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Ebola and preparedness for the outpatient setting. The Colorado Medical Society is proud to host:. featuring Connie Savor Price, MD. FOR AUDIO: Dial -In Number (U.S . & Canada): 866.740.1260 Access Code: 8586318. Ebola and Preparedness for THE outpatient setting. - PowerPoint PPT Presentation
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Ebola and preparedness for the outpatient setting
FOR AUDIO: Dial-In Number (U.S. & Canada): 866.740.1260
Access Code: 8586318
The Colorado Medical Society is proud to host:
featuring Connie Savor Price, MD
EBOLA AND PREPAREDNESS FOR THE OUTPATIENT SETTINGConnie Savor Price, MDChief, Infectious DiseasesDenver Health and HospitalProfessor of MedicineUniversity of Colorado
Colorado Medical SocietyNovember 4, 2014
Disclosures• Grants/Research Support: AHRQ; DHHS/CDC; VA
Foundation; Accelerate Diagnostics; Dept of Defense; Medimmune; Rebiotix
• Consultant: Accelerate Diagnostics, DHHS/Office of the Assistant Secretary for Preparedness and Response (ASPR), Johns Hopkins International, Kingdom of Saudi Arabia Ministry of Health
• Speaker’s Bureau: None
• Stock Shareholder: Doximity
• Other Financial or Material Support: None
Objectives
Upon completion of this webinar, participants should be able to . .
• Define the epidemiology of the current Ebola outbreak
• Describe the risk factors for transmission of Ebola
• Apply sound infection prevention strategies to suspected Ebola patients in the outpatient setting
BACKGROUND
Ebola patient left to die outside Liberian hospital because there is no more room
How Many People Have Been Infected?
• More than 13,000 people in Guinea, Liberia, Nigeria, Senegal and Sierra Leone have contracted Ebola since March
• More than 4,900 people have died• Liberia: cases doubling ~ every 15-20 days; Sierra Leone
and Guinea: cases doubling ~ every 30-40 days
http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html?_r=1
As of October 29, 2014
Where is the Outbreak?
Montserrado County in Liberia, which includes the capital, Monrovia, recorded over 300 new cases in the week ended Oct 21
Number of New Cases Each Week
New cases for the week ending Oct. 21
http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html?_r=1
Africa is the 2nd Largest Continent
2014 Ebola Outbreak
It is at least 4 times bigger than the continental US
The current Ebola activity is focused in a very small part of Western Africa
Cumulative Cases in LiberiaBest-case scenario
11,000-27,000 cases through Jan. 20
Worst-case Scenario
537,000-1.4 M cases through Jan. 20
http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html?_r=1MMWR September 23, 2014 / 63(Early Release);1-14
0
2
4
6
8
10
12
14H
undr
eds
of T
hous
andsAssumes 70 percent of patients
are treated in settings that confine the illness and that the dead are buried safely. About 18 percent of patients in Liberia and 40 percent in Sierra Leone are being treated in appropriate settings.
If the disease continues spreading without effective intervention
Range
Comparison to Past Ebola Outbreaks
2nd-worst yearSudan, Democratic Republic of Congo
602 cases (dark orange)431 deaths (light orange)
5thDemocratic Republic of Congo
3rdUganda
4thUganda, Democratic Republic of Congo
1stSierra Leone, Liberia, Guinea, Nigeria
315 cases254 deaths
425 cases224 deaths
413 cases224 deaths
6,553 cases3,083 deathsas of Sept. 26
1976 (virus discovered) 2014200720001995
http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html?_r=1
Ebola cases and deaths by year, and countries affected Cases Deaths
Why Is this Outbreak So Hard to Contain?
• Lack of knowledge amongst the population about Ebola• High mobility of people in this area of the world• Wide geographic spread of cases• Distrust of medical personnel• Fear• Incomplete contact tracing• Burial rituals- deceased people are usually washed and then
clothed• Culinary practices– bats, bushmeat• Lack of adequate public sanitation• Access to healthcare• Emergence in several highly populated areas in West Africa
US to Ramp Up Ebola ResponseInitiatives Planned by President Obama
http://www.wsoctv.com/ap/ap/top-news/us-to-assign-3000-from-us-military-to-fight-ebola/nhNR4/
There Are No Regularly Scheduled Direct Flights To The U.S. From Liberia, Guinea Or Sierra Leone
http://fivethirtyeight.com/datalab/why-an-ebola-flight-ban-wouldnt-work/
The two nurses who contracted Ebola at a Dallas hospital were transfered to biocontainment units in Atlanta and Bethesda
Omaha
Dallas
NIH
Atlanta
Paris
Madrid
London
FrankfurtLeipzig
HamburgOslo
A Spanish nurse contracted Ebola while treating a missionary who died in a Madrid Hospital.
Countries with Ebola outbreaks(Nigeria now contained)
Ebola Outside of Africa (n=18)Recovered In treatment Died
http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html?_r=1
As of Oct. 28, 2014
A doctor, who was recently in Africa treating Ebola patients, tested positive on Oct. 23.
New York
Timeline: Ebola Arrival and Spread in a Dallas Hospital
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Eb
ola
9/19 9/20 9/24 9/25 9/28* 9/30* 10/8 10/11 10/15
* Nurse 1 and 2 were treating the patient during this time
Ebola Among Health Care Workers In West Africa
West African Healthcare Workers MSF Healthcare Workers
As of October 14, 2014
cases deaths0
50
100
150
200
250
300
350
400
450416
233
700
3
MSF health-care workers in West Africa since March 2014
Number in-fected with Ebola
US Hospitals Designated To Accept Ebola Patients*
*A full list is forthcoming
Denver/Aurora
Omaha
Chicago
Atlanta
Bethesda
New York/Long Island
http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html?_r=1
The Ebola Virus• Ebola hemorrhagic fever or EVD
• Viral Hemorrhagic Fever• Rare and deadly disease • Caused by infection with one of the Ebola virus strains.
• Named after the Ebola River in the Democratic Republic of the Congo (formerly Zaire)
• First outbreak (Zaire 1976)• 318 human cases• 88% mortality• Spread has been due to healthcare sites, burial rituals and
close family contact with ill patient's
• Five types • Zaire, Sudan, Tai Forrest, Bundibugyo and Reston
Ebola Ranks Relatively Low On The Contagiousness Scale
Although HIV and Ebola have similar R0s, but Ebola's infections per unit of time is much higher than HIV.
R0 (“R-nought”)
Because people with Ebola aren't contagious until they show symptoms,R0 is certain to be way less than two in this country
When everyone is vaccinated, the R0 to ~zero for measles.
Where Does Ebola Come From?
Transmission
• Highly infectious but not highly transmissible• Index case likely becomes infected through contact with an infected animal
• Once an infection occurs in humans, the virus spreads through direct contact (through broken skin or mucous membranes) with• A sick person's blood or body fluids (urine, saliva, feces,
vomit, and semen)• Objects (such as gloves, needles) that have been
contaminated with infected body fluids (virus can survive in environment many days)
http://www.cdc.gov/vhf/ebola/transmission/index.html
Virus Survival
• Can survive for several hours on surfaces• Environmental testing of high touch surfaces in an Emory patient
room negative
• May survive up to 6 days in moist environment• Enveloped virus: standard disinfectants (detergent,
70%ethanol, bleach) are effectiveRibner B., IDWeek 2014
Symptoms in Confirmed and Probable Ebola Patients in West Africa, 2014
Fever
Fatigue
Vomitin
g
Diarrh
ea
Loss o
f appetite
Headache
Abdomin
al pain
Join
t pain
Musc
le p
ain
Chest p
ain
Difficu
lty s
wallowin
g
Cough
Difficu
lty b
reath
ing
Sore th
roat
Conjunct
ivitis
Unexpla
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Confusio
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Hiccups
Jaundice
Eye p
ain
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0
20
40
60
80
100
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68 66 65
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4439 39 37
3330
23 22 21 1813 11 10 8 6 6
Per
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t
Specific hemorrhagic symptoms wererarely reported (in <1% to 5.7% of patients).
(n=467-1151)
Dye, C. N Engl J Med 2014;371:1481-95
Time between Exposure and Disease Onset, West Africa, 2014
Dye, C. N Engl J Med 2014;371:1481-95
The mean incubation period was 11.4 days. Approximately 95% of the case patients had symptom onset within 21 days after exposure
Diagnosis• Laboratory findings may include low white blood cell and
platelet counts and elevated liver enzymes.• Virus detectable by real-time RT-PCR from 3-10 days
after symptoms appear (may be detectable earlier)• Collect a minimum volume of 4mL whole blood (preserved with
EDTA) in plastic collection tubes • All suspect cases should be immediately reported to the CDPHE
Communicable Disease Branch for approval for diagnostic testing
• Testing should encompass evaluation for other sources of febrile illness in the returned traveler
Treatment• Severely ill patients require intensive supportive care. • Patients are frequently dehydrated and require oral
rehydration with solutions containing electrolytes or intravenous fluids.
• New drug therapies are being evaluated. Emergency investigational new drug application and IRB needed• Mapp Biopharmaceutical and contact information at
• http://www.mappbio.com/
• ZMapp information at• http://www.mappbio.com/zmapinfo.pdf
• Chimerix brincidofovir information at • http://ir.chimerix.com/releasedetail.cfm?releaseid=874647
washingtonpost.com
British volunteer receives Ebola vaccine in second human trialBy Abby Phillip September 17
Felicity Hartnell, a clinical research fellow at Oxford University, injects Ruth Atkins with an experimental Ebola vaccine in Oxford, England. (Steve Parsons/Associated Press/Pool)
PLANNING CONSIDERATIONS FOR OUTPATIENT SETTING
Assumptions for Planning
• Cases will be rare• Cases will not involve multiple persons, likely just
individuals• Cases will likely present through Denver International
Airport (DIA), Emergency Departments (ED), Urgent Care, less likely on a routine clinic visit
• Based on the epidemiology to date in the US, these assumptions are functional for planning at this time, adjustments will be made if warranted.
• STAFF SAFETY IS #1 PRIORITY
“Ask. Isolate. Call.”
“ASK”Ask: About travel to the 3 countries of interest (Sierra Leone, Liberia, Guinea)Ask: About exposure to persons with EbolaAsk: About symptoms consistent with Ebola Virus DiseaseAsk: EVERYONE, EVERY TIMEWho should ask? MDs, nurses, triage staff, first responders, front office staff
Screening• Screening of patients at all points of first access
• Clinics, Urgent Care Centers, ED, Paramedics, Call Centers
• Patient waiting areas shall have signs posted instructing patients to notify provider if they have traveled to West Africa in past 3 weeks
• Providers shall have screening tools in provider work areas and exam areas with screening questions
Please alert your provider if you have traveled to West Africa in the past 3 weeks
Por favor, informe a su médico si usted ha viajado a África occidental en las últimas 3 semanas
S'il vous plaît alerter votre fournisseur si vous avez voyagé en Afrique de l'Ouest au cours des 3 dernières semaines
When to Suspect Ebola
Suspect Ebola in patients who have TRAVELED TO GUINEA, SIERRA LEON, or LIBERIA WITHIN 21 DAYS of symptoms or contact with blood or body fluids of another person known to have or suspected to have Ebola
AND
One or more of the following SYMPTOMS: Fever (subjective or measured greater than 38.0°C or 100.4°F) - Severe headache - Muscle Pain - Weakness - Abdominal (stomach) pain - Vomiting - Lack of Appetite - Diarrhea - Unexplained bleeding or bruising
Call CDPHE303-692-2700 or303-370-9395 (after hours)
Call 911
Modified from
Identify, Isolate
, Inform: E
mergency D
epartm
ent E
valuation
and
Managem
ent for Patients W
ho Present w
ith Possible E
bola V
irus D
isease http://w
ww
.cdc.gov/vhf/ebola/hcp/ed-manag
eme
nt-patients-possible-ebola.h
tml O
ct 31, 2014
Personal Protective Equipment• Initial Evaluation for Clinically Stable and “Dry” Patient
• Face shield • Mask or respirator• Gown- Impermeable or fluid resistant• Gloves (double)• Limit patient and environmental contact
• Hospital Management for Clinically Unstable or “Wet” Patient* • Impermeable gown, 2 layers of gloves, N95 or PAPR hood, Face
shield, Surgical hood, Boot covers• Strict donning/doffing protocol with trained staff• Always work in pairs • Must document competency• Essential staff only
*http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.htmlRequires evaluation and care in a specialized (usually ED) setting with facilities and trained staff
Good Doffing for Everyday Infection Prevention
The are general* recommendations for safe donning and doffing of PPE
*Specific recommendations for Ebola are described for the hospital setting in the CDC’s Infection Prevention and Control Recommendations for
Hospitalized Patients with Known or Suspected Ebola Virus Disease in U.S.
Hospitals
“CALL”What to report to CDPHE
(303-692-2700, evenings and weekends: 303-370-9395)
• All suspect cases should be immediately reported to CDPHE.
• Persons who have NO symptoms of Ebola but have exposure to Ebola (either “high-risk” or “some risk”).
• State health will notify local public health agencies of a suspect case in their jurisdiction immediately.
• State public health will assist all hospitals and local health departments with a suspect case. This includes coordinating with CDC, figuring out logistics, transport of patient (if needed), getting appropriate testing, case-finding, etc.
Then what?
Clinical and public health action plan, based on exposure risk and clinical presentation.
Environmental Contamination
• CDPHE will provide guidance• Do not attempt to disinfect area on your own• Block off contamination, move patients and healthcare workers away from contamination
Handling Waste in Clinics
• All waste will be handled as category A waste• Do not attempt to clean up or dispose of waste
OUTPATIENT TABLETOP
42-year-old Liberian male presents with low-grade fever and abdominal pain +/-vomiting. What is the next step?
A. Prescribe ciprofloxacin for his abdominal pain and send him home
B. Obtain the intake nurse’s notes
C. Ask him when he was last in Liberia
D. Draw a CBC and basic chemistries
E. Have the patient’s family member call the CDC
You are concerned for Ebola. What is the next step? Choose as many as apply
A. Put the patient in a negative airflow room
B. Find a PAPR and quickly learn how to use it
C. Notify public health
D. Put the patient in an exam room (ideally with a bathroom)
E. Wash your hands and put on gloves, gown (fluid resistant or impermeable), eye protection (goggles or face shield), facemask before continuing further evaluation
You learn he was in Monrovia 11 days ago. Before he can answer your questions about sick contacts, he vomits at the registration desk. What do you do next?
A. Immediately clean it up
B. Block off the area and relocate patients and staff away from the contaminated space
C. Pour bleach on it (you planned to replace the carpet anyway)
D. Ask the patient to clean it up
E. Evacuate the building
The patient is escorted to a private room. He was accompanied by family members. What do you do next? Choose as many as apply.
A. Escort the family members to a separate exam room
B. Ask if any of the family members feel ill
C. Ask them to leave the clinic immediately
D. Give them a mask
E. Collect their contact information
F. Call CDPHE
The patient’s temperature is measured at 103 degrees. CDPHE has sent paramedics and the patient is removed from your clinic. What do you do next?
A. Cancel your clinics for the next 21 days
B. Make sure you take out all the trash from the patient’s exam room
C. Book a cruise, leave ASAP
D. Perform fever and symptom monitoring for 21 days
E. Quarantine yourself in an outdoor tent
F. Await further guidance from CDPHE
Where do you find more information?
A. www.colorado.gov/ebolaB. www.cdc.gov/ebolaC. COHELP (303-389-1687 or 1-877-462-
2911)D. www.cms.orgE. All of the above
QUESTIONS?