Dr. Johnmark Opondo MB. ChB. (Nairobi UON), MPH ( Emory) Deputy Medical Health Officer Saskatoon Health Region

Transcription

1 Dr. Johnmark Opondo MB. ChB. (Nairobi UON), MPH ( Emory) Deputy Medical Health Officer Saskatoon Health Region

2 OBJECTIVES 1. To understand the basic science behind EVD 2. To review the issues behind the West Africa EVD outbreak 3. To review the planning and preparedness for an EVD case presentation in Saskatoon Health Region 4. To understand how an EVD case presenting in Saskatoon Health Region may impact the whole health-care system

3 OUTLINE EVD the Basics 101 EVD outbreak in West Africa Prevention and control Viral hemorrhagic fever and health system preparedness in Saskatoon Health Region Early problem identification Immediate isolation Safe care of infected individuals Clean the environment Monitoring and follow-up of contacts

4 WHAT IS VIRAL HEMORRHAGIC FEVER? A Severe multisystem syndrome Damage to overall vascular system Symptoms often accompanied by hemorrhage Incubation period 2 to 21 days Bleeding and unstable HAEMODYNAMICS IS life threatening in itself Includes conjunctivitis, petechia, ecchymosis Death is usually day 7 to 11 EVD is one of the most serious viral hemorrhagic fevers

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6 GUINEA SIERRA LEONE LIBERIA NIGERIA SENGAL

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8 WEST AFRICAN OUTBREAK CONTEXT Widespread pockets on multiple fronts Affected large cities Weak and fragile infrastructure Lack of understanding of disease transmission Distrust of government and foreigners Not seeking health care Social rituals / burial rituals Delayed response; more resources needed

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10 SUMMARY NUMBER OF CASES Country Total Cases Case Deaths Guinea 1, Liberia 4,665 2,705 Sierra Leone 3,896 1,281 Nigeria 20 8 TOTAL: 10,141 4,922 The Democratic Republic of Congo is also reporting cases but it is believed these are unrelated to the situation in West Africa. WHO 25 October 2014

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12 DIAGNOSIS Specimens must be sent to The national microbiology lab (NML) in Winnipeg PROVINCES OF BC AND QUEBEC Turn around time 24 hours Serology PCR IHC Viral isolation Electron microscopy

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14 PREVENTION AND CONTROL Promote bio-safety INFECTION CONTROL EDUCATION AND SUPPLIES FOR HOSPITALS AND AMBULACES Reduce the number of disease outbreaks Safe burial practices and leadership for culture change Clear communication for community and health care Prevent or reduce the spillover of zoonotic disease from animal reservoirs to humans Reduce contact with bats and consumption of bush meat

15 PREVENTION AND CONTROL Experimental vaccine under study If human case occurs To Decrease person-to-person transmission Strict Isolation of infected individuals is required Adherence to strict infection control practice Must plan and prepare the whole health care system to respond

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17 SENTINEL EVENTS FOR SASKATOON HEALTH REGION 1. Ebola outbreak declared in Guinea 2. Suspect EVD case in Saskatoon 3. Spread to Liberia, Sierra Leone and Nigeria 4. EVD alert in an airline passenger to Saskatoon 5. Region EVD Planning 6. Port Harcourt Doctor situation

18 POTENTIAL SCENARIOS FOR EVD CASE PRESENTATION IN SASKATCHEWAN As part of our planning, Saskatoon Health Region is considering a number of scenarios: Ill traveler with signs and symptoms of EVD is first identified at Saskatoon Airport or enroute Individual returns from an affected country and presents at a health care setting in Saskatoon Health Region with signs and symptoms of EVD

19 NATIONAL CASE DEFINITION: EVD For surveillance purposes, an EVD symptomatic person is defined as an individual presenting with fever of greater than 38.6 degrees Celsius AND at least one of the following additional symptoms: malaise myalgia severe headache conjunctival injection pharyngitis abdominal pain vomiting, and diarrhoea that can be bloody bleeding not related to injury unexplained haemorrhage erythematous maculopapular rash on the trunk 111

20 KEY STEPS IN THE CARE OF A EVD PATIENT PRE HOSPITAL 1. IN OUTBREAK COUNTRY 2. DURING AIR TRANSPORT 3. AT CANADIAN PORT OF ENTRY COMMUNITY MEDICAL SETTING 1. TRAVEL HISTORY 2. INFECTION CONTROL 3. PATIENT SAFETY ISSUES DIFFERENTIAL DIAGNOSIS 4. EMS TRANSPORT HOSPITAL 1. RECEPTION AND TRIAGE 2. ISOLATION 3. COHORT STAFF 4. CRITICAL INTERVENTIONS 5. LAB TESTING 6. IN HOSPITAL TRANSPORT 7. MANAGEMENT OF MEDICAL WASTE 8. COMMUNICATIONS Do NOT feel paralyzed by this, every medical worker and site should be prepared for an event like this

21 KNOWLEDGE IS POWER Personal Protective Equipment (PPE) Disposable impermeable gowns, gloves, masks and shoe covers, protective eyewear when splashing might occur, or if patient is disoriented or uncooperative Saskatoon Health Region EVD Protocol WHO and CDC developed manual Infection Control for Viral Hemorrhagic Fevers In the African Health Care Setting

22 PPE REQUIRED FOR CONTACT AND DROPLET PRECAUTIONS TYVEK SUIT IMPERMEABLE GOWN

23 IPAC PRACTICES FOR SUSPECTED EVD: DROPLET +CONTACT PRECAUTIONS Patient accommodation: Single room with dedicated bathroom; door closed If available, an Isolation room with anteroom for donning and removing PPE is preferable PPE for ALL staff entering the room Fluid resistant, long-sleeved, knitted cuffed gown Gloves Full face shield N95 mask Maintain a log of all people entering room: only essential staff should enter room

24 NORTH AMERICAN EXPERIENCE EMORY SPECIALIZED BIO CONTAINMENT UNIT IMMEDIATE ACCESS TO CDC EXPERTIZE NO SECONDARY CASES NEBRASKA SPECIALIZED BIO CONTAINMENT UNIT NO SECONDARY CASES DALLAS GENERAL HOSPITAL WITH ADVANCED FACILITIES 2 HEALTH CARE WORKERS GOT INFECTED

25 NORTH AMERICA EXPERIENCE BELLEVUE HOSPITAL, NYC SPECIALIZED BIO CONTAINMENT UNIT DESIGNATED AS THE PREFERRED TREATMENT SITE FOR NEW YORK RUH ST. PAUL'S WE DO NOT KNOW WHERE IN OUR SYSTEM A PATIENT WITH EBOLA WILL PRESENT FOR CARE. ALL HEALTH CARE PROVIDERS NEED TO BE PREPARED

26 PREVENTING THE SPREAD OF EVD REQUIRES A SYSTEM RESPONSE BEYOND PPE ESSENTIAL ELEMENTS OF RESPONSE EARLY PROBLEM IDENTIFICATION IMMEDIATE ISOLATION SAFE CARE OF INFECTED INDIVIDUALS CLEAN THE ENVIRONMENT KEY LESSONS LEARNT FACILITY LEADERSHIP INTENSIVE ONSITE SUPPORT CLEAR STANDARD PROCEDURES PRACTICE, PRACTICE, PRACTICE OVERSIGHT / TRAINED OBSERVER OF PPE DONNING AND DOFFING

27 SIGNAGE: KNOW AND USE YOUR SCREENING TOOLS DILIGENTLY ATTENTION A L L PAT I E N T S IF YOU recently traveled internationally or had close contact with someone who recently traveled internationally and was ill, AND YOU HAVE fever, cough, trouble breathing, rash, vomiting or diarrhea, PLEASE TELL STAFF IMMEDIATELY!

28 SASKATOON HEALTH REGION PATIENT PLACEMENT ACAL will direct any calls for potential adult cases to St. Paul s Hospital first EMS will bypass their local hospitals if potential case picked up in community and divert directly to Saskatoon Health Region or Regina Qu Appelle Health Region Potential cases should bypass Triage/Registration and be placed in designated ER rooms as quickly as possible

29 RECOMMENDED PPE FLUID IMPERVIOUS SHOE COVERS AND HEAD COVERS: BASIC AND FLUID RESISTANT BOOT SHOE COVERS FULL FACE SHIELD

30 WHEN WEARING PPE Avoid touching or adjusting PPE Remove gloves if they become torn or damaged Perform hand hygiene before donning new gloves Avoid touching your eyes, mouth or face with gloved or ungloved hands

31 TAKING OFF PPE Remove PPE going from the most contaminated to least contaminated Remove PPE carefully Avoid any contact between the soiled items (gowns & gloves) and any area of the face (eyes, nose or mouth) or areas of non-intact skin Hand Hygiene must be performed before moving to your face area and at any point if hand soiling occurs Discard PPE appropriately into no touch waste container

32 TREATMENT Strict isolation of affected patients is required Supportive therapy, with special attention paid to: maintaining fluid and electrolyte balance, circulatory volume, blood pressure and treating for any complicating infections. Report to health authorities Convalescent-phase plasma (limited availability) Argentine HF, Bolivian HF and Ebola Experimental drug m-zapp

33 KEY ISSUES IN EVD IN HOSPITAL CARE Hand hygiene Use recommended ppe Designate clean and dirty areas Always have a trained observer present Practice, practice, practice Limit number of care givers Disinfect high touch surfaces and conduct terminal cleaning

34 MANAGEMENT OF MEDICAL WASTE Anyone suspected of having a VHF must use a desginated toilet Ebola virus does not survive very long on surfaces Hospital grade disinfectant with a virucidal claim on the label should be effective Disinfect and dispose of instruments Use a 0.5% solution of sodium hypochlorite (1:10 dilution of bleach)

35 CASE DEFINITIONS Person under investigation (PUI) Probable case Confirmed case contact

36 PERSON UNDER INVESTIGATION A symptomatic person with clinical evidence of illness not attributed to another medical condition AND at least one of the following epidemiologic risk factors within the 21 days before the onset of symptoms: residence in or travel to an area where EVD transmission is active healthcare workers (HCWs) / personnel who have spent time in a setting where EVD patients are being assessed or cared for in an EVD-affected area who wore appropriate personal protective equipment (PPE) and adhered to appropriate infection prevention and control (IPC) measures (and with no known safety breaches) other patients and visitors who spent time in a healthcare facility where EVD patients are being treated household members of an EVD patient without high-risk exposures as defined below laboratory processing of body fluids of probable or confirmed EVD cases with appropriate PPE or standard biosafety precautions and no safety breaches participation in funeral rites or other direct exposure to human remains in the geographic area where the outbreak is occurring with appropriate PPE and no safety breaches. persons who had direct unprotected contact with bats or primates from EVD-affected country

37 PROBABLE CASE A symptomatic person with at least one of the following high-risk exposures within the 21 days before the onset of symptoms: percutaneous or mucous membrane exposure or direct skin contact with body fluids of a person with a confirmed or probable case of EVD without appropriate personal protective equipment OR laboratory processing of body fluids of probable or confirmed EVD cases without appropriate PPE or standard biosafety precautions OR participation in funeral rites or other direct exposure to human remains in the geographic area where the outbreak is occurring without appropriate PPE. Ref: Infectious Diseases Society of America. Guidelines for Evaluation of US Patients Suspected of Having Ebola Virus Disease, accessed August 7, 2014,

38 CONFIRMED CASE A person with laboratory confirmation of Ebola virus infection using at least one of the methods below: Isolation and identification of virus from an appropriate clinical specimen (blood, serum, tissue, urine specimens or throat secretions) OR detection of virus-specific RNA by reverse-transcriptase PCR from an appropriate clinical specimen (e.g. blood, serum, tissue) using two independent targets or two independent samples OR demonstration of virus antigen in tissue (e.g. skin, liver or spleen) by immunohistochemical or immunofluorescent techniques AND another test e.g. PCR OR demonstration of specific IgM AND IgG antibody by EIA, immunofluorescent assay or Western Blot OR demonstration of a fourfold rise in IgG serum antibody by EIA, immunofluorescent assay or Western Blot from serial samples

39 CONTACT A close contact is defined as an individual: Who has provided care to the patient (including health care worker, family member, funeral worker, or volunteer), or who has had other close physical contact with the patient or deceased body, that may have resulted in unprotected exposure to blood or body fluids from the patient directly or indirectly through contaminated surfaces or equipment; OR Who has worked in a laboratory handling specimens from EVD patients and may have had unprotected exposure to these specimens through the course of their work OR Had direct contact with fomites (inanimate objects such as clothing) that were contaminated with a patient s bodily fluids

40 CONTACT RISK ASSESSMENT Risk Category No Contact No Known Risk (Category 1) Low Risk (Category 2) High Risk (Category 3) Exposure No known contact No contact with the patient or body fluids Casual contact (sharing a room with the patient, without direct contact with body fluids or other potentially infectious material) Direct contact with the patient (routine medical/nursing care, handling of clinical/laboratory specimens), but did not handle body fluids, and wore PPE appropriately Those who transported the patient, who used PPE appropriately with no breech Household contact Unprotected exposure of skin or mucous membranes to potentially infectious blood or body fluids, including on clothing and bedding. This includes: Unprotected handling of clinical/laboratory specimens Mucosal exposure to splashes Needlestick injury Kissing and/or sexual contact

41 DEFINITIONS OF ACTIONS Definitions Self-monitoring Take temperature orally and record twice daily (if teaching is required, the Monitoring Officer shall do as much) Report any reading over 38.6 C to Public Health immediately Refrain from taking any antipyretic medications during the monitoring period (such as acetaminophen) Self-monitor for the appearance of any other symptoms of EVD (severe headache, muscle pain, malaise, sore throat, vomiting, diarrhea and rash) (have forms) Monitoring Officer If the close contact s exposure was not as a healthcare worker, Public Health is the Monitoring Officer If the close contact s exposure was as a healthcare worker in the workplace, Occupational Health and Safety will act as the Monitoring Officer

42 CONTACT MANAGEMENT Risk Category No Contact No Known Risk (Category 1) Low Risk (Category 2) High Risk (Category 3) Actions and Advice(1,6,7) Provide General Factsheet Reassure about absence of risk; Advise to contact the Monitoring Officer should they recall any contact Provide Self-Monitoring Factsheet No movement restrictions Travel by commercial transport allowed Self-monitor until 21 days after last known exposure If fever or symptoms develop must self-isolate immediately and contact the Monitoring Officer for further instruction Provide Self-Monitoring Factsheet There should be no travel out of town during the monitoring period Self-monitor until 21 days after last known exposure If fever or symptoms develop must self-isolate immediately and contact the Monitoring Officer for further instruction Isolate in hospital if symptomatic or at home if asymptomatic Household contacts of Category 3 close-contacts should be advised to take precautions(household Members of Category 3 Contacts) Self-monitor until 21 days after last known exposure If fever or symptoms develop must self-isolate immediately and contact Monitoring Officer for further instruction

43 THANK YOU DR. JOHNMARK OPONDO DEPUTY MEDICAL HEALTH OFFICER SASKATOON HEALTH REGION TELE: