The Colorado Medical Society is proud to host:
Ebola and preparedness
for the outpatient setting
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
Connie Savor Price, MD
Chief, Infectious Diseases
Denver Health and Hospital
Professor of Medicine
University of Colorado
Colorado Medical Society
November 4, 2014
Disclosures
• Grants/Research Support: AHRQ; DHHS/CDC; VA
Foundation; Accelerate Diagnostics; Dept of 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
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
BACKGROUND
Ebola patient left to die outside Liberian hospital because
there is no more room
How Many People Have Been Infected?
As of October 29, 2014
• More than 13,000 people in Guinea, Liberia, Nigeria, Senegal
and Sierra Leone have contracted Ebola since March
• More than 4,900 people 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
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
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
Cumulative Cases in Liberia
0
2
4
Range
Hundreds of Thousands
8
If the disease continues
spreading without
effective intervention
6
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.
10
12
11,000-27,000 cases through Jan. 20
Worst-case Scenario
537,000-1.4 M cases through Jan. 20
14
Best-case scenario
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
Comparison to Past Ebola Outbreaks
Ebola cases and deaths by year, and countries affected
1976 (virus discovered)
2nd-worst year
Sudan,
Democratic Republic of Congo
602 cases (dark orange)
431 deaths (light orange)
Cases
1995
5th
Democratic
Republic
of Congo
315 cases
254 deaths
Deaths
2000
3rd
Uganda
425 cases
224 deaths
2007
2014
4th
Uganda,
Democratic
Republic of
Congo
1st
Sierra Leone,
Liberia, Guinea,
Nigeria
413 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
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
Access to healthcare
Emergence in several highly populated areas in West Africa
US to Ramp Up Ebola Response
Initiatives Planned by President Obama
http://www.wsoctv.com/ap/ap/top-news/us-to-assign-3000-from-us-military-to-fight-ebola/nhNR4/
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/
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.
Omaha
Dallas
Oslo
London
Paris
NIH New York
Atlanta
The two nurses who
contracted Ebola at a Dallas
hospital were transfered to
biocontainment units in Atlanta
and Bethesda
Hamburg
Leipzig
Frankfurt
Madrid
A Spanish nurse contracted Ebola
while treating a missionary who
died in a Madrid Hospital.
Countries with Ebola outbreaks
(Nigeria now contained)
http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html?_r=1
9/25
9/28*
9/30*
10/8
Nurse1 tests
positive for
Ebola
9/24
Positive Ebola
test confirmed
9/20
Seeks care at
Dallas hospital
but is sent
home
9/19
Arrives in
Dallas to visit
family.
Nurse2 tests
positive for
Ebola
Patient dies
Admitted to
Dallas hospital
and placed in
“isolation”
Begins to
develop
symptoms
Boards flight
from Liberia.
Timeline: Ebola Arrival and Spread in a
Dallas Hospital
10/11
10/15
* Nurse 1 and 2 were treating the patient during this time
Ebola Among Health Care Workers In
As of October 14, 2014
West Africa
West African Healthcare Workers
450
MSF Healthcare Workers
416
400
3
350
300
233
250
200
150
700
100
50
0
cases
deaths
MSF
healthcare
workers in
West Africa
since March
2014
Number
infected with
Ebola
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
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
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
Where Does Ebola Come From?
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
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
Symptoms in Confirmed and Probable
Ebola Patients in West Africa, 2014
100
87
80
Specific hemorrhagic symptoms were
rarely reported (in <1% to 5.7% of patients).
76
Percent
68 66
65
60
53
44
40
20
39 39 37
(n=467-1151)
33
30
23 22 21
18
13 11
10
8
6
6
0
Dye, C. N Engl J Med 2014;371:1481-95
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
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
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
• Chimerix brincidofovir information at
• http://ir.chimerix.com/releasedetail.cfm?releaseid=874647
washingtonpost.com
British volunteer receives Ebola vaccine in
second human trial
By 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)
PLANNING CONSIDERATIONS
FOR OUTPATIENT SETTING
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
“Ask. Isolate. Call.”
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”
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
• Providers shall have screening tools in provider work
areas and exam areas with screening questions
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
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
Call 911
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-possibleebola.html Oct 31, 2014
Call CDPHE
303-692-2700 or
303-370-9395 (after
hours)
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
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
“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.
Then
what?
Clinical and
public health
action plan,
based on
exposure risk
and clinical
presentation.
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
Handling Waste in Clinics
• All waste will be handled as category A waste
• Do not attempt to clean up or dispose of waste
OUTPATIENT TABLETOP
42-year-old Liberian male presents with
low-grade fever and abdominal pain +/vomiting. What is the next step?
A. Prescribe ciprofloxacin for his abdominal pain and send
B.
C.
D.
E.
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
You are concerned for Ebola. What is the
next step? Choose as many as apply
A. Put the patient in a negative airflow room
B. Find a PAPR and quickly learn how to use it
C. Notify public health
D. Put the patient in an exam room (ideally with a
bathroom)
E. Wash your hands and put on gloves, gown (fluid
resistant or impermeable), eye protection (goggles or
face shield), facemask before continuing further
evaluation
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?
A. Immediately clean it up
B. Block off the area and relocate patients and staff away
from the contaminated space
C. Pour bleach on it (you planned to replace the carpet
anyway)
D. Ask the patient to clean it up
E. Evacuate the building
The patient is escorted to a private room. He
was accompanied by family members. What
do you do next? Choose as many as apply.
A. Escort the family members to a separate exam room
B. Ask if any of the family members feel ill
C. Ask them to leave the clinic immediately
D. Give them a mask
E. Collect their contact information
F. Call CDPHE
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?
A. Cancel your clinics for the next 21 days
B. Make sure you take out all the trash from the patient’s
C.
D.
E.
F.
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
Where do you find more information?
A. www.colorado.gov/ebola
B. www.cdc.gov/ebola
C. COHELP (303-389-1687 or 1-877-462-2911)
D. www.cms.org
E. All of the above
QUESTIONS?
Connie.Price@dhha.org