Infection Prevention and Control Recommendations for Hospitalized Patients Under Investigation (PUIs) for Ebola Virus Disease (EVD) in U.S. Hospitals

• Single patient room (containing a private bathroom) with the door closed
• Facilities should maintain a log of all people entering the patient’s room

• Consider posting personnel at the patient’s door to ensure appropriate and consistent use of PPE by all people entering the patient room

Guidance on Personal Protective Equipment (PPE) To Be Used By Healthcare Workers during Management of Patients with Confirmed Ebola or Persons under Investigation (PUIs) for Ebola who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea in U.S. Hospitals, Including Procedures for Donning and Doffing PPE

For U.S. Healthcare Settings: Donning and Doffing Personal Protective Equipment (PPE) for Evaluating Persons Under Investigation (PUIs) for Ebola Who Are Clinically Stable and Do Not Have Bleeding, Vomiting, or Diarrhea

• Recommended PPE varies depending on the symptoms of the patient

• Dedicated medical equipment (preferably disposable, when possible) should be used for the provision of patient care
• All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer’s instructions and hospital policies

• Limit the use of needles and other sharps as much as possible
• Phlebotomy, procedures, and laboratory testing should be limited to the minimum necessary for essential diagnostic evaluation and medical care
• All needles and sharps should be handled with extreme care and disposed in puncture-proof, sealed containers

• Avoid AGPs for patients with EVD, if possible.
• If performing AGPs, use a combination of measures to reduce exposures from aerosol-generating procedures when performed on patient with EVD.
• Visitors should not be present during aerosol-generating procedures.
• Limiting the number of HCP present during the procedure to only those essential for patientcare and support.
• Conduct the procedures in a private room and ideally in an Airborne Infection Isolation Room (AIIR) when feasible. Room doors should be kept closed during the procedure except when entering or leaving the room, and entry and exit should be minimized during and shortly after the procedure.
• HCP should wear appropriate PPE during aerosol-generating procedures.
• Conduct environmental surface cleaning following procedures (see section below on environmental infection control).

• Although there are limited data available to definitively define a list of AGPs, procedures that are usually included are Bilevel Positive Airway Pressure (BiPAP), bronchoscopy, sputum induction, intubation and extubation, and open suctioning of airways. Additional information about AGPs is available in Which procedures are considered AGPs in healthcare settings?.
• Because of the potential risk to individuals reprocessing reusable respirators, disposable filtering face piece respirators are preferred.

• HCP should perform hand hygiene frequently, including before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of PPE, including gloves.
• Healthcare facilities should ensure that supplies for performing hand hygiene are available.

• Hand hygiene in healthcare settings can be performed by washing with soap and water or using alcohol-based hand rubs. If hands are visibly soiled, use soap and water, not alcohol-based hand rubs.

• Facilities should follow safe injection practices as specified under Standard Precautions.

• Any injection equipment or parenteral medication container that enters the patient treatment area should be dedicated to that patient and disposed of at the point of use.

• Duration of precautions should be determined on a case-by-case basis, in conjunction with local, state, and federal health authorities.

• Factors that should be considered include, but are not limited to, presence of symptoms related to EVD, date symptoms resolved, other conditions that would require specific precautions (tuberculosis, Clostridium difficile) and available laboratory information.

Facility HCP monitoring and sick leave policies

• Facilities should develop policies for monitoring and management of HCP with potential ebola-virus exposure
  
  
• Facilities should develop sick leave policies for HCP that are non-punitive, flexible and consistent with public health guidance
  • Ensure that all HCP, including staff who are not directly employed by the healthcare facility but provide essential daily services, are aware of the sick leave policies.

HCP with high-risk exposures

• Per CDC interim guidance, people with high-risk exposures, including HCP, should be quarantined, monitored daily, and restricted from traveling by commercial transport until 21 days after their last high-risk exposure
  • High-risk exposures include (but are not limited to):
    • Percutaneous, mucous membrane, or skin contact with blood or body fluids of a person with known or suspected EVD
    • Direct contact* with person who has known or suspected EVD
    • Providing care to a patient with known or suspected EVD without use of all recommended PPE, or while experiencing a breach in recommended PPE that results in the potential for percutaneous, mucous membrane, or skin contact with the blood or body fluids of a patient with known or suspected EVD
    • Living in the same household as a person with known or suspected EVD
  • Asymptomatic HCP who had a high-risk exposure should
    • Receive medical evaluation and follow-up care including fever monitoring twice daily for 21 days after the last known high-risk exposure
    • Be restricted from work and from traveling by commercial transport during the 21-day monitoring period
• HCP who have a percutaneous or mucous membrane exposure to blood or body fluids, secretions, or excretions from a person with known or suspected EVD should
  • Stop working and immediately wash the affected skin surfaces with soap and water. Mucous membranes (e.g., conjunctiva) should be irrigated with copious amounts of water or eyewash solution.
  • Immediately contact their supervisor and occupational health program for assessment and access to postexposure management services for all appropriate pathogens (e.g., Human Immunodeficiency Virus, Hepatitis C, etc.).

*Direct contact means physical contact with a person with Ebola disease (alive or dead) or with objects contaminated with the body fluids of a person with Ebola disease (alive or dead) while not wearing recommended PPE or while experiencing a breach in PPE that could result in unprotected contact with the patient or their blood or body fluids.

Additional Considerations for HCP with potential unrecognized ebolavirus exposures 

• CDC has provided for persons, including HCP, with the potential for unrecognized ebolavirus exposures in the absence of reported high-risk exposures. Such HCP should be evaluated by their occupational health program and have their recommended postexposure management, including work restrictions, determined in collaboration with public health authorities.
  • In general, asymptomatic HCP with potential unrecognized ebolavirus exposures in the absence of high-risk exposures do not require work restriction

Considerations for HCP who develop signs or symptoms after caring for patients with known or suspected EVD or with potential unrecognized Ebola exposures

• HCP who develop sudden onset of fever, fatigue, intense weakness or muscle pains, vomiting, diarrhea, or any signs of hemorrhage should
  • Not report to work or should immediately stop working
  • Notify their supervisor and occupational health program, who should in turn notify local and state public health authorities
  • Seek prompt medical evaluation and testing
  • Comply with directives until they are to others

• Avoid entry of visitors into the patient’s room
  • Exceptions may be considered on a case by case basis for those who are essential for the patient’s wellbeing.
• Establish procedures for monitoring managing and training visitors.
• Visits should be scheduled and controlled to allow for:
  • Screening for EVD (fever and other symptoms) before entering or upon arrival to the hospital.
  • Evaluating risk to the health of the visitor and ability to comply with precautions.
  • Providing instruction, before entry into the patient care area on hand hygiene, limiting surfaces touched, and use of PPE according to the current facility policy while in the patient’s room.
  • Visitor movement within the facility should be restricted to the patient care area and an immediately adjacent waiting area.

• Visitors who have been in contact with the patient with EVD before and during hospitalization are a possible source of EVD for other patients, visitors, and staff.