Victorian guideline on viral haemorrhagic fevers

Scope of this guide

This publication will focus on the management of the four quarantinable viral haemorrhagic fevers (VHFs), given their increased capacity for human-to-human transmission.

The infectious agents for these quarantinable VHFs are:

• Lassa virus – an arenavirus that causes Lassa fever (LF)
• Crimean-Congo haemorrhagic fever (CCHF) virus – a bunyavirus that causes CCHF
• Orthoebolavirus (formally Ebolavirus) and Orthomarburgvirus) (formally Marburgvirus) – filoviruses. These will be referred to as Ebola virus disease (EVD) and Marburg virus disease (MVD) for this guide.

Similar principles may also be used for management of less common VHFs, although specific transmission patterns, clinical presentation and treatment approaches may differ.

Audience

This guide is intended for use by health services in Victoria, especially non-designated health services and primary care clinics. Designated health services (The Royal Melbourne Hospital and The Royal Children’s Hospital) have internal protocols for VHF.

Governance

A suspected or confirmed case of VHF is considered a health emergency in Victoria. The State Emergency Management Plan (SEMP), Health Emergencies Sub-Plan (HESP) sets out the arrangements for managing health emergencies. The HESP outlines an integrated and coordinated approach to minimising the impact of emergencies on the health system and protecting the health and wellbeing of Victorians. The plan includes guidance on mitigation, preparedness, response (including relief) and recovery arrangements.

In the instance of VHF, the department would act as the control agency and is responsible for establishing the management arrangements, including a coordinated and integrated health sector response.

VHF is an urgent notifiable condition under the Victorian Public Health and Wellbeing Regulations 2019. This requires notification from medical practitioners and pathology services of suspected and confirmed cases as soon as practicable and within 24 hours.

VHF is also a listed human disease and nationally notifiable under the Biosecurity Act 2015. As an LHD, VHF may be suspected at a port of entry (see Non-designated health services on VHF preparedness in designated and non-designated health services and primary care).

The Public health actions for VHF are to be undertaken in accordance with the Victorian Public Health Network VHF Disease Control Guidelines by the department and Local Public Health Units (LPHUs).

Roles and responsibilities

About viral haemorrhagic fevers (VHFs)

VHFs are a group of rare illnesses caused by several distinct families of viruses. Although some types of haemorrhagic fever viruses can cause relatively mild illnesses, many cause severe, life-threatening disease. EVD, LF, MVD and CCHF are of particular concern because they could be imported into Australia and be transmitted to other people, particularly health care personnel, by blood or body fluid inoculation. They are therefore subject to biosecurity measures as per the Biosecurity Act 2015.

Other VHFs that are less commonly transmissible between humans but are notifiable include:

• Severe Fever with Thrombocytopaenia Syndrome (SFTS) caused by the SFTS virus
• Argentine haemorrhagic fever (AHF) caused by the Junin virus
• Lujo haemorrhagic fever (LUHF) caused by the Lujo virus
• Bolivian haemorrhagic fever (BHF) caused by the Machupo virus
• Andes haemorrhagic fever (ANDV) caused by the Andes virus (a rodent-borne hantavirus).

Table 1. Key VHFs where human-to-human spread may occur

Note. Adapted from Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) guidance^{1, 2, 3, 4}

Clinical symptoms

Clinically apparent infections with any of these viruses may present with similar symptoms. Fever is typically insidious in onset and accompanied by severe headache, myalgia and malaise. Other symptoms include:

• retrosternal chest pain
• cough
• abdominal pain
• diarrhoea
• conjunctivitis
• facial swelling
• signs that include proteinuria and jaundice.

A bleeding diathesis leads to mucosal bleeding, haematemesis, melaena and haematuria. Severe infections are complicated by massive haemorrhage and multi-organ failure.⁵

Epidemiology and public health significance

LF, MVD and EVD viruses are restricted to Sub-Saharan Africa, where most human outbreaks have occurred. CCHF virus is more widely distributed in Africa, the Mediterranean region, the Middle East, eastern Europe, Central Asia and China. The origins of MVD and EVD viruses are still unclear, but most cases appear to have arisen in Africa.

Lassa virus is endemic in West African countries, such as Nigeria, Sierra Leone, Liberia and Guinea, with seasonal outbreaks and ongoing transmission linked to rodent exposure.⁶ EVD and MVD typically emerge in Central and East Africa, often associated with contact with infected wildlife or human-to-human transmission in health care or community settings.⁷

Several recent outbreaks have highlighted the ongoing threat posed by VHF. In early 2025, Uganda faced a Sudan virus (Ebola species) outbreak with 14 cases and four deaths, ending in April 2025.⁸ At the same time, the Democratic Republic of the Congo reported a deadly Ebola virus (Zaire strain) outbreak with 31 deaths out of 38 cases, prompting targeted vaccination using the Ervebo® vaccine.

MVD outbreaks in Tanzania and Rwanda also caused multiple deaths, with Tanzania reporting a 100% fatality rate among 10 cases in an outbreak declared in January 2025, highlighting the critical need for rapid response.⁹

Although CCHF and LF have not seen large-scale international outbreaks recently, both continue to cause sporadic cases and small outbreaks in endemic regions, particularly in West Africa for LF and Eastern Europe, Central Asia and parts of the Middle East for CCHF.¹⁰ Given the high case-fatality rates associated with these diseases, early diagnosis and prompt supportive treatment are critical to improving patient outcomes and preventing secondary transmission, especially in health care settings.

VHF should be considered in the differential diagnosis of any patient presenting with unexplained fever who has travelled to or resides in an area where VHF is endemic within the past 21 days. While there is now an approved vaccine for Ebola virus (Zaire strain), there are currently no licensed vaccines for LF, MVD, Sudan virus or CCHF.

Mode of transmission

The transmission of VHF varies by virus type. People can become infected with Lassa virus via exposure to food or household items contaminated with urine or faeces from infected Mastomys (a genus of rodent in the family Muridae endemic to Africa) or directly via contact with infected rats.

Lassa virus can also spread from person to person through direct contact with blood, urine, faeces or other bodily secretions of someone infected with Lassa virus.

CCHF virus is mainly transmitted by Hyalomma spp. tick bites or contact with infected animals, with nosocomial spread also reported.

For Ebola and Marburg viruses, the initial source is often unknown, but secondary transmission occurs through direct contact with infected body fluids or contaminated medical equipment.

Notes

¹ Centers for Disease Control and Prevention. (2025). Viral hemorrhagic fevers (VHFs)

² World Health Organization. (2025). Ebola virus disease

³ World Health Organization. (2025). Marburg virus disease

⁴ World Health Organization. (2025). Crimean-Congo haemorrhagic fever

⁵ Victorian Department of Health. (2025, June 11). Viral haemorrhagic fevers

⁶World Health Organization. (2024, December 5). Lassa fever

⁷ World Health Organization. (2025, April 24). Ebola disease

⁸ World Health Organization. (2025, April 15). Disease Outbreak News: Uganda Sudan virus outbreak ends

⁹ World Health Organization. (2025, February). Marburg virus disease – Tanzania and Rwanda outbreaks 2025

¹⁰ Centers for Disease Control and Prevention. (2023, December). Crimean-Congo hemorrhagic fever (CCHF) factsheet

This section provides guidance to health services for the management of a suspected or confirmed case of VHF. Refer to the surveillance case definition for confirmed and suspected cases in the glossary, noting that this case definition is the Communicable Disease Network Australia (CDNA) surveillance case definition. It is not the clinical criteria for diagnosis of VHF, which should be made in discussion with an infectious diseases specialist.

A single case of suspected or confirmed VHF must be notified to the LPHU immediately. LPHUs will receive the initial notification, immediately escalate to the department and undertake a preliminary risk assessment with the DCHO-CD. An IMT with relevant stakeholders will be convened by the department to coordinate the overall public health response. Certain actions recommended below will be discussed and agreed through the IMT.

Signs and symptoms of most VHFs are non-specific and similar to many other common causes of febrile illness in returning travellers. Because of this, travel history and epidemiological risk factors are critical in determining immediate management, which aims to prevent human-to-human transmission of VHF. A VHF infection is possible in any patient with the clinical and epidemiological characteristics outlined here.

Clinical characteristics

A compatible clinical illness as determined by consultation with an infectious disease physician. Common presenting signs and symptoms include:

• fever (recorded fever ≥ 38° in the previous 24 hours or subjective history of fever in the last 24 hours)
• myalgia
• prostration
• headache
• pharyngitis
• conjunctival injection
• flushing
• gastrointestinal symptoms.

This may be complicated by spontaneous bleeding, petechiae, hypotension and hypovolemic shock, oedema and neurologic involvement.

Epidemiological characteristics

VHF symptoms can appear anywhere from two to 21 days after exposure to the virus, depending on the virus. Illness typically progresses from ‘dry’ symptoms (fever, aches and fatigue) to ‘wet’ symptoms (diarrhoea, vomiting and in some cases, bleeding).¹

A person with EVD, MVD, or LF is not contagious until the appearance of symptoms.^{2, 3} A person can become infected with viruses causing VHF by coming into contact with an infected person’s bodily fluids, contaminated medical supplies and equipment, or contaminated environmental surfaces. Splashes to unprotected mucous membranes (for example, the eyes, nose or mouth) are particularly hazardous.

The epidemiological characteristics that raise the level of suspicion for VHF are that the person:

• reported returning from a specific local area of a country where there is a current VHF outbreak,* with or without direct contact with blood, other body fluids, secretions or excretions from a person or animal with confirmed or suspected VHF

OR

• travelled in or was resident in the specific local area of a country where VHF is endemic** and has recently been reported with one or more exposure risk factors that include:
  • receiving a tick bite or crushing a tick in an area endemic for CCHF
  • visiting caves or underground mines and being exposed to bat colonies or having had direct contact with primates, antelopes or bats in a Marburg or Ebola endemic area
  • living or working in basic rural conditions in an area endemic for LF
  • having persistent fever ≥72 hours, with malaria excluded and no alternative diagnosis apparent
  • having worked in a laboratory or animal facility that handles specimens or tissue contaminated with VHF.

*Information about current VHF outbreaks can be obtained from:

• WHO: Disease Outbreak News
• CDC: Outbreak History (Ebola specifically)
• GOV UK: High consequence infectious disease: country specific risk
• ProMED: Protecting Global Health, One Alert at a Time
• Centre for Infectious Disease Research and Policy (CIDRAP)
• BEACON: Disease Events

**Endemic areas for VHFs include:

• LF – parts of West Africa, including Sierra Leone, Liberia, Guinea and Nigeria
• MVD – the reservoir host of Marburg virus, the African fruit bat, is widely distributed across Africa. Marburg outbreaks have occurred in Uganda, Angola, Kenya, Zimbabwe and the Democratic Republic of Congo
• CCHF – Eastern Europe, particularly in the former Soviet Union, throughout the Mediterranean, in north-western China, central Asia, southern Europe, Africa, the Middle East and the Indian subcontinent.

Notes

¹ Centers for Disease Control and Prevention. (2024, May 9). Clinical screening and diagnosis for VHFs.

² World Health Organization. (2023, August). Infection prevention and control guideline for Ebola and Marburg disease. Geneva: World Health Organization.

³ Centers for Disease Control and Prevention. (2025, January 31). About Lassa fever.

Designated health services

All cases of confirmed VHF in Victoria should be managed at a designated health service. In Victoria, the designated quarantine hospitals to receive suspected and confirmed cases of VHF are:

• The Royal Melbourne Hospital (RMH) for suspected or confirmed cases of VHF aged 16 and above. A suspected or confirmed case of VHF in a pregnant woman, including a woman in labour, will be directed to RMH. RMH will activate a request to the Royal Women's Hospital to provide assistance as needed, including obstetric and midwifery expertise, so that all required care can be provided at RMH.
• The Royal Children’s Hospital (RCH) for suspected or confirmed VHF cases aged under 16 years. These patients will be admitted to the RCH for assessment and testing, after a discussion between the Chief Health Officer or delegate, and the duty emergency department consultant at RCH.

Non-designated health services

There is a department expectation that non-designated health services with sufficiently senior staff and the capacity to hold and test a low-possibility suspected case of VHF (see VHF case investigation flow chart) will do so, if requested by the department, in accordance with the principles outlined in Transfer to a designated health service to assess the need for transfer.

In addition to the steps outlined in Transfer to a designated health service, non-designated health services should consider having an internal escalation arrangement when a suspected or confirmed VHF case presents to an outpatient or subacute setting where there are limited facilities for effective isolation.

This arrangement can outline:

• systems to identify and notify suspected cases of VHF to the LPHU and relevant staff within the health service (infectious diseases, infection prevention, pathology and executive)
• an interim arrangement to safely manage a suspected case of VHF temporarily before transfer to a designated health service, in discussion with the department. This arrangement can focus on isolation of the patient, avoidance of direct contact and timely transfer of the patient, in discussion with the department.

Primary care

Primary care services and facilities should refer to Immediate actions on suspicion of VHF disease regarding initial actions for a suspected case of VHF.

For more information, primary case services may refer to their Primary Health Networks and HealthPathways at:

• North Western Melbourne and Eastern Melbourne Public Health Network
• Eastern Melbourne Public Health Network
• South Eastern Melbourne Public Health Network
• Gippsland Public Health Network
• Murray Public Health Network
• Western Victoria Public Health Network

Airports and seaports

The Biosecurity Act 2015 outlines how human health risks from arriving aircraft and vessels are managed, including suspected cases of VHF at port of first entry (for example, airport or seaport).

The Commonwealth Department of Health, Disability and Ageing is responsible for administering human health aspects of the Biosecurity Act 2015, but administrative arrangements are in place for Biosecurity Officers from DAFF to perform these functions, supported by state and territory health departments.

If VHF is suspected:

• a DAFF Biosecurity Officer will call the state HBO.
• the HBO will assess the likelihood of VHF and provide direction on case management, contact management, and provide advice on precautionary environmental cleaning and disinfection, in accordance with the Human Biosecurity Guidelines and the VHF Control Guidelines.
• following assessment, the patient will be transferred via AV to the designated health service for further investigation and treatment.

Non-designated health services

When VHF is suspected in a patient presenting to a non-designated health service or primary care clinic, transfer to a designated health service may not be immediate and may depend on location, resources, patient acuity and processing of laboratory results.

Decisions about direct transfer or collecting and sending blood specimens for VHF testing will be made on a case-by-case basis in consultation with the department. Regardless of approach, the local health service should plan to manage a suspected case for up to several hours (see VHF case investigation flow chart). This includes the following procedures.

Isolation and personal protective equipment (PPE)

This requires:

• isolating the patient immediately in a single room with the door closed. If available, this should be in a negative pressure ventilation room
• instituting PPE for staff as per Personal protective equipment (PPE)
• minimising unnecessary staff and family contact.

In non-designated health services where minimal PPE or isolation facilities and no IPC expertise are available (such as primary care), minimise the patient’s movement in the health service and isolate them in a single room away from other staff and patients with the door shut. Use the maximum level of PPE available at the practice (as outlined in Personal protective equipment (PPE)) in discussion with the department.

For non-designated health services with IPC teams, the level of PPE should be determined according to Personal protective equipment (PPE) and in discussion with the department.

Further history

This requires:

• keeping the patient informed of what is happening
• if not already ascertained, obtaining further information about VHF compatible symptoms, date of onset of illness, and dates and location of exposure to VHF. Other information may need to be gathered from the patient following discussion with the LPHU and the department.

Notification and escalation

This requires:

• notifying the LPHU without delay on 1300 651 160
• notifying other relevant teams where applicable (infection prevention, infectious diseases and executive)
• identifying a liaison person with the LPHU.

The LPHU will perform a risk assessment in collaboration with the DCHO-CD. An IMT will be set up to discuss and provide advice on further actions, including testing and transfer of patients.

Further diagnostic samples

This requires:

• avoiding diagnostic sampling (throat swab, aerosol-generating procedure or venepuncture) unless necessary or advised by the department
• keeping aside any pathology samples that have been taken as per the laboratory request (see Laboratory). DO NOT send them to the laboratory without discussion with the department
• that if other clinical specimens have been sent to the onsite/affiliated laboratory inadvertently (prior to suspicion of VHF being raised), alerting the onsite/affiliated laboratory immediately.

Further management

At non-designated health services where treatment is available, consider treating patients empirically for sepsis and malaria, in consultation with an infectious diseases specialist.

Transfer of patients

Transfer of a suspected or confirmed case is to be discussed with the department and decided according to the principles outlined in Transfer to a designated health service.

Do not call AV to organise transport to another health service unless advised by the department or if immediately essential for life-saving care.

Other IPC management

This requires:

• compiling a list of patients and staff (with contact details) who engaged with the patient or were in the immediate vicinity of the patient. Further contact tracing will be advised by the department
• environmental cleaning, disinfection and waste management to be managed as detailed in the IPC section (see Infection prevention and control) and in discussion with the department.

All transfers of a suspected or confirmed case will need to be discussed with the department. Refer to Patient transport for IPC measures relating to transfer of VHF patients.

Patients who should be transferred from a non-designated to a designated health service include:

• patients with a confirmed VHF diagnosis
• patients who are highly suspected to have VHF (those with consistent clinical picture and/or higher risk exposures/epidemiology)
• patients with ‘wet’ symptoms (for example, vomiting, diarrhoea and bleeding)
• critically unwell patients requiring urgent pathology and/or invasive or aerosol-generating procedures (for example, intubation, suctioning, active resuscitation)
• patients at a non-designated health service without the capacity to hold on to a suspected case before confirmation of diagnosis. These health services usually do not have suitable infrastructure to isolate a VHF case, or do not have infectious diseases or IPC expertise and capability.

Ambulance transfer arrangements

AV is equipped to transfer suspected or confirmed cases of VHF in Victoria:

• AV responders will follow AV’s established IPC precaution guidelines when managing suspected or confirmed VHF patients.
• Adequate quantities of PPE (as outlined in Infection prevention control) must be available to manage the case to completion at the receiving health service.
• Where the clinical condition of the patient allows, the department will coordinate the transfer of a suspected case with AV via established pathways and contacts.
• Health services should avoid direct transfer of a patient with suspected or confirmed VHF prior to receiving specific instruction from the department, unless necessitated due to the patient’s clinical condition or if the health service has been unable to contact the department.
• Cases involving paediatric patients requiring specialised retrieval will be coordinated by RCH through the Paediatric Infant Perinatal Emergency Retrieval (PIPER) service.
• Cases involving adult critical care patients requiring specialised retrieval will be coordinated through the Adult Retrieval Victoria (ARV) service.

Transfer of accompanying parents or carers

Parents or carers may request to accompany a patient (for example, a minor, an adult requiring a carer or a patient requiring an interpreter) during the transfer to the receiving health service.

This decision requires a risk assessment considering:

• the level of suspicion for the patient to have VHF
• potential infectivity of the patient
• potential for the parent/carer to have VHF
• AV’s ability to safely accommodate a parent/carer escort.

General principles include:

• for ‘dry’ symptoms only (for example, fever, myalgia and headache):
  • at the discretion of the department and AV, one parent or carer may accompany the patient
  • that the carer will be required to wear appropriate PPE and remain at least one metre away from the patient (if possible), avoiding physical contact
• for ‘wet’ symptoms (for example, vomiting, diarrhoea and bleeding)
  • a parent or carer cannot accompany the patient during transfer
  • alternative transport arrangements to the receiving health service must be made for the parent or carer.

Laboratory notification

VIDRL maintains the National High Security Quarantine Laboratory (NHSQL), a Physical Containment 4 (PC4) suit laboratory and Victoria’s designated centre for VHF testing. VIDRL is available 24/7 for testing of specific VHF pathogens.

Testing for VHF must be discussed with and approved by the department. Testing should be coordinated in consultation with the department, treating clinician, infectious disease specialist/microbiologist, pathology/laboratory team of the health service and VIDRL.

On approval, a nominated departmental representative should be the primary person to liaise with VIDRL, the health service pathology and courier service, unless an alternative arrangement has been made and agreed on.

Testing and specimen transfer

Testing for VHF is conducted at the NHSQL in the PC4 laboratory. Definitive testing includes:

• reverse transcription polymerase chain reaction (RT-PCR) – for example, for Ebola virus, Marburg virus, Lassa virus, CCHF virus, and emerging agents like Lujo virus, Sabiá virus and Rift Valley fever virus
• confirmation by sequencing
• virus isolation in cell culture
• whole genome sequencing for outbreak surveillance.

Adjunct testing in the form of serology and transmission electron microscopy may also be considered.

Specimen collection

General principles of specimen collection include that:

• specimen collection should preferably occur at a designated hospital (RMH or RCH) whenever possible
• if urgent transfer is not required and delaying collection may compromise diagnosis, venepuncture should be performed at the initial admitting hospital by an experienced clinician
• only essential specimens should be collected, and safety must take priority, in accordance with the National High Security Quarantine Laboratory Guideline for Management of Quarantinable Viral haemorrhagic Fevers.

See Appendix 4: Specimen collection and transport for suspected VHF for collection and packaging processes.

Other clinical sampling, including pathology

Testing for other infections common in returned travellers (for example, malaria, typhoid and dengue), or blood cultures (if clinically indicated) could be considered by clinicians in cases with appropriate epidemiological risk factors.

In general, differential diagnostic assays and routine pathology should be avoided while the possibility of VHF is being evaluated, and only performed at a Physical Containment 2 (PC2) laboratory when or if VHF has been excluded.

When VHF is suspected, DO NOT send any specimens to the laboratory unless VHF is excluded. DO NOT run blood gas testing on emergency department/intensive care unit analysers used for other patients. If necessary, consider using a handheld blood analyser (iSTAT machine) for point-of-care testing. However, these must be decontaminated after use and must not be used on other patients.

If other clinical specimens have been sent to the onsite/affiliated laboratory inadvertently (prior to suspicion of VHF being raised), alert the onsite/affiliated laboratory immediately.

Molecular assays

Nucleic acid testing, performed primarily on serum or plasma, has become the preferred diagnostic method for VHF pathogens. VIDRL uses laboratory-developed conventional and real-time RT-PCR assays. In silico analysis of primers and probes is conducted regularly to ensure fitness for detection of currently circulating strains. The commercial FilmArray BioThreat Panel (BioFire) is also used on suspected cases of VHF as an adjunct test.

Viraemia can be reliably detected from the time of presentation for at least 14 days; occasionally for as long as 21 days. To prevent false negatives, results obtained in the first 48 hours of illness should be confirmed by a second specimen obtained after this time when a high degree of clinical suspicion exists.

Genomic sequencing

Sanger sequencing of amplicons generated by conventional RT-PCR can be used to confirm the specific detection of a VHF pathogen. Whole genome sequencing using next-generation sequencing technologies can also be used to confirm the molecular detection and support contact tracing efforts, through detailed phylogenetics and genomic epidemiological analysis.

Virus isolation

Virus isolation from serum or other clinical material remains a reference method for confirmatory testing and can also be used for reagent production, test validation or research. Postmortem liver tissue is the most suitable source of virus after serum, while throat washings or urine samples have less commonly yielded virus.

PC4 containment is required for virus amplification in cell culture. Viral replication can be monitored by microscopy, immunofluorescence or real-time quantitative reverse transcription polymerase chain reaction (RT-qPCR).

Note: The filoviruses, Ebola virus and Marburg virus, are Tier 1 security sensitive biological agents in Australia. They may only be stored or manipulated in an appropriately accredited facility by authorised staff like the NHSQL VIDRL.

Serological tests

Antigen testing

Detection of viral antigens, most commonly using monoclonal antibodies in an antigen-capture enzyme immunoassay (EIA), has been widely used in the laboratory and in the field in endemic settings. Antigenaemia has been shown to clear with the appearance of immunoglobulin M, (IgM) on average, one to two days before RT-PCR became negative. Rapid antigen tests are generally not recommended in settings where RT-PCR is available due to poor sensitivity.¹

Antibody testing

Serology can be useful for sero-epidemiological purposes in endemic settings or outbreaks and as an adjunct to direct virus detection, especially in survivors during the convalescent period. Its use in acute diagnosis is limited, however, by the frequent failure for an antibody response to be mounted in fatal cases.

In addition, antibody responses may not be detectable in the early stages of infection, and cross-reactivity with other viruses in the same genus has been seen.² Virus neutralisation assays require live virus and containment facilities, limiting their use in resource-constrained settings.

The VIDRL does not currently use serological assays for diagnosis or confirmation of VHF.

Reporting

On validation of a positive or negative VHF result, the VIDRL microbiologist will notify the clinical microbiologist of the referring diagnostic laboratory, the LPHU and the department by phone.

A report will be issued to the referring laboratory and the department will be automatically notified by the VIDRL Laboratory Information Management System.

Quality assurance

VIDRL’s assays are National Association of Testing Authorities (NATA) accredited to the ISO 15189 standard. Assay primers and probes are regularly assessed for applicability to currently circulating strains by in silico analysis. The VIDRL also participates in The Royal College of Pathologists of Australasia Quality Assurance Program covering proficiency testing for VHF pathogens.

Notes

¹ Bettini, A., Lapa, D., & Garbuglia, A. R. (2023). Diagnostics of Ebola virus. Frontiers in Public Health, 11, Article 1234567.

² World Health Organization. (2025, February). Marburg virus disease – Tanzania and Rwanda outbreaks 2025.

Understand infection prevention and control (IPC) for viral haemorrhagic fevers, including PPE, environmental cleaning, and de-escalation of isolation and patient transport.

General IPC principles and patient management requirements include that:

• preventing the transmission of infection in health care settings requires the application of three main types of controls:
  • administrative support for the implementation of an evidence-based IPC program
  • adequate environmental and engineering infrastructure
  • PPE
• direct or indirect exposure of mucous membranes and non-intact skin to blood and other body fluids is the primary route of infection for VHF. There is no evidence that Ebola (or other VHF viruses) can penetrate intact skin¹
• although airborne transmission of VHF has not been demonstrated, the possibility of transmission via aerosol-generating events or procedures should not be excluded²
• transmission-based precautions must be implemented for all patients with suspected or confirmed VHF. Implement standard, contact and airborne precautions
• in some VHF cases, asymptomatic people in the incubation period are not contagious. VHF is not spread from asymptomatic people through routine clinical or household contact
• a person with VHF is not contagious until the appearance of symptoms. The illness typically progresses from ‘dry’ symptoms (fever, aches and fatigue) to ‘wet’ symptoms (diarrhoea, vomiting and sometimes, bleeding)
• patients are most infectious during the secretory or ‘wet’ phase of the illness
• procedures that increase environmental contamination with blood or body fluids should, wherever possible, be avoided. In particular, these include aerosol-generating procedures (AGPs). Clean and disinfect environmental surfaces as soon as possible after any such contamination occurs
• avoid unnecessary pathology testing. See Appendix 4: Specimen collection and transport for suspected VHF for further details about specimen collection procedures, including decontamination of samples
• PPE must be used when caring for anyone suspected or confirmed of having a VHF or when potentially coming into contact with their blood or body fluids. Choice of PPE should be based on the symptoms exhibited (that is, ‘dry’ or ‘wet’). See Personal protective equipment for more information
• limit the number of health care workers (HCWs) who provide care for a patient with suspected VHF
• limit the use of sharps, such as needles, as much as possible. Sharps should be handled with extreme care and disposed of into a disposable puncture-proof sharps container dedicated for the use of the patient. Consider the use of retractable safety devices, if available, noting staff should be trained in their use
• for non-designated hospitals and other health care settings, even when an early transfer is planned, arrangements for appropriate care while waiting for transfer will be required.

Patient placement

Management of patient placement includes that:

• patients with suspected VHF must be placed in a single room (with the door closed) with their own toilet and bathroom facilities. If ensuite facilities are not available, use a commode in the patient’s room
• a negative pressure ventilation room is not required for the management of patients with suspected VHF, unless AGPs will be performed.

Zoning

To ensure staff can safely don and doff PPE, careful consideration should be given to the location of the patient’s room and surrounding environment (for example, common corridors). Use of separate zones, based on the risk of environmental contamination, may be useful.

More information about zoning, including information about PPE for clinical care of patients with suspected or confirmed EVD in the Australian health care setting, can be found at Infection prevention and control principles and recommendations for Ebola virus disease.

Staff

All HCWs providing care for a patient with VHF should be trained for the respective roles they may be required to undertake. This includes how to safely don and doff PPE.

It is recommended that a trained buddy or observer be used to assist and supervise all staff when putting on and taking off their PPE. The role of the buddy is detailed in Buddy HCW role on Personal protective equipment.

HCWs who have medical or physical conditions that will interfere with the safe use of PPE should not care for patients with VHF.

Some conditions may preclude HCWs from providing direct patient care, including:

• underlying medical conditions that could affect the HCW’s ability to quickly and safely exit the room
• underlying medical conditions that could require another HCW to enter the room to provide urgent medical assistance
• non-intact skin (for example, dermatitis, abrasions or wounds)
• the inability to safely put on, use or take off PPE, or achieve a good fit with a P2/N95 respirator
• immune compromise.

Visitors

Visitors should not be permitted unless essential, for example, the parent or carer of a child with suspected or confirmed VHF.

Children should not visit because of the difficulty in ensuring adequate adherence to the use of PPE.

If someone other than a trained HCW must visit the patient, they must be trained and supervised in the correct use and safe removal of PPE.

Staff and visitor log

A log of all staff and visitors who enter and exit the room should be maintained.

Management of HCWs who cared for a patient with VHF

HCWs should closely monitor their health, including twice-daily body temperature measurements, and immediately report any relevant symptoms to their designated supervisor.

While they remain asymptomatic, HCWs can continue to work in the health care setting. They do not require quarantine if they have used adequate PPE with supervision.

If a PPE breach does occur (or other exposure), an assessment by an infectious diseases physician should be undertaken and consideration given to furloughing the HCW until the end of the relevant VHF incubation period.

Health services must advise the department if there is a PPE breach, to allow appropriate contact management.

De-escalation of isolation

If the diagnostic VHF blood test is negative, additional VHF IPC measures can be ceased. However:

• to prevent false negatives, results obtained in the first 48 hours of illness should be confirmed by a second specimen obtained after this time when a high degree of clinical suspicion exists
• consideration to other infectious diseases should continue as clinically indicated, which may require other transmission-based precautions. This will need to be assessed on a case-by-case basis.

Patients with confirmed VHF will remain in isolation until deemed to be non-infectious by the facility’s infectious diseases service, in consultation with the Chief Human Biosecurity Officer (contact the department on 1300 651 160).

Urgently contact the LPHU and the department (on 1300 651 160) and seek their advice if the patient would like to discharge themselves against medical advice.

Documentation and communication

Management of documentation and communication includes:

• documenting the rationale and timing for de-escalation
• notifying all relevant departments (for example, cleaning services, transport and the lab)
• updating signage and removing isolation notices only after final clearance.

Patient transport

When transporting a patient with suspected or confirmed VHF, remember:

• Transfers of patients should be limited to essential moves only.
• Identify the most direct path that will encounter the least number of people.
• All staff involved in the transport must wear the appropriate level of PPE (1 or 2), according to the clinical situation and setting (see Selection of PPE on Personal protective equipment) and their role during transportation.
• Consider using a transport hood (for example, the Medihood personal ventilation hood) on the patient where available. Where transport hoods are not available, the patient should wear a face mask if tolerated.
• A spill kit, with a solidifying product and vomit bag should accompany the patient.
• Before leaving the room:
  • notify the receiving team to ensure they are ready to receive the patient
  • confirm staff involved in the transport are aware of the route
  • lock down hallways and call for elevators that will be accessed
  • allocate staff to clear traffic from designated pathway.

General principles for selection and use of PPE

When selecting and using PPE, remember:

• PPE should protect the mucous membranes from exposure to blood and body fluids and self-contamination.
• PPE should be adequate, but not excessive, so as not to restrict movement or vision, increase the risk of heat stress for HCWs who may be required to wear the PPE for prolonged periods, or make donning and doffing the PPE more complex.
• PPE chosen should provide maximum protection with minimal discomfort for the wearer.
• Select PPE that is appropriately sized and fits correctly. PPE should also be of suitable quality to provide the required level of protection for the tasks to be undertaken.
• While wearing PPE, do not touch face protection (face shield, goggles or mask) while in the patient’s room.
• All staff who treat patients with suspected or confirmed VHF should be confident in the use of PPE.
• Each step when putting on and taking off PPE should be undertaken slowly and methodically, in accordance with the agreed sequence of the facility.
• Staff should remove any personal items that may become contaminated before donning PPE, such as staff ID cards, wrist watches, jewellery and stethoscopes.
• All health care facilities must ensure that a site-specific step-by-step process for the donning and doffing of PPE is developed and documented. Not only should PPE be put on appropriately, but removal of used PPE is high risk and requires a structured and systematic procedure.
• Dedicated separate areas should be set aside for donning and doffing PPE. PPE should be put on in a clean area away from the patient’s room to protect the PPE from contamination. PPE should be taken off immediately adjacent to the patient’s room to prevent the risk of contamination to other areas.
• Do not touch used PPE or contaminated surfaces in the area where PPE is taken off with bare hands or skin.
• If footwear or personal clothing (for example, underwear and socks) becomes contaminated by a patient’s blood or other body fluids, safely remove these items and discard them with the used PPE.
• Have a plan for a location for a HCW to shower if splashed with body fluids. If clothing or scrubs are contaminated, items may be cut off with scissors. Provide new scrubs prior to showering.

Selection of PPE – risk assessment

When assessing risk for selection of PPE, remember:

• A tiered risk management approach based on the clinical condition of the patient is recommended when selecting PPE.¹
• A risk assessment must be undertaken prior to selecting the PPE level to use, which also considers the patient’s ability to follow instructions (for example, children who may unexpectedly vomit).
• Selection of PPE is graded into two levels of PPE being:
  • Level 1 (Dry) – for use with clinically stable suspected VHF patients with ‘dry’ or low-risk symptoms only, such as fever, aches and fatigue
  • Level 2 (Wet) – for use with suspected VHF patients who are clinically unstable or have ‘wet’ symptoms, such as diarrhoea, vomiting or bleeding, and for confirmed VHF patients.
• When selecting which level of PPE to be used, consider the tasks to be undertaken, the environment in which the PPE is to be used and the person using the PPE.
• If health care facilities decide to add or modify PPE, they must consider the risks and benefits of any modification, and train HCWs on correct donning and doffing in the modified procedures.
• Consideration should also be given to how to safely remove PPE. This may include:
  • ensuring the type or style of PPE selected is relatively simple to remove (for example, boot or shoe covers may be too difficult to remove safely)
  • providing a chair for staff to sit on while removing PPE, particularly footwear
  • ensuring there is enough space for staff to be able to remove PPE without contaminating many surfaces.

While this guideline provides the principles for PPE selection and donning/doffing PPE sequences, health care facilities must always apply these to their own circumstances.

Level 1 (Dry) PPE

Level 1 (Dry) PPE may be used when evaluating a patient with suspected VHF and the patient has low-risk symptoms, that is, fever, headache, fatigue or malaise only.

All PPE is to be single-use and disposable and should include:

• a fluid-resistant long-sleeved gown that extends to at least mid-calf or fluid-resistant coveralls without an integrated hood
• a full-face shield or goggles
• a fluid-resistant P2/N95 respirator
• two pairs of gloves – the outer gloves should have extended cuffs (for example, sterile gloves can be used, as these have extended cuffs).

Note: head and neck coverings, and foot and leg coverings are not required.

Donning and doffing level 1 (Dry) PPE

Level 2 (Wet) PPE

Level 2 (Wet) PPE is recommended for use when providing care for patients confirmed to have VHF or patients with suspected VHF who have high-risk secretory symptoms, that is, vomiting, diarrhoea or bleeding.

In addition to protecting the mucous membranes, PPE should also provide full protection of all clothing, skin and hair.

All exposed skin must be covered.

All PPE is to be single-use and disposable, and should include:

• surgical scrubs (or equivalent)
• a fluid-resistant long-sleeved gown that extends to at least mid-calf or fluid-resistant coveralls without an integrated hood
• a full-face shield or goggles
• a head cover that covers all hair, ears and neck, and extends to the shoulders
• a fluid-resistant P2/N95 respirator (see section 5.4.5 regarding use of powered air-purifying respirators (PAPRs))
• two pairs of gloves – the outer gloves should have extended cuffs (for example, sterile gloves can be used, as these have extended cuffs)
• enclosed, fluid and sharps-resistant footwear
• plastic apron if fluid contamination is anticipated.

Donning and doffing level 2 (Wet) PPE

PAPRs

Use of PAPRs may be considered for Level 2 (Wet) PPE, particularly when staff will be with a clinically unstable patient for prolonged periods.

Facilities must develop their own procedures for the use of PAPRs, which will include donning/doffing procedures that align with the model of PAPR being used.

Other considerations if PAPRs are to be used include ensuring:

• all staff required to use this equipment have been trained and undertake refresher training on a regular basis
• adequate supplies of consumables
• equipment is maintained and serviced regularly as required
• waste generated can be adequately disposed of (for example, if clinical waste bins are sufficiently large for the hoods).

Buddy HCW role

The buddy should wear Level 1 (Dry) PPE, including a long-sleeved gown, face shield or googles, P2/N95 respirator and gloves.

Their role is to assist with the following actions:

• Help step the HCW through the agreed sequence for donning PPE. They can assist with donning PPE where required and should make sure all PPE is comfortable and correctly fitted before the HCW enters the patient room.
• Observe and advise the HCW while in the patient room for actual/potential PPE breaches (the buddy does not enter the room).
• Monitor and guide the HCW in designated removal area to ensure PPE is removed slowly and in the correct order, to avoid contamination of the HCW and the surrounding environment. The buddy’s role is to:
  • visually inspect HCW PPE to check for integrity and contamination. If visible contamination is observed, pass the HCW a disinfectant wipe to remove any soiling
  • read out steps for doffing PPE (consider using a checklist)
  • ensure correct hand hygiene technique is used when taking off PPE and dispense alcohol-based hand rub to prevent contamination of the dispenser
  • untie gown waist and neck ties
  • ensure all PPE is appropriately disposed of into the clinical waste receptacle
  • wipe chair, sink and floor with disinfectant in the doffing area.
• Accept waste from the patient room into another clinical waste bag. The buddy should hold the new clinical waste bag so the bag overlaps their hands, and the inner waste bag can be placed into the bag without coming into contact with the hands of buddy.
• Identify (and record if appropriate) any PPE breaches during patient care or during PPE removal. If a breach is seen during care, advise staff to leave the patient room, and if body fluids are seen on PPE, pass them a disinfectant wipe prior to removal of PPE. Seek advice from infection control or infectious diseases if the HCW is exposed.

Training

Specific and repeated training for HCWs is desirable, and all staff who treat patients with suspected or confirmed VHF should be confident in the use of PPE.

Training should also take place in the room and/or area a patient with VHF may be managed to ensure staff are familiar with the location.

Training sessions may highlight problems with types of PPE used and the sequences for donning and doffing PPE. Use these sessions as an opportunity to make improvements or adaptations as required.

Training should include:

• how to don and doff PPE, including the correct order to avoid cross-contamination
• how to check correct fit of PPE, including P2/N95 respirators
• disposal of used PPE and decontamination
• maintenance and storage of PPE
• hand hygiene.

Notes

¹ Commonwealth of Australia. (2015). Infection prevention and control principles and recommendations for Ebola virus disease: Including information about personal protective equipment for clinical care of patients with suspected or confirmed Ebola virus disease in the Australian healthcare setting.

Hand hygiene

Adequate hand hygiene is required at all times, including before, during and after the removal of PPE in the care of patients with VHF.

CDC and World Health Organisation guidance recommends the use of an alcohol-based hand rub (ABHR) on gloves when caring for VHF patients and when taking off PPE.¹ This has been advised in the case of VHF to reduce the viral burden on gloves, to further reduce the likelihood of self-contamination when doffing PPE, and is especially relevant after handling body fluids.

Should the choice be made that ABHR is not to be used directly on gloves, hand hygiene practices must still ensure safety for the patient, particularly prior to a procedure, as well as for the HCW.

Double gloving is recommended as it provides an outer layer that allows for the removal of a heavily soiled glove during patient care and during the PPE removal sequence. Additional layers (that is, beyond double gloving), are not recommended as they may make the HCW less dextrous and undertaking tasks more difficult.

More information about the use of ABHR on gloves can be found at:

• CDC: Viral Hemorrhagic Fevers: PPE FAQs
• Hand Hygiene Australia: Ebola Virus Disease and Disinfection Of Gloved Hands

Linen

For linen disposal:

• use disposable linen and clothing, wherever possible. If ‘reusable’ linen is used, it is to be disposed of as clinical waste
• linen saturated with fluids should be double bagged with both bags knotted and placed into a leak-proof rigid clinical waste bin.

Food services

For food services:

• single-use crockery and cutlery should be used wherever possible
• meals should be taken into the patient’s room by HCWs caring for the patient
• all food waste, disposable crockery and cutlery must be disposed of as clinical waste.
  

Waste

Patient with suspected VHF while waiting for results

Waste contaminated with blood or body fluids from a patient under investigation for VHF should have their waste managed in one of the following ways:

• left in the room until VHF has been excluded or confirmed (if there is sufficient space)
• stored (double bagged and in a rigid container) in a segregated area
• discarded immediately as clinical waste (for incineration), if there is insufficient room to store the waste.

If the patient is not producing secretions, clinical waste can be placed in sealed bags and disposed of as per the facility’s waste management policy, as there is minimal risk from this type of waste when patients are in the ‘dry’ or non-secretory phase.

Patient with confirmed VHF

All waste from patients with confirmed VHF is to be incinerated (or autoclaved), including:

• PPE
• linen
• medical supplies
• body fluids and contaminated items.

Facilities will need to determine how waste is to be safely removed from the patient room and where it is to be stored for final disposal.

A system should be developed for double-bagging all waste from the patient’s room. The first clinical waste bag from inside the patient’s room should be placed into a second clinical waste bag kept immediately outside the patient room. This may require a buddy system to be able to do this safely.

Clinical waste bags should be sealed before placing into a rigid outer container for transport.

If the waste includes a liquid component, use absorbent material to contain the fluid.

Fill bags to a maximum of three-quarters full to allow them to be adequately sealed.

The secure rigid outer container should be of sufficient dimensions to deposit and accommodate waste items likely to be generated in the routine care of the patient (for example, items of PPE).

Consideration could be given to using two types of waste bins – a lockable and sealable clinical waste bin for wet waste and an anatomical waste bin for other waste, as this can also be locked.

Organise with environmental services to deliver anatomical/clinical waste bins and facilitate ongoing supply of bins for the duration of the patient stay.

All used syringes, needles and sharps are to be placed into a designated sharps container, sealed and placed inside a clinical waste bin so it can be incinerated. Wipe the sealed sharps container, if visibly contaminated, with hospital-approved detergent/disinfectant wipes prior to removal from the patient’s room.

PPE

Staff handling VHF waste must wear Level 1 (Dry) PPE on Personal protective equipment (PPE), including:

• gloves
• long-sleeved gowns and aprons
• eye protection (goggles or face shields)
• a P2/N95 respirator
• closed shoes or boots.

In-hospital transport of waste

For in-hospital waste transport:

• use dedicated, closed containers for waste transport
• avoid transporting waste through public areas
• disinfect carts after each use with an approved detergent/disinfectant.

Storage of waste until collected

VHF waste should be stored in a safe and secure locked environment to prevent accidental or unauthorised access.

The secure rigid outer container must carry outer labelling consistent with UN2814/ADG Class 6.2 for transport and carry the text 'In the case of damage or leakage, immediately notify Public Health Authority.'

Treatment and disposal

Waste must be autoclaved, incinerated or otherwise inactivated before disposal.

Once properly treated, waste can be disposed of as regular medical waste.

Offsite transport and treatment

If untreated waste is transported offsite, it must comply with the Environmental Protection Regulations as a Category A Infectious substance, prescribed industrial waste.

The secure rigid outer container carrying this waste must be accompanied by a Transport Certificate setting out the prescribed waste as Hazard Category A waste/UN Number 2814. This includes the requirement for the waste generator to ensure that the waste transporter is aware of the transportation of VHF waste in permitted vehicles compliant with the Environment Protection Authority Victoria (EPA) special waste classification for VHF waste (R100).

Management of human waste

When managing human waste, remember:

• All human waste is potentially infectious.
• Although it is likely safe for human waste from patients with a VHF to be disposed of via the sewage system, it is recommended that all excreta be disposed of as clinical waste.
• All staff involved in the handling or disposal of human waste must wear the appropriate level of PPE (1 or 2) following a risk assessment (see Selection of PPE - risk assessment on Personal protective equipment).

Bedpans, urinals and commodes

Single-use bedpans and urinals are highly recommended. If reusable bedpans or urinals are all that is available, these must be discarded after use.

The method for disposal of excreta as clinical waste is as follows:

1. Solidify waste using high-absorbency granules or gel. If this is not available, place an incontinence pad in the receptacle to prevent leakage.
2. Place the bedpan or urinal, and contents, into a clinical waste bag and secure.
3. Consider double-bagging human waste disposed of via this method. Remove outer gloves, perform hand hygiene and reapply a second pair of gloves.

Nappies and incontinence pads

For nappies and incontinence pads:

• Place used items into a clinical waste bag and secure. Consider double-bagging human waste disposed of via this method.
• Remove outer gloves, perform hand hygiene and reapply a second pair of gloves.

Transmission of VHF is primarily from direct contact with body fluids of an infected person. While the environment may become contaminated, spot cleaning of body fluid spills at the time of contamination minimises the risk of transmission.

Limit room entry to essential staff only. Routine and spot cleaning in the patient’s room should be undertaken by staff caring for the patient.

PPE

All staff involved in the cleaning and disinfection of the patient room or communal equipment must wear the appropriate Level 1 or Level 2 of PPE, according to the relevant area or room they are cleaning.

Disinfectants

While sodium hypochlorite has been proven to be effective at inactivating VHF viruses, there are several disinfectant products commonly used in health care settings that are registered with the Therapeutic Goods Administration (TGA) as being effective. This includes some two-in-one detergent/disinfectant wipes. Contact your cleaning supplier for information on products available at your site.

Any disinfectant product used must be used at the recommended strength for the appropriate amount of ‘kill’ time.

Chlorine-based disinfectants, such as sodium hypochlorite, are most commonly used for environmental disinfection for VHF. Where available, granule, powder or gel forms should be used for the initial management of spills to minimise the risk of aerosolisation.

Note: chlorine solutions lose potency quickly. As such, they should be made up in smaller quantities as required or, at a minimum, daily.

Routine and spot cleaning

Routine environmental cleaning should be undertaken using either:

• a two-step detergent clean (physical clean with detergent followed by a chemical disinfectant)
• combined two-in-one detergent/disinfectant clean (physical clean using a combined detergent/disinfectant wipe/solution).

For routine and spot cleaning:

• regularly clean and disinfect surfaces in the patient care area, even in the absence of visible contamination
• immediately clean and disinfect any visible contamination of surfaces or equipment (spot cleaning)
• clean and disinfect hard, nonporous surfaces daily, including frequently touched surfaces (for example, bed rails and over-bed tables), counters and floors
• use disposable cleaning cloths, mop cloths and wipes, and dispose of these in leak-proof bags. Use a rigid waste receptacle designed to support the bag to help minimise contamination of the bag’s exterior
• routine cleaning of the PPE doffing area should be performed at least once per day and after the removal of grossly contaminated PPE
• cleaning should be performed by a HCW wearing Level 1 or Level 2 PPE (see Personal protective equipment)
• when cleaning and disinfection are complete, the HCW should carefully take off their PPE and perform hand hygiene.

Medical equipment and devices

For use of medical equipment and devices, remember:

• Equipment in the room should be limited to only what is essential for patient care.
• Equipment must be dedicated for the sole use of the patient for the duration of their stay.
• Wherever possible, single-use equipment should be used and be disposed of as VHF waste when no longer required.

Reusable medical devices

For reusable medical devises, remember:

• Reusable medical devices should be cleaned and disinfected in the room.
• Any visible contamination should first be wiped off similarly as described in the spill section.
• The items should then be cleaned in a two-step process, with a neutral detergent first, then with a disinfectant specified in the manufacturers’ instructions.

Blood and body fluid spills

Larger blood and body fluid spills (greater than 10cm) should be managed in the following manner:

1. Contain the spill by applying paper towel, a spill mat or absorbent sheet. Dispose of waste into a clinical waste bag.
2. Apply sodium hypochlorite granules or gel to any remaining spill residue, then cover with paper towel.
3. Leave for 30 minutes.
4. Remove paper towel and wipe up granules. Dispose of into a clinical waste bag.
5. Clean the area of the spill with detergent, then disinfectant or a combined two-in-one detergent disinfectant wipe. Dispose of cloth/wipe into a clinical waste bag.
6. Disinfect the area of the spill with a cloth saturated with sodium hypochlorite 5,000 ppm. Leave for 30 minutes. Dispose of cloth into a clinical waste bag.
7. Dry area with paper towel. Dispose of items into a clinical waste bag.

Discharge cleaning

Discharge cleaning should be carried out as for routine cleaning with the following additions:

• A higher concentration of sodium hypochlorite (5,000 ppm) should be used.
• All textiles contaminated with body fluids, including curtains, should be disposed of as clinical waste.
• If a negative pressure ventilation room was used (for example, an AGP was conducted), maintain negative pressure during discharge cleaning and for 30 minutes afterwards, before another patient is admitted to the room. The pre-filter should also be changed and checked for damage by appropriate personnel.

Management of cleaning equipment

For management of cleaning equipment, remember:

• All single-use cleaning cloths and the mop head should be disposed of in double-bagged clinical waste.
• All cleaning equipment (mop handles and buckets if used) should be cleaned after each use and kept in the room until the patient is discharged, and cleaning has been completed.
• It is preferable not to pour liquid waste or leftover cleaning solutions into an ensuite toilet to prevent aerosolisation or risk of splash. Remaining cleaning solutions should be disposed of using absorbent granules or gel, which is then disposed of as double-bagged clinical waste.

VHF viruses can be detected throughout the body after death. A such, VHF can be transmitted by laceration and puncture with contaminated instruments used during postmortem care, through direct handling of human remains without appropriate PPE, and from splashes of blood or other body fluids to unprotected mucosa which can occur during care of the deceased.

The following are important principles of care for people who have died due to VHF:

• Only personnel trained in handling infected human remains, and wearing PPE, should touch or move any VHF-infected remains or suspected VHF-infected remains.
• Handling of human remains should be kept to a minimum.
• Autopsies should not be performed on patients who die with VHF. An autopsy should only be done if directed by the coroner and following discussion with the department’s Communicable Disease section and the Victorian Institute of Forensic Medicine.
• When a deceased person has suspected VHF, but not confirmed, any post-mortem procedures should be delayed until testing for VHF is completed. Handle the body as if they have VHF, until confirmed otherwise.

Preparation of the deceased patient

In preparing the deceased patient, remember:

• Use Level 1 (Dry) PPE when handling the deceased.
• Do not remove intravascular devices or other invasive medical devices.
• Do not wash or clean the deceased.
• Place the body into a leak-proof body bag, zipper it closed, then place inside a second leak-proof body bag zippered closed.
• Once the body has been placed inside the first bag, the HCWs handling the body should change the outer layer of their gloves and apron. Disinfect the inner gloves before preplacing the second pair.
• If the zipper does not ‘seal’ the bag to make it leak-proof, consider using tape to seal the zipper.
• Take care that the bags are protected from punctures, either from the inside (for example, from medical devices left attached) or from external objects.
• Clearly label the outside bag with:
  • the name of the deceased
  • ‘Infectious Disease – Group A – Handle with Care’.
• Prior to transporting to the mortuary, use detergent/disinfectant to decontaminate the outer surface of the body bag.

Mortuary care

At the mortuary:

• do not open the body bags or remove the remains from the bag. Bagged remains should be placed directly into a casket or coffin, and sealed
• mortuary care personnel should wear Level 1 (Dry) PPE; single-use gloves (two pairs to be worn), a fluid-resistant or impermeable gown and surgical hood or a coverall, eye protection (goggles or face shield), and leg and shoe covers when handling the bagged remains
• in the event of leakage of fluids from the body bag, thoroughly clean and decontaminate areas of the environment (see Blood and body fluid spills on Environmental cleaning).

Handoff to funeral services

For funeral services, remember:

• Ensure a localised procedure is in place for transferring remains to funeral homes.
• Consideration could be given to transporting the body directly from the deceased’s room to a parked funeral vehicle, thereby avoiding the potential for contaminating another area in the facility.
• There should be no viewing of the deceased by family members. The body bags and casket/coffin should remain sealed.
• Funeral home staff must be trained and equipped with PPE.
• Avoid delays to minimise risk of decomposition and fluid leakage.
• Transportation of remains that contain VHF viruses should be minimised.

Additional information to support the Victorian guideline on viral haemorrhagic fevers.

This is a guide to the acronym and abbreviations used in the Victorian guideline on viral haemorrhagic fevers.

The following people contributed to the development of the first version of this guideline in 2025.

Clinical waste

Clinical waste includes wastes arising from medical, nursing, dental, veterinary, laboratory, pharmaceutical, podiatry, tattooing, body piercing, brothels, emergency services, blood banks, mortuary practices and other similar practices, and wastes generated in health care facilities or other facilities during the investigation or treatment of patients or research projects.

For more information, see Clinical and related waste – Operational guidance

National High Security Quarantine Laboratory (NHSQL)

The NHSQL is a physical containment level 4 facility designed for microorganisms that require the maximum level of containment.¹

Orthoebolavirus (genus name – formally Ebolavirus)²

Orthomarburgvirus (genus name – formally Marburgvirus)²

Surveillance case definition

CDNA surveillance case definitions should not be used for clinical diagnostic purposes.

Confirmed case

A confirmed case requires laboratory definitive evidence only.

Laboratory definitive evidence requires confirmation by the Victorian Infectious Diseases Reference Laboratory (VIDRL), Melbourne or the Special Pathogens Laboratory, CDC, Atlanta or the Special Pathogens Laboratory, National Institute of Virology, Johannesburg for:

• isolation of a specific virus

OR

• detection of a specific virus by nucleic acid testing or antigen detection assay

OR

• IgG seroconversion or a significant increase in antibody level or a fourfold or greater rise in titre to a specific virus.

Suspected case

A suspected case has compatible clinical evidence AND epidemiological evidence.

Clinical evidence requires a compatible clinical illness as determined by an infectious disease physician. Common presenting complaints are fever, myalgia and prostration, with headache, pharyngitis, conjunctival injection, flushing and gastrointestinal symptoms. This may be complicated by spontaneous bleeding, petechiae, hypotension and perhaps shock, oedema and neurologic involvement.

Epidemiological evidence requires:

• history of travel to an endemic/epidemic area within nine days (Marburg), 13 days (Crimean-Congo) or 21 days (Lassa, Ebola) of illness onset. Filoviruses are endemic in Sub-Saharan Africa, Lassa in Western Africa, Crimean-Congo in Africa and the Middle East to West China

OR

• contact with a confirmed case

OR

• exposure to viral haemorrhagic fever (VHF) infected blood or tissues.

Notes

¹ Victorian Infectious Diseases Reference Laboratory. (2025). High Security/Quarantine (VIDRL)

²Biedenkopf, N., Bukreyev, A., Chandran, K., Di Paola, N., & Formenty, P. B. H. (2023). Renaming of genera Ebolavirus and Marburgvirus to Orthoebolavirus and Orthomarburgvirus, respectively, and introduction of binomial species names within family Filoviridae. Archives of Virology, 168(1)

Use this checklist when there is a high possibility of managing a VHF case.

Downloads

General principles

• Specimen collection should preferably occur at a designated hospital (RMH or RCH) whenever possible.
• If urgent transfer is not required and delaying collection may compromise diagnosis, venepuncture should be performed at the initial admitting hospital by an experienced clinician.
• Only essential specimens should be collected, and safety must take priority, in accordance with the National High Security Quarantine Laboratory Guideline for Management of Quarantinable Viral haemorrhagic Fevers.

Specimens to collect

• Preferred specimens for virus detection include:
  • whole blood (ethylenediaminetetraacetic acid (EDTA) tube – mauve top)
  • for RT-PCR, serology (storage) and virus isolation.
• Alternative specimens (if blood collection not possible) include:
  • throat swab (in viral transport medium, screw-capped plastic tube)
  • urine sample
  • oral fluids/swabs – only if collection can be performed safely without inducing vomiting or coughing.
• Post-mortem specimens (if available) – serum, liver, spleen and kidney tissues (fixed in 10% (100,000 ppm) buffered formalin or 2.5% glutaraldehyde (25,000 ppm)).

Table 2. Tests available

Preparation

• PPE requirements for all personnel include:
  • double gloves
  • impervious long-sleeve gown
  • enclosed, fluid and sharps-resistant footwear
  • P2/N95 respirator
  • full-face visor.
• Label all specimen containers in advance with:
  • ‘Infectious Risk’
  • patient details, date/time of collection, sample type, clinical context.

Specimen collection

• Perform venepuncture or alternative specimen collection using strict precautions.
• Do not recap needles – dispose of immediately into sharps container.
• Place specimens for transport in a tightly sealed, watertight collection container, such as a Bio-Bottle or rigid screw-cap plastic tube certified for Category A – UN2814 Infectious Substances, Affecting Humans, and seal the cap with Parafilm.
• Decontaminate each specimen tube – wipe with paper towel soaked in 0.1% sodium hypochlorite (1,000 ppm).
• Package immediately (as outlined in Packaging for transport).

Packaging for transport

• For transport of all pathology specimens and associated materials, the packaging must consist of three components, in accordance with Requirements for the packaging and transport of pathology specimens and associated materials (fifth edition), which are the:
  • primary receptacle
  • secondary packaging
  • outer packaging.
• Wrap the primary collection container in absorbent material (sufficient to absorb potential leaks and provide cushioning to prevent breakage)
• Place in two sealable, leak-proof specimen bags (double-bag).
• Wipe outer bag with 0.1% sodium hypochlorite (1,000 ppm).
• Place the double-bagged primary collection container in a durable, watertight screw-cap mailing tube, metal can or bio-bottle. This secondary container should be sealed with tape. Several primary containers may be placed in one secondary container to a maximum of 50ml of specimen material.
• On the outside of the secondary container, attach the specimen labels and other relevant information.
• Insert into a rigid outer container (for example, esky) approved for Category A transport. Address to:

National High Security Quarantine Laboratory
Victorian Infectious Diseases Reference Laboratory (VIDRL)
The Doherty Institute
792 Elizabeth Street
Melbourne, VIC 3000

• Attach to the outer packaging:
  • an infectious substance label (‘Infectious Substances, Affecting Humans’)¹
  • a request form (specifying required tests)
  • a list of contents
  • ensure documentation for traceability. See the VIDRL chain of custody form.
• Maintain specimens at 4°C during storage/transport (do not freeze). Transport specimen for virus isolation chilled on wet or dry ice as appropriate, depending on the duration of shipping.

Handling and registration

• Ensure specimens are registered via pathology reception at the relevant hospital laboratory:
  • DO NOT use pneumatic tube or automated systems to deliver specimens to laboratory.
  • Where possible, avoid unnecessary double handling of specimen/s at multiple locations within a health service, by consideration of ways to register specimen/s that minimise transport of specimens to different parts of the health service.
• Complete documentation to include the following:
  • Record all staff handling specimens (name, role, date, time).
  • The documentation must accompany the specimen through to VIDRL.
• Limit handling to essential staff only.

Transport to VIDRL

• Use a courier service approved for handling Category A specimens and biosecurity material. Call the department and advise of transport details. If health services courier does not transport Category A specimens, contact the department (1300 651 160) and they can arrange the courier in consultation with LPHUs.
• The department officer will notify the on-call VIDRL medical microbiologist before dispatch of the specimen with the courier or bill number, as required for transport of a Tier 1 security sensitive biological agent
• The department officer will contact the VIDRL Laboratory Manager on-call (0438 599 439) to confirm details.
• Transport directly to the Doherty Institute. VIDRL staff will meet directly with the courier:
  • During business hours, the courier is to deliver specimens directly to the Doherty Reception (who will call VIDRL).
  • After hours, the courier is to call VIDRL Laboratory Manager on-call (0438 599 439) who will organise the appropriate personnel to meet them at the Elizabeth Street entrance.
  • DO NOT leave specimen/s in VIDRL after hours drop box.
  • Do not leave specimens unattended.
• VIDRL staff will collect and transfer specimens directly to the PC4 laboratory.

Refer to the following key documents for more information on recommendations for specimen collection:

• PHLN national high security quarantine laboratory guideline for management of quarantinable viral haemorrhagic fevers
• PHLN laboratory procedures and precautions for samples collected from patients with viral haemorrhagic fevers: Part A: Guidelines for laboratories that are not associated with a designated isolation hospital
• PHLN laboratory procedures and precautions for samples collected from patients with viral haemorrhagic fevers: Part B: Guidelines for laboratories that are associated with a designated isolation hospital

Notes

¹ Australian Commission on Safety and Quality in Health Care. (2022). Requirements for the packaging and transport of pathology specimens and associated materials (5th ed.)