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Current Countries affected:Liberia, Sierra Leone, Guinea, Mali

Ebola - Cumulative Cases and Deaths

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Cases Deaths

Guinea 2155 1312

Liberia 7635 3145

Sierra Leon

7109 1530

TOTAL

16,899

5,987

Modes of Transmission

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Early Symptoms - Nonspecific

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• Bleeding – Eyes– Ears– Nose– Mouth– Rectum(GI)

• Depression

Late Symptoms

In Africa as many as 90% of patients die from the disease. Patients usually die from the shock rather than blood loss.

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• Eye inflammation (Conjunctivitis)• Genital swelling (labia and scrotum)• Increased feeling of pain in skin• Rash over the entire body that often

contains blood *hemorrhagic)• Roof of mouth looks red• Seizures, coma, delirium

Is There a Cure?

• There are no antivirals effective against Ebola.• Passive IgG horses

– Given to infected monkeys– The 6 IgG recipients had no detectable day 5, in contrast

with 3 virus infected controls 7.0 log10 PFU/ml– Ebola monoclonal antibody being developed

Biopharmaceutical Inc.• Not yet been tested in humans for safety or

effectiveness. • The product is a combination of 3 different monoclonal

antibodies that bind to the protein of the Ebola virus.

• No antivirals • Passive IgG from hyperimmune horses AND now recovered humans

– Given to infected cynomolgus monkeys

– IgG study

• 6 IgG recipients - no detectable viremia day 5

• 3 control – All had viremia > 7.0 log10 PFU/ml

Arch of virology 1996;11:135

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– Ebola Monoclonal Ab

• Zmapp – under development (Mapp Biopharmaceutical Inc.

– Combination of 3 different monoclonal Abs that bind to the protein of the Ebola virus.

• Treatment given to Dr. Kent Brantly and Nancy Writebol

US Diagnosed Cases

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• Sept. 19 – Leaves Monrovia, Liberia, for a trip to the U.S.

• Exposed to Ebola but not exhibiting symptoms– Not contagious. – It's unclear if he knew he had been exposed.

• Sept. 20 – Changes planes in Brussels, Belgium and at Dulles– Arrives in Dallas

• Sept. 24– 1st Day of symptoms– Likely when he became contagious.

• Sept. 26– Seeks treatment at Texas Health Presbyterian Hospital Dallas (THPH)

• Communicates his recent his of travel to Liberia• Discharged to Ivy apartments (sister’s residence)

US Diagnosed Case 1 - Thomas Eric Duncan

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Second Hospital Visit - Thomas Eric Duncan

• Sept. 28– Transported back to THPH by ambulance - Critically ill

– Admitted to ICU and placed in isolation

• Sept. 30– Ebola is confirmed

• Oct. 1-2– Condition is upgraded to serious

– Contacts (paramedics and children) observed for symptoms

– Court orders family to stay indoors - Ivy Apt

• Oct. 4– Receives experimental drug brincidofovir

– Passive antibody not available

• Ebola survivor Kent Brantly’s plasma not compatible

– Condition is downgraded from serious to critical

• Oct. 6– Hazmat crews decontaminate apartment

– Quarantined family members are moved to an undisclosed location

• Oct. 8 – Duncan pronounced dead (2 weeks after symptoms)

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US Diagnosed Case 2 - Nina Pham

• 26-year-old Texan• Graduated with a BSN in 2010• Received certification in

critical care nursing 8/2014• Oct. 10 

– Febrile – She drove to the hospital– Isolated within 90 minutes. – Treated Duncan in the ICU

before his death at the hospital.

• Oct. 12– Ebola is confirmed– Transferred to NIH– Her dog was quarantined

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US Diagnosed Case 3 - Amber Vinson

• Oct. 13 – 29-yo nurse also treated Duncan at THPH– Visited Cleveland and Akron

• Ok’d by CDC to travel!!!– Travels back to Dallas with a low-grade fever

• 99.50F

• Oct. 14 – Vinson admitted to THPH with fever– National Nurses United releases statement disclosing alleged

conditions at THPH • Alleged that Duncan was treated for days without proper

protective gear• Protocols at the facility changed frequently

• Oct. 15– Ebola is confirmed - 2nd person to contract Ebola on U.S. soil– Hazmat crews clean apartment – Transferred to Emory Healthcare in Atlanta

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Controlled Travel Guidance

135 on flight13

More Complex Than Originally Thought

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No Cases!!!

US Diagnosed Case 4 - Craig Spencer

• Oct. 17– 33 yo physician– Treated Ebola patients in Guinea– Returned to U.S. via JFK– Passed all travel screening (no symptoms)

• Oct 17-23– Monitored fever twice a day– Went bowling– Ate at the Meatball Shop– Traveled on the NYC subway

• Oct. 23– Physician self reported fever to health department

and was transferred to NY Bellview hospital– Diagnosed with Ebola by CDC

• As of Oct 31st still hospitalized

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• The virus is most abundant in blood and diarrhea.– Urine– Vomit– Sputum– Breast milk– Sweat– Tears– Semen

• Believed that amount of Ebola virus in fluids, like saliva and sweat, to be much lower.

• Viremia – 1 ml blood

Body Fluids Containing Ebola

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Ebola HIV HCV

10 billion 50,000 – 100,000 5 - 20 million

Virus culture (RT-PCR) results from 54 clinical samples collected from 26 patients with laboratory-confirmed EbolaBausch D G et al. J Infect Dis. 2007;196:S142-S147© 2007 by the Infectious Diseases Society of America

Duration of Infectivity of Body Fluids

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• 1995 Ebola outbreak in the Democratic Republic of Congo – Followed family members of 27 infected patients – 78 people not infected

• Had no direct contact – 28 infected

• Had some sort of physical contact– “No convincing epidemiological evidence that airborne transmission

occurs from an infected person to a nearby non-infected person,"

• With aerosol generating procedures Ebola can be in large droplets, which neither travel very far nor hang in the air.

Generally, EBOLA IS NOT AIRBORNE

Is Ebola airborne?

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UPMC Ebola Preparedness

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Suspicious Patient - What to do?

•SCREEN

•ISOLATE

•CALL/EVALUATE SIMULTANEOUSLY– CALL 412-647-700– ADDENDING EVALUATES PATEINT

WE WILL HELP

YOU

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UPMC Ebola Website

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UPMC Ebola Protocol

• Protocol undergoes regular review

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• Risk Factors Residence in (or travel to) Africa

-OR-

Direct, unprotected contact with blood, other body fluids, secretions, or excretions of a person or animal with confirmed or suspected Ebola

Initial Ebola Patient Screening

Screen all patients where care is to be provided (to include home health) for symptoms and risk factors within 21 days of exposure :

AND

Symptoms Fever >37.5◦ C (>99.5◦ F) Aches Nausea

Patient Management

• Positive initial screen triggers and automated email to: – Ebola Team– Infection Control per facility

• Droplet/Contact Isolation is automatically ordered for patient• Place a mask over the nose and mouth of the patient

– Emergency Department• Place patients in single patient room. • A negative pressure room can be considered if an aerosol generating

procedure is expected BUT is NOT required. • Door must remain closed.

– Outpatient Area• Place patient in an exam room or private area. • Door must remain closed.

This triggers a further evaluation by the Ebola Team (412) 647-7000

A positive initial screen is defined by having both risk factors and consistent symptoms within 21 days of potential exposure

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• Risk Factors – Residence in (or travel to)

• Liberia• Sierra Leone• Guinea

-OR-

– Direct, unprotected contact with blood, other body fluids, secretions, or excretions of a person or animal with confirmed or suspected Ebola

EBOLA Team Secondary Evaluation

AND

• If the Ebola TEAM believes the “Patients Under Investigation” definition is met the UPMC Ebola core team and Department of Health (DOH) are notified.

• If transfer is necessary it will be coordinated by the Ebola Team via EMS

• Symptoms– Fever >37.5◦ C (>99.5◦ F) – Chills– Myalgia– Diffuse erythematous

maculopapular rash (day 5-7), usually involves face, neck, trunk, and arms, that can desquamate (shed)

– Severe, watery diarrhea – Nausea or vomiting– Abdominal pain– Confusion– Multi-organ failure – Septic shock

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3 Key Principles#1 – Rigorous and Repeated Training

#2 – No Skin Exposure When PPE is Worn

#3 – Trained Observer will ALWAYS accompany Care Giver in an in-patient setting

CDC Guidance for Personal Protective Equipment

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• Ebola Manager– Clinical Administrator (on-site 24/7)– No PPE required; remain outside soiled area– Oversee the healthcare workers and patient safety. – Ensure the safe and effective delivery of Ebola treatment.– Infection control

• Supply monitoring • Monitor/document persons entering room on personnel log

• Trained Observer– Only Physicians and Nurses

– Wears Level 1 PPE

– Observe donning/doffing PPE to ensure steps are completed safely in the appropriate sequence

– Address immediately (in real-time) any deviations from the prescribed process

– Observe overall conditions, including identification of any immediate HCW health needs

• Caregiver– Only Attending Physicians and Nurses

• NO TRAINEES – Wears Level 2 PPE– Responsible for all aspects of patient care– Perform Daily room cleaning

Ebola Clinical Response Team

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Isolation Precautions

LEVEL 1•Evaluating Patients with no anticipated exposure to blood or bodily fluids

•Trained observer

LEVEL 2•Evaluating Patients with anticipated exposure to blood or bodily fluids

•All care provided by Ebola Clinical Response Team

Who wears what?

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Isolation Precautions

LEVEL 1•Double-glove

•Impervious gown

•Surgical cap

•Surgical Mask

•Boot Covers

•Face Shield

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Isolation Precautions

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LEVEL 2•Double-glove

•Tycham Suit or Impervious gown

•Apron (only for copious fluid exposure)

•Surgical Hood

•N95 Mask

•Boot Covers

•Face Shield

•REQUIRES a Trained Observer

Isolation Precaution Education

• U learn Module* • PPE Donning and Doffing

• Video available on Ebola page on infonet

– Log in to My HUB and select the uLearn tab.

– From the My Current Learning page, click the launch button to the right of the Ebola Preparedness training.

– Mandatory for Select Staff– Available for ALL Staff

*For detailed instructions on how to launch and complete a web-based course, click on the following printable user guide:  How to Launch or Re-Launch a Course.

If you require additional assistance with accessing or completing this training, please contact the uLearn support team at: TDRegistration@upmc.edu.

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• Only Ebola Care Team will perform daily cleaning• Use EPA registered, hospital approved disinfectants for

disinfecting environmental surfaces, with label claim for non-enveloped virus, e.g., norovirus, rotavirus, adenovirus, poliovirus.

• OxyCide

• Clorox Bleach wipes or like product

• Terminal cleaning will happen per Ebola Environmental Protocol which includes but not limited to:– Letting room sit for period of time prior to cleaning

– Using florescent dye to monitor cleaning

– Supervisor assistance

– UV disinfection

– Disposable cleaning cloths, wipes and mops will be utilized

Patient Environment Cleaning

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• Disposal of ALL Material as Category A HAZARDOUS WASTE– Linens– Textile/cloth privacy curtains– All trash– Soiled PPE that is to be replaced in the room– Diagnostic Testing Materials

• Employees who prepare Ebola waste materials for transportation are must be trained in accordance with 49 C.F.R., Part 172, Subpart I

– Prepare shipping papers, packaging, labeling, and marking of packaging

• The training must include:– General awareness

– Function-specific

– Safety

– Security awareness training

Waste Management

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Despite CDC guidance supporting waste disposal, Allegheny County Sanitary Authority (ALCOSAN) does NOT permit human waste to be flushed into the sewer.

Questions?

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