Ebola primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] 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 1320 cases have occurred in the three countries and more than 725 people have died, making this the largest outbreak of Ebola in history. At least three 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 in the USA

Infection Control Precautions

The following recommendations should be followed when caring for persons with suspected viral hemorrhagic fever (VHF):

• 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 barrier precautions 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. All persons entering the patient's room should wear gloves and gowns to prevent contact with items or environmental surfaces that may be soiled. In addition, face shields or surgical masks and eye protection (e.g., goggles or eyeglasses with side shields) should be worn by persons coming within approximately 3 feet of the patient.
• Additional barriers may be needed depending on the likelihood and magnitude of contact with body fluids. For example, if copious amounts of blood, other body fluids, vomit, or feces are present in the environment, plastic apron, leg, and shoe coverings also may be needed.
• 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.
• Before exiting the room of a patient with suspected VHF, safely remove and dispose of all protective gear, and clean and disinfect shoes that are soiled with body fluids as described in the section on environmental infection control below.
• To prevent percutaneous injuries, needles and other sharps should be used and disposed of in accordance with recommendations for Standard Precautions.
• If the patient requires a surgical or obstetric procedure, consult your state health department and CDC regarding appropriate precautions for these invasive procedures.
• Although transmission by the airborne route has not been established, hospitals may choose to use Airborne Precautions for patients with suspected VHF who have severe pulmonary involvement or who undergo procedures that stimulate coughing and promote the generation of aerosols (e.g. aerosolized or nebulized medication administration, diagnostic sputum induction, bronchoscopy, airway suctioning, endotracheal intubation, positive pressure ventilation via face mask [e.g., biphasic intermittent positive airway pressure ventilation, continuous positive airway pressure ventilation], and high frequency oscillatory ventilation) to prevent possible exposure to airborne particles that may contain virus.

Environmental Infection Control Procedures

As part of the care of patients who are persons under investigation, or with probable or confirmed Ebola virus infections, hospitals are recommended to:

• Be sure environmental services staff wear recommended personal protective equipment including, at a minimum, disposable gloves, gown (fluid resistant/ impermeable), eye protection (goggles or face shield), and facemask to protect against direct skin and mucous membrane exposure of cleaning chemicals, contamination, and splashes or spatters during environmental cleaning and disinfection activities. Additional barriers (e.g., leg covers, shoe covers) should be used as needed. If reusable heavy-duty gloves are used for cleaning and disinfecting, they should be disinfected and kept in the room or anteroom. Be sure staff are instructed in the proper use of personal protective equipment including safe removal to prevent contaminating themselves or others in the process, and that contaminated equipment is disposed of as regulated medical waste.
• 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 as a regulated medical waste.

Use of Personal Protective Equipment (PPE) in Healthcare Settings

CDC Recommendations

• On October 16, 2014, the CDC announced revised recommendations for PPE given the two reported cases of Ebola in healthcare workers.

• The CDC announced that PPE suits will be standardized to ensure consistency in both training and use, possibly using only full-body suits.

• Use of a model of hood that protects health care worker’s neck has been recommended so the neck will not be exposed.

• Removing PPE will include enhanced and detailed step-by-step disinfection with specific sequencing for removal of each piece of equipment and the hand washing.

• The single most important aspect of safe care of Ebola is to have a site manager at all times who oversees the putting on and taking off of PPE and the care given in the isolation unit.

Images by Adrees Latif/REUTERS

Initial CDC Recommendations

• Single gloves are adequate for routine care of patients with Ebola; double-gloving is advised during invasive procedures (e.g., surgery) that pose an increased risk for blood exposure.
• Routine eye protection (i.e. goggles or face shield) is particularly important.
• Fluid-resistant gowns should be worn for all patient contact.
• Airborne precautions are not required for routine patient care; however, use of airborne infection isolation rooms (AIIRs) is prudent when procedures that could generate infectious aerosols are performed (e.g., endotracheal intubation, bronchoscopy, suctioning, autopsy procedures involving oscillating saws). N95 or higher level respirators may provide added protection for individuals in a room during aerosol-generating procedures.

Sequence for putting on personal protective equipment (PPE). CDC 2014.

Sequence for removing personal protective equipment (PPE). CDC 2014.

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)	All persons entering the patient room should wear at least: Gloves Gown (fluid resistant or impermeable) Eye protection (goggles or face shield) Facemask Additional PPE might be required in certain situations (e.g., copious amounts of blood, other body fluids, vomit, or feces present in the environment), including but not limited to: Double gloving Disposable shoe covers Leg coverings	Recommended PPE should be worn by HCP upon entry into patient rooms or care areas. Upon exit from the patient room or care area, PPE should be carefully removed without contaminating one’s eyes, mucous membranes, or clothing with potentially infectious materials, and either discarded, or for re-useable PPE, cleaned and disinfected according to the manufacturer's reprocessing instructions and hospital policies. Hand hygiene should be performed immediately after removal of PPE
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.