Awareness and sensitization seminar ByFaculty of MedicineKaduna State University

MYTHS AND REALITIES OF EBOLA VIRUS DISEASE (Updated

on Oct 19, 2014)

Presentation outline• 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 EVDDr. MA KanaDepartment 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

BurdenCase Counts – 20th October 2014

Countries With Widespread And Intense Transmission

Country Case definition Cases DeathsGuinea Confirmed 1217 671

Probable 191 191Suspected 111 0All 1519 862

Liberia Confirmed * *Probable * *Suspected * *All 4262 2484

Sierra Leone Confirmed 2977 932Probable 37** 161**Suspected 396 107All 3410 1200

Sierra Leone Confirmed 2977 932Total   9191 4546

Countries with Travel-associated Cases

Country Total cases Laboratory confirmed cases Total deaths Senegal 1 1 0Spain 1 1 0USA 3 3 1Total 5 5 1

Countries with Localized Transmission

Country Total cases Laboratory confirmed cases Total deaths Nigeria 20 19 8

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-MangaDepartment 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 HistoryEVD 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.

DiagnosisOnce 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).

TreatmentThere 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 ControlDr. Faruk AdiriDepartment 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

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Community prevention and Control• 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

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Prevention and Control-Animals

• 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

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Prevention and Control-Humans

• 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)

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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 co-authors 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-west-africa/c

ase-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/