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Ebola Virus Disease Implications for NMCP Staff and Patients CDR Karl C Kronmann, MD MPH Infectious Disease Staff, NMCP ACP, 17 Oct 2014.

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Presentation on theme: "Ebola Virus Disease Implications for NMCP Staff and Patients CDR Karl C Kronmann, MD MPH Infectious Disease Staff, NMCP ACP, 17 Oct 2014."— Presentation transcript:

1 Ebola Virus Disease Implications for NMCP Staff and Patients CDR Karl C Kronmann, MD MPH Infectious Disease Staff, NMCP ACP, 17 Oct 2014

2 Objectives State of the Ebola Outbreak in West Africa Ebola Virus Disease – Signs and symptoms, – Diagnosis and management (Respond) Infection Control – Transmission of EVD – Early Identification (Detect) – Precautions (Protect)

3 How Bad Is It? By January 20, 2015 if no additional interventions or behavior changes occur, Liberia and Sierra Leone will have approximately 550,000 Ebola Cases (1.4 million when corrected for underreporting) - CDC published in MMWR Sep 23, 2014 “For the medium term, at least, we must therefore face the possibility that EVD will become endemic among the human population of West Africa, a prospect that has never previously been contemplated.” - WHO published NEJM Sep 23, 2014

4 Ebola – What is different this time? Nurse visits graves from the 1976 Ebola outbreak in Zaire (DRC)

5 18 August 2014 MONROVIA, Liberia (AP) — Authorities in Liberia urgently searched on Monday for 17 people who fled an Ebola medical center over the weekend when it was attacked by looters who stole blood-stained sheets and mattresses and took them into an enormous slum. Ebola 2014

6 18 August 2014 MONROVIA, Liberia (AP) — Authorities in Liberia urgently searched on Monday for 17 people who fled an Ebola medical center over the weekend when it was attacked by looters who stole blood-stained sheets and mattresses and took them into an enormous slum. Ebola 2014

7 18 August 2014 MONROVIA, Liberia (AP) — Authorities in Liberia urgently searched on Monday for 17 people who fled an Ebola medical center over the weekend when it was attacked by looters who stole blood-stained sheets and mattresses and took them into an enormous slum. Ebola 2014 25 new cases 38 new cases 56 new cases 12 days Total 119 cases predicted as of today ???

8 18 August 2014 MONROVIA, Liberia (AP) — Authorities in Liberia urgently searched on Monday for 17 people who fled an Ebola medical center over the weekend when it was attacked by looters who stole blood-stained sheets and mattresses and took them into an enormous slum. Ebola 2014

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10 Numbers 2014 Briand S, et al. The international Ebola emergency. Aug 20, NEJM 2014 As of August 11 Ebola – 38 years of EVD Outbreaks Total cases prior to 2014: 2,390 (CFR=66.6%) Total cases in West Africa in 2014: 5,927 (CFR=47%) (as of 22 Sep)

11 Recent Increase in Cases Department of Defense (AFHSC): West Africa Ebola Surveillance Summary #31: Sep 18, 2014

12 Geographic differences Department of Defense (AFHSC): West Africa Ebola Surveillance Summary #29: Sep 15, 2014

13 Geographic differences Source: CDC

14 Map of Guinea Showing Initial Locations of the Outbreak of Ebola Virus Disease. Baize S et al. Emergence of Zaire Ebola Virus Disease in Guinea – Preliminary Report N Engl J Med 2014.

15 Country Profiles Country Per Capita GDP Life Expectancy at birth Multidim ensional poverty Official LanguageReligion $rankyearsrank USA52,8001479.5642n.a.EnglishChristian – 77% None – 12% Muslim – 1% Sierra Leone 1,40020857.3920172.68%English (limited) Muslim – 60% Christian – 10% Indigenous – 30% Haiti1,30020963.1818650.16%French, Creole Christian – 96% Guinea1,10021859.6019586.49%FrenchMuslim – 85% Christian – 8% Indigenous – 7% Liberia70022358.2119981.86%English (20%)Christian – 85% Muslim – 12% CIA World Fact Book and United Nations Development Programme

16 Transmission Chains in the Outbreak of Ebola Virus Disease in Guinea. Baize S et al. Emergence of Zaire Ebola Virus Disease in Guinea – Preliminary Report N Engl J Med April 16, 2014.

17 Transmission Chains in the Outbreak of Ebola Virus Disease in Guinea. March 10 – MOH notified of cluster of mysterious deaths March 12 – MSF contacted Baize S et al. Emergence of Zaire Ebola Virus Disease in Guinea – Preliminary Report N Engl J Med April 16, 2014. Days between “first” symptomatic case and MOH notification = 98 Days between death of grandmother and MOH notification = 68

18 Outbreak dynamics DiseaseR0R0 Generation time/ serial time Transmission RouteCFR Measles12-1811-12 daysAirborne2% Influenza1.4-4.03-4 daysDroplet (Airborne)0.1% Ebola 20141.4-2.029-15 daysContact, Droplet~70% Polio2-2010 daysFecal-Oral5-10% Smallpox5-714-16 daysAirborne30% SARS2-54-12 daysAirborne11%

19 Epidemic Curve WHO: Ebola Response Roadmap Situation Report: 18 September 2014 http://apps.who.int/iris/bitstream/10665/133833/1/roadmapsitrep4_eng.pdf?ua=1 24 June: MSF says outbreak is “out of control” and requests help 8 Aug: WHO declares PHEIC 10 March: Outbreak recognized

20 International Health Regulations 08 August 2014 – WHO declares Ebola outbreak to be a Public Health Emergency of International Concern (PHEIC) 2003 SARS Outbreak Major Revision of 1969 IHR -> IHR (2005) Date of PHEICDisease Outbreak 25 April 2009Influenza H1N1 (Mexico, USA) 5 May 2014Polio (Pakistan, Cameroon, Syria, et al) 8 Aug 2014Ebola Virus Disease in West Africa

21 Public Health Emergency of International Concern? Gire SK, et al. Genomic surveillance elucidates Ebola virus origin and transmission during the 2014 outbreak. Science 2014

22 Video http://nyti.ms/1qnLOQB

23 Viral Hemorrhagic Fevers Virus FamilyVirusGeographic locationReservoirNosocomial risk? ArenaviridaeLassa virusWest AfricaMouse (Mastomys natalensis.) YES BunyaviridaeCCHFAfrica, Middle East to West China Livestock, crows, hares, Hyalomma ticks YES RVFAfricaLivestock, mosquitoes No HFRSNorthern Asia and Europe Mice and ratsNo HantavirusAmericasMiceNo FlaviviridaeYFAfrica, Amazon basinPrimates, including humans, mosquitoes No Dengue HF/ DSS Southeast Asia, Carribean, South and Central America Aedes mosquitoesNo FiloviridaeMarburgSub-Saharan AfricaYES EbolaSub-Saharan Africa?BatsYES Bray and Johnson. “Viral Hemorrhagic Fevers” in Richman Clinical Virology

24 CDC Checklist for Health Care Facility Preparedness □ Review facility infection control policies □ Review environmental cleaning procedures and provide education/refresher training for cleaning staff □ Begin education and refresher training for HCP on – EVD signs and symptoms, – diagnosis, – how to obtain specimens for testing, – appropriate PPE use (including putting on and taking off PPE), – triage procedures (including patient placement), – HCP sick leave policies, – how and to whom EVD cases should be reported, – procedures to take following unprotected exposures □ Review triage procedures and ensure relevant questions (e.g., exposure to case, travel within 21 days from affected country) are asked during the triage process for patients arriving with compatible illnesses

25 Pathogenesis Feldman H, Geisbert TW. Ebola Hemorrhagic Fever. Lancet 2011

26 Signs and Symptoms Bleeding/Hemorrhage YearLocationBleeding/Hemorrhage 2014Guinea27% (4/15) 1995DRC41% (42/103) 1976Zaire (DRC)78% (174/223) Fatal cases 18% (6/34) Survivors 1976Sudan71% (130/183) Most common manifestation MELENA Ebola Virus Disease vs. Ebola Hemorrhagic fever

27 Signs and Symptoms Diarrhea YearLocationDiarrhea 2014Guinea, Liberia, Sierra Leone 78% (11/15) 66% (721/1099) 1995DRC85% (87/103) 1976Zaire (DRC)79% (180/228) Fatal cases 44% (15/34) Survivors 1976Sudan81% (130/183)

28 Signs and Symptoms Sudden Onset Fever (> 101.5 F)Severe headache

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30 Symptom Timing WHO Ebola in Sudan 1976. Bull WHO 1978

31 Incubation 2-21 days Burial or cremation Semen and ? breast milk

32 CDC Definition: Person Under Investigation (PUI) Clinical Criteria: (at least one) – Temp > 101.5 F – Severe headache – Diarrhea – Muscle pain, vomiting, abdominal pain, or unexplained bleeding AND Epidemiologic risk within past 21 days: (any one) – Contact with blood, other body fluid or human remains of a suspected EVD case – Travel to (or residence in) an area where EVD transmission is active – Direct handling of bats or non-human primates from disease endemic areas.

33 Initial Management INFECTION CONTROL! (Discussed separately) Consider empiric therapy – antimalarials and – broad spectrum antibiotics Supportive – Tylenol (avoid antiplatelet drugs) – HYDRATION (Oral Rehydration Solution or IV) – Antiemetics Management of sepsis and shock if needed Estimated 2014 deaths to date Liberia, Guinea, Sierra Leone EVD2,759 Malaria23,105

34 Diagnosis 1.INFECTION CONTROL! 2.Contact ID/VDH/CDC 3.4 ml in plastic EDTA tube 4.RT-PCR or Serology done at CDC 5.Rule out malaria. 6.Consider other diagnoses

35 Differential Diagnosis Malaria Typhoid Lassa fever Shigellosis (Dysentery) Meningococcal septicemia Bacterial sepsis Plague, leptospirosis, anthrax, relapsing fever, typhus, murine typhus, yellow fever, Chikungunya fever, and fulminant viral hepatitis, ?enterovirus, HIV-1. 1.Gire SK, et al. Genomic surveillance elucidates Ebola virus origin and transmission during the 2014 outbreak. Science 2014 2.Feldman H, Geisbert TW. Ebola Hemorrhagic Fever. Lancet 2011

36 Experimental Treatments “Secret Serums” Antibodies – Transfusion from convalescent patients – Three monoclonal antibody combo (ZMAPP) Antisense oligonucleotides – Small interfering RNAs (Tekmira TKM-Ebola) Inflammatory modulators – Type 1 interferons, ?statins Coagulation inhibitors – Heparin sulfate, APC Vaccines (Two are starting phase 1 trials soon) – Post exposure – Pre-exposure Feldman H, Geisbert TW. Ebola Hemorrhagic Fever. Lancet 2011

37 Expert Opinion “...the chance that the [Ebola] virus will establish a foothold in the United States or another high-resource country remains extremely small.” - Dr Anthony Fauci, NEJM Sept 18 “We do not view Ebola as a significant public health threat to the United States.” - Dr Beth Bell, CDC testimony to Congress, Sept 17 “And we have no doubt that we will stop [Ebola] in its tracks in Texas.” - Dr Tom Frieden, CDC Director Oct 5

38 Nursing barrier precautions Khan AS, et al. The Reemergence of Ebola Hemorrhagic Fever, DRC 1995 JID 1999

39 TRANSMISSION: Kikwit Risk Factors 1.Direct physical contact OR = undefined, p<0.01 2.Contact with Body fluids OR = 3.8, 95%CI (1.9-6.8) Dowell SF, et al. Transmission of Ebola Hemorrhagic Fever, DRC. JID 1999 No contact = no disease

40 Transmission of VHF in European healthcare settings Ftika and Maltezou. Viral Hemorrhagic Fevers in Healthcare Settings. J Hosp Inf 2013

41 Unsuspected Ebola in a Modern Hospital in South Africa PatientNumber of hospital days Procedures performed OutcomeInfection Control Number of secondary cases 40 year old male physician returning from Gabon 14EGD Colonoscopy Central line Thigh muscle bx SurvivedStandard1 46 year old female anesthetist assistant caring for source patient 13 (4 as sick staff, 9 as patient) LP Bone marrow bx Dialysis Laparotomy TransferredStandard0 9Swan-Ganz Intubation Laparotomy DiedHigh level barrier plus airborne 0 300 contacts followed with no secondary cases Richards GA, et al. Unexepected Ebola virus in a tertiary setting: Clinical and epidemiologic aspects. Crit Care Med 2000

42 Why the Confidence? LOCATIONPUBLIC HEALTH INFRASTRUCTUREHOSPITAL INFECTION CONTROL GUINEA, SIERRA LEONE, LIBERIA Public distrust Minimal presence of permanent staff outside capital cities Access to rural locations difficult Unreliable electricity Running water not always available PPE (e.g. gloves) rarely available Minimal or no routine Infection Control and cleaning Limited diagnostic and treatment capacity -> Lack of confidence in hospitals Barrier nursing techniques not used USA EUROPE High public trust Staff available for contact tracing and monitoring Public acceptance of quarantine, etc. No access issues Routine IC procedures Basic PPE plentiful Routine cleaning procedures Familiarity with barrier nursing techniques

43 Why the Confidence? LOCATIONPUBLIC HEALTH INFRASTRUCTUREHOSPITAL INFECTION CONTROL GUINEA, SIERRA LEONE, LIBERIA Public distrust Minimal presence of permanent staff outside capital cities Access to rural locations difficult Unreliable electricity Running water not always available PPE (e.g. gloves) rarely available Minimal or no routine Infection Control and cleaning Limited diagnostic and treatment capacity -> Lack of confidence in hospitals Barrier nursing techniques not used USA EUROPE High public trust Staff available for contact tracing and monitoring Public acceptance of quarantine, etc. No access issues Routine IC procedures Basic PPE plentiful Routine cleaning procedures Familiarity with barrier nursing techniques Contact identification and monitoring limited Quarantine disrupted and disobeyed No problem with contact identification and monitoring Quarantine accepted Insufficient hospital bed capacity Unfamiliarity with barrier nursing techniques Plenty of hospital bed capacity Familiarity with routine Infection Control

44 Preventing or ending an Ebola outbreak Early Identification of cases – Isolate symptomatic patients – barrier nursing – Trace and monitor contacts – isolate if symptoms – Decontaminate environment and prevent contact with cadavers (funeral preparation) Good hospital infection control and hygiene

45 MSF Staff Members Lead a Young Patient with Suspected Ebola into the Case-Management Center. Wolz A. N Engl J Med 2014. DOI: 10.1056/NEJMp1410179

46 Early Identification of PUI at NMCP Signs at patient entry points 1.Send patient to ER 2.ER eyeball triage 3.Send to Special Precautions Unit 4.ID confirmation of PUI 5.Further management in SPU (3 days to to rule out

47 CDC Case Definition Probable Case – PUI with risk exposure 1.High Risk a)Needlestick or mucous membrane exposure from EVD case b)Exposure without PPE I.Direct skin exposure to blood or body fluid of EVD case II.Processing blood or body fluid of EVD case III.Contact with dead body in area where EVD is occurring 2.Low Risk a)Household contact of EVD case b)Exposure without PPE i.Close contact (< 3 feet) for a prolonged period with EVD case ii.Brief direct contact with EVD case Interim Guidance for Monitoring and Movement of Persons with Ebola Virus Disease

48 Infection Control Plan at NMCP 1.Early identification and isolation 2.Standard plus ENHANCED Contact plus Airborne precautions 3.Limit staff 4.Limit visitors 5.Limit labs and procedures 6.Appropriate environmental cleaning

49 Enhanced Contact Precautions Enhanced PPE – Fluid impervious gowns or coveralls – Extras for sicker patients (boots, aprons, hoods, etc.) Individualized training – Donning and doffing PPE Viricidal agent available Monitor stationed outside room

50 Limited Staff Attending Physicians only (Critical Care and ID) Limited nursing – one RN per shift Monitor – Corpsman – Limit access – Assist with PPE. Verify before entry – Log all visitors

51 Will DoD Efforts Help West Africa? “If by late December 2014, approximately 70% of patients were placed either in Ebola Treatment Units (ETU) or home or in a community setting such that there is a reduced risk for disease transmission (including safe burial when needed), then the epidemic would almost be ended by January 20, 2015.” - CDC published in MMWR Sep 23, 2014

52 Questions

53 Passive Immunization with convalescent human blood or serum YearLocation Number of patients Number transfusions per patientResult 1976DRC13Died 1976UK12Survived 1995DRC817 survived 1 died DRC5?4 died 1 survived 2014Liberia, USA2??2 survived Mupapa, et al. Treatment of Ebola Hemorrhagic Fever with Blood Transfusions from Convalescent Patients. JID 1999

54 Early Recognition in Africa In African settings, what is the best way to recognize the presence of Ebola? Febrile disease with prominent bleeding Clusters of severe, febrile disease in families Spread of a severe febrile disease to HCWs Failure to respond to treatment [for malaria] Characteristic signs and symptoms Characteristic laboratory findings History of exposure to “bush meat” High index of suspicion

55 Early Recognition in Africa In African settings, what is the best way to recognize the presence of Ebola? Febrile disease with prominent bleeding Clusters of severe, febrile disease in families Spread of a severe febrile disease to HCWs Failure to respond to treatment [for malaria] Characteristic signs and symptoms Characteristic laboratory findings History of exposure to “bush meat” High index of suspicion Develop Health Infrastructure

56 Epidemiologic Curve Department of Defense (AFHSC): West Africa Ebola Surveillance Summary #31: Sep 18, 2014

57 Ebola – 38 years of EVD Outbreaks Total cases prior to 2014: 2,390 (CFR=66.6%) Total cases in West Africa in 2014: 2,722 (CFR=53%) (as of 25 Aug) YearCountryEbolavirus speciesCasesDeathsCase fatality 2012 Democratic Republic of Congo Bundibugyo572951% 2012UgandaSudan7457% 2012UgandaSudan241771% 2011UgandaSudan11100% 2008 Democratic Republic of Congo Zaire321444% 2007UgandaBundibugyo1493725% 2007 Democratic Republic of Congo Zaire26418771% 2005CongoZaire121083% 2004Sudan 17741% 2003 (Nov-Dec)CongoZaire352983% 2003 (Jan-Apr)CongoZaire14312890% 2001-2002CongoZaire594475% 2001-2002GabonZaire655382% 2000UgandaSudan42522453% 1996South Africa (ex-Gabon)Zaire11100% 1996 (Jul-Dec)GabonZaire604575% 1996 (Jan-Apr)GabonZaire312168% 1995 Democratic Republic of Congo Zaire31525481% 1994Cote d'IvoireTaï Forest100% 1994GabonZaire523160% 1979Sudan 342265% 1977 Democratic Republic of Congo Zaire11100% 1976Sudan 28415153% 1976 Democratic Republic of Congo Zaire31828088%

58 Infection Control - Transmission DateLocationExposureAttack Rate 1976ZaireFamily, living in contiguous structure, shared eating facility 5.6% 1976SudanFamily, sleeping in room without touching patient 0% Sleeping in room and touching patient23% Sleeping in room and nursing patient81% 1995DRCHousehold members who did not share nursing duties (but may have slept in room) 0% Transmission occurred through direct contact, unsterilized syringes (Zaire), and sexual


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