Ebola Virus Disease: 2014 Outbreak

Hi.  My name is Dr. Josée Pilon, and I’m the Acting National Medical Advisor with the Public Service Occupational Health Program at Health Canada. 

(A blue banner appears on screen with the name and title of the speaker. It reads Dr. Josée Pilon M.D, A/National Medical Advisor, Public Service Occupational Health Program, Health Canada)

So today, I’m going to be talking about Ebola virus disease and some basic occupational health safety principles that are applicable to Ebola.

The aim of this presentation is to provide you with some basic information as well as to alleviate some of the anxiety and the fears that is associated with Ebola. 

What I’m going to be talking today is on the signs and symptoms of Ebola, how it is spread and the transmission as well as a list of countries where there is currently the outbreak of Ebola, followed by risk and how to protect yourself, including a brief overview on the role of protective – on personal protective equipment followed by a summary of currently available treatment and closing off with some key messages for you to remember.

So what is Ebola virus disease? It is a severe viral infection that causes hemorrhagic fever in humans and animals.  It has been discovered 38 years ago, in 1976.  It was found in remote villages in Central Africa near tropical rainforests.

What is different with this current outbreak is that it is fairly large, fairly involved and affects major urban centres in three separate countries as well as rural areas. 

This particular outbreak has a case fatality rate in West Africa of approximately 70 percent.

Ebola infection can only be diagnosed through laboratory testing, and at the present time in Canada, it is done at Biosafety Level 4 labs with the National Medical Laboratory of the Public Health Agency of Canada.  The Public Health Agency of Canada is also providing assistance to our provinces to develop the capacity to do this test, which would permit for the early identification and diagnosis of possible Ebola cases, thereby being able to provide treatment or, if another diagnosis is made, to provide appropriate treatment to a person who presents with symptoms suggestive of Ebola.
Something to remember also about this particular disease, it has an incubation period of two to 21 days, with the average being eight to 10 days with this particular outbreak.

So what is incubation period?  It is the period of time when someone becomes infected with Ebola, but doesn’t yet manifest any symptoms.  So it is from the moment they catch the disease and then the infection remains inside the body, but it’s not active and there’s no transmission until the moment this person then manifests symptoms of Ebola.

So what are those symptoms of Ebola? 

(Image appears on screen with the title Signs and Symptoms of EVD. It provides an overview of the signs and symptoms of the virus. This includes the initial symptoms,fever and chills, muscle pain and weakness, headache, sore throat. Additional symptoms: nausea, vomiting, diarrhea, rash, impaired kidney and liver function, internal and external bleeding can occur in certain cases, and hemorrhagic symptoms  (oozing from the gums, blood in the stools) occur in about 50%-60% of cases, often in the later stages of disease.)

So the initial symptoms are fever, chills, muscle pain, fatigue, headaches and sore throat, and they sound very similar to that of the common cold as well as to that of influenza.  Additional symptoms then follow a few days later, and that is nausea, vomiting, diarrhea and a rash, and the rash is usually because of some bleeding under the skin.  There’s also impaired kidney and liver function, and this will be manifested by fatigue.  And by that time, the individual is quite sick, is also in need of significant supportive medical care in hospital. 

There can also be a manifestation of internal and external bleeding or hemorrhages, which can happen in certain cases.  This can be seen in approximately 50 to 60 percent of cases, but usually in the latter stages of the disease.  Now the hemorrhagic symptoms or the bleeding symptoms are not those that are commonly seen in movies that have been portrayed, for instance, by Hollywood.  It is usually more some oozing from the gums or some blood in the stools or in the vomitus as well as to have some bleeding from intravenous site.

So how is Ebola spread?

(Image appears on screen with the title How is Ebola Spread. The slide explains how the Ebola virus disease is spread through contact with blood, body fluids or tissues of infected persons; objects contaminated with blood or body fluids of an infected person; and infected animals (chimpanzees, gorillas, monkeys, forest antelope, pigs, porcupines, duikers and fruit bats.) It highlights that airborne spread has not been documented among humans.Infected persons are contagious only once they begin to show symptoms.They are not contagious during the incubation period.Ebola is not spread through casual contact.)

It requires direct contact with the blood, the body fluids or the tissues of an infected person.  Any object as well that is contaminated with that blood or the body fluids of an infected person is also potentially infectious.  As well, in countries where there is Ebola, particularly in Africa, some infected animals may also spread Ebola, and this is usually related to the butchering and the preparation of bush meat, such as with chimpanzee, gorillas and so on, and it is meat that is believed to have been contaminated by bats. 

The airborne spread of Ebola has not been documented amongst humans, so from person to person contact – from person to person transmission.  Again, the transmission is from direct contact with a sick individual that has symptoms of Ebola or contact with the body fluids. 

As well, another key point to remember is that Ebola is only contagious once the individual is showing symptoms of the disease.  So they are not contagious during the incubation period, which I’ve mentioned earlier was of 21 days.  Ebola is also not spread through casual contact.  So if I’m in the same room, for instance, with someone else who has the disease, I will not be at risk of the disease because unlike TB and influenza, it is not dispersed in the air.  It requires direct contact with the person – with its infected blood or body fluids.

So where is the Ebola outbreak at the present time?  There – it is mainly in West Africa, and the currently affected countries where there is widespread and intense transmission with thousands of cases and deaths are Guinea, Liberia and Sierra Leone.  There’s also a separate outbreak in the Democratic Republic of the Congo which is related to a different outbreak and a different strain of Ebola.

There also have been countries where there has been an initial case from an imported transmission, and there have been very limited cases of transmission within the country and usually to health care workers, and this is the United States, Spain and Mali.  We’ve also seen some limited transmission in Nigeria and Senegal.  However, they have been now declared Ebola-free.  And this is remarkable.  And it shows that this disease can be contained and can be controlled and we can stop the transmission.  And because of our robust medical care in Canada, the same can be applicable here should – in the unfortunate event that Ebola be diagnosed on Canadian soil.

So what is the risk to our employees?

(Image appears on screen with the title Risk to Employees: Very Low. This slide outlines general safety measures that federal employees should follow to protect themselves against the Ebola virus disease in the workplace. The risk to Canadians remains very low. This includes employees in overseas missions and at Points of Entry.
The Ebola virus does not spread easily from person to person. It is spread through contact with infected body fluids of persons showing signs of illness or those who have died. As long as appropriate precautions are taken, there is a very low risk of contracting Ebola. Individuals who have close unprotected (i.e. without personal protective equipment) contact with infected humans and animals are most at risk. These include hospital staff and health care workers, laboratory or quarantine facility workers, family members caring for patients, individuals handling deceased infected bodies and individuals handling infected wild animal carcasses.)

Our Chief Public Health Officer as well as Minister has repeatedly stated that the risk to Canadians remains very low.  And why is that so?  There has never been a case of Ebola in Canada, and Ebola is not easily transmitted from person to person.  And it is also a fragile virus.  We also have a robust medical system and public health system that will permit the early identification and subsequent management of any cases, including contact tracing and so on.  So all the public health measures are there necessary in order to contain and prevent further transmission of any possible imported case, should that happen in Canada.

So the Ebola does not spread easily from person to person.  It is spread through direct contact with infected body fluids of persons showing signs of illness or those who have died.  And as long as appropriate precautions are taken, there’s also very low risk of contracting Ebola.

And those people who are most at risk are not our employees; they’re mostly health care workers, and this is what has been seen in some countries.  It is the individuals who have very close and intimate contact with the sick because of the nature of their work and because this disease can be so serious and does require very close contact.  So it is the hospital staff, health care workers and nurses who are most at risk, and as well some laboratory and quarantine facilities worker because of some closer contact or because of manipulation of blood.

Family members also who care for these patients are also at greater risk, but this is more so in Africa and Western Africa where there might be limited capacity for the health care system to handle these cases, and unfortunately, they have to be cared at home.  This is not the case here where it is strongly recommended that any case, any suspected case be handled by our medical system.

Individuals as well who are handling deceased infected bodies are at risk as well as individuals who are handling infected wild animal carcasses or what is commonly called bush meat, but the bush meat is not the meat that is found in Canada.  It is bush meat that originated from Africa such as gorilla, chimpanzee and so on.  And it is also illegal to have this bush meat in Canada.

So how to protect yourself at work? 

(Image appears on screen with the title Protecting Yourself at Work. It lists further personal protective measures that federal employees should take to avoid contracting the Ebola virus disease. Know the symptoms of Ebola. Stay informed on the current outbreak. Follow your Health and Safety procedures, including recommendations for the safe and effective use of personal protective measures. Use general Safety Measures such as personal hygiene, such as frequent hand washing, avoiding touching your eyes, nose and mouth, and avoiding close contact with people who are sick. Regularly clean and disinfect of commonly used and shared surfaces.)

Well, assisting to this presentation is just one tool to protect yourself because you will know the symptoms of Ebola and how to recognize it and keeping informed on the current outbreak.  So it’s important to look at the source of information as well.  So the Public Health Agency of Canada has a lot of very useful information that you can use to keep informed and to obtain additional information on protection in the workplace, but other reliable sources include also the World Health Organization that are coordinating international efforts to control Ebola.

Following the health and safety procedures at work as well, including recommendations for the safe and effective use of personal protective equipment and personal protective measures are essential. 

There are also general safety measures that everyone can implement in the workplace, which are effective against many infectious diseases, not simply for Ebola.  And what are these measures?  There are three essential ones.  Personal hygiene such as hand-washing.  And if soap and water is not available, using an alcohol-based sanitizer is quite effective and recommended.  And when would you do hand-washing?  Before eating, whenever you touch your face or your eyes or your nose, it’s important to remember to practise hand hygiene, after sneezing or coughing and so on.

Avoiding touching your eyes, your nose, your mouth as well as avoiding close contact with people who are sick is also an important general safety measure to put in place.

And lastly, at work, regular cleaning and disinfection of commonly used and shared surfaces is also essential to have in place in order to minimize transmission of viruses that could be shared in the office.

With respect to Ebola and being overseas, particularly in West Africa, there are specific measures that are applicable to this viral infection, and they are related to its transmission with direct contact with blood and body fluids.

So what are these measures?  The avoidance of direct contact with blood, saliva, vomit, urine, and any body fluid is essential.  Avoiding contact with any object such as soiled needles and clothing of an infected person that has been soiled with blood or body fluid is essential.  This precautionary principle applies, however, to any unknown illness with any unknown infectious origin.  As well, practising regular hand hygiene, avoiding touching your eyes, nose and mouth, avoiding close contact with people who are sick, avoiding contact with the deceased, avoiding contact with animals and raw animal meat or bush meat when travelling are essential measures to put in place.

When travelling, you may be offered some meat that comes from tropical places and so on.  It is important to remember that if it’s well cooked, the risk of transmission is thereby negligible and not present.  It is believed that fruits bats are the likely natural reservoir of Ebola, and it’s also recommended to avoid any contact and any handling of fruit bats.

There are guidance documents available on the Public Health Agency of Canada website, which can also guide employers as well as our Health and Safety Unit to develop and implement their procedures to ensure health and safety of their employees in the workplace.  These are listed on that particular slide, and it is recommended to familiarize yourself with what is available on the Public Health Agency of Canada website.  There is also travel health notices should an employee be travelling overseas.  However, at the present time, there are travel health notices to avoid any essential travel to areas where there is currently widespread and intense transmission of Ebola, and that includes the following three countries:  Guinea, Liberia and Sierra Leone. 

I’m now going to go over a basic approach to – basic measures on how to approach a person of an unknown health status appearing sick who comes to your workplace, so either a client or a visitor.  And we are talking here about the non health care setting because there are particular procedures that would be applicable to first responders and to emergency medical system in response to a medical situation. 

So what is important to remember is to initially identify who is at risk of having Ebola, and it is those individuals who have the following history.  So a history of travel from a country where the outbreak is currently occurring.  Thereby, it’s essential to be up to date with respect to the current outbreak and where is it located at the present time.

Someone with a history of contact with a person or contact with a deceased who was infected with Ebola is also another risk factor that can be elicited in a conversation with this person who is sick.

And also any individual who is returning from a health care facility where Ebola is presently being treated could also potentially be an individual who is at risk of having Ebola when they have – when they are manifesting fever or any other illnesses. 

So once you’ve identified this particular individual, there are some measures that can be put in place in the workplace to protect yourself and protect others.  So these include the following. 

So isolating or separating this sick individual from the flow of normal visitors and from the flow of activity within your workplace. It may not be necessary to have what’s called an isolation room, but simply having an area that is dedicated for this person in order to remain until further assessment is done and further measures are applied. 

Remember to practise hand hygiene.  So any interaction with this person – should there be any interaction with this person, it is essential to remember to practise hand hygiene by offering this individual an alcohol-based hand sanitizer and doing the same for you. 

There should also be a procedure in place where there is a referral to the local health facilities in order to determine what further measures should be put in place and with the information that was gathered through a discussion with the sick person — for instance, their travel history, their symptoms and their contact.  But we have trained health professionals that also know how to ask these questions and will be able to get further information through their own specific medical risk assessment.

If there’s any close interaction that is required with a sick individual in the workplace, you may also want to consider the use of protective measures according to a risk assessment and based on your role and activities.  That at minimum will include the use of gloves if you have to provide some first aid.

It will also be necessary to consider having in place cleaning and disinfection procedures.  Securing the area where the person was located should be a consideration and should be done until there is confirmation of diagnosis.

Further infection prevention control measures will then be guided by the Occupational Health and Safety Unit as well as from the local public health authorities who will provide you with advice on the decontamination that is needed as well as the sanitization process should there be an unfortunate diagnosis of Ebola that is confirmed. 

This infographic is produced by the Public Health Agency of Canada, and it may be a useful document to have if your workplace has a regular flow of visitors that are coming from all over the world.

(Infographic appears on screen. This slide shows an infographic produced by the Public Health Agency of Canada. The infographic is divided into three sections. In the top section, in the upper left corner, the question “Have YOU travelled from Africa recently?” appears. Underneath the question, the words “You can only get Ebola if you have touched” are followed by three bullet points listing how the virus is transmitted. Underneath the three bullet points are pictures of blood droplets, a needle, a monkey and a bat. To the left of the image of the blood droplets is a bullet point stating that you cannot get Ebola from the air. At the centre of the infographic is an image of the continent of Africa. The countries affected by Ebola outbreaks are highlighted on the map. Below the map, is a list of the countries experiencing Ebola outbreaks. In the upper left corner of the infographic are the words “What to do if you feel sick”. Below these words is a picture of a calendar and a cell phone, and a recommendation that if you feel sick and were in Africa in the last 21 days, you should call a health care provider as soon as possible. The number 21 is highlighted in this sentence. To the right of the picture of the calendar is a list of three pieces of information that you should tell your health care provider if you feel sick. At the very bottom of the infographic is the URL for the Public Health Agency of Canada, the Public Health Agency of Canada signature and the Canada wordmark.)

In the bottom section,

And it may serve as a reminder of the type of question that you may ask them, particularly if they feel sick or unwell.  And one of the key questions is asking whether they have travelled from Africa recently and with the specific countries where the outbreak is currently happening that are described in that infographic.  And then having a telephone number of the public health authorities to contact should there be any need to do further action is also important to have as part of procedures that would be developed within your workplace.

Many people have asked also about the role of personal protective equipment. So I just wanted to provide here some basic information about what exactly is this because we’ve all seen in the media and in the news these health care workers with what is called like a moon suit.  So these workers are using this because it’s part of their day to day activity, and they have intimate contact with someone who is very sick, and they need this equipment to protect yourself.  It’s a little bit different within the workplace because we don’t have this type of contact, and it’s not expected that we will provide direct care to a person.

So the personal protective equipment is just one of the measures in infection prevention control.  It provides a barrier between the worker and the infectious agent, and that’s what a glove is.  The choice of the equipment such as a glove or a mask will depend on the activity that is conducted and also on the barrier that is required, according to the mode of transmission. 

And what does mode of transmission mean?  Well, it could be direct contact.  That’s why I wear gloves.  It could be by droplet, so a surgical mask or just a mask for a person who is sick and coughing will afford some protection and prevent the source from transmitting bacteria or viruses from coughing.  Or it could be airborne.  So there are different types of equipment that is used according to very specific situations.

It’s also essential to remember that if someone decides to use personal protective equipment, that it does require specific training for its proper use because not knowing how to use this equipment could also carry a risk by itself, so it requires very careful donning or putting on and careful removal according to a very specific sequence and procedures that would be provided to you in your workplace, should it be required, by your Occupational Health and Safety Unit. 

I’m now going to go over some – what are the – I’m now going to go over the treatment that is required for Ebola.  So at present, there is no specific licensed treatment that is available or a vaccine.  And patients are treated in hospitals for their symptoms according to clinical presentation following three key principles:  strict isolation to prevent the infection from spreading; intensive care and supportive therapy as well as maintenance of core body functions, which includes maintenance of fluid level, oxygen, blood pressure and so on.  This can only be afforded in hospital.  There are professional resources available on Public Health Agency of Canada website that will guide health professionals to get more information on treatment.

And on that particular website as well, there’s also additional information on infection and prevention controls that can be good resources to your local Health and Safety Unit. 

We’ve also heard of innovative and experimental therapy.  So what exactly is that?  It is a therapy that has not yet been proven to be effective, and it’s not part of the recommended routine treatment.  For instance, using a specific antibiotic for strep throat is fairly routine and standard.  So experimental therapy is different.  The drugs may not yet have received approval or gone through rigorous testing.  It hasn’t yet been proven to be effective in all cases.  There’s insufficient data or it hasn’t yet been tested in humans. 

However, there are clinical trials that are underway at the present time, and a lot of efforts with international stakeholders to pursue more scientific testing and trials to ensure that these treatment will be available in the near future for Ebola.  These includes vaccine such as the one that was discovered at the Public Health Agency of Canada as well as treatment specific to Ebola, which includes monoclonal antibodies, the famous ZMapp that we have heard that was administered to a few individuals that were medically evacuated.  ZMapp is interesting because it also has a Canadian involvement with the discovery of two of the three elements that forms this particular product. 

There are also other therapies that is available for – that will be considered for testing and that are used also as experimental therapy, and that includes plasma from individuals who have recovered in order to make use of their antibodies, certain antiviral and so on.

Lastly, I just want to relate again some key messages with respect to Ebola.

(Image appears on screen with the title Kew Messages. It lists four key messages that federal employees should remember regarding the Ebola virus disease. Ebola is not airborne. Transmission is from direct contact with body fluids from an infected and sick individual. There is no transmission during the incubation period. Regular hand hygiene is an essential component of infection control. Virus is easily destroyed by disinfectant such as bleach. At the bottom of the slide, three small clip-art pictures appear: a picture of a person using hand sanitizer; a picture of hands being washed under a running faucet; and a picture of a hand mixing a cleaning solution that includes bleach.)

It is not airborne and is not transmitted by air. It requires – it is transmitted through direct contact with body fluids from an infected and sick individual.  It’s also essential to remember that there is no transmission during the incubation period.  Another key message to remember is that regular hand hygiene is an essential component of infection control measures, and it will be useful for this particular condition, for Ebola, but also in any situation where there is a risk of transmission from infection.

The virus Ebola is also a fragile virus and is easily destroyed by routine disinfection and disinfectants such as bleach. 

So I hope that this presentation was useful and has assisted in providing you with useful information as well as alleviating some of the anxieties and the concerns that you may have with Ebola.  If any of you have questions that have not been answered or you have additional concerns, you are welcome to contact us through the Public Health Agency of Canada website, through web mail or at the Public Service Occupational Health Program.

Thank you.

(The Canada Wordmark appears on screen)