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The Ebola Outbreak: The CDC Director’s Guidance for Health care workers

Tom Frieden optimized

There has been a lot of fear about Ebola. The health care workers who care for Ebola patients are right to be concerned – and they should use that concern to increase their awareness and motivation to practice meticulous infection control measures.

Ebola virus is transmitted through direct contact with bodily fluids of an infected person who is sick with Ebola, or exposure to objects, such as needles, that have been contaminated with infected secretions.

Travel from Affected Region

There is a risk for Ebola to be introduced to the United States via an infected traveler from Africa. If that were to happen, widespread transmission in the United States is highly unlikely due to our systematic use of strict and standard infection control precautions in health care settings, although a cluster of cases is possible if patients are not quickly isolated. Community spread is unlikely due to differences in cultural practices, such as in West Africa where community and family members handle their dead.

CDC has advised all travelers arriving from Guinea, Liberia, Nigeria, and Sierra Leone to monitor their health for 21 days and watch for fever or other symptoms consistent with Ebola. If they develop symptoms, they should call ahead to their hospital or health care provider and report their symptoms and recent travel to the affected areas so appropriate precautions can be taken.

Health care workers should take good travel histories of patients and, if the patient has traveled within the past three weeks to affected parts of Africa, ask them about fever and symptoms consistent with Ebola. Patients who show signs and have symptoms consistent with Ebola should be promptly isolated, and state and local health authorities should be notified.  There have already been a handful of travelers returning from the region who had fever and sought care – this is to be expected. Several were diagnosed as having malaria, and one with influenzaB.

Health care workers are at risk for infection only when strict safety precautions or sharps management procedures are not followed. Protective measures known as Standard, Contact, and Droplet precautions are considered sufficient protection against transmission: these include gloves, gowns, face masks, and eye protection (goggles, face shield) for personnel providing routine care.

Symptoms and Recommendations for Testing

CDC’s Health Advisory Notice distributed on August 1, 2014, outlines guidelines for evaluation of U.S. patients suspected of having Ebola virus disease. [http://emergency.cdc.gov/han/han00364.asp]

Health care providers should be alert for and evaluate suspected patients for Ebola virus disease who have both consistent symptoms and risk factors, as follows:

1)     Clinical criteria, which includes fever of greater than 38.6 degrees Celsius (101.5 degrees Fahrenheit) and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage;

AND

2)     Epidemiologic risk factors within the past three weeks before the onset of symptoms, such as contact with blood or other body fluids of a patient known or suspected to have Ebola virus disease; residence in – or travel to – an area where Ebola virus disease transmission is active or participated in a burial ceremony; or direct handling of bats, rodents, or primates from disease-endemic areas.

Malaria diagnostics should also be a part of initial testing because it is a common cause of febrile illness in persons with a travel history to the affected countries.

CDC recommends making a risk assessment for all people with onset of fever within 21 days of having a high-risk exposure. A high-risk exposure includes any of the following:

  • percutaneous or mucous membrane exposure or direct skin contact with body fluids of a person with a confirmed or suspected case of Ebola virus disease without appropriate personal protective equipment;
  • laboratory processing of body fluids of suspected or confirmed Ebola virus disease cases without appropriate personal protective equipment or standard biosafety precautions; or
  • participation in funeral rites or other direct exposure to human remains in the geographic area where the outbreak is occurring without appropriate personal protective equipment.

For people with a high-risk exposure but without a fever, testing is recommended only if there are other compatible clinical symptoms present and blood work findings are abnormal (i.e., thrombocytopenia <150,000 cells/µL and/or elevated transaminases) or are unknown.

People considered to have a low-risk exposure include people in an affected country with a weaker public health system who spent time in a health care facility where Ebola virus disease patients are being treated (encompassing health care workers who used appropriate personal protective equipment, employees not involved in direct patient care, or other hospital patients who did not have Ebola virus disease and their family caretakers), or household members of an Ebola virus disease patient without high-risk exposures as defined above.

Those who had direct unprotected contact with bats or primates from Ebola virus disease-affected countries would also be considered to have a low-risk exposure.

Testing is recommended for people with a low-risk exposure who develop fever of greater than 38.6 degrees Celsius (101.5 degrees Fahrenheit) and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage and who also have unknown or abnormal blood work findings.

People with a low-risk exposure who have fever and abnormal blood work findings in the absence of other symptoms are also recommended for testing. Asymptomatic people with high- or low-risk exposures should be monitored daily for fever and symptoms for 21 days from the last known exposure and evaluated medically at the first indication of illness.

People with no known exposures as listed above but who have fever along with other symptoms and abnormal bloodwork within 21 days of visiting Ebola virus disease-affected countries should be considered for testing if no other diagnosis is found. Testing may be indicated in the same patients if fever is present with other symptoms and blood work is abnormal or unknown. Consultation with state and local health departments is recommended.

If testing is indicated, the state or local health department should be immediately notified. Health care providers should collect serum, plasma, or whole blood. A minimum sample volume of 4 milliters is recommended.

Do not ship samples in glass tubes. Samples should be shipped refrigerated or frozen on ice pack or dry ice. State guidelines may differ, and state and local health departments should be consulted prior to shipping.

CDC’s website [http://www.cdc.gov/ncezid/dhcpp/vspb/specimens.html] has detailed instructions and a link to the specimen submission form for CDC laboratory testing.

If You Have a Suspected or Confirmed Case

A suspected case needs to be isolated until diagnosis is confirmed or ruled out.

Patients should be placed in a single patient room (containing a private bathroom) with the door kept closed, and medical equipment should be dedicated to the individual patient.

Facilities should maintain a log of all people entering the patient’s room. Visitors should be avoided or limited.

Health care providers should wear gloves, gown (fluid resistant), eye protection (goggles or face shield), and a face mask. Additional personal protective equipment might be required in certain situations such as the presence of copious amounts of blood or other body fluids, vomit, or feces. Additional protection can include but is not limited to double gloving, disposable shoe covers, and leg coverings.

Health care staff should avoid performing aerosol-generating procedures on suspected or confirmed patients. If performing these procedures, personal protective equipment should include respiratory protection – N95 filtering facepiece respirator or higher – and the procedure should be performed in an airborne isolation room.

Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is of paramount importance, as blood, sweat, vomit, feces, and other body secretions represent potentially infectious materials.

Appropriate disinfectants for Ebola virus and other filoviruses include 10% sodium hypochlorite (bleach) solution, or hospital-grade quaternary ammonium or phenolic products. Health care providers performing environmental cleaning and disinfection should wear recommended personal protective equipment as described above and consider use of additional barriers such as shoe and leg coverings if needed.

Ebola is a fragile virus and is readily killed by soap and water, bleach, or other products as noted above.

Eye protection – a face shield or face mask with goggles – should be worn when performing tasks such as liquid waste disposal that can generate splashes. Standard procedures for cleaning and/or disinfection and disposal of environmental surfaces, equipment, textiles, laundry, and food utensils and dishware, per hospital policy and manufacturer instructions, should be followed.

For more information, see CDC’s updated infection control guidance for U.S. hospitals for handling patients with known or suspected Ebola: http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html

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Zakaria ShoebsaveyourlungsWilliam Palmer MDAllanKim Silverman Recent comment authors
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Zakaria Shoeb
Guest
Zakaria Shoeb

Ebola originate into straight contact with the bodily fluids of an individual who is diseased with the virus and already have the symptoms. Ebola does not transportable through the air. An individual in Delhi cannot fasten Ebola from an Ebola diseased individual in Mumbai without driving there and coming into straight contact with the Ebola diseased individual’s bodily fluids. But still it is dangerous as like as world war. Because it has no vaccine and so it is unstoppable. The wrong is that it is too far late to find out symptoms from an Ebola diseased individual and that time… Read more »

Allan
Guest
Allan

I wonder what the CDC’s answer is: NBC News: “A second health care worker at a Dallas hospital who tested positive for Ebola was isolated within “90 minutes” of her temperature being taken, officials said Wednesday.” [temps are taken twice per day] “The Centers for Disease Control and Prevention and Frontier Airlines have confirmed the new patient took a flight from Dallas-Fort Worth to Cleveland on Oct. 10 and returned to Dallas-Fort Worth on Monday evening — the day before she reported symptoms. Because of the proximity in time between the evening flight and first report of illness the following… Read more »

saveyourlungs
Guest
saveyourlungs

seems anyone suspecting they have the Ebola virus should stay in their home with their family, call in an Ebola medical isolation team to their home, rather than going in to a hospital unidentified until after the exposure event…. kind of backwards what we do. patients get isolated after their trek to and through the ER, to the hospital floor, in contact with countless #’s of medical & non medical people, then their lab results are found to be positive, then the hospital goes berserk with isolation measures…usually after the horse is out the barn….then everyone thinks “job well done”…..

William Palmer MD
Guest
William Palmer MD

I wonder if one could stimulate interferon–by, for example, giving live measles vaccine–whether this would inhibit the spread through the at-risk population? Interferon was discovered by the realization that people who had one viral infection did not get another. E.g. if you had chickenpox you did not get measels at the same time. Live viral vaccines may stimulate interferon production and giving many folks measles vaccine–I think we have plenty of this–would probably be safe enough as a desperate prophylactic procedure. Who knows, it might even help an active case.

William Palmer MD
Guest
William Palmer MD

I think we may be making two mistakes in our thinking about the mechanisms of Ebola spread. 1. There seem to be hundreds of anecdotes about its being spread by fomites, contact, touching, handling clothes, bedding, ceremonial objects at funerals. If fomite spread is truly common, then the real world appearance begins to shade into aerosol spread. In other words, extensive fomite spread looks like air-born spread. After all, if everything we contacted were a functional fomite, the mechanism would appear to be almost air-born. Assume fomite spread is highly significant, which it appears to be. Wouldn’t it be likely… Read more »

Peter1
Guest
Peter1

“however. We need more data to tell us the answer.”

Yes we do, and the data will evolve (as the disease may) with scientific investigation and observation from organizations like the CDC, NOT from the Rush Limbaugh/Fox News mentalities looking for liberal plots behind every bush.

Allan
Guest
Allan

Peter1, if one doesn’t look one will never find and that is probably one of the reasons you think things are swell. I can’t generally listen to Rush Limbaugh because he is on the air at the wrong time, but sometimes I am able. I heard a bunch of things he said on this issue. They demonstrated good insight and provided a good set of opinions for a specific viewpoint. Can you tell us what he said that was so wrong? Of course not. I haven’t listened to him enough to be able to form an opinion about his broadcasts.… Read more »

Peter1
Guest
Peter1

“Yes, we know where you get your opinions..”

Really, from where?

Allan
Guest
Allan

You don’t know where you get your opinions from? That is interesting.

Allan
Guest
Allan

I wonder if Tom Frieden can elaborate on his statement “we are all connected by the air we breathe” which is an argument for all nations to become involved, but indicates that Ebola might be airborne. Was this statement made because there are reasonable fears of airborne activity or was it made more as a political statement to ‘rally the troops’? There are many infectious diseases which suddenly could become airborne. To trust the CDC it has to function outside of the political spectrum, but it appears to me that it has been politicized in many different ways and that… Read more »

Peter1
Guest
Peter1

“but it appears to me that it has been politicized ”

Another anti-government conspiracy theory. Actually allan I think it’s a plot by the United nations and their liberal allies to take over the world.

Allan
Guest
Allan

Really, you don’t recognize that the CDC responds to political needs? How naive. Take a look at our drug approval process. Why did the CDC state that heterosexuals could not get HIV (AIDS at the time)? How does one get appointed to the CDC? Why is the CDC expanding its role?

LeoHolmMD
Guest
LeoHolmMD

I’m glad this post is being revisited with the first ebola case in the US. I think everyone needs to question why international travel and global agendas are being presented as a given in light of this outbreak. Again: Why lend the virus a plane? Quarantining is extremely difficult…it will become more difficult as it progresses.

Peter1
Guest
Peter1

“Why lend the virus a plane?”

Since you say quarantine is “extremely difficult” would we need to quarantine the entire region from boarding planes?

This outbreak is in areas of failed governments, no health care structure, little sanitation and high levels of superstition. Sorta like this country would be if if the Teaparty got what they wanted.

LeoHolmMD
Guest
LeoHolmMD

Right. No one in or out without substantial precautions, incubation lags and intense screening. Don’t need planes going in and out of failed governments, with inadequate infection control precautions and superstitions during a deadly disease outbreak. Most people find this sensible.

Peter1
Guest
Peter1

“Don’t need planes going in and out of failed governments,…”

That maybe would work if direct flights to USA. People find a way to move, it’s silly to think we can build a virtual wall around these places.

Allan
Guest
Allan

“Sorta like this country would be if if the Teaparty got what they wanted.”

Sorta an ignorant statement.

Kim Silverman
Guest

Kim Silverman
Everyone should have knowledge and should be informed to take precautions about these diseases. Most especially those people who are traveling. We must be aware about its Initial symptoms that include fever, intense weakness, muscle pain, headache and sore throat. These symptoms are followed by vomiting, diarrhea, rash, impaired kidney and liver function and sometimes internal and external bleeding.

diamondback
Guest
diamondback

The CDC has already confirmed that this new strain of EBOLA (this is NOT Ebola Zaire-discovered in 1976) can be transmitted through the air! The CDC has sent memos to U.S. airlines with specific instructions. http://www.infowars.com/cdc-concerned-about-airborne-transmission-of-ebola-virus/ This is the type of information that’s NOT being made public. Why? As the health community says, “To AVOID panic!!” Of course the American Public isn’t being told the truth— http://scgnews.com/ebola-what-youre-not-being-told?utm_source=share-tw We’re getting less and less media news coverage on this Ebola Outbreak. Why is this? Why should we be so naïve and so ignorant to even think that this virus WILL NOT spread… Read more »

Ron
Guest

I remember watching videos on the whole HIV outbreak in the early 90’s, this is very scary

Ron
Guest

Very interesting information regarding this outbreak

Maureen Coffey
Guest

One thing that seems nowhere to be covered is: what are statistics on false positives and false negatives in Ebola testing? How reliable are these tests? And, as we see from HIV testing, where a false positive or negative in one in 10,000 patients results in a 50% error rate in a population with around only one in 10,000 infected with the (HI) virus – how does a similar false positive (which would be less of a tragedy) or false negative (which could have enormous consequences) play out in various cultural scenarios?

Peter1
Guest
Peter1
sr
Guest

I must admit my initial take on transporting several Ebola patients to the US has been to ask why we were increasing the field of exposure. I think medical providers (of which I am one) and the general population are asking a similar question about the value of one vs the risk to many. But if the issue with such a deadly disease is really as straightforward as providing supportive care and meticulous infectious precautions, then it does seem like a real tragedy to just throw people’s lives away because we are afraid for our own, especially when relatively simple… Read more »

@BobbyGvegas
Guest

“in our interconnected society and lives, it’s simply not realistic to envision that there will be no movement of disease across borders and communities. So, there is a real value to the CDC proactively taking this disease on, both from humanitarian and public health reasons.”
__

Precisely.

Susan Torrance
Guest

Exactly when do you plan to quarantine contacts with the Ebola patients? Never?

diamondback
Guest
diamondback

http://helpthesheeple.com/2014/07/30/if-ebola-hits-u-s-even-healthy-americans-will-be-quarantined/ I do disagree with “IF” ebola hits the U.S. It’s already HERE!!