ebola virus disease implications for nmcp staff and patients cdr karl c kronmann, md mph infectious...
TRANSCRIPT
Ebola Virus DiseaseImplications for NMCP Staff and Patients
CDR Karl C Kronmann, MD MPHInfectious Disease Staff, NMCP
ACP, 17 Oct 2014
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)
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
Ebola – What is different this time?
Nurse visits graves from the 1976 Ebola outbreak in Zaire (DRC)
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.
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.
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.
Ebola 2014
25 new cases
38 new cases
56 new cases
12 days
12 days
12 days
Total 119 cases predicted as of today
???
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.
Ebola 2014
Ebola 2014
Numbers 2014
Briand S, et al. The international Ebola emergency. Aug 20, NEJM 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)
Recent Increase in Cases
Department of Defense (AFHSC): West Africa Ebola Surveillance Summary #31: Sep 18, 2014
Geographic differences
Source: CDC
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.
Country Profiles
Country
Per Capita GDP
Life Expectancy at birth
Multidimensional poverty
Official Language Religion
$ rank years rank
USA 52,800 14 79.56 42 n.a. English Christian – 77%None – 12%Muslim – 1%
Sierra Leone
1,400 208 57.39 201 72.68% English (limited)
Muslim – 60%Christian – 10%Indigenous – 30%
Haiti 1,300 209 63.18 186 50.16% French,Creole
Christian – 96%
Guinea 1,100 218 59.60 195 86.49% French Muslim – 85%Christian – 8%Indigenous – 7%
Liberia 700 223 58.21 199 81.86% English (20%) Christian – 85%Muslim – 12%
CIA World Fact Book and United Nations Development Programme
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.
Transmission Chains in the Outbreak of Ebola Virus Disease in Guinea.
March 10 – MOH notified of cluster of mysterious deaths
March 12 – MSF contacted
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
Outbreak dynamicsDisease R0 Generation time/
serial timeTransmission Route CFR
Measles 12-18 11-12 days Airborne 2%
Influenza 1.4-4.0 3-4 days Droplet (Airborne) 0.1%
Ebola 2014 1.4-2.02 9-15 days Contact, Droplet ~70%
Polio 2-20 10 days Fecal-Oral 5-10%
Smallpox 5-7 14-16 days Airborne 30%
SARS 2-5 4-12 days Airborne 11%
Epidemic Curve
WHO: Ebola Response Roadmap Situation Report: 18 September 2014 http://apps.who.int/iris/bitstream/10665/133833/1/roadmapsitrep4_eng.pdf?ua=1
24 June: MSF says outbreak is “out of control” and requests help
8 Aug: WHO declares PHEIC
10 March: Outbreak recognized
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
Pathogenesis
Feldman H, Geisbert TW. Ebola Hemorrhagic Fever. Lancet 2011
Signs and SymptomsBleeding/Hemorrhage
Year Location Bleeding/Hemorrhage
2014 Guinea 27% (4/15)
1995 DRC 41% (42/103)
1976 Zaire (DRC) 78% (174/223) Fatal cases18% (6/34) Survivors
1976 Sudan 71% (130/183)
Most common manifestation MELENA
Ebola Virus Disease vs.Ebola Hemorrhagic fever
Signs and SymptomsDiarrhea
Year Location Diarrhea
2014 Guinea, Liberia, Sierra Leone
78% (11/15)66% (721/1099)
1995 DRC 85% (87/103)
1976 Zaire (DRC) 79% (180/228) Fatal cases44% (15/34) Survivors
1976 Sudan 81% (130/183)
Signs and SymptomsSudden Onset
Fever (> 101.5 F) Severe headache
Symptom Timing
WHO Ebola in Sudan 1976. Bull WHO 1978
infection symptom onset
day 7 day 14 day 21 day 28+
Infectious Risk
survivors fatalities
DeathDay 8 (2-14)
Incubation 2-21 days
Burial or cremation
Semen and? breast milk
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.
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
Estimated 2014 deaths to date Liberia, Guinea, Sierra LeoneEVD 2,759
Malaria 23,105
Diagnosis1. INFECTION CONTROL!
2. Contact ID/VDH/CDC
3. 4 ml in plastic EDTA tube
4. RT-PCR or Serology done at CDC
5. Rule out malaria.
6. Consider other diagnoses
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.
1. Gire SK, et al. Genomic surveillance elucidates Ebola virus origin and transmission during the 2014 outbreak. Science 20142. Feldman H, Geisbert TW. Ebola Hemorrhagic Fever. Lancet 2011
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
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
Nursing barrier precautions
Khan AS, et al. The Reemergence of Ebola Hemorrhagic Fever, DRC 1995 JID 1999
TRANSMISSION:Kikwit Risk Factors
1. Direct physical contactOR = undefined, p<0.01
2. Contact with Body fluidsOR = 3.8, 95%CI (1.9-6.8)
Dowell SF, et al. Transmission of Ebola Hemorrhagic Fever, DRC. JID 1999
No contact = no disease
Transmission of VHF in European healthcare settings
Ftika and Maltezou. Viral Hemorrhagic Fevers in Healthcare Settings. J Hosp Inf 2013
Unsuspected Ebola in a Modern Hospital in South Africa
Patient Number of hospital days
Procedures performed
Outcome Infection Control
Number of secondary cases
40 year old male physician returning from Gabon
14 EGDColonoscopyCentral lineThigh muscle bx
Survived Standard 1
46 year old female anesthetist assistant caring for source patient
13 (4 as sick staff,9 as patient)
LPBone marrow bxDialysisLaparotomy
Transferred Standard 0
9 Swan-Ganz IntubationLaparotomy
Died High level barrier plus airborne
0
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
Why the Confidence?LOCATION PUBLIC HEALTH INFRASTRUCTURE HOSPITAL INFECTION CONTROLGUINEA, SIERRA LEONE,LIBERIA
• Public distrust• Minimal presence of permanent
staff outside capital cities• Access to rural locations difficult
• Unreliable electricity• Running water not always available• PPE (e.g. gloves) rarely available• Minimal or no routine Infection
Control and cleaning• Limited diagnostic and treatment
capacity -> Lack of confidence in hospitals
• Barrier nursing techniques not used
USAEUROPE
• High public trust• Staff available for contact tracing
and monitoring• Public acceptance of quarantine,
etc.• No access issues
• Routine IC procedures• Basic PPE plentiful• Routine cleaning procedures• Familiarity with barrier nursing
techniques
Why the Confidence?LOCATION PUBLIC HEALTH INFRASTRUCTURE HOSPITAL INFECTION CONTROLGUINEA, SIERRA LEONE,LIBERIA
• Public distrust• Minimal presence of permanent
staff outside capital cities• Access to rural locations difficult
• Unreliable electricity• Running water not always available• PPE (e.g. gloves) rarely available• Minimal or no routine Infection
Control and cleaning• Limited diagnostic and treatment
capacity -> Lack of confidence in hospitals
• Barrier nursing techniques not used
USAEUROPE
• High public trust• Staff available for contact tracing
and monitoring• Public acceptance of quarantine,
etc.• No access issues
• Routine IC procedures• Basic PPE plentiful• Routine cleaning procedures• Familiarity with barrier nursing
techniques
• Contact identification and monitoring limited
• Quarantine disrupted and disobeyed
• No problem with contact identification and monitoring
• Quarantine accepted
• Insufficient hospital bed capacity
• Unfamiliarity with barrier nursing techniques
• Plenty of hospital bed capacity
• Familiarity with routine Infection Control
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
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
Early Identification of PUI at NMCP
Signs at patient entry points
1. Send patient to ER2. ER eyeball triage 3. Send to Special Precautions Unit4. ID confirmation of PUI5. Further management in SPU (3
days to to rule out
CDC Case Definition
Probable Case – PUI with risk exposure1. High Risk
a) Needlestick or mucous membrane exposure from EVD caseb) Exposure without PPE
I. Direct skin exposure to blood or body fluid of EVD caseII. Processing blood or body fluid of EVD caseIII. Contact with dead body in area where EVD is occurring
2. Low Riska) Household contact of EVD caseb) Exposure without PPE
i. Close contact (< 3 feet) for a prolonged period with EVD caseii. Brief direct contact with EVD case
Interim Guidance for Monitoring and Movement of Persons with Ebola Virus Disease
Infection Control Plan at NMCP
1. Early identification and isolation2. Standard plus ENHANCED Contact plus
Airborne precautions3. Limit staff4. Limit visitors5. Limit labs and procedures6. Appropriate environmental cleaning
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
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
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
Questions
Passive Immunization with convalescent human blood or serum
Year LocationNumber of patients
Number transfusions per patient Result
1976 DRC 1 3 Died
1976 UK 1 2 Survived
1995 DRC 8 1 7 survived1 died
DRC 5 ? 4 died1 survived
2014 Liberia, USA 2? ? 2 survived
Mupapa, et al. Treatment of Ebola Hemorrhagic Fever with Blood Transfusions from Convalescent Patients. JID 1999
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
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
Develop Health Infrastructure
Epidemiologic Curve
Department of Defense (AFHSC): West Africa Ebola Surveillance Summary #31: Sep 18, 2014
Ebola – 38 years of EVD Outbreaks Total cases prior to 2014: 2,390 (CFR=66.6%)
Total cases in West Africa in 2014: 2,722 (CFR=53%) (as of 25 Aug)Year Country Ebolavirus species Cases Deaths Case fatality
2012 Democratic Republic of Congo Bundibugyo 57 29 51%
2012 Uganda Sudan 7 4 57%2012 Uganda Sudan 24 17 71%2011 Uganda Sudan 1 1 100%
2008 Democratic Republic of Congo Zaire 32 14 44%
2007 Uganda Bundibugyo 149 37 25%
2007 Democratic Republic of Congo Zaire 264 187 71%
2005 Congo Zaire 12 10 83%2004 Sudan Sudan 17 7 41%
2003 (Nov-Dec) Congo Zaire 35 29 83%
2003 (Jan-Apr) Congo Zaire 143 128 90%
2001-2002 Congo Zaire 59 44 75%2001-2002 Gabon Zaire 65 53 82%2000 Uganda Sudan 425 224 53%
1996 South Africa (ex-Gabon) Zaire 1 1 100%
1996 (Jul-Dec) Gabon Zaire 60 45 75%
1996 (Jan-Apr) Gabon Zaire 31 21 68%
1995 Democratic Republic of Congo Zaire 315 254 81%
1994 Cote d'Ivoire Taï Forest 1 0 0%1994 Gabon Zaire 52 31 60%1979 Sudan Sudan 34 22 65%
1977 Democratic Republic of Congo Zaire 1 1 100%
1976 Sudan Sudan 284 151 53%
1976 Democratic Republic of Congo Zaire 318 280 88%
Infection Control - TransmissionDate Location Exposure Attack Rate
1976 Zaire Family, living in contiguous structure, shared eating facility
5.6%
1976 Sudan Family, sleeping in room without touching patient
0%
Sleeping in room and touching patient 23%
Sleeping in room and nursing patient 81%
1995 DRC Household members who did not share nursing duties (but may have slept in room)
0%
Transmission occurred through direct contact, unsterilized syringes (Zaire), and sexual