Symposium article

Journal of International Medicine and Dentistry 2014; 1 (2): 48-58

JOURNAL OF INTERNATIONAL MEDICINE AND DENTISTRY

To search……………..to know………..…….to share ISSN No. 2350-045X

Ebola virus disease: Getting to know a new emerging foe!

Structural features, Pathogenesis and Laboratory Diagnosis: Shrikala Baliga1 (S.B.)

Clinical features, Treatment, Other aspects: Shalini M2 (S.M.)

Epidemiology, Prevention and Control: Prasanna Mithra P3, B. Unnikrishnan4,

Rekha T3 (P.M.P., B.U., R.T.)

1
Professor and Head, Department of Microbiology, Kasturba Medical College
(Manipal University), Mangalore- 575001.
2
Professor and Head, Department of General Medicine, Shridevi Institute of Medical
Sciences and Research Hospital, Tumkur- 572106.
3
Associate Professor, Department of Community Medicine, Kasturba Medical College,
(Manipal University), Mangalore- 575001.
4
Professor and Head, Department of Community Medicine, Kasturba Medical College
(Manipal University), Mangalore- 575001.

Abstract:
Viral hemorrhagic fevers have been at the top of the severity scale in terms of morbidity and
mortality among human beings. Many of the viruses have their reservoirs in animal kingdom and
from time to time they get introduced to humans and cause sporadic outbreaks and epidemics.
Thousands of people from the Western African region have already succumbed to the complications
due to Ebola virus infection.
The South East Asian region including India has been affected by several outbreaks of
communicable diseases like SARS, bird flu, swine flu etc. The current outbreak has been a global
concern due to its spread beyond the African continent. WHO has declared EVD as an
international health emergency and worldwide efforts have been enhanced to escalate research to
find a vaccine or cure for the disease.

Key words: Ebola Virus, WHO, Africa, Fruit bats, Wild animals, South Asia, Haemorrhage
Symposium: Ebola virus disease www.jimd.in

Introduction: number of their citizens. Examples include

Among all the tropical diseases, viral SARS, bird flu, swine flu etc. The current
hemorrhagic fevers have been at the top outbreak has been a global concern due to
of the severity scale in terms of its spread beyond the African continent
morbidity and mortality among human and few confirmed cases from United
beings. Many of the viruses have their States of America.
reservoirs in animal kingdom and from The sparse knowledge regarding the
time to time they get introduced to virulence factors and host responses have
humans and cause sporadic outbreaks hampered the development of treatment
and epidemics.1,2,3 Among the viral modalities and vaccine against Ebola Virus
hemorrhagic fevers, Ebola virus poses Disease (EVD). WHO has declared EVD
severe challenges to the health systems as an international health emergency and
of many countries, especially those of worldwide efforts have been enhanced to
the developing countries.1 Thousands of escalate research to find a vaccine or cure
people from the Western African region for the disease.
have already succumbed to the
complications due to Ebola virus Structural features and
infection.4 This can also spread to Pathogenesis: (S.B)
various countries across the borders in
addition to the country of origin.1, 2 Ebola and Marburg viruses are the only
In 1976, Ebola virus disease (EVD) members of family Filoviridae in the order
made its first appearance in the villages Mononegavirales8. Filoviruses are linear,
near Ebola River, in Democratic enveloped, non-segmented and single
Republic of Congo (due to which the stranded , negative sense RNA viruses.
disease got the name Ebola) and Sudan. Ebola virus has a diameter of 80 nm but
The current West African outbreak the length varies upto 14000nm assuming
(2014) is the largest in history in terms a shape of ‘6’ or hairpin. It has seven
of numbers and mortality. It has also genes which code for the various viral
spread to several countries starting in proteins- VP 34, VP30, VP24, VP 40,
Guinea then spreading to Sierra Leone RNA dependent RNA polymerase,
& Liberia and then by air to Nigeria, by glycoprotein and nucleoprotein (Figure I
9
land to Senegal.3,4,5 These countries do ). All are monocistronic i.e. code for one
not have a health system which is ready single protein except the gene coding for
to tackle this burden due the lack of glycoprotein which codes for two proteins-
human and infrastructural resources, GPI and GPII, both linked with disulphide
and these countries have just come out bonds. The ribonucleoprotein complex
of long periods of political unrest. The consists of the RNA genome surrounded
current African case toll has crossed by the nucleoprotein.
fourteen thousand.7 Outbreaks are also Pathogenesis:
reported from Boende, Equateur, and Ebola virus disease is considered to be a
an isolated part of the Democratic classic zoonosis with persistence in a
Republic of Congo, which were not reservoir which is present in the endemic
linked to the original West African areas. . In Africa, a particular variety of
outbreaks. 3,6,7 fruit bat is considered the reservoir of
The South East Asian region including infection for Zaire Ebola virus. Detection
India has been affected by several of virus RNA and antibodies have been
outbreaks of communicable diseases in the found in three species of tree roosting
recent past, wherein several countries bats- Hypsignathus monstrosus, Epomops
witnessed the morbidity and deaths of high franqueti, and Myonycteris torquata.10

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Journal of International Medicine and Dentistry 2014; 1 (2): 48-58
Symposium: Ebola virus disease www.jimd.in

Figure I: Structure of Ebola virus9

However, no reservoirs have been found sites. After infecting these cells, infection
for the other three African Ebola viruses. spreads to the regional lymph nodes
Apes, humans and other mammalian hosts through the lymphatics and to the liver and
are susceptible to infection and are spleen through the blood. From these
considered end hosts. Bats are thought to organs, the monocytes and macrophages
directly transmit the infection to humans or migrate out and infect other organs and
indirectly by infecting other susceptible tissues disseminating the infection.
animals which are hunted for meat1, 4 . Ebola virus is taken up into the endosome,
Human to human infection is through close where they are exposed to a low-pH
contact. environment. Two endosomal proteases
The possible mode of infection include cathepsin B and cathepsin L can
close contact with blood, secretions, body individually cleave Ebola virus GP1 to
fluids or organs of infected and dead yield an approximately 18-kD N-terminal
animals, consumption of bush meat from fragment, which is further digested by
infected animals, touching objects that cathepsin B. leaving only GP2. This causes
have come in contact with the virus and fusion between the viral envelope and the
parenteral transmission. Reuse of needles endosomal membrane leading to the
played an important part in the release of the viral genome into the
transmission of infection in the 1976 cytoplasm11.
outbreak of Zaire and Sudan Ebola virus. Though Ebola virus can infect the
The virus gains entry through the mucous endothelial cells, the damage resulting in
membranes and abrasions in skin. There is haemorrhages has been attributed to the
no airborne transmission. hepatocellular necrosis resulting in
Ebola has a broad cell tropism and infects decreased synthesis of coagulation and
a wide range of cells8. They infect plasma proteins. Due to infection of the
monocytes, macrophages, dendritic cells, adrenal cortex, there is impaired secretion
fibroblasts, hepatic cells, adrenal cortical of enzymes that synthesize steroids leading
cells and endothelial cells, though to hypotension and sodium loss with
monocytes, macrophages and dendritic hypovolemia , both leading to shock, a
cells are the early and preferred replication feature commonly seen in end stage Ebola

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Journal of International Medicine and Dentistry 2014; 1 (2): 48-58
Symposium: Ebola virus disease www.jimd.in

virus hemorrhagic fever8. Although include petechiae, ecchymoses,

lymphocytes are not infected by Ebola uncontrolled oozing from venepuncture
virus there is large scale depletion in the sites, mucosal haemorrhages and post-
spleen, thymus and lymph nodes of mortem evidence of visceral haemorrhagic
infected patients. This is mainly due to effusions.
apoptosis which is triggered by the A maculopapular rash associated with
abberant release of inflammatory varying severity of erythema and
mediators and cytokines like interleukin- desquamation can often be noted by day 5-
1b (IL-1b), tumour necrosis factor-a 7 of illness. This symptom is a valuable
(TNFa), IL-6, IL-15, IL-16, IL-1 receptor differential diagnostic feature and is
antagonist, IL-10, NO-, IL-8, by the usually followed by desquamation in
infected macrophages and monocytes- the survivors.
so called ‘Cytokine Storm’. The TNF and Initial evaluation 13
NO- are also responsible for the increasing Clinical criteria: fever > 38.6○ C [> 101.5○
endothelial permeability, decreased F] with additional symptoms listed above.
vascular tone and disseminate Epidemiological risk factors:
intravascular coagulation10. The various • Contact within previous 3 weeks with
viral proteins especially VP35 cause blood or other body fluids of patient
inhibition of type I IFN response which is with known or suspected EVD.
crucial for the Ebola virus survival. • Residence in or travel to area with
active EVD transmission.
Clinical features: (S.M.) • Participation in funeral and burial
rituals in disease endemic areas.
Ebola virus disease (EVD) is a public
• Direct handling of bats, rodents, or
health emergency of international concern
primates from disease endemic areas.
and the outcome is frequently fatal.
Use personal protective equipment to
The incubation period, i.e. the time
interval from infection caused by the virus examine patients with suspected
to the onset of symptoms is 2-21 days. infections.
Humans are not infectious until they Isolate patients immediately to prevent
develop symptoms. 12 transmission.
Symptoms: 8, 13 Physical examination: 14
Non-specific symptoms – abrupt onset of Body temperature – temperature of 39○C-
fever, chills, malaise followed by anorexia, 40○C early in the disease course is
headache, myalgia, arthralgia, sore throat. frequently observed. Wide swings in body
Gastrointestinal symptoms – Nausea, temperature during the course of the
vomiting, epigastric and abdominal pain illness, with drops below normal have
and diarrhoea occurs in first few days. been described.
Respiratory symptoms – chest pain, Blood pressure – initially the
shortness of breath, cough, nasal haemodynamic parameters may be normal.
discharge. Fatally infected patients are known to
Vascular symptoms – conjunctival proceed through hypotension and shock to
injection, symptoms of postural death.
hypotension and oedema. Pulse – it has been noted that relative
Neurological symptoms – headache, bradycardia is a common finding. As the
confusion and coma. disease progresses, in fatal cases there
could be severe tachycardia.
Haemorrhagic manifestations –
Respiratory rate – it increases in fatal
haemorrhage seen in about 50% of the
disease.
patients arise during the peak of illness and

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Journal of International Medicine and Dentistry 2014; 1 (2): 48-58
Symposium: Ebola virus disease www.jimd.in

Rash – in a number of outbreak reports, subjected to a laboratory investigation for

rash was seen in 25%-52% of individuals. Ebola virus infection16. A case under
It is frequently described as being non- investigation is defined as any person who
pruritic, erythematous, and maculopapular, has travelled to or stayed in a country that
sometimes beginning focally, and then has reported at least one confirmed case of
becoming diffuse, generalised and EVD, within a period of 21 days before the
confluent. onset of symptoms, and who presents with
Haemorrhage – patients often develop sudden onset of high fever and at least
multiple foci of mucosal hemorrhage, most three of the following symptoms:
evident in the conjunctiva, together with headache, vomiting, diarrhoea,
easy bruising and persistent bleeding from anorexia/loss of appetite, lethargy,
injection or venipuncture sites. However, stomach pain, aching muscles or joints,
hemorrhage is not seen in all patients, and difficulty swallowing, breathing
massive bleeding is usually observed only difficulties, hiccup or inexplicable
in fatal cases when it is typically localized bleeding/haemorrhaging or who died
to the gastrointestinal tract. Intracranial suddenly and inexplicably17.
haemorrhage has been described. Specimens for molecular detection should
Other findings – there could be pharyngeal ideally be taken when a patient exhibits
erythema with a complaint of sore throat, symptoms that meet the case definition of
enlarged lymph nodes and tender EVD. Specimens should be collected with
hepatomegaly. strict infection prevention and control
Course of the disease: measures adhered to throughout the
Non-fatal cases may improve around day process, including waste disposal and
6-11. 13 In few patients, convalescence is disinfection.
extended and often associated with If specimens are collected less than 3 days
sequelae such as myelitis, recurrent after onset of symptoms, additional
hepatitis, psychosis or uveitis. Pregnant specimens will be needed if the test result
women have an increased risk of on the first specimen is negative. The
miscarriage, and clinical findings suggest a second specimen should be collected at
high death rate for children of infected least 48 hours after the first specimen.
mothers as the transmission could be Whole blood for serological testing can be
through breast feeding or through close collected after 8 days of onset of
contact 14. symptoms (Figure II 18).
Patients with fatal disease develop clinical At least 4 ml whole blood EDTA is
signs early during infection and die collected for RT-PCR, while for
typically between day 6 and 16 with serological tests clotted blood is the ideal
hypovolemic shock and multi-organ failure specimen. Samples can be stored at room
8 temperature for up to 24 hours, 0-5°C for
.
Differential diagnosis 15 one week and at -70 °C for long-term
storage. They should be shipped on dry ice
Malaria, Typhoid fever, Shigellosis, if the specimen is referred to a WHO
Cholera, Leptospirosis, Plague, Collaborating Centre.
Rickettsiosis, Relapsing Fever, Meningitis, The various tests available (Table I) for
Hepatitis and other viral haemorrhagic Ebola virus disease are: RT-PCR, Antigen
fevers. capture ELISA, IgM and IgG antibody
detection, virus isolation,
Laboratory diagnosis: (S.B) immunohistochemistry
Any person who fits the definition of a
case under investigation should be

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Journal of International Medicine and Dentistry 2014; 1 (2): 48-58
Symposium: Ebola virus disease www.jimd.in

Table I: Laboratory tests for Ebola virus disease diagnosis

Investigation Specimen When after Adv/ Disadv Biosafety Level

onset of
symptoms

RT-PCR 4 ml EDTA 3-16 days Most sensitive, BSL 3 for non-inactivated

blood should be performed specimen
in WHO BSL 2 for inactivated
specimen(inactivated with
Guanidine Isothiacyanite)

Antigen Serum 3-16 days Seen early in disease BSL 3 for non-inactivated
detection sample and indicates acute specimen
infection BSL 2 for inactivated
specimen (inactivated with
gamma radiation)

IgM ELISA Serum, 2-30 to168 Monitors immune BSL 3 for non-inactivated
blood, days response in specimen
tissues confirmed EVD BSL 2 for inactivated
cases, IgM indicates specimen (inactivated with
presumptive gamma radiation)
diagnosis

IgG ELISA Serum, 6/8 days- Monitors immune BSL 3 for non-inactivated
Blood, many years response in specimen
Tissues confirmed EVD BSL 2 for inactivated
cases,A rise in titre specimen(inactivated with
indicates a gamma radiation)
presumptive
diagnosis

Virus Tissues, Can take several BSL 4

Isolation Blood days

Immunohisto Tissues, Used for BSL 3

chemistry dead wild retrospective
animals diagnosis,
localises viral
antigen

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Journal of International Medicine and Dentistry 2014; 1 (2): 48-58
Symposium: Ebola virus disease www.jimd.in

Figure II: Expected diagnostic test result18

stool, sputum and blood along with any

Treatment: (S.M.) objects that have come in contact with the
patient or the patient’s body fluids (such as
Patient management: 19 laboratory equipment), should be
1. Currently, no specific therapy is disinfected with a 0.5% sodium
available that has demonstrated efficacy in hypochlorite solution.
the treatment of EVD. In the absence of 5. Steroid therapy has no role.
specific therapy, a number of modalities 6. There is no role for antibiotics unless
have been tried/ experimented. None of there is evidence of secondary bacterial
them have been scientifically validated. infection.
2. General medical support is critical. Such Supportive Care:
care must be administered with strict 1. Supportive therapy with attention to
attention to barrier isolation. All body intravascular volume, electrolytes,
fluids (blood, saliva, urine, and stool) nutrition and comfort care is of benefit to
contain infectious virions and should be the patient. Intravascular volume
handled with great care. replenishment is one of the most important
3. Surgical intervention generally follows a supportive measures.
mistaken diagnosis in which Ebola 2. For high grade fever, patient should be
associated abdominal signs are mistaken treated with only Paracetamol. No other
for a surgical abdominal emergency. analgesic, antipyretic and in particular
Such a mistake may be fatal for the patient Aspirin should be given in this case as
and for any surgical team members, who these drugs may increase chances of
become contaminated with the patient’s bleeding. Tepid sponging should be done
blood. repeatedly to bring down the temperature
4. Survivors can produce infectious virions immediately in case of high grade fever.
for prolonged periods. Therefore, strict 3. Due to repeated vomiting and diarrhoea
barrier isolation in a private room away patient may present with shock and
from traffic patterns must be maintained electrolyte imbalance. Without vomiting
throughout the illness. Patient’s urine, and diarrhoea, patient also may have shock
due to capillary leakage and

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Journal of International Medicine and Dentistry 2014; 1 (2): 48-58
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haemoconcentration may be observed in stopped as these may increase chance of

this case. Plenty of oral fluids may be bleeding.
advised in mild hypotensive cases or those 10. Co-infection with EVD should be
who have no vomiting and diarrhoea. immediately treated with proper
4. There may be transient bone marrow antibiotics. In the early stage, if co-
suppression and patient may present with infection is not treated properly patient
leucopenia and thrombocytopenia for may develop sepsis and septic shock which
which patient may develop bleeding from may lead to fatal outcome.
different sites and may also have Diet and Activity:
superadded infection. Patient should be Nutrition is complicated by the patient’s
transfused with platelets when the count is nausea, vomiting, and diarrhoea. Good
below 20,000 cells/cu.mm or bleeding hydration is to be ensured with good
from any sites irrespective of platelet amount of protein supplements.
count. Recovery:
5. In case of severe shock and vomiting, Recovery often requires months and delays
patient may be treated with intravenous may be expected before full resumption of
fluids with crystalloids or colloids. normal activities. Weight gain and return
Intravenous fluid therapy should be of strength are slow. Ebola virus continues
carefully monitored to avoid fluid overload to be present for many weeks after
as most of the deaths are associated with it resolution of the clinical illness. Semen
due to rapid correction of fluid in severe from men recovering from Ebola infection
shock. Blood transfusion may be required has been shown to contain infectious virus
in those who have severe gastrointestinal and Ebola has been transmitted by sexual
bleeding and shock. Management should intercourse involving recovering men and
include replacement of coagulation factors their sex partners. Any individuals who
and heparin if disseminated intravascular were exposed to infected patients should
coagulation develops. be watched closely for signs of early Ebola
6. Patient may present with different organ virus disease.
involvement commonly liver and kidney.
Patient may present with jaundice due to Other aspects:
liver impairment and acute renal failure
due to acute tubular necrosis in case of Disposal of Dead Body
profound shock or direct renal Safe disposal of dead body must be done
involvement by Ebola virus. Patient may with proper precautions for prevention of
require dialysis in severe case of renal transmission of EVD. Ebola virus is
failure. present in almost all kinds of body fluids
7. Patient should be carefully managed by like blood, saliva, urine, vomit, stool, nasal
gastroenterologist in case of severe liver secretion, gastrointestinal secretion.
dysfunction. Therefore, it is mandatory that one should
8. Patient may require ICU support for not come in contact with these kinds of
breathlessness due to lung involvement or potentially infectious material. Relatives
critical condition. should be counselled properly regarding
9. High morbidity and mortality is the mode of transmission of EVD and to
associated with different co-morbid adopt safe practices for the disposal of
illnesses; therefore, EVD should be dead bodies. Ritual activities after death
carefully treated in patients of should be strictly avoided. Those persons
hypertension, diabetes, coronary artery who are dealing with the disposal of dead
diseases and pregnancy. In particular, in bodies require proper protection for
those patients who are on anti-platelet prevention of transmission of Ebola virus.
therapy, drugs should be temporarily Dead body should be packed with

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Journal of International Medicine and Dentistry 2014; 1 (2): 48-58
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impermeable leak proof body bags for safe with the blood, organs or other bodily
disposal and to prevent contamination. fluids of infected people, and with
contaminated surfaces and materials (e.g.
Epidemiology (P.M.P., B.U., R.T.) bedding, clothing). Also, health-care
workers carry the risk of infection while
Agent factors: treating patients with suspected or
Ebola viruses are part of the family confirmed EVD, especially when infection
Filoviridae, which have filamentous control precautions are not strictly
structures. Family also includes Lassa practised.3 Because the natural reservoir
fever and Marburg Viruses. Their genetic host of Ebola viruses has not yet been
material is a single-stranded non- confirmed, the mechanism by which the
segmented RNA. So far five species of virus first appears in a human outbreak is
Ebola Virus have been identified: Zaire, not completely understood. However,
Sudan, Ivory Coast, Bundibugyo and previous research findings suggest that the
Reston, based on the predominant first patient becomes infected through
geographical area they affect.6 Of these, contact with an infected animal.4
Reston species are not known to cause In Africa, Ebola is believed to spread as a
disease among humans. The main result of handling bush meat (meat of wild
reservoirs for Ebola virus are fruit bats, animals for eating purpose) and contact
which act as subclinical carriers of Ebola with infected bats. So far there is no
virus.1,2 They can survive for many weeks evidence of vectors like mosquitoes
outside the human body, especially on the involving in the transmission.4 During
contaminated surfaces. outbreaks of Ebola, healthcare settings like
Host factors: clinics, laboratories and hospitals also get
There is no particular preponderance for involved and witness faster spread of the
the virus towards a particular age group virus. Whenever staff in such health care
and no gender differences. settings do not use appropriate protective
Environmental factors: equipments like masks, gowns, gloves and
In the transmission of Ebola infection, goggles, chances of exposure to Ebola
many factors work in combination like increase manifolds.1,4
fruit production by different trees,
behaviour of the animals, drought and Prevention and control (P.M.P., B.U.,
rainfall, in addition to the several unknown R.T.)
environmental factors. The presence of
infected body fluids in the environment In health-care settings:
during different occasions can present a Whenever providing patient care, it is
potential risk for indirect transmission of preferable to use disposable equipments
the virus.20 and/or instruments, by the healthcare
Transmission: personnel. If instruments and equipments
The most common speculation by several are not disposable, they must be sterilized
studies is that fruit bats of Pteropodidae before using them again.4 In addition to
family are the natural hosts of Ebola this; during the times of outbreak,
Viruses. Human beings acquire Ebola healthcare workers should always follow
infection by close contact with the blood, standard precautions regarding hand
bodily secretions and organs of the hygiene, respiratory hygiene, using
infected animals such as monkeys, fruit personal protective equipment, safe
bats found ill or dead. 3 Later on, Ebola injection practices. 4,5 Laboratory samples
marks its way through human-to-human taken for investigation of Ebola infection
transmission occurring via direct contact should only be handled by the trained staff
(e.g. broken skin or mucous membranes) in suitably equipped laboratories.
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Journal of International Medicine and Dentistry 2014; 1 (2): 48-58
Symposium: Ebola virus disease www.jimd.in

Laboratory personnel should apply extra 2. Jeffs B. A clinical guide to viral

infection control measures to prevent haemorrhagic fevers: Ebola, Marburg and
contact with the patient’s body fluids and Lassa. Trop Doct 2006; 36(1):1–4.
any contaminated articles or surfaces. 3, 4, 5 3. Takada A, Kawaoka Y. The
In the community: pathogenesis of Ebola hemorrhagic fever.
Creating and improving awareness about Trends Microbiol 2001; 9(10): 506-11.
risk factors for Ebola infection and 4. Epidemiology of Haemorrhagic viral
protective measures is an effective way to diseases and their control measures.
reduce transmission in the community. Available at URL http://www.who.int
Gloves and appropriate personal protective (Accessed on 12-11-2014)
equipment should be worn when taking 5. Preventive and control measures of
care of ill patients at home. Regular hand Ebola. Available at URL
washing is required during the care of http://www.cdc.gov/vhf/ebola/index.html
patients at home. 2,3 People who have (Accessed on 13-11-2014).
recovered from the disease can still 6. The clinical and epidemiological
transmit the virus through their body fluids characteristics of Ebola Haemorrhagic
for up to 7 weeks after recovery.3 After Fever. Available from URL
this period, they can no longer spread the http://www.phac-aspc.gc.ca/lab-
virus.4 Burial ceremonies in which bio/res/psds-ftss/ebola-eng.php#footnote2
mourners have direct contact with the body (Accessed on 13-11-2014).
of the deceased person can also play a role
7. The West African updates and latest
in the transmission of Ebola. 20, 21, 22, 23
trends in Ebola Virus infection. Available
Thus the contagious nature of the Ebola
from URL
virus and the presence of the susceptible
http://www.cdc.gov/vhf/ebola/outbreaks/2
individuals along with the suitable
014-west-africa/case-counts.html
environmental conditions make way for
(Accessed on 13-11-2014)
the high possibility of a pandemic of Ebola
8. Feldmann H, Geisbert TW. Ebola
virus. This can even include regions like
Haemorrhagic Fever. Lancet 2011;
South Asia and Europe which have not
377(9768): 849–862.
reported cases yet.24 But readiness of the
9. ViralZone: a knowledge resource to
healthcare system cannot be over
understand virus diversity.
emphasized. Approaches to curtail the
(http://www.ncbi.nlm.nih.gov/pubmed?ter
Ebola virus spread should be multipronged
m=20947564) Hulo C, de Castro E,
i.e. at healthcare setting, community and
Masson P, Bougueleret L, Bairoch A,
the travel population. This should alert the
Xenarios I, Le Mercier. P Nucleic Acids
healthcare systems of all the countries and
Res 2011 Jan; 39(Database issue): D576-
call for the regional as well as global co-
82.
operation between the health systems of
10. Leroy EM, Gonzalez JP, Baize S.
different countries so that the future
Ebola and Marburg haemorrhagic fever
outbreaks of Ebola virus and other
viruses: major scientific advances, but a
hemorrhagic viral fevers can be prevented.
relatively minor public health threat for
This could also be the first step in
Africa. Clin Microbiol Infect 2011; 17(7):
reversing the chances of a pandemic.
964-76.
11. Kawaoka Y. How Ebola Virus Infects
References: cells. N Engl J Med 2005: 352(25); 2645-
2646.
1. Streinu CA. Editorial Ebola virus
12. Centers for Disease Control and
disease – a global threat. Germs 2014;
Prevention [Internet]. Atlanta. 2014.
4(3): 58.
Available from :

57
Journal of International Medicine and Dentistry 2014; 1 (2): 48-58
Symposium: Ebola virus disease www.jimd.in

http://www.cdc.gov/vhf/ebola/symptoms/i 2014. Available from:

ndex.html. http://nicd.nic.in/writereaddata/linkimages/
13. Briand S, Bertherat E, Cox P, clncl_case_mngmnt_ebola2014604494275
Formenty P, Kieny MP, Myhre JK et al. .pdf.
The International Ebola Emergency. N 20. Gonzalez JP, Pourrut X, Leroy E.
Eng J Med 2014; 371(13): 1180-3. Ebolavirus and other filoviruses. Curr Top
14. Kortepeter MG, Bausch DC, Bray M. Microbiol Immunol 2007; 315: 363-87.
Basic Clinical and Laboratory features of 21. Bausch DG, Jeffs B, Sprecher AG,
filoviral hemorrhagic fever. J Infect Dis Boumandouki, P. Treatment of Marburg
2011; 204(3): 810-6. and Ebola haemorrhagic fevers: a strategy
15. WHO/ Ebola Virus Disease: for testing new drugs and vaccines under
background and summary. Geneva. 2014. outbreak conditions. Antiviral Res 2008;
Available from: 78(1):150-61.
http://www.who.int/csr/don/2014_04_ebol 22. Francesconi P, Yoti Z, Declich S,
a/en/ Onek PA, Fabiani M, Olango J, et al.
16. Laboratory Guidance for diagnosis of Ebola Hemorrhagic Fever Transmission
Ebola Virus Disease. Interim Guidelines. and Risk Factors of Contacts, Uganda.
WHO. September 2014. Emerg Infect Dis 2003; 9(11): 1430-37.
WHO/EVD/GUIDANCE/LAB/14.1 23. Ng S, Cowling BJ. Association
17. Ebola surveillance in countries with no between temperature, humidity and
reported cases of Ebola Virus Disease. ebolavirus disease outbreaks in Africa ,
WHO. September 2014. 1976 to 2014. Euro Surveill 2014;19(35):
WHO/EVD/Guidance/SurvNonECount/14. pii= 20892. Available online:
1 http://www.eurosurveillance.org/ViewArti
18. Centers for Disease Control and cle.aspx?ArticleId=20892.
Prevention [Internet]. Atlanta. 2014. 24. Current situation and future threats due
Available from : to Ebola virus. Available from URL
http://www.cdc.gov/vhf/ebola/ppt/ebola- http://www.nhs.uk/conditions/ebola-
101-cdc-slides-for-us-healthcare- virus/pages/ebola-virus.aspx (Accessed on
workers.pptx 13-11-2014).
19. Clinical case management guidelines
of Ebola virus diseases [Internet]. New
Delhi. National Centre for Disease control;

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Conflicts of interest- Nil Date of submission: 20-11-2014
Acknowledgements-Nil Date of acceptance: 20-12-2014

58
Journal of International Medicine and Dentistry 2014; 1 (2): 48-58