Prevention and Eradication of Ebola in Nigeria - Coursework Example

Prevention and Eradication of Ebola in Nigeria CONTENT 3 INTRODUCTION 4 DISCUSSION 10 CONCLUSION 21 REFERENCES 22 Ebola virus disease (EVD) also called Ebola hemorrhagic fever is an acute, usually fatal illness in humans and some animals. (CDC, 2014) It is caused by Ebola virus that has an increasingly high reproduction rate. It mainly affects the immune system and leads to the decreased level of blood clotting that cause internal and external bleeding. The viruse can be transmitted from the wild animals such as bats, monkeys to humans or through human –to –human transmission. The statistic shows that an average rate of mortality from EVD is approximately 50%. (WHO, 2014)¹ The first Ebola virus outbreaks occurred in the villages of the Central Africa in 1976. Appropriate preventable and control actions during Ebola outbreaks may help to reduce the prevalence of the disease and the fatality rate. The most effective interventions during the Ebola outbreak are contact tracing, infection control, isolation, good laboratory service and social mobilization. A good example of successful eradication of the Ebola outbreak was observed in Nigeria with the survival rate 63% compared to the 30% in other regions of Western Africa. (Edwin Ikhuoria,2014) INTRODUCTION Patchwork 1 Ebola virus refers to the genus Ebolavirus that include five different virus species named for the region where they were primarily detected. They are Zaire ebolavirus, Bundibugyo ebolavirus, Reston ebolavirus, Sydan ebolavirus and Taї Forest ebolavirus. All of the species of the Ebolavirus genus contain one member virus. Among these viruses four provoke Ebola virus disease (EVD) in humans and Reston ebolavirus causes EVD in other primates. (Jens H. Kuhn, 2010) Figure 1 Ebola virus structure and electron micrograph (Mahanty S,2004) Ebola virus disease, also called Ebola hemorrhagic fever and defined as an acute usually fatal disease in humans. EVD characterized with the damage of the immune system and organs. Ebola virus has a quite high rate of the replication. After entering the human body through the contact with skin breaks or mucous membranes it rapidly replicates in different types of cells of the immune system such as monocytes, macrophages and dendritic cells and other types of cells such as fibroblasts, adrenal gland cells and liver cells. The immune cells transport the virus to the lymph nodes where further replication occurs and viral parts enter the blood stream. (Duane J. Funk, 2015) Hence, the virus major target is immune system cells especially macrophages. Virus reproduction in the immune cells triggers their programmed cell death that leads to the weakened immune system response. (Chippaux JP, 2014) After three days of the virus exposure it affects endothelial cells that form endothelium a thin layer of the interior surface of the lymphatic vessels and blood vessels. The viral glycoproteins cause breakdown of the endothelial cells that in turn leads to the blood vessels injury and acute, uncontrollable bleeding. Figure 2 Model of Ebola virus pathogenesis (Feldmann H,2011) Also, Ebola virus causes the decrease in the levels of blood-clotting cells. Outer and inner bleeding in affected patients associated with swelling and shock as a result of increasingly high loss of blood volume. (Fisher-Hoch SP, 1985) Usually, the time between Ebola virus exposure and the appearance of the symptoms called incubational period is approximately 2 – 21 days. The early symptoms connected with the Ebola virus disease are influenza like and include weakness, fatigue, fever, headache, muscle and joint pain, sore throat and decreased appetite. The body temperature during the incubational period usually rises up to 38.3 (101). Patients have diarrhea, vomiting and abdominal pain. At late stages of the viral infection swelling, chest pain, shortness of breath and confusion may occur. In 50% of all cases maculopapular rash was detected at 5 to 7 days after symptoms starts. The statistic shows that approximately 40-50% of patients infected with Ebola virus have decreased blood clotting and bleeding from the mucous membranes. (Karwowska K, 2015) Most commonly patients can have blood in stool, vomiting with blood and coughing up with blood. Also, in some of the cases bleeding into the whites of the eyes were detected. Heavy bleeding may occur in the gastrointestinal tract. (Goeijenbier M, 2014) Figure 3 Symptoms and signs of Ebola virus (CDC, 2014) Transmission of the Ebola virus is not that contagious compared to such common viruses as influenza, measles and colds. It can enter the human body through the skin and body fluids that include mucus, saliva, sweat, feces, vomit, tears, breast milk, urine and semen after the direct contact with infected animals. The scientists from the World Health Organization (WHO) informed that only seriously ill people can spread the Ebola virus in saliva. Most commonly infected patients spread the virus through vomit, blood and feces. The Ebola virus can survive several days in body fluids and several hours in dried condition on different objects. Also, it can survive approximately for 8 weeks in the semen after the recovery of the ill patient that`s increase the risk of transmission via sexual intercourse. The other risk of Ebola virus transmission is burial rituals as the virus can remain on the dead bodies of ill people during some period of time. (Donald G, 2015) For example, the statistic provides evidence that approximately 69% of infected people in Guinea during the 2014 Ebola outbreak were contaminated during Guinea burial rituals. (George Krucik, 2014) The natural source of the Ebola virus is supposed to be bats especially fruit bats. Human can be infected through contact with bats, chimps and monkeys or through human- to –human transmission that is the predominant feature of epidemics. The health care professionals are at the higher risk of Ebola virus infection as they regularly communicate with the infected patients. Usually, such incidents of transmission can happen in some parts of Africa with poorly functioning health care systems. For example, there are documented cases of Ebola virus transmission to the health care workers in Africa after reusing of hypodermic needles. It is quite necessary for all health care workers to wear appropriate protective clothing that include masks, gloves, gowns and eye protection. (George Krucik, 2014) The most effective preventable actions for Ebola virus spread are infection control that involves isolation of infected patients from other people, protection of the medical personnel who care for those infected with Ebola virus disease. The Centers for Disease Control and Prevention (CDC) recommends that all health care workers have to pass training for appropriate use and removal of personal protective equipment (PPE). That usually lasts 12 days. (CDC,2014) Other possible preventable actions are isolation and contacts tracing that are quite important in containment of the EVD outbreak. When Ebola virus disease is suspected in a person total diagnostics is necessary. It may include laboratory testing of the Ebola virus`s RNA or proteins, or antibodies in the human blood against Ebola virus. The best ways of EVD detection at early stages in patients or in human remains is cell culture and further polymerase chain reaction for virus RNA detection or enzyme-linked immunosorbent assay for detection of viral parts in human remains. Symptoms of EVD at early stages can be similar to other common diseases in Africa. Therefore, differential diagnosis is needed and requires consideration of different infectious and non-infectious diseases with the same early signs and symptoms. (WHO, 2015) Currently there is no any specific treatment for EVD approved by the Food and Drug Administration. The early management options of EVD are symptomatic treatment of the pain, fever, nausea and rehydration. Accordingly, to the World Health Organization treatment instructions it is quite important to avoid using aspirin and ibuprofen as they can provoke bleeding. To decrease bleeding such blood products as packed red blood cells, fresh frozen plasma or platelets may be used. But, further investigations of possible treatment plans for EVS are needed. (Barry M, 2014) DISCUSSION The EVD usually tends to occur in the tropical regions of Sub-Saharan Africa in outbreaks. The first documented outbreak of EVD was observed in Zaire and Sudan in 1976. The Sudan outbreak was caused by Sudan ebolavirus, 284 cases of infected people and 151 cases of death from EVD were fixed in Sudan. Figure 4 Survival and fatality rates associated with Ebola outbreaks (as of Aug 13. 2014) (Moran Ki, 2014) The other huge EVD outbreak occurred in the same year in the Zaire and was caused by Zaire ebolavirus. The rate of mortality in Zaire in 1976 was 88% 280 deaths among 318 cases. The EVD outbreak in Zaire was eradicated with the help of the World Health Organization through isolation of villagers, providing appropriate protective clothing and sterilizing medical equipment. The other known EVD outbreak was in Zaire, nowadays known as the Democratic Republic of Congo in 1995. It`s associated with 315 infected cases and 254 cases of deaths. The Sudan virus caused EVD outbreak in Uganda in 2000 resulted with 425 cases and 224 deaths. The other outbreak of EVD occurred in the Democratic Republic of Congo and had the highest mortality rate of 90% - 128 deaths among 143 infected cases. The case of the Russian scientist`s death was fixed in 2004. The reason of her death was contact with infected with the Ebola virus needle. (CDC,2014) During the period of April and August 2007 EVD outbreak occurred in four village regions in Zaire and caused 284 cases of infected patients and 187 deaths. The WHO established two EVD outbreaks in Uganda in 2012 caused by Sudan ebolavirus. The statistic from the WHO shows that during first EVD outbreak in Uganda 7 infected cases and 4 deaths were observed. Second small outbreak in Uganda resulted in 24 cases of infected individuals and 17 deaths. As of 15 October 2014 were documented 17 cases of infected patients outside the Africa and 4 cases of deaths. The first transmission of the Ebola virus outside the Africa was detected in Spanish nurse who was carrying a priest from the West Africa. The first case of EVD in the United Sates was documented in 30 of September in man who flew from Liberia to Texas. The other Ebola positive case in the United State was detected on the 23of October in doctor from the New York City who came back to the US from the Guinea. (WHO,2015) Figure 5 Locations of Ebola Virus infections and outbreaks (A)Regions in Africa with reported outbreaks of Ebola haemorrhagic fever caused by the three central African species of Ebola virus, Zaire Ebola virus (ZEBOV), Sudan Ebola virus (SEBOV), and Bundibugyo Ebola virus (BEBOV). (B) Reston Ebola virus (REBOV) has been introduced several times through imported macaques into USA from 1989 to 1996 (Philadelphia, PA; Reston, VA; San Antonio, TX) and into Italy (Siena) in 1992 (C) The source of the introduction in all cases of REBOV has been a primate export facility in the Philippines (Ferlite farm) (D) (Feldmann H,2011) Hence, there were several EVD outbreaks in the regions of Sub-Saharan Africa. Accordingly, to the statistic from the World Health Organization during the period from 1976 till 2013 confirmed approximately 1,716 cases of infected with Ebola virus patients. Figure 6 Ebola virus disease outbreaks from 1976 (Lei Zhang, 2014) Patchwork 2 The EVD outbreaks are quite common in Sub-Saharan Africa. Since the first outbreak in the Democratic Republic of Congo (DRC) in 1976 the disease outbreaks occurred in the different parts of Africa during the last 40 years. During this period of time, scientists did not find any appropriate and effective cures and vaccines. But, epidemiological studies of all outbreaks helped to accumulate solid knowledge about causation, risk factors, transmission, diagnosis, prevention, management and eradication of the outbreaks. Accordingly, to the previous experience, prevention and eradication of the EVD outbreaks requires understanding and management of causative agents, pathology, systems, people and contexts. The most important role in EVD eradication plays effective and adaptive interaction and cooperation of different health care systems. Complex adaptive health systems usually consist of independent agents that are able to adapt, self organize and change accordingly to the experience and are governed by feedback. Health care systems across the West Africa are quite weak and do not fully resourced. Disease management, infection prevention and eradication and clinical care are not highly developed and are causalities of health care weakness. Such situation is favourable to EVD outbreaks in the West Africa. Nowadays, post-exposure treatment and vaccines for EVD control are not available. Therefore, the most effective steps during EVD outbreaks are appropriate actions that help to eliminate the causes and circumstances of the outbreaks. (Ghana Med J, 2014) All preventive measures should be targeted on patient care, management of the dead bodies, burial and contact tracing. The Centres for Disease Control and Prevention and the World Health Organisation after the EVD outbreak in 1995 in the DRC that had the mortality rate of 80% developed an instruction book in English, French and Portuguese. It provides guidance for the preparation of the EVD outbreak management. It includes all possible safety measures concerning care of all patients to prevent further spread of the infection and different techniques that allow controlling the outbreaks of the EVD. The manual includes the following hints: Clinical diagnosis of the EVD Detailed planning of patient isolation and formation of the isolation area Description of the contact tracing that involve identification and monitoring of contacts Disinfection and sterilization of health care facilities and equipment Waste disposal and preparation of the body Transportation to the place of burial Accordingly, to the CDC and WHO manual the clinical diagnosis in the early stages of the epidemic is quite complicated because of poor specificity of the symptoms. After the detection of the virus that is responsible for the outbreak all suspected cases have to be considered as high risk and meet the exposure risks and case definition. (Duane J. Funk, 2015) Table 1 Case Definition of Ebola Virus Disease (EVD) Name Definition Index case Very first case found to be the origin of the outbreak Alert case Any person with sudden onset of high fever or sudden bleeding or sudden death or bleeding, blood in urine or bloody diarrhoea Suspect case Any person, dead or alive, who present (or presented before the death): (i) fever (>38.5°C or 101.5 °F) with additional symptoms (severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage) and (ii) epidemiologic risk factors within the past 21 days before the onset of symptoms (close contact with body fluids of a suspect or probable case of EVD, or direct handling of bush animals from disease-endemic areas) Probable case Person with symptoms compatible with EVD, as evaluated by a clinician, or a dead person with an epidemiological link with a confirmed case Contacts Person without suggestive symptom of the disease, but who has been in contact with a suspect or probable case of EVD (living in the same house, provided care during the illness, participated in the burial rites etc.). It should be important to assess the risk level. If laboratory samples are obtained at an appropriate time during the illness, the previous notification categories should be reclassified as “laboratory-confirmed” cases and “not a case” Confirmed case Case with positive laboratory response for either Ebola virus antigen or Ebola IgG antibody “Not a case” Person with no Ebola-specific detectable antibody or antigen (Jean-Philippe Chippaux,2014) Table 2 Definition and assessment of risk exposure Risk Level Definition High – risk exposure Percutaneous injury, e.g. needlestick, or mucous membrane exposure to body fluids of an EVD patient Direct care or exposure to body fluids of an EVD patient without appropriate personal protective equipment (PPE) Laboratory worker processing body fluids of confirmed EVD patients without appropriate PPE or standard biosafety precautions Participation in funeral rites that include direct contact with human remains in the geographic area where an outbreak is occurring without appropriate PPE Low – risk exposure Household member or other casual contact1 with an EVD patient Providing patient care or casual contact1 without high-risk exposure with EVD patients in health care facilities in EVD outbreak affected countries Not known exposure Persons with no known exposure were present in an EVD outbreak affected country in the past 21 days with no low-risk or high-risk exposures 1Casual contact is defined as (i) being within approximately 3 feet (1 meter) or within the room or care area for a prolonged period of time (e.g. healthcare personnel, household members) while not wearing recommended personal protective equipment; or (ii) having direct brief contact (e.g., shaking hands) with an EVD case while not wearing recommended personal protective equipment (Jean-Philippe Chippaux, 2014) The other important step in the EVD outbreak control and eradication is appropriate planning in the health care facilities They have to determine where patients with the different levels of exposure will be cared for and who will be caring for them.(Jean-Philippe Chippaux, 2014) Patchwork 3 The largest outbreak up to now is the ongoing 2014 West Africa Ebola virus outbreak that occurred in Nigeria, Guinea, Liberia, Mali and Sierra Leone. The detailed case study of the EVD outbreak in Nigeria and their successful experience of EVD eradication can be a good example for other part of the West Africa. The first confirmed case of Ebola positive patient in Nigeria was seriously ill traveler from Liberia. (Gatherer D, 2014) On July 17, 2014 this patient was diagnosed at the Liberian hospital with fever and the possibility of EVD. On July 20 he flew by commercial airline from Monrovia to Lagos being symptomatic against medical advices. After arrival in Lagos, Nigeria he was transported to the hospital with fever, diarrhea and vomiting. The sample of his blood was studied in Lagos University Teaching Hospital and was approved positive for acute EVD. This patient died on 25 July, 2014. After this Port Health Service conducted contact tracing. All detected and laboratory approved cases of infected individuals were isolated into the Ebola treatment facilities in Lagos and in Pourt Harcout. A contact tracing team was guided by highly educated epidemiologists that investigated all possible primary contacts. During the Ebola virus eradication in Nigeria suspected cases were reclassified into confirmed cases by epidemiologists if reverse – transcription polymerase chain reaction (RT-PCR) observed Ebola virus in the blood sample. The cases were defined as negative if RT-PCR testing of the blood samples that were gathered 48 hours was negative. (Duane J. Funk, 2015) Additionally, epidemiologists added to the testing protocol of PCR-negative suspected cases testing for anti-Ebola virus immunoglobulin G that can help to detect immune response to Ebola virus. As of September 24, 2014 epidemiologists detected 19 cases of infected with EVD patients and one probable case. Contact tracing team conducted approximately 18,500 face-to-face visits evaluated EVD symptoms development and detected 894 contacts. Patients with suspected Ebola virus were immediately transported into the suspected case isolation department by the case management team. After that, all suspected cases were tested for Ebola virus. Those who were Ebola positive were transferred into the confirmed case ward. Among 19 confirmed cases, 11 were discharged, one patient had a diagnosis of recovery stage and 8 patients had died. Therefore, the total mortality rate during the Ebola virus outbreak in Nigeria was 40%. The isolation and treatment departments in Lagos were free of patients as of September 24, 2014. Among 894 possible contacts 891 was successfully analyzed. The remaining three contacts were ill, but confirmed as Ebola negative. (CDC,2015) As of October 13, 2014 Nigeria was approved by the World Health Organization as free of Ebola virus. Accordingly, to the previous practice country can be confirmed as Ebola free if during the period of 42 days no new cases were detected and all possible contacts were detected and testing showed negative results for all suspected cases. Hence, an example of the Nigeria in Ebola virus eradication can be a lesson for other countries at risk. (Drazen JM, 2014) Accordingly, to the all actions that have been done in Nigeria to contain the Ebola virus outbreak it is possible to headline the main steps of the Nigerian response. The most crucial and important role during Ebola virus eradication in Nigeria played increased attention of aviation and health care professionals in Lagos that detected and isolated the first infected patient with Ebola virus. After the identification of the first case the Nigerian government acted quite quickly and effectively to accept appropriate intervention plan that will help in short intervals successfully contain and prevent the spread of Ebola outbreak. This plan was financially supported with $11.5 million. Also private sector participants made meaningful contributions towards Ebola eradication efforts. For example, Dangote Foundation donated $1 million for the Emergency Operation Center in Lagos. (CDC,2014) The key role in Ebola eradication in Nigeria played the Nigerian Centers for Disease Control and Prevention that was worked in cooperation with World Health Organization, state governments, UNICEF and US Centers for Disease Control and Prevention. This productive partnership helped to set up the Emergency Operations Center at the Central Public Health Laboratory in Lagos and Yaba. Also, they educated and increase awareness of the general public about Ebola virus disease symptoms, signs, and transmission methods and all possible preventable actions. Contact tracing program effectively detected all suspected cases. (Shrivastava SR,2015) The other actions of Nigerian government were: Prohibition transportation of corpses – both international and interstate Formation of an Ebola Treatment and Research Group with the purpose to conduct an extensive investigation of the Ebola virus Foundation of 6 testing centers nationwide Training of the Nigerian health care workers in Ebola limit and control related courses Postponement of reopening schools because of the Ebola epidemic Ensuring appropriate provision of the protective equipment for the health care workers Supplying isolated and suspected patients with adequate support Promoting an anti-stigmatization campaign (Edwin Ikhuoria, 2014) Hence, all of these preventable actions helped to control and eradicate an Ebola virus outbreak in one of the most densely populated megacities Lagos, Nigeria with a survival rate 63% that is two times higher than the 30% average in other West African Countries. (Robyn Dixon,2014) CONCLUSION Therefore, Ebola virus cause Ebola Virus Disease that affects immune system cells and cause internal and external bleeding. The most common symptoms are fever, headache, vomiting, diarrhea, abdominal pain, confusion. Humans can be infected by direct contact with ill animals or other humans through the injured skin or body fluids. A natural reservoir of Ebola is fruit bats. Diagnosis of the Ebola Virus Disease involves laboratory testing of the blood samples for viral RNA or proteins. The Ebola virus was firstly identified in Zaire and Sudan in 1976. Since that time several Ebola outbreaks occurred in the regions of Sub – Saharan Africa and some cases were observed outside the Africa in the United States, Italy, and Philippines. Ebola outbreaks resulted in 1,716 approved cases. The largest outbreak is the 2014 West Africa Ebola Outbreak. The Ebola outbreak occurred in Lagos, Nigeria on July 20, 2014. 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