About the AuthorsLinda Landesman, DrPH, MSW• Former Assistant VP, NYC Health and Hospitals Corporation

• Principal Investigator – first national curriculum on the public health management of disasters

• U Mass Online MPH Program

Isaac Weisfuse, MD, MPH• Former Deputy Commissioner, Division of Disease Control, NYC Department

of Health and Mental Hygiene

• Associate Professor, Columbia University Mailman School of Public Health

Ebola Virus• Prototype Viral Hemorrhagic Fever Pathogen

• Filovirus: enveloped, non-segmented, negative-stranded RNA virus

• Severe disease with high case fatality

• Absence of specific treatment or vaccine

• >20 previous Ebola and Marburg virus outbreaks

• 2014 West Africa Ebola outbreak caused by Zaire ebolavirus species (five known Ebola virus species)

Adapted from the CDC

Ebola Virus• Zoonotic virus – bats the

most likely reservoir, although species unknown

• Spillover event from infected wild animals (e.g., fruit bats, monkey, duiker) to humans, followed by human-human transmission

Adapted from the CDC

Ebola Virus Transmission• Virus present in high quantity in blood, body fluids, and excreta of symptomatic EVD-

infected patients• Opportunities for human-to-human transmission

– Direct contact (through broken skin or unprotected mucous membranes) with an EVD-infected patient’s blood or body fluids

– Sharps injury (with EVD-contaminated needle or other sharp)– Direct contact with the corpse of a person who died of EVD– Indirect contact with an EVD-infected patient’s blood or body fluids via a contaminated object (soiled

linens or used utensils)

• Ebola can also be transmitted via contact with blood, fluids, or meat of an infected animal

– Limited evidence that dogs become infected with Ebola virus – No reports of dogs or cats becoming sick with or transmitting Ebola

Adapted from the CDC

Human-to-Human Transmission• Infected persons are not contagious until onset of symptoms

• Infectiousness of body fluids (e.g., viral load) increases as patient becomes more ill

– Remains from deceased infected persons are highly infectious

• Human-to-human transmission of Ebola virus via inhalation (aerosols) has not been demonstrated

Adapted from the CDC

Clinical Features• Nonspecific early symptoms progress to:

– Hypovolemic shock and multi-organ failure

– Hemorrhagic disease

– Death

• Non-fatal cases typically improve 6-11 days after symptoms onset

• Fatal disease associated with more severe early symptoms– Fatality rates of 70% have been reported in rural Africa

– Intensive care, especially early intravenous and electrolyte management, may increase the survival rate

Adapted from the CDC

Ebola virus disease (EVD) cumulative incidence* — West Africa, October 18, 2014

Adapted from the CDC

2014 Ebola Outbreak, West Africa

WHO Ebola Response Team. N Engl J Med 2014. DOI: 10.1056/NEJMoa1411100 http://www.nejm.org/doi/full/10.1056/NEJMoa1411100?query=featured_ebola#t=articleResultsAdapted from the CDC

EVD Cases (United States)EVD has been diagnosed in the United States in four people, one (the index patient) who traveled to Dallas, Texas from Liberia, two healthcare workers who cared for the index patient, and one medical aid worker who traveled to New York City from Guinea

• Index patient – Symptoms developed on September 24, 2014 approximately four days after arrival, sought medical care at Texas Health Presbyterian Hospital of Dallas on September 26, was admitted to hospital on September 28, testing confirmed EVD on September 30, patient died October 8.

• TX Healthcare Worker, Case 2 – Cared for index patient, was self-monitoring and presented to hospital reporting low-grade fever, diagnosed with EVD on October 10, recovered and released from NIH Clinical Center October 24.

• TX Healthcare Worker, Case 3 – Cared for index patient, was self-monitoring and reported low-grade fever, diagnosed with EVD on October 15, recovered and released from Emory University Hospital in Atlanta October 28.

• NY Medical Aid Worker, Case 4 – Worked with Ebola patients in Guinea, was self-monitoring and reported fever, diagnosed with EVD on October 24, recovered and released from Bellevue Hospital in New York City November 11.

Information on U.S. EVD cases available at http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/united-states-imported-case.html Adapted from the CDC

EVD Algorithm for Evaluation of the Returned Traveler

**CDC Website to check current affected areas: www.cdc.gov/vhf/ebola

Algorithm available at: http://www.cdc.gov/vhf/ebola/pdf/ebola-algorithm.pdf

Checklist available at: http://www.cdc.gov/vhf/ebola/pdf/checklist-patients-evaluated-us-evd.pdf Adapted from the CDC

Interim Guidance for Monitoring and Movement of Persons with EVD Exposure

CDC has created guidance for monitoring people exposed to Ebola virus but without symptoms

RISK LEVEL PUBLIC HEALTH ACTION

Monitoring Restricted Public Activities Restricted Travel

HIGH risk Direct Active Monitoring Yes Yes

SOME risk Direct Active Monitoring Case-by-case assessment Case-by-case assessment

LOW riskActive Monitoring for some; Direct Active Monitoring for others

No No

NO risk No No No

www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html Adapted from the CDC

EVD Summary• The 2014 Ebola outbreak in West Africa is the largest in history and

has affected multiple countries

• Think Ebola: U.S. healthcare providers should be aware of clinical presentation and risk factors for EVD

• Human-to-human transmission by direct contact– No human-to-human transmission via inhalation (aerosols)

– No transmission before symptom onset

• Early case identification, isolation, treatment and effective infection control are essential to prevent Ebola transmission

Adapted from the CDC

Teaching Elements in Preparedness Casebook

• Ebola outbreak highlighted skills needed to respond to a highly infectious disease.

• Students can learn skills through cases about how others responded to public health emergencies.

• The cases in Case Studies in Public Health Preparedness and Response to Disasters examine how the ASPPH competencies apply in real life.

What Cases CoverExamples of needed skills and the cases which address these skills

• H1N1 Surveillance – tracking and investigating infectious disease during a pandemic

• Anthrax – using epidemiology, labs and regional health care resources

• Mandatory Flu – protecting health care workers in the hospital as they deliver care

• Hurricane Sandy – protecting individuals and workers in the community

• San Diego Fires – communicating with different audiences

• Hurricane Floyd – state agency responding to an evolving multi-layered disaster

• Pennsylvania Long Term Care – working with external agencies and what happens when that is not coordinated

Cases Sorted by Competencies: Leadership

• Mental Health Post 9-11

• Hurricane Floyd

• Pennsylvania Long Term Care

• CDC Surveillance

• Chilean Mine Collapse

• NYU and Coney Island Evacuations

• Deepwater Horizon Gulf Oil Spill

Cases Sorted by Competencies: Communicate and Manage Information

• Southern California Wildfires

• Anthrax

• CDC Surveillance

• Mandatory Vaccination

• Pennsylvania Long Term Care

• Hurricane Floyd

• New York University Hospital

Evacuation

• Martha Vineyard’s response to H1N1

• Republican National Convention

• Chilean Mine Collapse

• Madrid Bombing

Cases Sorted by Competencies: Plan For and Improve Practice

• Japan Earthquake, Tsunami and Nuclear Accident

• Hurricane Floyd

• CDC Surveillance

• Pennsylvania Long Term Care

• Coney Island Hospital Evacuation

• Madrid Bombings

• World Trade Center Evacuation

• Mental Health Post 9-11

• Anthrax

• Iowa Response to H1N1

Cases Sorted by Competencies Protect Worker Health and Safety

• Coney Island Hospital Evacuation

• New York University Hospital Evacuation

• Hurricane Floyd

• World Trade Center 9-11 Evacuation

• Anthrax

• Mandatory Evacuation

Anthrax• 1999 – Laboratory Response Network (LRN) initiated by

CDC, the APHL and the FBI

• October 2001 – anthrax events killed five Americans, terrorized millions and caused substantial financial damage

• 2009 – LRN instrumental in responding to a case involving gastrointestinal anthrax

Anthrax in New Hampshire• 2009 – 24 yo woman experienced sweating, myalgias and

back pain

• Within week had nausea and vomiting and was hospitalized in New Hampshire

• Blood drawn, surgeons performed exploratory laparotomy and saw she had necrosis of the terminal ileum

• Transferred to tertiary level hospital in Massachusetts

Anthrax in New Hampshire (cont’d)• Several lab tests drawn in NH were positive and by the American

Society for Microbiology criteria should have been sent to a reference lab for confirmation.

• The tech who ran the test was not a regular employee and was not familiar with the protocol

• She did not notify a supervisor and did not consult about the result

• The infectious disease practitioner thought the isolate was a contaminant

Anthrax in New Hampshire (cont’d)• Separate investigation conducted in MA with new blood work

• State reference lab found anthrax in culture

• MA lab notified NH HHS, CDC, and FBI

• NH conducted epidemiological investigation

• Patient was exposed to anthrax spores while participating in an African drumming event while a student at the University of New Hampshire

Anthrax Case Elements• Case describes response and provides insight into the world of detecting

biological threats

• The events exemplify the role of field epidemiology as public health detective

• The experience in New Hampshire can happen at any time and may be a naturally occurring disease or an intentional threat

• Involved multi-agency, multi-state collaboration

• The LRN allowed for laboratories to lead a quick, efficient, and coordinated response

Anthrax Case Competencies• Describes problem solving under emergency conditions and managing and

communicating information

• Illustrates the protection of worker health and safety and plans for improving practice

• Model Leadership actions

– The NH PHL had to quickly identify the causative agents and determine whether the case was linked to broader terrorist or naturally occurring threat

– Their swift actions saved the lives of exposed individuals and reduced potential additional exposures

– This case crossed state lines. It took significant leadership to work with multiple laboratories, both private and governmental to coordinate this response and have a successful outcome

– The director of the NH PHL and her designated leads had to balance the collection and sharing of scientific information from and to multiple sources in order to maintain situational awareness

Communication, Information, and Improving Practice

• Communicating and managing information was a critical aspect of the response

• Laboratory leadership had to develop messages and manage information sharing with key stakeholders

– Collecting the information and controlling it while maintaining specific legal protocols

• Several practices were improved following this anthrax drumming circle event

– The laboratory identified specific steps to improve the capabilities of their organization and clinical partner laboratories

• Laboratory staff adhered to biosafety and other safety guidelines to protect themselves from possible exposures

Anthrax and Ebola• How the laboratory response to an infectious disease is organized

– Similar in both anthrax and Ebola

• How the anthrax case was initially handled and eventually diagnosed

– Lab workers didn’t follow protocol in handling anthrax

– Hospital staff didn’t follow hospital guidelines in Emergency Department at Texas Health Presbyterian Hospital in Dallas

– CDC guidelines changed following care of index patient in Texas

Who was involved

Anthrax Ebola (Mr. Duncan)

New Hampshire and Massachusetts Hospitals

Texas Health Presbyterian Hospital in Dallas

New Hampshire Department of Health and Human Services,Massachusetts Department of Public Health, CDC, FBI, EPA, NH PHL, LRN Reference lab, EIS officer

Texas Department of Health, CDC, Department of Homeland Security, White House, Governors from several states, LRN Reference lab, EIS officers, Assistant Secretary for Preparedness and Response (hospitals) and the United States Public Health Service

Numerous state and federal agencies CERT (CDC Ebola Response Team) and FAST (Facility Assessment and Support Teams) after initial cases

How the epidemiological investigation was conducted

Anthrax Ebola (Index case)

State epidemiologist led team: New Hampshire Department of Environmental Services and Civil Support Team, hazardous material teams, local fire and other town officials, CDC Select Agent program, University of New Hampshire, CDC EIS officer, NH Department of Homeland Security, EPA, NH Department of Health and Human Services

CDC led team: Head of CDC, Texas Department of State Health Services, Dallas County Health Department, and others

Starting in October 2014, officials began screening airplane passengers for fever at five U.S. airports

Anthrax Ebola

Traced exposure from drumming circle event

• 100 people may have had contact with Mr. Duncan once symptomatic

• (50 low and 10 high risk contacts) monitored• 76 Texas Presbyterian Hospital health care workers monitored

because had some level of contact with• Unknown how many were exposed to Nina Pham• 16 people in Ohio who had contact with Amber Vinson were

voluntarily quarantined (who flew on a 138-passenger jet)• 112 health care workers involved in care of Craig Spencer,

hospitalized at Bellevue Hospital, NYC• NYC 's health department established a 24-hour a day operation

involving 500 staffers to keep track of over 200 persons from West Africa hot spots who arrive in New York every day

QUESTIONS?

Resources

Case Studies in Public Health Preparedness and Response to Disasters

By Linda Landesman & Isaac Weisfuse

© 2014 • 384 pages

Includes 3 bonus e-chapters

http://go.jblearning.com/Landesman

Resources

http://go.jblearning.com/Preparedness

Follow up Questions:

Linda Landesman, DrPH, MSWU. Mass. Amherst, School of Public Health

allandes@schoolph.umass.edu

Isaac Weisfuse, MD, MPHColumbia University Mailman School of Public Health

ibw3@columbia.edu

Sophie Fleck TeagueJones & Bartlett Learning, steague@jblearning.com