Health Alert
UPDATED GUIDANCE REGARDING TRIAGING PATIENTS AT AMBULATORY/NON-INPATIENT HEALTH CARE SETTINGS FOR POSSIBLE EBOLA INFECTIONS

Background

Countries with Ongoing Transmission

Symptoms and Mode of Transmission

Recommendations for Triaging, Handling, and Reporting Suspected Cases

Recommendations for Personal Protective Equipment

Facilities Performing Invasive/ Aerosol Generating Procedures

Recommendations for Cleaning

Questions? Or to Contact DPH

Background

This communication provides an update to the October 17, 2014 Delaware Health Alert regarding the ongoing Ebola virus disease outbreak.

The epidemic of Ebola virus disease (EVD) continues to unfold. Particularly affected are the West African countries of Sierra Leone, Liberia, and Guinea; but travel related cases have also shown up in other areas including Dallas, TX, and New York City.

Because of increased monitoring of travelers instituted by DPH in conjunction with CDC’s Division of Global Migration and Quarantine, 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. Virtually all such patients would already be under monitoring by DPH.

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 recovered.

There has been no community (non-healthcare) associated transmission in the United States.

Countries with Ongoing Transmission

The epidemic continues to evolve. For an updated 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

EVD-Symptoms and Mode of Transmission

Based on currently available information, 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
• Abdominal (stomach) pain
• Unexplained hemorrhage (bleeding or bruising)

Recommendations/Reporting

The Division of Public Health (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 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 DPH recommendation regarding PPE)
3. Develop a quick screening tool that can be used by front desk staff to assess patients coming into your facility, including screening for recent travel to West Africa, and for contact with a known Ebola patient in the U.S. An example of such a tool is included here at this url: http://www.dhss.delaware.gov/dhss/dph/php/files/ebolascreeningtoolupd.pdf
   on the DPH website.
4. Be sure that this screening is administered to all patients coming into your facility, rather than to a select few based on language, name, perceived accent, race, or other demographic.  Remember that there is no increased risk inherent to such factors as race, nationality or language. The risk is only present with recent travel and/or exposure to infected patients.
5. When responses to the screening tool suggest no exposure to Ebola, continue to manage patient as you normally would.
6. When responses to the screening tool suggests the possibility of Ebola exposure but the patient has no symptoms consistent with Ebola, 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
7. For those whose responses suggest the possibility of Ebola exposure AND who have ANY of the symptoms listed above, take the steps listed below:
   1. First, remain calm. Bear in mind that there are several travel related illness including malaria, typhoid fever and dengue 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 and other patients 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.  DPH will arrange for transport of the patient to the hospital for further evaluation
   4. Any staff person attending 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 detail also below.*

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 the care of persons suspected of having been exposed to Ebola: ** 

1. At the minimum: impervious gown, double gloving for all patient care, use of eye protection, face cover (such as a face shield) should be used.
2. In addition, it is important that the following additional measures be implemented if the patient is actively vomiting, bleeding, has diarrhea or is otherwise releasing copious bodily fluids:
   1. No area of the healthcare workers’ skin should be exposed and
   2. Shoe covers or boots should be utilized.
3. 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.

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

The CDC also provides detailed guidance on PPE removal available at http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html  AND  http://www.cdc.gov/vhf/ebola/hcp/ppe-training/index.html

**For facilities performing invasive procedures or aerosol generating procedures, see next section

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 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 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.

Reporting/Questions/Suspected Case

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

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