ebola outbreak in west africa last updated 15 september 2014
TRANSCRIPT
Pandemic and Epidemic Diseases department2 |
●Introduction to Ebola Virus Disease●Global Update●Essential Element for Control of On-going Outbreak●WHO response to the Outbreak
Ebola Virus DiseaseEbola Virus Disease
Pandemic and Epidemic Diseases department3 |
Introduction to Ebola Virus DiseaseIntroduction to Ebola Virus Disease
Pandemic and Epidemic Diseases department4 |
History of Ebola Virus OutbreaksHistory of Ebola Virus Outbreaks
● 1976, Ebola first appeared in 2 simultaneous outbreaks in Sudan and in Democratic Republic of Congo
● Since Ebola discovery in 1976 until December 2013:
23 outbreaks, 2388 human cases including 1590 deaths
● The 2014 current Ebola outbreak began in Guinea in December 2013. This outbreak now involves transmission in Guinea, Liberia, Nigeria, and Sierra Leone.
● As of 21 August 2014, countries have reported 2550 cases (1490 confirmed, 718 probable, 342 suspect), including 1339 deaths. Currently the largest EVD outbreak ever recorded.
Pandemic and Epidemic Diseases department5 |
Ebola and Marburg virusesEbola and Marburg virusesFamily Filoviridae, single-strand, negative-sense RNA virus
Genus Marburgvirus, 1 species Marburg marburgvirus– Virus 1: Marburg virus (MARV)– Virus 2: Ravn virus (RAVV)
Genus Ebolavirus, 5 distinct species– Species Taï Forest ebolavirus, virus: Taï Forest virus (TAFV)– Species Reston ebolavirus, virus: Reston virus (RESTV)– Species Sudan ebolavirus, virus: Sudan virus (SUDV)– Species Zaire ebolavirus, virus: Ebola virus (EBOV)– Species Bundibugyo ebolavirus, virus: Bundibugyo virus (BDBV)
Genus Cuevavirus*, Species Lloviu cuevavirus*– virus: Lloviu virus (LLOV)
Pandemic and Epidemic Diseases department6 |
Disease in animalsDisease in animals In Africa, since 1994, outbreaks from the EBOV and TAFV
observed in chimpanzees and gorillas
In Philippines, RESTV has caused severe EVD outbreaks in macaque monkeys farmed and was detected in monkeys imported into the USA in 1989, 1990 and 1996, and in monkeys imported to Italy from Philippines in 1992
Since 2008, RESTV viruses detected during several outbreaks of a deadly disease in pigs in Philippines and People’s Republic of China
Pandemic and Epidemic Diseases department7 |
● Incubation 2-21 days● Case Fatality Ratio 24-89%● Handling specimens requires BSL 4 ● Treatment is supportive but effective in reducing mortality
Rehydration, intensive care● Some potential specific treatment
Monoclonal antibodies• Very limited availability• Limited information on safety & efficacy
Other candidate drugs also in early stages of testing
● Vaccines in development
Ebola Virus DiseaseEbola Virus Disease
Pandemic and Epidemic Diseases department8 |
How Ebola Outbreaks Start
● First human cases start with infection by an animal Chimpanzes, gorillas, monkeys, forest antelopes, fruit bats,
porcupine... How 2014 outbreak in West Africa started is unknown
● Infection from person-to-person creates an outbreak Direct or indirect physical contact with body fluids of
infected person (blood, saliva, vomitus, urine, stool, semen)
● Well known locations where transmission occurs Hospital: health care workers, other patients, unsafe injections Communities: Family, friends, contacts caring for ill, through
funeral practices
Pandemic and Epidemic Diseases department11 |
Diagnosis Diagnosis ● Diseases that should be ruled out include: malaria, typhoid fever,
shigellosis, cholera, leptospirosis, plague, rickettsiosis, relapsing fever, meningitis, hepatitis and other viral haemorrhagic fevers
● Essential role of patient history; exposure to area/village with ongoing outbreak and/or contact with confirmed cases
● Diagnostic tests: ● Antibody-capture enzyme-linked immunosorbent assay (ELISA)● Antigen detection tests● Reverse transcriptase polymerase chain reaction (RT-PCR) assay● Electron microscopy● Virus isolation by cell culture
Pandemic and Epidemic Diseases department12 |
Short Duration ViraemiaShort Duration Viraemia
Time3-7 days
3-15 days
Fever
Virus / Antigen
Neutralizing /IgG ELISA Antibodies
IgM Antibodies
Incubation Disease(Figure adapted from T Ksiazek CDC/Atlanta)
Pandemic and Epidemic Diseases department13 |
● Preferred specimens Whole blood preserved with EDTA: see WHO guide
“How to safely collect blood samples from persons suspected to be infected with Ebola” on WHO website
Oral swabs from deceased patients● Laboratory diagnosis: Extreme biohazard risk; testing
should be conducted under maximum biological containment conditions. Samples handled by trained staff & processed in suitably equipped laboratories (BSL4).
Sample CollectionSample Collection
Pandemic and Epidemic Diseases department14 |
● Shipment of specimens should follow international standards shipping procedures for “transport of category A infectious substances” (triple packaging system)
● Shipping logistics coordinated through EDPLN network
● Category A for live virus● Category B for inactivated specimens
Specimens ShipmentSpecimens Shipment
Pandemic and Epidemic Diseases department15 |
● A network of high security diagnostic laboratories Human and Animal High Security Laboratories BSL-4 and selected
BSL-3
● Supports rapid response to detect, diagnose and control novel disease threats Laboratory response
Assay and reagent development
Technology transfer and training
Applied research
Global coordination and information exchange
Emerging and Dangerous Pathogens Laboratory Network (EDPLN)
Pandemic and Epidemic Diseases department16 |
EDPLN - 23 members globally
EDPLN - 23 members globally
Region of the Americas
WHO regions
African Region
South-East Asia Region
European Region
Eastern Mediterranean Region
Western Pacific Region
EDPLN member (6 members)
EDPLN member and WHO CC (15 members)
EDPLN member and veterinary laboratory (2 members)
Pandemic and Epidemic Diseases department17 |
Disease in humans: Clinical SymptomsDisease in humans: Clinical Symptoms
● Incubation period: 2 – 21 days
● Start with feverish syndrome: often characterized by the sudden onset of fever, intense weakness, muscle pain, headache and sore throat
● 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
Pandemic and Epidemic Diseases department18 |
Disease in Humans: Treatment Disease in Humans: Treatment
● Intensive supportive care is required
● Supportive care: monitor fluid and electrolyte balance and renal function, careful rehydration
● Provide supportive drug therapy : painkillers, antiemetic for vomiting, anxiolytic for agitation, +/-antibiotics and/or antimalarial drugs
● Some potential specific treatment Monoclonal antibodies Other candidate drugs also in early stages of testing
Pandemic & Epidemic Diseases department 20 |
Status of Ebola Outbreak 2014 as of 5 September 2014Status of Ebola Outbreak 2014 as of 5 September 2014
Pandemic & Epidemic Diseases department 21 |
Geographical location of confirmed an probable cases in West Africa
15 September 2014
Geographical location of confirmed an probable cases in West Africa
15 September 2014
Pandemic & Epidemic Diseases department 22 |
Ebola West Africa- Distribution of cases by week of onset
as of 15 September 2014
Ebola West Africa- Distribution of cases by week of onset
as of 15 September 2014
Pandemic & Epidemic Diseases department 23 |
Ebola West Africa- Distribution of cases by week of onset and by country (1)
as of 15 September 2014
Ebola West Africa- Distribution of cases by week of onset and by country (1)
as of 15 September 2014
Pandemic & Epidemic Diseases department 24 |
Ebola West Africa- Distribution of cases by week of onset and by country (2)
as of 15 September 2014
Ebola West Africa- Distribution of cases by week of onset and by country (2)
as of 15 September 2014
Pandemic & Epidemic Diseases department 25 |
Ebola West Africa- Distribution of cases by week of onset and by country (3)
as of 15 September 2014
Ebola West Africa- Distribution of cases by week of onset and by country (3)
as of 15 September 2014
Pandemic & Epidemic Diseases department 26 |
Response in countries with widespread and intense transmission
Response in countries with widespread and intense transmission
Pandemic and Epidemic Diseases department27 |
Essential Elements for Control of On-going Outbreak
Essential Elements for Control of On-going Outbreak
Pandemic and Epidemic Diseases department28 |
Essential components for controlEssential components for control
● Interim manual - Ebola and Marburg virus disease epidemics: preparedness, alert, control, and evaluation
● This document describes preparedness, prevention, and control measures that have been implemented successfully during previous epidemics
http://www.who.int/csr/disease/ebola/manual_EVD/en/
Pandemic and Epidemic Diseases department29 |
●National leadership and risk communication
●Outbreak control measures to stop transmission:
- Clinical Management and IPC
- Epidemiological investigation, surveillance and laboratories
- Behavioral and social interventions
- Logistics
Control the outbreakControl the outbreak
Pandemic and Epidemic Diseases department30 |
Psycho-social
support
Control of vectors and
reservoirs in nature
Triage In/out
Barriernursing
Clinical trialsEthics committee
Organizefunerals
Anthropologicalevaluation
SpecimensLaboratory
testing
Follow-upof contacts
Active case-finding
Infection
control
Social and Epidemiological
mobile teams
SecurityPolice
Lodging
Food
Formal and informal modes of
communication
Search the source
Databaseanalysis
FinancesSalaries
TransportVehicles
Epidemiological investigation,surveillance
and laboratory
Logistics
Clinical caseManagement
Behavioural and
social
interventions
Ethical aspects
Duty of careResearchCoordinationMedias
Communication Press
Journalists
Social andCultural
practices
Women, associations Traditional healersOpinion leaders
General strategy to CONTROL Ebola outbreak
Pandemic and Epidemic Diseases department31 |
Clinical Management and IPCClinical Management and IPC
Pandemic & Epidemic Diseases department 32 |
Clinical Management and Patient Care
Clinical Management and Patient Care
● The diagnosis is based on 3 components:
– History of exposure: 2-21 days (e.g., caring for family members, attending funeral, investigate network).
– Detailed clinical assessment (maintain high level of suspicion, differential diagnosis).– Laboratory investigations (false negatives in early phase possible).
● Early clinical features:
– Flu-like symptoms: weakness, malaise, fever, headache, hiccups.– Gastrointestinal: diarrhea, nausea, vomiting, difficulty swallowing. – Bleeding not usually an early sign.
● Observe case definitions for alert, suspect, and probable cases. Confirmation by laboratory results.
●Clinical management: predominantly supportive, symptom control, identification and treatment of comorbidities, co-infections.
Pandemic & Epidemic Diseases department 33 |
Patient Care: New Medicines and vaccines (1)Patient Care: New Medicines and vaccines (1)
● Several new treatment options are under development, among which: ZMap: a cocktail of three monoclonal antibodies
produced in plants Convalescent plasma Hyperimmune globulins made in horses or cattle siRNA (Lipid Nanoparticle Small interfering RNAs) BCX4430: a chemical which blocks viral replication T705: chemical substitution of constituent needed for
viral replication
Pandemic & Epidemic Diseases department 34 |
Patient Care: New medicines and vaccines (2)Patient Care: New medicines and vaccines (2)
● Two recombinant vaccines, based on a non-replicative Chimpanzee
adenovirus 3 vector or a VSV attenuated vector, have been shown
to protect non-human primates against Ebola virus infection. Their
development is being fast-tracked, with first-in-man Phase 1 clinical
likely to start in September 2014 in the USA
● None of the above products is currently registered for use in EVD,
which warrants an ethical discussion on how quickly they can be
made available to those in needs.
Pandemic & Epidemic Diseases department 35 |
Infection Prevention and Control Infection Prevention and Control
● Avoid shaking hands
●Personal Protective Equipment (PPE) not required if all below apply:
– Distance >1 meter from interviewee– Interviewing asymptomatic people– No contact with potentially contaminated environment
●Provide alcohol-based handrub solutions and instructions to perform hand hygiene
WHO Interim IPC Guidance - 2014 Updatehttp://www.who.int/csr/resources/who-ipc-guidance-ebolafinal-09082014.pdf
Pandemic & Epidemic Diseases department 36 |
IPC Essential Precautions in Healthcare Facilities
IPC Essential Precautions in Healthcare Facilities
● Standard precautions for all patients at all times
●Isolation of suspected and confirmed cases in separated rooms/areas with restricted access
●Exclusively dedicated staff and equipment for isolation rooms/areas
●Hand hygiene with alcohol-based handrub or water and soap
●Use of PPE (see next slide)
●Rigorous environmental cleaning and surfaces/objects decontamination
●Safe injection practices and sharps handling
●Post-exposure evaluation and care following professional accidentsWHO Interim IPC Guidance - 2014 Update
http://www.who.int/csr/resources/who-ipc-guidance-ebolafinal-09082014.pdf
Pandemic & Epidemic Diseases department 37 |
PPE for patient care and non clinical carePPE for patient care and non clinical care
● For visitors, health-care workers, cleaners, laboratory staff, anyone providing patient care and/or having contact with contaminated surfaces, blood or body fluids, clinical samples, infectious waste, dead bodies
●At least: gloves, gown, rubber boots/closed shoes with overshoes, and mask and eye protection for splashes
●Impermeable gown or plastic apron over gown and double gloves for any strenuous activity or tasks with contact with blood and body fluids
●Respirators needed only for aerosol-generating procedures
WHO Interim IPC Guidance - 2014 Updatehttp://www.who.int/csr/resources/who-ipc-guidance-ebolafinal-09082014.pdf
Pandemic and Epidemic Diseases department38 |
Epidemiological Investigation, surveillance and laboratories
Epidemiological Investigation, surveillance and laboratories
Pandemic and Epidemic Diseases department39 |
Any person that has travelled or/and has stayed, in a country that has reported at least one confirmed case of Ebola Virus Disease, within a period of 21 days before onset of symptoms, and :- with sudden onset of high fever and at least three of the following symptoms : headaches, vomiting, anorexia/loss of appetite, diarrhoea, lethargy, stomach pain, aching muscles or joints, difficulty swallowing, breathing difficulties, hiccupOR - with inexplicable bleedingOR- that died suddendly and inexplicably
Case definition (1): SUSPECTED CASECase definition (1): SUSPECTED CASE
Pandemic and Epidemic Diseases department40 |
PROBABLE CASEAny suspected case evaluated by a clinician that has had an epidemiological link with a confirmed case
LABORATORY-CONFIRMED CASESAny suspected or probable cases with a positive laboratory result. Laboratory-confirmed cases must test positive for the virus antigen, either by detection of virus RNA by reverse transcriptase-polymerase chain reaction (RT-PCR), or by detection of IgM antibodies directed against Ebola virus
NON-CASEAny suspected or probable case with a negative laboratory result. Non-cases are those which showed no specific antibodies, RNA or specific detectable antigens.
Case definition (2)Case definition (2)
Pandemic and Epidemic Diseases department41 |
- Report the case to the surveillance team- After obtaining express consent, collect a biological sample- Fill in a case notification form-Create a list of contacts of the suspected case-If subject is alive: explain to the patient (and family the need to go to hospital to receive adequate medical care) and arrange for hospital transfer-If subject has passed away, explain to the family the need for conducting a safe burial
Instructions when suspected case identified
Instructions when suspected case identified
Pandemic and Epidemic Diseases department43 |
Behavioral and Social Interventions
Behavioral and Social Interventions
Pandemic and Epidemic Diseases department44 |
An informed and engaged population is empowered to make the decisions to best protect themselves, their families and communities from the spread of Ebola virus
Experience has taught us that early and sustained engagement with affected communities is critical for effective disease outbreak control and can limit the spread of disease and lower mortality and morbidity
People at risk of contracting Ebola need to know:
- What is Ebola?
- How does it spread?
- What behaviors they need to change or adopt to best protect them selves and their families?
- Where they can get additional information?
It is critical that communities receive these messages from local trusted leaders, in language and voices they can relate to and understand
The importance of an informed and engaged population
The importance of an informed and engaged population
Pandemic and Epidemic Diseases department45 |
There are a number of important steps and processes that need to be followed to ensure behavioral change/engagement strategies are delivered effectively:
1. They must be data driven – To design effective messaging, tools and products local community knowledge, attitudes, practices and behaviors must be understood – these variables will effect the messaging, strategies and tools needed to engage a community
2. There must be local input into the strategies and messaging - Local community leaders and influencers must be consulted and should contribute to the designing of messages and suitable channels to best reach affected communities - People are more likely to pay attention to information from others that they already know, trust and who they feel are concerned about their well-being.
3. There should be a mix of strategies and approaches - Communities need to hear messages from multiple trusted channels which will lead to faster adoption of the desired protective behaviors
4. There should be robust and regular evaluation – It is critical that community engagement efforts are regularly evaluated for their impact and effectiveness
Establishing the processes to deliver an effective engagement strategy
Establishing the processes to deliver an effective engagement strategy
Pandemic and Epidemic Diseases department46 |
There are a number of priority actions that Ebola affected countries should take to inform and empower populations
1.The President should address the nation declaring Ebola a national health emergency – This address should be widely distributed through TV and radio channels
2.Senior government and UN leadership should travel to affected areas to demonstrate their leadership and support for these communities
3.A coordinating task team for community engagement should be established at national and appropriate sub-national levels with appropriate membership from all ministries, UN partners, International and National NGO Groups, Community Groups
4.Dialogue with local community leaders should be established to identify local, provincial and national leadership that can assist mobilization and engagement of local communities
5.Messages should be crafted and endorsed by this group that address the key behavioral practices relating to health facility patient care, home based care, safe burial and early reporting of cased to treatment centres
6.Rumors should be tracked closely with efforts established to correct and inform with appropriate information
Priority actions to quickly inform and empower populations
Priority actions to quickly inform and empower populations
Pandemic and Epidemic Diseases department47 |
WHO is responsible for ensuring messaging developed at all levels is technically accurate and matches the recommended Ebola outbreak containment strategies and priorities
WHO should support UNICEF and relevant government agencies, particularly the MoH, develop, role out and evaluate evidence based strategies to mobilize and engage with affected communities ensuring that these strategies match Ebola outbreak containment strategies and priorities
WHO should support UNICEF coordinate global partner support especially with agencies or organizations with the ability to support or deliver effective community engagement strategies in affected or at risk countries
The Role of WHOThe Role of WHO
Pandemic and Epidemic Diseases department48 |
Points of entry – International travel and transport
Points of entry – International travel and transport
Pandemic and Epidemic Diseases department49 |
States with EVD transmission:
Develop standard operational procedures and conduct exit screening of all persons at international airports, seaports and major land crossings: for unexplained febrile illness consistent with potential Ebola infection.
– The exit screening should consist of, at a minimum, a questionnaire, a temperature measurement and, if there is a fever, an assessment of the risk that the fever is caused by EVD.
For all points of entry:Ensure public health contingency emergency plan is in place at designated PoEAllocate space at PoE for health assessments in the event of suspected ill travellers is detected. Establish standard operation procedures when ill travellers need to be referred to designated hospitals including identification of adequate ambulance service.Ensure sufficient trained staff with appropriate and sufficient Personal Protective Equipment (PPE) and disinfectants.Raise awareness among conveyance operators for the need of immediate notification to PoE health authorities prior to arrival of any suspected case(s). In regard to air travel, coordinate health sector and stakeholders with civil aviation authorities, airport operators and airlines to facilitate contact tracing and event management, ensuring passenger locator form is on board and at airport and airport ground staff and crew trained for managing EVD and environmental contaminants in flight and at airport.Ensure timely communication between PoE and national health surveillance system Disseminate health information and raise awareness among PoE stakeholders of EVD
PoE - ITTPoE - ITT
Pandemic and Epidemic Diseases department50 |
WHO Response to the OutbreakWHO Response to the Outbreak
Pandemic and Epidemic Diseases department51 |
2-3 July: Emergency Ministerial meeting in Accra, Ghana operations coordination centre in Conakry, Guinea
31 July: Launch of Ebola Outbreak Response Plan Main pillars of activities; initial resource estimates
8 August: DG/WHO declares Public Health Emergency of International Concern Issues IHR Temporary Recommendations
BackgroundBackground
Pandemic and Epidemic Diseases department52 |
Unprecedented nature of event
Responds to demand for comprehensive guidance on Ebola response
The Roadmap consolidates country-specific experience & knowledge into a common framework to:
1. Assist governments & partners in revising/resourcing country-specific plans
2. coordinate international support to implement plans
Need for Updated Response RoadmapNeed for Updated Response Roadmap
Pandemic and Epidemic Diseases department53 |
GOAL:
Stop Ebola transmission globally within 6-9 months, while addressing the broader socioeconomic impact in intense transmission areas & rapidly managing consequences of international spread
Ebola Response RoadmapEbola Response Roadmap
Pandemic and Epidemic Diseases department55 |
Full Ebola intervention package (case mgmt, lab, contact tracing, safe burials, social mobilization)
Develop & apply complementary approaches for intense transmission areas
Institute short-term measures to limit national spread
Implement IHR recs to prevent international spread
Essential services & foundation for sector recovery
OBJ. 1 – PRIORITY ACTIVITIESOBJ. 1 – PRIORITY ACTIVITIES
Pandemic and Epidemic Diseases department56 |
OBJ 2. Emergency Response Countries Initiate emergency health procedures Immediately activate Ebola response
protocols/facilities Implement IHR Recs to prevent international spread
OBJ 3. Preparedness all unaffected countries countries bordering Ebola-infected areas countries international transportation hub(s)
OBJ. 2&3 – PRIORITY ACTIVITIESOBJ. 2&3 – PRIORITY ACTIVITIES
Pandemic and Epidemic Diseases department57 |
OPERATIONALIZING THE ROAD MAPOPERATIONALIZING THE ROAD MAP
Pandemic and Epidemic Diseases department58 |
MAJOR ROLES & RESPONSABILITIESMAJOR ROLES & RESPONSABILITIES
Pandemic and Epidemic Diseases department59 |
EBOLA WHO websiteEBOLA WHO website
http://www.who.int/csr/disease/ebola/en/
● Technical information Infection control Social mobilization Epidemiology Preparedness and response Patient care
● Guidelines
● Meeting reports
● Disease outbreak news