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Current Countries affected:
Liberia, Sierra Leone, Guinea, Mali
Ebola - Cumulative Cases and Deaths
Cases
Deaths
Guinea
2155
1312
Liberia
7635
3145
Sierra
Leon
7109
1530
TOTAL 16,899 5,987
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Modes of Transmission
• Direct contact (through broken skin or mucous
membranes) with a sick person's blood or body fluids
•
•
•
•
•
•
•
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Urine
Saliva
FECES
Vomit
Semen
Objects (such as needles) that have been contaminated
with infected body fluids
Infected animals
Early Symptoms - Nonspecific
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Late Symptoms
• Bleeding
– Eyes
– Ears
– Nose
– Mouth
– Rectum(GI)
• Depression
•
•
•
•
Eye inflammation (Conjunctivitis)
Genital swelling (labia and scrotum)
Increased feeling of pain in skin
Rash over the entire body that often
contains blood *hemorrhagic)
• Roof of mouth looks red
• Seizures, coma, delirium
In Africa as many as 90% of patients die from the disease.
Patients usually die from the shock rather than blood loss.
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Is There a Cure?
••
••
There
are no antivirals effective against Ebola.
No antivirals
Passive
Passive IgG
IgG horses
from hyperimmune horses AND now recovered humans
–– Given
Given to
to infected
infected monkeys
cynomolgus monkeys
–– The
IgG recipients had no detectable day 5, in
IgG 6
study
contrast
3 virus-infected
controls
7.0 log10
• 6 IgGwith
recipients
no detectable
viremia
day 5
PFU/ml
• 3 control – All had viremia > 7.0 log10 PFU/ml
– Ebola monoclonal antibody being developed
– Biopharmaceutical
Ebola Monoclonal Ab
Inc.
Zmapp
under
development
•• Not
yet –been
tested
in humans(Mapp
for safety or
Biopharmaceutical
Inc.
effectiveness.
– Combination of 3 different monoclonal
• The Abs
product
is a combination of 3 different
that bind to the protein of the
monoclonal
antibodies that bind to the
Ebola virus.
protein of the Ebola virus.
• Treatment given to Dr. Kent Brantly
and Nancy Writebol
Arch of virology 1996;11:135
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US Diagnosed Cases
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US Diagnosed Case 1 - Thomas Eric Duncan
• Sept. 19
– Leaves Monrovia, Liberia, for a trip to the U.S.
• Exposed to Ebola but not exhibiting symptoms
– Not contagious.
– It's unclear if he knew he had been exposed.
• Sept. 20
– Changes planes in Brussels, Belgium and at Dulles
– Arrives in Dallas
• Sept. 24
– 1st Day of symptoms
– Likely when he became contagious.
• Sept. 26
– Seeks treatment at Texas Health Presbyterian Hospital Dallas (THPH)
• Communicates his recent his of travel to Liberia
• Discharged to Ivy apartments (sister’s residence)
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Second Hospital Visit - Thomas Eric Duncan
•
Sept. 28
–
–
•
Sept. 30
–
•
–
Hazmat crews decontaminate apartment
Quarantined family members are moved to an undisclosed location
Oct. 8
–
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Receives experimental drug brincidofovir
Passive antibody not available
• Ebola survivor Kent Brantly’s plasma not compatible
Condition is downgraded from serious to critical
Oct. 6
–
–
•
Condition is upgraded to serious
Contacts (paramedics and children) observed for symptoms
Court orders family to stay indoors - Ivy Apt
Oct. 4
–
–
•
Ebola is confirmed
Oct. 1-2
–
–
–
•
Transported back to THPH by ambulance - Critically ill
Admitted to ICU and placed in isolation
Duncan pronounced dead (2 weeks after symptoms)
US Diagnosed Case 2 - Nina Pham
• 26-year-old Texan
• Graduated with a BSN in 2010
• Received certification in
critical care nursing 8/2014
• Oct. 10
– Febrile
– She drove to the hospital
– Isolated within 90 minutes.
– Treated Duncan in the ICU
before his death at the
hospital.
• Oct. 12
– Ebola is confirmed
– Transferred to NIH
– Her dog was quarantined
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US Diagnosed Case 3 - Amber Vinson
• Oct. 13
– 29-yo nurse also treated Duncan at THPH
– Visited Cleveland and Akron
• Ok’d by CDC to travel!!!
– Travels back to Dallas with a low-grade fever
• 99.50F
• Oct. 14
– Vinson admitted to THPH with fever
– National Nurses United releases statement disclosing alleged
conditions at THPH
• Alleged that Duncan was treated for days without proper
protective gear
• Protocols at the facility changed frequently
• Oct. 15
– Ebola is confirmed - 2nd person to contract Ebola on U.S. soil
– Hazmat crews clean apartment
– Transferred to Emory Healthcare in Atlanta
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Controlled Travel Guidance
13
135 on flight
More Complex Than Originally Thought
No Cases!!!
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US Diagnosed Case 4 - Craig Spencer
• Oct. 17
– 33 yo physician
– Treated Ebola patients in Guinea
– Returned to U.S. via JFK
– Passed all travel screening (no symptoms)
• Oct 17-23
– Monitored fever twice a day
– Went bowling
– Ate at the Meatball Shop
– Traveled on the NYC subway
• Oct. 23
– Physician self reported fever to health department
and was transferred to NY Bellview hospital
– Diagnosed with Ebola by CDC
• As of Oct 31st still hospitalized
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Body Fluids Containing Ebola
• The virus is most abundant in blood and diarrhea.
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–
–
–
–
–
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Urine
Vomit
Sputum
Breast milk
Sweat
Tears
Semen
• Believed that amount of Ebola virus in fluids, like saliva
and sweat, to be much lower.
• Viremia – 1 ml blood
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Ebola
HIV
HCV
10 billion
50,000 – 100,000
5 - 20 million
Duration of Infectivity of Body Fluids
Virus culture (RT-PCR) results from 54 clinical samples collected from 26 patients with laboratory-confirmed Ebola
Bausch D G et al. J Infect Dis. 2007;196:S142-S147
© 2007 by the Infectious Diseases Society of America
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Is Ebola airborne?
• 1995 Ebola outbreak in the Democratic Republic of Congo
– Followed family members of 27 infected patients
– 78 people not infected
• Had no direct contact
– 28 infected
• Had some sort of physical contact
– “No convincing epidemiological evidence that airborne transmission
occurs from an infected person to a nearby non-infected person,"
• With aerosol generating procedures Ebola can be in large
droplets, which neither travel very far nor hang in the air.
Generally, EBOLA IS NOT AIRBORNE
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UPMC Ebola Preparedness
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Suspicious Patient - What to do?
•SCREEN
•ISOLATE
•CALL/EVALUATE SIMULTANEOUSLY
– CALL 412-647-700
– ADDENDING EVALUATES PATEINT
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UPMC Ebola Website
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UPMC Ebola Protocol
• Protocol undergoes regular review
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Initial Ebola Patient Screening
Screen all patients where care is to be provided (to include home
health) for symptoms and risk factors within 21 days of exposure :
• Risk Factors
 Symptoms
 Residence in (or travel to) Africa
-OR Direct, unprotected contact with
blood, other body fluids,
secretions, or excretions of a
person or animal with confirmed
or suspected Ebola
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AND
 Fever >37.5◦ C (>99.5◦ F)
 Aches
 Nausea
Patient Management
A positive initial screen is defined by having both risk factors and
consistent symptoms within 21 days of potential exposure
• Positive initial screen triggers and automated email to:
– Ebola Team
– Infection Control per facility
• Droplet/Contact Isolation is automatically ordered for patient
• Place a mask over the nose and mouth of the patient
– Emergency Department
• Place patients in single patient room.
• A negative pressure room can be considered if an aerosol generating
procedure is expected BUT is NOT required.
• Door must remain closed.
– Outpatient Area
• Place patient in an exam room or private area.
• Door must remain closed.
This triggers a further evaluation by the Ebola Team (412) 647-7000
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EBOLA Team Secondary Evaluation
• Symptoms
• Risk Factors
– Residence in (or travel to)
• Liberia
• Sierra Leone
• Guinea
AND
–
–
–
–
-OR– Direct, unprotected contact
with blood, other body fluids,
secretions, or excretions of a
person or animal with
confirmed or suspected Ebola
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–
–
–
–
–
Fever >37.5◦ C (>99.5◦ F)
Chills
Myalgia
Diffuse erythematous
maculopapular rash (day 5-7),
usually involves face, neck, trunk,
and arms, that can desquamate
(shed)
Severe, watery diarrhea
Nausea or vomiting
Abdominal pain
Confusion
Multi-organ failure
Septic shock
• If the Ebola TEAM believes the “Patients Under Investigation” definition is met the UPMC Ebola
core team and Department of Health (DOH) are notified.
• If transfer is necessary it will be coordinated by the Ebola Team via EMS
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CDC Guidance for Personal Protective Equipment
3 Key Principles
#1 – Rigorous and Repeated Training
#2 – No Skin Exposure When PPE is Worn
#3 – Trained Observer will ALWAYS accompany
Care Giver in an in-patient setting
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Ebola Clinical Response Team
• Ebola Manager
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–
–
–
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Clinical Administrator (on-site 24/7)
No PPE required; remain outside soiled area
Oversee the healthcare workers and patient safety.
Ensure the safe and effective delivery of Ebola treatment.
Infection control
• Supply monitoring
• Monitor/document persons entering room on personnel log
• Trained Observer
–
Only Physicians and Nurses
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Wears Level 1 PPE
–
Observe donning/doffing PPE to ensure steps are completed safely in the appropriate sequence
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Address immediately (in real-time) any deviations from the prescribed process
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Observe overall conditions, including identification of any immediate HCW health needs
• Caregiver
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Only Attending Physicians and Nurses
• NO TRAINEES
Wears Level 2 PPE
Responsible for all aspects of patient care
Perform Daily room cleaning
Isolation Precautions
Who wears what?
LEVEL 1
• Evaluating Patients
with no anticipated
exposure to blood or
bodily fluids
• Trained observer
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LEVEL 2
• Evaluating Patients
with anticipated
exposure to blood or
bodily fluids
• All care provided by
Ebola Clinical
Response Team
Isolation Precautions
LEVEL 1
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•
•
•
•
•
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Double-glove
Impervious gown
Surgical cap
Surgical Mask
Boot Covers
Face Shield
Isolation Precautions
LEVEL 2
• Double-glove
• Tycham Suit or Impervious
gown
• Apron (only for copious
fluid exposure)
• Surgical Hood
• N95 Mask
• Boot Covers
• Face Shield
• REQUIRES a Trained
Observer
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Isolation Precaution Education
• U learn Module*
• PPE Donning and Doffing
– Log in to My HUB and select the
uLearn tab.
– From the My Current Learning
page, click the launch button to
the right of the Ebola
Preparedness training.
– Mandatory for Select Staff
• Video available on
Ebola page on
infonet
– Available for ALL Staff
*For detailed instructions on how to launch and complete a web-based course, click on the following printable user guide: How to
Launch or Re-Launch a Course.
If you require additional assistance with accessing or completing this training, please contact the uLearn support team at:
TDRegistration@upmc.edu.
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Patient Environment Cleaning
• Only Ebola Care Team will perform daily cleaning
• Use EPA registered, hospital approved disinfectants for
disinfecting environmental surfaces, with label claim for
non-enveloped virus, e.g., norovirus, rotavirus,
adenovirus, poliovirus.
• OxyCide
• Clorox Bleach wipes or like product
• Terminal cleaning will happen per Ebola Environmental
Protocol which includes but not limited to:
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–
–
–
–
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Letting room sit for period of time prior to cleaning
Using florescent dye to monitor cleaning
Supervisor assistance
UV disinfection
Disposable cleaning cloths, wipes and mops will be utilized
Waste Management
• Disposal of ALL Material as Category A HAZARDOUS WASTE
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–
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–
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Linens
Textile/cloth privacy curtains
All trash
Soiled PPE that is to be replaced in the room
Diagnostic Testing Materials
• Employees who prepare Ebola waste materials for transportation are
must be trained in accordance with 49 C.F.R., Part 172, Subpart I
– Prepare shipping papers, packaging, labeling, and marking of packaging
• The training must include:
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–
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General awareness
Function-specific
Safety
Security awareness training
Despite CDC guidance supporting waste disposal, Allegheny County Sanitary Authority
(ALCOSAN) does NOT permit human waste to be flushed into the sewer.
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Questions?
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