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Emerging Diseases of Concern

Health and Human Resources SubpanelGovernor’s Secure Commonwealth

InitiativeOctober 2014

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Enterovirus D68

• Enterovirus D68 (EV-D68) is one of more than 100 non-polio enteroviruses

• EV-D68 can cause mild to severe respiratory illness.

• EV-D68 likely spreads from person to person when an infected person coughs, sneezes, or touches contaminated surfaces.

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Enterovirus D68 in United States

From mid-August to October 15, 2014, CDC or state public health laboratories have confirmed a total of 780 people in 46 states and the District of Columbia with respiratory illness caused by EV-D68.

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Enterovirus D68 in Virginia

• As of October 15, EV-D68 lab-confirmed in the Central, Northern and Eastern Regions • 66 patients tested for EV-D68 (72 specimens) • 35 patients confirmed EV-D68 by CDC or DCLS

labs• 18 patients had rhinovirus or other

enteroviruses 

• 8 hospitals reported increases in ED visits and/or admissions in children presenting with possible EV-D68• St Mary's Hospital – 50% of children admitted

required PICU

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Enterovirus D68

• VDH continues to work with any facilities reporting a cluster of illness to facilitate lab testing where appropriate.

• VDH will continue traditional and enhanced surveillance to characterize the nature of the illness and these clusters.

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Seasonal influenza• Influenza comes to Virginia every year

• Season is October – May• Usually peaks December – February

• This year, we can expect to see multiple flu viruses circulating• Influenza A/H3N2, 2009 Influenza A/H1N1,

Influenza B• Influenza can have a large impact, especially in

group residential settings

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Virginia’s 2013-14 Flu Season_Insert Updated Slide

Recent uptick in Flu B

Peak activity week ending 1/18/2014, widespread for 11 weeks, 30 outbreaks

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Flu vaccine composition unchanged…2014-2015 trivalent influenza vaccines protect

against the following three viruses:• A/California/7/2009 (H1N1)pdm09-like virus • A/Texas/50/2012 (H3N2)-like virus • B/Massachusetts/2/2012-like virus

Quadrivalent vaccines also protect against:• B/Brisbane/60/2008-like virus

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Flu vaccine recommended for…

• All persons aged 6 months and older should be vaccinated annually.

• Vaccination of persons at high risk is especially important to decrease their risk of severe flu illness.

• People at high risk of serious flu complications include young children, pregnant women, people with chronic health conditions like asthma, diabetes or heart and lung disease, and people 65 years and older.

• Vaccination also is important for healthcare workers, and other people who live with or care for people at high risk to keep from spreading flu to those at high risk.

• Children younger than 6 months are at high risk of serious flu illness, but are too young to be vaccinated. People who care for them should be vaccinated instead.

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Other Emerging Infections

• Middle East Respiratory Syndrome Coronavirus (MERS-CoV)• May 2, 2014 – first U.S. imported case (IN)• May 11, 2014 – second U.S. imported case (FL)• Unrelated cases; both from Saudi Arabia

• Avian Influenza A H7N9 in China

Both diseases still need to be considered in ill travelers from affected countries. DCLS has ability to test in-house.

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Virginia’s Preparedness for Ebola Virus Disease

(EVD)Health and Human Resources Subpanel

Governor’s Secure Commonwealth Initiative

October 2014

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Ebola: The Basics

• Ebola virus is a type of viral hemorrhagic fever.• Virus spread person to person mainly by direct

contract with bodily fluids (blood, feces, vomit), less commonly by contaminated items (needles).

• Ebola is a severe and often fatal disease; begins with acute fever, progressing to multi-organ involvement.

• Infected person is contagious only after symptoms develop (usually 8-10 days (range 2 to 21 days) after exposure).

• Persons (healthcare workers, household members) caring for person acutely ill with Ebola are at highest risk of being infected.

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Ebola in Africa and the United States• Mar 2014: Outbreak began in

Guinea• Aug 8: WHO declared international

public health emergency• Sep 30: First case diagnosed in US

(Texas); traveler left Liberia Sep 19, arrived US Sep 20, and became symptomatic Sep 24

• Ongoing outbreaks in Guinea, Liberia, Sierra Leone. Limited but now contained spread in Nigeria. Now limited spread in the U.S. Sporadic detection in 2 other countries.

• 8,997 total reported cases and 4,493 deaths (Oct 12)

Image source: CDC (October 10, 2014)

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EVD Control Measures: Based on Established Core Public Health Actions• Surveillance

• Disease reporting• Communication

• Investigation• Implementation of control measures• Risk communication

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Statewide Hospital Preparedness Program

Far Southwest

Near Southwest

Central

Eastern

Northwest

Northern

• Regional Healthcare Coordinators develop their regional plans, polices and governance structure under the oversight of their Regional Healthcare Coalition

• Regions operate Regional Healthcare Coordination Centers (RHCC)

VDH provides the framework for statewide administration of HPP

VDH works through the Virginia Hospital and Healthcare Association (VHHA) to coordinate governance and initiatives to 6 Healthcare Coalitions with 300+ participating facilities

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Three EVD Scenarios to Consider

in VirginiaI. Individual arrives at Virginia airport (Dulles most

likely) with symptoms consistent with EVD (or likely exposure) and travel history to affected areas

II. Individual presents to Virginia hospital with symptoms consistent with EVD and a travel history to the affected areas

III. Individual with EVD identified in another state but had contact with Virginians

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I. Person Arrives at Airport

• Active planning over many years with CDC’s Division of Global Migration and Quarantine (DGMQ) for arrival of person with communicable condition

• Airlines trained to notify DGMQ of ill passengers. Captains have a legal responsibility.

• Entry screening will begin at Dulles 10/16/14. • Initial protocols developed

• Includes communication with local and state public health, EMS and hospitals

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Dulles Scenario, continued:

Four scenarios:1. Person has fever and symptoms consistent with

EVD• Transport by Airport EMS to accepting hospital

2. Person has no history of EVD exposure but is febrile/symptomatic• Assessment and, if appropriate, hospital

evaluation3. Person has history of EVD exposure but no

symptoms• CDC would provide a conditional release.

State may issue quarantine order. 4. No exposure history AND no symptoms

• Released with information sheet

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II. Person Presents to Virginia Hospital

• Hospital staff perform assessment and implement isolation

• Hospital staff report to and consult with local health department and follow the steps for testing approval within VDH and with Virginia’s State Lab, DCLS

• DCLS would test patient samples and forward portions to CDC for additional testing

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If Patient Tests Positive

• Case patient remains in isolation at hospital.• VDH initiates investigation

• includes contact tracing - something we do very regularly.

• On a daily basis, VDH staff would assess contact’s compliance with monitoring.

• If activities of well contacts need to be restricted, the VDH district health director would make that recommendation to the Commissioner.

• Commissioner would need to decide on quarantine order issuance

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Layers of Offense and Defense

• Public health and health care efforts in West Africa to get the outbreaks under control

• Exit screening at airports in West Africa• Entry screening at airports in the United

States• Early identification and isolation of persons

presenting with EVD in the United States• Aggressive contact investigations and

measures to prevent the spread of EVD infection in the United States

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Quarantine Orders

• Legal authority exists for State Health Commissioner to issue orders of quarantine for disease threats• If non-compliant with voluntary agreement, or• If such order is necessary to control the

disease

• Letters for EVD-related voluntary quarantine and orders for the two mandatory quarantine scenarios have been drafted

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Quarantine (continued)

• For persons under order:• law enforcement help with delivery• least restrictive setting (home quarantine

wherever possible)• daily monitoring for compliance• assurance that essential needs are met

• will require support and leadership from local jurisdiction, particularly local DSS.

• Ex parte court review required and person has right to challenge the order

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III. If Virginia resident is exposed to a case in another state• Once VDH receives such notification, efforts will

begin immediately to locate the exposed person(s)

• Once located, the person will be asked about exposures and any symptoms of illness • if well and exposure confirmed,

• VDH will actively monitor symptoms daily • determine need for Order of Quarantine

• if ill, VDH will take actions as previously described

• isolation and testing of patient, assurance of protection of healthcare workers, identification of contacts, interviewing and monitoring health of contacts, providing recommendations for disease control

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State Health Commissioner Actions• Maintain full situational awareness at local, state,

national and international levels.• Inform and regularly update public, healthcare

community, legislators and Executive Branch leadership about significant events/developments • Promote hygienic practices and influenza

vaccination• Evaluate each potential EVD case/contact as a

Communicable Disease of Public Health Threat• Determine need for individual orders of

isolation or quarantine

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Commissioner (continued)

• Coordinate efforts with neighboring jurisdictions• Direct agency resources to meet local needs• Identify need for interagency assistance• Declare Public Health Emergency if situation

warrants enhanced awareness and communication

• Request Governor declaration of emergency if an affected area needed to be isolated or quarantined

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Other Issues Addressed to Date

• Laboratory testing and transportation of samples• Personal protective equipment (PPE) stockpile• Emergency medical services’ transportation of

patients• Medical waste disposition• Fatality management• Healthcare coalition preparedness and response• Decontamination of a home• Planning for a call center

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Summary

Ebola is a very serious disease that has not been diagnosed in humans in Virginia before

VDH and our health care partners are as ready to respond as we can be today• Our staff are trained and capable in the

necessary core public health services• We will continue learning and sharing as new

information is obtainedWe will assure effective communication within our

organization, to Executive Branch leadership, with our partners across the state and in other states and with the public

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Resources

VDH Home Page• http://www.vdh.virginia.gov/

VDH Ebola Information for Healthcare Providers and Facilities• http://www.vdh.virginia.gov/epidemiology/ebola/index.ht

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VDH FAQs • http://www.vdh.virginia.gov/news/pdf/Ebola%20FAQ.pdf

CDC Ebola Information• http://www.cdc.gov/vhf/ebola/

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High risk exposuresPercutaneous (e.g., needle stick) or mucous membrane exposure to

blood or body fluids of EVD patientDirect skin contact with, or exposure to blood or body fluids of, an

EVD patient without appropriate personal protective equipment (PPE)

Processing blood or body fluids of a confirmed EVD patient without appropriate PPE or standard biosafety precautions

Direct contact with a dead body without appropriate PPE in a country where an EVD outbreak is occurring

Low risk/some risk exposuresHousehold contact with an EVD patientOther close contact with EVD patients in health care facilities or

community settings. Close contact is defined as• being within approximately 3 feet (1 meter) of an EVD patient

or within the patient’s room or care area for a prolonged period of time (e.g., health care personnel, household members) while not wearing recommended PPE for standard, droplet, and contact precautions

• having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended PPE