PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN

(PHEIC)

EBOLA (EVD)

-Dr.R.PARTHASARATHI,M.DDept of Community Medicine

PHEIC

Defined in IHR 2005 as

‘an extraordinary public health event which constitutes a public health risk to other States through the international spread of disease and may require a coordinated international response’.

Such events are required to be assessed for notification to WHO using a decision instrument

PHEIC

4 decision criteria used in assessment of a public health event are :

(a) The seriousness of the event’s public health impact.(b) The unusual or unexpected nature of the event.(c) The risk of international spread.(d) The risk that travel or trade restrictions will be

imposed by other countries.Any 2 criteria Notify WHO

A single case of smallpox, poliomyelitis (WPV), human influenza caused by a new subtype and SARS must be immediately notified to WHO, irrespective of the context in which it occurs.

PHEIC

EBOLA VIRUS DISEASE (EVD)

It is one of the world’s most virulent diseases. Formerly known as Ebola haemorrhagic fever. Severe, often fatal illness, with a case fatality rate

of up to 90%. EVD outbreaks occur primarily in remote villages in

Central and West Africa, near tropical rainforests.

All agents that cause viral hemorrhagic fever syndrome are RNA viruses with a lipid envelope, all are considered zoonoses, all damage the microvasculature, resulting in increased vascular permeability, and all are members of one of four families: Arenaviridae, Bunyaviridae, Flaviviridae, and Filoviridae.

EBOLA VIRUS

Ebola first appeared in 1976 in 2 simultaneous outbreaks in Nzara, Sudan, and in Yambuku, Congo.

Yambuku village near the Ebola River Family:Filoviridae  Genus: Ebolavirus (3 members Marburgvirus,

Cuevavirus) Species:5 types

1. Bundibugyo ebolavirus (BDBV)2. Zaire ebolavirus (EBOV)3. Sudan ebolavirus (SUDV)4. Reston ebolavirus (RESTV)5. Taï Forest ebolavirus (TAFV).

EBOLA SPECIES

BDBV, EBOV, and SUDV have been associated with large EVD outbreaks in Africa.

The RESTV species, found in Philippines and the People’s Republic of China, can infect humans, but no illness or death in humans from this species has been reported to date.

ENVIRONMENTAL PERSISTANCE

Under ideal conditions, Ebola virus could remain active for up to 6 days.

Persistence of Ebola virus in the patient care environment is short – within 24 hours

Ebola virus was found, relative to other enveloped viruses, to be quite sensitive to inactivation by ultraviolet light and drying; yet sub-populations did persist in organic debris.

2014 OUTBREAK

On 8 August 2014, WHO declared the Ebola virus disease outbreak in West Africa a Public Health Emergency of International Concern (PHEIC) in accordance with the IHR 2005.

The current EVD outbreak is believed to have begun in Guinea in December 2013. 

Viral sequencing shows strong homology (98%) with Zaïre Ebolavirus (EBOV)

As of August 16, 2014, 2,240 suspected or confirmed cases,

including 1383 laboratory-confirmed cases and

1,229 deaths

2014 OUTBREAK

TRANSMISSION

Natural Host: Fruit bats of the Pteropodidae family

(Hypsignathus monstrosus, Epomops franqueti, and Myonycteris torquata)

Source of human infection: Blood, secretions, organs, or other bodily fluids of infected animals, Bushmeat

(handling of infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope, and porcupines found ill or dead or in the rainforest)

EPIDEMICEPIZOOTIC ENZOOTIC

HUMAN-TO-HUMAN TRANSMISSION Direct contact (through broken skin or mucous

membranes) with the blood, secretions, organs or other bodily fluids of infected people

Indirect contact with environments contaminated with fluids.

Burial ceremonies (mourners direct contact with corpse) The patients become contagious once symptoms begin.

They are not contagious during incubation period. Virus transmitted through the semen for up to 7 weeks

after recovery from illness. Health-care workers have frequently been infected

INCUBATION PERIOD: 2 to 21 daysCASE FATALITY RATE: 53%

All cases in the current outbreak- H2H

SIGNS AND SYMPTOMS

PRODROME:sudden onset of fever, intense weakness,

muscle pain, headache and sore throat. VIRAEMIA:

vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases, both internal and

external bleeding (DIC)

Patients are infectious as long as their blood and secretions contain the virus.

PERSON UNDER INVESTIGATION (PUI)

A person who has both consistent symptoms & risk factors: 1) Clinical criteria, which includes fever of greater than 38.6

degrees Celsius or 101.5 degrees Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhoea, abdominal pain, or unexplained haemorrhage;

AND 2) Epidemiologic risk factors within the past 21 days before the

onset of symptoms, such as contact with blood or other body fluids or human remains of a patient known to have or suspected to have EVD; residence in—or travel to—an area where EVD transmission is active; or direct handling of bats, rodents, or primates from disease-endemic areas.

Probable Case A PUI who is a contact of an EVD case with

either a high or low risk exposure.

Confirmed Case A case with laboratory confirmed diagnostic

evidence of Ebola virus infection.

CASE DEFINITION FOR EVD

Contacts have different levels of exposure risk, as follows:

High risk exposuresA high risk exposure includes any of the

following: Percutaneous, e.g. the needle stick, or mucous

membrane exposure to body fluids of EVD patient Direct care or exposure to body fluids of an EVD

patient without appropriate PPE Laboratory worker processing body fluids of confirmed

EVD patients without appropriate PPE or standard biosafety precautions

Participation in funeral rites which include direct exposure to human remains in the geographic area where outbreak is occurring without appropriate PPE

CONTACTS OF AN EVD CASE

Low risk exposuresA Low risk exposure includes any of the

following: Household member or other casual contact* with

an EVD patient Providing patient care or casual contact* without

high-risk exposure with EVD patients in health care facilities in EVD outbreak affected countries

No known exposure Persons with no known exposure were present in

an EVD outbreak affected country in the past 21 days with no low risk or high risk exposures.

CONTACTS OF AN EVD CASE

Defined as being within approximately 3 feet (1 meter) or

within the room or care area for a prolonged period of time (e.g., healthcare personnel, household members) while not wearing PPE

OR having direct brief contact (e.g., shaking hands)

with an EVD case while not wearing PPE

Brief interactions, such as walking by a person or moving through a hospital, do not constitute casual contact.

*CASUAL CONTACT

Always rule outOther Viral Haemorrhagic Fevers.MalariaYellow feverDengue LeptospirosisTyphoid FeverShigellosisRickettsiosisRelapsing FeverCholeraPlagueHepatitis

DIFFERENTIAL DIAGNOSIS

Thrombocytopenia, leukopenia with a pronounced lymphopenia.

Neutrophilia develops after several days Elevations in aspartate aminotransferase and alanine

aminotransferase. Bilirubin may be normal or slightly elevated. With onset of anuria, BUN and serum creatinine rise. Terminally ill patients : Tachypnea, metabolic acidosis

Definitive diagnosis : Isolation of the virus in tissue culture or PCR.

LABORATORY FINDINGS

Definitive diagnosis by Antibody-capture ELISA Antigen detection tests Serum neutralization test- serological surveys RT-PCR assay Virus isolation by cell culture. Skin biopsies in postmortem diagnosis of infection

with Ebola virus

Blood samples collection and transport according to guidelines and to WHO accredited labs only

NCDC, New Delhi and NIV,Pune in our country

LABORATORY DIAGNOSIS

Highly sensitive and confirmatory tests

Isolate the patient • Triage rapidly to a separate room /holding area • The holding area should be:

- Distant from other crowded areas - Well ventilated - Have adequate sunlight

Notify the State and National Authority Clinical management: predominantly Supportive and

focus on early recognition of complications with appropriate symptom management.

Antipyretics, Anti-emetics, Rehydration therapy, Blood transfusion, Oxygen , Respiratory support and Anti-convulsants as needed

No specific drug treatment

MANAGEMENT

Zmapp Combination of monoclonal antibodies which binds

with outer glycoprotein of the virus and prevents its entry to the host cells

Efficacy yet to be proven, no clinical trials done till date.

In early trials- all Rhesus monkeys infected with virus survived when administered 1 hour after infection.

Produced using specific tobacco plants.  WHO authorised this treatment for a small group on

11th August,2014. Even if successful, stocks will not be available till

2015

Tekmira, a Canadian biotech company, has begun early human trials of a new drug 

Experimental treatment

NOT YET

An adenovirus-vectored Ebola glycoprotein gene has proved protective in nonhuman primates and is undergoing phase 1 trials in humans.

An experimental vesicular stomatitis virus–based vaccine has protected macaques when given both before and after infection with the Zaire Ebola virus.

Vaccine

Isolation and Quarantine, Notification Contact Tracing Standard Precautions–At All Times, For All

Patients Barrier nursing Hand washing Personal Protective Equipment (PPE) Injection safety, Safe sex practices Concomitant & Terminal Disinfection,

Sterilisation Following SOP for Blood sample collection and

Transport Appropriate Hospital Waste management Enhanced Surveillance Health Education: Myths

PREVENTION

PUTTING ON

PPE

REMOVE

PPE

STRATEGY FOR PREVENTION AND CONTROL

AIR TRAVELLERS

Exit screening and communication efforts on the ground in West Africa to prevent sick travellers from getting on planes.

Airports in Guinea, Liberia, and Sierra Leone are screening outbound travellers for Ebola symptoms, including fever, and passengers are required to respond to a health questionnaire.

Avoid non-essential travel- WHO Some countries have banned flights and entry to

people from the affected regions.

INDIA

No confirmed case of Ebola till date. The World Health Organisation (WHO) had informed

that one Indian passenger had travelled on the same flight in which an Ebola virus patient (a foreign national) was travelling from Monrovia to Lagos. He was tracked and found healthy.

 24-hour 'Emergency Operation Centre‘:011-23061469, 3205 and 1302

TN Helpline- 104 Rumours from Karnataka-WhatsApp message that

student from the National Institute of Technology Karnataka (NITK) in Dakshina Kannada districthad ebola and succumbed to it

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