Prevention and Control of Ebola Virus Disease in Health...

Prevention and Control of Ebola Virus Disease in Health Care Facilities with Limited Resources

Guide for LearnersFebruary 2015

AuthorsChandrakant Ruparelia

Melanie Curless Polly Trexler Meredith Black

Jhpiego is an international, non-profit health organization affiliated with The Johns Hopkins University. For more than 40 years, Jhpiego has empowered frontline health workers by designing and implementing effective, low-cost, hands-on solutions to strengthen the delivery of health care services for women and their families. By putting evidence-based health innovations into everyday practice, Jhpiego works to break down barriers to high-quality health care for the world’s most vulnerable populations. Published by: Jhpiego Corporation Brown’s Wharf 1615 Thames Street Baltimore, Maryland 21231-3492, USA www.jhpiego.org © Jhpiego Corporation, 2015. All rights reserved. Authors: Chandrakant Ruparelia, MD, MPH, Senior Technical Advisor, Jhpiego Melanie Curless, RN, MPH, Infection Control Epidemiologist, Department of

Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital Polly Trexler, MS, CIC, Associate Director, Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital

Meredith Black, MPH, Infection Control Epidemiologist, Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital

In the development of these materials, the authors referred to the latest World Health Organization (WHO) and U.S. Centers for Disease Control and Prevention (CDC) recommendations for health care workers on preventing the transmission of Ebola Virus Disease in health care facilities. www.who.int/csr/disease/ebola/en/ www.cdc.gov/vhf/ebola/

Prevention and Control of Ebola Virus Disease in Health Care Facilities with Limited Resources: Guide for Learners i

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

WORKSHOP DESCRIPTION ....................................................................................................... 1

Workshop Design ...................................................................................................................... 1

Workshop Syllabus .................................................................................................................... 2

INITIAL KNOWLEDGE ASSESSMENT QUESTIONS ................................................................. 5

CHECKLISTS FOR INFECTION PREVENTION AND CONTROL SKILLS ................................ 7

Using the Checklists .................................................................................................................. 7

CHECKLIST FOR HANDWASHING USING SOAP AND WATER .............................................. 8

CHECKLIST FOR HAND HYGIENE USING ALCOHOL-BASED HANDRUB/ 0.05% CHLORINE SOLUTION .................................................................................................. 10

CHECKLIST FOR PUTTING ON PPE ....................................................................................... 11

CHECKLIST FOR REMOVING PPE .......................................................................................... 13

CHECKLIST FOR COLLECTING BLOOD SAMPLES FROM SUSPECTED CASES OF EVD ....................................................................................................................................... 16

CHECKLIST FOR SHIPPING BLOOD SAMPLES OF SUSPECTED EBOLA CASES WITHIN A COUNTRY ................................................................................................................. 18

CHECKLIST FOR CONDUCTING SAFE AND DIGNIFIED BURIAL OF A PATIENT WHO DIED FROM EVD ............................................................................................. 20

WORKSHOP EVALUATION ...................................................................................................... 23

Prevention and Control of Ebola Virus Disease in Health Care Facilities with ii Limited Resources: Guide for Learners

ACKNOWLEDGMENTS The authors would like to acknowledge the valuable assistance of The Johns Hopkins Hospital, Department of Hospital Epidemiology and Infection Control, in particular Dr. Lisa Maragakis, Director of Hospital Epidemiology and Infection Control, in the development of this learning resource package. The authors would also like to thank the following individuals who provided support in the preparation of these materials: Dr. Ron Magarick, Marion Subah, Kelly Curran, Dr. Emmanuel Otolorin, Dr. Blami Dao, Dr. Oniyire Adetiloye, and Dr. Willy Shasha, for reviewing and providing technical input on drafts of the materials; Dr. Harshad Sanghvi, Dr. Alain Damiba, and Nancy Caiola, for their overall guidance; Young Kim, for general publications support; Rebecca Elliott, for help in developing supporting materials, including the PowerPoint presentations; Dana Lewison, for editorial assistance; and Courtney Weber and Bekah Walsh, for desktop publishing support.

Prevention and Control of Ebola Virus Disease in Health Care Facilities with Limited Resources: Guide for Learners 1

WORKSHOP DESCRIPTION WORKSHOP DESIGN This competency-based, hands-on training workshop is designed to prepare health care providers (doctors, nurses, and midwives) and other health care workers in infection prevention and control (IPC) at health care facilities in the event of an Ebola Virus Disease (EVD) outbreak. This workshop builds upon the current IPC knowledge and skills of learners and prepares them, in as short a time as possible, to implement appropriate interventions for prevention and control of an Ebola outbreak. Training emphasizes doing, not just knowing, and uses competency-based evaluations of performance. Though designed as a 3-day, group-based workshop, this workshop can be offered as an on-site training involving all staff members of health care facilities that are likely to receive or are currently receiving patients infected with Ebola. Successful completion of the workshop is based on satisfactory performance of recommended IPC skills for managing patients with EVD. The workshop covers both knowledge and skills in infection prevention and control:

Initial knowledge assessment: To identify individual and group learning needs, learners will complete the initial knowledge assessment questionnaire.

Interactive presentations: Interactive classroom presentations are designed to cover key technical areas, for example, basic epidemiology of Ebola Virus Disease, Standard Precautions and Isolation Precautions, screening and isolation, hand hygiene, personal protective equipment, waste management, and safe and dignified burial.

Demonstration and practice of skills: The facilitators demonstrate essential IPC skills, for example, hand hygiene, putting on and removing personal protective equipment (PPE), and screening and isolation using checklists. This demonstration and practice are followed by hands-on practice under supervision and coaching by the facilitators. In this way, learners master the skills needed to perform the essential IPC skills included in the course. Both facilitators and learners use the same checklists to support clear performance expectations.

Final knowledge assessment: This assessment is used near the end of the skills training to measure learners’ progress in learning information using standardized, multiple-choice questions.

Assessment of skills acquired: Assessment of learners’ performance is a continuous process during the workshop. Each learner is assessed with a competency-based checklist that everyone uses during the workshop. In determining whether the learner is qualified, the facilitators will observe each learner for selected skills or activities. The learner must be rated “satisfactory” in each skill or activity to be evaluated as qualified.

Prevention and Control of Ebola Virus Disease in Health Care Facilities with 2 Limited Resources: Guide for Learners

The successful completion of the course is based on mastery of both the knowledge and skills components as well as satisfactory overall performance of key skills including hand hygiene and putting on and removing PPE. It is recommended that within 2–4 weeks of the workshop, learners working in their health facilities be observed and evaluated by a trained IPC supervisor or one of the facilitators with the same checklist used during the training workshop.

WORKSHOP SYLLABUS

Workshop Description This 3-day workshop is designed to prepare learners in IPC practices recommended for prevention and control of Ebola Virus Disease so they have the competencies to protect themselves, patients, and community members visiting the health facility through a competency-based approach to learning.

Workshop Goals To prepare health care workers in using appropriate infection prevention and control practices to prevent the spread of EVD while providing care and treatment to suspected/confirmed cases of EVD.

Learning Objectives By the end of the workshop, the learner will be able to:

Describe the epidemiology and clinical management of EVD.

List the Standard Precautions and Isolation Precautions recommended for EVD.

Effectively screen people coming to the health facility and isolate suspected/known cases of EVD.

Demonstrate appropriate hand hygiene practices.

Appropriately put on and remove PPE recommended for EVD patient care.

Describe the management of pregnant and breastfeeding women during an Ebola outbreak.

Describe cleaning and disinfection of the patient care area and equipment used for suspected/ know cases of EVD.

Appropriately manage linen waste from known/suspected cases of EVD.

Describe key IPC steps during the following essential support functions during Ebola outbreaks:

a. Safe and dignified burial of human remains of EVD patients

b. Post-mortem examinations

c. Diagnostic laboratory activities


Manage people visiting health care facilities.

Manage exposure to Ebola virus via blood and body fluids.

Training/Learning Methods

Illustrated lectures and group discussion

Classroom demonstration

Individual and group exercise

Simulated practice and coaching

Training Materials

Reference manual: Preventing the Transmission of Ebola Virus Disease in Health Care Facilities with Limited Resources

Learner’s Guide

Facilitator’s Guide

Infection prevention equipment and materials

PowerPoint presentations

Learner Selection Criteria Learners for this workshop are health care workers at health care facilities.

Methods of Evaluation

Learner

Initial and final knowledge questionnaires

Hand hygiene and PPE skills evaluation

Workshop evaluation (to be completed by each learner)

Workshop Duration 3 days

Suggested Composition

24 Learners1

3 Facilitators

1 The workshop size will be limited by the available space (classroom and demonstration areas/rooms).

4 P

reve

nti

on

an

d C

on

tro

l of

Eb

ola

Vir

us

Dis

ease

in H

ealt

h C

are

Fac

iliti

es w

ith

Lim

ited

Res

ou

rces

: G

uid

e fo

r L

earn

ers

PR

EV

EN

TIN

G T

HE

TR

AN

SM

ISS

ION

OF

EB

OL

A V

IRU

S D

ISE

AS

E IN

HE

AL

TH

CA

RE

FA

CIL

ITIE

S W

ITH

LIM

ITE

D R

ES

OU

RC

ES

TR

AIN

ING

FO

R H

EA

LT

H C

AR

E W

OR

KE

RS

Ven

ue _

____

____

____

____

____

____

_ F

rom

___

____

____

____

____

_ T

o __

____

____

____

____

___

DA

Y 1

D

AY

2

DA

Y 3

A.M

. (4

ho

urs

)

• O

pen

ing

(30

min

utes

)

• W

elco

me,

lear

ner

intr

oduc

tions

• O

verv

iew

of t

he w

orks

hop

• G

roup

nor

ms

and

lear

ners

’ exp

ecta

tion

Init

ial K

no

wle

dg

e A

sses

smen

t (3

0)

An

swer

s to

init

ial k

no

wle

dg

e as

sess

men

t q

ues

tio

nn

aire

(15

) C

hap

ter

1: O

verv

iew

of E

bola

Viru

s D

isea

se (

EV

D)

(45)

T

ea b

reak

(15

) C

hap

ter

2: In

fect

ion

Pre

vent

ion

and

Con

trol

Pra

ctic

es

for

Pre

vent

ing

Ebo

la V

irus

Dis

ease

in H

ealth

Car

e F

acili

ties

(45)

C

hap

ter

3: S

cree

ning

and

Isol

atio

n fo

r E

bola

Viru

s D

isea

se a

t the

Hea

lth F

acili

ty (

60)

A.M

. (4

ho

urs

)

Ag

end

a (5

min

utes

) G

rou

p a

ctiv

ity:

Isol

atio

n an

d P

atie

nt F

low

for

E

VD

(60

) C

hap

ter

7: E

nviro

nmen

tal C

lean

ing,

Pro

cess

ing

Line

n, a

nd W

aste

Man

agem

ent P

ract

ices

to P

reve

nt

Tra

nsm

issi

on o

f Ebo

la V

irus

Dis

ease

E

nviro

nmen

tal c

lean

ing

in E

VD

pat

ient

car

e ar

ea (

30)

Tea

bre

ak (

15)

Ch

apte

r 7

(co

nt.

): P

roce

ssin

g lin

en a

nd w

aste

m

anag

emen

t (60

) C

hap

ter

8: S

uppo

rt A

ctiv

ities

dur

ing

Ebo

la V

irus

Dis

ease

Out

brea

ks

Saf

e an

d di

gnifi

ed b

uria

l of h

uman

rem

ains

, IP

C

durin

g po

st-m

orte

m e

xam

inat

ion

(30)

IP

C d

urin

g la

bora

tory

act

iviti

es, m

anag

ing

visi

tors

, an

d m

anag

ing

pers

ons

expo

sed

to E

bola

viru

s (3

0)

A.M

. (4

ho

urs

) A

gen

da

and

war

m-u

p (

5 m

inut

es)

Ch

apte

r 9:

Pla

nnin

g an

d P

repa

redn

ess

for

Ebo

la V

irus

Dis

ease

Out

brea

ks (

45)

Fin

al k

no

wle

dg

e as

sess

men

t (3

0)

Tea

bre

ak (

15)

Cla

ssro

om

pra

ctic

e an

d e

valu

atio

n o

f co

mpe

tenc

y (1

45)

LU

NC

H

LU

NC

H

P.M

. (3

ho

urs

) A

fter

no

on

war

m-u

p (

5 m

inut

es)

Ch

apte

r 4:

Han

d H

ygie

ne

Illus

trat

ed p

rese

ntat

ion

and

dem

onst

ratio

n (4

5)

Ch

apte

r 5: G

uida

nce

for

the

Use

of P

erso

nal P

rote

ctiv

e E

quip

men

t (P

PE

) fo

r M

anag

ing

Sus

pect

ed/C

onfir

med

C

ases

of E

bola

Viru

s D

isea

se

PP

E Il

lust

rate

d pr

esen

tatio

n an

d de

mon

stra

tion

(75)

T

ips

for

bein

g an

effe

ctiv

e tr

aine

d as

sist

ant (

10)

Ch

apte

r 6:

Infe

ctio

n P

reve

ntio

n an

d C

ontr

ol P

ract

ices

fo

r M

anag

ing

Ebo

la V

irus

Dis

ease

in P

regn

ant a

nd

Bre

astfe

edin

g W

omen

and

The

ir B

abie

s (4

0)

Su

mm

ary

of

the

day

(5)

and

tea

brea

k

P.M

. (3

ho

urs

) A

fter

no

on

war

m-u

p (

5 m

inut

es)

Cla

ssro

om

pra

ctic

e an

d e

valu

atio

n o

f key

co

mpe

tenc

ies:

Lea

rner

s co

ntin

ue to

pra

ctic

e ha

nd

hygi

ene,

PP

E, a

nd s

afe

inje

ctio

n pr

actic

e sk

ills,

and

fa

cilit

ator

s as

sess

and

eva

luat

e le

arne

rs fo

r co

mpe

tenc

y (1

70)

Su

mm

ary

of

the

day

(5)

and

tea

brea

k

P.M

.(3

ho

urs

) A

fter

no

on

war

m-u

p (

5 m

inut

es)

Cor

rect

ing

final

kno

wle

dge

asse

ssm

ent (

30)

Bra

inst

orm

ing

: Id

entif

ying

gap

s in

cur

rent

pr

actic

e to

pre

vent

tran

smis

sion

of E

VD

in th

e he

alth

faci

lity

(30)

D

evel

op

act

ion

pla

ns

for

stre

ngth

enin

g IP

C

prac

tices

at h

ealth

faci

litie

s (4

5)

Co

urs

e ev

alu

atio

n b

y le

arne

rs (

10)

Su

mm

ary

of

the

cou

rse

(10

) C

losi

ng

(10

)


INITIAL KNOWLEDGE ASSESSMENT QUESTIONS Instructions: In the space provided, print a capital T if the statement is true or a capital F if the statement is false.

EBOLA VIRUS DISEASE

1. A person exposed to the Ebola virus is contagious from the moment of exposure to the virus.

2. Human-to-human transmission of Ebola virus occurs through direct/indirect contact with blood and body fluids of an infected symptomatic person.

3. Bodies of patients who have died from EVD are highly infectious.

4. Ebola virus is secreted in breast milk and can potentially infect breastfed babies.

5. The incubation period of EVD is from 2–21 days before a person develops symptoms and signs after exposure.

6. The definition of a suspected case of EVD in health care facilities during outbreaks is any case that has tested positive during laboratory investigation.

IPC PRACTICES FOR PREVENTING EBOLA VIRUS DISEASE IN HEALTH CARE FACILITIES

7. Standard Precautions are designed for suspected or confirmed cases of Ebola Virus Disease.

8. Wearing recommended PPE is a critical IPC intervention for protecting health care workers managing patients with EVD.

9. An N-95 mask should be worn by all personnel entering the isolation room to prevent infection by the droplet route.

10. It is not necessary to wear double gloves during the care of EVD patients.

11. Each disease has only one route of transmission.

12. The single most important practice for reducing the transmission of infection within a health care facility is hand hygiene.

13. 0.05% chlorine solution can be used for hand hygiene during outbreaks in resource-limited settings when soap and running water or alcohol-based handrub is not available.

SCREENING AND ISOLATION FOR EBOLA VIRUS DISEASE AT THE HEALTH FACILITY

14. A well-designed screening form should capture history of exposure and signs and symptoms of Ebola Virus Disease to identify suspected cases of EVD.

15. The staff should wear personal protective equipment including double gloves, impermeable gown, face mask, and goggles or face shield during screening.


ENVIRONMENTAL CLEANING, PROCESSING LINEN, AND WASTE MANAGEMENT PRACTICES TO PREVENT TRANSMISSION OF EBOLA VIRUS DISEASE

16. 0.5% chlorine solution is a recommended disinfectant for cleaning Ebola Virus Disease patient care areas.

17. In order to prepare 0.5% chlorine solution from 5% household bleach, add 1 part of bleaching solution to 19 parts of water.

18. Dry sweeping, mopping, and dusting should never be used for cleaning patient care areas in a health facility.

19. Heavily soiled linen from EVD patient care should be sorted in the patient care area before further processing.

20. Any waste generated during the care of a patient with EVD should be considered contaminated.

21. Liquid contaminated waste could safely be disposed of in a pit latrine.

SUPPORT ACTIVITIES DURING EBOLA VIRUS DISEASE OUTBREAKS

22. Staff responsible for collecting blood samples from suspected cases of EVD should collect all supplies for collecting blood and wear recommended PPE before entering the isolation room.

23. Vacutainers containing blood should be wiped, wrapped in a paper towel, and then placed in a plastic container with a screw cap.

24. Patients dying of EVD should be handed over to relatives for immediate funerals.

PLANNING AND PREPAREDNESS FOR EBOLA VIRUS DISEASE OUTBREAKS

25. Coordination, communication, surveillance, and management of EVD cases are important components of managing Ebola outbreaks.


CHECKLISTS FOR INFECTION PREVENTION AND CONTROL SKILLS USING THE CHECKLISTS The checklists for infection prevention and control skills contain the tasks or activities performed by the staff in caring for patients with EVD. The checklists contain the key tasks, skills, and activities performed by the health care provider. The learner is not expected to perform all of the steps or tasks correctly the first time s/he practices them. Instead, the checklists are intended to:

Help the learner in learning the correct steps and the order in which they should be performed (skill acquisition); and

Measure progressive learning in small steps as the learner gains confidence and skill (skill competency).

Used consistently, the checklists help learners measure their progress and stay focused on the key steps or tasks. Furthermore, the checklists are designed to make communication (coaching and feedback) between the learner and facilitator easier and more objective and helpful. Because the checklist is used to help in developing skills, it is important that the rating (scoring) be done as carefully and objectively as possible. The learner’s performance of each step is rated as follows:

Place a “” in case box if step/task is performed satisfactorily, an “X” if it is not performed satisfactorily, or N/O if not observed. Satisfactory: Performs the step or task according to the standard procedure or guidelines Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines Not Observed: Step, task, or skill not performed by learner during evaluation by facilitator Not Applicable: Step, task, or skill not required to be performed by learner during evaluation

For the purpose of assessing learners’ performance and providing positive feedback and suggestions for improvement, the facilitator should consider each step individually during assessment. If the step is either not observed or unsatisfactorily performed, the facilitator should provide feedback to the learner. If all steps on the checklist are satisfactorily performed without missing any step, the learner is evaluated as competent.


CHECKLIST FOR HANDWASHING USING SOAP AND WATER

(To be used by Learners and Facilitators)



STEP/TASK CASES

PREPARATION

1. Ensure that clean water, either through a tap or a container with a pitcher, soap, and a personal towel or paper towels are available.

2. Ensure that there is a waste basket for disposal of paper towels.

WASHING HANDS

3. Turn on the tap and maintain a straight stream of water or use a pitcher to steadily pour water.

4. Avoid splashing clothes or other parts of the body.

5. Wet hands with water.

6. Apply enough soap to cover all hand surfaces.

7. Rub hands palm to palm using a circular motion.

8. Rub hands with the right palm over the left dorsum with interlaced fingers.

9. Change and rub hands with left palm over the right dorsum with interlaced fingers.

10. Rub hands palm to palm with fingers interlaced.

11. Clean the back of the fingers by rubbing interlocked fingers of both hands and bringing them under the opposing palm.

12. Clasp left thumb in right palm and perform rotational movement to rub left thumb.

13. Clasp right thumb in left palm and perform rotational movement to rub right thumb.

14. Perform rotational rubbing backward and forward with tips of clasped fingers of right hand in left palm.

15. Perform rotational rubbing backward and forward with tips of clasped fingers of left hand in right palm

16. Rinse hands with water.

17. Stop pouring water if using a pitcher.

18. Dry hands with a personal towel or a single-use paper towel.



STEP/TASK CASES

19. Use a towel to turn off the faucet.

20. Dispose of the towel in a waste container.

21. The whole procedure takes 40–60 seconds.


CHECKLIST FOR HAND HYGIENE USING ALCOHOL-BASED HANDRUB/ 0.05% CHLORINE SOLUTION



CHECKLIST FOR HAND HYGIENE USING ALCOHOL-BASED HANDRUB/

0.05% CHLORINE SOLUTION

STEP/TASK CASES

PREPARATION

1. Ensure availability of an alcohol-based handrub/0.05% chlorine solution in a container.

HAND HYGIENE USING ALCOHOL-BASED HANDRUB

2. Apply a palmful of the product (3–5 ml) in a cupped hand, covering all surfaces.

3. Rub hands palm to palm using a circular motion.

4. Rub hands with the right palm over the left dorsum with interlaced fingers.

5. Change and rub hands with left palm over the right dorsum with interlaced fingers.

6. Rub hands palm to palm with fingers interlaced.

7. Clean the back of the fingers by rubbing interlocked fingers of both hands and bringing them under the opposing palm.

8. Clasp left thumb in right palm and perform rotational movement to rub left thumb.

9. Clasp right thumb in left palm and perform rotational movement to rub right thumb.

10. Perform rotational rubbing backward and forward with tips of clasped fingers of right hand in left palm.

11. Perform rotational rubbing backward and forward with tips of clasped fingers of left hand in right palm

12. Once dry, your hands are safe.

13. The whole procedure takes 20–30 seconds.


CHECKLIST FOR PUTTING ON PPE (To be used by Learners and Facilitators)


CHECKLIST FOR PUTTING ON PPE

STEP/TASK CASES

PREPARATION

1. Check that: a. Scrub suit, appropriate size rubber boots, and hand hygiene supplies are

available. b. All PPE of the appropriate size that you need (gloves, plastic apron,

gown, mask or respirator, goggles or face shield, head cover/cap, and footwear) is available.

c. There is a designated area for putting on and removing PPE.

2. Find a trained assistant to help you in putting on and removing PPE.

3. Tie back hair; for eye glasses, use anti-fog and secure with tape (or remove); remove jewelry/tie/ID/cell phone, etc.

4. Use the bathroom.

5. Wash hands with soap or use alcohol-based handrub.

6. Put on scrub suit and rubber boots in the changing room. If rubber boots are not available, wear closed, puncture- and fluid-resistant shoes with no laces or opening at top of foot.

7. Perform a BRIEFING to review plan for time in isolation area and ensure that all needed equipment is prepared.

Trained assistant reads the following step-by-step instructions and ensures that the health care worker putting on PPE follows them.

8. Perform hand hygiene with soap and water or alcohol-based handrub; if they cannot be made available, use the interim option of 0.05% chlorine solution.

9. If not wearing rubber boots, put on shoe covers.

10. Put on first pair of gloves (if you have a short cuff pair, put them on now).

11. Coverall suit: Put on coverall suit of an appropriate size to allow free movements. Gown: Put on gown and ensure it fully covers torso from neck to knees, arms to end of wrists, and wraps around the back.

12. Coverall suit: Zip up and fasten the zip and neck tabs of the suit. Gown: Fasten the gown at the back of the neck and waist.

13. Tuck cuff of the inner gloves under the sleeves of the gown.

14. Cut thumb holes at the border of the cuff of the gown and insert thumbs.


CHECKLIST FOR PUTTING ON PPE

STEP/TASK CASES

15. Medical mask: Put on, tie securely, and pinch the bridge of the nose to ensure that the mask is correctly positioned. N-95 respirator: a. Cup the respirator in hand with the nosepiece at fingertips. b. Allow the headbands to hang freely below hand. c. Position the respirator under chin with the nosepiece up. d. Pull the top strap over the head; rest it high at back of head. e. Pull the bottom strap over the head and position it around the neck

below the ears. f. Place fingertips of both hands at the top of the metal nosepiece and mold

the nosepiece (USING TWO FINGERS OF EACH HAND) to the shape of your nose. (Note: pinching the nosepiece using one hand may result in less effective respirator performance.)

g. Perform seal check: 1. Exhale sharply: If positive pressure builds inside, there is no leakage.

If pressure does not build, adjust the respirator. 2. Inhale deeply: If there is no leakage, the respirator will cling to the

face. If it does not, adjust the mask.

16. Put on head cover, ensuring that face, neck, and head to eyebrows are fully covered.

17. Spray face shield or goggles with anti-fog and wipe with clean cloth.

18. Put on face shield or goggles and tighten to fit head securely and hold head cover in place.

19. Put on a second pair of gloves (these should have a long cuff pulled over the sleeves of the gown or suit).

20. Put on apron and tie at the back.

21. Have the trained assistant check: a. All skin is covered. b. Comfort: health care worker is able to extend the arms, bend at the

waist, and do range of motions, and no skin shows during movement. c. Anything that is not in place, and correct.

If using a mirror, check all PPE and correct as needed.

22. Ensure that the trained assistant asks the health care worker in PPE to move arms up and down to ensure that no area of skin or mucous membrane is exposed.

23. Enter the isolation room or patient care area after clearance from the trained assistant.

24. DO NOT TOUCH OR ADJUST PPE once in the isolation area; any movement of PPE is considered a breach.


CHECKLIST FOR REMOVING PPE (To be used by Learners and Facilitators)


CHECKLIST FOR REMOVING PPE

STEP/TASK CASES

PREPARATION

1. Ensure that there is a separate area for removing PPE, other than the one used for putting on PPE. The location of the area for removing PPE is such that it allows the health care worker to move into a low-risk area when PPE is removed.

2. Prepare a container with 0.5% chlorine solution in which to place re-useable PPE to be reprocessed.

3. Prepare a container with 0.05% chlorine solution for hand hygiene if ABHR and/or soap and water are not available.

4. Have a waste bag in a rigid waste container (no lid) ready to safely place used, disposable PPE (depending on workflow, two may be needed).

5. Ensure that there is a trained assistant available to help in removing PPE.

6. The trained assistant completes the following tasks: a. Put on PPE: Gown, shoe covers, goggles or face shield, mask, double

gloves (one long cuff). b. Remind the HCW to avoid automatic actions that may put him/her at risk

(e.g., touching the face or forehead). c. Read aloud each step of the procedure. d. Ensure that the HCW repeats back the step he/she is about to perform

(talk back) and confirms completing the step. e. Observe and confirm visually that the PPE has been removed properly.

7. Minimize touching of PPE. Disinfect gloves after any contact.

8. Inspect the PPE to assess for visible contamination, cuts, or tears before starting to remove. Have the trained assistant spray the front and the back of the PPE with 0.5% chlorine solution, pointing the spray nozzle downward. Alternative: Trained assistant hands 0.5% chlorine solution to HCW to wipe front of PPE and gloves.

9. Decontaminate outer gloves with ABHR or 0.5% chlorine solution, ensuring that all surfaces of the gloved hands are cleaned.

10. Remove apron by pulling it away from the body and rolling contaminated front inward, and place it in the waste bag. DO NOT TOUCH THE FRONT OF THE APRON. If reprocessing apron, put it in the container with 0.5% chlorine solution.



STEP/TASK CASES

11. Inspect the PPE under the apron to assess for visible contamination, cuts, or tears. If any breach, spray or wipe the area with 0.5% chlorine solution. If no breach, move to the next step.

12. Disinfect outer gloves with ABHR or 0.5% chlorine solution, ensuring that all surfaces of the gloved hands are cleaned.

13. Remove outer gloves and place them in waste bag.

14. Inspect inner gloves to assess for cuts or tears. If any breach, spray or wipe the area with 0.5% chlorine solution, release thumb from the hole in the coverall suit, remove gloves, perform hand hygiene on hands, and put on clean gloves up to the edge of the cover all suit, If no breach, move to next step.

15. Remove face shield: by tilting the head slightly forward, grabbing the rear strap, and pulling it over the head, gently allowing the face shield to fall forward. OR Remove goggles: by lifting back of strap overhead, and pulling out and away. Place them in waste bag or, if reprocessing, put them in the container with disinfectant. Note: Avoid touching the front surface of the shield or goggles.

16. Disinfect inner gloves with ABHR or 0.5% chlorine solution, ensuring that all surfaces of the gloved hands are cleaned.

17. Remove head cover by grasping it from the back and pulling it away from head (not touching face or skin).


19. Remove gown: Grasp shoulders of gown and pull forward to break ties (or have trained assistant to undo ties at back). Roll gown so contaminated inside surface is contained. OR Remove coverall suit: Undo sticky tabs or ties (use mirror as appropriate): a. Lift chin. b. Find zip at the level of your belly and carefully trace your fingers up to

find the zip tab and fasteners with one hand. c. Hold outside of the top of suit at collarbone level near to zip line with the

other hand (do not let it go). d. Unzip or unfasten suit completely (still holding top near zip). e. Gently pull the side of the suit you are holding partially over the

shoulder. f. Perform rotating movement of the shoulders (one by one) to remove

coverall and carefully move coverall down body, turning inside out. g. Do a “moon-walk” to remove legs of suit over your boots. h. Carefully place in waste bag, touching only the inside. i. Avoid contact of scrubs with outer surface of gown or suit.


21. If wearing shoe covers, remove them using hands-free technique, if possible, and place them in waste bag, touching only the inside of the shoe covers.

22. Disinfect inner gloves with ABHR or 0.5% chlorine solution, ensuring that all surfaces of the hands are cleaned.



STEP/TASK CASES

23. Remove inner gloves.

24. Perform hand hygiene with ABHR or 0.05% chlorine solution, ensuring that all surfaces of the hands are cleaned.

25. Put on a new pair of gloves.

26. Remove mask: Undo bottom tie first, then top tie. Holding by top ties, lift away from face. OR Remove N-95 respirator: a. Tilt the head slightly forward. b. Grasp first the bottom elastic strap at back of the head and pull away

from the head and up and over. c. Then grasp the top elastic strap and pull away from the head and up and

over. Discard mask or respirator by holding the strap/tie without touching the front.

27. Disinfect new inner gloves with ABHR or 0.5% chlorine solution, ensuring that all surfaces of the gloved hands are cleaned.

28. Clean first boot/shoe by: Spraying: Trained assistant sprays front, back, and bottom with 0.5% chlorine solution. Step clean boot/shoe into low-risk area while other foot remains in isolation area. OR Wipes: While keeping feet in isolation area, sit on a clean chair positioned in the low-risk area. Use 0.5% chlorine solution to clean first boot/shoe top, sides, and lastly bottom before stepping first boot into low-risk area.

29. Clean second boot/shoe by: Spraying: Trained assistant sprays front, back, and bottom with 0.5% chlorine solution. Step clean boot/shoe into low-risk area. You are now standing in the low-risk area. OR Wipes: Lift second foot that is in isolation area. Use 0.5% chlorine solution to clean second boot/shoe top, sides and lastly bottom before stepping into low-risk area. You now have both feet in the low-risk area. In addition: 0.5% chlorine foot bath may be positioned at exit of isolation area (but tops of boots should still be wiped down).

30. Disinfect gloves with ABHR or 0.5% chlorine solution, ensuring that all surfaces of the gloved hands are cleaned.

31. Remove gloves and place in waste bag.

32. Perform hand hygiene on bare hands with ABHR or soap and water.


CHECKLIST FOR COLLECTING BLOOD SAMPLES FROM SUSPECTED CASES OF EVD2



CHECKLIST FOR COLLECTING BLOOD SAMPLES FROM SUSPECTED CASES OF EVD

STEP/TASK CASES

PREPARATION

1. Before entering the patient’s room, assemble all necessary equipment: a. Assemble equipment for collecting blood. b. Assemble equipment for preventing infections (equipment for hand

hygiene, personal protective equipment, waste management materials). c. Fill out patient documentation for the sample. d. Assemble materials for packaging the samples. e. Ensure that assistant wearing gloves stays outside the room.

2. Put on all personal protective equipment (PPE): a. Wear rubber boots or shoe covers. b. Wear mask and goggles or face shield. c. Wear head cover. d. Perform hand hygiene. e. Wear gloves.

COLLECTING THE BLOOD SAMPLE

3. Organize supplies on a trolley near the patient’s bed.

4. Identify and prepare the patient.

5. Select the site for drawing blood, preferably at the bend of the patient’s elbow.

6. Apply a tourniquet around the patient’s arm.

7. Ask the patient to form a fist so that the veins are more prominent.

8. Disinfect the area where you will insert the needle using 70% alcohol or other available antiseptic.

9. When using a vacuum extraction system with holder, insert the blood collector tube into the holder.

10. Anchor the vein by holding the patient’s arm and placing your thumb below the place where you want to inject the needle.

11. Draw the blood.

2 Adapted, with the permission of the publisher, from: How to Safely Collect Blood Samples from Persons Suspected to Be Infected with Highly Infectious Blood-Borne Pathogens (e.g. Ebola), Geneva, World Health Organization, 2014, http://www.who.int/csr/resources/publications/ebola/blood-collect-en.pdf?ua=1; accessed September 22, 2014.


CHECKLIST FOR COLLECTING BLOOD SAMPLES FROM SUSPECTED CASES OF EVD

STEP/TASK CASES

12. When blood starts to flow, ask the patient to open his/her hand.

13. As soon as enough blood has been collected (minimum 5 ml), release the tourniquet before withdrawing the needle.

14. Gently withdraw the needle. Do not point the needle at yourself or anyone else.

15. Remove the blood collector tube from the holder and put it into the rack.

16. Place the needle in a leakproof, puncture-resistant sharps container.

17. Stop the bleeding and clean the skin.

18. Take the blood tube from the tray and wipe the blood tube with a disposable paper towel.

19. Put all other items that came into contact with blood into the infectious waste bag for destruction.

20. Protect the sample from breaking during transport by wrapping the tube of blood in a paper towel.

21. Ask the designated assistant (wearing gloves) to approach the patient room, without entering, holding an open, plastic, leakproof packaging container.

22. Place the wrapped tube of blood into the plastic, leakproof packaging container being held by the assistant. Do not touch the outside of the plastic leakproof packaging container with your gloves.

23. Have the assistant tightly close the top of the plastic, leakproof packaging container and prepare the blood sample for transport (see Checklist for Shipping Blood Samples).

24. Remove personal protective equipment very carefully, as described in the Checklist for Removing PPE.

25. Perform hand hygiene with soap and water or alcohol-based handrub.

26. Appropriately label and send blood sample(s) to the laboratory or prepare for shipping.


CHECKLIST FOR SHIPPING BLOOD SAMPLES OF SUSPECTED EBOLA CASES WITHIN A COUNTRY3



CHECKLIST FOR SHIPPING BLOOD SAMPLES OF SUSPECTED EBOLA CASES

WITHIN A COUNTRY

STEP/TASK CASES

PREPARING THE SHIPPING EQUIPMENT (BEFORE HANDLING SAMPLE)

1. Manage logistics: a. Identify name and phone number/email of responsible person at National

Reference Laboratory and lead epidemiologist/medical officer at Ministry of Health.

b. Verify schedule/timetable for company transporting the sample.

2. Assemble equipment for packaging sample: a. Packaging material b. Additional items if refrigeration is necessary c. Shipping/transporting information (receiver’s contact information,

questionnaire with patient information, laboratory form or letter, waterproof marker)

3. Locate the sample.

PREPARING THE SAMPLE

4. If the sample is in a plastic, leakproof primary container, skip to Packaging the Sample. If the sample is NOT in a plastic, leakproof primary container, follow the steps below.

5. Put on a gown, face protection (face shield or goggles and mask), and gloves (over cuffs).

6. Protect the sample from breaking during transport by wrapping the tube of blood in a paper towel or cushioning material.

7. Ask a designated assistant (who is wearing gloves) to approach you with the unscrewed, plastic, leakproof primary packing container.

8. Place the wrapped tube of blood into the plastic, leakproof primary packaging container, being careful not to touch the outside of the primary packaging container with contaminated gloves.

3 Adapted, with the permission of the publisher, from: How to Safely Ship Human Blood Samples from Suspected Ebola Cases within a Country by Road, Rail and Sea, Interim Guideline, Geneva, World Health Organization, 2014, http://apps.who.int/iris/bitstream/10665/137549/1/WHO_EVD_Guidance_Lab_14.3_eng.pdf, accessed February 4, 2015.


CHECKLIST FOR SHIPPING BLOOD SAMPLES OF SUSPECTED EBOLA CASES WITHIN A COUNTRY

STEP/TASK CASES

9. Have the designated gloved assistant tightly close the plastic, leakproof primary packaging container. When closed, the outside of the primary tube can be disinfected.

10. Have both the person preparing the sample and the assistant remove their personal protective equipment.

11. Put contaminated items into a bag for infectious waste for destruction.

12. Perform hand hygiene (both persons).

PACKAGING THE SAMPLE

13. Prepare the rigid shipping box by inserting the inner lining into it.

14. Open the secondary leakproof container.

15. Insert the absorbent material into the box.

16. Wrap the primary container with cushioning material.

17. Place the primary container(s) into the secondary container.

18. Close the secondary container.

19. If refrigeration is not necessary, place the secondary container into the lined, rigid shipping box and proceed to Step 21.

20. If refrigeration is necessary: a. Place the secondary leakproof container into a Styrofoam container and

surround it with ice packs; and b. Place the Styrofoam container into the rigid shipping box.

21. Put the laboratory form/letter and epidemiological questionnaire into an envelope.

22. Close the top of the box or boxes and tape the box(es) closed.

MARKING AND LABELING THE BOX

23. Write the name and addresses on the box.

24. Write the name and telephone number of the contact person at the National Reference Laboratory on the box.

25. Place the Infectious Substance label on the box.

26. Verify that the orientation arrows are on the box (mandatory on opposite sides of the box when total volume of infectious substances exceeds 50 ml).

FINALIZING THE SHIPMENT

27. Contact the National Reference Laboratory to inform them that samples have been sent.

28. Obtain a shipping and tracking receipt and store it in a safe location for 2 years.


CHECKLIST FOR CONDUCTING SAFE AND DIGNIFIED BURIAL OF A PATIENT WHO DIED FROM EVD4



CHECKLIST FOR CONDUCTING SAFE AND DIGNIFIED BURIAL OF A PATIENT WHO DIED

FROM EVD

STEP/TASK CASES

1. Prior to departure, compose the team and prepare disinfectants. The team: • There are 4 members of the team wearing full PPE for the field situation:

– 1 sprayer, wearing full PPE – 1 technical supervisor, not wearing PPE – 1 communicator, a person who interacts with the family and community – 1 religious representative, not wearing PPE

Disinfectants: • 0.05% chlorine solution for hand hygiene • 0.5% chlorine solution for disinfection

2. Assemble all necessary equipment: a. Assemble body bag to hold the body of the deceased. b. Assemble all necessary equipment to prevent infection. c. For hand hygiene: soap and water or alcohol-based handrub solution or

0.05% chlorine solution d. Personal protective equipment: disposable, non-sterile gloves, a pair of

heavy-duty gloves, rubber boots, coverall suit, goggles, and mask

For waste management: a. Hand sprayer containing 0.05% chlorine solution b. Back sprayer containing 0.5% chlorine solution c. Leakproof infectious waste bags: one for disposable and one for

reusable materials

4 Adapted, with the permission of the publisher, from: Field Situation: How to Conduct Safe and Dignified Burial of a Patient Who Has Died from Suspected or Confirmed Ebola Virus Disease, Geneva, World Health Organization, October 2014, http://apps.who.int/iris/bitstream/10665/137379/1/WHO_EVD_GUIDANCE_Burials_14.2_eng.pdf?ua=1, accessed December 6, 2014.


CHECKLIST FOR CONDUCTING SAFE AND DIGNIFIED BURIAL OF A PATIENT WHO DIED FROM EVD

STEP/TASK CASES

3. Arrival: Prepare burial with family and evaluate risks: a. Complete pre-departure preparation: Have pre-departure meeting, greet

the family members and offer condolences, identify family representative, and contact local faith representative.

b. Obtain the formal agreement of the family before proceeding. c. Follow burial guidelines based on the religion of the deceased. d. Verify that the grave is dug or send selected people in advance. e. Involve family members in every procedure as much as possible. f. Allow pictures. g. Dignified burial of a Christian patient:

- Respect the family’s requests. - Allow the family to carry out final rituals using non-touch techniques. - Provide a symbol of dignity and clothing. - Involve a religious leader in the procedure. - Allow offering of prayers, blessings, speeches, etc. - Identify burial site and prepare appropriate label for the grave. - Allow the family to put certain items in the grave as desired. - Allow the family members to throw the first soil.

h. Dignified burial of a Muslim patient: - Identify a Muslim religious leader in the community. - Respect the family’s requests. - Allow dry ablution of the body if requested. - Cover body with cloth before placing body in the bag and later in the

grave. - Shroud body in a cloth according to the religious leader’s advice. - Have a female member of the team manage a female deceased

patient. - Use a white body bag for Muslim patients.

4. Put on all PPE: a. Wear rubber boots, perform hand hygiene, put on coverall suit and

plastic apron, put on face mask and goggles, put hood up, make thumb hole in the suit, put on inner gloves under the cuff of the coverall, and put on outer gloves.

b. Assess and identify location for placing the body. c. Choose bag of correct size. d. Place coffin, if available, outside of the house. e. Identify places used by the deceased for cleaning and disinfection later.

5. Place the body in the body bag: • At least two members of the burial team wearing PPE enter the house:

a. Collect samples for confirmation of the cause of death. b. Place open body bag on the floor. c. Do not spray, wash, or embalm the body. d. Manipulate the body only as needed. e. Lift and place the body in the body bag. f. Close the body bag. g. Disinfect the outside of the bag.


CHECKLIST FOR CONDUCTING SAFE AND DIGNIFIED BURIAL OF A PATIENT WHO DIED FROM EVD

STEP/TASK CASES

6. Place the body bag in a coffin where culturally appropriate: a. Team members wearing PPE place body in the coffin. b. Put patient’s clothes and other objects in the coffin. c. Allow one family member to close the coffin. d. Disinfect the coffin. e. Respect the grieving time requested by the family. f. Decontaminate the coffin.

7. Sanitize the family’s environment: a. Dispose of any sharps used on the deceased patient. b. Clean all areas with water and detergent and disinfect with suitable

disinfectant. c. Gather all linen used by the deceased for disposal and replace with new

items.

8. Remove PPE, manage waste, and perform hand hygiene: a. Disinfect boots without removing them. b. Remove apron. c. Remove outer gloves. d. Remove coverall. e. Remove goggles from behind. f. Remove mask from behind. g. Remove inner gloves. h. Ensure that all PPE items are placed in appropriate bags. i. Wash hands.

9. Wear gloves and transport the coffin or the body bag to the cemetery: a. Utility gloves are sufficient to handle coffin. b. Family members should also wear gloves. c. Provide enough time to the family members for grieving. d. Allow some family members to sit with coffin in the rear of the car. e. Ensure that the front cabin is used only by the team members.

10. Burial at cemetery: Place coffin or body bag into the grave: a. Manually carry coffin or body bag to the grave. b. Place it on the ropes. c. Slowly lower the coffin/body bag into the grave. d. Respect any final rituals.

11. Burial at cemetery: Engage community for prayers: a. Respect the family members’ desires and needs. b. Have the family members close the grave. c. Have the family members wash their hands with 0.05% chlorine solution.

12. Return to the hospital or team headquarters: a. Organize the incineration of the single-use equipment at the hospital or

in another designated place. b. Process reusable equipment for reuse. c. At the end of the day’s work, remove the rubber boots and disinfect with

0.5% chlorine solution.


WORKSHOP EVALUATION (To be completed by Learners)

Please indicate on a 1–5 scale your opinion of the following workshop components: 5-Strongly Agree 4-Agree 3-No Opinion 2-Disagree 1-Strongly Disagree

WORKSHOP COMPONENT RATING

1. The initial knowledge questions helped me to study more effectively.

2. I am now confident in putting on and removing PPE recommended for Ebola patient care.

3. I am now confident in effectively assisting my fellow health care workers in putting on and removing recommended PPE for Ebola patient care.

4. The training approach used in this workshop made it easier for me to learn infection prevention and control practices for EVD.

5. The facilitators clearly stated the learning objectives.

6. The facilitators communicated clearly and effectively.

7. The information presented in the workshop was new to me.

8. The facilitators demonstrated enthusiasm in the subjects they taught.

9. The sessions were well-organized.

10. The facilitators asked questions and involved me in the sessions.

11. The content of the workshop was useful to my work.

12. The workshop made me feel more competent or skillful in my work.

13. I feel prepared for working with EVD patients and know what needs to be done to prevent transmission of EVD in my facility.

Additional Comments (use additional pages if needed)

What topics, if any, should be added to improve the workshop? Why?

What topics, if any, should be deleted to improve the workshop? Why?

The length of the workshop (3 days) was: (circle one) 1) Too long 2) Too short 3) Just right

Prevention and Control of Ebola Virus Disease in Health...

Documents

Transcript of Prevention and Control of Ebola Virus Disease in Health...