Ebola virus update

Dr Ann Koehler BSc MBBS FRCPA(Microbiol) MPHDirector, Communicable Disease Control Branch,Public Health & Clinical SystemsSA 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 symptomsPatients 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 AustraliaPORT/DATE 16-Oct 17-Oct 18-Oct 19-Oct 20-Oct 21-Oct 22-Oct 9-Aug to 15-Oct 16-Oct to 22-Oct

Grand Total

Adelaide 13 0 0 0 1 0 0 28 14 42Brisbane 0 0 0 1 2 0 3 115 6 121Darwin 0 0 0 0 0 0 0 3 0 3GoldCoast 0 0 0 0 0 0 0 1 0 1Melbourne 1 12 2 7 10 8 2 192 42 234Perth 2 4 4 4 0 4 3 302 21 323Sydney 0 15 3 4 1 0 2 192 25 217Broome & Horn Island 0 0 0 0 0 0 0 0 0 0Cairns 0 0 0 0 0 0 0 0 0 0Port Hedland 0 0 0 0 0 0Sunshine coast 0 0 0 0 0 0 0 0 0 0Grand Total 16 31 9 16 14 12 10 838 108 946

Arrivals to Australia from affected countriesApproximately 99 per week14 from Democratic Republic of Congo14 from Liberia, Sierra Leone, GuineaRemainder 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