Training structure EFFO Safety and good quality work Module 1: Ebola Virus Disease Module 2: Epidemic control on different levels Module 3: Standard precautions & disinfection Module 4: Screening & isolation Module 5: Personal protective equipment Module 6: Waste management & cleaning Support from the community Support from the hospital administration Support from the population 01.08.2017

Screening & Isolation Module 4 01.08.2017

Learning objectives module 4 General objectives To understand screening and isolation as important elements of infection control To apply practical approach to set up a temporary isolation unit Specific objectives To understand basics of screening To be able to detect a suspected case of viral hemorrhagic fever (VHF) (e.g. case definition of Ebola virus disease) To know how to apply national information on VHF / Ebola virus disease To be able to isolate patients without running a risk To be familiar with the structure of an isolation room Additional information This module mainly refers to viral hemorrhagic fevers; Ebola virus disease is marked in blue as an example. 01.08.2017 3

Ways of transmission and protective measures for VHF How to be protected against… … contact- / smear infection ? … droplet infection? … airborne infection ? … vector-borne infection ? Group discussion - Active development of protective measures with the group, e.g.: Contact- / smear infection: hand hygiene + gloves Droplet infection: hand hygiene + gloves + distance + respiratory protection if necessary Airborne infection: hand hygiene + gloves + distance + respiratory protection (e.g.: FFP-3-mask) Vector-borne disease: mosquito net (if vector (e.g. mosquito) occurs in the respective country Additional information The MSF‘ PPE concept comprises a FFP-3-mask. In the case of Ebola virus disease, this level of respiratory protection is not mandatory because the virus is not transmitted by air. Attention: Some interventions may provoke aerosols with the Ebola virus (e.g. intubation); also when vomiting, the occurrence of infectious aerosols can not be excluded. An adequate protection must be ensured! Different transmission paths require different measures to isolate the patients and to protect the personnel! 01.08.2017 4

Always also think of VHF ! Temporary Isolation unit Emergency room Hospital Is one of these patients infectious? Temporary Isolation unit Attention: If patients show up in the ambulance: also think of and identify suspected cases of VHF! Isolation: Suspected cases of VHF are being treated separated from other patients. Additional information Patients with suspected infectious disease: consider history of travel! (Example: a patient with symptoms of Ebola virus disease in the US have been sent home despite having documented the travel history – stay in Liberia during the Ebola epidemic (Ebola US-Patient Zero: lessons on misdiagnosis and effective use of electronic health records; Upadhyay et al., 2014) Discussion: At first, medical personnel is not adequately protected if an index case of VHF is identified in the hospital. This is why applying basic hygiene measures are crucial and must being followed in every situation. Isolation: Medical personnel enters the isolation unit only in PPE Attention to the main differential diagnostic: malaria (not directly infectious!) 01.08.2017 5

Different case definitions The case definition may differ from country to country and is defined by the respective health authorities. → Always know and apply the national guidelines! The case definition during an epidemic is different than in the pre-epidemic phase. pre-epidemic phase epidemic Additional information If a country has one confirmed case of VHF, this might be sufficient to call this an “epidemic”. For example, this would have been the case in Burkina Faso during the Ebola epidemic of 2013-16. 01.08.2017 6

Case definitions from WHO-AFRO Target group adapted case definition Ebola virus disease (Marburg fever) Routine surveillance: standard case definition for notification  suspected case  confirmed case 2. Community-based surveillance: standard case definition  alert case During an Ebola or Marburg outbreak: 3a. Case definition to be used by mobile teams or health stations / centres  suspected case 3b. Case definition for exclusive use by hospitals and surveillance teams  probable case  laboratory confirmed case  non-case 4. Standard definition for contacts persons of Ebola or Marburg cases  Case contacts  Contacts of dead or sick animals  Laboratory contacts Additional information During an outbreak, the case definitions are likely to be modified to be adapted to new clinical presentations or different modes of transmission related to the local event. Also the contact definitions are likely to be modified to be adapted to newly reported infection risk factors related to the local event. Literature The WHO recommends the following case definitions for Ebola or Marburg (as of april 2014): http://www.who.int/csr/resources/publications/ebola/ebola-case-definition-contact-en.pdf?ua=1&ua=1 The case definitions are taken from „Technical Gudelines for Integrated Disease Surveillance and Response (IDS) in the African Region“: http://www.afro.who.int/sites/default/files/2017-06/IDSR-Technical-Guidelines_Final_2010_0.pdf 01.08.2017 7

Case definition Ebola in the pre-epidemic phase Routine surveillance (pre-epidemic phase) according to WHO-AFRO Suspected case Ebola virus disease = person with Illness with onset of fever, and no response to treatment for usual causes of fever in the area at least one of the following signs:  bloody diarrhea  bleeding from gums  bleeding into skin (purpura)  bleeding into eyes and urine and Literature The WHO recommends the following case definitions for Ebola or Marburg (as of april 2014): http://www.who.int/csr/resources/publications/ebola/ebola-case-definition-contact-en.pdf?ua=1&ua=1 The case definitions are taken from „Technical Gudelines for Integrated Disease Surveillance and Response (IDS) in the African Region“: http://www.afro.who.int/sites/default/files/2017-06/IDSR-Technical-Guidelines_Final_2010_0.pdf Confirmed case = a suspected case with laboratory confirmation 01.08.2017 8

Case definition of Ebola virus disease during an epidemic 3a) During an outbreak of Ebola virus disease (Marburg fever) according to WHO-AFRO Suspected case Ebola virus disease (and Marburg fever): Any person, alive or dead, suffering or having suffered from a sudden onset of high fever and having had contact with:  a suspected, probable or confirmed Ebola case (or Marburg)  a dead or sick animal (for Ebola)  a mine (for Marburg) OR: Any person with sudden onset of high fever and at least three of the following symptoms:  headaches  anorexia / loss of appetite  lethargy  aching muscles or joints  breathing difficulties  vomiting  diarrhea  stomach pain  difficulty swallowing  hiccup OR: Any person with inexplicable bleeding OR: Any sudden, inexplicable death Group discussion Which important question must be considered when taking the patient‘s history in order to detect a suspected case? E.g.: Is the patient having fever? Did he / she have contact to a case of Ebola ? (Did he / she travel to an epidemic country, did he / she have visitors from such a country? Did he / she have contact to a dead or sick animal? # Does the patient have more symptoms (diarrhea, headache, vomiting,…etc) Does the patient present bleedings ? …? Literature The WHO recommends the following case definitions for Ebola or Marburg (as of april 2014): http://www.who.int/csr/resources/publications/ebola/ebola-case-definition-contact-en.pdf?ua=1&ua=1 The case definitions are taken from „Technical Gudelines for Integrated Disease Surveillance and Response (IDS) in the African Region“: http://www.afro.who.int/sites/default/files/2017-06/IDSR-Technical-Guidelines_Final_2010_0.pdf 01.08.2017 9

Overview: case definition for Ebola fever + bleeding fever + contact fever + unspecific symptoms unexplained bleeding or death → During an epidemic: Screening in the emergency room 01.08.2017

Screening during the Ebola epidemic (I) During the Ebola epidemic in West Africa as an example: → Set-up of a screening area in the entrance of the emergency room > 2 m distance to the patient (if PPE is not worn) PPE of personnel: at least mask, gloves, gowns Taking temperature routinely Interviewing the patients by questionnaire with case definition (symptoms, history, contacts, travels,…) Emergency room Screening Distance Additional information A designated are to screen the patient at the entrance: this area might be outside of the hospital Always stick to a distance of > 2 m, if no PPE is worn! (e.g. with a table) PPE of personnel  at least mask, gloves, gown / full PPE if direct patient contact Material for Screening: Thermometer (systematically taking the temperature!) If necessary: surgical mask for patient Explain all procedures to the patient + family In general: Distance is always important! → If the case definition is met: alerting and preparing the isolation unit 01.08.2017 11

Screening during the Ebola epidemic (II) The temperature of every person who enters the hospital in Liberia is measured. Taking the temperature at the international airport in Conakry, Guinea. Additional information During the Ebola epidemic in West Africa different concepts of PPE were used (also the personnel who did the screening) At different locations it has been screened differently ( airport, hospital, Ebola treatment centre) Photo credits http://www.who.int/features/2014/airport-screening-600.jpg Guinea: screening for Ebola at Conakry International Airport http://www.who.int/features/2015/ebola-ipc-at-redemption/en/ Source: WHO 01.08.2017

If there is a suspected case... I have fever and diarrhea! I am feeling very ill… Two weeks ago I visited my aunt in „Ebolia“ . Group discussion „Ebolia“ signifies a country where there is a current Ebola epidemic. Discuss the approach in managing suspected cases with participants (key messages on the next slides) ...what should you do? 01.08.2017 13

What to do in the event of suspected EVD (I) Do not panic, remain professional and take the following actions: Protect yourself: keep distance! Immediately inform your direct superior on the suspected case → Communicate with the local authorities (fill out and forward the case notification form) For examining or further treatment of the patient: Apply standard precautions and wear PPE Explain that there is a suspicion of Ebola and that for further treatment the patient has to be isolated. Also explain that eventually a different team will come and take blood samples. Isolate the patient Additional information - The communication between the patient and his family /accompanying person should be possible. 01.08.2017 14

Principles of isolation YELLOW AREA - low risk- GREEN AREA RED AREA - high risk - Patients Morgues Nursing / Medical team Cleaning team Wastes Incinerator Isolation area Inner barrier Exterior barrier Additional information It is crucial to understand the underlying logic of an isolation unit. This logic can always be applied. The red area can be regarded as the „place“ in the emergency room where a patient vomits, who presents for the first time. The vomit should be cleaned as soon in possible; this must be done in full PPE because the cleaning person “enters” a red area. adapted from MSF 01.08.2017

Preparing the isolation unit Clear separation from „normal“ hospital operations Sink and running water Separated toilets Capacities to handle waste and laundry Enough rooms for the expected number of patients All patients with confirmed diagnosis can be isolated on the same area. Suspected cases are isolated separately. Plan for transforming other areas into isolation areas 01.08.2017

Prototype for an isolation unit Patient entrance Donning GREEN AREA Patient room RED AREA Decontamination / Doffing YELLOW AREA GREEN AREA Patient‘s bed Disinfection / Material Disinfection Disin-fection Entrance Exit Reusable PPE Waste Toilets Waste Mirror Personnel circuit direction! 01.08.2017

Always follow directions ! Source: RKI 01.08.2017 18

Administrative Tasks in preparing an isolation unit Limit and monitor contact points between the entrance and the isolation area: One single entrance to the temporary isolation unit Guard to supervise the entrance List of authorized persons (personnel and visitors) Formal prohibition WITHOUT EXCEPTION Limit moving/transporting patients outside the unit as much as possible Minimize the number of staff in contact with cases Note This slide shows a selection of administrative tasks. Source: RKI 01.08.2017

Responsibilities and communication Clear distribution of responsibilities Build teams for specific tasks Ensure effective communication between teams Plan transfer to a treatment centre Photo credits The photo has been taking during a simulation in Nanoro, Burkina Faso. Source: RKI 01.08.2017

Communication with medias It is important to identify those responsible who communicate with the media at an early stage. The hospital staff must be informed in advance about topics that are passed on to the media. Photo credits The photo has been taking during a simulation in Senegal; a hospital staff is talking to the press. Source: RKI 01.08.2017

Thank you for your attention ! Copyright Images © leremy – Fotolia.com © evgdemidova - Fotolia © yayha – Fotolia.com 01.08.2017

Group work: clinical cases Group work: case 1 - 5 1) Discuss the case in the group 2) Present your case for the plenary Emergency room A suspected case? 01.08.2017