EBOLA Viral Disease Ebola latest final combined.pdf · Ebola Viral Disease (EVD) is one of numerous...

Ethiopian Public Health Institute

(EPHI)

September 2014

Addis Ababa, ETHIOPIA

EBOLA Viral Disease Interim Guideline

ii | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 4

TABLE OF CONTENTS

TABLE OF CONTENTS ............................................................................................................................... II

I. INTRODUCTION TO EBOLA VIRAL DISEASES ............................................................................. 1

1. Background ....................................................................................................................................................... 1

2. Mode of Transmission ....................................................................................................................................... 1

3. Incubation Period .............................................................................................................................................. 2

4. Sensitivity of the Virus ....................................................................................................................................... 2

5. Clinical Features of Ebola Virus Infection .................................................................................................... 2

II. EBOLA VIRUS DISEASE SURVEILLANCE AND LABORATORY DIAGNOSIS....................... 4

1. Purpose of Surveillance ..................................................................................................................................... 4

2. Case Definition of Ebola Virus Disease ............................................................................................................... 4

2.1. Case Definition Ebola Cases before Outbreak ........................................................................................................ 4

2.2. Case definitions During an Ebola Outbreak ............................................................................................................ 5

3. EVD Surveillance and Measures to Take ............................................................................................................. 5

3.1 Screening of Passengers at Ports of Entries ............................................................................................................. 5

3.2. Exposure Levels and Measures to Take if Exposures Encountered ......................................................................... 6

3.3. Contact Tracing and Contact Follow Up ................................................................................................................. 7

3.3 Contact Tracing ....................................................................................................................................................... 8

3.4 Rumors Verification ................................................................................................................................................ 9

3.5 Transporting a Suspected Case ............................................................................................................................. 10

4. Outbreak Investigation, Sample Collection and Shipment ................................................................................ 12

4.1 Outbreak Investigation ......................................................................................................................................... 12

4.2 Confirmation of Diagnosis by Laboratory: Collection of Specimen and Shipment ................................................. 13

III. CASE MANAGEMENT OF PATIENTS ........................................................................................ 14

1. Principles for Clinical Case Management .......................................................................................................... 14

2. Set Up and Organization of the Ebola Treatment Center .................................................................................. 14

2.1 Location ................................................................................................................................................................ 14

2.2 Buildings / Structures ............................................................................................................................................ 14

2.3 Risk Zones ............................................................................................................................................................. 15

2.4 Activities and Facilities in the Different Risk Zones ................................................................................................ 16

2.5 Fencing ................................................................................................................................................................. 17

2.6 Layout of Ebola Treatment Unit ............................................................................................................................ 17

iii | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 4

2.7 Patient screening area .......................................................................................................................................... 19

3. Patient Care at Ebola Treatment Unit ............................................................................................................... 19

3.1 Medical Staff ......................................................................................................................................................... 19

3.2 Admissions ............................................................................................................................................................ 19

3.3 Laboratory Tests ................................................................................................................................................... 20

3.4 Medical Care ......................................................................................................................................................... 20

3.5 Invasive Procedures .............................................................................................................................................. 21

3.6 Hydration .............................................................................................................................................................. 21

3.7 Management of Shock in EVD Patients ................................................................................................................. 21

3.8 Symptomatic Care ................................................................................................................................................. 25

3.9 Presumptive Treatment ................................................................................................................................. 27

3.10 Nutritional Support ........................................................................................................................................ 27

3.11 Psychological Support ......................................................................................................................................... 28

3.12 Children in the Ebola Treatment Unit .................................................................................................................. 29

3.13 Mothers with breastfeeding children .................................................................................................................. 29

3.14 Maternity and Ebola virus disease ...................................................................................................................... 29

4. Discharge ........................................................................................................................................................ 30

4.1 Discharge Criteria ........................................................................................................................................... 30

4.2 Important Procedures before Discharge ........................................................................................................ 30

4.3 Supportive Treatment and Follow up ............................................................................................................. 30

4.4 Patient Care in the Home Based Support and Risk Reduction ........................................................................ 31

4.5 Laboratory Tests ............................................................................................................................................ 31

4.6 Medical File .................................................................................................................................................... 31

4.7 Psychological Support .................................................................................................................................... 31

4.8 Management of Exposed Individuals ............................................................................................................. 31

IV. INFECTION PREVENTION AND CONTROL ............................................................................ 33

1. General Patient Care ....................................................................................................................................... 33

2. Disinfection in Ebola Treatment Units .............................................................................................................. 33

3. Patient Placement, Staff Allocation, Visitors .................................................................................................... 33

4. Personal Protective Equipment, Hand Hygiene and Other Precautions ............................................................. 34

4.1 Personal Protective Equipment Protocols ...................................................................................................... 34

4.2 Hand Hygiene Protocol ......................................................................................................................................... 36

4.3 Injection Safety ..................................................................................................................................................... 37

4.4 Environmental Cleaning ........................................................................................................................................ 38

2.5 Management of Linen and Blankets ............................................................................................................... 39

5. Waste Management ........................................................................................................................................ 40

6. Moving and Burial of Human Body ................................................................................................................... 42

6.1 Burial Procedure for Patient Dying in the Ebola Treatment Unit: .......................................................................... 42

6.2 Procedure for Burial of Suspect/Probable/Confirmed Patient Dying at Home ...................................................... 44

6.3 Cleaning a Room after Patient Death at Ward ...................................................................................................... 44

6.4 Procedure for house disinfection .......................................................................................................................... 45

iv | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 4

7. Managing Exposure to Virus ............................................................................................................................ 46

V. COMMUNICATION AND SOCIAL MOBILIZATION .................................................................... 47

1. Overview ......................................................................................................................................................... 47

2. Pre‐Epidemic Phase ......................................................................................................................................... 47

3. Epidemic Phase ............................................................................................................................................... 49

4. Integrated Communication Activities ............................................................................................................... 49

5. Key Messages .................................................................................................................................................. 51

1 | E V D I n t e r i m G u i d e l i n e , E P H I S e p t 2 0 1 4

I. INTRODUCTION TO EBOLA VIRAL DISEASES

1. Background

Ebola Viral Disease (EVD) is one of numerous Viral Hemorrhagic Fevers. It is a severe, often fatal disease in humans and non‐human primates (such as monkeys, gorillas, and chimpanzees).

Ebola virus disease is caused by infection with a virus of the family Filoviridae, genus Ebolavirus. When infection occurs, symptoms usually begin abruptly. The first Ebolavirus species was discovered in 1976 in what is now the Democratic Republic of the Congo near the Ebola River. Since then, outbreaks have appeared sporadically.

There are five identified subspecies of Ebolavirus. Four of the five have caused disease in humans: Ebola virus (Zaire ebolavirus); Sudan virus (Sudan ebolavirus); Taï Forest virus (Taï Forest ebolavirus, formerly Côte d’Ivoire ebolavirus); and Bundibugyo virus (Bundibugyo ebolavirus). The fifth, Reston virus (Reston ebolavirus), has caused disease in non‐human primates, but not in humans.

The natural reservoir host of ebolaviruses remains unknown. However, on the basis of available evidence and the nature of similar viruses, researchers believe that the virus is zoonotic (animal‐borne) with bats being the most likely reservoir.

2. Mode of Transmission

Because the natural reservoir of Ebola viruses has not yet been proven, the manner in which the virus

first appears in a human at the start of an outbreak is unknown. However, scientists believe that the first

patient becomes infected through contact with an infected animal, such as a fruit bat or primate (apes

and monkeys), which is called a spillover event. Person‐to‐person transmission follows and can lead to

large numbers of affected people. In some past Ebola outbreaks, primates were also affected by Ebola,

and multiple spillover events occurred when people touched or ate infected primates.

When an infection does occur in humans, the virus can be spread in several ways to others. Ebola is

spread through direct contact (through broken skin or mucous membranes in, for example, the eyes,

nose, or mouth) with:

blood or body fluids (including but not limited to urine, saliva, sweat, feces, vomit, breast milk,

and semen) of a person who is sick with Ebola

objects (like needles and syringes) that have been contaminated with the virus

infected fruit bats or primates (apes and monkeys)

Contact with infected corpses (human or animal): Bodies of deceased patients or animals that

died of EVD infection are highly contagious because of the high levels of virus in the corpses.

Often traditional burial rituals consist of washing and touching the body to prepare the body and

this practice will lead to infection.

Indirect contact with contaminated objects and environments.

Ebola does not spread through the air or by water, or in general, by food. However, Ebola may be spread

as a result of handling bush meat (wild animals hunted for food) and contact with infected bats. There is

no evidence that mosquitos or other insects can transmit Ebola virus. Only a few species of mammals (for

example, humans, bats, monkeys, and apes) have shown the ability to become infected with and spread

Ebola virus.


Healthcare providers caring for Ebola patients and the family and friends in close contact with Ebola

patients are at the highest risk of getting sick because they may come in contact with infected blood or

body fluids of sick patients.

During outbreaks of Ebola, the disease can spread quickly within healthcare settings (such as a clinic or

hospital). Exposure to Ebola can occur in healthcare settings where hospital staff are not wearing

appropriate protective equipment, including masks, gowns, and gloves and eye protection. Dedicated

medical equipment (preferable disposable, when possible) should be used by healthcare personnel

providing patient care. Proper cleaning and disposal of instruments, such as needles and syringes, is also

important. If instruments are not disposable, they must be sterilized before being used again. Without

adequate sterilization of the instruments, virus transmission can continue and amplify an outbreak.

Once someone recovers from Ebola, they can no longer spread the virus. However, Ebola virus has been

found in semen for up to 3 months. Abstinence from sex is recommended for at least 3 months. If

abstinence is not possible, condoms may help prevent the spread of disease.

3. Incubation Period

The incubation period (period between exposure and development of symptoms) is 2 to 21 days. During

the incubation period the patient is infected with the virus, but is asymptomatic and is not contagious.

During the first days of symptoms the levels of the virus increases and therefore its communicability

increases rapidly. If the patient doesn't manage to establish a proper immune response, then the level of

the virus continues to increase until death occurs. The corpse of a patient who died of EVD infection is

therefore highly contagious. If the immune response is sufficient, then the level of virus decreases

gradually until recovery.

4. Sensitivity of the Virus

It is believed that the Filovirus is not capable of surviving a long time outside the body of an infected

organism. The virus is thought to be able to survive up to some days in a liquid (blood, vomit, corpses,

etc). However, having a lipid (fatty) envelop makes the viruses fragile. Chlorine disinfection, Heat, Direct

sunlight (UV light), Soaps and detergents all destroy the lipid envelop of the virus, thereby killing the

virus.

5. Clinical Features of Ebola Virus Infection

Symptoms start generally and are similar to common diseases like malaria, shigellosis or typhoid. A

clinical diagnosis is therefore difficult. Symptoms develop progressively and filovirus infections can kill

rapidly.

Fever

Severe headache

Muscle pain

Weakness

Diarrhea

Vomiting

Abdominal (stomach) pain

Unexplained hemorrhage (bleeding or bruising)


Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola, but the average is 8 to 10

days.

Recovery from Ebola depends on good supportive clinical care and the patient’s immune response.

People who recover from Ebola infection develop antibodies that last for at least 10 years.

Table 1: Summary of signs and symptoms of EVD

General symptoms: … then often followed by

Intense tiredness and weakness Sudden onset of high grade fever fever Headache Muscle pains Arthralgia Conjunctivitis (1/3 of all patients after 5 days) Nausea and anorexia Painful throat and dysphagia Abdominal pain Hiccups

Chest pain Diarrhea (watery or bloody) Vomiting (sometimes bloody) Orchitis Rash Confusion and irritability Internal and external bleeding (in 30‐50% of

cases, often from mucosa and gingivae) Impaired liver and kidney function Abortion or miscarriage amongst pregnant

women Shock Death


II. EBOLA VIRUS DISEASE SURVEILLANCE AND LABORATORY DIAGNOSIS

1. Purpose of Surveillance

Considering the infectivity and high case fatality rate of EVD, early detection, timely specimen collection

and processing, immediate isolation of new cases and meticulous contact tracing will limit new chains of

transmission and have a significant impact on control of the epidemic.

With the current EVD outbreak in West Africa countries, Ebola surveillance will be initiated at ports of

entry (airports and land crossing areas) and in the general health system and at community level. The

purpose of this surveillance is:

For early and timely detection of suspected cases and/or outbreaks,

Rapid investigation and early laboratory verification of the etiology,

Contact tracing and follow up of contacts.

Health promotion is one of the priority activities to start with in an intervention. For an efficient

surveillance system, it is important to have a trusting relationship with the community to obtain an

optimum collaboration. The acceptance of being taken to the Ebola Treatment Center or to alert a case

to the surveillance team all depends on the confidence of the community in the intervention and the

health facilities. The teams must be trained to work in tactful and concerned manner that facilitates

developing good relations with the communities.

2. Case Definition of Ebola Virus Disease

2.1. Case Definition Ebola Cases before Outbreak

The following are the case definitions that we need to use for early recognition of suspected cases.

Suspected Case: ‐

A person who has both consistent symptoms and risk factors as follows:

Clinical criteria, a person having fever of greater than 38.60C , and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage;

AND

Epidemiologic risk factors within the past 21 days before the onset of symptoms, such as contact with blood or other body fluids or human remains of a patient known to have or suspected to have EVD; residence in—or travel to—an area where EVD transmission is active*; or direct handling of bats or non‐human primates from disease‐endemic areas.

Probable Case: ‐

A suspected case whose epidemiologic risk factors include high or low risk exposure(s) (see section 3.2 below for levels of exposure risk).

Confirmed Case: ‐

A case with laboratory‐confirmed diagnostic evidence of Ebola virus infection.

Community‐based surveillance: standard case definition

This definition of alert cases for Ebola virus disease has been developed for use by the

community or community‐based volunteers. It may be used for community‐based surveillance

during the pre‐epidemic phase and during the outbreak.


Alert case: Illness with onset of fever and no response to treatment of usual causes of fever in the

area, OR at least one of the following signs: bleeding, bloody diarrhea, bleeding into urine OR any

sudden death.

2.2. Case definitions During an Ebola Outbreak

During an outbreak, the case definitions are likely to be modified to be adapted to new clinical

presentations or different modes of transmission related to the local event.

a. Case definition to be used by mobile teams or health posts and health centres

Suspected Case:

Any person, alive or dead, suffering or having suffered from a sudden onset of high fever and

having had contact with:

a suspected, probable or confirmed Ebola case;

a dead or sick animal (for Ebola)

OR: any person with sudden onset of high fever and at least three of the following symptoms:

headaches

vomiting

anorexia / loss of appetite

diarrhea

lethargy

stomach pain

aching muscles or joints

difficulty swallowing

breathing difficulties

hiccup

OR: any person with inexplicable bleeding

OR: any sudden, inexplicable death.

b. Case definition for exclusive use by hospitals and surveillance teams

Probable case:

Any suspected case evaluated by a clinician

OR: Any deceased suspected case (where it has not been possible to collect specimens for

laboratory confirmation) having an epidemiological link with a confirmed case

Note: if laboratory specimens are collected in due time during the illness, the preceding

categories are reclassified as “laboratory confirmed” cases and “non‐case”.

Laboratory Confirmed Case: Any suspected or probably cases with a positive laboratory result.

Laboratory confirmed cases must test positive for the virus antigen, either by detection of virus

RNA by reverse transcriptase‐polymerase chain reaction (RT‐ PCR), or by detection of IgM

antibodies directed against Ebola.

None Case: Any suspected or probable case with a negative laboratory result. “Non‐case” showed no

specific antibodies, RNA or specific detectable antigens.

3. EVD Surveillance and Measures to Take

3.1 Screening of Passengers at Ports of Entries

With the current evidence of EVD in West Africa, and the declaration of Public Health Emergency of

International Concern, traveller screening – of passengers coming from currently affected countries is

an important activity and contribute to early detection of cases and prevent the importation of a the

disease or to delay such importation.


WHO advised countries with active EVD to do exit screening of passengers and prohibit passengers

from boarding the flight if sick. Doing the entry screening complements the work of exist screening of

passengers.

Major activities on passengers screening:‐

Raise awareness of EVD and disseminate information among all relevant stakeholders at POE,

Provision of sensitization /orientation to POE public health authorities, POE operators, conveyance operators

Raise awareness among conveyance operators of the need to immediately notify PoE health authorities prior to arrival of any suspected cases.

Ensure that passenger locator forms are on board flights and at the airport, and that airport ground staff and flight crew are trained in managing EVD and environmental contaminants

Provision of training on EVD to crew members, health workers, conveyance operators

Provision of training on the Case definition of EVD, infection prevention

Training of health workers on screening of passengers,

Screening is done with thermal thermometer detector or thermal scanner,

Designation of quarantine place,

Availing the necessary supplies (PPE) and tools (Case investigation form),

Suspected cases should be further screened and ruled for other causes,

Figure below is showing conceptual framework screening of embarking and disembarking passengers.

3.2. Exposure Levels and Measures to Take if Exposures Encountered

During screening evaluating risk of exposure of persons to Ebola Virus Disease and initiating

appropriate public health actions based on exposure risk and clinical assessment is critical.

Table 2: Exposures to EVD and Public Health Actions

Exposure Level Clinical Presentation Public Health Actions

High Risk Exposure

Percutaneous (e.g., needle stick) or mucous membrane exposure to body fluids of EVD patient

Direct care of an EVD patient or exposure to body fluids without appropriate personal protective equipment (PPE)

Laboratory worker processing body fluids of confirmed EVD patients without appropriate PPE or standard biosafety precautions

Participation in funeral rites which include direct exposure to human remains in the geographic area where outbreak is occurring without appropriate PPE

Fever OR other symptoms consistent with EVD without fever

Consideration as a probable case

Medical evaluation using infection control precautions for suspected Ebola, consultation with public health authorities, and testing if indicated

If air transport is clinically appropriate and indicated, only air medical transport (no travel on commercial conveyances permitted)

If infection control precautions are determined not to be indicated: conditional release and controlled movement until 21 days after last known potential exposure

Asymptomatic

Conditional release3 and controlled movement4 until 21 days after last known exposure

Low Risk Exposure

Household member or other casual Fever WITH OR WITHOUT other

Consideration as a probable case

Medical evaluation using initial infection control precautions for suspected Ebola, consultation with


Exposure Level Clinical Presentation Public Health Actions

contact with an EVD patient

Providing patient care or casual contact without high‐risk exposure with EVD patients in health care facilities in outbreak‐affected countries*

symptoms consistent with EVD

public health authorities, and testing if indicated

If air transport is clinically appropriate and indicated, air medical transport only (no travel on commercial conveyances permitted)

If infection control precautions are determined not to be indicated: Conditional release and controlled movement until 21 days after last known potential exposure

Asymptomatic

Conditional release3 and controlled movement4 until 21 days after last known exposure

No Known Exposure

In affected country

No low‐risk or high‐risk exposures Fever WITH other symptoms consistent with EVD

Consideration as a suspected case

Medical evaluation and optional consultation with public health authorities to determine if movement restrictions and infection control precautions are indicated

If movement restrictions and infection control precautions are determined not to be indicated: travel by commercial conveyance is allowed; self‐monitor until 21 days after leaving country

Asymptomatic

No movement restrictions

Travel by commercial conveyance allowed

Self‐monitor5 until 21 days after leaving country

* Outbreak‐affected countries include Guinea, Liberia, Nigeria and Sierra Leone as of August 4, 2014 1 Fever: measured temperature ≥ 38.6°C/ 101.5°F or subjective history of fever 2 Other symptoms: includes headache, joint and muscle aches, abdominal pain, weakness, diarrhea, vomiting, stomach pain, lack of appetite, rash, red

eyes, hiccups, cough, chest pain, difficulty breathing, difficulty swallowing, bleeding inside and outside of the body. Laboratory abnormalities include

thrombocytopenia (≤150,000 /µL) and elevated transaminases. 3 Conditional release: Monitoring by public health authority; twice‐daily self‐monitoring for fever; notify public health authority if fever or other

symptoms develop 4 Controlled movement: Notification of public health authority; no travel by commercial conveyances (airplane, ship, train, bus, taxi); timely access to appropriate medical care if symptoms develop 5 Self‐monitor: Check temperature and monitor for other symptoms 6 Consultation: Evaluation of patient's travel history, symptoms, and clinical signs in conjunction with public health authority

3.3. Contact Tracing and Contact Follow Up

Contact tracing is finding everyone who comes in direct contact with a sick Ebola patient contacts are

watched for signs of illness for 21 days from the last day they come in contact with Ebola patient. If a

contact develops with a fever or other Ebola Symptoms, they are immediately isolated, tested,

provided care, and the cycle starts again–all the new patient contacts are found and watched for 21

days. Even one missed contact can make the outbreak going.

Standard definition for contacts persons of Ebola cases

Important: during an outbreak, the contact definitions are likely to be modified to be adapted to

newly reported infection risk factors related to the local event

Ebola case contact: Any person having been exposed to a suspect, probable or confirmed case of

Ebola or Marburg in at least one of the following ways:

has slept in the same household with a case

has had direct physical contact with the case (alive or dead) during the illness

has had direct physical contact with the (dead) case at the funeral

has touched his/her blood or body fluids during the illness

has touched his/her clothes or linens


has been breastfed by the patient (baby)

Provided that this exposure has taken place less than 21 days before the identification as a contact

by surveillance teams.

Contacts of dead or sick animals: Any person having been exposure to a sick or dead animal in at least

one of the following ways:

has had direct physical contact with the animal

has had direct contact with the animal’s blood or body fluids

has carved up the animal

has eaten raw bush‐meat

Provided that this exposure has taken place less than 21 days before the identification as a contact by

surveillance teams

Laboratory contacts: Any person having been exposed to biological material in a laboratory in at least

one of the following ways:

has had direct contact with specimens collected from suspected Ebola or Marburg patients

has had direct contact with specimens collected from suspected Ebola or Marburg animal cases

Provided that this exposure has taken place less than 21 days before the identification as a contact by

surveillance teams.

Other infection risk factors include: contact with a hospital where Ebola cases are being treated;

infection; or vaccination in the 21 days preceding the onset of symptoms.

3.3 Contact Tracing

Contact tracing is finding everyone who comes in direct contact with a known sick Ebola patient or a

probable Ebola case. It requires listing all contacts of probable and confirmed cases using a contact

listing form (see annex 3).

The contact person should be followed and monitored for signs of illness for 21 days from the last

day he/she come in contact with Ebola patient or a probable Ebola case using a contact follow‐up

form (see annex 4)

If the contact person is asymptomatic for 21 days after exposure, he released the follow‐up.

Role of Contact Monitors

Review contacts for monitoring and tracing to ensure clear information is available

Visit the homes of listed contacts daily for observation for 21 consecutive days

Report symptomatic cases to supervisor and/or alert coordinator for further management

Review and exclude contacts that have completed 21 days

Submit daily reports about contacts to supervisors

Sensitize communities about referral and denial

Role of Alert Coordinator

Receives and logs in alerts in the alert management database

Disburses response teams for alerts that require immediate action

Presents a daily report of all alerts received and their status to the surveillance meeting

Coordinates with logistics team to ensure response teams are able to do their work


Receive, synthesize daily reports from Supervisors

Role of Woreda supervisor

list all contacts to probable and confirmed cases using a Contact listing form

What Information is required for contact tracing?

Laboratory Result

Total number of contacts listed using the contact listing form

Total number of contacts seen daily

Contacts with symptoms by writing “Y” to the symptoms and immediately reporting to the supervisor.

3.4 Rumors Verification

Rumours of EVD should be treated like real incidents and require urgent verification.

There may be rumors of people dying with haemorrhagic symptoms.

There may be an abnormal and unexpected increase in mortality in a certain area, particularly in members of the same family or one village.

Numerous health staff have fallen sick or died.

Rumours about EVD can reach the surveillance system by different routes:

By the community to the Health extension worker during their visit or Health promotion activities.

Spontaneously by the community member to anybody working in an area or their relative,

Media can report EVD cases or deaths.

As information may be numerous and the right information needs to be gathered before the rumour

verification team will go to see the case. Verify if the symptoms fit in the case definition, and make

sure that relevant information is noted before the verification team goes: e.g. the name of the

suspected case, name of the informant, Gott, Kebele, symptoms and contact history.

If a patient died at home, a medical person should take the clinical history from the family. If there is

a suspicion that the person could have died from Ebola, then the burial team needs to be alarmed to

perform safe burial practices.

Activities:

Each suspect needs to be checked by a medical person that decides if it is a real suspected case and needs to be taken to the Ebola quarantine and isolation ward.

A notification form should be filled in for each rumour (Annex 1). All rumours including the outcome should be registered in a Rumour Registration Book.

If the rumour case is identified as a suspect case, then the patient needs to be transported to the Ebola quarantine unit for assessment and possibly sample taking and admission. The suspected case should not be in contact with anybody until the ambulance team arrives.

As many of the rumour cases might be treatable to common illness, it is advised that always take drugs with you and you need to rule out other treatable diseases/conditions e.g. anti‐malarial, antibiotics and paracetamol.


Whenever you go to verify a rumour take with you at least 3 full PPE clothing with you: for the medical person, the sprayer and 1 spare.

Supplies for Rumor Investigating Team

The following items must be carried in the vehicle. Verify the presence of all items listed in the

following checklist before starting work.

Table 3: Items that are required by rumour investigating teams

3.5 Transporting a Suspected Case

When a suspect case is identified he/she must be transferred to the designated Ebola quarantine or

isolation ward.

To prevent contamination and spreading of infection, patients need to be transported in a safe way. A

pick‐up car with a closed (or open) back is the most preferred and practical to use:

Patients can be transported separately from the transporting staff

Patient is not visible during transport.

The outside is easy to disinfect.

The decision to take a person to Ebola quarantine ward often leads to highly emotional and tense

situations. Communication about the reasons and the procedures to the family and the community is

extremely important to avoid misunderstandings and mistrust.

Item Quantity per person (take spare items for 1 person with you)

Protective Equipment Plastic aprons 1 Goggles 1 Coveralls 1 Head covers 1 Masks 1 Examination gloves (box at least half full) 1 Rubber cleaning gloves 1 pair

Other equipment Total quantity for the team 10-litre spraying machine filled with 0.5% chlorine solution 1 1-litre hand-sprayer filled with 0.05% chlorine solution 1 Plastic sheeting 3m-3m 1 Thermometer 2 Plastic rubbish bags 4 Hand soap 1 bar HTH granules and 1 measuring spoon 1 kg Bucket with lid to hold re-usable protective items after use 1 Guideline for preparing chlorine solutions 1 Tape 1 roll

Medication Anti-malarial: Coartem, oral quinine (pregnant ladies), etc. Oral antibiotics: Ciprofloxacin, amoxicillin, etc. Paracetamol: adults and children Oral Rehydration Solution


Activities

Transportation of suspect cases to the Ebola treatment unit in a safe way.

Spraying of the place where the patient was accommodated.

Spraying of the back of the pick up where the patient was seated

A transport team should be trained, a driver, medical personnel two sprayers are the minimum team

members. They should take 5 PPE with them: 1 for medical person, 2 sprayers, 1 for the caretaker and

1 spare one.

Procedures when transporting the patient to Ebola treatment unit

Take the following items:

2 spraying machines: one for the sprayer dressed up and one for the sprayer undressed.

A mattress with plastic cover to put at the back of the pick up where the patient can lay or sit on during the transport.

Take stretcher to transport patient to the car and from the car to the Ebola ward in case the patient can't walk.

Something that is easy to disinfect on which the patient can step to facilitate to step into the back of the car if the patient can walk.

A bucket with a small amount of a prepared 0.5% solution can be taken at the back of the car in case there is a history of vomiting.

Dressing:

The driver and the health promoter should not be close to the patient and don't need to put on PPE protective clothes. They should be dressed in normal clothes to be as 'normal' and accessible for the population as possible. Explanation will be given to the community about the different steps.

Transporting Patient:

One caregiver can be allowed to support the patient during the transport and should stay on the back of the car with the patient. This person needs to wear protective clothes for caretakers.

If the patient is mobile and can walk alone: The patient will be instructed to take place in the back of the pickup. There is no need for the Rumour verification team to dress up if the patient will not be touched and they keep a distance. When touching anything touched by the patient, for example when closing the back of the pick‐up, examination gloves should be used and these should be sprayed before removal and disposed of safely

If the patient is too weak to walk and needs to be transported with the stretcher: Two people should get dressed up, put the patient on the stretcher and put in the back of the car, together with the caretaker. Dressing and undressing should take place in front of the community in a transparent way. If the patient is heavy, more people need to dress up.

Spraying of the house:

The house where the patient lived when he/she was sick needs to be sprayed. The ambulance team can spray the house before transporting the patient to the Ebola treatment unit or the burial/spraying team can be called. If the house can't be sprayed immediately then the door of the house needs to be locked and no one is allowed to enter the house until the arrival of the Spraying Team. It is advisable to spray the houses of all suspects immediately.


Arrival at the Ebola treatment unit;

The ambulance team should inform the Ebola treatment unit that they will arrive with a patient.

The pick‐up should drive up to the patient's entrance of the Ebola ward.

The back of the pick‐up, the mattress, the bucket (if unused), and other items used need to be properly disinfected with a 0.5% chlorine solution.

4. Outbreak Investigation, Sample Collection and Shipment

4.1 Outbreak Investigation

It is mandatory to establish Ebola Rapid Response Team (ERRT) members at every level to

conduct an investigation of reported Ebola Virus disease. Different experts can be identified

and trained. The RRT should include:

An Epidemiologist

A clinician

A laboratory technician

Environmental health specialist,

Public health officer

A representative of the local health authority,

More professionals based on the type of the PHE.

Partner experts from WHO or Centre for Disease Control (CDC), MSF and others can join to

assist the outbreak investigation.

Before the deployment of the RRTs, all the members of the RRT should be briefed on the

situation, the roles and responsibilities they are expected to play, means, time and frequency

of communication etc. There is a need to assign clear leadership role to one of the team

member based on their level of expertise. Begin the investigation in the most affected places.

Avail relevant resources that are required during the field activity such as,

Different formats (case based formats, line list, outbreak reporting formats)

This guideline and other relevant guidelines and reading materials

Supplies for collecting lab specimens

Supplies that are required for the investigation,

Infection prevention equipment such as personal protective equipment (PPE)

Laptop and wireless network for report writing and communicating reports,

Communication means (Mobile phone, Sat Phone, ‐‐‐) with communication cost if necessary.


The RRT should be sent as quickly as possible to investigate; the team must have all materials

and equipment necessary for safely carrying out an assessment: examining patients,

collecting samples, and packaging and transporting the samples according to standard.

4.2 Confirmation of Diagnosis by Laboratory: Collection of Specimen and Shipment

(SOP on Lab collection and shipment)


III. CASE MANAGEMENT OF PATIENTS

1. Principles for Clinical Case Management

Patient safety in hospital is a fundamental right that must be guaranteed to all hospital patients.

Nursing care staff must make the quality of reception, treatment, and care a priority.

Hospital staff must offer psychological support to patients and their families.

Patients and their families have a right to transparent, clear, understandable, accessible, and reliable information.

Each medical intervention requires the free and informed consent of the patient. Consent may be given in writing or orally

In the framework of biomedical research, consent forms must be written in the national language. If the person is unable to give consent (e.g. if they are underage), then the free and informed consent of a parent or legal guardian is required. If the patient is illiterate, then a third party may act as witness.

The patient’s beliefs and religion must be respected.

The patient’s right to privacy and confidentiality must be upheld.

Patients and their families must be given the opportunity to participate in health care decisions that affect them.

2. Set Up and Organization of the Ebola Treatment Center

The setup of the Ebola treatment center should allow activities to be performed in an easy manner with a

clear, rational movement and circulation of people and materials. Minimizing complexity, confusion and

physical exercise contributes to create a safe working environment.

2.1 Location

A single Ebola treatment center is the easiest to manage in terms of training, human resources and

logistics. However, there may be circumstances that require 2 or more settings.

The location of the Ebola should be:

As close as possible to the epicenter of the outbreak to minimize movements,

Easily accessible by cars (ambulance, material, water trucking, etc.),

At a strategic point to have sufficient water supply available,

Spacious to allow adequate space for all activities in the center.

2.2 Buildings / Structures

If there is an isolation area already in use, this can be improved for further use, or a new isolation area

can be built. Existing health structures or other buildings can be used. If no appropriate buildings are

available tent structures can be used, however good infection control will be difficult, and tents can

become extremely hot unless sheltered from the sun.


To avoid cross infection, suspected, porbable and confirmed cases need to be accommodated in

different rooms or buildings.

Other important issues are:

Beds need to be at least 1 meter separated to ensure privacy and prevent transmission of the

virus.

Wards/patient rooms should have a good ventilation to reduce heat and humidity and to

evacuate chlorine gas.

Use of air‐ conditioner or ventilator is not recommended.

Mosquito net use is not recommendable due the disinfection procedures, but mosquito

screening and insect traps can be installed on windows instead.

2.3 Risk Zones

There are 3 different risk areas in the ebola treatment centers (Isolation Centers) according to their

level of risk of contamination:

A. High‐risk zone

This area is where: Care for suspected, probable and confirmed patients take plac,

Bodies of deceased patient prepared for burial and temporarly stored

Launderying of contaminated clothes carried out.

Waste materials burried or burned.

Laterine and shower for the patients built.

All waste from Low‐risk zone is transferred to the High‐risk zone for disposal.

High‐risk zones outside the isolation facilities may include: Patient’s and deceased patient’s houses.

Morgues.

Medical laboratories and operating theatres.

Traditional health services where by cases visited.

Contamination:

The zone is highly contaminated and everything in this area is considered as being contaminated

including buildings, personal belongings, paperwork, patients and staff (prior to disinfection and

removal of PPE). All materials being used in high‐risk must stay in high‐risk zone.

Clothing:

All the staff entering this area should be dressed in full PPE (Scrub suit, coveralls, goggle or face

shield, face mask, gloves, boots and apron) and adapted PPE for visitors is mandatory. Patients

are not expected to wear PPE and can be admitted in normal clothes.

People:

Only patients, designated staff and authorized visitors are allowed to inter inside the high‐risk

zone.

B. Low‐risk zone


This area is where:

Dressing of full PPE takes place.

Laundarying of scrub suits, apron, boots, heavy duty gloves done

Store of supplies situated.

Doctors’ room located.

Contamination:

In principle no infectious material should remain, however there is real potential for

contamination to occur due to uncontrolled movement of contaminated people or material from

high riks zone.

Clothing:

All people entering the Low‐risk zone change into scrub suits, gloves and boots.

People:

Medical staff, cleaning staff, water/sanitation and logistic staff, etc.

C. No‐risk zone (Outside the Ebola risk zones)

No infectious material should be present outside the isolation area, but in an epidemic situation infectious material or persons can be anywhere.

General universal precautions to reduce EVD in health settings should be in place.

There is no ‘no‐risk zone’ in an EVD outbreak.

2.4 Activities and Facilities in the Different Risk Zones

Different activities and facilities are required inside the different risk zones in the Ebola treatment

unit.

A. High Risk Zone

Ward or rooms for suspect patients.

Ward or rooms for confirmed patients.

Ward or rooms or space for probable patients.

The following facilities should be available in suspected, probable and confirmed areas (i.e. 1

facility is needed in each area):

Latrines and bathing facilities

Small store for medication and material.

Water collection points (e.g. water taps)

Water point with 40 liter water buckets: 1 bucket for 0.5% chlorine solution and 1 bucket for 0.05% chlorine solutions

Potable water point for patients: 40 liter water bucket or tap

Hand washing point for patients

Laundry area


Shaded area for patients. (If possible close to outside fence to allow communication with relatives/friends that are outside the isolation facilities, but with double fencing or enough space to avoid physical contact or droplets transmission).

One waste zone with burning area, sharps pit and organic waste pit. (Do not use existing ones, as they can’t be reused after the outbreak is declared over.)

One Morgue.

Spare building for possible supplementary facilities (delivery, paediatrics, recovery zone etc.)

B. Low‐risk zone

Laundry and drying area.

Area for the preparation of chlorine solutions.

Doctor’s room: resting area and part of medical file papers will be stored here.

Small pharmacy and store.

Changing room to enter and exit Low‐risk zone.

Changing room to enter and exit High‐risk zone.

C. No‐risk zone (Outside the Ebola risk zones)

Kitchen for patients. (E.g. kitchen from hospital can be used.)

Latrine and shower for staff.

Psychological debriefing room for staff and patients

2.5 Fencing

Fencing is important to mark the different risk zones. By clearly indicated borders between the risk

zones the staffs is aware of entering a different risk level.

A fence should be put around the whole isolation facility to mark the borders between outside the isolation facility and inside the isolation facility. Use mesh fencing for transparency.

Physically separate High‐risk and Low‐risk zones in the Ebola treatment unit by fencing or using existing walls to prevent uncontrolled movements between the zones.

Different latrines, bathing facilities and stores should be created for suspected and confirmed patients to prevent cross infection between confirmed patients to negative suspect cases waiting for the lab results. Separation needs to be well indicated and understandable to prevent confusion amongst the patients and the staff.

2.6 Layout of Ebola Treatment Unit

The Ebola treatment unit layout should fit to the list of the facilities and functions the different risk

zones should serve. Accordingly the ideal lay out of the unit should look like the figure in Annex 5. The

shape can change depending on the existing situation of the space.

Entrance/exit points and disinfection

Numbers of entrance/exit points should be limited to be able to control people going in and

out and to ensure a proper disinfection.


Guards and disinfection points are needed at all entrance/exit points and the points need to

be well accessible for cars.

One entry/exit for entering the Low‐risk area for staff and caregivers.

Hand washing and shoe spraying with 0.05% chlorine solution at entry and exit to avoid taking

contamination into or outside the low risk area.

Two entries/exits for entering/leaving the High‐risk area: One for staff and caregivers (via the

Low‐risk area) with sprayer and disinfection area and one for patients directly

entering/leaving the suspect area with sprayer/guard for disinfection when discharged

patient leaves.

One separate exit for dead bodies close to mortuary.

Changing Rooms

Two different changing rooms are necessary (Example of layout of changing rooms See

Annex 6 and 7)

Changing room 1

Located at the entrance to the Low‐risk zone to take off normal clothing and change into

basic protective clothing when entering the Low‐risk zone.

Also used for take‐off basic protective clothing and change into normal clothing when leaving

the Low‐risk zone.

Important necessities for changing room 1:

Clean scrub suits, boots and gloves in sufficient quantities and sizes available.

Buckets or boxes to put in dirty clothes when changing.

A division for men and women to change clothes.

Shelves or hangers to leave normal (street) clothing.

Changing room 2

Located at the entrance to the High‐risk zone to put on and take off the additional PPE

required in the High‐risk zone.

Important necessities for changing room 2:

Staff entering clean and staff leaving dirty or potentially contaminated the High‐risk area

should not interfere with each other.

Entry path should be separated from the exit path to prevent cross contamination between

‘dirty’ people coming from the High‐risk area and ‘clean’ people from the Low‐risk area.

The border between the different risk zones should be clearly indicated.

Sufficient PPE with gloves in different seizes available.


Mirrors and adequate lighting to check protective gear. When dressing best is to dress in

pairs to be able to check each other when dressing.

Disinfection point for staff leaving the High‐risk area with sprayer and buckets (bowl) with

0.5% and 0.05% chlorine solution and clean water to wipe of the chlorine of the goggles.

2.7 Patient screening area

Screening of patients should be done in No‐Risk zone The health worker needs to dress in glove, face mask and eye goggle

Keep a distance of at least 1 meter from the patient

The patient has to face away from doctor at 90 degrees

Take temperature of the patient from behind

3. Patient Care at Ebola Treatment Unit

3.1 Medical Staff Medical and nursing care should be provided 24 hrs per day and 7 day per week.

Organize 8 hrs shifts. Adequate rest needs to be taken after shifts,

During each shift 2‐3 breaks need to be taken. The staff should undress and go out of the High‐risk area when having a break.

4 Teams can be formed: 1 team for each shift and 1 off.

Each team should contain medical doctor or Health officer and 2‐4 nurses, depending on the amount of patients admitted and the available human resources. It is advisable to work in couples for a good collaboration and to supervise each other.

A medical doctor should supervise and train the staff.

3.2 Admissions Admission should be possible 24 hrs around the clock. All identified suspect or probable cases need to

be admitted in the suspected or probable area until laboratory results are known or clinical discharge

criteria are reached (in absence of a lab).

The following activities need to be done on admission:

Explanation needs to be given to the patient and the patient's attendant about the reason of admission, the procedures and rules in the Ebola treatment unit, the location of toilets and showers and the visiting hours.

Ideally an information paper for patients and one for the patient's attendant should be read and explained.

All material will be provided from inside the Ebola ward to the patients. Items given from outside to the patient may need to be destroyed and this should be well explained to the patient and relatives. Under supervision it is allowed to bring food from home to the patient.

A bed in the suspected area needs to be prepared and indicated to the patient.

Different items need to be given to the patient like mattress, blanket, cup, plate, soap, etc. These items must not be shared in between patients.

Creation of a personal medical file containing the investigation form.

Observation sheet


Symptomatology and vital signs needs to be started on day of admission and continued during the

whole period of stay. Two forms should be filled in: 1 stays in the High‐risk area and 1 in the medical

room in the Low‐risk area.

Treatment sheet

Needs to be filled in with the prescribed treatment by the doctor in charge, also 1 sheet inside and 1

outside high‐risk area.

3.3 Laboratory Tests A lab test needs to be performed if possible on the day of admission. Samples should only be

taken for diagnostic purposes. Discharge decisions are taken on clinical grounds, but in some cases sample results might help in taking the decision. Sample taking is a high‐risk procedure. When taking a sample prudent behaviour and concentration is essential.

PPE doesn't protect a person from a needle stick incident.

If the result is negative and the sample is taken between days 0‐3 after onset of symptoms, the test should be repeated. The second sample needs to be taken on a day more than 3 days after start of symptoms. Also sometimes a clinically obvious case might have a negative laboratory result due to reverse transcriptase inhibitors present in the blood.

If the test is positive for Ebola the patient will need to be transferred to the confirmed area and the area where the patient was accommodated in the suspected ward need to be disinfected.

3.4 Medical Care After attending each patient the gloved hands should be washed with 0.5% chlorine solution

before changing the gloves to prevent spread of infections between patients.

Currently there is no curative treatment for Ebola virus diseases. Only supportive treatment can be offered to the patients. However experience in former outbreaks shows that supportive treatment reduces the suffering of the patients and aggressive invasive supportive treatment might maximize chances of survival.

Detailed data collection on treatment given and treatment outcome needs to be gathered to gain a better understanding and more information about the effects of the different supportive therapies.

Experimental treatments with different types of drugs or vaccines may be considered during an outbreak, if no harm for the patient can be expected and if consent is provided.

Medical equipment for physical examination like blood pressure machines and stethoscopes are difficult to use due to the barrier created by the protective clothing. Moreover the disinfecting procedures needed after each use, with chlorine solutions will destroy the material and reduce the reliability of the equipment.

No digital thermometers should be used. If only digital thermometers are available, each patient should have his own and after discharge or death, the thermometer should be destroyed.

Different levels of supportive treatment may be provided depending on the safety conditions in the isolation ward. Providing basic oral medication and rehydration solutions is easy and involves minimal risk for staff and patients.


3.5 Invasive Procedures

Invasive procedures like injected drugs, IV fluids and NG tubes are potentially dangerous for the

person performing them. It should be minimized and only be performed when the required safety

conditions are achieved.

Safety conditions for invasive procedures:

Availability of skilled, experienced and well trained staff

Adequate infection control

Sufficient lighting

2 people should perform the invasive procedure: one actually performing the procedure and the other assisting in handing out material and controlling the patient.

Patients should be properly positioned.

Sharp box and all material needed should be taken to the bedside.

Inserted cannulas should be well secured to avoid being pulled out by the patient, resulting in spreading contaminated blood.

Plastic cannulas should be used for IV infusions. Metal needles and butterflies should only be used for injections and not for drips, given the hazard they pose.

No risk should be taken with aggressive or confused patients. Tranquillizers should be given to them before performing dangerous procedures or such procedures should be avoided.

No invasive care should be provided to a patient where a non‐invasive alternative is equally effective, e.g. there is no need for injectable medication if oral medication is sufficient.

If injected treatments are given, medicines with long half‐lives should be chosen to minimize the number of injections that need to be given (e.g. Ceftriaxone).

Each invasive procedure is a dangerous action for the person performing the procedure and his

assistant. Therefore limit the invasive procedures to the absolutely necessary, but keep in mind that

intensive supportive treatment may have a positive impact on the outcome.

3.6 Hydration

Oral hydration

Ebola and Marburg provoke gastro‐intestinal symptoms such as watery diarrhoea, vomiting and anorexia, as well as causing fever. This may result in severe dehydration.

Oral Rehydration Solution (ORS) should be provided to patients able to drink and support needs to be given to weak patients. Patients with light vomiting should be put on anti‐emetics.

IV hydration

Patients with insufficient oral intake, severe diarrhoea or vomiting (insufficient input for increased output) or paralytic ileus should start IV hydration.

Perfusion rate and quantity of fluid depend on the grade of dehydration. Patients need to be monitored for signs of over‐hydration resulting in pulmonary oedema e.g. engorged jugular veins, tachypnoea or tachycardia.

3.7 Management of Shock in EVD Patients

General signs of shock (poor perfusion)

Low BP (SBP <90)


Fast weak pulse

Pallor or cold extremities

Decreased capillary refill

Dizziness or inability to stand

Decreased urine output(<30ml/hour)

Difficulty breathing

Impaired consciousness, lethargy, agitation, confusion.

Assessment of pulse and BP should be taken in the context of the patient's premorbid state, pregnancy, age, and medication. Some pregnant women, patients with chronic illness, and others may normally have a SBP <90 mmHg and have normal mental status, capillary refill, and urine output; they do not have shock.

VHF patients can be in shock from internal haemorrhage or from septic shock. The pathophysiology and the intensive supportive care for VHF are the same for septic shock from a bacterial infection, malaria and other causes of septic shock. Intensive supportive care is the only clinical management that can be provided to these patients and may have a positive impact on disease outcome.

VHF patients may also have co‐infection with bacteria or malaria that can contribute to septic shock. It should also be recognized that VHF patients can also develop hypovolemic shock as a result of haemorrhage.

The shock in a VHF patient may be a combined picture from haemorrhage, disseminated intravascular coagulation (DIC) and from sepsis. Call for help from the most experienced clinician available when a VHF patient develops shock.

Manage septic shock in adolescents and adults

Clinical Diagnosis

Suspected infection plus Hypotension (systolic blood pressure<90mmHg) plus One or more of the

following:

Pulse >100 per minute

Respiratory rate >24 breaths per min ute

Abnormal temperature (<36° C or >38° C).

General principles of managing patients with septic shock

Manage airway (see Quick Check).

Give oxygen (see Quick Check).

Give IV fluid rapidly (see specific fluid recommendations which follow).

Treat underlying cause.

Consider vasopressors if SBP <90 and signs of inadequate perfusion after fluid resuscitation.

Monitor ‐ record ‐ respond.

Give fluids rapidly

First give an initial 1000 ml LR or NS bolus, continue Ringer's lactate (LR) or Normal saline (NS) at 20 ml/kg/hour, not to exceed a maximum of 60 ml/kg in the first 2 hours (including the initial bolus).

Monitor systolic blood pressure (SBP) and clinical signs of perfusion (urine output, mental status).


If SBP remains <90 and signs of poor perfusion continue after fluid resuscitation over the first 2 hours,

Consider adding vasopressors (dopamine or epinephrine) using the instructions in Appendix D (How to give vasopressors).

To avoid fluid overload, decrease the rate of fluids to 5‐10 ml/kg/hour.

At 2‐6 hours, if SBP rises above 90, continue fluids at 2 ml/kg/hour. However, if the pulse is still high and there are other signs of poor perfusion, patient may still be volume‐depleted and need more fluids.

Watch carefully for signs of fluid overload (increased jugular venous pressure, increasing crepitation on auscultation). If present, decrease the rate of fluid administration. Call for help from more senior clinician to further evaluate overload and decide fluids

Give empirical IV antimicrobials within the first hour.

Antibiotics: Urgently administer broad spectrum antibiotics by IV. Take blood cultures before antibiotics, but do not delay treatment to get blood cultures.

Choice of antibiotics depends on presence of signs of local infection, local disease

Patterns and availability of antibiotics. A good choice is ceftriaxone 2 grams daily IV.

If community‐acquired pneumonia is suspected, refer to your national or institutional guidelines.

ceftriaxone (2 gram daily IV) or ampicillin 2 grams every 6 hours plus gentamicin 1.5 mg/kg IV every 8 hours, plus ciprofloxacin.

Antimalarials: Do bedside RDT for malaria and if positive start artesunate IV, or if not available, IV quinine

In addition to repeated measurement of SBP, pulse, respiratory rate and pulse‐ oximetry, regular clinical examination is important for patients in shock. Pay particular attention to the signs of poor perfusion and signs of fluid overload to help guide on‐going management.

Signs of poor perfusion:

decreased urine output

altered mental status

Signs of fluid overload:

worsening crepitation on auscultation

dyspnoea

elevated JVP

peripheral oedema

Manage septic shock in children

Children can also be infectious. Use standard precautions (see section 7). Signs of shock in children:

Cold hands plus

Weak or absent puIse and either

Capillary refill time > 3 seconds OR

AVPU less than Alert

Children in shock who require bolus fluid resuscitation are lethargic and have cold skin, prolonged


capillary refill, fast weak pulse and hypotension.

Check whether the child's hand is cold. If so, determine whether the child is in shock.

Check whether the capillary refill time is longer than 3 seconds. Apply pressure to whiten the nail of the thumb or the big toe for 5 seconds. Determine the time from the moment of release until total recovery of the pink colour

If capillary refill is longer than 3 seconds, check the pulse. Is it weak and fast? If the radial pulse is strong and not obviously fast, the child is not in shock. If you cannot feel the radial pulse of an infant (< 1 year old), feel the brachial pulse or, if the infant is lying down, the femoral pulse. If you cannot feel the radial pulse of a child, feel the carotid. (See the Emergency Triage Assessment and Triage guidelines).

General principles of managing children with septic shock

Manage airway.

Give oxygen through nasal prongs or catheter‐ start at 1‐2 litres/min to aim for oxygen

saturation 90%.

Give IV fluid ‐ initial 20 ml/kg LR or NS bolus.

Treat underlying cause

Administer empirical broad spectrum antibiotics (eg ceftriaxone 80 mg/kg once daily)

Antimalarials: Bedside RDT for malaria and if positive, start IV artesunate (or quinine if

artesunate is not available)

Consider vasopressors if failure of fluids and blood to raise SBP and if signs of inadequate

perfusion persist.

Monitor ‐ record ‐ respond.

Initial intravenous fluid resuscitation for children with shock (and no severe malnutrition)

Check that the child is not severely malnourished, as the fluid volume and rate is different

Insert an IV line (and draw blood for emergency laboratory investigations).

Attach Ringer's lactate or normal saline; make sure the infusion is running well.

Infuse 20 ml/kg over 1 hour.

Emergency Fluid management in Severe Malnutrition

Shock: Cold, hands pulse absent, slow (<60 bpm) or weak pulse and either capillary refill >3

seconds or reduced consciousness.

Give 15 ml/kg in 1 hour of Half Strength Darrow's (HSD) in 5% dextrose or Ringers lactate. If

HSD in 5% Dextrose not available it can be made by adding 50 ml 50% dextrose to 450 ml HSD

If child improves:

Repeat this bolus over another 1 hour.

Then switch to oral or ng fluids using ReSoMal at 10 ml/kg/hour for up to 10 hours.


As soon as conscious introduce F‐75 and appropriately reduce amount of ReSoMal given.

If child does not improve:

Give maintenance IV fluids at 4 ml/kg/hr.

Watch carefully for signs of fluid overload

His is due to Excess of too rapid iv fluid

Incorrect use of hypotonic rather than isotonic crystalloid solutions

Continuation of IV fluids for too long (once plasma leakage has resolved

Use of large volumes of IV fluid in children with severe capillary leakage

Early sign:

fast breathing, chest in drawing, Large pleural effusions, ascites, peri‐orbital or soft tissue

oedema

Late sign:

pulmonary oedema, cyanosis, irreversible shock (often a combination of ongoing hypovolaemia

and cardiac failure)

The management of fluid overload varies depending on whether the child is in or out of shock

Children who remain in shock and show signs of severe fluid overload are extremely difficult

to manage and have a high mortality.

Avoid diuretics, as they will cause further intravascular fluid depletion

Aspiration of large pleural effusions or ascites can be considered to relieve respiratory

symptoms, but the risk of bleeding should be recognized.

If shock has resolved but the child has fast breathing and large effusions, consult with

pediatric expert to consider giving oral or IV furosemide 1 mg/kg once or twice a day for 24

hours (and oxygen therapy)

If shock has resolved and the child is stable, stop IV fluids and keep the child on bed rest for

24‐48 hours. The excess fluid will be re‐ absorbed and lost through urinary diuresis.

Remark:

In case of shock crystalloids should be used. Colloids should be banned as it may affect blood clotting

and evidence of superiority of colloids over crystalloids is lacking in patients with shock.

3.8 Symptomatic Care

Ebola infections often provoke a painful throat and difficulty in swallowing. Therefore the amount of

tablets to be swallowed should be as low as possible and the size of the tablets as small as possible.

Also tablets may be crushed.

Anti‐pyretics:


Fever is a common feature in Ebola infections and paracetamol can be given to reduce the

temperature and the pain. Aspirin and other non‐steroidal anti‐inflammatories should not be used due

to their effect on blood clotting.

Pain control:

Pains caused by Ebola infections, like headache, abdominal pains and joint pains are often severe.

Adequate painkillers can reduce the suffering of the patients.

Table 4: Antipyretic types and dosage based on the pain level

Pain level Medication Dosing

Mild pain Paracetamol Adults: 1 g PO 6 hrs. PRN, max 4 g/24 hrs. Children: 15 mg/kg

Moderate pain Tramadol Adults: 50‐100mg PO/IM/slow IV 4‐6 hrs. PRN Children: do not use < 15 yrs.

Severe pain Morphine Children and adults: 0.1 mg/kg SC 4hrs PRN

Remarks:

There is interaction between tramadol and morphine, so these medications should not be given simultaneously.

Morphine may be combined with codeine.

Nausea, vomiting and dyspepsia:

Nausea and vomiting are common. Anti‐emetics like promethazine or metoclopramide can be used.

Ebola often provoke stomach pain and dyspepsia. Dyspepsia can be treated with cimetidine, ranitidine

or omeprazole.

Table 5: Drugs for nusea, vomitting and dyspepsia treatment and its dosage

Medication Dosage adults Dosage children 2‐10 yrs.’

Promethazine 25‐50mg PO every 6hrs PRN 10‐25mg PO every 6 hrs. PRN

Metoclopramide 10 mg PO/IM/slow IV every 6‐8 hrs. 2‐5 mg PO/IM/slow IV every 8 hrs.

Cimetidine 200‐400 mg OD

Anxiety

Anxiety is common. Psychologists can help to reduce anxiety. Diazepam (e.g. 5mg PO TID) might be

given to manage severe anxiety.

Agitation and confusion

Patients can get agitated, confused or aggressive and can be a danger to themselves and others.

Tranquillizers like chlorpromazine or diazepam can be given. Stop the usage of chlorpromazine if

sudden raise of temperature occurs: possible neuroleptic malignant syndrome (this is an uncommon,

but serious event when using chlorpromazine).

Table 6: Drugs for agitation and confusion treatment and its dosage

Medicine Adult dosage Children dosage Remarks

Chlorpromazine 25‐50 mg IV/IV/ PO every 8 hrs. PRN (half

dosage in elderly patients) 0.5mg/kg PRN

Further doses may be needed, but

wait minimum 20

Diazepam 5‐10mg IM PRN, not repeated within 1 hr. 0.3 mg/kg IV Minutes before next application.


3.9 Presumptive Treatment

Symptoms of Ebola infections are similar with malaria, typhoid or shigellosis and Ebola patients may

have concomitant infraction with these diseases that can interfere with their ability to build an

immune response to the Ebola infection. Therefore this disease must be rule out or appropriate

antibiotics and anti‐malarial treatment should be provided to all suspected patients on admission and

should not be delayed until the lab results of Ebola are known.

The systematic treatment needs to be used in a flexible way and can't replace the clinician's

judgment.

Broad spectrum antibiotics

A broad‐spectrum antibiotic with oral cefixime or injectable ceftriaxone should be given starting from

the day of admission to cover the wide range of pathologies. For penicillin allergic patients’

azithromycin can be prescribed. Duration should be minimum 5 days, but may be continued during the

whole length of stay to keep the patient covered, depending on the clinician's point of view.

However, the clinician should prescribe antibiotics always according to the presentation and severity

of the symptoms, and according to concomitant epidemics.

Anti‐malarial

A full regime of anti‐malarial treatment should be given on admission according to the anti‐malarial

protocol used. Coartem can be given safely according to the current protocol, but has many drug

interactions. Coartem can't be given simultaneously with ciprofloxacin, cimetidine, and macrolides

like erythromycin or anti‐psychotics like chlorpromazine.

Supplementation

Vitamin deficiencies may have a negative influence on the immune reaction of the patient to the virus

and should be corrected. Vitamin A, B, C or multivitamins can be beneficial to the patients.

Table 7: Medications and dosages of supplemental treatment

Type of Vitamin Dosage for adults Dosage for children

Vitamin A (Retinol) 200.000 IU PO on day 1,2 and 8 100.000 IU PO on day 1, 2 and 8 (children

between 6m‐1yr)

Vitamin B (Vit.B complex) 1 tab per day 1 tab per day

Vitamin C (Ascorbic acid) 250‐500mg PO 3times/day 125‐250 mg 3times/day

Multivitamin 1 tab per day 1 tab per day

3.10 Nutritional Support

Procedures to provide food

Food needs to be provided by the hospital, as some patients will not have family to provide food.

Food should be carried with containers that are locally used for the transport of human food

from outside the isolation facilities to the High‐risk area where it will be transferred in empty


containers inside the High‐risk area without contact between the containers. In the High‐risk area

it will be divided for the suspected area and the Confirmed area. Some food should be kept in the

Low‐risk area for the caregivers.

Families should also be allowed to provide food for their relatives, as this food is likely to be more

acceptable by the patients. Family can provide food to the patient 'over the fence' of the High‐

risk area under supervision of the staff, and no items should be taken inside the High‐risk area.

Plates inside the High‐risk area need to be disinfected and washed first before food can be

received. Help needs to be given to patients who are not able to eat independently.

Type of food

Ebola infections can provoke anorexia, vomiting and difficulty in swallowing. Inappropriate

feeding can contribute to an ineffective immune response to the infection. Food should be

easy to digest, well balanced and culturally acceptable.

The patient should be encouraged to take Plumpynut, besides the food provided by the

hospital, the hospital or the family. Alternatively porridge can be offered because it is easy to

swallow. NG tube feeding can be considered in severe feeding problems.

Nursing care

Nurses, rather than family members, should provide all basic nursing care, to reduce the risk

of transmission. However often there might not be sufficient nursing staff employed and

then family members may be needed to help providing care like feeding. These family

members must be instructed and supervised and protective clothing should be given.

Relatives involved in basic nursing care will be considered as a contact and will need to be

followed up for 21 days after their last visit to the Ebola treatment unit.

Nursing tasks (to be adapted to the available human resources and work load):

Patient monitoring: check temperature three times daily, Observation for symptoms that

need to be mentioned during the doctor's round.

Medication: (Separate stocks are needed for suspected and confirmed patients.) Medication

should be provided according to doctor's prescription and crossed after the patient's intake.

Call the doctor in case of any medical problem

Provide food, water and ORS and assists where needed and registers quantities.

Hygiene: help bathing in shower or in the bed and ensure clean bed linen for patient.

Explain what you are doing and why to the patient.

3.11 Psychological Support

Psychological support should be offered to all patients and families, ideally from the

beginning of the intervention. However providing psychological care in PPE might be

uncomfortable and difficult: The PPE is physically exhausting for the psychologist/counsellor


and for the patient it is impossible to see the face of the psychologist (seeing faces helps to

establish a good contact).

For mobile patients an area can be created where the patients can talk over the fence of the

High‐risk area with the psychologist at sufficient distance to prevent contamination.

3.12 Children in the Ebola Treatment Unit

Providing 24‐hour care and psychological support for babies and small children is difficult in

full protective clothing. The staff should provide the care as much as possible. However, for

the wellbeing of both children and parents, parents should be permitted to stay in the Ebola

treatment unit to care for their children.

Protective clothing should be provided and supervised by the staff in the Ebola treatment

unit. Parents/caregivers should take regular breaks and leave the Ebola treatment unit, e.g. at

times when there is food for them available in the Low‐risk area.

Ideally one person should take care of the child to minimize the number of people at risk of

infection, but it might be decided that more caretakers will care for the child during the

admission time. All caregivers will need to be followed up as contacts.

3.13 Mothers with breastfeeding children

There is a high risk that mothers with Ebola infection will infect their children. Therefore

precautions to minimize this risk must be taken:

Stop breastfeeding immediately and provide artificial milk or Plumpy nut (if child is > 6

months). Continue stimulation of milk production and relieve breast congestion with a breast

milk pump.

Separate child from the mother and close monitoring is needed for 21 days. Child is seen as a

close contact. Discourage breastfeeding from another women (wet‐nursing).

3.14 Maternity and Ebola virus disease

Obstetric patients pose special problems in an outbreak:

Vaginal bleeding is a common symptom and obstetric patients are likely to fit the alert or

suspected case definition for EVD.

Patients with EVD are likely to abort or to miscarry and have a very poor prognosis. During an

EVD outbreak it is difficult to differentiate between a 'normal' spontaneous

abortion/miscarriage and one induced by the EVD on clinical grounds alone; a blood sample

will help with the diagnosis. Full term deliveries are rare in Ebola treatment unit, but basic

facilities for deliveries and a private area to conduct them should be installed if possible.


4. Discharge

4.1 Discharge Criteria

The decision to discharge a patient should be taken on clinical grounds, but if available can be

supported by the laboratory results. A negative PCR means that the virus can't be detected anymore

in the body and the patient is unlikely to be contagious. Patients can be discharged if they meet all

following clinical criteria:

Clinical criteria:

3 days without fever or significant symptoms AND A significant improvement in clinical condition

AND Able to feed, wash and walk independently.

Laboratory support:

Antigen or PCR is negative on day 4 or later after the onset of the symptoms OR PCR turned

negative after having been positive AND patient is clinically cured OR If patients suffers

symptoms, but these are not thought to be due to EVD, 2 negative blood PCR's 48 hrs apart can

be used as discharge criteria. The patient might be referred to another ward.

Fever can be absent in late and terminal stages of the illness and is not a reliable sign for

discharge (or admission). Absence of fever cannot be used alone to plan discharges.

4.2 Important Procedures before Discharge

Disinfection

On discharge all clothes should be disinfected by soaking them for 30 min in a 0.05% chlorine solution,

then wash with soap, rinse with water and then air‐dry. Severely dirty clothes should be burnt. It is

useful when replacement clothing brought by family members is available. All discharged patients

should take a shower with 0.05% chlorine solution and put on his/hers replacement or clean clothes

and avoid any contact with items in the Ebola ward. Disinfect and return other belongings to the

patient. The patient can go to the patient exit where hands and feet will be sprayed. The hospital

belongings like bed, mattress (with plastic protection) and buckets need to be disinfected and may

be reused by another patient. Sheets should be burned and eating utensils thrown away.

Accompany patient to his/her home

Rejection of patients by their communities is a common phenomenon in EVD outbreaks. A medical

person or a health promoter or a psychologist should explain to the family and the community that

they are not contagious anymore and that touching them is not a problem.

4.3 Supportive Treatment and Follow up

Convalescent patients will be weak for some weeks or months and additional help can be

provided:

Provide 1‐2 month supply of vitamin supplements.

Provide Plumpy nut as additional food to the normal food for a Flexible time period;

depending on severity of weakness and poverty of family)


Provide condoms for 3 months to all male discharged patients and explain the purpose. The

virus can be found in the semen up to 3 months after unset of disease, so theoretically

infecting other people is possible.

Regular visits are recommendable to follow the recovery, to see if additional supportive is

needed and to help integration into the community.

4.4 Patient Care in the Home Based Support and Risk Reduction

The designated caregiver will be the person entering the HBSRR after a proper training is

given. The medical person might accompany the caregiver when entering the HBSRR on the

daily visits, however sometimes daily visits cannot be assured (workload, distances, etc.).

4.5 Laboratory Tests

If possible laboratory tests for confirmation should be taken in the Home Based Support and

Risk Reduction. Use of PPE is compulsory and sufficient light should be there when taking the

sample.

4.6 Medical File

A medical file should be created as for patients admitted in the Ebolatreatment unit with:

notification form, admission and investigation form, observation sheet and treatment sheet

No injected treatment can be provided (no ensured sufficient lighting, no continuous follow

up, etc) but painkillers, oral antibiotics, anti‐malarials and ORS can be given by the caretaker.

4.7 Psychological Support

Psychological support should be provided to the patient, family members and the

community. The psychologist can also play a role in trying to convince the people off

transport to and admission into the Ebola treatment unit.

4.8 Management of Exposed Individuals

Individuals including health workers with percutaneous or mucocutaneous exposure to

blood, body fluids, secretions, or excretions from a patient with suspected EVD should

immediately wash the affected skin surfaces with soap and water. Mucous membranes (e.g.

conjunctiva) should be irrigated with copious amounts of water or eyewash solution.

Exposed persons should be medically evaluated and receive follow‐up care, including fever

monitoring, twice daily for 21 days after exposure. In case of temperature above 38.3°C (101

°F), hospitalize immediately in strict isolation. The incubation period between exposure and

clinical symptoms is a minimum of 48 hours.

Health workers suspected of being infected should be isolated and the same

recommendations outlined in this document must be applied until a negative diagnosis is

confirmed. Contact tracing and follow‐up of family, friends, co‐workers, and other patients


who may have been exposed to a VHF virus through close contact with the infected health

workers is essential


IV. INFECTION PREVENTION AND CONTROL

1. General Patient Care

Strengthen and carefully apply standard precautions when providing care to all patients

regardless of the signs and symptoms they present with. This is especially important because the

initial manifestations of EVD may be non‐specific. Hand hygiene is the most important measure.

Gloves should be worn for any contact with blood or body fluid. Medical mask and goggles or

face shield should be used if there is any potential for splashes of blood or body fluids to the face,

and cleaning of contaminated surfaces is paramount.

2. Disinfection in Ebola Treatment Units

The Ebola virus is considered to be fragile and can be destroyed by applying the following

methods:

Disinfection: Through the use of chlorine solution (strength of 0.5% or 0.05% depending on

the purpose) in accordance with the procedures indicated in this guideline.

Alcohol based hand rub

Heat: Through medical waste incineration, sterilization by autoclave or burning.

UV rays: Through the direct exposure to sunlight.

Strict application of universal precautions: Through good hand hygiene by regularly washing

with soap and water.

Change cleaning solutions and refresh equipment frequently while being used during the day, as

they will get contaminated quickly (follow your hospital protocols if available). For preparing

chlorine‐based solutions, see instructions in Annex 6.

3. Patient Placement, Staff Allocation, Visitors

Put suspected or confirmed cases in isolation rooms with an adjoining dedicated toilet, shower,

sink equipped with running water, soap and single‐use towels, alcohol‐based hand rub

dispensers, stocks of medicines, good ventilation, screened windows, doors closed and

restricted access.

if isolation rooms are unavailable, cohort these patients in specific confined areas while

rigorously keeping suspected and confirmed cases separate and ensure the items listed here

for isolation rooms are readily available. Make sure that there is at least 1 meter distance

between patient beds.

Ensure that clinical and non‐clinical personnel are assigned exclusively to EVD patient

care areas and that members of staff do not move freely between the isolation areas

and other clinical areas during the outbreak.

Restrict all non‐essential staff from patient care areas.

Stopping visitor access to the patient is preferred, but if this is not possible, limit their

number to include only those necessary for the patient's well‐being and care, such as

a child's parent.

Do not allow other visitors to enter the isolation rooms/areas and ensure that any

visitors wishing to observe the patient do so from an adequate distance

(approximately 15 m).

Before allowing visitors to EVD patients to enter, screen them for signs and

symptoms of Ebola.

4. Personal Protective Equipment, Hand Hygiene and Other Precautions

4.1 Personal Protective Equipment Protocols

Personal Protective Equipments (PPEs) includes impermeable coveralls or gown, examination

gloves, heavy duty/rubber gloves, head covers, shoe covers, aprons, closed shoes or boots,

facemasks, goggle and face shields. The type of PPEs to be worn depends on the activity we

are handling. However, if one enters to the high risk zone, he/she should wear complete

PPEs.

Gloves (non‐sterile examination gloves) to protect hands.

A disposable, impermeable coveralls or gown to cover clothing and exposed skin.

A surgical mask for mouth and nose protections

Goggles or face shield for eye protection.

Rubber boots (closed, puncture and fluid resistant shoes) to avoid contamination

with blood or other body fluids or accidents with misplaced, contaminated sharp

objects.

Shoe covers to protect the soles of the shoes from dirt that might stick to.

Wear water proof apron when undertaking any strenuous activity (e.g. carrying a

patient) or tasks in which contact with blood and body fluids is anticipated (e.g., the

patient has symptoms like diarrhoea, bleeding or vomiting and/or the environment

could be contaminated with blood or body fluids).

Wear a respirator (FFP2 or EN certified equivalent or US NIOSH‐certified N95), if any

procedures that stimulate coughing or promote the generation of aerosols (e.g.,

aerosolized or nebulised medication administration, diagnostic sputum induction,

bronchoscopy, airway suctioning, endotracheal intubation, positive pressure

ventilation via face mask) is planned to be performed. Avoid aerosol‐generating

procedures if possible.

Do not recycle any single‐use disposable PPE. Carefully clean and decontaminate reusable

equipment.

Dressing and Undressing Protocols of PPE at Ebola Treatment Units

1. Dressing Protocol

Dressing Protocol for Entering Low–Risk Zone from No‐Risk Zone

1. Go to the dressing room in No‐Risk Zone

2. Remove street shoes and street clothes (your own shoes and clothes).

3. Put on scrub suit and your personal rubber boots. Tuck scrub suit into boots.

4. Wash your hands with soap and water or alcohol swab.

5. Put on one pair of disposable gloves.

6. Bath your foot with chlorine.

7. Go into the Low‐Risk Zone.

For those working in the laundry area at the low risk zone follow the following additional

steps

8. Disinfect gloved hands with 0.5% chlorine.

9. Put on face mask 10. Put on goggle 11. Put on heavy duty gloves 12. Put on heavy duty apron


Dressing Protocol for Entering High–Risk Zone from Low Risk‐Zone

1. Go to a dressing room in the Low‐Risk area (dressing room no 2)

2. Disinfect the gloved hand with 0.5% chlorine.

3. Put on the cover‐all (make sure the sleeves are under the 1st layer of glove and put

on a plaster on top of it)

4. Put on the foot cover (if available).

5. Put on a second layer of gloves*1 (should be done after the goggles or face shield

if using heavy duty gloves).

6. Put on the face mask.

7. Put on the hood of coverall (if the coverall do not have hood, put on head cover).

8. Put on goggles or face shield (which ever available)

9. Put on waterproof apron (if you expect exposure with body fluids)

10. Bath your feet in chlorine solution


12. Go into the high‐risk zone.

NOTE:

In every steps of dressing someone should monitor you to ensure that the dressing is properly done

2. Undressing Protocol

When Leaving High–Risk Zone to Low–Risk Zone

1. Disinfect gloved hands with 0.5% chlorine solution before entering undressing

room

2. Bath your feet in chlorine solution.

3. Enter the undressing room.

4. Peel off disposable apron and dispose safely (throw away in a bio‐hazard plastic

bag).

5. If the apron is to be reused, immerse the apron in the container of 0.5% chlorine solution and after that in the second container 0.05% chlorine solution and hang it close to the second footbath.

1 Always change 2nd layer of gloves when moving from one patient to another while caring. Wash your gloved hand with 0.5% chlorine or alcohol hand rub of the gloved hand before putting on new 2nd layer gloves.

6. Remove the shoe cover (if there is any)

7. Disinfect the outer pair of gloves with 0.5% chlorine solution and remove them.

A. If using surgical gloves: throw away in the waste bin.

B. If using heavy‐duty gloves: place in the bucket containing 0, 05% chlorine solution.


9. Remove goggles, disinfect with 0.5% and rinse with clean water.

10. Hang it close to the second footbath, next to the apron.

11. Disinfect the gloved hands with 0.5%.

12. Remove hood of the coverall (if a separate head cover is used, remove and throw

away in the waste bin).

13. Disinfect gloved hands with 0.5%.

14. Remove coverall and throw away in waste bin.


16. Remove mask and throw away in waste bin


18. Take goggles and apron with you.

19. Step in the second footbath.

20. Now you are in the Low‐risk area

21. Hang the goggle and the apron.

22. Remove the inner layer gloves and throw away in the waste bin.

23. Wash your hands with 0.05% or use alcohol hand rub.

24. Put a new pair of examination gloves.

When Leaving Low–Risk Zone to No–Risk Zone

1. Proceed to undressing room ‐ changing room 1.

2. Before entering the room, wash gloved hand with 0.5% chlorine.

3. Bath your feet in 0.5% chlorine solution and have boots sprayed.

4. Remove boots using boot remover and put on slipper.

5. Remove gloves and dispose into waste bin.

6. Remove scrub suit and place in collection container for disinfection and washing.

7. Put on street shoes and street clothes (your own clothes and shoes).

8. Wash your hands with soap and water or use alcohol hand‐rub or wash with 0.05%

Chlorine solution.

9. Spray soles of street shoes with 0.5% chlorine solution when exiting the changing

room.

10. If shower facility is available, you can take body shower.

NOTE:

For staff wearing heavy duty gloves, before entering in to changing room 1, remove and immerse the heavy

duty glove in 0.5% chlorine solution and put in the designated area and follow the above steps.

4.2 Hand Hygiene Protocol

Carefully apply the following precautions to avoid any possible unprotected direct contact with

blood and body fluids when providing care to any patient with Ebola, including suspected

cases.

Perform hand hygiene:

before donning gloves and wearing PPE on entry to the isolation room/area,

before any clean/aseptic procedures being performed on a patient,

after any exposure risk or actual exposure with the patient's blood and body fluids,

After touching (even potentially) contaminated surfaces/items/equipment in the

patient's surroundings, and after removal of PPE, upon leaving the care area.

Hand hygiene should be performed within the isolation rooms/areas every time it is needed

according to the above indications during care to a patient, along with change of gloves.

When caring for patients in the same room, it is essential to organize the complete care to each

patient before moving to the next and to perform hand hygiene between touching the patients.

Furthermore, neglecting to perform hand hygiene after removing PPE will reduce or negate any

benefits of the protective equipment. To perform hand hygiene, use chlorine 0.05%, an alcohol‐

based hand rub or soap and running water applying the correct technique recommended by

WHO (Annex 13 and 14).

Always perform hand hygiene with soap and running water when hands are visibly soiled.

Alcohol‐based hand rubs should be made available at every point of care (at the entrance and

within the isolation rooms/areas) and are the standard of care. However, if alcohol‐based hand

rubs are unavailable, perform hand hygiene with soap and running water every time necessary

according to the above indications. If clean water supply is not available, use 0.05% Chlorine

solution for hand hygiene.

4.3 Injection Safety

Each patient should have exclusively dedicated injection and parenteral medication

equipment which should be disposed of at the point of care. Syringes, needles or

similar equipment should never be reused.

Limit the use of needles and other sharp objects as much as possible.

Limit the use of phlebotomy and laboratory testing to the minimum necessary for

essential diagnostic evaluation and patient care.9

If the use of sharp objects cannot be avoided, ensure the following precautions are

observed:

Never replace the cap on a used needle.

Never direct the point of a used needle towards any part of the body.

Do not remove used needles from disposable syringes by hand, and do not bend,

break or otherwise manipulate used needles by hand.

Dispose of syringes, needles, scalpel blades and other sharp objects in

appropriate, puncture‐resistant containers.

Ensure that puncture‐resistant containers for sharps objects are placed as close as

possible to the immediate area where the objects are being used ('point of use') to

limit the distance between use and disposal, and ensure the containers remain

upright at all times. If the sharps container is far, never carry sharps in your hand but

place them all in a kidney dish or similar to carry to the sharps container.

Ensure that the puncture‐resistant containers are securely sealed with a lid and

replaced when 3/4 full.

Ensure the containers are placed in an area that is not easily accessible by visitors,

particularly children (e.g. containers should not be placed on floors, or on the lower

shelves of trolleys in areas where children might gain access).

4.4 Environmental Cleaning

Wear heavy duty/rubber gloves, impermeable gown and boots when cleaning the

environment and handling infectious waste.

In addition, wear facial protection (mask and goggle or face shield) and overshoes if

boots are unavailable, when undertaking cleaning activities with increased risk of

splashes or in which contact with blood and body fluids is anticipated (e.g., cleaning

surfaces heavily soiled with vomit or blood or cleaning areas closer than 1 meter from

a patient with symptoms like diarrhoea, bleeding or vomiting, etc.).

Clean floors and horizontal work surfaces at least once a day with clean water and

detergent. Cleaning with a moistened cloth helps to avoid contaminating the air and

other surfaces with air‐borne particles. Allow surfaces to dry naturally before using

them again.

Dry sweeping with a broom should never be done. Rags holding dust should not be

shaken out and surfaces should not be cleaned with dry rags.

Cleaning should always be carried out from "clean" areas to "dirty" areas, in order to

avoid contaminant transfer.

Do not spray (i.e. fog) occupied or unoccupied clinical areas with disinfectant. This is a

potentially dangerous practice that has no proven disease control benefit.

Procedures for cleaning surfaces or objects contaminated with blood, other body fluids:

Environmental surfaces or objects contaminated with blood, other body fluids,

secretions or excretions should be cleaned and disinfected as soon as possible using

standard hospital detergents/disinfectants (e.g. a 0.5% chlorine solution or a solution

containing 1000 ppm available free chlorine).

Decontaminate the area with 0.5% Chlorine solution for 20 minutes and then remove

the fluid and discard it to the toilet.

Disinfected as soon as possible with 0.5% chlorine solution.

Cleaning floors and horizontal work surfaces:

Clean floors and horizontal work surfaces at least once a day with clean water and

detergent.

Start cleaning from “clean” areas and end to “dirty” areas

Always use a moistened cloth to avoid contaminating the air and other surfaces with

air‐borne particles.

Allow surfaces to dry naturally before using them again.

2.5 Management of Linen and Blankets

Linen and blankets that has been used on patients can be heavily contaminated with body

fluids (e.g. blood, vomit) and splashes may result during handling. Wear complete PPE

(impermeable gown, heavy duty/rubber gloves, boots, facial mask and goggle or face shield),

when handling them.

Soiled linen or blankets should be placed in clearly‐labeled, leak‐proof bags or buckets

at the site of use and the container surfaces should be disinfected before removal

from the isolation room/area. If there is any solid excrement such as faeces or vomit,

scrap off carefully using a flat firm object and flush it down the toilet or in the sluice

before linen or blankets is placed in its container. If the linen or blankets is

transported out of the patient room/area for this procedure it should be put in a

separate container ‐ it should never be carried against the body.

Linen or blankets should be then transported directly to the laundry area in its

container and laundered promptly.

For low‐temperature laundering, wash linen or blankets with detergent and water,

rinse and then soak in 0.05% chlorine for approximately 30 minutes. Linen or blankets

should then be dried according to routine standards and procedures.

Washing contaminated linen or blankets by hand should be discouraged. However, if

washing machines are not available or power is not ensured, take the soiled linen or

blankets out of the container and empty it into a large drum container of hot water

and soap. Soak the linen or blankets in this drum and make sure it is totally covered

with water. Use a stick to stir; then throw out the water and refill the drum with clean

water and add bleach 1000 ppm and allow to soak for 10‐15 minutes. Remove the

linen or blankets and then rinse in clean water. Remove excess water and spread out

to dry. Avoid as much splashing as possible.

If safe cleaning and disinfection of heavily soiled linen or blankets is not possible or

reliable, burn the linen to avoid any unnecessary risks to individuals handling these

items.

5. Waste Management

Wear complete PPE (impermeable gown, heavy duty/rubber gloves, boots, facial mask and

goggle or face shield), when handling infectious waste. Goggles provide greater protection

than face shields from splashes that may come from below when pouring liquid waste from a

bucket. Avoid splashing when disposing of liquid infectious waste.

Waste should be segregated at point of generation to enable appropriate and safe handling.

For details refer to annex 9.

Sharps waste disposal:

Sharp objects (e.g. needles, syringes, glass articles, scalpel blades, cannulas and other

sharps) and tubing that has been in contact with blood or body fluids should be

placed inside puncture resistant waste containers.

These items should be located as close as practical to the patient care area where the

items are used, similarly in laboratories.

Disinfect the outside of the sharps box before transporting. Fill inside of the box with

0.5% chlorine solution before disposal to sharp pit.

Solid medical waste:

All used disposable PPE, non‐sharps and other infectious waste needs to be collected

in leak proof hazard waste bags and placed in covered waste bins.

collect waste bags when it ¾ full and close with a string ,

Pouring 0.5% chlorine solution on top of the waste bags prior to being securely sealed

as pre‐treatment disinfection is recommended. The procedure can create back‐splash,

so care should be taken to protect eyes.

Put new double bags in the bin immediately.

Put bags in a garbage‐bag‐holder or covered bins

Transport garbage bag holder or covered bins using trolley or wheelbarrow (bins

should never be carried against the body)

Put waste bags in a designated pit of appropriate depth (e.g. 2 m)

Disinfect the bins with 0.5% chlorine solution

After each waste load, the waste should be covered with a layer of soil 10 –15 cm

deep.

Waste should be placed in the pit up to the depth of 1.5 m. before totally covered and

sealed.

Burning waste in the pit or an incinerator may be used for short periods during an

outbreak to destroy solid waste.

The area designated for the final treatment and disposal of waste should have

controlled access to prevent entry by animals, untrained personnel or children.

Liquid waste:

All biological infectious liquid waste (i.e. faeces, vomit, urine, etc...) is to be disposed

of in patient latrines and disinfected by pouring 0.5% chlorine solution.

Controlled spills:

Collect the waste in a bucket with 2cm of 0.5% chlorine solution

When waste has been excreted, add enough 0.5% solution to cover

completely the waste

Allow minimum of 15 minutes for chlorine to act

Dispose into a special liquid waste pit or into a pit latrine.

Uncontrolled spills:

First rule: reduce the risk of uncontrolled splashes and spills

Pour 0.5% solutions directly on the spills without splashing

Leave for 15 minutes

Mop up with an absorptive pad or towel

Place the waste into the bucket

The soaked pads should be disposed of into a pit latrine, or into the waste pit

Washing the room

If vomit or excreta are on the bed or on the floor, pour one cup of 0.5% chlorine

solution over it.

Leave it for at least 15 minutes and then mop up with the absorbent pad (green

plastic side up).

The mattress must be covered with the plastic sheeting provided. The sheeting can

then be washed with an absorbent pad soaked with 0.5% chlorine solution.

Organic waste:

Organic waste originating from the human body introduces a huge biohazard and

must be disposed of immediately.

Organic waste can be collected in a double plastic bag supported by a garbage‐bag

holder. Close the bags with a string or tape. Disinfect the outside of the bag.

Organic waste can be disposed of in a specially built organic waste pit. If such a pit is

not available, dispose of into a pit latrine.

Patient’s clothes: move to discharge

Clothes from patients need laundered routinely while in the treatment unit. But upon

death or discharge the clothes should be burned and replaced for discharges.

Laundering in High risk area:

Patients blankets and bed sheets should be washed in high risk area

Wash confirmed, probable and confirmed cases blanket and bed sheets separatly

Label blankets and bed sheets to match the room and bed numbers. Linen and

blanket #1 always be used by bed #1,

Household waste:

All used household outreach kit material (i.e. gloves, masks, surgical gowns etc...) is

to be collected and contained in a waste bag. 0.5% chlorine solution is to be poured

over the top before being sealed.

The outside of the bag is to be sprayed with 0.5% chlorine solution prior disposal

through burning.

6. Moving and Burial of Human Body

The coordinator should be consulted for any decision making on movement and burial of

human body. The handling of human remains should be kept to a minimum.

The community should not spray, wash or wrap up dead body. Any practice of washing the

body in preparation of "clean burials" should be discouraged. Only trained personnel should

handle body during the outbreak.

The burial team should follow the procedures below in principle, but may need some

adaptation to take account of cultural and religious concerns:

6.1 Burial Procedure for Patient Dying in the Ebola Treatment Unit:

Tasks of Ebola treatment unit staff:

Prepare the body and transport to mortuary or hand‐over to the burial team

Following a death of a patient, the nurse in charge covers the body with a blanket.

The nurses put a screen around the bed of the deceased patient and call the burial

team to enter the High‐risk area.

Mobile patients in the ward should leave the ward temporary.

2‐3 people from the burial team and 2‐3 people from the cleaning team enter in full

protective clothing.

Body, blanket and clothes will be sprayed with 0.5% chlorine solution.

Write the name of the deceased person on the outside of the body bag with a

waterproof marker.

Spray the body bag inside.

The body will be wrapped in the blanket and placed with personal clothing in the

body bag.

Spray again inside the body bag, close the body bag securely (zip closed to the face of

the patient) and spray outside the body bag.

Place body bag on stretcher and transport body to the mortuary in the Ebola unit.

Transport of the body out of the mortuary and out of the Ebola treatment unit:

Walk to the morgue and put the prepared body in the body bag on a stretcher.

Carry the stretcher outside the mortuary and the Ebola treatment unit via the special

exit for corpses.

The coffin should be placed at the special exit for corpses and the burial car/pick up

should be parked close to it.

Ask the family if they want to see the face of the deceased person. If they want to see

it, open the body bag and show the face.

Then close the body bag.

If a coffin is used:

Spray the coffin inside with 0.5% chlorine solution.

Put the body in the coffin, close securely and spray outside.

If no coffin is used:

The body will need to be put in 2 body bags.

The second body bag needs to be sprayed inside, and then place the first body bag

with the body inside the second body bag.

Close the second body bag and spray the outside of the second body bag.

After the body is put in the coffin or second body bag:

Spray the stretcher thoroughly.

The Ebola treatment unit team will return dressed to the Ebola ward and the Burial

team will continue the safe burial procedures.

PPE is not required for individuals driving or riding a vehicle to collect human remains,

provided that drivers or riders will not be handling a dead body of a suspected or

confirmed case of EVD.

Burial Team:

The team needs to consist of a driver, 3 people and 1 supervisor (to lower a coffin you need to be minimum 4 persons) The driver’s responsibility is only to transport the team. Not involved on the activity of the burial team.

Tasks of the Burial team staff:

Transport of the body to the gravesite and burry the deceased.

Dressing:

Burial team wears coverall, examination gloves, heavy‐duty gloves and face mask.

Steps to take dead body from morgue on to the pick‐up car

Spray the place where the Ebola unit team walked outside the Ebola unit with a 0.5%

chlorine solution.

Place prepared (coffined or the body prepared in 2 body bags) body at the back of

the pickup and transport to gravesite.

Steps of Burial at the gravesite

Place ropes on ground at two or three intervals (knee, lower back, upper back) to use

to lower coffin into grave, and place coffin on top of the ropes. Latex protection

gloves need to be used when lowering the coffin.

Burial team lower coffin using the ropes into the grave.

Community members may help to lower the coffin and will fill the grave with earth.

Community members required examination gloves and latex protection gloves when

lowering the body.

Back of the pickup needs to be sprayed with 0.5% chlorine solution.

6.2 Procedure for Burial of Suspect/Probable/Confirmed Patient Dying at Home

Before giving protective materials, the supervisor of burial team should enter the

family compound to speak with the responsible person in family.

Explain the burial procedure and provide information on EVD transmission.

Explain why the body must be buried safely and explain the procedure for

disinfection of the body.

Ensure coffin (if used) and grave is prepared (2 meters deep).

Put on fully protective clothing (PPE). (Minimum 2 people.)

Follow procedures for preparation of the body and the use of body bags and/or

coffin.

Preparation of body

Spray the body and the area around body with 0.5% chlorine.

Spray sheet and/or blanket thoroughly with chlorine solution.

Wrap body in blanket and cover completely.

Open body bag and place body and personal clothing inside.

Close body bag securely.

Spray outside of body bag with 0.5% chlorine.

Put in coffin or second body bag as described before.

After removing the body from the house, disinfect the room in which the patient died

as well as the patient’s mattress.

Burn the mattress.

Undress the PPE in front of the community. (If situation allows!)

Put on examination gloves,

Proceed to the gravesite, put latex protection gloves when carrying the coffin to the

grave and lower the coffin/body in double bags as described before.

A Solidarity Kit needs to be provided.

6.3 Cleaning a Room after Patient Death at Ward

Cleaners remove the mattress for spraying with 0.5% chlorine solution and dry in the

sun or burn in case of heavy contamination. (Dirty mattress can be folded and tied

with some strings or cloths.

All remaining clothes and blankets are put in a plastic bag.

Mattress and bags are sprayed with 0.5% solution before transport.

Inform the waste burner that the material must be burned.

Cleaners collect all material used by the patient.

All plastic cups, cutlery, plates; buckets are washed with 0.05% solution and can be

reused by other patients or can be burned.

The bed, window, walls, and the whole floor are disinfected with 0.5% chlorine

solution by pouring with a cup or by spraying.

Put new/clean mattress on the bed.

Remove screen from the bed.

Cleaners remove all cleaning material.

When leaving cleaners and the burial team members thoroughly disinfect aprons,

boots, and gloved hands with 0.5% chlorine solution.

Inform the Nurse in Charge that the ward has been cleaned.

6.4 Procedure for house disinfection

House disinfection must be carried out in a sensitive manner. The process results in the destruction of some of the family’s belongings, and damage to other items may also occur. Clearly explain the procedure to the family, and obtain their agreement. Explain that a Solidarity Kit will be provided to replace the items destroyed.

People Participating

One family member (if they want): he/she must be dressed in full protective clothing

Disinfection team: supervisor, 2 sprayers.

People dressing up

Maximum 4 people will need to dress up and full PPE material should be taken for 5

people

2 sprayers, 1 supervisor, 1 family member and 1 extra PPE should always be taken.

Procedures

After the patient has left the room, the supervisor enters and assesses the area. If the

sprayers are experienced, the supervisor will not need to dress up and can supervise

from outside the house.

The 2 sprayers need to be dressed in PPE and should take 1 spraying machine.

One spraying person should spray everything and the other person should pick up the

clothes, blankets and mattress that need to be sprayed and put it outside to be

sprayed.

A family member may participate if wanted, and need to be fully dressed.

Disinfect by spraying 0.5% chlorine solution:

o General area where the patient was accommodated during his sickness.

o Reusable hard items, such as buckets, furniture, etc. and after the spraying

the family can clean the items with soap and water.

o Bed, windows, walls and the whole floor.

o Latrine.

o Mattress and let dry in the sun. (If not too contaminated or soiled.)

Disinfect by spraying 0.05% chlorine solution (solution to be prepared on the spot in a

basin or bucket provided by family):

o Bedding and clothing (but if very dirty need to be burned!); after disinfection

it can be washed with water and soap and then dried in the sun by the family

members.

o Eating utensils like plates, spoons, cups; after disinfection it can be cleaned

with water and soap by the family members.

In case of heavy contamination:

o Remove mattress, bedding, and clothing for burning.

o Dirty mattress can be folded and tied with some strings or cloths.

o Material to be burnt should be bagged or wrapped in plastic sheeting and

transported to the waste zone at the Marburg/Ebola unit for disposal.

Backfill any waste pits that have been used.

7. Managing Exposure to Virus

Persons including HCWs with percutaneous or muco‐cutaneous exposure to blood,

body fluids, secretions, or excretions from a patient with suspected or confirmed HF

should immediately and safely stop any current tasks, leave the patient care area, and

safely remove PPE.

Remove PPE carefully according to the steps indicated in this document because

exposure during PPE removal can be just as dangerous for nosocomial transmission

of EVD. Immediately after leaving the patient care area, wash the affected skin

surfaces or the percutaneous injury site with soap and water. Accordingly, irrigate

mucous membranes (e.g. conjunctiva) with copious amounts of water or an eyewash

solution, and not with chlorine solutions or other disinfectants.

Immediately report the incident to the local coordinator. This is a time‐sensitive task

and should be performed as soon as the HCW leaves the patient care unit.

Exposed persons should be medically evaluated including for other potential

exposures (e.g., HIV, HCV) and receive follow‐up care, including fever monitoring,

twice daily for 21 days after the incident. Immediate consultation with an expert in

infectious diseases is recommended for any exposed person who develops fever

within 21 days of exposure.

HCWs suspected of being infected should be cared for/isolated, and the same

recommendations outlined in this document must be applied until a negative

diagnosis is confirmed.

Contact tracing and follow‐up of family, friends, co‐workers and other patients, who

may have been exposed to Ebola virus through close contact with the infected HCW

is essential.

V. COMMUNICATION AND SOCIAL MOBILIZATION

1. Overview

Risk communication is about communicating potential risks of a disease outbreak on how to

bring the level of anxiety down and minimize consequent morbidity and mortality.

Like other diseases of international concern, Ebola Viral Disease causes huge level of fear and

anxiety that may lead to irrational thinking and inappropriate actions adding fuel to the

propagation of the disease further.

Due to rampant existence of sources of information, confusions and rumours evolve; mistrust

with regard to what is being undertaken may result. This leads to irrational thinking and

inappropriate actions which further add to the propagation of the disease outbreak.

The way people behave, what they do or do not do as informed has a tremendous impact on

outbreak control. Listening to understand the perception of the people about the disease,

analyze problem behaviors and use of epidemiological information is crucial. Therefore

successful outbreak control eventually depends on participation of individuals, communities and

organizations taking immediate and appropriate immediate action to prevent further

transmission, potential loss of life.

Communicating about risks need to be complemented with other communication approaches to

consciously influence, promote and coordinate specific behaviours requires through sound

planning of integrated communication strategy ( Behaviour Change Communication, social

mobilization and advocacy) informed by principles risk communication: Trust, reporting timely,

transparency and listening the public.

In addition, it will be of utmost important for communicators to understand the pattern of

outbreak situation in phases to anticipate what to respond when. Two major phases; namely pre

epidemic and epidemic can be identified and used to anticipate the information needs of the

general public, the media and stakeholders. Each phase requires unique information and detail

planning including monitoring of activities to take corrective and focused actions.

2. Pre‐Epidemic Phase

This is where planning for most of the work (assessment of risks with communication elements

integrated and of existing communication situation, integrated communication planning and

message development) should be done to boost preparedness.

This is phase is characterized by search for further technical information on the disease outbreak,

basic facts, information sharing, working with stakeholders, policy guidance, mobilization of

resources and logistics, acquiring and imparting skills, etc.

The process to centralize dissemination of information through setting up of coordination

partnerships is crucial to ensure that messages2 are standardized and all involved in the control

are speaking with one voice is imperative.

Measures to inform the public about the risks in order to allay fear and anxiety begin in this

phase.

Immediate Action

Analyze or do rapid assessment to determine what existing resources and ongoing

communication interventions are available.

Establish and strengthen social mobilization coordination teams. Do partners

mapping and foster partnership towards a coordinated communication response plan

and implementation. This stage will help in mobilization of resources, experts and

standardization of messages.

Develop timely, accurate and easily understood communication messages to ensure

that trust and confidence on measures being undertaken are built by the public.

These will help avoid rumors and misinformation and eventually minimize negative

public health impacts.

In consultation with health officials, plan schedule when to release information about

the status of the outbreak situation to maintain high level of transparency with what

is going on. With the support from health experts, message plans should include the

risk level; what is unknown and known about the outbreak, incidence and the

spread, specific measures taken and others what should be taken by individuals,

families, communities, health workers, hunters, etc. Allay public anxiety through

press statement and regular updates with stakeholders and partners such as the

media.

Conduct listening exercises with the people affected, gather and compile available

profile of community culture, behavior, etc. and identify mechanisms to listen public

opinion and concerns through for example – media monitoring of radios, TV,

newspapers and public enquiry phone in lines (call centers), if there are any.

Develop IEC materials targeting the media, health care workers and the general

public

Conduct sensitisation meetings for health care workers including school health teams

and with the epidemic task forces

Conduct media orientation to update with state of preparedness, global and regional

Ebola situation and key messages

2 See key messages at the end of this document

Conduct media talks on basic facts about Ebola (definition, causes, transmission,

treatment, prevention)

Train Health Extension Workers (HEWs) and support for house to house and

community mobilization

3. Epidemic Phase

The finding of a case or cases may create confusions and heighten looking for further

information. It is essential to get facts from reliable source. In other words, through media

monitoring and other means, it is important to gather information, verify this in consultation with

the technical team and provide factual information from the designated source for such task

(FMoH). The response to be given will determine reputation.

One of the best ways at this stage is to show empathy in the communication messages to be

delivered and inform the public the level of risk and plans for containment. Messages should also

focus on allaying anxiety and advise the public the right means of self‐protection, prevention and

collaborating with partners. In as much as possible, even when there is little and incomplete

information, it is better to communicate and explain that more information will be shared as time

goes depending ongoing investigation.

At this stage of epidemic, messages focusing on specific actions and behaviors to prevent spread

protect and measures targeting the public and specific groups need to be widely promoted and

disseminated.

Demand for factual information from the public and the media will be intense. It is important to

head on and fill in the gaps swiftly before rumors and misinformation circulates.

4. Integrated Communication Activities

National / Regional

Continue releasing updates regularly to the public, the media and stakeholders

Hold regular meetings of social mobilization team at all levels to continually monitor

situation, update messages and support implementation

Hold advocacy meetings with different stakeholders at all levels for their support and

contribution to adapting control measures within the community settings and to

identify potential barriers and solutions.

Strengthen multi ‐ sectoral involvement (Education, transportation, immigration, etc.)

for information sharing and promote control measures in respective sector settings

Promote psychosocial assistance and support activities for people affected and their

families

Disseminate IEC materials and messages

Organize and or make use of events to integrate or share information and raise

awareness

Media communications

The media is the most powerful communication network with the capacity to

disseminate outbreak information quickly, reach wider population, hard to reach

areas and everyone through creating discussions. It is important to make use of and

strengthen media communication:

Establish strong link and mechanism to ensure that timely and accurate information

is shared rapidly between the media and technical and social mobilization team

Continue media monitoring to dispel rumours and misinformation and communicate

information and stories that explain outbreak control measures

Share with the Media up‐to‐date information through press releases, regular

meetings and other means of communication

In Health‐Care Facilities

Strengthen health facility based education through provision of guidelines and

promotional materials

Ensure that information concerning the patient is communicated to the family

To the extent possible, facilitate safe family visits to the patient.

Encourage health facility based education

In the Community

Train Health Extension Workers, Health development Army, Volunteers, etc to

conduct intensive community dialogue on the control measures

Provide / disseminate promotional materials – posters, brochures – radio messages,

public meetings)

Understand the views of the population from their sociocultural perspective and

respond to their needs and concerns accordingly

Engage people affected or those in high‐risk occupations (health care workers,

nursing staff, persons conducting burials, traditional healers, hunters, wildlife

officers, ecologists, veterinarians, etc.)

Encourage community compliance with the recommended outbreak control

measures

Strengthen the capacity of HEWs:

o To promote the implementation of standard precautions when caring for sick

people in the home and when handling and disposing of dead animals found in

the forest,

o To promote community participation in epidemiological surveillance at the

community level (reporting, alert)

Promote the organization of safe burials by specialized teams under the supervision

of the medical team, respecting funeral ceremonies

Encourage the community to report Ebola Viral Disease to see a health care worker

(surveillance team) without delay.

Correct myths through providing responses that are both accurate and that resonate

with the community

In collaboration with opinion leaders, make use of events to integrate awareness‐

raising activities

Mobilize all relevant community structures to promote compliance with prevention

programmes and programmes to contain transmission of the disease

5. Key Messages

Ebola is a highly contagious and deadly disease which currently has no cure

Any person is susceptible to Ebola, if they come in contact with the Ebola Virus

There is neither vaccination nor treatment ‐ prevention is currently the only way to

remain free from Ebola.

If you discover or identify a suspected person with signs and symptoms and travel

history to Ebola affected countries, report immediately to health workers Or call a toll

free number 8335, EPHI staff will contact you.

Communicatei “What Ebola is, what causes it, mode of transmission, management,

prevention and means self‐protection when caring persons suspected of disease”.

Please look for the complete set of messages.

i What is Ebola Virus Disease (EVD)?

Ebola is a severe, often fatal illness in humans and animals such as monkeys, gorillas,

chimpanzees and fruit bats which is caused by infection with Ebola virus

EVD outbreaks occur primarily in remote villages in Central and West Africa, near

tropical rainforests

It is very infectious, and kills in a short time, but can be prevented.

How does it Spread?

The natural reservoir of the virus is unknown, but it is believed that Ebola is

introduced into the human population by infected animals.

Ebola spreads from exposure to Ebola virus through direct contact with the blood

and body fluids (such as saliva, urine, stool, sweat, etc.) of an infected person.

Families and friends, or any person can get the disease when they come in close

contact with such body fluids when caring for infected persons.

Exposure to Ebola Virus occurs also from coming to contact with the dead body

especially during the burial ceremonies.

Contact with objects used by infected person such as sharps (needles, razor blades),

syringes, soiled clothing and linen.

Health workers can get Ebola Virus when they treat patients infected with the virus

without wearing proper protective cloths such as eye goggles, masks, gowns, gloves

and take no proper precautions in discarding used needles and syringes.

The time it takes to develop signs and symptoms to be clearly seen in a person is 2 ‐

21 days

Signs and Symptoms of Ebola

EVD is characterized by sudden onset of:

Fever

Headache

Joint and muscle pain

Sore throat and weakness, later followed by

Diarrhea

Vomiting and stomach pain

Red eyes, raised rash

Impaired kidney and liver function, and

In some cases internal and external bleeding occurs.

How can it be Prevented?

There is neither vaccination for prevention nor treatment. Prevention is the only choice

that we all have to focus and advise others.

What are Key messages for prevention and protection?

1. Avoid direct contact with suspected persons who have EVD signs and symptoms and

travel history from West Africa.

2. Report immediately if there is a person suspected of having signs and symptoms of

Ebola and should be taken to an Ebola designated health care facility at 8335.

3. Avoid direct contact with blood and body fluids of a person suffering from Ebola or

dead person by wearing gloves, masks, and eye goggles.

4. Avoid direct contact with bed clothes, soiled clothing and other object used by an

infected person with Ebola

5. Health workers and support staff should wear eye goggles, gowns, gloves, masks,

and boots (protective personal equipment)

6. Burial preparations must be handled by teams oriented in handling body of person

who has died of Ebola; body should be buried immediately. Getting in contact with

the dead body should be avoided at all times and during burial rituals.

7. Avoid bush meat and close contact with Monkeys and Baboons.

8. Avoid handling of dead wild animals in the bushes.

9. Port of entry workers should be aware of how to protect themselves from getting

Ebola.

10. Always get latest updates of information to protect yourself and others.

ANNEX 1: Ebola Virus Disease Notification Form

Reporting Health Facility/site :

Woreda Zone Region

EBOLA Viral Disease

Name of Patient:

Date of Birth (DOB): Day/Month/Year (EC)

AGE (If DOB unknown):

Years: _____ Months: _____ (If under 12 mos.)

SEX: M = Male, F = Female

Patient’s Address: Kebele: House number:

Woreda: Zone: Region:

Locating Information

Location when symptom started: Current location:

Date of Onset: ___/___/___

Date Seen at Health Facility ___/___/___

Date Health Facility notified Woreda/zone: ___/___/___

Symptom /sign Yes /no Symptom /sign Yes /no

Fever difficulty swallowing

Headache internal and external bleeding

vomiting/nausea Bleeding of gums

diarrhea black blood in stool

intense weakness vomiting blood

abdominal pain nose bleeds

muscular pain

In/Out Patient 1=Inpatient 2=outpatient

Treatment given 1=YES (specify) 2= NO

Outcome of the patient at the time of report:

1=Alive 2=Dead 3=Unknown

Date sent by HF/Woreda/Zone/Region: ____________________ Date received at Woreda/Zone/Region: ___________________

Sent by: _______________________________________________ Received by: _________________________________________

Tel: ___________________________________________________ Tel: ________________________________________________

E‐mail: _________________________________________________ E‐mail: ______________________________________________

ANNEX 2: Ebola Case Investigation Form 1. NOTIFICATION

1.1 DATE of case detection (DD/MM/YEAR) ______ / ______ / ______ Case ID NUMBER: ______________________________

1.2 REPORTING institution: _______________________________________________________________________________

1.3 Form FILLED in by:

Full NAME: ________________________________________________________TEL:______________________________

1.4 Information PASSED on by (FULL name):

Full NAME: ________________________________________________________TEL:______________________________

1.5 RELATIONSHIP with the patient ________________________________________________________________________

2. IDENTIFICATION

1.6 NAME of patient: ___________________________________________________________________________________

1.7 DATE of birth: ________ / ________ / ________ AGE (in years): _______________ SEX: M F

1.8 ADDRESS:

CELL PHONE number: _______________________________________________________________________________

REGION: ______________________________ DISTRICT /SUB CITY: ______________________________

1.9 NATIONALITY: _____________________________________________________________________________________

1.10 OCCUPATION: (tick the appropriate circle and provide details if necessary)

Planter Homemaker Child Hunter/Bush meat-seller

Health-care worker, specify Health-care facility: _________________________________ Qualification: _____________________________

Mine worker/Gold prospector, specify Mining facility: _______________________________________________________________________

Starting date of mining activity: _______________________________________________________

Pupil/Student Other (specify) _____________________________________________________________

3. PATIENT’s CONDITION

1.11 CONDITION of the patient when found: ALIVE DEAD

1.12 If DECEASED … DATE of death ___________ / ___________ / ___________

1.13 PLACE of death

COMMUNITY (village or neighbourhood): _________________ DISTRICT /sub city: _______________

HOSPITAL (name and department): ____________________ DISTRICT /sub city: ______________

1.14 BURIAL place

NAME of village or neighbourhood: ___________________ DISTRICT /sub city: _______________

4. Clinical HISTORY

1.15 DATE onset of SYMPTOMs ___________ / ___________ / ___________

1.16 NAME of the place where the patient became ill ___________________DISTRICT /sub city: ________________

1.17 Has the patient MOVED around since he/she became ill ? YES NO Don’t Know

If the answer is “YES”, complete the list indicating Kebele, health‐care facilities, and districts:

Kebele _________________ Health‐care facility_____________________ District ___________________



1.18 Does the patient show any of the following symptoms (tick all applicable)

1.19 Has the patient had a fever? YES NO DKnow

If so, DATE of fever ONSET (DD/MM/YEAR): ___________ / ___________ / ___________

1.20 Does the patient have or had any of the following symptoms

(tick the corresponding boxes andprovide details if necessary):

Headaches YES NO DKNOW Diarrhea YES NO DKNOW Abdominal pain YES NO DKNOW Vomiting YES NO DKNOW Lethargy YES NO DKNOW Anorexia YES NO DKNOW Muscular pain YES NO DKNOW Difficulty swallowing YES NO DKNOW Difficulty breathing YES NO DKNOW Intense coughing YES NO DKNOW Skin rash YES NO DKNOW Bleeding at injection points YES NO DKNOW Bleeding gums (Gingivitis) YES NO DKNOW Bleeding in eye (conjunctival injection) YES NO DKNOW Dark or bloody stool(melaena) YES NO DKNOW Vomiting of blood (haematemesis) YES NO DKNOW Nose bleed (epistaxis) YES NO DKNOW Vaginal bleeding outside of menstruation YES NO DKNOW

2 RISK of EXPOSURE 2.1 Has the patient been in contact with a suspected or confirmed case in the 3 weeks preceding the onset of the symptoms?

YES NO DKnow If so, specify: Full NAME ______________________________________ TEL _________________________

2.2 At the time of contact, was the suspected case ALIVE or DEAD?

If dead, Date of death ______ / ______ / ______ Date of last contact with the case ______ / ______ / ______

2.3 Was the patient hospitalized or has he/she visited a hospital nearby in the 3 weeks preceding the onset of the symptoms?

YES NO DKnow

If so, where __________________________ when (dates) _____ / ____ / ______ to ____ / ____ / ______

2.4 Has the patient seen a traditional healer in the 3 weeks preceding the onset of the symptoms?

YES NO DKnow

If so, last name: ________________________ Village: __________________ District: __________________

WHERE and WHEN did the consultation take place?

Place _____________________________________________________ Date: ______ / ______ / ______

Has the patient received traditional treatment? YES NO DKnow

If so, specify the type of traditional treatment: ___________________________________

2.5 Has the patient attended any funerals in the 3 weeks preceding the onset of the symptoms?

YES NO DKnow

If so, FULL NAME of the deceased: ________________________________________________

2.6 Has the patient had contact with any wild animals in the 3 weeks preceding the onset of the symptoms?

YES NO DKnow

If so, kind of animal ____________________ Locality ________________ Date ____ / ____ / ______

2.7 Has the patient worked or spent time in a mine/cave inhabited by bat colonies in the 3 weeks preceding the onset of the symptoms?

YES NO DKnow

If so, name of the mine_________________ Locality ____________________ Date _____ / _____ / ______

2.8 Has the patient travelled in the 3 weeks preceding the onset of the symptoms?

YES NO DKnow

If so, where to ________________________ and when ____ / ____ / ______TO____ / ____ / ______ 3 Specimen collection 3.1 Did you collect specimens? YES NO

If so, when ______ / ______ / ______ Type of specimen? DK Blood Urine Saliva Biopsy Stool

4 for OFFICIAL use ONLY

ID Number

DATE form received at National/Regional level (Day/Month/Year in EC):

______ / ______ / ______

Final CLASSIFICATION of CASE 1

CONFIRMED 2

PROBABLE 3

SUSPECT

4 DISCARDED

ANNEX 3: Ebola Contact List Form

Region ___________________ Woreda _______________________________City/Town ___________________________________

Name of Patient __________ Sex (M / F) ____________________ Age: ____________ Suspected/Probable/Confirmed Case ______

Patient's telephone Number: _______________________ Patients relative contact's Number_________________________________

Kebele/Village Leader___________Woreda___________Kebele____________Village___________GoteKebele/ketene____________

Name of

contacts Woreda Kebele House Number

Telephone

number Comment

Ethiopian Puplic Health Institute: Contact Tracing form for VHD

Region‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Woreda‐‐‐‐‐‐‐‐‐‐‐‐‐‐City/Town

Name of Patient‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐sex: M / F Age:‐‐‐‐‐‐‐‐‐‐‐‐Suspected/Probable/Confirmed Case #:‐‐‐‐‐‐‐‐‐‐‐‐‐

Patient's Contact Number: ‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Patients relative contact's Number‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Kebele/Village Leader‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐Woreda‐‐‐‐‐‐‐‐‐‐‐Kebele‐‐‐‐‐‐‐‐‐‐‐‐‐‐Village‐‐‐‐‐‐‐‐‐Gote

Types of contact 1. Slept or ate in same household as the case 2. Direct physical contact with body of case

in the 21 days

5. Breast feeding of child 6. Funeral attedance

Date of last contact (MM/DD/YY):‐‐‐‐‐‐‐/‐‐‐‐‐‐‐‐/2014

/ / / / / / / / / / / / / / / / / / / / /

SYMPTOMS/SIGNS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Fever

Painful muscles of joints

Weakness

Nausea or Vomiting

Diarrhea (non‐bloody/bloody)

Headache

Painful throat or swallowing

Red eyes

Other symptoms

Temprature reading

Instructions: Please write 'Y" for yes and 'N' for no in the correct cell above

Tracer's name _________________________ Tracer's Contact phone number_________________

Any bleeding from nose, mouth,

ears or rectum

3. Touch body fluids (Saliva, Urine, Fesses ) 4. Manipulation of clothes or other objects

Days and Date Follow Up

ANNEX 4: Contact Monitoring Form

ANNEX 5: Ground Layout of Ebola Treatment Center

STAFF ENTRANCE/EXIT

Gloved hand washing facility

(0.05% CL)

LOW RISK zone

SCREENING room (tab

WRR WRR

IMMERSION tank

1

IMMERSION tank

2

IMMERSION tank

3

MORGUE

CORPSES

Mini STORE for high risk area

GUARD and

SPRAYER

Laundary washing and drying area

CHLORINE preparation area

WATER point

Gloved hand washing facility

(0.05% CL)

Store room

GUARD and

SPRAYER

STREET SHOES spraying

Bare hand washing facility

(0.05% CL)

Cleaners changing room

DOCTORs’ room

WRR WRR

Chlorine footbath

CHLORINE footbath


Hand washing

facility

PATIENT ENTRANCE/EXIT

CHLORINE footbath

Chlorine footbath

CHLORINE footbath

CHLORINE footbath

GLOVED hand washing facility

(0.5% CL)


(0.5% CL)

Laundry washing and drying area

WRR WRR

Sharps pit

Organic pit

Burning pit

CHANGING room

1

CHANGING room 2

Pit for Liquid waste

BARE hand washing facility

(0.05% CL)

bin for SOLID waste

WARD or ROOMs for CONFIRMED cases

SAFETY BOX for sharps

bin for SOLID waste

WARD or ROOMs for PROBABLE cases


bin for SOLID waste


(0.5% CL)

WARD or ROOMs for SUSPECTED cases


bin for SOLID waste

CHLORINE footbath

CHLORINE footbath

CHLORINE footbath

CHLORINE footbath

ANNEX 6: Layout of Changing Room 1 (Between No Risk Zone and Low Risk Zone)

STAFF ENTRANCE

BENCH or LINE

how to DRESS up CHART

BENCH or LINE

how to DRESS down CHART

OUTER fence

NO RISK ZONE (OUTSIDE)

STAFFEXIT

LOW RISK ZONE


(0.05% CL)


BODY SHOWER facility


(0.5% CL)


STREET shoes rack

STREET clothes hanger

SLIPPER or

SANDAL rack

RUBBER BOOTs rack

CHANGING cubicle for MALEs

NEW SCRUB suit


(0.05% CL)

new GLOVEs

CHANGING cubicle for FEMALEs

CHANGING cubicle for FEMALEs

WASHABLE Items

WASTE BIN Contaminated SCRUB suit

CHANGING cubicle for MALEs

WASHABLE Items

WASTE BIN Contaminated SCRUB suit

CHLORINE footbath

CHLORINE footbath

CHLORINE footbath

CHLORINE footbath

ANNEX 7: Layout of Changing Room 2 (Between Low Risk Zone and High Risk Zone)

how to un DRESS CHART

WASTE BIN (with ordinary plastic

bag lining)

INNER fence

WASTE BIN (for second glove)

STAFFEXIT LOW RISK ZONE

STAFF ENTRANCE

HIGH RISK ZONE


Mirror

APRON and GOGGLE hanger

STOCK of Biohazard bags

CHANGING ROOM


(0.5% CL)

BUCKET for apron and goggle immersion (0.5% CL)

BUCKET for 2nd round apron and goggle immersion

(0.05% CL)

BUCKET of clean water for cleaning

goggles

HANGER or TABLE to put goggle and

apron

CHANGING Cubicle

clean stuffs


COVERALL

hanger

FOOT COVER hanger

BENCH or

LINE

BENCH or

LINE


(0.5% CL)


(0.5% CL)

BARE hand washing facility (0.05% CL) and/or antiseptic hand rub

new GLOVEs


(0.5% CL)

ANNEX 8: Detailed Description on the Different Components of Isolation Center based on Respective Risk Zones

Risk Zone Areas and

Activities Facility

Location, Space

Quantity Size Recommended Material Remarks

High Risk

Zones

Suspected

Case

Ward for Suspected Cases One ward or individual rooms Minimum 10m2 per

patient

Existing building Tent or

Plastic sheeting

The use of tens should be avoided

(difficult infection control

Latrines for Suspected Cases

Less than 25m from ward or rooms 1

for male, 1 for female 1 per 20 for

female

Depth2.5m; 1.5m above

water table

Plastic squatting slab

Smooth concrete slab

Pit latrine advisable because it cannot

block (flush latrine can block)

Bath rooms for Suspect Cases



female

2.5m2

Impervious, non‐slip

concrete with slope to

drain

Connect to Sewage system or soak

away pit via grease trap

Compound for Suspect Cases Direct access from suspected cases’

ward

Minimal10m2 per

patient Patients area in Open air

Confirmed

Cases

Ward for confirmed cases One ward or Individual rooms

Less than 25m from

ward or rooms 1 for

male, 1 for female 1 per

20 for female


plastic or plastic sheeting The use of tents should be avoided

Latrines for confirmed Cases



female

Depth 2.5 m; 1.5m

above water table

Pit latrine advisable because it can

block (flush latrine can block)

Compound for Confirmed

Cases

Direct access from confirmed cases’

ward

Plastic squatting slab

Smooth concrete slab Patients area in open air

Bathrooms for Confirmed

Cases



female

2.5 m2

Impervious, non‐slip

concrete with slope to

drain

Connects to sewage system or soak

away pit via grease trap

Waste Zone

Burning pit 1 in waste zone, as far away as

possible from patients, staff, laundry

2x2x2.5m width burning

platform Local materials

Organic waste pit 1 in waste zone 1.5x1.5m Depth 2m Concrete roof slab with

lockable cover

Used for organic waste: placentas,

food, solid wet waste which is not

combustible, etc.

Sharps pit 1 in waste zone 2m3

Concrete lined pit with

roof slab and lockable

cover

Could be combined with organic waste

pit

Liquid pit 1 in waste zone 2m3 Just a pit

Risk Zone Areas and

Activities Facility

Location, Space


Laundry Area

Laundry washing area Away from burning site, adjacent to

laundry lines and water point Around 9m2 Concrete slab

Connect to sewage system or soak

away via grease trap

Laundry drying area Away from burning site, adjacent to

laundry area Around 15m2

Wooden or iron poles,

rope

Preferably in the sun (UV assists in

destroying the Ebola Virus

Corpses Morgue Easy access from patients area with

large exit for ambulance 5x4m


plastic sheeting(roof is

required)

In most of the settings there will be no

morgue, and the corpses will go

directly to the burial ground

Floor should be easy building

SLUICE Disinfection Foot bath, hand washing and

spraying location 1 between high‐risk and low‐risk zone

1.5x2.5m Foot bath:

80x80cm

Concrete or gravel floor

with footbath of plastic

sheeting

Should be full time staffed by a

guard/sprayer; Adjacent to the

changing room


spraying location 1 between high‐risk and low‐risk zone

1.5x2.5m Foot bath:

80x80cm

Concrete or quarrel floor


sheeting

Should be staffed full time by a

guard/sprayer; Adjacent to the

changing room

Low Risk

Zone

Putting on/off

protective

clothing

Changing room 1 At door between outside and low‐risk

zone 3x4m minimum


plastic sheeting

Separation between risk zones inside

the changing room must be clearly

indicated

Changing room 2 At door between low‐risk zone and

high‐risk zone 3x4m minimum


plastic sheeting

Separation between risk zone inside

the changing room must be clearly

indicated

Disinfection Chlorine preparation Close to water point 3x4m minimum Concrete slab Gravel bed

Must have good drainage into sewage

system or soak away via grease trap

Must be well‐ventilated(chlorine gas in

heavier than air

Administration Doctor’s room 1 room close to the patients area 3x4m minimum Local building material Must NOT be in High risk zone!

Laundry Area

Laundry washing area Away from burning site, adjacent to

laundry lines and water point Around 9m2 Concrete slab

Connect to sewage system or soak

away via grease trap

Laundry drying area Away from burning site, adjacent to

laundry area Around 15m2

Wooden or iron poles,

rope

Preferably in the sun (UV assists in

destroying the Ebola Virus

Security Guard shack Main entrance; Every exit from high‐

risk and low‐risk zone. 4m2

Existing Building Tent or

plastic sheeting

Storage Store room on compound 1 small store on compound for

several days stock 3x4 m


plastic sheeting

Risk Zone Areas and

Activities Facility

Location, Space



spraying location 1 between outside and low risk zone

1.5x2.5m Foot bath:

80x80cm

Concrete or gravel floor


sheeting

Should be full time staffed by a guard /

Sprayer, adjacent to the changing

room.

OUTSIDE

ISOLATION

UNIT

Storage General store room 1 outside isolation compound 8x4m Existing Building Tent or

plastic sheeting

Kitchen Kitchen for patients and

possible attendants 1 outside isolation compound 4x4m


plastic sheeting

Respect protocols; see also point III E b

“Kitchen and food for patients and

attendants

Staff room Lunch room for staff 1 outside isolation compound

Staff toilet Latrine 1 per 20 staff 2.5m2 Plastic squatting slap

Smooth concrete slab

ANNEX 9: Definition of Waste and Recommendations for Collection, Transport and Disposal

Definition and Examples Collection Transport Disposal

Burnable waste

Dry waste is all waste that has a low moisture

content and is therefore easily combustible, used

protective clothing (gowns, gloves, etc.), plastic,

syringes without needle, etc.

The bags should be supported in a garbage

bag‐holder. When the double bag is ¾ full,

collect it and close with a string or tape.

Disinfect the outer bag. Put new double

bags in the bin immediately

The waste worker must

transport the bag(s) to the

waste area

The bag(s) can be carried in a

wheel barrow to reduce the

risk of the bag splitting and

possible contamination of the

compound.

Bags must be burned without opening them.

Assist burning with paraffin where necessary. Wet waste is waste that has a high moisture

content

In Isolation, this will often be contaminated waste

that has been disinfected with chlorine (clothes,

mattresses, etc.)

Liquid Waste

All waste that can splash or spill is liquid waste.

Examples are: body fluids: Vomit, soft stools,

urine, blood and waste water (cleaning body fluids

can be excreted in two ways:

In controlled way (into a bucket):

In an uncontrolled way (spills on floor, bed,

clothes, etc).

Controlled spills:

Collect the waste in a bucket with 2cm of

0.5% chlorine solution

When waste has been excreted, add

enough 0.5% solution to cover completely

the waste

Allow minimum of 15 minutes for chlorine to

act

Transport the bucket to the

latrine without splashing or

spilling (lid). Do not transport

it in the low‐risk zone.

Liquid waste is best disposed of into a special

liquid waste pit or into a pit latrine.

Uncontrolled spills:

First rule: reduce the risk of uncontrolled

splashes and spills

Pour 0.5% solutions directly on the spills

without splashing

Leave for 15 minutes;

Mop up with an absorptive pad or towel;

Place the waste into the bucket

The soaked pads should be disposed of into a

pit latrine (never into a flush latrine!), or into

the waste pit / burning pit

Organic waste

‐Organic waste originating from the human body:

placentas, body parts, etc.

‐Other organic waste e.g. food leftovers.

Organic waste originating from the human

body introduces a huge biohazard and must

be disposed of immediately.

The bags must be brought to

the placenta pit (organic

waste pit) or latrine.

Definition and Examples Collection Transport Disposal

Organic waste can be collected in a double

plastic bag supported by a garbage‐bag

holder. Close the bags with a string or tape.

Disinfect the outside of the bag.

The bags must be brought to

the placenta pit (Organic

waste pit) or latrine.

Organic waste can be disposed of in a specially

built organic waste pit. If such a pit is not

available, dispose of into a pit latrine.

Waste Water ‐Run off water: rain water from the roof, or

compound

Avoid runoff water to flow from higher into

lower risk zones.

Direct wastewater to gutters,

ideally lined with concrete.

Runoff water and wastewater has to be

controlled and directed to safe disposal areas.

If wastewater is disposed of in a soak away, a

grease trap should be installed. The grease

trap must be disinfected before it’s cleaned

‐Waste water: water used for cleaning, from foot

baths, etc.

Wastewater has to be directed and

collected into a soak away or liquid pit.

Sharps

Items that can cause cuts or puncture wounds,

including needles, scalpels, knives, infusion sets,

saws, broken glass, nails, etc.

Sharps containers.

Disinfect outside of the

sharps box before

transporting. Fill inside with

0.5% chlorine solution before

disposal.

Sharps pit

ANNEX 10: Steps on Putting on Personal Protective Equipments with Donning Pictures

CHLORINE footbath


(0.5% CL)

3. Wash your hands with soap

and water or alcohol swab.

4. Put on one pair of

disposable gloves.

5. Bath your foot with

chlorine.

6. Disinfect the gloved hand

with 0.5% chlorine.

CHLORINE footbath

BARE hand washing facility (0.05% CL) or antiseptic handrub


(0.5% CL)

7. Put on the cover‐all (make sure the sleeves are under the 1st layer of glove

and put on a plaster on top of it)

8. Put on the foot cover (if available).

9. Put on a second layer of gloves*1 (should be done after the goggles or

face shield if using heavy duty gloves).

10. Put on the face mask.

11. Put on the hood of coverall (if the coverall do not have

hood, put on head cover).

12. Put on goggles or face shield (which ever available)

13. Put on waterproof apron (if you expect exposure with

body fluids)

14. Bath your feet in chlorine solution


16. Go into the high‐risk zone.

1. Remove street shoes and street clothes (your own shoes and clothes) in

dressing room 1.

2. Put on scrub suit and your personal rubber boots. Tuck scrub suit into

boots.

ANNEX 11: Steps on Removing Personal Protective Equipments with Pictures


18. Take goggles and apron with you.

19. Step in the second footbath.

20. Now you are in the Low‐risk area

21. Hang the goggle and the apron.

22. Remove the inner layer gloves and throw away in the waste bin.

23. Wash your hands with 0.05% or use alcohol hand rub.

24. Put a new pair of examination gloves.

1. Disinfect gloved hands with 0.5% chlorine solution before

entering undressing room

2. Bath your feet in chlorine solution.

3. Enter the undressing room.

4. Peel off disposable apron and dispose safely (throw away in a

bio‐hazard plastic bag).

5. If the apron is to be reused, immerse the apron in the container

of 0.5% chlorine solution and after that in the second container

0.05% chlorine solution and hang it close to the second footbath

(in changing room 2).

6. Remove the shoe cover (if there is any)

CHLORINE footbath


(0.5% CL)

7. Disinfect the outer pair of gloves with 0.5% chlorine solution and

remove them.

A. If using surgical gloves: throw away in the waste bin.

B. If using heavy‐duty gloves: place in the bucket containing 0,

05% chlorine solution.


9. Remove goggles, disinfect with 0.5% and rinse with clean water.

10. Hang it close to the second footbath, next to the apron.

11. Disinfect the gloved hands with 0.5%.

12. Remove hood of the coverall (if a separate head cover is used,

remove and throw away in the waste bin).


14. Remove coverall and throw away in waste bin.


16. Remove mask and throw away in waste bin

bucket with 0.05%

CHLORINE solution


(0.5% CL)

ANNEX 12: How to Don and Remove Non‐Sterile Examination Gloves

When the hand hygiene indication occurs before a contact requiring glove use, perform hand hygiene by rubbing with an

alcohol‐based hand rub or by washing with soap and water.

1 Take out a glove from its original

box

2 Touch only a restricted surface of the glove

corresponding to the wrist (at the top edge of the cuff)

3 Don the first glove

4 Take the second glove with the bare hand and touch only a restricted surface of glove

corresponding to the wrist

5 To avoid touching the skin of the forearm with the gloved hand, turn the external surface of the glove to be donned on the folded fingers of the gloved hand, thus permitting to glove

the second hand

6 Once gloved, hands should not touch anything else that is not defined by

indications and conditions for glove use

1 Pinch one glove at the wrist level to

remove it, without touching the skin of the forearm, and peel away from the hand, thus

allowing the glove inside out.

2 Hold the removed glove in the gloved hand and slide the fingers of the un‐gloved hand inside between the glove and the wrist. Remove the second glove by rolling it down the hand and fold into the first

glove.

3 Discard the removed gloves.

I. HOW TO DON GLOVES

II. HOW TO REMOVE

4 Then, perform hand hygiene by rubbing with an alcohol‐based handrub or by washing with soap and water

ANNEX 13: How to Hand Rub with Alcohol

ANNEX 14: How to Hand Wash

ANNEX 15: How to Make Chlorine Solutions for Environmental Disinfection

Check concentration (%) concentrate of the chlorine product you are using.

Determine total parts water needed using the following formula:

Total Parts (TP) water = [% Concentrate/% Dilute] ‐1

Mix 1 part concentrated bleach with the total parts water required.

Example 1:

Make a dilute solution (0.5%) from 5% concentrated solution.

Step 1: Calculate TP water: [5.0%/0.5%] – 1 = 10 ‐1= 9

Step 2: Take 1 part concentrated solution and add to 9 parts water.

Step 3: Label properly the prepared 0.5% chlorine solution.

Example 2:

Make a dilute solution for rinsing a gloved hand (0.05%) from 5% concentrated solution.

Step 1: Calculate Total Parts water: [5.0%/0.05%] – 1 = 100 ‐1= 99

Step 2: Take 1 part concentrated solution and add to 99 parts water.

Step 3: Label properly the prepared 0.05% chlorine solution.

Formula for making dilute solutions from dry powders

Check concentration (%) concentrate) of the powder you are using.

Determine grams bleach needed using the formula below:

Grams/Liter = [% Dilute/% Concentrate] x 1000

Mix measured amount of bleach powder with 1 liter of water.

Example:

Make a dilute chlorine‐releasing solution (0.5%) from a concentrated powder (35%).

Step 1: Calculate grams/liter: [0.5%/35%] x 1000 = 14.2 g/L

Step 2: Add 14.2 grams (14 g) to 1 liter of water

Take 1 part concentrated solution and add to 49 parts boiled (filtered if necessary) water.

ANNEX 16: Cleaning and Disinfection of Protective Equipments

Items that require routine and regular disinfection, cleaning and/or laundry are: aprons, goggles, scrub suits,

boots, and reusable gloves.

Disinfection of Aprons

Dip in bucket of 0.5% chlorine solution for 3 minutes and then scrub.

Dip in bucket of fresh 0.5% chlorine solution.

Rinse with clean water.

Hang to dry.

Disinfection of Goggles

Place goggles under a flow of 0.5% chlorine solution for 30 seconds, and

Ensure that all parts of the goggles have been soaked in the solution.

Rinse with clear water!!

Hang to dry in the sun.

Each user is responsible for ensuring that their goggles are disinfected and clean before putting them on.

Disinfection of Scrub Suits

Put scrub suits in fresh 0.05% chlorine solution.

Leave to soak for 30 minutes.

Rinse twice with clear water.

Wash with detergent and fresh water.

Rinse with clear water.

Hang to dry in the sun.

Cleaning and Disinfection of Boots

Put boots in fresh 0.05% chlorine solution.

Leave to soak for 30 minutes.

Rinse twice with clear water.

Dry upside down on sticks driven into the ground.

Disinfection of Reusable Gloves

Household gloves and heavy‐duty gloves can be reused after disinfection and cleaning.

Soak in 0.05% chlorine solution for 30 minutes.

Rinse twice with clean water.

Fill gloves with water and squeeze to check for any leaks.

Dry on sloping racks or on sticks driven into the ground.

ANNEX 17: Caretaker Task Instruction

Dressing and Undressing

The caretaker dresses up with complete PPE just like other health workers if to enter to high risk zone.

How to Provide the Food

Ask the patient to bring his plate to the door and spoon the food into it without touching.

If the patient cannot walk, the caretaker dresses and enters the room, and brings the plate to the door

where another family member spoons the food into it without touching.

How to Wash Utensils

Before entering the room, put a bucket half filled with 0.05% chlorine solution outside the door.

Carefully place the dirty utensils into the bucket without leaving the room or touching the bucket.

After 30 minutes, the bucket can be removed. The contents must be rinsed and washed with soap.

Put utensils in the sun to dry.

How to dispose of feces

Pour 1 cm of 0.5% chlorine solution into the bucket.

After use pour another cup of 0.5% chlorine solution over the contents and put the lid on.

Disinfect the outside of the bucket with 0.5% chlorine solution and place it outside the door.

Leave the bucket for at least 15 minutes, and once undressed and outside the room again, put on

clean gloves and pour the contents carefully into the latrine

Disinfect the latrine once a day with 0.5% chlorine solution.

ANNEX 18: Summary of Implementation of IPC Best Practices during Direct Patient Care and Related Activities

What? How? Who is responsible?

Create isolation rooms or

areas.

‐ Identify single rooms and prioritise these for

patients with known or suspected Ebola virus.

‐ Refer to guidance on setting up an isolation

area.

‐ Coordinator or IPC staff to identify

areas/rooms for patient placement.

‐ Health workers to adhere to

recommendations and report to the

coordinator when a patient is not placed in an

isolation room/area.

Restrict all non‐essential staff

from EVD patient care

rooms/areas.

‐ Ensure that clinical and non‐clinical personnel

are assigned exclusively to patient care areas and

that members of staff do not move freely

between these areas and other clinical areas

during the outbreak.

‐ Cohort staff between areas with suspected and

those with confirmed SVD patients.

‐ Use signage to alert restrictions of staff.

‐ Maintain a log of persons entering the room.

‐ Coordinator and/or IPC staff.

Limit the number of visitors

allowed access to the patient.

‐ Use signage and other communications to alert

restrictions of visitors. Make simple messages

understandable for the public but also be careful

to avoid stigmatization.

‐ Maintain a log of persons entering the room.

‐ Coordinator and/or IPC staff

‐ Involve patient or community representatives,

if available.



coordinator when they are not followed.

Ensure that all staff and

visitors correctly use and

remove recommended

personal protective equipment

(PPE).

‐ Ensure the equipment is always available and

promptly at the isolation rooms/areas entry.

‐ Provide staff and visitors with instructions on

the use and correct removal of PPE through

training and reminder posters.

‐ Coordinator and/or IPC staff


if available.




‐ Another staff member should be assigned to

supervise the sequence of putting on and

removing PPE by his/her colleague.

Ensure that all staff and

visitors perform hand hygiene

according to the above

recommendations. These hand

hygiene actions should be

performed when

recommended even if PPE is

worn.

‐ Provide staff and visitors with instructions on

the importance of hand hygiene best practices

through training and reminder posters.

‐ Ensure continuous availability of alcohol‐based

hand rub and soap, water and single‐use towels

at the isolation room/areas entry and at the point

of care.

‐ Coordinator and/or IPC staff.


if available.




What? How? Who is responsible?

Limit the use of needles and

other sharp objects as much as

possible. If this cannot be

avoided see instructions in the

text.

‐ Provide staff and carers with instructions on the

essential use of needles and sharps through

training and reminder posters.

‐ Ensure the equipment is available to do this.


recommendations.

Dispose of needles and other

sharp objects safely.

‐ Provide staff and carers with instructions on the

safe disposal of sharps through training and

reminder posters.





Create system of safe

management of waste and

linen.

‐ Provide staff and visitors/carers with

instructions on the safe management and

disposal of waste and linen through training and

reminder posters.





Limit the use of phlebotomy

and laboratory testing to the

minimum necessary for

essential diagnostic evaluation

and patient care.

‐ Provide staff with training and visual

instructions on the need for essential

phlebotomy and lab testing.


recommendations.

Only take a patient out of their

room/care area if they are free

of virus, or for essential, life‐

saving tests.

‐ Provide staff with training and visual

instructions on the appropriate times to take the

patient from their care area and on precautions

to take.




Undertake cleaning of the

environment and patient care

equipment safely following

recommendations in the text.

‐ Provide staff and visitors/carers with

instructions on cleaning through training and

reminder posters.

‐ Ensure the equipment is available to undertake

recommended cleaning.




ANNEX 19: Summary of Symptomatic Treatment Of Patients

Symptoms and or signs Treatment

Fever (>38.0 °C) Manage fever with paracetamol Avoid diclofenac, ibuprofen or aspirin due to platelet effects.

Acute significant bleeding/ moderate to severe pallor/ emergency signs of circulatory shock

Transfuse with whole blood

Pain Treat pain with paracetamol (if mild) or morphine if moderate and severe). Avoid diclofenac, ibuprofen or other NSAIDs due to platelet effects.

Difficulty breathing/ respiratory distress

Oxygen: titrate to Sp0 >90% If SpO2 < 90% start adult on 5 litres/minute (nasal prongs); start child at 1‐2

Litres/minute (nasal prongs) Evaluate for pneumonia, wheezing, fluid overload, congestive heart failure and manage accordingly. (Do not share nasal prongs ‐once used by a patient dispose.)

Diarrhoea, vomiting, signs of dehydration

Provide ORS even if no signs of dehydration Monitor signs of dehydration. If no, some or severe dehydration, use Fluid Plans A, B and C, respectively

If severely malnourished child with shock, see Chid pocket book.

Nausea and vomiting are common‐ anti‐emetic medications may provide some relief and facilitate oral rehydration. For adult, give chlorpromazine 25‐50 mg, 4 times daily IM or orally or metoclopramide 10 mg IV/ orally 3 times daily until

Vomiting stops. For children, give promethazine. Monitor for extrapyramidal signs.

Dyspepsia (i.e., "heartburn") In adults and children > 10 years, give omeprazole 20 mg orally daily or magnesium trisilicate, 2 tabs every 8 hours until symptoms resolved. In children 5‐12 years, give magnesium trisilicate: 5‐10 mls, 3 times daily

Convulsions

Approach convulsing patients with caution. Give diazepam to abort seizure if prolonged (rectally if there is not an IV already in place‐ adult 20 mg (4 ml of 10 mg/2ml solution); child 0.5 mg/kg)), then control with phenobarbital loading dose (child: 15 mg/kg over 15 minutes‐ IM or IV); adult: 10 mg/kg.

Signs of hypoglycaemia Test glucose (and monitor regularly) If low, give IV D50 5 ml/kg in child; 25 to 50 ml of D50 in adult Nutritional support

Anxiety Psychological support , Diazepam ‐adults: 5‐15 mg/day in 3 divided doses

Confusion in cooperative patient

Restrain with patient in calm and non‐aggressive fashion. Keep lighting on at night Consider diazepam 5 mg at night (adult)

Confusion and aggression in non‐cooperative patient

Give sedation‐haloperidol 5 mg IM (adult)

Shock See diagnosis and management of septic shock below.

ANNEX 20: Flow Diagram of EVD Contact Case Reporting at Woreda and Towns Level

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