Ebola – Clinical Updates with a Global Perspective

Coordinator:
Welcome and thank you for standing by. At this time, all participants are in a listen-only mode.

During the question and answer session, please press star one and record your name as prompted.

Today’s conference is being recorded. If you have any objections, you may disconnect at this time. I would now like to turn the meeting over to Ibad Khan. Thank you. You may begin.

Ibad Khan:
Thank you. Carolyn. Good afternoon. I’m Ibad Khan and I’m representing the Clinician

Outreach and Communication Activity, COCA, with the Emergency Risk Communications

Branch of the Centers for Disease Control and Prevention.

I am delighted to welcome to you to today’s COCA call, Ebola: Clinical Updates for the Global Perspective. We are pleased to have with us today Dr. Daniel Jernigan and Dr. Maleeka Glover to provide an update on the status of the Ebola update and updated guidance to healthcare providers who are presented with patients that have traveled from Liberia. Clinicians will also receive guidance on taking thorough histories and on using clinical judgment to evaluate patients.

There is no continuing education or slides provided for this call. Additional resources for clinicians are available on our COCA Web site at Emergency.cdc.gov/COCA. That address is Emergency.cdc.gov/COCA. Please look under the Ebola Call Web page.

Our first presenter today is Dr. Daniel Jernigan. Dr. Jernigan is the Deputy Director for the Influenza Division at the Centers for Disease Control and Prevention. He received his MD from Baylor College of Medicine and a Master of Public Health at the University of Texas. He is board certified in internal medicine and has completed an additional residency in preventive medicine.

Dr. Jernigan has over twenty years of CDC experience and is currently serving as the Incident Manager for CDC’s Ebola response.

Our second presenter, Dr. Maleeka Glover, is a senior research scientists and epidemiologist in the Influenza Coordination Unit at CDC. Dr. Glover received a doctorate in health and social behavior from the Harvard School of Public Health and a Master of Public Health in Epidemiology from the University of Michigan. She’s also a certified health education specialist.

For the Ebola response, Dr. Glover is serving as the epidemiology lead for both domestic and international epidemiology, and collaborates with states and providers regarding risk assessment of travelers from West Africa and persons under investigation.

In addition to today’s presenters, CDC subject matter experts will be available to answer questions regarding infection control, including PPE use, travel, global migration and quarantine, epidemiology, surveillance and state health during the Q and A section of today’s COCA call.

At the end of the presentation, you will have the opportunity to ask the presenters questions on the phone. Dialing star one will put you in the queue for questions. Questions will be limited to clinicians who would like information on clinical guidance related to Ebola. For those who have media questions, please contact CDC Media Relations at 404-639-3826, or send an email to Media@cdc.gov.

At this time, please welcome Dr. Jernigan.

Dr. Daniel Jernigan:
Thank you very much and thanks to all those that are taking time out of their busy days to listen

to us about some of the changes that are occurring to the screening and monitoring guidance.

So, very briefly I want to just give you a little background on where we are with Ebola, talk a little bit about some of the risk determinations that we have been working on here, and then go through some of the changes that are occurring to the screening and monitoring guidance. Then I’ll hand it over to Dr. Glover to go through the details of some of the handling of persons under investigation that are of interest to go through that.

So let me first just talk a little bit about what’s happening in West Africa right now. Currently, there are cases that are occurring in two countries. I think most everyone’s familiar with that, but those are in Guinea and in Sierra Leone. And those are happening at about two or three cases or so per day.

Those are happening in particular areas where we see recurrence of cases, especially along the border of Guinea and Sierra Leone. They’re occurring because of some exposures to traditional healers and to family clusters, and a number of activities in terms of contact tracing, case investigations, social mobilization. All of those different activities are well underway now and, in fact, at this point where the cases are going down, we want to increase the amount of that activity so that we can be sure to get to zero for those two countries.

In Liberia, it’s now been about eighty-two days since the last case. There was a case that died. That case - we’re forty-two days past from that case, and WHO declared on May 9 that Liberia no longer had an outbreak. At that time, WHO also recommended that there be ninety days of enhanced surveillance and that during that period of time that exit screening would occur in Liberia.

At this point, we are taking all of that into account and looking at the different transmission factors that are leading us to make some changes in some of our screening and monitoring guidance. There are a couple of reasons why Liberia is different from, say, Mali where some Ebola cases did occur, or from other African countries where Ebola has been in the past. And it’s also different from Sierra Leone and Guinea where there is currently transmission occurring.

So Liberia is actually a place that has former widespread transmission, so there are a number of people that have been affected. There are actually a number of survivors there now. And what we’ve learned with this recent outbreak in West Africa is that there are some kinds of transmission that we didn’t fully appreciate or sources of transmission in the past. One in particular is sexual transmission.

We know that there are several hundred men that are capable of transmitting through semen, and so that’s a place where there is a potential for there to be a reemergence of cases in Liberia. So that’s one thing that’s different here, and even though there are currently not any cases that we know of and surveillance is currently underway, there is the potential that there can be reemergence of cases in some unrecognized transmission period of time prior to them being recognized.

There are also - there is also the possibility that there are people that come over from Sierra Leone or from Guinea, and those individuals could also start some unrecognized chains of transmission before we know that they’re there. Those two things make Liberia in a different space than the countries that have had just a few cases of Ebola that have bene brought over.

So even though there is transmission there, those cases would need to get to the US, actually, for us to have Ebola happen in the United States. At this point, there’s been almost 20,000 people that have come though and have undergone active monitoring or direct active monitoring in the US, and we’ve not had any cases that have been under active monitoring or direct active monitoring so far.

So we’re in a situation now where the risk is actually very dynamic. It’s actually going down over time. The farther away we get from the last case in Liberia, the longer the individuals who may still have Ebola in their semen - as that continues to go down, it’s at the same time as the number of travelers are increasing. So it makes us want to take into account all of those factors trying to balance the risk that is changing and also the operational aspects of trying to do screening and monitoring in the US. We want to take those all into account.

So with that, we put out a statement on Friday and this information will be available on our Web site as well of the changes to the Liberia screening and monitoring that have occurred. So starting today, the US government will modify its enhanced Ebola entry screening and monitoring program for travelers from Liberia, recommending a stepdown approach to monitoring travelers from Liberia.

While the outbreak in Liberia has ended and routine travelers returning from Liberia are considered to be at very low risk, the United States will maintain a modified level of entry screening and ask travelers to subsequently watch their health for twenty-one days.

As a result of this change, CDC’s updating its interim US guidance for monitoring and movement of persons with potential Ebola virus exposure. That will be available on the Web soon.

Travelers from Liberia are still considered low, but not zero risk. So this is not a complete shutdown of all processes for these travelers. The travelers from Liberia will continue to be funneled through one of the five designated US airports and will be screened upon arrival by the US Customs and Border Protection. Once they are here, travelers will continue to have their temperatures taken at customs and border protection and will be asked questions about travel history and possible exposure to Ebola.

Travelers will also need to provide their contact information so that they health department at their destination can connect with them if needed. Each state will determine its own policy for whether to contact and monitor travelers arriving from Liberia. States should note that this will affect the state-to-state transfer of travelers from Liberia. So for those state departments that are on the call that weren’t able to hear that yesterday, you may not be able to know that state-to-state transfer information.

Travelers at the airport from Liberia will now receive a modified check and report Ebola care kit with instructions for them to watch their health for twenty-one days after leaving Liberia, and to contact their local health departments if they have a fever or any other symptoms consistent with Ebola. This change that’s happening does not affect US enhanced entry screening and post-arrival monitoring for travelers returning from Sierra Leone and Guinea; nor does it affect exit screening for travelers departing from Liberia.

So that information was sent out in a notice on Friday and also will be available on our Web site. At this point, let me hand it over to Maleeka Glover to give us the details on the clinical aspects.

Dr. Maleeka Glover:
Thanks Dr. Jernigan. Because no cases of Ebola among travelers and low but not zero risk of exposure who have been in countries with widespread transmission or former widespread transmission in the previous twenty-one days have been documented, other more common acute conditions consistent with the signs and symptoms should be considered and placed higher on the list of differential diagnoses as appropriate. And diagnostic testing should be conducted to confirm the diagnosis.

Travelers with low but not zero risk of Ebola exposure returning to the United States from Ebola-affected countries over the past year have had symptoms suggestive of Ebola most often have had malaria or respiratory infections.

For travelers with low but not zero risk of exposure returning from countries with widespread of former widespread Ebola transmission in current established control measures with signs and symptoms consistent with Ebola virus disease, healthcare providers should follow the guidance by country of travel.

For travelers from Sierra Leone or Guinea, we are asking that you continue to place that traveler in a private room, use Ebola PPE, and conduct a thorough travel Ebola virus exposure and health history, including vaccination prophylaxis compliance. And diagnostic testing and treatment should be based on clinical judgment, taking into account the patient’s risk of exposure to Ebola virus.

Evaluate the patient using clinical guidance and case definitions provided by CDC, and investigate other potential causes of the patient’s signs and symptoms without delays in patient care.

For travelers from Liberia only, we are asking that you also place the patient in a private room if they have signs and symptoms consistent with that of Ebola virus disease. However, we ask that you follow routine standard hospital infection control practices and protocols based on symptom presentation.

Again, conduct a thorough travel Ebola virus exposure and health history, including vaccination and prophylaxis compliance for other infectious diseases, diagnostic testing and treatment. Again, it should be based on clinical judgment, taking into account the patient’s exposure risk for EVD.

Continue to evaluate the patient using clinical guidance and case definitions provided by CDC. Follow standard hospital infection control protocols for use of patient care and other medical equipment, medical procedures, environmental infection control, and laboratory testing. And again, investigate other potential causes of the patient’s signs and symptoms without delay in patient care.

For travelers from Sierra Leone, Guinea, or Liberia with no signs and symptoms consistent with Ebola, you can follow standard hospital infection control practices and protocols.

Healthcare providers should consider a few of the more common acute syndromes for which persons under investigation have presented for evaluation, including the following: acute febrile illnesses with localized signs or symptoms. These can be manifested with or without localizing signs of acute fever.

Acute upper and lower respiratory tract illnesses -- these can be manifested with or without fever by sneezing, nasal congestion or stuffiness, nasal discharge, sore throat, hoarseness, eye burning or tearing, cough, malaise, muscle aches, and headaches.

Because the causes of common cold, sinusitis, pharyngitis, bronchitis, and pneumonia can be bacterial or viral, appropriate tests for these conditions should be used to establish an alternative diagnosis.

And lastly, acute gastrointestinal illnesses -- these can be manifested with or without fever by diarrhea, nausea, vomiting, abdominal pain, abdominal cramps, headache, and rash. Because the causes of acute GI illness are likely to be due to enteric pathogens, hydration and enteric treatment should be considered, taking into account travel-associated etiologies.

GI symptoms may also be associated with respiratory or systemic infection. Raid tests for malaria, influenza, respiratory, and gastrointestinal pathogens are very helpful. Proper interpretation of test results is needed as these rapid tests may not have the sensitivity or specificity necessary to rule out pathogens. Molecular assays have much higher sensitivity than rapid screening tests.

So for persons who are returning from Liberia that are low but not zero risk and that is the only category they currently fall in, if they do present with signs and symptoms that are consistent with Ebola, they are still by definition considered a PUI and we are, again, recommending that they be placed in a private room so that the hospital can follow routine standard hospital infection control practices and protocols based on symptom presentation.

Dr. Daniel Jernigan:
Thank you Dr. Glover for going over that with us. So at this point, I’ll hand it back to Ibad.

Ibad Khan:
Thank you Dr. Jernigan and Dr. Glover for providing our COCA audience with such a wealth of information. As a reminder, CDC subject matter experts are available to answer questions regarding infection control including PPE use, travel, global migration and quarantine, epidemiology, surveillance, and state health during this Q and A session.

Again, questions are limited to clinicians who would like information on clinical guidance related to Ebola. For those who have media questions, please contact CDC Media Relations at 404-639-3286, or send an email to Media@cdc.gov.

Operator, we will now open up the lines for the question and answer session, please.

Coordinator:
Thank you. We will now begin the question and answer session. If you would like to ask a question, please press star one. Make sure your phone is unmuted and you must record your name slowly and clearly to introduce your question. To withdraw that request, you may press star two.

Once again, for question or a comment, press star one and record your name at this time. One moment for our first question. And again, that is star one and you must record your name to introduce your question. And it is star two to withdraw that request. One moment please. And our first question or comment comes from Bernadette. Your line is open.

Bernadette:
Hi. Thank you for the call. I’m struggling a little bit on trying to understand the interpretation of procedures when you’re using the term PUI, private room, and routine infection control practices in the same sentence. I understand a Sierra Leone and a Guinea patient presenting with symptoms consistent with Ebola or suggestive of Ebola following through to be a PUI, which really activates a set of infection control protocols that are distinctly different from routine.

What I’m not clear about is if we have a Liberian patient who presents with an acute febrile illness and we’re still using the term PUI, but yet saying just follow standard infection control. That seems that we can do that without necessarily having to reference them as a person under investigation. Thank you.

Dr. Daniel Jernigan:
Yes. I think you point out an important point, and that is that there are a number of things that are - that we need to take into account when we’re thinking about how you operationalize these activities and the introduction of new categories of patients, of new terminology, et cetera. We’ve been trying to minimize that while at the same time providing some additional flexibility for these Liberian - these travelers from Liberia who actually have a lower risk than those from Sierra Leone and Guinea, but don’t have the same risk as travelers from other parts of West Africa.

And so we’ve been trying to account for how much we give the flexibility to versus us creating new categories. In this setting we’ve maintained the term PUI, but have asked that they go to that private room and that they get assessed; but the infection control processes that you use are actually those that would be routine or those that would be used as a part of routine care standard precautions.

We discussed, possibly, ill Liberian travelers, things like that, and other terms that you might have come up with, but we’ve stuck with this term PUI so that PUI now does not necessarily imply the use of the full PPE that’s described in the documents that you have.

We have some things that will be coming out very shortly, some flow diagrams, a statement that’s virtually word-for-word for that Maleeka presented, and that should be coming out very soon. And so that should, I think, help clear up some of this; but I think to your point, we are using the same term PUI, but we are saying that for those travelers from Liberia that they can be handled with an infection control practice that is not the full PPE.

Bernadette:
Okay, thank you.

Coordinator:
Thank you. And again as a reminder, if you have a question or a comment, it is star one. Make sure your phone is unmuted and you must record your name slowly and clearly to introduce your question. And to withdraw that request, you may press star two.

Once again, for further questions or comments at this time, please press star one and record your name. One moment while we stand by for further questions or comments.

One moment please.

And we do have Pat from the Department of Health. Your line is open.

Pat:
Hi. I just wanted to clarify, then, if it’s somebody from Liberia and an assessment is done and you determine they’re a PUI and you would like to draw blood, even at that point until you get the lab results back you will be using routine practices like just standard infection prevention and control that whole time. Or once you decide to draw the blood, would you be changing at all your procedures?

Dr. Daniel Jernigan:
At this point we are saying that you can use standard procedures in order to collect that blood. You do not have to have all of the same that you would have for the Sierra Leone and Guinea travelers.

Pat:
And then the only thing that would change that, then, is if the result comes back positive. Then obviously you would move to the Ebola infection prevention and control procedures at that point.

Dr. Daniel Jernigan:
Correct. We do think the risk is very low here and we do not want to have travelers from Liberia be unnecessarily delayed in their care. We do want to make sure that everybody thinks travel, that there are things that are other than Ebola. It is a risk, but a very low risk in these patients. The other things that are much more likely need to be considered.

And so we are not recommending that you do any testing for Ebola first before you do other things. We’re asking you to use your clinical judgment in these individuals and make sure that you think about those other causes, and that you do work up those because they are the more likely cause.

Coordinator:
Does that conclude the question or comment?

Pat:
Yes.

Coordinator:
Thank you very much. Our next question or comment comes from Amelia Baumstead. Your line is open.

Amelia Baumstead:
Hi, yes. I had a question. Normally it’s our procedure to contact our department of public health who is in contact with CDC regarding permission to run testing. I was wondering in the case of a traveler from Liberia that would come through O’Hare presenting with a fever and some low but not no risk -- would we need to still follow those same protocols to get permission to test? And would that permission to test be contingent on - say we’ve ruled out malaria or something else.

Dr. Daniel Jernigan:
At this point, we do encourage the discussion between the healthcare facility and the department of health. So yes, you would need to contact them if you wanted that Ebola testing to be performed. At this point, I think we’re not saying that you need to rule out all of these other things before Ebola. We think that if in your assessment that you determine that you’ve identified some risk factors that were not known previous or the constellation symptoms really point to what you might consider to be viral hemorrhagic fever, in that setting of course you’d be contacting the department of health.

What we’re asking is that these travelers when they do get sick to contact their state health departments or local health departments. That would then allow them to discuss with the health department about what the next step would be. Many of those will show up, and for those that show up we are expecting that you would contact the health department and walk through the possibilities there.

I think the experience so far among the staff here that have been engaging with the hospitals is that we can look at this at almost a case-by-case basis and help identify what the level of suspicion is and what kind of testing can be performed, and that the Ebola testing is not always required.

Amelia Baumstead:
Thank you.

Coordinator:
Thank you. And our next question or comment is from Albert Fif). Your line is open.

Albert Fife:
Yes, good afternoon. Thank you for doing this call. You did mention that all the travelers from Liberia will still be coming through the five airports that have been identified, but a modified packet will be given to them. How is that packet going to be modified or different from what’s given to the Sierra Leoneans or the Guineans?

Dr. Daniel Jernigan:
So - and I think that - remember that the decisions about what we do is a federal-wide agreement. And so the agreement at this point is that the funneling will continue. There’s some operational issues at high level with the customs and border protection folks that make it best for us to continue that funneling, notably so that we can restart the Liberian monitoring and screening again if we need to. So if there is a reemergence, having the funneling continue will allow us to more rapidly stand that back up.

When they come through, the traveler will not actually see or feel that much different from what’s been happening before with the travelers from Liberia. They will be asked the same questions that are on the form that customs and border protection will have. They will be identified as being from Liberia and they will also be - it will be determined whether they have had any travel to Sierra Leone or Guinea.

If they’ve had any travel to Sierra Leone and Guinea, they actually are treated as though they are a traveler from Sierra Leone and Guinea. If they answered any of the risk questions they’ll actually go the same way. They’ll be treated the same way.

For those that are not from Sierra Leone or Guinea, don’t answer the questions in a way that would put them in that category, then those Liberian - those travelers form Liberia are sent to an area where they receive a form that will be available on the Web site which basically gives the numbers of all the state health departments and it gives some information about what symptoms to be aware of, and a little card that they can take with them to the clinician when they show up.

They also get a thermometer and they are asked that if they have any symptoms for them to check their temperatures. But they are not being required to monitor their temperatures twice a day and record them. So that’s one other difference that’s happening with the travelers from Liberia. There also is no phone that is provided to them.

Albert Fife:
Okay. But the state health department will be informed about those travelers as has been happening in the past.

Dr. Daniel Jernigan:
We’ve offered the opportunity for state health departments to receive the names and contact information for these travelers, and probably thirty so far have elected to receive that information. And that’s actually still coming through, so that number may go up. But the travelers’ information actually is available so that if there is a concern, a question, or if a state health department who has elected not to receive that information decides they would like to have that information, it will be available.

Albert Fife:
Okay, thank you.

Coordinator:
Thank you. Our next question or comment comes from Christine Gilnetfine. Your line is open.

Christine Gilnetfine:
Hi, how are you? Thank you so much for your presentation. You started to touch briefly on my question, but I wanted to get a little further clarification. It’s my understanding that previously the returning travelers already knew which facilities they would report to should they start to be symptomatic. With the returning travelers from Liberia, is that no longer going to happen? And are we more likely to have random unannounced, if you would, patients present to our ER? Or would they still be advised to go through the local health department first?

Dr. Daniel Jernigan:
If a traveler becomes ill, they are instructed to contact the state health department who then can direct them to a healthcare facility that would be most appropriate for their presenting symptoms. And so if that’s the case, then some contact with that facility would be made. If a traveler arrives at a health facility that is not an assessment facility, our guidance is that the facility communicate with the state health department and then have that dialogue.

We’re not asking that all of these individuals go to an assessment hospital because we know that the numbers of travelers are increasing, that the risk is very low; but we do want to be aware of them when they do hit these facilities. But we recognize that more and more people will be probably going to these non-assessment hospitals, and so we’re trying to be flexible with that.

Christine Gilnetfine:
Okay. Thank you very much.

Coordinator:
Thank you. Our next question or comment comes from Yolissa Castanos. Your line is open.

Yolissa Castanos:
Hi. I have a question. We’re an outpatient clinic in upper Manhattan and I know you said that to do bloodwork you just needed to follow standard precautions but if they do present with symptoms, do we still isolate them and use PPE as recommended before?

Dr. Daniel Jernigan:
At this point if they’re presenting with symptoms that are listed already on the algorithm, those - we are asking that they be put into a private room to be isolated but that you can use your routine infection control practices. We’re not requiring that you use the full PPE at this point.

Yolissa Castanos:
Okay. So does that guideline - we no longer need to follow that as of now for any patients that are coming from Liberia?

Dr. Daniel Jernigan:
Just for those from Liberia. So this is a complicated and challenging thing in that we’re separating out Sierra Leone, Guinea from Liberia. And so those places - an additional activity on the healthcare providers to differentiate that among these travelers. However, we recognize that a number of healthcare facilities are wanting that flexibility to be able to use this lesser PPE partly because of the risk, but partly because of the operational issues.

Yolissa Castanos:
Right. So for the Sierra Leone and Guinea, do we still use the PPE?

Dr. Daniel Jernigan:
Yes, absolutely. And so that’s where this is a challenging guidance, but yes. For those travelers from Sierra Leone and Guinea, nothing has changed.

Yolissa Castanos:
Okay, great. Thank you very much.

Coordinator:
Thank you. And again as a reminder, for questions or comments it is star one. Make sure your phone is unmuted and you must record your name to introduce your question. And it is star two to withdraw that request.

Our next question or comment comes from Paul Butcher. Your line is open.

Paul Butcher:
Hi. It’s Paul Butcher from the Milwaukee Health Department. I wanted to talk about the clinician calling the public local health department for Liberians who have symptoms. If they’re - the clinician is ruling out malaria or other reportable diseases, wouldn’t it make sense even if Ebola is not high on the differential for the clinician to contact them for those other reportable diseases?

Dr. Daniel Jernigan:
Absolutely, and I think this is a good opportunity to have that dialogue about improving detection of travel-associated illnesses. So we want to make sure that people think travel, not just Ebola here.

And so if we look at the numbers of people that have gone through that have been symptomatic and have been tested, malaria is one of those common things that is showing up. We want to make sure that clinicians don’t delay in seeking that kind of care. So definitely follow the reportable condition requirements for your jurisdiction.

Paul Butcher:
Thank you.

Coordinator:
Thank you. And again as a reminder, it’s star one and record your name for a question or comment, and it is star two to withdraw that request. We’ll stand by for further questions or comments at this time.

And I’m currently showing no further questions or comments at this time. One moment. We just had one queue up, please. And we do have a question or comment from Brenda. Your line is open.

Brenda:
Hey there. I just had one question about the isolation of the patient. If you’re thinking that their risk is pretty low, the isolation doesn’t need to be a negative pressure room or just a private room?

Dr. Daniel Jernigan:
Yes. This is probably a problem with our terminology, but the way it’s described is a private room.

Brenda:
Okay.

Dr. Daniel Jernigan:
It is not airborne infection isolation.

Brenda:
Alright, thank you very much.

Coordinator:
And are you concluded with the question or comment?

Brenda:
Yes I am.

Coordinator:
Thank you. Our next question or comment comes from Alicia Cuccia. Your line is open.

Alicia Cuccia:
Hi there. I’m calling from LA County Department of Public Health. I would like to know if the Care Light document comes in another language besides English?

Dr. Daniel Jernigan:
Let me hand hat over to Dr. Clyde Brawn.

Dr. Clyde Brawn:
At this time, no, but we are considering doing some French as well. So as it stands it’s only in English.

Dr. Daniel Jernigan:
So the one that was sent out with the package last week is in English. French is not available right now, but we are trying to work on that.

Coordinator:
And does that conclude the question or comment?

Alicia Cuccia:
Yes. Thank you so much.

Coordinator:
Thank you. You’re welcome. Next question or comment comes from Eddie Reyes. Your line is open.

Eddie Reyes:
Hello. I have actually a clarification. In the beginning you said that most of the changes or the modifications will be available online.

Dr. Daniel Jernigan:
Yes. The goal is to have all of this in a way that’s going to be most useful for you both in narrative form as well as in some graphical form. And all of that information has gone through a number of steps that we have to follow and I believe has all been approved, and now is being prepared to be put up onto the Web.

So the goal here is for the word-for-word that you heard from Dr. Glover will be available as well as some graphics to help you with that as well. There’s also the modified monitoring and movement guidance that will be coming out. And then there will be some updated infection control guidance that will be coming out, but we’ll notify you and perhaps have a separate discussion on that when its’ available.

Eddie Reyes:
Alright, thank you.

Coordinator:
Thank you. Our next question or comment comes from Paula Abraham. Your line is open.

Paula Abraham:
Yes, good afternoon. I’m calling you from the VA Hospital in Houston. I may have missed a piece of information, but do you know how soon the official guidelines will be issued so we can change our local protocols here?

Dr. Daniel Jernigan:
So the official - the implementation date is actually today and so today we’re with this call initiating the dialogue about it and providing you the verbal description of it. And the written documents as soon as we can - it will be up on the Web. And sorry for the delay.

Paula Abraham:
Okay, thank you.

Coordinator:
Thank you. And again as a reminder, for further questions or comments at this time please press star one. Make sure your phone is unmuted and you must record your name slowly and clearly to introduce your question. And to withdraw that request, you may press star two.

Once again for further questions or comments, press star one at this time. Our next question or comment comes from Lisa Anderson. Your line is open.

Lisa Anderson:
Hi. Thank you so much for conducting the call today. I’m just a little bit confused and I wanted further clarification. So for those individuals who are coming back from Liberia and have some vague symptoms of fever, chills, and whatnot and are being evaluated in the ED, we - I’m hearing standard precautions. Is this routine standard precautions or should we be placing them on contact precautions?

Dr. Daniel Jernigan:
We recommend that you use the precautions that are directed by the symptoms that they’re presenting with. So if it’s contact, droplet, whatever, based on what their presentation is. So that would be standard.

Lisa Anderson:
Okay. Thank you very much.

Coordinator:
Thank you. And I’m currently showing no further questions or comments at this time. And again as a reminder, if you have a further question or comment, it’s star one and record your name. And it is star two to withdraw that request.

Again, for further questions or comments at this time, please press star one and record your name. One moment while we stand by for questions or comments.

Dr. Daniel Jernigan:
So if there are no further questions, I think maybe we could just make some final comments. We recognize that what we’re doing here is in the midst of a dynamic situation where the risk for transmission is changing in West Africa. There are a number of factors that are required to make sure that we can stay at zero in Liberia. We’re working very hard in an also dynamic situation in Sierra Leone and Guinea.

All of that is at a time when we are learning still about Ebola and about its transmission, so we want to be sure we are doing what we can to prevent any cases from happening here in the US.

With that, this guidance of course will be with us for a period of time and then is likely to change again based on the assessment of what’s happening in West Africa. As that happens, we will be communicating with you. If you have questions, please follow the appropriate way to get those questions to us and we’re happy to answer those. Ibad, let me hand this back to you.

Ibad Khan:
Thank you very much Dr. Jernigan. This concludes our Q and A session. On behalf of COCA, I would like to thank everyone for joining us today, with a special thank you to Dr. Jernigan, Dr. Glover, and our CDC subject matter experts.

The recording of this call and the transcript will be posted to the COCA Web site at Emergency.cdc.gov/COCA within the next few days. Again, that Web address is Emergency.cdc.gov/COCA.

There are no continuing education credits for this call. Resources for clinicians related to Ebola are available on the COCA Call Web page. Go to Emergency.cdc.gov/COCA. Click “COCA Calls” and then follow the links for the June 2015 Ebola Call. Thank you again for participating in today’s COCA call. Have a great day.

Coordinator:
Thank you. That concludes today’s conference call. Thank you for your participation. You may disconnect at this time.

END