Upload
phamduong
View
224
Download
0
Embed Size (px)
Citation preview
1
Dr. Christa Kitz
Medical MissionInstitute Wuerzburg
Departement fortropical medicine& epidemic control
MARBURG VIRUSoutbreak in ANGOLA
MARBURG Haemorrhagic Fever
Confirmed outbreak or caseCountry at risk
RDC1994: 301998-00:149 (123)
N= number of cases(n) = number of death
Kenya1980: 21987: 1
South Africa1975: 3
Uganda1967 (singes)2007: 3,(1)
Germany1967: 30 (7)
Yougoslavia1967: 1
Sweden1995 1, (0)
AngolaOct. 2004 - Nov. 2005252 (227)
EBOLA Haemorrhagic Fever
Confirmed outbreak or caseCountry at risk
n = number of cases
Uganda200/1: 425, (53)
(n) = number of death
South Africa1996: 1
Sudan1976: 284, (53)1979: 34, (65)Ivory cost
1994: 1
Gabun1994: 44, (63)1996: 37, (57)1996: 60, (75)2001: 123, (79)
DRC1976: 318, (88)1977: 1, (100)1995: 317, (77)2007:
ROC 2001-4:4 outbreaks143, (90)
Viral hemorrhagic fever
Marburg Virus
MARBURGVIRUSOutbreakin ANGOLA
October 2004 –November 2005
Age in years of patients with fever and hemorrhage,Angola, 13 October 2004 – 28 March 2005, n=124
46
35
11
26
0
5
10
15
20
25
30
35
40
45
50
<1 ano 1-4 anos 5-15 anos >15 anos
73% of cases < 5years
Viral hemorrhagic fever
Marburg Virus
Signs and symptoms of suspected cases ofMarburg VHF
Angola, 13 October 2004 – 24 March2005, n=104
100% 98%
64%
42%39%
32%
12%
0%
20%
40%
60%
80%
100%
Fever Hemorrhage Vomiting Diarrhoea Cough Icterus Headache
num
ber
ofc
ase
s
Viral hemorrhagic fever
Marburg Virus
2
VHF Microbiology
Arenavirus Bunyavirus
South american HF CCHFLassa-Fiever Rift Valley FeverLCM Hantavirus
Filovirus FlavivirusEbola HF Tic-borne- Encephalitis Marburg
HF Kyasanur Forest DiseaseOmsk HFGelbfieber
Dengue HF
Viral hemorrhagic fever
Marburg Virus
Viral hemorrhagic fever
Marburg Virus
General Facts Marburg
► Viral hemorrhagic fever caused by the MarburgVirus out of the Filoviridae family
► natural reservoir still unknown► initial recognition 1967 (Germany, Yugoslavia)► confirmed cases in DRC, Uganda, Kenya, Angola► Imported cases to Germany, Yugoslavia, South Africa,
Sweden► sporadic outbreaks
Viral hemorrhagic fever
Marburg Virus
VHF - EpidemiologyHemorrhagic Virus
►are all RNA-Virus;
►are dependant on a natural reservoir;
►are restricted in their geographic distribution;
► infect human beeings only occaisionally,can lead to local epidemics.
►animals and human beings are accidental hosts
Viral hemorrhagic fever
Marburg Virus
► filovirus are among the most virulent pathogens thataffect human beings
► pathogenic mechanism:
- Infect and kill a broad variety of cell types- Elicit strong inflammatory response
- Disseminated intravascular coagulation- Multi organe failure
Viral hemorrhagic fever
Marburg Virus
3
Lancet , Infectious deseases;Vol.4 August 2004
Viral hemorrhagic fever
Marburg Virus
General Facts Marburg
►acute onset of illness►Affects all age groups and both sexes► incubation period 2-21 days (3-9)►mortality rate 25-90%
Viral hemorrhagic fever
Marburg Virus
Transmission► Human-to-human:
– Direct contact with blood, tissues, secretionsor excretions of infected humans (care takers)
– Needle stick or cut
– nosocomial transmission frequently during outbreaks
– Inhalation of aerosolized virus not confirmed yet
Viral hemorrhagic fever
Marburg Virus
feversevere headachemyalgiaextreme fatigueconjunctival injection
Filovirus HF clinical course
0 1 2 3 4 5 6 7 8 9 days
severe sore throatchest and abdominal painrashdiarrhoea, vomiting
hemorrhagehiccupssomnolence, delirium, coma
CFR 25-90%
Infectivity
Inkubationszeit (Tage)Inkubationszeit (Tage)00 55 1010 1515 2020
PestPest
GelbfieberGelbfieber
KrimKrim--KongoKongo --FieberFieber
RiftRift ValleyValley--FieberFieber
DengueDengue--FieberFieber
HantaHanta--FieberFieber
LassaLassa--FieberFieber
EbolaEbola--FieberFieber
MarburgMarburg--FieberFieber
AffenpockenAffenpocken
Maximale InkubationszeitMaximale Inkubationszeit
Typische InkubationszeitTypische Inkubationszeit
Inkubationszeiten
Umgang mit hochkontagiösen Erkrankungen
Differenzialdiagnostik
< 21 Tage
“Non – specific” symptoms
► Fever >38 C (axillary)► Headache► Muscle and joint pain► Sore throat► Severe weakness
Compare with malaria, typhoid…..
Viral hemorrhagic fever
Marburg Virus
4
Gastro-intestinal features
►Nausea►Vomiting►Diarrhoea►Abdominal pains► Increasing tender hepatomegaly
Viral hemorrhagic fever
Marburg Virus
Complications►Profound hypovolaemic shock +
metabolic acidosis►Hypokalaemia►Hepatitis (biochemical and clinical)
Less common►Severe hemorrhage - cause?►pancreatitis►Adult Respiratory Distress syndrome
Viral hemorrhagic fever
Marburg Virus
Treatment has no priority !► Breaking the chain of transmission:
To isolate the patient with best staffprotection is the major aim during aVHF outbreak in a rural african setting.
Viral hemorrhagic fever
Marburg Virus
Treatment
► no standard treatment► supportive measures► balancing patients fluids and
electrolytes, maintaining oxygen statusand blood pressure
► treatment of any complicating infection
Viral hemorrhagic fever
Marburg Virus
Treatment Viral hemorrhagic fever
Marburg Virus
Respiratory Distress Syndrome
Treatment Viral hemorrhagic fever
Marburg Virus
►Empiricaltreatment
► Practicaldifficulties
► Monitor therapywith pulseoximetry
survivors amonghypoxic patients ?
Oxygen
5
TreatmentViral hemorrhagic fever
Marburg Virus
Intensive care ?
► Endangering staff► Resources► Contamination of
equipment
Treatment► 5 litres of ORS / day/ adult
Viral hemorrhagic fever
Marburg Virus
PRIORITIES ?► INTRAVENOUS
LINE
OR
► CLEANINGVOMITUSFROM theFLOOR
Viral hemorrhagic fever
Marburg Virus
“Side effects”during an outbreak of
haemorrhagic fever
Viral hemorrhagic fever
Marburg Virus
Viral hemorrhagic fever
Marburg Virus
Empty hospitals:The collapse of the general health systhem due tofear killed by far more than the Marburg Virus
Outbreak control
Coordination
Epidemiology
Education
Clinicians
Laboratory
Media AuthoritiesDiagnostic
Clinical
Specimentransfer
Dead Sick
Exposed
SurveillanceInvestigation
Prediction
Healthpersonnel
Specialgroups
Generalpopulation
VectorReservoir
DecisionsInfrastructureRegulationsVaccinations etc
Viral hemorrhagic fever
Marburg Virus
WHERE DOYOU FIT
IN?
6
GOARNGlobal Outbreak Alertand Response Network
► prepare for rapid deployment andcoordination of international resourcesin response to an outbreak ofinternational importance
Viral hemorrhagic fever
Marburg Virus
GOARNhas four phases:
1. Outbreak Alert2. Activation of an International Response3. International Field Response
4. Post Response Activities
++Ministeryof health
+ +
Viral hemorrhagic fever
Marburg Virus
++
Tasks of MSF during the outbreak
► Creating isolating facilities
► case management for patientswith Marburg haemorrhagic fever
Viral hemorrhagic fever
Marburg Virus
1. PROTECT staff
2. PROTECT caregiver
3. PROTECT other suspect patients
4. Treat with ORAL REHYDRATIONAvoid IV Rehydration / drugs
5. Treat with painkillers andother symptomatic therapy
6. INTENSIVE CARE
Isolation WardREQUIRES DIFFERENT PRIORITIES
Viral hemorrhagic fever
Marburg Virus
► Cap► Gown► Apron► Respirator Mask► Gloves► Goggles► boots
Personal ProtectiveEquipment (PPE)
Viral hemorrhagic fever
Marburg Virus
7
Triage(Screening
Room)
Suspected ward Probable ward
Patients- by self admission- by mobile team
CaseDefinition
Viral hemorrhagic fever
Marburg Virus
Burial team – early priority
Foto Kratzer MSF
Viral hemorrhagic fever
Marburg Virus
Viral hemorrhagic fever
Marburg Virus
Viral hemorrhagic fever
Marburg VirusViral hemorrhagic fever
Marburg Virus
8
Viral hemorrhagic fever
Marburg Virus
Viral hemorrhagic fever
Marburg Virus
Avoid i.v. fluids and using of sharps
Viral hemorrhagic fever
Marburg Virus
Strict control and disposal of sharps Cleaning and disinfectionHands Environment Laundry
Viral hemorrhagic fever
Marburg Virus
Hypochloritesolution
Viral hemorrhagic fever
Marburg VirusViral hemorrhagic fever
Marburg Virus
9
Disinfection with Chlorine
Viral hemorrhagic fever
Marburg Virus DiagnosticsViral hemorrhagic fever
Marburg Virus
DiagnosticsViral hemorrhagic fever
Marburg Virus Diagnostics
within a few days of the onset of symptoms:
► IGM ELISA► PCR► virus isolation
► after recovery (rare): IGM, IGG
Viral hemorrhagic fever
Marburg Virus
COMMUNICATION WITH LABORATORYAND INTERPRETING THE BLOOD RESULTS:
► Marburg PCR pos.: transfer to confirmed ward► Marburg PCR neg + clinical picture does not fit:
Discharge appropriately► Marburg PCR neg + clinical concerns: Repeat test
• Liase daily with the laboratory.• Results should be interpreted along side the
clinical picture• Patients may have few symptoms or signs• or false negative tests
Viral hemorrhagic fever
Marburg Virus
The psychological effects on patients, HCWs (not just front lineprofessionals), and their families.
Possible Risk factors:
• Loss of patients & colleagues
• Fear, uncertainty, confusion,• tiredness
• Sense of responsibility,• guilt & blame
Needs a culture of support.
Mental health:► Early psychological support
10
Foto Kratzer MSF
Viral hemorrhagic fever
Marburg Virus
Viral hemorrhagic fever
Marburg Virus
Vaccination:► 5.6.2005, 12.07.2006Steven Johnes & Heinz Feldmann;Nat. Microbiol. Lab. Winnipeg, Canada
► VSVAG/ MARVGP-Musoke vaccine :Attenuated, replication competent vaccineagainst MARV based on recombinant vesicularStomatitis virus expressingthe glycoprotein ofthe Musoke strain of MARV demonstratedcomplete protection against all known MARVstrains of Cynomolgus monkeys.
www.nature.com/naturemedicine,doi:10.1038/nm1258
Viral hemorrhagic fever
Marburg VirusUmgang mit hochkontagiösenErkrankungen
Management vonPatienten mithochkontagiösenErkrankungen
Missionsärztliche Klinik WürzburgTropenmedizinische Abteilung
Salvatorstraße 797074 Würzburg
Tel. 0931 / 791 2821Email: [email protected]
HamburgHamburg
BerlinBerlin
LeipzigLeipzig
MMüü nchennchen
WWüürzburgrzburg
FrankfurtFrankfurt
StuttgartStuttgart
SaarbrSaarbr üückencken
DD üüsseldorfsseldorf
Kompetenzzentren
in Deutschland
Behandlungszentrum
Kompetenzzentrum
Trainingszentrum
Schutzkonzepte und Probenmanagement
Hochkontagiöse Erkrankungen
• Anamnese Aufenthalt in einem bekannten Endemiegebiet
Risiko-Exposition
ungewöhnliches Cluster von Fällen
• Klinik Fieber
typisches klinisches Bild
Inkubationszeit < 21 Tage
• Labor Malaria-Diagnostik negativ
LDH ,Thrombozyten
Umgang mit hochkontagiösen Erkrankungen
Differenzialdiagnostik
Infektions-Alarmgemeingefährliche, lebensbedrohliche