Date adopted: November 10, 2014
This Guidance Document is meant to provide assistance to travellers, including health care and humanitarian workers on how to comply with the Order entitled Minimizing the Risk of Exposure to Ebola Virus Disease in Canada Order (No.2) published in the Canada Gazette Part I on November 15, 2014. This guidance is also meant to provide information to the public, other levels of government, implicated stakeholders, partners and health care professionals so the Order is implemented in a transparent, fair, consistent, and effective manner. Updates will be issued as more information becomes available.
The Order sets out mandatory requirements for travellers arriving into Canada from Guinea, Liberia and Sierra Leone which are countries affected by the Ebola Virus Disease (EVD) with widespread transmission, through strengthening border measures under the Quarantine Act. This Guidance Document provides recommendations and more detail on implementation of the Order and the monitoring and movement of travellers arriving from these three countries with or without symptoms of EVD. This document should be read in conjunction with the accompanying Canada Gazette Notice Order in Council - Minimizing the Risk of Exposure to Ebola Virus Disease in Canada Order No.2 .
Isolation of the sick and quarantine with social distancing or restricted movement of people who have been exposed to a communicable disease before they develop symptoms are part of classic public health measures to control the spread of infectious diseases. While the terms "isolation" and "quarantine" are defined and used in specific ways by public health, for the purpose of this document, the terms "isolate or isolation" mean being separated from others and are used for both those contacts with or without symptoms.
The degree of social distancing or movement restriction depends upon the way in which the communicable disease is transmitted, how contagious it is, whether an infected person is contagious before symptoms arise, and also an assessment of the personal circumstances.
In the current EVD outbreak, it is estimated that about half of the people who contract EVD die as a result, with a range from 25% to 90% fatality in past outbreaks. Ebola is transmitted by direct contact with infected bodily fluids or an infected dead body. Airborne transmission has not been shown to occur among humans, nor does the epidemiology of disease transmission indicate that this has been occurring.
Transmission between individuals does not occur before symptoms arise; however, the incubation period i.e. the time between infection and onset of symptoms, varies from 2 to 21 days. A patient's infectiousness greatly increases during the course of the illness when they are symptomatic.
While fever and/or headache are the most common early symptoms of Ebola infection, fever or headache may each only be present in 85%-90% of cases as a first symptom(s), thus the presence of fever or other symptoms, such as fatigue or muscle ache needs to be monitored frequently (twice a day) during the possible 21-day incubation period, before a person can be declared uninfected.
When compatible symptoms develop, the person needs to be able to immediately notify public health authorities, so that transportation can quickly occur to the designated Ebola treatment centre using trained persons wearing personal protective equipment.
While infected individuals are unlikely to spread the virus at the early stages of their illness, if they are in contact with large numbers of people when they first become sick, public health officials would likely be required to conduct contact tracing to document the lack of transmission and assure the public they are safe. Thus a strategy to limit contacts, particularly on public transportation or in settings where there are large numbers of individuals for contact tracing, would be very prudent.
An exposure and clinical risk assessment conducted by public health authorities, as well as an assessment of personal circumstances, will inform what activities and/or restrictions are required as part of an individual management plan. For example, measures to reduce body contact and/or social mixing with other people may be put in place based on a risk assessment of the particular circumstances.
The seriousness of this severe and often fatal illness requires an abundance of precaution, recognising that coordinated public health efforts significantly and positively impact on its management.
The objective of this document is to further protect the health and safety of the public by striving to ensure that all travellers arriving to Canada from Guinea, Liberia and Sierra Leone are identified and monitored by public health authorities.
This document provides guidance on public health measures to minimize the risk of exposure to EVD in Canada and pertains to any traveller, including health care and humanitarian workers, arriving into Canada from Guinea, Liberia and Sierra Leone by any point of entry - air, land and sea.
Consistent with the Order, all travellers arriving in Canada must disclose to a Screening Officer at the point of entry if they have been in Guinea, Liberia or Sierra Leone in the previous 21 days. The Screening Officer refers all travellers, including health care and humanitarian workers, with a recent history of travel to Guinea, Liberia or Sierra Leone to a Quarantine Officer for detailed screening and temperature check.
The detailed screening will allow the Quarantine Officer to determine which public health measures are to be taken, as below. Travellers are required to answer questions asked by the Screening Officer and Quarantine Officer.
Consistent with the Order, ill travellers, including health care and humanitarian workers, with EVD symptoms will immediately be required to undergo a medical examination by a medical practitioner(s) an acute care facility where Ebola infection control is in place (an EVD designated hospital if possible). No onward travel is permitted unless as arranged by the Quarantine Officer to reach a designated hospital under appropriate infection control procedures. The Quarantine Officer will coordinate the transfer of the traveller with the province or the territory and local public health authorities.
After the medical examination:
Consistent with the Order, travellers from Ebola outbreak affected countries who do not have EVD symptoms as assessed by Quarantine Officers, will be required to report to the local or provincial/territorial (P/T) public health authority for continued monitoring or, if the local or P/T public health authorities are unable to monitor, then they will report to Public Health Agency of Canada. After the detailed screening by a Quarantine Officer, these travellers are placed into one of three categories, 1) Healthy Travellers with High Risk of EVD Exposure; 2) Healthy Health Care and Humanitarian Workers with Protected EVD Exposure; or, 3) Healthy Travellers with No Known EVD Exposure.
These are travellers, including health care and humanitarian workers, who do not have symptoms and who have had unprotected exposure to the Ebola virus (i.e. known EVD exposure or unprotected direct contact).
Mandatory measures and recommendations are outlined below.
These travellers are health care and humanitarian workers who do not have symptoms and have had protected exposure to the Ebola virus (i.e. no known EVD exposure and no unprotected direct EVD contact).
Mandatory measures and recommendations are outlined below.
These are travellers who do not have symptoms and have no known exposure to the Ebola virus.
Mandatory measures and recommendations are outlined below.
Travellers to Canada, for whom these measures apply, who fail to self-report or follow the directions provided by Quarantine Officers by virtue of the Order could be subject to arrest and/or may be subject to penalties under the Quarantine Act including fines and/or imprisonment.
The Order states that the 21-day period begins on the day on which the person enters Canada however, if a person can prove that since leaving Guinea, Liberia or Sierra Leone, but before entering Canada, they have been in a place other than Guinea, Liberia or Sierra Leone, then the 21-day period is reduced by the number of days that the person spent in that place.
Requests for information about this document can be directed to 1-800- O-Canada.
Active monitoring: The individual actively self-monitors and immediately reports if Ebola virus disease (EVD) symptoms develop. They take their own temperature and record the reading twice daily and report temperatures and EVD symptoms to the public health authority daily, or at the frequency established by the public health authority.
Communicable disease: Means a human disease that is caused by an infectious agent or a biological toxin and poses a risk of significant harm to public health, or a disease listed in the schedule of the Quarantine Act, and includes an infectious agent that causes a communicable disease. It is a human disease that can be passed from person to person.
Coordinated public health efforts: In Canada, responsibility for public health is a shared one between the federal, provincial and territorial levels of government as well as at the local level. For example, the Public Health Agency of Canada contributes to federal efforts to identify and reduce public health risk factors and to support national readiness for public health threats, including responding to a public health emergency. Provinces and territories have public health legislation, which generally addresses communicable diseases and notifications to public health officials. The local level includes clinicians, public health staff, primary care providers, hospitals, emergency rooms, laboratories, schools and other service providers and collectors of health-related data. Coordinated efforts also include those at the international level.
Designated hospital: A hospital or hospitals within each province or territory that will receive and care for patients with Ebola virus disease.
Detailed screening by a quarantine officer: A Quarantine Officer asks the traveller questions about symptoms of Ebola Virus Disease and possible exposure to EVD, and taking of the traveller's temperature. Based on the results of the detailed screening, the quarantine officer determines actions to be taken with the traveller as outlined in the Order.
Direct active monitoring: The responsible public health authority assumes responsibility for checking individuals for presence of Ebola virus disease symptoms, including fever through direct observation twice a day.
Ebola virus disease (EVD):
Entry point: Means a point designated by the Minister under section 9 of the Quarantine Act or a point where a customs office, within the meaning of subsection 2(1) of the Customs Act is located. It includes entry points into Canada by land, sea and air.
Medical examination: A medical examination is conducted by a medical practitioner and includes ascertaining the relevant medical history and the travel history of the person being examined, the conduct of a physical examination and any laboratory tests or radiographic or diagnostic tests that are required to make a determination of whether the person might have a communicable disease.
Medical practitioner: A person who is entitled to practise medicine in Canada by the laws of a province.
Public health measure: Includes the monitoring and restriction of movement of a person who either has a communicable disease or who might have a communicable disease in order to keep them away from others to prevent the disease from spreading.
Quarantine officers (QO): QO administer and enforce the federal Quarantine Act at the points of entry in Canada through the collaboration, networking and training of key partners. QO may conduct health assessments and direct travellers or conveyances to take other measures (including detention). They are designated by the Minister, and must be "qualified health practitioners". In practice, QOs are registered nurses employed by the Public Health Agency of Canada.
Screening officers (SO): SO are Canada Border Services Agency Officers who are designated as Screening Officers under the Quarantine Act. SO are often the first officers to assess a traveller. Screening is a preliminary review of the traveller's health to determine if there is a possibility that the traveller has a communicable disease.
Public Health Agency of Canada: Documents will be updated as necessary based on further scientific data and other new information and posted
Centers for Disease Control and Prevention (CDC), United States:
World Health Organization:
Drazen JM et al. Ebola and quarantine. NEJM 2014 (e-publication Oct 27, 2014)
WHO Ebola Response Team. Ebola virus disease in West Africa - the first 9 months of the epidemic and forward projections. NEJM 2014 (e-publication Oct 16, 2014)