Transcript 07-23-2015-Bates-Monrovia-Medical-Unit

Commissioned Corps of the U.S. Public Health Service
Monrovian Medical Unit (MMU) Mission
at Camp Eason
(Margibi County, Liberia)
Obligatory Disclaimer
This presentation is solely from a personal
experience perspective;
and does not represent the official positions or
policies of the U.S. Public Health Service’s or U.S.
Department of Health and Human Service.
Presentation Outline
• Share Ebola Response to Liberia
– A personal perspective
• Update on Global Movement to Preparedness
– Lessons are being learned
– Things are changing
U.S. Public Health Service
Who Are We?
• A Uniformed Service comprised of 6,800
Officers under the direction of the U.S.
Surgeon General, Dr. Vivek Murthy
• Comprised of:
– Physicians, Dentists, Nurses, Therapists,
Pharmacists, Health Services, Environmental
Health, Dietitians, Engineers, Veterinarians and
Scientists.
U.S. Public Health Service
• The mission of the U.S. Public Health Service
Commissioned Corps is to protect, promote, and
advance the health and safety of our Nation. As
America's uniformed service of public health
professionals, the Commissioned Corps achieves
its mission through:
– Rapid and effective response to public health needs
– Leadership and excellence in public health practices
– Advancement of public health science
Ebola – The Background
• The 2014 Ebola outbreak is the largest in history
and the first Ebola outbreak in West Africa.
• This unprecedented outbreak has affected
multiple countries in and around West Africa,
with the countries of Sierra Leone, Liberia and
Guinea having been the hardest hit.
• Recognizing that the only way to eradicate the
threat of Ebola in America and the world is to
defeat it at its source, the U.S. has significantly
ramped up efforts to fight the virus in West
Africa.
United States Response
U.S. Strategy
POTUS: “Ebola epidemic in W. Africa and the humanitarian crisis
there is a top national security priority for the United States”
• Strategy is predicated on four key goals:
1. Controlling the epidemic at its source in West Africa;
2. Mitigating second-order impacts, including blunting the
economic, social, and political tolls in the region;
3. Engaging and coordinating with a broader global
audience; and
4. Fortifying global health security infrastructure in the
region and beyond.
Prior to Departure
• 65 Officers completed an intense 7-day
training conducted by the Center for Disease
Control and Prevention at FEMA’s Center for
Domestic Preparedness in Anniston, Alabama.
• A Total of 4 Teams deployed between Oct
2014 and May 2015.
• The MMU is now operated by the Liberian
Government.
Monrovia Medical Unit
• Our mission was to provide hope through care
to health care workers in Liberia who may
have the Ebola virus disease and continue
efforts with the Liberian and international
partners to build capacity for additional care.
Monrovia Medical Unit (MMU)
• The MMU is a 25-bed Ebola Treatment Unit
specifically designed to treat infected health
care workers such as doctors and nurses who
are at higher risk of infection, because they
are in close, sustained contact with Ebola
patients who are symptomatic and infectious.
Reference to the MMU
• Video Tour is available at:
• https://www.youtube.com/watch?v=bmyUb3
N5gAk
Early Clinical Presentation

Acute onset; typically 8–10 days after exposure
(range 2–21 days)

Signs and symptoms
 Initial: Fever, chills, myalgias, malaise, anorexia
 After 5 days: GI symptoms, such as nausea, vomiting, watery diarrhea,
abdominal pain
 Other: Headache, conjunctivitis, hiccups, rash, chest pain, shortness of
breath, confusion, seizures
 Hemorrhagic symptoms in 18% of cases

Other possible infectious causes of symptoms
 Malaria, typhoid fever, meningococcemia, Lassa fever and other
bacterial infections (e.g., pneumonia) – all very common in Africa
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Clinical Features

Nonspecific early symptoms progress to:
 Hypovolemic shock and multi-organ failure
 Hemorrhagic disease
 Death

Non-fatal cases typically improve 6–11 days after symptoms
onset

Fatal disease associated with more severe early symptoms
 Fatality rates of 70% have been reported in rural Africa
 Intensive care, especially early intravenous and electrolyte
management, may increase the survival rate
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Clinical Manifestations by Organ System
in West African Ebola Outbreak
Organ System
Clinical Manifestation
General
Fever (87%), fatigue (76%), arthralgia (39%), myalgia (39%)
Neurological
Headache (53%), confusion (13%), eye pain (8%), coma (6%)
Cardiovascular
Chest pain (37%),
Pulmonary
Cough (30%), dyspnea (23%), sore throat (22%), hiccups (11%)
Gastrointestinal
Vomiting (68%), diarrhea (66%), anorexia (65%), abdominal pain (44%),
dysphagia (33%), jaundice (10%)
Hematological
Any unexplained bleeding (18%), melena/hematochezia (6%),
hematemesis (4%), vaginal bleeding (3%), gingival bleeding (2%),
hemoptysis (2%), epistaxis (2%), bleeding at injection site (2%),
hematuria (1%), petechiae/ecchymoses (1%)
Integumentary
Conjunctivitis (21%), rash (6%)
WHO Ebola Response team. NEJM. 2014
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Examples of Hemorrhagic Signs
Hematemesis
Gingival bleeding
Bleeding at IV Site
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Laboratory Findings

Thrombocytopenia (50,000–100,000/mL range)

Leukopenia followed by neutrophilia

Transaminase elevation: elevation serum aspartate aminotransferase (AST) > alanine transferase (ALT)

Electrolyte abnormalities from fluid shifts

Coagulation: PT and PTT prolonged

Renal: proteinuria, increased creatinine
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EVD Summary

The 2014 Ebola outbreak in West Africa is the largest in history
and has affected multiple countries

Think Ebola: U.S. healthcare providers should be aware of clinical
presentation and risk factors for EVD

Human-to-human transmission by direct contact
 No human-to-human transmission via inhalation (aerosols)
 No transmission before symptom onset

Early case identification, isolation, treatment and effective
infection control are essential to prevent Ebola transmission
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MMU Team 1: Challenges
• Never been done before – a U.S. Government
asset transforming an Army “MASH” tent unit
into an ebola treatment center.
• Difficult diagnosis without lab test results.
• Lack of a ready supply stream and equipment.
• Learning who the response partners were in
country and how to work with them.
• Adjusting medical care standards based on
environment and resources.
Innovation Required !!
MMU Team 1: Schedule
• Worked 2 months straight except for 2 days
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Hour 1 – awake and get ready for commute
Hour 2 – Commute to MMU
Hour 4-16 for 12-hour shift
Hour 18 – Commute to “Lodging”
Hour 19 – Fall asleep for a 5 hour nap
Start all over again!
18 Guys in a tent
What did CAPT Bates do?
Logistics Team
• Whatever the task of the moment demanded.
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Supply and Inventory control
Infection control
Safety
Medical
Lab
Housekeeping
Pharmacy
Facilities and Supply
Dietary
Bug Control
Ebola Buster
Infection Control
1000 pounds of 65% HTH used
Biohazard Waste Process
How We Protected Ourselves
• Donning and Doffing Video
• Reference:
https://www.youtube.com/watch?v=mfT9ipzt
g5Y
PPE
Personal Protection Equipment
PPE
MMU Team 1: Outcomes
• The USPHS sent 65 clinicians, administrators, and
support staff to assist in the response effort.
• Health care providers in Liberia now had a place
to go if they contracted the ebola virus.
• The efforts of USAID, DoD, USPHS, Government
of Liberia, International Partners, and NGOs built
capacity for additional care in Liberia
• Over 100 providers from Africa were reported to
have joined the effort in Liberia during our tour.
A Successful Mission and Safe Return
The Global Movement to
Preparedness
Lessons Learned
• Countries with weak health systems and few
basic public health infrastructures cannot
withstand sudden shocks to their society
• Preparedness – swift action makes the difference
• No single control intervention is sufficient
• Community engagement is the linchpin for
successful control
More Lessons Learned
• Operations:
– Put the needs of patients and communities at the core
of any response. Evaluate and practice surge capacity
• Governance and Accountability
– A fast response will not happen without leadership.
Set priorities based on what is needed on the ground.
• Research and Development
– Strengthen research and development systems
focused on outcomes for the global public good.
Department of
Health and Human Services
• July 1, 2015 – DHHS launched a National Ebola
Training and Education Center and funded 3
hospitals to train, prepare U.S. health care
facilities for Ebola and other emerging threats.
• Regional Ebola treatments centers have been
established.
• Evaluation of the national response planning,
surge capacity, and supply stockpiles is
ongoing.
Most Importantly
Reactions and Responses
must not be
fear based !!
We Can’t Rely on Batman
Future Challenges
• Focus science based public health over politics
• Global collaboration and commitments to strengthening
public health infrastructures
• Commitment to collaborative and coordinated surge capacity
• Understanding the multi-factorial influencers of global public
health challenges (political, economic, cultural, social
determinants of health, funding, transportation, food/water,
etc.)
• Reconciling health care responses with cultural and societal
influencers
• Moving beyond disease specific preparedness to a global
infectious and communicable disease preparedness and
response capacity
A Patient Perspective
Recovery from Ebola
Returning to the healthcare workforce
Other Information
• Link to news Article in Gazette Record, Saint
Maries ID; regarding deployment to Liberia:
• http://www.stmariesid.com/fighting-ebola/
• Web link to the President’s recent update on
the Ebola outbreak activities.
• http://www.c-span.org/video/?3243051/president-obama-remarks-combating-ebola
Contact Information
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CAPT Dale M. Bates
U.S. Public Health Service
Phone: 206-615-2497 (office in Seattle)
Email: [email protected]
• Address:
• 23920 N Teddy Loop
• Rathdrum ID 83858