1. Emerging Infections in the United States Preparing for Ebola Maine EMS Prepared September 2014 Based on the CDC’s “Interim Guidance for Emergency Medical Services (EMS) and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States”

2. Introduction Number of emerging infectious diseases in the US at present – Enterovirus – Ebola Entering influenza season Important time to discuss these infectious diseases and consider how we as EMS providers approach patients with signs or symptoms of infection Use Ebola as an example

3. Background About Ebola Ebola is a virus that causes hemorrhagic fever First discovered along the Ebola River in the Democratic Republic of the Congo Rare disease, first described in 1976 – 24 outbreaks since Current outbreak is the largest with 6,263 cases and 2,917 deaths – Mortality = 47% – First patient diagnosed on US soil September 30, 2014

4. Facts About Ebola #1 Likelihood of contracting Ebola is LOW Unless: – Direct UNPROTECTED contact with BLOOD or BODY FLUIDS (urine, saliva, feces, vomit, sweat and semen) of a person who is sick with Ebola – OR, direct handling of bats of non-human primates from area with Ebola outbreaks

5. Facts About Ebola #2 Case Definitions Person Under Investigation (PUI) = person with both: – Clinical Criteria – fever (greater than 38.6°C/101.5°F) PLUS HA/Muscle pain/vomiting/diarrhea/abdominal pain/or unexplained hemorrhage AND – Epidemiologic risk factors within the past 21 days before the onset of symptoms Contact with blood or body fluids or human remains of a patient known to have or suspected to have Ebola Residence in or travel to an area where Ebola transmission is active Direct handling of bats or non-human primates from disease-endemic areas Probable Case = a PUI whose epidemiologic risk factors include high or low risk exposures Confirmed Case = a case with laboratory-confirmed diagnostic evidence of Ebola virus infection

7. Facts About Ebola #3 Exposure Risk Levels High Risk Exposures – Percutaneous (e.g. needle stick) or mucous membrane exposure to bloody or non-bloody body fluids of Ebola patients – Direct skin contact with, or exposure to blood or body fluids of an Ebola patient without appropriate PPE – Processing blood or body fluids of a confirmed Ebola patient without appropriate PPE or standard biosafety precautions – Direct contact with a dead body without appropriate PPE in a country where an Ebola outbreak is occurring

8. Facts About Ebola #4 Low Risk Exposures – Household contact with an Ebola patient – Other close contact with Ebola patients in health care facilities or community settings. Close contact = – Being within approximately 3 feet of an Ebola patient or within the patient’s room or care area for a prolonged period of time while NOT wearing recommended PPE – Having direct brief contact (ie shaking hands) with an Ebola patient while not wearing proper PPE – Walking by a person with Ebola does not constitute close contact

9. Facts About Ebola #5 Incubation Period = 2-21 days Signs and Symptoms = sudden fever, chills and muscle aches with diarrhea, nausea, vomiting, and abdominal pain occurring after about 5 days – May see chest pain, shortness of breath, headache or confusion – In severe cases – jaundice, severe weight loss, hemorrhage Treatment = supportive care – ? Treatment and ? Vaccine

10. How Does Ebola Occur in Maine? Two possible scenarios: 1.Patient contracts Ebola and travels to Maine 2.Patient with occult or NO evidence Ebola allowed to travel and symptoms develop in flight, forcing diversion to Maine airport

11. What About the Immigrant Populations in Maine?

13. What About Maine?

15. Current Guidance #1 Screen Patients for Disease – Both from EMD and from EMS Consider screening for risk factors in all patients presenting with signs and symptoms consistent with Ebola Symptoms = fever (greater than 38.6°C/101.5°F) PLUS HA/Muscle pain/vomiting/diarrhea/abdominal pain/or unexplained hemorrhage AND – Recall the Risk factors Also, consider other infectious processes – All-Hazards approach Influenza, MERS, ect.

16. Current Guidance #2 Report Concerns about Presence of Disease EMD to EMS EMS to Hospitals Hospitals to Public Health and CDC – Closest CDC Quarantine Station = Boston Special circumstances if disease becomes evident in flight

17. Current Guidance #3 If risk factors and concerns for Ebola, wear proper PPE and consider modification of management – PPE = standard, contact, and droplet precautions Gloves, Gown (fluid resistant or impermeable), Eye Protection (goggles or face shield that fully covers the front and sides of the face), Facemask, – “Additional PPE might be required in certain situations (e.g. large amounts of blood and body fluids in the environment) including but not limited to double gloving, disposable shoe covers, and leg coverings.”

18. Current Guidance #4 If risk factors and concerns for Ebola, wear proper PPE and consider modification of management – Consider modification of management Limit activities, especially during transport, that can increase the risk of exposure to infectious material – Airway management – Cardiopulmonary resuscitation, – Use of needles Limit the use of needles and other sharps as much as possible. All needles should be handles with extreme care and disposed of in puncture-proof containers Phlebotomy, procedures, and laboratory testing should be limited to the minimum necessary for diagnostic evaluation and medical care.

19. Conclusions Currently the likelihood of encountering an Ebola patient in Maine is LOW – Few possible scenarios in which this could occur Consider transmissible infectious diseases in patients with fever and engage in proper protective strategies Alert receiving hospitals of your concerns – Ebola, Influenza, etc.

20. For Right Now… Consider the currently active emerging infectious diseases – Ebola/Enterovirus/Influenza – Consider in patients with the proper symptom set – Ask about risk factors (contact/travel) Follow the CDC’s website for more information and for updates Practice proper personal protection – Especially as we enter influenza season – For patients with fevers and flu-like symptoms Consider face mask on the patient Provider PPE - Face masks, mucous membrane protection, gloves and hand washing Consider vaccination against influenza

21. Next Steps Service level consideration of these guidance and development of service-level policy – Level of PPE – Communication plan within the service and beyond the service Dialogue with hospitals Maine EMS development of EMD screening tool Maine EMS consideration of an approved management modification process for patients with suspected Ebola Continued surveillance of the disease state internationally and nationally Maine EMS ongoing dialogue with Public Health/Maine CDC

22. Questions?