Frimley Guidelines

IPC 16: Viral Haemorrhagic Fevers
(including Ebola virus disease)

Key Points

• The viral haemorrhagic fevers are severe and life-threatening viral diseases that have been reported in parts of Africa, South America, the Middle East and Eastern Europe.

• The purpose of this document is to provide guidelines on the assessment and management of patients with suspected or confirmed viral haemorrhagic fevers, such as Ebola virus disease.

• VHFs are categorised as High Consequence Infectious Diseases (HCID).

Version:13.0
Date Issued:19/08/2024
Review Date:24/07/2027
Key words:Viral Haemorrhagic Fevers, VHF, Isolation, Ebola

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Abbreviations

ACDPAdvisory Committee on Dangerous Pathogens
CCDCConsultant in Communicable Disease Control
EVDEbola virus disease
HICCHospital Infection Control Committee
HCIDHigh Consequence Infection Disease
HLIUHigh Level Isolation Unit
ICTIncident Control Team
PHEPublic Health England
VHFViral Haemorrhagic Fever

1.0 Scope of Guideline

The purpose of this document is to provide guidelines on the assessment and management of patients with suspected or confirmed viral haemorrhagic fevers (VHF), and to promote effective and evidence-based patient care.

This guideline applies to all staff employed by Frimley Health NHS Foundation Trust, and also to all visiting staff and contractors.

2.0 Background

VHF are severe and life-threatening viral diseases that have been reported in parts of Africa, South America, the Middle East and Eastern Europe. VHFs;

• can spread within a hospital setting;

• have a high case-fatality rate;

• are difficult to recognise and detect rapidly;

• have no effective, definitive treatment (ACDP 2015).

Viral haemorrhagic fevers (VHF) are viral infections caused by a number of groups of viruses:

2.1 Arenaviridae

• Lassa virus: the cause of Lassa fever, endemic in parts of west Africa

• Lujo virus: a novel virus that caused a small outbreak in South Africa following transmission in Zambia in 2008

• Junin virus: the cause of Argentinian haemorrhagic fever

• Guanarito virus: the cause of Venezuelan haemorrhagic fever

• Machupo virus: the cause of Bolivian haemorrhagic fever

• Chapare virus: the cause of Bolivian haemorrhagic fever

• Sabia virus: the cause of Brazilian haemorrhagic fever

2.2 Bunyaviridae

• Crimean-Congo haemorrhagic fever virus (CCHF)

• Hantaviruses, which cause haemorrhagic fever with renal syndrome, and Hantavirus pulmonary syndrome

• Rift Valley fever virus

2.3 Flaviviridae

• Alkhurma virus (Saudi Arabia)

• Kyasanur Forest virus (India, Karnataka State)

• Omsk virus (Siberia)  

2.4 Filoviridae

Ebola and Marburg viruses which cause the most severe forms of haemorrhagic fever. All recorded cases of VHF in the UK have been acquired abroad, with one exception of one laboratory worked who sustained a needle-stick injury (ACDP 2015). However, with increasing international travel and personnel deployed to endemic regions due to operational commitments, these diseases may be imported more frequently.

An evolving outbreak of Ebola virus disease in West Africa was first reported in March 2014, affected primarily Sierra Leone, Liberia and Guinea.

3.0 Mode of Transmission

• Direct or indirect contact with infected rats (Lassa fever), monkeys (Ebola, Marburg), and tick bite (Crimean-Congo fever).

• Direct contact (through broken skin or mucous membrane) with blood or body fluids, and indirect contact with environments contaminated with splashes or droplets of blood or body fluids.

4.0 Signs and Symptoms

  • Fever (>37.5°C)

  • Malaise

  • Headaches

  • Myalgia

  • Pharyngitis

  • Diarrhoea

  • Bloody diarrhoea

  • Vomiting

  • Rash

  • Bleeding

  • Shock

  • Lymphopaenia

  • Thrombocytopaenia

  • Raised aspartate transaminase (AST)

The incubation periods of these infections are usually 7-10 days (range of 3-21 days).

The period of infectivity can be up to 64 days post-onset.

Virus can survive on surfaces for approximately two weeks, and longer on fabrics/ soft furnishings.

5.0 PATIENT ASSESSMENT & MANAGEMENT

VHF viruses are classified as biosafety level four (BSL-4, the highest level) pathogens. Risk Assessment is a legal obligation under the Control of Substances Hazardous to Health (CoSHH) Regulations.

It is the responsibility of clinical teams and divisional managers to ensure their departments have systems in place to recognise and document the potential risk of VHF, ideally before the patient even arrives at the Trust during the referral process.

Patients should routinely be questioned about recent travel history and pyrexia prior to and on arrival to Emergency Departments, and any assessment and admission units, using the Epic Communicable Disease screening tool.

VHF infection is possible in any patient presenting with:

A) a pyrexia of unknown origin (>37.5°C), or a history of pyrexia within previous 24 hours AND has returned from (or is currently residing in) a VHF endemic country where there is a current VHF outbreak within 21 days of symptoms developing. (For a current list of VHF-endemic countries, refer to: www.gov.uk/guidance/viral-haemorrhagic-fevers-origins-reservoirs-transmission-and-guidelines). OR

B) a pyrexia of unknown origin (>37.5°C), or a history of pyrexia within previous 24 hours AND has cared for/come into contact with body fluids of /handled clinical specimens (blood, urine, faeces, tissues, laboratory cultures) from an individual or laboratory animal known or strongly suspected to have VHF.

The UKHSA Imported Fever Service (IFS) provides 24-hour, 7-days a week telephone access (Tel: 0844 778 8990) to expert clinical and microbiological advice. Hospital doctors across the UK can contact the IFS after discussion with the local microbiology, virology or infectious disease consultant.

5.1 Assessment of VHF risk in the Acute Care Setting

Refer to the UK Health Security Agency (UKHSA) Viral Haemorrhagic Risk Assessment, for clinical history and additional questions. Accessible at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/478115/VHF_Algo.pdf

The UKHSA Imported Fever Service (IFS) provides 24-hour, 7-days a week telephone access (Tel: 0844 778 8990) to expert clinical and microbiological advice. Hospital doctors across the UK can contact the IFS after discussion with the local microbiology, virology or infectious disease consultant.

RISK ASSESSMENT OF SUSPECTED CASES MUST BE CARRIED OUT BY A SENIOR CLINICIAN WITH ADVICE FROM THE ON-CALL CONSULTANT MICROBIOLOGIST/ VIROLOGIST FOLLOWED BY IFS, and categorised as one of the following:

• Low Possibility of VHF • High Possibility of VHF • Confirmed VHF

Refer to the flowcharts in Appendix A for the pathway and placement of suspected VHF cases.

5.2 Assessment of VHF risk in the Community Care Setting

If a patient under the care of FHFT Community Care Teams is noted to have returned from a viral haemorrhagic fever-endemic country in the past 21 days, and has a fever (>37.5°C) or history of a fever, the patient must be informed to call NHS 111 for advice. Inform the Trust on-call Microbiologist via switchboard, providing patient details, symptoms and travel history.

5.3 Management of ward/ department areas used for initial placement of patients with Suspected VHF

5.3.1 Ward G1 (Frimley Park Hospital)

Doors (A) between Infectious Diseases Unit and the rest of G1 to be closed and locked. Patient to be transferred to unit through external access fire doors (B). Staff requiring access must also use these doors. Rooms 6a and 6b are circled on the diagram. An intercom system is available for both negative-pressure isolation rooms.

5.3.2 Emergency Department, Blue (Wexham Park Hospital)

Screens and signage to be placed at points (A). Patient to be transferred to department through external access fire doors (B). Staff requiring access must also use these doors. Rooms 19 and 25 are circled on the diagram. The remaining five cubicles in this zone will be closed from use whilst a suspected case remains in isolation.

5.4 VHF Precautions Summary for the Hospital Setting

   
   		   
Low Possibility   of VHF   
High Possibility of VHF
(suspected case) 		   
Confirmed   VHF   		   
Comments   
   
Criteria   
The patient is not bleeding/ bruising and there is no
uncontrolled vomiting or diarrhoea

(Note: If patient has bruising or bleeding, manage as
High Possibility of VHF)
The patient is categorised
as a being a High Possibility
of VHF may or may not
be bleeding / have
uncontrolled vomiting or
diarrhoea
The patient has a positive
VHF test and may or may
not be bleeding / have
uncontrolled vomiting or
diarrhoea
VHF categories defined
as per ACDP guidance: https://www.gov.uk/government/publications/viral-haemorrhagic-fever-algorithm-and-guidance-on-management-of-patients
   
Notification   
On-call/ duty Microbiologist

Local Health Protection Team/ UKHSA/ CCDC
(if suspected infection is notifiable)
On-call/ duty
Microbiologist


Local Health
Protection Team/
UKHSA/ CCDC


Notify a HLIU concerning
patient management and
possible early transfer
On-call/ duty Microbiologist

Local Health Protection
Team/ UKHSA/ CCDC

Notify a HLIU concerning
patient management and
possible early transfer

UKHSA to notify NHSE
for onward communication
to ECDC
CCDC – Consultant in
Communicable Disease
Control

UKHSA – UK Health
Security Agency

NHSE – NHS England

ECDC - European
Centres for Disease
Control

HLIU – High Level
Isolation Unit

Patient placement
En-suite single room (door closed)
Presentation in ED:
WPH ED Blue: isolate
in room 19 or 25.

FPH: Transfer via
external entrance to
G1 Negative Pressure room.

Admission required:

Negative pressure
isolation room

(FPH: G1 or ICU;
WPH: MSSU or ICU)

Signage will be provided
by the IPC Team
Transfer to High-Level
Isolation Unit (HLIU)Appendix 4 (ACDP 2015 guidance)
Prior to transfer
from Trust:

Negative pressure isolation
room

(FPH: G1 or ICU;
WPH: MSSU, or ICU)

Signage will be
provided by the IPC Team
provides advice on
managing a confirmed
VHF patient in a
non-HLIU environment.

Appendix 5 (ACDP 2015 guidance) Transfer arrangements

All suspected/ confirmed
VHF cases will require
placement in a
negative-pressure
isolation room, regardless
of age or speciality under
which they are admitted.

In the event of suspected
VHF cases outnumbering
the negative pressure
isolation capacity and
HLIU beds in the UK,
the Imported Fever Service
and Royal Free Hospital
Infectious Diseases should
be contacted (020 7794 0500)
for advice on patient management.


Transfer between
wards/ depts
As per standard procedures
Do not transfer unless
under supervision of IPC
Team 		   
Appendix 5 (ACDP 2015 guidance) Transfer arrangements   
   
Contact   with people   
Limit contact with other people
Limit the number of HCWs
who come into contact with
the patient.

Restrict non-essential
personnel and visitors from
the patient care area.

Clinical staff only in the
room, i.e. no domestics
staff, HCWs to perform
routine cleaning.


Keep an up to date list of
staff who enter the room
(Appendix C) and who
have been in contact with
the patient throughout
their care for contact
assessment
Visiting restrictions should
apply for all High Possibility
and Confirmed cases until
VHF negative confirmed.

IPC Precautions
required
Standard IPC Precautions +
transmission-based precautions
based on the infectious disease
suspected
High Consequence Infectious
Disease precautions
There is no evidence of airborne
transmission - airborne precautions
are an additional precautionary control
measure

Personal Protective
Equipment (PPE
Standard IPC Precautions plus
transmission-based precautions based on
the infectious disease suspected
Refer to the NIPCM
(NHSE 2024a) Addendum on high consequence infection disease (HCID) personal protective equipment (PPE) for guidance
on PPE required for care of
patients with a VHF.

   
   
   
Equipment      
Single patient use B/P monitor

Single use wash bowl, thermometer etc.

Use needle safety devices where possible
Keep stock supplies out of the room

Make sure the equipment is required
before placing in the room

DO NOT remove equipment from the
room without permission of IPCT

Transport of
specimens
It is not necessary to
notify lab in advance
of sending specimens

Standard transport (sealed container)
CONTACT ON-CALL
MICROBIOLOGIST/
VIROLOGIST BEFORE
SENDING ANY SAMPLES



Notify lab in advance
of sending specimens

CL2

No vacuum transport
of specimens 		   
   

Specimens required
Malaria screen urgent

FBC, U&E, LFTs Glucose,
CRP, coagulation
studies, urine culture,
stool culture and blood
cultures CXR
(within the X ray department)
Urgent VHF testing

Urgent Malaria screen

FBC, U&E, LFTs
Glucose, CRP, coagulation
studies, culture and
blood cultures
Patient under the care
of the ID physician
Do not take specimens from high possibility
VHF case without prior discussion with
on-call Microbiologist/ Virologist

Refer to Appendix 6 of ACDP 2015 guidance for specimen collection
   
Healthcare   waste   
As per Standard IPC Precautions

Orange bag (Category B waste)
Double Yellow bag

Category A waste
(autoclave/incinerate)

Hold waste in patient’s
room until VHF status
is known
Double yellow bag

Category A waste
(autoclave/incinerate)

Hold in safe area until
transport available
to incinerate/ autoclave
Involve Trust waste teams early.

Refer NIPCM (2024): Section 1.9 to of Standard IPC Precautions
   
Laundry   
As per Standard IPC
Precautions
Disposable (Category A
waste autoclave/incinerate)

(if reusable treat as disposable) 		   
   
   
Crockery   & cutlery   		   
No special   requirements   		   
Disposable (Category A waste)   		   
   
   
Toileting   facilities   		   
As per Standard   IPC Precautions
   
   
Patient may use toilet facilities



If unavailable use commode
/ bedpan: solidify contents
– (Category A waste
autoclave/incinerate) 		   
See ACDP 2015 guidance    

Blood or body fluid
spillages
As per NIPCM (NHSE 2024b) Appendix 9, for decontamination of
blood and body fluid spills

Blood 10,000 ppm av cl

Contact time 3 minutes

Urine – solidify then discard
as Category A waste.

Use 10,000 ppm av cl for 3
minutes contact
time to disinfect area 		   
   

Incident Management
Team
Dependent on infectious agent suspected
Full IPCT, CCDC,
UKHSA, Pharmacy,
Management, Estates 		   
   

On-going patient
assessments
Monitor temperature.

Monitor for bleeding,
bruising and for diarrhoea
and or vomiting – if symptoms
appear discuss with on-call
Microbiologist/ Virologist

If malaria negative and patient
remains pyrexial and no other
diagnosis, then discuss with
on-call Microbiologist/ Virologist
If malaria negative and
patient pyrexial and no
other diagnosis, then
discuss with ID
physician/HLIU
Patient under the care
of the ID physician/HLIU 		   
   

Routine cleaning
of patient room 		   
As per Standard   IPC Precautions
   
   
Perform routine cleaning
and disinfection of
patient care area.

1000 ppm av cl for hard
surfaces

10,000 ppm av cl for
toileting facilities

This should be performed
by clinical staff as part
of care activities. 		   
   

Terminal clean
Decontaminate room with
1000 ppm av cl following
discharge / transferred as
per NIPCM (NHSE 2024a)
Decontaminate room with
1000 ppm av cl following
discharge/ transfer as per
NIPCM (NHSE 2024a)

Full fumigation (hydrogen
peroxide vapour – contracted
service) of the patient’s
room if VHF confirmed
Leave decontaminated equipment
within the area until HPV
decontamination process complete.

NB it will need to be confirmed
that HPV decontamination has
been successful before the room
can be reused. This may take
several days.

Estates services will need to be
involved regarding the ventilation
pre-HPV decontamination.

Stand Down/
discontinuation
of precautions
Consultant Microbiologist/
Virologist confirms safe
to stand down.

Eg. the patient is:

VHF negative

Responding to treatment
for an alternative diagnosis

Apyrexial for 24hrs
Consultant Microbiologist/
Virologist confirms safe
to stand down.

Eg. the patient is:

VHF negative

Responding to treatment
for an alternative diagnosis

Apyrexial for 24hrs

(discuss with Imported
Fever Service for other
diagnosis)
On patient discharge/
death 		   
   

Staff exposure
As per Standard
IPC Precautions
As per Standard
IPC Precautions

Provide full support
to staff and patient
family throughout
incubation period.
If during patient care a partial
or total breach of PPE occurs
(e.g. gloves separate from
sleeve exposing skin, a tear
develops in the outer glove, a
needlestick injury) the healthcare
worker must move immediately
to the PPE removal area to assess the exposure.

Care of deceased 		   
As per Standard   IPC Precautions
   
   
Viewing of the deceased
should be avoided.

Do not wash or dress
the deceased.

Place deceased in a
double sealable leak-proof
body bag, with absorbent
material between each bag.
Seal the bags, and disinfect
surface of outer bag with
1000ppm available
chlorine disinfectant.

Label bag as high risk of
infection and place in a
robust coffin with sealed
joints. Keep in a separate,
identified cold store unit in
the mortuary to await
prompt cremation or burial.

An infection control
notification sheet should be
completed in readiness for
the funeral directors.

Postmortem examinations
should not be performed.

Blood sampling can be
undertaken in the mortuary
by a competent person to
confirm or exclude VHF
diagnosis
   
Refer to NIPCM (NHSE 2024a) Appendix 12    

Staff support
Prevention / Management:

Ensure sufficient supplies of
appropriately fitting PPE to
the relevant specifications
are available.

Ensure sufficient staff are
face fit tested and FFP3
respirators are available if
required for any AGP

Showers are recommended
at the end of each shift for
staff exposed to blood or body fluids


Staff who care for these patients
must know about VHF:

That the viruses are typically present
in blood and body fluids including
urine, on contaminated instruments
and equipment, in waste on
contaminated clothing (including PPE)
and contaminated surfaces.

Mode of transmission is typically through
direct contact: exposure of broken skin
or mucous membranes to blood and / or
other body fluids when touching or when
aerosolising / splashing of blood / body
fluids occur.

Indirect transmission is typically via broken
skin contact with mucous membranes or
broken skin and contaminated equipment /
surfaces. All cuts and abrasions must be
covered. If this is not possible seek advice
on safety to enter patients’ rooms.

NB risk is typically highest during the later
stages of illness when vomiting, diarrhoea
and often haemorrhage may lead to splash
and droplet generation.

Links Included in the table

6.0 Public Health Management

The Consultant Microbiologist/ Virologist will notify the CCDC who may then convene and chair an Incident Management team (IMT) and the Trust Outbreak plan should be referred to. All contacts, including healthcare workers, will be followed up and monitored by the UKHSA team for a period of 21 days from their final contact with the patient and their environment.

7.0 Monitoring:

In the event of VHF case admission, this guideline would be monitored as part of the Emergency Preparedness Resilience and Response review process.

References

Advisory Committee on Dangerous Pathogens (Department of Health & Health and Safety Executive) 2015 Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence The Stationery Office, London. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/534002/Management_of_VHF_A.pdf

UK Health Security Agency 2024 Viral haemorrhagic fever: ACDP algorithm and guidance on management of patients. Webpages. Available at: https://www.gov.uk/government/publications/viral-haemorrhagic-fever-algorithm-and-guidance-on-management-of-patients

NHS England 2024a National Infection Prevention and Control Manual for England. Available at: https://www.england.nhs.uk/national-infection-prevention-and-control-manual-nipcm-for-england/

NHS England 2024b National Infection Prevention and Control Manual for England. Addendum on high consequence infectious disease (HCID) personal protective equipment (PPE). Available at: https://www.england.nhs.uk/national-infection-prevention-and-control-manual-nipcm-for-england/addendum-on-hcid-ppe/#app-2

World Health Organization 2016 Clinical management of patients with viral haemorrhagic fever: A pocket guide for frontline health workers (interim emergency guidance for country adaptation) WHO, Geneva. https://iris.who.int/bitstream/handle/10665/205570/9789241549608_eng.pdf

World Health Organization 2024 Haemorrhagic fevers, Viral. Webpages. Available at: https://www.emro.who.int/health-topics/haemorrhagic-fevers-viral/index.html

APPENDIX A: Initial Screen

APPENDIX B: Frequently Asked Questions

How are Viral Haemorrhagic Fevers, such as ebola virus spread? Infection occurs from direct contact through broken skin or mucous membranes with the blood, or other bodily fluids or secretions (stool, urine, saliva, semen) of infected people. Infection can also occur if broken skin or mucous membranes of a healthy person come into contact with environments that have become contaminated with a patient’s infectious fluids such as soiled clothing, bed linen, or used needles.

What are typical signs and symptoms of infection? Sudden onset of fever, intense weakness, muscle pain, headache and sore throat are typical signs and symptoms. This is followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases, both internal and external bleeding. Laboratory findings include low white blood cell and platelet counts, and elevated liver enzymes. The incubation period, or the time interval from infection to onset of symptoms, is from 2 to 21 days. The patients become contagious once they begin to show symptoms. They are not contagious during the incubation period. VHF infections/ causes can only be confirmed through laboratory testing.

What is the treatment? Severely ill patients require intensive supportive care. They are frequently dehydrated and need intravenous fluids or oral rehydration with solutions that contain electrolytes. There is currently no specific treatment to cure the disease. Some patients will recover with the appropriate medical care.

Are visitors allowed in areas where patients suspected or confirmed VHF disease are admitted? Stopping visitor access to patients infected with VHF is preferred. If this is not possible, access should be given only to those individuals who are necessary for the patient’s well-being and care, such as a child’s parent. Please contact the on-call Medical Microbiologist for advice prior to allowing family members to visit. Is hand hygiene important? Hand hygiene is essential and must be performed in line with the World Health Organization’s ‘5 Moments for Hand Hygiene’. It is important to note that neglecting to perform hand hygiene after removing PPE will reduce or negate any benefits of the PPE. Either an alcohol-based hand sanitiser or soap and running water can be used for hand hygiene, applying the correct technique recommended by WHO. It is important to always perform hand hygiene with soap and running water when hands are visibly soiled. Alcohol-based hand sanitiser should be made available at every point of care (at the entrance and within the isolation rooms and areas); running water, soap, and single use towels should also be always available.

What other precautions are necessary in the health-care setting? Other key precautions are safe injection and phlebotomy procedures, including safe management of sharps, regular and rigorous environmental cleaning, decontamination of surfaces and equipment, and management of soiled linen and of waste. In addition, it is important to ensure safe processing of laboratory samples from suspected or confirmed patients.

Will I put my family/other people at risk when I finish my shift? The World Health Organization says “If the individual has not developed symptoms, they cannot transmit EVD to those around them. If the individual does have symptoms, they should seek immediate medical attention at the first sign they are feeling unwell”.

Can I take breaks? Use the staff toilet etc? Yes, you can. The World Health Organization says “If the individual has not developed symptoms, they cannot transmit EVD to those around them. If the individual does have symptoms, they should seek immediate medical attention at the first sign they are feeling unwell”.

APPENDIX C Staff Contact List – Viral Haemorrhagic Fever

Patient NameNHS NumberHospital NumberLocationDate of Contact
Staff contact name (PRINT)DesignationContact phone number

Full version control record

Version:13.0
Guidelines Lead(s):Victoria Gentry (Infection Prevention Nurse Consultant) & Dr Manjula Meda (Consultant Microbiologist/ Infection Control Dr)
Contributor(s):Frimley Health IPC Working Group
Lead Director / Chief of Service:Melanie Van Limborgh (Chief of Nursing & Midwifery/ Director of Infection Prevention & Control)
Library check completed:23/07/2024
Ratified at:Healthcare Infection Control Committee 24 July 2024
Date Issued:19/08/2024
Review Date:24/07/2027
Pharmaceutical dosing advice and formulary compliance checked by:N/A
Key words:Viral Haemorrhagic Fevers; VHF; Isolation; Ebola

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

Version Control Sheet

VersionDateGuideline Lead(s)StatusComment
12July 2021Infection Prevention Nurse (Consultant) Consultant Microbiologist/ Infection ControlFinalApproved at HICC 15 July 2021
12.1February 2022Clinical Guidelines AdministratorInterimTransferred to new Clinical Guidelines Template
13July 2024Infection Prevention Nurse (Consultant) Consultant Microbiologist/ Infection ControlFinalApproved at HICC 24 July 2024

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