Ebola: Everything you thought you would never need to know How to prepare for the threat of Ebola in primary care 7 pm Wed 29 October 2014

CME / CPD / MOPS points

• To get points you must register online at goodfellowlearning.org & become member

• All registered attendees will receive an email

after this event with instructions & code to access certificate of attendance

• If you were not checked in at the door

please see Selena at AMRF door on the way out

Resources on website goodfellowlearning.org •Updated information for health professionals MoH

•Patient management guideline for primary care MoH

•Poster for general practice MoH

•Updates from Public Health England & CDC

•Video of this event to be uploaded early next week

Programme • Prof Felicity Goodyear-Smith Chair Department of General Practice and Primary Health Care, University of Auckland

• Dr Siouxsie Wiles Ebola: Separating fact from fiction Microbiologist, University of Auckland

• Dr Shanika Perera Enhancing primary care Ebola Virus Disease preparedness in the Auckland region

Medical Officer of Health, Auckland Regional Public Health Service

• Dr Sally Roberts Clinical & technical aspects including use of personal protective equipment & disinfection

Clinical Head of Microbiology, LabPlus, Auckland District Health Board

Programme • Dr Don Mackie National view of preparedness

for Ebola Chief Medical officer, Ministry of Health

Additional Panellists • Jane Pryer, RN Senior Advisor Healthcare Associated Infections

• Dr Bryn Jones, GP Chief Advisor, Sector Capability & Implementation (SCI)

Panel Discussion • Panel Q&A session after all speakers have

presented • Please keep questions until then • Attendees in main theatre (AMRF) will ask

questions 1st; those in 007 please provide Selena with written questions to be read by Chair & answered by panel

Ebola: separating fact

from fiction

Dr Siouxsie Wiles

Senior Lecturer Dept. Molecular Medicine & Pathology

University of Auckland

@SiouxsieW www.sciblogs.co.nz/infectious-thoughts

What is Ebola?

https://engtechmag.files.wordpress.com/2014/08/ebola-infographic.jpg

Image: FA Murphy CDC

What are the symptoms?

Incubation period

How is Ebola spread?

http://www.euronews.com/2014/08/14/everything-you-need-to-know-about-the-ebola-virus/

How contagious is Ebola?

How to tell if you have Ebola

Ebola in west Africa

How did the outbreak start?

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1404505

Where has the outbreak spread to?

How many cases to date?

http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html

Ebola deaths in west Africa

http://ebolacount.com/#death-count

New case in Mali

Reference: http://www.who.int/mediacentre/news/ebola/24-october-2014/en/

Image credit: http://www.lonelyplanet.com/maps/africa/mali/

Gomes MFC et al (2014). PLOS Currents Outbreaks. doi: 10.1371/currents.outbreaks.cd818f63d40e24aef769dda7df9e0da5.

Is it likely to spread to NZ?

http://news.softpedia.com/news/World-Health-Organization-OKs-Ebola-Drug-Trials-457419.shtml

Experimental treatments/vaccines

Enhancing primary care Ebola virus disease preparedness in the

Auckland region

29 October 2014 Goodfellow Presentation

Dr Shanika Perera Medical Officer of Health

Regional Planning

Borders

Community

Primary Care

Hospitals

St John

Health Professional

Advice

issued by ARPHS

Keep up-to-date with information

Obtain travel history from patients presenting with

fever

Isolate the suspected Ebola case immediately

Telephone ARPHS immediately

09 623 4600

Do not contact ambulance or hospital

services

ARPHS will inform if contact tracing is required

You will have support

Information

www.health.govt.nz www.arphs.govt.nz

3 take home messages

1. Keep up-to-date

2. Remain vigilant

3. Call ARPHS

Ebola: Everything you thought you would never need to know

Dr Sally Roberts Clinical Head of Microbiology, ADHB

Ebola Preparedness • Basic Science

– What we know about the virus • Managing the Borders and Primary Care

– Risk assessment – Clinical pathways – Communication strategies – Managing contacts

Updated information for health professionals: Ebola virus disease (EVD) 24 October 2014 The EVD situation is rapidly evolving. Please ensure that you check the health professional’s advice on www.health.govt.nz/ebolaguidance for any updated information.

Healthcare Settings

1. Risk assessment 2. Triage 3. Transportation 4. Clinical care 5. Diagnostic testing 6. Staff health and wellbeing 7. Environment and waste management

1: Risk Assessment • 1.3 Risk assessment (as at 24/10/2014) • The Ministry’s risk assessment currently indicates that

it is extremely unlikely that a confirmed case of EVD would be identified in New Zealand.

• However, it is considered more likely that a traveller that meets the suspect case definition for EVD would present and require management until laboratory testing ruled out EVD.

• If a suspected case were to present in New Zealand, given the location, population and frequency of international flight arrivals it is most likely that they would present in Auckland, Wellington or Christchurch.

2: Triage • Numerous routes

– Primary Care – Screening at the border – Emergency Department – St John’s Ambulance

• Travel history is important for any febrile traveller

• Case Definitions – See Ministry of Health

website

2: Triage – Identify

• Travel history • Meets case definition

– Isolate • Single room with ensuite • Barrier precautions • Hand hygiene

– Inform • Clinical assessment

team • IPC, Laboratory,

Security. Waste Management etc

• Public Health

3: Transportation

• To the healthcare facility – Ambulance Service – Self presentation

• Movement within the healthcare facility

3: Transportation

4: Clinical Care

• Well prepared and trained team • Team of HCW involved in the assessment

of each suspected case

How is Ebola spread? • Transmitted in the blood and body fluids of

people who are seriously ill • High viral load in the late stages of the illness

– Blood, faeces and vomit • Risk with other body fluids

– Sweat – never been isolated from sweat – Saliva and tears – may be present in the late

stages of the disease but studies are inconclusive – Detected in breast milk – Present in urine in the late stages of the illness – Present in semen after recovery

Transmission from body fluids and fomites (JID 2007; 196:S142-7)

• Uganda, outbreak of Sudan EBOV in 2000 • Collected body fluids (urine, stool, vomit and

sputum) from patients with laboratory confirmed EVD

• Used swabs to sample tears, nasal blood and skin surface

• Collected environmental samples 6 hours after cleaning

• Used viral culture and RT-PCR to detect virus

Body Fluids

Acute phase • Saliva (day 4-14) • Skin • Breast milk • Stool • Tears • (vomit) • (urine)

Convalescent phase • Breast milk (day

15) • Semen (day 40-45)

How long can the virus survive? • Fragile enveloped virus

– Easily destroyed by UV light, desiccation, high temperature and disinfectants

• 0.05% -0.1% bleach for environmental surfaces (1:100 or 1:200 dilution of household bleach)

• 1% bleach for blood and body fluid spills • Disinfectants active against norovirus, rotavirus,

adenovirus, poliovirus – May survive for a few days in a pool of body fluid

in a cool, damp place – Easily killed by soap and water and alcohol-

based hand rubs

Transmission to HCW • Very low infecting dose

– an infectious dose of 1 - 10 organisms by aerosol in non-human primates

• Contamination with blood and body fluids – Contact with non-intact skin – Contact with mucous membranes

• Not transmitted by the airborne route • Theoretical possibility that a person late in

the illness could cough violently and send wet droplets into the face of somebody nearby

Personal Protective Equipment

Personal Protective Equipment • Gloves • Gowns

– Semi-impervious, splash resistant disposable gowns

• Masks – Surgical mask

• Face shield/visor • Surgical hood/hair cover • Boot covers

PPE • Put on the right PPE

– Use of checklist to ensure that correct PPE is worn

• Removing PPE poses the greatest risk – Supported by assistant

giving instructions – Aim to avoid contamination

of exposed skin and mucous membranes during the process

• Importance of hand hygiene can not be underestimated

http://www.who.int/csr/disease/ebola/remove_ppequipment.pdf

Patient Placement • Single room with an ensuite • Airborne Infection Isolation Room (negative

pressure room) • Anteroom or dedicated corridor space for

donning and doffing PPE • Dedicated equipment • Dedicated healthcare team • Safe environmental cleaning and waste

management processes

5: Diagnostic Testing

• Diagnosis of EVD

• Assessing severity of illness – POCT

• Diagnosing other infectious diseases

– Malaria – Typhoid

Diagnosis of Ebola virus infection

• Detection of virus RNA in body secretions – Saliva – Blood

• Testing is done in Melbourne at a WHO

Reference Laboratory

6: Staff Health and Wellbeing

• Trained and supported staff • Record of staff providing direct patient

care including clinical staff, laboratory scientists and those managing waste

• Management of exposures – Sharp injuries – Unprotected exposures

• Monitoring of staff following protected exposure

7: Environment and Waste Management

• Cleaning of environmental surfaces – Quaternary ammonium compounds (QATS)

• Ammonium chloride – Bleach (Household Bleach ≈ 5%)

• 0.05% - 1% solutions prepared by diluting bleach with water • Ready diluted preparations – Genes 0.1% (Clorogene

Supplies) • Management of waste in primary care

– Yellow Infectious waste bags-double bagged – Manage as per infectious waste

• Management of body fluids – Manage blood and body fluid spills as per standard

approach

Patient Management Guideline for Primary Care Ebola virus disease (EVD) Updated 24 October 2014 This summary guideline has been developed specifically for primary care facilities and clinicians. It is based on the Ministry of Health’s Updated information for health professionals: Ebola virus disease (EVD) guidance document which has more detailed information and will be updated on the Ministry’s website on a regular basis: www.health.govt.nz/ebolaguidance It is important that health professionals phone their local Public Health Unit for advice regarding any person with history or symptoms of concern for any possible notifiable disease, even if they do not formally meet the

Useful Resources

• https://www.health.govt.nz/our-work/diseases-and-conditions/ebola-updates/ebola-information-health-professionals

• http://www.arphs.govt.nz/ • http://www.who.int/csr/disease/ebola/en/ • http://www.cdc.gov/vhf/ebola/about.html

Ebola: Everything you thought you’d need to know

Dr Don Mackie

Chief Medical Officer

Ministry of Health

Wednesday 29 October 2014

National Readiness

International Situation

• WHO provides regular reporting against their Ebola Response Roadmap Update (http://www.who.int)

• Widespread & intense transmission continues in Guinea, Liberia and Sierra Leone:

• >10,000 cases • >5,000 deaths

• Declared free of Ebola transmission: • Senegal - 17 October 2014 • Nigeria - 20 October 2014

‘An immediate, broad-based, and well-coordinated response can stop the Ebola virus, carried into a country in an infected traveller, dead in its tracks.’ (WHO)

Border Measures

• New Zealand Customs electronically pre-screening arriving passengers for travel history. Passengers are also asked to self-declare countries visited in the last 30 days.

• If identify as travelling in Sierra Leone, Guinea, Liberia, Democratic Republic of Congo, screened by Customs on: Symptoms? Direct contact with confirmed or suspect case? Living in a household with case? Providing medical care to an Ebola patient? Working in a laboratory for Ebola? Participated in a funeral involving direct contact with

the deceased body? • If “yes” or any uncertainty then a further risk assessment is

undertaken by public health officials

National readiness activities

• National Ebola Readiness Incident Management Team (IMT)

• Ebola Technical Advisory Group (ETAG)

• Resources: Health Professional Guidelines Factsheets for the public Signage Border cards

• Regular teleconferences with health sector, unions & professional

associations

Queries/Feedback: 1. Local Public Health Unit 09 623 4600 (ARPHS) 2. ebolareadiness@moh.govt.nz