Ebola Virus Disease (EVD): Implications for Schools

Melissa McMasters, RN, MSN Coordinator, Immunization and Infectious Disease Programs

Objectives

• • • • Describe the clinical presentation of potential pediatric patients with EVD Recommendations for schools Recommendations for colleges and universities How to talk to children about EVD

Current West African Outbreak

Source: Anthony England; @EbolaPhone

Country

Guinea Liberia Sierra Leone

Case Counts

Total cases

1667 6535 5338 13540

Lab-confirmed

1409 2515 3778 7702

Deaths

1018 2413 1510 4941

EVD in Children

• • • • Suspected index case in current outbreak: 2 year old who died in Guinea in December 2013 Data in pediatric patients is lacking In Guinea, 18% were children Of 4 originally affected countries, 13.8% were younger than 15

EVD in Children

• • Children and adolescents represent a small number of documented cases Cultural practice is to keep children away from sick family members

Progression of EVD (Adults)

Fever and Malaise Gastroenteritis Viral Sepsis

Clinical Presentation of US Cases

• 3 phases of Ebola Virus Disease (EVD) 1. Fever and Malaise (days 2-4) » Achy » Chills and Sweats » Flu like symptoms 2. Gastroenteritis (days 5-9) » Nausea » Vomiting (projectile) » » » » » Diarrhea (explosive) Significant fluid loss (4-12 L/day) Vascular leaking Oozing Nose and gum bleeds

Clinical Presentation Cont’d

3. Viral Sepsis » » Acute, critical phase Multi- organ failure » » » » » ARDS Dialysis Mechanical ventilation Encephalopathy Death

Course of Illness

• • • • Average of 28 days hospitalized Range of illness from moderate to severe All patients discharged reporting consistent and persistent generalized weakness and fatigue Criteria: 2 negative PCR’s from blood and asymptomatic

Presentation in Children

• • • Non specific presentation similar to other pediatric infectious diseases Fever, headache, myalgia followed by diarrhea and vomiting – 100% Febrile Differential Diagnoses – Malaria – Measles – Typhoid Fever

Treatment of EVD Pediatric Patients

• Key is supportive care of complications – Hypovolemia – Electrolyte abnormalities – Nutritional supplementation – And then acute, critical care if progression to septic phase

Pregnancy and Neonates

• • • • Pregnant women are not more susceptible But do have increased risk for severe illness and death Increased risk for spontaneous abortion and hemorrhaging No known neonates have survived

Monitoring Travelers

• • Currently MCPHD monitors all travelers from West Africa Travelers from Sierra Leone, Guinea, and Liberia can only enter through 1 of 5 quarantine stations 1. John F. Kennedy New York 2. Dulles Washington D.C.

3. Liberty New York 4. O’Hare Chicago 5. Hartsfield-Jackson Atlanta

Risk Levels for Travelers

1. Symptomatic individuals in the high, some, or low(but not zero) risk categories 2. Asymptomatic in high risk category 3. Asymptomatic in some risk category 4. Asymptomatic in the low (but not zero) risk category 5. No identifiable risk category

Active vs. Direct Active Monitoring

• • • •

Active Monitoring

Local public health authority assumes responsibility Daily communication Assess for symptoms and fever Minimum: Daily reporting of measured temperatures and symptoms to LHD and notify immediately if symptoms or fever develop

Direct Active Monitoring

• • • • Local public health authority assumes responsibility Direct observation Assess for symptoms and fever Minimum: Twice daily communication with one being observed and must notify LHD immediately if symptoms for fever develop

Monitoring and Restrictions

Risk Category

1. Symptomatic

Monitoring

Medical Evaluation 2. Asymptomatic High Risk Direct Active 3. Asymptomatic Some Risk Direct Active 4. Asymptomatic Low Risk Active 5. No Risk N/A

Travel Restrictions

Federal public health travel restrictions Controlled movement Federal public health travel restrictions No commercial travel Local and State will consider Allowed; must assure uninterrupted monitoring N/A

For Schools

• • Asymptomatic low risk will be monitored by health department for 21 days and will be allowed to attend school Asymptomatic some risk will be monitored by health department for 21 days and will not be allowed to attend school – How will their educational needs be addressed?

– Plans for e-learning, etc.

Caution

• • Issues of prejudice and discrimination Last week 2 Senegalese boys (born in America) were allegedly attacked and beaten after one of them sneezed in the cafeteria – http://newyork.cbslocal.com/2014/10/27/nyc leaders-say-african-children-bullied-at-school-in wake-of-ebola-scare/

Colleges and Universities

• • • • Level 3 Travel Warning for Liberia, Guinea, and Sierra Leone Avoid non-essential travel Postpone education-related travel CDC reports a minimum of 6 months to get outbreak under control but could be much longer

Why?

• • The health care systems in these countries are severely strained Risk is not only EVD but routine emergency health care needs of visiting US citizens will likely not be met – Car accident yet nearest hospital is overwhelmed treating EVD patients

Returning Students, Faculty and Staff

• • • • At this point, these individuals would fall under our active monitoring protocol Student health centers should follow CDC recommendations that apply to all US healthcare settings CDC does not recommend quarantining or isolating anyone based on travel history alone Work with local health department

References

• CDC Ebola Website – Outbreak in West Africa http://www.cdc.gov/vhf/ebola/outbreaks/2014 west-africa/index.html

– Monitoring Travelers http://www.cdc.gov/vhf/ebola/exposure/monitori ng-and-movement-of-persons-with-exposure.html

– Schools http://www.cdc.gov/vhf/ebola/children/index.ht

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