PHEIC Ebola Outbreak DRC

A PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN (PHEIC)
EBOLA VIRUS DISEASE
(EVD)
Presenter:
Dr. Jaiprakash
Junior Resident
Moderator:
Dr. Srishti Singh
Senior Resident
Department of Community Medicine, PGIMS, Rohtak

Contents
• Introduction
• Previous outbreak
• Epidemiology of Ebola
• Prevention and outbreak response
• Management
• The Ongoing epidemic of Ebola virus disease (EVD)
in Democratic Republic of Congo

Introduction
• Ebola virus disease is an emerging viral disease caused
by Ebola virus.
• This virus was first identified in 1976 in 2 simultaneous
outbreaks in Nzara, Sudan and in Yambuku, Congo.
• WHO Director-General Dr. Tedros Adhanom declared
the Ebola virus disease (EVD) outbreak in the
Democratic Republic of the Congo (DRC) a Public
Health Emergency of International Concern (PHEIC) on
17th july 2019.
https://www.who.int/news-room/detail/17-07-2019

PHEIC
Defined in International Health Regulations (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.
https://www.who.int/features/qa/emergency-committees/en

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 Severe Acute
Respiratory Syndrome (SARS) must be immediately notified to
WHO, irrespective of the context in which it occurs.
https://www.who.int/features/qa/emergency-committees/en

Table: Chronology of previous Ebola virus disease
outbreaksYear Country EVD
strain
Cases Death Case
Fatality
1976 Democratic Republic of Congo Zaire 318 280 88%
1976 Sudan Sudan 284 151 53%
2000 Uganda Sudan 425 224 53%
2003 Congo Zaire 143 128 90%
2014-2016 Sierra Leone Zaire 14124* 3956* 28%
2014-2016 Liberia Zaire 10675* 4809* 45%
2014-2016 Guinea Zaire 3811* 2543* 67%
2018 Democratic Republic of the Congo Zaire 54 33 61%
2018-2019 Democratic Republic of the Congo
(ONGOING)
Zaire 2659** 1782**
67%
* PROBABLE+CONFIRM CASE, ** PROBABLE+CONFIRM CASE (ONGOING)till 27 july 2019

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.
Epidemiology of Ebola
https://mohfw.gov.in/sites/default/files/39142885101407413159_0.pdf

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
 Species: 6 types
Zaire ebolavirus (EBOV)
 Sudan ebolavirus (SUDV)
 Bundibugyo ebolavirus(BDBV)
 Taï Forest ebolavirus (TAFV)
 Reston ebolavirus(RESTV)
 Bombali ebolavirus ( New 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.

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.

TRANSMISSION
 Natural Host: Fruit bats of the Pteropodidae family
 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 in
the rainforest)
https://www.cdc.gov/vhf/ebola/transmission/index.html

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.
CASE FATALITY RATE: up to 90%
 All cases in the current outbreak- HUMAN-TO-HUMAN

Basic pathogenesis
o It damages the endothelial cells that make up the lining of the
blood vessels and creates difficulty in coagulation of the
infected individual’s blood.
o As the vessel walls become more damaged, and the platelets
cannot coagulate, the individual undergoes hypovolemic shock
or a dramatic decrease in blood pressure.

Clinical features
o Incubation period - 2-21 days
Infected person is not infectious to others during this period.
o Initially- Pt. abruptly develops fever, severe headache, malaise,
myalgia, nausea and vomiting.
o Continued fever is joined by diarrhoea (often severe), chest pain
(accompanied by cough), prostration and depression.
o Maculopapular rash appears around day 5–7 and is followed by
desquamation.

o Additional findings include edema of the face, neck,
and/or scrotum; hepatomegaly; flushing; conjunctival
injection and pharyngitis.
o Severe bleeding and coagulation abnormalities, including
gastrointestinal bleeding, rash, and a range of
hematological irregularities, such as decreased WBC
count.
Clinical features conti…

o Disseminated intravascular coagulation (DIC).
o Hypotensive shock lead to Death .
o Around 10–12 days after the onset of disease, the sustained fever
may break, with improvement and eventual recovery of the
patient.
o Recrudescence of fever may be associated with secondary
bacterial infections or possibly with localized virus persistence.
o Late hepatitis, uveitis, and orchitis have been reported, with
isolation of virus from semen or detection of PCR products in
vaginal secretions for several weeks.
Clinical features conti…

PERSON UNDER INVESTIGATION
A person who has both consistent symptoms & risk factors:
 1) Clinical criteria, which includes fever of greater than 101
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
i. contact with blood or other body fluids or human remains of a
patient known to have or suspected to have EVD;
ii. residence in—or travel to—an area where EVD transmission
is active;
iii. direct handling of bats, rodents, or primates from disease-
endemic areas.
https://www.cdc.gov/vhf/ebola/clinicians/evaluating-patients/case-definition.html

Probable case (with or without bleeding):
o Any person (living or dead) having had contact with a
clinical case of Ebola hemorrhagic fever and with a
history of acute fever.
OR
o Any person (living or dead) with a history of acute
fever and three or more of the following Symptoms:
headache/ vomiting/nausea/ loss of appetite/ diarrhea/
intense fatigue/ abdominal pain/ general muscular or
articular pain/ difficulty in swallowing/ difficulty in
breathing/hiccoughs
OR
o Any unexplained death.
Case Definition EVD

Suspected (clinical) case:
o Any person ill or deceased who has or had fever with acute
clinical symptoms and signs of hemorrhage, such as bleeding of
the gums, nose-bleeds, conjunctival injection, red spots on the
body, bloody stools and/or melena (black liquid stools), or
vomiting blood(haematemesis) with the history of travel to the
affected area.
o Documented prior contact with an EVD case is not required.
Case Definition EVD

o The distinction between a suspected case and a
probable case in practice relatively unimportant as far
as outbreak control is concerned.
Confirmed Case:
o A suspected or probable case with laboratory
confirmation (positive IgM antibody, positive PCR or
Viral isolation).
Case Definition EVD

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 Personal Protective Equipment
(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.
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.
CONTACTS OF AN EVD CASE

Always rule out
 Other Viral Haemorrhagic Fevers.
 Malaria
 Yellow fever
 Dengue
 Leptospirosis
 Rickettsiosis
 Plague
 Hepatitis
DIFFERENTIAL DIAGNOSIS

 Thrombocytopenia, leukopenia mainly
lymphopenia.
 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
LABORATORY FINDINGS

Definitive diagnosis by
 Antibody-capture ELISA
 Antigen detection tests
 Serum neutralization test- serological surveys
 RT-PCR assay
 Virus isolation by cell culture.
 Skin biopsies in postmortem diagnosis of infection with Ebola
virus
LABORATORY DIAGNOSIS
Highly sensitive and
confirmatory tests

From whom the samples are to be collected?
o Any person ill or deceased who has or had fever with
acute clinical symptoms and signs of haemorrhage,
with the history of travel to the affected area.
o OR
o Any person (living or dead) having had contact with a
clinical case of EVD and with a history of acute fever.
SAMPLE COLLECTION

What sample/s is to be collected?
Ante-mortem:
o Blood sample : Serum/Plasma
Post-mortem:
o Tissue sample (liver, spleen, bone marrow,
kidney, lung and brain)

How to collect the samples?
o Samples should be collected with all biosafety
precautions (wearing gloves, gown, eye-shield)
o Accompanied with detailed history of patient on the
Performa.
o Before dispatching the sample disinfect the outer
surface of container using 1:100 dilution of bleach or
5% Lysol solution.
o Bold labelling of “Suspect Ebola” on all vials.

How to pack and transport the sample?
Sample Packaging and Transportation
o Sample should be safely packed in “Triple container”
packing and
o Transported under cold chain to the reference
laboratory with prior intimation
o Label should have name, Hospital number/ID number,
age and date of collection.

Samples should be sent to the following laboratories
under cold chain with prior intimation:
National Institute of Virology, Pune
National Centre for Disease Control, Delhi
Sample (blood/serum)- transported at 2-
80 C within 24 hrs.
In case of delay – store at -700C.
triple layer packaging system
Where the samples should be transported

STRATEGY FOR PREVENTION AND CONTROL

The WHO Strategic Action Plan for Ebola Outbreak Response
is divided into two parts:
A. Immediate actions to support the EVD affected countries.
B. Interventions in neighbouring at-risk countries to increase
preparedness and prevent the occurrence of additional
outbreaks.
https://www.who.int/csr/disease/ebola/evd-outbreak-response-plan-west-africa-2014-
annex1.pdf
WHO Strategic Action Plan

A.Immediate actions to support the EVD
affected countries.
1. Urgently strengthen the field response
 Output 1: A local response team is in place in each “hot spot”
 Output 2: Provision of field logistical support including
Personal Protective Equipment supply and local laboratory
facilities capacity
 Output 3: Provision of care to patients with effective infection
prevention and control in health care settings
 Output 4: Chains of transmission broken through active
surveillance, case investigation, contact tracing and follow-up
 Output 5: Public relations and reputation management, social
mobilization, and risk communications strengthened

2. Coordinate the outbreak response
• Manage the WHO Sub-regional Ebola Operations Coordination Centre
 outbreak response strengthened
 Cross-border coordination strengthened
• WHO’s leadership and coordination of EVD outbreak response
strengthened at all levels
Logistics management to support response activities
expert support provided for risk assessment
Global communication and information provided
External relations strengthened
Clinical support strengthened
Development of new medical treatments and interventions
against EVD advanced

Output 1: Preparedness plans activated and tested
Output 2: Active surveillance strengthened
Output 3: Laboratory diagnostic capacity strengthened
Output 4: Public information and social mobilization enhanced
Output 5: Case management and infection prevention and control
capacities strengthened
B. Preparedness in countries at-risk

o Coordination
o Rapid Response Team (RRT)
o Public Awareness and Community Engagement
o Infection Prevention and Control
o Case Management a) Ebola Treatment Centre (ETC)
b) Safe burials
o Epidemiological Surveillance
o Contact Tracing
o Laboratory
o Capacities at Points of Entry
o Budget
o Logistics
https://www.who.int/csr/resources/publications/ebola/ebola-preparedness-checklist
Consolidated Preparedness Checklist For EVD

 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
 Terminal Disinfection, Sterilisation
 Following SOP for blood sample collection and Transport
 Appropriate Hospital Waste management
 Enhanced Surveillance
 Health Education
PREVENTION

 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 NationalAuthority
 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 (some drugs under trial)
MANAGEMENT

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
 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.
Tekmira, a Canadian biotech company, has begun early
human trials of a new drug
Experimental treatment

• Nearly 800 people were ring vaccinated on an emergency basis
with VSV-EBOV when another Ebola outbreak occurred in Guinea
in March 2016.
• In 2017, in the face of a new outbreak of Ebola in the Democratic
Republic of the Congo, the Ministry of Health approved the
vaccine's emergency use, but it was not immediately deployed.
Effectiveness
• In April 2019, following a large-scale ring-vaccination scheme in
the DRC outbreak, the WHO published the preliminary results of
its research, in association with the DRC's Institut National pour la
Recherche Biomedicale, into the effectiveness of the ring
vaccination program, stating that the rVSV-ZEBOV-GP vaccine
had been 97.5% effective at stopping Ebola transmission, relative
to no vaccination.
Vaccine

AIR TRAVELLERS
 Exit screening and communication efforts on the ground in
West Africa to prevent sick travellers from getting on planes.
 Airports in DRC and Uganda 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.

INDIA
 No confirmed case of Ebola till date.
 24-hour 'Emergency Operation Centre'( 2014)
011-23061469, 3205 and 1302
 GUIDELINES issued in 2014 by MOHFW, no new updation.

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.
 That EVD outbreak is believed to have begun in Guinea in
December 2013.
 Viral sequencing showed strong homology (98%) with
Zaïre Ebolavirus (EBOV)

• The ongoing epidemic of Ebola virus disease (EVD) in the
Democratic Republic of Congo (DRC) is the tenth and largest EVD
outbreak in the DRC since Zaire ebola virus was first discovered
there in 1976.
• The outbreak has occurred in an area of conflict among multiple
armed groups . Despite porous international borders and considerable
population movement, however, transmission has been confined to
North Kivu and Ituri provinces.
• Though the current epidemic involved 2612 patients as of 23 july,
2019, with a case fatality rate of 67%, it is still an order of magnitude
smaller than the West African EVD epidemic of 2013–2016, which
caused more than 28,000 cases.
The Ongoing epidemic of EVD in Democratic Republic of Congo
N Engl J Med 2019; 381:373-383

Current data on Ongoing epidemic of EVD in DRC
https://www.who.int/emergencies/diseases/ebola/drc-2019/ebola-daily-case-numbers

Cont..
• A coordinated, multistrategy response in North Kivu and Ituri
provinces has been led by the DRC MOH, supported by the WHO
and more than 50 national and international partners.
• Preparedness measures have been implemented in bordering
provinces and neighboring countries of Uganda, South Sudan, and
Rwanda and in close coordination with their ministries of health.
• Factors potentially contributing to this containment include
conduct of about 55 million screenings,(Population 87 M)
surveillance of contacts (12,591 under surveillance currently),
testing of 280 samples per day, provision of safe and dignified
burials for most deaths, vaccination of high-risk people (112,485
vaccinated as of May 7, 2019), and medical treatment including
four investigational therapies.

Cont..
Major challenges however remain...
• Since late February 2019, a sharp rise in cases and increased
transmission have been observed.
• These coincide with organized attacks by armed groups targeting
response teams, deteriorating security, and the population’s
increasing distrust of the response effort.
• The risk of local and regional spread remains high given the high
proportion of deaths occurring outside treatment facilities,
ongoing nosocomial transmission.

• Persistent delays in detection and reporting.
• Timely identification of EVD cases in contacts of patients with
EVD remains challenging.
• In the context of insecurity and a highly mobile population often
fearful of the response effort, with individuals often hiding,
refusing to subject themselves to follow-up examinations, or
traveling to distant homes in heavily forested areas and other
destinations.

SURVEILLANCE
• Case detection and investigation activities have been gradually
strengthened over time and with the evolution of the outbreak.
• Of more than 1000 alerts reported each day from outbreak-
affected areas, 88 to 92% are investigated within the first 24
hours. Combined with cases detected by other mechanisms, this
results in a daily average of 280 suspected cases.
• The timeliness of identification of suspected cases and alerting of
health authorities continues to be suboptimal. The median time
from an alert of onset of illness to official report as a confirmed
case of EVD is 6.0 days.

CASE MANAGEMENT
• Ebola treatment centers provide aggressive rehydration, correction
of electrolyte imbalances, and nutritional support.
•
• A compassionate-use protocol (Monitored Emergency Use of
Unregistered and Investigational Interventions, or MEURI) is
offered to all patients with laboratory-confirmed EVD.
• This protocol includes three antibody-based therapies (MAb114,
ZMapp, and REGN-EB3) and one antiviral agent (Remdesivir).

o On June 11th 2019 WHO declared an outbreak of Ebola in Uganda,
after confirmation of a case of a 5 year-old boy who'd travelled to
neighbouring Democratic Republic of Congo for burial of a relative.
Upon return in Uganda, the boy developed symptoms and was
confirmed to be the country's first confirmed case.
o His 3 year-old brother and 50 year-old grandmother also succumbled
to the deadly virus. Since then, however no any other new cases have
been confirmed. All those who came into contact with the family
were isolated, vaccinated and effectively treated.
o Following the completion of the recommended 42 days without any
new Ebola case since the first Ebola cases last month, Uganda has
been declared Ebola-free by the WHO on July 27, 2019 .
Uganda declared Ebola-free by WHO
https://observer.ug/news/headlines/61468-world-health-organisation-declares-uganda-
ebola-free

PHEIC Ebola Outbreak DRC

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