4.2.1 Viral Haemorrhaghic Fevers
Viral Haemorrhagic Fever (VHF) is a general term for a severe illness caused by viruses and sometimes associated with bleeding.
4.2.1.1 Ebola and Marburg Haemorrhagic Fevers
Primary transmission is from animal to human, through contact with an infected animal or its product. Secondary transmission is from person to person through:
- Contact with a sick person or direct contact with the blood and/or secretions or with objects, such as needles that have been contaminated with infected secretions of an infected person.
- Breast feeding
- Sexual contact
The disease can spread rapidly within the health care setting. The virus enters through broken skin, mucous membrane or exchange of bodily fluids or ingestion, inhalation and injection of infectious material
Diagnostic Criteria
High grade fever and one or more of the following:
- Headache, body ache, abdominal pain, diarrhoea
- Unexplained haemorrhage may be present or not
Investigations
- Blood for RT-PCR
- Antigen detection or IgM (ELISA)
Note: | |
| Do not take specimen before wearing appropriate PPE and ensuring the patient is in an isolation ward/centre |
Non-Pharmacological Treatment:
There is no specific treatment for Ebola and Marburg Haemorrhagic Fever.
Supportive therapy includes:
- Mechanical ventilation, renal dialysis, and anti-seizure therapy may be required.
- Management of complications symptomatically
- Maintaining Oxygen status and Blood Pressure
Pharmacological Treatment
- A: Paracetamol 15mg/kg 8 hourly for 3 days
- Treat for any complicating infection and co-morbid condition
B: Give oxygen and manage hypoglycaemia if present - Fluid and electrolyte balance
A: Sodium Lactate Compund (Ringers Lactate), NS intravenously if cannot take fluids orally
Psychological support is given to patient and family
4.2.1.2 Rift Valley Fever
This is a viral zoonosis that is primarily spread amongst animals by the bite of infected mosquitoes, transmitting the Rift Valley virus. Aedes mosquitoes are the main vector biting animals. Transmission to human is mainly through direct or indirect contact with blood or organs of infected animals. The virus can be transmitted to human through;
- Handling of animal tissue during slaughtering or butchering, assisting with animal births, conducting veterinary procedures.
- Inoculation e.g via wound from infected knife or through contact with broken skin or through inhalation of aerosols produced during the slaughter of an infected animals.
- Infected mosquito.
Human become viraemic; capable of infecting mosquitoes shortly before onset of fever and for the first 3–5 days of illness. Once infected, mosquitoes remain so for life.
Diagnostic Criteria
- Acute febrile illness that does not respond to antibiotic or antimalarial therapy,
- Exhaustion, backache, muscle pains, headache (often severe),
- Photophobia
- Nausea/vomiting
- Evidence of bleeding into skin, bleeding from puncture wounds, from mucous membranes or nose, from gastrointestinal tract and unnatural bleeding from vagina
- Clinical jaundice (3-fold increase above normal of transaminases)
Investigations
Anti-RVF IgM ELISA antibodies or positive test on Reverse Transcriptase Polymerase Chain Reaction (RT-PCR)
- FBC
- Low Hb [Hb < 8 gm/dL – Severe pallor
- Low platelets < 100×109 / dL (thrombocytopenia)–small skin and mucous membrane haemorrhages (petechiae)
- Serum Creatinine
Treatment
There is no any established course of treatment of this disease. Most of human cases are relatively mild and of short duration so will not require any specific treatment.
4.2.1.3 Yellow Fever
An acute viral infection, transmitted to human through a bite of infected Aedes mosquitoes. It is caused by a virus that belongs to the family Flavivirus. The disease can be life threatening causing hemorrhagic fever and hepatitis.
Diagnostic Criteria
- Fever, headache, jaundice, muscle pain, nausea, vomiting and fatigue.
Non-Pharmacological Treatment
No specific anti-viral treatment, supportive therapies are recommended.
Prevention
Prevention and Control involve mosquito control and provision of Yellow Fever vaccine.
Indication of Yellow Fever Vaccination
- Persons ≥ 9 months of age
- Planning travel to or residence in an endemic area
- Planning travel to a country with an entry requirement
- Needs to be given ≥ 10 days prior to arrival in endemic area
4.2.1.4 Dengue Fever
Dengue is a mosquito-borne viral infection causing by the dengue fever virus, whose full life cycle involves the role of mosquito as a transmitter (or vector) and humans as the main victim and source of infection. Dengue does not spread directly from person to person, it is only spread through the bite of an infected Aedes aegypti mosquito.
Diagnostic Criteria
Dengue Febrile Illness (DF):
- retro-orbital or ocular pain, headache, rash, myalgia, arthralgia,
- hemorrhagic manifestations (e.g., positive tourniquet test, petechiae; purpura/ecchymosis; epistaxis; gum bleeding; blood in vomitus, urine, or stool; or vaginal bleeding,
- Anorexia, nausea, abdominal pain, and persistent vomiting may also occur but are not case-defining criteria.
Dengue Hemorrhagic Fever (DHF)
- Persistent high grade Fever lasting from 2–7 days
- Spontaneous bleeding
- Retro-orbital pain
- Joint, muscle and abdominal pain
- Macular or confluent blanching rash (noted during recovery period)
- Thrombocytopenia (>100,000 cells per mm3)
Dengue Shock Syndrome (DSS)
- All criteria for DHF plus circulatory failure as evidenced by rapid and weak pulse and narrow pulse pressure (<20mm Hg)
- Age-specific hypotension and cold, clammy skin and restlessness
Investigations
- Elisa for Dengue NSI antigen
- Serological tests: Dengue IgM & IgG Rapid Strip Test.
- FBP
Non-Pharmacological Treatment
No specific treatment is available for Dengue fever.
Pharmacological Treatment:
A: Paracetamol 15mg/kg 8 hourly for 3 days
A: Maintainance fluid (Ringers lactate, NS) intravenously if child cannot take enough orally
B: Blood transfusion and clotting factors.
B: Oxygen and manage hypoglycaemia if present
Note: | |
| No antibiotics are of proven value. |
| Children below 12 years require close monitoring for dangerous form. |
| Avoid Aspirin and other NSAIDs. |
| Steroids should not be used. |
4.2.1.5 Chikungunya Fever
Transmission: Chikungunya Virus Disease is caused by Chikungunya Virus, transmitted by the Aedes aegypti mosquito the same which transmit Dengue virus, West Nile and Yellow Fever viruses.
Diagnostic Criteria:
- Fever, Skin rashes, Conjunctivitis
- Muscle and joint pain (Polyarthritis), Malaise, Headache
- Minor haemorrhage, Leukopenia is common
Prevention and control: Vector control:removal and modification of breeding sites and reducing contact between mosquitoes and people.
Non-Pharmacological Treatment: Supportive
Pharmacological Treatment
- Symptomatic treatment
A: Sodium Lactate Compound (Ringers Lactate) intravenously
A: Give Paracetamol 15mg/kg 8 hourly for 3 days
4.2.2 Measles
Measles is an acute, highly communicable infectious disease caused by Measles virus. The mode of transmission is airborne, by droplet spread through coughing or sneezing, or by direct contact with nasal or throat secretions of infected persons.
Diagnostic Criteria
- Generalized, reddish (erythematous), blotchy (maculopapular) rash;
- History of fever usually above 38˚C (if not measured, then “hot” to touch);
- Dry cough; Sore throat; Runny nose (coryza);
- Inflamed eyes (conjunctivitis), tiny white spots with bluish-white centers on a red background found inside the mouth on the inner lining of the cheek- also called Koplik’s spots.
- In addition, children with measles frequently exhibit a dislike of bright light (photophobia), and often have a sore red mouth (stomatitis).
Pharmacological Treatment
Note: No specific antiviral treatment exists for measles virus
Adults: A: Paracetamol tablets 1g every 8 hours for 5 days
AND
A: Vitamin A 200000 IU orally, stat
In case of ocular involvement, add
A: Oxytetracycline eye ointment 1% apply once daily for 7 days
Children:
A: Paracetamol 10–15mg/kg body weight every 8 hours for 5 days
A: Vitamin A if less than 1 year give 100000 IU stat and if over 1 year give 200000 IU
Prevention
Routine measles vaccination for children combined with mass immunization campaigns
4.2.3 Rabies
(For more information on Rabies, please refer to the section on infectious diseases)
Rabies is an acute viral infection of the central nervous system that affects all mammals and is transmitted to man by animal bites via infected secretions, usually saliva.
Diagnostic criteria
- Early clinical features: apprehensiveness, restlessness, fever, malaise and headache
- Late features: excessive motor activity and agitation, confusion, hallucinations, excessive salivation, convulsions and hydrophobia
NOTE: Treat the person immediately after the animal bite, before onset of symptoms
Pharmacological Treatment
Local wound therapy:-wash wound thoroughly with running water and soap for 10 minutes, and repeat process with: A: 10% Povidone iodine; to prevent secondary bacterial infection.
Active immunization: Human Diploid Cell Vaccine (HDCV) – either ID or IM
A: Anti-rabies Vaccines (2- 3 IU/dose)
o IM: 1ml on days 0, 3, 7, 14, 28 (5 doses)
o ID: 0.2ml by dividing 0.1 ml on left shoulder and 0.1ml on right shoulder, on days 0, 3,7 and 28 (4 doses). Intradermal (ID) is mostly advised.
In addition, patients should receive rabies immune globulin with the 1st dose (day 0)
Passive Immunization
B: Anti-rabies human immunoglobulin 20 IU/kg half the dose given parenterally and the other half injected into and around the wound
AND
A: Tetanus toxoid vaccine, please refer to the section on Tetanus
4.2.4 Zika Virus Disease
Zika Virus Disease is caused by Zika Virus, transmitted by the Aedes aegypti mosquito, the same which transmit Dengue virus (DENV), Chikungunya, West Nile and Yellow Fever viruses.
Diagnostic Criteria:
- Fever, skin rashes, conjunctivitis,
- Joint pain, malaise, Headache – usually mild and last for 2–7 days.
- Neurological and auto-immune complications of Zika virus disease, babies born with microcephaly (Observed in northeast Brazil).
Investigations
- PCR and virus isolation from blood samples.
- Diagnosis by serology can be difficult as the virus can cross-react with other flaviviruses such as dengue, West Nile and yellow fever.
Prevention and control:
- Vector control: – removal and modification of breeding sites and reducing contact between mosquitoes and people
- Currently no proven vaccine to prevent Zika virus infection
Non-Pharmacological Treatment:
Supportive
Pharmacological Treatment
- Symptomatic treatment –
A: Sodium Lactate Compound (Ringers Lactate) intravenously
A: Paracetamol 15mg/kg 8 hourly for 3 days