Viral Haemorrhagic Fevers
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1 Viral Haemorrhagic Fevers Travel Medicine Conference Constanţa, September 2018 Dr Ian Cropley Department of Infectious Diseases High Level Isolation Unit Royal Free London NHS Foundation Trust
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3 Viral Haemorrhagic Fevers description of the viral haemorrhagic fevers current epidemiology imported VHF into Europe and USA what the West African Ebola outbreak has taught us new drugs and vaccines advice to travellers advice to health care workers volunteering in Lassa and Ebola outbreaks management of VHF patients in our unit
4 Hazard Group 4 biological agents Lassa fever Crimean-Congo haemorrhagic fever Marburg Ebola Kyasanur forest disease Guanarito haemorrhagic fever Omsk haemorrhagic fever Argentinian haemorrhagic fever Russian Spring summer encephalitis Bolivian haemorrhagic fever (Machupo) Nipah Hendra Brazilian haemorrhagic fever (Sabia) Smallpox Herpesvirus simiae infection (B virus)
5 Hazard Group 4 biological agents Lassa fever (Arenavirus) Crimean-Congo haemorrhagic fever (Bunyavirus) Marburg (Filovirus) Ebola (Filovirus) Kyasanur forest disease Guanarito haemorrhagic fever Omsk haemorrhagic fever Argentinian haemorrhagic fever Russian Spring summer encephalitis Bolivian haemorrhagic fever (Machupo) Nipah Hendra Brazilian haemorrhagic fever (Sabia) Smallpox Herpesvirus simiae infection (B virus)
6 The diseases All RNA viruses different epidemiology and modes of transmission all start as an influenza-like illness differing clinical courses
7 The diseases All RNA viruses different epidemiology and modes of transmission all start as an influenza-like illness differing clinical courses acute onset high fever leaky capillaries disturbance of coagulation variable severity and fatality rate high mortality once haemorrhagic features develop
8 The diseases All RNA viruses different epidemiology and modes of transmission all start as an influenza-like illness differing clinical courses acute onset high fever leaky capillaries disturbance of coagulation variable severity and fatality rate high mortality once haemorrhagic features develop but haemorrhagic features may not be prominent Ebola predominantly diarrhoeal
9 The diseases very limited treatment limited vaccine household and nosocomial transmission carers funeral rites, washing the deceased body
10 Lassa fever
11 Lassa fever Multi-mammate mouse/rat - Mastomys sp
12 Lassa fever Multimammate mouse/rat - Mastomys sp endemic in west Africa acquired from urine or faeces of multimammate mouse/rat
13 Lassa fever Multimammate mouse/rat - Mastomys sp endemic in west Africa acquired from urine or faeces of multimammate mouse/rat 300, ,000 cases per year 3,000 4,000 deaths/year (case fatality rate 1%)
14 Lassa fever Multimammate mouse/rat - Mastomys sp endemic in west Africa acquired from urine or faeces of multimammate mouse/rat 300, ,000 cases per year 3,000 4,000 deaths/year (case fatality rate 1%) hospital outbreaks from unsterilised needles etc
15 Lassa fever Multimammate mouse/rat - Mastomys sp endemic in west Africa acquired from urine or faeces of multimammate mouse/rat 300, ,000 cases per year 3,000 4,000 deaths/year (case fatality rate 1%) hospital outbreaks from unsterilised needles etc common cause of deafness
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17 Imported Lassa fever worldwide Year of import From To Occupation Clinical outcome 1969 Nigeria United States Nurse Survived 1971 Sierra Leone United Kingdom Nurse Survived 1971 Sierra Leone United Kingdom Physician Survived 1972 Sierra Leone United Kingdom Nurse Survived 1974 Nigeria Germany Physician Survived 1975 Nigeria United Kingdom Physician Died 1975 Sierra Leone United States Aid worker Survived 1976 Sierra Leone United States Aid worker Survived 1976 Nigeria United Kingdom Engineer Survived 1980 Upper Volta Netherlands Aid worker Survived 1981 Nigeria United Kingdom Teacher Survived 1982 Nigeria United Kingdom Diplomat Survived 1984 Sierra Leone United Kingdom Geologist Survived 1985 Sierra Leone United Kingdom Nurse Survived 1957 Sierra Leone/Liberia Israel Engineer Survived 1957 Sierra Leone Japan Engineer Survived 1989 Nigeria Canada Agricultural specialist Survived 1989 Nigeria United States Engineer Died 2000 Cote d'lvoire/ Burkina Faso/Ghana Germany Student Died 2000 Sierra Leone United Kingdom Peacekeeper Died 2000 Nigeria Germany Unknown Died 2000 Sierra Leone Netherlands Physician Died 2003 Sierra Leone United Kingdom Peacekeeper Survived 2004 Sierra Leone/Liberia United States Businessman Died 2004 Cote D'Ivoire/Chad United Kingdom Businessman Survived 2006 Sierra Leone Germany Visiting relatives Survived 2009 Nigeria United Kingdom Visiting relatives Died 2009 Mali United Kingdom Construction worker Died adapted from Macher AM and Wolfe MS. Emerging Infectious Diseases 2006;12(5):835-7
18 Crimea-Congo haemorrhagic fever - CCHF
19 Crimea-Congo haemorrhagic fever - CCHF Hyalomma ticks zoonosis (only humans develop disease) acquired by bite of infected tick by crushing infected tick from slaughter of viraemic livestock eg calf, goat, ostrich from blood contact with infected patient?from droplet infection
20 CCHF in the UK and elsewhere Outbreaks in Pakistan, Afghanistan Turkey, Kosovo, Albania have hundreds of cases each year Spain: 2016 one case acquired in Spain, transmitted to one health care worker 2018 one case acquired in Spain UK: Three imported cases from Zimbabwe (probable), Afghanistan, Bulgaria Greece: one imported case from Bulgaria Romania 134/471 (28%) of sheep in Northern Dobrogea seropositive for CCHF Ceianu CS. Vector Borne Zoonotic Dis Sep;12(9): doi: /vbz
21 Marburg and Ebola
22 Marburg and Ebola
23 Marburg and Ebola Marburg 1967: 31 cases in Germany from imported monkeys 2008: one case in Netherlands, one case USA. Had visited bat caves Ebola: no imported cases into Europe or USA
24 Marburg and Ebola Marburg 1967: 31 cases in Germany from imported monkeys 2008: one case in Netherlands, one case USA. Had visited a bat cave Ebola: no imported cases into Europe or USA UNTIL
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27 Ebola What have we learnt from 30,000 cases including 10,000 deaths? late recognition of epidemic community engagement vital safe burials, contact tracing, field diagnostics essential poor readiness of international response collapse of other health services
28 Ebola cases per week in Guinea and Sierra Leone
29 Ebola What have we learnt from 30,000 cases including 10,000 deaths? late recognition of epidemic community engagement vital safe burials, contact tracing, field diagnostics essential poor readiness of international response collapse of other health services no research studies ready to go unable to ascertain best treatment regime
30 Ebola What have we learnt from 30,000 cases including 10,000 deaths? late recognition of epidemic community engagement vital safe burials, contact tracing, field diagnostics essential poor readiness of international response collapse of other health services no research studies ready to go unable to ascertain best treatment regime optimisation of care in Europe/USA reduced mortality new drugs and therapeutics trialled in Europe/USA, probably effective
31 Ebola What have we learnt from 30,000 cases including 10,000 deaths? late recognition of epidemic community engagement vital safe burials, contact tracing, field diagnostics essential poor readiness of international response collapse of other health services no research studies ready to go unable to ascertain best treatment regime optimisation of care in Europe/USA reduced mortality new drugs and therapeutics trialled in Europe/USA, probably effective rvsv-zebov Ebola vaccine probably highly effective for ring vaccination
32 Ebola 2018: 2 outbreaks in Democratic Republic of Congo (DRC) 1 outbreak over 1 outbreak ongoing (148 cases, 96 deaths) mass vaccination with rvsz-zebov Ebola vaccine
33 How do we advise volunteers going to work in VHF setting? have all recommended travel vaccines take good malaria prophylaxis train properly in use of PPE arrange medical evacuation plans in event of illness
34 How do we advise volunteers going to work in VHF setting? have all recommended travel vaccines take good malaria prophylaxis train properly in use of PPE arrange medical evacuation plans in event of illness pre-travel vaccination with rvsv-zebov Ebola vaccine
35 How do we advise volunteers going to work in VHF setting? have all recommended travel vaccines take good malaria prophylaxis train properly in use of PPE arrange medical evacuation plans in event of illness pre-travel vaccination with rvsv-zebov Ebola vaccine system of reporting fever or illness from own room by phone to central point rapid test availability in field
36 How do we advise volunteers going to work in VHF setting? have all recommended travel vaccines take good malaria prophylaxis train properly in use of PPE arrange medical evacuation plans in event of illness pre-travel vaccination with rvsv-zebov Ebola vaccine system of reporting fever or illness from own room by phone to central point rapid test availability in field?availability of treatment Remdesivir (GS-5734), favipiravir, ZMapp, mab114, REGN?availability of Ebola post-exposure prophylaxis for needlestick injury medical evacuation
37 How do we advise volunteers returning to the UK after working in VHF treatment centre? Register with the Returning Workers Scheme (Public Health England).
38 How do we advise volunteers returning to the UK after working in VHF treatment centre? Register with the Returning Workers Scheme (Public Health England). No patient contact for 21 days Postpone non-essential medical and dental care Do not share razors or toothbrushes No unprotected sexual intercourse for 21 days Avoid situations where unable to leave quickly if unwell No trips on public transport longer than 2 hours No air travel take temperature twice daily report daily by telephone to designated Public Health contact
39 How do we advise volunteers returning to the UK after working in VHF treatment centre? Register with the Returning Workers Scheme (Public Health England). No patient contact for 21 days Postpone non-essential medical and dental care Do not share razors or toothbrushes No unprotected sexual intercourse for 21 days Avoid situations where unable to leave quickly if unwell No trips on public transport longer than 2 hours No air travel take temperature twice daily report daily by telephone to designated Public Health contact look after yourself and talk to your friends and family
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