These control should always be read together with the NSW Health Guideline (GL2016_002) NSW Contingency Plan for Viral Haemorrhagic Fevers.
Public health priority: Urgent. Ebola virus disease (EVD) is subject to Commonwealth Biosecurity legislation and is nationally notifiable.
PHU response time: Respond to patients under investigation, suspected case and confirmed cases immediately. Enter suspected and confirmed cases on NCIMS within 1 working day.
Case management: Immediately investigate all notified cases (suspect, probable or confirmed).
Contact management: Identify and follow-up contacts of probable or confirmed cases (and suspect cases, depending on patient risk assessment and particular circumstances) from the onset of symptoms in the case.
These control guidelines are part of the Series of National Guidelines (SoNG) which have been developed by the Communicable Disease Network Australia and noted by the Australian Health Protection Principal Committee (AHPPC). The SoNG's purpose is to provide nationally consistent guidance to public health units (PHUs) in responding to a notifiable disease event.
These control guidelines have been slightly modified for use by NSW Public Health Units. For the original version see the Australian Department of Health Series of National Guidelines. Last updated 21 August 2018.
This guidelines are specifically for responding to Ebola Virus Disease (EVD), but would also be relevant for responding to a suspected/confirmed case of Marburg haemorrhagic fever.
It is not directly applicable for Lassa fever, or for vector-borne viral haemorrhagic fevers (VHFs) such as Crimean Congo haemorrhagic fever (CCHF) or Rift Valley fever (RVF).
These guidelines form the national minimum standard for infection control for EVD, which is based on the latest available evidence. Individual organisations may develop policies or institute practices that exceed the national minimum standard. It should be noted that training and procedures are required to use any additional personal protective equipment (PPE) safely.
Urgent. EVD is a Listed Human Disease under the Biosecurity Act 2015 and is a listed human disease as viral haemorrhagic fever under the National Health Security Act 2007.
All travellers who arrive in Australia with clinical and epidemiological evidence that suggests the possibility of having contracted a VHF including EVD should be immediately notified to the public health unit (PHU) in that state or territory.
If a suspected case is notified from an international border, decisions concerning case and contact management, including assessment, transport, and isolation will be made by the jurisdictional Chief Human Biosecurity Officer (CHBO) or delegated by the CHBO to a Human Biosecurity Officer (HBO).
A clinical and exposure risk assessment must be conducted for suspected cases in consultation with the CHBO and relevant infectious diseases service using the EVD case definition (Section 7) and the patient assessment flow chart (Appendix 4).
The outcome of the risk assessment will determine whether the person under investigation requires laboratory testing for EVD.
In NSW, EVD testing should only be conducted following advice from an ID physician, PHU, the local laboratory, and the Clinical Microbiologist on call at the CIDMLS-ICPMR laboratory located at Westmead Hospital where EVD testing is conducted. See the patient assessment flow chart (Appendix 4) for contact details.
In NSW, most suspected EVD cases requiring EVD testing will be transferred to one of the two designated hospitals for Viral Haemorrhagic Fever cases (Westmead Hospital and Children's Hospital Westmead) as soon as possible. This means that for most cases, specimen collection for EVD testing can be conducted after transfer of the patient.
Where tests for VHF have been authorised, routine haematology and other tests should be deferred if possible without compromising patient care until the EVD result is available since blood is highly infectious.
In NSW, CIDMLS-ICPMR will coordinate referral of positive EVD samples to the national high security laboratory at VIDRL in Victoria for confirmation.
Refer to Section 8 – Laboratory Testing for more information.
Public health authorities should identify all contacts of suspect, probable or confirmed cases (depending on patient risk assessment and particular circumstances) from the time of onset of symptoms in the case. Refer to Section 11 - Contact Management for more information.
Contact tracing should focus on:
Disinfection and environmental decontamination are key components to control EVD. Cleaning and environmental decontamination is described in Section 10 and further detail is provided in Appendices 10 and 13.
EVD is caused by infection with Ebola viruses which belongs to the family Filoviridae, which also contains the Marburg virus. Six species (1-3) of the genus Ebolavirus have been identified:
Genus: Ebolavirus
The Zaire, Bundibugyo and Sudan viruses have been associated with large outbreaks in humans in Africa. Reston virus causes asymptomatic infections in humans, while Taï Forest viruses have not been associated with human outbreaks. The new species Bombali virus has not yet been identified in humans but could still pose a health risk (2).
Fruit bats of the Pteropodidae family are considered to be a likely natural host of the Ebola virus, with sporadic disease and outbreaks amongst other species such as chimpanzees, gorillas, monkeys, forest antelope and porcupines occurring from time-to-time (2, 4).
Ebola virus can be transmitted person-to-person via direct contact (through mucous membranes or broken skin) with (5):
Ebola virus does not spread through air or water or in general by food. However, in Africa, infection has been documented through the handling of infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines (12).
From two to 21 days; most commonly eight to 10 days.
People with EVD are not infectious until they develop symptoms. People are infectious as long as Ebola virus persists in their blood and secretions (13). The infectivity is low at the onset of symptoms, and increases as symptoms worsen and as bodily fluid secretions increase (i.e. during the acute period of illness). For example, a patient with profuse vomiting and diarrhoea is more infectious than a patient with a fever only. Infectivity is highest at the point of death and after death.
The period of risk for transmission through sexual contact after clinical recovery cannot currently be defined, and as a precaution, should be considered to continue indefinitely until further information is available. Ebola virus has been isolated from semen 82 days after onset (10); while a case of possible sexual transmission has been described where the contact occurred 179 days after likely onset (11).
Following recovery from EVD, the risk of infectivity from patients with persistent infection is unknown but appears to be low and is likely to decrease over time (14). The virus may persist for several months in immunologically protected sites (e.g. spinal or intraocular fluid and the testes) for an unknown length of time. Invasive procedures involving those sites in a person who has recovered from EVD will require a risk assessment for potential exposure.
The onset of symptoms is sudden and includes fever, myalgia, fatigue and headache. The next stage may include symptoms that are gastrointestinal (vomiting, diarrhoea), neurological (headaches, confusion), vascular, cutaneous (maculo-papular rash), and respiratory (sore throat, cough) with prostration. Cases may develop a profound electrolyte disturbance, a septic shock-like syndrome, and progress to multi-organ failure, sometimes accompanied by profuse internal and external bleeding.
The case-fatality rate (CFR) for the Zaire strain of Ebola Virus is estimated to be between 60% - 90%, followed by the Sudan virus (40-60%) (1). The CFR may be lower for other Ebola virus strains (15,16). Variability in reported case-fatality rates probably reflects viral strain, host factors and access to, and standards of clinical care (17).
Survivors report a range of sequelae described as post Ebola syndrome. The syndrome includes musculoskeletal pain, headaches and ocular problems (18). Late onset meningoencephalitis, memory loss and mental health disorders have also been reported (14).
Healthcare workers (HCW) and care givers in close contact with Ebola patients are at the highest risk of acquiring the disease as they are likely to come in contact with infected blood and bodily fluids. The risk of Ebola infections increases in resource poor settings with inadequate infection control.
People who are living in or travelling to affected areas of Africa may be at risk of infection; however, this risk is extremely low unless there has been direct exposure to the bodily fluids of an infected person (including unprotected sexual contact with confirmed cases up to three months after they have recovered), or an infected animal (alive or dead).
EVD was first recognised in 1976 in two simultaneous outbreaks, in Nzara, Sudan, and in Yambuku, Democratic Republic of Congo. As of 21 August 2018, there had been 37 reported outbreaks of EVD in humans with more than 31,000 cases, including over 12,000 cases documented as fatal, and an average case-fatality rate of 50 % (19). The largest outbreak to date was first reported in March 2014 in West Africa (involving the neighbouring countries Guinea, Liberia and Sierra Leone, Nigeria, the United States (US) and Mali) (20). The total number of reported cases was about 28,616 (21). World Health Organization (WHO) declared the last of the countries affected, Liberia, to be Ebola-free by June 2016 (22).
EVD outbreaks in humans have emerged periodically in several African countries (the Congo, Democratic Republic of Congo, Uganda, South Sudan and Gabon, Sierra Leone, Liberia, Guinea, Mali, Nigeria and a single case in Ivory Coast). Two laboratory contamination incidents in Russia, one in England and import-related cases in South Africa, Italy, Spain and the United States have also been implicated to the EVD outbreaks outside Africa (23).
There have also been a number of incidents involving Ebola Reston virus in animals, but no symptomatic human cases (24, 25).
With a very high case fatality rate (up to 90% in some outbreaks) and potential for large outbreaks that are difficult to control in resource poor settings, an outbreak of EVD is a public health emergency, with effective control requiring the co-operation of all sectors of the community in-country and the involvement of international agencies.
The significance of EVD to public health in Australia is much lower; with a low risk of imported cases, and even lower risk of spread in the event of an imported case. However, a single case in Australia would require an urgent public health response and would be treated as a communicable disease incident of national significance (CDINS), with considerable community and media interest. Declaration of a CDINS by Australia’s Chief Medical Officer (CMO) may trigger escalation through the stages of the Emergency Response Plan for Communicable Disease Incidents of National Significance (National CDPLAN). Escalation through the stages of the National CDPLAN may also be considered.
The risk of transmission in healthcare settings can be significantly reduced through the use of appropriate infection control precautions and environmental cleaning.
Travel restrictions are not routinely recommended for control of EVD, but it is recommended that travellers to countries where EVD occurs avoid areas where outbreaks are occurring.
People travelling in countries affected by EVD should maintain good hygiene practices. Travellers should avoid direct exposure to the body fluids of an infected person or animal (alive or dead), including avoiding the consumption of ‘bushmeat’. Travellers should avoid unprotected sexual contact with EVD cases up to three months after they have recovered.
As of mid-2018, there is no routine vaccination for the Ebola virus. During the end stages of the 2014-16 West African Ebola virus outbreak, experimental vaccines that had previously been developed were trialled for potential use in emergency situations and at-risk populations, with some evidence of efficacy and safety (26).
These experimental vaccines are not yet widely available and are not for general use. The WHO Strategic Advisory Group of Experts on immunization reviewed the candidate vaccines in June 2017, and recommended that the candidate vaccine rVSV-ZEBOV should be deployed in the context of an Ebola outbreak, via a ring vaccination strategy that includes vaccination of contacts, contacts of contacts, as well as local and international healthcare and frontline workers in the affected areas and areas that may be at risk from the expansion of the outbreak (27).
During the Ebola virus outbreaks in the Democratic Republic of Congo in 2018, ring vaccination of contacts of confirmed cases and contacts of contacts were undertaken using rVSV-ZEBOV (28)
Suspected, probable and confirmed cases of EVD infection should be entered onto NCIMS within one working day of notification/report. For surveillance purposes, only probable and confirmed cases are submitted to NNDSS.
In NSW, PHUs should immediately notify the Communicable Diseases Branch of suspected, probable and confirmed cases. Provide the case’s date of birth, sex, place of residence, indigenous status, date of onset, travel history, laboratory results, clinical status, likely place of acquisition, and follow-up action taken.
The Communicable Diseases Branch will immediately notify suspected, probable and confirmed EVD cases to the National Incident Room by telephone 02 6289 3030 or email health.ops@health.gov.au.
The case definition may have been updated since the publication of this guideline. Please check the case definitions for the latest version
Requires clinical evidence and limited epidemiological evidence.
Note: If a risk assessment determines that a person under investigation should be tested for Ebola virus, the person should be managed as a suspected case from that point forward regardless of clinical and epidemiological evidence.
Requires clinical evidence and epidemiological evidence.
Requires clinical evidence and epidemiological evidence and laboratory suggestive evidence of EVD.
Requires laboratory definitive evidence only.
For surveillance purposes, only probable and confirmed cases are submitted to the National Notifiable Diseases Surveillance System (NNDSS).
Requires fever of ≥38equires fever of ≥38oC. Additional symptoms such as unexplained haemorrhage or bruising severe headache, muscle pain, marked vomiting, marked diarrhoea, abdominal pain should also be considered.
Requires only travel to an EVD affected area (country/region) in the 21 days prior to onset.
Requires a lower risk exposure or higher risk exposure as defined below in the 21 days prior to onset.
Note: The presence of higher versus lower risk exposures, and the patient’s clinical condition may influence decisions about the need to transfer the patient to a designated EVD treatment hospital.
Note: Exposure to an EVD case in an Australian setting would require the case is probable or confirmed EVD according to laboratory criteria.
Includes:
Requires confirmation of EVD infection by VIDRL, Melbourne*, or CDC, Atlanta, or NIV, Johannesburg, through:
* The first case in any outbreak in Australia will also be confirmed by CDC, Atlanta or NIV, Johannesburg.
If a risk assessment determines that a person under investigation should be tested for Ebola virus, the person should be managed as a suspected case from that point forward regardless of clinical and epidemiological evidence.
To organise testing of a suspected case, the treating clinicians should contact their jurisdictional public health reference laboratory (in NSW, the CIDMLS-ICPMR laboratory service) for advice on specimen type, collection and transport. Treating clinicians should:
Appendix 4 (EVD Patient assessment flow chart) provides guidance on assessing the risk and deciding whether to test for Ebola virus. A risk assessment as per the EVD Patient Assessment Flow Chart should be conducted in liaison with the CHBO and an infectious diseases specialist.
In NSW, most suspected EVD cases requiring EVD testing will be transferred to one of the two designated hospitals for Viral Haemorrhagic Fever cases (Westmead Hospital and Children's Hospital Westmead) as soon as possible.
Testing for EVD in Australia is conducted at the National High Security Quarantine Laboratory (NHQSL) at VIDRL. In some jurisdictions facilities exist for the preliminary testing of samples for Ebola virus (NSW, QLD). Where preliminary testing is to be conducted at these facilities, samples should be sent to VIDRL from the jurisdictional public health laboratory for confirmatory testing.
Telephone contact with the VIDRL on-call microbiologist is essential before any specimen referral. The VIDRL on-call microbiologist can be contacted on mobile 0438 599 437. In case of difficulty back-up is provided by the VIDRL on-call laboratory manager (0438 599 439), and the Royal Melbourne Hospital Switchboard (03 9342 7000).
The primary diagnostic method is detection of Ebola virus by PCR in blood. PCR on a throat swab or urine may also be used and serology is also available.
The essential specimen for virus detection is venous blood. Blood (in EDTA tubes), throat swabs and possibly urine should be collected as per the National High Security Laboratory guidelines for management of human quarantinable viral haemorrhagic fevers (29).
Appropriate precautions must be used when collecting blood, urine or throat swab specimens. Infection control precautions are the same as those recommended for patient care, noting the particular recommendations for aerosol-generating procedures (see Section 9 - Case management, Isolation and Restriction, and Appendix 9).
Where tests for Ebola virus have been ordered, routine haematology and other tests should be minimised since blood is highly infectious. If other tests are required for the immediate management of the patient, these should only be performed in close collaboration with specialist physicians, laboratory staff and public health authorities and in laboratories designated to do this work, guided by (in NSW) the state viral haemorrhagic fever plan wherever possible
For laboratories not associated with a designated quarantine hospital, there are guidelines for handling material collected from suspected cases: Laboratory procedures and precautions for samples collected from patients with suspected viral haemorrhagic fevers: guidelines for laboratories that are not associated with a designated isolation hospital are available from the Australian Government Department of Health (30).
While samples should be ideally processed in laboratories with Physical Containment Level 3 (PC3) facilities, these guidelines provide information about enhanced precautions for handling material in PC2 facilities where required. The guidelines provide for the necessary on-site testing for other possible causes of the illness, and other testing required for the immediate and ongoing clinical management of the case. Work should be conducted in a biological safety cabinet.
Ebola virus is a Tier 1 Security Sensitive Biological Agent (SSBA). Laboratory personnel should refer to the SSBA standards when handling specimens (31). Specimens should be transported in accordance with current regulatory requirements (including SSBA guidelines).
More information about testing, contact details for VIDRL, guidance on the collection and handling of samples and procedures for transportation is available in the National High Security Laboratory guidelines for management of quarantinable viral haemorrhagic fevers (29).
If a sample is collected from a patient at the very early stages of illness and that returns a negative result on EVD PCR, then, in the absence of an alternative diagnosis through other testing, and in conjunction with continued illness, a follow-up PCR at least three days post development of symptoms is advisable. Re-testing should be considered when public health authorities and clinicians agree there is a material possibility of EVD or similar.
A person under investigation should be placed in a single room. Treating clinicians should contact their PHU as soon as possible for further advice on EVD risk assessment and to discuss any need for EVD testing. Persons under investigation must not be allowed to leave the hospital except if they are being transferred. Where there is a need to test, the person should be classified and managed as a suspected case.
Suspected, probable or confirmed cases should be immediately notified to the PHU then to the NSW Communicable Disease Branch who will notify the National Incident Room urgently. A follow up investigation should begin on the same day as notification.
The response to a notification will normally be carried out in collaboration with the treating clinicians, and be guided by the EVD PHU checklist (Appendix 2), the EVD Patient Assessment Flow Chart (Appendix 4) and the EVD Case Investigation Form (Appendix 5). The presence of higher versus lower risk exposures, and the patient’s clinical condition may influence decisions about the need to transfer.
PHU staff should ensure that action has been taken to confirm the onset date and symptoms of the illness.
For suspected, probable or confirmed cases:
Note: It is strongly recommended that PHU staff do not conduct face-to-face interviews, particularly if alternative methods (e.g. phone conversation) are available. However, if interviews with suspected, probable or confirmed cases or with persons under investigation who are being tested are conducted face-to-face, the person conducting the interview must have a thorough understanding of the indicated infection control practices and be competent in using appropriate PPE. Treating staff may conduct the interview rather than public health staff to reduce the number of people entering the room.
The procedures for risk assessment and management of contacts, including contact definitions, are outlined under Section 11. Contact Management.
Provide an EVD Factsheet to cases (Appendix 1) or contacts (Appendix 6) if appropriate.
In the absence of pathogen-specific interventions, patient management largely depends on supportive treatment, and vigilance for and prevention of complications.
Empiric therapy for conditions such as malaria and bacterial sepsis may be considered by treating clinicians, particularly if there are likely to be delays in the availability of laboratory test results.
Cases should be managed in the designated quarantine hospital where this is possible, unless alternative arrangements are necessary (e.g. initial presentation in a rural area, patient too ill to be transported, on the basis of risk assessment) or the recommended expert advice.
In summary, these should include – at a minimum:
Use of PPE, especially additional PPE, requires adequate training and supervision (refer to Staff training on the use of PPE below). The use of a “buddy” system, where staff members observe each other in the safe removal of PPE after patient contact, is recommended. A knowledgeable and experienced staff member should be assigned to oversee the safe use of PPE in the patient care area.Aerosol generating procedures (AGP) should be avoided in an EVD patient. If an AGP is essential, the PPE should include minimum as stated above. Staff members should limit the use of needles and other sharps as much as possible.
Visitors should be restricted to a limited number of immediate family members: and only adults who are well. Visitors enter the room of a suspected case, probable and or confirmed case while in isolation must be trained in the correct use and safe removal of recommended PPE and supervised during the visit. Direct contact with the patient should not be allowed. A log should be kept of any visitors, including contact details.
Where a suspected case initially tests negative for EVD, but there is no alternative diagnosis and a high index of suspicion remains, consideration should be given to continued isolation and use of the recommended infection control precautions, pending further testing (refer to Section 8. Laboratory testing) and re-assessment.
Individual organisations may develop institute facility-specific infection control recommendations that exceed the national minimum standard specified here. Training in the use of PPE is particularly important when using any additional measures (beyond usual transmission-based precautions), because without sufficient training, additional PPE can be unsafe (32).
For hospitals managing the ongoing care of probable or confirmed EVD cases refer to the Infection prevention and control principles and recommendations for Ebola Virus Disease document (33).
The guidance includes recommended administrative and environmental controls for healthcare facilities, principles of PPE, training on correct use of PPE, use of a trained observed, designating areas for PPE donning and doffing, preparation for doffing, selection of PPE for HCWs during management of Ebola patients and recommended PPE for HCWs and for observers.
Staff should be thoroughly trained in detailed procedures regarding how to put on and especially to take off PPE, including the correct order to avoid cross contamination and where used, to check that the respirator (P2/N95 mask) with which they are provided fits properly. They must also receive clear instructions on when PPE is to be used and how it is to be disposed of or, as appropriate, decontaminated, maintained and stored. This training should be held regularly.
It is important that training be extended to all staff who may come into contact with suspected, probable and confirmed cases. Infection Prevention and Control Expert Advisory Group (IPCEAG) document - Infection prevention and control principles and recommendations for Ebola virus disease – Including information about personal protective equipment for clinical care of patients with suspected or confirmed Ebola virus disease in the Australian healthcare setting (34) is recommended for putting on and taking off PPE used in ongoing care of probable or confirmed EVD cases.
The United States CDC Guidance on Personal Protective Equipment (PPE) to be used by HCWs during management of patients with confirmed Ebola Virus Disease in U.S or persons under investigation (PUIs) for Ebola who are Clinically Unstable or have bleeding, vomiting, or diarrhoea in U.S. Hospitals, including procedures for putting on (donning) and removing (doffing PPE ) (35) guidance includes instructions for use of Powered Air Purifying Respirators (PAPR) or surgical hoods use.
In NSW, current local VHF PPE training guidance should be sought and applied.
Without detailed and thorough training, the use of PPE beyond that which HCW regularly use may endanger staff.
Facilities should develop policies for monitoring and management of potentially exposed HCWs.
Facilities should keep a log of all staff that are involved in the care of EVD patients.
Persons with percutaneous or muco-cutaneous exposures to blood, body fluids, secretions, or excretions from a patient with suspected EVD should:
If the medical condition allows, a suspected case may be released from isolation and discharged following a negative test for EVD. They should be given a factsheet (Appendix 1) and contact details for the PHU and quarantine hospitals (Appendix 3).
Probable and confirmed cases may be released from isolation in consultation with an infectious diseases physician and PHU, and allowed to return home if recovered sufficiently from the illness. However, convalescent patients must be meticulous about personal hygiene due to the possibility of the presence of virus in bodily fluids, particularly semen, in which the presence of virus been demonstrated for up to three months after recovery (10). A case of possible sexual transmission has been described where the contact occurred 179 days after likely onset (11). The case should be given advice regarding safe sex for 12 months or until two negative PCR test results are taken a minimum of one week apart (36-38).
For patients who have recovered and been discharged after their acute illness, only standard precautions are needed when clinical evaluation and care is performed. There is no evidence that recovered patients of EVD pose any special risk to HCWs when this care involves contact with intact skin, sweat, tears, conjunctivae, saliva, and cerumen. In addition, individuals who have completely recovered from EVD and are not febrile, do not pose a risk of Ebola virus exposure through phlebotomy as such patients are not viraemic. For patients who present during convalescence with late stage manifestations of EVD, such as acute neurological or ocular symptoms, infection control practices recommended for evaluating persons under investigation for EVD should be used until testing for Ebola virus is negative (14).
This also applies where invasive procedures are being conducted on immunologically protected sites where there is the possibility of contact with spinal fluid, semen, or ocular contents (e.g. lumbar puncture, spinal anaesthesia, prostate or testicular surgery and intraocular procedures). EVD survivors who have any new or recurrent ocular or neurologic symptoms should seek care for complications associated with potential Ebola virus persistence. EVD survivors with fever should be assessed for both common community-acquired infections (e.g. malaria, influenza, common cold, typhoid fever, gastroenteritis, etc.) as well as possible complications related to Ebola virus persistence.
The Australian Red Cross Blood Service recommends that a case defers donating blood for 12 months from the date of recovery (this is a conservative deferral given the lack of evidence about the duration of viraemia post recovery).
It is recommended that a contact of someone with EVD defers donating blood for eight weeks from date of last contact before donation. If contact is ongoing, deferral should be increased to a maximum of 12 months from date of case recovery plus an additional eight weeks.
Recommended PPE for contact and droplet precautions includes:
Recommended PPE for enhanced contact and droplet precautions includes:
This section applies primarily to probable and confirmed cases, acknowledging there may be a need to consider environmental cleaning for a suspected case with a high pre-test probability of EVD.
Full PPE (covering all skin) must be worn when undertaking environmental cleaning, including a P2/N95 mask, because cleaning procedures have the potential to generate aerosols.
It is not usually recommended that environmental cleaning of a suspected case's residence or other potentially contaminated areas be undertaken prior to receipt of test results for EVD. In most jurisdictions, the time between notification of a suspected case and receipt of the preliminary laboratory test results will be less than 24 hours. If EVD is felt to be unlikely, it may be possible to allow household members to continue to reside in the home and leave potentially contaminated areas of a residence or other facility unused temporarily.
If significant delays are expected, or where areas are urgently required to be cleaned, environmental cleaning may be undertaken – in discussion with the relevant PHU. If a suspected case is considered to have a high pre-test probability of EVD based on the clinical and exposure risk assessment, environmental cleaning might be undertaken prior to the confirmation of a case.
Appendix 13 provides further detail on undertaking environmental cleaning in domestic premises.
If a suspected case test negative for EVD, and, re-testing is not required, no further special action is required for waste and isolated objects from the person’s residence.
Disinfection and environmental treatment is a key component to control EVD. All potentially contaminated personal items and items used in the treatment of the patient should be disinfected with an appropriate viricide. Ebola viruses are readily inactivated by low-level disinfectants. The preferred disinfectant solution is sodium hypochlorite made up to 1,000 parts per million (ppm) available chlorine (check the manufacturer’s instructions) for routine environmental cleaning and 5,000 ppm for body fluid spills (see below).
Once the patient has left the room the entire room should be cleaned with a neutral detergent and with a 1,000 ppm sodium hypochlorite solution. All cleaning equipment should be disposed of into clinical waste.
Appropriate PPE must be worn for cleaning body fluid spills, including gloves, disposable impermeable overshoes or boots, and P2/N95 masks with face shields/goggles and fluid resistant gowns or fluid resistant overalls. Spills should be cleaned using a spill kit. In the absence of a specific kit, spills should be absorbed with paper towels, liberally covered with a 5,000 ppm sodium hypochlorite solution and left to soak for 30 minutes before being wiped up, and disinfect the area again.
Limit the equipment that enters the patient’s room, as it must be dedicated to the patient throughout their stay and cannot be used elsewhere. Disposable equipment and linen should be used wherever possible.
See Appendix 10 for further information on cleaning and disinfection.
Items stained or containing body fluids are treated as clinical waste, and double bagged as the waste leaves the room. Waste must be stored securely prior to collection. Toilet waste may be flushed as usual, except where specific local requirements exist to the contrary. Disposable bed pans can be disposed of into the clinical waste after the addition of high absorbency gel, if available.
See Appendix 11 for further information on waste treatment and disposal.
Requirements for the disposal of bodies are prescribed under state and territory public health legislation (see Appendix 12).
Where local transmission of EVD is thought to have occurred, a thorough review of contributing environmental factors should be undertaken. This should include a review of infection control procedures, and opportunities for exposure to environments contaminated by body fluids.
If a case has had exposure to animals in Australia it may be appropriate to consult with the relevant state or territory animal health authority to assess the risk that animals could have become infected. Dogs have previously been shown to have developed antibodies to Ebola virus but, to date, it has not been reported that dogs have any clinical signs of infection (39).
Contact tracing is conducted to identify and monitor persons who may have had contact with a probable or confirmed EVD case. Contacts of suspected cases should also be considered for contact management, particularly if there is likely to be a delay in confirming or excluding the diagnosis in the suspected case.
Contacts should be provided with information about the disease and risk of transmission, and monitored for the development of symptoms for 21 days after the last exposure to the case while the case was likely to be infectious (i.e. the maximum incubation period) (see Appendix 6. Ebola Virus Disease Contacts Factsheet and Temperature Log sheet).
Based on an exposure risk assessment, there may be circumstances where restrictions are considered, such as for contacts who are HCWs, or for people planning travel to rural or remote areas with limited access to healthcare.
Contacts that develop a fever within 21 days of the last possible exposure to a suspected case should be immediately isolated, medically evaluated and assessed as per Appendix 4.
PHUs should identify all contacts of suspect, probable or confirmed cases (depending on patient risk assessment and particular circumstances) from the onset of symptoms in the case.
Contacts of an EVD case are assessed for their likely level of exposure using the contact questionnaire (Appendix 5), and managed according to risk category as per Table 1.
Table 1: Risk assessment and management for contacts of probable and confirmed* cases of EVD
* Contact tracing may be undertaken in response to a suspected case where there may be a delay in laboratory diagnosis.
+ Other symptoms include headache, joint and muscle aches, abdominal pain, weakness, diarrhoea, vomiting, stomach pain, rash, red eyes, chest pain, difficulty swallowing, bleeding (e.g. blood in stool or persistent bleeding from mouth or venepuncture sites or bruising).
Adapted from Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious disease of high consequence (40).
Demographic and epidemiological data should be collected from all persons identified as having had close contact with a probable or confirmed EVD case using the contact questionnaire (Appendix 5). Information on close contacts should be managed according to jurisdictional requirements.
Identification and assessment of the close contacts of suspected cases may be deferred pending the results of initial laboratory testing. However, contact tracing should be considered if EVD infection remains high on the list of differential diagnoses, even if initial laboratory results are negative.
In the event of a suspected case on an aircraft, see Section 12. Special Situations.
Routine laboratory screening for EVD infection is not recommended for asymptomatic contacts.
No specific prophylactic treatments are available for contacts.
Contacts should be counselled about their risk and the symptoms of EVD and provided with a factsheet (Appendices 6,7,8) suitable for their level of exposure, as per the table above.
Routine home isolation of asymptomatic contacts is not recommended, but contacts with higher or lower risk exposures to the case are advised to monitor their health for 21 days after the last possible contact with a probable or confirmed EVD case.
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 recommended based on a risk assessment of the particular circumstances. This may include avoiding sexual contact.Special arrangements for the monitoring of returning aid workers who have worked in healthcare or community settings apply (Appendix 7 - Returning aid workers who have worked in healthcare or community settings during an Ebola outbreak).
Work restrictions may be considered for some contacts with higher risk exposures or for healthcare worker contacts (see Table 1) for 21 days following the last possible contact with the case. Home isolation is not routinely recommended during this period if these individuals remain asymptomatic, but measures to reduce body contact and/or social mixing with other people may be recommended based on a risk assessment of the particular circumstances.
If the contact develops symptoms consistent with EVD within the 21 days following the last contact with the case, the individual should be immediately isolated and managed as per the current clinical recommendations for suspected EVD cases, with a clinical risk assessment (Appendix 4), and depending on the outcome of the risk assessment, urgent testing for EVD. The clinical management of symptomatic contacts should then be guided by Appendix 4, and may include monitoring and repeat testing.
Symptomatic contacts that test negative for Ebola virus by nucleic acid testing (NAT) will still need to be monitored for 21 days after their last contact with a probable or confirmed EVD case. If the symptomatic contact’s laboratory specimen was collected during the first three days of illness, re-testing for EVD can be considered, based on clinical judgement and results of other investigations. See Section 8. Laboratory testing: Re-testing.
In an Australian clinical setting, HCWs who have taken recommended infection control precautions, including the use of appropriate PPE, while caring for a probable or confirmed EVD case are not considered to have had low or high-risk exposures to EVD.
However, given that not all breaches in PPE are obvious and work conditions may elevate anxiety levels, HCWs caring for probable or confirmed EVD cases may be advised to monitor their temperature daily. This approach means that HCWs are managed as low risk contacts even in the absence of known lower risk exposures; however, no restriction in work duties is necessary while the HCW is asymptomatic.
Individual hospitals and healthcare organisations will need to implement their own occupational health and safety policies for staff caring for, or involved in the care of EVD cases. This might include hospital management conducting an interview or questionnaire for these staff at the beginning of each shift to ask about symptoms.
If the HCW develops symptoms consistent with EVD they should isolate themselves and notify their employer and PHU immediately.
Public health authorities and/or employers may take a precautionary approach to returned aid workers, particularly those who were involved in direct patient care in an Ebola outbreak, during the 21 days since the aid worker has left the EVD-affected country.
An exposure and clinical risk assessment conducted by public health authorities, as well as an assessment of personal circumstances, will inform what type of self-monitoring (temperature checks etc.) is required as part of an individual management and monitoring plan. Where appropriate, there may be advice given to the aid worker about restricting social mixing and avoiding bodily contact with others and/or being within easy travel to adequate tertiary health care.
The returned aid worker must not work in clinical care during their 21 day monitoring period. Employers might consider temporary re-assignment to non-direct patient care duties, or a non-punitive leave policy that covers the 21 day monitoring period.
Separately, the aid worker’s host organisation should have a policy for returning workers, including advice on self-monitoring of temperature and/or other symptoms of EVD for 21 days since leaving the EVD-affected country, being within easy travel distance of a hospital or adequate tertiary care, and the need for a period of restriction in clinical care activities during the monitoring period.
Appendix 7 outlines an approach to the management of returning aid workers.
Well-established processes are always in place at Australia’s international borders to screen ill travellers for EVD and all other Listed Human Diseases (LHD). Ill travellers (including passengers and crew) displaying signs or symptoms of an LHD are required to be reported to the Australian Government Department of Agriculture and Water Resources (Agriculture) as part of pre-arrival reporting requirements under the Biosecurity Regulations 2016. Once an ill traveller has been reported, an Agriculture biosecurity officer (BO) will conduct an assessment using the Traveller with Illness Checklist (TIC) to decide whether further action is required. If indicated by the TIC, the BO will contact a state or territory on call CHBO for further advice and direction.
However, during an outbreak overseas with widespread and intense transmission and where the risk of importation to Australia is increased, there may be a need for enhanced border screening measures and/or post border monitoring activities that extend beyond the above business-as-usual processes. This is to ensure that everyone who could be at risk is detected, safely managed, knows how to monitor their health and knows who to contact if they become unwell. The following options may be considered and adjusted to be commensurate with the risk.
Under policy direction from Health, BOs may screen all incoming passengers who have travelled in affected areas during the previous 21 days. These passengers can be asked about possible exposures to EVD and their body temperature may be measured.
Anyone who may have been in direct (unprotected) contact with an infected person or undertaken certain other high risk activities (e.g. funeral attendance) without sufficient personal protective measures, has a recent history of fever (previous 24 hours), or who has a measured body temperature of >38°C will be referred to a state or territory HBO for further assessment, which may include transfer to a designated quarantine hospital.
Passengers who have travelled in affected areas during the previous 21 days may be provided with written instructions on what to do should they develop any symptoms of EVD.
EVD communications, such as brochures or information cards, providing travel advice on prevention, protection, signs, symptoms and treatment can be made available at the border. The Australian Government Department of Agriculture and Water Resources is responsible for facilitating the display and availability of these items.
EVD signage can be displayed at the border in the form of printed banners or electronic screens. These communications consist of short awareness messages with infographics referring travellers to the Australian Government Department of Health’s website for more information.
Negative (non-automatic) pratique of aircraft and vessels Incoming aircraft or vessels can be made subject to negative pratique under the Biosecurity Act 2015. Travellers, air crew and cargo are not allowed to disembark until EVD risks have been evaluated and risk mitigation measures put in place. This border measure can be used for all incoming aircraft from a country at high-risk of exposure to EVD.
Under the Biosecurity Act 2015, travellers who are identified as having, or being suspected of having, an LHD, and who do not comply with recommended public health measures may be placed under a Human Biosecurity Control Order (HBCO). A number of measures can be imposed under an HBCO to manage the risk presented by the individual, including isolation, a requirement to undergo treatment, and restricting international travel.
Universal daily monitoring for travellers who have signs or symptoms of EVD and are returning from affected countries, or a traveller who is a contact of someone with EVD, regardless of risk, may be implemented to facilitate early clinical assessment of returning travellers and to assure public safety. Monitoring may be passive, active, daily or twice daily, depending on the individual circumstances of the traveller. Systems such as automated text message (41) or call centres may be used to collect monitoring data from returning travellers. Reporting of interstate travel may also be required during the period of monitoring. Where there is interstate travel, a formal handover between the HBO (or delegate) in the jurisdictions of travel will occur.
An assessment of possible transmission of Ebola virus on an aircraft should be undertaken on a case-by-case basis. This should occur after careful risk assessment, taking into account the index case status, the presence of symptoms during the flight, any potential exposures during the flight, and the goals of the contact tracing. Assessment of the risk of transmission will be the role of a HBO following identification of a suspected EVD case via the TIC (this is notified to the HBO by a BO).
Contact tracing should be considered for suspected, probable and confirmed cases if the case was symptomatic during the flight. To ensure a consistent approach, upon notification of an incident involving a case on an aircraft, an expert jurisdictional panel consisting of the jurisdictional executive group of CDNA should be urgently convened to assess risk and agree on the approach to contact tracing. Considerations for the expert panel will include whether the case was symptomatic during flight, and whether the symptoms were “wet” with copious vomiting, diarrhoea and other fluids, or “dry” with onset of fever, muscle pain, headache and sore throat. A wider radius of follow-up may be required for a “wet” case than the standard -/+1 seat, including the row and the toilets used by the case.
Co-travellers and crew members who had reported direct body contact , i.e. direct contact with the bodily fluids, or with objects likely to have been contaminated with such fluids, or with the skin of the index case should be traced. To gather this information, any records of significant events on the flight should be obtained from the airline.
As direct contact is the main route of transmission for Ebola virus, only the passengers who were seated in direct proximity to the index case should be included i.e. only passengers who were one seat away from the index case (+/- 1 seat in all directions). If the index case occupied an aisle seat, the passengers seated directly across the aisle from the index case should also be traced.
Crew members who provided in-flight service in the section of the aircraft where the index case was seated should be included as well as other crew members who had direct contact with the patient.
Inform cleaning staff of the suspected case prior to cleaning so that additional infection control precautions can be used. The cleaning staff that cleaned the section and seat where the index case was seated should be traced.
Previously published guidance has suggested that in the absence of specific incidents, the use of the toilet by the index case is not considered a risk for others (with the exception of the situation described below) and therefore not relevant when considering contact tracing (42).If there have been specific incidents such as the repeated and/or significant vomiting and/or diarrhoea in one or more of the toilets, efforts should be made to identify these toilet/s and associated aircraft section and persons who may have been exposed to the case’s bodily fluids in this setting.
If a crew member is the suspected EVD case, contact tracing efforts should concentrate on passengers seated in the area where the crew member was working during the flight and all of the other members of the crew.
Public health authorities may wish to communicate with every passenger from the aircraft, irrespective of their exposure risk, to provide basic information and establish a mechanism for public health follow up if required.
People included in the contact tracing should be managed according to Section 11. Contact Management. This requires an assessment of exposure risk and categorisation into high, low or no risk contacts. Management consists of one or more of the following:
If a diagnosis cannot be laboratory confirmed in a timely manner, contact tracing should be considered if the evidence strongly suggests EVD as the likely cause of the index case’s disease.
The National Incident Room at the Australian Government Department of Health coordinates the collection of international flight manifests and incoming passenger cards (IPCs) (health.opsAThealth.gov.au)
Attempts should be made to contact the airline to investigate whether crew members remember (or even recorded) any incidents on board which resulted in potential exposures to crew or passengers.
It is possible that there could be an ill international traveller on a subsequent domestic flight. Public health authorities may be notified of this via airline or airport staff. For the purpose of contact tracing, passenger manifests may be obtained in conjunction with airlines or airport authorities. Given that passenger manifests on domestic airlines may not have complete contact information, it may be necessary to obtain contact details urgently from disembarking passengers
If one or more suspected, probable or confirmed EVD cases are identified in a healthcare facility, an outbreak management team should be convened, including a senior facility manager, an infection control practitioner and appropriate clinical staff, in consultation with PHU staff. Control measures may include:
Although no EVD outbreaks in institutions other than in healthcare facilities have been reported, it is assumed that fellow residents in an institution may be at greater risk of infection if there has been a confirmed case living at the institution while infectious, particularly if there are shared bathroom/toilet facilities.
If one or more probable or confirmed EVD cases are identified in a residential care facility or institution, an outbreak management team should be convened, including PHU staff.
* See the Ebola Virus Disease (EVD) national control guidelines (SoNG). ** See NSW Health Guideline (GL2016_002) NSW Contingency Plan for Viral Haemorrhagic Fevers.
Links to Australian state and territory public health legislation, and the Commonwealth Quarantine Act and amendments are available from the Department of Health.
Public health staff should be familiar with the NSW Health Guideline (GL2016_002) NSW Contingency Plan for Viral Haemorrhagic Fevers which describes the local arrangements for testing, transfer and management of patients. This is summarised for EVD cases in Appendix 4.
Public health staff should also be familiar with the NSW Public Health Surveillance and Management Plan for Persons with Potential Ebola virus Exposure which describes local arrangements for the identification, risk assessment and management of person with potential Ebola virus exposure.