CT Governor’s Unified Command Team Guidance for First Responders (October 24, 2014)

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GUIDANCE FOR FIRST RESPONDERS

Important Information for All First Responders

At this time, the Connecticut Department of Public Health believes the risk of exposure to first responders in Connecticut to the Ebola virus to be extremely low. As such, the overwhelming majority of response situations will warrant only the usual level of precautions against blood borne pathogen exposure (“Universal Precautions”) for which first responders are routinely trained and that are utilized by first responders as part of their routine work on a daily basis. Please refer to your agency’s established Exposure Control Plan.

An important distinction: QUARANTINE versus ISOLATION

“Quarantine” consists of the physical separation and confinement of an individual, group of individuals or individuals present within a geographic area that are or are believed to have been exposed to a communicable disease or contamination. Individuals in quarantine do not have an active case of the disease. “Isolation” consists of the physical separation and confinement of an individual, or a group of individuals, present within a geographic area who are infected with a communicable disease or are contaminated, or whom the commissioner of public health reasonably believes to be infected with a communicable disease or to be contaminated, in order to prevent or limit the transmission of the disease to the general public. Individuals in isolation may have an active case of the disease. As of October 24, 2014, no individuals in the State of Connecticut are known to have an active case of the disease and that is why no individuals in Connecticut are in isolation.

UNIVERSAL PRECAUTIONS

It is important to remember that individuals can exhibit Ebola-like symptoms due to exposure to other infectious agents such as influenza or the norovirus. Since exposure to any infectious disease is always a workplace safety issue, it is important for all first responders to be familiar with and routinely follow “Universal Precautions” for preventing exposure to any infectious disease. Universal Precautions include:

• Treating any body fluid as if it is infectious;

• Wearing appropriate Personal Protective Equipment (PPE), including impermeable, disposable (i.e., nitrile) gloves and other necessary disposable protective clothing (gowns, face shields, booties, etc.) when exposure to blood or bodily fluids is anticipated;

Detailed Emergency Medical Services (EMS) Checklist for

Ebola Preparedness The U.S. Department of Health and Human Services (DHHS) Centers for Disease Control and Prevention (CDC) and Office of the Assistant Secretary for Preparedness and Response (ASPR), in addition to other federal, state, and local partners, aim to increase understanding of Ebola and encourage U.S.-based EMS agencies and systems to prepare for managing patients with Ebola and other infectious diseases. Every EMS agency and system, including those that provide non-emergency and/or inter-facility transport, should ensure that their personnel can detect a person under investigation (PUI) for Ebola, protect themselves so they can safely care for the patient, and respond in a coordinated fashion. Many of the signs and symptoms of Ebola are non-specific and similar to those of other common infectious diseases such as malaria, which is commonly seen in West Africa. Transmission of Ebola can be prevented by using appropriate infection control measures. This checklist is intended to enhance collective preparedness and response by highlighting key areas for EMS personnel to review in preparation for encountering and providing medical care to a person with Ebola. The checklist provides practical and specific suggestions to ensure the agency is able to help its personnel detect possible Ebola cases, protect those personnel, and respond appropriately. Now is the time to prepare, as it is possible that individuals infected with Ebola virus in West Africa may travel to the U.S., develop signs or symptoms of Ebola , and seek medical care from EMS personnel. EMS agencies, in conjunction with their medical directors, should review infection control policies and procedures and incorporate plans for administrative, environmental, and communication measures. The checklist format is not intended to set forth mandatory requirements or establish national standards. It is a list of activities that can help each agency prepare. Each agency is different and should adapt this document to meet its specific needs. In this checklist, EMS personnel refers to all persons, paid and volunteer who provide pre-hospital emergency medical services and have the potential for direct contact exposure (through broken skin or mucous membranes) with an Ebola patient’s blood or body fluids, contaminated medical supplies and equipment, or contaminated environmental surfaces. This detailed checklist for EMS is part of a suite of HHS checklists. This guidance is only for EMS agencies and systems; the CDC’s Interim guidance for EMS includes information for individual providers and for 9-1-1 Public Safety Answering Points. CDC is available 24/7 for consultation by calling the CDC Emergency Operations Center (EOC) at 770-488-7100 or via email at eocreport@cdc.gov.

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C=Completed; IP=In Progress; NS=Not Started

PREPARE TO DETECT C IP NS Train all EMS personnel on how to identify signs and symptoms of Ebola infections and to avoid risk of exposure.

Review CDC Ebola case definition for guidance on who meets the criteria for a PUI for Ebola.

Ensure EMS personnel are aware of current guidance: Interim Guidance Emergency Medical Services Systems.

Review patient assessment and management procedures and ensure they include screening criteria (e.g. relevant questions: travel within 21 days from affected West African country, exposure to case) for use by EMS personnel to ask individuals during the triage process for patients presenting with compatible symptoms.

Post screening criteria in conspicuous locations in EMS units, at EMS stations, and in other locations frequented by EMS personnel (see suggested screening criteria).

Designate points of contact within their EMS organization/system responsible for communicating with state and local public health officials. Remember: Ebola must be reported to local, state, and federal public health authorities.

Ensure that all personnel are familiar with the protocols and procedures for notifying the designated points of contact regarding a PUI for Ebola.

Conduct spot checks and reviews for staff to ensure they are incorporating Ebola screening into their patient assessment and management procedures and are able to initiate notification, isolation, and PPE procedures.

PREPARE TO PROTECT C IP NS Consider travelers with fever, fatigue, vomiting and/or diarrhea and returning from affected West African countries as potential cases, and obtain additional history.

Conduct a detailed inventory of available supplies of PPE suitable for standard, contact, and droplet precautions. Ensure an adequate supply, for EMS personnel, of:

• Fluid resistant or impermeable gowns, • Gloves, • Shoe covers, boots, and booties, and • Appropriate combination of the following:

o Eye protection (face shield or goggles), o Facemasks (goggles or face shield must be worn with facemasks), o N95 respirators (for use during aerosol-generating procedures)

• Other infection control supplies (e.g. hand hygiene supplies).

Ensure that PPE meets nationally-recognized standards as defined by the Occupational Safety & Health Administration (OSHA), National Institute for Occupational Safety and Health (NIOSH), Food and Drug Administration (FDA), or Interagency Board for Equipment Standardization and Interoperability.

Review plans, protocols, and PPE purchasing with community/coalition partners that promote interoperability and inter-agency/facility coordination.

Ensure Ebola PPE supplies are maintained in all patient care areas (transport unit and in bags/kits).

Verify all EMS personnel: • Meet all training requirements in PPE and infection control,

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• Are able to use PPE correctly, • Have proper medical clearance, • Have been properly fit-tested on their respirator for use in aerosol-

generating procedures or more broadly as desired, and • Are trained on management and exposure precautions for PUI for Ebola.

Encourage EMS personnel to use a “buddy system” when putting on and removing PPE.

Review CDC guidelines for isolation precautions and share with EMS personnel. Frequently spot-check (for example through quality assurance/quality improvement) to be sure standard, contact and droplet infection control and isolation guidelines are being followed, including safely putting on and removing PPE.

Ensure procedures are in place to require that all EMS personnel accompanying a patient in a transport unit are wearing (at minimum): gloves, gown (fluid resistant or impermeable), eye protection (goggles or face shield), and a facemask.

Ensure procedures are in place to limit EMS personnel exposure to PUI for Ebola during treatment and transport.

Review and update, as necessary, EMS infection control protocols/procedures. Review your policies and procedures for screening, isolation, medical consultation, and monitoring and management of EMS personnel who may have Ebola exposure and/or illness.

Review and update, as necessary, all EMS agency protocols and procedures for isolation of PUI for Ebola .

Review the agency’s infection control procedures to ensure adequate implementation for preventing the spread of Ebola.

Review protocols for sharps injuries and educate EMS personnel about safe sharps practices to prevent sharps injuries.

Emphasize the importance of proper hand hygiene to EMS personnel. Develop contingency plans for staffing, ancillary services, vendors, and other business continuity plans.

Review plans for special handling of linens, supplies, and equipment from PUI for Ebola.

Review environmental cleaning procedures and provide education/refresher training to appropriate personnel.

Provide education and refresher training to EMS personnel on healthcare personnel sick leave policies.

Review policies and procedures for screening and work restrictions for exposed or ill EMS personnel, and develop sick leave policies for EMS personnel that are non-punitive, flexible, and consistent with public health guidance.

Ensure that EMS personnel have ready access, including via telephone, to medical consultation.

PREPARE TO RESPOND C IP NS Review, implement, and frequently exercise the following elements with EMS personnel:

• Appropriate infectious disease procedures and protocols, including putting on and taking off PPE.

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• Appropriate triage techniques and additional Ebola screening questions, • Disease identification, testing, specimen collection and transport

procedures, • Isolation, quarantine and security procedures, • Communications and reporting procedures, and • Cleaning and disinfection procedures.

Review plans and protocols, and exercise/test the ability to appropriately share relevant health data between key stakeholders, coalition partners, public health, emergency management, etc.

Review, develop, and implement plans for: adequate respiratory support, safe administration of medication, and sharps procedures; and reinforce proper biohazard containment and disposal precautions.

Ensure that EMS agency leaders are familiar with their responsibilities during a public health emergency.

Consider identifying a Communications/Public Information Officer who: • Develops appropriate literature and signage for posting (topics may include

definitions of low-risk, high-risk and explanatory literature for patient, family members and contacts),

• Coordinates with public health on targeted risk communication messages for use in the event of a PUI for Ebola.

• Requests appropriate Ebola literature for dissemination to EMS personnel, patients, and contacts,

• Prepares written and verbal messages, ahead of time, that have been approved, vetted, rehearsed and exercised, and

• Works with internal department heads and clinicians to prepare and vet internal communications to keep EMS personnel informed.

Plan for regular situational briefs for decision-makers, including: • PUI for Ebola who have been identified and reported to public health

authorities, • Isolation, quarantine and exposure reports, • Supplies and logistical challenges, • Personnel status, and • Policy decisions on contingency plans and staffing.

Maintain situational awareness of reported Ebola case locations, travel restrictions, and public health advisories, and update patient assessment and management guidelines accordingly.

Incorporate Ebola information into educational activities (e.g. initial/ refresher training, drills, and exercises).

Implement, as needed, a multijurisdictional, multidisciplinary exchange of public health and medical-related information and situational awareness between EMS; the health care system; local, state, federal, tribal, and territorial levels of government; and the private sector.

Quick Resources List The CDC has produced several resources and references to help agencies prepare for Ebola, and more resources are in development. Information and guidance posted on these resources may change as experts learn more about Ebola. Frequently monitor the CDC’s Ebola Homepage, and review CDC’s Ebola response guide checklists for: • Clinician and healthcare workers,

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• Department of Transportation Guidance for Transporting Ebola Contaminated Items, a Category A Infectious Substance

• Patient Management for US Hospitals • Healthcare facilities. Stay informed! Subscribe to the following sources to receive updates about Ebola: • CDC Health Alert Network (HAN), • CDC Clinician Outreach and Communication Activity (COCA), • CDC National Institute for Occupational Safety and Health, and • U.S. Department of Labor’s Occupational Safety & Health Administration (OSHA)

Newsletter. Below are a few of the resources most relevant to healthcare preparedness: • Interim Guidance for Emergency Medical Services Systems and 9-1-1 PSAPs. • Ebola Virus Disease Information for Clinicians in U.S. Healthcare Settings, • Case Definition for Ebola Virus Disease. This case definition should be used for screening

patients and should be implemented in all healthcare facilities. • Safe Management of Patients with Ebola Virus Disease in US Hospitals, • Infection Prevention and Control Recommendations for Hospitalized Patients with Known

or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals. This document provides a summary of the proper Personal Protective Equipment (PPE).

• Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Patients with Suspected Infection with Ebola Virus Disease.

• Sequence for Removing Personal Protective Equipment (PPE) • National Guidance for Healthcare System Preparedness’ Capabilities, with particular

emphases on Capability #6 (Information Sharing) and Capability #14 (Responder Safety and Health)

Check CDC’s Ebola Hemorrhagic Fever website regularly for the most current information. State and local health departments with questions should contact the CDC Emergency Operations Center (770-488-7100 or eocreport@cdc.gov).

CT Governor’s Unified Command Team Guidance for First Responders (October 24, 2014)

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• Maintaining as much distance as possible when interacting with known or potentially infectious individuals;

• Putting on and taking off (donning and doffing) PPE properly, maintaining the integrity of the PPE, to avoid contaminating skin and clothing;

• Washing your hands vigorously with soap and water (or hand sanitizer ≥ 60% alcohol) after removing gloves, or after close contact with an ill person, or with body fluids or surfaces that may be contaminated;

• Avoiding touching your mouth, eyes, nose, or other mucous membranes with unwashed or gloved hands;

• Disposing of any contaminated PPE, used needles, or other potentially contaminated items in appropriate biohazard bags or sharps containers.

Respiratory protection is not part of routine Universal Precautions and is not necessary unless there is a respiratory hazard (such as coughing or sneezing), or there is anticipated exposure to airborne infectious diseases (such as influenza), or the individual is in isolation. It is important to remember that use of respiratory protection (such as the N95 respirator) requires employers to develop and maintain an OSHA-compliant respiratory protection program, including medical screening, fit testing and worker training prior to distribution and use of respirators in work settings. More information on compliance with the OSHA respiratory protection standard can be found online at https://www.osha.gov/SLTC/respiratoryprotection/.

INFORMATION FOR FIRST RESPONDERS WHEN DEALING WITH A POTENTIAL EXPOSURE TO EBOLA The special precautions referred to below are only recommended in cases in which a first responder is called to assist at a scene with an individual known or suspected to have exposure to Ebola virus:

Ebola is spread through the direct contact with an infectious person’s blood or body fluids (i.e., urine, feces, vomit, or saliva). Infection can also occur through contact with the blood or body fluids of someone that has died from Ebola. Since Ebola can survive for several days on surfaces, infection can occur as a result of direct contact with objects that contain infectious blood or body fluids (such as needles or bed sheets). A person who is exposed to Ebola virus cannot infect other individuals until symptoms, such as fever, nausea, vomiting or diarrhea begin. Symptoms of Ebola Virus Disease are similar to many other conditions, and include:

• Fever (≥ 100.4°F or 38.0°C) • Severe headache • Muscle pain • Weakness • Diarrhea

• Vomiting • Abdominal (stomach) pain • Unexplained bleeding or bruising

CT Governor’s Unified Command Team Guidance for First Responders (October 24, 2014)

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Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola, but the average is 8 to 10 days. If an individual has not exhibited symptoms after 21 days from exposure, they are not infected by Ebola.

PLEASE NOTE: Since symptoms of Ebola Virus Disease are similar to those associated with many other more common disease conditions, the most important factor to consider in identifying a possible Ebola case is whether the individual is known to have had recent close contact with a person with active Ebola Virus Disease or recent travel to Ebola-endemic areas of West Africa; specifically Guinea, Liberia and Sierra Leone. If neither of these has occurred within the last 21 days, it is highly unlikely that the person exhibiting symptoms has active Ebola Virus Disease.

ADDITIONAL PRECAUTIONS: CONTACT WITH PERSONS THAT ARE KNOWN OR SUSPECTED TO HAVE ACTIVE EBOLA VIRUS DISEASE

The following special precautions have been developed by the Centers for Disease Control and Prevention (CDC) and are recommended in cases where a first responder is called to assist at a scene with an individual known or suspected to have previous exposure to Ebola virus and active Ebola Virus Disease.1 Please note: It is anticipated that Fire and/or Law Enforcement officials may escort but are not usually expected to provide transport of persons to isolation or a medical facility.

1. Isolate the infectious individual away from bystanders and limit direct close contact (i.e. within 6 feet) with the infectious individual as much as possible. 2. Wear recommended personal protective equipment (PPE) at all times when in close proximity to the infectious individual to protect against direct skin and mucous membrane exposure to blood and other bodily fluids.2 All use of PPE should be in accordance with applicable OSHA standards. Recommended PPE includes: • Impermeable disposable gloves (i.e., nitrile or latex) (double gloving is recommended) • Fluid resistant or impermeable disposable gown • Eye protection (a face shield that fully covers the front and sides of the face) • Disposable N95 respirator (facemask-type) to prevent exposure to airborne droplets, preceded by a medical screening, fit testing and worker training by qualified individuals • Additional barriers (i.e., disposable leg covers, disposable shoe covers, double gloving) should be used at response scenes where large amounts of blood or other bodily fluids are present

1 The current Ebola outbreak in West Africa has been ongoing since March 2014 and has primarily affected Guinea, Liberia and Sierra Leone. It is important to note that there is currently no Ebola outbreak in the US. To date there have been 4 Ebola cases in the US, an index case who had contracted the disease in West Africa, and two other cases in nurses attending that initial case in close contact inside a healthcare facility.

2 On October 21, the Centers for Disease Prevention and Control (CDC) recently revised its “Guidance on Personal Protective Equipment To be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing),” and indicated that it is currently revising its “Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States.” As CDC guidance on PPE is revised, Connecticut’s Guidance will also be updated as well.

CT Governor’s Unified Command Team Guidance for First Responders (October 24, 2014)

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3. Limit activities, especially during transport, which can increase the risk of exposure to infectious material (e.g., airway management, cardiopulmonary resuscitation, use of needles). Phlebotomy, procedures and laboratory testing should be limited to the minimum necessary for essential diagnostic evaluation and medical care. 4. Limit the use of needles and other sharps as much as possible. All needles and sharps should be handled with extreme care and disposed in puncture-proof, sealed containers. 5. Pre-hospital resuscitation procedures (endotracheal intubation, open suctioning of airways, CPR) frequently result in a large amount of body fluids, such as saliva and vomit. Performing these procedures in a less controlled environment (e.g., moving vehicle) increases risk of exposure for EMS personnel. If conducted, perform these procedures under safer circumstances (e.g., stopped vehicle, hospital destination). 6. Use extreme caution when putting on and taking off (donning and doffing) PPE to avoid touching mucous membranes and contaminating skin and clothing. Appropriate procedures for donning and doffing PPE can be found on line at http://www.cdc.gov/HAI/prevent/ppe.html and http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf. 7. PPE should be worn upon entry into the scene and continued to be worn until personnel are no longer in contact with the patient;

8. Dispose of all contaminated clothing and other equipment in appropriate containers inside a hospital setting or keep double-bagged inside leak-proof containers or sharps containers and held in a secure location until they can be appropriately disposed;

9. Wash hands vigorously and thoroughly with soap and water after all PPE is removed and disposed.

10. DPH has released an updated Guidance Document on Cleaning and Disinfecting Indoor Spaces that includes specific advice on Ebola (attached.)

COMBATIVE PERSONS AND NON-COMPLIANT PATIENTS

The vast majority of persons with whom law enforcement personnel, fire fighters and emergency services responders come into contact, including persons who are placed in quarantine or isolation, are compliant and will adhere to your directions. In those instances, however, where a person is combative or a patient is non-compliant, customary policy and procedure regarding the use of force applies. Verbal commands should continue to be issued first and any force used be the least restrictive and of the shortest duration possible to address the risk at hand. First responders should be mindful nonetheless; that each form of force may cause additional conditions to occur that may require your attention. As examples, applying a chemical agent is likely to cause the combative person or non-compliant patient to produce tears and mucous and to cough, and any physical struggle to produce sweat. Maintaining a distance of six or more feet whenever possible, having PPE at the ready, washing your hands and other exposed skin vigorously with soap and water immediately after contact, and fully adhering to all of the other Universal Precautions is critical to your safety and wellbeing. NOTE: When the person’s first language is not English, communication may be inhibited, efforts to elicit assistance from others who speak that language is encouraged.

CT Governor’s Unified Command Team Guidance for First Responders (October 24, 2014)

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NOTE: The decision whether to have a law enforcement presence at the scene rests with the Authority Having Jurisdiction.

RECOMMENDED DISPATCHER CALL SCRIPT

The CDC recommends that 9-1-1 Public Safety Answering Points (PSAPs) and other emergency call centers use modified caller queries about Ebola when they consider that the risk of Ebola may be elevated in their communities (for example, in the event that patients with confirmed Ebola are identified in the area). Communication and collaboration among PSAPs, the EMS system, health care facilities, and the public health system is important for a coordinated response to Ebola. Each 9-1-1 and EMS system should seek the involvement of the Medical Control in their response area to provide appropriate medical oversight.

The following guidelines, based on CDC recommendations, have been reviewed by CT DPH, and are in place at the Department of Emergency Services and Public Protection:

Dispatchers should screen callers consistent with their Emergency Medical Dispatch (EMD) procedures. In addition, questions regarding travel listed below should be added. It is important for dispatchers to also question callers about:

• Recent travel in the last 21 days (particularly travel to Liberia, Sierra Leone, or Guinea in the last 21 days), or • Contact with a person who has Ebola virus disease, such as having touched someone who is sick with Ebola.

If these travel questions are in the affirmative and these questions if they are not included in the initial screening, also ask whether the person is experiencing the following:

• Fever greater than 100.4F • Severe headache, muscle pain, vomiting, diarrhea, abdominal pain or unexplained bleeding

Whenever possible, dispatchers should relay this information to first responders before they get to the location so they can put on the correct personal protective equipment (PPE).

If the caller is seeking general information about Ebola, the Dispatcher should refer the caller to www.211ct.org or www.ct.gov/ebola.

RECOMMENDATIONS IF A MUNICIPALITY RECEIVES A QUARANTINE ORDER

Once a quarantine order from the CT DPH has been issued, DPH will also notify the local public health director. The local public health director will notify the municipal Chief Executive Officer (CEO). It is recommended that the CEO convene a municipal Unified Command Team of appropriate partners including the police and fire chiefs and emergency management director to address potential public health, police, fire, EMS, and school issues. It must be recognized that there are confidentiality issues related to the release and collection of certain health-related information. Please contact CT DPH with any questions.

CT Governor’s Unified Command Team Guidance for First Responders (October 24, 2014)

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Under Connecticut law, an individual quarantined has:

• The right to consult an attorney; • The right to a hearing pursuant to Connecticut General Statutes Section 19a-131b, at which the person may be represented by counsel that will be provided at the expense of the state if the person is unable to pay for such counsel; and • Court fees will be waived if a hearing is requested.

Under Connecticut General Statutes Section 19a-131b, an appeal of the order of quarantine may be initiated in the appropriate Probate Court in the jurisdiction in which the person is quarantined by the person or his/her representative in writing to the Court by means of first class mail, fax machine, or the Internet, requesting a hearing.

BIOMEDICAL INFORMATION

In the event of an Ebola outbreak in Connecticut, the Department of Energy and Environmental Protection (DEEP) has indicated the following: If there is a case that occurs where Ebola biomedical waste materials are generated, DEEP has identified several facilities in the state where these materials can be brought and safely disposed of. Below are links to the DEEP Website for lists of permitted Biomedical Contractor resources that can be contacted for cleaning and transportation services if required.

List of licensed spill cleanup contractors

http://www.ct.gov/deep/lib/deep/emergency_response_spill_prevention/licensedspillcontractors.pdf

List of Biomedical transporters

http://www.ct.gov/deep/lib/deep/waste_management_and_disposal/transporters_and_facilities/biomedicalwastetransporters.pdf

Biomedical Waste Frequently Asked Questions

http://www.ct.gov/deep/cwp/view.asp?a=2718&q=325338&deepNav_GID=1646

Biomedical Waste Tracking Form

http://www.ct.gov/deep/lib/deep/waste_management_and_disposal/biomedical_waste/MedWstTrkForm.pdf

CT Governor’s Unified Command Team Guidance for First Responders (October 24, 2014)

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SUMMARY

This document has been developed to provide key information regarding the risk of, and appropriate precautions against, exposure to Ebola virus for first responders, including police, fire fighters, emergency medical services (EMS) personnel and other responders working in non-healthcare settings. It incorporates information primarily from the CDC, Connecticut Occupational Safety and Health Administration (CT OSHA), and CT DPH and represents the most current recommendations available at this time. This guidance may change over time in which case, this guidance will be revised and redistributed.

CT DPH is available to provide assistance on a case-by-case both with regard to epidemiological and occupational health issues.

In closing, as of October 24, 2014, the Connecticut Department of Public Health believes the risk of exposure to Ebola virus by first responders in Connecticut to be extremely low. As such, the overwhelming majority of response situations will warrant only the usual level of precautions against bloodborne pathogen exposure (“Universal Precautions”) for which first responders are routinely trained and are utilized by first responders as part of their routine work on a daily basis.

ADDITIONAL INFORMATION SOURCES

Centers for Disease Control and Prevention (CDC) Ebola Information: http://www.cdc.gov/vhf/ebola/

Occupational Safety and Health Administration (OSHA) Ebola Protection for Workers: https://www.osha.gov/SLTC/ebola/

Connecticut Department of Public Health – Ebola Virus Disease Information: http://www.ct.gov/dph/cwp/view.asp?a=3115&Q=554408&PM=1

Connecticut Department of Public Health

410 Capitol Avenue, Hartford, CT 06066

http://www.ct.gov/dph

Environmental & Occupational Health Assessment Program October 2014

Cleaning & Disinfecting

Indoor Spaces

Guidance Document

During the flu season or during an infectious

disease outbreak, there may be a need or desire to

do some extra cleaning and disinfecting of indoor

spaces. This document will provide information

about how to do this safely and properly.

Important Fact:

Disinfectants are meant to kill microorganisms. They are NOT designed to clean dirt, grime, and other organic matter off of surfaces.

Disinfectants do not work well if used on dirty surfaces. This is why most disinfectants say on the label that you should clean first before using them.

To Clean Large Surfaces Like Walls, Floors,

Lockers, etc.

Use an all-purpose cleaner that handles dirt and grime. It is not necessary for it to kill microorganisms. Detergents or soap and water are fine to use for cleaning.

The physical act of scrubbing or wiping removes a large percentage of microorganisms found on surfaces.

To Disinfect:

Reserve disinfectants for ‘high touch’ areas like door knobs, light switches, toilet flush handles, sink faucet handles- anything that many people touch.

Choose a disinfectant that satisfies all of the

requirements below:

The EPA registration no. must be on the label and must include types of sites where it can be used.

The label must list specific microorganisms that this product is effective against. Choose a product that will be effective against specific microorganisms of interest.

Things to Know About

Disinfectants

Any product that makes public

health claims like “kills household germs”

or kills microorganisms (bacteria, fungi,

viruses) must be registered by EPA and

display the following information on the

label:

EPA registration number

The names of the microorganisms it is

designed to kill

How the product should be used,

including types of surfaces

How long the product must be left on

the surface in order to work (contact

time or dwell time)

Certain precautionary statements

regarding safety and health

Choose the least toxic product by avoiding these signal words on the label: Danger, Warning, or Caution. Hydrogen peroxide based disinfectants are desirable because many formulations do not contain these signal words, and do not produce irritating vapors or odors.

Follow Label Directions for Contact Time

Be sure to leave the disinfectant on the surface for the amount of time specified on the label (contact time or dwell time) to be sure it works.

Connecticut Department of Public Health

Environmental & Occupational Health Assessment Program

860-509-7740 http://www.ct.gov/dph/ieq

Cleaning & Disinfecting Indoor Spaces October 2014 Page 2

To check a product label to be sure all of these

requirements are satisfied, go to this website:

http://pims.psur.cornell.edu/ProductName.php

Type in a product name, search, then go to the far right and click on NYS to get a picture of the actual label. You can see the EPA reg no., list of microbes, contact time, and other information.

See example below.

Specific advice about disinfecting indoor

spaces for Enterovirus D68 and Ebola

Virus from the US Centers for Disease

Control (CDC) and Environmental

Protection Agency (EPA)

There are no disinfectants approved for use against Enterovirus D68 or Ebola virus at this time, because manufacturers do not have these viruses to perform the efficacy tests required for EPA registration. CDC and EPA recommend using disinfectants effective against viruses in the same classes. Therefore, choose:

EPA-registered hospital disinfectants with label claims against non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus), which are broadly antiviral and capable of inactivating both enveloped and non-enveloped viruses.

Further Specific Disinfection Information:

Enterovirus D68: http://emergency.cdc.gov/han/han00369.asp

Ebola Virus: http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html

Cleaning Strategies for Spills of Blood

and Body Substances

Strategies for cleaning and disinfecting blood, vomit, feces, and other body secretions found on environmental surfaces will differ based on how much material needs to be cleaned up, and the type of setting in which the incident occurs. In general, the CDC recommends the following:

1. Put on disposable gloves. Respiratory protection (N-95 respirator) should be worn if the cleaning process is expected to generate aerosols.

2. Remove visible matter (blood, vomit, feces, etc.)

with absorbent materials like disposable paper towels. Discard into leak-proof containers (zip-lock bags will work).

3. Clean area with detergent or commercial all-purpose cleaning agent, following directions on the label.

4. Disinfect the surface using an EPA - registered hospital disinfectant effective against Norovirus. Leave the product in place for the amount of time listed on the label. Some labels may include longer contact times for blood and body fluids.

5. Alternatively, after removing the human material, then using an all-purpose cleanser, household bleach may be used to disinfect the area. Mix 1 part bleach + 9 parts water into a clean container. DO NOT USE STRAIGHT BLEACH– more is not better, it can be harmful. Try to use fresh bleach. Leave this solution in place for at least 10 minutes.

Connecticut Department of Public Health

Environmental & Occupational Health Assessment Program

860-509-7740 http://www.ct.gov/dph/ieq

Cleaning & Disinfecting Indoor Spaces October 2014 Page 3

CT DPH Contacts:

Infectious Disease Questions: Epidemiology Program: 860-509-7994

Cleaning & Disinfection Questions: Environmental & Occupational Health Assessment Program: 860-509-7740 Food Service Facility Questions: Food Protection Program: 860-509-7297 (For specific information about regulations for food service areas and management of facilities involved in a foodborne disease outbreaks)

Please note:

School guidance is provided in a separate document, Cleaning Schools Effectively, The Safe and Healthy Way: Guidance for Superintendents and Facility Managers.