Public Health Monitoring of Returning Travellers

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1 Introduction Ebola virus disease (EVD) is associated with a high fatality rate, and is currently affecting several countries in West Africa. Although the risk in Canada is very low, Ontario s health care system must be prepared for the possibility of persons with the disease, or incubating the disease, entering the province. In Ontario, those most at risk are individuals recently returned from affected countries/areas in West Africa and health workers that provide care for suspect and confirmed cases in Ontario health care settings. The Ministry of Health and Long-Term Care maintains a list of the affected countries/areas on its EVD Website at This Directive provides instructions to primary health care settings 1, and their management and employees, concerning precautions and procedures necessary to protect the health of patients and workers and significantly reduce the risk of spreading infectious diseases. The Chief Medical Officer of Health has issued directives on precautions and procedures related to EVD for acute care settings and emergency medical services. Further directives and guidance for other settings, including laboratories, will follow. Public Health Monitoring of Returning Travellers Public Health Agency of Canada s Quarantine Services Program identifies travellers returning from affected countries/areas at the Canadian border. Asymptomatic travellers receive a quarantine order requiring them to report to their local public health unit. The public health unit monitors the travellers health for the 21 days since departure from the affected countries/areas. The public health unit advises travellers to monitor their temperature twice daily and if symptoms become apparent, to notify the public health unit and seek care at a hospital emergency department. Travellers are advised not to present at a primary health care setting. The public health monitoring process should limit the number of returning travellers that present at primary health care settings for EVD-related care. Symptoms of Ebola Virus Disease The symptoms of EVD include: fever (38 C or greater) severe headache muscle pain diarrhea 1 Primary health care settings may include family health teams, community health centres, Aboriginal health access centres, walk-in clinics, nurse-practitioner led clinics and solo practitioners such as family physicians, general practitioners and paediatricians. 1

2 vomiting sore throat abdominal pain unexplained bleeding Precautions and Procedures Education and Training Primary health care settings must ensure that staff members (including primary health care providers 2 and other staff) are familiar with the risk posed by the EVD outbreak in West Africa. Primary health care settings must provide staff members with education and training on the following topics: symptoms of EVD process to screen patients for EVD (by telephone, through signage, at the reception desk) recommended occupational health & safety (OHS) and infection prevention & control (IPAC) measures to stop the transmission of EVD in primary health care settings, including Routine Practices and Additional Precautions process to refer a suspect case to the nearest hospital emergency department Screening Telephone screening Staff members must ask patients that telephone the primary health care setting about symptoms compatible with EVD and travel history to an affected country/area. Staff members may use the sample screening tool provided in Appendix A to screen patients over the phone. Patients who have symptoms compatible with EVD and travel history must be told not to visit the office they should be connected with a primary health care provider (during the initial phone call or a phone call back). The primary health care provider must review the patient s symptoms and travel history. If the primary health care provider suspects the patient may have EVD, he/she must advise the patient to go to the nearest hospital emergency department for further assessment. The primary health care provider can support the patient to arrange transportation to the nearest hospital emergency department, either by private vehicle or ambulance. The patient must be instructed to avoid physical contact with others and not to take public transportation to the hospital emergency department. Passive screening Signs 3 must be posted at all entrances to the primary health care settings, as well as at the reception desk, asking patients about symptoms compatible with EVD and travel 2 A primary health care provider is a regulated health care professional such as a family physician, nurse practitioner or registered nurse. 3 Sample signage will be available on the Ministry of Health and Long-Term Care's EVD Website at 2

3 history to an affected country/area. Patients meeting both criteria should be instructed to use alcohol-based hand rub, put on a surgical mask and proceed to the reception desk. Reception desk screening Staff members must ask patients that were not already screened over the phone about symptoms compatible with EVD and travel history to an affected country/area. Staff members should be at least one metre (three feet) away from the patient during the screening process, preferably behind a suitable structural barrier (e.g., glass or Plexiglass shield). Staff members may use the sample screening tool in Appendix A to screen patients at the reception desk. Results of In-Person Screening Patients with symptoms compatible with EVD and travel history Primary health care settings must take the following actions for patients who have symptoms compatible with EVD and travel history to an affected country/area: The patient should use alcohol-based hand rub and put on a surgical mask. Staff should maintain at least one metre distance from the patient and avoid any physical contact. The patient must be advised to go to the nearest hospital emergency department (see the section on Patient Referral to a Hospital Emergency Department for additional information). Further assessment to confirm the diagnosis of EVD, including taking laboratory specimens, must be done at a hospital. Blood must not be drawn from these patients in primary health care settings or by a private laboratory. Patients with no symptoms compatible with EVD and travel history If the patient has travel history to an affected country/area and no relevant symptoms, the primary health care provider may check the patient s temperature prior to further assessment: The patient should be moved to a private room with the door closed. If the patient has a temperature of 380C or greater, the primary health care provider must advise the patient to go to the nearest hospital emergency department (see the section on Patient Referral to a Hospital Emergency Department for additional information). If the patient has no fever, the primary health care provider can provide usual care in the primary health care setting. The primary health care provider can verify that the returning traveller has been linked with the public health unit (see the section on Public Health Monitoring of Returning Travellers for more information) Patient Referral to a Hospital Emergency Department If EVD is suspected based on symptoms compatible with EVD and travel history to an affected country/area, health workers at the primary health care setting must advise the patient to go immediately to the nearest hospital emergency department. The patient 3

4 must avoid physical contact with others. To facilitate referral to a hospital emergency department, health workers at the primary health care setting must: Inform the patient of the location of the nearest hospital emergency department. Advise the patient not to use public transportation the patient must use a private vehicle or an ambulance. If an ambulance is called, alert the ambulance that the patient is suspected of having EVD, as well as the presence of symptoms such as vomiting, diarrhoea or bleeding. Alert the hospital emergency department as to the arrival of the patient, the suspected diagnosis of EVD, the patient s symptoms, and the method by which the patient will arrive. If the patient needs to remain in the primary health care setting until the arrival of the ambulance, he/she must be placed in a private room, separate from other patients and staff, with the door closed. This room should be cleared of removable items to reduce the environmental cleaning and decontamination that will be required should the patient be confirmed to have EVD. Staff members entering the patient s room must wear the following PPE: gown gloves surgical mask After the Patient Leaves the Primary Health Care Setting After the patient is transported to the nearest hospital emergency department, the primary health care setting must: cordon off any areas that the patient contaminated with body fluids (e.g., vomit, blood, feces) post a do not enter sign on the door of the private room ensure that no one enters the private room or any contaminated areas record the names and contact information of all staff, patients and visitors that were in the reception area and/or had contact with the patient in the event that contact management activities are required by the public health unit contact the public health unit for guidance on the cleaning and decontamination of the private room and contaminated areas Reporting Primary health care providers must inform their public health unit of patients referred to the nearest hospital emergency department for further assessment. Primary health care settings can locate their public health unit by using the Ministry of Health and Long-Term Care s public health unit locator tool. Questions Health sector employers and health workers may contact the ministry s Health Care Provider Hotline by phone at or by at 4

5 with questions or concerns about this Directive. Health sector employers and health workers are also required to comply with applicable provisions of the Occupational Health and Safety Act and its Regulations. Dr. David L. Mowat, MBChB, MPH, FRCPC Interim Chief Medical Officer of Health 5

6 Draft version 3 of the CMOH Primary Health Care Directive for consultation by health Appendix A. EVD Screening Tool for Primary Health Care Settings Staff members in primary health care settings can use this tool to screen patients by the phone or in person. Staff members should ask patients both questions (question 1 and question 2). The answers can determine the appropriate actions to manage the patient. 1. Is the patient feeling unwell with symptoms such as: fever of 38 o C (101 o F) or greater feeling feverish severe headache muscle pain diarrhea vomiting sore throat stomach pain unexplained bleeding YES to ANY of the above NO to ALL of the above 2. In the past 21 days or within 21 days before symptoms started (if symptoms are present), has the patient been to any of the following countries/areas4: Guinea Sierra Leone Liberia Democratic Republic of Congo (Equateur Province) YES NO Actions by Primary Health Care Settings If the answer is yes to both questions, the patient has failed screening and should be referred to the nearest hospital emergency department. The staff member provider should follow the procedures outlined in this Directive. If the patient answers yes to only question 2, the staff member should follow the procedures in the Directive. 4 For the current list of updated list of geographic areas, visit the Ministry of Health and Long- Term Care s EVD Website at 6

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