Awareness and sensitization seminar By Faculty of Medicine Kaduna State University

1. Awareness and sensitization seminar ByFaculty of MedicineKaduna State University MYTHS AND REALITIES OF EBOLA VIRUS DISEASE (Updated on Oct 19, 2014)

2. 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

3. Introduction Professor OY Elegba Department of Medical Microbiology

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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

15. 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.

16. 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.”

17. 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.

18. 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”.

19. Epidemiology of EVDDr. MA KanaDepartment of Community Medicine

20. 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

21. 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

22. Ebola Landscape

25. 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

26. 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

27. 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

28. Transmission and Infectivity

29. Distribution

30. Ebola outbreaks, 1976-2014

31. 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

33. Burden Case Counts – 20th October 2014

34. Countries With Widespread And Intense Transmission

35. Countries with Travel-associated Cases

36. Countries with Localized Transmission

37. 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.

38. 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.

39. 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

40. Management of Ebola Virus Disease(EVD) Dr. Halima Bello-Manga Department of Haematology

41. Management of EVD The management of EVD is hinged on the following principles; • Proper history and Physical Examination • Lab investigation(diagnosis). • Supportive therapy

42. Medical History EVD 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.

43. 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.

45. Diagnosis Once 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( espat post mortem).

46. Treatment There 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.

47. 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.

49. 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

50. 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).