There has been a great deal of attention focussed on the West African Ebola outbreak in recent weeks, especially since there have been a small number of imported cases in to developed countries (only one of these was an unknown case, in Dallas). It is worth pausing for a moment, before going on to spare a thought for the West African countries that have been battling the outbreak for the last year in a setting of extremely poor infrastructure and resources with a poor and sluggish world response. Today I’m joined by Dr David Holland, Clinical Director Infection Services to give you an up-to-date account on a number of issues related to Ebola and CM Health’s response.
What is Ebola?
Ebola Virus Disease (EVD) has been known about for decades and is one of the viral haemorrhagic group of viruses with a high mortality. In the past outbreaks have been relatively small and limited to rural villages and towns, and infection control measures have succeeded in controlling it. The difference this time is that the virus has entered an urban environment, with more opportunities to spread in poor living environments and ignorance of medical science. The maximum incubation period is 21 days after last exposure. The individual will not develop Ebola after that time.
How does it spread?
We know how this virus spreads. It is by exposure to blood-contaminated body fluids (one of the primary manifestations of this illness is bleeding). However, it is important to know that in the initial stages of the illness patients do not manifest these problems but experience flu-like symptoms with fever, muscle aches, headache followed by gastro intestinal symptoms before bleeding occurs later. Therefore the infectivity of a patient in the early stages is very small in normal social interactions. The need for personal protective equipment at this stage is as a standardised procedure to be cautious. The risk to anyone in the community and healthcare workers not immediately caring for patients in the later stages of Ebola is miniscule. However, this issue raises trepidation especially with the degree of media focus.
What is the risk of a patient presenting to New Zealand and Middlemore?
To borrow a risk assessment from our security services as to the risk of a terrorist event, the risk is “unlikely but possible”. The numbers of people currently infected in West Africa have increased (about 5000 current cases in a total population of 30 million) and are likely to increase further. About 30 people per month have come from that part of the world into New Zealand in recent times – mainly New Zealanders who work there and go and return – this number may be decreasing as events unfold. I am unaware of specific at-risk groups in West Africa but I would guess it is among the poorer and socially deprived and ex-pat New Zealanders may be less likely to be infected. In contrast the US receives 4500 people from Ebola affected countries per month.
Why is Middlemore Hospital one of the four main centres to receive a patient?
Along with Auckland, Christchurch and Wellington, Middlemore is designated one of the lead hospitals in managing any future Ebola patient. According to a long-established protocol Middlemore Hospital is the designated receiving hospital for an ill-traveller from Auckland Airport. Therefore, shortly after WHO (World Health Organisation) issued a global alert, regional discussions took place and Middlemore started preparing. Guiding principles from the start have been:
- that there should be a suitable physical facility appropriate to the isolation and care of patients away from general hospital patients and staff – the biocontainment unit (BCU)
- that appropriate PPE (personal protective equipment) be available appropriate with the task
- and most importantly stringent infection control protocols be in place with BCU staff fully trained for the safe application of infection control and putting on and taking off of PPE
Minimisation of general staff risk
Our approach in the design and refinement of our protocols has been to minimise, as much as possible the involvement of the general staff of the hospital. How are we doing this? Potentially exposed individuals – essentially those who have been in Sierra Leone, Liberia, or Guinea are identified on entry to NZ. They are screened for any sign of illness and given written instructions on what to do immediately if they become unwell. Those instructions say to ring Healthline or their GP and an ambulance will be arranged to transport them from their home directly to the BCU, hence bypassing the Emergency Department. The patient will be met by Infection Disease specialists and escorted into the unit and investigation and management commenced. If somehow this clear advice is circumvented and the person presents to the ED triage desk there is signage asking them to declare their travel history immediately and they will be ushered into isolation without delay. Infection Disease physicians will be alerted, arrive and escort the patient to the BCU with necessary precautions. Practical guidelines, including scripts for staff and patient information are being rolled out. A number of simulation exercises have been conducted and more are planned. There are scenarios that can be imagined and are being worked through, but risk needs to be kept in perspective.
Patient care in the BCU
Once the patient is in the BCU they will be cared for exclusively by trained staff – essentially Infection Disease specialists and trained nurses under continuous monitoring and assistance by the Infection control team. Involvement by other specialties is to be minimized as much as possible. Clinical discussions can occur in the BCU. The rooms have windows and intercom from areas where staff can communicate from a safe area to those inside, without need for entry. Again unlikely scenarios can be constructed but as far as possible escalation of care will be carefully evaluated and balanced to avoid futility and unnecessary risk to staff. Disinfection and cleaning procedures for the BCU unit have carefully been considered and include the use of a hydrogen peroxide vapour system (Bioquell™). The BCU will be a valuable resource in future for other infectious diseases that may be introduced such as the current MERS virus (Middle-Eastern respiratory system)
Questions from America
The Dallas hospital experience has prompted some concerns. Some have chosen to interpret events by suggesting the virus is airborne. There is no evidence for this but what is emerging from investigations is that a far likelier explanation is the level of training and infection control procedures with the equipment used was inadequate – with clear breaches identified. These are salutary lessons and re-emphasize our approach of a specific unit, appropriate protective equipment and proper training.
The response to the current Ebola episode is playing out very similarly to scares in recent years – Bird Flu, SARS, H1N1 flu with similar media attention and medical and nursing professional concerns. As in the case of SARS – consistent, stringent application of infection control principles will control this outbreak – it is sad that the area of the world suffering this scourge has such poor resources to manage it and hopefully the world is waking up to what is needed.
Dr David Holland, Clinical Director Infection Services
It’s clear to see that a lot of work has been put in to the planning and organising for an Ebola contingency over the last couple of months. I would like to thank all those involved particularly David, Stephen McBride and the rest of Infection Diseases, management, engineering, microbiology and infection prevention and control.
In the next week or two a lunchtime session involving Q&A will be organised for interested staff to attend.