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triad
Department of Community Medicine, North DMC Medical College, Hindu Rao Hospital, Delhi, India
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
Problem Statement
The first outbreak occurred in Zaire (Congo) in 1976
followed by several outbreaks within Africa (except one
slightly less (61%) in hospitalized patients.[5,6] Globally remained restricted to a limited area [Table 1]. The rising
there were a total of 28,639 reported confirmed, probable trend of EVD outbreaks have occurred due to increased
and suspect cases of EVD in affected countries with 11,316 movement of people into previously inaccessible areas
deaths (Feb 2016) with a similar proportion in males and increased consumption of bush meat.[9] Figure 2
and females. As per WHO notification, human to human depicts Ebola outbreak (cases and death) in the African
transmission ended in Sierra Leone (Nov 2015); Guinea continent according to the years. The roots of current
(Dec 2015) and Liberia (Jan 2016). These countries have outbreak emanated somewhere during December 2013
entered into a 90days period of enhanced surveillance but it is not known with certainty how the index case
adults aged 1544 years are three to four times more became infected. [10] Genetic similarities among the
likely to be affected than children aged less than 14 years. samples of current outbreak suggest a single event of
A total of 874 confirmed health worker infections and 509 virus transmission from the natural reservoir followed by
deaths were reported in the abovementioned countries.[7] sustained humantohuman transmission.[11]
animal reservoir. Ebola viruses enter the human body via convert the virus from the enzootic cycle to the epizootic
mucosal surfaces, abrasions, and injuries in the skin or by cycle of transmission [Figure 3].
direct parental transmission. It is likely that for the index
case, infection occurs after human contact with primates, for Clinical Features
example, due to hunting or consumption of infected animals
while other mammals such as antelopes and rodents have The symptoms of EVD begin with fever, headache, fatigue,
also been mentioned as potential reservoirs.[34] Due to the sore throat, and muscle pain, which later progress to anorexia,
high viral loads seen in the body fluids of EVD patients, nausea, diarrhea, vomiting, rash, abdominal pain, cough,
humantohuman transmission can easily occur. This shortness of breath, postural hypotension, edema, headache,
transmission seems to take place through body fluid contact
confusion, and coma. In certain cases, a maculopapular rash
and not by airborne transmission (e.g., infective aerosols).
develops after 57 days of the symptoms.[37,38] Hemorrhagic
When hygiene and personal protective measures are not
complications such as mucosal hemorrhages, nose bleeding,
adequate, the risk is considerable.[35] Furthermore, cultural
vomiting/coughing up of blood, blood in the stool, petechiae,
aspects such as local funeral ceremonies with potential
ecchymoses, and uncontrollable bleeding from venipuncture
contact with body fluids from patients who have died from
sites are seen in severe cases, along with other features such
EVD contributed to the magnitude of this outbreak.[36]
as severe metabolic disturbances, convulsion, shock, and
Sylvatic Ebola fever multiple organ failure. These complications are the most
In the tropical rainforests, Ebola occurs in monkeys and common causes of death in EBVinfected patients.[39] Figure 4
chimpanzees that consume halfeaten fruits left over by depicts the usual progression of EBV in humans.
fruit bats. These infected monkeys then pass the virus to
other monkeys by coming in contact of the body fluids Laboratory Diagnosis
of infected monkeys, chimpanzees, or pigs, etc. Humans
entering the forest come in contact with these infected Pathogenesis
monkeys or pigs due to hunting, bush meat preparation, Ebola after enters the body at the cellular level docks
and logging of woods; thus, humans enter the cycle and with the cell membrane and then viral RNA is released
into the cytoplasm leading to the production of new viral After 3 days of the symptoms, the Ebola virus usually
proteins. New viral genomes rapidly coated in protein reaches detectable levels in blood and cannot be ruled
create cores, viral cores, stack up in cell, migrate to the out earlier than 3 days by any test. Even during the
cell surface and produce transmembrane proteins, then convalescent stage, the virus can be isolated from the
push through cell surface and become enveloped by cell blood, semen, tears, urine, feces, vaginal secretions,
membrane ssRNA genome mutations, which are capable and milk [Figure 5]. IgM enzymelinked ELISA,
of rapid mutation, very adaptable in evading host antigencapture ELISA, PCR, and virus isolation are the
defenses and environmental change, can cause direct diagnostic tests available and IgM and IgG antibodies
infection of tissues, immune dysregulation, hypovolemia, are used later in the disease course for the diagnosis of
vascular collapse, electrolyte abnormalities, multiorgan Ebola [Table 2].
failure, septic shock, disseminated intravascular
coagulation (DIC), and coagulopathy. Laboratory findings in EVD include coagulation
derangements such as prothrombin time (PT) and
Virus isolation and serology prolonged prothrombin time (PTT) prolonged,
It is difficult to diagnose Ebola virus in the early stages due a nd l e u k o p e ni a f o l l ow e d by n e u t r o p h i l i a ,
to nonspecific symptoms, which coexist in patients who thrombocytopenia (50,000100,000/mL range), and
are suffering from common diseases such as malaria and elevated liver enzyme: Elevation serum aspartate
typhoid fever. Seroconversion of the EVD can be detected aminotransferase (AST) > alanine transferase (ALT)
in the blood only when patient symptoms suggest a high and renal defects that include proteinuria and increased
level of virus load inside the body. This requires 3 days creatinine. Early and wellregulated inflammatory
in order to reach for viral detectable levels. Laboratory response with elevated interlukin (IL)6 concentration
test conducted in diagnosis such as antigencapture and IL1beta presence in a symptomatic patient is
enzymelinked immunosorbent assay (ELISA) testing, indicative of a good outcome while a defective innate
immunoglobin M (IgM) ELISA, and polymerase chain immune reaction with excessive macrophage/monocyte
reaction (PCR) using specific primers are used within a few activation with release of interleukin10, absent antibody
days of the onset of symptoms.[40] Immunohistochemistry response and elevated concentration of interleukin1RA,
testing, PCR, and virus isolation could be tested [Table 2]. and neopterin after a few days of the onset of disease
A team of international scientists under Cambridge are associated with a fatal outcome.[42] According to a
University released a dataset in 2015 that allows the study, lymphoid depletion and lymphopenia associated
global scientific community to monitor the pathogens with Zaire Ebola virus was most likely due to lymphocyte
evolution on a realtime basis. Sequencing the genome of apoptosis via Fas/Fas ligand (FasL) interaction. The
a virus tells us how it spreads and changes while passing excessive macrophage/monocyte activation leads to a
from one person to another. Rapid sequencing (in a matter cytokine storm triggering disseminated intravascular
of days) enables epidemiologists to decipher the source coagulation, hypotension, and vascular dysfunction,
of individual strains and helps to eliminate the need to resulting in multiple organ failure, vascular collapse,
rely upon Ebola patients to detail their travel history as and shock. [43] According to a recent study, elevated
different strains can be tracked without difficulty.[41] thrombomodulin and ferritin levels have been associated
with the death and hemorrhage in Ebola virusinfected
patients.[44]
Figure 4: Clinical feature of EBV in humans as observed in Figure 5: Detection of virus from different body fluids during
2014 outbreak the acute and convalescent phases
Plans for emergency care including adequate Table 3: Public health monitoring and movement/restriction
quarantine facilities of people with EBV according to risk exposure
Prompt diagnosis and isolation of the suspected Risk Public health action
patient level Monitoring Restricted Restricted
Symptomatic management public activities travel
Adequate laboratory facilities and support High risk Direct active monitoring Yes Yes
Proper surveillance, case management, and contact Some Direct active monitoring Casebycase Casebycase
tracing risk assessment assessment
Health education and removal of stigma/myth/ Low risk Active monitoring for No No
misconception some; direct active
Restriction of the movement of people suffering from monitoring for others
EBV No risk No No No
Training of health care providers EBV=Ebola virus
Is India safe from EBV? But this does not rule out India to be safe from Ebola as
The current situation is unlikely to favor establishment it can be imported through any case/incubating Ebola
of EBV in India because of the following: traveler visiting India. The Government of India has issued
Bats: Absence of Pteropiridae family bats in India;
standard operating guidelines for the surveillance, control,
febrile immune response of bats resulting in
and management of EBV disease in accordance with the
attenuation of viral load; and localized flight range
of bats in the African subcontinent WHO protocols. India has health organization quarantine
Environment: Absence of high absolute humidity centers at 24 airports with all international airports and
and low temperature, along with rains for the sea ports to be equipped with thermal scanners in the
breeding of Ebola virus near future. The government has identified about 10
Virus: Absence of virus in the Indian subcontinent. laboratories in the country that will handle testing if a
Surveillance at major international airports, case is reported and in New Delhi, Dr. Ram Manohar
especially during the risk period. Lohia Hospital has been designated as nodal hospital
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