Matthew Rollosson, RN, MPH&TM Nurse Epidemiologist

Tacoma-Pierce County Health department 2 April 2015

Preferred over “Ebola hemorrhagic fever” ◦ Most people with EVD do not have

hemorrhagic symptoms Higher risk for bleeding Disseminated intravascular coagulation Thrombocytopenia

◦ Massive fluid loss due to vomiting and diarrhea ◦ Death is usually due to dehydration and

electrolyte disturbances

1976, Yambuku, Zaïre (now the Democratic Republic of the Congo)

◦ Near the Ebola River

◦ Species that causes most EVD outbreaks

Current outbreak in West Africa

Fruit bats are most likely the natural reservoir

Infects monkeys and apes ◦ Large die-offs of chimpanzees and gorillas

◦ Reston ebolavirus

Lab workers had serologic evidence of infection

No symptoms

◦ Taï Forest ebolavirus

One human infection

Acquired during autopsy of a chimpanzee

Outbreaks may be associated with hunting or butchering animals or eating infected meat ◦ Bat soup

◦ Bushmeat

Direct contact with blood or body fluids of a symptomatic person ◦ Skin Cuts, abrasion

◦ Mucous membranes ◦ Parenteral Reusing unsterilized needles

Accidental needle sticks

◦ Funeral ceremonies

Respiratory droplets? ◦ Not airborne

Not effectively transmitted by inanimate objects

Incubation period

◦ 2 to 21 days

Mean 6 – 12 days

“Dry” symptoms ◦ Sudden onset

Fever

Muscle pain

Fatigue

May be a transient rash

“Wet” symptoms

◦ Vomiting, diarrhea

◦ Bleeding disorders

Gastrointestinal bleeding

Bleeding from venipuncture sites

Mucous membranes

Neurological symptoms

Easily mistaken for other diseases

Health care personnel at risk for infection Outbreaks frequently associated with

transmission in health care facilities

- Hepatitis - Shigellosis

- Malaria - Typhoid fever

- Meningococcemia - Typhus

- Plague - Yellow fever

Frequently infected ◦ Illness not

recognized as EVD

◦ Lack of appropriate PPE

Fewer health care workers available ◦ Death

◦ Flee out of fear of infection

No specific medications to treat EVD

Hydration and electrolyte replacement

◦ Oral rehydration solution (ORS)

◦ Intravenous fluid

Antimalarial

Antibiotics to treat/prevent translocation of bacteria from the GI tract

Nutritional support Fowler et al., 2014

Sodium

Potassium

Glucose ◦ Sodium/glucose

co-transport

◦ Enhanced water absorption

Atia & Buchman, 2009

Death or recovery

◦ 7 to 14 days after symptom onset

◦ Prolonged convalescence

◦ Survivors presumed to be immune

Species-specific neutralizing antibodies

◦ Virus may be present in semen weeks after recovery

Rehydration and electrolyte replacement improve survival

West African Ebola epidemic traced to a 2-year-old child in Guinea who died from the disease December 6, 2013

◦ First outbreak of EVD in West Africa

March 10 2014: World Health Organization (WHO) notified of an outbreak of an unknown infectious disease characterized by fever, vomiting, and diarrhea in Guinea

Zaïre ebolavirus identified in blood from patients who were hospitalized with the disease

Baize et al., 2014

…modest further intervention efforts at that point could have achieved control.”

WHO Ebola Response Team (2014)

Epidemic spreads to

◦ Liberia in March

◦ Sierra Leone in May

◦ Nigeria in July

August 8, 2014: WHO declared the Ebola epidemic in West Africa a Public Health Emergency of International Concern

Cases Deaths

Guinea 495 367

Liberia 554 294

Nigeria 13 2

Sierra Leone 717 298

Totals 1,779 961

By the end of August, the total numbers of EVD cases and deaths exceeded that of all previous Ebola epidemics combined

CDC, 2015

New cases of Ebola virus disease, October 19–November 8, 2014 - CDC

100 bed capacity

◦ 44 confirmed

◦ 56 suspect

Patients referred by

◦ District health officers

◦ Community Care Centers

◦ Other health care facilities

Triage

Suspect ◦ Fever and contact

with an EVD case or dead/sick animal

OR

◦ Fever and other EVD symptoms

OR

◦ Inexplicable bleeding

OR

◦ Inexplicable death WHO 2014

Laboratory confirmed ◦ PCR+

OR

◦ IgM+

Asymptomatic for 3 days

Negative PCR

◦ Both confirmed and suspect cases

Martha Phillips

Infection control ◦ Doffing ◦ Chlorine

Patient care ◦ Oral rehydration

solution not at bedside

◦ Staff avoided contact with patients

Patient records ◦ Census ◦ Laboratory results ◦ Medication

administration

WHO recommends: ◦ Face shield or goggles

◦ Fluid-resistant medical/surgical mask

◦ Double gloves

◦ Disposable gown/coverall

◦ Head cover

◦ Waterproof apron

◦ Waterproof boots WHO 2014

Partners in Health

Tropical Africa

◦ Hot

◦ Humid

According to the CDC,

“Wearing PPE increases the risk for heat-related illnesses.”

Hydration

Electrolyte replacement

◦ Oral rehydration solution

Doffing PPE safely takes time

◦ Go to the toilet before donning PPE!

Rest

Skin care

◦ Cuts and abrasions are portals of entry

Ebolaviruses ◦ Lipid envelope Derived from host cell ◦ Destroyed by Alcohol Chlorine Heat Detergents Soap UV light

CDC ◦ May restrict travel into the U.S. and between states

◦ No authority within states

◦ Recommendations

CDC does not recommend “quarantining” asymptomatic individuals with some or low risk of infection

Washington State follows CDC guidance on travelers returning from Ebola-affected countries ◦ Some of my colleagues who live in other states

haven’t been as fortunate

Travelers entering the U.S. from Ebola-affected counties must be screened at one of five airports

Categorized according to risk

Health departments of counties of residence notified

Risk Exposure Monitoring (asymptomatic)

High risk Needle-stick from a symptomatic patient

Contact with body fluids from a symptomatic patient without appropriate PPE

Contact with a dead body without PPE

Direct active monitoring

Controlled movement

Exclusion from workplace, public places

Some risk Direct contact with a symptomatic person while wearing appropriate PPE

Direct active monitoring

Health officer may impose additional restrictions, if appropriate

Low (but not zero) risk

Having been in a country with widespread Ebola transmission without known exposure

Active monitoring No restrictions on

work, travel, or public places

Local health department: ◦ Active monitoring Self-reporting of temperature and EVD

symptoms Twice daily 21 days

◦ Direct active monitoring Self-reporting of temperature and EVD

symptoms Twice daily

Direct observation of contact by health department personnel 21 days

United States

◦ 10/11/14 to 3/24/15

11,361 travelers screened.

◦ 3/16/15 to 3/22/15

1,989 people in active or direct active monitoring

CDC

Washington State

◦ 131 low risk

◦ 20 some risk

Pierce County

◦ 10 low risk

◦ 2 some risk

No high risk contacts in Washington State

No cases of EVD in Washington State

a person suspected of having EVD is seen in health care facility in Pierce County?

◦ Don’t panic ◦ Call TPCHD

a person the health department is monitoring develops a fever and/or symptoms of EVD? ◦ The health department will arrange transportation to an

appropriate health care facility for evaluation

It’s probably not EVD ◦ Malaria ◦ Gastroenteritis ◦ Influenza

Infectious diseases

◦ Tuberculosis: 1,500,000

◦ Malaria: 584,000

Children under 5 years of age: 453,000

◦ Measles: 145,700

◦ Pertussis (whooping cough): 89,000

Atia, A. N. & Buchman, A. L. (2009). Oral rehydration solutions in non-cholera diarrhea: a review. American Journal of Gastroenterology, 104(6), 2596-2604.

Bausch, D. G., Towner, J. S., Dowell, S. F., Kaducu, F., Lukwiya, M., Sanchez, A., et al. (2007). Assessment of the risk of Ebola virus transmission from bodily fluids and fomites. Journal of Infectious Diseases, 196(Supple. 2), S142-S147.

Baize, S., Pannetier, D., Oestereich, L., Rieger, T., Koivogui, L., Magassouba, N., et al. (Emergence of Zaire Ebola virus disease in Guinea. New England Journal of Medicine, 371(15),1418-1425. doi:10.1056/NEJMoa1404505.

Blumberg, L., Enria, D., & Bausch, D. G. (2014). Viral hemorrhagic fevers. In J. Farrar, P. J. Hotez, T. Junghanss, G. Kang, D. Lalloo, & N. J. White (Eds.) Manson's tropical diseases, 23rd Ed. [Electronic version]. Elsevier.

Centers for Disease Control and Prevention. (October 3, 2014). Ebola virus disease outbreak – Nigeria, July-September, 2014. Morbidity and Mortality Weekly Report, 63(39), 867-872. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6339a5.htm.

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Centers for Disease Control and Prevention. (November 21, 2014). Update: Ebola virus disease epidemic – West Africa, November 2014. Morbidity and Mortality Weekly Report, 63(46),1064-1066. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6346a6.htm.

Centers for Disease Control and Prevention. (December 12, 2014). Ebola virus disease in health are workers – Sierra Leone, 2014. Morbidity and Mortality Weekly Report, 36(49), 1168-1171. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6349a6.htm.

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Centers for Disease Control and Prevention. (2015). Outbreaks chronology: Ebola virus disease. http://www.cdc.gov/vhf/ebola/outbreaks/history/chronology.html.

Centers for Disease Control and Prevention (2015). Experiences of CDC and Emory Healthcare in Managing Persons Under Investigation for Ebola. http://emergency.cdc.gov/coca/calls/2015/callinfo_033115.asp

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Schieffelin, J. S., Shaffer, J. G., Goba, A., Gbakie, M., Gire, S. K., Colubri, A., et al. (2014). Clinical illness and outcomes in patients with Ebola in Sierra Leone. New England Journal of Medicine, 371(22), 2092-2100. doi:10.1056/NEJMoa1411680

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