The 2013-2014 Ebola virus epidemic in West Africa was the largest outbreak of Ebola virus disease in history. It began in Guinea in December 2013 and spread to Liberia and Sierra Leone. By October 2014, there were over 9,000 cases and 4,500 deaths. The index case was a 2-year old boy in Guinea who died in December 2013, and the outbreak was not recognized as Ebola for several months allowing it to spread. Several experimental treatments are being studied for this outbreak, including Zmapp monoclonal antibodies, TKM-Ebola RNA interference drug, and the antiviral drug Favipiravir.

2. سَسَننُُرِرِييهِهِممْْ آآييََااتتِِننََاا فِيفِيي ي االلففََااققِِ وَ وَففِِيي ))
أأََننفُفُسِسِهِهِممْْ ححَكَكتتّهُ ّهُ ى يى ي ييَكَكتتَكَكببَكَكيَيّهُ َّهُ نَكنَك للَكَكهُ الهُ المْفِمْفِ أوَكأوَكنَنّهُ َّهُ ههُ الُ ال االلْفِْفِححَكَكقُقُّ َأّ َأ أوأووَكوَكللَكَكمْفِمْفِ ييَكَككْفِكْفِفِيفِي
((بِبِيِِيرَكرَكبِبّ شَِّ شَككَكَك أوَكأوَكنَنّهُ َّهُ ههُ الُ ال ععَكَكللَكَكى يى ي ككُ الُ اللِّ شَلِّ شَ شَكشَكي ي ْفِْفِءٍ شءٍ ش شَكشَكهِيهِييَيَددٌ)ٌ)) ) ((ففصصللتت,, 5533

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4. Introduction
- Ebola virus disease (EVD) is a severe often fatal disease in
humans and non human primates (monkeys, gorillas and
chimpanzees).
- The disease is caused by infection with ebola virus, named
after a river in the Democratic Republic of the Congo (formerly
Zaire) in Africa, where it was first recognized.

5. Epidemiology
- Ebola virus disease 1st appeared in 1976 with two subsequent
outbreaks of acute viral haemorrhagic fever.
- The 1st outbreak occurred in Nazara, South Sudan with 284
cases (151 deaths, CFR 53%). It is caused by Sudan ebola
virus.
- The 2nd outbreak occurred in Yambuku “near the Ebola river”,
Democratic Republic of the Congo with 318 cases (280
deaths, CFR 88%). It is caused by Zaire ebola virus.

6. Democratic Republic of the Congo, 2nd outbreak
Ebola river
South Sudan, 1st outbreak

7. Epidemiology
- Since these original outbreaks, there have been
approximately 20 other outbreaks occurring through to 2013.
- Before 2014, the total number of cases 2407 (1582 deaths).
- In 2014, there are two ongoing EVD outbreaks.
•The 1st is the 2013-2014 ebola virus epidemic in west Africa.
•The 2nd is the 2014 Democratic Republic of the Congo ebola
virus outbreak, began in August 2014 with 68 cases (49
deaths) “9 October 2014”.

8. Causative Agent
- EVD is caused by four of five viruses classified in the genus
Ebolavirus, family Filoviridae, order Mononegavirals.
- The four disease causing viruses are:
•Bundibugyo ebola virus (BDBV).
•Sudan ebola virus (SUDV), case fatality rate 40-60%.
•Zaire ebola virus (EBOV), associated with more severe disease with
case fatality rate 60-90%.
•Taï Forest ebola virus (TAFV), also known as Côte d’Ivoire ebola virus.

9. Causative Agent
•The 5th virus, Reston ebola virus (RESTV), is not thought to be disease
causing in humans.
- Ebolavirons are filamentous particles that may appear in the
shape of shepherd’s crook or in the shape of a "U" or a "6",
and they may be coiled, toroid, or branched. The virus is 80 nm
in width, but vary in length from 974 to 1086 nm.
- Ebolavirons contain linear non-segmented, single stranded,
non infectious RNA genomes.

10. Ebola virus particles under EM

11. Reservoir
- Bats are considered the most likely natural reservoir of ebola
virus.
- Plants, arthropods, and birds were also considered.
- In the wild, transmission may occur when infected fruit bats
drop partially eaten fruits or fruit pulp, then land mammals such
as gorillas may feed on these fallen fruits.
- Fruit bats are also eaten by people in parts of west Africa
where they are smoked, grilled or made into a spicy soup.
However, transmission by this method is rare and outbreaks

12. Reservoir
are usually traceable to a single case where an individual has
handled the carcass of
gorilla, chimpanzee or
duiker.
Fruit bats

13. Mode of transmission
- Human to human transmission occurs only via direct contact
with blood or body fluids from an infected person or by contact
with objects contaminated by the virus, especially needles and
syringes.
- Body fluids that may transmit ebola virus include saliva,
mucous, vomitus, feces, sweat, tears, breast milk, urine and
semen.
- Male survivors may be able ttoo ttrraannssmmiitt tthhee ddiisseeaassee vviiaa sseemmeenn
ffoorr nneeaarrllyy 22 mmoonntthhss..

14. Mode of transmission
- Airborne transmission hasn’t been
documented during EVD outbreaks.

15. Clinical picture
- Incubation period: 2-21 days (mean 8-10 days).
- Onset: sudden.
- Early manifestations include influenza like stage with fever,
malaise, chills, myalgia, severe headache and arthralgia.
- Subsequent manifestations indicate multisystem involvement
and include:
•GIT: anorexia, nausea, vomiting, diarrhea, abdominal pain “
sometimes associated with elevated serum amylase and true
pancreatitis”.

16. Clinical picture
•Respiratory: chest pain, shortness of breath, cough, nasal discharge.
•Vascular: conjunctival injection, postural hypotension, oedema.
•Neurological: headache, confusion, coma.
- Haemorrhagic manifestations arise in 40-50% of cases,
typically 5-7 days after first symptoms and include petechiae,
ecchymosis, bleeding from puncture sites and mucous
membranes “GIT, nose, vagina and gums”. Heavy bleeding is
rare and is usually confined to the GIT. In general the
development of bleeding symptoms often indicate a worse
prognosis.

17. Clinical picture
- In about 5-50% of cases a maculopapular rash associated
with varying severity of erythema appears 5-7 days of the
illness and usually desquamate in survivors.
- In late stages shock, convulsions, severe metabolic
disturbances and DIC occurs.
- Death occurs within 7-16 days “usually between 8-9 days”.

20. Laboratory findings
-Are less characteristic including:
•Early leucopenia “as low as 1000 cells/mL” with lymphopenia and
subsequent neutrophilia, atypical lymphocytes. In late stages there is
leucocytosis.
•Thrombocytopenia “50000-100000/mL”.
•Highly raised serum transaminases “typically AST > ALT”.
•Hyperproteinaemia and proteinuria.
•PT and PTT are prolonged and FDP may be detectable.

21. Diagnosis of EVD
- Ebola virus is a WHO risk group 4 pathogen (i.e. greatest
threat to humans). So, it requires a biosafety level 4 (BSL-4)
laboratory for diagnosis.
1) Within a few days after beginning of symptoms:
•Antigen capture ELISA.
•IgM ELISA.
•PCR.
•Virus isolation.
2) Later in disease course or after recovery:
•IgM and IgG antibodies.

22. Diagnosis of EVD
3) Retrospectively in deceased patients:
•Immunohistochemistry testing.
•PCR.
•Virus isolation.
BSL-4 positive pressure suit BSL-4 laboratory

23. Differential diagnosis
-Marburg virus disease.
-Other viral hemorrhagic fevers.
-Falciparum malaria.
-Typhoid fever.
-Shigellosis.
-Rickettsial diseases such as typhus.
-Cholera.
-Gram-negative septicemia.
-Borreliosis such as relapsing fever.
-EHEC enteritis.
-Leptospirosis.

24. Differential diagnosis
-Scrub typhus.
-Plague.
-Q fever.
-Candidiasis.
-Histoplasmosis.
-Trypanosomiasis.
-Visceral leishmaniasis.
-Hemorrhagic smallpox.
-Measles.
-Fulminant viral hepatitis.
-Acute promyelocytic leukemia.

25. Differential diagnosis
-Hemolytic uremic syndrome.
-Snake envenomation.
-Clotting factor deficiencies/platelet disorders.
-Thrombotic thrombocytopenic purpura.
-Hereditary hemorrhagic telangiectasia.
-Kawasaki disease.
-Warfarin poisoning.

26. Treatment
- No specific treatment is currently approved.
- Treatment is primarily supportive in nature and early
treatment improve survival.
- Supportive measures may include:
•Patient isolation.
•Management of pain, nausea, fever, anxiety.
•Oral or IV rehydration with maintenance of electrolyte balance.
•Provision of blood products such as packed RBCs, platelets, fresh
frozen plasma or clotting factors when needed.

27. Treatment
•Heparin to prevent DIC, when needed.
•Antimalarial medications and antibiotics are often used before the
diagnosis is confirmed.
•Management of organ failure e.g. dialysis for renal failure and
extracorporeal membrane oxygenation may be used for lung
dysfunction.

28. Prevention
- Barrier isolation of patients.
- Wearing of protective clothing by
attending personnel including masks,
gloves, impermeable gowns and
goggles or face shields.
- Sterilizing equipment and surfaces
and routine use of disinfectants.
- Avoid touching the bodies of patients
who have died from ebola.
A hospital isolation ward
Health care workers wear
protective clothing

29. Prevention
- Quarantine of patients is usually effective in
decreasing spread of the disease.
- Burial of dead bodies should be done with
extreme caution, incinerate all waste.
- Contact tracing, it involves finding everyone
who had close contact with infected
individuals and watching for signs of illness
for 21 days.
CDC worker incinerates
medical waste from Ebola
patients in Zaire in 1976
Mass graves for
ebola victims

30. Prognosis
- The disease has a high mortality rate which varies between
25-90% of those infected.
- Early and effective treatment of symptoms may reduce the
fatality rate significantly.
- If an infected person survives, recovery may be quick and
complete.
- Prolonged infections are often complicated by the occurrence
of long term problems such as orchitis, arthralgia, myalgia,

31. Prognosis
skin peeling or hair loss. Eye symptoms such as photophobia,
excess lacrimation, iritis, iridocyclitis, choroiditis and blindness
have also been described.
EVD prevention
poster used in
Kikwit outbreak

32. The 2013-2014 Ebolavirus EEppiiddeemmiicc iinn
WWeesstt AAffrriiccaa

33. The 2013-2014 ebola virus epidemic in west Africa
- The most severe ebola virus outbreak recorded as regards to
both the number of human cases and fatalities exceeding the
sum of all previous identified cases.
- It began in Guinea in December 2013 then spread to Liberia
and Sierra Leone.
- A small outbreak of twenty cases then occurred in Nigeria
where it has been contained, and one case occurred in
Senegal, where the outbreak was declared over on 17 October
2014.

34. The 2013-2014 ebola virus epidemic in west Africa
- Cases of secondary infections of medical workers in the
United States and Spain occurred, neither of which has yet
spread to the general population.

35. The 2013-2014 ebola virus epidemic in west Africa
- The index case is a 2 years old boy called Emile who died on
6 December 2013 in the village of Meliandou, Guinea. His
mother, sister, and grandmother then became ill with similar
symptoms and also died. People infected by those victims
spread the disease to other villages.
- Although Ebola represents a major public health issue in sub-
Saharan Africa, no cases had ever been reported in West
Africa and the early cases were diagnosed as other diseases
more common to the area. TThhuuss,, tthhee ddiisseeaassee hhaadd sseevveerraall
mmoonntthhss ttoo sspprreeaadd bbeeffoorree iitt wwaass rreeccooggnniizzeedd aass eebboollaa..

36. The 2013-2014 ebola virus epidemic in west Africa
- The total number of cases is 9216 (4555 deaths, CFR 71%)
“ 14 October 2014”
-WHO believes that this substantially understates the
magnitude of the outbreak with possibly 2.5 times more cases
being under reported.
-WHO stated that there could be as many as 10,000 new ebola
cases per week by December 2014.

37. The 2013-2014 ebola virus epidemic in west Africa
- Experimental treatments
- A number of experimental treatments are being studied.
- In the USA, the FDA's animal efficacy rule is being used to
demonstrate reasonable safety to obtain permission to treat
people who are infected with Ebola.
- This rule is used because the normal path for testing drugs is
not possible for diseases caused by dangerous pathogens like
ebola.

38. The 2013-2014 ebola virus epidemic in west Africa
- Experimental treatments
- WHO released a statement that the use of not yet proven
treatments is ethical in certain situations in an effort to treat or
prevent the disease.
•Medications
- The WHO has recognized that transfusion of whole blood or
purified serum from Ebola survivors is the therapy with the
greatest potential to be implemented immediately although
there is little information on its efficacy.

39. The 2013-2014 ebola virus epidemic in west Africa
- Experimental treatments
-a A number of experimental treatments arree bbeeiinngg ccoonnssiiddeerreedd ffoorr
uussee iinn tthhee ccoonntteexxtt ooff tthhiiss oouuttbbrreeaakk,, aanndd aarree ccuurrrreennttllyy oorr wwiillll
ssoooonn uunnddeerrggoo cclliinniiccaall ttrriiaall::
•Zmapp: a combination of monoclonal antibodies. The limited supply of
the drug has been used to treat 7 individuals infected with the Ebola
virus. Although some of them have recovered, the outcome is not
considered to be statistically significant.
•TKM-Ebola: an RNA interference drug. The drug started Phase 1 trial
and has received limited approval from the FDA for emergency use.

40. The 2013-2014 ebola virus epidemic in west Africa
- Experimental treatments
•Favipiravir (Avigan): an antiviral drug approved in Japan for treatment
of influenza pandemics, appears to be useful in a mouse model of
Ebola.
•BCX4430: is a broad-spectrum antiviral drug undergoing animal testing
as a potential human treatment for Ebola.
•Brincidofovir: is a broad-spectrum antiviral drug. FDA approved the trial
to test its safety and effectiveness in ebola patients.
•JK-05: The drug can selectively inhibit virus replication by inhibiting the
RNA polymerase.

41. The 2013-2014 ebola virus epidemic in west Africa
- Experimental treatments
•Lamivudine: was reported to be used successfully to treat 13 out of 15
ebola infected patients by a doctor in Liberia, as part of a combination
therapy also involving IV fluids and antibiotics to combat bacterial
infection. However, western virologists have expressed caution about
the results, due to the small number of patients treated and confounding
factors present.
•Clomiphene and toremifene: antiestrogens used to treat infertility and
breast cancer, its found that they inhibit the progress of Ebola virus in
vitro as well as in infected mice.
•Melatonin: has been suggested as a potential treatment for Ebola
based on promising in vitro results.

42. The 2013-2014 ebola virus epidemic in west Africa
- Experimental vaccines
-Two vaccines are under development:
•cAd3-ZEBOV vaccine.
•rVSV-ZEBOV vaccine.

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