Ebola Virus Disease (EVD)

Information available as of December 2015

Reservoir and transmission to

humans

• Researchers believe that the virus is animal-borne and that bats are the most likely reservoir

• Bats infect chimpanzees, gorillas, forest antelopes, porcupines

• Humans handle and eat bush meat (bats, chimpanzees, gorillas)

• Infected human passes from person to person

• Ebola is not a new disease – discovered 1976

• Before the current situation, outbreaks have appeared sporadically in Africa.

• Source Pubic Health Ontario, Presentation Sept 2, 2014, www.publichealthontario.ca, and CDC http://wwwnc.cdc.gov/eid/page/ebola-spotlight

Areas Affected

West Africa

•Guinea

• Sierra Leone

• Liberia

Source MOHLTC

http://www.health.gov.on.ca/en/public/programs/emu/ebola/

Ebola in West Africa Outbreak

Distribution MapSource CDC accessed December 16 2015

Context for Outbreak in

Africa

Widespread on multiple fronts

• Affected large cities

• Weak and fragile infrastructure

• Lack of knowledge of the disease

• Distrust of government and foreigners

• Not seeking health care

• Social rituals / burial rituals

From Pubic Health Ontario, Presentation Sept 2, 2014, www.publichealthontario.ca

Key Facts

• Most infected individuals likely to have known exposures

(not unrecognized exposures)

• Other diseases associated with travel to these areas are

more likely. Examples are: malaria, influenza,

meningococcal, typhoid fever

• Source: Ministry of Health and Long-Term Care & Public Health Ontario August 28, 2014

Transmission of EVD

• Incubation is 2 to 21 days (usually 8 – 10 days)

• Patients are only infectious when symptomatic

• Patients are increasingly infectious as they get sicker

Source: Ministry of Health and Long-Term Care & Public Health Ontario August 28, 2014

Transmission of EVD

EVD is associated with a high fatality rate. Although the risk in

Canada is low, those most at risk are individuals recently

returned from affected countries/areas in West Africa and

health care workers who manage patients with EVD.

Transmission of EVD can occur:

• Directly through contact with blood and or body fluids or

droplets . Body fluids include: urine, saliva, stool, vomit,

sweat, tears, breast milk and semen.

• Contact with patient care equipment or surfaces

contaminated with blood and/or body fluids, and

• Possibly through generation of aerosols created during

aerosol generating proceduresSource MOHLTC Directive # 1 for Hospitals Revised August 27, 2015

Clinical Manifestations

The symptoms of EVD include:

• Fever

• Severe headache

• Muscle pain

• Diarrhea

• Vomiting

• Sore throat

• Abdominal pain

• Unexplained bleeding

Source MOHLTC Directive # 1 for Hospitals Revised August 27, 2015

WHCA Hospitals Designated as

Screening Hospitals

• The Ministry of Health and Long Term care has

implemented a 3 tier system of care for EVD or Suspect

Patients:

1. Screening Hospitals

2. Testing Hospitals

3. Treatment Hospitals

• WHCA hospitals are designated as Screening Hospitals

• As Screening Hospitals we are expected to screen, isolate

and transfer any patient identified as being at risk for

EVD (no testing will be done at any of our sites)

Enhanced Measures at Canadian

Borders to Manage Travellers From

Areas Affected by EVD

• Patients that have had travel to an EVD affected area are

required by the Quarantine Officer upon entering

Canada to report to their local Public Health Unit

• The Public Health Unit monitors these individuals for any

signs or symptoms during a 21 day monitoring period

• If they develop symptoms, the Public Health Unit

supports patients to access an appropriate testing or

treatment hospital. Therefore they would not routinely

be directed to access care at our sites.

Screening in Place - Passive

Signs are posted at

entrances asking

patients if they have

travelled or had

contact with someone

ill who has travelled

and if they feel unwell

to clean their hands,

put on a mask and go

to registration

Infection Prevention and

Control – Active ScreeningActive:

All patients registering (emergency, admissions and clinics

including OBS) are asked regarding travel and if they answer yes

to travel to a country “of risk” they will be asked regarding any

symptoms.

After hours, nursing at NWHC will conduct screening via the

after hours phone

Screening at Registration Points,

After Hours Obstetrical and Emergency

Countries of Risk•Guinea

•Sierra Leone

•Liberia

Symptoms of Risk•Fever

•Severe headache

•Muscle Pain

•Diarrhea

•Vomiting

•Unexplained bleeding

•Sore throat

•Abdominal pain

This tool is available at registration areas, in the emergency

departments and in the inpatient areas as a resource for screening

for travel areas of risk and symptoms of risk

Active Screening – Process If An

Individual At Risk Is Identified • If the patient has travelled but has no symptoms, they are not

considered at risk. Remember EVD can only be transmitted

when the patient is symptomatic

• If the individual registering the patient identifies a patient that

answers yes to travel and yes to symptoms, they will

immediately notify the emergency department to prepare a

room to further assess the patient. They will ask the patient to

put on a mask and clean their hands, continue the registration

process and ask the patient to remain at the registration area.

The patient will be informed that because of their travel

history and symptoms they will be moved to the emergency

department to be seen

Individual at Risk is Identified

• The emergency department will prepare the emergency room

removing non essential equipment as follows: Room 7 PDH,

Room 3 LMH, Room 3 GMCH and obtain the Ebola kit

• The emergency nurse will clear the transportation route of any

visitors, patients or other health care providers

• They will escort the patient to the emergency department

room wearing PPE (required PPE will be noted in another

slide)

• Routes for moving the patient to the ER department are

located in the Ebola policy and procedure and Ebola kit

• Housekeeping must be contacted to clean the registration and

transportation route once the patient leaves this area

Infection Prevention and

Control Practices – Patient

Placement Emergency• As with all patient interactions HCW’s must

perform a risk assessment (to determine

exposure risk prior to patient contact).

• Place in a room by themselves using

Droplet + Contact Enhanced Precautions.

Place signage on the door and pull the

checklist in the Ebola kit for step by step

instructions

Patient Placement - Emergency• Equipment must be dedicated to the patient - ideally use

disposable equipment when possible. Nothing leaves

the room unless it is appropriately cleaned and

disinfected

• Close the door to the room (if able) – entry is limited to

essential care providers only. Volunteers or students

(except Senior Residents and Fellows) should not be

involved in the management of a suspect EVD patient

• The patient must not use the public bathroom. They

must use a dedicated commode – Hygie bags are

included in the Ebola kit. The patient should not leave

the room

Care of Patient – WHCA

Designated as Screening

Hospitals Only• If after further assessment by a physician, the patient is deemed to

be a suspect case of Ebola Virus Disease, the following will be

notified immediately: Administration on call, Public Health, Public

Health Ontario, Infection Prevention and Control and an

Occupational Health and Safety Rep

• All persons entering room must sign entry log (in kit)

• Arrangements will be made through Criticall to transfer the patient

to a designated testing or treatment hospital

Care of Patient - Emergency

• No lab samples will be drawn or tested on site

• No aerosol generating medical procedures will be

performed. For example: no nebulized therapies, no

suctioning, no intubation, no bag mask ventilation

Patient Care• The number of Health Care Workers in contact with the

patient should be minimized

• Two registered nurses are required for providing care at

all times; they must have no other duties. The two

nurses do not need to be in the room at the same time

and all of the time

• In addition, a trained observer must be present to

monitor health care worker activities and wellbeing.

They will ensure strict adherence to donning and doffing

of PPE procedures.

• A manager or supervisor must be available on site at all

times

• Visitors are limited to pediatric cases. These visitors

must be trained on PPE procedures

Personal Protective Equipment

as per Ministry Directive #1Revised August 27, 2015

Screening (beyond registration point if no barrier

present)/Triage

• Fit tested seal checked N95 respirator

• Full face shield

• Gloves (nitrile)

• Fluid resistant gown

Personal Protective Equipment

as per Ministry Directive #1Revised August 27, 2015

Suspect/Confirmed Case and/or the patient environment

or touching anything that may be contaminated with the

patient’s blood or other body fluids

• Fit tested seal checked N95 respirator

• Fluid impermeable lower leg/foot coverings

• Full length face shield

• Fluid impermeable gown with cuffs

• Full head covering

• Double extended cuff nitrile gloves (one under and one

over gown cuff

** PPE should ensure no exposure of the skin, hair or clothing

Patient Care

Three Zones Designated

There are 3 zones designated for the care of a suspect Ebola

patient

1. The cold (clean) zone which is the area outside of the

patient room or in the hallway

2. The warm zone is near the exit of the patient room or in the

anteroom if one is available and is potentially contaminated

3. The hot zone is the area within the patient room and is

considered contaminated

PPE will be put on in the cold zone and will be removed in the

warm zone at the doorway/exit of the room or in the anteroom

if one is available

Donning/Doffing PPEA trained observer must be present to instruct health care

workers how to don (put on) and doff (remove) PPE. The

trained observer will follow a checklist and read aloud step by

step instructions

Trained observers will receive specific training on their role

Any health care worker required to wear PPE for EVD will be

trained on donning and doffing PPE and will have practice drills

to ensure they are competent in this task

If PPE becomes heavily contaminated with blood or other body

fluids, health care workers must remove PPE in the warm zone

and don fresh PPE as per hospital procedure

Patient Equipment

• Disposable dishes will be used

Housekeeping:

• No special cleaning agent is required – hospital approved

disinfectant is effective against the virus

• Environmental workers will wear the same PPE as other health

care workers entering the room

Waste

• Biohazardous waste pails will be used for all waste

• Special procedures for waste handling are required

Linen

• All linen of a suspect case will be discarded

Patient Equipment and Sharps

Disposable equipment will be used when possible. No

equipment will leave the room unless it is appropriately cleaned

and disinfected

Sharps

• Extra care must be taken when handling sharps

• Safety engineered needles MUST be used

• Sharps must be disposed at the point of care by the individual

using it

• Perform essential procedures only. If initiating IV access the

most experienced individual should perform this task only if

deemed medically necessary

Patient Transportation

• The patient will be transported to a testing or treatment

facility in collaboration with Criticall

• Patient to remain in the room at all times – except for transfer

to a testing or treatment facility

• The person exiting the room must remove PPE in the

anteroom/patient room and applies new PPE if assisting in

transport

• The person receiving/transporting the patient receives the

patient in the hallway wearing PPE

• The patient must wear a mask during transportation

Final note – things change

• The outbreak is evolving and new information continues to be

released

• Our goal is to keep everyone safe, informed and to be

prepared

• Watch for any e-mail updates

Questions…..

Contact Infection Prevention

and Control or your Manager