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ebola-epidemiology
1. EPIDEMIOLOGY,
DISEASE AND SITUATION
ASSESSMENT
BY,
DR. B. GURUMURTHY
HOUSE SURGEON
EBOLA –
GUIDE-DR.
LAXMIKANT L
ASSOCIATE PROFESSOR,
DEPT OF COMMUNITY MEDICINE
2. AGENT FACTORS
AGENT
• Ebola virus contain single-strand,
noninfectious RNA genomes.
• Ebolavirus genomes are approximately 19
kilobase pairs long and contain seven genes
RESERVIOR OF INFECTION
• Fruit Bats.
• Plants, arthropods, and birds have also been considered.
SOURCE OF INFECTION
• The most infectious body fluids are blood, feces, and
vomitus.
• Also urine, semen, and breast milk.
• Saliva and tears
3. HOST FACTORS
AGE
• Infection rates are significantly lower in children than in
adults.
• Epidemiologic evidence suggests that children are less
likely to come into direct contact with ill patients than adults
are.
SEX
• No sexual predilection
• Men, by the nature of their work exposure in forest and
savanna regions, may be at increased risk of acquiring a
primary infection.
RACE
Because most cases of Ebola virus infection have occurred
in sub-Saharan Africa, most patients have been black.
However, no evidence exists for a specific racial predilection
4. ENVIRONMENT FACTORS
Studies have shown that low temperature
and high humidity favors ebola virus
infection.
INCUBATION PERIOD
• The Ebola incubation period is the period of time
between infection with the Ebola virus and the
appearance of symptoms associated with the
disease.
• Incubation period can be as short as 2 days or as
long as 21 days
5. MODE OF TRANSMISSION
Person-to-person
Contact with infected animals
Exposure to bats
Nosocomial transmission
9. INVESTIGATIONS
Basic Investigation:
low platelet count
initially decreased white blood cell count followed by an increase in the
white blood cell count
elevated levels of the liver enzymes alanine aminotransferase (ALT)
and aspartate aminotransferase (AST)
abnormalities in clotting such as a prolonged prothrombin time, partial
thromboplastin time, and bleeding time
Specific Investigations:
Studies for isolating virus
RT-PCR
Tissue culture
Serologic testing for antibody and antigen
IgM-capture ELISA
IgG-capture ELISA
Antigen detection ELISA
10. DIAGNOSIS
Medical history, especially travel and work history
along with exposure to wildlife
Diagnosis is confirmed by isolating the virus, detecting
its RNA or proteins, or detecting antibodies against the
virus in a person's blood.
Cell culture
PCR
ELISA
During outbreaks most common diagnostic methods
are real time PCR and ELISA detection of proteins,
11. TREATMENT
No Ebolavirus-specific treatment is currently approved.
Treatment is primarily supportive in nature.
It includes :
Minimizing invasive procedures,
Balancing fluids and electrolytes to counter dehydration,
Administration of anticoagulants early in infection to prevent or
control disseminated intravascular coagulation,
Administration of procoagulants late in infection to
control bleeding,
Maintaining oxygen levels,
Pain management,
Medications to treat bacterial or fungal secondary infections.
13. Barriers to rapid containment
of the Ebola outbreak
11 AUGUST,2014
• LACK OF CAPACITY MAKES INFECTION
CONTROL DIFFICULT
• FEAR IS HARD TO OVERCOME
• TRANSMISSION
• VIGILANCE MEANS BETTER DETECTION
EMERGENCY MEETING ON THE ROLE OF
EXPERIMENTAL THERAPIES IN OUTBREAK
RESPONSE
14. Ebola: Experimental therapies and
rumoured remedies
15 AUGUST 2014
Intense media coverage of experimental medicines and
vaccines is creating some unrealistic expectations
WHO has advised that the use of experimental medicines
and vaccines under the exceptional circumstances of this
outbreak is ethically acceptable.
All rumours of any other effective products or practices are
false
15. Ebola situation in Nigeria and Guinea:
encouraging signs
19 AUGUST 2014
In Nigeria
The situation in Lagos, Nigeria, where the first
imported case was detected in July, looks reassuring.
The city’s 12 confirmed cases are all part of a single
chain of transmission.
There were no further confirmed cases outside the
initial transmission chain.
The full recovery to date of one infected contact is
additional good news.
16. Ebola situation in Nigeria and Guinea:
encouraging signs
19 AUGUST 2014
In Guinea
Public awareness of the facts about Ebola is higher
there than in the other affected countries.
Innovative solutions are being found
But progress is fragile, with a real risk that the
outbreak could experience another flare-up.
17. Anecdotal evidence about experimental
Ebola therapies
21 AUGUST 2014
Clinicians working in Liberia have informed WHO
that 2 doctors and 1 nurse have now received the
experimental Ebola therapy, ZMapp.
The nurse and one of the doctors show a marked
improvement. The condition of the second doctor is
serious but has improved somewhat.
ZMapp is one of several experimental treatments and
vaccines for Ebola that are currently undergoing
investigation.
At present, supplies of all are extremely limited.
18. Why the Ebola outbreak has been
underestimated
22 AUGUST 2014
Many families hide infected loved ones in their homes
Others deny that a patient has Ebola
Most fear the stigma and social rejection when a diagnosis
is confirmed
Quantities of staff, supplies, and equipment, including
personal protective equipment, cannot keep up with the
need
Hospital and diagnostic capacities have been overwhelmed
In rural villages, corpses are buried without notifying
health officials and with no investigation of the cause of
death
The existence of numerous “shadow-zones”.
19. Unprecedented number of medical staff
infected with Ebola
25 AUGUST 2014
To date, more than 240 health care workers have developed the
disease in Guinea, Liberia, Nigeria, and Sierra Leone, and more
than 120 have died.
The factors that help explain the high proportion of infected
medical staff:
Shortages of personal protective equipment or its
improper use
Few medical staff for such a large outbreak
The compassion
WHO estimates that, in the three hardest-hit countries, only one
to two doctors are available to treat 100,000 people
Increase in the level of anxiety: if doctors and nurses are getting
infected, what chance does the general public have?
20. Ebola situation in Port Harcourt, Nigeria
3 SEPTEMBER 2014
THE RESPONSE:
Nigerian health workers and WHO epidemiologists are monitoring more than
200 contacts. Of these, around 60 are considered to have had high-risk or very
high-risk exposure.
An Ebola Emergency Operations Centre has been activated, with support from
the US Centers for Disease Control and Prevention.
A mobile laboratory, with RT-PCR diagnostic capacity, is set up and
functional.
A 26-bed isolation facility for the management of Ebola cases is in place, with
plans for possible expansion.
WHO has 15 technical experts on the ground.
Twenty-one contact-tracing teams are at work and adequate transportation.
Two decontamination teams are equipped and operational, as is a burial
team.
Screening is under way at domestic and international airport gates.
Social mobilization efforts have been stepped up, initially targeting key
community and religious leaders.
21. Ebola situation in Liberia: non-conventional
interventions needed
8 SEPTEMBER 2014
THE RESPONSE:
Liberia yields 3 important conclusions that need to shape the
Ebola response in high-transmission countries.
First, conventional Ebola control interventions are not having an
adequate impact in Liberia, though they appear to be working
elsewhere in areas of limited transmission, most notably in
Nigeria, Senegal, and the Democratic Republic of Congo.
Second, far greater community engagement is the cornerstone of
a more effective response. Where communities take charge,
especially in rural areas, and put in place their own solutions and
protective measures, Ebola transmission has slowed
considerably.
Third, key development partners who are supporting the
response in Liberia and elsewhere need to prepare to scale up
their current efforts by three- to four-fold.
22. Ebola situation in Senegal remains stable
12 SEPTEMBER 2014
Preventing further transmission of Ebola:
Aggressive efforts to identify additional contacts continue
The investigation and response teams face difficulties in
keeping close contacts in isolation for the 21-day monitoring
period.
Contacts have remained in their homes, usually with their
families, where they are checked twice daily for symptoms and
tested if symptoms develop.
Some contacts have resisted monitoring, but none has been lost
to follow-up.
Although Senegal has banned all flights from other affected
countries, road travellers from Guinea and elsewhere can cross
the country’s porous borders.
WHO has repeatedly advised countries not to issue travel bans
To support the global response, Senegal has agreed to open a
humanitarian corridor to facilitate the transport and delivery of
international personnel and supplies to affected countries.
23. Experimental therapies: growing interest in the
use of whole blood or plasma from recovered
Ebola patients (convalescent therapies)
Convalescent therapy was first used for a young
woman infected with Ebola in the Democratic Republic
of Congo (then Zaire) in 1976 – the year the virus first
emerged
During the 1995 Ebola outbreak in Kikwit, Democratic
Republic of Congo, whole blood collected from
recovered patients was administered to eight patients
In the current outbreak, convalescent therapies have
been used in a few patients.
In one well-known case, an American doctor, who became infected while
working in Monrovia, Liberia, received whole blood from a recovered
patient
26 SEPTEMBER 2014
24. CONT..
26 SEPTEMBER 2014
As the epidemic worsens, interest in convalescent therapies
grows
The number of cases continues to grow exponentially
Good supportive clinical care is becoming increasingly
difficult to implement.
WHO is currently holding discussions with health experts
in the Democratic Republic of Congo, Guinea, Liberia,
Nigeria, and Sierra Leone with aim to identify practical
needs for implementation
25. How does WHO declare the end of an Ebola
outbreak?
14 OCTOBER 2014
For WHO to declare an Ebola outbreak over, a country must
pass through 42 days, with active surveillance demonstrably in
place, supported by good diagnostic capacity, and with no new
cases detected. Active surveillance is essential to detect chains
of transmission that might otherwise remain hidden.
Incubation period
The period of 42 days, with active case-finding in place, is twice
the maximum incubation period for Ebola virus disease and is
considered by WHO as sufficient to generate confidence in a
declaration that an Ebola outbreak has ended.
26. The outbreak of Ebola virus disease in
Senegal is over
17 OCTOBER 2014
Senegal is free of Ebola virus transmission
Factors that contributed to success:
Strong political leadership at the highest level.
Early detection and response, aided by a detailed plan and a
quickly-activated National Crisis Committee.
Stepped up surveillance, especially at the country’s many
entry points by road.
Rapid mobilization of resources from both domestic and
international sources; solid preparedness plans are thought
to have earned the confidence of donors.
Support from operational partners, including WHO.
27. CONT..
Nationwide public awareness campaigns that made good use
of media experts, embedded in the Ministry of Health and
Welfare and allowed to closely observe its emergency
actions, and local radio networks.
Deliberate and heavy emphasis on multisectoral
collaboration among all relevant government ministries,
backed by community engagement every step along the way.
Direct support to patient contacts as a strong incentive for
cooperation and compliance, through the provision of social
support in the form of money, food, and psychological
counselling.
Support for reintegration of the recovered patient into a
society that could understand why he posed no risk of
contagion to others.
28. Nigeria is now free of Ebola virus
transmission
20 OCTOBER 2014
What accounts for this great news?
The country’s strong leadership and effective coordination of the
response.
The Nigerian response to the outbreak was greatly aided by the
rapid utilization of a national public institution (NCDC) and the
prompt establishment of an Emergency Operations Centre,
supported by the Disease Prevention and Control Cluster within the
WHO country office.
Another key asset was the country’s first-rate virology laboratory
affiliated with the Lagos University Teaching Hospital.
In addition, high-quality contact tracing by experienced
epidemiologists expedited the early detection of cases and their
rapid movement to an isolation ward, thereby greatly diminishing
opportunities for further transmission.
