1 Emerging Diseases of Concern Health and Human Resources Subpanel Governor’s Secure Commonwealth Initiative October 2014

2 Enterovirus D68 Enterovirus D68 (EV-D68) is one of more than 100 non-polio enteroviruses EV-D68 can cause mild to severe respiratory illness. EV-D68 likely spreads from person to person when an infected person coughs, sneezes, or touches contaminated surfaces.

3 Enterovirus D68 in United States From mid-August to October 15, 2014, CDC or state public health laboratories have confirmed a total of 780 people in 46 states and the District of Columbia with respiratory illness caused by EV-D68.

4 Enterovirus D68 in Virginia As of October 15, EV-D68 lab-confirmed in the Central, Northern and Eastern Regions 66 patients tested for EV-D68 (72 specimens) 35 patients confirmed EV-D68 by CDC or DCLS labs 18 patients had rhinovirus or other enteroviruses 8 hospitals reported increases in ED visits and/or admissions in children presenting with possible EV-D68 St Mary's Hospital – 50% of children admitted required PICU

5 Enterovirus D68 VDH continues to work with any facilities reporting a cluster of illness to facilitate lab testing where appropriate. VDH will continue traditional and enhanced surveillance to characterize the nature of the illness and these clusters.

6 Seasonal influenza Influenza comes to Virginia every year Season is October – May Usually peaks December – February This year, we can expect to see multiple flu viruses circulating Influenza A/H3N2, 2009 Influenza A/H1N1, Influenza B Influenza can have a large impact, especially in group residential settings

7 Virginia’s Flu Season_Insert Updated Slide Recent uptick in Flu B Peak activity week ending 1/18/2014, widespread for 11 weeks, 30 outbreaks

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9 Flu vaccine composition unchanged… trivalent influenza vaccines protect against the following three viruses: A/California/7/2009 (H1N1)pdm09-like virus A/Texas/50/2012 (H3N2)-like virus B/Massachusetts/2/2012-like virus Quadrivalent vaccines also protect against: B/Brisbane/60/2008-like virus

10 Flu vaccine recommended for… All persons aged 6 months and older should be vaccinated annually. Vaccination of persons at high risk is especially important to decrease their risk of severe flu illness.persons at high risk People at high risk of serious flu complications include young children, pregnant women, people with chronic health conditions like asthma, diabetes or heart and lung disease, and people 65 years and older.young childrenpregnant womenpeople 65 years and older Vaccination also is important for healthcare workers, and other people who live with or care for people at high risk to keep from spreading flu to those at high risk.healthcare workers Children younger than 6 months are at high risk of serious flu illness, but are too young to be vaccinated. People who care for them should be vaccinated instead.People who care for them

11 Other Emerging Infections Middle East Respiratory Syndrome Coronavirus (MERS-CoV) May 2, 2014 – first U.S. imported case (IN) May 11, 2014 – second U.S. imported case (FL) Unrelated cases; both from Saudi Arabia Avian Influenza A H7N9 in China Both diseases still need to be considered in ill travelers from affected countries. DCLS has ability to test in-house.

12 Virginia’s Preparedness for Ebola Virus Disease (EVD) Health and Human Resources Subpanel Governor’s Secure Commonwealth Initiative October 2014

13 Ebola: The Basics Ebola virus is a type of viral hemorrhagic fever. Virus spread person to person mainly by direct contract with bodily fluids (blood, feces, vomit), less commonly by contaminated items (needles). Ebola is a severe and often fatal disease; begins with acute fever, progressing to multi-organ involvement. Infected person is contagious only after symptoms develop (usually 8-10 days (range 2 to 21 days) after exposure). Persons (healthcare workers, household members) caring for person acutely ill with Ebola are at highest risk of being infected.

14 Ebola in Africa and the United States Mar 2014: Outbreak began in Guinea Aug 8: WHO declared international public health emergency Sep 30: First case diagnosed in US (Texas); traveler left Liberia Sep 19, arrived US Sep 20, and became symptomatic Sep 24 Ongoing outbreaks in Guinea, Liberia, Sierra Leone. Limited but now contained spread in Nigeria. Now limited spread in the U.S. Sporadic detection in 2 other countries. 8,997 total reported cases and 4,493 deaths (Oct 12) Image source: CDC (October 10, 2014)

15 EVD Control Measures: Based on Established Core Public Health Actions Surveillance Disease reporting Communication Investigation Implementation of control measures Risk communication

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17 Statewide Hospital Preparedness Program Regional Healthcare Coordinators develop their regional plans, polices and governance structure under the oversight of their Regional Healthcare Coalition Regions operate Regional Healthcare Coordination Centers (RHCC) VDH provides the framework for statewide administration of HPP VDH works through the Virginia Hospital and Healthcare Association (VHHA) to coordinate governance and initiatives to 6 Healthcare Coalitions with 300+ participating facilities

18 Three EVD Scenarios to Consider in Virginia I.Individual arrives at Virginia airport (Dulles most likely) with symptoms consistent with EVD (or likely exposure) and travel history to affected areas II.Individual presents to Virginia hospital with symptoms consistent with EVD and a travel history to the affected areas III.Individual with EVD identified in another state but had contact with Virginians

19 I. Person Arrives at Airport Active planning over many years with CDC’s Division of Global Migration and Quarantine (DGMQ) for arrival of person with communicable condition Airlines trained to notify DGMQ of ill passengers. Captains have a legal responsibility. Entry screening will begin at Dulles 10/16/14. Initial protocols developed Includes communication with local and state public health, EMS and hospitals

20 Dulles Scenario, continued: Four scenarios: 1.Person has fever and symptoms consistent with EVD Transport by Airport EMS to accepting hospital 2.Person has no history of EVD exposure but is febrile/symptomatic Assessment and, if appropriate, hospital evaluation 3.Person has history of EVD exposure but no symptoms CDC would provide a conditional release. State may issue quarantine order. 4.No exposure history AND no symptoms Released with information sheet

21 II. Person Presents to Virginia Hospital Hospital staff perform assessment and implement isolation Hospital staff report to and consult with local health department and follow the steps for testing approval within VDH and with Virginia’s State Lab, DCLS DCLS would test patient samples and forward portions to CDC for additional testing

22 If Patient Tests Positive Case patient remains in isolation at hospital. VDH initiates investigation includes contact tracing - something we do very regularly. On a daily basis, VDH staff would assess contact’s compliance with monitoring. If activities of well contacts need to be restricted, the VDH district health director would make that recommendation to the Commissioner. Commissioner would need to decide on quarantine order issuance

23 Layers of Offense and Defense Public health and health care efforts in West Africa to get the outbreaks under control Exit screening at airports in West Africa Entry screening at airports in the United States Early identification and isolation of persons presenting with EVD in the United States Aggressive contact investigations and measures to prevent the spread of EVD infection in the United States

24 Quarantine Orders Legal authority exists for State Health Commissioner to issue orders of quarantine for disease threats If non-compliant with voluntary agreement, or If such order is necessary to control the disease Letters for EVD-related voluntary quarantine and orders for the two mandatory quarantine scenarios have been drafted

25 Quarantine (continued) For persons under order: law enforcement help with delivery least restrictive setting (home quarantine wherever possible) daily monitoring for compliance assurance that essential needs are met will require support and leadership from local jurisdiction, particularly local DSS. Ex parte court review required and person has right to challenge the order

26 III. If Virginia resident is exposed to a case in another state Once VDH receives such notification, efforts will begin immediately to locate the exposed person(s) Once located, the person will be asked about exposures and any symptoms of illness if well and exposure confirmed, VDH will actively monitor symptoms daily determine need for Order of Quarantine if ill, VDH will take actions as previously described isolation and testing of patient, assurance of protection of healthcare workers, identification of contacts, interviewing and monitoring health of contacts, providing recommendations for disease control

27 State Health Commissioner Actions Maintain full situational awareness at local, state, national and international levels. Inform and regularly update public, healthcare community, legislators and Executive Branch leadership about significant events/developments Promote hygienic practices and influenza vaccination Evaluate each potential EVD case/contact as a Communicable Disease of Public Health Threat Determine need for individual orders of isolation or quarantine

28 Commissioner (continued) Coordinate efforts with neighboring jurisdictions Direct agency resources to meet local needs Identify need for interagency assistance Declare Public Health Emergency if situation warrants enhanced awareness and communication Request Governor declaration of emergency if an affected area needed to be isolated or quarantined

29 Other Issues Addressed to Date Laboratory testing and transportation of samples Personal protective equipment (PPE) stockpile Emergency medical services’ transportation of patients Medical waste disposition Fatality management Healthcare coalition preparedness and response Decontamination of a home Planning for a call center

30 Summary Ebola is a very serious disease that has not been diagnosed in humans in Virginia before VDH and our health care partners are as ready to respond as we can be today Our staff are trained and capable in the necessary core public health services We will continue learning and sharing as new information is obtained We will assure effective communication within our organization, to Executive Branch leadership, with our partners across the state and in other states and with the public

31 Resources VDH Home Page VDH Ebola Information for Healthcare Providers and Facilities VDH FAQs CDC Ebola Information

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33 High risk exposures Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids of EVD patient Direct skin contact with, or exposure to blood or body fluids of, an EVD patient without appropriate personal protective equipment (PPE) Processing blood or body fluids of a confirmed EVD patient without appropriate PPE or standard biosafety precautions Direct contact with a dead body without appropriate PPE in a country where an EVD outbreak is occurring Low risk/some risk exposures Household contact with an EVD patient Other close contact with EVD patients in health care facilities or community settings. Close contact is defined as being within approximately 3 feet (1 meter) of an EVD patient or within the patient’s room or care area for a prolonged period of time (e.g., health care personnel, household members) while not wearing recommended PPE for standard, droplet, and contact precautions having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended PPE