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Ebola Virus Disease and Clinical Care: Ebola Virus Disease and Clinical Care:

Ebola Virus Disease and Clinical Care: - PowerPoint Presentation

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Ebola Virus Disease and Clinical Care: - PPT Presentation

Part I History Transmission and Clinical Presentation US Department of Health and Human Services Centers for Disease Control and Prevention This presentation is current as of December ID: 914754

virus ebola case transmission ebola virus transmission case patients clinical contact disease person symptoms presentation screening fever body signs

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Slide1

Ebola Virus Disease and Clinical Care:

Part I: History, Transmission, and Clinical Presentation

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

This presentation is current as of December 2014. This presentation contains materials from Centers for Disease Control and Prevention (CDC), Médecins Sans Frontières (MSF), and World Health Organization (WHO).

version 12.03.2014

Preparing Healthcare Workers to

Work in

Ebola Treatment Units (

ETUs)

in Africa

Slide2

Learning Objectives

Describe the routes of Ebola virus transmissionExplain when and how patients are infectiousDescribe the clinical features of patients with Ebola Describe screening criteria for Ebola virus disease (EVD) used in West Africa

Explain how to identify patients with suspected EVD who present to the ETU

Slide3

Viral Hemorrhagic Fevers

Arenaviridae

Bunyaviridae

Filoviridae

FlaviviridaeLassa HFArgentine HFBolivian HF

Venezuelan HFBrazilian HF

Hantavirus Genus

Congo-Crimean

HF

Rift

Valley FeverEbolaMarburgLloviuDengueYellow feverKyasanurOmsk

Slide4

Ebola Virus

Slide5

Ebola Transmission

This presentation contains materials from CDC, MSF, and WHO

Slide6

Ebola Virus

Filoviridae Family of zoonotic RNA viruses: Marburg virus and

Ebola virus species

>20 previous Ebola

and

Marburg outbreaks

In previous outbreaks, the case-fatality rates have varied by subtype: E. Zaire (57%-90%), E. Sudan (approximately 50%), E. Bundibugyo (32%), and E. Reston (0%--evidence of infection but no clinical illness

).

Previous

West African case: Tai Forest Virus,

Côte d’Ivoire

Slide7

Ebola Virus Transmission Cycle

Zoonotic virus– bats are the most likely reservoir, although species unknownSpillover event from infected animals to humans, followed by person-to-person transmission

Slide8

Ebola Virus TransmissionSources

Transmission occurs via direct or indirect contact with body fluids from Ebola-infected

persons or animalsPotentially infectious body fluids include:

BloodRespiratory secretionsUrine Feces

VomitSalivaSweatBreast milk Semen, vaginal secretionsProlonged detection by PCR in semen (up to 101 days after infection and recovery)Transmission risk uncertain

Slide9

Ebola Virus TransmissionKey Concepts

Infected persons are not contagious until onset of symptomsInfectiousness of body fluids (e.g., viral load) increases as patients become more

illCorpses are highly infectious Direct contact with an infected person or recently deceased person are the most common routes of transmission

Transmission also occurs through contact with objects or surfaces contaminated by blood or other body fluids containing virus

Slide10

Ebola Virus Transmission

Routes of Virus EntryEstablished route – direct contact with blood or otherbody f

luidsEyes or other mucous membranesBreaks in the skin

Percutaneous injuries from objects contaminated with infectious materials (e.g., needlestick injury)Possible routesSexual contact

BreastfeedingAerosol transmission is unlikely Person-to-person transmission of Ebola virus via inhalation (aerosols) has not been demonstratedEpidemiology is not consistent with aerosol transmission

Slide11

Ebola Virus Transmission

Opportunities for Person-to-Person TransmissionProviding routine care for infected personsHousehold or communityHealthcare

settingHandling or preparing corpses

Contact with objects contaminated by virus (e.g., soiled

linen, soiled clothes, or used utensils)Accidental injuries from virus-contaminated sharps

Slide12

Ebola Virus TransmissionIncubation Period

The time from the moment of exposure to the virus until onset of symptoms or signs of diseaseIncubation period is usually 9-11 daysIncubation period ranges from 2 -21

days

Slide13

Clinical Presentation

This presentation contains materials from CDC, MSF, and WHO

Slide14

Initial Clinical Presentation of Ebola Virus Disease

Signs and symptomsFever, chills, myalgia, malaise, weakness, nausea, headacheGI symptoms very common: vomiting, diarrhea, abdominal painSpontaneous abortion/miscarriage

Hemorrhage is a late sign, occurring in <50% of cases, and much less common at presentationOther possible infectious causes of

signs and symptoms similar to EVDLassa fever, malaria, typhoid fever, meningococcemia, and other bacterial

infections – all very common in West AfricaDon’t expect all symptoms or consistent sequence in every patient

Slide15

Clinical Features in Severe Ebola Virus Disease

Sepsis presentationHypovolemiaOliguria Signs of liver injuryCytokine storm Hemorrhagic symptoms (<50%)

Ranging from gum “oozing” to (less commonly) epistaxis or mucocutaneous bleeding, GI bleeding

Neuropsychiatric abnormalities (agitation, confusion)Acute malnutritionShock, multiple organ

failure

Slide16

Initial Laboratory Findings of Ebola Virus Disease

Low platelet count (thrombocytopenia)Low WBC count (leukopenia)Electrolyte abnormalities from fluid shifts (e.g., diarrhea, fever, interstitial fluid leak)

Transaminitis (AST>ALT)Increased creatinineClotting abnormalities

Note: in many ETUs, few lab tests will be available

Slide17

Clinical Appearance

Hematemesis

Slide18

Clinical Appearance

Gingival Bleeding

Slide19

Clinical Appearance

Bleeding from IV Site

Slide20

Risk Factors for Death from Ebola Virus Disease

Patient characteristics Age <5 years or >45 years (perhaps related to viral load)Pregnancy

Exposure characteristicsLarge inoculum

Hollow bore needlestick

Exposure to corpse or patient with advanced diseaseClinical characteristics Short incubation time Rapid progression of symptoms Liver and kidney involvementUnexplained bleedingAltered mental status

Slide21

Long-term Issues for Surviving Patients with Ebola

Arthralgia or myalgia (frequent, severe, and persistent)Cardiac injury (e.g. myocarditis)Cerebral complications (e.g., seizures, encephalopathy)Eye problemsMalnutritionMental health issues

Prolonged fatigue

Slide22

Other Considerations for Patients with Fever or Hemorrhage

Many diseases in West Africa present with fever or have hemorrhagic manifestations

Amniotic fluid embolism

Gram-negative sepsis

Hemolytic-uremic syndrome

Lassa fever

Leptospirosis

Leukemia

Malaria

Meningitis

Plague

Rickettsial

diseases

Staphylococcal sepsis

Shigellosis

Thrombotic thrombocytopenic

purpura

Toxic shock syndrome

Typhoid fever

Viral hepatitis

Warfarin poisoning

It is important to consider and manage other treatable infections in the ETU.

Slide23

Screening for Ebola

This presentation contains materials from CDC, MSF, and WHO

Slide24

Case Definition for Screening Patients for Ebola

Applying a uniform case definition is critical for case identification, tracking, and control of the epidemicCase definitions for screening differ

by location (e.g., West Africa vs. United States)

Use the locally relevant case definition

Slide25

Screening for ETU Referral

All patients must be screened (triaged) before entering the ETUNot done in high-risk PPE

Healthcare workers should perform triage at least one meter (three feet) from potential patientsPurpose of triage is to quickly isolate patients who might have EVD then obtain diagnostic tests

Most ETUs perform screening using case definition recommended by WHO for suspected

EVD in AfricaSlightly different case definitions could be used in different locationsIf screening assessment indicates patient is suspected of having Ebola, isolate immediately and admit to suspect area of ETU or arrange transfer to the ETU

Slide26

Example: WHO Screening Algorithm for Healthcare Facilities in

Guinea

Slide27

WHO Definition of “Contact”

Any person having been exposed to a suspect, probable, or confirmed case of Ebola in at least one of the following ways:Has slept in the same household with a caseHas had direct physical contact with the case (alive or dead) during the illness

Has had direct physical contact with the (dead) case at the funeralHas touched his/her blood or body fluids during the

illnessHas touched his/her clothes or linens

Has been breastfed by the patient (baby) Contact’s exposure must have taken place less than 21 days before their identification as a contacthttp://www.who.int/csr/resources/publications/ebola/ebola-case-definition-contact-en.pdf

Slide28

Summary

Incubation period range is 2-21 days, but most commonly 9-11 days after contactNo transmission before symptom onsetTransmission by direct contact with ill people, body fluids, contaminated materials,

corpses, animalsNonspecific early symptoms progress to signs of sepsis: hypovolemic

shock, multi-organ failure, and sometimes hemorrhagic diseaseAppropriate triage of patients with signs and symptoms

that could be EVD is critical to reducing risk for healthcare workers, other patients and the community

Slide29

U.S. Department of Health and Human Services

Centers for Disease Control and Preventionhttp://www.cdc.gov/vhf/ebola