Preparedness for Ebola Virus Disease

Dr.Diksha Bigamal , Dr. Saurav MitraDr. Seema Wasnik, Dr. M.D. Kaur

Dr. (Prof) Rajesh Sood

Introduction• EVD ( Viral Hemorrhagic Fever ) –a fatal disease in

humans & non human primates – monkeys, gorillas & chimpanzees.

• Family – Filoviridae, Genus – Ebolavirus• 5 species identified- ZAIRE ebola virus

Sudan ebola virus

Tai Forest virus

Bundibugyo virus

Reston ebola virus

EPIDEMIOLOGY• First outbreak – 1976 in Yambuku, Democratic

Republic of CONGO, near Ebola river.

• 1976-2012 – 24 outbreaks reported, Central Africa

• Current outbreak ( 2014) – largest as reported by WHO

• 8 August, the WHO declared the epidemic to be an international public health emergency.

• September , 2014 West Africa Ebola Outbreak - 2,000 deaths. 

• Liberia, the most affected country, reported 200 new cases a week for the past three weeks. 

CLINICAL FEATURES

• Incubation period: 2-21 days

• Stage I (non-specific): - diarrhea, nausea and vomiting, anorexia abdominal pain - headaches, arthralgia ,myalgia - maculopapular rash.

• Stage II (Specific): - Hemorrhage - anuria - sore throat, tachypnoea, dysphagia & hiccups

- multi organ failure

CLINICAL FEATURES• Differential diagnosis : malaria, dengue, typhoid

fever, shigellosis, rickettsial disease, thrombotic thrombocytopenic purpura, hereditary hemorrhagic telangiectasia, Kawasaki disease.

• Prognosis : high mortality rate: 50% -90%.

• Late complications : Arthralgia -ocular diseases - hearing loss - orchitis.

MODE OF TRANSMISSION

• Reservoir : fruit bats are natural hosts.

• Contact : blood , secretions, body fluids & carcasses of infected animals or infected person

• Needle pricks & sexual route

• No airborne transmission

HOW TO DIAGNOSE ??

• Signs & symptoms• H/o of travel to endemic zone• Contact with an infected person.

&

• IgM ELISA & Real time Polymerase chain reaction

Definitions :

Suspected case :

• h/o of travel • close contact with symptomatic person travelling from

EVD area in the past 21 days • fever ≥ 101˚ F , along with ≥ 1 :

- headache, bodyache

- diarrhoea, vomiting , abdominal pain

- unexplained hemorrhage.

Definitions :

• Confirmed case : above features & lab confirmed diagnostic evidence by any one of following :

-- ELISA

- Real time Polymerase Chain Reaction ( RT-PCR)

TREATMENT

• No specific treatment available.

• General supportive measures : adequate hydration, nutritional support & symptomatic treatment.

TREATMENT ( contd..)

• Experimental trials :  Z Mapp and an RNA interference drug called TKM-Ebola.

• Two "promising" Ebola vaccines made by GlaxoSmithKline Plc and New Link Genetics

HOSPITAL MANAGEMENT

• Isolate the patient.• Follow universal precautions inc. PPE ( personal

protective equipment)• Restrict visitors• Avoid aerosol generating procedures• Implement environmental infection control measures• Proper disposal of biological wastes

Guidelines for hospital infection

control –

Sources : WHO & CDC

1. Direct patient care :

• Isolate the patient in a single room (door closed) with separate bathroom.

• Restrict entry to the EVD ICU.

• Maintain a log book.

• Use of Personal Protective Equipment is essential

• double gloving, Disposable shoe covers, leg coverings.

SINGLE PATIENT ISOLATION

ISOLATION WARD

LOG OF VISITORS IN ISOLATION AREA :

Date Name Service Time in Time out

12.8.14 Dr. Saurav Intensive care

9:30 am 10:00 am

12.8.14 Lokesh cleaning 10:15 am 10:45 am

12.8.14 Nalini staff Nursing care

11:00 am 11:20 am

Sequence for

Donning the PPE

Sequence for Removing PPE

• Remove the boots.

• Remove the inner pair of gloves.

• Remove inner layer of clothes / scrub suit.

• Wash hands with soap and clean water

Use of sharps

2. EQUIPMENT CARE

• Use disposable equipments.

• Non- disposable equipments -disinfected 10% sodium hypochlorite solution.

• Sample collection – properly labelled “ SUSPECT EBOLA “ in non –glass , leak proof containers.

Sample collection :

• ELISA - results within 5 to 6 hours

RT-PCR – results within 48 hours.

• Avoid routine blood samples in EVD suspected patients till report from NCDC is received.

• Wear 3 pair of gloves.

• Discard after sample collection

BLOOD SAMPLES

• Collect 4ml blood in EDTA vial• Wrap in tissue paper • Keep in triple layer sealed packed pouches• Send in leak proof ice boxes.• The HCW, transporting the sample wears PPE kit.

Lab Person

3. ENVIRONMENTAL CARE

• Objects contaminated with blood, other body fluids, disinfected - 1% Sodium Hypochlorite or 5% Lysol.

• Wear PPE while handling contaminated objects & linen

• Soiled linen –

treat with10%bleach,

place in labelled, leak-proof  bags

4. Waste Management• Segregate waste for appropriate and safe handling.

• Separate HCW are designated for collection and disposal of infectious waste.

• HCW to wear (PPE) gloves, gown and closed shoes (e.g. boots) when handling solid infectious waste.

• Faeces, urine, vomit & liquid waste - disposed of in the sanitary sewer along with 500ml 1 %bleach.

• Every item which is in contact with patient like mask,I.v sets etc.- packed in double yellow bags, disposed by designated HCW.

• ICU floor ,walls, Ventilators, beds are mopped with 10 % bleaching solution when patients are not occupying the ICU.

Handling of dead body

- should not be sprayed, washed or embalmed

- wear PPE while handling.

- ritual practices should be avoided

- packed in double impermeable leak proof body bag

- burial depth – 1.5 m above ground water level with 1m covering of soil.

BURIAL OF DECEASED

Managing accidental Exposures

Accidental needle stick injury –

1. Immerse the exposed site in 70% alcohol for 20 - 30 seconds.

2. Wash with soap and clean water.

3. Flush the site in running water for 20 to 30 seconds.

4. Incident reporting.

Managing accidental Exposures

Follow up accidental exposures:

1. Regular monitoring - Body temperature twice daily.

2. If temperature ≥ 38.5˚C (101˚F) the health facility staff should be isolated as suspected case of VHF.

Initiatives at rml hospital

• Dr. RML hospital, New Delhi is designated as the nodal hospital, in Northern India for handling EVD patients.

• A control room for EVD outbreak is operating in the DGHS(Room No543-A,A Wing), Nirman Bhawan.

• Integrated disease surviellence Programme(IDSP) network is kept on alert to track passengers from EVD affected areas at airport.

• National Institute of Virology, Pune and National Centre for Disease Control (NCDC) , Delhi are geared to test samples for diagnosis of EVD.

Proforma for EVD suspect patients :

Specific questions

• Detailed h/o travel to the following African countries in the last 21 days : Liberia, Guinea, Sierra Leone and Nigeria.

• Detailed h/o contact with blood or body fluids of an EVD symptomatic patient or through infected objects.

Signs and Symptoms:• Date of onset of fever• Hemorrhages from gums / hematemesis /melena

epistaxsis/purpura/petechiae/eccymosis/any other specify?

• Headache/joint aches/muscle aches/diarrhea/vomiting/stomach pain

Condition of patient :Stable/Critical

Date of Collection of sample

• Total patients – 10.

• All tested negative.

One is never afraid of the unknown; one is afraid of the known coming to an end.

Thank you