CDC update on Ebola Response and PPE: 10-20-2014

OPERATOR: Welcome and thank you for standing by.  At this time all participants are on a listen-only mode until the question and answer session of today's conference.  On ask a question please press star 1 on the touch-tone phone and record your name at the prompt.  This call is being recorded if you have objects you may disconnect at this time.  I would like to turn the call over to Dr. Barbara Reynolds.  Ma'am, you may begin. 

BARBARA REYNOLDS: Thank you, Susan.  Good evening.  You are joining CDC's Ebola response update with the discussion on PPE.  We will be updating this guidance on our internet this evening, but because of the connections and links we're not sure exactly when it will show up, but it will be well this evening and we will also be sending you a fact sheet that summarizes the guidance shortly.  So I’d like to now introduce our one speaker for the evening, CDC director Dr. Tom Frieden. 

TOM FRIEDEN: Good evening, everyone and sorry for the late hour.  We did want to give you the information when it becomes available.  At CDC, we have a mission and a method.  Our mission is to protect health and our method is to base decisions on data.  Yesterday, the last of the community contacts of Mr. Duncan before he was isolated completed their 21-day monitoring period.  13 were health care workers who cared for him in that first emergency department visit.  Three were household or community contacts.  In all, more than 50 were monitored every single day and none developed Ebola.  As we know, two nurses did develop Ebola and our thoughts are with them.  We hope for their continued and full recovery.  Other health care workers who cared for  Mr. Duncan are still within the 21-day incubation period.  They and others are being monitored daily for fever or symptoms.  They're limiting their contact with others and they're coming in for evaluation at the slightest sign of illness.  I thank them for being part of the solution despite the hardship this causes to them for this period.  The guidelines we're releasing today are updated.  They provide an increased margin of safety.  They provide a consensus on better protecting health care workers because even a single health care worker infection is unacceptable. One of the many challenges dealing with Ebola is that there's never been a case in this country until less than a month ago.  It is truly unprecedented here.  CDC had guidelines for Ebola and other hemorrhagic fevers which were issued in 2008 and updated in August of this year.  They were developed by experts at CDC with consultation and approval from infectious disease control experts around the U.S.  and consistent with world health organization guidelines and have been used successfully before.  The hospital caring for the first patient, Mr. Duncan, relied on these guidelines.  Two health care workers became infected.  This is unacceptable.  Even a single health care worker infection is one too many.  We may never know exactly how that happened, but the bottom line is that the guidelines didn't work for that hospital.  Dallas showed that taking care of Ebola is hard.  The way care is given in this country is riskier than in Africa.  There's more hands-on nursing care and there are more high-risk procedures such as intubation.  This guidance has been reviewed by people in institutions with lots of experience treating Ebola in the U.S.  in fact, all of the people who have experience treating Ebola in the U.S. as well as doctors without borders, MSF.  That includes input and review by Emory, Nebraska, NIH.  This results in a consensus that allows an increased margin of safety and there are three key points about how to take care of Ebola while minimizing your risk.  The first is prior to working with Ebola patients, anyone who is going to work with them must be repeatedly trained in and demonstrate competency performing all of the things that they're going to need to do, specifically putting on and taking off proper personal protective equipment or PPE.  Second, no skin may be exposed when PPE is worn and third, every step of every time a health care worker puts on and takes off personal protective equipment they must be supervised by a trained observer who documents proper completion of established PPE protocols.  It's very important for the media to convey because it's an important message for health care workers that these are three comprehensive aspects.  The guidelines go through great detail and much more than CDC guidelines generally do in terms of what are the things that need to be done, but while a lot of attention has been paid to the equipment and while that's critical and important, the greatest risk in Ebola care is in the taking off of whatever equipment health care worker has on whether there's skin exposed or not.  And one of the critical aspects of these guidelines is a very structured way of doing that step by step which is supervised and in a way, ritualized so that it is done the same way each time with standardized equipment.  It's also important that the protective equipment is just one aspect of infection control.  There are others that are critically important.  The first is prompt screening and triage.  In hospitals often infections occur from undiagnosed patients and in Africa today most of the infections in health care workers are in health care workers who aren't caring in Ebola treatment units and they're in a general health system not thinking Ebola.  So it's critically important that every front line health worker thinks Ebola and what does that mean?  Any time you have a patient with fever or other signs of infection, ask where they've been for the past 21 days.  If they've been in Liberia, Guinea or Sierra Leone then you need to get help and we have an outline of what's done in that situation.   It’s also very important that there is a site manager who oversees Ebola care in a facility that's providing care for Ebola patients.  It's hard to care for Ebola.  So every aspect of not just the PPE and the supplies and the care given within the treatment unit needs to be overseen.  It's important on limit personnel in the room so no one who doesn't have to be there is there and to limit procedures to those essential for treatment and to ensure effective environmental cleaning.  Front line workers have been very clear that they want more training and we agree.  Every health care worker needs to learn how to screen a patient who may have Ebola, asked about travel history as it becomes routine.  CDC is increasing training offerings for health care staff across the country and we'll be developing materials and videos, but really there's no alternative to hands-on training.  Putting the materials on, taking them off repeatedly in a way that's observed and done in a systematic fashion.  This additional guidance doesn't change the guidance for other settings such as airport screening and there are important implications for these changes.  It's clear now that while every hospital needs to be able to consider, isolate and evaluate patients for Ebola there's a need for specialized centers when there is a patient with confirmed Ebola or a number of patients if that were to happen in the future.  We need to increase the margin of safety.  We are constantly looking for any way to protect Americans better.  We understand there is a lot of concern and we agree with the concern of health care workers.  Any infection is unacceptable.  At CDC, we'll tell you what we know when we know it.  We'll work together to fight the virus and we're encouraged that these guidelines represent a consensus and increased margin of safety for health care workers. 

BARBARA REYNOLDS: All right.  Susan, thank you.  It's time to take questions. 

OPERATOR: Okay.  Thank you again, to ask a question please press star 1 on your touch-tone phone.  Our first question is from Miriam Falco with CNN Medical News. Your line is open. 

MIRIAM FALCO: Thank you for taking questions, Dr. Frieden.  First of all, how long will it take for hospitals across this country to be trained up, to get that training and to get the proficiency to treat Ebola patients and you mentioned that there's a need for specialized centers and are you suggesting that as someone is diagnosed with Ebola they should be moved to one of the specialized centers which on average have about 11 beds for Ebola patients?  And also what can you tell us about this recent talk about is the incubation period of 21 days actually accurate and should it be longer? 

TOM FRIEDEN:  Thank you.  There are many hospitals in the country that are already in the process of becoming proficient in care of patients with Ebola.  We're focusing first on Dallas where they've been dealing with Ebola and in case there are additional cases that arise there, they'll be ready to care are for them.  The role of site manager there that is outlined in the guidance is something that CDC directly played in that extraordinary circumstance, but the health care workers there have done an excellent job of providing high-quality and safe care for the patients.  The guidelines here are structured and they provide very detailed information about different aspects of the care.  So it's possible for hospitals to be ready to do this.  I've been in touch with health commissioners from around the country which are identifying specialized facilities within their jurisdictions where they want to work.  As you recall at CDC, we announced that we would have Ebola response teams for any confirmed case of Ebola, we would go.  We would help and if appropriate we would  assist in the transfer of the patient or in the care of them there. So that's the general approach and in terms of the incubation period, the article you're referring to looks at modeled data.  When we look at actual data where we remain quite confident in the 21-day period.

BARBARA REYNOLDS: Thank you, Susan, next question, please. 

OPERATOR: Thank you.  Our next question is from Sherry Jacobson of Dallas Morning News.  Your line is open. 

SHERRY JACOBSON: Good evening.  I was hoping if you could tell us whether or not you would actually specify the kinds of personal, protective equipment that should be used, the maker, whatever there's been disparity in what people are using now. 

TOM FRIEDEN:  Sure.  We don't recommend any particular company.  We recommend specifications and one area we provide two options in the university of Nebraska which has done an excellent job of caring and Emory university which has done an excellent job of caring and we allow them to do both.  One of them uses an N-95 respirator or face mask.  The other uses what's called a PAPR or positive air pressure respirator.  Either option works.  Either option is protective.  Those of you that follow medical procedures in detail will note on review that we are recommending either of those options, but not a face mask and that's not because we think that Ebola is airborne, but rather because we think that what gets done in American hospitals can be so risky, whether that's suctioning or intubation or other things that may not be done in other parts of the world or in Africa where Ebola is spreading now that we wanted to add that extra margin of safety. 

BARBARA REYNOLDS: Thank you, Susan.  Next question, please. 

OPERATOR: Thank you.  Our next question is from John Roberts with Fox News.  Your line is open. 

JOHN ROBERTS: Dr. Frieden, good evening to you.  I'm led to believe that, doctor, you're giving more thought to the idea not of a travel ban, per se, but examining the prudence of restrict in some way, shape or form perhaps on the visa front travel from west Africa to the united states.  What can you tell us about that? 

TOM FRIEDEN: Thanks, John.  You know, I’ve said from the outset that we'll support any measures that better protect Americans and we know there are American citizens and others that have legal residence in this country who travel back and forth to the affected countries.  Today, what we're able to do is do exit screening every time someone leaves, do entry screening to the U.S. and track people once they're here providing all of the detailed locating information to the state and health department.  We don't want to lose that and we don't want to undermine the response, but as long as those two issues of being able to track people and being able to respond effectively are addressed, we have absolutely no objections, we don't have an interest in people traveling and we have an interest in protecting Americans, and the concerns that we have are that we not undermine the process that's currently allowing us to track people and screen out people who may be sick, on the one hand and that we don't do things that might make it harder to stop the outbreak there because if this outbreak does spread to other countries in Africa, it becomes much, much harder for us.  These guidelines are going to be implemented throughout the U.S., but the number of people who will screen positive or they have symptoms and they may come from one of the three countries and they may have Ebola.  That's a very small number.  If the number of countries associated expanded beyond these three relatively small countries that may be a different situation and much more challenging.  So the protection of Americans is our top priority and we're willing to look at whatever works that increases that protection. 

BARBARA REYNOLDS: Thank you, Susan.  Next question, please. 

OPERATOR: Thank you.  Our next question is from Shelby Holiday with Bloomberg Television.  Your line is open. 

SHELBY HOLIDAY: Hi.  Yes.  Thank you for taking questions.  When you were discussing the new protocols, things like these health care workers must be properly trained and they must have a supervisor.  Can this be enforced and who has the authority to oversee those protocols some. 

TOM FRIEDEN: CDC is not a regulatory agency.  OSHA, the occupational safety and health agency -- administration, is the organization that is involved in occupational health regulation and each state may regulate the health care facilities within its jurisdiction. 

BARBARA REYNOLDS: Thank you, Susan.  Next question, please. 

OPERATOR: Thank you.  Our next question is from Rob Stein with the NPR.  Your line is open. 

ROB STEIN: Thank you very much for taking may question.  I was wondering how you could tell us how these guidelines from the doctors without borders does and why do they differ? 

TOM FRIEDEN: So, um, we worked closely with MSF.  I've personally gone through the donning procedure.  They're based on them, but there are some things that are hard to translate from an African context in the tent hospital to a hospital in the U.S.  for example, MSF uses bleach spray while you stand in a gravel pit to spray down your personal protective equipment after.  That's very difficult to translate to the U.S. contacts and so we are recommending wipes that will be virusidal or kill the materials to wipe off the outer protective covering of the personal protective equipment.  That's probably the most significant difference that I’m aware of in these guidelines and it really relates to the environment that we're in.  Upon some facilities and we have this as a may consider type of recommendation will also do a showering out after all of the PPE is off just in case there's been any contamination to provide a shower and that's not done I think for logistical reasons by the MSF treatment units in Africa, but many other aspects of the recommendations are quite identical and we don't use street clothes and we don't use people's own shoes and we use complete covering.  We use either PAPRs or N-95s.  It's very similar with maybe that one difference. 

BARBARA REYNOLDS: Thank you, Susan.  Next question, please. 

OPERATOR: Thank you.  Our next question is from Mike Stobbe with the Associated Press.  Sir, your line is open. 

MIKE STOBBE: Hi.  Thank you for taking the question.  I just want to clarify, when should people put on the gear some once the test result comes back confirming Ebola or if they're taking a travel history or find out that the person has been to west Africa and it's suspected.  If you can say a bit more about that.  Also, is there anything in the guidelines about areas for, like, ante rooms or areas for putting on or taking off personal protective equipment.  Does it have to be a room that's adjacent to the patient's room or can it be just the entrance way to their room?  Do you have any more information about that, and one more, I’m sorry.  How many specialized hospitals are you hoping to have union line to be referral centers for Ebola patients some? 

TOM FRIEDEN:  So, yes to the ante-room question.  It's very important that there be clean and dirty areas and they be separated.  That's an MSF concept that's now in the guidelines.  There's flexibility because hospitals have different layouts to what the ante room could be.  It could be the room of an adjacent patient and it could be an ante room from an isolation hospital room the way many transplant and hospital rooms have.  It could be even if there were no alternatives, a cordoned off area with plastic sheeting in a hallway as long as you can be compliant with fire codes.  In terms of this -- mike, what was your -- I don't know if you're off.  The first question -- in terms of the number of specialized hospitals we're looking at that intensively now and working with states as well as others, but there was a first question you asked.  Oh, when to trigger the PPE.  So just based on our experience in recent months, CDC has been consulted more than 400 times by people who think this might be Ebola and that's good.  We want to get that index of suspicion so that people call us immediately.  Of those, about 10 percent were concerning enough that we said, yes, get a test of those tests only one was positive.  But for anyone at high risk we recommend this form of PPE or if it's not available, the highest available form. 

BARBARA REYNOLDS: Okay.  Thank you.  We have time for just one last question, please.  Susan? 

OPERATOR:  Thank you.  The question is from Kyle Mazza with UNF News.  Sir, your line is open. 

KYLE MAZZA: Thank you.  Dr. Frieden, I have two questions for you.  One, we are somewhat confused on the Ebola czar and the CDC's role in all of this.  Can you shed some light on that and try to explain to everyone what's the difference between an Ebola czar and the CDC’s role?  What is their role?  And the second question that I have is going in some detail about the supervisor that should oversee health care workers.  Can you just elaborate on what that means for people that are already on the field?  How long will those changes go into effect with the oversight?  Are they already in place? 

TOM FRIEDEN: Thank you.  So I’m delighted that there's a government-wide coordinator.  I think it's a terrific development.  The fighting Ebola in the U.S.  and globally is a major undertaking that requires a whole of government response.  I've spoken to Mr. Klain.  I'm looking forward to his visit to Atlanta next week and very much looking forward to working with him.  I think that will help us as we focus on CDC on the public health aspects on the response here and West Africa and other parts of Africa to have the coordination, accountability and trouble shooting and keep us moving quickly and on track.  In terms of what's called the site manager.  This is also something we've learned from MSF or doctors without borders.  They found it extremely important that there would be one person who is a member of the hospital staff who will be overseeing both the donning and doffing and also the care inside and also something like, instead of picking up trash with your hand, get a clamp and pick it up with the clamp so we don't contaminate your gloves or overseeing the logistics to make sure that enough supplies are there and making sure that those are continuous and uninterrupted. 

BARBARA REYNOLDS: Thank you.  We have time for just one more question, please. 

OPERATOR: Okay, Thank you. Our next question is from Betsy McKay of "The Wall Street Journal," your line is open. 

BETSY MCKAY: Hi, thanks.  Dr. Frieden, just a couple of questions if you still can, one is as you mentioned, this was a work of consensus, and I’m wondering what were some of the biggest points of discussion or debate when the guidelines were being developed and the second is I wanted to ask about the s.w.a.t. teams that you will now have going into hospitals.  At what point would they go?  They would go when CDC confirms an Ebola case or when a hospital calls and says it has a possible Ebola case or at what point would they go? 

TOM FRIEDEN: So in terms of points of debate, really not much.  You know, previous guidelines from W.H.O. and ourselves allowed exposure of skin, and I think that made people nervous and it's certainly sensible to say that that's not something that should happen because of the chance that someone will unconsciously touch their face.  That's exposed and that could result in contamination, even though facilities that have used that procedure have used it without infections in the past.  We felt we really have to go to the increased margin of safety given what we've seen here.  I guess the only area that I can think of that had some discussion was the issue of respiratory protection and there again we're putting an extra margin of safety by saying it should be either an N-95 or a PAPR, positive air pressure respirator.  We're saying we don't want a health care worker who is already suited up and it takes a while to suit up and say oh, I’m going to suction this patient.  That might have aerosol generation and I’ll leave, take all of this off and take an N-95 and come back.  We said we're not going to recommend that face masks be used, but rather N-95s or PAPRs, any because for other things that are less relevant.  In terms of the CDC Ebola response teams we would go for any confirmed case and if there were a situation where we believed there would be reason to likely rule in, we would consider going in at that time, as well.  I would say that of the 400 calls and the 40 or 50 tests that have been done, the only one that the staff brought to my attention before the test result came back was Mr. Duncan because his history was so consistent with Ebola as was his travel and clinical history.  We would certainly be proactive in that regard and we are now doing rapid assessments of hospitals that are interested and willing to take Ebola patients going through what it takes, reviewing their preparedness and identifying areas that may require further work or congratulating them on excellent work done.  So I want to thank you all for joining us at this late hour.  To sum up, bottom line here, we're increasing the margin of safety with a real consensus guideline that has three key changes.  One, training, practicing, demonstrated hands-on experience so that the health care workers are comfortable donning and PPE, no skin exposure and observation of every single step, putting on and taking off the PPE and we're also focusing on other aspects of care that are critically important and such as triage and limiting the number of personnel and even one health care worker infection is one too many and I’m looking forward now to working closely with helps, health care workers and others throughout the country rapidly for them to understand and implement these guidelines.  Thank you very much. 

BARBARA REYNOLDS: Thank you.  This concludes tonight's briefing on the Ebola response by CDC and PPE update.  For those of you who may have joined a little late, I want you to know that the guidelines will be up live tonight on the internet.  There hear some connections that need to be made before it is live to everyone.  However, we did share a fact sheet with you all that will give you summary of the guidance.  If you have additional questions you are welcome to call CDC media at 404-639-3286.  Thank you. 

OPERATOR: Thank you all for participating in today's conference.  That does conclude this call.  Please disconnect your lines.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES