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PERSONAL PROTECTIVE EQUIPMENT (PPE)


INSTRUCTIONAL VIDEOS
The following training videos are a joint collaboration between Health Canada, the Royal College of Physicians and Surgeons of Canada, the Public Health Agency of Canada and IPAC Canada

 

Ebola Virus Disease (EVD)

Ebola virus disease (formerly known as Ebola haemorrhagic fever) is a severe, often fatal illness caused by Ebola virus. EVD has a case fatality rate of up to 90%. It is one of the world's most virulent diseases.

The virus is transmitted by direct contact with the blood, body fluids and tissues of infected animals or people. Severely ill patients require intensive supportive care. During an outbreak, those at higher risk of infection are health workers, family members and others in close contact with sick people and deceased patients. Ebola virus is not airborne, but may be spread via droplets that are coughed or sneezed from a sick person and enter the eyes, nose, or mouth of another person who is less than two metres away. More information about airborne and droplet transmission.

Epidemiology

2022 Outbreak 

On 20 September 2022, the Ministry of Health in Uganda, together with the World Health Organization - Regional Office for Africa (WHO AFRO) confirmed an outbreak of EVD due to Sudan ebolavirus in Mubende District, Uganda, after one fatal case was confirmed. As of November 7, 2022 Ugandan health authorities have confirmed 136 cases of Ebola, including 53 deaths.

For more information refer to: WHO Ebola Disease Outbreak News  

2018-2020 Outbreak

On 1 August 2018, the Ministry of Health of the Democratic Republic of the Congo declared a new outbreak of Ebola virus disease in North Kivu Province. 

As of June 21, 2020, a total of 3,470 EVD cases, including 3,317 confirmed and 153 probable cases have been reported, of which 2,287 cases died (overall case fatality ratio 66%), and 1,171 have recovered. Of the total confirmed and probable cases, 57% (n=1,970) were female, 29% (n=1,002) were children aged less than 18 years, and 5% (n=171) were healthcare workers.

The Ebola virus outbreak in the Democratic Republic of the Congo continues to evolve in a particularly complex and challenging environment, characterized by a volatile security context, which has hindered the implementation of some key response activities. Successes have been reported from the field and strides have also been made in improving Infection, Prevention and Control (IPC) capacities in health facilities. Enhanced surveillance performance has helped ensured faster isolation of sick individuals, which in turn decreases the likelihood of infection in the community. Continued access and heightened vigilance is required to sustain these gains in case investigation and contact tracing activities. 

Initial data from a randomized clinical trial (RCT) of EVD therapeutics were announced. The data showed that two of the four treatments trialled were more effective in treating EVD. As a result, patients in the four Ebola treatment centres that participated in the RCT will now be randomized to receive the two better performing treatments.

The world’s second largest Ebola outbreak on record was declared over on 25 June 2020. The nearly two year long outbreak was particularly challenging because it took place an active conflict zone. The response involved training thousands of health workers, registering 250 000 contacts, testing 220 000 samples, providing patients with equitable access to advanced therapeutics, vaccinating over 303 000 people with the highly effective rVSV-ZEBOV-GP vaccine, and offering care for all survivors after their recovery.

Summary of epidemiological facts and experience to date: [ref: WHO]
  • The incubation period of EVD varies from 2 to 21 days. An outbreak of EVD is considered to be over when 42 days (double the 21-day incubation period of the ebolavirus) has elapsed since the last patient in isolation became laboratory negative for EVD.
  • Ebola virus is transmitted among humans through close and direct physical contact with infected bodily fluids, the most infectious being blood, faeces and vomit. In a household study, secondary transmission took place only if direct physical contact occurred. No transmission was reported without this direct contact.
  • Ebola virus has also been detected in breast milk, urine and semen. In a convalescent male, the virus can persist in semen for at least 70 days; one study suggests persistence for more than 90 days. Saliva and tears may also carry some risk. However, the studies implicating these additional bodily fluids were extremely limited in sample size and the science is inconclusive. In studies of saliva, the virus was found most frequently in patients at a severe stage of illness. The whole live virus has never been isolated from sweat.
  • Airborne transmission has never been documented.
  • There is no risk of transmission during the incubation period and only low risk of transmission in the early phase of symptomatic patients. The risk of infection during transport of persons can be further reduced through use of infection control precautions.
  • Ebola virus can also be transmitted indirectly, by contact with previously contaminated surfaces and objects. The risk of transmission from these surfaces is low and can be reduced even further by appropriate cleaning and disinfection procedures.

Surveillance

[Ref: PHAC]

EVD has been nationally notifiable in Canada since 2000. As a nationally notifiable disease, ebolavirus cases are reported to the Public Health Agency of Canada through national surveillance systems. The Agency also works closely with its national and international partners, including the World Health Organization, to track EVD outbreaks.

Health care workers in Canada should be vigilant for persons with symptoms compatible with EVD and who have returned from affected countries within 21 days of symptom onset.

Case Classification: [Ref: PHAC]

A person with EVD-compatible symptoms is defined as an individual presenting with fever (temperature ≥ 38.0 degrees Celsius) OR at least one of the following symptoms/signs:

  • subjective fever
  • malaise
  • myalgia
  • headache
  • arthralgia
  • fatigue
  • loss of appetite
  • conjunctival redness
  • sore throat
  • chest pain
  • abdominal pain
  • nausea
  • vomiting
  • diarrhoea that can be bloody
  • haemorrhage
  • erythematous maculopapular rash on the trunk

Epidemiological Risk Factors:

  • Individual who cared for a case of Ebola Virus Disease (EVD).
  • Laboratory worker handling Ebola virus or processing body fluids from a case of EVD.
  • Individual who spent time in a healthcare facility where cases of EVD are being treated in a country/region with widespread and intense Ebola virus transmission.
  • Sexual contact with an EVD case.
  • Close contact in households, healthcare facilities, or community settings with a person with Ebola while the person was symptomatic - close contact is defined as being for a prolonged period of time within approximately 2 meters (6 feet) of a person with Ebola.
  • Contact with any human remains of a case of EVD or contact with human remains in a country/region with widespread and intense Ebola virus transmission.
  • Contact with bats, primates or wild animal bush meat from affected countries/regions.
  • A travel history to a country/region with widespread and intense Ebola virus transmission within 21 days constitutes a low risk factor.

Person Under investigation (PUI)

A person with EVD-compatible symptoms (as defined above) AND EVD has not been ruled out.
  • A travel history to a country/region with widespread and intense EVD transmission within 21 days of symptom onset OR exposure to one of the epidemiological risk factors within 21 days of symptom onset.
  • With or without pending laboratory results for EVD.

Confirmed Case

A person with laboratory confirmation of EVD infection using at least one of the methods below:
  • Isolation and identification of virus from an appropriate clinical specimen (e.g., blood, serum, tissue, urine specimens or throat secretions) (performed at the National Microbiology Laboratory) OR
  • Detection of virus-specific RNA by reverse-transcriptase PCR from an appropriate clinical specimen (e.g., blood, serum, tissue) using two independent targets or two independent samples AND confirmed by the National Microbiology Laboratory by nucleic acid testing or serology OR
  • Demonstration of virus antigen in tissue (e.g., skin, liver or spleen) by immunohistochemical or immunofluorescent techniques AND another test (e.g., PCR) OR
  • Demonstration of specific IgM AND IgG antibody by EIA, immunofluorescent assay or Western Blot by the National Microbiology Laboratory or an approved WHO collaboration centre OR
  • Demonstration of a fourfold rise in IgG titre by EIA, immunofluorescent assay from an acute vs. a convalescent serum sample (performed at the National Microbiology Laboratory).

For more information on EVD surveillance:

Signs and Symptoms

EVD is a severe acute viral illness often characterized by the sudden onset of fever, intense weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhoea, rash, impaired kidney and liver function. Bleeding from gums, nose, injection sites and gastrointestinal tract occurs in about 50% of patients. Dehydration and significant wasting occur as the disease progresses. Laboratory findings include low white blood cell and platelet counts and elevated liver enzymes.

People are infectious as long as their blood and secretions contain the virus. The incubation period is 2 to 21 days. Other diseases that should be ruled out before a diagnosis of EVD can be made include: malaria, typhoid fever, shigellosis, cholera, leptospirosis, plague, rickettsiosis, relapsing fever, meningitis, hepatitis and other viral haemorrhagic fevers.

There is no effective antiviral treatment for ebolavirus infections. Treatment is supportive, and is directed at maintaining renal function and electrolyte balance, and at combatting haemorrhage and shock.

Infection Prevention and Control

For health care providers in Canada: [Ref: PHAC]

  • Ebola virus is transmitted by direct contact (e.g., through broken skin or mucous membranes) with the blood or other body fluids (e.g., stool, urine, saliva, semen) of an infected individual and/or indirectly through contact with environmental surfaces and fomites contaminated with body fluids. Airborne transmission has not been documented.
  • The incubation period of EVD varies from 2 to 21 days. Cases are not considered to be communicable before the onset of symptoms but communicability increases with each subsequent stage of illness and the case remains communicable as long as blood and body fluids secretions contain the virus. This includes the post-mortem period.
  • Use Contact and Droplet Precautions, in addition to Routine Practices, in settings where contact with patients suspected or confirmed to have EVD is anticipated. The need for enhanced PPE (e.g., double gloving, leg and shoe coverings, hair/head covering) is determined by assessing the risk of heavy exposure to blood and body fluids.
  • The effectiveness of PPE (gowns, gloves, masks, facial protection, respirators) is highly dependent on appropriate selection and proper use, including correct technique and sequence for putting on and taking off PPE, discarding into designated receptacles, and hand hygiene to minimize risk of transmission 
  • In health care settings when aerosol generating medical procedures must be performed on suspected or confirmed EVD patients, strategies to reduce aerosol generation must also be implemented.

PERSONAL PROTECTIVE EQUIPMENT (PPE)

INSTRUCTIONAL VIDEOS
The following training videos are a joint collaboration between Health Canada, the Royal College of Physicians and Surgeons of Canada, the Public Health Agency of Canada and IPAC Canada

Vaccines

  • To date, at least 15 vaccines are being developed (in North America, Europe, Russia and China), with four main candidates in varying advanced stages of human testing. The two lead vaccine candidates started human clinical trials in September 2014 and data on their safety and immunogenicity profiles were ready by December-January, breaking all records in terms of vaccine trial Phase I timelines. WHO played a key role in this endeavour, by identifying and coordinating numerous trial sponsors to test the vaccines contemporaneously in the US, Canada, and several countries in Europe and Africa. 

  • Ebola Vaccines -Overview (WHO -2018)
  • Global Ebola Vaccine Implementation Team (GEVIT) Practical Guidance on the Use of Ebola Vaccine in an outbreak response - DRAFT (WHO -2017)
Summary of Recommended IPAC Practices for Hospitalized Patients with EVD (Ref: PHAC)
  1. Accommodation [more information]:
    • Single patient room with dedicated toilet/commode, door closed.
    • Maintain a log of all persons entering room; only essential personnel to enter.
    • Patients who also have symptoms compatible with airborne infections (i.e., measles, tuberculosis) should be placed in an airborne infection isolation room (AIIR) as soon as possible.
    • Although Ebola virus is not transmitted by the airborne route, it may be practical for facilities with airborne infection isolation rooms (AIIR) to isolate suspected EVD patients in an AIIR as this will allow an appropriate space (anteroom) for putting on and taking off personal protective equipment (PPE), ensure the presence of a dedicated washroom, and allow aerosol-generating medical procedures (AGMPs) to be performed, if required.
    • Consider assignment of trained individual to monitor appropriate selection, application, removal and disposal of PPE, to avoid contamination of the HCW, and to monitor entry to room (i.e., limit entry to only essential HCWs).
  2. Hand Hygiene: Hand hygiene is according to the Four/Five Moments for Hand Hygiene (provincial recommendations should apply). Use alcohol-based hand rub, or soap and water if hands are visibly soiled.
  3. Precautions:
    • Perform a point-of-care risk assessment before every interaction with the patient [more information].
    • Use Routine Practices for all care [more information].
    • Use Droplet and Contact Precautions for all care.
    • PPE should be removed and disposed of in the anteroom and hand hygiene performed before touching the face. If an anteroom is not available, PPE should be removed at the doorway before exiting the room. PPE should be discarded in the patient room.
  4. Personal Protective Equipment (PPE) [more information]:
    • PPE should be provided in a clean area outside the patient's room or in the anteroom.
    • Consider assignment of trained individual to monitor appropriate selection and application, removal and disposal of PPE, to observe and ensure HCW not contaminating self and to monitor entry to room (i.e., limit entry to only essential HCWs).
    • The need for enhanced PPE (e.g. double gloving, leg and shoe coverings, hair/head covering), is determined by assessing the risk of heavy exposure to blood and body fluids). Note: In late stages of EVD, there may be copious secretions and excretions.
    • Gloves:
      • Should fit securely over gown cuff and should be worn to enter the patient room
      • Should be removed and discarded into a no-touch waste receptacle and hand hygiene should be performed on exit from the patient room
    • Gown:
      • A long-sleeved, cuffed, fluid-resistant or impermeable gown should be put on prior to entry to the room
      • Reusable gowns should be removed and placed into a no-touch used linen receptacle immediately after use and hand hygiene should be performed before leaving the patient room
      • Disposable gowns should be discarded into a no-touch waste receptacle immediately after use and hand hygiene should be performed before leaving the patient room
    • Facial Protection:
      • Facial protection (i.e., mask and eye protection, or mask and face shield) should be worn on entry to the room
      • Masks with visors are not suitable; face shields should be long enough to prevent splashing underneath; eye glasses are not suitable eye protection
      • AGMPs (aerosol-generating medical procedures):
        • Avoid if possible.
        • If an AGMP is necessary, carry out procedure in an Airborne Infection Isolation Room (AIIR) using Airborne Precautions + Droplet and Contact Precautions. If an AIIR is not available, use a single room.
        • Use current recommendations to reduce aerosol generation. See http://publications.gc.ca/site/eng/440707/publication.html.
  5. Equipment:
    • Only take essential equipment into the patient room.
    • Use disposable equipment whenever possible, or dedicate equipment to the patient.
    • Limit the use of needles/sharps as much as possible.
    • Clean equipment according to routine hospital practices.
    • There are no indications for the use of disposable dishes/cutlery, except in the circumstance of non-functioning dishwashing equipment.
  6. Linen:
    • Disposable linen is preferred.
    • Place soiled linen in clearly-labelled, leak-proof bags at the point-of-use. Handle with minimum agitation to avoid contamination of air, surfaces and persons.
    • Transport linen directly to the laundry area and handle according to routine protocols.
    • Perform hand hygiene after handling soiled linen.
  7. Environmental Cleaning:
    • Provide education and appropriate PPE to those responsible for environmental cleaning.
    • Assign responsibility and accountability for cleaning and disinfection of patient care environment; consider auditing to ensure appropriate processes.
    • Use approved hospital-grade disinfectants for cleaning the environment.
    • Surfaces that are likely to be touched and/or used frequently should be cleaned and disinfected on a more frequent schedule. This includes surfaces that are in close proximity to the patient (e.g., bedrails, bedside/over-bed tables, call bells) and frequently touched surfaces in the patient care environment, such as door knobs, surfaces in the patient's bathroom.
    • Additional cleaning measures or frequency may be warranted in situations where environmental soiling has occurred.
    • When precautions are discontinued or the patient is moved, terminal cleaning of the room/bed space and bathroom, changing of privacy curtains and cleaning and disinfection or changing of string/cloth call bells or light cords should be done.
    • Biomedical waste (e.g., items soaked with blood or secretions) should be contained in impervious waste-holding bags or double bags according to municipal/regional regulations.
    • Blood, suctioned fluids, excretions and secretions should be disposed of in a sanitary sewer or septic system according to municipal/regional regulations.
  8. Visitors: Only essential visitors should enter the patient's room.
 

More information:

Laboratory Information and Specimen Collection

[Ref: PHAC]

Samples from patients are an extreme biohazard risk. Testing for Ebola virus should be conducted under maximum biological containment conditions.

The Public Health Agency's National Microbiology Laboratory (NML) is the only facility in Canada that can work with live haemorrhagic fever viruses such as Ebola virus. The NML offers the world's highest level of containment and meets or exceeds all national and international guidelines for safety and security.

Health professionals should not undertake any laboratory testing on a patient suspected of having EVD or any other viral haemorrhagic fever infection.

If a sample requires testing, immediately contact the Agency's 24-hour emergency line: 1-800-545-7661. An expert will assist you in developing an Emergency Response Assistance Plan for the safe shipping of the sample to the Agency's NML.

Travel Advice

As of June 12, 2019 it is recomended that Canadians should practise special health precautions, such as receiving additional vaccinations. A notice at this level would be issued if there is an outbreak in a limited geographic location, a newly identified disease in the region or a change in the existing pattern of disease (Level 2 Travel Warning) 

The risk of a tourist or businessman/woman becoming infected with Ebola virus during a visit to the affected areas and developing disease after returning is extremely low, even if the visit included travel to the local areas from which primary cases have been reported. Transmission requires direct contact with blood, secretions, organs or other body fluids of infected living or dead persons or animals, all unlikely exposures for the average traveller. Tourists are in any event advised to avoid all such contacts. [Ref: WHO]

Ebola Links

Public Health Agency of Canada (PHAC)
World Health Organization (WHO)
Centers for Disease Control (CDC)
Provincial

British Columbia

Manitoba

Alberta

New Brunswick

Newfoundland/Labrador

Nova Scotia

Ontario

Other Links