west africa 2014 - illinois public health association · slide 10 ak 76 r malaria kers. ... slide...
TRANSCRIPT
Slide 1
EBOLA 2014
WEST AFRICA
Hosted by:
Bhagavatula Ramakrishna, M.D.
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Slide 2 CENTRAL AND EAST AFRICA
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Slide 3
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Slide 4 EBOLA IN WEST AFRICA
2014
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Slide 5
“It is a disease of poverty and neglect of health systems. It is an infection that causes epidemics only if basic hospital hygiene is not respected.”
Dr. Peter Piot (one of the first researchers to identify Ebola Virus in 1976)
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Slide 6 Ebola Hemorrhagic Fever
Ebola hemorrhagic fever (Ebola HF)
is one of numerous Viral Hemorrhagic
Fevers. It is a severe, often fatal
disease in humans and nonhuman
primates (such as monkeys, gorillas,
and chimpanzees).
Ebola HF is caused by infection with a virus of the family Filoviridae, genus Ebola virus. When infection occurs, symptoms usually begin abruptly. The first Ebola virus species was discovered in 1976 in what is now the Democratic Republic of the Congo near the Ebola River. Since then, outbreaks have appeared sporadically.
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Slide 7 There are five species of Ebola
virus--a negative single-stranded RNA virus in the family of Filoviridae.
The three species:
Bundibugyo
Zaire
Sudan Ebola viruses Responsible
For all the Outbreaks
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Slide 8 There are two other Ebola viruses:
The Reston virus which is limited to the Philippines and has not caused human disease;
The Tai Forest Ebola virus caused disease in a scientist doing an autopsy on a chimpanzee.
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Slide 9 Ebola Cycle
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Slide 10 The First Outbreak
September 1976
Injection of Chloroquine for malaria leads to a febrile hemorrhagic illness in a patient and then spreads to healthcare workers.
In two months, 318 cases of viral hemorrhagic fever with 88% mortality in 55 villages in Congo (now Democratic Republic of Congo) (DRC).
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Slide 11 EBOLA VIRUS OUTBREAK
The virus was identified and named after the Ebola River that traverses the affected regions.
Since then there have been 20 outbreaks of Ebola Virus Disease (EVD).
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Slide 12 These were all sporadic, mostly in
Central and Eastern Africa.
The 2014 EVD was the first outbreak to occur in West Africa.
From 1979 to 1994, there were no cases reported.
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Slide 13 Transmission
How do you get the Ebola virus?Direct contact with:
1. Bodily fluids of a person who is sick with or has died from Ebola (blood, vomit, urine,faeces sweat, semen, spit and other fluids).
2. Objects contaminated with the virus(needles, medical equipment).
3. Infected animals (by contact with blood or body fluids or infected meat).
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Slide 14 Reservoir and vectors of Ebola virus are not understood well.
Ebola virus is a zoonotic disease. Fruit bats were implicated as the virus replicates in these bats and the virus was isolated from the guano.
Monkeys and other non-human primates may serve as intermediate hosts.
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Slide 15 Transmission (Continued)
Because the natural reservoir of ebolaviruses has not yet been proven, the manner in which the virus first appears in a human at the start of an outbreak is unknown. However, researchers have hypothesized that the first patient becomes infected through contact with an infected animal.
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Slide 16 Transmission (Continued)
Healthcare workers 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.
During outbreaks of Ebola HF, the disease can spread quickly within healthcare settings (such as a clinic or hospital). Exposure to Ebola viruses can occur in healthcare settings where hospital staff are not wearing appropriate protective equipment, such as masks, gowns, and gloves.
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Slide 17 Clinical Course
Incubation period 2-21 days
Most patients develop symptoms between day 8-10.
Abrupt onset of fever, chills, myalgia, sometimes macules, papules, rash
Watery diarrhea, nausea, vomiting
Hemorrhagic sequela such as
Petechiae and ecchymosis
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Slide 18 Signs & Symptoms
Symptoms of Ebola HF Typically Include: Some Patients May Experience:
� Fever � A Rash
� Headache � Red Eyes
� Joint and muscle aches � Hiccups
� Weakness � Cough
� Diarrhea � Sore throat
� Vomiting � Chest pain
� Stomach pain � Difficulty breathing
� Lack of appetite � Difficulty swallowing
� Bleeding inside & outside of the body
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Slide 19 Clinical Course (cont’d)
Death usually occurs 6-16 days after onset of symptoms.
Recovered patients have prolonged weakness, poor appetite, and failure to gain weight.
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Slide 20 VIRAL PERSISTENCE
Dr. J. B. Varken, an American Physician, who survived Ebola in September 2014 (Sierra Leone):
- Developed posterior uveitis 14 weeks after recovery
- Aqueous humor sample positive for EBOV-RNA, but conjunctival and tear samples were negative.
- There is a report of sexually transmitted Ebola because of persistence of the virus in the testes.
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Slide 21 Pathogenesis
The virus causes multi-organ system failure.
It invades endothelium and causes endothelial damage.
Causes a cytokine storm by attacking macrophages that leads to intense inflammation, hepatic necrosis, severe sepsis leading to death.
Hepatic necrosis plus thrombo-cytopenia, etc., lead to hemorrhage and death.
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Slide 22 Pathogenesis of Ebola Virus (Cont’d)
Reason for Hemorrhagic Fever
1) Macrophages leak cytokines (IL-1beta, nitric oxide, TNF alpha) cause fever and inflammation and hypotension
2) Endothelial cell damage causes capillary (vascular) leak, hypotension and shock
3) Coagulopathy triggered by macrophage synthesized cell-surface tissue factor that triggers extrinsic coagulation pathway and DIC.
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Slide 23 Pathogenesis of Ebola
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Slide 24 Diagnosis
Diagnosis Ebola HF in an individual who has been infected for only a few days is difficult, because the early symptoms, such as red eyes and a skin rash, are nonspecific to Ebola virus infection and are seen often in patients with more commonly occurring diseases.
However, if a person has the early symptoms of Ebola HF, and there is reason to believe that Ebola HF should be considered, the patient should be isolated and public health professionals notified. Samples from the patient can then be collected and tested to confirm infection.
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Slide 25 Diagnosis (Continued)
Laboratory tests used in diagnosis include:Timeline of Infection Diagnostic Tests Available
Within a few days after symptoms begin
- Antigen-capture enzyme-linked immunosorbent assay (ELISA) testing
- IgM ELISA- Polymerase chain reaction (PCR)- Virus isolation
Later in disease course or after recovery
- IgM and IgG antibodies
Retrospectively in deceased
New Rapid Bedside tests Approved by the FDA
- Immunohistochemistry testing- PCR- Virus isolation
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Slide 26 TreatmentSupportive:
Blood product transfusion
Electrolyte replacement
Fluid resuscitation
Vasopressors
Ventilator support
Evaluate for any concurrent infections, such as malaria, typhoid fever, etc.
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Slide 27 Investigational Drugs:
Z.Mapp. (Mapp. Biopharmaceutical) a combination of 3 different monoclonal antibodies that bind to the protein of Ebola Virus.
Bricidofovir
Blood and Serum from persons who have recovered from Ebola Virus Disease Have been used.
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Slide 28 VACCINES
PHASE I STUDIES
Two vaccines being studied (New England Journal of Medicine (NEJM), April 2015).
A recombinant chimpanzee adenovirus and a vesicular stomatitis virus. These express Ebola surface glycoprotein.
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Slide 29 How Trials will Work
for Ebola Vaccines (by Bonnie Berkowitz & Patterson Clark, Published February 8, 2015)
Two promising Ebola vaccines have begun clinical trials in West Africa. A different type of trial is planned for each of the three countries hit hardest by the epidemic. This phase could take a year or more, said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. A trial’s length depends on the spread of the epidemic, and this one is subsiding.
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Slide 30 The VaccinesChimp adenovirus—made by GlaxoSmithKline
A chimpanzee cold virus is used as a carrier to deliver a gene that makes the outer protein for the Zaire strain of Ebola. The virus is not alive and not able to replicate, but it can still express a protein. Once injected into the body, it makes a protein that triggers an immune response. It cannot cause infection.
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Slide 31 The Vaccines (Cont’d.)
VSV-Zebov—made by NewLink and Merck
The vesicular stomatitis virusvaccine works similarly to the adenovirus vaccine, except that the virus is alive and replicates itself so that it makes more and more of the Ebola protein. It cannot cause an Ebola infection. One of several earlier trials was stopped because some participants developed joint pain, but the side effect was determined to be mild enough to restart the trial.
A few tens of millions of doses will be available in 2015, according to the World Health Organization.
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Slide 32 Prevention
The prevention of Ebola HF presents many challenges. Because it is still unknown how exactly people are infected with Ebola HF, there are few established primary prevention measures.
When cases of the disease do appear, there is increased risk of transmission within healthcare settings. Therefore, healthcare workers must be able to recognize a case of Ebola HF and be ready to employ practical viral hemorrhagic fever isolation precautions or barrier nursing techniques. They should also have the capability to request diagnostic tests or prepare samples for shipping and testing elsewhere.
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Slide 33 Prevention (Continued)
Barrier nursing techniques include:
� wearing of protective clothing (such as
masks, gloves, gowns, and goggles).
� the use of infection control measures (such as complete
equipment sterilization and routine use of disinfectant).
� isolation of Ebola HF patients from contact with
unprotected persons.
The aim of all of these techniques is to avoid contact with
the blood or secretions of an infected patient. If a patient
with Ebola HF dies, it is equally important that direct
contact with the body of the deceased patient be
prevented.
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Slide 34 Prevention (Continued)
Centers for Disease Control and Prevention (CDC), in conjunction with the World Health Organization, has developed a set of guidelines to help prevent and control the spread of Ebola HF. Entitled Infection Control for Viral Hemorrhagic Fevers in the African Healthcare Setting, the manual describes how to:
� recognize cases of viral hemorrhagic fever (such as
Ebola HF).
� prevent further transmission in healthcare setting by
using locally available materials and minimal financial
resources.
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Slide 35 Travel
If you must travel to an area with known Ebola cases, make sure to do the following:
� Practice careful hygiene. 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.
� 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 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
(/vhf/ebola/symptoms/index.html).
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Slide 36 2014 Ebola Outbreak in Context
A two-year-old toddler died from the disease (Guéckédou Prefecture, Guinea) in December 2013.
2014 outbreak started in Meliandou, Guinea.
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Slide 37 In March, Medicins' sans Frontières
(MSF), Doctors without Borders, reported a mysterious illness that killed 59 of first 86 cases.
Then the disease spreads to Liberia, Senegal, Nigeria, Sierra Leone, and Mali—all from infected travelers crossing borders.
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Slide 38
Outside Africa
September 30, 2014—The first case of EVD was diagnosed in the United States in a patient from Liberia to Dallas, Texas.
Healthcare workers also were infected.
OUT SIDE AFRICA
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Slide 39 Similar transmission from a
repatriated nun to a healthcare worker occurred in Spain.
Nigeria very quickly controlled the outbreak with a team of dedicated doctors and healthcare workers who died taking care of the patients and government policies that helped.
In DRC (Congo), another unrelated outbreak is going on at the same time; this was a different strain of Ebola.
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Slide 40 WEST AFRICA
EBOLA OUTBREAK
CASE COUNTS
Total Cases
Updated: ▪ From March 3,2014 to June 19 ,2015
▪ Cases : 27,352
▪ Deaths : 11,193
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Slide 41 What Caused this Large Outbreak?
Previous outbreaks occurred in rural isolated villages with limited access to medical care resulting in high mortality, but limited transmission.
With industrialization and globalization of commerce, there is now increased travel from isolated areas to densely populated urban areas.
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Slide 42
Increased access to healthcare helped increase nosocomial transmission and spread of the disease.
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Slide 43 Nigeria’s healthcare system and
brave doctors contained the disease quickly (2 doctors died in this outbreak).
Outside of West Africa,the United States reported a case—a traveler from Liberia. Thomas Eric Duncan died from the illness.
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Slide 44 All but three cases were acquired out
of West Africa, and all were healthcare workers (2 in the USA and a Spanish nurse, Teresa Romero).
Second person to die on U.S. soil was Martin Salia, a surgeon from Sierra Leone (treated in Nebraska).
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Slide 45 Note: Nobody in Mr. Duncan’s family
or contacts in the community contracted Ebola.
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Slide 46 Why this Outbreak Continued
Cultural and Societal Factors:
Family members often take care of the patients (relatives) putting themselves at risk.
Family members are fearful that the hospitals themselves are causing the infections.
People hiding the patients and their contacts from health authorities.
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Slide 47 Poor hygiene and sanitation and poor
public health system.
Burial practices in several parts of West Africa include close contact of the family members with the deceased.
Illegal bushmeat trade.
Increased contact between animals and humans.
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Slide 48 The Current Policy to Deal with EBOLA
Screening Travelers from The Affected Countries at one of the five
International Airports
Monitoring the persons for symptoms for 21 days
Symptomatic Patients are Referred to Acute Health care Facility immediately
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Slide 49 Acute Health Care Facilities
Front Line Hospitals.
Ebola Assessment Hospitals.
Ebola Treatment Centers.
There are 55 Designated Ebola Treatment Centers in the Country.
Three Bio containment centers also Serve as Treatment Centers.(NIH,EMORY and Nebraska). )
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Slide 50 Lessons Learned
Response to an Outbreak in Africa, (Dr. Stan Deresinski, Editor, Infectious Disease Alert):
- Cable news and politicians spread panic and chaos in public health policy.
- Enormous efforts put forth and money wasted for activities in the country to prevent Ebola here.
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Slide 51 Public Health Issues
Bill Gates (in NEJM)
- The world response was not adequate to Ebola outbreak.
- A more virulent virus, such as influenza and measles could cause 10 million deaths.
- The WHO has a Global Outbreak Alert and Response Network, but it is severely underfunded.
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Slide 52 Bill Gates (Cont’d.)
What could be done?Build a warning and response system
for outbreaks.
This system should:
- be coordinated by a global institution that is given enough authority and funding to be effective.
- enable fast decision-making at a global level.
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Slide 53
- expand investment in research and development and clarify regulatory pathways for developing new tools and approaches.
- improve early warning and detection systems, including scalable everyday systems that can be expanded during an epidemic.
Bill Gates (Cont’d.)What could be done?
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Slide 54
- involve a reserve corps of travel personnel and volunteers.
- strengthen healthcare systems in low and middle income countries.
- incorporate preparedness exercises to study how to improve the response system.
Bill Gates (Cont’d.)What could be done?
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Slide 55 Dr. Gregg Gonsalves, NEJM 2014
“We all have to become activists if we were to protect the public health from being used as a tool to serve primarily political purposes as it has been over the past few weeks in the U.S.”
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Slide 56 Dr. Craig Spencer, Ebola Treater in
Africa and a Patient in the USA
“We all lose when we allow irrational fear fueled in part by prime time ratings and political expediency to supersede pragmatic public healthcare policy.”
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Slide 57 Centers for Disease Control and
Prevention (CDC)
Dr. Thomas Friedman came under a lot of criticism because of the way he communicated with the media during Ebola outbreak.
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Slide 58 The American Psychiatric Association
Annual meeting in Toronto,
Dr. Daniel Witter, M.D., Ph.D., discussed this issue.
He recommended the following:
- Do not over-reassure.
- Acknowledge uncertainty.
- Do not ridicule the public’s emotions.
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Slide 59
- Tell people what to expect.
- Offer people things to do.
- Acknowledge errors, deficiencies, and misbehaviors.
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