JUNE 2023

EMS INFECTIOUS
DISEASE PLAYBOOKVERSION 2.0

This document was created in 2017 using official or best practiceinformation taken from multiple organizations that was vetted andassembled by subject matter experts working for the TechnicalResources, Assistance Center, and Information Exchange (TRACIE)
at the request of the U.S. Department of Health and Human Services(HHS) Administration for Strategic Preparedness and Response (ASPR).
The aim was not to develop novel guidance for emergency medical
services (EMS) agencies, but to unify multiple sources of information
in a single, concise planning document addressing the full spectrum of
infectious agents for EMS agencies developing their service policies.
This document does not represent official policy of HHS ASPR or otherfederal or private agencies.
The information contained in this playbook is intended as a planningresource and should be incorporated into agency standard operatingprocedures and reviewed by the EMS medical director. EMS agencies
should review the playbook and understand that while the core
principle is preventing exposure to potentially infectious body fluids,
there are multiple types of personal protective ensembles that may
be appropriate based on the biological threat. Donning and doffing
procedures are dependent on the personal protective equipment(PPE) ensemble selected. Appropriate education and training are
critical to the success of infection prevention and control protocols.
The authors, ASPR TRACIE, and HHS ASPR do not take responsibility
or bear liability for any clinical care outcomes, provider injury/illness,or inaccuracies in or resulting from this document. The playbook wasrevised in 2023 (with links updated in 2024) and all recommendations
were current at the time of publication and vetted to the best of
our ability.
Inclusion of specific references and resources is offered as an
acknowledgement of their contribution of material and for additional
information for EMS planners but does not constitute endorsement orvouch for accuracy or applicability of the referenced documents.

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D I S PATCH/RE SPO NDE R ACTIO NSS TA N DARD PRE CAUTIO NSC O N TACT PRECAUTIO NS

D R O P L ET PRE CAUTIO NS

A I R B ORNE PRE CAUTIO NSS P E C IAL RESPIRATO RY PRECAUTIO NS

E V D - V HF PRE CAUTIO NSS P E C IAL CO NSIDE RATIO NSR E F E RE NCE S

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G E NER A L PR IN CIPLES – CA LL TA K ING / D IS PATCH•

Safe response by EMS requires an integrated approach, including: appropriate
information from the caller and dispatcher; appropriate protocols for response, clinicalcare, application of administrative and environmental controls and use of PPE by EMS
responders; and transport to a health care facility that can provide effective evaluation andtreatment of the suspected condition.

•

Ideally, 911 call takers/emergency medical dispatchers will identify patients with apotentially infectious disease through integrated routine screening questions and relay that
information to emergency responders prior to their arrival on the scene.

•

During the caller interrogation, if information about communicable diseases is offered, calltakers ensure the information is documented and relayed to responders in accordancewith established policies/protocols on how to share patient-related information.

•

Screening for suspected high consequence infectious diseases (HCID) often involves
questioning the caller/patient about recent international travel and presenting signs andsymptoms. The timeframe for these conditions varies (e.g., 14 days for Middle East
Respiratory Syndrome [MERS], 21 days for Ebola Virus Disease [EVD]). The playbook uses
21 days in the general screen for consistency since this timeframe is inclusive of the HCIDs
but can be adjusted as required if screening for specific pathogens.

•

Local screening questions may be needed during outbreaks and can be inserted into
the dispatch algorithm and keyed to the appropriate precautions. EMS agencies should
consult with local and state public health and EMS authorities to identify required
modifications to processes and protocols to ensure consistency with Centers for Disease
Control and Prevention (CDC) guidance.

•

If persons under investigation for a HCID are known to public health, it may be beneficial
for public safety to enter a temporary note on their address in the computer-aided
dispatch (CAD) system to alert 911 responders to the potential for illness/exposure. Thisis a local decision dependent on the systems and policies in the community and the noteshould be removed once the infectious period has passed.

•

Fever may be a helpful contributing sign or symptom but should not be used to exclude
the presence of communicable disease as it is not universally present.

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G E NER A L PR IN CIPLES – R ES PO N S E•

Regardless of dispatch information, EMS responders should be vigilant for travel history
and signs and symptoms of communicable disease (e.g., fever, cough, gastrointestinal [GI]symptoms, unusual rash). Standard precautions should always be used with the additionof appropriate transmission-based precautions whenever history or exam findings warrant.

•

EMS responders should implement strict standard and transmission-based precautions
based on the patient’s clinical information to avoid exposure to potentially infectious bodily
fluids, droplets, and airborne particles.

•

Responders should avoid direct contact with a patient who may have a communicabledisease until they are wearing appropriate PPE.

•

Maintaining distance from the patient and increasing fresh air circulation can reduce
respiratory transmission. Maintaining a distance of at least six feet is generally
recommended unless specific PPE is worn.1•

Responders should understand and practice with PPE so they can efficiently and safely
don and doff the equipment without self-contamination.

•

Patients, caregivers, and bystanders may find responders wearing high levels of PPE
such as hoods, suits, and respirators alarming. Communicating with and calming anxious
persons may be more challenging due to PPE. Responders should be mindful of thisand be prepared to provide reassurance and to address public distress and fear. Hand
gestures and other non-verbal actions may help with reassurance as it may be difficult forothers to hear responders.

•

Limit the number of EMS responders in direct contact with a potentially infectious patientto the minimum required to perform tasks safely.

The maximum distance for droplet transmission is unresolved and many illnesses are not strictly droplet or
aerosol transmitted but involve both. The recommendation to maintain a distance of 6 feet or more is usedthroughout this document to be uniform. The CDC review https://www.cdc.gov/infection-control/hcp/isolationprecautions/scientific-review.html provides additional details.
1

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EMS must be able to implement effective infection control practices for responder
safety while avoiding excessive delays in care. Training and practice should allow
EMS responders to provide lifesaving medical care without waiting for a specialized
response team.

•Specialized transport should be reserved for stable patients with a suspected HCID
(e.g., EVD, Marburg Virus Disease [MVD], Smallpox) or for inter-facility transport of thosepatients with a suspected or confirmed HCID. Communities may also have dedicatedmedical transport services equipped to manage HCID patients built into their regionaltransportation plans for planned patient movements.

•

Hand hygiene (e.g., handwashing with non-antimicrobial soap and water, alcohol-based
hand rub [ABHR], or antiseptic handwash) is one of the best ways to remove pathogens,avoid getting sick, and prevent the spread of pathogens to others. (Note that ABHRs
do not protect against spores such as Clostridium difficile [C. difficile] and efficacy fornorovirus is incomplete and depends on formulation.)•

Placing a surgical mask2 on the patient (for source control) helps to contain infectious
respiratory droplets and is recommended if tolerated. Patients unable to tolerate a mask
should: cover their nose and mouth when coughing or sneezing; use tissues to containrespiratory secretions (and, after use, dispose them in the nearest waste receptacle); andperform hand hygiene after having contact with respiratory secretions and contaminatedobjects or materials.

•

Influenza and other diseases can transmit via the ocular surfaces as well as other mucous
membranes. Responders should use PPE to protect the mucous membranes of the eyes,
nose, and mouth during procedures and patient care activities that are likely to generatesplashes or sprays of blood, body fluids, secretions, and excretions. Select masks,
goggles, face shields, and combinations of each according to the need anticipated by thetask performed.

The term surgical mask is used for simplicity and includes additional masks that are medical grade, flexible
fabric, half-face mask with multiple layers and water-resistant surface suitable for standard or droplet
precautions. When used for source control (as in this example) the material does not need to be water-resistant.
2

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Infection control practices can evolve with novel and emerging pathogens or during
infectious disease outbreaks or epidemics. The EMS agency must be aware of how thesechanges may affect employees and adjust policies and practice accordingly.3•

EMS agencies should practice their response to a patient with a suspected or confirmed
HCID with health care facilities and state, local, tribal, and territorial public health entities.

3

The CDC maintains a web page with information on current outbreaks at https://www.cdc.gov/outbreaks/.

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DISPAT C H SC REENING A L GORI T HM **Dispatch screening is designed to suggest the highest potential level of precautions that may be required.
On-scene evaluation is required to adjust precautions according to history and exam. Transmission based
precautions are always accompanied by standard precautions.
Precautions
to Consider:

Examples

911 Call for Illness/
Sick Person

Local
Infectious Disease
Outbreak or
Epidemic Screening
Questions

Yes

Specific Exposure
and/or Symptoms

Yes

Disease-Specific
Precautions

No
No
Yes

EVD/VHF

EVD/VHF
Precauons

Yes

MERS/COVID-19/
Novel Influenza

Special Respiratory
Precautions

International Travel/
Illness Screening
Questions

No Specific Syndrome Identified

Cough/RespiratorygpyInfection
Infec
ction
InfeconYes

TB/Chickenpox/
Measles Exposure/
Risk

No

Vomiting/Diarrhea

Yes

No

Yes

Airborne
Precautions

Droplet Precautions

Contact
Precauons

No

Other Symptoms

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Standard
Precautions

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NOTES O N THE D IS PATCH SCR EE NING A LGOR ITHM:•

EMS agencies should have an individual designated to be the point of contact for publichealth and to monitor available resources (e.g., CDC website, health alerts) for outbreaks ofconcern and communicate to all crews relevant information about potential cases, signs,
and symptoms.

•

Basic travel and symptom screening offers guidance on a level of transmission-based
precautions for responders. Additional evaluation is required on-scene to determine theappropriate transmission-based precautions, which may affect the PPE needed (either
increased or decreased) for the responder.

•

If a medically trained dispatcher is not available, these screening questions may still be
used. Best practice would incorporate these questions into the emergency medical dispatch
algorithm. The responding personnel may also be able to establish contact with the patient/caller via a callback number to gather additional information. EMS systems should tailor thesefunctions and adopt processes appropriate for their structure and staffing.

•

Because many respiratory diseases generate both droplet nuclei and airborne particulates
and because EMS will not usually know the specific pathogen, EMS services may opt to use
respirators rather than surgical masks for illnesses in situations of uncertainty.

•

Responders should be aware of infectious disease outbreaks or epidemics in theircommunity and, based on a “doorway evaluation,” be prepared to rapidly adopt appropriate
infection control precautions in accordance with established public health guidelines.

A D D ITIO N A L D IS PATCH CO N S ID ER ATIO N S
The following information may be used to update/modify dispatch reference cards:•

Call taker obtains location (and phone number) and patient status information (e.g., age,consciousness, whether breathing normally).
»

Implement dispatch life support to include giving the caller instructions to help treat
the patient until the responding EMS unit arrives per service protocols.

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Subsequent “chief complaint” information regarding type/severity of medical emergency:»•

Consider modifying the response to “ambulance only” for calls involving patientswith a suspected HCID (EVD/viral hemorrhagic fever [VHF] or Special Respiratory
Precautions) based on travel or exposure history (i.e., cancel first responder unlessunconscious, difficulty breathing, or other immediate life threat).

Chief complaint – If illness-related 911 call, additional screening questions include:–

Priority symptoms – severe bloody vomiting or diarrhea (e.g., large amounts of GI
blood loss), decreased level of consciousness, respiratory difficulty, chest pain.

–

Pertinent medical history - any known illness or exposures to Methicillin-resistant
Staphylococcus aureus (MRSA), tuberculosis (TB), C. difficile, COVID-19,
norovirus, etc.

–

Pertinent travel history - any international travel within the previous 21 days.

For the following specific chief complaints, the call taker should ask additionalquestions and provide emergency medical dispatch instructions as indicated:»

Breathing problems»

Cardiac/respiratory arrest»

Chest pain»

Convulsions/seizure»

Headache»

Hemorrhage (non-traumatic)»

Sick person»

Unconscious/fainting (or near)»

Unknown problem (person down)

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Additional questions:•»

Is there anyone else on-scene who is also sick?

»

Are there any known exposures to a diagnosed disease?

»

In the last two days any:–

Fever or chills?

−

Vomiting or diarrhea?

–

Severe cough?

−Active bleeding?

For any positive questions, the emergency medical dispatcher will alert first responders and
EMS providers being dispatched of potential for a patient with a communicable disease andto implement infection control measures as indicated. This designation is preliminary andresponders may be able to adjust precautions based on further information from the patient/family. If language barriers prevent questions, the dispatcher should advise the crew that theycannot rule out an infectious patient.
Implement emerging infectious disease surveillance tool4 whenever a novel or dangerous
disease is endemic in specific areas.

4

Example: Emerging Infectious Disease Surveillance Tools (COVID-19)

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ON-SCENE ASSESSMENT
ALGORITHM
ConsiderEVD/VHF with travel/exposure history - E
Norovirus with exposure history - C
C. difficile with history/diagnosis - C
Otherwise - S

Fever, flu-like

ConsiderNovel influenza, MERS, or similar with travel or exposure history - SR
Influenza - D
Strep pharyngis - D
Otherwise - S
COVID-19 - A, C, face shield

Cough/respiratory

ConsiderNovel influenza, MERS, similar with travel or exposure history - SR
Pneumonia - D for many causes
TB with diagnosis or risk factors - A
Otherwise - D

Skin

ConsiderLarge open wounds, drainage - C
Measles - exposure or typical rash - A
Zoster with open lesions - A, C
Chickenpox - A, C
Meningococcal disease (purpuric rash to extremies, usually very ill) - D
Mpox - A, C, face shield
MDR Shigella - CPrioranbioc-resistantinfecon

ConsiderMRSA - C
Vancomycin-resistant enterococci - C

GISigns/Symptoms

Type of Precauons(Transmission-based precauons are always accompanied by standard precauons.)

S Standard

C Contact

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D Droplet

A Airborne

SR Special Respiratory

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FIR ST R ES PO ND ER S A ND EMS R ES PO ND ERS•

Responders should:»

Have access to and monitor radio or CAD for alerts regarding potential risks.

»Ask dispatch/the communications center for additional information if needed.

»

Identify patients who may be infected with a communicable disease by verbal
screening, noting symptoms, and recognizing potential hazards.

»

Upon recognizing a patient with a suspected communicable disease, notify dispatch/the communications center to ensure the enroute ambulance responders areprepared to implement appropriate infection prevention and control measures.

»

Apply PPE appropriate for the patient’s condition prior to making direct
patient contact.

»

For patients with respiratory illnesses, attempt to conduct the interview at least 6 feetaway from the patient as this may provide some protection.

»

Ask any patient with respiratory symptoms to wear a surgical mask if they cantolerate it.

»

Limit the number of EMS responders making patient contact to the minimum
required to perform tasks safely. Consider the strategy of one responder putting on
PPE and managing the patient while the other responder does not engage in direct
patient care but instead provides the “doorway evaluation” and communications/charting. The second responder should be prepared to quickly don the appropriate
PPE should the first responder require assistance.

»

Avoid unnecessary direct contact with the patient.

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Use caution when approaching a disoriented or delirious patient as erratic behavior(e.g., flailing or staggering) can place EMS responders at additional risk of exposure.

»

Keep nonessential equipment away from the patient or patient’s environment tominimize contamination on the scene and in the ambulance.

»

If patient has nausea or vomiting, treat symptoms per protocols, provide emesis bag,and contain any emesis.

»

For profuse diarrhea, consider asking the patient to wear an absorbing undergarment
and/or wrapping the patient in an impermeable sheet to reduce contamination ofother surfaces.6»

Choose a receiving facility appropriate for the suspected disease (based on regional
HCID plans as appropriate) and alert them about the patient, suspected condition,
current symptoms, and estimated time of arrival (ETA) as early as possible.

»

Contact medical control with questions or for additional guidance.

For geographically associated HCIDs (e.g., VHF), the public health or EMS medical authority
may request responders ask additional screening questions about:
1. Travel history and/or direct exposure to potential case within the number of days of the
incubation period for the illness of interest.
2. Specific signs and symptoms of illness.
Responders should contact the EMS or public health authority for guidance about family
members or close patient contacts who may be at the scene.

6

NETEC offers a training video on the use of a containment wrap in a special pathogen isolation area.

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GE NE R A L P P E C O N S I DERATIO NS
The following is a list of PPE referred to throughout this document. This is a suggested list
only. Quantities and exact PPE stocked are dependent on ambulance service protocols
and transport volumes/patient population. Modifications may be necessary for specialized
transport units or during specific epidemics/pandemics.
•

Disposable exam gloves – standard gloves for standard precautions.

•

Disposable exam gloves – with elongated cuffs for use with barrier gowns/coveralls.

•

Reusable goggles that can be cleaned OR face shield.

•

Surgical masks for patients and responders.

•

Disposable fluid-resistant gown OR disposable fluid-resistant coverall.

•

Disposable National Institute for Occupational Safety and Health (NIOSH)-approved,
fit-tested, disposable N957 or equivalent/higher level respirator (e.g., reusable half-faceelastomeric respirator N95 or higher rating mask or powered air purifying respirator[PAPR] with full hood and high-efficiency particulate air [HEPA] filter).

•

Disposable boot/shoe covers.

EVD/VHF Precautions – additional equipment required:•

Full face shield (plus consideration of a head cover).

•Respiratory protection options:»N95 respirator worn with impermeable hood that covers head and shoulders and fullface shield.

»

PAPR with HEPA filtration and integrated impermeable drape-style hood.

•

Boots (disposable or reusable).

•

Fluid-resistant coverall – if service uses gowns for other contact exposures.

•

OPTION: Disposable, impermeable apron in addition to fluid-resistant coverall for
unstable or “wet” patients.

7

Throughout this document, disposable N95 respirators should be NIOSH-approved and fit tested.

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Dispatch/Responder Actions
R E SO U R C E S­ CDC Current Outbreak List
­ Containment Wrap in a Special Pathogen Isolation Area
­ Emerging Infectious Disease Surveillance Tool (COVID-19)­ Interim Guidance for EMS Systems and 9-1-1 Answering Points­ Protocol 36: Pandemic/Epidemic/Outbreak­ Review of Scientific Data Regarding Transmission of Infectious Agents in Healthcare Settings

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Standard Precautions
E X A MPLE D IS E AS ES
Acquired immune deficiency syndrome (AIDS)/human immunodeficiency
virus (HIV) ∙ anthrax (cutaneous or pulmonary) ∙ botulism ∙ cellulitis ∙dengue ∙ minor wound infections including abscess ∙ nonspecific upper
respiratory infections.

GOA L OF PR ECAUTIO N S
Apply standard practice to protect against contact with blood, body
fluids, non-intact skin (including rashes), and mucous membranes for all
patient encounters. Examples include routine use of hand hygiene andgloves and adding eye protection and mask when caring for patients withrespiratory symptoms and during airway interventions, or gown for potential
splash exposures.

D IS PATCH ACTIO N S

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Resource assignment: Usual assignment of first responders
and appropriate basic life support (BLS)/advanced life support(ALS) response.

•

Patient instructions: Usual pre-arrival instructions (e.g., turn on porch
light, control animals, gather medications).

•

Crew instructions: Advise responding crew of patient illness/symptoms.

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A R R IV ING EM S ACTIO N S /CO N S ID ER ATIO N S•

Assess patient upon arrival from a distance of at least six feet if possible.

•

Adjust infection prevention precautions as required.

•

Perform hand hygiene before and after patient care activities.

PPE

8

•

Gloves during patient contact for any potential exposure to infectious
agents or bodily fluids.

•

Goggles/face shield and surgical mask for any airway procedures(intubation, suctioning) or patient with active cough from apparent
infectious source and to protect mucous membranes from splash/liquid exposure.

•

Impermeable gown for any situation likely to generate splash/liquid exposures.

•

Consider using a checklist or graphic to assist with proper donningand doffing.8•

PPE should be removed in an appropriate doffing area to prevent
secondary contamination. Meticulous care should be taken to avoid
self-contamination. PPE waste should be placed in a labeled leakproof container.

•

Potential exposures should be reported according to existing
service protocols.

Example: Sequence for Donning and Removing Personal Protective Equipment

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PATIE NT CA R E CO N S ID ER ATIO N S•

Provide a surgical mask for all patients with acute infectious respiratory
symptoms who can tolerate it.

•

Provide tissues to patients for secretion control and encourage patient
hand hygiene and cough etiquette practices.

TR A N S POR T CO N S ID ER ATIO N S•

Standard transportation to appropriate health care facility.

•

If the patient compartment is equipped with an exhaust fan, ensure that
it is turned on.

A MBUL A N CE D ECO NTA MIN ATIO N

9•

Any visibly soiled surface must first be cleaned and decontaminatedusing an Environmental Protection Agency (EPA)-registered9 disinfectant
according to directions on the label.

•

Disinfect all potentially contaminated/high touch surfaces including thestretcher with an EPA-registered disinfectant according to directions on
the label.

•

Medical equipment (e.g., stethoscope, blood pressure [BP] cuff) making
patient contact should be disposable or cleaned and disinfected before
use on another patient.

Selected EPA-Registered Disinfectants is relevant to all mentions of EPA-registered disinfectants in this document.

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Standard Precautions
R E SO U R C E S­ Considerations for Selecting Protective Clothing used in Health care for Protection
against Microorganisms in Blood and Body Fluids­ Guideline for Isolation Precautions 2007
­ Selected EPA-Registered Disinfectants­ Sequence for Donning and Removing Personal Protective Equipment­ Standard Precautions for All Patient Care

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Contact Precautions
E X A M P L E DISE ASES
Excessive wound drainage ∙ MRSA ∙ Vancomycin-resistant enterococci(VRE) ∙ C. difficile ∙ norovirus* ∙ other suspected infectious diarrhea ∙head lice/body lice/scabies ∙ respiratory syncytial virus (RSV)*.

GOA L OF PR ECAUTIO N S•

Provide impermeable barriers to infectious agents that are either
highly pathogenic, drug resistant, contagious, or persistent andthat can easily be contracted or spread to other environments via
fomites and surface contact.

D IS PATCH ACTIO N S•

Resource assignment: Usual assignment of first responders andappropriate BLS/ALS response.

•

Patient instructions: Usual pre-arrival instructions (e.g., turn on porch
light, control animals, gather medications).

•

Crew instructions: Advise responding crew of patient illness/symptoms.

*Wear mask during vomiting/diarrhea if norovirus is suspected. Also wear mask if RSV is suspected.

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A R R IV ING EM S ACTIO N S /CO N S ID ER ATIO N S•

Be aware of any community-based outbreaks of norovirus, RSV, orother epidemic disease requiring contact precautions and obtainrelevant history as indicated.

•

Assess patient upon arrival from a distance of at least six feet if possible.

•»

Inquire specifically about C. difficile and MRSA history.

»

Look for evidence of infestation or large open draining wounds.

Adjust infection prevention precautions as required based on symptoms(e.g., add protection for the eyes, nose, and mouth by using a mask
and goggles or face shield when it is likely that there will be a splashor spray of any respiratory secretions or other body fluids as defined instandard precautions).
»•

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Not all GI illness requires contact precautions, but since norovirus
and C. difficile (among others) do, consider maintaining contact
precautions unless clearly not required (and can assume standard
precautions at that point).

Perform hand hygiene before and after all patient care activities. Thisshould involve hand washing or alternative methods that do not relyon alcohol-based solutions that may not be effective against norovirus
or C. difficile.

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Contact Precautions
PPE•

Consider using a checklist or graphic to assist with proper donningand doffing.

•

Report potential exposures according to existing service protocols.

Type:
•

Disposable fluid-resistant gown that protects the provider’s legs without
becoming a trip hazard or consider disposable fluid-resistant coveralls.

•

Disposable gloves.

•

Ensure strict adherence to standard precautions based on situation(e.g., mask, goggles/face shield for splatter risk or airway interventions).

Donning:
1. Personal items (e.g., jewelry [including rings], watches, cell phones,pens) should ideally be removed and stowed. Long hair should be tiedback. Eyeglasses should be secured with a tie.
2. Inspect PPE prior to donning to ensure not torn or ripped, that all
required supplies are available, and that correct sizes are selected forthe responder.
3. Perform hand hygiene; allow hands to dry before moving to next step
4. Put on gown or coverall. Ensure large enough to allow
unrestricted movement.
5. Put on gloves. Ensure the cuffs are pulled over the sleeves of the gown
or coverall and are tight.
6. After donning, the integrity of the ensemble should be verified. The
responder should go through a range of motions to ensure sufficient
range of movement while all areas of the body remain covered.

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Contact Precautions
Doffing:
Remove PPE only in an appropriate doffing area. Meticulous care should
be taken to avoid self-contamination. PPE waste should be disposed of inaccordance with medical waste protocols.
1. Inspect the PPE for visible contamination, cuts, or tears before removal.
If visibly soiled, remove the PPE in a manner that avoids contact withthe contaminated surface. If cut or torn, assess for soilage of underlying
garment or skin after removal.
2. Remove gown or coverall and discard.
•

Gown: Depending on gown design and location of fasteners,
the responder can either untie or gently break fasteners. Pull
the gown away from the body, being careful not to touch theinside with hands. Once the gown is off shoulders, pull the gown
down one arm and then the other. Roll the gown inward while
progressing downward.

•

Coverall: Tilt head back to reach zipper or fasteners. Unzip or
unfasten completely before rolling down while turning inside out.
Avoid other contact with outer surface of coverall during removal,
touching only the inside of the coverall.

•

Dispose of gown or coverall per medical waste protocols.

3. Inspect the glove outer surfaces for visible contamination, cuts, or tears.
•

Back to Contents

Visible contamination, cut, or tear: If glove is visibly soiled, remove
the gloves in a manner that avoids contact with the contaminatedsurface. Wash hands with soap and water if visibly soiled. Perform
hand hygiene with ABHR on bare hands. If the glove is cut or torn,
inspect the underlying skin for abrasion or break in the skin, contact
supervisor, and follow service exposure guidelines.

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Contact Precautions•

No visible contamination, cuts, or tears: Remove the gloves andperform hand hygiene, ideally with hand washing as ABHR is
helpful but not sufficient for norovirus or C. difficile.10

4. Perform hand hygiene.
•

Visibly dirty, contaminated, or soiled with blood or body fluids: Wash
hands with soap and water, then perform hand hygiene with ABHR.

•

Not visibly soiled: Perform hand hygiene with handwashing; use
ABHR if handwashing is not available.

5. Inspect for any contamination of the responder uniform. If there iscontamination, secure the garment for cleaning. Contaminated clothingshould be washed or discarded in accordance with pathogen-specificguidelines, generally with hot water, usual detergent, and the addition ofhousehold bleach as appropriate for the garment.

PATIE NT CA R E CO N S ID ER ATIO N S•

Provide anti-emetics per service clinical care guidelines.

•

Cover draining wounds with adequately absorbent dressings.

•

Anticipate additional stool/vomitus to reduce contamination of the
responder and the ambulance (emesis bags, towels available, and/or impermeable sheet placed on stretcher). Consider the use of acontainment wrap.

ABHR do not kill the spores of C. difficile and are variably effective for norovirus depending on the formulationand concentration.
10

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Contact Precautions
TR A N S POR T CO N S ID ER ATIO N S•Consider applying an impermeable barrier sheet to the patient to protect
the responder and environmental surfaces in the presence of excessive
wound drainage, fecal incontinence, or other discharges.

•

Advise receiving hospital of patient on contact precautions who should
preferably be transported to a private room.

A MBUL A N CE D ECO NTA MIN ATIO N

Back to Contents•

Any visibly soiled surface should be cleaned using an EPA-registereddisinfectant according to directions on the label.

•

Medical equipment (e.g., stethoscope, BP cuff) making patient contact
should be disposable or cleaned and disinfected before use on another
patient. Other visibly contaminated equipment should similarly be cleaned
and disinfected.

•

Confirmed or suspected C. difficile infection decontamination should utilize
hypochlorite solutions. EPA-registered disinfectants with sporicidal activity
may be sufficient but limited data is available.

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Contact Precautions
R E SO U R C E S­ C. diff: Facts for Clinicians­ Considerations for Selecting Protective Clothing used in Health care for Protection
against Microorganisms in Blood and Body Fluids­ Guidelines for Isolation Precautions 2007
­ Sequence for Donning and Removing Personal Protective Equipment­ Selected EPA-Registered Disinfectants

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Droplet Precautions
E X A MPLE D IS E AS ES
Neisseria meningitidis ∙ mumps ∙ mycoplasma ∙ streptococcal andmany other causes of pneumonia ∙ parvovirus ∙ pertussis ∙pneumonic plague ∙ rhinovirus ∙ rubella ∙ seasonal influenza ∙streptococcal pharyngitis.

GOA L OF PR ECAUTIO N S•

Protection of responder’s mucous membranes and respiratory systemfrom exposure to potentially infectious droplets during direct patientcare activities.

D IS PATCH ACTIO N S

Back to Contents•

Resource assignment: Usual assignment of first responders andappropriate BLS/ALS response except in infectious disease outbreakor epidemic situation consider restricting first responders if no lifethreatening symptoms (chest pain, difficulty breathing, altered mental
status) present.

•

Patient instructions: Usual pre-arrival instructions (e.g., turn on porch
light, control animals, gather medications, ask patient to wear a mask ifthey have one and can tolerate it).

•Crew instructions: Advise responding crew of patient illness/symptoms.

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Droplet Precautions
A R R IV ING EM S ACTIO N S /CO N S ID ER ATIO N S•

Be aware of any community-based outbreaks of influenza or otherepidemic disease requiring droplet precautions and obtain relevant
history as indicated.

•

Assess patient upon arrival from a distance of at least six feet if possible.
»

Inquire specifically about influenza or other specific exposures.

•

Adjust infection prevention precautions as required based on
symptoms/ history. Maintain strict adherence to standard precautions.

•

Perform hand hygiene before and after all patient care activities.

PPE•

Consider using a checklist or graphic to aid PPE compliance.11•

PPE should be removed in an appropriate doffing area to prevent
secondary contamination. Care should be taken to avoid selfcontamination. PPE waste should be placed in an appropriate container.

•

Report potential exposures according to existing service protocols.

Type:

11

•

Disposable surgical mask (N95 respirator not required but optional per
service protocols).

•

Disposable gloves.

•

Eye protection – goggles or face shield.

Example: Sequence for Donning and Removing Personal Protective Equipment

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Droplet Precautions
Donning:
1. Select gloves and mask and inspect to ensure not torn or ripped andthat they are the correct size.
2. Perform hand hygiene with ABHR; allow hands to dry before moving tonext step.
3. Put on gloves.
4. Put on eye protection if using.12
5. Put on surgical mask.

Per CDC, no recommendation for routinely wearing eye protection, but influenza and other diseases cantransmit via the ocular surfaces as well as other mucous membranes. Use PPE to protect the mucous
membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely togenerate splashes or sprays of blood, body fluids, secretions, and excretions. Select masks, goggles, faceshields, and combinations of each according to the tasks performed or anticipated.

12

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Droplet Precautions
Doffing:
Care should be taken to avoid self-contamination when removing mask andgloves. Appropriately dispose of PPE.
1. Inspect PPE for visible contamination, cuts, or tears before starting to
remove. If visibly soiled, remove the PPE in a manner that avoids contact
with the contaminated surface. If cut or torn, assess for soilage ofunderlying garment or skin after removal.
2. Remove and discard gloves, taking care not to contaminate hands whenremoving the gloves. Dispose of gloves in accordance with medical
waste protocols.
3. Remove eye protection: Remove by strap; avoid touching the front surfaceof the eye protection. Perform hand hygiene with ABHR. Reusable
goggles must be thoroughly cleansed and disinfected with EPA-registereddisinfectant wipes.
4. Remove the surgical mask by tilting the head slightly forward, grasping
the elastic straps, sliding them off the ears/head, and removing the mask
without touching the front fabric. Dispose of the mask.
5. Perform hand hygiene: If hands are visibly dirty or soiled with blood orbody fluids or other material, wash hands with soap and water, thenperform hand hygiene with ABHR. If hands are not visibly soiled, simply
perform hand hygiene with ABHR.
6. Inspect for any contamination of the responder uniform. If there iscontamination, remove the soiled garment and secure it for cleaning.
Contaminated clothing should be washed or discarded in accordancewith disease-specific guidelines, generally with hot water, usual detergent,and the addition of household bleach as appropriate for the garment.

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PATIE NT CA R E CO N S ID ER ATIO N S•

Provide a surgical mask for all patients with acute infectious respiratory
symptoms who can tolerate it.

•

Provide tissues to patients for secretion control and encourage patient
hand hygiene and cough etiquette practices.

•

Responders not in appropriate PPE should maintain a distance of atleast 6 feet from the patient and should wear gloves to guard against
infectious agents on the surfaces of objects close to the patient.

•

Minimize use of nebulizers to avoid aerosolization of respiratory droplets;
consider metered dose inhalers instead.

•

Minimize airway interventions that may cause coughing (e.g., suctioning)
to degree possible.

TR A N S POR T CO N S ID ER ATIO N S

Back to Contents•

Standard transportation.

•

Consider having the patient compartment exhaust vent on high andisolating the driver compartment if performing aerosol generatingprocedures (airway suctioning, intubation, aerosolized medication
administration, non-invasive positive pressure ventilation). Increase
ventilation by having air or heat on non-recirculating cycle and/or
opening windows.

•

Advise receiving hospital of respiratory symptoms and that a private (butnot negative pressure) room is preferred.

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Droplet Precautions
A MBUL A N CE D ECO NTA MIN ATIO N•

Any visibly soiled surface should be cleaned using an EPA-registereddisinfectant according to directions on the label.

•

Disinfect all potentially contaminated/high touch surfaces including thestretcher with an EPA-registered disinfectant according to directions on
the label.

•

Medical equipment (e.g., stethoscope, BP cuff) making patient contact
should be disposable or cleaned and disinfected before use on
another patient.

R E SO U R C E S­ Guidelines for Isolation Precautions 2007
­ Sequence for Donning and Removing Personal Protective Equipment­ Selected EPA-Registered Disinfectants

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A ir bor ne Precautions
E X A MPLE D IS E AS ES
Measles ∙ TB (suspected or confirmed pulmonary or laryngeal) ∙ varicella(chickenpox).

GOA L OF PR ECAUTIO N S•

Provide respiratory protection against inhalation of potentially infectious
suspended droplet nuclei/aerosols (agents suspended in the air that are
respirable and remain infectious over long distances).

D IS PATCH ACTIO N S

Back to Contents•

Resource assignment: Consider restricting assignment to ambulance
only if no life-threatening symptoms (chest pain, difficulty breathing,altered mental status) present and high suspicion for airborne disease to
decrease first responder exposure.

•

Patient instructions: Usual pre-arrival instructions (e.g., turn on porch
light, control animals, gather medications, ask patient to wear a mask ifthey have one and can tolerate it).

•Crew instructions: Advise responding crew of patient illness/symptoms
and concern for airborne transmissible infection.

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A ir bor ne Precautions
A R R IV ING EM S ACTIO N S /CO N S ID ER ATIO N S•

Be aware of any community or institution-based outbreaks of TB,
measles, or other disease requiring airborne precautions and obtainrelevant history as indicated.

•

Assess patient upon arrival from a distance of at least six feet if possible.
»

Inquire specifically about TB, measles, or other relevant exposures.

•

Wear appropriate respiratory protection when making patient contact
or interacting with patient in a closed space. Adjust infection prevention
precautions as appropriate based on symptoms and exposure
history. Change to standard (or droplet) precautions if not significantly
concerned about airborne spread. Maintain strict adherence tostandard precautions.

•

Perform hand hygiene before and after patient care activities.

PPE•

Consider using a checklist to assist with proper donning and doffing.

•

Report potential exposures according to existing service protocols.

Type:
•

•

Back to Contents

Disposable NIOSH-approved, fit-tested N95 respirator.
»

EMS agencies often use PAPRs with full hood and HEPA filter for
airborne precautions for employees who cannot safely fit test on
N95 respirators due to facial hair, facial structure, and other factors.

»

For the purposes of consistency and simplicity, the use of respirators
for all infectious agents known to be transmitted by infectious
aerosols is recommended.

Disposable exam gloves.

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A ir bor ne Precautions
Donning:
1. Inspect PPE prior to donning to ensure that it is in serviceable condition(e.g., correct size, gloves not torn or ripped, respirator not soiled orcreased; if using PAPR, check motor, airflow, and battery status).
2. Perform hand hygiene with ABHR; allow hands to dry before
donning gloves.
3. Put on gloves.
4. Put on respirator.
•

N95 or elastomeric respirator: Apply respirator, mold to nose/face,and perform fit check to ensure seal.

•

PAPR: Turn on PAPR motor, apply hood ensuring inner andouter liner drape smoothly over shoulders, and adjust headband
to comfort.

Doffing:
PPE should be doffed in an appropriate removal area (particularly if usinga PAPR). Care should be taken to avoid self-contamination during removal.
Appropriately dispose of PPE waste. PAPR should be placed in a separate
bag and/or managed by service protocol.
1. Inspect glove surfaces for visible contamination, cuts, or tears.

Back to Contents•

Visible contamination, cut, or tear: If glove is visibly soiled, remove
the gloves in a manner that avoids contact with the contaminatedsurface and dispose in biohazard bag. Wash hands with soap andwater if visibly soiled. Perform hand hygiene with ABHR. If the glove
is cut or torn, inspect the underlying skin. If any break in the skin,contact supervisor and follow service exposure guidelines.

•

No visible contamination, cuts, or tears: Remove and discard gloves,
taking care not to contaminate hands during removal. Dispose ofgloves in accordance with medical waste protocols. Perform handhygiene with ABHR.

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A ir bor ne Precautions
2. Respirator.
•

N95: Remove N95 respirator tilting the head slightly forward,
grasping the elastic straps, sliding them off the ears/head,and removing the respirator without touching the front fabric.
Appropriately dispose of respirator.

•

Elastomeric half-face respirator: Remove respirator by straps, wipe
surface with EPA-registered disinfectant wipe, and allow to dry.
Remove gloves worn during disinfection and perform hand hygienewith ABHR.

•

PAPR with External Belt-Mounted Blower (if used): Remove PAPR
belt and set PAPR down in front of body. Lean forward, grasp topof hood (avoid grabbing hose), slowly remove hood by pulling off
and straight down to floor. Retain the belt-mounted blower unit andreusable PAPR components in a separate bag for disinfection (mustbe wiped down with EPA-registered disinfectant wipes and allowed
to air dry).

3. Perform hand hygiene.
•

Visibly dirty, contaminated, or soiled with blood or body fluids: Wash
hands with soap and water, then perform hand hygiene with ABHR.

•

Not visibly soiled: Perform hand hygiene with ABHR.

4. Inspect for any contamination of the responder uniform. If there iscontamination, secure the garment for cleaning. Contaminated clothingshould be washed or discarded in accordance with disease-specificguidelines, generally with hot water, usual detergent, and the addition ofhousehold bleach as appropriate for the garment.

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A ir bor ne Precautions
PATIE NT CA R E CO N S ID ER ATIO N S•

Ensure strict adherence with standard precautions.

•Ask the patient to wear a surgical mask (N95 respirator not required) if
they are able to tolerate it.

•

Provide tissues to patients for secretion control and encourage patient
hand hygiene and cough etiquette practices.

•

The performance of procedures that can generate suspended
droplet nuclei/aerosols (i.e., aerosol-generating procedures), such as
endotracheal intubation, non-invasive ventilation, and open suctioningof the respiratory tract have been associated with higher risk oftransmission of infectious agents to health care personnel, including M.
tuberculosis. Protection of the eyes – in addition to respirator and gloves– is recommended while performing these procedures in accordancewith standard precautions.

•

If clinically indicated and available, rapid sequence intubation should beconsidered for any patient requiring definitive airway management toavoid aerosol generation as a consequence of coughing.

TR A N S POR T CO N S ID ER ATIO N S

Back to Contents•

Notify the receiving hospital of the need for an airborne infection
isolation room (AIIR) for patient placement.

•

Consider having the patient compartment exhaust vent on high andisolating the driver compartment from the patient compartment.
Consider having the driver compartment ventilation fan set to highwithout recirculation.

•

If driver/pilot compartment is not isolated from the patient compartment,
vehicle operator should wear N95 respirator.

•

Patients who are intubated should be ventilated with a bag-valve device
or ventilator equipped with a HEPA filter in-line or on the exhalation port.

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A ir bor ne Precautions
A MBUL A N CE D ECO NTA MIN ATIO N•

Any visibly soiled surface should be cleaned using an EPA-registereddisinfectant according to directions on the label.

•

Disinfect all potentially contaminated/high touch surfaces including thestretcher with an EPA-registered disinfectant according to directions on
the label.

•

Medical equipment (stethoscope, BP cuff, etc.) making patient contact
should be disposable or cleaned and disinfected before use on
another patient.

R E SO U R C E S­ Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in
Health care Settings­ Respiratory Protection Standards­ Selected EPA-Registered Disinfectants­ Sequence for Donning and Removing Personal Protective Equipment

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Special Respirator y Precautions
E X A MPLE D IS E AS ES
MERS ∙ novel influenza strains (e.g., H5N1) ∙ smallpox
COVID-19.

∙ Mpox ∙GOA L OF PR ECAUTIO N S

Back to Contents•

Provide protection of mucous membranes and respiratory protection
against inhalation of potentially infectious suspended droplet nuclei/
aerosols (agents suspended in the air that are respirable and remain
infectious over long distances).

•

Create an impermeable barrier to reduce spread of highly pathogenic
viruses on surfaces and via fomites during direct patient care activities(standard + contact + airborne + eye protection).

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Special Respirator y Precautions
D IS PATCH ACTIO N S

Back to Contents•

In addition to travel history to affected countries, EMS agencies mayneed to ask screening questions based on local cases.

•

Resource assignment: Consider restricting assignment to ambulance
only if no life-threatening symptoms (chest pain, difficulty breathing,altered mental status) present to decrease first responder exposure.
Consider use of dedicated infectious disease medical transport services
if built into the community’s regional transportation plan for planned
movement of patients with special respiratory disease.

•

Patient instructions: Usual pre-arrival instructions (e.g., turn on porch
light, control animals, gather medications, ask patient to wear a mask
if they have one and can tolerate it). Request family member to meetarriving personnel at door.

•

Crew instructions: Advise responding crew of patient illness/symptoms
and concern for special pathogen.

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Special Respirator y Precautions
A R R IV ING EM S ACTIO N S /CO N S ID ER ATIO N S•

Be aware of any community-based outbreaks of Mpox/MERS/novel
influenza/COVID-19 type diseases or other disease requiring special
precautions and obtain relevant travel and exposure history as indicated.

•

Ensure appropriate training and education on PPE use andpatient management.

•

Conduct “doorway evaluation” if possible. If stable and verbal, minimize
contact with patient while donning appropriate PPE.

•

Ensure history is consistent with dispatch information.
»

Back to Contents

Inquire specifically about relevant travel and exposures.

•

Adjust infection prevention precautions as required based on symptoms.
Change to standard or other respiratory precautions based on
symptoms if no significant concern for special pathogen. Maintain strict
adherence to standard precautions.

•

For possible special pathogens, minimize number of direct responders.

•

Perform hand hygiene before and after all patient care activities.

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Special Respirator y Precautions
PPE
Type:

Back to Contents•

Disposable N95 or equivalent/higher level respirator (e.g., re-usable halfface elastomeric respirator N95 or higher rating mask or PAPR with fullhood and HEPA filter).

•

Disposable face shield or disposable or cleanable goggles (if not using
hooded PAPR).

•

Disposable fluid-resistant gown that extends to at least mid-calf or
disposable fluid-resistant coveralls.

•

Disposable gloves with extended cuffs.

•

Consider disposable boot/shoe covers.

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Special Respirator y Precautions
Donning:
1. Personal items (e.g., jewelry [including rings], watches, cell phones,
pagers, pens) should ideally be removed and stowed. Long hair should
be tied back. Eyeglasses should be secured with a tie.
2. Inspect PPE prior to donning to ensure that it is in serviceable condition(e.g., correct size, gloves not torn or ripped, respirator not soiled orcreased; if using PAPR check motor, airflow, and battery status).
3. Perform hand hygiene with ABHR; allow hands to dry before
donning gloves.
4. Put on gloves.13
5. Put on gown or coverall. Ensure large enough to allow unrestrictedmovement. Ensure cuffs of gloves are pulled over the sleeve of the gown
or coverall.
6. Put on boot/shoe covers.
7. Put on respirator.
•

N95 or elastomeric respirator: Apply respirator, mold to nose/
face, perform fit check to ensure intact seal; apply face shield if notusing goggles.

•

PAPR: Turn on PAPR motor, apply hood ensuring inner liner (ifequipped) is tucked into coverall (if used) and outer liner drapessmoothly over shoulders and adjust headband to comfort.

8. If not using hooded PAPR, apply full face shield or goggles.
9. After donning, the integrity of the ensemble should be verified by the
responder. The responder should go through a range of motions toensure sufficient range of movement without suit binding/stretching while
all areas of the body remain covered.

EMS agencies may prefer to double glove for suspected highly virulent pathogens (e.g., MERS, Clade I
Mpox). Ensure the cuffs of inner gloves are tucked under the sleeve of the gown or coverall. Ensure the cuffs
of outer gloves are pulled over the sleeves of the gown or coverall and are tight. Consider taping, if required.
13

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Doffing:
PPE should be doffed in a designated removal area, particularly when usinga PAPR. Care should be taken to avoid self-contamination during removal.
Place all PPE waste in a labeled, leak-proof biohazard bag. PAPR should beplaced in a separate biohazard bag and/or managed by service protocol.
1. Inspect the PPE for visible contamination, cuts, or tears before
removal. Clean any visible contamination with an EPA-registereddisinfectant wipe.
2. Disinfect gloved hands with either an EPA-registered disinfectant wipe inaccordance with manufacturer recommendations or ABHR.14 If doublegloving, remove tape if applied and remove and discard outer gloves
into biohazard bag, taking care not to contaminate inner gloves in
the process.
3. Inspect the glove outer surfaces for visible contamination, cuts, or tears.
•

Visible contamination, cut, or tear: If glove is visibly soiled, then clean
the glove with either an EPA-registered disinfectant wipe or ABHR,
remove the gloves, perform hand hygiene with ABHR on barehands, and don a new pair of gloves. If the glove is cut or torn, after
removal and hand hygiene, check the underlying skin and review
occupational exposure protocol with supervisor.

•

No visible contamination, cuts, or tears: Disinfect gloves with either
an EPA-registered disinfectant wipe or ABHR.

4. Remove gown or coverall and boot/shoe covers and discard.
(Note: Gown or coverall should be removed before face protection andrespirator. If that is not possible due to the design of the PPE, remove
the gown or coverall after face protection and respirator.)

Preliminary research suggests that multiple applications of some types of ABHR may affect nitrile and latex
gloves. Switching the type of glove or ABHR product used is necessary if glove integrity decreases (e.g., they
start to tear or rip) or unusual changes (e.g., gloves become sticky, shrink, or harden) that would affect workrelated tasks are observed during training and practice.

14

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Gown: Depending on gown design and location of fasteners, theresponder can either untie or gently break fasteners. Pull the gown
away from body, being careful not to touch the inside with hands.
Once the gown is off shoulders, pull the gown down one arm andthen the other. Roll the gown inward while progressing downward.

•

Coverall: Tilt head back to reach zipper or fasteners. Unzip or
unfasten completely before rolling down while turning inside out.
Avoid contact with outer surface of coverall during removal, touching
only the inside of the coverall.

•

Dispose of gown or coverall into the biohazard bag.

5. Disinfect gloves with either an EPA-registered disinfectant wipeor ABHR.
6. Remove goggles or face shield (if used) sliding fingers under straps andsliding up and off away from face. Do not touch the front surface of thegoggles/shield. Discard into biohazard bag. If re-using goggles, mustclean all surfaces with EPA-approved disinfectant wipes.
7. Disinfect gloves with either an EPA-registered disinfectant wipeor ABHR.
8. Respirator.

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N95 respirator: Tip head slightly forward, remove by sliding fingers
under the elastic straps and sliding them off the ears/head allowing
the mask to fall away from the face being careful not to touch thefront of the mask. Discard into the biohazard bag.

•Elastomeric half-face respirator: Remove respirator by straps without
touching the front surface of the respirator, wipe surface with EPAapproved disinfectant cloth, and allow to dry.

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PAPR with External Belt-Mounted Blower: Remove PAPR belt
and set PAPR down in front of body. Lean forward, grasp top ofhood, (avoid grabbing hose), and slowly remove hood by pulling
off and straight down to floor. Retain the belt-mounted blower unit
and reusable PAPR components in a designated bag or area fordisinfection in accordance with manufacturer instructions (must be
wiped down with EPA-approved disinfectant and allowed to air dry).

9. Disinfect gloved hands with either an EPA-registered disinfectant wipeor ABHR. Remove and discard gloves, taking care not to contaminate
bare hands during removal process. Dispose of gloves into thebiohazard bag.
10. Perform hand hygiene.
•

Visibly dirty, contaminated, or soiled with blood or body fluids: Wash
hands with soap and water, then perform hand hygiene with ABHR.
Refer to the Occupational/Health Exposures information in the
Resources/Special Considerations section for additional guidance toensure that occupational health is aware of potential exposure.

•Not visibly soiled: Perform hand hygiene with ABHR.

11. Responders should inspect for any contamination of their uniform.
If there is contamination, remove and secure garment for cleaning.
Contaminated clothing should be washed or discarded in accordancewith disease-specific guidelines, generally with hot water, usual
detergent, and the addition of household bleach, as appropriate forthe garment.

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PATIE NT CA R E CO N S ID ER ATIO N S

Back to Contents•

Ask the patient to wear a surgical mask (N95 respirator not required) if
they are able to tolerate it.

•

Provide tissues to patients for secretion control and encourage patient
hand hygiene and cough etiquette practices.

•

Exercise caution when performing aerosol-generating procedures(endotracheal intubation, airway suctioning, administration of nebulized
medication, non-invasive ventilation [e.g., continuous positive airway
pressure (CPAP)/bilevel positive airway pressure (BiPAP)], and/or
cardiopulmonary resuscitation [CPR]). Only perform these procedures if
medically necessary and cannot be postponed.

•

If clinically indicated and available, rapid sequence intubation should beconsidered for patients requiring definitive airway management to avoid
aerosol production from coughing.

•

Ventilate patients who are intubated with a bag-valve device or ventilator
with a HEPA filter in-line or on the exhalation port.

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TR A N S POR T CO N S ID ER ATIO N S•

Notify the receiving hospital of the need for an AIIR for
patient placement.

•

The patient compartment exhaust vent should be on high and thedriver compartment should be isolated from the patient compartment
if possible. The driver compartment ventilation fan should be set tohigh without recirculation.

•

The vehicle operator should wear an N95 respirator if the patientcompartment and cab cannot be isolated.

•

EMS agencies should have a plan for family members wishing toaccompany the patient that minimizes additional crew exposures.

A MBUL A N CE D ECO NTA MIN ATIO N

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Any visibly soiled surface should be cleaned using an EPA-registereddisinfectant according to directions on the label.

•

Disinfect all potentially contaminated surfaces including the stretcher
with an EPA-registered disinfectant according to directions on the label.

•

Medical equipment (e.g., stethoscope, BP cuff) making patient contact
should be disposable or cleaned and disinfected using appropriate
disinfectants before use on another patient.

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R E SO U R C E S­ Considerations for Selecting Protective Clothing used in Health care for Protection
against Microorganisms in Blood and Body Fluids­ Disinfectants for Emerging Viral Pathogens (EVPs): List Q­ Interim Guidance for Infection Control Within Health care Settings When Caring for
Confirmed Cases, Probable Cases, and Cases Under Investigation with Novel Influenza
A Viruses Associated with Severe Disease­ Interim Infection Prevention and Control Recommendations for Health care Personnel
During the Coronavirus Disease 2019 (COVID-19) Pandemic­ Infection Prevention and Control of Mpox in Health care Settings­ Middle East Respiratory Syndrome (MERS)­ Selected EPA-Registered Disinfectants

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E V D-V H F Precautions
E X A MPLE D IS E AS ES
EVD ∙ MVD ∙ Lassa fever ∙ Crimean-Congo fever.

GOA L OF PR ECAUTIO N S•

Provide maximal impermeable barrier and respiratory protection against
highly pathogenic VHF viruses.

D IS PATCH ACTIO N S
1. Inquire about travel and direct exposure history within the previous
21 days.
•Has patient traveled to or lived in a country with hemorrhagic fever
virus transmission?

•

Has patient had direct contact with a person who is confirmed orsuspected to have EVD/VHF? (including local cases, if applicable)»

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If yes, does the patient have any fever, severe headache, muscle
pain, weakness, fatigue, diarrhea, vomiting, abdominal (stomach)pain, or unexplained hemorrhage (bleeding or bruising)?

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Notify responding units of any affirmative answer(s) to thesequestions. Provide following guidance/ask crew to reference
guidance and cancel first responder units if no life-threatening
symptoms present (unconscious/altered mental status, difficulty
breathing, chest pain).

2. Instructions to patients and EMS providers for EVD/VHF positive screen:•

Instruct other people at the scene to restrict contact with patientunless wearing appropriate PPE. Provide usual pre-arrival
instructions (e.g., turn on porch light, control animals, gather
medications, ask patient to wear a mask if they have one and cantolerate it). Request bystander on scene to meet arriving personnel
at door. Ask bystander to ensure patient is wearing clean clothingprior to EMS arrival, if possible.

•

Alert any first responders (if required for emergent symptoms) and
EMS responders being dispatched of potential for a patient withpossible exposure/signs and symptoms of EVD/VHF before they
arrive on scene. This may best be done via CAD, text messaging, orother secure means.

•

Advise EMS responders to don appropriate PPE before directcontact with the patient.
»

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Advise EMS responders before entering the scene to wear
the highest level of PPE recommended if complaints include
bleeding, vomiting, or diarrhea.

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Back to Contents•

If responding to an airport or other port of entry to the United States,
notify the CDC Port Health Station for the port of entry. Contact
information for CDC Port Health Stations can be accessed at https://www.cdc.gov/quarantine/quarantinestationcontactlistfull.html.

•

Dispatch should notify EMS supervisor and others per
service protocols.

•

Consider alerting EVD/VHF specialized personnel and equipment/
ambulance if available as secondary responder and the patient isstable enough to await this resource.

•

If patient is transported, ensure follow-up with hospital regarding final
diagnosis and report any exposures or issues to public health.

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A R R IV ING EM S ACTIO N S /CO N S ID ER ATIO N S

Back to Contents•

Be aware of any international and/or community-based outbreak.

•Consider the strategy of one responder putting on PPE with the use ofa trained observer and managing the patient while the other responder
does not engage in patient care but provides the “doorway evaluation”
and communications/charting from at least 6 feet away from the patient.
The second responder should be prepared to quickly and safely don theappropriate PPE should the first responder require assistance.

•

Ensure history is consistent with dispatch information.
»

Inquire specifically about travel and relevant exposures.

»

If initial assessment confirms suspicion of EVD/VHF and patientis stable and alert, then continue specialized EMS ambulance
response to location, if available.

•

Adjust infection prevention precautions as required based on
symptoms and suspicion. Change to standard precautions withappropriate transmission-based precautions based on symptoms if nosignificant concern for EVD/VHF. Maintain strict adherence to standard
precautions.

•

Minimize number of direct caregivers.

•

Perform hand hygiene before and after all patient care activities.

•

Ensure that appropriate ALS/BLS care is provided. The vast majority ofsuspected cases will not have EVD/VHF.

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PPE
Initial responders to suspect case without active bleeding, vomiting,or diarrhea.15
Donning:
1. Use a checklist and a trained observer.16
2. Personal items (e.g., jewelry [including rings], watches, cell phones,
pagers, pens) should be stowed. Long hair should be tied back.
Eyeglasses should be secured with a tie.
3. Visually inspect the PPE to ensure that it is not torn or ripped, allrequired PPE and supplies are available, and the correct sizes
are selected.
4. Perform hand hygiene with ABHR. When using ABHR, allow hands to
dry before moving to next step.
5. Put on inner gloves.
6. Put on gown or coverall. Ensure gown or coverall is large enough toallow unrestricted movement. Ensure cuffs of inner gloves are tucked
under the sleeve cuff.
7. Put on surgical mask.17

15

PPE: Clinically Stable Patients Suspected to have VHF

16

CDC provides videos demonstrating donning and doffing procedures for various PPE combinations.

EMS agencies may recommend use of an N95 respirator for all suspect cases. Use of surgical masks is
consistent with CDC guidance for suspected cases when exposure to blood and body fluids is not anticipatedand aerosol-generating procedures are not performed.
17

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8. Put on second pair of gloves (with extended cuffs). Ensure the cuffs arepulled over the sleeves of the gown or coverall (consider taping).
9. Put on full face shield over the surgical mask to protect the eyes as wellas the front and sides of the face. Consider use of a head cover.
10. Verify the integrity of the ensemble (e.g., there should be no cuts or tears
in the PPE). The responder should be comfortable and able to extend
the arms, bend at the waist, and go through a range of motions while allareas of the body remain covered.
Doffing:
Doffing is a high-risk step in VHF patient care. PPE should be doffed
in a designated PPE removal area. Meticulous care should be taken during
this process to avoid self-contamination as this is a major contributor
to responder disease. Place all PPE waste in a labeled leak-proof
biohazard bag.
1. Use a checklist and a trained observer.
2. Inspect the PPE for visible contamination, cuts, or tears before starting
to remove. If any visible contaminant, disinfect using an EPA-registereddisinfectant wipe.
3. Disinfect outer-gloved hands with either an EPA-registered disinfectant
wipe in accordance with manufacturer recommendations or ABHR.
Remove tape if applied and remove and discard outer gloves, taking
care not to contaminate inner gloves in the process. Dispose of outer
gloves into biohazard bag.
4. Inspect the inner glove outer surfaces for visible contamination, cuts,or tears.
•

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Visibly soiled, cut, or tear: Clean the glove with either an EPAregistered disinfectant wipe or ABHR, remove the inner gloves
and discard into biohazard bag, perform hand hygiene with
ABHR on bare hands, and don a new pair of gloves. For cut
or tear, inspect skin for injury and report potential exposure tosupervisor immediately.

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No visible contamination and no cuts or tears: Disinfect the innergloves with either an EPA-registered disinfectant wipe or ABHR.

5. Remove the face shield (and head cover/hood if used) by tilting thehead slightly forward, grabbing the rear strap, and pulling it over thehead, allowing the face shield to fall forward. Avoid touching the front
surface of the face shield. Discard the face shield into the designatedbiohazard bag.
6. Disinfect inner gloves with either an EPA-registered disinfectant wipeor ABHR.
7. Remove gown or coverall.
•

Gown: Depending on gown design and location of fasteners,
the responder can either untie or gently break fasteners. Pull
the gown away from the body, being careful not to touch theinside with hands. Once the gown is off shoulders, pull the gown
down one arm and then the other. Roll the gown inward while
progressing downward.

•

Coverall: Tilt head back to reach zipper or fasteners. Unzip or
unfasten coverall completely before rolling down while turning insideout. Avoid contact with outer surface of coverall during removal,
touching only the inside of the coverall.

•

Dispose of gown or coverall into the biohazard bag.

8. Disinfect inner gloves with either an EPA-registered disinfectant wipe or
ABHR. Remove and discard gloves, taking care not to contaminate barehands during removal.
9. Perform hand hygiene with ABHR and don a new pair of gloves.
10. Remove the surgical mask by tilting the head slightly forward, grasping
the elastic straps, and pulling the straps off the ears and/or top of headto release the mask allowing it to fall forward off the face. Avoid touching
the front of the mask. Discard into the biohazard bag.

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11. Disinfect gloved hands with either an EPA-registered disinfectant wipeor ABHR. Remove and discard gloves, taking care not to contaminate
bare hands during removal process. Dispose of inner gloves into thebiohazard bag.
12. Perform hand hygiene with ABHR.
13. Inspect for any contamination of the responder uniform. If there
is contamination, remove the soiled garment and place it into thebiohazard bag, cleanse skin with ABHR, and immediately informsupervisor of the potential exposure.

PPE
Transport of confirmed case or those with active bleeding, vomiting,or diarrhea.18
Note: Services may elect to use N95 respirator in combination withimpermeable hood that covers head and shoulders and a full face shield.
The previous PPE section may be modified for use of this ensemble.
This section covers donning/doffing with PAPR with impermeable drapestyle hood. Services may elect to add a heavier impermeable apron for
high-risk situations.
Donning:
1. Identify trained observer and use a checklist.
2. Ensure hydration and use the restroom prior to donning if possible.

18

PPE: Confirmed Patients and Clinically Unstable Patients Suspected to have VHF

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3. Personal items (e.g., jewelry [including rings], watches, cell phones,
pagers, pens) should ideally be stowed. Long hair should be tied back.
Eyeglasses should be secured with a tie.
4. Visually inspect the PPE ensemble to ensure it is the correct size, ingood condition (e.g., not torn or ripped), and all required PPE andsupplies are available. Check battery status and test the PAPR motor
and airflow. Check that the filters fit securely, and ensure all filter caps
are off.
5. Don and test two-way radio headset microphone (if using).
6. Perform hand hygiene with ABHR; allow hands to dry before moving tonext step.
7. Put on first pair of gloves.
8. Put on coverall; ensure unrestricted movement. Ensure cuffs of innergloves are tucked under the sleeve cuff.
9. Put on impermeable boots, pull coverall material over top of boot andtape (leaving tab) if suit and boots allow. If using boot covers per service
protocols, put on boot covers.
10. Put on second pair of gloves (with extended cuffs). Ensure the cuffs arepulled over the sleeves of the coverall (consider taping).
11. Turn PAPR on and put on belt and then hood. Ensure inner hood (ifpresent) is tucked into coverall and outer hood drapes over shoulders.
Ensure comfortable airflow and adjust headband if required.
12. Put on disposable apron, if using.
13. Observer and responder should verify the integrity of the ensemble (e.g.,there should be no cuts or tears in the PPE). The responder should be
comfortable and able to extend the arms, bend at the waist, and go
through a range of motions without binding/stretching the coverall.

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Doffing:
Doffing is a high-risk step in VHF patient care. PPE should be doffed
in a designated PPE removal area. Meticulous care should be taken during
this process to avoid self-contamination as this is a major contributor
to responder disease. Place all PPE waste in a labeled leak-proof
biohazard bag.
1. Identify a trained observer and use a checklist.
2. Inspect the PPE for visible contamination, cuts, or tears before starting
to remove. If any visible contaminant, clean using an EPA-registereddisinfectant wipe.
3. Disinfect outer gloves with EPA-registered disinfectant or ABHR.
4. Remove apron if using (e.g., by breaking or untying neck strap andreleasing waist ties) and roll the apron away from body, containing thesoiled outer surface while rolling; discard apron into biohazard bag being
careful not to contact other surfaces. Re-inspect underlying coverall.
5. Disinfect outer-gloved hands with either an EPA-registered disinfectant
wipe in accordance with manufacturer recommendations or ABHR.
Remove tape if used and remove and discard outer gloves, taking care
not to contaminate inner gloves in the process. Dispose of outer gloves
into biohazard bag.
6. Inspect the inner gloves’ outer surfaces for visible contamination, cuts,or tears.

Back to Contents•

Visibly soiled, cut, or tear: Clean the glove with either an EPAregistered disinfectant wipe or ABHR, remove the inner gloves anddiscard into biohazard bag, perform hand hygiene with ABHR on
bare hands, and don a new pair of gloves. For cut or tear, inspectskin for injury and report any potential exposure immediately
to supervisor.

•

No visible contamination and no cuts or tears: Disinfect the innergloves with either an EPA-registered disinfectant wipe or ABHR.

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7. Remove PAPR with External Belt-Mounted Blower: Remove PAPR belt
and set PAPR down in front of body. Lean forward, grasp top of hood(avoid grabbing hose), slowly remove hood by pulling off and straight
down to floor.
8. Retain the belt-mounted blower unit and reusable PAPR components ina separate bag for disinfection.
9. Disinfect inner gloves with either an EPA-registered disinfectant wipeor ABHR.
10. Remove coverall.
•

Tilt head back to reach zipper or fasteners. Unzip or unfasten
coverall completely and release tape at boot cuff. If wearing booties,
remove these.

•

Avoid contact with outer surface of coverall during removal, touching
only the inside of the coverall as hands slide down the inside of thesuit, rolling it inside-out.

•

Step out of boots onto clean surface.

•

Boots Disposable: Discard both boots and coverall into
biohazard bag.

•Boots Re-usable: After stepping out of boots, dispose of coverall
into biohazard bag, then place boots into separate bag for later
decontamination.

11. Disinfect inner-gloved hands with either an EPA-registered disinfectant
wipe or ABHR. Remove and discard gloves, taking care not to
contaminate bare hands during removal. Dispose of inner gloves into thebiohazard bag.
12. Perform hand hygiene with ABHR.
13. Observer and responder inspect for any contamination of their uniform.
If there is contamination, remove the soiled garment and place it intoa leak-proof biohazard bag, cleanse skin with ABHR, and inform thesupervisor of potential exposure.
14. Step into clean area.

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PATIE NT CA R E CO N S ID ER ATIO N S

Back to Contents•

Ask the patient to wear a surgical mask (N95 respirator not required) if
they are able to tolerate it.

•

Be aware that the biggest risk to suspect EVD/VHF patients iswithholding appropriate treatment as few will actually have the disease.

•

Recognize that the more body fluids, the higher the transmission risk.

•

Anticipate potential stool/vomitus and control contamination of
the responder and the ambulance (use emesis bags, towels, and/or place impermeable sheet on stretcher). Refer to the Ambulance
Decontamination section for additional information.

•

Minimize the number of responders who make patient contact.

•

Use dedicated medical equipment (ideally disposable) for the provisionof patient care whenever possible.

•

Strongly consider having the patient wear a barrier garment, surgicalmask, and gloves if tolerated.

•

Patient should wear an adult undergarment if having large volumesof diarrhea.

•

Exercise caution when performing aerosol-generating procedures(endotracheal intubation, airway suctioning, administration of nebulized
medication, CPAP/BiPAP, CPR). Only perform these procedures if
medically necessary and cannot be postponed. (Note that cardiac
arrest early in the illness may be due to electrolyte imbalance and may
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Do not perform phlebotomy or any other invasive procedures unlessurgently required for patient care or stabilization. Handle any needles
and sharps with extreme care and dispose in puncture-proof, sealedcontainers that are specific to the single patient. Do not dispose of usedneedles and sharps in containers that have sharps from other patientsin them.

•

Consider giving oral or nasal medicine to reduce nausea and/or pain perservice protocols rather than injectable.

•

Use hands-free communications devices (e.g., tactical headsets) inside
the PPE ensemble to facilitate communication and avoid contaminationof radios.

•Complete charting either verbally to a partner in a clean area orafter transport.

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TR A N S POR T CO N S ID ER ATIO N S – G E NER A L

19•Advise the designated receiving hospital as early as possible about asuspect case to allow them preparation time.

•

If the patient is a highly suspect case and stable, consider specialized
ambulance preparation and transport (refer to next section) if time andacuity allow.

•

Interfacility transport of confirmed case should be performed by EMS
personnel with properly prepared ambulances or patient containment
devices (refer to next section).

•

For emergency transport, consider applying an impermeable barrier
sheet or cocoon to the patient19 to protect the responder andenvironmental surfaces in the presence of incontinence, draining
wounds, or other discharges.

•

The driver’s compartment should remain clean. No family members or
patient belongings are permitted in the driver’s compartment.

•

Suspect EVD/VHF cases should be transported to a hospital capable ofevaluation and initial management and placed into a dedicated isolation
room. Placement should be coordinated in consultation with local/statepublic health authorities and the receiving facility.

•

Consider deferring ambulance decontamination for a brief period
to determine if EVD/VHF can be quickly ruled out during initial
hospital assessment.

•

Formal decontamination after transport of a suspect/confirmed caseshould occur in a designated area by trained personnel as described in
the next section.

NETEC offers a training video on the use of a containment wrap in a special pathogen isolation area.

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EMS agencies should have a plan for family members wishing toaccompany the patient that prevents crew exposures to highly
infectious diseases.

•

Identify point of contact at the hospital to allow EMS to obtain final
diagnosis/test results and inform employee monitoring and waste
disposition process.

SPECIALIZED AMBULANCE PREPARATION/
INTERFACILITY TRANSFER 20
Assumptions:•

All involved health care providers (hospital and out-of-hospital) havereceived education and training and demonstrated competencies for
EVD/VHF PPE and patient management.

•

Health care facilities and specialized transporting ambulance agencies
have protocols for the management of patients, exposures, andambulance preparation and decontamination.

•

Facilities and transporting ambulance agencies conduct exercises toevaluate their integration.

Ambulance preparation•

If a commercial patient containment system is used, these guidelines
may be modified accordingly. EMS personnel must be carefully trainedon these systems—including appropriate cleaning, disposition, andimpact on mission recovery—and understand the limitations on patientcare they impose.

Adapted from Example: Standard Operating Procedure (SOP) for Patient Handoff between a Healthcare
Facility and a Transporting Ambulance.

20

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Apply clear plastic sheets (at least 4mil) or similar impermeable barrier
cloth to walls of ambulance and duct tape in place. If the ceiling is aflat impermeable surface, the agency may elect not to apply plastic tothe ceiling.

•

Overlap all seams by at least 1 inch.

•

Apply sheets to walls, cutting holes for air supply/vents and exhaust.

•

Seal any conduit between the driver compartment and the passenger
compartment with plastic sheeting.

•Protect floor and benches with clear plastic sheets (at least 6mil),cutting holes for stretcher locks. At this point all surfaces should beprotected by plastic. A large bag or plastic sheeting may be used for the“jump” seat.

•Protect stretcher with impervious sheet.

•

Make immediately available ABHR, emesis bags, and a spill kit/
absorbent disposable rags.

•

Stow essential medical equipment in patient compartment sealed inside
a clear plastic bag for easy access.

•Pre-pack medical supplies into individual plastic bags. Some may electto reorganize bags/kits to minimize extra contents and/or to makecleaning easier (e.g., using plastic tray organizers [instead of fabricbags], packing into sliding closure clear plastic bags).

•

Stow additional medical equipment in patient compartment behinddisposable barriers, protecting it from unnecessary exposure, butavailable if needed by cutting plastic.

•

Stow oxygen delivery kit in patient compartment and sealed inside
a clear plastic bag for easy access. Consider manual disposable
suction unit.

•

Set all climate controls for fresh, non-recirculating air if possible.

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Set ventilation system in driver compartment on high and nonrecirculating; crack windows/vents open.

•

Set exhaust vent in patient compartment on high.

Prior to Transport

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Ensure EMS personnel have points of contact and means ofcommunication with sending facility, receiving facility, public healthauthority, emergency management, law enforcement (or agency
providing security for the transport), and (if applicable) aviation andregulated (Category A) hazardous waste management and disposal.

•

Consider notifying EMS agency’s public information officer.

•

Consider secure methods of communication to avoid monitoring by the
media or public.

•

Communicate with the sending facility to confirm patient’s clinicalcondition and risk of contact with infectious body fluids (e.g., bleeding,vomiting, diarrhea) and treatment prior to transport (e.g., anti-pyretic,
anti-emetic, intravenous fluids [IVF]).

•

Determine if the patient will be ambulatory or non-ambulatory.

•

Confirm whether additional passengers are being transported (e.g.,
loved one, caregiver).

•

Ensure adequate inventory of supplies and appropriately sized
PPE for the personnel who are assigned to the transport mission
using checklists.

•

Ensure procedures and training to limit contamination of ambulanceenvironmental surfaces (e.g., isolation of driver compartment, draping).

•

Confirm for both origin and destination facility the location for patient
hand-off. This location will likely be pre-determined by facilities andchosen to minimize environmental exposure at the facility and prevent
exposure of unprotected staff, patients, and visitors.

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Confirm for both origin and destination facility the location for donningand doffing of PPE for transporting ambulance responders and ensure
ambulance decontamination and disinfection location established.

•

Ensure there is a plan at the destination hospital and ambulance
decontamination location for managing regulated (Category A)
hazardous waste including used responder PPE.

•

Ensure appropriate supervision for the doffing of ambulance responder
PPE as hospital PPE and doffing protocols may be different.

•

Determine the need for additional security (and related personnel needs)
with sending and receiving facility during transport and at the healthcare facilities.

•

Ensure medical director (or appropriate person providing medical
oversight) is immediately available for consultation throughout
the transport.

•

Communicate with sending facility for patient updates and to confirm
patient transfer location.

•

Contact sending facility to verify patient management steps have beentaken to facilitate event-free transport and reduce risk of exposure
including sufficient medications and drips for the transport time plus
additional waiting/traffic/transfer time.

•

Establish guidelines to define the clinical care objectives for patients
whose condition deteriorates enroute to the receiving facility.

•

Hold mission briefing for transport team to review:»

Purpose and team primary contacts.

»

Transport provider health check.

»

Patient history and condition.

»

Infection control posture (ambulance configuration andpersonnel PPE).

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Team member (e.g., paramedic, emergency medical technician[EMT], driver, supervisor/safety officer, EMS physician) roles
and responsibilities (including supervision of donning anddoffing procedures).

»

Relevant clinical care guidelines including appropriateness ofinterventions or invasive procedures.

»Transportation of patient specimens and medication, if applicable.

»

Transfer of paper or electronic ambulance patient care records in a
way that avoids contaminating the receiving facility.

»

Decontamination and disinfection procedure.

»

Waste collection and mission recovery.

»

Post-mission surveillance and test result follow up for patient if notconfirmed case.

»Interaction with security/law enforcement during the transport and at
the receiving facility.

»

Special considerations (e.g., length of transport, transfer of patient
across state borders, vehicle malfunction and other contingencies).

»

Media policies.

During Transport

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Depart for patient location.

•

Communicate with designated point of contact at each facility the arrival
ETA of transporting ambulance.

•

Observe donning of PPE and, when ready, proceed to make patient
contact (only the minimum number of providers necessary to manage
the patient should be present).

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Conduct brief patient assessment to determine patient’s stability,“dry” or “wet” symptoms, and need for intervention before and/or
during patient transport. Define appropriate interventions for patient
deterioration. Minimize patient contact. For example, consider not
obtaining vital signs if patient is “dry,” has no visual evidence of distressor shock, and transport time is not prolonged.

•

Transport patient in impervious suit if ambulatory, or in impervious
sheets if non-ambulatory and stretcher-bound, as tolerated.

•

Consider any patient belongings (typically bagged, labeled,
and transported with the patient in the patient compartment) to
be contaminated.

•

Any documents provided by sending facility should be free ofcontamination. When in doubt, consider them contaminated andpackage as appropriate for transport by ambulance personnel.

•

Report patient’s condition and ETA to receiving facility to facilitate theirreadiness to receive patient from transport agency immediately upon
arrival, thus avoiding PPE-induced fatigue/dehydration for patient,ambulance crew, and receiving staff.

•

Ensure any changes in patient condition are communicated to thereceiving facility enroute.

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Arrival to receiving facility

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Confirm arrival with receiving facility and specific route of travel within
facility before patient leaves ambulance.

•

Ensure route of travel is secured.

•Transport patient to designated location in receiving facility – via
the most direct route to isolation room, either ambulatory or via
stretcher depending on patient condition. If any concern for stretcher
contamination, transfer patient to hospital cart upon exit fromambulance.

•

Transfer patient care to receiving facility team as arranged(and exercised).

•

Proceed to designated decontamination/disinfection station.

•

Package waste from transport prior to doffing PPE. Transfer waste
to hospital or appropriate agency as previously arranged and inaccordance with applicable regulations.

•

If ambulance personnel are performing ambulance cleaning anddisinfection and have not exceeded service threshold for time in PPE,
they may proceed with cleaning of visibly soiled areas and removal of
barrier drapes prior to doffing.

•

Ambulance personnel doff PPE under supervision of qualified personnel(transport agency PPE ensemble and hospital PPE may differ).

•

After donning of appropriate PPE for disinfection, proceed withdisinfection of the ambulance per protocol.

•

Conclude mission, debrief responders, and initiate surveillance
as appropriate.

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A MBUL A N CE D ECO NTA MIN ATIO N 2 1
1. Identify Decontamination Area:•

Select an appropriate site for ambulance decontamination that
protects the vehicle and the team from the weather, preferably awell-ventilated, climate controlled, large, enclosed garage/structure.

•

Establish a secure perimeter.

•

Include considerations for waste management, security
plan, public perception, and media visibility when selecting
decontamination site.

•

Define and mark the clean/dirty zone boundary around theambulance that requires PPE to cross.

2. Before Decontamination and Disinfection:•

Ensure appropriate supplies available:»

Yellow caution tape.

»

Appropriate sizes of PPE for personnel performing
decontamination.

»

Leak proof biohazard bags.

»

Garbage bags.

»

Autoclave bags with rubber bands or alligator clips.

»

EPA-registered disinfectant wipes.

»

Bottled water.

»

Absorbable rags.

»

Alcohol based hand sanitizer.

Adapted from Example: Standard Operating Procedure (SOP) for Decontamination of an Ambulance that has
Transported a Person Under Investigation or Patient with Confirmed Ebola.
21

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Absorbent towels.

»

Spill kit (absorbent towels, leak proof container, EPA-registereddisinfectant).

»

Bio-safety check-off sheet, briefing template, donning check-off
sheet, doffing check-off sheet, point of contact list.

•

The vehicle operator and patient care provider may be responsiblefor decontamination and disinfection of the transport unit or aseparate team may be used. Both approaches have advantages.

•

All waste, including PPE, drapes, and wipes, should be considered
Category A infectious substances, and should be packaged
appropriately for disposal.

•

Personnel must be in appropriate PPE during decontamination anddisinfection. A third person should also be available as a trained
observer and to assist as needed.

•

PPE should be donned and doffed per previous guidelines.

•

PPE selection should consider worker protection for biological
exposures as well as based on the disinfectant used.22

3. Spill decontamination:

22•

Grossly contaminated and visibly soiled surfaces must be
decontaminated prior to disinfection.

•

Gross surface contamination must first be absorbed using
absorbent towels and cleaned using an EPA-registered disinfectant.

•

Used absorbent materials and cleaning wipes are placed in alabeled leak-proof container.

•

After removal of visible contaminants, surfaces require disinfection
as described in next step.

PPE Selection Matrix for Occupational Exposure to Ebola Virus

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4. Disinfection:

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If test results will be available rapidly, consider waiting to see if thepatient rules out, in which case usual practices for decontamination
and waste management can be used.

•

Disinfect the outside of any bags containing unused medical
equipment as well as the stretcher, PAPR motor housings, etc. withan EPA-registered disinfectant according to directions on the label.

•

If equipment was removed from a protective bag in transit, assess
the equipment to determine if it can be properly decontaminatedand disinfected, or disposed of. All non-dedicated, non-disposable
medical equipment used for patient care should be cleaned
and disinfected according to manufacturer’s instructions andagency policies.

•

If the interior of the ambulance was draped prior to transport,
remove the draping by rolling the drapes down outside in, from theceiling to the floor of the unit starting at the front of the compartment
and moving to the rear.

•

Roll flooring drapes from the front to rear of the compartment, rolling
drapes outside in.

•

To facilitate packaging and transport, drapes can be gently cut into
segments. It is important that all drape materials are in sections thatare small enough to facilitate the insertion of the biohazard bags into
an autoclave or pre-determined Category A infectious substancepackaging for disposal.

•

Personnel should manually disinfect the interior of the patient carecompartment with an EPA-registered disinfectant according todirections on the label. This should include attention to proper
contact time and particular detail for high-touch surfaces such as
door handles and steps using care to limit mechanically generated
aerosols (e.g., no scrub brushes) and using the surface wipe method
to disinfect.

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Once the manual interior wipe down has been completed,collect and package all waste as Category A waste. Place waste
in biohazard bags for disposal. All bags will be closed using a
gooseneck technique and the outer surface disinfected with an
EPA-registered disinfectant according to directions on the label.
All waste is double-bagged and exterior surfaces disinfected.
Biohazard bags may be inserted into autoclave bags provided by
the receiving facility.

•

Manually wipe with disinfectant the ambulance’s exterior patientloading doors and handles, and any areas that may have been
contaminated.

•

The full exterior of the ambulance does not require a disinfectant
wipe down.

•Once all surfaces (including waste bags) have been wiped withdisinfectant, then supervised doffing of PPE can occur into a final
biohazard bag, which is closed and disinfected.

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5. After disinfection/decontamination:•

Dispose of all waste according to organization protocols as well as
local and federal regulations for Category A infectious substances.
Best practice may be to transfer waste to the hospital for disposition.
If the patient rules out for EVD/VHF, the waste can be handled withusual processes.

•

Additional cleaning methods may also be used. While not required,this may provide additional assurance to personnel and the publicprior to returning the vehicle to service.
»•

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Ultraviolet germicidal irradiation, aerosolized chlorine dioxide,or hydrogen peroxide can be used for an additional disinfection
step. However, these should not replace the manual cleaningof visibly soiled surfaces, as their efficacy against organisms inbody fluids has not been fully established. Use of these methods
may require specialized equipment and PPE.

The ambulance can then be returned to service.

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R E SO U R C E S­ Bloodborne Infectious Diseases Risk Factors­ Bloodborne Pathogens Standard, 29 CFR 1910.1030­ Considerations for Safe Transport of Patients Infected with Ebola Virus­ Considerations for Selecting Protective Clothing used in Healthcare for Protection
against Microorganisms in Blood and Body Fluids­ Example: Standard Operating Procedure (SOP) for Decontamination of an Ambulancethat has Transported a Person Under Investigation or Patient with Confirmed Ebola­ Handling VHF-Associated Waste­ Interim Guidance for Environmental Infection Control in Hospitals­ List L: Disinfectants for Use Against the Ebola Virus­ Managing Solid Waste Contaminated with a Category A Infectious Substance­ Port Health Station Contact List
­ PPE: Clinically Stable Patients Suspected to have VHF­ PPE: Confirmed Patients and Clinically Unstable Patients Suspected to have VHF­ PPE Selection Matrix for Occupational Exposure to Ebola Virus­ Safe Handling, Treatment, Transport, and Disposal of Ebola-Contaminated Waste­ Transport and Management of Patients with Confirmed Ebola Virus Disease

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H A ND H YG IE NE 2 3•During the delivery of health care, avoid unnecessary touching of surfaces in close proximity
to the patient to prevent both contamination of clean hands from environmental surfaces
and transmission of pathogens from contaminated hands to surfaces.

•

When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled
with blood or body fluids, wash hands with soap and water.

•

If hands are not visibly soiled, or after removing visible material with soap and water, thepreferred method of hand sanitizing is with ABHR.

•

Wash hands with non-antimicrobial soap or with antimicrobial soap and water if contact
with possible norovirus or spores (e.g., C. difficile or Bacillus anthracis) is likely to haveoccurred. The physical action of washing and rinsing hands under such circumstances isrecommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents
have poor or variable activity against these pathogens.

•

Do not wear artificial fingernails if duties include direct contact with patients at high risk for
infections with associated adverse outcomes.

PA ND EMIC•

PPE guidance for novel pathogens (e.g., novel influenza, novel coronavirus) may change
rapidly. EMS agencies should monitor information from CDC and regulatory organizations
at the state and federal level and have established contacts with infection prevention andcontrol professionals.

•

Novel influenza and coronavirus strains are usually initially managed according to Special
Respiratory (standard + contact + airborne + eye protection) Precautions. If in doubt, theservice should apply Special Respiratory Precautions until disease-specific guidanceis available.

23

2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

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Special Considerations•

Dispatch should update questions to reflect any screening needed for international,
domestic, or local cases.

•

Responding personnel should have a low threshold to mask the patient and wear
appropriate PPE as novel respiratory viruses may be transmissible prior to the onsetof symptoms.

•

Pandemics can place enormous strain on EMS services due to high call volumes andprovider illness. Crisis standards of care plans may need to be implemented, including but
not limited to:»

Adjusting resource assignments based on availability (e.g., police only on reported
vehicle crash until non-ambulatory injuries confirmed).

»

Auto-answering and deferring callers to information/prescribing lines for nonemergency situations.

»

Recommending private transport when appropriate.

»

Changing to “closest hospital” transportation or “batch” transports.

»

Deferring select 911 requests for service.

»

Expanding “left at scene” discretion/guidelines and treat and no-transport guidelines.

»

Allowing non-hospital destinations for appropriate patients.

»

Changing staffing, crew configuration, and using novel response structures (e.g., “jumpcars,” community paramedic response).

»

Adopting N95 respirator conservation or re-use strategies.

•

If EPA-registered disinfectants become unavailable or are in short supply during apandemic, consider diluted bleach solution as per CDC and World Health Organization(WHO) guidance listed under the References section.

•

Changes to 911 communications center protocols and EMS responses will require medical
director and service director policy development and approval and may require local
ordinance and state statutory relief. These policies and supporting governmental actions
should be planned prior to an incident that overwhelms EMS resources.

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PED I ATR IC IS SUES•

Children may be very fearful of caregivers in high-level PPE. Ensure the ability to communicate
with the child and explain what is happening and why in an age-appropriate manner.

•

Caregivers who follow infectious precautions may be kept with the child in the ambulance ifthey wear appropriate PPE, have been providing care for the child during the current illness,and there is no substantial risk of body fluid exposure during transport.

•

Pediatric intravenous access can be difficult and the need for access must be balanced
against the potential risk for needlesticks in the setting of potential blood-borne pathogens.

•Appropriate sizes of simple masks should be available for children.

•

Consider nasal/oral routes for analgesia and anxiolysis if intravenous access is not obtained.

•

Ensure that comfort objects (e.g., blanket, stuffed animal) can accompany the patient
during transport.

•

Do not avoid indicated procedures and medications for children simply because of aperceived risk of distress.

•

Children are able to compensate for hypovolemia much better than adults by increasing theirheart rate. However, hypotension and cardiovascular collapse can occur with little warning.
Elevated heart rates can also be seen with fever, anxiety, and pain, making a determination oforigin difficult. Assess perfusion, history, and other signs before assuming tachycardia is not
related to early shock/sepsis.

•

When possible, specialized EVD/VHF transport units should include agencies that routinely
provide pediatric critical care interfacility transport.

•

EVD commonly induces miscarriage. Providers should be aware of this issue and potential
exposures and complications.

•Portable pediatric isolation transport units are available but should only be used by personnel
trained in their operation and limitations. The use of these units may significantly increase thepatient’s anxiety during transport.

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A EROMED ICA L TR A N S POR T
Note: This section refers to domestic air medical transport providers only.
•

Policies on rotor-wing and fixed-wing transport of potentially infectious patients should bein place in each agency and should include questions at the dispatch level and a process
for providing information to the crews. Careful consideration should be given to whether
aeromedical transport is appropriate for the specific patient. This may include consultation
with the service medical director.

•

Ensure dispatch provides sufficient information to anticipate potential infectious risks.

•

Obtain patient information from original hospital for mission planning including suspectdisease, signs/symptoms, appropriate PPE, equipment, and medications.

•Contact destination hospital to ensure appropriate reception planning including isolation
room (if required) staff, cart, PPE, and traffic/patient movement plan. Ensure adequate
medications are available including drips for transport (taking potential delays into account).

•

For flights involving interface with ground transport units, ensure communications plan andconfirm appropriately trained and equipped providers (define needs and roles – driver only
vs. assuming medical care) as well as special ambulance preparation if there is suspicion
for EVD/VHF. Maintain communications to verify arrival times.

•

Provide information for ground unit or receiving hospital briefing as required.

•

Ensure the transfer of medical records occurs safely and that records are not contaminated(e.g., seal in zippered clear plastic bag which can be wiped with disinfectant prior
to hand-off).

•

Review general patient care considerations for specific infectious precautions.

•

Spill kit, alcohol-based hand disinfectant, emesis bags, suction, disposable rags, biohazard
bags, and medical supplies should be organized similar to ground unit recommendations
for suspect EVD/VHF transports.

•

For long duration flights, consider providing a chemical toilet to ambulatory patients.

•

Aeromedical clinical personnel should carefully plan and use PPE similar to ground units(including N95 use – must ensure that the selected disposable or elastomeric mask iscompatible with helmets).

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Aeromedical clinical personnel should carefully plan in-flight medical contingencies
and have appropriate medications and equipment available to reduce contamination of
non-required materials.

•

Intubation should be performed at the hospital of origin if there is any concern about
existing or potential respiratory insufficiency. Rapid sequence techniques should be used (asopposed to sedation-only techniques) to mitigate possible generation of infectious aerosols.

•

Consider a self-enclosed (e.g., helmet-type) positive airway pressure device if available
instead of usual non-invasive ventilation strategies.

•

Consider oxygen supply and demand as most portable oxygen supplies are not capable ofsustained high flow applications.

•Intubated cases with suspected airborne, droplet, special respiratory, or EVD/VHF diseases
should have a HEPA filter in-line or on the ventilator exhaust.

•

Responders should anticipate altitude-dependent changes in pulmonary mechanics as wellas oxygen delivery. If a patient is not able to maintain oxygenation prior to transport despite
intubation, positioning, paralysis, and 100% oxygen delivery, medical control consultation
should be obtained.

•

Movement of known EVD/VHF patients must be reported to CDC/Federal Aviation
Administration (FAA) due to federal quarantine and isolation laws.

•

Transports of suspect or confirmed EVD/VHF patients are typically performed byground units but air ambulance should be considered for long distances. To containinfected materials and minimize contamination of the aircraft, a portable isolation unit isrecommended for air ambulance transport. Coordination with the public health authority
may help to identify qualified air ambulances through HHS.

•

Pilots in rotor-wing aircraft transporting non-intubated airborne or special respiratory
precautions patients should wear an appropriately fitted N95 respirator.

•

Aeromedical services should ensure availability of medical control consultation
during transport.

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OCCUPATIO N A L HE A LTH / E X POSUR ES•

Initial and ongoing training in the types of available PPE and demonstrated proficiency indonning and doffing of PPE is critical to worker safety.

•

EMS personnel – both dispatch and responders – should be provided awareness andeducation about evolving diseases and known outbreaks in the community (e.g., highprevalence of active TB in shelter population, known norovirus outbreak in local nursing
home population) and appropriate PPE to protect workers from these risks as part of usual
operational processes.

•

Significant blood and body fluid exposures should be reported immediately to a supervisor.
A medical evaluation should be completed based on organizational recommendations
or policy.
»

Significant exposures for EMS include blood, bloody saliva or urine, amniotic fluid
exposure to eyes, mucous membranes, non-intact skin or by needlestick or bites. Any
contact with blood or body fluids of EVD/VHF patients may be significant and should
prompt decontamination and appropriate reporting.

»Appropriate HIV and hepatitis screening/Hepatitis B antibody serology should beavailable whenever indicated.

»

Anti-HIV prophylaxis should be available whenever indicated.

»

An infection prevention and control provider should be available for consultation by theagency as needed and be able to obtain patient test results.

•

Contaminated clothing should be washed or discarded in accordance with disease-specificguidelines, generally with hot water, usual detergent, and the addition of household bleachas appropriate for the garment. Discarding contaminated clothing in accordance withregulated waste protocols is preferred when dealing with special pathogens.

•

Higher levels of PPE cause increased heat stress as well as increased motor limitations that
may lead to injury. These factors should be considered when determining the duties andduration of work while wearing the PPE ensemble.

•

Responders should be fit for duty (including appropriate fatigue mitigation) and free of
acute illness.

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Special Considerations•

Responders should be medically monitored after providing care to a confirmed special
pathogen case, even in the absence of a recognized exposure, for subjective illness andfever for the duration of the incubation period to ensure that any developing illness isrecognized and swiftly evaluated. TB, hepatitis, and other exposures may require interval
employee testing.

•

EMS agencies should consider policies ensuring twice daily contact with exposed
personnel to discuss potential symptoms and document fever checks for
special pathogens.

•

Any responder who develops signs of illness should not report to work or should
immediately stop working and notify their supervisor.
»

Prompt medical evaluation should be arranged and notification of local and state healthdepartments should occur as appropriate.

•

Responders should be assessed regarding possibility of post-exposure prophylaxis ortreatment depending on the agent and exposure. Post-exposure prophylaxis is seldom
indicated with the exception of direct contact with patients confirmed to have Neisseria
meningitidis or after a needlestick or other high-risk exposure to an HIV positive source
patient. Prophylaxis may be considered in unprotected exposures to special pathogens in
consultation with infectious disease experts.

•

EMS agencies should consider standardizing pre-exposure immunization requirements for
personnel in accordance with public health vaccination recommendations.

•Behavioral health effects on responders exposed to or caring for a patient with a rare
and highly infectious disease can be significant. Provision of support, resources, andappropriate follow-up is required to improve resiliency. Repeated exposures or a prolonged
incident will increase risks of behavioral health consequences.

•

Patients suspected of having a contagious disease, particularly one associated with highmortality or stigma, will have significant behavioral health consequences that must be
addressed through reassurance, provision of support, timely and accurate information
about their condition as well as normal responses to isolation and stress, and access tomore specialized and culturally specific behavioral health follow-up and resources.

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In case of PPE breach for EVD/VHF precautions:•Move immediately away from sources of contamination to an area where the breach can beevaluated and doffing of PPE is possible.

•

Assess the nature of the breach.

•

Assess the risk of exposure to skin and mucous membranes.

•

Doff PPE according to usual protocol – do not create additional risk by rushing doffing or
skipping steps.

•

Wash thoroughly any exposed skin with soap and water, after which an ABHR can also be
used. Care should be taken not to abrade or damage the skin.

•

Flush exposed mucous membranes thoroughly with water.

•

Note that bleach solutions are not recommended for cleansing of skin as they may damage
the protective outer layer of the skin.

•

Inform supervisory personnel, occupational health, and public health authorities
immediately in the case of exposure to bodily fluids.

•

Assess responder for the possibility of post-exposure prophylaxis or vaccination.

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Special Considerations
R E SO U R C E S­ Blood/Body Fluid Exposure Option­ Bloodborne Infectious Diseases Risk Factors­ Bloodborne Pathogens and Needlestick Prevention­ Collecting, Preserving and Shipping Specimens for the Diagnosis of Avian Influenza
A(H5N1) Virus Infection Guide for Field Operations, Annex 7. Disinfection­ Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response­ Crisis Standards of Care: A Toolkit for Indicators and Triggers­ EMS Pandemic Influenza Guidelines for Statewide Adoption­ Example: Standard Operating Procedure (SOP) for Air-to-Ground (Air-Ground)
Patient Handoff­ Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
­ Interim Guidance for Air Medical Transport­ Q&A’s about the Transport of Pediatric Patients (<18 years of age) Suspected or with
Confirmed Viral Hemorrhagic Fever (VHF)­ Ryan White HIV/AIDS Treatment Extension Act of 2009
­ Updated US Public Health Service Guidelines for the Management of Occupational
Exposure to Human Immunodeficiency Virus and Recommendations for
Postexposure Prophylaxis

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References
ASPR and National Association of County and City Health Officials. (2022). Building
Workforce Resilience through the Practice of Psychological First Aid: A Course for Leadersand Teams. (Free registration required.)This course offers community leaders and teams the opportunity to consider and pursue coping andstress management strategies for supporting colleagues during a disaster response as stress levels
increase for workers and the demands on organizations become more urgent.
CDC. (2007). 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings.
This document provides infection control guidelines for healthcare settings across thecontinuum of care.
CDC. (2007). 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings, Appendix A.
Though somewhat dated, this table provides a good association of selected infections and conditions
with the type and duration of precautions. Note that EMS will not have a diagnosis to work with at thetime of the encounter and will need to be conservative when assessing risk.
CDC. (2013). Blood/Body Fluid Exposure Option.
This document assists healthcare facilities in recording health care worker bloodborne pathogen
exposures and their management.
CDC. (2024). Handling VHF-Associated Waste.
The information on this webpage helps healthcare providers and facility staff safely handle, transport,
and dispose of waste associated with the care of patients with suspected or confirmed viralhemorrhagic fevers.
CDC. (2024). Clinical Guidance for Ebola Disease.
This webpage provides a variety of general resources for health care workers who may manage
patients with Ebola Disease.
CDC. (2024). PPE: Clinically Stable Patients Suspected to have VHF.
This document provides guidance to healthcare workers on donning and doffing PPE while evaluatinga clinically stable person under investigation for viral hemorrhagic fever who does not have bleeding,vomiting, or diarrhea.

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References
CDC. (2024). C. diff: Facts for Clinicians.
This webpage provides answers to frequently asked questions related to C. difficile.
CDC. (2024). PPE FAQs.
This guidance answers frequently asked questions on topics such as the type of PPE to be wornin various situations, training resources, characteristics of different PPE items, donning and doffing
protocols, and management of supplies.
CDC. (2024). Interim Guidance for Air Medical Transport.
This document provides guidance to air medical transport services on the safe transportation ofpatients with Ebola Disease or Marburg Virus Disease.
CDC. (2024). PPE: Confirmed Patients and Clinically Unstable Patients Suspected to have VHF.
This webpage includes guidance on the types of PPE that should be used by those caring for patientswith select viral hemorrhagic fevers. It also includes steps for donning and doffing PPE as well as what
trained observers should do to ensure these steps are followed.
CDC. (n.d.). Guideline for Disinfection and Sterilization in Healthcare Facilities (2008). (Accessed
6/3/2024.)
This guidance provides an overview of performance characteristics of various disinfectants toassist in selection.
CDC. (2024). Infection Prevention and Control of Mpox in Healthcare Settings.
This webpage provides recommendations for Mpox infection prevention in health care settings. EMS
responders are included among the health care personnel considered in the recommendations.
CDC. (2024). Interim Guidance for EMS Systems and 9-1-1 Answering Points.
This guidance provides details on the steps EMS providers should take when caring for a patient underinvestigation for select viral hemorrhagic fevers.
CDC. (2022). Interim Guidance for Infection Control within Healthcare Settings When Caring
for Confirmed Cases, Probable Cases, and Cases under Investigation with Novel Influenza A
Viruses Associated with Severe Disease.
This webpage provides guidance on avian influenza A (H7N9), Asian H5N1, and newly detected avian
influenza H5 viruses in the U.S.

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CDC. (2022). Interim Infection Prevention and Control Recommendations for Healthcare
Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic.
This guidance provides information on the implementation of infection prevention practices in various
health care settings. It includes considerations for EMS vehicle configuration when transporting suspect
or confirmed COVID-19 patients.
CDC. (2019). Middle East Respiratory Syndrome (MERS).
This webpage provides background information about MERS, details where cases have been reported,
answers frequently asked questions, and provides information for healthcare professionals, laboratories,
and travelers.
CDC. (2024). Clinical Safety: Occupationally-acquired Infections and Healthcare Workers.
This web page includes resources to support occupational infection prevention practices and health care
worker safety. It includes information on special pathogens, occupational infection prevention and control,
bloodborne pathogen exposures and infections, personal protective equipment, immunization, aerosol
generating procedures, and links to additional education and training resources.
CDC. (2007). Part III: Precautions to Prevent Transmission of Infectious Agents.
This section of the 2007 Guideline for Isolation Precautions describes the circumstances under which
each type of infection control precaution is applied.
CDC. (2024). Port Health Station Contact List.
This page provides information on the 20 CDC Port Health Stations.
CDC. (n.d.). Sequence for Donning and Removing Personal Protective Equipment. (Accessed
6/3/2024.)
This poster includes graphics demonstrating the steps to safely don and doff PPE.
Department of Emergency Health Services. (n.d.). Emerging Infectious Diseases Videos forPrehospital Providers. (Accessed 6/3/2024.) University of Maryland Baltimore County.
This instructional series, comprised of nine modules, includes an introduction to infectious diseases,
basic infection control concepts, considerations for personal protective equipment (including donningand doffing), personnel decontamination, patient transport, and transfer of patient care for patients with
Ebola and other highly infectious diseases.

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References
Environmental Protection Agency. (2023). Disinfectants for Emerging Viral Pathogens (EVPs):
List Q.
This page assists users in identifying products whose maker claims have efficacy against difficult toinactivate viruses. The Emerging Viral Pathogens guidance applies to Marburg virus, Ebola virus, Mpox
virus, SARS-CoV-2 and its variants, and Rabbit Hemorrhagic Disease virus.
Environmental Protection Agency. (2022). List L: Disinfectants for Use Against Ebola Virus.
The EPA lists products that meet the CDC’s criteria for use against the Ebola virus on hard, non-porous
surfaces. Products are listed by name and indicate whether they are approved for use in hospital/healthcare facilities, institutions such as schools and offices, and residences.
Environmental Protection Agency. (2022). Selected EPA-Registered Disinfectants.
This webpage lists antimicrobials registered by EPA as effective against a varietyof pathogens.
Food and Drug Administration. (2023). N95 Respirators, Surgical Masks, Face Masks, andBarrier Face Coverings. U.S. Department of Health and Human Services.
This web page describes the characteristics and intended uses of N95 respirators and various types ofmasks and face coverings.
InterAgency Board for Equipment Standardization and Interoperability. (2014).
Recommendations on Selection and Use of Personal Protective Equipment for First
Responders against Ebola Exposure Hazards.
The InterAgency Board for Equipment Standardization and Interoperability reviewed current U.S.
government guidance related to PPE in order to develop recommendations for first responders on PPE
selection and decontamination. The recommendations include descriptions of PPE items for high andlow risk exposures and detailed specifications/standards for recommended PPE.
International Academies of Emergency Dispatch. (2020). Emerging Infectious Disease
Surveillance Tool (COVID-19).
This protocol is intended to guide the response of EMS agencies to a patient potentially infected with
SARS-CoV-2.

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References
International Academies of Emergency Dispatch. (2020). Protocol 36: Pandemic/Epidemic/
Outbreak.
This protocol is intended to guide the response of EMS agencies during a pandemic, epidemic,or outbreak.
Isakov, A. (2020). Protecting the Healthcare Worker in the Era of Novel Coronavirus, Bird Flu andOther Serious Communicable Disease.
The one-hour online training increases awareness among EMS responders who may be exposed
to individuals with serious communicable diseases of infection prevention practices and infectious
disease threats.
Isakov, A., Miles, W., Gibbs, S., et al. (2015). Transport and Management of Patients with
Confirmed Ebola Virus Disease. Annals of Emergency Medicine. 66(3):297-305.
This article describes the partnerships between hospitals and EMS agencies in Nebraska and Georgia
to develop policies and practices ensuring the safe transport and management of patients with serious
communicable diseases.
Jenkins, J., Hsu, E., Russell, A., et al. (2022). Infection Prevention and Control for theEmergency Medical Services and 911 Workforce. U.S. Department of Health and Human
Services, Agency for Healthcare Research and Quality.
This technical brief summarizes current evidence related to EMS and 911 workforce exposures toinfectious pathogens and practices to prevent, recognize, and control exposures and illness.
Kuhar, D., Henderson, D., Struble, K., et al. (2013). Updated US Public Health Service
Guidelines for the Management of Occupational Exposure to Human Immunodeficiency
Virus and Recommendations for Postexposure Prophylaxis. Infection Control and Hospital
Epidemiology. 34(9):875-892.
This document provides recommendations on the management of health care workers withoccupational exposure to blood or other body fluids possibly containing HIV.
Lowe, J., Jelden, K., Schenarts, P., et al. (2014). Considerations for Safe Transport of Patients
Infected with Ebola Virus. Prehospital Emergency Care. 19(2):179-183.
This article discusses the coordinated response between the Nebraska Biocontainment Unit andOmaha Fire Department EMS to transport patients with confirmed EVD from West Africa from theairport to the high-level isolation unit.

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References
The National Academies of Science, Engineering, and Medicine. (2012). Crisis Standards ofCare: A Systems Framework for Catastrophic Disaster Response.
This report provides a foundation for the underlying principles of crisis standards of care, the steps
needed for implementation, and the pillars of the emergency response system that ensures crisis
standards of care planning and response occurs.
The National Academies of Science, Engineering, and Medicine. (2013). Crisis Standards ofCare: A Toolkit for Indicators and Triggers.
This toolkit includes indictors, triggers, and tactics for EMS pandemic planning in Toolkit Part 2:
Emergency Medical Services, pages 145-158.
National Emerging Special Pathogens Training and Education Center (NETEC). (2018).
Containment Wrap in a Special Pathogen Isolation Area.
This training video demonstrates how to transfer a patient infected with a special pathogen in acontainment wrap.
NETEC. (2024). Q&A’s about the Transport of Pediatric Patients (<18 years of age) Suspected orwith Confirmed Viral Hemorrhagic Fever (VHF).
This webpage provides first responders with information to help protect themselves, younger patients, andpatients’ family members by answering the most frequently asked questions.
NETEC. (n.d.). Example: Standard Operating Procedure (SOP) for Air-to-Ground (Air-Ground)
Patient Handoff. (Accessed 6/3/2024.)
This sample SOP is intended to enable the successful handoff of patients between air and groundambulance agencies.
NETEC. (n.d.). Example: Standard Operating Procedure (SOP) for Decontamination of an
Ambulance that has Transported a Person under Investigation or Patient with Confirmed
Ebola. (Accessed 6/3/2024.)
This sample SOP is intended to assist EMS agencies in standardizing procedures and responsibilities
related to the decontamination and disinfection of ambulances used to transport patients with EVD.
NETEC. (n.d.). Example: Standard Operating Procedure (SOP) for Patient Handoff between a
Healthcare Facility and a Transporting Ambulance. (Accessed 6/3/2024.)
This sample SOP is intended to enable planning between an EMS agency and healthcare facility on thehandoff of patients with serious communicable diseases.

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NETEC. (2022). EMS Biosafety Transport: Viral Hemorrhagic Fevers: Ebola Virus Disease.
This online course instructs EMS professionals in biosafety considerations when transporting patientssuspected or confirmed to be infected with a viral hemorrhagic fever.
NETEC. (2023). EMS Guidelines for Marburg Virus Disease.
This page provides background information on Marburg virus disease, describes the identify-isolateinform framework, discusses the hierarchy of controls, and provides links to additional resources.
NETEC. (2022). EMS Response to the Current Outbreak of Mpox.
This page provides a situation update on the Mpox outbreak and strategies for EMS to prevent
disease transmission.
NETEC. (n.d.). NETEC Exercise Templates. (Accessed 6/3/2024.)
This web page includes links to various Homeland Security Exercise and Evaluation Program-compliant
templates to assist health care coalitions, frontline facilities, assessment hospitals, state-designatedEbola treatment centers, regional Ebola and special pathogen treatment centers, and their respective
response partners in the planning and conduct of exercises on the identification, assessment,
treatment, management, transport, and transfer of high-risk patients. The site includes tabletop exercise
templates for regional transport plans for both Ebola and airborne special pathogens. There is also a
beginners guide to assist users new to exercise planning.
National Highway Traffic Safety Administration. (2007). EMS Pandemic Influenza Guidelines forStatewide Adoption. U.S. Department of Transportation.
This document provides guidance to EMS agencies on the development of pandemic influenza
plans and protocols. While the document precedes the 2009 H1N1 pandemic it is still the mostcomprehensive planning resource for EMS.
The National Institute for Occupational Safety and Health. (2024). Bloodborne Infectious
Diseases Risk Factors.
This webpage includes various resources for health care workers potentially exposed to a bloodborne
infectious disease through a needlestick or sharps injury.

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References
The National Institute for Occupational Safety and Health. (2020). Considerations for Selecting
Protective Clothing used in Healthcare for Protection against Microorganisms in Blood and
Body Fluids.
This webpage provides considerations for the selection of PPE items based on their barrier properties
and includes links to current standards and specifications for fluid-resistant and impermeable gowns
and coveralls.
Occupational Safety and Health Administration. (n.d.). Bloodborne Pathogens Standards, 29
CFR 1910.1030. (Accessed 6/3/2024.)
This page contains the regulatory language for the bloodborne pathogens standard.
Occupational Safety and Health Administration. (2009). Pandemic Influenza Preparedness andResponse Guidance for Healthcare Workers and Healthcare Employers.
This document provides an overview of infection control and other standards appropriate forpandemic influenza.
Occupational Safety and Health Administration. (2014). PPE Selection Matrix for Occupational
Exposure to Ebola Virus.
The U.S. Department of Labor shares information on the type of PPE to be worn in various situations(e.g., normal work activities, casual interaction, providing medical and supportive care, cleaning anddisinfecting environments, and dealing with waste).
Occupational Safety and Health Administration. (n.d.). Respiratory Protection Standards.
(Accessed 6/3/2024.)
This page contains standards on respirators, respiratory protection, and the medical
evaluation program.
Occupational Safety and Health Administration. (2016). Safe Handling, Treatment, Transport,
and Disposal of Ebola-Contaminated Waste.
This fact sheet provides a step-by-step summary of actions workers should take from the point Ebolacontaminated waste is generated through final disposal.

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References
Sehulster, L. and Chinn, R. (2003). Guidelines for Environmental Infection Control in HealthCare Facilities: Recommendations of CDC and the Healthcare Infection Control Practices
Advisory Committee (HICPAC). Morbidity and Mortality Weekly Report. 52(RR10):1-42.
This report provides recommendations for environmental infection control in healthcare facilities. Notethat an erratum to this report is also available.
U.S. Department of Health and Human Services and U.S. Department of Transportation. (n.d.).
Guidance for Developing a Plan for Interfacility Transport of Person Under Investigation orConfirmed Patients with Ebola Virus Disease in the United States. (Accessed 6/3/2024.)
This guidance is intended to support EMS agencies in the development of plans and procedures for theinterfacility transport of suspected or confirmed Ebola Disease or Marburg Virus Disease patients.
Various Federal Agencies. (2022). Managing Solid Waste Contaminated with a Category A
Infectious Substance.
This federal interagency guidance is intended to improve the safe handling of Category A contaminatedsolid waste.
World Health Organization. (2006). Collecting, Preserving and Shipping Specimens forthe Diagnosis of Avian Influenza A(H5N1) Virus Infection Guide for Field Operations:Annex 7. Disinfection.
This guide provides information on the preparation of chlorine bleach solutions for disinfection purposes.
World Health Organization. (2007). Standard Precautions in Health Care.
This fact sheet provides healthcare facility recommendations for standard precautions.

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Index of A bbrev iations
ABHR
AIDS
AIIR
ALS
AMT
ASPR
BiPAP
BLS
BP
CAD
CDC
CPAP
CPR
ECC
EMS
EMT
EPA
ETA
EVD
FAA
GI
HCID
HEPA
HHS
HIV
IVF
MERS
MRSA
MVD
NETEC
NIH
NIOSH
PAPR
PPE

alcohol-based hand rub
acquired immune deficiency syndrome
airborne infection isolation room
advanced life support
air medical transport
Administration for Strategic Preparedness and Response
bilevel positive airway pressure
basic life support
blood pressure
computer aided dispatch
Centers for Disease Control and Prevention
continuous positive airway pressure
cardiopulmonary resuscitation
emergency communications center
emergency medical services
emergency medical technician
Environmental Protection Agency
estimated time of arrival
Ebola virus disease
Federal Aviation Administration
gastrointestinal
high consequence infectious disease
high-efficiency particulate air
U.S. Department of Health and Human Services
human immunodeficiency virus
intravenous fluids
Middle East Respiratory Syndrome
Methicillin-resistant Staphylococcus aureus
Marburg virus disease
National Emerging Special Pathogens Training & Education Center
National Institutes of HealthNational Institute for Occupational Safety and Healthpowered air-purifying respirator
personal protective equipment

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Index of A bbrev iations
PSAP
PUI
RSV
SOP
TB
TRACIE
VHF
VRE
WHO

public safety answering point
persons under investigation
respiratory syncytial virus
standard operating procedure
tuberculosis
Technical Resources, Assistance Center, and Information Exchange
viral hemorrhagic fever
Vancomycin-resistant enterococci
World Health Organization

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Acknowledgments
This playbook is a project of ASPR TRACIE with initial draft
materials developed by Alexander Isakov, MD, MPH, Emory
University; additional contributions and editing by John Hick, MD,
HHS ASPR TRACIE and Hennepin County Medical Center; andreview by the TRACIE team in 2017. ASPR TRACIE gratefully
acknowledges the contribution of materials from CDC, HHS/ASPR,
the Emory‑Grady EMS Biosafety Transport Program (Wade Miles,
Aaron Jamison, Gail Stallings, John Arevalo, Jim Zerylnick,Sam Shartar), and the EMS Biosafety Transport Consortium(Emory University/Grady EMS, University of Nebraska Medical
Center/Omaha Fire Department, U.S. Department of State/Office ofOperational Medicine, National Institutes of Health (NIH) Division ofFire and Rescue Services/NIH Division of Occupational Health and
Safety, Fire Department of New York, Phoenix Air Group, American
Medical Response). Dr. Isakov revised the playbook in 2023 withextensive review and input from Dr. Hick; Chad Bowman, MSN,
RN, CFRN, NR‑P, LIFELINE Critical Care Transport Team, The
Johns Hopkins Hospital; Stefanie Lane, MPH, MS, Massachusetts
General Hospital Center for Disaster Medicine; Chris Laporte,
Mass General Brigham; Wade Miles, NRP, Emory University Officeof Critical Event Preparedness and Response; Ben Tysor, NRP,
Omaha Fire and Rescue; and the ASPR TRACIE team.
Additionally, ASPR TRACIE thanks the following subject matter
experts for their review of the original and/or Version 2.0 of theplaybook: Eric Alberts, CEM, FPEM, FPEM‑HC, CHPP, CHEP,
SEM, Orlando Health, Inc.; Howard Backer, MD, MPH, California
Emergency Medical Services Authority; Paul Biddinger, MD,
FACEP, Mass General Brigham; Paul Brooks, Department ofHomeland Security Office of Health Affairs; Thomas Breyer,
International Association of Fire Fighters; Stephen Cantrill, MD,
Denver Health and Hospital Authority; John Chiaramonte, Mission
Critical Partners, Inc.; Carol Cunningham, MD, Ohio Departmentof Public Safety; Drew Dawson, National Highway Traffic Safety
Administration Office of Emergency Medical Services (former);
Daniel Dodgen, PhD, ASPR Office of Policy and Planning;
Chad Dowell, MS, National Institute for Occupational Safety and
Health; Eileen Frazer, RN, CMTE, Commission on Accreditationof Medical Transport Systems; Patricia Frost, RN, MS, Contra
Costa Health Services; Scott Giberson, BSPharm, MPH, Centers
for Medicare and Medicaid Services; Jack Herrmann, MSEd,
ASPR Office of Policy and Planning; Ken Hopper, ASPR Officeof Emergency Management; Kevin Horahan, JD, MPH, ASPR
Office of Emergency Management; Rick Hunt, MD, ASPR Hospital
Preparedness Program; Mark Jarrett, MD, MBA, MS, Northwell
Health; Rachel Kaul, LCSW, ASPR Office of Policy and Planning;
Jon Krohmer, MD, National Highway Traffic Safety Administration;
Pamela Lane, MA, National Association of Emergency Medical
Technicians; Sherline Lee, MPH, Centers for Disease Control
and Prevention; Syra Madad, DHSc, MSc, New York City Health+ Hospitals; Robert McClintock, International Association of FireFighters; Rick Murray, EMT‑P, American College of Emergency
Physicians; Amber Payne-Gregory, RN, BSN, MBA, CFRN,
CMTE, Airmed International; Dave Pigott, MD, The University of
Alabama at Birmingham Medicine; Frank Pratt, MD, MPHTM, Los
Angeles County Department of Public Health; Angel Rivasrivera,
MSN, BSN, ASPR Office of Emergency Management; Dennis
Rowe, NREMT‑P, National Association of Emergency Medical
Technicians; Terry Schenk, MS, CEM, Florida Department of
Health; Leslee Stein-Spencer, RN, MS, National Associationof State EMS Officials; Amy Valderrama, PhD, RN, Centers for
Disease Control and Prevention; Lynn White, MS, American
Medical Response; and representatives of the National Associationof EMS Physicians and the National Association of Emergency
Medical Technicians.
.

Brought to you by HHS ASPR, theTechnical Resources, Assistance Center,and Information Exchange (TRACIE) was
created to meet the information andtechnical assistance needs of regional
ASPR staff, healthcare coalitions,healthcare entities, healthcare providers,emergency managers, public healthpractitioners, and others working indisaster medicine, healthcare system
preparedness, and public healthemergency preparedness. Find out moreby visiting https://asprtracie.hhs.gov/ oraccessing this fact sheet, or email uswith any questions or requests fortechnical assistance.