• A load of Ebola – guidelines & resources for prehospital providers

    by Alan Batt. Last modified: 02/01/15

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    Last updated: 02/01/2015

    We’ve gathered the latest guidelines on Ebola preparedness for Paramedics and prehospital care providers right here in one place. Here you will find additional reading on Ebola and viral haemorrhagic fevers, recommended levels of PPE precautions, diagnosis and management of Ebola infection and downloadable resources.

    Ebola Virus

    Ebola, previously known as Ebola haemorrhagic fever, is a rare and deadly disease caused by infection with one of the Ebola virus strains. Ebola can cause disease in humans and nonhuman primates (monkeys, gorillas, and chimpanzees).

    Ebola is caused by infection with a virus of the family Filoviridae, genus Ebolavirus. There are five identified Ebola virus species, four of which are known to cause 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 nonhuman primates, but not in humans.

    Ebola viruses are found in several African countries. Ebola was first discovered in 1976 near the Ebola River in what is now the Democratic Republic of the Congo. Since then, outbreaks have appeared sporadically in Africa.

    The natural reservoir host of Ebola virus remains unknown. However, on the basis of evidence and the nature of similar viruses, researchers believe that the virus is animal-borne and that bats are the most likely reservoir. Four of the five virus strains occur in an animal host native to Africa.

    CDC, 2014

    Prehospital Guidelines

    02/01/2015 – CDC have updated their Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients Under Investigation (PUIs) for Ebola Virus Disease (EVD) in the United States – http://www.cdc.gov/vhf/ebola/healthcare-us/emergency-services/ems-systems.html

    02/12/14 – CDC have updated their Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients Who Present With Possible Ebola Virus Disease in the United States- http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html 

    CDC Detailed Emergency Medical Services (EMS) Checklist for Ebola Preparedness

    Download from http://www.cdc.gov/vhf/ebola/pdf/ems-checklist-ebola-preparedness.pdf

    CDC Guidance on Air Medical Transport for Patients with Ebola Virus Disease – http://www.cdc.gov/vhf/ebola/hcp/guidance-air-medical-transport-patients.html

    Personal Protective Equipment

    Update 20/10/2014 – CDC Updates PPE requirements – (http://www.cdc.gov/media/releases/2014/fs1020-ebola-personal-protective-equipment.html)

    • All healthcare workers must undergo rigorous training and are practiced and competent with PPE, including putting it on and taking it off in a systemic manner
    • No skin exposure when PPE is worn
    • All workers are supervised by a trained monitor who watches each worker putting PPE on and taking it off.

    CDCEbolaPPE

    PPE should be used by prehospital care personnel as follows:

    • PPE should be worn upon entry into the scene and continued to be worn until personnel are no longer in contact with the patient.
    • PPE should be carefully removed without contaminating one’s eyes, mucous membranes, or clothing with potentially infectious materials.
    • PPE should be placed into a medical waste container at the hospital or double bagged and held in a secure location.
    • Re-useable PPE should be cleaned and disinfected according to the manufacturer’s reprocessing instructions and EMS agency policies.
    • Hand hygiene should be performed immediately after removal of PPE.

    The CDC have also published a series of PPE donning and doffing videos that will supplement any local training program.

    Cleaning Vehicles

    The CDC have issued the following general guidelines for cleaning or maintaining EMS transport vehicles and equipment after transporting a patient with suspected or confirmed Ebola:

    • EMS personnel performing cleaning and disinfection should wear recommended PPE (as described) and consider use of additional barriers (e.g., rubber boots or shoe and leg coverings) if needed. Face protection (facemask with goggles or face shield) should be worn since tasks such as liquid waste disposal can generate splashes.
    • Patient-care surfaces (including stretchers, railings, medical equipment control panels, and adjacent flooring, walls and work surfaces) are likely to become contaminated and should be cleaned and disinfected after transport.
    • A blood spill or spill of other body fluid or substance (e.g., feces or vomit) should be managed through removal of bulk spill matter, cleaning the site, and then disinfecting the site. For large spills, a chemical disinfectant with sufficient potency is needed to overcome the tendency of proteins in blood and other body substances to neutralize the disinfectant’s active ingredient.
    • An EPA-registered hospital disinfectant with label claims for viruses that share some technical similarities to Ebola (such as, norovirus, rotavirus, adenovirus, poliovirus) and instructions for cleaning and decontamination of surfaces or objects soiled with blood or body fluids should be used according to those instructions. After the bulk waste is wiped up, the surface should be disinfected as described in the bullet above.
    • Contaminated reusable patient care equipment should be placed in biohazard bags and labeled for cleaning and disinfection according to agency policies. Reusable equipment should be cleaned and disinfected according to manufacturer’s instructions by trained personnel wearing correct PPE. Avoid contamination of reusable porous surfaces that cannot be made single use.
    • Use only a mattress and pillow with plastic or other covering that fluids cannot get through. To reduce exposure among staff to potentially contaminated textiles (cloth products) while laundering, discard all linens, non-fluid-impermeable pillows or mattresses as appropriate.

    Treatment & Management

    UpToDate have made their review on the diagnosis and treatment of Ebola and Marburg virus disease available in full for free. View the full UpToDate review here for evidence-based recommendations on diagnosing and managing viral haemorrhagic fevers such as Ebola and Marburg by going to http://www.uptodate.com/contents/diagnosis-and-treatment-of-ebola-and-marburg-virus-disease.

    The United States Army Medical Research Institute of Infectious Diseases (USAMRIID) provide a free PDF copy of their excellent Medical Management of Biological Casualties Handbook (aka the Blue Book) from http://www.usamriid.army.mil/education/bluebookpdf/USAMRIID%20BlueBook%207th%20Edition%20-%20Sep%202011.pdf. This book also provides an interesting insight into the history of biological warfare, and into other biological agents such as anthrax, smallpox and botulinum etc.

    Further reading

     
    Peacock G, Uyeki TM, Rasmussen SA. Ebola Virus Disease and Children: What Pediatric Health Care Professionals Need to Know. JAMA Pediatr. 2014 Oct 17. PMID: 25325785.
    openaccess

     
    Chowell G, Nishiura H. Transmission dynamics and control of Ebola virus disease (EVD): a review. BMC Med. 2014 Oct 10;12(1):196. PMID: 25300956.
    openaccess

     
    Toner E, Adalja A, Inglesby T. A Primer on Ebola for Clinicians. Disaster Med Public Health Prep. 2014 Oct 17:1-5. PMID: 25325294.
    openaccess

    ALISON (an online learning provider) is offering a free online course titled Understanding the Ebola Virus and How You Can Avoid It. A useful resource for healthcare workers, and the general public alike – http://alison.com/courses/Understanding-the-Ebola-Virus-and-How-You-Can-Avoid-It

     

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    Alan Batt

    Alan Batt

    Paramedic, educator, researcher
    Alan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.

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