Management of highly pathogenic infectious diseases 

in Europe:A European Network survey 

by EuroNIHDPr Philippe BROUQUI

Emerging Infectious and Tropical Diseases Research UnitUHI of Infectious and Tropical Disease Marseille

URMITE CNRS/IRD UMR 6236/198EURONHID

Financial Disclosures: None ESCMID O

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Problems posed by HP agents• Highly pathogenic agent / Highly Infectious disease

• EUNID defines a highly infectious disease as an infection that is transmissible from person to person; is life threatening; presents a serious hazard in the health‐care setting and the community; and requires specific control measures – Known or yet unknown agent equivalent to class 3 and 4 agent but 

H to H transmissible• Ex : It does not include most vector‐borne agent but includes pandemic 

influenza

– Propitiously causing hospital acquired and population life threatening outbreaks

– Usually detected first in health care setting outbreaks and further as laboratory acquired accident.

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Example of HPA

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Eunid /EuroNHID• EC funded European Networks for 

Highly Infectious Diseases.– To define recommendation for 

optimal management of patients with HID based upon literature (Eunid).

• No evidence based features

– To investigate the appropriateness between recommendations and observation in a field‐study of official European referral centers for care of HID (EuroNHID)

• Survey 16 countries– 47 referral centers

– Check lists based upon our recommendation

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Eunid recommendations

• Published in two companion papers in the Lancet Infectious disease– Design and operation of HLIU

• Location, connection, technical features, access to diagnostic laboratory, autoclaving…. 

– Management of patient with a HID• At the emergency department, isolation, laboratory sampling, endoscopy, Imaging…. Necropsy 

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Isolation units HLIU

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Patient management a ED

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Imaging and dialysis

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Pediatrics and IC practice

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Invasive procedures

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POST Mortem examination

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HLIU in Europe

The Euro‐HNID Survey

(F Fusco)

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HLIU:Hopital Spallanzani Rome“10 NSB4 Isolation Rooms / 35 Quarantine rooms”

One BSL4 and 2 BSL3 integrated  diagnostic laboratories

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HLIU Marseille BSL3 (2005) (6 rooms with ICU)

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Marseille France HLIU • Built as a BSL3 laboratory replacing hoods by beds

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London Royal Free Hospital Isolator

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Nancy France HLIU ( 4 beds) 

• 4 isolation bed rooms in BSL3 at the infectious disease outpatient unit – dedicated entrance

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MILAN Italy (Lugi Sacco)

• HID patient admission in a separate ID emergency unit close to the ED of the hospital

• HCW specifically trained 

• Transfer to ID wards

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MILAN Italy

• # 90 one bed room 3 floors– independent negative 

pressure

– including 20 in BSL”2/3”

– BSL2/3 imaging room

• # 100 Chronic post infectious beds in another closely located building 

• Specifically trained team

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Milan Italy

• BSL3 Necropsy room located within the hospital– Working routinely

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# 200 pages Manual for safe management of HID21

Euro NHID survey results

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Chapter 2 – MEDICAL ISSUESS. Schilling (Germany)

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Chapter 3 ‐ PERSONNEL MANAGEMENTS. Schilling (Germany)

A: A special shift plan to be used in the case of HID patients that consider all of explored items is available.

B: A special shift plan to be used in the case of HID patients is not available, but some of the explored items are available to address these specific needs.

C: A special shift plan to be used in the case of HID patient/s does not exist, and explored items are not available to address these specific needs.

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Chapter 4 – MANAGEMENT OF DIAGNOSTIC PROCEDURES

P Brouqui (France)

– 81% of the surveyed isolation facilities throughout Europe are located nearby a BSL3 lab

– 19 % the referral centres, which do not have such lab facilities, protocols for secure handling of sample are available.

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38; 81%

9; 19%

0; 0%

A

B

C

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Where are performed microbiological and routine 

diagnostic test ?

• Recommendation for sampling– Sampling HID patients for laboratory analysis should be performed in the 

isolation room of the ED or in the Isolation Unit  following written protocols 

– Should use if possible bedside laboratory test analysis (ex malaria test) 

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Inside the isolation area

(same room or other room)

In the BSL-3 reference lab

In the general lab, with closed-

type authomatized

analysers

In the general lab, without use of closed-type authomatized

analysers

Appropriate location and procedures for microbiological test

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1015202530

Inside the isolation area

(same room or other room)

In the BSL-3 reference lab

In the general lab, with closed-

type authomatized

analysers

In the general lab, without use of closed-type authomatized

analysers

Appropriate location and procedures for routine tests

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Chap 5 ‐ EMERGENCY DEPTF Fusco (Italia)

A: The Emergency Department associated with isolation facility is equipped with a single room (ideally with negative pressure) for isolation with a direct access and a dedicated route

B:  The Emergency Department associated with isolation facility has a specific area for isolation, but without specific technical/logistic features

C:  The Emergency Department associated with isolation facility has not a specific area for isolation

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Chap 5 ‐ EMERGENCY DEPTF Fusco (Italia)

A: The Emergency Department has all the structural/logistic features and procedures for the limiting of spreading of Infectious Diseases

B: The Emergency Department has partially adequate structural/logistic features and procedures (at least 3 explored items in place)

C:  The Emergency Department has not adequate structural/logistic features and procedures (less than 3 explored items in place)

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Chap 5 ‐ EMERGENCY DEPTF Fusco (Italia)

A:  A specifically trained triage HCWs is available on 24h‐basis

B:  A specifically trained triage HCWs is available, but not on 24h‐basis

C:  A specifically trained triage HCWs is not available

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Chapter 11 – WASTE MANAGEMENT

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How Does this impacted the management of the last 

pandemic ?

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Distribution of 2009 Flu patients in Marseilles university referral center 

hospital 

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Hospital acquired Influenza in HCP

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50

100

150

200

250

0

5

10

15

20

43 44 45 46 47 48 49 50 51 52 53 1Pediatric Dpt Ped emerg Dpt.Adult emerg Dpt. Adult medicine DptESCMID

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Hospital acquiredcases in Patients

  Hospital personnel cases

Cases diagnosed(inpatients and outpatients)

Cases hospitalized

Public Hospital of Marseilles (All departments)

9 100 1046 262

Pediatric Emergency rooms / 2 512 /

Adult Emergency rooms  / 19 190 /

Infectious Diseases department

1 0 210 57

Medical departments but infectious diseases department

7 21 / 41

Pediatric departments 1 15 / 136

Intensive Care Unit 0 3 35 35

Gynaecology‐Obstetrics  1 4 57 11

Hospital acquired Influenza in HCP

• Only 2 HAI cases were reported for both ID and PER while they cared for 75% of patients

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Take home messages

• We are poor lonesome cowboys and we are a long long way from home– Training and organizing emergency rooms of the hospitals

– Discussing mandatory vaccination of HCP when possible

– Improving technical features and training in our referral centers with using the EuroNHID survey as basis for implementation

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Authors and contributors (in alphabetic order):

•Barbara Bannister (Steering Committee member, Royal Free Hospital, Infection & Immunity Division, London, United Kingdom);•Hans-Reinhard Brodt (Steering Committee member, Klinikum der Johann Wolfgang Goethe Universitaet, Med Klinik III/ Infektiologie, Frankfurt, Germany);•Philippe Brouqui (Steering Committee member, Assistance Publique des Hopitaux de Marseille, France);•Giuseppina De Iaco (Project Coordinator, Istituto Nazionale per le Malattie Infettive, Lazzaro Spallanzani, Rome, Italy); •Francesco M. Fusco (Project Coordinator, Istituto Nazionale per le Malattie Infettive, Lazzaro Spallanzani, Rome, Italy);•René Gottschalk (Steering Committee member, Office of Public Health, Frankfurt, Germany);•Giuseppe Ippolito (Project Leader, Istituto Nazionale per le Malattie Infettive, Lazzaro Spallanzani, Rome, Italy);•Helena C. Maltezou (Steering Committee member, Hellenic Centre for Infectious Disease Control, Athens, Greece);•Simone Lanini, (Project collaborator, Istituto Nazionale per le Malattie Infettive, Lazzaro Spallanzani, Rome, Italy);•Vincenzo Puro (Scientific Project Coordinator, Istituto Nazionale per le Malattie Infettive, Lazzaro Spallanzani, Rome, Italy); •Stefan Schilling (Steering Committee member, Klinikum der Johann Wolfgang Goethe Universitaet, Med Klinik III/ Infektiologie, Frankfurt, Germany);•Gail Thomson (Steering Committee member, Health Protection Agency, England).Other EuroNHID partners:

-Norbert Vetter, Project partner, Otto Wagner Spital, Interne Lungenabteilung, Vienna, Austria;-Mira Kojouharova, Project patner, National Centre for Infectious and Parasitic Diseases, Sofia, Bulgaria;-Kremena Parmakova, Project collaborator, National Centre for Infectious and Parasitic Diseases, Sofia, Bulgaria;-Peter Skinhoj, Project partner, Epidemiklinikken Rigshospitalet, Copenhagen, Denmark;-Heli Siikamaki, Project partner, Central Hospital, Helsinki University, Division Infectious Diseases, Aurora Hospital, Helsinki, Finland;-Christian Perronne, Project partner, Hospital Pitié-Salpetrière, Service de Maladies Infectieuses et Tropicales, Paris, France;-Olga Adrami, Project collaborator, Hellenic Centre for Infectious Disease Control, Athens, Greece;-John Lambert, Project partner, University College of Dublin, Mater Misericordiae Hospital, Dublin, Republic of Ireland;-Robert Hemmer, Project partner, National Service of Infectious Diseases, Centre Hospitalier de Luxembourg, Luxembourg;-Michael Borg, Project partner, Saint Luke’s Hospital, Malta;-Andrzej Horban, Project partner, Hospital of Infectious Diseases, Warsaw, Poland;-Josef Higersberger, Project collaborator, Hospital of Infectious Diseases, Warsaw, Poland;-Janusz Stanczak, Project collaborator, Hospital of Infectious Diseases, Warsaw, Poland;-Franc Strle, Project partner, University Medical Centre, Ljubljana, Slovenia;-Antoni Trilla, Project partner, Hospital Clinic Universitat de Barcelona, Unitat de Suport i Prevencio', Barcelona, Spain

Other EuroNHID staff:-Ramona Iacovino, Administrative Support, Istituto Nazionale per le Malattie Infettive, Lazzaro Spallanzani, Rome, Italy;-Fabrizio La Trofa, Technical Support, Istituto Nazionale per le Malattie Infettive, Lazzaro Spallanzani, Rome, Italy.ESCMID

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