Transcript MYTHS AND REALITIES OF EBOLA VIRUS DISEASE

MYTHS AND REALITIES OF
EBOLA VIRUS DISEASE (Updated
on Oct 19, 2014)
Awareness and sensitization seminar
By
Faculty of Medicine
Kaduna State University
Presentation outline
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Introduction – Professor Elegba (Medical Microbiology)
Epidemiology – Dr. MA Kana (Community Medicine)
Treatment – Dr. H Bello-Manga (Haematology)
Prevention – Dr. F Adiri (Community Medicine)
Conclusion – Professor OY Elegba
Authors of the lecture on Myths and Realities of EVD
Introduction
Professor OY Elegba
Department of Medical Microbiology
Introduction
• Ebola Virus Disease is a severe, highly infectious and often rapidly
fatal illness that first appeared in 1976 almost simultaneously in
Nzara, Sudan and Yambuku in the Democratic republic of Congo.
• They were of two different strains, the Sudan strain and the Zaire
strain.
• The natural reservoir was never identified.
• The third strain was discovered during necropsy in 1994 in Cote
D’Ivoire , a fourth, from Uganda called the Bundibugyo strain in
2008 and a fifth strain, the Reston strain was discovered accidentally
in a military laboratory, Virginia USA also in 2008 from samples
brought from the Phillipines.
Introduction
• EVD is caused by Ebola Virus belonging to a group of
viruses responsible for Viral hemorrhagic fevers like
Lassa fever, Yellow fever, Marburg and Dengue fever.
• They are called ‘hemorrhagic’ because of the distinct
scary bleeding that occur during the course of the
illness.
• The word hemorrhagic is now left out in the case of
Ebola because the illness is not always accompanied
by bleeding.
Introduction
• The virus is a complex level four pathogen.
• It is an enveloped RNA virus belonging to the family
Filoviridae, genus Ebolaviridae and order
Mononegavirales.
• Four of the five strains are known to have caused
disease in man.
• These are Zaire Ebola virus (EBOV previously ZEBOV),
Sudan Ebola virus (SUDV previously SEBOV), Tai
forest Ebola virus formerly known as Cote D’Ivoire
Ebola virus (TAFV previously CIEBOV),
and
Bundibugyo Ebola virus (BDBV previously BEBOV.
Introduction
• The Reston strain has not been linked with any
infections in humans and is largely found in East
Asia.
• The filoviridae has two other members which are
Marburg and Cuevavirus with Marburg said to be
almost as vicious as Ebola.
• The different strains of Ebola have different
mortality rates ranging between 50-90%.
• The deadliest of the strain is the Zaire strain which is
responsible for the present outbreak.
Introduction
• There have been several outbreaks in central and
eastern Africa but
• these outbreaks were all contained within few
months.
• The total number of cases from all the previous
outbreaks were 2,387 and 1,590 deaths according to
World Health Organization in comparison with the the
present outbreak where over 4,000 cases and over
2,000 deaths have been recorded.
• Presently, about six African countries have been
affected including Nigeria, Liberia, Senegal, Cote
D’Ivoire, Guinea and the Democratic Republic of
Congo.
Introduction
• The virus is transmitted from infected animals that live in the rain
forest through contact with blood and other body secretions.
• It then spreads amongst humans in discriminatively.
• Health workers and family members of the sick being most at risk.
• It cannot be spread by airborne routes but can be spread by
droplets.
• Current outbreak is characterized by eruption of symptoms 4-6
days after exposure.
• The outbreak has almost ‘crushed’ the countries affected both
economically and health wise especially in the way it decimates
their health workers.
• It is also known that there is seropositivity in most regions of
Africa even in areas where no cases have been reported yet.
Introduction
• The origin of this virus is not known, but fruit bats
(Pteropodidae) are considered the most likely hosts
based on available evidence e.g the absence of
clinical signs in them is characteristic of a reservoir
specie.
• High lethality in monkeys, chimpanzees, and gorillas
make them unlikely natural reservoirs
• Evidence has implicated that wild pigs and porcupine
may also be natural hosts to the virus
Introduction
• This virus cause havoc by first evading the dendritic cells
and macrophages thereby confusing the immune system
of the body.
• With it’s continued replication, the more powerful
antibodies and cytokines are produced massively
resulting in what is referred to as ‘cytokine storm’
characterized by the symptoms and signs of the disease.
• This host response to the virus eventually affect all
organs, bursting blood vessels and causing bleeding both
internally and externally and also causing severe
dehydration from the vomiting and diarrhea resulting in
low blood pressure and death.
Introduction
• The current outbreak crossed porous borders and has been
going on for months.
• It has defied all predictions and it is impossible to predict how
it will end.
• Prof Langwick of Cornell University said, “Part of what we’re
seeing is our intense inter-connectedness in today’s world.
People travel. People need to travel to make their livelihoods,
to get food, to see relatives, to care for each other, for their
jobs and their profession. And I think we’re seeing a very
effective and devastating virus take advantage of the fact that
we are a very inter-connected world.”
Introduction
• There are no proven drugs or vaccines to treat or prevent
Ebola even though researches are going on along these
lines.
• The rarity of the disease and it’s prevalence in largely
poor African nations has not provided enough incentive
for big pharmaceutical companies to tackle this virus.
• Only small biotechnological, pharmaceutical firms, and
Government funded laboratories have been attracted to
this forage and taken up the challenge
• These companies and groups are often poorly funded
and do not have the where with all to tackle such
gigantic research programs and often may not record
huge successes.
Introduction
• The quick and horrible death of Ebola victims and the
potential threat of epidemics was captured in the
1994 best selling non-fiction thriller “The Hot Zone”
and “Outbreak”, the epidemic is no longer just a
threat, it is real
• It is how we will conquer it that is important, and
conquer it we must.
• This virus has been considered a possible vehicle for
bioterrorism.
• The US CDC and Prevention lists the virus as a
category A Bioterrorism agent alongside Anthrax and
Smallpox.
• All these must be addressed fully so that we will not
be caught “unprepared”.
Epidemiology of EVD
Dr. MA Kana
Department of Community Medicine
Myths
• There are claims that the following measures have
prophylactic or curative effect
• Chewing bitter cola (Gracinia cola or G. Afzelii)
• Eating ewedu; cochorus olitorius (a vegetable commonly
eaten as soup in Nigeria)
• Salt bath and drink
• Kerosene bath
• Bath with bleaching agent (sodium hypochlorite)
• Social media has been used to transmit information
about these myths
• Consequently, many have died in Nigeria as a result of
the ingestion of over concentrated salt drink
• Research and health education is required to verify and
highlight the danger of these claims
Where is Ebola virus found in nature?
• Because the natural reservoir of ebola viruses
has not yet been proven
• The manner in which the virus first appears in
a human at the start of an outbreak is unknown
• However, researchers have hypothesized that
the first patient becomes infected through
contact with an infected animal
Ebola Landscape
Where do cases of Ebola virus disease occur?
• In the past Confirmed cases of Ebola HF have been
reported in the Democratic Republic of the Congo,
Gabon, Sudan, the Ivory Coast, Uganda, and the
Republic of the Congo
• Ebola HF typically appears in sporadic outbreaks,
usually spread within a health-care setting (a
situation known as amplification)
• It is likely that sporadic, isolated cases occur as
well, but go unrecognized
• When an infection does occur in humans, the virus can be
spread in several ways to others
• The virus is spread through direct contact (through broken
skin or mucous membranes) with
• a sick person's blood or body fluids (urine, saliva, feces,
vomit, breast milk and semen)
• objects (such as needles) that have been contaminated
with infected body fluids; home – cooking utensils,
towels, bed linen
• infected animals
• Handling of corpse and burial rites
• Other modes of transmission are being investigated
• Healthcare workers and the family and friends in
close contact with Ebola patients are at the highest
risk of getting sick because they may come in
contact with infected blood or body fluids
• During outbreaks of EVD, the disease can spread
quickly within healthcare settings (such as a clinic or
hospital)
• Exposure to ebola viruses can occur in healthcare
settings where hospital staff are not wearing
appropriate protective equipment, such as masks,
gowns, and gloves
Transmission and Infectivity
Distribution
Ebola outbreaks, 1976-2014
• The 2014 Ebola outbreak is the largest Ebola
outbreak in history and the first in West Africa
• The current outbreak is affecting multiple countries
in West Africa with Guinea, Liberia and Sierra Leone
most affected
• To date, four countries, Nigeria, Senegal, Spain, and
the United States of America have reported a case or
cases imported from a country with widespread and
intense transmission
• In Nigeria, there have been 20 cases and eight
deaths, while in Senegal, there has been one case
• Nigeria and Senegal have contained its spread
Burden
Case Counts – 20th October 2014
Countries With Widespread And Intense Transmission
Country
Guinea
Liberia
Sierra Leone
Sierra Leone
Total
Case definition
Cases
Deaths
Confirmed
1217
671
Probable
Suspected
All
Confirmed
Probable
Suspected
All
Confirmed
Probable
Suspected
All
Confirmed
191
111
1519
*
*
*
4262
2977
37**
396
3410
2977
9191
191
0
862
*
*
*
2484
932
161**
107
1200
932
4546
Countries with Travel-associated Cases
Country
Senegal
Spain
USA
Total
Total cases
1
1
3
5
Laboratory confirmed cases
1
1
3
5
Total deaths
0
0
1
1
Countries with Localized Transmission
Country Total cases Laboratory confirmed cases Total deaths
Nigeria 20
19
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Ebola Outbreak in The Congo DRC
• As at 9 October 2014, and following a retrospective
laboratory review of cases, there have been 68 cases (38
confirmed, 28 probable, 2 suspected) of Ebola virus disease
(EVD) reported in the Democratic Republic of the Congo,
including eight among healthcare workers (HCWs)
• In total, 49 deaths have been reported, including eight
among HCWs. 852 contacts have now completed 21-day
follow‐up
• Of 269 contacts currently being monitored, all (100%) were
seen on 9 October, the last date for which data has been
reported.
• The last confirmed case was isolated on 4 October
• This outbreak is unrelated to that affecting Guinea, Liberia,
Nigeria, Sierra Leone, Spain, and the United States of
America.
Situation report – 20th October 2014
• In Nigeria, all 891 contacts have now completed
21‐day follow‐up (362 contacts in Lagos, 529 contacts
in Port Harcourt).
• A second EVD-negative sample was obtained from the
last confirmed case on 8 September (39 days ago)
• In Senegal, a second EVD‐negative sample was
obtained from the single confirmed case on 5
September (42 days ago)
• WHO officially declares the Ebola outbreak in Senegal
over on 17th October 2014
• In Spain, 72 people, including 13 high-risk contacts, are
being monitored.
• In the United States of America, 125 contacts are being
monitored.
Consequences of EVD
• Global pandemic - The combination of modern health systems
and the limited communicability of the virus make it unlikely to
spread in developed countries.
• Political right and freedom: On Aug. 6, Liberian President Ellen
Johnson Sirleaf declared a national emergency and suspended
constitutional rights for a 90-day period, citing “unrest” that
represents a “clear and present danger” to the country.
• Social - The virus has torn an already fragile society in affected
countries damaged from years of civil war
• Health system – overwhelmed resources and infrastructure,
loss of valuable human resource
• Economy – loss of revenue (tourism, trade, agriculture)
• Future of the impact: medical waste: scavenging and wildlife
migration, bioterrorism, national debt, political, economic and
social instability, threat to national security
Management of Ebola Virus
Disease(EVD)
Dr. Halima Bello-Manga
Department of Haematology
Management of EVD
The management of EVD is hinged on the following
principles;
• Proper history and Physical Examination
• Lab investigation(diagnosis).
• Supportive therapy
Medical History
EVD in its initial phase mimicks many other febrile illnesses e.g.
malaria, common cold, typhoid fever, thus a high index of
suspicion has to be shown.
A history of exposure to the disease in the last 2-21 days prior to
the onset of symptoms should be established.
Exposure could be in the form of ;
• Contact with a person diagnosed with the disease e.g. caring
for, visiting or even a attending the burial of an infected
person. (Patients at risk include; health care workers, family
and friends, traditional healers, morticians, etc)
• Hx of contact with contaminated materials used by a patient
diagnosed with the disease, e.g. bed linen, eating utensils,
medical equipment, etc.
Medical History Cont’d
• Contact
with
infected
animals
e.g
apes/chimpanzees, fruit bats, pigs ( especially
during processing) or eating.
• History of travel to endemic areas or contact
with someone with a hx of travel to such
areas.
Diagnosis
Once a case of EVD is suspected, the person is isolated
and samples are sent for diagnosis. Samples are
considered highly infectious and should be treated as
such.
Diagnostic investigations include;
• ELISA ( Ag capture, IgM Antibody)
• RT-PCR (confirmatory)
• IgM and IgG detection
• Virus isolation ( cell culture)
• Electron microscopy
• Immunohistochemistry( esp at post mortem).
Treatment
There is no specific treatment medicine/drug or vaccine
for EVD. (those available are in the trial phase) thus, the
hallmark for the Rx of the Dx remains SUPPORTIVE, which
include;
• Provision of IV fluids and correcting electrolyte
imbalances.
• Maintaining Oxygen saturation and blood pressure.
• Treating other secondary infections with
antimicrobials.
• Good nutrition.
• Use of anticoagulants in cases of DIC.
Treatment Cont’d
• Blood transfusion ( blood from patients that have
recovered from EVD) seems to help and the WHO has
approved its use in the treatment of patients.
• In addition to the above, in actively bleeding patients
with DIC, blood transfusion is used in replacing clotting
factors, red cells and platelets( esp if component
transfusion is done).
• Psychological support is a very important aspect in the
mx of ebola as the dx is associated with a lot of fear and
anxiety because of its high mortality rate.
Prognosis
EVD has a very high fatality rate of up to
90% (when little or no medical
intervention is instituted), with supportive
care, it reduces to about 50% or lower
with early appropriate intervention
Glimpses of Hope
• The current outbreak has caused a heightened
international response towards this emerging disease
and the world (mostly 1st world) has swung into action
towards getting a cure for the disease.
• The experimental drug ZMapp seems to be effective in
the treatment. ( not available for use now).
• At least 10 drugs and 2 vaccines against Ebola Virus dx
are currently under development (WHO).
Prevention and
Control
Dr. Faruk Adiri
Department of Community Medicine
Community Prevention and
Control
• Wash your hands regularly and properly – use soap, disinfectant
hand sanitizers
• Avoid physical contacts (hand shake, hugging, kissing)
• DO NOT touch, wash or kiss an infected person/ dead body
• Avoid their body fluids, including blood, vomit, faeces, urine
• DO NOT touch or eat “bush meat” and don’t eat bats
• Cook animal product thoroughly
4/2/2016
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Community prevention and
Control
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Call your medical centre early and tell them about your illness
Listen to the advice/key messages.
You may be sent to a special hospital
Keep away from others so they don’t get sick
Be especially careful of your vomit and diarrhoea
Safe burial practices
Practice general sanitation/hygiene
4/2/2016
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Prevention and Control-Animals
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During outbreaks quarantine premises/farms affected
PPE while handling animals
Cull infected animals
Incineration of carcasses
Supervise burials closely
Ban movements and sale of infected animals from affected areas
Active animal health surveillance
4/2/2016
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Prevention and Control-Humans
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Raise awareness with key messages
Avoid close contact (within 1 meter)
Proper hand washing
PPE while handling patients
Standard precaution/procedure for infection control
Safe burial practice (incineration)
4/2/2016
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Principles of Prevention
• Contact tracing
• Active case management
• Surveillance
Conclusion
• Ebola, supposedly does not travel through the air, making it
harder to transmit than other pathogens that cause epidemics
such as the Influenza virus.
• It has been established that with good health care practices,
the disease can be contained and may not be as vicious a killer
as other infections that have bedeviled us in the past.
• The Flu virus kills up to ½ a million every year and even as high
as 50 million during the great pandemic of 1917-1918, not to
mention emerging infectious diseases like resistant
tuberculosis, and even severe antibiotic resistance that has
now become a huge public health issue.
• So it is extremely important that we do not panic as fear can
drive sick people underground making contact tracing
impossible and aiding the spread to unaffected areas.
Conclusion
• The present outbreak started in Guinea and quickly spread to two
other West African countries which are about the poorest on earth.
• These countries are all inundated with poor health care, resulting in
challenges that are probably too heavy for them to bear.
• These, accompanied with the biases and prejudices of the local
populations, have made responses inadequate resulting into what
we have today.
• It may be necessary to involve All concerned, like, community
leaders, religious gurus and even traditional healers for effective
intervention as long as they are aware of the risks of Ebola as “good
healers are skillful in conceiving and promoting therapies that
intervene in the dynamics of biological diseases and human
relationships”
Conclusion
• Prof Langwick of Cornell University said that when people live
in an area with poor health facilities surrounded by death and
fear of death, it is an infuriating and terrifying situation which
can result in desperation.
• This desperation can result in distrust and violence as
happened recently in Liberia.
• How we care for our people especially in the face of danger is
very important and Prof Langwick described it very
appropriately as the ethics of living, the ethics of caring.
• This is the time to act and be prepared.
Conclusion
• As yet, we are lucky that Ebola is not in this part of the
country. So what is important now is for us to prevent it from
getting here and prepare for how we will control it if and
when it eventually gets here.
• We can play our parts by educating ALL around us, in our
homes, classes, religious settings etc etc.
• Correct politely, bad habits like spitting, sneezing without
covering the mouth and blowing of the nose publicly, and
teach people about basic infection control themes like
washing hands properly.
• Emphasis must be placed on how this disease is transmitted
especially amongst sick family members and about safe burial
practices.
Conclusion
• We must not let what happened in Liberia Guinea and Sierra
Leone be repeated here.
• Plan, Plan Plan. Identify health workers including
epidemiologists that will be capable of dealing with the
situation
• PPE and other essentials must be provided adequately. So also
we must have ambulances, and even train specially those who
will undertake burials.
• Link with local Government council chairmen so as to avoid
“shadow zones”
• Data collection is extremely important and epidemiological
surveillance must be instituted.
Conclusion
• Interestingly, caregivers at the front line bear the brunt of this
dreadful disease- a sobering fact being the demise of the five coauthors of an Ebola genome analysis study who died before even the
publication of their work.
• The research project published in the JOURNAL OF SCIENCE
sequenced the Ebola genome thus paving way for plotting mutation
and thereby finding the origin of the virus.
• The research has provided data about how the virus operates and
hopefully will help in the development of effective drugs and
vaccines.
• We must salute these fellows, MBALU FONNIE, ALEX MOGBOI, ALICE
KOROMA, MOHAMMED FULLAH AND SHEIK HUMARR KHAN who
died in the process of finding solution to the problem of Ebola.
• Coming nearer home, we must salute our health care workers like Dr
Stella Adadevoh and others who lost their lives in the process of
treating the Index case Patrick Sawyer..
Conclusion
•In a video which appeared in the White House website and
was aimed at West African countries struggling with the
outbreak, President Obama said “Stopping this disease won’t
be easy. But we know how to do it. You are not alone, together
we can treat those who are sick with respect and dignity. We
can save lives and our countries can work together to improve
Public Health so this kind of outbreak doesn’t happen again”
•AND FINALLY
LET US ALL PREVENT EBOLA
Acknowledgement
• The organizations and authors of reports and information we
cited for the development of this presentation
• World Health Organization Global Alert and Response (GAR)
Situation Reports
• World Health Organization Disease Outbreak News (DON)
• World Health Organization’s Epidemic and Pandemic Alert and
Response (EPR)
• Guinea: Ebola epidemic declared, MSF launches emergency
response
• http://www.cdc.gov/vhf/ebola/outbreaks/2014-westafrica/case-counts.html
• http://apps.who.int/iris/bitstream/10665/136645/1/roadmap
update17Oct14_eng.pdf?ua=1
• http://www.who.int/csr/disease/ebola/en/