Primary Health Care Nursing: Ebola Virus Disease Analysis and Report

This report provides a detailed overview of the Ebola virus disease, encompassing its outbreaks, transmission, and impact on public health. It begins by describing the virus's characteristics, including its genome and replication process, and then delves into the history of outbreaks, notably the lar...Read More

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The recent outbreak of Ebola virus disease spread across countries and caused many
fatalities. The speed of international travel and the risk of unknown transmission of the virus
that could spread through human to human contact brought into focus the need to prevent
outbreaks and the safety measures required to control the spread of the deadly infectious
disease.
The Ebola virus genome is a 19 kb strand of negative sense RNA and has 7 viral
genes (Baron, 1996). Helically arranged viral nucleoproteins envelop the virus and a lipid
bilayer coats the virion. Upon infection, the monocytes, macrophages and the dendritic cells
are the sites where replication of the virus occurs. Infected cells move to the lymph nodes,
spleen and liver and the infection disseminates. The virus can infect a variety of cells and it
can modulate the gene expression of the host immune response cells. This leads to apoptosis
of the lymphocytes and attenuation of the interferons. Expression of pro-inflammatory
cytokines, reduction in number of platelets causes bleeding complications. Kidney injury,
hepatitis and pancreatitis ensue (BMJ, 2017).
Infection from the Ebolavirus first occurred in the year 1976 in what is now Nzara,
South Sudan and in Yumbaku, a village near the Ebola river, in the Democratic Republic of
Congo. 20 other outbreaks have occurred since then. In recent times, the virus affected a
multitude of people in West Africa in a large outbreak from 2014 to 2016 in which several
people lost their lives. The epidemic proved to be complex, it began in Guinea and spread to
the neighbouring countries of Sierra Leone and Liberia. An illness which can often be fatal, it
can kill up to 90% of the people infected (National Academies of Sciences, 2016). In the
2014 to 2016 outbreak 28,646 people were diagnosed with Ebola virus infection and 11,323
deaths were reported, in what was one of the most difficult pandemic to deal with, in recent
times (WHO, 2017).

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Since it was transmitted to the humans through the fruit bat, a loacal delicacy in sub-
Saharan Africa, the Ebola virus disease is a zoonosis and causes high mortality. It is a single
strand RNA virus. Exposure to infection occurs through mucus or ruptured skin. The cause of
the spread of disease are dietary habits, insufficient supply of disposable equipment in
hospitals and funeral rites. The virus remains active in the dead body, so quick disposal of
dead bodies with minimum contact and wearing protecting clothing is important to curb the
transmission of the virus. The infection also spreads through blood, organs, secretions and
body fluids of the infected people. Even the surfaces, clothing and materials contaminated
with infected fluids can cause infection if adequate care while handling is not taken (WHO,
2017). The infection may occur through contact with body fluids of the patient through
mucosal surface, needles contaminated with the virus or abrasions on the skin, putting
healthcare workers at high risk (Lee & Saphire, 2009). Healthcare workers from other
countries who were working in Africa and had come from Spain, The United Kingdom and
the USA were also infected with the virus (Arima & Shimada, 2015). The infection begins
abruptly after an incubation period that varies from 2 days to 21 days. Influenza like
symptoms develop and patients may suffer from shock and multiple organ failure. Symptoms
of the digestive system that cause diarrhoea and vomiting occur commonly. Standard
disinfectants used in hospitals and healthcare facilities can kill the virus (Karwowska, 2015).
It is suspected that morbidity and mortality could be higher because several cases remain
unreported. The genus Ebola has five known species, Bundibugyo, Sudan, Reston, Zaire and
Tai Forest. The Zaire ebolavirus, the Bundibugyo ebolavirus and the Sudan ebolavirus have
caused large outbreaks on the African continent. The latest outbreak from 2014-2016 was
caused by the Zaire virus (WHO, 2017).
The incubation period of Ebola virus after infection occurs and it takes 2 to 21 days
for the first symptoms to appear. Only a person with symptoms can pass on the infection but

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someone who is infected but is not showing symptoms cannot pass on infection to others.
Sudden fever accompanied with considerable fatigue is the first symptom to appear.
Headache, muscle pain and sore throat may often be seen in patients. Vomiting and diarrhea
follow occur and some patients may complain of skin rash. Impairment of the kidney and
liver function are followed by internal and external bleeding. Bleeding of gums and blood in
stools are advanced symptoms and may be observed after a few days. A low white blood cell
count and low platelet count are the usual results of laboratory diagnosis of blood samples.
Liver enzymes remain elevated also (WHO, 2017).
Patients are given supportive care and rehydration with oral or intravenous fluids is
often effective. Treatment is given for specific symptoms that have been observed in the
patient. A proven treatment or drug for the Ebola virus disease is yet to become available.
Several therapies, drugs, blood products and immune therapies are currently being tested and
evaluated for clinical use. An experimental Ebola vaccine has shown promise and has been
found to offer protection from the virus in Guinea. The vaccine known as rVSV-ZEBOV was
tested in a trial involving 11841 people in 2015. 5837 people of those who received the
vaccine, did not return with an Ebola infection for 10 days after the vaccine was administered
whereas, 23 cases were reported from among those who had not received a vaccine. Guinea's
ministry of health, Norwegian Institute of Public Health, Medecins sans Frontieres
collaborated with WHO and other international partners in conducting the trials of the
vaccine. The vaccination protocol adopted was of the ring type and the vaccine was the viral
vector type of vaccine. Some rings were vaccinated after the detection of a case while other
rings received a vaccination after a period of three weeks after detection.
In a study on the rVSV∆G-ZEBOV-GP vaccine, which is a recombinant, vaccine that
is also replication competent the antibody titres persisted upto 360 days. The vaccine is based
on vesicular stomatitis virus glycoprotein which has been replaced by the Zaire Ebola virus

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surface glycoprotein, which has been used as the main antigen for vaccine development
against Ebola. The most important take away from this trial has been the longevity of the
neutralizing antibody response until long after the vaccination was administered to the
participants of the trial. A range of vaccine doses were examined during the study for
immunogenicity. The lower doses of the vaccine also developed neutralising antibody titres
but the response was rather slow and took longer than the higher doses of vaccine. In an
outbreak setting, it would be important to develop immunity from the vaccine in a rapid
manner, so only higher doses were then tested (Clarke & Bradfute, 2017). Even at higher
doses the incidence of arthritis as a side effect of the vaccine was reported at a much lower
rate than with some other Ebola vaccines that were tested earlier. This vaccine was developed
by NewLink Genetics, Merck Vaccines and the Public Health Agency of Canada (WHO,
2015).
Several other vaccines are in various stages of clinical trials. A 2-dose vaccine has
been developed by Johnson & Johnson and Bavarian Nordic. They have used an approach
called heterologous prime-boost. The candidate vaccine that are being tested are Ad26EBOV
and MVA-EBOV. The vaccine had undergone the Phase-I trials in 2015. Anothe r
biotechnology company from the US, Novavax, has developed a recombinant vaccine based
on the Guinea strain of the Ebola virus. The Phase I trials of this vaccine were done in
Australia. A recombinant influenza vaccine candidate against Ebola was developed by the
Russian Federal Ministry of Health. An oral adenovirus platform based vaccine, a vaccine
based on the vesicular stomatitis virus is being tested by the company Profectus Biosciences.
Protein Sciences, has developed an alternative recombinant protein based vaccine. Inovia,a
company workin in the area of vaccine development has developed a DNA vaccine and the
Jefferson University is working on a recombinant rabies vaccine.

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Other approaches for treatment that are being tried include transfusion of
convalescent whole blood and plasma as a largely investigational therapy. This therapy has
been used in several patients with Ebola virus disease. Trials were conducted in Liberia and
Guinea.
An antiviral drug Favipiravir from Fujifilm/Toyama in Japan has been tried on
patients with low to moderate levels of virus under a Phase II trial. The antiviral drug has
been found to be effective in treatment of patients who are suffering from early stage Ebola
virus disease. The case fatality has been estimated to have decreased to 15% from an earlier
30%, but since the trial does not have concurrent controls the WHO is treading with caution
when deciding about its efficacy (WHO, 2015).
Another drug under Phase II trials is TKM-100802 (siRNA) by Tekmira, Canada at
Kerry Town, Sierra Leone. siRNAis a short sequence of RNA that has the potential to cleave
the Ebola RNA in cells of infected persons and can prevent the virus from multiplying. A
100% rate of treatment has been achieved when it was tested on monkeys. A human trial has
been halted after a clinical endpoint was met. ZMapp from MappBio in US is a cocktail of
three monoclonal antibodies was used to treat the Ebola virus disease at a rate of 100%
among non human primates. This product has been used on patients on compassionate
grounds. But its efficacy is yet to be proven.
MIL-77 MabWorks, developed by a company in China is under Phase I trials is also
based on monoclonal antibodies and is as effective as Zmapp. BCX-4430 Biocryst, USA is a
broad spectrum nucleoside analogue and its safety data is being collected. Interferons that
have been approved for treatment of Hepatitis B and C and multiple sclerosis have been
tested as a therapy on a few Ebola patients (WHO, 2015).

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There are several control of outbreak measures that have been suggested by the WHO.
Raising awareness of the risks for Ebola infection, taking protective measures, such as
vaccination can reduce transmission of the disease. Surveillance and contact tracing, good
laboratory services for prompt diagnosis, safety during burials and mobilisation of social
resources is a good strategy for controlling the spread and preventing an outbreak if infection
occurs. Risk reduction measures include reducing the risk of wildlife to human transmission
that can occur due to consumption of raw meat of fruit bat or monkeys/apes. Handling should
be done with gloves on and any consumption should be preceded with thorough cooking.
Reducing risk of human to human transmission can be done by avoiding contact with body
fluids. Gloves and protective gear and clothing should be used when caring for patients at
home or in hospitals. Hand washing can prevent the spread of infection to a large extent. Risk
of transmission through sexual contact can be avoided by practice of safe sex by male
patients for one year after the infection occurrence or until two successive semen specimens
test negative for the virus. Outbreaks can be prevented by ensurinf a safe and prompt burial
of the dead. Health of people who were in contct with patients should be monitored for up to
21 days and they should be checked for symptoms. The healthy should maintain a safe
distance from the infected. Maintenance of good hygiene and a clean environment are
necessary for prevention.
The WHO supports countries at risk for prevention of Ebola virus disease and has
developed plans for preparedness. Whenever an outbreak is reported the WHO responds by
supporting surveillance, providing laboratory services, engaging the community, infection
control mechanisms, logistical support provision, training and supporting safe burials.
In conclusion, it is important to understand that if an outbreak caused by the Ebola
virus occurs, the safety measures can reduce the spread of the infection among people of the
community and health workers. Awareness among the community members, better diagnosis,

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prevention through vaccination, more research on treatment through drugs and control
measures can be adopted to prevent an outbreak and reduce fatalities among patients.
References
Arima, Y. & Shimada, T., 2015. Epidemiological situation of Ebola virus disease in West Africa..
Uirusu, pp. 65(1):47-54..

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Baron, S., 1996. Medical Microbiology.. 4th ed. s.l.:Galveston (TX): University of Texas Medical
Branch at Galveston.
BMJ, 2017. /pathophysiology.html. [Online]
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http://bestpractice.bmj.com/best-practice/monograph/1210/basics/pathophysiology.html
[Accessed 27 August 2017].
Clarke, E. & Bradfute, S., 2017. Advances in Ebola virus vaccination. The Lancet Infectious Diseases,
17(8), p. 787–788.
Karwowska, K., 2015. Ebola virus disease. Pol Merkur Lekarski. , 38(223), pp. 42-45.
Lee, J. E. & Saphire, E. O., 2009. Ebolavirus glycoprotein structure and mechanism of entry. Future
Virology, pp. 4(6), 621–635. http://doi.org/10.2217/fvl.09.56.
National Academies of Sciences, E. a. M., Division, H. a. M., Health, B. o. G. & Threats., F. o. M., 2016.
The Ebola Epidemic in West Africa: Proceedings of a Workshop.. s.l.: National Academies Press (US).
WHO, 2015. emp_ebola_q_as/en/. [Online]
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[Accessed 27 August 2017].
WHO, 2017. ebola-situation-reports. [Online]
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WHO, 2017. factsheets/fs103/en/. [Online]
Available at: http://www.who.int/mediacentre/factsheets/fs103/en/