Tuesday, October 21, 2014

Ebola Preparedness Webinar For EMS Personnel


Columbus Fire Department Medic 7 - Wikipedia


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As part of their continuing efforts to prepare frontline medical personnel on what to do if they are presented with a possible or suspected Ebola case, the CDC and the Office of the Assistant Secretary for Preparedness and Response (ASPR) will hold a webinar tomorrow afternoon geared for EMS personnel.


Webinar: Ebola Preparedness for Emergency Medical Services

ASPR and CDC staff will discuss the previously developed and distributed Detailed Emergency Medical Services Checklist for Ebola Preparedness, which highlights activities that EMS agencies and systems should consider to prepare for managing patients with Ebola and other infectious diseases. This checklist is intended to enhance collective preparedness and response by highlighting key areas for EMS agencies to review in preparation for a person under investigation (PUI) for Ebola. The checklist provides practical and specific suggestions to ensure agencies are able to detect possible Ebola cases, protect employees, and respond appropriately.

Additionally, CDC collaborated with staff and representatives from the Federal Interagency Committee on EMS (FICEMS) to develop

Interim Guidance for Emergency Medical Services Systems and 911 PSAPs. FICEMS staff will discuss this guidance, intended for use by managers to understand and explain to staff how to respond and stay safe and by individual providers to respond to suspected Ebola patients and to stay safe.

The purpose of this webinar is to further explain these documents and address any questions that you may have.  Staff from several FICEMS member agencies will field questions. FICEMS includes representatives from ASPR, CDC, the National Highway Traffic Safety Administration, the Department of Homeland Security’s Office of Health Affairs, the U.S. Fire Administration, an appointed State EMS Director and other agencies. 

Please note that we will ONLY be taking live questions via the webinar Q&A feature during this event. Due to the expected high volume of questions, we will not be able to address all questions during the call.

In an effort to maximize availability of call-in lines, please consider joining this webinar with multiple colleagues on one computer.

Please note: An audio recording and transcript will be made available on this page following the call.

CDC: Updated Interim PPE Guidance For HCWs Dealing With Ebola


Credit CDC


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The updated CDC guidance on donning and doffing PPEs when working with suspected or confirmed Ebola cases - which we previewed last night (see CDC Announces Stricter PPE Recommendations For Ebola) - is fleshed out in the following document posted overnight on the CDC’s Ebola web portal.

When you return you’ll find a short listing of non-CDC online resources (listed on the CDC site) with experience dealing with Ebola.



Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing)


On this Page

This guidance is current as of October 20, 2014

The following procedures provide detailed guidance on the types of personal protective equipment (PPE) to be used and on the processes for donning and doffing (i.e., putting on and removing) PPE for all healthcare workers entering the room of a patient hospitalized with Ebola virus disease (Ebola). The guidance in this document reflects lessons learned from the recent experiences of U.S. hospitals caring for Ebola patients and emphasizes the importance of training, practice, competence, and observation of healthcare workers in correct donning and doffing of PPE selected by the facility.

This guidance contains the following key principles:

  1. Prior to working with Ebola patients, all healthcare workers involved in the care of Ebola patients must have received repeated training and have demonstrated competency in performing all Ebola-related infection control practices and procedures, and specifically in donning/doffing proper PPE.
  2. While working in PPE, healthcare workers caring for Ebola patients should have no skin exposed.
  3. The overall safe care of Ebola patients in a facility must be overseen by an onsite manager at all times, and each step of every PPE donning/doffing procedure must be supervised by a trained observer to ensure proper completion of established PPE protocols.

In healthcare settings, Ebola is spread through direct contact (e.g., through broken skin or through mucous membranes of the eyes, nose, or mouth) with blood or body fluids of a person who is sick with Ebola or with objects (e.g., needles, syringes) that have been contaminated with the virus. For all healthcare workers caring for Ebola patients, PPE with full body coverage is recommended to further reduce the risk of self-contamination.

To protect healthcare workers during care of an Ebola patient, healthcare facilities must provide onsite management and oversight on the safe use of PPE and implement administrative and environmental controls with continuous safety checks through direct observation of healthcare workers during the PPE donning and doffing processes.

(Continue . . . .)




External (Non-CDC) Resources on PPE


Monday, October 20, 2014

CDC Announces Stricter PPE Recommendations For Ebola




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Although the full set of guidance documents have yet to make their appearance on the CDC’s website, this evening in an unusually late (7pm) press briefing, CDC Director Thomas Frieden  provided some details on the CDC’s new, tougher guidance on Healthcare Worker’s PPEs when treating suspected or confirmed Ebola cases.

Dr. Frieden outlined three important upgrades to their earlier PPE recommendations:

  1. No exposed skin
  2. N95 or PAPR instead of  surgical or facemask
  3. Use of virocidal wipes on exterior of PPEs before doffing


Additionally, Dr. Frieden stated that HCWs would need enhanced training in the donning and doffing of PPEs, and facilities should appoint someone to act as a full time site supervisor to monitor and assist in PPE use and removal when treating an Ebola patient.

Here is a brief summary emailed out by the CDC in advance of the publication of the new guidance, which should be online later tonight.



CDC Fact Sheet:

Tightened Guidance for U.S. Healthcare Workers on Personal Protective Equipment for Ebola

The Centers for Disease Control and Prevention 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 taking it on and off in a systemic manner
  • No skin exposure when PPE is worn
  • All workers are supervised by a trained monitor who watches each worker taking PPE on and off. 

All patients treated at Emory University Hospital, Nebraska Medical Center and the NIH 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 donning and doffing 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 US 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 imperable gown that extends to at least mid-calf  or coverall without intergraded 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 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, donned and doffed correctly.
  • Designated areas for putting on and taking off PPE. Facilities should ensure that space and lay-out 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 taking PPE on and 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 focuses 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 on-site 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.

Saudi MOH: 2 New MERS Cases (Taif & Riyadh)



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The uptick in MERS case in Saudi Arabia over the past six weeks continues (see Saudi MOH Statement On Recent MERS Cases In Taif & Saudi Arabia – A MERS Surge?) with the Saudi MOH announcing two more cases today – one a HCW from Taif.


By my count this raises to 14 the number of cases in Taif since early September, with 4 of them being Healthcare workers.

Saudi MOH Statement On Recent MERS Cases In Taif


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Earlier today, in Saudi Arabia – A MERS Surge?, we looked at recent reports of MERS cases in Taif and a hospital inspection conducted yesterday by Health Minister Faqih.  


Today the Saudi MOH site has posted the following statement regarding these recent cases, and the steps they are taking to address the situation.



Health Minister Reviews Response to MERS-CoV in Taif

20 October 2014

His Excellency Eng. Adel M. Fakeih, the acting Minister of Health, conducted an urgent inspection Sunday of King Faisal and King Abdulaziz hospitals in response to a MERS-CoV cluster in Taif.

The Ministry’s Command & Control Center has confirmed nine MERS-CoV cases in the Taif area over the last two weeks.

“The concerning rate of infection in Taif suggests we may see additional cases of MERS-CoV there in the coming days,” Minister Fakeih said. “This is a reminder of the dangers to the public of unprotected contact with camels and the need for healthcare workers to follow proper infection-control procedures.”

In addition to sporadic cases most likely linked to exposure to infected camels, there have been some secondary infections that involved patients and healthcare workers at local hospitals.

“We might not be able to eradicate MERS-CoV from nature, but the Ministry must do everything possible to protect patients and healthcare workers from this disease,” the Minister said. “Even one MERS-CoV infection acquired in the hospital is a crisis that demands an immediate and comprehensive response.”
The Ministry is taking the following steps with immediate effect:

  • Public health experts are tracing people who came into contact with each of the MERS-CoV patients.
  • The dialysis unit at King Abdulaziz Hospital is being disinfected. To reduce overcrowding, the Ministry is moving up to 20 additional dialysis machines to King Faisal Hospital, which will allow the Ministry to divert some dialysis patients there from King Abdulaziz Hospital to King Faisal Hospital.
  • King Abdulaziz Hospital will transfer MERS-CoV patients to King Faisal Hospital, the designated MERS-CoV hospital for Taif.
  • The Ministry is moving a mobile laboratory to Taif to accommodate the need for additional testing and to expedite the delivery of test results.
  • Both hospitals are transferring some of their intensive-care patients, when feasible, to Jeddah and Riyadh.
  • Experts are assessing and monitoring infection-control measures at the MOH facilities. This includes fit testing for the face masks that healthcare workers wear while treating patients.
  • The existing isolation ward for MERS-CoV patients at King Faisal Hospital is being split into two wards, one for suspected cases and one for confirmed cases.
  • MOH dialysis units in Taif are adding an additional shift with the goal of preventing infection by reducing the number of patients who are being treated in each session.

The Minister was joined by Dr. Anees Sindi, Deputy Commander of the Ministry’s Command & Control Center and Dr. Abdullah Assiri, World Health Organization focal point and Assistant Deputy Minister for Preventive Health.

“The response to coronavirus continues to involve all those who can add value to our efforts to control the virus, including the World Health Organization and U.S. Centers for Disease Control and Prevention,” Minister Fakeih said. “There is no vaccine for MERS-CoV, but we can work together to reduce the number of infections. That’s why some of the greatest minds in Saudi Arabia – eminent professors and doctors from universities and hospitals across the Kingdom – are working with the Ministry to fight the spread of this virus.”

The Command & Control Center has conducted a comprehensive review of the operations at both Taif hospitals in recent days. The deputy commander toured both facilities on Saturday with the head of clinical operations at the Center. The head of the infection-control team has been working onsite in Taif since last week.

The ongoing collaboration with the Ministry of Agriculture is expanding in Taif because some of the recent infections are thought to be associated with exposure to infected camels.

Please visit http://www.moh.gov.sa/ccc for recommendations on how to prevent MERS-CoV infection and the latest information about confirmed cases in the Kingdom of Saudi Arabia.

CDC Guidance: Initial Steps In Caring For A Suspected Ebola Patient


Credit FEMA


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Given the current concerns over the possibility of having another Ebola patient walk into a hospital Emergency room, Clinic, or Doctor’s office the CDC has been working on various types of guidance, and we expect updated advice on PPEs to be released in the next few days (see NIH: `More Stringent’ PPE Standards For Ebola On The Way).


While clinicians have been asked to be alert for the signs of Ebola in anyone with recent travel history to West Africa, there hasn’t been a set of coordinated guidelines telling healthcare workers what to do next.


Yesterday, in an attempt to provide some `first steps’  for front line workers confronted with a possible Ebola patient, the CDC released the following infographic and advice, outlining what steps `should’ and `should not be done for a patient under investigation (PUI) for Ebola.




Could it be Ebola?[PDF - 1 page]


When Caring for Suspect or Confirmed Patients with Ebola

 What SHOULD be done for a patient under investigation (PUI) for Ebola virus disease?

  1. Activate the hospital preparedness plan for Ebola, which should include
    1. Initiate the notification plan for suspect or confirmed Ebola patient immediately.
    2. Ensure hospital infection control is notified.
    3. Create a clinical care team led by a senior level experienced clinician that includes at a minimum a hospital infection control specialist, a senior nurse, an infectious disease specialist, and critical care consultants.
    4. Assign a senior staff member from the clinical care team to coordinate testing and reporting of results from the hospital laboratory, state health department laboratory, CDC, and local and state public health. For a list of state and local health department phone numbers, see http://www.cdc.gov/vhf/ebola/outbreaks/state-local-health-department-contacts.html.
  2. Isolate the patient in a separate room with a private bathroom.
  3. Ensure a standardized protocol is in place for how and where to remove and dispose of personal protective equipment (PPE) properly and that this information is posted in the patient care area.
  4. When interviewing the patient, collect data on:
    1. Earliest date of symptom onset and the sequence of sign/symptom development preceding presentation to an emergency department.
    2. Detailed and precise travel history (e.g., dates, times, locations).
    3. Names of any persons with whom the patient may have had contact during and any time after the earliest date of symptom onset.
  5. Consider and evaluate for all potential alternative diagnoses (e.g. malaria, typhoid fever).
  6. Reassure patient and family that appropriate care will be provided.
  7. Ensure patient has the ability to communicate with family.

What SHOULD NOT be done for a patient under investigation for Ebola virus disease?

  1. Don’t have any physical contact with the patient (e.g., perform examination, collect clinical samples, position for x-rays) without first putting on appropriate PPE and using recommended infection control practices necessary to prevent Ebola virus transmission.
  2. Don’t neglect the patient’s medical needs; assess and treat patient’s other medical conditions as indicated (e.g., diabetes, hypertension).
  3. Don’t forget to evaluate for all potential alternative diagnoses (e.g. malaria, typhoid fever).
  4. Don’t perform elective tests or procedures; minimize sample collection, laboratory testing, and diagnostic imaging (e.g., blood draws, X-rays) to those procedures necessary to provide acute care.
  5. Don’t allow family members to visit without putting on appropriate PPE; provide a telephone for family to communicate with patient.

Don’t judge or snub the patient; maintain a professional and compassionate atmosphere.

General Information