ebola virus and its common presentations and the current scenario... Please leave a comment if you like it..

1. Speaker: Abhinav Agarwal
Moderator: Dr. Ankur Singh

2. Covered Headings:-
 Introduction
 Transmission
 Pathogenesis
 Clinical Features (Ebola Hemorrhagic Fever)
 Diagnosis
 Case definitions
 Management
 Precautions
 Accidental Exposure
 Cough and Hand Hygiene

3. Introduction:-
 Filoviridae family (filovirus)
 Ebola Virus
 Marburg Virus
 Ebola virus (five species):-
 Côte d’Ivoire
 Reston
 Sudan
 Zaïre
 Bundibugyo
 Only one Marburg virus species.
 The Marburg virus and Ebola Zaïre, Sudan, and Bundibugyo
subtypes have been associated with large(VHF) outbreaks case
fatality rate ranging from 25%–90%
 The first cases of EVD were detected in the Democratic Republic
of Congo (DRC) and Sudan (1976).

4. Transmission:-
 Natural Hosts:-
 Bat species mainly
Pteropodidae
 The geographic distribution of
Ebola and Marburg viruses
probably corresponds to that
of fruit bats (Pteropodidae).
 In Africa, the infection of
human cases with Ebola
virus disease has occurred
through the handling of
infected chimpanzees,
gorillas, monkeys, bats.

5. Transmission (cont.):-

6. Transmission (cont.):-
 In order to reduce the risk of Ebola virus amplification
in pigs, public and animal, health authorities should:
 conduct a risk assessment to determine if there are pig
farms within proximity to the outbreak;
 implement control measures to prevent pig-to-human
transmission, including strengthening the food
production system;
 contain confirmed Ebola infection in pig populations;
 apply appropriate biosafety measures in order to prevent
bats from introducing the Ebola virus into pig
populations.

7. Pathogenesis:-
 Endothelial cells, mononuclear
phagocytes, and hepatocytes are the
main targets of infection.
 After infection, a secreted glycoprotein
(sGP) known as the Ebola virus
glycoprotein (GP) is synthesized.
 The presence of viral particles and cell
damage ,resulting from budding causes
the release of cytokines ( TNF-α, IL-
6, IL-8, etc.)(Cytokine storm)
 The cytopathic effect, from infection in
the endothelial cells, results in a loss of
vascular integrity.
 This loss in vascular integrity is
furthered with synthesis of GP, which
reduces specific integrins responsible
for cell adhesion to the inter-cellular
structure, and damage to the liver,
which leads to coagulopathy.

8. Ebola Hemorrhagic Fever:-
 Incubation Period:
 Anywhere from 2-21 days
 Symptoms:-
 Fever and headache
 Joint and muscle aches
 Weakness
 Nausea and vomiting
 Diarrhea (may be bloody)
 Red eyes
 Raised rash
 Chest pain and cough
 Stomach pain
 Severe weight loss
 Bleeding, usually from the eyes, and bruising (people near death may
bleed from other orifices, such as ears, nose and rectum)
 Internal bleeding

9. Diagnosis:-
 Clinical:
 Difficult because early symptoms (red eye, skin rash) are
nonspecific to virus.
 Takes a combination of many symptoms characteristic of
Ebola.
 Laboratory Diagnosis:
 antigen detection using the ELISA test
 detection of IgM antibodies directed against Ebola
 seroconversion or increasing IgG antibody titres in two
subsequent specimens collected within a week of each other
 detection of virus RNA by reverse transcriptase-polymerase
chain reaction (RT- PCR) and sequencing
 detection by immunohistochemical (IHC) staining of the
patients’ tissue or blood
 viral isolation.

10. Case Definitions for health centres:
 SUSPECTED CASE:
 Any person, alive or dead, suffering or having suffered from a
sudden onset of high fever and having had contact with:
 - a suspected, probable or confirmed Ebola or Marburg case;
 - a dead or sick animal (for Ebola)
 - a mine (for Marburg)
 OR: any person with sudden onset of high fever and at least three
of the following symptoms:
 • headaches • vomiting
 • anorexia / loss of appetite • diarrhoea
 • lethargy • stomach pain
 • aching muscles or joints • difficulty swallowing
 • breathing difficulties • hiccup
 OR: any person with inexplicable bleeding
 OR: any sudden, inexplicable death.

11.  PROBABLE CASE:
 Any suspected case evaluated by a clinician
 OR: Any deceased suspected case (where it has not been
possible to collect specimens for laboratory
confirmation) having an epidemiological link with a
confirmed case
 LABORATORY CONFIRMED CASE:
 Any suspected or probably cases with a positive
laboratory result. Laboratory confirmed cases must test
positive for the virus antigen, either by detection of virus
RNA by (RT- PCR), or by detection of IgM antibodies

12.  NON-CASE:
 Any suspected or probable case with a negative laboratory result.
“Non-case” showed no specific antibodies, RNA or specific
detectable antigens.
 Ebola case contacts:
 Any person having had contact with an Ebola in the 21 days
preceding the onset of symptoms in at least one of the following
ways:
 Having slept in the same household with a case
 Has had direct physical contact with the case (dead or alive) during
the illness
 Has had direct physical contact with the (dead) case at the funeral,
 Has touched his/her blood or body fluids during the illness
 Has touched his/her clothes or linens
 Has been breastfed by the patient (baby)

13. Case Management:-
 No specific management
 Palliative care: rehydration
 Symptomatic treatment: pain-killers, antiemetics,
anxiolytics, antibiotics, antimalarial remedies.
 Use of oxygen
 In the event of severe bleeding: transfusion of blood or
previously-tested blood components
 Monitor biochemical and blood values of patients to
maintain electrolyte balance.
 Do not use products containing salicylates (i.e.
acetylsalicylic acid/aspirin) or other NSAIDS as these
increase the risk of bleeding.

14.  DRUGS:-
 TKM-Ebola (RNAi-based):- Tekmira Pharmaceuticals
Corp. (entered phase 1 trial but halted by FDA)
 Nucleoside analog:-
 Army Medical Research
 Institute of Infectious Diseases
 Monoclonal antibodies:- Many labs/companies (ZMapp)
 AVI-7537 (antisense-based):- Sarepta Therapeutics
ZMapp given to 2 U.S. Patients in Liberia showed
promising results.

15.  VACCINES:-
 VSV(Vesicular stomatitis virus)-based vaccines
 Profectus BioSciences
 Public Health Agency of Canada
 Adenovirus-based vaccines
 Many different vaccines labs/companies (GSK,
Johnson and Johnson)

16. Epidemic:-
Epidemic curves in humans and animals at the human-animal interface

17. Keys to controlling EVD
outbreaks include:
 Collaboration with wildlife
mortality surveillance systems
 active case identification and
isolation of patients from the
community.
 identifying contacts of ill or
deceased persons and tracking
the contacts daily for the entire
incubation period of 21 days
 investigation of retrospective
and current cases.
 identifying deaths in the
community and using safe burial
practices
 daily reporting of cases
 Education of health-care
workers regarding safe infection-
control practices

18. Standard Precautions in Healthcare:
 Establishment of an isolation
ward;
 Training of health-care workers
 Use of personal protective
equipment (PPE; masks, gowns,
boots, etc.)
 Safe transport of patients to the
isolation ward;
 Decontamination of soiled areas
and the transport vehicle;
 Safe management of health-care
waste
 Examination and triage of
patients on admission to the
isolation ward;
 Drafting and posting of a
standard treatment protocol; and
 Visitors must wear adequate PPE.

19. Accidental Exposure:
 In case of accidental
exposure (needlestick
injury, contact with body
fluids, etc.):
 Immediately wash with
soapy water (use pure
water for the eyes)
 Report the incident
immediately to a
supervisor.
 Monitor the exposed
person for a period of 21
days, including overall
condition, psychological
condition, temperature,
etc.

20. Hospital Discharge:-
 Once the laboratory diagnostic tests shows that antibodies are
developed and they no longer have an active infection
 Recovering patients are no longer contagious to others and their
return home or transfer to a general hospital is safe.
 Once the patient is back home
 After recovery, the patient may feel tired for a period of up to two
months. It is important that the patient:
 Get plenty of rest.
 Eat a varied diet (for example bread, vegetables, fruit, meat, beans).
 Drink plenty of water to rehydrate.
 Warning: Male patients must be informed that their sperm may
still be contagious for a period of three months (61days) after
leaving hospital and Ebola may be transmitted during sexual
intercourse.

21. Summary of surveillance and investigation findings
 Cumulatively, 1975 cases of Ebola virus disease and 1069 deaths
have been reported across the three countries. The cumulative
case fatality rate is 54.1%.
Epicurve of Ebola virus disease outbreak in West Africa (Guinea, Liberia, and Sierra Leone),
by week of onset, December 2013 – June 2014

23. Hand Hygiene:-
 Study published in American
Journal of Infection Control
 Nearly twice as many bacteria
were transferred during a
handshake compared to high
five, whereas the fist bump
gave the lowest transmission.
 The relationship between
bacterial transfer and contact
area is consistently positive.
 The high transmission level
observed for handshakes does
not appear to be purely a
function of its large contact
area, but also depends on
duration and strength.

24.  High Five  Fist Bump

25. References:-
 Ebola and Marburg virus disease epidemics: preparedness,
alert, control, and evaluation WHO June 2014,
WHO/HSE/PED/CED/2014.05
 Ebola Viral Disease Outbreak — West Africa, MMWR /
June 27, 2014 / Vol. 63 / No. 25
 Interim Infection Control Recommendations for Care of
Patients with Suspected or Confirmed Filovirus (Ebola,
Marburg) Hemorrhagic Fever, BDP/EPR/WHO, Geneva
March 2008.
 S Mela, DE Whitworth. ‘The fist bump: A more hygienic
alternative to the handshake’ American Journal of Infection
Control 42 (2014) 916-7