Questions and Answers Related to the Commissioner's Order on Ebola Virus Disease (EVD) Preparedness - Updated 3/3/15

1. Does the term "Covered Personnel" include persons qualified to ride in ambulances, EMTs, AEMTs, and members of fire companies?

A: "Covered Personnel" is defined in the Commissioner's Order as all employees, contractors, students, and all other personnel who may come into contact with a Patient (defined as either a PUI or person with confirmed EVD), or a laboratory specimen from such Patient, or who will be involved in the cleaning or disinfection of equipment or patient care areas, including vehicles used to transport patients. "Contact" is defined in the Commissioner's Order as coming into physical contact, entering a Patient room, coming within 3 feet of a Patient or performing laboratory testing on a specimen from such Patient. Persons qualified to ride in ambulances, EMTs, AEMTs, members of fire companies, and all other persons working or volunteering for ambulance and advanced life support first response service agencies and qualified to provide patient care may come into contact with a Patient and are, therefore, Covered Personnel under the Commissioner's Order. Ambulance and advanced life support first response service agencies must determine which members of their organizations may come into contact with a Patient and, therefore, must be designated Covered Personnel.

2. Is there a preferred EMS to be called outside of NYC in the event that a PUI presents to one of our primary care offices or urgent care facilities?

A. No. There is no preferred EMS to be called outside of NYC. The Commissioner's Order requires that all diagnostic and treatment centers, off campus emergency departments and hospitals that will not be providing ongoing care for a patient with confirmed EVD develop a written transport protocol for the safe transportation of any Patient to another facility. The transport protocol must identify an ambulance service as well as the receiving facility.

3. Will hospitals designated for the care of patients with EVD have an area that can be used for decontaminating the interior of an ambulance before it makes the return trip?

A. The Commissioner's Order requires that ambulance services implement a written protocol to safely clean and disinfect any vehicle or equipment that came into contact with a Patient, in accordance with applicable specifications at Specifications required under the Commissioner's Order. Ambulance services should communicate directly with all receiving hospitals regarding any assistance that can be provided with decontaminating ambulances, as this is likely to vary by facility.

4. Are volunteer ambulance corps being briefed on the Order and the requirement for protocols?

A. Yes. All ambulance and advanced life support first response services, licensed under Article 20 of the PHL, including volunteer ambulance companies, have been served the Commissioner's Order and are subject to the provisions of the Commissioner's Order specified for ambulance services.

1. Where would a funeral home obtain a hermetically sealed casket and the documentation?

A. The Commissioner's Order requires that funeral directors and funeral establishments maintain compliance with the applicable specifications for Safe Handling of Human Remains of Ebola Patients in US Hospitals and Mortuaries. "Hermetically sealed casket" is defined in this document as a casket that is airtight and secured against the escape of microorganisms. Metal caskets must be ordered for those patients who die from EVD that are to be buried, and should be available from casket suppliers. What makes a metal casket hermetically sealed is the soldering that would attach the lid to the bottom of the casket. Soldering is a process in which the two metals are joined together by melting and flowing a filler metal (solder) into the joint. Some monument dealers offer soldering of caskets. Once the remains of a patient who has died from EVD are released to the funeral director, there is no embalming of the remains and the final disposition of the remains should occur promptly.

2. If cremation has to be done in a hermetically sealed casket, do you know of a crematory in NYS that cremates metal? We don't know of any.

A. The Commissioner's Order requires that funeral directors and funeral establishments maintain compliance with the applicable specifications for Safe Handling of Human Remains of Ebola Patients in US Hospitals and Mortuaries. This document provides that "Remains should be cremated or buried promptly in a hermetically sealed casket". To comply with this requirement, the remains must either be cremated, OR the remains must be buried promptly in a hermetically sealed casket. If the remains are to be cremated, the specifications do not require that remains be placed in a hermetically sealed casket as part of the cremation process. All remains of a person who has expired from EVD should be wrapped in plastic and immediately placed in two leak proofpouches. The pouches should be sealed and are not to be opened. For cremation, the pouched remains can be placed in a container suitable for cremation.

1. Are Nigeria and Senegal included in the countries considered as high risk for EVD?

A. No, not at this time. Check the CDC website for the current list of affected countries.

2. Are dogs and cats of individuals who have been exposed to EVD potentially infectious?

A. The CDC, US Department of Agriculture, and the American Veterinary Medical Association do not believe that pets are at significant risk for EVD in the United States. More information about EVD and pets is available at: Questions and Answers about Ebola and Pets.

1. What actions should hospitals take when they have identified an employee with a low or high-risk exposure? How will hospitals handle employees who provided care for a PUI or patient with confirmed EVD? Will they be allowed to continue working after providing care a PUI or patient with confirmed EVD?

A. All covered entities must maintain a log of all personnel who come into contact with either a PUI, or a patient with confirmed EVD, or a patient's area or equipment, regardless of the level of PPE worn at the time of contact. Covered Entities shall measure the temperature twice daily of all personnel who come in contact with a patient, a patient's area or equipment, or obtain the temperatures from off-duty personnel. The log must describe each person's measured temperatures and any symptoms. "Contact" for the purposes of this provision is defined as coming in physical contact, entering a patient room, coming within three feet of a Patient, or performing laboratory testing on a specimen from a Patient. Staff who come into contact with a person with confirmed EVD who were not wearing appropriate PPE must remain at home and be monitored for temperature and symptoms for 21 days.

2. How should health care personnel who have travelled to Guinea, Sierra Leone or Liberia be managed? Is there any guidance or protocols for dealing with health care workers returning from trips to Africa?

A. All travelers returning from these three countries are screened at the airport when arriving in the U.S. The NYSDOH receives a list of individuals who have been screened. LHDs are provided with the names of the individuals arriving from these countries, and the LHDs will contact individuals to rescreen them and make a plan in the event they develop symptoms. Health care workers who have been exposed to patients with EVD, EVD patient body fluids or human remains from EVD patients without appropriate PPE must not return to work for 21 days after exposure and will be requested to voluntarily quarantine. Those entities subject to the Commissioner's Order (general hospitals; diagnostic and treatment centers and off-campus emergency departments; ambulance and advanced life support first response services; and funeral directors and funeral establishments) must follow the applicable specifications contained in the order for Covered Personnel who come in contact with a Patient.

3. The required written registration protocol must include a plan for the Covered Personnel on all shifts who would be involved in the medical evaluation or other care of a PUI placed in "isolation" for the medical evaluation of EVD. Are we expected to have a plan that will place all covered employees in isolation for up to 21 days?

A. The Commissioner's Order requires all general hospitals, diagnostic and treatment centers, and off campus emergency departments to implement a written patient registration protocol for the immediate identification, isolation, and medical evaluation of any person presenting for care who meets the risk factors noted in the order. Isolation in this sentence refers to isolation of the PUI. If an individual who meets the definition of Covered Personnel in the Commissioner's Order comes into contact with a PUI, before the Covered Personnel has donned appropriate PPE, and the PUI is later confirmed as having EVD, the Covered Personnel must remain at home and be monitored for temperature and symptoms, for 21 days after contact.

1. If a hospital does not have the capability to provide ongoing care for a patient with EVD, what preparations are they required to complete based on the Commissioner's Order?

A. All hospitals must be prepared to identify, isolate, diagnose and provide initial care and stabilization for persons meeting the Centers for Disease Control and Prevention (CDC) definition of persons under investigation (PUI), i.e., persons with consistent symptoms and travel history to EVD affected countries within the last 21 days. The hospital must provide personnel who may come into contact with such individuals or their laboratory specimens, or who may be involved in cleaning or disinfection of equipment or their patient care areas, with personal protective equipment (PPE) and training. Isolated patients must receive appropriate clinical care. Under the Commissioner's Order, a hospital that does not have the capability to provide ongoing care must develop a written transport protocol for the safe transportation of a PUI or a patient with confirmed EVD. The transport protocol must identify an ambulance service as well as the receiving facility. The transport protocol must include provisions requiring prompt notification that the protocol has been initiated to the receiving facility, local health department (LHD), NYSDOH, and the ambulance service. The hospital should coordinate with the NYSDOH to determine if and when to carry out that plan. The Commissioner's Order should be reviewed for specifics regarding these items, as well as additional requirements.

2. Are hospitals required to designate an inpatient isolation room for a PUI or patient with confirmed EVD, or is the isolation room used for the initial evaluation of the patient in the ED or adjacent area sufficient?

A. Hospitals must designate an isolation room that meets the requirements of the Commissioner's Order and is most appropriate given the physical layout and other characteristics of the individual facility with the overall goal of minimizing any possible exposures to staff and other patients. If the hospital plans to provide ongoing care to a patient with EVD, it must designate a negative pressure room in the hospital, as outlined in the Commissioner's Order, to provide that care. It is not necessary for the isolation room to be an inpatient room unless the patient is being admitted to an inpatient unit.

3. Our hospital does not have negative pressure rooms in our operating or labor and delivery areas. How should we handle a patient with confirmed EVD who requires these services?

A. The Order requires facilities to designate a negative pressure room for the inpatient care of a PUI or a patient with confirmed EVD. Special circumstances such as patients with confirmed EVD that require an operating room or labor and delivery will be dealt with on a case by case basis with guidance from the NYSDOH and the CDC.

4. If EVD is not spread through airborne transmission, can you please explain the rationale for placing a patient with EVD in a negative pressure room?

A. The Commissioner's Order specifies that general hospitals that will provide ongoing care of patients with suspected or confirmed EVD must place the patient in a negative pressure room. This will minimize the need for patient movement within the hospital during the period of ongoing care, and it will ensure that the patient is housed in the ideal location should aerosolizing procedures need to be performed as part of the patient's care. In addition, CDC's revised PPE guidance (10/21/14) recommends respiratory protection for health care personnel caring for confirmed EVD patients including either N-95 masks or pressurized air purifying respirators (PAPRs).

1. Will there be any additional hospitals designated for the care of EVD in other areas of the state?

A. The NYSDOH continues to work with all hospitals, including regional tertiary care centers, to prepare for a Person under Investigation (PUI) or patient with confirmed EVD. Additional hospitals may agree in the near future to be designated publicly for the care of patients with EVD. As stated in the Commissioner's Order, all hospitals must be prepared to rapidly identify, isolate, diagnose and provide initial care and stabilization for a PUI or patient with confirmed EVD.

2. How did the NYSDOH identify the hospitals as the centers for treating EVD? What requirements will the hospitals have to follow when treating a PUI or patient with confirmed EVD?

A. The hospitals are regional tertiary care centers that have agreed to be designated as centers for the care of PUIs or patients with confirmed EVD. These hospitals must comply with the requirements set forth in the Commissioner's Order, including but not limited to the requirement that the hospitals develop a written plan for the ongoing care of confirmed cases. The Commissioner's Order requires the plan to include specific items if ongoing care will be provided at the hospital. Hospitals agreeing to be designated to provide care to PUIs or patients with confirmed EVD may submit an initial plan to the NYSDOH for review. The NYSDOH is working closely with designated centers to ensure that New York is continuously prepared to safely treat anyone who is exposed to or contracts Ebola.

3. Now that there are facilities that have agreed to be designated publicly for the care of a PUI or a patient with confirmed EVD, will the direction be to send patients directly to one of these facilities from home?

A. Ambulance services should continue to transport patients to the most appropriate medical facility based on the condition of the patient, even if it is not one of the hospitals designated for the care of a patient with EVD. All general hospitals, diagnostic and treatment centers, and off campus emergency departments must be prepared to identify, isolate, diagnose and provide initial care and stabilization for PUIs. However, if a patient meeting the CDC definition of PUI can be safely transported to a designated hospital, that should be done.

4. Does a hospital need to receive laboratory confirmation that a patient has EVD prior to transferring the patient to a hospital that has agreed to be designated publicly for the care of patients with EVD, or other regional tertiary care center?

A. No, the hospital does not need to receive laboratory confirmation that a patient has EVD prior to transferring the patient to a receiving facility. Under the Commissioner's Order, a hospital that does not have the capability to provide ongoing care must develop a written transport protocol for the safe transportation of a PUI (or a patient with a confirmed EVD) to a receiving facility. All general hospitals, diagnostic and treatment centers, and off campus emergency departments, however, must be prepared to identify, isolate, diagnose and provide initial care and stabilization for PUIs, and must provide Covered Personnel, as defined in the Commissioner's Order, who may come into contact with those individuals or their laboratory specimens, or who may be involved in cleaning or disinfection of equipment or their patient care areas, with personal protective equipment (PPE) and training. Isolated patients must receive appropriate clinical care for as long as necessary to stabilize the patient and arrange transport. Covered entities should coordinate with the LHD and the NYSDOH to determine if and when to carry out their transport protocol.

1. Can facilities continue to use a room that it has designated to be used for the isolation of a patient in need of medical evaluation of EVD?

A. Yes. A facility may continue to use a room designated by the facility for the isolation of a patient in need of medical evaluation of EVD. The facility's plan for isolation should address actions to be taken in the event the room is in use and it becomes necessary to use it for isolation.

2. There are no patient rooms in our facility with private bathrooms. Do we need to supply portable commodes to each of our facilities for use in the isolation room?

A. Yes. The Commissioner's Order requires that all general hospitals, diagnostic and treatment centers, and off campus emergency departments designate a room for isolation of a Patient, and that the room must have access to a private bathroom or have a portable commode.

3. Our facility has only open bays with curtains. Are we required to do construction to comply with the requirement in the Order to have a room for the isolation of any PUI?

A. Hospitals, diagnostic and treatment centers and off campus emergency departments are required by the Commissioner's Order to designate a room for isolation that is in, or in proximity to, the area in which Patients would reasonably be expected to present for care, for patients in need of medical evaluation of EVD. The room must have a door, and it must have access to a private bathroom or have a portable commode. Space must be identified in or adjacent to the room, to be used by staff to don and remove PPE. Such space must have access to hand-washing facilities. If the space is adjacent to the room to be used for isolation, traffic in the area must be restricted to avoid exposure of other persons. Access to the room to be used for isolation and adjacent rooms must be restricted to avoid exposure of other persons. A facility that has patient areas consisting only of open bays with curtains must consider alternate locations within the facility that would meet the requirements of the Order, such as offices or by moving the PUI to a section of the room that is restricted in some manner that can limit any contact with others.

4. Are there any guidelines or standards for what type of portable commode would be acceptable for isolation rooms that do not have an adjoining private bathroom? Can a bedpan be used?

A. The Commissioner's Order requires that all general hospitals, diagnostic and treatment centers, and off campus emergency departments designate a room for isolation of a Patient, and that the room must have access to a private bathroom or have a portable commode. The NYSDOH is not recommending a particular type of portable commode that should be purchased. Covered Entities should assure, however, that the surfaces are solid and can be easily cleaned. Facilities may not use bedpans for this purpose.

1. How should hospital laboratories arrange transport specimens to the NYSDOH Wadsworth Laboratory for EVD testing?

A. Hospitals must maintain a readily available inventory of biohazard containers for the safe transportation of specimens to the NYSDOH or the New York City Department of Health and Mental Hygiene laboratory for testing for EVD. Such containers must meet applicable specifications at: Specifications required under the Commissioner's Order. Hospitals must ensure that staff are available on every shift, who are trained and certified in the packaging and shipping of infectious substances, for the purpose of submitting specimens for EVD testing. Training must cover classifying infectious substances, proper packaging of infectious substances, and labeling packages to meet regulatory requirements. Hospitals should coordinate with the LHD and NYSDOH to arrange transport.

2. Should hospitals collect blood specimens from patients with suspected EVD while awaiting transport to an Ebola care center?

A. Essential bloodwork should be obtained following the guidance on the CDC website and NYSDOH website.

3. Our clinical laboratory does not want to package patient samples to forward to the public health laboratory for testing for EVD. The laboratory has no appropriate shipping containers and has no trained or certified personnel.

A. The Commissioner's Order requires hospitals to maintain a readily available inventory of biohazard containers for the safe transportation of specimens to the NYSDOH or NYCDOHMH laboratory for testing for EVD. Such containers must meet applicable specifications at Specifications required under the Commissioner's Order. In addition hospitals are required to develop a written biohazard risk assessment and protocol for the receipt, processing, and testing of any laboratory samples from patients. This standard is also required as part of the Clinical Laboratory Evaluation Program Standards (see Safety Sustaining Standard of Practice).

Safety precautions, including readily available PPE, must meet applicable specifications for the safe handling of specimens at: Specifications required under the Commissioner's Order. In addition, the Commissioner's Order requires that hospitals ensure that staff are available, on every shift, who are trained and certified in the packaging and shipping of infectious substances, for the purpose of submitting specimens for EVD testing. Training must cover classifying infectious substances, proper packaging of infectious substances, and labeling packages to meet regulatory requirements.

Training courses on packaging and shipping are available via the following:

Additionally, CDC offers refresher training for personnel who have been previously certified at: Packing and Shipping Division 6.2 Materials

4. Can you please provide more guidance on how labs should handle specimens after testing has been completed? The guidelines state to "soak in 10% bleach for 24 hours". For blood tubes does that mean putting capped tubes into a container and covering it with the bleach solution, in which case only the outside of the tubes have been decontaminated, or "POP" the top of the tubes, allowing the blood, serum or plasma to mix with the bleach solution?

A: The Commissioner's Order requires facilities to comply with the NYS Guidelines for Handling of Specimens from Patients with Suspected or Confirmed EVD. Laboratory personnel, wearing appropriate PPE, should wet a piece of gauze or absorbent towel with a U.S. Environmental Protection Agency (EPA)-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus) and wipe the outside of the blood tube. The gauze and the disinfected blood tube should then be placed in a plastic bag and packaged with other contaminated waste for appropriate disposal or autoclaving.

1. When will the NYSDOH facility visits start?

A. The facility visits began during the week of 10/20/14.

2. What members will comprise the NYSDOH response team that is deployed to any facility with a patient with confirmed EVD and how will you integrate with the CDC response team?

A. The NYSDOH has subject matter experts available to provide consultation in the following areas: infection control (personal protective equipment, isolation); hospital and other clinical setting requirements; emergency medical services; laboratory services; LHD requirements, sanitation (clinical and non-clinical areas); epidemiology (contact tracing) and others. Subject matter experts will be deployed as needed, as determined by NYSDOH. The NYSDOH will work with the CDC response team, as appropriate.

3. Has the NYSDOH created a hotline?

A. Yes, the NYSDOH has established an Ebola Information Line that is staffed by trained operators. The phone number is 1-800-861-2280.

1. Guidance is needed for private physicians and drug stores. For the physicians' office staff, are there triage questions that should be asked in order to redirect a person to a more appropriate setting such as an emergency room?

A. CDC has posted guidance for community settings on their website.

2. Are Licensed Home Care Agencies (LHCSAs) covered by the Commissioner's Order?

A. No. The Commissioner's Order applies to Covered Entities, defined in the order as general hospitals regulated pursuant to Article 28 of the Public Health Law (PHL); diagnostic and treatment centers and off-campus emergency departments regulated pursuant to Article 28 of the PHL; ambulance and advanced life support first response services licensed under Article 30 of the PHL; and funeral directors and funeral establishments licensed and registered under Article 34 of the PHL. The definition of Covered Entity in the Commissioner's Order does not include home care agencies licensed under Article 36 of the public health law (LHCSAs).

3. Are urgent care centers included as Covered Entities in the Commissioner's Order?

A. The Commissioner's Order defines Covered Entities as general hospitals regulated pursuant to Article 28 of the Public Health Law (PHL); diagnostic and treatment centers and off-campus emergency departments regulated pursuant to Article 28 of the PHL ambulance and advanced life support first response services licensed under Article 30 of the PHL; and funeral directors and funeral establishments licensed and registered under Article 34 of the PHL. Only those urgent care centers that are operated by general hospitals or are diagnostic and treatment centers are required to comply with the Commissioner's Order.

4. We sponsor a WIC unit located in a separate building from the LHD. Are we required to ask WIC clients questions about travel history and symptoms to comply with the order?

A. No. The Commissioner's Order applies to Covered Entities, defined in the order as general hospitals regulated pursuant to Article 28 of the Public Health Law (PHL); diagnostic and treatment centers and off-campus emergency departments regulated pursuant to Article 28 of the PHL; ambulance and advanced life support first response services licensed under Article 30 of the PHL; and funeral directors and funeral establishments licensed and registered under Article 34 of the PHL. The definition of Covered Entity in the Commissioner's Order does not apply to WIC agencies. While some WIC local agencies are administered by hospitals, the Commissioner's Order would not apply to these WIC agencies.

5. Does the Commissioner's Order apply to certain outpatient settings such as specialty clinics and ambulatory surgery centers?

A. The Commissioner's Order applies to all general hospitals, diagnostic and treatment centers, and off-campus emergency departments regulated under Article 28 of the Public Health Law (PHL). Questions have been asked about the applicability of the Order in settings that are regulated under Article 28 of the PHL and must comply with the Order, such as local health department sexually transmitted disease and immunization clinics; ambulatory surgery centers; school based health centers; PACE long term care programs and dental and family planning clinics. NYSDOH also received questions concerning the applicability of the Commissioner's Order to urgent care centers; primary care clinics; cancer treatment centers; wound care clinics;medical school physician faculty practices; physical therapy settings; radiology settings; college health clinics; mental health clinics and cardiac rehabilitation settings.

If these outpatient settings are regulated under Article 28 of the PHL as a freestanding clinic or an extension site of a general hospital or a diagnostic and treatment center, then they must comply with the Commissioner's Order. Please see the answer to Q.6 in Other Settings for more information on how outpatient settings can prepare and be in compliance with the Commissioner's Order.

6. While CDC guidance on PPE for outpatient settings is being developed, how can outpatient settings prepare and be in compliance with the Commissioner's Order?

A. The Commissioner's Order requires all general hospitals, diagnostic and treatment centers, and off-campus emergency departments regulated under Article 28 of the PHL to: identify two lead contacts for EVD preparedness; provide all covered personnel with PPE; conduct training for all covered personnel on PPE; develop a written patient registration protocol and conduct drills; post signage; designate an isolation room; notify the LHD or the NYCDOHMH of a PUI; develop a written transport protocol for the safe transportation of a PUI or a patient with confirmed EVD; maintain documentation of personnel coming into contact with a PUI or a patient with confirmed EVD or the PUI or Patient's areas and monitor personnel; implement a protocol for handling of medical waste; implement a cleaning and disinfection protocol and implement a patient registration protocol and a plan for the covered personnel on all shifts to be involved in medical evaluation or care. The Commissioner's Order should be reviewed for specifics regarding these items, as well as additional requirements.

CDC has posted guidance for community settings on their website.

7. Are outpatient facilities required to follow this plan and register two lead people as points of contact in the Health Commerce System?

A. Yes. The Commissioner's Order applies to Covered Entities, defined in the order to include general hospitals regulated pursuant to Article 28 of the Public Health Law (PHL); diagnostic and treatment centers and off-campus emergency departments regulated pursuant to Article 28 of the PHL. Outpatient facilities that are diagnostic and treatment centers or off-campus emergency departments regulated pursuant to Article 28 of New York State Public Health Law are Covered Entities, and are required under the Order to identify to the NYSDOH at least two points of contact for EVD preparedness and response activities, one of whom must be available 24 hours per day, seven days per week. The lead points of contact must be assigned to the role of 24/7 Ebola Lead in the Health Commerce System (HCS) Communication Directory by the organization's HCS coordinator. Instructions are available at: https://apps.health.ny.gov/pub/ctrldocs/alrtview/postings/HCS Role Assignment.pdf.

8. What are the triage questions that should be asked in a homeless shelter?

A: CDC has posted guidance for community settings on their website. If a homeless shelter wishes to assess its clients for risk for Ebola, staff should inquire whether people have traveled within the last 21 days to Liberia, Guinea, or Sierra Leone, and whether they are experiencing any symptoms of EVD including fever, headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage. Patients answering yes to both questions should be moved into a private room or area while arrangements are made to transfer the patient to a health care facility.

1. Is the written registration protocol required for people coming into hospitals for outpatient lab work, physical therapy appointments or outpatient X-rays? What about blood draw stations in buildings outside of the hospital?

A. Yes. The Commissioner's Order requires that all general hospitals, diagnostic and treatment centers, and off-campus emergency departments implement a written patient registration protocol for the immediate identification, isolation and medical evaluation of any person presenting for care with (1) a travel history within the last 21 days to Liberia, Guinea, or Sierra Leone, or any other country that CDC designates as having a widespread EVD outbreak; and (2) any symptoms of EVD as specified in the Attachment to the Order.

2. Is the hospital or the EMS agency responsible for notifying NYSDOH of a PUI?

A. The Commissioner's Order requires all general hospitals, diagnostic and treatment centers and off-campus emergency departments to immediately notify the LHD or the New York City Department of Health and Mental Hygiene, as applicable, when a PUI is placed in isolation for the medical evaluation of EVD. If ambulance services become aware of a PUI, it is recommended that they notify the hospital and the LHD immediately.

3. Can the screening that is required as part of the written patient registration protocol under the Commissioner's Order be verbal or are we required to maintain written documentation to ensure that appropriate screening is taking place?

A. The written patient registration protocol may provide for the use of verbal screening of patients for travel history and symptoms.

4. Family planning clinics schedule patient appointments with very little time between the scheduling and appointment dates. Can the scheduler obtain a travel history and screen for symptoms over the telephone?

A. Yes. The Commissioner's Order requires that all general hospitals, diagnostic and treatment centers, and off-campus emergency departments implement a written patient registration protocol for the immediate identification, isolation and medical evaluation of any person presenting for care with (1) a travel history within the last 21 days to Liberia, Guinea, or Sierra Leone, or any other country that CDC designates as having a widespread EVD outbreak; and (2) any symptoms of EVD as specified in the Attachment to the Order. The clinic may establish in its written patient registration protocol, a process that includes screening patients over the telephone to determine if the patient is a PUI. If a patient is identified as a PUI, the scheduler must obtain contact information for the patient, and request that the patient remain at his or her location. In accordance with the Commissioner's Order, the clinic should then immediately notify the LHD. Covered Entities that choose to have schedulers inquire about relevant travel history and symptoms over the telephone, however, still need to screen any person who presents for care.

5. Is there a standard form for patient registration? Is it correct that all patients must provide a form prior to each visit and upon reception outlining their travels and symptoms?

A. The Commissioner's Order requires that all general hospitals, diagnostic and treatment centers, and off-campus emergency departments implement a written patient registration protocol for the immediate identification, isolation and medical evaluation of any person presenting for care with (1) a travel history within the last 21 days to Liberia, Guinea, or Sierra Leone, or any other country that CDC designates as having a widespread EVD outbreak; and (2) any symptoms of EVD as specified in the Attachment to the Order. There is not a standard form that is required to be used for patient registration. There is no requirement that patients must provide a form prior to each visit andupon reception outlining their travels and symptoms. The facility's written patient registration protocol must include the means by which patients will be asked their travel histories and symptoms and how this process will be implemented at the facility.

6. The Order requires that the written patient registration protocol include a plan for the covered personnel on all shifts who would be involved in medical evaluation or other care of a PUI. Does the plan for covered personnel have to include all staff who would be involved from the time of a completed registration form identifying a PUI to the time the PUI is transported to another facility?

A. All general hospitals, diagnostic and treatment centers, and off campus emergency departments are required under the Commissioner's Order to implement a written patient registration protocol for the immediate identification, isolation and medical evaluation of a PUI. The plan that is required to be included in the patient registration protocol must identify all of those persons who would be involved in the care from registration through isolation and medical evaluation so that they can be trained, deployed and, following the care of a PUI, monitored.

7. For public health clinics, is screening to occur for all who enter the building or only those coming in for medical care (e.g. postal workers, interpreters, patient family members or other visitors)?

A. The Commissioner's Order requires that all general hospitals, diagnostic and treatment centers, and off-campus emergency departments implement a written patient registration protocol for the immediate identification, isolation and medical evaluation of any person presenting for care with (1) a travel history within the last 21 days to Liberia, Guinea, or Sierra Leone, or any other country that CDC designates as having a widespread EVD outbreak; and (2) any symptoms of EVD as specified in the Attachment to the Order. The Order requires that Covered Entities screen only those persons presenting for care.

8. My facility provides outpatient services, and no primary or urgent medical care, and has developed a written patient registration protocol that has one receptionist providing directions to a PUI on how to move to an isolation room while minimizing close contact. Can the monthly drill required under the Commissioner's Order be limited to that one receptionist?

A. For facilities in outpatient settings that will not be performing a medical evaluation of a PUI, but only isolating the Patient and implementing their transport protocol, it is important that the number of personnel used to isolate a Patient be minimized. Accordingly, the drills on the patient registration protocol that are required to be conducted monthly with personnel on all shifts can be with one receptionist if that is the extent of the personnel that is appropriate for the protocol at your facility.

9. What should facilities do if a patient refuses screening or leaves after being screened as having recent travel history and risk factor criteria that for an EVD PUI?

A. The current EVD traveler monitoring process in NYS significantly decreases the likelihood of a person at risk for EVD entering a medical setting unannounced. All at-risk travelers are actively monitored by public health staff to identify early symptoms compatible with EVD and direct them to designated hospitals, where possible. Regardless, it is prudent to maintain readiness at all facilities throughout NYS. Initially, upon presentation to the registration area, staff should assess the patient for a relevant travel history and presenting symptoms. If the initial staff query identifies that the patient has a travel history to an Ebola affected country* during the previous 21 days and identifies symptoms consistent with EVD, designated staff should isolate the patient for medical evaluation of EVD as stated under the Commissioners Order and notify the LHD. If the patient refuses any of the EVD screening steps, or refuses to be isolated if the screening is positive, it is important to understand his/her concerns and provide an explanation regarding the reasons for the questions asked and the subsequent recommendations. If the patient continues to refuse, contact the LHD where the healthcare facility (HCF) is located. Alternatively, the HCF may contact the NYSDOH Bureau of Communicable Disease Control at (518) 473-4439 or after hours, the NYSDOH Public Health Duty Officer Helpline 1-866-881-2809. (Refer to CDC "Legal Authorities for Isolation and Quarantine" document for further details:).

*A travel history to Liberia, Guinea, or Sierra Leone, or any other country that CDC designates as having a widespread EVD outbreak or cases in urban areas with uncertain control measures or exposure to a person with EVD in the last 21 days.

1. What are the current PPE recommendations for hospital employees?

A. The CDC website contains the most recent PPE recommendations. These recommendations are also included on the NYS DOH website, Specifications required under the Commissioner's Order at: Specifications Required Under Commissioner's Orders.

2. Several types of PPE are on backorder. What should hospitals do to obtain these products? How should hospitals conduct PPE training and drills with staff when we are unable to obtain PPE supplies?

A. Covered Entities should continue to order the PPE needed to comply with the Commissioner's Order and document all efforts and communications with manufacturers and distributors. Covered Entities should explore whether other facilities within their healthcare system or geographic area have PPE that can be provided to them to help them comply with the Commissioner's Order. Entities with an inadequate supply of PPE should use the minimum amount of PPE needed to conduct training and drills for Covered Personnel who are most likely to come into contact with a PUI. When additional supplies become available, additional training should be conducted. The NYSDOH is maintaining a supply of PPE that can be deployed to any facility that is caring for a PUI or patient with confirmed EVD that has exhausted all local sources of PPE.

3. Will there be any training offered or easily accessible training materials?

A. Yes. On Tuesday, October 21, 2014, from 10 a.m. to 1:00 p.m. NYSDOH will join representatives from the CDC, the Greater New York Hospital Association, 1199 SEIU and the Partnership for Quality Care for an Ebola educational session for health care workers. The event will include national and New York City-area infection control experts, and a hands-on demonstration of wearing and removing equipment. The education session will take place at the Javits Convention Center in New York City. The session is available to live stream at http://gnyha.org/ebolatraining.

4. Guidance for Local Health Departments (LHD) on PPE for monitoring contacts is needed.

A. Contact monitoring guidance has been developed and issued to LHDs.

5. Can you please further explain the "infection control expertise" that is required for the designated trainers that Covered Entities need to use to train Covered Personnel on the donning and removing of PPE?

A. The Commissioner's Order requires that all general hospitals, diagnostic and treatment centers, off-campus emergency departments, and ambulance services conduct in-person training for all Covered Personnel, on donning and removing PPE, including physically practicing donning and removing PPE in the setting that will be used for Patients. A designated trainer with infection control expertise selected by the Covered Entity must be present at the training to assess whether Covered Personnel have initially achieved satisfactory competence. The designated trainer with infection control expertise, must at a minimum, have one of the following credentials: physician, licensed practical nurse, registered nurse, emergency medical technician, certification in infection control issued by the Certification Board of Infection Control and Epidemiology, or hold the role of either hospital epidemiologist, infection control practitioner, infection preventionist, or whose duties include environmental health and safety or employee health; and also possess an understanding of and experience in each of the following:

  • modes and mechanisms of transmission of pathogenic organisms in the healthcare setting and strategies for prevention and control;
  • selection of PPE for preventing patient and healthcare worker contact with potentially infectious materials;
  • experience with proper donning and removal of PPE;
  • guidance on the proper use of PPE; and
  • experience implementing standard precautions and transmission based precautions.

6. In the Commissioner's Order on Page 2 in the "covered personnel" training section there is a reference to achieving "satisfactory competence" in the use of PPE. Is that defined anywhere?

A. The Commissioner's Order requires that the Covered Entity conduct in-person training for all Covered Personnel, on donning and removing PPE. A designated trainer with infection control expertise must be present at the training to assess whether Covered Personnel have initially and upon reassessment, achieved satisfactory competence. "Satisfactory competence" is not defined in the Commissioner's Order. The determination as to whether Covered Personnel have achieved satisfactory competence in donning and removing PPE is to be made by the designated trainer.

7. What is the purpose of the PPE that the NYSDOH is purchasing? Will it be predeployed to facilities, or deployed only to the identified hospitals, or held by the NYSDOH?

A. The Commissioner's Order requires that all general hospitals, diagnostic and treatment centers, off-campus emergency departments, and ambulance services provide all Covered Personnel with PPE that, at a minimum, meets the applicable specifications required under the Order. The NYSDOH maintains a Medical Emergency Response Cache (MERC) with a supply of PPE that includes but is not limited to impermeable gowns, Tychem suits and powered air purifying respirators (PAPR). This supply can be made available in an emergency situation for hospitals caring for a PUI or confirmed EVD patient who are unable to obtain PPE after exhausting their supply mechanisms.

8. Is the level of PPE required for the inpatient care of a patient with confirmed EVD as reflected in the recent, updated CDC guidance, necessary to use in any outpatient setting where a PUI may present for care?

A. While outpatient settings must continue to provide PPE for Covered Personnel under the Commissioner's Order and provide appropriate training on the PPE, the level of PPE provided to Covered Personnel in these settings need not be at the same level of PPE currently recommended by CDC for the management of an inpatient with confirmed EVD. It is anticipated the CDC will release PPE guidelines for outpatient settings to address PPE requirements for a person with travel history and clinical presentation that would raise concern about EVD. Until such time that CDC guidance is available, PPE used for droplet and contact precautions can be used in outpatient settings where it is likely that a PUI will be identified and isolated pending transfer to another setting, and limited patient contact is expected. PPE appropriate for use to prevent transmission in these instances (standard, contact and droplet precautions) includes an impervious gown, surgical mask, face shield and gloves, at a minimum. Information about isolation precautions can be found at: http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html.

9. Should hospitals include environmental services staff among those who need to be trained in PPE and involved in daily cleaning, or should it be the clinical team that performs necessary daily cleaning and disinfecting?

A. All general hospitals, diagnostic treatment centers, off campus emergency department, and ambulance services are required under the Commissioner's Order to conduct in-person training for all Covered Personnel on donning and removing PPE. "Covered Personnel" is defined in the Order to include all employees, contractors, students, and all other personnel who may be involved in the cleaning or disinfection of equipment or Patient care areas. Hospitals need to determine how daily and terminal cleaning activities will occur and what staff will be involved in such activities. Staff that will perform the necessary cleaning activities within the isolation areas would be considered Covered Personnel in the Commissioner's Order and must be trained in donning and removing PPE.

10. My facility is unable to find certain PPE items. Are there any suggestions for how to find alternate availability?

A. At this time all healthcare product vendors are experiencing delays in the availability of PPE items and it may be necessary to contact multiple vendors in an attempt to locate items. Most manufacturers offer comparable products, however, it is important to compare specifications to ensure each item meets the appropriate guidelines for the patient setting. The availability of product changes on a daily basis. All manufacturers have increased production to meet current demands. Vendors can usually offer an estimated date for when an item on backorder will be available.

11. My facility provides outpatient services, and no primary or urgent medical care, and has a very limited number of Covered Personnel. Can the required monthly reassessment of Covered Personnel's use of personal protective equipment be a written test of staff recall of key PPE steps?

A. While outpatient settings must continue to provide PPE for Covered Personnel under the Commissioner's Order and provide appropriate training on the PPE, the level of PPE provided to Covered Personnel in these settings need not be at the same level of PPE currently recommended by CDC for the management of an inpatient with confirmed EVD.Accordingly, monthly reassessments of Covered Personnel in outpatient settings serving a population at very low risk for EVD can use strategies such as a written test of Covered Personnel's ongoing competence with PPE.

12. Which personnel in facilities subject to the October 16th 2014 Commissioner's Order need to undergo retraining for PPE each month? Does every such individual need to practice donning and doffing of PPE each month? What training would NYSDOH deem sufficient for monthly retraining?

A: Covered personnel are defined in the Commissioner's Order as those employees, contractors, students and other personnel who may come into contact with a patient, laboratory specimen, or body of a patient with possible or confirmed EVD, or be involved in the cleaning or disinfection of equipment or patient care areas, including vehicles used to transport patients, used for a patient, laboratory specimen or body of a patient with possible or confirmed EVD.

For general facilities (including, but not limited to, non-designated hospitals, diagnostic and treatment centers, off campus emergency departments and emergency services), monthly retraining is required for those identified by the facility as personnel who are in roles that meet the definition of Covered Personnel in the Order. The facility may limit the number of staff designated to serve in these roles, so long as adequate coverage is available on all shifts and in all locations where possible EVD infected patients may present to the facility. Monthly reassessments need not include actual donning and doffing PPE by all Covered Personnel, however, monthly reassessments should include observation by Covered Personnel of correct donning and doffing procedures performed by at least one individual. Facilities may consider utilizing a video demonstration of proper donning and doffing procedures for this purpose. Reassessments may also include strategies such as a written test of Covered Personnel's ongoing competence with PPE. Other monthly reassessment activities should include review of procedures for rapid identification and isolation of Patients.

For general hospitals designated as Ebola assessment and treatment hospitals, Covered Personnel who will be providing direct care to Ebola patients should train and practice donning and doffing the PPE that will be used in the isolation unit monthly. PPE used for training should be reused to the extent possible.

13. For the monthly retraining requirement and maintenance of EVD preparedness for NYS general facilities (non-designated EVD hospitals), the Department's FAQ's clarify that it is allowable to use video training materials on PPE donning and doffing. Could you please provide some video tools that can be used for retraining?

  1. CDC/Johns Hopkins Ebola training modules. (Posted October 29, 2014, there are multiple training modules which include PAPR and N95 PPE training).
  2. CDC/Medscape PPE training video (Posted October 29, 2014, 13 minutes, PAPR training not included).
  3. CDC/Greater New York Healthcare Association Ebola PPE training video. Oct. 21, 2014 Javits Center NYC PPE training session: (20 minutes, PAPR training not included).
  4. University of Nebraska PPE training video: unmcheroes.org or Biological PPE: Ebola - Donning (YouTube). (Posted October 24, 2014, 8 minutes, PAPR training not included).

Hospitals can augment their retraining protocols by including their own retraining videos with their specific PPE procedures, however, the video should include the features covered in the referenced PPE training video demonstrations. There are a variety of Ebola PPE educational videos available for your review on YouTube, which may be of value with your specific institutional PPE protocols. See FAQ #12 (under commissioner's orders, questions and answers, PPE) for further clarification of the required retraining for non-designated hospitals.

1. Has the NYSDOH developed a document to share with hospitals which has the required signage with translations to keep them uniform across the state?

A. Yes, sample signage in the required languages can be found at the following location: Specifications Required Under Commissioner's Orders.

2. Is the use of the NYSDOH signage required for entrances to hospitals?

Yes. The Commissioner's Order states that all general hospitals, diagnostic and treatment centers and off campus emergency departments must post signs prominently at all entrances, at reception, and at triage locations in at least English, French, Spanish, Chinese, Russian, Italian, Korean, and Haitian Creole asking all persons presenting for care to provide their international travel history. For the convenience of facilities, signage with translations is available on the NYSDOH website at: International Travelers Poster, but hospitals may use other signage that meets the requirements of the Commissioner's Order, if they wish.

3. Some of the signage translations are not downloading. Who can I call for help? An English version of the signage is needed and we cannot find it on your site. We also need a Polish version for the many Polish people in our community?

A. If you are unable to download the signage from the website, please submit an e-mail to Ebola.Preparedness@health.ny.gov and someone from the NYSDOH will contact you to provide technical assistance or find an alternate method of sending you the document files. A Polish translation has also been posted. The English version of the signage is located on the website at: International Travelers Poster.

4. Is it possible to get the International Travelers Poster in Arabic? We have a large Arabic speaking population in our community.

A. Yes. The document was translated into Arabic and posted to the NYSDOH website.

5. We are unable to print both the Spanish and Haitian Creole languages. They appear to be overlaid on the English version. Can this be corrected, or is there another source to obtain these posters?

A: Anyone using Firefox who has tried to access those two posters previously should refresh his or her browser or clear all recent history. Once that isdone, the file should read properly.

6. We have posted the travel history signs in the eight languages specified in the Commissioner's Order. The areas in which the signs are to be posted are limited in space. Our refugee/immigrant population speaks many languages not specified in the order. In order to provide the best instruction for our population are we allowed to substitute one of the eight specified languages for one our populations actually do speak?

A. The Commissioner's Order states that all general hospitals, diagnostic and treatment centers and off campus emergency departments must post signs prominently at all entrances, at reception, and at triage locations in at least English, French, Spanish, Chinese, Russian, Italian, Korean, and Haitian Creole asking all persons presenting for care to provide their international travel history. For the convenience of hospitals, signage with translations is available on the NYSDOH website at: International Travelers Poster, but hospitals may use other signage that meets the requirements of the Commissioner's Order, if they wish. Pursuant to 10 NYCRR 405.7, hospitals are required to have a language access plan and make an annual needs assessment utilizing demographic information available from the United Stated Bureau of Census, hospital administrative data, school system data, or other sources, that will identify limited English speaking groups comprising more than one percent of the total hospital service area population. If the hospital has determined that its population includes other groups not represented by the languages noted in the Commissioner's Order, the hospital should post signs in the additional languages applicable to its population.

7. Why do the "International Travelers Posters" on your Ebola website mention cough and rash?

A. The Commissioner's Order requires general hospitals, diagnostic and treatment centers, and off campus emergency departments to post signs prominently at all entrances, at reception, and at triage locations in English, French, Spanish, Chinese, Russian, Italian, Korean and Haitian Creole asking all persons presenting for care to provide their international travel history. For the convenience of facilities, signage with translations is available on the NYSDOH website at: International Travelers Poster, but hospitals may use other signage that meets the requirements of the Commissioner's Order, if they wish. The International Travelers Poster is a resource for hospitals and providers to use to help identify a variety of communicable diseases that are often associated with travel (e.g. Middle East Respiratory Syndrome or MERS). Although not specific for EVD, the International Travelers Poster requests that staff be notified immediately if a person presents who has traveled internationally or had close contact with someone who has recently traveled internationally, and is exhibiting symptoms. The poster helps to strengthen the public health and health care system since early identification and isolation of individuals who may have a communicable disease helps to prevent additional exposures.

8. One provider has reduced the size of the downloadable signs in the multiple languages. Is this in compliance?

A. Yes. The signage provided on the NYSDOH website can be reduced in size as long as it continues to be easy to read and posted prominently. The Commissioner's Order requires all general hospitals, diagnostic and treatment centers, and off campus emergency departments to post signs prominently at all entrances, at reception, and at triage locations, in at least English, French, Spanish, Chinese, Russian, Italian, Korean and Haitian Creole asking all persons presenting for care to provide their international travel histories.

1. Should hospitals that have identified a PUI or patient with confirmed EVD coordinate with the LHD and NYSDOH to coordinate patient transport to an Ebola care center?

A. Yes.

2. How long do facilities need to keep a PUI or patient with confirmed Ebola prior to transport?

A. All Covered Entities must be prepared to identify, isolate, diagnose and provide initial care and stabilization for a PUI. Isolated patients must receive appropriate clinical care for as long as necessary to stabilize the patient and arrange transport. The hospital should coordinate with the NYSDOH to determine if and when to carry out their transport protocol.

3. Must hospitals have written agreements with ambulance service providers for the transport of persons with suspected or confirmed EVD?

A. The Commissioner's Order requires that a hospital's transport protocol identify an ambulance service that will be used to transport EVD patients. Verbal agreements with ambulance service providers are acceptable, but the details of the arrangement should be specified in the hospital's written protocol.

4. If a community-based clinic sees a patient with a fever and travel history to Sierra Leone, Guinea, or Liberia meeting the CDC definition of a PUI what should they do?

A. All Article 28 facilities should have a plan to isolate a PUI prior to transport and to provide PPE to staff. They should also have a transport protocol in place. The facility should notify their LHD of a suspected case. Facilities must develop a written transport protocol for the safe transportation of any patient to another facility. The transport protocol must identify an ambulance service as well as the receiving facility. The transport protocol must include prompt notification that the protocol has been initiated to the receiving facility, LHD, NYSDOH, and the ambulance service. The facility should coordinate with the NYSDOH to determine if and when to carry out that plan.

5. Must specific hospitals be named in the protocol to transfer patients with EVD for ongoing care if that is the hospital's plan?

A. Yes. The Commissioner's Order requires that written transport protocols developed by general hospitals that will not be providing ongoing care for patients with EVD must identify an ambulance service as well as the receiving facility. The transport protocol must also include provisions requiring prompt notification that the protocol has been initiated to the receiving facility, LHD, NYSDOH, and the ambulance service. The hospital should coordinate with the NYSDOH to determine if and when to carry out that plan. Notification to the receiving facility and the ambulance service will allow them to direct staff to use PPE and prepare vehicles and receiving areas.

6. In New York City will FDNY Emergency Medical Service (FDNY EMS) facilitate transportation to one of the facilities designated for the care of patients with EVD or are hospitals expected to contract with an independent EMS provider for patients presenting at an outpatient setting?

A. All facilities must develop a written transport protocol for the safe transportation of any patient to another facility. The transport protocol must identify an ambulance service as well as the receiving facility. In New York City, the New York City Department of Health and Mental Hygiene (NYCDOHMH) has arrangedto have FDNY EMS serve as the ambulance service for any PUI in the five boroughs of NYC. The Commissioner's Order requires that the transport protocol include provisions requiring prompt notification that the protocol has been initiated to the receiving facility, local health department, NYSDOH and the ambulance service. Covered entities in NYC should immediately contact the NYCDOHMH regarding any PUI being placed in isolation to receive additional guidance and discuss any potential transfer.

7. Do facilities need to contact designated hospitals in advance and create an agreement to transfer patients to them, or may facilities reference these hospitals in their transport protocols without contacting them directly?

A. Under the Commissioner's Order, a hospital that does not have the capability to provide ongoing care, and diagnostic and treatment centers and off-campus emergency departments must develop a written transport protocol for the safe transportation of a PUI or a patient with confirmed EVD. The transport protocol must identify an ambulance service as well as the receiving facility. The transport protocol must also include provisions requiring prompt notification that the protocol has been initiated to the receiving facility, LHD, NYSDOH, and the ambulance service. Facilities should discuss with the receiving facility and ambulance service, in advance, their intent to specifically identify them in their protocol as the receiving facility and ambulance service that will be called on in the event the facility intends on transferring a PUI or a patient with confirmed EVD. Since the protocol must include provisions requiring prompt notification that the protocol has been initiated to the receiving facility, LHD, NYSDOH, and the ambulance service, identifying points of contact and keeping those up to date is an important part of the protocol.

8. If a facility screens patients who call for appointments on the phone and identifies a PUI, should the patient be kept on hold while the facility calls the LHD for guidance?

A. All facilities must develop a written transport protocol for the safe transportation of any Patient to another facility. The transport protocol must identify an ambulance service as well as the receiving facility. The transport protocol must include prompt notification that the protocol has been initiated to the receiving facility, LHD, NYSDOH and the ambulance service. The transport protocol may specify that, if a PUI is identified via a phone screening, the facility will determine the location of the PUI, tell the PUI to stay at that location and call the ambulance service identified in the protocol. The facility may opt to keep the PUI on hold while calling the ambulance service. Notification to the LHD, the NYSDOH and the receiving facility may take place immediately after arrangements are made for the safe transport of the PUI.

1. Can liquid waste from a Patient be discharged into the sanitary sewer without pre-treatment?

A. Yes. The Commissioner's Order requires that general hospitals, diagnostic and treatment centers, off-campus emergency departments and ambulance services to implement a written protocol to safely contain, store and dispose of regulated medical waste in compliance with the applicable specifications at Specifications required under the Commissioner's Order. Current NYSDOH and NYSDEC regulations allow hospitals, laboratories, and other facilities to discharge liquid waste containing pathogens directly into the sanitary sewer, unless specifically prohibited by local law or ordinance. Additionally, current CDC guidance states that sanitary sewers may be used for the safe disposal of patient waste. Human waste from patients with many infectious diseases is routinely discharged into the sanitary sewer system without any special pretreatment. Ebola virus is more sensitive to environmental inactivation than many of these other infectious agents. In previous outbreaks of Ebola in Africa, no transmission was documented through incidental exposure to contaminated wastewater. Pretreatment has been used for liquid waste from hospitalized patients with EVD in other states. Whenever disinfecting or disposing of liquid waste, care should be taken to avoid splashes, exposures to chemical disinfectants and incidental contact with body fluids.

2. Do combined sewer overflows (CSOs) pose an additional health concern if waste from a PUI or a patient confirmed EVD is present in the sanitary sewer system?

A. In general, CSOs present a health concern because they can result in fecal contamination of surface waters used for recreational activities such as boating and swimming. Many potential disease-causing organisms are present in any CSO. Accordingly, beach closings are already routinely issued when a CSO impacts a regulated swimming beach. Ebola virus is more sensitive to environmental inactivation than many of these other infectious agents. In previous outbreaks of Ebola in Africa, no transmission was documented through incidental exposure to contaminated wastewater.

3. Can the wastewater associated with cleaning be discharged into the existing plumbing/sanitary sewer or into an individual septic system?

A. Yes. Wastewater from cleaning can be discharged into existing sanitary sewer lines or individual septic system unless specifically prohibited by local law or ordinance. Ebola virus is more sensitive to environmental inactivation than many other infectious agents. In previous outbreaks of Ebola in Africa, no transmission was documented through incidental exposure to contaminated wastewater.

4. Any waste related to the medical evaluation of a PUI falls into Category A. Is a protocol to contact a waste hauler that has been identified as being qualified to accept infectious waste sufficient to meet the requirements of the order? Are identified waste haulers required to accept waste from any facility that comes into contact with a PUI? Does the NYSDOH have a list of approved haulers of infectious waste?

A. The Commissioner's Order requires all general hospitals, diagnostic and treatment centers, off-campus emergency departments, and ambulance services to implement a written protocol to safely contain, store and dispose of regulated medical waste (RMW). If a facility will be sending untreated RMW generated from the care of a PUI or patient with confirmed EVD off-site for treatment, the protocol must identify a transporter that is permitted by the U.S. Department of Transportation (USDOT) to transport EVD waste, which is designated as category A.

The USDOT issued an emergency special permit authorizing several RMW transporters to transport EVD RMW. Information on the transporters authorized under the nationwide special permit issued by USDOT can be found at: Transporting Infectious Substances Questions and Answers. Some of these transporters operate in New York State. The facility must confirm with the U.S. Dept. of Transportation that the RMW transporter being used has approval under the USDOT emergency special permit to transport untreated EVD RMW. USDOT can be reached at Specialpermits@dot.gov. The facility must also contact the transporter to ensure that it is willing and able to accept the waste.

Note that authorized waste haulers are not required by law to accept waste. If a facility has made diligent efforts to identify a transporter that is willing and able to accept the waste, but have been unable to do so, please contact the Department at rmwp@health.ny.gov.

If a facility will be sending RMW generated from the care of a PUI or a patient with confirmed EVD off-site for treatment, the facility must comply with the packaging requirements described in the emergency special permit before the waste can be picked up by the RMW transporter. Information on the USDOT emergency special permit (DOT SP 16279) can be found at: Transporting Infectious Substances.

1. Does this notification pertain to Skilled Nursing Facilities/Long Term Care facilities?

A. No, this Commissioner's Order does not apply to nursing homes.

2. The Order, Attachment A pages 1-2 states that facilities have 10 days for compliance. Please confirm the deadline for compliance.

A. TheCommissioner's Order requires all Covered Entities to immediately begin implementation and compliance with the requirements set forth in Attachment A to the Order. Full implementation and compliance must be achieved by no later than 10 calendar days of the Covered Entity's receipt of the Order. The Attachment cites to specifications entities must meet that are available on the NYSDOH website at: Specifications Required Under Commissioner's Orders. However, if there are changes to the information posted on the NYSDOH website, Covered Entities will be provided additional time per the web site update to achieve full implementation and compliance with such changes.

3. What are the roles and functions of the two lead points of contact for EVD preparedness and response activities as required in Attachment A of the Commissioner's Orders?

A. The primary roles and functions of the two lead points of contact for EVD preparedness and response activities include: arranging to provide documentation required in the Commissioner's Order, on request; receiving updates about new information from the CDC, NYSDOH and NYCDOHMH and assuring that information is made available to appropriate facility staff; and responding to requests for information and inquiries from the LHD, NYCDOHMH, and NYSDOH.

4. Is a hospital required to take any action regarding a person who accompanies a patient to a health center and the patient subsequently becomes a PUI placed into isolation?

A. Yes. The Commissioner's Order requires all general hospitals, diagnostic and treatment centers and off campus emergency departments to immediately notify the LHD when a PUI is placed in isolation for the medical evaluation of EVD. When the PUI is being placed into isolation, the facility should obtain the name and contact information of any companion(s) who accompanied the patient to the facility and, as part of its notification responsibilities, share this information with the LHD to assist the LHD in contact tracing.

5. Our facility has prepared the required written policies for Ebola preparedness. In addition to assigning the two points of contact on the HCS website, where should we submit our written policy?

A. The Commissioner's Order requires that all general hospitals, diagnostic and treatment centers, and off-campus emergency departments implement a written patient registration protocol for the immediate identification, isolation and medical evaluation of any person presenting for care with (1) a travel history within the last 21 days to Liberia, Guinea, or Sierra Leone, or any other country that CDC designates as having a widespread EVD outbreak; and (2) any symptoms of EVD as specified in the Attachment to the Order. The written protocols do not need to be submitted to the Department for review but must be made available to the Department upon request.