Presentation given to Pierce County safety committee

1. Matthew Rollosson, RN, MPH&TM
Nurse Epidemiologist
Tacoma-Pierce County Health department
2 April 2015

2.  Preferred over “Ebola hemorrhagic fever”
◦ Most people with EVD do not have
hemorrhagic symptoms
 Higher risk for bleeding
 Disseminated intravascular coagulation
 Thrombocytopenia
◦ Massive fluid loss due to vomiting and
diarrhea
◦ Death is usually due to dehydration and
electrolyte disturbances

3.  1976, Yambuku, Zaïre (now the Democratic
Republic of the Congo)
◦ Near the Ebola River
◦ Species that causes most EVD outbreaks
 Current outbreak in West Africa

5.  Fruit bats are most likely the natural reservoir
 Infects monkeys and apes
◦ Large die-offs of chimpanzees and gorillas
◦ Reston ebolavirus
 Lab workers had serologic evidence of infection
 No symptoms
◦ Taï Forest ebolavirus
 One human infection
 Acquired during autopsy of a chimpanzee
 Outbreaks may be associated with hunting or
butchering animals or eating infected meat
◦ Bat soup
◦ Bushmeat

6.  Direct contact with blood or body fluids of a
symptomatic person
◦ Skin
 Cuts, abrasion
◦ Mucous membranes
◦ Parenteral
 Reusing unsterilized needles
 Accidental needle sticks
◦ Funeral ceremonies
 Respiratory droplets?
◦ Not airborne
 Not effectively transmitted by inanimate
objects

7.  Incubation period
◦ 2 to 21 days
 Mean 6 – 12 days
 “Dry” symptoms
◦ Sudden onset
 Fever
 Muscle pain
 Fatigue
 May be a transient rash

8.  “Wet” symptoms
◦ Vomiting, diarrhea
◦ Bleeding disorders
 Gastrointestinal bleeding
 Bleeding from venipuncture sites
 Mucous membranes
 Neurological symptoms

9.  Easily mistaken for other diseases
 Health care personnel at risk for infection
 Outbreaks frequently associated with
transmission in health care facilities
- Hepatitis - Shigellosis
- Malaria - Typhoid fever
- Meningococcemia - Typhus
- Plague - Yellow fever

10.  Frequently infected
◦ Illness not
recognized as EVD
◦ Lack of appropriate
PPE
 Fewer health care
workers available
◦ Death
◦ Flee out of fear of
infection

11.  No specific medications to treat EVD
 Hydration and electrolyte replacement
◦ Oral rehydration solution (ORS)
◦ Intravenous fluid
 Antimalarial
 Antibiotics to treat/prevent translocation of
bacteria from the GI tract
 Nutritional support
Fowler et al., 2014

12.  Sodium
 Potassium
 Glucose
◦ Sodium/glucose
co-transport
◦ Enhanced water
absorption
Atia & Buchman, 2009

13.  Death or recovery
◦ 7 to 14 days after symptom onset
◦ Prolonged convalescence
◦ Survivors presumed to be immune
 Species-specific neutralizing antibodies
◦ Virus may be present in semen weeks
after recovery
 Rehydration and electrolyte replacement
improve survival

14.  West African Ebola epidemic traced to a 2-year-
old child in Guinea who died from the disease
December 6, 2013
◦ First outbreak of EVD in West Africa
 March 10 2014: World Health Organization (WHO)
notified of an outbreak of an unknown infectious
disease characterized by fever, vomiting, and
diarrhea in Guinea
 Zaïre ebolavirus identified in blood from patients
who were hospitalized with the disease
Baize et al., 2014

15.  …modest further intervention efforts
at that point could have achieved
control.”
 WHO Ebola Response Team (2014)
 Epidemic spreads to
◦ Liberia in March
◦ Sierra Leone in May
◦ Nigeria in July

16.  August 8, 2014: WHO declared the Ebola
epidemic in West Africa a Public Health
Emergency of International Concern
Cases Deaths
Guinea 495 367
Liberia 554 294
Nigeria 13 2
Sierra Leone 717 298
Totals 1,779 961

17.  By the end of August, the total numbers of
EVD cases and deaths exceeded that of all
previous Ebola epidemics combined
CDC, 2015

18. New cases of Ebola virus disease, October 19–November 8, 2014
- CDC

19.  100 bed capacity
◦ 44 confirmed
◦ 56 suspect

20.  Patients referred by
◦ District health
officers
◦ Community Care
Centers
◦ Other health care
facilities
 Triage

21.  Suspect
◦ Fever and contact
with an EVD case or
dead/sick animal
OR
◦ Fever and other EVD
symptoms
OR
◦ Inexplicable bleeding
OR
◦ Inexplicable death
WHO 2014
 Laboratory
confirmed
◦ PCR+
OR
◦ IgM+

22.  Asymptomatic for 3 days
 Negative PCR
◦ Both confirmed and suspect cases

23. Martha Phillips

24.  Infection control
◦ Doffing
◦ Chlorine
 Patient care
◦ Oral rehydration
solution not at
bedside
◦ Staff avoided contact
with patients
 Patient records
◦ Census
◦ Laboratory results
◦ Medication
administration

25.  WHO recommends:
◦ Face shield or goggles
◦ Fluid-resistant
medical/surgical mask
◦ Double gloves
◦ Disposable
gown/coverall
◦ Head cover
◦ Waterproof apron
◦ Waterproof boots
WHO 2014
Partners in Health

26.  Tropical Africa
◦ Hot
◦ Humid
 According to the
CDC,
“Wearing PPE
increases the risk
for heat-related
illnesses.”

27.  Hydration
 Electrolyte replacement
◦ Oral rehydration solution
 Doffing PPE safely takes time
◦ Go to the toilet before donning PPE!
 Rest
 Skin care
◦ Cuts and abrasions are portals of entry

32.  Ebolaviruses
◦ Lipid envelope
 Derived from host cell
◦ Destroyed by
 Alcohol
 Chlorine
 Heat
 Detergents
 Soap
 UV light

34.  CDC
◦ May restrict travel into the U.S. and between states
◦ No authority within states
◦ Recommendations
 CDC does not recommend “quarantining”
asymptomatic individuals with some or low
risk of infection
 Washington State follows CDC guidance on
travelers returning from Ebola-affected
countries
◦ Some of my colleagues who live in other states
haven’t been as fortunate

35.  Travelers entering the U.S. from Ebola-
affected counties must be screened at one
of five airports
 Categorized according to risk
 Health departments of counties of residence
notified

36. Risk Exposure Monitoring
(asymptomatic)
High risk  Needle-stick from a
symptomatic patient
 Contact with body fluids from a
symptomatic patient without
appropriate PPE
 Contact with a dead body
without PPE
 Direct active
monitoring
 Controlled
movement
 Exclusion from
workplace, public
places
Some risk  Direct contact with a
symptomatic person while
wearing appropriate PPE
 Direct active
monitoring
 Health officer may
impose additional
restrictions, if
appropriate
Low (but
not zero)
risk
 Having been in a country with
widespread Ebola transmission
without known exposure
 Active monitoring
 No restrictions on
work, travel, or
public places

37.  Local health department:
◦ Active monitoring
 Self-reporting of temperature and EVD
symptoms
 Twice daily
 21 days
◦ Direct active monitoring
 Self-reporting of temperature and EVD
symptoms
 Twice daily
 Direct observation of contact by health
department personnel
 21 days

38.  United States
◦ 10/11/14 to 3/24/15
 11,361 travelers screened.
◦ 3/16/15 to 3/22/15
 1,989 people in active or direct active
monitoring
CDC

39.  Washington State
◦ 131 low risk
◦ 20 some risk
 Pierce County
◦ 10 low risk
◦ 2 some risk
 No high risk contacts in Washington State
 No cases of EVD in Washington State

41.  a person suspected of having EVD is seen in
health care facility in Pierce County?
◦ Don’t panic
◦ Call TPCHD
 a person the health department is monitoring
develops a fever and/or symptoms of EVD?
◦ The health department will arrange transportation to an
appropriate health care facility for evaluation
 It’s probably not EVD
◦ Malaria
◦ Gastroenteritis
◦ Influenza

45.  Infectious diseases
◦ Tuberculosis: 1,500,000
◦ Malaria: 584,000
 Children under 5 years of age: 453,000
◦ Measles: 145,700
◦ Pertussis (whooping cough): 89,000

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non-cholera diarrhea: a review. American Journal of
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 Bausch, D. G., Towner, J. S., Dowell, S. F., Kaducu, F., Lukwiya, M.,
Sanchez, A., et al. (2007). Assessment of the risk of Ebola virus
transmission from bodily fluids and fomites. Journal of Infectious
Diseases, 196(Supple. 2), S142-S147.
 Baize, S., Pannetier, D., Oestereich, L., Rieger, T., Koivogui, L.,
Magassouba, N., et al. (Emergence of Zaire Ebola virus disease in
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doi:10.1056/NEJMoa1404505.
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 Centers for Disease Control and Prevention. (October 3, 2014). Ebola
virus disease outbreak – Nigeria, July-September, 2014. Morbidity
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http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6339a5.htm.

49.  Centers for Disease Control and Prevention. (November 20, 2014).
Interim guidance for healthcare workers providing care in West
African countries affected by the Ebola outbreak: limiting heat
burden while wearing personal protective equipment (PPE).
http://www.cdc.gov/vhf/ebola/hcp/limiting-heat-burden.html.
 Centers for Disease Control and Prevention. (November 21, 2014).
Update: Ebola virus disease epidemic – West Africa, November 2014.
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http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6346a6.htm.
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