Infection Prevention and Control Recommendations for Patients in U.S. Hospitals who are Suspected or Confirmed to have Selected Viral Hemorrhagic Fevers (VHF)

What to know

This guidance refers only to the following viral hemorrhagic fevers: Ebola, Marburg, Lassa, Crimean Congo Hemorrhagic Fever (CCHF) and the South American Hemorrhagic Fevers (i.e., those caused by Junin, Machupo, Chapare, Guanarito and Sabia viruses). Refer to the pathogen-specific pages for further information about the individual pathogens (e.g., signs and symptoms, incubation periods, routes of transmission, diagnosis, treatments).

Summary of recommendations

This guidance refers only to the following viral hemorrhagic fevers: Ebola, Marburg, Lassa, Crimean Congo Hemorrhagic Fever (CCHF) and the South American Hemorrhagic Fevers (i.e., those caused by Junin, Machupo, Chapare, Guanarito and Sabia viruses). Refer to the pathogen-specific pages for further information about the individual pathogens (e.g., signs and symptoms, incubation periods, routes of transmission, diagnosis, treatments).

Who this is for: Healthcare personnel in any healthcare setting. The guidance is most relevant for hospital staff caring for a patient who is suspected or confirmed to have viral hemorrhagic fever (VHF).

What this is for: Guidance to help healthcare personnel follow recommended infection prevention and control practices when caring for a patient suspected or confirmed to have VHF.

How this relates to other VHF guidance: This guidance outlines the key areas for infection prevention and control for VHFs in U.S. hospitals and healthcare settings.

Key Points

  1. CDC recommends a combination of measures to prevent transmission of VHFs in healthcare settings including personal protective equipment (PPE). These should be used in addition to routine Infection Prevention Control practices that are implemented daily to prevent transmission (or spread) of infectious diseases from patient to patient and patient to healthcare personnel.
  2. Healthcare personnel might need to take additional infection control steps if the patient has other conditions or illnesses caused by specific infectious diseases, such as tuberculosis.
  3. Healthcare personnel can be exposed to these viruses by coming into contact with a patient's body fluids, contaminated medical supplies and equipment, or contaminated environmental surfaces. Splashes to unprotected mucous membranes (for example: the eyes, nose, or mouth) are particularly hazardous. Procedures that can increase environmental contamination with infectious material or create aerosols (tiny particles in the air) should be minimized.

The table below outlines precautions recommended for management of a hospitalized patient suspected or confirmed to have VHF. Note that this guidance outlines only those measures specific to the pathogens listed at the top of the guidance. Duration of specific infection control measures need to account for patients that may have other conditions or illnesses for which other measures are indicated (e.g., tuberculosis, multidrug-resistant organisms).

Though these recommendations focus on the hospital setting, the recommendations for personal PPE and environmental infection control measures are applicable to any healthcare setting. In this guidance healthcare personnel (HCP) refers all people, paid and unpaid, working in healthcare settings who have the potential for exposure to patients and/or to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or aerosols generated during certain medical procedures. HCP include, but are not limited to, physicians, nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainees, contractual personnel, home healthcare personnel, and people not directly involved in patient care (for example: clerical, dietary, housekeeping, laundry, security, maintenance, billing, chaplains, and volunteers) but potentially exposed to infectious agents that can be transmitted to and from HCP and patients. This guidance is not intended to apply to people outside of healthcare settings.

As additional information becomes available, these recommendations will be re-evaluated and updated as needed. These recommendations are based upon the following considerations:

  • High rate of morbidity and mortality (serious illness and possibly death) among infected patients
  • Risk of human-to-human transmission

For full details of routine infection control measures that should be implemented day-to-day in U.S. healthcare settings see 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting.

For information on symptoms of VHF and modes of transmission, see Viral hemorrhagic fevers (VHFs) | CDC.

Key Infection Control Precautions Recommended for Preventing Transmission of VHFs in U.S. Hospitals

* For laboratory personnel, the recommendations for PPE only apply when in the patient care area. Laboratory personnel who are in the laboratory, not the patient care area, need to follow the recommendations outlined in relevant laboratory guidance.

Component

Recommendation

Comments

Patient Placement

  • Single patient room (containing a private bathroom) with the door closed
    • Adequate space for donning (putting on) and doffing (taking off) PPE
  • Facilities should maintain a log of all people entering the patient’s room
  • Consider posting personnel at the patient’s door to ensure appropriate and consistent use of PPE by all people entering the patient room

Personal Protective Equipment (PPE)

All PPE should be used in the context of a comprehensive infection control program that follows CDC recommendations and must follow applicable Occupational Safety and Health Act of 1970 (OSHA) requirements, including the Bloodborne Pathogens (29 CFR 1910.1030), PPE (29 CFR 1910.132), and Respiratory Protection (20 CFR 1910.134) standards, and other requirements under OSHA (e.g., the General Duty Clause, section 5(a)(1); and prohibitions against discrimination or retaliation against workers, section 11(c)).

Patient Care Equipment

  • Dedicated medical equipment (preferably disposable, when possible) should be used for the provision of patient care
  • All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer’s instructions and hospital policies

Patient Care Considerations

  • Limit the use of needles and other sharps as much as possible
  • Phlebotomy, procedures, and laboratory testing should be limited to the minimum necessary for essential diagnostic evaluation and medical care
  • All needles and sharps should be handled with extreme care and disposed in puncture-proof, sealed containers

Aerosol Generating Procedures (AGPs)

  • Avoid AGPs for patients with VHF, if possible.
  • If performing AGPs, use a combination of measures to reduce exposures from aerosol-generating procedures when performed on these patients.
  • Visitors should not be present during aerosol-generating procedures.
  • Limiting the number of HCP present during the procedure to only those essential for patientcare and support.
  • Conduct the procedures in a private room and ideally in an Airborne Infection Isolation Room (AIIR) when feasible. Room doors should be kept closed during the procedure except when entering or leaving the room, and entry and exit should be minimized during and shortly after the procedure.
  • HCP should wear appropriate PPE during aerosol-generating procedures.
  • Conduct environmental surface cleaning following procedures (see section below on environmental infection control).
  • Although there are limited data available to definitively define a list of AGPs, procedures that are usually included are Bilevel Positive Airway Pressure (BiPAP), bronchoscopy, sputum induction, intubation and extubation, and open suctioning of airways. Additional information about AGPs is available in Which procedures are considered AGPs in healthcare settings?
  • Because of the potential risk to individuals reprocessing reusable respirators, disposable filtering face piece respirators are preferred.

Hand Hygiene

  • HCP should perform hand hygiene frequently, including before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of PPE, including gloves.
  • Healthcare facilities should ensure that supplies for performing hand hygiene are available.
  • Hand hygiene in healthcare settings can be performed by washing with soap and water or using alcohol-based hand rubs. If hands are visibly soiled, use soap and water, not alcohol-based hand rubs.

Environmental Infection Control

Safe Injection practices

  • Facilities should follow safe injection practices as specified under Standard Precautions.
  • Any injection equipment or parenteral medication container that enters the patient treatment area should be dedicated to that patient and disposed of at the point of use.

Duration of Infection Control Precautions

  • Duration of precautions should be determined on a case-by-case basis, in conjunction with local, state, and federal health authorities.
  • Factors that should be considered include, but are not limited to, presence of symptoms, date symptoms resolved, other conditions that would require specific precautions (e.g. tuberculosis, Clostridium difficile) and available laboratory information.

Monitoring and Management of Healthcare Personnel

Facility HCP monitoring and sick leave policies

  • Facilities should develop policies for monitoring and management of HCP with potential VHF exposure.
  • Facilities should develop sick leave policies for HCP that are non-punitive, flexible and consistent with public health guidance.
    • Ensure that all HCP, including staff who are not directly employed by the healthcare facility but provide essential daily services, are aware of the sick leave policies.

HCP with high-risk exposures

  • Per CDC interim guidance, people with high-risk exposures, including HCP, should be quarantined, monitored daily, and restricted from traveling by commercial transport until 21 days1 after their last high-risk exposure
    • High-risk exposures include (but are not limited to):
      • Percutaneous, mucous membrane, or skin contact with blood or body fluids of a person suspected or confirmed to have VHF
      • Direct contact2 with person suspected or confirmed to have VHF
      • Providing care to a patient suspected or confirmed to have VHF without use of all recommended PPE, or while experiencing a breach in recommended PPE that results in the potential for percutaneous, mucous membrane, or skin contact with the blood or body fluids of the patient
    • Living in the same household as a person suspected or confirmed to have VHF
    • Asymptomatic HCP who had a high-risk exposure should
      • Receive medical evaluation and follow-up care including fever monitoring at least daily for 21days1 after the last known high-risk exposure
      • Be restricted from work and follow all other recommendations related to quarantine and restriction from commercial transport during the 21-day1 monitoring period
  • HCP who have a percutaneous or mucous membrane exposure to blood or body fluids, secretions, or excretions from a person suspected or confirmed to have VHF should
    • Stop working and immediately wash the affected skin surfaces with soap and water. Mucous membranes (e.g., conjunctiva) should be irrigated with copious amounts of water or eyewash solution.
    • Immediately contact their supervisor and occupational health program for assessment and access to postexposure management services for all appropriate pathogens (e.g., Human Immunodeficiency Virus, Hepatitis C, etc.).

1This time period is based on the outer limit of the incubation period for the suspected pathogen. For Ebola, Marburg, Lassa, Chapare and Sabia, this is 21 days. However, for Crimean-Congo Hemorrhagic Fever it is 14 days. Further information about incubation periods for specific VHFs is available.

2 Direct contact means physical contact with a person with VHF (alive or dead) or with objects contaminated with the body fluids of a person with VHF (alive or dead) while not wearing recommended PPE or while experiencing a breach in PPE that could result in unprotected contact with the patient or their blood or body fluids.

Additional Considerations for HCP with VHF exposures that are not high risk or who cared for patients while wearing full PPE and had no known exposures

  • CDC has provided guidance for persons, including HCP, with the potential for unrecognized exposures in the absence of reported high-risk exposures. Such HCP should be evaluated by their occupational health program and have their recommended postexposure management, including work restrictions, determined in collaboration with public health authorities.
    • In general, these asymptomatic HCP who have not had a high-risk exposure do not require work restriction but should be advised to self-monitor for a period of 211 days after the last known contact with the patient or their body fluids. Monitoring can be conducted by phone, video conferencing, other electronic means (e.g., text message, email, app, web form), or in person, according to resources available in that jurisdiction.

Considerations for HCP who develop signs or symptoms after caring for patients suspected or confirmed to have VHF or with potential unrecognized exposures

  • HCP who develop symptoms of VHF (e.g., sudden onset of fever, fatigue, intense weakness or muscle pains, vomiting, diarrhea, or any signs of hemorrhage) should
    • Not report to work, or should immediately stop working
    • Notify their supervisor and occupational health program, who should in turn notify local and state public health authorities
    • Seek prompt medical evaluation and testing in consultation with public health authorities

Monitoring, Management, and Training of Visitors

  • Avoid entry of visitors into the patient’s room
    • Exceptions may be considered on a case-by-case basis for those who are essential for the patient’s wellbeing.
  • Establish procedures for monitoring managing and training visitors.
  • Visits should be scheduled and controlled to allow for:
    • Screening for VHF (fever and other symptoms) before entering or upon arrival to the hospital.
    • Evaluating risk to the health of the visitor and ability to comply with precautions.
    • Providing instruction, before entry into the patient care area on hand hygiene, limiting surfaces touched, and use of PPE according to the current facility policy while in the patient’s room.
    • Visitor movement within the facility should be restricted to the patient care area and an immediately adjacent waiting area.
  • Visitors who have been in contact with the patient before and during hospitalization are a possible source of VHF for other patients, visitors, and staff.
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Content Source:
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)