2014 EBOLA VIRUS DISEASE Jackie Dawson, PhD Public Health Epidemiologist Chelan, Douglas, Grant, Kittitas and Okanogan Counties 509-886-6428 [email protected].

2014 EBOLA VIRUS DISEASE

Jackie Dawson, PhDPublic Health EpidemiologistChelan, Douglas, Grant, Kittitas and Okanogan [email protected]

Center for Food Security and Public Health Iowa State University - 2004

Viral Hemorrhagic Fever Viruses

Arenaviridae Bunyaviridae Filoviridae Flaviviridae

Junin Crimean- Congo H.F. Ebola Kyasanur

Forest Disease

Machupo Hantavirus Marburg Omsk H.F.

Sabia Rift Valley fever Yellow Fever

Guanarito Dengue

Lassa

Ebola Outbreak, Reston, VA

October 2, 1989: 100 crab-eating macaques flown from the Philippines to New York City and trucked to Reston, VA.

By November 1: 29 monkeys died Vet dissected one of the dead monkeys searching for the

cause of death. There was blood in the intestines Diagnosed as simian hemorrhagic fever virus Frozen samples wrapped in tin foil & shipped to United States

Medical Research Institute of Infectious Diseases (USAMRIID). By the time the samples reached the lab, they had thawed out and were dripping fluids.

Diagnosis = EBOLA Marburg roused no glow in the monkey cells; the Ebola-Sudan

made them glow a little; the Ebola-Zaire lit them up like light bulbs.

“The idea that a filovirus might burn through a warehouse 10 miles from the capital greatly disturbed the army scientists.”http://ispub.com/IJPRM/2/1/12768

Ebola (Reston, VA)

November 28, 1989: 6 weeks after monkeys began dying in Reston, USAMRIID verified the Ebola finding.

Because of the threat that Ebola might spread to staff, Reston and the greater Washington, DC community, the Army determined that all remaining monkeys would be immediately euthanized.

COL Gerald “Jerry” Jaax was in charge of eradicating the virus. An initial entry team examined the buildings layout, entrances, exits, and unprotected openings.

LTC Nancy Jaax (wife of COL Jaax), a veterinarian and pathologist, conducted a walkthrough to determine the condition of the monkeys and what problems an operations team might encounter: blood, body fluids, as well as excited monkeys.

Hazelton staff and animal handlers were still working in the building without hazmat suits and most were unaware of the grave danger that they were in.

Ebola (Reston, VA)

November 30, 1989: LTC Nancy Jaax and another officer donned Hazmat suits and began to euthanizing 65 monkeys. 

By late afternoon, the monkeys were dead & the remains were triple-bagged for incineration.

450 monkeys remained alive. December 5, a group of 91 animal care specialists broken up into 2-

person teams entered the facility. Consisting of mostly young soldiers, most were unfamiliar with

encapsulating suits, the tools they would be working with, the behavior of monkeys or of the full potential of the medical problem they were facing.

 One of the monkeys escaped. Efforts to net the animal were unsuccessful and only agitated the other monkeys. Shooting it was out of the question for fear that a loose round would end up somewhere unwanted. And, no one had thought of bringing a dart gun or other immobilizing device. Ultimately, it was decided to let the monkey roam freely and to try again the next day.

Ebola (Reston, VA)

“Several of us spent the better part of a day trying to catch it. When we talk about the Reston incident, we compare the frustration of that day with the Hollywood version in the movie ‘Outbreak,’ in which an infected monkey was coaxed from a tree and captured within minutes. It is a great example of reality vs. Hollywood”.

Finally the escapee was caught after it had jammed itself into a crevice leaving only its rump exposed. The creature was quickly euthanized.

Ebola (Reston, VA)

Dec 6th: building decontamination efforts began─ chipping, scrubbing and bleaching.

This continued for 11 days, followed by the introduction of Bacillus subtilis niger. Strains of the species Bacillus subtilis (spores) are used

for sterilization control. Their death presumes all bacteria and viruses to be dead.

About 6:00 p.m. on December 18, electric fry pans, set on high, volatized the formaldehyde crystals. For three days, the building was cooked. Finally it was determined that the building was decontaminated.

Reston’s three month ordeal with Ebola was over.

Ebola (Reston, VA) Conclusion While the cleanout of the monkey

house was going on, 2 out of 4 monkey care takers were hospitalized -both survived.

Conclusion: new species of Ebola virus, which they named Ebola-Reston.

The new virus was highly pathogenic in monkeys but apparently not in humans. 

2014 Ebola Outbreak West Africa

www.cdc.gov/vhf/ebola/resources/distribution-map-guinea-outbreak.html

Ebola Outbreaks, 1976-2013

Ebola “subtypes”•Zaire•Sudan•Tai Forest (Ivory Coast)•Bundibugyo (Uganda)

•2014 West Africa:97% identical to Zaire ebolavirus) identified earlier in the Democratic Republic of the Congo and Gabon.

Ebola

Symtoms appear most commonly 8-10 days after exposure

Fever of >38.6o Celsius (101.5o F)

www.cdc.gov/vhf/ebola/outbreaks/guinea/qa.html

http://www.cdc.gov/vhf/ebola/pdf/west-africa-outbreak-infographic.pdf

Ebola reservoir ? WHO believes that fruit bats may be the

natural host of the Ebola virus in Africa In Africa, Ebola may be spread as a result

of hunting, processing, and consuming infected animals (e.g., bushmeat).

New York City, home to nearly 77 000 West Africans (most of them in the Bronx), is the epicenter of the bushmeat trade in the U.S.

One recent study estimated that 273 tons of bushmeat is imported into Charles de Gaulle Airport on Air France carriers every year. From France, the imported goods often travel on to America.

Ebola cases and deaths

WHO: >240 health-care workers have developed the disease and > 120 have died

Ebola Cases and Deaths (West Africa)August 28, 2014Suspected and Confirmed Case Count: 3069Suspected Case Deaths: 1552Laboratory Confirmed Cases: 1752 Updates on cases and deaths can be found on the CDC website: http://www.cdc.gov/vhf/ebola/outbreaks/guinea/index.html

Ebola Virus Disease

In the current outbreak, the majority of Ebola virus disease cases are a result of: human-to-human

transmission and failure to apply appropriate

infection prevention/control measures in:▪ home care▪ clinical settings▪ burial rituals

Environmental Survival

Virus is believed to be able to survive for some days in liquid outside an infected organism,

Disinfection: Chlorine Heat direct sunlight soaps and detergents

What should U.S. hospitals do if they have a patient with suspect EVD?

Early recognition is critical for infection control. Healthcare providers should be alert for and evaluate any patients suspected of having EVD who have (see EVD case definition):

A fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage;

AND

Risk factors within the past 3 weeks before the onset of symptoms, such as contact with blood or other body fluids of a patient known to have or suspected to have EVD; residence in—or travel to—an area where EVD transmission is active; or direct handling of bats, rodents, or primates from disease-endemic areas.

Malaria diagnostics should also be a part of initial testing.

If a patient in a U.S. hospital is identified to have suspected or confirmed EVD, what infection control precautions should be put into place?

Follow standard, contact, and droplet precautions, including the following recommendations:

Isolate the patient: Patients should be isolated in a single patient room (containing a private bathroom) with the door closed.

Wear appropriate PPE: Healthcare providers entering the patients room should wear: gloves, gown (fluid resistant or impermeable), eye protection (goggles or face shield), and a facemask. Additional protective equipment might be required in certain situations (e.g., copious amounts of blood, other body fluids, vomit, or feces present in the environment), including but not limited to double gloving, disposable shoe covers, and leg coverings.

Restrict visitors: Avoid entry of visitors into the patient's room. Exceptions may be considered on a case by case basis for those who are essential for the patient's wellbeing. A logbook should be kept to document all persons entering the patient's room. See CDC's infection control guidance on procedures for monitoring, managing, and training of visitors.

Avoid aerosol-generating procedures: Avoid aerosol-generating procedures. If performing these procedures, PPE should include respiratory protection (N95 or higher filtering facepiece respirator) and the procedure should be performed in an airborne infection isolation room.

Implement environmental infection control measures: Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is of paramount importance, as blood, sweat, vomit, feces, urine and other body secretions represent potentially infectious materials should be done following hospital protocols.

http://www.cdc.gov/vhf/ebola/hcp/patient-management-us-hospitals.html

CDC: persons under investigation, or with probable or confirmed Ebola virus infections, hospitals are recommended to:

Use a U.S. Environmental Protection Agency (EPA)-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus) to disinfect environmental surfaces in rooms of patients with suspected or confirmed Ebola virus infection. 

CDC: persons under investigation, or with probable or confirmed Ebola virus infections, hospitals are recommended to: Avoid contamination of reusable

porous surfaces that cannot be made single use.

Use only a mattress and pillow with plastic or other covering that fluids cannot get through.

Do not place patients with suspected or confirmed Ebola virus infection in carpeted rooms and remove all upholstered furniture and decorative curtains from patient rooms before use.

http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf

•PPE is hot and cumbersome•Some doctors work beyond their physical limits, trying to save lives in 12-hour shifts, every day of the week.•Staff who are exhausted are more prone to make mistakes

http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf

Public Health

Ebola resources

Ebola Virus Disease Information for Clinicians in U.S. Healthcare Settings http://www.cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcare-settings.html

Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United Stateshttp://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html

Guidance for Safe Handling of Human Remains of Ebola Patients in U. S. Hospitals and Mortuaries http://www.cdc.gov/vhf/ebola/hcp/guidance-safe-handling-human-remains-ebola-patients-us-hospitals-mortuaries.html   Health Alert Network (HAN) INFOService: CDC Ebola Response Update http://emergency.cdc.gov/han/han00367.asp   Case Definition for Ebola Virus Disease (EVD) http://www.cdc.gov/vhf/ebola/hcp/case-definition.html

Interim Guidance for Monitoring and Movement of Persons with Ebola Virus Disease Exposure http://www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html

Factsheet: Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Patients with Suspected Infection with Ebola Virus Disease

http://www.cdc.gov/vhf/ebola/pdf/ebola-lab-guidance.pdf

Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html  

Sequence for Putting On and Removing Personal Protective Equipment (PPE) http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf    Interim Guidance about Ebola Infection for Airline Crews, Cleaning Personnel, and Cargo Personnel http://www.cdc.gov/quarantine/air/managing-sick-travelers/ebola-guidance-airlines.html  

Advice for Colleges, Universities, and Students about Ebola in West Africa http://wwwnc.cdc.gov/travel/page/advice-for-colleges-universities-and-students-about-ebola-in-west-africa

Ebola – experimental treatments/ preventions

Experimental: Zmapp= 3 different monoclonal antibodies BioCryst Pharmaceuticals-unlike a vaccine

BCX-4430 is being developed as a post-exposure treatment

NIH/GlaxoSmithKline vaccine takes a single protein from the ebolavirus and pairs it with a chimpanzee cold virus

FDA can authorize access through an emergency Investigational New Drug (IND) application.

http://www.cdc.gov/vhf/ebola/outbreaks/guinea/qa-experimental-treatments.html