Slide 1. Slide 2. Slide 3 EBOLA 2014 WEST AFRICA CENTRAL AND EAST AFRICA. Hosted by: Bhagavatula Ramakrishna, M.D.

Transcription

1 Slide 1 EBOLA 2014 WEST AFRICA Hosted by: Bhagavatula Ramakrishna, M.D. Slide 2 CENTRAL AND EAST AFRICA Slide 3

2 Slide 4 EBOLA IN WEST AFRICA 2014 Slide 5 It is a disease of poverty and neglect of health systems. It is an infection that causes epidemics only if basic hospital hygiene is not respected. Dr. Peter Piot (one of the first researchers to identify Ebola Virus in 1976) Slide 6 Ebola Hemorrhagic Fever Ebola hemorrhagic fever (Ebola HF) is one of numerous Viral Hemorrhagic Fevers. It is a severe, often fatal disease in humans and nonhuman primates (such as monkeys, gorillas, and chimpanzees). Ebola HF is caused by infection with a virus of the family Filoviridae, genus Ebola virus. When infection occurs, symptoms usually begin abruptly. The first Ebola virus species was discovered in 1976 in what is now the Democratic Republic of the Congo near the Ebola River. Since then, outbreaks have appeared sporadically.

3 Slide 7 There are five species of Ebola virus--a negative single-stranded RNA virus in the family of Filoviridae. The three species: Bundibugyo Zaire Sudan Ebola viruses Responsible For all the Outbreaks Slide 8 There are two other Ebola viruses: The Reston virus which is limited to the Philippines and has not caused human disease; The Tai Forest Ebola virus caused disease in a scientist doing an autopsy on a chimpanzee. Slide 9 Ebola Cycle

4 Slide 10 The First Outbreak September 1976 Injection of Chloroquine for malaria leads to a febrile hemorrhagic illness in a patient and then spreads to healthcare workers. In two months, 318 cases of viral hemorrhagic fever with 88% mortality in 55 villages in Congo (now Democratic Republic of Congo) (DRC). Slide 11 EBOLA VIRUS OUTBREAK The virus was identified and named after the Ebola River that traverses the affected regions. Since then there have been 20 outbreaks of Ebola Virus Disease (EVD). Slide 12 These were all sporadic, mostly in Central and Eastern Africa. The 2014 EVD was the first outbreak to occur in West Africa. From 1979 to 1994, there were no cases reported.

5 Slide 13 Transmission How do you get the Ebola virus? Direct contact with: 1. Bodily fluids of a person who is sick with or has died from Ebola (blood, vomit, urine,faeces sweat, semen, spit and other fluids). 2. Objects contaminated with the virus (needles, medical equipment). 3. Infected animals (by contact with blood or body fluids or infected meat). Slide 14 Reservoir and vectors of Ebola virus are not understood well. Ebola virus is a zoonotic disease. Fruit bats were implicated as the virus replicates in these bats and the virus was isolated from the guano. Monkeys and other non-human primates may serve as intermediate hosts. Slide 15 Transmission (Continued) Because the natural reservoir of ebolaviruses has not yet been proven, the manner in which the virus first appears in a human at the start of an outbreak is unknown. However, researchers have hypothesized that the first patient becomes infected through contact with an infected animal.

6 Slide 16 Transmission (Continued) Healthcare workers and the family and friends in close contact with Ebola patients are at the highest risk of getting sick because they may come in contact with infected blood or body fluids. During outbreaks of Ebola HF, the disease can spread quickly within healthcare settings (such as a clinic or hospital). Exposure to Ebola viruses can occur in healthcare settings where hospital staff are not wearing appropriate protective equipment, such as masks, gowns, and gloves. Slide 17 Clinical Course Incubation period 2-21 days Most patients develop symptoms between day Abrupt onset of fever, chills, myalgia, sometimes macules, papules, rash Watery diarrhea, nausea, vomiting Hemorrhagic sequela such as Petechiae and ecchymosis Slide 18 Signs & Symptoms Symptoms of Ebola HF Typically Include: Fever Headache Joint and muscle aches Weakness Diarrhea Vomiting Stomach pain Lack of appetite Some Patients May Experience: A Rash Red Eyes Hiccups Cough Sore throat Chest pain Difficulty breathing Difficulty swallowing Bleeding inside & outside of the body

7 Slide 19 Clinical Course (cont d) Death usually occurs 6-16 days after onset of symptoms. Recovered patients have prolonged weakness, poor appetite, and failure to gain weight. Slide 20 VIRAL PERSISTENCE Dr. J. B. Varken, an American Physician, who survived Ebola in September 2014 (Sierra Leone): - Developed posterior uveitis 14 weeks after recovery - Aqueous humor sample positive for EBOV-RNA, but conjunctival and tear samples were negative. - There is a report of sexually transmitted Ebola because of persistence of the virus in the testes. Slide 21 Pathogenesis The virus causes multi-organ system failure. It invades endothelium and causes endothelial damage. Causes a cytokine storm by attacking macrophages that leads to intense inflammation, hepatic necrosis, severe sepsis leading to death. Hepatic necrosis plus thrombocytopenia, etc., lead to hemorrhage and death.

8 Slide 22 Pathogenesis of Ebola Virus (Cont d) Reason for Hemorrhagic Fever 1) Macrophages leak cytokines (IL-1beta, nitric oxide, TNF alpha) cause fever and inflammation and hypotension 2) Endothelial cell damage causes capillary (vascular) leak, hypotension and shock 3) Coagulopathy triggered by macrophage synthesized cell-surface tissue factor that triggers extrinsic coagulation pathway and DIC. Slide 23 Pathogenesis of Ebola Slide 24 Diagnosis Diagnosis Ebola HF in an individual who has been infected for only a few days is difficult, because the early symptoms, such as red eyes and a skin rash, are nonspecific to Ebola virus infection and are seen often in patients with more commonly occurring diseases. However, if a person has the early symptoms of Ebola HF, and there is reason to believe that Ebola HF should be considered, the patient should be isolated and public health professionals notified. Samples from the patient can then be collected and tested to confirm infection.

9 Slide 25 Diagnosis (Continued) Laboratory tests used in diagnosis include: Timeline of Infection Diagnostic Tests Available Within a few days after symptoms begin - Antigen-capture enzyme-linked immunosorbent assay (ELISA) testing - IgM ELISA - Polymerase chain reaction (PCR) - Virus isolation Later in disease course or after recovery Retrospectively in deceased New Rapid Bedside tests - IgM and IgG antibodies - Immunohistochemistry testing - PCR - Virus isolation Slide 26 Supportive: Treatment Blood product transfusion Electrolyte replacement Fluid resuscitation Vasopressors Ventilator support Evaluate for any concurrent infections, such as malaria, typhoid fever, etc. Slide 27 Investigational Drugs: Z.Mapp. (Mapp. Biopharmaceutical) a combination of 3 different monoclonal antibodies that bind to the protein of Ebola Virus. Bricidofovir Blood and Serum from persons who have recovered from Ebola Virus Disease Have been used.

10 Slide 28 VACCINES PHASE I STUDIES Two vaccines being studied (New England Journal of Medicine (NEJM), April 2015). A recombinant chimpanzee adenovirus and a vesicular stomatitis virus. These express Ebola surface glycoprotein. Slide 29 How Trials will Work for Ebola Vaccines (by Bonnie Berkowitz & Patterson Clark, Published February 8, 2015) Two promising Ebola vaccines have begun clinical trials in West Africa. A different type of trial is planned for each of the three countries hit hardest by the epidemic. This phase could take a year or more, said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. A trial s length depends on the spread of the epidemic, and this one is subsiding. Slide 30 The Vaccines Chimp adenovirus made by GlaxoSmithKline A chimpanzee cold virus is used as a carrier to deliver a gene that makes the outer protein for the Zaire strain of Ebola. The virus is not alive and not able to replicate, but it can still express a protein. Once injected into the body, it makes a protein that triggers an immune response. It cannot cause infection.

11 Slide 31 The Vaccines (Cont d.) VSV-Zebov made by NewLink and Merck The vesicular stomatitis virus vaccine works similarly to the adenovirus vaccine, except that the virus is alive and replicates itself so that it makes more and more of the Ebola protein. It cannot cause an Ebola infection. One of several earlier trials was stopped because some participants developed joint pain, but the side effect was determined to be mild enough to restart the trial. A few tens of millions of doses will be available in 2015, according to the World Health Organization. Slide 32 Prevention The prevention of Ebola HF presents many challenges. Because it is still unknown how exactly people are infected with Ebola HF, there are few established primary prevention measures. When cases of the disease do appear, there is increased risk of transmission within healthcare settings. Therefore, healthcare workers must be able to recognize a case of Ebola HF and be ready to employ practical viral hemorrhagic fever isolation precautions or barrier nursing techniques. They should also have the capability to request diagnostic tests or prepare samples for shipping and testing elsewhere. Slide 33 Prevention (Continued) Barrier nursing techniques include: wearing of protective clothing (such as masks, gloves, gowns, and goggles). the use of infection control measures (such as complete equipment sterilization and routine use of disinfectant). isolation of Ebola HF patients from contact with unprotected persons. The aim of all of these techniques is to avoid contact with the blood or secretions of an infected patient. If a patient with Ebola HF dies, it is equally important that direct contact with the body of the deceased patient be prevented.

12 Slide 34 Prevention (Continued) Centers for Disease Control and Prevention (CDC), in conjunction with the World Health Organization, has developed a set of guidelines to help prevent and control the spread of Ebola HF. Entitled Infection Control for Viral Hemorrhagic Fevers in the African Healthcare Setting, the manual describes how to: recognize cases of viral hemorrhagic fever (such as Ebola HF). prevent further transmission in healthcare setting by using locally available materials and minimal financial resources. Slide 35 Travel If you must travel to an area with known Ebola cases, make sure to do the following: Practice careful hygiene. Avoid contact with blood and body fluids. Do not handle items that may have come in contact with an infected person s blood or body fluids. Avoid funeral or burial rituals that require handling the body of someone who has died from Ebola. Avoid contact with bats and nonhuman primates or blood, fluids, and raw meat prepared from these animals. Avoid hospitals where Ebola patients are being treated. The U.S. embassy or consulate is often able to provide advice on facilities. After you return, monitor your health for 21 days, and seek medical care immediately if you develop symptoms of Ebola (/vhf/ebola/symptoms/index.html). Slide Ebola Outbreak in Context A two-year-old toddler died from the disease (Guéckédou Prefecture, Guinea) in December outbreak started in Meliandou, Guinea.

13 Slide 37 In March, Medicins' sans Frontières (MSF), Doctors without Borders, reported a mysterious illness that killed 59 of first 86 cases. Then the disease spreads to Liberia, Senegal, Nigeria, Sierra Leone, and Mali all from infected travelers crossing borders. Slide 38 Outside Africa OUT SIDE AFRICA September 30, 2014 The first case of EVD was diagnosed in the United States in a patient from Liberia to Dallas, Texas. Healthcare workers also were infected. Slide 39 Similar transmission from a repatriated nun to a healthcare worker occurred in Spain. Nigeria very quickly controlled the outbreak with a team of dedicated doctors and healthcare workers who died taking care of the patients and government policies that helped. In DRC (Congo), another unrelated outbreak is going on at the same time; this was a different strain of Ebola.

14 Slide 40 CASE COUNTS Total Cases WEST AFRICA EBOLA OUTBREAK Updated: From March 3,2014 to June 19,2015 Cases : 27,352 Deaths : 11,193 Slide 41 What Caused this Large Outbreak? Previous outbreaks occurred in rural isolated villages with limited access to medical care resulting in high mortality, but limited transmission. With industrialization and globalization of commerce, there is now increased travel from isolated areas to densely populated urban areas. Slide 42 Increased access to healthcare helped increase nosocomial transmission and spread of the disease.

15 Slide 43 Nigeria s healthcare system and brave doctors contained the disease quickly (2 doctors died in this outbreak). Outside of West Africa,the United States reported a case a traveler from Liberia. Thomas Eric Duncan died from the illness. Slide 44 All but three cases were acquired out of West Africa, and all were healthcare workers (2 in the USA and a Spanish nurse, Teresa Romero). Second person to die on U.S. soil was Martin Salia, a surgeon from Sierra Leone (treated in Nebraska). Slide 45 Note: Nobody in Mr. Duncan s family or contacts in the community contracted Ebola.

16 Slide 46 Why this Outbreak Continued Cultural and Societal Factors: Family members often take care of the patients (relatives) putting themselves at risk. Family members are fearful that the hospitals themselves are causing the infections. People hiding the patients and their contacts from health authorities. Slide 47 Poor hygiene and sanitation and poor public health system. Burial practices in several parts of West Africa include close contact of the family members with the deceased. Illegal bushmeat trade. Increased contact between animals and humans. Slide 48 The Current Policy to Deal with EBOLA Screening Travelers from The Affected Countries at one of the five International Airports Monitoring the persons for symptoms for 21 days Symptomatic Patients are Referred to Acute Health care Facility immediately

17 Slide 49 Acute Health Care Facilities Front Line Hospitals. Ebola Assessment Hospitals. Ebola Treatment Centers. There are 55 Designated Ebola Treatment Centers in the Country. Three Bio containment centers also Serve as Treatment Centers.(NIH,EMORY and Nebraska). ) Slide 50 Lessons Learned Response to an Outbreak in Africa, (Dr. Stan Deresinski, Editor, Infectious Disease Alert): - Cable news and politicians spread panic and chaos in public health policy. - Enormous efforts put forth and money wasted for activities in the country to prevent Ebola here. Slide 51 Public Health Issues Bill Gates (in NEJM) - The world response was not adequate to Ebola outbreak. - A more virulent virus, such as influenza and measles could cause 10 million deaths. - The WHO has a Global Outbreak Alert and Response Network, but it is severely underfunded.

18 Slide 52 Bill Gates (Cont d.) What could be done? Build a warning and response system for outbreaks. This system should: - be coordinated by a global institution that is given enough authority and funding to be effective. - enable fast decision-making at a global level. Slide 53 Bill Gates (Cont d.) What could be done? - expand investment in research and development and clarify regulatory pathways for developing new tools and approaches. - improve early warning and detection systems, including scalable everyday systems that can be expanded during an epidemic. Slide 54 Bill Gates (Cont d.) What could be done? - involve a reserve corps of travel personnel and volunteers. - strengthen healthcare systems in low and middle income countries. - incorporate preparedness exercises to study how to improve the response system.

19 Slide 55 Dr. Gregg Gonsalves, NEJM 2014 We all have to become activists if we were to protect the public health from being used as a tool to serve primarily political purposes as it has been over the past few weeks in the U.S. Slide 56 Dr. Craig Spencer, Ebola Treater in Africa and a Patient in the USA We all lose when we allow irrational fear fueled in part by prime time ratings and political expediency to supersede pragmatic public healthcare policy. Slide 57 Centers for Disease Control and Prevention (CDC) Dr. Thomas Friedman came under a lot of criticism because of the way he communicated with the media during Ebola outbreak.

20 Slide 58 The American Psychiatric Association Annual meeting in Toronto, Dr. Daniel Witter, M.D., Ph.D., discussed this issue. He recommended the following: - Do not over-reassure. - Acknowledge uncertainty. - Do not ridicule the public s emotions. Slide 59 - Tell people what to expect. - Offer people things to do. - Acknowledge errors, deficiencies, and misbehaviors.