Emerging disease surveillance & response (ESR) WHO Regional Office for the Western Pacific (WPRO)

1. Ebola Virus Disease (EVD) Emerging disease surveillance & response (ESR) WHO Regional Office for the Western Pacific (WPRO) 15 August 2014

2. Outline • Epidemiological Summary • Ebola Disease Background • Ebola Transmission • EVD Regional Framework for Action • Current situation assessment • Country Responses (West Africa)

3. Epi Summary: Geographical distribution

4. Epi Summary: Number of cases by country23 December 2013 – 15 August CFR = 54% Infected at least 194 HCW including 95 death as of 15 August

5. Epicurve by week of EVD onset in Guinea, Liberia and Sierra Leone December 2013 to August 2014. (As of 04 August) Liberia Outbreak response operations started Sierra Leone Guinea Laboratory Confirmation 21 March Alert 13 March 15 cases inc. 9 deaths Alert from Méliandou 26 January 5 death w diarrhoea

6. EVD Background and Transmission

7. EVD Background • Ebola virus belongs to the filovirus family which causes haemorrhagic fever • Named after the Ebola River next to Yambuku (DRC former Zaire) where one of the first recorded outbreaks occurred in 1976 • 5 distinct Ebola strains: • Bundibugyo ebolavirus • Zaire ebolavirus • Reston ebolavirus • Sudan ebolavirus • Taï Forest ebolavirus The outbreak in West Africa is caused by Zaire ebolavirus (EBOV)

8. Hypothesis of EBOLA virus Transmission 1. Virus reservoir : Fruit bats The virus maintains itself in fruit bats. The bats spread the virus during migration. 4. Secondary transmission 2. Epizootic in primates 3. Primary human infection Infected fruit bats enter in direct or indirect contact with other animals and pass on the infection, sometimes causing large-scale epidemics in gorillas, chimpanzees and other monkeys or mammals (e.g. forest antelopes). Humans are infected either through direct contact with infected bats (rare event), or through handling infected dead or sick animals found in the forest (more frequent) Secondary human-to-human transmission occurs through direct contact with the blood, secretions, organs or other body fluids of infected persons. High transmission risk when providing direct patient care (healthcare workers) or handling dead bodies (funerals). Source: WHO

9. Human to human transmission • Direct contact with blood, body fluids, tissues • Indirect contact with contaminated environment • Caring for symptomatic cases • Handling bodies during funerals • Transmission amplified in health care settings • No risk during incubation period

10. EVD Regional Framework for Action

11. EVD Framework for Action The relevant WHO advice and guidance materials are related to: • Keeping up-to-date • Surveillance, public health investigation and risk assessment • Laboratory • Clinical management and infection prevention and control • Public health emergency response and international travel measures • Risk communications and social mobilization

12. Keeping up to date • The current EVD outbreak in West Africa involves multiple locations and cross-border movements among communities • Transmission is facilitated by direct contact with the body fluids (blood, sputum, semen, etc.) of EVD cases • Health-care workers have frequently been infected while treating symptomatic patients with EVD • Although the likelihood that EVD will reach the West Pacific Region is low, Member States and WHO need to be prepared for this situation.

13. Surveillance The effectiveness of EVD surveillance depends on the timeliness of case detection and laboratory confirmation of EVD infection Possible points of detection of EVD cases • Health Authorities must ensure: • National surveillance systems are capable of detecting suspected cases of EVD • Clinicians and health care workers understand and implement: • EVD case definition • Safe specimens collection and shipment for laboratory confirmation • Reporting mechanism that promotes regular and immediate reporting

14. EVD Case Definition SUSPECTED CASE: • Any person, alive or dead, suffering or having suffered from a sudden onset of high fever and having had contact with: - a suspected, probable or confirmed Ebola or Marburg case; - a dead or sick animal (for Ebola) OR: any person with sudden onset of high fever and at least three of the following symptoms: • headaches • vomiting • anorexia / loss of appetite • diarrhoea • lethargy • stomach pain • aching muscles or joints • difficulty swallowing • breathing difficulties • hiccup OR: any person with inexplicable bleeding OR: any sudden, inexplicable death.

15. Case Definition (2) PROBABLE CASE: • Any suspected case evaluated by a clinician OR: Any deceased suspected case that has had an epidemiological link with a confirmed case CONFIRMED CASE: • Any suspected or probably cases with a positive laboratory result. Laboratory confirmed cases must test positive for the virus antigen, either by detection of virus RNA by reverse transcriptase-polymerase chain reaction (RT- PCR), or by detection of IgM antibodies directed against Ebola.

16. Public health investigation, Risk assessment Contact Tracing for persons who may have come into contact with infected person is an important part of a comprehensive control DEFINITION OF CONTACT • Contacts of Ebola case(s): • slept in the same household with a case • direct physical contact with the case (dead or alive) • touched blood, body fluids , clothes or linens of case(s) • breastfed by the patient (baby) • Contacts with dead or sick animals • Laboratory contact • direct contact with specimens collected from suspected Ebola patients or animal Source WHO: http://who.int/csr/resources/publications/ebola/ebola-case-definition-contact-en.pdf

17. Surveillance, Public health investigation, Risk assessment • Monitor all contacts over a period of 21 days after their latest exposure. • Conduct a clinical evaluation of contacts if they become ill during that 21-day period (epidemiological and clinical evaluation in order to classify the case using the case definition) • Refer contacts identified as suspected or probable cases to the isolation ward.

18. Laboratory testing for Ebola virus • Ensure strict IPC during specimen collection. • Handling live virus (e.g. isolation) should be dealt with at BSL-4. • Molecular diagnosis of Ebola virus is most commonly used. • Reference laboratories are available in- and outside WPR. • Packaging and shipping in accordance to International Air Transport Agency (IATA) guidelines. • Contact WHO laboratory focal point for more details about testing and referral.

19. Clinical Management and Infection Prevention and Control (IPC) Incubation period: From 2 to 21 days ** Cases are not contagious during the incubation period** Disease Symptoms: • Sudden onset of fever, intense weakness, muscle pain, headache and sore throat • Followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases, both internal and external bleeding source WHO: http://www.who.int/csr/don/2014_04_ebola/en/

20. Clinical Management and Infection Prevention and Control (IPC) Treatment: • To date, specific medicine or vaccine are not available. Several vaccines and medicines are being tested and evaluated. • Treatment is based on supportive care such as: • Rehydration • Symptomatic treatment • Psychological support • Suspected or confirmed cases should be isolated from other patients Modified Ebola and Marburg virus disease epidemics preparedness alert control and evaluation, Interim version 1.1 June2014. http://www.who.int/csr/disease/ebola/PACE_outbreaks_ebola_marburg_en.pdf?ua=1

21. Clinical Management and Infection Prevention and Control (IPC) IPC in a healthcare setting: • Standard precautions • Ensure that prior to entering the patient isolation rooms/areas, all visitors and health-care workers rigorously use personal protective equipment (PPE) and perform hand hygiene • PPE should include at least: gloves, gown, boots/closed shoes with overshoes (and mask and eye protection for splashes).

22. Clinical Management and Infection Prevention and Control (IPC) IPC in a healthcare setting: • Isolation of suspected or confirmed cases in isolation rooms or cohort them in specific confined areas • Exclusively assign clinical and non-clinical personnel patient care areas • Ensure regular and rigorous environmental cleaning, decontamination of surfaces and equipment and management of soiled linen and of waste • Ensure safety of injections and phlebotomy procedures and management of sharps. • Ensure safe processing of laboratory samples

23. Clinical Management and Infection Prevention and Control (IPC) • IPC measures while handling dead bodies or human remains of suspected or confirmed patients with HF for post-mortem examination and burial preparation • Promptly evaluate, care for, and if necessary, isolate health-care workers or any person exposed to blood or body fluids from suspected or confirmed patients with EVD

24. Public Health Emergency Response and International Travel Measures Current Challenges in Ongoing Response • Geographical spread: First large Ebola outbreak in West Africa • Need for systems strengthening: Weakness of surveillance • Need for stronger risk communications and social mobilization: Failure of social interventions: strong community resistance, strong traditional beliefs & cultural practice • Transmission issues: Mix of Ebola transmission documented: rural, urban, and cross-border. • Large percentage of HCW affected: Health care facilities serving as amplification places for Ebola

25. Issues Critical to Response • Cross-border infections • Travelers testing negative • Need for strengthened coordination & contact tracing difficult given health infrastructure in countries • Many partners at limits of capacity • Ongoing weaknesses in operations • Socio-economic impact (ie. airlines shutting down flights, stigmatization)

26. WHO Response Operations Summary Surge Capacity--Declaration of WHO ERF Grade 3 emergency on 25 Jul 2014 • International deployments: Deployment of several mobile laboratories and development of national lab capacities • Over 330 experts have been deployed in the 3 countries by WHO and GOARN partners (ie. epidemiologists, infection prevention and control experts, clinicians, logisticians, anthropologist, communication experts) • Core services/Logistics: timely shipment of needed PPEs and others medical supplies • Risk communications: Information products published (Website AFRO and HQ) daily

27. IHR Emergency Committee Group of international experts convened to assess the situation advice the DG on EVD outbreak on 6 – 7 August, 2014 Main outcomes: • The EVD constitutes a Public Health Emergency of International Concern (PHEIC) • Public health recommendations given to countries EVD transmission, at-risk countries and those with border crossings and all states.

28. IHR Emergency Committee Advice for all countries: • provide general public and travelers with accurate and relevant information to reduce the risk of exposure. • be prepared to facilitate the evacuation and repatriation of nationals (e.g. health workers) who have been exposed to Ebola.

29. IHR EC Recommendations for all countries Capacity strengthening: States should be prepared to detect, investigate, and manage Ebola cases; this should include assured access to a qualified diagnostic laboratory for EVD and, where appropriate, the capacity to manage travelers originating from known Ebola-infected areas who arrive at international airports or major land crossing points with unexplained febrile illness Travel and Trade: There should be no general ban on international travel or trade

30. General Health Advice to Travelers • Travelers to affected areas should be provided with the information on: • risks • measures to minimize the risks • advice for managing a potential exposure • Returning visitors from affected areas should be alerted and seek rapid medical attention and mention travel history, if: • develop symptoms (fever, weakness, muscle pain, headache, sore throat, vomiting, diarrhoea, rash, or bleeding) within 3 weeks after return • or if have suspected exposure to Ebola virus

31. WHO: Statement on travel and transport in relation to Ebola virus disease outbreak • WHO, the International Civil Aviation Organization (ICAO), the World Tourism Organization (UNWTO), Airports Council International (ACI), International Air Transport Association (IATA) and the World Travel and Tourism Council (WTTC) activated a Travel and Transport Task Force. • Affected countries are requested to conduct exit screening of all persons at international airports, seaports and major land crossings. • Any person with an illness consistent with EVD should not be allowed to travel unless the travel is part of an appropriate medical evacuation.

32. WHO: Statement on travel and transport in relation to Ebola virus disease outbreak • Non-affected countries need to strengthen the capacity to detect and immediately contain new cases, while avoiding measures that will create unnecessary interference with international travel or trade. • WHO does not recommend any ban on international travel or trade, in accordance with advice from the WHO Ebola EC. • Travel restrictions and active screening of passengers on arrival at sea ports, airports or ground crossings in non-affected countries that do not share borders with affected countries are not currently recommended by WHO.

33. Risk communication and Social Mobilization • Core elements of an effective risk communication system for response to high risk or emergency events which would allow for targeted planning and preparedness efforts on areas of agreed upon weakness. • Transparency and first announcement of a real or potential risk: Ensure those at risk can protect themselves and that trust between authorities, populations and stakeholders is maintained and strengthened.

34. Risk communication and Social Mobilization Public Communication Coordination: This capacity helps takes advantage of available public communication resources, allows for coordinated messaging reducing the possibility of confusion and overlap, and strengthens the reach and influence of the advice provided.

35. Risk communication and Social Mobilization Information dissemination including media relations: • High demand for information, and the crucial role of advice to minimize a threat makes the rapid and effective dissemination of information crucial during serious events. • Mass Media relations remains a pillar of effective information sharing, but it is also important to access other trusted information sources such as those at risk, including new media channels, existing information sharing networks and non- traditional media

36. From December 2013-15 August 2014 Current situation assessment Country Responses, West Africa

37. Guinea • Developed national response plan which included: • Strengthening coordination of response activities at all levels • Strengthening early detection of suspected cases and identification of contacts • Case management and infection prevention and control and psychosocial support • Social mobilization, public information and communications • A high-level political delegation from the Government conducted a field visit to Gueckedou to engage with local and opinion leaders in an effort to build relationships of trust. • Closed all land borders with Sierra Leone. The borders with Liberia have been closed for some time. • Exit screening is currently being tested in Conakry, in partnership with the US CDC.

38. Liberia • State of Emergency since 6 of August 2014 • Multi-disciplinary National Task Force including: • Incident Management System case management • infection control and psychosocial support • epidemiology and laboratory • social mobilization, media and communication • logistics and security • Treatment centers scaled up • National technical staff deployed to support counties affected and at risk • Developed outbreak response plan which included: • Effective coordination of the outbreak response activities at all levels • Strengthen early detection, investigation, reporting, active surveillance and diagnostic capacity • Institution of prompt and effective case management and psychosocial support • Create public awareness on risk, prevention and control

39. Sierra Leone • Development of outbreak response plan including: • Effective coordination of outbreak response at all levels • Strengthen early detection, reporting and referral of suspected cases through active surveillance and outbreak investigation • Institute prompt and effective case management of all suspected cases • Create public awareness on risk, prevention and control. • Mapping of where treatment centres are most needed and their subsequent establishment • Mapping of locations where laboratories most in need and subsequent establishment

40. Nigeria • State of Emergency declared on 8 of August 2014 • National Incident Command holds daily meetings and was expanded to include Heads of Federal health institutions • Case management measures implemented • Contact tracing • Surveillance and laboratory harmonization • Social mobilization • Treatment centre set up for managing cases of EVD

41. Inter-country level response A Joint Declaration of Heads of State and Government of the Mano River Union* was issued and leaders pledged to commit additional resources to the outbreak. This will include the following measures: • Focus on cross-border regions, including isolation of specific areas by police and military • Material support to the citizens in these areas • Health-care centers in these zones will be strengthened for treatment, testing, and contact tracing • Burials will be done in accordance with national health regulations *Côte d’Ivoire, Guinea, Liberia, and Sierra Leone

42. Useful References for Framework for Action Epidemiology • Human infections with Zaïre Ebolavirus in West Africa, 24 June 2014 http://who.int/csr/disease/ebola/EVD_WestAfrica_WHO_RiskAssessment_20140624.pdf?ua=1&ua=1&ua=1 Preparedness and response • Ebola and Marburg virus disease epidemics: preparedness, alert, control, and evaluation http://who.int/csr/disease/ebola/PACE_outbreaks_ebola_marburg_en.pdf Infection control • Interim summary of infection control recommendations http://who.int/csr/bioriskreduction/filovirus_infection_control/en/ Patient care • WHO guidelines on drawing blood: best practices in phlebotomy http://whqlibdoc.who.int/publications/2010/9789241599221_eng.pdf Social mobilization • A toolkit for behavioural and social communication in outbreak response http://who.int/ihr/publications/combi_toolkit_outbreaks/en/ Travel and transport risk assessment http://www.who.int/csr/disease/ebola/faq-ebola/en/

43. EBOLA WHO website • Technical information • Infection control • Social mobilization • Epidemiology • Preparedness and response • Patient care • Guidelines • Meeting reports • Disease outbreak news http://www.who.int/csr/disease/ebola/en/