1. Ebola virus disease - Transmission through body fluids; perspectives from outbreak response in Liberia Dr Margaret Fitzgerald Public Health Medicine

2. Ebola Filoviridae Ebolavirus – 5 viruses/species –Ebola (Zaire) –Sudan –Bundibugyo –Tai Forest –Reston Marburgvirus (single species) Cuevavirus 2

3. Host - ? Fruit bat Any of these can infect humans

4. Once a human is infected, human-to- human transmission occurs

5. How are humans infected? Human-to-human transmission –Direct contact with blood or secretions of infected people, including urine, faeces, vomit, spit, sweat, semen and breast milk –Exposure to objects or environment contaminated with infected secretions –Burial ceremonies through direct contact with the body Access through mucosal surface / breaks in skin / parenteral Healthcare workers must practice strict infection prevention and control precautions 5

6. Human-to-Human Transmission Ebola is transmitted through: –Touching body fluids of a person who is sick with or has died from Ebola, –Touching or using objects contaminated with Ebola – But is it actually sexually acquired ? –Knowledge mostly from studies of semen

7. Ebola Transmission Assessment of the Risk of Ebola Virus Transmission from Bodily Fluids and Fomites. S142 JID 2007:196 (Suppl 2) Bausch et al. –Clinical specimens from 26 lab confirmed cases of Ebola plus environmental specimens collected from isolation ward, for presence of EBOV. –Virus was detected by culture and/or PCR 16 / 54 clinical specimens (including saliva, stool, semen, breast milk, tears, nasal blood, and a skin swab) and in 2/ 33 environmental specimens. –Conclusion : EBOV is shed in a wide variety of bodily fluids during the acute period of illness but that the risk of transmission from fomites in an isolation ward and from convalescent patients is low when currently recommended infection control guidelines for the viral hemorrhagic fevers are followed. http://jid.oxfordjournals.org/content/196/Supplement_2/S142.full http://www.livescience.com/47218-ebola-transmission-routes.html http://www.cdc.gov/vhf/ebola/transmission/human-transmission.html Review Evidence and understanding of Ebola virus transmission is based on epidemiologic and laboratory data, summarized below, including investigations of >20 African outbreaks since 1976.66 Sexual transmission of Marburg virus (but not Ebola virus) has been described3636 http://www.cdc.gov/vhf/ebola/transmission/index.html?s_cid=cs_4053

8. Virus culture and reverse-transcription polymerase chain reaction (RT-PCR) results from 54 clinical samples collected from 26 patients with laboratory-confirmed Ebola hemorrhagic fever. Bausch D G et al. J Infect Dis. 2007;196:S142-S147 © 2007 by the Infectious Diseases Society of America

9. Signs and Symptoms Signs generally 2-21 days after contact with a person who is sick with Ebola –Most commonly 1-2 weeks, mean 11.4 days People who do not show signs of disease cannot spread the disease Also people ill with Ebola ? Likely to be able to have sex?

10. Ebola Virus – typical path through a human being 10 Note: On day 7-9 gastrointestinal symptoms can occur; vomiting, diarrhoea and abdominal pain Death from hypovolemic shock and multiorgan failure: 6-16 days

12. Liberia MAJOR CHRONOLOGICAL EVENTS 12 17th March 2014: Reports from Lofa County Health Officer of 2 suspected cases of hemorrhagic fever in Foya 21 March 2014: EVD was Laboratory confirmed in Guinea 22 nd March 2014: Joint MOH-WHO team to Foya for investigation and response 24 th March 2014: NTF is established 30 th March 2014: EVD confirmed in Liberia 1 st April 2014: Joint MOH-WHO investigation team ( including Chief Medical Officer, MOH and WR) travel to Lofa 25 th May 2014: Onset of 2 nd wave of EVD outbreak (no case reported between 10 April and 24 th May) 30 th July 2014: President Launches National EVD Response Plan August Quarantine in City Aug- Sept Humanitarian crisis declared WHO ROAD MAP

13. Liberia case Investigation in community with EPI Questionnaire (3-4 pages)

15. Early MOH-WHO Treatment unit

16. Ebola Treatment Unit (ETU) Patient Register Book

17. Laboratory 1 st test can be negative in early days of illness; need to repeat Test for recovery – sequential tests Convalescence virus in semen

18. Burial Had to design new EPI form for cremations/ burials

19. Survive and advice

20. Convalescence Virus can continue to be found in semen for seven weeks after recovery from the disease Sexual transmission of Ebola not definitively established, studies shown that the virus can persist in semen for longer than in blood or other body fluids hence advice re condom and abstention

21. Recovery and Stigma India man detained at Delhi airport post recovery as semen tests positive Nov. 10, carried documents from Liberia confirming he had successfully undergone Ebola treatment and had been declared free of any symptoms, the health ministry said. He was placed in quarantine as a precautionary measure as authorities tested his blood over the next several days. Although his blood tests were clear, authorities decided to test his semen before releasing him from quarantine. Those tests showed traces of the virus.

22. How EVD outbreak has grown since March 2014 Source: http://www.telegraph.co.uk/

23. Acknowledgements Adapted from materials produced by: –Darina O Flanagan HPSC –Dr Orla Condell and Nadine Zeitleman EuPHEM and EPIET WHO Goarn –World Health Organisation (WHO) –Centers for Disease Control and Prevention (CDC) –Nigerian Centre for Disease Control and Prevention –Public Health England –Dr Todd F Hatchette, Nova Scotia, Canada

24. More Information Health Protection Surveillance Centre http://www.hpsc.ie/News/MainBody,14571,en.html CDC http://www.cdc.gov/vhf/ebola/index.html WHO http://www.who.int/csr/disease/ebola/en/ HSE http://www.hse.ie/eng/services/Campaigns/Ebolaupdate. html