Transcript WHO Ebola Response Team. N Engl J Med 2014. DOI: 10.1056

A deadly Disease
 Solon, the sage of Athens, argued that one
couldn't judge a person's happiness until one
knew the manner of his death.
 The Greeks recognized that we're all destined to
die and that the best we can hope for is a death
that benefits our family or humanity.

NEJM -9/25/2014- Josh Mugele
EVD
 “The Ebola outbreak that is ravaging West Africa.
More than 400 health care workers in West Africa
have been infected with Ebola during the current
outbreak, and 233 had died as of 10/8.
 More than 8,900 people in Guinea, Liberia,
Nigeria, Senegal and Sierra Leone have
contracted Ebola since March, according to the
World Health Organization, making this the
biggest outbreak on record. More than 4,400
people have died.
Health Workers infected and Mortality
Ebola cases
in health
care
workers in
West Africa
Source:
WHO
416 Infected
Blue
233
Deaths( red)
Numbers of Confirmed and Probable Ebola Cases Reported Weekly from Guinea, Sierra
Leone, and Liberia from December 23, 2013, to August 11, 2014.
Briand S et al. N Engl J Med 2014;371:1180-1183.
Districts Affected by Ebola Virus Disease in Three Countries in Africa.
WHO Ebola Response Team. N Engl J Med 2014. DOI:
10.1056/NEJMoa1411100
Public Health Crisis
 Public health interventions including
characterizing the outbreak epidemiology,
contact tracing, social mobilization, and public
education are essential steps in stopping Ebola
and will ultimately save many more lives than
can be saved by individual patient care.
 The high mortality associated with Ebola,
however, threatens the ability to perform many of
these tasks.
 NEJM 9/2014 Lamontagne F
Structure of Ebolavirus.
Feldmann H. N Engl J Med 2014. DOI: 10.1056/NEJMp1405314
Filoviridae
 Ebola is caused by infection with a virus of the family of
Filoviridae genus Ebolavirus.
 There are five identified Ebola virus species, four of
which are known to cause disease in humans: Ebola
virus (Zaire ebolavirus); Sudan virus (Sudan ebolavirus);
Taï Forest virus (Taï Forest ebolavirus, formerly Côte
d’Ivoire ebolavirus); and Bundibugyo virus (Bundibugyo
ebolavirus). The fifth, Reston virus (Reston ebolavirus),
has caused disease in nonhuman primates, but not in
humans.
Transmission
 The Ebola virus infects cells by attaching
itself to the cell receptor, punching into the
cell membrane and injecting a viral RNA
in the cytoplasm.
 The RNA instructs the nucleus DNA to
make viral copies using the cell
machinery. The new copies of the Ebola
virus are released into the blood stream
to infect other cells. The virus can be
found in all body fluids and skin.
Ebola Virus Disease
 Fatal cases were associated with severe
abnormalities of liver and kidney function,
marked CD8 lymphocytopenia and elevated
plasma levels of several cytokines and
chemokines (IL-1 , IL-1RA, IL-6, MCP-1, MCSF
and MIP-1 ).
 Higher levels of sCD40L were seen in patients
who survived compared with those who died.
(sCD40L is a member of the TNF superfamily
that has prothrombotic and pro-inflammatory
activities.)
Ebola Virus Disease
 In transgenic mice, I- B -mediated blockade of

NF- B-activation had no effect on the increase in proinflammatory cytokines in plasma or in the four target
organs, but biomarkers of endothelial activation (ICAM1,VCAM-1) in these organs were reduced.
 As a result, multi-organ failure did not develop and
survival improved. Thus, blockade of NF- B activation
preserved endothelial barrier integrity, demonstrating
that endothelial cells were the targets, not necessarily
the origin, of sepsis-induced inflammation.
Clinical symptomes

“ EVD presents much as many other viral
infections do, with nonspecific signs such as
fever, asthenia, body aches but a rash.
 After a few days, however, the predominant
clinical syndrome is a severe gastrointestinal
illness with vomiting, hematemesis and diarrhea.


Volume depletion with a range of metabolic
disorders ensues, and hypovolemic shock
ultimately occurs”.
Ebola Virus Disease
 Evidence of endothelial activation (elevated
levels of sICAM) was observed in those with
hemorrhagic disease, and abnormal elevations in
biomarkers of coagulopathy (thrombomodulin,
Ddimer) were seen in those who died.
 These observations of endothelial dysfunction
and coagulopathy confirm the findings of other
studies of clinical EVD and experimental Ebola
virus infection of non-human primates .
Moreover, similar findings are seen in
experimental and human sepsis .
Diagnosis /Treatment
 Blood test to detect the Virus ( Elisa, Western
blot)
 No treatment available
 In US Zmapp a cocktail of Antibodies
Transfusions
 WHO issued new interim guidance on "Use of
convalescent whole blood or plasma collected
from patients recovered from Ebola virus disease
for transfusion during outbreaks".
 The document is addressed to national health
authorities and blood transfusion services.
Fluid Ressucitation is
Key

Intravenous catheters, fluids, and electrolyte
replacement are readily available but thus far are
being used much too sparingly.
 When patients can no longer drink, placement of
an intravenous catheter and delivery of
appropriate replacement solutions are required,
but we have seen many critically ill patients die
without adequate intravenous fluid resuscitation
Recovery
 Recovery from Ebola depends on good
supportive care and the patient’s immune
response. People who recover from Ebola
infection develop antibodies that last for at least
10 years, possibly longer.

Do not know people who recover are immune
for life or if they can become infected with a
different species of Ebola. Some people who
have recovered from Ebola have developed longterm complications, such as joint and vision
problems.
International Aids
 Medecins Sans Frontieres
 Chinese Field Hospitals
 US Military- CDC
 French active in Guinee
 Partners in Health
 Cuban Doctors are in fields
 Russian and British group
For more Info

Centers for Disease Control
and
Prevention www.cdc.gov/vhf/ebol
a
CDC latest advice focus on PPE
With no skin exposure