Ebola

1. Ebola Patient management Infection Prevention and Control - October 2014

2. Ebola • Background • Case definition • Signs & Symptoms • Transmission • PPE • Donning/ doffing order with goggles and mask • N95 mask fit test • Jupiter hood • Donning/ doffing order with Jupiter hood • Patient management • Resources

3. Background Ebola Virus Disease (EVD) – previously called Ebola haemorrhagic fever - is one of numerous Viral Hemorrhagic Fevers. Fruit bats are considered to be the natural hosts with outbreaks identified amongst chimpanzees, gorillas, monkeys. Since first being identified in 1976, there have been 24 outbreaks in Central and East Africa.

4. Background The current outbreak is the first in West Africa. Countries with Widespread Transmission • Guinea • Liberia • Sierra Leone Localized Transmission • Nigeria (Port Harcourt & Lagos) • Spain (Madrid) • United States (Dallas, TX) Travel-associated Case(s)2 • Senegal (Dakar) • WHO – situation updates http://www.who.int/csr/don/archive/disease/ebola/en/

5. Background • The CDC publishes updated numbers of cases. • This can be accessed from: CDC http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html • Total Cases as at October 24, 2014 are tabled below as published by the CDC on October 25 - http://www.cdc.gov/vhf/ebola/outbreaks/guinea/index.html

6. Background As of the 30th October 2014, there have been no cases in Australia The risk of an outbreak in Australia is very low There is no evidence that Ebola is present in Australian bats Should a case be identified in Victoria, the RCH & RMH are the designated Ebola receiving hospitals

7. RCH process A guideline has been developed to managed identified cases within RCH. Relevant staff are being trained in correct donning and doffing of PPE.

8. Case definition Suspected Case Definition • Fever ≥ 380C in the last 24 hours WITH OR WITHOUT additional symptoms such as • severe headache, • muscle pain, • vomiting, • diarrhoea, • abdominal pain, or • unexplained haemorrhage AND

9. Case definition In the 21 days prior to symptoms: Residence in—or travel to—an area where EVD transmission is active OR A high risk exposure OR A low risk exposure

10. High Risk Exposure • Percutaneous • Mucous membrane or • Skin contact or exposure to blood and body fluid of a confirmed EVD patient withoutappropriate PPE Processing blood or body fluids of a confirmed EVD patient withoutappropriate PPE / biosafety precautions Direct contact with a dead body withoutappropriate PPE whereEVD transmission is active http://docs.health.vic.gov.au/docs/doc/F379C2BD968364E8CA257D540008B3CA/$FILE/Victorian%20Ebola%20Virus%20Disease%20Response%20Plan_September%202014.pdf

11. Low Risk Exposure Household contacts with a confirmedcase of EVD Persons who have had direct contact with bats or primates in States with activeEVD Being in the same room as an EVD patient with active vomiting/ diarrhoea/ coughing/ aerosol generating procedure withoutappropriate PPE Having direct brief contact –eg shaking hands with an EVD patient withoutappropriate PPE http://docs.health.vic.gov.au/docs/doc/F379C2BD968364E8CA257D540008B3CA/$FILE/Victorian%20Ebola%20Virus%20Disease%20Response%20Plan_September%202014.pdf

12. Active EVD areas • CDC and WHO provide updated lists of areas where EVD transmission is active. • This can be accessed from: • CDChttp://www.cdc.gov/vhf/ebola/index.html • WHOhttp://www.who.int/csr/disease/ebola/en/

13. Case definition Malaria diagnostics should also be a part of initial testing because it is a common cause of febrile illness in persons with a travel history to the affected countries. Source: http://emergency.cdc.gov/han/han00364.asp

14. Signs and Symptoms • Symptoms may appear anywhere from 2 to 21 days after exposure to EVD 8-11 days is most common. • Initially symptoms may have a sudden onset of • Fever • Headache • Joint and muscle aches • Stomach pain

15. Signs and Symptoms Later symptoms can include • Diarrhoea • Rash • Vomiting • Stomach pain • Unexplained bleeding or bruising

16. Transmission

17. Transmission Transmission can onlyoccur when a case has symptoms. In healthcare settings, transmission occurs through contamination of the HCWs mucous membranes or broken skin with Direct contact of blood or body fluids of an infected person Contact with a contaminated environment and equipment

18. Transmission If after 21 days an exposed person does not develop symptoms, they will not become ill with EVD

19. Personal Protective Equipment - PPE PPE requirements vary with: • the patients condition • the length of time the HCW is in the patient room • procedures to be undertaken • confirmation of EVD

20. PPE Minimum PPE requirements include: • Overshoes • Coveralls or disposable scrubs • Gloves • Gown (fluid resistant) • Balaclava • Eye protection (goggles) • Facemask Additional PPE is required in the presence of copious blood or body fluids and includes: • Powered Air Purifying Respirator (PAPR) with Jupiter hood

21. PPE A PAPR with Jupiter hood may be worn to protect the HCW • during aerosol generating procedures (AGPs) • for comfort if the HCW will be in the room for prolonged periods of time • if the HCW cannot perform an adequate fit check with a face mask • if the standard PPE does not provide adequate head coverage

22. PPE Rules Collect all items before starting Perform hand hygiene prior to donning PPE NEVERrush the removal of PPE

23. N95 mask rules Perform Hand Hygiene prior to donning & doffing mask Handle mask by edges and ties HCWs with facial hair may not be able to achieve a good fit test and should consider a PAPR for AGPs A fit check should be carried out every time a mask is applied

24. N95 mask rules Masks should never be re-used Wet or damaged masks should be discarded immediately Masks should be discarded when no longer required and NEVER allowed to dangle on front of uniform

25. N95 mask – prior to donning Hold mask upside down by the sides Push sides together to separate the mask edges Bend nose piece slightly Loosen and separate elastic ties

26. N95 – donning Picture courtesy of QLD health Place the mask under chin and bring elastic ties over head Fit flexible nose piece over nose bridge and across cheeks to create a snug fit Adjust elastics ties for comfort and fit over the crown of the head and at the base of the neck.

27. N95 – mask fit test Picture courtesy of QLD health • Perform a fit test: • Inhale – mask should collapse • Exhale – check for leakage around face • Note: • Air should not leak around the mask • Glasses or goggles should not fog up • If necessary, repeat donning of mask to achieve a good fit

28. N95 mask – doffing Picture courtesy of QLD health Perform hand hygiene Handle mask ONLY by elastic ties Lift the bottom elastic over head first Lift off top elastic Discard into bin Perform hand hygiene

29. PPE –Donning a Jupiter hood • Ensure belt has filters attached • Fasten belt and adjust to fit • Belt should sit on hips • Remove belt • Insert charged battery and ensuring it clicks into place • Attach respirator hose to belt by lining up metal nibs with holes in belt attachment, twist to secure • Attach hose to hood and ensure clicks in place • Turn on with one short press of button

30. PPE –Donning a Jupiter hood Allow hood to inflate Roll up back of hood to open Place chin in hood and pull hood over head Ensure grey head band sits horizontal on forehead Hood collar should sit under the gown when entering patient room Make sure hood is comfortable before entering patient room

31. PPE – donning and doffing Refer to the Infection Prevention and Control website for EVD PPE donning and doffing instructions http://webedit.rch.org.au/uploadedFiles/Main/Content/infection_control/EVD-PAPR-PPE-Donning-and-doffing-text.pdf

32. PPE donning Jupiter hood& coveralls

33. PPE doffing Jupiter hood& coveralls

34. Patient management Management of: Traffic management Room supplies Food Linen Waste Room cleaning Patient transfer Handling of deceased patient Specimen collection

35. Patient management Traffic Management A log of all HCWs entering the room must be maintained Limit room access to essential staff only Family/ visitors should be restricted to essential carers only

36. Patient management Room supplies Limit equipment taken into the room to what is required for that shift Any item that can not be adequately decontaminated on patient discharge WILL be discarded

37. Patient management • Food • Meals should be ordered with disposable crockery and cutlery. • All leftover food/items should be discarded into yellow clinical waste bags and treated as waste • Linen (including curtains if present) • Should be discarded into yellow clinical waste bags and treated as waste

38. Patient management • Waste • Place an anatomical sulobin outside the patient room • Carps through Support Services • Waste generated in the patient room should be placed directly into a yellow clinical waste bag • Room waste bags should be double bagged at the anteroom door using a buddy before being placed directly into the anatomical sulobin • If excess fluid is present a third clinical waste bag may be required prior to placing waste in the sulo bin

39. Patient management • Room cleaning • Daily cleaning of horizontal surfaces and spills to be undertaken by nurse caring for patient • Refer to procedure for detailed instructions • Cleaning equipment • single use only or • cleaned after use and kept in the room until the patient is discharged • Discharge clean – request Infectious clean EVD via CARPS

40. Patient management Transfer of patient • Emergency to Rosella • Director of Operation (7am to 16.30pm Monday to Friday) Nursing Hospital Manager (after hours) to facilitate Handling of deceased patient • Contact Anatomical Pathologist on call via switchboard

41. Initial Diagnostic Specimen Collection Notify and collect specimen collection kit from Laboratory Services ext 55904 When specimens have been collected they mustbe hand delivered to Laboratory Services Do NOT use the pneumatic tube

42. Initial Diagnostic Specimen Collection Collect the following specimens into tubes labelled with patient details: • EDTA blood for Ebola virus PCR • Serum gel tube • Flocked throat swab Refer to specimen collection guide in EVD Kit • Video - Remember: Hand deliver to Laboratory Services Do NOT use the pneumatic tube

43. Additional Pathology testing Avoid unnecessary pathology testing • If required -the iSTAT device will be used at the patient bedside for the following assays: Na, K, Cl, Ca, Glucose, Urea, Creatinine, lactate, Haematocrit, Haemoglobin, blood gases (pH, pCO2, pO2, Bicarbonate, BE, sO2), INR, ACT. • Obtain iSTAT from on call Clinical technologist via switchboard • Additional tests may be submitted to the laboratory using the specimen collection and transport kit ONLY AFTER consultation with the Medical Microbiologist on call.

44. Resources Series of National Guidelines –SoNG http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-ebola.htm/$File/EVD-SoNG.pdf Chief Health Officer, Victoria - http://health.vic.gov.au/chiefhealthofficer/alerts/alert-2014-07-ebola-virus-disease.htm CDC http://www.cdc.gov/vhf/ebola/index.html?s_cid=cdc_homepage_feature_001 WHO http://www.who.int/csr/disease/ebola/en/ Department of Health Ebolavirus Disease Information for Travellers, Patients and Consumers