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
THANK YOU
PREVENTION IS THE ONLY CURE
THANK YOU...