Ebola

Specific Information for Workers (by Job Type)

Healthcare Workers

OSHA's PPE Selection Matrix for Occupational Exposure to Ebola Virus provides task-based guidance to help employers select appropriate PPE for workers who may be exposed to ebolavirus, including healthcare workers evaluating individuals with suspected EVD, caring for hospitalized patients, transporting individuals with suspected or confirmed EVD, and performing cleaning and waste handling tasks where ebolavirus contamination may be present.

Use transmission-based precautions appropriate for ebolaviruses (i.e., based on each worker's job tasks and exposure risk, typically a combination of contact and droplet precautions with airborne precautions for aerosol-generating procedures).

OSHA requires that all workers who are required to wear PPE, including those involved in the care of EVD patients, receive training on how to properly use PPE and demonstrate competency in donning and doffing according to OSHA's PPE standard, 29 CFR 1910.132(f)(1)(iii). CDC also offers guidance describing its recommendation to use an observer to monitor healthcare workers donning and doffing PPE. Like all workers, healthcare workers must follow safe hand hygiene practices.

As required by the BBP standard, healthcare workers must use safe injection practices and infection control techniques and wear appropriate PPE to avoid exposure to infected blood and body fluids, contaminated objects, or other contaminated environmental surfaces. CDC guidance for U.S. healthcare workers caring for patients with EVD include wearing:

  • surgical scrubs or disposable garments under PPE,
  • dedicated washable footwear,
  • double gloves,
  • boot covers that are waterproof and extend to at least mid-calf or leg covers,
  • single use fluid-resistant or impermeable gown that extends to at least mid-calf or coverall without integrated hood,
  • disposable N95 or PAPR,
  • disposable full-face shield,
  • surgical hoods to ensure complete coverage of the head and neck,
  • a waterproof apron that covers the torso to the level of the mid-calf should be used if EVD patients have vomiting or diarrhea.

The type of PPE worn will depend on the health of the person under investigation (PUI) or patient. Examination and treatment of clinically stable patients will require less personal protection than for patients who are considered clinically unstable, who may have diarrhea, bleeding, or vomiting, and/or require invasive or aerosol-generating procedures. For more information about the distinction between clinically stable and unstable persons and the types of PPE needed, see CDC's Guidance for Clinically Stable PUIs and Guidance on Personal Protective Equipment (PPE) for Clinically Unstable PUIs.

Aerosol Generating Procedures

Healthcare workers who perform aerosol-generating procedures (AGPs) are at the highest risk of exposure to aerosolized ebolavirus particles. Aerosol-generating, clinical procedures that may be performed on a patient with EVD include:

  • bronchoscopy
  • intubation
  • ventilation
  • active resuscitation

Bronchoscopy, intubation, and airway management are best performed on EVD patients as early, semi elective procedures, rather than as emergency procedures. When performing AGPs on patients with EVD is deemed necessary, use extreme caution and wear full-coverage, impermeable PPE as described in OSHA's PPE Selection Matrix for Occupational Exposure to Ebola Virus.

Healthcare personnel should receive simulated training wearing full PPE before carrying out these procedures on patients. Bag-mask and positive pressure ventilation should be avoided to decrease the risk of aerosolizing secretions.

For more information about PPE selection for workers caring for patients with EVD, see CDC's Guidance on Personal Protective Equipment (PPE).

Emergency Medicine

Emergency Department (ED) medical staff should work closely with local public health officials and emergency responders when receiving PUIs and patients with confirmed EVD. In the unlikely event that a patient with suspected EVD is received, CDC provides a flow diagram specifically for ED medical staff to manage these situations in Identify, Isolate, Inform: Emergency Department Evaluation and Management for Patients Under Investigation [PUIs] for Ebola Virus Disease [EVD].

Cleaning and Infection Control

Where OSHA's Bloodborne Pathogen standard 29 CFR 1910.1030(d)(4)(ii) applies, it requires that contaminated work surfaces be cleaned and decontaminated after contact with blood or other potentially infectious materials. Appropriate disinfectants such as those described as effective and registered for use in the EPA's List L should be used to decontaminate work surfaces Healthcare workers who clean and disinfect areas where there are patients with suspected or confirmed EVD should wear appropriate PPE and follow OSHA's Cleaning and Decontamination of Ebola on Surfaces and CDC's Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus.

Special Precautions

Healthcare workers and responders involved with patients with suspected or confirmed ebolavirus infections must wear enhanced PPE and may be asked to work extended, rotating, consecutive, or otherwise unusual shifts. These conditions increase the risk of injuries and accidents and can contribute to poor health and worker fatigue. The NIOSH/OSHA pamphlet Preventing Worker Fatigue Among Ebola Healthcare Workers and Responders provides guidance for protecting workers responding in the United States, but the same concepts apply to those working in other countries.

Appropriate PPE must be worn when handling remains of deceased patients infected with ebolavirus since the virus survives in body fluids after death. Ebolaviruses can be transmitted in postmortem care settings by direct handling of human remains, through splashes of blood and other body fluids into unprotected mucous membranes, and by puncture or laceration with contaminated instruments. For more information, see CDC's Guidance for Safe Handling of Human Remains of Ebola Patients in U.S. Hospitals and Mortuaries.

Pre-exposure vaccination with Ervebo® may be used to prevent EVD in first responders and healthcare workers at federally designated Ebola Treatment Centers or state-designated Special Pathogens Treatment Centers involved in the care and transport of patients infected or suspected to be infected with ebolavirus.

The CDC is the authoritative source for information for healthcare workers who care for, treat, and otherwise interact with patients who are known to have or are suspected of having EVD. CDC provides guidance and recommendations, including the following publications:

CDC also provides information for workers who may be exposed to ebolavirus through environmental contamination in healthcare settings:

Laboratory Workers

Laboratory workers who handle samples containing ebolavirus, including for diagnostic testing of patients with suspected or confirmed EVD and as part of research and development work, must be protected from exposure to the virus on the job.

The infectious dose of ebolavirus is very low, less than 10 viral particles, and biological specimens from patients may contain high numbers of ebolavirus particles. Exposure to such specimens can result in severe disease. Ebolaviruses are classified as Federal Select Agents under US 42 CFR Part 73 and are regulated under the Federal Select Agent Program (FSAP) because they are not native to the US and have the potential to pose a severe threat to both human and animal health. Under FSAP, the ownership, use, and transfer of materials containing ebolavirus are monitored to ensure they are housed at safe, secure facilities. FSAP inspects all laboratories to ensure that biosafety and biosecurity measures for handling ebolaviruses and other Select Agents are in place and approves all individual access to these pathogens based on security screening. All incidents involving theft, loss, or release must be reported to FSAP, and system failures may be reported to appropriate authorities. Noncompliance with FSAP may result in corrective measures, and potentially criminal or civil penalties based on the nature of the infraction.

Employers of laboratory workers are responsible for following applicable OSHA requirements, which may include OSHA's Bloodborne Pathogens (29 CFR 1910.1030), Personal Protective Equipment (29 CFR 1910.132), and Respiratory Protection (29 CFR 1910.134) standards. In addition to OSHA requirements that are broadly applicable to occupational exposure to ebolavirus and related hazards, such as chemicals used for cleaning and disinfection, laboratory employers must also follow specific requirements that apply to labs. For additional information on OSHA requirements, visit the Standards section of this web page.

According to CDC's Biosafety in Microbiological and Biomedical Laboratories (BMBL), 6th Edition, cultures and specimens containing ebolavirus must be handled at a Biosafety Level 4 (BSL-4) facility with HEPA-filtrated laboratory exhaust. BSL4 is the highest level of biocontainment, so very few laboratories in the U.S. are equipped to meet the biosafety and biosecurity requirements to manipulate ebolavirus specimens or cultures.

The following sections of the BMBL (may be of particular relevance to employers and workers in laboratories that may handle ebolavirus:

  • Section IV - Laboratory Biosafety Level Criteria
  • Section VIII - F - Arboviruses and Related Zoonotic Viruses

Research laboratories that manipulate ebolavirus are subject to FSAP regulations and workers must undergo additional security measures and take enhanced procedural training. Clinical laboratories in the U.S. that may handle specimens that may contain ebolavirus should follow CDC's Guidance for Transport and Shipment of Specimens for Ebola Virus Testing.

Laboratory workers packaging and transporting specimens that may contain ebolavirus must use biosafety precautions including appropriate PPE and adhere to international packaging and shipping instructions under United Nations Regulations UN2814; Infectious Substances Affecting Humans included in Category A. Transport of infectious substances in the U.S. is also regulated under the U.S. Department of Transportation and is subject to specific state and local transportation laws.

Employers must also be prepared to decontaminate laboratory work environments safely and effectively and to handle waste generated from both the laboratory work and cleaning and decontamination activities. Different or additional engineering controls, PPE, and other measures may be needed to protect workers from exposure to hazardous chemicals used for cleaning and disinfection as described in 29 CFR 1910.1200. CDC's Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus provides information on cleaning and decontamination applicable to laboratory settings. When selecting disinfectants, employers should consult the EPA's List L of selected and registered antimicrobial products that meet the CDC criteria for use against ebolavirus. OSHA's Safe Handling, Treatment, Transport and Disposal of Ebola-Contaminated Waste fact sheet details best practices throughout the waste cycle, from the point of waste generation through final disposition of treated waste products.

Pre-exposure vaccination with Ervebo® may be used to prevent EVD in clinical and research laboratory workers and other staff who work at BSL-4 facilities with ebolavirus.

Mortuary and Death Care Workers

Ebolavirus survives in tissues and body fluids of human remains after death. Mortuary and death care workers who may receive cadavers from persons who have died of EVD must be trained to wear PPE and handle infectious remains. In addition, engineering controls such as negative air pressure rooms or airborne infection isolation rooms (AIIRs) and biosafety cabinets (BSCs) should be utilized to prevent exposure to aerosolized droplets containing ebolavirus. To prevent exposure, follow CDC's Guidance for Safe Handling of Human Remains of Ebola Patients in U.S. Hospitals and Mortuaries that describes appropriate control measures for post-mortem handling, transportation and disposition of human remains. The following measures can be used to protect mortuary care workers:

  • Handle body bags wearing long-cuffed, disposable gloves and a long-sleeved disposable gown.
  • Do not wash or clean the body.
  • Do not open body bags.
  • Do not remove inserted medical devices (intravenous lines, endotracheal tubing, or other implanted devices) from the body.
  • Do not embalm the body.
  • Cremate the remains. If cremation cannot be performed safely due to risk of explosion of implanted medical devices, consider burial in metal or other caskets instead.
Special Considerations

Funeral directors and funerary care staff must balance the safe handling of human remains with family members' religious and/or cultural practices for death and mourning. These practices have significant social and psychological impacts on families of the deceased, so care must be taken to respect families' wishes to the extent that it can be done safely.

In past EVD outbreaks, spiritual and cultural death practices, such as washing and wrapping the deceased, contributed to further spread of disease. To prevent death care transmission, guidelines for safe and dignified burial were developed in consultation with world religious and health leaders in the context of EVD and other hemorrhagic fevers. These guidelines are intended to allow families to follow spiritual practices, such as (dry) washing and shrouding of the body bag containing the deceased, while wearing appropriate PPE.

Airline and Other Travel Industry Personnel
Airline Workers

The safety and health of flight crews are typically under the jurisdiction of the Federal Aviation Administration (FAA) and such workers are generally not subject to OSHA requirements. In 2014, an FAA-OSHA Memorandum of Understanding (MOU) extended some OSHA protections to and authority over cabin crewmembers aboard aircraft in operation. Although not subject to the General Duty Clause, airline flight crews are subject to the Bloodborne Pathogens (29 CFR 1910.1030), Noise (29 CFR 1910.95), and Hazard Communication (29 CFR 1910.1200) standards.

Workers involved in airline and airport service operations including flight attendants, cleaning and provisioning staff, and cargo personnel, may be exposed to ebolavirus in several ways, including exposure to infectious body fluids in lavatories and direct exposure to individuals sick with EVD.

Currently, airline service worker exposure to ebolavirus is unlikely. Passengers originating from locations with an ongoing EVD outbreak pose the greatest hazard to airline and travel workers, however, if transmission levels are high from the originating country, the US may impose border entry restrictions. In most cases, passengers leaving an EVD-affected country will undergo additional health screening by trained medical staff. Further, under the Aviation and Transportation Security Act (49 U.S.C. 114), the Transportation Security Administration (TSA) may take actions necessary to protect both transportation workers and US citizens from communicable diseases. Under TSA authority, the CDC may issue Do Not Board and Lookout Lists. These lists are intended to prevent passengers who are known to have contagious diseases such as EVD or have had contact with persons ill with EVD from boarding transportation to the US or to ensure such passengers undergo required medical screening before boarding transportation to the US, respectively.

The CDC provides practical guidance for cabin crews in preventing disease transmission in Preventing Spread of Disease on Commercial Aircraft: Guidance for Cabin Crew. The International Air Transportation Association (IATA) recommends that airline operators should ensure all passenger aircraft in its fleet are equipped with one or more Universal Precaution Kits (UPK) for use by cabin crew members in managing ill passengers and suspected exposure to infectious diseases. The IATA's Universal Precaution Kit (UPK) includes PPE and equipment for workers who may perform work tasks such as cleaning up blood, vomit, or other body fluids from a sick passenger that could result in exposure to ebolavirus.

If a passenger or cabin crew member becomes ill with symptoms that are consistent with EVD and has recently traveled to or lived in an affected country, airline workers are advised to protect themselves and others by taking the following steps:

  • Assign a single crew member, or two as needed, to care for the ill person.
  • Isolate or separate the ill person from others as much as possible, ideally near a restroom for their exclusive use.
  • Provide access to soap and water or an alcohol-based hand sanitizer to encourage hand hygiene.
  • Provide sick travelers and crew with surgical masks that cover the nose and mouth to reduce the number of droplets expelled into the air by talking, sneezing, or coughing (if tolerated).
  • Provide the person with an air sickness bag if vomiting.
  • Provide the ill person with a plastic bag to dispose of soiled materials (tissues, air sickness bags, etc.).
  • Avoid direct contact with the ill person and their body fluids.
  • Wear disposable gloves if direct contact is necessary for care.
  • Clean hands with soap and water or an alcohol-based hand rub after every contact with the ill person/their belongings or immediate environment.

Cabin crew members who are assisting the ill person should use good hand hygiene and wear PPE (such as disposable gloves and masks) according to the employer's occupational health and safety protocol and as recommended by the CDC.

Disinfection

Treat all body fluids, including diarrhea, vomit, blood, and phlegm, as infectious. Cabin and cleaning crews should avoid direct contact with visibly soiled and potentially contaminated surfaces and materials and wear appropriate PPE as recommended by the CDC.

Disinfection and clean up should include wiping down lavatories and frequently touched surfaces in the passenger cabin (armrests, seat backs, tray tables, light and air controls, and adjacent walls and windows) with a disinfectant from the EPA's List L. Restrict access, where possible, to the affected area until disinfection activities are completed.

Maritime Industry and Travel Workers

The risk of exposure to EVD by maritime industry and travel workers is lower than that for airline industry workers, since the annual number of airline passengers outnumber cruise ship travel passengers by greater than 100 to 1. Additionally, very few cruise lines have embarkation points near EVD-endemic regions. There is additional risk associated with prolonged contact in semi-enclosed and sometimes crowded environments, however.

The CDC has issued specific Maritime Guidance for both cruise ships and non-passenger vessels operating in US waters. Although much of this information was developed for prevention of COVID-19, the guidelines include universal recommendations for crew members to reduce the risk of illness and transmission of disease including hand hygiene, appropriate use of PPE, and other best practices.

Medical Care

The American College of Emergency Physicians (ACEP) has instituted Health Care Guidelines for Cruise Ship Medical Facilities that lay out requirements for availability and quality of medical care and facilities on cruise ships for crew and passengers. Oceangoing cruise lines carrying 100 or more passengers that are members of the Cruise Line International Association (CLIA), the primary marketing organization for North American cruise lines, have agreed to follow and exceed these ACEP guidelines.

The Maritime Labour Convention (MLC 2006 Title 4.1) requires the presence of a medical doctor on board ships with 100 or more crew members on an international voyage of greater than three days, regardless of the number of passengers.

All illnesses and deaths of passengers or crew, whether on board or debarked, must be reported by the master of any ship entering a US port under US Federal Regulations (42 CFR 71.21) within 15 days of arrival or departure (whichever is shorter).

For more information about protection against travel-related EVD, please visit the CDC's Interim Guidance on Risk Assessment and Management of Persons with Potential Ebolavirus Exposure.

Border, Customs, and Quarantine Measures
Travel and Immigration

Workers involved in border patrol and security, immigration and customs enforcement, and public health investigation and quarantine work may encounter individuals with EVD arriving at U.S. borders from foreign countries impacted by epidemics.

The CDC has prepared Considerations for Health Screening at Points of Entry to assist customs and border workers by describing strategies to recognize illnesses and take appropriate secondary actions to prevent infectious diseases from crossing international borders.

EVD is considered a Communicable Disease of Public Health Significance. Persons having EVD are subject to isolation by Presidential Executive Order and people exposed to EVD must be held under quarantine.

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 Part 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.

Customs, Cargo, and Port Inspectors

These types of workers may also be exposed to infected blood and body fluids or other potentially infectious materials, or contaminated objects and environmental surfaces, as they perform tasks such as inspection of cargo, baggage, and arriving aircraft or vessels.

Live Animals and Bushmeat

Ebolavirus outbreaks are thought to occur from spillover events where the virus is passed from wild animals, living or dead, to humans through direct contact. Wild animals imported from parts of Africa play a role in transmission of communicable diseases. Bats, pigs, non-human primates (chimpanzees and gorillas), and duikers, which are small antelopes, have the potential to transmit ebolaviruses.

Although the risk of ebolavirus transmission from illegally imported wild animals is low, port authorities and cargo inspectors should consider risk of EVD from wild animals originating in or imported from Central Africa, or from animals that have been housed with wild animals originating in or imported from Central Africa. The CDC has authority over the importation of animals that can transmit diseases to humans, including pets. Entry of certain animals, including African rodents, is prohibited by law. For more information about restrictions on importation of living animals, visit CDC's Bringing an Animal into the U.S. webpage.

The importation of bushmeat, which is raw or partially processed meat from wild animals that is intended for human consumption, is also illegal, since it can carry communicable diseases, including EVD. Care must be taken to prevent direct contact with bushmeat and packing materials contaminated with tissue and fluids from these carcasses.

Customs agents, cargo handlers, port inspectors and other personnel involved in global entry of people and goods may be required to handle hazardous materials. Appropriate PPE as described in General Recommendations for Employers should be used to prevent exposure to EVD.

Emergency Responders

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

Healthcare workers, emergency medical teams (EMTs) and others who must have contact with individuals with EVD must follow applicable requirements, which may include OSHA's Bloodborne Pathogens standard (29 CFR 1910.1030). CDC also provides guidance and recommendations for protecting these workers.

The CDC's Emergency Services webpage provides comprehensive guidance for emergency responders who may be required to evaluate, treat, and transport ill persons known or suspected to have, EVD.

Managers of 9-1-1 Emergency Call Centers (ECCs) and Emergency Medical Service (EMS) systems where medical first responders include several agencies such as fire, EMTs, and law enforcement should:

  • Ensure that all responders receive training to respond to persons under investigation (PUIs) for EVD, including PPE use and best practices.
  • Develop agency-wide plans in coordination with local public health authorities to respond to a PUI for EVD, assigning roles and responsibilities as appropriate.
  • Screen all emergency calls from the public about potential exposure to EVD before dispatching emergency responders. Emergency Call Center (ECC) workers should ask callers about risk factors (travel history, contact with suspected or known EVD patient, etc.) and symptoms to ensure they are consistent with the current case definition of EVD.
Emergency Transport

Drivers transporting PUIs to or between hospitals and healthcare facilities should be physically separated from the vehicle's patient compartment. For safety, drivers of emergency vehicles should not be involved in treatment or evaluation of the PUIs. EMTs having contact with the PUI should not drive the emergency vehicle. Vehicles used to transport PUIs and persons ill with EVD should be thoroughly disinfected after transport while wearing PPE as described in CDC's Interim Guidance for Emergency Medical Services (EMS) Systems. Standard Operating Procedures (SOPs) for ambulance and emergency vehicle decontamination can be found on the CDC website.

Air Medical Transport

Special consideration must be given to air medical transport (AMT) of persons with EVD because of the special circumstance associated with air travel. CDC has developed Guidance on Air Medical Transport (AMT) to assist in decision-making and ensure safety of pilots and medical staff. Key points from this guidance include:

  • Air transport of an EVD patient is mission-specific and requires coordination with health and civil aviation authorities at origin and destination.
  • Pilots and crew members not involved in patient care should not participate in movement of the patient and should not enter the patient-designated area.
  • A portable isolation unit is recommended to contain waste and prevent contamination of the aircraft.
  • Infection control practices should be planned before the mission.
  • All clinical and patient care staff must receive training to wear appropriate PPE according to CDC guidelines.

For more information about workers in emergency response and preparedness, please visit OSHA's webpage on Emergency Preparedness and Response. NIOSH provides additional guidance for workers, including emergency responders, who may be exposed to biological agents, such as ebolavirus and other infectious pathogens.