Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Emergency Communications Centers/Public Safety Answering Points (ECC/PSAPs) for Management of Patients Suspected to have Selected Viral Hemorrhagic Fevers in the United States
This guidance refers only to the following viral hemorrhagic fevers: Ebola, Marburg, Lassa, Crimean Congo Hemorrhagic Fever (CCHF) and the South American Hemorrhagic Fevers (i.e., those caused by Junin, Machupo, Chapare, Guanarito and Sabia viruses). Refer to the pathogen-specific pages for further information about the individual pathogens (e.g., signs and symptoms, incubation periods, routes of transmission, diagnosis, treatments).
Who this is for: EMS clinicians (including emergency medical responders (EMR), emergency medical technicians (EMTs), advanced EMTs (AEMTs), paramedics, and other medical first responders who could be providing patient care in the field, such as law enforcement and fire service personnel), managers of 9-1-1 ECC/PSAPS, EMS agencies, EMS systems, and agencies with medical first responders.
What this is for: Guidance to assure EMS and first responders are safe and patients are appropriately managed while handling inquiries and responding to patients suspected to have viral hemorrhagic fever (VHF). The information contained in this document is intended to complement existing guidance for healthcare personnel.
How to use: Employers and supervisors should use this information to understand and explain to staff how to respond and stay safe. Supervisors can use this information to prepare, educate, and train EMS personnel. Individuals can use this information to stay safe when responding to PUIs.
- The likelihood of contracting viral hemorrhagic fever (VHF) in the United States is extremely low unless a person has direct contact with the blood or body fluids of a person with VHF who has symptoms or the blood or body fluids of a person who has died of VHF.
- It is important for ECC/PSAPs to question callers about:
- Risk factors for exposure to VHF (e.g., contact with a person suspected or confirmed to have VHF while in an area endemic for and/or currently experiencing VHF outbreaks); AND
- Signs and symptoms of VHF (such as fever, severe headache, muscle pain, weakness, fatigue, diarrhea, vomiting, abdominal pain, and unexplained hemorrhage).
- Managers of 9-1-1 ECC/PSAPs, EMS agencies, EMS systems, and agencies with medical first responders such as fire and law enforcement should collaborate with local public health authorities to develop coordinated plans for responding to a patient suspected to have VHF in a given jurisdiction, including the possibility of designating certain teams for this response.
- All personnel should be educated and trained regarding VHF response protocols. Those who may respond to a patient suspected to have VHF also should be educated and trained in the use of the appropriate PPE consistent with their response role.
- If ECC/PSAP call takers have information alerting them to a patient suspected to have VHF, they should make sure first responders and EMS clinicians are made aware of the potential for a patient with possible exposure/signs and symptoms of VHF before responders arrive on scene. This will enable EMS clinicians to select and correctly put on recommended PPE. The fundamental principle of standard and transmission-based precautions is to prevent contact with blood or potentially infectious body fluid.
- Before treating and/or transporting a patient, personnel should have been educated, trained, and demonstrated competency in all VHF-related infection control practices and procedures, specifically in donning and doffing proper PPE.
- When EMS clinicians arrive at the scene, they should immediately check for symptoms and risk factors for VHF and don PPE appropriate to the situation. When transporting a patient suspected to have VHF, EMS clinicians should notify the receiving healthcare facility in advance, so that proper infection control precautions are ready to be implemented at the healthcare facility before arrival. EMS medical directors and EMS agencies should collaborate with healthcare and public health agencies to define local or regional protocols for transporting a patient suspected to have VHF to an appropriate facility for VHF triage and care.
- Local protocols should be developed for cleaning and disinfecting of the ambulance and equipment as well as disposing of medical waste consistent with this guidance.
VHF spreads through direct contact (such as through broken skin or mucous membranes in the eyes, nose, or mouth) with blood or body fluids of a person who is sick with or has died from VHF or direct contact with objects (such as needles and syringes) contaminated with body fluids from a person sick with VHF or the body of a person who died from the selected VHF. Signs and Symptoms can vary depending on the VHF. Examples that can occur across all of the VHFs addressed in this guidance include fever, severe headache, muscle pain, weakness, fatigue, diarrhea, vomiting, abdominal (stomach) pain, and unexplained hemorrhage (e.g., bleeding from gums, blood in urine, or bruising). The timing of symptom onset depends on the incubation period of the virus. For Ebola, Marburg, Lassa, and the South American Hemorrhagic Fevers, the outer limit of the incubation period is 21 days; however, for Crimean Congo Viral Hemorrhagic Fever this period is 14 days.
Attention is needed when coming into direct contact with a recent traveler from a country experiencing an outbreak of VHF or where VHF is endemic and who also has signs and symptoms of VHF. The initial signs and symptoms of VHF are often nonspecific and similar to other infectious diseases, such as malaria and typhoid. VHF should be considered in anyone with a fever who has traveled to, or lived in, an area where VHF is present; however most of these patients in the United States will not have VHF.
Transport by emergency medical services (EMS) presents unique challenges because of the uncontrolled nature of the work, the potential for resuscitation procedures being needed, enclosed space during transport, and a varying range of patient acuity.
Key safe work practices include avoiding:
- Unprotected exposure to blood or body fluids of patients with VHF through contact with skin, mucous membranes of the eyes, nose, or mouth.
- Injuries with contaminated needles or other sharp objects.
- Aerosol-generating procedures when possible.
Coordination among 9-1-1 ECC/PSAPs, the EMS system, healthcare facilities, and the public health system is important. Educating, training, and exercising with all stakeholders is critical when preparing to respond to PUIs. Each 9-1-1 and EMS system should include an EMS medical director to provide appropriate medical oversight.
Recommendations for 9-1-1 ECC/PSAPs
If a community is considered at higher risk for having patients with VHF, state and local EMS authorities should coordinate with state and local public health, ECC/PSAPs, and other emergency call centers to use modified caller queries about VHF, outlined below. This should be decided from information provided by local, state, and federal public health authorities, including the city or county health department(s), state health department(s), and CDC.
Modified Caller Queries
It will be important for ECC/PSAPs to question callers and determine the possibility of anyone having signs or symptoms and risk factors for VHF. This information should be communicated immediately to EMS clinicians before arrival in order to assign the appropriate EMS resources. Local or state public health officials should also be notified. ECC/PSAPs should utilize medical dispatch procedures that are coordinated with their EMS medical director and with the local public health department.
- Use modified caller queries that ask for risk factors for VHF.
- If ECC/PSAP call takers have information alerting them to a person suspected to have VHF, they should make sure any first responders and EMS clinicians are made aware of the potential for a patient with possible exposure/signs and symptoms of VHF before the responders arrive on scene.
- If responding to a report of an ill traveler at an airport or other port of entry to the United States, the ECC/PSAP or EMS unit is requested to notify the CDC Quarantine Station for the port of entry if the traveler meets the criteria for signs or symptoms listed below. For contact information check the CDC Quarantine Station Contact List. The ECC/PSAP or EMS unit also may call CDC’s Emergency Operations Center at (770) 488-7100 to be connected with the appropriate quarantine station.
- Fever (has a measured temperature of 100.4°F [38°C] or greater, or feels warm to the touch, or gives a history of feeling feverish) accompanied by one or more of the following:
- skin rash;
- difficulty breathing;
- persistent cough;
- decreased consciousness or confusion of recent onset;
- new unexplained bruising or bleeding (without previous injury);
- persistent diarrhea;
- persistent vomiting (other than air sickness);
- headache with stiff neck; or
- appears obviously unwell
- Fever (has a measured temperature of 100.4°F [38°C] or greater, or feels warm to the touch, or gives a history of feeling feverish) accompanied by one or more of the following:
Recommendations for EMS and Medical First Responders
For the purposes of this section, “EMS clinician” means prehospital EMS and medical first responders. These EMS clinician practices should be based on the most up-to-date clinical recommendations and information from appropriate public health authorities and EMS medical direction.
When state and local EMS authorities determine there is an increased risk, they may direct EMS clinicians to modify their practices as described below.
- If ECC/PSAP call takers advise the patient is suspected of having VHF, EMS clinicians should put on appropriate PPE before entering the scene. PPE options are described in detail below.
- Initial assessment in circumstances of increased risk should include wearing all appropriate PPE if approaching within 6 feet. Only one EMS clinician should approach the patient and perform the initial screening. Based on the initial screening, if the EMS clinician suspects VHF, then all other personnel should wear appropriate PPE for all subsequent interactions. Keep other emergency responders further away, while assuring they are still able to support the EMS clinician with primary assessment duties.
- During patient assessment and management, EMS clinicians should consider VHF signs, symptoms, and risk factors (e.g., history of being in an area endemic for and/or currently experiencing VHF outbreaks, contact with a person suspected or confirmed to have VHF while in an area endemic for and/or currently experiencing VHF outbreaks).
- Patients with relevant exposures should be questioned regarding the presence of signs or symptoms of VHF.
Safety and PPE
Based on the clinical presentation of the patient, there are two PPE options.
- If the patient is not exhibiting obvious bleeding, vomiting, or diarrhea and does not appear to be acutely ill, EMS personnel should follow the PPE guidance for patients suspected to have VHF who are clinically stable.
- If the patient is exhibiting obvious bleeding, vomiting, or diarrhea or is clinically unstable then EMS personnel should wear PPE described in Guidance on Personal Protective Equipment (PPE) in U.S. Healthcare Settings during Management of Patients Confirmed to have Selected Viral Hemorrhagic Fevers or Patients Suspected to have Selected Viral Hemorrhagic Fevers who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea. This PPE should also be worn if the patient requires invasive or aerosol-generating procedures (such as intubation, suctioning, cardiopulmonary resuscitation). Extreme care should be followed in these instances.
- PPE should be put on before entering a scene and continued to be worn until clinicians no longer are in contact with the patient. PPE should be carefully put on and removed under the supervision of a trained observer as described in Guidance on Personal Protective Equipment (PPE) in U.S. Healthcare Settings during Management of Patients Confirmed to have Selected Viral Hemorrhagic Fevers or Patients Suspected to Have Selected Viral Hemorrhagic Fevers who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea.
- If blood, body fluids, secretions, or excretions from a patient suspected to have VHF come into direct contact with the EMS clinicians’ unprotected skin or mucous membranes, then the EMS clinician should immediately STOP working. They should wash the affected skin surfaces with a cleansing or antiseptic solution, and mucous membranes (e.g., conjunctiva) should be irrigated with a large amount of water or eyewash solution, as per usual protocols. All waste should be placed in a biohazard bag. EMS clinicians should immediately report exposure to an occupational health provider, supervisor, or designated infection control officer for immediate care.
Patient management and Infection Control
EMS clinicians can safely manage a patients suspected to have VHF by following the recommendations for appropriate PPE and following these recommendations:
- Use caution when approaching the patient. On rare occasions, illness can cause delirium, with erratic behavior, such as flailing or staggering. This type of behavior can place EMS clinicians at additional risk of exposure.
- Keep the patient separated from others as much as possible.
- Limit the number of personnel who care for the patient. All personnel within the range of coughs and splashes (i.e., 6 feet) of the patient must wear PPE.
- Limit activities, especially during transport, that can increase the risk of exposure to infectious material.
- Invasive procedures should be limited to those essential for patient management.
- Limit the use of needles and other sharps as much as possible. Needles and sharps should be handled with extreme care and disposed in puncture-proof, sealed containers specific to the care of this patient, in accordance with OSHA’s Bloodborne Pathogens Standard, 29 CFR 1910.1030 . Do not dispose of used needles and sharps in containers that have sharps from other patients in them.
- Consider giving the patient oral medicine to reduce nausea, per medical director protocols and consistent with scope of practice.
- If patient is vomiting, give them a large red biohazard bag to contain any emesis.
- If patient has profuse diarrhea, consider wrapping the patient in an impermeable sheet to reduce contamination of other surfaces.
- Prehospital resuscitation procedures such as endotracheal intubation, open suctioning of airways, and cardiopulmonary resuscitation frequently result in a large amount of body fluids, such as saliva and vomit. Performing these procedures in a less controlled environment (for example, a moving vehicle) increases risk of exposure to infectious pathogens for EMS clinicians. Perform these procedures according to protocol under safer circumstances (e.g., when the vehicle has stopped, upon arrival at the hospital destination) and wear the PPE recommended for use during aerosol-generating procedures.
- Donning and doffing of PPE must be supervised by a trained observer to ensure proper completion of established PPE protocols. In collaboration with the receiving hospital, EMS agencies should consider how best to facilitate a supervised doffing process.
Prehospital care considerations
EMS systems should design their procedures to accommodate their local operational challenges while still following the principles of CDC PPE guidance.
- It may be as simple as having one clinician put on PPE and manage the patient while the other provider does not engage in patient care but serves in the role of trained observer.
- There may be situations where a patient must be carried and multiple personnel are required to put on PPE. In those instances, EMS clinicians having had contact with the patient must remain in the back of the ambulance and should not join or serve as the driver.
- EMS agencies may consider sending additional resources to eliminate the need for putting on PPE by additional clinicians. For example, a dedicated driver for the ambulance may not need to wear PPE if they remain > 6 feet from the patient and other EMS clinicians, and do not provide patient care.
- Doffing of PPE must be performed with meticulous care to prevent self-contamination. See guidance on PPE doffing and ensure education and training emphasizes adherence to a standardized protocol.
- Prepare and use safe procedures to treat and transport the patient to the hospital.
- The person driving the ambulance should contact the receiving hospital and follow local or regional protocols to transport the patient to the receiving hospital.
- Remove and keep nonessential equipment away from the patient on the scene and in the ambulance. This will eliminate or minimize contamination.
- Avoid contamination of reusable porous surfaces not designated for single use. Cover the stretcher with an impermeable material.
- Conduct appropriate patient assessment according to established protocols, using minimal equipment.
EMS Transport of Patient to a Healthcare Facility
People who may have an exposure history and signs and symptoms suggestive of VHF should be transported to a healthcare facility prepared to further evaluate and manage the patient as instructed by EMS medical direction and local/regional protocols. These should be consistent with the predefined transportation/destination plan developed by public health officials, hospital, medical, and EMS personnel.
- Isolate the driver from the patient compartment.
- During transport, ensure that an appropriate disinfectant (EPA-registered hospital disinfectant from List Q; for Ebola, products from List L can also be used) is available.
EMS personnel involved in the interfacility transfer of patients suspected or confirmed to have VHF should follow donning and doffing procedures as recommended in CDC guidance. Provide patient care as needed to minimize contact with the patient and follow infection control guidelines noted below.
Documentation of patient care
- Documentation of patient care should be done after EMS clinicians have completed their personal cleaning and decontamination of equipment and the vehicle. Any written documentation should match the verbal communication given to the emergency department providers at time of patient handover.
- EMS documentation should include a listing of public safety providers involved in the response and level of contact with the patient (e.g., no contact with patient, provided direct patient care). This documentation may need to be shared with local public health authorities.
Cleaning EMS Transport Vehicles after Transporting a Patient Suspected to Have VHF
The following are general guidelines for cleaning or maintaining EMS transport vehicles (i.e., ambulances) and equipment after transporting the patient:
- Personnel performing cleaning and disinfection where body fluids from the patient are present should wear PPE as recommended by CDC. If no body fluids from the patient are present, follow PPE guidance for Patients Suspected to have VHF who are Clinically Stable and Do Not Have Bleeding, Vomiting, or Diarrhea.
- Use an EPA-registered hospital disinfectant from List Q (for Ebola, products from List L can also be used) to disinfect environmental surfaces in the transporting vehicle and rooms of the patient. Cleaning and decontaminating surfaces or objects soiled with blood or body fluids are addressed below. There should be the same careful attention to the safety of EMS personnel during cleaning and disinfection of transport vehicles as during care of the patient.
- Patient-care surfaces (including stretchers and wheels, railings, door handles, medical equipment control panels, adjacent flooring, walls, and work surfaces), as well as stretcher wheels, brackets, and other areas are likely to become contaminated and should be cleaned and disinfected thoroughly after each transport.
- A blood spill or spill of other body fluids or substances should be managed by personnel wearing correct PPE. This includes removing bulk spill matter, cleaning the soiled site, and then disinfecting the site. Follow the chemical disinfectant product’s labeled instructions and dispose of the potentially contaminated materials used during the cleaning and disinfecting process as recommended in CDC guidance.
- Contaminated reusable patient care equipment (such as glucometer, blood pressure cuff) should be placed in biohazard bags and labeled for cleaning and disinfection or disposal according to agency policies and manufacturer recommendations. Reusable equipment should be cleaned and disinfected according to manufacturer’s instructions by trained personnel wearing correct PPE. Avoid contamination of reusable porous surfaces not designated as single use.
- Use only a mattress and pillow with intact plastic or other covering that fluids cannot penetrate.
- To reduce exposure among staff to potentially contaminated textiles (cloth products) while laundering, discard used linens and nonfluid-impermeable pillows or mattresses as appropriate at the receiving facility.
Except for Chapare virus, the selected hemorrhagic fever viruses are Category A infectious substances regulated by the U.S. Department of Transportation’s Hazardous Materials Regulations (HMR, 49 C.F.R., Parts 171-180). Any item transported for disposal that is contaminated or suspected of being contaminated with a Category A infectious substance must be packaged and transported in accordance with the HMR. This includes: disposable medical equipment; sharps; linens; and used healthcare products such as soiled absorbent pads or dressings, emesis pans, portable toilets; used PPE such as, gowns or coveralls, masks, gloves, goggles, face shields, respirators, and booties; and contaminated waste from cleaning. EMS systems should work with designated receiving hospitals to dispose of waste from these patients.
Follow-up and/or Reporting Measures by EMS Clinicians After Caring for a Patient Suspected to have VHF
- EMS clinicians should be aware of the follow-up and/or reporting measures they should take after caring for the patient.
- EMS agencies should develop policies for monitoring and management of EMS personnel potentially exposed to VHF.
- EMS agencies should develop sick-leave policies for EMS personnel that are nonpunitive, flexible, and consistent with public health guidance.
- Ensure all EMS personnel, including staff who are not directly employed by the healthcare facility but provide essential daily services, are aware of the sick-leave policies.
- EMS personnel with exposure to blood or body fluids should immediately
- STOP working and wash the affected skin surfaces with a cleansing or antiseptic solution, and mucous membranes (such as conjunctiva of the eye) should be irrigated with a large amount of water or eyewash solution, as per usual protocols. All wipes and solution should be placed in a biohazard bag.
- Contact occupational health/supervisor/designated infection control officer for immediate assessment and access to post-exposure management services.
- Receive medical evaluation and follow-up care, based upon EMS agency policy and consultation with local, state, and federal public health authorities. Additional monitoring and movement restrictions may be imposed by public health authorities for personnel with unprotected exposure to a patient with EVD.
- All mission personnel should be advised to self-monitor for a period of 21* days after the last known contact with the patient. They should immediately report elevated body temperature or subjective fever or any other signs or symptoms consistent with VHF to their occupational health/supervisor/designated infection control officer.
- *For Crimean Congo Hemorrhagic Fever 14 days should be used.