Shaheen Methar's fantastic talk on Ebola at ICAN 2014 in Harare, Zimbabwe. Thanks for letting me share her talk)

1. Ebola
Outbreak
Lessons
learnt!
Prof
Shaheen
Mehtar
Chair
ICAN,
UIPC,
Stellenbosch
Uni,
CT

2. In
the
beginning…
• In
2012
and
2013
there
was
an
outbreak
of
Ebola
amongst
the
great
apes
in
the
DRC
and
surrounding
areas
which
largely
went
unnoLced
(
over
5000
apes
died)
• On
13
Dec
2013
a
2
year
old
child
was
diagnosed
with
Ebola
in
Guinea-­‐
contact
with
infected
bush
meat!)
• That
was
the
epicentre
of
the
outbreak
which
also
largely
went
unnoLced

3. Spread
like
wildfire.

4. Low
resource
countries
• High
supersLLous
beliefs
• Great
dependence
and
reverence
for
tradiLonal
heads
and
healers
• SLgma
associated
with
lack
of
knowledge
• No
tradiLonal
heads
of
tribes
or
healers
were
include
in
the
HC
program
• Inadequate
infrastructure-­‐
highly
burdened

5. There
was
total
panic
&
confusion!

6. Lesson
No
1:
involve
the
community
• Locate
the
heads
of
community,
tribal,
urban,
or
government
structures
• Respect
the
culture
and
tradiLon
• Explain
and
educate-­‐
• They
will
understand
• You
will
get
their
trust.
• They
will
influence
the
community
Locals
talking
and
discussion
EVD

7. Lesson
2:
A
weak
healthcare
system
2012
Guinea
Liberia
Sierra
Leone
Total
populaLon
(millions)
11.45
4.19
6
<
5y
mort
/
1
000
live
births
101
75
182
Mort
15
&
60
yr
m/f
(/
306/277
1000
pop)
71%
(ID)
282/246
444/426
Total
expenditure
on
health
per
capita
($)
%
of
GDP
67
(6.3)
102
(15.5)
205
(15.1)
Doctors
/10
000
pop
(regional
average
4.6)
0.03
0.1
0.2
Nurses-­‐
/10
000
pop
(regional
average
12.6)
0.04
2.7
1.7
Nigeria
169
124
371/346
161
(6.1)
4.1
16.1

8. Healthcare
structures
for
EVD
Strengthen
the
communicaLon
for
improved
contact
tracing

9. Lesson
3:
weak
surveillance
system

10. In
Africa
from
Dec
2013
DRC-­‐
separate
outbreak

11. 30
Sept,
first
case
outside
Africa!

12. Funding
started
coming
–
in
late
August!
• NOW
IS
A
POLITICAL
ISSUE
• American
lives
are
at
stake!
– Money-­‐
coming
in!
– Deployment
of
troops
– Healthcare
workers
– Mobile
laboratories
– Mobilizing
global
resources
• Contain
Ebola
in
West
Africa
to
stop
it
spreading
to
USA
&
Europe!!
Need
5000
more
HCWs!

13. Lesson
4:
The
leadership
gap
• The
flaws
in
the
internaLonal
response
was
slow,
uncoordinated
and
not
parLcularly
strong,
most
global
health
experts
agree.
• By
the
Lme
the
World
Health
OrganizaLon
officially
called
it
a
public
health
emergency
in
August,
the
outbreak
was
already
exploding
in
Liberia,
Sierra
Leone
and
Guinea.
• MSF
was
in
West
Africa
for
malaria
and
took
over
Ebola-­‐
insufficiently
prepared!
hjp://www.poliLco.com/story/2014/09/the-­‐ebola-­‐leadership-­‐gap-­‐111405.html#ixzz3HQKTR1a6
hjp://www.poliLco.com/story/2014/09/the-­‐ebola-­‐leadership-­‐gap-­‐111405.html#ixzz3HQKHAPdB

14. Outbreak
rages
on!
• Ebola
could
infect
1.4
million
in
Liberia
and
Sierra
Leone
by
end
of
January
2015
(PredicLve
model
by
CDC)
• WHO
budget
cut
in
past
5
years
by
$16
billion!
• Total
budget
today
is
only
$4
billion!

15. And
Today?

16. Lesson
5:
IniLally
untrained
HCW
sent
to
work
with
EVD
Panic
response
from
most
organizaLons!!
Healthcare
workers
affected
• A
total
of
450
health-­‐care
workers
(HCWs)
are
known
to
have
been
infected
with
EVD
up
to
the
end
of
23
October
2014:
• 80
in
Guinea;
228
in
Liberia;
11
in
Nigeria;
127
in
Sierra
Leone;
one
in
Spain;
and
three
in
the
United
States
of
America.
• A
total
of
244
HCWs
have
died.

17. EVD
exposure
risk
in
HCW
Contact
areas
in
the
workplace
Number
%
Total
number
interviewed
279
In
paLent
room
233
84
Feeding
&
talking
145
52
Examining
paLent
43
15
Lab
handling
blood
17
6
Taking
blood
31
13
Washed
paLent
10
4
Washed
paLent
clothes
7
3
Washed
cadaver
20
7
Contact
at
home
&
HCF
30
Contact
at
home
only
3
JID
1999;179
(Suppl
1)
Ebola
Serologic
Survey
of
Health
Workers

18. HCW
contact
with
EVD
Category
Number
%age
A_ack
rate
37/
429
9%
Physicians
4/13
31%
Nurses
22/212
10%
Technicians
7/62
11%
Others
4/111
4%
Type
of
contact
Number
%age
Direct
204
73%
Indirect
3
33%
Unlikely
63
64%
Unknown
9
56%

19. How
infecLous
is
Ebola?

20. Lesson
6:
First
IPC
principles
FIRST!!
• CONTACT
PRECAUTIONS!
• Which
means
– IsolaLon
– Hand
hygiene
– Gloves
– Splash
protecLon
for
mucous
membranes
– ProtecLon
of
skin
• AdministraLve
controls
– Triage
– Test
– Separate
suspected
and
confirmed
cases
• Environmental
controls
– Clean
and
dry
– VenLlaLon
• PPE

21. Dressing
up
for
Ebola

22. Differences
in
PPE
–both
effecLve?

23. Difference
in
isolaLon
faciliLes-­‐
2014
Rudimentary:
Plasac
buckets
for
disinfectant
or
even
possibly
vomit
from
paaents
stand
in
front
of
simple
paraaons
put
up
to
make
cubicles
for
the
ever-­‐increasing
number
of
paaents
Isolator
used
to
treat
VHF
at
the
RFH

24. Challenges
with
IsolaLon
areas
• Shortage
of
staff-­‐
so
stay
on
duty
longer
than
the
recommended
70
min
• Overcrowding-­‐
heavy
contact
within
the
faciliLes
• NO
venalaaon-­‐
???
• HCW
get
over
heated
in
Tyvek
coverall
suits-­‐
39o
C
inside.
• Loss
of
funcLon
by
HCWs
and
make
mistakes

25. A
lot
of
chlorine
spraying!
• Try
to
keep
the
environment
clean
and
dry!

26. WHO
Interim
IPC
guidance
for
EVD
• General
guidelines
for
containment
of
Ebola
• Produced
in
10
days!
• Widely
circulated
• Adapted
by
ICAN

27. OTHER
WHO
GUIDELINES
(ICAN
involved)
Specific:
Personal
Protecave
Equipment
• What
is
recommended?
• How
to
use
it?
• Discussion
on
the
use
of
chlorine
Specific:
Healthcare
Waste
Management
• What
is
recommended?
• What
should
not
be
done?
• ApplicaLon
of
these
GL
in
various
countries

28. PPE
when
handling
a
case
of
EVD
Both
dressing
and
undressing
should
be
supervised
by
a
trained
member
of
the
team-­‐
(buddy
system).
These
instrucaons
should
be
displayed
on
the
wall
in
the
dressing
and
undressing
room:
hjp://who.int/enLty/csr/disease/ebola/put_on_ppequipment.pdf?ua=1
hjp://who.int/enLty/csr/disease/ebola/remove_ppequipment.pdf?ua=1

29. Taking
puung
on
and
taking
off
PPE
• “First-­‐on-­‐last
off”
• Remove
the
most
contaminated
PPE
items
first-­‐
gloves
• Hand
hygiene
must
be
performed
immediately
aver
glove
removal
– Perform
hand
hygiene
whenever
ungloved
hands
touch
contaminated
PPE
items
• Be
careful
to
avoid
any
contact
between
the
soiled
items
(e.g.
gloves,
gowns)
and
any
area
of
the
face
(i.e.
eyes,
nose
or
mouth)
or
non-­‐intact
skin
• Discard
disposable
items
in
a
waste
container
• Use
a
buddy
to
help!
• AVOID
CONTACT
WITH
THE
OUTSIDE
OF
PPE!

30. Revised
CDC
guidelines
Sept
2014
WHY
INCREASE
FOOT
PROTECTION?

31. Work
and
personnel
flow
PaLents
staff
Support
services
??

32. What
do
you
think
of
this?

33. MANAGING
EXPOSURE
TO
INFECTION
• Mucous
membranes
(e.g.
conjuncLva)
should
be
irrigated
with
copious
amounts
of
water
or
eyewash
soluLon
ONLY.
DO
NOT
USE
CHLORINATED
WATER!
• Follow
up
care,
including
fever
monitoring,
twice
daily
for
21
days
aver
exposure.
• Immediate
consultaLon
with
an
expert
in
infecLous
diseases
is
recommended
for
any
exposed
person
who
develops
fever
within
21
days
of
exposure.
• Contact
tracing
and
follow-­‐up
of
family,
friends,
co-­‐workers
and
other
paLents,
who
may
have
been
exposed
to
an
HF
virus
through
close
contact
with
the
infected
HCW
is
essenLal

34. South
African
Guidelines-­‐
well
prepared
• SA
always
had
good
guidelines
for
VHF-­‐
have
been
used
by
other
countries
across
the
world
• Now
modified
using
MSF,
Red
Cross,
CDC
guidelines-­‐
lijle
evidence
for
some
of
the
recommendaLons.
• HCW
at
risk
during
removal
of
PPE-­‐
use
a
buddy
system
• Keep
the
areas
clean
and
dry
• Unnecessary
use
of
chlorine
spray
increases
risk

35. Are
you
prepared
• Go
to
the
ICAN
website
at
www.icanetwork.co.za
and
complete
the
surveymonkey
checklist
for
ebola
preparedness!

36. ICAN
PARTNERSHIPS
• Funding
of
resource
centres
educaLon
programmes
for
HCW
in
– Uganda
(Samsung)
– CDC-­‐
teaching
in
Resource
Centres
– Sierra
Leone
(London
Mining
Co)
– Links
with
WHO-­‐
GOARN-­‐
involved
in
policy
making
with
WHO
– Geung
volunteers
from
across
UK
and
Europe
• Community
SMS/Text
messaging
communicaLons
– Looking
for
mass
media
noyicaLon

37. ICAN
EBOLA
Training
Programme
• Partnership
between
the
UIPC
and
ICAN
• A
5
day
EVD
IPC
course
has
been
established
• Will
be
run
in
Uganda
by
end
2014
• Curriculum
for
EVD
IPC
course
– Microbiology,
Epidemiology
and
Laboratory
Services
– The
Paaent:
diagnosis,
IPC
management,
surveillance
– The
HCW:
IPC
precauLons.
HH,
PPE,
Contact
precauLons,
reporLng
and
accident
management
– Support
services:
waste,
linen,
water
supply,
burial
and
Post
mortem,
transportaLon,
layout
of
ETU
– The
community
and
communicaaon
about
Ebola,
documentaLon
and
checklists
www.ICANetwork.co.za

38. Summary
• Do
not
forget
the
basic
IPC
principles
• Good
IPC
is
of
the
essence-­‐
safe,
and
sensible!
• Keep
the
environment
clean
and
dry!
•
Vaccines
are
coming!