By The Gypsy Nurse

October 16, 2014

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Diagnose Ebola vs Flu vs Other: Is it Ebola or Flu?

How do you tell if it’s Ebola or Flu? Is there a rapid test to Diagnose Ebola?

**Please Note:  This is the most current information that I can find. If you have updated information, please feel free to post it in the comments. Just trying my best to answer questions.

There is a rapid test that can rule out or diagnosis the FLU. For Enterovirus D68, the CDC states, “EV-D68 can only be diagnosed by doing specific lab tests on specimens from a person’s nose and throat. Many hospitals and some doctor’s offices can test ill patients to see if they have enterovirus infection. However, most cannot do specific testing to determine the type of enterovirus, like EV-D68. CDC and some state health departments can do this sort of testing.CDC developed, and started using on October 14, a new, faster lab test for detecting EV-D68.”  Read more about what CDC was doing about EV-D68 in 2014.
“….but, What about Ebola?”

Diagnosing EBOLA

Several blood tests can diagnose Ebola.  It’s important to note that according to WHO, “Samples from patients are an extreme biohazard risk; laboratory testing on non-inactivated samples should be conducted under maximum biological containment conditions.”  According to the information found on Wikipedia, Ebola is included in the Level-IV Viruses; there are a limited number of facilities in the US that are even qualified to deal with a ‘Level-IV” virus.
According to the CDC, “Ebola virus is detected in blood only after the onset of symptoms, usually fever. It may take up to 3 days after symptoms appear for the virus to reach detectable levels. The virus is generally detectable by real-time RT-PCR from 3-10 days after symptoms appear.

Specimens ideally should be taken when a symptomatic patient reports to a healthcare facility and is suspected of having an Ebola exposure. However, if the onset of symptoms is <3 days, a later specimen may be needed to completely rule out Ebola virus, if the first specimen tests negative.”

For additional information on Collection, Storage and Handling of Lab Specimens: Printable factsheet: Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Patients with Suspected Infection with Ebola Virus Disease.

Diagnostic Timeline for Ebola

Unfortunately, according to the information that I’ve been able to find, there is no rapid test, nor can you diagnose ebola via lab tests before the patient is symptomatic.  The recommendations state that testing should be done on the first sign of symptoms but further state that an initial negative should be re-tested.

(graph below obtained from WHO)

Timeline of Infection Diagnostic tests available
Within a few days after symptoms begin
  • Antigen-capture enzyme-linked immunosorbent assay (ELISA) testing
  • IgM ELISA
  • Polymerase chain reaction (PCR)
  • Virus isolation
Later in the disease course or after recovery
  • IgM and IgG antibodies
Retrospectively in deceased patients
  • Immunohistochemistry testing
  • PCR
  • Virus isolation
 

What is a ‘Level-IV’ virus

According to Wikipedia: Biosafety level 4

This level is required for work with dangerous and exotic agents that pose a high individual risk of aerosol-transmitted laboratory infections, agents which cause severe to fatal disease in humans for which vaccines or other treatments are not available, such as Bolivian and Argentine hemorrhagic fevers, Marburg virusEbola virusLassa virusCrimean-Congo hemorrhagic fever, and various other hemorrhagic diseases. This level is also used for work with agents such as smallpox that are considered dangerous enough to require additional safety measures, regardless of vaccination availability. When dealing with biological hazards at this level, a positive pressure personnel suit with a segregated air supply is mandatory. The entrance and exit of a level four biolab will contain multiple showers, a vacuum room, ultraviolet lightroom, and other safety precautions designed to destroy all traces of the biohazard. Multiple airlocks are employed and are electronically secured to prevent both doors from opening at the same time. All air and water service going to and coming from a biosafety level 4 (or P4) lab will undergo similar decontamination procedures to eliminate the possibility of an accidental release.

ACCORDING To The CDC: BSL-4

Pyramid showing the four BSLs with the highest risk level, BSL-4, highlighted at the top. Levels 1-3 are grey.BSL-4 builds upon the containment requirements of BSL-3 and is the highest level of biological safety. There are a small number of BSL-4 labs in the United States and around the world. The microbes in a BSL-4 lab are dangerous and exotic, posing a high risk of aerosol-transmitted infections. Infections caused by these microbes are frequently fatal and without treatment or vaccines. Two examples of microbes worked within a BSL-4 laboratory include Ebola and Marburg viruses.

US

Centers for Disease Control and Prevention United StatesGeorgia, Atlanta   Currently operates in two buildings—one of two facilities in the world that officially hold smallpox.
Georgia State University United StatesGeorgia, Atlanta   Is an older design “glovebox” facility.
National Bio and Agro-Defense Facility (NBAF), Kansas State University United StatesKansas, Manhattan   Under construction. Facility to be operated by the Department of Homeland Security, and replace the Plum Island Animal Disease Center (which is not a BSL-4 facility). Planned to be operational by 2015, but likely delayed.
National Institutes of Health (NIH) United StatesMaryland, Bethesda   Located on the NIH Campus, it currently only operates with BSL-3 agents.
Integrated Research Facility United StatesMaryland, Fort Detrick   Under construction. This facility will be operated by the National Institute of Allergy and Infectious Diseases(NIAID). It is planned to begin operating in 2009 at the earliest.[needs update]
National Biodefense Analysis and Countermeasures Center (NBACC) United StatesMaryland, Fort Detrick   Under construction, it will be operated by the Department of Homeland Security.
US Army Medical Research Institute of Infectious Diseases (USAMRIID) United StatesMaryland, Fort Detrick 1969 Old building
US Army Medical Research Institute of Infectious Diseases (USAMRIID) United StatesMaryland, Fort Detrick 2017? The new building, currently under construction
National Emerging Infectious Diseases Laboratory(NEIDL), Boston University United States, MassachusettsBoston   Under construction by Boston University, building and staff training complete, waiting for regulatory approval.
NIAID Rocky Mountain Laboratories United StatesMontana, Hamilton   National Institute of Allergy and Infectious Diseases
Kent State University, Kent Campus United StatesOhioKent   Operates as a clean lab at level 3 for training purposes. Scheduled for conversion to a hot level 4 lab in response to a bioterrorism event in the USA.
Galveston National Laboratory, National Biocontainment Facility United StatesTexas, Galveston   Opened in 2008, the University of Texas Medical Branch operates the facility.[28]
Shope Laboratory United StatesTexas, Galveston   Operated by the University of Texas Medical Branch (UTMB).
Texas Biomedical Research Institute United StatesTexasSan Antonio   The only privately owned BSL-4 lab in the US.

 

 The U.S. Centers for Disease Control and Prevention (CDC) now maintains 20 quarantine stations in the United States, which can detain and examine people — and animals — believed to be carrying dangerous infectious diseases.

By The Gypsy Nurse

October 15, 2014

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Ebola Fear

There is a ton of Ebola fear and controversy in the media.  Blame is being placed on the CDC, the Hospitals, the Nurses.  When HIV/AIDS broke out in the 80’s we as a society experienced many of the same things that we’re seeing today with Ebola.  Fear, Panic, Media sensationalism.

The NY Times has a run-down of the news from that time-period that you might say is being replicated now with Ebola

The AIDS Epidemic:1981-1987

1981: Unusual Outbreaks

June 5
The Centers for Disease Control and Prevention’s newsletter Morbidity and Mortality Weekly (MMWR) makes a reference to five cases of an unusual pneumonia in Los Angeles.

July 3
Rare Cancer Seen in 41 Homosexuals
The C.D.C.’s MMWR publishes its first description of a outbreak of 41 cases of Karposi’s Sarcoma, a rare skin cancer.

August 29
2 Fatal Diseases Focus of Inquiry
Two rare diseases have struck more than 100 homosexual men in the United States in recent months, killing almost half of them, and a medical study group has been formed to find out why.

December 10
Researchers report in The New England Journal of Medicine that harmless viruses and bacteria can often cause fatal illnesses in homosexual men.

By the end of 1981: 121 deaths

1982: Anxiety, Confusion
447 deaths

May 11
New Homosexual Disorder Worries Officials
A serious disorder of the immune system that has been known to doctors for less than a year – a disorder that appears to affect primarily male homosexuals – has now afflicted at least 335 people.

August 8
A Disease’s Spread Provokes Anxiety
The New York Times reports about the growing anxiety among gay men.

December 10
Infant Who Received Transfusion Dies of Immune Deficiency Illness
The C.D.C. reports that an infant died of acquired immune deficiency syndrome (AIDS) after receiving multiple transfusions.

The Ebola Fear

This fear is real and warranted.  Hospitals are being criticized for not providing proper PPE (Personal Protective Equipment) and nurses are being criticized for not utilizing the equipment properly or not following protocol. i.e. the recent discussions of the Dallas Nurse diagnosed with Ebola after flying commercially.

In July of this year TedTalks had a conversation about the drawbacks of the US being a ‘reactive society’. Being reactive isn’t necessarily the right way to respond but it is a response. Fortunately, here in the US we at least have this option. As policies and procedures are modified, staff are being trained and proper equipment is being provided. These are all late in coming but they are coming and for this, we should be thankful.  It’s not the pro-active response that many of us would have hopped for or expected but there are things being done. There are several items that can be addressed that take some of the ‘blame’ away and put information and education in the hands of those on the frontline dealing with this deadly virus and we are now beginning to see hospitals and health care facilities begin to implement and deal with these items.

Positive Responses and Implementation of Change

In a recent discussion via the Gypsy Nurse Network on Facebook, the question on ‘positive response’ was asked.  What are hospitals and health care facilities doing to manage this virus? We got some great responses and proof that the Hospitals and Health Care systems are beginning to work on the issues at hand. (Note: The following quotes are from actual nurses working in the mentioned hospitals)

EQUIPMENT, TRAINING, SUPPORT, EDUCATION
“I work in an ED, we have a new cart with all the equipment on it that would be needed. It includes instructions for putting on the PPE and removal of it, and we have all been oriented to this cart. The 2 isolation rooms in this ED are also the first 2 rooms closest to the lobby.”

North Shore Medical Center in Salem, MA

“I’m in ER. We have had frequent updates in our shift change huddle for a couple of months. Inserviced on isolation transport module. Maps of Africa and information posted in all triage rooms. Recently because of circumstances have increasing education including donning and doffing equipment and PAPPER respirators.”

– MMC in Portland, ME

 “At John Peter Smith hospital in Fort Worth, TX we have now added a question on the triage and admission assessment asking about recent travel. I don’t work in ED but I know that they have been doing drills in case of a case coming to us.”

JPS Fort Worth, TX

“At St. Louis university hospital a town hall meeting was held . Protocol set up for the Ebola pts. A strict PPE with N95 and suits not plastic gown will be wore special training for the nurse only two MD will handle all the cases.”

– St Louis University Hospital, St Louis , MO

“Policy in place, memos posted, online training including how to take special PPE on & off. Hazmat suits ordered by Infection Control. new “first contact” screening tool (specific questions about travel & symptoms) house wide. And this is an HCA hospital! Designated area of care here in Reston that includes most remote room, limited staff, & ICU goes to them with portable equipment should the need arise. We’re as ready as anyone can be, I think!”

HCA, Reston, VA

“Also at an HCA in LaFayette, Louisiana. Had a mandatory meetings Mon and Tues where we got handouts and questions answered, online review of donning PPE and focusig on the taking off. Implemented a “buddy system” if/when working with EVD patients to help hold each other accountable with keeping precautions clear. Special carts created. And HCA is having pts being treated as air born and staff is to wear n-95’s instead of just surgical masks.”

– HCA Hospital Lafayette, LA

“Numerous CEUs on Ebola and new policies in place on PPE, discussed contamination of the OR equipment and how an isolation area being set up on another floor, ready for the worst. Doubt very much the OR stuff will come into play since unlikely a pt would survive any procedures when hemorrhaging is a key component of the disease.”

– Undisclosed Hospital in Miami, FL

“We had a staff meeting today to discuss how to properly wear PPE and we are wearing the gear they wear when doing total joints and will have a buddy watch us put it on and take it off to help prevent accidental contamination”

Inova Fairoaks


 Education is Key

For those of us in the medical field, education is KEY!  Not only to educate ourselves but our patients, families and communities.

The Following guidelines are copied from: http://www.cdc.gov/vhf/ebola/

Guidance & Recommendations

Infection Prevention and Control of Ebola Virus Disease in US Hospitals
Posting date: Wednesday, August 20, 2014
Faculty: David T. Kuhar, MD

Patient Evaluation

Laboratory (specimen collection, transport, testing, submission)

Protecting Healthcare Workers

Diagnosis

General Information

By The Gypsy Nurse

April 14, 2014

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Volunteering in Liberia: Understanding the Risks

The Gypsy Nurse is heading to Liberia with Cross Cultural Care

As you probably already read, The Gypsy Nurse is going to be volunteering in Liberia.  I plan to bring you along with me; virtually and give you a ‘feet on the ground’ accounting of the entire process.
“Cross Cultural Care (C3) is an international non-government organization (NGO) that pairs western health care providers with medical staff in areas of the developing world to assist with medical training and health capacity building.

Cross Cultural Care (C3) was founded by Dr. Robert Montana, an American Emergency Medicine physician who decided to create such a program while volunteering in North India.”  – http://www.cross-culturalcare.org/about/

The Gypsy Nurse will be spending the entire month of May 2014 in Liberia. I’ll be volunteering with C3 in Robertsport, Liberia.

In the previous article, we discussed the ‘To-Do List.’  I’m still working through all of the paperwork. My renewed passport came back and is now on it’s way to the Liberian Consulate in D.C. for my visa.  I’ve filled out all of the appropriate forms for my Liberian Nursing Permit. I’ve faxed, emailed, and made copies of everything I can think of. I think I’m done with the paperwork!  Now it’s just a waiting game to see if my Visa and Nursing permit come back without any issues.

Understanding the Risks

I knew that heading into Liberia would expose me to many diseases that I’m unaccustomed to. From Malaria, Dengue Fever, Yellow Fever, Typhoid, etc., there are certain risks one takes when traveling to a developing country.  This is not totally new to me as I’ve previously been vaccinated for many of these due to my personal travels in Vietnam and South and Central America. It is best to understand the risks beforehand to educate yourself about these diseases.

What I didn’t know was that an outbreak of the Ebola Virus would be spreading in the wake of my arrival.

I have to be honest…hearing about the outbreak of this highly contagious hemorrhagic fever gave me a moment of pause. I had to seriously weigh the options on whether or not to follow through with my commitment to C3 to volunteer. Dr. Robert Montana, the founder of C3, personally emailed me to update me on the situation and informed me that “You should be aware that there is NO CRITICAL CARE in Liberia even in the capital and air evac may be impossible if you are suspected with the disease.” and allowed me to back out of the trip if I so chose.

I’ve spent the past week researching the disease and considering my options. As of April 4th, there were two confirmed and several un-confirmed Ebola cases in Monrovia (the capital in which I’ll be arriving). There were no current reported or suspected cases in Robertsport, where I’ll be volunteering. Guinea’s bordering country is where the outbreak is currently the worst, with a few cases in both Liberia and the border country of Sierra Leone. Many agencies are currently assisting the Liberian Ministry of Health in efforts to confine the spread. UNICEF, MSW/Doctors without Borders, WHO, and multiple NGO’s are involved in the containment efforts.

Based on the current information available…

I’ve decided to follow through with my commitment to C3, baring any drastic changes in the current situation. I knew when I volunteered that there was a possibility of contracting a deadly disease; the fact that there is a current outbreak will make me more vigilant in my personal protection and care of others. Understanding the risk has made me more aware of the situation and cautious.

In light of the information I’ve received, my packing list has changed slightly to include: masks, gloves, goggles, and a supply of hand sanitizer.

_______________________________________

Along with volunteering, The Gypsy Nurse plans to bring the reader an inside peek at this volunteer opportunity.  With an emphasis on the people served, the cultural differences, and the impact that Cross Cultural Care is providing to Grand Cape Mount’s communities. Liberia.  I am excited to have this opportunity to utilize my nursing skills to assist Dr. Montana in his vision to provide training, mentoring, and growth of skills as a strategy towards lasting change and improved healthcare access for the communities served by St Timothy Hospital. If you would like to contribute to the ongoing efforts of C3, you can donate HERE.

There will be much more information to come as I share the entire process with you to give you a “Feet on the Ground” perspective.