http://www.inosr.net/inosr-applied-sciences/ Aziz INOSR APPLIED SCIENCES 2(1): 1-6, 2016 ©INOSR PUBLICATIONS International Network Organization for Scientific Research ISSN: 2705-165X

Understanding hemorrhagic fever (EHF)

Aziz Bahra

Department of Pharmacology University of Karachi Pakistan. ABSTRACT This study evaluates what its known about disease in West Africa, involving Zaire Ebola hemorrhagic fever. Ebola virus is , was the largest outbreak of one of at least 30 known viruses capable Ebola virus disease in history. The virus of causing viral hemorrhagic fever spreads through direct contact with body syndrome. The genus Ebolavirus is fluids, such as blood from infected humans currently classified into 5 separate species: or other animals, Ebola hemorrhagic fever , , Tai first appeared in Zaire (currently, the Forest (Ivory Coast) ebolavirus, Reston Democratic Republic of the Congo or DRC ebolavirus, and . or Congo) in 1976. The 2014-2016 outbreak of Ebola virus Keywords: Ebola, hemorrhagic, fever, EHF. INTRODUCTION Ebola hemorrhagic fever (EHF) also known infected humans or other animals.[6] as Ebola virus disease (EVD or simply Spread may also occur from contact with Ebola, is a viral hemorrhagic fever of items recently contaminated with bodily humans and other primates caused by fluids.[7] Spread of the disease through .[1] Signs and symptoms the air between primates, including typically start between two days and humans, has not been documented in three weeks after contracting the virus either laboratory or natural conditions.[8] with a fever, sore throat, muscular pain, Semen or breast milk of a person after and headaches.[2] Vomiting, diarrhea and recovery from EVD may carry the virus for rash usually follow, along with decreased several weeks to months. Fruit bats are function of the liver and kidneys.[3] At believed to be the normal carrier in this time, some people begin to bleed nature, able to spread the virus without both internally and externally.[4] Ebola is being affected by it. Other diseases such a rare but deadly virus that causes fever, as malaria, cholera, typhoid fever, body aches, and diarrhea, and sometimes meningitis and other viral hemorrhagic bleeding inside and outside the body. As fevers may resemble EVD. Blood samples the virus spreads through the body, it are tested for viral RNA, viral antibodies damages the immune system and organs. or for the virus itself to confirm the Ultimately, it causes levels of blood- diagnosis. Control of outbreaks requires clotting cells to drop. This leads to coordinated medical services and severe, uncontrollable bleeding. The community engagement. This includes disease was known as Ebola hemorrhagic rapid detection, contact tracing of those fever but is now referred to as Ebola who have been exposed, quick access to virus. It kills up to 90% of people who are laboratory services, care for those infected. The disease has a high risk of infected, and proper disposal of the dead death, killing 25% to 90% of those through cremation or burial. Samples of infected, with an average of about 50%.[5] body fluids and tissues from people with This is often due to low blood pressure the disease should be handled with from fluid loss, and typically follows 6 to special caution. Prevention includes 16 days after symptoms appear. limiting the spread of disease from The virus spreads through direct contact infected animals to humans by handling with body fluids, such as blood from potentially infected bushmeat only while

1 http://www.inosr.net/inosr-applied-sciences/ Aziz INOSR APPLIED SCIENCES 2(1): 1-6, 2016 wearing protective clothing, and by strains are responsible for the high death thoroughly cooking bushmeat before rates. The four Ebola strains are termed as eating it.[9] It also includes wearing follows: Zaire, Sudan, Tai Forest, and proper protective clothing and washing Bundibugyo virus, with Zaire Ebola virus hands when around a person with the being the most lethal strain. Researchers disease. An has been have found a fifth strain termed Reston in studied in Africa with promising results. the Philippines. The strain infects While there is no approved treatment for primates, pigs, and humans and causes Ebola as of 2019, two treatments (REGN- few if any symptoms and no deaths in EB3 and mAb114) are associated with humans. Most outbreaks of the more improved outcomes [10]. Supportive lethal strains of Ebola have occurred in efforts, also, improve outcomes. This sub-Saharan West Africa and mainly in includes either oral rehydration therapy small- or medium-sized towns. Health (drinking slightly sweetened and salty care professionals believe bats, monkeys, water) or giving intravenous fluids as well and other animals maintain the non- as treating symptoms. The disease was human virus life cycle in the wild; first identified in 1976, in two humans can become infected from simultaneous outbreaks: one in Nzara (a handling and/or eating infected animals. town in South Sudan) and the other in Once an Ebola outbreak is recognized, Yambuku (Democratic Republic of the African officials isolate the area until the Congo), a village near the outbreak ceases [13]. However, in the from which the disease takes its outbreak that began in West Africa in name.[11] EVD outbreaks occur March 2014, some of the infected people intermittently in tropical regions of sub- reached larger city centers before the Saharan Africa.[12] Between 1976 and outbreak was recognized; this caused 2013, the World Health Organization further spread. The infecting Ebola virus reports 24 outbreaks involving 2,387 detected during this outbreak was the cases with 1,590 deaths. The largest Zaire strain, the most pathogenic strain of outbreak to date was the epidemic in West Ebola. Health agencies are terming this Africa, which occurred from December outbreak as an "unprecedented epidemic." 2013, to January 2016, with 28,646 cases This epidemic spread quickly in the West and 11,323 deaths. It was declared no African countries of Guinea and Sierra longer an emergency on 29 March 2016. Leone. In addition, countries of Liberia, Other outbreaks in Africa began in the Nigeria, Senegal, Uganda, and Mali all Democratic Republic of the Congo in May reported confirmed infections with Ebola. 2017, and 2018. In July 2019, the World In addition, a few infections or flare-ups Health Organization declared the Congo of Ebola virus infection appeared in the Ebola outbreak a world health emergency. United States, Spain, and the United History of Ebola Hemorrhagic Fever Kingdom (see for example, the case of Ebola hemorrhagic fever first appeared in Pauline Cafferkey, a nurse who became Zaire (currently, the Democratic Republic infected); most of the people with Ebola of the Congo or DRC or Congo) in 1976. in these countries either were imported The original outbreak was in a village infections from West Africa or were newly named Yambuku near the Ebola River spread infections from treating patients after which the disease was named. who originally became infected in Africa. During that time, researchers identified Another outbreak occurred in the DRC in the virus in person-to-person contact May 2018 in Bikoro, a small town 80 miles transmission. Of the 318 patients from Mbandaka, with 46 reported diagnosed with Ebola, 88% died. The infections and 26 deaths. Unfortunately, second outbreak occurred in Nzara, South the large city of Mbandaka, with over 1 Sudan, in 1976, with 151 deaths. Since million people, has recorded at least three that time, there have been multiple people with Ebola. The DRC hopes to outbreaks of Ebola virus, and researchers isolate or stop the spread of Ebola in the have identified five strains; four of the two areas by vaccinating anyone who may

2 http://www.inosr.net/inosr-applied-sciences/ Aziz INOSR APPLIED SCIENCES 2(1): 1-6, 2016 have had some physical contact with an A person infected with Ebola cannot infected person with a new chimeric virus spread the disease until they develop vaccine that in 2015 showed good results symptoms [17]. in Ebola-infected patients. Health officials Symptoms of EVD can be sudden and now report over 1,000 deaths due to include: Ebola in areas like Butembo in the Congo  Fever (DRC) and neighboring countries in an  Fatigue ongoing outbreak over the last 9 months  Muscle pain [14] [15]. This outbreak is difficult to  Headache control because it is happening in a war  Sore throat zone where cooperation between This is followed by: countries to control the outbreak is  Vomiting uncoordinated and even considered  Diarrhoea unwelcome.  Rash How Ebola hemorrhagic fever (EHF)  Symptoms of impaired kidney and Transmitted liver function It is thought that fruit bats of the  In some cases, both internal and Pteropodidae family are natural Ebola external bleeding (for example, virus hosts. Ebola is introduced into the oozing from the gums, or blood in human population through close contact the stools). with the blood, secretions, organs or  Laboratory findings include low other bodily fluids of infected animals white blood cell and platelet such as fruit bats, chimpanzees, gorillas, counts and elevated liver enzymes. monkeys, forest antelope or porcupines Diagnosis of Ebola hemorrhagic fever found ill or dead or in the rainforest. (EHF) Ebola then spreads through human-to- It can be difficult to clinically distinguish human transmission via direct contact EVD from other infectious diseases such (through broken skin or mucous as malaria, typhoid fever and meningitis. membranes) with: Confirmation that symptoms are caused  Blood or body fluids of a person by Ebola virus infection are made using who is sick with or has died from the following diagnostic methods: Ebola  antibody-capture enzyme-linked  Objects that have been immunosorbent assay (ELISA) contaminated with body fluids  antigen-capture detection tests (like blood, feces, vomit) from a  serum neutralization test person sick with Ebola or the body  reverse transcriptase polymerase of a person who died from Ebola chain reaction (RT-PCR) assay Health-care workers have frequently been  electron microscopy infected while treating patients with  ·virus isolation by cell culture. suspected or confirmed EVD. This occurs Careful consideration should be given to through close contact with patients when the selection of diagnostic tests, which infection control precautions are not take into account technical specifications, strictly practiced [16]. disease incidence and prevalence, and Burial ceremonies that involve direct social and medical implications of test contact with the body of the deceased can results [18]. It is strongly recommended also contribute in the transmission of that diagnostic tests, which have Ebola. undergone an independent and People remain infectious as long as their international evaluation, be considered blood contains the virus. for use. Symptoms of Ebola hemorrhagic fever  Diagnostic tests evaluated through (EHF) the WHO Emergency Use The incubation period, that is, the time Assessment and Listing process interval from infection with the virus to Current WHO recommended tests include: onset of symptoms, is from 2 to 21 days.

3 http://www.inosr.net/inosr-applied-sciences/ Aziz INOSR APPLIED SCIENCES 2(1): 1-6, 2016  Automated or semi-automated called rVSV-ZEBOV, was studied in a trial nucleic acid tests (NAT) for routine involving 11 841 people. Among the 5837 diagnostic management. people who received the vaccine, no Ebola  Rapid antigen detection tests for cases were recorded 10 days or more after use in remote settings where NATs vaccination. In comparison, there were 23 are not readily available. These cases 10 days or more after vaccination tests are recommended for among those who did not receive the screening purposes as part of vaccine. surveillance activities, however Prevention and control of Ebola reactive tests should be confirmed hemorrhagic fever (EHF) with NATs. Good outbreak control relies on applying The preferred specimens for diagnosis a package of interventions, including case include: management, surveillance and contact  Whole blood collected in tracing, a good laboratory service, safe ethylenediaminetetraacetic acid burials and social mobilisation. (EDTA) from live patients Community engagement is key to exhibiting symptoms. successfully controlling outbreaks [22].  Oral fluid specimen stored in Raising awareness of risk factors for Ebola universal transport medium infection and protective measures collected from deceased patients (including vaccination) that individuals or when blood collection is not can take is an effective way to reduce possible. human transmission. Risk reduction Samples collected from patients are an messaging should focus on several extreme biohazard risk; laboratory testing factors: on non-inactivated samples should be  Reducing the risk of wildlife-to- conducted under maximum biological human transmission from contact containment conditions. All biological with infected fruit bats, monkeys, specimens should be packaged using the apes, forest antelope or triple packaging system when transported porcupines and the consumption nationally and internationally [19]. of their raw meat. Animals should Treatment of Ebola hemorrhagic fever be handled with gloves and other (EHF) appropriate protective clothing. Supportive care - rehydration with oral or Animal products (blood and meat) intravenous fluids - and treatment of should be thoroughly cooked specific symptoms improves survival. before consumption. There is as yet no proven treatment  Reducing the risk of human-to- available for EVD. However, a range of human transmission from direct potential treatments including blood or close contact with people with products, immune therapies and drug Ebola symptoms, particularly with therapies are currently being evaluated their bodily fluids. Gloves and [20]. appropriate personal protective In the ongoing 2018-2019 Ebola outbreak equipment should be worn when in DRC, the first-ever multi-drug taking care of ill patients. Regular randomized control trial is being hand washing is required after conducted to evaluate the effectiveness visiting patients in hospital, as and safety of drugs used in the treatment well as after taking care of patients of Ebola patients under an ethical at home [23]. framework developed in consultation with  Outbreak containment experts in the field and the DRC [21]. measures, including safe and Vaccines of Ebola hemorrhagic fever dignified burial of the dead, (EHF) identifying people who may have An experimental Ebola vaccine proved been in contact with someone highly protective against EVD in a major infected with Ebola and monitoring trial in Guinea in 2015. The vaccine, their health for 21 days, the

4 http://www.inosr.net/inosr-applied-sciences/ Aziz INOSR APPLIED SCIENCES 2(1): 1-6, 2016 importance of separating the of EVD practice safer sex and healthy from the sick to prevent hygiene for 12 months from onset further spread, and the importance of symptoms or until their semen of good hygiene and maintaining a tests negative twice for Ebola clean environment [24]. virus. Contact with body fluids  Reducing the risk of possible should be avoided and washing sexual transmission, based on with soap and water is further analysis of ongoing recommended. WHO does not research and consideration by the recommend isolation of male or WHO Advisory Group on the Ebola female convalescent patients Virus Disease Response, WHO whose blood has been tested recommends that male survivors negative for Ebola virus [25]. CONCLUSION A number of medical complications have dedicated programme can be set up for been reported in people who recovered care for people who recovered from from Ebola, including mental health Ebola. WHO aims to prevent Ebola issues. Ebola virus may persist in some outbreaks by maintaining surveillance for body fluids, including semen. Ebola Ebola virus disease and supporting at-risk survivors need comprehensive support countries to develop preparedness plans. for the medical and psychosocial This document provides overall guidance challenges they face and also to minimize for control of Ebola and virus the risk of continued Ebola virus outbreaks transmission. To address these needs, a REFERENCES 1. Gatherer D 2014. "The 2014 Ebola Infection". Digestive Diseases and virus disease outbreak in West Sciences (Review). 60 (9): 2590– Africa". J Gen Virol. 95 (Pt 8): 603. 1619–24. 6. Simpson DI 2016. "Marburg and 2. Magill A (2013). Hunter's tropical Ebola virus infections: a guide for medicine and emerging infectious their diagnosis, management, and diseases (9th ed.). New York: control" (PDF). WHO Offset Saunders. p. 332. Publication No. 36: 3. Hoenen T, Groseth A, Falzarano D, 10f. Archived (PDF) from the Feldmann H (May 2006). "Ebola original on 21 2014. virus: unravelling pathogenesis to 7. Ebola Virus, Clinical Presentation". combat a deadly disease". Trends Medscape. Archivedfrom the in Molecular Medicine. 12 (5): 206– original on 1 2012. 15. . 8. Feldmann H, Geisbert TW (March 4. Brown CS, Mepham S, Shorten RJ 2011). "Ebola haemorrhagic 2016. "Ebola Virus Disease: An fever". Lancet. 377 (9768): 849– Update on Epidemiology, 62. . Symptoms, Laboratory Findings, 9. Shantha JG, Yeh S, Nguyen QD Diagnostic Issues, and Infection (November 2016). "Ebola virus Prevention and Control Issues for disease and the eye". Current Laboratory Professionals". Clinical Opinion in Laboratory Ophthalmology (Review). 27 (6): Medicine(Review). 37 (2): 269–84. 538–44. 5. Sharma N, Cappell MS 2015. 10. West TE, von Saint André-von "Gastrointestinal and Hepatic Arnim A 2014 "Clinical Manifestations of Ebola Virus presentation and management of

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