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Below find an overview of the August 11, 2014 teleconference on the Ebola update presented by the New Jersey Department of Health. NJ Department of Health Assistant Commissioner Christopher Rinn Last Friday, the World Health Organization declared the outbreak in West Africa to be an international health emergency – only the third declaration of its kind since 2007. Earlier last week, the CDC raised its operational response level to one, its highest level of response to support the Ebola efforts. This activation raised the staffing of the key Incident Command positions to a 24/7 basis in the CDC’s Emergency Operations Center This activation was largely due to the amount of staff on the ground in West Africa and the need to support them around the clock, especially with the significant time difference. Good morning, thank you for taking time to join us on this conference call The Department wants to take this opportunity to share information, lessons learned and review protocols for preventing the spread of disease Want to take a moment to thank my staff for their efforts to monitor and respond, in particular Shereen Semple, who was leading our Communicable Disease Service response these past two weeks Commissioner O’Dowd’s Update: Currently, there are no reported or confirmed cases of Ebola in New Jersey or in the United States. CDC Director Thomas Frieden told Congress last Thursday he does not view Ebola “as a significant danger to the US because it is not transmitted easily, does not spread from people who are not ill, and we know how to stop Ebola with strict infection control practices which are already in widespread use in American hospitals.” But the situation in several West African countries is bad and getting worse – the experience is unprecedented – biggest and most complex outbreak ever documented As of Friday, there are nearly 1,800 confirmed and suspected cases and nearly 1,000 deaths This is a reminder that public health is global. On July 20th, an American man who had previous contact with an Ebola infected patient boarded a plane in Liberia & flew to Nigeria. During that flight, the man exhibited symptoms; was later diagnosed with Ebola & died 5 days later Unfortunately health care workers did not use infection control measures in caring for the man before Ebola was diagnosed & there are now confirmed Nigeria cases that were exposed from that initial airport case. The outbreak began in March - CDC was on the ground in West Africa in April & and as of Friday had 33 people in affected countries and 19 on their way. 1 CDC Director told Congress Thursday that the outbreak will be stopped, but it will take months (3-6 months in a best case scenario) & CDC expects will leave behind systems to prevent, detect and stop Ebola & other outbreaks before they spread in the future We have the tools to deal with this through traditional public health response. The evidence suggests that person to person transmission of the disease does not occur through casual contact, but does spread through direct contact with bodily fluids of a person who is symptomatic. To protect Americans we have to stop the chain of transmission at the source in West Africa. One key way is through airport screenings prior to departure in the impacted countries to prevent sick individuals from getting on planes. CDC is working to put these procedures into effect. However, given the incubation period - it is possible that there will be some travelers who become sick in this country and we need to be prepared to respond to and appropriately managed these cases. As we have seen in the past week, hospitals and airports are able to identify & quickly respond to potential cases—even if they prove to have no known exposure to Ebola apart from travel history As one of the most diverse states in the nation, healthcare workers in this state need to be on high alert to suspect and take infection control actions immediately in individuals with travel history and symptoms. This is a critical step to preventing the spread of disease. Preparedness New Jersey has a well-established relationship with our healthcare providers and our local health officials who are well experienced in monitoring and preventing disease spread Our hospitals have infection prevention programs and are ready to deal with potential infectious patients that come through their doors at any given day Last week, these protocols were put into action when CentraState Medical Center had an individual with flu-like symptoms and recent travel to West Africa, who arrived via ambulance at their emergency room and became a “patient under investigation” CentraState, as a precautionary measure, implemented their infectious disease protocols during the patient’s transport and arrival to the hospital – including using an isolation room specifically designed for infectious patients o After consultation with the CDC, it was determined that the patient, despite recent travel history to West Africa, had no known exposure to Ebola. And this patient was discharged on Wednesday This is an example of the system working well 2 Communication To support all of the health care system, the Department continues to share the information we have through our LINCS system – please read and distribute these messages timely as the situation is evolving and new information continues to become available. In the past two weeks we have sent out several alerts about the Ebola outbreak in West Africa o These messages included guidelines for infection prevention in hospitals, guidelines for evaluating cases, and contact information for reporting suspect cases to public health authorities We are also working on messaging to specific audiences—for example universities that may have international students, local health departments and EMS providers As we provide this information, we want you to share with your communities o You know your communities best – be sensitive to this issue o Now is the time to reach out and educate It is natural to have fear in this situation but we need to ensure that the potential fear we may have when dealing this situation is converted into appropriate and compassionate behaviors. For example ensuring that patients with travel history are managed with appropriate and meticulous infection control measures but also with compassion for their situation and individual fear. It is important to stay informed, review best practices and share lessons learned so we can be better prepared to respond. The Department will continue to work with our federal partners to monitor the situation. We will continue to share information as we receive it through our LINCS system and our website, Lessons Learned – EMS Transport, Emory University Hospital/Grady EMS Wade Miles, Director of EMS Operations, Emory University Hospital, Grady EMS, discussed lessons learned from EMS transport of Ebola patients to Emory Hospital. The EMS transport mission is a clinical isolation unit that was developed to support CDC workers who were working with and/or treating highly infectious diseases. This unit now also is available for those at the quarantine stations at the Hartsfield-Jackson International Airport. 3 Hand-selected paramedics are selected and trained for this unit. They go through specialized education and training programs on disease transmission and care while protecting workers from illness. Ebola is not airborne, making it easier to control. After patients were transported to hospital, proper recovery procedures needed to be followed – destroying PPE and disinfecting the ambulance were key areas. Communication with the hospital team was the key to ensuring a smooth operation Communicable Disease Services Update: Shereen Semple, epidemiologist and vector borne disease program coordinator, New Jersey Department of Health, reported on the following: Ebola presents as an abrupt onset of fever and symptoms that may include chills, weakness, and body aches, gastrointestinal symptoms such as vomiting and diarrhea, and possibly hemorrhaging. It is spread through direct, human-to-human transmission from people who are symptomatic. The disease is not spread by people who may have been exposed but are not ill with Ebola, and the disease is not spread through casual contact. It is also not airborne or transmitted by food or water. Ebola is spread through direct contact with bodily fluids of a sick person, or exposure to objects that have been contaminated with bodily fluids from a sick person, such as needles. The incubation period for Ebola Virus is 2 to 21 days, with most people who have been directly exposed becoming ill within 8-10 days. Current guidelines from the CDC establish three levels of risk for individuals who may have been exposed to Ebola or are returning from an affected country in West Africa. These three levels include high risk exposure, low risk exposure and no known exposure. Both the high and low risk categories involve contact with an infected person, body or contaminated object. The difference between the high and low risk categories lies in whether the contact was protected or unprotected. An example of a high risk exposure would be a person coming into contact with someone who has Ebola without wearing any gloves, gown, face mask or other PPE. An example of a low risk exposure is a household member of an Ebola patient, where direct patient care and direct contact is not administered. 4 The majority of people returning from Ebola-affected areas fall into the category of no known exposure, and that simply means they traveled to a country with Ebola and had no contact with someone with the virus. Since Ebola virus is transmitted only through direct contact, they would have no known chance of contacting the disease. NJ Ebola Virus Reporting and Notification Protocol Ebola virus is an immediately notifiable condition under NJAC 8:57. It falls under the category of Viral Hemorrhagic Fever. As such, hospitals or clinicians with suspect and/or confirmed cases of Ebola Virus would isolate the person and immediately report the case to the Local Health Department where the person resides, or the Local Health Department where the hospital is located. The local health department would immediately contact the NJDOH CDS. After receiving notification, the NJDOH CDS would then work with the hospital and clinician and, in consultation with the CDC, follow guidelines to further evaluate the case according to risk and clinical presentation. If, after consulting with the NJDOH and CDC, a case requires further evaluation, the person would remain in strict isolation and the NJDOH would guide the hospital in collection and transport of specimens for Ebola testing at the CDC. There is currently no testing for Ebola virus at any commercial or state public health lab, and testing performed at the CDC requires approval from state health departments prior to sending specimens. NJDOH Outreach Since viral hemorrhagic fever has always been an immediately reportable disease in New Jersey, the NJDOH CDS already has a SME to provide guidance on Ebola virus. Following the escalating outbreak in West Africa and recent health advisory issued by the CDC, the NJDOH CDS expanded current staff to form an EBOLA VIRUS Response Team, with expertise in areas including infection prevention, clinical evaluation, laboratory guidelines and health education. These team members have been working closely to review and disseminate guidelines as they are made available by the CDC. To date, the NJDOH has sent four LINCS messages including recommendations and guidelines pertaining to EBOLA VIRUS, including the CDC health advisory and reminders about disease reporting requirements in NJ, guidelines on infection prevention, guidelines for clinicians evaluating cases of suspect EBOLA VIRUS and guidelines for collecting and sending laboratory specimens for Ebola testing at the CDC. In addition to sending these guidelines via LINCS, the NJDOH is working with its public health and 5 health care partners to send these messages to stakeholders via targeted email lists, and the current guidelines, FAQ and links to other CDC websites such as Travel Advisories are posted on the NJDOH website. Links to EBOLA VIRUS information are prominently displayed on our home page, with additional details on the CDS website for viral hemorrhagic fever. The NJDOH and EBOLA VIRUS Response Team is also working to develop additional messaging for specific audiences, such as guidelines for university students returning from EBOLA VIRUS-affected areas and guidelines for EMS and first responders transporting suspect cases for evaluation at healthcare facilities. These targeted messages will be distributed through LINCS and sent directly to key stakeholders for additional dissemination. Finally, the EBOLA VIRUS Response Team is working to develop a webinar for clinicians who may have to deal with suspect cases so they are well-informed as to the questions to ask and the tests to order. These, and other tools and messages, will be updated and pushed out as guidance is issued by the CDC. NJDOH Partnering As the public health and health care community continue to monitor the situation in West Africa and engage in preparedness activities in the US, the Ebola virus Response Team has been working to routinely communicate with key stakeholders in ensuring our guidance is always current and reaching audiences who need to know. The NJDOH CDS has been in routine contact with partners such as the CDC Special Viral Pathogens Branch and the CDC Division of Global Migration and Quarantine (DGMG), who provide daily consultation and updates to the NJDOH CDS on issues such as screening symptomatic travelers for risk factors for EBOLA virus. NJ EBOLA virus Case Count (zero) and Summary of Suspect Case Investigation While there are no cases of Ebola virus in New Jersey, the NJDOH CDS recently worked with a LHD and hospital to evaluate a “person under investigation” for Ebola virus. In this particular situation, our notification protocol was appropriately utilized, where the LHD was notified of a potential case in transit to a hospital, and the LHD immediately notified the NJDOH CDS. After the person arrived at the hospital, the NJDOH worked closely with the LHD, clinician, IP and laboratory to evaluate the patient for risk factors and clinical symptoms. As guidelines state, the hospital immediately placed the person in strict isolation and maintained appropriate infection prevention measures for the entire duration of clinical evaluation. In 6 consultation with the CDC, the NJDOH and the hospital clinicians, it was determined the person had no known exposure to Ebola virus, other than travel to an affected area; clinical symptoms improved and the person was eventually removed from isolation and discharged without testing for Ebola Virus. While the NJDOH CDS has disseminated guidelines on infection prevention for health care facilities managing suspect cases of Ebola virus, many of these guidelines have been in place for other infectious diseases and our hospitals already have the tools and expertise to implement these precautions. While the CDC continues to maintain the risk of Ebola virus transmission in the US is very low, the NJDOH CDS will continue to distribute updated guidelines to our partners and remain available for questions to help ensure we are prepared to safely manage Ebola virus and other emerging pathogens. Local Health/Local Hospital Lessons Learned: Margy Jahn, Health Officer, Freehold Health Officer, provided the following “lessons learned” from a patient investigation. The call to dispatch regarding a potential Ebola patient was unexpected, resulting in some concern for health risks to first responders (EMS, police, others) Perhaps consider advisory for first responders as part of the early outreach. Also emphasize to them that local health is a resource for an unfamiliar disease/illness. Communications went well between LHD, CDS (DOH) and ED doctor CentraState Doctor and ICP were pleased with access to NJDOH and CDC staff. Rumors about the patient travelled and county OEM felt disconnected from the action, even though this is not the first point of contact for the Freehold LHD. As the investigation proceeded, the patient was seen as low-risk, CDC was not inclined to test, so no information was communicated to local OEM as there was really nothing to report in the eyes of the LHD A follow up discussion between LHD and local and county OEM revealed that the notoriety of the disease and the potential fallout suggested that - even this was not a high risk - the OEM chain of command should have received a “heads up” so they were in the know when contacted by police and other EMS EMS wished to have follow-up discussion and confirmation on the status of patient and risk to responders. 7 Karyn Young-Engleman, Infection Control Coordinator, CentraState Medical Center, provided the following lessons learned: Timely communication with NJ DOH and LHD. Questions that were unable to be answered were discussed with CDC and answered in a timely manner. Very good physician-to- physician and epidemiologist- to- Infection Preventionist (IP) communication. Health department staff available at all times. Initial and continuous assessment of risk of transmission by IP Observation of health care worker during donning and removal of personal protective equipment (PPE) using written instructions. One nurse and observer assigned to only this patient. Maintained list of all personnel entering room; strict restriction of number of people entering room. Dedicated patient care equipment (needed for routine patient care) Dedicated portable x-ray machine for x-rays required on patient. Dedicated EKG machine for patient. Staffing issues to be considered: One nurse (along with observer) per shift was adequate for this patient because the time required to be in PPE was not extensive. PPE are extremely hot and cause sweating. If the patient requires lengthy nursing intervention, two nurses would need to be assigned to the patient and rotate care. Provide water for health care workers. Further information needed: CDC instructions for donning and removal of PPE do not include instructions for removal of shoe/foot coverings. Detailed instructions for handling laboratory specimens. Patient may require specimens to be sent to all areas of the lab (microbiology, chemistry, hematology, pathology). Ebola virus is handled in a high level containment laboratory at the CDC and community hospitals do not have that level of containment. Instructions needed for cleaning a CAT scan machine (at one point we thought a CAT scan may be necessary, as patient improved this diagnostic test was not necessary). Need to anticipate any “non-portable” diagnostic testing needed and provide guidance for decontaminate of those diagnostic machines. If the machine(s) cannot be cleaned with a 8 bleach or phenolic disinfectant, is cleaning per manufacturer’s instructions, followed by a quarantine time in which the virus will die, a safe practice. Disposal of waste: Can items contaminated with infected body fluids be handled as all other red bag waste. Disposal of sharps: Can impervious, rigid sharps container be handled as all other sharps containers. Contaminated linen: guidance needed. Care of the deceased. Institutional Readiness: Alison Gibson, Assistant Commissioner, Division of Health Facilities Survey and Field Operations, NJDOH, recommended facilities take the following precautions: Review 8:34G Subchapter 14, of the Hospital licensing Standards, for Infection Control Requirements. Review all infection control policies and procedures with all hospital staff. Ensure that all employees are practiced in standard, contact and airborne precautions, to include isolation precautions, the use of Personal Protection Equipment (PPE), disinfection, and the management of infectious waste Review occupational health policies for managing potentially exposed or affected employees, including requirements for return to work requirements. The requirement is to be found at 8:43G-20.1(a) Review all staffing policies, update call lists and connections with agencies. Ensure adequate staffing levels. Staffing policies are to be found throughout 8:43G, and the requirement for contingency plans is to be found at 8:43G-17.1(a) iv Review visitor and security policies; determine how to treat potential exposures, and how to communicate infection control measures to patients and visitors. Risk Communication Tom Slater, Risk Communication Manager, Public Health Infrastructure, Laboratories and Emergencies Response, NJDOH, recommended the following risk communication strategies: 9 Dust off your risk communication plan. Prepare your messages now – before there is an Ebola virus case in NJ. Messages should be simple, clear and concise. They should be understood by a wide range of audiences. Avoid jargon. It’s important to balance between reassuring the general public and staff that we have been preparing for infectious disease and the uncertain paths that viruses can take. Also, it’s important to realize the public’s perception of an “exotic” disease such as Ebola versus familiar diseases like influenza. When dealing with unfamiliar diseases like Ebola it becomes crucial to get ahead of any misinformation or rumors. Teachable moments are more effective now – when people are not stressed. Discuss with staff, patients, residents, visitors and families protocols that may be taken. Spokespersons should be identified and prepared now. Practice message delivery beforehand. The DOH website has risk communication information at www.nj.gov/health/er/rc_res.shtml. All health care professionals need to stay informed. It’s important to get information from reliable sources. The NJDOH will share updated talking points and key messages from the CDC. CDC and DOH websites are also excellent sources. Information is liable to change quickly and often. 10