Infectious Disease/EBOLA Guidelines for the School Clinic

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1 Infectious Disease/EBOLA Guidelines for the School Clinic Background: The procedures in the accompanying algorithm provide guidance on evaluation and management of individuals who present with possible Ebola Virus Disease. The guidance in this document reflects the most recent information from the Centers for Disease Control (CDC) adapted from the protocol for Emergency Department management. The risk of transmission of Ebola virus from an individual depends upon the likelihood that the individual will have confirmed Ebola Virus Disease combined with the likelihood and degree of exposure to infectious blood or body fluids. That risk depends on the severity of disease; severe illness is strongly associated with high levels of virus production. In addition, close contact with the individual and invasive medical care can increase opportunities for transmission. As a result, health care workers working directly with hospitalized patients diagnosed with Ebola are at greatest risk. In general, the majority of febrile individuals presenting to the school nurse do not have Ebola Virus Disease, and the risk posed by individuals with early, limited symptoms is lower than that from an individual hospitalized with severe Ebola Virus Disease. Nevertheless, because early symptoms of Ebola Virus Disease are similar to other febrile illnesses, triage and evaluation processes by the school nurse should include systematic assessment of individuals for the possibility of Ebola Virus Disease. Review the CDC website regularly to remain current on countries with wide spread transmission of Ebola, risk factors and monitoring. Student Enrollment Identify exposure history from the most reliable person enrolling the student: ASK: 1. Have you or anyone in your family lived in or traveled to a country with widespread Ebola transmission? 2. Have you or anyone in your family had contact with an individual with confirmed Ebola Virus Disease within the previous 21 days? Where? When? Indicate responses on the Health Inventory and sign/date. If No travel history, enroll with routine assessment of general health using information recorded on health inventory and other available assessment information.

2 If Yes AND travel was within the past 21 days to countries currently designated by CDC including Liberia, Guinea and Sierra Leone (updated on the CDC website at o CONTACT Health and Medical Services for guidance from local health department. Health and Medical Services will contact the local health department and put them in contact with the nurse or other reliable source for more information. o Be prepared to provide the health department representative with information about exposure history. SEE LEVEL OF RISK ASSESSMENT AT END OF DOCUMENT Day to Day systematic triage and evaluation processes by the school nurse for the possibility of Ebola Virus Disease 1. Identify Exposure History: Immediately upon entrance to the nurse s office, or in advance of entry if possible, a relevant exposure history should be taken including exposure criteria of whether the individual has resided in or traveled to a country with widespread Ebola transmission or had contact with an individual with confirmed Ebola Virus Disease within the previous 21 days. Because the signs and symptoms of Ebola Virus Disease may be nonspecific and are present in other infectious and noninfectious conditions that are more frequently encountered in the United States, relevant exposure history should be first elicited to determine whether Ebola Virus Disease should be considered further. If the individual is unable to provide history due to clinical condition or other communication barrier, history should be elicited from the next most reliable source (e.g. family, friend, classroom teacher). Notify School Administrator and Health and Medical Services if there is travel history to a country with widespread Ebola transmission regardless of symptoms. Health and Medical Services will contact the local health department and put them in contact with the nurse or other reliable source for more information. 2. Identify signs and symptoms: Individuals who meet the exposure criteria should be further questioned regarding the presence of signs or symptoms compatible with Ebola Virus Disease. These include: fever (subjective or 100 F or headache, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or hemorrhage (e.g., bleeding gums, blood in urine, nose bleeds, coffee ground emesis or melena dark, tarry stools). NOTE: To minimize transmission risk, only a healthcare worker should provide individual care if there is relevant travel history and signs or symptoms consistent with Ebola Virus Disease. 2

3 All individuals should be routinely managed using precautions to prevent any contact with blood or body fluids. If an exposure history is unavailable, clinical judgment should be used to determine whether to empirically implement the following protocol. If a relevant exposure history is reported and signs or symptoms consistent with Ebola Virus Disease are present, the following measures should be implemented IMMEDIATELY: 3. Isolate the individual in a private room or separate enclosed area with private bathroom and adhere to procedures and precautions designed to prevent transmission by direct or indirect contact (e.g. dedicated equipment, hand hygiene, and restricted individual movement) until further notice. Activate campus emergency plan with Administrator including contacting EMS. Administrator may consider using lock down procedures in anticipation of EMS arrival. Do not leave individual alone. They should remain in view for ongoing assessment. Once appropriate PPE has been put on, continue obtaining additional history and performing physical examination and routine interventions. All individuals providing care who have contact with the individual should put on appropriate PPE based on the individual s clinical status. If the individual is clinically stable, those providing care should at a minimum wear: 1) face shield, 2) surgical face mask, 3) impermeable gown and 4) two pairs of gloves. If the individual is exhibiting obvious bleeding, vomiting, copious diarrhea or a clinical condition that warrants invasive or aerosol-generating procedures (e.g., suctioning, active resuscitation), PPE designated for the care of such individuals should be used. A log should be maintained of all individuals who enter the school clinic or area. If the individual requires active resuscitation, this should be done using equipment dedicated to the individual. Ensure that any students in the clinic are transferred to another designated area. Ensure that medication and treatment supplies are moved to a designated area. 4 Notify School Administrator and Health and Medical Services and other appropriate staff. Health and Medical Services will activate nursing support and report to the relevant local health department immediately. Call 911 for transport to the nearest emergency center. Provide information to EMS regarding signs and symptoms as suspected case of Ebola. Provide contact information for individual Administrator will designate trained individual to provide medications and remain with students move to the designated area. 5. Further evaluation and management: 3

4 Decontamination will be handled by the appropriate department to be contacted by campus Administrator. The Plant Operator must receive guidance from CFS before cleaning the area or removing contaminated articles. All disposable designated equipment should be placed in double bag container or biohazard red bag. 4

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6 DETERMINING LEVEL OF RISK (Updated CDC guidelines as of ) LEVEL OF RISK EXPOSURE FACTORS ACTIONS High risk includes Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids of a person with Ebola while the person was symptomatic Cannot attend school, work regardless of presence or absence of symptoms. Some risk includes: Exposure to the blood or body fluids (including but not limited to feces, saliva, sweat, urine, vomit, and semen) of a person with Ebola while the person was symptomatic without appropriate personal protective equipment (PPE) Processing blood or body fluids of a person with Ebola while the person was symptomatic without appropriate PPE or standard biosafety precautions Direct contact with a dead body without appropriate PPE in a country with widespread Ebola virus transmission Having lived in the immediate household and provided direct care to a person with Ebola while the person was symptomatic Close contact in households, healthcare facilities, or community settings with a person with Ebola while the person was symptomatic Close contact is defined as being for a prolonged period of time while not wearing appropriate PPE within approximately 3 feet (1 meter) of a person with Ebola while the person was symptomatic Medical evaluation is required prior to attendance. Notify School/Dept. Administrator, Health and Medical Services by phone at or by afterhours contact for Emergency Preparedness Plan Complete communicable disease report Cannot attend school, work regardless of presence or absence of symptoms. Medical evaluation is required prior to attendance. Notify School/Dept. Administrator, Health and Medical Services by phone at or by afterhours contact for Emergency Preparedness Plan Complete communicable disease report 6 Update October 29, 2014

7 LEVEL OF RISK EXPOSURE FACTORS ACTIONS Low (but not zero) risk includes : Having been in a country with widespread Ebola virus transmission within the past 21 days and having had no known Depends on the individual is with or without symptoms as described exposures below: Having brief direct contact (e.g., shaking hands), while not wearing appropriate PPE, with a person with Ebola while the person was in the early stage of disease Brief proximity, such as being in the same room for a brief period of time, with a person with Ebola while the person was symptomatic direct contact while using appropriate PPE with a person with Ebola while the person was symptomatic With symptoms: Fever (subjective fever or measured temperature 100 F) OR any of the following: vomiting, diarrhea, unexplained bruising or bleeding Traveled on an aircraft with a person with Ebola while the person was symptomatic With symptoms Cannot attend school, work. Medical evaluation is required prior to attendance. Activate Emergency Notification Isolation precautions EMS inform that there is a suspected case Decontamination procedures Asymptomatic (no fever, vomiting, diarrhea, or unexplained bruising, or bleeding) Without Symptoms Notify School/Dept. Administrator, Health and Medical Services by phone at or by afterhours contact in Emergency Preparedness Plan Complete communicable disease report when feasible May attend school, work. No restrictions on travel, work. 7 Update October 29, 2014

8 LEVEL OF RISK EXPOSURE FACTORS ACTIONS No identifiable risk includes: Contact with an asymptomatic person who had contact with person with Ebola May attend school unless ill for other reasons. Contact with a person with Ebola before the person developed symptoms No restrictions on travel, work. Having been more than 21 days previously in a country with widespread Ebola virus transmission Having been in a country without widespread Ebola virus transmission and not having any other exposures as defined above 8 Update October 29, 2014