Public health management of cases and contacts of Ebola disease in the community setting in Canada (2024)

On this page

• Introduction
• Target audience and scope
• Background
• Public health management of persons under investigation, confirmed cases and convalescent persons
• Public health management of contacts
• Additional tools and templates
• Appendix A: Summary of recommendations for asymptomatic contacts, according to exposure risk to a case during the period of communicability
• References

Updated: May 2024

Introduction

The strategy outlined in this guidance supports rapid case and contact management to ensure timely assessment of contacts in order to reduce opportunities for transmission, with the objective of containment of the virus.

This guidance document updates the previous Public Health Management of Cases and Contacts of Ebola Virus Disease in the Community Setting in Canada (August 1, 2018), to ensure the guidance remains appropriate in the context of more recent international outbreaks of Ebola disease. This updated version has been expanded to include recommendations for managing cases and contacts of Ebola disease (EBOD) caused by:

• Ebola virus (species Orthoebolavirus zairense) or EBOV
• Sudan virus (species Orthoebolavirus sudanense) or SUDV
• Bundibugyo virus (species Orthoebolavirus bundibugyoense) or BDBV
• Taï Forest virus (species Orthoebolavirus taiense) or TAFV

This document makes the assumption that, while most of the current available scientific evidence comes from experience with EBOV, all orthoebolaviruses (EBOV, SUDV, BDBV, TAFV) likely behave similarly and therefore share the same recommendations for Ebola disease case and contact management. This guidance document is subject to change as new information becomes available.

This guidance document is informed by currently available scientific evidence, expert opinion and guidance developed by other countries and agencies, such as the World Health Organization (WHO), European Centre for Disease Prevention and Control (ECDC), United Kingdom (UK) Health Security Agency, and United States Centers for Disease Control and Prevention (CDC).

This document should be read in conjunction with relevant federal, provincial, territorial and local legislation, regulations and policies, and should be adapted to local context as required.

This document has been developed based on the Canadian context and therefore may differ from guidance developed by other countries.

Target audience and scope

This document is intended to support federal, provincial, territorial and local public health authorities in the event that a suspected and/or confirmed case or contact of Ebola disease is identified within their jurisdiction. Due to the nature of the pathogen, such an occurrence would require close interjurisdictional collaboration. Using a risk assessment approach, this guidance focuses on providing advice on the community management of cases and contacts of Ebola disease. Clinical judgement remains essential and this, along with jurisdictional policies, may result in decisions that differ from recommendations provided in this document.

Recommendations for health care workers with occupational exposure in Canada are beyond the scope of this document. Health care workers with occupational exposure should be managed as per employer policy, and with consultation with public health authorities as required. Refer to:

• Ebola disease: For health professionals and humanitarian aid workers
• Infection Prevention and Control measures for Ebola disease in acute care settings
• Routine practices and additional precautions for preventing the transmission of infection in healthcare settings

Guidance pertaining to laboratory, specimen testing, clinical care, infection prevention and control measures in other settings (such as Canadian points of entry, healthcare settings, pre-hospital care settings, passenger conveyances, and airline cabins) are addressed in other guidance documents.

For advice to the general public, public health officials may refer to the following resources:

• Ebola disease: Symptoms and treatment
• Ebola disease: Prevention and risks
• Ebola disease: Monitoring

Background

The following key points form the basis for the recommendations within this document.

Transmission

• Person-to-person transmission can occur:
  • through direct physical contact with blood and/or other body fluids (such as feces, urine, vomitus, saliva, sweat, amniotic fluid, breast milk, semen) from an infected symptomatic person or dead body
  • indirectly through physical contact with surfaces and fomites (such as needles, medical equipment, clothes, bedding) that are contaminated with these fluids. Orthoebolavirus may remain viable on surfaces and in liquids for several days dependent on environmental factors.
  • through vertical transmission
    • during pregnancy and/or delivery
    • during breastfeeding (including during convalescence)
  • through sexual transmission during the acute phase. Additionally, semen from an individual who recently recovered from Ebola disease can be infectious during convalescence (see Communicability section below).
• Orthoebolaviruses are not transmitted between humans through airborne transmission.
• Animal-to-human transmission can occur through direct contact with infected live or dead animals from endemic areas (such as fruit bats and non-human primates). Human-to-animal transmission is also theoretically possible and therefore precautions, such as avoiding contact with animals, are recommended. For further guidance, please refer to Guidance regarding animal ownership and contact by individuals with potential ebolavirus exposure and Guidance for management of companion animals that have been exposed to a human with Ebola virus disease.

Communicability

• A person with Ebola disease is considered to be infectious with the onset of the first symptom. Prior to becoming symptomatic, they are not considered to be infectious.
• The risk of transmission is highest when viral load is greatest, such as when a person is acutely symptomatic with diarrhea, vomiting and/or bleeding.
• A person with Ebola disease is considered to be infectious for as long as their blood and body fluids contain the virus.^{Footnote 1Footnote 12Footnote 13}
  • This includes the post-mortem period; the body of a person who died from Ebola disease is highly infectious.^{Footnote 2Footnote 3}
  • During recovery, EBOV can persist for weeks to months in some body fluids (such as semen, cerebrospinal fluid, and breast milk).^{Footnote 1Footnote 4Footnote 8} It is likely that SUDV and other orthoebolaviruses have similar viral kinetics (see section Convalescent cases).

Clinical presentation and course of illness

• Ebola disease has an incubation period of between 2 and 21 days. Symptoms typically begin 6 to 10 days after exposure.
• There is usually a sudden onset of non-specific symptoms, such as fever, myalgia, severe headache, fatigue, sore throat and malaise.
• Gastrointestinal symptoms, such as vomiting and diarrhea, occur four or five days later. A rash can also develop at that stage.
• Diarrhea and vomiting are often profuse in later stages of the illness, and can lead to severe volume depletion, electrolyte abnormalities, wasting and shock, as well as symptoms of impaired kidney and liver function.
• Other serious late manifestations include chest pain, shortness of breath, confusion, seizures, and hemorrhagic manifestations (bruising, bleeding from the gastrointestinal tract, venipunctures, and intravenous sites, or from other mucosae such as gums or nose). The course of the disease can be further complicated by secondary bacterial infections.
• In non-fatal cases, people with Ebola disease are often febrile for several days and typically begin improving around day six to eleven.^{Footnote 9} Full recovery occurs over a long period of time, and is often associated with sequelae such as myelitis, arthritis, recurrent hepatitis, uveitis, and mental health issues.^{Footnote 1}
• The average Ebola disease case fatality rate is around 50%. Case fatality rates (CFR) have varied from 25-90% in past outbreaks, depending on the Orthoebolavirus species implicated.^{Footnote 16} Treatment can decrease the CFR; however, death still occurs commonly, usually 7 to 12 days after symptom onset.^{Footnote 2}

Treatment

• Individuals with Ebola disease should receive care in highly specialized centers, to ensure appropriate supportive care (maintaining blood pressure, electrolyte balance and organ systems function) under strict infection prevention and control precautions.
• A number of investigational therapeutics, namely antivirals and monoclonal antibodies, are being developed or studied. The efficacy of treatments targeted at EBOV (such as Inmazeb or Ebanga) has not been established against other species such as SUDV.
• There is currently no Health Canada-approved treatment for Ebola disease. However, in outbreak situations, investigational therapeutics have been used under an ethical framework developed by the World Health Organization called the Monitored Emergency Use of Unregistered and Investigational Interventions. The framework is not designed to evaluate the drugs but to provide treatment on compassionate grounds. In the event of a confirmed case of Ebola disease occurring in Canada, the Public Health Agency of Canada (PHAC) would work with the province or territory to facilitate access to appropriate treatment. Province and territories can contact PHAC's Health Portfolio Operations Centre (HPOC) at 1-800-545-7661.

Vaccine

• Two vaccine products have been developed against EBOV.
  • The rVSV-ZEBOV-GP (Ervebo, Merck) is exclusively targeted at EBOV. While Ervebo^® is now licensed for use in Canada, it is not currently marketed in the country, and is thus unavailable to the vast majority of travellers at this point in time.
  • The prime-boost regimen Ad26.ZEBOV (Zabdeno) – MVA-BV-Filo (Mvabea) produced by Janssen was granted a marketing authorization by the European Medicines Agency. While the prime vaccine is targeted exclusively at EBOV, the booster vaccine contains antigens from 4 different species of the Filoviridae family (EBOV, SUDV, TAFV and Marburg virus).
  • These products were used in investigational trials and on compassionate grounds during recent EBOV outbreaks (West Africa in 2014-16, Democratic Republic of the Congo in 2018). 
  • These vaccines may also be offered to front-line humanitarian workers deploying to Ebola disease-affected areas, as an outbreak management measure. The provision of vaccination against EBOV to Canadian humanitarian workers who travel to Ebola disease-affected areas to provide care to confirmed EBOV cases or their contacts or engage in safe burials, is the responsibility of the organization delivering these services.
• Products only containing EBOV antigens are not expected to be effective against SUDV. New vaccine candidates targeting SUDV are under development.
• None of these vaccines are currently marketed in Canada. In the event of an Ebola disease case in Canada, the impacted jurisdiction should contact PHAC's Health Portfolio Operations Centre (HPOC) at 1-800-545-7661, for options to access vaccines.
• Consult the Canadian Immunization Guide on the use of rVSV-ΔG-ZEBOV-GP (Ervebo) vaccine against EBOV as pre-exposure and post-exposure prophylaxis.

Risk in Canada

• Although the risk of exposure to orthoebolaviruses in Canada is considered to be very low, it is conceivable that a case or contact connected to an outbreak in an Ebola disease-affected area could be identified in Canada.^{Footnote 10}
  • An Ebola disease-affected area is defined as a region where there has been a confirmed locally acquired case of Ebola disease or where an individual with an infectious case of Ebola disease has resided.
  • Information on affected areas can be found through the WHO Disease Outbreak News webpage.
  • For more information see Committee to Advise on Tropical Medicine and Travel (CATMAT): Ebola disease prevention, monitoring and surveillance recommendations.
• If a case or contact were to be identified in Canada, public health authorities at all levels would be involved in the response.
• PHAC works closely with its national and international partners to track and to monitor Ebola disease activity around the world and assesses the risk of Ebola disease in Canada on an ongoing basis.
• PHAC is required to report confirmed cases to the WHO, as part of Canada's commitments under the International Health Regulations (2005).

Public health management of persons under investigation, confirmed cases and convalescent persons

National case definitions for Ebola disease have been established for use during past Ebola outbreaks. In Canada, the national case definition includes definitions for both a person under investigation (PUI) and a confirmed case.

The role of public health in Ebola disease detection and management is multifaceted and includes: the early identification of cases and contacts through surveillance; case and contact management; providing information and educational resources to the public and health care professionals; and communication.

Canadian public health authorities monitor and respond, as necessary, to all Ebola disease outbreaks and adjust recommended practices in Canada as required.

Persons under Investigation

When notified of a person meeting the PUI case definition public health should:

• direct the individual to take immediate measures to prevent transmission to others, if these are not already in place (refer to Recommendations for symptomatic contacts) and
• arrange, as per P/T protocol, for the individual to undergo a medical assessment at an appropriate acute care facility to confirm or to rule out Ebola disease

Public health authorities are requested to notify the PHAC Health Portfolio Operations Centre (HPOC) at 1-800-545-7661 concurrently with notifications to their provincial and territorial authority, of all PUIs requiring Orthoebolavirus testing within 24 hours of ordering the test, using the Ebola Disease Case Report Form and information available at the time of the initial report. The case report form can be updated as additional information becomes available.

For management of contacts of PUIs, see the Contact management section.

It should be noted that testing negative for Ebola disease within 72 hours of symptom onset does not rule out Ebola disease, and in this case, testing should be repeated. Until Ebola disease has been ruled out by a negative test 72 hours or more after symptom onset, the PUI should be managed with appropriate infection prevention and control precautions as per an Ebola disease case. Even if Ebola disease has been appropriately ruled out, the appropriate level of contact precautions should be maintained for 21 days from the last exposure.

Confirmed cases

Confirmed cases of Ebola disease in Canada should be hospitalized in specialized Ebola disease treatment centres with the capacity to provide appropriate treatment and effective isolation.

It is recommended that public health authorities liaise regularly with appointed hospital staff for the duration of the patient's hospitalization, to monitor progress and to be actively involved with discharge planning.

Public health authorities must report all confirmed cases immediately to PHAC Health Portfolio Operations Centre (HPOC) at 1-800-545-7661 concurrently with notifications to their provincial and territorial health authority. The Ebola Disease Case Report Form should be completed using the information available at the time of reporting, and updated as further information becomes available.

Convalescent cases

The decision to discharge (PDF) convalescent cases should be made jointly, in consultation with infectious disease specialists and public health authorities. Discharge is determined on a case-by-case basis when the patient is physically well enough to leave the hospital and their infectious risk is minimal. Discharge may be considered if:

• the patient has been symptom free for greater than 72 hours, and
• two consecutive blood samples, obtained at least 24 hours apart, have been negative for the orthoebolaviruses by PCR

Upon discharge, the convalescent case must receive education and counselling to address the associated disease sequelae and prevent transmission to others during their convalescence, since orthoebolaviruses can persist in certain body fluids and organs for weeks to months (such as semen, inner eye, cerebrospinal fluid, breast milk).^{Footnote 15Footnote 16}

Counseling of the convalescent case should include:

• instructions regarding any medical follow-up that may be required, and
• information regarding possible transmission of Ebola disease and ways to prevent transmission

With respect to sexual transmission, for male convalescent cases^{Footnote 17} it is recommended that until their semen is determined to be orthoebolavirus free through testing, the individual should be advised to either abstain from sexual contact or use safer sex practices including correct and consistent condom use.

The semen of Ebola disease survivors is assumed to contain orthoebolavirus for the first 3 months after disease onset. Testing of the semen by RT-PCR should be performed at 3 months, and if still positive then every month thereafter, until two consecutive samples test negative (with an interval of at least one week between tests).^{Footnote 19}

Until their semen has twice tested negative for orthoebolavirus, survivors should also practice good hand and personal hygiene, by immediately and thoroughly washing with soap and water after any physical contact with semen, including after masturbation.^{Footnote 19}

If semen testing is not done, it is recommended that abstinence or safer sex practices including correct and consistent condom use be continued for at least 12 months after onset of symptoms.^{Footnote 19} This interval may be adjusted as additional information becomes available on the prevalence of orthoebolaviruses in the semen of survivors over time.

Individuals who have discontinued breastfeeding during their acute illness should not resume breastfeeding upon discharge home, unless two consecutive samples of breastmilk, obtained with an interval of at least 24 hours, test negative by orthoebolavirus RT-PCR.^{Footnote 14Footnote 15Footnote 16Footnote 17Footnote 18Footnote 19} Practice good hand hygiene and personal hygiene when taking breastmilk samples by immediately and thoroughly washing with soap and water after any physical contact with breastmilk.

Public health management of contacts

For the purposes of this document, a contact is a person who has been or may have been exposed to an orthoebolavirus (such as EBOV, SUDV) in the past 21 days. Exposure could occur in Canada if there is a case of Ebola disease in Canada, or could have occurred in another country, particularly in a country with an Ebola disease-affected area.

Exposure can occur through:

• direct physical contact with body fluids of an infected symptomatic person or dead body
• through sexual contact during the acute phase or during the convalescent period (to date, transmission from convalescent patients has only been described from sexual contact with males)
• indirectly from an orthoebolavirus contaminated surface or fomite
• through vertical transmission
  • during pregnancy and/or delivery
  • during breastfeeding
• through direct contact with infected animals

Contact tracing

Contact tracing identifies all individuals who may potentially have been exposed to an orthoebolavirus, in order to:

• implement measures to reduce the risk of transmission to others should the contact become infected with Ebola disease by:
  • ensuring contacts are aware of their potential exposure
  • discussing any symptom monitoring expectations
  • implementing risk mitigation measures
  • informing contacts of what to do if they develop Ebola disease symptoms; and
• ensure the contact receives the earliest and most appropriate care by:
  • identifying symptoms as early as possible
  • facilitating prompt clinical assessment by a health care provider, and appropriate laboratory diagnostic testing
  • referring to the appropriate designated health care facility, using appropriate infection prevention and control practices

In Canada, local public health authorities are responsible for initiating contact tracing.

• Contact tracing of a confirmed case should begin immediately.
• If there is a high index of suspicion that a PUI will have Ebola disease given the exposure history and clinical information provided, contact tracing should begin immediately.
• If there is a low index of suspicion (for example, another diagnosis is considered more likely, but an orthoebolavirus test was ordered), at a minimum, the names and information to reach potential contacts should be collected from a PUI.

Risk assessment of contacts

The following factors related to communicability, incubation period and exposure provide the foundation for the risk assessment and management of contacts.

• Someone with Ebola disease becomes infectious at the time of onset of the first symptom(s).
• The risk of transmission from someone with Ebola disease is lower in the early stages of disease, when the viral load is lower. The risk of transmission increases over time, as the viral load rises and the person with Ebola disease develops later stage symptoms such as diarrhea, vomiting or bleeding. For more information see Communicability.
• The incubation period is 2 to 21 days after an exposure. The upper end of the range (21 days) determines the length of time contact monitoring and precautions are recommended to minimize the risk of transmission.
• Due to the limitations of available evidence, uncertainties remain regarding the level, duration and type of protection provided by vaccinations. It is important to note that the individual risk assessment of contacts should not change based on vaccination status.
• All contacts of a confirmed case should be rapidly identified and assessed by public health authorities, to determine their risk of exposure and to implement the appropriate public health recommendations As noted above, contact tracing may also be initiated for PUIs depending on the level of suspicion that the PUI has Ebola disease.

To identify potential contacts, public health should consider the case or PUI's:

• living environment/household contacts and sexual contacts
• workplace, school, or childcare centre attendance
• travel history
• recreational, religious, and social activities
• health care visits
• methods of transportation
• animal contact, including pets and livestock

To facilitate determining the most appropriate public health recommendations, contacts are classified according to their risk of exposure as follows: high risk exposure, low risk exposure or no risk.

The start of the exposure period (communicable period) is determined by the onset of the first symptoms in the confirmed case or PUI.

Note: Animal contacts should be reported to Provincial or Territorial animal health authorities for further risk assessment. For further guidance, please refer to Guidance regarding animal ownership and contact by individuals with potential ebolavirus exposure and Guidance for management of companion animals that have been exposed to a human with Ebola virus disease.

Clinical judgement is required to determine risk

Clinical judgement remains essential for risk assessment and may, along with jurisdictional policies, result in decisions that differ from recommendations provided in this document.

It is recognized that there may be instances where a person was in close proximity to someone with Ebola disease, without known physical contact with the individual, their bodily fluids, or with contaminated objects or surfaces in their environment. The exposure risk categorizations (in other words, high risk, low risk, or no risk) and subsequent contact management in these circumstances require a careful risk assessment which should consider:

• the length and number of interaction(s) (longer and multiple exposures potentially increasing the risk)
• the kind of symptoms the individual with Ebola disease was exhibiting at the time (such as coughing, vomiting, external bleeding and/or diarrhea, which may generate infectious droplets and/or contaminate the environment more heavily)
• the distance between the individual with Ebola disease and the contact (the risk being inversely proportional to the distance)
• the use of appropriate infection prevention and control measures, including personal protective equipment, when applicable

A high-risk of exposure during the communicable period includes any of the following:

• All household and sexual contacts of a case
• Physical contact, without adhering to recommended infection prevention and control measures or due to a breach in infection prevention and control measures, with:
  • the body surface/mucous membranes of someone with symptomatic Ebola disease, the individual's body fluids, or dead body;
  • objects or surfaces that may be contaminated with orthoebolaviruses from the body fluids of someone with Ebola disease, including bedding, clothing, medical instruments, and laboratory specimens;
  • an infected animal (dead or alive).
• Unprotected contact with semen from an individual recently recovered from Ebola disease (see section Convalescent cases for key counseling points).
• A child exposed to breastmilk of an individual with Ebola disease.

A low-risk of exposure during the period of communicability occurs in a person who is not a household or sexual contact of a case, but had one of the following:

• Physical contact, while adhering to recommended infection prevention and control measures and without known breach with:
  • the body surface/mucous membranes of someone with symptomatic Ebola disease, the individual's body fluids, or dead body;
  • objects or surfaces that may be contaminated with orthoebolaviruses from the body fluids of someone with Ebola disease, including bedding, clothing, medical instruments, and laboratory specimens;
  • an infected animal (dead or alive).
• Stayed in an Ebola disease-affected area but does not meet any of the criteria for a high-risk exposure.

A person is considered at no risk based on the following:

• They do not meet any of the criteria above for high-risk or low-risk exposures (in other words, they are not a household or sexual contact; did not have any physical contact with someone with Ebola disease, their body fluids or dead body, or with objects or surfaces that could be contaminated by body fluids from someone with Ebola disease, or with an infected animal; and they did not stay in an Ebola disease-affected area.
• The exposure occurred more than 21 days ago and therefore the incubation period for Ebola has passed.

Travellers

Under the Quarantine Act, travellers must self-identify to a Canada Border Services Agent on arrival in Canada if they have:

• reasonable grounds to suspect that they have or might have Ebola disease
• recently been in close proximity to a person who has, or is reasonably likely to have Ebola disease

Travellers with any risk of exposure are recommended to call the appropriate public health authority during the first business day following arrival in Canada to self-identify.

Public health authorities assessing the risk of exposure in travellers returning from an Ebola disease-affected area should apply the criteria above. It should be noted that some countries have low testing capacity, so people with Ebola disease may not have received laboratory confirmation. Therefore, exposure categorization of contacts should be applied as listed above if exposure occurred to someone who was considered to be likely to have Ebola disease (based on symptoms and local epidemiologic risk), even if it could not be confirmed due to the absence of testing. Additional information is available in the Committee to Advise on Tropical Medicine and Travel (CATMAT) statement "Ebola disease prevention, monitoring and surveillance recommendations".

Contact management

The goal of contact management is to monitor an individual at risk of developing Ebola disease symptoms in order to minimize the risk of transmission to others and ensure they receive timely and appropriate care if symptoms develop. The public health guidelines for contact management in the Canadian community setting are detailed below and a supporting summary table can be found at the end of this document (see Appendix A).

It is acknowledged that public health authorities may need to enhance or tailor the recommendations to best manage various situations, and that provincial/territorial guidance may differ. Public health authorities will determine the appropriate approach to monitor and support the patient, as well as to assess and ensure compliance with instructions.

Breastfeeding

Ebola disease contacts who are breastfeeding should be provided with clear information regarding the relative risks and benefits for their child and themselves of continued breastfeeding during the 21-day post exposure period. Abstinence from breastfeeding for the duration of the 21-day post-exposure period is recommended for high risk contacts. Contacts may elect to express breastmilk throughout the 21-day post exposure period to increase chance of successfully resuming breastfeeding if they do not become infected. Contacts should perform good hand hygiene and personal hygiene by immediately and thoroughly washing with soap and water after any physical contact with breastmilk. Public health implications should be considered, and clinical judgement used to support breastfeeding contacts in their decision-making.

Breastfeeding should be stopped if Ebola disease is suspected or confirmed in a lactating individual or in a breastfeeding child. The child should be separated from the breastfeeding person and provided a breastmilk substitute as needed. Given the risk associated with manipulation of infectious body fluids, it is not recommended to attempt to maintain lactation by pumping and discarding breastmilk during an Ebola disease episode. A child exposed to breastmilk from an individual with suspected or confirmed Ebola disease should undergo close monitoring for signs and symptoms of Ebola disease for 21 days. In the case of EBOV, post-exposure prophylaxis for the child can be considered on a case-by-case basis and in accordance with existing research protocols^{Footnote 18}.

Recommendations for all asymptomatic Ebola disease contacts (low-risk and high-risk)

During the 21-day period following the last potential exposure to orthoebolaviruses, all contacts, both with low-risk and high-risk exposures, should:

• Receive active public health monitoring for symptoms and counselling. Following an initial assessment, the frequency and method of this follow-up may vary depending on the risk level of the contact and other factors. The contact should be provided with information on how to reach public health officials at any time of the day or night.
• Self-monitor for symptoms of Ebola disease, including checking and documenting oral temperature twice daily (AM and PM), and immediately if they start feeling chills/feverish (Temperature Recording Form for Contacts of Ebolaviruses [PDF]).
• Develop a plan to isolate from others and access healthcare if symptoms occur.
• Try to avoid medications that are known to lower fever (such as acetaminophen, ibuprofen, acetylsalicylic acid) as these medications could mask an early symptom of Ebola disease. If these medications must be taken due to symptoms that could be consistent with Ebola disease, the contact should inform public health officials. If seeking health care, the contact should notify the health care provider of their exposure, symptoms and that they have taken a fever-reducing medication.
• Advise all health care providers that they encounter, including paramedical services, of their potential Ebola disease exposure.
• Postpone elective medical visits and other elective procedures (such as elective dental visits, elective blood tests).
• Refrain from donating blood, sperm and any other body fluids, organs or tissue.
• Maintain good infection prevention and control measures with regards to body fluids, regular cleaning and disinfection of high-touch surfaces (particularly in the washrooms) and good hand hygiene practices.
• Report any travel intentions outside of the public health jurisdiction, to the public health authority. Travel outside the public health jurisdiction during the 21-day monitoring period requires careful consideration of risk and should not occur without prior discussion with, and agreement of public health authorities at the point of origin and the destination.

Should symptoms compatible with Ebola disease develop, contacts should immediately isolate from others, including household members (in other words, physically separate and ensure a 2-metre distance from other people and animals), and notify public health officials (see Recommendations for symptomatic contacts section).

Additional recommendations specific for asymptomatic Ebola disease contacts with a high-risk of exposure

During the 21-day period following the last potential exposure to the orthoebolavirus, in addition to the recommendations for all Ebola disease contacts, contacts with a high-risk of exposure should:

• Not have interactions with others outside of the household, including:
  • not attending public places (for example, do not attend workplace, school, childcare centres, stores, funerals, religious gatherings, social events) except for seeking essential, non-elective medical care.
  • not travelling on public/commercial conveyances (such as a bus, train, taxi, airplane).
  • not having visitors into the house.
• Minimize or avoid direct contact, where possible, with those in their household, including abstaining from sexual contact and breastfeeding, for the duration of the 21-day period (e.g., separate bedrooms, separate bathrooms, activities of daily living, such as dishes and laundry, done separately).
• Avoid all animal contact, if possible. If animal contact cannot be avoided, measures should be taken to reduce the chance that an animal would be considered exposed if the person develops symptoms. Consult with appropriate public health and animal health officials as necessary. For further guidance, please refer to Guidance regarding animal ownership and contact by individuals with potential ebolavirus exposure and Guidance for management of companion animals that have been exposed to a human with Ebola virus disease.

Additional recommendations specific for asymptomatic Ebola disease contacts with only low-risk exposure

During the 21-day period following the last potential exposure to the orthoebolavirus, in addition to the recommendations for all Ebola disease contacts, the following is recommended for contacts with only low-risk of exposure:

• essential activities can be maintained but direct contact and populated environments should be avoided.

Recommendations for symptomatic contacts

Contacts who develop symptoms compatible with Ebola disease, should be advised to:

• immediately isolate (in other words, stay home until they seek health care and maintain a 2-metre distance, with no physical contact with people or pets/animals) if not already isolated from others;
• ensure that others do not come into contact with their blood or body fluids (including urine, feces, blood, vomit, saliva, sweat, breastmilk and semen) or anything that may have come in contact with their blood or body fluid (such as linens, clothing, toilet, toiletries), including using a separate bathroom if possible; wash hands after vomiting, any bleeding or using the bathroom;
  • Urine, stool and vomit may be disposed of through the normal sanitary sewer system, or in accordance with municipal/regional regulations.

Public health authorities should arrange, per Provincial/Territorial protocol, for the individual to have a medical assessment at a predetermined acute care facility, to confirm or to rule out Ebola disease.

It is recommended that the individual not take public conveyances (i.e., do not take a bus, train, taxi, rideshare) to that facility. Depending on the nature/severity of symptoms and proximity to the facility, the individual may be able to take a private vehicle to the hospital while avoiding direct contact with others, or may need to take an ambulance to the hospital.

It is important to ensure that the Paramedic Services (if involved) and the receiving acute care facility are informed of the orthoebolavirus exposure and of symptoms compatible with Ebola disease in advance to help to ensure that appropriate infection prevention and control measures are in place during transport and upon their arrival at the acute care facility.

For infection prevention and control guidance for safe prehospital care and ground transport of suspected PUI or confirmed Ebola disease cases, refer to the Infection Prevention and Control Measures for Prehospital Care and Ground Transport of Persons Under Investigation for Ebola Disease or with Confirmed Ebola Disease.

A contact who develops symptoms meets the definition of a PUI. For management of contacts of PUIs, see the Contact tracing section.

Public health authorities should plan for the appropriate notifications within their jurisdiction and to the Public Health Agency of Canada should a PUI or a confirmed case be identified. The timing and mechanism of public communication should also be planned for.

Recommended management of Ebola disease-associated waste in the home setting

Confirmed cases of Ebola disease will require hospitalization and involvement of public health officials for follow-up with waste management and environmental cleaning in the home setting. This follow-up may also be required for some PUIs, particularly if there is a high index of suspicion that they have Ebola disease. An assessment of the home setting should be done to determine which specific areas/room(s) are visibly or potentially contaminated, and arrangements made for a company with appropriate expertise in infection prevention and control to provide management of Ebola disease-associated waste and for environmental cleaning.

The handling of Ebola disease-associated waste and environmental cleaning in the home setting should not be done by family/other household members or friends.

Refer to Measures for the Management of Ebola Virus Disease-associated waste and linen in home settings for detailed recommendations.

Additional tools and templates

The following tools and templates may help to support the public health follow-up of contacts.

• Temperature Recording Form for Contacts of Ebola Virus (PDF)
• Ebola Virus Contact Monitoring Form (PDF)
• Ebola Virus Contact Tracing Report Form (PDF)

Related links

These links provide information on topics such as:

• infection prevention and control
• border and travel health
• Ebola disease vaccines
• public health management

Some resources use the term Ebola virus disease or discuss Ebola virus specifically. The majority of the information available in these documents remains relevant in the context of Ebola disease more broadly.

Infection prevention and control

• Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings
• Measures for the management of Ebola virus disease-associated waste and linen in home settings

Laboratory testing

• Biosafety guidelines for laboratories handling specimens from patients under investigation for Ebola disease
• Molecular Detection of Ebola virus

Border and travel health

• Ebola disease prevention, monitoring and surveillance recommendations
• Environmental sanitation practices to control the spread of communicable disease in passenger conveyances and terminals
• Guidance for Airline Cabin Crews, Cleaning Personnel and Cargo Personnel: How to Protect Yourself and Others from Ebola Virus Disease

Ebola disease vaccines

• Ervebo product monograph (PDF, 1.1 MB)
• Sudan Ebolavirus Vaccine Tracker - List of vaccine candidates in research and development (World health Organization)
• Summary of the evaluations and recommendations on the three Sudan ebolavirus vaccines that are candidates for inclusion in the planned ring vaccination trial in Uganda ("Tokomeza Ebola") (World Health Organization)
• Current information on clinical trials
• Efficacy of Phase 3 clinical trials in Guinea

Related websites

• Ebola virus disease (World Health Organization)
• Disease Outbreak News (World Health Organization)
• Ebola (Ebola Virus Disease) (Centers for Disease Control and Prevention)

Appendix A: Summary of recommendations for asymptomatic contacts, according to exposure risk to a case during the period of communicability

Note: Clinical judgement remains essential for risk assessment and may, along with jurisdictional policies, result in decisions that differ from recommendations provided in this document. See Clinical judgement required to determine risk section to assist with the risk assessment.

Note: In the case of Ebola disease caused by EBOV, also consult Ebola virus vaccine: Canadian Immunization Guide on the use of rVSV-ΔG-ZEBOV-GP (Ervebo) vaccine.

No risk

Exposures

Not meeting any of the criteria for high-risk or low-risk exposures, or the exposure occurred > 21 days ago and therefore the incubation period for Ebola has passed.

General recommendations for no risk contacts

• Reassurance
• Education

Specific recommendations for no risk contacts

Nil

Low risk

Exposures

Not a household or sexual contact of a case but had one of the following:

• Physical contact^{Footnote a}, while adhering (with no known breach) to recommended infection prevention and control measures, with:
  • the body surface/mucous membranes of a symptomatic Ebola disease case, the individual's body fluids, or dead body,
  • objects or surfaces potentially contaminated with orthoebolaviruses (such as bedding, clothing, medical instruments, laboratory specimens)
  • an infected animal (dead or alive)
• Stayed in an Ebola disease-affected area, but does not meet any high-risk criteria

General recommendations for low risk and high risk contacts

Provide information to the contact on how to reach public health officials at any time of the day or night.

For 21 days following the last exposure to an orthoebolavirus:

• Receive active public health monitoring for symptoms and counselling. The frequency and method of follow-up to be determined on a case-by-case basis following an initial assessment.
• Self-monitor for symptoms of Ebola disease, including the documentation of oral temperature twice daily (AM and PM) and immediately if feeling chills/feverish.
• Develop a plan to isolate and access healthcare if symptoms occur.
• Avoid medications that lower fever (for example, acetaminophen, nonsteroidal anti-inflammatory medications) as they could mask early symptoms of Ebola disease.
• Advise all healthcare providers, including paramedical services, of the potential Ebola disease exposure.
• Postpone elective medical visits and procedures.
• Do not donate blood, sperm and other body fluids, organs or tissue.
• Maintain good infection prevention and control measures with regards to body fluids, regular cleaning of washrooms and good hand hygiene
• Report any travel intentions outside of the public health jurisdiction to the public health authority. Travel outside the public health jurisdiction during the 21-day monitoring period requires careful consideration of risk and should not occur without prior discussion with, and agreement of public health authorities at the point of origin and the destination.

If symptoms compatible with Ebola disease develop, immediately isolate and notify public health officials.

Specific recommendations for low risk contacts

Essential activities can be maintained but direct contact and populated environments should be avoided.

High risk

Exposures

• Household and/or sexual contact of a case
• Had physical contact^{Footnote a}, without adhering to recommended infection prevention and control measures or following a breach in infection prevention and control measures, with:
  • the body surface/mucous membranes of a symptomatic Ebola disease case, the individual's body fluids, or dead body
  • objects or surfaces potentially contaminated with orthoebolavirus (such as bedding, clothing, medical instruments, laboratory specimens)
  • an infected animal (dead or alive)
• Unprotected contact with semen from an individual recently recovered from Ebola disease.
• A child exposed to breastmilk of an individual with Ebola disease.

General recommendations for low risk and high risk contacts

Provide information to the contact on how to reach public health officials at any time of the day or night.

For 21 days following the last exposure to an orthoebolavirus:

• Receive active public health monitoring for symptoms and counselling. The frequency and method of follow-up to be determined on a case-by-case basis following an initial assessment.
• Self-monitor for symptoms of Ebola disease, including the documentation of oral temperature twice daily (AM and PM) and immediately if feeling chills/feverish.
• Develop a plan to isolate and access healthcare if symptoms occur.
• Avoid medications that lower fever (for example, acetaminophen, nonsteroidal anti-inflammatory medications) as they could mask early symptoms of Ebola disease.
• Advise all healthcare providers, including paramedical services, of the potential Ebola disease exposure.
• Postpone elective medical visits and procedures.
• Do not donate blood, sperm and other body fluids, organs or tissue.
• Maintain good infection prevention and control measures with regards to body fluids, regular cleaning of washrooms and good hand hygiene
• Report any travel intentions outside of the public health jurisdiction to the public health authority. Travel outside the public health jurisdiction during the 21-day monitoring period requires careful consideration of risk and should not occur without prior discussion with, and agreement of public health authorities at the point of origin and the destination

If symptoms compatible with Ebola disease develop, immediately isolate and notify public health officials.

Specific recommendations for high risk contacts

• Do not have direct contact with others outside of the household, including:
  • Do not attend public places (for example, do not attend workplace, school, childcare centres, stores, funerals, religious gatherings, social events) except for seeking essential, non-elective medical care.
  • Do not travel on public/commercial conveyances (such as a bus, train, taxi, airplane)
  • Do not have visitors into the house.
• Minimize or avoid direct contact where possible with those in their household, including abstaining from sexual contact and breastfeeding for the duration of the 21-day period (e.g., separate bedrooms, separate bathrooms, activities of daily living, such as dishes and laundry, done separately).
• Avoid all animal contact, if possible. If animal contact can not be avoided, measures should be taken to reduce the chance that an animal would be considered exposed if the person develops symptoms. Consult with appropriate public health and animal health officials as necessary.

References