Ebola Virus Disease (EVD) Information available as of March 2016

Reservoir and transmission to humans Researchers believe that the virus is animal-borne and that bats are the most likely reservoir Bats infect chimpanzees, gorillas, forest antelopes, porcupines Humans handle and eat bush meat (bats, chimpanzees, gorillas) Infected human passes from person to person Ebola is not a new disease – discovered 1976 Before the current situation, outbreaks have appeared sporadically in Africa. Source Pubic Health Ontario, Presentation Sept 2, 2014, and CDC

Areas Affected West Africa Guinea Sierra Leone Liberia Source MOHLTC

Ebola in West Africa Outbreak Distribution Map Source: CDC accessed March

WEST AFRICA Source accessed October

Context for Outbreak in Africa Widespread on multiple fronts Affected large cities Weak and fragile infrastructure Lack of knowledge of the disease Distrust of government and foreigners Not seeking health care Social rituals / burial rituals From Pubic Health Ontario, Presentation Sept 2, 2014,

Key Facts Most infected individuals likely to have known exposures (not unrecognized exposures) Other diseases associated with travel to these areas are more likely. Examples are: malaria, influenza, meningococcal, typhoid fever Source: Ministry of Health and Long-Term Care & Public Health Ontario August 28, 2014

Transmission of EVD Incubation is 2 to 21 days (usually 8 – 10 days) Patients are only infectious when symptomatic Patients are increasingly infectious as they get sicker Source: Ministry of Health and Long-Term Care & Public Health Ontario August 28, 2014

Transmission of EVD EVD is associated with a high fatality rate. Although the risk in Canada is low, those most at risk are individuals recently returned from affected countries/areas in West Africa and health care workers who manage patients with EVD. Transmission of EVD can occur: Directly through contact with blood and or body fluids or droplets. Body fluids include: urine, saliva, stool, vomit, sweat, tears, breast milk and semen. Contact with patient care equipment or surfaces contaminated with blood and/or body fluids, and Possibly through generation of aerosols created during aerosol generating procedures Source MOHLTC Directive # 1 for Hospitals Revised August 27, 2015

Clinical Manifestations The symptoms of EVD include: Fever Severe headache Muscle pain Diarrhea Vomiting Sore throat Abdominal pain Unexplained bleeding Source MOHLTC Directive # 1 for Hospitals Revised August 27, 2015

WHCA Hospitals Designated as Screening Hospitals The Ministry of Health and Long Term care has implemented a 3 tier system of care for EVD or Suspect Patients: 1. Screening Hospitals 2. Testing Hospitals 3. Treatment Hospitals WHCA hospitals are designated as Screening Hospitals As Screening Hospitals we are expected to screen, isolate and transfer any patient identified as being at risk for EVD (no testing will be done at any of our sites)

Screening in Place - Passive Signs are posted at entrances asking patients if they have travelled or had contact with someone ill who has travelled and if they feel unwell to clean their hands, put on a mask and go to registration

Infection Prevention and Control – Active Screening Active: All patients registering (emergency, admissions and clinics including OBS) are asked regarding travel and if they answer yes to travel to a country “of risk” they will be asked regarding any symptoms. After hours, nursing at NWHC will conduct screening via the after hours phone

Screening at Registration Points, After Hours Obstetrical and Emergency Countries of Risk Guinea Sierra Leone Liberia Symptoms of Risk Fever Severe headache Muscle Pain Diarrhea Vomiting Unexplained bleeding Sore throat Abdominal pain This tool is available at registration areas, in the emergency departments and in the inpatient areas as a resource for screening for travel areas of risk and symptoms of risk

Active Screening – Process If An Individual At Risk Is Identified If the patient has travelled but has no symptoms, they are not considered at risk. Remember EVD can only be transmitted when the patient is symptomatic If the individual registering the patient identifies a patient that answers yes to travel and yes to symptoms, they will immediately notify the emergency department to prepare a room to further assess the patient. They will ask the patient to put on a mask and clean their hands, continue the registration process and ask the patient to remain at the registration area. The patient will be informed that because of their travel history and symptoms they will be moved to the emergency department to be seen

Individual at Risk is Identified The emergency department will prepare the emergency room removing non essential equipment as follows: Room 7 PDH, Room 3 LMH, Room 3 GMCH and obtain the Ebola kit The emergency nurse will clear the transportation route of any visitors, patients or other health care providers They will escort the patient to the emergency department room wearing PPE (required PPE will be noted in another slide) Routes for moving the patient to the ER department are located in the Ebola policy and procedure and Ebola kit Housekeeping must be contacted to clean the registration and transportation route once the patient leaves this area

Infection Prevention and Control Practices – Patient Placement Emergency As with all patient interactions HCW’s must perform a risk assessment (to determine exposure risk prior to patient contact). Place in a room by themselves using Droplet + Contact Enhanced Precautions. Place signage on the door and pull the checklist in the Ebola kit for step by step instructions

Patient Placement - Emergency Equipment must be dedicated to the patient - ideally use disposable equipment when possible. Nothing leaves the room unless it is appropriately cleaned and disinfected Close the door to the room (if able) – entry is limited to essential care providers only. Volunteers or students (except Senior Residents and Fellows) should not be involved in the management of a suspect EVD patient The patient must not use the public bathroom. They must use a dedicated commode – Hygie bags are included in the Ebola kit. The patient should not leave the room

Care of Patient – WHCA Designated as Screening Hospitals Only If after further assessment by a physician, the patient is deemed to be a suspect case of Ebola Virus Disease, the following will be notified immediately: Administration on call, Public Health, Public Health Ontario, Infection Prevention and Control and an Occupational Health and Safety Rep All persons entering room must sign entry log (in kit) Arrangements will be made through Criticall to transfer the patient to a designated testing or treatment hospital

Care of Patient - Emergency No lab samples will be drawn or tested on site No aerosol generating medical procedures will be performed. For example: no nebulized therapies, no suctioning, no intubation, no bag mask ventilation

Patient Care The number of Health Care Workers in contact with the patient should be minimized Two registered nurses are required for providing care at all times; they must have no other duties. The two nurses do not need to be in the room at the same time and all of the time In addition, a trained observer must be present to monitor health care worker activities and wellbeing. They will ensure strict adherence to donning and doffing of PPE procedures. A manager or supervisor must be available on site at all times Visitors are limited to pediatric cases. These visitors must be trained on PPE procedures

Personal Protective Equipment as per Ministry Directive #1 Revised August 27, 2015 Screening (beyond registration point if no barrier present)/Triage Fit tested seal checked N95 respirator Full face shield Gloves (nitrile) Fluid resistant gown

Personal Protective Equipment as per Ministry Directive #1 Revised August 27, 2015 Suspect/Confirmed Case and/or the patient environment or touching anything that may be contaminated with the patient’s blood or other body fluids Fit tested seal checked N95 respirator Fluid impermeable lower leg/foot coverings Full length face shield Fluid impermeable gown with cuffs Full head covering Double extended cuff nitrile gloves (one under and one over gown cuff ** PPE should ensure no exposure of the skin, hair or clothing

Patient Care Three Zones Designated There are 3 zones designated for the care of a suspect Ebola patient 1.The cold (clean) zone which is the area outside of the patient room or in the hallway 2.The warm zone is near the exit of the patient room or in the anteroom if one is available and is potentially contaminated 3.The hot zone is the area within the patient room and is considered contaminated PPE will be put on in the cold zone and will be removed in the warm zone at the doorway/exit of the room or in the anteroom if one is available

Donning/Doffing PPE A trained observer must be present to instruct health care workers how to don (put on) and doff (remove) PPE. The trained observer will follow a checklist and read aloud step by step instructions Trained observers will receive specific training on their role Any health care worker required to wear PPE for EVD will be trained on donning and doffing PPE and will have practice drills to ensure they are competent in this task If PPE becomes heavily contaminated with blood or other body fluids, health care workers must remove PPE in the warm zone and don fresh PPE as per hospital procedure

Patient Equipment Disposable dishes will be used Housekeeping: No special cleaning agent is required – hospital approved disinfectant is effective against the virus Environmental workers will wear the same PPE as other health care workers entering the room Waste Biohazardous waste pails will be used for all waste Special procedures for waste handling are required Linen All linen of a suspect case will be discarded

Patient Equipment and Sharps Disposable equipment will be used when possible. No equipment will leave the room unless it is appropriately cleaned and disinfected Sharps Extra care must be taken when handling sharps Safety engineered needles MUST be used Sharps must be disposed at the point of care by the individual using it Perform essential procedures only. If initiating IV access the most experienced individual should perform this task only if deemed medically necessary

Patient Transportation The patient will be transported to a testing or treatment facility in collaboration with Criticall Patient to remain in the room at all times – except for transfer to a testing or treatment facility The person exiting the room must remove PPE in the anteroom/patient room and applies new PPE if assisting in transport The person receiving/transporting the patient receives the patient in the hallway wearing PPE The patient must wear a mask during transportation

Final note – things change The outbreak is evolving and new information continues to be released Our goal is to keep everyone safe, informed and to be prepared Watch for any updates

Questions ….. Contact Infection Prevention and Control or your Manager