Ebola: 22,000 cases, 8700 deaths. Enterovirus D68: 1100 cases, 14 deaths. Chikungunya virus: almost a million cases in the Western Hemisphere

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Kelly Mason
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1 Sally Williams MD

2 Ebola: 22,000 cases, 8700 deaths Enterovirus D68: 1100 cases, 14 deaths Chikungunya virus: almost a million cases in the Western Hemisphere

3 } A nonpolio enterovirus identified in 1962, similar to a rhinovirus } Spread by secretions like common colds } Usually causes mild respiratory disease } Can cause severe respiratory disease and death in children with asthma } Previously only rare outbreaks until August 2014 } Distantly related to poliovirus

4 } 45 states had cases, including many deaths from respiratory failure } Treatment only supportive } All RAD patients advised to have an asthma action plan and seek care early

5 } 2 Oregon girls, one with virulent strain of enterovirus, develop mysterious paralysis } Bailey Sheehan, who lives in Welches, developed flu-like symptoms in October which turned into paralysis of her right leg and arm. She's learned to walk with a brace.

-First reported in 2005-25 cases in 2012-107 children with acute flaccid myelitis since August 2014 -Average age 7, most with respiratory illness

6 -First reported in cases in children with acute flaccid myelitis since August Average age 7, most with respiratory illness prior to onset of paralysis -Many have positive nasal test, few have positive CSF -CDC is currently calling it an association between D68 and paralysis

} Origin in Makonde language from Tanzania and Mozambique for that which bends up } Single strand RNA alphavirus } Transmitted most commonly by the Aedes aegypti

8 } Origin in Makonde language from Tanzania and Mozambique for that which bends up } Single strand RNA alphavirus } Transmitted most commonly by the Aedes aegypti mosquito } Concern for Aedes albopictus also } Over 75% of infected will have symptoms } In nonendemic areas 1/3-3/4 will be infected } Prior to 2006 only in Africa and SE Asia

9 Aedes aegypti, known to transmit yellow fever, dengue, chikungunya. Has white markings on legs. Females feed dusk & dawn. Aedes albopictus, the tiger mosquito. They bite during the day, live closer to humans than aegypti. Previously only in SE Asia, moving worldwide

11 } Started with St Martin in the Caribbean in Dec 2013, 2200 cases by March 2014 } Over 1 million suspected cases since that time

12 Florida now has 11 cases of local acquisition, e.g. mosquito biting infected person, picking up virus and transmitting it to another person from bite.

13 Lindsay Lohan in Bora Bora where she contracted CHIKV

14 } Incubation period is 2-7 days } Presents with sudden onset very high fever, usually lasting 2 days but can be longer -DDx dengue (breakbone fever), malaria } Usually with severe joint pain for 5-7 days } Often with rash, headache, fatigue } Prolonged joint pain and debilitation common >50% had joint pain over 3 years after infection Worse prognosis with age > 45, rheum disease Appears virus establishes persistent infection

} Global Warming: Tiger mosquitoes now found as far north as New York Aedes can survive winters now } Increase in people traveling and bringing back diseases then

15 } Global Warming: Tiger mosquitoes now found as far north as New York Aedes can survive winters now } Increase in people traveling and bringing back diseases then getting bitten by local skeeters } Globalization: plants and products spread all over the world Aedes mosquitoes thought to have originally come to Texas in old tires

16 } Serologic testing is done at CDC or Quest } Once infected you are immune, unlike dengue } Anyone returning from endemic area with fever, rash, joint pain should be tested for both CHIKV and dengue } CHIKV tends to have worse joint pain } We are likely to see many more cases given travel and higher temperatures.

17 First outbreak in 1976 on Zaire Sudan border. Rare cases until 1995 outbreak in Zaire (DRC). In cases in Uganda, recognized risks of care giving, funerals, health care workers. From March 2014 about 22,000 cases of Zaire type Ebola in west Africa with over 8700 deaths.

18 As you can see, the epidemic is not slowing Although reports from January encouraging.

} First reported by MSF from SE Guinea on March 24, 2014 already with 86 cases and 59 deaths } First case likely a 2 yr old boy in December 2013 in a forested area of Guinea close to Sierra Leone and

19 } First reported by MSF from SE Guinea on March 24, 2014 already with 86 cases and 59 deaths } First case likely a 2 yr old boy in December 2013 in a forested area of Guinea close to Sierra Leone and Liberia (fruit bats are natural hosts of Ebola) } Diagnosis delayed as Ebola had never been seen there before, only in eastern Africa } In the setting of an impoverished very mobile society the disease quickly spread across borders, into cities } Once it reached the Guinean capital Conakry it was unstoppable

21 } Direct contact with blood, body fluids or skin of infected person Blood, vomit and feces most infective Also in urine, saliva, breast milk and semen Detectable in semen up to 3 months } Infectivity is related to viral levels which are low initially and become very high near death Preparing bodies for burial an extreme risk } Also risk with eating bush meat, contact with fruit bats

} Ebola and Marburg are in the Filoviridae family, causes of extremely virulent illnesses and often hemorrhagic fever The Ebola Zaire species is causing the current outbreak } They infect multiple

23 } Ebola and Marburg are in the Filoviridae family, causes of extremely virulent illnesses and often hemorrhagic fever The Ebola Zaire species is causing the current outbreak } They infect multiple different cell types enabling widespread damage } They disable immune responses by replicating in dendritic cells and causing lymphocyte apoptosis } They active the coagulation } pathway to cause coagulopathy

24 } Incubation 9-11 days, then fever,myalgia, rash } GI symptoms start about 5 days Vomiting, diarrhea very common } Patients die of multiorgan failure at average 7-9 days or recover after about 6 days } About 18% have bleeding toward end of life } Case fatality averages 70% } Worse prognosis with age>45, bleeding } If survive are then immune

9/28: Returns to ED, isolated for concern of Ebola. Has diarrhea, fever and vomiting. Moved to ICU. Gown and gloves used.

26 September 19,2014: Thomas Duncan leaves Liberia 9/20: arrives Dallas 9/24: develops symptoms of fever, abd pain and congestion 9/25: goes to ED, sits for an hour, evaluated and dced with T102 and diagnosis of sinusitis. Differing reports of travel history given. 9/28: Returns to ED, isolated for concern of Ebola. Has diarrhea, fever and vomiting. Moved to ICU. Gown and gloves used. 9/30: Test positive, hazmat suits used, respirators added 10/1 10/4: Develops multiorgan failure 10/8 am: expires 10/11: ICU nurse Nina Pham tests positive 10/15: ICU nurse Amber Vinson tests positive, both survive

27 A whole new meaning to the word viral

28 } All 3 countries reporting lowest weekly case count in months } New outbreaks have occurred due to resistance from communities to outside intervention In Guinea 60% of cases linked to burials 1 funeral alone led to 356 deaths Burial rituals a very strong cultural issue } 800 health worker infections with 500 deaths } There are 43 open treatment centers currently } Hopefully epidemic will eventually peter out

29 } Treatment currently just supportive } Zmapp monoclonal antibody given to 2 US pts Mouse antibodies after exposure to Ebola } Transfusions from survivors Hoping for high antibody levels } Brincidofovir Active against pox, herpes and adenoviruses (DNA) Appeared active for Ebola even though is RNA virus } Favipiravir Developed in Japan as anti-influenza drug

30 A single use biofiltration device that rapidly eliminates viruses and glycoproteins from the blood. It uses lectin affinity plasmapheresis to pull out large size viruses while leaving lymphocytes in the blood. Has been tested on 2 patients, one whose viral load decreased from 400,000 viruses /ml to 1000 after treatment (total 240 million viruses removed). Both patients survived, likely as their own immune systems were able to fight the smaller amount of virus.

Ebola Virus Patient Advisory

22 September 2014 Ebola Virus Patient Advisory Introduction Ebola virus was first identified in Sudan and Zaire in 1976. It belongs to the family of Filoviridae. It causes Ebola Virus Disease (EVD), formerly