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EbolaEpidemiology, Response and ChallengesKim Delahanty, BSN, PHN, MBA/HCM, CIC

Administrative Director Infection Prevention Clinical Epidemiology

Frank Myers, MA, CIC

Infection Preventionist III

Monique Imroth, BA

Director of Emergency Preparedness and Response

University of California San Diego Health System

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Ebola

• A hemorrhagic fever transmitted via bodily fluids: droplet and contact NOT AIRBORNE

• Currently only endemic to West Africa: Liberia, Sierra Leone and Guinea

• Healthcare workers have a higher risk for infection than others

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Reality Check

• San Diego does not have a large West African Community

• Texas, New York and Rhode Island do

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What You Can Do to Protect Yourself

• FEVER = TRAVEL HISTORY, 100% of the time!

• Know your geography

• West Africa = think Ebola

• Philippines = think Measles

• Middle East = think MERS Co-V

• Caribbean = think Chikungunya (no risk)

• Anywhere tropical = think Malaria (no risk)

• No travel history = safe right?

• Wrong!

• Pertussis

• Enterovirus D68

• TB

• Influenza

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Hypsignathus monstrosusa.k.a. Hammerhead Fruit Bat a.k.a the vector

www.inaturalist.org www.tumblr.com

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Let’s Look at the Facts

• In these countries ambulance teams that pick up Ebola victims are given 2 pairs of gloves and 1 pair of booties (no gowns) per shift

• Trips to pick up victims average 4-6 hours due to poor roads

• These countries have little or no running water outside of hospitals and cities

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Household Transmission

• 27 households with 173 surviving members who interacted with primary cases

• 28 of the 173 (16%) developed EHF

• All secondary cases had direct physical contact with index case; none of 78 without physical contact developed infection

• Additional risk from touching cadaver or seeing patient in the hospital late in the illness

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Risks of household transmission of Ebola hemorrhagic fever (EHF) among 173 household

contacts of 27 EHF patients, after adjusting for direct physical contact during illness and

contact with the patient's body fluids.

Dowell S F et al. J Infect Dis. 1999;179:S87-S91Kikwit Outbreak, DRC

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Ebola Virus: Clinical Course

0 2 5 10 19

Incubation Period

Illness Period

0 5 7 14 30Shock and

Multiorgan

Failure

Defervescence

And Recovery

Death

Arthralgia,

Arthritis,

Hepatitis,

Myelitis,

Orchitis

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• Patients cleared from isolation after negative blood test for virus

• Yet patients urine will carry virus for 2 more weeks

• Think of this when toileting is discussed later

• Semen will continue to carry virus up to 3 months

• Test for virus has a 24 hour turn around time

Recovery

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• If the patient declines at the 5-7 day period stool and vomitus is copious

• 10-15 liters of highly infectious waste a day

• Normal waste handling systems break down

• Toileting considered safe for HIV was not allowed in Atlanta and Dallas

• Subsequent studies show it is not a risk to toilet Ebola waste

• Ebola Waste is considered high risk waste

• Storage on site different

• Special permits needed

• In Dallas waste reached the ceiling of the patient room

Health Care Challenges

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Health System Response Plan

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Ebola Response Task Force

• Infection, Prevention Control and Epidemiology

• Emergency Preparedness

• Physicians and nurses from the following areas

• Critical Care

• Emergency Medicine

• Ambulatory

• OB

• RT

• Lab

• Pharmacy

• Facilities Engineering

• Environmental Services

• Communications

• Administration

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Health System Response Plan – The Plan

• Evidence-based

• Intentionally a working plan

• Pragmatic

• Assessing realistic risk in all populations we serve

• Comprehensive, detailed and across continuum of care

• Effective and actionable

• Safe for our providers, other patients and visitors and families

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Health System Response Plan

Core elements:

• Emergency Department

• Ambulatory

• Flow of infected patient

• Infectious Disease Care Unit (IDCU)

• Ebola PPE Kit, containing personal protective equipment (PPE)

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• People traveling from endemic countries are followed upon entry into the US

• Followed again on arrival to SD

• Temperature taken two times a day when in window period

• Designated hospitals for care of patient

• UCSD is the only designated hospital in San Diego

Advantages of the current state

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Health System Response Plan –Emergency Department

Emergency Department

• Standardized questionnaires at Check In including fever and travel history

• EPIC documentation tools

• Patient information sheet

• Process for managing a suspect patient

• ISOLATE, contact IPCE MD via page operator per protocol

• Await IPCE MD Instructions for communication with SDPH and patient disposition

• Safely transport to the IDCU

• Staff training on specialized Ebola PPE and drills starting week Oct 20

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Health System Response Plan – Ambulatory

Ambulatory

• Standardized questionnaires at registration combined with phone triage

• EPIC documentation tools

• Patient information sheet

• Process for managing a suspect patient

• ISOLATE, contact IPCE MD via page operator per protocol

• Await IPCE MD Instructions for communication with SDPH and patient disposition

• Staff communication and education ongoing

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The Ebola patient flyer

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• Most of the US is ignorant of West African geography

• High fear environment

• Gaming the system

• Appearing to be an Ebola patient can be percieved as having advantages

Surveillance always finds something

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Who of the following is contagious for Ebola?

• “I have vomiting & diarrhea and just flew in on South West Airlines from Liberia.”

• “I flew in on a plane from Ethiopia and sat next to a Nigerian 3 days ago – and then I sneezed today.”

• “I drank from a bottle today that I shared with someone who said he was from Africa, west Africa that is, I think.”

• “I have a fever and I was in Equatorial Guinea last week. “

NONE OF THE ABOVE

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Infectious Disease Care UnitIDCU

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• Mandatory

• ICU capable

• Preferably away from other patients

• Not for IC reasons but for PR reasons

• Dallas nearly bankrupt

• Negative airflow

• State regulation

• Spacious

• Preferred

• Flow from dirty to clean

• Donning and doffing area with observation

Unit Needs

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We didn’t have thatWe had a lemon so

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Health System Response Plan –Infectious Disease Care Unit

Infectious Disease Care Unit

• Located in MOS North

• Facilities and Engineering has modified to create a self-contained care unit

• Ante-room

• Staff respite spaces

• Communication infrastructure

• Ability to handle waste

• Separation between clean and dirty

• Designated and separate spaces for donning and doffing

• Two observers directly outside the containment areas

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IDCU Synopsis

• The unit was converted from a Cath Lab Recovery area.

• It is approximately 1500 sq. ft. of space

• About 120 people have volunteered to provide care

• Almost 90% of personnel have been trained to current PPE

• CDC, CHPH, Cal ohsa and NIOSH visited on December 5, 2014

• Making adjustments based on recommendations

• Management of unit is currently a multi-disciplinary approach

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Health System Response Plan – Infectious Disease Care Unit

Infectious Disease Care Unit Personnel

• Within the contained care area

• Two physicians [one critical care]

• Three nurses [two critical care]

• One RT

• In the anteroom, will have trained observer in continuous communication monitoring infection prevention practices to ensure the safety of the care team

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• To limit staff in the room

• PA system with over ride given to those outside the IDCU

• IPADs

• Computers inside

• How to listen to heart rate, breath sounds

Communication

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The Room (for Direct and ED Admissions)

• No woven material! (like curtains or chairs) –if they are in there they get pitched

• All materials in the room will be sequestered:

• Disposable material will be destroyed

• Non disposable materials will be sequestered

• Safe cleaning and disinfection protocols have been developed

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Ebola Waste:Cleaning, Handling of Trash/Linen Guidance

• CDC Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus should be

followed (http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html)

• Trash and Linen will be managed by EVS dedicated personnel and should be separate from other

clinical linen and waste.

• Dedicated medical equipment (preferably disposable, when possible) should be used for patient care.

• All non-dedicated, non-disposable medical equipment used for patient care should be thoroughly

cleaned and disinfected with hospital apaproved disinfectants and according to manufacturer’s

recommendations.

• All disposable items and linen in the patient’s room must be managed as biohazardous waste.

• When removing from room, place biohazard bag in second clean red bag held by another staff

member with clean gloves (i.e. double bag), to assure the outer bag is clean.

• Before exiting the patient room or care area, personal protgective equipment (PPE) should be carefully

removed without contaminating one’s eyes, mucous membranes, or clothing with potentially infectious

materials. Disposed of in a red biohazard trash bag/can.

• If gross contamination of the room is present, contact EVS for blood/body fluid management.

• Health care workers or EVS workers performing environmental cleaning

and disinfection must wear all recommended PPE.

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Ebola PPE Kit

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Checklist for Patients Being Evaluated for Ebola Virus Disease (EVD) in the United States

Upon arrival to clinical setting/triage

� Assess the patient for a fever (subjective or ≥ 100.4°F / 38.0°C)

� Determine if the patient has symptoms compatible EVD such as headache, weakness, muscle pain, vomiting, diarrhea, abdominal pain or hemorrhage

� Assess if the patient has a potential exposure from traveling to a country with widespread Ebola transmission* or having contact with an Ebola patient in the 21 days before illness onset Suspect Ebola if fever or compatible Ebola symptoms and an exposure are present See next steps in this checklist and the Algorithm for Evaluation of the Returned Traveler for Ebola at http://www.cdc.gov/vhf/ebola/pdf/ebola-algorithm.pdf

Upon initial assessment

� Isolate patient in single room with a private bathroom and with the door to hallway closed

� Implement standard, contact, & droplet precautions � Notify the hospital Infection Control Program at ________________________________________

� Report to the health department at ____________

Conduct a risk assessment for: High-risk exposures

� Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fuids from an EVD patient

� Direct skin contact with skin, blood or body fuids from an EVD patient

� Processing blood or body fuids from an EVD patient without appropriate PPE

� Direct contact with a dead body in an Ebola-af ected area without appropriate PPE

Low-risk exposures

� Household members of an EVD patient or others who had brief direct contact (e.g., shaking hands) with an EVD patient without appropriate PPE

� Healthcare personnel in facilities with EVD patients who have been in care areas of EVD patients without recommended PPE

Use of personal protective equipment (PPE)

� Use a buddy system to ensure that PPE is put on and removed safely

Before entering patient room, wear:

� Gown (fuid resistant or impermeable) � Facemask � Eye protection (goggles or face shield) � Gloves

If likely to be exposed to blood or body fluids, additional PPE may include but isn’t limited to:

� Double gloving � Disposable shoe covers � Leg coverings

Upon exiting patient room

� PPE should be carefully removed without contaminating one’s eyes, mucous membranes, or clothing with potentially infectious materials

� Discard disposable PPE � Re-useable PPE should be cleaned and disinfected per the manufacturer’s reprocessing instructions

� Hand hygiene should be performed immediately after removal of PPE

During aerosol-generating procedures

� Limit number of personnel present � Conduct in an airborne infection isolation room � Don PPE as described above except use a NIOSH certif ed f t-tested N95 f ltering facepiece respirator for respiratory protection or alternative (e.g., PAPR) instead of a facemask

Patient placement and care considerations

� Maintain log of all persons entering patient’s room � Use dedicated disposable medical equipment (if possible)

� Limit the use of needles and other sharps � Limit phlebotomy and laboratory testing to those procedures essential for diagnostics and medical care

� Carefully dispose of all needles and sharps in puncture-proof sealed containers

� Avoid aerosol-generating procedures if possible � Wear PPE (detailed in center box) during environmental cleaning and use an EPA-registered hospital disinfectant with a label claim for non-enveloped viruses**

Initial patient management

� Consult with health department about diagnostic EVD RT-PCR testing***

� Consider, test for, and treat (when appropriate) other possible infectious causes of symptoms (e.g., malaria, bacterial infections)

� Provide aggressive supportive care including aggressive IV fuid resuscitation if warranted

� Assess for electrolyte abnormalities and replete � Evaluate for evidence of bleeding and assess hematologic and coagulation parameters

� Symptomatic management of fever, nausea, vomiting, diarrhea, and abdominal pain

� Consult health department regarding other treatment options

This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.

* See 2014 Ebola Outbreak in West Africa — Case Counts or http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html to determine if a country has widespread Ebola transmission

** See Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus or http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html

*** See Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Persons Under Investigation for Ebola Virus Disease in the United States or http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-specimen-collection-submission-patients-suspected-infection-ebola.html

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Don and Doff PPE in Correct OrderVersion 1

Donning (Don OUTSIDE the Patient Room) Removing (Remove IN the Patient’s Room or

Anteroom)

1. Clean and Dry hands

1. Remove 1st pair of Gloves. Wipe 2nd pair of gloves with Cavicide 1 wipe

2. Leg/Shoe covers

2. Remove leg/shoe covers

3. Impermeable Gown (tie in the back and

drape over the leg/shoe covers)

4. Remove gown from the front along with the 2nd pair of gloves. Roll the gown inside itself

5. Hand hygiene.

4. Put the mask with the face shield on

6. Remove the hood from the back 7. Remove the mask/Face Shield from back

5. Put the hood on. Tuck face shield into hood

8. Perform hand hygiene.

6. Don 2 sets of gloves over gown cuffs

9. Dispose of all PPE in biohazard waste as it is removed

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Everything is Written in Sand

• WHO, CDC and state guidelines contradict each other

• Why not go with the highest standard?

• If you aren’t used to the PPE you may be likely to contaminate yourself when doffing

• If you are overheated from a suit more likely to wipe brow

• Sometimes data proves more is worse or useless (double bagging biohazardous waste)

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EDV PPE Version 1

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• Offer respiratory protection

• Completely cover

• Have built in redundancy

• (2 layers of gloves)

• Allow staff to work for hours

• Allow staff identification outside in observation area

• Can be doffed safely

PPE musts

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• Can be doffed by only 1 person

• Everyone can doff it

• Can be doffed in a controlled manner

• Does not require a “hot rinse”

• Spraying and splashing are bad

• Cleaning when doffing is contained

• Is disposable

PPE Preferred

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• Doffing the most dangerous time

• Zero variation

• Completely visible to all sides

• Dirty to clean movement

• The doffer must enter with some physical reserve

• Process takes ~ 30 minutes

• Doffing observer can only do two doffs before they want to rush the process.

• Explicit Checklists a Must

Donning and DoffingLeave your brain at home

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No detail of donning or doffing too small

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7 pages of doffing

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Many versions, a lot of trial

and error

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No exposed skin (some versions only lasted 1 time)

Extended hood

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I want to wear what they wear in Africa!

• Designed for outside wash down

• Designed to be reusable

• Persons have been infected handling these

• Require two people to doff

• USAID says “unsafe”

• Duration of wearer ~30 minutes

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• Keeping everyone competent at donning and doffing

• Explaining updates of PPE

• Incorporating lessons learned on different fronts

• Complying with different guidelines

• Establishing expertise

• Defending choices

• Ever changing guidelines from CDC, CDPH and Cal OSHA

• Modeling exposures

• Glow Germ• Chocolate Pudding• Oatmeal

CHALLENGES

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How to Wrap an Ebola Decedent

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This Ebola PPE guidance has been updated to add detail,

clarify where needed, and improve the format.

Specifically, the guidance was updated to:

Expand the rationale for respiratory protection

•Clarify that the trained observer should not serve as an assistant for doffing

•PPE Suggest that a designated doffing assistant or “buddy” might be helpful, especially in doffing

with the powered air purifying respirator (PAPR) option

•Modify the PAPR doffing procedure to make the steps clearer

•Change the order of boot cover removal. Boot covers should now be removed after the gown or

coverall

•Clarify the types of gowns and coveralls that are recommended and provide a link to

considerations for gown and coverall selection

•Emphasize the importance of frequent cleaning of the floor and work surfaces in the doffing area.

CDC updates as of September 2015.

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The updated PPE guidance for confirmed Ebola patients can be found on CDC’s

website: http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html. CDC’s PPE guidance for clinically stable persons under investigation for Ebola can

be found here: http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance-clinically-stable-puis.html The frequently asked questions page can be found here:

http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/faq.html

Resources

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Thank you!