EBOLA Haemorrhagic Fever Marburg Virus - UK Essen€¦ · MARBURG VIRUS outbreak in ANGOLA ......

1

Dr. Christa Kitz

Medical MissionInstitute Wuerzburg

Departement fortropical medicine& epidemic control

[email protected]

MARBURG VIRUSoutbreak in ANGOLA

MARBURG Haemorrhagic Fever

Confirmed outbreak or caseCountry at risk

RDC1994: 301998-00:149 (123)

N= number of cases(n) = number of death

Kenya1980: 21987: 1

South Africa1975: 3

Uganda1967 (singes)2007: 3,(1)

Germany1967: 30 (7)

Yougoslavia1967: 1

Sweden1995 1, (0)

AngolaOct. 2004 - Nov. 2005252 (227)

EBOLA Haemorrhagic Fever

Confirmed outbreak or caseCountry at risk

n = number of cases

Uganda200/1: 425, (53)

(n) = number of death

South Africa1996: 1

Sudan1976: 284, (53)1979: 34, (65)Ivory cost

1994: 1

Gabun1994: 44, (63)1996: 37, (57)1996: 60, (75)2001: 123, (79)

DRC1976: 318, (88)1977: 1, (100)1995: 317, (77)2007:

ROC 2001-4:4 outbreaks143, (90)

Viral hemorrhagic fever

Marburg Virus

MARBURGVIRUSOutbreakin ANGOLA

October 2004 –November 2005

Age in years of patients with fever and hemorrhage,Angola, 13 October 2004 – 28 March 2005, n=124

46

35

11

26

0

5

10

15

20

25

30

35

40

45

50

<1 ano 1-4 anos 5-15 anos >15 anos

73% of cases < 5years


Marburg Virus

Signs and symptoms of suspected cases ofMarburg VHF

Angola, 13 October 2004 – 24 March2005, n=104

100% 98%

64%

42%39%

32%

12%

0%

20%

40%

60%

80%

100%

Fever Hemorrhage Vomiting Diarrhoea Cough Icterus Headache

num

ber

ofc

ase

s


Marburg Virus

2

VHF Microbiology

Arenavirus Bunyavirus

South american HF CCHFLassa-Fiever Rift Valley FeverLCM Hantavirus

Filovirus FlavivirusEbola HF Tic-borne- Encephalitis Marburg

HF Kyasanur Forest DiseaseOmsk HFGelbfieber

Dengue HF


Marburg Virus


Marburg Virus

General Facts Marburg

► Viral hemorrhagic fever caused by the MarburgVirus out of the Filoviridae family

► natural reservoir still unknown► initial recognition 1967 (Germany, Yugoslavia)► confirmed cases in DRC, Uganda, Kenya, Angola► Imported cases to Germany, Yugoslavia, South Africa,

Sweden► sporadic outbreaks


Marburg Virus

VHF - EpidemiologyHemorrhagic Virus

►are all RNA-Virus;

►are dependant on a natural reservoir;

►are restricted in their geographic distribution;

► infect human beeings only occaisionally,can lead to local epidemics.

►animals and human beings are accidental hosts


Marburg Virus

► filovirus are among the most virulent pathogens thataffect human beings

► pathogenic mechanism:

- Infect and kill a broad variety of cell types- Elicit strong inflammatory response

- Disseminated intravascular coagulation- Multi organe failure


Marburg Virus

3

Lancet , Infectious deseases;Vol.4 August 2004


Marburg Virus

General Facts Marburg

►acute onset of illness►Affects all age groups and both sexes► incubation period 2-21 days (3-9)►mortality rate 25-90%


Marburg Virus

Transmission► Human-to-human:

– Direct contact with blood, tissues, secretionsor excretions of infected humans (care takers)

– Needle stick or cut

– nosocomial transmission frequently during outbreaks

– Inhalation of aerosolized virus not confirmed yet


Marburg Virus

feversevere headachemyalgiaextreme fatigueconjunctival injection

Filovirus HF clinical course

0 1 2 3 4 5 6 7 8 9 days

severe sore throatchest and abdominal painrashdiarrhoea, vomiting

hemorrhagehiccupssomnolence, delirium, coma

CFR 25-90%

Infectivity

Inkubationszeit (Tage)Inkubationszeit (Tage)00 55 1010 1515 2020

PestPest

GelbfieberGelbfieber

KrimKrim--KongoKongo --FieberFieber

RiftRift ValleyValley--FieberFieber

DengueDengue--FieberFieber

HantaHanta--FieberFieber

LassaLassa--FieberFieber

EbolaEbola--FieberFieber

MarburgMarburg--FieberFieber

AffenpockenAffenpocken

Maximale InkubationszeitMaximale Inkubationszeit

Typische InkubationszeitTypische Inkubationszeit

Inkubationszeiten

Umgang mit hochkontagiösen Erkrankungen

Differenzialdiagnostik

< 21 Tage

“Non – specific” symptoms

► Fever >38 C (axillary)► Headache► Muscle and joint pain► Sore throat► Severe weakness

Compare with malaria, typhoid…..


Marburg Virus

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Gastro-intestinal features

►Nausea►Vomiting►Diarrhoea►Abdominal pains► Increasing tender hepatomegaly


Marburg Virus

Complications►Profound hypovolaemic shock +

metabolic acidosis►Hypokalaemia►Hepatitis (biochemical and clinical)

Less common►Severe hemorrhage - cause?►pancreatitis►Adult Respiratory Distress syndrome


Marburg Virus

Treatment has no priority !► Breaking the chain of transmission:

To isolate the patient with best staffprotection is the major aim during aVHF outbreak in a rural african setting.


Marburg Virus

Treatment

► no standard treatment► supportive measures► balancing patients fluids and

electrolytes, maintaining oxygen statusand blood pressure

► treatment of any complicating infection


Marburg Virus

Treatment Viral hemorrhagic fever

Marburg Virus

Respiratory Distress Syndrome

Treatment Viral hemorrhagic fever

Marburg Virus

►Empiricaltreatment

► Practicaldifficulties

► Monitor therapywith pulseoximetry

survivors amonghypoxic patients ?

Oxygen

5

TreatmentViral hemorrhagic fever

Marburg Virus

Intensive care ?

► Endangering staff► Resources► Contamination of

equipment

Treatment► 5 litres of ORS / day/ adult


Marburg Virus

PRIORITIES ?► INTRAVENOUS

LINE

OR

► CLEANINGVOMITUSFROM theFLOOR


Marburg Virus

“Side effects”during an outbreak of

haemorrhagic fever


Marburg Virus


Marburg Virus

Empty hospitals:The collapse of the general health systhem due tofear killed by far more than the Marburg Virus

Outbreak control

Coordination

Epidemiology

Education

Clinicians

Laboratory

Media AuthoritiesDiagnostic

Clinical

Specimentransfer

Dead Sick

Exposed

SurveillanceInvestigation

Prediction

Healthpersonnel

Specialgroups

Generalpopulation

VectorReservoir

DecisionsInfrastructureRegulationsVaccinations etc


Marburg Virus

WHERE DOYOU FIT

IN?

6

GOARNGlobal Outbreak Alertand Response Network

► prepare for rapid deployment andcoordination of international resourcesin response to an outbreak ofinternational importance


Marburg Virus

GOARNhas four phases:

1. Outbreak Alert2. Activation of an International Response3. International Field Response

4. Post Response Activities

++Ministeryof health

+ +


Marburg Virus

++

Tasks of MSF during the outbreak

► Creating isolating facilities

► case management for patientswith Marburg haemorrhagic fever


Marburg Virus

1. PROTECT staff

2. PROTECT caregiver

3. PROTECT other suspect patients

4. Treat with ORAL REHYDRATIONAvoid IV Rehydration / drugs

5. Treat with painkillers andother symptomatic therapy

6. INTENSIVE CARE

Isolation WardREQUIRES DIFFERENT PRIORITIES


Marburg Virus

► Cap► Gown► Apron► Respirator Mask► Gloves► Goggles► boots

Personal ProtectiveEquipment (PPE)


Marburg Virus

7

Triage(Screening

Room)

Suspected ward Probable ward

Patients- by self admission- by mobile team

CaseDefinition


Marburg Virus

Burial team – early priority

Foto Kratzer MSF


Marburg Virus


Marburg Virus


Marburg VirusViral hemorrhagic fever

Marburg Virus

8


Marburg Virus


Marburg Virus

Avoid i.v. fluids and using of sharps


Marburg Virus

Strict control and disposal of sharps Cleaning and disinfectionHands Environment Laundry


Marburg Virus

Hypochloritesolution


Marburg VirusViral hemorrhagic fever

Marburg Virus

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Disinfection with Chlorine


Marburg Virus DiagnosticsViral hemorrhagic fever

Marburg Virus

DiagnosticsViral hemorrhagic fever

Marburg Virus Diagnostics

within a few days of the onset of symptoms:

► IGM ELISA► PCR► virus isolation

► after recovery (rare): IGM, IGG


Marburg Virus

COMMUNICATION WITH LABORATORYAND INTERPRETING THE BLOOD RESULTS:

► Marburg PCR pos.: transfer to confirmed ward► Marburg PCR neg + clinical picture does not fit:

Discharge appropriately► Marburg PCR neg + clinical concerns: Repeat test

• Liase daily with the laboratory.• Results should be interpreted along side the

clinical picture• Patients may have few symptoms or signs• or false negative tests


Marburg Virus

The psychological effects on patients, HCWs (not just front lineprofessionals), and their families.

Possible Risk factors:

• Loss of patients & colleagues

• Fear, uncertainty, confusion,• tiredness

• Sense of responsibility,• guilt & blame

Needs a culture of support.

Mental health:► Early psychological support

10

Foto Kratzer MSF


Marburg Virus


Marburg Virus

Vaccination:► 5.6.2005, 12.07.2006Steven Johnes & Heinz Feldmann;Nat. Microbiol. Lab. Winnipeg, Canada

► VSVAG/ MARVGP-Musoke vaccine :Attenuated, replication competent vaccineagainst MARV based on recombinant vesicularStomatitis virus expressingthe glycoprotein ofthe Musoke strain of MARV demonstratedcomplete protection against all known MARVstrains of Cynomolgus monkeys.

www.nature.com/naturemedicine,doi:10.1038/nm1258


Marburg VirusUmgang mit hochkontagiösenErkrankungen

Management vonPatienten mithochkontagiösenErkrankungen

Missionsärztliche Klinik WürzburgTropenmedizinische Abteilung

Salvatorstraße 797074 Würzburg

Tel. 0931 / 791 2821Email: [email protected]

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BerlinBerlin

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MMüü nchennchen

WWüürzburgrzburg

FrankfurtFrankfurt

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SaarbrSaarbr üückencken

DD üüsseldorfsseldorf

Kompetenzzentren

in Deutschland

Behandlungszentrum

Kompetenzzentrum

Trainingszentrum

Schutzkonzepte und Probenmanagement

Hochkontagiöse Erkrankungen

• Anamnese Aufenthalt in einem bekannten Endemiegebiet

Risiko-Exposition

ungewöhnliches Cluster von Fällen

• Klinik Fieber

typisches klinisches Bild

Inkubationszeit < 21 Tage

• Labor Malaria-Diagnostik negativ

LDH ,Thrombozyten

Umgang mit hochkontagiösen Erkrankungen

Differenzialdiagnostik

Infektions-Alarmgemeingefährliche, lebensbedrohliche

EBOLA Haemorrhagic Fever Marburg Virus - UK Essen€¦ · MARBURG VIRUS outbreak in ANGOLA ......

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