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Index Cases
Guinea December 2013 - March 2014
Index Case
1st victim, 2-year-old child in Guinea. Family hunted bat. Died
12/6/13.
Women attending a funeral of a tradition healer who treated
Guinean Ebola patients, spread it to Sierra Leone…
Ebola virus disease (EVD) cumulative
incidence* — West Africa, October 18, 2014
How Many Cases?
As of Sep 22, 2014

As of 1/19/15, 21,649 people in Guinea, Liberia, Nigeria, Senegal, Sierra Leone, and Mali
have contracted Ebola since March, 2014

Largest outbreak on record.

More than 8609 people have died
file:///C:/Users/cprice/Documents/What%20You%20Need%20to%20Kn
ow%20About%20the%20Ebola%20Outbreak%20-%20NYTimes.com.html
Expected # cases in Liberia and
Sierra Leone
Best-case scenario
4
0
2
Hundreds of Thousands
10
8
If the disease continues
spreading without
effective intervention
6
Assumes 70 percent of patients are
treated in settings that confine the
illness and that the dead are
buried safely. About 18 percent of
patients in Liberia and 40 percent
in Sierra Leone are being treated in
appropriate settings.
12
14
11,000-27,000 cases through Jan. 20
Worst-case Scenario
537,000-1.4 M cases through Jan. 20
http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.htm
MMWR September 23, 2014 / 63(Early Release);1-14
Population
Liberia – 4.29M, Guinea 11.75M, Sierra
Leone 6.09M
1
15
150 250
500
SENEGAL
MALI
GUINEABISSAU
GUINEA
SIERRA
LEONE
Guéckédou
IVORY
COAST
LIBERIA
150 Miles
Kenema
NIGERIA
Monrovia
Areas affected as of Sept. 17
Comparison to Past Ebola
Outbreaks
1976 (virus discovered)
2nd-worst year
Sudan,
Democratic Republic of Congo
602 cases (dark orange)
431 deaths (light orange)
1995
2000
2007
5th
Democratic
Republic
of Congo
3rd
Uganda
4th
Uganda, Democratic
Republic of Congo
425 cases
224 deaths
413 cases
224 deaths
315 cases
254 deaths
2014
1st
Sierra Leone,
Liberia, Guinea,
Nigeria
4,963 cases
2,453 deaths
as of Sept. 13
http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html?_r=0#history
Previous Ebola Outbreaks
WHEN
WHERE
# CASES
MORTALITY
1976
Zaire
318
88%
1977
Sudan
34
65%
1994
Gabon
52
60%
1995
Congo
315
80%
1996
Gabon
37
57%
2000-01
Uganda
425
53%
2001-02
Gabon and
Congo
122
79%
2002-03
Congo
143
89%
2003
Congo
35
83%
2004
S. Sudan
17
41%
2007
DRC
264
71%
2007-08
Uganda
149
25%
2008-09
DRC
32
47%
2012-13
DRC/Uganda
53
38%
Why so Bad?

It came to cities

Burial rituals

Culinary practices – Bushmeat, bats

Patients hiding, distrustful, lack of knowledge

Lack of adequate public sanitation

Wide geographic spread, highly mobile population

Lack of resources to isolate and do contact tracing
THE VIRUS HAS NOT MUTATED TO BECOME AIRBORNE!
19 September 2014 Last updated at 04:58 ET
Ebola outbreak: Guinea health team killed
Some villagers in Guinea have been scared by the appearance of
health workers trying to combat Ebola
Some of the bodies - of health workers, local officials and journalists - were found in a septic
tank in a village school near the city of Nzerekore.
Correspondents say many villagers are suspicious of official attempts to combat the disease.
http://www.bbc.com/news/world-africa-29256443
JFK Hospital in Monrovia
Any positive signs?

Numbers are WAY OFF and VASTLY UNDERESTIMATE
the epidemic’s magnitude BUT…

Number of new cases in some epicenters of outbreak have
been dropping over weeks-months. Case incidence rate has
declined in Guinea since 12/14 and in Liberia since 10/14

Improvement in safe burials

MSF withdrawing from some areas

Mali: outbreak over
Ebola in HCW

W. African HCW: 416 HCW, 233 deaths

Medecins Sans Frontieres HCW: 700 HC workers deployed,
3 infected, 0 deaths
We may continue to see cases in HCW
We can protect ourselves
Data from Stanford: 8 - 130 cases in US by end of
2014
Ebola in the US: 10 cases

Emory:

Kent Brantly, MD – HCW – ZMapp – recovered

Nancy Writebol – HCW – Zmapp – recovered

Ian Crozier, MD – HCW – recovered

Amber Vinson – HCW in TX of ED – recovered

NIH

Nina Pham – HCW of ED – transfusion of Brantly - recovered

NE Med Ctr

Rick Sarca, MD – HCW – transfusion of Brantly and TKM – recovered

Ashoka Mukpo – NBC cameraman – tx and brincidofovir – recovered

Martin Salia, MD. Sierra Leonian, lives in US, symptoms in S.L – Zmapp and
plasma – DIED 11/17

NY/Bellevue

Craig Spencer, MD – HCW – brincidofovir - in hospital

Texas Presbyterian

Eric Duncan, Liberian tourist – brincidofovir - DIED
Ebola in Travelers

86 of 1993 travelers to the US from Ebola-affected areas were
referred for additional evaluation by the CDC. None
diagnosed with EVD.

Of 80,000 air passengers from EVD-affected countries
between August and October, 2014, none who were denied
travel because of screening have been reported as having
Ebola, and of those allowed to travel, none are known to
have had EVD symptoms during travel.
Ebola in Africans Here



No direct flights to or from Africa to DIA.
DIA is a major connection hub for flights from Chicago
O’Hare.
Signs are posted
Dallas Case
The story

9/14 Eric Duncan cared for
pregnant woman who died

9/19 He flew to Texas

9/24 Symptoms began

9/25 Dallas ER: T103, abd pain,
nausea

9/28 Admitted ? Lag to isolation

9/30 Ebola confirmed

10/8 died

10/11 and 10/15 nurses positive
What we learned

There should be designated
hospitals and designated
caregivers

In Denver: designated hospitals
are Denver Health, University of
Colorado, Children’s

Ebola is only contagious when
someone has symptoms and is ill
R-naught
Most Deadly Viruses
1.
SMALLPOX: Killed 300 million in 20th century, wiped out in
1979
2.
INFLUENZA: Killed 57 million since 1918, 250,000 deaths
/year from seasonal flu
3.
HIV: killed 39 million since 1981
4.
ROTAVIRUS: 450,000 deaths / year
5.
MEASLES: 122,000 deaths / year
6.
YELLOW FEVER: 122,000 deaths / year
7.
DENGUE: 22,000 deaths / year
Ebola Virus

Zoonotic virus – bats the most likely reservoir, although
species unknown

Spillover event from infected wild animals (e.g., fruit bats,
monkey, duiker) to humans, followed by human-human
transmission
Reservoir
Hemorrhagic fevers

FILOVIRUSES


ARENAVIRUSES


Chapare HF (rural Bolivia),
Lujo HF (S Africa), Lassa
fever
BUNYAVIRUSES


Marburg and Ebola
Crimean-Congo HF, HFRS,
Hanta, Puumala, Rift Valley
Fever…
FLAVIVIRUSES

Dengue, Yellow Fever,
OMSK, Alkhurma

All are RNA Viruses

All are covered or enveloped

All have a Natural Reservoir

They are geographically
distributed by the reservoir
Death rates of 5 Ebola Species
Transmission

Highly infectious but not highly transmissible

Index case likely becomes infected through contact
with an infected animal

Once an infection occurs in humans, the virus spreads
through direct contact (through broken skin or mucous
membranes) with



A sick person's blood or body fluids (urine, saliva, feces,
vomit, and semen)
Objects (such as gloves, needles) that have been contaminated
with infected body fluids (virus can survive in environment
many days)
Infected animals
http://www.cdc.gov/vhf/ebola/transmission/index.html
Sierra Leone NEJM,
2014:371:1481-95
Hemorrhagic signs
5.7%
Symptoms

Acute onset; typically 8–10 days after exposure
(range 2–21 days)

Signs and symptoms
 Initial: Fever, chills, myalgia, malaise, anorexia
 After 5 days: GI symptoms, such as nausea, vomiting, watery
diarrhea, abdominal pain
 Other: Headache, conjunctivitis, hiccups, rash, chest pain,
shortness of breath, confusion, seizures
 Hemorrhagic symptoms in 5-20% of cases

Other possible infectious causes of symptoms
 Malaria, typhoid fever, meningococcemia, Lassa fever and other
bacterial infections (e.g., pneumonia) – all very common in
Africa
Examples of Hemorrhagic Signs
Hematemesis
Gingival bleeding
Bleeding at IV Site
Diagnosis

Laboratory findings may include low white blood cell and
platelet counts and elevated liver enzymes.

Virus detectable by real-time RT-PCR from 3-10 days after
symptoms appear



Collect a minimum volume of 4mL whole blood (preserved
with EDTA) in plastic collection tubes
All suspect cases should be immediately reported to the
CDPHE Disease Control and Environmental Epidemiology
Branch for approval for diagnostic testing
Testing should encompass evaluation for other sources of
febrile illness in the returned traveler
Treatment

Severely ill patients require intensive
supportive care. Patients are frequently
dehydrated and require oral rehydration with
solutions containing electrolytes or intravenous
fluids.

No specific treatment is available.

New drug therapies are being evaluated.
Potential New Treatments

Vaccines – several in development, GSK one starting trial

Zmapp: 3 monoclonal synthetic antibodies that bind to protein of
Ebola

Brincidofovir: safety studies OK, works for other viruses, “shot in
the dark”

TKM Ebola: interferes with Ebola’s RNA

Favipiravir: Used in Jaoan to treat Flu, shows promise against
Ebola in animals

Transfusions of plasma from recovered Ebola patient (Emory
stockpiling)

Amiodarone – ion channel blockers inhibit filoviral cell entry
Inhaled Ebola Vaccine

Inhaled Ebola vaccine may offer long-term protection from vinhaled Ebola
vaccine may offer long-term protection from virus The University of Texas
at Austin News, 11/07/2014

A potentially breathable, respiratory vaccine in development has been shown
to provide long–term protection for non–human primates against the deadly
Ebola virus, as reported this week in the online edition of the journal
Molecular Pharmaceutics. Results from a recent pre–clinical study represent
the only proof to date that a single dose of a non–injectable vaccine platform
for Ebola is long lasting, which could have significant global implications in
controlling future outbreaks. A breathable vaccine could surmount the
logistical obstacles of storing, transporting and administering injectable
vaccines in parts of Africa most afflicted by the virus. Professor Maria Croyle
and graduate student Kristina Jonsson–Schmunk of The University of Texas at
Austin’s College of Pharmacy, who co–authored the paper with Dr. Gary
Kobinger and his team at the National Microbiology Laboratory in Winnipeg,
will make a presentation on the newly published work at the 2014 American
Association of Pharmaceutical Scientists (AAPS) Annual Meeting and
Exposition.rus The University of Texas at Austin News, 11/07/2014
Ask!
dAsky
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dddindthedpastd21ddays.
ddAnddexposure
dddTodpersonsdwi thdEbola.
ddAnddsymptomsd
dddFever,dheadache,djoi ntdFdmuscledaches,dweak ness,dddd
dddfati gue,ddi arrhea,dvomi ti ng,dstomachdpai n,dlossdofdd
dddappeti te,dsometi mesdbleedi n g.
ISOLATEyy
yyyIfytravelyoryexposureycriteriayareymetyandytheypersonyhasyy
yyysymptomsyofyEbola2yplaceytheypersonyinyayprivateyroom(
CALLyUS
yyyNotifyyhospitalyleadershipyandyCDPHEyaty3) 3(692(27) ) y
yyy3afteryhoursy3) 3(37) (93950(
w w w (colorado(go v5ebola
CDPHE
Flyer
Algorithm
CDPHE: ASK, ISOLATE, CALL

ASK everyone, everytime




ISOLATE if travel or exposure history AND symptoms


About travel to Sierra Leone, Guinea or Liberia within 21
days.
About exposure to anyone with Ebola
About signs and symptoms
Private room, private bath, limit personnel and determine PPE
Call: Notify Infection Control and Task Force. Call CDPHE
303-692-2700 (afterhours: 303-370-9395)
CDC Guidance for Infection Control
Component
Patient Placement
Personal Protective
Equipment (PPE)
(special attention to donning
and doffing sequence)
Patient Care Equipment
Recommendation
•Single patient room (containing a private bathroom) with the
door closed
•Facilities should maintain a log of all persons entering the
patient's room
•All persons entering the patient room should wear at least:
•Gloves
•Gown (fluid resistant or impermeable)
•Eye protection (goggles or face shield)
•Facemask
•Additional PPE might be required in certain situations (e.g.,
copious amounts of blood, other body fluids, vomit, or feces
present in the environment), including but not limited to:
•Double gloving
•Disposable shoe covers
•Leg coverings
•N95 respirator or higher (PAPR) for aerosol
generating proc.
•Dedicated medical equipment (preferably disposable, when
possible)
•Non-dedicated, non-disposable equipment used for patient
care should be cleaned and disinfected according to
manufacturer's instructions
http://www.medscape.com/viewarticle/8
33907
Donning and Doffing of PPE video
Keys to PPE

Always work in pairs, have an observer

Those using PPE must be comfortable with the PPE

Doffing to avoid contamination



Be tedious – takes 15 minutes
Don’t touch face
Perform hand hygiene between each step
CDC Ebola Guidance

Ambulatory Care Evaluation of Patients with Possible Ebola Virus Disease (Ebola)[PDF 1 page]

Infection Prevention and Control for Hospitalized Patients with Known or Suspected
Ebola in U.S. Hospitals

Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During
Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including
Procedures for Putting On (Donning) and Removing (Doffing)

Environmental Infection Control in Hospitals for Ebola Virus – Interim Guidance

Ebola-Associated Waste Management

Recommendations for Safely Performing Acute Hemodialysis in Patients with Ebola
Virus Disease in U.S. Hospitals

Safe Handling of Human Remains of Ebola Patients in U. S. Hospitals and Mortuaries
Ebola or Flu
Websites

www.colorado.gov/ebola

COHELP (for patients) 303-389-1687 or 1-877-462-2911

www.cdc.gov/ebola


Checklist for Patients Being Evaluated for Ebola Virus
Disease (EVD) in the United States
Ebola Virus Disease (Ebola) Algorithm for Evaluation of the
Returned Traveler