Training on the Ebola virus disease duration 3

Training on the Ebola virus disease (duration 3 days) Efficient by Edification – EFFO 01. 10. 2018

Training structure Safety and good quality work EFFO Module 1: Ebola Virus Disease Module 2: Module 3: Module 4: Module 5: Module 6: Epidemic control on different levels Standard precautions & disinfection Screening & isolation Personal protective equipment Waste management & cleaning Support from the community Support from the hospital administration Support from the population 01. 10. 2018

Ebola virus disease Module 1 (Part 1) 01. 10. 2018

Learning objectives module 1 (part 1) General objectives - To know general information on Ebola virus disease - To be motivated to practice to gain more confidence and skills when dealing with suspected Ebola patients Specific objectives 1. Epidemiology of the outbreak 2013 -2016 and the outbreak in Democratic Republic of the Congo (North Kivu, 2018) 2. Modes of contamination and transmission of Ebola virus 3. Incubation period 4. Symptoms 5. Differential diagnosis 01. 10. 2018

Presentation outline Module 1 Part 2 -now- -later- 1. Epidemiology 2. Information about the Ebola virus 3. Transmission and incubation period 4. Symptomatology 5. Differential diagnosis 01. 10. 2018 1. Laboratory diagnosis: PCR, rapid tests 2. Pathophysiology 3. Care of cases 4. Work in the isolation area and the stress caused

Ebola virus outbreaks in Africa since 1976 Source: CDC 01. 10. 2018

2014: An extraordinary situation New situation: • Very high number of cases • Several countries affected • Failure of conventional measures to control the epidemic 1976 602 cases and 431 deaths in Sudan and DR Congo 01. 10. 2018 1995 2000 West Africa 2013 -2016 2002 2007 Several less serious epidemics in Congo, Uganda, DR Congo with > 100 cases 2013 -2016 Over 28 600 cases and over 11 300 deaths

Health workers at risk «The patient scares me…? !» • More than 800 health care workers were infected in the West-African outbreak more than 500 died. Ø You can protect yourself! Ø You must know HOW to and train it! • Health workers are key persons in the fight against Ebola! Another problem: Ebola can destroy health structures → “ordinary” patients no longer receive treatment 01. 10. 2018

Ebola outbreak in DRC 2018 (as of October 2018) • Course of the outbreak: - Late July : cluster of 26 cases of an undiagnosed illness in Mabalako Health Zone (20 community deaths) - August 1 st : Notification to WHO → Outbreak of Ebola Virus Disease (EVD) in North-Kivu / Ituri in the Democratic Republic of Congo (DRC) • More than 200 cases in total up to now • Also health care workers affected 01. 10. 2018

North-Kivu Province • Densely populated province (> 8 million inhabitants) • Borders with 4 other Provinces in DRC / Uganda & Rwanda August 2018

Challenges in North Kivu /Ituri • Intense insecurity (armed conflicts) and a deteriorating humanitarian crisis • > 1 million internally displaced people • Logistic challenges due to poor infrastructure • Inaccessibility of contacts because of armed rebel activity • High rates of cross border movement to and from neighbouring countries → Risk of local propagation and further spread at the national and regional level = very high (WHO risk assessment) 01. 10. 2018

Information about the Ebola virus (I) • “Ebola” is the name of a river in northern Zaire, close to where the virus has been discovered in 1976 • The Ebola virus belongs to the family of Filoviridae, genus: Ebolavirus • There are five different species: - Zaire ebola virus - Sudan ebola virus - Bundibugyo ebola virus - Taï Forest ebola virus - Reston ebola virus (macaques) Ebolavirus: electron-microscopical picture Source: CDC/ Cynthia Goldsmith 01. 10. 2018

Information about the Ebola virus (II) The Ebola virus has an envelope. Enveloped viruses can be destroyed by: • Chlorine solution • heat (1 h 60°C) • UV-rays (sunlight) • Detergents (soap) Several methods are combined for greater safety. more information in Module 6 01. 10. 2018 Structure of Ebola virus Source: Feldmann, N Engl J Med 2014

The Ebola virus in humans and animals Source: RKI 1. Reservoir of the virus: probably fruit bats and bats 01. 10. 2018 2. Epizootic in primates and other mammals 3. Primary infection in humans 4. Secondary transmission by direct or indirect contact

Incubation period of the Ebola virus disease The incubation period is the time between infection and the appearance of the first symptoms of a disease. The incubation period is individual and depends, for example, on the amount of infectious agents and the immune system. In the case of Ebola: • No symptoms no risk of transmission • Incubation period: 2 to 21 days, mostly 8 -9 days 01. 10. 2018

Modes of transmission The virus is highly contagious! It is transmitted by infected body fluids , through damaged skin, mucosa (e. g. eyes, nose, mouth) and parenterally through CONTACT with: • blood • vomit • stool • breast milk • saliva • tears • sweat • semen • urine 01. 10. 2018

Mode of transmission (how? ) The disease is highly contagious! It is transmitted by infected blood or body fluids through direct or indirect contact: • direct contact with sick or deceased persons • during care at home or in hospital • certain burial practices • contact with clothing, bed sheets, or other objects contaminated with a patient`s fluids • The more the person is sick, the higher the risk of transmission 01. 10. 2018

The initial symptoms of Ebola virus disease • Fever • Nausea • Headache • Vomiting • Muscle pain • Diarrhea • Intense weakness • Abdominal pain • Loss of appetite • Rash Ø The clinical symptoms of Ebola virus disease differ individually. Ø The symptoms are typical but not specific. 01. 10. 2018

The different phases of Ebola virus disease __________________________________ Phase of Time since Clinical features illness Symptom Onset ______________________________________________________________________________________ Early febrile Phase 0 -3 days Fever, malaise, fatigue, body aches Gastrointestinal Phase 3 -10 days Primary: epigastric pain, nausea, vomiting, diarrhea Associated: persistent fever, asthenia, headache, conjunctival injection, chest pain, abdominal pain, arthralgia, myalgia, hiccups, delirium Shock or recovery 7 -12 days Shock: diminished consciousness or coma, rapid thready pulse, oliguria, anuria, tachypnea Recovery: resolution of gastrointestinal symptoms, increased oral intake, increased energy Late ≥ 10 days Gastrointestinal haemorrhage, secondary infections, meningocomplications encephalitis, persistent neurocognitive abnormalities ___________________________________________ (According to Chertow et al. , 2014) 01. 10. 2018

Case fatality rate of Ebola virus disease • Ebola virus disease is fatal in 30 to 90% of the cases • Case fatality rate depends on the virus causing the outbreak • Case fatality rate is influenced by: - the quality of medical care - the time point: How early receives a patient medical care? Ø Outbreak 2013 -2016 in West Africa: Case fatality rate ca. 63% 01. 10. 2018

Sequelae of Ebola virus disease • According to a study in Guinea after the Ebola outbreak 20132016 76% of patients presented with post-Ebola virus disease symptoms. • The most frequent symptoms were: – General symptoms (40%): fatigue, fever, anorexia – Musculoskeletal pain (38%) – Headache (35%) – Depression (17%) – Abdominal pain (22%) – Ocular disorders (18%) 01. 10. 2018

Which symptom is this? Source: CDC 01. 10. 2018

Differential diagnosis These symptoms are also common with other diseases: • malaria • plague • typhoid fever • leptospirosis • meningococcal disease • rickettsiosis • shigellosis • Relapsing fever • cholera • Other viral haemorrhagic fevers (e. g. Yellow fever, Lassa fever, Dengue fever, Crimean-Congo haemorrhagic fever) • hepatitis • viral influenza 01. 10. 2018

How to prevent transmission? What you should know… What you should do… Direct or indirect contact without protection can be very dangerous Use personal protective equipment (PPE) The Ebola virus is NOT spread by air like, e. g. measles A distance of two metres is sufficient for protection No symptoms � no risk for transmission 01. 10. 2018 WATCH OUT FOR THE EXCEPTION! Possible transmission after clinical recovery through sexual contact (semen)

Ebola remains endemic The risk for new Ebola virus disease outbreaks will remain: • There can always be suspected cases for new Ebola virus disease. • Recurrent outbreaks! • Animal Reservoir? (fruit bats or bats) • Exposition to infected body fluids of survivors is possible, but the risk of Ebola virus disease transmission through casual or household contact is very low. • Crucial importance of long-term follow-up for survivors! Westafrica • 1976 1995 01. 10. 2018 2000 2002 2007 2013 -2016 2017 • • 2018

The correct use of PPE is important! Train the use of each PPE element! Some of the difficult elements are : Hood Goggles Mask Gloves (removal) Source: RKI 01. 10. 2018