Ebola Virus Information Page
On March 23, 2014, the Ministry of Health in Guinea notified the World Health Organization (WHO) of a rapidly evolving outbreak of Ebola Virus Disease (EVD). Since then, the outbreak has expanded to include the West African countries of Sierra Leone, Liberia and most recently, a cluster of cases in Nigeria. As of October 27, 2014 the WHO has reported a cumulative total of 13703 suspect and confirmed cases, 7637 laboratory confirmed cases, and 4922 suspected case deaths. For the latest updates on Ebola activity, please visit http://www.cdc.gov/vhf/ebola/index.html.
EVD is an infectious disease caused by the Ebola virus. Symptoms may appear anywhere from 2 to 21 days after exposure and include fever, headache, joint and muscle aches, weakness, diarrhea, vomiting, stomach pain, and abnormal bleeding. It is classified as a viral hemorrhagic fever (VHF) because of the fever and abnormal bleeding. Among the VHFs, Ebola is feared because of its high mortality. There are no specific treatments but supportive therapy can be provided to address bleeding and other complications.
Important facts about Ebola include:
Current science shows that people CANNOT get EVD through the air, food, or water.
Ebola virus is transmitted through direct contact with the blood or bodily fluids of an infected symptomatic person or though exposure to objects (such as needles) that have been contaminated.
Persons are not contagious until they develop symptoms.
Persons at highest risk for EVD include healthcare workers and family and friends of infected patients.
Early identification of cases is crucial.
Effective isolation of patients and appropriate infection control measures applied to any suspect EVD patient would contain any potential spread.
The risk of the spread of EVD in California is extremely low. Our advanced health care system has appropriate protocols in place to prevent the spread of this often deadly disease. While we should be aware of the disease, its symptoms and its potential, it is extremely unlikely that Ebola poses a public health risk to Californians. At the present time, no confirmed cases have been identified in California.
Information on Reporting of Suspect Ebola Patients
The California Department of Public Health (CDPH) works with local health jurisdictions to keep the public safe by preparing for the unlikely event that a traveler returning to California from affected countries is suspected of having Ebola Virus Disease (EVD). An important component of being prepared is early identification and testing of suspect cases and implementation of infection control practices to contain the disease.
The CDPH, in accordance with guidelines from the Centers for Disease Control and Prevention (CDC), advises that healthcare providers in the U.S. should consider Ebola virus infection in patients who meet the case definition for EVD. The CDC guidance is available at: http://www.cdc.gov/vhf/ebola/hcp/case-definition.html.
CDPH has developed an interim case report form, entitled “Viral Hemorrhagic Fever”, available at http://cdph.ca.gov/programs/cder/Documents/CDPH%20Viral%20Hemorrhagic%20Fever%20Case%20Report%20Form.pdf.
Incidents can be reported in CALREDIE under “Viral Hemorrhagic Fever (e.g., Crimean-Congo, Ebola, Lassa and Marburg viruses)”. Jurisdictions not participating in CalREDIE can fax the case report form to (916) 552-8973 or send the report via secure email to firstname.lastname@example.org.
Per Title 17 CCR 2500, EVD and infections with other Viral Hemorrhagic Fevers (VHF) are reportable. All persons suspected of having EVD should be reported immediately to the LHJ.
Information on testing for Ebola virus disease (EVD) in California - Updated October 17, 2014
All testing for EVD in the United States is coordinated by the U.S. Centers for Disease Control and Prevention (CDC). No specimens will be tested without consultation with the appropriate local health department and the California Department of Public Health (CDPH). Testing is available at CDC and several public health laboratories nationwide, including the Los Angeles County Department of Public Health laboratory. All results of EVD testing done at an alternative laboratory must be confirmed at CDC.
CDPH recognizes the urgency of testing for EVD. Important decisions related to patient care, follow up of contacts, and environmental decontamination depend on test results. CDPH will work with CDC to expedite testing as much as possible. Nevertheless, it is important to remember that confirmatory testing by CDC will be done for all tests and may take 1-3 days. It is also important to remember that it may take up to 72 hours following onset of symptoms for enough virus to be present in blood to detect. Thus, while an initial positive test is very useful for management, it may take several days to rule out EVD following an initial negative test.
Health care providers should immediately report suspect EVD patients to their local health department. The local health department will provide assistance with a risk assessment and contact CDPH to discuss testing, if appropriate.
Ebola virus is detected in blood only after onset of symptoms, most notably fever. It may take up to 3 days post-onset of symptoms for the virus to reach detectable levels. Virus is generally detectable by real-time reverse-transcriptase polymerase chain reaction (RT-PCR).
The preferred specimen for Ebola testing at CDC is a minimum volume of 4mL whole blood in a plastic collection tube. Do not submit specimens to CDC in glass containers or in heparinized tubes. Whole blood preserved with EDTA is preferred but whole blood preserved with sodium polyanethol sulfonate (SPS), citrate, or with clot activator is acceptable. Specimens should be immediately stored or transported at 2-8°C or frozen on cold-packs to the CDC.
The CDC “Interim Guidance for Specimen Collection, Transport, Testing and Submission for Persons Under Investigation for Ebola Virus Disease in the United States” was updated on August 26, 2014 and is available at: http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-specimen-collection-submission-patients-suspected-infection-ebola.html. A very useful one page poster summarizing the guidance is available at: http://www.cdc.gov/vhf/ebola/pdf/ebola-lab-guidance.pdf.
Recommendations for specimen collection by staff: Any person collecting specimens from a patient with a case of suspected Ebola virus disease should wear gloves, water-resistant gowns, full face shield or goggles, and masks to cover all of nose and mouth. Additional personal protective equipment (PPE) may be required in certain situations.
Recommendations for laboratory testing by staff: Any person testing specimens from a patient with a suspected case of Ebola virus disease should wear gloves, water-resistant gowns, full face shield or goggles, and masks to cover all of nose and mouth, and as an added precaution use a certified class II Biosafety cabinet or Plexiglass splash guard with PPE to protect skin and mucous membranes. All manufacturer-installed safety features for laboratory instruments should be used.
In certain situations staff may opt to use a higher level of protection, including use of an N95 facemask, particularly if the patient is vomiting or having copious diarrhea at time of specimen collection or if aerosol generating procedures are being conducted during laboratory testing. Risk assessments should be conducted by each laboratory director, biosafety officer, or other responsible personnel to determine the potential for sprays, splashes, or aerosols generated from laboratory procedures. They should adjust, as needed, PPE requirements, practices, and safety equipment controls to protect the laboratorian’s skin, eyes, and mucous membranes.
Specimen Handling, Packaging and Shipping
Specific directions for transport, handling, packaging and shipping of specimens to CDC are outlined in the CDC document referred to above. Additional CDPH guidance for packaging and shipping specimens for Ebola testing can be found at the links below.
Specimens for ruling out Ebola virus infection will likely fall under Category A. The only available courier for shipping Category A and risk group 4 agents (require Biosafety Level 4 handling, such as Ebola virus) in California is World Courier. World Courier is available 24/7 and they can be reached at (516) 354-2600 or (800) 221-6600.
The person doing the shipping at the hospital must be trained and certified by the employer to package and ship in accordance with International Air Transport Association (IATA) and Federal Department of Transportation (DOT) regulations. The person doing the shipping at the hospital can contact their local public health laboratories for packaging and shipping guidance if they are unfamiliar with IATA regulations and training.
Before sending specimens, the case MUST be reported to the local health department and CDPH.
The following two forms must be submitted with the specimen in order for CDC to proceed with testing:
- CDC’s Viral Special Pathogens Branch Specimen Submittal Form available at: http://www.cdc.gov/ncezid/dhcpp/vspb/pdf/specimen-submission.pdf
- CDC DASH form 50-34, available at: http://www.cdc.gov/laboratory/specimen-submission/pdf/form-50-34.pdf
Upon review and approval, local public health laboratories can assist with filling out of these two forms and can provide further guidance on how to arrange for shipment to CDC.
U.S. hospitals can safely manage a patient with EVD by using all recommended isolation and infection control procedures. Standard, contact, and droplet precautions are recommended for management of hospitalized patients with known or suspected EVD. On August 26, 1014, CDC issued the “Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals”, available at http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html. The guidance lists the following recommendations for hospitalized patients with suspect EVD infection:
- Patients should be placed in single patient room (containing a private bathroom) with the door closed.
- All persons entering the patient room should wear at least: gloves, gown (fluid resistant or impermeable), eye protection (goggles or face shield), and facemask.
- Additional PPE, such as double gloving, disposable shoe covers, and leg covering, might be required in situations when copious amounts of blood vomit, feces or other body fluids are present in the environment).
- Perform hand hygiene immediately after removal of PPE.
- Phlebotomy, procedures, and laboratory testing should be limited to the minimum necessary for essential diagnostic evaluation and medical care.
- Aerosol generating procedures (e.g., Bilevel Positive Airway Pressure (BiPAP), bronchoscopy, sputum induction, intubation and extubation, and open suctioning of airways) should be performed in a private room and ideally in an Airborne Infection Isolation Room (AIIR) when feasible. HCP should wear gloves, a gown, disposable shoe covers, and either a face shield that fully covers the front and sides of the face or goggles, and respiratory protection that is at least as protective as a NIOSH certified fit-tested N95 filtering facepiece respirator or higher (e.g., powered air purifying respiratory or elastomeric respirator) during aerosol generating procedures.
Medical Waste Management
This California Department of Public Health (CDPH) document provides both general guidance for Ebola medical waste management based on federal guidelines and standards as well as more specific guidance regarding packaging, labelling and treatment.
CDPH recommends that all healthcare facility Environmental Services personnel and Infection Control staff work together to develop facility-specific protocols for safe handling of Ebola related medical waste.
Ebola medical waste management guidance provided by the federal Centers for Disease Control and Prevention (http://www.cdc.gov/vhf/ebola/hcp/medical-waste-management.html) should be reviewed closely and checked regularly, including appropriate infection control practices (http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html) for the handling and packaging of medical waste.
Packaging for Onsite Treatment
Place waste into a red biohazard bag. Disinfect the waste using CDC guidance, i.e., use a U.S. Environmental Protection Agency (EPA)-registered hospital disinfectant with a label claim for a non-enveloped virus. Tie off the bag, disinfect the exterior of the bag, and place it into a second red bag. Place into a rigid container with a tight-fitting lid. Transport immediately to a dedicated, locked storage area. Do not store this waste in an intermediate storage area.
Do not solidify suction canisters due to aerosolization of the fluids. Do not use reusable suction canister systems. Disinfect the outside of the canister. Place the canister into a red bag, disinfect the exterior, then place into a rigid container with a tight-fitting lid.
Sheets, curtains, pillows, and other linens should also be handled as red bag waste.
Disinfect the rigid, secondary containers and the transport cart.
Be aware that a suspected or known case may generate as much as eight 55-gal drums per day.
Labeling for Treatment
For onsite treatment, label the outside of the rigid container as "Infectious Isolation Waste."
For offsite treatment (see below), label waste as "Infectious Isolation Waste" and "Incineration Only."
For autoclaving onsite:
If storage space becomes an issue, hospitals should use other designated, locked and secured locations within the facility. Hospitals shall notify their LEA or CDPH if they require a temporary variance for storage time requirements.
Packaging for Offsite Treatment
If onsite treatment is not available, your facility may package the waste to be transported to an incinerator. Autoclave efficacy testing has not been completed on triple packaging required by the federal Department of Transportation (http://www.phmsa.dot.gov/pv_obj_cache/pv_obj_id_E7AFD0A1C5DBDDE54BCAAA0A80F9D6898FF50400/filename/suspected_ebola_patient_packaging_guidance_final.pdf) Therefore, the waste must be incinerated. California sends its incinerable waste to Alabama, Maryland, North Dakota, Oklahoma, Utah, and Texas.
Additional information will be provided by CDPH as it becomes available.
On October 7, 2014, the CDC issued updated travel alerts (Level 3) for Guinea (Level 3 Travel notice: Guinea), Sierra Leone (Level 3 Travel notice: Sierra Leone), and Liberia (Level 3 Travel notice: Liberia). All non-essential travel to these three countries should be avoided. Also on October 7, 2014, the CDC downgraded the travel notice for Nigeria from Level 2 to Level 1 (Level 1 Travel notice: Nigeria) because of the decreased risk of Ebola in Nigeria.
- The CDC "Interim Guidance for Monitoring and Movement of Persons with Ebola Virus Disease Exposure", available at http://www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html. This guidance provides a framework for determining the appropriate public health actions based on risk factors and clinical presentation. It also includes criteria for monitoring exposed people and for when movement restrictions may be needed. At this time, CDC is NOT recommending that asymptomatic contacts of EVD patients be quarantined, either in facilities or at home.
Other Available Guidances and Tools
The CDC poster “Sequence for putting on and removing Personal Protective Equipment”, available at: http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf. This updated poster emphasizes guidance to perform hand hygiene between steps if hands become contaminated and immediately after removing all PPE.
There are multiple acceptable sequences and methods for removing PPE. Regardless of the sequence or method used, the important principles are that the most contaminated items are removed first, and that the person removing PPE does not contaminate themselves or others during the process. If two pairs of gloves are used, the most contaminated outer gloves can be removed first and the inner gloves last, in order to limit additional contamination of remaining PPE during removal. Performing hand hygiene between steps, and especially prior to removal of a mask or respirator, can help prevent contaminating one’s eyes and/or mucous membranes while removing the mask or respirator. Healthcare personnel should familiarize themselves and practice methods of donning and removal of any PPE used, in advance of the time when PPE will be needed.
Availability of PPE supplies, hand hygiene, and appropriate waste containers at the point needed can be facilitated by placing any suspect EVD patient in a room with an anteroom. An anteroom is particularly helpful if airborne isolation is implemented and respirators must be removed after leaving the patient room and closing the door. If a room with an anteroom is unavailable, a suspect EVD patient can be placed in a room that is spatially separated from other occupied patient rooms in a low traffic area (e.g., at the end of a hallway), with a designated area for hand hygiene and waste containers outside the room and separate from other patient care areas.
Although the role of the environment in transmission of Ebola virus has not been established, in this guidance CDC recommends higher levels of precaution to reduce the potential risk posed by contaminated surfaces in the patient care environment “given the apparent low infectious dose, potential of high virus titers in the blood of ill patients, and disease severity.” Disinfection products with higher potency than what is normally required for an enveloped virus such as Ebola are therefore now recommended. Such products include Environmental Protection Agency-registered hospital disinfectants with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus), and would also include bleach solution. In addition, the new guidance recommends that porous surfaces that cannot be made single use (e.g., carpeting, upholstered furniture and curtains) should be avoided in rooms of suspect EVD patients, and that potentially contaminated textiles (e.g. linens, non-fluid-impermeable pillows or mattresses, and privacy curtains) be discarded as regulated medical waste.
This CDC guidance recommends PSAPs question callers about risk factors and signs and symptoms of Ebola “when risk of Ebola is elevated in their community (e.g., in the event that patients with confirmed Ebola are identified in the area).” Please note that the risk of Ebola in California communities is not elevated, but Ebola infections might occur in persons in California who recently traveled to West Africa where an Ebola outbreak is occurring. PSAPs should therefore:
Question all callers who report fever (with or without additional symptoms of severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained bleeding) regarding history of travel during the 21 days prior to onset of fever to a region where an Ebola outbreak is occurring.
Question all callers reporting fever and travel history consistent with potential Ebola exposure regarding contact with blood or body fluids of a person with known or suspected Ebola.
CDC also recommends PSAPs alert first responders and EMS personnel prior to arrival on scene regarding any person with possible Ebola. If responding at an airport or other port of entry to the United States, the PSAP should notify the CDC Quarantine Station for the port of entry. Contact information for CDC Quarantine Stations can be accessed at the following link: http://www.cdc.gov/quarantine/quarantinestationcontactlistfull.html.
In addition to CDC recommendations for PPE to be used by EMS personnel responding to a call regarding a person with possible Ebola, EMS personnel may opt to wear a N95 respirator (or equivalent) if the patient is vomiting or having copious diarrhea or bleeding, particularly if occurring in an enclosed and less controlled environment (e.g., moving vehicle). The CDC guidance outlines additional recommendations for EMS transfer of patients with suspected Ebola to healthcare facilities, including inter-facility transport considerations