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IMPORTANT: EBOLA THREAT!

Readiness for emerging infectious disease threats, including Ebola Virus Disease (EVD)

We recently attended a briefing with the Ministry of Health (MOH) on Ebola readiness in New Zealand. The following is a summary of what was discussed however if you want to know more, please have a look at the links below and if that still does not satisfy you, let us know.

You should also be aware of what your employer has in place to protect you and your colleagues from the risk of infection, should you be involved in the care of, or in contact with the body fluids etc. of a patient affected (or potentially affected) by Ebola.

Before we go further – do you HAVE to be involved in the care of a patient with a disease such as Ebola where there may be a personal risk to you?  This question may have been “muddied” by CMDHB recently suggesting they would call for “volunteers” should an Ebola patient be admitted to their facility.  Also to put in context, whilst doctors and nurses may have a patient in front of them who is so identified, many of you may not know that what you are working with has an Ebola risk associated with it – Laboratories would be a case in point where perhaps (not a current plan but for the sake of example) a blood sample seeking to determine potassium levels in a patient with fever and diarrhoea could be….

There is a balance here between your rights as an employee and therefore the employers (and your own) responsibility under health and safety legislation to minimise risk, and the fact that it is your job to care for people who are ill.  In the lab example, all specimens are normally treated as infectious – because whether Ebola, HIV, H1N1, TB, meningococcal…. We may not know until the lab itself does the diagnosis (and maybe not even then).  So standard protection protocols are in place… which brings us on to the answer for the primary question.  Our view is that yes you can be required to treat a patient IF the employer takes all reasonable steps to ensure your safety.  In the case of Ebola, whilst much has been said about health care workers being infected, we must remember that this has largely been in countries where protection for the helpers has been minimal, and in the case of the nurse in Dallas, where they failed to use the protective equipment provided properly.

For your information, this is some of the advice the NZ Medical Council has given doctors which may be pertinent to the wider health professional audience.

  • As long as the doctor has access to and uses the correct personal protective equipment, has the appropriate assistance to use the equipment, and understands and is versed in the necessary infection control practices of the institution, the Council expects the doctor to be able to treat any patient with Ebola or any other infectious illness.
  • Overseas experience has clearly shown that health care workers can safely provide care to patients with Ebola as long as the health care workers adhere to the strict protocols in the use and disposal of personal protective equipment at all times.
  • Any departure from the established protocols places not only the doctor at risk, but also the community at large. A deliberate departure could be considered unethical.
  • Council does not expect any doctor to deliberately put themselves in danger to treat a patient in an emergency; therefore no doctor should risk exposure to Ebola if personal protective equipment is inadequate or not available. Similarly it is clear that the correct use of personal protective equipment includes appropriate assistance to both don and remove the equipment. A lack of such support would place the doctor at unacceptable personal risk.
  • It is good medical practice for all doctors to be aware of the infection control policies and practices in their places of work.

The risk of contracting Ebola if the correct personal protective equipment (PPE) is used and used correctly is reportedly very low.  Plans are underway to form identified staff groups for Ebola response and case management in NZ and senior staff will be identified to lead these teams. However if you might be called on to care for a patient, please take this opportunity to check with your DHB as to when your training will occur, or for confirmation that you will not be required to be involved in care.

It goes without saying that if you have not been trained, you cannot be required (and should not) risk exposure.  So we suggest that rather than wait for your DHB to come and ask you, be proactive and ask them where their planning is at:

  • Who is on the staff list of those who might be involved in care; and
  • if you are on it, where is your training?
Bigger Picture

The risk to New Zealand of a patient with Ebola reaching us remains low.  New Zealand is isolated by travel time, distance and low numbers of travellers to and from affected countries; however that doesn’t preclude us from being prepared.

And being prepared is key.  Countries that have had Ebola transmission have been able to clear themselves of disease e.g. Senegal had an imported case and was subsequently cleared of infection.  In the words of WHO “an immediate, broad based, and well-coordinated response can stop the Ebola virus, carried into a country in an infected traveller, dead in its tracks.”

Click here to view full a copy of the Under the Microscope Issue31

Some facts about Ebola:

  • Infection can only be acquired through contact with infected blood or body fluids from symptomatic individuals.
  • The incubation period is 2-21 days, usually between 8-10 days.
  • Individuals cannot infect others until they have symptoms so it is not like the Flu where we can shed virus and infect others up to two weeks before we get any symptoms (hence increased need for Flue vaccination!).
  • As the illness develops, so too does infectivity.
  • Ebola is not airborne and not as infectious as flu or measles.  WHO advises that there is also no evidence that viruses such as Ebola change their mode of transmission – i.e. that it will suddenly become infectious through an airborne route?

What is NZ doing?

First we have pre-screening of all passengers at the border.  NZ Customs is checking passengers travel histories and passengers are also being asked to self-declare. Any risk including a level of uncertainty is being referred to public health for further investigation.

We have a setup with Australia to do Ebola testing.  It makes sense to limit the number of labs doing this testing to get a level of clinical expertise as well as limiting potential sources of exposure and risk of spread through poor “waste management”.  That does not mean Labs won’t have samples from patients with Ebola should we get a case here however (note the “process for patient management” below).

An Ebola Technical Advisory Group has been formed to lead and advise best practice.

Professor John Crump, ID physician, microbiologist, previous experience as a US CDC Epidemic Intelligence Service Officer

  • Dr Mark Beale, GP and ID physician, prior experience as head of Viral Haemorrhagic Fever unit
  • Dr Colin McArthur, Intensive Care Specialist
  • Dr Deborah Williamson, Microbiologist

PPE

The latest Centre for Disease Control (CDC) guidelines for those caring for and treating Ebola patients is - no skin exposure.  Staff members who are a part of the Ebola care and response teams will need to have adequate training about Ebola, and the correct use of PPE.  Middlemore Hospital has elected to use a one piece suit to reduce the risk of contamination, other DHB’s are yet to formalise plans.  To reduce the risk of infection, a buddy system must be used to ensure the correct removal and disposal of contaminated PPE i.e. one disrobing, one watching to ensure they do so safely.

Laboratory TestingAs we say, Ebola confirmation testing by PCR will be undertaken by one laboratory in Australia.  The majority of testing will be done in the patient’s room by Point of Care Testing (POCT).  Further planning around the testing and disposal of samples that have reached the laboratory prior to diagnosis, or for testing for supportive therapies is underway, we have requested details of this be supplied to us also.  Be aware of any requirement to QA POCT that may be used or of any implications around waste management the arise from the POCT equipment.

Waste management of contaminated blood/ body fluids/ samples

Whilst planning around waste disposal for the isolation units has been made, further planning for waste disposal in other areas is unclear, we have asked for further details of this to be provided to us.

Process for patient management

From first presentation, patients (and contacts as necessary) will be “contained” in negative pressure rooms at the local DHB and assessed by a clinical team on site.  Special training for individuals involved in this front line should be underway by now (but if it is not, please let us know).  The local medical officer of health will be notified who will then coordinate between the referring and subsequent receiving specialist unit/hospital (Middlemore, Auckland, Wellington or Christchurch).  Ambulance transfer will occur to the receiving unit.

If a patient is identified in the community, again transfer to the local hospital’s negative pressure facility and thereafter to the specialist unit will occur.Sites for treatment of suspected and confirmed Ebola patients

Middlemore Hospital (located close to the airport) is set up to take all suspected international travellers, and to be the main treatment centre.  We have toured this facility and can confirm they appear to have thought of everything – right down to the possibility that an Ebola patient may simultaneously have appendicitis so what would we do? Other treatment sites (we have not yet had the opportunity to check these out) are as follows:

  • Auckland City Hospital
  • Wellington Hospital
  • Christchurch Hospital

Useful Links if you want to know more:

Click here to view full a copy of the Under the Microscope Issue31

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