Ebola - goodfellow unit

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?
Image: FA Murphy CDC
https://engtechmag.files.wordpress.com/2014/08/ebola-infographic.jpg
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
Image credit: http://www.lonelyplanet.com/maps/africa/mali/
Reference: http://www.who.int/mediacentre/news/ebola/24-october-2014/en/
Is it likely to spread to NZ?
Gomes MFC et al (2014). PLOS Currents Outbreaks.
doi: 10.1371/currents.outbreaks.cd818f63d40e24aef769dda7df9e0da5.
Experimental treatments/vaccines
http://news.softpedia.com/news/World-Health-Organization-OKs-Ebola-Drug-Trials-457419.shtml
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.
2.
3.
4.
5.
6.
7.
Risk assessment
Triage
Transportation
Clinical care
Diagnostic testing
Staff health and wellbeing
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 alcoholbased 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/diseas
e/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
Useful Resources
• https://www.health.govt.nz/ourwork/diseases-and-conditions/ebolaupdates/ebola-information-healthprofessionals
• 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
National Readiness
Dr Don Mackie
Chief Medical Officer
Ministry of Health
Wednesday 29 October 2014
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