1. Ebola outbreak in West Africa Last updated 15 September 2014

2. Pandemic and Epidemic Diseases department 2 |2 | ● Introduction to Ebola Virus Disease ● Global Update ● Essential Element for Control of On- going Outbreak ● WHO response to the Outbreak Ebola Virus Disease

3. Pandemic and Epidemic Diseases department 3 |3 | Introduction to Ebola Virus Disease

4. Pandemic and Epidemic Diseases department 4 |4 | History 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.

5. Pandemic and Epidemic Diseases department 5 |5 | Ebola and Marburg viruses Family 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)

6. Pandemic and Epidemic Diseases department 6 |6 | Disease 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

7. Pandemic and Epidemic Diseases department 7 |7 | ●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 Disease

8. Pandemic and Epidemic Diseases department 8 |8 | 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

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11. Pandemic and Epidemic Diseases department 11 | 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

12. Pandemic and Epidemic Diseases department 12 | Short Duration Viraemia Time 3-7 days3-15 days Fever Virus / Antigen Neutralizing / IgG ELISA Antibodies IgM Antibodies Incubation Disease (Figure adapted from T Ksiazek CDC/Atlanta)

13. Pandemic and Epidemic Diseases department 13 | ●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 Collection

14. Pandemic and Epidemic Diseases department 14 | ●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 Shipment

15. Pandemic and Epidemic Diseases department 15 | ●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)

16. Pandemic and Epidemic Diseases department 16 | 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)

17. Pandemic and Epidemic Diseases department 17 | Disease 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

18. Pandemic and Epidemic Diseases department 18 | 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

19. Pandemic and Epidemic Diseases department 19 | Global Update

20. Pandemic & Epidemic Diseases department 20 | Status of Ebola Outbreak 2014 as of 5 September 2014

21. Pandemic & Epidemic Diseases department 21 | Geographical location of confirmed an probable cases in West Africa 15 September 2014

22. Pandemic & Epidemic Diseases department 22 | Ebola West Africa- Distribution of cases by week of onset as of 15 September 2014

23. Pandemic & Epidemic Diseases department 23 | Ebola West Africa- Distribution of cases by week of onset and by country (1) as of 15 September 2014

24. Pandemic & Epidemic Diseases department 24 | Ebola West Africa- Distribution of cases by week of onset and by country (2) as of 15 September 2014

25. Pandemic & Epidemic Diseases department 25 | Ebola West Africa- Distribution of cases by week of onset and by country (3) as of 15 September 2014

26. Pandemic & Epidemic Diseases department 26 | Response in countries with widespread and intense transmission

27. Pandemic and Epidemic Diseases department 27 | Essential Elements for Control of On-going Outbreak

28. Pandemic and Epidemic Diseases department 28 | Essential 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/

29. Pandemic and Epidemic Diseases department 29 | ● 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 outbreak

30. Pandemic and Epidemic Diseases department 30 | Psycho- social support Control of vectors and reservoirs in nature Triage In/out Barrier nursing Clinical trials Ethics committee Organize funerals Anthropological evaluation Specimens Laboratory testing Follow-up of contacts Active case-finding Infection control Social and Epidemiological mobile teams Security Police Lodging Food Formal and informal modes of communication Search the source Database analysis Finances Salaries Transport Vehicles Epidemiological investigation, surveillance and laboratory Logistics Clinical case Management Behavioural and social interventions Ethical aspects Duty of care Research Coordination Medias Communication Press Journalists Social and Cultural practices Women, associations Traditional healers Opinion leaders General strategy to CONTROL Ebola outbreak

31. Pandemic and Epidemic Diseases department 31 | Clinical Management and IPC

32. Pandemic & Epidemic Diseases department 32 | 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.

33. Pandemic & Epidemic Diseases department 33 | 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

34. Pandemic & Epidemic Diseases department 34 | 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.

35. Pandemic & Epidemic Diseases department 35 | 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 Update http://www.who.int/csr/resources/who-ipc-guidance-ebolafinal-09082014.pdf

36. Pandemic & Epidemic Diseases department 36 | 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 accidents WHO Interim IPC Guidance - 2014 Update http://www.who.int/csr/resources/who-ipc-guidance-ebolafinal-09082014.pdf

37. Pandemic & Epidemic Diseases department 37 | PPE 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 Update http://www.who.int/csr/resources/who-ipc-guidance-ebolafinal-09082014.pdf

38. Pandemic and Epidemic Diseases department 38 | Epidemiological Investigation, surveillance and laboratories

39. Pandemic and Epidemic Diseases department 39 | 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, hiccup OR - with inexplicable bleeding OR - that died suddendly and inexplicably Case definition (1): SUSPECTED CASE

40. Pandemic and Epidemic Diseases department 40 | PROBABLE CASE Any suspected case evaluated by a clinician that has had an epidemiological link with a confirmed case LABORATORY-CONFIRMED CASES Any 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-CASE Any 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)

41. Pandemic and Epidemic Diseases department 41 | - 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

42. Pandemic and Epidemic Diseases department 42 | - To be completed soon Contact tracing

43. Pandemic and Epidemic Diseases department 43 | Behavioral and Social Interventions

44. Pandemic and Epidemic Diseases department 44 | 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

45. Pandemic and Epidemic Diseases department 45 | 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

46. Pandemic and Epidemic Diseases department 46 | 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

47. Pandemic and Epidemic Diseases department 47 | 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 WHO

48. Pandemic and Epidemic Diseases department 48 | Points of entry – International travel and transport

49. Pandemic and Epidemic Diseases department 49 | 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 PoE Allocate 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 - ITT

50. Pandemic and Epidemic Diseases department 50 | WHO Response to the Outbreak

51. Pandemic and Epidemic Diseases department 51 | 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 Background

52. Pandemic and Epidemic Diseases department 52 | 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 Roadmap

53. Pandemic and Epidemic Diseases department 53 | 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 Roadmap

54. Pandemic and Epidemic Diseases department 54 | Ebola Response Roadmap

55. Pandemic and Epidemic Diseases department 55 | 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 ACTIVITIES

56. Pandemic and Epidemic Diseases department 56 | 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 ACTIVITIES

57. Pandemic and Epidemic Diseases department 57 | OPERATIONALIZING THE ROAD MAP

58. Pandemic and Epidemic Diseases department 58 | MAJOR ROLES & RESPONSABILITIES

59. Pandemic and Epidemic Diseases department 59 | EBOLA 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

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