Dr. Wagdy AminTraining officer

G.D For Chest Diseases and Tuberculosis

Ministry of Health & Population

drwagdy@yahoo.com

Epidemic viruses

• Severe Acute Respiratory Syndrome (SARS)

• AH5N1

• AH1N1

• Corona

• Ebola

Introduction

Seasonal Influenza

• Influenza (the flu) is a contagiousrespiratory illness caused by influenzaviruses.

• It can cause mild to severe illness, and attimes can lead to death.

Influenza A• The Influenza A virus subtypes that have been confirmed in

humans, ordered by the number of known human pandemic deaths, are:

• H1N1 caused "Spanish Flu" and 2009 H1N1 outbreak

• H2N2 caused "Asian Flu"

• H3N2 caused "Hong Kong Flu"

• H5N1 is "bird flu", endemic in avian

• H7N7 has unusual zoonotic potential

• H1N2 is currently endemic in humans and pigs

• H9N2, H7N2, H7N3, H10N7 (avian)

• The Influenza A virus subtypes are labeled according to an H number (for hemagglutinin) and an N number (for neuraminidase).

Influenza B

• Influenza B viruses are only known to infect humans .

• influenza B viruses evolve slower than A viruses and

faster than C viruses.

• Influenza virus B mutates at a rate 2-3 times lower than

type A.

Influenza C

• Influenza C viruses are known to infect humans and pigs.

• Flu due to the type C species is rare compared to types A or B, but can be severe and can cause local epidemics.

H5N1 “Avian/Bird Flu”• Avian influenza is an infection caused by avian (bird) influenza

(flu) viruses.

• These influenza viruses occur naturally among birds.

• Wild birds worldwide carry the viruses in their intestines, but usually do not get sick from them.

• Avian influenza is transmissible to humans (this requires extremely close contact with infected birds, particularly feces).

• H7N1 and H9N2 (also bird flu)

H1N1 “Swine Flu”

• 2009 H1N1 (referred to as “swine flu” early on) is a new influenza virus causing illness in people.

• This new virus was first detected in people in the United States in April 2009.

• This virus is spreading from person-to-person worldwide, probably in much the same way that regular seasonal influenza viruses spread.

• On June 11, 2009, the WHO signaled that a pandemic of 2009 H1N1 flu was underway.

The Makings of a Pandemic• The gene’s segmented nature facilitates genetic reassortment

which leads to genetic diversity in type A.

– Antigen drifts (minor)

– Antigen shifts (major)

• The major antigenic variations underlie the deadly worldwide pandemics (1918 ‘Spanish’, 1957 ‘Asian’, 1967 ‘Hong Kong’) .

• The 1918 Spanish flu is the most serious pandemic in recent history, killing 50 million people (500,000 U.S. deaths).

• The most recent ones were the Asian Flu in 1957 (70,000 U.S. deaths) and the Hong Kong Flu in 1968 (34,000 U.S. deaths).

• In pandemic, virus is transmissible human to human.

More Flu…The “canine influenza virus” is an influenza H3N8 influenza virus

(not a human influenza virus) that was originally an equine (horse) influenza virus.

• This virus has spread to dogs and can now spread between dogs.

• Vaccination is available .

H7N7 and H3N8 “Horse Flu”

• The disease has a nearly 100% infection rate in an unvaccinated horse population with no prior exposure to the virus.

• While equine influenza is historically not known to affect humans, the impact of an outbreak among even the animal population would have been devastating.

Severe Acute Respiratory Syndrome (SARS)

Severe Acute Respiratory Syndrome (SARS): Epidemiology

• A worldwide outbreak of severe acuterespiratory syndrome (SARS) has beenassociated with exposures originating froma single ill health care worker fromGuangdong Province, China.

•China's Ministry of

Health reported a total of

2,914 cases of severe acute

respiratory syndrome

(SARS) on the Chinese

mainland.

•1,299 patients had been

discharged from hospitals

upon recovery

•131 had died.

April 27.

SARS: Timeline of an Outbreak

Nov. 16, 2002 -- The first case of an atypical pneumonia in the Guangdong province in China.

Feb. 26, 2003 -- First cases of unusual pneumonia reported in Hanoi, Vietnam.

Feb 28, 2003 -- World Health Organization officer Carlo Urbani, MD, examines an American businessman with an unknown form of pneumoniain a French hospital in Hanoi, Vietnam.

March 10, 2003 – doctor Urbani reports an unusualoutbreak of the illness, which he calls sudden acuterespiratory syndrome or SARS, to the main office ofthe WHO. He notes that the disease has infected anusually high number of healthcare workers (22) at thehospital.

March 12, 2003 -- WHO issues a global alert about anew infectious disease of unknown origin in bothVietnam and Hong Kong.

March 29, 2003 -- Carlo Urbani, who identified the firstcases of SARS, dies as a result of the disease.

Pathogenesis

• Clinically, most infections cause a mild, self-limited disease (classical 'cold' or upset stomach), but there may be rare neurological complications.

• SARS is a form of viral pneumonia where infection encompasses the lower respiratory tract.

• They are transmitted by aerosols of respiratorysecretions, by the faecal-oral route, and bymechanical transmission.

• Most virus growth occurs in epithelial cells.

• Occasionally the liver, kidneys, heart or eyes may beinfected, as well as other cell types such asmacrophages.

• In cold-type respiratory infections, growth appearsto be localized to the epithelium of the upperrespiratory tract.

SARS Virus

– Survived as long as 24 hours in the environment.

– Finding of virus in faeces.

– Occasionally linked with pneumonia in humans, specially with immunocompromised.

– Can cause severe illness in animals.

– Incubation period: 2-7 days

SARS Clinical Picture (Hong Kong)

– The most common symptoms included fever (in 100 percent of the patients);

– chills, rigors, or both (73.2 percent); and myalgia(60.9 percent).

– Cough and headache were also reported in more than 50 percent of the patients.

– Other common findings were lymphopenia (in 69.6 percent), thrombocytopenia (44.8 percent), and elevated lactate dehydrogenase and creatine kinase levels (71.0 percent and 32.1 percent, respectively).

– 78.3% had abnormal chest radiographs

Factors predictive of ICU admission and death

• Advanced age.

• High peak creatinine kinase

• High lactate dehydrogenase

• High initial absolute neutrophil count

• Low serum sodium level

INVESTIGATIONS

• Selected investigations are intended to determine the cause of the respiratory illness.

Test for viral, bacterial and other usual respiratory pathogens

Identify common pathogens circulating in the community which may be responsible for the illness

INVESTIGATIONS

• Blood work:

• blood cultures X 2

• CBC, diff, AST, ALT, bilirubin, alkaline phosphatase, LDH, CPK, urea, creatinine, electrolytes

• other diagnostic tests as indicated by patients condition

INVESTIGATIONS

• Respiratory samples:

NP swab #1: rapid antigen detection for respiratory viruses, viral cultures, viral PCR

ETT aspirate : SARS investigation • throat swab #1: Group A strep

• throat swab #2: Mycoplasma PCR

• Blood for serology:

One clotted tube[5 cc] labelled “SARS serology”

• Stool:

For viral electron microscopy

Treatment

• Empirical therapy most commonly included antibiotics, oseltamivir, and intravenous ribavirin.

• Mechanical ventilation was required in severe cases .

2. SARS Specific Therapy

The efficacy of ribavirin in treating SARS is not known but if ribavirin is being started, use intravenous ribavirin.

3. Additional Therapy for SARS

• Corticosteroids

• Oral ribavirin

•Oseltamivir

AVIAN Influenza

Human disease associated with influenza A subtype H5N1 re-emerged in January 2003, for the first time since an outbreak in Hong Kong in 1997." Three people in one family were infected after visiting Fujian province in mainland China and 2 died

Global spread of A H5N1 map

638 cases 379 deaths 59%

0

20

40

60

80

100

120

140

160

180

200

87

38

1

45

1

173

193

32113

25

12

125

51

29

1

30

0

63

161

22011

17

4

62

cases deaths

Cases / cases fatality rate /yearin Egypt

Year Cases Deaths Case–fatality rate (%)

2006 18 10 55.52007 25 9 362008 8 4 502009 39 4 10.22010 29 13 44.82011 39 15 38.42012 11 5 45.42013 4 3 752014 2 0 0Total 175 63 36

To date, a total of 175 human cases, including 63 deaths, have been reported in Egypt from avian influenza A(H5N1).

0

10

20

30

40

2006 2007 2008 2009 2010 2011 2012 2013 2014

18

25

8

39

29

39

11

42

10 9

4 4

1315

53

0

Cases Deaths

a 56-year-old female from Damanhour. a 4-year-old male, from Damietta

Influenza A viruses have 16 H subtypes and 9 N subtypes.

• In poultry, the viruses can mutate, usually within a few months, from then low pathogenic avian influenza (LPAI) form into the highly pathogenic form (HPAI).

• Only viruses of the H5 and H7 subtypes are known to cause the highly pathogenic (HPAI) form of the disease.

Influenza A HA and NA Subtypes

H15, H16

H14

H13

H12

H11

H10

H3

H2

H1

H9

H8

H7

H6

H5

H4

N9

N8

N7

N6

N5

N3

N4

N2

N1

The AVIAN H5N1 virus has raised concerns about a potential human pandemic because:

• It is especially virulent.

• It is being spread by transported domestic poultry.

• It can be transmitted from birds to mammals and humans.

Symptoms

• Most patients infected with the H5N1 virus show initial symptoms of fever (38 C or higher) followed by influenza-like respiratory symptoms, including cough, rhinorrhea, sore throat, and (less frequently) shortness of breath.

• Watery diarrhea is often present in the early stages of illness, and may precede respiratory symptoms by up to one week.

• Gastrointestinal symptoms (abdominal pain, vomiting) may occur and headache has also been reported.

Pharmaceutical treatment.

• Antivirals should be readily available for the treatment of suspected and confirmed cases. http://www.who.int/csr/disease/avian_influenza/en/

H1 N1

H2 N2

H3 N3

H4 N4

H5 N5

H6 N6

H7 N7

H8 N8

H9 N9

H10

H11

H12

H13

H14

H15

Hosts

Haemagglutinin subtype Neuraminidase subtype

Severe atypical pneumonia outbreak associated with influenza A(H1N1)pdm09 in Egypt, 2013–2014 season.

• During 2013

– ILI in outpatient clinics = 1.712.476 patients = 4.5% from all attendees

• During January 2014

– ILI in outpatient clinics = 191.428 patients = 4.9% from all attendees

• Positive cases for A H1N1 = 24%

Clinical Management of A(H1N1)

VIRUS Infection

Case Definitions

Suspected case of A(H1N1)

• an individual with acute respiratory illness and fever

(reported or documented fever), and one of the followings;

cough, sore throat, shortness of breath, difficulty in

breathing or chest pains with onset:

– Within 7 days of close contact with a person who is probable or

confirmed case of A(H1N1) 2009 virus infection, OR

– Within 7 days of travel to a country/community where there

has been one or more confirmed cases of A(H1N1) 2009 virus

infection;

OR

– Resides in a community where there is one or more confirmed

cases of A(H1N1) 2009 virus infection.

Probable case of A(H1N1) 2009

• An individual with an influenza-like illness

who is positive for influenza A that is

unsubtypeable by real-time PCR

• OR

– An individual with a clinically compatible illness

or who died of an unexplained acute respiratory

illness who is considered to be epidemiologically

linked to a probable or confirmed case.

Confirmed Case of A(H1N1)

• An individual with an influenza-like illness

with laboratory confirmed A(H1N1) 2009

virus infection by one or more of the following

test:

• Real-time RT-PCR

• Viral culture

Influenza like illness (ILI)

• A person with

sudden onset of fever of >38°C and at-least

one of the following two respiratory symptoms

in the absence of other known causes:

– Dry cough

– Sore throat

Severe acute respiratory illness (SARI)

• A person meeting the case definition of

influenza-like illness (sudden onset of fever > 38

C with at-least one of the following two respiratory

symptoms- dry cough, sore throat in the absence of

other diagnosis)

AND

• Shortness of breath OR difficulty in breathing

requiring hospital admission

Acute Respiratory Infection (ARI)

• defined as an acute respiratory tract illness that

is caused by an infectious agent transmitted

from person to person.

• The onset of symptoms is typically rapid, over

a period of hours to several days.

• Symptoms include fever, cough, and often sore

throat, coryza, shortness of

breath, wheezing, or difficulty breathing.

Clinical Presentation

• Vary from asymptomatic infection through to serious

fatal illness that may include exacerbation of other

underlying conditions and severe viral pneumonia with

multi-organ failure.

These are:

– (i) Mild or non-severe illness;

– (ii) Signs and symptoms of progression to severe

illness; (Moderate)

– (iii) Severe illness.

Mild illness (Non severe)

Patients with mild Influenza-like illness may present with

some or all of the following symptoms:

• Fever (Between 38 to 39 0C), dry cough, sore

throat, rhinorrhea, headache, muscle pain, malaise, but

no shortness of breath or dyspnoea.

• Gastrointestinal illness, such as diarrhoea and/or

vomiting, especially in children, but without any

evidence of dehydration.

• The general condition of these patients will be good

without any signs of hypotension or mental confusion.

Signs and symptoms of progression to severe

illness

• Patients presenting initially with mild

influenza-like illness may rapidly progress to

more severe illness in the course of the disease.

• The followings are some of the clinical signs

and symptoms indicating rapid progression of

a patient to severe illness, which would

necessitate an urgent review of patient’s

clinical management:

• Symptoms and signs suggesting oxygen impairment orcardiopulmonary insufficiency:

– Shortness of breath (with activity or at rest), difficulty inbreathing, turning blue, bloody or coloured sputum, chest pain, low bloodpressure;

– Fast or laboured breathing in children less than 5 years of age;

– Hypoxia as indicated by pulse oximetry, if available (Oxygen saturation ≤90%)

• Symptoms and signs suggesting CNS complications:

– Altered mental status, unconscious, drowsiness, or difficult to awaken;recurring or persistent convulsions (seizures), confusion, severe weaknessor paralysis.

• Evidence of sustained virus replication or invasive secondary bacterialinfection:

– Based on laboratory testing or clinical signs (e.g. persistent or recurrenthigh fever and other symptoms beyond three days even when undertreatment with analgesics or antipyretics).

• Severe dehydration:

– Decreased activity, dizziness, decreased urine output, lethargy.

Severe illness

Patients showing any of the following clinical signs and symptoms would

be considered as suffering from severe illness due to influenza:

• Severe respiratory distress:

– Severe breathlessness, e.g. unable to complete sentences in one breath.

Use of accessory muscles, supra-clavicular recession, tracheal tug or

feeling of suffocation (For adult patients)

– Lower chest in-drawing, sternal recession or noisy breathing when

calm (For paediatric patients)

• Increased respiratory rate measured over at least 30 seconds:

– Over 30 breaths per minute (For adult patients)

– ≥ 50 breaths per minute if under 1 year or ≥40 breaths per minute if ≥ 1

year (For paediatric patients)

• Oxygen saturation ≤92% on pulse oximetry, breathingair or on oxygen:

– Absence of cyanosis is a poor discriminator for severe illness.

• Respiratory exhaustion

– New abnormal breathing pattern, e.g. alternating fast and slowrate or long pauses between breaths (For adult patients)

– Apnoea defined as a ≥ 20 second pause in breathing (Forpaediatric patients)

• Evidence of severe clinical dehydration or clinicalshock

– Systolic blood pressure <90mmHg and/or diastolic bloodpressure <60mmHg. Sternal capillary refill time >2seconds, reduced skin turgor (For adult patients)

– Sternal capillary refill time >2 seconds, reduced skinturgor, sunken eyes or fontanelle (For paediatric patients)

• Altered conscious level

– New confusion, striking agitation or seizures (For

adult patients)

– Strikingly agitated or irritable, seizures, or floppy

infant (For paediatric patients)

• Causing other clinical concern to the

clinician or to the specialist doctor

– e.g. a rapidly progressive or an unusually

prolonged illness.

Groups at high risk for complications

• Pregnant women

• Adults 65 years of age and older;

• Children younger than 5 years old (In particular less than 2 years);

• Persons with the following underlying conditions at any age:

– Chronic Broncho-pulmonary disease (Including asthma),

– Chronic cardiovascular disease (except hypertension)

– Chronic neurologic disorder (Cerebral palsy, stroke, multiplesclerosis, muscular dystrophy, etc)

– Immune suppressed patients

– Haematological disorder

– Chronic liver or renal failure

– Metabolic disorder (specially Diabetes mellitus),

– Morbid obesity

• Healthcare personnel in the hospital settings caring for patientsinfected with A(H1N1) 2009 influenza virus;

Mild cases

Home Isolation Symptomatic treatment

Improvementprogress

Hospital isolationTamifluSamples

Positive

Negative

Discharge , treat according to the case

Continue Tamiflue, assessment after 5 days

Improved Progress

Discharge , stop Tamiflu , Treat according to the case

Continue isolation , doubling tamiflu dose , assess for hospital or ICU admission

Mild case with risk factors

Home isolation Tamiflu

No samples

Improved progress

• Continue Tamifue for 5 days

• Stop isolation 24 hs after symptoms disappear

•Hospital isolation •Doubling tamiflu dose •Samples •Assessment after 5 days

Sever cases

االطفال

البالغين

1. Hospital Isolation 2. Tamiflu3. Samples ( throat – naso

pharyngeal ) 4. Cultute for secretion )

criteria for consideration of patients’ admission at the ICU

Patient showing no signs of improvement and remainnon-responsive to antiviral treatment using oseltamiviras evidenced by the followings:

•Signs of progressive infiltrates on chest x-ray

•Persistent hypoxia ( SpO2 < 85%) despite maximum oxygen saturation;

•Progressive hypercapnoea;

•Presence of compromised haemodynamics;

•Signs of sepsis and imminent shockA higher dose regimen of Oseltamivir (150 mg twice daily for up to 10 days)may be considered in adult patients admitted in the Intensive Care UnitA higher dose regimen (double the normal dose regimen) may also beconsidered in children as well.

antiviral agents for influenza

• Neuraminidase inhibitors

– Oseltamivir (including Tamiflu™, Antiflu™)

– Zanamivir (including Relenza™)

– Peramivir (not registered in most countries)

Hemaggluti

nin

Neuraminidase

Lipid bilayer

M1 matrix protein

M2 ion channel

M2 Inhibitors Amantadin

e Rimantadin

e

Other antiviral and adjunctive treatments include

RibavirinArbidolInterferonImmune plasma

Treatment protocol for antiviral treatment

Dosage recommendations for antiviral treatment using oseltamivir

Age groupsAgent

=>6513-6410-125-91-4Duration

Oseltamivir

75 mg

twice daily

75 mg

twice daily

Weight-adjusted doses:

30 mg twice daily for ≤ 15 kg

45 mg twice daily for >15 to 23 kg

60 mg twice daily for >23 to 40 kg

75 mg twice daily for >40 kg

5 days

Zanamivir (In situations where oseltamivir is not available or if the virus is resistant to oseltamivir but known

or likely to be susceptible to zanamivir,

10 mg , (2 inhalations) twice daily 5 days

Use of antibiotics, corticosteroids and other supporting treatment for

hospitalized patients

In addition to antiviral treatment using oseltamivir , the following

supportive treatment should be considered :

• Supportive cares (antipyretics like acetaminophen for fever, adequate

rehydration for correcting dehydration, etc) are sufficient in the majority of

patients.

• Oxygen Therapy: oxygen saturation should be monitored by pulse

oximetry whenever possible. Supplemental oxygen should be provided to

correct hypoxemia depending on the severity (nasal

cannula, facemask, facemask with reservoir, intubation and assisted

ventilation).

• Corticosteroids: Corticosteroids should not be routinely used.

• Antibiotics: Antibiotic chemoprophylaxis should not be used. When

secondary bacterial pneumonia is suspected, treatment with antibiotics

should follow recommendations from national guidelines for community-

acquired pneumonia.

Hospital discharge criteria for patients with either confirmed, probable or suspected H1N1 infection

• Patient becomes afebrile;

• Absence of dyspnoea;

• Satisfactory oral fluid tolerance;

• No signs of dehydration;

• Respiratory rate 30 bpm;

• Oxygen saturation 92%

• Underlying chronic health conditions not exacerbated in patients in high-

risk group for complication.

Patients should be discharged after receiving the full five day course of

oseltamivir or 24 hours after becoming afebrile, whichever is earlier.

Antiviral Treatment using Oseltamivir for patients admitted at the ICU

• A higher dose regimen of Oseltamivir (150 mg twice daily for up to

10 days) may be considered in adult patients admitted in the ICU

• A higher dose regimen (double the normal dose regimen) may also

be considered in children as well.

• patients with severe or progressive illness not responding to normal

antiviral treatment regimen, higher doses of oseltamivir and longer

duration of treatment may be appropriate, although there is no

clinical trial evidence to show benefit.

• An adult dose of 150 mg bd for up to 10 days is being used in some

situations.

Middle East Respiratory Syndrome Corona-virus (MERS-CoV)

• Middle East Respiratory SyndromeCoronavirus (MERS-CoV) is a novelcoronavirus, which was first described inSeptember 2012.

• The virus causes respiratory tract infectionsranging from asymptomatic or mild disease tosevere pneumonia associated with multi-organ failure and death

• The first case of a novelcoronavirus, now calledMiddle East respiratorysyndrome coronavirus(MERS-CoV), wasidentified in a patientwith acute pneumoniaand renal failure inJeddah, Kingdom of SaudiArabia (KSA) in June 2012

Corona Cases and deaths 8/11/2014)%(Deaths casesCountry

42.7% 340796 Saudi Arabia 27%933Emirate 57%47 Qatar56%59 Jordan 75%34United Kingdom 33%13 Kuwait33%13 Tunisia

100%22Oman 50%12France 50%12Germany

100%11Malaysia 0%01Italy 0%01Philippine0%01Spain 0%01Grace 0%01Egypt 0%02Netherland

100%11Iran 50%12Algeria 42%364867Total

• The exact mechanism through which MERS-CoV

infection is acquired remains uncertain.

• Primary cases, The majority of infections are sporadic

• but human to human transmission has been

documented both in hospital and in community settings

Transmission of MERS-CoV

• Pneumonia has been the most common clinical presentation;

• five patients developed Acute Respiratory Distress Syndrome

(ARDS).

• Renal failure, pericarditis and disseminated intravascular

coagulation (DIC) have also occurred.

• no virus-specific prevention or treatment (e.g. vaccine or antiviral

drugs) is available.

• As all confirmed cases reported to date have occurred in adults

1. focuses on the early recognition and management ofpatients with SARI and includes early initiation ofsupportive and infection prevention and controlmeasures, and therapeutics.

2. focuses on management of patients who deteriorateand develop severe respiratory distress and ARDS.

3. focuses on the management of patients who deteriorateand develop septic shock.

4. focuses on ongoing care of the critically ill patient andbest practices to prevent complications.

1. Recognize severe manifestations of acute

respiratory infections

Definitions of clinical syndromes

“Patient under investigation” for novel coronavirus infection

• A person with an acute respiratory infection, which may include history of fever or measured fever (≥ 38 °C,) and cough;

– AND suspicion of pulmonary parenchymal disease (e.g. pneumoniaor ARDS), based on clinical or radiological evidence of consolidation:

– AND residence in or history of travel to the Arabian Peninsula orneighboring countries within 10 - 14 days before onset of illness:

– AND not already explained by any other infection oraetiology, including all clinically indicated tests for community-acquired pneumonia according to local management guidelines.

– It is not necessary to wait for test results for other pathogensbefore testing for novel coronavirus.

Suspect

Initiate infection prevention and control measures

• Droplet precautions– These infection prevention and control measures should

be started when the patient enters triage with symptomsof acute febrile respiratory illness.

– Organize the space and process to permit spatialseparation (at least 1 meter) between each patient withacute respiratory infections and other individuals notwearing PPE.

– Ensure that triage and waiting areas are adequatelyventilated.

– Encourage the use of respiratory hygiene (i.e. coveringthe mouth and nose during coughing or sneezing with amedical mask, cloth mask, tissue or flexedelbow), followed by hand hygiene.

• Airborne precautions should be used foraerosol-generating procedures, which havebeen consistently associated with an increasedrisk of pathogen transmission .– The most consistent association of increased risk of

transmission to healthcare workers (based onstudies done during the SARS outbreaks of 2002–2003) was found for tracheal intubation.

– Increased risk of SARS transmission was alsoreported when performing non-invasiveventilation, tracheotomy and manual ventilationbefore intubation; however, these findings wereidentified from a limited number of very low-qualitystudies.

Then 1. Give supplemental oxygen therapy to patients with SARI2. Collect respiratory and other specimens for laboratory

testing3. Give empiric antimicrobials to treat suspected

pathogens, including community-acquired pathogens4. Use conservative fluid management in patients with SARI

when there is no evidence of shock5. Do not give high-dose systemic corticosteroids or other

adjunctive therapies for viral pneumonitis outside thecontext of clinical trials

6. Closely monitor patients with SARI for signs of clinicaldeterioration, such as severe respiratory distress/respiratoryfailure or tissue hypoperfusion/shock, and apply supportivecare interventions

2. Management of severe respiratory distress,

hypoxemia and ARDS

3. Management of septic shock

4. Prevention of complications

A number of therapeutic interventions forcoronavirus were investigated during the largemulti-national outbreak of Severe AcuteRespiratory Syndrome (SARS) in 2003

• To date, no antiviral therapy has been approved for treatment of patients with MERS-CoV infection.

• Reviews of the available literature suggest that a combination of ribavirin and pegylated interferon may be of benefit to patients with severe MERS-CoVinfection.

• Furthermore, the combination was shown to inhibit MERS-CoV in cell culture and appeared to improve clinical outcome in animal studies.

• Both agents are associated with significant potential adverse effects and hence their unlicensed use should be carefully balanced against any potential harm.

To be considered eligible for oral ribavirinand subcutaneous pegylated interferon therapy, the patient must fulfill ALL the following criteria:

1. Laboratory-confirmed MERS-CoV infection

2. Clinical and radiological evidence of pneumonia

3. The patient requires invasive or non-invasive ventilatory support or showing progressive hypoxemia

4. Approval by one consultants in Adult Infectious Diseases

1. Patients who do not consent to the proposed

treatment regimen.

2. Patients who have known allergy to any agent

in the treatment protocol.

Administration Protocol:

Monitoring:

1. Both ribavirin and Peg-interferon are associatedwith considerable potential adverse effects. Inaddition to any clinical or laboratory monitoringthat is dictated by the patient’s condition,

2. the following investigations are essential beforestarting pegylated interferon 2-alfa therapy andribavirin and on daily basis throughout thetreatment course

3. Conscious patients must have a formalpsychiatric assessment if there is any clinicalevidence of psychosis or acute confusion

Changes to the treatment protocol:

• Changes in the treatment protocol inresponse to toxicity or clinicaldevelopments are permitted.

• A consultant in adult infectiousdiseases must approve all suchchanges.

Ebola Outbreaks 1976-2014

Historical Background in 2 simultaneous

outbreaks, first in Nzara which is small town in southof Sudan which infected over 284 people, with amortality rate of 53%.

• After view month another out break occurred inYambuku in Democratic Republic of Congo. The latterwas in a village situated near the fromwhich the disease takes its name

• In Congo outbreak 318 people infected with highestmortality rate of 88% .

• 24 outbreaks reported by WHO from 1976 till 2012 .

• first outbreak occurred in Sudan ( Newly south of Sudan ) and Democratic Republic of Congo with mortality rate of 53% and 88% respectively .

• Countries involved in outbreaks was , Sudan , Congo , Uganda ,Gabon , South Africa ( one case in 1996 ) and Cote d'Ivoire ( one case in 1994).

• No case reported out of Africa till 2012 .• The maximum No of infected patients was 425 in

Uganda outbreak 2000 .

August 1, 2014, the Guinea Ministry of Healthannounced a total of 485 suspect and confirmed casesof Ebola virus disease (EVD), including 358 fatal cases.

• 340 cases across Guinea have been confirmed bylaboratory testing to be positive for Ebola virusinfection.

• August 1, 2014, the Ministry of Health and Sanitationof Sierra Leone and WHO reported a cumulative totalof 646 suspect and confirmed cases, including 540laboratory confirmations and 273 reported fatal cases

• August 1, 2014, the Ministry of Health and SocialWelfare of Liberia and WHO have reported 468suspect and confirmed EHF cases (including 129laboratory confirmations) and 255 reportedfatalities.

• August 1, 2014, the Nigerian Ministry of Healthand WHO reported 4 suspect and probable casesand 1 fatal probable case.

• Nigerian Suspected and Confirmed Case Countare 4 .

What is Ebola virus disease (EVD)?• Ebola virus disease (formerly known as Ebola haemorrhagic

fever) is a severe, often fatal illness, with a death rate of upto 90%.

• The illness affects humans and nonhuman primates(monkeys, gorillas, and chimpanzees).

• Ebola first appeared in 1976 in two simultaneousoutbreaks, one in a village near the Ebola River in theDemocratic Republic of Congo, and the other in a remotearea of Sudan.

• The origin of the virus is unknown but areconsidered the likely host of the Ebola virus, based onavailable evidence.

Case counts October 24, 2014

Countries with widespread transmission

Country Total cases Lab. Conf. cases

Total deaths

Guinea 1760 1479 1054

Liberia 6919 2514 2766

Sierra Leone

4862 4149 1130

Total 13241 8142 4950

08 November 2014

Countries with travel associated cases

Country Total cases Lab. Conf. cases Total deaths

Mali 1 1 1

Senegal 1 1 0

2 2 1

Country Total cases Lab. Conf. cases Total deaths

Nigeria 20 19 8

Spain 1 1 0

United State 4 4 1

25 24 9

• The outbreak of Ebola Virus in Nigeria andSenegal were declared over on 17 Octoberand 19 October 2014.

• A national EVD outbreak is considered to beover when 42 days ( Double the 21 daysincubation period ) has elapsed since the lastpatient in isolation became laboratorynegative for EVD

How many people could become infected?

2. How do people become infected with the virus?

• In the current outbreak in West Africa, the majority of cases in humans have occurred as a result of

• Infection occurs from through broken skin or mucous membranes with the blood, or other bodily fluids or secretions (stool, urine, saliva, semen) of infected people.

• Infection can also occur if broken skin or mucous membranes of a healthy person come into

such as soiled clothing, bed linen, or used needles.

• More than 200 health-care workers have beenexposed to the virus while caring for Ebolapatients.

• This happens because theyor were

not properly applyingwhen caring for the patients.

• Health-care providers at all levels of the healthsystem – hospitals, clinics, and health posts –should be briefed on the nature of the diseaseand how it is transmitted, and strictly followrecommended infection control precautions.

• People are infectious as long as their blood andsecretions contain the virus. For this reason, infectedpatients receive close monitoring from medicalprofessionals and receive laboratory tests to ensure thevirus is no longer circulating in their systems

• Men whoto their partner through their semen for

up to 7 weeks after recovery. For this reason, it isimportant for men to avoid sexual intercourse for at least7 weeks after recovery or to wear condoms if havingsexual intercourse during 7 weeks after recovery.

• Generally, a person must come into contact with ananimal that has Ebola and it can then spread within thecommunity from human to human.

Who is most at risk?

During an outbreak, those at higher risk of infection are:

• health workers;• family members or others in close contact with

infected people;• mourners who have direct contact with the

bodies.• More research is needed to understand if some

groups, such as immuno-compromised people or those with other underlying health conditions, are more susceptible than others to contracting the virus.

incubation period

2 to 21 days

• The incubation period from time of infection to symptoms is 2 to 21 days.

What are typical signs and symptoms of infection?

• Sudden onset of fever, intense weakness, muscle pain, headache and sore throat are typical signs and symptoms.

• This is followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases, both internal and external bleeding.

• Laboratory findings include low white blood cell and platelet counts, and elevated liver enzymes.

• The patients become infectious once they begin to show symptoms.

• They are not contagious during the incubation period.( 2- 21 days)

• Ebola virus disease infections can only be confirmed through laboratory testing.

What is the treatment?• There is currently no specific treatment to cure the

disease.

• Severely ill patients require intensive supportive care. They are frequently dehydrated and need intravenous fluids or oral rehydration with solutions that contain electrolytes.

• Some patients will recover with the appropriate medical care.

• Isolation from other patients and treated by health workers using strict infection control precautions.

Should patients with suspected or confirmed Ebola virus be separated from other patients?

• Isolating patients with suspected or confirmedEbola virus disease in single isolation rooms isrecommended.

• Where isolation rooms are not available, it isimportant to assign designated areas, separatefrom other patients, for suspected and confirmedcases.

• Access to these areas should berestricted, needed equipment should bededicated strictly to suspected and confirmedEVD treatment areas, and clinical and non-clinicalpersonnel should be exclusively assigned toisolation rooms and dedicated areas.

Stopping visitor access to patients infected withEVD is preferred.

If this is not possible, access should be givenonly to those individuals who are necessaryfor the patient’s well-being and care, such as achild’s parent.

Is hand hygiene important?

Hand hygiene is essential and should be performed:• before donning gloves and wearing PPE on entry to

the isolation room/area;• before any clean or aseptic procedures is being

performed on a patient;• after any exposure risk or actual exposure with a

patient’s blood or body fluids;• after touching (even potentially) contaminated

surfaces, items, or equipment in the patient’ssurroundings; and

• after removal of PPE, upon leaving the isolationarea.

• Either an alcohol-based hand rub or soap andrunning water can be used for hand hygiene.

• It is important to always perform hand hygienewith soap and running water when hands arevisibly soiled.

• Alcohol-based hand rubs should be madeavailable at every point of care (at the entranceand within the isolation rooms and areas);running water, soap, and single use towels shouldalso be always available.

Keeping Healthy

• Maintain a healthy lifestyle; attention to rest, diet, exercise, and relaxation helps maintain physical and emotional health.

• Resilience