In light of the first imported case Ebola to the United States the Yale-Tulane ESF-8 Planning and Response Network has produced this special report which focuses on operations and preparedness here at home.. The report was compiled entirely from open source materials. Please feel free to forward the report to anyone who might be interested.

1. YALE- TULANE ESF-8 SPECIAL REPORT
UNITED STATES – EBOLA 2014
US – IMPORTED CASE
HEALTHCARE WORKERS
CONTACT TRACING - DALLAS
CDC RESPONSE - DALLAS
CURRENT SITUATION
LESSONS LEARNED
WHAT IS EBOLA?
PT EVALUATION
22 OCTOBER 2014
TEXAS
DALLAS COUNTY HEALTH
DEPARTMENT
TEXAS DEPARTMENT OF
STATE HEALTH SERVICES
US FEDERAL
GOVERNMENT
THE WHITE HOUSE
CDC
• CDC - EBOLA
• HEALTH ALERT
NETWORK (HAN)
• CLINICIAN OUTREACH
AND COMMUNICATION
ACTIVITY (COCA)
• CDC NEWS ROOM
NIOSH
• EBOLA AND OTHER
EMERGING
INFECTIOUS DISEASES
OSHA
SAFETY AND HEALT H
TOPICS - EBOLA
FDA
REFERENCE MATERIALS
NEWS SOURCES
• ALERTNET
• NY TIMES
• WASHINGTON POST
• Reuters
ASSOCIATION AND
COMMISIONS
• THE JOINT COMMISSION
• EBOLA PREPAREDNESS
RESOURCES
• NACCHO
PREPARENESS RESOURCES:
• COMMUNITY PLANNING
CONFIRMED CASES OF EBOLA (US)
PORTALS, BLOGS, AND RESOURCES
• AVIAN FLU DIARY
• DISASTER INFORMATION
RESEARCH CENTER
• CIDRAP
• H5N1
• INTERNATIONAL SOS
• NCDMPHP RESILIENCE
THROUGH LEARNING - EBOLA
• VIROLOGY DOWN UNDER BLOG
PPE

2. CONFIRMED CASES OF EBOLA (US)
CASES OF EBOLA OUTSIDE OF WEST AFRICA
At least 17 Ebola cases have been treated outside of West Africa in the
current outbreak, including two Dallas hospital workers who have tested
positive for Ebola. Most of these involve health and aid workers who
contracted Ebola in West Africa and were transported back to their home
country for treatment. Four cases were diagnosed outside of West Africa:
A Liberian man who began showing symptoms four days after arriving in
Dallas, a Spanish nurse who became ill after treating a missionary in a Madrid
hospital and the two Dallas hospital workers who were involved in the
treatment of the Liberian man. These cases are compiled from reports by the
federal Centers for Disease Control and Prevention, the World Health
Organization, Doctors Without Borders and other official agencies.
As of 21 OCT 2014, 3 Ebola patients remain hospitalized in the US.
Eight confirmed cases of Ebola have been treated in the United
States: 1 died, 6 have been discharged, 2 remain in the hospital.
1 U.S. citizen died abroad, having never returned to the States.
• Dr. Kent Brantly (missionary) -- Discharged from Emory University
Hospital in Atlanta on August 21.
• Nancy Writebol (missionary) -- Discharged from Emory University
Hospital on August 19.
• Thomas Eric Duncan (Liberian) -- Died October 8; was treated for Ebola at
Texas Health Presbyterian Dallas.
• Amber Vinson (nurse at Texas Health Presbyterian) -- Currently receiving
treatment at Emory University Hospital after being transported from
Dallas on October 15.
• Nina Pham (nurse at Texas Health Presbyterian) -- Currently receiving
treatment; Transferred to a NIH hospital in Maryland, from Dallas, for
treatment on October 16, 2014
• Dr. Rick Sacra (missionary) -- Discharged from the Nebraska Medical
Center on September 25; was admitted to a hospital in Worcester,
Massachusetts, for a respiratory virus on October 4; and was released the
following day.
• Ashoka Mukpo (NBC News freelancer) – Discharged from the Nebraska
Medical on 21 October 2014.
• US Doctor (name unknown) -- Discharged from Emory University
Hospital after having been hospitalized for 6 weeks. The American doctor
who had quietly returned to the U.S. after contracting Ebola working in
Sierra Leone in September.

3. US – IMPORTED CASE
SITUATION: EBOLA IN THE US: A single imported case from
Liberia, Thomas Eric Duncan, was confirmed on September
30,2014 with Ebola. Two healthcare workers who tended to Mr
Duncan confirmed infected in October, all in Texas. They are the
first people to get infected with Ebola within the United States and
represent the first person-to-person spread outside of Africa.
Extensive contact tracing is currently underway
US INDEX PATIENT
On September 30, 2014, the Centers for Disease Control and
Prevention (CDC) reported that Thomas Eric Duncan traveled
from Monrovia, Liberia, on September 19, 2014, and arrived
in Dallas, Texas, on September 20. On September 24, he developed
symptoms, and sought medical care at 10:00 p.m. on September
25. He was admitted to the hospital on September 28. On
September 30, the CDC laboratory confirmed that he was infected
with Ebola virus. (CDC- 30 SEP)
EXPOSURE IN LIBERIA
Thomas Eric Duncan, a Liberian national in his mid-40s, had lived
in Monrovia, Liberia. On September 15, 2014, Duncan helped to
transfer his housemate and landlord's daughter who had Ebola, to
the hospital. The family was turned away due to lack of space and
Duncan helped carry Williams from the taxi back into her home,
where she died. (NYT-1 OCT)
TRAVEL HISORY
Duncan flew on September 19 from Monrovia to Brussels, where,
according to United Airlines, he took Flight 951 to Washington
Dulles Airport and continued to Dallas/Fort Worth on Flight 822,
arriving September 20. (NYT-1 OCT)
DUNCAN’s TRAVEL HISTORY FROM LIBERIA-WASHINGTON/
DULLES – DALLAS/FT WORTH

4. US – IMPORTED CASE
DUNCAN IS HOSPITALIZED
• The hospital notified Dallas County Health and Human
Services (DCHHS) on Monday, September 29, 2014, whose
personnel arrived on site shortly thereafter.72 CDC officials
were notified later on September 29, but did not arrive at the
hospital campus until October 1, 2014. (HEARING - 16 OCT 14)
• CDC and Texas Department of State Health Services (DSHS)
laboratory testing confirmed the diagnosis of Ebola on
Tuesday, September 30, 2014. (HEARING - 16 OCT 14)
• DCHHS states it is the lead agency charged with the ongoing
contact investigation to determine who may have been
exposed to Duncan while he was contagious. The
investigation has, thus far, identified forty-eight individuals out
of a broader group with risk of exposure. Ten individuals are
considered to be at high risk. These forty-eight contacts are
being monitored for twenty-one days from their time of
exposure. (HEARING - 16 OCT 14)
• Duncan received an experimental drug (Brincidofovir)during
the course of his treatment. He was also intubated and on
dialysis for an unknown period of time.
• DEATH: On October 8, 2014, Thomas Eric Duncan dies.
(TXDSHS-8 OCT)
DEVLOPS SYMPTOMS
Duncan began experiencing symptoms on September 24, 2014 and
went to the Texas Health Presbyterian Hospital emergency room late
in the evening of September 25. During this visit, his reported
symptoms were a 100.1 °F (37.8 °C) fever, abdominal pain for two
days, a headache, and decreased urination. The ER nurse had asked
about his travel history and recorded that he had come from Liberia;
however; the significance of this information was missed by the
hospital staff. He was diagnosed with a "low-grade, common viral
disease" and was sent home with a prescription for antibiotics.
(Reuters – 1 OCT)
Duncan began vomiting on September 28, 2014, and was
transported the same day to Texas Health Presbyterian Hospital
emergency room by ambulance where he was diagnosed with Ebola.
SOURCE: HEARING ON EXAMINING THE U.S. PUBLIC HEALTH RESPONSE TO THE EBOLA OUTBREAK (16 OCT 14)

5. HEALTHCARE WORKERS
HOW MANY HEALTH CARE WORKERS HAVE CONTRACTED EBOLA?
• The news that a Dallas nurse who helped care for Thomas Eric
Duncan was infected with the Ebola virus has fed fears of health
care workers across the United States. Nina Pham is the first
patient to be infected in the United States. A second nurse
treating Duncan, Amber Vinson, has tested positive for Ebola.
•
More than 400 health care workers in West Africa have been
infected with Ebola during the current outbreak, and 233 had
died as of Oct. 8. The World Health Organization said that the
high rates of infection among medical workers could be
attributed to shortages or improper use of protective equipment;
not enough medical personnel; and long working hours in
isolation wards.
TWO US HEALTHCARE WORKERS CONTRACT EBOLA
• 11 OCT - A healthcare worker, Nina Pham, 26, a nurse who cared for Duncan
at Texas Presbyterian Hospital, reported having a low grade fever overnight
and was referred for testing. The Texas Department of State Health Services’
laboratory returned a preliminary test that was positive for Ebola at
approximately 9:30 p.m. on October 11. (16 OCT 14)
• 12 OCT - CDC testing performed on October 12 confirmed this result.
Pham is isolated and interviewed by CDC to identify any contacts or
potential community exposures. To date, CDC officials have identified
one close contact, who is being monitored for fever and other
symptoms. (16 OCT 14)
• 13 OCT - Amber Vinson, 29, another nurse who treated Duncan at
Texas Health Presbyterian Hospital flies from Cleveland to Dallas on
Frontier Airlines Flight 1143, arriving at 8:16 p.m. She has no symptoms,
but her temperature was 99.5 degrees that morning. She called the
Centers for Disease Control and Prevention before boarding, and no one
told her not to fly. (ABC NEWS - 16 OCT)
• 14 OCT - Vinson is taken to Texas Health Presbyterian Hospital in Dallas
with a fever. (ABC NEWS - 16 OCT)
• 15 OCT - Vinson is diagnosed with Ebola shortly after midnight and
flown to Emory University Hospital that evening .( TXDSHA – 15 OCT)
• 16 OCT - Nina Pham, the first person to contract Ebola in the United
States while caring for a patient in Dallas, was transferred to a National
Institutes of Health Clinical Center in Bethesda. Pham's transfer to the
facility, one of four in the United States with a special biocontainment
unit, occurred Thursday evening, October 16, 2014. (WP- 16 OCT)

6. CONTACT TRACING - DALLAS
INITIAL CONTACT TRACING - DUNCAN
• Authorities began tracing Duncan’s contacts and initially began
monitoring around 100 people who may have had contact with the Ebola
patient. This conservative approach cast a 'wide net' and includes people
who are likely not at risk but were screened anyway. (CDC- 10 OCT)
• During the CDC's press briefing., it was confirmed that 10 people
had contact with the Duncan, none of whom had symptoms, and the
rest had possible contact. (CDC- 10 OCT)
• Four close family members of the patient, believed to be amongst the
“high risk” contacts, were asked to stay home at least until October 19,
when the 21-day incubation period for the virus would have lapsed.
After failing to comply with this request, they were formally ordered to
remain confined to their apartment. The family was forced to remain in
the apartment for days, despite the fact that it was contaminated with
Duncan’s waste products and bodily fluids. The family has since been
moved to an undisclosed location. (HEARING - 16 OCT 14)
INITIAL CONTACT TRACING – PHAM: According CDC there is only one
person who may have had contact with Nina Pham while she had
symptoms/could possibly have spread Ebola to others. That person is under
"active monitoring" and has no symptoms. (SOS – 12 OCT)
INITIAL CONTACT TRACING – VINSON: Amber Vinson’s contacts tracing is
more complex due to her travel. CDC and Frontier Airlines are tracking
those who were on her flights .(CDC- 15 OCT)

7. CONTACT TRACING - DALLAS
Public health officials attempt to reach all contacts/possible contacts
every day to check for fever and other symptoms. Daily follow-up
with contacts/possible contacts will continue for 21 days from the
date of each person’s exposure. (CDC- 16 OCT)
CDC EXPANDS PASSENGER NOTIFICATION
Based on additional information obtained during interviews of close
contacts to the second healthcare worker from Texas Presbyterian
Hospital who tested positive for Ebola, the Centers for Disease
Control and Prevention (CDC) is expanding its outreach to airline
passengers who flew from Dallas Fort Worth to Cleveland on Frontier
flight 1142 on Oct. 10.
CDC is now asking passengers on Frontier Airlines flight 1142
Dallas/Fort Worth to Cleveland on Oct. 10 and passengers on
Frontier Airlines flight 1143 from Cleveland to Dallas/Fort Worth on
Oct. 13 to call 1 800-CDC INFO (1 800 232-4636). Public health
professionals will interview passengers about the flight, answer their
questions, and arrange follow up if warranted. Individuals who are
determined to be at any potential risk will be actively monitored.
(CDC - 16 OCT)
DATE: 10/17/2014 - Numbers are accurate as of 5 p.m., 16 OCT are updated
at approximately noon each day.
CONFIRMED CASES: 3
* CONTACTS: 11
**POSSIBLE CONTACTS: 132
TOTAL: 143
* Contacts – Definite exposure
** Possible Contacts – Possible exposure
NOTE: The number of possible contacts increased significantly Oct. 14 to
account for a group of healthcare workers who were previously self-monitoring
and are now being actively monitored following a healthcare
worker's Ebola diagnosis over the weekend. Another case was diagnosed
Oct. 15, which also impacted the numbers.
Contacts are defined as people who had definite exposure to an Ebola
patient.

8. CDC RESPONSE - DALLAS
CDC SUPPORT IN DALLAS
• In addition to an initial team of 10 public health professionals sent
on September 30 to support contact tracing and response after an
index patient was hospitalized with Ebola in Dallas, CDC has sent
new resources to Dallas to support the highest standard of infection
control. (14 OCT)
• CDC has deployed a second team of 16 to Dallas to train and assist
the hospital in infection control and the monitoring of health care
workers who had contact with the index patient.
• These join the 2 CDC officials who were assisting the hospital
previously. The additional CDC team includes experts in:
‒ Infection control
‒ Ebola virus control and infectious diseases
‒ Laboratory science
‒ Personal protective equipment
‒ Hospital epidemiology
‒ Workplace safety
• The team includes experts who successfully controlled outbreaks of
Ebola in Africa in the past two decades, including in health-care
settings. Team members have worked with Doctors Without
Borders on infection control protocols and trained others in Africa
to follow those protocols.
• In addition, two infection control nurses from Emory University
hospital who successfully treated Ebola patients without
contracting or transmitting infection joined the response at the
Dallas hospital to provide peer-to-peer training and support.
FOCUS OF THE DALLAS HOSPITAL INVESTIGATION
The CDC team is assisting the hospital in rapidly reducing the risk of
further spread of Ebola and investigating how the healthcare workers
may have become infected with Ebola. The team is evaluating:
• What personal protective equipment (PPE) is being used and how
it is being put on and taken off ?
• What medical procedures were done on the index patient that
may have exposed the healthcare worker?
• The decontamination processes for workers leaving the isolation
unit ?
• Oversight and monitoring of all infection control practices,
particularly putting on and taking off PPE, at each shift in each
location where this occurs?
• What enhanced training and/or changes in protocol may be
needed?
FOR MORE DETAILS SEE:
http://www.cdc.gov/media/releases/2014/fs1014-ebola-investigation-
fact-sheet.pdf

9. CURRENT SITUATION
The President has put into motion the following action to ensure we effectively
treat and prevent the spread of Ebola (15 OCT):
• The CDC will now send a rapid response team, a "swat team, essentially" to be
on the ground within 24 hours as soon as someone is diagnosed with Ebola so
the CDC can walk the local hospital through the protocols step-by-step. That
includes use and disposal of protective equipment.
• Lessons learned from the problems that occurred in Dallas to hospitals, clinics,
and first-responders will be communicated around the country on a ongoing
and up-to-date basis.
• The federal government will work carefully with the city of Dallas and the
state of Texas to ensure that, in the event any other cases arise among health
workers, they are properly cared for in a way that is consistent with public
safety.
• Continue to conduct “contact-tracing" to ensure that anyone who may have
come into contact with the affected individuals are being monitored in a way
to prevent the further spread of this disease.
• Continue to monitor the health status of the other health care workers in
Dallas.
• Continue screening processes at airports and make sure teams are in place to
transport suspected cases to specialized, secure hospitals if needed.
• Continue to lead the international response in West Africa because "the
investment we make in helping Liberia, Sierra Leone, and Guinea deal with this
problem is an investment in our own public health."
President Obama has asked Ron Klain, who
served as chief of staff to both Vice President
Biden and former vice president Al Gore, to
manage the government’s response to the
deadly virus as public anxiety grows over its
possible spread. (WP-17 OCT).
The United States issued stringent new protocols on Monday, October
20,2014 for health workers treating Ebola victims, directing medical teams
to wear protective gear that leaves no skin or hair exposed to prevent
medical workers from becoming infected.
Under new protocols, Ebola healthcare workers also must undergo special
training and demonstrate competency in using protective equipment. Use of
the gear, now including coveralls, and single-use, disposable hoods, must be
overseen by a supervisor to ensure proper procedures are followed when
caring for patients with Ebola, which is transmitted through direct contact
with bodily fluids but is not airborne. (CDC protocols: (CDC-20 OCT))
The Pentagon will create a 30-person team of
medical experts that will provide support for
civilian doctors who might lack proficiency in the
deadly Ebola virus or other infectious diseases.
(WP-19 OCT)
The Pentagon announced Sunday that it will create a 30-person team of
medical experts that could quickly leap into a region if new Ebola cases
emerge in the United States, providing support for civilian doctors who lack
proficiency in fighting the deadly virus.
Defense Secretary Chuck Hagel ordered the Pentagon’s Northern Command,
which has a prime focus on protecting homeland security, to send this new
team to Fort Sam Houston in Texas for high-level preparations to respond to
any additional Ebola cases beyond the three confirmed in the country.

10. CURRENT SITUATION - TRAVEL
TEXAS HEALTH OFFICIALS ORDER ANY PERSON WHO ENTERED THE ROOM OF
THE FIRST EBOLA PATIENT AT A DALLAS HOSPITAL NOT TO TRAVEL BY PUBLIC
TRANSPORT
Texas health officials have instructed any person who entered the room of
the first Ebola patient at a Dallas hospital not to travel by public transport,
including planes ship, buses or trains, or visit groceries, restaurants or
theaters for 21 days, until the danger of developing Ebola has expired. (17
OCT)
The instructions, issued by the Texas Department of State Health Service late
Thursday, cover more than 70 health workers involved in providing care for
Thomas Duncan, the Liberian national who became the first patient to test
positive for Ebola in the United States.
Amber Vinson, 29, a nurse who treated Duncan and
became ill with Ebola traveled on Frontier Airlines from
Dallas to Cleveland and back
THE DEPARTMENT OF HOMELAND SECURITY ANNOUNCED IT WOULD
BEGIN REQUIRING ALL PASSENGERS FROM THREE WEST AFRICAN
COUNTRIES AFFECTED BY EBOLA (LIBERIA, SIERRA LEONE OR GUINEA)
TO ARRIVE ONLY AT THE FIVE U.S. AIRPORTS WITH HEIGHTENED
SECURITY MEASURES.
• The five airports are John F. Kennedy International in New York,
O’Hare International in Chicago, Hartsfield-Jackson International in
Atlanta, Washington Dulles International near Washington, D.C., and
Newark Liberty International in Newark, N.J.
• Thee new measures would go into effect on Wednesday, September
22 (WSJ- 21 OCT)
• There are no direct flights from the three countries to the U.S.
• Just three big international airlines serve Liberia, Guinea and Sierra
Leone: Air France-KLM SA, Brussels Airlines and Royal Air Maroc of
Morocco. Most travelers from those countries connect to the U.S. via
Paris, Brussels or Casablanca, Morocco.
• The CDC and the Department of Homeland
Security (DHS) announced that the
following five U.S. airports will begin
enhanced Ebola screening for all travelers
coming from Ebola-affected countries:
John F. Kennedy International Airport (in
New York), Newark, Washington-Dulles,
Chicago O'Hare and Atlanta. (WHITE
HOUSE – 8 OCT) .
• Screening was initiated at JFK on 11 OCT
(WSJ- 11 OCT), and at Atlanta, Chicago,
Washington, Newark airports on 16 OCT
(AP -16 OCT)

11. PRELIMINARY LESSON LEARNED FROM DALLAS
DIAGNOSING EBOLA IS VERY DIFFERENT FROM TREATING EBOLA
Texas Health Presbyterian Hospital Dallas (THD) was and remains well
prepared and equipped based upon the best available information to treat
patients already identified as having EVD.
Where THD fell short initially was in its ability to detect and diagnose EVD,
as evidenced by Mr. Duncan’s first visit to the ED. As a result, following
Mr. Duncan’s initial admission, THD have changed their screening process
in the ED to capture the patient’s travel history at the first point of contact
with ED staff. This process change makes the travel history available to all
caregivers from the beginning of the patient’s visit in the ED.
Additionally, THD have modified its Electronic Health Record (HER) in
multiple ways to increase the visibility and documentation of information
related to travel history and infectious exposures related to EVD. These
include:
• Better placement/title of the screening tool
• Expanded screening questions, which include:
– Exposure to persons known or suspected to have EVD
– High-risk activities for persons who have traveled
to Ebola endemic areas such as: “have you touched a dead
animal or helped carry someone sick”
– A pop up identifying the patient as high-risk for Ebola with
explicit instructions for next steps if the answer to any of the
screening questions is positive
COMMUNICATION IS CRITICAL BUT IT IS NO SUBSTITUTE FOR
TRAINING
Despite the communications regarding EVD preparedness that occurred
between August 1 and October 1, THD realized a need for more
proactive, intensive, and focused training for frontline responders in the
diagnosis of EVD.
Therefore an E) refresher course was provided to THD ED nurses.
Additionally, an “in -service” face-to-face training was provided starting
with the night shift and continued at the start of every shift for a number
of days.
The education included screening of suspected patients, documenting
response to travel questions in the Electronic Health Record and proper
donning and offing of PPE
EBOLA EXTENDS BEYOND THE WALLS OF THE HOSPITAL
In a crisis like this, a hospital’s focus needs to be on providing exceptional
care. Coordination and collaboration with federal, state, and local
agencies is critical to limiting the perimeter of Ebola, managing contact
identification interviews, and establishing community confidence.
SOURCE: DR. DANIEL VARGA, CHIEF CLINICAL OFFICER AND SENIOR
VICE PRESIDENT, TEXAS HEALTH RESOURCES (16 OCT 2014)

12. PRELIMINARY LESSON LEARNED FROM DALLAS
HEALTHCARE WORKERS WHO ARE EXPOSED SHOULD NOT TRAVEL
Amber Vinson, the second health care worker, had a fever of 99.5
degrees when she flew from Cleveland to Dallas, according to the CDC.
While other passengers' risks of exposure are low, the fact that she was
being monitored due to exposure and had a slight fever meant that she
definitely should not have been on a plane.
LESSON LEARNED: CDC guidance in this setting outlines the need for
what is called “ controlled movement”. That can include a charter plane,
a car, but it does not include public transport. CDC will from this moment
forward ensure that no other individual who is being monitored for
exposure undergoes travel in any way other than controlled movement.
(CDC – 15 OCT )
HOSPITAL PREPAREDNESS
Both infected healthcare workers have been evacuated to specialized
hospitals that have biocontainment units and highly trained staff in
infectious diseases.
The problem is that not all hospitals are equally prepared or equipped to
combat Ebola. There are four hospitals in the country that have top-level
biocontainment units including the Emory University Hospital in Atlanta
and NIH Medical Center in Bethesda, Maryland, University of Nebraska in
Omaha and St. Patrick Hospital in Missoula, Montana. There are limited
beds available at these facilities (approx. 12 beds in total). Using these
hospitals alone is only feasible as long as the number of cases in the US
remain low.
LESSON LEARNED:
• DIAGNOSIS: Every hospital in the country needs to be ready to
diagnose Ebola .
• PERSONAL PROTECTIVE EQUIPMENT
‒ PPE suits will be standardized, to include a specific type of suit to
ensure consistency in both training and use, possibly using only full-body
suits. This is consistent with current CDC recommendations.
‒ Use of a model of hood that protects health care worker’s neck to
prevent exposure.
‒ Removing PPE now includes an enhanced and detailed step-by-step
disinfection of hands process with specific sequencing for removal
of each piece of equipment and the hand washing required.
• OVERSIGHT AND MONITORING: The single most important aspect of
safe care of Ebola is to have a site manager at all times who oversees
the putting on and taking off of PPE and the care given in the isolation
unit. A site manager is now in place and will be at the hospital 24/7 as
long as Ebola patients are receiving care
• ESTABLISH A DEDICATED CDC RESPONSE TEAM: CDC is setting up a
dedicated CDC Response Team that could be on the ground at any
hospital that receives a confirmed Ebola infected patient within a few
hours. The CDC Response Team would provide in person, expert
support and training on infection control, healthcare safety, medical
treatment contact tracing, waste and decontamination, public
education and other issues. The CDC Response Team would help
ensure that clinician, and state and local public health practitioners
consistently follow strict standards of protocol to ensure safety of the
patient and healthcare workers

13. WHAT IS EBOLA?
Starts with:
• Sudden onset of fever (greater than 38.6°C or 101.5°F)
• Intense weakness, muscle pain
• Headache, sore throat
Followed by:
• Vomiting, diarrhea, rash
• Impaired kidney and liver function
• Internal and external bleeding
Ebola creates holes in blood vessels, often causing bleeding and
shock. It does this by killing endothelial cells, which form the
blood vessels’ lining and other partitions in the body. When those
cells die, blood and other fluids can leak out. Organs shut down.
The virus replicates very quickly, before most people’s bodies can
mount an attack. People often have massive bleeding 7 to 10 days
after infection.
It effectively disables the immune system by hampering the
development of antibodies and T cells that would target the virus.
Scientists are not certain exactly how. (Washington Post)
WHAT IS EBOLA?
• Ebola virus disease (EVD), formerly known as Ebola hemorrhagic fever,
is a severe, often fatal illness in humans, caused by a filovirus.
• EVD outbreaks have a case fatality rate of up to 90%.
• First appeared in 1976 in Sudan and Democratic Republic of Congo. The
latter was in a village situated near the Ebola River, from which the
disease takes its name.
HOW IS IT TRANSMITTED
SIGNS AND SYMPTOMS
• The virus that causes Ebola is not airborne
• Ebola is spread by close contact with an infected person.
• Ebola is spread through direct contact with:
o Blood or body fluids (such as saliva, sweat, vomit, semen, stool
or urine) of an infected person or animal, or
o Through contact with objects that have been contaminated with
the blood or other body fluids of an infected person.
RISK OF EXPOSURE
• Healthcare providers caring for Ebola patients and the family and friends
in close contact with Ebola patients are at the highest risk of contracting
Ebola because they may come in contact with the blood or body fluids of
sick patients.
• People also can become infected with Ebola after coming in contact with
infected wildlife. For example, in Africa, Ebola may be spread as a result of
handling bush meat (wild animals hunted for food) and contact with
infected bats.
WAYS IN WHICH THE VIRUS IS TRANSMITTED. SOURCE: THE HERALD
SOURCE : CDC WHO KEY POINTS – EBOLA VIRUS DISEASE, WEST AFRICA
INCUBATION: The incubation period is usually four to ten days but can vary from
two to 21 days (most commonly 8-10 days)

14. DIAGNOSIS
WHAT IS EBOLA?
• Early diagnoses difficult because symptoms are nonspecific to Ebola
• Definitive diagnoses made through laboratory testing:
‐ PCR
‐ ELISA
‐ Virus isolation
‐ IgM and IgG antibodies
TREATMENT
• Symptoms of Ebola are treated as they appear. The following basic interventions, when
PREVENTION
• Avoid all contact with blood or fluids of infected people
• Isolation of Ebola patients
• Basic infection control measures
‐ Equipment sterilization
‐ Routine disinfection
‐ Hand hygiene
• Prompt and safe burial of dead
SOURCE : CDC WHO
used early, can significantly improve the chances of survival:
• Providing intravenous fluids (IV)and balancing electrolytes (body salts)
• Maintaining oxygen status and blood pressure
• Treating other infections if they occur
• No FDA-approved vaccine or medicine (e.g., antiviral drug) is available for Ebola.
• Experimental vaccines and treatments for Ebola are under development, but they have
not yet been fully tested for safety or effectiveness.
• Recovery from Ebola depends on good supportive care and the patient’s immune
response. People who recover from Ebola infection develop antibodies that last for at
least 10 years, possibly longer. It isn't known if people who recover are immune for life
or if they can become infected with a different species of Ebola. Some people who have
recovered from Ebola have developed long-term complications, such as joint and vision
problems.

15. PATIENT EVALUATION
1. Activate the hospital preparedness plan for Ebola, which should include
• Initiate the notification plan for suspect or confirmed Ebola patient
immediately.
• Ensure hospital infection control is notified.
• Create a clinical care team led by a senior level experienced clinician that
includes at a minimum a hospital infection control specialist, a senior nurse, an
infectious disease specialist, and critical care consultants.
• Assign a senior staff member from the clinical care team to coordinate testing
and reporting of results from the hospital laboratory, state health department
laboratory, CDC, and local and state public health. For a list of state and local
health department phone numbers, see
http://www.cdc.gov/vhf/ebola/outbreaks/state-local-health-department-contacts.
html.
2. Isolate the patient in a separate room with a private bathroom.
3.Ensure a standardized protocol is in place for how and where to remove and
dispose of personal protective equipment (PPE) properly and that this information
is posted in the patient care area.
4.When interviewing the patient, collect data on:
• Earliest date of symptom onset and the sequence of sign/symptom
development preceding presentation to an emergency department.
• Detailed and precise travel history (e.g., dates, times, locations).
• Names of any persons with whom the patient may have had contact during and
any time after the earliest date of symptom onset.
5. Consider and evaluate for all potential alternative diagnoses (e.g. malaria,
typhoid fever).
6. Ensure patient has the ability to communicate with family.
GENERAL INFORMATION
Ebola virus disease Information for Clinicians in U.S. Healthcare Settings
Safe Management of Patients with Ebola Virus Disease (EVD) in U.S. Hospitals
Could It Be Ebola Poster

16. EBOLA PREPAREDNESS CONSIDERATIONS FOR
OUTPATIENT/AMBULATORY CARE SETTINGS
Go to http://www.phe.gov/Preparedness/responders/ebola/Documents/ebola-preparedness-considerations.pdf to
download this document with its active hyperlinks

17. GUIDANCE ON PERSONAL PROTECTIVE EQUIPMENT TO BE USED BY HCW DURING
MANAGEMENT OF PATIENTS WITH EBOLA VIRUS DISEASE IN U.S. HOSPITALS
KEY PRINCIPLES:
• Prior to working with Ebola patients, all healthcare workers
involved in the care of Ebola patients must have received
repeated training and have demonstrated competency in
performing all Ebola-related infection control practices and
procedures, and specifically in donning/doffing proper PPE.
• While working in PPE, healthcare workers caring for Ebola
patients should have no skin exposed.
• The overall safe care of Ebola patients in a facility must be
overseen by an onsite manager at all times, and each step of
every PPE donning/doffing procedure must be supervised by a
trained observer to ensure proper completion of established
PPE protocols.
DURING PATIENT CARE
• PPE must remain in place and be worn correctly for the duration
of exposure to potentially contaminated areas. PPE should not
be adjusted during patient care.
• Healthcare workers should perform frequent disinfection of
gloved hands using an ABHR, particularly after handling body
fluids.
• If during patient care a partial or total breach in PPE (e.g., gloves
separate from sleeves leaving exposed skin, a tear develops in
an outer glove, a needlestick) occurs, the healthcare worker
must move immediately to the doffing area to assess the
exposure. Implement the facility exposure plan, if indicated by
assessment.
DOFFING
• The removal of used PPE is a high-risk process that requires a
structured procedure, a trained observer, and a designated area
for removal to ensure protection
• PPE must be removed slowly and deliberately in the correct
sequence to reduce the possibility of self-contamination or
other exposure to Ebola virus
• A stepwise process should be developed and used during
training and daily practice
PRINCIPLES OF PPE: Healthcare workers must understand the
following basic principles to ensure safe and effective PPE use,
which include that no skin may be exposed while working in PPE:
DONNING
• PPE must be donned correctly in proper order before entry into
the patient care area and not be later modified while in the
patient care area.
• The donning activities must be directly observed by a trained
observer.
GO TO http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html for the guidance on PPE that CDC put out as of 20 OCT 2014

18. GUIDANCE ON PERSONAL PROTECTIVE EQUIPMENT TO BE USED BY HCW DURING
MANAGEMENT OF PATIENTS WITH EBOLA VIRUS DISEASE IN U.S. HOSPITALS
DOUBLE GLOVING
• Double gloving provides an extra layer of safety during direct
patient care and during the PPE removal process.
• Beyond this, more layers of PPE may make it more difficult to
perform patient care duties and put healthcare workers at greater
risk for percutaneous injury (e.g., needlesticks), self-contamination
during care or doffing, or other exposures to Ebola.
• If healthcare facilities decide to add additional PPE or modify this
PPE guidance, they must consider the risk/benefit of any
modification, and train healthcare workers on correct donning and
doffing in the modified procedures.
TRAINING ON CORRECT USE OF PPE
• Training ensures that healthcare workers are knowledgeable and
proficient in the donning and doffing of PPE prior to engaging in
management of an Ebola patient.
• Comfort and proficiency when donning and doffing are only
achieved through repeated practice on the correct use of PPE.
Healthcare workers should be required to demonstrate
competency in the use of PPE, including donning and doffing while
being observed by a trained observer, before working with Ebola
patients.
• In addition, during practice, healthcare workers and their trainers
should assess their proficiency and comfort with performing
required duties while wearing PPE. Training should be available in
formats accessible to individuals with disabilities or limited English
proficiency. Target training to the educational level of the intended
audience.
USE OF A TRAINED OBSERVER
• Because the sequence and actions involved in each donning and
doffing step are critical to avoiding exposure, a trained observer
will read aloud to the healthcare worker each step in the
procedure checklist and visually confirm and document that the
step has been completed correctly.
• The trained observer is a dedicated individual with the sole
responsibility of ensuring adherence to the entire donning and
doffing process.
• The trained observer will be knowledgeable about all PPE
recommended in the facility’s protocol and the correct donning
and doffing procedures, including disposal of used PPE, and will
be qualified to provide guidance and technique
recommendations to the healthcare worker.
• The trained observer will monitor and document successful
donning and doffing procedures, providing immediate corrective
instruction if the healthcare worker is not following the
recommended steps. The trained observer should know the
exposure management plan in the event of an unintentional
break in procedure.
CDC recommends facilities use a powered
air-purifying respirator (PAPR) or an N95
or higher respirator in the event of an
unexpected aerosol-generating procedure.
SOURCE: CDC - 20 OCT

19. GUIDANCE ON PERSONAL PROTECTIVE EQUIPMENT TO BE USED BY HCW DURING
MANAGEMENT OF PATIENTS WITH EBOLA VIRUS DISEASE IN U.S. HOSPITALS
Given the intensive and invasive care that U.S. hospitals provide
for Ebola patients, the tightened guidelines are more directive in
recommending no skin exposure when PPE is worn.
CDC is recommending all of the same PPE included in the August
1, 2014 guidance, with the addition of coveralls and single-use,
disposable hoods.
Goggles are no longer recommended as they may not provide
complete skin coverage in comparison to a single-use, disposable
full-face shield. Additionally, goggles are not disposable, may fog
after extended use, and healthcare workers may be tempted to
manipulate them with contaminated gloved hands.
PPE RECOMMENDED FOR U.S. HEALTHCARE WORKERS CARING
FOR PATIENTS WITH EBOLA INCLUDES:
• Double gloves
• Boot covers that are waterproof and go to at least mid-calf or
leg covers
• Single-use fluid resistant or impermeable gown that extends
to at least mid-calf or coverall without integrated hood.
• Respirators, including either N95 respirators or powered air
purifying respirator (PAPR)
• Single-use, full-face shield that is disposable
• Surgical hoods to ensure complete coverage of the head and
neck
• Apron that is waterproof and covers the torso to the level of
the mid-calf (and that covers the top of the boots or boot
covers) should be used if Ebola patients have vomiting or
diarrhea
The guidance describes different options for combining PPE to
allow a facility to select PPE for their protocols based on
availability, healthcare personnel familiarity, comfort and
preference while continuing to provide a standardized, high level
of protection for healthcare personnel.
The guidance includes having:
SOURCE: CDC - 20 OCT
PHOTOS: University of Nebraska Medical Center (UNMC)

20. DONNING BIOLOGICAL PPE- EBOLA PATIENTS
(UNIVERSITY OF NEBRASKA)
http://app1.unmc.edu/nursing/heroes/pdf/vhfppe/donningBiologicalPPE-EbolaPatients-8.5x11-CC-v1.02.pdf

21. DONNING BIOLOGICAL PPE- EBOLA PATIENTS
(UNIVERSITY OF NEBRASKA)
http://app1.unmc.edu/nursing/heroes/pdf/vhfppe/donningBiologicalPPE-EbolaPatients-8.5x11-CC-v1.02.pdf

22. DOFFING BIOLOGICAL PPE- EBOLA PATIENTS
(UNIVERSITY OF NEBRASKA)
http://app1.unmc.edu/nursing/heroes/pdf/vhfppe/doffingBiologicalPPE-EbolaPatients-8.5x11-CC-v1.01.pdf

23. DOFFING BIOLOGICAL PPE- EBOLA PATIENTS
(UNIVERSITY OF NEBRASKA)
http://app1.unmc.edu/nursing/heroes/pdf/vhfppe/doffingBiologicalPPE-EbolaPatients-8.5x11-CC-v1.01.pdf

24. DOFFING BIOLOGICAL PPE- EBOLA PATIENTS
(UNIVERSITY OF NEBRASKA)
http://app1.unmc.edu/nursing/heroes/pdf/vhfppe/doffingBiologicalPPE-EbolaPatients-8.5x11-CC-v1.01.pdf

25. REFERENCE
DIAGNOSIS
• Case Definition for Ebola Virus Disease (EVD)
SPECIMEN COLLECTIONS
• Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Persons Under Investigation
for Ebola Virus Disease in the United States
• Factsheet: Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Patients with
Suspected Infection with Ebola Virus Disease[PDF - 1 page]
MONITORING AND MOVEMENT
• Interim Guidance for Monitoring and Movement of Persons with Ebola Virus Disease Exposure
PT TRANSPORT
• Guidance: Air Medical Transport for Patients with Ebola
• Interim Guidance: EMS Systems & 9-1-1 PSAPs: Management of Patients in the U.S.
PATIENT MANAGEMENT
• Safe Management of Patients with Ebola Virus Disease (EVD) in U.S. Hospitals
INFECTION CONTROL
• Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola
Virus Disease in U.S. Hospitals
• Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus
HANDLING OF REMAINS
• Guidance for Safe Handling of Human Remains of Ebola Patients in U. S. Hospitals and Mortuaries