3/14/2015

Recent Emerging Infections:

Its Implications In Preparedness and
Response
Presented By:
Vito G. Roque, Jr., MD
Department of Health

Presentation Content Through The Kindness of Director Lyndon L. Lee Suy

Presentation Content
ERV (Ebola Reston Virus)
- For Animals Only (But For How Long?)
Emerging Acute Respiratory Syndromes
- SARS and MERS (Relatives Do Not Co-Exist)
EVD (Ebola Virus Disease)
- The Dreaded One (How Long Will Be My
Stay?)

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Ebola reston virus

The Ebola Viruses

RNA Virus
Family: Filoviridae
Genus: Ebola virus
Ebola Virus Sub-Types
Zaire
Sudan
Reston
Cte dIvoire or Ivory Coast
Bundibugyo

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Ebola reston virus

Known to cause disease to non-human
primates (monkeys, gorillas & chimpanzees) &
often fatal
Only Ebola subtype in the family of filoviruses
that does not cause clinical illness in humans
No reported human deaths among cases
Humans develop antibodies to ERV but do not get
sick

Ebola reston History

Year Country No. of Percentage
Human of Deaths Situation
Cases Among Cases

1989 USA 0 0% Ebola Reston (ER) was introduced into

quarantine facilities in Reston, Virginia;
Alice, Texas & Philadelphia,
Pennsylvania by monkeys imported
from the Philippines. Four humans
developed antibodies to ER but did not
become ill.

1990 USA 0 0% ER was introduced once again into

quarantine facilities in Virginia and
Texas by monkeys imported from the
Philippines. Four humans developed
antibodies and did not get sick.

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Ebola reston History

Year Country No. of Percentage
Human of Deaths Situation
Cases Among Cases
1992 Italy 0 0% ER was introduced into quarantine
facilities in Sienna by monkeys
imported from the same export
facility in the Philippines that was
involved in the episodes in the USA.
No humans were infected.
1996 Philippines 0 0% ER virus was identified in a monkey
export facility in the Philippines. No
human infections were identified.
2008 Philippines 0 0% ER virus was found in pigs from
farms in Pandi, Bulacan and
Manaoag, Pangasinan. Six humans*
developed antibodies to ER but did
not become ill.

Transmission of Ebola viruses

Droplet infection
Direct contact
With infected cynomolgus monkeys (Macacca
fascicularis) or crab-eating macaques
With dead carcasses of infected animals
Particularly with the blood, secretions, organs or other
bodily fluids
Sexual transmission

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FRUIT BATS
Transmission
Reservoir???

?
? ERV
??
Much has yet to be learned
about disease transmission

Finding the True Source (Reservoir) of

the Disease
NO answer yet
What is the reservoir of the
disease?
What caused the pigs to get the
Ebola reston virus?
The effectiveness of disease control measures
depends on finding the source of Ebola reston
virus

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Prevention of Emerging Infectious Diseases Will

Require Action in Each of These Areas
Surveillance and Response
Applied Research
Infrastructure and Training
Prevention and Control

Surveillance and Response

Detect, investigate, and monitor emerging
pathogens, the diseases they cause, and the
factors influencing their emergence, and
respond to problems as they are identified.

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Applied Research
Integrate laboratory science and
epidemiology to increase the
effectiveness of public health practice.

Infrastructure & Training

Strengthen public health infrastructures to
support surveillance, response, and research and
to implement prevention and control programs.
Provide the public health work force with the
knowledge and tools it needs.

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Prevention & Control

Ensure prompt implementation of
prevention strategies and enhance
communication of public health
information about emerging diseases.

Preventing Emerging
Infectious Diseases: More to Do
Enhance communication: locally, regionally,
nationally, globally
Increase global collaboration
Share technical expertise and resources
Provide training and infrastructure support globally
Ensure political support
Ensure judicious use of antibiotics
Vaccines for all

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Coronaviruses
Human CoVs first isolated in the 1960s
Six human CoVs identified to date:
HCoV 229E
HCoV OC43
HCoV NL63
HCoV HKU1
SARS CoV
Middle East Respiratory Syndrome Coronavirus
(MERSCoV)

Non-SARS Human CoVs

Worldwide
Winter & spring in temperate climates
Exposure common in early childhood
Droplet, contact & indirect contact
Symptoms & viral loads high first few days of
illness
Incubation period 2-5 days

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Non-SARS Human CoVs

Most often associated with upper respiratory
tract infections in children
Pneumonia & lower tract infections in
immunocompromised individuals & the
elderly
May play a role in exacerbations of underlying
respiratory diseases

SARS
1st recognized in Nov. 2002 as sporadic cases
in Guandong province, China
Outbreak period 2002 2003
Hong Kong hotel contributed to spread of
virus to several countries

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SARS
Incubation period 2-10 days
Droplet transmission
Aerosol spread
Fomites
Fecal respiratory transmission at an apartment
complex in Hong Kong
Transmission most likely during 2nd week of
illness
Super spreading events

Middle East Respiratory Syndrome

Corona Virus
1st identified in September 2012
Cases retrospectively idenitifed as early as
March 2012
Different from other coronaviruses in humans,
including SARS
Most similar to coronaviruses found in bats

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MERS-CoV
Several studies have identified MERS-CoV in
high proportion of camels
Likely reservoir
Identical gene segment found in one bat
Mode of transmission is unclear
Respiratory?
Foodborne?
Few primary cases with direct camel contact

MERS-CoV
Most people who got infected with MERS-CoV
developed severe acute respiratory illness
with symptoms of fever, cough, and shortness
of breath
Common symptoms are acute, serious
respiratory illness with fever, cough, shortness
of breath and breathing difficulties

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MERS-CoV
Case demographics
Males > Females
Median age 49 years (9 months 94 years)
Incubation period 2 14 days
Infection period
Under investigation
Not believed to be contagious before onset

MERS-CoV
75% identified as secondary
Mostly healthcare workers (19% of all cases)
Many with no or minor symptoms
Many clusters identified
Healthcare
Household (estimated 1.3% secondary attack rate)
No sustained human to human transmission

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MERS-CoV
MERS-CoV has been shown to spread between
people who are in close contact*
Transmission from infected patients to
healthcare personnel has also been observed
Clusters of cases in several countries are being
investigate
*Close contact is defined as a) any person who provided care for the patient,
including a healthcare worker or family member, or had similarly close physical
contact; or b) any person who stayed at the same place (e.g. lived with, visited) as
the patient while the patient was ill.

MERS-CoV
Treatment is largely supportive and should be
based on the patients clinical condition
Medical care is supportive and to help relieve
symptoms
Currently, there is no available vaccine against
MERSCoV

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MERS-CoV
Infection Control
Healthcare settings
Contact, droplet & airborne isolation
Fit-tested N95 or higher level respirators
Gowns, gloves & eye protection
Negative pressure airborne infection isolation
Surgical mask when out of room
Home
Precautions for ill persons, care givers & close contacts
Self-monitor if asymptomatic

MERS-CoV
Critical to prevent the possible spread of MERS-
CoV in health care facilities
Health-care facilities that provide for patients
suspected or confirmed to be infected with
MERS-CoV infection should take appropriate
measures to decrease the risk of transmission of
the virus from an infected patient to other
patients, health-care workers and visitors
Health-care workers should be educated, trained
and refreshed with skills on infection prevention
and control

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MERS-CoV
It is not always possible to identify patients
with MERS-CoV early because some have mild
or unusual symptoms
It is important that health-care workers apply
standard precautions consistently with all patients
regardless of their diagnosis in all work
practices all the time

MERS-CoV
Droplet precautions should be added to the
standard precautions when providing care to
all patients with symptoms of acute
respiratory infection
Contact precautions and eye protection
should be added when caring for probable or
confirmed cases of MERS-CoV infection
Airborne precautions should be applied when
performing aerosol generating procedures

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MERS-CoV
Wash your hands often with soap and water for 20
seconds, and help young children do the same
If soap and water are not available, use an alcohol-based
hand sanitizer
Cover your nose and mouth with a tissue when you
cough or sneeze then throw the tissue in the trash
Avoid touching your eyes, nose, and mouth with
unwashed hands
Avoid close contact, such as kissing, sharing cups, or
sharing eating utensils, with sick people
Clean and disinfect frequently touched surfaces, such
as toys and doorknobs

Ebolavirus
Long narror virus, length
1400 nm & width 80 nm
Filamentous
RNA with protein as inner
core, matrix layer next,
then membrane from
host cell outside
RNA codes for 8 proteins
Virus takes over the cell

http://visualscience.ru/en/projects/ebola/po
ster/

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Ebola Virus
Filovirus family (Filoviridae)
Five species
Zaire Ebolavirus
Sudan Ebolavirus
Bundibugyo Ebolavirus
Tai Forest Ebolavirus
Reston Ebolavirus

Reston Ebolavirus
The Good Cousin
Found in the Philippines & China
Causes respiratory disease in pigs
Infects humans, but NO disease
Pig farmers, abattoir workers, others have
antibodies

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Natural History
Virus enters the cell
Any cell, but particularly uses macrophages,
dendritic cells & monocytes
Spreads to lymph nodes via lymphatics & then
to liver & spleen via blood
Secondary spread to all organs
Exits the body in feces, saliva, sweat, tears,
sputum, skin cells, breast milk, semen, urine,
vomitous

No Virus Before Symptoms are Observed

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Pathogenesis of Ebolavirus
Destroy cells
Focal necrosis in many
organs
Suppress inflammation
Cause cytokine storm
Induces clotting
Multi-organ focal necrosis
& disseminated
intravascular coagulation
with focal hemorrhage &
minimal inflammation
Liver with Ebolavirus(red) Martineset al J
Pathol2014

Survival Outside Host

Dried
24 hr at 25C; 14 days at 4C
In Fluids
Up to 46 days at 25C
Ebolavirus is killed by:
Heat at 60C for 1 hr
Alcohols
3% acetic acid
1% glutaraldehyde
Handwashing with soap & water will kill Ebolavirus
Piercyet al J ApplMicrobiol2010;109:1531; Sagripantiet al Arch
Virol2010; 155:2035; Health Canada PDSS -http://www.phac-
aspc.gc.ca/lab-bio/res/psds-ftss/ebola-eng.php

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Ebola in West Africa

Guinea, Sierra Leone, Liberia

How did it start?

First case (index case) 2
years old child in village
of Meliandou in Guinea
died on 6 December
2013
Transmitted locally &
new outbreaks started
when people moved
the virus across Guinea
Gatherer J Gen Virol2014

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Case Definitions
Person Under Investigation (PUI)
Any person who has resided in or traveled to any
of the countries with ongoing widespread EVD
transmission in the past 21 days
OR
Any person who had significant contact with a
suspect / probable / confirmed EVD case in the
past 21 days

Case Definitions
Suspect Case
A PUI who develops at
least one of the following
signs & symptoms during
the 21-day incubation
period:
Fever Difficulty of swallowing or sore throat
Difficulty in breathing
Headache
Drowsiness or lethargy
Nausea / Vomiting
Bleeding (from different sites such as
Anorexia / loss of appetite gums, skin, eyes, urine, etc.)
Intense fatigue hiccups
Diarrhea
Abdominal pain
Muscle or joint pains

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Case Definitions
Probable EVD Case
Any suspected case evaluated by a
clinician/epidemiologist having an epidemiological
link with a confirmed case (where it was possible
to collect specimen for laboratory confirmation)
OR
Any deceased suspected case (where it was not
possible to collect specimen for laboratory
confirmation) having an epidemiological link with
a confirmed case

Case Definitions
Laboratory Confirmed EVD Case
A suspected case with laboratory confirmation of
infection with EVD

Discarded / Non EVD Case

A suspected case with a negative laboratory result
that was from a blood specimen collected at least
72 hours after onset of symptoms

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Patient Screening & Triage

The objective of screening is to quickly identify
people with a travel history to countries with
ongoing transmission of Ebola
The objective of triage is to determine if these
persons have symptoms of EVD & if so, to
promptly isolate them.
Personnel in health facilities at first points of
contact should be trained on EVD screening
procedures
Triage should be done by health care personnel

Triage Area
All health care facilities MUST designate a triage
area, which should be located as near as possible
to the Ebola isolation unit of the hospital to
prevent patients from gaining access to the whole
hospital facility
It should be separate from the general
emergency room to prevent potential
transmission of EVD to other patients & hospital
staff
The area should have adequate ventilation &
room air exchange

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Chain of Infection
Certain conditions must be met in order for a
microbe or infectious disease to be spread
from person to person

Ebola & the Chain of Infection in

Healthcare Facilities
Pathogenic microorganism:
Ebola Virus
Reservoir:
Patient infected with Ebola
Means of Escape:
Blood & body fluids
Mode of Transmission:
Direct contact with blood & body fluids of infected person
Contact with contaminated surfaces/equipment
Means of Entry:
Non-intact skin, mucous membranes, sharps injury
Host susceptibility:
Poor nutrition, stress, exhaustion, non-intact skin

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Infection Control
What? Breaking the chain of infection
Why? Prevent infections within health facilities
How? Consistent practice of protocols that
prevent an infectious agent moving from one
host to another
Who? Protects:
Patients
HCWs
Visitors
Other staff

If carefully implemented, Infection

Prevention & Control measures will reduce
or stop the spread of the virus & protect
health-care workers & others.
WHO, 2014. Interim Infection Prevention & Control Guidance for Care of Patients with
Suspected or Confirmed Filovirus Hemorrhagic Fever in Health Care Settings with Focus
on Ebola

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Clinical Manifestations
Non-specific & can be misdiagnosed as a
nonspecific viral illness or malaria
Includes fever, severe headache, myalgia,
arthralgia, diarrhea, abdominal pain, nausea &
vomiting
In the advanced stage, patients may have
respiratory distress, bleeding diathesis, hepatic &
kidney failure & may progress to delirium or
coma & then hypovolemic shock & death

Diagnosis
The immunoglobulin M & Immunoglobulin G
enzyme-linked immunosorbent assay (ELISA)
non-specifically detect antibodies against the
clinically relevant Ebola viral strains
Relatively sensitive & specific
RT-PCR
Virus Isolation
Serologic testing for Ebola Ag

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Treatment
Objective:
To provide optimal care to the patient with maximal
protection of the health care personnel
No FDA-approved vaccines or medicines available
for ebola
Treatment is mainly supportive & symptomatic
Fluid balance
Nutrition
Managing hemorrhagic complications

Criteria for Discharge

Patients should only be discharged if ALL of
the following conditions are fulfilled:
Two negative (blood) RT-PCR tests done 72 hours
apart
Asymptomatic for at least 72 hours

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Summary
Efficient screening & triage is important
Quarantine & monitoring strategies depend on the risk level for EVD
transmission
Cornerstone of management in EVD is advanced supportive therapy
which include:
Fluid & electrolyte balance
Management of hemorrhagic complications
Other supportive treatment including nutritional support & malaria
management
Novel treatment still warrant further investigation
Balance between patient care & healthcare worker safety should be
achieved
Institution should be ready to handle specific issues that may arise in the
course of management in EVD via a multidisciplinary approach

Points To Remember
Live With
Worked With
Cared For
Stay Clean
Stay Safe

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Salamat po!

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