- The disease
- Routine prevention activities
- Surveillance objective
- Data management
- Case definition
- Laboratory testing
- Case management
- Environmental evaluation
- Contact management
- Special situations
- References and additional sources of information
- Jurisdiction specific issues (NSW)
This protocol is specifically for responding to 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 PPE safely.
Public health priority
Urgent. EVD is a quarantinable disease and is nationally notifiable.
All travellers who arrive in Australia with clinical and epidemiological evidence that suggests the possibility of having contracted a quarantinable VHF including EVD should be immediately notified to the Department of Health in the state or territory.
If a suspected case is notified from an international border, decisions concerning case and contact management, including assessment, transport, isolation and quarantine will be made by the jurisdictional Chief Human Biosecurity Officer (CHBO) or delegated by the CHBO to a Human Biosecurity Officer (HBO).
Actions in the event of a suspected case
- Consider the possibility of EVD in persons with clinically compatible symptoms and with a compatible travel and/or exposure history
- Isolate the case and institute appropriate infection control and the use of personal protective equipment.
- Notify the C/HQO through the state or territory Department of Health of all persons under investigation for EVD.
- Conduct a clinical and exposure risk assessment in consultation with the C/HBO and relevant infectious diseases service, using the EVD case definition and the patient assessment flow chart.
- Use the outcome of the risk assessment to determine whether the person under investigation requires laboratory testing for EVD.
- Assess the risk to contacts before or after confirmation, depending on the circumstances and the C/HQO advice.
- A clinical and exposure risk assessment must be conducted for suspected cases in consultation with the C/HQO and relevant infectious diseases service using the EVD case definition in 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.
- Further details on laboratory testing is in Section 8.
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. The management of contacts is described in Section 11.
Control of environment
Disinfection and environmental decontamination is a key component to control of EVD. Cleaning and environmental decontamination is described in Section 10 and further detail is provided in Appendices 12 and 13.
2. The disease
EVD is caused by an Ebola virus.
Ebola viruses are in the family Filoviridae, which also contains Marburg virus. There are five species. The Zaire, Bundibugyo and Sudan species have been associated with large outbreaks in Africa, while Reston and Tai Forest species have not been associated with human outbreaks.
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 and forest antelope occurring from time-to-time.
Mode of transmission
Ebola virus is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals (often therefore through hunting or preparation of "bushmeat"). In Africa, infection has been documented through the handling of infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead or in the rainforest.
Transmission of Ebola Virus does not occur prior to the onset of symptoms of EVD. The infectivity is known to be low at the onset of symptoms, and increases as symptoms worsen and as the bodily fluid secretions increase. 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.
Ebola virus then spreads through person-to-person transmission via contact with:
- the blood or bodily fluids (including but not limited to urine, saliva, faeces, vomit, breast milk, and semen) of people with EVD, and the bodies of people who have died of EVD.
- objects (e.g. needles, syringes) contaminated with blood or bodily fluids of people with EVD
Transmission through sexual contact may be possible for up to three months after clinical recovery [1-4]. Participating in traditional burial ceremonies in affected areas of Africa is a known high risk activity for transmission.
The risk for infection in healthcare settings can be significantly reduced through the use of standard and transmission-based infection control precautions and environmental cleaning (see Section 9. Case management and Appendix 11–12).
Airborne transmission to humans, as occurs for tuberculosis or measles, has never been documented.
From 2 to 21 days; most commonly 8 to 10 days.
People with are not infectious until the onset of symptoms of EVD. People are infectious as long as their blood and secretions contain the virus. Ebola Virus was isolated from semen 82 days after onset ; and transmission through sexual contact may therefore be possible for up to three months after clinical recovery.
Clinical presentation and outcome
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 50% and 90%, while for other species, the CFR may be lower. Variability in reported case-fatality rates probably reflects viral strain, host factors and access to and standards of clinical care.
Persons at increased risk of disease
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 infected animal (alive or dead).
Caring for ill relatives or contact with the body after death are known risk factors for infection. Healthcare workers, particularly those in resource poor settings with inadequate infection control, are also at risk.
Disease occurrence and public health significance
EVD was first recognised in 1976 in two simultaneous outbreaks, in Nzara, Sudan, and in Yambuku, Democratic Republic of Congo. As of 10 September 2014, there had been 30 reported outbreaks of EVD in humans with more than 7,000 cases, including 4,047 documented as fatal (overall case-fatality rate 56%).[3,5] The largest outbreak to date began in December 2013 in West Africa (involving the neighbouring countries Guinea, Liberia and Sierra Leone, with limited spread in Nigeria), with more than 6,000 clinically-compatible cases as of 21 September 2014 (continuing).
There have also been a number of incidents involving Ebola Reston virus in animals, but never a symptomatic human case. All outbreaks in humans (excluding asymptomatic Ebola Reston infections) have occurred in central Africa (the Congo, Democratic Republic of Congo, Uganda, South Sudan and Gabon) except for the current (at the time of writing) outbreak in West Africa, a single case in Ivory Coast, two laboratory contamination incidents in Russia and an import-related case in South Africa.
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 event of national significance, with considerable community and media interest.
3. Routine prevention activities
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.
4. Surveillance objectives
- To rapidly identify, isolate and treat cases, and prevent transmission to their contacts
- To identify and provide information to contacts and ensure that they are isolated rapidly should symptoms occur
5. Data management
Suspected, probable and confirmed cases of EVD infection should be entered onto NCIMS ideally within one working day of notification/report. For surveillance purposes, only probable and confirmed cases are submitted to NNDSS.
Public health units 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.opsAThealth.gov.au.
7. Case definition
Person under investigation
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.
Clinical evidence requires 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.
Limited epidemiological evidence
Limited epidemiological evidence requires only travel to an EVD affected area (country/region) in the 21 days prior to onset.
Epidemiological evidence requires a lower risk exposure or higher risk exposure as defined below in the 21 days prior to onset.
Lower risk exposures
- household contact with an EVD case (in some circumstances this might be classified as higher risk such where the household was in a resource poor setting),
- being within approximately 1 metre of an EVD patient or within the patient’s room or care area for a prolonged period of time (e.g., healthcare workers, household members) while not wearing recommended personal protective equipment (See Section 9. Case management),
- having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended personal protective equipment.
Higher risk exposures
- percutaneous (e.g. needle stick) or mucous membrane exposure to blood or body fluids of an EVD patient (either suspected or confirmed)
- direct skin contact with blood or body fluids of an EVD patient without appropriate personal protective equipment (PPE),
- laboratory processing of body fluids of suspected, probable, or confirmed EVD cases without appropriate PPE or standard biosafety precautions,
- direct contact with a dead body without appropriate PPE in a country where an EVD outbreak is occurring,
- direct handling of sick or dead animals from disease-endemic areas consumption of “bushmeat” in country where EVD is known to occur.
Laboratory suggestive evidence
Laboratory suggestive evidence includes:
- Isolation of virus pending confirmation by CDC, Atlanta or NIV, Johannesburg; or;
- Detection of specific virus by nucleic acid testing, antigen detection assay, or electron microscopy pending confirmation by CDC, Atlanta or NIV, Johannesburg; or
- IgG seroconversion or a significant increase in antibody level or a fourfold or greater rise in titre to specific virus pending confirmation by CDC, Atlanta or NIV, Johannesburg; or
- Detection of IgM to a specific virus.
Laboratory definitive evidence
Laboratory definitive evidence requires confirmation by the Special Pathogens Laboratory, CDC, Atlanta, or the Special Pathogens Laboratory, National Institute of Virology (NIV), Johannesburg.
- Isolation of a specific virus; or
- Detection of specific virus by nucleic acid testing or antigen detection assay; or
- IgG seroconversion or a significant increase in antibody level or a fourfold or greater rise in titre to specific virus.
8. Laboratory testing
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:
- notify the Public health Unit as soon as possible for further advice on EVD risk assessment, and public health management if indicated, and
- contact the on-call Clinical Microbiologist at CIDMLS-ICPMR for advice on appropriate specimen type, collection and transport.
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 C/HQO and an infectious diseases specialist.
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.
In NSW, CIDMLS-ICPMR will coordinate referral of positive EVD samples to the national high security laboratory at VIDRL in Victoria for confirmation.
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).
Collecting, handling and transport laboratory specimens
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. Throat swabs and urine may also be collected. Blood (in EDTA tubes), throat swabs and possibly urine should be collected as per the National High Security Laboratory guidelines for management of human quarantine.
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 Infection control, and isolation and restriction and Appendix 11).
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 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 Department of Health.
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. 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.
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 remains a clinical decision based on the patient’s ongoing condition.
9. Case management
Person under investigation
A person under investigation should be placed in a single room. Treating clinicians should contact their local public health unit 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 and confirmed cases
Suspected, probable or confirmed cases should be immediately notified to the 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 clinicians managing the case, and be guided by the EVD public health unit 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:
- Confirm results of relevant pathology tests, or recommend that tests be done
- Determine if the diagnosis has been discussed with the case or relevant care-giver before beginning any interview
- Review public health management of cases and contacts
- Ensure appropriate infection control guidelines are followed in caring for the case
- Identify the likely source of infection.
Note: 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.
Identification of contacts
The procedures for risk assessment and management of contacts, including contact definitions, are outlined under Section 11. Contact Management.
Provide an EVD Fact Sheet to cases (Appendix 1), 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 recommended on expert advice.
Infection control, and isolation and restriction
In summary, these should include – at a minimum:
- Placement of the patient in a single room with private bathroom and an anteroom, with the door closed. In hospitals where such facilities are not available, interim arrangements may be required, such as use of commodes in the patient’s room and unoccupied adjacent rooms for anterooms;
- Healthcare worker (HCW) to use a P2/N95 mask, and cover all skin using a suitable combination of PPE, such as a disposable fluid resistant gown, gloves, and eye protection (e.g. goggles or face shield), leg and shoe coverings, overalls when entering a patient care area. Double gloving might also be considered
- Close attention to hand hygiene; and
Use of PPE, especially additional PPE, requires adequate training and supervision – see 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 – at a minimum as stated above – a P2/N95 mask, and cover all skin, using a suitable combination of PPE, such as a disposable fluid resistant gown, gloves, and eye protection (e.g. goggles or face shield), leg and shoe coverings, overalls when entering a patient care area. Double gloving might also be considered. 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 who come into contact with suspected case, probable and confirmed cases must be protected according to recommended infection control guidelines. Direct contact with the patient should not be allowed.
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 (see 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.
For hospitals managing the ongoing care of probable or confirmed EVD cases, the United States Centers for Disease Control (CDC) Guidance on Personal Protective Equipment to be used by healthcare workers during management of patients with Ebola Virus Disease in U.S. Hospitals, including procedures for putting on (donning) and removing (doffing) are recommended.
The CDC 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, selection of PPE for healthcare workers during management of Ebola patients, recommended personal protective equipment for HCW and for observers and preparation for doffing.
Staff training on the use of PPE
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.
General guidance on donning and removing PPE is available from the NHMRC.
The CDC Guidance on Personal Protective Equipment is recommended for donning and doffing for PPE used in ongoing care of probable or confirmed EVD cases and includes instructions on the use of Powered Air Purifying Respirators (PAPR) or surgical hoods.
Without detailed and thorough training, the use of PPE beyond that which healthcare workers regularly use may endanger staff. Without training, additional PPE may be ineffective.
Management and monitoring of potentially exposed healthcare workers
Facilities should develop policies for monitoring and management of potentially exposed HCW.
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:
- Stop working and immediately wash the affected skin surfaces with soap and water. Mucous membranes (e.g., conjunctiva) should be irrigated with copious amounts of water or eyewash solution
- Immediately contact occupational health/supervisor for assessment and access to post exposure management services for all appropriate pathogens (e.g., Human Immunodeficiency Virus, Hepatitis C, etc.)
Release of cases from quarantine
A suspected case may be released from isolation and discharged if the medical condition allows after testing negative for EVD, unless a high index of suspicion remains (such as in the absence of an alternative diagnosis). They should be given a factsheet (Appendix 1) and contact details for the state/territory public health unit (Appendix 3).
Probable and confirmed cases may be released from isolation in consultation with an infectious diseases physician and public health authorities 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.4 The case should be given advice about the use of condoms, or abstinence from sex.
The Australian Red Cross Blood Service recommends that a case defers 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)
Summary of PPE recommendations for patient management
For suspected, probable or confirmed cases
- Surgical scrubs
- Hand hygiene
- Disposable, fluid repellent long sleeve gown
- Disposable face shield, surgical hood to cover head and neck*, and P2/N95 mask or disposable PAPR hood
- Disposable fluid-repellent below-knee boot covers
- Double gloves (with long cuffs)
- Waterproof apron if vomiting/diarrhoea
10. Environmental evaluation
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 public health unit. 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.
Where environmental cleaning occurs, full PPE (covering all skin) and with a P2/N95 mask must be used and complete cleaning regimes must be undertaken, as for a probable or confirmed case, as outlined in this document and Appendix 12. During cleaning, household members should not be present.
For probable and confirmed cases, advice will be given about appropriate disposal of waste and isolated objects by the relevant public health unit. Advice about further environmental cleaning procedures will be given as necessary.
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.
Cleaning and disinfection
Routine environmental cleaning and disinfection
Disinfection and environmental treatment is a key component to control of 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 ppm 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 the clinical waste.
Body fluid spill
Appropriate PPE must be worn for cleaning body fluid spills (as described above in Infection control, isolation and restriction). 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.
Patient equipment and linen
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 12 for further information on cleaning and disinfection.
Waste treatment and disposal
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 13 for further information on waste treatment and disposal.
Disposal of the deceased
Requirements for the disposal of bodies are prescribed under state and territory public health legislation (see Appendix 14).
Other factors to consider
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 animal health authorities 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
11. Contact management
Identification of contacts
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).
Based on an exposure risk assessment, there may be circumstances where restrictions are considered, such as for contacts who are healthcare workers, or for people planning travel to rural or remote areas with limited access to healthcare.
Contacts who develop a fever within 21 days of the last possible exposure to an infectious case should be immediately isolated, medically evaluated and assessed as per Appendix 4.
Public health authorities 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 the table below.
Table 1: Risk assessment and management for contacts of probable and confirmed* cases of EVD
||No direct contact with the patient or body fluids but who have been in the near vicinity of the patient.
- Reassure about very low risk;
- Provide casual contacts factsheet (Appendix 6);
|Lower risk exposures
- Household contact with an EVD case (in some circumstances this might be classified as higher risk such where the household was in a resource poor setting) or
- Close contact in healthcare or community settings where close contact is defined as:
- being within approximately 1 metre of an EVD patient or within the patient’s room or care area for a prolonged period of time (e.g., health care personnel, household members) while not wearing recommended personal protective equipment (See Infection control, and isolation and restriction)
- having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended personal protective equipment
- Healthcare workers (see below).
- Explain what is meant by low risk;
- Twice daily self-monitoring for fever for 21 days from last exposure; provide thermometer and instructions on use;
- Notify public health authority if fever or other symptoms+ develop.
- Provide low risk contacts factsheet (Appendix 7);
- Consider daily (or twice daily) active monitoring by Public Health Unit;
- 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.
|Higher risk exposures
- Contacts with higher risk exposures have had direct contact with the patient or their bodily fluids.
- percutaneous (e.g. needle stick) or mucous membrane exposure to blood or body fluids of an EVD patient
- direct skin contact exposure to blood or body fluids of an EVD patient without appropriate personal protective equipment (PPE)
- laboratory processing of body fluids of suspected, probable, or confirmed EVD cases without appropriate PPE or standard biosafety precautions, or
- direct contact with a dead body without appropriate PPE
- Inform about risks;
- Twice daily self-monitoring for fever for 21 days from last exposure; provide thermometer and instructions on use;
- Daily (or twice daily) active monitoring by Public Health Unit;
- Notify public health authority if fever or other symptoms+ develop.
- Provide high risk close contacts factsheet (Appendix 8).
- 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.
* Contact tracing may be undertaken in response to a suspected case where there may be a delay in laboratory diagnosis.
+ Other symptoms includes headache, joint and muscle aches, abdominal pain, weakness, diarrhoea, vomiting, stomach pain, rash, red eyes, chest pain, difficulty swallowing, bleeding inside or outside the body.
Adapted from United Kingdom Department of health, Management if Hazard Group 4 viral haemorrhagic fevers and similar human infectious disease of high consequence.
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 aeroplane, 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.
Quarantine and restriction
Routine home quarantine 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 healthcare workers apply (See below “Returning aid workers who have worked in healthcare or community settings during an EVD outbreak”, Appendix 9).
Close contacts with high risk exposures
Work restrictions may be considered for some contacts with higher risk exposures or for healthcare worker contacts (see Table) for 21 days following the last possible contact with the case. Home quarantine 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.
Management of symptomatic contacts
If the contact develops symptoms consistent with EVD infection 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 infection. The clinical management of symptomatic contacts should then be guided by Appendix 4, and may include monitoring and repeat testing.
Symptomatic contacts who test negative for EVD 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.
Healthcare workers working in Australia
In an Australian clinical setting, healthcare workers 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, healthcare workers caring for probable or confirmed EVD cases may be advised to monitor their temperature daily. This approach means that healthcare workers 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 develop symptoms consistent with EVD infection they should isolate themselves and notify their employer and public health unit immediately.
Returning aid workers who have worked in healthcare or community settings during an EVD outbreak
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 EVD 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 care.
The returned aid worker must not work in clinical care for 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 designated quarantine hospital or adequate tertiary care, and the need for a period of restriction in clinical care activities during the monitoring period.
Appendix 9 outlines an approach to the management of returned healthcare workers.
The Australian Red Cross Blood Service recommends that contacts of an Ebola case should not donate blood until cleared of infection by the absence of illness 21 days post last contact and an additional 5 weeks has passed.
12. Special situations
Suspected, probable or confirmed case who travelled by aeroplane
An assessment of possible transmission of Ebola 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.
Goals of contact tracing
- Prevention of onward transmission and awareness-raising for early detection in passengers/crew/ground staff who have had direct contact with the index case, or direct contact with the bodily fluids of the index case.
- Reassurance for passengers/crew/ground staff with negligible exposure to the index case and subsequently low/no risk of EVD.
When should contact tracing an aeroplane be considered?
Contact tracing should be considered for suspected, probable and confirmed cases if the case was symptomatic during the flight.
Contact tracing should focus on:
- Any person who reported direct contact with the index case, 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 patient.
- Passengers who were seated in direct proximity to the index case, i.e. passengers who were one seat away from the index case (+/- 1 seat in all directions). In some situations, a more inclusive approach may be appropriate, such as where an ill passenger in a window seat has climbed over two adjacent passengers to access the aisle during the flight.
- Crew members who provided in-flight service in the section of the aircraft where the index case was seated should be included in the trace-back,
- Cleaning staff that cleaned the section and seat where the index case was seated.
Passengers and crew with reported direct contact
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.
Passengers +/-1 seat
As direct contact is the main route of transmission for Ebola, only the passengers who were seated in direct proximity to the index passenger 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 three passengers seated directly across the aisle from the index case should also be traced.
Crew members of plane section
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.
Cleaning staff of plane section
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.
Passengers who shared the same toilet as the index case
Previously published guidance has suggested that in the absence of specific incidents, the use of the lavatory by the index case is not considered a risk for others and therefore not relevant when considering contact tracing .
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 aeroplane section and persons who may have been exposed to the case’s bodily fluids in this setting.
The index case is a crew member
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.
Persons with no direct exposure to the index case
Public health authorities may wish to communicate with every passenger from the aeroplane, irrespective of their exposure risk, to provide basic information and establish a mechanism for public health follow up if required.
Management of aeroplane contacts
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:
- Provision of information through factsheets and discussion with public health authorities.
- Assessment of the need for medical evaluation of the contact if they are reporting symptoms at time of first interview; or following exposure to the index case.
- Advice on the need for self-monitoring for temperature and notification to public health units and/or presentation to health facilities if they develop a fever within 21 days of last exposure to the index case.
Collecting event and passenger information
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 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
Outbreaks in healthcare facilities
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:
- identification and monitoring of close contacts
- active case finding and treatment
- isolation and/or cohorting
- work restriction for healthcare workers who have had close contact (i.e. unprotected exposure) with a suspected, probable or confirmed case
- distribution of fact sheets and other information
- epidemiological studies to determine risks for infection.
Outbreaks in residential care facilities or other residential institutions (e.g. prisons or boarding schools)
There have been few if any reports of EVD outbreaks in institutions other than in healthcare facilities. Nevertheless, 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.
13. References and additional sources of information
- Bausch DG, Towner JS, Dowell SF, Kaducu F, Lukwiya M, Sanchez A, et al. Assessment of the risk of Ebola virus transmission from bodily fluids and fomites. J Infect Dis 2007;196 Suppl. 2:S142-147.
- Rowe AK, Bertolli J, Khan AS, Mukunu R, Muyembe-Tamfum JJ, Bressler D, et al. Clinical, virologic, and immunologic follow-up of convalescent Ebola hemorrhagic fever patients and their household contacts, Kikwit, Democratic Republic of the Congo. Commission de Lutte contre les Epidemies a Kikwit. J Infect Dis 1999;179 Suppl. 1:S28-35.
- World Health Organization. Ebola virus disease Fact sheet N°103. 2014.
- Rodriguez LL, De Roo A, Guimard Y, Trappier SG, Sanchez A, Bressler D, et al. Persistence and genetic stability of Ebola virus during the outbreak in Kikwit, Democratic Republic of the Congo, 1995. J Infect Dis 1999;179(1):S170-176.
- World Health Organization. Ebola virus disease in West Africa, situation as of 10 September 2014.
- European Centre for Disease Prevention and Control. Risk assessment guidelines for diseases transmitted on aircraft. Part 2: Operational guidelines for assisting in the evaluation of risk for transmission by transmission. 2010.
Appendix 1. Ebola virus disease factsheet
Appendix 2. PHU checklist for Ebola virus disease
Appendix 3. Jurisdictional Public Health Unit Contact Details and Isolation Hospitals *
Appendix 4. NSW Ebola Virus Disease Patient Assessment Flow Chart [PDF]
Appendix 5. Ebola Virus Disease Case Report Form and Ebola Virus Disease Contact Questionnaire [PDF]
Appendix 6. Ebola Virus Disease Casual Contacts Factsheet
Appendix 7. Ebola Virus Disease Low-Risk Contacts Factsheet and Temperature Log sheet
Appendix 8. Ebola Virus Disease High-Risk Contacts Factsheet and Temperature Log sheet
Appendix 9. Guidance for Returning Aid Workers who have Worked in Healthcare or Community Settings During an Ebola Virus Disease Outbreak *
Appendix 10. Guidance for Aircrews and Cleaning Staff in Management of Ebola Virus Disease *
Appendix 11. Infection Control Advice **
Appendix 12. Cleaning and Disinfection **
Appendix 13. Waste Treatment and Disposal **
Appendix 14. Post-Mortem Care and Examination **
* See the Ebola virus disease national control guidelines (SoNG).
** See NSW Health Guideline (GL2016_002) NSW Contingency Plan for Viral Haemorrhagic Fevers.
15. Jurisdiction specific issues
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.