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Ebola Virus Disease

Key facts 

Ebola virus disease (EVD), formerly known as Ebola haemorrhagic fever, is a rare but severe, often fatal illness in humans.    The virus is transmitted to people from wild animals and spreads in the human population through human-to-human transmission.    The average EVD case fatality rate is around 50%. Case fatality rates have varied from 25% to 90% in past outbreaks.   

Community engagement is key to successfully controlling outbreaks.    Good outbreak control relies on applying a package of interventions, namely case management, infection prevention and control practices, surveillance and contact tracing, a good laboratory service, safe and dignified burials and social mobilisation.   

Vaccines to protect against Ebola are under development and have been used to help control the spread of Ebola outbreaks in Guinea and in the Democratic Republic of the Congo (DRC).    Early supportive care with rehydration, symptomatic treatment improves survival. There is no licensed treatment proven to neutralize the virus but a range of blood, immunological and drug therapies are under development.   

Pregnant and breastfeeding women with Ebola should be offered early supportive care. Likewise vaccine prevention and experimental treatment should be offered under the same conditions as for non-pregnant population.The Ebola virus causes an acute, serious illness which is often fatal if untreated. EVD first appeared in 1976 in 2 simultaneous outbreaks, one in what is now Nzara, South Sudan, and the other in Yambuku, DRC. The latter occurred in a village near the Ebola River, from which the disease takes its name.

The 2014–2016 outbreak in West Africa was the largest Ebola outbreak since the virus was first discovered in 1976. The outbreak started in Guinea and then moved across land borders to Sierra Leone and Liberia. The current 2018-2019 outbreak in eastern DRC is highly complex, with insecurity adversely affecting public health response activities.The 2014–2016 outbreak in West Africa was the largest Ebola outbreak since the virus was first discovered in 1976.

The outbreak started in Guinea and then moved across land borders to Sierra Leone and Liberia. The current 2018-2019 outbreak in eastern DRC is highly complex, with insecurity adversely affecting public health response activities.The virus family Filoviridae includes three genera: Cuevavirus, Marburgvirus, and Ebolavirus. Within the genus Ebolavirus, six species have been identified: Zaire, Bundibugyo, Sudan, Taï Forest, Reston and Bombali. The virus causing the current outbreak in DRC and the 2014–2016 West African outbreak belongs to the Zaire ebolavirus species.

Transmission

It is thought that fruit bats of the Pteropodidae family are natural Ebola virus hosts. Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals such as fruit bats, chimpanzees, gorillas, monkeys, forest antelope or porcupines found ill or dead or in the rainforest.Ebola then spreads through human-to-human transmission via direct contact (through broken skin or mucous membranes) with:Blood or body fluids of a person who is sick with or has died from Ebola.

Objects that have been contaminated with body fluids (like blood, feces, vomit) from a person sick with Ebola or the body of a person who died from EbolaHealth-care workers have frequently been infected while treating patients with suspected or confirmed EVD. This occurs through close contact with patients when infection control precautions are not strictly practiced.Burial ceremonies that involve direct contact with the body of the deceased can also contribute in the transmission of Ebola.People remain infectious as long as their blood contains the virus.

If a breastfeeding woman who is recovering from Ebola wishes to continue breastfeeding, she should be supported to do so. Her breast milk needs to be tested for Ebola before she can start.If a breastfeeding woman who is recovering from Ebola wishes to continue breastfeeding, she should be supported to do so. Her breast milk needs to be tested for Ebola before she can start.For more, read the guidelines on the management of pregnancy and breastfeeding in Ebola.

Symptoms

The incubation period, that is, the time interval from infection with the virus to onset of symptoms, is from 2 to 21 days. A person infected with Ebola cannot spread the disease until they develop symptoms. Symptoms of EVD can be sudden and include:Fever-Fatigue-Muscle pain-Headache-Sore throat.

This is followed by:Vomiting-Diarrhoea-Rash-Symptoms of impaired kidney and liver function. In some cases, both internal and external bleeding (for example, oozing from the gums, or blood in the stools).Laboratory findings include low white blood cell and platelet counts and elevated liver enzymes.

Diagnosis

It can be difficult to clinically distinguish EVD from other infectious diseases such as malaria, typhoid fever and meningitis. Many symptoms of pregnancy and Ebola disease are also quite similar. Because of risks to the pregnancy, pregnant women should ideally be tested rapidly if Ebola is suspected.Confirmation that symptoms are caused by Ebola virus infection are made using the following diagnostic methods: antibody-capture enzyme-linked immunosorbent assay (ELISA)antigen-capture detection tests-serum neutralization test-reverse transcriptase polymerase chain reaction (RT-PCR) assay-electron microscopy-virus isolation by cell culture.Careful consideration should be given to the selection of diagnostic tests, which take into account technical specifications, disease incidence and prevalence, and social and medical implications of test results. It is strongly recommended that diagnostic tests, which have undergone an independent and international evaluation, be considered for use.

Diagnostic tests evaluated through the WHO Emergency Use Assessment and Listing process

Current WHO recommended tests include:Current WHO recommended tests include:   

Automated or semi-automated nucleic acid tests (NAT) for routine diagnostic management.   

Rapid antigen detection tests for use in remote settings where NATs are not readily available. These tests are recommended for screening purposes as part of surveillance activities, however reactive tests should be confirmed with NATs.The preferred specimens for diagnosis include:    Whole blood collected in ethylenediaminetetraacetic acid (EDTA) from live patients exhibiting symptoms.   

Oral fluid specimen stored in universal transport medium collected from deceased patients or when blood collection is not possible.Samples collected from patients are an extreme biohazard risk; laboratory testing on non-inactivated samples should be conducted under maximum biological containment conditions. All biological specimens should be packaged using the triple packaging system when transported nationally and internationally.Treatment Supportive care - rehydration with oral or intravenous fluids - and treatment of specific symptoms improves survival.

There is as yet no proven treatment available for EVD. However, a range of potential treatments including blood products, immune therapies and drug therapies are currently being evaluated.In the ongoing 2018-2019 Ebola outbreak in DRC, the first-ever multi-drug randomized control trial is being conducted to evaluate the effectiveness and safety of drugs used in the treatment of Ebola patients under an ethical framework developed in consultation with experts in the field and the DRC.Pregnant and breastfeeding women with Ebola should be offered early supportive care, like general population.

Likewise experimental treatment should be offered under the same conditions as for non-pregnant population.VaccinesAn experimental Ebola vaccine proved highly protective against EVD in a major trial in Guinea in 2015. The vaccine, called rVSV-ZEBOV, was studied in a trial involving 11 841 people. Among the 5837 people who received the vaccine, no Ebola cases were recorded 10 days or more after vaccination. In comparison, there were 23 cases 10 days or more after vaccination among those who did not receive the vaccine.

The rVSV-ZEBOV vaccine is being used in the ongoing 2018-2019 Ebola outbreak in DRC. Pregnant and breastfeeding women should have access to the vaccine under the same conditions as for the general population.Initial data indicates that the vaccine is highly effective.WHO’s Strategic Advisory Group of Experts has stated the need to assess additional Ebola vaccines.

Prevention and control

Good outbreak control relies on applying a package of interventions, including case management, surveillance and contact tracing, a good laboratory service, safe burials and social mobilisation. Community engagement is key to successfully controlling outbreaks. Raising awareness of risk factors for Ebola infection and protective measures (including vaccination) that individuals can take is an effective way to reduce human transmission. Risk reduction messaging should focus on several factors:Good outbreak control relies on applying a package of interventions, including case management, surveillance and contact tracing, a good laboratory service, safe burials and social mobilisation. Community engagement is key to successfully controlling outbreaks. Raising awareness of risk factors for Ebola infection and protective measures (including vaccination) that individuals can take is an effective way to reduce human transmission. Risk reduction messaging should focus on several factors:   

Reducing the risk of wildlife-to-human transmission from contact with infected fruit bats, monkeys, apes, forest antelope or porcupines and the consumption of their raw meat. Animals should be handled with gloves and other appropriate protective clothing. Animal products (blood and meat) should be thoroughly cooked before consumption.    Reducing the risk of human-to-human transmission from direct or close contact with people with Ebola symptoms, particularly with their bodily fluids. Gloves and appropriate personal protective equipment should be worn when taking care of ill patients. Regular hand washing is required after visiting patients in hospital, as well as after taking care of patients at home.   

Outbreak containment measures, including safe and dignified burial of the dead, identifying people who may have been in contact with someone infected with Ebola and monitoring their health for 21 days, the importance of separating the healthy from the sick to prevent further spread, and the importance of good hygiene and maintaining a clean environment.    Reducing the risk of possible sexual transmission, based on further analysis of ongoing research and consideration by the WHO Advisory Group on the Ebola Virus Disease Response, WHO recommends that male survivors of EVD practice safer sex and hygiene for 12 months from onset of symptoms or until their semen tests negative twice for Ebola virus. Contact with body fluids should be avoided and washing with soap and water is recommended. WHO does not recommend isolation of male or female convalescent patients whose blood has been tested negative for Ebola virus.   

Reducing the risk of transmission from pregnancy related fluids and tissue, Pregnant women who have survived Eboa disease need community support to enable them to attend frequent antenatal care (ANC) visits, to handle any pregnancy complications and meet their need for sexual and reproductive care and delivery in a safe way. This should be planned together with the Ebola and Obstetric health care expertise. Pregnant women should always be respected in the sexual and reproductive health choices they make.

Reference: World Health Organization

" The Frontier Of Death"- The serpent and the rainbow" 

Two Nights Later I was met at the front door of an East Side Mahattan apartment by a tall, strikingly handsome woman whose long hair was pulled up over her head in the manner of a Renoir model.

We shook hands."Mr.Davis? I'm Marna Anderson, Nate Kline's daughter. Do come in. " She turned abruptly and led me through a corridor of clinical whiteness into a large room crowded with colour. Approaching me fom the head of an immense refectory table was a short man in a white linen suit and an antique vest of silk broacade.

"You must be Wade Davis. Nate Kline. I'm glad you could make it."

There were perhaps nine people in the room, and through Kline made the obligatory introductions, it was in a manner so perfunctory as to let me know that none of them mattered. He lingered only when we reached an elderly man, sitting narrow and stiff in a corner of the room.

 " I'd like you to meet my older colleagues, professor Heinz Leham. Heinz is the former head of psychiatry and psychopharmacology at McGill."

"Ah,Mr. Davis," Lehman said softly, " I am delighted that you have joined our little venture."

" I don't know that I have."

"Yes, well, let us wait and see."

Kline directed me to a sofa where three pleasant by nondescript women sat sipping cocktails, their attentions scattered. A few moments passed in gossip, and then they began to question me about my life with an enthusiasm that made me feel uncomfortable. As soon as I had a chance I got up and began to circulate, making my way toward the bar, where I poured myself a drink. The room was filled with art Hatian paintings, antique games and puzzles, a Persian chest with gilt decorations, a small forest of native early American weather vanes, iron horses poised in flight. 

The lights of the city drew me out onto the balcony. Low clouds swept through the high corridors of darkness slowly dissolving the summits of the skyscrapers, and from far below came the sound of tires running over glistening pavement. looking back through the window, I saw Kline moving vigorously about the room, ushering the last of his dinner guests to the door. His movements seemed ostentatiously virile, reminding me of the kind of elderly man who might ask you in public to place your hand on his chest to measure the strength of his heart.

He seemed ill cast as a doctor, exhibiting a vanity more likely in a poet. Leham, on the other hand-tall, thin, and frail-appeared born to be a psychiatrist, and I couldn't help wondering what vocation he would have pursued had he lived in an earlier age, before men were prepared to yield their feelings to analysis.

Marina joined her fathert at the door of the apartment, linking her arm lightly in his as they said good night to their guests. One sensed immediately the bond between them, how they chose to act as one person, so that his glance became he gesture, which beckoned me in from the balcony.

Emptied of the other guests, the room strangely came to life. Lehman, visibly more at ease, moved to its center. He fixed me with a smile.Emptied of the other guests, the room strangely came to life. Lehman, visibly more at ease, moved to its center. He fixed me with a smile.

"Let me relieve you of any further suspense, Mr. Davis. We understand  from Professor Schultes that you are attracted to unusual places. We propose to send you to the frontier of death. if what we are about to tell you is true, as we believe it is, it means that there are men and women dwelling in the continuous present, where the past is dead and the future consists of fear and impossible desires.

"I glanced at him skeptically, and then at Kline, who picked up from Lehman automatically.

"The first problem is to know when the dead are truly dead." kline paused, regarding me deliberately."Diagnosing death is an age old problem. Petrarch the Elder are full of reports of men rescued at the last minute from the pyre. Eventually to prevent such mishaps the emperor had to fix by law the interval between apparent death and burial at eight days.

"Perhaps we should do the same,"interjected Leham. " Recall the Sheffield case?

"Kline nodded, and turned back to me. " Not fifteen years ago English doctors experimenting with a portable cardiograph at the Sheffield mortuary detected signs of life in a young woman certified dead from a drug overdose."

Leham added with a smile, " There was an even more sensational case here in New York around the same time. A postmortem operation at the city morgue was disrupted just as the first cut was being made. The patient leapt up and siezed the doctor by the throat, who promptly died of shock.

"I looked across the table at the two of them, trying to conceal a faint premonition of horror. They were both old, their voices hard and clinical. It was as if the imminent presence of death had so saturated their minds at this late point of their lives that they looked upon it as a source of amusement. I had to remind myself that these men were professionals who had earned some of the highest awards of American Science.

"By definition death is the permanent cessation of vital functions." Kline leaned back in his chair, clasping his hands and smiling. "But waht constitutes cessation, and how is one to recognize the function in question?."

"Breathing, pulse, body temperature, stiffness....whatever, " I answered somewhat awkardly, still uncertain what they were getting at.

"You can't always tell. Breathing can occur with such gentle movements of the diaphragm as to be imperceptible. Besides, the absence of respiration may represent a suspension, not a cessation. As for body temperature, people are pulled out of frozen lakes and snowfields all the time."

"The eyes of the dead tell you nothing," added Lehman. "the muscle of the Iris continue to contract for hours after death. Skin color can be useful..."

"Hardly in this case, " Kline interrupted, glancing at Lehman. "The pallor of death only shows up in light-skinned individuals. As for hearbeat, any drug that induces hypotension can result in an unreadable pulse. In fact, deep narcosis can manifest every symptom of death: shallow imperceptible breathing, a slow and weakened pulse, a dramatic decrease in body temperature, complete immobility.

Kline poured himself a brandy. " No warmth, no breath, shall testify thou lives.' Friar Laurence to Juliet, gentlemen. perhaps our most famous reference to drug-induced suspended animation."

"In fact," Leham concluded, " there are only two means of ascertaining death. One is by no means infallible and involves a brain scan and cardiogram. That requires expensive machinery. The other, and the only one that is certain, is putrefaction. And that requires time."

Reference:The Serpent and The Rainbow: Wade Davis

Big study shows more doubt on Malaria drugs for Coronavirus

Malaria drugs pushed by President Donald Trump as treatments for the coronavirus did not help and were tied to a greater risk of death and heart rhythm problems in a new study of nearly 100,000 patients around the world.Malaria drugs pushed by President Donald Trump as treatments for the coronavirus did not help and were tied to a greater risk of death and heart rhythm problems in a new study of nearly 100,000 patients around the world.

Friday’s report in the journal Lancet is not a rigorous test of hydroxychloroquine or chloroquine, but it is by far the largest look at their use in real world settings, spanning 671 hospitals on six continents.

“Not only is there no benefit, but we saw a very consistent signal of harm,” said one study leader, Dr. Mandeep Mehra, a heart specialist at Brigham and Women’s Hospital in Boston.

Researchers estimate that the death rate attributable to use of the drugs, with or without an antibiotic such as azithromycin, is roughly 13% versus 9% for patients not taking them. The risk of developing a serious heart rhythm problem is more than five times greater.Even though it is only observational, the size and scope of the study gives it a lot of impact, said Dr. David Aronoff, infectious diseases chief at Vanderbilt University Medical Center.

“It really does give us some degree of confidence that we are unlikely to see major benefits from these drugs in the treatment of COVID-19 and possibly harm,” said Aronoff, who was not involved in the research.US President Donald Trump speaks during the "Rolling to Remember Ceremony: Honoring Our Nations Veterans and POW/MIA" on May 22, 2020, from the Truman Balcony at the White House in Washington, DC. -

The US is observing Memorial Day on May 25 honoring the men and women who died while serving in the US military. (Photo by MANDEL NGAN / AFP) (Photo by MANDEL NGAN/AFP via Getty Images)US President Donald Trump speaks during the "Rolling to Remember Ceremony: Honoring Our Nations Veterans and POW/MIA" on May 22, 2020, from the Truman Balcony at the White House in Washington,

DC. - The US is observing Memorial Day on May 25 honoring the men and women who died while serving in the US military. (Photo by MANDEL NGAN / AFP) (Photo by MANDEL NGAN/AFP via Getty Images)Trump repeatedly has pushed the malaria drugs, and has said he is taking hydroxychloroquine to try to prevent infection or minimize symptoms from the coronavirus.

The drugs are approved for treating lupus and rheumatoid arthritis and for preventing and treating malaria, but no large rigorous tests have found them safe or effective for preventing or treating COVID-19. People sick enough to be hospitalized with the coronavirus are not the same as healthy people taking the drugs in other situations, so safety cannot be assumed from prior use, Mehra said.These drugs also have potentially serious side effects.

The Food and Drug Administration has warned against taking hydroxychloroquine with antibiotics and has said the malaria drug should only be used for coronavirus in formal studies.Lacking results from stricter tests, “one needs to look at real-world evidence” to gauge safety or effectiveness, Mehra said. The results on these patients, from a long-established global research database, are “as real world as a database can get,” he said.His study looked at nearly 15,000 people with COVID-19 getting one of the malaria drugs with or without one of the suggested antibiotics and more than 81,000 patients getting none of those medications.

A group of people on a field: Devastating industries the world over, the coronavirus pandemic is battering businesses across the globe. With half the global population under some sort of lockdown, economic activity has pretty much ground to a halt and a deep recession is looming.

Yet while almost every sector is feeling the pain, some are hurting significantly more than others and may even suffer irrevocable damage. Click or scroll through to take a look at the industries set to struggle to bounce back.In all, 1,868 took chloroquine alone, 3,783 took that plus an antibiotic, 3,016 took hydroxychloroquine alone and 6,221 took that plus an antibiotic.

About 9% of patients taking none of the drugs died in the hospital, versus 16% on chloroquine, 18% on hydroxychloroquine, 22% on chloroquine plus an antibiotic, and 24% on hydroxychloroquine plus an antibiotic.After taking into account age, smoking, various health conditions and other factors that affect survival, researchers estimate that use of the drugs may have contributed to 34% to 45% of the excess risk of death they observed.

About 8% of those taking hydroxychloroquine and an antibiotic developed a heart rhythm problem vs. 0.3% of the patients not taking any of the drugs in the study. More of these problems were seen with the other drugs, too.The results suggest these drugs are “not useful and may be harmful” in people hospitalized with COVID-19, professor Christian Funck-Brentano, of the Sorbonne University in Paris, wrote in a commentary published by the journal. He had no role in the study.

Experiments underway now to test these drugs in a strict manner “need to be completed and should not be stopped prematurely,” Aronoff said.Even though the Lancet study was large, observational look-backs like this “cannot control for every possible factor that may be responsible for observed results,” he said.The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

Reference:By Deena R Beasley: Reuters -23/02/2020: 3 hrs ago

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NIH trial: Gilead's drug works best in COVID patients on oxygen

(Reuters) - The U.S. National Institutes of Health (NIH) on Friday said that data from its trial of Gilead Sciences Inc's remdesivir show that the drug offers the most benefit for COVID-19 patients who need extra oxygen but do not require mechanical ventilation.

(Reuters) - The U.S. National Institutes of Health (NIH) on Friday said that data from its trial of Gilead Sciences Inc's remdesivir show that the drug offers the most benefit for COVID-19 patients who need extra oxygen but do not require mechanical ventilation.The peer-reviewed data was published in the New England Journal of Medicine.

The trial, for which final results are still trickling in, showed that recovery time for patients given remdesivir was shortened by four days, or 31%, compared to placebo patients. The biggest benefit was seen in patients who were sick enough to need supplemental oxygen, but were not on a ventilator.

The data detailed in the journal is similar to early results that the NIH released last month from the study, which began in February with 1,063 participants in 10 countries.Researchers now calculate that after follow up, 7% of patients given remdesivir will have died, compared with 12% in the placebo group, but they said the difference in the death rate was not significant.

"Our findings highlight the need to identify COVID-19 cases and start antiviral treatment before the pulmonary disease progresses to require mechanical ventilation," the researchers wrote.They noted that "given high mortality despite the use of remdesivir," it is likely that the antiviral drug would be more effective in combination with other treatments for COVID-19, the respiratory illness caused by the novel coronavirus.Gilead said it expects results from its own study of remdesivir in patients with moderate COVID-19 at the end of this month.

"We look forward to the initiation of combination studies of remdesivir to understand whether the addition of other drugs may enhance patient outcomes," Gilead Chief Medical Officer Merdad Parsey said in a statement.The Food and Drug Administration authorized emergency use of remdesivir on May 1, and Gilead has been supplying the drug to hospitals as part of a pledge to donate 1.5 million vials - or enough for at least 140,000 patients.(Reporting by Manojna Maddipatla in Bengaluru; Editing by Aditya Soni, Aurora Ellis and Sonya Hepinstall)

Reference: By Deena Beasley: Reuters 23/02/2020: 3 hrs ago