Form 0920-1033 Att D HCW.EVD.expriskreport_SierraLeone

2014 Emergency Response to Ebola in West Africa: Data Collection for Assisting Foreign and International Entities to Conduct Public Health Activities

Att D HCW.EVD.expriskreport_SierraLeone

Healthcare Worker- Ebola Virus Disease Exposure Risk Report - Sierra Leone

OMB: 0920-1033

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Form Approved

OMB No. 0920-1033

Exp. Date 04/30/2015

Initials of person completing form: ________

Date of completion of form (dd/mm/yy): _____________

PLEASE SEND COMPLETED FORM TO: _________________________________

Health-care workers (HCWs) and Ebola Virus Disease (EVD) exposure risk:

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Case ID number: ____________________

reporting form to be completed for EVD cases in HCWs


Thank you for considering this study. The Sierra Leone Ministry of Health, together with the World Health Organization and the Centers for Disease Control are trying to learn more about how and why health care workers in Sierra Leone are getting Ebola virus disease. We want to learn more about how people are getting sick so that we can help prevent infections in the future. We will ask you some questions about what happened before you fell ill. If you agree, we would also like to ask some questions to your co-workers to learn more about what might have happened to make you ill. You will not be punished for practices that may have exposed you to Ebola virus infection and we will not share your information outside of study staff. We will record your name and address so that health workers can find you and make sure we only ask you these questions once. Only the study team can see your information and they will only look at your information when they are working on the study. All the information will be in locked computer files on a protected computer at WHO. Information will be summarized in reports. We will not report anything about you individually. You are free to choose whether or not to be in this study. You are also free to say no to any part of this study. You will not lose any of your usual health services or other benefits even if you say no. Even if you say yes, you may change your mind at any time. If you have questions or concerns, you can call Dr. Alie Wurie at the Ministry of Health at +232-076671100. (Provide card with phone # and name).

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  1. BASIC INFORMATION

Person being interviewed:

Patient Co-worker (not supervisor)

Patient’s supervisor Family member (specify): ______________________

Other (specify): ______________________

Site of interview

Home of patient Workplace of patient (specify): ____________________

Holding center/ETU/CCC Other: ________________________


Case classification: Suspected Confirmed Unknown

Case status at evaluation: Alive Deceased (date: ___/___/___) Unknown

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  1. PATIENT (HCW) IDENTITY

Last name___________________ First Name________________ Second Name_________________

Date of birth (mm/dd/yy) ___/___/___ Age (years)_____ Sex M F

Village of residence ____________­­­_____ District ____________ Nationality: _________________

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  1. CLINICAL COURSE

Date of symptom onset ___/___/___ Date patient stopped working: ___/___/____

Date of first visit to healthcare facility: ___/___/___ Facility name: _________________

Was patient admitted at first visit? Yes No DK (don’t know)

If NO, what was the suspected diagnosis?

Suspect malaria Suspect other infection

Suspect typhoid Other: _________________________

If patient WAS NOT admitted at first presentation, please check all activities patient undertook/treatments patient received between symptom onset and isolation

Took antimalarials Took ORAL antibiotics Took IV antibiotics Took NSAIDS

Sought care with a traditional healer Sought care from a family member/friend

Sought care from another healthcare worker outside of a healthcare facility

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Public reporting burden of this collection of information is estimated to average 30 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1033).


Went to a different healthcare facility for care

Shape7 Was patient ever isolated for their Ebola infection? Yes No DK

If YES, date of patient isolation: ___/___/___

Site of patient isolation:

Holding center (specify): ___________________

Alternate site/room at hospital specifically for healthcare worker isolation

Other: ____________________________________

Was patient transferred to Ebola treatment center? Yes No DK

If YES, date of transfer: ___/____/_____

Ebola treatment center where patient treated: ________________

Ebola blood testing

Date of blood draw for testing ___/___/___ Date of confirmation: ___/___/___

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4. PATIENT’S OCCUPATION (tick the appropriate box and provide details if/when necessary)

Ambulance driver Ambulance driver mate Burial team CHO CHA Cleaner

Community health worker Contact tracer District medical officer Doctor

Laboratory staff Midwife Morgue staff Porter

Nurse Nurse’s Aide Office staff SECHN

Security officer Surveillance officer Traditional healer Traditional birth attendant

Other (specify): ________________


Primary work place at the time of infection:

Ebola Treatment Center Ebola Care Unit “Transit”/”Holding” center Public hospital Community Care Center (CCC) Observational Interim Care Center (OICC)

DHMT OfficeOutpatient setting Laboratory Ambulance DK

Other type of HCF:____________

If patient worked at a healthcare facility (HCF), provide HCF name: ____________________

If hospital or outpatient, setting, what service:

General Care Maternity Laboratory Medicine Pediatric Surgery

Emergency Blood Transfusion Administration Morgue

Other (specify): ___________


At their primary occupation, was patient a volunteer? Yes No DK


ADDITIONAL work place (paid or voluntary) at the time of infection:

Ebola Treatment Center Ebola Care Unit “Transit”/”Holding” center Public hospital

Community Care Center (CCC) Observational Interim Care Center (OICC) DHMT Office

Outpatient setting Laboratory Ambulance DK Other type of HCF (specify):______

Other NON-HCF (specify):___________________________________________________________


If hospital or clinical outpatient setting, what service:

General Care Maternity Laboratory Medicine Pediatric Surgery

Emergency Blood Transfusion Administration Morgue Other (specify): ____


At the additional workplace, was patient a volunteer? Yes No DK


Was patient known to provide health-related care to neighbors, family, or others outside

of their work? Yes No DK (don’t know)

Shape9 5. EXPOSURES

Workplace-associated activities that may have led to exposure (check all that apply):

Provided general patient care (took vital signs, examined patients)

Fed patients or administered oral medications Delivered babies

Bathed or cleaned patients Moved patients (touched patients)

Gave injection Drew blood Performed fingerprick

Recapped needle Discarded sharps

Put in IV/handled line Placed/handled urinary catheter

Cleaned blood/vomit/diarrhea Cleaned the patient room or ward

Handled lab specimens Controlled bleeding Touched contaminated surfaces Performed invasive procedure Performed /assisted with surgery

Moved dead bodies Performed autopsy

Cleaned or disinfected latrines

Handled waste Handled linen or clothes or mattresses (cleaners)

Other: (specify) ____________________________


Contact with EVD patients outside the primary work facility

Did the HCW have contact* with anyone who had suspected/confirmed EVD outside of the primary work facility during the three weeks before their symptom onset?

Yes No DK

If YES, specify relationship of EVD patient with HCW (check all that apply):

Patient Other HCW Household member Other friend / relative None

Specify type of exposure:

Provided general patient care (took vital signs, examined patients)

Fed patients or administered oral medications Delivered babies

Bathed or cleaned patients Moved patients (touched patients)

Gave injection Drew blood Performed fingerprick

Recapped needle Discarded sharps

Put in IV/handled line Placed/handled urinary catheter

Cleaned blood/vomit/diarrhea Cleaned the patient room or ward

Handled lab specimens Controlled bleeding Touched contaminated surfaces

Performed invasive procedure Performed /assisted with surgery

Moved dead bodies Performed autopsy

Cleaned or disinfected latrines Handled waste

Handled linen or clothes or mattresses (cleaners)

Physically assisted patient in ambulance or other vehicle

Touched patient during home visit (e.g., DSO or contact tracer)

Other: (specify) ____________________________________________________


Did the HCW attend any funeral of someone who might have died of Ebola in the 3 weeks preceding the onset of the symptoms? Yes No DK

If YES, did the HCW participate in the preparation of burials that involved touching the dead body without adequate PPE (gloves, impermeable gown, impermeable head cover with neck protection, rubber boots, face mask and face shield or goggles)? Yes No DK



Shape10 6. MOST LIKELY EXPOSURE TO EVD

Did the interviewee describe any single exposure that most likely led to infection? Yes No DK

If No or DK, skip to question 7

If Yes, specify the date: ___/___/___ (dd/mm/yy)


Setting where suspected exposure occurred:

Ebola Treatment Center Ebola Care Unit “Transit”/”Holding” center Public hospital

Community Care Center (CCC) Observational Interim Care Center (OICC)

Outpatient setting Laboratory Ambulance DK

Other type of HCF (specify):_________________________

Patient’s home Someone else’s home (specify):________________

Other community setting (specify) _____________________________


Mode of exposure:

Needle stick Scalpel cutBlood/body fluid splash on intact skin
Blood/body fluid splash on non-intact skin Blood/body fluid splash on eye
Blood/body fluid splash on mouth/lips Other (specify) __________________________

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7. INFECTION PREVENTION AND CONTROL ASPECTS OF PRIMARY WORK PLACE

Use of PPE and Standard Precautions

At time of exposure, was a screening station set up at the primary work facility to separate suspect/possible Ebola patients from other patients? Yes No DK N/A (not applicable)


At time of exposure, were there spraying staff at primary work facility? Yes No DK N/A


If exposure was at work, was PPE available to the patient at time of exposure? Yes No DK

If YES, which:

Single gloves Double gloves Disposable gown Waterproof apron

Coverall (Tyvek-like) Coverall (Tychem-like) Cap Hood

Face shield Face mask Goggles N-95 or above respirator

Closed resistant shoes Shoe covers Rubber boots Leg covers

Other (specify): ____________


If exposure was at work, was any PPE USED by patient at time of exposure? Yes No DK

If YES, which:

Single gloves Double gloves Disposable gown Waterproof apron

Coverall (Tyvek-like) Coverall (Tychem-like) Cap Hood

Face shield Face mask Goggles N-95 or above respirator

Closed resistant shoes Shoe covers Rubber boots Leg covers

Other (specify): ____________


If NO, why not?

No PPE at facility PPE present, but did not think the situation required it

PPE present, but did not know how to use PPE present, but forgot/neglected to use

Other: _________________________________________________

Did the HCW apply duct tape to secure PPE? Yes No DK


Were hand hygiene products available at time of exposure? Yes No DK

If Yes, which: Running (tap) water Chlorinated water from reservoir

Soap Disposable towels Alcohol antiseptic

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About how many minutes did HCW stay in PPE** during each entry in isolation/ETU per day?__ mins

About how many times per day did HCW enter isolation/ETU in PPE? _____ times per day

About how many days did HCW work in isolation/ETU per week?___days Not applicable


Was HCW trained on infection prevention/control in the context of the Ebola outbreak? Yes No

If YES, please indicate the training organization below:

National Government DHMT staff Hospital staff

WHO CDC MSF UNMEER Other (specify): ___________________ Don’t know


Were other healthcare workers quarantined as a result of this HCW infection? Yes No DK


If YES, (approximate if exact number unknown), how many HCW were quarantined? ______


*Contact defined as the HCW touching, without proper personal protective equipment (PPE), a suspect or confirmed EVD patient or their bodily fluids

**PPE=gloves, impermeable gown or coverall, impermeable head cover with neck protection, rubber boots, face mask and face shield or goggles


Additional details of exposure or comments: ­­­­­­­____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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ADMINISTRATIVE USE ONLY:


Is case in VHF? Yes No DK Not yet, but check back later (<1 month after onset)


If yes, is case marked as Healthcare Worker in VHF? Yes No


VHF case ID: ___________________

Version 4.0 24 December 2014 Page 11


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