EMS Strategies for Ebola

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Ebola Risk for EMS Personnel  

While it is unlikely that emergency medical services (EMS) personnel in the United States will encounter a person infected with Ebola virus during routine operations, an Ebola outbreak reported anywhere in the world increases the risk for encountering a patient who recently traveled from the affected area and became infected. The virus can spread quickly within health care settings among personnel who do not use proper infection control while caring for patients suspected or confirmed to be infected with Ebola virus. That’s why it’s important that EMS professionals follow an identify, isolate, and inform strategy, and implement a hierarchy of controls to prevent transmission of infectious diseases.

Identify, Isolate, and Inform for EMS  

The identify, isolate, and inform paradigm is a way for EMS personnel to:  

1. Assess the risk that the person they are interacting with might be infected with a high consequence infectious disease,

2. Implement infection prevention measures to reduce the risks of exposure, and  

3. Inform others that the person that they are caring for might be infected with a high consequence infectious disease.  

Identify, isolate, and inform has been used by EMS and frontline health care workers in the United States for Ebola virus disease in the past, and more recently for monkeypox.    

Identify  

In the first step, you are trying to identify the likelihood that the person you are interacting with is infected with Ebola virus disease (EVD). It can be broken down into two parts: signs and symptoms of illness and travel or exposure history.   

This screening can be done by the 911 call taker in the emergency medical dispatch center or by the personnel responding in the field, or both.   

To identify someone with EVD it is important to recognize the signs and symptoms. Early on they are non-specific: fever, muscle aches, chills. At some point in the course of the illness, a patient will develop gastrointestinal symptoms: nausea, vomiting, diarrhea, and abdominal pain. Eventually the signs may progress to organ failure, septic shock, and even death.  

The next step is to identify travel to a country with an ongoing EVD outbreak or exposure to someone with confirmed disease in the last 21 days. Find information about current and past Ebola outbreaks (CDC, https://www.cdc.gov/ebola/outbreaks/, Accessed 10/19/2022).

There are a lot of illnesses that present with symptoms like those of Ebola virus disease, and you cannot conclude that the patient has EVD from this screening, but it raises suspicion.  

See the CDC’s guidance on screening patients for EVD (CDC, https://www.cdc.gov/ebola/hcp/clinical-guidance/, Accessed 10/19/2022). 

Identifying the risk that someone might have Ebola virus disease through screening for signs and symptoms of illness and travel history leads you then to consider how to best protect yourself and others from exposure to potentially infectious bodily fluids.  

Isolate  

Ebola virus disease is transmitted through close contact with people that are infected and through exposure of their infectious bodily fluids to your eyes, nose, mouth, or to a break in your skin. Infectious bodily fluids from patients infected with Ebola include blood, saliva, vomit, diarrhea, urine, and even sweat.

The incubation period for Ebola virus disease is between 2-21 days. Typically, it incubates over 8-10 days, and then you start to develop signs and symptoms of illness. To protect yourself from exposure to infectious bodily fluids, EMS personnel should implement standard, contact, and droplet precautions, as well as airborne precautions if an aerosol generated procedure is anticipated.   

Patients that may have been exposed to someone with Ebola virus disease are not contagious until they have symptoms. Once they develop signs and symptoms, they can transmit the illness.  

Inform  

In the EMS community, when you respond to 911 calls there are several responders that arrive on scene. If you believe, based on the signs and symptoms and the travel history of the patient, that they might have Ebola virus disease it is important to let other responders know, to avoid unprotected exposure.   

For many EMS personnel it may be important to alert local and or state public health authorities. They may have resources for you like special pathogen transport programs or other assistance they can render to manage and transport the patient.   

It is also important to inform your supervisory personnel and, if you’re going to transport that patient to a facility, you need to inform that facility so they can receive that patient safely.   

In communicating this, it’s important to protect the privacy of the patient.   

Hierarchy of Controls  

Implementation of a hierarchy of controls is a method of creating environmental changes, changes in administrative policies and work practices, and the use of personal protective equipment (PPE) to prevent exposure to infectious bodily fluids.   

Make changes to the environment in the ambulance

• Separate the driver compartment and the patient compartment. 
• Adjust air handling to introduce fresh air into both compartments.  
• Turn exhaust fans on high in the patient compartment. 
• Drape the interior of the ambulance to protect those environmental surfaces from exposure to infectious bodily fluids, should that patient vomit or have uncontrolled diarrhea. If that happened, it would contaminate the surfaces of the ambulance and it would make it more difficult to clean and disinfect.   

Measures to prepare the patient for transport

• Put a surgical mask on the patient to avoid transmission of the virus through saliva. 
• Wrap the patient in an impervious sheet or have them wear a coverall, if tolerated, to contain any contamination from their clothes and help contain infectious bodily fluids.  
• Consider placing the patient in undergarments that can collect potentially infectious diarrhea. Have a leak proof container on hand for vomiting.  
• Consider pretreating the patient with anti-nausea medicine before transporting the patient to reduce the risk of vomiting.  

Establish protective behaviors for EMS personnel 

• Stay at least 6 feet from the patient, when possible, to reduce the chance of transmission, in particular from heavy droplets.  
• Limit the number of personnel that are in direct care of the patient.  
• Implement a procedure where the driver of the ambulance does not make patient contact to avoid contamination of the driver compartment of the ambulance.  

Practice safe clinical care

• Be careful with the use of sharps around anyone suspected of having Ebola virus disease.  
• Limit aerosol generating procedures.  
• Implement standard precautions, plus transmission-based precautions, specifically contact and droplet, as well as airborne precautions if performing an aerosol generating procedure.   

Personal Protective Equipment (PPE) for Ebola  

If you have a patient that has confirmed EVD, the CDC recommends an impermeable gown or coverall, the use of a full face shield, a NIOSH-approved, fit tested N95 respirator or higher protection, double gloves, boot covers, and an apron.  

For a person under investigation (PUI) for EVD and who is unstable—they have unstable vital signs, vomiting, diarrhea or are otherwise likely to spread bodily fluids—the same PPE applies.   

See the CDC’s guidance on PPE for confirmed EVD or unstable PUIs (CDC, https://www.cdc.gov/viral-hemorrhagic-fevers/hcp/guidance/ppe-clinically-unstable.html, Accessed 10/19/2022). 

If the patient is a PUI but stable—for instance, someone presenting with fever but no vomiting or diarrhea—there is another option for an appropriate PPE ensemble: fluid resistant gown or coverall, full face shield, a simple surgical mask, and double gloves. See the CDC’s guidance on PPE for stable PUIs. 

Whatever PPE ensemble you select, make sure you have proven checklists for donning and doffing of the PPE and that you have trained observers participating in the donning and doffing of PPE. The CDC offers guidance on this, as well as recommendations for PPE for personnel working as the trained observer.  

See NETEC’s flyer on the role of the trained observer.  

Portable Isolation Units

Portable isolation units provide a level of barrier protection preferred by many personnel managing and transporting patients with high consequence infectious diseases. They are an alternative to using barrier drapes and other methods of source control.

Personnel planning to use a portable isolation unit should consider operating procedures for patient management and the unit’s cleaning and disinfection, or disposal. If the plan calls for disposal and the patient was infected with a special pathogen, like Ebola virus, it would need to be managed as Category A waste (HMR, 49 C.F.R., Parts 171-180).

In addition, in some cases, portable isolation units may not be tolerated well by patients due to the confines of the unit. Patient access is also curtailed potentially interfering with patient management.

Cleaning and Disinfection After Transporting a Patient  

After transfer of care to the receiving facility the ambulance will need to be cleaned and disinfected. An EPA-registered hospital grade disinfectant is recommended. The U.S. Department of Transportation considers waste from Ebola virus disease patients to be Category A. EMS personnel need to have a procedure for properly disposing of any waste generated during care of a patient. The easiest thing to do is to leave it with the receiving facility, which should already have procedures for disposal of Category A waste.  

Evaluating Personnel for Signs and Symptoms  

After an emergency response event, it is recommended that you observe the crew for signs and symptoms for a full incubation cycle of 21 days or until the patient has been ruled out for EVD. If the patient tests positive for Ebola virus disease, you must continue to monitor personnel for signs and symptoms for the full 21 days. This may be done in collaboration with public health.

Prevention and Treatment  

The licensed vaccine for Ebola is only effective against the Zaire ebolavirus. There is currently no licensed vaccine for the Sudan ebolavirus.   

Supportive care is the mainstay of treatment for patients with Ebola virus disease and if provided early can greatly increase chances of recovery. This may include IV fluids and electrolytes to replace those lost through vomiting and diarrhea, maintenance of blood pressure, ventilatory assistance, and even renal replacement therapy.   

In countries where the most outbreaks have occurred, the average case fatality rate for Ebola virus disease is 50 percent or higher. However, in the United States and other higher resource countries that can provide critical care for ill patients early on, the outcomes are much better. For example, during the 2014-2016 outbreak in West Africa, 11 people were treated for Ebola virus disease in the United States and 9 recovered.   

There are monoclonal antibody therapies that are effective against Ebola, and you can learn more about that from your regional emerging special pathogen treatment center (RESPTC), from the CDC website, or NETEC.   

Additional EMS Resources

Guidance for Emergency Medical Services and 9 1 1 communication centers (CDC, https://www.cdc.gov/vhf/ebola/clinicians/emergency-services/ems-systems.html, Accessed 10/4/2024)

Guidance for developing a plan for interfacility transport of persons under investigation or confirmed to have Ebola virus disease in the United States (CDC https://www.cdc.gov/vhf/ebola/clinicians/emergency-services/interfacility-transport.html, Accessed 10/19/2022, No longer available).

EMS Infectious Disease Playbook

Considerations for safe EMS transport of patients infected with Ebola virus

Transport and management of patients with confirmed or suspected Ebola virus disease

Ebola: Knowledge resources for responders

Regional Transport Ebola Tabletop Exercise Template