Ebola Virus Disease (EVD) Scott Lindquist, MD, MPH Washington State Epidemiologist for Communicable Diseases and Deputy Health Officer www.nwcphp.org/hot-topics Overview Ebola virus disease The basics The current outbreak Monitoring travelers from Ebola-affected countries Healthcare facility and laboratory preparedness Public health system preparedness 1
Ebolavirus Virus of the family Filoviridae, genus Ebolavirus Discovered in 1976 near Ebola River (DRC) 4 of 5 subspecies cause disease in humans Ebola virus (Zaire ebolavirus) Sudan virus (Sudan ebolavirus) Taï Forest virus (Taï Forest ebolavirus) Bundibugyo virus (Bundibugyo ebolavirus) Bats are most likely reservoir Occurs in animal hosts native to Africa Source: CDC 2
Ebola Virus Disease Symptoms Symptoms Typically Include fever (>101.5 F) headache, muscle pain weakness diarrhea, vomiting abdominal pain lack of appetite Symptoms Can Include rash red eyes cough, hiccoughs sore throat, chest pain difficulty breathing or swallowing, unexplained bleeding inside and outside of the body Transmission of EVD Spread through direct contact--through broken skin or mucous membranes-- with: a sick person's blood or body fluids: urine, saliva, feces, vomit, and semen objects--such as needles that have been contaminated with infected body fluids infected animals 3
Treatment Supportive care balancing the patient s fluids and electrolytes maintaining their oxygen status and blood pressure treating them for any complicating infections Experimental therapy ZMapp: monoclonal antibodies TKM-Ebola: RNA interference drug Ebola Virus Outbreaks, 1976 2008 4
The Outbreak Current Outbreak in West Africa* Largest outbreak to date > 14,000 cases > 5000 deaths Widespread transmission in Guinea, Liberia & Sierra Leone Healthcare workers and close contacts of cases at highest risk No definitive treatment or vaccine, only supportive care Areas affected by 2014 outbreak *As of November 14, 2014 5
CDC Travel Notices Level 3 Warning: Avoid Nonessential Travel Guinea Liberia Sierra Leone Level 2 Alert: Practice Enhanced Precautions Nigeria Mali Travel Screening In Washington State Exit screening in Ebola-affected countries Entry screening in 5 US airports Travelers need to enter US via these airports Completion of declaration form & temperature screen Distribution of CARE kits Contact information electronically transmitted to DOH Monitoring of travelers in Washington by LHJs 6
WA State Monitoring of Travelers Exposure Risk Category High risk (e.g., direct contact with infected body fluids) Some risk (e.g., close contact with a person showing symptoms of Ebola; direct contact with an Ebola patient in Africa while wearing appropriate PPE) Low but not zero risk LHJ Type of Monitoring Direct Active Monitoring Direct Active Monitoring Direct Active Monitoring for US based healthcare workers (e.g., been in a country with widespread Ebola transmission but no known exposures; direct Active Monitoring for all contact with an Ebola patient in others US while wearing appropriate http://www.doh.wa.gov/portals/1/documents/5100/420-132-ebola-lhj-monitoringguide.pdf PPE) Restrictions on Movement Yes Public Health Order for Restrictive Movement; involuntary home quarantine order if contact refuses to adhere to restrictions Not routinely unless risk assessment warrants additional restrictions. See some risk letter template for further voluntary restrictions No Washington Hospital Preparedness 7
Plan for Washington 1. Treatment (severely sick) 8 hospitals 2. Screening and basic care all hospitals 3. Screening and planning all clinics Levels of Healthcare Facility Preparedness in Washington State Outpatient / ambulatory care settings Rapidly identify, safely isolate & transfer patients Ebola screening facilities Rapidly identify, isolate, evaluate & safely provide short-term care (if necessary) to patients Ebola treatment facilities (e.g., tertiary hospitals) Rapidly identify, isolate & safely provide ongoing care Need dedicated and adequate treatment areas, highly skilled and trained staff, appropriate equipment and excellent infection control procedures 8
8 Hospitals Stepping Forward 1. CHI Franciscan Health (Harrison Medical Center Bremerton campus) 2. MultiCare Tacoma General Hospital 3. Providence Regional Medical Center Everett 4. Providence Sacred Heart Medical Center and Children s Hospital (Spokane) 5. Seattle Children s Hospital 6. Swedish Medical Center (Issaquah) 7. Virginia Mason Hospital (Seattle) 8. UW Medicine (Harborview Medical Center, UW Medical Center, Valley Medical Center) Healthcare Facility Preparedness Collaborating with WSHA, WSMA, WSNA, LHJs, and Northwest Healthcare Response Network Sent two letters to all Washington State association members on preparedness activities Gave three webinars on how to identify, isolate and evaluate patients with suspected Ebola virus disease in the outpatient and ED setting Hospital Readiness checklist, CDC site visits and Local hospital drills and exercises 9
Patients with Possible Ebola in Ambulatory Settings (1) Isolate in private room Avoid unnecessary direct contact If direct contact is necessary, use PPE and dedicated equipment Limit personnel to those essential for care If bleeding, vomiting, or uncontained diarrhea (wet symptoms), if possible, and patient is stable, do not reenter room until EMS trained to transport Ebola arrive No blood draws or other procedures unless necessary to stabilize patient Consult with health department before cleaning blood/body fluids Patients with Possible Ebola in Ambulatory Settings (2) Immediately inform LHJ Transfer to Ebola screening hospital identified by LHJ Coordinate regarding Notifying the receiving hospital EMS transport arrangements Patients with possible Ebola should only be sent to hospitals or facilities specifically designated by public health officials 10
Cleaning, Disinfection and Waste Disposal Cleaning staff should wear appropriate PPE Use EPA-registered hospital disinfectant with label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus) to disinfect surfaces and reusable equipment Discard all linens, non-fluid-impermeable pillows or mattresses, dishes and utensils as medical waste Ebola virus is Category A infectious substance; any potentially contaminated item must be packaged and transported following DOT Hazardous Materials Regulations For large spills, use a chemical disinfectant (bleach) For liquid waste: 1 cup of bleach in toilet, let stand 5 minutes before flushing http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html http://www.epa.gov/oppad001/list-l-ebola-virus.html https://www.osha.gov/publications/osha_fs-3756.pdf http://www.doh.wa.gov/portals/1/documents/1000/ebolawastewatertreatmentpro.pdf Infection Control Precautions Standard Contact Droplet Photo: CDC 11
Putting on Basic PPE Before Care of Potential Ebola Patient Go to designated PPE donning area with PPE buddy Open PPE kit or select PPE, inspect to make sure it s intact and right size surgical facemask face shield impermeable gown 2 pairs gloves Put on inner gloves Put on gown Put on surgical facemask Put on face shield Put on outer gloves, making sure cuff of sleeves is covered Perform patient care Removing Basic PPE After Care of Potential Ebola Patient (1) Go to designated PPE doffing area with PPE buddy Have red biohazard bag for discarding used PPE Inspect PPE for holes or tears Perform hand hygiene Remove outer gloves, perform hand hygiene Remove face shield; perform hand hygiene Remove facemask; perform hand hygiene 12
Removing Basic PPE After Care of Potential Ebola Patient (2) Remove gown and inner gloves in one action, being sure to only touch the clean inside of the gown and gloves Wash hands with soap and water, if available, otherwise use hand sanitizer Practice putting on and taking off PPE before actual use http://www.cdc.gov/hicpac/2007ip/2007ip_fig.html CDC Guidance on PPE To Be Used by Healthcare Workers During Management of Patients with Ebola in U.S. Hospitals Updated 10/20/14, more stringent, calls for No physical contact with patient until PPE in place Full barrier precautions for inpatient care Training and assessment of competency No exposed skin Site manager to observe and ensure no breaches during care and when donning and doffing PPE Be aware of what is recommended and why http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html http://www.cdc.gov/vhf/ebola/hcp/ppe-training/index.html 13
WA State EMS Preparedness Created a table with EMS providers by county trained and willing to transport Ebola patients Shared CDC recommendations and training materials with EMS partners Testing for Ebola at the Washington State Public Health Laboratories Performed validation testing for CDC Ebola PCR assay; performed risk assessment Trained staff to perform testing 24/7 Distributed category A shippers to LHJs Trained labs and LHJs to package specimens 14
Mandate to Protect Patient Privacy HIPAA Act of 1996 & Washington State Health Care Information Act (Ch. 70.02) forbid accessing patient information except for Treatment of the patient Payment Health care operations Access only minimum necessary to perform job Do not share information that could identify patient Honoring Patient s Rights HIPAA Fact Sheet www.wsha.org/files/82/hipaa%20fact%20sheet.pdf 15
Public Health System Preparedness Conducting weekly conference calls with LHJs and tribes Established epidemiologic surge capacity to assist LHJs with identifying and monitoring contacts of patients with Ebola Contracted with environmental cleaning company Public Communication Preparedness Translated Ebola fact sheet into Spanish, Chinese, Korean, Russian, Somali, Ukrainian, Vietnamese, and French Responded to numerous media requests Developed a communication plan for initial case Established and tested call center for the public 16
Questions? 17