An introduction to the 2014 West Africa Ebola outbreak for educational use, with additional sources for health professionals in need of up-to-date information. Updated on 7th December, 2014, with additional infographics and WHO data. Infographics may be requested for professional use on a creative commons/source attribution basis (micrognome.priobe.net). An interactive version will be available for educational use via the Nearpod share site.

1. EBOLA 2014

2. Caveat
This presentation is intended for educational use and should
not be used as a sole source of professional guidance.
The information used to prepare this presentation was correct
on 7th December, 2014.
For updates on geographical, epidemiological and clinical
developments, readers should check CDC, WHO and other
regularly updated official information sources.

3. SITREP 2nd December
• Spain declared Ebola-free
• Cases levelling off in parts of Liberia
• Reduced case increase in Guinea
• Cases still increasing in Sierra Leone
• Preparedness stepped up in neighbouring countries
• Target of 70% quarantine; 70% hygienic burials
• Transmission in Mali localised

4. The current situation
Despite the large numbers of cases resulting from continued transmission within the three West
African countries of Liberia, Sierra Leone and Guinea, few cases and little continued local
transmission has occurred elsewhere. Spain and Senegal have been declared Ebola-free. Mali and
the USA have had limited local transmission. Nigeria and Senegal have been successful in mobilising
a public health response before EVD took hold. Other nations in West Africa at risk of disease spread
via their land borders have managed to prevent cross-border spread so far [at 2-DEC-14].

5. The numbers to date
Country Total Deaths
Liberia 7650 3155
Sierra Leone 7420 1609
Guinea 2186 1349
Nigeria 20 8
Mali 8 6
Senegal 1 0
Outside Africa 5 1
TOTAL 17290 6128
Source = AFRO, WHO, as of 2nd December, 2014. Total cases = confirmed,
presumed & suspected. Data collation requires time, and confirmation demands
specialist laboratory services which are in high demand. All figures are provisional
and subject to revision as new data becomes available.

6. Clinical timeline
Days from infection Stages Clinical features
7-9 Early symptoms Headache, lassitude, fever, myalgia
10 Escalation Sudden onset high fever, haematemesis,
passivity
11 Deterioration Bruising, bleeding from mouth, nose and
rectum, signs of brain damage
12 Conclusion Internal bleeding, fits, loss of
consciousness, death

7. Laboratory confirmation
• WHO risk group 4 status requires all work on live Ebola virus to
be performed under high level containment
• Inactivation and extraction of EBOV RNA allows subsequent
laboratory work to be performed safely.
• Specialist laboratory services are required to confirm EVD by
detection of EBOV RNA (PCR), antigens or live virus in tissue
culture
• 18 laboratories currently provide confirmation of EVD in the
three countries with continuing high level transmission, all
within 24hr of sample collection. 3 additional labs are pending,
with an aim for same-day confirmation to support faster contact
tracing and disease control.

8. Clinical management
• As no antiviral agent or vaccine had been licensed for EVD prior to the
current emergency, specific treatment options are still under investigation.
• Experimental drugs and blood product transfusion from recovered
patients are under trial.
• The mainstay of clinical care for infected patients is supportive care,
particularly intravenous fluid replacement and organ system support.
• Clinical staff are at potential risk of secondary infection (see virus
transmission, above) and require personal protective equipment to ensure
comprehensive contact precautions are followed.

9. PPE
• The Centers for Disease Control now recommend complete
body surface covering with personal protective equipment
when caring for patients with EVD
• This includes all of:
– protective face mask, plus goggle or visor
– suit with hood, or high neck gown plus balaclava hood
– Protective leggings
– Double overshoes
– Double gloves
• For front-line care of high risk patients, waterproof aprons, positive
pressure hoods and heavy duty outer gloves are preferred
• All PPE use should be restricted to trained operators, working under direct
supervision and with access to decontamination support / contaminated
waste disposal during PPE removal

10. International response to Ebola epidemic
Treatment centres already open (green) are either close to the rural communities
where the epidemic started, or in major cities. Those under construction (orange) are
near the West African coast, while planned centres (grey) push along the coastal strip
and further inland. [Information source: BBC. 10-OCT-14, based on national
government, WHO & USAID data].

11. Origins of the 2014 epidemic
First reports of Ebola Virus Disease came from four rural districts in the southeast of Guinea
in March 2014.

12. International spread
Shortly afterwards suspected cases were identified in Sierra Leone and Mali, but were
not confirmed by the teams sent to assist. However, new cases were reported from two
rural districts in northeastern Liberia, bordering on Guinea.

13. Further local spread
Additional cases began to appear in Guinea’s capital, Conakry, followed by Monrovia in
Liberia. Westward spread extended to Sierra Leone, and eventually to the capital, Freetown.

14. Virus transmission
The Centers for Disease Control and Prevention
list three route of Ebola virus transmission:
1. Direct contact with human body fluids from people with
infection: blood, faeces, urine, vomit and other
secretions
2. Contact with contaminated medical products such as
syringe needles
3. Consumption of wild animal meat (“bushmeat”)

15. The Ebolavirus
Drawn from micrograph of the first Ebola virus isolated from a human patient in Vero cell cultures in
1976. Magnification, approx. x 40,000. Virions are fused end-to-end and resemble spaghetti. The
appearance varies considerably. Source of electron micrograph: F.A. Murphy, School of Veterinary
Medicine, University of California, Davis.
The current epidemic is due to an Ebola virus (EBOV) strain belonging to the Zaire clade. Ebolaviruses are
filoviridae, so called because of their tubular or cylindrical virus particles of 80nm diameter and up to
1000nm long. EBOV is a negative sense, RNA virus with a matrix, nucleocapsid and envelope. The
envelope comprises a lipid bilayer from which glycoprotein spikes project. The Zaire lineage is the most
virulent of the Ebolaviruses. Ebola virus is a WHO Risk Group 4 pathogen.

16. Cellular pathogenesis of Ebolavirus disease
Redrawn from original to show how cellular response to Ebolavirus leads
to clinical outcomes [Mohamadzadeh et al. Nature Reviews Immunology
(2007) 7, 556-567]

17. Risk management
• Inward travel to West Africa: is your journey really necessary? If so, check
your travel insurance covers medical evacuation under quarantine
conditions, and be prepared for major travel disruption.
• Outward travel from West Africa: is your journey really necessary? Public
health authorities have closed some international borders and will be
applying rigorous checks along your route. Any contact with known or
suspected cases of Ebola Virus Disease should not travel away from home
during the quarantine period of 21 days.
• Health workers travelling to assist: detailed advice on personal protection
is available from the CDC, the WHO, public health authorities in country,
and experienced NGOs such as MSF.

18. Key points
• Ebola haemorrhagic fever is now called Ebolavirus Disease (EVD)
• Transmission is by direct contact with patients or their body fluids,
contaminated medical products, or bushmeat.
• EVD is fatal in up to 90% cases; around 60% in the current epidemic. This
figure will alter when the epidemic stats to falter.
• Experimental antiviral treatment (Zmapp & TKM-Ebola) and vaccine
candidates are under investigation.
• Although cases of EVD have been managed outside Africa during this
epidemic in the USA and Spain, no further transmission has occurred
outside hospital in these locations to date.
• The international response aims to meet the diagnosis, treatment and
infection control demands of the West African Ebola epidemic but is still
short of its objectives in high transmission locations.