1. Handling Human Remains Only personnel trained in handling infected human remains, and wearing PPE, should touch, or move, any Ebola-infected remains. Handling of human remains should be kept to a minimum. Autopsies on patients who die of Ebola should be avoided. If an autopsy is necessary, the state health department and CDC should be consulted regarding additional precautions. http://www.cdc.gov/vhf/ebola/hcp/guidance-safe-handling-human-remains-ebola-patients-us-hospitals- mortuaries.html

2. US Clinical Information http://www.cdc.gov/vhf/ebola/hcp/cli nician-information-us-healthcare- settings.htmlhttp://www.cdc.gov/vhf/ebola/hcp/cli nician-information-us-healthcare- settings.html http://www.scientificamerican.com/ar ticle/ebola-doctor-reveals-how- infected-americans-were-cured/

3. Detailed Hospital Checklist for Ebola Preparedness http://www.cdc.gov/v hf/ebola/pdf/hospital -checklisk-ebola- preparedness.pdf

6. Ebola Testing Recommendations Conduct only essential lab testing and take appropriate precautions Include malaria ddx since it is the most common cause of fever in persons travelling in the affected area Do not use pneumatic tubes to collect blood

7. Patient Testing Timeline of InfectionDiagnostic tests available Within a few days after symptoms begin Antigen-capture enzyme-linked immunosorbent assay (ELISA) testing IgM ELISA Polymerase chain reaction (PCR) Virus isolation Later in disease course or after recovery IgM and IgG antibodies Retrospectively in deceased patients Immunohistochemistry testing PCR Virus isolation

8. Follow up recommendations for those negative for EVD Self-monitor twice daily for fever and other symptoms for 21 days from last exposure Seek medical eval at first sign of illness

9. Treatment of Ebola No specific therapy approved Need supportive care - Balancing the patients' fluids and electrolytes -Maintaining their oxygen status and BP -Treating them for any complicating infections Investigational therapeutics of limited availability Preventive vaccines in development

10. ZMAPP Therapeutic Mapp Biopharmaceutical Inc., San Diego -- 2003Mapp Biopharmaceutical Inc National Institutes of Health and the Defense Threat Reduction Agency involved in development 3-mouse monoclonal antibody but can also be made from tobacco plants

11. Other Therapeutics Investigational Tekmira-Ebola therapeutic Began in 2010 using RNAi therapeutics in non-human primates Small interfering RNAs (siRNAs) targeting the Zaire Ebola virus (ZEBOV) RNA polymerase L protein 100% protection in non-human primates Phase 1 trial began Jan. 2014 FDA recently put trial on hold—needs info

12. Chinese Treatment Sept. 2: JK-05 in development for past 5 years Academy of Military Sciences Has manufacturing approval for emgx use Inhibits viral replication

13. Japanese Treatment Favipiravir (T-705) Discovered in 1998 to tx flu Also tx: Yellow Fever, Flavivirus, WNV, WEE, Norovirus Blocks RNA polymerase Phase III in US for flu tx

14. Other Therapeutics BCX4430 BioCryst new anti-RNA polymerase—in development (Aug. 2014)

15. Vaccines In June, 2005 scientists at Fort Detrick, Maryland announced that they had successfully vaccinated monkeys against the deadly Ebola virus In March 2014, the NIH awarded a five- year $28 million grant to establish a collaboration between researchers from 15 institutions NIH EBOV testing in Sept. 2014 by GSK

16. Vaccines (cont.) Oxford University Jenner Institute starting vaccine trials in Oxford then Gambia and Mali (Sept. ‘14) Canadian VSV-EBOV has shown effectiveness as vaccine and after being exposed to the virus --vaccine sent to Canadian hospitals, WHO Geneva, Emory Hospital

17. Why Ebola worries the Defense Department http://www.washingtonpost.com/blogs/worldviews/wp/2014/08/05/why-ebola- worries-defense-department/ A Liberian military policeman holds his rifle with gloves to avoid contact with the deadly Ebola virus during the burial of several Ebola victims in the Johnsonville community outside Monrovia.

18. Bioterrorism/Warfare Airborne transmission of Ebola Zaire has been demonstrated in monkeys in a controlled laboratory experiment Boko Harem stronghold near Ebola outbreak area U.S. Army Medical Research Institute for Infectious Diseases and U.S. Department of Defense’s Joint Project Manager Transformational Medical Technologies Office interested in defense needs

19. An Opportunity to Do More WHO ineffective so far—no $$$ International Health Systems Fund-- “A dedicated International Health Systems Fund at WHO would rebuild broken trust, with the returns of longer, healthier lives and economic development far exceeding the costs. This fund would encompass both emergency response capabilities and enduring health-system development.” L. O. Gostin. Lancet. Sept. 2014 ► Multi-billion $ international investment similar to PEPFAR and Global Fund to Fight AIDS, Tb, and Malaria

20. Conclusions Even though scientists have recently made breakthroughs there is still need for extensive research to find vaccines and therapeutics for this deadly virus. Best efforts are directed towards preventing the spread of the disease by determining its source. ► Need International Health Systems Fund or similar to prevent/respond to future incidents

21. Contact Information John J. Lanza, MD, PhD, MPH, FAAP Florida Department of Health in Escambia County 850/528-5201 JohnJ.Lanza@FLHealth.gov www.EscambiaHealth.com