Virtual Grand Rounds/Clinical Update: Ebola Outbreak, DRC and Uganda

The second Grand Rounds session discussing the Ebola Outbreak in DRC and Uganda.

Speakers:
Ankita Sagar, MD, MPH, FAACP, FAMWA, System Vice President of Clinical Transformation and Well-Being, CommonSpirit Health

Christopher Baliga, MD, NW Region Medical Director of Infection Prevention and Employee Health, SCrPT ID Co-Chair, CommonSpirit Health Infection Prevention Council, CommonSpirit Health

Transcript

SPEAKER_01 0:04

Good morning, everybody. Uh, Friday, June 5th. Welcome to our CPEO Grand Rounds. We are so excited to have you back to join us. And this discussion is going to be focused on Ebola, which seems very timely and appropriate. We did not plan for it, but it just so happened to be the right moment. And for today's grand rounds, it is my pleasure to introduce once again, backed by popular demand, Dr. Christopher Baliga, who has completed his internal medicine residency at Casey Western University, a research and clinical HIV fellowship at Baylor College of Medicine, and his ID Fellowship at the University of Washington. He is our Northwest Region Medical Director for Infection Prevention and Employee Health, and somebody that I have leaned on heavily over the last few years to help us think through a lot of different infectious disease and prevention topics. Apologies, Dr. Vivekanandan could not join us today, but she sends her best, and we will have her back for a future Grand Round. With that, Dr. Baliga, I will hand the floor to you and thank you so much.

SPEAKER_00 1:18

Well, thank you again for the opportunity to speak. I'm going to do my best to channel uh Dr. Vivekanandan, who unfortunately had a sudden obligation and couldn't come to Grand Rounds today. She did work on the slide deck, and hopefully, I will do uh a reasonable job of conveying what she wanted to convey here. Um so, as you heard, this was going to be the second part of our interesting diseases that you can uh now catch or re-emerging diseases uh in uh here in America. And this was because at the first talk there was an unexpected uh uh event, which was a hontivirus that kind of captured our attention. And just as we were finishing that talk is when Ebola emerged. And so we actually have re-engineered this to be all about Ebola to give you the latest information of what's going on and how common spirit is preparing for it. So, objectives of today are really to understand the epidemiology of Ebola and the current Ebola outbreak, to try to be able to recognize the clinical features, diagnostic tests, lab findings, and management of Ebola. Be aware of the current CDC screening criteria for the Ebola outbreak, be aware of appropriate PPE for healthcare workers in the US for managing suspected or confirmed Ebola patients. Be aware of her special rules around managing lab wastes and labs, uh, I'm sorry, labs and waste for Ebola patients, and be aware of the common spirit response that has been developed to help us uh keep ourselves safe and provide care for our patients. So a little bit about Ebola. Ebola was first identified in 1976, and there have subsequently been over 40 outbreaks of various Ebola viruses. At this point, we're averaging one a year at least. The largest outbreak on record was the West African outbreak in 2013 to 2016. This was from uh the Zaire strain, which causes Ebola virus disease. And just to remind ourselves of this, in December of 2013 in Guinea, a two-year-old developed bloody diarrhea and subsequently passed away. Multiple family members became infected, including a nurse and a midwife. That midwife was from another village and became sick, infected multiple members of her family, traveled to a larger hospital for care, uh, and subsequently infected staff at the district hospital. Subsequently, those staff then infected uh other family members and more staff as they were cared for, and the outbreak spreaded or spreads to larger transportation centers, and the outbreak really exploded at that point. Uh, final numbers were 28,600 people were infected, 11,325 people died. That's about a 40% mortality rate, which is staggering. Um, and as I was preparing for this grand rounds, I was looking at the current outbreak numbers for grand rounds I gave in 2014 when we were talking about Ebola in the United States at that time. And just to put this in perspective for today, uh the numbers for this 2013 outbreak at the point was about 45% of the final numbers, but very large compared to what you're going to hear today for the current outbreak. So, some virology of Ebola, because I am a lapsed researcher and uh like this kind of stuff. Uh it's a filovirus, it's an enveloped filamentous, non-segmented, negative sense RNA virus, and it has you know this filamentous shape. It's very different from the shape you probably think of for most viruses. Uh every virus typically has a protein in a cell that binds to lead to the virus to be taken into a cell. And for Ebola, there's a transmembrane glycoprotein on the surface that initially binds to several cellular targets. The C-type lectins are the most famous ones, and that induces a macropinocytosis of the virus into the cell and an endosome. And in that endosome environment uh between the pH and other chemicals, uh, it will cleave and modify the glycoprotein such that it now is uh the real receptor. I'm sorry, the real uh binding protein is exposed that will bind to the true receptor, which is the NPC1 protein, that'll lead to the virus entering into the cytoplasm of the cell, and that's where the uh cycles begin. So, just a general update on what we're talking about here. Ebola virus is confusing in terms of the taxonomy. Um and so on this table, let's just focus on Ebola here down below. Uh, there are four strains of Ebola virus that typically affect people. Um, there is at the top the bunde buggio virus, there's the Sudan virus, there's the Thai forest virus, and then the the classic Ebola virus, which is the Zaire strain, if you will, um, that was the virus in the prior outbreak. The one that we're talking about now is the Bundabugio virus. So it's a different virus, and the name is different. So, really, this is Bunda Buggio viral disease. And I just want to call out uh something that we've noticed here with our EHR screening, and we'll talk about this further in the talk. But uh there are actually two Congos in Africa, if you didn't know, there's the Democratic Republic of Congo, which is where the current uh outbreak is situated. And then there's also the Republic of the Congo, uh, which has been involved in other outbreaks, but is not involved in this one. And so just be aware when your staff are entering the travel screening that there are two options. And when they type in Congo, at least in our EHR, it's defaulting to the Republic of the Congo as opposed to the Democratic Republic. So just keep that in mind. So Punta Buggio viral disease, it is a less severe illness than Ebola viral disease. It replicates less efficiently or rapidly than Ebola virus, and it has a mortality of about 25 to 50 percent versus the greater than 70% for Ebola viral disease. Now, I'll put in the caveat that it is a rare disease. This is only the third outbreak recorded of it, and so the knowledge that we have on it is not nearly as extensive as the knowledge that we have for Ebola viral disease. One of the other big differences is that there are not any approved therapeutics or vaccines for the Bunda Buggio viral disease. And really reflecting uh that they've been unable to do a lot of research on it, given that it has been uh to date relatively rare. So, where does Ebola viral or Ebola come from? Um, it is thought to reside in bats, likely fruit bats, and from there it will then lead to epizootic outbreaks, which are outbreaks in animals, uh mammals that are in the forest, primates, and other animals, and then from there, occasionally it will travel over into people. And this is thought to happen by exposure to secretions from these animals, blood, uh, either from uh hunting or coming across dead animals, or a lot of times these animals are being used for food, and so in the process of hunting, uh slaughtering, uh butchering them, you can uh lead to potential infection. So that's the thought. Once it gets to people, of course, it can spread with within us. And you know, I just want to call out that although there's good evidence that fruit bats are the reservoir for Ebola virus in nature, while this has been proven for Marburg virus, it has not been proven for Ebola simply because we haven't been able to identify uh replication competent or infectious virus out of the bats. But that is still thought to be where the Ebola resides. So, how do you get it? Um, it's direct contact with bodily fluids into broken skin or mucous membranes. So this can be vomit, diarrhea, uh blood, semen, breast milk, and they can get eyes, mouth, nasal passages, broken skin. It is not spread through the air, so it is not a respiratory virus, uh, thankfully. So it's not nearly as contagious as uh SARS or COVID or measles, and it is less commonly spread through fomites or contaminated surfaces. It can survive in dry blood for a long time, but it doesn't seem to live as long on other surfaces. So the current outbreak. Uh thought to have developed or began weeks before April 24th, and we'll talk about why April 24th is there. Uh thought to have begun in the Tori province of the Democratic Republic of the Congo. On April 24th, a nurse became ill with an Ebola-like illness, subsequently testing positive as the first confirmed case. Eight attending staff that cared for the nurse also developed compatible symptoms. And uh, because this was a nurse, it is thought that they acquired the illness through the uh through their job, through providing health care to other patients, and so they think that this was been going on for some time. On May 5th, the WHO was notified of an unknown illness with high mortality in the Tori province in the Democratic Republic of the Congo, included four healthcare workers who died over four days. And testing uh that was initially designed for Ebola viral disease as opposed to the Bunibugio viral disease returned as either negative or indeterminate and led to a little bit of a delay, not uh quite a bit of delay actually in making the diagnosis, although eventually they did uh get testing specific for Bunda Buggio viral disease and confirmed the cases. On May 17th, the WHO declared the outbreak of public health emergency of international concern, and this is the second highest alert that the WHO has, uh, second only to a global pandemic. So, what are our current numbers? Uh this was as of yesterday on the CDC website and the Democratic Republic of the Congo. There were 363 confirmed cases and 62 confirmed deaths. Uh in Uganda, as of the fourth, there were 16 confirmed cases, one confirmed death, one probable case, and one probable death. Now you may remember that uh as of last week we were talking about numbers uh close to a thousand cases. Uh they have shrunk because the DRC has managed to work through a very large backlog of laboratory testing and have ruled out the majority of those cases. Uh, so the current numbers are smaller. I will still hazard, though, that uh it is uh an outbreak that is relatively widespread at this point uh in a part of the country and part of the world where resources are not uh as good as they could be. Um and these numbers may are likely bigger than we think. I actually, for here's the map of the three of the two countries in question. We have cases in the DRC and Uganda. Uh to date, all the cases in Uganda have been in Kampala, but I was told by the Washington Department of Health yesterday that the CDC was going to change their current definitions of risk from being uh mostly in Kampala and saying all of Uganda is at risk. And that's because of the significant amount of people that are crossing the borders, especially in the northeastern part of the DRC into uh northwestern Uganda and into the South Sudan. And that's actually why South Sudan is listed on uh the CDC's guidance for uh Ebola monitoring. Uh this is the rapid risk assessment from the WHO, uh last updated on the 22nd of May, so this is a little old at this point, but has not officially changed. And it shows their risk assessment for people both in the countries impacted as well as regionally and globally. And you can see that in countries impacted, they say there's a very high risk. In the region, it's a high risk, but globally there is a low risk. Concerns about the current outbreak. Uh, this is already the third largest Ebola outbreak in history, uh, is occurring in a remote resource poor area. It's occurring in an area of military conflict. There are two active insurgent groups in these areas. So M23 is a relatively uh well-organized group that uh has allowed healthcare to uh function in their area, and then there's an Islamic State affiliate group uh that has not been as forthcoming to allow healthcare into the area. There's been massive population displacement because of this. Over 2 million people have been displaced. I think I read 10 million people are facing hunger. And it's also a gold mining area with a lot of trade, frequent movement of people for that purpose. So that is contributing to the massive amount of people that are going across borders into other parts of the DRC. And of course, as people move with infection, then they spread it. The outbreak was identified late, both because of these reasons and because of initial uh diagnostic issues using testing for the more common Xaire strain. And there's limited experience with this virus. Uh, this is like I said, this is only the third outbreak. Vaccines and therapeutics that are available are almost exclusively directed against the Xyre Ebola virus, and so this will be uh an area that will be looked at. So the CDC has a response. This uh editorial came out on the third by the acting director of the CDC. Um, and the CDC's response uh is essentially focused in three areas. It's to prevent importation of the virus into the U.S., provide care to Americans in the affected region. We may have heard they're trying to care for people that are high-risk exposures or have Ebola in Kenya as opposed to bringing them back to the U.S. And they're also trying to work to increase aid to the DRC so they can manage this outbreak on their own. Uh on May 18th, and this was updated on May 22nd, the CDC issued a Title 42 order uh prohibiting covered aliens who have departed from or traveled through the DRC, Uganda, and South Sudan in the prior 21 days from entering the United States. Initially, this was only for non-permanent residents, but this was expanded on the 22nd to actually be anyone who's not a U.S. citizen is going to be uh prohibited from entering the United States. U.S. citizens who have been in or transited through the same countries are being bundled to four airports. Uh, uh Dulles in Washington, Hartsfield in Atlanta, JFK in New York, and Bush in Houston, where they are undergoing what's called enhanced public health screening. This is essentially a symptom survey, uh temperature taking, and then being recorded for monitoring. If the travelers are asymptomatic, they're going to be allowed to go on home, but they will be asked to monitor symptoms for 21 days and isolate if they become symptomatic. Depending on their level of risk as defined by the CDC, they will be have various levels of monitoring that could range from just the traveler having been told to tell us if you get sick to check-ins daily to even an in-person check-in uh if for highest risk people. The current plan, uh, as we heard, is really to attempt to keep sick or those that are likely to become sick out of the United States, whether they're Americans or not. Um, and as evidenced by this missionary physician who was infected uh in the DRC is now in Germany uh with the plan uh to house high-risk exposures and positive Americans in Kenya. We'll see if that goes through. Kenyan courts have currently blocked that path, um, but that is the current plan. So, what are the clinical features of Ebola? Uh so the infection occurs after exposure to a person who is sick or has died of Ebola. There's an incubation period that can last from two to 21 days, usually four to 17 days. Person will feel well in the incubation period and have no symptoms, and and importantly, cannot transmit the virus. One of the features of Ebola virus is that the amount of virus that becomes that is contagious increases as the disease progresses. So it's actually highest at the time of death of the patient. Uh in the initial phase of Ebola, it's kind of a milder symptom. It's called or milder phase, it's called the dry phase. Uh, and patients have nonspecific symptoms, fever, fatigue, headache, joint pain, muscle pain, back pain, and a sore throat. As you progress uh by about day four of the disease, you start to get uh what's you enter what's called the wet phase, which is where you start to have nausea vomiting and diarrhea. Uh bleeding can occur in some cases, hiccups, eye redness, and eventually the patient uh uh will either recover or pass away. Um if you die, it's typically on seven to ten days after the onset of symptoms. And one of the uh features of this is that even after death, uh the virus remains there and contagious on the body, uh, and it is uh easy to catch even at that point. That isn't true for most things. Once you die, it's hard for you to spread it. Uh in general, uh patients who eventually pass away from Ebola typically have a more severe disease and they get more severe symptoms early in their illness. And I think reflected by the fact that a lot of them will pass away between seven to ten days. Patients will improve typically fever for about six days before they start to recover. And it's important to call out that the features are non-specific and the differential diagnosis is broad, especially in this part of the world. So, one of the key points that the CDC calls out is anyone with concern for a viral hemorrhagic fever should be tested for malaria. And so malaria is certainly a common co-infection: dengue, typhoid, riquetzial illness, measles, leptospirosis, yellow fever. And then there are other viral hemorrhagic fevers like Marburg, Crimean Congo hemorrhagic fever, lasso fever, riff alle fever. I want to call out that uh traditionally we called Ebola a uh the name included the term viral hemorrhagic fever. Uh, and that we've moved away from that. If you notice now it's Ebola viral disease or Bunda Bugio viral disease. And part of the reason is bleeding is not as common a component as it is with other hemorrhagic fevers. And so we want to expand people's minds so they're not focused on, well, if they're not bleeding in front of me, then it probably isn't uh Ebola. So I like this. This was a study in the Newland Journal that looked at the patients that were in the US and Europe uh with Ebola during this outbreak in 2013 to 2016. And I like it because it it gives us a very highly monitored, highly investigated cohort of people. And there's two graphs here. One is what are the symptoms at the onset of illness? And on the right, you've got the symptoms at time of admission to the hospital. And at the onset of illness, fatigue overwhelmingly is the most common issue that people report. Um, they are also fevering uh and they're weak and tired. A lot of the other symptoms, though, are relatively rare. And uh, if we talk about uh diarrhea here, you know, you're looking at about 10% of cases, nausea, 10% of cases, vomiting is even less than that. So in the beginning, um there they tend to have just a febrile illness. But by the time they get sick enough to come into the hospital, you notice that several of these have changed. They're still fevering, anorexia has become a big issue, nausea is now a bigger issue, diarrhea becomes a big issue, and then a rash can be there. Conjunctival injection is actually pretty common that's present in over half of patients, they have abdominal pain and vomiting. So the pattern of symptoms vary based from when you first see them, but if you're seeing them when they're sick enough to present to healthcare and come in for admission, they typically have a different pattern of illness. There are they are typically in at this point kind of the wet phase. So, what were the clinical courses in these people that uh were uh either in the US or Europe uh where they got infected or they were they were brought out of Africa? Almost 50% developed hypoxia at some point, all had diarrhea, and I just call out the median output of diarrhea was three liters a day. It ranged from uh 100 mls to 10 liters. And so um, I like to say this is cholera levels of diarrhea, and you can imagine then why it is so easy for virus to spread in that environment. 33% developed renal abdominal. Maladies, 59% met SERS criteria. About a third of them had either encephalopathy or encephalitis. A third had evidence of a bleeding diathesis, although it was usually mild. Bleeding gums, epistaxis, bruising, patechia was the most common findings. Almost all received IV fluids. And I call this out because one of the reasons why we think the mortality rate is lower when in Western healthcare versus in Africa has to do with the ability of teams to provide care to patients. And you have to remember that if you're in an Ebola unit, and we'll talk a little bit about the PPE later, you are in a lot of garb in a place that doesn't have air conditioning, it's hot and humid. The amount of time that staff can spend caring for all of the patients in the unit is about 45 minutes at a time. And if you stay longer than that, you tend to pass out yourself. And so most patients in Africa are actually managed from this severe volume derangement with oral rehydration solutions. Whereas if you're in the West, we would be giving IV fluids. And that itself is thought to make a big difference in mortality. 11% of the patients had malaria actually as a coinfection. 14% received blood products, 22% received fresh frozen plasma, 18% received platelets, and 70% received supplemental oxygen. 50% had non-invasive ventilation and 7% mechanical ventilation, 90% were dialyzed. So what are the lab features and diagnosis of Ebola? So lab findings, leukopenia, frequently with lymphopenia, followed later by elevated neutrophils in the left shift, thermocytopenia, 50,000 to 100,000, elevated amylase, which is from pancreatic infection or inflammation, elevated transaminasis, AST greater than ALT values may peak at over a thousand, proteinurea with elevated creatinine, electrode abnormalities from fluid shifts, prolonged PT, PTT, and elevated fibrin degradation products, which reflect disseminated intravascular coagulation. So, how do you confirm Ebola? So the test of choice is a real-time reverse transcriptase polymerase chain reaction. So an RTPCR. This is the gold standard. This is what public health will be using. This detects viral RNA in blood, plasma, serum, urine, oral fluid, or semen, breast milk as well. There are over 50 laboratory response network laboratories located throughout the United States that are capable of doing this. And we are using primers specific for the Bunabuggio strain. So we do have that available and ready to go. It is worth remembering that for the first three days after symptom onset, the PCR may be negative. And so in test, if you have someone that has really just started to have symptoms, you may get an initial negative test that you then have to repeat three days later to show if they really do have it or not. A virus is generally detectable by this test between three to ten days after symptom onset. So if you do it too early, you may miss it. If you do it too late, you may miss it. Ideally, a specimen should be taken when a symptomatic patient reports to a healthcare facility and is suspected of having the bowl exposures. And just remember if it's less than three days, you may need to do it again. If you have a specimen, it should be uh shipped on frozen or dry ice. Uh, do not submit specimens in glass containers to the CDC and you don't use heparin tubes. It's uh EDTA. And I just put a picture on the left here uh for those that aren't aware. This is a Ebola is a category A waste and it's a category A pathogen for shipping. And so it needs to be packaged uh in a special way, uh, multiple layers, leak-proof containers, special packaging. Um, and there's only certain carriers that will accept a category A pathogen for shipping. And so this is an issue that we have. And just on that vein, just briefly to talk about waste management, um, again, category A waste, this isn't something you can just throw away. Um, it needs special uh a special process that will ultimately lead to being deactivated and incinerated. And just to call out that the handling, transport, treatment, and disposal of waste generated during the care of patients under evaluation or with confirmed viral hemorrhagic fevers is subject to a lot of regulations set forth by both federal, state, and local levels. Um, there are three principles for the safe handling of in-hospital and clinic management of waste. Safe containment and packaging should be performed as close as possible to the point of generation. Staff should avoid opening containers to manipulate the waste after primary containment. And uh, in a lot of our sites, the plan for the waste is essentially to keep it in the room until the patient leaves the room. Uh, limit the number of personnel entering the patient care area and those handling generated waste before and after primary containment. This is a general principle for everything to do with Ebola patients. You want to limit the number of people that could be exposed and always use appropriate personal protective equipment and procedures for handling the waste until on-site inactivation or transport away from the hospital for off-site inactivation. All right, back to the clinical Ebola, treatment and prevention. So treatment is primarily supportive care. Uh treat the hypovolemia and sepsis. So aggressive IV fluid resuscitation, hemodynamic support if needed, ICU level of care if needed, volume losses, again, like I said, five to ten liters per day are not unheard of. Look for and treat coinfections, whether it be malaria or bacteria. And if you are in an Ebola treatment unit in Africa, you will often be empirically given treatment for malaria and antibiotics. Electrolyte and acid-base management. So aggressively manage electrolytes that you're losing from vomiting and diarrhea, a correction of acid-based derangements. Um as you develop multisystem organ failure, oxygen, mechanical ventilation if necessary, correction of severe coagulopathy, try to minimize invasive procedures because you may bleed from them, and of course, renal replacement therapy if needed. Symptomatic management, manage fever and GI symptoms, avoid NSAIDs for the bleeding risks, and of course, use of anti-emetics. Now, I told you that there aren't any approved uh treatments for Bundabuchio viral disease, but the WHO has listed out several treatments that they recommend for uh advancement to clinical trials, I think is how they phrase it. Um they are not proven, they are not FDA approved. Um, but what they have recommended for advancement are uh IV remdesivir. You may remember this drug. Uh I had actually forgotten that remdesivir was initially developed as an Ebola uh medication before it was found that it had some activity against COVID, but they are recommending REMdesivir again. Uh there are monoclonal antibodies, there's uh two of them, MBP134 and MAFTIVIMAB, that are uh recommended for exploration of effectiveness. Uh uh interestingly, there's a there's an uh FDA-approved cocktail for Ebola treatment that's available now for the Xyre strain. It includes the MAFTIVAMAB as well as another monoclonal antibody plus uh the uh uh obaldesvere antiviral. And what's interesting to me is that the WHO has recommended it for study as a post-exposure prophylaxis, this oral antiviral, as opposed to being used for treatment. Um I don't know the details on why that is. Uh there are two possible vaccine candidates that are recommended by the WHO for inclusion in studies. Uh, Iavi, which is the International AIDS vaccine initiative, has a recombinant uh vesicular stomatitis virus vaccine candidate. And then the Oxford Serum Institute of India has a uh chimpanzee adenovirus uh vaccine candidate uh also that they're working on. Both of these are thought to be many months away from trials. Uh not recommended by the WHO, but mentioned in other articles that I've seen in the press is uh a Moderna mRNA vaccine that's also in development. Uh and I will say that the um missionary who is uh in uh that was transported out of uh Africa is uh who's American actually received monoclonal antibodies already. People are also talking about pool convalescent plasma. This was a a uh technique that was used with some success in the 2013-2016 outbreak. Um so people are starting to work on next steps. So I'm hoping that as time goes on here, we may actually have some effective treatment options available. All right, three key principles for Ebola. I if I if you remember nothing else from this talk, uh, it is to identify, isolate, and inform. So what does this mean? So identify, find the people that are at risk. So this is a screening, travel and exposure history, symptom screening. So the CDC interim screening guidelines, there's uh kind of divided up into two flavors here. There's a non-occupational exposure and an occupational exposure. And I just want to call out that the people at highest risk for contracting Ebola are close family members, people caring for somebody sick with Ebola or involved in funeral ceremonies for someone who passed away from Ebola, or healthcare workers who are caring for patients when they are in their wet phase. So the non-occupational exposures is exposure to a person with an acute febrile illness from a compatible epidemiologic history. So coming from an area of concern, having visited a healthcare facility or a traditional healer in an area of concern, attending a funeral or burial, and then contact with bats, bat urine or droppings, or non-human primates, contact with blood, fluid, or raw meat from these animals, or entry into areas known to be inhabited by bats like caves or mines. Occupational high-risk exposures are providing health care, performing environmental cleaning or handling of waste in an Ebola treatment unit, or for patients with Bunduvial viral disease in any clinical setting. Entry into a patient care area of an Ebola treatment unit for any reason, providing health care to an acutely ill patient not known to have Bundavigua viral disease, environmental cleaning or handling of waste in a regular healthcare facility, clinical laboratory work associated with the treatment unit or other healthcare setting or burial work. So some limitations of the current screenings from the CDC. So strengths are it does help identify travelers with recognized exposure risk. It supports early public health follow-up, provides education regarding symptom monitoring, leads to a controlled entry of these people into healthcare if they have symptoms. But some limitations are it really relies on an accurate self-reporting of both travel, of the exposure, and of developing symptoms. Travelers on a broken itinerary may be missed at ports of entry. So if you were in the DRC and then you flew through the Netherlands, you stayed there for a day and then caught a flight back to the US, the CDC won't know this. And there was at least early on some uh stories in the press of people that if they didn't volunteer that they came from an Ebola area at risk, then the CDC wasn't catching them. So it's not foolproof. Uh early Ebola symptoms are nonspecific and of course may resemble common viral illnesses. Travelers may be asymptomatic during screening and develop symptoms later. Exposure activities may not be recognized or disclosed. Self-monitoring depends on symptoms recognition and timely reporting. Trust, cultural, and language barriers may impact willingness to disclose exposures or symptoms, and individuals may be hesitant to report exposures due to concerns about stigma, employment, travel restrictions, or interactions with government agencies. Why healthcare screening remains critical is we are another step to try to identify these patients. Early identification leads to early isolation. It helps with staff education preparedness. It allows us to work in close coordination with public health, and it actually helps build some community outreach and trust building. I just want to call out that our all of our EMRs within Common Spirit are currently active for travel screening. So patients are being asked today if they have any of these risk factors. All right, isolation. So inform, isolate, and or uh identify, isolate inform. So isolate is what you do next. So if you find someone that screens in, um, step one is to put a mask on them. Step two is to move them into a private room, ideally a private room with a private bathroom and a door that can remain closed. And uh if possible, then they can be in uh uh an airborne infection isolation room or an AIIR. Typically we call this a negative pressure room in healthcare. Um, and you should definitely do this if you're planning to do an aerosol generated procedure like intubation. Okay, inform immediately notify infection prevention at your site, unit or local hospital leadership, and local public health. So these are the three tenets that I want everyone to take away from this. So PPE. Um Ebola is not uh not forgiving. If you are exposed, the risk of contracting it is high. Um and so PPE is is key to keeping us safe. And unfortunately, it is not PPE that we use regularly, it is a very uh aggressive version of PPE. And the reason we do this is because this is tried and true in Ebola treatment units across the world and has been shown to be very effective at keeping us safe, although it is still relatively easy to uh contaminate yourself. So we're not going to talk a lot in detail about this. You can just see pictures here. It's essentially fully covered. You are supposed to wear fluid-resistant uh gowns, coveralls if you've got them, uh double gloving, uh face shield, N95s, or or cappers papers, uh, your booties on your legs, something that can keep you completely clean. Um, and we need to be uh trained in how to use these because it is easy to contaminate yourself when you're taking them off. And one of the key tenants, of course, is to have a trained observer that's watching you do it, making sure you're doing it right, not uh leading to self-contamination. And I'll just say that um across our sites we have various versions of PPE, uh, so that you need to really look at your local facility uh guidelines for what you have and then how to do it. So, Common Spirit, uh, or in general, we have an Ebola exposure control plan. And key principles of this are early identification and isolation, engineering controls, which are dedicated safe zones. You want to create clear separation of clean or cold zones, we call it, and then dirty or hot zones for patient and PPE removal areas. So you've got a clean area and dirty area, and you've got to keep it clean. Um, there should be strict one-way traffic flow. You go from clean to dirty. Um, and you should have designated PPE donning and doffing areas with appropriate signage. Um, so you know what it is, people there to help you do it right. You want rigorous work practices where you limit room entry to essential personnel, logging all entries and exits, mandatory trained observer for every PPE donning and doffing, strict adherence to sharp safety and waste disposal protocols, and frequent disinfection of patient areas and critical equipment. Uh PPE should be a comprehensive PPE ensemble. So, as we talked about, gown, cover all, face shield, double gloves, boot shoe covers, respiratory protection, in 95s or papers, cappers. PPE should be fluid resistant, it's a level four gown. And you should have demonstrated competency in donning and doffing before engaging in patient care. There should be robust training and support, starting with foundational knowledge, progressing through tabletop discussions to refine understanding, and culminating in realistic simulation drills to ensure practical proficiency and team coordination under pressure. Comprehensive training in Ebola viral disease, PPE and control methods for at-risk healthcare workers, immediate response protocols for potential exposures, including post-exposure monitoring, ongoing plan review updates, and incorporating employee feedback, an incident command structure, and a 21-day monitoring for each healthcare worker that has cared for a patient with Ebola. So, Common Spirit Resources. If you go to Common Ground, you'll see there at the top right a link for our toolkits. And many people, uh, including uh Dr. Vivan, uh, have worked to develop these resources and they are very good. I actually am quite impressed with them. If you click on it, you'll be taken to a page that will have this information, and there are links for pretty much everything that they put out there, whether that's uh an S-bar for an update, uh templates for response plans, drill templates if you need it. There's information on PPE, including donning and doffing checklists, videos, calculators for how much PPE you need. Uh KneeTech is a government entity that helps prepare and train for high-consequence infectious diseases. Um there's guidance from employee health. Patient exposure log tracking forms are there. The communications that we've sent out to team members are there. There's signage for putting up uh warning signs in your waiting room to let us know if there's any risk for Ebola. Um, there's a link to a five-minute check-in that Dr. Favanana did with Dr. McGinn about Ebola and Huntavirus, uh EHR optimizations and scripts, uh, and then other resources that are there, including links to government uh websites. It it's it's pretty all inclusive. Everything there that you need is there. Um so this is designed to be something that in the middle of the night, if you need help, you can go look for it and there's information available to you. You will probably also have local site information available for your region or market, and so keep an eye for that as well. In theory, all of these will be linking together. So, common spirit. So we have set up incident command and response. Um, we are working on the system Ebola response plan. We've had drill templates are there, we're encouraging drilling occurring at your sites. We've asked for incident command structure activation uh both regionally and at local sites. We are focused on screening and early identification. So travel and symptom screening tools are present. Uh EHR screening scripts and workflows are present, ambulatory clinic response algorithms are present, and healthcare worker exposure assessments are present. We have donning and doffing checklists, for PB training videos. It's all there for you. So take-home points that I I want you to leave with. Um there have not been any cases in the US to date, and the thought is that the risk to the US public is low. And even in the 2013 to 2016 outbreak, if you recall, when we had the one imported case in Dallas, um the number of people involved was in Africa was much higher than it is now. So I think the risk currently is even lower than it was back then. All U.S. citizen travelers from impacted countries are being identified and monitored by the CDC and local public health, which, as I said, means that if they were to develop symptoms, it will hopefully be a controlled entry into healthcare where public health is aware, they've told the patients what to do, they've called and shared that information with the local facilities and so that they are prepared to receive them when they come. There is decades of experience on how to track, quarantine, and isolate patients, as well as how to end outbreaks. And it's using tried and true public health techniques. Identify, isolate, and inform. Remember that. And common spirit continues to monitor the situation and has policies and procedures in place if Ebola does appear in the US. And so I don't want it to be all doom and gloom. Um this picture, so just a little bit of levity on what is a very serious situation. This picture here in front of you was uh is from the CDC website of Ebola, slightly different than the one that was in the New England Journal article I had in the front. But back in 2013, my youngest child was uh almost four, and every time he saw me working on the talk, he kept saying, like Mickey Mouse, Mickey Mouse. He thought that the virus looked like Mickey Mouse. Um he is now much older and uh is not saying that anymore. But on that, I will stop and we will see what questions we have.

SPEAKER_01 43:41

Thank you so much, Dr. Valiga. This is great. Um, quite the the review of Ebola and um also quite a bit on what we should be doing and how we should be thinking about it. Um there are a few questions, so I'm going to get right to them. I'll save my question for later. Folks, if you have your hand raised in the in the queue, please put your question into the chat or in the QA. So first and foremost, let's get to the question around facility versus ambulatory sites, because there is a difference in what we can do. And really first and foremost, thinking about screening. So we talked a little bit about the travel screening that is happening at registration, hopefully, regardless of the site that patients in. Beyond that, if ambulatory sites were to identify a person who may be at risk, what is the recommendation from a practical standpoint? Let's let's start there first. And then we'll go to the PPE question.

SPEAKER_00 44:51

Yeah. So if this were to happen, and it might, um hopefully with our screening techniques, uh people will be aware and they will then escalate to their site leadership and the clinicians involved that there's a patient that screened positive. Uh they'll be given a mask and they'll be put into a room. So that is primarily what every site can do. At that point, our policies would ask that uh team members would either call into the room or you can stand at the door and talk to them to try to get more information. And the point of this will be you're going to have to decide as a clinician taking care of this patient, along with your local infection prevention, infectious disease, clinical leadership teams, and importantly public health, how concerned are we? Is this someone that uh we should really be concerned about, Bundapuju viral disease or any other viral hemorrhagic hemorrhagic fever? Or can we say, you know, they were they were in uh Uganda, they weren't in Kampala, um, they have no exposure. Um, you know, their symptoms are from something else. And that conversation with the clinician, the patient, and public health is important because that will help decide what happens next. It may be as simple as being like, okay, we're not really concerned about this, and uh we can resume normal clinic operations. It may be that uh we're like, okay, this doesn't sound uh or this sounds concerning. And uh for most sites, that would then involve arranging for transport of that patient to a uh center that is better at capable of managing a typically an acute care center like a hospital. Um, depending on where you are, there are every state has a robust public health response. If if I have to say, if there was an advantage of going through 2014, it was that American healthcare and public health, I believe, are better prepared today to deal with an Ebola patient than they were back then. Um, and so every state has identified uh healthcare facilities that are capable of taking care of patients with a viral hemorrhagic fever versus those that are not, and and they can triage based on their local protocols where the patient will go.

unknown 47:14

Yeah.

SPEAKER_01 47:15

So what I'm hearing is let's say a patient says they did they do screen positive on the travel, questionable on the symptoms, take them into a room, close the door, interview the patient, call local leadership, call local public health, discuss the case, and then decide is this truly a high-risk patient or is this somebody who may be a low risk? Um, but then the following steps would be guided by local leadership as well as um the public health. Um there's quite a few questions on okay, so let's talk about lab equipment and mechanical ventilation, given that there is specific procedures that need to be followed in the event this is a person that we are taking care of who does have Ebola. Um, so let's get the first thing was around waste management, EVS. I wanted to just share with everybody. So we in the incident commands for the system, we are having these conversations with EVS on waste management. There is a very specific protocol that we are working on, and we are going to be providing that guidance and by we, I want to say infection prevention, ID, our regional CMOs, our um larger supply chain colleagues, informatics, the enterprise resilience team, as well as regional representation beyond that. So um from the waste management perspective on the system side, I can speak to it to say more to come on it. But Dr. Baliga, from your perspective, what are the special precautions we need to think about when we think about body waste management, lab equipment? Is this are these labs being done in the regular point-of-care testing, or should we be separating these out in some way, shape, or form?

SPEAKER_00 49:18

Yeah, it it's challenging. I mean, I will say that there's a lot of rules and regulation about around waste, around uh even uh sewer outflow around labs, um, diagnostics for patients who have Ebola, and for a good reason, um it is highly contagious, and uh the healthcare worker environment is is brought. Uh waste is a problem, and and as you said, uh it requires special handling. The waste needs to be stored in or around the area. You're not supposed to be moving it around your facility. So, like I said, at a lot of places the policy is just leave it in the room. Um if you when it leaves, you need it needs to be inactivated and it needs to be then incinerated. Um, and you've got to transport it to an incinerator unless your hospital happens to have an incinerator on site. Um, and so it is it is challenging in that there's special rules, special packaging, um, and only certain companies will do it, only certain uh uh companies can transport it. Uh, and so this will all be very hyperlocal, I think, in what you need to do, and you have to work with your local teams on it, as as Dr. Sagar has said, many people at the national level are working on this too to try to make this as painless as it can be, but it is it's a challenge. I mean, I'm not gonna sugarcoat it. Um, the same is true for labs. Um, there are facilities whose uh plan is primarily to uh put a patient in a room and do the bare minimum labs, which it can range from nothing or it can be as much as uh trying, you know, drawing the vial that will be sent for RNA testing and giving it to the state and stopping. And and this is because if someone actually has Ebola as a disease, then the rules are such that non-dedicated equipment uh is difficult or even for some equipment impossible to clean. And so it's a challenge that scares labs, um, scares me. Uh and so for a lot of our sites, we are saying that dedicated equipment, like an Istat machine point of care testing is what you want to try to use. And ideally, that would be taken into the patient's room, it would stay there for their stay. Um almost assuredly, most of the people that we do this for will ultimately not have Ebola. And so then the equipment is released and we can use it again. Um, the the downside to this is that almost assuredly the patient will not have Ebola and they're in our care for something else. Um, and so as I said, the CDC actually recommends everyone get a malaria test. Uh, and if you watch the CDC webinar uh last week, um they had a little discussion on how you can uh you know use the thick and thin smear, have your microscope. So centers that are planning on doing things like that often will have either equipment that's just gonna go in the room and stay there or go into the area if you have if you're big enough to have a dedicated space for this, that you the equipment is already there or you take it there. And again, it just sits there until the the rule in or roll out. And if they rule in, then probably the equipment will be destroyed after the patient leaves. And if they rule out, then then it doesn't matter and you can use it normally. Um I think those were the points.

unknown 53:00

Yeah.

SPEAKER_01 53:01

Am I missing one? No, I think those are those are spot on. There's quite a few questions. So I am going to ask John Kaneshi, who's our Maya in the background. John, can we get a copy down all these questions so that we make sure we can do a FAQ document as a follow-up? Um, and all it'll be published on the Common Ground website for everybody to see. Um, because we may not get to all of these questions. So these are good questions. Um one of the questions that I think um I I ask this a lot of our leaders, and I asked this a lot of myself, is what keeps you up at night about about Ebola specifically, this strain of virus disease. Thoughts what keeps you up at night, and how do you think the system can prepare better? Or are we prepared as best as we can right now?

SPEAKER_00 53:53

So for me, what what worries me most about all of the viral hemorrhagic fevers is the level of rigor with the PPE that is needed for staff. And I don't know that's fair. I guess I should say what worries me most are is the mortality rate for the patients, um, which is high. But um my role as the infection prevention and employee health uh here in the Northwest, um it is unforgiving if you use the PPE correctly and appropriately, which primarily means that you're putting it on correctly to begin with, and then you're removing it in the appropriate steps with the appropriate methods at the end, um, you will be protected. But it is very easy to mess that up. Um and you know, are we prepared? I think some sites are better prepared than others. Um, it is challenging to ensure that all team members have spent enough time uh donning and doffing PPE uh in a controlled manner so that they feel comfortable when it actually happens. Um if you recall, and there's other things that can go wrong. I mean, I always bring up the example of uh Texas Health Presbyterian in Dallas. So this was the hospital in 2014 that actually was very well prepared for Ebola. They had practice management, they had a dedicated team and space in place. Um, but the the index patient there presented to screening at the ER with symptoms, um, what symptoms? Uh actually screened in, you know, that they did the appropriate screening. It was identified, and uh the clinicians in the ER were unaware of it. And so they and they didn't think of it at the time, and so the patient was sent home. Um, you know, that that worries me too. Don't don't be that hospital. We have screening in place. Make sure that if you screen positive, that A, you're letting somebody know if you're the person that did the screening, and B, that if you're the on the other side that you know where to look, uh, if nobody tells you, so that you at least know what's happening.

unknown 56:17

Yeah.

SPEAKER_00 56:18

Um but the PPE, that that's my my biggest my biggest thing. Um in America, we have decided that every facility in the country should be prepared to manage Ebola at least for a little bit. Um and the patient the places that do this really well are places that practice all the time and have a team in place that are ready to go. Um, and so that that is to me our biggest challenge uh in America and for healthcare, and that's true across common spirit as well.

unknown 56:51

Sure.

SPEAKER_01 56:52

I think um, I guess on my end, one of the things being part of that system team, what's gives me hope is the fact that there are so many folks, not just at the system level, but really at the regional and the market level that are involved in this. Now, one other thing that gives me hope is the fact that there's so many people here this morning who are asking the right questions and looking for information. So I think that is what I am banking on. Um one of the things I wanted to underscore for everybody is look, this is a great um opportunity for us to work as that team. And I think that um from the system incident command all the way to the regional market and local levels, um if there are questions that are coming up, please ask us. We may not be aware what we're not aware of, uh, but we can definitely make sure that the questions get answered. And the other part of it is that um I know there are more and more questions coming. So, John, you you've you've got your um work cut out for you to keep up with the questions. Um the other thing I just wanted to say was on the EHR side of things, we are aware that um there is a gap between where the questions are showing up versus where the patients are in their clinical encounter, and that is being addressed um fairly rapidly. So we will have updates on that and we will share it. Um it is top of the hour. So, Dr. Baliga, thank you so much for dedicating your time, expertise, and sharing this amazing presentation with us. We missed Dr. Vivekanandan, but we will have her back at our future one. But thank you everybody for joining in. Uh, video recording will be shared and posted on the link as well. Thanks everyone. Have a good one.