Ebola Experience in Sierra Leone Grand Rounds, May 2015 Marshfield Clinic

Welcome to Grand Rounds!
Friday, May 29, 2015
Vijay Aswani MD PhD FACP
Department of Internal Medicine & Pediatrics
Marshfield Clinic
Ebola:
A Personal Perspective as a Short-term Clinician
in Sierra Leone, West Africa

Disclosure Statement
I, Vijay Aswani, MD PhD FACP, do not have any
relevant financial interest or other relationships
with a commercial entity producing health-care
related product and or services.

Ebola:
CME Activity Objectives
1. Identify if a patient meets case definition for Ebola Virus Disease
2. Recognize how to triage, identity and isolate a patient with Ebola Virus
Disease
3. Describe the epidemiology of the Ebola Virus Disease 2014-15 epidemic in
West Africa
4. Discuss the structure of Ebola Treatment Centers and Holding Centers.
5. Select the appropriate infection prevention and control for viral
hemorrhagic fevers
6. Review how to triage, isolate and manage a traveler from West Africa
who presents with symptoms of Ebola Virus Disease

Ebola Virus
 Prototype Viral Hemorrhagic
Fever Pathogen
 Filovirus: enveloped,
non-segmented, negative-
stranded RNA virus
 Severe disease with high
case fatality
 Absence of specific
treatment or vaccine
 >20 previous Ebola and
Marburg virus outbreaks
 2014 West Africa Ebola
outbreak caused by
Zaire ebolavirus species
(five known Ebola virus
species)
4

Report of an International Commission (1978). Ebola haemorrhagic fever in Zaire, 1976. Bull World
Health Organ. 1978; 56(2): 271–293.

The Ebola river was
60 miles away from
Yambuku. Yambuku
was so small, it is
not on this map

Brauburger L, Hume A,
Mühlberger E, Olejnik J. 2012.
Forty-Five Years of Marburg
Virus Research. Viruses 2012,
4(10), 1878-1927

5 distinct Ebola species
and associated mortality
26 epidemics of Ebola
Case fatality rates:
– Zaire (EBOV), 21-90%
– Sudan (SUDV), ~ 50%
– Bundibugyo (BDBV),
32%
– Tai Forest (TAFV), 0%
– Reston (RESTV), 0%
S Baize, et al. DOI: 10.1056/NEJMoa1404505
Sierra Leone

Transmembrane glycoproteins
Matrix (VP40 & VP24)
Nucleocapsid (VP30 & NP)
Negative-sense single-stranded RNA
Polymerase complex (VP35 & L)
http://www.nejm.org/doi/full/10.1056/NEJMp1410741
Ebola Genomics

Early Clinical Presentation
 Acute onset; typically 8–10 days after exposure
(range 2–21 days)
 Signs and symptoms
 Initial: Fever, chills, myalgias, malaise, anorexia
 After 5 days: GI symptoms, such as nausea, vomiting, watery
diarrhea, abdominal pain
 Other: Headache, conjunctivitis, hiccups, rash, chest pain,
shortness of breath, confusion, seizures
 Hemorrhagic symptoms in 18% of cases
 Other possible infectious causes of symptoms
 Malaria, typhoid fever, meningococcemia, Lassa fever and other
bacterial infections (e.g., pneumonia) – all very common in Africa
11

Clinical Manifestations by Organ System
in West African Ebola Outbreak
Organ System Clinical Manifestation
General Fever (87%), fatigue (76%), arthralgia (39%), myalgia (39%)
Neurological Headache (53%), confusion (13%), eye pain (8%), coma (6%)
Cardiovascular Chest pain (37%),
Pulmonary Cough (30%), dyspnea (23%), sore throat (22%), hiccups (11%)
Gastrointestinal Vomiting (68%), diarrhea (66%), anorexia (65%), abdominal pain
(44%), dysphagia (33%), jaundice (10%)
Hematological Any unexplained bleeding (18%), melena/hematochezia (6%),
hematemesis (4%), vaginal bleeding (3%), gingival bleeding
(2%), hemoptysis (2%), epistaxis (2%), bleeding at injection site
(2%), hematuria (1%), petechiae/ecchymoses (1%)
Integumentary Conjunctivitis (21%), rash (6%)
WHO Ebola Response team. NEJM. 2014
12

Examples of Hemorrhagic Signs
Bleeding at IV Site
Hematemesis
Gingival bleeding
13

Ebola Virus Disease Surveillance
Alert Case:
Illness with onset of fever and no response to treatment of usual causes of
fever in the area,
OR
one of the following:
• bleeding,
• bloody diarrhea,
• bleeding into urine
OR
any sudden death
Report for
evaluation

Ebola Evaluation
Alert Case
SUSPECTED CASE:
alive or dead,
sudden onset of high fever and
had contact with:
- a suspected, probable or confirmed Ebola or a dead or sick animal
OR
any person with sudden onset of high fever and
at least three of the following symptoms:
• headaches • vomiting
• anorexia / loss of appetite • diarrhea
• lethargy • stomach pain
• aching muscles or joints • difficulty swallowing
• breathing difficulties • hiccup
OR
any person with inexplicable bleeding
OR
any sudden, inexplicable death.

Ebola Evaluation
Isolate & test
Lab:
IgM
RT-PCR
Virus
isolation
Positive
Negative
Confirmed
Case
Non-
Case
Trace
contacts
Alert case or probable case
A PROBABLE CASE is:
Any suspected case evaluated by a clinician
OR
Any deceased suspected case with an epidemiological
link with a confirmed case
Isolate in an ETU or CCC

Who are Contacts?
• Any person having been exposed to a suspect, probable or confirmed case
of Ebola in at least one of the following ways:
• has slept in the same household with a case
• has had direct physical contact with the case (alive or dead) during the illness
• has had direct physical contact with the (dead) case at the funeral
• has touched his/her blood or body fluids during the illness
• has touched his/her clothes or linens
• has been breastfed by the patient (baby)
• Contacts of dead or sick animals:
• has had direct physical contact with the animal
• has had direct contact with the animal’s blood or body fluids
• has carved up the animal
• has eaten raw bush-meat
• Laboratory contacts:
• has had direct contact with specimens collected from suspected Ebola
patients
• has had direct contact with specimens collected from suspected Ebola animal
casesFollow contact for at least 21 days after exposure

Does he meet Case Definition?
A 38 year old BBC journalist presents to the
health facility with a 1 day history of fever
nausea, flu like symptoms and odynophagia. She
arrived in Liberia 3 days ago and was covering a
story about Ebola virus disease of affected
homes in the worst hit Todoe village in
Montserrado county which is know to be also
swampy. Reports to have been using clean
water to wash her hands during her field work.

Ebola Virus
 Zoonotic virus – bats the most likely reservoir, although
species unknown
 Spillover event from infected wild animals (e.g., fruit bats,
monkey, duiker) to humans, followed by human-human
transmission
19

Outbreak Distribution — West Africa, May 27, 2015
Map includes total confirmed EVD cases reported to WHO
20Source: WHO; http://apps.who.int/ebola/current-situation/ebola-maps

2014 Ebola Outbreak
Reported Cases (Suspected, Probable, and Confirmed) in Guinea,
Liberia, and Sierra Leone
This graph shows the total reported cases (suspected, probable, and confirmed) in Guinea, Liberia, and Sierra
Leone provided in WHO situation reports beginning on March 25, 2014, through the most recent situation report
on May 13, 2015.
21
0
2000
4000
6000
8000
10000
12000
14000
Total Cases, Guinea
Total Cases, Liberia
Total Cases, Sierra Leone

2014 Ebola Outbreak in West Africa -
Case Counts
(current to May 24, 2015)
Source: http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html

2014 Ebola Outbreak in West Africa -
Case Counts
(current to May 24, 2015)
1. Countries transitioning to being declared free of Ebola, determined by
WHO
2. WHO declared the end of the current Ebola outbreak in Liberia on May 9,
2015, after 42 days (two incubation periods) had passed since the last
Ebola patient was buried.
Source: http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html

On January 9, 2015 I resigned
my position at the Marshfield
Clinic. I joined Partners In
Health – A Boston-based
organization to become a
Short-term clinician in their
Ebola Response in Sierra
Leone, West Africa

Sierra Leone
• Population: ~ 5 million
• Independent in 1961
• Civil war (1991 to 2002): acts
of extreme brutality, over
50,000 deaths and
displacement of over 2
million people
• Life expectancy: 48 years
• Ranks 180 out of 187
countries in Human
Development Index
http://www.sl.undp.org/content/sierraleone/en/home/countryinfo.html

Photo credit: Vijay Aswani, MD 2015
Team of Ebola Clinicians at Boston before leaving for
Liberia and Sierra Leone
January 2015

The first Ebola message seen at the shuttle boat port in
Freetown, Sierra Leone
January 2015

Freetown, Sierra Leone
January 2015

Siaka Stadium, Freetown, Sierra Leone.
Site of WHO Ebola Training
January 2015

Source: https://s-media-cache-
ak0.pinimg.com/236x/3a/80/83
/3a80831f017a4800070aa686a2
030b7d.jpg
Putting on PPE for the first time
during the WHO training in
Freetown, Sierra Leone. The number
is the time I donned.
January 2015

Outside view of the Maforki Ebola Treatment Unit in Port
Loko, Sierra Leone
February 2015

Tree of Hope outside the Maforki Ebola Treatment Center in
Port Loko, Sierra Leone.
February 2015

Inside the ‘Green Zone’ of the Maforki Ebola Treatment
Unit, Port Loko, Sierra Leone
February 2015

Boots stood to dry in the ‘Green Zone’ of the Maforki
Ebola Treatment Unit, Port Loko, Sierra Leone
February 2015

Faceshields drying in the ‘Green Zone’ of the Maforki
February 2015

Photo credit: Marc Rosenthal, RN 2015
Triage area of the Maforki Ebola Treatment Unit, Port
Loko, Sierra Leone
February 2015

Receiving a patient into the triage area of the Maforki
February 2015

Spraying down the ambulance with 0.5% chlorine in the
Triage area of the Maforki Ebola Treatment Unit, Port
Loko, Sierra Leone
February 2015

Risk Zones in ETUs
LOW-RISK ZONE
Supportive activities such as chlorine preparation, medical staff
meetings, laundry of resuable materials, pharmacy and stores
HIGH-RISK ZONE
Where patients are cared for, contaminated waste is being
treated, and corpse is being handled
Subdivided into suspects, probable, confirmed, waste
management
Highly contaminated
Between High and Low Risk
Disinfection facilities
There is no « no-risk » zone
Between Low and High Risk
Screening Area

Entrance
Staff
W a t e r
R e s e r v e s
C l e a n i n g
A r e a
Medical Staff, shift
transmission and
rest
Mobile LAB
Dressing
(Scrubs)
PPE
Changing
Room
Entrance
ambulance,
visiting
family,
IPC Staff,
rest
Pharmacy
storage of
material
Removal
of PPE
Toilet
Exit pt
Suspect/Probable
Confirmed
Screening
Area
Car disinfection
Corpse
Removal
HIGH RISK
LOW RISK
LOW RISK

Entrance
Staff
W a t e r
R e s e r v e s
C l e a n i n g
A r e a
Medical Staff, shift
transmission and
rest
Mobile LAB
Dressing
(Scrubs)
PPE
Changing
Room
Entrance
ambulance,
visiting
family,
IPC Staff,
rest
Pharmacy
storage of
material
Remov
al of
PPE
Toilet
Car disinfection
Corpse
Removal
Exit pt
Suspect
Confirmed
Screening
Area

The Suspect wards of the Maforki Ebola Treatment Unit (Hot
zone), Port Loko, Sierra Leone
February 2015

Nurse in PPE (Personal Protective Equipment in the Maforki
February 2015

Clinician team in the Hot zone – Suspect ward of Maforki
February 2015

The helipad at the Sierra Leone Armed Forces station in
Freetown, Sierra Leone where we took a UN chopper to Kono
district
February 2015

Riding the UN helicopter from Freetown to Kono district,
Sierra Leone
February 2015

Aerial view of helipad in Freetown, Sierra Leone
February 2015

The UN chopper takes off after dropping us off in Kono
district, Sierra Leone
February 2015

Outside view of the Ebola testing lab in Kono district,
Sierra Leone
February 2015

Ebola testing lab in Kono district, Sierra Leone
February 2015

IRC Ebola Treatment Unit in Kono district, Sierra Leone
February 2015

Road to Ebola Community Care Center in Kambia, Sierra
Leone
February 2015

Ebola Community Care Center nurses station in Kamsondo,
Sierra Leone
February 2015

Ebola Community Care Center Red Zone in Kamsondo, Sierra
Leone
February 2015

Ebola Community Care Center Doffing station in Kamsondo,
Sierra Leone
February 2015

Photo credit: Vijay Aswani, MD, 2015
Ebola Community Care Center Red Zone in Condama, Kono
district, Sierra Leone
February 2015

EVD Cases (United States)
 EVD has been diagnosed in the United States in four people: one
(the index patient) who traveled to Dallas, Texas from Liberia, two
healthcare workers who cared for the index patient, and one medical
aid worker who traveled to New York City from Guinea
 Index patient – Symptoms developed on September 24, 2014 approximately
four days after arrival, sought medical care at Texas Health Presbyterian Hospital
of Dallas on September 26, was admitted to hospital on September 28, testing
confirmed EVD on September 30, patient died October 8.
 TX Healthcare Worker, Case 2 – Cared for index patient, was self-monitoring
and presented to hospital reporting low-grade fever, diagnosed with EVD on
October 11, recovered and released from NIH Clinical Center October 24.
 TX Healthcare Worker, Case 3 – Cared for index patient, was self-monitoring
and reported low-grade fever, diagnosed with EVD on October 15, recovered and
released from Emory University Hospital in Atlanta October 28.
 NY Medical Aid Worker, Case 4 – Worked with Ebola patients in Guinea, was
self-monitoring and reported fever, diagnosed with EVD on October 24,
recovered and released from Bellevue Hospital in New York City November 11.
79
Information on U.S. EVD cases available at http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/united-states-imported-case.html.

EVD Cases (United States)
 During this outbreak, six health workers and one journalist
have been infected with Ebola virus while in West Africa
and transported to hospitals in the United States.
 One of the health workers died on November 17 after being
transported from Sierra Leone to Nebraska Medical Center.
 On March 13, an American health worker volunteering in
Sierra Leone was evacuated to the United States for
treatment after testing positive for Ebola.
 The patient recovered and was discharged from NIH Clinical
Center on April 9, 2015.
80

EVD Risk Assessment
*CDC website to check current affected areas: http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-
map.html
HIGH-RISK EXPOSURE
Percutaneous (e.g., needle stick) or mucous
membrane exposure to blood or body fluids of
a person with Ebola while the person was
symptomatic
OR
Exposure to the blood or body fluids (including
but not limited to feces, saliva, sweat, urine,
vomit, and semen) of a person with Ebola while
the person was symptomatic without
appropriate personal protective equipment
(PPE)
OR
Processing blood or body fluids from an Ebola
patient without appropriate PPE or standard
biosafety precautions
OR
Direct contact with a dead body without
appropriate PPE in a country with widespread
transmission or cases in urban areas with
uncertain control measures*
OR
Having lived in the immediate household and
provided direct care to a person with Ebola
while the person was symptomatic
SOME RISK EXPOSURE
In countries with widespread transmission or
cases in urban areas with uncertain control
measures*:
• Direct contact while using appropriate PPE
with a person with Ebola while the person
was symptomatic or with the person’s body
fluids
• Any direct patient care in other healthcare
settings
OR
Close contact in households, healthcare
facilities, or community settings with a person
with Ebola while the person was symptomatic
• Close contact is defined as being for a
prolonged period of time while not wearing
appropriate PPE within approximately 3 feet
(1 meter) of a person with Ebola while the
person was symptomatic

EVD Risk Assessment (continued)
*CDC website to check current affected areas: http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-
map.html
NO IDENTIFIABLE RISK
EXPOSURE
Contact with an asymptomatic person who had
contact with person with Ebola
OR
Contact with a person with Ebola before the person
developed symptoms
OR
Having been more than 21 days previously in a
country with widespread transmission or cases in
urban areas with uncertain control measures*
OR
Having been in a country with Ebola cases, but
without widespread transmission or cases in urban
settings with uncertain control measures*, and not
having any other exposures as defined above
OR
Having remained on or in the immediate vicinity of
an aircraft or ship during the entire time that the
conveyance was present in a country with
widespread transmission or cases in urban areas
with uncertain control measures* and having had
no direct contact with anyone from the community
LOW (but not zero) RISK
EXPOSURE
Having been in a country with widespread
transmission or cases in urban areas with
uncertain control measures* within the past 21
days and having no known exposures
OR
Having brief direct contact (e.g. shaking hands)
while not wearing appropriate PPE, with a
person with Ebola while the person was in the
stage of disease
OR
Brief proximity, such as being in the same
room for a brief period of time, with a person
with Ebola while the person was symptomatic
OR
In countries without widespread transmission
or cases in urban settings with uncertain
control measures*: direct contact while using
appropriate PPE with a person with Ebola while
the person was symptomatic or with the
person’s body fluids
OR
Traveled on an aircraft with a person with
Ebola while the person was symptomatic

Practical Considerations for Evaluating
Patients for EVD in the United States
 CDC encourages all U.S. healthcare providers to
 Ask patients with Ebola-like symptoms about travel to West
Africa or contact with individuals with confirmed EVD in the 21
days before illness onset
 Know the signs and symptoms of EVD
 Know the initial steps to take if a diagnosis of EVD is suspected
 CDC has developed documents to facilitate these
evaluations
 Evaluating International Travelers for Level of Risk
• Available at http://www.cdc.gov/vhf/ebola/pdf/ebola-guidance-
travelers.pdf
 Think Ebola: Early recognition is critical for infection control
• Available at http://www.cdc.gov/vhf/ebola/pdf/could-it-be-ebola.pdf
83

Interim Guidance for Monitoring and
Movement of Persons with EVD Exposure
CDC has created guidance for monitoring people exposed
to Ebola virus but without symptoms
www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html
RISK LEVEL PUBLIC HEALTH ACTION
Monitoring Restricted
Public Activities
Restricted
Travel
HIGH risk Direct Active Monitoring Yes Yes
SOME risk Direct Active Monitoring
Case-by-case
assessment
Case-by-case
assessment
LOW risk
Active Monitoring
for some;
Direct Active Monitoring
for others
No No
NO risk No No No

Algorithm available at http://www.cdc.gov/vhf/ebola/pdf/could-it-be-ebola.pdf
85

Welcome to Grand Rounds!
Ebola:

The Obamas
are really
Popular in
Sierra Leone

WHO Ebola Response Team. N Engl J Med 2015;372:1274-1277.
Age-Group–Specific Incidence of Ebola Virus Disease in West Africa, Incubation Period,
Intervals from Onset to Death and Onset to Hospitalization, and Case Fatality Rate.

Appreciation
• My wife and daughter: Amy and Phoebe Aswani
• My mother and brother: Pushpa and Johnny Aswani
for their support
• Marshfield Clinic
• Partners in Health
• Med-Peds department providers and staff
• My patients
• All who prayed
Thank you!

Ebola Experience in Sierra Leone Grand Rounds, May 2015 Marshfield Clinic

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