Monday, October 20, 2014

CDC Announces Stricter PPE Recommendations For Ebola




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

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

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


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

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



CDC Fact Sheet:

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

The Centers for Disease Control and Prevention is tightening previous infection control guidance for healthcare workers caring for patients with Ebola, to ensure there is no ambiguity.  The guidance focuses on specific personal protective equipment (PPE) health care workers should use and offers detailed step by step instructions for how to put the equipment on and take it off safely. 

Recent experience from safely treating patients with Ebola at Emory University Hospital, Nebraska Medical Center and National Institutes of Health Clinical Center are reflected in the guidance.

The enhanced guidance is centered on three principles:

  • All healthcare workers undergo rigorous training and are practiced and competent with PPE, including taking it on and off in a systemic manner
  • No skin exposure when PPE is worn
  • All workers are supervised by a trained monitor who watches each worker taking PPE on and off. 

All patients treated at Emory University Hospital, Nebraska Medical Center and the NIH Clinical Center  have followed the three principles. None of the workers at these facilities have contracted the illness.

Principle #1: Rigorous and repeated training

Focusing only on PPE gives a false sense of security of safe care and worker safety. Training is a critical aspect of ensuring infection control. Facilities need to ensure all healthcare providers practice numerous times to make sure they understand how to appropriately use the equipment, especially in the step by step donning and doffing of PPE. CDC and partners will ramp up training offerings for healthcare personnel across the country to reiterate all the aspects of safe care recommendations.  

Principle #2: No skin exposure when PPE is worn

Given the intensive and invasive care that US hospitals provide for Ebola patients, the tightened guidelines are more directive in recommending no skin exposure when PPE is worn. 

CDC is recommending all of the same PPE included in the August 1, 2014 guidance, with the addition of coveralls and single-use, disposable hoods.  Goggles are no longer recommended as they may not provide complete skin coverage in comparison to a single use disposable full face shield.  Additionally, goggles are not disposable, may fog after extended use, and healthcare workers may be tempted to manipulate them with contaminated gloved hands.  PPE recommended for U.S. healthcare workers caring for patients with Ebola includes:

  • Double gloves
  • Boot covers that are waterproof and go to at least mid-calf or leg covers
  • Single use fluid resistant or imperable gown that extends to at least mid-calf  or coverall without intergraded hood.
  • Respirators, including either N95 respirators or powered air purifying respirator (PAPR)
  • Single-use, full-face shield that is disposable
  • Surgical hoods to ensure complete coverage of the head and neck
  • Apron that is waterproof and covers the torso to the level of the mid-calf should be used if Ebola patients have vomiting or diarrhea

The guidance describes different options for combining PPE to allow a facility to select PPE for their protocols based on availability, healthcare personnel familiarity, comfort and preference while continuing to provide a standardized, high level of protection for healthcare personnel.

The guidance includes having:

  • Two specific, recommended PPE options for facilities to choose from. Both options provide equivalent protection if worn, donned and doffed correctly.
  • Designated areas for putting on and taking off PPE. Facilities should ensure that space and lay-out allows for clear separation between clean and potentially contaminated areas
  • Trained observer to monitor PPE use and safe removal
  • Step-by-step PPE removal instructions that include:
    • Disinfecting visibly contaminated PPE using an EPA-registered disinfectant wipe prior to taking off equipment
  • Disinfection of gloved hands using either an EPA-registered disinfectant wipe or alcohol-based hand rub between steps of taking off PPE.

Principle #3: Trained monitor

CDC is recommending a trained monitor actively observe and supervise each worker taking PPE on and off. This is to ensure each worker follows the step by step processes, especially to disinfect visibly contaminated PPE. The trained monitor can spot any missteps in real-time and immediately address.

PPE is Only One Aspect of Infection Control

It is critical to focus on other prevention activities to halt the spread of Ebola in healthcare settings, including:

  • Prompt screening and triage of potential patients
  • Designated site managers to ensure proper implementation of precautions
  • Limiting personnel in the isolation room
  • Effective environmental cleaning

Think Ebola and Care Carefully

The CDC reminds health care workers to “Think Ebola” and to “Care Carefully.” Health care workers should take a detailed travel and exposure history with patients who exhibit fever, severe headache, muscle pain, weakness, diarrhea, vomiting, stomach pain, unexplained hemorrhage. If the patient is under investigation for Ebola, health care workers should activate the hospital preparedness plan for Ebola, isolate the patient in a separate room with a private bathroom, and to ensure standardized protocols are in place for PPE use and disposal. Health care workers should not have physical contact with the patient without putting on appropriate PPE.     

CDC’s Guidance for U.S. Healthcare Settings is Similar to MSF’s (Doctors Without Borders) Guidance

Both CDC’s and MSF’s guidance focuses on:

  • Protecting skin and mucous membranes from all exposures to blood and body fluids during patient care
  • Meticulous, systematic strategy for putting on and taking off PPE to avoid contamination and to ensure correct usage of PPE
  • Use of oversight and observers to ensure processes are followed
  • Disinfection of PPE prior to taking off: CDC recommends disinfecting visibly contaminated PPE using an EPA-registered disinfectant wipe prior to taking off equipment.  Additionally, CDC recommends disinfection of gloved hands using either an EPA-registered disinfectant wipe or alcohol-based hand rub between steps of taking off PPE. Due to differences in the U.S. healthcare system and West African healthcare settings, MSF’s guidance recommends spraying as a method for PPE disinfection rather than disinfectant wipes. 

Five Pillars of Safety

CDC reminds all employers and healthcare workers that PPE is only one aspect of infection control and providing safe care to patients with Ebola. Other aspects include five pillars of safety:

  • Facility leadership has responsibility to provide resources and support for implementation of effective prevention precautions.  Management should maintain a culture of worker safety in which appropriate PPE is available and correctly maintained, and workers are provided with appropriate training. 
  • Designated on-site Ebola site manager responsible for oversight of implementing precautions for healthcare personnel and patient safety in the healthcare facility.
  • Clear, standardized procedures where facilities choose one of two options and have a back-up plan in case supplies are not available.
  • Trained healthcare personnel: facilities need to ensure all healthcare providers practice numerous times to make sure they understand how to appropriately use the equipment.
  • Oversight of practices are critical to ensuring that implementation protocols are done accurately, and any error in putting on or taking off PPE is identified in real-time, corrected and addressed, in case  potential exposure occurred.

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



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


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

Saudi MOH Statement On Recent MERS Cases In Taif


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


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



Health Minister Reviews Response to MERS-CoV in Taif

20 October 2014

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

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

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

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

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

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

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

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

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

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

Please visit for recommendations on how to prevent MERS-CoV infection and the latest information about confirmed cases in the Kingdom of Saudi Arabia.

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


Credit FEMA


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


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


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




Could it be Ebola?[PDF - 1 page]


When Caring for Suspect or Confirmed Patients with Ebola

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

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

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

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

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

General Information

Saudi Arabia – A MERS Surge?


Credit ECDC MERS-CoV Epidemiological Update


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Roughly six weeks ago, after a relatively quiet July and August, we began to see a slow uptick in the number of MERS-CoV infections being reported out of Saudi Arabia.  While the numbers remain modest – even compared to the same time last year – the clustering in Taif east of  Mecca prior to the Hajj is concerning.


Local officials have publically been denying charges of a serious outbreak in the Taif region (see FluTrackers thread Saudi Arabia - Taif government denies coronavirus MERS epidemic in hospitals),  but the following line list put together by Sharon Sanders shows 13 cases in Taif over the past 6 weeks.

Recent MoH announced infections in Taif:

September 2014:
740) #861 - Male, 43, Saudi, hospitalized in ICU - Taif, Saudi Arabia
744) #865 - Male, 27, Saudi, hospitalized in ward - Taif, Saudi Arabia
745) #866 - Male, 65, Saudi, in stable condition - Taif, Saudi Arabia
763) #884 - Male, 37, health care worker, hospitalized in ward - Taif, Saudi Arabia
765) #886 - Male, 40, health care worker, Expat, hospitalized in ICU - Taif, Saudi Arabia
October 2014:
769) #890 - Male, 60, Saudi, hospitalized in ICU, camel exposure - Taif, Saudi Arabia
770) #891 - Male, 69, Saudi, hospitalized in ICU - Taif, Saudi Arabia
772) #893 - Male, 77, Saudi, hospitalized in ICU - Taif, Saudi Arabia
774) #896 - Male, 70, Saudi, hospitalized in ICU - Taif, Saudi Arabia
777) #899 - Female, 42, Expat, health care worker, hospitalized in ward - Taif, Saudi Arabia
778) #900 - Male, 60, Saudi, died - Taif, Saudi Arabia Death
780) #902 - Male, 66, Saudi, hospitalized in ICU - Taif, Saudi Arabia
781) #903 - Male, 65, Saudi, hospitalized in ICU - Taif, Saudi Arabia

These cases were pulled from FluTracker’s detailed 2012-2014 Case List of MoH/WHO Novel Coronavirus MERS nCoV Announced Cases.


While Arabic print media (and even Arabic language social media) has been largely quiet about MERS the past few months  – replaced with stories about the Hajj and Africa’s Ebola threat – over the past couple of days Arabic twitter chatter on MERS has taken off once again.


Unlike last spring, when the role of camels in transmitting the virus was often dismissed (see Saudi MOA Spokesman: Camel Link Unproven), `camels as vectors’ appears to be the newly adopted meme in the media, to the exclusion of any talk of nosocomial or community transmission.


Last September we saw the KSA MOH Reiterates Camel Warnings On MERS, and while the exact role of camels in the transmission of MERS to humans has yet to be established, increasingly camels are being viewed as a  likely zoonotic source of the virus (see EID Journal: Replication & Shedding Of MERS-CoV In Inoculated Camels).


Although certainly a factor, camel-to-human transmission is unlikely to be the cause of the bulk of cases being reported.  A number of cases are reportedly Health care workers, and hospitals have been a frequent amplifying center for MERS outbreaks.


After saying little about the MERS situation in Saudi Arabia for several weeks, yesterday Health Minister Faqih visited King Faisal hospital, and today the media are carrying an obvious `photo opportunity’ along with  warnings  that `additional cases’ might be expected in Taif.



Health Minister: No cure for "Corona" .. and we expect other injuries in Taif (Photos)

Designated Health Minister Adel Mohamed Fakih, the citizens and residents of Ta'if should take necessary preventive actions on dealing directly with the camels, to protect themselves from the virus "Corona".

This came during his visit to King Abdul Aziz specialist hospital, the King Faisal Hospital in the province, yesterday. The current infection rates in Taif refers to the possibility of new cases in the next period.

He said: "maybe we can uproot the coronavirus in the near perspective because there is no cure or vaccine yet, but the Health Ministry must do whatever they can and all its potential for treating patients and health practitioners and community protection from HIV infection."

In the same context the command and control center of the Ministry of health a number of immediate actions to curb the infection after recording nine cases of "Corona", including follow-up to the Ministry of public health experts for all close contacts of patients infected with HIV "SK" in Taif, and transfer any cases of Corona to King Faisal Hospital, transfer unit mobile laboratories to Taif, enabling doctors to obtain the results of virus detection in cases of suspected virus "SK" in record time not exceeding 6 hours.

Meanwhile Arabic twitter chatter is rife with speculation that there are several more cases about to be announced.

Stay tuned.

Sunday, October 19, 2014

Ohio Daily Ebola Contact Report – Oct 19th



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Although the primary Ebola focus in the United States has focused on Dallas, Texas - public health authorities in Ohio are also managing more than 150 contacts (close and otherwise) of Texas nurse Amber Vinson who visited family shortly before being diagnosed with Ebola.

Most of these contacts are considered casual/low-risk, and so only three are `quarantined’.


Others must either have their temperatures taken twice daily (Tier 2A) or self monitor their temperatures (Tiers 2B and 3).  Some travel restrictions are imposed.

Earlier today, the number of contacts was reported as only 29, but a new update indicates 153 total contacts.  This number could change as the epidemiological investigation continues.


What is of particular interest, beyond the numbers, are how contacts are categorized.


Yesterday the State of Ohio – which had already announced Stricter Ebola Quarantine Protocols just two days ago, decided to up the ante just a bit.



New Restrictions on Travel Designed To Ensure Health Monitoring Compliance, Protect Travelers

COLUMBUS – Today the Ohio Department of Health (ODH) again strengthened the state’s recommended Ebola quarantine protocols to limit travel of people currently required to have their health condition monitored daily by a local health department and those required to report their health condition themselves to a local health department.

The new Ebola quarantine recommendations mean:

  • Ohioans required to have a public health official monitor their health condition daily would be prohibited from leaving their health department’s jurisdiction unless the health department jurisdiction to which they are travelling agrees to assume that daily monitoring responsibility. If that agreement is not reached, the individual cannot travel and must keep their daily monitoring appointments in their home health department jurisdiction.
  • Ohioans under self-monitoring and reporting requirements cannot leave the United States due to the inability to track them down in the event they fail to meet their daily reporting requirements.

“As we’ve seen, travel is a potential problem. It’s why the people of Ohio are dealing with the situation we have right now. We don’t want to take the slightest chance for this disease to potentially spread, we don’t want people in other places to have to deal with what we’re dealing with and we don’t want potentially sick Ohioans to go beyond the reach of the good care we know we have here at home in the unlikely event that they get sick,” said Dr. Mary DiOrio, state epidemiologist and interim chief of the ODH Bureau of Prevention and Health Promotion. “We’re taking an aggressive approach, no doubt about it, but it’s just common sense. Some might criticize us for being too aggressive, but we’re comfortable taking that criticism.”

Ohio’s revised quarantine protocols can be viewed here


All individuals shall be given written notice of their exposure category and the intervention and sign acknowledgement of the notice. The notice shall also apprise the individual of their responsibility to notify any first responder they come in contact with of their exposure category and intervention