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About the Authors
Linda Landesman, DrPH, MSW
•
Former Assistant VP, NYC Health and Hospitals Corporation
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Principal Investigator – first national curriculum on the public health
management of disasters
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U Mass Online MPH Program
Isaac Weisfuse, MD, MPH
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Former Deputy Commissioner, Division of Disease Control, NYC Department of
Health and Mental Hygiene
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Associate Professor, Columbia University Mailman School of Public Health
Ebola Virus
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Prototype Viral Hemorrhagic Fever Pathogen
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Filovirus: enveloped, non-segmented, negative-stranded
RNA virus
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Severe disease with high case fatality
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Absence of specific treatment or vaccine
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>20 previous Ebola and Marburg virus outbreaks
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2014 West Africa Ebola outbreak caused by Zaire
ebolavirus species (five known Ebola virus species)
Adapted from the CDC
Ebola Virus
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Zoonotic virus – bats the
most likely reservoir,
although species
unknown
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Spillover event from
infected wild animals
(e.g., fruit bats, monkey,
duiker) to humans,
followed by humanhuman transmission
Adapted from the CDC
Ebola Virus Transmission
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Virus present in high quantity in blood, body fluids, and excreta of symptomatic EVDinfected patients
Opportunities for human-to-human transmission
–
–
–
–
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Direct contact (through broken skin or unprotected mucous membranes) with an EVD-infected
patient’s blood or body fluids
Sharps injury (with EVD-contaminated needle or other sharp)
Direct contact with the corpse of a person who died of EVD
Indirect contact with an EVD-infected patient’s blood or body fluids via a contaminated object
(soiled linens or used utensils)
Ebola can also be transmitted via contact with blood, fluids, or meat of an infected
animal
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Limited evidence that dogs become infected with Ebola virus
No reports of dogs or cats becoming sick with or transmitting Ebola
Adapted from the CDC
Human-to-Human Transmission
• Infected persons are not contagious until onset of symptoms
• Infectiousness of body fluids (e.g., viral load) increases as
patient becomes more ill
– Remains from deceased infected persons are highly infectious
• Human-to-human transmission of Ebola virus via inhalation
(aerosols) has not been demonstrated
Adapted from the CDC
Clinical Features
• Nonspecific early symptoms progress to:
– Hypovolemic shock and multi-organ failure
– Hemorrhagic disease
– Death
• Non-fatal cases typically improve 6-11 days after symptoms onset
• Fatal disease associated with more severe early symptoms
– Fatality rates of 70% have been reported in rural Africa
– Intensive care, especially early intravenous and electrolyte management, may
increase the survival rate
Adapted from the CDC
Ebola virus disease (EVD) cumulative incidence* —
West Africa, October 18, 2014
Adapted from the CDC
2014 Ebola Outbreak, West Africa
WHO Ebola Response Team. N Engl J Med 2014. DOI: 10.1056/NEJMoa1411100 http://www.nejm.org/doi/full/10.1056/NEJMoa1411100?query=featured_ebola#t=articleResults
Adapted from the CDC
EVD Cases (United States)
EVD has been diagnosed in the United States in four people, one (the index patient) who
traveled to Dallas, Texas from Liberia, two healthcare workers who cared for the index
patient, and one medical aid worker who traveled to New York City from Guinea
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Index patient – Symptoms developed on September 24, 2014 approximately four days after arrival, sought medical care at
Texas Health Presbyterian Hospital of Dallas on September 26, was admitted to hospital on September 28, testing
confirmed EVD on September 30, patient died October 8.
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TX Healthcare Worker, Case 2 – Cared for index patient, was self-monitoring and presented to hospital reporting lowgrade fever, diagnosed with EVD on October 10, recovered and released from NIH Clinical Center October 24.
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TX Healthcare Worker, Case 3 – Cared for index patient, was self-monitoring and reported low-grade fever, diagnosed
with EVD on October 15, recovered and released from Emory University Hospital in Atlanta October 28.
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NY Medical Aid Worker, Case 4 – Worked with Ebola patients in Guinea, was self-monitoring and reported fever,
diagnosed with EVD on October 24, recovered and released from Bellevue Hospital in New York City November 11.
Information on U.S. EVD cases available at http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/united-states-imported-case.html
Adapted from the CDC
EVD Algorithm for
Evaluation of the
Returned Traveler
**CDC Website to check current
affected areas:
www.cdc.gov/vhf/ebola
Algorithm available at:
http://www.cdc.gov/vhf/ebola/pdf/ebolaalgorithm.pdf
Checklist available at:
http://www.cdc.gov/vhf/ebola/pdf/checkl
ist-patients-evaluated-us-evd.pdf
Adapted from the CDC
Interim Guidance for Monitoring and Movement
of Persons with EVD Exposure
CDC has created guidance for monitoring people exposed to Ebola virus but
without symptoms
RISK LEVEL
PUBLIC HEALTH ACTION
Monitoring
Restricted Public Activities
Restricted Travel
HIGH risk
Direct Active Monitoring
Yes
Yes
SOME risk
Direct Active Monitoring
Case-by-case assessment
Case-by-case assessment
LOW risk
Active Monitoring for some;
Direct Active Monitoring for others
No
No
NO risk
No
No
No
www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html
Adapted from the CDC
EVD Summary
• The 2014 Ebola outbreak in West Africa is the largest in history and
has affected multiple countries
• Think Ebola: U.S. healthcare providers should be aware of clinical
presentation and risk factors for EVD
• Human-to-human transmission by direct contact
– No human-to-human transmission via inhalation (aerosols)
– No transmission before symptom onset
• Early case identification, isolation, treatment and effective infection
control are essential to prevent Ebola transmission
Adapted from the CDC
Teaching Elements in Preparedness Casebook
• Ebola outbreak highlighted skills needed to respond
to a highly infectious disease.
• Students can learn skills through cases about how
others responded to public health emergencies.
• The cases in Case Studies in Public Health
Preparedness and Response to Disasters examine
how the ASPPH competencies apply in real life.
What Cases Cover
Examples of needed skills and the cases which address these skills
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H1N1 Surveillance – tracking and investigating infectious disease during a pandemic
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Anthrax – using epidemiology, labs and regional health care resources
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Mandatory Flu – protecting health care workers in the hospital as they deliver care
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Hurricane Sandy – protecting individuals and workers in the community
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San Diego Fires – communicating with different audiences
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Hurricane Floyd – state agency responding to an evolving multi-layered disaster
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Pennsylvania Long Term Care – working with external agencies and what happens
when that is not coordinated
Cases Sorted by Competencies:
Leadership
• Mental Health Post 9-11
• Hurricane Floyd
• Pennsylvania Long Term Care
• CDC Surveillance
• Chilean Mine Collapse
• NYU and Coney Island Evacuations
• Deepwater Horizon Gulf Oil Spill
Cases Sorted by Competencies:
Communicate and Manage Information
• Southern California Wildfires
• Anthrax
• CDC Surveillance
• Mandatory Vaccination
• Pennsylvania Long Term Care
• Hurricane Floyd
• New York University Hospital
Evacuation
• Martha Vineyard’s response to
H1N1
• Republican National
Convention
• Chilean Mine Collapse
• Madrid Bombing
Cases Sorted by Competencies:
Plan For and Improve Practice
• Japan Earthquake, Tsunami
and Nuclear Accident
• Madrid Bombings
• Hurricane Floyd
• World Trade Center
Evacuation
• CDC Surveillance
• Mental Health Post 9-11
• Pennsylvania Long Term
Care
• Anthrax
• Coney Island Hospital
Evacuation
• Iowa Response to H1N1
Cases Sorted by Competencies
Protect Worker Health and Safety
• Coney Island Hospital Evacuation
• New York University Hospital Evacuation
• Hurricane Floyd
• World Trade Center 9-11 Evacuation
• Anthrax
• Mandatory Evacuation
Anthrax
• 1999 – Laboratory Response Network (LRN) initiated by
CDC, the APHL and the FBI
• October 2001 – anthrax events killed five Americans,
terrorized millions and caused substantial financial
damage
• 2009 – LRN instrumental in responding to a case
involving gastrointestinal anthrax
Anthrax in New Hampshire
• 2009 – 24 yo woman experienced sweating, myalgias and
back pain
• Within week had nausea and vomiting and was hospitalized in
New Hampshire
• Blood drawn, surgeons performed exploratory laparotomy and
saw she had necrosis of the terminal ileum
• Transferred to tertiary level hospital in Massachusetts
Anthrax in New Hampshire (cont’d)
• Several lab tests drawn in NH were positive and by the American
Society for Microbiology criteria should have been sent to a
reference lab for confirmation.
• The tech who ran the test was not a regular employee and was not
familiar with the protocol
• She did not notify a supervisor and did not consult about the result
• The infectious disease practitioner thought the isolate was a
contaminant
Anthrax in New Hampshire (cont’d)
• Separate investigation conducted in MA with new blood work
• State reference lab found anthrax in culture
• MA lab notified NH HHS, CDC, and FBI
• NH conducted epidemiological investigation
• Patient was exposed to anthrax spores while participating in
an African drumming event while a student at the University of
New Hampshire
Anthrax Case Elements
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Case describes response and provides insight into the world of detecting
biological threats
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The events exemplify the role of field epidemiology as public health
detective
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The experience in New Hampshire can happen at any time and may be a
naturally occurring disease or an intentional threat
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Involved multi-agency, multi-state collaboration
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The LRN allowed for laboratories to lead a quick, efficient, and coordinated
response
Anthrax Case Competencies
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Describes problem solving under emergency conditions and managing and
communicating information
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Illustrates the protection of worker health and safety and plans for improving practice
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Model Leadership actions
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The NH PHL had to quickly identify the causative agents and determine whether the case was
linked to broader terrorist or naturally occurring threat
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Their swift actions saved the lives of exposed individuals and reduced potential additional
exposures
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This case crossed state lines. It took significant leadership to work with multiple laboratories, both
private and governmental to coordinate this response and have a successful outcome
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The director of the NH PHL and her designated leads had to balance the collection and sharing of
scientific information from and to multiple sources in order to maintain situational awareness
Communication, Information,
and Improving Practice
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Communicating and managing information was a critical aspect of the response
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Laboratory leadership had to develop messages and manage information
sharing with key stakeholders
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Several practices were improved following this anthrax drumming circle event
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Collecting the information and controlling it while maintaining specific legal protocols
The laboratory identified specific steps to improve the capabilities of their organization and
clinical partner laboratories
Laboratory staff adhered to biosafety and other safety guidelines to protect
themselves from possible exposures
Anthrax and Ebola
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How the laboratory response to an infectious disease is organized
– Similar in both anthrax and Ebola
•
How the anthrax case was initially handled and eventually diagnosed
– Lab workers didn’t follow protocol in handling anthrax
– Hospital staff didn’t follow hospital guidelines in Emergency Department at Texas
Health Presbyterian Hospital in Dallas
– CDC guidelines changed following care of index patient in Texas
Who was involved
Anthrax
Ebola (Mr. Duncan)
New Hampshire and Massachusetts
Hospitals
Texas Health Presbyterian Hospital in Dallas
New Hampshire Department of Health and
Human Services,
Massachusetts Department of Public
Health, CDC, FBI, EPA, NH PHL, LRN
Reference lab, EIS officer
Texas Department of Health, CDC, Department of
Homeland Security, White House, Governors from
several states, LRN Reference lab, EIS officers,
Assistant Secretary for Preparedness and Response
(hospitals) and the United States Public Health Service
Numerous state and federal agencies
CERT (CDC Ebola Response Team) and FAST (Facility
Assessment and Support Teams) after initial cases
How the epidemiological investigation was conducted
Anthrax
Ebola (Index case)
State epidemiologist led team: New Hampshire
Department of Environmental Services and Civil
Support Team, hazardous material teams, local fire
and other town officials, CDC Select Agent program,
University of New Hampshire, CDC EIS officer, NH
Department of Homeland Security, EPA, NH
Department of Health and Human Services
CDC led team: Head of CDC, Texas
Department of State Health Services, Dallas
County Health Department, and others
Starting in October 2014, officials began
screening airplane passengers for fever at five
U.S. airports
Anthrax
Ebola
Traced exposure from
drumming circle event
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•
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100 people may have had contact with Mr. Duncan once symptomatic
(50 low and 10 high risk contacts) monitored
76 Texas Presbyterian Hospital health care workers monitored
because had some level of contact with
Unknown how many were exposed to Nina Pham
16 people in Ohio who had contact with Amber Vinson were
voluntarily quarantined (who flew on a 138-passenger jet)
112 health care workers involved in care of Craig Spencer,
hospitalized at Bellevue Hospital, NYC
NYC 's health department established a 24-hour a day operation
involving 500 staffers to keep track of over 200 persons from West
Africa hot spots who arrive in New York every day
QUESTIONS?
Resources
Case Studies in Public Health
Preparedness and Response
to Disasters
By Linda Landesman & Isaac Weisfuse
© 2014 • 384 pages
Includes 3 bonus e-chapters
http://go.jblearning.com/Landesman
Resources
http://go.jblearning.com/Preparedness
Follow up Questions:
Linda Landesman, DrPH, MSW
U. Mass. Amherst, School of Public Health
[email protected]
Isaac Weisfuse, MD, MPH
Columbia University Mailman School of Public Health
[email protected]
Sophie Fleck Teague
Jones & Bartlett Learning, [email protected]