Patients who have suspected rabies should be placed on Contact Precautions (see Chapter 89) to minimize the number of possible healthcare worker exposures and to minimize anxiety, although Standard Precautions are adequate (14). Possible cases should be reported to public health officials immediately, so that they can assist with an epidemiologic and diagnostic workup. Healthcare workers who have had a significant exposure should receive postexposure prophylaxis (15). Casual contact with a person with rabies (i.e., touching the patient) or contact with noninfectious fluid or tissue (e.g., blood or feces) does not constitute an exposure and is not an indication for prophylaxis (7). Postexposure prophylaxis is recommended after contact with human rabies only if a bite or nonbite exposure (e.g., contamination of abraded skin or mucous membranes with saliva, nerve tissue, urine sediments, or other potentially infectious material) can be documented. Because postexposure prophylaxis after the onset of disease is of no known benefit, such treatment for patients after onset of clinical rabies is not recommended.

Any program to prevent transmission of CJD and TSEs from patients in hospitals should first seek to detect all such patients before brain or other high-risk tissues (dura mater, spinal cord, and eyes) are biopsied. Such patients can be identified by screening patients for “unexplained dementia without a detectable brain mass.” Any patient meeting this description should be considered to have CJD until proven otherwise even if another diagnosis such as vasculitis is being considered. The neurosurgeons, pathologists, and others in the operating room, the pathology department, and the infection control department should be alerted about such a patient if a biopsy of high-risk tissue is being considered. Some neurosurgeons may elect not to biopsy potential CJD patients unless an alternate, treatable diagnosis is also under consideration. Hospitals should develop a CJD protocol for nervous system tissue biopsies done on such patients (28, 29 and 30,31). Disposable surgical instruments should be used when possible. Reusable instruments should be discarded or sterilized according to a CJD protocol or the instruments should be quarantined until another diagnosis is made. Powered instruments, such as drills and saws, should be avoided or covered by a disposable protective shield. Brain and other high-risk tissues should be labeled as “suspected CJD” before being sent to pathology. The pathology department should have a plan to track such tissue and quarantine and disinfect instruments, such as microtomes, that contact CJD tissue. It is important to note that formalin- and glutaraldehyde-fixed tissues may be infectious indefinitely (29). Confirmed CJD tissue can be managed as regulated medical waste per state regulations. No one suspected of having CJD should serve as a blood or tissue donor even though transmission of classic CJD has never been linked to blood, but vCJD has been transmitted via blood transfusion (32,33). Blood or blood products from such patients should be disposed of per state regulations for regulated medical waste.

CJD patients should be cared for using Standard Precautions (14). Sharps injuries involving spinal fluid or high-risk tissues can be cleansed using 0.5% sodium hypochlorite or 1 N sodium hydroxide (28,29). During an operation or autopsy, disposable surgical caps, water-repellant gowns, aprons, double gloves, and face visors (covering eyes, nose, and mouth) should be worn (29). Autopsies should be done only if the pathologist is aware of the potential diagnosis of CJD and uses the Precautions mentioned previously for the autopsy suite and pathology laboratory (29). When the patient dies, the morgue and funeral home should be notified that the patient had suspected or confirmed CJD.

If clinicians feel that VHF is likely, they should take two immediate steps: (a) notify local and state health departments and the Centers for Disease Control and Prevention (CDC) and (b) institute special precautions, including the use of a private room and use of gloves for all patient and specimen contact. The CDC in 1988 recommended precautions for VHF that were updated in 1995 and 2005 (34,35,50). Blood, urine, feces, vomitus, and respiratory droplets should be considered infectious. Gloves, gowns, face shields, and goggles should be used as necessary to prevent exposures to these body fluids. Patients should be placed on Contact Precautions (see Chapter 95) (14). In addition, the following measures should be implemented: (a) eye covering (goggles or shields) for all contact within 3 ft, (b) a negative pressure room and use of a high-efficiency particulate air respirator (mask) if aerosolization of virus is likely (e.g., patients who have a prominent cough), (c) use of class II biologic safety cabinet following biosafety level 3 practices for laboratory specimens, and (d) pretreatment of serum specimens with polyethylene glycol p-tert-octylphenyl ether (10 µL of 10% Triton X-100 per mL of serum) for 1 hour (50). All specimens should be marked with the biohazard symbol, so that all persons handling these specimens will be alerted to use proper precautions, including gloves. If a patient with any VHF dies, all unnecessary handling of the body, including embalming and autopsy, should be avoided. The corpse should be placed in an airtight bag and cremated or buried immediately.

Patients who likely have Lassa fever should be treated with ribavirin, as should all individuals who have had unprotected contact with the patient’s body fluids or excretions (44). Examples of unprotected contact include sexual intercourse, shared use of eating or drinking utensils, and failure to use gloves to handle items known to be contaminated with the patient’s blood or secretions.