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Try out PMC Labs and tell us what you think. Learn More. After an imported case of Marburg hemorrhagic fever was reported in in the Netherlands, control measures to prevent transmission were implemented. To evaluate consequences of these measures, we administered a structured questionnaire to contacts classified as either having high-risk or low-risk exposure to body fluids of the case-patient; 77 A total of 67 Strict compliance with daily temperature monitoring decreased from Contacts expressed concern about development of Marburg hemorrhagic fever Public health authorities should specifically address consequences of control measures on the daily life of contacts.

In July in the Netherlands, an imported case of Marburg hemorrhagic fever MHF 1 was diagnosed in a person after possible exposure in a bat cave in Uganda.

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MHF is caused by Marburg virus, which belongs to the family Filoviridae 23. The main route of transmission is by direct contact with blood or body fluids 4. The virus was discovered in during a laboratory outbreak in Marburg, Germany 56.

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Apart from this person, since the outbreak in Marburg, MHF has been diagnosed only once outside Africa 7. Because of the high case-fatality rate and propensity for further transmission, a case of MHF is considered to be a public health emergency of international concern and requires prompt intervention to isolate the case-patient and trace and monitor all contacts for early s of disease.

Persons at risk for contracting MHF caused by prior or ongoing contact with an infected person were identified by means of a public health investigation conducted by public health services.

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The national outbreak response team issued guidelines for classification of these contacts and control measures, including restrictions on leaving the country. Imported cases of hemorrhagic fever and other severe diseases with the potential to spread among health care workers and the general population have a small, yet realistic chance of occurring in the Western world, as was the situation with Ebola fever and Lassa fever 8 — Outbreaks can also originate from other sources, as was the case with Ebola-Reston virus Because there are no alternative interventions, such as vaccination or prophylactic treatment, to protect contacts from acquiring MHF, control measures are aimed at early identification of possible case-patients and isolating them from the rest of the population.

However, we do not know how persons exposed to MHF respond when confronted with control measures.

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To date, the consequences of measures to control outbreaks e. Evidence is needed to determine the effectiveness of follow-up procedures for MHF contacts. Contacts were categorized as high-risk or low-risk on the basis of their exposure history. We describe criteria to optimize the effect of control measures and provide proper care to contacts exposed to a person-to-person transmissible virus with the potential to cause severe disease. This study was determined to be part of the public health response to the imported case of MHF and follow-up of contacts.

Therefore, explicit ethical evaluation was not necessary.

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On July 2,after returning from a visit to Uganda from June 5 through June 28, a year-old woman showed development of chills and high fever. She was admitted to hospital A on July 5. Initially, hemorrhagic fever was not included in the differential diagnosis and she was placed in a general ward among other patients, without specific contact precautions.

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Because she later showed clinical deterioration, liver failure, and tendency to hemorrhage, hemorrhagic fever was suspected and she was transferred to hospital B on July 7. In hospital B, she was placed in strict isolation in accordance with guidelines prescribed for pathogens belonging to Hazard Group 4 We placed the patient in a single room with negative air pressure ventilation and an anteroom for 2 reasons.

First, although evidence for airborne transmission of MHF in humans has not been documented, transmission by aerosols has been demonstrated in animal models 7. Second, the patient was likely to undergo aerosol-generating procedures e.

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On July 10, the diagnosis of MHF was confirmed; the next day, the patient died. A complete case history and the public health response have been reported 1. The outbreak response team formulated measures for follow-up of contacts considered to be at risk for exposure.

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Measures were based on preexisting national and international guidelines on management of hemorrhagic fever caused by filoviruses 18 — The patient was considered to be potentially infectious from the onset of fever July 2 until death July The period of monitoring contacts was set at 21 days after the last contact with the patient or patient body fluids. The public health service traced the contacts in the community. The hospital hygienist and occupational physician, and attending physicians were responsible for in-hospital contacts.

Contacts were provided with written instructions Table 1. Contacts classified as at high risk for contracting the disease i. Furthermore, they were prohibited from leaving the country and were told to report any intention to leave to the public health authority. Contacts who had handled the patient or her body fluids while carrying out strict isolation measures were perceived to be at low risk for exposure. This group was strongly encouraged not to travel abroad.

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A retrospective cohort study involving the contacts was conducted by using an online questionnaire. Data were collected from December through Februarywhich was 5—7 months after possible exposure.

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At the same time, serologic testing was conducted to assess asymptomatic transmission. We recorded personal characteristics of respondents and any symptoms during the monitoring period. The questionnaire 62 questions addressed understanding of control measures, clarity of instructions, reported compliance with measures, and perceived interference with daily life e.

To develop questions regarding interference and reported compliance, we drew from the current literature on the effect of restrictive measures during outbreaks 1415 Depending on the type of question, respondents were asked to answer either yes or no questions, or to choose an option on Likert scales of 1—5 1, completely disagree; 2, disagree; 3, neutral; 4, agree; and 5, strongly agree or 1, never; 2, seldom; 3, sometimes; 4, often; 5, always.

To evaluate stress levels, we used the Revised Impact of Event Scale IES-R; Dutch versiona item international instrument deed to measure situations in life that are perceived as stressful The instrument was divided into 3 subscales: intrusion e.

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Each subscale contained questions derived from the Diagnostic and Statistical Manual of Mental Disorders criteria 4th edition for posttraumatic stress disorder Items were scored on a Likert scale of 0—4 0, not at all; 1, a little bit; 3, quite a bit; 4, extremelywhich added up to a maximum score of We assessed recalled stress during the monitoring period IES during and persisting stress during the 7 days before the completion of the questionnaire IES after.

Descriptive statistics were calculated. Means and SDs were calculated for answers given on the Likert scale. were stratified by type of exposure risk i. Differences in means were calculating by using the Student t test.

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We constructed overall scales. The overall scale for understanding of measures items regarding awareness of the measures and their rationale proved invalid and was not used in further analysis.

Retrospective evaluation of control measures for contacts of patient with marburg hemorrhagic fever

To determine which variables influenced stress levels during the monitoring period, we developed a linear regression model by using the IES during monitoring as a dependent variable and personal characteristics sex, education, agerisk level, clarity of instructions scale, compliance scale, and interference scale as independent variables. The same model was constructed by using the IES after the monitoring period as the dependent variable.

Serologic testing was performed by using an immunofluorescence antibody IFA assay with blood samples collected from contacts 5—7 months after the monitoring period. Laboratory methods have been reported 1. Of eligible participants, 78 One person provided systematically inconsistent answers and was excluded, which left 77 respondents The response rate was Of the 77 respondents, 46 Mean age was 38 years in the high-risk group and 43 years in the low-risk group this difference was not ificant.

Respondents were comparable to nonrespondents with respect to sex M:F ratio During the monitoring period, nonspecific symptoms those commonly occurring during the prodromal phase of hemorrhagic fever syndromes, e. Of the 77 respondents, 60 Of 60 contacts aware of the request, 54 All respondents were aware of the need to measure temperature twice a day, 67 Not feeling ill was the reason for disagreement in the remaining 3 3.

Only 58 Written instructions with detailed information on the control measures were received by 61 Of these 61 respondents, 45 There were no ificant differences between the risk groups. Of 45 respondents who were prohibited from traveling high-risk group17 Two