From: Subject: Interim Guidance for Managing Patients with Suspected Viral Hemorrhagic Fever in U.S. Hospitals | CDC Infection Control in Healthcare Date: Fri, 4 Jan 2008 14:14:54 -0800 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0205_01C84EDC.2D808C30" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3198 This is a multi-part message in MIME format. ------=_NextPart_000_0205_01C84EDC.2D808C30 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.cdc.gov/ncidod/dhqp/bp_vhf_interimGuidance.html Interim = Guidance for Managing Patients with Suspected Viral Hemorrhagic Fever in = U.S. Hospitals | CDC Infection Control in Healthcare
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Interim Guidance for Managing Patients with Suspected Viral = Hemorrhagic=20 Fever in U.S. Hospitals


Released: May 19, 2005=20

This document updates recommendations (MMWR = 1995;=20 44(25);475-9) for managing patients with suspected viral hemorrhagic = fever=20 (VHF) who are admitted to U.S. hospitals. This document provides = additional=20 epidemiologic data on the transmission of VHF and updated = recommendations on=20 infection control precautions during patient care, environmental = infection=20 control procedures, case reporting, specimen handling and testing, = handling of=20 human remains, and post-exposure management. The terms and categories of = isolation in this document are based on those outlined in the Guideline for = Isolation=20 Precautions in Hospitals (1). These interim recommendations will be = updated=20 as additional information becomes available.

Transmission Risk

In Africa, transmission of VHF in healthcare settings has been = associated=20 with reuse of contaminated needles and syringes and with provision of = patient=20 care without appropriate barrier precautions to prevent exposure to=20 virus-containing blood and other body fluids (including vomitus, urine, = and=20 stool) (1-3). The transmission risks associated with various body fluids = have=20 not been well defined because most caregivers who have acquired = infection had=20 contacts with multiple fluids.

The risk for person-to-person transmission of hemorrhagic fever = viruses is=20 greatest during the latter stages of illness when virus loads are = highest;=20 latter stages of illness are characterized by vomiting, diarrhea, shock, = and, in=20 less than half of infected patients, hemorrhage. No VHF infection has = been=20 reported in persons whose contact with an infected person occurred only = during=20 the incubation period (i.e., before onset of fever). The incubation = period for=20 VHF ranges from 2 days to 3 weeks, depending on the viral agent (1). = There are=20 reports of Ebola virus transmission occurring within a few days after = onset of=20 fever; however, the presence of other symptoms in the source patients = and the=20 level of exposure to body fluids among secondary cases are unknown in = these=20 instances (CDC, unpublished data, 1995). In studies involving three = monkeys=20 experimentally infected with Ebola virus (Reston strain), fever and = other=20 systemic signs of illness preceded detection of infectious virus in the = animals=92=20 pharynx by 2-4 days, ,in the conjunctivae and on anal swabs by 5-6 days, = and in=20 the nares by 5-10 days (8).

In studies involving nonhuman primates, monkeys could be infected by=20 mechanically generated small-particle aerosols (4-7), but epidemiologic = studies=20 in humans do not indicate that VHF is readily transmitted from person to = person=20 by the airborne route (1,2). Airborne transmission was considered as a = possible=20 explanation for a hospital-associated cluster of Lassa fever infections = in which=20 the index patient had severe pulmonary involvement, but the mode of = transmission=20 for that outbreak was not determined (3). Although unproven, airborne=20 transmission of VHF is a hypothetical possibility during procedures that = may=20 generate aerosols.

Case Reporting and Specimen Testing

All suspected cases of VHF should be reported immediately to local = and state=20 health departments and to CDC (Special Pathogens Branch, 404 639-1115). = Consult=20 the Special Pathogens Branch before obtaining or sending specimens to = CDC for=20 confirmatory testing. State health departments should also be notified = before=20 sending specimens to CDC. For links to state health departments visit = the "Information = Networks and=20 Other Information Sources" page on the CDC Web site.

Risk Categories

VHF should be suspected in febrile persons who, within 3 weeks before = onset=20 of fever, have either 1) traveled in the specific local area of a = country where=20 VHF has recently occurred; 2) had direct unprotected contact with blood, = other=20 body fluids, secretions, or excretions of a person or animal with VHF; = or 3) had=20 a possible exposure when working in a laboratory that handles = hemorrhagic fever=20 viruses. The likelihood of acquiring VHF is considered low in persons = who do not=20 meet any of these criteria. Even following travel to areas where VHF has = occurred, persons with fever are more likely to have infectious diseases = other=20 than VHF (e.g., common respiratory viruses, endemic infections such as = malaria=20 or typhoid fever). Clinicians should promptly evaluate and treat = patients for=20 these more common infections while awaiting confirmation of a VHF = diagnosis.=20

Infection Control Precautions

The following recommendations should be followed when caring for = persons with=20 suspected VHF.

  • Patients who are hospitalized or treated in an outpatient = healthcare=20 setting should be placed in a private room and Standard, = Contact, and=20 Droplet Precautions should be initiated. Patients with respiratory = symptoms also should wear a face mask to contain respiratory droplets = prior to=20 placement in their hospital or examination room and during transport = (See:=20 Respiratory Hygiene/Cough Etiquette in Healthcare Settings).=20
  • Caretakers should use barrier precautions to prevent skin or = mucous=20 membrane exposure of the eyes, nose, and mouth with patient blood, = other body=20 fluids, secretions (including respiratory droplets), or excretions. = All=20 persons entering the patient's room should wear gloves and gowns to = prevent=20 contact with items or environmental surfaces that may be soiled. In = addition,=20 face shields or surgical masks and eye protection (e.g., goggles or = eyeglasses=20 with side shields) should be worn by persons coming within = approximately 3=20 feet of the patient.=20
  • Additional barriers may be needed depending on the likelihood and=20 magnitude of contact with body fluids. For example, if copious amounts = of=20 blood, other body fluids, vomit, or feces are present in the = environment,=20 plastic apron, leg, and shoe coverings also may be needed.=20
  • Nonessential staff and visitors should be restricted from entering = the=20 room of patients with suspected VHF. Maintain a log of persons = entering the=20 patient=92s room.=20
  • Before exiting the room of a patient with suspected VHF, safely = remove and=20 dispose of all protective gear, and clean and disinfect shoes that are = soiled=20 with body fluids as described in the section on environmental = infection=20 control below.=20
  • To prevent percutaneous injuries, needles and other sharps should = be used=20 and disposed of in accordance with recommendations for Standa= rd=20 Precautions.=20
  • If the patient requires a surgical or obstetric procedure, consult = your=20 state health department and CDC regarding appropriate precautions for = these=20 invasive procedures.=20
  • Although transmission by the airborne route has not been = established,=20 hospitals may choose to use = Airborne Precautions for patients with suspected VHF who have = severe=20 pulmonary involvement or who undergo procedures that stimulate = coughing and=20 promote the generation of aerosols (e.g. aerosolized or nebulized = medication=20 administration, diagnostic sputum induction, bronchoscopy, airway = suctioning,=20 endotracheal intubation, positive pressure ventilation via face mask = [e.g.,=20 biphasic intermittent positive airway pressure ventilation, continuous = positive airway pressure ventilation], and high-frequency oscillatory=20 ventilation) to prevent possible exposure to airborne particles that = may=20 contain virus.
    Specimen Handling=20
  • Alert laboratory staff to the nature of the specimens prior to = sending=20 them to the clinical laboratory. Specimens should remain in the = custody of=20 designated laboratory personnel until testing is completed. Due to the = potential risks associated with handling infectious materials, = laboratory=20 testing should be limited to the minimum necessary for essential = diagnostic=20 evaluation and patient care.=20
  • While obtaining clinical laboratory specimens from the patient, = use=20 infection control precautions for patient care outlined in this = document.=20 Place specimens in sealed plastic bags, then transport them in a = clearly=20 labeled, durable, leak-proof container directly to the specimen = handling area=20 of the laboratory. Care should be taken not to contaminate the = external=20 surfaces of containers.=20
  • Process clinical specimens in a class II biological safety cabinet = following biosafety level 3 practices. If possible, pretreat serum = used in=20 laboratory tests with the combination of heat-inactivation at 56=B0 C = and=20 polyethylene glycol p-tert-octylphenyl ether (Triton(=AE) X-100)*; = treatment=20 with 10 uL of 10% Triton(=AE) X-100 per 1 mL of serum for 1 hour = reduces the=20 titer of hemorrhagic fever viruses in serum, although 100% efficacy in = inactivating these viruses should not be assumed. For tests in which = the=20 validity is affected by the presence of a detergent in the serum, heat = inactivation alone may be of some benefit in reducing infectivity (9). =
  • Blood smears (e.g., for malaria) are not infectious for VHF after = fixation=20 in solvents.=20
  • Attempts to isolate or cultivate the virus should not be part of = routine=20 clinical laboratory diagnosis when VHF is suspected. If such = procedures are=20 done on specimens where VHF is suspected, biosafety level 4 facilities = and=20 procedures are required (See: = Biosafety in Microbiological and Biomedical Laboratories, = 4th=20 Edition ).=20
  • Routine cleaning and disinfecting procedures can be used for = automated=20 analyzers; analyzers should be disinfected after use as recommended by = the=20 manufacturer or with a 500 parts per million solution (1:100 dilution) = of=20 sodium hypochlorite (1/4 cup of household bleach to 1 gallon=20 water).
    Environmental Infection Control Procedures=20
  • Environmental surfaces or inanimate objects contaminated with = blood, other=20 body fluids, secretions, or excretions should be cleaned and = disinfected using=20 standard procedures (See See: Guideline = for=20 Environmental Infection Control in Healthcare Facilities).=20
  • Disinfection can be accomplished using a U.S. Environmental = Protection=20 Agency (EPA)-registered hospital disinfectant or a 1:100 dilution of = household=20 bleach (1/4 cup bleach to 1 gallon water). For grossly soiled = surfaces, (e.g.,=20 vomitus or stool), use a 1:10 dilution of household bleach.=20
  • Soiled linens should be placed in clearly labeled leak-proof bags = at the=20 site of use, transported directly to the laundry area, and laundered = following=20 routine healthcare laundry procedures. (See: Guideline = for=20 Environmental Infection Control in Healthcare Facilities)=20
  • Liquid medical waste such as feces and vomitus can be disposed of = in the=20 sanitary sewer following local sewage disposal requirements=20 (www.cdc.gov/ncidod/hip/enviro/guide.htm). Care should be taken to = avoid=20 splashing when disposing of these materials.=20
  • When discarding solid medical waste (e.g., needles, syringes, and = tubing)=20 contaminated with blood or other body fluids from VHF patients, = contain the=20 waste with minimal agitation during handling. Properly contained = wastes should=20 be managed according to existing local and state regulations for = ensuring=20 health and environmental safety during medical waste treatment and = disposal.=20 On-site treatment of the waste in an incinerator or a = gravity-displacement=20 autoclave for decontamination purposes will help to minimize handling = of=20 contaminated waste. Alternatively, off-site medical waste treatment = resources=20 may be used (See:=20 Guideline for Environmental Infection Control in Healthcare = Facilities).=20

Handling of Human Remains

If the patient dies, handling of the body should be minimized. The = remains=20 should not be embalmed. Remains should be wrapped in sealed leak-proof = material=20 and cremated or buried promptly in a sealed casket. If an autopsy is = necessary,=20 the state health department and CDC should be consulted regarding = appropriate=20 precautions.

Management of Exposures

Persons with percutaneous or mucocutaneous exposures to blood, body = fluids,=20 secretions, or excretions from a patient with suspected VHF should = immediately=20 wash the affected skin surfaces with soap and water. Mucous membranes = (e.g.,=20 conjunctiva) should be irrigated with copious amounts of water or = eyewash=20 solution. Exposed persons should receive medical evaluation and = follow-up care,=20 including fever monitoring twice daily for 21 days after exposure. = Consultation=20 with an infectious diseases expert is recommended for exposed persons = who=20 develop fever within 21 days of exposure.

*Use of trade names and commercial sources is for identification only = and=20 does not imply endorsement by the Public Health Service or the U.S. = Department=20 of Health and Human Services.

References

  1. CDC. Management of patients with suspected viral hemorrhagic fever. = MMWR=20 1988;37 (no. S-3):1-15.

  2. Baron RC, McCormick JB, Zubeir OA. Ebola virus disease in southern = Sudan:=20 hospital dissemination and intrafamilial spread. Bull WHO=20 1983;61:997-1003.

  3. Carey DE, Kemp GE, White HA, et al. Lassa fever: epidemiological = aspects of=20 the 1970 epidemic, Jos, Nigeria. Trans R Soc Trop Med Hyg = 1972;66:402-8.

  4. Dalgard DW, Hardy RJ, Pearson SL, et al. Combined simian = hemorrhagic fever=20 and Ebola virus infection in cynomolgus monkeys. Lab Anim Sci = 1992;42:152-7.=20

  5. CDC. Update: filovirus infections among persons with occupational = exposure=20 to nonhuman primates. MMWR 1990;39:266-7.

  6. Johnson E, Jaax N, White, Jahrling P. Lethal experimental infection = of=20 rhesus monkeys by aerosolized Ebola virus. Int J Exp Pathol = 1995;76:227-36.=20

  7. Pokhodynev VA, Gonchar NI, Pshenichnov VA. Experimental study of = Marburg=20 virus contact transmission. Vopr Virusol 1991;36:506-8.

  8. Jahrling PB, Geisbert TW, Jaax NK, et al. Experimental infection of = cynomolgus macaques with Ebola-Reston filoviruses from the 1989-1990 = US=20 epizootic. Arch Virol Suppl 1996;11:115-34.

  9. Bhagat CI Lewer M, Prins A, Beilby JP. Effects of heating plasma at = 56=20 degrees C for 30 min and at 60 degrees C for 60 min on routine = biochemistry=20 analytes. Ann Clin Biochem 2000;37(6):802-4.

Date last modified: May 19,=20 2005
Content source: 
Division of = Healthcare=20 Quality Promotion (DHQP)
National Center for Preparedness, = Detection, and=20 Control of Infectious Diseases (NCPDCID)

 

3D"CDC
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Centers for Disease Control and Prevention, 1600 Clifton Rd, = Atlanta,=20 GA 30333, U.S.A
Tel: (404) 639-3311 / Public Inquiries: (404) = 639-3534 /=20 (800) 311-3435
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FONT-SIZE: 1.2em; = PADDING-BOTTOM: 0px; MARGIN: 10px 0px; PADDING-TOP: 0px; BORDER-BOTTOM: = #ccc 1px solid; FONT-FAMILY: Arial, Helvetica, sans-serif } H5 { FONT-SIZE: 14px; FONT-FAMILY: Arial, Helvetica, sans-serif } #articleCol H5 { CLEAR: left; PADDING-RIGHT: 0px; PADDING-LEFT: 0px; FONT-SIZE: 14px; = PADDING-BOTTOM: 0px; MARGIN: 10px 0px; PADDING-TOP: 0px; BORDER-BOTTOM: = #ccc 0px; FONT-FAMILY: Arial, Helvetica, sans-serif } UL.featItems { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 0px; MARGIN: = 10px 0px 25px; PADDING-TOP: 0px; LIST-STYLE-TYPE: none } UL.featItems IMG { BORDER-RIGHT: #000000 1px solid; PADDING-RIGHT: 0px; BORDER-TOP: = #000000 1px solid; PADDING-LEFT: 0px; FLOAT: left; PADDING-BOTTOM: 0px; = MARGIN-LEFT: 0px; BORDER-LEFT: #000000 1px solid; MARGIN-RIGHT: 10px; = PADDING-TOP: 0px; BORDER-BOTTOM: #000000 1px solid } UL.featItems LI P.title { FONT-WEIGHT: bold; FONT-SIZE: 1em; MARGIN-BOTTOM: 0px } UL.featItems P.body { BORDER-RIGHT: #000000 0px solid; BORDER-TOP: #000000 0px solid; = MARGIN-TOP: 0px; FONT-SIZE: 11px; MARGIN-BOTTOM: 0px; MARGIN-LEFT: 87px; = BORDER-LEFT: #000000 0px solid; BORDER-BOTTOM: #000000 0px solid } UL.featItems LI { PADDING-RIGHT: 0px; MARGIN-TOP: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: = 20px; PADDING-TOP: 0px; BACKGROUND-REPEAT: no-repeat } UL.catalogItems { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 0px; MARGIN: = 10px 0px 25px; WIDTH: 555px; PADDING-TOP: 0px; LIST-STYLE-TYPE: none } UL.catalogItems IMG { BORDER-RIGHT: #000000 1px solid; PADDING-RIGHT: 0px; BORDER-TOP: = #000000 1px solid; PADDING-LEFT: 0px; FLOAT: left; PADDING-BOTTOM: 0px; = MARGIN-LEFT: 0px; BORDER-LEFT: #000000 1px solid; MARGIN-RIGHT: 10px; = PADDING-TOP: 0px; BORDER-BOTTOM: #000000 1px solid } UL.catalogItems LI P.title { FONT-WEIGHT: bold; FONT-SIZE: 1em; MARGIN-BOTTOM: 0px } UL.catalogItems P.body { BORDER-RIGHT: #000000 0px solid; BORDER-TOP: #000000 0px solid; = MARGIN-TOP: 0px; FONT-SIZE: 11px; MARGIN-BOTTOM: 0px; MARGIN-LEFT: 87px; = BORDER-LEFT: #000000 0px solid; BORDER-BOTTOM: #000000 0px solid } UL.catalogItems LI { PADDING-RIGHT: 0px; MARGIN-TOP: 0px; PADDING-LEFT: 0px; FLOAT: left; = PADDING-BOTTOM: 20px; MARGIN-RIGHT: 0px; PADDING-TOP: 0px; = BACKGROUND-REPEAT: no-repeat } #rightCol { MARGIN-TOP: 0px; MARGIN-LEFT: 555px; PADDING-TOP: 0px } #rightCol UL { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 0px; MARGIN: = 0px; PADDING-TOP: 0px; LIST-STYLE-TYPE: none } #pageIndex { BORDER-RIGHT: #cccccc 1px solid; PADDING-RIGHT: 5px; BORDER-TOP: = #cccccc 1px solid; PADDING-LEFT: 5px; PADDING-BOTTOM: 5px; BORDER-LEFT: = #cccccc 1px solid; PADDING-TOP: 5px; BORDER-BOTTOM: #cccccc 1px solid; = BACKGROUND-COLOR: #ffffe5 } #pageIndex OL { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; LIST-STYLE-POSITION: inside; = FONT-SIZE: 0.9em; PADDING-BOTTOM: 0px; MARGIN: 0px 0px 0px 15px; = PADDING-TOP: 0px } #pageIndex H5 { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; FONT-SIZE: 12px; PADDING-BOTTOM: = 5px; MARGIN: 0px; PADDING-TOP: 5px } A { COLOR: #003366 } #dividerBlack { BORDER-TOP: #000000 1px dotted; MARGIN-TOP: 4px; DISPLAY: block; = BORDER-LEFT-WIDTH: 1px; BORDER-BOTTOM-WIDTH: 1px; PADDING-BOTTOM: 4px; = MARGIN-RIGHT: 5px; BORDER-RIGHT-WIDTH: 1px } .dividerBlack { BORDER-TOP: #000000 1px dotted; MARGIN-TOP: 4px; DISPLAY: block; = BORDER-LEFT-WIDTH: 1px; BORDER-BOTTOM-WIDTH: 1px; PADDING-BOTTOM: 4px; = MARGIN-RIGHT: 5px; BORDER-RIGHT-WIDTH: 1px } UL#pageFunct LI { PADDING-LEFT: 20px; PADDING-BOTTOM: 3px } LI#email { BACKGROUND-POSITION: 5px 3px; BACKGROUND-IMAGE: = url(images/ico_email.gif); BACKGROUND-REPEAT: no-repeat } LI#print { BACKGROUND-POSITION: 5px 3px; BACKGROUND-IMAGE: = url(images/ico_printversion.gif); BACKGROUND-REPEAT: no-repeat } LI#pdf { BACKGROUND-POSITION: 5px 3px; BACKGROUND-IMAGE: = url(images/ico_pdf.gif); BACKGROUND-REPEAT: no-repeat } LI#wmp { BACKGROUND-POSITION: 5px 3px; BACKGROUND-IMAGE: = url(images/ico_wmp.gif); BACKGROUND-REPEAT: no-repeat } #rightCol H4 { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; FONT-SIZE: 14px; PADDING-BOTTOM: = 5px; MARGIN: 0px; PADDING-TOP: 5px } #rightCol H5 { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; FONT-SIZE: 12px; PADDING-BOTTOM: = 5px; MARGIN: 0px; PADDING-TOP: 5px } UL.quickLinks { PADDING-LEFT: 20px; MARGIN: 0px } UL.quickLinks LI { BACKGROUND-POSITION: 0px 0px; PADDING-LEFT: 15px; FONT-SIZE: 0.9em; = BACKGROUND-IMAGE: url(images/core/arrow2.gif); PADDING-BOTTOM: 8px; = MARGIN: 0px; BACKGROUND-REPEAT: no-repeat } UL.quickLinks LI.pdf { BACKGROUND-POSITION: 0px 0px; PADDING-LEFT: 25px; FONT-SIZE: 0.9em; = BACKGROUND-IMAGE: url(images/icon_pdf_f01.gif); PADDING-BOTTOM: 8px; = MARGIN: 0px; BACKGROUND-REPEAT: no-repeat } UL.quickLinks LI.ppt { BACKGROUND-POSITION: 0px 0px; PADDING-LEFT: 25px; FONT-SIZE: 0.9em; = BACKGROUND-IMAGE: url(images/icon_ppt_f01.gif); PADDING-BOTTOM: 8px; = MARGIN: 0px; BACKGROUND-REPEAT: no-repeat } UL#footerMenu { PADDING-RIGHT: 2px; BORDER-TOP: #c4c4c4 1px solid; PADDING-LEFT: 5px; = FONT-WEIGHT: bold; FONT-SIZE: 11px; BORDER-LEFT-COLOR: #c4c4c4; = PADDING-BOTTOM: 5px; MARGIN: 0px; COLOR: #000000; PADDING-TOP: 3px; = BORDER-BOTTOM: #c4c4c4 1px solid; LIST-STYLE-TYPE: none; = BACKGROUND-COLOR: #f5f5f5; BORDER-RIGHT-COLOR: #c4c4c4 } UL#footerMenu LI { DISPLAY: inline; FONT-WEIGHT: normal; MARGIN-LEFT: 1px; MARGIN-RIGHT: = 1px } #footer { CLEAR: left; WIDTH: 760px; HEIGHT: 88px; BACKGROUND-COLOR: #e5e5e5 } #footerContent { PADDING-RIGHT: 10px; PADDING-LEFT: 10px; PADDING-BOTTOM: 0px; = PADDING-TOP: 0px } ADDRESS { FONT-SIZE: 0.9em; WIDTH: 420px; FONT-STYLE: normal } #ftrImgs IMG { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; FLOAT: left; PADDING-BOTTOM: = 0px; MARGIN: 0px; PADDING-TOP: 0px } #address { MARGIN-TOP: 5px; FLOAT: left } #ftrImgs A { MARGIN-TOP: 10px; DISPLAY: block; FONT-SIZE: 10px } #breadCrumbs { DISPLAY: block; FONT-SIZE: 0.9em; MARGIN-BOTTOM: 10px } .guideLine { BORDER-RIGHT: #cccccc 1px solid; PADDING-RIGHT: 0px; BORDER-TOP: = #cccccc 1px solid; PADDING-LEFT: 0px; PADDING-BOTTOM: 0px; MARGIN: 10px = 0px 0px 10px; BORDER-LEFT: #cccccc 1px solid; PADDING-TOP: 0px; = BORDER-BOTTOM: #cccccc 1px solid } UL.guidelineSubItems { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 0px; MARGIN: = 5px; PADDING-TOP: 0px; LIST-STYLE-TYPE: none } UL.guidelineSubItems LI { PADDING-LEFT: 25px; BACKGROUND-IMAGE: url(images/core/arrow2.gif); = PADDING-BOTTOM: 5px; BACKGROUND-REPEAT: no-repeat; LIST-STYLE-TYPE: none } UL.guidelineSubItems LI.pdf { PADDING-LEFT: 25px; BACKGROUND-IMAGE: url(images/icon_pdf_f01.gif); = PADDING-BOTTOM: 5px; BACKGROUND-REPEAT: no-repeat; LIST-STYLE-TYPE: none } UL.guidelineSubItems LI.ppt { PADDING-LEFT: 25px; BACKGROUND-IMAGE: url(images/icon_ppt_f01.gif); = PADDING-BOTTOM: 5px; BACKGROUND-REPEAT: no-repeat; LIST-STYLE-TYPE: none } UL.guidelineSubItems LI.wmp { PADDING-LEFT: 25px; BACKGROUND-IMAGE: url(images/icon_wmp_f01.gif); = PADDING-BOTTOM: 5px; BACKGROUND-REPEAT: no-repeat; LIST-STYLE-TYPE: none } .guideLine TABLE { FONT-SIZE: 11px } .guideLine TABLE TH { BACKGROUND-COLOR: #f2f8f9; TEXT-ALIGN: left } .guideLine P { MARGIN-LEFT: 10px; MARGIN-RIGHT: 10px } .guideline H3 { =09 } .document_list { BORDER-RIGHT: #cccccc 1px solid; PADDING-RIGHT: 0px; BORDER-TOP: = #cccccc 1px solid; PADDING-LEFT: 0px; PADDING-BOTTOM: 0px; MARGIN: 10px; = BORDER-LEFT: #cccccc 1px solid; PADDING-TOP: 0px; BORDER-BOTTOM: #cccccc = 1px solid } .document_list TABLE { FONT-SIZE: 0.95em } .document_list TABLE TH { BACKGROUND-COLOR: #cccccc; TEXT-ALIGN: left } .document_list TABLE TH.sub { BACKGROUND-COLOR: #f2f8f9; TEXT-ALIGN: left } .document_list TABLE H5 { PADDING-LEFT: 0px; FONT-WEIGHT: bold; FONT-SIZE: 100%; PADDING-BOTTOM: = 0px; MARGIN: 0px; PADDING-TOP: 0px } .document_list TABLE TD { VERTICAL-ALIGN: top } .document_list P { FONT-SIZE: 11px; MARGIN-LEFT: 10px; MARGIN-RIGHT: 10px } .trOdd { BACKGROUND-COLOR: #f2f8f9 } #globalNav { MARGIN-BOTTOM: 25px } UL.featSubItems { MARGIN-TOP: 0px; DISPLAY: block; PADDING-LEFT: 45px; LIST-STYLE-IMAGE: = url(images/core/arrow.gif); MARGIN-BOTTOM: 20px; MARGIN-LEFT: 65px; = PADDING-TOP: 0px } UL.featSubItems LI { MARGIN-BOTTOM: 2px } UL.articleSubItems { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 0px; MARGIN: = 0px; PADDING-TOP: 0px; LIST-STYLE-TYPE: none } UL.articleSubItems LI { PADDING-LEFT: 15px; BACKGROUND-IMAGE: url(images/core/arrow2.gif); = PADDING-BOTTOM: 5px; BACKGROUND-REPEAT: no-repeat; LIST-STYLE-TYPE: none } UL.articleSubItems LI LI { PADDING-LEFT: 0px; FONT-SIZE: 11px; BACKGROUND-IMAGE: url(none); = PADDING-BOTTOM: 5px; MARGIN-LEFT: 0px; LIST-STYLE-TYPE: none } UL.articleSubItems LI.pdf { PADDING-LEFT: 25px; BACKGROUND-IMAGE: url(images/icon_pdf_f01.gif); = PADDING-BOTTOM: 5px; BACKGROUND-REPEAT: no-repeat; LIST-STYLE-TYPE: none } UL.articleSubItems LI.ppt { PADDING-LEFT: 25px; BACKGROUND-IMAGE: url(images/icon_ppt_f01.gif); = PADDING-BOTTOM: 5px; BACKGROUND-REPEAT: no-repeat; LIST-STYLE-TYPE: none } UL.articleSubItems LI.wmp { PADDING-LEFT: 25px; BACKGROUND-IMAGE: url(images/icon_wmp_f01.gif); = PADDING-BOTTOM: 5px; BACKGROUND-REPEAT: no-repeat; LIST-STYLE-TYPE: none } #leftCol H3.article { CLEAR: left; MARGIN-TOP: 15px; PADDING-LEFT: 0px; FONT-SIZE: 1.3em; = MARGIN-BOTTOM: 0px; PADDING-BOTTOM: 0px; MARGIN-LEFT: 0px; = BACKGROUND-COLOR: #ffffff; BORDER-BOTTOM-STYLE: none } P.dateLine { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 0px; MARGIN: 0px = 0px 15px; COLOR: #999999; PADDING-TOP: 0px } #guideLines { PADDING-RIGHT: 10px; MARGIN-TOP: 0px; PADDING-LEFT: 10px; = PADDING-BOTTOM: 10px; PADDING-TOP: 10px; BACKGROUND-COLOR: #dae9f8 } #guideLines SELECT { PADDING-RIGHT: 0px; MARGIN-TOP: 5px; PADDING-LEFT: 0px; MARGIN-BOTTOM: = 0px; PADDING-BOTTOM: 0px; WIDTH: 300px; PADDING-TOP: 0px } #guideLines P { FONT-SIZE: 1em; PADDING-BOTTOM: 5px; MARGIN: 0px } #featCol H4.featItems { MARGIN-TOP: 15px } #featCol H4.guideLines { FONT-SIZE: 1.3em; BORDER-TOP-STYLE: none; BORDER-RIGHT-STYLE: none; = BORDER-LEFT-STYLE: none; BORDER-BOTTOM-STYLE: none } #guidelines INPUT.goBtn { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 0px; MARGIN: = 0px; PADDING-TOP: 0px } A.breadCrumbs { MARGIN-BOTTOM: 0px } A.pdfLink { BACKGROUND-POSITION: 0px 0px; DISPLAY: inline; PADDING-LEFT: 28px; = BACKGROUND-IMAGE: url(images/icon_pdf_f01.gif); PADDING-BOTTOM: 5px; = BACKGROUND-REPEAT: no-repeat } A.pptLink { BACKGROUND-POSITION: 0px 0px; DISPLAY: inline; PADDING-LEFT: 28px; = BACKGROUND-IMAGE: url(images/icon_ppt_f01.gif); PADDING-BOTTOM: 5px; = BACKGROUND-REPEAT: no-repeat } A.wmpLink { BACKGROUND-POSITION: 5px 0px; DISPLAY: inline; PADDING-LEFT: 28px; = BACKGROUND-IMAGE: url(images/icon_wmp.gif); PADDING-BOTTOM: 5px; = BACKGROUND-REPEAT: no-repeat } #featCol H3 { BACKGROUND-COLOR: #dae9f8 } #breadCrumbs { MARGIN-TOP: 5px; MARGIN-BOTTOM: 5px } #topicNav { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 0px; MARGIN: = 0px; PADDING-TOP: 5px; BORDER-BOTTOM: #d4ba8a 1px solid; HEIGHT: 36px; = BACKGROUND-COLOR: #fff3dc } #topicNav UL { PADDING-RIGHT: 0px; PADDING-LEFT: 3px; PADDING-BOTTOM: 0px; MARGIN: = 0px; PADDING-TOP: 0px; LIST-STYLE-TYPE: none } #topicNav UL LI { CLEAR: right; FLOAT: left; MARGIN-RIGHT: 3px } #topicNav UL LI A.wide { WIDTH: 90px } #topicNav UL LI.here A { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; FONT-WEIGHT: bold; WIDTH: 86px; = BORDER-BOTTOM: #ffffff 1px solid; BACKGROUND-COLOR: #ffffff } #topicNav UL LI A { BORDER-RIGHT: #d4ba8a 1px; PADDING-RIGHT: 5px; BACKGROUND-POSITION: 50% = top; BORDER-TOP: #d4ba8a 1px; DISPLAY: block; PADDING-LEFT: 5px; = BACKGROUND-IMAGE: url(images/core/tabTop.gif); BORDER-LEFT: #d4ba8a 1px; = WIDTH: 76px; PADDING-TOP: 4px; BORDER-BOTTOM: #d4ba8a 1px; = BACKGROUND-REPEAT: no-repeat; HEIGHT: 32px; BACKGROUND-COLOR: #ffe0a7; = TEXT-ALIGN: center; TEXT-DECORATION: none } #topicNav UL LI A:hover { COLOR: #000000; BACKGROUND-COLOR: #ffffff } #topicListRight H4 { PADDING-LEFT: 8px; FONT-SIZE: 12px; PADDING-BOTTOM: 5px; MARGIN: 0px; = PADDING-TOP: 5px; BORDER-BOTTOM: #e5e5ce 0px solid; BACKGROUND-COLOR: = #ffffe5 } #topicListRight UL LI.here { FONT-WEIGHT: bold; COLOR: #000000; BACKGROUND-COLOR: #ffffff; = TEXT-DECORATION: none } #topicListRight UL LI { PADDING-RIGHT: 0px; BACKGROUND-POSITION: 7px 9px; DISPLAY: block; = PADDING-LEFT: 16px; BACKGROUND-IMAGE: url(images/core/arrow.gif); = PADDING-BOTTOM: 3px; MARGIN: 0px; PADDING-TOP: 3px; BORDER-BOTTOM: = #e5e5ce 0px solid; BACKGROUND-REPEAT: no-repeat; BACKGROUND-COLOR: = #ffffe5 } #topicListRight { BORDER-TOP: #039 3px solid; MARGIN-BOTTOM: 5px; BORDER-BOTTOM: #039 3px = solid } A:hover { COLOR: #000000; TEXT-DECORATION: none } #resourceListRight H4 { PADDING-LEFT: 8px; FONT-SIZE: 12px; PADDING-BOTTOM: 5px; MARGIN: 0px; = PADDING-TOP: 5px; BORDER-BOTTOM: #e5e5ce 0px solid; BACKGROUND-COLOR: = #ffffff } #resourceListRight UL LI.here { FONT-WEIGHT: bold; COLOR: #000000; BACKGROUND-COLOR: #ffffff; = TEXT-DECORATION: none } #resourceListRight UL LI { PADDING-RIGHT: 0px; BACKGROUND-POSITION: 7px 9px; DISPLAY: block; = PADDING-LEFT: 16px; BACKGROUND-IMAGE: url(images/core/arrow.gif); = PADDING-BOTTOM: 3px; MARGIN: 0px; PADDING-TOP: 3px; BORDER-BOTTOM: = #e5e5ce 0px solid; BACKGROUND-REPEAT: no-repeat; BACKGROUND-COLOR: = #ffffff } #resourceListRight { MARGIN-BOTTOM: 5px } #resourceListRight H4 { PADDING-LEFT: 8px; FONT-SIZE: 12px; BORDER-BOTTOM-WIDTH: 0px; = PADDING-BOTTOM: 5px; MARGIN: 0px; PADDING-TOP: 5px; BACKGROUND-COLOR: = #ffffff } #resourceListRight UL LI.here { FONT-WEIGHT: bold; COLOR: #000000; BACKGROUND-COLOR: #ffffff; = TEXT-DECORATION: none } #resourceListRight UL LI { PADDING-RIGHT: 0px; BACKGROUND-POSITION: 7px 9px; DISPLAY: block; = PADDING-LEFT: 16px; BACKGROUND-IMAGE: url(images/core/arrow.gif); = BORDER-BOTTOM-WIDTH: 0px; PADDING-BOTTOM: 3px; MARGIN: 0px; PADDING-TOP: = 3px; BACKGROUND-REPEAT: no-repeat; BACKGROUND-COLOR: #ffffff } #resourceListRight { MARGIN-BOTTOM: 5px } #box { PADDING-RIGHT: 10px; PADDING-BOTTOM: 10px; MARGIN-LEFT: 330px; = PADDING-TOP: 10px; HEIGHT: 100% } #box H3 { PADDING-LEFT: 15px; FONT-SIZE: 12px; PADDING-BOTTOM: 5px; PADDING-TOP: = 0px; BORDER-BOTTOM: #e5e5ce 0px solid; BACKGROUND-COLOR: #ffffe5 } #box P { PADDING-LEFT: 10px; FONT-SIZE: 10px; PADDING-BOTTOM: 5px; PADDING-TOP: = 0px; BORDER-BOTTOM: #e5e5ce 0px solid; BACKGROUND-COLOR: #ffffe5 } #introBox { MARGIN-TOP: 4px; DISPLAY: block; FLOAT: left; MARGIN-BOTTOM: 15px; = WIDTH: 541px; BACKGROUND-COLOR: #ffffe5 } .subTopicIntro { BACKGROUND: none transparent scroll repeat 0% 0%; FLOAT: left; WIDTH: = 320px } #box UL { PADDING-LEFT: 15px } .new { COLOR: #900 } .fact_sheet_bottom { DISPLAY: none } .releaseDate { FONT-SIZE: 0.95em; COLOR: #999999 } .lastModified { FONT-SIZE: 0.95em; FLOAT: left; PADDING-BOTTOM: 20px; COLOR: #999999; = PADDING-TOP: 20px } .pdfLabel { BACKGROUND-POSITION: 0px 0px; DISPLAY: inline; PADDING-LEFT: 10px; = FONT-SIZE: 0.95em; PADDING-BOTTOM: 5px; COLOR: #999999; = BACKGROUND-REPEAT: no-repeat } .genericLabel { BACKGROUND-POSITION: 0px 0px; FONT-SIZE: 0.95em; BACKGROUND-IMAGE: = none; PADDING-BOTTOM: 5px; COLOR: #999999; BACKGROUND-REPEAT: no-repeat } .label { BACKGROUND-POSITION: 0px 0px; FONT-SIZE: 0.9em; BACKGROUND-IMAGE: none; = PADDING-BOTTOM: 5px; BACKGROUND-REPEAT: no-repeat } .fileTypelabel { BACKGROUND-POSITION: 0px 0px; PADDING-LEFT: 28px; FONT-SIZE: 0.95em; = BACKGROUND-IMAGE: none; PADDING-BOTTOM: 5px; BACKGROUND-REPEAT: = no-repeat } .pptLabel { BACKGROUND-POSITION: 0px 0px; DISPLAY: block; PADDING-LEFT: 28px; = FONT-SIZE: 0.95em; BACKGROUND-IMAGE: url(images/icon_ppt_f01.gif); = PADDING-BOTTOM: 5px; COLOR: #999999; BACKGROUND-REPEAT: no-repeat } .scroll { BORDER-RIGHT: #666 1px solid; PADDING-RIGHT: 8px; BORDER-TOP: #666 1px = solid; PADDING-LEFT: 8px; PADDING-BOTTOM: 8px; OVERFLOW: scroll; = BORDER-LEFT: #666 1px solid; WIDTH: 535px; PADDING-TOP: 8px; = BORDER-BOTTOM: #666 1px solid; HEIGHT: 250px; BACKGROUND-COLOR: #ccc } A.button { PADDING-RIGHT: 0px; DISPLAY: block; PADDING-LEFT: 0px; FONT-WEIGHT: = bold; FONT-SIZE: 100%; BACKGROUND-IMAGE: = url(images/buttonBackground.gif); PADDING-BOTTOM: 0px; MARGIN: 5px auto; = WIDTH: 132px; PADDING-TOP: 5px; BACKGROUND-REPEAT: no-repeat; = FONT-FAMILY: Arial, Helvetica, sans-serif; HEIGHT: 28px; = BACKGROUND-COLOR: transparent; TEXT-ALIGN: center; TEXT-DECORATION: none } A.buttonDis { PADDING-RIGHT: 0px; DISPLAY: block; PADDING-LEFT: 0px; FONT-WEIGHT: = bold; FONT-SIZE: 100%; BACKGROUND-IMAGE: = url(images/buttonBackground.gif); PADDING-BOTTOM: 0px; MARGIN: 5px auto; = WIDTH: 132px; PADDING-TOP: 5px; BACKGROUND-REPEAT: no-repeat; = FONT-FAMILY: Arial, Helvetica, sans-serif; HEIGHT: 28px; = BACKGROUND-COLOR: transparent; TEXT-ALIGN: center; TEXT-DECORATION: none } A.button:link { COLOR: #002577 } A.button:visited { COLOR: #002577 } A.button:hover { BACKGROUND-POSITION: 0px -36px; COLOR: #ff7200 } A.button:active { BACKGROUND-POSITION: 0px -36px; COLOR: #ff7200 } #headershadow { BACKGROUND-IMAGE: url(images/core/hmHdrShadow.gif); MARGIN-BOTTOM: 0px; = PADDING-BOTTOM: 0px; LINE-HEIGHT: 4px; BACKGROUND-REPEAT: repeat-x } ------=_NextPart_000_0205_01C84EDC.2D808C30 Content-Type: text/css; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.cdc.gov/ncidod/dhqp/print.css BODY { FONT-SIZE: 12pt; BACKGROUND: white } .title { FONT-WEIGHT: bold; FONT-SIZE: 1.7em; MARGIN: 0px } .dateUnderTitle { FONT-SIZE: 1em; MARGIN: 0px } #menu { DISPLAY: none } #wrapper { BORDER-TOP-WIDTH: 0px; PADDING-RIGHT: 0px; PADDING-LEFT: 0px; = BORDER-LEFT-WIDTH: 0px; BACKGROUND: none transparent scroll repeat 0% = 0%; FLOAT: none! important; BORDER-BOTTOM-WIDTH: 0px; PADDING-BOTTOM: = 0px; MARGIN: 0px 5%; WIDTH: auto; COLOR: black; PADDING-TOP: 0px; = BORDER-RIGHT-WIDTH: 0px } #content { BORDER-TOP-WIDTH: 0px; PADDING-RIGHT: 0px; PADDING-LEFT: 0px; = BORDER-LEFT-WIDTH: 0px; BACKGROUND: none transparent scroll repeat 0% = 0%; FLOAT: none! important; BORDER-BOTTOM-WIDTH: 0px; PADDING-BOTTOM: = 0px; MARGIN: 0px 5%; WIDTH: auto; COLOR: black; PADDING-TOP: 0px; = BORDER-RIGHT-WIDTH: 0px } DIV#content { BORDER-TOP: #930 1px solid; MARGIN-LEFT: 10%; PADDING-TOP: 1em } DIV#mast { MARGIN-BOTTOM: -8px } DIV#mast IMG { VERTICAL-ALIGN: bottom } A:link { FONT-WEIGHT: bold; BACKGROUND: none transparent scroll repeat 0% 0%; = COLOR: #520; TEXT-DECORATION: underline } A:visited { FONT-WEIGHT: bold; BACKGROUND: none transparent scroll repeat 0% 0%; = COLOR: #520; TEXT-DECORATION: underline } #featCol { MARGIN-LEFT: 10px } DIV#topicNav { DISPLAY: none } DIV#topicList { DISPLAY: none } DIV#topicList UL { DISPLAY: none } #pageFunct { DISPLAY: none } #breadCrumbs { DISPLAY: none } DIV#globalNav { DISPLAY: none } DIV#rightCol { DISPLAY: none } #headershadow { DISPLAY: none } .omniture { DISPLAY: none } .pageindex { DISPLAY: none } .fact_sheet_bottom { DISPLAY: block } UL#footerMenu { DISPLAY: none } DIV#footerContent { DISPLAY: none } DIV#address { DISPLAY: none } DIV#ftrImgs { DISPLAY: none } #searchBar { DISPLAY: none } UL#globalNav { DISPLAY: none } #bannerFunc { DISPLAY: none } #spanishLink A { DISPLAY: none } #divider { DISPLAY: none } UL#globalMenu { DISPLAY: none } #leftCol H2 { PADDING-LEFT: 0px; FONT-WEIGHT: normal; FONT-SIZE: 24px; = PADDING-BOTTOM: 7px; MARGIN: 0px; PADDING-TOP: 0px; FONT-FAMILY: "Times = New Roman", Times, serif; BACKGROUND-COLOR: #cccccc } .question { FONT-WEIGHT: bold; MARGIN-BOTTOM: 10px } .answer { MARGIN-TOP: 0px; MARGIN-BOTTOM: 8px } #articleCol_lnav H4 { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; FONT-SIZE: 18pt; PADDING-BOTTOM: = 0px; MARGIN: 0px; PADDING-TOP: 0px; BORDER-BOTTOM: #fee57f 2px solid; = FONT-FAMILY: "Times New Roman", Times, serif } #articleCol_lnav H5 { FONT-SIZE: 14pt; MARGIN: 0px; PADDING-TOP: 10px; BORDER-BOTTOM: #fee57f = 2px solid } #articleCol_lnav H6 { FONT-SIZE: 12pt; MARGIN: 0px; PADDING-TOP: 10px } ------=_NextPart_000_0205_01C84EDC.2D808C30 Content-Type: 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