Ebola Virus

Oct 2014

Ebola virus disease

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Ebola virus outbreak• Ebola is a large enveloped virus

• Filamentous 970 nm long • Diameter is about 80nm. • Negative-stranded RNA linear genome, • About 18-19 kb in size. Encodes for seven

proteins.

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The current outbreak

• Approximately 10.000 people infected with more than 4500 deaths (mortality rate around 50%)

• Liberia• Sierra Leone• Guinea• Nigeria (limited)

• A few cases in :• US, Spain

• The current risk for Ebola infection in the US is very low.

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Ebola transmission- person to person• Ebola is transmitted via contaminated blood and body fluids.• Casual contact is not enough to transmit the disease: mucous membrane

(mouth, nose, eyes), broken skin of a non-infected person for transmission to occur, or needle sticks.

• Incubation period is 2-21 days.• Asymptomatic person are not contagious.

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Ebola symptoms• Primary symptoms include:

• Sudden onset fever• Intense weakness• Muscle pain• Sore throat

• Later symptoms include:• Rash, red eyes, hiccups, cough• Chest pain, difficulty breathing and/or swallowing• Bleeding inside and outside the body• Vomiting and diarrhea

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Ebola Prevention Measures• In Healthcare, standard, contact and droplet precautions include:

• Gloves, gowns, face shield (or goggles and mask). Boots and leg covers are used where splashing can occur.

• Environmental surface and patient care equipment disinfection. Use a disinfectant with non-enveloped virus claims (polio, noro, adeno, or rota viruses.)

• Hand hygiene • Treat all blood and body fluids as potentially infectious• Isolation of people suspected to have Ebola to prevent transmission to others• Handle deceased people with the same precautions• Handle wastes as other medical waste, but send with approved handler • Linens – burning/disposal is preferred, but laundering may be acceptable

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Ebola effective disinfectants• Ebola is a Biosafety Level 4 (BSL4) pathogen. It is highly controlled by

government agencies.• There are no products on the market in the US with an Ebola claim• Ebola is a large enveloped virus which is easy to kill on environmental surfaces.

EPA and CDC are working together to issue guidance in regard of disinfectants • CDC guidance is to use a disinfectant with non-enveloped virus claims against

pathogens such as poliovirus, norovirus, adenovirus, or rotavirus. CDC also has guidance recommending 1000 ppm chlorine bleach.

• Most Healthcare disinfectants meet this standard including: Oxivir (all) Virex (all), and Expose. We would not recommend a disinfectant unless it has a non-enveloped virus claim.

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Ebola and the impact on Healthcare cleaning practices

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Outbreak Prevention Planning

• Development of an outbreak prevention plan for Healthcare should include the elements above to address environmental risks

• For this presentation, we will focus only on the elements impacted by Ebola.

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Risk Assessment and Planning

Environmental Hygiene Plan

(Products, Process, Tools)Stock Extra Supplies Training for Staff

Visitor Communication Materials

Hand Hygiene (Access, Products, Signage)

Blood and Body Fluid Cleanup Respiratory Hygiene

Staff Personal Hygiene Vaccinations for Staff Personal Protective Equipment

Compliance Monitoring and Auditing

Pathogen Assessment Cycle

• Whether Ebola or some other emerging pathogen, the steps above outline the process to follow.

• Creating documentation is always recommended to clarify what guidance was used and why specific changes to practices are being implemented.

• There is always risk present. The goal of doing this type of assessment is not to remove risk, but to reduce it to an acceptable level.

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Identify Pathogen

Understand Implications

Create or Modify

Practices

Implement Practices

Train Staff Audit Compliance

Ebola in a few sound bites• Very dangerous, often fatal if you get infected• Largely transmitted the same as HIV, so think about how you would protect

people from bloodborne pathogens• Dealing with Ebola is less about doing a series of practices you are not doing

and more about doing the current practices correctly all the time, with some minor tweaks.

• Proper procedures performed properly protects people

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Ebola - What Doesn’t Change• Stock Extra Supplies – not a big enough issue thus far to carry extra stock • Hand Hygiene – practices do not change for Ebola• Respiratory Hygiene – not the most likely route of transmission• Staff Personal Hygiene – no changes anticipated• Vaccinations for Staff – no vaccine available for virus• Compliance Monitoring and Auditing – increased auditing may be desirable,

but no clear benefit from doing so at this point

• While these elements are important, they are least impacted by concerns about Ebola and not likely to require additional measures to protect staff and patients from Ebola.

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Risk Assessment and Planning• The facility risk assessment document should include specific detail about

assessing and dealing with the risk of Ebola. Among the areas needing clarity are:

• Blood and body fluid cleanup procedures• Personal protective equipment needed• Changes to disinfectants or cleaning process or tools• Signage for public areas or staff• Training that will be needed – and documentation of completion

• Doing this risk assessment starts with understanding the Epidemiology of the Ebola virus – how is it transmitted, what protective measures are needed.

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Environmental Hygiene Plan• There are three key areas of environmental hygiene that we consider in outbreak

preparedness• Products

• What disinfectants are needed to kill this pathogen on surfaces and how do we apply it to prevent splashing?

• Will alcohol hand sanitizers kill this pathogen on hands?• Do our current products meet this standard? If not, where would the products need to be

changed – patient rooms, ED, OR, etc.• Process

• Do our current cleaning processes address the risk of environmental transmission?• Have we looked at implications for cleaning tools, ambulances, diagnostic equipment, soft

surfaces, linens• What about wastes from a room with a known or suspected Ebola patient• Are linens being handled differently? Incineration is preferred at this point.

• Tools and Supplies• Are we using any cleaning tools that should be changed – wiping cloths, mops, vacuums,

floor machines? Should we use disposable wipes rather than materials requiring laundering?16

Visitor Communication Materials• Are signs for the public (or staff) needed to help communicate the risks of

Ebola?• Consider posters, pamphlets, door hangers, table tents, etc. How can you

reassure the public you are addressing the risk – and what do you want them to do differently?

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Blood and Body Fluid Cleanup• Ebola is highly infectious and is believed to be most commonly transmitted

through blood and body fluids. The most likely exposure for staff is through contaminated blood and body fluids.

• Patients with Ebola disease can projectile vomit and bleed onto touch surfaces, the bedding, and floor.

• Staff cleaning up blood and body fluid spills need the following:• Disinfectant meeting CDC or WHO guidance• Gloves, fluid resistant gowns, mask, face shield. May need leg and foot coverings. Are

any of these reused or all disposable• Absorbent used? What about scraper and dustpan to collect?• Waste is now Category A and cannot be put with general waste. May need to

incinerate or autoclave prior to disposal. Stericycle has DOT exemption to allow Ebola wastes to be handled in the US.

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Personal Protective Equipment• Staff doing cleaning need access to:

• Gloves – nitrile or other chemical resistant disposable gloves• Fluid resistant gowns – note not all gowns are good at repelling fluids• Masks – to protect nose and mouth• Face shield - to protect eyes. Some facilities may choose to include goggles as well• Leg coverings – if splashing might occur• Foot coverings – if splashing might occur

• Auditing of “proof of competence” in how to put on and take off the PPE is recommended in addition to written training materials. Indications for hand hygiene should also be included.

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Training for Staff• The staff training related to Ebola needs to include the following:

• Proper use and removal of PPE• Blood and body fluid cleanup• Cleaning procedures and any modifications for Ebola

• Training is also an opportunity to reinforce the importance of:• Hand hygiene• Respiratory hygiene• Personal hygiene• Monitoring their own health for illness. Fever is often the first indicator that you are

getting sick.

• Note that facilities using BSCs for some portion of cleaning need to anticipate training their staff as well.

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In Summary• Ebola is potentially very dangerous, but following best practice recommendations

can help reduce the risk to acceptable levels.• We can never guarantee that we can completely prevent the transmission of

Ebola, because mistakes happen, but proper procedures can significantly reduce the risk.

• Proper planning can make dealing with a new pathogen, such as Ebola, much more manageable.

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