​Background

On September 20, 2022, Uganda declared an outbreak of EVD caused by Sudan virus (species Sudan ebolavirus). On October 7, 2022, the California Department of Public Health (CDPH) distributed a Health Alert summarizing the current situation and guiding clinicians to suspect EVD in a patient who has signs and symptoms consistent with EVD (fever, severe headache, muscle pain, weakness, fatigue, vomiting, diarrhea, stomach pain, and unexplained bleeding) and an epidemiological risk factor (e.g., travel to affected areas in Uganda) within 21 days before the onset of symptoms. If there is suspicion for EVD, healthcare providers should immediately take EVD specific infection control precautions and notify their local health department (LHD).

Guidance for Frontline Healthcare Facilities

Although CDC has indicated the risk of Ebola importation to the United States is currently low, all California frontline healthcare facilities should prepare to be able to:

• Identify and triage persons with relevant Ebola exposure history and signs or symptoms, and immediately
• Isolate the patient and ensure appropriate steps are taken to protect staff caring for the patient, and immediately
• Inform the facility infection control program, LHD, and your respective district office.

The LHD and CDPH will work together to determine if the patient is a patient under investigation (PUI) warranting testing for Ebola, and if so, arrange a transfer as quickly as possible to a facility that can provide further Ebola assessment. However, transfer may take up to 12-24 hours, so all facilities should have plans to manage a PUI for 24 hours as they await transfer.

Frontline healthcare facilities should prepare now to identify, isolate and inform their LHD regarding an Ebola PUI:

• Develop or re-establish Ebola-specific policies and procedures, including roles and points of contact within the facility and with the LHD.
• Implement routine triage screening for international travel for all patients presenting with potentially infectious symptoms.
• Develop processes that minimize the time in triage from identification to isolation in a private room with a dedicated bathroom or commode for any person who should be evaluated for whether they meet PUI criteria. 
• Determine a method for performing detailed patient/family interviews in coordination with public health to rapidly clarify a patient's PUI status with minimal contact between healthcare personnel and the patient, such as via telephone communication while the healthcare personnel (HCP) remains outside the isolation room.
• Select and standardize the personal protective equipment (PPE) ensemble(s) the facility will use for an Ebola PUI in accordance with CDPH PPE guidance. It is unlikely that frontline healthcare facilities will be required to provide prolonged care (>12–24 hours) for a severely ill patient at high risk for EVD. Accordingly, most patients can be cared for in these hospitals using PPE in CDPH's guidance for a clinically stable PUI.
• Ensure your facility has enough appropriate PPE supplies to care for PUI while awaiting transfer.
• Identify and train a small group of volunteer staff ahead of time who will care for a PUI and provide repeated training and practice, especially for doffing PPE.  
• Conduct a first-patient drill or exercise to review and practice procedures and identify potential gaps in readiness.
• Develop facility-specific protocols for safe handling of Ebola-related medical waste. CDPH has developed interim guidelines for EVD medical waste management. The interim guidelines can be found at the CDPH Medical Waste Management Program Website.

Frontline healthcare facilities should prioritize planning for the most likely scenario, not the most extreme; for example, a clinically stable patient presenting with fever and travel in Uganda but without an epidemiologic risk factor or exposure to Ebola. Symptoms of EVD are similar to other illnesses associated with international travel, including malaria, which is the most common cause of undifferentiated fever in returning travelers from sub-Saharan Africa. Because malaria can progress rapidly and severely, early diagnosis and treatment are critical and malaria testing should not be delayed. If public health determines a patient is not a PUI and not being tested for Ebola, the patient can be managed with Standard or Transmission-based Precautions (depending on other suspected diagnoses) while being tested and managed for malaria.

If you have any questions regarding this AFL, please contact the Healthcare Associated Infections Program via email at HAIprogram@cdph.ca.gov.

Sincerely,

Original signed by Cassie Dunham

Cassie Dunham

Deputy Director

Resources:

• CDPH Ebola Information for Healthcare Providers
• CDC Interim Guidance for Preparing Frontline Healthcare Facilities for PUIs for EVD
  
• Ebola Virus Disease Fact Sheet