November 2014 Ebola Outbreak in West Africa - Responding to an extraordinary epidemic

November 2014

Ebola Outbreak in West Africa

Responding to an extraordinary
           epidemic

          Olaf Müller

Viral Haemorrhagic Fevers
Ø Diverse group of diseases
Ø Zoonoses and frequently arbo viruses
Ø Pathogenesis (e.g. immune suppression) not well understood
Ø Potential for epidemics/pandemics/bioterrorism
Ø Few drugs (e.g. Ribavirin) and vaccines (e.g. Yellow Fever)
   available

Viral Haemorrhagic Fevers
Genus         Disease       Geography      Origin       Mortality
Arenavirus    Lassa HF      West Africa    Rodents      2-15%
Filovirus     Ebola/Marburg          SSA   Bats         25-90%
Hantavirus    HF/Ren Syndr Asia, Europe Rodents         1-15%
Nairovirus    Crim Congo    Asia, Europe, Ticks         15-30%
              HF            Africa
Phlebovirus   Rift Valley HFAfrica, Asia   Mosquitoes   50%
Flavivirus    Dengue,       Tropics/sub-T Aedes M.

Marburg Virus

                                            Detected 1967 in
                                            Marburg (imported
                                            monkeys from
Only 1 import through a tourist in Europe   Uganda)

Ebola Virus

          First outbreaks in Zaire
          in 1976 (Ebola River)

          • Sudan-Type
          • Zaire-Type
          • Ivory Coast-Type
          • Uganda-Type
          • Reston-Type
          (monkeys, not humans,
          spread through air)

          Rarely been exported
          (only SSA – SA)

Ebola Origin
August 26, 1976, in Yambuku, a town in northern Zaïre.
A 44-year-old school teacher returned from a small hike.
His went to the doctor and because of his high fever they
gave him a quinine shot which is good against malaria.

A week later, he had uncontrolled vomiting, bloody
diarrhea, trouble breathing and then bleeding from his
nose, mouth, and anus.

He died ~14 days after the onset of symptoms.

He started an epidemic that killed 280 of the 313 infected
persons (88%).

Ebola Origin

Ebola Virus
Transmission: Healthy fruit-bats (direct contact, cave
visits), contact with other mammalian who got infected
(e.g. chimpanzees/gorillas, antelopes, pigs), human-human (R0 1-3)

Outbreaks: Explosive outbreaks in remote areas with hundreds of
deaths (health workers, family members) for a few months (n=22)

Clinic: 2-21 days incubation period (median 7 days), sudden onset
with high fever, headache, muscle pain, exanthema, diarrhea,
hemorrhages, death typically on day 6-16.

Infectiousness: Starts with symptoms, virus persists in semen

Diagnosis and treatment: Antigen ELISA & PCR during acute
disease; AB later; only supportive measures; strict infection control

Current Ebola Outbreak
History: Started in Guéckédou District of Guinea with the first case
recorded on December 2, 2013 (2 year old, followed by sister,
mother, grandmother, nurse, participants of funeral, hospital staff);
until April 2014 cases mainly in Guinea and a few in the border areas
to Liberia and Sierra Leone; by August 16 the cumulative number of
confirmed, probable, and suspected cases was 2240, with 1229
deaths (more than in all former outbreaks in SSA combined).

First outbreak affecting multiple countries.
Imports to Nigeria, Senegal, Mali and USA.

Current Ebola Outbreak
Latest figures (12.11.2014):
Ø Total number of recorded cases: 14.098 (estimate x 2-4?)
       - Guinea: 1.878         - Sierra Leone: 5.368
       - Liberia: 6.822        - Mali: 4
       - Nigeria: 20; (no new cases since 05.09)
       - Senegal: 1 (no new cases since 29.08)
       - USA: 4        - Spain: 1
Ø Total number of deaths: 5.160

       ??? CDC - January 2015: 1.4 million ???

Current Ebola Outbreak
Bamako/Mali (13.11.2014):
Die Regierung in Mali hat am späten Dienstagabend den zweiten
Ebola-Fall des Landes gemeldet. Ein Krankenpfleger, der einen
Ebola-Patienten aus Guinea betreut hatte, sei selbst an der Krankheit
gestorben, teilte das behandelnde Krankenhaus in der Hauptstadt mit.
Nach Behördenangaben starb der Patient aus Guinea, ohne dass er
auf Ebola getestet wurde. Sein Leichnam wurde – nach einer großen
Beerdigungszeremonie, da er ein bekannter religiöser Führer war -
zurück in sein Heimatland gebracht, alles ohne die
Sicherheitsvorkehrungen, die beim Umgang mit an Ebola
Verstorbenen nötig sind. Die Privatklinik, ein Teil des Personals und
der Patienten wurde unter Quarantäne gestellt und von einem
schweren Polizeiaufgebot abgeriegelt.

Geographical Situation

Exponential Increase

Monthly Incidence by Country

Ebola Treatment Centers 11/2014

Ebola laboratories 11/2014

Healthworker figures
Country                    Cases             Deaths

Guinea                     92                51
Liberia                    329               162
Sierra Leone               128               102
Mali                       1                 1
USA                        3                 0
Spain                      1                 0
-------------------------------------------------------
Total                      554               316
(12. 11. 2014)

Impact on other diseaes
The Ebola epidemic only represents the tip of the
iceberg in terms of the health burdens present in
West Africa. Many people might now die from
treatable diseases such as respiratory infections,
diarrhoea, and, of particular importance, malaria.

Malaria patients in Liberia are refusing to be
treated in the same facility as Ebola patients.
To address the consequences of avoiding
treatment facilities, MSF has distributed ACT
to 300 000 people in Monrovia. A decrease in
the number of cases of malaria-related fever
will help reduce the strain on Ebola treatment
centres.

The International Response
Ø The international response came rather late (expert error)
Ø MSF has warned in May that the epidemic is out of control
Ø American army deploys 3000 soldiers/health staff/experts
Ø Cuba sends 250 medical doctors; Uganda sends Ebola experts
Ø Other follow slowly – E.g. UK, Germany (DRK/2 hospitals) …
Ø Biomedical research is highly supported and speeded up
   Active vaccines will likely play the biggest role (see below)
   Passive vaccines may also get a role (serum banks/survivers)
   Drugs are not so clear (WHO list of 120 candidates; Favipiravir &
   Brincidofivir, Zmapp/mix of three gentec antibodies, TKM-Ebola)

Thanks and let’s discuss