Ebola Virus Disease

and the Maritime

Ray Jarris, MD
President/Chief Medical Officer
MD Solutions International
Agenda
Welcome and Opening Remarks: 9:00
Karen Conrad - NPFVOA
Jennifer Graves, RN - Exec. Director SMC/Ballard
Ebola Overview - Ray Jarris MD MDSI 9:10
CDC Update Lt. Kristen Wendorf MD CDC/EIS 9:30
EMS Perspective - Craig Aman, MICP MDSI 9:50
PPE Supply Chain - Wayne Morse, Bellegrove 10:00
Legal Overview - Lafcadio Darling, JD B,W & H 10:10
Insurance Implications - Ed Rhone Parker, S& F 10:30
Q & A/ Planning Steps 10:50
Adjourn 11:30
History of Ebola
1976 First recognition of Ebola
virus in Zaire
Several other outbreaks
between 1976 and 2013
2000 2001 there were 425
cases
2014 Epidemic in West Africa
is largest in history estimate of
10K cases and 5K deaths
Senegal and Nigeria recently
declared Ebola free
First confirmed U.S. case 9/30
How Did Ebola Start?
Ebola in the U.S.
9/30 First confirmed case in the US - Dallas
10/8 First U.S. death
10/10 Healthcare worker in Dallas
10/12 Airport Screening begins
10/14 Second healthcare worker in Dallas
10/20 Family of US victim cleared
10/23 DWB Physician case in NYC
10/24 CDC Monitoring of all W. Africa Travelers
Daily temp and symptom reporting
10/24 First HCW with EVD released
10/24 N Korea bans all foreign tourists
10/28 Second HCW with EVD released
How Ebola is spread?
Direct contact of blood or body fluids of infected person to
mucous membranes or non-intact skin
Exposure to contaminated objects such as needles
Not transmitted through air, water or food
Wearing and correctly removing the proper personal
protective equipment (PPE) will provide protection to
caregivers.
PPE Recommendations are evolving
No FDA-Approved medicine or vaccine currently available
but in development
Does not respond to anti-viral medications
Infected persons are not considered contagious until
they show symptoms
6
Ebola Myths
7
Ebola Signs/Symptoms
Initial signs look like the flu
Gastrointestinal symptoms follow
severe diarrhea
nausea, vomiting and stomach pain
Bleeding can occur
Red bumpy rash
Bruising
Mouth bleeding
Redness of the eyes
Other symptoms may include:
chest pain
shortness of breath
Headache
Confusion
hiccoughs
Seizures & swelling of the brain can
also occur
09/2010 Copyright 2010 MDSI 9
Other Concerns
Middle Eastern Respiratory
Syndrome (MERS)
Risk Factors
Travel to Middle East
Exposure to Camels
Similar Symptoms to Ebola
30% Mortality
Identify, Isolate, Escalate
Symptom Screen First
Severe Upper Respiratory
Infection
Pneumonia
Travel Screen Second
Maritime Strategies
Early notification of mariners to avoid travel to West
Africa and Middle East
Implement screening procedures
21 Day notice of no boarding vessel
Influenza vaccination
Reinforce and Educate
Cough Etiquette
Hand Hygiene
Alcohol gel and hand washing
Alcohol gel at gangway for all boarding
Gel before entering galley
Increase cleaning of common areas
Key Strategy
Identify
Isolate
Escalate
(or Detect, Protect, Treat)
12
Travel Screen
13
Symptom Screen
14
Identify
Location - Strategies will vary:
Office
Dock
At Sea
Resources:
Contracted Medical/Nursing Team
AMR Ambulance Staff
Develop Identification Process and Strategy
Travel Screen if positive, mask and gel, Isolate
Symptom screen, if positive, Continue to Isolate:
Limit access
PPE for contacts
Avoid Body Fluid Exposure
Notify:
Site Manager/CAPT
On land EMS for containment
Public Health
At Sea USCG
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Isolate
Person Under Investigation (PUI)
Isolate to area away from others
Mask if tolerated
Caregivers
Proper PPE
Limit number of caregivers
Necessary interventions
Focus on appropriate PPE will evolve
Update 10/20 CDC no exposed skin
Phase 1 and 2 PPE defined
Phase 1 Current materials on hand, enhanced given knowledge from
Emory and Dallas
Phase 2 Optimize with Providence and consultations with regional,
national and international agencies on best practice this is ongoing
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Escalate
Complete and document screening
Isolate person away from crew and other passengers
Notify Ships Captain or Plant Manger
Seek Physician advice
Provide initial supportive care
Contact Vessel/Plant Management
Contact Public Health Office of destination port
Alaska (907) 269-8000
Washington (206) 296-4600
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PPE
CDC No exposed skin
Observer/Monitor recommended
Doffing high risk for self-exposure
Donning and Doffing Training and Drills
Train with checklist and observer
Various equipment combinations
Face Shield
Hood
Water Impermeable gown/apron
N-95 mask or PAPR
Double surgical gloves
Water Proof booties
Assessment & Treatment
Avoid exposure to body fluids PPE
Attempt to keep 6 10 feet distance
Minimize exposures to others including first
responders, medical officer(s) and others
Maintain a log of all who enter isolation area
Those with contact should be isolated and monitored
Close door to isolation area or stateroom
Limit medical equipment in isolation area
Do not draw blood unless directed by public health
Specialized shipping of blood sample
Utilize oral medication for fever, nausea, pain
Initiate IV and fluid administration only if directed
Difficult ethical decisions may surface
Transportation
Work with:
State and federal public health officials
USCG RCCs
Medical Consultation Service
High likelihood ship will be quarantined
Anticipate 21 day observation period and possibly
quarantine of all exposed
Uncertainty of air ambulance transport
Cleaning
Ebola virus may survive:
Dry surfaces (doorknob, countertop) for several
hours.
Blood and body fluids for several days
Cleaning staff must use complete PPE
1:10 bleach to water solution
Cleaning waste becomes biohazard waste
Hazardous Waste
Remains in containment area
Body fluids should not enter ships blackwater or
plant/community disposal system
Sharps box for needles and syringes
Unique storage containers
Arrange for specialized hazardous waste removal
Contents of room become biohazards
Dedicated medical equipment such as BP cuff and
stethoscope become biohazards dispose
Classified as a Category A Hazardous Waste by DOT
(http://www.phmsa.dot.gov/portal/site/PHMSA/menuitem.6f23687cf7b00b0f22e4c6962d9c8
789/?vgnextoid=4d1800e36b978410VgnVCM100000d2c97898RCRD&vgnextchannel=d248724
dd7d6c010VgnVCM10000080e8a8c0RCRD&vgnextfmt=print)
Kristen Wendorf, MD, MS
Ebola
Emergency Operations Center
Current Situation
Guinea, Sierra Leone, Liberia
>10,000 cases in West Africa
Approximately 5,000 deaths
Ongoing transmission
United States
4 cases diagnosed in US
1 death
http://whqlibdoc.who.int/bulletin/1978/Vol56-No2/bulletin_1978_56(2)_271-293.pdf
Risk of Transmission
The virus is spread through direct contact (through
broken skin or mucous membranes) with
a sick person's blood or body fluids (urine, saliva, feces, vomit,
and semen)
objects (such as needles) that have been contaminated with
infected body fluids
infected animals (e.g., processing of infected animals e.g., for
bushmeat)
NOT spread by airborne route
NOT spread by asymptomatic individuals
Persons at highest risk:
Healthcare providers caring for Ebola patients
Family and friends in close contact with Ebola patients
Viral Replication
Virus found in body fluids
by day 3 of symptoms
Increases rapidly as
patient becomes more ill
High level of live virus in
body fluids of deceased
If body is at room temperature,
virus lives for days
Virus can live on surfaces
for several hours, but
killed by UV light, bleach,
chlorine
Who might spread Ebola?
Asymptomatic individuals are NOT contagious
Early symptoms of Ebola (fever)
LOW risk of transmission with early symptoms
LOW viral levels in blood and body fluids (might test negative)
None of Duncans household members infected
Late symptoms of Ebola (5-10L diarrhea)
HIGH risk of transmission with late symptoms (or deceased
corpse), to care-givers NOT wearing appropriate PPE
HIGH viral levels in blood and body fluids
Protection Against Ebola
Personal protective equipment (PPE)
Provides barrier so that virus from blood and body fluids cannot
make contact with mucus membranes
PPE for stable patients
Face shield, surgical mask, impermeable gown, 2 pairs of gloves
PPE for people with obvious bleeding, vomiting, copious
diarrhea, or high clinical severity
N95 or PAPR, full gown and hood, gloves, boots, apron
Environmental cleaning
CDC with guidelines for cleaning potentially contaminated areas
Prevention Air Travel
Exit screening
Conducted in all Guinea, Sierra Leone, and Liberia
Aims to prevent ill persons from travelling
Aims to prevent those at high risk of becoming ill from traveling
Entry screening
Identifies persons who became ill while traveling for medical
treatment
Identifies travelers returning from areas with Ebola transmission
for monitoring by Public Health
Prevention Seaports
Coast Guard, US Customs, and Border Protection work with
CDC
Prior to departure from Liberia, Guinea, or Sierra Leone
Crew screened in Ebola-affected countries prior to boarding
During travel
Any ill crewmembers required to be reported to Coast Guard
At arrival in US
At ports of entry, all deaths or ill passengers are reported to CDCs
Regional Quarantine Station
Coast Guard reviews Advanced Notice of Arrivals (ANOA) from
commercial vessels entering a US port from a foreign port to determine
if the vessel has visited a country impacted by Ebola
Most arriving ships from affected region take >3 weeks to make trip
Prevention Crew Members
Screen crew, employees, and passengers for risk of
infection or exposure prior to boarding
Follow guidelines from DGMQ
Work with Public Health to determine disposition of any ill or
exposed individuals
Supplies
Have complete PPE and cleaning supplies available
In case of unexpected, Ebola-like illness in recent
traveler to Guinea, Liberia, or Sierra Leone
Detect and isolate potentially infected individuals
Practice appropriate infection control and biohazard disposal
measures
Public Health Monitoring
All arrivals from Guinea, Sierra Leone, and Liberia
monitored
Symptomatic patients immediately isolated
Asymptomatic patients monitored for 21 days
Check temperature and symptoms twice daily
Movement restrictions dependent on risk level
Any symptoms immediately reported to public health
Public Health Monitoring
If monitored travelers become symptomatic, public
health will provide guidance on the following:
Transportation to healthcare facility for evaluation
Ebola testing
Follow up with any potentially exposed contacts
King County Ebola preparedness
EMS training for receiving calls, approaching potential cases,
wearing appropriate PPE, and decontamination of vehicle
Hospitals training on Ebola protocols and PPE, and preparing
isolation space and treatment team for possible Ebola patients
Outpatient facilities implementing protocols for identification and
triage of suspect cases
Current Situation in King County
No suspected cases
Public Health has protocols in place to monitor
travelers returning from affected areas
Ebola Virus Disease
and the Maritime
The EMS Perspective
Craig Aman, MICP
Chief Operating Officer
MD Solutions International
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EMS Areas of Emphasis
Infection Control Plan
EVD specific messaging
Dispatcher and responder
screening protocols
Response and treatment
protocols
Patient transport
High Risk PPE and
decontamination
Responder training
Coordination with partner
agencies KCEMS, SKCPH
and AMR
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Screening
Begins with call-taker
Flu-like symptoms?
Travel history
Possible contact
Responders
Cautious approach
Confirm symptoms
Confirm travel history
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Response and Treatment
Response
Infectious Circumstance Travel History
Treatment and decon team
Safety Chief and EMS Supervisor
Adopt a Hazmat approach with 6-10 hot zone
Treatment
High risk PPE
Limit personnel contact
Limit interventions
Transport is the priority
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PPE
CDC acknowledges increased
risk for EMS providers due to
environment
High Risk PPE
N95 mask
Goggles
Tyvek suite with hood and
booties
Double gloves
Taped wrists and zipper
Specific decon procedure
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Training
2.5 hours long
EVD background
Response, treatment and
transport protocols
PPE
Indications
Donning
Doffing
Decontamination
Contact vs. exposure
follow-up
41
Maritime Application
Infection Control Plan for vessel or facility
Screening
PPE/decon, procedures and training
Response, treatment and transport guidelines
Longer term
Isolation
Temperature monitoring
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