Transcript Slide 1

Ebola virus update
Dr Ann Koehler BSc MBBS FRCPA(Microbiol) MPH
Director, Communicable Disease Control Branch,
Public Health & Clinical Systems
SA Health
Aim of information session
 Increase awareness of Ebola virus disease and
exposing myths that exist about the virus
 Increase awareness of what general practices and
other health services should be doing to prepare
 Increase awareness of what infection control
measures (including personal protective equipment
(PPE)) is recommended in general practice
 Provide advice on what to do if you have a
suspected case of Ebola virus disease at your
practice
High infection rates in West Africa
 Generally poor infection control and PPE
 People most at risk are family members, carers, traditional
healers, and those participating in traditional burial rituals
 Funeral practices
 Account for 25% of cases, up to 60% in Liberia
 Community spread mostly occurs through social networks
 Epidemiology supports contact transmission, not aerosol –
absence of clusters of cases in which no direct contact
occurred
 Transmission through direct contact with contaminated blood
or body fluids most often through oral or mucous membrane
exposure
Human to human transmission*
 Risk of transmission during incubation period or from
asymptomatic persons is negligible (other than
through blood transfusion)
 Levels of virus highest in terminal phase of illness
 Large outbreaks almost always result of amplification
in healthcare settings in which basic infection control
measures have broken down
 In the original 1976 outbreak, only 5.3% of household
contacts were estimated to be infected, although
the secondary attack risk was higher (27%) in first
degree relatives within households
Blumberg L et al. Viral haemorrhagic fevers. Manson’s Tropical Diseases
Low infection rates outside of endemic areas
 Except for recent healthcare worker
infections in Spain and the USA and earlier
cases among laboratory workers, there has
never been Ebola virus transmission outside
of Africa
 In countries with good public health systems,
any transmission will be rapidly contained
(have even seen this in Nigeria recently)
Other infection routes
 Contact with infected animals – apes and bats, alive or dead
 Handling or consumption of infected bush meat
 Breastfeeding by infected women (convalescent ??)
 Sexual partner of known or suspected male case
 Virus in semen up to 3 months after clinical recovery
 Receiving health care from provider who is looking after EVD
patients and not taking appropriate infection control measures
 Contact with contaminated items e.g. medical material, linens
 Virus cannot survive very long in non-organic material
Insights from Dallas patient
 First presentation:
 Presented on 25/9 with fever, headache, abdo
pain
 Gave travel history but this was not considered by
doctor
 Had CT scan, extensive travel through hospital +
HCW contact
 Discharged to home with antibiotics
 No special PPE worn by staff
 No HCW or other patients infected during this
presentation
Insights from Dallas patient
 2nd Presentation 28/9
 Diagnosis of Ebola virus infection not made until 30/9
 From 2 staff infected in this second phase during 28 –
30/9
 He had extensive production of bodily fluids because of
vomiting and diarrhoea
 One nurse had placed a rectal tube in patient
 A lot of variability in use of PPE
 172 contacts traced for the 2 nurses and patient including
patient’s fiancee who had cared for him in cramped flat
while he had profuse diarrhoea
 Apart from 2 nurses described above, no infections
Other hospital exposures
 Spanish nurse’s assistant
 Cared for priest in terminal phase of illness
 Entered his room on 2 occasions
 to change diaper
 after he had died
 Thinks she contaminated herself while removing
PPE; recalls touching her face with gloved hand
 No other HCWs infected in this episode
 South Africa 1997
 Undiagnosed patient who eventually died
 Over 300 HCWs exposed, none infected
 Ebola usually begins with a flu-like syndrome with
fever and profound weakness, often
accompanied by arthralgia, myalgia,
headache, anorexia and hiccups. These are
usually followed by gastrointestinal symptoms:
nausea, vomiting, and diarrhoea. Patients may
also complain of dysphagia
Early clinical features
Intense tiredness, weakness,
malaise
Conjunctivitis
Sudden onset fever >38C axillary
Nausea, anorexia
Throat pain, difficulty swallowing
Headache
Myalgia
Abdominal pain
Diarrhoea (can be bloody)
Hiccups
Arthralgia
Often overlap of early and late symptoms
Patients often do not develop all the signs and symptoms
Late clinical features
Confusion, irritability
seizures
Chest pain
Diarrhoea (watery or bloody)
Vomiting (may be bloody)
Rash including ecchymoses,
petechiae, purpura
Oozing from puncture sites
Epistaxis
Haemoptysis
Melaena, haematochezia
Gingival bleeding
Unexplained vaginal bleeding
Conjunctival haemorrhage
Haematuria
Bleeding from eyes
Miscarriage (fetal mortality ~100% in
3rd trimester)
Shock
Respiratory distress of shock
Pathophysiology
 Incubation period 2 – 21 days (most commonly < 10
days)
 Abrupt onset of symptoms
 Microvascular instability and imparied haemostasis
are the consistent hallmarks
 External haemorhage is not always seen
 Much more in common with septic shock
 Mortality usually results from intense inflammatory
process
 Insufficient effective circulating intravascular volume
 Hypotension
 Cellular dysfunction
 Multiorgan failure
Recovery
 Mortality rate varies: Zaire strain 50-90%
 About 70% in current outbreak
 Virus clears rapidly from blood upon symptom
resolution
 Clearance may be delayed up to 3 months in
immunologically protected sites e.g. kidney,
gonads, chambers of the eye
Risk in South Australia
 Except for recent healthcare worker infections in
Spain and the USA and earlier cases among
research laboratory workers, there has never
been Ebola virus transmission outside of Africa
 In countries with good public health systems, any
transmission will be rapidly contained (have
even seen this in Nigeria recently)
Risk in South Australia
PORT/DATE
Adelaide
Brisbane
Darwin
GoldCoast
Melbourne
Perth
Sydney
Broome & Horn Island
Cairns
Port Hedland
Sunshine coast
Grand Total
16-Oct 17-Oct 18-Oct 19-Oct 20-Oct 21-Oct 22-Oct 9-Aug to 15-Oct 16-Oct to 22-Oct
13
0
0
0
1
2
0
0
0
0
0
0
0
12
4
15
0
0
0
0
0
0
2
4
3
0
0
0
1
0
0
7
4
4
0
0
0
16
0
31
0
9
0
16
1
2
0
0
10
0
1
0
0
0
0
14
0
0
0
0
8
4
0
0
0
0
0
12
0
3
0
0
2
3
2
0
0
0
0
10
28
115
3
1
192
302
192
0
0
0
0
838
14
6
0
0
42
21
25
0
0
0
0
108
Grand
Total
42
121
3
1
234
323
217
0
0
0
0
946
Arrivals to Australia from affected countries
Approximately 99 per week
14 from Democratic Republic of Congo
14 from Liberia, Sierra Leone, Guinea
Remainder were from Nigeria which has controlled outbreak
Border measures
 Exit screening from affected countries
 Electronic tracking of flights for individuals depending on how
ticket booked
 All people entering Australia will be asked if they have been in
an Ebola-affected area within the past 21 days
 If so will have
 Temperature screening (infra-red thermometer)
 Questioning on symptoms
 Questioning on exposure risks
 Any concerns will be reported to Human Quarantine Officers
(CDCB medical officers)
 If no concerns will be asked to monitor temperature for 21 days
and given information card including hotline number to use if
they develop symptoms
Post arrival
 Hotline goes to HealthDirect
 Script followed; if necessary referred to SAAS for
further risk assessment
 If necessary SAAS will contact CDCB duty
medical officer for advice
 If symptoms consistent with EVD SAAS will collect
patient and transfer to quarantine hospital
 Royal Adelaide Hospital for adults
 Women’s & Children’s Hospital for children
Specific groups
 Healthcare workers:
 Weekly list of returnees. All contacted within 24
hours and risk assessed. Bd temps, limited
movement. Each agency has protocols
 Humanitarian entrants:
 Now home quarantine before departure for 21
days. No new visas announced 27th. Existing visa
holders 21 days exit quarantine
Walk-in patients
 Extremely unlikely as all will have
 Arrived from West Africa only within last 3 weeks
 Have been given information card which will lead
to them being directed to SAAS
 If did present would be likely to be early as late
presentations more likely to require SAAS
 Infectivity in early disease low – increases as
disease progresses
Walk-in patients
 If EVD possible:
 escort patient to single room
 use PPE for contact and droplet precautions
 Contact CDCB duty medical officer 1300 232 272
(24/7) for risk assessment and to discuss
investigation/ transfer
 If indicated, SAAS will take patient to quarantine
hospital
PPE: Contact and Droplet
Precautions
 Long-sleeved gown (preferably disposable)
 Surgical mask
 Protective eyewear ( or combined visor/surgical
mask)
 Disposable gloves
Observations from a MSF field worker
(ID physician from Singapore)
 “I think the dangers of excess PPE are underrated
 It is a pity the response to HCW infections is ‘wear more PPE’
 Those working in Ebola treatment units in West Africa have been
well trained and practiced
 Are being sprayed with chlorine as they take it off
 Are being observed by an equally experienced buddy
 The full body suits are difficult to remove and are a source of
unnecessary risk
 In Singapore we are likely to take them out of our protocol
altogether
 We will revert to contact precautions plus”
Contact tracing
 For any notifiable disease, the identification,
management and monitoring of contacts
external to the healthcare setting is always the
responsibility of the CDCB
 As Ebola virus infection is a quarantinable
disease, the CDCB as the human quarantine
service will also be closely involved in contact
tracing and follow up for contacts within the
healthcare setting
Laboratory testing
 SA Pathology is the only laboratory in SA which
can do Ebola virus testing
 Testing must be discussed with the on-call
microbiologist from SA Pathology prior to
collection
 Most febrile cases recently arrived from West
Africa will be more likely to have malaria or
dengue and these should always be tested for
Environmental cleaning
 For confirmed cases, cleaning staff should wear
full PPE
 Routine cleaning using sodium hypochlorite
1000 ppm available chlorine
 Spills/vomit/other bodily fluids –
 Preferably use spill kit
 Sodium hypochlorite 5000 ppm available chlorine
Workforce issues
 HCWs who have cared for confirmed case:
 May continue to work in clinical role if no high
risk exposures (e.g. needle stick injury)
 Monitor temperature twice daily
 Present for assessment immediately if develop
temperature or other symptoms
Updates
 For current information on affected areas,
regular updates are available from the WHO
website http://www.who.int/csr/don/en/
 Regular updates of areas affected and other
clinical information will also be posted on the SA
Health website
http://www.sahealth.sa.gov.au/ebola