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What U.S. Hospitals Need to Know to Prepare for Ebola Virus Disease

Moderator:Loretta Jackson Brown

Presenters:Barbara Knust, DVM, MPH and David Kuhar, MD

Date/Time:August 5, 2014 2:00 pm ET

Coordinator:
Welcome and thank you for standing by. All participants are on listen-only until the question and answer session of today’s conference. To ask a question press Star 1 on your touch-tone phone, record your name after the prompt and I will introduce you. This call is being recorded. If you have any objections you may disconnect at this time. I would like to now turn the call over to Ms. Loretta Jackson Brown. Ma’am you may begin.

Loretta Jackson Brown:
Thank you, Jennifer. Good afternoon. I’m Loretta Jackson Brown, and I’m representing the Clinician Outreach and Communication Activity (COCA) with the Healthcare Preparedness Activity at the Centers for Disease Control and Prevention. I’m delighted to welcome you to today’s COCA call, What U.S. Hospitals Need to Know to Prepare for Ebola Virus Disease.

We are pleased to have with us today Dr. Barbara Knust and Dr. David Kuhar here to provide an update on the status of the outbreak in West Africa and steps U.S. healthcare facilities can take to prepare for the possibility of caring for a patient with Ebola virus disease.

There is no continuing education or slides provided for this call. Additional resources for clinicians are available on our COCA website at emergency.cdc.gov/coca. Look under the Ebola Call Webpage.

Our first presenter today is Dr. Barbara Knust. Dr. Knust is an epidemiologist and veterinarian in CDC’s Viral Special Pathogens Branch. She is currently serving as a team lead for the CDC Ebola response. She came to CDC in 2009 as an Epidemic Intelligence Service Officer. She has the deployed to seven different countries and multiple states to study high hazard viruses such as the Ebola virus. Dr. Knust has a Veterinarian Degree from Michigan State University and a Masters in Public Health from the University of Minnesota.

Our second presenter is Dr. David Kuhar. Dr. Kuhar is a Medical Officer in CDC’s Division of Healthcare Quality Promotion. Dr. Kuhar came to CDC in 2010. As part of his role at CDC, he serves as a subject matter expert on emerging pathogens, developed guidelines regarding infection prevention in health care settings, and investigates infectious disease outbreaks in healthcare settings.

Dr. Kuhar received his Doctorate of Medicine from Emory University, completed his residency in internal medicine at New York University Medical Center and an infectious disease fellowship at Mount Sinai Medical Center in New York.

At the end of the presentation, you will have the opportunity to ask the presenters’ questions on the phone dialing Star 1 will put you in the queue for questions. Questions will be limited to clinicians who would like information on clinical guidance related to Ebola virus disease. For those who have media questions please contact CDC Media Relations at 404-639-3286 or send an email to media@cdc.gov.

In addition to today’s presenters, Dr. Nicky Cohen, Global Migration Task Force Science Chief for the Ebola Response will be available to answer questions during the Q and A session of today’s COCA call. At this time please welcome Dr. Knust.

Dr. Barbara Knust:
Yes, hello and good afternoon everyone. This is Barbara Knust speaking. So first I’ll just start with a few brief comments just about the West Africa Ebola outbreak.

We first heard about this outbreak in the end of March of this year with some cases that were reported from Guinea and a few additional cases that had gone over the border into Liberia.

There was an initial response at that time. And we had CDC people out to those countries and the outbreak appeared to be under control in March.

And then in May, the end of May, we had a resurgence of cases. And cases spilled over back into Liberia and also into Sierra Leone.

Last week, we found out about additional case in Nigeria that was a person who had traveled from Liberia.

And so currently this case count is about 1,600 cases that have been reported since the outbreak first began and nearly 900 deaths.

CDC has been sending additional staff and personnel and joining the international effort to respond to this outbreak and we are focusing on the following areas in terms of outbreak response: epidemiology, data management, health education and communication, and also providing assistance with global migration and in discussion about additional involvement as well.

And so, in terms of the overview of Ebola virus disease, first we’ll talk about Ebola and Marburg hemorrhagic fever, which are both kinds of filoviruses.

There is five different species of Ebola virus and one species of Marburg virus. The Ebola virus species that is currently the source of the outbreak in West Africa is called Zaire Ebolavirus, or just Ebola virus for short.

Previous outbreaks of Zaire Ebolavirus were located in Central Africa. This is the first outbreak of Zaire Ebolavirus that’s been found in West Africa and there is only one previous single case of Ebola virus that had occurred in Côte d’Ivoire in 1994.

This is the first time that we’ve seen an Ebola virus outbreak certainly with multiple people involved in this part of the world.

But because of the ecology of the virus, we are not necessarily considering it to be all that unusual because in terms of the filovirus ecology we believe that bats are the most likely reservoir of Ebola viruses.

Marburg virus is very closely related as we had mentioned before. And we know that the reservoir for Marburg virus is the Egyptian fruit bat.

And there’s also...

Loretta Jackson Brown:
Operator are we set?

Coordinator:
Yes. I do apologize. I was trying to find the line that did that.

Loretta Jackson Brown:
Okay. We’ll continue.

Dr. Barbara Knust:
Okay. As I was saying about filovirus ecology, with Ebola we have found some evidence of bats that have had antibodies and some PCR evidence of Ebola RNA in their blood and we continue to do ecological investigations to determine the species that might serve as a reservoir.

Additional animal species that can become infected include nonhuman primates and some small antelope species called a duiker. Nonhuman primates also develop severe hemorrhagic disease.

In terms of zoonotic transmission, which is how outbreaks get their start, people become infected through direct contact either through slaughter or consumption of infected animals. And that can include bats, or primates, or other infected species such as the duiker as I had mentioned previously.

Environmental exposure is also potential zoonotic transmission. And persons can become - could become infected through entering caves or buildings that are heavily infested with bats.

Human to human transmission occurs and that is what really fuels the outbreak once the zoonotic transmission spills over from animals into people.

And the human to human transmission really must be thought of in terms of the medical setting and the household setting that we encounter in Africa.

And so this is the setting that people frequently do not have access to things such as running water, and soap, or ways to clean ones self if one becomes contaminated with blood or body fluid.

But the kind of exposures that we consider to be high risk would be things such as percutaneous or mucous membrane exposure to body fluids of the symptomatic Ebola virus patient, providing direct care of a symptomatic patient or exposure to blood and body fluids without standard bio safety precautions, doing processing of body fluids of confirmed patients without appropriate PPE, or standard bio safety precautions and participation in funeral rites which include direct exposure to human remains in the geographic area where an outbreak is occurring without appropriate PPE.

Low risk exposures include having casual contact with an EVD patient either by being a household member or providing patient care that is just a casual contact kind of a situation rather than direct exposure to blood and body fluid without PPE.

And casual contact we’re defining in here to be within three feet of a patient for a prolonged period of time.

And so brief interaction such as walking by a person or moving through a hospital would not constitute casual contact in this setting and would not be considered a low risk exposure.

In terms of the virus, it is not that difficult to inactivate, 10% bleach hospital grade phenolics or quaternary ammonium solutions are appropriate disinfection procedures. The virus is liable to desiccaton.

Essentially the things that need to be cleaned and disinfected, such as blood and body fluid contamination, using these materials is the appropriate way to disinfect and inactivate the virus.

As far as clinical manifestations go, the incubation period for Ebola virus infection is it varies from two to 21 days, although most frequently the incubation is about seven days.

The symptoms include an abrupt onset of fever, with headaches, chills, malaise and myalgias also present.

GI symptoms are very common with patients. Nearly all exhibit some level of vomiting, diarrhea or abdominal pain.

Hemorrhagic symptoms, although we hear about the very frequently and association and also we frequently have referred to Ebola disease as Ebola hemorrhagic fever,hemorrhagic symptoms really only occurred in fewer than half of the cases. And that can vary from outbreak to outbreak but it’s also a feature that has been reported with this outbreak as well.

Mild hemorrhagic symptoms can be petechiae, epistaxis, ecchymosis, or bruising severe hemorrhagic symptoms can be GI hemorrhage, shock, or DIC.

Hemorrhagic symptoms do not necessarily equate disease severity, although in severe cases there can be more frequency hemorrhagic symptoms.

Less commonly seen is a rash typically on the trunk and shoulders, conjunctivitis, pharyngitis, cough, and hiccups.

In Ebola virus infected patients it is important to remember that prior to the onset of symptoms, which especially includes fever, the virus is not transmissible.

So there’s no period of time prior to onset of symptoms where the patient is contagious or could be considered to be infectious to others.

Once a patient is symptomatic all body fluid should be considered to be able to carry the virus and so that includes things like saliva, stool, urine.

Virus quantity does increase until a patient dies. And death usually occurs nine to ten days post onset.

In the current outbreak, the fatality rate in Guinea - which is the area where we have the best data for patients - it’s about 75percent.

If a patient survives past the second week of infection, so to day 14, there is an increased chance of survival for the patient.

And the convalescent period and resolution of viremia is something that especially a return to full health can be a very prolonged period for people.

In terms of the pathogenesis of the virus, the way that Ebola causes the profound symptoms that it can cause is it gains entry into macrophages and dendritic cells and really dis-regulates the immune functions so that there’s just an impaired global immune response of the patient.

Lymphocytes are given the signal to undergo apoptosis, and there’s also liver and adrenal gland necrosis that’s present.

The release of inflammatory mediators is what causes vascular leakage, hypotension, and also leads to the hemorrhagic manifestations.

In terms of classic laboratory findings, leukopenia is an early sign with granulocytosis. Thrombocytopenia is present universally and elevated transaminases in particular AST and ALT.

Renal dysfunction can also be present. Usually it occurs later on in the course of disease with the elevated BUN and creatinine.

And elevated D-dimers, prothrombin and PTT can also occur in patients as well. And again that hemorrhagic manifestations are not universally present.

In terms of clinical care there are not specific treatments that are currently available so supportive care is really the cornerstone of care for patients and that includes especially fluids, nutritional support and antibiotics to reduce the secondary infection risk.

The use of non-steroidal anti-inflammatories is controversial. It has been used in the past.

For laboratory diagnostics first I’ll just describe a little bit about the course of viremia and then the development of antibodies in a patient after onset of symptoms.

So fever is a very early sign of disease. And viremia, as detected by measuring virus RNA in the blood and detected using RTPCR, is usually viremia occurs a few days after the onset of fever.

And that’s actually an important criteria for ruling out Ebola virus disease in a patient is that we do wait until 72 hours after onset of viremia to detect virus by PCR before we say whether a patient has passed the is indeed negative for Ebola infection. (A negative RT-PCR result >72 hours post-onset of symptoms would be sufficient to rule out EVD in a patient with acute disease. Please refer to the article “Ebola Haemorrhagic Fever” http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673610606678.pdf)

But viremia rapidly increases and the peak viremia level is usually about a week after onset of symptoms.

IgM usually comes and it starts to be detectable about ten days after onset and IgG follows a few days after that.

Viremia we typically will follow patients in detecting the level of viremia that is present. And that is our criteria for releasing a patient from the isolation ward is the resumption of detectable viremia in the patient’s peripheral blood.

And that can take anywhere from a couple of weeks to three weeks; just really depends on the patient and their clinical course.

The - and antibody response also really counteracts the viremia. So as IgM and IgG especially start to come up we see that the virus levels decline quite precipitously.

IgM persists for approximately three to six months. And IgG can - has been detected to persist in one patient it was up to 11 years. We think that it’s probably a lifelong presence in the blood.

In addition to PCR and serology to detect antibodies, we also are able to perform virus isolation. Antigen ELISA immuno fluorescent antibody tests and then immunohistochemistry is available on postmortem specimens.

In terms of identifying patients and the evaluation - evaluating patients we do - we did provide in the health alert notice that - or health advisory notice that was sent out last week some guidance in terms of what would be constituted a person to be investigated.

And that includes a patient that has a fever of greater than 101.5 Fahrenheit or 38.6 Celsius and additional symptoms such as headache, muscle pain, vomiting, diarrhea and abdominal pain or unexplained hemorrhage and the patient having risk factors within the past 21 days before the onset of symptoms such as contact with blood or body fluids of a patient known to have or suspected to have Ebola virus disease, residence in or travel to an area where Ebola virus disease transmission is active or direct handling of animals that could be infected from - in disease endemic areas.

And so we would recommend patients who have a high risk exposure, and as I mentioned previously a high risk exposure includes contact with a confirmed or suspected patient blood or body fluid contact, direct patient care or participation in funerals.

And if those - if a person has had a high risk exposure in the last 21 days it’s recommended that if they develop a fever that - first of all it’s recommended that they are doing daily fever checks - but if they develop a fever testing is recommended if they develop a fever with any other symptoms and - or even without any other symptoms.

And patients should be handled with the appropriate precautions that Dr. Kuhar will mention in the next few moments.

For patients who have low risk contact, and the low risk contact we had spoken about previously which would be casual contact with a known or suspected Ebola virus disease patient within the past 21 days, testing is recommended if the patients developed fever and have - and if they - if there’s no fever present and other symptoms may be present that may be a point where consultation might be recommended to determine if testing is indicated.

For patients who have no known exposure and developed fever with other symptoms, abnormal blood work within 21 days of visiting an Ebola virus disease affected country that is just a point where they may be considered for testing particularly if there’s no other diagnosis that is found.

Testing may be also indicated in the same patients if a fever is present with other symptoms and blood work is abnormal or unknown. And that is a time when consultation is recommended for local and state health departments.

Ebola virus disease or suspected Ebola virus disease is a notifiable disease and so if Ebola virus disease is suspected local or state health departments should be notified. And CDC can also provide consultation on whether testing is indicated in conjunction with a local or state health department.

Dr. David Kuhar:
This is David Kuhar with CDC. Infection prevention and control recommendations for hospitalized patients with known or suspected Ebola hemorrhagic fever in U.S. hospitals was posted on CDC’s website on August 1, 2014.

Standard, contact, and droplet precautions are recommended for management of hospitalized patients with known or suspected Ebola hemorrhagic fever.

Though these recommendations focus on the hospital setting, the recommendations for personal protective equipment and environmental infection control measures are applicable to any healthcare setting; however, this guidance is not intended to apply to persons outside of healthcare settings.

For patient placement, we recommend isolating a patient in a single patient room containing a private bathroom with the door closed.

Facilities should maintain a log of all persons entering the patient’s room. And personnel entering the patient’s room should be limited to those essential for care.

For patient care equipment, dedicated medical equipment, preferably disposable when possible, should be used for the provision of patient care.

All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to the manufacturer’s instructions and hospital policies.

For personal protective equipment, all persons entering the patient room should wear at least: gloves, a gown, fluid resistant or impermeable, eye protection, goggles or a face shield, and a face mask.

Additional personal protective equipment might be required in certain situations, such as when there may be copious amounts of blood, or other body fluids, vomit, or feces present in the environment.

For these situations additional personal protective equipment could include but is not limited to: double gloving, disposable shoe covers, leg coverings.

Upon exit from the patient room or care area, it is very important that PPE be carefully removed without contaminating one’s eyes, mucous membranes, or clothing with potentially infectious materials.

And then either discarded, or for reusable PPE cleaned and disinfected according to manufacturer’s reprocessing instructions and hospital policies.

A few patient care considerations: you should limit the use of needles and other sharps as much as possible, phlebotomy procedures and lab testing should be limited to the minimum necessary for essential diagnostic evaluation and medical care.

And all needles and sharps should be handled with extreme care and disposed in puncture proof sealed containers.

For aerosol generating procedures, we recommend to avoid aerosol generating procedures for patients infected with Ebola hemorrhagic fever.

If performed, should limit the number of personnel present during the procedure to those essential for patient care and support.

You should be conducting procedures in a private room and ideally an airborne infection isolation room when feasible.

Healthcare personnel 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, as well as respiratory protection that is at least as protective as a NIOSH certified fit tested N95 filtering face piece respirator or higher.

For environmental infection control, diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is paramount as blood, sweat, emesis, feces, and other body secretions represent potential infectious materials.

Healthcare personnel performing environmental cleaning and disinfection should wear recommended PPE and consider use of additional barriers.

Face protection, or face shield, or face mask with goggles should be worn when performing tasks such as liquid waste disposal that can generate splashes.

Following standard procedures per hospital policy and manufacturing instructions for cleaning and disinfection for environmental surfaces and equipment, textiles and laundry, food utensils, and dishware is recommended and with that I’ll end my presentation.

Loretta Jackson Brown:
Thank you Dr. Knust and Dr. Kuhar for providing our COCA audience with such a wealth of information. We are aware that many of you were not able to hear or join the call at the beginning.

Please note that the call is being recorded and a call audio and transcript will be available on our COCA webpage at emergency.cdc.gov/coca. You can look under the Ebola call for the information. We will repeat that Web address again at the end of the call.

As a reminder, Dr. Nikki Cohen from CDC is available during this question and answer portion of today’s COCA call and that questions are limited to clinicians who would like information on clinical guidance related to Ebola virus disease.

For those who have media questions, again please contact CDC media relations at 404-639-3286 or send an email to media@cdc.gov. Operator we will now open up the lines for the question and answer session.

Coordinator:
Thank you. To ask a question please press Star 1 on your touch-tone phone, un-mute your phone, record your name clearly after the prompt and I will introduce you. Your name will be required to ask your question. Again that’s Star 1 to ask a question. One moment please for incoming questions.

Scott Cormier your line is open.

Scott Cormier:
Thank you. As it relates to PPE, do we have an understanding of how the American doctor and nurse who are now in Atlanta contracted the disease?

Dr. Tim Uyeki:
We’re not able to disclose patient information for issues of confidentiality.

Dr. Tim Uyeki:
And that was Dr. Tim Uyeki from the clinical team. I’m sorry we cannot address any individual patient questions.

Loretta Jackson Brown:
Operator we’ll take the next question.

Coordinator:
The next question is from David Croissant.

David Croissant:
Yes. Do you have any information or recommendations concerning incubation, CPAP, BiPAP or other potentially lifesaving procedures?

Dr. David Kuhar:
Again we have recommendations for aerosol generating procedures in the infection control guidelines for U.S. hospitals that include personal protective equipment as I described including wearing an N95 respirator.

David Croissant:
Thank you.

Loretta Jackson Brown:
Operator.

Coordinator:
The next question comes from Chris Lehr. Your line is open.

Chris Lehr:
Hi. We wanted to know if you have a recommendation about handling a body and what kind of information does the hospital need to provide to the mortuary for disposal of the body?

Dr. David Kuhar:
We do not currently have guidance on the handling of dead bodies but it is under development.

Chris Lehr:
Thank you.

Coordinator:
The next question is from Freda Lyon. Your line is open.

Freda Lyon:
Yes. My question is about employees that have traveled to the affected area and returning to work in the hospital and healthcare situation. What should we do to screen those employees? Should we screen those employees, et cetera?

Dr. Nicky Cohen:
Hi this is Dr. Nicky Cohen from the Global Migration Team. We are currently recommending that all travelers to the affected area monitor their health for 21 days after the last known exposure and actually 21 days after leaving the country when they return to the United States.

Specifically for healthcare workers, we recommend that if they have been working in a healthcare setting that they be evaluated for potential exposures and that [state or local health department or (please refer to CDC guidance http://www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html and http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html)] CDC be consulted if they are returning to work in the healthcare environment.

Loretta Jackson Brown:
Thank you. Operator we will take the next question.

Coordinator:
The next question is from Jeffrey Silvers. Your line is open.

Jeffrey Silvers:
Yes thank you. My question relates to laboratory testing that is done on a known Ebola virus patient who is hospitalized such as handling a urine specimen for urinalysis, CBC for blood smears and other fluids for cell counts and glucose et cetera.

Dr. Barbara Knust:
This is Barbara Knust speaking. And we are currently developing recommendations to deal with the specific questions about in house laboratory testing and safety. And so we will be coming out with those soon.

Jeffrey Silver:
Thank you.

Coordinator:
The next question comes from Steve Schron. Your line is open.

Steve Schron:
Thank you for a very interesting phone call. I have three brief questions to ask. The first is the need for droplet and contact precautions in a regular room.

If the aerosol generating procedures need to be done the patient would need to be moved to a negative airflow room.

Would it just not make more sense to put all suspected Ebola patients into a negative airflow room to begin with so you don’t have to move the patient?

My second question for you is the PPE removal and a droplet contact precaution room. Is it safe to remove all the garb within the room and then perform hand hygiene?

And my third question pertains to Emory. A great deal has been made with them having a high tech isolation suite to accommodate Ebola patients and most of us don’t have that luxury. Is that a double standard when it comes to caring for suspected Ebola patients? Thank you.

Dr. David Kuhar:
This is David Kuhar. To respond to your first question about droplet and contact precautions if you anticipate the need for aerosol generating procedures you shouldn’t - you certainly could have them placed in a negative pressure room. I’d say that’s up to the hospital policy on how they like to manage their patients.

Woman:
Can you...

Loretta Jackson Brown:
Operator...

Woman:
Hold on operator. We’re going to go back to that last caller. Could you...

Coordinator:
Yes I can recall him.

Woman:
We just want him to repeat his second and third question here

Coordinator:
Okay.

Man:
Okay yes.

Coordinator:
Your line is open again.

Steve Schron:
My second question pertains to removal of PPE in a droplet and contact precaution room. Is it acceptable to remove the garb within the room and then perform hand hygiene?

And my third question pertains to Emory with Emory having a high tech isolation suite which most of us don’t have. Is it a double standard when Emory is able to use a high tech isolation suite and the rest of us don’t have that luxury?

Dr. David Kuhar:
Got you. For your second question, yes, the process you described is acceptable to remove the PPE in the room, discard it and then perform hand hygiene.

As for the Emory units, you know, remember Emory is using pre-existing protocols and processes that have been practiced for the management of patients infected with pathogens where modes of transmission are not understood.

These precautions are sufficient for Ebola but remember there have been Ebola outbreaks since the 1970s. Modes of human to human transmission are understood for Ebola. It is not transmitted through the air.

And ultimately any U.S. hospital following CDC’s infection control recommendation that’s able to isolate a patient in a private room is capable of safely managing a patient with Ebola virus disease.

Coordinator:
And the next question comes from Donna Kent. Your line is open.

Donna Kent:
Hi. I think you answered part of this but laboratory specimens and the handling of them. If you have a suspect case, you know, you’re - I’m basically hearing that, you know, you rule out other infections probably but how are you going to manage those laboratory specimens in a clinical laboratory in a hospital?

Dr. Barbara Knust:
Yes. This is Barbara Knust speaking again and we have - we are pausing to provide any recommendations at this point while things are still going through rungs of clearance.

We certainly know that it’s a very important to provide that information to you as soon as we possibly can and we certainly are working very hard to bring that out.

So that will be coming to you shortly. And so we’ll pause on recommendations at this point in time until that is available.

Oh yes and we also are planning on having an additional COCA call once those recommendations are available for your questions at that point in time.

Donna Kent:
Thank you.

Coordinator:
The next question comes from Connie Bryant. Your line is open.

Connie Bryant:
Hi. This is Connie Bryant at Emory University Hospital. And I’m asking this question for Dr. Bruce Ribner but you had answered it early on. His question was guidance for handling dead bodies if you had guidelines developed yet? And you answered that you were working on them I believe.

Dr. David Kuhar:
Hi. This is David Kuhar. Yes that guidance is under development and coming soon.

Connie Bryant:
Thank you.

Loretta Jackson Brown:
And I will add -- this is the Loretta the moderator -- for those who are interested in receiving those guidance the time they come out and additional information from COCA I suggest that you please subscribe to COCA. We do send out email updates related to this CDC emergency as well as other health alerts. And you can subscribe to COCA by sending an email to coca@cdc.gov to receive the latest updates.

Coordinator:
The next question comes from Peggy Thompson. Your line is open.

Peggy Thompson:
Thank you. I was calling with actually two questions. One is have you had any concerns with hospitals who use outside laundry facilities in managing the linen from patients who are, you know, suspected of having Ebola virus?

And the second is I have a little bit of concern with the discrepancy between the level of precautions that we’re telling people are acceptable to use and what I’m seeing used and I understand that it’s very different situation as far as what they’re dealing with over in Sierra Leone.

But, you know, the level of precautions I’m seeing people take over there is pretty much, you know, total head coverage, and full face mask, and, you know, reusable gloves and all that stuff.

And I just feel like when you’re a healthcare worker and you’re in a patient’s room, you may or may not know when the patient is going to, you know, expose you to body fluids. And that’s why we’re constantly telling people to be on the safe side.

And I just want to make sure that we’re taking an appropriate level of precaution to protect our healthcare workers.

Dr. David Kuhar:
This is David Kuhar. So to your first question about laundry, we understand that there have been a lot of questions about, I think, for a little more comprehensive guidance on environmental infection control handling of laundry and such.

And we are working on a supplement for healthcare environmental infection control that will, I think, will be linked to the infection control guidance and will be coming soon.

As for the difference in personal protective equipment you might see, you know, there are important differences between providing care or performing public health tasks in Africa versus a U.S. hospital.

In field medical settings, additional personal protective equipment may be necessary to protect healthcare workers. In some places in Africa, workers might not have the ability to prepare for potential exposures.

For example, in some areas care may be provided in clinics with limited resources, no running water, no climate control, no floors and inadequate medical supplies.

And workers could be in those areas for several hours with a number of patient - infected patients.

Certain job responsibilities and tasks such as attending to dead bodies may also require different personal protective equipment than what is used when providing care for infected patients in a hospital.

Remember, you know, we do recommend gloves, gowns, eye protection and a face mask but additional personal protective equipment might be required for certain situations even in a U.S. hospital. And it’s important to anticipate those situations.

Loretta Jackson Brown:
Thank you. Operator we will take the next question.

Coordinator:
The next question comes from Dr. Michael Holland. Your line is open.

Dr. Michael Holland:
Yes. Customs and border patrol say that Ebola positive patients may have already walked across the border. Why the disconnect between the - what I’m hearing on this call about, you know, considering the virulence of this disease and the indifference being shown to the southern border where Ebola could walk across the Arizona border at any time and in fact why in the world would you bring two Ebola patients into this country rather than send the treatment to the patients?

Dr. Barbara Knust:
The first - to first address your comment about the patients who were brought into the United States it was not a decision that CDC made to bring these patients in. And we - our role in that decision merely is providing guidance in terms of doing it safely and being as safe as we possibly can with that situation.

Dr. David Kuhar:
Yes. And this is David Kuhar. You know, it’s important to remember that to not allow our fear of the unknown to really overtake our compassion for U.S. citizens who have gone abroad to help to control one of the largest outbreaks of Ebola in history.

Remember, I mean any U.S. hospital able to isolate a patient in a single patient room and follow CDC’s infection control recommendations is capable of safely managing patients infected with this disease.

Coordinator:
The next question comes from Diane Lange. Your line is open.

Diane Lange:
Hi. I had had a question about the PPE. And I realize that you said facemask and shield but when you reference to N95 masks that - for infection prevention this just kind of gives me a double standard it’s like are we – do we need a negative airflow for these patients or not? Are we only looking at negative airflow for certain situations when they are incubated or aerosol producing procedures?

Dr. David Kuhar:
Hi. This is David Kuhar. I’m sorry if what I have said may have been confusing. For aerosol generating procedures, we recommend to conduct them in a private room and ideally an airborne infection isolation room and for aerosol generating procedures, only, instead of a face mask to wear an N95 filtering face piece respirator or higher level of respiratory protection.

Diane Lange:
Okay. Thank you.

Coordinator:
The next question comes from Caroline Peterson. Your line is open.

Caroline Peterson:
Hi. I have a question about personal protective equipment related to Tyvek suits. Some of my staff have asked if that in fact is indicated?

And in listening to what’s being said today my response would be and I wondered if it was appropriate that it may be indicated if additional protection is needed such as leg covers that type of thing. What are your thoughts on that?

Dr. David Kuhar:
I think that that’s fair, you know, additional personal protective equipment might be required in certain situations.

There isn’t necessarily one brand of personal protective equipment that you wear. It’s important that you avoid contact with blood and body fluids.

However it’s also very important to remember that personal protective equipment needs to be carefully removed without contaminating oneself, one’s eyes, one’s mucous membranes or clothing.

So if personnel are using personal protective equipment that they’re not familiar with they need to be trained and ready to remove it safely.

Caroline Peterson:
Makes sense.

Coordinator:
And the next question comes from John Keysner. Your line is open.

John Keysner:
Is Ebola a sexually transmitted infection?

Dr. Barbara Knust:
This is Barbara Knust and yes Ebola can be sexually transmitted. I didn’t get too much into it but the virus can persist in semen. It has been detected even three months after patient onset of symptoms.

And so that’s something that is important in Africa with survivors is that they are actually discharged from isolation units with the instructions that they should abstain from sexual activity for the next three months. And so that is an important point.

Breast milk is another body fluid where the virus can persist after the resumption of viremia in the patient.

Coordinator:
The next question comes from Alisha Rizzo. Your line is open.

Alisha Rizzo:
Hi. Thank you. Mine is also from the laboratory perspective. After a suspected case what are the tests that we are ordering to actually confirm that it is Ebola and are they sent to the CDC or the state Department of Health?

Dr. Barbara Knust:
So as far as the testing goes, CDC is the reference lab for the United States to provide diagnostic testing for Ebola virus.

And this - if the decision to test is made, that’s a decision that is reported to CDC through your state or local health department. And so they - everyone works in concert and everyone is aware that that is undergoing and is in place.

And we are available for consultation to determine to provide assistance in determining if laboratory testing is indicated and provide guidance on shipping of specimens.

Alisha Rizzo:
Thank you.

Coordinator:
The next question comes from Pam Faulk. Your line is open.

Pam Faulk:
Thank you very much but my question has already been answered. Thank you.

Coordinator:
The next question came in for - is from Barbara Russell. Your line is open.

Barbara Russell:
Thank you. My question has kind of been answered too. I had that concern about that double standard. It’s very hard to convince emergency room staff and others that we just have to wear a gown, and gloves and mask.

And then we see on TV with them in all their suits head to toe in this room where they say they’re going to burn everything that comes out of it.

So is there anything that can be done to correct what Emory is doing and what is Emory wearing when they go in the rooms?

Dr. David Kuhar:
I think questions for patient management at Emory should be directed to Emory and let them answer. However I - all I can say again is, you know, images you see abroad that fieldwork can require very different personal protective equipment as there a different risks and different tasks.

Provision of care in a hospital is a more controlled setting. And as I said before we know how Ebola is transmitted. It is not transmitted through the air.

They have decades of experience with this disease and following a recommended precaution and ensuring that you do not have contact with infectious blood and body fluids will keep personnel safe.

Dr. Barbara Knust:
This is Barbara Knust. I might add that there is a report, it was written by Guy Richards in 2000 in Critical Care Medicine that is the case report of a patient who came into tertiary care facility in South Africa.

And that is a very excellent case report of a patient who was treated for several days, actually wound up dying, and had over 300 people that came into contact with the patient in some way they were using standard precautions and there were no secondary cases.

And so it is a testament to the effectiveness of standard precautions in terms of being excellent preventive measures for a variety of pathogens.

Coordinator:
The next question comes from Beth Wallace. Your line is open.

Beth Wallace:
But my question has already been answered. Thanks.

Coordinator:
If your question has already been answered you can press Star 2 and remove yourself from the queue. The next question is from Heather Scott. Your line is open.

Heather Scott:
Hi. Thank you. I just wanted to check with regard to disposal of the liquid waste. Is the sanitary sewer acceptable?

Dr. Barbara Knust:
In a word yes.

Heather Scott:
Okay. That works.

Coordinator:
The next question comes from Annie Chang or - I’m sorry Dr. Aveda your line is open.

Dr. Aveda:
This is Dr. Aveda. And I’m calling to find out about the monoclonal antibody. One of the presenters said monoclonal antibody was used. Where do we get it from and what exactly is the training?

Dr. Tim Uyeki:
This is Tim Uyeki from the clinical team. So as Barbara Knust said there are no approved therapeutics for Ebola. We cannot comment about the treatment that is being administered to the Emory patients.

So that’s all we can say right now. There’s a lot of work going on in terms of - and there has been for many years - in terms of development of investigational therapeutics as well as investigational vaccines but there’s nothing approved at this time.

Coordinator:
The next question comes from Annie Chang. Your line is open.

Woman:
I did.

Coordinator:
The next question comes from Judith Goldstein. Your line is open.

Judith Goldstein:
My question is partly addressed. It was regarding the laboratory specimens and the handling but the additional piece that I wanted to ask was about the laboratory equipment used to process those specimens; how do you disinfect that?

Dr. Barbara Knust:
The lab guidance will cover that information as well.

Judith Goldstein:
Thank you.

Coordinator:
The next question comes from Lita Padrone.

Lita Padrone:
Yes. I don’t mean to belabor this personal protective equipment but we had started to formulate a plan to have those Tyvek suits available for our emergency room staff so that while they were evaluating the patient they would be completely covered including their heads.

I don’t see anything about head covering. So I ask that you address that specifically. But also when you say impervious, I’m understanding from today’s conference call that that will be a patient by patient determination, so that impervious gown should be enough, unless there’s so much body fluid that you want to cover legs.

And I just want you to confirm that we’re right. We’re on the right track. A gown should be enough unless the patient is putting out so much body fluid that you want to cover legs? And separately please address the head coverings.

Again our physicians and so on are asking about how come, on television we see heads are - you know, covered from head to toe?

Dr. David Kuhar:
First in short I think you expressed it very well that you may need to wear more if you anticipate - if you’re in a situation where you - there are copious amounts of blood and body fluids in the environment.

As for head coverings, we do not specifically call this out. If you anticipate contact of your head with between your head and infectious body fluids then you should cover your head.

Coordinator:
The next question comes from Marsha Goldoff. Your line is open.

Marsha Goldoff:
I was wondering if you had recommendations for infection control measures while you’re evaluating an outpatient traveling from an area who might have another febrile disease such as malaria or typhoid?

Dr. Barbara Knust:
This is Barbara Knust. And I think getting a very good travel history to determine if there were any risk exposure factors is a very important piece.

And so having an understanding of whether this person was taking care of a sick person, involved in any kind of funeral proceedings that would involve direct handling of bodies, or other risk factors as I had outlined before, that really gives a sense of what the index of suspicion would be for this patient and determining how to proceed forward.

Loretta Jackson Brown:
Operator.

Coordinator:
The next question yes.

Loretta Jackson Brown:
Could you tell me how many questions we have in the queue?

Coordinator:
We have 95 questions.

Loretta Jackson Brown:
Okay. So that tells me we will not be able to get to all the questions. We will take two more questions.

Coordinator:
Okay. The next question comes from Rosemary Myers.

Rosemary Myers:
Hello. My question comes from an outpatient perspective. We’re working on developing some travel triage screening things.

My concern is how do we recommend disposition of the patient from a home setting that we might suspect could be contaminated with the virus and how should we handle that?

Dr. Barbara Knust:
Just to clarify are you trying to determine what the travel history of the person was in a home setting where they may have been caring for sick persons who may be - who may have been infected with the Ebola virus? Is that your question?

Rosemary Myers:
No I’m sorry I wasn’t clear. Our hospital has a huge outpatient services associated with it and we have a lot of RNs who triage fever over the phone.

And this would be a case where a patients calling in with chief complaint of fever who has been identified with a positive travel history and a positive exposure to EVD.

What, you know, I don’t want to just advise our staff to have them come into an emergency room. I’m not sure that’s appropriate or if we should have them stay in place, contact the CDC, and then look at what the next steps would be for the proper disposition of sending the patient to care?

Coordinator:
The final question comes from John Fitch. Your line is open.

Woman:
Sorry operator could you pause for a second? We’re just deciding who’s going to answer that last question.

Coordinator:
Okay.

Woman:
Just one second please.

Loretta Jackson Brown:
And while waiting to hear from our SMEs I do want to remind everyone if you have additional questions for our presenters today please put them in an email and send them to coca@cdc.gov. And we will get a response to you. So please stand by.

Dr. Barbara Knust:
Okay. So this is Barbara Knust. Going back to your question again we were just making sure we were getting the picture correctly.

And so I think if a patient in terms of triaging a patient with a fever, the typical rules of whether a patient should be hospitalized apply with adding the additional travel history question of whether a person may have had a risky exposure to Ebola virus disease if they do have a travel history.

And so if a patient did indicate that in that travel they did have exposure to blood and body fluids of sick persons or funeral experience previous in their travel history that would be an indication to come into the hospital to be evaluated.

But then otherwise if they merely have a travel history it would go back to whether they are sick enough to need hospital care in general.

Woman:
Operator can we take the final question?

Coordinator:
Okay. The final question is from John Fitch.

Loretta Jackson Brown:
We’ll take one more operator if that is not working.

Coordinator:
Okay. Okay Jennifer Ryan. Your line is open.

Jennifer Ryan:
Good afternoon. I apologize if this is somewhat of a specific question but in regards to the aerosol producing procedures and instituting airborne precautions for those patients, we utilize PAPRs in our facility.

And the way those are ventilated there are a few small holes on the bottom part of the hood. Would you recommend that we need to use a face mask in addition to that?

It seems like the only communication would be to the chin but if any at all any thoughts on that or is that kind of overkill?

Dr. David Kuhar:
This is David Kuhar. The PAPRs should have positive airflow, blowing air essentially out from the face area so they should be no airflow going into the PAPRs through the holes that you were describing. And no you should not wear and you would not need to wear facemask in addition to that underneath your PAPR.

Jennifer Ryan:
Thank you.

Dr. David Kuhar:
But one other thing to remember this is a disease that is primarily - we’re talking about transmitted by contact with blood and body fluids.

You need to be very careful about removal and disinfection of the PAPR. Disposable N95 respirators may be preferable.

Loretta Jackson Brown:
Thank you. Presenters as we close would you like to make any final comments to emphasize any particular point for our clinician audience?

Dr. Nicky Cohen:
Hi. This is Nicky Cohen from Global Migration. I answered a question earlier regarding healthcare workers who had been in the affected countries returning to work in the hospitals and I advised that CDC be consulted.

We are also requesting that [the state or local health department or (please refer to CDC guidance http://www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html)] CDC be consulted if healthcare workers who have been working in healthcare facilities in countries affected with Ebola intend to travel back to the United States so that we can make sure that any concerns are related to the travel itself.

Loretta Jackson Brown:
Thank you. And Dr. Knust we’re also getting some emails in regard to an article you referenced. Is that article in the public domain and is it available for us to post on our COCA Webpage?

Dr. Barbara Knust:
Yes. I would be very happy to provide the names of a few different articles that would be helpful for the audience.

Loretta Jackson Brown:
Okay great. We will have those on our COCA Webpage. So on behalf of COCA, I would like to thank everyone for joining us today with a special thank you to Dr. Knust, Dr. Kuhar, Dr. Cohen, and Dr. Uyeki.

We invite you to communicate to our presenters after the call. If you have additional questions for today’s presenters, please email us at coca@cdc.gov. Put “Ebola COCA call” in the subject of your email and we will ensure that your question is forwarded to them for a response. Again the email address is COCA@cdc.gov.

The recording of this call in the transcript will be posted to the COCA web site at emergency.cdc.gov/coca within the next few days.

There are no continuing education credits for this call. Resources for clinicians related to Ebola virus disease are available on the COCA Call Webpage.

Go to emergency.cdc.gov/coca, click COCA Call, and then follow the link for the 2014 Ebola call.

To receive information on upcoming COCA calls subscribe to COCA by sending an email to coca@cdc.gov and right subscribe in the subject line.

Thank you again for participating in today’s COCA call. Have a great day.

Coordinator:
This concludes today’s telepresence - teleconference you may disconnect your lines at this time.

END

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