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Ebola

Ebola

Introduction

The virus family Filoviridae includes three genera: Cuevavirus, Marburgvirus, and Ebolavirus. There are five species of Ebolavirus that have been identified: Zaire, Bundibugyo, Sudan, Reston and Taï Forest. The first three, Bundibugyo ebolavirus, Zaire ebolavirus, and Sudan ebolavirus have been associated with large outbreaks in Africa. The virus causing the 2014 West African outbreak belongs to the Zaire species. (1)
The Ebola virus causes an acute, serious illness which is often fatal if untreated. Ebola virus disease (EVD) first appeared in 1976 in 2 simultaneous outbreaks, one in Nzara, Sudan, and the other in Yambuku, Democratic Republic of Congo. The latter occurred in a village near the Ebola River, from which the disease takes its name.
The current outbreak in West Africa, (first cases notified in March 2014), is the largest and most complex Ebola outbreak since the Ebola virus was first discovered. There have been more cases and deaths in this outbreak than all others combined. It has also spread between countries starting in Guinea then spreading across land borders to Sierra Leone and Liberia, by air (one traveler to Nigeria, and by land (one traveler) to Senegal.
The most severely affected countries, Guinea, Sierra Leone and Liberia have very weak health systems, lacking human and infrastructural resources, having only recently emerged from long periods of conflict and instability. On August 8, the WHO Director-General declared this outbreak a Public Health Emergency of International Concern. (1)
Infection with the Ebola virus can be deadly: Ebola Hemorrhagic Fever (EHF) has had a fatality rate up to 90 percent in some outbreaks. Individuals with EHF generally have symptoms typical of viral illnesses, including fever, fatigue, muscle pain, headache, and sore throat. The illness progression includes nausea, vomiting, diarrhea, and impaired organ function. In some cases, rash, internal and/or external bleeding, and death may occur.

Naturally-occurring EHF outbreaks are believed to start with contact with infected wildlife (alive or dead), and then spread from person to person through direct contact with body fluids such as, but not limited to, blood, urine, sweat, semen, breast milk, vomit, and feces. The infection can be spread when body surfaces that can easily absorb blood-borne pathogens, such as open cuts, scrapes, or mucous membranes (e.g., lining of mouth, eyes, or nose) come into direct contact with infectious blood or body fluids.

Transmission

Ebola virus is not spread through:
●Casual contact
●Air
●Water
●Food grown or legally purchased in the U.S.
People are exposed to Ebola virus by direct contact with the body fluids of a person who is sick with or has died from Ebola. (blood, vomit, urine, feces, sweat, semen, spit, other fluids),Objects contaminated with the virus (needles, medical equipment), Infected animals (by contact with blood or fluids or infected meat).

Early Symptoms
Ebola can only be spread to others after symptoms begin. Symptoms can appear from 2 to 21 days after exposure. Symptoms include:
• Fever
• Headache
• Diarrhea
• Vomiting
• Stomach pain
• Unexplained bleeding or bruising
• Muscle pain

Symptoms typically appear abruptly, within 2-21 days (8-10 days is most common) following exposure to the virus. Thus, individuals exposed while living, working, or traveling in areas experiencing an ongoing outbreak or where EHF is endemic could develop symptoms up to three weeks after exposure. However, EHF is believed to be contagious only once an individual begins to show symptoms. After 21 days, if an exposed person does not develop symptoms, they will not become sick with Ebola.

EHF is not generally spread through casual contact. The risk of infection with Ebola virus is minimal if you have not been in close contact with the body fluids of someone sick with or recently deceased from EHF.

While a case may not be diagnosed immediately, it is easy to identify and isolate symptomatic individuals. Only persons having close contact with someone who is sick with EHF or with their body fluids are at significant risk for exposure. This generally includes healthcare workers or family members caring for a sick individual. Airline flight crew, servicing and cargo employees; laboratory workers; mortuary and death care workers; individuals involved in border protection, customs, and quarantine operations; emergency responders; and other workers in other critical sectors may come into contact with sick individuals or their body fluids. (2)

Patients become infectious once they are symptomatic (2 to 21 days after infection; see box), and may remain infectious even after symptoms subside (virus persists in body fluids). The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) estimate an interval of 7 weeks to 3 months for continued infectivity and recommend precautions for this period. Once someone recovers from Ebola, they can no longer spread the virus. However, Ebola virus has been found in semen for up to 3 months. Abstinence from sex (including oral sex) is recommended for at least 3 months. If abstinence is not possible, condoms may help prevent the spread of disease. (3)

Prevention

OSHA’s Bloodborne Pathogens standard (29 CFR 1910.1030) covers exposure to Ebola virus. Ebola is among the subset of contact-transmissible diseases to which the Bloodborne Pathogens standard applies, as it is transmitted by blood or other potentially infectious materials as defined in the standard.

In situations where workers may be exposed to bioaerosols containing Ebola virus, employers must also follow OSHA’s Respiratory Protection standard (29 CFR 1910.134).

Other elements of infection control for Ebola, including a number of precautions for contact-transmissible diseases, are covered under OSHA’s Personal Protective Equipment (PPE) standard (29 CFR 1910.132) and the General Duty Clause of the Occupational Safety and Health (OSH) Act of 1970, which requires employers to keep their workplace free of recognized hazards that can cause death or serious harm to workers.

Employers may also be required to follow these and other standards to protect their workers from exposure to chemicals used for cleaning and disinfection. Depending on the specific chemicals used, different or additional PPE (e.g., elastomeric respirators with appropriate cartridges) may be required. (4)

Currently, most workers in the U.S. are unlikely to encounter Ebola virus or individuals with Ebola Hemorrhagic Fever (EHF). However, exposure to the virus or someone with EHF may be more likely in certain sectors, including the healthcare, mortuary/death care, and airline servicing industries. Workers who interact with people, animals, goods, and equipment arriving in the U.S. from foreign countries with current EHF outbreaks are at the greatest risk for exposure.

Precautionary measures for preventing exposure to the Ebola virus depend on the type of work, potential for Ebola-virus contamination of the work environment, and what is known about other potential exposure hazards. Infection control strategies may have to be modified to include additional selections of personal protective equipment (PPE), administrative controls, and/or safe work practices. OSHA has developed interim guidance to help prevent worker exposure to Ebola virus and individuals with EHF.

CDC has activated its Emergency Operations Center (EOC) to help coordinate technical assistance and control activities with partners. CDC has deployed several teams of public health experts to the West Africa region and plans to send additional public health experts to the affected countries to expand current response activities.

If an ill traveler arrives in the U.S., CDC has protocols in place to protect against further spread of disease. These protocols include having airline crew notify CDC of ill travelers on a plane before arrival, evaluation of ill travelers, and isolation and transport to a medical facility if needed. CDC, along with Customs & Border Patrol, has also provided guidance to airlines for managing ill passengers and crew and for disinfecting aircraft. CDC has issued a Health Alert Notice reminding U.S. healthcare workers about the importance of taking steps to prevent the spread of this virus, how to test and isolate patients with suspected cases, and how to protect themselves from infection. (5) (See Additional Resources below)

Interim general guidance for workers

The following are OSHA’s requirements and recommendations for protecting workers whose work activities are conducted in an environment that is known or reasonably suspected to be contaminated with Ebola virus (e.g., due to contamination with blood or other potentially infectious material). These general guidelines are not intended to cover workers who have direct contact with individuals with EHF.

Employers should follow recognized and generally accepted good infection control practices, and must meet applicable requirements in the Personal Protective Equipment standard (29 CFR 1910.132, general requirements) and the Respiratory Protection standard (29 CFR 1910.134).
Use proper personal protective equipment (PPE) and good hand hygiene protocols to avoid exposure to infected blood and body fluids, contaminated objects, or other contaminated environmental surfaces. Wear gloves, wash hands with soap and water after removing gloves, and discard used gloves in properly labeled waste containers.

Workers who may be splashed, sprayed, or spattered with blood or body fluids from environmental surfaces where Ebola virus contamination is possible must wear face and eye protection, such as a full-face shield or surgical masks with goggles. Aprons or other fluid-resistant protective clothing must also be worn in these situations to prevent the worker’s clothes from being soiled with infectious material.

Workers tasked with cleaning surfaces that may be contaminated with Ebola virus must be protected from exposure. Employers are responsible for ensuring that workers are protected from exposure to Ebola and that workers are not exposed to harmful levels of chemicals used for cleaning and disinfection. OSHA’s Cleaning and Decontamination of Ebola on Surfaces (PDF*) Fact Sheet provides guidance on protecting workers in non-healthcare/non-laboratory settings from exposure to Ebola and cleaning and disinfection chemicals. CDC also offers specific guidance for workers cleaning and disinfecting surfaces that have been in contact with blood or body fluids from a traveler known to have or suspected of having EHF.

Employers must train workers about the sources of Ebola exposure and appropriate precautions. Employers must train workers required to use personal protective equipment on what equipment is necessary, when and how they must use it, its limitations and how to dispose of the equipment. In addition where workers are exposed to blood or other potentially infectious materials, employers must provide the training required by the Bloodborne Pathogens standard, including information about how to recognize tasks that may involve exposure and the methods to reduce exposure, including engineering controls, work practices, and personal protective equipment.

OSHA’s “Protecting Workers during a Pandemic” (PDF*) Fact Sheet provides general guidance about principles of worker protection that may be useful during a wide-spread disease outbreak.
The National Institute for Occupational Safety and Health (NIOSH) Ebola page also provides guidance for protecting workers. (4)

Disinfectants for Ebola virus

• Use an EPA-registered disinfectant suitable for non-enveloped viruses (e.g., adenovirus, norovirus, poliovirus) to treat contamination/spills and to disinfect surfaces after bulk spill material has been removed. See www.epa.gov/oppad001/chemregindex.htm. Follow manufacturer instructions for the specific disinfectant.
• When commercial disinfectant products are unavailable, common household bleach and other appropriate disinfectants may be effective alternatives.
• Use a 1:10 solution of bleach to water (e.g., 1 cup of bleach in 9 cups of water).
• Never mix chemicals together. Certain combinations of chemicals can be deadly or can reduce the effectiveness of the disinfectant. (4)

Guidelines for cleaning and disinfection

• Immediately clean and disinfect any visible surface contamination from blood, urine, feces, vomit, or other body fluids that may contain Ebola virus.
• Isolate areas of suspected Ebola virus contamination until decontamination is completed to minimize exposure to individuals not performing the work.
• Cover spills with absorbent material (e.g., paper towels), then pour disinfectant on to saturate the area, and allow bleach to soak into spills for at least 30 minutes before cleaning to allow it to kill any virus or other infectious agents that may be present.
• Treat any visible contamination or bulk spill matter with a suitable disinfectant (described on p. 2) before cleaning up and removing bulk material.
• After disinfecting and removing bulk material, clean and decontaminate the
surface using the disinfectant.
• Ensure adequate ventilation in areas where workers are using disinfectants, including by opening windows and doors, or using mechanical ventilation equipment.
• In some cases, the use of chemical disinfectants may require an employer to train workers about how to protect themselves against chemical hazards and comply with OSHA’s Hazard Communication, 29 CFR 1910.1200, and other standards. (4)

Additional Resources: (From OSHA (3))

General Ebola Information

• Ebola Hemorrhagic Fever. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).
• Ebola and Other Emerging Infectious Diseases. National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).
• Questions and Answers on Ebola (PDF). Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).
• Ebola Virus Disease. World Health Organization (WHO).
• Frequently Asked Questions on Ebola Virus Disease. World Health Organization (WHO).
• Information Resources on Ebola Virus Diseases. World Health Organization (WHO).
• Blog post – Eradicating Ebola: In U.S. Biomedical Research, We Trust. Director’s Blog, National Institutes of Health (NIH), U.S. Department of Health and Human Services (HHS).

Ongoing Ebola Outbreak

• Health Alert Network. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. Provides up-to-date information about urgent public health incidents with public information officers; federal, state, territorial, and local public health practitioners; clinicians; and public health laboratories.
• Ebola Virus Disease Update – West Africa. World Health Organization (WHO).
General Resources for Workers
• Bloodborne Infectious Diseases. National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS). Though not specific to Ebola, describes engineering controls and work practices to prevent exposure to blood and other body fluids through which the virus is transmitted.
• Protecting Workers during a Pandemic (PDF*) Fact Sheet. Occupational Safety and Health Administration (OSHA), U.S. Department of Labor (DOL). Provides general guidance about principles of worker protection that may be useful during a wide-spread disease outbreak. Covers social distancing, engineering controls, respiratory protection, and other infection control methods.
• Workplace Safety & Health Topics – Ebola. National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Cleaning and Decontamination

• Cleaning and Decontamination of Ebola on Surfaces (PDF*) Fact Sheet. Occupational Safety and Health Administration (OSHA), U.S. Department of Labor (DOL). Provides guidance on protecting workers in non-healthcare/non-laboratory settings from exposure to Ebola virus, and from harmful levels of chemicals used for cleaning and disinfection.

Information for Healthcare Workers

• Healthcare Infection Control Practices Advisory Committee (HICPAC). Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).
• Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola. World Health Organization (WHO).
• Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in US Hospitals. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).
• Safe Management of Patients with Ebola Virus Disease in U.S. Hospitals. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).
• Guidance on Air Medical Transport for Patients with Ebola Virus Disease. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).
• Interim Guidance for Environmental Infection Control in Hospitals for Ebola Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).
• CDC Infection Control for Viral Hemorrhagic Fevers in the African Health Care Setting. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).
• CDC Viral Hemorrhagic Fevers: Infection Control Posters for the African Health Care Setting. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Information for Airline Cabin Crews

• Interim Guidance about Ebola Virus Infection for Airline Flight Crews, Cleaning Personnel, and Cargo Personnel. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).
• Infection Control Guidelines for Cabin Crew Members on Commercial Aircraft. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).
• Guidance for Airlines on Reporting Onboard Deaths or Illnesses to CDC. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).
• Guidance for managing ill onboard passengers (PDF). International Civil Aviation Organization (ICAO).

Information for Mortuary & Death Care Workers

• Guidance for Safe Handling of Human Remains of Ebola Patients in U. S. Hospitals and Mortuaries. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Information for Laboratory Workers

• Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Persons Under Investigation for Ebola Virus Disease in the United States. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).
• Interim Laboratory Guidelines for Handling/Testing Specimens from Cases or Suspected Cases of Hemorrhagic Fever Virus (HFV) (PDF). American Society for Microbiology (ASM).Kortepeter, M. G., Martin, J. W., Rusnak, J. M., Cieslak, T. J., Warfield, K. L., Anderson, E. L., & Ranadive, M. V. (2008).
• Managing Potential Laboratory Exposure to Ebola Virus by Using a Patient Biocontainment Care Unit (PDF). Emerging Infectious Diseases, 14(6), 881.
• Biosafety in Microbiological and Biomedical Laboratories (BMBL), 5th Edition. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS). Features the most recent guidance on protecting workers in laboratory environments. The following sections may be of particularly relevance to employers and workers regarding Ebola:
• Section VII – Occupational Health and Immunoprophylaxis (PDF)
• Section VIII – E – Viral Agents Agent Summary (PDF)
• Biosafety Laboratory Competency Guidelines. Morbidity and Mortality Weekly Report (MMWR), 15 April 2011, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS). Describes competencies involved with understanding the hazards in a laboratory setting.

Information for Emergency Responders

• Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Information for Other Types of Workers

• Humanitarian Aid Workers during Ebola Outbreak. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Monitoring and Surveillance

• National Bioforensic Analysis and Countermeasures Center (NBACC). U.S. Department of Homeland Security (DHS). Provides information about a highly sophisticated laboratory that conducts specialized work in bioforensic analysis. Located at Ft. Detrick, MD, this laboratory is the designated federal facility to conduct and facilitate technical forensic analysis and interpretation of materials recovered following a BW/BT attack.
• U.S. Quarantine Stations. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS). Comprehensive system that serves to limit the introduction and spread of contagious diseases in the United States.
• Division of Global Migration and Quarantine (DGMQ). Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS). DGMQ quarantine stations work to detect and respond to ill travelers who have serious diseases of public health interest, including Ebola. Stations are located at points of entry (e.g., international airports) and are designed to help prevent arriving travelers from spreading diseases within the U.S.
Morbidity and Mortality Reporting Tools

• Guidance for Airlines on Reporting Onboard Deaths or Illnesses to CDC. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

References:
(1) World Health Organization (WHO) – Ebola virus disease Fact Sheet No. 103 Updated September 2014
(2) Us Department of Health and Human Services, Centers for Disease Control and Prevention, Publication Facts about Ebola CS250531
(3) Us Department of Health and Human Services, Centers for Disease Control and Prevention, Questions and Answers on Ebola http://www.cdc.gov/vhf/ebola/transmission/index.html
(4) OSHA – https://www.osha.gov/SLTC/ebola/index.html
(5) Us Department of Health and Human Services, Centers for Disease Control and Prevention, Questions and Answers on Ebola http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/qa.html