Professional Documents
Culture Documents
85]
R ev i ew A r t i c l e
Abstract
Ebola virus disease(EVD) is one of the most virulent pathogens among viral hemorrhagic fevers affecting economically deprived
countries of the world with reported case fatality rates of up to 90% due to multiorgan failure and severe bleeding complications.
The most recent outbreak of 2014 has set the alarm bell ringing across the globe for increased focus, funding, research, and
development toward the control and management of this emerging viral communicable disease that has a potential pandemic
threat. This manuscript review and update current knowledge with regard to epidemiology of EVD problem statement, historical
perspective, agent, host, environment, reservoir of infection, routes of transmission, pathogenesis, clinical features, laboratory
diagnosis, management, and control. The review was undertaken using the key words epidemiology, public health, outbreak control
of Ebola virus, EVD, emerging disease, and/or pandemic disease through medical search engines and abstracting databases
such as Pubmed, Google Scholar, and websites of international health agencies such as the World Health Organization(WHO)
and Centers for Disease Control and Prevention(CDC).
Keywords: Burial practices, communicable disease, emerging disease, environment, epidemiology, infection, public health, risk
exposure, surveillance, transmission
Introduction
Ebola virus disease(EVD) is a zoonotic disease caused by an
RNA virus of the family Filoviridae and genus Ebola virus
leading to severe hemorrhagic fever and fulminant septic
shock.[1] In the 2014 outbreak though with the roots being
discovered in late 2013, events in West Africa changed
the perception of EVD from an exotic tropical disease to a
global health security and threat.[2] This review manuscript
describes the current update with regard to disease burden,
historical insight, agent, host, environment, reservoir, source,
routes of transmission, pathogenesis, clinical features,
laboratory diagnosis, and control and management of EVD.
Problem Statement
The first outbreak occurred in Zaire(Congo) in 1976
followed by several outbreaks within Africa(except one
Access this article online
Quick Response Code:
Website:
www.tjmrjournal.org
DOI:
10.4103/1119-0388.198096
[Downloaded free from http://www.tjmrjournal.org on Thursday, January 12, 2017, IP: 59.180.61.85]
Kaur, etal.: Ebola virus disease
Historical Perspective
Agent Factors
Reservoir of Infection
Fruit bats of the Pteropodidae family are considered to
be the natural reservoirs of Ebola virus.[13]
[Downloaded free from http://www.tjmrjournal.org on Thursday, January 12, 2017, IP: 59.180.61.85]
Kaur, etal.: Ebola virus disease
Year
1976
Second
1989
Third
2014
Regions affected
Central Africa, Democratic Republic
of Congo(ZAIRE), and Sudan
South Africa
Reston, Virginia
West Africa-affecting Guinea, Sierra
Leone, Liberia, and Nigeria
Description
First outbreak of Ebola. Hemorrhagic fever
Mysterious outbreak(initially diagnosed as Simian hemorrhagic
fever virus among a shipment of crabeating macaque monkeys
imported from the Philippines. Named Reston Ebola virus
Largest outbreak to date
EBV=Ebola virus
Source of Infection
The virus is transmitted from wildlife to people through
contact with infected fruit bats and through intermediate
hosts such as monkeys, apes, or pigs that become infected
through contact with bat saliva or feces. Ebola virus
can infect humans by direct contact with the blood and
body fluids of infected animals such as apes, gorillas,
and monkeys.[1416] No evidences show that pet cat/
dogs, mosquitoes, or other insects can transmit Ebola
virus. Humantohuman transmission occurs through
direct contact with organs, blood, secretions of the
body and other fluids(such as urine, feces, semen,
breast milk, mucus, vomit) of an infected person and
materials contaminated with these fluids.[17,18] Infected
syringes and needles are other ways by which the virus
can be transmitted while air or water does not spread
EVD. Breaches in the control of infections and universal
precautions have resulted in frequent infections among
health workers. Direct contact with the body of a deceased
person during burial ceremonies is another classic way
by which Ebola can be transmitted.[19]
Environment
Host Factors
Mode of Transmission
Period of Infectivity
[Downloaded free from http://www.tjmrjournal.org on Thursday, January 12, 2017, IP: 59.180.61.85]
Kaur, etal.: Ebola virus disease
Clinical Features
The symptoms of EVD begin with fever, headache, fatigue,
sore throat, and muscle pain, which later progress to anorexia,
nausea, diarrhea, vomiting, rash, abdominal pain, cough,
shortness of breath, postural hypotension, edema, headache,
confusion, and coma. In certain cases, a maculopapular rash
develops after 5-7days of the symptoms.[37,38] Hemorrhagic
complications such as mucosal hemorrhages, nose bleeding,
vomiting/coughing up of blood, blood in the stool, petechiae,
ecchymoses, and uncontrollable bleeding from venipuncture
sites are seen in severe cases, along with other features such
as severe metabolic disturbances, convulsion, shock, and
multiple organ failure. These complications are the most
common causes of death in EBVinfected patients.[39] Figure4
depicts the usual progression of EBV in humans.
Laboratory Diagnosis
Pathogenesis
Ebola after enters the body at the cellular level docks
with the cell membrane and then viral RNA is released
[Downloaded free from http://www.tjmrjournal.org on Thursday, January 12, 2017, IP: 59.180.61.85]
Kaur, etal.: Ebola virus disease
[Downloaded free from http://www.tjmrjournal.org on Thursday, January 12, 2017, IP: 59.180.61.85]
Kaur, etal.: Ebola virus disease
Prevention of Ebola
Various case definitions and risk assessment as advocated
for EBV for priority attention include:[45]
Person under investigation
A person who has both consistent symptoms and risk
factors as follows:
Clinical criteriaFever(>38.6C or 101.5F) and
additional symptoms such as severe headache,
muscle pain, vomiting, diarrhoea, abdominal pain,
or unexplained haemorrhage; and epidemiologic
risk factors within the past 21days before the onset
of symptoms such as contact with blood or other
body fluids or human remains of a patient known
to have or suspected to have EVD; residence in or
travel to an area where EVD transmission is active;
or direct handling of bats or nonhuman primates
from diseaseendemic areas
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 the sudden
onset of high fever and at least three of the following
symptoms, i.e., headache, vomiting, anorexia/loss of
appetite, diarrhoea, lethargy, stomach pain, aching
muscles or joints, difficulty swallowing, breathing
difficulties, and hiccup or any person with inexplicable
bleeding or any sudden, inexplicable death
Probable case: Any suspected case evaluated by a
clinician or any deceased suspected case(where it
was not possible to collect specimens for laboratory
confirmation) having an epidemiological link with
a confirmed case
Confirmed case: Acase with laboratoryconfirmed
diagnostic evidence of Ebola virus infection
Laboratory confirmed case: Any suspected or
probable cases with a positive laboratory result.
Laboratoryconfirmed cases must test positive for
the virus antigen, either by the detection of virus
Control Measures
The health system capacity of developing countries
involved in EVD outbreak is very low and requires both
shortand longterm control measures. The international
community gave an overwhelming, decisive but delayed
response. Some of the generic and specific viral control
measures include:[4752]
[Downloaded free from http://www.tjmrjournal.org on Thursday, January 12, 2017, IP: 59.180.61.85]
Kaur, etal.: Ebola virus disease
Restricted
travel
Yes
Casebycase
assessment
No
No
EBV=Ebola virus
Status
Phage I
Phage I
Feature
Attenuated
adenovirus
Attenuated VSV
2015a)
Company
GSK and NIAID
NewLink Genetics
and PHAC
Bavarian Nordic
Attenuated
vaccinia virus
AdVac
2015a)
Attenuated
Crucell
adenovirus
SynCon
Preclinical Polyvalent vaccine Inovio
VesiculoVax Preclinical Attenuated VSV
ProfectusBioSciences
VSV=Vesicular stomatitis virus, EBV=Ebola virus, MVA-BN=Modified vaccinia
ankara-bavarian nordic, GSK=Glaxo smith kline, NIAID=National institute of allergy and
infectious diseases, PHAC=Public Health Agency of Canada
Status
Phage I
Favipiravir
TKMEbola
Brincidofovir
BCX4430
Approved
for IAV
Phage I
Phage III
Preclinical
AVI7537
Phage I
Feature
Three chimeric
monoclonal antibodies
Inhibition of viral RNA
dependent RNA
siRNA
Oral nucleotide analog
Inhibition of viral RNA
polymerase
Binding Ebola RNA
Company
LeafBio,
Inc.
Fujifilm
Tekmira
Chimerix
BioCryst
Sarepta
But this does not rule out India to be safe from Ebola as
it can be imported through any case/incubating Ebola
traveler visiting India. The Government of India has issued
standard operating guidelines for the surveillance, control,
and management of EBV disease in accordance with the
WHO protocols. India has health organization quarantine
centers at 24 airports with all international airports and
sea ports to be equipped with thermal scanners in the
near future. The government has identified about 10
laboratories in the country that will handle testing if a
case is reported and in NewDelhi, Dr.Ram Manohar
Lohia Hospital has been designated as nodal hospital
[Downloaded free from http://www.tjmrjournal.org on Thursday, January 12, 2017, IP: 59.180.61.85]
Kaur, etal.: Ebola virus disease
References
1. WHO Ebola Response Team. Ebola virus disease in West
Africathe first 9months of the epidemic and forward
projections. NEngl J Med 2014;371:148195.
2. Arwady MA, Bawo L, Hunter JC, Massaquoi M, Matanock A,
DahnB, etal. Evolution of Ebola virus disease from exotic
infection to global health priority, Liberia, Mid2014. Emerg
Infect Dis 2015;21:57884.
3. BriandS, BertheratE, CoxP, FormentyP, KienyMP, MyhreJK,
etal. The international Ebola emergency. N Engl J Med
2014;371:11803.
4. LeroyEM, LaboubaI, MagangaGD, BerthetN. Ebola in West
Africa: The outbreak able to change many things. Clin Microbiol
Infect 2014;20:O5979.
5. Ebola Virus Disease. Fact Sheet No. 103. Geneva: World Health
Organization; Available from: http://www.who.int/mediacentre/
factsheets/fs103/en/.[Last accessed on Mar 2015 01].
6. Ebola Response Roadmap Situation Report. Geneva: World
Health Organization. Available from: http://www.who.int/
csr/disease/ebola/situationreports/en/. [Last accessed on
2015Mar 01].
7. Ebola Response Roadmap Situation Report. Geneva: World
Health Organization. Available from: http://www.apps.who.int/
ebola/currentsituation/ebolasituationreport1july20.[Last
accessed on 2015Jul 25].
8. WeyerJ, GrobbelaarA, BlumbergL. Ebola virus disease: History,
epidemiology and outbreaks. Curr Infect Dis Rep 2015;17:480.
9. MuyembeTamfum JJ, Mulangu S, Masumu J, Kayembe JM,
KempA, PaweskaJT. Ebola virus outbreaks in Africa: Past and
present. Onderstepoort J Vet Res 2012;79:451.
10. Baize S, Pannetier D, Oestereich L, Rieger T, Koivogui L,
MagassoubaN, etal. Emergence of Zaire Ebola virus disease in
Guinea. NEngl J Med 2014;371:141825.
11. GireSK, GobaA, AndersenKG, SealfonRS, ParkDJ, KannehL,
etal. Genomic surveillance elucidates Ebola virus origin and
transmission during the 2014 outbreak. Science 2014;345:136972.
12. Hartman AL, Bird BH, Towner JS, Antoniadou ZA, Zaki SR,
NicholST. Inhibition of IRF3 activation by VP35 is critical for the
high level of virulence of ebola virus. JVirol 2008;82:2699704.
13. Leroy EM, Kumulungui B, Pourrut X, Rouquet P, Hassanin A,
YabaP, etal. Fruit bats as reservoirs of Ebola virus. Nature
2005;438:5756.
14. Ebola Virus Disease. Fact Sheet No. 103. Geneva: World Health
Organization; 2014.
15. Ebola Virus Disease. Available from: http://www.cdc.gov/vhf/
ebola/transmission.[Last accessed on 2015Feb 15].
16. Leroy EM, Rouquet P, Formenty P, Souquire S, Kilbourne A,
FromentJM, etal. Multiple Ebola virus transmission events and
rapid decline of central African wildlife. Science 2004;303:38790.
17. WamalaJF, LukwagoL, MalimboM, NgukuP, YotiZ, MuseneroM,
etal. Ebola hemorrhagic fever associated with novel virus strain,
Uganda, 20072008. Emerg Infect Dis 2010;16:108792.
18. Bausch DG, Towner JS, Dowell SF, Kaducu F, Lukwiya M, Sanchez A,
etal. Assessment of the risk of Ebola virus transmission from
bodily fluids and fomites. J Infect Dis 2007;196(Suppl2):S1427.
19. Legrand J, Grais RF, Boelle PY, Valleron AJ, Flahault A.
Understanding the dynamics of Ebola epidemics. Epidemiol
Infect 2007;135:61021.
20. Drazen JM, Kanapathipillai R, Campion EW, Rubin EJ,
HammerSM, MorrisseyS, etal. Ebola and quarantine. NEngl J
Med 2014;371:202930.
21. Recommendations for Breast Feeding/Infant Feeding in the
Context of Ebola. Centers for Disease Control and Prevention. Ebola
Virus Disease. Available from: http://www.cdc.gov/vhf/ebola/
hcp/recommendationsbreastfeedinginfantfeedingebola.
html.[Last accessed on 2015Mar 20].
22. Chippaux JP. Outbreaks of Ebola virus disease in Africa: The
beginnings of a tragic saga. J Venom Anim Toxins Incl Trop
Dis2014;20:44.
23. MisasiJ, SullivanNJ. Camouflage and misdirection: The fullon
assault of ebola virus disease.Cell2014;159:47786.
24. Khl A, Phlmann S. How Ebola virus counters the interferon
system.Zoonoses Public Health2012;59(Suppl2):11631.
25. PinzonJE, WilsonJM, TuckerCJ, ArthurR, JahrlingPB, FormentyP.
Trigger events: Enviroclimatic coupling of Ebola hemorrhagic
fever outbreaks. Am J Trop Med Hyg 2004;71:66474.
26. Bausch DG, Schwarz L. Outbreak of ebola virus disease in
Guinea: Where ecology meets economy. PLoS Negl Trop Dis
2014;8:e3056.
27. JohnsonBK, WambuiC, OchengD, GichogoA, OogoS, LibondoD,
etal. Seasonal variation in antibodies against Ebola virus in
Kenyan fever patients. Lancet 1986;1:1160.
28. Busico KM, Marshall KL, Ksiazek TG, Roels TH, Fleerackers Y,
FeldmannH, etal. Prevalence of IgG antibodies to Ebola virus
in individuals during an Ebola outbreak, Democratic Republic
of the Congo, 1995. JInfect Dis 1999;179(Suppl1):S1027.
29. GrosethA, FeldmannH, StrongJE. The ecology of Ebola virus.
Trends Microbiol 2007;15:40816.
30. OSheaTJ, CryanPM, CunninghamAA, FooksAR, HaymanDT,
LuisAD, etal. Bat flight and zoonotic viruses. Emerg Infect Dis
2014;20:7415.
31. ZhangG, CowledC, ShiZ, HuangZ, BishopLillyKA, FangX, etal.
Comparative analysis of bat genomes provides insight into the
evolution of flight and immunity. Science 2013;339:45660.
32. Rouquet P, Froment JM, Bermejo M, Kilbourn A, Karesh W,
ReedP, etal. Wild animal mortality monitoring and human Ebola
[Downloaded free from http://www.tjmrjournal.org on Thursday, January 12, 2017, IP: 59.180.61.85]
Kaur, etal.: Ebola virus disease
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.