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Ebola Current status of the outbreak in West Africa and a historical perspective Michael Martin Thailand MOPH-US CDC Collaboration 15 September 2014.

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Presentation on theme: "Ebola Current status of the outbreak in West Africa and a historical perspective Michael Martin Thailand MOPH-US CDC Collaboration 15 September 2014."— Presentation transcript:

1 Ebola Current status of the outbreak in West Africa and a historical perspective Michael Martin Thailand MOPH-US CDC Collaboration 15 September 2014

2 Ebola Filovirus, causes hemorrhagic fever Incubation 5-10 days (range 2-19 days) Fever, myalgias, headache, rash, CNS, bleeding Mortality varies: Sudan 50%, Zaire 80%

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4 Ebola West Africa 2014 Largest Ebola outbreak in history and the first in West Africa As of September 6, 2014, in countries with widespread, intense Ebola transmission CasesDeaths Total15, Liberia Sierra Leone Guinea

5 Ebola cases, March – November 2014 (N = 15,901)

6 Ebola cases reported October 19– November 8, 2014

7 Cumulative incidence of Ebola November 8, 2014

8 Ebola Outbreaks CountryTownCasesDeathsSpeciesYear CongoYambuku318280Zaire1976 South SudanNzara284151Sudan1976 CongoTandala11Zaire1977 South SudanNzara3422Sudan1979 GabonMekouka5231Zaire1994 Ivory CoastTai Forest10Taï Forest1994 CongoKikwit315250Zaire1995 GabonMayibout3721Zaire1996 GabonBooue6045Zaire1996 South AfricaJohannesburg21Zaire1996 UgandaGulu425224Zaire2000 GabonLibreville6553Zaire2001 CongoNot specified5743Zaire2001 CongoMbomo143128Zaire2002 CongoMbomo3529Zaire2003 South SudanYambio177Zaire2004 CongoLuebo264187Zaire2007 UgandaBundibugyo14937Bundibugyo2007 CongoLuebo3215Zaire2008 UgandaLuwero District11Sudan2011 UgandaKibaale District11*4*Sudan2012 CongoIsiro Health Zone36*13*Bundibugyo2012 UgandaLuwero District6*3*Sudan2012 Guinea, Sierra Leone, Liberia multiple1752*897*Zaire2014

9 Ebola Outbreaks CountryTownCasesDeathsSpeciesYear CongoYambuku318280Zaire1976 South SudanNzara284151Sudan1976 CongoTandala11Zaire1977 South SudanNzara3422Sudan1979 GabonMekouka5231Zaire1994 Ivory CoastTai Forest10Taï Forest1994 CongoKikwit315250Zaire1995 GabonMayibout3721Zaire1996 GabonBooue6045Zaire1996 South AfricaJohannesburg21Zaire1996 UgandaGulu425224Zaire2000 GabonLibreville6553Zaire2001 CongoNot specified5743Zaire2001 CongoMbomo143128Zaire2002 CongoMbomo3529Zaire2003 South SudanYambio177Zaire2004 CongoLuebo264187Zaire2007 UgandaBundibugyo14937Bundibugyo2007 CongoLuebo3215Zaire2008 UgandaLuwero District11Sudan2011 UgandaKibaale District11*4*Sudan2012 CongoIsiro Health Zone36*13*Bundibugyo2012 UgandaLuwero District6*3*Sudan2012 Guinea, Sierra Leone, Liberia multiple1752*897*Zaire2014

10 1 st Ebola outbreak 1976, 120-bed Yambuku Hospital in Zaire Initially spread through syringes and needles 13 of 17 hospital staff became sick, and 11 died The hospital was closed when the medical director and three Belgian missionaries died Many patients and contacts fled out of fear and suspicion of medical system, sought treatment from traditional healers Breman JG, Johnson KM. Ebola Then and Now. NEJM DOI: /NEJMp

11 Ebola response leadership Outbreak Commission established, lead by Minister of Health, daily meetings: share information, define action steps Commission members went to Yambuku to define extent of outbreak, find cases, assess clinical care and lab needs Others remained in Kinshasa to organize surveillance, isolate contacts, and marshal resources Contact tracing teams, led by MD or RN, trained to recognize Ebola, interview techniques, patient isolation, and personal protection

12 Epicurve

13 Actions that help end outbreak Commission worked closely with national and local leaders Coordinating with partners, transparent and clear line of authority and responsibilities Explaining what was known and not known, treating patients, visiting villages, using evidence-based guidance

14 Ebola Outbreaks CountryTownCasesDeathsSpeciesYear CongoYambuku318280Zaire1976 South SudanNzara284151Sudan1976 CongoTandala11Zaire1977 South SudanNzara3422Sudan1979 GabonMekouka5231Zaire1994 Ivory CoastTai Forest10Taï Forest1994 CongoKikwit315250Zaire1995 GabonMayibout3721Zaire1996 GabonBooue6045Zaire1996 South AfricaJohannesburg21Zaire1996 UgandaGulu425224Sudan2000 GabonLibreville6553Zaire2001 CongoNot specified5743Zaire2001 CongoMbomo143128Zaire2002 CongoMbomo3529Zaire2003 South SudanYambio177Zaire2004 CongoLuebo264187Zaire2007 UgandaBundibugyo14937Bundibugyo2007 CongoLuebo3215Zaire2008 UgandaLuwero District11Sudan2011 UgandaKibaale District11*4*Sudan2012 CongoIsiro Health Zone36*13*Bundibugyo2012 UgandaLuwero District6*3*Sudan2012 Guinea, Sierra Leone, Liberia multiple1752*897*Zaire2014

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16 Outbreak investigation launched Identify and confirm cases Isolate and care for infected patients Identify contacts to stop the chains of transmission Monitor contacts for 21 days Bring the outbreak to an end

17 Surveillance definitions Alert – used by community to alert health-care professionals – Sudden onset high fever, sudden death, hemorrhage Suspect – used by mobile team to decide whether to transport patient to isolation ward – Fever and contact with potential case, unexplained bleeding, fever + 3 or more (HA, V/D, body/joint pains) Probable – suspect criteria and evaluated by MD Presumptive – suspect or probable + bleeding or fever + 3 or unexplained death Lab confirmed – probable + Ebola Ag or Ab

18 Exposure definitions High risk exposures – Percutaneous or mucous membrane exposure to blood or body fluids of EVD patient – Skin contact to blood or body fluids of EVD patient without appropriate PPE – Processing blood or body fluids of confirmed EVD patient without appropriate PPE or biosafety precautions – Direct contact with dead body without PPE in EVD outbreak country Low risk exposures – Household contact with an EVD patient – Other close contact with EVD patients in health care or community settings. being within 3 feet (1 meter) of EVD patient or in patient’s room for prolonged period (e.g., health care personnel, household members) while not wearing PPE direct brief contact (e.g., shaking hands) with EVD patient while not wearing PPE – Brief interactions: walking by person or moving through hospital, not close contact No known exposure – Having been in a country with a EVD outbreak and having had no high or low risk exposures

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20 Gulu Ebola Outbreak 2000 Largest Ebola outbreak until suspected cases/224 (53%) deaths Transmission: funerals, families, health care workers (14/22 St. Mary’s Hospital staff infected) Signs and symptoms among 62 confirmed- cases at Gulu Hospital SymptomsNo. (%) Diarrhea41 (66) Asthenia40 (64) Headache39 (63) Vomiting37 (60) Abdominal pain34 (55) Bleeding12 (20)

21 Gulu activities Ill suspect cases hospitalized Contacts followed for 21 days Burial teams trained Community education Cessation of traditional healing and burial practices Cessation of large public gatherings Updated hospital infection-control measures Dr. Matthew Lukwiya

22 Infection Control Training

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24 Mobile teams

25 Assessing potential cases and deaths

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27 Collecting specimens for testing

28 Burial preparation

29 Routine medical care

30 Hospital modifications: evaluation area

31 Guinea Number of new cases of Ebola virus disease reported — West Africa, September 28–October 18

32 MSF Ebola Treatment Center

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34 Contact tracing in Conakry Kaloum Matam Dixinn Matoto Ratoma

35 S S S S S Kaloum Matam Dixinn Matoto Ratoma

36 S S S S S AC Kaloum Matam Dixinn Matoto Ratoma

37 S S S S S AC Kaloum Matam Dixinn Matoto Ratoma

38 Contact tracing

39 Chain of transmission A graphic that shows the links from one case to others Why is it important – organizing cases – cases not in the chain

40 Méliandou (Tékoulo) Lolobengou (TK) Fassaba (TK) Guéckédou Hôpital (CU) Kagbadou (TK) Moigbadou (FA) Dengendo u (GU) Dawa (GU) Sowadou (FA) Tolobendou (GU) Dendoube ndou (GU) Baladou (CU) Pewaou (FA) Kouang o (FA) Fassa (GU) Dendou Pombo (CU) Yendeni (CU) Colobangou (TE) Yomadou (TE) Tékoulo Centre (TK) Nangolo (CU) Katkama (GU) Kiéto (GU) Kahilahou (GU) Wassaya (GU) Farakoro (GU) Massakondou (GU) Kissène (FA) Waoutoh (CU) Farako1, 2 (CU) Heremakon o (CU) Gbanbaiss a (CU) Gueckedo u Lele (CU) Gbandou (NO) Solondon i (CU) Kango (CU) Lycée Bambou (CU) Soro1 (GU) Maadou (GU) Fassaba (GU) Préfectures CU : Commune Urbaine FA : Fangamadou GU : Guendembou NO : Nongoua TK : Tékoulo TE : Temessadou Sendebalou (GU) Bombodou (TK) Origine village Méliandou: mode de contamination inconnu Les Chaînes de transmission Ebola, zone forestiere, de Gueckedou

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42 Forecariah MF (nephew) Confirmed, died 15Sep2014 MS (FLF co-wife) Confirmed, Died 22Sep2014 FLF No test, died 09Sep2014 Guerisseur No test, symptoms YC (FLF co-wife) Confirmed, Died 06Oct2014 NC (aunt) No test, Died 10Oct2014 BC (1 st husband) ?, alive 22Sep2014 MC (son, 2yo) Confirmed, died 18Sep2014 MC (daughter) Confirmed, alive 22Oct2014 FY (FLF daughter) No test, died 05Oct contacts 33 contacts

43 Ebola treatment centers, Conakry, Guinea (n=38), March-April 2014 Bah EI, et al. Clinical presentation of patients with Ebola virus disease in Conakry, Guinea. NEJM 2014.

44 Kenema Government Hospital Sierra Leone (n=109), May-June 2014 Incubation period: 6-12 days Case fatality rate: 74% Schieffelin JS, et al. Clinical illness and outcomes in patients with Ebola in Sierra Leone. NEJM 2014;371:2092.

45 Treatment Symptomatic treatment Intravenous fluids and electrolytes Oxygenation and hematologic support Treating other infections Zmapp combination 3 monoclonal antibodies to Ebola TkM-Ebola: interfering RNA targets RNA polymerase AVI-7537: RNA targets Ebola protein BCX-4430: adenosine analogue

46 Vaccines Recombinant Vesicular Stomatitis Virus Carry GP from Zaire and Sudan Ebola virus Advantages: – Pre-existing immunity of humans to VSV low – Replication-competent vector Single dose elicited strong Ab and CMI responses and protected 4/4 monkeys Post-exposure treatment protected 4/8 Zaire and 4/4 Sudan

47 Outbreak Control Identify and confirm cases Isolate and care for infected patients Trace contacts to stop the chains of transmission Monitor contacts for 21 days Ensure safe burial practices Ensure health care workers strictly follow infection control practices in hospitals

48 What will slow the response Human cost; health care workers Misinformation and ignorance Quarantines and travel restrictions Lack of resources and people Lagos (5.2m), Kinshasa (9.5m), Nairobi (3.1m) Ebola will not become global health threat – spreads through direct contact with infected bodily fluids – containment achievable in middle and high-income countries Shift of focus to other global emergencies

49 What will help control Ebola Ensure adequate staff to care for patients and do contact tracing Ensure support for treatment units and infection control Provide information and training to health care workers, community leaders, and the public on Ebola and how to stop transmission Maintain isolation of patients, good clinical care, meticulous contact tracing, and rapid, culturally sensitive burials Avoid quarantines and travel restrictions


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