Since March of 2014 an epidemic of Ebola Virus Disease (EVD) has been spreading in West Africa. This is the largest EVD outbreak ever identified and it has been spiraling out of control. The World Health Organization reports to date at least 12,000 cases of EVD and over 5000 deaths. Those figures exceed all previous known Ebola cases and deaths combined. For the most part, cases have occurred in Liberia, Guinea and Sierra Leone. A few cases have occurred in neighbouring countries. Also, to date a handful of cases have occurred outside of Africa – most notably one nurse became infected while caring for a patient who returned to Spain and two nurses became infected while providing care to a patient who had travelled to Dallas, Texas. Fortunately all three of these nurses have survived their disease.
There has been much concern raised both at the provincial and national level, that we have potential for cases showing up in our hospitals. This is a real concern. Does it mean we should panic – no, but we need to be ready.
While the probability of Ebola virus disease (EVD) in Canada remains low, being prepared for that possibility remains essential. Along with the care of patients, health care worker safety is of paramount importance. Being prepared will help ensure that healthcare workers can safely and effectively care for patients with EVD. This relies on the development of clear clinical processes, the availability and use of appropriate Personal Protective Equipment (PPE) and appropriate training for staff in those processes and equipment.
In preventing the transmission of EVD, PPE represents only one type of control. Of equal importance are administrative controls and environmental/engineering controls. All three must act as complementary parts in a system.
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Ebola is spread through direct contact (via broken skin or mucous membranes) with the body fluids of an Ebola-infected person. Uncertainty exists regarding the spread of Ebola virus by short-range aerosols. Aerosol generating medical procedures (AGMP) should be avoided if at all possible. If an AGMP must be performed, personnel in the room should be kept to a minimum and all health care workers present must don a fit-tested N95 respirator. Every effort should be made to avoid direct contact with infectious materials. Prior to providing care for confirmed or suspected EVD patients, health care workers require training in infection prevention and control procedures, including specific EVD-related PPE donning and doffing (removal) procedures. When donning PPE, health care workers need to ensure that all areas of their bodies are covered, especially the mucous membranes of their eyes, nose and mouth. Removing PPE, in particular involves a heightened risk; healthcare workers should remove the PPE slowly and follow the guidance of the trained observer.
All care settings should have a process in place that will be used for the triage, assessment and disposition of any person under investigation (PUI) or confirmed Ebola case. An assessment of risk should be performed when evaluating the level of preventive measures required for a given clinical situation in a given care area. Ideally a PUI or confirmed EVD patient would be assessed and managed in a designated isolation room with a dedicated washroom. A negative pressure room with an antechamber is preferred, but may not be feasible given institutional infrastructure. If this is not available, PUI or confirmed EVD patients may be cared for in a private room with the door closed.
Ideally the isolation room should be equipped with an intercom and have large observation windows. Facility maintenance should ensure that air exchanges are adjusted to their optimal level. There should be designated PPE donning and doffing areas; these areas may vary based on institutional infrastructure. Ideally designated donning areas should be different than designated doffing areas.
In any setting where a PUI or confirmed EVD patients are present increased staffing will be required to meet the anticipated increase in workload. Health care workers entering the room of the patient must be kept to an absolute minimum. Students, medical care teams and other personnel not essential to that patient’s care must not enter the room. One physician should examine the patient while the rest of the medical team remains outside the room. Health care workers caring for PUI or confirmed EVD cases should self-monitor for symptoms on a daily basis with direction from public health and workplace health. If for any reason they suspect a breach in their PPE has occurred while providing care, the health care worker should immediately exit the room, carefully doff their PPE and report the breach to their workplace health provider. Processes need to be developed for management of any health care worker who may have had an inadvertent explore.
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Finally, issues around housekeeping and handling of biohazardous waste must be addressed. Prior to admitting a PUI or confirmed EVD case to a room, all non-essential equipment and furniture (including curtains) should be removed from the room. All equipment and supplies taken into the room should be disposable if possible. If any equipment is not disposable, it should be dedicated to the patient for the duration of their stay, and must be thoroughly cleaned and disinfected prior to removal from the room. Ensuring that environmental services workers are safe and properly trained is also of paramount importance. If these workers are entering the room of a patient they should be donning the same PPE as health care workers providing direct care.
Providing care to PUI or confirmed EVD cases generates a lot of waste. This includes used PPE, bedding, supplies and a variety of other disposables. Each site must have processes in place for handling this waste, a designated area that is for its storage, and a system for ensuring that the waste is transported safely to a facility where it will be incinerated.
Every facility needs to work closely with their local and regional infection prevention and control programs to ensure that the planning, training, processes and necessary equipment are all in place. The likelihood is that we won’t see EVD cases in most Canadian health care facilities – but we need to be ready just in case.
EBOLA TIMELINE:
(World Health Organization, Centers for Disease Control and Prevention (CDC), Public Health Agency of Canada (PHAC)
1976: Ebola first appears. WHO estimates the ebola virus disease (EVD) claims lives of over 1590 people between 1976 and 2012.
2014
March 23: WHO reports Ebola outbreak in Guinea
March 29 – Liberia confirms its first case of EVD
April 16 – The New England Journal of Medicine publishes a report speculating the first case of the outbreak was a two year old child who died on December 6th 2013.
May 25 – Sierra Leone confirms its first cases of EVD
June 26 – WHO ramps up response – the outbreak causes concern because the disease is being transmitted in communities and health care settings and appearing in cities and rural/border areas in West Africa
July 27 – Nigeria confirms its first cases of EVD
August 24 – The Democratic Republic of Congo reports an outbreak of EVD (unrelated to West Africa outbreak)
September 30 – Dr. Thomas Frieden, director of the CDC, announces the first diagnosed case of Ebola in the United States. The person has been hospitalized and isolated at Texas Health Presbyterian Hospital in Dallas, Texas, since September 28
October 6 – A nurse’s assistant in Spain becomes the first person known to have contracted Ebola outside Africa in the current outbreak. She is eventually released from hospital.
October 8 –The first patient diagnosed with Ebola in the US (Thomas Erin Duncan) dies of the disease. He contracted Ebola in Liberia and was visiting family in Texas when he developed symptoms
October 11– A Dallas nurse who cared for the now-deceased Thomas Erin Duncan tests positive for Ebola during a preliminary blood test. She is the first person to contract Ebola on American soil. She is eventually released from hospital
October 15 – A second Dallas nurse who cared for Thomas Eric Duncan, is diagnosed with Ebola. She is eventually released from Hospital
October 17 –Senegal is declared free of Ebola
October 20 – Nigeria is declared free of Ebola
October 31 – Canada suspends the issuance of visas for residents and nationals of countries with widespread and persistent intense transmission (at odds with the World Health Organization)
Nov 10 – Government of Canada introduces strengthened public health measures for arriving travellers from Ebola-stricken countries -which include reporting to a local health authority in Canada and self-monitoring for up to 3 weeks
Nov 21 – WHO declares end of Ebola outbreak in the Democratic Republic of Congo (unrelated to outbreak in West Africa)
EBOLA NUMBERS:
Confirmed, probable or suspected cases of Ebola as of November 9, 2014 (World Health Organization and CDC):
Democratic Republic of Congo – 66 cases, 49 deaths
Guinea – 1971 cases, 1192 deaths
Liberia – 7069 cases, 2964 deaths
Mali – 4 cases, 4 deaths (infection originated in Guinea)
Nigeria – 20 cases, 8 deaths
Senegal – 1 case, 0 deaths (infection originated in Guinea)
Sierra Leone – 6073 cases, 1250 deaths
Spain – 1 case, 0 deaths
United States – 4 cases, 1 death (two infections originated in the United States, one in Liberia and one in Guinea)
Quick facts on Ebola in Canada:
(Source: PHAC)
- There has never been a case of Ebola in Canada.
- Canada remains at the forefront of the international response to Ebola, and continues to contribute to the response to the outbreak in West Africa. The Government of Canada has committed over $65 million to the global efforts to support the health, humanitarian and security interventions deployed to address the spread of the disease.
- The Government of Canada also committed an additional $27.5 million to support research into experimental vaccines and treatments, additional Quarantine Officers, and support local public health agencies with community preparedness. The Agency continues to work with its provincial and territorial partners to plan and conduct exercises to enable the Rapid Response Teams to easily integrate with provincial and territorial colleagues to provide additional support and resources on request.
- The Agency has a second Mobile Laboratory Team ready to deploy to West Africa on request from the WHO.