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Ebola Virus Disease (EVD) 
Dr. Rizwan S A, M.D., 
Department of Community Medicine, 
VMCH&RI, Madurai, 
“Got no time for wild polemics, hung up on epidemics” – Anonymous
Outline 
 Why learn about EVD? 
 History 
 Epidemiology 
 Virological and clinical aspects 
 Management 
 Control measures 
 Challenges 
 Pandemic threat 
Rizwan SA, VMCHRI 2/35
Outline 
 Why learn about EVD? 
 History 
 Epidemiology 
 Virological and clinical aspects 
 Management 
 Control measures 
 Challenges 
 Pandemic threat 
Rizwan SA, VMCHRI
Why learn about EVD? 
 Limited scientific understanding 
 Highly fatal disease 
 Causes large outbreaks 
 Difficult to contain 
 No proven treatment or vaccine 
 A pandemic threat 
Rizwan SA, VMCHRI 4/35
Outline 
 Why learn about EVD? 
 History 
 Epidemiology 
 Virological and clinical aspects 
 Management 
 Control measures 
 Challenges 
 Pandemic threat 
Rizwan SA, VMCHRI
A story – 1/3 
Rizwan SA, VMCHRI 6/35
A story – 2/3 
Rizwan SA, VMCHRI 7/35
A story – 3/3 
Rizwan SA, VMCHRI 8/35
Outline 
 Why learn about EVD? 
 History 
 Epidemiology 
 Virological and clinical aspects 
 Management 
 Control measures 
 Challenges 
 Pandemic threat 
Rizwan SA, VMCHRI
Epidemiological aspects 
 Natural host - Fruit bats of 
Pteropodidae family 
 Reservoir – fruit bats 
 Sources – bush meat, NHP, 
Infected humans, fomites 
 Incubation period – 2 to 21 days 
 Communicability – high, virus 
isolated after 90 days of recovery 
 Case fatality – 50 to 90% 
 Immunity – long term not 
proven, deceased patients failed 
to produce immune response 
 No. of outbreaks – >30 
Rizwan SA, VMCHRI 10/35
Geographic distribution – 1/2 
 First outbreak occurred in 
Zaire (Congo) in 1976 
 Followed by several 
outbreaks, all in Africa 
(except one in Philippines, 
Italy, USA) 
 Latest on-going outbreak in 
west Africa started in 
March 2014 in Guinea 
Rizwan SA, VMCHRI 11/35
Geographic distribution – 2/2
Modes of transmission 
 Direct contact (through broken skin or mucous 
membranes) with 
 a sick person's blood or body fluids (urine, saliva, faeces, 
vomit, semen) 
 objects (such as needles) that have been contaminated with 
infected body fluids 
 infected animals 
 High risk groups – bush meat hunters, forest dwellers, 
health workers, relatives of patients, funeral attendees, 
corpse handlers, lab personnel 
Rizwan SA, VMCHRI 13/35
Transmission cycle 
Rizwan SA, VMCHRI 15/35
Outline 
 Why learn about EVD? 
 History 
 Epidemiology 
 Virological and clinical aspects 
 Management 
 Control measures 
 Challenges 
 Pandemic threat 
Rizwan SA, VMCHRI
Virological 
aspects 
• Family Filoviridae in the order 
Mononegavirales 
• Five species 
• Zaire, Sudan, Taï, Reston, 
Bundibugyo 
• Enveloped, non-segmented, 
negative-strand RNA virus, 
filamentous 
• Genes arranged linearly 
coding for seven structural 
proteins - NP, VP35, VP40, GP, 
VP30, VP24 and L with NP 
• GP, transmembrane protein 
and responsible for receptor 
binding and membrane 
fusion 
Rizwan SA, VMCHRI
Clinical features 
• Range from minor viral illness 
to fatal haemorrhagic fever 
• Ebola haemorrhagic fever 
(Ebola HF) is type of Viral 
Haemorrhagic Fevers 
• Most common constellation 
of symptoms is together 
called Ebola Virus Disease 
• EVD – duration 2 to 20 days, 
fever, nausea, vomiting, non-bloody 
diarrhoea, abdominal 
pain, conjunctivitis, 
weakness, severe headache 
and myalgia 
• E. Hemorrhagic fever - 
hematemesis, epistaxis, 
increased postpartum 
bleeding, bleeding gums etc., 
Rizwan SA, VMCHRI
Outline 
 Why learn about EVD? 
 History 
 Epidemiology 
 Virological and clinical aspects 
 Management 
 Control measures 
 Challenges 
 Pandemic threat 
Rizwan SA, VMCHRI
Diagnosis 
 CDC case definitions 
 Person Under Investigation 
 Probable case 
 Confirmed case 
 Non-case 
 Exposure risk levels 
• In early phase - Antigen-capture 
ELISA, IgM ELISA, 
PCR, Virus isolation 
• In later phase - IgM and IgG 
antibodies 
• In deceased patients – 
immunohistochemistry, PCR, 
virus isolation 
• Strict precautions during 
transportation of samples 
and all testing in BSL-4 lab 
• Differentials – Lassa fever, 
malaria, shigellosis, cholera, 
leptospirosis, plague, 
rickettsiosis, relapsing fever, 
other viral haemorrhagic 
fevers 
20/35 Rizwan SA, VMCHRI
Treatment  Experimental treatments 
 ZMapp – a combo of 3 monoclonal 
antibodies 
 TKM-Ebola – targets RNA of the 
virus 
 MB-2003 - prevents infection in 
mice and non-human primates 
when administered as post-exposure 
prophylaxis within one to 
two days 
 BCX-4430 – RNA polymerase inh 
 Favipiravir, AVI 7288 
 Whole blood and convalescent 
serum transfusion from recovered 
patients 
• No proven antiviral drug 
• Symptomatic treatment only 
• Providing intravenous fluids 
and balancing electrolytes 
(body salts) 
• Maintaining oxygen status 
and blood pressure 
• Treating other infections if 
they occur 
• Barrier-nursing techniques 
• Personal Protective 
Equipment 
• Infection control measures 
• Isolation of Ebola patients 
from contact 
Rizwan SA, VMCHRI
Outline 
 Why learn about EVD? 
 History 
 Epidemiology 
 Virological and clinical aspects 
 Management 
 Control measures 
 Challenges 
 Pandemic threat 
Rizwan SA, VMCHRI
Control measures – 1/5 
 Public health measures - early 
detection and isolation, contact 
tracing and rigorous infection 
control measures 
 Screening of travellers from 
affected countries in airports, 
seaports and land borders 
 Quarantine and observation of 
suspected cases for 21 days from 
exposure 
 Awareness generation among 
people, removing misconceptions 
Rizwan SA, VMCHRI 24/35
Control measures – 2/5 
 All suspected or confirmed cases, single 
closed patient room 
 Avoiding contact 
 A log book containing details of persons 
entering 
 Personal protective equipment for 
caretakers 
 Dedicated medical equipment 
 Minimum use of sharps 
 Disinfection of samples - heating to 60°C 
for one hour, in 3% acetic acid 
 Only BSL 4 lab should handle samples 
 Hospital monitoring policy for staff 
In this 2014 photo provided by the Samaritan's Purse aid organization, Dr. Kent Brantly, left, treats an Ebola patient at the Samaritan's Purse Ebola Case Management 
Center in Monrovia, Liberia. On Saturday, July 26, 2014, the North Carolina-based aid organization said Brantly tested positive for the disease and was being treated at a 
hospital in Monrovia. 
View of an isolation center for people infected with Ebola at Donka Hospital in Conakry. Rizwan SA, VMCHRI 25/35
Control measures – 3/5 
 Vaccines 
 Virus like particles: ZEBOV (VP40, CG and NP) 
 Non-replicating vectors: alpha virus, DNA vaccines, recombinant adenovirus based 
vectors (rAD) 
 Replication competent vectors: Recombinant Paramyxovirus-based vectors, 
Recombinant vesicular stomatitis virus-based vectors (rVSV), Recombinant rabies 
virus based (rRABV) 
 The first vaccine platform that successfully protected NHPs from Ebola virus infection 
was a recombinant adenovirus serotype 5(rAd5) vector 
 Latest - chimpanzee-derived replication-defective adenovirus (ChAd) vaccine 
Rizwan SA, VMCHRI 26/35
Control measures – 4/5 
 Social aspects 
 Cultural practices – burial rituals 
 Illiteracy and lack of awareness 
 Fear of modern medicine, equipment 
 False rumours and misinformation 
 Ethical issues of giving experimental treatment 
Rizwan SA, VMCHRI 27/35
Control measures – 5/5 
 International cooperation 
 CDC, WHO, European Mobile Laboratory (EMLab) Project, African 
Union 
 Voluntary agencies - MSF, Samaritan’s Purse 
 Staff, Outbreak response teams, lab experts, doctors, equipment, 
gloves, medicines, disinfectants 
 Research for medicines and vaccines 
Rizwan SA, VMCHRI 28/35
Outline 
 Why learn about EVD? 
 History 
 Epidemiology 
 Virological and clinical aspects 
 Management 
 Control measures 
 Challenges 
 Pandemic threat 
Rizwan SA, VMCHRI
Challenges to control 
 Lack of effective treatment and vaccine 
 Weak public health infrastructure, manpower, weak labs 
 Poverty and Illiteracy 
 Lack of political stability 
 Delayed international response 
 Failure to anticipate and incorporate social aspects 
 Funding problems 
Rizwan SA, VMCHRI 30/35
Outline 
 Why learn about EVD? 
 History 
 Epidemiology 
 Virological and clinical aspects 
 Management 
 Control measures 
 Challenges 
 Pandemic threat 
Rizwan SA, VMCHRI
Pandemic threat 
 None of the past outbreaks have developed into a pandemic 
But, 
 2014 outbreak – As of August 31, 2014, 3707 cases and >1800 
people dead across 5 countries 
 WHO’s declared ‘Public Health Emergency of International Concern’ 
in August 2014 
 Attack rate - 12.6 cases per 10,000 inhabitants, Ro is 2.7 
 No population level immunity 
 Bioterrorism 
Rizwan SA, VMCHRI 32/35
Take home messages 
 Ebola is an new and emerging infection 
 Ability to cause large outbreaks with high casualty 
 In the absence of proven treatments, prevention is the 
main weapon 
 Social aspects are very important in control 
 Simple and established PH measures are sufficient 
 A potential pandemic 
Rizwan SA, VMCHRI 33/35
Home work 
 Group 1 - Learn the principles of outbreak investigation – 
watch the movie ‘Contagion’ and write a one page 
summary 
 Group 2 - A one page summary on conditions needed to 
declare a pandemic 
 Group 3 - A one page summary of how India is planning 
to respond to this threat, the agencies involved and your 
ideas for preparedness in our hospital 
Rizwan SA, VMCHRI 34/35
Reference materials 
 CDC website http://www.cdc.gov/vhf/ebola/about.html 
 WHO website http://www.who.int/csr/disease/ebola/en/ 
 The Lancet Ebola Resource Centre 
http://ebola.thelancet.com/ 
 Journals - Bulletin of the WHO, NEJM and BMJ, August and 
September 2014 issues 
 Image courtesy – bbc.co.uk, google images, CDC and WHO 
Rizwan SA, VMCHRI
Thank You

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Ebola virus disease/ Ebola outbreak

  • 1. Ebola Virus Disease (EVD) Dr. Rizwan S A, M.D., Department of Community Medicine, VMCH&RI, Madurai, “Got no time for wild polemics, hung up on epidemics” – Anonymous
  • 2. Outline  Why learn about EVD?  History  Epidemiology  Virological and clinical aspects  Management  Control measures  Challenges  Pandemic threat Rizwan SA, VMCHRI 2/35
  • 3. Outline  Why learn about EVD?  History  Epidemiology  Virological and clinical aspects  Management  Control measures  Challenges  Pandemic threat Rizwan SA, VMCHRI
  • 4. Why learn about EVD?  Limited scientific understanding  Highly fatal disease  Causes large outbreaks  Difficult to contain  No proven treatment or vaccine  A pandemic threat Rizwan SA, VMCHRI 4/35
  • 5. Outline  Why learn about EVD?  History  Epidemiology  Virological and clinical aspects  Management  Control measures  Challenges  Pandemic threat Rizwan SA, VMCHRI
  • 6. A story – 1/3 Rizwan SA, VMCHRI 6/35
  • 7. A story – 2/3 Rizwan SA, VMCHRI 7/35
  • 8. A story – 3/3 Rizwan SA, VMCHRI 8/35
  • 9. Outline  Why learn about EVD?  History  Epidemiology  Virological and clinical aspects  Management  Control measures  Challenges  Pandemic threat Rizwan SA, VMCHRI
  • 10. Epidemiological aspects  Natural host - Fruit bats of Pteropodidae family  Reservoir – fruit bats  Sources – bush meat, NHP, Infected humans, fomites  Incubation period – 2 to 21 days  Communicability – high, virus isolated after 90 days of recovery  Case fatality – 50 to 90%  Immunity – long term not proven, deceased patients failed to produce immune response  No. of outbreaks – >30 Rizwan SA, VMCHRI 10/35
  • 11. Geographic distribution – 1/2  First outbreak occurred in Zaire (Congo) in 1976  Followed by several outbreaks, all in Africa (except one in Philippines, Italy, USA)  Latest on-going outbreak in west Africa started in March 2014 in Guinea Rizwan SA, VMCHRI 11/35
  • 13. Modes of transmission  Direct contact (through broken skin or mucous membranes) with  a sick person's blood or body fluids (urine, saliva, faeces, vomit, semen)  objects (such as needles) that have been contaminated with infected body fluids  infected animals  High risk groups – bush meat hunters, forest dwellers, health workers, relatives of patients, funeral attendees, corpse handlers, lab personnel Rizwan SA, VMCHRI 13/35
  • 14. Transmission cycle Rizwan SA, VMCHRI 15/35
  • 15. Outline  Why learn about EVD?  History  Epidemiology  Virological and clinical aspects  Management  Control measures  Challenges  Pandemic threat Rizwan SA, VMCHRI
  • 16. Virological aspects • Family Filoviridae in the order Mononegavirales • Five species • Zaire, Sudan, Taï, Reston, Bundibugyo • Enveloped, non-segmented, negative-strand RNA virus, filamentous • Genes arranged linearly coding for seven structural proteins - NP, VP35, VP40, GP, VP30, VP24 and L with NP • GP, transmembrane protein and responsible for receptor binding and membrane fusion Rizwan SA, VMCHRI
  • 17. Clinical features • Range from minor viral illness to fatal haemorrhagic fever • Ebola haemorrhagic fever (Ebola HF) is type of Viral Haemorrhagic Fevers • Most common constellation of symptoms is together called Ebola Virus Disease • EVD – duration 2 to 20 days, fever, nausea, vomiting, non-bloody diarrhoea, abdominal pain, conjunctivitis, weakness, severe headache and myalgia • E. Hemorrhagic fever - hematemesis, epistaxis, increased postpartum bleeding, bleeding gums etc., Rizwan SA, VMCHRI
  • 18. Outline  Why learn about EVD?  History  Epidemiology  Virological and clinical aspects  Management  Control measures  Challenges  Pandemic threat Rizwan SA, VMCHRI
  • 19. Diagnosis  CDC case definitions  Person Under Investigation  Probable case  Confirmed case  Non-case  Exposure risk levels • In early phase - Antigen-capture ELISA, IgM ELISA, PCR, Virus isolation • In later phase - IgM and IgG antibodies • In deceased patients – immunohistochemistry, PCR, virus isolation • Strict precautions during transportation of samples and all testing in BSL-4 lab • Differentials – Lassa fever, malaria, shigellosis, cholera, leptospirosis, plague, rickettsiosis, relapsing fever, other viral haemorrhagic fevers 20/35 Rizwan SA, VMCHRI
  • 20. Treatment  Experimental treatments  ZMapp – a combo of 3 monoclonal antibodies  TKM-Ebola – targets RNA of the virus  MB-2003 - prevents infection in mice and non-human primates when administered as post-exposure prophylaxis within one to two days  BCX-4430 – RNA polymerase inh  Favipiravir, AVI 7288  Whole blood and convalescent serum transfusion from recovered patients • No proven antiviral drug • Symptomatic treatment only • Providing intravenous fluids and balancing electrolytes (body salts) • Maintaining oxygen status and blood pressure • Treating other infections if they occur • Barrier-nursing techniques • Personal Protective Equipment • Infection control measures • Isolation of Ebola patients from contact Rizwan SA, VMCHRI
  • 21. Outline  Why learn about EVD?  History  Epidemiology  Virological and clinical aspects  Management  Control measures  Challenges  Pandemic threat Rizwan SA, VMCHRI
  • 22. Control measures – 1/5  Public health measures - early detection and isolation, contact tracing and rigorous infection control measures  Screening of travellers from affected countries in airports, seaports and land borders  Quarantine and observation of suspected cases for 21 days from exposure  Awareness generation among people, removing misconceptions Rizwan SA, VMCHRI 24/35
  • 23. Control measures – 2/5  All suspected or confirmed cases, single closed patient room  Avoiding contact  A log book containing details of persons entering  Personal protective equipment for caretakers  Dedicated medical equipment  Minimum use of sharps  Disinfection of samples - heating to 60°C for one hour, in 3% acetic acid  Only BSL 4 lab should handle samples  Hospital monitoring policy for staff In this 2014 photo provided by the Samaritan's Purse aid organization, Dr. Kent Brantly, left, treats an Ebola patient at the Samaritan's Purse Ebola Case Management Center in Monrovia, Liberia. On Saturday, July 26, 2014, the North Carolina-based aid organization said Brantly tested positive for the disease and was being treated at a hospital in Monrovia. View of an isolation center for people infected with Ebola at Donka Hospital in Conakry. Rizwan SA, VMCHRI 25/35
  • 24. Control measures – 3/5  Vaccines  Virus like particles: ZEBOV (VP40, CG and NP)  Non-replicating vectors: alpha virus, DNA vaccines, recombinant adenovirus based vectors (rAD)  Replication competent vectors: Recombinant Paramyxovirus-based vectors, Recombinant vesicular stomatitis virus-based vectors (rVSV), Recombinant rabies virus based (rRABV)  The first vaccine platform that successfully protected NHPs from Ebola virus infection was a recombinant adenovirus serotype 5(rAd5) vector  Latest - chimpanzee-derived replication-defective adenovirus (ChAd) vaccine Rizwan SA, VMCHRI 26/35
  • 25. Control measures – 4/5  Social aspects  Cultural practices – burial rituals  Illiteracy and lack of awareness  Fear of modern medicine, equipment  False rumours and misinformation  Ethical issues of giving experimental treatment Rizwan SA, VMCHRI 27/35
  • 26. Control measures – 5/5  International cooperation  CDC, WHO, European Mobile Laboratory (EMLab) Project, African Union  Voluntary agencies - MSF, Samaritan’s Purse  Staff, Outbreak response teams, lab experts, doctors, equipment, gloves, medicines, disinfectants  Research for medicines and vaccines Rizwan SA, VMCHRI 28/35
  • 27. Outline  Why learn about EVD?  History  Epidemiology  Virological and clinical aspects  Management  Control measures  Challenges  Pandemic threat Rizwan SA, VMCHRI
  • 28. Challenges to control  Lack of effective treatment and vaccine  Weak public health infrastructure, manpower, weak labs  Poverty and Illiteracy  Lack of political stability  Delayed international response  Failure to anticipate and incorporate social aspects  Funding problems Rizwan SA, VMCHRI 30/35
  • 29. Outline  Why learn about EVD?  History  Epidemiology  Virological and clinical aspects  Management  Control measures  Challenges  Pandemic threat Rizwan SA, VMCHRI
  • 30. Pandemic threat  None of the past outbreaks have developed into a pandemic But,  2014 outbreak – As of August 31, 2014, 3707 cases and >1800 people dead across 5 countries  WHO’s declared ‘Public Health Emergency of International Concern’ in August 2014  Attack rate - 12.6 cases per 10,000 inhabitants, Ro is 2.7  No population level immunity  Bioterrorism Rizwan SA, VMCHRI 32/35
  • 31. Take home messages  Ebola is an new and emerging infection  Ability to cause large outbreaks with high casualty  In the absence of proven treatments, prevention is the main weapon  Social aspects are very important in control  Simple and established PH measures are sufficient  A potential pandemic Rizwan SA, VMCHRI 33/35
  • 32. Home work  Group 1 - Learn the principles of outbreak investigation – watch the movie ‘Contagion’ and write a one page summary  Group 2 - A one page summary on conditions needed to declare a pandemic  Group 3 - A one page summary of how India is planning to respond to this threat, the agencies involved and your ideas for preparedness in our hospital Rizwan SA, VMCHRI 34/35
  • 33. Reference materials  CDC website http://www.cdc.gov/vhf/ebola/about.html  WHO website http://www.who.int/csr/disease/ebola/en/  The Lancet Ebola Resource Centre http://ebola.thelancet.com/  Journals - Bulletin of the WHO, NEJM and BMJ, August and September 2014 issues  Image courtesy – bbc.co.uk, google images, CDC and WHO Rizwan SA, VMCHRI

Editor's Notes

  1. Yambuku village in Zaire, Belgian missionary, A Belgian nun taken ill, a Belgian doctor sent her blood sample to a Antwerp Belgium in a commercial flight in a passenger baggage. In the lab it was received by Dr. Peter Piot a clinical microbiologist,
  2. who under electron microscope saw this spagetti shaped virions, he did not know what they were, they looked like marburg virus, so he sent the foto to other experts in the world. They confirmed that it was not marburg virus. That was the moment of discovery for Piot. The nun died and several villagers were affected by similar illness and were dying. Piot travelled to Yambuku and
  3. Investigated the epidemic through detailed history taking and maps to make connections. In three months time they carried out extensive isolation of cases and contacts. They thought of naming the virus after the Yambuku village but thought that it would stigmatise the village, so they name the virus after the nearest river, the Ebola River.
  4. NHP Gorillas, chimps are considered carriers, Human carrier not established
  5. Transmission between natural reservoirs and humans is rare, and outbreaks are often traceable to a single case where an individual has handled the carcass of a gorilla, chimpanzee, or duiker.[5] The virus then spreads person-to-person, especially within families, hospitals, and during some mortuary rituals where contact among individuals becomes more likely
  6. It is an enveloped, non-segmented, negative-strand RNA virus. (1) It is filamentous in appearance, but it might have various shapes as branched, circular, U, 6, or long and straight. (5) The virus particles of Ebola contains genes arranged linearly coding for seven structural proteins - NP, VP35, VP40, GP, VP30, VP24 and L with NP as 3’ end (leader) and L as 5’ end (trailer). (6,7,8) (13) Among the seven, GP is the only transmembrane protein of Ebola virus and is responsible for receptor binding and membrane fusion.
  7. People should be made aware that this disease can be prevented from spreading by following certain hygiene practices but it is very difficult to treat and cure already affected patients. A misinformed community can severely hamper surveillance systems as people avoid giving contact histories for tracing exposed individuals, travel histories for fear of being subjected to quarantine, concealing affected family members from surveillance staff, and unauthorised removal of dead bodies from hospitals to fulfil native burial rituals. duration of precautions for Ebola should be determined on a case-to-case basis, in coordination with local, state, national and international health authorities.