Centers for Infectious Disease Research and Policy (CIDRAP)
by Lisa Schnirring
October 14, 2014
The US Centers for Disease Control and Prevention (CDC) has established an Ebola response team to immediately deploy to any hospital that has a confirmed Ebola patient, one of several steps under way as federal health officials reassess the nation's response in the wake of an infected Dallas nurse.
CDC Director Tom Frieden, MD, MPH, said at a media telebriefing today that 76 health workers in addition to the nurse at Texas Health Presbyterian Hospital in Dallas who had contact with Thomas Eric Duncan, the Liberian man who died from Ebola at the hospital on Oct 8, are being actively monitored, and so far none have reported any symptoms.
Contact monitoring, shoring up infection control
Federal and state health officials are deeply concerned about the health workers' exposure after the nurse who helped care for Duncan became ill and tested positive. The nurse, Nina Pham, is in stable condition and said in a statement today that she is doing well and was thankful for the outpouring of support and prayers.
Frieden said CDC and state epidemiology investigators so far have not identified any personal protective equipment (PPE) or infection control problems that led to Pham's exposure. Since they haven't pinpointed a cause, officials are worried that others on Duncan's healthcare team may have had the same exposure as Pham.
The 48 people originally identified as Duncan-s contacts have passed the 8- to 10-day mark identified as the peak Ebola infection period, and none have reported symptoms. Though it's decreasingly likely that any will get sick, they will be monitored for the full 21-day incubation period for the disease.
Health officials are also monitoring the one person Pham had contact with while she had symptoms, and so far he is showing no symptoms, Frieden said.
CDC and state partners have undertaken several steps in response to Pham's infection, including having a manager on the isolation unit to oversee all aspects of infection control, enhancing training with the assistance of two nurses from Atlanta's Emory University Hospital's special isolation unit, and recommending that the number of staff caring for Ebola patients on the isolation unit be limited so they can become more comfortable and systematic in managing patients with the disease.
Frieden said the CDC will also beef up its Ebola infection control training and resources for health providers across the country. "I've been hearing loud and clear from healthcare workers that they're worried and don't feel prepared," he said. "A single infection in a healthcare worker is unacceptable."
Lessons learned from Emory, Nebraska Medical Center
In light of recent Ebola develpments, a CDC conference call today for health providers on hospital preparedness for the disease attracted a record number of participants, according to Stephen Redd, MD, senior advisor for the CDC's Ebola response. He said at least 5,650 people took part on the call, which featured doctors from two hospitals that treated US patients who got sick with Ebola in West Africa-Emory and Nebraska Medical Center (NMC).
Alexander Isakov, MD, MPH, Emory's director of prehospital and disaster medicine addressed the stark image of ambulance transport teams wearing head-to-toe Tyvek suits and powered air-purifying respirator (PAPR) gear, a contrast to CDC-recommended standard and droplet precautions. Though Emory officials are on board with CDC recommendations, he said, it made operational sense to have the workers wear the extra gear to avoid having to wipe the sweat off their brows or risk their eyewear fogging up in the Atlanta heat.
Also, advanced Ebola infections come with copious amounts of vomiting, diarrhea, and sometimes bleeding, and the extra precautions gave the staff a greater degree of confidence and protected them in case they needed to do aerosol-generating procedures, he said.
Bruce Ribner, MD, MPH, director of Emory's Serious Communicable Disease Unit, told the group that in the patient care unit, wearing body suits and hooded PAPR was the most efficient, practical, and comfortable option for staff. He added that whatever form of PPE a hospital uses for treating Ebola patients, it is critical to perform proper donning and doffing, especially doffing. He said Emory has a buddy system and a checklist for the donning and doffing steps.
He said Emory has a small point-of-care lab next to its isolation unit, which addresses several of the hospital's infection control concerns.
Philip Smith, MD, medical director of NMC's biocontainment unit, spoke about the usefulness of selecting a nursing staff early on who can be trained to manage high-risk infections such as Ebola. He said NMC has about 40 health workers on the team, and that 6 are typically on duty at any one time.
Selection of PPE, based on CDC recommendations, is an evolving process with the staff, and there's no one-size-fits-all solution for all facilities, he said. For example, the NMC staff has opted to wear bonnets for better head protection and duct tapes the first two layers of gloves to their gowns.
Angela Hewlett, MD, associate director of NMC's biocontainment unit, said waste disposal has been a challenge, and that the facility has had to take special steps to meet demands of waste disposal providers and water treatment authorities. She said NMC has an autoclave on the unit to decontaminate all Ebola materials.
To address patient family issues, NMU has appointed an advocate to streamline communication between patients, their families, and the media, and to meet the needs of Ebola patients and their families during the hospital stay, she said.
WHO Ebola lead sees promising, worrisome trends
At a media telebriefing in Geneva today, Bruce Aylward, MD, MPH, the World Health Organization's (WHO's) assistant director-general in charge of Ebola outbreak response, said that it's too soon to say if illness levels in the outbreak countries have plateaued, especially due to data collection and processing issues.
He also spoke of both worrisome and hopeful trends that responders on the ground are seeing. He said that, as of today, the countries have reported 8,915 suspected or confirmed infections and 4,447 deaths.
Roughly 95% of cases are occurring in 19 of the 67 districts across the three countries, about the same as a month ago, Aylward said. Worrisome signs are that the geographic range of the virus continues to expand, with cases near the border with Ivory Coast and that Ebola infection levels continue to rise in the capital cities of all three outbreak countries: Guinea, Liberia, and Sierra Leone.
On the positive side, he said trends suggest that cases are starting to decrease in some of the traditional outbreak hot spots: Liberia's Lofa County and Sierra Leone's Kenema and Kailahun districts. Responders on the ground indicate that the downturns are real and are the result of behavior changes in affected communities, Aylward said.
"This is Ebola. This is a horrible and unforgiving disease, and you have to get down to zero," he said.
The main challenges to outbreak response efforts are getting all the responders on a common operational and crisis management plan and infrastructure problems in all three countries, Aylward said.
Meanwhile, the United Nations Mission for Ebola Emergency Response (UNMEER) has set targets, which it refers to as the "70-70-60 plan": 70% safe burials and 70% of suspected cases isolated in 60 days (by Dec 1). By that point, responders expect about 5,000 to 10,000 new cases each week.
He said the targets are ambitious, and meeting them will depend on how fast the international response scales up. The burial goal is clearly achievable in cities such as Monrovia, he said, but will be more difficult to reach in rural areas where transportation is more difficult and local people may have more deeply engrained practices.
Aylward said health officials are working on ways to measure their progress toward the 70-70-60 plan.
WHO notes Nigeria and Senegal success, warns about testing reports
The WHO said today if ongoing efforts in Nigeria and Senegal find no more Ebola cases in the next few days, it will declare the outbreaks over there, according to a new situation update.
Two Ebola incubation periods-42 days-must pass without a new case being reported before the WHO considers an outbreak to be over. Senegal reaches the end of the period on Oct 17, and Nigeria reaches that point on Oct 20. In Nigeria, contact tracing reached 100% in Lagos and 98% in Port Harcourt.
On a related topic, the WHO said it is alarmed by media reports of suspected Ebola cases imported into new countries that are said to be "negative" within hours of the patient's entry into the country. Such rapid determination of infection status is impossible, which raises credibility questions.
Early detection of Ebola in suspected cases requires RNA or viral antigen testing, and two negative polymerase chain reaction tests conducted 48 hours apart are required for an asymptomatic patient to be discharged from the hospital or for a suspected case to be ruled out, the WHO said. It added that lab results should be sent as quickly as possible to the WHO, based on current regulations, and that there is a system in place for national reference labs to have their lab results accepted by WHO.
MMWR reports detail Liberia experiences
In an early release of Morbidity and Mortality Weekly Report (MMWR) today, CDC epidemiologists and their African colleagues published two reports, one on a cluster of healthcare-related infections in an Ebola treatment unit and nearby hospital in Monrovia and one on the development of an incident management system to help the country's response.
In the same MMWR issue, New York City health officials spelled out their preparedness and surveillance for Ebola.
Liberia's health ministry asked the CDC to help it investigate a cluster of infections in health workers in late July, which involved five infected people-three Liberians and two Americans. Two died from their infections.
CDC experts interviewed infected workers, other health staff, and volunteers in person and by phone and visited the hospital and nearby treatment center to gauge their risk and work environments.
The team found three opportunities for Ebola transmission: at the hospital emergency department before patients were diagnosed with Ebola, gaps in daily fever and symptom monitoring in hospital and treatment unit staff, and physical contact between hospital and treatment unit staff in common areas, which could have resulted in coworker transmission. They concluded that no common exposure explained all five cases.
Staff reportedly adherence to PPE protocols, but cleaning activities at sites in the hospital may have contributed to the infection risk, the CDC said. In addition, four of the infected health workers often or exclusively worked at night, and fatigue and reduced supervision may have played a role, the group wrote.
The findings underscore the importance of prompt diagnosis and isolation of Ebola patients, as well as daily fever screening for staff, according to the authors. They also noted that separating hospitals from treatment units might help minimize the chance of health worker exposures.
In the second report, the CDC team described its experience in July helping Liberia's health ministry set up an incident manage system to respond to the Ebola outbreak. By Aug 10, the country had appointed an incident manager in the health ministry who focused only on Ebola and chaired daily meetings on the response.
The health ministry, though it was relatively unfamiliar with the incident management system, readily adopted it even though its operation for helping manage the crisis will be an evolving process, the CDC authors wrote.
Report on NYC preparedness
In report on New York City's Ebola preparedness, city health officials wrote that since the city is a frequent entry point for West African travelers, the detection of the first US case in Texas prompted the city to enhance its readiness, which it had been working on since late July. By early August city officials had developed reporting criteria and infection control guidance.
As of Oct 6, the health department had received queries from health providers about 88 patients, 49 of whom had not been to the outbreak area within 21 days of getting sick. Of 11 who met the investigation criteria, none had a high-risk or low-risk exposures, the group reported. One was tested for Ebola, and the results were negative.
Other diagnoses were malaria (8) and typhoid fever (1), while two others had no clear diagnosis. Two patients were discharged with fever and remained in home isolation for several days.
The group wrote that the experience shows the benefits of clear case reporting criteria, building preparedness relationships with local healthcare providers, and rapid communication.
Canada announced yesterday that a phase 1 trial of its Ebola vaccine has begun at the Walter Reed Army Institute of Research in Silver Spring, Md., according to a government press release. Canada has supplied vials of the vaccine, which was developed by the Public Health Agency of Canada. The trial will assess efficacy and safety and involves about 40 volunteers, the Canadian Press reported today, and results are expected in December. (See related CIDRAP News story today.)
Germany recorded its first Ebola death when a 53-year-old Sudanese health worker who had been working for the United Nations in Liberia died in a hospital in Leipzig, USA Today reported today. He died despite "intensive medical procedures," the hospital said. A Senegalese Ebola patient was released from a Hamburg hospital on Oct 3, and a Ugandan patient is still receiving care in Frankfurt, the story said.
In the wake of news that two Ebola-infected nurses-one in Spain and one in Texas-owned dogs, with the one in Spain being euthanized over fears of disease spread, the CDC yesterday posted questions and answers on Ebola and pets. "At this time, there have been no reports of dogs or cats becoming sick with Ebola or of being able to spread Ebola to people or other animals. . . . There is limited evidence that dogs become infected with Ebola virus, but there is no evidence that they develop disease," the agency said. The CDC said it's not known whether pets' fur or paws could spread the virus but recommended keeping them away from any suspected Ebola patients.
Nancy Snyderman, MD, chief medical correspondent for NBC News, issued a statement yesterday apologizing for her team's violation of their voluntary quarantine, Newsweek reported today. "As a health professional, I know that we have no symptoms and pose no risk to the public, but I am deeply sorry for the concerns this episode caused," she said. After cameraman Ashoka Mukpo tested positive for Ebola, NBC News President Deborah Turness told the team on Oct 21 to place themselves under quarantine for 21 days, but Snyderman had been seen several times in public since then. On Oct 10 New Jersey officials made the quarantine mandatory because of the breaches.
Editorial Director Jim Wappes contributed to this report.