Training structure Safety and good quality work Module 1: Knowledge about Ebola Virus Disease Support from the community Support from the hospital administration Support from the population Module 3: Standard pre- cautions Module 2: Community response Module 6: Water, disinfection and cleaning Module 5: Personal protective equipment Module 4: Triage & isolation EFFO Ebola

Ebola virus disease (EVD) Module 1 - Part II

Learning objectives module 1 (part 2) General objectives To know general information on EVD and be motivated to practice to gain more confidence and skills when dealing with suspected Ebola patients. Specific objectives 1.To know the principle of diagnosis 2.To know the basics of pathophysiology 3.To recognise the bases on the treatment of EVD 4.To know the special challenges when working in an isolation unit

Presentation outline Module 1: EVD Part 1 INTRODUCTION I.Epidemiological situation II.Information about the Ebola virus III.Modes of transmission and incubation period IV.Symptomatology V.Differential diagnosis Part 2 I.Positive diagnosis: PCR, rapid tests II.Pathophysiology of EVD III.Care of cases IV.Work in the isolation area and the stress caused

The diagnosis The definitive diagnosis is carried out in a specialised laboratory In the hospitals, a suspected case must be detected: by the symptoms and by the case definition

Diagnosing Ebola The diagnosis can also be carried out in a mobile laboratory. The laboratory takes about 3 hours to screen for the Ebola virus. This is done by polymerase chain reaction (PCR). Transport can be time consuming. Avoid accidents when taking samples or during packaging and transportation. © RKI Martin Richter

Rapid test Testing and validation in progress. Gold standard: PCR © RKI Martin Richter

Pathophysiology Infection through damaged skin, mucous membranes or parenterally The Ebola virus enters the immune cell (monocytes, macrophages, dendritic cells) Bloodstream carries the infection to the liver to the spleen to the lymph nodes The infection of many tissues The response is individual, the symptoms and complications can be very different

Pathophysiology Secondary infection (low levels of lymphocytes) Septic shock Blood clots Haemorrhage Fluid build-up in the brain (cerebral oedema) Renal failure Hepatic failure Pancreatitis (severe abdominal pain) Intestinal damage leading to diarrhoea and dehydration

Care of patient at MSF - history Médecins sans Frontières (MSF) has a great deal of experience with EVD. Treatment has changed over the years: 1.until 1995: symptomatic treatment 2.from 1995: antibiotic treatment, anti-malarial treatment, palliative care 3.from 2007: invasive treatment, biochemical diagnosis 4.from 2014: experimental drugs (Favipiravir, Brincidofovir, VSV, convalescent plasma)

Care of suspected cases Treatment primarily consists of supportive treatment and symptomatic treatment  At the medical level  At the psychosocial level Always protect yourself  by using PPE  in psychosocial and physical terms (note: working in PPE is hard) Any invasive procedure represents a risk to the health worker who performs it Only perform invasive procedures when absolutely necessary

Patient care (non invasive)  Fever and/or pain -> paracetamol (avoid diclofenac, aspirin, ibuprofen -> effect on platelets)  Diarrhoea, vomiting -> food on demand  Signs of hypoglycaemia: -> sugary drink  Treatment of other problems -> broad spectrum antibiotic, anti-malarial treatment

Patient care (invasive procedures)  Diarrhoea, vomiting, signs of dehydration -> intravenous rehydration  Signs of hypoglycaemia: sugary drink if possible or i.v. D50  Seizures: intravenous or intrarectal diazepam  … (Transfusion of whole blood, platelets, dialysis, experimental treatments)

Experimental treatments of EVD Examples of drugs: -Monoclonal antibodies (ZMapp) -Convalescent plasma -Antivirals (Favipiravir, Brincidofovir) -RNA-based antivirals (siRNA) -Immunostimulants -Anti-haemorrhagic (FX06) -Anti-coagulant (rNAPc2) -Several candidate vaccines are under development and being tested (VSV) The main problems: evidence of benefit for patients availability Symptomatic and non-specific treatment is still the mainstay of treatment of EVD

The patient’s diet Meals are served in appropriate and individualised containers Plates are washed and decontaminated Always include vitamins in the treatment Families can also deliver food to their relatives, but the food needs to be handed over to the patient by a health worker in PPE

Treating EVD The best practices for patients are evolving! -Medication -Diet -Experimental treatments -Vaccine candidates are being tested -> Discuss the case with colleagues and the authorities responsible to determine the treatment plan

The stress caused by Ebola Physical fatigue Physical isolation (not allowed to touch others) Constant awareness and vigilance required May be contaminated or may contaminate others Fear of dying Tension between public health priorities and the needs of the patient Stigmatisation Consequences in communities and families  These are some of the challenges for health workers and patients  Explain every procedure and gesture to the patient to reassure them (permanent dialogue)

Procedure in case of a suspected case -Triage -> suspected case identified -Patient is isolated immediately (distance of > 2 metres!) -The suspected case is communicated to the persons responsible -Contacts are documented (epidemiology) -The isolation unit is enabled -The team in PPE can take care of the patient A patient with typical symptoms of EVD and with a very suspicious story comes to your health facility The patient doesn´t scare me!

Working in the isolation unit -Always in pairs (1 “clean” and 1 “dirty” person) -Know/discuss what to do before putting on PPE (communication is more difficult and you cannot stay in the PPE for more than 1 hour) -Prepare medicines, food, waste bag, etc. If you forget something, you can’t turn around easily (one way flow in the isolation unit!) -Don’t forget documentation (warning, the document stays in the red zone) -Person responsible in the green zone to give instructions for decontamination needs to be ready

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