Management of Suspected EVD Patients in a Primary Care Setting

Management of Suspected EVD Patients in a Primary Care Setting Version 1.0 9/12/2014

Management of Suspected EVD Patients in a Primary Care Setting This guidance is aimed at clinical staff undertaking direct patient care in primary care, including GP surgeries, and out-of-hours centres. These guidelines should be available to staff and prominently displayed. GPs are advised to print out these guidelines for ease of access.

Important Contact Details Local Department of Public Health: In hours office number ……………………………. Out of Hours number …………………….………… Local EVT Receiving Hospital contact details: Name…………………………………………………. Hospital………………………………………………. Direct Contact Number……………………………… Alternative Number…………………………………..

HSE-Health Protection Surveillance Centre

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Management in Suspected EVD Patients in a Primary Care Setting1 

Assessment of a patient’s risk of Ebola Virus disease (EVD) should be undertaken by appropriate medical team in the local Emerging Viral Threats (EVT) Receiving Hospital (“Receiving Hospital”). However, despite being extremely unlikely, the possibility exists that such patients may present initially to primary care and therefore General Practitioners (GPs) should be aware of how to safely triage, and refer such patients appropriately, to the local Receiving Hospital for review and care.

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In the event that a patient, who might pose a risk of EVD, either telephones the surgery or presents in person, follow the Ebola Virus Disease (EVD) Risk Assessment for use in General Practice (the “GP Algorithm”) available at http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Ebola/EbolaInformationforGeneralPractitioners/File,1497 7,en.pdf (see also Appendix 1) to ensure safe and effective management of the patient.

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The preferred method of assessment is over the telephone rather than having a patient arrive in the Surgery.

SCENARIO 1: Patient Phoning the Surgery 

If a patient telephones seeking an appointment, check travel history and clinical status over the phone: 1. Has the patient returned from or was resident in an affected country in the 21 days before onset of symptoms? AND 2. Does the patient have a fever or has a history of fever in the last 24 hours?

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If the patient answers yes to both questions: o

Instruct patient not to visit surgery/OOH centre and

o

Self-isolate pending arrangements for assessment in an acute setting.

If the patient does not have the above two features, they can be assessed as normal.

SCENARIO 2: Patient Presenting in Person to the Surgery 

Should a patient present unannounced to the Surgery in person, immediately on presenting to reception, they should be asked the above two questions: 1. Has the patient returned from or was resident in an affected country in the 21 days before onset of symptoms? AND 0

0

2. Does the patient have a fever (>38.6 C/101.5 F) or has a history of fever in the last 24 hours? 1

This document has been approved by the Scientific Advisory Committee of the Health Protection Surveillance Centre


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Management of Suspected EVD Patients in a Primary Care Setting Version 1.0 9/12/2014 

Staff should adopt a “Talk, don’t Touch” approach, maintaining a distance of >1 metre at all times (NB if the patient is coughing or vomiting then a distance of 2-3 metres should be maintained).

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If the patient answers “Yes” to both questions: o

immediately isolate the patient in a side room away from all other patients/staff

o

the patient should be instructed to remain in the side room until arrangements for transfer have been organised

o

If the patient needs to use the WC, this must be sealed off and not used by other patients/staff.

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The patient should not be examined, unless ABSOLUTELY NECESSARY

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If, at the time of a consultation it becomes apparent that the patient is extremely ill and requires even cursory clinical examination, prior to any further assessment the GP should immediately don PPE (gloves, long-sleeved gown, mask and goggles) prior to direct patient contact.

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If PPE use is considered necessary, it should be donned and doffed in line with the document Irish guidelines on Personal Protective Equipment (PPE) to be used in suspected or confirmed Ebola virus disease (EVD) scenarios available at http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Ebola/EbolaInformationforGeneralPractitioners/File,1495 8,en.pdf. See also Appendix 2 at the end of this document.

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Waste should be segregated and quarantined in line with the Waste Guidance (see Appendix 4 at the end of this document).

Infection Control Precautions 

Standard Precautions must be used for ALL PATIENTS at ALL TIMES

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Any non-social contact with a patient suspected of having EVD will require: o

Standard, Droplet and Contact Precautions and the PPE required will be :

o

Hand hygiene, gloves, fluid repellent surgical mask, long sleeved fluid repellent/resistant surgical mask gown, goggles or visor (see Appendix 2 at the end of this document).

Transfer of Patient Presenting in Person 

Once a patient is suspected of EVD (having presented either in person or on the telephone), inform the local Receiving Hospital using GP referral pathway available (see GP EVD Referral Pathway Appendix 1) before arranging transfer (keep a note of the above necessary telephone details)

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Arrange transport to nearest EVT Receiving Hospital (for details see GP EVD Referral Pathway document available at http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Ebola/EbolaInformationforGeneralPractitioners/File,1497 8,en.pdf)


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Transport options should be considered on a case by case basis. Patients should not use public transport.

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Transport options include: o

Transport by someone with whom the patient has been in contact within the previous 24 hours OR

o

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Transfer via ambulance if: 

Signs such as vomiting or diarrhoea are present, or



The patient appears very ill.

If the patient is sufficiently ill that an ambulance is required, it is crucial that the Ambulance Service is alerted to the possibility of EVD

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Once the National Ambulance Service is informed, they will undertake a risk assessment with the National Isolation Unit (NIU) - this risk assessment will determine in which hospital the patient will be assessed (either the local Receiving Hospital or the NIU)

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Inform your local Department of Public Health - see bottom left-hand panel of Ebola Virus Disease – EVD – Risk Assessment for use in General Practice (Appendix 1 of this document)

Post-Transfer of Patient Presenting in Person Once the patient has left the Surgery for hospital:  

Contact Public Health for advice (see bottom left-hand panel of Ebola Virus Disease – EVD – Risk Assessment for use in General Practice – see Appendix 1 of this document) NB: If the patient has symptoms such as vomiting, diarrhoea and/or bleeding then environmental contamination poses a serious risk, and decontamination must only be undertaken by the HSE-contracted cleaners.

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Seal off room in which patient was assessed and other areas used by patient e.g. toilet.

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Do not use this room until outcome of the risk assessment/EVD test results are known.

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Wipe clean high contact surfaces such as door handles or touch screens using standard disinfectants. Undertake scrupulous hand hygiene

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Segregate & quarantine waste (see Appendix 4)

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Compile a contact list of patients/staff who may have been in contact with the patient

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Details of infection control and waste disposal in a GPs surgery following a diagnosis of EVD are available in the document Infection Prevention & Control and Waste Disposal in NonHospital Settings available at http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Ebola/EbolaInformationforGeneralPractitioners/File,1 4980,en.pdf (see also Appendix 4).


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Results of EVD Assessment/Test Public Health will inform you of the outcome of the risk assessment. If the patient is positive for EVD: 

Public Health will be in contact to make arrangements for decontamination of surgery, removal of waste, and will initiate contact identification and assessment.

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A specialist decontamination company will carry out all necessary cleaning and decontamination of the Surgery.

If the patient is negative for EVD: 

Dispose of waste in usual manner

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Clean and disinfect sealed off areas in usual manner

Surgery Pre-Incident Preparation 

To ensure that suspected EVD patients are identified as early as possible, all GP surgeries should PROMINENTLY display the Infection Risk Poster (available at http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Ebola/Posters/File,14780,en.pdf)

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Specific local advice (including local arrangements for contacting your local Receiving hospital and EVD Coordinator) can be obtained from your local Department of Public Health (see Appendix 4 of this document).

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A document, Referral Pathways to Hospital for Suspect Ebola Patients - Information for GPs contains the contact telephone numbers and addresses of all EVT Designated Receiving Hospitals and is available at http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Ebola/EbolaInformationforGeneralPractitioners/File,1497 8,en.pdf

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Surgeries and out of hours centres should clearly display information requesting patients to tell the receptionist on arrival if they are unwell and have returned from an Ebola-affected area within the last 21 days (there is also a poster for GP’s surgeries’ waiting rooms is available here). Any patients identifying themselves to reception staff should not sit in the general waiting room once EVD is considered a possibility. These patients should be isolated in a single side room immediately to limit contact. It may be appropriate to ask them to return to their car pending assessment by telephone.


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Important Features of EVD 

The risk of an EVD case in Ireland is very low.

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At the moment, the most likely manner in which a patient with EVD will appear in Ireland will be when a Humanitarian Aid Worker with known EVD is intentionally repatriated back into the country for treatment at the country’s National Isolation Unit; the likelihood of a person presenting cold in a GP’s surgery or via an immigration centre is extremely low. However, as this possibility, however small, exists it is important to ensure contingencies to manage such an eventuality are in place.

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Those infected with EVD can only spread the virus to others once they have developed symptoms. In the early stages these include fever, headache, joint and muscle pain, sore throat, and intense muscle weakness.

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EVD is not transmitted through normal social contact (such as shaking hands or sitting next to someone), especially in the early stages of the disease

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EVD is not transmitted when Personal Protective Distance (>1 metre) is maintained (apart from handshaking etc.)

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Once someone has become sufficiently ill to be infectious, they will almost certainly be unable to move or interact socially.

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Immediate hand hygiene is an extremely important infection control measure; the Ebola virus is not a robust virus, and is readily inactivated, for example, by soap and water or by alcohol.

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Those patients that are at highest risk of onward transmission are those who are bleeding, vomiting and coughing.

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It is important to remember that transmission of EVD from person to person is only through direct contact with the blood or body fluids of a symptomatic infected person. The infectivity of Ebola virus increases with duration of illness; it tends to be less infectious in the early phases of illness.

Waste management 

If an EVD patient presents in a GP’s surgery, clinical waste is very unlikely to have been generated unless the patient was very unwell with vomiting, bleeding or coughing.

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If the patient was unwell and generated fluid waste or the patient required physical examination, then cleaning and decontamination will be necessary and PPE will have to be disposed.

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After the patient leaves the General Practice treatment room(s), place any soft items (e.g. probe cover for thermometers etc.) in contact with the patient, into a yellow UN approved healthcare risk waste bag.

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Place any other soft decontamination / cleaning equipment i.e. gloves, paper towels etc. into the yellow UN approved healthcare risk waste bag.

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Only fill each yellow UN approved healthcare risk waste bag to 2/3rds full.


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Swan-tie each waste bag (for full information see guidance document Packaging and Transport of waste from suspect and confirmed cases of the Ebola Virus available at http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Assessingapossiblecase/File,14932,en.pdf)

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Await until outcome of EVD testing before deciding on further management

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See Appendix 4 for fuller details.

Notification of Infectious Disease and Tracing/Monitoring of Contacts Once a thorough assessment has been made and EVD is either considered likely or has been confirmed by laboratory testing, the hospital clinicians will inform the local Department of Public Health who will immediately undertake the necessary public health response and appropriate follow up of contacts, including arranging decontamination of potentially contaminated premises. The Department of Public Health will identify and organise follow up for any primary care contacts, which will include health care staff who dealt with the patient while symptomatic. A confirmation of EVD and subsequent initiation of public health action usually occurs within 24 hours of admission to hospital. Contacts are required to self-monitor and report relevant symptoms to Public Health. Where contacts develop relevant symptoms or signs they will be assessed in an appropriate acute hospital setting, and not referred to primary care. If there are specific concerns in the primary care setting, your local Department of Public Health can be contacted to discuss any specific public health issues at the point of referral to hospital or if the patient has additional high risk factors.

Decontamination following reception of an EVD Patient Once the suspected case has been transferred to hospital for further investigation, the room in which the patient had been isolated in or any potentially contaminated areas e.g. toilets should remain sealed off until a diagnosis of EVD has been excluded. It may be necessary to quarantine the room for up to 24hrs until results are available to confirm or out-rule EVD. Once a diagnosis of EVD has been confirmed, your local Department of Public Health will organise to have the appropriate cleaning company dispatched to the location to undertake the necessary cleaning and decontamination. Once the cleaning company is satisfied that any cleaning, decontamination and disposal of soiled items has taken place, the location can revert to normal use. Full information is contained in the document Infection Prevention & Control and Waste Disposal in Non-Hospital Settings available at http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Ebola/EbolaInformationforGeneralPractitioners/File,14980,en. pdf HSE-Health Protection Surveillance Centre

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Further Information/Guidance Further information on EVD can be found at: 

Ebola Information for GPs

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Information for Health Professionals

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Information for the general public


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Appendix 1 – Ebola Virus Disease (EVD) Risk Assessment for use in General Practice


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Appendix 2 – PPE Pack for General Practice Standard GP EVD PPE Pack 1. The gloves included in the pack are non-powdered nitrile gloves and meet European standards EN 2750 and EN 2760 2. The surgical face mask has a bacterial efficiency filtration of 98% and a splash resistance of >160mm Hg which is greater than the required level of >=120mm Hg. They are Type11R. 3. The gown is an impervious isolation gown which meets EN04 4. The goggles conform to EN166


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Appendix 3 - Important Web Addresses for Ebola Virus Disease

1. Notification of Infections (Director of Public Health/Medical Officer of Health) http://www.hpsc.ie/NotifiableDiseases/Whotonotify/ alternatively see bottom left-hand panel of Ebola Virus Disease – EVD – Risk Assessment for use in General Practice (Appendix 1 of this document)

2. Infection Risk Poster (http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Ebola/Posters/File,14780,en.pdf)

3. Ebola Information for General Practitioners http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Ebola/EbolaInformationforGeneralPractitioners/

4. Ebola Virus Disease: clinical management and guidance http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Ebola/Guidance/

5. Irish guidelines on Personal Protective Equipment (PPE) to be used in suspected or confirmed Ebola virus disease (EVD) scenarios: http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Ebola/EbolaInformationforGeneralPractitioners/File,1495 8,en.pdf.

6. EVD News Updates: http://www.hpsc.ie/News/MainBody,14571,en.html


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Appendix 4 - Infection Prevention & Control and Waste Disposal in Non-Hospital Settings Guidance Note for Public Health **For full document see here http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Ebola/EbolaInformationforGeneralPractitioners/File,14980,en.pdf

Background Decontamination in any location exposed to an Ebola virus disease (EVD) patient, will only be necessary once a patient has been confirmed as having EVD. Prior to the diagnosis being confirmed, the area in which a patient has been isolated should be quarantined off to ensure that no-one else can enter the room or use the facilities used by that patient.

In a GP’s surgery: Once the suspected case has been transferred to hospital for further investigation, the room in which the patient had been isolated in or any potentially contaminated areas (e.g. toilets, for example, should not be used until a diagnosis of EVD has been excluded) must be quarantined. It may be necessary to quarantine the room for up to 24hrs until results are available to confirm or out-rule EVD. Full details on management of suspected EVD patients in a GP’s Surgery are available at http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Ebola/EbolaInformationforGeneralPractitioners/File,14979,en.pdf. The Ebola Virus Disease (EVD) Risk Assessment for use in General Practice is available at http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Ebola/EbolaInformationforGeneralPractitioners/File,14977,en.pdf

In a Patient’s Residence: Any room used by the suspected case, such as bedroom, toilet/ shower/ bathroom facilities may also need to be quarantined once the diagnosis is confirmed. In the event that all rooms within the residence were used and are deemed to be a possible risk of infection to others that live within that residence, these members of the residence may be relocated until a diagnosis has been out-ruled or confirmed. In the first instance, members of the patient’s household may contact their local GP. They should be referred to the local Department of Public Health who will advise on these issues and the follow-up steps to be taken by the other members of the effected/ quarantined residence. Public Health staff will liaise with the hospital to clarify the outcome of the risk assessment and EVD testing, if performed, and based on this, will advise General Practice on cleaning and decontamination that is required. Once a diagnosis of EVD has been confirmed, the local Department of Public Health will contact the HSEcontracted cleaning company directly (see contact details at the end of this document) which will then will be dispatched to the location to undertake the necessary cleaning and decontamination. Once the cleaning company is satisfied that any cleaning, decontamination and disposal of soiled items has taken place the location can revert to normal use. HSE-Health Protection Surveillance Centre

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General Practice Surgery – Non-fluid Producing and Fluids Producing Patients Special circumstances relate to a General Practice Surgery. Once patient has left the surgery the room in which the patient was assessed should be sealed off along with other areas used by patient e.g. toilet. These rooms must NOT be used until the outcome of the risk assessment/EVD test results are known. It may be necessary to quarantine these areas for up to 24hrs until results are available. At the same time, a list should be compiled of any of patients and/or staff who may have been in contact with the patient.

A patient is considered to be a Non-fluid Producing Patient if they had minimal symptoms (such a fever, mild headache/myalgia with no vomiting, diarrhoea or bleeding; otherwise they are a Fluid Producing Patient (vomiting, haemorrhage, diarrhoea).

Non-fluid Producing Patient If the patient has symptoms limited to fever with no vomiting or diarrhoea the practice can undertake the following cleaning of other communal areas through which the patient may have passed (but not the room in which the patient was quarantined), using Standard Precautions and appropriate PPE (i.e. gloves): 

The room in which the patient has been risk assessed, and the toilets if they have been used by the patient, should be quarantined off and should not be used pending the results of the patient’s EVD test. However, the waiting area and surgery do not need to be closed.

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High contact surfaces such as door handles or touch screens should be wiped using standard disinfectants.

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Clean and disinfect all patient care equipment used in accordance with the manufacturer’s instructions.

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Public areas where the suspected case has passed through and spent minimal time in (such as corridors) but which are not visibly contaminated with bodily fluids do not need to be specially cleaned and disinfected.

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The GP may continue to consult if a different room is available, but should ensure they have washed their hands thoroughly with soap and water.

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Waste: o

After the patient leaves the General Practice treatment room(s), place any soft items (e.g. probe covers for thermometers etc.) in contact with the patient, into a yellow UN approved healthcare risk waste bag.

o

Place any other soft decontamination/cleaning equipment i.e. gloves, paper towels etc. into the yellow UN approved healthcare risk waste bag in a specially secured/locked area.

o

Only fill each yellow UN approved healthcare risk waste bag to 2/3rds full.

o

If the diagnosis is confirmed, waste will be collected by the contracted waste company; if the EVD test is negative, it can go through the normal waste disposal mechanism.

o

Your local Department of Public Health will provide the contact details of the waste disposal company (they can be found in the full document available at http://www.hpsc.ie/AZ/Vectorborne/ViralHaemorrhagicFever/Ebola/EbolaInformationforGeneralPractitioners/File,14980, en.pdf


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Fluid Producing Patient If the patient has symptoms such as vomiting, diarrhoea and/or bleeding then environmental contamination is highly likely and poses a serious risk, and decontamination must only be undertaken by the HSEcontracted cleaners. This company (Derrycourt) can be accessed via the local Department of Public Health (contact details are at the end of this document). Areas that the patient contaminated and the room in which the patient waited/was assessed and any toilet area used by the patient must be quarantined off immediately. 

The Department of Public Health should be informed and the surgery should be immediately closed pending an urgent risk assessment by the local Department of Public Health who will inform the HSE-contracted cleaners and advise on appropriate decontamination.

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Patients and staff should leave the surgery, but a record must be kept of people present during the time that the patient was on the premises, in order to assist with contact tracing and providing information to all the patients and practice staff.

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Waste: o

If the patient was unwell and generated fluid waste or the patient required physical examination, then cleaning and decontamination will be necessary and PPE will have to be disposed.

o

If the diagnosis is confirmed, waste will be collected by the contracted waste company (SRCL); if the EVD test is negative, waste can go through the normal channels.

Cleaning & Disinfection Decontamination Processes – Summary Information In a GP’s Surgery and in the home of a suspected EVD patient, cleaning will be necessary if the diagnosis is confirmed. There are three possible levels to this process: cleaning; cleaning followed by disinfection and cleaning followed by sterilisation. Cleaning A surfactant based cleaning product must first be used, prior to the use of disinfectant products or systems. Steam cleaning is not an appropriate decontamination process in known cases of EVD, due to the increased risk of generating aerosols. Therefore the affected individual or next of kin will need to be informed that certain items from the affected area may need to be removed as category A waste for appropriate end disposal by incineration.

Items that are permeable and have been contaminated with blood or body fluids will need to be appropriately removed from the facility/ home as category A waste in appropriate leak-proof packaging. This will include visibly soiled furniture, upholstery, carpets, and soft furnishings, with in the Surgery or in the home. In addition, in a patient’s home, special attention will have to be paid to permeable mattresses, permeable pillows, cushions, sheets, towels, clothing etc. NB: Unless visibly soiled, soft furnishings and mattresses do not need to be specially cleaned.

Certain products/ items by nature of their contact or potential contact with blood or body fluids or contaminated hands, will need to be removed as category A waste, such as tooth brushes, toiletries, disposable razors, electric razors, exposed/opened food items, opened disposable paper products, such as toilet rolls, kitchen paper towels etc.

Impermeable items and surfaces can be cleaned and then adequately decontaminated. Some impermeable items with easily perishable surfaces or parts may need to be rinsed/ cleaned with general neutral purpose detergent after being disinfection with hypochlorite or NaDCC compounds to remove any residual disinfectant that may perish the item over time.


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Disinfection It is important to ensure that products used in the decontamination procedure have been validated as effective against Viral Haemorrhagic Fever (VHF) pathogens. Appropriate agents include Chlorine releasing agents and sodium dichloroisocyanurate (NaDCC) agents.

Chemical Disinfection 

1,000 ppm chlorine releasing agent where no blood/blood stained body fluid contamination has occurred.



10,000 ppm chlorine releasing agent - for disinfection of blood stained body fluid contamination.

Sterilisation This involves the use of steam to clean heat resistant fabrics and surfaces.


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