Lewis Rubinson MD PhD Director Critical Care Resuscitation Unit R Adams Cowley Shock Trauma Center Associate Professor of Medicine University of Maryland School of Medicine RELEVANT DISCLAIMERS AND DISCLOSURES ID: 783817
Download The PPT/PDF document "EBOLA VIRUS DISEASE: Perspective of Bot..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
EBOLA VIRUS DISEASE: Perspective of Both a Clinician and a Suspect Case
Lewis Rubinson MD, PhD
Director, Critical Care Resuscitation Unit
R Adams Cowley Shock Trauma Center
Associate Professor of Medicine
University of Maryland School of Medicine
Slide2RELEVANT DISCLAIMERS AND DISCLOSURESSite PI (Univ of MD) and Protocol Comm Co-Chair for a US DHHS FDA/BARDA contract for the United States Critical Illness and Injury Trials Group Program in Emergency Preparedness
Scientific Advisory Board member for GlaxoSmithKLine and Phillips/Respironics
Received honoraria and travel support from academic and public health professional societies.
Subcontractor to ICF international for an Ebola preparedness effort for the US DHHS Office of the Assistant Secretary for Preparedness and Response
World Health Organization consultant clinician in Sierra Leone. This talk has not been approved by the WHO and should not be considered to express any official policies or information releases. The details and opinions expressed are only my own.
Slide3EBOLA VIRUS HISTORY20+ documented outbreaks after 1st identified outbreak in 1976
Largest previous outbreak in Gulu, Uganda (2000) with 425 documented human cases
Public health and community-initiated measures controlled past outbreaks
Early case finding/ contact tracing, early isolation, case management (healthcare), and proper mgmt of dead bodies
Slide4EBOLA VIRUS DISEASE 2014 WEST AFRICA? Initial case in Guinea in Dec 2013
Mar 2014- outbreak rapidly takes hold in urban Guinea
WHAT WAS PROVEN ABOUT EVD CLINICAL CARE BEFORE 2014?Prior clinical guidance based on limited data and care in very challenging environments
Oral vs parenteral fluid resuscitation was opinion-based
Driven from cholera experience, but N/V and mental status issues may make different
Amount of fluid is controversial
Addl supportive care regimens were opinion-derived and controversial when compared to modern critical care knowledgebase
Nutrition (? Importance, timing, amount)
Slide6SUMMER PRE-DEPLOYMENT DUE DILIGENCEResponding to disasters for nearly 15 years (mostly US-based)
Security, accountability, logistics, medical pre-screening, vaccinations and malaria proph, life/disability insurance
Background in biosecurity
Had served on VHF WGs over past decade
Read everything I could about EVD and brushed up on trop med
Reached out to USG, WHO and other colleagues with boots on ground clinical knowledge and situational awareness to better ready myself
Self-directed crash course in Sierra Leone history, culture, politics, security situation and geography
Kenema Government Hospital
Slide7IN THE MEANTIME…
Slide8WHERE IS SIERRA LEONE?
Slide9SIERRA LEONE
Slide10SIERRA LEONEDecade long civil war ended in 2002
GDP ~ $4 billion (2012)
Approx 6 million people
> 40% 0-14 years old
Life expectancy < 50 y/o
~ 100 physicians for country prior to EVD
Worst maternal mortality in world (2000)
Literacy rate ~ 35%
Minerals are major resources (diamonds, bauxite, gold)
Slide11TRAVELING TO KENEMAFlights scheduled, cancelled and routes changedBaltimore to Phila, to Paris, to Nouakchott, Mauritania to Conakry, Guinea—UNHAS flight to Freetown, SL
Due to flight changes no visa for Guinea
In custody for several hours (language barrier) until Visa approved
Luggage did not arrive
At hotel, learned from email that MD I was to replace in Kenema has been med evac for EVD
UNHAS flight following day, no water taxis running to Freetown since no commercial aircraft
4 hr delay getting ground trans and 5+ hr drive to Freetown
Slide12STILL TRAVELING TO KENEMAPromed and email traffic chatter that pts are stacking up at referring facilities since US MD was evacuated Kenema
UN security briefing, WHO mission brief, skipped the bank
Still no luggage. Given a bottle of hand sanitizer from WHO communications lead
“You’re going to Kenema, you will need it more than me”
5 hr drive to Kenema
Slide13WEST AFRICA: BASELINECourtesy CDR James Lawler
Slide14MAJOR PILLARS OF EVD CONTROLContact tracing and case finding
Early isolation
Clinical care
Safe treatment of the dead
Slide15ARRIVAL AT KENEMA GOVERNMENT HOSPITAL~30 + HCW infections, nearly 20 died
No SL physicians working in ETU
Since Dr. Crozier illness and evac, no clinical oversight in ETU
Unknown census
Only dedicated Lassa ward in the world
ETU referral center for western/central SL
Slide16LEARNING FROM THE EXPERTSI was clinical lead for KGH but team effort to make KGH function.
WHO team responsible for elements of patient care when I arrived
Frederique Jacquerioz (trop med, Lassa expert, EVD experience in Guinea)
Suzanne Donovan (IC physician from LA, very thoughtful about PPE)
Dario Gramuglia (logisitician, EVD experience with MSF)
Rebecca Stretch (IC nurse, tons of EVD experience with month experience at KGH)
Henry Kyobe Bosa (Ugandan physician with significant EVD outbreak experience)
PLEASE SHOW ME HOW TO STAY SAFE!!
Slide17HOW IS AND WHEN IS EBOLA TRANSMITTED?EVD is transmitted from infectious body fluids entering your body (through mucus membranes or skin breaks)
Sicker people with more symptoms have production of larger volumes of body fluids (emesis, diarrhea) ---typically more infectious
Most of these people are too symptomatic to be out and about
Close contacts at home who are caring for these people or sharing bathrooms, etc
Healthcare workers…in US especially ICU workers (intensity of exposure and duration of exposure)
450 HCWs infected as of Oct 2014
Fomite transmission less likely but depends on ambient conditions
Airborne transmission unconfirmed but aerosolization with projectile vomiting, therapeutic interventions, flushing of toilet with large infectious burden of stool all plausible
Slide18Virus culture and reverse-transcription polymerase chain reaction (RT-PCR) results from 54 clinical samples collected from 26 patients with laboratory-confirmed Ebola hemorrhagic fever.Bausch D G et al. J Infect Dis. 2007;196:S142-S147
© 2007 by the Infectious Diseases Society of America
Slide19GERMANY DURING THIS OUTBREAK
Kreuels B et al.
N Engl J Med
2014
Slide20Risks of household transmission of Ebola hemorrhagic fever (EHF) among 173 household contacts of 27 EHF patients, after adjusting for direct physical contact during illness and contact with the patient's body fluids.Dowell S F et al. J Infect Dis. 1999;179:S87-S91
© 1999 by the Infectious Diseases Society of America
Slide21Virus culture and reverse-transcription polymerase chain reaction (RT-PCR) results from 33 environmental samples.Bausch D G et al. J Infect Dis. 2007;196:S142-S147
© 2007 by the Infectious Diseases Society of America
Slide22Slide23Slide24TRICKS OF THE TRADE
Slide25Slide26THE CLOCK STARTS…ITS ALREADY HOT
Slide27BUDDY CHECK
Slide28DISCIPLINED DOFFING
Slide29PPE FOR RESOURCE-RICH COUNTRIESWest African transmission/ prevention is more similar than different for resource-rich countries.
No simple PPE widget to buy and you are protected (takes discipline and detailed process to minimize self-contamination)
Transmission in resource rich may have better environmental controls but impact on care interventions and disease transmission remains largely uncertain
Airborne precautions are not unreasonable because interplay with modern therapeutics (oxygen delivery, etc) remains unknown
Best means to disinfect during PPE doffing remains uncertain
Spray disinfectant (bleach, hydrogen peroxide) vs wipes
Slide30ORGANIZATION OF AN ETUSuspect ward- Annex at KGHPts who are triaged as suspect
Ambulance pts
Mixture of EVD and non-EVD pts
Confirmed ward- Med/surg ward at KGH
“
best” place to provide care
Convalescent ward
Pts significantly improving w/o rebound sxs and awaiting neg PCR
HCW flow should always go from Suspect ward to either Confirmed or Convalescent ward
ETU is “high risk”, outside of ETU must be protected. No one in PPE, once in ETU can leave without doffing/ disinfection. Materials which cannot be disinfected stay in ETU
Slide31GOING INDr. Henry and I were “clinical buddies”Typically 2 hours in am and 2 hours in pm
Heat limitations for duration and times of day for ETU access
Unreliable electricity made night shifts too unsafe
We established consensus amongst us and nurses about goals for particular shift
We kept each other on track because could be distracted off target by so many needs in ETU
Final buddy check of PPE and hands go to apron (just like in OR when not actively involved in procedure)
We start in the suspect ward
Slide32KGH STAFF
Slide33THE ANNEX
Slide34SUSPECT WARDWe enter through the front gate and hop the trip hazard and pass the first few rooms to meet people outsideThere are clearly sick people with probable EVD in ward but we bypass them to try to talk to lower suspicion folks first
Do not want to give someone EVD because they were incorrectly triaged to ETU
Update the census and determine duration of sxs
PCR may be at detection threshold or below in early disease (need 72 hrs to r/o)
Census then matched to EVD PCR list (huge issue about pt id, sample matching integrity)
Goals of suspect ward
Get low-med suspect pts PCR so can be d/cd rapidly
Identify very high suspicion pts and make sure they have PCR so can move to confirmed unit for more aggressive treatment
Keep all pts separated but really try to separate high prob from all others
Slide35CENSUS EXAMPLE
Slide36PERSONS UNDER INVESIGATION (PUI) FOR EVDUS CDC, state and local public health have criteria for screening
All US healthcare entities which must be able to screen/ temporarily isolate and protect HCWs from EVD
Can’t control where possible persons with EVD present
Timely travel from impacted areas or occupational exposure to EVD are best 1
st
screening questions
Causes of fever and other symptoms are much more likely to be due to non-EVD etiologies
Even in West Africa, sick contact is best way to assess risk of EVD
Slide37SCREENINGScreening criteria must be translated to make clinically operational
Symptom duration is not part of criteria but useful (nausea/vomiting for weeks is not EVD)
Diagnostics for alternate diagnosis may not be available at your institution
Slide38MAKING THE EVD DXSamples require special handlinghttp://www.cdc.gov/vhf/ebola/hcp/interim-guidance-specimen-collection-submission-patients-suspected-infection-ebola.html
For most hospitals, ability to rapidly “rule out” will be paramount
Even with rapid dx PCR, may not be able to rule out in first 72 hrs
Towner JS et al
. J Virol
2004.
Slide39RESOURCE-RICH GENERAL ISOLATION STRATEGIESPt is cared for in dedicated space and not moved (except from ED depending on hosp plan)
Diagnostics- most labs are only using POC tests
CDC guidance suggests can use general labs but most hospitals will not be doing so
Limited labs (will vary by equipment and process solutions)
Bedside ultrasound mainstay of imaging
Some facilities are using portable diag Xray as well
No CT, MR, cath lab, etc for suspected or confirmed EVD at most hospitals
American College of Surgeons put out EVD guidance
Will require extensive training, planning and facilities commitment if any hospital chooses to operationalize
Slide40POSSIBLE ADVERSE CONSEQUENCES OF PUI PROCESSPerson travels recently from impacted countryHas neurological signs/sxs suggestive of acute CVA
Do you go immediately to CT scanner for possible TPA admin for CVA?
How do you decide what is best for pt?
How are facility and staff safety factored in?
If there is a time sensitive window, what process is in place to optimize outcomes when EVD PCR from LRN cannot be turned around in necessary window?
Slide41RAPID EVD ASSESSMENT TEAMMust be able to rapidly assess likelihood of EVD
Risk to pt if delayed dx or tx
Are there alternatives?
Risk to HCWs or facility for proposed eval/tx
CT scan vs procedure
Requires immediate activation of multi-disciplinary team
Public health, ID/inf control, clinicians, risk mgmt
Must have endorsement by hosp leadership to make decision or must make rapid rec and hospital leadership must make timely decision
Should be formalized and tested prior to need
Slide42ANNEX CONTINUEDNow we start assessing the pts who are high risk for EVD. Many are lying on the ground, prostrate. Some are near death. Most are in the same position as when they were brought in from the ambulances.
We provide water and Oral rehydration fluids (ORF) to those who everyone who can tolerate it as we assess them
We treat seriously ill with empiric ACT (for malaria), and ceftriaxone (or cipro) during severe GI dysfunction
We have approx 60-90 sec per pt and you learn how to assess pts in any position without breaching your PPE
We must move on as we still have the entire confirmed ward to see
Slide43ON TO THE CONFIRMED WARD15-20 pts are sitting outside of unit on open walkwayMany complain of myalgias, pruritus but generally “well-appearing”
We provide water, ORF, and paracetemol to each. We get their info, but we must move on
Inside ward, numerous pts at various stages of illness
Initial screen for severe illness---walking, eating, under blankets, signs of bleeding (gingival, epistaxis, peri-IV)
Slide44Ibrahima Bah E et al. N Engl J Med 2014 epub.
Slide45N Engl J Med 2014 1481-1495.
Slide46OTHER PREDICTORS OF POOR OUTCOME
N Engl J Med
2014 1481-1495.
Slide47AND STILL MORE PREDICTORS
Schieffelin JS et al.
N Engl J Med
2014 epub.
Slide48SURVIVORS
Slide49CONAKRY CLINICAL EXPERIENCE
Ibrahima Bah E et al.
N Engl J Med
2014 epub.
Slide50RUBINSON’S PRINCIPLES (= OPINIONS) FOR EVD CAREMinimization of numbers of people in pt’s room
Minimization of exposure
? Role of routine exam and assessments
Balancing pt needs with staff safety
There should be no emergencies
Procedures should be pre-briefed, choreographed and done by experienced, team-players
PACE
Novel therapeutics should be used in clinical trial if possible
Limited organ support reasonable but many interventions/ diagnostics will put staff, institution at high risk
Slide51A BIT OF A PERSONAL MISHAP1 day prior to finishing at KGH I stuck myself with an 18 G hollow bore needle through soiled glovesDeep stick
Determined by WHO and CDC to be high risk exposure and to be medically evacuated to NIH biocontainment center
Elected to enroll in rVSV vaccine PEP study
Slide52AN INTERESTING JOURNEYMost HCWs who become infected with EVD did not recognize exposureI simply had to wait for the future
Long drive back to Freetown and flight to US
Slide53EVD FEAR TAKES OVER USTold not to open door of airplane in AzoresConsidered dangerous and at time asymptomatic and only 48 hrs after exposure
Large police escort moving at very fast speed to get me to NIH
Had started to feel a bit ill at end of flight (anticipated timing for PEP sxs)
Symptomatic at NIH and Mr. Jordan ill in Dallas
Slide54FEELING NOT SO GREAT
Lai L et al.
JAMA
2015 epub.
Slide55GREAT CARE BUT VERY ISOLATING
Slide56FEAR AND POLITICS OVER SCIENCEDallas case and secondary caseExcessive public fear due to failed risk communication strategies
Became clear my sxs were due to PEP and I was all better
Length of stay at NIH longer than sxs warranted and then placed under what was essentially home arrest
Never would hurt anyone, but despite much more experience with EVD than any of the folks managing me, there was no place to appeal except in courts
Did not want to be identified to protect my daughter
Slide57PUBLIC HEALTH AND RESPONSE AGENCIES MUST BRING SENSIBILITY BACK TO RESPONSE:DON’T LET FEAR DEFEAT SCIENCE