Ebola Virus: The Current Epidemic and How it Impacts William Osler Health System

Sergio M. Borgia, MD, MSc, FRCP(C)Infectious DiseasesInfection Prevention & Control ConsultantWilliam Osler Health System – Brampton Civic HospitalAssistant Professor, McMaster UniversityDepartments of Medicine & Infectious Diseases

Objectives

Review the ecology and biology of Ebola Virus Disease

Update on the current West African Ebola epidemic

Review how EVD impacts William Osler and Osler’s EVD preparedness plan

Classification of Ebolavirus

Order Mononegavirales

• Enveloped, nonsegmented, negative strand RNA viruses• Family Filoviridae contains 3 genera:

Ebolavirus (1976) Marburgvirus – Lake Victoria marburgvirus (1967)

Cuevavirus – Lloviu virus (bats, Spain, 2002)

• Zaire ebolavirus: 1976, Democratic Republic of Congo.• Sudan ebolavirus: 1976, Sudan.• Bundibugyo ebolavirus: 2007, Uganda.• Taі Forest ebolavirus (formerly Cote d’Ivoire Ebolavirus): 1994, Ivory Coast.

Single case, veterinary worker handling primate.• Reston ebolavirus: 1989, Philippines.

Macaques, swine.Human laboratory workers seropositive but no clinical disease.

Field’s Virology, 5th Ed., 2008

NEJM October 10, 2014

Ebolavirus: Structure

CDC, Field’s Virology, 5th Ed., 2008

Reservoir & Transmission to Humans

• Fruit bats reservoir of virus - Drop partially eaten fruits• Bats infect chimpanzees, gorillas, forest antelopes, porcupines• Humans handle and eat bush meat (bats, chimpanzees, gorillas)• Infected human passes from person to person

Centers for Disease Control and Prevention; Virus Ecology Graphic http://www.cdc.gov/vhf/ebola/resources/virus-ecology.html

Ebolavirus Ecology

Transmission of Ebolavirus

Transmitted through contact of body fluids of a symptomatic patient.

• Fastest incubation period has been reported associated with needle

stick injury.

• Viral load may correlate with disease severity and survival.

• This is NOT an airborne disease. Thus the pulmonary disease is

hemorrhage and ARDS associated with severe sepsis.

Mandell , Principles and Practice of Infectious Diseases, 6th Ed.

Pathogenesis: How Does Ebolavirus Cause Disease?

• Virus replicates in the blood, travels throughout body and infects liver cells, blood vessels and skin•Eventually every organ is affected. End organ damage and multi-organ dysfunction• Diffuse intravascular coagulopathy (DIC) with platelet and coagulation factor consumption which leads to bleeding• There is strong cytokine/inflammatory mediator release of TNF-a and inflammatory cascade.

Ebolavirus: Early Clinical Manifestations

•Incubation period range 2-21d Sudden onset of Fever >38.0 C•Flu-like symptoms: chills, myalgias, and malaise, sore throat, rash on trunk around day 5•Nausea, vomiting , abdominal pain, diarrhea•Respiratory symptoms of chest pain, shortness of breath and cough•CNS symptoms: Headache, confusion and coma

Mandell , Principles and Practice of Infectious Diseases, 6th Ed.

Ebolavirus: Later Clinical Manifestations

• Hypotension, peripheral edema• Bleeding manifestations develop in >50% (internal/external)• Can vary from petechiae & easy bruising, to mucosal hemorrhage, uncontrolled bleeding and massive GI blood loss

• Multi-organ dysfunction: kidneys and Liver• Laboratory abnormalities

-Thrombocytopenia and leukopenia-Elevated transaminases (AST > ALT), amylase, D-dimer-Reduced albumin

Ebolavirus: Care of the Patient

• Treatment is supportive:Aggressive fluid resuscitationCorrection of electrolyte imbalanceHemodynamic supportClotting factors; blood and blood products

Some literature to suggest that critical care outcomes are better but very small numbers

Experimental treamtments…

Xiangguo Qiu et al.Reversion of advanced Ebola virus disease in nonhuman primates with Zmapp, Nature

http://www.nature.com/nature/journal/vnfv/ncurrent/pdf/nature13777.pdf

Post Exposure Prophylaxis/Treatment

ZMapp - “Secret Serum” – PHAC and others-Three monoclonal Abs against parts of the gp

Tekmira – TKM – Ebola – Burnaby, British Columbia (Small interfering RNAs)

BCX-4430 – BioCryst Pharmaceuticals (Small molecule Adenosine analogue)

Favipiravir Japan (Small nucleotide analogue) Rx Influenza

Sarepta: Binds to viral RNA and stops replication

VSV-EBOV1 - Public Health Agency of Canada (Recombinant vesicular stomatitis virus – Live vaccine)

Baize S, Pannetier D, Oestereich L, Rieger T, Koivogui L, Magassouba N, et al. Emergence of Zaire Ebola virus disease in Guinea – preliminaryreport. N Engl J Med. 2014 Apr 16. [Epub ahead of print]. Figure 1, Map of Guinea showing initial locations of the Ebola virus disease.

Ebolavirus 2014: Origins of Current Outbreak

• Initial (suspect) cases occurred in a family in Guéckédou, Guinea

• December 2013 / January 2014

• Spread to a number of health care workers and then among their family

Members

• Not all initial cases were definitively linked

http://www.nejm.org/doi/full/10.1056/NEJMoa1404505#t=article

Initial Location of Current Outbreak

NEJM October 10, 2014

Outbreaks or Episodes of Filovirus Infections

http://apps.who.int/iris/bitstream/10665/136161/1/roadmapupdate10Oct14_eng.pdf

Ebolavirus 2014: Case Counts and Map

Martin, Leopoldo 2014

Ebola Case and Death Count, 2014

International New York Times, October 15, 2015

Ebolavirus Cases Outside of Africa

World Health Organization. Global Health Observatory Data Repository http://apps.who.int/gho/data/node.country.country-CAN?lang=en Geneva: World Health Organization; 2014 [accessed 2014 Aug 31]

Context for Current EVD Outbreak

Osler IPAC (Nike Rowaye)

Osler: African Traveller Summary

http://who.int/csr/resources/publications/ebola/response-roadmap/en/

WHO: Ebola Response Roadmap

• WHO convened ethics panel on August 11 regarding use

of unapproved vaccines and medications

• Determined ethical in special circumstances

• Moral duty to evaluate these interventions in

the best possible studies under the circumstances

• Many issues:

-Conducting research in the midst of the

outbreak

-Who gets drugs

-Payment

-Consent

-Protection from liabilities

http://www.publichealthontario.ca/en/BrowseByTopic/InfectiousDiseases/Pages/Viral-Hemorrhagic-Fevers.aspx#.VDxl30ty4ds

Local Response to EVD: PHO Guidance

http://www.publichealthontario.ca/en/eRepository/EVD_Risk_Assessment_Evaluation_Returning_Travellers.pdf

EVD: PHO Risk Assessment Tool

http://www.publichealthontario.ca/en/eRepository/EVD_Risk_Assessment_Evaluation_Returning_Travellers.pdf

EVD: PHO Risk Assessment Tool

EVD: PHO Risk Assessment Tool

http://www.publichealthontario.ca/en/eRepository/EVD_Risk_Assessment_Evaluation_Returning_Travellers.pdf

EVD: PHO Risk Assessment Tool

http://www.publichealthontario.ca/en/eRepository/EVD_Risk_Assessment_Evaluation_Returning_Travellers.pdf

MOHLTC Ebola Directive (Oct 17)

Ebolavirus PPE: MOH Directive

Changes to PPE (Oct 17, 2014)

Ebolavirus PPE for Aerosol Generating Medical Procedure

All staff entering the Airborne Infection Isolation Room (AIIR) must wear:

Powered Air Purifying Respirator

(PAPR) with a hood

full body barrier protection

double gloves* (one under and one

over cuff)

*Indicates where Osler exceeds MOHLTC recommendations

IPAC Precautions for EVD at Osler:Droplet + Contact Precautions + Airborne*• Patient accommodation:• Single room with dedicated bathroom (min requirement); door closed• consider use of an isolation room that has an anteroom for donning or doffing PPE

• PPE for all staff entering the room:-fluid-resistant (Level 4 gown everywhere*), long-sleeved, cuffed gown-gloves (double 12’ long-cuff glove in ‘under-over’)-full face protection (face shield)-N95 respirator mask-lower leg & shoe coverings-goggles-hood(covering neck and shoulders / head covering (bouffant cap)

•PAPR use in AIIR when performing AGMPs

Osler Intranet

EVD PPE Doffing Sequence (Osler)

Osler EVD PPE Training & Education• When: Since October 17 EVD PPE training has been underway

in high risk areas: ED, Critical Care, Lab, DI, Women & Child’s, OR

• Who: Superuser trainers include IPAC, RRTs, and Quality who are training local experts including resource nurses, educators, and some frontline staff and support staff in high risk areas.

• How: Train the Trainer methodology for donning and doffing PPE. Those trained are to take their learning back to their units to train point of care staff and physicians.

• Where: At BCH there is a centralized education room set up by RRT N.2.107 and teams are also going to local areas to train on units. At EGH teams are training in local areas on units

General PPE training now for EVD PPE

BCH  PPE Training Sessions - AuditoriumDATE Session 1 Session 2 Session3 Session 4October 29 2:30 – 2:45 pm 3:00 – 3:15 pm 3:30 – 3:45pm 4:00 – 4:15 pmNovember 18

5:00 – 5:15 pm 5:30 – 5:45 pm 6:00 – 6:15 pm 6:30 – 7:00 pm

November 19

1:30 – 1:45 pm 2:00 – 2:15 pm 2:30 – 2:45 pm 3:00 – 3:15 pm

November 25

9:00 – 9:15 am 9:30 – 9:45 am 10:00 – 10:15 am

10:30 – 10:45 am

EGH  PPE Training Sessions – West End CafeteriaDATE Session 1 Session 2 Session3 Session 4October 30 9:00 – 9:15 am 9:30 – 9:45 am 10:00 – 10:15

am10:30 – 10:45

amNovember 13

5:00 – 5:15 pm 5:30 – 5:45 pm 6:00 – 6:15 am 6:30 – 6:45 pm

November 20

10:00 – 10:15 am

10:30 -10:45 am

11:00 – 11:15 am

11:30 – 11:45 am

November 26

12:30 -12:45 pm

1:00 – 1:15 pm 1:30 – 1:45pm 2:00 – 2:15 pm

• In addition, PPE training sessions coming up in BCH Auditorium and West End Cafe are now being converted to EVD PPE training sessions

• For local unit specific training please page and ask IPAC and they will coordinate to meet specific training needs

MOHLTC Ebola Directive October 17, 2014

Ebola: Nursing Care

Two Registered Nurses are required for providing care at all times. Only those nurses fully

trained, tested and drilled on hazards, protections and equipment donning and doffing

should provide care and must have no other duties, and should monitor each other’s

adherence to procedures, particular donning and doffing personal protective equipment

(PPE).

PPE should be removed and disposed of in the anteroom and hand hygiene performed

before touching the face. If an anteroom is not available, PPE should be removed at the

doorway upon exiting the room. PPE should be discarded in the patient room.

Fully trained and tested nurses and other HCWs should observe each other’s doffing of PPE

to ensure that inadvertent contamination of eyes, mucous membranes, skin or clothing

does not occur.

Monitoring & Management of Potentially Exposed HCWs

Where is the Osler EVD Policy Located?

IPAC and Osler’s Commitment