Download Below find an overview of the August 11, 2014 teleconference on

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.
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
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
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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.
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
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.
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
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
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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
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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.
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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
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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:
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
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.
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