Indian J Pediatr (March 2015) 82(3):207–209 DOI 10.1007/s12098-015-1713-7

COMMENTARY

Ebola Virus - An Indian Perspective Veena Mittal & Mala Chhabra & S. Venkatesh

Received: 1 January 2015 / Accepted: 21 January 2015 / Published online: 11 February 2015 # Dr. K C Chaudhuri Foundation 2015

The current ongoing outbreak of Ebola Virus Disease (EVD) in West Africa is unprecedented in many ways. It is certainly one of the largest and deadliest outbreaks in recent times. It began in Guinea in late 2013 and spread to neighboring countries of Liberia and Sierre Leone. A total of 18,464 suspected, probable and confirmed (11,699) cases with 6841 deaths have been reported till 13th December 2014. Limited transmission is reported from United States of America (4 cases, 1 death) and Mali (8 cases, 6 deaths) whereas, Nigeria (20 cases, 8 deaths), Senegal (1 case, 0 deaths) and Spain (1 case, 0 deaths) have been declared free of EVD [1]. The outbreak has mounted exceptional concern, preparedness and response worldwide as it is dreaded as one of the most virulent disease causing high fatality in humans. It has no specific treatment or vaccine despite it being known since 1976 when it first appeared in Democratic Republic of the Congo (DRC) in two simultaneous outbreaks in Nzara, Sudan, and Yambuku, DRC. Until December 2013, a total of 23 outbreaks recorded 2388 human cases and 1590 deaths [2]. Formerly known as Ebola hemorrhagic fever, in the current outbreak EVD involved the health care workers and further weakened the already compromised health care system in the affected countries. Notably, experimental drugs were used in the treatment of humans. UN and other agencies and experts have accelerated the research, clinical trials and resolution of V. Mittal (*) : M. Chhabra Zoonosis Division, National Centre for Disease Control, Dte.GHS, 22-Sham Nath Marg, Delhi 110054, India e-mail: [email protected] S. Venkatesh National Centre for Disease Control, Dte.GHS, 22-Sham Nath Marg, Delhi, India

ethical concerns so that drugs and vaccines can be made available for prevention and control of EVD. Ebolavirus is one of three members of the Filoviridae family (filovirus), along with genus Marburgvirus and Cuevavirus. There are five distinct species of Ebolavirus viz. Bundibugyo ebolavirus (BDBV), Zaire ebolavirus (EBOV), Reston ebolavirus (RESTV), Sudan ebolavirus (SUDV) and Taï Forest ebolavirus (TAFV). While BDBV, EBOV, and SUDV have been associated with large EVD outbreaks in Africa, RESTV and TAFV have not yet been implicated in a human outbreak. The RESTV species, found in Philippines and the People’s Republic of China, can infect humans, but no illness or death in humans has been reported [3, 4]. The natural reservoir of Ebola viruses has not yet been proven conclusively. However, fruit bats Hypsignathus monstrosus, Epomops franqueti and Myonycteris torquata, may be the natural hosts in Africa. Human beings can get infected and initiate human to human transmission on contact with infected animals or their carcasses. In Africa, infection has been documented through the handling of infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead or in the rainforest [3]. The most common mode of human-to-human transmission is direct contact through broken skin or unprotected mucous membranes e.g., the eyes, nose, or mouth, with the blood or body fluids (urine, feces, saliva, semen, and other secretions) of a person who is sick or has died of EVD. However, infection cannot be transmitted before the appearance of symptoms. Transmission may also occur with contaminated needles or infected animals. Ebola does not spread through the air or by water. In Africa, it can spread by handling infected bush meat. There is no evidence that mosquitoes and other insects can transmit the virus [3].

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People are infectious as long as their blood and secretions contain the virus. Ebola virus has been isolated from semen 82 d after onset of illness [5]. High risk group includes those who are in close contact viz. relatives or Health Care Workers (HCWs) of an EVD patient, handlers of dead body of an EVD patient. After an incubation period of 2–21 d (average 8–10 d) patient develops fever and non specific symptoms such as severe headache, fatigue, muscle pain, vomiting, diarrhea, abdominal (stomach) pain, or unexplained hemorrhage (bleeding or bruising). Patient may rapidly progress to multi-organ involvement, hemorrhages and shock. Ebola virus is a group four agent and requires high containment facility. EVD can be diagnosed by RT PCR, antigen detection or IgM antibody detection. Virus isolation is technically demanding and is carried out in BSL 4 facility. There is no specific anti-viral drug or vaccine available for EVD. Symptomatic treatment is given and complications are managed as they appear. Maintenance of hydration, electrolyte balance and managing infections remains the mainstay of the treatment [3, 6]. ZMapp (Mapp Biopharmaceutical Inc.), cocktail of three different monoclonal antibodies that bind to protein of Ebola virus and some investigational vaccines and drugs are being developed/supported by NIH and Department of Defense (DoD), USA [3]. Undoubtedly, EVD with its high mortality and morbidity, rapid and high rate of human-to-human transmission and no approved vaccine or therapeutics, has heightened anxiety across the world. However, the strategies to control EVD are simple and time-tested epidemiological principles of early detection, prompt response and prevention of further spread. The importance of communicating clear and accurate information to all stakeholders including the general public is the need of the hour. Central and state governments have demonstrated high-level commitment and preparatory activities are being undertaken. Ministry of Health and Family Welfare (MoH&FW), Govt of India, has taken multiple steps to prevent EVD and promptly respond when the case is detected in the country. 24×7 control room is in operation in the office of Director, Emergency and Medical Relief (EMR) for information on EVD. The Joint Monitoring Group (JMG) of various stakeholders of different ministries under the chairpersonship of Director General of Health Services meets frequently to discuss the evolving situation of EVD, review and revise the preparedness activities. Guidelines for surveillance and contact tracing, health care providers, hospital infection control, environmental control, clinical case management, collection storage and transportation of samples have been prepared and uploaded on the MoH&FW and NCDC websites [7, 8]. Advisory has been issued to State Surveillance Officers of all the states/UTs, Airlines,

Indian J Pediatr (March 2015) 82(3):207–209

travelers visiting from/to affected countries and families staying in the affected countries [7, 8]. The country is ready with the surveillance plan envisaging two epidemiological scenarios. The case definitions and response in each of the situation is different. The first case scenario, that is the current phase, is an “Alert or Pre-epidemic” phase when there is no confirmed case of Ebola in the country but can have a case in future. The second scenario is an epidemic phase if there is a confirmed case in the country or more than one case or clustering in the community. In the Alert or Pre-epidemic scenario, the surveillance system should be robust enough to report any suspect case at the earliest. Ministry of Health & Family Welfare has issued advisory to the Airlines, inbound flights to India from affected countries. Matter for in-flight announcement apprising the passengers about EVD, signs and symptoms, declaration of ill health at the point of entry (POE) and subsequent self-monitoring and reporting has been prepared and provided to the airlines. All the airlines have been advised to keep first aid kits, universal precaution kits as per the International Civil Aviation Organisation (ICAO) guidelines and a stock of triple layer masks, disposable hand gloves, hand sanitizer and disposal bags. They have been issued guidelines for isolation and management of the suspect/patient on-board and aircraft disinfection. Dedicated crewmember to assist the ill traveller, should use the suitable personal protection equipment (PPE) for dealing with the traveler and for cleaning procedures on board as needed. On arrival, aircraft crew should help the Airport Health Officer (APHO) and health personnel’s in contact tracing. Health alerts have also been displayed on airports at strategic locations. In India, the entry screening is being carried out at the international airports and seaports. The guidelines are issued to the airlines through Ministry of Civil Aviation/Ministry of Health. A standard operating procedure is followed for entry screening. A health declaration card needs to be filled up at PoE particularly for those arriving from affected countries (as intimated from Government of India from time to time). Asymptomatic patients with history of contact are advised to self-monitor and report to designated facility/ State Surveillance Officer if the symptoms develop. A symptomatic patient with history of contact is being isolated at the identified isolation facility and investigated for EVD. If the test is positive for Ebola, response strategies will be implemented with daily follow up of the patient’s contacts for 30 d after exposure. Contact tracing is one of the interventions that have been used to effectively control EVD outbreaks in the Nigeria. Persons in close contact with confirmed Ebola case (alive or dead) are at higher risk of infection. All potential contacts of Ebola cases should be identified within first 72 h of reporting a confirmed (dead or alive)/suspected case and closely observed for 30 d from the last day of exposure. Contacts that develop

Indian J Pediatr (March 2015) 82(3):207–209

illness should be immediately isolated to prevent further transmission of infection. An effective system for contact tracing should be established at the onset of the outbreak. Early involvement and full cooperation of affected communities is critical for successful contact tracing. The elements of contact tracing include three basic elements, namely, contact identification, contact listing and contact follow-up. Guidelines for hospital infection control and health care providers have been detailed as per international recommendations. Standard contact and droplet precautions are recommended for management of hospitalized patients with known or suspected Ebola virus disease (EVD). Recommendations for personal protective equipment (PPE) and environmental infection control measures have been updated with the evolving situation of EVD. As preparedness, the isolation facility with single patient room (containing a private bathroom) with the door closed has been identified at designated hospitals in different states. Facilities should maintain a log of all persons entering the patient's room. All the health care workers who come in contact with the suspect/confirmed case of EVD should wear complete PPE which includes double gloves, boot covers that are waterproof and go to at least mid-calf, single-use impermeable gown, respirators, including either N95 respirators or powered air purifying respirator (PAPR), face shield, surgical hoods to ensure complete coverage of the head and neck. Waterproof apron should be used if Ebola patient has vomiting or diarrhea. The enhanced guidance is centered on the principle of “no skin exposure” when PPE is worn [7, 8]. Proper, step wise donning and doffing of PPE should be done with extreme care and under supervision. Hand washing should be done before and after direct patient care, after any contact with potentially contaminated surfaces, and after removal of PPE. Neglecting to perform hand hygiene after removing PPE will reduce or negate any benefits of the protective equipment. Guidelines for use of dedicated disposable patient care equipment, restricting use of needles and sharps, management of waste including sharps, management of laundry, use of appropriate disinfectants are available on National Centre for Disease Control & Ministry of Health & FW website [7, 8]. Guidelines for handling human remains have also been formulated. Postmortem should be best avoided. Cremation/burial should be performed with minimal handling and gathering. For laboratory diagnosis, National Centre for Disease Control (NCDC), Delhi and National Institute of Virology (NIV), Pune have been currently designated to undertake diagnosis of EVD in high containment (BSL3/4) facility. ELISA test for antigen detection and PCR (Real time and conventional) are being undertaken for diagnosis. Ten ICMR laboratories are being strengthened to undertake diagnosis of EVD. Ebola virus is detected in blood only after onset of symptoms, most notably fever. It may take up to 3 d post-onset of symptoms for

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the virus to reach detectable levels. Specimens should be taken when a symptomatic patient is first seen; however, if symptom onset occurred less than 3 d before the patient seeks care, a subsequent specimen will be required to completely rule out EVD. To build capacity of health care workers training courses were organised for master trainers and RRTs of states/UTs which included lectures covering all aspects, demonstrations of donning and doffing PPE, collection, packaging and transportation of samples and mock drills at Points of Entry (POE). The Ministry of Health in collaboration with WHO, India Office is preparing a comprehensive contingency plan for EVD. In addition, IEC material (Tri-fold pamphlets) is being prepared for travelers and health care providers. Government of India has taken a proactive stand to control EVD. India is among the top five financial contributors to the United Nations’ Ebola response [9]. WHO, on August 8th, 2014 has declared it as Public Health Emergency of International Concern. No one in the world is safe unless the epidemic is controlled in West Africa and that there are close to 45,000 Indians in the affected countries. Early recognition, immediate institution of infection control practices and contact tracing is therefore the most critical aspect. Conflict of Interest None. Source of Funding None.

References 1. CDC, Ebola (Ebola Virus Disease) 2014 West Africa Outbreak. http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/casecounts.html. Accessed 25 Dec 2014. 2. WHO, Ebola Virus Disease Fact Sheet No 103. http://www.who.int/ mediacentre/factsheets/fs103/en/. Accessed 24 Oct 2014. 3. Key Messages – Ebola Virus Disease, West Africa, Prepared by the Joint Information Center, Emergency Operations Center, Centers for Disease Control and Prevention for external distribution. Updated November 5, 2014. Accessed 8 Nov 2014. 4. Miranda MEG, Miranda NLJ. Reston ebolavirus in humans and animals in the Philippines: a review. J Infect Dis. 204;3:S757–60. 5. Mackay IM, Arden KE. Ebola virus in the semen of convalescent men. www.thelancet.com/infection Published online November 19, 2014 http://dx.doi.org/10.1016/S1473-3099(14)71033-3. 6. King JW, et al. Ebola Virus Infection Treatment & Management. Medscape Reference © 2011 WebMD, LLC.http://emedicine. medscape.com/article/216288-treatment. 7. Ebola Virus Disease, Ministry of Health & Family Welfare, Government of India, http://www.mohfw.nic.in/index4.php?lang= 1&level=0&linkid=370&lid=2904. 8. Guidelines for Ebola Virus Disease. National Centre for Disease Control, Dte General of Health Services, Ministry for Health & Family Welfare, GOI. http://www.ncdc.gov.in/index1.asp?linkid=265. 9. Business Standard, 9th October 2014. (http://www.business-standard. com/article/pti-stories/india-among-top-5-financial-contributors-toebola-response-114100900112_1.html).

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