Risk Assessment for Travelers from Ebola-Affected Countr

Department of Health and Human Services OMB Approved

Centers for Disease Control and Prevention 0920-0821

Exp 08/31/2015

EXPOSURE RISK ASSESSMENT FOR TRAVELERS FROM EBOLA OUTBREAK-AFFECTED COUNTRIES

Instructions to Q-station staff: Read the following risk assessment questions to the traveler. We are interested in the highest level of exposure the traveler experienced. If you receive an answer that indicates HIGH-RISK exposure, it is not necessary to continue with the remaining questions. Get a description of any high-risk activities identified. If no high-risk exposures, get a description of some-risk exposures. NOTE: “person with Ebola” includes confirmed or suspect cases.

Tell patient: There is an Ebola outbreak going on in [insert country name]. I am going to ask you a few questions to assess any exposures you might have had to the Ebola virus. This will help us decide if you need additional evaluation.

1. Were you ever exposed to blood or other body fluids of a person with Ebola?

1. If YES: Did the exposure include getting stuck with a needle or other sharp object, or splashed in the eye, nose or mouth?

YES (to needlestick/mucous membrane exposure) = HIGH RISK

9. If NO (to needlestick/mucous membrane exposure): Did you wear appropriate personal protective equipment (gloves, gown, and face protection including goggles/face shield and masks) every time you were exposed?

NO (to PPE use) = HIGH RISK

2. Did you provide direct care to anyone with Ebola while the person was sick? This includes in a household or health care setting.

1. If YES: Did you wear appropriate personal protective equipment (gloves, gown, and face protection including goggles and masks) at all times?

NO (to PPE use) = HIGH RISK

3. Did you work in a laboratory in [Ebola-affected country]?

1. If YES: Did you process body fluids of Ebola patients?

1. If YES (to processing body fluids): Did you wear appropriate PPE and follow standard lab biosafety precautions at all times?

NO (to PPE use or biosafety precautions) = HIGH RISK

4. Did you directly handle dead bodies in [Ebola-affected country]? This might include participating in funeral or burial rites or any other activities that involved handling dead bodies.

1. If YES: Did you wear appropriate PPE (gloves, gowns, and face protection including goggles/face shield and masks) at all times?

NO (to PPE use) = HIGH RISK

5. Did you live in the same household as a person with Ebola while that person was sick?

1. Confirm Ebola patient’s date of onset and date of last contact (in relation to symptom onset of Ebola patient].

YES (household member during symptomatic period) = SOME RISK

6. Have you spent time in the same room with any person with Ebola while the person was sick?

1. If YES: Were you wearing appropriate protective equipment at all times?

• If NO (to PPE use): Ask about the following

1. Were you within 3 feet (1 meter) of the person with Ebola? YES = SOME RISK

2. Did you have any physical contact with the person with Ebola (e.g. shaking hands)? YES = SOME RISK

3. Did you spend a long period of time in the room? [Get an estimate of time and distance and a description of activities then consult leadership/SME.]

4. Did you have any other contact with a person with Ebola? [Get an estimate of time and distance and a description of activities then consult leadership/SME.]

If NONE of the above exposures identified: NO KNOWN EXPOSURE

Public reporting burden of this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-0821.