Decision No. 2968/QD-BYT dated August 8, 2014, guidance on diagnosis and treatment of Ebola virus diseases

DECISION

GUIDANCE ON DIAGNOSIS AND TREATMENT OF EBOLA VIRUS DISEASES

THE MINISTER OF HEALTH

Pursuant to the Government's Decree No. 63/2012/ND-CP dated August 31, 2012 defining the functions, tasks, powers and organizational structure of the Ministry of Health;

At the request of National Hospital of Tropical Diseases in Dispatch No. 409/BVNDTW dated August 08, 2014 providing Guidance on diagnostic and treatment of diseases caused by Ebola virus,

At the request of Medical Service Authority – the Ministry of Health,

DECIDES:

Article 1. Guidance on diagnosis and treatment of EBOLA virus diseases is promulgated together with this Decision

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Article 3. This Decision takes effect from the day on which it is signed.

Article 4. Chief of the Ministry Office , Director of Medical Service Authority, Chief Inspector of the Ministry of Health, Departments of the Ministry of Health, Directors of hospitals affiliated to the Ministry of Health; Directors of Services of Health, heads of health authorities of other Ministries, heads of relevant units are responsible for the implementation of this Decision./.

PP THE MINISTER
DEPUTY MINISTER




Nguyen Thi Xuyen

GUIDANCE

DIAGNOSIS AND TREATMENT OF EBOLA VIRUS DISEASE

I. OVERVIEW

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- Ebola virus is one of three genera of family Filoviridae (filovirus). The other two are Marburgvirus and Cuevavirus. There are five species of ebolaviruses including:

+ Zaire ebolavirus (EBOV)

+ Sudan ebolavirus (SUDV)

+ Bundibugyo ebolavirus (BDBV)

+ Taï Forest ebolavirus (TAFV).

+ Reston ebolavirus (RESTV)

BDBV, EBOV, and SUDV have caused major epidemics in Africa, while RESTV and TAFV have never caused any epidemic.

- Targets of infection:

+ Hunters and people who live in the forest and come into contact with infected or infected dead animals (chimpanzees, apes, monkeys, antelopes, porcupines, fruit bats, etc.)

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+ Undertakers and people having physical contact with the infected patients’ dead bodies.

+ Health workers who directly take care of infected patients

II. Symptoms

1. Clinical symptoms

- The incubation period varies between 2 and 21 days

- Common symptoms include:

+ Acute fever

+ Headache, muscle pain and weariness

+ Vomiting/nausea

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+ Stomach pain

+ Conjunctivitis

- Rash: initially a dark red color as small as pins at hair follicles, then maculopapular rash with clear boundaries, and ultimately spread usually within the first week of infection.

- Haemorrhage symptoms

+ Black stool

+ Bleeding from injection sites

+ Coughing up blood, gingival bleeding

+ Blood in urine

+ Vaginal bleeding

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- Blood formula: usually leucopenia, thrombocytopenia

- Increase in AST, ALT Creatinine and urea in blood may increase while the disease develops

- Coagulation: disseminated intravascular coagulation

- Urine test: proteinuria

- Test for causes: looking for antigens, antibodies, PCR, and virus culture Samples used for testing are blood that are preserved during transport medium and conformable with regulations on transport of blood-borne viruses.

IV. Ebola diagnosis

1. Suspected cases:

- Having an epidemiological link within 03 weeks before symptoms are observed:

+In direct contact with blood or bodily fluids of patients with confirmed or suspected Ebola virus disease

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+ In direct contact with bats, rats, or primates from epidemic areas

- - Having clinical symptoms of the disease

2. Confirmed cases:

Confirmed cases are suspected cases that are confirmed by positive PCR test.

3. Distinguishing diagnosis:

- Ebola virus disease must be distinguished from:

+ Dengue hemorrhagic fever

+ Streptococcus suis disease

+ Septicemia due to meningococcal disease

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+ Leptospira

+ Malaria with complications

V. Treatment

1. Principles

- No specific treatment exists; treatment is primarily supportive in nature.

- All suspected cases must undergo examination at hospitals, isolated, and sampled to test. Confirmed cases must be hospitalized and completely isolated.

2. Supportive treatment:

Symptom

Response

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- Reduce temperature with Paracetamol: 10-15 mg/kg of body weight every 4 – 6 hours, not more than 60 mg/kg of body weight per day

- Avoid using NSAIDs (Diclofenac, Ibuprofen, etc.) or medicines that contain Salicylate medicines because they will worsen coagulation.

Pain

- Reduce pain with Paracetamol (if pain is mild) or morphine (if pain is moderate or severe)

- Avoid using NSAIDs (Diclofenac, Ibuprofen, etc.) or medicines that contain Salicylate medicines because they will worsen coagulation.

Diarrhoea, vomiting, showing signs of dehydration

- Administer Oresol even when there are no signs of dehydration

- Monitor the signs of dehydration and carry out rehydration according to the treatment regimen

- Vomiting and nausea are very common. Antiemetics might help reduce the symptoms and enable the patient to take Oresol For adults: Chlorpromazine 25-50mg, intramuscular injection 4 times per day; or Metoclopramide 10mg, intravenous injection or oral administration 3 times per day until vomiting stops. For children over 2 years: administer Promethazine, monitor signs

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- Use Diazepam to stop the convulsion. Adults: 20 mg; Children: 0.1 – 0.3 mg/kg, slow intravenous injection. Then suppress the convulsion with Phenobacbital. Adults: 00 mg/kg; Children: 10 - 15 mg/kg, slow intravenous injection for 15 minutes.

Signs of acute bleeding/paleness, emergency signs of hypovolemic shock

- Transfuse blood and blood products

Shock, multiple organ dysfunction (if any)

- Ensure the circulatory volume, fluid balance; maintain blood pressure and urine production.

- Filter blood, perform ECMO is necessary

3. Cautions:

- Pregnant women face a very high risk of miscarriage/preterm delivery, and postpartum bleeding. The administration of oxytocin and postpartum intervention must comply with instruction in order to stop the bleeding.

- Breastfeeding women: Ebola virus can be transmitted through breast-milk. If the mother is suspected of having Ebola virus disease, the mother and her children must be hospitalized and isolated until they are treated. The mother should stop breastfeeding.

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A patient shall be discharged when:

- There is no fever for at least 3 days without signs of discharge of virus into the environment such as watery stool, coughing, bleeding, etc.

- Clinical symptoms are reduced, the patient’s condition is stable, and the patient can do everyday activities himself/herself.

- With regard to test results:

+ Negative PCR test (from the 3^rd day after first symptoms)

+ If clinical symptoms are not reduced after 2 negative PCR tests that are carried out at an interval of 48 hours, one of which is carried out on the 3^rd day or later from first symptoms, the patient may be taken care of outside the isolation ward.

VI. Prevention of Ebola virus prevention

1. Principles

- Takes measures to prevent and control contamination.

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- Medical facilities must take standard prevention measures and prevention according to routes of transmission.

- Provide information and reports the cases in accordance with Circular No. 48/2010/TT-BYT dated December 31, 2010 of the Ministry of Health.

2. Patients

- Isolate and treat patients at medical facilities in accordance with instructions of the Ministry of Health.

- Use personal protective equipment to minimize transmission.

- Avoid coming into contract with or moving patients; use personal protective equipment and specialized vehicles when it is necessary to move patients. Contaminated, dumped items, and excrements of patients must be treated and sterilized as prescribed.

- Ebola virus can be able to persist in semen and breast-milk, thus it is necessary to inform patients of how to prevent transmission after they are discharged.

- Dead bodies must be handled in accordance with Circular No. 02/2009/TT-BYT dated May 26, 2009 on guidelines for hygienic burial and cremation.

3. People in close contact:

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- Avoid being contact with patients

- Practice proper personal hygiene, regularly wash hands with soap; use antiseptics for the nasal route.

- Make a list of people in close contact and monitor their health for 21 days from the last contact. Inform the people in contact of the signs of the disease, prevention and treatment so that they can avoid infection, monitor their own health, and recognize symptoms of Ebola virus diseases themselves. Notify the nearest medical facility if the symptoms are observed for timely diagnosis and treatment.

4. Transmission prevention at treatment facilities:

- Adhere to regulations on classifying, isolating, and treating patients, take measures for controlling contamination, provide personal protective equipment for health workers, caretakers, and other patients at the facility in accordance with instructions of the Ministry of Health.

5. Sterilization, environmental remediation, and waste treatment at hospitals:

Comply with the procedures of environmental remediation and waste treatment applied to isolated areas for highly infectious diseases.

6. Vaccines:

No vaccine against Ebola virus is currently available.

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