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Ebola

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Alyssa Ablan

on 30 July 2015

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Transcript of Ebola

http://www.npr.org/sections/goatsandsoda/2014/10/25/358898029/gear-wars-whose-ebola-protective-suit-is-betterhttp://www.npr.org/sections/goatsandsoda/2014/10/25/358898029/gear-wars-whose-ebola-protective-suit-is-betterhttp://www.npr.org/sections/goatsandsoda/2014/10/25/358898029/gear-wars-whose-ebola-protective-suit-is-bhttp://www.npr.org/sections/goatsandsoda/2014/10/25/358898029/gear-wars-whose-ebola-protective-suit-is-better
What is ebola virus (EBOV)?
It is
one
of
five
known viruses within the genus Ebolavirus (ebolavirus (EBOV), Sudan virus, Tai Forest virus, Bundibugyo virus, Reston virus)

Four of the five known Ebolaviruses, including EBOV,
cause a severe and often fatal hemorrhagic fever
in humans and other mammals, known as Ebola virus disease (EVD).
How is Ebola Virus transmitted?
Direct contact
through broken skin or mucus membranes with an EVD-infected patient's blood or bodily fluids.
How is Ebola Virus
Transmitted?
The viral-load or
infectiousness
of bodily fluids increases as the person becomes more ill.
What is ebola virus (EBOV)?
Epizootics
caused by ebolavirus appear sporadically, producing high mortality among non-humane primates & duikers and may precede human
outbreaks
.
Ebola
It is a
zoonotic
virus. New evidence strongly implicates bats as the
reservoir hosts
for ebolavirus.
Little is known about how the virus first passes to humans. When the virus does pass to humans, it triggers waves of
human-to-human transmission
and often leads to an
epidemic
.
Source: CDC
Indirect contact
with an EVD-infected patient's blood or bodily fluids (utensils, soiled bedding).
Direct contact
with the corpse of someone who died of EVD. (The ritual washing of Ebola victims at funerals has played a significant role in the spread of infection).

Can also be
transmitted
from contact with semen from a man who has recovered from Ebola
The bodily remains from someone who has died from EVD is highly
contagious
.
Ebola is not spread by water, through the air, or by food. However, in Africa, Ebola may be spread through the handling of
bushmeat
(wild animals hunted for food).
Source: CDC
How Do You Handle Ebola in an Acute Care Setting?
1.
Initiate
2.
Identify
3.
Isolate
4.
Inform
Initiate
Source: www.cdc.gov/vhf/ebola/hcp
Think "Ebola"
when approaching patient.
Always use
standard precautions.
If you suspect Ebola,
immediately separate
the patient from others.
Identify

Ask if they've
traveled to a country with widespread
transmission
of Ebola or uncertain control measures (Guinea or Sierra Leone) within the last 21 days.

OR

Ask if they've been in
close contact
with someone with Ebola.

Ask if they've had a
fever
at home, or assess if they currently have a fever, of > or = 100.4 F (38 C).

Other symptoms
: severe headache, muscle pain, weakness, fatigue, diarrhea, vomiting, abdominal pain, unexplained bleeding and bruising.
If patient has both
exposure
and
symptoms
,
immediately isolate
the patient and inform others.
Isolate
If you suspect Ebola infection during your assessment,
TAKE ACTION.
Isolate the patient
in a private room.
Wear appropriate
PPE
.
Limit
the number of healthcare workers who enter the room.
Keep a log
of anyone who enters the room.
Consider
other diagnoses
and appropriately evaluate.
Do not perform unnecessary tests or procedures.
Avoid
aerosol-producing procedures.
Follow
CDC guidelines
for disinfecting, cleaning, and waste management.
Inform
Alert others, including
public health authorities.
Notify the appropriate staff
at your facility, including those in the infection control program.
Contact
your local and state
public health
authorities.
Consult
with local or state public health authorities about
testing
for Ebola.
"Healthcare providers caring for Ebola patients and 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."
-CDC 2015
December 2013
A 2-year old boy in Gueckedou, Guinea, dies after suffering for four days with an unidentified hemorrhagic fever.

The toddler's mother and 3-year-old sister die seven days later.

When Patient Zero's grandmother dies the next month, People come from all over for her funeral; her village is close to the Sierra Leone and Liberian borders. Exposed to the virus, they bring it home, and it spreads widely
Limited health care system in West Africa
Physician: 1000 people
-
Liberia
0.014
-
Sierra Leone
0.022
-
Guinea
0.1
-
US
2.5
April 2014
4th:
An Ebola treatment center in Guinea was attacked by an angry mob claiming foreigners were spreading Ebola. Healthcare workers in the worst-affected areas faced increased hostility from fearful, suspicious people. Rural families hide their sick or dead relatives in their homes.
March 2014
MSF warns the spread is unprecedented due to the geography of the outbreak - all past outbreaks were contained and involved more remote locations
Residents in Guinea are getting sick with fever, vomiting, and severe diarrhea. Health care workers and the families who cared for those with the "mysterious disease" also get sick

14th
: Guinea health ministry starts tracing the outbreak. They take blood and stool samples, but not in a systematic fashion nor with patient's consent

24th
:
Guinea
has 87 suspected cases of viral haemorrhagic fever, with 61 deaths

29th
: Senegal closes the border with Guinea

30th
: 112 suspected and confirmed cases in Guinea, with 70 deaths

31st
:
Liberia
confirms its first two cases of the virus;

Sierra Leone
reports its first suspected deaths
Aid organizations begin flocking to the region to determine the extent of the outbreak
- Fatality Rate: 86%
- Median Pt: 35
- More women die from the disease than men
WHO recommends better infection control for healthworkers but recommends against travel or trade restrictions for the affected countries
MSF healthcare workers bring food to their patients
Separation of blood cells from plasma cells to isolate Ebola RNS and test for the virus at the European Mobile Lab in Guinea
8th:

-
Guinea:
157 cases, 101 deaths
-
Liberia:
23 suspected cases, 7 deaths
-
Sierra Leone:
Suspected cases
-
Ghana & Mali:
Suspected cases, which were later determined to be from a different cause

15th:
MSF reports that the epidemic is now fatal in up to 90% of cases
May 2014
Ebola victim is lowered into a grave in Sierra Leone
2nd:
Of the infections, at least 25 are health care workers
-
Guinea
: 226 cases, 149 deaths
-
Liberia
: 13 cases, 11 deaths

26th:

Sierra Leone
confirms it's first deaths from the virus
June 2014
4th:
Ebola patients have been identified in more than 60 seperate locations across the three West African countries, complicating efforts to slow the outbreak
-
Guinea:
328 cases, 208 deaths
-
Sierra Leone
: 79 cases, 6 deaths
-
Liberia
:
11 new possible cases

13th:
One of the CDC labs that handles Ebola closes after it's discovered 86 workers may have been unintentionally exposed to anthrax because of the lab's mishandling of samples

26th:
-
Guinea:
600 cases, 390 deaths
MSF states that the epidemic is out of control

Mortality rate is up to 90%
WHO sends additional epidemiologists, lab and infection experts, clinical managers logisticians, and communication teams
PPE drying after use at a treatment center in Liberia
July 2014
1st:
WHO reports 759 cases total, 467 deaths, making it the largest in terms of the number of cases and deaths as well as geographical spread
By the end of June, MSF sent more than 300 staff members and 40 tons of equipment & supplies
3rd:
Health ministers of 11 African nations meet in Ghana to discuss Ebola. They agree to a joint strategy with WHO to set up a subregional control center in Guinea to coordinate the response

4th:
Uganda announces measures to screen people arriving from Ebola-affected countries

8th:
844 cases total, 518 deaths (of which 32 are health care workers)

20th:
Of the 1,093 confirmed, probable, and suspected cases, 660 people have died.

25th:
The first American citizen dies in
Nigeria
. His case raises fears that the virus could spread beyond the countries at the heart of the outbreak.
Death rate lowers to 60%

27th:
Two American aid workers are infected with Ebola
-
Guinea:

427 cases, 319 deaths
-
Sierra Leone
:
525 cases, 224 deaths
-
Liberia:

249 cases, 129 deaths
- Total:
1,201 cases, 672 deaths
Liberia closes it's borders, restricts public gatherings, and orders hotels, restaurants, and entertainment venues to play an Ebola safety video

28th:
CDC sends a health alert notice to remind health care workers to take precautions and to prepare for the "remote possibility" that one of the travelers could get Ebola and return to the US while sick. Health care workers should ask about a patient's travel history, know the symptoms of Ebola, and know about infection control

29th:
Evacuation order for all nonessential personnel from Liberia

30th:
Peace Corps announces it is removing all of its 340 volunteers from the affected region. Many other aid organizations follow suit
State of Emergency in Sierra Leone
Biological containment system used for transporting American Ebola patients by air out of Liberia
Dr Sheik Umar Khan died from Ebola after leading Sierra Leone's fight against the epdemic
Border checkpoint in Liberia
2nd:
An American health care worker arrives in the US and is sent to an isolation ward in Atlanta. He's the first patient infected with Ebola treated on American soil

4th:
The two American health care workers improve significantly, they received an experimental Ebola drug called ZMapp
- Obama holds the largest event any US President has held with African heads of state and government at the White House - Ebola is not on the official agenda. Every key African nation leader is at the summit with the exception of the leaders of the countries involved in the Ebola epidemic

4th:
Liberia, Guinea, and Sierra Leone ban public gatherings and close schools

5th:
White House press secretary states they are confident that the screening measures in place will be effective in protecting the American public

20th:
Liberia fires shots and uses tear gas to disperse a crowd that tried to break out o quarantine

31st:
Nigeria traces everyone who may have been exposed to a symptomatic passenger who flew to Lagos - 20 confirmed and probable cases. Quick response!
USAID announces they will provide $14.6 million in funding; World Bank announces it will give up to $200 million in funding to build up public health systems
August 2014
-
Total:
2,473 cases, 1,350 deaths
-
Guinea:
579 cases, 396 deaths
-
Sierra L.
: 907 cases, 374 deaths
-
Liberia
:
972 cases, 576 deaths
-
Nigeria:
15 cases, 4 deaths
- New case in
Senegal
State of Emergency in Liberia
WHO leaders meet and determines the outbreak a Public Health Emergency of International Concern
"...but it took two Americans getting the disease in order for the international community and the US to take serious notice of the largest outbreak of the disease in history"
- Samaritan's Purse
MSF has 670 staff responding, but "reached its limits in terms of available staff"
Zambian government & Ivory Coast bans travelers from Ebola affected countries
American Aid worker recovers from Ebola
Ebola ward in Liberia
Ivory Coast closes the border it shares with Guinea Liberia
September 2014
2nd:
NIH announces an Ebola vaccine human safety trial has a green light from the FDA. It's the first test of this type

19th:
Sierra Leone begins a three-day nationwide lockdown. People are not allowed to leave their homes, giving volunteers a chance to go door-to-door to educate people. This turns up more cases

20th:
Liberian
Thomas Duncan
arrives in Dallas to visit relatives. He has been unknowingly exposed to the Ebola virus

25th:
An American worker is released from the hospital after recovering from the Ebola virus; he recieved a blood transfusion from an Ebola survivor (which may have contained antibodies) as well as an experimental Ebola drug

26th:
Duncan returns to the hospital in Dallas with a high fever. He tells staff he just returned from Liberia. The hospital sends him home with antibiotics

28th:
Duncan is admitted into isolation. First known case of Ebola diagnosed in the US

30th:
CDC sends 10 public health professionals to perform contact tracing for the Dallas Ebola patient
Health workers place a corpse into a body bag in Liberia
More than 4,200 cases have been reported since December, with more than 2,200 fatalities
US will send another $10 million (on top of the $100 already sent). USAID also sends $75 million
Gates Foundation pledges $50 million
2,800 dead, 5,800+ total cases. Fatality Rate = 71%
Ebola has orphaned 3,700 children, and scared relatives don't want to take them in
October 2014
Death toll is 4,922 out of 10,141 diagnosed cases. 443 Health Care workers infected
3rd:
DOD says it will send up to 4,000 troops to West Africa to fight the epidemic

7th:
Nursing Assistant in Spain becomes the first to catch Ebola outside of West Africa during this outbreak

10th:
Health care workers in Liberia go on strike

11th:
Ebola screenings begin at JFK

12th:
A nurse who took care of Duncan, the US patient, is diagnosed with Ebola. This is the first known transmission of the virus in the US. Another nurse who took care of Duncan reports an elevated temperature to the CDC; they do not prohibit her from flying - she takes a flight to Ohio
White House says they will commit more than $350 million to fighting the outbreak
Affected Countries: Guinea, Liberia, Sierra Leone, Spain, US, Nigeria, Senegal
WHO declares the Ebola outbreak in Senegal over
Nigeria is considered free of Ebola virus transmission
Mandatory 21 day quarantine on all health care workers returning from West Africa
"I feel like my basic human rights have been violated,"
- Kaci Hickox
24th:
The two nurses are deemed Ebola-free

26th:
CDC expresses concern that mandatory quarantines will discourage healthcare workers from volunteering

26th:
A quarantined American nurse tells CNN that she doesn't have Ebola and is being treated inhumanely at the University Hospital in Newark where she is being kept under mandatory quarantine since she had contact with Ebola patients overseas.

29th:
NY Gov. now says healthcare workers who have cared for Ebola patients should remain in their homes for 21 days but will not be automatically subjected to quarantine
Nurse Kaci Hickox in an isolation tent
2014 Outbreak timeline
Ebola may be spread through large droplets but only when infected person is extremely ill
Pathophysiology
1. Ebola virus comes into contact with mucous membrane or break in skin
2. Macrophages & dendritic immune cells engulf foreign invader
3. Virus releases contents & replicates within cell,
infected immune cell produce pro-inflammatory mediators & tissue factor
4. Virus buds outs forming viral envelope & outer glycoprotein to enter new cells for further infection and replication
Systemic inflammatory response
Cytokine storm
Disseminated intravascular coagulation
Signs & Symptoms
Hemorrhagic fever
Headache
GI dysfunction-n/v & diarrhea
Impaired kidney & liver
Hypotension
Volume deficit
Death-
due to organ failure
Incubation period: 2 - 21 days
(from infection, to onset of S/Sx)
Ebola virus interferes with interferon and dendritic cell responses that restrict viral replication and initiate antigen specific responses
Response to Viral Invasion
Number of new cases of EVD
in West Africa Sept 23-Oct 18
EVD Cumulative Incidence West Africa, October 18
Cumulative number of EVD cases reported by epidemiologic week in West Africa:
March 29 - October 18
Treating Ebola
Current approach: treat symptoms as they appear
currently no FDA approved vaccine or medication for Ebola
Accepted Ebola treatment is termed "supportive care"
maintain adequate cardiovascular function while immune system mobilizes adaptive response
focus on preventing volume depletion
Early Phase Patients:
1) Provide oral anti-emetics
2) Provide anti-diarrheals
3) Attempt to have patient take in as much fluid by mouth as possible.
Fluid/Electrolyte Imbalances
In resource poor areas with limited monitoring and lab capability:
Provide 5 or more liters of balanced crystalloid solution [0.9% sodium chloride supplemented with K+ or lactated ringers]
Assess urine frequency, volume, color, skin turgor and moisture to determine how much fluids to provide
In resource rich areas:
Careful assessment of I/Os, vascular ultrasound, indwelling catheters for central venous pressure monitoring, to determine how much fluid volume to give.
Invasive BP if possible [inserted into an artery]
provide IV fluids
correct electrolyte imbalances
maintain O2 saturation
treat other infections as they appear
Respiratory support
• Respiratory failure may occur and patient needs intubation, however provider must remember that ventilators may generate
infectious aerosols

Additional supportive treatments
• Antipyretics to decrease fever [acetaminophen, paracetamol]. Hepatic dysfunction may be occurring simultaneously so dose is often decreased.
NSAIDS should be avoided
due to risk of renal failure
• Other analgesics
• Anti-emetics
• Anti-diarrheals
• Parenteral nutrition

Personal Protective Equipment (PPE):
MSF vs. WHO
-"Gold Standard"
-No exposed skin
-Thicker gloves
& suits (heavier)
-Longer to dress
-45 min patient
time
-More costly
-Exposed skin
(around face)
-Thinner material
-Shorter to dress
-4 hrs patient time
-Less costly
*Trend is to rely on more protective gear rather than less
PPE Standards
-Goggles or face shield;
-Mask; PAPR and/or N95 Resp preferred
-Hood covers the neck and shoulders, worn over mask
-Disposable suit (secured w/ front zipper)
-Apron (neck to below knees)
-Surgical gloves
-Second pair of surgical or rubber gloves
- Rubber boots w/ covers

*CDC guidelines for US hospitals- all skin should be covered
*Training on how to remove potentially contaminated PPE gear is crucial



Control
&
Prevention

Screenings
Combination of determining
level of risk of exposure
and determining presence/absence of
symptoms

Border exit
Border entry
Health care setting
Treating Ebola with Antivirals
Drugs developed for other purposes have been used in recent epidemic
MSF collaborating with big pharma to test therapies in Africa under the FDA "compassionate use protocol"
Current therapies being tested on humans
favipiravir
brincidofovir
favipiravir
Nucleoside analog that inhibits replication of RNA viruses. Has been approved in
Japan
for the treatment of influenza. Use for Ebola patients is based on a study that prevented death in Ebola-infected mice. Currently being tested on Ebola-infected macaques.
Human tests: preliminary results show drug decreases motality rates of in humans with low to moderate levels of Ebola in blood. No effect on those with high levels of virus in blood.
brincidofovir
Acyclic nucleotide analog being developed for treatment of poxvirus, cytomegalovirua and other DNA virus infections. Has been tested on humans in Phase II and Phase III trials but has not been proved for licensure.
drug has been used with Ebola patients in the US under "Emergency Investigational New Drug" application, approved via the FDA
Changes in treatment?
Then (1976) vs. Now (2014/2015)
First recorded outbreak had a higher mortality rate (88%) but was quickly contained and stoppped.
Why?
First outbreak happened in a small village due to reusing dirty needles. After outbreak began hospital quickly closed.
Current outbreak: globalization! Despite more awareness of virus, state, country, nation borders are more fluid. Travel is easy.
Treatment is not that different - more experimental drugs now, but "supportive" approach is still the same, just with better technology and communication.
1976 outbreak as a public health model?
Risk to Health Care Workers
-As of January 2015, the WHO reported a total of 838 health care workers are known to have been infected with Ebola virus disease. 495, or 59%, of these workers have died.
-These health care workers include doctors, nurses and other people working at Ebola treatment centers
-They are among those in the CDC's "highest risk" category

Risk to Health Care Workers in the US
Two health care workers who cared for the index patient in Texas were confirmed to have Ebola Virus

Both recovered and were discharged from the hospital

Difference? Meticulous infection control? Better equipment? Better screening? Less prevalence of Ebola Virus?
Precautions to Decrease Risk of Transmission to Health Care Workers
-Think Ebola!
If signs and symptoms appear to point towards Ebola Virus implement precaution measures ASAP
-Follow CDC infection control recommendations / training guidelines in US hospital
-Protect yourself: Wear proper PPE and remove it / dispose of it according to CDC guidlines
Image from Bloomberg.com
http://www.bloomberg.com/bw/articles/2014-10-16/ebola-what-the-next-week-will-tell-us-about-americas-risk
Lessons Learned
Active Case Finding
Contact Tracing
: in epidemiology it’s the process of identifying and screening individuals who may have come in contact with an infected person
http://www.pih.org/media/need-to-know-contact-tracing

Potential for
early identification
of cases

May identify people who are too sick to seek care

Potential to identify other social determinants of the spread of an illness

Malaria is endemic and is a cause of considerable morbidity and mortality in Guinea, Liberia, and Sierra Leone, particularly in children under 5 years of age.

Prevalence rates among children aged 6-59 months of infection with Plasmodium falciparum are: Liberia 45%, Sierra Leone 46%, and Guinea 47%

Malaria complicates Ebola triage and management
; because of overlapping, non-specific symptoms, many patients suffering from malaria will meet the case definition for “suspect Ebola” and will require Ebola testing; they may be isolated with other Ebola patients, exposing them to the virus they didn’t already have
Patients who believe they have malaria
may not seek care
for fear of being labeled a suspected case of Ebola
Malaria-related deaths may be deemed Ebola deaths, leading to unnecessary contact tracing
The breakdown in the health care system means that care for malaria patients is sparse, further contributing to the public health crisis. A study published in the Lancet found that
untreated malaria cases as a result of reduced health system capacity
probably contributed substantially to the morbidity caused by the Ebola crisis: an additional 10,900 malaria-attributable deaths

Lancet Infect Dis 2015; 15: 825–32 Published Online April 24, 2015 http://dx.doi.org/10.1016/S1473-3099(15)70124-6


In the Ebola epidemic a contact is
any person who has been exposed to a suspect, probable, or confirmed case of EVD
in at least one of the following ways:

Has
slept
in the same household as a case

Has had
direct physical contact
with the case (alive or dead) during the illness

Has had
direct physical contact with the (deceased)
case at a funeral or during burial preparation rituals

Has
touched the blood or body fluids
of a case during their illness

Has
touched the clothes or linens
of a case

A baby who has been
breastfed
by the patient
Active Case Finding
contact tracing team
must establish trust
with the community

risk to contact tracing team members; must be well trained

contact tracing can only break the chain of EVD transmission if it is i
mplemented immediately
when a case of EVD is found. Any delay and even one missed contact can lead to a rapid spread of EVD.

Benefits of Contact Tracing
Challenges of Contact Tracing
Malaria
RISK TO HEALTHCARE WORKERS
How is Ebola Diagnosed?
Early diagnosis
is challenging as early symptoms such as fever are also seen in other common diseases, such as malaria and typhoid fever.
At this point
samples can be collected
and tested to confirm infection. It may take up to three days after symptoms start for the virus to reach detectable levels.
Isolation and notification of public health authorities
should occur when a person presents with early symptoms and has also potentially had contact with the Ebola virus.
How is Ebola Diagnosed?
Different diagnostic tests
are used depending on the timeline of the infection.
Early in the course of the disease:
Antigen-capture enzyme-linked immunosorbent assay (ELISA) testing
IgM ELISA
Polymerase chain reaction (PCR)
Virus isolation
In deceased patients:
Immunohistochemistry testing
PCR
Virus isolation
Later in disease course or after recovery:
IgM and IgG antibodies
Control & Prevention
Challenges
NPR on PPE:
Globalization leads to increased movement of people and diseases
Media's ability to sensationalize and influence opinions about diseases/health in general
Investment toward well-functioning health care systems improves our ability to deal with epidemics
When symptoms of a disease are so nonspecific, lab confirmation of diagnosis is crucial to management of an epidemic
Difference of care between Americans who contracted EVD and those in West Africa
The CDC-recommended steps to dealing with Ebola in an acute care or community health setting.
How Ebola is transmitted.
http://www.npr.org/sections/goatsandsoda/2014/10/25/358898029/gear-wars-whose-ebola-protective-suit-is-better

*If time permits

Members contributions
Alyssa:
Initial layout of presentation, introduction to EVD, transmission
Tina:
Pathophysiology and transmission
Christina:
History of outbreaks, diagnosis of EVD
Sarah:
2014 outbreak timeline, organization of prezi
Jessi:
Healthcare workers and ppe
Jen:
Control and prevention
Leah:
Treatment of EVD, vaccines



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