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Ebola virus update Dr Ann Koehler BSc MBBS FRCPA(Microbiol) MPH Director, Communicable Disease Control Branch, Public Health & Clinical Systems SA Health.

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Presentation on theme: "Ebola virus update Dr Ann Koehler BSc MBBS FRCPA(Microbiol) MPH Director, Communicable Disease Control Branch, Public Health & Clinical Systems SA Health."— Presentation transcript:

1 Ebola virus update Dr Ann Koehler BSc MBBS FRCPA(Microbiol) MPH Director, Communicable Disease Control Branch, Public Health & Clinical Systems SA Health

2 Aim of information session  Increase awareness of Ebola virus disease and exposing myths that exist about the virus  Increase awareness of what general practices and other health services should be doing to prepare  Increase awareness of what infection control measures (including personal protective equipment (PPE)) is recommended in general practice  Provide advice on what to do if you have a suspected case of Ebola virus disease at your practice

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4 High infection rates in West Africa  Generally poor infection control and PPE  People most at risk are family members, carers, traditional healers, and those participating in traditional burial rituals  Funeral practices  Account for 25% of cases, up to 60% in Liberia  Community spread mostly occurs through social networks  Epidemiology supports contact transmission, not aerosol – absence of clusters of cases in which no direct contact occurred  Transmission through direct contact with contaminated blood or body fluids most often through oral or mucous membrane exposure

5 Human to human transmission*  Risk of transmission during incubation period or from asymptomatic persons is negligible (other than through blood transfusion)  Levels of virus highest in terminal phase of illness  Large outbreaks almost always result of amplification in healthcare settings in which basic infection control measures have broken down  In the original 1976 outbreak, only 5.3% of household contacts were estimated to be infected, although the secondary attack risk was higher (27%) in first degree relatives within households Blumberg L et al. Viral haemorrhagic fevers. Manson’s Tropical Diseases

6 Low infection rates outside of endemic areas  Except for recent healthcare worker infections in Spain and the USA and earlier cases among laboratory workers, there has never been Ebola virus transmission outside of Africa  In countries with good public health systems, any transmission will be rapidly contained (have even seen this in Nigeria recently)

7 Other infection routes  Contact with infected animals – apes and bats, alive or dead  Handling or consumption of infected bush meat  Breastfeeding by infected women (convalescent ??)  Sexual partner of known or suspected male case  Virus in semen up to 3 months after clinical recovery  Receiving health care from provider who is looking after EVD patients and not taking appropriate infection control measures  Contact with contaminated items e.g. medical material, linens  Virus cannot survive very long in non-organic material

8 Insights from Dallas patient  First presentation:  Presented on 25/9 with fever, headache, abdo pain  Gave travel history but this was not considered by doctor  Had CT scan, extensive travel through hospital + HCW contact  Discharged to home with antibiotics  No special PPE worn by staff  No HCW or other patients infected during this presentation

9 Insights from Dallas patient  2 nd Presentation 28/9  Diagnosis of Ebola virus infection not made until 30/9  From 2 staff infected in this second phase during 28 – 30/9  He had extensive production of bodily fluids because of vomiting and diarrhoea  One nurse had placed a rectal tube in patient  A lot of variability in use of PPE  172 contacts traced for the 2 nurses and patient including patient’s fiancee who had cared for him in cramped flat while he had profuse diarrhoea  Apart from 2 nurses described above, no infections

10 Other hospital exposures  Spanish nurse’s assistant  Cared for priest in terminal phase of illness  Entered his room on 2 occasions  to change diaper  after he had died  Thinks she contaminated herself while removing PPE; recalls touching her face with gloved hand  No other HCWs infected in this episode  South Africa 1997  Undiagnosed patient who eventually died  Over 300 HCWs exposed, none infected

11  Ebola usually begins with a flu-like syndrome with fever and profound weakness, often accompanied by arthralgia, myalgia, headache, anorexia and hiccups. These are usually followed by gastrointestinal symptoms: nausea, vomiting, and diarrhoea. Patients may also complain of dysphagia

12 Early clinical features Intense tiredness, weakness, malaise Conjunctivitis Sudden onset fever >38C axillaryNausea, anorexia Throat pain, difficulty swallowingHeadache MyalgiaAbdominal pain Diarrhoea (can be bloody)Hiccups Arthralgia Often overlap of early and late symptoms Patients often do not develop all the signs and symptoms

13 Late clinical features Confusion, irritabilityseizures Chest painDiarrhoea (watery or bloody) Vomiting (may be bloody)Rash including ecchymoses, petechiae, purpura Oozing from puncture sitesEpistaxis HaemoptysisMelaena, haematochezia Gingival bleedingUnexplained vaginal bleeding Conjunctival haemorrhageHaematuria Bleeding from eyesMiscarriage (fetal mortality ~100% in 3 rd trimester) ShockRespiratory distress of shock

14 Pathophysiology  Incubation period 2 – 21 days (most commonly < 10 days)  Abrupt onset of symptoms  Microvascular instability and imparied haemostasis are the consistent hallmarks  External haemorhage is not always seen  Much more in common with septic shock  Mortality usually results from intense inflammatory process  Insufficient effective circulating intravascular volume  Hypotension  Cellular dysfunction  Multiorgan failure

15 Recovery  Mortality rate varies: Zaire strain 50-90%  About 70% in current outbreak  Virus clears rapidly from blood upon symptom resolution  Clearance may be delayed up to 3 months in immunologically protected sites e.g. kidney, gonads, chambers of the eye

16 Risk in South Australia  Except for recent healthcare worker infections in Spain and the USA and earlier cases among research laboratory workers, there has never been Ebola virus transmission outside of Africa  In countries with good public health systems, any transmission will be rapidly contained (have even seen this in Nigeria recently)

17 Risk in South Australia Arrivals to Australia from affected countries Approximately 99 per week 14 from Democratic Republic of Congo 14 from Liberia, Sierra Leone, Guinea Remainder were from Nigeria which has controlled outbreak

18 Border measures  Exit screening from affected countries  Electronic tracking of flights for individuals depending on how ticket booked  All people entering Australia will be asked if they have been in an Ebola-affected area within the past 21 days  If so will have  Temperature screening (infra-red thermometer)  Questioning on symptoms  Questioning on exposure risks  Any concerns will be reported to Human Quarantine Officers (CDCB medical officers)  If no concerns will be asked to monitor temperature for 21 days and given information card including hotline number to use if they develop symptoms

19 Post arrival  Hotline goes to HealthDirect  Script followed; if necessary referred to SAAS for further risk assessment  If necessary SAAS will contact CDCB duty medical officer for advice  If symptoms consistent with EVD SAAS will collect patient and transfer to quarantine hospital  Royal Adelaide Hospital for adults  Women’s & Children’s Hospital for children

20 Specific groups  Healthcare workers:  Weekly list of returnees. All contacted within 24 hours and risk assessed. Bd temps, limited movement. Each agency has protocols  Humanitarian entrants:  Now home quarantine before departure for 21 days. No new visas announced 27 th. Existing visa holders 21 days exit quarantine

21 Walk-in patients  Extremely unlikely as all will have  Arrived from West Africa only within last 3 weeks  Have been given information card which will lead to them being directed to SAAS  If did present would be likely to be early as late presentations more likely to require SAAS  Infectivity in early disease low – increases as disease progresses

22 Walk-in patients  If EVD possible:  escort patient to single room  use PPE for contact and droplet precautions  Contact CDCB duty medical officer (24/7) for risk assessment and to discuss investigation/ transfer  If indicated, SAAS will take patient to quarantine hospital

23 PPE: Contact and Droplet Precautions  Long-sleeved gown (preferably disposable)  Surgical mask  Protective eyewear ( or combined visor/surgical mask)  Disposable gloves

24 Observations from a MSF field worker (ID physician from Singapore)  “I think the dangers of excess PPE are underrated  It is a pity the response to HCW infections is ‘wear more PPE’  Those working in Ebola treatment units in West Africa have been well trained and practiced  Are being sprayed with chlorine as they take it off  Are being observed by an equally experienced buddy  The full body suits are difficult to remove and are a source of unnecessary risk  In Singapore we are likely to take them out of our protocol altogether  We will revert to contact precautions plus”

25 Contact tracing  For any notifiable disease, the identification, management and monitoring of contacts external to the healthcare setting is always the responsibility of the CDCB  As Ebola virus infection is a quarantinable disease, the CDCB as the human quarantine service will also be closely involved in contact tracing and follow up for contacts within the healthcare setting

26 Laboratory testing  SA Pathology is the only laboratory in SA which can do Ebola virus testing  Testing must be discussed with the on-call microbiologist from SA Pathology prior to collection  Most febrile cases recently arrived from West Africa will be more likely to have malaria or dengue and these should always be tested for

27 Environmental cleaning  For confirmed cases, cleaning staff should wear full PPE  Routine cleaning using sodium hypochlorite 1000 ppm available chlorine  Spills/vomit/other bodily fluids –  Preferably use spill kit  Sodium hypochlorite 5000 ppm available chlorine

28 Workforce issues  HCWs who have cared for confirmed case:  May continue to work in clinical role if no high risk exposures (e.g. needle stick injury)  Monitor temperature twice daily  Present for assessment immediately if develop temperature or other symptoms

29 Updates  For current information on affected areas, regular updates are available from the WHO website  Regular updates of areas affected and other clinical information will also be posted on the SA Health website


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