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