Ebola primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: :Serge Korjian M.D., Michael Maddaleni, B.S., Guillermo Rodriguez Nava, M.D. [2]

Travelers' Health Updated: July 31, 2014 Warning – Level 3, Avoid Nonessential Travel An outbreak of Ebola has been ongoing in Guinea since March 2014. This outbreak also affects Sierra Leone and Liberia; to date more than 8000 cases have occurred in the three countries and more than 4000 people have died, making this the largest outbreak of Ebola in history. At least ten Americans have been infected; two are health care workers in an Ebola clinic. Affected areas include Boffa, Conakry, Dabola, Dinguiraye, Guékédou, Kissidougou, Kouroussa, Macenta, Siguiri, and Télimélé prefectures. Instances of civil unrest and violence against aid workers have been reported in West Africa as a result of the outbreak. The public health infrastructure in Guinea is being severely strained as the outbreak grows. CDC recommends that US residents avoid nonessential travel to Guinea. If you must travel, such as for humanitarian aid work in response to the outbreak, protect yourself by following CDC’s advice for avoiding contact with the blood and body fluids of people who are ill with Ebola.

Overview

The transmission of Ebola can be limited by implementing preventive measures in both endemic and nonendemic areas which include isolation of infected patients; using gloves/masks/gowns and other standard barrier precautions; routine hand-washing; careful handling, disposal and/or maintenance of sharp objects; proper waste management and proper handling of human remains after death.

Primary Prevention

Use of Personal Protective Equipment (PPE) in Healthcare Settings

On October 20, 2014, the CDC released revised recommendations for PPE given the two reported cases of Ebola in healthcare workers.Images by Adrees Latif/REUTERS

Principles of PPE

Healthcare workers must understand the following basic principles to ensure safe and effective PPE use, which include that no skin may be exposed while working in PPE:

• Donning

• PPE must be donned correctly in proper order before entry into the patient care area and not be later modified while in the patient care area. The donning activities must be directly observed by a trained observer.

• During Patient Care

• PPE must remain in place and be worn correctly for the duration of exposure to potentially contaminated areas. PPE should not be adjusted during patient care.
• Healthcare workers should perform frequent disinfection of gloved hands using an ABHR, particularly after handling body fluids.
• If during patient care a partial or total breach in PPE (e.g., gloves separate from sleeves leaving exposed skin, a tear develops in an outer glove, a needlestick) occurs, the healthcare worker must move immediately to the doffing area to assess the exposure. Implement the facility exposure plan, if indicated by assessment.

• Doffing

• The removal of used PPE is a high-risk process that requires a structured procedure, a trained observer, and a designated area for removal to ensure protection
• PPE must be removed slowly and deliberately in the correct sequence to reduce the possibility of self-contamination or other exposure to Ebola virus
• A stepwise process should be developed and used during training and daily practice

Double gloving provides an extra layer of safety during direct patient care and during the PPE removal process. Beyond this, more layers of PPE may make it more difficult to perform patient care duties and put healthcare workers at greater risk for percutaneous injury (e.g., needlesticks), self-contamination during care or doffing, or other exposures to Ebola. If healthcare facilities decide to add additional PPE or modify this PPE guidance, they must consider the risk/benefit of any modification, and train healthcare workers on correct donning and doffing in the modified procedures.

Recommended PPE

• PAPR or N95 Respirator. If a NIOSH-certified PAPR and a NIOSH-certified fit-tested disposable N95 respirator is used in facility protocols, ensure compliance with all elements of the OSHA Respiratory Protection Standard, including fit testing, medical evaluation, and training of the healthcare worker.

• PAPR: A PAPR with a full face shield, helmet, or headpiece. Any reusable helmet or headpiece must be covered with a single-use (disposable) hood that extends to the shoulders and fully covers the neck and is compatible with the selected PAPR. The facility should follow manufacturer’s instructions for decontamination of all reusable components and, based upon those instructions, develop facility protocols that include the designation of responsible personnel who assure that the equipment is appropriately reprocessed and that batteries are fully charged before reuse.
• A PAPR with a self-contained filter and blower unit integrated inside the helmet is preferred.
• A PAPR with external belt-mounted blower unit requires adjustment of the sequence for donning and doffing, as described below.
• N95 Respirator: Single-use (disposable) N95 respirator in combination with single-use (disposable) surgical hood extending to shoulders and single-use (disposable) full face shield.
• If N95 respirators are used instead of PAPRs, careful observation is required to ensure healthcare workers are not inadvertently touching their faces under the face shield during patient care.

• Single-use (disposable) fluid-resistant or impermeable gown that extends to at least mid-calf or coverall without integrated hood. Coveralls with or without integrated socks are acceptable.

• Consideration should be given to selecting gowns or coveralls with thumb hooks to secure sleeves over inner glove. If gowns or coveralls with thumb hooks are not available, personnel may consider taping the sleeve of the gown or coverall over the inner glove to prevent potential skin exposure from separation between sleeve and inner glove during activity. However, if taping is used, care must be taken to remove tape gently.
• Experience in some facilities suggests that taping may increase risk by making the doffing process more difficult and cumbersome.

• Single-use (disposable) nitrile examination gloves with extended cuffs. Two pairs of gloves should be worn. At a minimum, outer gloves should have extended cuffs.
• Single-use (disposable), fluid-resistant or impermeable boot covers that extend to at least mid-calf or single-use (disposable) shoe covers.

• Boot and shoe covers should allow for ease of movement and not present a slip hazard to the worker.

• Single-use (disposable) fluid-resistant or impermeable shoe covers are acceptable only if they will be used in combination with a coverall with integrated socks.
• Single-use (disposable), fluid-resistant or impermeable apron that covers the torso to the level of the mid-calf should be used if Ebola patients have vomiting or diarrhea.

• An apron provides additional protection against exposure of the front of the body to body fluids or excrement.
• If a PAPR will be worn, consider selecting an apron that ties behind the neck to facilitate easier removal during the doffing procedure.

Use of a Trained Observer

Because the sequence and actions involved in each donning and doffing step are critical to avoiding exposure, a trained observer will read aloud to the healthcare worker each step in the procedure checklist and visually confirm and document that the step has been completed correctly. The trained observer is a dedicated individual with the sole responsibility of ensuring adherence to the entire donning and doffing process. The trained observer will be knowledgeable about all PPE recommended in the facility’s protocol and the correct donning and doffing procedures, including disposal of used PPE, and will be qualified to provide guidance and technique recommendations to the healthcare worker. The trained observer will monitor and document successful donning and doffing procedures, providing immediate corrective instruction if the healthcare worker is not following the recommended steps. The trained observer should know the exposure management plan in the event of an unintentional break in procedure.

Designated Areas for Donning and Doffing

Facilities should ensure that space and layout allow for clear separation between clean and potentially contaminated areas. It is critical that physical barriers (e.g., plastic enclosures) be used where necessary, along with visible signage, to separate distinct areas and ensure a one-way flow of care moving from clean areas (e.g., area where PPE is donned and unused equipment is stored) to the patient room and to the PPE removal area (area where PPE is removed and discarded).

• Post signage to highlight key aspects of PPE donning and doffing, including

• Designating clean areas vs. potentially contaminated areas
• Reminding healthcare workers to wait for a trained observer before removing PPE
• Reinforcing need for slow and deliberate removal of PPE to prevent self-contamination
• Reminding healthcare workers to perform disinfection of gloved hands in between steps of the doffing procedure, as indicated below.

Designate the following areas with appropriate signage:
1. PPE Storage and Donning Area

• This is an area outside the Ebola patient room (e.g., a nearby vacant patient room, a marked area in the hallway outside the patient room) where clean PPE is stored and where healthcare workers can don PPE before entering the patient’s room. Do not store potentially contaminated equipment, used PPE, or waste removed from the patient’s room in this area. If waste must pass through this area, it must be properly contained.

2. Patient Room

• This is a single-patient room. The door is kept closed. Any item or healthcare worker exiting this room should be considered potentially contaminated.

3. PPE Removal Area

• This is an area in proximity to the patient’s room (e.g., anteroom or adjacent vacant patient room that is separate from the clean area) where healthcare workers leaving the patient’s room can doff and discard their PPE. Alternatively, some steps of the PPE removal process may be performed in a clearly designated area of the patient’s room near the door, provided these steps can be seen and supervised by a trained observer (e.g., through a window such that the healthcare worker doffing PPE can still hear the instructions of the trained observer). Do not use this clearly designated area within the patient room for any other purpose. Stock gloves in a clean section of the PPE removal area accessible to the healthcare worker while doffing.

• In the PPE removal area, provide supplies for disinfection of PPE and for performing hand hygiene and space to remove PPE, including a place for sitting that can be easily cleaned and disinfected, where the healthcare workers can remove boot covers. Provide leak-proof infectious waste containers for discarding used PPE. Perform frequent environmental cleaning and disinfection of the PPE removal area, including upon completion of doffing procedure by healthcare workers.

• If a facility must use the hallway outside the patient room as the PPE removal area, construct physical barriers to close the hallway to through traffic and thereby create an anteroom. In so doing, the facility should make sure that this hallway space complies with fire-codes. Restrict access to this hallway to essential personnel who are properly trained on recommended infection prevention practices for the care of Ebola patients.

Facilities should consider making showers available for use by healthcare workers after doffing of PPE.

Donning Procedure

PAPR-Protocol - This donning procedure assumes the facility has elected to use PAPRs. Use a trained observer to verify successful compliance with the protocol.

1. Engage Trained Observer: The donning process is conducted under the guidance and supervision of a trained observer, who confirms visually that all PPE is serviceable and has been donned successfully. The trained observer uses a written checklist to confirm each step in donning PPE and can assist with ensuring and verifying the integrity of the ensemble. No exposed skin or hair of the healthcare worker should be visible at the conclusion of the donning process.
2. Remove Personal Clothing and Items: Change into surgical scrubs (or disposable garments) and dedicated washable (plastic or rubber) footwear in a suitable clean area. No personal items (e.g., jewelry, watches, cell phones, pagers, pens) should be brought into patient room.
3. Inspect PPE Prior to Donning: Visually inspect the PPE ensemble to be worn to ensure that it is in serviceable condition, that all required PPE and supplies are available, and that the sizes selected are correct for the healthcare worker. The trained observer reviews the donning sequence with the healthcare worker before the healthcare worker begins the donning process and reads it to the healthcare worker in a step-by-step fashion.
4. Perform Hand Hygiene: Perform hand hygiene with ABHR. When using ABHR, allow hands to dry before moving to next step.
5. Put on Inner Gloves: Put on first pair of gloves.
6. Put on Boot or Shoe Covers.
7. Put on Gown or Coverall: Put on gown or coverall. Ensure gown or coverall is large enough to allow unrestricted freedom of movement. Ensure cuffs of inner gloves are tucked under the sleeve of the gown or coverall
   1. If a PAPR with a self-contained filter and blower unit that is integrated inside the helmet is used, then the belt and battery unit must be put on prior to donning the impermeable gown or coverall so that the belt and battery unit are contained under the gown or coverall.
   2. If a PAPR with external belt-mounted blower is used, then the blower and tubing must be on the outside of gown or coverall to ensure proper airflow.
8. Put on Outer Gloves: Put on second pair of gloves (with extended cuffs). Ensure the cuffs are pulled over the sleeves of the gown or coverall
9. Put on Respirator: Put on PAPR with a full face-shield, helmet, or headpiece
   1. If a PAPR with a self-contained filter and blower unit integrated inside the helmet is used, then a single-use (disposable) hood that extends to the shoulders and fully covers the neck must also be used. Be sure that the hood covers all of the hair and the ears, and that it extends past the neck to the shoulders.
   2. If a PAPR with external belt-mounted blower unit and attached reusable headpiece is used, then a single-use (disposable) hood that extends to the shoulders and fully covers the neck must also be used. Be sure that the hood covers all of the hair and the ears, and that it extends past the neck to the shoulders.
10. Put on Outer Apron (if used): Put on full-body apron to provide additional protection to the front of the body against exposure to body fluids or excrement from the patient.
11. Verify: After completing the donning process, the integrity of the ensemble is verified by the trained observer. The healthcare worker should be comfortable and able to extend the arms, bend at the waist, and go through a range of motions to ensure there is sufficient range of movement while all areas of the body remain covered. A mirror in the room can be useful for the healthcare worker while donning PPE.
12. Disinfect Outer Gloves: Disinfect outer-gloved hands with ABHR. Allow to dry prior to patient contact.

N95 Protocol - This donning procedure assumes the facility has elected to use N95 masks. Use a trained observer to verify successful compliance with the protocol.

1. Engage Trained Observer: The donning process is conducted under the guidance and supervision of a trained observer who confirms visually that all PPE is serviceable and has been donned successfully. The trained observer will use a written checklist to confirm each step in donning PPE and can assist with ensuring and verifying the integrity of the ensemble. No exposed skin or hair of the healthcare worker should be visible at the conclusion of the donning process.
2. Remove Personal Clothing and Items: Change into surgical scrubs (or disposable garments) and dedicated washable (plastic or rubber) footwear in a suitable, clean area. No personal items (e.g., jewelry, watches, cell phones, pagers, pens) should be brought into patient room.
3. Inspect PPE Prior to Donning: Visually inspect the PPE ensemble to be worn to ensure it is in serviceable condition, all required PPE and supplies are available, and that the sizes selected are correct for the healthcare worker. The trained observer reviews the donning sequence with the healthcare worker before the healthcare worker begins and reads it to the healthcare worker in a step-by-step fashion.
4. Perform Hand Hygiene: Perform hand hygiene with ABHR. When using ABHR, allow hands to dry before moving to next step.
5. Put on Inner Gloves: Put on first pair of gloves.
6. Put on Boot or Shoe Covers.
7. Put on Gown or Coverall: Put on gown or coverall. Ensure gown or coverall is large enough to allow unrestricted freedom of movement. Ensure cuffs of inner gloves are tucked under the sleeve of the gown or coverall.
8. Put on N95 Respirator: Put on N95 respirator. Complete a user seal check.
9. Put on Surgical Hood: Over the N95 respirator, place a surgical hood that covers all of the hair and the ears, and ensure that it extends past the neck to the shoulders. Be certain that hood completely covers the ears and neck.
10. Put on Outer Apron (if used): Put on full-body apron to provide additional protection to the front of the body against exposure to body fluids or excrement from the patient.
11. Put on Outer Gloves: Put on second pair of gloves (with extended cuffs). Ensure the cuffs are pulled over the sleeves of the gown or coverall.
12. Put on Face Shield: Put on full face shield over the N95 respirator and surgical hood to provide additional protection to the front and sides of the face, including skin and eyes.
13. Verify: After completing the donning process, the integrity of the ensemble is verified by the trained observer. The healthcare worker should be comfortable and able to extend the arms, bend at the waist and go through a range of motions to ensure there is sufficient range of movement while all areas of the body remain covered. A mirror in the room can be useful for the healthcare worker while donning PPE.
14. Disinfect Outer Gloves: Disinfect outer-gloved hands with ABHR. Allow to dry prior to patient contact.

Doffing Procedure

PAPR Protocol - PPE doffing should be performed in the designated PPE removal area. Place all PPE waste in a leak-proof infectious waste container.

1. Engage Trained Observer: The doffing process is conducted under the supervision of a trained observer, who reads aloud each step of the procedure and confirms visually that the PPE is removed properly. Prior to doffing PPE, the trained observer must remind the healthcare worker to avoid reflexive actions that may put them at risk, such as touching their face. Post this instruction and repeat it verbally during doffing. Although the trained observer should minimize touching the healthcare worker or the healthcare worker’s PPE during the doffing process, the trained observer may assist with removal of specific components of PPE, as outlined below. The trained observer disinfects the outer-gloved hands immediately after handling any healthcare worker PPE.
2. Inspect: Inspect the PPE to assess for visible contamination, cuts, or tears before starting to remove. If any PPE is potentially contaminated, then disinfect using an *EPA-registered disinfectant wipe. If the facility conditions permit and appropriate regulations are followed, an *EPA-registered disinfectant spray can be used, particularly on contaminated areas.
3. Disinfect Outer Gloves: Disinfect outer-gloved hands with either an *EPA-registered disinfectant wipe or ABHR, and allow to dry.
4. Remove Apron (if used): Remove and discard apron taking care to avoid contaminating gloves by rolling the apron from inside to outside.
5. Inspect: Following apron removal, inspect the PPE ensemble to assess for visible contamination or cuts or tears. If visibly contaminated, then disinfect affected PPE using an *EPA-registered disinfectant wipe.
6. Disinfect Outer Gloves: Disinfect outer-gloved hands with either an *EPA-registered disinfectant wipe or ABHR.
7. Remove Boot or Shoe Covers: While sitting down, remove and discard boot or shoe covers.
8. Disinfect and Remove Outer Gloves: Disinfect outer-gloved hands with either an *EPA-registered disinfectant wipe or ABHR. Remove and discard outer gloves, taking care not to contaminate inner glove during removal process.
9. Inspect and Disinfect Inner Gloves: Inspect the inner gloves’ outer surfaces for visible contamination, cuts, or tears. If an inner glove is visibly soiled, cut, or torn, then disinfect the glove with either an *EPA-registered disinfectant wipe or ABHR. Then remove the inner gloves, perform hand hygiene with ABHR on bare hands, and don a clean pair of gloves. If visible contamination, cuts, or tears are identified on the inner gloves, then disinfect the inner-gloved hands with either an *EPA-registered disinfectant wipe or ABHR.
10. Remove Respirator (PAPR):
    1. If a PAPR with a self-contained filter and blower unit integrated inside the helmet is used, then wait until Step 15 for removal and go to Step 11.
    2. If a PAPR with an external belt-mounted blower unit is used, then all components must be removed at this step.
       1. Remove and discard disposable hood.
       2. Disinfect inner gloves with either an *EPA-registered disinfectant wipe or ABHR.
       3. Remove headpiece, blower, tubing, and the belt and battery unit. This step might require assistance from the trained observer. Disinfect inner gloves with either an *EPA-registered disinfectant wipe or ABHR.
       4. Place all reusable PAPR components in an area or container designated for the collection of PAPR components for disinfection.
11. Remove Gown or Coverall: Remove and discard.
    1. Depending on gown design and location of fasteners, the healthcare worker can either untie fasteners, receive assistance by the trained observer to unfasten the gown, or gently break fasteners. Avoid contact of scrubs or disposable garments with outer surface of gown during removal. #Pull gown away from body, rolling inside out and touching only the inside of the gown.
    2. To remove coverall, tilt head back and reach under the PAPR hood to reach zipper or fasteners. Use a mirror to help avoid touching the skin. Unzip or unfasten coverall completely before rolling down and turning inside out. Avoid contact of scrubs with outer surface of coverall during removal, touching only the inside of the coverall.
12. Disinfect Inner Gloves: Disinfect inner gloves with either an *EPA-registered disinfectant wipe or ABHR
13. Disinfect Washable Shoes: Sitting on a new clean surface (e.g., second clean chair, clean side of a bench) use an *EPA-registered disinfectant wipe to wipe down every external surface of the washable shoes.
14. Disinfect Inner Gloves: Disinfect inner gloves with either an *EPA-registered disinfectant wipe or ABHR.
15. Remove Respirator (if not already removed): If a PAPR with a self-contained filter and blower unit that is integrated inside helmet is used, then remove all components.
    1. Remove and discard disposable hood
    2. Disinfect inner gloves with either an *EPA-registered disinfectant wipe or ABHR
    3. Remove and discard inner gloves taking care not to contaminate bare hands during removal process
    4. Perform hand hygiene with ABHR
    5. Don a new pair of inner gloves
    6. Remove helmet and the belt and battery unit. This step might require assistance from the trained observer.
16. Disinfect and Remove Inner Gloves: Disinfect inner-gloved hands with either an *EPA-registered disinfectant wipe or ABHR. Remove and discard gloves taking care not to contaminate bare hands during removal process.
17. Perform Hand Hygiene: Perform hand hygiene with ABHR.
18. Inspect: Perform a final inspection of healthcare worker for any indication of contamination of the surgical scrubs or disposable garments. If contamination is identified, immediately inform infection preventionist or occupational safety and health coordinator or their designee before exiting PPE removal area.
19. Scrubs: Healthcare worker can leave PPE removal area wearing dedicated washable footwear and surgical scrubs or disposable garments.
20. Shower: Showers are recommended at each shift’s end for healthcare workers performing high-risk patient care (e.g., exposed to large quantities of blood, body fluids, or excreta). Showers are also suggested for healthcare workers spending extended periods of time in the Ebola patient room.
21. Protocol Evaluation/Medical Assessment: Either the infection preventionist or occupational safety and health coordinator or their designee on the unit at the time should meet with the healthcare worker to review the patient care activities performed to identify any concerns about care protocols and to record healthcare worker’s level of fatigue

N95 Protocol - PPE doffing is performed in the designated PPE removal area. Place all PPE waste in a leak-proof infectious waste container.

1. Engage Trained Observer: The doffing process is conducted under the supervision of a trained observer, who reads aloud each step of the procedure and confirms visually that the PPE has been removed properly. Prior to doffing PPE, the trained observer must remind healthcare workers to avoid reflexive actions that may put them at risk, such as touching their face. Post this instruction and repeat it verbally during doffing. Although the trained observer should minimize touching healthcare workers or their PPE during the doffing process, the trained observer may assist with removal of specific components of PPE as outlined below. The trained observer disinfects the outer-gloved hands immediately after handling any healthcare worker PPE.
2. Inspect: Inspect the PPE to assess for visible contamination, cuts, or tears before starting to remove. If any PPE is visibly contaminated, then disinfect using an *EPA-registered disinfectant wipe. If the facility conditions permit and appropriate regulations are followed, an *EPA-registered disinfectant spray can be used, particularly on contaminated areas.
3. Disinfect Outer Gloves: Disinfect outer-gloved hands with either an *EPA-registered disinfectant wipe or ABHR.
4. Remove Apron (if used): Remove and discard apron taking care to avoid contaminating gloves by rolling the apron from inside to outside.
5. Inspect: Following apron removal, inspect the PPE ensemble to assess for visible contamination or cuts or tears. If visibly contaminated, then disinfect affected PPE using an *EPA-registered disinfectant wipe.
6. Disinfect Outer Gloves: Disinfect outer-gloved hands with either an *EPA-registered disinfectant wipe or ABHR.
7. Remove Boot or Shoe Covers: While sitting down, remove and discard boot or shoe covers.
8. Disinfect and Remove Outer Gloves: Disinfect outer-gloved hands with either an *EPA-registered disinfectant wipe or ABHR. Remove and discard outer gloves taking care not to contaminate inner gloves during removal process.
9. Inspect and Disinfect Inner Gloves: Inspect the inner gloves’ outer surfaces for visible contamination, cuts, or tears. If an inner glove is visibly soiled, cut, or torn, then disinfect the glove with either an *EPA-registered disinfectant wipe or ABHR. Then remove the inner gloves, perform hand hygiene with ABHR on bare hands, and don a clean pair of gloves. If visible contamination, cuts, or tears are identified on the inner gloves, then disinfect the inner-gloved hands with either an *EPA-registered disinfectant wipe or ABHR.
10. Remove Face Shield: Remove the full face shield by tilting the head slightly forward, grabbing the rear strap and pulling it over the head, gently allowing the face shield to fall forward and discard. Avoid touching the front surface of the face shield.
11. Disinfect Inner Gloves: Disinfect inner gloves with either an *EPA-registered disinfectant wipe or ABHR.
12. Remove Surgical Hood: Unfasten (if applicable) surgical hood, gently remove, and discard. The trained observer may assist with unfastening hood.
13. Disinfect Inner Gloves: Disinfect inner gloves with either an *EPA-registered disinfectant wipe or ABHR.
14. Remove Gown or Coverall: Remove and discard.
    1. Depending on gown design and location of fasteners, the healthcare worker can either untie fasteners, receive assistance by the trained observer to unfasten to gown, or gently break fasteners. Avoid contact of scrubs or disposable garments with outer surface of gown during removal. Pull gown away from body, rolling inside out and touching only the inside of the gown.
    2. To remove coverall, tilt head back to reach zipper or fasteners. Unzip or unfasten coverall completely before rolling down and turning inside out. Avoid contact of scrubs with outer surface of coverall during removal, touching only the inside of the coverall.
15. Disinfect and Change Inner Gloves: Disinfect inner gloves with either an *EPA-registered disinfectant wipe or ABHR. Remove and discard gloves taking care not to contaminate bare hands during removal process. Perform hand hygiene with ABHR. Don a new pair of inner gloves.
16. Remove N95 Respirator: Remove the N95 respirator by tilting the head slightly forward, grasping first the bottom tie or elastic strap, then the top tie or elastic strap, and remove without touching the front of the N95 respirator. Discard N95 respirator.
17. Disinfect Inner Gloves: Disinfect inner gloves with either an *EPA-registered disinfectant wipe or ABHR
18. Disinfect Washable Shoes: Sitting on a new clean surface (e.g., second clean chair, clean side of a bench) use an *EPA-registered disinfectant wipe to wipe down every external surface of the washable shoes.
19. Disinfect and Remove Inner Gloves: Disinfect inner-gloved hands with either an *EPA-registered disinfectant wipe or ABHR. Remove and discard gloves taking care not to contaminate bare hands during removal process.
20. Perform Hand Hygiene: Perform hand hygiene with ABHR.
21. Inspect: Perform a final inspection of healthcare worker for any indication of contamination of the surgical scrubs or disposable garments. If contamination is identified, immediately inform infection preventionist or occupational safety and health coordinator or their designee before exiting PPE removal area.
22. Scrubs: Healthcare worker can leave PPE removal area wearing dedicated washable footwear and surgical scrubs or disposable garments.
23. Shower: Showers are recommended at each shift’s end for healthcare workers performing high risk patient care (e.g., exposed to large quantities of blood, body fluids, or excreta). Showers are also suggested for healthcare workers spending extended periods of time in the Ebola patient room.
24. Protocol Evaluation/Medical Assessment: Either the infection preventionist or occupational health safety and health coordinator or their designee on the unit at the time should meet with the healthcare worker to review the patient care activities performed to identify any concerns about care protocols and to record healthcare worker’s level of fatigue.

Infection Control Precautions

• Patients who are hospitalized or treated in an outpatient healthcare setting should be placed in a private room and Standard, Contact, and Droplet Precautions should be initiated.. Patients with respiratory symptoms also should wear a face mask to contain respiratory droplets prior to placement in their hospital or examination room and during transport.
• Caretakers should use appropriate PPE (detailed below) to prevent skin or mucous membrane exposure of the eyes, nose, and mouth with patient blood, other body fluids, secretions (including respiratory droplets), or excretions.
• Nonessential staff and visitors should be restricted from entering the room of patients with suspected VHF. Maintain a log of persons entering the patient’s room.
• Use a U.S. Environmental Protection Agency (EPA)-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus) to disinfect environmental surfaces in rooms of patients with suspected or confirmed Ebola virus infection. Although there are no products with specific label claims against the Ebola virus, enveloped viruses such as Ebola are susceptible to a broad range of hospital disinfectants used to disinfect hard, non-porous surfaces. In contrast, non-enveloped viruses are more resistant to disinfectants. As a precaution, selection of a disinfectant product with a higher potency than what is normally required for an enveloped virus is being recommended at this time. EPA-registered hospital disinfectants with label claims against non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) are broadly antiviral and capable of inactivating both enveloped and non-enveloped viruses.
• Avoid contamination of reusable porous surfaces that cannot be made single use. Use only a mattress and pillow with plastic or other covering that fluids cannot get through. Do not place patients with suspected or confirmed Ebola virus infection in carpeted rooms and remove all upholstered furniture and decorative curtains from patient rooms before use.
• To reduce exposure among staff to potentially contaminated textiles (cloth products) while laundering, discard all linens, non-fluid-impermeable pillows or mattresses, and textile privacy curtains into the waste stream and disposed of appropriately.
• The Ebola virus is a classified as a Category A infectious substance by and regulated by the U.S. Department of Transportation’s (DOT) Hazardous Materials Regulations (HMR). Any item transported offsite for disposal that is contaminated or suspected of being contaminated with a Category A infectious substance must be packaged and transported in accordance with the HMR. This includes medical equipment, sharps, linens, and used health care products (such as soiled absorbent pads or dressings, kidney-shaped emesis pans, portable toilets, used Personal Protection Equipment (gowns, masks, gloves, goggles, face shields, respirators, booties, etc.) or byproducts of cleaning) contaminated or suspected of being contaminated with a Category A infectious substance.

Key Components of Standard, Contact, and Droplet Precautions Recommended for Prevention of EVD Transmission in U.S. Hospitals

Component	Recommendation	Comments
Patient Placement	Single patient room (containing a private bathroom) with the door closed Facilities should maintain a log of all persons entering the patient's room	Consider posting personnel at the patient’s door to ensure appropriate and consistent use of PPE by all persons entering the patient room
Personal Protective Equipment (PPE)	Detailed above
Patient Care Equipment	Dedicated medical equipment (preferably disposable, when possible) should be used for the provision of patient care All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer's instructions and hospital policies
Patient Care Considerations	Limit the use of needles and other sharps as much as possible Phlebotomy, procedures, and laboratory testing should be limited to the minimum necessary for essential diagnostic evaluation and medical care All needles and sharps should be handled with extreme care and disposed in puncture-proof, sealed containers
Aerosol Generating Procedures (AGPs)	Avoid AGPs for patients with EVD. If performing AGPs, use a combination of measures to reduce exposures from aerosol-generating procedures when performed on Ebola HF patients. Visitors should not be present during aerosol-generating procedures. Limiting the number of HCP present during the procedure to only those essential for patient-care and support. Conduct the procedures in a private room and ideally in an Airborne Infection Isolation Room (AIIR) when feasible. Room doors should be kept closed during the procedure except when entering or leaving the room, and entry and exit should be minimized during and shortly after the procedure. HCP should wear gloves, a gown, disposable shoe covers, and either a face shield that fully covers the front and sides of the face or goggles, and respiratory protection that is at least as protective as a NIOSH certified fit-tested N95 filtering facepiece respirator or higher (e.g., powered air purifying respiratory or elastomeric respirator) during aerosol generating procedures. Conduct environmental surface cleaning following procedures (see section below on environmental infection control). If re-usable equipment or PPE (e.g. Powered air purifying respirator, elastomeric respirator, etc.) are used, they should be cleaned and disinfected according to manufacturer instructions and hospital policies. Collection and handling of soiled re-usable respirators must be done by trained individuals using PPE as described above for routine patient care	Although there are limited data available to definitively define a list of AGPs, procedures that are usually included are Bilevel Positive Airway Pressure (BiPAP), bronchoscopy, sputum induction, intubation and extubation, and open suctioning of airways. Because of the potential risk to individuals reprocessing reusable respirators, disposable filtering face piece respirators are preferred.
Hand Hygiene	HCP should perform hand hygiene frequently, including before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of PPE, including gloves. Healthcare facilities should ensure that supplies for performing hand hygiene are available	Hand hygiene in healthcare settings can be performed by washing with soap and water or using alcohol-based hand rubs. If hands are visibly soiled, use soap and water, not alcohol-based hand rubs.
Safe Injection practices	Facilities should follow safe injection practices as specified under Standard Precautions.	Any injection equipment or parenteral medication container that enters the patient treatment area should be dedicated to that patient and disposed of at the point of use.
Duration of Infection Control Precautions	Duration of precautions should be determined on a case-by-case basis, in conjunction with local, state, and federal health authorities.	Factors that should be considered include, but are not limited to: presence of symptoms related to EVD, date symptoms resolved, other conditions that would require specific precautions (e.g., tuberculosis, Clostridium difficile) and available laboratory information
Monitoring and Management of Potentially Exposed Personnel	Facilities should develop policies for monitoring and management of potentially exposed HCP Facilities should develop sick leave policies for HCP that are non-punitive, flexible and consistent with public health guidance Ensure that all HCP, including staff who are not directly employed by the healthcare facility but provide essential daily services, are aware of the sick leave policies. Persons with percutaneous or mucocutaneous exposures to blood, body fluids, secretions, or excretions from a patient with suspected EVD should: Stop working and immediately wash the affected skin surfaces with soap and water. Mucous membranes (e.g., conjunctiva) should be irrigated with copious amounts of water or eyewash solution. Immediately contact occupational health/supervisor for assessment and access to postexposure management services for all appropriate pathogens (e.g., Human Immunodeficiency Virus, Hepatitis C, etc.) HCP who develop sudden onset of fever, intense weakness or muscle pains, vomiting, diarrhea, or any signs of hemorrhage after an unprotected exposure (i.e. not wearing recommended PPE at the time of patient contact or through direct contact to blood or body fluids) to a patient with EVD should: Not report to work or should immediately stop working Notify their supervisor Seek prompt medical evaluation and testing Notify local and state health departments Comply with work exclusion until they are deemed no longer infectious to others For asymptomatic HCP who had an unprotected exposure (i.e. not wearing recommended PPE at the time of patient contact or through direct contact to blood or body fluids) to a patient with Ebola HF Should receive medical evaluation and follow-up care including fever monitoring twice daily for 21 days after the last known exposure. Hospitals should consider policies ensuring twice daily contact with exposed personnel to discuss potential symptoms and document fever checks May continue to work while receiving twice daily fever checks, based upon hospital policy and discussion with local, state, and federal public health authorities.
Monitoring, Management, and Training of Visitors	Avoid entry of visitors into the patient's room Exceptions may be considered on a case by case basis for those who are essential for the patient's wellbeing. Establish procedures for monitoring managing and training visitors. Visits should be scheduled and controlled to allow for: Screening for EVD (e.g., fever and other symptoms) before entering or upon arrival to the hospital Evaluating risk to the health of the visitor and ability to comply with precautions Providing instruction, before entry into the patient care area on hand hygiene, limiting surfaces touched, and use of PPE according to the current facility policy while in the patient's room Visitor movement within the facility should be restricted to the patient care area and an immediately adjacent waiting area.	Visitors who have been in contact with the EVD patient before and during hospitalization are a possible source of EVD for other patients, visitors, and staff.

Primary Prevention in Endemic Areas

Standard Precautions

A patient with a virus hemorrhagic fever (VHF) may come to the health facility at any point in his or her illness:

• When the possibility of exposure is often highest
• Before the specific cause of the patient’s illness is known

Because an health worker cannot always know when a patient’s body fluids are infectious, standard precautions should be used with all patients in the health care setting, regardless of their infection status. Standard Precautions are designed to prevent unprotected contact between the health care worker and:

• Blood and all body fluids whether or not they contain blood
• Mucous membranes.

When a specific diagnosis is made, additional precautions are taken, based on how the disease is transmitted.

Limited supplies and resources may prevent a health facility from using all the Standard Precautions all the time. However, health facilities should establish and maintain a basic, practical level of Standard Precautions that can be used routinely with patients in their health facility. At a minimum, consider the services in the health facility that present a risk of disease transmission due to potential contact with blood and all body fluids, broken skin or mucous membranes. For health facility staff who work in such areas, establish at least:

• A source of clean water
• Routine handwashing before and after any contact with a patient who has fever
• Safe handling and disposal of sharp instruments and equipment, including needles and syringes

Infection Control Measures

Routine Hand Washing

Handwashing is the most important precaution for the prevention of infections. Handwashing before and after contact with a patient who has fever should be a routine practice in the health facility even when VHF is not present. Washing hands with soap and water eliminates microorganisms from the skin and hands. This provides some protection against transmission of VHF and other diseases. In services where health care workers see patients with fever, provide at least:

• Cake soap cut into small pieces.
• Soap dishes. Microorganisms grow and multiply in humidity and standing water. If cake soap is used, provide soap dishes with openings that allow water to drain away.
• Running water, or a bucket kept full with clean water.
• A bucket for collecting rinse water and a ladle for dipping, if running water is not available.
• One-use towels. Sharing towels can result in contamination. Use paper towels. If they are not available, provide cloth towels that can be used once and then laundered. If towels are not available, health care workers and health facility staff can air-dry their hands

Make sure health facility staff know the steps of hand-washing:

1. Place a piece of soap in the palm of one hand
2. Wash the opposite hand and forearm. Rub the surfaces vigorously for at least 10 seconds. Move soap to the opposite hand and repeat
3. Use clean water to rinse both hands and then the forearms. If running water is not available, pour clean water from a bucket over the soapy hands and forearms. The rinse water should drain into another bucket
4. Dry the hands and forearms with a clean, one-use towel. First dry the hands and then the forearms. Or let rinsed hands and forearms air-dry

Use of Personal Protective Equipment (PPE)

MSF (Doctors Without Borders) Protocol

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Handling Equipment

• Disease transmission can occur through accidental needlestick injuries. Make sure health facility staff always handle sharp instruments safely. Do not recap needles after use.
• Limit invasive procedures to reduce the number of injectable medications. This will limit the opportunities for accidental needlestick injuries.
• When an injection is necessary, always use a sterile needle and sterile syringe for each injection.
• To discard disposable needles and syringes safely: Disposable needles and syringes should be used only once. Discard the used disposable needle and syringe in a puncture-resistant container. Then burn the container in an incinerator or pit for burning.
• If puncture-resistant containers are not available, use empty water, oil, or bleach bottles made with plastic or other burnable material. Adapt them for use as puncture-resistant containers.
• Reusable needles and syringes are not recommended. If reusable needles and syringes are used, clean, disinfect and sterilize them before reuse, according to your hospital’s policy.
• Needles and syringes used with VHF patients require special care. Cleaning staff should wear two pairs of gloves when handling needles and syringes used with any patient with a known or suspected VHF.
• Whenever possible, use disposable needles and syringes only once and then discard them safely.
• In situations when disposable needles and syringes must be reused, make sure they are cleaned and disinfected after each use. Disinfection with bleach will reduce the risk of transmission of VHF and blood-borne diseases, such as HIV infection and viral hepatitis.

1. Obtain a jar or pan. Clean and disinfect it.
2. Place the disposable needle and syringe in a pan of soapy water after use. Fill the needle and syringe with soapy water. Leave them to soak until they are cleaned.
3. Take the soaking needles and syringes to the cleaning area.
4. Clean them very carefully in soap and water. Remove any blood or other biological waste, especially from the area around the syringe fittings. Blood or other biological products may collect in these small openings.
5. Draw full-strength bleach into the needle and syringe.
6. Soak for 30 seconds, and then expel bleach into a container for contaminated waste.
7. Soak again by once more drawing full-strength bleach into the needle and syringe. Soak for 30 seconds, and then expel bleach into the container for contaminated waste.
8. Let the disinfected needle and syringe air-dry. Store them in a clean jar or pan that has been disinfected.

Decontamination

• Environmental surfaces or objects contaminated with blood, other body fluids, secretions or excretions should be cleaned and disinfected using standard hospital detergents/disinfectants. Application of disinfectant should be preceded by cleaning.
• Do not spray (i.e. fog) occupied or unoccupied clinical areas with disinfectant. This is a potentially dangerous practice that has no proven disease control benefit.
• Wear gloves, gown and closed shoes (e.g. boots) when cleaning the environment and handling infectious waste. Cleaning heavily soiled surfaces (e.g. soiled with vomit or blood) increases the risk of splashes. On these occasions, facial protection should be worn in addition to gloves, gown and closed, resistant shoes.
• Soiled linen should be placed in clearly-labelled, leak-proof bags or buckets at the site of use and the container surfaces should be disinfected (using an effective disinfectant) before removal from the site. Linen should be transported directly to the laundry area and laundered promptly with water and detergent. For low-temperature laundering, wash linen with detergent and water, rinse and then soak in 0.05% chlorine for approximately 30 minutes. Linen should then be dried according to routine standards and procedures.
• Linen that has been used by HF patients can be heavily contaminated with body fluids (e.g. blood, vomit) and splashes may result during handling. When handling soiled linen from hemorrhagic fever patients, use gloves, gown, closed shoes and facial protection.
• If safe cleaning and disinfection of heavily soiled linen is not possible or reliable, it may be prudent to burn the linen to avoid any unnecessary risks to individuals handling these items.

Waste Management

• Waste should be triaged to enable appropriate and safe handling.
• Sharp objects (e.g. needles, syringes, glass articles) and tubing that has been in contact with the bloodstream should be placed inside puncture resistant containers. These should be located as close as practical to the area in which the items are used.
• Collect all solid, non-sharp, medical waste using leak-proof waste bags and covered bins.
• Waste should be placed in a designated pit of appropriate depth (e.g. 2 m deep and filled to a depth of 1–1.5 m). After each waste load the waste should be covered with a layer of soil 10–15 cm deep.
• An incinerator may be used for short periods during an outbreak to destroy solid waste. However, it is essential to ensure that total incineration has taken place. Caution is also required when handling flammable material and when wearing gloves due to the risk of burn injuries if gloves are ignited.
• Placenta and anatomical samples should be buried in a separate pit.
• The area designated for the final treatment and disposal of waste should have controlled access to prevent entry by animals, untrained personnel or children.
• Wear gloves, gown and closed shoes (e.g. boots) when handling solid infectious waste.
• Waste, such as feces, urine and vomit, and liquid waste from washing, can be disposed of in the sanitary sewer or pit latrine. No further treatment is necessary.
• Wear gloves, gown, closed shoes and facial protection, when handling liquid infectious waste (e.g. any secretion or excretion with visible blood even if it originated from a normally sterile body cavity). Avoid splashing when disposing of liquid infectious waste. Goggles provide greater protection than visors from splashes that may come from below when pouring liquid waste from a bucket.

Postmortem Care

Postmortem Examinations

• Post-mortem examination of hemorrhagic fever patient remains should be limited to essential evaluations only and should be performed by trained personnel.
• Personnel examining remains should wear eye protection, mask, gloves and gowns as recommended for patient care.
• In addition, personnel performing autopsies of known or suspected HF patients should wear a particulate respirator and eye protection or face shield, or a powered air purifying respirator (PAPR).
• When removing protective equipment, avoid any contact between soiled gloves or equipment and the face (i.e. eyes, nose or mouth).
• Hand hygiene should be performed immediately following the removal of protective equipment used during post-mortem examination and that may have come into contact with potentially contaminated surfaces.
• Place specimens in clearly-labelled, non-glass, leak-proof containers and deliver directly to designated specimen handling areas.
• All external surfaces of specimen containers should be thoroughly disinfected (using an effective disinfectant) prior to transport.
• Tissue or body fluids for disposal should be carefully placed in clearly marked, sealed containers for incineration.

Movement and Burial of Human Remains

• The handling of human remains should be kept to a minimum. Take account of cultural and religious concerns:
  • Remains should not be sprayed, washed or embalmed.
  • Only trained personnel should handle remains during the outbreak.
  • Personnel handling remains should wear personal protective equipment (gloves, gowns, apron, surgical masks and eye protection) and closed shoes.
  • Protective equipment is not required for individuals driving or riding a vehicle to collect human remains.
  • Protective equipment should be put on at the site of collection of human remains and worn during the process of collection and placement in a body bag.
  • Protective equipment should be removed immediately after remains have been placed in a body bag and then placed inside a coffin.
  • Remains should be wrapped in sealed, leak-proof material and should be buried promptly.

To read more about guidance for safe handling of human remains of Ebola patients, click here.

Managing Exposure to Infection

• Persons including health care workers (HCWs) with percutaneous or mucocutaneous exposure to blood, body fluids, secretions, or excretions from a patient with suspected hemorrhagic fever should immediately wash the affected [[skin surfaces with soap and water. Mucous membranes (e.g. conjunctiva) should be irrigated with copious amounts of water or eyewash solution.
• Exposed persons should be medically evaluated and receive follow up care, including fever monitoring, twice daily for 21 days after exposure. Immediate consultation with an expert in infectious diseases is recommended for any exposed person who develops fever within 21 days of exposure.
• HCWs suspected of being infected should be isolated, and the same same precautions must be applied until a negative diagnosis is confirmed.
• Contact tracing and follow-up of family, friends, co-workers and other patients, who may have been exposed to an hemorrhagic fever virus through close contact with the infected HCW is essential.

Other Transmission-Based Precautions

Airborne Transmission

1. Place the patient in an isolation room that is not air-conditioned or where air is not circulated to the rest of the health facility. Make sure the room has a door that can be closed.
2. Wear a HEPA or other biosafety mask when working with the patient and in the patient's room.
3. Limit movement of the patient from the room to other areas. Place a surgical mask on the patient who must be moved.

Droplet Transmission

1. Place the patient in an isolation room.
2. Wear a HEPA or other biosafety mask when working with the patient.
3. Limit movement of the patient from the room to other areas. If patient must be moved, place a surgical mask on the patient.

Vaccination

Vaccines have been produced for both Ebola and Marburg that were 99% effective in protecting a group of monkeys from the disease. These vaccines are based on either a recombinant Vesicular stomatitis virus or a recombinant Adenovirus carrying the Ebola spikeprotein on its surface. Early human vaccine efforts, like the one at NIAID in 2003, have so far not reported any successes.