Prevention and Control of Ebola virus

Prevention, the cornerstone

NO TREATMENT

NO VACCINE

"There's no treatment under the skyThere's only to suffer and die"

- Dr. Rajarshi Gupta

Dynamics of the 2014 outbreak- What's different?

For any infection of epidemic proportions we have the standard SIR model

R(removed/dead)death/removal rate

Longer the person stays infected and symptomatic,the more he spreads

S(susceptible) I(infected)Infection rate

Major Zaire subtype outbreaks till date

Place Year Cases Fatality %

Zaire 1976 318 88

Republic of Congo

(formerly Zaire)

1995 315 81

Gabon 1996 60 74

Republic of Congo

2002 143 89

Republic of Congo

2007 264 71

Dynamics of the 2014 outbreak

S(susceptible) I(infected) R(removed/dead)Infection rate

death/removal rate

Longer the person stays symptomatic, more he spreads

2014 epidemic Zaire subtype has a fatality of 55.3%

Patient stays symptomatic longer and transmits infection to more people

2014 Guinea, Liberia,

Sierra Leone, Nigeria

1603

cases

887 deaths (55.3%)

Courtesy World Health Organization,as of August 6, 2014

Role of mass media - The public panic dilemma

Also called " Infection of the mind"

OR

"Thought contagion"

Public panic fueled by mass media before adequate prevention policies are laid down by bodies like WHO/CDC, can cause epidemics to worsen by,

1. General mistrust of public in authorities

2. Measures taken by people themselves without adequate knowledge

CITY A(affected)

CITY B(unaffected)

Premature panic generated by mass media, escape to safe city

Symptomatic

Incubating + susceptibleCarriage of infection to

unaffected cities because people in affected cities panicked,yet didn't know how to prevent infection spread from symptomaticpatients

Dead bodies dumped into street in Liberia by panic stricken relatives, to avoid identification by government and risk been ostracized by community or kept in quarantine

Courtesy dailymail.co.uk

OTHER HORRORS OF LACK OF KNOWLEDGE THAT PREVENT DISEASE CONTAINMENT

Patient isolation

Preferably a separate building

If not possible a separate place in same building

Well ventilated

Strictly meant for authorised personnel only

Single patient self contained isolation unit

Entry/Exit

Multiple patients' self contained isolation unit

Entry/Exit

Personal Protective Equipment(PPE)

Instructions as per the CDC guidelines

To be strictly adhered to

And the sequence to be followed exactly as stated

Before attending to patient

Edge of the second pair of gloves should be over the cuff of the gown

Normally, a triple layered facemask to prevent splashes

HEPA filter masks or N95 masks when performing aerosol generating procedures eg. intubation

After attending to patient

Disinfect outer gloves in soapy water and dispose them in waste buckets

• Remove inner layer of clothes and dress in street clothes.

• Wash hands with soap and clean water before leaving.

BLEACH SOLUTIONS

Ordinary bleach solution has a 5% chlorine concentration.

1:10 bleach is a solution with 0.5%(w/v) chlorine concentration.

1:100 bleach is a solution with 0.05%(w/v) chlorine concentration.

* 0.5% chlorine is caustic and corrosive so ordinarily not used in disinfection

Disinfect Reusable Supplies and Equipment

With 1:100 bleach solutions prepared dailyThermometer ( soak 10mins, then air dry)

Stethoscope ( wipe metal part for 30secs, then air dry)

Bedpans, buckets, utensils ( soak for 15 mins, then air dry, wash with soap water)

Laundry itemslike gowns, sheets ( soak for 30 mins, then soak overnight in soapy water, scrub,rinse and dry)

Disposal of non-reusable wasteDisinfectCarry in secure containers to incineration siteSite should be away from populated areasBurn in sufficient amount of fuelRestrict access to children who might pick up thingsRestrict access to animals who might spread wasteDeep burial of incineration ash(at least 2 metres)

Waste sharps to be shredded and disinfected or autocalvedUsed disinfectants if not poured down drains, to be burnt

with waste

Dead body disposal1. Place the body in a “body bag” (mortuary sack) and

close it securely. Spray the body bag with 1:10 bleach solution.

2. Shortest route to burial site

3. Atleast 2 meters deep burial ground. Burial staff must have Personal Protective Equipment(PPE).

4. Counsel family that body can't be viewed

5. Counsel family that only close members are allowed for burial

* Driver need not wear protective clothing if he does not come in contact with body

PPE while burial - CORRECTPeople standing around - WRONG

Disinfection of vehicle after transporting patient

Contact tracing Identify Patient’s Contacts and Travel History

Ask the patient (or a family member who can answer for the patient):

1.Where do you live?

2.When did the symptoms begin?

3.Who else is sick in your family (or village)?

4.Where have you travelled recently?

Use the answers to identify others who had contact with thepatient. Provide them with information about VHF and when to seek

care.

Identify Key Community Resources

Businesses

Schools

Sports clubs and other recreational clubs

Service organizations

Volunteer organizations and community service groups Sports clubs and other recreational clubs

Service organizations

Volunteer organizations and community service groups.

Meet with Community Leaders and Assess the current Situation

Describe the Target Population

Maps of the town

The size of the population

Major ethnic groups in the town

Locations of any special populations such as refugees orsquatter settlements where the risk of disease transmissionmay be particularly high

How many people may be affected by the outbreak

The populations at greatest risk

Describe modes of transmission

Describe actions necessary

Develop specific messages- Door to door- Mass media-Posters and banners- Via churches, mosques, religious leaders

Some posters being used to demonstrate prevention in community( CDC, WHO,

UNICEF)

Everything boils down to Standard precautions

1. Hand hygiene2. Gloves3. Facial protection4. Gown5. Prevention of needle stick injuries and injuries from other

sharp instruments6. Respiratory hygiene and cough etiquette7. Environmental cleaning8. Proper handling of linen9. Biomedical waste management10. Proper handling of patient care equipment

Courtesy World Health Organization, October 2007

Practical viewpoint: Precautions for vascular access in Ebola patients

No additional precautions required

Standard precautions as per Occupational Safety & Health Administration(OSHA) ie.

OSHA's Bloodborne Pathogens Standard

Monitoring and Movement of Personswith Ebola Virus Disease(EVD) Exposure

High risk exposure(needle stick injuriesinfectious splashlab work without PPE

funeral rites without PPE)

Symptomatic

Full evaluation with infection control precautions for EVD and contact history

Air medical transport only, if transport of patient is clinically indicated NO P

UBLIC

TRANSPORT

Monitoring and Movement of Personswith Ebola Virus Disease(EVD) Exposure

High risk exposure(needle stick injuries

infectious splash

lab work without PPE

funeral rites without PPE)

Asymptomaticor symptoms evaluated and not likely to be EVD

Conditional release and controlled movement

until 21 days after last known exposure

Monitoring and Movement of Personswith Ebola Virus Disease(EVD) Exposure

Low risk exposure(Household member,

casual contact with patient)

Conditional release and controlled movement

until 21 days after last known exposure

Conditional release:

Monitoring by public health authority;

Twice-daily self-monitoring for fever;

Notify public health authority if fever or other symptoms develop

Controlled movement:

Notification of public health authority; no travel by commercial conveyances (airplane, ship, and train);

Local travel for asymptomatic individuals (e.g. taxi, bus) should be assessed in consultation with local public health authorities;

Timely access to appropriate medical care if symptoms develop

Preventive steps in India

23063205

23061469

23061302 } Helpline made operational since

August 10, 2014 morning

Airport surveillance for symptomatic individuals

Preparing centres for management of possible Ebola cases

Summary• Ebola is a viral hemorrhagic fever normally

circulating in fruit bats and wild animals• A BSL-4 pathogen, spreads through body fluid

contact• High case fatality• Humans are accidental host• No treatment, no licensed vaccine• Prevention is the only cure• Active surveillance necessary to identify sources

and susceptibles

THANK YOU

References• Infection Control for Viral Haemorrhagic Fevers in the African Health Care Setting;

World Health Organization, Centers for Disease Control and Prevention

• Interim Guidance for Monitoring and Movement of Persons with Ebola Virus Disease Exposure, Centers for Disease Control and Prevention,August 2014

• Interim Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals, Centers for Disease Control and Prevention

• On the existence of a threshold for preventive behavioral responses to suppress epidemic spreadingFaryad Darabi Sahneh, Fahmida N. Chowdhury & Caterina M. ScoglioScientific Reports 2, Article number: 632 Received 19 June 2012 doi:10.1038/srep00632 Accepted 25 July 2012 Published 05 September

• 2007 Guideline for Isolation Precautions: Preventing Transmission of InfectiousAgents in Healthcare Settings, Centers for Disease Control and Prevention