Ebola, Measles, Chikungunya Disclosures What’s Next? • I have no relevant financial relationships with the manufacturers of any commercial products or Meg Fisher, MD Medical Director commercial services discussed in this CME activity • I may discuss unapproved uses of drugs and vaccines
Objectives Ebola, AKA Ebola HF • Ebola hemorrhagic fever • Be aware of new infectious agents • Filoviridae, genus Ebolavirus • Discuss risks for acquiring Ebola, • 5 subspecies: Zaire, Sudan, Tai measles, Chikungunya Forest, Bundibugyo, Reston • Be ready for enteroviruses, new • Humans, primates, bats and old • Discovered 1976, Ebola river, DRC
Ebola Epidemiology 2014 Ebola West Africa • Guinea: ongoing • Liberia: resolved • Sierra Leone: ongoing • Nigeria: resolved • Senegal: resolved • Mali: resolved • Exports: US, UK, Spain
1 Ebola Epidemiology Ebola Clinical illness • Sporadic outbreaks in Africa • Incubation 8-10 days (range 2-21) • Spread by direct contact with blood or • All ages body fluids of symptomatic person • Asymptomatic to rapidly fatal • In Africa, contact with bushmeat, bats • Fever, headache, myalgia, weakness, • Outbreak started 2/2014; almost over diarrhea, vomiting, abdominal pain • 5/11/15: West Africa – 26,757 cases, • Tissue necrosis, bleeding, organ 14,954 confirmed, 11,079 deaths failure, death in 50 to 80%
Ebola Diagnosis Ebola Treatment • No evidence of virus outside of Africa • Supportive care • Consider in returning traveler, • No antiviral yet especially health care volunteer, with • ZMapp: mixture of monoclonal fever and “flu-like” illness antibodies - experimental • Notify health department • Isolation and infection control • Studies: virus isolation, PCR, serology
Ebola Prevention Ebola Vaccines • For travelers and people in Africa, • Testing in progress; looking good but avoid contact with bats, sick animals, many fear the vaccine and the meat of wild animals • Several candidate vaccines have been • Avoid contact with the blood and developed or are being developed body fluids of Ebola patients • No product has been licensed • Avoid funeral practices which allow contact with blood or body fluids
2 Measles Measles in the US • RNA virus: family Paramyxoviridae, • 1st Vaccine genus Morbillivirus licensed • Transmitted by droplets and air 1963 • Extremely contagious • About 95% effective • Incubation period 8 to 12 days • US measles • Contagious 4 days prior to 4 days free since after the rash appears 2000
Measles in the US 2015 Outbreak • 2014: over 600 cases and 23 outbreaks • US travelers bring measles home • Travelers to US bring measles along • Secondary spread to unimmunized contacts
Clinical Illness Fever, Cough, Conjunctivitis • Fever, cough, conjunctivitis • Day 2 to 3 of fever, Koplik spots appear • One to 3 days later, rash appears on the face, maculopapular to confluent • Rash spreads and then fads over days
3 Koplik spots Complications • Otitis media • Respiratory: pneumonia (viral and bacterial); laryngotracheitis • Encephalitis • Subacute sclerosing panencephalitis
Diagnosis Treatment • Clinical • Confirm with serology: IgG and IgM • Isolate the patient: air and droplet • Virus isolation: nasopharyngeal swab, • Report the case urine • Vitamin A: Once daily for two days • Report all suspected cases: 200,000 IU age > 12 mo; 100,000 IU local health department – if not available, call the state 6‐11 mo; 50,000 IU < 6 mo daytime: (609) 826‐5964 • Ribavirin: in vitro, not approved after hours: (609) 392‐2020
Prevention Chikungunya Virus • Measles vaccine: MMR • Togaviridae, Alphavirus genus Routine: 12‐15 mo, 4‐6 yr • Transmitted by Aedes mosquitoes Post‐exposure: within 72 hours • First cases: 1952 Tanzania • Immunoglobulin 0.25 ml/kg (max 15) • Spread in Africa, India, Asia, Europe • Travelers/outbreaks: MMR for ages 6 • 2013 Caribbean Islands to 12 mo; child: give 2nd dose • Spread to US, Central and South America
4 Chikungunya Epidemiology Chikungunya Vectors • Aedes aegypti: tropics and subtropics • Ae. albopictus: temperate and cool • Both species bite throughout the day Aedes • Both transmit other diseases: Dengue Mosquito • Mosquito control key to controlling Countries with viral transmission the disease (as of March 2015)
Chikungunya Clinical Illness Chikungunya Diagnosis • Incubation 3 to 7 days (range 1 – 12) • Suspect in travelers returning with • Fever and joint pain fever and joint pain • Chikungunya: Kimakonde means • Differential Diagnoses: Dengue, to bend up or become contorted leptospirosis, malaria, rickettsia, • Other symptoms: muscle pain, parvovirus, enteroviruses, adenovirus headache, nausea, fatigue and rash • Lymphopenia, low platelets • Mild to severe illness • Virus isolation, PCR, serology
Chikungunya Treatment Chikungunya Prevention • Supportive care • Avoid mosquitoes • There are no specific antivirals • High risk patients should consider limiting travel • Isolation from mosquitoes • Use mosquito netting, insect • Usually recover over 7 to 10 days but repellents, and long sleeve clothing joint complaints may persist
5 What’s Next Enterovirus D68 • First recovered in US in 1962 • Current outbreak reported in August in Missouri and Illinois • Rapid spread across the US • Viruses live in gut; disease occurs outside the gut: lungs, brain, other Time will tell
EV-D68 - 10/12-18/2014 Enterovirus D68
• Respiratory: mild cold to wheeze to respiratory failure • Neurologic: weakness, polio like • Asymptomatic: virus in nose and gut, shed for weeks • Enteroviruses circulate spring to fall
Enterovirus D68 Prevention • Diagnosis: respiratory panel + for • Wash your Rhinovirus/Enterovirus hands • Definitive testing at CDC: • Don’t pick currently for neurologic only your nose • Treatment: supportive • Stay home • No antiviral and no vaccine when sick
6 Reference Websites • www.cdc.gov • www.who.int/en/
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