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9.5 Liu Ebola.Pptx 4/23/15 Ebola Update: One Year Later… Catherine Liu, MD Associate Professor, Department of Medicine, Division of, Infectious Diseases, University of California San Francisco Medical Director, Hospital Epidemiology and Infection Control, UCSF Disclosures • None 1 4/23/15 West African Ebola Outbreak: How Did it Begin? • Dec 2013: 1st case in Guinea • March 2014: WHO no<fied of outbreak in Guinea • July 2014: CDC releases first health advisory reGardinG Ebola epidemic • AuGust 2014: WHO declares epidemic a “public health emerGency of internaonal concern” Background • Member of Filoviridae family • Natural reservoir - ? Fruit bats • Named aer Ebola river in DRC • 5 species: – Zaire (1976) – Sudan (1976) – Reston (1989) – imported monkeys from Philippines – Cote d’Ivoire/ Tai Forest (1994) – Bungibugyo (2007) 2 4/23/15 What is Ebola Virus? • SinGle-stranded RNA virus, Filoviridae family • Natural reservoir unknown ? Fruit bats • Named aer the Ebola river in the DRC • 5 species: – Zaire (1976) – Sudan (1976) – Cote d’Ivoire/ Tai Forest (1994) – Reston (1989) – primate pathoGen – Bundibugyo (2007) 2014 West African Ebola Outbreak 3 4/23/15 2014 West Africa Outbreak – Why did it Happen? An Old Disease in A New Context Deforestation “The increase in Ebola outbreaks since 1994 is frequently associated with dras<c chanGes in forest ecosystems in tropical Africa” – 2012 study in Journal of Veterinary Research 4 4/23/15 Bushmeat Consumption Transmission During Burial Ceremonies for Dead 5 4/23/15 Spread of Infection from Movement of People Inadequate Medical Personnel (1 doctor per 100,000 population) 6 4/23/15 Ebola Disease Progression RECOVERY or Massive fluid losses (5-10 L/day*) Prolonged convalescence if survive *Dr. Bruce Ribner, IDWeek Update 2014 Diagnosis of Ebola • PCR most sensi<ve – May take 3 days aer symptom onset to reach detectable levels – TAT 12-24 hrs • ReEBOV Rapid An<Gen – Approved by WHO 2/15, FDA EUA 2/15 – TAT 15 minutes – ê sensi<vity vs PCR – Other rapid tests under development 7 4/23/15 How is Ebola Transmied? • Direct contact (throuGh broken skin or mucous membranes, i.e. eyes, nose mouth) – With blood or bodily fluids (saliva, mucus, vomit, urine, feces) from an infected person – Sharps injuries (contaminated needles or syrinGes) – With bIood or bodily fluids from infected animals (bats, primates, bushmeat) • Indirect contact (uncommon) – With infected person’s blood or bodily fluids via a contaminated object (i.e. soiled linens) 8 4/23/15 Airborne Transmission of Ebola? CONTROL MONKEYS Transmission due to aerosolizaon of infected droplets from pressure washing of cages EXPERIMENTALLY INFECTED MONKEYS Jaax, et al., Lancet 1995 Recent Studies Show No Evidence of Airborne Transmision • Infected macaques died on day 6 – Virus detected in blood, 0.3 m oral/ nasal/ rectal swabs • Uninfected macques followed for 28 days – Oral, rectal, nasal swabs – Blood samples Infected macaques Uninfected • No evidence of infecon macaques – Viral PCR neGave – Ebola IgM and IgG neGave Alimon< et al Scien<fic Rep 2014 9 4/23/15 How Contagious is Ebola? R0 = average # of people that one sick person will infect 10 4/23/15 When during Ebola infecon does transmission occur? • Not contagious un<l symptom onset • Infec<vity increases as paent becomes more ill – No pts managed by MSF contracted disease from an infected contact durinG early febrile phase of illness – No secondary cases in Dallas when pt ini<ally presented despite lack of PPE – No secondary cases in NY – Remains from deceased infected persons are hiGhly infecous Survival Outside Host • Survives on dry surfaces for several hours • Survives in bodily fluids (ie blood) for several days at room temperature • Easily inac<vated by hospital-Grade disinfectants includinG bleach • Emory hospital: “...environmental tes9ng in the [two] pa9ent rooms had no detecon of viral RNA and included many high touch surfaces such as bed rails and surfaces in the bathroom...” (Dr. Bruce Ribner) 11 4/23/15 What are current treatment opons for Ebola? • There is no approved treatment for Ebola • Mainstay of treatment is intensive suppor<ve care (intravenous fluids, electrolyte reple<on, blood transfusion, pressors, oxygen, empiric an<bio<cs for secondary bacterial infec<on) • Experimental druGs and vaccines under development Experimental Drugs and Vaccines Drug/ Vaccine Mechanism of AcRon Clinical Trials? Favipravir Approved in Japan for Rx of influenza 2014 Noncontrolled trial in Guinea 12/14, prelim results 69 pts ↓ mortality Brincidofovir RNA polymerase inhibitor, beinG studied in RCT Liberia launched adenovirus 1/2/15, trial halted 2/1/15 slow enrollment ZMapp 3 monoclonal an<bodies tarGe<nG Ebola virus RCT Liberia launched Glycoprotein, 8/10 US treated pts survived. 2/27/15 TKM-Ebola Small interferinG (siRNA) drug Phase 1 safety study launched in US human volunteers 12 4/23/15 Experimental Drugs and Vaccines Drug/ Vaccine Mechanism of AcRon Clinical Trials? Convalescent Plasma from Ebola survivors in Monrovia RCT launched in 12/14 in Plasma Sponsored by Bill&Melinda Gates Foundaon Liberia Therapy in collaboraon with WHO Convalescent Plasma from Ebola survivors in Guinea RCT launched in 12/14 Plasma Sponsored by EU, Wellcome Trust, and MSF Therapy Convalescent Plasma from Ebola survivors in Sierra Leone RCT TBD Plasma Sponsored by Sierrra Leone Acon Group Therapy NIAID/ GSK Uses chimpanzee adenovirus type 3 as vector Phase III launched Vaccine Liberia 2/15 (CAd3-EBOZ) NIH/ Merck/ Vesicular stoma<s virus vector Phase III launched NewLink Liberia 2/15, Guinea (VSV-EBOV) 3/15 Ebola Outbreak: Current Status • Overall decline in number of new cases, but GenG to zero remains a challenGe • Lessons learned from success stories in NiGeria, SeneGal, and Mali • 12 cases treated in the US; 2 deaths • Unintended consequences: – Disrup<on of immunizaon services, access to care/ treatment for malaria 13 4/23/15 UCSF Ebola Response: Key Planning Areas • ScreeninG and Triage Protocols • Isolaon Unit • StaffinG and TraininG • Exercises and drills • PPE selec<on and acquisi<on • External AGencies • Communicaon 27 Screening and Triage Ask, Mask, Isolate, Communicate 28 14 4/23/15 Screen to Idenfy “Person Under Invesgaon” “In the last 21 days have you traveled to Guinea, Liberia or Sierra Leone OR had contact with an Ebola paent?” Yes “Do you have fever, headache, weakness, muscle pain, voming, diarrhea, stomach No pain, unusual bleeding or bruising?” Yes 29 Biocontainment Center 15 4/23/15 Staffing and Training 31 PPE Donning Checklist 16 4/23/15 PPE Doffing Checklist Lessons Learned From Ebola • Investment in Global outbreak response system, public health infrastructure, disease surveillance, R&D needed • Humility is wise when dealinG with an unfamiliar communicable infec<ous disease • Mul<disciplinary coordinaon and communicaon at all levels key • Dedicated team of providers for repeated traininG on PPE, scenario/workflows facilitates local preparedness efforts 17 .
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