1. Images from CDC and WHO for Ebola Virus Disease Primary Screening (Pre-departure/Exit Screening)

2. This training and related materials is intended for countries to use and adapt based on country policies, standard operating procedures and needs. This document and related materials was developed based on United States (US) guidelines and should be adapted for local use. Some US guidelines differ from those of the World Health Organization (WHO); US guidelines may be more conservative. Principles of Personal Protective Equipment (PPE) use should be followed and users should be appropriately trained. Purpose [DELETE this slide before presenting]

3. By the end of this training, you should be able: Detect travelers who may be sick or have been exposed to Ebola by using screening tools Refer travelers who may be sick or have been exposed to Ebola to secondary screening for further evaluation Describe personal protective equipment (PPE) to wear when screening Learning Objectives

4. What is Ebola? What are the primary screening and referral steps to detect travelers who may be sick or have been exposed to Ebola? What safety and health measures should you take to protect yourself? Practice scenarios Training Topics

5. Ebola

6. Ebola is A severe, often fatal disease in humans and animals (such as monkeys, gorillas, and chimpanzees) Caused by the Ebola virus Highly infectious, but can be prevented What is Ebola?

7. Discovered in 1976 in what is now the Democratic Republic of the Congo, along the Ebola River Since then, outbreaks have appeared sporadically in Africa Scientists are not sure, but believe that bats are the most likely source of the virus Where Does Ebola Come From ?

8. Bats May Infect Other Animals

9. Any of These Animals can Infect Humans

10. Once a human is infected, human-to-human transmission can occur Human-to-Human Transmission

11.  Objects contaminated with the virus BloodSemen UrineSaliva VomitFeces It only spreads when infected people are sick It is spread through direct contact (through broken skin or mucous membranes) with  A sick person’s body fluids How is Ebola Spread from Human to Human?

12. You CANNOT get Ebola through Air Water Food Note: In Africa, Ebola may be spread as a result of hunting, processing, and consumption of infected animals (e.g., bushmeat) You Cannot Get Ebola Through

13. A person infected with Ebola is NOT contagious until symptoms appear Symptoms generally begin 2-21 days after exposure (with an average of 8-10 days) What Happens When Infection Occurs?

14. Fever Severe headache Muscle pain Vomiting Stomach pain Diarrhea Unexplained bleeding or bruising What are the Signs and Symptoms of Ebola?

15. Heat Bleach Bleaching products (at appropriate concentrations) Alcohol-based hand sanitizers can significantly reduce virus levels, but they do not kill Ebola What can Kill Ebola Virus on Objects or Surfaces?

16. First outbreak in West Africa Countries currently affected include Liberia Sierra Leone Guinea Largest Ebola outbreak in history What is the Ebola Situation in West Africa?

17. Pre-departure/exit screening is one public health measure that may reduce and potentially slow the spread of Ebola to other countries Early recognition of Ebola is important for providing appropriate patient care and preventing the spread of infection Your role in the exit screening process is crucial to its success Why Conduct Exit Screening for Ebola?

18. 1. Identify travelers at ports of entry who are suspected of having Ebola or known to have been exposed to Ebola 2. Reduces further spread of disease by preventing travelers who are sick or may have been exposed to Ebola from boarding a commercial conveyance (such as an airplane) What is the Purpose of Pre- Departure/Exit Screening for Ebola?

19. Should NOT travel on a commercial conveyance (such as an airplane) until they have monitored their symptoms for 21 days after their exposure Should delay travel until they are cleared to travel by a doctor or public health authority Travelers Who Have Been Exposed to Ebola

20. Travelers at ports of entry/exits who are suspected of having Ebola or known to have been exposed to Ebola are identified through Pre- departure/Exit Screening How are Travelers Exposed to Ebola Identified at Ports of Entry/Exits?

21. Screening occurs in two parts Primary Screening Traveler assessed for potentially being sick or exposed to Ebola using pre-established criteria If any of the criteria are met, the traveler and his/her companions are referred to secondary screening for further evaluation Secondary Screening Referred travelers and companions are further evaluated with a medical evaluation and interview How is Screening Conducted?

22. Your role in the exit screening process is crucial to its success Use the screening tools to detect travelers who may be sick or have been exposed to Ebola Refer travelers who are sick or may have been exposed to Ebola to secondary screening for further evaluation Describe appropriate personal protective equipment (PPE) to wear when conducting screenings What is Your Role in Primary Screening?

23. Primary Screening (Pre-departure/Exit Screening) Steps to Identify Travelers Suspected of Having or Being Exposed to Ebola

24. Primary Screening Poster 1. Review the answers to the Primary Screening Form (Traveler Health Questionnaire ) 2. Look for and ask about symptoms 3. Measure the traveler’s temperature What are the Primary Screening Steps?

25. Liberia Step 1: Review the Answers to the Primary Screening Form (or Traveler Health Questionnaire)

26. Primary Screening Form (or Traveler Health Questionnaire)

27. Have you experienced any of the following symptoms today OR within the past 48 hours (2 days)? Please check Yes or No. Fever of ___C or feeling feverish? Severe headache Vomiting? Diarrhea? Stomach or abdominal pain? Muscle or joint pain? Unexplained bruising or bleeding? Review of Questions on the Primary Screening Form: Symptoms

28. In the last 21 days, have you experienced any of the following? Yes or No Were you ever exposed to blood or other body fluids of a person with Ebola? Did you provide direct care to anyone with Ebola while the person was sick? This includes in a household or health care setting. Have you worked in a laboratory that processes body fluids of Ebola patients? Review of Questions on the Primary Screening Form: Exposures

29. Did you directly handle dead bodies?  This might include participating in funeral or burial rites or any other activities that involved handling dead bodies. Do you live in the same household as a person with Ebola while that person was sick? Review of Questions on the Primary Screening Form: Additional Exposures (1)

30. Have you had spent time in the same room within 1 meter of any person with Ebola, spent significant time with an Ebola patient, or any physical contact with an Ebola patient? Have you ever been stuck with a needle or other sharp object, or splashed in the eye, nose or mouth with bodily fluids of someone with Ebola? Review of Questions on the Primary Screening Form: Additional Exposures (2)

31. If all questions have been answered “NO” proceed to Step 2 If the travelers answered “YES” to any of the questions on the form  Ask the traveler and his/her companions to step aside  Refer the traveler and companions to Secondary Screening Check the Secondary box on the “Primary Screening” form Complete the “Referred to Secondary Screening Log” Notify Secondary Screening Team Lead Call an escort Step 1: Review the answers to the Primary Screening Form

32. Step 2: Look For and Ask About Symptoms

33. Does the traveler appear to have any of the following symptoms?  Appears feverish: flushed face, glassy eyes, or chills Note: Ask traveler if they have taken fever- reducing medicine or feel feverish. If Yes, take that as an indication of fever  Vomiting Has vomited two or more times (not due to motion sickness) Step 2: Look For and Ask About Symptoms (1)

34. Diarrhea:  Loose, watery stools that occur more frequently than usual (at least 3 episodes within a 24-hour period) Unexplained bruising or bleeding from:  Gums, ears, or nose  Areas on the skin with no obvious explanation (such as injury)  Vomiting blood, or bloody stool or urine Step 2: Look For and Ask About Symptoms (2)

35. After looking for and asking about certain symptoms, make a decision: If at least one of the symptoms is observed or the traveler reports any of these symptoms  Ask traveler and his/her companions to step aside  Refer them to secondary screening by marking “Primary Screening” form and complete the “Referred to Secondary Screening” log  Notify Secondary Screening Team Lead  Call on an escort If none of these symptoms are observed or reported, proceed to step 3 Step 2: Look For and Ask About Symptoms (3)

36. Step 3: Measure the Traveler’s Temperature

37. Use a non-contact thermometer Take action based on the traveler’s temperature  If traveler’s temperature is lower than ___◦C traveler should be allowed to continue their travel  If traveler’s temperature is greater than ___◦C, do the following (see next slide) Step 3: Measure the Traveler’s Temperature

38. 1. Ask traveler and companions to step aside 2. Refer traveler and companions to secondary screening Check the Secondary box on the “Primary Screening” form Complete the “Secondary Screening Log” Notify Secondary Screening Team Lead Call an escort If traveler’s temperature is greater than or equal to ___◦C

39. “Your health and your companion’s health is important to us. Based on the [INSERT SCENARIO], you will need a more detailed screening before you are allowed to travel today. Your travel companions will also go with you to the secondary screening area. This will help us determine if you or your travel companions are at risk of developing Ebola or need further evaluation. Please step to the side and wait for an escort to take you to the secondary screening area. Please let me know if you have any questions. Thank you for your patience.” Script To Use When referring the traveler and his/her companions to secondary screening read the following:

40. Safety and Health Measures to Protect Yourself

41. Your safety is a priority! You may come into close contact with sick or exposed travelers in your role To protect yourself and others you should:  Maintain 1 meter between yourself and all travelers  Know what the standard protocols are for putting on, using, and removing personal protective equipment (PPE)  Correctly wear gloves, a face shield, and a face mask during screening  Wash your hands often What Safety and Health Measures Should You Take? (1)

42. Know how to use the thermometer Only do the job that you have been assigned Monitor your stress levels- do only what you physically and mentally can handle Stay hydrated Make sure you take breaks Report all hazards or incidents to Primary Team Lead Call _________ if you have a life-threatening emergency What Safety and Health Measures Should You Take? (2)

43. Practice Scenarios

44. A traveler walks up to your primary screening station. What is your first step? Practice Scenarios Scenario 1

45. A traveler walks up to your primary screening station. What is your first step? Answer: Request the traveler’s “Traveler Health Questionnaire” (or Primary Screening Form). Review the answers to the “Traveler Health Questionnaire” (or Primary Screening Form) and notice if any questions are answered “YES” Practice Scenarios Scenario 1: Answer

46. In reviewing the “Primary Screening Form” you see that a “Yes” has been marked off on one of the questions. What do you do next? Practice Scenarios Scenario 1: Follow-up Question

47. In reviewing the “Primary Screening Form” you see that a “Yes” has been marked off on one of the questions. What do you do next? Answer: Ask the traveler and his/her companions to step aside, mark the secondary box on the questionnaire/form and refer them to secondary screening by marking the “Primary Screening” form and the “Referred to Secondary Screening” log, notifying Secondary Screening Team Lead, and calling on an escort. Practice Scenarios Scenario 1: Follow-up Question Answer

48. A traveler walks up to your station. You have reviewed the “Primary Screening Form”(or Traveler Health Questionnaire). It appears complete. The traveler has not answered “YES” to any of the questions. What is your next step? Practice Scenarios Scenario 2

49. A traveler walks up to your station. You have reviewed the “Primary Screening Form”(or Traveler Health Questionnaire). It appears complete. The traveler has not answered “YES” to any of the questions. What is your next step? Answer: Look for and ask about certain signs or symptoms. If screeners can’t remember, refer them to the “Traveler Health Questionnaire” (or the Primary Screening poster). Practice Scenarios Scenario 2: Answer

50. What does a fever look like? Practice Scenarios Scenario 2: Follow-up Question A

51. What does a fever look like? Answer: Practice Scenarios Scenario 2: Follow-up Question A Answer Flushed face Glassy eyes Chills

52. What else is an indication of fever? Practice Scenarios Scenario 2: Follow-up Question B

53. What else is an indication of fever? Answer: If a traveler tells you he/she had a fever or feels feverish or is taking fever-reducing medication. Practice Scenarios Scenario 2: Follow-up Question B Answer

54. Who can define or describe the other symptoms to look out for? Practice Scenarios Scenario 2: Follow-up Question C

55. Who can define or describe the other symptoms to look out for? Answer: Vomiting: 2 or more times (not due to motion sickness) Diarrhea: loose, watery stools that occur more frequently than usual (at least 3 episodes within a 24 hour period) Stomach or abdominal pain: stomach aches or cramps Muscle or joint pain: general body aches and pains. Bruising or bleeding from the body: noticeable and unusual bruising and bleeding from gums, ears, nose, or areas on the skin with no obvious explanation (such as injury), vomiting blood, or has bloody stool or urine Practice Scenarios Scenario 2: Follow-up Question C Answer

56. A traveler has moved through the first two steps in primary screening. You have not noticed any “Yes” answers on the “Primary Screening Form”(or Traveler Health Questionnaire). You have not observed any signs or symptoms listed on the “Primary Screening Form”(or Traveler Health Questionnaire). What is your next step? Practice Scenarios Scenario 3

57. A traveler has moved through the first two steps in primary screening. You have not noticed any “Yes” answers on the “Primary Screening Form”(or Traveler Health Questionnaire). You have not observed any signs or symptoms listed on the “Primary Screening Form”(or Traveler Health Questionnaire). What is your next step? Answer: Check the traveler’s temperature with a non- contact thermometer. Practice Scenarios Scenario 3: Answer

58. What is the temperature reading that meets the criteria for referring the traveler to Secondary Screening? Practice Scenarios Scenario 3: Follow-up Question A

59. What is the temperature reading that meets the criteria for referring the traveler to Secondary Screening? Answer: A ___ ◦ C [COUNTRY SPECIFIC] or higher means the traveler and companions need to be referred to Secondary Screening. Practice Scenarios Scenario 3: Follow-up Question A Answer

60. Can someone show me how to use the non- contact thermometer? Practice Scenarios Scenario 3: Follow-up Question B

61. Can someone show me how to use the non- contact thermometer? Answer: Instructor will need to demonstrate the instructions for the specific thermometers used at this port. Practice Scenarios Scenario 3: Follow-up Question B Answer

62. The traveler’s temperature reads as ___ °C [INSERT COUNTRY SPECIFIC INFORMATION]. What is your next step? Practice Scenarios Scenario 4:

63. The traveler’s temperature reads as ______°C. What is your next step? Answer: Ask traveler and companions to step aside Refer them to secondary screening  Check Secondary on the “Primary Screening”  Complete the “Secondary Screening” log  Notify Secondary Screening Team Lead  Call on an escort. Reminder: a _____°C or higher means traveler and companions need to be referred to Secondary Screening. Practice Scenarios Scenario 4: Answer

64. A traveler walks up to your station. As you collect the “Traveler Health Questionnaire” (or Primary Screening form), you notice the traveler appears feverish. What do you do? Practice Scenarios Scenario 5

65. A traveler walks up to your station. As you collect the “Traveler Health Questionnaire” (or Primary Screening form), you notice the traveler appears feverish. What do you do? Answer: Since fever was observed Ask traveler and companions to step aside Refer them to secondary screening  Check Secondary on the “Primary Screening”  Complete the “Secondary Screening” log  Notify Secondary Screening Team Lead  Call on an escort. Practice Scenarios Scenario 5: Answer

66. Primary Screening Job Aid/Poster