1. Ebola Virus Disease Dr. Oluwafemi Akinyele Popoola Lecturer and Consultant Community Physician Lecture delivered at Bodija-Ashi Baptist Church 14 th September, 2014.

2. Session Objectives Describe the epidemiology of Ebola virus Highlight past outbreaks State main symptoms Describe how knowledge of the epidemiology and transmission dynamics of Ebola Virus informs its control strategies

3. What is Ebola Virus Disease Ebola Virus Disease: is one of the numerous viral Hemorrhagic Fevers. It is a severe, often fatal disease in humans and nonhuman primates – CDC Incubation period 2-21days (usual 8 – 10 days) Causation: infection with a virus – Family Filoviridae and genus Ebolavirus – Five subspecies of Ebolavirus Zaire ebolavirus; Sudan ebolavirus; Tai Forest ebolavirus; and Bundibugyo ebolavirus Reston ebolavirus (disease only in nonhuman primates)

4. YearCountry 1976 Sudan DRC 1977DRC 1979Sudan 1994 Gabon Cote d’Ivoire 1995 Liberia DRC 1996 Gabon South Africa 2000-2001Uganda 2001-2002 Gabon Congo 2002-2003Congo 2004Sudan 2005Congo 2007 DRC Uganda 2011Uganda 2012 Uganda DRC History of Ebola outbreaks in the African Region

5. Ebola outbreak in Guinea, Liberia and Sierra Leone, Epicurve by week of onset, December 2013 to 19 July 2014 (n=1002) Alert from Méliandou 26 January 5 death w diarrhoea Alert 13 March 15 cases inc. 9 deaths 21 March Labortory Confirmation Outbreak response operationsstarted 26 May Sierra Leone declared outbreak 31 March Liberia declared outbreak 23 March WHO deployed multi- diciplinary international experts 23 March Mobile laboratory deployed through EDPLN

6. Case Definitions Suspected (clinical) case: Any person ill or deceased with fever and hemorrhage. Documented prior contact with an EVD case is not required Confirmed Case A case with laboratory confirmed diagnostic evidence of ebola virus infection.

7. Any person (living or dead) with contact with a clinical case of EVD and a history of acute fever. OR Any person (living or dead) with a history of acute fever and three or more of the following - headache/ vomiting/nausea/ loss of appetite/ diarrhea/ intense fatigue/ abdominal pain/ general muscular or articular pain/ difficulty in swallowing/ difficulty in breathing/ hiccoughs OR Any unexplained death.  Distinction between a suspected case and a probable case in practice relatively unimportant as far as outbreak control is concerned. Probable case (with or without bleeding):

8. Definition of contact A person without any symptoms has had physical contact with a case or the body fluids of a case within the last three weeks. The notion of physical contact may be proven or highly suspected such as having shared the same room/bed, cared for a patient, touched body fluids, or closely participated in a burial ceremony (physical contact with the corpse).

9. Current Status by August 9, 2014 (WHO) New *ConfirmedProbableSuspectTotals by country Guinea Cases deaths 11 6 362 238 133 11 2 506 373 Liberia Cases Deaths 45 29 158 146 306 125 135 52 599 323 Nigeria Cases Death 0000 0000 10 2 3030 13 2 Sierra Leone Cases Deaths 13 17 656 276 37 34 37 5 730 315 Totals Cases Deaths 69 52 1176 660 486 294 186 59 1848 1013 *New cases were reported between 7 and 9 August, 2014.

10. Transmission Cycles Animal to Man Initial source of outbreak in human populations Often occurs in rural areas Man to Man Source of epidemic propagation in human populations All body fluids are infected Infected humans only transmit the virus AFTER THEY BECOME SICK!!! Risk is increased during hospital care of infected individuals Improper disposal of dead bodies also transmits disease

11. Routes of Transmission Direct contact Blood or secretions of infected person Infected needles and other equipments contaminated with infected secretions Others Through families and friends contact with infectious secretions of ill person Virus can still be present in semen 6 weeks after illness Factors aiding transmission Hospital settings: inappropriate use of PPE; Lack of point of care risk assessment Community settings: burial rites; treatment seeking delays/denials

12. Transmission dynamics Natural reservoir not conclusive – However, WHO believes fruit bats may be the natural host First patient in outbreaks most likely infected by animal Health workers more susceptible to infection Higher risk of transmission (high viral loads) – Later stages : vomiting, diarrhoea, shock, haemorrhage

13. Hypothesis of Ebola Virus transmission at the human-animal interface

14. Symptoms of Ebola Virus Disease MAIN Fever – at least 38C Weakness Diarrhoea Vomiting Headache Joint and muscle aches Stomach pain Lack of appetite ADDITIONAL A Rash Red Eyes Hiccups Cough Sore throat Chest pain Difficulty breathing Difficulty swallowing Bleeding inside and outside of the body

15. Definitive Diagnosis LABORATORY BASED – Antibody-capture enzyme-linked immunosorbent assay (ELISA) – Antigen detection tests – Serum neutralization test – Reverse transcriptase polymerase chain reaction (RT-PCR) assay – Electron microscopy – Virus isolation by cell culture

16. HOW DO WE PREVENT EBOLA DISEASE INFECTIONS

17. Facts about the Virus? Easily destroyed – soaps, detergent, chlorine, heat. Highly infectious Highly pathogenic – causes a serious disease with high risk of death Humans only become infectious when sick Virus shed in ALL body fluids No evidence of air borne transmission No licensed vaccine or specific treatment Can only be diagnosed via specialised lab tests

18. Prevention Strategies Prevention of Community infections/HE – Prevention of new infections – Early recognition of infected individuals – Tracing and surveillance of contacts of infected individuals Prevention of hospital infections – Isolation of infected individuals – Supportive treatment of infected individuals

19. Community Prevention during Outbreaks Reducing the risk of wildlife-to-human transmission from contact with infected fruit bats or monkeys/apes/other bush meats and the consumption of their raw meat. Animals should be handled with gloves and other appropriate protective clothing. Animal products (blood and meat) should be thoroughly cooked before consumption.

20. Community Prevention during Outbreaks Close physical contact with Ebola patients should be avoided. Gloves and appropriate personal protective equipment should be worn when taking care of ill patients at home. Regular hand washing is required after visiting patients in hospital, as well as after taking care of patients at home

21. Community Prevention during Outbreaks Communities affected by Ebola should inform the population about the nature of the disease and about outbreak containment measures, including burial of the dead. People who have died from Ebola should be promptly and safely buried Manage rumours during outbreak Do not hide cases or contacts

22. Control in Hospital Settings Ebola is highly infectious and must be treated in specialised isolation centres Standard precautions for all patients Infection based precautions for probable or confirmed cases Proper decontamination of all surfaces

23. Summary Ebola causes a serious disease with high risk of death Cases present with fever and other symptoms diagnosis requires specialised lab tests Prevention strategies – Practice good personal hygiene, frequent hand washing with soap and water – Avoid close contact with possibly infected individuals – Proper investigation and isolation of all cases – Tracing and surveillance of contacts of Ebola patients

24. Thank you for your attention