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Shaheen Methar's fantastic talk on Ebola at ICAN 2014 in Harare, Zimbabwe. Thanks for letting me share her talk)
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Ebola Outbreak Lessons learnt!
Prof Shaheen Mehtar Chair ICAN,
UIPC, Stellenbosch Uni, CT
In the beginning…
• In 2012 and 2013 there was an outbreak of Ebola amongst the great apes in the DRC and surrounding areas which largely went unnoLced ( over 5000 apes died)
• On 13 Dec 2013 a 2 year old child was diagnosed with Ebola in Guinea-‐ contact with infected bush meat!)
• That was the epicentre of the outbreak which also largely went unnoLced
Spread like wildfire.
Low resource countries
• High supersLLous beliefs • Great dependence and reverence for tradiLonal heads and healers
• SLgma associated with lack of knowledge
• No tradiLonal heads of tribes or healers were include in the HC program
• Inadequate infrastructure-‐ highly burdened
There was total panic & confusion!
Lesson No 1: involve the community
• Locate the heads of community, tribal, urban, or government structures
• Respect the culture and tradiLon
• Explain and educate-‐ • They will understand • You will get their trust. • They will influence the community
Locals talking and discussion EVD
Lesson 2: A weak healthcare system
2012 Guinea Liberia Sierra Leone
Total populaLon (millions) 11.45 4.19 6
< 5y mort / 1 000 live births 101 75 182
Mort 15 & 60 yr m/f (/1000 pop)
306/277 71% (ID) 282/246 444/426
Total expenditure on health per capita ($) % of GDP
67 (6.3)
102 (15.5)
205 (15.1)
Doctors /10 000 pop (regional average 4.6) 0.03 0.1
0.2
Nurses-‐ /10 000 pop (regional average 12.6) 0.04 2.7
1.7
Nigeria
169
124
371/346
161 (6.1)
4.1
16.1
Healthcare structures for EVD Strengthen the communicaLon for improved contact tracing
Lesson 3: weak surveillance system
In Africa from Dec 2013
DRC-‐ separate outbreak
30 Sept, first case outside Africa!
Funding started coming – in late August!
• NOW IS A POLITICAL ISSUE • American lives are at stake!
– Money-‐ coming in! – Deployment of troops – Healthcare workers – Mobile laboratories – Mobilizing global resources
• Contain Ebola in West Africa to stop it spreading to USA & Europe!!
Need 5000 more HCWs!
Lesson 4: The leadership gap
• The flaws in the internaLonal response was slow, uncoordinated and not parLcularly strong, most global health experts agree.
• By the Lme the World Health OrganizaLon officially called it a public health emergency in August, the outbreak was already exploding in Liberia, Sierra Leone and Guinea.
• MSF was in West Africa for malaria and took over Ebola-‐ insufficiently prepared! hjp://www.poliLco.com/story/2014/09/the-‐ebola-‐leadership-‐gap-‐111405.html#ixzz3HQKTR1a6 hjp://www.poliLco.com/story/2014/09/the-‐ebola-‐leadership-‐gap-‐111405.html#ixzz3HQKHAPdB
Outbreak rages on!
• Ebola could infect 1.4 million in Liberia and Sierra Leone by end of January 2015 (PredicLve model by CDC)
• WHO budget cut in past 5 years by $16 billion! • Total budget today is only $4 billion!
And Today?
Lesson 5: IniLally untrained HCW sent to work with EVD
Panic response from most organizaLons!! Healthcare workers affected • A total of 450 health-‐care workers (HCWs) are known to have been infected with EVD up to the end of 23 October 2014:
• 80 in Guinea; 228 in Liberia; 11 in Nigeria; 127 in Sierra Leone; one in Spain; and three in the United States of America.
• A total of 244 HCWs have died.
EVD exposure risk in HCW
JID 1999;179 (Suppl 1) Ebola Serologic Survey of Health Workers
Contact areas in the workplace Number % Total number interviewed 279 In paLent room 233 84 Feeding & talking 145 52 Examining paLent 43 15 Lab handling blood 17 6 Taking blood 31 13 Washed paLent 10 4 Washed paLent clothes 7 3 Washed cadaver 20 7 Contact at home & HCF 30 Contact at home only 3
HCW contact with EVD Category Number %age A_ack rate 37/ 429 9% Physicians 4/13 31% Nurses 22/212 10% Technicians 7/62 11% Others 4/111 4%
Type of contact Number %age
Direct 204 73% Indirect 3 33% Unlikely 63 64% Unknown 9 56%
How infecLous is Ebola?
Lesson 6: First IPC principles FIRST!!
• CONTACT PRECAUTIONS!
• Which means – IsolaLon – Hand hygiene – Gloves – Splash protecLon for mucous membranes
– ProtecLon of skin
• AdministraLve controls – Triage – Test – Separate suspected and confirmed cases
• Environmental controls – Clean and dry – VenLlaLon
• PPE
Dressing up for Ebola
Differences in PPE –both effecLve?
Difference in isolaLon faciliLes-‐ 2014
Rudimentary: Plasac buckets for disinfectant or even possibly vomit from paaents stand in front of simple paraaons put up to make cubicles for the ever-‐increasing number of paaents
Isolator used to treat VHF at the RFH
Challenges with IsolaLon areas
• Shortage of staff-‐ so stay on duty longer than the recommended 70 min
• Overcrowding-‐ heavy contact within the faciliLes
• NO venalaaon-‐ ??? • HCW get over heated in Tyvek coverall suits-‐ 39o C inside.
• Loss of funcLon by HCWs and make mistakes
A lot of chlorine spraying!
• Try to keep the environment clean and dry!
WHO Interim IPC guidance for EVD
• General guidelines for containment of Ebola
• Produced in 10 days! • Widely circulated • Adapted by ICAN
OTHER WHO GUIDELINES (ICAN involved)
Specific: Personal Protecave Equipment • What is recommended? • How to use it? • Discussion on the use of
chlorine
Specific: Healthcare Waste Management • What is recommended? • What should not be done? • ApplicaLon of these GL in
various countries
PPE when handling a case of EVD Both dressing and undressing should be supervised by a trained member of the team-‐ (buddy system). These instrucaons should be displayed on the wall in the dressing and undressing room:
hjp://who.int/enLty/csr/disease/ebola/put_on_ppequipment.pdf?ua=1 hjp://who.int/enLty/csr/disease/ebola/remove_ppequipment.pdf?ua=1
Taking puung on and taking off PPE • “First-‐on-‐last off” • Remove the most contaminated
PPE items first-‐ gloves • Hand hygiene must be performed
immediately aver glove removal – Perform hand hygiene whenever ungloved hands touch contaminated PPE items
• Be careful to avoid any contact between the soiled items (e.g. gloves, gowns) and any area of the face (i.e. eyes, nose or mouth) or non-‐intact skin
• Discard disposable items in a waste container
• Use a buddy to help! • AVOID CONTACT WITH THE
OUTSIDE OF PPE!
Revised CDC guidelines Sept 2014
WHY INCREASE FOOT PROTECTION?
Work and personnel flow PaLents
staff
Support services ??
What do you think of this?
MANAGING EXPOSURE TO INFECTION
• Mucous membranes (e.g. conjuncLva) should be irrigated with copious amounts of water or eyewash soluLon ONLY. DO NOT USE CHLORINATED WATER!
• Follow up care, including fever monitoring, twice daily for 21 days aver exposure.
• Immediate consultaLon with an expert in infecLous diseases is recommended for any exposed person who develops fever within 21 days of exposure.
• Contact tracing and follow-‐up of family, friends, co-‐workers and other paLents, who may have been exposed to an HF virus through close contact with the infected HCW is essenLal
South African Guidelines-‐ well prepared
• SA always had good guidelines for VHF-‐ have been used by other countries across the world
• Now modified using MSF, Red Cross, CDC guidelines-‐ lijle evidence for some of the recommendaLons.
• HCW at risk during removal of PPE-‐ use a buddy system
• Keep the areas clean and dry • Unnecessary use of chlorine spray increases risk
Are you prepared
• Go to the ICAN website at www.icanetwork.co.za and complete the surveymonkey checklist for ebola preparedness!
ICAN PARTNERSHIPS • Funding of resource centres educaLon programmes for HCW in – Uganda (Samsung) – CDC-‐ teaching in Resource Centres – Sierra Leone (London Mining Co) – Links with WHO-‐ GOARN-‐ involved in policy making with WHO
– Geung volunteers from across UK and Europe
• Community SMS/Text messaging communicaLons – Looking for mass media noyicaLon
ICAN EBOLA Training Programme • Partnership between the UIPC and ICAN • A 5 day EVD IPC course has been established • Will be run in Uganda by end 2014 • Curriculum for EVD IPC course
– Microbiology, Epidemiology and Laboratory Services – The Paaent: diagnosis, IPC management, surveillance – The HCW: IPC precauLons. HH, PPE, Contact precauLons, reporLng and accident management
– Support services: waste, linen, water supply, burial and Post mortem, transportaLon, layout of ETU
– The community and communicaaon about Ebola, documentaLon and checklists
www.ICANetwork.co.za
Summary
• Do not forget the basic IPC principles
• Good IPC is of the essence-‐ safe, and sensible!
• Keep the environment clean and dry!
• Vaccines are coming!
