Ebola

From OSHWiki
Jump to: navigation, search


Introduction

Ebola hemorrhagic fever (EHF) (sometimes called Ebola Virus Disease, or EVD) is the disease caused by infection with an Ebola virus. It is a type of viral hemorrhagic fever (VHF) brought on by any of several strains of viruses in the Ebolavirus genus. Ebola viruses are capable of causing severe, life-threatening disease. Many people who get EHF die from it. Workers performing tasks involving close contact with symptomatic individuals with EHF or in environments contaminated or reasonably anticipated to be contaminated with infectious body fluids are at risk of exposure. These workers may include workers in the healthcare, mortuary and death care, airline, and other travel service industries.

EHF is usually marked by fever, muscle pain, headache, and sore throat. The illness progression includes nausea, vomiting, diarrhea, and impaired organ function. In some cases, rash, internal and/or external bleeding, and death may occur.

In areas of Africa where Ebola viruses are common, suspected reservoirs include primate and bat populations. While there are no known animal reservoirs of the disease in the U.S., there is concern related to possible spread of EHF among human populations due to the availability and reach of global travel. Under certain conditions, exposure to just one viral particle can result in development of EHF. Depending on the strain and the individual infected with the disease, EHF may be fatal in 50-90 percent of cases.1,2

The U.S. Centers for Disease Control and Prevention (CDC) categorizes Ebola virus as a Category A select agent. This group includes high-priority agents that pose a risk to national security because they can be easily disseminated or transmitted from person to person; result in high mortality rates and have the potential for major public health impact; might cause public panic and social disruption; and require special action for public health preparedness. Because symptoms of EHF may appear consistent with many other viral illnesses (e.g., influenza, malaria), diagnosis and treatment of EHF could be delayed during an outbreak. Employers of workers at risk for exposure to Ebola virus in their work environments should be familiar with methods for hazard recognition, control, and prevention.

Healthcare workers in Zaire treated Ebola case #3 from the 1976 outbreak. Today, healthcare workers are among the highest risk group of workers for exposure to Ebola and should take appropriate precautions when in contact with sick individuals or environments contaminated with Ebola.

Background

Ebola Hemorrhagic Fever (EHF) was first identified in 1976 following simultaneous outbreaks in Sudan and Zaire (now the Democratic Republic of Congo, or DRC) in Africa.1 Though both outbreaks were attributed at the time to the same virus, two separate viruses were later identified as having caused the respective outbreaks: Sudan Ebola virus (SUDV) and Zaire Ebola virus (EBOV). EHF, and subsequently the EBOV strain, was named after the Ebola River in Zaire near the village where it was isolated.2

EHF results from infection with viral species in the Ebolavirus genus of the family Filoviridae, including EBOV, SUDV, and Bundibugyo Ebola virus (BDBV). Two additional species, Reston Ebola virus (RESTV) and Côte d’Ivoire or Taï Forest Ebola virus (TAFV) are included in the genus, but are not known to cause outbreaks among humans.

In the 20 years following the initial outbreak of EBOV and SUDV, scientists identified the three additional species of Ebola viruses. RESTV was found in Cynomolgus monkeys (crab-eating macaques) at an animal quarantine facility in Reston, Virginia, in 1989.3 The monkeys were imported from the Philippines, where RESTV now appears to be endemic. Several workers who had contact with monkeys and pigs with RESTV infections developed laboratory-identified subclinical (asymptomatic) infections.2 TAFV was isolated from a veterinary researcher who had performed a necropsy on a chimpanzee that died of EHF. The researcher is the only known human case of TAFV-attributable EHF. The final known species, BDBV, caused a small outbreak among humans in western Uganda in 2007.4

Though Ebola viruses have caused outbreaks in humans, non-human primates, and pigs, the natural host of the pathogen is unknown. Antibody testing research suggests that bats may be a reservoir.

Hazard Recognition

Infection with the Ebola virus can be deadly: Ebola Hemorrhagic Fever (EHF) has had a fatality rate up to 90 percent in some outbreaks.1 Individuals with EHF generally have symptoms typical of viral illnesses, including fever, fatigue, muscle pain, headache, and sore throat. The illness progression includes nausea, vomiting, diarrhea, and impaired organ function. In some cases, rash, internal and/or external bleeding, and death may occur.

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

EHF is not generally spread through casual contact. The risk of infection with Ebola virus is minimal if you have not been in close contact with the body fluids of someone sick with or recently deceased from EHF. You can also get EHF by eating or butchering meat (e.g., bush meat) from an animal infected with Ebola virus.

Symptoms typically appear abruptly, within 2-21 days (8-10 days is most common) following exposure to the virus. Thus, individuals exposed while living, working, or traveling in areas experiencing an ongoing outbreak or where EHF is endemic could develop symptoms up to three weeks after exposure. However, EHF is believed to be contagious only once an individual begins to show symptoms.

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

Certain species of fruit bats are thought to be the natural reservoir for Ebola virus. EHF outbreaks are believed to start as a result of contact with infected animals or animal carcasses

Medical Information

The most common routes of transmission of Ebola viruses are: ◾Contact of the eyes or other mucous membranes with blood or body fluids of a person or animal with Ebola Hemorrhagic Fever (EHF), ◾Contact with contaminated equipment or other objects; and ◾Ingestion of infectious blood or body fluids.

Ebola virus is believed to be viable outside of the body for several days. An evaluation of the persistence of certain Category A select agents in the environment suggests that viruses of the family Filoviridae, of which Ebola viruses are members, may remain stable for 4-5 days in dried blood.[1]

Though transmission through inhalation of airborne virus is not currently a primary concern during naturally-occurring outbreaks, it may be possible for Ebola virus to be aerosolized under certain conditions. CDC has provided guidance for healthcare workers who must perform aerosol-generating procedures on patients known to have or suspected of having EHF. Pathogenicity (i.e., how the virus acts on the body to cause disease) and symptoms are typically the same regardless of the initial route of infection with Ebola virus.

Workers in settings outside of healthcare also should avoid the use of compressed air when cleaning environmental surfaces, as it might spread infectious material through the air.[2]

Symptoms of Ebola typically appear within 2-21 days (8-10 days is most common) following infection, and the illness runs its course within 14-21 days of symptom onset.

As the infection progresses, patients often experience a rash and severe bleeding as the blood loses its ability to coagulate and blood vessel membranes become more permeable. Lymphocyte counts drop and neutrophils spike. Ebola patients ultimately die from diffuse bleeding and shock.

Medical Management and Countermeasures

There is currently no treatment, antiviral therapy, or approved vaccine for EHF or Ebola virus. Supportive hospital care for patients with EHF (like other viral hemorrhagic fevers) includes fluid and blood replacement, maintaining stable blood pressure, and treating other comorbidities (i.e., other injuries or infections) as appropriate.

Individuals who may have come into contact with Ebola virus may be quarantined at the discretion of public health officials. Quarantine periods typically last through the 2-21-day incubation period for Ebola, unless an individual is otherwise shown to be free of infection. Suspected and confirmed cases of Ebola should be isolated to prevent transmission of the disease to other individuals. If possible, isolating suspected cases separately from confirmed cases also may help prevent transmission.

Healthcare providers have a variety of tools at their disposal to test for Ebola virus infection and diagnose EHF, including blood tests that can detect antibodies to the Ebola virus or the RNA of the virus itself. Cell culture and electron microscopy are also used to identify Ebola virus.

The U.S. Department of Homeland Security has identified EHF as a high-priority threat. The U.S. Department of Health and Human Services is prioritizing the development of vaccines and other medical countermeasures for EHF and Ebola virus accordingly.3 The National Institutes of Health (NIH) has had some success with experimental vaccines in non-human primate models. Ongoing research into recombinant adenoviruses, recombinant vesicular stomatitis viruses (VSVs), and other recombinant vaccine products is underway, but human trials are still needed to demonstrate safety and efficacy.4 Research efforts continue in a number of nations to develop an effective vaccine and other medical countermeasures, such as antibody serum, to prevent or treat EHF and related diseases.

CDC's Ebola page provides the most up-to-date information on medical aspects of Ebola virus infection and EHF.

  1. [1] Sinclair, R., Boone, S. A., Greenberg, D., Keim, P., & Gerba, C. P. (2008). Persistence of category A select agents in the environment. Applied and environmental microbiology, 74(3), 555-563.
  2. [2] Interim Guidance about Ebola Virus Infection for Airline Flight Crews, Cleaning Personnel, and Cargo Personnel. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS)

Standards

This section highlights OSHA standards, preambles to final rules, and directives (instructions for compliance officers) that may be applicable in the event of possible worker exposure to the Ebola virus. Employers whose workers may be exposed to the Ebola virus would likely need to comply with provisions from a combination of these standards in order to implement a comprehensive worker protection program.

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

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

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

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

Depending on the specific work task, setting, and exposure to biological or chemical agents, additional OSHA standards, including the following, may also apply:

General Industry 29 CFR 1910

Preambles to final rules

◾Bloodborne Pathogens 29 CFR 1910.1030

Directives

Procedures for the Occupational Exposure to Bloodborne Pathogens(PDF). CPL 02-02-069, (2001, November 27). Establishes policies and provides clarification to ensure uniform inspection procedures are followed when conducting inspections to enforce the Occupational Exposure to Bloodborne Pathogens Standard.

Inspection procedures for the Respiratory Protection Standard. CPL 02-00-158, (2014, June 26). Establishes agency interpretations and enforcement policies, and provides instructions to ensure uniform enforcement of the Respiratory Protection Standard (29 CFR 1910.134).

Memoranda of Understanding

Information on Memorandum of Understanding between OSHA and the U.S. Department of Transportation, Federal Aviation Administration (FAA) on Flight Attendant/Cabin Crew Health and Safety. The safety and health of flight crews are under the jurisdiction of the Federal Aviation Administration (FAA) and such workers are generally not subject to OSHA requirements. However, under a memorandum of understanding between the FAA and OSHA, they are subject to the following

However, under a memorandum of understanding between the FAA and OSHA, they are subject to the following OSHA standards:

Bloodborne Pathogens (29 CFR 1910.1030)Occupational Noise Exposure (29 CFR 1910.95)Hazard Communication (29 CFR 1910.1200)

Control and Prevention

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

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

Interim general guidance for workers

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

◾Employers should follow recognized and generally accepted good infection control practices, and must meet applicable requirements in the Personal Protective Equipment standard (29 CFR 1910.132, general requirements) and the Respiratory Protection standard (29 CFR 1910.134).

◾Use proper personal protective equipment (PPE) and good hand hygiene protocols to avoid exposure to infected blood and body fluids, contaminated objects, or other contaminated environmental surfaces.

◾Wear gloves, wash hands with soap and water after removing gloves, and discard used gloves in properly labeled waste containers.

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

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

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

OSHA's "Protecting Workers during a Pandemic" (PDF*) Fact Sheet provides general guidance about principles of worker protection that may be useful during a wide-spread disease outbreak.

Healthcare Workers

The U.S. Centers for Disease Control and Prevention is the authoritative source for information for healthcare workers who care for, treat, and otherwise interact with patients who are known to or are suspected of having EHF. CDC provides guidance and recommendations, including the following publication:

Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in US Hospitals

CDC also provides information for workers who may be exposed to Ebola virus through environmental contamination in healthcare settings: ◾Interim Guidance for Environmental Infection Control in Hospitals for Ebola (Applicable to housekeeping staff in healthcare workplaces)

Through the Hazard Alert Network, the U.S. Department of Health and Human Services (HHS) has issued [ http://emergency.cdc.gov/han/han00364.asp "Guidelines for Evaluation of US Patients Suspected of Having Ebola Virus Disease"] The purpose of this guidance is 1) to provide updated guidance to healthcare providers and state and local health departments regarding who should be suspected of having EHF, 2) to clarify which specimens should be obtained and how to submit for diagnostic testing, and 3) to provide hospital infection control guidelines.

Employers of healthcare workers are responsible for following applicable OSHA requirements, including OSHA's Bloodborne Pathogens standard (29 CFR 1910.1030). For additional information on OSHA standards, visit the Standards section of this web page.

Generally, healthcare workers must use proper personal protective equipment (PPE) and other infection control measures to avoid exposure to infected blood and body fluids, contaminated objects, or other contaminated environmental surfaces. WHO and CDC recommend that healthcare workers in close contact with EHF patients (< 1 meter) wear face protection (a face shield or a medical mask and goggles); a clean, non-sterile long-sleeved gown; and gloves (sterile gloves for some procedures).1,2 Select these items based on their ability to protect the worker from splashes of blood, body fluids, or other sources of infectious material. Following good hand hygiene protocols, safe injection practices, and other infection control techniques may further reduce healthcare worker exposure to Ebola virus and other infectious agents.

Although Ebola virus transmission by the airborne route has not been established, hospitals and other medical care facilities may choose to follow CDC recommendations for airborne precautions for patients with suspected EHF (and other VHF diseases) who have severe pulmonary involvement or who undergo procedures that stimulate coughing and promote the generation of aerosols. Aerosol-generating procedures may include: ◾aerosolized or nebulized medication administration ◾diagnostic sputum induction ◾bronchoscopy ◾airway suctioning ◾endotracheal intubation ◾positive pressure ventilation via face mask (e.g., biphasic intermittent positive airway pressure ventilation or continuous positive airway pressure ventilation) ◾high-frequency oscillatory ventilation

For additional information, refer to CDC's Interim VHF guidance (PDF)

Healthcare workers deploying to and/or working in Ebola-impacted areas (e.g., countries in Africa where the virus is currently spreading) may require additional protections. Under austere conditions, facilities for routine hand hygiene, cleaning and decontamination of environmental surfaces, adequate air exchange and ventilation, and other factors that reduce exposure to and transmission of Ebola virus may not exist. Frequent contact with high densities of Ebola patients may also require higher levels of respiratory protection (including encapsulating suits with powered air-purifying respirators) and other PPE. CDC offers two guidance documents for workers in African healthcare settings: ◾CDC Infection Control for Viral Hemorrhagic Fevers in the African Health Care Setting ◾CDC Viral Hemorrhagic Fevers: Infection Control Posters for the African Health Care Setting

Airline and other travel industry personnel

Workers involved in airline and airport service operations—including flight attendants, cleaning and provisioning staff, and cargo personnel—may be exposed to Ebola virus in a number of scenarios, including exposure to infectious body fluids in lavatories and direct exposure to individuals sick with EHF. Currently, airline service worker exposure to Ebola virus is unlikely. Passengers originating from locations affected by the ongoing EHF outbreak pose the greatest hazard to workers in the airline service industry.

The CDC has prepared guidance for airline flight crews, cleaning personnel, and cargo operations workers.

Employers must provide protective clothing and equipment for workers who may perform tasks that could result in exposure to Ebola virus. This would include employees whose work tasks include cleaning up blood, vomit, or other body fluids from a sick passenger.

Disinfection and clean up should include wiping down lavatory surfaces and frequently touched surfaces in the passenger cabin, such as armrests, seat backs, tray tables, light and air controls, and adjacent walls and windows with an Environmental Protection Agency (EPA) registered cleaner/disinfectant that has been tested and approved for use by the airplane manufacturers.

CDC recommends that airline and other travel industry workers consider providing sick travelers with surgical masks (if the sick person can tolerate wearing one) to reduce the number of droplets expelled into the air by talking, sneezing, or coughing.

Note on Flight Crews: The safety and health of flight crews are under the jurisdiction of the Federal Aviation Administration (FAA) and such workers are generally not subject to OSHA requirements. However, under a policy adopted by memorandum of understanding between the FAA and OSHA, they are subject to OSHA’s Bloodborne Pathogens, Noise, and Hazard Communication standards. The Personal Protective Equipment standard and the General Duty Clause was not included in this memorandum of understanding.

Mortuary and death care workers

Mortuary and death care workers who must have contact with the remains of individuals known or suspected to be contaminated with Ebola virus must use proper PPE and other infection control measures to avoid exposure to infected blood and body fluids, contaminated objects, or other contaminated environmental surfaces. These workers must wear face protection (a face shield or a medical mask and goggles); a clean, non-sterile long-sleeved gown; and gloves (sterile gloves for some procedures) where required to protect the worker against contact with contaminated materials. These items must be selected based on their ability to protect the worker from splashes of blood, body fluids, and other sources of infectious material. Following good hand hygiene protocols and other infection control techniques may further reduce mortuary and death care worker exposure to Ebola and other infectious agents.

Laboratory workers

Ebola viruses are considered Biosafety Level (BSL) 4 agents. BSL-4 includes dangerous and exotic agents that pose a high individual risk of aerosol-transmitted laboratory infections and life-threatening disease that is frequently fatal, for which there are no vaccines or treatments. Laboratory workers should follow CDC guidelines for working in BSL-4 labs, including using biosafety cabinets and/or wearing full body, air-supplied, positive-pressure suits.3 Handle samples taken from suspected human and animal Ebola cases for laboratory testing in properly equipped laboratories. Take precautions during necropsy and other laboratory procedures involving the remains of humans and animals infected with Ebola virus.

CDC provides updated guidance for collecting, transporting, and testing specimens from persons known to have or suspected of having EHF. The American Society for Microbiology (ASM) also published recommendations (PDF) for handling and testing specimens, which employers may use as guidance for providing additional protection for their workers against exposure to Ebola virus.

CDC's "Biosafety in Microbiological and Biomedical Laboratories (BMBL), 5th Edition" features the most recent guidance on protecting workers in laboratory environments. The following sections may be of particular relevance to employers and workers whose workplaces may contain Ebola virus: ◾Section VII – Occupational Health and Immunoprophylaxis (PDF) ◾Section VIII - E – Viral Agents Agent Summary (PDF)

The CDC Morbidity and Mortality Weekly Report (MMWR) also featured biosafety laboratory competency guidelines. A useful matrix describes staff competencies across a number of skill domains, including identifying and describing hazards, controlling potential exposures, implementing administrative controls, and preparing for and responding to emergencies.

Border, customs and quarantine workers

Workers involved in border patrol and security, immigration and customs enforcement, and public health investigation and quarantine work may encounter individuals with EHD arriving at U.S. borders from foreign countries impacted by the ongoing epidemic. These types of workers may also be exposed to infected blood and body fluids or other potentially infectious materials, contaminated objects, or other contaminated environmental surfaces as they perform tasks such as inspection of cargo, baggage, and arriving aircraft or vessels.

The U.S. Centers for Disease Control and Prevention (CDC) has prepared interim guidance for airline flight crews, cleaning personnel, and cargo operations workers. Some of these guidelines may be applicable to border, customs and quarantine workers.

Generally, employers must provide protective clothing and equipment for workers who may perform tasks that could result in exposure to Ebola virus, including, for example, employees who would be expected to clean up vomit or other body fluids from a sick passenger.

CDC recommends providing sick travelers with surgical masks (if the sick person can tolerate wearing one) to reduce the number of droplets expelled into the air by talking, sneezing, or coughing. Sick individuals may be requested to wear surgical masks when interacting with border, customs, or quarantine workers.

Most border, customs, and quarantine workers at international ports of entry are likely to be employees of the U.S. Government. The Occupational Safety and Health (OSH) Act of 1970, Section 19, Executive Order 12196, and 29 CFR 1960 require the head of each Federal agency to establish and maintain an effective and comprehensive occupational safety and health program. Federal employers must protect their workers from known occupational safety and health hazards. OSHA's Federal Agency Programs page provides additional information for federal employers and workers.

Emergency responders

In the event that the ongoing EHF outbreak reaches the U.S., emergency responders, including emergency medical service (EMS) workers, may encounter patients known to have or suspected of having EHF. The job duties of emergency responders may also put them in situations where exposure to Ebola-contaminated environments is possible. In these scenarios, CDC and OSHA guidance for healthcare workers can help prevent exposure.

Healthcare workers and others who must have contact with individuals with EHF must follow appropriate requirements, including OSHA’s Bloodborne Pathogens standard (29 CFR 1910.1030). CDC also provides guidance and recommendations for protecting these workers.

Through the Hazard Alert Network, HHS has issued "Guidelines for Evaluation of US Patients Suspected of Having Ebola Virus Disease." The purpose of this guidance is 1) to provide updated guidance to healthcare providers and state and local health departments regarding who should be suspected of having EHF, 2) to clarify which specimens should be obtained and how to submit for diagnostic testing, and 3) to provide hospital infection control guidelines.

In other scenarios where Ebola or Ebola-containing body fluids contaminate environmental surfaces, food (e.g., meat), or human or animal remains, emergency responders may be at no greater risk of exposure than healthcare workers. An incident commander should assess the hazard to workers and require appropriate PPE and other controls based on the specific details of an emergency response.

OSHA's Emergency Preparedness and Response page provides additional information for emergency response and recovery workers and their employers.

CDC and NIOSH provide additional guidance for workers, including emergency responders, who may be exposed to biological agents, such as Ebola and other VHFs.

Workers in critical sectors

Employers in critical infrastructure / key resource (CIKR) sectors may wish to review their personnel and evaluate whether they are at particularly high risk for exposure. For example, in the transportation industry, some vehicle conductors, such as bus drivers, may have frequent direct contact with ill individuals while others who have similar job classifications, such as subway drivers sitting in separate cabs, may not. Pharmacists dispensing medication to ill individuals may need higher levels of protection as they are likely to have frequent contact with ill individuals. Such workers may require higher levels of protection than the average worker, who is unlikely to be in an environment known or suspected to be contaminated with the Ebola virus.

Employers in such industries may need to explore strategies for: ◾Obtaining, selecting, and stockpiling protective clothing and equipment. ◾Providing medical evaluations, fit-testing, and training for workers who may be required to wear respirators. ◾Incorporation of engineering controls into work settings to prevent worker exposure to infectious agents (e.g., pressurization across glass windows in pharmacies, banks, or other areas where workers perform customer service tasks). ◾Cleaning and decontamination of environmental surfaces.

OSHA's Respiratory Protection and Personal Protective Equipment (PPE) pages provide additional information about these topics.

If you think you have been exposed…

Any worker who thinks he or she may have been exposed to Ebola virus, including through travel, assisting an ill traveler or other person, handling a contaminated object, or cleaning a contaminated environment (such as an aircraft) should take the following precautions: ◾Notify your employer immediately. ◾Monitor your health for 21 days. Watch for fever (temperature of 101°F/38.3°C or higher), muscle pain, headache, sore throat, diarrhea, vomiting, rash, and other symptoms consistent with Ebola. ◾Seek medical attention if you develop any of these symptoms. ◾Before visiting a health care provider, alert the clinic or emergency room in advance about your possible exposure to Ebola virus so that arrangements can be made to prevent spreading it to others. ◾When traveling to a health care provider, limit contact with other people. Avoid all other travel.

If you are located abroad, contact your employer for help with locating a health care provider. The U.S. embassy or consulate in the country where you are located can also provide names and addresses of local physicians.

Worker Rights

Any worker who may reasonably be expected to come into contact with the Ebola virus, either from the work environment or from direct contact with individuals infected, has the right to know the hazards associated with this potential exposure and how to protect themselves during work activities. Any occupational exposure to blood or other potentially infectious materials fall under the requirements in the Bloodborne Pathogens Standard (29 CFR 1910.1030). Other occupational exposures may require protection of workers under the PPE Standard (29 CFR 1910.132), Respiratory Protection Standard (29 CFR 1910.134), or the General Duty Clause of the OSH Act (29 USC 654(a)).

Employers should educate workers about the hazards to which they are exposed and to provide reasonable means by which to abate those hazards. Additional information about communicating job hazards to workers is available on OSHA’s Hazard Communicationpage. While OSHA’s Hazard Communication Standard (29 CFR 1910.1200) does not apply to the Ebola virus itself, employers may be required to comply with the standard when chemicals are used for cleaning and disinfection of the work environment.

References

Heinz Feldmann and Thomas Geisbert, "Ebola haemorrhagic fever." The Lancet 377, no. 7968 (2011), 849-862, http://dx.doi.org/10.1016/S0140-6736 (10)60667-8. Ebola Virus Disease World Health Organization (WHO).

Heinz Feldmann and Hans-Dieter Klenk, "Filoviruses," in Medical Microbiology, 4th edition, ed. S. Baron (Galveston, TX: University of Texas Medical Branch at Galveston, 1996).

Jonathan S. Towner, Tara K. Sealy, Marina L. Khristova, César G. Albariño, Sean Conlan, Serena A. Reeder, et al., "Newly Discovered Ebola Virus Associated with Hemorrhagic Fever Outbreak in Uganda," PLoS Path 4, no. 11 (2008).

Kevin J. Olival, Ariful Islam, Meng Yu, Simon J. Anthony, Jonathan H. Epstein, Shahneaz Ali Khan, Salah Uddin Khan, et al., "Ebola virus antibodies in fruit bats, Bangladesh," Emerging Infectious Diseases 19, no. 2 (2013), 270.

Ebola Virus Disease," World Health Organization (WHO).

Interim Guidance about Ebola Virus Infection for Airline Flight Crews, Cleaning Personnel and Cargo Personnel. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Sinclair, R., Boone, S. A., Greenberg, D., Keim, P., & Gerba, C. P. (2008).Persistence of category A select agents in the environment. Applied and environmental microbiology, 74(3), 555-563.

Public Health Emergency Medical Countermeasures Enterprise (PHEMCE) Strategy (PDF), U.S. Department of Health and Human Services, accessed April 12, 2014.

Thomas Hoenen, Allison Groseth, and Heinz Feldmann, "Current Ebola vaccines," Expert Opinion on Biological Therapy 12, no. 7 (2012): 859-872

"Recognizing the Biosafety Levels," U.S. Centers for Disease Control and Prevention.

Additional Resources

General Ebola Information

Ebola Hemorrhagic Fever. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Ebola and Other Emerging Infectious Diseases. National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Questions and Answers on Ebola [3] Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Ebola Virus Disease. World Health Organization (WHO).

Frequently Asked Questions on Ebola Virus Disease. World Health Organization (WHO).

Information Resources on Ebola Virus Diseases. World Health Organization (WHO).

Blog post – Eradicating Ebola: In U.S. Biomedical Research, We Trust. Director’s Blog, National Institutes of Health (NIH), U.S. Department of Health and Human Services (HHS).

Ongoing Ebola Outbreak

Health Alert Network. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. Provides up-to-date information about urgent public health incidents with public information officers; federal, state, territorial, and local public health practitioners; clinicians; and public health laboratories.

Ebola Virus Disease Update - West Africa. World Health Organization (WHO).

General Resources for Workers

Bloodborne Infectious Diseases. National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS). Though not specific to Ebola, describes engineering controls and work practices to prevent exposure to blood and other body fluids through which the virus is transmitted.

Protecting Workers during a Pandemic (PDF*) Fact Sheet. Occupational Safety and Health Administration (OSHA), U.S. Department of Labor (DOL). Provides general guidance about principles of worker protection that may be useful during a wide-spread disease outbreak. Covers social distancing, engineering controls, respiratory protection, and other infection control methods.

Workplace Safety & Health Topics – Ebola. National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Cleaning and Decontamination

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

Information for Healthcare Workers

Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing). Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Tightened Guidance for U.S. Healthcare Workers on Personal Protective Equipment for Ebola Fact Sheet. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in US Hospitals. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Safe Management of Patients with Ebola Virus Disease in U.S. Hospitals. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS)..

Guidance on Air Medical Transport for Patients with Ebola Virus Disease. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Interim Guidance for Environmental Infection Control in Hospitals for Ebola Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

CDC Infection Control for Viral Hemorrhagic Fevers in the African Health Care Setting. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

CDC Viral Hemorrhagic Fevers: Infection Control Posters for the African Health Care Setting. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Healthcare Infection Control Practices Advisory Committee (HICPAC). Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Information for Airline Cabin Crews

Interim Guidance about Ebola Virus Infection for Airline Flight Crews, Cleaning Personnel, and Cargo Personnel. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Infection Control Guidelines for Cabin Crew Members on Commercial Aircraft. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

◾[http://www.cdc.gov/quarantine/air/reporting-deaths-illness/guidance-reporting-onboard-deaths-illnesses.html Guidance for Airlines on Reporting Onboard Deaths or Illnesses to CDC. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Guidance for managing ill onboard passengers (PDF). International Civil Aviation Organization (ICAO).

Information for Mortuary & Death Care Workers

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

Information for Laboratory Workers

Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Persons Under Investigation for Ebola Virus Disease in the United States. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

Interim Laboratory Guidelines for Handling/Testing Specimens from Cases or Suspected Cases of Hemorrhagic Fever Virus (HFV) (PDF). American Society for Microbiology (ASM).

◾Kortepeter, M. G., Martin, J. W., Rusnak, J. M., Cieslak, T. J., Warfield, K. L., Anderson, E. L., & Ranadive, M. V. (2008). Managing Potential Laboratory Exposure to Ebola Virus by Using a Patient Biocontainment Care Unit (PDF). Emerging Infectious Diseases, 14(6), 881.

◾Biosafety in Microbiological and Biomedical Laboratories (BMBL), 5th Edition. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS). Features the most recent guidance on protecting workers in laboratory environments. The following sections may be of particularly relevance to employers and workers regarding Ebola: ◦Section VII – Occupational Health and Immunoprophylaxis (PDF) ◦Section VIII - E – Viral Agents Agent Summary (PDF)

Biosafety Laboratory Competency Guidelines. Morbidity and Mortality Weekly Report (MMWR), 15 April 2011, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS). Describes competencies involved with understanding the hazards in a laboratory setting.

Information for Emergency Responders

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

Information for Other Types of Workers

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

Monitoring and Surveillance

National Bioforensic Analysis and Countermeasures Center (NBACC). U.S. Department of Homeland Security (DHS). Provides information about a highly sophisticated laboratory that conducts specialized work in bioforensic analysis. Located at Ft. Detrick, MD, this laboratory is the designated federal facility to conduct and facilitate technical forensic analysis and interpretation of materials recovered following a BW/BT attack.

U.S. Quarantine Stations. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS). Comprehensive system that serves to limit the introduction and spread of contagious diseases in the United States.

Division of Global Migration and Quarantine (DGMQ). Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS). DGMQ quarantine stations work to detect and respond to ill travelers who have serious diseases of public health interest, including Ebola. Stations are located at points of entry (e.g., international airports) and are designed to help prevent arriving travelers from spreading diseases within the U.S.

Morbidity and Mortality Reporting Tools

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