PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN (PHEIC)

1. PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN (PHEIC) EBOLA (EVD) -Dr.R.PARTHASARATHI,M.D Dept of Community Medicine

2. PHEIC Defined 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 instrument

3. PHEIC 4 decision criteria used in assessment of a public health event are : (a) The seriousness of the event’s 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 SARSmust be immediately notified to WHO, irrespective of the context in which it occurs.

4. PHEIC

5. Ebola virus disease (EVD) • It is one of the world’s 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.

6. Ebola virus • Ebola first appeared in 1976 in 2 simultaneous outbreaks in Nzara, Sudan, and in Yambuku, Congo. • Yambuku village near the Ebola River • Family:Filoviridae • Genus: Ebolavirus (3 members Marburgvirus, Cuevavirus) • Species:5 types • Bundibugyoebolavirus (BDBV) • Zaire ebolavirus (EBOV) • Sudan ebolavirus (SUDV) • Reston ebolavirus (RESTV) • Taï Forest ebolavirus (TAFV).

7. Ebola SPECIES • BDBV, EBOV, and SUDV have been associated with large EVD outbreaks in Africa. • The RESTV species, found in Philippines and the People’s Republic of China, can infect humans, but no illness or death in humans from this species has been reported to date.

8. ENVIRONMENTAL PERSISTANCE • Under 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.

9. 2014 OUTBREAK • On 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 ZaïreEbolavirus (EBOV) • As of August 16, 2014, 2,240 suspected or confirmed cases, including 1383 laboratory-confirmed cases and 1,229 deaths

10. 2014 OUTBREAK

11. TRANSMISSION • Natural Host: Fruit batsof the Pteropodidae family (Hypsignathusmonstrosus, Epomopsfranqueti, and Myonycteristorquata) • 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)

12. ENZOOTIC EPIZOOTIC EPIDEMIC

13. Human-to-Human transmission • Direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people • Indirect 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 days CASE FATALITY RATE: 53% • All cases in the current outbreak- H2H

15. Signs and symptoms • PRODROME: 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.

17. Person 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 in—or travel to—an area where EVD transmission is active; or direct handling of bats, rodents, or primates from disease-endemic areas.

18. Case Definition for EVD Probable Case • A PUI who is a contact of an EVD case with either a high or low risk exposure. Confirmed Case • A case with laboratory confirmed diagnostic evidence of Ebola virus infection.

19. Contacts of an EVD Case Contacts have different levels of exposure risk, as follows: High risk exposures A high risk exposure includes any of the following: • Percutaneous, e.g. the needle stick, or mucous membrane exposure to body fluids of EVD patient • Direct care or exposure to body fluids of an EVD patient without appropriate PPE • Laboratory worker processing body fluids of confirmed EVD patients without appropriate PPE or standard biosafety precautions • Participation in funeral rites which include direct exposure to human remains in the geographic area where outbreak is occurring without appropriate PPE

20. Contacts of an EVD Case Low risk exposures A Low risk exposure includes any of the following: • Household member or other casual contact* with an EVD patient • Providing patient care or casual contact* without high-risk exposure with EVD patients in health care facilities in EVD outbreak affected countries No known exposure • Persons with no known exposure were present in an EVD outbreak affected country in the past 21 days with no low risk or high risk exposures.

21. *Casual contact Defined 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 OR • having 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.

22. DIFFERENTIAL Diagnosis Always rule out • Other Viral Haemorrhagic Fevers. • Malaria • Yellow fever • Dengue • Leptospirosis • Typhoid Fever • Shigellosis • Rickettsiosis • Relapsing Fever • Cholera • Plague • Hepatitis

23. Laboratory findings • Thrombocytopenia, leukopenia with a pronounced lymphopenia. • Neutrophilia develops after several days • Elevations in aspartateaminotransferase and alanineaminotransferase. • 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.

24. Laboratory DIAGNOSIS Definitive diagnosis by • Antibody-capture ELISA • Antigen detection tests • Serum neutralization test- serological surveys • RT-PCR assay • Virus 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 only • NCDC, New Delhi and NIV,Pune in our country Highly sensitive and confirmatory tests

25. MANAGEMENT • Isolate 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 Authority • Clinical 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 needed • No specific drug treatment

26. Experimental treatment Zmapp • Combination of monoclonal antibodies which binds with outer glycoprotein of the virus and prevents its entry to the host cells • Efficacy 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 2015 Tekmira, a Canadian biotech company, has begun early human trials of a new drug 

27. Vaccine • NOT 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 virus–based vaccine has protected macaques when given both before and after infection with the Zaire Ebola virus.

28. PREVENTION • Isolation and Quarantine, Notification • Contact Tracing • Standard Precautions–At All Times, For All Patients • Barrier nursing • Hand washing • Personal Protective Equipment (PPE) • Injection safety, Safe sex practices • Concomitant & Terminal Disinfection, Sterilisation • Following SOP for Blood sample collection and Transport • Appropriate Hospital Waste management • Enhanced Surveillance • Health Education: Myths

29. PPE PUTTING ON

30. PPE REMOVE

31. STRATEGY FOR PREVENTION AND CONTROL

32. AIR TRAVELLERS • Exit 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- WHO • Some countries have banned flights and entry to people from the affected regions.

33. INDIA • No 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 1302 • TN Helpline- 104 • Rumours from Karnataka-WhatsApp message that student from the National Institute of Technology Karnataka (NITK) in Dakshina Kannada districthadebola and succumbed to it

35. PREVENTIONIS THE ONLY CURE THANK YOU... THANK YOU