Washington State Ebola Response: From Identify, Isolate and Inform to Frontline, Assessment and Treatment Scott Lindquist MD MPH State Communicable Disease Epidemiologist for Washington State Region 9 Healthcare Coalition Ebola Symposium

Ebola virus disease The current outbreak Monitoring travelers from Ebola-affected countries Healthcare facility and laboratory preparedness Overview

Virus of the family Filoviridae, genus Ebolavirus Discovered in 1976 near Ebola River (DRC) 4 of 5 subspecies cause disease in humans Ebola virus (Zaire ebolavirus) Sudan virus (Sudan ebolavirus) Taï Forest virus (Taï Forest ebolavirus) Bundibugyo virus (Bundibugyo ebolavirus) Bats are most likely reservoir Occurs in animal hosts native to Africa Ebolavirus Source: CDC

fever (>101.5°F) headache, muscle pain weakness diarrhea, vomiting abdominal pain lack of appetite rash red eyes cough, hiccoughs sore throat, chest pain difficulty breathing or swallowing, unexplained bleeding inside and outside of the body Symptoms Typically Include Symptoms Can Include Ebola Virus Disease Symptoms

Spread through direct contact--through broken skin or mucous membranes-- with: a sick person's blood or body fluids: urine, saliva, feces, vomit, and semen objects--such as needles that have been contaminated with infected body fluids infected animals Transmission of EVD

Supportive care balancing the patient’s fluids and electrolytes maintaining their oxygen status and blood pressure treating them for any complicating infections Experimental therapy ZMapp: monoclonal antibodies TKM-Ebola: RNA interference drug Human plasma Treatment

Ebola Virus Outbreaks, 1976–2008

The Outbreak

Current Outbreak in West Africa* Largest outbreak to date > 25,907cases > 10,736 deaths Widespread transmission in Guinea, Liberia & Sierra Leone Healthcare workers and close contacts of cases at highest risk No definitive treatment or vaccine, only supportive care Areas affected by 2014 outbreak *As of November 14, 2014

Level 3 Warning: Avoid Nonessential Travel Guinea Liberia Sierra Leone CDC Travel Notices

Exit screening in Ebola-affected countries Entry screening in 5 US airports Travelers need to enter US via these airports Completion of declaration form & temperature screen Distribution of “CARE” kits Contact information electronically transmitted to DOH Monitoring of travelers in Washington by LHJs Travel Screening In Washington State

WA State Monitoring of Travelers Exposure Risk Category LHJ Type of Monitoring Restrictions on Movement High risk (e.g., direct contact with infected body fluids) Direct Active Monitoring Yes – Public Health Order for Restrictive Movement; involuntary home quarantine order if contact refuses to adhere to restrictions Some risk (e.g., close contact with a person showing symptoms of Ebola; direct contact with an Ebola patient in Africa while wearing appropriate PPE) Direct Active Monitoring Not routinely unless risk assessment warrants additional restrictions. See “some risk” letter template for further voluntary restrictions Low but not zero risk (e.g., been in a country with widespread Ebola transmission but no known exposures; direct contact with an Ebola patient in US while wearing appropriate PPE) Direct Active Monitoring for US based healthcare workers Active Monitoring for all others No

Travelers Monitored since September 196 (9 Spokane, 1 Lincoln, 1 Okanogan, 1 Stevens) Travelers currently being monitored 10 Total tested for Ebola 1 WA State Monitoring of Travelers

Outpatient / ambulatory care settings Rapidly identify, safely isolate & transfer patients Ebola assessment facilities Rapidly identify, isolate, evaluate & safely provide short-term care (if necessary) to patients Ebola treatment facilities (e.g., tertiary hospitals) Rapidly identify, isolate & safely provide ongoing care Need dedicated and adequate treatment areas, highly skilled and trained staff, appropriate equipment and excellent infection control procedures Levels of Healthcare Facility Preparedness in Washington State

1.Treatment facilities– 3 hospitals 2.Assessment facilities– 8-9 hospitals 3.Screening and planning – all hospitals and clinics Plan for Washington

1.CHI Franciscan Health (Harrison Medical Center – Bremerton campus) 2.Providence Regional Medical Center Everett 3.Providence Sacred Heart Medical Center and Children’s Hospital (Spokane) 4.Seattle Children’s Hospital 5.Swedish Medical Center (Issaquah) 6.Evergreen Hospital (Kirkland) 7.UW Medicine (Harborview, UW Medical Center) 8.Peace Health (Whatcom and Vancouver) 9.St. Mary’s (Walla Walla) 8 Hospital Systems Stepping Forward

Performed validation testing for CDC Ebola PCR assay; performed risk assessment Trained staff to perform testing 24/7 Distributed category A shippers to LHJs Trained labs and LHJs to package specimens Testing for Ebola at the Washington State Public Health Laboratories

Traveler from Liberia Designated as low risk Symptoms Abdominal pain Admitted to Hospital A (County A) Admitted to Hospital B (County B) Transfer to Hospital C (County C) Scenario

Questions?