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Ebola Reference Resources for Environmental Service Professionals

UPDATED 1-12-15

AHE will keep you informed of all the latest developments on Ebola as we received them. Check this webpage often and watch for AHE or AHA Advisory emails.

 

35 hospitals identified as Ebola treatment centers. The Department of Health and Human Services Dec. 2 announced that state health officials have identified 35 hospitals with Ebola treatment centers, with more expected in the coming weeks. The announcement was part of an update from the White House on the government’s efforts and the need for immediate, additional funding. In a statement, AHA President and CEO Rich Umbdenstock said, “America’s hospitals are investing enormous time and resources to enhance our country’s readiness for the new and real threat of Ebola.” In addition, he reiterated the AHA’s request for “Congress to approve at least $500 million in funds to help hospitals better prepare to win the battle against Ebola.” An AHA ad launched Dec. 2 in Politico highlights the importance of hospital preparedness funding.

What is Ebola?

Ebola is a rare and deadly disease caused by infection with one of the Ebola virus strains. Symptoms include, fever, headache, muscle pain, weakness, diarrhea, vomiting, stomach pain and unexplained bleeding or bruising.8, 9

How is Ebola transmitted/spread?

Ebola is spread through direct contact with broken skin or mucous membranes, such as, the eyes, nose, or mouth with

  • blood of a person who is sick with Ebola
  • body fluids of a person who is sick with Ebola (urine, saliva, sweat, feces, vomit, breast milk, and semen) of a person who is sick with Ebola
  • objects that have been contaminated with the virus (i.e. needles and syringes)
  • infected animals10

How Ebola is NOT transmitted/spread

Ebola is not spread via the air, water, food (except from handling infected bushmeat from the region), mosquitos and other insects or contact with people who have survived Ebola (except the virus will remain in semen for up to 3 months after the infection)

Case Definition for Ebola Virus Disease (EVD)

Recommended Protocols for Personnel Caring for the Environment of Ebola Patients

According to the CDC, “The role of the environment in transmission has not been established. Limited laboratory studies under favorable conditions indicate that Ebolavirus can remain viable on solid surfaces, with concentrations falling slowly over several days.” 1 As such, following consistent protocols for cleaning and surface disinfection is critical.

While your facility may not ever have an Ebola patient, it is wise to establish internal communication with infection preventionists, nursing and epidemiology to establish protocols, processes and nail down who will do what with respect to cleaning and disinfection. Establish processes for equipment cleaning as well.    

With respect to personal protective equipment (PPE), retrain staff on proper donning and removal of PPE and have them practice for proper sequence. A good tip for practicing removal is using chocolate syrup to illustrate the potential for spreading fluids while providing a visual to gain confidence in doing it correctly. Confidence removes fear.

CDC Issues Updated PPE Guidance 

Considerations for U.S Healthcare Facilities to Ensure Adequate Supplies of Personal Protective Equipment (PPE) for Ebola Preparedness NEW

Donning and Doffing of PPE for Ebola Isolation Units Video 

Guidance for the Selection and Use of Personal Protective Equipment in Healthcare Settings

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)

Information for healthcare workers and settings NEW

List of 48 U.S. Ebola treatment centers NEW

Preparing Ebola assessment hospitals NEW

Preparing Ebola treatment centers NEW

Preparing frontline healthcare facilities NEW

Sequence for Donning and Removing Personal Protective Equipment

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

To be sure you are protecting yourself and your staff, read, review and be clear on PPE recommendations as noted in the Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus  from the CDC.

As part of the care of patients who are persons under investigation, or with probable or confirmed Ebola virus infections(http://www.cdc.gov/vhf/ebola/hcp/case-definition.html), hospitals are recommended to:

Avoid contamination of reusable porous surfaces that cannot be made single use. Use only a mattress and pillow with plastic or other covering that fluids cannot get through. Do not place patients with suspected or confirmed Ebola virus infection in carpeted rooms and remove all upholstered furniture and decorative curtains from patient rooms before use.

Textiles & cleaning cloths

To reduce exposure among staff to potentially contaminated textiles (cloth products) while laundering, discard all linens, non-fluid-impermeable pillows or mattresses, and textile privacy curtains into the waste stream and disposed of appropriately.

Disinfectants:

Use a U.S. Environmental Protection Agency (EPA)-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus) to disinfect environmental surfaces in rooms of patients with suspected or confirmed Ebola virus infection.

Of special note in the guidance:

Although there are no products with specific label claims against the Ebola virus, enveloped viruses such as Ebola are susceptible to a broad range of hospital disinfectants used to disinfect hard, non-porous surfaces. In contrast, non-enveloped viruses are more resistant to disinfectants. As a precaution, selection of a disinfectant product with a higher potency than what is normally required for an enveloped virus is being recommended at this time. EPA-registered hospital disinfectants with label claims against non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) are broadly antiviral and capable of inactivating both enveloped and non-enveloped viruses.

The CDC Frequently Asked Questions is taken directly from the CDC website We are copying them here to save you time. http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html

1. How can I determine whether a particular EPA-registered hospital disinfectant is appropriate for use in the room of a patient with suspected or confirmed Ebola virus infection?

Begin by looking at the product label or product insert or, if these are not available, search the EPA search engine for this information. Users should be aware that an 'enveloped' or 'non-enveloped virus' designation may not be included on the container label. Instead check the disinfectant's label for at least one of the common non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus).

2. Are there special instructions for cleaning and disinfecting the room of a patient with suspected or confirmed Ebola virus infection?

Daily cleaning and disinfection of hard, non-porous surfaces (e.g., high-touch surfaces such as bed rails and over bed tables, housekeeping surfaces such as floors and counters) should be done.4 Before disinfecting a surface, cleaning should be performed. In contrast to disinfection where products with specific claims are used, any cleaning product can be used for cleaning tasks. Use cleaning and disinfecting products according to label instructions. Check the disinfectant's label for specific instructions for inactivation of any of the non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) follow label instructions for use of the product that are specific for inactivation of that virus. Use disposable cleaning cloths, mop cloths, and wipes and dispose of these in leak-proof bags. Use a rigid waste receptacle designed to support the bag to help minimize contamination of the bag's exterior. 

3. How should spills of blood or other body substances be managed?

The basic principles for blood or body substance spill management are outlined in the United States Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standards (29 CFR 1910.1030).5 CDC guidelines recommend removal of bulk spill matter, cleaning the site, and then disinfecting the site.4 For large spills, a chemical disinfectant with sufficient potency is needed to overcome the tendency of proteins in blood and other body substances to neutralize the disinfectant's active ingredient. An EPA-registered hospital disinfectant with label claims for non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) and instructions for cleaning and decontaminating surfaces or objects soiled with blood or body fluids should be used according to those instructions.

4. How should disposable materials (e.g., any single-use PPE, cleaning cloths, wipes, single-use microfiber cloths, linens, food service) and linens, privacy curtains, and other textiles be managed after their use in the patient room?

These materials should be placed in leak-proof containment and discarded appropriately. To minimize contamination of the exterior of the waste bag, place this bag in a rigid waste receptacle designed for this use. Incineration or autoclaving as a waste treatment process is effective in eliminating viral infectivity and provides waste minimization. If disposal requires transport offsite then this should be done in accordance with the U.S. Department of Transportation’s (DOT) Hazardous Materials Regulations (HMR, 49 C.F.R., Parts 171-180).6, 7 Guidance from DOT has been released for Ebola.7

5. Is it safe for Ebola patients to use the bathroom?

Yes. Sanitary sewers may be used for the safe disposal of patient waste. Additionally, sewage handling processes (e.g., anaerobic digestion, composting, and disinfection) in the United States are designed to inactivate infectious agents. 

6. How long does the Ebola virus persist in indoor environments?

Only one laboratory study, which was done under environmental conditions that favor virus persistence, has been reported. This study found that under these ideal conditions Ebola virus could remain active for up to six days.1 In a follow up study, Ebolavirus was found, relative to other enveloped viruses, to be quite sensitive to inactivation by ultraviolet light and drying; yet sub-populations did persist in organic debris.2

In the only study to assess contamination of the patient care environment during an outbreak, conducted in an African hospital under "real world conditions", virus was not detected by either nucleic acid amplification or culture in any of 33 samples collected from sites that were not visibly bloody. Virus was detected on a blood-stained glove and bloody intravenous insertion site by nucleic acid amplification, which may detect non-viable virus, but not by culture for live, infectious virus.3 Based upon these data and what is known regarding the environmental infection control of other enveloped RNA viruses, the expectation is with consistent daily cleaning and disinfection practices in U.S. hospitals that the persistence of Ebola virus in the patient care environment would be short – with 24 hours considered a cautious upper limit.

7. Are wastes generated during delivery of care to Ebola virus-infected patients subject to select agent regulations?

As long as facilities treating Ebola virus-infected patients follow the CDC's Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals(http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html); waste generated during delivery of care to Ebola virus-infected patients would not be subject to Federal select agent regulations (See the exclusion provision 42 CFR § 73.3(d)(1)). However, this would not apply to any facility that intentionally collected or otherwise extracted the Ebola virus from waste generated during the delivery of patient care.

8. Are wastes generated during delivery of care to Ebola virus-infected patients subject to any special transportation requirements?

Yes, wastes contaminated or suspected to be contaminated with Ebola virus must be packaged and transported in accordance U.S. DOT Hazardous Materials Regulations (HMR, 49 C.F.R., Parts 171-180).6, 7

Once a patient with suspected Ebola Virus Disease (e.g., Patients under investigation) is no longer suspected to have Ebola Virus disease (EVD) or has ruled out for EVD, their waste materials no longer need to be managed as if contaminated with Ebola Virus.

WASTE HANDLING

Interim Guidance for Managers and Workers Handling Untreated Sewage from Individuals with Ebola in the United States 11/20/14

Information on the Survivability of the Ebola Virus in Medical Waste 11/21/14

Ebola Medical Waste Management (key information from the CDC)

What is a Category A Infectious Substance?

Ebola is classified as a Category A substance, a biological agents or pathogen that is rarely seen in the United States and:

•can be easily disseminated or transmitted from person to person;

•result in high mortality rates and have the potential for major public health impact;

•might cause public panic and social disruption; and

•require special action for public health preparedness.13

For information and clarification on the how Category A infectious substances must be disposed of and transported refer to

Transporting Category A Infectious Substances

Department of Transportation Resource

The U.S. Department of Transportation’s Pipeline and Hazardous Materials Safety Administration (PHMSA) in coordination with the Centers for Disease Control and Prevention (CDC) announced that it has issued an emergency special permit allowing a Lake Forest, Ill.-based company to transport large quantities of Ebola-contaminated waste from Texas Health Presbyterian Hospital Dallas for disposal. More

Pipeline and Hazardous Materials Safety Administration (PHMSA) special permit Q & A

DOT Guidance

DOT Transporting Infectious Substances Brochure

ADDITIONAL EBOLA RELATED RESOURCES

American Hospital Association Resources

Ebola Preparedness Resources

Ebola Screening Criteria

Detailed Hospital Checklist for Ebola Preparedness

Center for Disease Control

Interim Guidance for U.S. Hospital Preparedness for Patients with Possible or Confirmed Ebola Virus Disease: A Framework for a Tiered Approach 

Interim Guidance for Preparing Frontline Healthcare Facilities for Patients with Possible Ebola Virus Disease 

Interim Guidance for Preparing Ebola Assessment Hospitals 

Interim Guidance for Preparing Ebola Treatment Centers 

Checklist for Patients Being Evaluated for EVD, U.S.

Ebola Virus Disease(EVD) Algorithm for Evaluation of the Returned Traveler

Ebola Screening Criteria Template for EMS

Ebola Transmission Table

HAN 371: Evaluating Patients for Possible Ebola Virus Disease: Recommendations for Healthcare Personnel and Health Officials

Infection Control for Viral Hemorrhagic Fevers in the African Health Care Setting

Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus

Interim Guidance: EMS Systems & 9-1-1 PSAPs: Management of Patients in the U.S.

Open Letter to All U.S. Healthcare Professionals from Dr. Nicole Lurie, the Assistant Secretary for Preparedness and Response, regarding the current Ebola situation.

 CDC/ASPR Checklists:

Webinar Recording Available on Ebola Preparedness for U.S. Health Care System

A recording of a recent webinar hosted by ASPR and CDC on Ebola Preparedness for the U.S. health care system is now available for viewing. The webinar focused on the Detailed Hospital Checklist for Ebola Preparedness, which highlights the activities that all hospitals can take to prepare for the possibility of a patient exposed to Ebola arriving for medical care. This information is especially useful for hospital emergency managers, infection control officers, hospital leadership, and clinical staff. The checklist provides practical and specific suggestions to ensure hospitals can detect possible Ebola cases, protect their employees, and respond appropriately.

Centers for Medicare & Medicaid Services

Ebola-related EMTALA requirements 

WHO Resources

Infection prevention and control guidance for care of patients in health-care settings, with focus on Ebola

 

At the request of the Chief Medical Officer in ASPR’s Office of Biomedical Advanced Research and Development Authority (BARDA) 10-16-14

Please note this video: Clinical Update and 5-minute Ebola virus disease (EVD) management and lessons learned video. The video provides a summary by Dr. Bruce Ribner on caring for Ebola patients in the US, and the video is an interview with Dr. Ribner. Dr. Ribner led the team at Emory University that cared for two patients with Ebola virus disease (EVD) in August.

Video: Dr. Bruce Ribner’s Interview on EVD Management and Lesson Learned

*Taken from ID Week 2014 program. Special thanks to the partners at ID Week for sharing this information with the wider health care community.

Emory Ebola Patient Synopsis

Preparing for Ebola

References

  1. Sagripanti JL, Rom AM, Holland LE. Persistence in darkness of virulent alphaviruses, Ebola virus, and Lassa virus deposited on solid surfaces. Arch Virol 2010; 155:2035-2039
  2. Sagripanti JL, Lytle DC. Sensitivity to ultraviolet radiation of Lassa, vaccinia, and Ebola viruses dried on surfaces. Arch Virol 2011; 156:489–494
  3. Bausch DG et al. Assessment of the Risk of Ebola Virus Transmission from Bodily Fluids and Fomites. J Infect Dis 2007; 196:S142–7
  4. CDC Guidelines for Environmental Infection Control in Healthcare Facilities[PDF - 249 pages] (see: Environmental Surfaces Section).
  5. OSHA Bloodborne Pathogen Standard 29 CFR 1910.1030
  6. DOT. Guidance for Transporting Ebola Contaminated Items, a Category A Infectious Substance
  7. DOT. Hazardous Materials Regulations [49 CFR Parts 100-1999; 49 CFR 172.700; 49 CFR 173.134(a)(5))
  8. About Ebola Virus Disease. (2014, October 3). Retrieved October 6, 2014.
  9. Signs and Symptoms. (2014, October 3). Retrieved October 6, 2014.
  10. Transmission. (2014, October 3). Retrieved October 6, 2014.
  11. (2014, January 28). Retrieved October 6, 2014.
  12. Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Virus Disease in U.S. Hospitals. (n.d.).
  13. Bioterrorism Agents/Diseases. (n.d.). Retrieved October 8, 2014.
  14. Ribner BS. Treating patients with Ebola virus infections in the US: lessons learned. Presented at IDWeek, October 8, 2014. Philadelphia PA
  15. Hill CE, Burd EM, Kraft CS, et al. Laboratory test support for Ebola patients within a high-containment facility. Lab Medicine 2014:45(3):e109-111.

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