Advertisement

EuroNHID checklists for the assessment of high-level isolation units and referral centres for highly infectious diseases: results from the pilot phase of a European survey

      Abstract

      Healthcare settings have been identified as preferential for the transmission of many agents causing highly infectious diseases (HIDs). Infection control procedures strongly reduce the risk of transmission of HIDs in hospital settings, when adequately applied. The main objective of the European Network for Highly Infectious Diseases (EuroNHID), a network co-funded by the European Commission, is to assess the current capabilities for dealing with HIDs in Europe, specifically in the context of infection control and healthcare worker (HCW) safety, through conducting an on-the-field survey of high-level isolation units (HLIUs)/referral centres for the management of HIDs in participating countries. During the first year of the project's activities, specifically designed, evidence-based checklists were developed. This review introduces the EuroNHID checklists as a standard tool for the assessment of hospital capabilities concerning infection control and HCW safety in the management of patients with HIDs, and presents preliminary results from five HLIUs.

      Keywords

      Introduction

      High-level isolation units (HLIUs) are clinical facilities specifically designed to provide high-quality patient care while minimizing nosocomial transmission of highly contagious and hazardous diseases, in order to protect healthcare workers (HCWs), other patients, and the entire population. Specific consensus statements for the design and operation of HLIUs have been recently issued by panels of experts from both the USA and Europe [
      • Bannister B
      • Puro V
      • Fusco FM
      • Heptonstall J
      • Ippolito G
      • EUNID Working Group
      Framework for the design and operation of high-level isolation units: consensus of the European Network of Infectious Diseases.
      ,
      • Smith PW
      • Anderson AO
      • Christopher GW
      • et al.
      Designing a biocontainment unit to care for patients with serious communicable diseases: a consensus statement.
      ].
      The European Network for Highly Infectious Diseases (EuroNHID) project, a network co-funded by the European Commission (EC), began its activities in 2007 with the objective of assessing current capabilities in dealing with highly infectious diseases (HIDs) in Europe, specifically in the context of infection control procedures and HCW safety, through on-the-field surveys of HLIUs/referral centres for the management of HIDs in participating countries. In order to perform this survey, during the first year of the project's activities, specifically designed, uniform checklists were developed.
      This review introduces the EuroNHID checklists as a standard tool for the assessment of hospital capabilities concerning infection control and HCW safety in the management of patients with HIDs, and presents preliminary results from five HLIUs.

      Methods

      National public-health authorities in countries that have, or are planning, an HLIU were contacted by the Coordination Team, with the help of the EC, and asked to suggest (although not formally to endorse) physicians with expertise in HID/HLIU management as national representatives.
      EuroNHID includes national representatives from 15 member states (Austria, Bulgaria, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Malta, Poland, Slovenia, Spain and UK) and is coordinated by the Italian National Institute for Infectious Diseases (INMI) ‘L. Spallanzani’, Rome, Italy. Most of the participants are clinicians working in HLIUs or centres designated for referral of patients with HIDs, who, as a whole, have backgrounds in infectious diseases (IDs), intensive care, infection control, pulmonary medicine, occupational health, and public health. A project Steering Committee was constituted at the beginning of the project.
      A networking strategy was adopted in order to develop the checklists. During a preliminary meeting (Rome, 22 October 2007) with the Steering Committee, topics and items to be explored in the checklists were selected, starting from participants’ experiences, available literature, preparedness plans, as well as guidelines of international authorities for the management of HIDs. The list of selected topics and items was approved by all national representatives. Each main topic was then assigned to a Steering Committee member with specific expertise, who drafted a preliminary checklist. Advanced checklist versions were developed in order to incorporate comments, suggestions and additional evidence from all participants. Final agreement was reached during a general meeting (Rome, 10–11 April 2008). The checklists were developed as standard and shared survey tools and are not intended to set forth mandatory requirements or establish a national standard for legal preparedness.
      In order to check the applicability of these checklists, the Coordination Team and the Steering Committee decided to perform a pilot phase of the survey, applying the checklists in their own HLIU/referral centre. Moreover, we also contacted the staff of another HLIU in Sweden, which is not included in the project, and asked them to apply the checklists, as an external control.

      Results

       EuroNHID checklists

      Three different checklists have been developed, including 44 items and 148 specific questions. The main areas explored were:
      Checklist 1, hospital resources: infrastructure (including location, capacity and infrastructures), technical aspects (including technical infrastructures, control and maintenance issues, availability of medical equipment, diagnostic capability), personnel availability, and an optional section on infection control in the Emergency Department/Medical Admission Department.
      Checklist 2, hospital procedures: administrative aspects, management of personal protective equipment (PPE) (including selection, donning and removal procedures, and supplying), hand hygiene (including specific procedures and existence of adequate technical features), prevention of needle-stick injuries (including existence of adequate devices), transportation of patients (including logistic and technical aspects), routine hygiene and disinfection, waste management (including logistic and technical features), post-mortem procedures, surge capacity procedures.
      Checklist 3, HCW safety: organizational and administrative aspects of HCW safety (including services available, procedures of assessment of safety culture and climate), medical aspects of HCW safety (including pre- and post-exposure management), education and training of HCWs.
      Complete checklists are available online, at the European Network of Infectious Diseases (EUNID) website (http://www.eunid.eu), after registration, in the page ‘Documents’.

       Pilot phase

      The final version of the checklists was applied in HLIUs in France (Marseille), Germany (Frankfurt), Italy (Rome), Sweden (Linköping) and the UK (London). The resources/procedures/capabilities available in the unit are briefly described below.

       Bio Safety Level 3 ward of the infectious disease and tropical medicine service, CHU Nord AP-HM, Marseille, France (Fig. 1)

      The HLIU in Marseille was built in 2005, and is located in a separate building, connected with a bridge to the main general, university hospital. It is also routinely used for other ID patients.
      Figure thumbnail gr1
      FIG. 1.Inside of the high-level isolation unit at CHU Nord AP-HM, Marseille, France.
      Four single rooms and two double rooms are available. Two single rooms are provided with equipment for intensive care (IC) and are also equipped for assistance to paediatric patients. Each room is sealed, and is provided with negative pressure (up to −50 Pa), high-efficiency particulate air (HEPA) filtration of both supply and exhausted air, with 25 air changes per hour, and an anteroom for the entire unit. Additional technical features of the unit and of the room are reported in Table 1. Available medical equipment is summarized in Table 2.
      TABLE 1Additional technical features of units and isolation rooms
      CHU Nord AP‐HM, FranceJ. W. Goethe‐University, GermanyINMI ‘L. Spallanzani’, Italy (currently operating unit)Royal Free Hospital, UKLinköping University Hospital, Sweden
      Unit
       Separate entrance for HCWsXXXXX
       Separate entrance for HID patientXXXXX
       Existence of security circuit
      A secure perimeter around the HLIU that is only accessible to members of staff/authorized personnel, consisting of a fence with or without closed circuit television (CCTV) in the case of stand‐alone units or CCTV and closed doors in the case of HLIUs integrated into other buildings.
      and/or    security personnel
      XXX
       Emergency power generating systemXXXXX
       Pass‐through autoclave/sXX
      Not located within the facility, and not used exclusively for the unit.
      X
      Isolation room
       Internal communication systemXXXXX
       Negative air pressure indicatorsXXXXX
       Self‐closing doorsXXXXX
       Private bathroomXXXXX
      a A secure perimeter around the HLIU that is only accessible to members of staff/authorized personnel, consisting of a fence with or without closed circuit television (CCTV) in the case of stand‐alone units or CCTV and closed doors in the case of HLIUs integrated into other buildings.
      b Not located within the facility, and not used exclusively for the unit.
      TABLE 2Availability of medical equipments
      CHU Nord AP‐HM, FranceJ. W. Goethe‐University, GermanyINMI ‘L. Spallanzani’, Italy (currently operating unit)Royal Free Hospital, UKLinköping University Hospital, Sweden
      Portable ultra‐sonographX
      Not permanently stationed in the unit, available ‘on call’.
      XX
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      Portable X‐rayXXX
      Not permanently stationed in the unit, available ‘on call’.
      XX
      Not permanently stationed in the unit, available ‘on call’.
      Mechanical ventilatorX
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      XX
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      Minor surgery setsX
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      Equipment for renal replacement/CVVHDF
      Continuous Veno‐Venous Hemodiafiltration.
      X
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      ECG
      Portable electrocardiograph, and/or monitor integrated into life‐support systems.
      XXXXX
      Transesophageal EchocardiographX
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      Blood gas analyserX
      Not permanently stationed in the unit, available ‘on call’.
      XXXX
      BronchoscopeX
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      Gastro‐/colonoscopeX
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      X
      Not permanently stationed in the unit, available ‘on call’.
      a Not permanently stationed in the unit, available ‘on call’.
      b Continuous Veno‐Venous Hemodiafiltration.
      c Portable electrocardiograph, and/or monitor integrated into life‐support systems.
      A Bio Safety Level (BSL) 3 referral laboratory is approximately 10 km away. In the case of HID patients, routine haematological and biochemistry tests are performed in the referral laboratory.
      In the unit, five ID physicians, one IC specialist, eight ID nurses, six IC nurses and four radiology technicians have been specifically trained for dealing with HIDs, also through participation in practical exercises. The staff, during an event involving an HID, is totally dedicated to HID patient/s.
      Some services for the safety of these HCWs are in operation within the unit: the risk manager, an infection control team, and an occupational health service. Protocols for the management of biological and chemical accidents, and policies for vaccination and chemoprophylaxis of HCWs are in place in the unit, and a service for psychological support to HCWs involved in giving care to HID patients is available. The infection control procedures in place in the unit are summarized in Table 3.
      TABLE 3Availability of infection control procedures
      CHU Nord AP‐HM, FranceJ. W. Goethe‐University, GermanyINMI ‘L. Spallanzani’, Italy (currently operating unit)Royal Free Hospital, UKUniversity Hospital Linköping, Sweden
      PPE selection, donning and removalSpecific procedures available, including use of respiratory masks. Fit‐test not performedSpecific procedures available, including performance of fit‐test in case of use of respiratory masksSpecific procedures available, including (not regularly) performance of fit‐test in case of use of respiratory masksStandard procedures as in other hospital wards, fit‐test not performed because special plastic isolators are in use, not requiring high‐level PPESpecific procedures available, including (not regularly) performance of fit‐test in case of use of respiratory masks
      Hand hygieneAlcohol‐based solutionAlcohol‐based gel and solutionLiquid soap and alcohol‐based solutionLiquid soap and alcohol‐based gelLiquid soap and alcohol‐based solution
      Prevention of needle‐stick injuriesSeveral specific devices in useSeveral specific devices in useSeveral specific devices in useSeveral specific devices in useSeveral specific devices in use
      Final disinfectionSurface disinfection and fumigationSurface disinfection onlySurface disinfection onlySurface disinfection and fumigationSurface disinfection and fumigation
      Management of solid wasteIncineration in an outside facility after transportation in a locked containerUse of autoclave before incinerationIncineration in an outside facility after transportation in a locked containerUse of autoclave before incinerationIncineration in a nearby facility in the hospital
      Management of liquid wasteChlorinationUse of autoclave before disposalChlorinationSolidification through a gel and autoclavedSolidification through a gel and disposal together with solid waste
      Transportation of HID patient outside the hospitalNormal ambulance and ‘full standard PPE’Specifically designed, negative pressurized, HEPA‐filtered transporter equipped for ICSpecifically designed, negative pressurized, HEPA‐filtered ambulance and stretcher isolatorNormal ambulance and ‘full standard PPE’ or stretcher isolator (by risk assessment)Specifically designed, negative pressurized, HEPA‐filtered transporter equipped for IC
      Transportation of HID patient within the hospitalAlong reserved pathwaysAlong reserved pathwaysAlong reserved pathways with stretcher isolatorAlong reserved pathways or stretcher isolator (by risk assessment)Along reserved pathways
      Post‐mortem proceduresSpecific procedures available, BSL‐3 autopsy room or specific devices not availableSpecific procedures available, specifically trained pathologist and specific devices availableSpecific procedures available, BSL‐3 autopsy room, specifically trained pathologist, and specific devices availableNeedle necropsies onlyNo pre‐existing planning for regular autopsiesin HID (will presumably be minimized to needle biopsies/sampling)
      Strategies for promoting Infection ControlCampaigns, posters, leaflets, videos and management of and participation into table‐top and practical exercisesCampaigns, lectures and management of and participation into table‐top and practical exercisesCampaigns, posters, lectures and management of and participation into table‐top and practical exercisesCampaigns, posters, lectures and management of and participation into table‐top and practical exercisesCampaigns, posters, lectures, videos and management of and participation in practical exercises

       Infectious Disease Ward, Johann Wolfgang Goethe-University, Frankfurt, Germany (Figs 2 and 3)

      The HLIU in Frankfurt is located in a separate building and is used on a daily basis for other ID patients. It was constructed in 2001, on the same site as a general, university hospital.
      Figure thumbnail gr2
      FIG. 2.Front view of the high-level isolation unit at Johann Wolfgang Goethe-University in Frankfurt, Germany.
      Figure thumbnail gr3
      FIG. 3.Interior of the high-level isolation unit at Johann Wolfgang Goethe-University in Frankfurt during the management of a viral haemorrhagic fever case in 2006.
      In the unit, three double rooms are available for isolation of HID patients, both for adults and children. One room is equipped for two IC patients. Each room is sealed and is equipped with negative pressure (up to −30 Pa), HEPA filtration of supply and exhausted air, and anteroom. Further technical features and medical equipment available are given in Tables 1 and 2.
      Diagnostic capabilities for virology (BSL 3 level only) and bacteriology are available in the same campus, while a BSL 4 level laboratory is 80 km away. Tools for microbiology, routine haematology and clinical chemistry are available in the patients’ rooms.
      In the unit, personnel have been specifically trained for dealing with HID patients (through a specific training programme and participation in practical exercises at the local and regional level), including 27 physicians covering many medical specialties, 19 nurses, four technicians and ten housekeeping staff. Plans are in place to ensure that, during an HID event, the trained staff are totally dedicated to HID patient/s. These HCWs have been selected also on the basis of an evaluation of physical aptitude.
      In order to ensure their safety, an infection control and biosafety team are operating in the unit, and protocols for accident management are in place. Periodically, the HCWs’ fears and concerns about HID, and the confidence of HCWs in safety policies (safety climate) are assessed, through personal interview, anonymous questionnaire and group discussion. Protocols for the evaluation of the health status of these HCWs exist, also monitoring absence. Policies for vaccination and chemoprophylaxis of HCWs are available. A psychological support service for HCWs and external consultants is available, too. Protocols for post-exposure management of HCWs and external consultants also exist. Finally, many infection control procedures are in place in the unit (see Table 3 for details).

       INMI ‘L. Spallanzani’, Rome, Italy (Fig. 4)

      The INMI ‘L. Spallanzani’ is an institute for research and care dedicated to IDs, and includes a 250-bed hospital, laboratories and services. The INMI is located near a general public hospital. At the INMI site a new, separate HLIU with direct entrance from the road is under construction. This unit comprises at ground floor level 10 sealed single rooms, each with a separate entrance for patients, double staff anteroom (for entrance from and exit to staff corridor), self-closing doors, autoclave and pass-through box. Each room has a separate air-handling system and is equipped with negative pressure, more than 12 air changes per hour and HEPA filtration of exhaust air, and can operate independently from the others. Medical equipment and devices necessary for diagnosis and care of the patients, including a mobile computed tomography scan, are permanently located within the unit, and dedicated to HID patients only. In the same floor BSL 4 and BSL 3 laboratories are available. On the upper floor, 20 single-bed rooms for isolation/quarantine of HCWs or patient contacts are available. Specific infection control procedures for this HLIU, which will provide the maximum level of biosafety and biosecurity, are under development.
      Figure thumbnail gr4
      FIG. 4.The high-level isolation unit currently under construction at National Institute for Infectious Diseases ‘L. Spallanzani’, Rome, Italy.
      This new HLIU is soon available but currently, in the case of an event, a patient will be managed in a single-bed isolation unit for both adults and children, renovated in 2007, and located in the main hospital building. This unit is not routinely used, has separate entrances for patients and for HCWs, and is equipped with negative pressure, more than 12 air changes per hour, HEPA filtration of supply and exhausting air, double anteroom (for entrance and exit), and is equipped with IC capabilities. Additional technical features of the currently operating isolation unit are given in Table 1, while medical equipment available is given in Table 2.
      BSL 3–4 laboratories are present at the INMI site, while routine haematological and microbiology tests are performed in the central hospital laboratory or in the BSL 3 environment, according to risk assessment.
      A specifically trained task force comprising physicians, nurses and technicians is available, and their number is adequate for the current single-bed isolation unit.
      An infection control team, an occupational health service and a biosafety risk manager are in charge of HCW safety. In the case of an HID event, specific protocols exist for the management of many types of accident (e.g. biological accident, fainting while wearing PPE, mechanical accident or fire in the unit) and for vaccination and chemoprophylaxis. The confidence of HCWs in safety policies, as well as safety culture, has been assessed through anonymous questionnaire and group discussion. The health status of HCWs is constantly monitored and psychological assistance is available during and after an HID event. Moreover, during the event, the staff is dedicated to HID patients only. Also, protocols for post-exposure HCW evaluation, management and surveillance are in place. Specific infection control procedures currently in place in the isolation unit are given in Table 3.

       Royal Free Hospital, London, UK (Fig. 5)

      Recently re-built in 2008, this HLIU is located in a separate ward within the main university hospital building, and is reserved for HID patients.
      Figure thumbnail gr5
      FIG. 5.The plastic isolator (Trexler Unit) in use at Royal Free Hospital, London, UK.
      The unit has two large single rooms (c. 100 m2), with a single-bed flexible-film isolator equipped for IC and suitable for both adults and children. The plastic isolator is completely sealed, and is equipped with four protective suites directly attached to the longer sides of flexible-film, with the front side within the isolator. Also, the rooms are sealed and provided with negative pressure (–40 Pa), with more than 12 air changes per hour, HEPA filtration of incoming and outcoming air, and two separate anterooms for the way in and out (exit is via shower and change procedures) (1). For other technical features and medical equipment available, see Tables 1 and 2.
      The HLIU includes an adjoining suite that contains a BSL 3 flexible-film laboratory isolator, enhanced by being of a completely enclosed (glove-box) design and having HEPA filtration in the air inlet, as well as the exhaust pathway. This laboratory provides an extensive range of pathology tests, including haematology, biochemistry, coagulometry, automated cross-matching, blood film and parasitology procedures, bacterial cultures in a range of atmospheres and a range of on–off serological tests. A BSL 4 laboratory for virology is located approximately 5 km away.
      Fourteen physicians (specialized in ID, IC, Microbiology and Laboratory Medicine, Psychiatry), 33 nurses and eight housekeeping and maintenance persons are in force at the unit. All are trained to deal with HID patients, on the basis of a unit-specific training programme. Some services are in place for the safety of these HCWs (risk manager, infection control team and biosafety manager) and protocols for the management of many types of accidents exist. Safety culture and safety climate in the unit are monitored through personal interviews and group discussion, and implemented also through the participation of HCWs in safety planning. Moreover, for the HCWs involved in the management of an HID event special insurance and special compensation (additional remuneration, deferral leave) are planned.
      The health status and absenteeism of these HCWs are monitored, and a psychological support service is also available. Protocols for vaccination and chemoprophylaxis exist, together with procedures for post-exposure evaluation and management of HCWs. Table 3 shows the infection control procedures in place in the unit.

       Department of Infectious Diseases, University Hospital, Linköping, Sweden (Fig. 6)

      The HLIU, built in 1997, is located on ground level within the infectious disease ward, in an extension of the University Hospital main building. In 2004 the security and ventilation systems of the unit were renovated. The unit is used on a daily basis for isolation and treatment of IDs in general.
      Figure thumbnail gr6
      FIG. 6.The entrance for healthcare workers in the high-level isolation unit operating at the University Hospital of Linköping, Sweden.
      The unit consists of three rooms, two double rooms with IC capability and one room for laboratory facilities. Each room has double anterooms that permit staff to enter from the central corridor, whereas patients enter from the outside. When the unit is ‘activated’, entrance is not possible from the general ward section. Staff enter the unit from the exterior through a separate entrance to a dressing area with shower and rest room. Each ward room is sealed with a verified negative pressure gradient of −50 Pa. Incoming and outgoing air is HEPA-filtered and the ventilation provides six air changes per hour. Other technical features are included in Table 1, while medical equipment is listed in Table 2.
      A laboratory equipped within the unit is the site of all chemical analysis, comparability tests prior to blood transfusions, microbiological analysis (BSL 2), malaria rapid tests, slides and microscopy. Bedside analysers are used for blood gas and glucose analysis. For risk Group 3–4 agents, samples are sent by certified couriers to the BSL 4 laboratory at the Swedish Institute for Infectious Disease Control in Stockholm, a distance of 200 km away.
      The staff of the unit are multidisciplinary and recruited from mainly specialists in infectious diseases, intensive care and from the different laboratory disciplines involved. All work in the unit is voluntary and prior training in PPE is mandatory. Approximately 60 staff persons, including doctors and nurses, are continuously trained.
      Local existing occupational health services and hospital infection control teams are operative and the former have preparation and experience in psychosocial debriefing support. These services also provide for post-exposure management of HCWs. The infection control procedures in place are summarized in Table 3.

      Discussion

      In view of an increase in emerging diseases and HID occurrence and due to emerging situations such as globalization, a substantial part of national preparedness plans and guidelines is dedicated to isolation of cases in hospitals and establishing criteria for hospitals in terms of structures, procedures and staff [
      • Bannister B
      • Puro V
      • Fusco FM
      • Heptonstall J
      • Ippolito G
      • EUNID Working Group
      Framework for the design and operation of high-level isolation units: consensus of the European Network of Infectious Diseases.
      ,
      • Smith PW
      • Anderson AO
      • Christopher GW
      • et al.
      Designing a biocontainment unit to care for patients with serious communicable diseases: a consensus statement.
      ,
      • WHO
      Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care. WHO interim guidelines.
      ,
      • CDC
      ,
      • Jensen PA
      • Lambert LA
      • Iademarco MF
      • Ridzon R
      • CDC
      Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005.
      ,
      • European Commission
      ]. Indeed, hospital capabilities, including adequate infrastructures, infection control procedures and HCW management, are fundamental issues for HID containment.
      In order to obtain effective isolation, different technical approaches have been adopted throughout the world. In the USA, three HLIUs are available; these units are usually constructed near BSL 3–4 laboratories, in order to deal with potential laboratory-acquired infections [
      • Marklund LA
      Patient care in a biological safety level-4 (BSL-4) environment.
      ]. In Europe, different approaches exist. In some countries, HLIUs are available, or are under construction. In the UK, ‘Trexler Units’-type isolators, a particular type of HLIU (a negative-pressure single-bed film isolator, with PPE incorporated in the plastic envelope), are in use [
      • Crowcroft N
      • Brown D
      • Gopal R
      • et al.
      Current management of patients with viral haemorrhagic fevers in the United Kingdom.
      ]. In other countries, HLIUs do not exist, and these patients are managed in standard negative pressure hospital rooms. Finally, different approaches were seen during the SARS epidemic in some countries with local transmission, such as the creation of temporary isolation wards, using negative pressure tents or mobile modules [
      • Fung CP
      • Hsieh TL
      • Tan KH
      • et al.
      Rapid creation of a temporary isolation ward for patients with severe acute respiratory syndrome in Taiwan.
      ,
      • Parmar HA
      • Lim TC
      • Goh JS
      • Tan JT
      • Sitoh YY
      • Hui F
      Providing optimal radiology service in the severe acute respiratory syndrome outbreak: use of mobile CT.
      ,
      • Svoboda T
      • Henry B
      • Shulman L
      • et al.
      Public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in Toronto.
      ]. A similar approach has sometimes been used in limited-resource countries, for example, in order to maintain appropriate isolation during viral haemorrhagic fever outbreaks in Africa [
      • Jeffs B
      • Roddy P
      • Weatherill D
      • et al.
      The Medecins Sans Frontieres intervention in the Marburg hemorrhagic fever epidemic, Uige, Angola, 2005. I. Lessons learned in the hospital.
      ].
      The cost of these special facilities is high, both for construction and for operation and maintenance, and, generally, no ‘special’ reimbursement is planned for these patients by Public Health Systems. Thus, some cost-saving strategies are used. HLIUs could be used flexibly, with more than one level of infection containment, in order to also admit patients with diseases requiring a lower level of isolation, such as TB or other potentially severe airborne infections. Moreover, HLIUs could also be used as an essential tool for training in the management of HIDs, and as a site for specifically designed simulation, both at national and international levels. In such ways HLIUs could have multiple day-by-day functionality, and all the specific procedures could be continually exercised. Formal transnational agreements for the transport of HID patients to the nearest HLIU from countries where these facilities are not available are advisable, but several open questions still exist concerning the feasibility and safety of long-distance transport of these patients, both by ground and by air [
      • Bannister B
      • Puro V
      • Fusco FM
      • Heptonstall J
      • Ippolito G
      • EUNID Working Group
      Framework for the design and operation of high-level isolation units: consensus of the European Network of Infectious Diseases.
      ].
      In recent years, several other networks and consensus conferences for developing agreements on the management of HIDs and isolation facilities have been created, both within Europe [in particular the European Network for Diagnostics of ‘Imported’ Viral Diseases (ENIVD), the Inventory of Resources for Infectious Diseases in Europe and EUNID projects] and in the USA (the Consensus Conference on Designing Bio-containment Units). However, from recent public health threats, such as the SARS epidemic, we have learned that it is important to assess the effectiveness of infection control procedures planned by national and local authorities, as well as to improve HCWs’ knowledge of and compliance with safer procedures and use of devices. Indeed, ‘real-life’ obstacles in the application of these plans, together with lack of harmonization and standards, are among the main obstacles to effective and coordinated interventions. In this contect, EuroNHID checklists represent a valuable common and standardized instrument for self-assessing and implementing resources and procedures. The added value of the project consists in providing an ‘on the field’ evaluation of European capabilities that could allow the transition from a theoretical to a practical, and practicable, approach to infection control and HCW safety in the management of patients affected by HIDs, and from a quantitative to a qualitative evaluation of hospital capability in dealing with transmissible agents of HIDs. The survey, which is currently on-going, will cover approximately 35 HLIUs/referral centres in 15 European countries, and will provide a more comprehensive picture of European preparedness in facing HIDs.
      Preliminary results are encouraging, and the pilot phase has also demonstrated the applicability of checklists: indeed, this initial survey, performed in five HLIUs, revealed substantial harmony in infection control procedures, and evidenced the feasibility, in real life, of these protocols and strategies. All units have similar protocols for PPE, hand hygiene, prevention of needle-stick injuries, final disinfection, treatment of infectious waste, transport of HID patients, and management of human remains. Moreover, all units have in place strategies for promoting the application of these procedures, through a specific education programme and participation in (and management of) exercises at local, regional, national and international levels. Also, the medical aspects of HCW safety are very similar: additional vaccination and chemoprophylaxis are available, and protocols for post-exposure management are in place. The main difference emerged as an aspect of HCW management: special insurance and compensation for those involved in the management of HID patients are planned only in the UK. The impact of this and other minor differences will be evaluated when the complete survey results are available.
      Despite these promising results, the applicability of checklists requires further assessment in the other HLIUs/referral centres: indeed, it is possible that Steering Committee members developed the checklists with their own units in mind. Despite the fact that an HLIU not involved in the project has also been surveyed, a single external control is not sufficient. Another limitation is the fact that the checklists have been applied in centres with similar levels of technology, experience and expertise in the management of HIDs. Assessment is required in countries with different resources, experiences and priorities, and in centres with lower levels of specialization and technology.
      The survey results could be used by health authorities and hospital administrators for the implementation and updating of national hospital capabilities. This approach will improve common know-how and will support those who deal with HIDs, in order to identify aspects that require strengthening, altering or accelerating, and to identify potential solutions.

      Acknowledgements

      We thank R. Iacovino for her support throughout the project, and F. N. Lauria for his contribution and critical reading.
      Other members of the EuroNHID Study Group are: O. Adrami, Hellenic Centre for Disease Control and Prevention, Athens, Greece; Michael Borg, St Luke's Hospital, Malta; R. Gottschalk, Public Health Office, Frankfurt am Main, Germany; R. Hemmer, Centre Hospitalier de Luxembourg, Barblé, Luxembourg; A. Horban, Hospital of Infectious Diseases, Warsaw, Poland; M. Kojouharova, National Centre of Infectious and Parasitic Diseases, Sofia, Bulgaria; C. Perronne, Unité des Maladies Infectieuses–Hôpital Universitaire Raymond Poincaré, Paris, France; J. Lambert, University College of Dublin, Dublin, Ireland; H. Siikamäki, Helsinki University Central Hospital, Helsinki, Finland; P. Skinhoj, Rigshospitalet, Copenhagen, Denmark; F. Strle, University Medical Centre, Ljubljana, Slovenia; A. Trilla, University of Barcelona, Barcelona, Spain; N. Vetter, Otto Wagner Spital, Vienna, Austria.

      Transparency Declaration

      This work was partly supported by the EC grant EuroNHID (2006205), and by the Ministero della Salute, Italia-Ricerca Corrente, Istituti di Ricovero e Cura a Carattere Scientifico.

      References

        • Bannister B
        • Puro V
        • Fusco FM
        • Heptonstall J
        • Ippolito G
        • EUNID Working Group
        Framework for the design and operation of high-level isolation units: consensus of the European Network of Infectious Diseases.
        Lancet Infect Dis. 2009; 9: 45-56
        • Smith PW
        • Anderson AO
        • Christopher GW
        • et al.
        Designing a biocontainment unit to care for patients with serious communicable diseases: a consensus statement.
        Biosecur Bioterror. 2006; 4: 351-365
        • WHO
        Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care. WHO interim guidelines.
        (last accessed: 20 January 2009).
        • CDC
        Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. Centers for Disease Control and Prevention, 2007 (last accessed: 20 January 2009).
        • Jensen PA
        • Lambert LA
        • Iademarco MF
        • Ridzon R
        • CDC
        Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005.
        MMWR Recomm Rep. 2005; 54: 1-141
        • European Commission
        Summary of EU waste legislation.
        (last accessed: 20 January 2009).
        • Marklund LA
        Patient care in a biological safety level-4 (BSL-4) environment.
        Crit Care Nurs Clin North Am. 2003; 15: 245-255
        • Crowcroft N
        • Brown D
        • Gopal R
        • et al.
        Current management of patients with viral haemorrhagic fevers in the United Kingdom.
        Euro Surveill. 2002; 7: 44-48
        • Fung CP
        • Hsieh TL
        • Tan KH
        • et al.
        Rapid creation of a temporary isolation ward for patients with severe acute respiratory syndrome in Taiwan.
        Infect Control Hosp Epidemiol. 2004; 25: 1026-1032
        • Parmar HA
        • Lim TC
        • Goh JS
        • Tan JT
        • Sitoh YY
        • Hui F
        Providing optimal radiology service in the severe acute respiratory syndrome outbreak: use of mobile CT.
        AJR Am J Roentgenol. 2004; 182: 57-60
        • Svoboda T
        • Henry B
        • Shulman L
        • et al.
        Public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in Toronto.
        N Engl J Med. 2004; 350: 2352-2361
        • Jeffs B
        • Roddy P
        • Weatherill D
        • et al.
        The Medecins Sans Frontieres intervention in the Marburg hemorrhagic fever epidemic, Uige, Angola, 2005. I. Lessons learned in the hospital.
        J Infect Dis. 2007; 196: S154-S161