Ebola: what you need to do as an employer if you have employees travelling to West Africa

    • Dr Steve Iley hosted the below webinar on 28 October focusing on UK employers, helping you to gain an understanding firstly around what is Ebola, how does it spread, and the signs and symptoms. The video explains what employers should be doing for employees who are globally mobile, specifically those travelling to and from infected countries.

      The risk continues to be low outside of the already affected countries and we will continue to monitor the situation.

      The number of cases and the continuing spread of infection indicate the risk level will not fall in the immediate future. We expect isolated cases will continue to be found in other countries due to the volume of international travel and mobility of populations. The advice from specialists is that these cases should be containable in developed countries.

      As an employer you should now develop a good strategy for communicating with your workforce. It is highly likely that the perceived risk of Ebola will be disproportionate to the actual risk, which could have the potential to lead to disruption of business if employees are not fully informed of the actual risks and sensible precautions to take.

      As an employer you should have checked and updated your pandemic and disaster recovery plans. If you have employees or colleagues travelling to West Africa, reviewing your plans is particularly urgent, however we recommend all employers have robust plans in place.

      You should assess the need for any travel to the affected areas and monitor the situation closely, as the advice from authorities can change quickly as the situation develops.

      At this time, we do not recommend screening of employees outside of the affected countries. Returning travelers should follow the advice below and businesses should have a plan in place should any returning traveler from an affected country declare symptoms at work. See symptoms below.

      Returning travellers from affected areas need to be informed of Ebola (or Ebola Virus Disease EVD) symptoms to look for and what to do if they are concerned.

      Information and regular updates on the Ebola outbreak can also be found in online sources including:

      Information on Ebola virus and travel

      Below is a summary of key points for:

      • people travelling to and from the areas affected by the virus
      • more detailed information regarding the current outbreak and the virus itself

      Key Points for Travellers

      • Infection is by contact with blood or body fluids of an infected person or an infected animal, or by contact with contaminated objects.
      • Incubation period is 2 to 21 days.
      • Symptoms include fever, weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhoea, rash, and in some cases, bleeding.
      • Persons who come into direct contact with body fluids of an infected person or animal are at risk.
      • There is no vaccine.
      • Practise careful hygiene.
      • Avoid all contact with blood and body fluids of infected people or animals.
      • Do not handle items that may have come in contact with an infected person’s blood or body fluids.
      • If you stayed in the areas where Ebola cases have been recently reported seek immediate medical attention if you feel sick ( fever, headache, aches, sore throat, diarrhoea, vomiting, stomach pain, rash, or red eyes). (1)

      Summary of epidemiological facts and experience

      • The incubation period of Ebola varies from 2 to 21 days. Person-to-person transmission by means of direct contact with infected persons and/or their body fluids/secretions is considered the principal mode of transmission. In a household study, secondary transmission took place only if direct physical contact occurred. No transmission was reported without this direct contact. Airborne transmission has not been documented during previous Ebola outbreaks.
      • There is no risk of transmission during the incubation period and only low risk of transmission in the early phase of symptomatic patients. The risk of infection during transport of persons can be further reduced through use of infection control precautions.
      • In the current outbreak, infected travellers have crossed borders with neighbouring countries and other cases occur in countries via air travel.

      People who have returned from affected areas who have a sudden onset of symptoms such as fever, headache, sore throat and general malaise within three weeks of their return should immediately seek medical assistance.

      Transmission, signs & symptoms, diagnosis and treatment

      Transmission

      The first human case in an outbreak of Ebola is acquired through contact with blood, secretions organs or other bodily fluids of an infected animal. The virus is then transmitted to others through direct contact with the blood, secretions, organs or other bodily fluids of infected persons. People can also become infected through contact with objects, such as needles or soiled clothing, that have been contaminated with infected secretions. Hospital workers have frequently been infected in Ebola outbreaks through close contact with infected patients, and insufficient use of correct infection control precautions and barrier nursing procedures. Outbreaks have also been fuelled by traditional burial practices, in which mourners have direct contact with the bodies of the deceased. Acquisition via sexual contact with a convalescent case is possible as the virus is present in semen for up to 7 weeks after recovery.

      Humans may also be infected if they handle infected animals, or come into contact with their bodily fluids or cell cultures, and cases have been documented in people who handled infected chimpanzees, gorillas and forest antelopes, both dead and alive, in the Ivory Coast, the Republic of Congo and Gabon. The harvesting of migrating fruit bats was thought to be the source of a large outbreak in the DRC (Democratic Republic of Congo) in 2007.

      Ebola virus is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals. In Africa, infection has occurred through the handling of infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead or in the rainforest. It is important to reduce contact with high-risk animals (ie fruit bats, monkeys or apes) including not picking up dead animals found lying in the forest or handling their raw meat.

      Once a person comes into contact with an animal that has Ebola and is infected by the virus, it can spread from human to human. Infection occurs from direct contact (through broken skin or mucous membranes) with the blood, or other bodily fluids or secretions (stool, urine, saliva, semen) of infected people. Semen can contain virus for some weeks after apparent recovery from the illness. Infection can also occur if broken skin or mucous membranes of a healthy person come into contact with environments that have become contaminated with an Ebola patient’s infectious fluids such as soiled clothing, bed linen, or used needles.

      Infection generally does not occur through routine, social contact (such as shaking hands) with asymptomatic individuals. The likelihood of contracting any viral hemorrhagic fever (VHF), including Ebola, is considered very low unless there has been travel to a known affected area and direct contact with the blood or body fluids (eg, saliva, urine) of symptomatic infected persons or animals, or objects that have been contaminated with body fluids. The cause of fever in persons who have travelled in areas where VHF is present is more likely to be a common infectious disease, but such persons should be evaluated by a health-care provider to be sure.

      Signs and symptoms

      Ebola is a severe acute viral illness often characterized by sudden onset of fever, intense weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhoea, rash, impaired kidney and liver function, stomach pain and in some cases, both internal and external bleeding. Laboratory findings include low white blood cell and platelet counts and elevated liver enzymes.

      People are infectious as long as their blood and secretions contain the virus. Ebola virus was isolated from semen 61 days after onset of illness in a man who was infected in a laboratory.

      The incubation period, that is, the time interval from infection with the virus to onset of symptoms, is 2 to 21 days. (2)

      Diagnosis

      Clinical diagnosis of Ebola virus disease in the early stages of infection is difficult, as early symptoms are non-specific and similar to those of many other diseases. However once later symptoms develop a clinical diagnosis of Ebola may be made. Laboratory findings show low counts of white blood cells and platelets, and elevated liver enzymes

      Tests are available to detect viral DNA or antibodies to the virus, and it may also be isolated in cell culture. Tests have been developed to allow rapid laboratory diagnosis during outbreaks. People can also be tested for antibodies after their recovery.

      Treatment

      There is no specific treatment or vaccine available for Ebola virus disease, however potential new vaccines and drug therapies are being developed and tested. Patients require intensive supportive therapy including intravenous fluids or oral rehydration with solutions including electrolytes, maintaining their oxygen status and blood pressure.

      Guidance for Workers and Travellers

      Recommendations

      If you travel to an area affected by a VHF (Viral Hemorrhagic Fever) such as Ebola outbreak, the following precautions are recommended:

      Before you leave

      • Assemble a travel health kit containing basic first aid and medical supplies. Be sure to include a thermometer, household disinfectant, alcohol-based hand rubs for hand hygiene. In addition, you should include a supply of surgical masks and disposable gloves if you may be in situations where you have close contact with persons suspected of having a VHF infection.
      • Inform yourself and others who may be travelling with you about Ebola virus. This includes obtaining and remaining aware of up-to-date, reliable information on the specific areas affected, as these may change over time. be sure you are up to date with all your immunisations, and see your health-care provider at least 4-6 weeks before travel to get any additional immunisations, medications, or information you may need.
      • Check your travel insurance plan or get additional insurance that covers medical evacuation in the event of illness.
      • Identify in-country health-care resources in advance of your trip

      For workers and travellers in an area where Ebola virus disease has been reported

      Maintain the basic precautions that apply. These include:

      • avoiding contact with ill or dead animals (especially primates and bats) as well as consumption of "bushmeat" (wild animals, including primates, sold in local markets for consumption as food)
      • adhering to safe sex practices including the use of barrier contraception

      If you are involved in medical care you should maintain the general principles of infection control, including:

      • sterilisation and proper disposal of needles and equipment
      • proper disposal of body fluids, tissues and patient excretions
      • careful and frequent handwashing using soap and water (or waterless alcohol-based hand rubs when soap is not available).
      • wearing gloves

      In addition, you should observe barrier techniques when in close contact with persons or animals suspected or known to have Ebola virus infection. This includes wearing protective gowns, gloves, masks and eye protection or face shields:

      • when wearing disposable gloves, wash the gloves with soap and water before removing them.
      • do not reuse the gloves; instead dispose of them according to recommended infection control precautions.
      • after disposing of the gloves, wash your hands again (2a)

      If you think you have Ebola virus infection or symptoms compatible with Ebola virus disease:

      Whilst in the affected area, if you or your family members develop fever or other symptoms such as chills, muscle aches, nausea, vomiting, or rash:

      • visit a health-care provider immediately and inform them that you may have had contact with Ebola virus disease. The nearest Embassy or Consular Office can help you find a provider in the area, and you are encouraged to identify these resources in advance.
      • when travelling to a health-care provider, limit your contact with others. All other travel should be avoided.
      • remember that other potential causes of the illness (such as malaria) should not be overlooked
      Guidance for people returning from areas affected by the Ebola outbreak

      People returning from an affected area who have had a potential exposure to Ebola virus disease should monitor their health for 21 days post exposure. Any person who becomes ill, even if only a fever, should consult a health-care provider immediately and tell him or her about their recent travel and potential contacts.

    • References

      1)  Health Protection Agency - Public Health England - Advice to travelers June 2014

      2)  World Health Organisation Transmission of EBV Ebola Virus Disease April 2014

      2a) World Health Organisation Guidance to Travellers July 2014

    • Dr Steve Iley

      Viewpoint by Dr Steve Iley, Medical Director for AXA PPP healthcare’s Health Services division

      Steve is responsible for the delivery of occupational health services and clinical governance across the company’s health services business. He is a qualified GP and a member of the Colleges of Travel Medicine and Occupational Medicine. He has extensive experience in corporate, travel and occupational health and has worked in Russia, Australia, Singapore and Bermuda during his training. Steve is a member of the Faculty of Occupational Medicine.