Monday, October 13, 2014

Ebola virus - A Short Primer on Virus Survival and Disinfection

Here is a short primer on Ebola - condensed from information from the CDC website - focusing on disinfection and survival in the environment.
 
Survival in the Environment
 
According to the CDC, under ideal conditions where there is organic material (such as blood), the Ebola virus was show to survive up to 6 days in the environment.  But these viruses are susceptible to drying, UV and disinfectants.  (I is important to point out that there have been limited studies.)
 
That said, without organic material, it will die off quickly, so it is not likely to be present on doorknobs and light switches or other items that people simply touch (without blood or other organic residue).

How does this compare to Norovirus which can survive in the environment for weeks to months?  There are two categories of viruses - non-enveloped and enveloped.  All viruses are comprised of by genetic material within a protein structure or capsid....but enveloped viruses also have a lipid envelope surrounding that protein capsid while the non-enveloped virus do not.  Ebola is an enveloped virus, and that outer lipid layer, so important for attachment and entry to the cell, is more subject to environmental conditions.  Norovirus, a non-enveloped virus, is more resistant.
 
Disinfection
 
According to the CDC, Use a U.S. Environmental Protection Agency (EPA)-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus) to disinfect environmental surfaces in rooms of patients with suspected or confirmed Ebola virus infection. Although there are no products with specific label claims against the Ebola virus, enveloped viruses such as Ebola are susceptible to a broad range of hospital disinfectants used to disinfect hard, non-porous surfaces.
 
Basically, if it is good against the more hardy viruses like Norovirus, it will be fine against Ebola.

Transmission
 
From the CDC Website (below)
When an infection does occur in humans, the virus can be spread in several ways to others. Ebola is spread through direct contact (through broken skin or mucous membranes in, for example, the eyes, nose, or mouth) with
  • blood or body fluids (including but not limited to urine, saliva, sweat, feces, vomit, breast milk, and semen) of a person who is sick with Ebola 
  • objects (like needles and syringes) that have been contaminated with the virus
  • infected animals
  • Ebola is not spread through the air or by water, or in general, by food. However, in Africa, Ebola may be spread as a result of handling bushmeat (wild animals hunted for food) and contact with infected bats. There is no evidence that mosquitos or other insects can transmit Ebola virus. Only mammals (for example, humans, bats, monkeys, and apes) have shown the ability to become infected with and spread Ebola virus.
       
Symptoms 
  • Fever (greater than 38.6°C or 101.5°F)
  • Severe headache
  • Muscle pain
  • Weakness
  • Diarrhea
  • Vomiting
  • Abdominal (stomach) pain
  • Unexplained hemorrhage (bleeding or bruising)
 
Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola, but the average is 8 to 10 days.
 
Recovery from Ebola depends on good supportive clinical care and the patient’s immune response. People who recover from Ebola infection develop antibodies that last for at least 10 yrs


 
CDC Website
 
Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus
 
 
 
Ebola viruses are transmitted through direct contact with blood or body fluids/substances (e.g., urine, feces, vomit) of an infected person with symptoms or through exposure to objects (such as needles) that have been contaminated with infected blood or body fluids. The role of the environment in transmission has not been established. Limited laboratory studies under favorable conditions indicate that Ebolavirus can remain viable on solid surfaces, with concentrations falling slowly over several days.1, 2 In the only study to assess contamination of the patient care environment during an outbreak, virus was not detected in any of 33 samples collected from sites that were not visibly bloody. However, virus was detected on a blood-stained glove and bloody intravenous insertion site.3 There is no epidemiologic evidence of Ebolavirus transmission via either the environment or fomites that could become contaminated during patient care (e.g., bed rails, door knobs, laundry). However, given the apparent low infectious dose, potential of high virus titers in the blood of ill patients, and disease severity, higher levels of precaution are warranted to reduce the potential risk posed by contaminated surfaces in the patient care environment.
 
Be sure environmental services staff wear recommended personal protective equipment (PPE) including, at a minimum, disposable gloves, gown (fluid resistant/ impermeable), eye protection (goggles or face shield), and facemask to protect against direct skin and mucous membrane exposure of cleaning chemicals, contamination, and splashes or spatters during environmental cleaning and disinfection activities. Additional barriers (e.g., leg covers, shoe covers) should be used as needed. If reusable heavy-duty gloves are used for cleaning and disinfecting, they should be disinfected and kept in the room or anteroom. Be sure staff are instructed in the proper use of personal protective equipment including safe removal to prevent contaminating themselves or others in the process, and that contaminated equipment is disposed of appropriately. (see question 8).
 
Use a U.S. Environmental Protection Agency (EPA)-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus) to disinfect environmental surfaces in rooms of patients with suspected or confirmed Ebola virus infection. Although there are no products with specific label claims against the Ebola virus, enveloped viruses such as Ebola are susceptible to a broad range of hospital disinfectants used to disinfect hard, non-porous surfaces. In contrast, non-enveloped viruses are more resistant to disinfectants. As a precaution, selection of a disinfectant product with a higher potency than what is normally required for an enveloped virus is being recommended at this time. EPA-registered hospital disinfectants with label claims against non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) are broadly antiviral and capable of inactivating both enveloped and non-enveloped viruses.
Avoid contamination of reusable porous surfaces that cannot be made single use. Use only a mattress and pillow with plastic or other covering that fluids cannot get through. Do not place patients with suspected or confirmed Ebola virus infection in carpeted rooms and remove all upholstered furniture and decorative curtains from patient rooms before use.
To reduce exposure among staff to potentially contaminated textiles (cloth products) while laundering, discard all linens, non-fluid-impermeable pillows or mattresses, and textile privacy curtains into the waste stream and disposed of appropriately.
The Ebola virus is a classified as a Category A infectious substance by and regulated by the U.S. Department of Transportation’s (DOT) Hazardous Materials Regulations (HMR, 49 C.F.R., Parts 171-180). Any item transported offsite for disposal that is contaminated or suspected of being contaminated with a Category A infectious substance must be packaged and transported in accordance with the HMR. This includes medical equipment, sharps, linens, and used health care products (such as soiled absorbent pads or dressings, kidney-shaped emesis pans, portable toilets, used Personal Protection Equipment (gowns, masks, gloves, goggles, face shields, respirators, booties, etc.) or byproducts of cleaning) contaminated or suspected of being contaminated with a Category A infectious substance.6, 7 (see question 8).
Frequently Asked Questions
1. How can I determine whether a particular EPA-registered hospital disinfectant is appropriate for use in the room of a patient with suspected or confirmed Ebola virus infection?
 
Begin by looking at the product label or product insert or, if these are not available, search the EPA search engine for this information. Users should be aware that an 'enveloped' or 'non-enveloped virus' designation may not be included on the container label. Instead check the disinfectant's label for at least one of the common non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus).
2. Are there special instructions for cleaning and disinfecting the room of a patient with suspected or confirmed Ebola virus infection?
 
Daily cleaning and disinfection of hard, non-porous surfaces (e.g., high-touch surfaces such as bed rails and over bed tables, housekeeping surfaces such as floors and counters) should be done.4 Before disinfecting a surface, cleaning should be performed. In contrast to disinfection where products with specific claims are used, any cleaning product can be used for cleaning tasks. Use cleaning and disinfecting products according to label instructions. Check the disinfectant's label for specific instructions for inactivation of any of the non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) follow label instructions for use of the product that are specific for inactivation of that virus. Use disposable cleaning cloths, mop cloths, and wipes and dispose of these in leak-proof bags. Use a rigid waste receptacle designed to support the bag to help minimize contamination of the bag's exterior.
3. How should spills of blood or other body substances be managed?
 
The basic principles for blood or body substance spill management are outlined in the United States Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standards (29 CFR 1910.1030).5 CDC guidelines recommend removal of bulk spill matter, cleaning the site, and then disinfecting the site.4 For large spills, a chemical disinfectant with sufficient potency is needed to overcome the tendency of proteins in blood and other body substances to neutralize the disinfectant's active ingredient. An EPA-registered hospital disinfectant with label claims for non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) and instructions for cleaning and decontaminating surfaces or objects soiled with blood or body fluids should be used according to those instructions.
4. How should disposable materials (e.g., any single-use PPE, cleaning cloths, wipes, single-use microfiber cloths, linens, food service) and linens, privacy curtains, and other textiles be managed after their use in the patient room?
 
These materials should be placed in leak-proof containment and discarded appropriately. To minimize contamination of the exterior of the waste bag, place this bag in a rigid waste receptacle designed for this use. Incineration or autoclaving as a waste treatment process is effective in eliminating viral infectivity and provides waste minimization. If disposal requires transport offsite then this should be done in accordance with the U.S. Department of Transportation’s (DOT) Hazardous Materials Regulations (HMR, 49 C.F.R., Parts 171-180).6, 7 Guidance from DOT has been released for Ebola.7
5. Is it safe for Ebola patients to use the bathroom?
 
Yes. Sanitary sewers may be used for the safe disposal of patient waste. Additionally, sewage handling processes (e.g., anaerobic digestion, composting, and disinfection) in the United States are designed to inactivate infectious agents.
6. How long does the Ebola virus persist in indoor environments?
 
Only one laboratory study, which was done under environmental conditions that favor virus persistence, has been reported. This study found that under these ideal conditions Ebola virus could remain active for up to six days.1 In a follow up study, Ebolavirus was found, relative to other enveloped viruses, to be quite sensitive to inactivation by ultraviolet light and drying; yet sub-populations did persist in organic debris.2
 
In the only study to assess contamination of the patient care environment during an outbreak, conducted in an African hospital under "real world conditions", virus was not detected by either nucleic acid amplification or culture in any of 33 samples collected from sites that were not visibly bloody. Virus was detected on a blood-stained glove and bloody intravenous insertion site by nucleic acid amplification, which may detect non-viable virus, but not by culture for live, infectious virus.3 Based upon these data and what is known regarding the environmental infection control of other enveloped RNA viruses, the expectation is with consistent daily cleaning and disinfection practices in U.S. hospitals that the persistence of Ebola virus in the patient care environment would be short – with 24 hours considered a cautious upper limit.
7. Are wastes generated during delivery of care to Ebola virus-infected patients subject to select agent regulations?
 
As long as facilities treating Ebola virus-infected patients follow the CDC's Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals(http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html); waste generated during delivery of care to Ebola virus-infected patients would not be subject to Federal select agent regulations (See the exclusion provision 42 CFR § 73.3(d)(1)). However, this would not apply to any facility that intentionally collected or otherwise extracted the Ebola virus from waste generated during the delivery of patient care.
8. Are wastes generated during delivery of care to Ebola virus-infected patients subject to any special transportation requirements?
 
Yes, wastes contaminated or suspected to be contaminated with Ebola virus must be packaged and transported in accordance U.S. DOT Hazardous Materials Regulations (HMR, 49 C.F.R., Parts 171-180).6, 7
 
Once a patient with suspected Ebola Virus Disease (e.g., Patients under investigation) is no longer suspected to have Ebola Virus disease (EVD) or has ruled out for EVD, their waste materials no longer need to be managed as if contaminated with Ebola Virus.
References
Sagripanti JL, Rom AM, Holland LE. Persistence in darkness of virulent alphaviruses, Ebola virus, and Lassa virus deposited on solid surfaces. Arch Virol 2010; 155:2035-2039
Sagripanti JL, Lytle DC. Sensitivity to ultraviolet radiation of Lassa, vaccinia, and Ebola viruses dried on surfaces. Arch Virol 2011; 156:489–494
Bausch DG et al. Assessment of the Risk of Ebola Virus Transmission from Bodily Fluids and Fomites. J Infect Dis 2007; 196:S142–7


 
CDC Website
Transmission
 
 Because the natural reservoir host of Ebola viruses has not yet been identified, the manner in which the virus first appears in a human at the start of an outbreak is unknown. However, researchers believe that the first patient becomes infected through contact with an infected animal.
 
When an infection does occur in humans, the virus can be spread in several ways to others. Ebola is spread through direct contact (through broken skin or mucous membranes in, for example, the eyes, nose, or mouth) with
  • blood or body fluids (including but not limited to urine, saliva, sweat, feces, vomit, breast milk, and semen) of a person who is sick with Ebola 
  • objects (like needles and syringes) that have been contaminated with the virus
  • infected animals
  • Ebola is not spread through the air or by water, or in general, by food. However, in Africa, Ebola may be spread as a result of handling bushmeat (wild animals hunted for food) and contact with infected bats. There is no evidence that mosquitos or other insects can transmit Ebola virus. Only mammals (for example, humans, bats, monkeys, and apes) have shown the ability to become infected with and spread Ebola virus.
 
Healthcare providers caring for Ebola patients and the family and friends in close contact with Ebola patients are at the highest risk of getting sick because they may come in contact with infected blood or body fluids of sick patients.
 
During outbreaks of Ebola, the disease can spread quickly within healthcare settings (such as a clinic or hospital). Exposure to Ebola can occur in healthcare settings where hospital staff are not wearing appropriate protective equipment, including masks, gowns, and gloves and eye protection.
 
Dedicated medical equipment (preferable disposable, when possible) should be used by healthcare personnel providing patient care. Proper cleaning and disposal of instruments, such as needles and syringes, is also important. If instruments are not disposable, they must be sterilized before being used again. Without adequate sterilization of the instruments, virus transmission can continue and amplify an outbreak.
 
Once someone recovers from Ebola, they can no longer spread the virus. However, Ebola virus has been found in semen for up to 3 months. People who recover from Ebola are advised to abstain from sex or use condoms for 3 months.
 
 
Prevention
 
There is no FDA-approved vaccine available for Ebola.
 
If you travel to or are in an area affected by an Ebola outbreak, make sure to do the following:
  • Practice careful hygiene. For example, wash your hands with soap and water or an alcohol-based hand sanitizer and avoid contact with blood and body fluids.
  • Do not handle items that may have come in contact with an infected person’s blood or body fluids (such as clothes, bedding, needles, and medical equipment).
  • Avoid funeral or burial rituals that require handling the body of someone who has died from Ebola.
  • Avoid contact with bats and nonhuman primates or blood, fluids, and raw meat prepared from these animals.
  • Avoid hospitals in West Africa where Ebola patients are being treated. The U.S. embassy or consulate is often able to provide advice on facilities.
  • After you return, monitor your health for 21 days and seek medical care immediately if you develop symptoms of Ebola(http://www.cdc.gov/vhf/ebola/symptoms/index.html).
 
Healthcare workers who may be exposed to people with Ebola should follow these steps:
  • Wear protective clothing, including masks, gloves, gowns, and eye protection.
  • Practice proper infection control and sterilization measures. For more information, see “Infection Control for Viral Hemorrhagic Fevers in the African Health Care Setting”.
  • Isolate patients with Ebola from other patients.
  • Avoid direct contact with the bodies of people who have died from Ebola.
  • Notify health officials if you have had direct contact with the blood or body fluids, such as but not limited to, feces, saliva, urine, vomit, and semen of a person who is sick with Ebola. The virus can enter the body through broken skin or unprotected mucous membranes in, for example, the eyes, nose, or mouth

4 comments:

  1. There is one (in my eyes serious) misconception currently transported by the media (and no doubt stemming from "learned circles"): that you are not contagious unless you have developed symptoms. This suggests to the uninitiated that e.g. fever screening might catch all Ebola victims (including lots of false positives with "only" e.g. a flue - but better safe than sorry). But not so: the weaker a person's immune systems, the less violent to non-existent their initial response, e.g. no fever. Then these people go undetected, spread the virus further etc. We certainly need more clarification on many still little understood issues around Ebola.

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  3. Ebola Virus is one of a group of viruses that cause a hemorrhagic fever syndrome. Symptoms of Ebola virus infection are similar to those produced by other hemorrhagic fever viruses and include fever, fatigue, malaise, reddened eyes, weakness, joint pain, muscle pain, headache, nausea, vomiting, and diarrhea. Patients experience a loss of appetite and often stomach pains. Some patients experience sore throat, rash, cough, hiccups, chest pain, breathing problems, and difficulty swallowing.

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