GL, book ed. Atlas of Infectious Diseases, vol 8. Philadelphia: Churchill 

Livingstone. 10.1-10.26, 1997 

World Health Organization. Ebola haemorrhagic fever in Sudan, 1976. Report of 

a WHO/International Study Team. Bull WHO: 56: 247-270, 1978 

World Health Organization. Ebola haemorrhagic fever in Zaire, 1976. Report of 

an International Commission. Bull WHO: 56: 271-293, 1978 
Sanchez A, Ksiazek TG, Rollin PE, Peters CJ, Nichol ST, Khan AS, and BWJ Mahy. 

Reemergence of Ebola virus in Africa. Emerging Infectious Diseases: 1: 96-97, 

1995 

Sureau PH. Firsthand clinical observations of hemorrhagic manifestations in Ebola 

hemorrhagic fever in Zaire. Reviews of Infectious Diseases: 11suppl: s790-s793, 

1989 

Patient Management 

Centers for Disease Control. Management of patients with suspected viral 

hemorrhagic fever. MMWR: 37(suppl 3): 1-16, 1988 

Garner JS, Hospital Infection Control Practices Advisory Committee. Guidelines 

for Isolation Precautions in Hospitals. Hospital Infections Program, Centers for 

Disease Control and Prevention. January 1996 

Peters CJ, Johnson ED, and KT McKee Jr. Filoviruses and management of patients 

with viral hemorrhagic fevers. In: Belshe RB, ed. Textbook of Human Virology. 

St. Louis: Mosby-Year Book. pp. 699-712, 1991 

Paverd, Norma. Crimean-Congo haemorrhagic fever: A protocol for control and 

containment in a health care facility. Nursing RSA Verpleging: 3(5): 22-29, (6): 

41-44, (7): 33-38, 1988 

Disinfection 

Favero MS and WW Bond. Sterilization, disinfection, and antisepsis in the 

hospital. In: Murray PR, ed. Manual of Clinical Microbiology. Washington, D.C.: 

American Society of Microbiology. pp. 183-200, 1991 

Haverkos HW and TS Jones. HIV, drug-use paraphernalia and bleach. (Review) 

Journal of Acquired Immune Deficiency Syndromes: 7: 741-742, 1994 

McCoy CB, Rivers JE, McCoy HV, Shapshak P, Weatherby NL, Chitwood DD, 

Page JB, Inciard JA, and DC McBride. Compliance to bleach disinfection 

protocols among injecting drug users in Miami. Journal of Acquired Immune

Deficiency Syndromes: 7: 773-776, 1994 

Ohio State University Extension Service and US Department of Agriculture. 

Emergency Disinfection of Water Supplies, AEX-317. 

http://www.ag.ohio-state.edu/~ohioline/aex-fact/317.html 

194 
Watters JK. Historical perspective on the use of bleach in HIV/AIDS prevention. 

Journal of Acquired Immune Deficiency Syndromes: 7: 743-746, 1994 

Watters JK, Jones TS, Shapeshak P, McCoy CB, Flynn N, Gleghorn A, and 

D Vlahov. Household bleach as disinfectant for use by injecting drug users (letter: 

comment). Lancet: 342: 742-743, 1993 

World Health Organization. Cholera and other diarrhoeal diseases control ­

technical cards on environmental sanitation. Document WHO/EMC/DIS/97.6. 

Geneva: 1997 

Suggested Readings in French 

Baudon D. Virus Ebola et fièvre jaune: les leçons à tirer des épidémies. 

Médecine Tropicale: 55: 133-134, 1995 

Bausch DG et PE Rollin. La fièvre de Lassa. Annales de l’Institut Pasteur: 8: 

223-231, 1997 

Feldmann H, Volchkov VE, et HD Klenk. Filovirus Ebola et Marburg. Annales de

l’Institut Pasteur: 8: 207-222, 1997 

Ingold FR, Toussirt M, et C Jacob. Les modes de prévention du sida: intérêt et 

limites de l’utilisation de l’eau de Javel. Bulletin de l’Académie Nationale de

Médecine: 178: 279-291, 1994 

LeGuenno, B. Le point sur l’épidémie de fièvre hémorragique à virus Ebola au 

Gabon. Bulletin Épidémiologique Hebdomadaire: 3: 3, 1997 

Prehaud, C et M Bouloy. La fièvre de la vallée du Rift - Un modèle d’étude des 

fièvre hémorragiques virales. Annales de l’Institut Pasteur: 8: 233-244, 1997 

World Health Organization. Fièvre hémorragique à virus Ebola / Ebola 

haemorrhagic fever. Weekly Epidemiological Record / Relevé Épidémiologique

Hebdomadaire: 70: 149-151, 1995 

World Health Organization. Fièvre hémorragique à virus Ebola: Résumé de la 

flambée au Gabon / Ebola haemorrhagic fever: A summary of the outbreak in 

Gabon. Weekly Epidemiological Record / Relevé Épidémiologique

Hebdomadaire: 72: 7-8, 1997 

World Health Organization. Lutte contre les zoonoses. Fièvre hémorragique de 

Crimée-Congo / Zoonoses control. Crimean-Congo haemorrhagic fever. Weekly

Epidemiological Record / Relevé Épidémiologique Hebdomadaire: 71: 381-382, 

195 

1996 
World Health Organization. Une flambée de fièvre de la vallée du Rift en Afrique


orientale, 1997-1998 / An outbreak of Rift Valley fever, eastern Africa, 1997-1998.


Weekly Epideimiological Record / Relevé Epidemiologique Hebdomadaire: 73:


105-109, 1998


Zeller H. La fièvre hémorragique de Crimée Congo. Annales de l’Institut Pasteur: 

8: 257-266, 1997


196

Index


Accidental exposure 81-82, 120


Advance preparation for VHF Isolation


Precautions


Assessing readiness 116-118


In-service training 185-186


Preparing for outbreak 146-147


Staff training 118-119


Supplies checklists 41-42, 123-131, 141-142


Burial 45, 48, 49, 97-99


Community mobilization 103-112


Diagnostic testing


Laboratory testing 171-172


Skin biopsy 173, 175-179


Disinfectants


Bleach solutions 34, 41-42, 68-71, 128-129,


141-142, 161


Other chlorine products 161


Soapy water solution 34, 41-42, 72, 141-142


Disinfection


Bedding 80-81


Bedpan 76


Body of deceased patients 97-98


Boots 57, 79 


Gloved hands 73


Gloves, reusable 74


Infectious waste 78


Laundry 79


Needles and syringes


Disposable 15-16


Reusable 15


Patient’s utensils 76


Spills 77-78


Thermometers and stethoscopes 75-76


Vehicles, after transporting bodies 99


Water, drinking and cleaning 157-159


What to disinfect 67


Family


Role in patient care 39-40


Burial 97


Glossary 8


Isolation area 117


Plan 32, 143-144


Purpose 31


Requirements 31-32


Security 37-38


Supplies 34-36


Isolation area (changing room)


Checklist of supplies 41, 141


Sample layout 32, 33


How to set up 37


Isolation area (patient area)


Checklist of supplies 42, 142


Sample layout 32, 33


Posters 26, 165-169, 181-184


Protective clothing


Making protective clothing 149-152


Order for putting on clothing 53-56


Order for taking off clothing 57-62


Purchasing protective clothing 153-155


Recommended items 45-46


Apron 48-49


Boots 47


Eyewear 52


Gloves 46, 49-50


Gown 47-48


Head cover 51-52


Mask 50-51


Scrub suit 46


Who needs to wear protective clothing 45


Standard Precautions 11


Handwashing 12-13, 116, 133


Minimum level for your health facility 12


Disposal of sharp instruments 14-16, 133


Precautions 133-134


Viral haemorrhagic fevers


Case definitions 145, 146


Clinical features 137, 138


Epidemiology 135-136


General 3, 119


Prevention 139


Reporting 27


Suspecting 21-23


Transmission 3, 4, 120


VHF Coordinator


Role 18, 115-116


Selection 18, 115-116


197

VHF Isolation Precautions


Adapting for a large number of patients


145-147


Recommended precautions 17, 120


Reducing risk of transmission 17, 25-26


When to begin using 22, 23, 25, 26


Who needs to use 16, 25, 117-118


Waste disposal


Incinerator 86


Items to be disposed of 85


Methods 85-86


Pit 92


Making an incinerator 89-91


Selecting and training staff 87-88


Selecting site 89


Security 93


198