MINISTRY or- EALTH mqu mme Response to Suspected Ebola Virus Disease Cases in New Zealand: Key themes from sector and Ministry debriefs July 2015 Background complexity of the outbreak resulted in the World Health Organization decl - - Health Emergency of International Concern (PHEIC), under the Inte an 2005. While the risk of Ebola was very low, the New Zealand a enhanced their readiness for a potential Ebola ca? While some activity has been EVD-speci? as cap hospitals, much of the other actii' rea Activity over the last 12 . ing in the international Ebola response. This included a 21-day self-monitoring - from the date of departure from the Ebola-affected country, and daily contact - blic health unit raining5 exercising and enhancement, of four referral hospitals (Auckland, Middlemore, Wellington and Christchurch) which were preferred hospitals for de?nitive care of a con?rmed EVD patient - supporting the development of SOPs and training for clinical staff from receiving hospitals, St John and Wellington Free Ambulance staff on the correct use of personal protective equipment (PPE), medical waste disposal and specialised equipment - purchase of specialised equipment; to transport suspect or con?rmed EVD patients who mayr pose an infection risk (Isopods) and iStat point of care testing machines for each of the four referral hospitals 1 From the introduction of additional screening on 10 August 2014 until 27 July 2015, 147 persons have been identi?ed through enhanced New Zealand border screening as having travel history to Sierra Leone, Guinea or Liberia in the 30 days before arriving in New Zealand. Of those, 48 have been returning humanitarian aid workers 42 of whom completed 21 days of self-monitoring in accordance with Ministry of Health protocols. The other six aid workers had no high risk contacts so were not required to undergo self-monitoring. Response to Suspected Ebola Virus Disease Cases in New Zealand 1 0 development and maintenance of SOPs and clinical guidance for the sector including primary care - provision of public information and information for health professionals through a variety of media 0 managing elements of the deployment and return and self-monitoring for New Zeal and resident health care workers and humanitarians working within the response. The intent of this report is to highlight key thematic issues that have emerged from recent operational debriefs and planning activity and share these with the sector to inform current work. These issues will also be addressed within the current work to revise and update the 2004 National Health Emergency Plan for Infectious Diseases (NHEP Infectious Disease Plan /5 r? Key themes A \5 Coordination of readiness activity - v. of pandemic . - 1% a across the health .1 regional and local responses includi . and 2010 Canterbury earthquakes, RENA ship groun - i- -: ous local events. Key principles such as the Coordinated I - are well understood and in most areas there are effec - . . . . together clinical and non?clinical areas to address emergi - 's 'ng the NHEP Infectious Disease Plan which will update merg infectious disease. It is recognised that the current NI-IEP . . veloped in 2004 post-SAKS and was effectively superseded by the All mergency Plan and the New Zealand Influenza Pandemic Action Plan. . on infectious disease management and focuses on overall coordination. - 0 ed NHEP Infectious Disease Plan needs to articulate elements of the technical response, '11 an overarching framework provided by the NHEP. Speci?c elements need to include: a description of scalable infectious disease management capability in public health, primary care, ambulance, tertiary hospitals and the Ministry of Health - establishment of an Infectious Disease Technical Advisory Group with core membership able to provide broad and speci?c advice on emerging disease threats in the same manner as the Ebola Technical Advisory Group. Membership may be altered to incorporate speci?c clinical expertise in a particular disease threat; however the core areas of IPC, intensive care, infectious disease, laboratory clinical microbiology, and primary care served EVD readiness well. It may be necessary to consider some other areas such as Chief Operating Of?cers, public information management and ambulance sectors - a framework that provides for infectious disease management across a range of disease types and transmission methods from a single imported case to respiratory disease with pandemic potential 2 Response to Suspected Ebola Virus Disease Cases in New Zealand - further development of intelligence, communication and decision support tools. Information dissemination worked effectively by email to single points of contact, health sector emergency managers, medical of?cers of health and public health unit managers. Strategic communication was undertaken with joint letters from the Chief Medical Of?cer and Chief Nurse to the sector. Most information was also posted to the Ministry of Health website, and the primary care sector also utilised information ?ow via the Royal New Zealand College of General Practioners and their electronic newsletter (e-pulse). Health EMIS was also effective for sharing protected information within a secure cloud. Infection prevention control Appropriate infection prevention and control (IPC) is a critical aspect to manag infectious patient. Good IPC protects staff and patients, and the revision of Diseases will provide clear guidance on what capacity and capability sh a need to ensure a common understanding of baseline capacityi and business as usual across primary care, ambulance and trigger point for undertaking additional training or ex Additional IPC issues emerged and were man $21 as di - .- care, private homes where a patient may 1 ill, ai a communication with members of he. Key principles to be inco 0 IPC needs to ads need to have the capacity to engage and support readiness activity in as outside a traditional hospital setting . - ciated PPE and training frameworks need to be considered in different settings such 'mary care and tertiary. 0 People capability - EVD required a subset of clinical staff in referral hospitals and ambulance to become competent in a much higher level of PPE than they would normally operate in. High nursing ratios, and heightened public awareness, especially following the Texas cases, exacerbated staf?ng issues. 0 Practical staf?ng plans need to be developed by all tertiary and likely referral hospitals that provide for the maintenance of high level skills and knowledge in a small cohort of staff, with surge plans to deliver rapid training and exercising in the event of an emergent threat. - Training and exercising needs to he graduated and comprehensive. Practical skills and procedures should be practised once training in donning and dof?ng is completed. - Surge plans should also include refresher trainings and brie?ngs for staff immediately before the arrival of a suspect patient. It is quite possible there may be a couple of hours? notice and this should be used for ??nal rehearsals?. This must also be balanced with the need to safely manage a no notice presentation direct to a facility. It will be challenging to maintain competency and skills for high level PPE use with few, if any, actual presentations. Response to Suspected Ebola Virus Disease Cases in New Zealand 3 0 Clinical staff with practical experience in the 2014/15 Ebola outbreak or other disease events should be identi?ed locally and a plan developed to engage them for input or mentoring. - Pandemic HR guidance should be updated to address emerging infectious diseases. a Medical Council and NZNO Pandemic and Disaster Guidelines should be incorporated into the revised NHEP Infectious Disease Plan. - DHBs need to plan for inter-DHB surge support, including scenarios where a patient cannot be moved to a preferred referral hospital. Impact of PPE and high care ratios may mean that even large hospitals may quickly exhaust their local resource. DHBs identi?ed different approaches to managing and developing this resource. - Standardisation of high level PPE and associated IPC practices would better enable inter-DHB support. - National and local planning groups need to continue to work together to ctice PPE and IPC evolved globally throughout the 2014 15 EVD response. Personal protective equipment (PPE) The receiving hospitals hold relatively low volu manage a con?rmed EVD case much larger - At the height of EVD readiness, there we - high level PPE dif?cult to use. Innovations in 'ng that PPE ensemble and donning and dof?ng response in West Africa, but that not all may be transferrable eferral hospitals developed their training scenarios from simple PPE donning and dof?ng to practising patient transfer, treatment, waste management and emergency procedures in PPE. Waste management 0 The events highlighted that existing waste storage and management protocols at the hospital may have struggled to cope with the volume of waste created by a con?rmed EVD case. 0 As the majority of hospital waste is category Baor less, hospital planning groups need to ensure they have contracts established with medical waste companies in order to provide and manage suitable category A waste containers in suf?cient volume at the time of a suspect case or other event generating category A2 waste. 0 Primary sector should ensure that their IPC guidelines for medical waste management for routine presentations are known and understood and that these re?ect the escalation via public health units in the event of assessing a con?rmed EVD case. 2 See UN 2314 Infectious substances 4 Response to Suspected Ebola Virus Disease Cases in New Zealand a Management of medical waste during patient transfer needs to be planned for. Case management Health agencies worked effectively with border management agencies at national and local level and Customs provided effective pre-screening and initial border screening for travels from the affected countries. - Following the Gore and Nelson suspect EVD cases, the Border Risk Assessment and Guidelines for Health Care Professionals have been rewritten to strengthen the requirement for a suspect case to be assessed by an infectious disease specialist or clinical microbiologist. - The infectious disease clinical network should ensure that they are con?dent .. er a local infectious disease clinician or a clinical microbiologist is able to be deplo i - . 'ary .- 1vate hospital to assess a suspect case in either a hospital without that spe .. - Early clinical assessment will inform the most ef?cient a - .. - fer op th'; atient, clinical staff and the public, as well as the most ap . . I There was a high degree of self-monitoring workers, meaning - Early clinical assessment will a a anagement to start early, optimising patient outcom - DHBs need to plan fo clinicians mana referral etween their public health unit and lude liaison across several PHU areas and a a 1en as identi?ed in. The Ministry will continue to identi?cation or coordination of specialist resources rel. the 10 - - ndertook considerable work to enhance their capability to manage a modi?cation and ?t~out of ward areas. This work was commensurate with imely and appropriate. The work and effort of staff involved was critical to not feasible for many facilities to provide totally separate isolation of these treatment areas. Planning for an EVD case in some areas therefore disproportionately impacted the operation of the hospital including closure of ward areas in order to ensure effective isolation. Middlemore Hospital was fortunate that they were able to dedicate and develop a wing as a dedicated ?bio- containment? unit. i the low likelihood of highly pathogenic emerging infectious disease in New Zealand, it is - Conversely the geographic population distribution in New Zealand and patient transfer challenges necessitated multiple centres for EVD. Restrictions on self-monitoring location, i.e. a requirement to stay in Auckland, were not appropriate for a variety of reasons and New Zealand was recognised for its proportional and appropriate response under the International Health Regulations. - The four referral centres should, in the short term, retain their planning and operating procedures to utilise their pre-identi?ed EVD isolation areas in the event of an emerging infectious disease. 0 The NHEP Infectious Disease Plan needs to articulate the expected level of capability for emerging infectious disease in primary care, ambulance, and receiving and referral hospitals, noting that referral hospital (5) for a speci?c emerging infectious disease may best be determined Response to Suspected Ebola Virus Disease Cases in New Zealand 5 by the proposed Infectious Disease Technical Advisory Group at the time. Planning needs to recognise that emerging infectious diseases will likely require a disease-speci?c response against a baseline capacity. 0 Several other high income jurisdictions modi?ed their triage and assessment process in the latter stages of domestic readiness so that suspect EVD patients presented at the nearest medical facility where their medical condition was then reviewed by a clinician and an Infectious Diseases Technical Advisory Group expert to determine transfer to a referral centre or not. This approach is essentially consistent with our existing plan, which includes the possibility that a patient may ?rst present at primary or secondary care. The advantage of this approach is that the ?at?risk? patient has early access to medical care irrespective of where they are located in the country. The disadvantage is that delays in diagnosis may mean that the patient cannot be on-transferred to one of the four speci?ed treatment centres. The main objective of triage via a he re system is that patients can be clinically assessed and transferred as early as possible atment th 0 initiated. This is an important lesson from the Gore and Nelson cases? etha - a i iate for EVD st app for them. determining the clinical needs of the patient and what form of tr - of awareness in because of the gradual onset of 1' The alternative to this is to restrict the distance from . - . contact can reside at during the incubation peri d. i returning health care workers. It may a} . recommendation from the Infec is - foro ech' speci?ed referral hospitals.@ Patient tr ases we to Christchurch and Wellington referral hospitals ebrie examined arrangements for both ambulance and helicopter way to enhance this capability: enhance this process and increase the level of clinical care provided to a suspect case before being placed in an Isopod and during the ?ight. Life?ight Auckland is no longer the ?xed wing aeromedical provider for Auckland DHB and readiness work is now under way with the new provider, New Zealand Air Ambulance Service (NZAAS). - Simulation training for ambulance staff, with input from a clinician with experience in an Ebola treatment centre would be bene?cial to improve clinical care and support during the transfer. a The size of the Isopod means it is impractical to deploy it within a BK117 or Squirrel helicopter (used by the majority of aeromedical providers) and effort was concentrated on arrangements with the 8-76 helicopter utilised by NEST. The 3-76 has numerous advantages over these smaller helicopters including large cabin, high speed, high levels of crew comfort and extended range. However NEST is based in Auckland and Whangarei and the 8?76 is likely to be replaced in the next few years. 6 Response to Suspected Ebola Virus Disease Cases in New Zealand 0 Until then the 8-76 should remain the preferred civilian helicopter platform due to its internal size, speed and operating range, however planning needs to be enhanced to better de?ne triggers and timeframes to ensure as effective a response as possible to along distance mission. - The AME capability, across civilian and military, rotary and ?xed wing, needs to be documented and endorsed by stakeholders, including any service restrictions or limitations. - During the response to the Nelson case, it was assessed that the patient was and that transfer by Isopod was not clinically required. However no aeromedical provider had been engaged on the possibility of transfer Without an Isopod, and the default planning assumption had always been that transfer by air would be in an Isopod for an to moderately unwell patient. - AME providers, other than those engaged in the readiness planning, had little engagement and were unwilling, in spite of extensive clinical and manager'a transport a suspect EVD case without an Isopod. Signi?cant delays a making transport arrangements that deviated from the agreed . - New Zealand Defence Force (NZDF) provided an NH-go transport a patient in PPE only from Nelson to Well? a capability in this area to support future missio - provider of last resort. ational Ambulance Sector . 6 ere suitable and should continue. 2015 with New Zealand Air Ambulance nistry of Health, NASO and NZDF to con?rm - Transport costs for aeromedical transfe rally Of?ce (NASO) as an exceptio .u - eMi The Ministry purchased modi?ed Isopod and iStat point of care testing machines to use in the transportation and testing of suspected EVD cases. DHBs led the procurement of a wide range of consumables, especially higher level PPE ensembles that were not previously used in the sector, as well as fit out and modi?cation of identi?ed ward areas. The Ministry and referral hospitals worked together to ensure that contracts for areas such as clinical waste management were met. Globally there was a shortage of many items of higher level PPE during the initial stages of the response. There are very limited isolation transport options and New Zealand lacks commercial or military aircraft equivalent to the small number of aircraft in the US or Europe that are large enough to use other isolation systems. Isopods have been modi?ed and used for air transport by Western Australia ?ying doctors since SARS in 2003 and no viable alternative seems to have been developed in the interim. Response to Suspected Ebola Virus Disease Cases in New Zealand 7 Suspect EVD case management Pre?hospital The Gore and Nelson suspect EVD cases were identi?ed by their public health unit in response to self-monitoring by the returned health care worker. Both patients were located in smaller DHBS and a transfer to a referral beepital was initiated. a The transfer of suspected EVD patients from Gore and Nelson generated signi?cant media interest. 0 The Ministry followed normal procedure around maintaining patient privacy; however the very high level of media interest, information available on social media, and a family member choosing to speak to media, meant maintaining anonymity was dif?cult. The media obtained personal information on the patients, including photos networking sites. In the second case, early advice was provided to the ing to protect their privacy on their social media accounts. Calls from media to the patients? phones made it dif?cult During the ?rst case, ambulance staff reporte transport from home to the receiving ho emotional support or contact from crew in the transfer may address this Dedicated contact need - ed and PHU and the patie - t. apre-h clinical care, support and - ia han ould be planned for. Depending on the disease type and a n_ {1ous dvisory Group, alternative patient pathways may be used . ferral hospital for initial assessment, this approach has been fully . - ll, transfer type and destination as well as the public health response. ological and clinical support should also be arranged for the patient while transport options . being arranged. In hospital The Gore and Nelson suspect cases were accommodated in isolation rooms at the receiving hospitals. - Patients found the isolation environment very challenging due to long periods with no contact and the inability to take any personal items into the room. 0 Referral hospitals should plan for patient support and welfare within isolation, including communication with their families. - An information-sharing protocol, recognising the high degree of likely media and stakeholder interest, should be developed and shared with agencies at an early stage of the response. - With the exception of Middlemore, which has established a dedicated bio-containment unit wing, there will be signi?cant disruption caused by an isolated patient with EVD or a similar disease. A key decision for the Infectious Disease Technical Advisory Group will be to advise on the optimum location and number of referral centres speci?c to the disease. 8 Response to Suspected Ebola Virus Disease Cases in New Zealand Diagnostic testing - The commercial arrangement with a specialist medical logistics company and Air New Zealand to provide sample shipping to the VIDRL reference laboratory in Melbourne worked effectively when it was used in the second case. Use of an NZDF ?ight in the ?rst case, to achieve an earlier arrival time to Melbourne, resulted in a very modest time saving and required additional operational coordination at national and local levels. - Clear criteria for requesting support from NZDF over the commercial solution need to be agreed but should be an exceptional option. Returning humanitarian and health care workers Border The health assessments at the border went well; public health staff mee returning health care workers and the risk assessment was ef - Pu alth nit International alrports 1n their coverage area need to contl us meet tron. ed that border operations were effective and unobtru Health Organization as meeting the rec 1 ealth Emergency of engagement from international rates of Ebola transmission, provided ious Disease Technical Advisory Group should consider any restriction on maximum . 0 re distance to a referral hospital, dependent on the characteristics of the emerging infectious disease. MINISTRY OF HEALTH MANth?l 27 July 2015 HP 6223 Response to Suspected Ebola Virus Disease Cases in New Zealand 9