Global & Disaster Medicine

Archive for the ‘Ebola’ Category

The largest patient movement exercise in U.S. Department of Health and Human Services’ history began 4/10/18 to test the nationwide ability to move patients with highly infectious diseases safely and securely to regional treatment centers.

HHS

HHS sponsors its largest exercise for moving patients with highly infectious diseases

The largest patient movement exercise in U.S. Department of Health and Human Services’ history began today to test the nationwide ability to move patients with highly infectious diseases safely and securely to regional treatment centers.

“Saving lives during crises requires preparation and training,” explained HHS Assistant Secretary for Preparedness and Response Robert Kadlec, M.D. “A tremendous amount of coordination, synchronization, and skill is needed to move patients with highly infectious diseases safely. We have to protect the patients and the healthcare workers caring for those patients. This type of exercise helps ensure that everyone involved is ready for that level of complexity.”

Coordinated by the HHS Office of the Assistant Secretary for Preparedness and Response, more than 50 organizations will participate, including the Department of State, Department of Transportation, the Regional Ebola Treatment Centers, local and state health and emergency management agencies, hospitals, airport authorities, and non-government organizations.

Throughout the exercise, participants react as if the incident is real. They must take the necessary actions and employ the appropriate resources to manage and protect the patients, the workforce and the environment and safely transport the patients.

The exercise focuses on moving seven people acting as patients with Ebola symptoms in different regions of the country. The patients, including one pediatric patient, first present themselves at one of the following healthcare facilities: CHI St. Luke’s Health-The Woodlands Hospital in The Woodlands, Texas; Medical University of South Carolina in Charleston, South Carolina; Norman Regional Hospital in Norman, Oklahoma; St. Alphonsus Regional Medical Center in Boise, Idaho, and St. Luke’s Regional Medical Center in Boise, Idaho.

At each facility, healthcare workers will collect and ship samples for diagnostic tests to state laboratories, which in turn will practice running the necessary laboratory tests to diagnose the patients with Ebola. As part of the exercise, each patient will receive a positive diagnosis. Using appropriate isolation techniques and personal protective equipment, health care workers then must take steps to have six of the patients transported by air to designated Regional Ebola Treatment Centers. These patients will be placed into mobile biocontainment units for these flights. The pediatric patient will be placed into protective equipment and transported by ground ambulance.

The treatment centers that will receive the patients are Cedars-Sinai Medical Center in Los Angeles, California; Emory University Hospital in Atlanta, Georgia; Providence Sacred Heart Medical Center in Spokane, Washington; and University of Texas Medical Branch in Galveston, Texas. The pediatric patient will be transported to Texas Children’s Hospital West Campus in Houston, Texas.

The participating airports are Boise Airport in Boise, Idaho; Charleston International Airport in Charleston, South Carolina; DeKalb-Peachtree Airport in Atlanta, Georgia; Ellington Field Airport in Houston, Texas; Los Angeles International Airport in Los Angeles, California; Spokane International Airport in Spokane, Washington; and Will Rogers World Airport in Oklahoma City, Oklahoma. Upon arrival, local emergency responders will transfer the patients to ground ambulances for transportation from the airports to the treatment centers.

HHS and the Department of State previously collaborated on exercises to move Americans acting as Ebola patients from West African countries to Ebola treatment centers in the United States. In public health emergencies or disasters, the U.S. government orchestrates the return of Americans to the United States, including Americans who are sick or injured.

This exercise runs through April 12. Participants will gather on April 13 to assess the exercise, compare actions across the country, and share best practices for moving patients with highly infectious diseases.

Note to editors: Video sound bites from Dr. Kadlec are available for download at https://www.dropbox.com/sh/ktvdv44y7z68ly7/AAAf2H_JzzY8i-tzREY6VfaAa?dl=0 exit disclaimer icon.


Household Transmission of Ebola Virus: risks and preventive factors, Freetown, Sierra Leone, 2015

J Infect Dis

“…..We enrolled 150 index Ebola cases and 838 contacts; 83 (9.9%) contacts developed Ebola during 21-day follow-up. In multivariable analysis, risk factors for transmission included index case death in the household, Ebola symptoms but no reported fever, age <20 years, more days with wet symptoms; and providing care to the index case (P<0.01 for each). Protective factors included avoiding the index case after illness onset and a piped household drinking water source (P<0.01 for each).….”


Disease X: A pathogen with the potential to spread and kill millions but for which there are currently no, or insufficient, countermeasures available.

The Telegraph

“……It was the third time the committee, consisting of leading virologists, bacteriologists and infectious disease experts, had met to consider diseases with epidemic or pandemic potential. But when the 2018 list was released two weeks ago it included an entry not seen in previous years.

In addition to eight frightening but familiar diseases including Ebola, Zika, and Severe Acute Respiratory Syndrome (SARS), the list included a ninth global threat: Disease X…….”
Diseases threatening a public health emergency*
  • Crimean-Congo haemorrhagic fever (CCHF)
  • Ebola virus disease and Marburg virus disease
  • Lassa fever
  • Middle East respiratory syndrome coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS)
  • Nipah and henipaviral diseases
  • Rift Valley fever (RVF)
  • Zika
  • Disease X

*Diseases posing significant risk of an international public health emergency for which there is no, or insufficient, countermeasures. Source: World Health Organization (WHO), 2018


A new prophylactic vaccine was immunogenic and effective against multiple filoviruses, including Ebola and Marburg, in monkeys

PLOS

A prophylactic multivalent vaccine against different filovirus species is immunogenic and provides protection from lethal infections with Ebolavirus and Marburgvirus species in non-human primates

“…..These results demonstrate that it is feasible to generate a multivalent filovirus vaccine that can protect against lethal infection by multiple members of the filovirus family.…….”

 


Real-time Assay for the Detection of Filoviruses (Ebola and Marburg viruses)

Sensitive Multiplex Real-time RT-qPCR Assay for the Detection of Filoviruses

Dedkov Vladimir G., Magassouba N’Faly, Safonova Marina V., Bodnev Sergey A., Pyankov Oleg V., Camara Jacob, Sylla Bakary, Agafonov Alexander P., Maleev Victor V., and Shipulin German A.. Health Security. February 2018, 16(1): 14-21. https://doi.org/10.1089/hs.2017.0027

“……The high specificity and sensitivity of the assay make it useful for clinical and epidemiologic investigations in the field of filovirus fever diseases and their etiological agents…..”

Colorized negative stained transmission electron micrograph depicting a Marburg virus virion, in the filovirus family.

CDC

Filoviruses belong to a virus family called Filoviridae and can cause severe hemorrhagic fever in humans and nonhuman primates. So far, only two members of this virus family have been identified: Marburgvirus and Ebolavirus. Five species of Ebolavirus have been identified: Taï Forest (formerly Ivory Coast), Sudan, Zaire, Reston and Bundibugyo. Ebola-Reston is the only known Filovirus that does not cause severe disease in humans; however, it can still be fatal in monkeys and it has been recently recovered from infected swine in South-east Asia.

Structurally, filovirus virions (complete viral particles) may appear in several shapes, a biological features called pleomorphism. These shapes include long, sometimes branched filaments, as well as shorter filaments shaped like a “6”, a “U”, or a circle. Viral filaments may measure up to 14,000 nanometers in length, have a uniform diameter of 80 nanometers, and are enveloped in a lipid (fatty) membrane. Each virion contains one molecule of single-stranded, negative-sense RNA. New viral particles are created by budding from the surface of their hosts’ cells; however, filovirus replication strategies are not completely understood.

Colorized negative stained transmission electron micrograph depicting a Marburg virus virion, in the filovirus family.

Filovirus history

The first Filovirus was recognized in 1967 when a number of laboratory workers in Germany and Yugoslavia, who were handling tissues from green monkeys, developed hemorrhagic fever. A total of 31 cases and 7 deaths were associated with these outbreaks. The virus was named after Marburg, Germany, the site of one of the outbreaks. In addition to the 31 reported cases, an additional primary case was retrospectively serologically diagnosed.

After this initial outbreak, the virus disappeared. It did not reemerge until 1975, when a traveler, most likely exposed in Zimbabwe, became ill in Johannesburg, South Africa. The virus was transmitted there to his traveling companion and a nurse. A few sporadic cases and 2 large epidemics (Democratic Republic of Congo in 1999 and Angola in 2005) of Marburg hemorrhagic fever (Margurg HF) have been identified since that time. For information on known Marburg HF cases and outbreaks, please refer to the chronological list.

Ebolavirus was first identified in 1976 when two outbreaks of Ebola hemorrhagic fever (Ebola HF) occurred in northern Zaire (now the Democratic Republic of Congo) and southern Sudan. The outbreaks involved what eventually proved to be two different species of Ebola virus; both were named after the nations in which they were discovered. Both viruses showed themselves to be highly lethal, as 90% of the Zairian cases and 50% of the Sudanese cases resulted in death.

Since 1976, Ebolavirus have appeared sporadically in Africa, with small to midsize outbreaks confirmed between 1976 and 1979. Large epidemics of Ebola HF occurred in Kikwit, Democratic Republic of Congo in 1995, in Gulu, Uganda in 2000, in Bundibugyo, Uganda in 2008, and in Issiro, DRC in 2012. Smaller outbreaks were identified in Gabon, DRC, and Uganda. For information on known Ebola HF cases and outbreaks, please refer to the chronological list.

Animal hosts

It appears that Filoviruses are zoonotic, that is, transmitted to humans from ongoing life cycles in animals other than humans. Despite numerous attempts to locate the natural reservoir or reservoirs of Ebolavirus and Marburgvirus species, their origins were undetermined until recently when Marburgvirus and Ebolavirus were detected in fruit bats in Africa. Marburgvirus has been isolated in several occasions from Rousettus bats in Uganda.

Spreading Filovirus infections

In an outbreak or isolated case among humans, just how the virus is transmitted from the natural reservoir to a human is unknown. Once a human is infected, however, person-to-person transmission is the means by which further infections occur. Specifically, transmission involves close personal contact between an infected individual or their body fluids, and another person. During recorded outbreaks of hemorrhagic fever caused by a Filovirus infection, persons who cared for (fed, washed, medicated) or worked very closely with infected individuals were especially at risk of becoming infected themselves. Nosocomial (hospital) transmission through contact with infected body fluids – via reuse of unsterilized syringes, needles, or other medical equipment contaminated with these fluids – has also been an important factor in the spread of disease. When close contact between uninfected and infected persons is minimized, the number of new Filovirus infections in humans usually declines. Although in the laboratory the viruses display some capability of infection through small-particle aerosols, airborne spread among humans has not been clearly demonstrated.

During outbreaks, isolation of patients and use of protective clothing and disinfection procedures (together called viral hemorrhagic fever isolation precautions or barrier nursing) has been sufficient to interrupt further transmission of Marburgvirus or Ebolavirus, and thus to control and end the outbreak. Because there is no known effective treatment for the hemorrhagic fevers caused by Filoviruses, transmission prevention through application of viral hemorrhagic fever isolation precautions is currently the centerpiece of Filovirus control.

In conjunction with the World Health Organization (WHO), CDC has developed practical, hospital-based guidelines, titled Infection Control for Viral Haemorrhagic Fevers in the African Health Care Setting. The manual can help healthcare facilities recognize cases and prevent further hospital-based disease transmission using locally available materials and few financial resources.


During the 2014–2015 outbreak of Ebola virus disease in Guinea, 13 type 2 circulating vaccine-derived polioviruses (cVDPVs) were isolated from 6 polio patients and 7 healthy contacts.

EID

Fernandez-Garcia MD, Majumdar M, Kebe O, Fall AD, Kone M, Kande M, et al. Emergence of vaccine-derived polioviruses during Ebola virus disease outbreak, Guinea, 2014–2015. Emerg Infect Dis. 2018 Jan [date cited]. http://dx.doi.org/10.3201/eid2401.171174

DOI: 10.3201/eid2401.171174

“…Although OPV has many advantages (easy administration by mouth, low cost, effective intestinal immunity, and durable humoral immunity), it has the disadvantage of genetic instability. Because of the plasticity and rapid evolution of poliovirus genomes and selective pressures during replication in the human intestine, vaccine poliovirus can lose key genetic determinants of attenuation through mutation or recombination with closely related polio and nonpolio enterovirus strains, acquiring the neurovirulence and infectivity characteristics of wild-type poliovirus (WPV) (3). Because of this genetic instability, in settings where a substantial proportion of the population is susceptible to poliovirus, OPV use can lead to poliovirus emergence and sustained person-to-person transmission and spread in the community of genetically divergent circulating vaccine-derived polioviruses (cVDPVs). ….”


Ebola Virus Disease Outcome in Elderly People during the 2014 Outbreak in Guinea

AJTDH

Prognostic and Predictive Factors of Ebola Virus Disease Outcome in Elderly People during the 2014 Outbreak in Guinea

“Elderly people occupy a prominent position in African societies; however, their potential linkage to high case fatality rate (CFR) in Ebola virus disease (EVD) was often overlooked. We describe the predictive factors for EVD lethality in the elderly. A total of 2,004 adults and 309 elderly patients with confirmed EVD were included in the analysis. The median age (interquartile range) was 35 years (23–44) in adults and 65 years (60–70) in the elderly. The proportion of funeral participation was significantly higher in the elderly group than in the adult group. Duration (in days) between the onset of symptoms and admission was significantly longer in elderly. CFR in the elderly people was also significantly higher (80.6%) than in the adult group (66.2%). Funeral participation constituted a risk factor for the transmission of EVD in elderly people.”

 


Ebola’s survivors: Cataracts

NY Times

“….Cataracts usually afflict the old, not the young, but doctors have been shocked to find them in Ebola survivors as young as 5. And for reasons that no one understands, some of those children have the toughest, thickest cataracts that eye surgeons have encountered, along with scarring deep inside the eye….”

PHIL Image 17772

Under a magnification of 25,000X, this scanning electron microscopic (SEM) image depicts numerous filamentous Ebola virus particles budding from a chronically-infected VERO E6 cell.

 


Predicting Ebola in a patient: Headache, diarrhea, difficulty breathing, nausea and vomiting, loss of appetite, and conjunctivitis. The laboratory tests most useful were creatinine, creatine kinase, alanine aminotransferase, and total bilirubin.

Oza, S., Sesay, A. A., Russell, N. J., Wing, K., Boufkhed, S., Vandi, L….Checchi, F. (2017). Symptom- and Laboratory-Based Ebola Risk Scores to Differentiate Likely Ebola Infections. Emerging Infectious Diseases, 23(11), 1792-1799. https://dx.doi.org/10.3201/eid2311.170171.

“…..This risk score correctly identified 92% of Ebola-positive patients as high risk for infection; both scores correctly classified >70% of Ebola-negative patients as low or medium risk. Clinicians can use these risk scores to gauge the likelihood of triaged patients having Ebola while awaiting laboratory confirmation…..”


Guidelines focusing on the delivery of supportive care measures to patients in Ebola treatment units where health care resources are limited

Evidence-based guidelines for supportive care of patients with Ebola virus disease
Lamontagne, François et al.
The Lancet


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