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;


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