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PUBLIC HEALTH EMERGENCY
OF INTERNATIONAL CONCERN
(PHEIC)
EBOLA (EVD)
-Dr.R.PARTHASARATHI,M.D
Dept of Community Medicine
PHEIC
Defined in IHR 2005 as
‘an extraordinary public health event which
constitutes a public health risk to other States
through the international spread of disease and
may require a coordinated international
response’.

Such events are required to be assessed for notification to
WHO using a decision instrument
PHEIC
4 decision criteria used in assessment of a public health
event are :
(a) The seriousness of the event’s public health impact.
(b) The unusual or unexpected nature of the event.
(c) The risk of international spread.
(d) The risk that travel or trade restrictions will be
imposed by other countries.
Any 2 criteria Notify WHO

A single case of smallpox, poliomyelitis (WPV), human
influenza caused by a new subtype and SARS must be
immediately notified to WHO, irrespective of the context in which
it occurs.
PHEIC
EBOLA VIRUS DISEASE (EVD)
It is one of the world’s most virulent diseases.
 Formerly known as Ebola haemorrhagic fever.
 Severe, often fatal illness, with a case fatality rate of up
to 90%.
 EVD outbreaks occur primarily in remote villages in
Central and West Africa, near tropical rainforests.
 All agents that cause viral hemorrhagic fever syndrome
are RNA viruses with a lipid envelope, all are
considered zoonoses, all damage the microvasculature,
resulting in increased vascular permeability, and all are
members of one of four families: Arenaviridae,
Bunyaviridae, Flaviviridae, and Filoviridae.

EBOLA VIRUS
Ebola first appeared in 1976 in 2 simultaneous outbreaks in
Nzara, Sudan, and in Yambuku, Congo.
 Yambuku village near the Ebola River
 Family:Filoviridae
 Genus: Ebolavirus (3 members Marburgvirus, Cuevavirus)
 Species:5 types
1.
Bundibugyo ebolavirus (BDBV)
2.
Zaire ebolavirus (EBOV)
3.
Sudan ebolavirus (SUDV)
4.
Reston ebolavirus (RESTV)
5.
Taï Forest ebolavirus (TAFV).

EBOLA SPECIES


BDBV, EBOV, and SUDV have been associated with
large EVD outbreaks in Africa.
The RESTV species, found in Philippines and the
People’s Republic of China, can infect humans, but no
illness or death in humans from this species has been
reported to date.
ENVIRONMENTAL PERSISTANCE



Under ideal conditions, Ebola virus could remain active
for up to 6 days.
Persistence of Ebola virus in the patient care environment
is short – within 24 hours
Ebola virus was found, relative to other enveloped
viruses, to be quite sensitive to inactivation by ultraviolet
light and drying; yet sub-populations did persist in
organic debris.
2014 OUTBREAK
On 8 August 2014, WHO declared the Ebola virus
disease outbreak in West Africa a Public Health
Emergency of International Concern (PHEIC) in
accordance with the IHR 2005.
 The current EVD outbreak is believed to have begun
in Guinea in December 2013.
 Viral sequencing shows strong homology (98%) with
Zaïre Ebolavirus (EBOV)
 As of August 16, 2014,
2,240 suspected or confirmed cases, including
1383 laboratory-confirmed cases and
1,229 deaths

2014 OUTBREAK
TRANSMISSION

Natural Host: Fruit bats of the Pteropodidae family
(Hypsignathus monstrosus, Epomops franqueti, and
Myonycteris torquata)

Source of human infection: Blood, secretions, organs, or
other bodily fluids of infected animals, Bushmeat
(handling of infected chimpanzees, gorillas, fruit bats,
monkeys, forest antelope, and porcupines found ill or
dead or in the rainforest)
ENZOOTIC
EPIZOOTIC
EPIDEMIC
HUMAN-TO-HUMAN
TRANSMISSION
Direct contact (through broken skin or mucous membranes)
with the blood, secretions, organs or other bodily fluids of
infected people
 Indirect contact with environments contaminated with fluids.
 Burial ceremonies (mourners direct contact with corpse)
 The patients become contagious once symptoms begin. They
are not contagious during incubation period.
 Virus transmitted through the semen for up to 7 weeks after
recovery from illness.
 Health-care workers have frequently been infected

INCUBATION PERIOD: 2 to 21 days
CASE FATALITY RATE: 53%
 All cases in the current outbreak- H2H
SIGNS AND SYMPTOMS
PRODROME:
sudden onset of fever, intense weakness, muscle pain,
headache and sore throat.
 VIRAEMIA:
vomiting, diarrhoea, rash, impaired kidney and liver
function, and in some cases, both internal and
external bleeding (DIC)

Patients are infectious as long as their blood and
secretions contain the virus.
PERSON UNDER INVESTIGATION (PUI)
A person who has both consistent symptoms & risk factors:
1) Clinical criteria, which includes fever of greater than 38.6
degrees Celsius or 101.5 degrees Fahrenheit, and additional
symptoms such as severe headache, muscle pain, vomiting,
diarrhoea, abdominal pain, or unexplained haemorrhage;
AND
 2) Epidemiologic risk factors within the past 21 days before the
onset of symptoms, such as contact with blood or other body
fluids or human remains of a patient known to have or suspected
to have EVD; residence in—or travel to—an area where EVD
transmission is active; or direct handling of bats, rodents, or
primates from disease-endemic areas.

CASE DEFINITION FOR EVD
Probable Case

A PUI who is a contact of an EVD case with
either a high or low risk exposure.
Confirmed Case

A case with laboratory confirmed diagnostic
evidence of Ebola virus infection.
CONTACTS OF AN EVD CASE
Contacts have different levels of exposure risk, as follows:
High risk exposures
A high risk exposure includes any of the following:
 Percutaneous, e.g. the needle stick, or mucous
membrane exposure to body fluids of EVD patient
 Direct care or exposure to body fluids of an EVD patient
without appropriate PPE
 Laboratory worker processing body fluids of confirmed
EVD patients without appropriate PPE or standard
biosafety precautions
 Participation in funeral rites which include direct
exposure to human remains in the geographic area
where outbreak is occurring without appropriate PPE
CONTACTS OF AN EVD CASE
Low risk exposures
A Low risk exposure includes any of the following:
 Household member or other casual contact* with an
EVD patient
 Providing patient care or casual contact* without highrisk exposure with EVD patients in health care
facilities in EVD outbreak affected countries
No known exposure
 Persons with no known exposure were present in an
EVD outbreak affected country in the past 21 days with
no low risk or high risk exposures.
*CASUAL CONTACT
Defined as
 being within approximately 3 feet (1 meter) or within
the room or care area for a prolonged period of time
(e.g., healthcare personnel, household members) while
not wearing PPE
OR
 having direct brief contact (e.g., shaking hands) with
an EVD case while not wearing PPE

Brief interactions, such as walking by a person or
moving through a hospital, do not constitute casual
contact.
DIFFERENTIAL DIAGNOSIS
Always rule out
 Other Viral Haemorrhagic Fevers.
 Malaria
 Yellow fever
 Dengue
 Leptospirosis
 Typhoid Fever
 Shigellosis
 Rickettsiosis
 Relapsing Fever
 Cholera
 Plague
 Hepatitis
LABORATORY FINDINGS
Thrombocytopenia, leukopenia with a pronounced
lymphopenia.
 Neutrophilia develops after several days
 Elevations in aspartate aminotransferase and alanine
aminotransferase.
 Bilirubin may be normal or slightly elevated.
 With onset of anuria, BUN and serum creatinine rise.
 Terminally ill patients : Tachypnea, metabolic acidosis


Definitive diagnosis : Isolation of the virus in tissue culture
or PCR.
LABORATORY DIAGNOSIS
Definitive diagnosis by
 Antibody-capture ELISA
 Antigen detection tests
 Serum neutralization test- serological surveys
 RT-PCR assay
Highly sensitive and
confirmatory tests
 Virus isolation by cell culture.
 Skin biopsies in postmortem diagnosis of infection with
Ebola virus
Blood samples collection and transport according to
guidelines and to WHO accredited labs only
 NCDC, New Delhi and NIV,Pune in our country

MANAGEMENT
 Isolate
the patient
• Triage rapidly to a separate room /holding area
• The holding area should be:
- Distant from other crowded areas
- Well ventilated
- Have adequate sunlight
 Notify
the State and National Authority
 Clinical management: predominantly Supportive and
focus on early recognition of complications with
appropriate symptom management.
 Antipyretics, Anti-emetics, Rehydration therapy, Blood
transfusion, Oxygen , Respiratory support and Anticonvulsants as needed
 No specific drug treatment
Experimental treatment
Zmapp
Combination of monoclonal antibodies which binds with
outer glycoprotein of the virus and prevents its entry to the
host cells
 Efficacy yet to be proven, no clinical trials done till date.
 In early trials- all Rhesus monkeys infected with virus
survived when administered 1 hour after infection.
 Produced using specific tobacco plants.
 WHO authorised this treatment for a small group on 11th
August,2014.
 Even if successful, stocks will not be available till 2015

Tekmira, a Canadian biotech company, has begun
early human trials of a new drug
Vaccine
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

NOT YET
An adenovirus-vectored Ebola glycoprotein gene has
proved protective in nonhuman primates and is undergoing
phase 1 trials in humans.
An experimental vesicular stomatitis virus–based vaccine
has protected macaques when given both before and after
infection with the Zaire Ebola virus.
PREVENTION
Isolation and Quarantine, Notification
 Contact Tracing
 Standard Precautions–At All Times, For All Patients
 Barrier nursing
 Hand washing
 Personal Protective Equipment (PPE)
 Injection safety, Safe sex practices
 Concomitant & Terminal Disinfection, Sterilisation
 Following SOP for Blood sample collection and
Transport
 Appropriate Hospital Waste management
 Enhanced Surveillance
 Health Education: Myths

PPE
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STRATEGY FOR PREVENTION AND CONTROL
AIR TRAVELLERS
Exit screening and communication efforts on the ground
in West Africa to prevent sick travellers from getting on
planes.
 Airports in Guinea, Liberia, and Sierra Leone are
screening outbound travellers for Ebola symptoms,
including fever, and passengers are required to respond
to a health questionnaire.
 Avoid non-essential travel- WHO
 Some countries have banned flights and entry to people
from the affected regions.

INDIA
No confirmed case of Ebola till date.
 The World Health Organisation (WHO) had informed
that one Indian passenger had travelled on the same
flight in which an Ebola virus patient (a foreign
national) was travelling from Monrovia to Lagos. He was
tracked and found healthy.
 24-hour 'Emergency Operation Centre‘:
011-23061469, 3205 and 1302
 TN Helpline- 104
 Rumours from Karnataka-WhatsApp message that
student from the National Institute of Technology
Karnataka (NITK) in Dakshina Kannada districthad
ebola and succumbed to it

T
PREVENTION IS THE
H Y
ONLY CURE
A O
U
N
THANK YOU...
K