Sandbox/ebola

West Africa outbreak

First affected Districts in Guinea and neighboring areas.

Affected Distribution of confirmed and suspected cases as of 16 June 2014.

On March 23, 2014, the Ministry of Health of Guinea notified the World Health Organization WHO) of a rapidly evolving outbreak of Ebola virus disease (EVD) in forested areas south eastern Guinea: Guekedou, Macenta, Nzerekore and Kissidougou districts. As of 22 March, 2014, a total of 49 cases including 29 deaths (case fatality ratio: 59%) were reported. Four health care workers were among the victims. At the same time, suspected cases in border areas of Liberia and Sierra Leone were being investigated. Six blood samples were tested at Institut Pasteur in Lyon, France, resulting positive for Ebola virus by PCR, confirming the first Ebola virus disease outbreak in Guinea. Preliminary results from sequencing of a part of the L gene showed strong homology with Zaire Ebolavirus. The ministry of health together with the WHO and other partners initiated measures to control the outbreak and prevent further spread. Médecins Sans Frontières, Switzerland (MSF-CH) started working in the affected areas and assisted with the establishment of isolation facilities, and also supported transport of the biological smaples from suspected cases and contacts to international reference laboratories for urgent testing. The Emerging and Dangerous Pathogens Laboratory Network (EDPLN) worked with the Guinean VHF Laboratory in Donka, the Institut Pasteur in Lyon, the Institut Pasteur in Dakar, and the Kenema Lassa fever laboratory in Sierra Leone to make available appropriate Filovirus diagnostic capacity in Guinea and Sierra Leone.

On 30 March, 2014, the Ministry of Health of Liberia provided updated details on the suspected and confirmed cases of Ebola virus disease in Liberia. As of 29 March, seven clinical samples, all from adult patients from Foya district, Lofa County, were tested by PCR using Ebola Zaire virus primers by the mobile laboratory of the Institut Pasteur (IP) Dakar in Conakry. Two of those samples tested positive for the ebolavirus. There were 2 deaths among the suspected cases; a 35 year-old woman who died on 21 March tested positive for ebolavirus while a male patient who died on 27 March tested negative. At that time, Foya was the only district in Liberia that reported confirmed or suspected cases of Ebola Hemorrhagic Fever. As of 26 March, Liberia had 27 contacts under medical follow-up. Liberia established a high level National Task Force to lead the response. Response partners include WHO, the International Red Cross (IRC), Samaritan’s Purse (SP) Liberia, Pentecostal Mission Unlimited (PMU)-Liberia, CHF-WASH Liberia, PLAN-Liberia, UNFPA and UNICEF.

On 3 April, 2014, the outbreak was confirmed to be caused by a strain of ebolavirus with very close homology (98%) to the Zaire ebolavirus. This is the first time the disease has been detected in West Africa.

As of 17 June 2014, in Guinea a total of 7 new cases and 5 new deaths were reported from Gueckedou (4 cases and 5 deaths) and Boffa (3 cases and 0 deaths). This brings the cumulative number of cases and deaths reported from Guinea to 398 (254 confirmed, 88 probable and 56 suspected) and 264 deaths. The geographical distribution of these cases and deaths is as follows: Conakry (70 cases and 33 deaths); Guéckédou (224 cases and 173 deaths); Macenta (41 cases and 28 deaths); Dabola, (4 cases and 4 deaths); Kissidougou (8 cases and 5 deaths); Dinguiraye (1 case and 1 death); Telimele (30 cases and 9 deaths); Bofa (19 cases and 10 deaths) and Kouroussa (1 case and 1 death). Twenty four (24) patients are currently in EVD Treatment Centres: Conakry (6), Guéckédou (9), Telimele (3) and Boffa (6). The number of contacts currently being followed countrywide is 1,258 and distributed as follows: Conakry (252), Guéckédou (529), Macenta (52), Telimele (118), Dubreka (118) and Boffa (189). So far 69.4% (2,848 contacts being followed-up out of a 4,106 contacts registered since the beginning of the outbreak) have completed the mandatory 21 days observation period.

In Liberia a total of 9 new cases and 5 new deaths were reported from Lofa (6 cases and 0 death) and Montserado (3 cases and 5 deaths). This brings the cumulative number of cases and deaths reported from Liberia to 33 (18 confirmed, 8 probable and 7 suspected) and 24 deaths. The geographical distribution of these cases and deaths is as follows: Lofa (21 cases and 14 deaths); Montserado (8 cases and 8 deaths); Margibi (2 cases and 2 deaths) and Nimba (2 cases and 0 death). Five (5) patients are currently in EVD Treatment Centres in Lofa. The number of contacts currently being followed countrywide is 108 and distributed as follows: Lofa (95), Montserado (13). So far 41.5% (108 contacts being followed-up out of a 260 contacts registered since the beginning of the outbreak) have completed the mandatory 21 days observation period.

In Sierra Leone a total of 31 new cases and 4 new deaths were reported from Kailahun (29 cases and 4 deaths), Kono (1 case) and Western (1 case). This brings the cumulative number of cases and deaths reported from Sierra Leone to 97 (92 confirmed, 3 probable and 2 suspected) and 49 deaths. The geographical distribution of these cases and deaths is as follows: Kailahun (92 cases and 46 deaths); Kambia (1 cases and 0 deaths); Port Loko (2 cases and 1 deaths); Kono, (1 case and 0 death) and Western (1 cases and 1 death. Thirty three (33) patients are currently in EVD Treatment Centre of Kenema. The number of contacts currently being followed countrywide is 37 from Kailahun. Contact listing is continuing in Kailahun, Kambia and Port Loko.

physical

Vital signs

• Fever: up to 20% of patients with lung cancer

• Hypertension: Cushing's syndrome

General appearance

• Cachexic: weight loss and anorexia
• Jaundice: liver metastases
• Pale skin and conjunctiva: anemia of chronic disease.
• Cyanotic: dyspnea
• Lymphadenopathy (> 1 cm)
• Soft tissue mass

• 

  Cachexia

HEENT

Head

• Moon facies: Cushing's syndrome

Eyes

• Jaundice: liver metastases OR
• Conjunctival pallor: anemia of chronic disease
• Miosis, ipsilateral ptosis and lack of facial sweating: Horner's syndrome

Throat

• Hoarseness: superior vena cava syndrome

• 

  Horner's Syndrome

Lungs

• Unilateral wheeze
• Pleural effusion

Abdomen

• Hepatomegaly (> 13 cm span): liver metastases

Musculoskeletal system

• Digital clubbing
• Bone tenderness: bone metastases
• Osteoarthropathy: painful symmetrical arthropathy of the knees, wrist, and knees, and periosteal new bone formation.

• 

  Clubbing

• 

  Clubbing

Neurological

• Ataxia, dysarthria, nystagmus and sever vertigo: cerebellar degeneration
• Proximal muscles of lower extremities weakness and fatiguability, abnormal gait, hyporeflexia, increased deep-tendon reflexes after facilitation, autonomic dysfunction, and paresthesias

Skin

• Acquired Tylosis
• Trip palms
• Erythema gyratum repens

Contact precautions

Use Standard Precautions

A patient with a virus hemorrhagic fever may come to the health facility at any point in his or her illness,

• When the possibility of exposure is often highest, and
• Before the specific cause of the patient’s illness is known.

Because a health worker cannot always know when a patient’s body fluids are infectious. Standard Precautions should be used with all patients in the health care setting, regardless of their infection status. Standard Precautions are designed to prevent unprotected contact between the health care worker and

• Blood and all body fluids whether or not they contain blood
• Mucous membranes.

When a specific diagnosis is made, additional precautions are taken, based on how the disease is transmitted.

Establish and Maintain a Minimum Level of Standard Precautions

Limited supplies and resources may prevent a health facility from using all the Standard Precautions all the time. However, health facilities should establish and maintain a basic, practical level of Standard Precautions that can be used routinely with patients in their health facility. At a minimum, consider the services in the health facility that present a risk of disease transmission due to potential contact with blood and all body fluids, broken skin or mucous membranes. For health facility staff who work in such areas, establish at least:

• A source of clean water.
• Routine handwashing before and after any contact with a patient who has fever.
• Safe handling and disposal of sharp instruments and equipment, including needles and syringes.

Establish Routine Handwashing

Handwashing is the most important precaution for the prevention of infections. Handwashing before and after contact with a patient who has fever should be a routine practice in the health facility even when VHF is not present. Washing hands with soap and water eliminates microorganisms from the skin and hands. This provides some protection against transmission of VHF and other diseases. In services where health care workers see patients with fever, provide at least:

• Cake soap cut into small pieces.
• Soap dishes. Microorganisms grow and multiply in humidity and standing water. If cake soap is used, provide soap dishes with openings that allow water to drain away.
• Running water, or a bucket kept full with clean water.
• A bucket for collecting rinse water and a ladle for dipping, if running water is not available.
• One-use towels. Sharing towels can result in contamination. Use paper towels. If they are not available, provide cloth towels that can be used once and then laundered. If towels are not available, health care workers and health facility staff can air-dry their hands.

Make sure health facility staff know the steps of handwashing:

1. Place a piece of soap in the palm of one hand.
2. Wash the opposite hand and forearm. Rub the surfaces vigorously for at least 10 seconds. Move soap to the opposite hand and repeat.
3. Use clean water to rinse both hands and then the forearms. If running water is not available, pour clean water from a bucket over the soapy hands and forearms. The rinse water should drain into another bucket.
4. Dry the hands and forearms with a clean, one-use towel. First dry the hands and then the forearms. Or let rinsed hands and forearms air-dry.

Handle and Dispose of Sharp Instruments Safely

• Disease transmission can occur through accidental needlestick injuries. Make sure health facility staff always handle sharp instruments safely. Do not recap needles after use.
• Limit invasive procedures to reduce the number of injectable medications. This will limit the opportunities for accidental needlestick injuries.
• When an injection is necessary, always use a sterile needle and sterile syringe for each injection.
• To discard disposable needles and syringes safely: Disposable needles and syringes should be used only once. Discard the used disposable needle and syringe in a puncture-resistant container. Then burn the container in an incinerator or pit for burning.
• If puncture-resistant containers are not available, use empty water, oil, or bleach bottles made with plastic or other burnable material. Adapt them for use as puncture-resistant containers.

Disinfect Reusable Needles and Syringes Safely

• Reusable needles and syringes are not recommended. If reusable needles and syringes are used, clean, disinfect and sterilize them

before reuse, according to your hospital’s policy.

• Needles and syringes used with VHF patients require special care. Cleaning staff should wear two pairs of gloves when handling needles and syringes used with any patient with a known or suspected VHF.

Disinfect Disposable Needles and Syringes That Must Be Reused

• Whenever possible, use disposable needles and syringes only once and then discard them safely.
• In situations when disposable needles and syringes must be reused, make sure they are cleaned and disinfected after each use. Disinfection with bleach will reduce the risk of transmission of VHF and blood-borne diseases, such as HIV infection and viral hepatitis.

Obtain a jar or pan. Clean and disinfect it.

1. Place the disposable needle and syringe in a pan of soapy water after use. Fill the needle and syringe with soapy water. Leave them to soak until they are cleaned.
2. Take the soaking needles and syringes to the cleaning area.
3. Clean them very carefully in soap and water. Remove any blood or other biological waste, especially from the area around the syringe fittings. Blood or other biological products may collect in these small openings.
4. Draw full-strength bleach into the needle and syringe.
5. Soak for 30 seconds, and then expel bleach into a container for contaminated waste.
6. Soak again by once more drawing full-strength bleach into the needle and syringe. Soak for 30 seconds, and then expel bleach into the container for contaminated waste.
7. Let the disinfected needle and syringe air-dry. Store them in a clean jar or pan that has been disinfected.

Use VHF Isolation Precautions

• Isolate the patient.
• Wear protective clothing in the isolation area, in the cleaning and laundry areas and in the laboratory. Wear a scrub suit, gown, apron, two pairs of gloves, mask, headcover, eyewear, and rubber boots.
• Clean and disinfect spills, waste, and reusable equipment safely.
• Clean and disinfect soiled linens and laundry safely.
• Use safe disposal methods for non-reusable supplies and infectious waste.
• Provide information about the risk of VHF transmission to health facility staff. Reinforce use of VHF Isolation Precautions with all health facility staff.
• Provide information to families and the community about prevention of VHFs and care of patients.