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Guidance Document - Minimizing the Risk of Exposure to Ebola Virus Disease in Canada through Strengthened Quarantine Measures

Date adopted: November 10, 2014

Foreword

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 .

1. Introduction

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.

1.1 Objective

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.

1.2 Scope

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.

2. Guidance

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.

2.1 Measures for Ill Travellers (WITH symptoms)

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:

  • Travellers determined to have a possible or probable diagnosis of EVD will be isolated in hospital until discharge.
  • Travellers with a diagnosis other than Ebola who do not require hospitalization, will subsequently be required to report to a 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. Those who have had known EVD exposure or unprotected direct contact with a person showing symptoms of EVD will be required to isolate themselves without delay (see 2.2.1).

2.2 Measures for Healthy Travellers (NO symptoms)

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.

2.2.1 Healthy Travellers with High Risk of 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).

  • These travellers are those who have had direct contact with a person with EVD and/or their bodily fluids, their dead body, or any another known source of exposure to the Ebola virus. Unprotected exposure also includes a breach of personal protective equipment and a needle stick injury. The number of these travellers should be very few as the vast majority of these travellers would have been monitored prior to departure from an affected country or prior to arrival to Canada.

Mandatory measures and recommendations are outlined below.

  • Consistent with the Order, report immediately to the public health authority in the manner specified by the Quarantine Officer, and during the 21-day period that effectively begins on the day the person leaves an affected country, these travellers are required to:
    • Self-isolate without delay and remain in isolation from other people for up to 21 days depending on the date of departure from the Ebola affected area as instructed by the public health authority. Remaining in isolation from other people means the following: avoiding onward travel on public transportation from the point of entry, such as a connecting flight or bus; avoiding any other public transportation; avoiding public places; not going to work; avoiding crowds such as at shopping malls, medical clinics, grocery stores, funerals, and religious congregations; and, avoiding physical contact with others. Living with other people, including family members or room-mates, is not permitted for the duration.
    • Measure and record their body temperature twice a day and report it to the public health authority in the time and manner specified.
    • Answer questions asked by the public health authority regarding body temperatures or other EVD symptoms.
    • Report any travel intentions to the public health authority.
    • Immediately report any symptoms of EVD to the public health authority and follow any instructions provided to them.
  • The following measures are recommended during the 21-day period:
    • The location for self-isolation should be near a designated hospital, and when possible, be within a 1-hour drive in order to facilitate rapid transfer and should be confirmed with the public health authority.
    • If unable to self-isolate at home, the traveller may be isolated in an alternative facility, such as that provided by a non-government organisation or arranged for federally.
    • While the traveller is required to monitor EVD symptoms as above, how this is achieved is at the discretion of the public health authority. Direct active monitoring is recommended where the traveller is to be monitored directly by a public health authority visiting two times a day checking for EVD symptoms, including temperatures.

2.2.2 Healthy Health Care and Humanitarian Workers with Protected EVD Exposure

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).

  • This group of health care or aid workers has had direct contact with a person with EVD and/or their bodily fluids, their dead body, or any another source of exposure to the Ebola virus and have taken appropriate precautions by wearing personal protective equipment.

Mandatory measures and recommendations are outlined below.

  • Consistent with the Order, report to the public health authority in the manner specified by the Quarantine Officer, and during the 21-day period that effectively begins on the day the person leaves an affected country, these travellers are required to:
    • Measure and record their body temperature twice a day and report it to the public health authority in the time and manner specified.
    • Answer questions asked by the public health authority regarding body temperatures or other EVD symptoms.
    • Report any travel intentions to the public health authority.
    • Immediately report any symptoms of EVD to the public health authority and follow any instructions provided to them.
  • The following measures are recommended during the 21-day period:
    • Onward travel from the point of entry to a final destination by way of public transportation, such as a connecting flight or bus, should be discussed with the Quarantine Officer. The onward travel should be reviewed on a case by case basis with the public health authority.
    • Arrival at the final destination should be within 12 hours of the last Quarantine Officer check, with no more than 3 hours spent on public transportation.
    • The location of the final destination should be near an acute care facility where Ebola infection control is in place (an EVD designated hospital if possible) or where transport to one can be done in a timely and appropriate manner and should be confirmed with the public health authority.
    • While requirements to monitor EVD symptoms are included above, how this is achieved is at the discretion of the public health authority. In these cases, active monitoring should be sufficient where the traveller monitors and records their own EVD symptoms twice a day including temperatures, and reports them daily to a public health authority.
    • Avoid using public transportation and avoid crowds such as at shopping malls, medical clinics, grocery stores, funerals, and religious congregations.
    • Avoid providing direct patient care.
    • Avoid direct person-to-person touching. A distance from others of at least 3 feet (1 meter) should be maintained.
    • On a case by case basis, consider living arrangements, work, and leisure activities and how they can be done while minimizing direct contact.

2.2.3 Healthy Travellers with No Known EVD Exposure

These are travellers who do not have symptoms and have no known exposure to the Ebola virus.

  • These are travellers, including humanitarian workers, who have had no direct contact with EVD and/or their bodily fluids, their dead body, or any another source of exposure to Ebola.

Mandatory measures and recommendations are outlined below.

  • Consistent with the Order, report to the public health authority in the manner specified by the Quarantine Officer, and during the 21-day period that effectively begins on the day the person leaves an affected country, these travellers are required to:
    • Measure and record their body temperature twice a day and report it to the public health authority in the time and manner specified.
    • Answer questions asked by the public health authority regarding body temperatures or other EVD symptoms.
    • Report any travel intentions to the public health authority.
    • Immediately report any symptoms of EVD to the public health authority and follow any instructions provided to them.
  • The following measures are recommended during the 21-day period:
    • There should be no restrictions on onward travel from the point of entry to a final destination by way of public transportation, such as a connecting flight or bus.
    • The location of the final destination should be near an acute care facility where Ebola infection control is in place (an EVD designated hospital if possible) or where transport to one can be done in a timely and appropriate manner.
    • Activities such as attendance at work, going out in public places, and use of public transportation should be able to continue, unless otherwise instructed by the public health authority.
    • While requirements to monitor EVD symptoms are included above, how this is achieved is at the discretion of the public health authority. In these cases, active monitoring should be sufficient where the traveller monitors and records their own EVD symptoms twice a day including temperatures, and reports at the frequency specified by the public health authority.

3. Compliance

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.

4. Reduction of the 21-day period

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.

5. Contact Information

Requests for information about this document can be directed to 1-800- O-Canada.

6. Glossary of Terms

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):

  • Description: Ebola virus disease (EVD), formerly known as Ebola haemorrhagic fever, is a severe, often fatal illness in humans.
  • Symptoms: The incubation period, that is, the time interval from infection with the virus to onset of symptoms is 2 to 21 days. People are not infectious until they develop symptoms. Ebola virus disease symptoms include fever greater than or equal to 38 degrees Celsius, generally feeling unwell, chills, severe headache, red eyes, sore throat, abdominal pain, vomiting, diarrhea, rash, muscle pain and weakness and unexplained bleeding that is not related to injury.
  • Transmission: Ebola virus is transmitted by direct contact with infected animals and the blood or other body fluids (e.g. stool, urine, saliva, semen) of an infected individual or corpse, and indirectly through contact with surfaces and instruments (e.g. needles) contaminated with infected blood or body fluids. Ebola virus is not spread from human to human through airborne transmission.

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.

7. Appendix A: Other Guidance Documents

Public Health Agency of Canada: Documents will be updated as necessary based on further scientific data and other new information and posted

Health Canada:

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

Australia:

World Health Organization:

8. Key References

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)