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

EbolaCurrent status of the outbreak in

West Africa and a historical perspective

Michael MartinThailand MOPH-US CDC Collaboration

15 September 2014

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%

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

Cases DeathsTotal 15,901 5674Liberia 7168 3016Sierra Leone 6599 1398Guinea 2134 1260

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

Ebola cases reported October 19–November 8, 2014

Cumulative incidence of Ebola November 8, 2014

Ebola OutbreaksCountry Town Cases Deaths Species YearCongo Yambuku 318 280 Zaire 1976

South Sudan Nzara 284 151 Sudan 1976

Congo Tandala 1 1 Zaire 1977


Gabon Mekouka 52 31 Zaire 1994

Ivory Coast Tai Forest 1 0 Taï Forest 1994

Congo Kikwit 315 250 Zaire 1995

Gabon Mayibout 37 21 Zaire 1996

Gabon Booue 60 45 Zaire 1996

South Africa Johannesburg 2 1 Zaire 1996

Uganda Gulu 425 224 Zaire 2000

Gabon Libreville 65 53 Zaire 2001

Congo Not specified 57 43 Zaire 2001

Congo Mbomo 143 128 Zaire 2002


South Sudan Yambio 17 7 Zaire 2004

Congo Luebo 264 187 Zaire 2007

Uganda Bundibugyo 149 37 Bundibugyo 2007


Uganda Luwero District 1 1 Sudan 2011

Uganda Kibaale District 11* 4* Sudan 2012

Congo Isiro Health Zone 36* 13* Bundibugyo 2012

Uganda Luwero District 6* 3* Sudan 2012Guinea, Sierra Leone, Liberia multiple 1752* 897* Zaire 2014











Uganda Gulu 425 224 Zaire 2000













1st 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 2014. DOI: 10.1056/NEJMp1410540

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

Epicurve

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











Uganda Gulu 425 224 Sudan 2000













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

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

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

Gulu Ebola Outbreak 2000

• Largest Ebola outbreak until 2014• 425 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

Symptoms No. (%)

Diarrhea 41 (66)

Asthenia 40 (64)

Headache 39 (63)

Vomiting 37 (60)

Abdominal pain 34 (55)

Bleeding 12 (20)

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

Infection Control Training

Mobile teams

Assessing potential cases and deaths

Assessing potential cases and deaths

Collecting specimens for testing

Burial preparation

Routine medical care

Hospital modifications: evaluation area

Guinea

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

MSF Ebola Treatment Center

MSF Ebola Treatment Center

Contact tracing in Conakry

Kaloum

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Contact tracing

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

Méliandou (Tékoulo)

Lolobengou (TK)

Fassaba (TK)

Guéckédou Hôpital (CU)

Kagbadou (TK)

Moigbadou(FA)

Dengendou

(GU)

Dawa (GU)

Sowadou(FA)

Tolobendou (GU)

Dendoubendou (GU)

Baladou (CU)

Pewaou(FA)

Kouango

(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)

Heremakono

(CU)

Gbanbaissa

(CU)

Gueckedou Lele (CU)

Gbandou(NO)

Solondoni

(CU)

Kango (CU)

Lycée Bambou

(CU)Soro1 (GU)

Maadou (GU)

Fassaba (GU)

PréfecturesCU : Commune UrbaineFA : FangamadouGU : GuendembouNO : NongouaTK : TékouloTE : Temessadou

Sendebalou (GU)

Bombodou (TK)

Origine village Méliandou: mode de contamination inconnu

Les Chaînes de transmission Ebola, zone forestiere, de Gueckedou

Forecariah

MF (nephew)Confirmed, died

15Sep2014

MS (FLF co-wife)Confirmed, Died

22Sep2014

FLFNo test, died09Sep2014

GuerisseurNo test,

symptoms

YC (FLF co-wife)Confirmed, Died

06Oct2014

NC (aunt)No test, Died 10Oct2014

BC (1st husband)?, alive

22Sep2014

MC (son, 2yo)Confirmed, died

18Sep2014

MC (daughter)Confirmed, alive

22Oct2014

FY (FLF daughter)No test, died 05Oct2014

63 contacts

33 contacts

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.

Kenema Government HospitalSierra 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.

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

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

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

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

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

Documents

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