3/26/2015 Ebola: Past, Present, & Future Janet A. Jokela, MD, - - PDF document

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3/26/2015 Ebola: Past, Present, & Future Janet A. Jokela, MD, - - PDF document

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3/26/2015 Ebola: Past, Present, & Future Janet A. Jokela, MD, MPH, FACP, FIDSA Head, Department of Medicine, University of Illinois at Urbana Champaign Governor, ACP Downstate Region Illinois Chapter April 2015: Alaska ACP & AKOMA

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Janet A. Jokela, MD, MPH, FACP, FIDSA Head, Department of Medicine, University of Illinois at Urbana‐Champaign Governor, ACP Downstate Region Illinois Chapter April 2015: Alaska ACP & AKOMA Meeting

Ebola: Past, Present, & Future

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No financial or other conflicts of interest

3

Objectives

  • List features of the Ebola virus & Ebola virus disease
  • Describe the current Ebola outbreak in West Africa
  • Describe infection control measures and

preparedness efforts

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Patient

  • 45 year old man presented with abdominal pain, dizziness,

nausea, headache

  • T100.1°F
  • Nasal congestion, abdominal tenderness
  • CT head, abdomen/pelvis: no acute disease
  • WBC 3.08, platelets 92, glucose 180, creatinine 1.41, AST 94

(normal < 34)

  • T 103.2°F  T 101.2°F
  • Discharged: sinusitis & abdominal pain; acetaminophen

5

Three days later…

  • Returned with diarrhea, abdominal pain, fever
  • Admitted to the hospital
  • 12 hours later: explosive diarrhea, projectile vomiting
  • Day #2: too weak to use bedside commode, transferred to

ICU

  • Day #3: diagnosed with Ebola
  • Day #11: dies from Ebola

Photo of Thomas Eric Duncan

thescoopblog.dallasnews.com

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Calendar of Ebola Patient Duncan course. http://www.nytimes.com/interactive/2014/07/ 31/world/africa/ebola-virus-outbreak-qa.html

8

Past…

  • List features of the Ebola virus & Ebola virus disease
  • Describe the current Ebola outbreak in West Africa
  • Describe infection control measures and

preparedness efforts

9

Ebola Virus

  • Ebola Virus Disease (EVD)
  • Causes severe illness with 50%-90% mortality
  • First discovered in 1976
  • Democratic Republic of Congo
  • Sporadic outbreaks
  • 36% involved <10 people
  • Only 1 has involved more than 450 people

cdc.gov

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Ebola Virus

  • ssRNA
  • Filoviridae, genus Ebolavirus
  • Five species:
  • Zaire, Sudan, Taï Forest, Bundibugyo; Reston
  • Reservoirs in Nature

–

Fruit bats, other?

  • Disease: Humans, nonhuman primates (gorillas,

chimpanzees, monkeys)

cdc.gov 11 12

Transmission

  • Direct contact body fluids
  • Blood, urine, diarrhea, vomit, semen
  • Deceased
  • Medical environment/waste
  • e.g., syringes
  • “Bushmeat”
  • 21‐day incubation

cdc.gov

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  • Appear 2‐21 days after exposure
  • Fever higher than 101.5○ F
  • Severe headache
  • Muscle pain
  • Weakness
  • Diarrhea
  • Vomiting
  • Abdominal pain
  • Unexplained bleeding or bruising

Signs/Symptoms

cdc.gov 14

Chertow DS et al. N Engl J Med 2014;371:2054‐2057.

Clinical Timeline

CLINICAL FEATURES OF EBOLA VIRUS DISEASE Chart from New England Journal of Medicine Calendar of Ebola Patient Duncan course. http://www.nytimes.com/interactive/2014/07/ 31/world/africa/ebola-virus-outbreak-qa.html

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Calendar of Ebola Patient Duncan course. http://www.nytimes.com/interactive/2014/07/ 31/world/africa/ebola-virus-outbreak-qa.html Calendar of Ebola Patient Duncan course. http://www.nytimes.com/interactive/2014/07/ 31/world/africa/ebola-virus-outbreak-qa.html

18

Clinical findings

  • Fluid losses: 5‐10 L/day
  • Hypovolemia
  • Despite weight gains 15‐20 kg
  • Electrolyte imbalance
  • arrhythmias
  • Malnutrition
  • Virus detected: blood, urine, vomitus, stool, semen, on skin
  • Environmental testing (Emory): no virus

Lyon GM, et al. NEJM, 12/18/2014

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Graph from: Lyon GM, et al. NEJM, 12/18/2014

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Unexpected findings: Emory

  • Point of care lab vs. hospital lab
  • Shipping commercial carriers
  • Local water authority
  • Bleach
  • Autoclaving waste
  • Media
  • Pizza

Lyon GM, et al. NEJM, 12/18/2014

fastpizzamountainview.com, scoopnest.com

21

Environment

  • Six hours (saliva, blood, fecal material, urine,

semen)

  • Stable longer: if dark or cold, moist
  • Bodies: up to a week
  • Disinfected by 0.05% bleach

cdc.gov

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Clinical course

  • Age (Sierra Leone)
  • Under 21 years—57% fatality rate
  • Over 45—94% fatality rate
  • Antibodies
  • Monoclonal: Zmapp
  • From survivors

Schieffelin JS, et al. NEJM, 11/27/2014 23

Diagnosis & Treatment

  • Testing performed via CDC/Public Health
  • No vaccine or medication proven effective
  • Only treatment is supportive care

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Present…

  • List features of the Ebola virus & Ebola virus disease
  • Describe the current Ebola outbreak in West Africa
  • Describe infection control measures and

preparedness efforts

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Moving Target…

jbblog.flopro.taco-hvac.com

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Ebola Outbreak 2014‐2015

  • Persistent transmission only in Sierra Leone &

Guinea

  • Liberia: last Ebola patient sent home 3/6/2015
  • As of March 11, 2015
  • 24,385 total cases
  • 10,019 deaths
  • In the US
  • 2 cases acquired here—recovered
  • 8 imported cases—two deaths

cdc.gov

Graph – how many people have been Infected in Africa? NYTimes, Feb. 17, 2015

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Graph of new patients each week: Liberia, Sierra Leone, Guinea NYTimes, 3/11/2015 http://www.nytimes.com/ interactive/2014/07/31/world/ africa/ebola‐virus‐outbreak‐qa.html Map of Cases of Ebola Outside of West Africa NYTimes, November 5, 2014 http://www.nytimes.com/interactiv e/2014/07/31/world/africa/ebo la-virus-outbreak-qa.html

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Patients diagnosed in U.S.

  • Sept. 30—first patient diagnosed Dallas (dies Oct. 8)
  • Oct. 10—nurse diagnosed (d/c 10/24)
  • Oct. 15—second nurse diagnosed (d/c 10/28)
  • Oct. 23—medical worker diagnosed NYC
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Multi‐pronged effort

The Opinion Pages: Room for Debate NYTimes, October 2, 2014

kiimblecharting.tumblr.com

NYTimes photo of young Girl on ground with crowd And police watching from Across the street

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Craig Spencer, MD

“Failing to stop the epidemic at its source threatens everyone”

Spencer C, NEJM, 2/25/2015

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Present…

  • List features of the Ebola virus & Ebola virus disease
  • Describe the current Ebola outbreak in West Africa
  • Describe infection control measures and

preparedness efforts

36

Triage

  • Travel history
  • Private room

cdc.gov

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Prevention Measures

  • Staff
  • Regular practice
  • Limit number of staff entering the patient room
  • Dedicated clinical care team (inpatient)
  • Post an Entry Log outside of patient room
  • Properly don, doff, and dispose of PPE
  • Perform hand hygiene diligently
  • Visitors
  • No visitors in the patient room

cdc.gov

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Biocontainment Units

  • Emory
  • Omaha, NE
  • NIH
  • Missoula, MT

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Special units

  • Patient care rooms
  • Anteroom
  • Autoclave
  • Point‐of‐care lab
  • Nebraska: 5 rooms, 2 beds each
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Staff

  • 21 RN team
  • Routine, ongoing training; volunteers
  • Respiratory therapists, patient care technicians
  • Day shift: 6 staff members (at least 3 RN’s)
  • Autoclaver
  • “Doffer”
  • Bedside nurse always with patient
  • Four hours at a time

medscape.com 44

In the patient room

  • Anytime staff member has contact with patient, or fluids:
  • uter gloves removed, middle layer bleach wiped, replace outer

gloves

  • Every night:
  • Staff clean room (not housekeeping)
  • Every surface bleach wiped
  • Separate mop buckets each area (nurse’s station, patient room,

hallway)

  • Mop heads changed

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Personal Protective Equipment

  • Surgical boot covers (knee high)
  • Impermeable gown
  • Hood
  • Gloves: three pairs
  • N‐95 mask
  • Face shield
  • Apron (for specific procedures, then removed

immediately)

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Future…

  • What are the other current issues and concerns?

47

Questions

  • Does the infectious dose of virus depend upon how

it enters the body?

  • Does the length of the incubation period depend

upon how the person was infected?

  • Optimal decontaminants?
  • Economic and social impact?
  • Etc…

48

IOM Research Priorities

  • PPE training
  • Supply chain optimization
  • Standards for PPE apparel/equipment
  • Developing a framework for evaluating the system in which

PPE is embedded

  • Compliance with PPE use
  • Healthcare worker fatigue
  • Socializing in the workplace & with family

2014

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Vaccine

  • Multiple efforts
  • Entering final stages of trial in Guinea (03/2015)
  • Fewer patients: more challenging

50

Recovered

  • r is she?...

Photo from nydailynews.com Showing US President Hugging Dallas nurse after She was released for Ebola Treatment

October 24, 2014

Washington Post photo Of Nina Pham, Ebola survivor

Nina Pham survived Ebola, but she says she has experienced hair loss, body aches and insomnia in the months following her infection. (Smiley N. Pool/Dallas Morning News via AP) March 9, 2015

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Post‐Ebola Syndrome

  • Develops within weeks, duration months
  • Visual problems
  • May progress to blindness
  • Fatigue
  • Myalgias, arthralgias
  • Pathogenesis unknown
  • No known treatment

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Airport Screening

  • ~125 passengers/day from Guinea, Liberia, Sierra Leone
  • Since August 2014 exit screening:
  • 80,000+ passengers: 77+ denied boarding, none with Ebola
  • Entry screening October 2014:
  • JFK, Newark, Dulles, Atlanta, O’Hare
  • Three levels; monitored by local health depts.
  • Two left without symptoms, diagnosed in U.S.
  • Dallas patient, NYC patient

cdc.gov 54

New PPE

http://qz.com/346620/a-wedding-gown- designer-gave-the-ebola-hazmat-suit-a- makeover/

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New PPE

http://qz.com/346620/a-wedding-gown- designer-gave-the-ebola-hazmat-suit-a- makeover/

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Getting to Zero‐Zero

  • Zero cases, Zero transmissions
  • Pockets persist
  • Complacency
  • Unsafe burial practices

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Future

  • Screening
  • Vaccine
  • Hospital/Medical preparedness
  • Training
  • West Africa
  • Cities
  • Culture
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Thank you

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