Every time a different disease surfaces in the news like MERS, Ebola or Enterovirus D 68, one of the first questions people ask is, “Is there a vaccine for it?” A new documentary created for NOVA on PBS – Vaccines – Calling the Shots recently outlined the history of vaccines and the possibility of vaccine-preventable diseases returning to the U.S. It’ll take an hour to watch, but it’s excellent – especially for us public health enthusiasts.
This week the Governor signed an Executive Order establishing the Governor’s Council on Infectious Disease Preparedness and Response. The Council consists of 20 public health, health-care, and other multi-sectorial partners, with the ADHS Director as the Chair. Our task will be to ensure that Arizona is prepared to rapidly and effectively respond to various infectious diseases.
We’ll be developing a plan that will: 1) Include methods for rapidly identifying and assessing cases, protocols for providing healthcare treatment and infection control to prevent healthcare worker infections, and case contact investigations to prevent secondary infections in the community; 2) Identify ways to strengthen collaboration among healthcare organizations, medical communities, government agencies, law enforcement, non-profit organizations, and the community-at-large in order to effectively address infectious disease transmission and treatment; and 3) Serve as a reliable and transparent source of information and education for Arizona leadership and citizens.
We’ll provide a preliminary report to the Governor by December 1, 2014 and continue to report to the Governor on a regular basis as the situation requires.
You can be part of the solution too. You can reduce your chances of getting sick and spreading illness by immunizing your family against influenza right now.
Epidemiologists (aka disease investigators) use a number of tools to estimate the contagiousness and spread of a disease. One such tool is the R0 (R nought), which represents the average number of people one sick person will infect. It’s calculated by estimating the chances of exposure, number of susceptible persons, length of contagious period, how the disease spreads, and how much time passes between exposure and becoming contagious.
For example: the HIV virus has an R0 of 4. One person with HIV, on average, infects 4 others. Remember, SARS, the respiratory scare in 2003? That also has an R0 of 4. Measles, on the other hand, has an R0 of 18. You can see why public health responds so quickly to a single positive measles case.
For Ebola, the R0 has been estimated at 2. So on average, one person infects two others. It doesn’t mean that Ebola is less serious than SARS, measles or influenza – it just means it doesn’t spread as easily as they do.
The goal of public health in an outbreak is to bring the R < 1. When that happens, spread of a disease stops and sick patients don’t infect others. In the case of Measles, this can be done by vaccinating exposed persons and reducing the sick person’s exposure to others.
In the case of Ebola, the focus is on quick identification of cases, isolation (literally using barrier and containment methods to keep patients from infecting anyone else), and identification of case contacts, monitoring them, and isolating any that are a suspect case. ADHS is providing guidance to hospitals on this strict infection control policy, and will continue to update them as the recommendations change.
One of the roles we play in any outbreak is making sure that our partners in the state have all the information they need to respond to a situation and be safe in that response. I’ve posted about our continuing education of those partners, but now we’ve created a one-page stop for partner.
Our Ebola Preparedness website contains all the information we’ve sent out through our Health Alert Network. There are toolkits for hospitals, outpatient clinics, EMS providers and laboratories.
We will continue to push information to our partners, especially as things change. We anticipate new information today about personal protective gear . So stay tuned
Two Ebola virus disease cases have been identified among healthcare workers in Texas, underscoring the importance of maintaining strict adherence to infection control precautions when working with Ebola patients. We know that the general public in the US isn’t at risk – but we also know that healthcare workers have the highest risk. The good news is that the risk of transmission can be dramatically reduced as long as certain protocols and procedures are followed. This means following them at the structural level (i.e. the treating facility), the clinical team level, and the individual level. With this many levels of possible breakdown it can be challenging to fully protect workers. But it’s entirely possible – after all Doctors Without Borders has been doing it successfully for months now in West Africa.
CDC has checklists for hospitals, healthcare facilities, healthcare providers, and EMS to facilitate readiness and gap assessments for healthcare professionals. If presented with a patient experiencing fever or other Ebola symptoms, healthcare providers should take the following steps:
- Inquire about a history of travel to West African countries with Ebola outbreaks (Guinea, Liberia, and Sierra Leone) in the 21 days before illness onset for any patient presenting with fever or other symptoms consistent with Ebola;
- Immediately isolate a patient who reports a travel history to an Ebola-affected country (currently Liberia, Sierra Leone, and Guinea) and who is exhibiting Ebola symptoms in a private room with a private bathroom and implement standard, contact, and droplet precautions (gowns, face mask, eye protection, and gloves);
- Notify your local health department. The local public health department will help to evaluate risk, coordinate with the ADHS and help to arrange for specimen shipment and testing at the ADHS Lab (if warranted);
- If testing is warranted based on consultation with public health, ensure all proper personal protective equipment and precautions for collecting a blood borne pathogen sample are followed;
- Maintain a log tracking all people in contact with the patient, including visitors, healthcare workers, environmental services, and others. Infection prevention and environmental control guidelines must be followed to protect staff and other patients;
- Healthcare workers treating an Ebola virus disease patient should monitor their temperature twice a day for 21 days. Most healthcare workers who treat Ebola patients will never contract it themselves, but it’s important to be vigilant as a precaution; and
- There is no specific FDA approved treatment for Ebola virus disease but supportive care can greatly benefit patient recovery. CDC has some treatment information on their website.
Throughout the course of patient treatment, it’s critical that healthcare facilities follow all personal protective equipment guidance. We’ve learned from other hospitals who have treated Ebola patients that having a 24/7 site manager to monitor protective equipment including donning and doffing is critical. Other facilities have had success using the buddy system to double check methods. Practicing proper donning and doffing will help ensure appropriate use in the event an Ebola patient does present at your facility.
Communication between direct-care workers and systems level workers are keys for success. Assessing your readiness and following the CDC guidance are crucial to reducing likelihood of disease spread.
As Ebola cases continue to rise worldwide and in the US, ADHS is redoubling our efforts to ensure Arizona’s healthcare and public health systems are prepared to respond to potential Ebola cases. Right now, our top priorities are ensuring the rapid identification and prompt isolation of cases in order to reduce disease spread to healthcare workers and close contacts of the patient. We have been providing resources and guidance to healthcare and public health partners to underscore the importance of asking for a 21-day travel history for any patients who report a fever or other Ebola symptoms. We’ve also emphasized the importance of immediate isolation of any suspect cases with healthcare workers implementing standard, contact, and droplet precautions while risk assessment and test results are pending. These are critical steps in stopping the transmission of Ebola to other people.
In the coming days, we will be releasing toolkits to support healthcare facilities, healthcare providers, and first responders in assessing and improving their readiness to respond to an Ebola case. The toolkits will synthesize existing CDC resources into those most relevant for the audience and situation. A wealth of federal resources for Ebola preparedness and response are available on CDC’s Ebola website to enhance the overall preparedness of public health and healthcare systems.
In 1348, London was 4 million strong, but within 2.5 years a third of those had “fallen down.” The streets were narrow and cramped, often piled ankle deep with human and animal waste. The putrid smell contaminated everything in the city. Those infected with the new and ghastly plague placed posies in their pockets and rosaries around their necks. Their symptoms include severe fever, chills, headache, muscle weakness and pain, swollen lymph nodes, and sometimes respiratory or GI illness. Between one third and two thirds of Europe’s population was decimated within just a few decades.
The plague was known then as the Black Death, but it’s recognized today as the bacteria Yersinia pestis. Scientific advances have turned it from a fearsome figure to a controllable nuisance. Arizona has not had a single plague case in the past 5 years; the last confirmed case was in 2007.
Unfortunately for our rodent brethren, this is not the case. In the 1300s, rats of the Rattus rattus variety were the primary rodent carrier of the fleas that spread plague. Now the burden falls to others. Prairie dogs, squirrels, rabbits, cats, and their predators have been found to be carriers of plague in Arizona. Most recently fleas collected in Doney Park, near Flagstaff, tested positive for Yersinia pestis.
Staying safe from plague is pretty easy – pets should have flea protection (cats are susceptible), and people should use insect repellant if they’re in flea-infested areas. People and pets should stay away from dead animals and wild animal burrows. Human infections are rare, but early antibiotic intervention is the key to successful treatment. When we apply what we’ve learned about biology, sanitation, and public health over the years, the serious diseases of our ancestors become mere nursery rhymes for our children.
For the last few months we’ve been reviewing our medical marijuana rules to make changes to them in response to an Arizona Superior Court judge’s decision. In addition to the changes needed to comply with the Court’s ruling, also proposing other changes to the medical marijuana rules that affect qualifying patients, caregivers, and dispensaries that include:
- Reducing the fees for qualifying patients who are 65 years of age or older, under 18 years of age, veterans, receiving SSI or SSDI benefits, or receiving hospice services;
- Reducing the fees for the caregivers of qualifying patients who are under 18 years of age or receiving hospice services;
- Adding a process for qualifying patients who are incapacitated and have a guardian to get a registry identification card;
- Adding palliative care of PTSD to the list of qualifying medical conditions;
- Clarifying requirements for the cultivation of marijuana;
- Revising procedures for allocating dispensary registration certificates;
- Clarifying who can sign documents and make requests on behalf of a dispensary; and
- Clarifying requirements for inventory control, dispensing and transporting medical marijuana, and accepting donated marijuana.
After posting drafts of revised rules in February and June and meeting with people affected by the rules in June and July, we’re now posting a third draft, which includes changes based on the comments we received, and an on-line survey for comments on the new draft. Based on the comments that we receive on the third draft, we’ll submit a Notice of Proposed Rulemaking which will include official Oral Proceedings. After that, we’ll finalize the new regulations. We plan to have the revised rules in effect by Summer 2015. Here are the new draft rules.
The CDC developed an Ebola self-assessment tool for states last week called Top 10 Ebola Response Planning Tips: Ebola Readiness Self-Assessment for State and Local Public Health Officials. The self-assessment (which is posted on the CDC’s Ebola Website) provides a tool for states to evaluate their overall Ebola readiness. Our team has been going through the checklist to identify additional interventions and to develop and implement an action plan to address any preparedness and response gaps in Arizona.
A couple of the key gaps were closed last week by our Lab with the proficiency testing and the development of our Ebola-specific laboratory website. We implemented some healthcare system interventions last week (leveraging our public health licensing authority), and we’ll be conducting additional interventions this week.