Health

Alert

UPDATED GUIDANCE REGARDING TRIAGING PATIENTS AT AMBULATORY/NON-INPATIENT HEALTH CARE SETTINGS FOR

POSSIBLE EBOLA INFECTIONS (UPDATED 12/5/2014)

Background

Countries with Ongoing Transmission

Monitoring of Travelers to Delaware

Symptoms and Mode of Transmission

Recommendations for Triaging, Handling, and Reporting Suspected Cases

What should I expect when I call DPH about a potential case in my facility?

Recommendations for Personal Protective Equipment (PPE)

Facilities Performing Invasive/ Aerosol Generating Procedures

Recommendations for Cleaning

Questions? Or to Contact DPH

Background

This communication provides an update to the November 5, 2014 Delaware Health Alert regarding the ongoing Ebola virus disease outbreak.

Countries with Ongoing Transmission

The epidemic of Ebola virus disease (EVD) in West Africa continues to evolve. Mali was recently added to the list of Ebola-affected

countries that includes Liberia, Guinea, and Sierra Leone.  On November 17, WHO declared the Ebola outbreak in the Democratic

Republic of the Congo (DRC) to be over. This outbreak in DRC was unrelated to the ongoing Ebola outbreak in West Africa.

For an up-to-date list of countries with ongoing high level transmission, visit the Centers for Disease Control and Prevention (CDC)

website at http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-map.html

Monitoring of Travelers to Delaware

The CDC is conducting enhanced entry screening at five U.S. airports (New York’s JFK International, Washington-Dulles, Newark,

Chicago-O’Hare, and Atlanta) for all U.S.-bound air travelers who have been in Guinea, Liberia, Sierra Leone, or Mali. Contact

information of travelers with a final destination, or home address, in Delaware are referred to the Delaware Division of Public Health

for 21-day monitoring of temperature and monitoring for Ebola symptoms.

A total of 42 travelers from these countries have been referred to the DPH and currently, DPH is monitoring the health of 15 ‘low

risk’ travelers and one traveler with ‘some risk’ for Ebola.  All travelers remain healthy with no symptoms,

including the ‘some risk’ traveler whose monitoring ends on December 7.  Due to this enhanced monitoring system, it is

unlikely that patients responding “yes” to travel and/or exposure relevant to Ebola and complaining of symptoms will present

to your non-hospital facility.

There has been no community (non-hospital) associated transmission of Ebola in the United States.  There has been evidence of

healthcare associated transmission of EVD in the United States, with two nurses who cared for a man with travel-related EVD in Dallas, TX

contracting the disease. Both nurses received immediate treatment and have since recovered.

Symptoms and Mode of Transmission

Based on currently available information, the Ebola virus is only transmitted by patients who have symptoms. Transmission occurs when a

susceptible individual comes in contact with blood or other bodily fluids of an infected individual.

Symptoms of EVD occur after an incubation period of two to 21 days and include:

• fever (temperature greater than 100.4⁰F or 38⁰C)
• severe headache
• muscle pain
• weakness
• diarrhea
• vomiting
• stomach pain
• unexplained hemorrhage (bleeding or bruising)

Recommendations for Triaging, Handling, and Reporting Suspected Cases

DPH is providing the guidance below to outpatient facilities including but not limited to urgent care centers and outpatient clinics in

order to help with triaging and handling patients who may have had potential exposures to the Ebola virus.

1. Ensure that staff is familiar with the signs and symptoms of EVD listed above.
2. Have on hand several sets of personal protective equipment (PPE) and ensure that staff is familiar with their use. (See below for DPHrecommendation regarding PPE)
3. Front desk staff should continue to assess patients coming into your facility through use of a quick screening tool that includes aquestion on recent travel to West Africa and a question on contact with a known Ebola patient in the U.S. An example of a screening tool

   is available on the DPH website: http://www.dhss.delaware.gov/dph/php/files/ebolascreeningtoolupd.pdf.

   • Be sure that this screening is administered to all patients coming into your facility, rather than to a select few based onlanguage, name, perceived accent, race, or other demographics.  Remember that there is no increased risk inherent to such

     factors as race, nationality or language. The risk is only present with recent travel to Ebola-affected countries and/or exposure to

     patients infected with Ebola.

   • When responses to the screening tool suggest no exposure to Ebola, continue to manage patient as you normally would.
   • When responses to the screening tool suggest the possibility of Ebola exposure but the patient has no symptoms consistent withEbola, continue to treat the patient as you would normally, but also contact the DPH Office of Infectious Disease Epidemiology 24/7

     at 888-295-5156, including weekends and holidays

   • For those whose responses suggest the possibility of Ebola exposure AND who have ANY of the symptoms listed above, take the stepslisted below:
     1. First, remain calm. Bear in mind that there are several travel-related illnesses, including malaria, typhoid fever anddengue, that are much more common than Ebola, and whose symptoms overlap with Ebola. You may very well be seeing any of these

        other illnesses.

     2. Separate the patient from staff, other patients, and visitors in a room that has a door and private bathroom, if available.
     3. Contact the DPH Office of Infectious Disease Epidemiology 24/7 at 888-295-5156, including weekends and holidays.  A DPHEpidemiologist will interview the patient over the phone and DPH will arrange for transport of the patient to the hospital for

        further evaluation if needed.

     4. Minimize the number of staff that has contact with the patient, while continuing to ensure patient safety. Any staff personattending to the patient should be appropriately attired in PPE. See PPE recommendations below.
     5. After the patient has left, clean the room where he/she was kept following CDC guidelines at http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html.Further details are below.

What should I expect when I call DPH about a potential case in my facility?

Focus is on safety and efficiency, not on speed

With Ebola virus disease, the emphasis must be on safety (of the patient and of healthcare providers) rather than on speed. Consequently,

the response when you call will be a deliberate but efficient one rather than a speedy one (unlike what happens with medical

emergencies). When you call the DPH to arrange transport, a chain of responses will be set up including alerting a specialized EMS unit

to deploy to your facility, notifying the receiving hospital and other important parties and ensuring that the receiving hospital is

ready to take the patient. The response will be safe and deliberate but will take longer than your facility typically expects with

routine calls to emergency medical services. Expect to wait on average 60-90 minutes from the time you make the call to the time the

patient is picked up.

Recommendations for Personal Protective Equipment (PPE)

For non-hospital settings in which invasive procedures and aerosol-producing procedures are NOT performed, DPH is

recommending the following for attending to  persons suspected of having been exposed to Ebola (Person Under Investigation), while

awaiting the patient’s transport from your facility.

• No one should have direct contact with a Person Under Investigation for Ebola without wearing appropriate personal protectiveequipment (PPE).
• A single staff member (trained in proper donning and removal of PPE) should be designated to interact with the Person UnderInvestigation. (Please contact DPH if you need assistance with training your staff in proper donning and removal of PPE)
• At a minimum, health care workers should use the following PPE before direct patient contact:
  • Face shield & surgical face mask,
  • Impermeable gown, and
  • Two pairs of gloves.
• It is important that the following additional measures be implemented if the patient is actively vomiting, bleeding, has diarrhea oris otherwise releasing copious bodily fluids:
  • No area of the healthcare worker’s skin should be exposed and
  • Shoe covers or boots should be utilized.
• Proper attention should be paid to removal of PPE after care of the patient suspected to have Ebola. Facilities should practice the“buddy system” in which one healthcare worker observes another removing PPE after caring for a suspected Ebola patient.
• The designated staff member should refrain from direct interaction with other staff and patients in the office until PPE has beensafely removed in a designated, confined area.

Refer to the CDC guidance on personal protective equipment to be used by healthcare workers during management of patients with ebola

virus disease: http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html

Video training on PPE is available from CDC at: http://www.cdc.gov/vhf/ebola/hcp/ppe-training/index.html

A poster on safe donning and removal of PPE: http://www.cdc.gov/HAI/pdfs/ppe/ppeposter1322.pdf

An easy-to-understand graphic for PPE removal:  http://www.who.int/csr/disease/ebola/remove_ppequipment.pdf?ua=1

Recommendations for Facilities Performing Invasive or Aerosol Generating Procedures

DPH recommends that outpatient/non-hospital facilities consider deferring non-emergency invasive or aerosol-generating procedures on

individuals with history of travel to affected areas or history of exposure to known Ebola cases until at least 21 days have passed since

their last potential exposure.

If aerosol generating procedures (such as nebulizer treatments) or invasive procedures must be done in an outpatient setting, DPH

recommends that such facilities follow CDC guidelines for PPE use in hospital settings available at link below and that the number of

staff involved in the procedure be limited to the minimum number that can safely be involved. For further information: http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html.

*Recommendations for Cleaning

When cleaning up after a suspected Ebola patient has been removed from your facility, you should follow CDC guidelines for cleaning is

available at: http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html

Cleanup should be done by individuals adequately attired in appropriate PPE, with proper attention to careful removal of PPE, as is done

for those who have cared for the patient.

Questions? Or to Contact DPH

Call the DPH Office of Infectious Disease Epidemiology 24/7 at 888-295-5156, including weekends and holidays.

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