Ebola Virus Disease Preparedness and Response16th HSDP ARM, Dire Dawa, 15 Oct 2014

Ethiopian Public Health Institute

By: -

Dr Daddi Jima

D/Director General, EPHI

What is Ebola Virus Disease?

Epidemiology

• Ebola Viral Disease (EVD) is one of numerous Viral Hemorrhagic Fevers. It is a severe, often fatal disease in humans and nonhuman primates.

Epidemiology

Genus Ebolavirus comprises 5 distinct species:

• Bundibugyo Ebola virus (BDBV)

• Zaire Ebola virus (EBOV)

• Sudan Ebola virus (SUDV)

• Reston Ebola virus (RESTV)

• Taï Forest Ebola virus (TAFV).

EpidemiologyGeographical distribution of Ebola and Marburg outbreaks in Africa (1967-2014)

Epidemiology• Ebola Hemorrhagic Fever was first found in 1976

• It struck two countries within that yeara. Sudan – in a town called N’zarab. Democratic Republic of Congo

• In these two instances the mortality rate was between 50 –90%

• Following those epidemics, Ebola hit Africa in many other instances

EpidemiologyYear Country Cases Deaths Case fatality

2012 Democratic Republic of Congo 57 29 51%

2012 Uganda 7 4 57%

2012 Uganda 24 17 71%

2011 Uganda 1 1 100%

2008 Democratic Republic of Congo 32 14 44%

2007 Uganda 149 37 25%

2007 Democratic Republic of Congo 264 187 71%

2005 Congo 12 10 83%

2004 Sudan 17 7 41%

2003 (Nov-Dec) Congo 35 29 83%

2003 (Jan-Apr) Congo 143 128 90%

2001-2002 Congo 59 44 75%

2001-2002 Gabon 65 53 82%

2000 Uganda 425 224 53%

1996 South Africa (ex-Gabon) 1 1 100%

1996 (Jul-Dec) Gabon 60 45 75%

1996 (Jan-Apr) Gabon 31 21 68%

1995 Democratic Republic of Congo 315 254 81%

1994 Cote d'Ivoire 1 0 0%

1994 Gabon 52 31 60%

1979 Sudan 34 22 65%

1977 Democratic Republic of Congo 1 1 100%

1976 Sudan 284 151 53%

1976 Democratic Republic of Congo 318 280 88%

Where does Ebola hide?

Fruit Bats

• Fruit bats do not show any symptoms

• Best candidate to be the reservoir

Where does Ebola hide?

• The virus was detected in ofgorillas, chimpanzees, and duiker,

• Their high mortality rate makes them unlikely to be natural reservoirs.

Historical Background

Current Ebola Outbreak

Date 8-Oct-14 CFR

TotalCases 8,399

48%Deaths 4,033

GuineaCases 1,350

58%Deaths 778

LiberiaCases 4,076

57%Deaths 2,316

Sierra LeoneCases 2,950

32%Deaths 930

NigeriaCases 20

40%Deaths 8

SenegalCases 1

0%Deaths 0

United StatesCases 1

100%Deaths 1

SpainCases 1

0%Deaths 0

Cases, Deaths and CFR of Ebola outbreak, 2014

Current Ebola Outbreak

0

1,000

2,000

3,000

4,000

5,000

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7,000

8,000

9,000

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g-1

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g-1

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24

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-14

Total Cases Total Deaths

Guinea Cases Guinea Deaths

Liberia Cases Liberia Deaths

Sierra Leone Cases Sierra Leone Deaths

Current Ebola Outbreak

Total cases71 cases (30 confirmed, 26 probable, 15 suspected)

Total Deaths 43 (CFR = 61 %)

DRC Ebola cases and deaths as of 5 October 2014

Transmission

Fruit

Bats

• Reservoirs

• Transmit to Wild Animals

• Transmit to Humans

Wild

Animals

• Outbreaks

• Transmit to Humans

Humans

• Outbreaks

• Human to Human transmission

Transmission

TransmissionEbola: Epidemic curves in humans and animals at the human-animal interface

Transmission

• Ebola then spreads in the community through human-to-human transmission, with infection resulting from:• Direct contact (through broken skin or mucous membranes)

with the blood, secretions, organs or other bodily fluids of infected people or secretions (stool, urine, saliva, semen), and

• Indirect contact with environments contaminated with such fluids, .

• Infection can also occur if broken skin or mucous membranes of a healthy person come into contact with environments that have become contaminated with an Ebola patient’s infectious fluids such as soiled clothing, bed linen, or used needles.

• Burial ceremonies in which mourners have direct contact with the body of the deceased person can also play a role in the transmission of Ebola.

Transmission

Signs and Symptoms

EVD is a severe acute illness. • Early symptoms include sudden onset of

• fever – 38.6 C, severe headache, muscle pain, chills, intense weakness.

• Around the fifth day, a skin rash can occur.

• This is followed by vomiting, sore throat, abdominal pain and diarrhea.

• Symptoms become increasingly severe and may include jaundice (yellow skin) severe weight loss, mental confusion, impaired kidney and liver function, and in some cases, both internal and external bleeding, shock, and multi-organ failure.

Incubation Period

• The incubation period, or the time interval from infection to onset of symptoms, is from 2 to 21 days (most commonly 8-10 days).

• The patients become contagious once they begin to show symptoms.

• They are not contagious during the incubation period.

Diagnosis1. ClinicalSuspected CaseA person who has both consistent symptoms and risk factors as follows:

Clinical criteria, which includes fever of greater than 38.6 C and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage;

AND Epidemiologic risk factors within the past 21 days before the onset of symptoms, such as contact with blood or other body fluids or human remains

of a patient known to have or suspected to have EVD; residence in—or travel to—an area where EVD

transmission is active; or direct handling of bats, rodents, or primates from disease-

endemic areas.

Diagnosis

ClinicalProbable Case

A Suspected case who is a contact of an EVD case with either a high or low risk exposure.

Diagnosis

2. Laboratory• It requires Bio-safety level 4 laboratory –

• Anti-body capture (ELISA)• Antigen detection test• RT-PCR• Electron microscope• Cell culture

NB: Before diagnosing a patient as Ebola, other common fever causing diseases should be ruled out.

Measures to TakeExposure Level Clinical Presentation Public Health Actions

High Risk Exposure

Percutaneous (e.g., needle stick) or mucous

membrane exposure to body fluids of EVD

patient

Direct care of an EVD patient or exposure to

body fluids without appropriate personal

protective equipment (PPE)

Laboratory worker processing body fluids of

confirmed EVD patients without appropriate

PPE or standard biosafety precautions

Participation in funeral rites which include

direct exposure to human remains in the

geographic area where outbreak is

occurring without appropriate PPE

Fever OR other

symptoms consistent with EVD

without fever

Consideration as a probable case

Medical evaluation using infection control

precautions for suspected Ebola,

consultation with public health authorities,

and testing if indicated

If air transport is clinically appropriate and

indicated, only air medical transport (no

travel on commercial conveyances

permitted)

If infection control precautions are

determined not to be

indicated: conditional

release and controlled movement until 21

days after last known potential exposure

Asymptomatic

Conditional release3 and controlled

movement4 until 21 days after last known

exposure

Measures to TakeExposure Level Clinical Presentation Public Health Actions

Low Risk Exposure

Household member or other casual

contact with an EVD patient

Providing patient care or casual

contact without high-risk exposure

with EVD patients in health care

facilities in outbreak-affected

countries*Fever WITH OR

WITHOUT other

symptoms consistent with

EVD

Consideration as a probable case

Medical evaluation using

initial infection control

precautions for suspected Ebola,

consultation with public health

authorities, and testing if indicated

If air transport is clinically

appropriate and indicated, air

medical transport only (no travel on

commercial conveyances

permitted)

If infection control precautions are

determined not to be

indicated: Conditional

release and controlled

movement until 21 days after last

known potential exposure

Asymptomatic

Conditional release3 and controlled

movement4 until 21 days after last

known exposure

Measures to TakeExposure Level Clinical Presentation Public Health Actions

No Known Exposure

In affected country

No low-risk or high-risk exposures

Fever WITH other

symptoms consistent with

EVD

Consideration as a person under

investigation (PUI)

Medical evaluation and optional

consultation with public health

authorities to determine if

movement restrictions and infection

control precautions are indicated

If movement restrictions

and infection control

precautions are determined not to

be indicated: travel by commercial

conveyance is allowed; self-

monitor until 21 days after leaving

country

Asymptomatic

No movement restrictions

Travel by commercial conveyance

allowed

Self-monitor5 until 21 days after

leaving country

Treatment and Vaccine

• Standard treatment for Ebola HF is still limited to supportive therapy.

• Experimental drug therapy: Zmapp, Tekmira

• Vaccines: US, Canada

Prevention and ControlStrategy for the prevention and control of Ebola outbreaks

Level of Preparedness and Response

Training and Sensitization• More than 50 persons trained for direct

involvement

Training and Sensitization

• 250 health workers from different hospitals (private and government) of Addis Ababa

• 365 airport, airline, immigration, police and security and Hotel staff, ensuring that communities, risk groups understand the respond appropriately to the risk.

• Training for Regional PHEM focal persons and clinicians from Regional Hospitals

• 100 health workers, working for Addis Ababa police, trained on EVD

• Owners and managers from 145 hotels that are 3 star and above trained

Training and Sensitization

• Training of police and military personnel

Screening and Surveillance

• Screening at Bole airport

• Screening - West African countries plus Uganda, Kenya and South Sudan (total 21 countries)

• All others who has travel history

Screening and Surveillance

0

500

1000

1500

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2500

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3500

4000

4500

Number of People being Screened Perday for High Temperature at Bole Airport, Ethiopia 2014

Screening and Surveillance• Screening at borders at

8 major land crossings: • Moyale (6)• Togowachale• Dewale• Galafi,• Humera• Metema• Kumruk• Gambella (2)

Screening and Surveillance

• Surveillance• Activation of EOC• Training of Rapid

Response Team• Allocation of

transportation service:• 4 ambulances• 2 dedicated vehicles

• Fill formats and Follow up of passengers who enter Ethiopia

Screening and Surveillance

• Surveillance: Rumor verifications

• Receive calls from HWs and the public

• More than 150 calls received through

toll free number –8335• Call answered till Midnight – 24/7

Screening and Surveillance

• Rumor Reporting and Verifications

• Media scanning

Logistics and Supplies

• Personal Protective Equipments

• Infection prevention materials

• Isolation center

• Laboratory supplies

Isolation Center

• Two sites prepared and equiped• New Amanuel Hospital – >50 bed capacity

• Yeka Woreda 12 HC – 15 bed capacity

1. Health Education and Awareness Creation

• Media briefing,

• Press release

• TV and Radio spots on air

• Media trainings

• Plan to use community structures and the Health Extension Program

Health Education and Awareness Creation

• Website – www.ephi.gov.et

Health Education and Awareness Creation

• Brochures (Amharic, English, French),

Technical Document Preparation• Case definition• Measures and Monitoring • Formats • Guidelines• SOP

Coordination and Leadership• National Ebola Committee -

High level Committee involving relevant line Ministries -chaired by the Deputy Prime Minister,

• National Ebola Technical Committee – EPHI

• High level taskforce (different sectors and partners) chaired by The Minister of Health,

• Technical Working Group from different sectors and partners led by EPHI with different sub TWG

• Sub national Task forces and TWG are being established

• Command post a airport

Coordination and LeadershipStructure set

Coordination and Leadership

NEC visit to Isolation Center

Preparedness and Response Plan• Ebola preparedness and response plan prepared

• Pre-positioning• Scenario 1• Scenario 2

Scenarios Budget required

Pre-positioning 112,535,122 Birr

Scenario 1 162,213,265

Scenario 2 677,117,652 Birr

Laboratory Capacity

• We started to collaborate with NAHDIC• EPHI staff trained at SA lab• BSL 3 lab will be soon functional• Stationary lab• Mobile lab

What is Next

1. Establish Coordination Mechanism

• Include all the relevant sectors and partners

Preparedness and Response Plan

• A comprehensive Ebola Preparedness and Response plan needs to be prepared at each level as soon as possible• Involve all relevant sectors and partners

Strengthen Screening and Surveillance

• Isolation /Quarantine center identification and equipping

• Engage all Hospitals and HC to report any suspected cases

• Train RRT for Rumor investigation

• Strengthen screening at border crossings and neighboring woredas

Create Awareness at All Levels

• Train all the health workers and health management teams at each level.

• Create community awareness, ensure their ownership

• engage the local media in a continued manner

• Ensure information flow mechanisms

Logistics

• Ensure logistics are available for the isolation and quarantine sites

• Ensure materials required for basic infection prevention are available in all health facilities