Wednesday, August 1, 2012

WHO: Ebola in Uganda

The Ministry of Health (MoH) of Uganda has notified WHO of an outbreak of Ebola haemorrhagic fever in Kibaale district in the western part of the country.

A total of 20 cases, including 14 deaths have been reported since the beginning of July 2012. The index case was identified in a family from Nyanswiga village, Nyamarunda sub-county of Kibaale district, where nine of the deaths were recorded. The deceased include a clinical officer who attended to a patient, and her four month-old child. Nine of the 14 deaths have occurred in a single household.

Laboratory confirmation was done by the Uganda Virus Research Institute in Entebbe.

Currently, two patients are hospitalized and are in stable condition. The first is a 38 year-old female who attended to her sister, the clinical officer who died. She was admitted to the hospital on 26 July 2012. The second is a 30 year-old female who participated in conducting the burial of the index case. She was admitted to the hospital on 23 July 2012. Both cases were admitted to hospital with fever, vomiting, diarrhoea and abdominal pain. Neither of the cases has so far shown bleeding, a symptom that often appears in viral haemorrhagic fever patients.

The MoH is working with stakeholders and partners to control the outbreak. Response plans at the national and district levels are being finalised. A national task force coordinated by the MoH has been re-activated at the MOH headquarters and holds daily meetings. In Kibaale a district task force has been formed to better coordinate field response. The neighbouring districts have been put on high alert about the outbreak and to step up surveillance.

A team of experts from MoH, WHO and Centers for Disease Control and Prevention (CDC) is in Kibaale to support the response operations. All possible contacts that were exposed to the suspected and confirmed cases since 6 July 2012 are being identified for active follow up. The necessary supplies and logistics required for supportive management of patients are being mobilized.

Kibaale hospital has established a temporary isolation ward for suspected, probable and confirmed cases. Médecins Sans Frontières (MSF), Holland, has mobilized necessary requirements for setting up isolation centre at the hospital. The MoH and Mulago Hospital have mobilized some staff to manage the isolation centre but more are urgently needed.
The MoH has advised the public to take measures to avert the spread of the disease and to report any suspected patient to the nearest health unit.

WHO does not recommend that any travel or trade restrictions are applied to Uganda.


Ebola Hemorrhagic Fever

The Ebola virus belongs to the Filoviridae family (filovirus) and is comprised of five distinct species: Zaïre, Sudan, Côte d’Ivoire, Bundibugyo and Reston.

Zaïre, Sudan and Bundibugyo species have been associated with large Ebola haemorrhagic fever (EHF) outbreaks in Africa with high case fatality ratio (25–90%) while Côte d’Ivoire and Reston have not. Reston species can infect humans but no serious illness or death in humans have been reported to date.
Human infection with the Ebola Reston subtype, found in the Western Pacific, has only caused asymptomatic illness, meaning that those who contract the disease do not experience clinical illness. The natural reservoir of the Ebola virus seems to reside in the rain forests of the African continent and in areas of the Western Pacific. There is evidence that bats are involved, but much work remains to be done to definitively describe the natural transmission cycle.

Transmission

The Ebola virus is transmitted by direct contact with the blood, secretions, organs or other body fluids of infected persons. Burial ceremonies where mourners have direct contact with the body of the deceased person can play a significant role in the transmission of Ebola.

The infection of human cases with Ebola virus through the handling of infected chimpanzees, gorillas, and forest antelopes – both dead and alive – has been documented in Côte d'Ivoire, the Republic of Congo and Gabon. The transmission of the Ebola Reston strain through the handling of cynomolgus monkeys has also been reported.
Health care workers have frequently been infected while treating Ebola patients, through close contact without correct infection control precautions and adequate barrier nursing procedures.

Incubation period: two to 21 days.

Symptoms

Ebola is characterized by the sudden onset of fever, intense weakness, muscle pain, headache and sore throat. This is often followed by vomiting, diarrhea, rash, impaired kidney and liver function, and in some cases, both internal and external bleeding. Laboratory findings show low counts of white blood cells and platelets as well as elevated liver enzymes.

Diagnosis

Specialized laboratory tests on blood specimens detect specific antigens and/or genes of the virus. Antibodies to the virus can be detected, and the virus can be isolated in cell culture. Tests on samples present an extreme biohazard risk and are only conducted under maximum biological containment conditions. New developments in diagnostic techniques include non-invasive methods of diagnosis (testing saliva and urine samples) and testing inactivated samples to provide rapid laboratory diagnosis to support case management during outbreak control activities.

Therapy and Vaccine

Severe cases require intensive supportive care, as patients are frequently dehydrated and in need of intravenous fluids or oral rehydration with solutions containing electrolytes.
No specific treatment or vaccine is yet available for Ebola hemorrhagic fever. Several potential vaccines are being tested but it could be several years before any is available. A new drug therapy has shown some promise in laboratory studies and is currently being evaluated.

Experimental studies using hyper-immune sera on animals have shown no protection against the disease.

Containment

Suspected cases should be isolated from other patients and strict barrier nursing techniques implemented.
Tracing and follow up of people who may have been exposed to Ebola through close contact with patients are essential.

All hospital staff should be briefed on the nature of the disease and its transmission routes. Particular emphasis should be placed on ensuring that invasive procedures such as the placing of intravenous lines and the handling of blood, secretions, catheters and suction devices are carried out under strict barrier nursing conditions. Hospital staff should have individual gowns, gloves, masks and goggles. Non-disposable protective equipment must not be reused unless they have been properly disinfected.

Infection may also spread through contact with the soiled clothing or bed linens from a patient with Ebola. Disinfection is therefore required before handling these items. Communities affected by Ebola should make efforts to ensure that the population is well informed, both about the nature of the disease itself and about necessary outbreak containment measures, including burial of the deceased. People who have died from Ebola should be promptly and safely buried.

Contacts

As the primary mode of person-to-person transmission is contact with contaminated blood, secretions or body fluids, people who have had close physical contact with patients should be kept under strict surveillance. Their body temperature should be checked twice a day, with immediate hospitalization and strict isolation in case of the onset of fever. Hospital staffs that come into close contact with patients or contaminated materials without barrier nursing attire must be considered as contacts and followed up accordingly.

Early History

The Ebola virus was first identified in a western equatorial province of Sudan and in a nearby region of Zaïre (now the Democratic Republic of the Congo) in 1976 after significant epidemics in Yambuku in northern Democratic Republic of the Congo, and Nzara in southern Sudan.

About 1850 cases with over 1200 deaths have been documented since the Ebola virus was discovered.

Natural Reservoir

The natural reservoir of the Ebola virus is unknown despite extensive studies, but it seems to reside in the rain forests on the African continent and in the Western Pacific. Although non-human primates have been a source of infection for humans, they are not thought to be the reservoir. They, like humans, are believed to be infected directly from the natural reservoir or through a chain of transmission from the natural reservoir.

On the African continent, Ebola infections of human cases have been linked to direct contact with gorillas, chimpanzees, monkeys, forest antelope and porcupines found dead in the rainforest. So far, the Ebola virus has been detected in the wild in carcasses of chimpanzees (in Côte-d’Ivoire and the Republic of the Congo), gorillas (Gabon and the Republic of the Congo) and duikers (the Republic of the Congo).

Different hypotheses have been developed to explain the origin of Ebola outbreaks. Laboratory observation has shown that bats experimentally infected with Ebola do not die, and this has raised speculation that these mammals may play a role in maintaining the virus in the tropical forest.

Extensive ecological studies have been carried out or are under way in the Republic of the Congo and Gabon to identify the Ebola's natural reservoir.



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