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Infection prevention and control measures for Ebola disease in acute care settings

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Table of contents

Introduction

Preamble

This guidance document updates the previous Infection Prevention and Control Measures for Ebola Virus Disease (EVD) in Healthcare Settings (August 28, 2019). This version has updated recommendations for:

  1. Classification of person under investigation (PUI) for Ebola disease (EBOD)
  2. Personal protective equipment
  3. Duration of precautions
  4. Nomenclature

Background

EBOD is part of a group of illnesses called Viral Hemorrhagic Fevers (VHFs) that are caused by several distinct families of viruses. The infection prevention and control (IPC) advice in this document is developed for EBOD, however, the guiding principles and IPC measures are applicable for management of persons under investigation or confirmed disease in healthcare settings associated with other agents that cause VHFs (i.e., Lassa, Marburg, Crimean-Congo).

EBOD is a severe acute viral illness that begins with fever, often with malaise, myalgia, and headache, and is typically followed by progressive gastrointestinal symptoms that include anorexia, nausea, abdominal discomfort, and subsequent vomiting and diarrhea. Diarrhea and vomiting are often profuse in later stages of the illness and leads to severe volume depletion, electrolyte abnormalities, and shock. While hemorrhage may occur, usually from the gastrointestinal tract, it is a late manifestation and occurs in a minority of patients. The incubation period of EBOD varies from 2 to 21 days. People with EBOD are not infectious during the incubation period.

Risk and transmission

Ebola virus (EBOV) is transmitted by direct contact (i.e., through non-intact skin or mucous membranes) with the blood or other body fluids (e.g., stool, emesis, urine, saliva, semen and sweat) of an infected individual and/or indirectly through contact with environmental surfaces and fomites contaminated with blood or other body fluids. The risk of transmission increases with the amount of infectious material to which the individual is exposed.

Cases are not communicable before the onset of symptoms but communicability increases with each subsequent stage of illness. Individuals with EBOD are most infectious in later stages of their illness when viral load rises and they experience copious fluid loss due to diarrhea, vomiting or hemorrhage. Cases remain communicable as long as blood or other body fluids contain the virus. This includes the convalescence period, before they have recovered, and the post-mortem period. Further details on IPC precautions during these periods are provided in the sections on "Duration of precautions and handling bodies of deceased patients".

Investigations conducted to date have not demonstrated human-to-human transmission of EBOV in the absence of direct contact with an infected case. This takes into account the thousands of EBOD cases in Africa and the very small number of EBOD cases in Europe and the United States. EBOV is not spread through the airborne route.

Public health case management relies on early identification of EBOD cases, individual isolation and care, diligent contact tracing, appropriate IPC measures, and safe burial. The following document contains additional information on case and contact management in community settings:

Aim and scope of this guideline

The purpose of this document is to provide guidance on the minimum level of IPC measures in healthcare settings in the event that a person under investigation for EBOD or patient with EBOD is identified within a Canadian healthcare facility. Clinical judgement remains essential, and this, along with jurisdictional policies, may result in decisions that differ from recommendations provided in this document.

This document has been developed based on the Canadian context and therefore may differ from guidance developed by other countries.

Recommendations for non-acute healthcare settings are beyond the scope of this document.

Guideline development methodology

PHAC developed this guideline with technical expertise from the National Advisory Committee on Infection Prevention and Control (NAC-IPC) and subject matter experts. The recommendations are informed by a review of the evidence, expert opinion and core IPC principles as identified in PHAC's Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings. This advice is based on currently available scientific evidence and expert opinion and adopts a precautionary approach where the evidence is lacking or inconclusive. It is subject to review and change as new information becomes available.

Please refer to Appendix A for a list of members.

Target users

The target audiences for this document are IPC professionals, Occupational Health and Safety professionals, healthcare organizations, and healthcare providers responsible for educating healthcare workers (HCWs) on IPC. The advice is intended for acute healthcare settings where there may be potential for contact with a person under investigation (PUI) for EBOD or confirmed to have EBOD.

Role of provinces and territories

The advice contained in this document should be read in conjunction with relevant federal, provincial, territorial and local legislation, regulations, and policies. Recommended measures should not be regarded as rigid standards, but principles and recommendations which may be used to inform IPC practice.

Application of hierarchy of controls to EBOD: engineering controls, administrative controls and personal protective equipment

The hierarchy of controls is a fundamental occupational health and safety framework, designed to optimize protection of HCWs from exposures to hazards, including infectious hazards such as EBOD. Following the hierarchy of controls will produce safer systems and reduce potential illness or injury for HCWs.

Elimination

While elimination may not be possible, to mitigate risk of transmission in healthcare facilities, systems and protocols should be in place to limit the care of persons under investigation for EBOD or confirmed patients with EBOD to designated locations within a hospital (e.g., ER, ICU), or designated hospitals with dedicated personnel.

Substitution

Substitution as part of the hierarchy of controls is not a feasible approach to preventing transmission of EBOV.

Engineering controls

Engineering controls are used to either remove the hazard or put a barrier between the HCW and the hazard. Engineering controls are those elements of the healthcare organization's physical plant/infrastructure that function to prevent exposure to and/or transmission of the infectious agent at the source, or along the path of the hazard.

Examples of engineering controls in managing a patient with EBOD include:

Administrative controls

Administrative controls include the policies, procedures, education, training and patient care practices intended to prevent exposure to and/or transmission of an infectious agent to a susceptible host during the provision of health care. Each healthcare organization should develop comprehensive policies and procedures for putting on and removing personal protective equipment. To be effective in preventing transmission of EBOD and/or detecting cases of EBOD, administrative controls should be applied from the first encounter with a PUI and continue until the patient leaves the healthcare setting, is no longer infectious, or is deceased (note, proper post-mortem care is required).

Examples of administrative controls in managing a patient with EBOD include:

In addition to organizational practices, there are federal, provincial and territorial Occupational Health and Safety Acts and Regulations that require compliance. This is typically accomplished through implementation of policies, procedures, education and training. In many provinces and territories, Joint Health and Safety Committees are also legislated and are jointly chaired by a management and a HCW representative. Hospitals will also have internal responsibility systems (IRS), which is the underlying philosophy of the occupational health and safety legislation in all Canadian jurisdictions. The fundamental principle of the IRS is that everyone in the workplace - both employees and employers - is responsible for their own safety and for the safety of co-workers.

Personal protective equipment

Personal Protective Equipment (PPE) refers to all personal equipment and clothing recommended by the employer for use by the HCW. For the equipment to be effective, the other controls must be in place. Federal, provincial and territorial Occupational Health and Safety Acts define specific duties for the employer, supervisor and HCW regarding PPE. The employer must ensure that the appropriate PPE is available and in good working order and that there has been comprehensive instruction, training and supervision in its correct usage. The supervisor and HCW must know the hazards for any potential exposure to blood, other body fluids, or surfaces contaminated with EBOV. The supervisor is responsible to ensure that the HCW uses the PPE required by the employer and the HCW shall use the PPE required by the employer.

Healthcare organizations need to ensure an adequate supply of appropriate PPE to protect HCWs and that their HCWs are adept in the application, use and removal of their PPE.

Organizational risk assessment

A major responsibility of any healthcare organization is the evaluation of the components in the hierarchy of controls to minimize the risk of exposure to and transmission of microorganisms within healthcare settings, including EBOV. This organizational risk assessment (ORA) is central to any healthcare organization's preparation and planning to protect all individuals (e.g., HCW, patient, visitor, and contractor) from EBOD in all healthcare settings. Organizations have a responsibility to provide information and train HCWs regarding the organization's ORA and its impact on their practice. For example, the availability of functioning airborne infection isolation rooms (AIIRs) may affect when and where aerosol-generating medical procedures (AGMPs) are performed.

The ORA will characterize the organization's patient population, level and intensity of health care provided and resources available, including the various skilled workers required to provide the necessary care. Conducting an ORA will help the facility identify the effectiveness of present control measures and the breadth of the hierarchy of controls to prevent transmission of the EBOV.

The ORA as it relates to EBOD should be conducted on a regular basis. ORA frequency is determined by:

Examples of aspects of an organizational risk assessment in managing a patient with EBOD include:

Occupational health considerations

General guidelines for HCW's fitness to provide direct care to patients with EBOD

Fitness to work incorporates factors that relate to the individual HCW's ability to safely perform the duties of their job. The HCW should be encouraged to communicate any concerns regarding potential impact on their underlying health conditions through the usual reporting mechanism within their organization (e.g. supervisor, manager, Occupational Health Service). Any work restrictions/limitations can then be shared appropriately, protecting the personal health privacy of the individual.

Certain health conditions or pregnancy preclude some HCWs from providing direct care for patients with EBOD. The principles for identifying these conditions are based on the following considerations:

Examples of conditions that should be assessed for when determining fitness to provide direct care to patients with EBOD include:

Where necessary, the ability of a HCW to engage in work activities related to caring for a patient with EBOD should be assessed by an Occupational Health and Safety professional.

HCW awareness when caring for a patient with EBOD

These recommendations apply to all persons who have the potential for exposure to PUIs or patients with confirmed EBOD.

Routine practices

Routine practices are the IPC measures used in the routine care of all patients, at all times, in all healthcare settings and are determined by the circumstances of the patient, the environment and the task to be performed. Routine practices and additional precautions are covered in detail in PHAC's Routine Practices and Additional Precautions guidance document.

Routine practices include:

An assessment should be conducted prior to every interaction to determine the infectious risk posed to oneself and others.

Triage and screening

Acute healthcare settings should have the following triage measures in place:

Refer to Appendix B: Algorithm for screening and assessment for Ebola disease in persons presenting to healthcare settings for a quick reference guide for frontline healthcare workers involved in triage and screening.

Additional precautions for Ebola disease management

Additional precautions in addition to routine practices are required for the care of all PUIs and confirmed patients with EBOD. Please refer to Table 3. PPE recommended for care of a stable PUI, unstable PUI or confirmed case. Additional precautions are covered in detail in PHAC's Routine Practices and Additional Precautions guidance document.

Classification of persons under investigation for EBOD

EBOD cases will require hospitalization for diagnosis and supportive care during their acute illness. Based on clinical presentation and laboratory results, patients will be classified as:

Table 1. Examples of clinical presentation of stable and unstable PUI for EBOD
Stable PUI Unstable PUI
  • Vital signs within normal limits
  • No hemorrhaging (bleeding)
  • Formed stool
  • No vomiting
  • Signs and symptoms of shock (e.g., respiratory distress, hypotension, neurological impairment)
  • Hemorrhaging (bleeding)
  • Possibility of intubation or resuscitation
  • Diarrhea
  • Vomiting
  • Other clinical findings suggesting that the patient is likely to contaminate their environment with blood and body fluids
Note: this list is not exhaustive and is to be used in concert with a Point of Care Risk Assessment (PCRA).

Recommendations for source control

Recommendations for the use of personal protective equipment

The effectiveness of PPE (e.g., gowns, aprons, hazardous material suits, foot and leg coverings, gloves, head and neck coverings, masks, face shields, eye goggles, and respirators) is highly dependent on prior training and experience of the HCW with the PPE. Prior to working with patients with EBOD, the HCW must have had comprehensive training and observed and ongoing practice with the PPE. They must be adept at its use and removal, including correct technique for putting on and removing, discarding into designated receptacles, and hand hygiene to minimize risk of transmission.

Important principles of personal protective equipment (PPE):

Experience suggests that the greatest risk of contamination with EBOV comes from lapses in IPC techniques, especially when removing PPE. HCWs caring for a patient with EBOD should always be paired with a Trained Monitor who will coach, assist as necessary, and observe the HCW complete the following activities:

Table 2. Roles and responsibilities of the trained monitor
N/A Trained Monitor
Responsibility To assist with and ensure adherence to entire PPE use and removal process by HCWs providing direct patient care, and visitors (if permitted).
Role
  • Monitor / supervise PPE use and safe removal; generally does not enter patient room.
  • Guide / read aloud to HCW or visitor each step in putting on the PPE (use checklist).
  • Ensure appropriate PPE is selected and correctly used.
  • During PPE removal, observe and assist with removal of specific components of PPE.
  • Visually confirm and document that each step was completed correctly for PPE use and removal.
  • Constantly monitor technique while HCW or visitor is in patient room.
  • Provide immediate corrective instruction in real-time if HCW or visitor is not following recommended steps.
  • Should know the facility EBOD exposure management plan in event of unintended breach in procedure.

Number Needed

One Trained Monitor at all times for each individual entering the room.

PPE recommendations for EBOD

For stable PUI, the recommended PPE includes:

  • Fluid-resistant mask
  • Separate face shield or goggles
  • Gloves
  • Fluid-resistant or impermeable gown

If patient requires an invasive medical procedure or AGMP, follow PPE for Unstable PUI or Confirmed case.

For unstable PUI or confirmed EBOD, the recommended PPE includes:

  • Fit-tested N95 respirator (or equivalent, or higher protection)
  • Separate face shield
  • Double gloves
  • Fluid-resistant or impermeable gown or hazardous material suit
  • Fluid impermeable apron
  • Fluid resistant or impermeable body coverings including foot/leg and head/neck coverings

Although EBOD is not an airborne disease, we recommend a fit-tested N95 respirator (or equivalent, or higher protection) for all unstable PUI or confirmed EBOD. This recommendation is based on:

While some facilities have chosen to use powered air purifying respirators (PAPRs), these are not required for the care of patients with EBOD. Their removal poses a recognized potential risk for self-contamination if worn by HCWs who are not adept at their use and removal. Effective cleaning of reusable components of the equipment is challenging, requiring multiple steps.

There are two general types of body coverings that have been used by organizations that have experience providing care to patients with EBOD:

Either is acceptable (when used with the other components of PPE), provided that it meets the criteria outlined in Table 3.

Table 3. PPE recommended for care of a stable PUI, unstable PUI or confirmed case
Stable PUI Unstable PUI or confirmed case
  • Fluid-resistant mask
  • Separate face shield or goggles
  • Gloves
  • Fluid-resistant or impermeable gown
  • Fit-tested N95 (or equivalent, or higher protection)
  • Separate face shield
  • Double gloves
  • Fluid-resistant or impermeable gown or hazardous material suit
  • Fluid impermeable apron
  • Fluid resistant or impermeable body coverings including foot/leg and head/neck coverings
If patient requires an invasive medical procedure or AGMP, follow PPE for Unstable PUI or Confirmed case. All exposed skin is protected

Patient placement and patient transfers between or within facilities

Patient placement

Patient transfers between or within facilities

Environmental cleaning

Provide education, hands-on training, practice, and observation of ability to adhere to correct processes and procedures, and appropriate PPE to those responsible for environmental cleaning.

Environmental cleaning staff should, at minimum, wear the same level of protection as HCWs providing care to the patient.

Assign responsibility and accountability for cleaning and disinfection of patient care environment; and monitor to ensure appropriate processes.

A disinfectant with a broad spectrum virucide claim with a Health Canada drug identification number (DIN) should be used according to the manufacturer's instruction.

Surfaces that are likely to be touched and/or used frequently should be cleaned and disinfected on a more frequent schedule. This includes surfaces that are in close proximity to the patient (e.g., bedrails, bedside/over-bed tables, call bells) and frequently touched surfaces in the patient care environment, such as door knobs and surfaces in the patient's bathroom.

When precautions are discontinued or the patient is moved or discharged, everything in the room that cannot be cleaned and disinfected should be discarded into a designated no-touch biohazardous waste receptacle.

Cleaning and reprocessing of medical equipment

Dedicated equipment
Reprocessing (cleaning, disinfection and sterilization of medical equipment)

Waste, linen, and nutritional services

Waste and linen management

Patient bed linen should be changed regularly and when soiled, upon discontinuation of precautions and following patient discharge. Linen should:

Different jurisdictions have different requirements for disposal of human waste. For further information on management of waste, including the disposal of urine, stool and emesis, and linen refer to Appendix C: Management of Ebola disease-associated waste in Canadian healthcare settings.

Handling dishes and cutlery

Use disposable dishes/cutlery and dispose of in a designated biohazardous waste receptacle at the point-of-use.

Education of patients and visitors

Patients, their visitors, families and decision makers should be educated about the additional precautions being used, the duration of precautions, as well as the prevention of transmission of disease to others, with a particular focus on hand hygiene and respiratory hygiene.

Discharge planning (including but not limited to continuation of infection control precautions in the home setting) should be managed on a case-by-case basis in consultation with the IPC program, infectious disease specialists, and public health officials.

Visitor considerations

Avoid entry of visitors into the patient room. Exceptions may be considered on a case-by-case basis for those who are essential for the patient's wellbeing (e.g., caregiver of children). Visits should be scheduled and monitored to allow for:

Visitors should be made aware of the risk of self-contamination when using their PPE, and movement within the facility should be restricted to the patient care area only.

Handling bodies of deceased patients

Post-mortem examinations (if necessary) and human remains handling should be done in accordance with respective federal and provincial or territorial regulations.

In addition to routine practices, PPE consistent with an unstable PUI or confirmed EBOD case should be used. This includes a fit-tested N95 respirator (or equivalent, or greater protection) with face shield, double gloves, fluid-resistant or impermeable gown or hazardous materials suit, fluid-impermeable apron, fluid-resistant or impermeable body coverings including foot/leg and head/neck coverings.

Medical devices (i.e., intravenous catheters, urinary catheter, or endotracheal tubes) should be left in place.

At the site of the death, the body should be wrapped in high quality puncture-resistant plastic shroud. Care should be taken to prevent the contamination of the exterior surface of the shroud. A leak-proof body bag should be used over the shroud. Once closed the body bag should not be re-opened. While wearing PPE, perform cleaning and disinfection of the outer bag with a broad spectrum virucide disinfectant registered with a Health Canada DIN, according to the manufacturer's instruction.

Handling of human remains should be kept to a minimum (e.g., no autopsies unless necessary, no embalming, and no post-mortem care) and direct contact with the human remains must only be done by trained HCWs.

Duration of precautions

The decision to discontinue precautions for PUIs or patients with confirmed EBOD should be made on a case-by-case basis, jointly in consultation with the IPC program, infectious disease specialists, and public health officials.

Patients should be advised that some body fluids remain positive for some time after the virus is no longer detectable in the blood and advised on the appropriate personal precautions to take with close contacts. This includes semen and breast milk. Refer to the Public Health Management of Cases and Contacts of Ebola Disease in the Community Setting in Canada for specific recommendations on case management of convalescent confirmed cases after discharge from hospital.

Notification

Refer to the Public Health Management of Cases and Contacts of Ebola Disease in the Community Setting in Canada for notification protocols.

A PUI or confirmed case should be reported immediately to the infection prevention and control program, laboratory and local public health officials as per jurisdictional protocols in the respective province or territory in Canada. Ensure a timely, person-to-person discussion of the case with relevant authorities.

Concurrent with a request for laboratory services for EBOD or other VHF, provinces and territories are requested to notify and provide a clinical history of the patient's illness to the Public Health Agency of Canada.

Laboratory precautions

Public health authorities should be involved in provision of information regarding laboratory testing requirements and specimen transport protocols. Prior to collecting specimen, contact facility laboratory to notify them of the possible diagnosis and for specific instructions before collecting or sending any specimens to the laboratory. The decision for specimen collection and testing should be predicated on the clinical status of the patient and based on an on-going risk assessment. No viral culture should be attempted outside of the Public Health Agency of Canada's National Microbiology (NML) Containment Level 4 laboratory.

For diagnostic or confirmatory services for EBOD, liaise with the provincial public health laboratory of your jurisdiction to coordinate with the National Microbiology Laboratory (NML) Operations Centre Director (OCD). The NML OCD will work with the requesting provincial jurisdiction to activate the Emergency Response Assistance Plan.

Laboratories receiving specimens from person under investigation (PUI) for EBOD must be aware that improper handling of these specimens may pose a risk to the health of laboratory personnel. Consult the "Biosafety Guidelines for Laboratories Handling Specimens from Patients under Investigation for Ebola Virus Disease" before any testing occurs.

Wipe specimen container using a disinfectant with a broad spectrum virucide claim with a Health Canada DIN, according to the manufacturer's instructions, in the patient room prior to placing into a secure container for transport. Consult the "Biosafety Guidelines for Laboratories Handling Specimens from Patients under Investigation for Ebola Virus Disease".

Do not send specimens in a pneumatic tube system.

Appendix A: Acknowledgements

National Advisory Committee on Infection Prevention and Control (NAC-IPC)

Joanne Embree, MD, MSc
Pediatric Infection Disease Specialist, Shared Health
Professor, University of Manitoba
Winnipeg, MB

Matthew P. Muller, MD, PhD, FRCPC
Associate Professor, University of Toronto
Medical Director, Infection Prevention & Control, Unity Health Toronto
Toronto, ON

Molly Blake RN BN MHS CIC
Program Director, Infection Prevention & Control, Winnipeg Regional Health Authority (WRHA)
Acting Program Director, Medical Device Reprocessing, WRHA
Winnipeg, MB

Patsy Rawding, RN, BScN, CIC
Health Services Manager, Infection Prevention & Control
Western Zone, NSHA Lead Manager in LTC
Middleton, NS

Patrice Savard, MD, MSc, FRCPC
Clinical Associate Professor, University of Montreal
Clinical microbiologist and Infectious diseases specialist, CHUM
Medical director, nosocomial infection prevention and control unit, CHUM
Montréal, QC

Jennie Johnstone, MD, PhD, FRCPC
 Associate Professor, University of Toronto
Medical Director Infection Prevention and Control, Sinai Health
 Toronto, ON

Stephanie W. Smith, MD, MSc, FRCPC
Professor, Division of Infectious Diseases, Department of Medicine, University of Alberta
Director, Infection Prevention and Control, University of Alberta Hospital
Edmonton, AB

Suzanne Rhodenizer Rose RN BScN MHS CIC
Director, Clinical Planning, QEII New Generation Project
Project Infection Control Specialist
Halifax, NS

Anne Masters-Boyne, R.N., M.N.
Occupational Health Nurse, Employee Health Services, Horizon Health Network
Fredericton, NB

Jennifer Happe, BSc, MSc
Alberta Children's Hospital
Director, Infection Prevention and Control Canada
Infection Control Professional, Alberta Health Services
Calgary, AB

Nisha Thampi, MD, MSc, FRCPC
Medical Director, Infection Prevention and Control Program, Division of Infectious Diseases, Children's Hospital of Eastern Ontario
Associate Professor, Department of Pediatrics, University of Ottawa
Ottawa, ON

Susy Hota MSc MD FRCPC
Medical Director, Infection Prevention and Control
Infectious Diseases Specialist, University Health Network
Associate Professor, Department of Medicine, Division of Infectious Diseases, University of Toronto
Toronto, ON

Brian Sagar, MSc, BA
Senior Director, Communicable Disease
British Columbia Ministry of Health
Victoria, BC

Healthcare-acquired Infection Prevention and Control Section

Maureen McGrath, BScN., RN
Steven Ettles, MPH
Amanda Graham, MPH
Jennifer Selkirk, MSc., RN

Appendix B: Algorithm for screening and assessment for Ebola disease in persons presenting to healthcare settings

Download a printable PDF version of Appendix B.

Figure - Text description

An algorithm for the screening and assessment of patients presenting to a healthcare setting is used as a tool to assess risk of EBOD and to make decisions about the appropriate IPC measures to enact. This is based on a multi-stage assessment of a person's travel history, possible contact with EBOD via a person(s) under investigation (PUI), confirmed patient(s) with EBOD, or laboratory specimens, and symptoms.

The algorithm begins with an initial assessment of the person presenting to the healthcare setting. Assess the following factors:

  • a. Within the previous 21 days, has the person lived in or travelled to a country with endemic Ebola, or a public health notice due to widespread Ebola transmission?
  • b. Within the previous 21 days, is the person known to have had contact with a PUI for EBOD or patient confirmed to have EBOD, including through burial?
  • c. Within the previous 21 days, has the person had contact with laboratory specimens from PUI or patient(s) confirmed to have EBOD?
  • d. Within the previous 21 days, has the person had contact with primates, bats, or wild animal bush meat from EBOD-affected countries or regions?

If the answer to any of the above questions is NO, there is no risk of EBOD. As such, healthcare workers should proceed with usual assessment and implement IPC measures as per Routine Practices and Additional Precautions (RPAP). The EBOD-specific assessment ends at this point for this person.

If the answer to any of the above questions is YES, the assessment should continue with an assessment of the person's symptoms. Assess the following:

  • e. Does the person have a fever of greater than or equal to 38 degrees Celsius, or
  • f. Does the person have at least one other EBOD-compatible symptom?

If the answer to these questions is NO, healthcare workers should proceed with usual assessment, implement IPC measures as per RPAP, and notify public health authorities.

Next, assess:

  • g. Does the patient require hospitalization for reasons unrelated to EBOD?

If the answer is YES:

  • Advise infection prevention and control (IPC), Occupational Health and Safety (OHS), and infectious disease on admission;
  • Monitor and record temperature and other EVD-compatible symptoms at least twice daily for 21 days after last exposure or travel;
  • Inform public health of outcome of monitoring;
  • Notify public health if patient is to be discharged prior to end of the 21 day monitoring period.
  • If the patient develops fever or other EBOD-compatible symptoms within 21 days of last exposure or travel, consider as a PUI for EBOD. Refer to the "PUI for EBOD" section of this description.

If the answer is NO:

  • Contact public health for guidance on next steps of monitoring for 21 days after the last exposure or travel;
  • Public health should be satisfied with the patient's status and arrangements for monitoring before the patient leaves the facility.

"PUI for EBOD": If the answer to question (e) [Does the person have a fever of greater than or equal to 38 degrees Celsius?] or (f) [Does the person have at least one other EBOD-compatible symptom?] is YES, the person should be considered as a person under investigation (PUI) for EBOD. Initiate the following actions:

  • Have the patient perform hand hygiene and adhere to respiratory hygiene (i.e., put on mask);
  • Initiate IPC measures including contact and droplet precautions;
  • Place patient in a single room with private toilet facility, access to designated patient hand hygiene sink or supplies, and door closed;
  • Limit exposure to essential healthcare workers and minimize their exposure;
  • Have a Trained Monitor keep log of healthcare workers entering patient's room;
  • Immediately notify local public health authorities for guidance on further action;
  • Apply appropriate precautions for safe management of potentially contaminated waste or linen;
  • For public health follow up, record the names of healthcare workers and other people who may have had unprotected exposure to patient or patient's blood and bodily fluids (BBF).

If a PUI for EBOD is identified in an AMBULATORY CARE SETTING, i.e., outside of an acute care facility, complete the following actions:

  • Do not perform any interventions or procedures that may put healthcare workers in direct contact with the patient's BBF. If healthcare worker must have direct patient contact, appropriate PPE should be worn as per Table 3 of the guideline
  • Contact local public health or other designated authorities for guidance on patient transfer to designated EBOD hospital. Adhere to the current guideline.
  • Contact local public health or other designated authorities for instructions on cleaning the environment;
  • PUI for EBOD seeking care by phone should be advised to remain in place.

If a PUI for EBOD is identified in a HOSPITAL SETTING, complete the following actions:

  • Notify IPC, OHS, infectious disease, medical microbiology and other relevant personnel;
  • Perform a risk assessment to determine the infectious risk posed to healthcare workers and others;
  • Inform your facility's laboratory of PUI for EBOD and obtain specific instructions prior to collecting specimens for analysis. Initiate protocols for EBOD testing and testing for alternative or co-existing infections (e.g., malaria and typhoid fever);
  • If EBOD is confirmed, contact local public health authorities for guidance on patient transport to designated EBOD hospital;
  • Have a Trained Monitor observe healthcare workers PPE use and patient care;
  • If EBOD negative, notify public health if patient is to be discharged prior to end of 21 day monitoring period.

If the PUI for EBOD is stable, the following PPE should be used by healthcare workers:

  • Fluid-resistant mask with separate face shield or goggles
  • Gloves
  • Fluid-resistant or impermeable gown
  • If the patient requires an aerosol-generating medical procedure (AGMP), a fit-tested N95 (or equivalent, or higher protection) should be used.

If the PUI for EBOD is unstable, or if EBOD is confirmed, the following PPE should be used by healthcare workers:

  • Fit-tested N95 (or equivalent, or higher protection) with separate face shield
  • Double gloves
  • Fluid-resistant or impermeable gown or hazardous material suit
  • Fluid impermeable apron
  • Fluid-resistant or impermeable foot/leg and head/neck coverings
  • All exposed skin is protected

Appendix C: Management of Ebola disease-associated waste in Canadian healthcare settings

This guidance addresses the safe management (handling, containment, transport and disposal) of waste generated in healthcare settings from persons under investigation and persons confirmed with EBOD.

Its use is intended for healthcare organizations, in particular, individuals responsible for facility and medical waste management, and those responsible for IPC and occupational health and safety training and education of healthcare workers (HCWs) and environmental services personnel who may be involved with EBOD-associated waste management.

The guidance is based on currently available scientific evidence, standards and regulations, and adopts a precautionary approach where the evidence is lacking or inconclusive. It is subject to review and change as new information becomes available.

The guidance should be read in conjunction with relevant federal, provincial, territorial and local legislation, regulations, and policies, and adapted to local requirements as necessary.

This guidance does not cover the management of waste in laboratory settings, guidance for cleaning, disinfection and sterilization of equipment or guidance on the management of the deceased body.

EBOD-associated waste

EBOV is categorized as a Risk Group 4 agent, is likely to cause serious disease and effective treatment is not available. Waste contaminated with EBOV requires special handling and disposal to prevent exposure to the virus.

All EBOD-associated waste is considered biohazardous (or infectious) waste and includes items (including linen and sharps) contaminated with human blood and body fluids (i.e., respiratory secretions, saliva, emesis, feces, urine, dialysate/effluent) that warrants special handling and disposal as they may in certain situations present a risk of disease transmission.

EBOD-associated waste that has been appropriately incinerated or autoclaved is not infectious and does not pose a health risk. The following guidance on the safe management of EBOD-associated waste is recommended for healthcare organizations that do not have on-site facilities or means to inactivate EBOD-associated waste by incineration or autoclaving.

Recommended measures for the healthcare organization

It is the responsibility of the healthcare organization to minimize the risk of exposure to and transmission of infectious diseases. The following measures are recommended for healthcare organizations for the safe management of EBOD-associated waste:

Recommended management of EBOD-associated waste generated in healthcare settings

All HCWs (i.e., nurses, doctors) and environmental services personnel handling EBOD-associated waste should wear appropriate PPE, including enhanced PPE based on a risk assessment, along with following guidance for safe removal of PPE, according to the organization's policy.

Examples of waste:

Human waste

Linen

If test result for EBOV is negative: No further special handling of the stored reusable linen required. Regular laundry process for stored reusable linen is appropriate and disposal of reusable linen into waste stream is not necessary.

If test result for EBOV is positive: Stored containers of linen should be packaged and transported separately off-site and disposed of in accordance with applicable legislation for regulated biohazardous waste.

Other non-sharps waste

If test result for EBOV is negative: No further special handling of the stored waste is required. Regular waste disposal process as per organization's protocol for biohazardous waste is appropriate.

If test result for EBOV is positive: Stored containers of waste should be packaged and transported separately off-site and disposed of in accordance with applicable legislation for regulated biohazardous waste.

Sharps waste

Recommended management of on-site spills related to EBOD-associated blood and other body fluids

References

Public Health Agency of Canada

Canada

Centers for Disease Control and Prevention (CDC), United States

Public Health Ontario

World Health Organization

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