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Ebola and preparedness for the outpatient setting

Ebola and preparedness for the outpatient setting. The Colorado Medical Society is proud to host:. featuring Connie Savor Price, MD. FOR AUDIO: Dial -In Number (U.S . & Canada): 866.740.1260 Access Code: 8586318. Ebola and Preparedness for THE outpatient setting.

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Ebola and preparedness for the outpatient setting

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  1. Ebola and preparedness for the outpatient setting The Colorado Medical Society is proud to host: featuring Connie Savor Price, MD FOR AUDIO: Dial-In Number (U.S. & Canada): 866.740.1260 Access Code: 8586318

  2. Ebola and Preparedness for THE outpatient setting Connie Savor Price, MD Chief, Infectious Diseases Denver Health and Hospital Professor of Medicine University of Colorado Colorado Medical Society November 4, 2014

  3. Disclosures • Grants/Research Support: AHRQ; DHHS/CDC; VA Foundation; Accelerate Diagnostics; Deptof Defense; Medimmune; Rebiotix • Consultant: Accelerate Diagnostics, DHHS/Office of the Assistant Secretary for Preparedness and Response (ASPR), Johns Hopkins International, Kingdom of Saudi Arabia Ministry of Health • Speaker’s Bureau: None • Stock Shareholder: Doximity • Other Financial or Material Support: None

  4. Objectives Upon completion of this webinar, participants should be able to . . • Define the epidemiology of the current Ebola outbreak • Describe the risk factors for transmission of Ebola • Apply sound infection prevention strategies to suspected Ebola patients in the outpatient setting

  5. BACKGROUND

  6. Ebola patient left to die outside Liberian hospital because there is no more room

  7. How Many People Have Been Infected? As of October 29, 2014 • More than 13,000people in Guinea, Liberia, Nigeria, Senegal and Sierra Leone have contracted Ebola since March • More than 4,900people have died • Liberia: cases doubling ~ every 15-20 days; Sierra Leone and Guinea: cases doubling ~ every 30-40 days http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html?_r=1

  8. New cases for the week ending Oct. 21 Where is the Outbreak? Montserrado County in Liberia, which includes the capital, Monrovia, recorded over 300 new cases in the week ended Oct 21 Number of New Cases Each Week http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html?_r=1

  9. Africa is the 2nd Largest Continent It is at least 4 times bigger than the continental US The current Ebola activity is focused in a very small part of Western Africa 2014 Ebola Outbreak

  10. Cumulative Cases in Liberia Best-case scenario 11,000-27,000 cases through Jan. 20 Worst-case Scenario 537,000-1.4 Mcases through Jan. 20 0 2 4 6 8 10 12 14 Assumes 70 percent of patients are treated in settings that confine the illness and that the dead are buried safely. About 18 percent of patients in Liberia and 40 percent in Sierra Leone are being treated in appropriate settings. If the disease continues spreading without effective intervention Hundreds of Thousands Range http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html?_r=1 MMWR September 23, 2014 / 63(Early Release);1-14

  11. Comparison to Past Ebola Outbreaks Ebola cases and deaths by year, and countries affected Cases Deaths 2014 1976 (virus discovered) 2007 1995 2000 4th Uganda, Democratic Republic of Congo 5th Democratic Republic of Congo 3rd Uganda 1st Sierra Leone, Liberia, Guinea, Nigeria 2nd-worst year Sudan, Democratic Republic of Congo 602 cases (dark orange) 431 deaths (light orange) 315 cases 254 deaths 413 cases 224 deaths 425 cases 224 deaths 6,553 cases 3,083 deaths as of Sept. 26 http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html?_r=1

  12. Why Is this Outbreak So Hard to Contain? • Lack of knowledge amongst the population about Ebola • High mobility of people in this area of the world • Wide geographic spread of cases • Distrust of medical personnel • Fear • Incomplete contact tracing • Burial rituals- deceased people are usually washed and then clothed • Culinary practices– bats, bushmeat • Lack of adequate public sanitation • Accessto healthcare • Emergence in several highly populated areas in West Africa

  13. US to Ramp Up Ebola ResponseInitiatives Planned by President Obama http://www.wsoctv.com/ap/ap/top-news/us-to-assign-3000-from-us-military-to-fight-ebola/nhNR4/

  14. There Are No Regularly Scheduled Direct Flights To The U.S. From Liberia, Guinea Or Sierra Leone http://fivethirtyeight.com/datalab/why-an-ebola-flight-ban-wouldnt-work/

  15. Ebola Outside of Africa (n=18) Recovered In treatment Died As of Oct. 28, 2014 A doctor, who was recently in Africa treating Ebola patients, tested positive on Oct. 23. Oslo Hamburg London Leipzig Paris Omaha Frankfurt New York NIH Madrid Dallas Atlanta A Spanish nurse contracted Ebola while treating a missionary who died in a Madrid Hospital. The two nurses who contracted Ebola at a Dallas hospital were transfered to biocontainment units in Atlanta and Bethesda Countries with Ebola outbreaks (Nigeria now contained) http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html?_r=1

  16. Timeline: Ebola Arrival and Spread in a Dallas Hospital 9/28* 10/8 9/25 9/24 9/19 9/20 9/30* 10/11 10/15 * Nurse 1 and 2 were treating the patient during this time

  17. Ebola Among Health Care Workers In West Africa As of October 14, 2014 West African Healthcare Workers MSF Healthcare Workers

  18. US Hospitals Designated To Accept Ebola Patients* *A full list is forthcoming New York/ Long Island Omaha Bethesda Chicago Denver/Aurora Atlanta http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html?_r=1

  19. The Ebola Virus • Ebola hemorrhagic fever or EVD • Viral Hemorrhagic Fever • Rare and deadly disease • Caused by infection with one of the Ebola virus strains. • Named after the Ebola River in the Democratic Republic of the Congo (formerly Zaire) • First outbreak (Zaire 1976) • 318 human cases • 88% mortality • Spread has been due to healthcare sites, burial rituals and close family contact with ill patient's • Five types • Zaire, Sudan, Tai Forrest, Bundibugyo and Reston

  20. Ebola Ranks Relatively Low On The Contagiousness Scale R0 (“R-nought”) Although HIV and Ebola have similar R0s, but Ebola's infections per unit of time is much higher than HIV. When everyone is vaccinated, the R0 to ~zero for measles. Because people with Ebola aren't contagious until they show symptoms,R0 is certain to be way less than two in this country

  21. Where Does Ebola Come From?

  22. Transmission • Highly infectious but not highly transmissible • Index case likely becomes infected through contact with an infected animal • Once an infection occurs in humans, the virus spreads through direct contact (through broken skin or mucous membranes) with • A sick person's blood or body fluids (urine, saliva, feces, vomit, and semen) • Objects (such as gloves, needles) that have been contaminated with infected body fluids (virus can survive in environment many days) http://www.cdc.gov/vhf/ebola/transmission/index.html

  23. Virus Survival • Can survive for several hours on surfaces • Environmental testing of high touch surfaces in an Emory patient room negative • May survive up to 6 days in moist environment • Enveloped virus: standard disinfectants (detergent, 70%ethanol, bleach) are effective Ribner B., IDWeek 2014

  24. Symptoms in Confirmed and Probable Ebola Patients in West Africa, 2014 (n=467-1151) Dye, C. N Engl J Med 2014;371:1481-95

  25. Time between Exposure and Disease Onset, West Africa, 2014 The mean incubation period was 11.4 days. Approximately 95% of the case patients had symptom onset within 21 days after exposure Dye, C. N Engl J Med 2014;371:1481-95

  26. Diagnosis • Laboratory findings may include low white blood cell and platelet counts and elevated liver enzymes. • Virus detectable by real-time RT-PCR from 3-10 days after symptoms appear (may be detectable earlier) • Collect a minimum volume of 4mL whole blood (preserved with EDTA) in plastic collection tubes • All suspect cases should be immediately reported to the CDPHE Communicable Disease Branch for approval for diagnostic testing • Testing should encompass evaluation for other sources of febrile illness in the returned traveler

  27. Treatment • Severely ill patients require intensive supportive care. • Patients are frequently dehydrated and require oral rehydration with solutions containing electrolytes or intravenous fluids. • New drug therapies are being evaluated. Emergency investigational new drug application and IRB needed • Mapp Biopharmaceutical and contact information at • http://www.mappbio.com/ • ZMapp information at • http://www.mappbio.com/zmapinfo.pdf • Chimerixbrincidofovir information at  • http://ir.chimerix.com/releasedetail.cfm?releaseid=874647

  28. washingtonpost.comBritish volunteer receives Ebola vaccine in second human trialBy Abby Phillip September 17 Felicity Hartnell, a clinical research fellow at Oxford University, injects Ruth Atkins with an experimental Ebola vaccine in Oxford, England. (Steve Parsons/Associated Press/Pool)

  29. Planning considerations for OUTPATIENT SETTING

  30. Assumptions for Planning • Cases will be rare • Cases will not involve multiple persons, likely just individuals • Cases will likely present through Denver International Airport (DIA), Emergency Departments (ED), Urgent Care, less likely on a routine clinic visit • Based on the epidemiology to date in the US, these assumptions are functional for planning at this time, adjustments will be made if warranted. • STAFF SAFETY IS #1 PRIORITY

  31. “Ask. Isolate. Call.”

  32. Ask: About travel to the 3 countries of interest (Sierra Leone, Liberia, Guinea) Ask: About exposure to persons with Ebola Ask: About symptoms consistent with Ebola Virus Disease Ask: EVERYONE, EVERY TIME Who should ask? MDs, nurses, triage staff, first responders, front office staff “ASK”

  33. Screening • Screening of patients at all points of first access • Clinics, Urgent Care Centers, ED, Paramedics, Call Centers • Patient waiting areas shall have signs posted instructing patients to notify provider if they have traveled to West Africa in past 3 weeks • Providersshall have screening tools in provider work areas and exam areas with screening questions

  34. Please alert your provider if you have traveled to West Africa in the past 3 weeks Por favor, informe a su médico si usted ha viajado a África occidental en las últimas 3 semanas S'il vous plaît alerter votre fournisseur si vous avez voyagé en Afrique de l'Ouest au cours des 3 dernières semaines

  35. When to Suspect Ebola Suspect Ebola in patients who have TRAVELED TO GUINEA, SIERRA LEON, or LIBERIA WITHIN 21 DAYS of symptoms or contact with blood or body fluids of another person known to have or suspected to have Ebola AND One or more of the following SYMPTOMS: Fever (subjective or measured greater than 38.0°C or 100.4°F) - Severe headache - Muscle Pain - Weakness - Abdominal (stomach) pain - Vomiting - Lack of Appetite - Diarrhea - Unexplained bleeding or bruising

  36. Modified from Identify, Isolate, Inform: Emergency Department Evaluation and Management for Patients Who Present with Possible Ebola Virus Disease http://www.cdc.gov/vhf/ebola/hcp/ed-management-patients-possible-ebola.html Oct 31, 2014 Call CDPHE 303-692-2700 or 303-370-9395 (after hours) Call 911

  37. Personal Protective Equipment • Initial Evaluation for Clinically Stable and “Dry” Patient • Face shield • Mask or respirator • Gown- Impermeable or fluid resistant • Gloves (double) • Limit patient and environmental contact • Hospital Management for Clinically Unstable or “Wet” Patient* • Impermeable gown, 2 layers of gloves, N95 or PAPR hood, Face shield, Surgical hood, Boot covers • Strict donning/doffing protocol with trained staff • Always work in pairs • Must document competency • Essential staff only *http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html Requires evaluation and care in a specialized (usually ED) setting with facilities and trained staff

  38. Good Doffing for Everyday Infection Prevention The are general* recommendations for safe donning and doffing of PPE *Specific recommendations for Ebola are described for the hospital setting in the CDC’s Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Virus Disease in U.S. Hospitals

  39. “CALL” What to report to CDPHE (303-692-2700, evenings and weekends: 303-370-9395) • All suspect cases should be immediately reported to CDPHE. • Persons who have NO symptoms of Ebola but have exposure to Ebola (either “high-risk” or “some risk”). • State health will notify local public health agencies of a suspect case in their jurisdiction immediately. • State public health will assist all hospitals and local health departments with a suspect case. This includes coordinating with CDC, figuring out logistics, transport of patient (if needed), getting appropriate testing, case-finding, etc.

  40. Then what? Clinical and public health action plan, based on exposure risk and clinical presentation.

  41. Environmental Contamination • CDPHE will provide guidance • Do not attempt to disinfect area on your own • Block off contamination, move patients and healthcare workers away from contamination

  42. Handling Waste in Clinics • All waste will be handled as category A waste • Do not attempt to clean up or dispose of waste

  43. OUTPATIENT TABLETOP

  44. 42-year-old Liberian male presents with low-grade fever and abdominal pain +/-vomiting. What is the next step? • Prescribe ciprofloxacin for his abdominal pain and send him home • Obtain the intake nurse’s notes • Ask him when he was last in Liberia • Draw a CBC and basic chemistries • Have the patient’s family member call the CDC

  45. You are concerned for Ebola. What is the next step? Choose as many as apply • Put the patient in a negative airflow room • Find a PAPR and quickly learn how to use it • Notify public health • Put the patient in an exam room (ideally with a bathroom) • Wash your hands and put on gloves, gown (fluid resistant or impermeable), eye protection (goggles or face shield), facemask before continuing further evaluation

  46. You learn he was in Monrovia 11 days ago. Before he can answer your questions about sick contacts, he vomits at the registration desk. What do you do next? • Immediately clean it up • Block off the area and relocate patients and staff away from the contaminated space • Pour bleach on it (you planned to replace the carpet anyway) • Ask the patient to clean it up • Evacuate the building

  47. The patient is escorted to a private room. He was accompanied by family members. What do you do next? Choose as many as apply. • Escort the family members to a separate exam room • Ask if any of the family members feel ill • Ask them to leave the clinic immediately • Give them a mask • Collect their contact information • Call CDPHE

  48. The patient’s temperature is measured at 103 degrees. CDPHE has sent paramedics and the patient is removed from your clinic. What do you do next? • Cancel your clinics for the next 21 days • Make sure you take out all the trash from the patient’s exam room • Book a cruise, leave ASAP • Perform fever and symptom monitoring for 21 days • Quarantine yourself in an outdoor tent • Await further guidance from CDPHE

  49. Where do you find more information? • www.colorado.gov/ebola • www.cdc.gov/ebola • COHELP (303-389-1687or 1-877-462-2911) • www.cms.org • All of the above

  50. Questions? Connie.Price@dhha.org

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