Emerging disease surveillance & response (ESR)WHO Regional Office for the Western Pacific (WPRO)

23 August 2014

Ebola Virus Disease (EVD)

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• Background• Epidemiology • Regional Framework for Action• Global Responses

- WHO- Affected countries - WPR Member States

Outline

Background

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History of Ebola Virus Outbreaks

• 1976, Ebola first appeared in 2 simultaneous outbreaks in Democratic Republic of Congo and Sudan

• Since Ebola discovery in 1976 until December 2013:• 23 outbreaks, 7 countries in Africa • 2388 human cases including 1590 deaths

• Current Ebola outbreak from December 2013• Started in Guinea • The outbreak now involves transmission in Liberia, Nigeria

and Sierra Leone.

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Aetiology• Ebola virus belongs to the filovirus family which cause hemorrhagic

fever• 5 species:

– Bundibugyo ebolavirus (BDBV)– Zaire ebolavirus (EBOV)– Reston ebolavirus (RESTV)– Sudan ebolavirus (SUDV)– Taï Forest ebolavirus (TAFV).

The outbreak in West Africa is caused by Zaire ebolavirus (EBOV).

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1. Virus reservoir :Fruit bats

Infected fruit bats enter in direct or indirect contact with other animals and pass on the infection, sometimes causing large-scale epidemics in gorillas, chimpanzees and other monkeys or mammals (e.g. forest antelopes).

Secondary human-to-human transmission occurs through direct contact with the blood, secretions, organs or other body fluids of infected persons. High transmission risk when providing direct patient care (healthcare workers) or handling dead bodies (funerals).

3. Primary human infection2. Epizootic in primates

Humans are infected either through direct contact with infected bats (rare event), or through handling infected dead or sick animals found in the forest (more frequent)

4. Secondary transmission

The virus maintains itself in fruit bats. The bats spread the virus during migration.

Transmission of Ebola

Source: WHO

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• Incubation period: 2-21 days• Case Fatality Ratio 24-89%• Symptoms:

- Sudden onset of fever, intense weakness, muscle pain, headache and sore throat

- Followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases, both internal and external bleeding

• Treatment is supportive but effective in reducing mortality- Rehydration, intensive care

• Some potential specific treatment - Very limited availability - Limited information on safety & efficacy• Vaccines in development

Ebola Virus Disease

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Current Risk Assessment

• The current EVD outbreak in West Africa involves multiple locations and cross-border movements among communities

• Transmission is facilitated by direct contact with the body fluids (blood, sputum, semen, etc.) of EVD cases

• Health-care workers have frequently been infected while treating symptomatic patients with EVD

• Although the likelihood that EVD will reach the West Pacific Region is low, Member States and WHO need to be prepared for this event.

Epidemiology

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Number of cases by country23 December 2013 – 22 August 2014

Confirmed Probable SuspectTotals

(by Country)Guinea

Cases 443 139 25 607Deaths 264 139 3 406

Liberia Cases 269 554 259 1082

Deaths 222 267 135 624Nigeria

Cases 12 0 4 16Deaths 5 0 0 5

Sierra Leone Cases 804 40 66 910

Deaths 353 34 5 392Totals

Cases 1528 733 354 2615Deaths 844 440 143 1427

CFR = 55%Infected at least 216 HCW including 113 deathCFR 52%

as of 22 August 2014

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Epi Summary: Geographical distribution

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Epicurve by week of EVD onset in Guinea, Liberia and Sierra Leone December 2013 to August 2014. (As of 11 August)

Alert 13 March 15 cases inc. 9 deaths

Sierra Leone

Liberia

Guinea

Alert from Méliandou26 January

5 death w diarrhoea

Laboratory Confirmation

21 March

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WPR Framework for Action

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Framework for ActionThe relevant WHO advice and guidance materials are related to:

1.Surveillance, public health investigation and risk assessment2.Laboratory3.Clinical management and infection prevention and control4.Public health emergency response and international travel measures5.Risk communications and social mobilization

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Framework for ActionThe relevant WHO advice and guidance materials are related to:

1.Surveillance, public health investigation and risk assessment2.Laboratory3.Clinical management and infection prevention and control4.Public health emergency response and international travel measures5.Risk communications and social mobilization

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Surveillance, Public health investigation, Risk assessment

• National surveillance systems should be capable of detecting suspected cases

• Clinicians and health care workers understand and implement:• EVD case definition• Safe specimens collection and shipment for laboratory confirmation• Reporting mechanism, including IHR notification to WHO

Possible points of detection of EVD cases

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Case Definition during the outbreakSUSPECTED CASE: •Any person, alive or dead, suffering or having suffered from a sudden onset of high fever and having had contact with: - a suspected, probable or confirmed Ebola case; - a dead or sick animal (for Ebola) OR: any person with sudden onset of high fever and at least three of the following symptoms: • headaches • vomiting • anorexia / loss of appetite • diarrhoea • lethargy • stomach pain • aching muscles or joints • difficulty swallowing • breathing difficulties • hiccup OR: any person with inexplicable bleeding OR: any sudden, inexplicable death.

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Case Definition (2)PROBABLE CASE:

•Any suspected case evaluated by a clinician OR•Any deceased suspected case (where it has not been possible to collect specimens for laboratory confirmation) having an epidemiological link with a confirmed case

CONFIRMED CASE: •Any suspected or probably cases with a positive laboratory result. Laboratory confirmed cases must test positive for the virus antigen, either by detection of virus RNA by reverse transcriptase-polymerase chain reaction (RT- PCR), or by detection of IgM antibodies directed against Ebola.

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Contact tracing of EVD case

Contact Tracing of any person having been exposed to a suspected, probable or confirmed case of Ebola in at least one of the following ways:

• slept in the same household with a case • direct physical contact with the case (dead or alive) • touched blood, body fluids , clothes or linens of case(s)• breastfed by the patient (baby) • contacts with dead or sick animals• direct contact with specimens collected from suspected Ebola patients

or animal

Source WHO: http://who.int/csr/resources/publications/ebola/ebola-case-definition-contact-en.pdf

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Contact management

• Monitor all contacts over a period of 21 days after their latest exposure.

• Conduct a clinical evaluation of contacts if they become ill during that 21-day period (epidemiological and clinical evaluation in order to classify the case using the case definition)

• Refer contacts identified as suspected or probable cases to the isolation ward.

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Framework for ActionThe relevant WHO advice and guidance materials are related to:

1.Surveillance, public health investigation and risk assessment

2.Laboratory3.Clinical management and infection prevention and control4.Public health emergency response and international travel measures5.Risk communications and social mobilization

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Diagnosis

• Diseases that should be ruled out include: malaria, typhoid fever, shigellosis, cholera, leptospirosis, plague, rickettsiosis, relapsing fever, meningitis, hepatitis and other viral haemorrhagic fevers

• Essential role of patient history; exposure to area/village with ongoing outbreak and/or contact with confirmed cases

• Laboratory diagnostic tests: ₋ Antibody-capture enzyme-linked immunosorbent assay (ELISA)₋ Antigen detection tests₋ Reverse transcriptase polymerase chain reaction (RT-PCR) assay₋ Electron microscopy₋ Virus isolation by cell culture

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Key points for laboratory investigation

• Ensure strict IPC during specimen collection.

• Handling live virus (e.g. isolation) should be dealt with at BSL-4.

• Molecular diagnosis of Ebola virus is most commonly used.

• Packaging and shipping in accordance to International Air

Transport Agency (IATA) guidelines.• Contact WHO laboratory focal point for more details about

testing and reference laboratories.

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Framework for ActionThe relevant WHO advice and guidance materials are related to:

1.Surveillance, public health investigation and risk assessment2.Laboratory

3.Clinical management and infection prevention and control4.Public health emergency response and international travel measures5.Risk communications and social mobilization

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Clinical management• Intensive supportive care is required

• Supportive care: monitor fluid and electrolyte balance and renal function, careful rehydration

• Provide supportive drug therapy : painkillers, antiemetic for vomiting, anxiolytic for agitation, +/-antibiotics and/or antimalarial drugs

• Some potential specific treatment• Monoclonal antibodies• Other candidate drugs also in early stages of testing

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Patient Care New Medicines and vaccines

Patient Care New Medicines and vaccines

Several new treatment options are under development, among which:• zMapp: a cocktail of three monoclonal antibodies produced in

plants• Convalescent plasma• Hyperimmune globulins made in horses or cattle• siRNA (Lipid Nanoparticle Small interfering RNAs)• BCX4430: a chemical which blocks viral replication• T705: chemical substitution of constituent needed for viral

replication

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IPC Precautions in Healthcare FacilitiesIPC Precautions in Healthcare Facilities

• Implement standard infection control precautions in health-care facilities

for all patients at all times

• Isolation of suspected and confirmed cases in separated rooms/areas with

restricted access

• Exclusively dedicated staff and equipment for isolation rooms/areas

• Use of PPE, Hand hygiene with alcohol-based hand rub or water and soap

• Rigorous environmental cleaning and surfaces/objects decontamination

• Safe injection practices and sharps handling

• Post-exposure evaluation and care following professional accidents

WHO Interim IPC Guidance - 2014 Updatehttp://www.who.int/csr/resources/who-ipc-guidance-ebolafinal-09082014.pdf

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Framework for ActionThe relevant WHO advice and guidance materials are related to:

1.Surveillance, public health investigation and risk assessment2.Laboratory3.Clinical management and infection prevention and control

4.Public health emergency response and international travel measures5.Risk communications and social mobilization

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Public health emergency preparedness and International Travel Measures

States should be prepared to manage and respond to EVD: • No general ban on international travel or trade; restrictions

applied to the travel of EVD cases and contacts • Active entry screening of passengers at POEs are not currently

recommended• where appropriate, the capacity to manage travelers with

unexplained febrile illness at POE.• If appropriate and reasonable, prepare to facilitate medical

evacuation and repatriation of nationals (e.g. health workers) who have been exposed to Ebola.

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General Health Advice to Travelers• Travelers to affected areas should be provided with the information

on: – risks – measures to minimize the risks– advice for managing a potential exposure

• Returning visitors from affected areas should be alerted and seek rapid medical attention and mention travel history, if:

– develop symptoms (fever, weakness, muscle pain, headache, sore throat, vomiting, diarrhoea, rash, or bleeding) within 3 weeks after return

– or if have suspected exposure to Ebola virus

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Framework for ActionThe relevant WHO advice and guidance materials are related to:

1.Surveillance, public health investigation and risk assessment2.Laboratory3.Clinical management and infection prevention and control4.Public health emergency response and international travel measures

5.Risk communications and social mobilization

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Risk communication and social mobilization

• Health Emergency Communications: Rapid dissemination of information and health messages to at-risk or target populations to reduce confusion, anxiety and fear.

• Operational Communications: Timely exchange of information among health authorities, clinicians, laboratories, decision-makers, and other disciplines and other sectors to ensure coordinated response and inform decision-making.

• Behaviour Change Communications: Development and implementation of programmes for positive behaviour changes. Two-way dialogue with community level to work out what is feasible (eg. Hand washing campaign and access to clean water).

WHO, Affected countries and WPR

Global responses to EVD

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WHO response actions• Declaration of WHO ERF Grade 3 emergency on 25 Jul 2014• Technical guidance and support (monitoring, surveillance, risk

assessment, framework for action)• International deployments:

– Deployment of several mobile laboratories and development of national lab capacities

– Over 400 experts have been deployed by WHO and GOARN partners (epidemiologists, infection prevention and control experts, clinicians, logisticians, anthropologist, communication experts)

• Core services/Logistics: – timely shipment of needed PPEs and others medical supplies – deliver emergency food aid into quarantined

• Risk communications: Information products published

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IHR Emergency Committee Meeting

Group of international experts convened to assess the situation advice the DG on EVD outbreak on 6 – 7 August, 2014

Main outcomes:

•The EVD constitutes a Public Health Emergency of International Concern (PHEIC)•Public health recommendations given to countries EVD transmission, at-risk countries and those with border crossings and all states.

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WHO will host a consultation on potential Ebola therapies and vaccines

• On 11 August 2014, a panel of experts , convened by WHO, reached consensus that in the circumstances of current Ebola outbreak, it is ethical to offer unproven interventions with as yet unknown.

• Next consultation, planed for 4-5 September has been convened to gather expertise about the most promising experimental therapies and vaccines and their role in containing the Ebola outbreak in west Africa.

• The expertise among the more than 100 participants is wide, ranging from pharmaceutical research and the clinical demands of Ebola care, to expertise on ethical, legal, and regulatory issues.

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Affected country responses• Developed national response plans which included:

– Strengthening coordination of response activities at all levels– Strengthen early detection, reporting and referral of suspected cases

through active surveillance and outbreak investigation– Strengthening surveillance on identification of contacts– Case management and infection prevention and control and psychosocial

support– Social mobilization, Education of the public on the disease and preventive

measures – Increased number of Treatment centers for managing cases of EVD

• A State of Emergency has been declared • Exit screening for ALL travellers

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Inter-country level response

A Joint Declaration of Heads of State and Government of the Mano River Union* was issued and leaders pledged to commit additional resources to the outbreak. This will include the following measures:

– Focus on cross-border regions, including isolation of specific areas by police and military

– Material support to the citizens in these areas– Health-care centers in these zones will be strengthened for treatment,

testing, and contact tracing – Burials will be done in accordance with national health regulations

*Côte d’Ivoire, Guinea, Liberia, and Sierra Leone

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WPR Member States1. Surveillance, public health investigation and risk assessment

– case definition– Alogrithm

2. Laboratory– Capacity development

3. Clinical management and infection prevention and control– Meetings with and sharing information to HCWs

4. Public health emergency response and international travel measures– Advice to traveler to and from affected countries

5. Risk communications and social mobilization– F&Q, poster, etc

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EBOLA WHO website

http://www.who.int/csr/disease/ebola/en/

• Technical information

• Guidelines

• Meeting reports

• Disease outbreak news