Description of the Algorithm for Screening and Assessment for Ebola Virus Disease (EVD) in Persons Presenting to Healthcare Settings

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 algorithm describes the process for screening and assessment for Ebola Virus Disease in persons presenting to healthcare settings.

Stage 1: Initial assessment

This is a decisive point. To start with, the following questions should be asked: "Within the previous 21 days, has the person lived in or travelled to a country with widespread and intense Ebola transmission OR is the person known to have had contact with a person under investigation / suspect or confirmed case of Ebola Virus Disease (including through burial); contact with laboratory specimens from suspect or confirmed Ebola Virus Disease cases; contact with primates, bats or wild animal bush meat from affected countries or regions?

Note that Guinea, Liberia, and Sierra Leone were affected by the outbreak of Ebola Virus Disease. For currently affected areas, refer to: WHO Current Situation.

"Suspect" refers to person under investigation as described in National Case Definition: Ebola Virus Disease.

Stage 2:

If the answer to the questions in stage 1 is NO, there is no risk of Ebola Virus Disease. Therefore, proceed with usual assessment and implement infection prevention and control measures as per Routine Practices and Additional Precautions. Refer to Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings.

Stage 3:

This is a decisive point. If the answer to any question in stage 1 is YES, the following question should be asked: "Does the patient have a fever of 38°C or more OR at least one of the other Ebola Virus Disease compatible symptoms?" Ebola Virus Disease-compatible symptoms include subjective fever, malaise, myalgia, headache, arthralgia, fatigue, loss of appetite, conjunctival redness, sore throat, chest pain, abdominal pain, nausea, vomiting, diarrhoea that can be bloody, haemorrhage or erythematous maculopapular rash on the trunk.

Stage 4:

If the answer to the question in stage 3 is YES, the person is under investigation or considered an Ebola Virus Disease suspect, thus these recommendations apply:

• Have patient perform hand hygiene and adhere to respiratory hygiene (i.e., put on mask).
• Initiate Infection Prevention and Control measures including contact and droplet precautions. Refer to the document Infection Prevention and Control Expert Working Group: Advice on Infection Prevention and Control Measures for Ebola Virus Disease in Healthcare Settings.
• 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 health care workers only and minimize their exposure.
• Have a Trained Monitor keep log of health care workers entering patient's room. Refer to the document Infection Prevention and Control Expert Working Group: Advice on Infection Prevention and Control Measures for Ebola Virus Disease in Healthcare Settings.
• IMMEDIATELY notify your local Public Health authorities for guidance on further action.
• Apply appropriate precautions for safe management of potentially contaminated waste or linen. Refer to the document Infection Prevention and Control Expert Working Group: Advice on the Management of Ebola Virus Disease-associated Waste in Canadian Healthcare Settings.
• For Public Health follow-up, record the names of health care workers and other people who may have had unprotected exposure to patient or patient's blood and body fluids. Refer to the guidance Public Health Management of Cases and Contacts of Human Illness Associated with Ebola Virus Disease.

Stage 5:

If the answer to the question in stage 3 is NO, proceed with usual assessment and implement infection prevention and control measures as per Routine Practices and Additional Precautions. Refer to Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings.

Notify Public Health authorities.

Stage 6:

This is a decisive point. Ask the question: "Does patient require hospitalization for reasons unrelated to Ebola Virus Disease?"

Stage 7:

If the answer to the question in stage 6 is NO, these recommendations apply:

• Contact your public health authorities for guidance on the next monitoring steps for 21 days after the last exposure or travel. Refer to Public Health Management of Cases and Contacts of Human Illness Associated with Ebola Virus Disease.
• Public Health should be satisfied with the patient's status and the arrangements for monitoring before the patient leaves the facility.

Stage 8:

If the answer to the question in stage 6 is YES, these recommendations apply:

• Advise Infection Prevention and Control, Occupational Health and Safety, and Infectious Disease on admission.
• Monitor and record temperature and other Ebola Virus Disease-compatible symptoms at least twice daily for 21 days after the last exposure or travel.
• Inform Public Health of outcome of monitoring.
• Notify Public Health if patient is to be discharged prior to the end of 21 day monitoring period.

Stage 9:

If a fever or other Ebola Virus Disease symptoms develop within 21 days of the last exposure or travel, consider as person under investigation or as suspect for Ebola Virus Disease. The decision making pathway continues to Stage 4.

Stage 10:

If the patient is in an ambulatory care setting (outside of an acute care facility) at stage 4, these recommendations apply:

• Do not perform any interventions or procedures that may put healthcare workers in direct contact with patient's blood or body fluids. If healthcare workers must have direct patient contact, appropriate personal protective equipment should be used as per Table 3 or 4 of the Infection Prevention and Control Advice Document. Refer to Infection Prevention and Control Expert Working Group: Advice on Infection Prevention and Control Measures for Ebola Virus Disease in Healthcare Settings.
• Note that recommended personal protective equipment for contact and droplet precautions for Ebola Virus Disease include (as per Table 3 in Infection Prevention and Control Advice document): gloves, fluid-resistant or impermeable gown, fluid-resistant mask (respirators for aerosol generating medical procedures) with eye goggles or face shield. Head and neck coverings, and foot and leg coverings are not required. If there is a risk of exposure to blood or other body fluids, enhanced personal protective equipment should be used.
• Note that recommendations for enhanced personal protective equipment for Ebola Virus Disease include (as per Table 4 in Infection Prevention and Control Advice document): double gloves, fluid-resistant or impermeable body coverings including foot and leg coverings, head and neck coverings, gown, or hazardous material suit, fluid-impermeable apron, fluid-resistant mask (respirators for aerosol generating medical procedures) with eye goggles or face shield. All exposed skin and clothing are covered.
• Contact local Public Health or other designated authorities for guidance on patient transfer to designated Ebola Virus Disease hospital; adhere to current Advice document, Infection Prevention and Control Expert Working Group: Advice on Infection Prevention and Control Measures for Ebola Virus Disease in Healthcare Settings.
• Contact local Public Health or other designated authorities for instructions on cleaning the environment.
• A person under investigation (or considered a suspect case) seeking care by phone should be advised to remain in place. Person should be advised to minimize exposure of body fluids to household members or others and given phone number to notify Public Health. The facility should also notify Public Health. If this is a medical emergency, both the ambulatory care facility and patient should call emergency medical services, informing them of the patient's Ebola risk factors so that emergency medical services personnel arrive in appropriate personal protective equipment.

Stage 11:

If the patient is in a hospital setting, these recommendations apply:

• Notify Infection Prevention and Control, Occupational Health and Safety, Infectious Disease, Medical Microbiology, and other relevant personnel.
• Perform a point-of-care risk assessment to determine risk of exposure to the patient's blood or body fluids (that is: blood, stool, emesis, urine, saliva and sweat). A point-of-care risk assessment is performed by health care workers to determine the appropriate infection prevention and control measures (e.g., enhanced personal protective equipment) to protect the health care workers 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).
• Inform your facility's laboratory of person under investigation/suspect for Ebola Virus Disease and obtain specific instructions prior to collecting specimens for analysis. Initiate protocols for Ebola Virus Disease testing and testing for alternative or co-existing infections (e.g., malaria and typhoid fever).
• If Ebola Virus Disease is confirmed, contact local Public Health authorities for guidance on patient transport to a designated Ebola Virus Disease hospital.
• Have a Trained Monitor observe Health Care Workers' Personal Protective Equipment use and patient care. Refer to Infection Prevention and Control Expert Working Group: Advice on Infection Prevention Control Measures for Ebola Virus Disease in Healthcare Settings.
• If test for Ebola Virus Disease is negative, notify Public Health if patient is to be discharged prior to end of 21 day monitoring period.
• Where applicable, the hospital should notify the Quarantine Officer of Ebola Virus Disease test results prior to discharge of patient. Persons returning from affected countries and sent to hospital by a Quarantine Officer from the point-of-entry are required to comply with the Order entitled Minimizing the Risk of Ebola Virus Disease in Canada Order (No. 2). The Ebola Virus Disease test results for such patients should be reported to the Quarantine Officer. If the patient is to be discharged prior to the end of the 21 day monitoring period, the patient should contact the Quarantine Officer to receive follow up instructions before leaving the hospital. Refer to Guidance Document - Minimizing the Risk of Exposure to Ebola Virus Disease in Canada through Strengthened Quarantine Measures for mandatory requirements set out in this Order.

Stage 12:

If the point-of-care risk assessment indicates there is a higher risk of exposure to blood and/or body fluids, these recommendations apply:

• Continue with contact and droplet precautions.
• Healthcare workers to use enhanced personal protective equipment as outlined in Table 4 of the Infection Prevention and Control Advice Document. Recommendations for enhanced Personal Protective Equipment for Ebola Virus Disease include (as per Table 4 in Infection Prevention Control Advice document): double gloves, fluid-resistant or impermeable body coverings including foot and leg coverings, head and neck coverings, gown, or hazardous material suit, fluid-impermeable apron, fluid-resistant mask (respirators for aerosol generating medical procedures) with eye goggles or face shield. All exposed skin and clothing are covered.
• Aerosol generating medical procedures should not be performed unless absolutely necessary (e.g., intubation) and strategies to reduce aerosol generation should be implemented.
• Use airborne precautions for aerosol generating medical procedures.

Stage 13

If the point-of-care risk assessment indicates there is a lower risk of exposure to blood and body fluids, these recommendations apply:

• Continue with contact and droplet precautions.
• Healthcare workers to use personal protective equipment as outlined in Table 3 of Infection Prevention and Control Advice document. Recommended Personal Protective Equipment for contact and droplet precautions for Ebola Virus Disease include (as per Table 3 in Infection Prevention Control Advice document): gloves, fluid-resistant or impermeable gown, fluid-resistant mask (respirators for aerosol generating medical procedures) with eye goggles or face shield. Head and neck coverings, and foot and leg coverings are not required. Note: If there is a risk of exposure to blood or other body fluids, enhanced Personal Protective Equipment should be used.
• Aerosol generating medical procedures should not be performed unless absolutely necessary (e.g., intubation) and strategies to reduce aerosol generation should be implemented.
• Use airborne precautions for aerosol generating medical procedures.