Ebola virus disease Preparedness PGIMER DR RMLHospital New Delhi August 2014

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Preparedness for Ebola Virus Disease

• Dr.Diksha Bigamal , Dr. Saurav Mitra
• Dr. Seema Wasnik, Dr. M.D. Kaur
• Dr. (Prof) Rajesh Sood

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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

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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.

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• 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. 

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CLINICAL FEATURES

• Incubation period 2-21 days
• Stage I (non-specific)
• - diarrhea, nausea and vomiting,
  anorexia
• abdominal pain
• - headaches, arthralgia ,myalgia
• - maculopapular rash.

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• Stage II (Specific)
• - Hemorrhage
• - anuria
• - sore throat, tachypnoea, dysphagia
  hiccups
• - multi organ failure

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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.

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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

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HOW TO DIAGNOSE ??

• Signs symptoms
• H/o of travel to endemic zone
• Contact with an infected person.
• IgM ELISA Real time Polymerase chain reaction

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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.

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Definitions

• Confirmed case above features lab confirmed
  diagnostic evidence by any one of following
• -- ELISA
• - Real time Polymerase Chain Reaction (
  RT-PCR)

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TREATMENT

• No specific treatment available.
• General supportive measures adequate hydration,
  nutritional support symptomatic treatment.

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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

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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

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• Guidelines for hospital infection control
• Sources WHO CDC

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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.

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SINGLE PATIENT ISOLATION
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ISOLATION WARD
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LOG OF VISITORS IN ISOLATION AREA
Date Name Service Time in Time out
12.8.14 Dr. Saurav Intensive care 930 am 1000 am
12.8.14 Lokesh cleaning 1015 am 1045 am
12.8.14 Nalini staff Nursing care 1100 am 1120 am
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• Sequence for
• Donning the PPE

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• Sequence for Removing PPE

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• Remove the boots.
• Remove the inner pair of gloves.
• Remove inner layer of clothes / scrub suit.
• Wash hands with soap and clean water

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Use of sharps
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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.

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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

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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.

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Lab Person
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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 with10bleach,
• place in labelled, leak-proof  bags

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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.

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• 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.

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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.

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BURIAL OF DECEASED
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Managing accidental Exposures

• Accidental needle stick injury
• Immerse the exposed site in 70 alcohol for 20 -
  30 seconds.
• Wash with soap and clean water.
• 3. Flush the site in running water for 20 to 30
  seconds.
• 4. Incident reporting.

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Managing accidental Exposures

• Follow up accidental exposures
• Regular monitoring - Body temperature twice
  daily.
• If temperature 38.5C (101F) the health
  facility staff should be isolated as suspected
  case of VHF.

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Initiatives at rml hospital
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• 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.

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• 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.

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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.

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• 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/vomitin
  g/stomach pain
• Condition of patient Stable/Critical
• Date of Collection of sample

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• Total patients 10.
• All tested negative.

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