New emerging viral infections clinical Aspects

1. Dr. Wagdy Amin
Training officer
G.D For Chest Diseases and Tuberculosis
Ministry of Health & Population
drwagdy@yahoo.com

2. Epidemic viruses
• Severe Acute Respiratory Syndrome (SARS)
• AH5N1
• AH1N1
• Corona
• Ebola

3. Introduction

4. Seasonal Influenza
•Influenza(theflu)isacontagiousrespiratoryillnesscausedbyinfluenzaviruses.
•Itcancausemildtosevereillness,andattimescanleadtodeath.

5. Influenza A
•The Influenza A virus subtypes that have been confirmed in humans, ordered by the number of known human pandemic deaths, are:
•H1N1 caused "Spanish Flu" and 2009 H1N1 outbreak
•H2N2 caused "Asian Flu"
•H3N2 caused "Hong Kong Flu"
•H5N1 is "bird flu", endemic in avian
•H7N7 has unusual zoonoticpotential
•H1N2 is currently endemic in humans and pigs
•H9N2, H7N2, H7N3, H10N7 (avian)
•The Influenza A virus subtypes are labeled according to an H number (for hemagglutinin) and an N number (for neuraminidase).

6. Influenza B
•Influenza B viruses are only known to infect humans .
•influenza B viruses evolve slower than A viruses and faster than C viruses.
•Influenza virus B mutates at a rate 2-3 times lower than type A.

7. Influenza C
•Influenza C viruses are known to infect humans and pigs.
•Flu due to the type C species is rarecompared to types A or B, but can be severeand can cause local epidemics.

8. H5N1 “Avian/Bird Flu”
•Avian influenza is an infection caused by avian (bird) influenza (flu) viruses.
•These influenza viruses occur naturally among birds.
•Wild birds worldwide carry the viruses in their intestines, but usually do not get sickfrom them.
•Avian influenza is transmissible to humans (this requires extremely close contact with infected birds, particularly feces).
•H7N1 and H9N2 (also bird flu)

9. H1N1 “Swine Flu”
•2009 H1N1 (referred to as “swine flu” early on) is a new influenza virus causing illness in people.
•This new virus was first detected in people in the United States in April 2009.
•This virus is spreading from person-to-person worldwide, probably in much the same way that regular seasonal influenza viruses spread.
•On June 11, 2009, the WHO signaled that a pandemic of 2009 H1N1 flu was underway.

10. The Makings of a Pandemic
•The gene’s segmented nature facilitates genetic reassortmentwhich leads to genetic diversity in type A.
–Antigen drifts (minor)
–Antigen shifts (major)
•The major antigenic variations underlie the deadly worldwide pandemics (1918 ‘Spanish’, 1957 ‘Asian’, 1967 ‘Hong Kong’) .
•The 1918 Spanish flu is the most serious pandemic in recent history, killing 50 million people (500,000 U.S. deaths).
•The most recent ones were the Asian Flu in 1957 (70,000 U.S. deaths) and the Hong Kong Flu in 1968 (34,000 U.S. deaths).
•In pandemic, virus is transmissible human to human.

11. More Flu…
The “canine influenza virus”is an influenzaH3N8 influenza virus (not a human influenza virus) that was originally an equine (horse) influenza virus.
•This virus has spread to dogs and can now spread between dogs.
•Vaccination is available .
H7N7 and H3N8 “Horse Flu”
•The disease has a nearly 100% infection rate in an unvaccinated horse population with no prior exposure to the virus.
•While equine influenza is historically not known to affect humans, the impact of an outbreak among even the animal population would have been devastating.

12. Severe Acute Respiratory Syndrome (SARS)

13. Severe Acute Respiratory Syndrome (SARS): Epidemiology
•Aworldwideoutbreakofsevereacuterespiratorysyndrome(SARS)hasbeenassociatedwithexposuresoriginatingfromasingleillhealthcareworkerfromGuangdongProvince,China.

14. •China'sMinistryofHealthreportedatotalof2,914casesofsevereacuterespiratorysyndrome(SARS)ontheChinesemainland.
•1,299patientshadbeendischargedfromhospitalsuponrecovery
•131haddied. April 27.

17. SARS: Timeline of an Outbreak
Nov. 16, 2002--The first case of an atypical pneumonia in the Guangdong province in China. Feb. 26, 2003--First cases of unusual pneumonia reported in Hanoi, Vietnam. Feb 28, 2003 --World Health Organization officer Carlo Urbani, MD, examines an American businessman with an unknown form of pneumoniain a French hospital in Hanoi, Vietnam.

18. March10,2003–doctorUrbanireportsanunusualoutbreakoftheillness,whichhecallssuddenacuterespiratorysyndromeorSARS,tothemainofficeoftheWHO.Henotesthatthediseasehasinfectedanusuallyhighnumberofhealthcareworkers(22)atthehospital.
March12,2003--WHOissuesaglobalalertaboutanewinfectiousdiseaseofunknownorigininbothVietnamandHongKong.
March29,2003--CarloUrbani,whoidentifiedthefirstcasesofSARS,diesasaresultofthedisease.

20. Pathogenesis
•Clinically, most infections cause a mild, self- limited disease (classical 'cold' or upset stomach), but there may be rare neurological complications.
•SARSis a form of viral pneumonia where infection encompasses the lower respiratory tract.

21. •Theyaretransmittedbyaerosolsofrespiratorysecretions,bythefaecal-oralroute,andbymechanicaltransmission.
•Mostvirusgrowthoccursinepithelialcells.
•Occasionallytheliver,kidneys,heartoreyesmaybeinfected,aswellasothercelltypessuchasmacrophages.
•Incold-typerespiratoryinfections,growthappearstobelocalizedtotheepitheliumoftheupperrespiratorytract.

22. SARS Virus
–Survived as long as 24 hours in the environment.
–Finding of virus in faeces.
–Occasionally linked with pneumonia in humans, specially with immunocompromised.
–Can cause severe illness in animals.
–Incubation period: 2-7 days

23. SARS Clinical Picture (Hong Kong)
–The most common symptoms included fever(in 100 percent of the patients);
–chills, rigors, or both (73.2 percent); and myalgia(60.9 percent).
–Cough and headache were also reported in more than 50 percent of the patients.
–Other common findings were lymphopenia(in 69.6 percent), thrombocytopenia(44.8 percent), and elevated lactate dehydrogenaseand creatinekinaselevels(71.0 percent and 32.1 percent, respectively).
–78.3% had abnormal chest radiographs

25. Factors predictive of ICU admission and death
•Advanced age.
•High peak creatininekinase
•High lactate dehydrogenase
•High initial absolute neutrophilcount
•Low serum sodium level

26. INVESTIGATIONS
•Selected investigations are intended to determine the cause of the respiratory illness.
Test for viral, bacterial and other usual respiratory pathogens
Identify common pathogens circulating in the community which may be responsible for the illness

27. INVESTIGATIONS
•Blood work:
•blood cultures X 2
•CBC, diff, AST, ALT, bilirubin, alkaline phosphatase, LDH, CPK, urea, creatinine, electrolytes
•other diagnostic tests as indicated by patients condition

28. INVESTIGATIONS
•Respiratory samples:
NP swab #1: rapid antigen detection for respiratory viruses, viral cultures, viral PCR
ETT aspirate : SARS investigation
•throat swab #1: Group A strep
•throat swab #2: MycoplasmaPCR
•Blood for serology:
One clotted tube[5 cc] labelled“SARS serology”
•Stool:
For viral electron microscopy

29. Treatment
•Empirical therapy most commonly included antibiotics, oseltamivir, and intravenous ribavirin.
•Mechanical ventilation was required in severe cases .

30. 2.SARS Specific TherapyThe efficacy of ribavirinin treating SARS is not known but if ribavirinis being started, use intravenous ribavirin.

31. 3.Additional Therapy for SARS
•Corticosteroids
•Oral ribavirin
•Oseltamivir

32. AVIAN Influenza

33. Human disease associated with influenza A subtype H5N1 re-emerged in January 2003, for the first time since an outbreak in Hong Kong in 1997." Three people in one family were infected after visitingFujianprovince in mainlandChinaand 2 died

34. Global spread of A H5N1 map638 cases 379 deaths 59%

35. 0
20
40
60
80
100
120140160
180
200
87
381
451
173193
3
2
11325
12
125
51
291
300
63161
2
2
01117
4
62
casesdeaths

36. Cases / cases fatality rate /yearin Egypt
Year
Cases
Deaths
Case–fatality rate (%)
2006
18
10
55.5
2007
25
9
36
2008
8
4
50
2009
39
4
10.2
2010
29
13
44.8
2011
39
15
38.4
2012
11
5
45.4
2013
4
3
75
2014
2
0
0
Total
175
63
36

37. To date, a total of 175 human cases, including 63 deaths, have been reported in Egypt from avian influenza A(H5N1).
0
10
20
30
40
2006
2007
2008
2009
201020112012
2013
2014
1825
839
2939
11
4
2
10
94413
15
5
30
CasesDeaths
a 56-year-old female from Damanhour.
a 4-year-old male, from Damietta

38. Influenza A viruses have 16 H subtypes and 9 N subtypes.
•In poultry, the viruses can mutate, usually within a few months, from then low pathogenic avian influenza (LPAI) form into the highly pathogenic form (HPAI).
•Only viruses of the H5 and H7 subtypes are known to cause the highly pathogenic (HPAI) form of the disease.

39. Influenza A HA and NA Subtypes
H15, H16
H14
H13
H12
H11
H10
H3
H2
H1
H9
H8
H7
H6
H5
H4
N9
N8
N7
N6
N5
N3
N4
N2
N1

40. The AVIAN H5N1 virus has raised concerns about a potential human pandemic because:
•It is especially virulent.
•It is being spread by transported domestic poultry.
•It can be transmitted from birds to mammals and humans.

41. Symptoms
•Most patients infected with the H5N1 virus show initial symptoms of fever (38 C or higher) followed by influenza-like respiratory symptoms, including cough, rhinorrhea, sore throat, and (less frequently) shortness of breath.
•Watery diarrhea is often present in the early stages of illness, and may precede respiratory symptoms by up to one week.
•Gastrointestinal symptoms (abdominal pain, vomiting) may occur and headache has also been reported.

42. Pharmaceutical treatment.
•Antiviralsshould be readily available for the treatment of suspected and confirmed cases. http://www.who.int/csr/disease/avian_influenza/en/

45. H1
N1
H2
N2
H3
N3
H4
N4
H5
N5
H6
N6
H7
N7
H8
N8
H9
N9
H10
H11
H12
H13
H14
H15
Hosts
Haemagglutinin subtype
Neuraminidase subtype

48. Severe atypical pneumonia outbreak associated with influenza A(H1N1)pdm09 in Egypt, 2013–2014 season.
•During 2013
–ILI in outpatient clinics = 1.712.476 patients = 4.5% from all attendees
•During January 2014
–ILI in outpatient clinics = 191.428 patients = 4.9% from all attendees
•Positive cases for A H1N1 = 24%

49. Clinical Management of A(H1N1) VIRUS Infection

50. Case Definitions

51. Suspected case of A(H1N1)
•anindividualwithacuterespiratoryillnessandfever(reportedordocumentedfever),andoneofthefollowings; cough,sorethroat,shortnessofbreath,difficultyinbreathingorchestpainswithonset:
–Within7daysofclosecontactwithapersonwhoisprobableorconfirmedcaseofA(H1N1)2009virusinfection,OR
–Within7daysoftraveltoacountry/communitywheretherehasbeenoneormoreconfirmedcasesofA(H1N1)2009virusinfection;
OR
–ResidesinacommunitywherethereisoneormoreconfirmedcasesofA(H1N1)2009virusinfection.

52. Probable case of A(H1N1) 2009
•Anindividualwithaninfluenza-likeillnesswhoispositiveforinfluenzaAthatisunsubtypeablebyreal-timePCR
•OR
–Anindividualwithaclinicallycompatibleillnessorwhodiedofanunexplainedacuterespiratoryillnesswhoisconsideredtobeepidemiologically linkedtoaprobableorconfirmedcase.

53. Confirmed Case of A(H1N1)
•Anindividualwithaninfluenza-likeillnesswithlaboratoryconfirmedA(H1N1)2009virusinfectionbyoneormoreofthefollowingtest:
•Real-timeRT-PCR
•Viralculture

54. Influenza likeillness(ILI)
•A person with suddenonsetoffeverof>38°C and at-least one of the following two respiratory symptoms in the absence of other known causes:
–Drycough
–Sorethroat

55. Severeacuterespiratoryillness(SARI)
•Apersonmeetingthecasedefinitionofinfluenza-likeillness(suddenonsetoffever>38Cwithat-leastoneofthefollowingtworespiratorysymptoms-drycough,sorethroatintheabsenceofotherdiagnosis)
AND
•ShortnessofbreathORdifficultyinbreathingrequiringhospitaladmission

56. Acute Respiratory Infection (ARI)
•definedasanacuterespiratorytractillnessthatiscausedbyaninfectiousagenttransmittedfrompersontoperson.
•Theonsetofsymptomsistypicallyrapid,overaperiodofhourstoseveraldays.
•Symptomsincludefever,cough,andoftensorethroat,coryza,shortnessofbreath,wheezing,ordifficultybreathing.

57. Clinical Presentation
•Varyfromasymptomaticinfectionthroughtoseriousfatalillnessthatmayincludeexacerbationofotherunderlyingconditionsandsevereviralpneumoniawithmulti-organfailure.
Theseare:
–(i)Mildornon-severeillness;
–(ii)Signsandsymptomsofprogressiontosevereillness;(Moderate)
–(iii)Severeillness.

58. Mild illness (Non severe)
PatientswithmildInfluenza-likeillnessmaypresentwithsomeorallofthefollowingsymptoms:
•Fever(Between38to390C),drycough,sorethroat,rhinorrhea,headache,musclepain,malaise,butnoshortnessofbreathordyspnoea.
•Gastrointestinalillness,suchasdiarrhoeaand/orvomiting,especiallyinchildren,butwithoutanyevidenceofdehydration.
•Thegeneralconditionofthesepatientswillbegoodwithoutanysignsofhypotensionormentalconfusion.

59. Signs and symptoms of progression to severe illness
•Patientspresentinginitiallywithmildinfluenza-likeillnessmayrapidlyprogresstomoresevereillnessinthecourseofthedisease.
•Thefollowingsaresomeoftheclinicalsignsandsymptomsindicatingrapidprogressionofapatienttosevereillness,whichwouldnecessitateanurgentreviewofpatient’sclinicalmanagement:

60. •Symptomsandsignssuggestingoxygenimpairmentorcardiopulmonaryinsufficiency:
–Shortnessofbreath(withactivityoratrest),difficultyinbreathing,turningblue,bloodyorcolouredsputum,chestpain,lowbloodpressure;
–Fastorlabouredbreathinginchildrenlessthan5yearsofage;
–Hypoxiaasindicatedbypulseoximetry,ifavailable(Oxygensaturation≤ 90%)
•SymptomsandsignssuggestingCNScomplications:
–Alteredmentalstatus,unconscious,drowsiness,ordifficulttoawaken; recurringorpersistentconvulsions(seizures),confusion,severeweaknessorparalysis.
•Evidenceofsustainedvirusreplicationorinvasivesecondarybacterialinfection:
–Basedonlaboratorytestingorclinicalsigns(e.g.persistentorrecurrenthighfeverandothersymptomsbeyondthreedaysevenwhenundertreatmentwithanalgesicsorantipyretics).
•Severedehydration:
–Decreasedactivity,dizziness,decreasedurineoutput,lethargy.

61. Severe illness
Patientsshowinganyofthefollowingclinicalsignsandsymptomswouldbeconsideredassufferingfromsevereillnessduetoinfluenza:
•Severerespiratorydistress:
–Severebreathlessness,e.g.unabletocompletesentencesinonebreath. Useofaccessorymuscles,supra-clavicularrecession,trachealtugorfeelingofsuffocation(Foradultpatients)
–Lowerchestin-drawing,sternalrecessionornoisybreathingwhencalm(Forpaediatricpatients)
•Increasedrespiratoryratemeasuredoveratleast30seconds:
–Over30breathsperminute(Foradultpatients)
–≥50breathsperminuteifunder1yearor≥40breathsperminuteif≥1year(Forpaediatricpatients)

62. •Oxygensaturation≤92%onpulseoximetry,breathingairoronoxygen:
–Absenceofcyanosisisapoordiscriminatorforsevereillness.
•Respiratoryexhaustion
–Newabnormalbreathingpattern,e.g.alternatingfastandslowrateorlongpausesbetweenbreaths(Foradultpatients)
–Apnoeadefinedasa≥20secondpauseinbreathing(Forpaediatricpatients)
•Evidenceofsevereclinicaldehydrationorclinicalshock
–Systolicbloodpressure<90mmHgand/ordiastolicbloodpressure<60mmHg.Sternalcapillaryrefilltime>2seconds,reducedskinturgor(Foradultpatients)
–Sternalcapillaryrefilltime>2seconds,reducedskinturgor,sunkeneyesorfontanelle(Forpaediatricpatients)

63. •Alteredconsciouslevel
–Newconfusion,strikingagitationorseizures(Foradultpatients)
–Strikinglyagitatedorirritable,seizures,orfloppyinfant(Forpaediatricpatients)
•Causingotherclinicalconcerntotheclinicianortothespecialistdoctor
–e.g.arapidlyprogressiveoranunusuallyprolongedillness.

64. Groups at high risk for complications
•Pregnantwomen
•Adults65yearsofageandolder;
•Childrenyoungerthan5yearsold(Inparticularlessthan2years);
•Personswiththefollowingunderlyingconditionsatanyage:
–ChronicBroncho-pulmonarydisease(Includingasthma),
–Chroniccardiovasculardisease(excepthypertension)
–Chronicneurologicdisorder(Cerebralpalsy,stroke,multiplesclerosis,musculardystrophy,etc)
–Immunesuppressedpatients
–Haematologicaldisorder
–Chronicliverorrenalfailure
–Metabolicdisorder(speciallyDiabetesmellitus),
–Morbidobesity
•HealthcarepersonnelinthehospitalsettingscaringforpatientsinfectedwithA(H1N1)2009influenzavirus;

66. Mild cases Home Isolation Symptomatic treatment
Improvementprogress
Hospital isolation
Tamiflu
SamplesPositive
Negative Discharge , treat according to the case Continue Tamiflue, assessment after 5 days
Improved ProgressDischarge , stop Tamiflu, Treat according to the case Continue isolation , doubling tamifludose , assess for hospital or ICU admission

67. Mild case with risk factors Home isolation TamifluNo samples
Improved
progress
•Continue Tamifuefor 5 days
•Stop isolation 24 hsafter symptoms disappear
•Hospital isolation
•Doubling tamifludose
•Samples
•Assessment after 5 days

68. Sever cases
الاطفا
ل
البالغي
ن
1.Hospital Isolation
2.Tamiflu
3.Samples ( throat –nasopharyngeal )
4.Cultutefor secretion )

69. criteria for consideration of patients’ admission at the ICU
Patientshowingnosignsofimprovementandremainnon-responsivetoantiviraltreatmentusingoseltamivirasevidencedbythefollowings:
•Signsofprogressiveinfiltratesonchestx-ray
•Persistent hypoxia( SpO2< 85%) despite maximum oxygen saturation;
•Progressive hypercapnoea;
•Presence of compromised haemodynamics;
•Signs of sepsisand imminent shock
AhigherdoseregimenofOseltamivir(150mgtwicedailyforupto10days) maybeconsideredinadultpatientsadmittedintheIntensiveCareUnit
Ahigherdoseregimen(doublethenormaldoseregimen)mayalsobeconsideredinchildrenaswell.

70. antiviral agents for influenza
•Neuraminidase inhibitors
–Oseltamivir(including Tamiflu™, Antiflu™)
–Zanamivir(including Relenza™)
–Peramivir(not registered in most countries) Hemagglutinin
NeuraminidaseLipid bilayer
M1 matrix protein
M2 ion channel
M2 Inhibitors
Amantadine
Rimantadine
Other antiviral and adjunctive treatments includeRibavirinArbidolInterferonImmune plasma

71. Treatment protocol for antiviral treatment
Dosage recommendations for antiviral treatment using oseltamivir
Age groups
Agent
=>65
13-64
10-12
5-9
1-4
Duration
Oseltamivir
75 mg twice daily
75 mg twice daily
Weight-adjusted doses:
30 mg twice daily for ≤ 15 kg
45 mg twice daily for >15 to 23 kg
60 mg twice daily for >23 to 40kg
75 mg twice daily for >40kg
5 days
Zanamivir(In situations where oseltamivir is not available or if the virus is resistant to oseltamivir but known or likely to be susceptible to zanamivir,
10mg , (2 inhalations) twice daily
5 days

72. Use of antibiotics, corticosteroids and other supporting treatment for hospitalized patients
In addition to antiviral treatment using oseltamivir, the following supportive treatment should be considered :
•Supportive cares(antipyretics like acetaminophen for fever, adequate rehydrationfor correcting dehydration, etc) are sufficient in the majority of patients.
•Oxygen Therapy: oxygen saturation should be monitored by pulse oximetrywhenever possible. Supplemental oxygen should be provided to correct hypoxemia depending on the severity (nasal cannula, facemask, facemask with reservoir, intubation and assisted ventilation).
•Corticosteroids: Corticosteroids should not be routinely used.
•Antibiotics: Antibiotic chemoprophylaxis should not be used. When secondary bacterial pneumonia is suspected, treatment with antibiotics should follow recommendations from national guidelines for community- acquired pneumonia.

73. Hospital discharge criteria for patients with either confirmed, probable or suspected H1N1 infection
•Patient becomes afebrile;
•Absence of dyspnoea;
•Satisfactory oral fluidtolerance;
•No signs of dehydration;
•Respiratory rate30 bpm;
•Oxygen saturation92%
•Underlying chronic health conditionsnot exacerbated in patients in high- risk group for complication.
Patients should be discharged after receiving the full five day course of oseltamiviror 24 hours after becoming afebrile, whichever is earlier.

74. Antiviral Treatment using Oseltamivir for patients admitted at the ICU
•AhigherdoseregimenofOseltamivir(150mgtwicedailyforupto10days)maybeconsideredinadultpatientsadmittedintheICU
•Ahigherdoseregimen(doublethenormaldoseregimen)mayalsobeconsideredinchildrenaswell.
•patientswithsevereorprogressiveillnessnotrespondingtonormalantiviraltreatmentregimen,higherdosesofoseltamivirandlongerdurationoftreatmentmaybeappropriate,althoughthereisnoclinicaltrialevidencetoshowbenefit.
•Anadultdoseof150mgbdforupto10daysisbeingusedinsomesituations.

77. Middle East Respiratory Syndrome Corona-virus (MERS-CoV)

78. •MiddleEastRespiratorySyndromeCoronavirus(MERS-CoV)isanovelcoronavirus,whichwasfirstdescribedinSeptember2012.
•Theviruscausesrespiratorytractinfectionsrangingfromasymptomaticormilddiseasetoseverepneumoniaassociatedwithmulti- organfailureanddeath

79. •Thefirstcaseofanovelcoronavirus,nowcalledMiddleEastrespiratorysyndromecoronavirus(MERS-CoV),wasidentifiedinapatientwithacutepneumoniaandrenalfailureinJeddah,KingdomofSaudiArabia(KSA)inJune2012

80. Corona Casesand deaths 8/11/2014
)%(
Deaths
cases
Country
42.7%
340
796
Saudi Arabia
27%
9
33
Emirate
57%
4
7
Qatar
56%
5
9
Jordan
75%
3
4
United Kingdom
33%
1
3
Kuwait
33%
1
3
Tunisia
100%
2
2
Oman
50%
1
2
France
50%
1
2
Germany
100%
1
1
Malaysia
0%
0
1
Italy
0%
0
1
Philippine
0%
0
1
Spain
0%
0
1
Grace
0%
0
1
Egypt
0%
0
2
Netherland
100%
1
1
Iran
50%
1
2
Algeria
42%
364
867
Total

81. •TheexactmechanismthroughwhichMERS-CoVinfectionisacquiredremainsuncertain.
•Primarycases,Themajorityofinfectionsaresporadic
•buthumantohumantransmissionhasbeendocumentedbothinhospitalandincommunitysettings
TransmissionofMERS-CoV

82. •Pneumoniahasbeenthemostcommonclinicalpresentation;
•fivepatientsdevelopedAcuteRespiratoryDistressSyndrome(ARDS).
•Renalfailure,pericarditisanddisseminatedintravascularcoagulation(DIC)havealsooccurred.
•novirus-specificpreventionortreatment(e.g.vaccineorantiviraldrugs)isavailable.
•Asallconfirmedcasesreportedtodatehaveoccurredinadults

83. 1.focusesontheearlyrecognitionandmanagementofpatientswithSARIandincludesearlyinitiationofsupportiveandinfectionpreventionandcontrolmeasures,andtherapeutics.
2.focusesonmanagementofpatientswhodeteriorateanddevelopsevererespiratorydistressandARDS.
3.focusesonthemanagementofpatientswhodeteriorateanddevelopsepticshock.
4.focusesonongoingcareofthecriticallyillpatientandbestpracticestopreventcomplications.

84. 1. Recognize severe manifestations of acute respiratory infections
Definitions of clinical syndromes

85. “Patient under investigation” for novel coronavirusinfection
•A person with an acute respiratory infection, which may include history of fever or measured fever (≥ 38 °C,) and cough;
–ANDsuspicionofpulmonaryparenchymaldisease(e.g.pneumoniaorARDS),basedonclinicalorradiologicalevidenceofconsolidation:
–ANDresidenceinorhistoryoftraveltotheArabianPeninsulaorneighboringcountrieswithin10-14daysbeforeonsetofillness:
–ANDnotalreadyexplainedbyanyotherinfectionoraetiology,includingallclinicallyindicatedtestsforcommunity- acquiredpneumoniaaccordingtolocalmanagementguidelines.
–Itisnotnecessarytowaitfortestresultsforotherpathogensbeforetestingfornovelcoronavirus. Suspect

86. Initiate infection prevention and control measures
•Dropletprecautions
–Theseinfectionpreventionandcontrolmeasuresshouldbestartedwhenthepatiententerstriagewithsymptomsofacutefebrilerespiratoryillness.
–Organizethespaceandprocesstopermitspatialseparation(atleast1meter)betweeneachpatientwithacuterespiratoryinfectionsandotherindividualsnotwearingPPE.
–Ensurethattriageandwaitingareasareadequatelyventilated.
–Encouragetheuseofrespiratoryhygiene(i.e.coveringthemouthandnoseduringcoughingorsneezingwithamedicalmask,clothmask,tissueorflexedelbow),followedbyhandhygiene.

87. •Airborneprecautionsshouldbeusedforaerosol-generatingprocedures,whichhavebeenconsistentlyassociatedwithanincreasedriskofpathogentransmission.
–Themostconsistentassociationofincreasedriskoftransmissiontohealthcareworkers(basedonstudiesdoneduringtheSARSoutbreaksof2002– 2003)wasfoundfortrachealintubation.
–IncreasedriskofSARStransmissionwasalsoreportedwhenperformingnon-invasiveventilation,tracheotomyandmanualventilationbeforeintubation;however,thesefindingswereidentifiedfromalimitednumberofverylow-qualitystudies.

88. Then
1.GivesupplementaloxygentherapytopatientswithSARI
2.Collectrespiratoryandotherspecimensforlaboratorytesting
3.Giveempiricantimicrobialstotreatsuspectedpathogens,includingcommunity-acquiredpathogens
4.UseconservativefluidmanagementinpatientswithSARIwhenthereisnoevidenceofshock
5.Donotgivehigh-dosesystemiccorticosteroidsorotheradjunctivetherapiesforviralpneumonitisoutsidethecontextofclinicaltrials
6.CloselymonitorpatientswithSARIforsignsofclinicaldeterioration,suchassevererespiratorydistress/respiratoryfailureortissuehypoperfusion/shock,andapplysupportivecareinterventions

89. 2. Management of severe respiratory distress, hypoxemia and ARDS
3. Management of septic shock
4. Prevention of complications

90. Anumberoftherapeuticinterventionsforcoronaviruswereinvestigatedduringthelargemulti-nationaloutbreakofSevereAcuteRespiratorySyndrome(SARS)in2003

91. •To date, no antiviral therapy has been approved for treatment of patients with MERS-CoVinfection.
•Reviews of the available literature suggest that a combination of ribavirinand pegylatedinterferonmay be of benefit to patients with severe MERS-CoVinfection.
•Furthermore, the combination was shown to inhibit MERS-CoVin cell culture and appeared to improve clinical outcome in animal studies.
•Both agents are associated with significant potential adverse effects and hence their unlicensed use should be carefully balanced against any potential harm.

92. To be considered eligible for oral ribavirinand subcutaneous pegylatedinterferon therapy, the patient must fulfill ALL the following criteria:
1. Laboratory-confirmedMERS-CoVinfection
2. Clinical and radiological evidence of pneumonia
3. The patient requires invasive or non-invasive ventilatorysupport or showing progressive hypoxemia
4. Approval by one consultantsin Adult Infectious Diseases

93. 1. Patients who do not consent to the proposed treatment regimen.
2. Patients who have known allergyto any agent in the treatment protocol.

94. Administration Protocol:

95. Monitoring:
1.BothribavirinandPeg-interferonareassociatedwithconsiderablepotentialadverseeffects.Inadditiontoanyclinicalorlaboratorymonitoringthatisdictatedbythepatient’scondition,
2.thefollowinginvestigationsareessentialbeforestartingpegylatedinterferon2-alfatherapyandribavirinandondailybasisthroughoutthetreatmentcourse
3.Consciouspatientsmusthaveaformalpsychiatricassessmentifthereisanyclinicalevidenceofpsychosisoracuteconfusion

96. Changes to the treatment protocol:
•Changesinthetreatmentprotocolinresponsetotoxicityorclinicaldevelopmentsarepermitted.
•Aconsultantinadultinfectiousdiseasesmustapproveallsuchchanges.

99. Ebola Outbreaks 1976-2014

101. Historical Background in2simultaneousoutbreaks,firstinNzarawhichissmalltowninsouthofSudanwhichinfectedover284people,withamortalityrateof53%.
•AfterviewmonthanotheroutbreakoccurredinYambukuinDemocraticRepublicofCongo.Thelatterwasinavillagesituatednearthefromwhichthediseasetakesitsname
•InCongooutbreak318peopleinfectedwithhighestmortalityrateof88%.

102. •24 outbreaks reported by WHO from 1976 till 2012 .
•first outbreak occurred in Sudan ( Newly south of Sudan ) and Democratic Republic of Congo with mortality rate of 53% and 88% respectively .
•Countries involved in outbreaks was , Sudan , Congo , Uganda ,Gabon , South Africa ( one case in 1996 ) and Cote d'Ivoire ( one case in 1994).
•No case reported out of Africa till 2012 .
•The maximum No of infected patients was 425 in Uganda outbreak 2000 .

103. August1,2014,theGuineaMinistryofHealthannouncedatotalof485suspectandconfirmedcasesofEbolavirusdisease(EVD),including358fatalcases.
•340casesacrossGuineahavebeenconfirmedbylaboratorytestingtobepositiveforEbolavirusinfection.
•August1,2014,theMinistryofHealthandSanitationofSierraLeoneandWHOreportedacumulativetotalof646suspectandconfirmedcases,including540laboratoryconfirmationsand273reportedfatalcases

104. •August1,2014,theMinistryofHealthandSocialWelfareofLiberiaandWHOhavereported468suspectandconfirmedEHFcases(including129laboratoryconfirmations)and255reportedfatalities.
•August1,2014,theNigerianMinistryofHealthandWHOreported4suspectandprobablecasesand1fatalprobablecase.
•NigerianSuspectedandConfirmedCaseCountare4.

105. What is Ebola virus disease (EVD)?
•Ebolavirusdisease(formerlyknownasEbolahaemorrhagicfever)isasevere,oftenfatalillness,withadeathrateofupto90%.
•Theillnessaffectshumansandnonhumanprimates(monkeys,gorillas,andchimpanzees).
•Ebolafirstappearedin1976intwosimultaneousoutbreaks,oneinavillageneartheEbolaRiverintheDemocraticRepublicofCongo,andtheotherinaremoteareaofSudan.
•TheoriginofthevirusisunknownbutareconsideredthelikelyhostoftheEbolavirus,basedonavailableevidence.

108. Case counts October 24, 2014

109. Countries with widespread transmission
Country
Total cases
Lab. Conf. cases
Total deaths
Guinea
1760
1479
1054
Liberia
6919
2514
2766
Sierra Leone
4862
4149
1130
Total
13241
8142
4950
08 November 2014

110. Countries with travel associated cases
Country
Total cases
Lab. Conf. cases
Total deaths
Mali
1
1
1
Senegal
1
1
0
2
2
1
Country
Total cases
Lab. Conf. cases
Total deaths
Nigeria
20
19
8
Spain
1
1
0
United State
4
4
1
25
24
9

111. •TheoutbreakofEbolaVirusinNigeriaandSenegalweredeclaredoveron17Octoberand19October2014.
•AnationalEVDoutbreakisconsideredtobeoverwhen42days(Doublethe21daysincubationperiod)haselapsedsincethelastpatientinisolationbecamelaboratorynegativeforEVD

112. How many people could become infected?

114. 2. How do people become infected with the virus?
•In the current outbreak in West Africa, the majority of cases in humans have occurred as a result of
•Infection occurs from through broken skin or mucous membranes with the blood, or other bodily fluids or secretions (stool, urine, saliva, semen) of infected people.
•Infection can also occur if broken skin or mucous membranes of a healthy person come into such as soiled clothing, bed linen, or used needles.

115. •Morethan200health-careworkershavebeenexposedtotheviruswhilecaringforEbolapatients.
•Thishappensbecausetheyorwerenotproperlyapplyingwhencaringforthepatients.
•Health-careprovidersatalllevelsofthehealthsystem–hospitals,clinics,andhealthposts– shouldbebriefedonthenatureofthediseaseandhowitistransmitted,andstrictlyfollowrecommendedinfectioncontrolprecautions.

116. •Peopleareinfectiousaslongastheirbloodandsecretionscontainthevirus.Forthisreason,infectedpatientsreceiveclosemonitoringfrommedicalprofessionalsandreceivelaboratoryteststoensurethevirusisnolongercirculatingintheirsystems
•Menwhototheirpartnerthroughtheirsemenforupto7weeksafterrecovery.Forthisreason,itisimportantformentoavoidsexualintercourseforatleast7weeksafterrecoveryortowearcondomsifhavingsexualintercourseduring7weeksafterrecovery.
•Generally,apersonmustcomeintocontactwithananimalthathasEbolaanditcanthenspreadwithinthecommunityfromhumantohuman.

118. Who is most at risk?
During an outbreak,those at higher risk of infection are:
•health workers;
•family members or others in close contact with infected people;
•mournerswho have direct contact with the bodies.
•More research is needed to understand if some groups, such as immuno-compromisedpeople or those with other underlying health conditions, are more susceptible than others to contracting the virus.

119. incubation period
2 to 21 days
•The incubation period from time of infection to symptoms is 2 to 21 days.

120. What are typical signs and symptoms of infection?
•Sudden onset of fever, intense weakness, muscle pain, headache and sore throatare typical signs and symptoms.
•This is followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases, both internal and external bleeding.

121. •Laboratory findings include low white blood cell and platelet counts, and elevated liver enzymes.
•The patients become infectious once they begin to show symptoms.
•They are not contagious during the incubation period.( 2-21 days)
•Ebola virus disease infections can only be confirmed through laboratory testing.

123. What is the treatment?
•There is currently no specific treatment to cure the disease.
•Severely ill patients require intensive supportive care. They are frequently dehydrated and need intravenous fluids or oral rehydration with solutions that contain electrolytes.
•Some patients will recover with the appropriate medical care.
•Isolationfrom other patients and treated by health workers using strict infection control precautions.

124. Should patients with suspected or confirmed Ebola virus be separated from other patients?
•IsolatingpatientswithsuspectedorconfirmedEbolavirusdiseaseinsingleisolationroomsisrecommended.
•Whereisolationroomsarenotavailable,itisimportanttoassigndesignatedareas,separatefromotherpatients,forsuspectedandconfirmedcases.
•Accesstotheseareasshouldberestricted,neededequipmentshouldbededicatedstrictlytosuspectedandconfirmedEVDtreatmentareas,andclinicalandnon-clinicalpersonnelshouldbeexclusivelyassignedtoisolationroomsanddedicatedareas.

125. StoppingvisitoraccesstopatientsinfectedwithEVDispreferred.
Ifthisisnotpossible,accessshouldbegivenonlytothoseindividualswhoarenecessaryforthepatient’swell-beingandcare,suchasachild’sparent.

126. Is hand hygiene important?
Handhygieneisessentialandshouldbeperformed:
•beforedonningglovesandwearingPPEonentrytotheisolationroom/area;
•beforeanycleanorasepticproceduresisbeingperformedonapatient;
•afteranyexposureriskoractualexposurewithapatient’sbloodorbodyfluids;
•aftertouching(evenpotentially)contaminatedsurfaces,items,orequipmentinthepatient’ssurroundings;and
•afterremovalofPPE,uponleavingtheisolationarea.

127. •Eitheranalcohol-basedhandruborsoapandrunningwatercanbeusedforhandhygiene.
•Itisimportanttoalwaysperformhandhygienewithsoapandrunningwaterwhenhandsarevisiblysoiled.
•Alcohol-basedhandrubsshouldbemadeavailableateverypointofcare(attheentranceandwithintheisolationroomsandareas); runningwater,soap,andsingleusetowelsshouldalsobealwaysavailable.

131. Keeping Healthy
•Maintain a healthy lifestyle; attention to rest, diet, exercise, and relaxation helps maintain physical and emotional health.
•Resilience