Ebola Virus Disease (EVD) Outbreak 2014 (Template slide set designed to be edited to meet VAMC needs) Created 10.3.2014 DATE/MONTH 2014 1

2014 West Africa Outbreak The 2014 Ebola outbreak is the largest Ebola outbreak in history and the first in West Africa. The current outbreak is affecting multiple countries in West Africa. Insert Current Case Counts http://www.cdc.gov/vhf/ebola/out breaks/guinea/index.html To update map: http://www.cdc.gov/vhf/ebola/resources/distribution-map-guinea-outbreak.html#areas To update case counts: http://www.cdc.gov/vhf/ebola/outbreaks/guinea/i ndex.html Review CDC What’s New page: http://www.cdc.gov/vhf/ebola/outbreaks/guinea/whats-new.html 2 Current as of 10/2/2014 2

Impact on United States On September 30, CDC confirmed the first travel-associated case of Ebola to be diagnosed in the United States in a person who had traveled to Dallas, Texas from Liberia. The patient did not have symptoms when leaving West Africa, but developed symptoms approximately five days after arriving in the U.S. (arrived Sept. 20). Contact tracing, a standard public health procedure, is immediately employed in order to identify and monitor those who may have been potentially exposed to a sick patient. Even with the first U.S. confirmed case, Ebola does not pose a significant risk to the United States. Contact tracing involves interviewing the patient when possible; interviewing every family member with known contact; identifying all possible names of individuals who may have come into contact with the patient while the patient was exhibiting symptoms indicating an active infection; identifying all locations and movements of the individual between time of symptom onset to when the patient was put into isolation. A map is then constructed identifying the time, place, level of contact the patient has with individuals. Use concentric circle approach, high to low risk individuals are identified so that as many contacts as possible can be tracked. Contact tracing pdf: http://www.cdc.gov/vhf/ebola/pdf/contact-tracing.pdf 3 3

General EVD Background Ebola Virus Disease (EVD) is one of numerous viral hemorrhagic fevers (VHFs). The first Ebola virus species was discovered in 1976 in what is now the Democratic Republic of the Congo near the Ebola River. Since then, outbreaks have appeared sporadically in Africa. EVD is often severe in humans, with case fatality rates reaching 50-90% in developing countries. After an incubation period of a few days, symptoms usually begin abruptly. The natural reservoir host of Ebolaviruses remains unknown. However, evidence suggests it is a zoonosis (animal-borne) with bats being the most likely reservoir. Four of the five subtypes occur in an animal hosts native to Africa. There are five identified subspecies of Ebolavirus . Four of the five have caused disease in humans: Zaire virus (Zaire ebolavirus) – most common subspecies known for Ebola outbreaks in Africa and is the virus causing the 2014 West African outbreak. Sudan virus (Sudan ebolavirus) – responsible for past outbreaks primarily in Sudan and Uganda. Bundibugyo virus (Bundibugyo ebolavirus) – responsible for a 2007 outbreak in Uganda and 2012 outbreak in DRC Taï Forest virus (Taï Forest ebolavirus, formerly Côte d’Ivoire ebolavirus) – responsible for 1994 outbreak in Côte d’Ivoire Reston virus (Reston ebolavirus) – seen in the Philippines and has caused disease in nonhuman primates, but not in humans. 4 4

General EVD Transmission Because the natural reservoir of Ebola viruses has not yet been clearly demonstrated, the manner in which the virus is first introduced in to the human population at the start of an outbreak is not well understood. It appears the first patient becomes infected through direct contact with the body fluid of an infected animal. Ebola virus is spread from one person to another through direct contact with: Ebola-infected blood or body fluids, such as, but not limited to, urine, saliva, feces, vomit, and semen Objects, such as needles, that have been contaminated with infected body fluids Healthcare workers, family and friends, and others who come into close contact with Ebola-infected patients (including corpses of those who expired due to EVD) have the highest risk of exposure. 5 5

General EVD Transmission Image: http://www.cdc.gov/vhf/ebola/index.html?s_cid=cdc_homepage_feature_001 accessed 9/22/2014 Because the natural reservoir of Ebola viruses has not yet been clearly demonstrated, the manner in which the virus is first introduced in to the human population at the start of an outbreak is not well understood. It appears the first patient becomes infected through direct contact with the body fluid of an infected animal. Ebola virus is spread from one person to another through direct contact with: Ebola-infected blood or body fluids, such as, but not limited to, urine, saliva, feces, vomit, and semen Objects, such as needles, that have been contaminated with infected body fluids Healthcare workers, family and friends, and others who come into close contact with Ebola-infected patients (including corpses of those who expired due to EVD) have the highest risk of exposure. 6 6

General EVD Presentation Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola virus, although 8-10 days is most common. Only symptomatic Ebola- infected patients are able to transmit EVD; Patients without symptoms who are infected with Ebola virus are not contagious. Image: http://www.cdc.gov/vhf/ebola/symptoms/index.html accessed 9/24/2014 Incubation period: typical incubation period is between 8 and 10 days, although symptoms may appear anywhere from 2 to 21 days after exposure. Symptoms and disease: First symptoms are the sudden onset of fever fatigue, muscle pain, headache and sore throat. This is followed by vomiting, diarrhoea, rash, symptoms of impaired kidney and liver function, and in some cases, both internal and external bleeding (e.g. oozing from the gums, blood in the stools). Laboratory findings include low white blood cell and platelet counts and elevated liver enzymes. 7 7

General EVD Assessment Timely diagnosis and treatment of EVD is important but challenging because the disease is difficult to diagnose clinically in the early stages of infection. Because early symptoms, such as headache and fever, are nonspecific to EVD, cases of EVD may be initially misdiagnosed. It is important to obtain an accurate and complete history of travel or potential contact with an Ebola case from a patient exhibiting Ebola-like symptoms. CDC checklist for Patients Being Evaluated for EVD in US: http://www.cdc.gov/vhf/ebola/pdf/checklist-patients-evaluated-us-evd.pdf Be sure to consult with infectious diseases specialist and local public health about decisions regarding hospital admission, diagnostic tests, or further management. 8 Excerpt from CDC checklist for Patients Being Evaluated for EVD in US 8

General EVD Treatment There is no specific cure for Ebola virus infection. There are currently no specific vaccines to prevent Ebola infection. There are no specific medications (e.g., antiviral drug) that have been proven to be effective against Ebola. Symptoms of Ebola are treated supportively, as they appear. The following basic interventions, when used early, can increase the chances of survival. Providing intravenous fluids and balancing electrolytes (body salts) Maintaining oxygen status and blood pressure Treating other infections if they occur 9 9

Development of Treatments and Vaccines A number of potential candidate drugs and vaccines are in development. The CDC maintains a FAQ on current candidates at: http://www.cdc.gov/vhf/ebola/outbreaks/guinea/qa-experimental- treatments.html For further information on drug development, approval process, and research please contact the appropriate agency: FDA media office: fdaoma@fda.hhs.gov NIH media office: niaidnews@niaid.nih.gov CDC media office: media@cdc.gov ASPR media office: Gretchen.Michael@hhs.gov ZMapp, being developed by Mapp Biopharmaceutical Inc., is an experimental treatment, for use with individuals infected with Ebola virus. It has not yet been tested in humans for safety or effectiveness. The product is a combination of three different monoclonal antibodies that bind to the protein of the Ebola virus. The U.S. government, specifically, the NIH's National Institute of Allergy and Infectious Diseases, the Department of Defense's Defense Threat Reduction Agency (DTRA), and the HHS' Biomedical Advanced Research and Development Authority (BARDA), has provided support for the development of this experimental treatment. On August 28, 2014, NIH announced that initial human testing of an investigational vaccine to prevent Ebola virus disease will begin the following week by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health. The early human tests are being conducted at the NIH Clinical Center in Bethesda, Md. The initial trial includes 20 adults, who received the vaccine in differing doses. Some results will likely come by year's end. Two other companies, Tekmira and Biocryst Pharmaceuticals, receive funding from the Department of Defense's Defense Threat Reduction Agency and have therapeutic candidates for Ebola in early development. The Department of Defense is working with a company called Newlink to develop an Ebola vaccine candidate. BioCryst, with NIH support, is working to develop an antiviral drug to treat Ebola virus that is expected to begin Phase 1 testing later this year. http://www.cdc.gov/vhf/ebola/outbreaks/guinea/qa-experimental-treatments.html 10 10

Infection Prevention and Control Recommendations CDC recommends standard, contact, and droplet precautions for management of hospitalized patients with known or suspected Ebola Viral Disease (EVD). Generally, VHA follows the most up-to-date CDC guidance, which is periodically updated and can be found at: http://www.cdc.gov/vhf/ebola/hcp/index.html. Though these recommendations focus on the hospital setting, the recommendations for personal protective equipment (PPE) and environmental infection control measures are applicable to any healthcare setting. VA-specific guidance, including any deviations from CDC guidance, will be issued to VA facilities, as appropriate. 11 11

Donning PPE Current VA PPE Recommendations All persons entering the patient room should wear at least: Gloves Gown (fluid resistant or impermeable) Eye protection (goggles or face shield) Facemask Additional PPE might be required in certain situations (e.g., copious amounts of blood, other body fluids, vomit, or feces present in the environment), including but not limited to: Double gloving Disposable shoe covers Leg coverings Head covering http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf accessed 9/22/2014 12 12

Doffing PPE To prevent self-contamination, it is important to remove the most contaminated PPE first. This will help to prevent contaminants from spreading to other places as additional PPE items are removed. http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf accessed 9/22/2014 13 13

Potential VHA Impacts Scenario 1 An individual presents to local VA emergency/urgent care with a fever of 102°F (38.9°C) and recent travel to Africa where he may have been in an area experiencing EVD cases.  Scenario 2 A VA employee has a concern about EVD based on epidemiological history (i.e. recent travel to high-risk countries and/or contact with a known of suspected EVD patient), but is asymptomatic. Additional discussion of these scenarios was transmitted to VHA September 16th, 2014: 14 14

For Additional Information Ebola Fact Sheet Ebola Update (as of August 2014)

For Additional Information For VA Questions: contact the VHA National Infectious Diseases Service at 513-246-0270 or Aaron Eagan in the VHA Office of Public Health via email at aaron.eagan@va.gov For general information: Centers for Disease Control and Prevention (CDC) http://www.cdc.gov/vhf/ebola/index.html World Health Organization (WHO) http://www.who.int/csr/disease/ebola/en/ 16