PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN

PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN (PHEIC)EBOLA (EVD)-Dr.R.PARTHASARATHI,M.DDept of Community MedicineBushmeatismeatfrom wild animals hunted in Africa, Asia, and South America1PHEICDefined 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 instrumentPHEIC4 decision criteria used in assessment of a public health event are :(a) The seriousness of the events 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.stocks3PHEIC

Ebola virus disease (EVD)It is one of the worlds 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 virusEbola first appeared in 1976 in 2 simultaneous outbreaks in Nzara, Sudan, and in Yambuku, Congo. Yambuku village near the Ebola RiverFamily:Filoviridae Genus: Ebolavirus (3 members Marburgvirus, Cuevavirus)Species:5 typesBundibugyo ebolavirus (BDBV)Zaire ebolavirus (EBOV)Sudan ebolavirus (SUDV)Reston ebolavirus (RESTV)Ta Forest ebolavirus (TAFV).

6Ebola SPECIESBDBV, EBOV, and SUDV have been associated with large EVD outbreaks in Africa.

The RESTV species, found in Philippines and the Peoples Republic of China, can infect humans, but no illness or death in humans from this species has been reported to date.

characteristic filamentous form with a uniform diameter of approximately 80 nm but display great variation in length. Filaments may be straight, but they are often folded on themselves. Ebola virus has a nonsegmented negative-stranded RNA genome containing 7 structural and regulatory genes7ENVIRONMENTAL PERSISTANCEUnder 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 OUTBREAKOn 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 Zare Ebolavirus (EBOV)As of August 16, 2014, 2,240 suspected or confirmed cases, including 1383 laboratory-confirmed cases and 1,229 deaths2014 OUTBREAK

TRANSMISSIONNatural Host: Fruit bats of thePteropodidaefamily

(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)11

EPIDEMICEPIZOOTIC ENZOOTIC

Human-to-Human transmissionDirect contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected peopleIndirect 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- H2Hthe survival rate has been higher than previous outbreaks. ALL CASESWHO advises that the deceased be handled and buried by trained case management professionals, who are equipped to properly bury the dead.

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Signs and symptomsPRODROME: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. A maculopapular rash, more easily seen on white skin than on dark skin, may be present around day 5 of infection and is most evident on the trunk. Bilateral conjunctival injection is also commonMyocarditis and pulmonary edema also are seen in the later stages of the disease. Terminally ill patients often die tachypneic, hypotensive, anuric, and in a coma.

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Evidence of mucous membrane involvement includes conjunctivitis, odynophagia or dysphagia, and bleeding from multiple sites in the gastrointestinal tract. Terminally ill patients often are obtunded, anuric, tachypneic, normothermic, and in shock. Although the mechanism is unclear, hiccups have been noted in fatal cases of Ebola.16Person 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 inor travel toan area where EVD transmission is active; or direct handling of bats, rodents, or primates from disease-endemic areas.Central and western africa17Probable CaseA PUI who is a contact of an EVD case with either a high or low risk exposure.

Confirmed CaseA case with laboratory confirmed diagnostic evidence of Ebola virus infection.

Case Definition for EVDContacts 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 patientDirect care or exposure to body fluids of an EVD patient without appropriate PPELaboratory worker processing body fluids of confirmed EVD patients without appropriate PPE or standard biosafety precautionsParticipation 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 CaseLow risk exposuresA Low risk exposure includes any of the following:Household member or other casual contact*with an EVD patientProviding patient care or casual contact*without high-risk exposure with EVD patients in health care facilities in EVD outbreak affected countries

No known exposurePersons with no known exposure were present in an EVD outbreak affected countryin the past 21 days with no low risk or high risk exposures.

Contacts of an EVD CaseDefined 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 ORhaving 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 contactpersonal protective equipment 21Always rule outOther Viral Haemorrhagic Fevers.MalariaYellow feverDengue LeptospirosisTyphoid FeverShigellosisRickettsiosisRelapsing FeverCholeraPlagueHepatitis

DIFFERENTIAL Diagnosispersonal protective equipment 22Thrombocytopenia, leukopenia with a pronounced lymphopenia.Neutrophilia develops after several daysElevations 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 findingsDefinitive diagnosis byAntibody-capture ELISAAntigen detection testsSerum neutralization test- serological surveysRT-PCR assayVirus 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 onlyNCDC, New Delhi and NIV,Pune in our country

Laboratory DIAGNOSISHighly sensitive and confirmatory testsbecause of the presence of large amounts of viral antigen, the relatively low risk posed by sample collection, and the lack of cold-chain requirements for formalin-fixed tissues.24Isolate 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 AuthorityClinical 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 neededNo specific drug treatment

MANAGEMENT25Zmapp Combination of monoclonal antibodies which binds with outer glycoprotein of the virus and prevents its entry to the host cellsEfficacy 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 2015Tekmira, a Canadian biotech company, has begun early human trials of a new drug

Experimental treatment2 americans and 1 spanish priest, MYTHS26NOT 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 virusbased vaccine has protected macaques when given both before and after infection with the Zaire Ebola virus.Vaccine2 americans and 1 spanish priest, MYTHS27Isolation and Quarantine, NotificationContact TracingStandard PrecautionsAt All Times, For All Patients Barrier nursingHand washingPersonal Protective Equipment (PPE)Injection safety, Safe sex practicesConcomitant & Terminal Disinfection, SterilisationFollowing SOP for Blood sample collection and TransportAppropriate Hospital Waste managementEnhanced SurveillanceHealth Education: MythsPREVENTION2 americans and 1 spanish priest, MYTHS28PUTTING ONPPE

2 americans and 1 spanish priest, MYTHS29REMOVEPPE

2 americans and 1 spanish priest, MYTHS30STRATEGY FOR PREVENTION AND CONTROL

AIR TRAVELLERSExit 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- WHOSome countries have banned flights and entry to people from the affected regions.

Like france kenya US India32INDIANo 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 1302TN Helpline- 104Rumours from Karnataka-WhatsApp message that student from the National Institute of Technology Karnataka (NITK) in Dakshina Kannada districthad ebola and succumbed to it

Liberia to nigeria.........Nigerian women heading to India dead in UAE33

THANK YOU

PREVENTION IS THE ONLY CURE

THANK YOU...

PREVENTION IS THE ONLY CURE35