72 Ebola
72.1 Strategy To Stop Ebola Transmission
Marta 23/10/18
Pillars of Care:
- Case Management
- Case Finding, Contact Tracing
- Safe and Dignified Burials (Particularly infectious once death, high viral burden). You need big community involvement
- Social Mobilisation. Your strategy needs to work with the community that are effected. Needs engagement
72.1.1 Case Management
This is safe care for patients, but also safety for staff.
Staff safety was essential as initially many were dying from Ebola. But you need some patient engagement, as they were dying for lack of IV fluids/Abx, etc.
- IPC guidance (PPE/Hand Washing/Etc)
- Effective care based on clinical guidelines
- Consider special populations (Pregnant, Paediatrics, HIV)
- Consider how care appears to family members (is the ETU killing off patients?)
- Aspects of laboratory use (double protection of the samples to allow transport)
Gene Xpert gives ebola results within 90 minutes
Q: Give a major presenting cause of reduced GCS in Ebola A: Hypoglycaemia
72.1.2 Case Finding
Steps:
- Alerted of case
- Investigate the case
- Trace contacts
- Monitor contacts for 3 weeks
If quarantine is enacted, you need to arrange that patients have food supply, you need to arrange that patients have someone that will look after their land and animals. Else they will not follow quarantine.
Patients had a single number to contact if they thought they/someone else had ebola. But then there were no ambulances to pick people up! So citizens didn’t trust the government and hotline, as no ambulances to take people to centres.
Q: Why do you try and trace contacts in an outbreak? A: Catching cases early reduces disease transmission and increases chance of individual survival
72.1.3 Safe Burial
Q: When are the two riskiest moments after death in Ebola transmission?
A: - Preparation of the body (washing the body) - The funeral ceremony itself (touching/hugging/kissing the body)
Needed engagement w/ burial teams through allowing families choice in how the ceremony works.
Some West African funerals/rites go on for several days
You need specific “burial teams” and they also need PPE
72.2 Virology & Diagnostics
Colin Brown, Naomi Walker
Enveloped -ve ssRNA virus
Really small genome (19kb)
Seven structural proteins (entry, genome, reproduction, transcription, host interferon resopnse, reproduction). Really simple virus, nothing there that should make it be latent (but it is!)
Most ebola tests are for the glycoprotein outer
Behaves like other -ve SSRNA viruses when it comes to entering cells. Goes to brain kidney pancreas liver, but really likes monocytes, neutrophils, NK cells. It kills NK cells, inactivates neutrophils, prevents macrophages from producing IFN. Increases levels of TNF IL-6. Attacks dendritic cells and turns of IFN response, preventing signalling to CD4 T cells.
It’s got an early proinflammatory stage initially, causing endothelial leakage. This is what causes fluid loss and bleeding.
When it attacks organs it’s got a direct toxic affect on these organs.
And it downregulates immune response.
You get a really high viraemia. The higher the viraemia, the more likely you are to die.
72.2.1 Principles of Diagnostics
Diagnostic Pathway:
- Assess against the case definition ->
- Meets the case definition ->
- Diagnostic test against body fluid (usually blood) ->
- Consider what the result means depending on how good the test is:
This can split you into:
- Confirmed EVD
- Possible EVD (for further testing)
- No EVD
You might end up as Possible EVD when:
- Negative test but pre-test probability v high
- Negative test but v early testing after symptom onset
- Positive test when you think it was v unlikely
At all stages of the testing process you need to follow full biosafety precautions. This includes transporting samples to lab!
72.2.2 Testing Options
- Viral Culture - only way that tells you if you’ve got “live virus”
- PCR (NAAT) - GOLD STANDARD currently (sens/spec) tells you there a viral fragments there, so do you know if it’s live infectious virus or not?
- EIA (immunoassay)
- Xpert (rapid NAAT)
- Lateral flow RDT (rapid POC)
72.2.2.1 Ideal Test
- Sens spec
- Cheap
- Low tech
- Rapid
- Transmissibility/Prognosticates
- Culturally approprate
- Safe
- Easy
- Low intraoperator variability
72.2.2.2 PCR
- Good sensitivity and specificity
- Lab based
- Hours to days
- Good for viral load (sort of, uses a proxy measure called the Cycle Threshold)
- Doesn’t tell you if virus alive or dead
You need to deactivate virus, extract genetics, then amplification. Can do loads of samples together, but is time consuming, and expensive, and need loads of infrastructure.
72.2.2.3 “Point of Care” PCR
- Xpert platform
- Still high sensitivity and specificity
- Takes 4 hours to run
- Looks at a couple of targets
- Currently in use in DRC
Needs less infrastructure than old PCR
72.2.2.4 Antibody Tests
Variety of antibody tests that are useful, but not as useful as PCR.
Role is more to work out whether someone previously had ebola, rather than “do thy have ebola right now”. Helped identify all the asymptomatic ebola patients.
72.2.2.5 Lateral Flow Assays
Works like a pregnancy test. Some commercially available.
72.3 Community Engagement
Golden rule of community engagment, start where the community are. Don’t try and create new systems, use what the community already use and trust.
A good outreach strategy is:
- multi platform,
- that uses existing communication networks,
- that must be trusted,
- that must be targeted at your population (example is patients may not use twitter, but journalists love it),
- that is consistent!
- that is culturally appropriate
- that is in the right language,
- that meets your objectives
- dialogue based
- mutually supportive (verbal plus written/etc)
Often women use different social structures than men.
Communities often don’t really trust NGOs (~20% trust), they do trust community health workers
Key groups:
- Religious leaders
- Moto taxis
72.3.1 Techniques
- Posters
- Community Leaders
- Radio/TV - Difficulty here is often linked to political groups
- Social Media
- Face To Face
72.4 Knowledge Attitudes Practice (KAP) Survey
Gold standard for working out if your intervention works.
So we see in Beni and Butembo > 90% know how to protect themselve from Ebola and where to go. Over 80% know what the symptoms are.
72.4.1 DRC Problems
The problems with Beni currently is the conflict setting. Patients refused to go to treatment centres and absconding. Thats how cases got to Beni in the first place. And how cases got to Tchemia, and Kalunguta, and Musienne, and Masereka.o
This is what we mean when we say communities decide on whether a strategy works or fails.
Contact tracing should increase over time, and as an outbreak goes on proportion from known contacts should increase. That’s not what we’re seeing in DRC. The proportion from outside known cases goes up and up.
Red Cross have found the communities think that this is created to interfere with elections, or ethnic cleansing. “Its deliberatly introduced by humanitarians to benefit the employees, they strategy of the doctors to make lots of money.”
There’s been a long history of violence and massacres in Beni of civilians. 13,000 have died in massacres between 2014-2016, thought by government sorted militias.
1/4 believe that ebola is not real
1/3 believe that ebola is fabricated for financial gain
Almost half in Beni believe it’s fabricated to destabilise the region
Opposition politicians are reporting this even further.
There is a whole industry on essential oils, and hemp chocolate, and general bullshit in America on selling “ebola cures”
72.4.1.1 Solutions
Blasting information at people doesn’t work, it has to be a conversation with people. And remember as an NGO person you may be seen as part of the “conspiricy to kill everyone”
You have to listen, you have to find out what people are talking about for rumoured causes and cures. These rumours will change week by week. You need to follow changes. You need to use anthropologists! Rapid anthroplogical surveys and summaries needed.
SSHAP (Social science and humanitarian action platform)
Community engagement is needed in all pillars of the response. You need to feedback to all operational decision makers, they need to take it into account.
It takes about 6 weeks for a community to come to terms with having Ebola, after encountering it for first time.
Your relationship with the community starts the second you turn up.
Just cos a community isn’t engaging with your response doesn’t mean they aren’t responding! They’re doing things themselves. Limiting physical contact, barbers visibly disinfecting, roadside stalls offering handwashing, churches are offering services, communities are monitorine who’s coming in, they’re using plastic bags to protect it.
Top Three Community Demands Currently in DRC:
- Better Overall Healthcare
- WASH Supplies: Soap, Disinfectant
- Blanket Vaccinations - Why are only contacts getting it? Why not me?
- Explain Who You Are? Who’s the Ebola response team.
72.5 Organisation at the Ebola Treatment Centre and Screening
Ebola holding units, to group patients who are suspected ebola. These came out of the 2014 epidemic to try and break transmission, taking “maybe ebola” patients out of community.
The point is to isolate patients, keep staff and patients safe, provide good clinical care to patients.
How do you acheive this?
- Limit access to patients and contaminated areas
- Control movement of staff
- Disinfection practices
- Safe disposal of waste
- Safe handling of bodies
72.5.1 Zones
Green Zone versus Red Zone
Green: No risk activities should happen here. (Supporting activites, Medical Staff, Cleaning Staff, Family members not at risk)
Red: Patients, Protected Staff, Waste, Morgue, Lab, Patients’ houses and vehicles. ALso should includ screening and disinfection.
Other areas: Training, counselling, rest, food, meeting.
72.5.2 Screening Area
This should be built to safely screen a large number of patients. Paitents may come by themselves, or they may be sent by an ambulance/family member/taxi.
72.5.2.1 Principles
You want complete separation betwen patient and health worker, no possibility of worker to cross over to patient side, unless wearring PPE. When healh care worker physically separated, not needed full PPE
Patient should be able to access their zone from outside, and have direct access to suspect and probable wards.
Physical separation should be at least 1.5 metres. This is done in a gap
72.5.2.2 Precautions of Screening
- Green zone staff use gown, face protection, and gloves
- “Red Zone” hygeinists in full PPE will disinfect the patient side after patient leaves.
- No physical exam performed
- Instruct patient how to use digital thermometer themselves
72.5.2.3 Flow
Patients should move from least to most contaminated zone. You should never go back the way.
Low risk -> Suspected -> Probable -> Confirmed -> Ward
Separate entrance for staff than patients
72.5.2.4 In the High Risk Zone
“Keep calm, cool, collected” 3C’s
You can’t run, can’t treat anything as emergency, can’t lose your own perspective of whats going on
- Work with a buddy
- Limited time inside
- Plan what you’re doing before you go in.
- What you take in does not come out
72.6 PPE
Marta
Ebola doesn’t live too long in inorganic material, but can be transmitted by any bodily fluid (blood first, then any other fluid).
You have to be very mindful of what you have touched, and how you hands close to face.
The more important phase of PPE is not putting it on, it’s taking it off.
There is not one true form of PPE for Ebola, multiple equal strategies.
Prior to West African Ebola outbreak, there were very little use of gloves/gowns/etc in Sierra Leone. Now the culture has completely changed.
Care of EVD Patients:
- Scrubs and Boots
- Face Protection to prevent splashes (face shield/goggles, and mask)
- Gloves (double: inner and outer)
- Gown/Coverall to cover clothing/exposed skin: The gown is more for screening area, the coverall is more for patient care
- Head Cover/Hood
- Disposable Waterproof Apron
For heavy cleaning/dead body management:
- Rubber gloves as outer pair (thicker)
- Reusable Apron (thicker)
Boots:
Waterproof plastic/rubber boots by all healthcare workers.
If no boots, then closed shoes plus shoe covers
Gloves:
Double. Need to be right size.
The outer glove should have a long cuff, ideally to mid-forearm.
Suit:
Needs to be balance of impermeability versus temperature and sweat. The more impermable the more you sewat and uncomfortable.
Head/Hair Protection:
Seperate hood?
- Freedom of Movement = +
- When removing PPE leads to exposed face = -
Mask:
In general any basic surgical mask that covers mouth and nose is safe. The worry with paper masks when they get wet, you sweat, and the mask becomes more porous.
So if you use a surgical mask, you need something else as well.
Goggles/Face Shield:
Problems with goggles is they fog super easily. You can wash them and decontaminate them easily
The face shields can get knocked off very easily, but convenient with air flow etc.
Apron:
These can be disposable or waterproof
72.6.1 Common Mistakes
Coverall - wrists can be exposed with wide moement
Don’t try to fix it by taping the gloves. What happens when you try to take it off?
Fix the gown with a loop to someithng
Masks - non structured masks can collapse against mouth
Goggles - when they fog so much you cannot see, don’t touch the goggles to adjust them! The face is the last thing you should touch. You can fix it with anti-fog spray or alcohol sanitiser.
72.7 Buddy System And Supervision
You never go in alone. Pair your new staff with more experienced ones.
First entry of unit: Just putting on PPE, walking through unit, doff, feedback
Directly supervise PPE every step of removal
Write name and function on gowns and time of entry
72.7.1 Inside ETU
No running, no emergency!
72.7.2 Glove Hygeine
- Wash hands between patients
- Change gloves between patients
72.7.3 Putting on PPE
- No personal items
- scrubs and boots
- move to clean area
- gather PPE
- perform hand hygeine
- floow donning sequence
Routine:
- first pair of gloves
- then coverall, with the gloves under the cuff of it
- make thumb hole in PPE coverall to stop it riding down arm
- then face mask on
- then goggles/face shield
- then hood up / or put on separate hood / or face shiled and bonnet
- put on apron
- second pair of gloves
- check yourself in the mirror
- get buddy to check you
Routine Off:
I’m contaminated, anything could be contaminated
No rush, do it SLOWLY
My gloves and my apron are the most contaminated bit
- Listen to assessor
- Stop and ask if any doubt
Let hygeinist know if PPE soiled
- Exit w buddy
- Step into bucket of 0.5% chlorine
- Wash outer gloves for ONE MINUTE - 0.5% chlorine (that’s too strong for skin, will burn, but fine for this)
- Remove apron, break at shoulder and back, don’t touch front as contaminated.
Wash outer goves again for another minute - 0.5% chlorine
- Now if using separate hood/bonnet, remove it before removing coverall. Close eyes as removing hood
- Remove coverall whilst trying not to touch anything
- After freeing houlder remove outer gloves and put it on the floor
- Wash inner gloves with 0.5%
- Remove goggles from the back
- Wash inner gloves with 0.5% chlorine
- Remove gloves
- Wash boots
Wash hands with water and soap or 0.05% chlorine. Wash until elbow.
Remember to divide disposable with reusable.
YOU NEED TO PROTECT YOUR FACE, THIS IS THE WAY YOU WILL GET INFECTED. DON’T WASH YOUR FACE AS YOU GET OUT!
72.8 EVD Survivors
Naomi Walker (26/10/18)
72.8.1 Ebola Complications
Most major complication of ebola is often Stigma! (This can also affect health care workers)
There have been loads of studies of ebola symptoms in survivors, but v few have controls (only two). You need to try and control for baseline illness, and not lots of these trials have done this. They still found loads of the same symptoms though.
72.8.1.1 Common
- Mental health
- Neurological (headache most common, significant cerebral atrophy seen in disabled patients)
- Hearing (less common than vision)
- Vision (common, large amounts of disability, not really any opthalmologists)
- Abdo (chronic pain, not well understoof)
- MSK
- Sexual Health
Most common is joint pain, then headache, then muscle ache, then sleep disturbance
Most common serious complication would be eye symptoms
Other more common in survivors include:
- retroorbital pain
- fatigue
- difficulty swallowing
72.8.1.2 Acute
72.8.1.2.1 Eye Complications:
They definitely increase in ebola survivors:
- Uveitis
- Conjunctivitis
- Cataract
- Scar/Ulcers
Inflammation in the eye is common, and 1/4 can be blind in that eye
72.8.1.3 Pathogenesis
Why are survivors getting these?
- Is it continued immune activation?
Is it immune complex deposition? (you get it in Dengue)
- Do patients with more severe disease, get more complications?
Patients with immunomodulatory therapy seem to have higher rates of complications. Is it that the severe patients who would have died otherwise, are now surviving with complications?
72.8.2 WHO Guidelines
There are national guidelines in Sierra Leone. They also had financial support for survivors, free health care for survivors. UNfortunately a lot of that funding is now gone.
72.8.3 Infection Prevention and Control in survivors
When treating survivors, check temperature, no examining witth bare hands according to WHO
72.8.3.1 Pregnancy and Childbirth?
- Full PPE is needed for delivery at childbirth of survivors (if ebola during pregnancy) (most likely will be stillbirth)
72.1.4 Social Mobilisation
Really an aspect of all other pillars. Needed for everything.