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Infection Prevention and Control Expert Working Group: Advice on Infection Prevention and Control Measures for Ebola Virus Disease in Healthcare Settings

The Public Health Agency of Canada (PHAC) requested the advice of its Infection Prevention and Control Expert Working Group to develop this document on appropriate infection prevention and control (IPC) measures to assist healthcare organizations and complement provincial / territorial public health Glossary P efforts in establishing appropriate precautions for the management of Ebola virus disease (EVD)Glossary E in healthcare settings Glossary H.

Based on experience to date in the United States (US) and Europe, and with implementation of border screening processes that provide direction to individuals arriving in Canada from countries currently affected by EVD, it is expected that individuals with EVD will present to hospitals for care and not to other healthcare settings, such as physician offices, walk in clinics, and pharmacies. Even so, the advice in this document is applicable to all healthcare settings.

The purpose of this document is to provide background and advice on what the minimum level of infection control measures should be based on a review of available scientific evidence. This advice has informed the IPC Statement developed by PHAC. The target audiences for this document are IPC professionals, Occupational Health and Safety professionals Glossary O, healthcare organizations, and healthcare providers responsible for educating health care workers (HCWs)Glossary H on IPC. The advice is intended for healthcare settings where there may be potential for contact with a symptomatic patient who is suspected (person under investigation) or confirmed to have EVD.

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 to inform the development of guidance.

This advice is based on currently available scientific evidence and adopts a precautionary approach where the evidence is lacking or inconclusive. It is subject to review and change as new information becomes available.

Table of Contents

Background

EVD is a severe acute viral illness first identified over 30 years ago that begins with fever, often with malaise, myalgia, and headache, and is typically followed by progressive gastrointestinal symptoms that include anorexia, nausea, and abdominal discomfort, followed by vomiting and diarrhea. The diarrhea and vomiting is often profuse in later stages of the illness and, without treatment, 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. Secondary bacterial infections are common. The incubation period of EVD varies from 2 to 21 days. People with EVD are not infectious during the incubation period. Ebola virus has been detected in semen for up to 3 and a half months in men with EVD. Otherwise, once someone has recovered from EVD, they can no longer spread the infection.

Risk and Transmission

Multiple previous EVD outbreaks have occurred in Africa and have been extensively studied. Most of our recent information on EVD comes from the experience reported in West AfricaFootnote 1, Footnote 2 Update on currently affected areasExternal Link should be obtained from the World Health Organization (WHO). Evidence to date indicates that the clinical course of infection and transmissibility are similar to previous EVD outbreaks.Note 1 In those countries that have been most affected by EVD (Guinea, Liberia, and Sierra Leone), the risk of transmission has been highest among family members and close contacts of people with EVD and among HCWs providing care to patients with EVD in the context of the local healthcare setting and system. From a public health perspective, the risk of transmission of EVD in Canada is considered to be very low.

Ebola virus 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 materials that the individual is exposed to.

Cases are not communicable before the onset of symptoms but communicability increases with each subsequent stage of illness. Patients with EVD 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 EVD in the absence of direct contact with an infected case. This takes into account the thousands of EVD cases in Africa and the very small number of EVD cases in Europe and the US. Ebola Virus Disease is not spread through the airborne route.

Public health case management relies on early identification of EVD cases, patient isolation and care, diligent contact tracing, appropriate infection prevention and control measures, and safe burial. The following web links should be consulted:

Preventing Exposure to and Transmission of EVD

Cases will require hospitalization for supportive care and isolation. ContactGlossary C and droplet precautions Glossary D, in addition to routine practices Glossary R, are to be implemented in settings where contact with patients suspected or confirmed to have EVD is anticipated. In healthcare settings, when aerosol-generating medical procedures (AGMPs)Glossary A must be performed, strategies to reduce aerosol generation must also be implemented. Routine practices include the use of personal protective equipment (PPE) Glossary P and barriers worn by HCWs to protect the patient from transmission of microorganisms, and to protect the HCW from exposure to bloodborne and other microorganisms (e.g., through splashes/sprays of blood, other body fluids, respiratory tract or other secretions or excretions). The need for enhanced PPE Glossary E(e.g., double gloving, head and neck coverings Glossary H, foot and leg coverings Glossary F) is determined by assessing the risk of exposure to blood or other body fluids, which can be anticipated to increase the risk of exposure to Ebola virus. Refer to Table 1 for factors influencing risk of exposure to Ebola virus within healthcare settings.

HCWs should conduct a point-of-care risk assessment Glossary P and identify whether the nature of the EVD patient's symptoms (e.g., diarrhea, vomiting) will require the use of enhanced PPE.

The effectiveness of PPE (e.g., gowns Glossary G, aprons Glossary A, hazardous material suits Glossary H, foot and leg coverings, gloves Glossary G, head and neck coverings Glossary H, masks Glossary M, face shields Glossary F, eye goggles Glossary E, and respirators Glossary R) is highly dependent on prior training and experience with the PPE, as well as appropriate selection and education on their proper use, including correct technique for putting on and removing, discarding into designated receptacles, and hand hygiene Glossary H to minimize risk of transmission.

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

  1. combination of gown, foot and leg coverings, neck and head coverings, or
  2. hazardous material suit Glossary H.

Either is acceptable (when used with the other components of PPE) provided that it meets the criteria outlined in Tables 3 and 4.

Prior to working with EVD patients, the HCW who will use the selected PPE must have had prior comprehensive training and observed practice with the PPE and be adept at its use and removal.

While some facilities have chosen to use powered air purifying respirators (PAPRs) Glossary P, these are not required for the care of patients with EVD. Their removal poses a recognized 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.

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. This will require:

  • an organizational risk assessment Glossary O to identify where patients with EVD are likely to present and receive care;
  • identification of HCWs who will have a lead role in EVD response and who may come into contact with EVD patients and/or their environment; and
  • comprehensive education, training, and repeated observed practice on specific PPE selected for HCW use in each facility.

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

  • put on PPE;
  • remove PPE;
  • provide care to the patient with EVD; and
  • recommend corrective action when necessary (e.g., if PPE becomes dislodged).

Refer to Table 2 for the definition and role of the Trained Monitor.

Even in temperature controlled environments, it is important to recognize that a HCW who is wearing enhanced PPE may be at risk of overheating, fatigue, and potential dehydration. This should be taken into consideration in scheduling of work.

In healthcare settings when AGMPs must be performed on suspect or confirmed EVD patients, strategies to reduce aerosol generation must also be implemented.

Application of Hierarchy of Controls to EVD: Engineering Controls, Administrative Controls and Personal Protective Equipment

The hierarchy of controls Glossary H is a fundamental occupational health and safety framework, designed to optimize protection of the worker from exposures to hazards, including infectious hazards such as EVD. Following the hierarchy of controls will produce safer systems and reduce illness or injury. Engineering and administrative controls Glossary A are at the top of the hierarchy of controls.

Engineering controls Glossary E are used to either remove the hazard or put a barrier between the worker 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. They do not depend on the individual's knowledge, practice or compliance, thus reducing the opportunity for error.

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

  • Use of plastic partition at triage Glossary T
  • Accommodation in a single inpatient room with designated private toilet and patient sink and anteroom
  • Use of airborne infection isolation rooms Glossary A for AGMPs
  • Designated staff hand washing sinks
  • Point-of-care alcohol-based hand rub (ABHR) Glossary A
  • Point-of-use sharps containers
  • Designated no touch biohazardous waste Glossary B receptacles
  • Safety-engineered needles and needleless systems
  • Point-of-care laboratory testing

Administrative controls Glossary A 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. To be effective in preventing transmission of EVD and/or detecting cases of EVD, administrative controls must be implemented from the first encounter with a suspect case and continue until the infected source leaves the healthcare setting, is no longer infectious, or is deceased (note, proper post-mortem care is required). Ineffective or inconsistent application of administrative controls may lead to unnecessary exposure.

Occupational Health and Safety Legislation: 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 Glossary J are also legislated and are jointly chaired by a management and a worker representative. Hospitals will also have internal responsibility systems (IRS) Glossary I, 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 his or her own safety and for the safety of co-workers.

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

  • Screening protocols for relevant travel history and symptoms at multiple points of entry
  • Triage procedures and prompt initiation of isolation and appropriate PPE
  • Case and contact tracing
  • Outbreak Management Policy
  • Initiation of Incident Management Structure
  • Designated regional centres for care of patients
  • Designated transport vehicles
  • Designated care teams
  • Trained Monitor to coach and monitor proper use, putting on and removing of PPE
  • Specialized training, including drills, in the selection, application, use, removal and disposal of PPE
  • Respiratory Protection Programs
  • Limiting the number of HCWs providing care to an EVD patient
  • Determining HCW fitness to provide care to EVD patients

General guidelines for HCWs' fitness to provide direct care to EVD patients

Fitness to work Glossary F incorporates factors that relate to the individual HCW's ability to safely perform the duties of their job. The HCW must be made aware whenever there are changes in the tasks to be performed, changes in the work environment within which these tasks are performed, or changes in recommended PPE. 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 EVD patients. The principles for identifying these conditions are based on the following considerations:

  • Inability to sustain work times required while providing direct patient care in the recommended PPE.
  • Demonstrated or expected higher EVD mortality based on the underlying health condition(s).

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

  • Underlying medical conditions that could affect the HCW's ability to exit the room quickly and safely, or that may require another HCW to enter the room to provide urgent medical assistance to the HCW (e.g. seizure disorder, hypoglycemia)
  • Inability to safely put on, use, or remove recommended PPE (e.g. fit-testing failure; claustrophobia, body morphology, mobility issues)
  • Skin integrity
  • Immune competence
  • History of heat stroke
  • Pregnancy (due to reported maternal mortality of >95% and fetal mortality of 100%).

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

Personal Protective Equipment Glossary P refers to all personal equipment and clothing recommended by the employer for use by the HCW. In healthcare settings, PPE is often the primary focus, and although it is a critical element in implementing infection prevention and control practices, it is the last control between the worker and the infectious hazard. 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 worker regarding PPE. The employer must ensure that the appropriate equipment and 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 Ebola virus. The supervisor is responsible to ensure that the HCW uses the equipment/PPE required by the employer and the HCW shall use the equipment/PPE required by the employer.

To ensure the health and safety of HCWs caring for patients with EVD, a co-ordinated and systematic approach must be implemented. The principles include following the hierarchy of controls; remembering that engineering controls can be the most effective in preventing or limiting exposure in the first place. Administrative controls, with emphasis on vigilant screening of patients; patient care models that minimize the number of HCWs exposed; careful selection of effective PPE; and education and repeated training will best prepare the HCW for the provision of safe patient care.

IPC Measures for Healthcare Settings

Routine practices Glossary R and additional precautions Glossary A (RPAP) provide information for IPC measures for management of ill individuals with infectious diseases. This document is specific to EVD and provides additional precautions intended for healthcare settings where individuals with EVD-compatible symptoms may present.

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 Ebola virus. 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 EVD 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 AGMPs are performed and may influence the point-of-care risk assessment (PCRA) performed by HCWs.

The ORA will characterize the organization's patient population, level and intensity of health care provided and resources available, including the various skilled workers. It will need to evaluate the effectiveness of present control measures and the breadth of the hierarchy of controls to prevent transmission of the Ebola virus.

Routine Practices

Routine practices are the IPC measures for use 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.

Performing an ORA and addressing deficiencies provides the framework to ensure that appropriate components in the hierarchy of controls related to routine practices are in place in order to minimize the risk of exposure to and transmission of Ebola virus within healthcare settings.

Routine practices include:

  • Point-of-care risk assessment
  • Hand hygiene program (including point-of-care ABHR)
  • Source control Glossary S
  • Patient placement, accommodation, and flow
  • Aseptic technique
  • Use of PPE
  • Sharps safety Glossary S and prevention of bloodborne pathogen transmission
  • Management of the patient care environment
    1. Cleaning of the patient care environment
    2. Cleaning and disinfection of non-critical Glossary N patient care equipment
    3. Handling of waste and linen
  • Education of patients, families and visitors
  • Visitor management
A risk assessment approach should be used prior to every interaction with a symptomatic patient (suspect or confirmed), to support the use of additional IPC measures (e.g., enhanced PPE) where indicated.

Point-of-Care Risk Assessment

A point-of-care risk assessment (PCRA) is performed by HCWs to determine the appropriate IPC measures to protect the HCW from exposure to the Ebola virus (e.g., from sprays of blood or other body fluids, respiratory tract or other secretions or excretions and contaminated needles and other sharps).

Table 1. Factors influencing risk of exposure to Ebola virus within healthcare settings
Source Lower risk of exposure Higher risk of exposure
EVD-infected patient
  • Early stage of EVD (e.g., fever with fatigue and myalgia)
  • Convalescing stage of EVD when diarrhea and vomiting have resolved
  • Patient's body fluids (e.g., blood, formed stool, emesis) contained
  • Formed stool
  • No emesis
  • Continence
  • Good hygiene
  • Capable of self-care
  • Adequate patient placement
  • Later stages of EVD, involving copious fluid loss (e.g., vomiting, diarrhea, bleeding)
  • Patient's body fluids (e.g., blood, diarrhea, emesis) soiling the environment
  • Diarrhea
  • Emesis
  • Incontinence
  • Poor hygiene
  • Not capable of self-care due to physical condition, age or cognitive impairment
  • Inadequate patient placement
Interventions
  • Procedures or interventions that do not put the HCW in direct contact with patient's body fluids (e.g., triage or history taking)
  • Providing the patient with an emesis basin to use whenever possible based on his/her condition
  • Supporting the patient in independent use of toilet and bathroom whenever possible based on his/her condition
  • Allowing the patient to complete vomiting or the diarrhea episode before providing direct care whenever possible
  • Use of disposable or single use equipment
  • Involving a risk of percutaneous injury to the HCW with a sharp instrument or needle contaminated with the patient's body fluids (e.g., phlebotomy, intravenous insertion)
  • Involving direct contact with patient's blood or other body fluids (e.g., changing incontinence product, cleaning soiled environment, attending to the patient during diarrhea or vomiting, and post-mortem care)
  • Direct or indirect contact with contaminated environment or fomites (e.g., cleaning and disinfection of patient care equipment and environment)

Triage and Screening Glossary S

Healthcare settings should have the following triage measures in place:

  • Ability to direct patients who have called the doctor's office, clinic or Emergency Department (ED) notifying that they are feeling feverish and/or have a fever or other symptoms compatible with EVD and have a travel history to an Ebola-affected area, to an appropriate care setting and initiate necessary IPC measures immediately upon arrival.
  • A physical barrier (e.g., plastic partition at triage desk) located between infectious sources (e.g., patients with symptoms of EVD) and susceptible hosts (e.g., other patients, HCWs).
  • Supplies for emesis management and respiratory hygiene Glossary R available (masks, tissues, basins, hand hygiene products, designated hand washing sinks and no-touch biohazardous waste Glossary B receptacles).
  • Patients with symptoms should be assessed in a timely manner for EVD and for other alternative or co-existing potential communicable infections (e.g., malaria, meningitis, dysentery, typhoid fever, tuberculosis, measles, gastroenteritis).
  • Assess for travel within 21 days to Ebola-affected areas, or contact with an individual with onset of symptoms within 21 days of travel to an Ebola-affected area.
  • Assess for symptoms of EVD: presenting with fever (temperature of 38°C or history of feverishness) OR at least one of the following symptoms: fatigue, loss of appetite, vomiting, diarrhea, headache, abdominal pain, muscle or joint pain, conjunctival injection, pharyngitis, or unexplained bleeding.
  • Refer to Appendix II - Algorithm for Screening and Assessment for Ebola Virus Disease in Persons Presenting to Healthcare Settings for a quick reference guide for front line healthcare workers involved in triage and screening.

Source Control

  • Place suspect or confirmed EVD patient in single room with dedicated toilet or commode; keep the door closed.
  • Advise the patient to perform HH and adhere to respiratory hygiene.
  • Only essential HCWs with appropriate PPE to enter the patient's room.
  • Assign a Trained Monitor to coach and monitor appropriate use, removal, and disposal of PPE, to avoid contamination of the HCW and the environment outside of the patient's room.
  • Patients should be asked and assisted to perform hand hygiene after toileting and vomiting.
  • AGMPs should be minimized on patients suspected or confirmed to have EVD.
  • If AGMPs are absolutely necessary (e.g., intubation), implement strategies to reduce aerosol generation Glossary S:
    1. AGMPs should be anticipated and planned for.
    2. Appropriate patient sedation should be used.
    3. The number of HCWs in the room should be limited to those required to perform the AGMP and to those highly skilled in performing the required task.
    4. AGMPs should be performed in an airborne infection isolation room (also referred to as negative pressure room).
    5. Appropriate ventilation (e.g., number of air changes, level of air filtration and correct direction of air flow) should be maintained.
    6. Single rooms (with the door closed and away from other patients), should be used in settings where airborne infection isolation rooms are unavailable.
    7. Fit tested, seal checked respirators (NIOSH approved N95 at minimum) should be worn by all HCWs in the room during an AGMP.
    8. Closed endotracheal suction systems should be used wherever possible.

Hand Hygiene (HH)

  • Frequent use of ABHR (60-90% alcohol) or washing with soap and water (if hands are visibly soiled) including but not limited to:
    1. before entry to patient room and putting on PPE,
    2. before putting on a clean pair of gloves for the removal of soiled PPE,
    3. after contact with blood/body fluids,
    4. after removing PPE (e.g., gloves, gown, mask, facial shield, eye goggles, head and neck coverings, etc.), and
    5. after leaving patient room.

IPC Precautions

  • Routine Practices
  • Additional Precautions:
    1. Contact
    2. Droplet
    3. Strategies to prevent aerosol generation if AGMPs are absolutely necessary (e.g., intubation)
    4. Airborne precautions if AGMP in progress
Table 2. Roles and responsibilities of Ebola Site Manager and Trained Monitor
  Ebola Site Manager Glossary E Trained MonitorGlossary T
Responsibility To oversee safe and effective delivery of EVD patient care with responsibility for all aspects of EVD infection prevention and control in a facility. To assist with and ensure adherence to entire PPE use and removal process by HCWs providing direct patient care.
Role
  • Oversee the overall safe care of EVD patients in a facility at all times
  • Oversee implementation of administrative and engineering controls
  • Evaluate care before, during and after HCW enters an isolation or treatment area
  • Provide immediate corrective instruction in real-time if HCW is not following recommended steps
  • Know and apply the facility EVD exposure management plan Glossary E in event of unintended breach in procedure
  • Monitor and evaluate supplies
  • Monitor entry to room (i.e., limit entry to only essential HCWs)
  • Monitor / supervise PPE use and safe removal; generally does not enter patient room
  • Guide / read aloud to HCW, 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 is in patient room
  • Provide immediate corrective instruction in real-time if HCW is not following recommended steps
  • Should know the facility EVD exposure management plan in event of unintended breach in procedure
Number needed At least one Site Manager should be onsite at all times in the location where an EVD patient is being cared for One Trained Monitor at all times for each HCW providing patient care

Duration of Precautions

For patients suspected to have EVD:

  • Contact and droplet precautions and strategies to reduce aerosol generation during AGMPs should remain in effect until EVD is excluded.
  • As reverse transcriptase polymerase chain reaction (RT-PCR) testing for Ebola virus in blood may be negative within the first 72 hours of symptom onset, a second test may be required (depending on clinical situation) before an EVD diagnosis can be excluded.
  • A single negative RT-PCR test result for Ebola virus from a blood specimen collected more than 72 hours after symptom onset, rules out EVD.

For patients confirmed to have EVD:

  • Additional precautions for EVD must be continued until the patient is clinically improved and determined to no longer have virus circulating in the blood. This determination is based on having two negative plasma Ebola RNA RT-PCR tests at least 24 hours apart. Following confirmation by this method that virus is no longer present in blood and consultation between experts in IPC, infectious diseases and Public Health, additional precautions for EVD can be discontinued.
  • Criteria for discontinuation of additional precautions include patient's ability to comply with instructions and continence for stool and urine.

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 (positive for up to 90 days after), and breast milk (not yet well studied but suggested to be positive for up to 15 days after). Refer to the Public Health Management of Cases and Contacts of Human Illness associated with Ebola Virus Disease for specific recommendations on case management of convalescent confirmed cases after discharge from hospital.

Negative testing for EVD does not rule out infection with one of the other Viral hemorrhagic fevers (VHF) Glossary V. Patients with appropriate epidemiological history and symptoms compatible with other VHF should remain in appropriate isolation precautions.

Notification

  • Refer to the Public Health Management of Cases and Contacts of Human Illness associated with Ebola Virus Disease for notification Glossary N protocols.
  • A suspect (person under investigation) or confirmed case should be reported immediately to the IPC Program, laboratory and local public health as per jurisdictional protocols in the respective province or territory in Canada.
  • Concurrent with a request for laboratory services for EVD 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 Health Portfolio Operations Centre at 1-800-545-7661.
  • Clarification of further information may be requested from the patient's clinician in order to optimize the delivery of the requested laboratory service(s).

Healthcare WorkersGlossary H

These recommendations apply to all persons, paid or unpaid, who have the potential for exposure to suspect or confirmed EVD patients.

  • Be aware of signs and symptoms of EVD; appropriate control measures; and the need to self-monitor Glossary S while caring for suspect or confirmed cases of EVD and for 21 days following last contact with an EVD patient.
  • Eating or drinking shall not occur in areas where direct patient care is provided or in reprocessing Glossary R or laboratory areas.
  • HCWs with non-intact skin integrity should not have contact with suspect or confirmed EVD cases or their environment.
  • To prevent self-contamination, workers should avoid touching the mucous membranes of their eyes, nose and mouth with their hands.
  • Potential occupational/community exposure to EVD (e.g., direct exposure without appropriate PPE, percutaneous injuries) should be reported to immediate manager/supervisor and occupational health services or delegate as well as to Public Health, as above.
  • First aid should be performed immediately if there has been exposure to blood or other body fluids.
    1. The exposure should be reported immediately to the manager/supervisor and occupational health services or delegate, and immediate medical attention should be obtained.
    2. The site of a percutaneous injury should be thoroughly rinsed with running water, and any wound should be gently cleansed with soap and water.
    3. Mucous membranes of the eyes, nose or mouth should be flushed with running water if contaminated with blood, body fluids, secretions or excretions.
    4. Non-intact skin should be rinsed thoroughly with running water if contaminated with blood, body fluids, secretions or excretions.
    5. Appropriate follow-up for blood-borne pathogens should be initiated.

Personal Protective Equipment (PPE)

  • HCWs need to understand the basic principles of safe and effective PPE use:
    1. PPE must be large enough to allow unrestricted free movement of body and arms.
    2. PPE must be intact and correctly in place before entering the patient care area.
    3. PPE must be worn for the duration of exposure to potentially contaminated areas. It must not be adjusted during patient care. If a breach in PPE occurs, the HCW should stop patient care, initiate PPE removal process, and then leave the patient room.
    4. Removal of PPE presents a high-risk for self-contamination if not done properly. It requires a structured and monitored process and must be done slowly and deliberately.
    5. If the Trained Monitor will be assisting the HCW with either putting on and/or removing PPE, a risk assessment for exposure will need to be conducted for the Trained Monitor to determine the required PPE for him/her to safely assist the HCW.
  • Clean and potentially contaminated areas need to be clearly demarcated and evident to all HCWs working in the area, and traffic flow should minimize the risk of contamination.
  • PPE should be put on in a clean area either outside the patient room or in the anteroom. If the anteroom is used for removing soiled PPE, then it must not be considered a clean area and clean supplies, including PPE, should not be stored there.
  • The HCW should have sufficient and undisturbed time to put on and remove PPE correctly.
  • Have a Trained Monitor coach and observe appropriate selection, application, removal and disposal of PPE; observe that the HCW does not self-contaminate.
  • The need for enhanced PPEGlossary E (e.g., double gloving, head and neck coverings, foot and leg coverings), is determined by assessing the risk of exposure to blood or other body fluids (e.g., vomiting, diarrhea, bleeding). If a risk of exposure to body fluids exists, all skin should be covered. Note: In late stages of EVD, copious secretions and excretions should be anticipated. In this situation, enhanced PPE that will cover all exposed skin and is fluid-resistant Glossary F or impermeable Glossary I should be worn.

Table 3 and Table 4 present information on the types of PPE recommended for use by HCWs providing care to a patient with EVD with a lower risk of exposure to blood or other body fluids and for HCWs with a higher risk of exposure to blood or other body fluids respectively. Each table recommends a sequence for putting on and for removing specific types of PPE. The type of PPE and the sequence for putting on and removing PPE may vary depending on organizational needs, PPE choices and preferences, and the PCRA. Each healthcare organization should develop comprehensive policies and procedures for putting on and removing PPE with a clear goal of reducing the possibility of self-contamination.

Table 3. Types of PPE for lower risk of exposure to blood or other body fluids

Recommended PPE for contact and droplet precautions include: gloves, fluid-resistant or impermeable gown, fluid-resistant mask with eye goggles or fluid-resistant mask with face shield. Head and neck coverings, and foot and leg coverings are not required.


Notes:

  • If there is increased risk of exposure to blood or other body fluids, the HCW should cover all exposed skin with enhanced PPE.
  • If an AGMP is absolutely necessary, airborne precautions must be initiated including use of a respirator (instead of a mask) by HCWs. The respirator should be taken off outside the patient room using a clean pair of gloves as described in the sequence for removing PPE in Table 4.

SUGGESTED SEQUENCE FOR PUTTING ON PPE

Note: The sequence for putting on PPE may vary depending on organizational needs, and PPE choices and preferences. Each healthcare organization should develop comprehensive policies and procedures for putting on PPE.

  • Prior to entry to the patient room.
  • Inspect PPE for defects and appropriate size prior to putting on.
  • Remove all personal items (e.g., jewellery, identification tag, stethoscope, cell phone, pager, pens, etc.).
  • Pull back hair from face and neck and secure.

Perform hand hygiene (HH)

  • Using ABHR (60-90% alcohol) or hand washing using soap and water if hands visibly soiled.

Put on gown

  • Fluid-resistant or impermeable, cuffed, long enough to cover from neck to knees and to wrists (including sleeves).
  • Tie gown securely at the waist and neck (in the back), with edges overlapping to completely cover clothing, front and back.

Put on facial protection (i.e., mask and eye goggles, or mask and face shield)

  • Fluid-resistant mask with eye goggles or fluid-resistant mask with face shield long enough to prevent splashing underneath.
  • Secure ties, loops or straps.
  • Mould metal piece to nose bridge.
  • Eyes, nose, mouth, and chin are fully covered with minimal gap between the mask and the face.
  • Masks with visors are not suitable.
  • Eye glasses are not suitable eye protection.
  • Eye protection must fit over prescription eye glasses.

Put on gloves

  • Durable and fit appropriate to the task.
  • Fit securely over gown cuff.

PROPER USE OF PPE DURING PATIENT CARE

  • Inspect PPE equipment continually for tears and/or fluid penetration.
  • If difficulties with PPE (e.g., fogging, tearing of gloves), the HCW should stop patient care, initiate PPE removal process (as described below), and then leave the patient room.
  • If PCRA indicates increased risk of exposure to blood or other body fluids (e.g., patient at risk for vomiting or experiencing diarrhea), the HCW should stop patient care, initiate PPE removal process (as described below), and then leave the patient room. After completion of PPE removal process, HCW should put on enhanced PPE (as described in Table 4) prior to re-entering patient room.
  • Do not touch facial protection.

SUGGESTED SEQUENCE FOR REMOVING PPE

Note: The sequence for removing PPE may vary depending on the PPE used. Each healthcare organization should develop comprehensive policies and procedures for removing PPE with a clear goal of reducing the possibility of self-contamination.

  • Inspect PPE prior to taking it off to assess for visible contamination, cuts, or tears.
  • Remove PPE before leaving the patient room or in a designated soiled area immediately outside the patient room.
  • Additional opportunities for HH may be present based on risk assessment.

Remove gloves

  • Remove gloves using the glove-to-glove/skin-to-skin technique.
    1. Grasp outside edge near the wrist and peel away, rolling the glove inside out.
    2. Reach under the glove on the other hand and peel away.
  • Discard immediately into a designated no-touch biohazardous waste receptacle.

Perform hand hygiene (HH)

Remove gown

  • Remove gown, without contaminating self, by undoing the neck and waist ties, pull and remove gown without touching skin/clothing or agitating gown unnecessarily, then turn gown inside out on itself, and roll it up.
  • Discard disposable and reusable gowns into a designated no-touch biohazardous waste receptacle.

Perform HH

Remove facial protection (i.e., mask and eye goggles, or mask and face shield)

  • Remove facial protection carefully without contaminating self (skin, hands or clothes).
  • Remove the face shield by tilting the head slightly forward, grabbing the rear strap and pulling it over the head, gently allowing the face shield to fall forward.
  • Remove the eye goggles by pulling gently on the straps of the goggles away from face.
  • Remove the mask by untying the bottom tie then the top tie, or grasp straps or ear loops of mask. Pull forwards off the head, bending forward to allow mask to fall way from face.
  • Discard disposable facial protection immediately after use into a designated no-touch biohazardous waste receptacle.

Perform HH and exit patient room or designated soiled area.

Table 4. Types of enhanced PPE for higher risk of exposure to blood or other body fluids

Recommended PPE for enhanced PPE include: double gloves; fluid-resistant or impermeable body coverings including foot and leg coverings, head and neck coverings (such as surgeon's head covering), gown, or hazardous material suit; fluid-impermeable apron; facial protection (mask with eye goggles or mask with face shield); and a respirator for AGMP. All exposed skin is covered.

SUGGESTED SEQUENCE FOR PUTTING ON ENHANCED PPE

Note: The sequence for putting on PPE may vary depending on organizational needs, and PPE choices and preferences. Each healthcare organization should develop comprehensive policies and procedures for putting on PPE.

  • Prior to entry to the patient room.
  • Inspect PPE for defects and appropriate size prior to putting on.
  • Remove all personal items (e.g., jewellery, identification tag, stethoscope, cell phone, pager, pens, etc.).
  • Pull back hair from face and neck and secure.

Sequence if gown used

Perform HH

  • Using ABHR (60-90% alcohol) or hand washing using soap and water if hands visibly soiled.

Put on foot and leg coverings

  • Fluid-resistant or impermeable, and long enough to cover the legs below the gown, and secured in place.
  • Securely fitted to avoid risk of tripping.
  • Shoe compatible with coverings, and allows for easy removal.

Perform HH

Put on mask (if no AGMP)

  • Fluid-resistant.
  • Secure ties or loops.
  • Mould metal piece to nose bridge.
  • Nose, mouth, and chin are fully covered with minimal gap between the mask and the face.
  • Masks with visors are not suitable.

Put on respirator (instead of mask, for AGMP)

  • Fit-testing is required.
  • Place elastic bands correctly to hold in place.
  • Seal check is required to assess adequate fit.

Put on eye goggles (if face shield not used)

  • Secure straps.
  • Masks with visors are not suitable.
  • Eye glasses are not suitable eye protection.
  • Eye goggles should fit over prescription eye glasses.

Put on head and neck coverings

  • Fluid-resistant or impermeable.
  • Cover all of the hair and the ears, and extend past the neck and shoulders.

Put on inner gloves

  • Durable and fit appropriate to the task.

Put on gown

  • Fluid-resistant or impermeable, cuffed, long enough to cover from neck to knees and to wrists (including sleeves).
  • Tie gown securely at the waist and neck (in the back), with edges overlapping to completely cover clothing, front and back.
  • Ensure inner gloves fit securely under gown cuffs.

Put on apron (if used)

  • Fluid-impermeable apron to provide additional protection to the front of the body against exposure to the patient's body fluids.

Put on face shield (if used; preferred over eye goggles as part of enhanced PPE for EVD care)

  • Face shield should be long enough to prevent splashing underneath.
  • Secure strap.
  • Face shield should fit over prescription eye glasses.

Put on outer gloves

  • Durable and fit appropriate to the task.
  • Fit securely over gown cuff.

OR

Sequence if hazardous material suit used

Perform HH

  • Using ABHR (60-90% alcohol) or hand washing using soap and water if hands visibly soiled.

Put on foot and leg coverings (if not part of hazardous material suit)

  • Fluid-resistant or impermeable, and long enough to cover the legs below the suit, and secured in place.
  • Securely fitted to avoid risk of tripping.
  • Shoe compatible with coverings, and allows for easy removal.

Perform HH

Put on mask (if no AGMP)

  • Fluid-resistant.
  • Secure ties or loops.
  • Mould metal piece to nose bridge.
  • Nose, mouth, and chin are fully covered with minimal gap between the mask and the face.
  • Masks with visors are not suitable.

Put on respirator (instead of mask, for AGMP)

  • Fit-testing is required.
  • Place elastic bands correctly to hold in place.
  • Seal check is required to assess adequate fit.

Put on eye goggles (if face shield not used)

  • Secure straps.
  • Masks with visors are not suitable.
  • Eye glasses are not suitable eye protection.
  • Eye goggles should fit over prescription eye glasses.

Put on head and neck coverings (if not part of hazardous material suit)

  • Fluid-resistant or impermeable.
  • Cover all of the hair and the ears, and extend past the neck and shoulders.

Put on inner gloves

  • Durable and fit appropriate to the task.
  • Fit securely under suit cuff.

Put on hazardous material suit

  • Fluid-resistant or impermeable, whole body garment allowing unrestricted freedom of movement.
  • Ensure suit is appropriately sized.

Put on apron (if used)

  • Fluid-impermeable apron to provide additional protection to the front of the body against exposure to the patient's body fluids.

Put on face shield (if used; preferred over eye goggles as part of enhanced PPE for EVD care)

  • Face shield should be long enough to prevent splashing underneath.
  • Secure strap.
  • Face shield should fit over prescription eye glasses.

Put on outer gloves

  • Durable and fit appropriate to the task.
  • Fit securely over hazardous material suit cuff.

Note: When enhanced PPE is required to care for a patient with EVD, the preferred eye protection would be a face shield long enough to prevent splashing underneath.

PROPER USE OF ENHANCED PPE DURING PATIENT CARE

  • Inspect PPE equipment continually for tears and/or fluid penetration.
  • If difficulties with PPE (e.g., fogging, tearing of gloves), the HCW should stop patient care, initiate PPE removal process (as described below), and then leave the patient room or designated soiled area.
  • Do not touch facial protection.

SUGGESTED SEQUENCE FOR REMOVING ENHANCED PPE

Note: The sequence for removing PPE may vary depending on the PPE used. Each healthcare organization should develop comprehensive policies and procedures for removing PPE with a clear goal of reducing the possibility of self-contamination.

  • Inspect PPE prior to taking it off to assess for visible contamination, cuts, or tears.
  • Remove PPE before leaving the patient room or designated soiled area immediately outside the patient room, except for the respirator, which should only be removed outside the patient room, and discarded immediately into a designated no-touch biohazardous waste receptacle.
  • Items used in designated soiled area (such as swivel stool) should remain in that area or be cleaned if removed from that area.
  • Additional opportunities for HH may be present based on risk assessment.

Sequence if gown used

Remove outer gloves

  • Outer gloves should be removed first.
  • Remove outer gloves by pulling on outside of gloves, while taking care not to contaminate inner gloves.
  • Discard gloves immediately into a designated no-touch biohazardous waste receptacle.

Remove apron (if used)

  • Remove apron, without contaminating self, then roll apron inside out.
  • Discard apron immediately after use into a designated no-touch biohazardous waste receptacle.

Remove gown

  • Remove gown, without contaminating self, by undoing the neck and waist ties, pull and remove gown without touching skin/clothing or agitating gown unnecessarily, then turn gown inside out on itself, and roll it up.
  • Discard disposable and reusable gowns into a designated no-touch biohazardous waste receptacle.

Remove inner gloves

  • Remove gloves using the glove-to-glove/skin-to-skin technique.
    1. Grasp outside edge near the wrist and peel away, rolling the glove inside out.
    2. Reach under the glove on the other hand and peel away.
  • Discard immediately into a designated no-touch biohazardous waste receptacle.

Perform HH and put on a clean pair of gloves

Remove face shield (if used)

  • Remove face shield carefully without contaminating self (skin, hands or clothes).
  • Remove the face shield by tilting the head slightly forward, grabbing the rear strap and pulling it over the head, gently allowing the face shield to fall forward.
  • Discard disposable face shield immediately after use into a designated no-touch biohazardous waste receptacle.

Remove gloves as instructed above, discard into a designated no-touch biohazardous waste receptacle, perform HH and put on a clean pair of gloves

Remove head and neck coverings

  • Remove head and neck coverings without contaminating self by unfastening the coverings, and gently pulling coverings away from the face.
  • Discard disposable head and neck coverings immediately after use into a designated no-touch biohazardous waste receptacle.

Remove gloves as instructed above, discard into a designated no-touch biohazardous waste receptacle, perform HH and put on a clean pair of gloves

Remove mask (if used)

  • Remove mask carefully without contaminating self (skin, hands or clothes).
  • Untie bottom tie then top tie, or grasp straps or ear loops of mask. Pull forwards off the head, bending forward to allow mask to fall way from face.
  • Discard mask immediately after use into a designated no-touch biohazardous waste receptacle.

Remove eye goggles (if used)

  • Remove eye goggles carefully without contaminating self (skin, hands or clothes).
  • Remove the eye goggles by pulling gently on the straps of the goggles away from face.
  • Discard disposable eye goggles immediately after use into a designated no-touch biohazardous waste receptacle.

Remove gloves as instructed above, discard into a designated no-touch biohazardous waste receptacle perform HH and put on a clean pair of gloves

Remove foot and leg coverings

  • While sitting down (on a swivel stool for example) in the designated soiled area, untie fastening; remove one leg and foot covering. Slowly pivot clean foot into the designated clean area at proximity.
  • Discard disposable foot and leg covering into a designated no-touch biohazardous waste receptacle.
  • Remove the second leg and foot covering, discard as above, then remove the gloves and discard as above, and slowly pivot second foot into the designated clean area at proximity.

Perform HH and exit patient room or designated soiled area.

If respirator is used, put on a clean pair of gloves and remove respirator once outside the patient room

  • If disposable respirator is used, remove respirator by straps without touching its front and contaminating gloves.
  • Discard disposable respirator immediately after use into a designated no-touch biohazardous waste receptacle.
  • If reusable respirator is used, remove respirator carefully to avoid self-contamination. Removal of reusable respirators requires particular attention to detail and observed practice to ensure no contamination.
  • Place reusable respirator into appropriate receptacle for reprocessing.

Remove gloves

  • Remove gloves using the glove-to-glove/skin-to-skin technique.
    1. Grasp outside edge near the wrist and peel away, rolling the glove inside out.
    2. Reach under the glove on the other hand and peel away.
  • Discard immediately into a designated no-touch biohazardous waste receptacle.

Perform HH

Sequence if hazardous material suit used

Remove outer gloves

  • Outer gloves should be removed first.
  • Remove outer gloves by pulling on outside of gloves, while taking care not to contaminate inner gloves.
  • Discard gloves immediately into a designated no-touch biohazardous waste receptacle.

Remove apron (if used)

  • Remove apron, without contaminating self, then roll apron inside out.
  • Discard apron immediately after use into a designated no-touch biohazardous waste receptacle.

Remove hazardous material suit

  • Remove suit, by tilting head back to reach zipper or fasteners. Unzip or unfasten biohazardous material suit completely before rolling down and turning inside out.
  • Avoid self-contamination during removal process by ensuring that soiled inner gloves and outside of suit do not touch inner clothing or skin.
  • Discard disposable suit into a designated no-touch biohazardous waste receptacle.

Remove inner gloves

  • Remove gloves using the glove-to-glove/skin-to-skin technique.
    1. Grasp outside edge near the wrist and peel away, rolling the glove inside out.
    2. Reach under the glove on the other hand and peel away.
  • Discard immediately into a designated no-touch biohazardous waste receptacle.

Perform HH and put on a clean pair of gloves

Remove face shield (if used)

  • Remove face shield carefully without contaminating self (skin, hands or clothes).
  • Remove the face shield by tilting the head slightly forward, grabbing the rear strap and pulling it over the head, gently allowing the face shield to fall forward.
  • Discard disposable face shield immediately after use into a designated no-touch biohazardous waste receptacle.

Remove gloves as instructed above, discard into a designated no-touch biohazardous waste receptacle, perform HH and put on a clean pair of gloves

Remove head and neck coverings

  • Remove head and neck coverings without contaminating self by unfastening the coverings, and gently pulling coverings away from the face.
  • Discard head and neck coverings immediately after use into a designated no-touch biohazardous waste receptacle.

Remove gloves as instructed above, discard into a designated no-touch biohazardous waste receptacle, perform HH and put on a clean pair of gloves

Remove mask (if used)

  • Remove mask carefully without contaminating self (skin, hands or clothes).
  • Untie bottom tie then top tie, or grasp straps or ear loops of mask. Pull forwards off the head, bending forward to allow mask to fall way from face.
  • Discard mask immediately after use into a designated no-touch biohazardous waste receptacle.

Remove gloves as instructed above, discard into a designated no-touch biohazardous waste receptacle, perform HH and put on a clean pair of gloves

Remove eye goggles (if used)

  • Remove eye goggles carefully without contaminating self (skin, hands or clothes).
  • Remove the eye goggles by pulling gently on the straps of the goggles away from face.
  • Discard disposable eye goggles immediately after use into a designated no-touch biohazardous waste receptacle.

Remove gloves as instructed above, discard into a designated no-touch biohazardous waste receptacle, perform HH and put on a clean pair of gloves

Remove leg and foot coverings (if used)

  • While sitting down (on a swivel stool for example) in the designated soiled area, remove one leg and foot covering by first untying fastening. Slowly pivot clean foot into the designated clean area at proximity.
  • Discard disposable leg and foot covering into a designated no-touch biohazardous waste receptacle.
  • Remove the second leg and foot covering, discard as above, then remove the gloves and discard as above, and slowly pivot second foot into the designated clean area at proximity.

Perform HH and exit patient room or designated soiled area.

If respirator is used, put on a clean pair of gloves and remove respirator once outside the patient room.

  • If disposal respirator is used, remove respirator by straps without touching its front and contaminating gloves.
  • Discard disposable respirator immediately after use into a designated no-touch biohazardous waste receptacle.
  • If reusable respirator is used, remove respirator carefully to avoid self-contamination. Removal of reusable respirators requires particular attention to detail and observed practice to ensure no contamination.
  • Place reusable respirator into appropriate receptacle for reprocessing.

Remove gloves

  • Remove gloves using the glove-to-glove/skin-to-skin technique.
    1. Grasp outside edge near the wrist and peel away, rolling the glove inside out.
    2. Reach under the glove on the other hand and peel away.
  • Discard immediately into a designated no-touch biohazardous waste receptacle.

Perform HH

Placement and Accommodation

  • Place isolation sign on door.
  • Single room, private bathroom, door to remain closed.
  • AIIR to be used for AGMPs.
  • There is an area outside the EVD patient room where clean PPE is stored and where HCWs can put on PPE before entering the patient's room. Do not store potentially contaminated equipment, used PPE, or waste from the patient's room in this area. If waste must pass through this area, it must be properly contained.
  • Room that will allow monitoring of HCW by a trained monitor during HCW-patient interaction.
  • Only essential personnel with appropriate PPE to enter the patient room.
  • Monitor and maintain a log of all persons entering and exiting the patient room.
  • There is a clearly demarcated area in close proximity to the patient's room where HCWs can remove and discard their PPE.

Transport and Flow

  • Patient to remain in room unless medically necessary to leave.
  • Transfer of patients within the facility should be avoided unless medically required.
  • Prior to transfer, the most direct route to take should be chosen and closed off to avoid exposure of other individuals (e.g. HCWs, visitors, etc.).
  • When transfer or movement in healthcare facilities is necessary, the patient should be provided with a clean gown, clean bedclothes and bedding and drainage should be contained.
  • The patient should perform HH with assistance as necessary before leaving the room.
  • Transport staff should put on the recommended PPE to enter the patient room.
  • Soiled PPE should be removed prior to exiting the patient room or designated soiled area.
  • Clean PPE should be put on after leaving the patient room to transport the patient to area in case there is a need to handle the patient during transport and at transport destination.
  • The patient must be taken directly to the receiving area, free of other patients and HCWs who are not involved in the patient's care.
  • Personnel in the area to which the patient is to be transported must be informed of precautions to follow and instructed to see the patient immediately to reduce time outside of the patient room.

Handling of Sharps

  • Limit the use of needles and other sharps as much as possible. Safety engineered needles and needleless systems should be made available and used.
  • Used needles should never be recapped; used needles and other used single-use sharp items must be disposed of immediately into designated puncture-resistant containers that are easily accessible at the point-of-use.
  • Used needles and other sharp instruments should be handled with care to avoid injuries during disposal.
  • In the event of a percutaneous injury with an EVD-contaminated sharp, the trained monitor must advise the immediate manager/supervisor and occupational health services or delegate as well as public health, as per usual organizational protocol.
  • The HCW should initiate and obtain first aid as described in the Healthcare Workers section.

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 for specific instructions.
  • 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 virus 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 EVD, liaise with the provincial public health laboratory of your jurisdiction to coordinate with the National Microbiology Laboratory (NML) Operations Center Director (OCD) at 1-866-262-8433. 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 EVD must be aware that improper handling of these specimens may pose a risk to the health of laboratory personnel. Consult the "Interim biosafety guidelines for laboratories handling specimens from PUI for Ebola virus disease" before any testing occurs.
  • Notify the laboratory of the possible diagnosis before sending any specimens to the laboratory.
  • Wipe specimen containers with a disinfectant in the patient room prior to placing into a secure container for transport. Consult the "Interim biosafety guidelines for laboratories handling specimens from PUI for Ebola virus disease".
  • Do not send specimens in a pneumatic tube system.

Dedicated Equipment

  • Non-critical patient care equipment (disposable when possible) should be dedicated to the patient for single-patient use and labeled appropriately.
  • Non-critical reusable patient-care equipment (e.g., commode) should be dedicated to the use of one patient and cleaned and disinfected according to manufacturer/organizational policy before reuse with another patient.
  • Single-use devices should be used and discarded in a designated no-touch biohazardous waste receptacle after use.
  • The use of single-patient-use disposable bedpans is preferred over reusable bedpans and commodes for the patient unable to use a toilet.
  • Re-useable bedpans and commodes should be provided for single patient use and labeled appropriately.

Reprocessing (Cleaning, Disinfection and Sterilization of Medical Equipment)

  • Attention to appropriate cleaning and disinfection of medical equipment is important.
  • Semi-critical Glossary S and critical equipment is to be reprocessed according to usual organizational policies and procedures. No special measures are required.
  • For proper handling and disposal of items contaminated with blood or other body fluids of an infected person refer to Infection Prevention and Control Measures for the Management of Ebola Virus Disease-associated Waste and Linen in Canadian Healthcare Settings (pending).
  • In selecting disinfectants that are expected to inactivate Ebola virus on non-critical hard surfaces and medical devices, Health Canada recommends products with the following approved criteria:
    1. Registered in Canada with a Drug Identification Number
    2. Labeled as a "broad spectrum virucide" claim and/or acknowledge effective testing against any of: Adenovirus type 5, Bovine Parvovirus, Canine Parvovirus and Poliovirus type 1
  • Provide education, hands-on training, repeated practice, observation of ability to adhere to correct processes and procedures, and appropriate PPE to those responsible for reprocessing (decontamination, cleaning, disinfection and sterilization) reusable medical equipment.
  • Assign responsibility and accountability for reprocessing non-critical patient care equipment.
  • Non critical patient care equipment should be cleaned and disinfected according to a regular schedule and when visibly soiled.
  • The use of single-patient-use disposable items, such as bedpans and blood pressure cuffs, is preferred.

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 Glossary E.
  • Environmental cleaning staff should 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 drug identification number 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, 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.

Handling Bodies of Deceased Patients

  • Routine practices and contact precautions Glossary C should be used and this includes gloves, fluid-resistant or impermeable, long-sleeved, cuffed gown, fluid-resistant mask and face shield or eye goggles to protect against splashing and sprays of blood and body fluids.
  • 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 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 surface decontamination of the outer bag by removing visible soil on outer surfaces with a broad spectrum virucide disinfectant, 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.
  • Post-mortem examinations (if necessary) and human remains handling should be in accordance with federal and provincial/territorial regulations.

Handling Dishes and Cutlery

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

Waste and Linen Management

  • Patient bed linen should be changed regularly and when soiled, upon discontinuation of precautions and following patient discharge.
    1. Soiled linen should be placed in a designated no-touch biohazardous waste receptacle at the point-of-use.
    2. Soiled linen should be handled with minimum agitation to avoid contamination of air, surfaces and persons.
  • For further information on management of waste, including the disposal of urine, stool and emesis, and linen refer to the Infection Prevention and Control Measures for the Management of Ebola Virus Disease-associated Waste and Linen in Canadian Healthcare Settings (pending). The purpose of the guidance will be to provide IPC guidance to complement provincial/territorial public health efforts in establishing appropriate precautions for the safe management (handling, containment and transport) of waste, including urine, stool, and emesis, and linen contaminated or potentially contaminated with Ebola virus. The guidance is for the management of waste and linen generated from suspect (person under investigation) and confirmed EVD cases.

Education of Patients and Visitors

  • Patients, their visitors, families and their decision makers should be educated about the precautions being used, the duration of precautions, as well as the prevention of transmission of disease to others, with a particular focus on HH 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 infectious disease specialists, IPC program and Public Health.

Visitor Management

  • Avoid entry of visitors into the patient room
    1. Exceptions may be considered on a case by case basis for those who are essential for the patient's wellbeing.
  • Establish procedures for monitoring, managing and training visitors.
  • Visits should be scheduled and controlled to allow for:
    1. Screening for EVD (e.g., fever and other symptoms) before entering or upon arrival to the hospital.
    2. Evaluating risk to the health of the visitor and ability to comply with precautions.
    3. Providing instruction, before entry into the patient care area on hand hygiene, limiting surfaces touched, and use of PPE according to the current facility policy while in the patient's room.
    4. Visitor movement within the facility should be restricted to the patient care area and an immediately adjacent waiting area.

List of Acronyms

ABHR:
Alcohol based hand rub
AGMP:
Aerosol generating medical procedures
AIIR:
Airborne infection isolation room
CDC:
Centers for Disease Control and Prevention
ED:
Emergency Department
EVD:
Ebola virus disease
HCW:
Healthcare worker
HH:
Hand hygiene
IPC:
Infection prevention and control
NML:
National Microbiology Laboratory
OCD:
Operations Center Director
ORA:
Organizational risk assessment
PCR:
Polymerase chain reaction
PCRA:
Point-of-care risk assessment
PH:
Public Health
PPE:
Personal protective equipment
PUI:
Persons under investigation
RPAP:
Routine practices and additional precautions
VHF:
Viral Haemorrhagic Fever
WHO:
World Health Organization

Infection Prevention and Control Expert Working Group

  • Dr. Lynn Johnston, MD MSc FRCPC (Chair)
    Professor, Dalhousie University
    Division Chief, Infectious Diseases, Capital District Health Authority
    Halifax, NS
  • Molly Blake, RN BN MHS GNC(C) CIC
    Program Director, Infection Prevention & Control Program, Winnipeg Regional Health Authority
    Winnipeg, MB
  • Julie Carbonneau, RN
    Occupational Health Nurse, Public Service Occupational Health Program
    Health Canada, Quebec Region
  • Dr. Maureen Cividino, MD CCFP FCFP BScN DOHS CCBOM CIC
    Occupational Physician, St Joseph's Healthcare Hamilton, ON
    IPAC Physician, Public Health Ontario
  • Nan Cleator, RN CCHN(c) CVAA(c)
    National Practice Consultant
    Victorian Order of Nurses (VON) Canada
  • Dr. Joanne Embree, BSc MD MSc FRCPC
    Professor, University of Manitoba
    Pediatric Infectious Diseases, Winnipeg Regional Health Authority
    Winnipeg, MB
  • Della Gregoraschuk, BA RN BScN OHN(C)
    Corporate Occupational Health Advisor
    Health and Wellness Centre of Expertise
    Workplace Health & Safety, AHS - AB
  • Dr. Bonnie Henry, MD MPH FRCPC
    Associate Professor, University of British Columbia
    Deputy Provincial Health Officer, Ministry of Health - BC
    Victoria, BC
  • Dr. Matthew P. Muller, BSc MD PhD
    Assistant Professor, University of Toronto
    Associate Medical Director, Infection Prevention & Control, St. Michael's Hospital
    Toronto, ON
  • Patsy Rawding, RN BScN CIC
    Occupational Health, Infection Control and Nurse Educator Shannex
    Annapolis Valley NS
  • JoAnne Seglie, RN COHN-S
    Occupational Health Nurse, Occupational Health and Safety
    General Continuing Care Centre Covenant Health
    Edmonton, AB
  • Jane Stafford, RN BN CIC
    Consultant - Infection Prevention and Control Health Systems Standards and Performance, Department of Health Government of New Brunswick
  • Sandra Savery, RN BScN MScAdm
    Coordonnatrice en Prévention et Contrôle des Infections, CSSS des Sommets, Ste-Agathe-des-Monts, QC
  • Dr. Geoffrey Taylor, MD FRCPC FACP
    Professor, University of Alberta
    Medical Director, Infection Prevention and Control, University of Alberta Hospital/Mazankowski Alberta Heart Institute/Stollery Children's Hospital
    Edmonton, AB
  • Dr. Mary Vearncombe, MD FRCPC
    Associate Professor, University of Toronto
    Medical Director, Infection Prevention & Control, Sunnybrook Health Sciences Centre
    Toronto, ON
  • Catherine Walker, RN MScN CIC CCHC
    Director of Health Protection,
    Health Protection - ON
  • The Infection Prevention and Control Expert Working Group gratefully acknowledges input from subject matter expert at Médecins Sans Frontières, Dr. Tim Jagatic.

References

Public Health Agency of Canada:

  • Interim Guidance - Public Health Management of cases and contact of human illness associated with EVD http://www.phac-aspc.gc.ca/id-mi/vhf-fvh/cases-contacts-cas-eng.php
  • National Case Definition: Ebola Virus Disease EVD http://www.phac-aspc.gc.ca/id-mi/vhf-fvh/national-case-definition-nationale-cas-eng.php
  • Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings (2013) http://www.phac-aspc.gc.ca/nois-sinp/guide/summary-sommaire/tihs-tims-eng.php
  • Hand Hygiene Practices in Healthcare Settings (2013) http://publications.gc.ca/site/eng/430135/publication.html
  • Ebola virus disease http://healthycanadians.gc.ca/diseases-conditions-maladies-affections/disease-maladie/ebola/index-eng.php
  • Ebola Outbreak in West Africa: Travel Health Notice http://www.phac-aspc.gc.ca/tmp-pmv/notices-avis/index-eng.php
  • Ebola Virus Pathogen Safety Data Sheet http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/ebola-eng.php

Canada:

  • Canadian Critical Care Society, Canadian Association of Emergency Physicians, Association of Medical Microbiology and Infectious Diseases. Ebola Clinical Care Guidelines Report #2 – Updated October 28, 2014 http://www.ammi.ca/media/73235/Ebola%20Clinical%20Care%20Guidelines%20v2%2028%20Oct%202014.pdf

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

  • Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U. S Hospitals http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html
  • Centers for Disease Control and Prevention. Surveillance and Preparedness for Ebola Virus Disease - New York City, 2014. MMWR. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6341a5.htm?s_cid=mm6341a5_w

Public Health Ontario:

  • Viral Haemorrhagic Fever: Update for Clinicians (July 22, 2014) http://www.publichealthontario.ca/en/eRepository/VHF_Update_for_Clinicians_July_22_2014.pdf
  • Provincial Infectious Disease Advisory Committee (PIDAC) Best Practices for Environmental Cleaning for Prevention and Control of Infections In All Health Care Settings - 2nd edition http://www.publichealthontario.ca/en/eRepository/Best_Practices_Environmental_Cleaning_2012.pdf
  • PIDAC Routine Practices and Additional Precautions in All Health Care Settings, 3rd edition http://www.publichealthontario.ca/en/eRepository/RPAP_All_HealthCare_Settings_Eng2012.pdf
  • Environmental Cleaning Toolkit http://www.publichealthontario.ca/en/ServicesAndTools/Tools/Pages/Environmental_Cleaning_Toolkit.aspx
  • Infection Prevention and Control for Clinical Office Practice http://www.publichealthontario.ca/en/eRepository/IPAC_Clinical_Office_Practice_2013.pdf
  • Public Health Ontario. Algorithm for Assessment of Potential Ebola Virus Disease (EVD) in the Emergency Department. September 2, 2014 http://www.publichealthontario.ca/en/eRepository/EVD_algorithm_emergency_departments.pdf

World Health Organization:

  • Ebola disease: background and summary http://www.who.int/csr/don/2014_04_ebola/en/
  • Ebola virus disease http://www.who.int/mediacentre/factsheets/fs103/en/
  • Interim Infection Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola. WHO August 2014 http://www.who.int/csr/resources/who-ipc-guidance-ebolafinal-09082014.pdf
  • World Health Organization. Clinical management of patients with Viral Hemorrhagic Fever: A pocket guide for the front-line health worker; Interim emergency guidance- generic draft for West African adaptation. 2014 http://apps.who.int/iris/bitstream/10665/130883/2/WHO_HSE_PED_AIP_14.05.pdf

Footnotes

Footnote 1
Fowler RA et al. Caring for Critically Ill Patients with Ebola Virus Disease, Perspectives from West Africa. Am J Respir Crit Care Med 2014;190:733-737. Oct 1, 2014 http://www.atsjournals.org/doi/pdf/10.1164/rccm.201408-1514CP
Footnote 2
WHO Ebola Response Team. Ebola Virus Disease in West Africa -- The First 9 Months of the Epidemic and Forward Projections. N Engl J Med 2014;371:1481-1495. October 16, 2014. http://www.nejm.org/doi/pdf/10.1056/NEJMoa1411100