Interim Western Australia Viral Haemorrhagic Fever Response Plan

Interim Western Australia
Viral Haemorrhagic
Fever Response Plan
26 October 2014
health.wa.gov.au
Contents
About this document
2
1.
3
2.
3.
Introduction
1.1. Background
3
1.2. Legislative basis
4
1.3. Quarantine hospitals
4
1.4. Other hospitals
5
Overview of Viral Haemorrhagic Fevers
6
2.1. Incubation periods
6
2.2. Clinical features of cases of VHF
6
2.3. Specific treatments for VHF patients
7
2.4. Transmission
7
Initial assessment and management of a possible VHF case
9
Appendix 1 - Assessment and management of suspected cases of Ebolavirus disease in
Emergency Departments
12
Appendix 2 - EVD risk assessment checklist
13
Appendix 3 - National case definitions of Ebolavirus disease
16
Appendix 4 - Public Health response and Public Health Unit responsibilities
18
Appendix 5 - Infection prevention and control guidelines for Ebolavirus disease (non-quarantine
hospitals)
20
Appendix 6 - Healthcare worker education and training resources for Ebolavirus disease
25
Appendix 7 - Donning and doffing PPE procedures checklist
26
Appendix 8 - Cleaning and disinfection
27
Appendix 9 - Waste treatment and disposal
30
Appendix 10 - Post-mortem care and examination
33
Appendix 11 - EVD patient transfer and transport guidelines
37
Appendix 13 - Ebolavirus disease fact sheet
40
Appendix 14 - Fact sheet for contacts of a person with Ebolavirus disease
43
Appendix 16 - Contact numbers
44
Appendix 17 - Specimen collection and handling
46
Appendix 18 - WA EVD laboratory testing guidelines
46
Appendix 19 - Ebolavirus Disease Case Report Form
47
1
About this document
The Interim Western Australia Viral Haemorrhagic Fever Response Plan replaces the 2007 Contingency
Plan for the Public Health Management of Viral Haemorrhagic Fever Within Western Australia. It is an
extensive revision and has been prompted by the large outbreak of Ebolavirus disease (EVD) in West
Africa. The focus, therefore, is on EVD and much of the information in the appendices is specific for
EVD. However, the principles of managing other types of VHF are very similar and this document could
equally be used to provide management guidance for those diseases.
The word „Interim‟ is included in the title because the information within the document is likely to change
frequently owing to the rapidly changing nature of the 2014 EVD outbreak, and also to reflect the fact
that guidance on all facets of the response is not yet included. This information will, over time, be added
to the appendices, the titles of which are already included. The main text of the document is unlikely to
change significantly.
2
1. Introduction
1.1. Background
This document provides the framework to guide the response to suspected and confirmed cases of
VHFs in WA, and should assist each hospital in producing a site-specific response plan. Viral
haemorrhagic fevers (VHFs) covered by this plan (Ebolavirus disease, Marburg virus disease, Lassa
fever and Crimean-Congo haemorrhagic fever) are a group of infectious diseases that cause serious
illness in humans, with high case fatality rates and the potential for person-to-person transmission,
including in healthcare settings. These viruses are endemic in specific geographic regions - primarily in
Africa, but also including the Middle East, Eastern Europe and Asia.
Other haemorrhagic fevers that are not characterised by person-to-person spread, such as yellow fever,
severe dengue infections, hantaviruses and South American arenavirus infections, are not covered by
this document.
VHFs do not occur in Australia and establishment here is unlikely as environmental conditions do not
support the natural reservoirs and vectors of these viruses. The possibility of a VHF case being
diagnosed in Western Australia (WA) is very low, and relates primarily to travellers from endemic areas,
particularly from Africa. However, the risk may be increased in certain circumstances, such as during
periodic epidemics of Ebolavirus disease (EVD) that have occurred in central Africa since 1976. The
large outbreak of EVD in several West African countries in 2014, including spread to populous urban
areas, has posed the most significant risk of spread to Australia and other developed countries, more so
by returning humanitarian workers than by returning tourists or citizens of these countries travelling to
Australia.
To date, the only documented case of significant VHF diagnosed in Australia was a convalescent case of
Lassa fever diagnosed in a rural hospital in NSW in 1985. Other suspect cases investigated previously
have eventually been diagnosed as other febrile illnesses, including malaria, leptospirosis or Human
Immunodeficiency Virus seroconversion illness.
Contingency planning for VHFs aims to enable early identification of suspect cases; appropriate
assessment, laboratory testing and clinical management in a safe environment; and prevention of
transmission.
3
Diagnosis and management of VHFs in WA presents several challenges:

the rarity of patients presenting with VHFs in Australia heightens the risk of misdiagnosis

the early clinical presentation (e.g. fever, headache, pharyngitis, myalgia) is non-specific and
mimics more common and less severe conditions

the risk for transmission to contacts, including healthcare workers (HCWs), particularly during the
early symptomatic phase prior to the diagnosis being considered and appropriate infection
prevention and control precautions implemented

while evidence and international guidelines indicate that suspected, probable and confirmed cases
should be isolated in a single room with use of standard and transmission-based (contact and
droplet) infection prevention and control precautions, the high level of consequences if
transmission of VHFs such as EVD occurs, means that more stringent precautions to prevent
aerosol transmission are likely to be used in Australian healthcare settings, where this is possible.
This is also reflected in guidelines for handling of specimens in laboratories.
1.2. Legislative basis
VHFs are classified as “dangerous infectious diseases” for purposes of notification and public health
management in WA (Health Act 1911). This allows the use of additional powers, as defined in section
251 of the Act, to facilitate public health management of cases and contacts, such as orders requiring
isolation, quarantine, testing and disinfection, should this be appropriate.
VHFs are also nationally notifiable and are prescribed quarantinable diseases under the Commonwealth
Quarantine Act 1908, which in effect means that responsibility for surveillance, cost of treatment and
control of these diseases lies with the Commonwealth Department of Health. In practice, however,
Commonwealth responsibility is limited to national coordination and activities at international borders,
and the WA Department of Health (WA Health) accepts delegated responsibility for clinical and public
health management of these diseases, with the Director of the Department‟s Communicable Disease
Control Directorate being appointed the Chief Human Quarantine Officer for the state, under
Commonwealth legislation. Other WA Health medical officers are similarly appointed as Human
Quarantine Officers (see Appendix 15). Costs incurred in treating a patient with a suspected
quarantinable disease are, at least in theory, recoverable from the Commonwealth.
1.3. Quarantine hospitals
In WA, Sir Charles Gairdner Hospital (SCGH) is the designated hospital for the treatment of adults
(including pregnant women) with quarantinable diseases, including VHFs. Princess Margaret Hospital
(PMH) is designated for treatment of children. These hospitals have purpose-built isolation rooms,
4
including in their intensive care units, for the containment of patients with VHFs and other high-risk
pathogens, in order to minimise the risk of transmission to HCWs, other patients and visitors.
PathWest at the QE II Medical Centre campus, adjacent to SCGH, maintains an accredited physical
containment level 3 (PC3) laboratory with capacity to undertake a range of microbiological and other
diagnostic testing on blood and other specimens from patients being investigated for VHFs.
1.4. Other hospitals
All hospitals must consider that a person in whom a diagnosis of a VHF needs to be ruled out, or even a
real case, could self-present or be referred to an emergency department by a general practitioner. Such
cases will need to be assessed, managed and in some situations admitted, prior to it being feasible to
arrange transfer to either of the designated quarantine hospitals. Each hospital, including those in
country regions, should therefore have in place a response plan for the assessment, treatment and
referral of patients with suspected VHFs. Plans should include provision for:

an isolation care area with an adjoining ante-room or an adjacent unoccupied room, with private
bathroom facilities, to manage patients until they can be transferred, while recognising that the
labile nature of VHF infections may make timely transfer difficult

appropriate personal protective equipment (PPE) for HCWs managing VHF cases, according to
Appendix 5

the provision of education to HCWs on necessary infection prevention and control measures and
on the use of appropriate PPE

arrangements for transfer of patients to SCGH or PMH (for paediatric patients) as soon as clinically
practicable.
5
2. Overview of Viral Haemorrhagic Fevers
2.1. Incubation periods
Incubation periods for these diseases are:
i
Lassa fever
6 – 21 days
ii
Ebolavirus disease
2 – 21 days
iii
Marburg virus disease
3 – 10 days
iv
Crimean-Congo haemorrhagic fever
1 – 12 days
2.2. Clinical features of cases of VHF
These infections have variable and non-specific clinical manifestations. As an example, Lassa Fever is
thought to have an overall mortality rate of 5% but this rises to 15-20% in hospitalised patients. Mortality
rates in outbreaks of EVD in Africa have ranged from 50-90%, with variability probably related to different
levels of care available, and perhaps to virulence characteristics of different strains of the virus.
Epidemics and small clusters of VHFs due to nosocomial transmission among hospitalised patients and
staff have been reported, primarily associated with EVD in Africa. In the early phase of these diseases
when non-specific influenza-like symptoms predominate, the risk of transmission is thought to be low,
but in those who progress to haemorrhage, collapse and organ failure, their body fluids are highly
infectious.
Ebola and Marburg virus disease: Characterised by the sudden onset of fever, malaise, myalgia, and
headache, followed by pharyngitis, vomiting, diarrhoea, and a maculo-papular rash. Haemorrhagic
manifestations are seen in less than half of cases. Haemorrhage and shock are more likely in the second
week.
Lassa fever: Characterised by the gradual onset of fever, malaise, myalgia, headache, vomiting and
diarrhoea. Pharyngitis and conjunctivitis are prominent. Only 20 per cent have severe symptoms, which
may include pleural effusions, haemorrhage, seizures, encephalopathy and oedema of the face and
neck.
Crimean-Congo haemorrhagic fever: Characterised by the sudden onset of fever with headache,
myalgia, arthralgia, abdominal pain, and vomiting. Conjunctivitis, pharyngitis and palatal petechiae are
also common. Bruising and widespread haemorrhage typically starts after four days.
6
2.3. Specific treatments for VHF patients
Administration of the anti-viral drug ribavirin may be appropriate in some cases, on the recommendation
of an infectious disease physician. A stock of ribavirin is maintained for this purpose in the Pharmacy
Department at SCGH. Experimental treatments, albeit in very limited supply, may have contributed to
recovery in some HCWs infected with Ebolavirus during the 2014 West African epidemic.
2.4. Transmission
Following initial human infection from an animal source, transmission of VHFs is usually from person-toperson by contact with contaminated body fluids, either directly or via fomites. However, transmission by
airborne droplets has not been discounted in some cases.
However, the severity and consequences of infection require that a more elaborate and strict level of
containment be consistently maintained for the prevention of nosocomial transmission, both at the
bedside and in the diagnostic laboratory.
At the time of writing this plan, transmission of EVD to HCWs in western countries had occurred on three
occasions (two from one index case and one from another), during the 2014 outbreak. The reasons for
these transmissions is purported to be a breach in protocols for the use of PPE.
7
Table 1 - Summary of the major characteristics of the viral haemorrhagic fevers
8
3. Initial assessment and management of a possible
VHF case
This section concerns assessment and management of a person in whom VHF is suspected in an
emergency department (ED) of a hospital other than designated quarantine hospitals (Sir Charles
Gardiner Hospital (SCGH) for adults; or Princess Margaret Hospital (PMH) for child cases). The
designated quarantine hospitals have their own VHF plans that include management of suspected and
confirmed cases in their EDs, wards and intensive care units.
The following actions should be taken by a medical practitioner/ health professional who suspects VHF
on the basis of a patient‟s symptoms (fever, or symptoms of fever, with or without additional symptoms
such as headache, myalgia, arthralgia, vomiting, diarrhoea, abdominal pain or unexplained
bleeding/bruising in past 24 hours) and travel history (travel to a country where there is an outbreak of a
VHF, or contact with a person with a VHF, or the blood or body fluids of a person with a VHF within the
incubation period of the VHF (up to 21 days)):

immediately isolate the patient in a negative pressure isolation room (NPIR) (or single room if
NPIR not available) and minimise unnecessary staff and family contact. Do not allow the patient
to leave the health service

ensure appropriate infection prevention and control precautions are taken by all staff (and by
parent(s) of a child case if it is essential for them to remain with the patient) who are providing
care in the same room (See Appendix 5)

where available within a health facility, notify the Infection Prevention and Control Practitioner

obtain clinical and exposure information to allow an appropriate initial risk assessment to be
made (an example is shown in Appendix 2 EVD Risk Assessment Checklist)

notify the on-call public health physician at the Communicable Disease Control Directorate
(CDCD) on (08) 9388 4801(during office hours) or (08) 9328 0553 (after-hours paging system)

a final risk assessment will be undertaken between the practitioner, the CDCD on-call public
health physician and the on-call microbiologist from the designated quarantine hospital, and
further management advised

depending on the risk assessment, the patient may remain in isolation in the ED they presented
to and have samples taken for urgent testing for VHF at PathWest QE II Laboratory (if deemed
low risk), or may be transferred immediately to the designated quarantine hospital (if deemed
higher risk)
9

avoid taking a throat swab or undertaking any aerosol generating procedure or venepuncture
unless immediately essential for clinical care (see Appendix 18 WA EVD laboratory testing
guidelines [currently under development])

avoid calling St John Ambulance or the Royal Flying Doctor Service or organising any transport
to another health service unless advised by on-call CDCD public health physician, or is
immediately essential for life-saving care. Transfer will be organised by CDCD and SCGH/PMH
in accordance with Appendix11 EVD Patient transfer and transport guidelines

if advised by the on-call CDCD public health physician, compile a list of patients and staff who
were in contact with the patient, including their mobile phone numbers and other contact
information

if a patient is shown to have a VHF and has been transferred to a designated quarantine hospital,
environmental cleaning, disinfection and waste management should be carried out as detailed
Appendix 8 Cleaning and disinfection and Appendix 9 Waste treatment and disposal.

take any other actions advised by the on-call CDCD public health physician relating to risk
management or risk communication to staff and patients.
10
The remainder of this document applies specifically to Ebolavirus Disease (EVD).
Sections for other VHFs will be added at a later date. The appendices will be populated
further as policies and procedures are developed
11
Appendix 1 - Assessment and management of suspected cases of
Ebolavirus disease in Emergency Departments
Does the patient report:
(i) A documented FEVER, or symptoms of fever (sweats, chills, rigors or night sweats), with or without
ADDITIONAL SYMPTOMS such as headache, myalgia, arthralgia, vomiting, diarrhoea, abdominal pain
or unexplained bleeding/bruising in past 24 hours.
(ii) TRAVEL within a country where there is currently an EVD outbreak* in the 21 days prior to illness onset.
YES
NO
‘PATIENT UNDER INVESTIGATION‟
 Alert Senior Medical Officer and Senior Nurse.
 Triage nurse to don PPE and ensure droplet and contact precautions.
 Give surgical mask patient to patient, ask them not to touch anything and escort
(preferably walking) to single room via a predefined route. Staff member to walk
2m ahead to clear path of others
 Provide a vomit bag if vomiting.
NOT EVD: Standard
precautions and normal
medical evaluation
Senior ED Medical Officer to undertake INITIAL RISK ASSESSMENT
(use Appendix 2 – EVD risk assessment checklist in Interim Western Australia Viral
Haemorrhagic Fever Response Plan)
Call the on-call public health physician from the CDCD
(08 9388 4801(BH); 08 9328 0553 (A/H)) who will undertake
FINAL RISK ASSESSMENT in liaison with the on-call
microbiologist from the designated quarantine hospital
‘SUSPECTED CASE‟
Suspected case
deemed LOW RISK
of having EVD
NOT A „SUSPECTED CASE‟
Standard precautions and
normal medical evaluation
*EVD OUTBREAK COUNTRY LIST
EVD outbreaks at 24/10/2014
 Guinea
 Liberia
 Sierra Leone
 Democratic Republic of the Congo.
Check WHO for recent updates:
www.who.int/csr/don/en/
Suspected case
deemed HIGHER RISK
of having EVD
infection
 Take samples for Ebolavirus as per PathWest QEII
sampling kit, if available, or on advice of on-call
microbiologist from designated quarantine hospital
 Patient to remain in ED in isolation until results known
Arrange immediate
transfer to designated
quarantine hospital
(SCGH-adults; PMH –
children)
WA Health Interim Western Australia Viral Haemorrhagic Fever Response Plan 26 October 2014
PPE for ‘Suspected cases’: Standard plus
contact, droplet and additional respiratory
precautions (‘no skin exposure’ approach)
 Hand Hygiene
 Double glove
 Long sleeved, cuffed, fluid repellent gown
(inner and outer)
 Disposable full face visor
 Fluid repellent N95 or P2 mask/respirator
 Fluid resistant hood to protect head and neck
 Overshoes and leg coverings.
 Fluid repellent N95 or P2 mask/respirator
 Use a P2+ respirator and non vented goggles
for AGP.
 Impermeable boots
(where available, higher level PPE ensembles
(Jupiter hoods and powered air purifying
respirators (PAPRs)) can be used for patients
who have diarrhoea or vomiting)
Other considerations for ‘suspected cases’
 Maintain log of all persons entering patient's
room.
 Limit use of needles and other sharps.
 Limit phlebotomy and laboratory testing to
those procedures essential for diagnosis and
medical care
 Avoid aerosol generating procedures (AGP)
 Restrict entry to room to necessary staff.
 Alert your infection control team and ID
Physician
12
Appendix 2 – EVD risk assessment checklist
Patient’s name: .......................................................
DOB:.........................
UMRN:...........................
Clinician:..................................................................
Date:........................
Time:..............................
EBOLA VIRUS DISEASE RISK ASSESSMENT – HISTORY CHECK LIST
• Examining HCW: standard plus contact, droplet and additional respiratory precautions.
• Assistant HCW: >2m away from patient at all times, documents history and examination findings and
does not examine the patient.
HISTORY:
1. Reason for attending hospital.
Felt unwell
Concerned about possible
exposure to someone with
Ebola Virus Disease (EVD)
Accompanied another
patient:................................
.............................................
SYMPTOMS:
2. Patient’s symptoms and signs.
Fever
Abdominal pain(details):
- onset:
- timings:
Diarrhoea*
Told to attend ED by:
Public Health Unit/CDCD
GP
Other:................................
blood
Lethargy
Myalgia
Arthralgia
Nausea
Anorexia
Sore throat
SOB
Cough*
Sneezing*
Hiccups
Unexplained bruising
(locations):
Bleeding*
- nose
- eyes
- vaginal
- urine
- sputum
Chest pain:
Other:
Vomiting*
blood
Headache (details):
Rash(locations):
* secretory symptoms
3. Past medical history:
4. Medications:
5. Allergies:
6. Occupation:
7. Other family members who are unwell:
RISK OF EXPOSURE TO EVD
13
8. Travel in last 21 days.
To EVD affected country:
Liberia
Sierra Leone
Guinea
Democratic Republic of Congo
Other:........................................
Dates:
Cities/towns visited:
Accommodation:
Hotel (details e.g. 5 star)........................................
Stayed with family/friends
Other: ....................................................................
Villages/rural regions visited:
Reason for visit:
9. High risk activities in Ebola affected country.
Has worked/visited a hospital, clinic, laboratory or other health care setting.
Details (e.g. location, presence of EVD patients)
Any:
Needle stick injury from an EVD patient.
Mucous membrane exposed to blood or body fluids
from an EVD patient.
Direct skin contact with skin, blood or body fluids
from an EVD patient.
Processed blood or body fluids from an EVD patient
without appropriate PPE.
Direct contact with a dead body in an Ebola-affected
area without appropriate PPE.
Has spent time in care areas of EVD patients without
appropriate PPE.
Has had contact with a sick person in the community.
Type of contact
Close contact, cared for
Brief direct contact e.g.
patient.
shaking hands
Unknown diagnosis
Suspected EVD
Confirmed EVD
Diagnosis other than EVD
PPE used
Yes, all of
Occasionally
time.
or not at all.
Other activities:
Attended a funeral (details e.g. contact with dead)
Consumption of bush meat
LIKELIHOOD OF ALTERNATIVE PATHOLOGY
10. Protective/risk factors for other diseases.
Mosquito bites
Consumption of unsafe water
Taken malaria prophylaxis
Consumption of spoiled food
Patient’s name: .......................................................
Contact with wild animals (e.g. bats)
Tick bite
DOB:.........................
UMRN:...........................
14
Clinician:...................................................................
Date:..........................
Time:............................
EBOLA VIRUS DISEASE RISK ASSESSMENT – PHYSICAL EXAMINATION
• Examining HCW: standard plus contact, droplet and additional respiratory precautions.
• Assistant HCW: >2m away from patient at all times, documents history and examination findings and
does not examine the patient.
INITIAL
A:
B:
C:
RR
TEMPERATURE:
GCS: E
SpO2
M
V
PR
BP
Pupils:
IF THE ABOVE ARE ALL NORMAL AND PATIENT IS COMFORTABLE CONSIDER CALLING CDCD AT THIS POINT.
Abdominal:
Cardio-respiratory:
Orifices: any bleeding?
DO NOT USE A STETHOSCOPE
Skin: any rash or bruising?
Neurological:
Avoid aerosol generating procedures e.g. examination of throat.
15
Appendix 3 - National case definitions of Ebolavirus
disease
CNDA National guidelines for Ebolavirus disease (EVD) http://www.health.gov.au/ebola classifies
patients into the following categories :
Person under investigation
Requires clinical evidence and limited epidemiological evidence.
Clinical evidence requires fever >38o. Additional symptoms such as unexplained haemorrhage or
bruising, muscle pain, marked vomiting, marked diarrhoea, should also be considered
Limited epidemiological evidence requires only travel to an EVD-affected area.
Suspected case
Requires clinical evidence and epidemiological evidence.
Clinical evidence – as above
Epidemiological evidence requires a low risk or high risk exposure as defined below.
Lower risk exposures:

Household contact with an EVD case (in some circumstances this might be classified as higher
risk such as where the household was in a resource-poor setting)

Being within approximately 1 metre of an EVD patient or within the patient‟s room or care area for
a prolonged period of time (e.g., healthcare workers, household members) while not wearing
recommended personal protective equipment (PPE)

Having direct brief contact (e.g., shaki8ng hands) with an EVD patient while not wearing
recommended PPE
Higher risk exposures:

Percutaneous (e.g. needle stick) or mucous membrane exposure to blood or body fluids of an
EVD patient (either suspected or confirmed)

Direct skin contact with blood or body fluids of an EVD patient without appropriate personal
protective equipment (PPE),

Laboratory processing of body fluids of suspected, probable, or confirmed EVD cases without
appropriate PPE or standard biosafety precautions, or

Direct contact with a dead body without appropriate PPE in a country where an EVD outbreak is
occurring, or

Direct handling of sick or dead animals from disease-endemic areas consumption of “bushmeat”
in a country where EVD is known to occur.
16
Probable case
Requires clinical evidence and epidemiological evidence, AND, laboratory suggestive evidence of EVD.
Clinical evidence – as above
Laboratory suggestive evidence includes:
Isolation of virus pending confirmation by CDC, Atlanta or NIV, Johannesburg; OR;

Detection of specific virus by nucleic acid testing, antigen detection assay, or electron microscopy
pending confirmation by CDC, Atlanta, or NIV, Johannesburg; OR

IgG seroconversion or a significant increase in antibody level or a fourfold or greater rise in titre
to specific virus pending confirmation by CDC, Atlanta, or NIV, Johannesburg; OR

Detection of IgM to a specific virus pending confirmation by CDC, Atlanta, or NIV, Johannesburg.
Confirmed case
Requires laboratory definitive evidence only.
Laboratory definitive evidence requires confirmation of EVD infection by the Special Pathogens
Laboratory, CDC, Atlanta, or the Special Pathogens Laboratory, National Institute of Virology (NIV),
Johannesburg.

Isolation of a specific virus; OR

Detection of specific virus by nucleic acid testing or antigen detection assay; OR

IgG seroconversion or a significant increase in antibody level or a fourfold or greater rise in titre
to specific virus.
Note: If a risk assessment determines that a person under investigation should be tested for Ebolavirus,
the person should be managed as a suspected case from that point forward regardless of clinical and
epidemiological evidence.
17
Appendix 4 – Public Health response and Public
Health Unit responsibilities
WA Health will undertake the following actions in accordance with the CDNA national guidelines for
public health management of EVD as part of the public health response to a suspected or confirmed
case of EVD:

undertake an assessment of a potential suspected case

advise on public health aspects of case management, including making an EVD factsheet
available (Appendix 13 Ebolavirus disease fact sheet, and Appendix 14 Fact sheet for
contacts of a person with Ebolavirus disease)

undertake all contact tracing and contact management, including categorisation of risk,
determining control measures required (such as exclusion of contacts from a workplace) and
undertaking active surveillance if required

provide relevant directions, advice and alerts to the public.
WA Health will assess the nature of the exposures of any contacts of a suspected or confirmed case of
EVD. The approaches likely to be taken for categories of contacts are described below.
Follow-up for people with high risk exposures will be managed by WA Health and may involve:

making an EVD factsheet available (Appendices 13 and/or 14)

exclusion of health care workers and those whose work involves direct physical contact with
members of the public from working for 21 days from the date of last contact

restriction from undertaking certain activities at the direction of DH

person to take own temperature twice daily for 21 days from last exposure, preferably using a
digital thermometer and oral readings, and to notify their local public health unit if febrile or unwell

daily active monitoring by a public health unit officer by telephone

any other actions required by WA Health.
Follow-up for people with low risk exposures will be managed by WA Health and may involve:

making an EVD factsheet available (Appendices 13 and/or 14)

person to take own temperature twice daily for 21 days from last exposure, preferably using a
digital thermometer and oral readings, and to notify their local public health unit if febrile or unwell

any other actions required by WA Health.
18
Follow-up for people with an exposure assessed as casual contact will be managed by WA Health and
may involve:

making an EVD factsheet available (Appendices 13 and/or 14);

any other actions required by WA Health.
CDCD will inform the relevant PHU of patients under investigation, suspected, probable and confirmed
cases of EVD.
PHU Responsibilities
If a PHU staff member becomes aware of a patient under investigation, suspected, probable or
confirmed case of EVD before CDCD, they should contact CDCD immediately. PHUs will carry out their
responsibilities in accordance with the Communicable Disease Network of Australia (CDNA) Ebolavirus
Disease National Guidelines for Public Health Units. (http://www.health.gov.au/ebola)
1. Using the Ebolavirus Disease Case Report Form (Appendix 19), contact the patient‟s doctor to:

confirm the onset date and symptoms of the illness

confirm results of relevant pathology tests, or recommend that tests be done in accordance with
local laboratory referral protocols

find out if the case or relevant care-giver has been told what the diagnosis is before beginning the
interview

inform the doctor that public health staff will be contacting the patient/next of kin/carer.

review case management including infection control measures being used in caring for the case.
2. Interview the case or care-giver to complete exposure and contact history and other details

complete the exposure history and other sections of the EVD Investigation Form.

identify close contacts according to the contact definition.
3. Follow-up patient‟s contacts to:

assess risk of EVD transmission

determine current symptoms, if any

explain symptoms and need to immediately report any new symptoms

explain to healthcare worker close contacts any need for work restrictions during the potential
incubation period if there has been exposure

provide an EVD Disease Factsheet and recommend any self-monitoring for relevant contacts.
4. Notify CDCD (if not already done) and update data on WANIDD and Epi Info.
5. CDCD will notify Commonwealth Department of Health, Office of Health Protection.
6. Refer all media to the Communications Directorate (08 9222 4333).
19
Appendix 5 – Infection prevention and control
guidelines for Ebolavirus disease (non-quarantine
hospitals)
Guidance is provided in this Appendix for infection prevention and control of persons under investigation
for Ebolavirus disease (EVD) and the subsequent management of those persons considered as
suspected or probable cases of EVD in hospitals other than designated quarantine hospitals (Sir Charles
Gairdner Hospital (SCGH) for adults and Princess Margaret Hospital (PMH) for children). Strict
adherence to standard precautions and the adoption of transmission-based contact and droplet
precautions is essential in the management of these patients. The two designated quarantine hospitals,
SCGH and PMH, have specific policies and procedures in place for their respective settings.
In healthcare settings, Ebolavirus is spread through direct contact (e.g. through broken skin or through
mucous membranes of the eyes, nose, or mouth) with blood or body fluids of a person who is infected
with EVD, or with objects (e.g. needles, medical equipment, environmental surfaces) that are
contaminated with the virus. There is no epidemiological evidence that EVD is transmitted via the
airborne route, however, due to the severe nature of the disease, more stringent precautions have been
recommended. Correct application of personal protective equipment (PPE) that provides full body
coverage (i.e. no skin exposure) and protection from potential aerosolized droplets is recommended to
reduce the risk of direct or self-contamination.
All HCWs providing care to suspected cases of EVD must have undertaken competency-based training
on the correct application and removal of the designated PPE (Appendix 6 - Healthcare worker
education and training resources).
1. Infection prevention and control for a ‘person under investigation’
Any person presenting to a non-quarantine hospital that meets the criteria for „a person under
investigation‟ (Appendix 3), shall be asked to wear a fluid resistant surgical mask and placed in a
negative pressure isolation room (NPIR) (also referred to as an „airborne infection isolation room‟) as
soon as possible. If an NPIR is not available, use a single room. An initial risk assessment must be
undertaken by the senior ED medical officer (MO).
If the patient‟s condition allows, the initial risk assessment may simply be the taking of a history from the
patient at a distance (greater than 2 meters), or may require physical examination if this is deemed
appropriate, and this will govern the level of PPE required. If the patient can be interviewed and
20
assessed with no direct contact and a distance of >2m can be maintained, then no PPE is required. If
direct contact with the patient is required, or the patient is symptomatic with vomiting or diarrhoea, the
MO or HCW attending the patient should don PPE (gown, gloves, P2 or N95 mask, face shield and foot
covers) while the initial risk assessment is undertaken.
Following the initial risk assessment by the attending MO, this should be discussed with the on-call
public health physician from the Communicable Disease Control Directorate (CDCD) who, in turn, will
discuss with the on-call microbiologist from the designated quarantine hospital and make a final risk
assessment. Following this final risk assessment, a decision will be made as to whether testing for EVD
is indicated. Once a decision is made to test the patient for Ebolavirus, the patient changes from a
„person under investigation‟ to a „suspected case‟. A decision will then be made to either transfer the
patient to a designated quarantine hospital or continue to manage the patient in their current location. If
the final risk assessment judges the patient not to have EVD, they can be managed in accordance with
routine infection prevention and control precautions.
2. Infection prevention and control of a ‘suspected case’ of EVD
Depending on the final risk assessment by the on-call public health physician from the CDCD and the
on-call microbiologist from the designated quarantine hospital, the patient may remain isolated in the
hospital ED to which they presented and have samples taken for urgent testing for EVD at PathWest
QEII Laboratory (if deemed lower risk), or may be transferred immediately to the designated quarantine
hospital (if deemed higher risk) (Appendix 11). Until such time as the patient is either transferred to the
designated quarantine hospital or a negative result is returned for the lower risk patient who stays in situ,
the infection prevention and control precautions described in the following sections (2.1-2.6) are the
minimum required.
Note that, owing to the higher risk that larger metropolitan hospitals will encounter a case of EVD, a
pragmatic decision has been made for these hospitals to stock a limited number of higher level PPE
ensembles for use in patients who have diarrhoea or vomiting (Jupiter hoods and powered air purifying
respirators (PAPRs)).
2.1 Patient room placement, staff allocation and visitors

Allocate patient to a NPIR with ensuite and ante room. If this preferred accommodation is not
available, place in a single room with private bathroom or have a dedicated bathroom facility
adjacent. The door should be closed. If a dedicated bathroom is not available, provide patient
with urinal / commode using disposal products. Any fluid waste must be solidified prior to disposal
in the clinical waste bin (Refer Appendix 9).
21
 There needs to be clearly identified areas for the donning and doffing PPE.
 A HCW shall be assigned as a trained Observer and stationed outside the patient‟s room to
monitor access, ensure consistent and appropriate PPE use and assist with donning of PPE. A
second person, an Assistant, is required to help in doffing of PPE.
 Initiate a log of all HCWs entering the patient‟s room. Only essential medical and nursing HCWs
are to enter the room and anteroom. HCWs who are immunocompromised, pregnant or those
with non-intact skin e.g. dermatitis, abrasions are not to care for the patient.
 Stopping visitor access to the patient is preferred. If it is unavoidable, visitors must be restricted,
registered in the log and be supplied with full PPE.
2.2 Hand hygiene
 Hand hygiene must be performed in accordance with the „5 Moments‟ and at nominated points in
the donning and doffing of PPE.
 Hand hygiene can be performed by washing with antiseptic soap and water or by using alcohol
based hand rubs.
2.3 Personal protective equipment (PPE)
 All HCWs entering the patient room, including the Assistant, are to change into disposable
surgical scrubs prior to donning:
o
a pair of fluid-resistant disposable overshoes
o
knee high fluid-resistant boot/leg covers
o
fluid resistant hood to protect head and neck
o
single use long sleeved impervious (AAMI Level 4) gown
o
N95 or P2 mask – must be fit checked prior to entering the room. HCWs unable to achieve
the correct fit should not enter the room.
o
disposable safety glasses
o
full face shield
o
double gloves – at a minimum the outer gloves should have long cuffs.
 The Observer is to remain outside of the room or at a distance from the Assistant and HCW who
has provided care to the patient
 When exiting the room, PPE shall be carefully removed as per the Donning and Doffing
Procedure Checklist (Appendix 7), following instruction one step at a time from the Observer.
 The Observer is to read each step out aloud, and the HCW and Assistant are to wait for each
prompt before proceeding to the next step.
22
 Care shall be taken not to contaminate one‟s eyes, mucous membranes or clothing with
potentially infectious material.
 Any breach or contamination event must be reported immediately.
 All PPE should be discarded directly into the clinical waste bin as it is removed.
 All HCFs are to have donning and doffing procedure check lists to assist in this process
(Appendix 7 - HCW education and training resources).
2.4 Patient care equipment
 Dedicated medical equipment (preferably disposable, when possible) should be used for the
provision of patient care.
 Disposable linen is to be used and disposed of into clinical waste.
 Disposable crockery and utensils are to be used if required.
 Any non-disposable medical equipment used for patient care should be cleaned and disinfected
according to manufacturer's instructions and hospital policies. It is not to be re-used on another
patient until a definitive diagnosis is made. In the event a patient is confirmed with EVD all
reusable medical equipment is to be quarantined until advice is received from the Chief Human
Quarantine Officer (CHQO).
 All waste generated within the room is to be disposed of into clinical waste bins.
2.5 Patient care considerations
 Limit the use of needles and other sharps wherever possible. If used, they must be handled and
disposed of with extreme care by the user in a puncture resistant sharps container at point of use.
 Pathology testing suspected or probable cases will be undertaken after transfer to a quarantine
hospital.
 Avoid performing aerosol generating procedures (AGPs) e.g throat swabs, suctioning, and
intubation. If they are unavoidable, they must be performed in a NPIR, with restricted HCWs
present who must be wearing a powered air-purifying respirator (PAPR). Conduct environmental
surface cleaning following procedures.
 The patient may use the toilet. Toilet waste is to be managed in accordance with Appendix 9 -
Waste treatment and disposal. If the patient is unable to use the toilet, disposable bedpans /
urinals are to be used. The contents must be solidified by adding a sachet of absorbent granules
and disposing of in clinical waste once solidified. (Appendix 9).
23
2.6 Environmental cleaning
Cleaning and disinfection of the patient‟s environment is essential to minimise the risk of environmental
contamination and subsequent transmission of the virus from environmental surfaces or patient care
equipment. Following patient transfer to a QH, the following terminal cleaning is to be performed:
 HCWs involved in terminal cleaning are to wear full PPE as described in 2.3 and in addition
chemical resistant neoprene rubber gloves.
 Nursing and medical HCWs are to ensure all disposable items in the room, including linen are
contained in clinical waste bins and clean any reusable medical equipment with detergent
followed by disinfectant wipes.
 Any blood or body fluid spills must be managed by nursing or medical HCWs and actioned as
soon as possible (Appendix 8).
 Once the room is empty of all used items, staff responsible for cleaning, can perform a 2-step
clean using detergent and water followed by disinfection with 0.5% (5,000ppm) sodium
hypochlorite.
 All clinical waste and any reusable equipment are to be quarantined in the ante room or the
patient room until notified of a confirmed diagnosis. If EVD is excluded, handling of clinical waste
and patient equipment is per routine management.
 If a diagnosis of EVD is confirmed, any reusable equipment is to be managed as per 2.5 and
disposal of the clinical waste is to be followed as per Appendix 9.
3. Death of suspected EVD case
In the event a suspected case was to decease in a NQ hospital, refer to Appendix 10.
4. Management of HCWs following occupational exposure
The management of a HCW who sustains an occupational exposure with blood or body fluids from a
suspected EVD Case is described in Appendix 12.
24
Appendix 6 – Healthcare worker education and
training resources for Ebolavirus disease
All HCWs are be required to demonstrate competency in the use of PPE, including donning and doffing,
before providing care to patients with suspected, probable or confirmed Ebolavirus disease. They must
have received repeated training and have demonstrated competency while being observed by a trained
observer in the correct application and removal of the designated personal protective equipment (PPE).
Training ensures that HCWs are knowledgeable and proficient in the donning and doffing of PPE prior to
engaging in management of patient with suspected, probable or confirmed Ebola. Comfort and
proficiency when donning and doffing are only achieved through repeated practice on the correct use of
PPE. In addition, during practice, HCWs and their trainers should assess their proficiency and comfort
with performing required duties while wearing PPE.
All HCFs are to ensure they have a register of HCW trained in accordance with the WA Health
Ebolavirus Training Package and assessed as competent. The following resources are available at:
[TBA]
o WA Health Donning and Doffing Personal Protective Equipment

Video 1 PPE with non-PAPR use

Video 2 PPE with use of PAPR
o WA Health Written Instructions and Checklist
o WA Health Competency Certificate
o WA Health PPE Descriptor Poster
25
Appendix 7 – Donning and doffing PPE procedures
checklist
26
Appendix 8 - Cleaning and disinfection
General
The information in this Appendix primarily applies to those patients who have been categorised as
probable or confirmed Ebolavirus disease (EVD) cases. The personal protective equipment (PPE)
requirements for environmental cleaning are the same as those for patient care. There may be situations
that require environmental cleaning of a residence or other non-hospital setting prior to the availability of
laboratory test results for a suspected case with a high pre-test probability. This should follow the
principles outlined in this Appendix, following discussion with public health authorities.
Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials
is required as blood, sweat, vomitus, faeces and other body secretions represent potentially infectious
materials.
All staff carrying out cleaning and disinfection must be trained in the use of appropriate PPE and have
been assessed as competent in the donning and removal of the PPE as described in Appendix 7 Donning and doffing PPE procedures checklist. In addition to the PPE described, staff performing
cleaning, are to wear chemical resistant neoprene gloves which are to be discarded to clinical waste
after each use. Disposable cleaning equipment is to be used and discarded into clinical waste bins after
use.
Disinfectants
Ebolaviruses are readily inactivated by disinfectants that are active against other viruses such as
norovirus and rotavirus. The preferred disinfectant solution is sodium hypochlorite made using powder
sachets, granules or tablets to (0.1%) 1,000 ppm parts per million (ppm) available chlorine (follow
manufacturer‟s instructions) for routine environmental cleaning and (0.5%) 5,000 ppm for spills.
Neutral soaps and detergents should be used liberally for washing hands and the patient. Do not use
disinfectants as part of routine patient washing.
Routine environmental cleaning
Daily clean of all hard, non-porous surfaces such as floors, toilets, counters, and high-touch surfaces
(e.g. door handles, bed rails, light switches, call bells and tables) still applies and the room should be
cleaned as per usual practice. Visibly soiled surfaces should be wiped clean with single use detergent
cloths until visibly clean.
A two-step clean is required: a daily clean with neutral detergent is required while the patient is in the
27
isolation room. All cleaned surfaces should then be disinfected using the freshly prepared sodium
hypochlorite solution.
Dispose of all cleaning cloths and mop heads into the clinical waste after each clean.
The patient toilet should be cleaned with a 1,000 ppm sodium hypochlorite solution after each use, after
the contents have been flushed.
Terminal cleaning
Terminal cleaning should be carried out as per routine cleaning. Prior to commencing the clean, the
room is to be „stripped‟ i.e. ensure all disposable equipment, rubbish and linen is discarded into clinical
waste bins and the containers sealed.
Once the patient has left the room the entire room should be cleaned with a neutral detergent then
allowed to air dry. Dispose of all cleaning clothes and mop heads into the clinical waste.
Once the room is air dry repeat the cleaning process with a 1,000 ppm sodium hypochlorite solution and
ensure the disinfectant is liberally applied to all surfaces within the isolation room. Dispose of all cleaning
equipment including buckets, mop handles, mop heads, cloths into the clinical waste after a terminal
clean.
Allow the room to air dry. Where negative pressure is being used, maintain the negative pressure during
the terminal clean. Then allow an additional 30 minute period after the room has air dried before
switching off the negative pressure and allowing the next patient to enter the room.
Any non-disposable medical equipment used for patient care should be cleaned and disinfected
according to manufacturer's instructions and hospital policies. It is not to be re-used on another patient
until a definitive diagnosis is made. In the event a patient is confirmed with EVD, all reusable medical
equipment is to be quarantined until advice is received from the on-call public health physician from the
Communicable Disease Control Directorate.
Spills management
Any blood or body fluid spill must be contained and managed as soon as possible after the event has
occurred. The HCW managing the spill must be wearing the same PPE as HCWs caring for the patient,
which includes a pair of fluid-resistant disposable overshoes, knee high fluid-resistant boot/leg covers,
fluid resistant hood to protect head and neck, single use long sleeved impervious gown, a fit-checked
N95 or P2 mask, disposable safety glasses, full face shield and double, long-cuffed gloves (see
28
Appendix 6 - Infection prevention and control guidelines for Ebolavirus disease (non-quarantine
hospitals)).
Remove any bulk matter with disposable cloths and discard in clinical waste. Remove outer gloves,
discard and perform hand hygiene with an ABHR. Don a new pair of outer gloves. Absorbent granules
should be placed on the spill and covered with paper towels to limit the spread of the spill. Leave until all
liquid is absorbed removing and disposing of the absorbed spill and paper towel.
Limit the spread of the spill and remove any bulk matter by covering with absorbent paper towels or
absorbent granules, liberally covered with a 5,000 ppm sodium hypochlorite solution and left to soak for
30 minutes before being wiped up. Leave until all liquid is absorbed removing and disposing of the
absorbed spill and paper towels into clinical waste for disposal.
Following the removal of the initial material, remove outer gloves, discard and perform hand hygiene with
an alcohol-based hand rub. Don a new pair of outer gloves. The area of contamination should again be
liberally covered with a 5,000 ppm sodium hypochlorite solution and left for 30 minutes before rinsing.
Patient Equipment
Limit the equipment that enters the patient‟s room. The patient must have their own dedicated equipment
that remains with them for the duration of their hospitalisation. Use disposable products when available.
When reusable non-critical equipment leaves the patient room ensure a two stage cleaning with a
neutral detergent followed by a second clean with a 1,000 ppm sodium hypochlorite solution. For semi
critical and critical equipment ensure routine disinfection/sterilization reprocessing occurs, no additional
disinfection or sterilization cycle is required.
Linen
The use of disposable linen is preferable.
Linen is treated as clinical waste. For linen wet from body fluids, place into a leak-proof bag and not a
cloth linen bag.
Patient clothing
Patient clothing should be disposed of in the clinical waste. The patient should wear hospital clothing and
gowns and not their own clothes. Patient clothing and linen must not be processed in a domestic
washing machine.
29
Appendix 9 – Waste treatment and disposal
This Appendix is based on waste treatment and disposal methods described in Appendix 13 of the
Ebolavirus Disease (EVD) CDNA National Guidelines for Public Health Units, and incorporating
recommendations from The Environmental Health Standing Committee (enHealth) [a standing
committee of the Australian Health Protection Principal Committee (AHPPC)].
1. Clinical waste, including bed linen, patient clothing disposable personal protective equipment
and other waste
The PPE requirements for personnel involved in environmental cleaning are the same as those
engaged in patient care.
All waste is to be treated as clinical waste. Any bulk liquid waste must be solidified using high
absorbency granules prior to transfer to clinical waste bags.
All waste to be disposed of in accordance with WA Health Clinical and Related Waste Management
Policy and Operational Directive OD 0258/09 Clinical and Related Waste Management – General
Requirements and OD 0259/09 (Clinical and Related Waste Management – Clinical Wastes).
All items are to be double-bagged in clinical waste bags that adhere to Australian Standards and be
leak proof. Facilities should have a system of double bagging the clinical waste which should involve
keeping the first clinical waste bags inside the patient room and then placing these bags inside a
second clinical waste bag kept outside the patient room.
Waste bags must then be placed inside rigid puncture-proof and sealable containers, which in turn
should be disinfected with sodium hypochlorite made up to 1,000 parts per million (ppm) available
chlorine.
Prior to collection by the contractor, waste must be stored securely and access restricted to
authorised and trained personnel.
High-temperature incineration is the approved method for disposal. Other disposal methods will
require specific DOH approval [as of 24 October 2014, enHealth is reviewing whether autoclaving of
clinical waste followed by transport to approved landfill transport facilities is to be permitted, and
30
standards/evidence required for approval of any disposal method other than high-temperature
incineration].
2. Effluent waste and toilet procedure
International (WHO, CDC) and National (CDNA EVD National Guidelines for Public Health Units)
EVD guidelines recommend that effluent waste can be safely disposed of direct to mains sewer and
septic systems. However, enHealth recommends that additional measures such as addition of
chlorine in a suitable concentration for a spill to the toilet waste [e.g. Milton tablets (1% sodium
hypochlorite) = 10,000 ppm available chlorine] and allowing up to 30 minutes, prior to flushing
provides further surety in the unlikely event of a breach of mains sewer in close proximity to the
treating hospital or hospital wastewater infrastructure.
Where possible, automatic chlorine dosing of toilets or by hospital staff with appropriate PPE to clean
(P2/N95 mask and PPE) as per guideline as opposed to relying on the patient to undertake these
steps, as well as frequent cleaning and a cleaning schedule to be displayed inside room.
In all cases, ensure the toilet lid is down when flushing. If staff are required to flush the toilet, it is
recommended they wear a P2/N95 mask in addition to their other PPE in case of aerosols when the
toilet is flushed.
If a patient is unable to use the private bathroom, a disposable pan should be used. The contents of
the pan are to be solidified with high-absorbency gel then both the pan and contents disposed into
clinical waste.
The patient toilet should be cleaned with a 1000ppm sodium hypochlorite solution after each use with
lid closed, after the contents have been flushed.
3. Waste companies transporting contaminated waste
All waste should be considered as clinical waste. Double-bagged waste to be placed in a rigid
puncture-proof container, sealed, then surface disinfected prior to transport.
4. Non-hospital setting decontamination
Ambulance and patient vehicle decontamination: Apply WHO standard for washing of vehicles
using non-hose or aerosol generating method, including use of PPE, debulking of blood or other
31
body fluids, or spills ( and wiping and soaking, with disposal into clinical waste) in the vehicle and
use of with sterilising spray. Avoid high pressure spray due to risk of aerosols.
These procedures to be carried out using Ambulance companies‟ own washdown facility or that of a
hospital, and liquid waste produced as a result of decontamination and cleaning of patient transport
vehicles, must be disposed of down drains that lead to a holding tank that can be sterilised, or to
mains sewer.
Private residences or other accommodation: whenever possible, decontamination of potentially
infected homes should be delayed by 6 days to allow denaturing of infectious virus particles, thereby
reducing risk of exposure. However, this may not be possible with potential EVD cases due to public
attention or home quarantine. In these circumstances, infection control personnel, first responders
(e.g. fire fighters or police cleaning crews) and/or other contracted entities should undertake
decontamination methods consistent with CDNA EVD National Guidelines for Public Health Units.
Focus on disposal or of porous items and disinfection of non-porous items. EVD appears not be
viable outside the human or animal body beyond six days, so to provide additional surety, premises
should be vacated for at least seven days prior to re-occupation.
5. Mortuary waste
See Appendix 14 of CDNA EVD National Guidelines for Public Health Units and NHMRC Infection
Control Guidelines outline procedures post-mortem care and disposal of the deceased.
6. Funeral premises
All mortuaries must be constructed according to requirements in National Construction Code with
drainage to sewer.
7. Training body handlers such as hospital staff and funeral directors
Apply standard outlined in CDNA national guidelines for EVD, noting that while cremation is
preferred, immediate burial is permissible.
32
Appendix 10 – Post-mortem care and examination
Definitions for terms used in this appendix
Cremation: The act of reducing human remains to ash by intense heat.
Leakproof bag: A body bag that is puncture-resistant and sealed in a manner so as to contain all
contents and prevent leakage of fluids during handling, transport, or shipping.
Safe handling of human remains of a patient with Ebolavirus disease
These recommendations give guidance on the safe handling of human remains that may contain
Ebolavirus and are for use by personnel who perform care of the deceased in hospitals and mortuaries.
In patients who die with Ebolavirus infection, virus can be detected throughout the body. Ebolavirus can
be transmitted by laceration and puncture with contaminated instruments used during post-mortem care,
through direct handling of human remains without appropriate personal protective equipment, and
through splashes of blood or other body fluids (e.g. urine, saliva, faeces) to unprotected mucosa (e.g.
eyes, nose, or mouth) which occur during care of the deceased.

The following are important principles of care in these circumstances:

Only personnel trained in handling infected human remains, and wearing PPE, should touch, or
move, any Ebola-infected remains or suspected Ebola-infected remains;

Handling of human remains should be kept to a minimum;

Post-mortems should not be performed on patients who die with Ebolavirus disease. If a postmortem is requested, the CDCD and PathWest Forensic Pathology should be consulted.
Roles and responsibilities in the care of the deceased
The completion of a death certificate by a medical practitioner is a vital part of the notification process of
a death to the Registrar of Births, Deaths and Marriages and enables an authority to be provided to the
funeral director to arrange disposal of the deceased. Completing a death certificate and reporting a
death to the Coroner are mutually exclusive exercises. Doctors should be familiar with the criteria for
reporting deaths to the Coroner. A death as a result of Ebolavirus disease would not ordinarily be
reported to a Coroner. If a diagnosis of Ebolavirus disease has been made prior to death and there are
no other criteria for reporting the death, a death certificate could be completed.
Personal protective equipment for care of the deceased
Personal protective equipment (PPE): Prior to contact with the deceased, post-mortem care personnel
must wear at least the following PPE: impervious gown with full sleeve coverage, eye protection (e.g.
33
face shield, goggles), single use sub-micron fluid resistant facemask, shoe covers, and double gloves.
Additional PPE (leg coverings, apron) might be required in certain situations (e.g. copious amounts of
blood, vomit, faeces, or other body fluids that can contaminate the environment).
Putting on, wearing, removing, and disposing of protective equipment: PPE should be in place BEFORE
entering the room, contact with the deceased, worn during the process of collection and placement in
body bags, and should be removed immediately after and discarded as regulated medical waste. Use
caution when removing PPE as to avoid contaminating the wearer. Hand hygiene (washing your hands
thoroughly with soap and water) should be performed immediately following the removal of PPE.
Preparation of the deceased
Preparation of the deceased: All contact with the deceased should be minimized. At the site of death, the
deceased should be placed in leak-proof body bag not less than 150 μm thick and zippered closed.
Change your gown or gloves after placing the deceased in the bag. Leave any intravenous lines or
endotracheal tubes that may be present in place. Avoid washing or cleaning the deceased. The bagged
remains should then be placed in another leak-proof plastic body bag not less than 150μm thick and
zippered closed before being transported to the morgue.
Surface decontamination: Prior to transport to the mortuary, perform surface decontamination of the
outer body bag by first removing visible surface contamination on bag surfaces with recommended
disinfectants which can kill a wide range of viruses. An example of an effective disinfectant is sodium
hypochlorite (Appendix 8). Follow the product‟s label instructions. After any visible contamination has
been removed, reapply the disinfectant to the entire bag surface and allow to air dry. Following the
removal of the body, the patient room should be cleaned and disinfected. Reusable equipment should be
cleaned and disinfected according to standard procedures. For more information on environmental
infection control, please refer to “Interim Guidance for Environmental Infection Control in Hospitals for
Ebolavirus” (http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-controlin-hospitals.html).
Individuals driving or riding in a vehicle carrying deceased persons: PPE is not required for individuals
driving or riding in a vehicle carrying deceased persons, provided that drivers or riders will not be
handling the body and the body is safely contained in a disinfected body bag as described above.
Mortuary Care

Do not open the body bags and do not remove remains from the body bags. Bagged remains
should be placed directly into a sealed casket.
34

Do not perform embalming. The risks of occupational exposure to Ebolavirus while embalming
outweighs its advantages; therefore, bodies infected with Ebolavirus should not be embalmed.

Mortuary care personnel should wear at least the PPE listed above (surgical scrub suit, surgical
cap, impervious gown with full sleeve coverage, eye protection (e.g., face shield, goggles),
facemask, shoe covers, and double gloves) when handling the bagged remains.

In the event of leakage of fluids from the body bag, thoroughly clean and decontaminate areas of
the environment with recommended disinfectants (refer Appendix 6). Reusable equipment should
be cleaned and disinfected according to standard procedures. For more information on
environmental infection control, please refer to Interim Guidance for Environmental Infection
Control in Hospitals for Ebolavirus (http://www.cdc.gov/vhf/ebola/hcp/environmental-infectioncontrol-in-hospitals.html).
Disposition of remains

There should be no viewing of the deceased by family members. The body bags and casket
should remain sealed.

Remains should be cremated or buried promptly in a sealed casket.

Once the bagged body is placed in the sealed casket, no additional cleaning is needed unless
leakage has occurred.

As an additional precaution gloves should be worn when handling the sealed casket.

No PPE is needed when handling the cremated remains.

The Australian Funeral Directors Association, Funeral Industry Infection Control Guidelines, 2008
can be obtained from: http://afda.org.au/media/member/ICG.pdf
Transportation of human remains
Transportation of remains that contain Ebolavirus should be minimized.
Reported deaths
CDCD will be alerted if Police who attend a reported death suspect that a deceased person may have
Ebolavirus disease. If the deceased was reported to have flu like symptoms immediately prior to death
and has recently travelled to an affected area in Africa, CDCD will notify the SCGH on-call microbiologist
and the PathWest Forensic Pathology on-call pathologist. PathWest Forensic Pathology will advise
Police to secure the scene and await further advice.
PathWest Forensic Pathology‟s on-call pathologist, in consultation with CDCD and the SCGH on-call
microbiologist will make the decision to either treat the deceased as “suspected Ebola” or a normal case.
PathWest Forensic Pathology will also notify the Chief Health Officer and the State Coroner immediately.
35
If the decision is made to treat the deceased as “suspected Ebola” the deceased is to remain in situ and
a PathWest Forensic Pathology Pathologist with appropriate PPE will attend the scene and collect
appropriate specimens in accordance with Appendix 18.
References
Centers for Disease Control and Prevention, Guidance for Safe Handling of Human Remains of Ebola
Patients in Hospitals and Mortuaries. Available from: http://www.cdc.gov/vhf/ebola/hcp/guidancesafehandling-human-remains-ebola-patients-us-hospitals-mortuaries.html
36
Appendix 11 - EVD patient transfer and transport
guidelines
Assessing need for transfer of a suspected case to a designated hospital
The following patients will generally be transferred to the designated quarantine hospitals as a matter of
urgency – Sir Charles Gairdner Hospital (SCGH) for adult cases, including pregnant women, and
Princess Margaret Hospital (PMH) for child cases:

a confirmed case of Ebolavirus disease (EVD)

a suspected case of EVD with high risk exposures and a highly consistent clinical picture.
The following factors are likely to favour immediate transfer to SCGH/PMH before confirmation of EVD
and should be considered in a discussion between the on-call public health physician from the
Communicable Disease Control Directorate (CDCD), the on-call microbiologist from SCGH/PMH, and
the referring practitioner:

Higher likelihood of EVD:
o
clinical features highly consistent with EVD in the opinion of an infectious diseases specialist
(such as unexplained haemorrhage)
o
one or more high risk exposure(s) (for definitions, see Ebolavirus Disease (EVD) CDNA
National Guidelines for Public Health Units



Criticality of patient allied to need for urgent pathology:
o
patient is critical or requires intensive care
o
urgent need for general pathology.
Lower negative predictive value of initial testing to exclude EVD:
o
timeframe since onset of illness is less than 72 hours
o
indeterminate result on initial testing.
Lower capability of health service to handle a suspected case:
o
health service does not have appropriate infection prevention and control capability;
o
health service does not have infectious diseases expertise.
A case that is to be transferred to SCGH/PMH after consideration of the above factors will have all
testing including for EVD and routine pathology conducted at the receiving hospital.
For patients who are deemed appropriate to remain at the presenting health facility, specimens will be
collected at that facility for transport to PathWest QE II Laboratory at SCGH for EVD testing and routine
pathology should be avoided until EVD is excluded.
37
Transfer arrangements
Transfers will be activated by the on-call CDCD public health physician and the on-call microbiologist in
consultation with the most appropriate transport provider, i.e St John Ambulance or Royal Flying Doctor
Service.
A medical practitioner should not organise transfer of a patient with suspected or confirmed EVD unless
the situation is critical and the on-call CDCD public health physician has not been able to be contacted
for any reason.
St John Ambulance and Royal Flying Doctor Service are equipped to transfer suspected or confirmed
cases of EVD in WA.
St John Ambulance and Royal Flying Doctor Service will use infection prevention and control
precautions including standard, contact and droplet precautions for the transfer of suspected cases.
Where there are copious amounts of blood or body fluid present, additional PPE may be required as
described in the section on Infection prevention and control.
For a paediatric patient requiring specialised retrieval, PMH will coordinate retrieval through the Newborn
Emergency Transport Service of Western Australia.
38
Appendix 12 – Management of healthcare workers
following occupational exposure
39
Appendix 13 - Ebolavirus disease fact sheet
What is Ebolavirus Disease (EVD)?
Ebolavirus Disease (EVD) is a serious and often fatal disease caused by a virus. There are several
strains of the virus. EVD was previously called Ebola haemorrhagic fever.
Fruit bats are considered to be the natural host of Ebolaviruses, with outbreaks amongst other species
such as chimpanzees, gorillas, monkeys and forest antelope from time to time. There have been 24
outbreaks in humans of EVD in Central and East Africa since the virus was first identified in 1976. While
there is evidence of one strain of Ebolavirus being present in animal populations in some parts of Asia,
there have been no reports of human illness outside of Africa. The current outbreak is the first in West
Africa.
There is no evidence that it is present in Australian bats or other animals in Australia. There have been
no cases in Australia.
What are the symptoms?

Ebolavirus can cause a serious illness, with a sudden onset of fever, muscle and joint aches,
weakness, and headache.

The next stage is characterised by vomiting, diarrhoea, rash and malfunction of liver and kidneys.

Some cases present with profuse internal and external bleeding and progress to multi-organ
failure.

Between 50 and 90% of cases of EVD will die of the disease.
How is it spread?

Ebolavirus is introduced into the human population through close contact with the blood,
secretions, organs or other bodily fluids of infected animals (e.g. through the hunting or
preparation of "bushmeat").

Ebolavirus then spreads from person to person via contact with the blood, secretions, or other
bodily fluids of infected people, and contact with environments contaminated with such fluid,
including in healthcare settings.

Transmission through sexual contact may occur up to three months after clinical recovery.

Airborne transmission is not known to occur.

Traditional burial ceremonies conducted in affected areas of Africa are a known high risk activity
for transmission.
40
Who is at risk?
People who are living in or travelling to affected areas of Africa may be at risk of infection; however, the
risk of infection is extremely low unless there has been direct contact with the bodily fluids of an infected
person or animal (alive or dead).
Caring for ill relatives is a known risk factor for infection, and healthcare workers, particularly those in
resource poor settings with inadequate infection control are also at risk.
How is it prevented?
Good hygiene and infection control around EVD cases is the only way to prevent spread of disease.
There is no vaccine for EVD. Hunting and contact with "bushmeat" in affected areas should be avoided.
What should I do if I become unwell after travel in areas affected by EVD?
If you become ill or feel unwell while travelling in areas affected by EVD, you should not wait until you
arrive back in Australia to seek medical assistance. Instead you should see a doctor or go to the local
emergency department.
If you have returned within the last 21 days from travel to areas affected by EVD and develop a fever,
vomiting, diarrhoea and other symptoms, you should see your doctor or go to the emergency department
to work out why you are ill. It is important that you mention your symptoms and which countries you have
visited when you first arrive at the medical practice or hospital emergency department.
You may be separated from others to prevent further spread of infection.
How is it diagnosed?
EVD is diagnosed by a blood test that detects the virus. Urine and/or a swab from throat or nose may
also be examined to look for the virus. Testing for EVD is done in a public health laboratory with special
biosafety facilities.
How is it treated?
There is currently no specific treatment for people who are sick with EVD, but general intensive medical
care can be life-saving.
What is the public health response?
Special procedures to prevent the spread of EVD are in place to manage the situation in the event there
is a case of EVD in Australia. These include:
41

Doctors and laboratories are required to notify state/territory health departments of any
suspected cases.

Isolation of suspected cases from other people.

Identification of people who have been in contact with the case by Public Health authorities so
that these people are given information about the risk of infection and monitored for any signs or
symptoms of the disease.

Special safety guidelines including wearing protective equipment to prevent spread of Ebolavirus
to health care workers managing cases and laboratory staff handling specimens.
Public health unit staff will investigate all cases to find out how the infection occurred, identify other
people at risk of infection, implement control measures and provide other advice.
Further information

World Health Organization (WHO) EVD updates available from the WHO website:
(www.who.int/csr/disease/)

Australian Department of Health – EVD website (https://www.health.gov.au/ebola)
42
Appendix 14 - Fact sheet for contacts of a person
with Ebolavirus disease
43
Appendix 16 - Contact numbers
DEPARTMENT OF HEALTH, WESTERN AUSTRALIA, AFTER HOURS EMERGENCY CONTACT
NUMBERS
OFFICER
TELEPHONE
TELEPHONE
(OFFICE HOURS)
(AFTER HOURS)
WA Chief Human Quarantine
Mob: 0429 153 201
Mob:
0429 153 201
Officer
Tel: (08) 9388 4800
or
Dr Paul Armstrong
Fax: (08) 9388 4888
Tel: (08) 9328 0553
Manager - State Ambulance
Tel: (08) 9334 1234
Tel: (08) 9334 1234
Operations
Fax: (08) 9334 1207
Fax: (08) 9334 1207
Mob:
Mob:
St John Ambulance
Duty Manager
0434 664 413
0434 664 413
Australian Government
Airport Managers
Department Of Agriculture
Mob:
0434 305 895
(formerly AQIS)
Mob:
0434 664 414
Perth Airport Duty Manager
Tel: (08) 9478 8501
Tel: (08) 9478 8501 (24 hrs)
Westralia Airports Corporation
Fax: (08) 94788590
Control Centre:
Perth International Airport
Tel: (08) 9478 8572
Fax: (08) 9478 8574
Perth Airports Emergency
Tel: (08) 9478 8816
Planning Manager
Fax: (08) 9478 8889
Manager, Safety
Mob: 0477 114 115
Fremantle Port Authority
Tel: (08) 9432 3660
Mob:
0439 977 820
Mob:
0477 114 115
Fax: (08) 9336 1391
Office of Health Protection
Director, Human Quarantine
Duty Officer – National Incident
(Commonwealth Department of
Tel: (02) 6289 8408
Room - 24 hour service
Health and Ageing)
Fax: (02) 6285 1994
or
Tel:
(02) 6289 3030
Director, Border Health
Fax:
(02) 6289 3040
Tel: (02) 6289 2705
Fax: (02) 6289 2600
44
STATE HUMAN QUARATINE OFFICERS, WESTERN AUSTRALIA
OFFICER
TELEPHONE
(OFFICE HOURS)
TELEPHONE
(AFTER HOURS)
Dr Gary Dowse
(Communicable Disease Control
Directorate)
Mob: 0408 917 799
Tel: (08) 9388 4849
Tel: (08) 9328 0553
Dr Paul Effler
(Communicable Disease Control
Directorate)
Mob: 0407 727 131
Tel: (08) 9388 4818
Tel: (08) 9328 0553
Dr Donna Mak
(Communicable Disease Control
Directorate)
Mob: 0437 781 930
Tel: (08) 9388 4828
Tel: (08) 9328 0553
Dr A Keil
(Princess Margaret Hospital)
Tel: (08) 9340 8222
Fax: (08) 9380 4474
Tel: (08) 9340 8222
(PMH switchboard)
Dr D Smith
(PathWest)
Tel: (08) 9383 4438
Tel: (08) 9346 3333
(switchboard)
Fax: (08) 9346 3960
Tel: (08) 9346 2536
(PathWest Security)
Dr T Inglis
(PathWest)
Tel: (08) 9383 4548
Tel: (08) 9346 3333
(Page 4450)
Fax: (08) 9382 8046
Tel: (08) 9346 2536
(PathWest Security)
Dr Marissa Gilles
Public Health Physician
WACHS – Midwest
Mob: 0429 086 740
Tel: (08) 9956 1985
Tel: (08) 9328 0553
Dr Clare Huppatz
Public Health Physician
WACHS – Goldfields
Mob: 0408 917 799
Tel: (08) 9388 4849
Tel: (08) 9328 0553
Dr Heather Lytlle
Public Health Physician
WACHS – Pilbara
Mob: 0409 170 056
Tel: (08) 9080 8200
Tel: (08) 9328 0553
Dr Naru Pal
Public Health Physician
WACHS – South West / Gt.
Southern
Mob: 0429 686 998
Tel: (08) 9842 7500
Tel: (08) 9328 0553
45
Appendix 17 – Specimen collection and handling
Appendix 18 – WA EVD laboratory testing guidelines
46
Appendix 19 - Ebolavirus Disease Case Report Form
47
This document can be made available in alternative formats
on request for a person with a disability.
© Department of Health 2014
Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart
from any fair dealing for the purposes of private study, research, criticism or review, as permitted under
the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes
whatsoever without written permission of the State of Western Australia.