Ebola Wessex CPD Event 14/11/14 Dr Ishani Kar-Purkayastha, CCDC, Wessex PHE Centre wessex@phe.gov.uk Tel: 0345 055 2022
Outline Background About the current outbreak Situation in the UK Clinical management Public Health management Guidance Questions 2 Presentation title - edit in Header and Footer
1976 Outbreak near the Ebola river in Zaire (now DRC). New virus isolated 3 Presentation title - edit in Header and Footer
Origins Filoviridae virus species 5 different serotypes Zaire (75-95% fatality), Sudan (53-65% fatality), Bundibugyo (25% fatality), Taï Forest and Reston Zoonosis (persistence in reservoir species) Bats likely candidates as reservoirs Transmission from animal to human is an infrequent event By CDC/Cynthia Goldsmith [Public domain], via Wikimedia Commons. Available at http://commons.wikimedia.org/wiki/file%3aebola_virus_virion.jpg When outbreaks occur in humans they generally have high mortality rates but burn out quickly The outbreak in West Africa this year is unusual in scale and it s nature 4 Presentation title - edit in Header and Footer
Ebola in Africa Source:https://www.gov.uk/ebola-and-marburg-haemorrhagic-fevers-outbreaks-and-case-locations 5 Presentation title - edit in Header and Footer
The current outbreak The largest and most complex outbreak in west Africa First cases were notified in March 2014 More cases and deaths in this outbreak than all others combined Spread between countries: starting in Guinea across land borders to Sierra Leone and Liberia 6 Presentation title - edit in Header and Footer
Current Outbreak Declared, on August 8 2014, by the WHO Director-General as a Public Health Emergency of International Concern The most severely affected countries: Guinea, Sierra Leone and Liberia weak health systems lacking human and infrastructural resources recently emerged from long periods of conflict and instability porous land borders urban areas affected: increased population density; increased movement 7 Presentation title - edit in Header and Footer
8 Presentation title - edit in Header and Footer Source: http://www.who.int/csr/disease/ebola/photos/geographic-map-29-oct-2014.png?ua=1
Cumulative deaths up to 9 November Source: http://www.bbc.co.uk/news/world-africa-28755033 9 Presentation title - edit in Header and Footer
Interventions in 3 worst affected countries Prompt & accurate diagnosis Isolating and treating patients Contact identification Conducting burials in a safe and dignified manner Hygiene measures: hand washing, cleaning Social mobilisation and community engagement 10 Presentation title - edit in Header and Footer
Ebola Worldwide and in the UK Europe Repatriated cases and transmission in Spain USA Imported case with transmission in Dallas Mali two probable, two confirmed cases Senegal, Nigeria - clear UK: One repatriated case 11 Presentation title - edit in Header and Footer
Clinical presentation Fever Severe headache Muscle pain Weakness Fatigue Diarrhea Vomiting Abdominal (stomach) pain Unexplained hemorrhage (bleeding or bruising) 12 Presentation title - edit in Header and Footer
Transmission Direct physical contact with a patient s bodily fluids such as blood, vomit, diarrhoea. Infection can occur if broken skin or mucous membranes of a healthy person come into contact with environments that have become contaminated with an Ebola patient s infectious fluids such as soiled clothing, bed linen, or used needles. Ebola is not spread through ordinary social contact. 13 Presentation title - edit in Header and Footer
Diagnosing cases in the UK For early diagnosis of viral haemorrhagic fevers taking a travel history is key. Place Guinea, Sierra Leone and Liberia in the last 21 days Contact with a case or with the fluids of a case/animal Symptoms Fever; extreme weakness; sore throat; diarrhoea; vomiting; bleeding. 14 Presentation title - edit in Header and Footer
A) Does the patient have a fever [>38 o C] or history of fever in past 24 hours AND has returned from (or is currently residing in) a VHF endemic country (https://www.gov.uk/viral-haemorrhagic-fevers-origins-reservoirs-transmission-and-guidelines or see VHF in Africa map at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/354636/vhf_africa_2014_update.jpg) within 21 days? OR B) Does the patient have a fever [>38 o C] or history of fever in past 24 hours AND has cared for/come into contact with body fluids of /handled clinical specimens (blood, urine, faeces, tissues, laboratory cultures) from an individual or laboratory animal known or strongly suspected to have VHF? NO to A AND B VHF Unlikely; manage locally YES to A only YES to B ADDITIONAL QUESTIONS: Has the patient travelled to any area where there is a current VHF outbreak? (http://www.promedmail.org/) Has the patient lived or worked in basic rural conditions in an area where Lassa Fever is endemic? (https://www.gov.uk/lassa-fever-origins-reservoirs-transmission-and-guidelines#epidemiology) Has the patient visited caves OR mines, or had contact with primates, antelopes or bats in a Marburg / Ebola endemic area? (https://www.gov.uk/ebola-and-marburg-haemorrhagic-fevers-outbreaks-and-case-locations) Has the patient travelled in an area where Crimean-Congo Haemorrhagic Fever is endemic (http://www.who.int/csr/disease/crimean_congohf/global_cchfrisk_20080918.png?ua=1 AND sustained a tick bite* or crushed a tick with their bare hands OR had close involvement with animal slaughter? MINIMAL RISK Standard precautions apply: Hand hygiene, gloves, plastic apron (Eye protection and fluid repellent surgical facemask and for splash inducing procedures) STAFF AT RISK Hand hygiene, gloves, plastic apron, fluid repellent surgical facemask, eye protection (FFP3 respirator for aerosol generating procedures ) Patients that have extensive bruising, active bleeding, uncontrolled diarrhoea, uncontrolled vomiting: Hand hygiene, double gloves, fluid repellent disposable gown/suit, eye protection, FFP3 respirator STAFF AT HIGH RISK Hand hygiene, double gloves, fluid repellent disposable gown or suit, plastic apron (over disposable gown/suit) eye protection, FFP3 respirator NO No to ALL additional questions CLINICAL QUESTION TO DETERMINE INFECTION CONTROL BEHAVIOUR AND PROTECT STAFF: does the patient have extensive bruising or active bleeding? YES to ANY ADDITIONAL QUESTION YES HIGH POSSIBILITY OF VHF ISOLATE PATIENT IN A SIDE ROOM Urgent Malaria investigation Full blood count, U&Es, LFTs, Clotting screen, CRP, glucose, blood cultures Inform laboratory of possible VHF case (for specimen waste disposal purposes if confirmed) Yes VHF Unlikely; manage locally LOW POSSIBILITY OF VHF Urgent Malaria investigation Urgent local investigations as normally appropriate, including blood cultures Malaria Negative Alternative diagnosis confirmed? No Yes Clinical concern OR continuing fever after 72 hours? No * If an obvious alternative diagnosis has been made e.g. Discuss with Infection Consultant (Infectious Disease/Microbiology/Virology) Possibility of VHF; Infection Consultant to consider discussion of VHF screen with Imported Fever Service (0844 7788990) 15 Presentation title - edit in Header and Footer Malaria Positive: Manage as Malaria; VHF unlikely Continuing fever after 72 hours? Yes CLINICAL QUESTION TO DETERMINE INFECTION CONTROL BEHAVIOUR AND PROTECT STAFF: does the patient have extensive bruising OR active bleeding OR uncontrolled diarrhoea OR uncontrolled vomiting? Is the patient fit for outpatient management? Inform/update Local Health Protection Unit Ensure patient contact details recorded Patient self isolation Follow up VHF screen result No Malaria Negative No Negative Manage locally Discuss with Infection Consultant (Infectious Disease/Microbiology/Virology) Infection Consultant to arrange VHF screen with Imported Fever Service (0844 7788990) Notify Local Health Protection Unit Consider empiric antimicrobials Admit VHF Result Yes Positive CONFIRMED VHF Contact High Level Isolation Unit for transfer (020 7794 0500: Royal Free) Launch full public health actions, including categorisation and management of contacts Inform lab if other lab tests are needed
Public Health management Stopping transmission Prompt Isolation & Treatment PPE Waste disposal & decontamination Contact management Identification & monitoring 16 Presentation title - edit in Header and Footer
Assessing contacts at risk Based on level of exposure Category 1 (No risk) No direct contact with the patient or body. Casual contact, e.g. sharing a room with the patient, without direct contact with body fluids or other potentially infectious material. Category 2 (Low risk) Direct contact with the patient, e.g. routine medical/nursing care, handling of clinical/laboratory specimens, but did not handle body fluids, and wore personal protective equipment appropriately. Category 3 (High risk) Unprotected exposure of skin or mucous membranes to potentially infectious blood or body fluids, including on clothing and bedding. 17 Presentation title - edit in Header and Footer
Managing Contacts Category 1 (No risk) Reassure; provide factsheet. Category 2 (Low risk) Passive monitoring (fever & other disease compatible symptoms for 21 days) Category 3 (High risk) Active monitoring 18 Presentation title - edit in Header and Footer
Additional actions Additional actions during this outbreak: Screening at the ports LHR, LGW, MCR, BHAM, St Pancras Intnl. Returning HCWs scheme either pre-flagged or picked up at the ports and will be followed up by PHE Centres Planning & Preparation with local government, health partners and other emergency services Development of guidance Training and education 19 Presentation title - edit in Header and Footer
Guidance For healthcare settings Acute Trusts Primary Care For non healthcare locations Environmental cleaning Educational settings Prisons Public Health Q&As https://www.gov.uk/government/collections/ebola-virus-disease-clinicalmanagement-and-guidance 20 Presentation title - edit in Header and Footer
References https://www.gov.uk/government/collections/ebola-virus-disease-clinicalmanagement-and-guidance https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/3 54640/VHF_guidance_document_updated_links.pdf http://www.who.int/csr/disease/ebola/situation-reports/en/ 21 Presentation title - edit in Header and Footer
The discovery of ebola http://online.wsj.com/articles/footage-from-1976-documents-discovery-of-ebolavirus-1413470954 http://www.youtube.com/watch?v=xc4gzev8fio 22 Ebola Wessex CPD Event 14/11/14
Questions? 23 Presentation title - edit in Header and Footer