Ebola Virus: Guidance for Infection Control for Healthcare Workers

Active and direct active monitoring

Active monitoring means that the state or local public health authority assumes responsibility for establishing regular communication with potentially exposed individuals, including checking daily to assess for the presence of symptoms and fever, rather than relying solely on individuals to self-monitor and report symptoms if they develop. Direct active monitoring means the public health authority conducts active monitoring through direct observation. The purpose of active (or direct active) monitoring is to ensure that, if individuals with epidemiologic risk factors become ill, they are identified as soon as possible after symptom onset so they can be rapidly isolated and evaluated. Active (or direct active) monitoring could be either conducted on a voluntary basis or compelled by legal order. Active (or direct active) monitoring and prompt follow-up should continue and be uninterrupted if the person travels out of the jurisdiction.
Active monitoring should consist of, at a minimum, daily reporting of measured temperatures and symptoms consistent with Ebola (including severe headache, fatigue, muscle pain, fatigue or weakness, diarrhea, vomiting, abdominal pain, or unexplained hemorrhage) by the individual to the public health authority. Temperature should be measured using an FDA-approved thermometer (e.g. oral, tympanic or noncontact). People being actively monitored should measure their temperature twice daily, monitor themselves for symptoms, report as directed to the public health authority, and immediately notify the public health authority if they develop fever or other symptoms. Initial symptoms can be as nonspecific as fatigue. Clinical criteria for required medical evaluation according to exposure level have been defined (see Table), and should result in immediate isolation and evaluation. Medical evaluation may be recommended for lower temperatures or nonspecific symptoms based on exposure level and clinical presentation.
Controlled movement
Controlled movement limits the movement of people. For individuals subject to controlled movement, travel by long-distance commercial conveyances (e.g., aircraft, ship, bus, train) should not be allowed; if travel is allowed, it should be by noncommercial conveyance such as private chartered flight or private vehicle, and occur with arrangements for uninterrupted active monitoring. Federal public health travel restrictions (Do Not Board) may be used to enforce controlled movement. For people subject to controlled movement, use of local public transportation (e.g., bus, subway) should be discussed with and only occur with approval of the local public health authority.
Isolation means the separation of an individual or group who is reasonably believed to be infected with a quarantinable communicable disease from those who are not infected to prevent spread of the quarantinable communicable disease. An individual could be reasonably believed to be infected if he or she displays the signs and symptoms of the quarantinable communicable disease of concern and there is some reason to believe that an exposure had occurred.
Quarantine in general means the separation of an individual or group reasonably believed to have been exposed to a quarantinable communicable disease, but who is not yet ill (not presenting signs or symptoms), from others who have not been so exposed, to prevent the possible spread of the quarantinable communicable disease.
Use of Public Health Orders
Equitable and ethical use of public health orders includes supporting and compensating persons who make sacrifices in their individual liberties and freedoms for public good. Specifically, considerations must be in place to provide shelter, food and lost wage compensation, and to protect the dignity and privacy of the individual. Persons under public health orders should be treated with respect and dignity. Considerable thoughtful planning is needed to implement public health orders properly.
Recommendations for specific groups and settings:
Healthcare workers
For the purposes of risk exposure to Ebola, regardless of country, direct patient contact includes doctors, nurses, physician assistants and other healthcare staff, as well as ambulance personnel, burial team members, and morticians. In addition, others who enter into the treatment areas where Ebola patients are being cared for (such as observers) would be considered to potentially have patient contact and be at risk. Healthcare workers who have no direct patient contact and no entry into active patient management areas, including epidemiologists, contact tracers, airport screeners, as well as laboratory workers who use appropriate PPE, are not considered to have an elevated risk of exposure to Ebola, i.e., are considered to be in the low (but non-zero) risk category.
The high toll of Ebola virus infections among healthcare workers providing direct care to Ebola patients in countries with widespread transmission suggests that there are multiple potential sources of exposure to Ebola virus in these countries, including unrecognized breaches in PPE, inadequate decontamination procedures, and exposure in patient triage areas. Due to this higher risk, these healthcare workers are classified in the some risk category, for which additional precautions are recommended upon their arrival in the United States (see Table).
Healthcare workers who provide care to Ebola patients in U.S. facilities while wearing appropriate PPE and with no known breaches in infection control are considered to have low (but not zero) risk of exposure because of the possibility of unrecognized breaches in infection control and should have direct active monitoring. As long as these healthcare workers have direct active monitoring and are asymptomatic, there is no reason for them not to continue to work, including in hospitals and other patient care settings, nor is there a reason for them to have restrictions on travel or other activities. Review and approval of work, travel, use of public conveyances, and attendance at congregate events are not indicated or recommended for such healthcare workers. (Read the CDC's Full Recommendations)

CDC Website Ebola: Tightened Guidance for U.S. Healthcare Workers on Personal Protective Equipment (10/21/14)

The (CDC) is tightening previous infection control guidance for healthcare workers caring for patients with Ebola, to ensure there is no ambiguity.  The guidance focuses on specific personal protective equipment (PPE) health care workers should use and offers detailed step by step instructions for how to put the equipment on and take it off safely.

Recent experience from safely treating patients with Ebola at Emory University Hospital, Nebraska Medical Center and National Institutes of Health Clinical Center are reflected in the guidance.
The enhanced guidance is centered on three principles:
  • All healthcare workers undergo rigorous training and are practiced and competent with PPE, including putting it on and taking it off in a systemic manner
  • No skin exposure when PPE is worn
  • All workers are supervised by a trained monitor who watches each worker putting PPE on and taking it off. 
All patients treated at Emory University Hospital, Nebraska Medical Center and the National Institutes of Health Clinical Center  have followed the three principles. None of the workers at these facilities have contracted the illness.
Principle #1: Rigorous and repeated training
Focusing only on PPE gives a false sense of security of safe care and worker safety. Training is a critical aspect of ensuring infection control. Facilities need to ensure all healthcare providers practice numerous times to make sure they understand how to appropriately use the equipment, especially in the step by step putting on and taking off of PPE. CDC and partners will ramp up training offerings for healthcare personnel across the country to reiterate all the aspects of safe care recommendations.  
Principle #2: No skin exposure when PPE is worn
Given the intensive and invasive care that U.S. hospitals provide for Ebola patients, the tightened guidelines are more directive in recommending no skin exposure when PPE is worn.
CDC is recommending all of the same PPE included in the August 1, 2014 guidance, with the addition of coveralls and single-use, disposable hoods.  Goggles are no longer recommended as they may not provide complete skin coverage in comparison to a single-use, disposable full-face shield.  Additionally, goggles are not disposable, may fog after extended use, and healthcare workers may be tempted to manipulate them with contaminated gloved hands.  PPE recommended for U.S. healthcare workers caring for patients with Ebola includes:
  • Double gloves
  • Boot covers that are waterproof and go to at least mid-calf or leg covers
  • Single-use fluid resistant or impermeable gown that extends to at least mid-calf  or coverall without integrated hood.
  • Respirators, including either N95 respirators or powered air purifying respirator (PAPR)
  • Single-use, full-face shield that is disposable
  • Surgical hoods to ensure complete coverage of the head and neck
  • Apron that is waterproof and covers the torso to the level of the mid-calf (and that covers the top of the boots or boot covers) should be used if Ebola patients have vomiting or diarrhea
The guidance describes different options for combining PPE to allow a facility to select PPE for their protocols based on availability, healthcare personnel familiarity, comfort and preference while continuing to provide a standardized, high level of protection for healthcare personnel. 
The guidance includes having:
  • Two specific, recommended PPE options for facilities to choose from. Both options provide equivalent protection if worn, put on and removed correctly.
  • Designated areas for putting on and taking off PPE. Facilities should ensure that space and layout allows for clear separation between clean and potentially contaminated areas
  • Trained observer to monitor PPE use and safe removal
  • Step-by-step PPE removal instructions that include: Disinfecting visibly contaminated PPE using an EPA-registered disinfectant wipe prior to taking off equipment
  • Disinfection of gloved hands using either an EPA-registered disinfectant wipe or alcohol-based hand rub between steps of taking off PPE.
Principle #3: Trained monitor
CDC is recommending a trained monitor actively observe and supervise each worker putting PPE on and taking it off. This is to ensure each worker follows the step by step processes, especially to disinfect visibly contaminated PPE. The trained monitor can spot any missteps in real-time and immediately address.
PPE is Only One Aspect of Infection Control
It is critical to focus on other prevention activities to halt the spread of Ebola in healthcare settings, including:
  • Prompt screening and triage of potential patients
  • Designated site managers to ensure proper implementation of precautions
  • Limiting personnel in the isolation room
  • Effective environmental cleaning
Think Ebola and Care Carefully
The CDC reminds health care workers to “Think Ebola” and to “Care Carefully.” Health care workers should take a detailed travel and exposure history with patients who exhibit fever, severe headache, muscle pain, weakness, diarrhea, vomiting, stomach pain, unexplained hemorrhage. If the patient is under investigation for Ebola, health care workers should activate the hospital preparedness plan for Ebola, isolate the patient in a separate room with a private bathroom, and to ensure standardized protocols are in place for PPE use and disposal. Health care workers should not have physical contact with the patient without putting on appropriate PPE.     
CDC’s Guidance for U.S. Healthcare Settings is Similar to MSF’s (Doctors Without Borders) Guidance
Both CDC’s and MSF’s guidance documents focus on:
  • Protecting skin and mucous membranes from all exposures to blood and body fluids during patient care
  • Meticulous, systematic strategy for putting on and taking off PPE to avoid contamination and to ensure correct usage of PPE
  • Use of oversight and observers to ensure processes are followed
  • Disinfection of PPE prior to taking off: CDC recommends disinfecting visibly contaminated PPE using an EPA-registered disinfectant wipe prior to taking off equipment. Additionally, CDC recommends disinfection of gloved hands using either an EPA-registered disinfectant wipe or alcohol-based hand rub between steps of taking off PPE. Due to differences in the U.S. healthcare system and West African healthcare settings, MSF’s guidance recommends spraying as a method for PPE disinfection rather than disinfectant wipes. 
Five Pillars of Safety
CDC reminds all employers and healthcare workers that PPE is only one aspect of infection control and providing safe care to patients with Ebola. Other aspects include five pillars of safety:
  • Facility leadership has responsibility to provide resources and support for implementation of effective prevention precautions.  Management should maintain a culture of worker safety in which appropriate PPE is available and correctly maintained, and workers are provided with appropriate training. 
  • Designated onsite Ebola site manager responsible for oversight of implementing precautions for healthcare personnel and patient safety in the healthcare facility.
  • Clear, standardized procedures where facilities choose one of two options and have a back-up plan in case supplies are not available.
  • Trained healthcare personnel: facilities need to ensure all healthcare providers practice numerous times to make sure they understand how to appropriately use the equipment.
  • Oversight of practices are critical to ensuring that implementation protocols are done accurately, and any error in putting on or taking off PPE is identified in real-time, corrected and addressed, in case potential exposure occurred.

  • Fever (greater than 38.6°C or 101.5°F)
  • Severe headache
  • Muscle pain
  • Weakness
  • Diarrhea
  • Vomiting
  • Abdominal (stomach) pain
  • Unexplained hemorrhage (bleeding or bruising)
  • Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola, but the average is 8 to 10 days.
**Recovery from Ebola depends on good supportive clinical care and the patient’s immune response. People who recover from Ebola infection develop antibodies that last for at least 10 years.

Because the natural reservoir host of Ebola viruses has not yet been identified, the manner in which the virus first appears in a human at the start of an outbreak is unknown. However, researchers believe that the first patient becomes infected through contact with an infected animal.
When an infection does occur in humans, the virus can be spread in several ways to others. Ebola is spread through direct contact (through broken skin or mucous membranes in, for example, the eyes, nose, or mouth) with:
  • blood or body fluids (including but not limited to urine, saliva, sweat, feces, vomit, breast milk, and semen) of a person who is sick with Ebola 
  • objects (like needles and syringes) that have been contaminated with the virus 
  • infected animals 
  • Ebola is not spread through the air or by water, or in general, by food. However, in Africa, Ebola may be spread as a result of handling bushmeat (wild animals hunted for food) and contact with infected bats. There is no evidence that mosquitos or other insects can transmit Ebola virus. Only mammals (for example, humans, bats, monkeys, and apes) have shown the ability to become infected with and spread Ebola virus.
Healthcare providers caring for Ebola patients and the family and friends in close contact with Ebola patients are at the highest risk of getting sick because they may come in contact with infected blood or body fluids of sick patients.
During outbreaks of Ebola, the disease can spread quickly within healthcare settings (such as a clinic or hospital). Exposure to Ebola can occur in healthcare settings where hospital staff are not wearing appropriate protective equipment, including masks, gowns, and gloves and eye protection.

Standard, contact, and droplet precautions are recommended for management of hospitalized patients with known or suspected Ebola virus disease (EVD) (See Table below). Note that this guidance outlines only those measures that are specific for EVD; additional infection control measures might be warranted if an EVD patient has other conditions or illnesses for which other measures are indicated (e.g., tuberculosis, multi-drug resistant organisms, etc.).
Though these recommendations focus on the hospital setting, the recommendations for personal protective equipment (PPE) and environmental infection control measures are applicable to any healthcare setting. In this guidance healthcare personnel (HCP) refers all persons, paid and unpaid, working in healthcare settings who have the potential for exposure to patients and/or to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or aerosols generated during certain medical procedures. HCP include, but are not limited to, physicians, nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainees, contractual personnel, home healthcare personnel, and persons not directly involved in patient care (e.g., clerical, dietary, house-keeping, laundry, security, maintenance, billing, chaplains, and volunteers) but potentially exposed to infectious agents that can be transmitted to and from HCP and patients. This guidance is not intended to apply to persons outside of healthcare settings.