INTERIM GUIDANCE Ebla Event Management at Pints f Entry September 2014 Wrld Health Organizatin 2014. All rights reserved. The designatins emplyed and the presentatin f the material in this publicatin d nt imply the expressin f any pinin whatsever n the part f the Wrld Health Organizatin cncerning the legal status f any cuntry, territry, city r area r f its authrities, r cncerning the delimitatin f its frntiers r bundaries. Dtted and dashed lines n maps represent apprximate brder lines fr which there may nt yet be full agreement. All reasnable precautins have been taken by the Wrld Health Organizatin t verify the infrmatin cntained in this publicatin. Hwever, the published material is being distributed withut warranty f any kind, either expressed r implied. The respnsibility fr the interpretatin and use f the material lies with the reader. In n event shall the Wrld Health Organizatin be liable fr damages arising frm its use. WHO/EVD/Guidance/PE/14.1
Acknwledgements This guidance was prepared by WHO in cllabratin with experts frm WHO and with the Internatinal Civil Aviatin Organizatin, the Internatinal Air Transprt Assciatin and the US Centers fr Disease Cntrl and Preventin, Atlanta, USA. 2
I. Intrductin As the Ebla virus disease (EVD) cntinues t claim lives and put pressure n health systems in West Africa, its transmissin acrss brders has prmpted a need t manage suspected cases at Pints f Entry (PE).1 This shuld be cnducted accrding t WHO recmmendatins and risk assessments, and adapted accrding t the unique characteristics f each PE. It shuld als be cnsistent with internatinal best practices and standard peratinal prcedures (e.g. fr air pints f entry by the Internatinal Civil Aviatin Organizatin and Internatinal Air Transprt Assciatin). This interim guidance dcument is intended fr Natinal Fcal Pints fr the Internatinal Health Regulatins (IHR)(2005) 1, PE public health authrities, PE peratrs, cnveyance peratrs, crew members and ther stakehlders invlved in the management f Public health event It shuld be used as a reference and in cnjunctin with WHO publicatins n cntingency planning at PE, lcal established capacities and emergency plans. It is recmmended that the cntents f this dcument be adapted t the present situatin, lcal requirements and cmmn practice. Public health emergency plans and standard peratinal prcedures shuld be in place at designated PEs, in accrdance with internatinal best practices, agreements, and the IHR. The aim is t prvide: early detectin f ptentially infected persns; t assist in implementing WHO recmmendatins related t Ebla management; and t prevent the internatinal spread f the disease while allwing PE authrities t avid unnecessary restrictins and delays. T mitigate the risk f infectius travellers barding aircraft and ther mdes f transprtatin, and minimize the interference t PE peratins, the fllwing measures shuld be established. States with Ebla virus disease (EVD) transmissin: Cnduct exit screening f all persns at internatinal airprts, seaprts and majr land crssings fr unexplained febrile illness cnsistent with ptential Ebla infectin. At a minimum, the exit screening shuld cnsist f a questinnaire, a temperature measurement and, if there is a fever, an assessment f the risk that the fever is caused by EVD. Fr all pints f entry: Ensure a public health emergency cntingency plan is in place at each designated PE. Fr internatinal airprts, the aerdrme emergency plan shuld include a public health cmpnent, in accrdance with Internatinal Civil Aviatin Organizatin Health related requirements. Allcate a place at PE fr health assessments, in the event f suspected illness detected in a traveller. Establish standard perating prcedures fr refer ill travellers t designated hspitals, including the identificatin f adequate ambulance services. 1 PE- Pints f Entry: a passage fr internatinal entry r exit f travellers, baggage, carg, cntainers, cnveyances, gds and pstal parcels as well as agencies and areas prviding services t them n entry r exit. Frm the Internatinal Health Regulatins (2005). 3
Ensure a sufficient number f trained staff, with apprpriate and sufficient Persnal Prtective Equipment (PPE) and disinfectant. Raise awareness amng cnveyance peratrs f the need t immediately ntify PE health authrities prir t arrival f any suspected cases. Ensure that passenger lcatr frms are n bard flights and at the airprt, and that airprt grund staff and flight crew are trained in managing EVD and envirnmental cntaminants. Maintain effective and rapid cmmunicatin between PE health authrities and the natinal health surveillance system. Prmptly establish lines f cmmunicatin between public health and transprt sectr fficials, e.g. representatives f the natinal civil aviatin authrity, airprt peratrs and aircraft peratrs. Raise awareness f EVD and disseminate infrmatin amng all relevant stakehlders at PE. 4
II. Management f events During travel, a ptential case may be detected at varius pints. The apprpriate respnse depends n the nature f the expsure, the status f glbal alerts and awareness f varius parties. (Figure 1) Figure 1. Ptential pints f public health hazard detectin r ntificatin. Preliminary standard respnse at PE: recmmended actins t be taken at specified stages f travel (see figure 1) Steps Questins Surce f infrmatin Recmmendatins fr actin Detectin at PE at departure Des the passenger appear t be unwell? Are the symptms cnsistent with suspected EVD? Symptms may include: fever, weakness, muscle pain, headache, sre thrat, vmiting, diarrhea, rash, r bleeding If the cuntry is unaffected by Ebla: - Has the passenger had previus cntact with anyne suspected r cnfirmed t have Ebla? - Des the passenger s recent travel histry include a cuntry where there is an EVD utbreak? If Yes t any f the abve questins, please refer t recmmendatins fr Ebla case management at PE f rigin in cuntries with EVD transmissin. Health authrity at PE and ther PE staff (custms, brder security, grund staff, etc.) The PE health authrity shuld cnsider making prir arrangements in crdinatin with the PE peratr, cnveyance peratr, ther stakehlders at PE, and the natinal health authrity fr early detectin and t prevent ill persns with symptms f EVD frm disembarking prvide infrmatin t travellers at pints f entry n the ptential risk f EVD - prvide reginal r natinal public health cntact infrmatin - ensure any persn with an illness cnsistent with EVD is nt permitted t travel unless the travel is part f an apprpriate medical evacuatin, if PE is at the cuntries with EVD transmissin - identify interpreters if needed. If the traveller has recently travelled t an EVD-affected area, and is shwing symptms indicative f EVD, the PE health authrity shuld cnsider the fllwing actins: - activating the public health emergency plan at the PE - arranging medical examinatin - arranging transprt f suspected cases t designated hspitals - arranging cllectin f clinical specimens r envirnmental specimens 5
- arranging transprt and delivery f clinical specimens t an apprpriate labratry - strengthening surveillance and public health measures at PE - maintaining effective and rapid cmmunicatin between PE health authrities and the natinal health surveillance system. At the PE f a cuntry with EVD transmissin, exit screening f all persns shuld be cnducted at internatinal airprts, seaprts and majr land crssings, fr unexplained febrile illness cnsistent with ptential EVD infectin. At a minimum, the exit screening shuld cnsist f a questinnaire, a temperature measurement and, if there is a fever, an assessment f the risk that the fever is caused by EVD. Ensure persnal prtective equipment (PPE) and hand hygiene practice and prducts are available (alchl-based hand-rub slutins, running water, sap, and single-use twels). Staff cnducting exit screening shuld be trained in the crrect use f PPE and infectin cntrl in handling suspected cases. Additinal actins fr travellers with suspected EVD at PE, prir t embarking (either at the cunter, in the passenger lunge prir t barding r at the time f barding) Is the traveller/crew symptmatic (number f affected passengers/crew)? What was the time/date f illness nset? Des travel histry imply cntact with anyne suspected f having EVD, r with a histry f previus travel in EVD- affected areas? Has any death ccurred? What is the traveller s health status? (Symptmatic? High risk f EVD expsure?) Cnveyance peratrs, agents, staff, passengers, PE persns, r ther authrities Fr PE f cuntries with EVD transmissin, any persn with an illness cnsistent with EVD shuld nt be allwed t travel unless the travel is part f an apprpriate medical evacuatin Air Travel/Aircraft If traveller/crew member displays symptms related t EVD r is cnsidered t be in clse cntact with EVD (r ther cmmunicable diseases) - Medical clearance is required by the airline - If a traveller des nt present medical clearance t the airline and refuses t delay his/her travel, the airline may exercise its right t refuse barding, in the case f air travel - Ensure Public Health Passenger Lcatr Frms (PLFs) see http://www.capsca.rg/capscarefs.html are available n bard the aircraft and/r at the destinatin PE. Maritime/ship - If traveller/crew shws symptms related t EVD r is cnsidered t be in clse cntact with EVD), the traveller shuld disembark and be placed under public health bservatin and arrangements made fr a medical examinatin - The PE health authrity shuld cnsider activating the cntingency plan at the PE, including adequate prtectin f staff in cntact with the suspected case and his/her immediate envirnment arrange transprt f suspected cases t designated hspitals arrange cllectin f clinical specimens r envirnmental cntaminant samples arrange transprt and delivery f clinical specimens t an 6
apprpriate labratry strengthen surveillance and public health measures at PE maintain effective and rapid cmmunicatin between PE health authrities and the natinal health surveillance system If there is a death linked t the event, the PE health authrity shuld - cntact medical services and the security sectr t investigate the cause f death; - check if cntact tracing is needed - ensure that the death has been registered On bard flight/ship Are the symptms cnsistent with EVD? Symptms may include: fever, weakness, muscle pain, headache, sre thrat, vmiting, diarrhea, rash, r bleeding Is the envirnment f the plane/ship cntaminated (by vmit, spilled bld, ther bdy fluid)? Hw many passengers and staff were expsed? Is there a dctr n bard? Fr aircraft, des the peratr have access t grund- based medical supprt? Has the traveller received medical assistance during the flight? Des the traveller require medical attentin upn arrival (clinical signs and symptms amng travellers and severity)? Has the captain/ master been infrmed f the incident and have the PE authrities been ntified? (Fr aircraft, see ICAO Prcedures fr Air Navigatin Services Air Traffic Management: In ICAO Health Related Dcuments: http://www.capsca.rg/capscarefs.html ) Are any enhanced precautins fr the disembarkatin f ill and healthy travellers needed? Air Travel/Aircraft - Is the distributin f passenger lcatr frms warranted t cnduct cntact Aircraft: - Health Part f The Aircraft General Declaratin - Passenger Lcatr Frm Ship: - Maritime f Health Declaratin - Ship sanitatin certificates - Medical lg bk, including infrmatin regarding the health status f passengers/crew members, health cntrl measures including medical/prphylaxis treatment administered, en rute; - List f medicines accrding t natinal regulatins, etc. The PE health authrity shuld make prir arrangements in crdinatin with the PE peratr, cnveyance peratr, ther stakehlders at the PE, and the natinal health authrity t - prepare in advance basic disease/health infrmatin in several languages - prvide reginal r natinal public health cntact infrmatin - ensure access t radi medical supprt, if needed (fr aircraft, in cllabratin with the aircraft perating agency). If the traveller has recently been t an EVD-affected area, and is shwing symptms indicative f EVD, the PE health authrity shuld cnsider: - cllecting infrmatin frm crew and include what (if any) medical assistance was administered prir t arrival - arranging a medical assessment upn arrival f the aircraft/ship/grund vehicle at the PE r send a dctr t bard the ship en rute - identifying PE space requirements fr arriving travellers fr interview and health assessments, with access t tilet facilities and seating - cllecting clinical specimens and/r envirnmental samples accrding t natinal practice, if needed Fr air Travel/aircraft: - public health authrities shuld crdinate with aircraft and airprt peratrs and ensure that passenger lcatr frms are available n the flight and/r at destinatin airprts. Airprt persnnel and cabin crew shuld be apprpriately trained and medical and universal precautin kits (see belw) fr managing EVD cases/cntacts shuld be available n bard, in accrdance with ICAO guidelines, and at pints f entry. - crew shuld fllw IATA SOPs n the management f cmmunicable disease n bard http://www.iata.rg/whatwed/safety/health/pages/diseases.aspx and WHO 2014 Ebla Virus Disease (EVD) utbreak in West Africa - Travel and transprt risk assessment: Interim guidance fr public health authrities and transprt sectr 4.2.3 Guidance fr internatinal air 7
tracing? - Des the traveller have additinal travel planned (currently in-transit)? - Was there persnal prtective equipment r a universal precautin kit n bard? Was it used? Were apprpriate supplies available and used? transprt; http://www.wh.int/csr/disease/ebla/en/ - Identificatin f cntacts. - Ensure passenger lcatr frms (see http://www.capsca.rg/capscarefs.html) are available n bard the aircraft and/r at the destinatin PE. - Ensure the capacity t cllect, use and securely stre persnal infrmatin n passenger lcatr frms - Identify clse cntacts r persns expsed and ensure they receive infrmatin abut health measures - Cmmunicate with the health authrities at the destinatin f the clse cntacts Fr Maritime/Ship - Raise awareness amng shipping cmpanies f the need t immediately ntify the prt health authrity prir t arrival if a persn n bard is suspected f having cntracted EVD - Ensure the ship s master, dctr r crew member appinted fr health issues n bard is fully infrmed and is educated abut the risks f EVD, and the precautins and prtective measures t be taken by crew members t prevent them frm cntracting the virus - Crew shuld fllw WHO 2014 Ebla Virus Disease (EVD) utbreak in West Africa - Travel and transprt risk assessment: Interim guidance fr public health authrities and transprt sectr 4.2.4 Guidance fr ship and shipping cmpanies (http://www.wh.int/csr/disease/ebla/en/) Detectin during transit (frm affected t unaffected area, r frm unaffected t affected area, r t and frm affected areas) Have the apprpriate measures been taken n bard the cnveyance? Is a human life in danger? Des the traveller require medical attentin upn arrival at the PE (clinical signs and symptms amng travellers and severity)? Are any precautins fr the disembarkatin f ill and healthy travellers needed? Flight: - Health Part f The Aircraft General Declaratin - Passenger Lcatr Frm Ship: - Maritime f Health Declaratin - Ship sanitatin certificates - Medical lg bk - List f medicines accrding t natinal regulatins, etc. The PE health authrity shuld make prir arrangements in crdinatin with the PE peratr, cnveyance peratr, ther stakehlders at the PE, and the natinal health authrity t - ensure sufficient availability f PE staff, persnal prtective equipment fr respnders and disinfectants - prvide reginal r natinal public health cntact infrmatin - identify interpreters if needed. If traveller/crew shws symptms related t EVD r is cnsidered t be a clse cntact with EVD, the PE health authrity shuld cnsider the fllwing actins: - identify space requirements fr interview and health assessments. The space shuld have access t tilet facilities and seating - cnduct an investigatin if the travel histry indicates previus travel t an EVD-affected area. - inspect the cnveyance fr envirnment cntaminatin and supervise cleaning staff t apply public health measures (decntaminatin and disinfectin, etc.) 8
- ensure access t medical supprt, if needed - ensure visa and custms clearance if disembarking fr medical supprt is needed - ensure patient lcatr frms are available at Prt Health at the destinatin airprt (template can be fund at http://www.capsca.rg/capscarefs.html) At destinatin where inbund flight/ship frm/passin g thrugh EVD affected areas are available Is there a ptential t spread the infectin and t cntaminate the envirnment? Are special measures needed upn arrival at the pints f entry? Des the cnveyance need any supplies? Des the situatin demand that health authrities/experts be invlved (clinicians, epidemilgists, envirnmentalists, experts in respnding t chemical r radilgical events?) Is the cnveyance cming frm an affected area where WHO has recmmended measures? Have clinical specimens r envirnmental samples been cllected r d fficers f the respnsible health authrity need t cllect them? When is the cnveyance scheduled t depart? Are there a large number f cnnectins t internatinal r dmestic pints f entry? Aircraft: - Health Part f the Aircraft General Declaratin - Passenger Lcatr Card Ship: - Maritime f Health Declaratin - Ship sanitatin certificates - Medical lg bk - List f medicines accrding t natinal regulatins, etc The PE health authrity shuld make prir arrangements in crdinatin with the PE peratr, cnveyance peratr, ther stakehlders at the PE, and the natinal health authrity t - ensure sufficient Prt health staff, persnal prtective equipment, and disinfectants are available. - determine a suitable prduct fr disinfectin with the aircraft peratr. Sdium hypchlrite (bleach) is nt an acceptable disinfectant n bard an aircraft. - raise awareness amng relevant stakehlders and persnnel at PE, including carg handlers, that packages that are visibly siled with bld r bdy fluids shuld nt be handled - identify interpreters if needed. If traveller/crew shws symptms related t EVD r is cnsidered t be a clse cntact with EVD the, PE health authrity shuld cnsider: - activating the cntingency plan at the PE if necessary. The aerdrme emergency plan shuld include a public health cmpnent. - arranging delivery f supplies that the cnveyance may need (e.g. persnal prtective equipment, medicines, cleaning and disinfectin, waste dispsal) - cmmunicating with ther authrities/ experts, where apprpriate, t assess the risk t prtect public health and determine the necessary cntrl measures and evaluate their effectiveness - authrizing disembarkatin f travellers withut illness r suspected EVD and cnducting medical fllw up with passengers as needed - minimizing cntact between grund staff and ill travellers r the cntaminated envirnment - inspecting cnveyance n bard fr envirnment cntaminatin - arranging the cllectin f clinical specimens r envirnmental samples accrding t natinal practice, if needed - supervising cleaning staff t apply public health measures, as apprpriate (decntaminatin and disinfectin, etc.). Please refer t WHO 2014 Ebla Virus Disease (EVD) utbreak in West Africa - Travel and transprt risk assessment: Interim guidance fr public health authrities and transprt sectr http://www.wh.int/csr/disease/ebla/en/ ; and http://www.iata.rg/whatwed/safety/health/dcuments/health-guidelines- 9
After travel Are the symptms cnsistent with EVD? Symptms may include: fever, weakness, muscle pain, headache, sre thrat, vmiting, diarrhea, rash, r bleeding Des previus travel histry indicate cntact with anyne suspected f infectin with Ebla virus? Des the passenger have a histry f recent travel in the areas affected by the Ebla utbreak? cleaning-crew.pdf and - reprting the event t the IHR NFP if apprpriate, fr further assessment and ntificatin t WHO accrding t natinal plans and prtcls if necessary - arranging interview and health assessments. The space shuld have access t tilet facilities and seating, water and washing facilities. - arranging transprt f suspected cases t designated hspitals arranging transprt and delivery f clinical specimens t an apprpriate labratry - preparing fr triage t minimize flight disruptins - in the case f maritime/ship, additinal cncern shuld be given t: discussin (cnsult/interview) with the ship master, ship medical staff and if necessary travellers wh are ill and may be in quarantine r islatin n bard already keeping recrds f the findings and taking ntes f the evidence fund (e.g. infectin n bard/hazards identified) and measures taken (t cmply with/recmmended by) in the Ship Sanitatin Cntrl Certificate, accrding t IHR article 39.5 establishing cmmunicatin, natinally r internatinally, with cmpetent authrities at the next knwn prt, t prmptly infrm them if they are unable t carry ut the required cntrl measures at the prt. Maintain nging cmmunicatin with cnveyance peratrs (airlines, ships, grund vehicles), airprt and air traffic services, maritime and prt authrities. Further details n civil aviatin prcedures related t public health see http://www.capsca.rg/dcumentatin/icaohealthrelatedsarp sandguidelines.pdf) The ill persn shuld seek medical assessment and care at a hspital If their recent travel histry indicates cntact with anyne suspected f having EVD, r with a histry f recent travel in EVD-affected areas, cntact tracing shuld be undertaken t identify clse cntacts (eg. passenger/crew ne seat away frm ill traveller n the same flight). PE health authrities shuld make arrangements t facilitate repatriatin f cases and transprtatin f specimens. Strengthen cmmunicatin between natinal health surveillance and PE. 10
References: CDC, 2014. Interim Guidance abut Ebla Virus Infectin fr Airline Flight Crews, Cleaning Persnnel, and Carg Persnnel, Atlanta: CDC. ECDC, 2014. Rapid Risk Assessment Outbreak f Ebla Virus Disease in West Africa. IATA, 2011. Suspected Cmmunicable Disease: General Guidelines fr Cabin Crew, Mntreal: Internatinal Air Transprt Assciatin. IATA, 2014. Suspected Cmmunicable Disease: General Guidelines fr Cleaning Crew, Mntreal: Internatinal Air Transprt Assciatin. ICAO, 2009. ICAO and Management f cmmunicable disease. [Online] Available at: http://www.ica.int/meetings/amc/ma/capsca_scm1/capscascm01_day01_04_icao_evans.pdf ICAO, 2013. ICAO Health Related Dcuments. [Online] Available at: http://www.capsca.rg/dcumentatin/icaohealthrelatedsarpsandguidelines.pdf WHO/ICAO/IATA, 2009. WHO technical advice fr case management f Influenza A(H1N1) in air transprt, Geneva:: Wrld Health Organizatin. WHO, 2009. Guide t Hygiene and Sanitatin in Aviatin (3rd ed). Geneva: WHO. WHO, 2009, Respnding t New Influenza A(H1N1):Optins fr interventins at internatinal pints f entry Available at http://www.wpr.wh.int/emerging_diseases/optinsfrbrderandtravelmeasures20090530final_2.pdf WHO; 2012, Guide fr public health emergency cntingency planning at designated pints f entry. WHO, 2013. Passenger Lcatr Card. [Online] Available at: http://www.ica.int/safety/aviatinmedicine/pages/guidelines.aspx WHO, 2014. Travel and transprt risk assessment: Recmmendatins fr public health authrities and transprt sectr Available at: http://www.wh.int/ith/updates/20140421/en/ 11