Ebola virus is the cause of a viral hemorrhagic fever disease Ongoing outbreak in West Africa reported in March 2014

Transcription

1 Ebola Virus Disease Marcus Zervos MD Division Head, Infectious Diseases Medical Director, Infection Prevention Henry Ford Health System Professor of Medicine Wayne State University School of Medicine Detroit, MI October 10, 2014

2 Introduction Ebola virus is the cause of a viral hemorrhagic fever disease Ongoing outbreak in West Africa reported in March 2014 Guinea, Sierra Leone, Liberia, Nigeria Senegal-one travel associated case US- travel associated cases Total of 8,033 cases; 3,865 deaths Severe, often fatal disease; Fatality Rate=55-60%

3 Disease Overview Referred to as Ebola Virus Disease (EVD) Spread by direct contact with blood or other body fluids (including urine, feces, semen, breast milk, possibly others) Symptoms include: Fever (>38.6C or 101.5F), severe headache, muscle pain, vomiting, diarrhea, abdominal pain, abnormal bleeding, maculopapular rash may develop Incubation period usually 8-10 days (ranging 2-21 days) with abrupt onset Patients are contagious when symptomatic No treatment or vaccine supportive care

4 Situation growing much worse Exponential increases in numbers of patients. Grave lack of facilities to care for patients, PPE infection prevention, HCW and training. Patients unable to get in to facilities, lay in floors of hallways, no food or therapy. Various quarantines involving neighborhoods, regions quarantine centers raided, travel bans, airline cancellations limits AID Mass cremations, take place in rural areas In Monrovia bodies were simply were burned in a pile; There are so many that it can sometimes take all night.

5 Suspect Case: Person Under Investigation A person who has both symptoms AND risk factors: 1. Fever (>38.6C or 101.5F), and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain or unexplained hemorrhage AND 2. Risk factors within past 21 days before onset of symptoms contact with blood or other body fluid or human remains of person known or suspected to have EVD Residence in, or travel to an area where EVD transmission is ACTIVE Currently Sierra Leone, Guinea, Liberia, Nigeria Direct handling of bats, rodents, or primates from disease-endemic areas

6 Process for Suspected EVD AVOID ALL CONTACT WITH BLOOD AND BODY FLUID Place mask on patient Implement Airborne Plus Precautions (Gloves, Gowns, N95 and Eye Protection) Place patient in negative pressure room (Use private room if no NP room is available) Order Airborne Plus Precautions in Epic Contact Infection Control and Consult Infectious Diseases HFH ID On Call Pager: HFH IC On Call: and your local Infection Prevention Specialist Contact Lab. Call Lab Supervisor On Call at: (all locations to use this number) Do not collect or transport any specimens until lab is notified Call Michigan Department of Community Health (MDCH) for evaluation and/or approval for diagnostic testing at: Communicable Disease Division (517) M-F, 8 AM-5 PM; (517) after hours and weekends Wear appropriate PPE Gloves, gowns (fluid resistant or impermeable), eye protection (goggles or face shield), N-95 mask or PAPR Double gloving, shoe covers and leg covers may be required in case of large amount of blood, vomit or other body fluids The most important aspect of control for EVD is strict standard, contact, and droplet precautions, all of which are included in the Airborne Plus protocol.

7 Process for Suspected EVD Restrict visitors Monitor entry to room Keep logbook of all persons entering patient s room Avoid aerosol-generating procedures If required, MUST be in a negative pressure environment and use N-95 or PAPR Examples: BiPAP, bronchoscopy, sputum induction, intubation, extubation, open suctioning of airways Implement environmental control measures Diligent environmental cleaning of utmost importance Clean equipment and environmental surface per hospital protocol EVS personnel to use PPE as described above Use dedicated, preferably disposable equipment for patient care If equipment re-usable, clean per hospital or manufacturer instruction Minimize blood draws, procedures and testing Limit use of needles and sharps DO NOT USE PNEUMATIC TUBE SYSTEM FOR TRANSPORT

8 AIRBORNE PLUS PRECAUTIONS Visitors: Report to nurse before entering Visitantes: Favor de notificar a la(el) enfermera(o) de su presencia antes de entrar a la habitación. Gracias. ممنوع دخول هذه الغرفة بدون ا ذن من الممرضة (In addition to Standard Precautions) On entering the room, you must wear: N95 Mask or P.A.P.R. (Powered Air-Purifying Respirator) Goggles/Eye Protection (Disinfect after each use) Gown Gloves YES NO Negative Pressure Room Required Keep room door closed. Limit visitors Visitors must wear mask, gown, gloves and eye protection Utilize dedicated equipment (i.e., stethoscope, blood pressure cuff, etc.) or clean between patient use. Remove gown, gloves & eye protection before leaving the patient environment. Remove N95 Mask after leaving room. Dispose of mask, gown, gloves & disposable eye protection after each use. Hand hygiene must be performed immediately after PPE removed. Alcohol Hand Sanitizer During Transport: Patient wears surgical mask. (Vent dependent patients should have filter on ambu bag) REV

9 Diagnostic Testing Criteria Testing is guided by risk level of exposure. High-risk exposure Percutaneous or mucous membrane exposure or direct skin contact with body fluids of a person with a confirmed or suspected case of EVD without appropriate PPE Lab processing of body fluids of suspected or confirmed EVD cases without appropriate PPE or standard biosafety precautions, or Participation in funeral rites or other direct exposure to human remains in area where outbreak is occurring without appropriate PPE CDC recommends testing for all persons with onset of fever within 21 days of having a high risk exposure For those with high-risk exposure but no fever, testing recommended only if other clinical symptoms present and blood work abnormal

10 Diagnostic Testing Criteria Low-risk exposure Persons who spent time in healthcare facility where EVD patients being treated (including healthcare workers who used appropriate PPE, employees not doing direct patient care, other hospital patients who didn t have EVD and their family caretakers) Household members of an EVD patient without high-risk exposures Persons who had direct unprotected contact with bats or primates from EVDaffected countries Testing is recommended for persons with low-risk exposure who develop fever AND either: Other symptoms & unknown or abnormal blood work OR Abnormal blood work findings, but no other symptoms Asymptomatic persons with high or low-risk exposures to be monitored daily for fever and symptoms for 21 days from last known exposure and medically evaluated at first sign of illness Contact MDCH regarding testing for those who traveled to an EVD-affected country within 21 days, but do not meet criteria for high or low-risk exposure

11 Precautions: Travel Bans Don t support a travel ban right now: Because people with financial means can travel to an intermediate country before entering the United States. West Africa's many porous borders make such travel even easier. A ban could also encourage people to lie about where they have been, "One of the real concerns is that if travel outlawed it will discourage people from coming forth with the truth." It isn t enforceable Does it discriminate based on profiling by color Temperature not reliable, can take antipyretic, not have fever at time of travel Aid workers being banned from travel to affected areas

12 Airport Screening Washington-Dulles, Newark, Chicago-O'Hare, and Atlanta international airports. After passport review: Travelers from Guinea, Liberia, and Sierra Leone escorted by to an area of the airport set aside for screening. Trained staff will observe them for signs of illness, ask them a series of health and exposure questions and will take their temperature with a non-contact thermometer. If the travelers have fever, symptoms or the health questionnaire reveals possible Ebola exposure, they will be evaluated by a CDC quarantine station public health officer. Travelers from these countries who have neither symptoms/fever nor a known history of exposure will receive health information for self-monitoring. Today, all outbound passengers are screened for Ebola symptoms in the affected countries. Of 36,000 people screened, 77 people were denied boarding a flight. None of the 77 had Ebola.

13 Solutions All of us can have a role, connect, anticipate and beware of complacency: GET INVOLVED Requires collaborative, multidisciplinary approaches, build partnerships (IT, engineering, behavior, legal business) Improve infection prevention and treatment. Need exhaustive case and contact finding, effective response to patients and community and preventive interventions. Discovery and development of new treatments/vaccines Advance detecting and monitoring Improve access to health care, training, use of community workers, mhealth, distance learning Implementation science, programs

14 Control: Barriers Inadequate supply or distribution mechanism for medications, PPE, access to health care, providers Civil unrest Hoarding Indiscriminant use Lag time in making rapid tests that are POC Inadequate surveillance network Inadequate quarantine mechanism (need to communicate plans before)

15 MDR TB and Travel

16 Role of Academic Community Provide education To provide preventive care that promotes prevention and health rather than just curative care To conduct research To assume institutional responsibility for maximizing the sustainable health of a defined population To develop expertise in deployment of health resources To provide advocacy and equity for the health of the population Stuck C. et al Infect Dis Clin North Am 1995;9:2;419-23

17 Get Involved: Many Opportunities Haiti: survey on health attitudes, health structure, malaria species, resistance and severe febrile disease Suriname: HIV TB Peru: Epidemiology of antimicrobial resistance, health care associated infection, new antibiotics from plants India: TB and HIV Global to local: STD, Street Detroit, immunization Training: delegations, global training, distance learning conferences Many other: eg Kenya relief, WHSO (medical mission, water), HFH and WSU community outreach, FQHC

18 Conclusions Infectious diseases will continue to demand attention Are most important in developing world Are controllable and is the responsibility of the global community We share common problems Initiatives must be developed to overcome economic, social, religious, governmental, and regional barriers for prevention and control Requires long term commitment, new and sustainable solutions, partnerships and multidisciplinary support

19 Conclusion: Lessons learned Need to prepare for potential pandemic and disasters, knowing will happen again; waiting for new deadly microbe to spread is too late (need for better surveillance) We have the power to prevent and defeat infectious diseases, but only we step up the fight The battle is a continual process as Anthony Fauci noted winning does not mean stamping out every disease but rather getting out ahead of the next one We must pool our greatest resources our imagination and intellect to fight this collective fight. For as Joshua Lederberg noted, Pitted against microbial genes, we have mainly our wits. The solution, the power to change the world is in your hands (Stanford Ovshinsky)

20 Resources Available CDC website: MDCH Guidelines: BOLA_Guidance_464829_7.pdf

21 Infection Prevention & Control webpage on Henry