Ebola Virus: the Epidemic Abroad and Critical Preparations at Home

Allison Arwady MD, MPH

November 2, 2014 1

Ebola Virus: the Epidemic Abroad and Critical Preparations at Home

Allison Arwady, MD, MPHEpidemic Intelligence Service

Centers for Disease Control and Prevention

November 2, 20141

• I have no financial conflicts of interest to report.

• This talk represents my personal experiences and does not necessarily represent the viewpoint or opinions of the Centers for Disease Control and Prevention or the Illinois Department of Public Health.

Outline

• Background on Ebola Virus Disease

– Pregnancy/neonatal outcomes in prior outbreaks

• Outbreak Response, West Africa/Liberia

• Preparations at Home

– Risk of transmission

– Importance of travel history, monitoring

– Personal Protective Equipment

CDC Team/Allison Arwady

Ebola Virus: the Epidemic Abroad and Critical Preparations at Home

Allison Arwady MD, MPH

November 2, 2014 2

Those who recover have antibodies that last at least 10 years

What you need to know about the Ebola outbreak. New York Times. Updated: Oct 29, 2014.

Reported Ebola Cases, March 21 − October 29, 2014

Doubling Time 2-3 weeks

Right Now in West AfricaWeek ending October 21: Montserrado County (includes Monrovia) reported over 300 new cases

WHO Data. Interactive graphic from New York Times website. Vogel G. news.sciencemag.org 28 August, 2014.

Ebola Virus: the Epidemic Abroad and Critical Preparations at Home

Allison Arwady MD, MPH

November 2, 2014 3

Signs and Symptoms

Schieffelin, et al. NEJM 2014.

Case Fatality Rates, Sierra Leone

Schieffelin, et al. NEJM 2014.

Outcomes in Pregnancy• Pregnant women may have more severe presentations

– Vaginal bleeding common, profuse

• Yambuku, 1976: 82 (46%) of 177 Ebola‐ infected women were pregnant

– 89% mortality among pregnant women (88% overall)

– 19 spontaneous abortions (23%) 

– 10 live births, all died within 19 days 

WHO. Bull World Health Organ. 1978; 56:71-93.

Outcomes in Pregnancy• Kikwit, 1995: 15 (14%) of 105 Ebola‐infected women were pregnant

– Maternal outcomes: 93% mortality

• ALL with fever, diarrhea, vomiting, conjunctivitis, hiccups, abdominal pain, neurologic signs

• ALL with hemorrhage (vaginal bleeding) 

– Fetal outcomes

• 10 spontaneous abortions (66%), 3 curettage

• 1 stillbirth at 32 weeks

• 1 delivery of full‐term infant, died 3 days later

• Anecdotal data in current epidemic

Mupapa et al., JID, 1999. 179: S11-12.

Comparing Outbreaks

• Current outbreak unprecedented in scale

• Clinical course and transmissibility similar to earlier outbreaks

– Incubation period

– Duration of illness

– Case fatality rate 

– Estimations of basic reproductive number

WHO Ebola Response Team. N Engl J Med 2014;371:1481-1495.

Ebola Virus: the Epidemic Abroad and Critical Preparations at Home

Allison Arwady MD, MPH

November 2, 2014 4

Liberian Observer, “First West Point Ebola Body Removed Wednesday.” August 14, 2014

United States Liberia

Gross Domestic Productper capita

$46,400 $454 (184th/189 countries)

Health care spending per capita per year

$6,719 $15

Physicians per 100,000 pop. 242 <5 (1-2 by some estimates)

Infant mortality (per 1000 live births) 6.1 76.4

Civil war (1989-2003): poor literacy, weak infrastructure

Outbreak Response Goals

1. Patient care (Ebola Treatment Units)– Careful staff training and support

– Personal protective equipment (PPE)

2. Stop transmission– Case identification

– Contact tracing 

– Infection control (e.g. health care settings, safe burials)

3. Community educationCDC team/Allison Arwady

Republic of Liberia Ministry of Health and Social Welfare website: www.mohsw.gov.lr/content_display.php?press_id=84&sub=press_release

Ebola National Call Center

CDC Team/Allison ArwadyCDC Team/Allison Arwady

Ebola Virus: the Epidemic Abroad and Critical Preparations at Home

Allison Arwady MD, MPH

November 2, 2014 5

CDC Team/Allison ArwadyCDC team/Sally Ezra

27CDC team/Satish Pillai/Jennifer Hunter

CDC team/Joseph Forrester

CDC team/Allison ArwadyCDC team/Allison Arwady CDC Team/Allison ArwadyCDC Team/Allison Arwady CDC Team/Allison Arwady

Ebola Virus: the Epidemic Abroad and Critical Preparations at Home

Allison Arwady MD, MPH

November 2, 2014 6

CDC team/Joseph Forrester CDC Team/Joseph Forrester

Indirect Impacts• “Dying as a result of Ebola but not from Ebola”

– Pregnant women with vaginal bleeding turned away 

– Health care system largely non‐functional

• WHO: Summer 2013 Liberia had 52% of infants delivered by skilled birth attendant; May‐Aug 2014 down to 38%

• Prenatal care: 45% to 21%

• Received treatment for malaria: 48% to 29%

• Vaccination programs

• Economic, nutrition, educational impacts

• Orphans http://www.washingtonpost.com/world/africa/with-ebola-crippling-the-health-system-liberians-die-of-routine-medical-problems/2014/09/20/727dcfbe-400b-11e4-b03f-de718edeb92f_story.html

CDC Team/Joseph Forrester

Ebola Virus: the Epidemic Abroad and Critical Preparations at Home

Allison Arwady MD, MPH

November 2, 2014 7

Ebola Cases Diagnosed in the U.S.Two imported, Two locally acquiredDoctor Arrived August 2  From Liberia Recovered

Hygienist Arrived August 2 From Liberia Recovered

Doctor Arrived September 5 From Liberia Recovered

Doctor Arrived September 9 From Sierra Leone Recovered

Visitor Diagnosed September 30

In Dallas Died

Cameraman Arrived October 6 From Liberia Recovered

Nurse Diagnosed October 11  In Dallas Recovered

Nurse Diagnosed October 15 In Dallas Recovered

Doctor Diagnosed October 23 In New York City In treatment

Also: 3 in Spain (1 transmission), 1 in France, 1 in Britain, 3 in Germany, 1 in Norway Doucleff. NPR. Oct 23.

Factors in Transmission• Route of exposure

– Direct skin contact < Blood or body fluids < Percutaneous

• Stage of illness

• Use of barrier precautions

• Viral load (higher in those with fatal outcomes)

Ebola Virus Levels Over Time

Towner JS et al. J Virol. 2004, 78(8): 4330.

• Virus RNA levels- increase logarithmically during acute phase of

illness- are, on average, 2 log10 higher in patients who died than in patients who survived

Household Transmission

• 173 household contacts of 27 patients in Kikwit-28/173 (16%) developed Ebola

• ALL had direct physical contact with the ill index patient

• NO infections among those who denied direct contact with the ill index patient

• Increased risk of infectionBody fluid exposure; adult family members; touched cadaver; exposed during patient’s late hospital phase

Dowell SF, et al. JID, 1999.

Unrecognized Ebola in Tertiary Care Setting

• Index patient admitted, not recognized as EVD, recovered- During hospitalization: Upper, lower endoscopy

• One HCW infected (placed central line)- Not diagnosed for 12 days, eventually died- During hospitalization: LP, intubation, dialysis, laparotomy, wound exploration

• > 300 HCW with contact with either patient monitored- No other secondary cases

Richards GA, et al. Crit Care Med. 2000; 28(1): 240-4.

Ebola Virus: the Epidemic Abroad and Critical Preparations at Home

Allison Arwady MD, MPH

November 2, 2014 8

What’s Next?

• Evolving recommendations as we learn more about the virus and prepare for patients in different settings

– Protecting health care workers is paramount

– Patients have a range of presentations and present different risks of transmission at different stages of disease

• Emphasizing HISTORY: TRAVEL plus symptoms

• Public health monitoring travelers (airport)

Personal Protective Equipment (US)

• http://www.cdc.gov/vhf/ebola/hcp/ppe‐training/index.html

Final Thoughts• In West Africa, unprecedented numbers

– Standard practices not yet controlling epidemic

• Change in how we think about global health security and global interconnectedness– We are all as vulnerable as our weakest point

• Health care settings – Importance of infection control and protecting health care workers– Need for data and best practices

• The epidemic abroad AND preparations at home– Crucial work in the U.S.– Keep risk in perspective– Humanitarian response and source control

http://www.breitbart.com/Big‐Peace/2014/10/31/Two‐Week‐Old‐Baby‐Girl‐Survives‐Ebola‐in‐Sierra‐Leone

Ebola Virus: the Epidemic Abroad and Critical Preparations at Home

Allison Arwady MD, MPH

November 2, 2014 9

One Patient (Germany)

49Kreuels, et al. NEJM. 2014. DOI: 10.1056/NEJMoa1411677

XHC

C

Nurse (officer in charge)Vaccinator

Nurse

Physician assistantNurse (ER supervisor)Nurse anesthetistNurseNurse aideNurse aideNurse aideNurse aideStudent nurse

Lab technicianLab aideLab aideLab aideX-ray technicianCleanerSecurity guardMedication dispenserNurse (officer in charge, OPD)

16/21 (76%) died