Ebola Virus Disease Implications for NMCP Staff and Patients

1. Ebola Virus DiseaseImplications for NMCP Staff and Patients CDR Karl C Kronmann, MD MPHInfectious Disease Staff, NMCP ACP, 17 Oct 2014

2. Objectives • State of the Ebola Outbreak in West Africa • Ebola Virus Disease • Signs and symptoms, • Diagnosis and management (Respond) • Infection Control • Transmission of EVD • Early Identification (Detect) • Precautions (Protect)

3. How Bad Is It? • By January 20, 2015 if no additional interventions or behavior changes occur, Liberia and Sierra Leone will have approximately 550,000 Ebola Cases (1.4 million when corrected for underreporting) - CDC published in MMWR Sep 23, 2014 • “For the medium term, at least, we must therefore face the possibility that EVD will become endemic among the human population of West Africa, a prospect that has never previously been contemplated.” - WHO published NEJM Sep 23, 2014

4. Ebola – What is different this time? Nurse visits graves from the 1976 Ebola outbreak in Zaire (DRC)

5. Ebola 2014 18 August 2014 MONROVIA, Liberia (AP) — Authorities in Liberia urgently searched on Monday for 17 people who fled an Ebola medical center over the weekend when it was attacked by looters who stole blood-stained sheets and mattresses and took them into an enormous slum.

6. Ebola 2014 18 August 2014 MONROVIA, Liberia (AP) — Authorities in Liberia urgently searched on Monday for 17 people who fled an Ebola medical center over the weekend when it was attacked by looters who stole blood-stained sheets and mattresses and took them into an enormous slum.

7. Ebola 2014 Total 119 cases predicted as of today 56 new cases 12 days 38 new cases 18 August 2014 MONROVIA, Liberia (AP) — Authorities in Liberia urgently searched on Monday for 17 people who fled an Ebola medical center over the weekend when it was attacked by looters who stole blood-stained sheets and mattresses and took them into an enormous slum. 12 days 25 new cases 12 days ???

8. Ebola 2014 18 August 2014 MONROVIA, Liberia (AP) — Authorities in Liberia urgently searched on Monday for 17 people who fled an Ebola medical center over the weekend when it was attacked by looters who stole blood-stained sheets and mattresses and took them into an enormous slum.

9. Ebola 2014

10. Numbers 2014 As of August 11 Ebola – 38 years of EVD Outbreaks Total cases prior to 2014: 2,390 (CFR=66.6%)Total cases in West Africa in 2014: 5,927 (CFR=47%) (as of 22 Sep) Briand S, et al. The international Ebola emergency. Aug 20, NEJM 2014

11. Recent Increase in Cases Department of Defense (AFHSC): West Africa Ebola Surveillance Summary #31: Sep 18, 2014

12. Geographic differences Source: CDC

13. Map of Guinea Showing Initial Locations of the Outbreak of Ebola Virus Disease. Baize S et al. Emergence of Zaire Ebola Virus Disease in Guinea – Preliminary Report N Engl J Med 2014.

14. Country Profiles CIA World Fact Book and United Nations Development Programme

15. Transmission Chains in the Outbreak of Ebola Virus Disease in Guinea. Baize S et al. Emergence of Zaire Ebola Virus Disease in Guinea – Preliminary Report N Engl J Med April 16, 2014.

16. Transmission Chains in the Outbreak of Ebola Virus Disease in Guinea. Baize S et al. Emergence of Zaire Ebola Virus Disease in Guinea – Preliminary Report N Engl J Med April 16, 2014. Days between “first” symptomatic case and MOH notification = 98 Days between death of grandmother and MOH notification = 68 March 10 – MOH notified of cluster of mysterious deaths March 12 – MSF contacted

17. Outbreak dynamics

18. Epidemic Curve 8 Aug: WHO declares PHEIC 24 June: MSF says outbreak is “out of control” and requests help 10 March: Outbreak recognized WHO: Ebola Response Roadmap Situation Report: 18 September 2014 http://apps.who.int/iris/bitstream/10665/133833/1/roadmapsitrep4_eng.pdf?ua=1

19. Video http://nyti.ms/1qnLOQB

20. CDC Checklist for Health Care Facility Preparedness □ Review facility infection control policies □ Review environmental cleaning procedures and provide education/refresher training for cleaning staff □ Begin education and refresher training for HCP on • EVD signs and symptoms, • diagnosis, • how to obtain specimens for testing, • appropriate PPE use (including putting on and taking off PPE), • triage procedures (including patient placement), • HCP sick leave policies, • how and to whom EVD cases should be reported, • procedures to take following unprotected exposures □ Review triage procedures and ensure relevant questions (e.g., exposure to case, travel within 21 days from affected country) are asked during the triage process for patients arriving with compatible illnesses

21. Pathogenesis Feldman H, Geisbert TW. Ebola Hemorrhagic Fever. Lancet 2011

22. Signs and Symptoms Bleeding/Hemorrhage Most common manifestation MELENA Ebola Virus Disease vs. Ebola Hemorrhagic fever

23. Signs and Symptoms Diarrhea

24. Signs and Symptoms Sudden Onset Fever (> 101.5 F) Severe headache

26. Symptom Timing WHO Ebola in Sudan 1976. Bull WHO 1978

27. Burial or cremation Semen and ? breast milk Incubation 2-21 days

28. CDC Definition:Person Under Investigation (PUI) • Clinical Criteria: (at least one) • Temp > 101.5 F • Severe headache • Diarrhea • Muscle pain, vomiting, abdominal pain, or unexplained bleeding AND • Epidemiologic risk within past 21 days: (any one) • Contact with blood, other body fluid or human remains of a suspected EVD case • Travel to (or residence in) an area where EVD transmission is active • Direct handling of bats or non-human primates from disease endemic areas.

29. Initial Management • INFECTION CONTROL! (Discussed separately) • Consider empiric therapy • antimalarials and • broad spectrum antibiotics • Supportive • Tylenol (avoid antiplatelet drugs) • HYDRATION (Oral Rehydration Solution or IV) • Antiemetics • Management of sepsis and shock if needed

30. Diagnosis INFECTION CONTROL! Contact ID/VDH/CDC 4 ml in plastic EDTA tube RT-PCR or Serology done at CDC Rule out malaria. Consider other diagnoses

31. Differential Diagnosis • Malaria • Typhoid • Lassa fever • Shigellosis (Dysentery) • Meningococcal septicemia • Bacterial sepsis • Plague, leptospirosis, anthrax, relapsing fever, typhus, murine typhus, yellow fever, Chikungunya fever, and fulminant viral hepatitis, ?enterovirus, HIV-1. Gire SK, et al. Genomic surveillance elucidates Ebola virus origin and transmission during the 2014 outbreak. Science 2014 Feldman H, Geisbert TW. Ebola Hemorrhagic Fever. Lancet 2011

32. Experimental Treatments“Secret Serums” • Antibodies • Transfusion from convalescent patients • Three monoclonal antibody combo (ZMAPP) • Antisense oligonucleotides • Small interfering RNAs (Tekmira TKM-Ebola) • Inflammatory modulators • Type 1 interferons, ?statins • Coagulation inhibitors • Heparin sulfate, APC • Vaccines (Two are starting phase 1 trials soon) • Post exposure • Pre-exposure Feldman H, Geisbert TW. Ebola Hemorrhagic Fever. Lancet 2011

33. Expert Opinion “. . .the chance that the [Ebola] virus will establish a foothold in the United States or another high-resource country remains extremely small.” - Dr Anthony Fauci, NEJM Sept 18 “We do not view Ebola as a significant public health threat to the United States.” - Dr Beth Bell, CDC testimony to Congress, Sept 17 “And we have no doubt that we will stop [Ebola] in its tracks in Texas.” - Dr Tom Frieden, CDC Director Oct 5

34. Nursing barrier precautions Khan AS, et al. The Reemergence of Ebola Hemorrhagic Fever, DRC 1995 JID 1999

35. TRANSMISSION:KikwitRisk Factors • Direct physical contact OR = undefined, p<0.01 • Contact with Body fluids OR = 3.8, 95%CI (1.9-6.8) No contact = no disease Dowell SF, et al. Transmission of Ebola Hemorrhagic Fever, DRC. JID 1999

36. Transmission of VHF in European healthcare settings Ftika and Maltezou. Viral Hemorrhagic Fevers in Healthcare Settings. J HospInf 2013

37. Unsuspected Ebola in a Modern Hospital in South Africa 300 contacts followed with no secondary cases Richards GA, et al. Unexepected Ebola virus in a tertiary setting: Clinical and epidemiologic aspects. Crit Care Med 2000

38. Why the Confidence?

39. Why the Confidence? • Insufficient hospital bed capacity • Unfamiliarity with barrier nursing techniques • Contact identification and monitoring limited • Quarantine disrupted and disobeyed • No problem with contact identification and monitoring • Quarantine accepted • Plenty of hospital bed capacity • Familiarity with routine Infection Control

40. Preventing or ending an Ebola outbreak • Early Identification of cases • Isolate symptomatic patients – barrier nursing • Trace and monitor contacts – isolate if symptoms • Decontaminate environment and prevent contact with cadavers (funeral preparation) • Good hospital infection control and hygiene

41. MSF Staff Members Lead a Young Patient with Suspected Ebola into the Case-Management Center. Wolz A. N Engl J Med 2014. DOI: 10.1056/NEJMp1410179

42. Early Identification of PUI at NMCP Send patient to ER ER eyeball triage Send to Special Precautions Unit ID confirmation of PUI Further management in SPU (3 days to to rule out Signs at patient entry points

43. CDC Case Definition Probable Case – PUI with risk exposure • High Risk • Needlestick or mucous membrane exposure from EVD case • Exposure without PPE • Direct skin exposure to blood or body fluid of EVD case • Processing blood or body fluid of EVD case • Contact with dead body in area where EVD is occurring • Low Risk • Household contact of EVD case • Exposure without PPE • Close contact (< 3 feet) for a prolonged period with EVD case • Brief direct contact with EVD case Interim Guidance for Monitoring and Movement of Persons with Ebola Virus Disease

44. Infection Control Plan at NMCP • Early identification and isolation • Standard plus ENHANCED Contact plus Airborne precautions • Limit staff • Limit visitors • Limit labs and procedures • Appropriate environmental cleaning

45. Enhanced Contact Precautions • Enhanced PPE • Fluid impervious gowns or coveralls • Extras for sicker patients (boots, aprons, hoods, etc.) • Individualized training • Donning and doffing PPE • Viricidal agent available • Monitor stationed outside room

46. Limited Staff • Attending Physicians only (Critical Care and ID) • Limited nursing – one RN per shift • Monitor – Corpsman • Limit access • Assist with PPE. Verify before entry • Log all visitors

47. Will DoD Efforts Help West Africa? “If by late December 2014, approximately 70% of patients were placed either in Ebola Treatment Units (ETU) or home or in a community setting such that there is a reduced risk for disease transmission (including safe burial when needed), then the epidemic would almost be ended by January 20, 2015.” - CDC published in MMWR Sep 23, 2014

48. Questions

49. Passive Immunization with convalescent human blood or serum Mupapa, et al. Treatment of Ebola Hemorrhagic Fever with Blood Transfusions from Convalescent Patients. JID 1999

50. Early Recognition in Africa In African settings, what is the best way to recognize the presence of Ebola? • Febrile disease with prominent bleeding • Clusters of severe, febrile disease in families • Spread of a severe febrile disease to HCWs • Failure to respond to treatment [for malaria] • Characteristic signs and symptoms • Characteristic laboratory findings • History of exposure to “bush meat” • High index of suspicion