Experiences of CDC and Emory Health Care in Managing Persons Under Investigation for Ebola

Coordinator:
Welcome and thank you for standing by. At this time, all participants are in a listen-only mode until the question and answer session. At that time, to ask a question, you may press star 1 on your touchtone phone.

Today’s conference is being recorded. If you have any objections, please disconnect at this time. And I’ll turn today’s meeting over to Loretta Jackson Brown. Thank you; you may begin.

Loretta Jackson Brown:
Thank you, Candy. Good afternoon. I’m Loretta Jackson Brown and I’m representing the Clinician Outreach and Communication Activities -- COCA -- with the Division of Strategic National Stockpile at the Centers for Disease Control and Prevention. I’m delighted to welcome you to today’s COCA call - Experiences of CDC and Emory Health Care in Managing Persons Under Investigation for Ebola.

CDC, our planners, presenters, and their spouse’s partners wish to disclose they have no financial interest or other relationships with the manufacturers of commercial products, supplies of commercial services, or commercial supporters. Planners have reviewed content to ensure that there is no bias.

This presentation will not include any discussion of the unlabeled use of a product or products under investigational use. PowerPoint slides are available to download for today’s call. The PowerPoint slide set can be found on our COCA website at emergency.cdc.gov/coca. Click on COCA calls; the slide set is located on the March 31 call webpage under call materials.

Free continuing education is offered for the COCA call. Instructions on how to earn credit will be provided at the end of the call. At the end of the presentation, you will also have the opportunity to ask the presenters questions. On the phone, dialing star 1 will put you in the queue for questions.

At conclusion of today’s session, the participant will be able to state the number of travelers and persons under investigation for Ebola in the U.S. from August 2014 to March 2015, discuss the most common diagnosis for persons under investigation for Ebola, describe the importance for appropriate evaluation of persons under investigation for Ebola and Assessment hospitals, and compare and contrast different options for evaluation of persons under investigation of Ebola.

Today’s first presenter is Dr. Emily Koumans. Dr. Koumans is team lead for CDC’s Ebola Response Domestic Clinical Inquiries Team. Her team responds to inquiries and issues around persons under investigation for Ebola from clinicians, state and local health departments, and HHS. Dr. Koumans earned a Doctorate of Medicine and a Master’s in public Health from Harvard University.

Our second presenter is Dr. Henry Wu. Dr. Wu is an assistant professor in the Department of Medicine at Emory University. He is also Co-director of Emory University Midtown Travel Well Center. The center implemented a protocol to evaluate persons under investigation for Ebola in the ambulatory setting. Dr. WU is a specialist in infectious disease and internal medicine. He earned a Doctorate of Medicine from Harvard University Medical School.

Again, the PowerPoint slides are available for download for today’s call. Go to emergency.cdc.gov/coca, click on COCA calls; the slide set is located on the March 31 call webpage under call materials.

At this time, please welcome Dr. Koumans

Dr. Emily Koumans:
Good afternoon everyone. I’m going to start this slideshow - I hope those of you on the call have managed to access it - the overview of the presentation. First I’ll introduce the Clinical Inquiries Team, give a little
background on the returning U.S. travelers and how they’re screened, and the geographic distribution of inquiries in persons under investigation, describe some common diagnoses, and go over three case studies, and
then I’ll turn it over to Dr. Wu from Emory who’s going to describe the outpatient management of PUIs there. And then we’ll have time for questions.

The next slide shows a graph of the pyramid of travelers coming from affected countries and how many actually have had confirmed Ebola since the screening system was put into place in October. I’ll start with the travelers on the bottom, which is all travelers from affected countries.

And I’m going to turn it over to Dr. Nicky Cohen from the Global Migration Task Force.

Dr. Nicky Cohen:
Hi, thank you Emily. So I just wanted to - on the next slide, which is titled Layered Lines of Defense against Ebola. It describes some of the safeguards that we have in place for detecting and preventing the travel of people who are potentially symptomatic with or exposed to Ebola.

So, starting on the right-hand side of the slide or in the East, we have travelers leaving the affected countries – all of whom currently go through an exit screening process where they’re screened for potential exposures and observed symptoms. And if they do have any reported histories of exposures or symptoms, they are not permitted to travel. For travel en route we actually have a regulatory requirement for reporting of any deaths on-board or illness that meet certain syndrome definitions to the CDC if the flight is arriving in the United States. For flights travelling to other countries, the reporting would be to the country of destination.

So this is another mechanism to potentially identify ill travelers while they are traveling, even before arriving the United States. And we also have processes where - with - agreements with other agencies to - who are trained to detect travelers and notify us if they’re detected. And then, as you’re aware, since October, we have been doing enhance entry screening at five U.S. Airports where travelers on itineraries that originate in Guinea, Liberia, and Sierra Leone are required to arrive. And during this entry screening process, they’re again screened for potential exposures and symptoms. And if they meet the symptom criteria for a PUI, they will be referred for medical evaluation directly from the airport and the majority of travelers are referred to health departments then for the post-arrival monitoring.

On the next slide titled U.S. Entry Screening Data, this is just a brief summary of the travelers who have been screened since October. As you can see, we have screened over 11,000 travelers - 11% of whom have been referred to CDC at the airport for additional public health assessment, either for potential exposure or symptoms. Less than 1% have been transported from the airport for medical evaluation and none of these travelers have been detected with Ebola on entry, although one traveler was detected after entry in October while being monitored during his 21-day incubation period.

Dr. Emily Koumans:
Great; thanks, Nicky. The next slide is a - going up the pyramid. We’re looking at the - now, the travelers who are being monitored from affected countries. Of those, some developed symptoms and some of those travelers report their symptoms and some of those need evaluation. So, we have this data from the State Coordination Task Force.

The next slide shows the travelers monitored in the United States from March 16 to March 22. This is actually a pretty typical week. There were over 1,900 persons in active or direct active monitoring by the state. 73 of those were in the some- or high-risk category, at any time and 29 states were participating in the monitoring with some- or high-risk persons. 99.9% of travelers were contacted successfully and are enrolled in active or direct active monitoring. And zero people under monitoring in the U.S. have been diagnosed with Ebola since the end of October. Now, the next slide is, again, the top of the pyramid - getting to the travelers who needs an evaluation and who are reported to CDC. Some of these are inquiries; they may be travelers from other countries. And of those, some are PUIs or persons who need an investigation. We had 272 of those since October - actually 281, now - it’s an update. Of those, 117 have been tested for Ebola and zero has had Ebola.

Next slide is on the clinical Inquiries Team. The Domestic Clinical Inquiries Team here at CDC addresses inquiries about the evaluations of travelers who may be persons under investigation. We document these inquiries and the PUIs and their management, then we do a large amount of communication to HHS, other federal partners, state and local health departments.

The next slide shows a map of the United States with the colors showing the - the colors of the state showing the number of inquiries and the number on the state showing the number of people tested. So you can see that the dark colors of Georgia and Texas, those are the states with the largest numbers of inquiries. Wyoming actually had no data so that’s dark, but zero. And the number on the state is the number tested. The largest number of people tested has also been from Texas and this largely reflects what happened in October.

Next slide is the distribution of inquiries and testing by epidemiologic leak through March 28. And it shows a large spike in the number of inquiries in October, weeks 40 through 46. And then, since then, a pretty steady rate of inquires through the influenza season and the yellow - the top of the bars in yellow - that denotes people tested.

The next slide shows the top five diagnoses among PUIs that have been reported to CDC. We looked at a period of time from December 1 through March 24, 2015, whether - when there were 110 PUIs. And we actually have either a confirmed laboratory or a very probable diagnosis. The top diagnosis was gastroenteritis with 36 or 33%. The next most common diagnosis was an upper respiratory infection; 19 people, or 17%. And then 18 people - a close third - was influenza, or 16%. Malaria - there were 10 people, or 9%, and the rest were unknown or other.

I’m, next, going to go through several cases which highlight some of the issues around PUI management. And several months ago, a 4-year old arrived from Liberia, was classified as low but not zero risk, had no known Ebola exposures and was started on active monitoring. On Day 15, this child developed a fever to 101.7, had no other symptoms, and the rest of the family was well. The health department recommended an evaluation on Day 16 and the child went to Hospital A. And at the hospital, a fever of 102 Fahrenheit was documented and there was one, moderately loose stool. A rapid test for malaria was positive for both plasmodium falciparum and vivax. Other laboratory tests showed a hematocrit of 19, platelets of 42,000, and the total bili of 3.5, suggesting the rather advanced malaria infection. And Hospital A was uncomfortable treating this child PUI despite an alternative diagnosis of malaria. So, the child was transferred late on Day 17 by EMTs in full PPE to a different hospital. And, there, the child received continued treatments and had slow clinical improvement but there was a delay in malaria treatment. Ebola testing was performed more than 72 hours after the development of symptoms that was negative, highlighting the concern of Ebola even three days after a diagnosis has been made.

Case Study #2 is an illustration about media. So a traveler arrived from Guinea to the United States. Monitoring was initiated by the local health department. The traveler reported a fever of 102 Degrees Fahrenheit to the local health department on Day 5, early in the morning. The local health department called the local hospital to initiate the evaluation, and then notified the state. The hospital called EMS to arrange transport because this person did not have a means of getting to the emergency room. And then, the - on-EMS radio, was heard that a possible Ebola patient was being transported. Now, EMS radio is monitored by the media. And the reporter who monitored this radio filed a press report. And then, we heard about this person through the press and HHS says the rest of CDC and the state health department were also unaware that this PUI was getting an evaluation. So we’ve learned that we can ask EMS not to use the radio.

Case Study #3 is a 47-year old who entered the U.S. from Liberia. This was a low- but not zero-risk traveler who was engaged in training workers and was being monitored in a rural state. The traveler developed a temperature of 101.1 and fatigue with myalgia on Day 5 of monitoring. In the previous week, a family member had had fever, headache, and vomiting and other family members also reported feeling sick with cold symptoms. There was a conference call with the state health department, during which the Domestic Clinical Inquiries team and the state agreed on the need for an evaluation. But there was some concern expressed about the hospital readiness and capacity and the possible media exposure and the concern about confidentiality for this person because of the small size of the town. And, also, the - whether there was an actual need for admission for these symptoms in an evaluation. So there was an agreement to test for respiratory viruses using a rapid test for influenza as well as a PCR in the state lab. The specimen was collected while the PUI was in the car in the ER parking lot by someone in full PPE. The PUI then returned to self-isolation at home. The E - the emergency department prescribed olsetamivir for this PUI, the six family members, as well as prophylaxis for those who are not sick in the household but presumably had been exposed. The PUI then developed sore throat and coughs that evening, which we felt was consistent with influenza and the PUI was advised to take temperature before taking antipyretics - a very typical recommendation for us. The rapid influenza came back negative but the PCR was positive for Influenza A. So, 24 hours after initiating treatment, the PUI had substantially improved, was afebrile off antipyretics. There was some residual myalgia congestion and cough and the family members were also improved. The PUI returned to work two days later. The only wrinkle in this scenario was that the state lab PCR machine was not used for 24 to 36 hours until clinical improvement assured the team that Ebola was not the diagnosis. But the stoppage did necessitate some specimens for testing to other labs.

So the take-home points from our case studies is that appropriate care should be provided in a timely manner for PUIs and the - a PUI - the designation of someone as a PUI shouldn’t delay care. Immediate notification can often be managed and the - we, at CDC, are very happy to help with that. And then, I think I’m going to transition, now, to Henry Wu in considering how and when an outpatient management of PUIs may be advantageous.

Go ahead, Dr. Wu.

Dr. Henry Wu:
Great. Thank you, Dr. Koumans, for the invitation to share experiences evaluating PUI at the Emory Travel Well Center. In case you don’t know, Travel Well is Emory’s Travel Clinic. And early on, after the Ebola epidemic progressed, it became clear to us that we would potentially need to evaluate potentially a large number of returned travelers from affected countries with ill symptoms.

And to address this need, we developed a procedure to see patients in the outpatient setting. And on my first slide, I ask why even consider ambulatory evaluation of PUI? And what we were thinking is that probably - and I think some of the data just presented with support - that most PUI are at low risk for actual Ebola infection – both the low epidemiologic risk in - low, but not zero epidemiologic risk category and also just a - based on a clinical assessment.

And for the vast majority of these patients, an emergency department or in-patient care may not be necessary, particularly given that most common travel-related sections do not require this level of care. We were also thinking about the potential burden on our colleagues in the emergency department and in-patient resources as well as our colleagues at our Ebola treatment unit.

So it had became clear that developing a way to evaluate some of these patients at an outpatient would be important. Finally, seeing patients who are at low risk in the outpatient setting potentially also can minimize patient stress and exposure to hospitalization risks and possibly minimize public visibility. On the next slide, I have listed the key parts of the PUI clinic visit.

And I do want to emphasize at this point that the -as - you know, I’m going to cover the process we went through to develop our protocol and some of the details and lessons we have learned. And even if folks out there may not be considering an outpatient evaluation unit, I hope some of our lessons may still be helpful with, you know, if you are considering your protocols for your emergency departments in other settings.

So, essentially, we started by deconstructing a clinic visit and looked at each step, considering how each could be conducted with attention to infection control, patient care, and privacy. And these steps are, first, a triage in scheduling; second, arrival to clinic; third, the exam room itself for the PUI care team; next, the clinical approach we took, laboratory testing issues, disposition and follow-up; and finally, waste management and environmental cleaning.

And I’ll go over each one of these steps in more detail. First step, of course, is determining if the PUI is appropriate to be seen in the outpatient setting. We are referred PUIs from other parts of Emory Health Care, or potentially directly from public health authorities.

When we hear about a patient, we immediately consider if they meet our criteria for - outpatient evaluation versus triage to the emergency department or potentially to our colleagues at Emory’s Ebola treatment unit. And we refer to it as the Serious Communicable Diseases Unit - or SCDU, in short.

The first criteria is that there really should be a low suspicion for Ebola and that - most likely, we probably would not even pursue Ebola testing on this patient. And this is for a couple reasons. Obviously, a patient with confirmed or highly-likely Ebola infection are better management - better managed in the Ebola treatment unit.

On a practical level, we also had to consider that Ebola testing, even at Emory, can have a turnaround time of several hours. So keeping somebody in clinic for an extended period would not be ideal. Secondly, another criteria that there really must be no significant wet symptoms -- that is, nausea, vomiting or bleeding or profuse diarrhea. And this is primarily an infection control concern and patients with these symptoms are generally triaged to the emergency department setting. Also, there, of course, must be no medical indication for emergency department or hospitalization. Of course, if the PUI sounds like they will need IV fluids or are medically unstable, then certainly, we will triage them elsewhere.

And finally, a practical time consideration; our clinic has standard clinic hours. So if we do hear about a PUI during the weekend when our clinic will be closed for some time, we will then triage them to the emergency department so an evaluation will not be delayed. On the next slide, once we schedule a patient, our team notifies key - a key list of internal and external stakeholders and collaborators, including the public health authorities, infection control, our laboratory, our SCDU team, our security staff, environmental services, and even our neighboring clinics that are next door to us.

And that was one of the lessons learned as we implemented our procedure; it’s important to let the folks who may see our team know what’s going on and so they can explain - potentially tell their patients what’s going to – you know, what they may have seen.

Next slide is our arrival to our clinic procedure. We designed this procedure with the goals of minimizing PUI exposure to other patients, staff, as well as minimize visibility as much as possible. To this end, we instruct the patient to arrive at a back door entrance - basically an old ambulance entrance where they can leave their car and avoid the need to use the patient lot and the usual elevators and lobby entrances. We meet them there with an arrival team. This is made up of the travel or clinic physician, the nurse, and the security escort in PPE. We give the patient - the PUI - a surgical mask and transport them via wheelchair. The security escort plays a key role.

First, they secure the route through the hospital and the service elevator. Secondly, they’re instructed not to come in contact with the PUI and maintain a distance and therefore, they remain clean and they’re able to carry our clean supplies, which we do bring with us. We do bring down an emesis bag, towels, extra gloves, and we keep these on hand just in case there is an unexpected episode of emesis or other event during transport.

On the next slide, I’m describing - I describe our exam room and - when we get to our clinic, basically, the physician and nurse enter the exam room with the patient. The room is actually a standard clinic room, but we have prepared it to minimize the surface area that will be - need to be decontaminated. So all unnecessary decorations, furniture, and equipment have been removed.

We also prepare the room by placing all the equipment that the team will likely need ready in the room - mostly disposable equipment such as disposable stethoscopes, pen lights, other exam equipment, as well as phlebotomy materials, specimen swabs, etcetera. Some equipment that might be needed but not necessarily is kept outside the room. This includes a bedside commode or a urinal in case the patient needs to use the bathroom.

On the next slide, I describe the team - our PUI evaluation team - the roles and the various training. Are - there are basically four core members, each with a unique role. I’ve already mentioned the physician who is the team lead and evaluates the patients and reports to the public health authorities. The nurse, in addition to transporting the patient, measures the vital signs and collects blood specimens in the exam room. And this is, of course, since we are unable to use our regular outpatient laboratory for phlebotomy. We have a third team member we call the buddy and this is a - the team member who is stationed outside the room in PPE and is watching the PUI and the evaluation team inside the room. And the buddy’s role is to monitor the situation, look for PPE breaches and as well as monitor the room exiting procedure and PPE doffing process. The buddy also helps with handing over needed equipment when needed in the room. And finally, the last member of our team, since the buddy cannot leave the doorway, we have a fourth team member that serves as - we call him the runner - to transport specimens, help with communications, and do any other errands as needed. And so the first three members of our team - the physician, nurse, and buddy - are trained in PPE, both in the donning and doffing procedures.

On our next slide, I describe our clinical approach to the PUIs. And the approach we use is a little different from the usual sick traveler we typically performed. Of course, we do a thorough history and exam including asthmatic exposures, travel dates, malaria, prophylaxis adherence, vaccination history, and sick exposures both within the - in the Ebola-affected country as well as back here in the U.S. And we do - for testing, we do fairly aggressive routine lab testing and potentially much more than we typically do in a non-PUI patient.

As for Ebola testing, however, we consider it. However, this is not routine. Again, any patient who is highly likely to have Ebola or we have significant concern about that would be likely triaged elsewhere. And, again, therefore the goal is that the patients we’d see in the clinic are unlikely to need - or to have Ebola testing as indicated.

Finally, we strongly consider empiric treatment, such as olsetamivir for influenza or possibly antibiotics if we suspect a bacterial infection or possibly even empiric anti-malarials. And the key goal, really, is to not miss dangerous, treatable infections while confirming an alternative diagnosis, if possible, though, of course, we always keep in mind that an alternative diagnosis does not rule out Ebola.

We are aggressive in our treatments because we like - we try to treat the likely cause of illness to facilitate recovery. And then, we consider a patient that recovers, as would be expected for an alternative diagnosis be essentially ruled out.

On the next slide, I go into more detail about our lab testing. Our routine panel of labs for the febrile PUI includes that CBC with differential, a complete metabolic panel, a malaria rapid diagnostic test and smears as well as two sets of blood cultures. We consider other tests according to symptoms and somebody with respiratory symptoms, we may do nasopharyngeal swab for rapid influenza PCR and viral respiratory panels.

We may do throat swabs for strep. We may consider a urine study if they have urinary symptoms. And this is all collected in the room. We label and package the specimen in the room. And, again, in the usual setting where we do not strongly suspect Ebola and are not pursuing Ebola testing, we then actually have the specimens transported to our routine hospital lab where the testing is performed.

On the other hand, if we were to pursue Ebola testing, we do have a separate procedure where the specimens – all specimens - are specially packaged and transported under a - special precautions to our Serious Communicable Diseases Unit and Laboratory for Ebola testing as well as routine tests to be done there.

On their next slide, we describe our disposition or follow-up procedure. If we do not suspect Ebola and the PUI is clinically stable, we will discharge them home to self-isolation. We might, sometimes, wait for initial STAT lab test results such as the CBCs, MP, the metabolic panel, and the malaria rapid diagnostic tests to provide supporting evidence that there’s no indication for immediate hospitalization. Of course, we always review our disposition plan with the public health authority before proceeding and make sure we’re all in agreement. We give the PUI a 24/7 contact information for our clinic’s physician and after discharge, we follow them very closely. We typically call them that evening and also the next day to reassess them and confirm that they are – appear to be recovering as would be expect for whatever alternative diagnosis we suspect. Anyone who worsens or has persistent symptoms is brought back for more evaluation and potentially Ebola testing. And should we bring them back, we again reassess them and determine whether or not they are best seen in our clinic versus another setting like the emergency department. Next slide, a few notes just on waste management and environmental cleaning.

When we do discharge a PUI, if we are not suspecting Ebola, our environmental services team conducts a terminal cleaning of the room. All disposable equipment is disposed of in the biohazard waste chain. Alternatively, in the situations where we have a high suspicion of Ebola and we are, you know - for example, pursuing Ebola testing - potentially, we would have cleaning done by our - a special team from our Serious Communicable Diseases Unit.

My last slide here really just emphasize that advanced planning is critical. You know, the coming up with this procedure took a long process. We had to engage all the various stakeholders in the planning and support from our institution was key. Practice was critical including a mini-drilled tabletop exercises. And finally, each time after we’ve implemented this procedure, we’ve reviewed how things went and looked for ways to improve the process. And that’s the last of what I’m covering.

Thanks for your attention. I’ll turn it over to Loretta for the questions.

Loretta Jackson Brown:
Thank you, presenters, for providing our COCA audience with such a wealth of information. We will now open up the lines for the question and answer session. Questions are limited to clinicians who would like information on PUI for Ebola. For those who have media questions, please contact CDC Media Relations at 404-639-3286 or send an e-mail to media@cdc.gov.

Operator.

Coordinator:
At this time, to ask a question, press star 1 please. Please unmute your line and record your name to be introduced. Again, for all questions, press star 1. If you’d like to withdraw the request at any time, you may press star 2. Thank you.

One moment please for your first question.

Loretta Jackson Brown:
And while we’re waiting for the first questions, just a point of discussion to our presenters. Why isn’t Ebola testing done on everyone?

Dr. Henry Wu:
Okay, this is Dr. Wu here. And it’s a very good question and it was much as a practical as well as a clinical decision. As I mentioned, even in our institutions, the turnaround time for Ebola testing can be extended. And, obviously, it does take a lot of resources to perform. So, given the number of PUI, you know, we were anticipating to see, it didn’t seem practical to pursue Ebola testing on everybody. Furthermore, again, in the outpatient setting at least, we are typically seeing folks very early in the course of their illness when the testing itself may not even be very sensitive. So given the low suspicion as well as the practical issues, it seems that routine testing would not have been a practical or even medically necessary.

Loretta Jackson Brown:
Thank you, Dr. Wu. Operator, do we have our first question?

Coordinator:
Yes, we do. As a reminder for others, again, for questions, press star 1. Our first question is Dr. (Rossi Hassad). Your line is over.

Dr. (Rossi Hassad):
Dr. (Rossi Hassad), Mercy College - I’m concerned about the accuracy of diagnostic testing, especially rapid diagnostic testing. What has been your experience regarding false negatives and false positives, I guess, in this case, particularly false positives?

Dr. Henry Wu:
Are you referring specifically to Ebola testing or other diagnostic testing?

Dr. (Rossi Hassad):
Ebola testing - yes.

Dr. Emily Koumans:
Oh, so, yes, there’s a - it is well known that the PCR test for Ebola, even if it is a PCR test in the first 72 hours may not necessarily pick up Ebola for someone who does have Ebola. It - so in West Africa, for example, where the prior probability for someone having Ebola is higher and their exposures are probably more than the typical traveler who comes back to the United States, the testing may get done early.

But if someone is, you know, has had symptoms consistent with Ebola in that setting, they are often isolated and then the testing is repeated. In the United States, it’s really a - as Dr. Wu suggests, it’s a clinical judgement as to whether or not Ebola testing is even needed. And our experience in the Clinical Inquiries Team at CDC is that many PUIs do not need Ebola testing and often will be improved after 72 hours, at which point, Ebola testing certainly isn’t clinically indicated if someone has been afebrile and has no more symptoms.

Does that address your question?

Dr. (Rossi Hassad):
Well, I was wondering at the more granule level, have you had PUIs who, upon screening, rapid diagnostic testing screened positive but that wasn’t confirmed?

Dr. Emily Koumans:
No. No, we have not had any positive screens for Ebola.

Dr. (Rossi Hassad):
Okay, thank you.

Coordinator:
Thank you. Next question - (Warner Hudson), your line is open.

Dr. (Warner Hudson):
Hi, this is Dr. (Warner Hudson) from UCLA Health System, Reagan Hospital where we’ve done a number of rule-outs. Can you talk about the experience of, as clinicians caring for persons under suspicion and being a member of the Ebola team, the experience of the monitoring, the logging - how that whole process went for you as clinicians?

Dr. Henry Wu:
Are you referring to monitoring after we see them - a PUI in the clinic or are you talking about just the active monitoring after travel?

Dr. (Warner Hudson):
Well, I’m talking about the people who are really caring for Ebola patients - so the monitoring would start once you realize you have an Ebola patient that would continue until the end of the incubation period.

Dr. Emily Koumans:
Oh, so the health - you’re talking about the health care workers...

Dr. (Warner Hudson):
Correct.

Dr. Emily Koumans:
Who would need to monitor themselves…

Dr. (Warner Hudson):
The healthcare workers...

Dr. Emily Koumans:
Because they were part of the healthcare team?

Dr. (Warner Hudson):
Correct - who were being monitored.

Dr. Emily Koumans:
Right. So those - they would be part of the routine monitoring in those states and they would be entered into the state monitoring system. But we haven’t had that recently. I think Nebraska, the - and NIH has had some recently.

Dr. (Warner Hudson):
Is the - just trying to get a sense of how that went for the clinicians involved.

Dr. Emily Koumans:
Do you have any experience of how they went at Emory?

Dr. Henry Wu:
No, I don’t have any information on that. But I think, just as Dr. Koumans mentioned, they’re subject to the same guidelines and policies as anyone who has traveled and had similar exposures.

Dr. Emily Koumans:
Right. So I think that those temperatures twice a day and reporting - I think that’s the extent of it.

Dr. (Warner Hudson):
Right. I mean, it’s a lot of people and you’ve got people in the hospital monitoring, you got health departments monitoring. Just wondering how it goes. I’ve heard differing reports from Emory, Bellevue, Nebraska. Anyway, we’ll hold that for another session, I guess. Thank you.

Dr. Henry Wu:
Thank you.

Dr. Emily Koumans:
You’re welcome.

Coordinator:
Thank you. Again, for questions from the phone, press star 1 please. Our next question comes from (Anita Very). Your line is open.

(Anita Very):
Thank you. I’m calling from the Boston Public Health Commission and I’m trying to clarify if precautions used by your laboratory for testing specimens for a PUI vary depending on the clinician’s diagnosis.

Dr. Henry Wu:
Hi. So, I - if you’re referring specifically to our Emory Health System Laboratory, that’s a very good question. We, essentially - what I was describing is really a two-tiered approach for our PUIs. If - you know, if the setting where we are suspicious enough about Ebola where we are going to pursue Ebola testing, then the lab testing is performed in the - in a - in the laboratory that is within the Serious Communicable Diseases Unit.

So that is our specialty Ebola treatment unit. For the PUI that we determine after our clinical assessment that are unlikely to have Ebola, we actually have - our lab actually tests them. A routine onsite lab does do the testing for the routine testing -- our CBCs, blood cultures, etcetera.

So - and, you know, they use - the standard precautions that would be recommended for clinical laboratories.

(Anita Very):
Thank you. That’s been a huge issue in some of our health care facilities in Boston.

Dr. Henry Wu:
Oh, and I certainly - I would say, you know, we got to this point. You know, it was not certainly a decision that was just made off the bat; this was just something that, you know, with a lot of discussion and review of recommendations and guidelines that we came to. We’ve been - more than comfortable with that.

(Anita Very):
Thank you.

Coordinator:
Thank you. Again, for any questions, press star 1 please and please record your name. Again, press star 1.

Loretta Jackson Brown:
Operator, do we have any questions in the queue?

Coordinator:
It looks like we do have one in queue. Stand by please. Alright, thank you. We have a question from (Stephen
Bach). Your line is open.

(Stephen Bach):
Thank you very much for the great webinar. I have a quick question about your clinic setting. I like your setup with that safety person in the doorway to be the assistant to make sure the donning - and particularly the doffing - of PPE is done safely and appropriately. What happens when your clinic has a door that is solid - you can’t see through it? Do you stand there with the door propped open?

Dr. Henry Wu:
Good question, actually. That is our clinic. The door is open.

(Stephen Bach):
Okay. You do leave it open.

Dr. Henry Wu:
And it’s - and this buddy system - really, the direct - we directly adopted from the protocols from our Ebola treatment unit at Emory where they very - you know, adhered to the system very strictly of constantly monitoring each other.

(Stephen Bach):
Sure. Great.

Dr. Henry Wu:
And if we do not - we have a standard clinic - the door is closed so we - it is open. And, you know, it does require us to secure that whole hallway so as to - for privacy issues and various reasons. So, I’ll be the first to admit that the - being a PUI in our clinic, it’s not small deal; this is not a 40-minute visit and, you know, patients before and after.

We do a lot of juggling of our schedules. It takes up at least four, if not more, of our staff time - several hours. So it is very resource-intensive on our end but I think in the bigger picture is - it actually saves in other ways.

(Stephen Bach):
Sure. We - our concern is that the patient shows up to the clinic visit for other purposes and then says, and by the way, I also have these symptoms. And so the triage starts at the front desk and then we have to put this person in an exam room and kind of close off a portion of the clinic to then respond to this. But it wasn’t the big plan to come to our clinic as a PUI. They become a PUI upon arrival.

Dr. Henry Wu:
Yes. We do - I didn’t go into detail into Emory’s screening process, but that is all of the concern. At the moment, any patient making an appointment at Emory is actually, on the phone, asked if they’ve traveled and have symptoms.

(Stephen Bach):
Right.

Dr. Henry Wu:
So the hope is that we catch them even before they make an appointment.

(Stephen Bach):
Okay.

Dr. Henry Wu:
But should somebody unexpectedly arrive as a walk-in or did not offer these - this history or symptoms in advance, the - our front desks of all our clinics are instructed to perform essentially what you just mentioned - to immediately isolate the patient. And then at that point, then, they would contact our infectious control department. And then at that point, arrangements would be made to have that patient be transported appropriately.

(Stephen Bach):
That’s great. Thank you so much.

Coordinator:
Thank you. Next question is (Susanne Fasuli). Your line is open.

(Susanne Fasuli):
Hi. I missed part of the phone call and I wanted to know what do you do with all of the patient care equipment once the patient has been, you know, gone through the whole regime of being an Ebola or patient under investigation? Do you just destroy everything or what?

Dr. Henry Wu:
We try as much as possible to use disposable equipment that includes the, you know, disposable isolation stethoscope, we used the disposable BP cuff, a battery operated thermometer, etcetera. The equipment that are not as easy to dispose are cleaned - terminally cleaned - and wiped down appropriately. So - but the idea is to maximize the amount of disposable equipment. The room is stripped down of excess furniture, decorations, everything to really minimize the amount of surface area that we would need - that would need to be cleaned.

(Susanna Fasuli):
Okay thank you. The reason I’m asking is because we have a designated area and - for a patient should we get one. And we were going to set up like an - like, a lab next door but we - the lab manager is wanting to use that piece of equipment because it’s just basically sitting in the basement now. And so she was thinking that we could take the small lab equipment and put it in the room and have the lab nurse - I mean, the nurses do the test and I’m not thinking that’s a good idea.

Dr. Henry Wu:
I would - yes, I would agree that - yes, any less complicated surfaces to clean is going to be a - make things much easier, you know. And we try as much as possible to triage PUIs who might have wet symptoms not to come to clinic but you know, our concern is that if somebody develops wet symptoms, does have vomiting and etcetera during the visit, we have to be prepared to handle that situation.

(Susanna Fasuli):
Yes, okay, I appreciate that. Thank you.

Coordinator:
Thank you. Next question - (Tammy Chandler), your line is open.

(Tammy Chandler):
Yes, I was just wondering how do you treat staff that have either taken care of the Ebola patients or a person under investigation after they’ve taken care of these people, during their 21-day monitoring. Are they - excuse me - mixed back into staffing and patient care duties or are they off work for the monitoring time?

Dr. Henry Wu:
There’s no restriction - work restriction - during the monitoring period.

Loretta Jackson Brown:
Operator, are you there?

Coordinator:
Yes. Is she finished with the question?

(Susanna Fasuli):
Yes, that’s all I needed.

Coordinator:
Thank you. Our next question - (Russell Eghart). Your line is open.

(Russell Eghart):
Hi. Yes, I was going to get back to the question previously about rapid testing. So there was a - the FDA issued an emergency use authorization for an Ebola rapid test. I think it was about a month or so ago. I take it that they’re not utilizing the test in Emory or are you aware of anybody in the U.S. using the test or if there are plans to use it as a screening diagnostics tool or do you think it’s probably just better to rely on the typical molecular test?

Dr. Emily Koumans:
Thank you for the question. I believe Emory does have the BioFire test. BioFire is actually a platform that’s used for multiple pathogens. It’s very useful for screening but for the EUA - for Ebola - what we understand is that the BioFire may be a three-bullet in conjunction with the PCR tests but they should be run concordantly.

So you would - you might have one test result earlier than the other but they would both be run - and in a sense, the Bio - the PCR test is being done to sort of quality control and make sure that the BioFire results isn’t used so that - used appropriately.

(Russell Eghart):
Okay, I was actually referring to the - I’m not sure how this is pronounced - the Re -E-B-O-V Antigen Rapid Test, which is - apparently gives - can give you a result in 15 to 20 minutes.

Dr. Emily Koumans:
I don’t know if we have recent experience with that.

(Russell Eghart):
Okay, thank you.

Coordinator:
Thank you. And as a reminder for questions, press star 1. Our next question is (Genevieve). Your line is open.

Dr. (Beatstrom):
Yes, good morning. Thank you for that great presentation. My name is Dr. (Beatstrom) with the Oregon Health Authority. Had a question about your interactions with the local health departments and perhaps how you coordinate with them if one of the persons under monitoring become symptomatic and have you built up relationship - just curious - around that - for the controlled evaluation of PUMs who become symptomatic? Thanks.

Dr. Emily Koumans:
Yes, thanks for that question. So the Domestic Clinical Inquiries Team takes calls and e-mails - gets e-mailed questions from state and local health departments and public health authorities. The phone number for anyone who wants to call is 770-488-7100.

And the team is here 24 hours a day, 7 days a week; there’s always someone who could be reached and who is able to not only takes the information, but also collect a team here at CDC who is able to help address any questions or provide, sort of, guidance in management. So we try - sometimes we need a conference call to do that; sometimes we can provide answers if it’s a short question.

But, generally, we try to help the health departments in navigating the variety of issues that come up for PUIs and their management whether that’s, you know, the duration of the hospital stay or there might be some media questions, the alternative diagnosis testing - there are also experts here at CDC to address those issues.

So we’re always happy to help and really just to try to provide guidance and support for the decisions that folks there in the hospital and in the health departments need to make. Does that help?

Dr. (Beatstrom):
Thank you. And I was wondering if - sort - I was wondering - also wondering, Dr. Wu, if that clinic has become - if they are coordinated with the local health department so that no PUMs in the area who become symptomatic or if they’re being - using the Emory clinic and that great setup that’s been put together there to assist with evaluating PUMs who aren’t - you know, don’t have any wet systems - symptoms and aren’t sick enough to go to the ED.

See what I’m saying - I was wondering...

Dr. Henry Wu:
I work closely with the health departments and they certainly knew how to reach us. I wouldn’t necessarily say I’m - we - there are various points of contacts at Emory, obviously. We have our colleagues and our Ebola treatment unit and infection control. And then, really, we over - we all work together when we hear about something. So - but - so, in short, you know, when we are notified of a patient, you know, we collaborate with each other and we have developed ties with the health departments.

Dr. (Beatstrom):
Thank you.

Coordinator:
Thank you. Our last question comes from (Eva Palmer). Your line is open.

(Eva Palmer):
Yes, hi. Thank you. My question is for Dr. Wu regarding some of the information that was presented on the ambulatory site. And we - you know, we’ve been, on a rare occasion, working collaboratively with our local public health departments. So it hasn’t been something that we - is something that we think will probably happen, but what our one question is is as we are a hospital with many ambulatory sites so we’ve built in workflows for the ambulatory sites in case they were to have a walk-in patient.

So the one thing that we’ve not been able to really identify clearly is if they walk in, we’re wondering what your experience were with this if they walked in and they were screened at - you know, at check-in to be a person of concern - not necessarily a PUI at that level. They were, you know, put into an isolation - you know, a designated room.

At what point, if they’re dry - we’ve actually had some pushback by staff -- if they’re a dry patient, what – where do you go into advanced PPE? I mean, if they’re if they were to happen to come to your Emory ambulatory area and they were a dry patient - made it that far - would you, prior to really establishing them being PUI, do anything more than standard precautions or minimal PPE?

That’s really my question.

Dr. Henry Wu:
That’s - so you’re talking about not necessarily folks who present to our clinics but other ambulatory sites.

(Eva Palmer):
Potentially someone who would make it through, who gets screened at check-in to be a positive traveler, maybe with a fever. So they get put back into a room and then staff need to go in and do additional questioning. So our ambulatory sites are convenient care - specifically, they have wanted to put on full PPE -- so, enhanced PPE, PAPR [powered air-purifying respirator], you know, everything even though the patient is not wet.

I was just wondering have you, in your processes there, would you have someone do an assessment for PUI status prior to donning full PPE?

That make sense?

Dr. Henry Wu:
That’s a very good question. And I think you’re correct. I think just because somebody has triggered the flag and is correctly isolated does not necessarily mean that staff need to come in in full PPE. And obviously, there are practical issues if we’re talking about multiple ambulatory sites. And as you, I’m sure, are already aware, PPE involves not - you know, a lot of expense and training to properly use.

(Eva Palmer):
Yes.

Dr. Henry Wu:
So it’s not as simple as, you know, sending PPE kits to all the ambulatory sites. But the most important thing is just keeping distance, obviously, as, you know, as the patient is assessed. And, you know, the way our procedure would work, our clinic would immediately notify our infection control department to further evaluate the patient to determine if, you know, potentially, there’s a, you know - PUI criteria are met.

And since you brought up the PPE question, I will say that in our ambulatory setup at Travel Well, we use the lower-level PPE, not the pappers on the routine, you know - not by any means - again, this is the gowns, double gloves, face shields, you know, head bonnet, two coverings, etcetera, but we are not using pappers or, you know - and you know, our exam room is not negative pressure, you know. So I mean - so I should probably make that clear.

(Eva Palmer):
Well, I appreciate that, yes; right, right. You know, we - you know, we’re pretty confident in the public health system alerting us to folks in the area, but, you know, if just one came through the - we have kind of a pushback with staff wanting to come out to a waiting area to gather someone in, you know, full bio-terrorist gear doesn’t seem practical.

You know, there seems to be the - but I like the idea of the distance; I appreciate that.

Dr. Henry Wu:
Yes, and I - you know, I - and we’ve always gotten all kinds of feedback like that from our staff. And it’s important to consider that. I’d like to emphasize to my own staff that anyone who presents in our clinic setting and who just happens to walk in is likely going to have to be somebody with mild illness and presenting early in the illness course.

And so even in that really, really small chance that it is a true case that somehow just, you know, appears suddenly, it probably is extremely low-risk. I mean, we still - you know, precautions should be made but there – but again, I think just explaining that and - goes a long way in relaying staff concerns. The way our staff has – and our staff has gotten very used to us - as well as our neighboring clinics who don’t directly participate.

But they know we are just being extra careful, just in case. And if anything, they’re more comfortable with that fact because we are all aware that there are many folks traveling, coming back and forth and the fact that we do - are very careful, we catch things early. And if anything, we know we are taking plenty precautions.

I think that really reassures our staff.

(Eva Palmer):
Very good. Thank you.

Loretta Jackson Brown:
On behalf of COCA, I would like to thank everyone for joining us today with a special thank you to our presenters -- Dr. Koumans and Dr. Wu.

If you are a member of the Guinean Diasper in the U.S. and are a medical professional with clinical, public health, or epidemiology experience and you would like to volunteer as a healthcare worker, there are a number of organizations providing those services in regions of Africa where the Ebola epidemic is occurring.

For example, doctors without borders or U.S. AID. If you do volunteer as a healthcare worker, ensure to stay up-to-date on treatment information through COCA. If you would like to provide logistical, material, or financial support, you can do so through donations to organizations such as the CDC Foundation, Doctors Without Borders, UNICEF, or the Robert Wood Johnson Foundation among others.

Information about non-federal organizations are provided as a service to our audience and are not an endorsement of these organizations or their programs by CDC or the federal government. CDC is not responsible for the content of the individual’s organization website.

The recording of this call and the transcript will be posted to the COCA website at emergency.cdc.gov/coca within the next few days.

Free continuing education is available for this call. Those who participated in today’s COCA conference call and would like to receive continuing education should complete the online evaluation by April 30 using course code WC2286. If you will listen to this call on-demand, you will need to complete the online evaluation between May 1, 2015 and March 31, 2016. Use course code WD2286. All continuing education credits and contact hours for COCA conference calls are issued online through TCE Online - the CDC Training and Continuing Education Online system at www.cdc.gov/tceonline. To receive information on upcoming COCA calls, please subscribe to COCA by sending us an e-mail to coca@cdc.gov; write subscribe in the subject line.

Also, CDC launched a Facebook page for our health partners. Like our page at healthpartnersoutreach to receive coca updates. Thank you again for being a part of today’s COCA call. Have a great day.

Coordinator:
Thank you for your participation. That does conclude today’s conference. You may disconnect at this time.

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