Ebola: Preparation & Practice

1. Ebola: Preparation & Practice October 20, 2014 Elizabeth Foster, MBA Area 1 Emergency Preparedness Coordinator Alabama Department of Public Health

2. What is Ebola: Five Fast Facts • A viral hemorrhagic fever • First reported 1976 • About 30 outbreaks since that time • Current outbreak started in March 2014 • Current countries of concern include Guinea, Liberia, Sierra Leone

3. Epidemiological Risk Factors for Ebola • Travel to or living within the past 3 weeks before onset of symptoms in a country of risk. • Contact with blood or body fluids of a patient known to have or suspected to have Ebola

4. Major Clinical Features • Fever of 101.5 F or greater-87% of patients • Weakness-76% of patients • Vomiting-68% of patients • Diarrhea-66% of patients • Loss of appetite-65% of patients • Headache • Abdominal pain • Muscle pain • Unexplained bleeding

5. Other Clinical Features of Ebola May Include • Rash • Conjunctivitis • Cough • Sore throat • Chest pain • Difficulty breathing • Difficulty swallowing • Hiccups

6. Incubation Period for Ebola • Range 2-21 days • Average is 8-10 days

7. Transmission of Ebola • Blood • Body fluids • Urine • Saliva • Feces • Vomit • Semen • Breast milk (not known to be transmitted from mother to infant)

8. Mechanisms of Transmission of Ebola • Percutaneous needle stick or mucosal exposure to virus contaminated blood or body fluids • Direct care or exposure to body fluids without appropriate PPE • Laboratory processing of blood or body fluids without appropriate PPE or standard biosafety precautions • Funeral rites with human remains without appropriate PPE

9. Ebola is not transmitted from • Mosquitoes or other insects

10. Infectivity of Ebola • Contagious from onset of symptoms until recovery • Body fluids may contain virus for up to three weeks • Semen may contain virus for up to three months-sexual abstinence or condoms

11. Survival of Ebola • Ebola can survive in ideal conditions on surfaces for several hours • Ebola can survive under ideal conditions in blood or body fluids outside body for several days • HOWEVER, studies have shown that survival on surfaces not visibly contaminated is unlikely after 24 hours • THUS, environmental cleaning is important

12. Treatment of Ebola • There are no approved treatments available for Ebola. • Clinical management focus - supportive care of complications: • Recommended care includes: • volume repletion • maintenance of blood pressure (with vasopressors if needed) • maintenance of oxygenation • pain control • nutritional support • Treating secondary bacterial infections and pre-existing comorbidities Source: Centers for Disease Control and Prevention. http://www.cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcare-settings.html

13. Treatment of Ebola (continued) • Among patients from West Africa, large volumes of intravenous fluids have often been required to correct dehydration due to diarrhea and vomiting. • There are no approved vaccines available for Ebola. Several investigational Ebola vaccines are in development, and Phase I trials are underway for some vaccine candidates.

14. Contracting Risk for First Responders • The likelihood of contracting Ebola is extremely low unless a person has direct unprotected contact with the blood or body fluids (like urine, saliva, feces, vomit, sweat, and semen) of a person who is sick with Ebola or direct handling of bats or nonhuman primates from areas with Ebola outbreaks.

15. Modified Queries for Dispatch • Screen callers for the following symptoms • Has the patient or someone at the residence, have fever of 38.0 degrees Celsius or 100.4 degrees Fahrenheit or greater? • Has the patient or someone at the residence experienced severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained bleeding?

16. Modified Queries for Dispatch • Screen callers for risk factors within the past 3 weeks before onset of symptoms • Has the patient had contact with blood or body fluids of a patient known to have or suspected to have Ebola • Has the patient had residence in–or traveled to–a country where an Ebola outbreak is occurring • Has the patient direct handling of bats or nonhuman primates from disease-endemic areas

17. Modified Queries for Dispatch • If dispatch confirms information alerting them to a person with possible Ebola, they should make sure any first responders and EMS personnel are made confidentially aware of the potential for Ebola before the responders arrive on scene.

18. Patient Assessment for First Responders • Address scene safety • If the patient is suspected of having Ebola, EMS personnel should put on the PPE appropriate for suspected cases of Ebola before entering the scene. • Keep the patient separated from other persons as much as possible. • Use caution when approaching a patient with Ebola. Illness can cause delirium, with erratic behavior that can place EMS personnel at risk of infection

19. Patient Assessment for First Responders • First responders should consider the symptoms and risk factors of Ebola. • Fever of greater than 38.0 degrees Celsius or 100.4 degrees Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage. • If any of these symptoms are affirmed, first responders should then ask the patient about risk factors within the past 3 weeks before the onset of symptoms.

20. Patient Assessment for First Responders • Risk factors for 3 weeks prior onset of symptoms are: • Contact with blood or body fluids of a patient known to have or suspected to have Ebola • Residence in—or travel to— a country where an Ebola outbreak is occurring  • Direct handling of bats or nonhuman primates from disease-endemic areas

21. Patient Assessment for First Responders • Based on the presence of symptoms and risk factors • Put on or continue to wear appropriate PPE • Follow the scene safety guidelines for suspected case of Ebola • The patient then should be isolated and STANDARD, CONTACT, and DROPLET precautions followed during further assessment, treatment, and transport • If there are no risk factors, proceed with normal EMS care

22. EMS Transfer of Patient Care to a Healthcare Facility • EMS personnel should notify the receiving healthcare facility when transporting a suspected Ebola patient, so that appropriate infection control precautions may be prepared prior to patient arrival.  • Any U.S. hospital that is following CDC's infection control recommendations and can isolate a patient in a private room‎ is capable of safely managing a patient with Ebola.

23. EMS Transfer of Patient Care to a Healthcare Facility • If patient is not transported (refusal or pronouncement) • Notify Alabama Department of Public Health, Epidemiology Division: 1-800-338-8374 to report an Immediate Extremely Urgent 4-hour Notifiable Disease • Complete Ebola Consultation Record http://www.ADPH.org/Ebola/Default.asp?id=6785 and fax to 334-206-3734 or email to CDFax@ADPH.state.AL.US (Form is in your packet). • Compile a list of healthcare workers that came in contact with the patient, along with their personal contacts.

24. First Responder Infection Control Measures • EMS personnel can safely manage a patient with suspected or confirmed Ebola by following recommended isolation and infection control procedures • Protecting mucous membranes of the eyes, nose, and mouth from splashes of infectious material • Avoid self-inoculation from soiled gloves • Limit activities, especially during transport, that can increase the risk of exposure to infectious material

25. First Responder Infection Control Measures • First Responder infection control procedures continued • Limit the use of needles and other sharps as much as possible • All needles and sharps should be handled with extreme care and disposed in puncture-proof, sealed containers

26. Use of Personal Protective Equipment (PPE) • EMS personnel should wear when in contact with a suspected Ebola patient: • Gloves • Gown (fluid resistant or impermeable) • Eye protection (goggles or face shield that fully covers the front and sides of the face) • Facemask • Additional PPE might be required in certain situations including but not limited to double gloving, disposable shoe covers, and leg coverings.

27. Use of Personal Protective Equipment (PPE) • Recommended PPE should be used by EMS personnel as follows • PPE should be worn upon entry into the scene and continued to be worn until personnel are no longer in contact with the patient. • PPE should be carefully removed without contaminating one’s eyes, mucous membranes, or clothing with potentially infectious materials. • PPE should be placed into a medical waste container at the hospital or double bagged and held in a secure location.

28. Use of Personal Protective Equipment (PPE) • Recommended PPE should be used by EMS personnel as follows • Re-useable PPE should be cleaned and disinfected according to the manufacturer's reprocessing instructions and your agency’s policies. • Hand hygiene should be performed immediately after removal of PPE.

29. Donning Personal Protective Equipment • Train on Proper Procedures and use buddy system to ensure proper use • Impermeable gown or suit • N-95 Mask • Goggle/Face Shield • Gloves • Shoe/Boot cover

30. Use of Personal protective equipment (PPE)

31. Removing Personal Protective Equipment Continued • Train according to guidelines/charts • Use buddy system to enhance proper removal of PPE

32. Removing Personal Protective Attire CAREFULLY as it is Contaminated • Remove gloves • Remove face shield • Remove gown • Remove mask • Perform hand hygiene • Do not wear scrub suit that was worn under PPE including shoes away from unit

33. Environmental Infection Control • Environmental cleaning and disinfection, and safe handling of potentially contaminated materials is essential to reduce the risk of contact with blood, saliva, feces, and other body fluids that can soil the patient care environment.

34. Environmental Infection Control • EMS personnel performing environmental cleaning and disinfection should: • Wear recommended PPE and consider use of additional barriers (e.g., shoe and leg coverings) if needed. • Wear face protection (facemask with goggles or face shield) when performing tasks such as liquid waste disposal that can generate splashes

35. Environmental Infection Control • EMS personnel performing environmental cleaning and disinfection should: • Use an EPA-registered hospital disinfectant with a label claim for one of the non-enveloped to disinfect environmental surfaces. Disinfectant should be available in spray bottles or as commercially prepared wipes for use during transport. • Spray and wipe clean any surface that becomes potentially contaminated during transport.

36. First Responder Post Exposure Guidance • EMS personnel who are exposed to blood, bodily fluids, secretions, or excretions from a patient with suspected or confirmed Ebola should immediately wash the affected skin surfaces with soap and water. Mucous membranes should be irrigated with a large amount of water or eyewash solution.

37. Hand Hygiene • Before donning PPE • After removing PPE

38. Guidance for Safe Handling of Human Remains of Ebola Patients • Only personnel trained in handling infected human remains, and wearing PPE, should touch, or move, any Ebola-infected remains. • Handling of human remains should be kept to a minimum. • Autopsies on patients who die of Ebola should be avoided. If an autopsy is necessary, the Alabama health department and CDC should be consulted regarding additional precautions.

39. Personal Protective Equipment for Postmortem Care Personnel • Prior to contact with body, postmortem care personnel must wear PPE consisting of: surgical scrub suit, surgical cap, impervious gown with full sleeve coverage, eye protection (e.g., face shield, goggles), facemask, shoe covers, and double surgical gloves

40. Personal Protective Equipment for Postmortem Care Personnel • PPE should be in place BEFORE contact with the body, worn during the process of collection and placement in body bags, and should be removed immediately after and discarded appropriately .

41. Personal Protective Equipment for Postmortem Care Personnel • Use caution when removing PPE as to avoid contaminating the wearer.  • Hand hygiene (washing your hands thoroughly with soap and water or an alcohol based hand rub) should be performed immediately following the removal of PPE. If hands are visibly soiled, use soap and water.

42. Postmortem Preparation • Preparation of the body • At the site of death, the body should be wrapped in a plastic shroud • After wrapping, the body should be immediately placed in a leak-proof plastic bag not less than 150 μm thick and zippered closed • The bagged body should then be placed in another leak-proof plastic bag not less than 150 μm thick and zippered closed before being transported to the morgue.

43. Postmortem preparation • Surface decontamination • Perform surface decontamination of the corpse-containing body bags by removing visible soil on outer bag surfaces with EPA-registered disinfectants which can kill a wide range of viruses • Reusable equipment should be cleaned and disinfected according to standard procedures.

44. Postmortem preparation • Individuals driving or riding in a vehicle carrying human remains • PPE is not required for individuals driving or riding in a vehicle carrying human remains, provided that drivers or riders will not be handling the remains of a suspected or confirmed case of Ebola, and the remains are safely contained and the body bag is disinfected

45. References • www.cdc.gov • www.adph.org

46. Contact Information • Elizabeth Foster, Area 1 EP Coordinator Email: Elizabeth.Foster@adph.state.al.us Office Phone: 256-389-3534 Work Cell: 256-460-8932 • Karen M. Landers, Area Health Officer Office Phone: 256-383-1231 Work Cell: 256-246-1714

47. Questions