Preparedness for Ebola virus Disease PGIMER DR RMLHospital New Delhi August 2014

1. Preparedness for
Ebola Virus Disease
Dr.Diksha Bigamal , Dr. Saurav Mitra
Dr. Seema Wasnik, Dr. M.D. Kaur
Dr. (Prof) Rajesh Sood

2. Introduction
• EVD ( Viral Hemorrhagic Fever ) –a fatal disease in
humans & non human primates – monkeys, gorillas &
chimpanzees.
• Family – Filoviridae, Genus – Ebolavirus
• 5 species identified- ZAIRE ebola virus
Sudan ebola virus
Tai Forest virus
Bundibugyo virus
Reston ebola virus

4. EPIDEMIOLOGY
• First outbreak – 1976 in Yambuku, Democratic
Republic of CONGO, near Ebola river.
• 1976-2012 – 24 outbreaks reported, Central Africa
• Current outbreak ( 2014) – largest as reported by WHO
• 8 August, the WHO declared the epidemic to be an
international public health emergency.

5. • September , 2014 West Africa Ebola Outbreak - 2,000
deaths.
• Liberia, the most affected country, reported 200 new
cases a week for the past three weeks.

7. CLINICAL FEATURES
• Incubation period: 2-21 days
• Stage I (non-specific):
- diarrhea, nausea and vomiting, anorexia
abdominal pain
- headaches, arthralgia ,myalgia
- maculopapular rash.

8. • Stage II (Specific):
- Hemorrhage
- anuria
- sore throat, tachypnoea, dysphagia & hiccups
- multi organ failure

9. CLINICAL FEATURES
• Differential diagnosis : malaria, dengue, typhoid
fever, shigellosis, rickettsial disease, thrombotic
thrombocytopenic purpura, hereditary hemorrhagic
telangiectasia, Kawasaki disease.
• Prognosis : high mortality rate: 50% -90%.
• Late complications : Arthralgia
-ocular diseases
- hearing loss
- orchitis.

10. MODE OF TRANSMISSION
• Reservoir : fruit bats are natural hosts.
• Contact : blood , secretions, body fluids & carcasses of
infected animals or infected person
• Needle pricks & sexual route
• No airborne transmission

11. HOW TO DIAGNOSE ??
• Signs & symptoms
• H/o of travel to endemic zone
• Contact with an infected person.
&
• IgM ELISA & Real time Polymerase chain reaction

12. Definitions :
Suspected case :
• h/o of travel
• close contact with symptomatic person travelling from
EVD area in the past 21 days
• fever ≥ 101˚ F , along with ≥ 1 :
- headache, bodyache
- diarrhoea, vomiting , abdominal pain
- unexplained hemorrhage.

13. Definitions :
• Confirmed case : above features & lab confirmed
diagnostic evidence by any one of following :
-- ELISA
- Real time Polymerase Chain Reaction ( RT-PCR)

14. TREATMENT
• No specific treatment available.
• General supportive measures : adequate hydration,
nutritional support & symptomatic treatment.

15. TREATMENT ( contd..)
• Experimental trials : Z Mapp and an RNA
interference drug called TKM-Ebola.
• Two "promising" Ebola vaccines made by
GlaxoSmithKline Plc and New Link Genetics

16. HOSPITAL MANAGEMENT
• Isolate the patient.
• Follow universal precautions inc. PPE ( personal
protective equipment)
• Restrict visitors
• Avoid aerosol generating procedures
• Implement environmental infection control measures
• Proper disposal of biological wastes

17. Guidelines for hospital infection
control –
Sources : WHO & CDC

18. 1. Direct patient care :
• Isolate the patient in a single room (door closed) with
separate bathroom.
• Restrict entry to the EVD ICU.
• Maintain a log book.
• Use of Personal Protective Equipment is essential
• double gloving, Disposable shoe covers, leg coverings.

19. SINGLE PATIENT ISOLATION

20. ISOLATION WARD

21. LOG OF VISITORS IN ISOLATION AREA :
Date Name Service Time in Time out
12.8.14 Dr. Saurav Intensive
care
9:30 am 10:00 am
12.8.14 Lokesh cleaning 10:15 am 10:45 am
12.8.14 Nalini staff Nursing
care
11:00 am 11:20 am

22. Sequence for
Donning the PPE

25. Sequence for Removing PPE

28. • Remove the boots.
• Remove the inner pair of gloves.
• Remove inner layer of clothes / scrub suit.
• Wash hands with soap and clean water

30. Use of sharps

31. 2. EQUIPMENT CARE
• Use disposable equipments.
• Non- disposable equipments -disinfected 10% sodium
hypochlorite solution.
• Sample collection – properly labelled “ SUSPECT
EBOLA “ in non –glass , leak proof containers.

32. Sample collection :
• ELISA - results within 5 to 6 hours
RT-PCR – results within 48 hours.
• Avoid routine blood samples in EVD suspected patients
till report from NCDC is received.
• Wear 3 pair of gloves.
• Discard after sample collection

33. BLOOD SAMPLES
• Collect 4ml blood in EDTA vial
• Wrap in tissue paper
• Keep in triple layer sealed packed pouches
• Send in leak proof ice boxes.
• The HCW, transporting the sample wears PPE kit.

35. Lab Person

36. 3. ENVIRONMENTAL CARE
• Objects contaminated with blood, other body fluids,
disinfected - 1% Sodium Hypochlorite or 5% Lysol.
• Wear PPE while handling contaminated objects & linen
• Soiled linen –
treat with10%bleach,
place in labelled, leak-proof bags

37. 4. Waste Management
• Segregate waste for appropriate and safe handling.
• Separate HCW are designated for collection and disposal
of infectious waste.
• HCW to wear (PPE) gloves, gown and closed shoes
(e.g. boots) when handling solid infectious waste.
• Faeces, urine, vomit & liquid waste - disposed of in the
sanitary sewer along with 500ml 1 %bleach.

38. • Every item which is in contact with patient like mask,I.v
sets etc.- packed in double yellow bags, disposed by
designated HCW.
• ICU floor ,walls, Ventilators, beds are mopped with 10
% bleaching solution when patients are not occupying
the ICU.

39. Handling of dead body
- should not be sprayed, washed or embalmed
- wear PPE while handling.
- ritual practices should be avoided
- packed in double impermeable leak proof body bag
- burial depth – 1.5 m above ground water level with
1m covering of soil.

40. BURIAL OF DECEASED

41. Managing accidental Exposures
Accidental needle stick injury –
1. Immerse the exposed site in 70% alcohol for 20 - 30
seconds.
2. Wash with soap and clean water.
3. Flush the site in running water for 20 to 30 seconds.
4. Incident reporting.

42. Managing accidental Exposures
Follow up accidental exposures:
1. Regular monitoring - Body temperature twice daily.
2. If temperature ≥ 38.5˚C (101˚F) the health facility staff
should be isolated as suspected case of VHF.

43. Initiatives at rml hospital

44. • Dr. RML hospital, New Delhi is designated as the nodal
hospital, in Northern India for handling EVD patients.
• A control room for EVD outbreak is operating in the
DGHS(Room No543-A,A Wing), Nirman Bhawan.

45. • Integrated disease surviellence Programme(IDSP)
network is kept on alert to track passengers from EVD
affected areas at airport.
• National Institute of Virology, Pune and National
Centre for Disease Control (NCDC) , Delhi are geared
to test samples for diagnosis of EVD.

46. Proforma for EVD suspect patients :
Specific questions
• Detailed h/o travel to the following African countries in
the last 21 days : Liberia, Guinea, Sierra Leone and
Nigeria.
• Detailed h/o contact with blood or body fluids of an
EVD symptomatic patient or through infected objects.

47. Signs and Symptoms:
• Date of onset of fever
• Hemorrhages from gums / hematemesis /melena
epistaxsis/purpura/petechiae/eccymosis/any other
specify?
• Headache/joint aches/muscle
aches/diarrhea/vomiting/stomach pain
Condition of patient :Stable/Critical
Date of Collection of sample

48. • Total patients – 10.
• All tested negative.

49. One is never afraid of the
unknown; one is afraid of the
known coming to an end.

50. Thank you