Transcript Ebola

Ebola
Facts, experiences, opinions,
and some teaching from my
time in Liberia.
Kari Jones, MD
Objectives
• Gain an understanding of why Ebola has killed so
many people in West Africa
• Appreciate cultural differences as barriers to
healthcare in both West Africa and the US
• Share a cautious common sense approach to
Ebola
• Demonstrate effective PPE
• Relieve some anxiety about Ebola in the US
AFRICA
Africa
• Countries affected by Ebola since it’s recognition
Liberia: the only U.S. Colony in Africa
• Beginning in 1822, slaves
were sent back to Liberia
to form a free colony
• By mid 1940’s William
Tubman was the
democratic president for
30 years of growth
• Then unrest, coups and
then civil war up until
2003
• 200,000 killed and 800,000
displaced in 1990’s
• Currently a democracy
under Ellen Johnson
Sirleaf
IN Liberia vs USA
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12x more likely to die in infancy
2.8x more babies per woman
Die 21 years sooner
Use 99% electricity
Make 99% less income
Spend 99.9% less on health care
• 90 physicians in the country: 1 psychiatrist, 1 internist, 2
pediatricians, 3 OB’s
• ~1400 nurses and 400 midwives as well
• About 4.3 million people
• 1:53,000 vs 1:400 physician to patient ratios
Death toll to date
• In its latest toll, WHO said that through November
10th, 2,812 people had died in Liberia
• In Sierra Leone, 1,187 people had died as of
November 11th
• Guinea, where the outbreak began late last year,
counted 1,166 deaths also as of November 11th
• 324 health care workers have died out of ~570
infected in all three countries
Why is Ebola so bad in
West Africa?
• This seems easy, but is really a complicated question!!
• And as we go through answers, think about how the U.S.
differs
• And notice as it gets it more complicated, the slides get
very busy!
Easy answers:
• Lack of health care workers
• Lack of protective equipment for the health care
workers
• Lack of sanitation and electricity to provide clean
patient care facilities; made worse during the rainy
season (This didn’t really seem to play a role)
• No health care infrastructure to handle a national
crisis (county health departments are not found in
Liberia in the form you see them in the U.S.)
A little more complicated…
• Distrust after a civil war: was their someone behind
the illnesses? People would go for treatment and
never come home. (This was a big factor!!)
• Prominent health care officials denying it’s
existence
• Lack of basic medical understanding in general
population
• The cultural norm is very dependent on human
touch, especially with the recently deceased
• Fear: people that sought treatment died
And then, just to make it worse…
• People started to realize the illness was real and deadly and
contagious
• But, there was no place for them to contain the sick patients
(let alone provide good medical care)
• They closed the 3 main hospitals in Liberia: no health care was
available for a couple weeks
• Health care workers were most affected at the beginning due
to lack of knowledge and protection, so subsequently it was
hard to convince other health care workers to work. (locally
and internationally)
• The health care provided was minimal at best due to lack of
personnel and PPE and supplies
• There was no way to protect family members who were had
to take care of them at home (ponder that a bit: leave your relative at
a center knowing they will probably die but you all will be okay or take them
home again)
And that is where my story
begins!
What was I doing in Liberia?
• Samaritan’s Purse: DART personnel
• MSF needed help, SP thought they could help
• Foya was up north, several months old and running
well
• Monrovia (ELWA) was the new Ebola treatment
center, and it was quickly growing
This is the inside of a newer center…
Not quite the same ambiance as the CDC poster, but still
better than ELWA
Patient Amenities
Patients all have names
Cleaning never ends
The Newest Treatment
Center
This was the ELWA 2 treatment center
Yes, that’s a person laying on the ground in front of the window, most likely
passed away.
Sort of reminds me of a jail cell
Preparation for moving to
the morgue
Walk out of ELWA 2 and it’s a sunny
day in Monrovia
Nancy’s house: an Ebola
treatment center
Joy can be found anywhere!
The last fire
Leaving Liberia
Donning the PPE
Donning continued
Donning complete
Doffing the PPE
• Each step is preceded by
handwashing with bleach
0.05% or hand spraying
with 0.5%
• Whole body is sprayed:
front and back
• Hands washed
• First gloves removed
• Hands washed
• Apron removed
• Hands washed
• Goggles removed
• Hands washed
Hood removed
Hands washed
Gown removed
Hands washed
Mask removed
Hands washed
Gloves removed
Hands washed
Boots sprayed and
removed
• Then go wash your hands
at bucket of bleach
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Ebola in the U.S. – Don’t Panic
• People understand basic medical issues here
• People believe what the government tells them about
medical items
• We can share information nationally in a rapid manner
• We have an infrastructure that can trace and follow
possible sick contacts
• We have facilities to isolate patients
• We have PPE for health care workers
• We have excellent health care if admitted
• We have no need to touch each other if we think we
might get sick!
Ebola in the U.S. – Don’t panic, but….
• Cautious common sense
• Protect yourself if there is a real threat of Ebola
• Your safety is more important than the care of the
patient (this is a hard concept to caring health care
workers)
• Never hurry
• Never cut corners on safety (this isn’t the flu)
How does this affect the County
Health Departments?
• This is where the onus of work is going to be done
o contact tracing and follow up is key
• You are the number everyone can call if they think
they have an Ebola patient.
o Should have a plan known by all as to what steps to take depending on
where the call comes from
o It should be simple, and safe: remember, if no one is touching the patient,
then no one is going to catch it.
o Should have the questionnaire to screen patients readily available
o The vast majority of new Ebola patients are mobile and able to get
themselves to whichever facility you deem appropriate
o Need a clean-up plan to follow after patient
Opinions and ideas for every county
• Have a gutted ambulance available for transport
• Have bleach available for any encounters
o For cleaning up wherever the patient went
o For disinfecting any vomit or diarrhea or blood that the patient puts out
o For washing hands
• Know when PPE is needed and when it’s not
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Be smart: if you’re the driver of a transport you will not be exposed
If you’re riding in the back with them, then you need PPE
If you’re assessing someone via questionnaire: you do not need PPE
If you are having contact with the patient: you need PPE
If you are a sanitation person cleaning up bodily fluids: you need PPE
• PPE should be done appropriately if it is going to be
worn
o There are risks to doffing inappropriately, so don’t do it if not needed
o If you leave any part of you exposed, the PPE will not do it’s job
Opinions and ideas continued…
• Maximize the safety of healthcare workers
o Limit the number of workers and locations that are exposed to an Ebola
patient
o Assess health care workers’ ability to appropriately don and doff the PPE
independently (supervised, but doffing done on their own)
o Provide practice of care that minimizes risk of exposure to virus as patient’s viral
load increases (DNR, DNI, minimal tubes and drains)
• Emergency responders
o Be prepared for the unexpected
o Always have gloves available, and goggles and mask if worried about Ebola
• If we get an Ebola patient in Washington: I hope they
are triaged in one ER room and transported to a facility
that has already demonstrated the infrastructure to
manage them safely and well.
o I have no idea why a hospital in Washington would currently keep an Ebola
patient: it could be done, but it seems unnecessary
Survivor!!!
The End
Thank you