Monday, December 18, 2017

OCMA Blog

Updated Ebola Guidance from the OC Health Care Agency

The Ebola epidemic of West Africa has led to 13268 cases as of November 7, with 8168 confirmed cases and 4960 deaths. The epidemic seems likely to continue for at least the next several months. There still have been no suspect Ebola cases in Orange County.

To date, there have been no confirmed Ebola cases in California.
 The Orange County Health Care Agency will be monitoring persons returning from countries with widespread Ebola virus transmission (currently Liberia, Guinea, and Sierra Leone) or who have had contact with a confirmed Ebola case within the previous 21 days.  The risk of Ebola in the U.S. remains low, and the risk of a symptomatic (infectious) patient that we are not following presenting unannounced for health care is even lower, but something we all continue to prepare for.  The following recently released documents may be of assistance to you in your preparations:

1)      Algorithm for Ambulatory Care Evaluation of Patients with Possible Ebola Virus Disease – CDC document, modified by OCHCA with Orange County contact information (attached)

2)      Algorithm for Emergency Department Evaluation and Management of Patients with Possible Ebola Virus Disease:  http://www.cdc.gov/vhf/ebola/pdf/ed-algorithm-management-patients-possible-ebola.pdf 

3)      Web-based training- Guidance for Donning and Doffing PPE during Management of Patients with Ebola in US Hospitals:  http://www.cdc.gov/vhf/ebola/hcp/ppe-training/index.html 

Traveler Assessment
Travelers coming from a country experiencing widespread Ebola disease will be assessed upon arrival to one of five airports in the United States. Information about the traveler will be passed on to local public health departments. The Orange County Health Care Agency will monitor any such travelers in our county daily to assess for symptoms. A hospital will be pre-designated for each of these travelers, based on factors such as a patient’s insurance type and proximity to a facility. That facility will be contacted ahead of time, to assure that the patient receives prompt care if needed. However, it is not certain that this system will identify all travelers from the affected areas, so area hospitals need to be prepared in the event that a suspect case arrives at their facility without prior warning.

Healthcare providers should assess all patients for a history of travel to countries experiencing widespread Ebola disease, which includes Guinea, Sierra Leone, and Liberia at this point. Providers should report any suspect Ebola cases to the Orange County Health Care Agency immediately at 714-834-8180 during regular hours, or 714-628-7008 after hours.

All Orange County hospitals need to prepare to isolate and evaluate a potential Ebola patient.

There is no designated Ebola hospital in Orange County. University of California-Irvine Medical Center has indicated that it will accept one confirmed Ebola case. However, suspect cases identified at a different hospital will need to be cared for at that facility until the case is confirmed, which may take from 24-72 hours. For suspect cases that present to an outpatient clinical setting not associated with a hospital, Orange County Public Health will facilitate transfer of the patient to the closest appropriate facility.

Orange County Health Care Agency can assist with testing a patient for possible Ebola disease.

The test of choice for Ebola is serum PCR. Tests can be falsely negative if performed in the first three days of illness. Patients who test serum PCR negative but have a clinical and exposure history consistent with Ebola may need repeat testing performed. This test is currently performed at selected public health laboratories.

For more information, see http://ochealthinfo.com/phs/about/dcepi/epi/disease/ebola . For healthcare worker recommendations, see www.cdc.gov/vhf/ebola/hcp/index.html. A hospital checklist for Ebola preparedness can be found at www.cdc.gov/vhf/ebola/pdf/hospital-checklist-ebola-preparedness.pdf.

Please let us know if you have any questions.

If you have any comments or questions or would like to be added to the distribution list, please email us at epi@ochca.com 

HCA/Epidemiology & Assessment
1719 W. 17th St., Bldg. C/79
Santa Ana, CA 92706
(P) 714-834-8180
(F) 714-834-8196


Ebola Resources from the OC Health Care Agency

The first case of Ebola Virus Disease (EVD) diagnosed in the United States was confirmed on September 30, 2014 in Dallas, Texas. However, the risk of an Ebola outbreak in the United States remains low. Health care providers should remember to obtain a travel history for any patients with febrile illness, and be familiar with Ebola's clinical presentation and infection control requirements.  Any suspect cases meeting the clinical and epidemiologic criteria for EVD should be reported immediately to Orange County Public Health Epidemiology at 714-834-8180. 


For more information, see www.ochealthinfo.com/ebola

For specific health care-related guidance including infection prevention and environmental infection control precautions, see www.cdc.gov/vhf/ebola/hcp/index.html

To receive alerts, updates and newsletters on communicable disease issues affecting Orange County, email epi@ochca.com.


New guidance from CDC on Ebola

Below message is from the Orange County HCA / Epidemiology & Assessment

Guidance for Safe Handling of Human Remains of Ebola Patients in U. S. Hospitals and Mortuaries (August 25, 2014) 
http://www.cdc.gov/vhf/ebola/hcp/guidance-safe-handling-human-remains-ebola-patients-us-hospitals-mortuaries.html

From Dr. Erin Epson, Assistant Chief / Public Health Medical Officer of the CDPH Healthcare-Associated Infections Program:
CDC has issued Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus, available at: http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html. Although the role of the environment in transmission of Ebola virus has not been established, in this guidance CDC recommends higher levels of precaution to reduce the potential risk posed by contaminated surfaces in the patient care environment “given the apparent low infectious dose, potential of high virus titers in the blood of ill patients, and disease severity.” Disinfection products with higher potency than what is normally required for an enveloped virus such as Ebola are therefore now recommended. Such products include Environmental Protection Agency-registered hospital disinfectants with a label claim for a non-enveloped virus (e.g. norovirus, rotavirus, adenovirus, poliovirus), and would also include bleach solution. In addition, the new guidance recommends that porous surfaces that cannot be made single use (e.g. carpeting, upholstered furniture and curtains) should be avoided in rooms of suspect Ebola virus disease (EVD) patients, and that potentially contaminated textiles (e.g. linens, non-fluid-impermeable pillows or mattresses, and privacy curtains) be discarded as regulated medical waste. This guidance regarding appropriate disinfection products and management of potentially contaminated textiles is different and replaces the environmental infection control elements of the previously issued Infection Prevention and Control Recommendations for Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals.

CDC has also updated a poster depicting the sequence for putting on and removing personal protective equipment (PPE), available at: http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf. This updated poster emphasizes guidance to perform hand hygiene between steps if hands become contaminated, in addition to immediately after removing all PPE. 

There are multiple acceptable sequences and methods for removing PPE. Regardless of the sequence or method used, the important principles are that the most contaminated items are removed first, and that the person removing PPE does not contaminate themselves or others during the process. If two pairs of gloves are used, the most contaminated outer gloves can be removed first and the inner gloves last, in order to limit additional contamination of remaining PPE during removal.  Performing hand hygiene between steps, and especially prior to removal of a mask or respirator, can help prevent contaminating one’s eyes and/or mucous membranes while removing the mask or respirator. Healthcare personnel should familiarize themselves and practice methods of donning and removal of any PPE used, in advance of the time when PPE will be needed. 

Availability of PPE supplies, hand hygiene, and appropriate waste containers at the point needed can be facilitated by placing any suspect EVD patient in a room with an anteroom.  An anteroom is particularly helpful if airborne isolation is implemented and respirators must be removed after leaving the patient room and closing the door. If a room with an anteroom is unavailable, a suspect EVD patient can be placed in a room that is spatially separated from other occupied patient rooms in a low traffic area (e.g., at the end of a hallway), with a designated area for hand hygiene and waste containers outside the room and separate from other patient care areas.

If you have any comments or questions or would like to be added to the distribution list, please email us at epi@ochca.com.


Communicable Disease News: Pertussis Epidemic in OC & Ebola Virus Update

Update on California's Pertussis Epidemic

Pertussis activity continues at epidemic levels in Orange County and statewide.
As of 8/16/2014, 250 pertussis cases have been reported in Orange County, compared with 43 cases at this time last year. Pertussis peaks in incidence every 3-5 years as the number of susceptible people in the population increases; the last epidemic in California was in 2010.

Infants under 12 months of age are at highest risk for severe infection and death. To protect this vulnerable population the following is recommended:

  • Immunize pregnant women with Tdap during every pregnancy at 27-36 weeks gestation. This dose protects mom and provides the infant with high levels of protective transplacental antibodies.
  • Encourage close contacts of infants to be up-to-date with their pertussis vaccine (cocooning).
  • Vaccinate infants and children with DTaP followed by Tdap according to the childhood immunization schedule: http://www.cdc.gov/vaccines/vpdvac/pertussis/recssummary.htm

Diagnostic Testing: Suspect pertussis cases should be tested by nasopharyngeal PCR. PCR is most sensitive within 3 weeks of the onset of the cough (up to 6 weeks for infants). Consider obtaining a CBC: a WBC count that is ≥ 20,000/mm3 with ≥ 10,000 lymphocytes/mm3 in a young infant with a cough illness is strongly suggestive of pertussis infection.

Management of Cases:

  • Treatment: Antimicrobial treatment should begin as soon as possible after diagnosis, particularly in infants. Treatment may lessen symptoms if begun early during illness and will shorten the period of infectivity.
  • Prophylaxis: The CDC and AAP recommend post-exposure prophylaxis for all close contacts of a pertussis case. However, during widespread community outbreaks, OCHCA will focus its efforts on postexposure prophylaxis for high-risk contacts, including infants under 1 year of age, pregnant women, and their contacts.
  • Infection control: Health care workers should use standard and droplet precautions, including a surgical or procedure mask and eye protection when evaluating suspect pertussis patients. Droplet precautions should be maintained until 5 days after the patient is placed on effective therapy, or if no treatment until 21 days after cough onset.
  • Management of cases in school settings: Cases should be excluded from childcare settings until completion of 5 days of antibiotic treatment, from K-12 grade schools until completion of 3 days of antibiotics, and for 21 days if no antibiotic treatment.

Resources:

General pertussis info for clinicians: http://www.cdc.gov/pertussis/
Tdap for pregnant women: http://www.cdc.gov/vaccines/vpd-vac/pertussis/tdap-pregnancy-hcp.htm

Click here for full Pertussis Newsletter.


Ebola Outbreak In West Africa

West Africa has been experiencing a large outbreak of Ebola Virus Disease (EVD) since December of 2013. As of August 15, 2,127 confirmed or suspect cases of disease including 1,145 suspected case deaths have been reported in Guinea, Liberia, Sierra Leone and Nigeria. It was reported last night (August 19) that Kaiser Permanente in Sacramento is testing a patient for suspected Ebloa Virus, aside from that, two United States citizens were transported to Emory University for further care after contracting the disease while caring for patients with EVD in Liberia. Though the risk of Ebola to the United States or Orange County is small, the potential exists for imported disease in persons traveling from countries where EVD is active. Medical providers should keep up to date on this outbreak and know which patients merit evaluation for EVD.

Providers should contact Orange County Public Health at 714-834-8180 (714-628-7008 after hours) immediately upon identifying any patient with potential EVD. Orange County Public Health can assist with assessment and testing of any case meeting the CDC-defined criteria for a Person Under Investigation, which includes:

1. Clinical criteria:

a. Fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, and
b. Additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage

AND

2. Epidemiologic risk factors within the past 21 days before the onset of symptoms, such as:

a. Contact with blood or other body fluids or human remains of a patient known to have or suspected to have EVD or
b. Residence in-or travel to-an area where EVD transmission is active* or
c. Direct handling of bats, rodents, or primates from disease-endemic areas.

Persons who have had direct contact with Ebola cases through healthcare work or social exposure in West Africa are at particularly high risk for developing disease. For further description of risk factors and clinical recommendations to prepare for or manage Ebola, see www.cdc.gov/vhf/ebola/hcp/index.html.

*As of August 15, countries where EVD is active include Guinea, Liberia, Sierra Leone and Nigeria.

Infection Prevention and Control
Standard, contact and droplet precautions are indicated for suspected EVD. Personal protective equipment (PPE) should include gloves, gown, eye protection (goggles or face shield) and facemask. Additional PPE is necessary if copious blood or other fluid is present in the environment, including double gloving, disposable shoe covering, and leg covering. PPE should be discarded on leaving room taking care to avoid contamination when removing.

Laboratory Testing
The diagnostic test of choice for EVD is PCR testing of the blood. The virus is generally PCR-detectable from 3-10 days post-onset of symptoms. If the onset of symptoms is less than 3 days prior to specimen collection, a subsequent specimen will be required to completely rule out EVD. Testing is available through the CDC. Orange County Public Health can assist with assuring appropriate transport of specimens.

For updated information on the outbreak, including countries where EVD is active, go to: www.cdc.gov/vhf/ebola/outbreaks/guinea/index.html.

Contact Orange County Public Health at 714-834-8180 with any questions.


CDC Health Advisory: Guidelines for Evaluation of US Patients Suspected of Having Ebola Virus Disease

CDC HEALTH ADVISORY: EBOLA VIRUS

Summary
The Centers for Disease Control and Prevention (CDC) continues to work closely with the World Health Organization (WHO) and other partners to better understand and manage the public health risks posed by Ebola Virus Disease (EVD). To date, no cases have been reported in the United States. The purpose of this health update is 1) to provide updated guidance to healthcare providers and state and local health departments regarding who should be suspected of having EVD, 2) to clarify which specimens should be obtained and how to submit for diagnostic testing, and 3) to provide hospital infection control guidelines.
 
U.S. hospitals can safely manage a patient with EVD by following recommended isolation and infection control procedures. Please disseminate this information to infectious disease specialists, intensive care physicians, primary care physicians, hospital epidemiologists, infection control professionals, and hospital administration, as well as to emergency departments and microbiology laboratories.

 
Background
CDC is working with the World Health Organization (WHO), the ministries of health of Guinea, Liberia, and Sierra Leone, and other international organizations in response to an outbreak of EVD in West Africa, which was first reported in late March 2014. As of July 27, 2014, according to WHO, a total of 1,323 cases and 729 deaths (case fatality 55-60%) had been reported across the three affected countries. This is the largest outbreak of EVD ever documented and the first recorded in West Africa.  

EVD is characterized by sudden onset of fever and malaise, accompanied by other nonspecific signs and symptoms, such as myalgia, headache, vomiting, and diarrhea. Patients with severe forms of the disease may develop hemorrhagic symptoms and multi-organ dysfunction, including hepatic damage, renal failure, and central nervous system involvement, leading to shock and death. The fatality rate can vary from 40-90%. 
 
In outbreak settings, Ebola virus is typically first spread to humans after contact with infected wildlife and is then spread person-to-person through direct contact with bodily fluids such as, but not limited to, blood, urine, sweat, semen, and breast milk. The incubation period is usually 8-10 days (ranges from 2-21 days). Patients can transmit the virus while febrile and through later stages of disease, as well as postmortem, when persons touch the body during funeral preparations. 

Patient Evaluation Recommendations to Healthcare Providers
Healthcare providers should be alert for and evaluate suspected patients for Ebola virus infection who have both consistent symptoms and risk factors as follows: 1) Clinical criteria, which includes fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage; AND 2) Epidemiologic risk factors within the past 3 weeks before the onset of symptoms, such as contact with blood or other body fluids of a patient known to have or suspected to have EVD; residence in-or travel to-an area where EVD transmission is active; or direct handling of bats, rodents, or primates from disease-endemic areas. Malaria diagnostics should also be a part of initial testing because it is a common cause of febrile illness in persons with a travel history to the affected countries.
 
Testing of patients with suspected EVD should be guided by the risk level of exposure, as described below:

CDC recommends testing for all persons with onset of fever within 21 days of having a high-risk exposure. A high-risk exposure includes any of the following:

  • percutaneous or mucous membrane exposure or direct skin contact with body fluids of a person with a confirmed or suspected case of EVD without appropriate personal protective equipment (PPE),
  • laboratory processing of body fluids of suspected or confirmed EVD cases without appropriate PPE or standard biosafety precautions, or
  • participation in funeral rites or other direct exposure to human remains in the geographic area where the outbreak is occurring without appropriate PPE.

For persons with a high-risk exposure but without a fever, testing is recommended only if there are other compatible clinical symptoms present and blood work findings are abnormal (i.e., thrombocytopenia <150,000 cells/µL and/or elevated transaminases) or unknown.  

Persons considered to have a low-risk exposure include persons who spent time in a healthcare facility where EVD patients are being treated (encompassing healthcare workers who used appropriate PPE, employees not involved in direct patient care, or other hospital patients who did not have EVD and their family caretakers), or household members of an EVD patient without high-risk exposures as defined above. Persons who had direct unprotected contact with bats or primates from EVD-affected countries would also be considered to have a low-risk exposure. Testing is recommended for persons with a low-risk exposure who develop fever with other symptoms and have unknown or abnormal blood work findings. Persons with a low-risk exposure and with fever and abnormal blood work findings in absence of other symptoms are also recommended for testing. Asymptomatic persons with high- or low-risk exposures should be monitored daily for fever and symptoms for 21 days from the last known exposure and evaluated medically at the first indication of illness. 

Persons with no known exposures listed above but who have fever with other symptoms and abnormal bloodwork within 21 days of visiting EVD-affected countries should be considered for testing if no other diagnosis is found. Testing may be indicated in the same patients if fever is present with other symptoms and blood work is abnormal or unknown. Consultation with local and state health departments is recommended.  
 
If testing is indicated, the local or state health department should be immediately notified. Healthcare providers should collect serum, plasma, or whole blood. A minimum sample volume of 4 mL should be shipped refrigerated or frozen on ice pack or dry ice (no glass tubes), in accordance with IATA guidelines as a Category B diagnostic specimen. Please refer to http://www.cdc.gov/ncezid/dhcpp/vspb/specimens.html for detailed instructions and a link to the specimen submission form for CDC laboratory testing. 

Recommended infection control measures
U.S. hospitals can safely manage a patient with EVD by following recommended isolation and infection control procedures, including standard, contact, and droplet precautions.  Early recognition and identification of patients with potential EVD is critical.  Any U.S. hospital with suspected patients should follow CDC's Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals (http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html). These recommendations include the following:

  • Patient placement: Patients should be placed in a single patient room (containing a private bathroom) with the door closed. Healthcare provider protection: Healthcare providers should wear: gloves, gown (fluid resistant or impermeable), shoe covers, eye protection (goggles or face shield), and a facemask.  Additional PPE might be required in certain situations (e.g., copious amounts of blood, other body fluids, vomit, or feces present in the environment), including but not limited to double gloving, disposable shoe covers, and leg coverings.
  • Aerosol-generating procedures:  Avoid aerosol-generating procedures. If performing these procedures, PPE should include respiratory protection (N95 filtering facepiece respirator or higher) and the procedure should be performed in an airborne isolation room.
  • Environmental infection control: Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is paramount, as blood, sweat, emesis, feces and other body secretions represent potentially infectious materials. Appropriate disinfectants for Ebola virus and other filoviruses include 10% sodium hypochlorite (bleach) solution, or hospital-grade quaternary ammonium or phenolic products. Healthcare providers performing environmental cleaning and disinfection should wear recommended PPE (described above) and consider use of additional barriers (e.g., shoe and leg coverings) if needed. Face protection (face shield or facemask with goggles) should be worn when performing tasks such as liquid waste disposal that can generate splashes. Follow standard procedures, per hospital policy and manufacturers' instructions, for cleaning and/or disinfection of environmental surfaces, equipment, textiles, laundry, food utensils and dishware. 

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