updated status report till aug 31

1. EBOLA VIRUS DISEASE
(EVD)
MADHUR VERMA
PG 3RD YEAR
DEPTT OF COMMUNITY MEDICINE
PGIMS ROHTAK

2. CONTENTS
• Introduction & history
• Microbiology
• Transmission
• Pathogenesis & clinical features
• Vaccination & Prevention
• Current status in world and India

3. INTRODUCTION
Ebola Virus Disease (EVD)
• One of the most fatal Viral Hemorrhagic
Fevers
• Severe, often fatal disease in humans (90%)
and nonhuman primates (monkeys, gorillas, and
chimpanzees).

4. INTRODUCTION
 The first Ebolavirus species : 1976
Democratic Republic of the Congo(zaire)-
Ebola River.
• 24 outbreaks appeared sporadically
(1976-2012).
• The current outbreak :West Africa(Guinea,
Liberia, Sierra Leone and Nigeria )

5. Ebola In Bioterrorism
• According to CDC it is a potential
biological threat falling in category A
(highest priority pathogens)
Category A Priority Pathogens
Bacillus anthracis (anthrax) , Clostridium botulinum toxin (botulism), Yersinia pestis (plague),
Variola major (smallpox), Francisella tularensis (tularemia) ,Viral hemorrhagic fevers
Category B Priority Pathogens
Burkholderia pseudomallei (melioidosis), Coxiella burnetii (Q fever), Brucella species
(brucellosis),Burkholderia mallei (glanders),Chlamydia psittaci (Psittacosis), Ricin toxin (Ricinus
communis), Epsilon toxin (Clostridium perfringens), Staphylococcus enterotoxin B (SEB) Typhus
fever (Rickettsia prowazekii), Food- and waterborne pathogens, Mosquito-borne encephalitis
viruses
Category C Priority Pathogens
Nipah and Hendra viruses, Tickborne hemorrhagic fever viruses, Bunyaviruses, Flaviruses,
Kyasanur Forest virus, Tickborne encephalitis complex flaviviruses
Yellow fever virus, Tuberculosis, including drug-resistant TB, Influenza virus, Rickettsias
Rabies virus, Prions, Chikungunya virus, Coccidioides spp., (SARS-CoV), MERS-CoV,
• Under the guise of wanting to aid victims
of an Ebola outbreak, members of the
Aum Shinrikyo cult in Japan were
reported to have travelled to central
Africa in 1992 in an attempt to obtain
Ebola virus for use in a bioterrorist
attack. (Harrison 18th ed)

6. Basic microbiology
EVD is caused by four of five viruses
classified in the genus Ebolavirus, family Filoviridae.
• pleomorphic,
• negative-sense RNA viruses
• genome organization is most similar to
the Paramyxoviridae(MEASLES).

7. Appear in the shape of a shepherd's crook or in
the shape of a "U" or a "6“, bowl of spaghetti
appr & they may be coiled, toroid, or branched.
The five Ebola viruses are closely related to
the Marburg viruses as the both genera are the
part of same family filoviridae. (Harrison 18th ed)

8. SUB SPECIES OF EBOLA VIRUS
Four of the five have caused disease in humans:
• Ebola virus (Zaire ebolavirus); EBOV
• Sudan virus (Sudan ebolavirus); SUDV
• Taï Forest virus (Taï Forest ebolavirus); TAFV
• Bundibugyo virus (Bundibgyo ebolavirus).
BDBV
• Reston virus (RESTV), has caused disease in
nonhuman primates, but not in humans.

9. Ebola virus is the sole member of
the Zaire ebolavirus species, and the most
dangerous of the known Ebola disease-causing
viruses, as well as being responsible
for the largest number of outbreaks.[16]

11. • The natural reservoir host of Ebola viruses :
Fruit bats (Pteropodidae family) in Africa
• Humans and Nonhuman primates are the
accidental hosts.

12. • Since 1994, Ebola outbreaks from the EBOV
and TAFV species have been observed in
chimpanzees and gorillas.
• RESTV has caused severe EVD outbreaks in
macaque monkeys (Macaca fascicularis)
farmed in Philippines and detected in monkeys
imported into the USA in 1989, 1990 and
1996, and in monkeys imported to Italy from
Philippines in 1992.

13. • 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.

15. TRANSMISSION

16. Transmission
• Ebola is introduced into the human population:
close contact with the blood, secretions,
organs or other bodily fluids of infected
animals.
• In Africa, infection has been documented
through the handling of infected
chimpanzees, gorillas, fruit bats, monkeys,
forest antelope and porcupines found ill or
dead or in the rainforest.

17. Transmission
How is human to human transmission of Ebola
Virus occurring?
Ebola virus is transmitted through direct
contact with the blood or bodily fluids of an
infected symptomatic person or though
exposure to objects (such as needles) that have
been contaminated with infected secretions.
It is not transmitted through air.
http://nicd.nic.in/writereaddata/linkimages/FAQ_ebola_20144909470493.pdf

18. Transmission
• Burial ceremonies in which mourners have
direct contact with the body of the deceased
person can also play a role in the transmission
of Ebola.
• Men who have recovered from the disease can
still transmit the virus through their semen
for up to 7 weeks after recovery from illness.

19. Basic pathogenesis
• 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.
• As the vessel walls become more
damaged, and the platelets cannot
coagulate, the individual undergoes
hypovolemic shock or a dramatic
decrease in blood pressure

20. Host immune responses to Ebola virus and cell damage due to direct infection of monocytes
and macrophages cause the release of cytokines associated with inflammation and fever (A).
Sullivan N et al. J. Virol. 2003;77:9733-9737

21. Clinical features*
 Incubation period - ( 2-21 days)– WHO
7–10 days (range,3–16days)
Infected person is not infectious to others during this period
(MoHFW )
 Initially- pt. abruptly develops fever, severe headache,
malaise, myalgia, nausea, and vomiting.
 Continued fever is joined by diarrhoea (often severe),
chest pain (accompanied by cough), prostration, and
depressed mentation.
 Maculopapular rash appears around day 5–7 and is
followed by desquamation.
* HARRISON 18TH ed

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

23. Clinical features
• DIC
• Hypotensive shock l/t Death
 Around 10–12 days after the onset of disease, the
sustained fever may break, with improvement and
eventual recovery of the patient.
 Recrudescence of fever may be associated with
secondary bacterial infections or possibly with
localized virus persistence.
 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.

24. SIGNS AND SYMPTOMS

25. DIFFERENTIAL DIAGNOSIS
Diseases to be ruled out before a diagnosis of
EVD:
Malaria Plague
Typhoid Fever Rickettsial fever
Shigellosis Relapsing Fever
Cholera Meningitis
Leptospirosis Hepatitis
Other viral hemorrhagic fevers

26. CLINICAL CASE DEFINITION*
Suspected case :-
• high grade fever more than 101 degrees F,
• Patient having history of travel or close
contact with symptomatic person traveling
from Ebola Virus Disease affected areas in the
past 21 days,
*http://who.int/csr/resources/publications/ebola/ebola-case-definition-contact-en.pdf

27. • Along with one or more of the following
additional symptoms:-
• Headache
• Body ache
• Unexplained haemorrhage
• Abdominal pain
• Diarrhoea
• Vomiting

28. Confirmed case:
• A case with the above features and
laboratory confirmed diagnostic evidence of
Ebola virus infection at a BSL-3 facility by
any one of the following:-
• Ig M (ELISA)
• Antigen detection
• RT-PCR

29. CLINICAL DIAGNOSIS
• All suspected patient, investigate for :
• Ig M (ELISA),
• Antigen detection,
• RTPCR to confirm.
 However this test result may not help in the
clinical management of the patient.

30. CLINICAL DIAGNOSIS
• For proper care and management also
investigate:
• liver function test,
• kidney function test,
• Electrolytes,
• Haemacrit,
• Repeated platelet count,
• Haemoglobin,
• WBC.

31. Guidelines for collection,
storage and transportation of
samples from suspected cases
of
Ebola Virus Disease (EBVD)*
*http://nicd.nic.in/writereaddata/linkimages/glines_ebola_virus2014
6701988323[1]728874458.pdf

32. From whom the samples are to be
collected?
• 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.
• OR
• Any person (living or dead) having had contact
with a clinical case of EBVD and with a history
of acute fever

33. Collection, packaging and transportation
of samples
• Ebola virus : Risk group 4 virus
• Classification Clinical samples of Biohazardous should Agents by be Risk collected Group (RG) (taken using from all
NIH
Guidelines for Research Involving Recombinant DNA Molecules, May 1999)
universal precautions and
• Handled in specially-equipped, high biosafety
level laboratories (BSL 3 plus or 4).
• Risk Group 1 (RG1) Agents that are not associated with disease in healthy
adult humans.
• Risk Group 2 (RG2) Agents that are associated with human disease which is
rarely serious and for which preventative or therapeutic interventions are
often available.
• Risk Group 3 (RG3) Agents that are associated with serious or lethal human
disease for which preventive or therapeutic interventions may be available (high
individual risk but low community risk).
• Risk Group 4 (RG 4) Link Agents to BSL LAB that CLASSIFICATION
are likely to cause serious or lethal human
disease for which preventive or therapeutic interventions are not usually
available) (high individual risk and high community risk)
https://www.google.co.in/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&
uact=8&ved=0CEAQFjAC&url=http%3A%2F%2Fwww.cdc.gov%2Fbiosafety%2Fpubl
ications%2Fbmbl5%2Fbmbl5_sect_iv.pdf&ei=h04BVPHCF8qKuASE5IDQBQ&usg=A
FQjCNGc0nTdtiYUsyUmGD2abl3cgNLfyw&sig2=qwxQf_vdyQtyfiJjfloggQ&bvm=b
v.74115972,d.c2E

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

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

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

37. Where the samples should be
transported?
• 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

38. Instructions from NIV PUNE
• Sample (blood/serum)- transported at
2-80 C within 24 hrs.
• In case of delay – store at -700C.
• triple layer packaging system

39. Case Management in a Hospital
• Isolate the patient
• Follow standard precautions including
appropriate Personal Protective
Equipments(PPE)
• Restrict visitors
• Avoid aerosol generating procedures.
• Implement environmental infection control
measures.
• Proper disposal of potentially infected
material following biohazard precautions

40. TREATMENT
• Currently, no specific therapy is available
that has demonstrated efficacy.
Supportive Care
• Intravascular volume repletion is one of the
most important supportive measures.
• IV therapy should be carefully monitored to
avoid fluid overload :
• most of the deaths :- due to rapid correction
of fluid in severe shock

41. • For high grade fever patient should be
treated with only tablet paracetamol.
(avoid aspirin )
• Due to repeated vomiting and diarrhoea
patient may present with shock and
electrolyte imbalance : plenty of oral fluids

42. • Transient bone marrow suppression with
leukopenia and thrombocytopenia
• develop bleeding from different sites
• Transfuse with platelets when the count is
below 20000/cmm or bleeding from any sites
irrespective of platelet count.

43. • Different organ involvement :liver and kidney
• Patient may require dialysis in severe case of
renal failure.
• Patient should be carefully managed by
gastroenterologist in case of severe liver
dysfunction
• Patient may require ICU support for
breathlessness due to lung involvement or
critical condition

44. • EVD patients should be carefully treated with
known case of Hypertension, Diabetes,
coronary artery diseases and pregnancy.
• Patients on Anti-platelet drugs :temporarily
stopped -increase chance of bleeding.
• Co-infection with EVD should be immediately
treated with proper antibiotic.
• Early stage if co-infection is not treated
properly : sepsis & septic shock -develop :lead
to fatal outcome.

45. Diet and Activity
• Nutrition is complicated by the patient’s
nausea, vomiting, and diarrhoea.
• Good hydration is to be ensured with good
amount of protein supplement.

46. Recovery
• Recovery often requires months, and delays
may be expected before full resumption of
normal activities.
• Weight gain and return of strength are slow.
• Ebola virus continues to be present for many
weeks after resolution of the clinical illness

47. Disposal of Dead Body
• Safe disposal of dead body with proper
precaution for prevention of transmission of
EVD.
• Ritual activities after death should be
strictly avoided OR with the help of
professionals trained for this purpose.
• Those persons who are dealing with the
disposal of dead bodies requires proper
protection.

48. Disposal of Dead Body
• Dead body should be packed with impermeable
leaky proof body bags for safe disposal and to
prevent contamination of the environment
with body fluids.
• Anyone who has accidently come in contact
with blood or body fluids should be kept
under quarantine and observed for 21 days

50. vaccines
• Currently no vaccines are available for the
disease.
• The most promising candidates are DNA
vaccines or vaccines derived
from adenoviruses, vesicular stomatitis
Indiana virus (VSIV)or filovirus-like
particles (VLPs) because these candidates
could protect nonhuman primates from
ebolavirus-induced disease. DNA vaccines,
adenovirus-based vaccines, and VSIV-based
vaccines have entered clinical trials.

51. PREVENTION & CONTROL
• Risk of infection with Ebola virus and how
to avoid it
• Casual contact in public places with people
that do not appear to be sick do not transmit
Ebola.
• Mosquitoes do not transmit the Ebola virus.

52. • Ebola virus is easily killed by soap, bleach,
sunlight, or drying.
• Ebola virus survives only a short time on
surfaces that have dried in the sun.

53. Reducing the risk of Ebola infection
in people
• Reducing the risk of wildlife-to-human
transmission
• from infected fruit bats or monkeys/apes and
the consumption of their raw meat.
• Animals should be handled with gloves and
other appropriate protective clothing.
• Animal products (blood and meat) should be
thoroughly cooked before consumption.

54. Reducing the risk of human-to-human transmission in
the community
• Close physical contact with Ebola patients should be
avoided.
• Gloves and appropriate personal protective equipment
should be worn and should be disposed after use as
per biosafety guidelines.
• Regular hand washing is required after visiting
patients in hospital, as well as after taking care of
patients at home.
• Dead patients to be handled for cremation/burial
under biosafety precautions

55. Controlling infection in health-care
settings
• Human-to-human transmission of the Ebola :avoid
direct or indirect contact with blood and body fluids.
• Transmission to healthcare workers :appropriate
infection control measures have not been observed.
• Not always possible to identify patients with EBV
early because initial symptoms may be non-specific.
• Health-care workers should apply standard
precautions consistently with all patients – regardless
of their diagnosis – in all work practices at all times.

56. Controlling infection in health-care
settings
• basic hand hygiene,
• respiratory hygiene,
• use of personal protective equipment
(according to the risk of splashes or other
contact with infected materials),
• safe injection practices and
• safe handling after death of infected patient

57. Measures to be taken in addition to
Standard Precautions:
• When in close contact (within 1 metre) of
patients with EBV,
 wear face protection (a face shield or a medical
mask and goggles),
 a clean, non-sterile long-sleeved gown, and
 gloves (sterile gloves for some procedures).
 Laboratory workers are also at risk.
 Samples for diagnosis :handled by trained staff
 processed in suitably equipped laboratories.

58. CURRENT OUTBREAK OF EVD 2014
epidemiological week 35
For review of the epidemiological situation and
response monitoring country reports fall into three
categories:
1. those with widespread and intense transmission
(Guinea, Liberia, and Sierra Leone)
2. those with an initial case or cases, or with
localized transmission (Nigeria)
3. those sharing land borders with areas of active
transmission (Benin, Burkina Faso, Côte d’Ivoire,
Guinea-Bissau, Mali, Senegal) and those with
international transportation hubs

59. Source: http://www.msal.gov.ar/images/stories/epidemiologia/ebola/pdf/evd-sitrep1-20140828.pdf

60. CURRENT STATUS
• The total number of probable,
confirmed and suspect cases in the
current outbreak of Ebola virus disease
(EVD) UNDER in THE West PROVISION Africa OF IHR is 2005 3052, WHO
with
Declared the current EVD outbreak to be a
1546 “PUBLIC deaths HEALTH ((between EMERGENCY the beginning Of
of
January INTERNATIONAL 2014 CONCERN”
(epidemiological week 1)
on August 8th , 2014.
and 25 August 2014 (epidemiological
week 34)))
• The overall case fatality rate is 51%. It
ranges from 41% in Sierra Leone to
66% in Guinea.

61. COMBINED
EPIDEMIOLOGICAL CURVE

62. RESPONSE MONITORING
Sources of information include: WHO
and Ministries of Health reports,
OCHA 3 W matrix and maps, reports
from UNICEF Conakry and Geneva,
situation reports from NGOs (IMC)
and communications with other
partners and foreign medical teams.

63. Current status in India
• "We are carefully screening all passengers
coming from Ebola infected countries at the
airport itself. As of today there is no
suspected case of Ebola in India," the
health minister said in Indore.- Aug 27, 2014

64. STATUS IN INDIA
As per instructions released by MOHFW on 8-8-14:
• Nearly 44, 000 Indians reside in the regions affected
by the deadly disease.
• Ministry of civil aviation & ministry of Home Affair to
work together to get information on passengers visiting
from or transiting through the affected countries, with
a mandatory health card for such passengers.
• In the event that any of these travellers develop
symptoms, a surveillance system has been set up to
track them.
• Travellers to India from affected areas are required to
self-report during immigration.

65. CURRENT STATUS OF EBVD IN
INDIA
• issued directives to airlines on Ebola, with
improved surveillance & alert IDSP network.
• States are directed to identify a senior
officer as the nodal officer to send reports
at regular intervals to MOHFW.
• SSO are requested to continue surveillance of
contacts and suspects for 21 days
• Health professionals are guided to limit
interactions with media .

66. • Hospitals to ensure availability of personal
protective equipments.
• The health ministry has set up a 24-hour
emergency helpline(01123061469/3205/1302)
for handling queries.

67. GLOBAL HEALTH SECURITY
STOPPING EBOLA OUTBREAK
FIND

68. GLOBAL HEALTH SECURITY
STOPPING EBOLA OUTBREAK
RESPOND

69. GLOBAL HEALTH SECURITY
STOPPING EBOLA OUTBREAK
RESPOND

71. REFERENCES:
1. Ebola hemorrhagic fever: Centers for Disease
Control and Prevention (CDC). Available from:
http://www.cdc.gov/vhf/ebola/
2. Guidelines for Ebola Virus Disease (EVD):
National Centre for Disease Control (NCDC).
Available from:
http://nicd.nic.in/index2.asp?slid=543&sublinkid
=177
3. World Health Organization. Ebola Virus Disease.
Available from:
http://www.who.int/mediacentre/factsheets/fs
103/en/

72. Thank you