1. Commissioned Corps of the U.S. Public Health Service Monrovian Medical Unit (MMU) Mission at Camp Eason (Margibi County, Liberia)

2. Obligatory Disclaimer This presentation is solely from a personal experience perspective; and does not represent the official positions or policies of the U.S. Public Health Service’s or U.S. Department of Health and Human Service.

3. Presentation Outline Share Ebola Response to Liberia – A personal perspective Update on Global Movement to Preparedness – Lessons are being learned – Things are changing

4. U.S. Public Health Service Who Are We? A Uniformed Service comprised of 6,800 Officers under the direction of the U.S. Surgeon General, Dr. Vivek Murthy Comprised of: – Physicians, Dentists, Nurses, Therapists, Pharmacists, Health Services, Environmental Health, Dietitians, Engineers, Veterinarians and Scientists.

5. U.S. Public Health Service The mission of the U.S. Public Health Service Commissioned Corps is to protect, promote, and advance the health and safety of our Nation. As America's uniformed service of public health professionals, the Commissioned Corps achieves its mission through: – Rapid and effective response to public health needs – Leadership and excellence in public health practices – Advancement of public health science

6. Ebola – The Background The 2014 Ebola outbreak is the largest in history and the first Ebola outbreak in West Africa. This unprecedented outbreak has affected multiple countries in and around West Africa, with the countries of Sierra Leone, Liberia and Guinea having been the hardest hit. Recognizing that the only way to eradicate the threat of Ebola in America and the world is to defeat it at its source, the U.S. has significantly ramped up efforts to fight the virus in West Africa.

7. United States Response U.S. Strategy POTUS: “ Ebola epidemic in W. Africa and the humanitarian crisis there is a top national security priority for the United States” Strategy is predicated on four key goals: Strategy is predicated on four key goals: 1.Controlling the epidemic at its source in West Africa; 2.Mitigating second-order impacts, including blunting the economic, social, and political tolls in the region; 3.Engaging and coordinating with a broader global audience; and 4.Fortifying global health security infrastructure in the region and beyond.

8. Prior to Departure 65 Officers completed an intense 7-day training conducted by the Center for Disease Control and Prevention at FEMA’s Center for Domestic Preparedness in Anniston, Alabama. A Total of 4 Teams deployed between Oct 2014 and May 2015. The MMU is now operated by the Liberian Government.

9. Monrovia Medical Unit Our mission was to provide hope through care to health care workers in Liberia who may have the Ebola virus disease and continue efforts with the Liberian and international partners to build capacity for additional care.

10. Monrovia Medical Unit (MMU) The MMU is a 25-bed Ebola Treatment Unit specifically designed to treat infected health care workers such as doctors and nurses who are at higher risk of infection, because they are in close, sustained contact with Ebola patients who are symptomatic and infectious.

13. Reference to the MMU Video Tour is available at: https://www.youtube.com/watch?v=bmyUb3 N5gAk https://www.youtube.com/watch?v=bmyUb3 N5gAk

14. Early Clinical Presentation  Acute onset; typically 8–10 days after exposure (range 2–21 days)  Signs and symptoms  Initial: Fever, chills, myalgias, malaise, anorexia  After 5 days: GI symptoms, such as nausea, vomiting, watery diarrhea, abdominal pain  Other: Headache, conjunctivitis, hiccups, rash, chest pain, shortness of breath, confusion, seizures  Hemorrhagic symptoms in 18% of cases  Other possible infectious causes of symptoms  Malaria, typhoid fever, meningococcemia, Lassa fever and other bacterial infections (e.g., pneumonia) – all very common in Africa 14

15. Clinical Features  Nonspecific early symptoms progress to:  Hypovolemic shock and multi-organ failure  Hemorrhagic disease  Death  Non-fatal cases typically improve 6–11 days after symptoms onset  Fatal disease associated with more severe early symptoms  Fatality rates of 70% have been reported in rural Africa  Intensive care, especially early intravenous and electrolyte management, may increase the survival rate 15

16. Clinical Manifestations by Organ System in West African Ebola Outbreak Organ SystemClinical Manifestation GeneralFever (87%), fatigue (76%), arthralgia (39%), myalgia (39%) NeurologicalHeadache (53%), confusion (13%), eye pain (8%), coma (6%) CardiovascularChest pain (37%), PulmonaryCough (30%), dyspnea (23%), sore throat (22%), hiccups (11%) GastrointestinalVomiting (68%), diarrhea (66%), anorexia (65%), abdominal pain (44%), dysphagia (33%), jaundice (10%) HematologicalAny unexplained bleeding (18%), melena/hematochezia (6%), hematemesis (4%), vaginal bleeding (3%), gingival bleeding (2%), hemoptysis (2%), epistaxis (2%), bleeding at injection site (2%), hematuria (1%), petechiae/ecchymoses (1%) IntegumentaryConjunctivitis (21%), rash (6%) WHO Ebola Response team. NEJM. 2014 16

17. Examples of Hemorrhagic Signs Bleeding at IV Site Hematemesis Gingival bleeding 17

18. Laboratory Findings  Thrombocytopenia (50,000–100,000/  L range)  Leukopenia followed by neutrophilia  Transaminase elevation: elevation serum aspartate amino- transferase (AST) > alanine transferase (ALT)  Electrolyte abnormalities from fluid shifts  Coagulation: PT and PTT prolonged  Renal: proteinuria, increased creatinine 18

19. EVD Summary  The 2014 Ebola outbreak in West Africa is the largest in history and has affected multiple countries  Think Ebola: U.S. healthcare providers should be aware of clinical presentation and risk factors for EVD  Human-to-human transmission by direct contact  No human-to-human transmission via inhalation (aerosols)  No transmission before symptom onset  Early case identification, isolation, treatment and effective infection control are essential to prevent Ebola transmission 19

20. MMU Team 1: Challenges Never been done before – a U.S. Government asset transforming an Army “MASH” tent unit into an ebola treatment center. Difficult diagnosis without lab test results. Lack of a ready supply stream and equipment. Learning who the response partners were in country and how to work with them. Adjusting medical care standards based on environment and resources.

21. Innovation Required !!

22. MMU Team 1: Schedule Worked 2 months straight except for 2 days Hour 1 – awake and get ready for commute Hour 2 – Commute to MMU Hour 4-16 for 12-hour shift Hour 18 – Commute to “Lodging” Hour 19 – Fall asleep for a 5 hour nap Start all over again!

23. 18 Guys in a tent

24. What did CAPT Bates do? Logistics Team Whatever the task of the moment demanded. – Supply and Inventory control – Infection control – Safety – Medical – Lab – Housekeeping – Pharmacy – Facilities and Supply – Dietary – Bug Control

25. Ebola Buster

26. Infection Control

27. 1000 pounds of 65% HTH used

28. Biohazard Waste Process

29. How We Protected Ourselves Donning and Doffing Video Reference: https://www.youtube.com/watch?v=mfT9ipzt g5Y https://www.youtube.com/watch?v=mfT9ipzt g5Y

30. PPE Personal Protection Equipment

31. PPE

32. MMU Team 1: Outcomes The USPHS sent 65 clinicians, administrators, and support staff to assist in the response effort. Health care providers in Liberia now had a place to go if they contracted the ebola virus. The efforts of USAID, DoD, USPHS, Government of Liberia, International Partners, and NGOs built capacity for additional care in Liberia Over 100 providers from Africa were reported to have joined the effort in Liberia during our tour.

33. A Successful Mission and Safe Return

34. The Global Movement to Preparedness Lessons Learned Countries with weak health systems and few basic public health infrastructures cannot withstand sudden shocks to their society Preparedness – swift action makes the difference No single control intervention is sufficient Community engagement is the linchpin for successful control

35. More Lessons Learned Operations: – Put the needs of patients and communities at the core of any response. Evaluate and practice surge capacity Governance and Accountability – A fast response will not happen without leadership. Set priorities based on what is needed on the ground. Research and Development – Strengthen research and development systems focused on outcomes for the global public good.

36. Department of Health and Human Services July 1, 2015 – DHHS launched a National Ebola Training and Education Center and funded 3 hospitals to train, prepare U.S. health care facilities for Ebola and other emerging threats. Regional Ebola treatments centers have been established. Evaluation of the national response planning, surge capacity, and supply stockpiles is ongoing.

37. Most Importantly Reactions and Responses must not be fear based !!

38. We Can’t Rely on Batman

39. Future Challenges Focus science based public health over politics Global collaboration and commitments to strengthening public health infrastructures Commitment to collaborative and coordinated surge capacity Understanding the multi-factorial influencers of global public health challenges (political, economic, cultural, social determinants of health, funding, transportation, food/water, etc.) Reconciling health care responses with cultural and societal influencers Moving beyond disease specific preparedness to a global infectious and communicable disease preparedness and response capacity

40. A Patient Perspective

41. Recovery from Ebola Returning to the healthcare workforce

42. Other Information Link to news Article in Gazette Record, Saint Maries ID; regarding deployment to Liberia: http://www.stmariesid.com/fighting-ebola/ Web link to the President’s recent update on the Ebola outbreak activities. http://www.c-span.org/video/?324305- 1/president-obama-remarks-combating-ebola http://www.c-span.org/video/?324305- 1/president-obama-remarks-combating-ebola

44. Contact Information CAPT Dale M. Bates U.S. Public Health Service Phone: 206-615-2497 (office in Seattle) Email: dbates@hrsa.govdbates@hrsa.gov Address: 23920 N Teddy Loop Rathdrum ID 83858