EBOLA Viral Disease Interim Guideline - (EPHI) Ethiopian Public Health Institute
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EBOLA Viral Disease
Interim Guideline
Ethiopian Public Health Institute
(EPHI)
September 2014
Addis Ababa, ETHIOPIATABLE OF CONTENTS
TABLE OF CONTENTS ............................................................................................................................... II
I. INTRODUCTION TO EBOLA VIRAL DISEASES ............................................................................. 1
1. Background ....................................................................................................................................................... 1
2. Mode of Transmission ....................................................................................................................................... 1
3. Incubation Period .............................................................................................................................................. 2
4. Sensitivity of the Virus ....................................................................................................................................... 2
5. Clinical Features of Ebola Virus Infection .................................................................................................... 2
II. EBOLA VIRUS DISEASE SURVEILLANCE AND LABORATORY DIAGNOSIS....................... 4
1. Purpose of Surveillance ..................................................................................................................................... 4
2. Case Definition of Ebola Virus Disease ............................................................................................................... 4
2.1. Case Definition Ebola Cases before Outbreak ........................................................................................................ 4
2.2. Case definitions During an Ebola Outbreak ............................................................................................................ 5
3. EVD Surveillance and Measures to Take ............................................................................................................. 5
3.1 Screening of Passengers at Ports of Entries ............................................................................................................. 5
3.2. Exposure Levels and Measures to Take if Exposures Encountered ......................................................................... 6
3.3. Contact Tracing and Contact Follow Up ................................................................................................................. 7
3.3 Contact Tracing ....................................................................................................................................................... 8
3.4 Rumors Verification ................................................................................................................................................ 9
3.5 Transporting a Suspected Case ............................................................................................................................. 10
4. Outbreak Investigation, Sample Collection and Shipment ................................................................................ 12
4.1 Outbreak Investigation ......................................................................................................................................... 12
4.2 Confirmation of Diagnosis by Laboratory: Collection of Specimen and Shipment ................................................. 13
III. CASE MANAGEMENT OF PATIENTS ........................................................................................ 14
1. Principles for Clinical Case Management .......................................................................................................... 14
2. Set Up and Organization of the Ebola Treatment Center .................................................................................. 14
2.1 Location ................................................................................................................................................................ 14
2.2 Buildings / Structures ............................................................................................................................................ 14
2.3 Risk Zones ............................................................................................................................................................. 15
2.4 Activities and Facilities in the Different Risk Zones................................................................................................ 16
2.5 Fencing ................................................................................................................................................................. 17
2.6 Layout of Ebola Treatment Unit ............................................................................................................................ 17
ii | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 42.7 Patient screening area .......................................................................................................................................... 19
3. Patient Care at Ebola Treatment Unit............................................................................................................... 19
3.1 Medical Staff ......................................................................................................................................................... 19
3.2 Admissions ............................................................................................................................................................ 19
3.3 Laboratory Tests ................................................................................................................................................... 20
3.4 Medical Care ......................................................................................................................................................... 20
3.5 Invasive Procedures .............................................................................................................................................. 21
3.6 Hydration .............................................................................................................................................................. 21
3.7 Management of Shock in EVD Patients ................................................................................................................. 21
3.8 Symptomatic Care ................................................................................................................................................. 25
3.9 Presumptive Treatment ................................................................................................................................. 27
3.10 Nutritional Support ........................................................................................................................................ 27
3.11 Psychological Support ......................................................................................................................................... 28
3.12 Children in the Ebola Treatment Unit .................................................................................................................. 29
3.13 Mothers with breastfeeding children .................................................................................................................. 29
3.14 Maternity and Ebola virus disease ...................................................................................................................... 29
4. Discharge ........................................................................................................................................................ 30
4.1 Discharge Criteria........................................................................................................................................... 30
4.2 Important Procedures before Discharge ........................................................................................................ 30
4.3 Supportive Treatment and Follow up ............................................................................................................. 30
4.4 Patient Care in the Home Based Support and Risk Reduction ........................................................................ 31
4.5 Laboratory Tests ............................................................................................................................................ 31
4.6 Medical File .................................................................................................................................................... 31
4.7 Psychological Support .................................................................................................................................... 31
4.8 Management of Exposed Individuals ............................................................................................................. 31
IV. INFECTION PREVENTION AND CONTROL ............................................................................ 33
1. General Patient Care ....................................................................................................................................... 33
2. Disinfection in Ebola Treatment Units .............................................................................................................. 33
3. Patient Placement, Staff Allocation, Visitors .................................................................................................... 33
4. Personal Protective Equipment, Hand Hygiene and Other Precautions ............................................................. 34
4.1 Personal Protective Equipment Protocols ...................................................................................................... 34
4.2 Hand Hygiene Protocol ......................................................................................................................................... 36
4.3 Injection Safety ..................................................................................................................................................... 37
4.4 Environmental Cleaning ........................................................................................................................................ 38
2.5 Management of Linen and Blankets ............................................................................................................... 39
5. Waste Management ........................................................................................................................................ 40
6. Moving and Burial of Human Body................................................................................................................... 42
6.1 Burial Procedure for Patient Dying in the Ebola Treatment Unit: .......................................................................... 42
6.2 Procedure for Burial of Suspect/Probable/Confirmed Patient Dying at Home ...................................................... 44
6.3 Cleaning a Room after Patient Death at Ward ...................................................................................................... 44
6.4 Procedure for house disinfection .......................................................................................................................... 45
iii | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 47. Managing Exposure to Virus ............................................................................................................................ 46
V. COMMUNICATION AND SOCIAL MOBILIZATION .................................................................... 47
1. Overview ......................................................................................................................................................... 47
2. Pre‐Epidemic Phase ......................................................................................................................................... 47
3. Epidemic Phase ............................................................................................................................................... 49
4. Integrated Communication Activities ............................................................................................................... 49
5. Key Messages .................................................................................................................................................. 51
iv | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 4I. INTRODUCTION TO EBOLA VIRAL DISEASES
1. Background
Ebola Viral Disease (EVD) is one of numerous Viral Hemorrhagic Fevers. It is a severe, often fatal disease
in humans and non‐human primates (such as monkeys, gorillas, and chimpanzees).
Ebola virus disease is caused by infection with a virus of the family Filoviridae, genus Ebolavirus. When
infection occurs, symptoms usually begin abruptly. The first Ebolavirus species was discovered in 1976 in
what is now the Democratic Republic of the Congo near the Ebola River. Since then, outbreaks have
appeared sporadically.
There are five identified subspecies of Ebolavirus. Four of the five have caused disease in humans: Ebola
virus (Zaire ebolavirus); Sudan virus (Sudan ebolavirus); Taï Forest virus (Taï Forest ebolavirus, formerly
Côte d’Ivoire ebolavirus); and Bundibugyo virus (Bundibugyo ebolavirus). The fifth, Reston virus (Reston
ebolavirus), has caused disease in non‐human primates, but not in humans.
The natural reservoir host of ebolaviruses remains unknown. However, on the basis of available evidence
and the nature of similar viruses, researchers believe that the virus is zoonotic (animal‐borne) with bats
being the most likely reservoir.
2. Mode of Transmission
Because the natural reservoir of Ebola viruses has not yet been proven, the manner in which the virus
first appears in a human at the start of an outbreak is unknown. However, scientists believe that the first
patient becomes infected through contact with an infected animal, such as a fruit bat or primate (apes
and monkeys), which is called a spillover event. Person‐to‐person transmission follows and can lead to
large numbers of affected people. In some past Ebola outbreaks, primates were also affected by Ebola,
and multiple spillover events occurred when people touched or ate infected primates.
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 fruit bats or primates (apes and monkeys)
Contact with infected corpses (human or animal): Bodies of deceased patients or animals that
died of EVD infection are highly contagious because of the high levels of virus in the corpses.
Often traditional burial rituals consist of washing and touching the body to prepare the body and
this practice will lead to infection.
Indirect contact with contaminated objects and environments.
Ebola does not spread through the air or by water, or in general, by food. However, Ebola may be spread
as a result of handling bush meat (wild animals hunted for food) and contact with infected bats. There is
no evidence that mosquitos or other insects can transmit Ebola virus. Only a few species of mammals (for
example, humans, bats, monkeys, and apes) have shown the ability to become infected with and spread
Ebola virus.
1|EVD Interim Guideline, EPHI Sept 2014Healthcare 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. Dedicated
medical equipment (preferable disposable, when possible) should be used by healthcare personnel
providing patient care. Proper cleaning and disposal of instruments, such as needles and syringes, is also
important. If instruments are not disposable, they must be sterilized before being used again. Without
adequate sterilization of the instruments, virus transmission can continue and amplify an outbreak.
Once someone recovers from Ebola, they can no longer spread the virus. However, Ebola virus has been
found in semen for up to 3 months. Abstinence from sex is recommended for at least 3 months. If
abstinence is not possible, condoms may help prevent the spread of disease.
3. Incubation Period
The incubation period (period between exposure and development of symptoms) is 2 to 21 days. During
the incubation period the patient is infected with the virus, but is asymptomatic and is not contagious.
During the first days of symptoms the levels of the virus increases and therefore its communicability
increases rapidly. If the patient doesn't manage to establish a proper immune response, then the level of
the virus continues to increase until death occurs. The corpse of a patient who died of EVD infection is
therefore highly contagious. If the immune response is sufficient, then the level of virus decreases
gradually until recovery.
4. Sensitivity of the Virus
It is believed that the Filovirus is not capable of surviving a long time outside the body of an infected
organism. The virus is thought to be able to survive up to some days in a liquid (blood, vomit, corpses,
etc). However, having a lipid (fatty) envelop makes the viruses fragile. Chlorine disinfection, Heat, Direct
sunlight (UV light), Soaps and detergents all destroy the lipid envelop of the virus, thereby killing the
virus.
5. Clinical Features of Ebola Virus Infection
Symptoms start generally and are similar to common diseases like malaria, shigellosis or typhoid. A
clinical diagnosis is therefore difficult. Symptoms develop progressively and filovirus infections can kill
rapidly.
Fever
Severe headache
Muscle pain
Weakness
Diarrhea
Vomiting
Abdominal (stomach) pain
Unexplained hemorrhage (bleeding or bruising)
2|EVD Interim Guideline, EPHI Sept 2014Symptoms 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.
Table 1: Summary of signs and symptoms of EVD
General symptoms: … then often followed by
Intense tiredness and weakness Chest pain
Sudden onset of high grade fever fever Diarrhea (watery or bloody)
Headache Vomiting (sometimes bloody)
Muscle pains Orchitis
Arthralgia Rash
Conjunctivitis Confusion and irritability
(1/3 of all patients after 5 days) Internal and external bleeding (in 30‐50% of
Nausea and anorexia cases, often from mucosa and gingivae)
Painful throat and dysphagia Impaired liver and kidney function
Abdominal pain Abortion or miscarriage amongst pregnant
Hiccups women
Shock
Death
3|EVD Interim Guideline, EPHI Sept 2014II. EBOLA VIRUS DISEASE SURVEILLANCE AND LABORATORY DIAGNOSIS
1. Purpose of Surveillance
Considering the infectivity and high case fatality rate of EVD, early detection, timely specimen collection
and processing, immediate isolation of new cases and meticulous contact tracing will limit new chains of
transmission and have a significant impact on control of the epidemic.
With the current EVD outbreak in West Africa countries, Ebola surveillance will be initiated at ports of
entry (airports and land crossing areas) and in the general health system and at community level. The
purpose of this surveillance is:
For early and timely detection of suspected cases and/or outbreaks,
Rapid investigation and early laboratory verification of the etiology,
Contact tracing and follow up of contacts.
Health promotion is one of the priority activities to start with in an intervention. For an efficient
surveillance system, it is important to have a trusting relationship with the community to obtain an
optimum collaboration. The acceptance of being taken to the Ebola Treatment Center or to alert a case
to the surveillance team all depends on the confidence of the community in the intervention and the
health facilities. The teams must be trained to work in tactful and concerned manner that facilitates
developing good relations with the communities.
2. Case Definition of Ebola Virus Disease
2.1. Case Definition Ebola Cases before Outbreak
The following are the case definitions that we need to use for early recognition of suspected cases.
Suspected Case: ‐
A person who has both consistent symptoms and risk factors as follows:
Clinical criteria, a person having fever of greater than 38.60C , and additional symptoms such as
severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage;
AND
Epidemiologic risk factors within the past 21 days before the onset of symptoms, such as contact
with blood or other body fluids or human remains of a patient known to have or suspected to
have EVD; residence in—or travel to—an area where EVD transmission is active*; or direct
handling of bats or non‐human primates from disease‐endemic areas.
Probable Case: ‐
A suspected case whose epidemiologic risk factors include high or low risk exposure(s) (see
section 3.2 below for levels of exposure risk).
Confirmed Case: ‐
A case with laboratory‐confirmed diagnostic evidence of Ebola virus infection.
Community‐based surveillance: standard case definition
This definition of alert cases for Ebola virus disease has been developed for use by the
community or community‐based volunteers. It may be used for community‐based surveillance
during the pre‐epidemic phase and during the outbreak.
4|EVD Interim Guideline, EPHI Sept 2014Alert case: Illness with onset of fever and no response to treatment of usual causes of fever in the
area, OR at least one of the following signs: bleeding, bloody diarrhea, bleeding into urine OR any
sudden death.
2.2. Case definitions During an Ebola Outbreak
During an outbreak, the case definitions are likely to be modified to be adapted to new clinical
presentations or different modes of transmission related to the local event.
a. Case definition to be used by mobile teams or health posts and health centres
Suspected Case:
Any person, alive or dead, suffering or having suffered from a sudden onset of high fever and
having had contact with:
a suspected, probable or confirmed Ebola case;
a dead or sick animal (for Ebola)
OR: any person with sudden onset of high fever and at least three of the following symptoms:
headaches stomach pain
vomiting aching muscles or joints
anorexia / loss of appetite difficulty swallowing
diarrhea breathing difficulties
lethargy hiccup
OR: any person with inexplicable bleeding
OR: any sudden, inexplicable death.
b. Case definition for exclusive use by hospitals and surveillance teams
Probable case:
Any suspected case evaluated by a clinician
OR: Any deceased suspected case (where it has not been possible to collect specimens for
laboratory confirmation) having an epidemiological link with a confirmed case
Note: if laboratory specimens are collected in due time during the illness, the preceding
categories are reclassified as “laboratory confirmed” cases and “non‐case”.
Laboratory Confirmed Case: Any suspected or probably cases with a positive laboratory result.
Laboratory confirmed cases must test positive for the virus antigen, either by detection of virus
RNA by reverse transcriptase‐polymerase chain reaction (RT‐ PCR), or by detection of IgM
antibodies directed against Ebola.
None Case: Any suspected or probable case with a negative laboratory result. “Non‐case” showed no
specific antibodies, RNA or specific detectable antigens.
3. EVD Surveillance and Measures to Take
3.1 Screening of Passengers at Ports of Entries
With the current evidence of EVD in West Africa, and the declaration of Public Health Emergency of
International Concern, traveller screening – of passengers coming from currently affected countries is
an important activity and contribute to early detection of cases and prevent the importation of a the
disease or to delay such importation.
5|EVD Interim Guideline, EPHI Sept 2014WHO advised countries with active EVD to do exit screening of passengers and prohibit passengers
from boarding the flight if sick. Doing the entry screening complements the work of exist screening of
passengers.
Major activities on passengers screening:‐
Raise awareness of EVD and disseminate information among all relevant stakeholders at POE,
Provision of sensitization /orientation to POE public health authorities, POE operators,
conveyance operators
Raise awareness among conveyance operators of the need to immediately notify PoE health
authorities prior to arrival of any suspected cases.
Ensure that passenger locator forms are on board flights and at the airport, and that airport
ground staff and flight crew are trained in managing EVD and environmental contaminants
Provision of training on EVD to crew members, health workers, conveyance operators
Provision of training on the Case definition of EVD, infection prevention
Training of health workers on screening of passengers,
Screening is done with thermal thermometer detector or thermal scanner,
Designation of quarantine place,
Availing the necessary supplies (PPE) and tools (Case investigation form),
Suspected cases should be further screened and ruled for other causes,
Figure below is showing conceptual framework screening of embarking and disembarking
passengers.
3.2. Exposure Levels and Measures to Take if Exposures Encountered
During screening evaluating risk of exposure of persons to Ebola Virus Disease and initiating
appropriate public health actions based on exposure risk and clinical assessment is critical.
Table 2: Exposures to EVD and Public Health Actions
Exposure Level Clinical Presentation Public Health Actions
High Risk Exposure
Consideration as a probable case
Percutaneous (e.g., needle stick) or Medical evaluation using infection control
precautions for suspected Ebola, consultation with
mucous membrane exposure to body
public health authorities, and testing if indicated
fluids of EVD patient Fever OR other
Direct care of an EVD patient or If air transport is clinically appropriate and
symptoms consistent indicated, only air medical transport (no travel on
exposure to body fluids without with EVD without commercial conveyances permitted)
appropriate personal protective fever
equipment (PPE) If infection control precautions are determined
Laboratory worker processing body not to be indicated: conditional
fluids of confirmed EVD patients release and controlled movement until 21 days
without appropriate PPE or standard after last known potential exposure
biosafety precautions
Participation in funeral rites which Conditional release3 and controlled
include direct exposure to human
Asymptomatic movement4 until 21 days after last known
remains in the geographic area where
exposure
outbreak is occurring without
appropriate PPE
Low Risk Exposure
Consideration as a probable case
Fever WITH OR Medical evaluation using initial infection control
Household member or other casual WITHOUT other precautions for suspected Ebola, consultation with
6|EVD Interim Guideline, EPHI Sept 2014Exposure Level Clinical Presentation Public Health Actions
contact with an EVD patient symptoms consistent public health authorities, and testing if indicated
Providing patient care or casual with EVD If air transport is clinically appropriate and
contact without high‐risk exposure indicated, air medical transport only (no travel on
with EVD patients in health care commercial conveyances permitted)
facilities in outbreak‐affected If infection control precautions are determined
countries* not to be indicated: Conditional
release and controlled movement until 21 days
after last known potential exposure
Conditional release3 and controlled
Asymptomatic movement4 until 21 days after last known
exposure
No Known Exposure
Consideration as a suspected case
Medical evaluation and optional consultation with
In affected country public health authorities to determine if movement
Fever WITH other restrictions and infection control precautions are
No low‐risk or high‐risk exposures
symptoms consistent indicated
with EVD If movement restrictions and infection control
precautions are determined not to be indicated:
travel by commercial conveyance is allowed; self‐
monitor until 21 days after leaving country
No movement restrictions
Asymptomatic Travel by commercial conveyance allowed
Self‐monitor5 until 21 days after leaving country
*
Outbreak‐affected countries include Guinea, Liberia, Nigeria and Sierra Leone as of August 4, 2014
1
Fever: measured temperature ≥ 38.6°C/ 101.5°F or subjective history of fever
2
Other symptoms: includes headache, joint and muscle aches, abdominal pain, weakness, diarrhea, vomiting, stomach pain, lack of appetite, rash, red
eyes, hiccups, cough, chest pain, difficulty breathing, difficulty swallowing, bleeding inside and outside of the body. Laboratory abnormalities include
thrombocytopenia (≤150,000 /µL) and elevated transaminases.
3
Conditional release: Monitoring by public health authority; twice‐daily self‐monitoring for fever; notify public health authority if fever or other
symptoms develop
4
Controlled movement: Notification of public health authority; no travel by commercial conveyances (airplane, ship, train, bus, taxi); timely access to
appropriate medical care if symptoms develop
5
Self‐monitor: Check temperature and monitor for other symptoms
6
Consultation: Evaluation of patient's travel history, symptoms, and clinical signs in conjunction with public health authority
3.3. Contact Tracing and Contact Follow Up
Contact tracing is finding everyone who comes in direct contact with a sick Ebola patient contacts are
watched for signs of illness for 21 days from the last day they come in contact with Ebola patient. If a
contact develops with a fever or other Ebola Symptoms, they are immediately isolated, tested,
provided care, and the cycle starts again–all the new patient contacts are found and watched for 21
days. Even one missed contact can make the outbreak going.
Standard definition for contacts persons of Ebola cases
Important: during an outbreak, the contact definitions are likely to be modified to be adapted to
newly reported infection risk factors related to the local event
Ebola case contact: Any person having been exposed to a suspect, probable or confirmed case of
Ebola or Marburg in at least one of the following ways:
has slept in the same household with a case
has had direct physical contact with the case (alive or dead) during the illness
has had direct physical contact with the (dead) case at the funeral
has touched his/her blood or body fluids during the illness
has touched his/her clothes or linens
7|EVD Interim Guideline, EPHI Sept 2014 has been breastfed by the patient (baby)
Provided that this exposure has taken place less than 21 days before the identification as a contact
by surveillance teams.
Contacts of dead or sick animals: Any person having been exposure to a sick or dead animal in at least
one of the following ways:
has had direct physical contact with the animal
has had direct contact with the animal’s blood or body fluids
has carved up the animal
has eaten raw bush‐meat
Provided that this exposure has taken place less than 21 days before the identification as a contact by
surveillance teams
Laboratory contacts: Any person having been exposed to biological material in a laboratory in at least
one of the following ways:
has had direct contact with specimens collected from suspected Ebola or Marburg patients
has had direct contact with specimens collected from suspected Ebola or Marburg animal cases
Provided that this exposure has taken place less than 21 days before the identification as a contact by
surveillance teams.
Other infection risk factors include: contact with a hospital where Ebola cases are being treated;
infection; or vaccination in the 21 days preceding the onset of symptoms.
3.3 Contact Tracing
Contact tracing is finding everyone who comes in direct contact with a known sick Ebola patient or a
probable Ebola case. It requires listing all contacts of probable and confirmed cases using a contact
listing form (see annex 3).
The contact person should be followed and monitored for signs of illness for 21 days from the last
day he/she come in contact with Ebola patient or a probable Ebola case using a contact follow‐up
form (see annex 4)
If the contact person is asymptomatic for 21 days after exposure, he released the follow‐up.
Role of Contact Monitors
Review contacts for monitoring and tracing to ensure clear information is available
Visit the homes of listed contacts daily for observation for 21 consecutive days
Report symptomatic cases to supervisor and/or alert coordinator for further management
Review and exclude contacts that have completed 21 days
Submit daily reports about contacts to supervisors
Sensitize communities about referral and denial
Role of Alert Coordinator
Receives and logs in alerts in the alert management database
Disburses response teams for alerts that require immediate action
Presents a daily report of all alerts received and their status to the surveillance meeting
Coordinates with logistics team to ensure response teams are able to do their work
8|EVD Interim Guideline, EPHI Sept 2014 Receive, synthesize daily reports from Supervisors
Role of Woreda supervisor
list all contacts to probable and confirmed cases using a Contact listing form
What Information is required for contact tracing?
Laboratory Result
Total number of contacts listed using the contact listing form
Total number of contacts seen daily
Contacts with symptoms by writing “Y” to the symptoms and immediately reporting to the
supervisor.
3.4 Rumors Verification
Rumours of EVD should be treated like real incidents and require urgent verification.
There may be rumors of people dying with haemorrhagic symptoms.
There may be an abnormal and unexpected increase in mortality in a certain area, particularly
in members of the same family or one village.
Numerous health staff have fallen sick or died.
Rumours about EVD can reach the surveillance system by different routes:
By the community to the Health extension worker during their visit or Health promotion
activities.
Spontaneously by the community member to anybody working in an area or their relative,
Media can report EVD cases or deaths.
As information may be numerous and the right information needs to be gathered before the rumour
verification team will go to see the case. Verify if the symptoms fit in the case definition, and make
sure that relevant information is noted before the verification team goes: e.g. the name of the
suspected case, name of the informant, Gott, Kebele, symptoms and contact history.
If a patient died at home, a medical person should take the clinical history from the family. If there is
a suspicion that the person could have died from Ebola, then the burial team needs to be alarmed to
perform safe burial practices.
Activities:
Each suspect needs to be checked by a medical person that decides if it is a real suspected
case and needs to be taken to the Ebola quarantine and isolation ward.
A notification form should be filled in for each rumour (Annex 1). All rumours including the
outcome should be registered in a Rumour Registration Book.
If the rumour case is identified as a suspect case, then the patient needs to be transported to
the Ebola quarantine unit for assessment and possibly sample taking and admission. The
suspected case should not be in contact with anybody until the ambulance team arrives.
As many of the rumour cases might be treatable to common illness, it is advised that always
take drugs with you and you need to rule out other treatable diseases/conditions e.g. anti‐
malarial, antibiotics and paracetamol.
9|EVD Interim Guideline, EPHI Sept 2014 Whenever you go to verify a rumour take with you at least 3 full PPE clothing with you: for the
medical person, the sprayer and 1 spare.
Supplies for Rumor Investigating Team
The following items must be carried in the vehicle. Verify the presence of all items listed in the
following checklist before starting work.
Table 3: Items that are required by rumour investigating teams
Item Quantity per person (take spare items for 1
person with you)
Protective Equipment
Plastic aprons 1
Goggles 1
Coveralls 1
Head covers 1
Masks 1
Examination gloves (box at least half full) 1
Rubber cleaning gloves 1 pair
Other equipment Total quantity for the team
10-litre spraying machine filled with 0.5% chlorine solution 1
1-litre hand-sprayer filled with 0.05% chlorine solution 1
Plastic sheeting 3m-3m 1
Thermometer 2
Plastic rubbish bags 4
Hand soap 1 bar
HTH granules and 1 measuring spoon 1 kg
Bucket with lid to hold re-usable protective items after use 1
Guideline for preparing chlorine solutions 1
Tape 1 roll
Medication
Anti-malarial: Coartem, oral quinine (pregnant ladies), etc.
Oral antibiotics: Ciprofloxacin, amoxicillin, etc.
Paracetamol: adults and children
Oral Rehydration Solution
3.5 Transporting a Suspected Case
When a suspect case is identified he/she must be transferred to the designated Ebola quarantine or
isolation ward.
To prevent contamination and spreading of infection, patients need to be transported in a safe way. A
pick‐up car with a closed (or open) back is the most preferred and practical to use:
Patients can be transported separately from the transporting staff
Patient is not visible during transport.
The outside is easy to disinfect.
The decision to take a person to Ebola quarantine ward often leads to highly emotional and tense
situations. Communication about the reasons and the procedures to the family and the community is
extremely important to avoid misunderstandings and mistrust.
10 | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 4Activities
Transportation of suspect cases to the Ebola treatment unit in a safe way.
Spraying of the place where the patient was accommodated.
Spraying of the back of the pick up where the patient was seated
A transport team should be trained, a driver, medical personnel two sprayers are the minimum team
members. They should take 5 PPE with them: 1 for medical person, 2 sprayers, 1 for the caretaker and
1 spare one.
Procedures when transporting the patient to Ebola treatment unit
Take the following items:
2 spraying machines: one for the sprayer dressed up and one for the sprayer undressed.
A mattress with plastic cover to put at the back of the pick up where the patient can lay or sit
on during the transport.
Take stretcher to transport patient to the car and from the car to the Ebola ward in case the
patient can't walk.
Something that is easy to disinfect on which the patient can step to facilitate to step into the
back of the car if the patient can walk.
A bucket with a small amount of a prepared 0.5% solution can be taken at the back of the car in
case there is a history of vomiting.
Dressing:
The driver and the health promoter should not be close to the patient and don't need to put
on PPE protective clothes. They should be dressed in normal clothes to be as 'normal' and
accessible for the population as possible. Explanation will be given to the community about
the different steps.
Transporting Patient:
One caregiver can be allowed to support the patient during the transport and should stay on
the back of the car with the patient. This person needs to wear protective clothes for
caretakers.
If the patient is mobile and can walk alone: The patient will be instructed to take place in the
back of the pickup. There is no need for the Rumour verification team to dress up if the
patient will not be touched and they keep a distance. When touching anything touched by the
patient, for example when closing the back of the pick‐up, examination gloves should be used
and these should be sprayed before removal and disposed of safely
If the patient is too weak to walk and needs to be transported with the stretcher: Two people
should get dressed up, put the patient on the stretcher and put in the back of the car,
together with the caretaker. Dressing and undressing should take place in front of the
community in a transparent way. If the patient is heavy, more people need to dress up.
Spraying of the house:
The house where the patient lived when he/she was sick needs to be sprayed. The ambulance
team can spray the house before transporting the patient to the Ebola treatment unit or the
burial/spraying team can be called. If the house can't be sprayed immediately then the door of
the house needs to be locked and no one is allowed to enter the house until the arrival of the
Spraying Team. It is advisable to spray the houses of all suspects immediately.
11 | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 4Arrival at the Ebola treatment unit;
The ambulance team should inform the Ebola treatment unit that they will arrive with a
patient.
The pick‐up should drive up to the patient's entrance of the Ebola ward.
The back of the pick‐up, the mattress, the bucket (if unused), and other items used need to be
properly disinfected with a 0.5% chlorine solution.
4. Outbreak Investigation, Sample Collection and Shipment
4.1 Outbreak Investigation
It is mandatory to establish Ebola Rapid Response Team (ERRT) members at every level to
conduct an investigation of reported Ebola Virus disease. Different experts can be identified
and trained. The RRT should include:
An Epidemiologist
A clinician
A laboratory technician
Environmental health specialist,
Public health officer
A representative of the local health authority,
More professionals based on the type of the PHE.
Partner experts from WHO or Centre for Disease Control (CDC), MSF and others can join to
assist the outbreak investigation.
Before the deployment of the RRTs, all the members of the RRT should be briefed on the
situation, the roles and responsibilities they are expected to play, means, time and frequency
of communication etc. There is a need to assign clear leadership role to one of the team
member based on their level of expertise. Begin the investigation in the most affected places.
Avail relevant resources that are required during the field activity such as,
Different formats (case based formats, line list, outbreak reporting formats)
This guideline and other relevant guidelines and reading materials
Supplies for collecting lab specimens
Supplies that are required for the investigation,
Infection prevention equipment such as personal protective equipment (PPE)
Laptop and wireless network for report writing and communicating reports,
Communication means (Mobile phone, Sat Phone, ‐‐‐) with communication cost if
necessary.
12 | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 4The RRT should be sent as quickly as possible to investigate; the team must have all materials
and equipment necessary for safely carrying out an assessment: examining patients,
collecting samples, and packaging and transporting the samples according to standard.
4.2 Confirmation of Diagnosis by Laboratory: Collection of Specimen and Shipment
(SOP on Lab collection and shipment)
13 | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 4III. CASE MANAGEMENT OF PATIENTS
1. Principles for Clinical Case Management
Patient safety in hospital is a fundamental right that must be guaranteed to all hospital
patients.
Nursing care staff must make the quality of reception, treatment, and care a priority.
Hospital staff must offer psychological support to patients and their families.
Patients and their families have a right to transparent, clear, understandable,
accessible, and reliable information.
Each medical intervention requires the free and informed consent of the patient.
Consent may be given in writing or orally
In the framework of biomedical research, consent forms must be written in the
national language. If the person is unable to give consent (e.g. if they are underage),
then the free and informed consent of a parent or legal guardian is required. If the
patient is illiterate, then a third party may act as witness.
The patient’s beliefs and religion must be respected.
The patient’s right to privacy and confidentiality must be upheld.
Patients and their families must be given the opportunity to participate in health care
decisions that affect them.
2. Set Up and Organization of the Ebola Treatment Center
The setup of the Ebola treatment center should allow activities to be performed in an easy manner with a
clear, rational movement and circulation of people and materials. Minimizing complexity, confusion and
physical exercise contributes to create a safe working environment.
2.1 Location
A single Ebola treatment center is the easiest to manage in terms of training, human resources and
logistics. However, there may be circumstances that require 2 or more settings.
The location of the Ebola should be:
As close as possible to the epicenter of the outbreak to minimize movements,
Easily accessible by cars (ambulance, material, water trucking, etc.),
At a strategic point to have sufficient water supply available,
Spacious to allow adequate space for all activities in the center.
2.2 Buildings / Structures
If there is an isolation area already in use, this can be improved for further use, or a new isolation area
can be built. Existing health structures or other buildings can be used. If no appropriate buildings are
available tent structures can be used, however good infection control will be difficult, and tents can
become extremely hot unless sheltered from the sun.
14 | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 4To avoid cross infection, suspected, porbable and confirmed cases need to be accommodated in
different rooms or buildings.
Other important issues are:
Beds need to be at least 1 meter separated to ensure privacy and prevent transmission of the
virus.
Wards/patient rooms should have a good ventilation to reduce heat and humidity and to
evacuate chlorine gas.
Use of air‐ conditioner or ventilator is not recommended.
Mosquito net use is not recommendable due the disinfection procedures, but mosquito
screening and insect traps can be installed on windows instead.
2.3 Risk Zones
There are 3 different risk areas in the ebola treatment centers (Isolation Centers) according to their
level of risk of contamination:
A. High‐risk zone
This area is where:
Care for suspected, probable and confirmed patients take plac,
Bodies of deceased patient prepared for burial and temporarly stored
Launderying of contaminated clothes carried out.
Waste materials burried or burned.
Laterine and shower for the patients built.
All waste from Low‐risk zone is transferred to the High‐risk zone for disposal.
High‐risk zones outside the isolation facilities may include:
Patient’s and deceased patient’s houses.
Morgues.
Medical laboratories and operating theatres.
Traditional health services where by cases visited.
Contamination:
The zone is highly contaminated and everything in this area is considered as being contaminated
including buildings, personal belongings, paperwork, patients and staff (prior to disinfection and
removal of PPE). All materials being used in high‐risk must stay in high‐risk zone.
Clothing:
All the staff entering this area should be dressed in full PPE (Scrub suit, coveralls, goggle or face
shield, face mask, gloves, boots and apron) and adapted PPE for visitors is mandatory. Patients
are not expected to wear PPE and can be admitted in normal clothes.
People:
Only patients, designated staff and authorized visitors are allowed to inter inside the high‐risk
zone.
B. Low‐risk zone
15 | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 4This area is where:
Dressing of full PPE takes place.
Laundarying of scrub suits, apron, boots, heavy duty gloves done
Store of supplies situated.
Doctors’ room located.
Contamination:
In principle no infectious material should remain, however there is real potential for
contamination to occur due to uncontrolled movement of contaminated people or material from
high riks zone.
Clothing:
All people entering the Low‐risk zone change into scrub suits, gloves and boots.
People:
Medical staff, cleaning staff, water/sanitation and logistic staff, etc.
C. No‐risk zone (Outside the Ebola risk zones)
No infectious material should be present outside the isolation area, but in an epidemic
situation infectious material or persons can be anywhere.
General universal precautions to reduce EVD in health settings should be in place.
There is no ‘no‐risk zone’ in an EVD outbreak.
2.4 Activities and Facilities in the Different Risk Zones
Different activities and facilities are required inside the different risk zones in the Ebola treatment
unit.
A. High Risk Zone
Ward or rooms for suspect patients.
Ward or rooms for confirmed patients.
Ward or rooms or space for probable patients.
The following facilities should be available in suspected, probable and confirmed areas (i.e. 1
facility is needed in each area):
Latrines and bathing facilities
Small store for medication and material.
Water collection points (e.g. water taps)
Water point with 40 liter water buckets: 1 bucket for 0.5% chlorine solution and 1 bucket for
0.05% chlorine solutions
Potable water point for patients: 40 liter water bucket or tap
Hand washing point for patients
Laundry area
16 | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 4 Shaded area for patients. (If possible close to outside fence to allow communication with
relatives/friends that are outside the isolation facilities, but with double fencing or enough
space to avoid physical contact or droplets transmission).
One waste zone with burning area, sharps pit and organic waste pit. (Do not use existing
ones, as they can’t be reused after the outbreak is declared over.)
One Morgue.
Spare building for possible supplementary facilities (delivery, paediatrics, recovery zone etc.)
B. Low‐risk zone
Laundry and drying area.
Area for the preparation of chlorine solutions.
Doctor’s room: resting area and part of medical file papers will be stored here.
Small pharmacy and store.
Changing room to enter and exit Low‐risk zone.
Changing room to enter and exit High‐risk zone.
C. No‐risk zone (Outside the Ebola risk zones)
Kitchen for patients. (E.g. kitchen from hospital can be used.)
Latrine and shower for staff.
Psychological debriefing room for staff and patients
2.5 Fencing
Fencing is important to mark the different risk zones. By clearly indicated borders between the risk
zones the staffs is aware of entering a different risk level.
A fence should be put around the whole isolation facility to mark the borders between
outside the isolation facility and inside the isolation facility. Use mesh fencing for
transparency.
Physically separate High‐risk and Low‐risk zones in the Ebola treatment unit by fencing or
using existing walls to prevent uncontrolled movements between the zones.
Different latrines, bathing facilities and stores should be created for suspected and confirmed
patients to prevent cross infection between confirmed patients to negative suspect cases
waiting for the lab results. Separation needs to be well indicated and understandable to
prevent confusion amongst the patients and the staff.
2.6 Layout of Ebola Treatment Unit
The Ebola treatment unit layout should fit to the list of the facilities and functions the different risk
zones should serve. Accordingly the ideal lay out of the unit should look like the figure in Annex 5. The
shape can change depending on the existing situation of the space.
Entrance/exit points and disinfection
Numbers of entrance/exit points should be limited to be able to control people going in and
out and to ensure a proper disinfection.
17 | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 4 Guards and disinfection points are needed at all entrance/exit points and the points need to
be well accessible for cars.
One entry/exit for entering the Low‐risk area for staff and caregivers.
Hand washing and shoe spraying with 0.05% chlorine solution at entry and exit to avoid taking
contamination into or outside the low risk area.
Two entries/exits for entering/leaving the High‐risk area: One for staff and caregivers (via the
Low‐risk area) with sprayer and disinfection area and one for patients directly
entering/leaving the suspect area with sprayer/guard for disinfection when discharged
patient leaves.
One separate exit for dead bodies close to mortuary.
Changing Rooms
Two different changing rooms are necessary (Example of layout of changing rooms See
Annex 6 and 7)
Changing room 1
Located at the entrance to the Low‐risk zone to take off normal clothing and change into
basic protective clothing when entering the Low‐risk zone.
Also used for take‐off basic protective clothing and change into normal clothing when leaving
the Low‐risk zone.
Important necessities for changing room 1:
Clean scrub suits, boots and gloves in sufficient quantities and sizes available.
Buckets or boxes to put in dirty clothes when changing.
A division for men and women to change clothes.
Shelves or hangers to leave normal (street) clothing.
Changing room 2
Located at the entrance to the High‐risk zone to put on and take off the additional PPE
required in the High‐risk zone.
Important necessities for changing room 2:
Staff entering clean and staff leaving dirty or potentially contaminated the High‐risk area
should not interfere with each other.
Entry path should be separated from the exit path to prevent cross contamination between
‘dirty’ people coming from the High‐risk area and ‘clean’ people from the Low‐risk area.
The border between the different risk zones should be clearly indicated.
Sufficient PPE with gloves in different seizes available.
18 | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 4 Mirrors and adequate lighting to check protective gear. When dressing best is to dress in
pairs to be able to check each other when dressing.
Disinfection point for staff leaving the High‐risk area with sprayer and buckets (bowl) with
0.5% and 0.05% chlorine solution and clean water to wipe of the chlorine of the goggles.
2.7 Patient screening area
Screening of patients should be done in No‐Risk zone
The health worker needs to dress in glove, face mask and eye goggle
Keep a distance of at least 1 meter from the patient
The patient has to face away from doctor at 90 degrees
Take temperature of the patient from behind
3. Patient Care at Ebola Treatment Unit
3.1 Medical Staff
Medical and nursing care should be provided 24 hrs per day and 7 day per week.
Organize 8 hrs shifts. Adequate rest needs to be taken after shifts,
During each shift 2‐3 breaks need to be taken. The staff should undress and go out of the High‐
risk area when having a break.
4 Teams can be formed: 1 team for each shift and 1 off.
Each team should contain medical doctor or Health officer and 2‐4 nurses, depending on the
amount of patients admitted and the available human resources. It is advisable to work in
couples for a good collaboration and to supervise each other.
A medical doctor should supervise and train the staff.
3.2 Admissions
Admission should be possible 24 hrs around the clock. All identified suspect or probable cases need to
be admitted in the suspected or probable area until laboratory results are known or clinical discharge
criteria are reached (in absence of a lab).
The following activities need to be done on admission:
Explanation needs to be given to the patient and the patient's attendant about the reason of
admission, the procedures and rules in the Ebola treatment unit, the location of toilets and
showers and the visiting hours.
Ideally an information paper for patients and one for the patient's attendant should be read
and explained.
All material will be provided from inside the Ebola ward to the patients. Items given from
outside to the patient may need to be destroyed and this should be well explained to the
patient and relatives. Under supervision it is allowed to bring food from home to the patient.
A bed in the suspected area needs to be prepared and indicated to the patient.
Different items need to be given to the patient like mattress, blanket, cup, plate, soap, etc.
These items must not be shared in between patients.
Creation of a personal medical file containing the investigation form.
Observation sheet
19 | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 4You can also read
