All you need to know about current ebola outbreak'2014

1. PUBLIC HEALTH EMERGENCY OF
INTERNATIONAL CONCERN (PHEIC)
EBOLA (EVD)
-Dr.R.PARTHASARATHI,M.D
Dept of Community Medicine

2. PHEIC
Defined in IHR 2005 as
‘an extraordinary public health event which
constitutes a public health risk to other States
through the international spread of disease and
may require a coordinated international response’.
 Such events are required to be assessed for notification to
WHO using a decision instrument

3. PHEIC
4 decision criteria used in assessment of a public health event
are :
(a) The seriousness of the event’s public health impact.
(b) The unusual or unexpected nature of the event.
(c) The risk of international spread.
(d) The risk that travel or trade restrictions will be imposed by
other countries.
Any 2 criteria Notify WHO
 A single case of smallpox, poliomyelitis (WPV), human
influenza caused by a new subtype and SARS must be
immediately notified to WHO, irrespective of the context in which it
occurs.

4. PHEIC

5. EBOLA VIRUS DISEASE (EVD)
 It is one of the world’s most virulent diseases.
 Formerly known as Ebola haemorrhagic fever.
 Severe, often fatal illness, with a case fatality rate of up to
90%.
 EVD outbreaks occur primarily in remote villages in
Central and West Africa, near tropical rainforests.
 All agents that cause viral hemorrhagic fever syndrome are
RNA viruses with a lipid envelope, all are considered
zoonoses, all damage the microvasculature, resulting in
increased vascular permeability, and all are members of
one of four families: Arenaviridae, Bunyaviridae,
Flaviviridae, and Filoviridae.

6. EBOLA VIRUS
 Ebola first appeared in 1976 in 2 simultaneous outbreaks in
Nzara, Sudan, and in Yambuku, Congo.
 Yambuku village near the Ebola River
 Family:Filoviridae
 Genus: Ebolavirus (3 members Marburgvirus, Cuevavirus)
 Species:5 types
1. Bundibugyo ebolavirus (BDBV)
2. Zaire ebolavirus (EBOV)
3. Sudan ebolavirus (SUDV)
4. Reston ebolavirus (RESTV)
5. Taï Forest ebolavirus (TAFV).

7. EBOLA SPECIES
 BDBV, EBOV, and SUDV have been associated with large
EVD outbreaks in Africa.
 The RESTV species, found in Philippines and the People’s
Republic of China, can infect humans, but no illness or
death in humans from this species has been reported to
date.

8. ENVIRONMENTAL PERSISTANCE
 Under ideal conditions, Ebola virus could remain active for
up to 6 days.
 Persistence of Ebola virus in the patient care environment is
short – within 24 hours
 Ebola virus 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.

9. 2014 OUTBREAK
 On 8 August 2014, WHO declared the Ebola virus
disease outbreak in West Africa a Public Health
Emergency of International Concern (PHEIC) in
accordance with the IHR 2005.
 The current EVD outbreak is believed to have begun in
Guinea in December 2013.
 Viral sequencing shows strong homology (98%) with
Zaïre Ebolavirus (EBOV)
 As of August 16, 2014,
2,240 suspected or confirmed cases, including
1383 laboratory-confirmed cases and
1,229 deaths

10. 2014 OUTBREAK

11. TRANSMISSION
 Natural Host: Fruit bats of the Pteropodidae family
(Hypsignathus monstrosus, Epomops franqueti, and
Myonycteris torquata)
 Source of human infection: Blood, secretions, organs, or
other bodily fluids of infected animals, Bushmeat
(handling of infected chimpanzees, gorillas, fruit bats,
monkeys, forest antelope, and porcupines found ill or
dead or in the rainforest)

12. ENZOOTIC EPIZOOTIC EPIDEMIC

13. HUMAN-TO-HUMAN TRANSMISSION
 Direct contact (through broken skin or mucous membranes) with
the blood, secretions, organs or other bodily fluids of infected
people
 Indirect contact with environments contaminated with fluids.
 Burial ceremonies (mourners direct contact with corpse)
 The patients become contagious once symptoms begin. They
are not contagious during incubation period.
 Virus transmitted through the semen for up to 7 weeks after
recovery from illness.
 Health-care workers have frequently been infected
INCUBATION PERIOD: 2 to 21 days
CASE FATALITY RATE: 53%
 All cases in the current outbreak- H2H

15. SIGNS AND SYMPTOMS
 PRODROME:
sudden onset of fever, intense weakness, muscle pain,
headache and sore throat.
 VIRAEMIA:
vomiting, diarrhoea, rash, impaired kidney and liver
function, and in some cases, both internal and external
bleeding (DIC)
Patients are infectious as long as their blood and secretions
contain the virus.

17. PERSON UNDER INVESTIGATION (PUI)
A person who has both consistent symptoms & risk factors:
 1) Clinical criteria, which includes fever of greater than 38.6
degrees Celsius or 101.5 degrees Fahrenheit, and additional
symptoms such as severe headache, muscle pain, vomiting,
diarrhoea, abdominal pain, or unexplained haemorrhage;
AND
 2) Epidemiologic risk factors within the past 21 days before the
onset of symptoms, such as contact with blood or other body
fluids or human remains of a patient known to have or suspected
to have EVD; residence in—or travel to—an area where EVD
transmission is active; or direct handling of bats, rodents, or
primates from disease-endemic areas.

18. CASE DEFINITION FOR EVD
Probable Case
 A PUI who is a contact of an EVD case with either a
high or low risk exposure.
Confirmed Case
 A case with laboratory confirmed diagnostic
evidence of Ebola virus infection.

19. CONTACTS OF AN EVD CASE
Contacts have different levels of exposure risk, as follows:
High risk exposures
A high risk exposure includes any of the following:
 Percutaneous, e.g. the needle stick, or mucous membrane
exposure to body fluids of EVD patient
 Direct care or exposure to body fluids of an EVD patient
without appropriate PPE
 Laboratory worker processing body fluids of confirmed
EVD patients without appropriate PPE or standard
biosafety precautions
 Participation in funeral rites which include direct exposure
to human remains in the geographic area where outbreak
is occurring without appropriate PPE

20. CONTACTS OF AN EVD CASE
Low risk exposures
A Low risk exposure includes any of the following:
 Household member or other casual contact* with an EVD
patient
 Providing patient care or casual contact* without high-risk
exposure with EVD patients in health care facilities in EVD
outbreak affected countries
No known exposure
 Persons with no known exposure were present in an EVD
outbreak affected country in the past 21 days with no low
risk or high risk exposures.

21. Defined as
*CASUAL CONTACT
 being within approximately 3 feet (1 meter) or within the
room or care area for a prolonged period of time (e.g.,
healthcare personnel, household members) while not
wearing PPE
OR
 having direct brief contact (e.g., shaking hands) with an
EVD case while not wearing PPE
 Brief interactions, such as walking by a person or
moving through a hospital, do not constitute casual
contact.

22. DIFFERENTIAL DIAGNOSIS
Always rule out
 Other Viral Haemorrhagic Fevers.
 Malaria
 Yellow fever
 Dengue
 Leptospirosis
 Typhoid Fever
 Shigellosis
 Rickettsiosis
 Relapsing Fever
 Cholera
 Plague
 Hepatitis

23. LABORATORY FINDINGS
 Thrombocytopenia, leukopenia with a pronounced
lymphopenia.
 Neutrophilia develops after several days
 Elevations in aspartate aminotransferase and alanine
aminotransferase.
 Bilirubin may be normal or slightly elevated.
 With onset of anuria, BUN and serum creatinine rise.
 Terminally ill patients : Tachypnea, metabolic acidosis
 Definitive diagnosis : Isolation of the virus in tissue culture or
PCR.

24. LABORATORY DIAGNOSIS
Definitive diagnosis by
 Antibody-capture ELISA
 Antigen detection tests
 Serum neutralization test- serological surveys
 RT-PCR assay
 Virus isolation by cell culture.
Highly sensitive and
confirmatory tests
 Skin biopsies in postmortem diagnosis of infection with Ebola
virus
 Blood samples collection and transport according to
guidelines and to WHO accredited labs only
 NCDC, New Delhi and NIV,Pune in our country

25. MANAGEMENT
 Isolate the patient
• Triage rapidly to a separate room /holding area
• The holding area should be:
- Distant from other crowded areas
- Well ventilated
- Have adequate sunlight
Notify the State and National Authority
 Clinical management: predominantly Supportive and focus
on early recognition of complications with appropriate
symptom management.
 Antipyretics, Anti-emetics, Rehydration therapy, Blood
transfusion, Oxygen , Respiratory support and Anti-convulsants
as needed
 No specific drug treatment

26. Experimental treatment
Zmapp
 Combination of monoclonal antibodies which binds with outer
glycoprotein of the virus and prevents its entry to the host
cells
 Efficacy yet to be proven, no clinical trials done till date.
 In early trials- all Rhesus monkeys infected with virus
survived when administered 1 hour after infection.
 Produced using specific tobacco plants.
 WHO authorised this treatment for a small group on 11th
August,2014.
 Even if successful, stocks will not be available till 2015
Tekmira, a Canadian biotech company, has begun early
human trials of a new drug

27.  NOT YET
Vaccine
 An adenovirus-vectored Ebola glycoprotein gene has proved
protective in nonhuman primates and is undergoing phase 1
trials in humans.
 An experimental vesicular stomatitis virus–based vaccine has
protected macaques when given both before and after
infection with the Zaire Ebola virus.

28. PREVENTION
 Isolation and Quarantine, Notification
 Contact Tracing
 Standard Precautions–At All Times, For All Patients
 Barrier nursing
 Hand washing
 Personal Protective Equipment (PPE)
 Injection safety, Safe sex practices
 Concomitant & Terminal Disinfection, Sterilisation
 Following SOP for Blood sample collection and Transport
 Appropriate Hospital Waste management
 Enhanced Surveillance
 Health Education: Myths

29. P
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PPE

30. R
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PPE

31. STRATEGY FOR PREVENTION AND CONTROL

32. AIR TRAVELLERS
 Exit screening and communication efforts on the ground in
West Africa to prevent sick travellers from getting on
planes.
 Airports in Guinea, Liberia, and Sierra Leone are screening
outbound travellers for Ebola symptoms, including fever,
and passengers are required to respond to a health
questionnaire.
 Avoid non-essential travel- WHO
 Some countries have banned flights and entry to people
from the affected regions.

33. INDIA
 No confirmed case of Ebola till date.
 The World Health Organisation (WHO) had informed that
one Indian passenger had travelled on the same flight in
which an Ebola virus patient (a foreign national) was
travelling from Monrovia to Lagos. He was tracked and
found healthy.
 24-hour 'Emergency Operation Centre‘:
011-23061469, 3205 and 1302
 TN Helpline- 104
 Rumours from Karnataka-WhatsApp message that student
from the National Institute of Technology Karnataka (NITK)
in Dakshina Kannada districthad ebola and succumbed to it

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