1. PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN (PHEIC)
EBOLA (EVD)
Bushmeat is meat from wild animals hunted in Africa, Asia, and South America
-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. Any 2 criteria Notify WHO
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 SARS must be immediately notified to WHO, irrespective of the context in which it occurs.
stocks

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
Bundibugyo ebolavirus (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.
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 genes

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 Zaïre Ebolavirus (EBOV)
As of August 16, 2014,
2,240 suspected or confirmed cases, including laboratory-confirmed cases and
1,229 deaths

10. 2014 OUTBREAK

11. TRANSMISSION Natural Host: Fruit bats of the Pteropodidae family
(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)

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
 the survival rate has been higher than previous outbreaks. ALL CASES
WHO advises that the deceased be handled and buried by trained case management professionals, who are equipped to properly bury the dead.

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.
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 common
Myocarditis 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.

16. 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.

17. Person Under Investigation (PUI)
A person who has both consistent symptoms & risk factors:
1) Clinical criteria, which includes fever of greater than degrees Celsius or 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.
Central and western africa

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.
personal protective equipment

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

23. Laboratory findings
Thrombocytopenia, leukopenia with a pronounced lymphopenia.
Neutrophilia develops after several days
Elevations 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.

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
because 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.

25. MANAGEMENT Isolate the patient Notify the State and National Authority
• 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 
2 americans and 1 spanish priest, MYTHS

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.
2 americans and 1 spanish priest, MYTHS

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
2 americans and 1 spanish priest, MYTHS

29. PPE
PUTTING ON
2 americans and 1 spanish priest, MYTHS

30. PPE
REMOVE
2 americans and 1 spanish priest, MYTHS

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.
Like france kenya US India

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‘:
, 3205 and 1302
TN Helpline- 104
Rumours 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 UAE

35. PREVENTION IS THE ONLY CURE
THANK YOU...
THANK YOU
PREVENTION IS THE ONLY CURE