Ebola, Emergency Medicine, and Global Bioethics

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1 Ebola, Emergency Medicine, and Global Bioethics Sarah M Winston Bush, MD Assistant Professor University of Cincinnati Department of Emergency Medicine

2 A look at the medicine

3 What does Ebola look like High fevers Vomiting Diarrhea Fatigue Loss of Appetite Abdominal Pain Headaches clinically? Myalgias Cough Maculopapular Rash Hiccups

4 Hemorrhage? Occurs ~50% of time GI in origin Mucosal bleeding Hematomas Oozing IV sites Conjunctival Hemorrhage

5 80 bed center in Kailahun Tents of patients suspected, probable, confirmed PCR testing can take up to 24 hours Strict PPE guidelines Buddy system Restricted to 40 minutes at a time in PPE and in the tents Treatment Supportive only Discharge criteria neg blood test and 3 days symptom free

6 Common: Renal Failure Hypokalemia Lactic acidosis Elevated Liver Function Tests Uncommon: Hemorrhage (typically GI)

7 Barriers to treatment in West Africa: Late presentation Lack of equipment PPE Oxygen Electrolyte testing Hemodynamic monitoring IV supplies and IVFs Community mistrust Communication barriers

8 Diagnostics Rule out other common causes Malaria Other endemic infectious diseases Ebola test: Africa some sites have onsite PCR testing that can take up to 24 hours US: Send out test to CDC

9 Supportive care Treatment IVF resuscitation early Correct hypovolemic shock and electrolyte disturbances Nutrition Treat concomitant malaria Prevention of secondary infection

10 Treatment Isolation Prevent the spread Role of antibiotics Experimental drugs? ZMapp Brincidofovir Blood transfusion

11 1995 outbreak in DRC 5 donor pts IgG and IgM antibodies to Ebola 8 recipient patients ages Prior to transfusion: 7/8 treated for Malaria 3/8 had hemorrhagic symptoms 8/8 tested positive for Ebola antigens 7/8 survived Pt 8 never developed IgM antibodies to Ebola despite transfusion

12 Here in Cincinnati 911 dispatchers have begun screening EMS has been educated on appropriate screening & precautions Immediate application of PPE Immediate decontamination of ambulances with bleach to prevent further spread

13 UCMC Emergency Plans for Ebola Goals: Provide quality care to all patients Prevent further exposures

14 UCMC Emergency Plans for Ebola Triage: Flu like illness Appropriate travel history West Africa: Guinea, Liberia, Nigeria, Senegal, Sierra Leone Democratic Republic of the Congo Exposure history Redundancy within the EMR Immediate Isolation

15 UCMC Emergency Plans for Ebola PPE carts Assessment and Treatment Malaria and other infectious causes Notification

16 Thank you!

17 References Baize, et al. (2014). Emergence of Zaire Ebola virus in Guinea. N Engl J Med Briand, et al. (2014) The International Ebola Emergency. N Engl J Med. 371: Decker, et al. (2014). Preparing for Critical Care Services to Patients with Ebola. Annals of Internal Medicine. downloaded Fowler, et al. (2014). Caring for critically ill patients with Ebola virus disease. Am J Respir Crit Care Med. 190: Frieden, et al. (2014). Ebola 2014 New challenges, new global response and responsibility. N Engl J Med. 371: Gatherer, D. (2014). The 2014 ebola virus disease outbreak in West Africa. Journal of general virology. 95, Gostin, Lucey, & Phelan. (2014). The Ebola Epidemic: A global health emergency. JAMA. 312: Mupapa, et al. (1999). Treatment of Ebola hemorrhagic fever with blood transfusion from convalescent patients. Journal of infectious disease.179: S Wolz, A. (2014). Face to face with Ebola An emergency care center in Sierra Leone. N Engl J Med. 371: WHO ebola response team. (2014). Ebola virus in West Africa the first 9 months of the epidemic and forward projections. N Engl J Med WHO. WHO recommended guidelines for epidemic preparedness and response: Ebola Hemorrhagic Fever. downloaded

20 Outcomes:

21 From Dec 30, Sept 14, confirmed/probable cases Median age 32 years 318 infected health care workers (151 deaths)

Virological analysis: no link between Ebola outbreaks in west Africa and Democratic Republic of Congo Situation assessment - 2 September 2014 (*) Both Zaire species of Ebola DRC: close to

22 Virological analysis: no link between Ebola outbreaks in west Africa and Democratic Republic of Congo Situation assessment - 2 September 2014 (*) Both Zaire species of Ebola DRC: close to 1995 outbreak in Kitwit, DRC strain No connection between the two outbreaks Index case in DRC: Pregnant woman eating bushmeat

23 Clinical presentation Africa US Mainstays of diagnosis and treatment Resuscitation Supportive care Isolation Plans at UCMC ED EMS/911

24 Mode of Transmission Contact with any bodily fluids Airborne transmission never been confirmed Percutaneous (ie the dreaded needle stick) Contact with dead bodies

Ebola Facts. October 14, 2014

Ebola Facts. October 14, 2014 Ebola Facts October 14, 2014 Symptoms of Ebola Initial symptoms are nonspecific - may include fever, chills, myalgias, and malaise. Patients can progress to develop gastrointestinal symptoms: severe watery