Dr.

Wagdy Amin
Training officer
G.D For Chest Diseases and Tuberculosis
Ministry of Health & Population
drwagdy@yahoo.com
 Epidemic viruses
• Severe Acute Respiratory Syndrome (SARS)
• AH5N1
• AH1N1
• Corona
• Ebola
Introduction
 Seasonal Influenza

• Influenza (the flu) is a contagious

respiratory illness caused by influenza
viruses.
• It can cause mild to severe illness, and at
times can lead to death.
 Influenza A
• The Influenza A virus subtypes that have been confirmed in
humans, ordered by the number of known human pandemic
deaths, are:
• H1N1 caused "Spanish Flu" and 2009 H1N1 outbreak
• H2N2 caused "Asian Flu"
• H3N2 caused "Hong Kong Flu"
• H5N1 is "bird flu", endemic in avian
• H7N7 has unusual zoonotic potential
• H1N2 is currently endemic in humans and pigs
• H9N2, H7N2, H7N3, H10N7 (avian)
• The Influenza A virus subtypes are labeled according to an H
number (for hemagglutinin) and an N number (for
neuraminidase).
 Influenza B
• Influenza B viruses are only known to infect humans .

• influenza B viruses evolve slower than A viruses and

faster than C viruses.

• Influenza virus B mutates at a rate 2-3 times lower than

type A.
 Influenza C

• Influenza C viruses are known to infect humans and

pigs.
• Flu due to the type C species is rare compared to
types A or B, but can be severe and can cause local
epidemics.
 H5N1 “Avian/Bird Flu”
• Avian influenza is an infection caused by avian (bird) influenza
(flu) viruses.
• These influenza viruses occur naturally among birds.
• Wild birds worldwide carry the viruses in their intestines, but
usually do not get sick from them.
• Avian influenza is transmissible to humans (this requires
extremely close contact with infected birds, particularly feces).
• H7N1 and H9N2 (also bird flu)
 H1N1 “Swine Flu”
• 2009 H1N1 (referred to as “swine flu” early on) is a new
influenza virus causing illness in people.
• This new virus was first detected in people in the United States
in April 2009.
• This virus is spreading from person-to-person worldwide,
probably in much the same way that regular seasonal
influenza viruses spread.
• On June 11, 2009, the WHO signaled that a pandemic of 2009
H1N1 flu was underway.
 The Makings of a Pandemic
• The gene’s segmented nature facilitates genetic reassortment
which leads to genetic diversity in type A.
– Antigen drifts (minor)
– Antigen shifts (major)
• The major antigenic variations underlie the deadly worldwide
pandemics (1918 ‘Spanish’, 1957 ‘Asian’, 1967 ‘Hong Kong’) .
• The 1918 Spanish flu is the most serious pandemic in recent
history, killing 50 million people (500,000 U.S. deaths).
• The most recent ones were the Asian Flu in 1957 (70,000 U.S.
deaths) and the Hong Kong Flu in 1968 (34,000 U.S. deaths).

• In pandemic, virus is transmissible human to human.

 More Flu…
The “canine influenza virus” is an influenza H3N8 influenza virus
(not a human influenza virus) that was originally an equine
(horse) influenza virus.
• This virus has spread to dogs and can now spread between dogs.
• Vaccination is available .

H7N7 and H3N8 “Horse Flu”

• The disease has a nearly 100% infection rate in an unvaccinated
horse population with no prior exposure to the virus.
• While equine influenza is historically not known to affect
humans, the impact of an outbreak among even the animal
population would have been devastating.
Severe Acute Respiratory Syndrome
(SARS)
Severe Acute Respiratory Syndrome (SARS):
Epidemiology

• A worldwide outbreak of severe acute

respiratory syndrome (SARS) has been
associated with exposures originating from
a single ill health care worker from
Guangdong Province, China.
•China's Ministry of April 27.
Health reported a total of
2,914 cases of severe acute
respiratory syndrome
(SARS) on the Chinese
mainland.
•1,299 patients had been
discharged from hospitals
upon recovery
•131 had died.
 SARS: Timeline of an Outbreak

Nov. 16, 2002 -- The first case of an atypical

pneumonia in the Guangdong province in China.

Feb. 26, 2003 -- First cases of unusual pneumonia

reported in Hanoi, Vietnam.

Feb 28, 2003 -- World Health Organization officer

Carlo Urbani, MD, examines an American
businessman with an unknown form of pneumonia
in a French hospital in Hanoi, Vietnam.
March 10, 2003 – doctor Urbani reports an unusual
outbreak of the illness, which he calls sudden acute
respiratory syndrome or SARS, to the main office of
the WHO. He notes that the disease has infected an
usually high number of healthcare workers (22) at the
hospital.

March 12, 2003 -- WHO issues a global alert about a

new infectious disease of unknown origin in both
Vietnam and Hong Kong.

March 29, 2003 -- Carlo Urbani, who identified the first

cases of SARS, dies as a result of the disease.
 Pathogenesis

• Clinically, most infections cause a mild, self-

limited disease (classical 'cold' or upset
stomach), but there may be rare neurological
complications.
• SARS is a form of viral pneumonia where
infection encompasses the lower respiratory
tract.
• They are transmitted by aerosols of respiratory
secretions, by the faecal-oral route, and by
mechanical transmission.
• Most virus growth occurs in epithelial cells.
• Occasionally the liver, kidneys, heart or eyes may be
infected, as well as other cell types such as
macrophages.
• In cold-type respiratory infections, growth appears
to be localized to the epithelium of the upper
respiratory tract.
 SARS Virus
– Survived as long as 24 hours in the
environment.
– Finding of virus in faeces.
– Occasionally linked with pneumonia in humans,
specially with immunocompromised.
– Can cause severe illness in animals.
– Incubation period: 2-7 days
 SARS Clinical Picture (Hong Kong)
– The most common symptoms included fever (in
100 percent of the patients);
– chills, rigors, or both (73.2 percent); and myalgia
(60.9 percent).
– Cough and headache were also reported in more
than 50 percent of the patients.
– Other common findings were lymphopenia (in
69.6 percent), thrombocytopenia (44.8 percent),
and elevated lactate dehydrogenase and
creatine kinase levels (71.0 percent and 32.1
percent, respectively).
– 78.3% had abnormal chest radiographs
Factors predictive of ICU admission and
death

• Advanced age.
• High peak creatinine kinase
• High lactate dehydrogenase
• High initial absolute neutrophil count
• Low serum sodium level
 INVESTIGATIONS

• Selected investigations are intended to determine

the cause of the respiratory illness.

Test for viral, bacterial and other usual respiratory

pathogens

Identify common pathogens circulating in the

community which may be responsible for the
illness
 INVESTIGATIONS

• Blood work:
• blood cultures X 2
• CBC, diff, AST, ALT, bilirubin, alkaline phosphatase,
LDH, CPK, urea, creatinine, electrolytes
• other diagnostic tests as indicated by patients
condition
 INVESTIGATIONS

• Respiratory samples:
NP swab #1: rapid antigen detection for respiratory viruses,
viral cultures, viral PCR

ETT aspirate : SARS investigation

• throat swab #1: Group A strep
• throat swab #2: Mycoplasma PCR

• Blood for serology:

One clotted tube[5 cc] labelled “SARS serology”
• Stool:
For viral electron microscopy
 Treatment

• Empirical therapy most commonly

included antibiotics, oseltamivir, and
intravenous ribavirin.
• Mechanical ventilation was required in
severe cases .
2. SARS Specific Therapy
The efficacy of ribavirin in treating SARS is
not known but if ribavirin is being started,
use intravenous ribavirin.
3. Additional Therapy for SARS

• Corticosteroids

• Oral ribavirin

•Oseltamivir
AVIAN Influenza
Human disease associated with influenza A
subtype H5N1 re-emerged in January 2003,
for the first time since an outbreak in Hong
Kong in 1997." Three people in one family
were infected after visiting Fujian province in
mainland China and 2 died
 Global spread of A H5N1 map

638 cases
379 deaths 59%
 193 200
173 180
161
160

125
140
120
100
80
62 63

45
60
38
25
30 29 40
17
12
7 58
20
4 13 11 22 23
01 01 11 1
0

cases deaths
Cases / cases fatality rate /year
in Egypt
Year Cases Deaths Case–fatality
rate (%)
2006 18 10 55.5
2007 25 9 36
2008 8 4 50
2009 39 4 10.2
2010 29 13 44.8
2011 39 15 38.4
2012 11 5 45.4
2013 4 3 75
2014 2 0 0
Total 175 63 36
 To date, a total of 175 human cases, including 63 deaths, have
been reported in Egypt from avian influenza A(H5N1).

39 39
40
29
30 25
a 56-year-old female
from Damanhour.
a 4-year-old male, from
18 Damietta
20 15
13
10 11
9 8
10 5
4 4 4 3
2
0
0
2006 2007 2008 2009 2010 2011 2012 2013 2014
Cases Deaths
 Influenza A viruses have 16 H subtypes and 9 N
subtypes.
• In poultry, the viruses can mutate, usually within a
few months, from then low pathogenic avian
influenza (LPAI) form into the highly pathogenic form
(HPAI).
• Only viruses of the H5 and H7 subtypes are known to
cause the highly pathogenic (HPAI) form of the
disease.
 Influenza A HA and NA Subtypes
H1 N1
H2 N2
H3 N3
H4 N4
H5 N5
H6 N6
H7 N7
H8 N8
H9 N9
H10
H11
H12
H13
H14
H15, H16
The AVIAN H5N1 virus has raised concerns
about a potential human pandemic
because:
• It is especially virulent.
• It is being spread by transported
domestic poultry.
• It can be transmitted from birds to
mammals and humans.
 Symptoms
• Most patients infected with the H5N1 virus show
initial symptoms of fever (38 C or higher) followed by
influenza-like respiratory symptoms, including
cough, rhinorrhea, sore throat, and (less frequently)
shortness of breath.
• Watery diarrhea is often present in the early stages
of illness, and may precede respiratory symptoms by
up to one week.
• Gastrointestinal symptoms (abdominal
pain, vomiting) may occur and headache has also
been reported.
 Pharmaceutical treatment.

• Antivirals should be readily available for

the treatment of suspected and
confirmed cases.
http://www.who.int/csr/disease/avian_influenza/en/
 Hosts
Haemagglutinin subtype Neuraminidase subtype

H1 N1
H2 N2
H3 N3
H4 N4
H5 N5
H6 N6
H7 N7
H8 N8
H9 N9
H10
H11
H12
H13
H14
H15
 Severe atypical pneumonia outbreak associated with
influenza A(H1N1)pdm09 in Egypt, 2013–2014 season.

• During 2013
– ILI in outpatient clinics = 1.712.476 patients =
4.5% from all attendees
• During January 2014
– ILI in outpatient clinics = 191.428 patients = 4.9%
from all attendees

• Positive cases for A H1N1 = 24%

Clinical Management of A(H1N1)
VIRUS Infection
Case Definitions
 Suspected case of A(H1N1)
• an individual with acute respiratory illness and fever
(reported or documented fever), and one of the followings;
cough, sore throat, shortness of breath, difficulty in
breathing or chest pains with onset:
– Within 7 days of close contact with a person who is probable or
confirmed case of A(H1N1) 2009 virus infection, OR
– Within 7 days of travel to a country/community where there
has been one or more confirmed cases of A(H1N1) 2009 virus
infection;
OR
– Resides in a community where there is one or more confirmed
cases of A(H1N1) 2009 virus infection.
 Probable case of A(H1N1) 2009

• An individual with an influenza-like illness

who is positive for influenza A that is
unsubtypeable by real-time PCR
• OR
– An individual with a clinically compatible illness
or who died of an unexplained acute respiratory
illness who is considered to be epidemiologically
linked to a probable or confirmed case.
 Confirmed Case of A(H1N1)

• An individual with an influenza-like illness

with laboratory confirmed A(H1N1) 2009
virus infection by one or more of the following
test:
• Real-time RT-PCR
• Viral culture
 Influenza like illness (ILI)

• A person with
sudden onset of fever of >38 °C and at-least
one of the following two respiratory symptoms
in the absence of other known causes:
– Dry cough
– Sore throat
 Severe acute respiratory illness (SARI)

• A person meeting the case definition of

influenza-like illness (sudden onset of fever > 38
C with at-least one of the following two respiratory
symptoms- dry cough, sore throat in the absence of
other diagnosis)
AND
• Shortness of breath OR difficulty in breathing
requiring hospital admission
 Acute Respiratory Infection (ARI)

• defined as an acute respiratory tract illness that

is caused by an infectious agent transmitted
from person to person.
• The onset of symptoms is typically rapid, over
a period of hours to several days.
• Symptoms include fever, cough, and often sore
throat, coryza, shortness of
breath, wheezing, or difficulty breathing.
 Clinical Presentation
• Vary from asymptomatic infection through to serious
fatal illness that may include exacerbation of other
underlying conditions and severe viral pneumonia with
multi-organ failure.
These are:
– (i) Mild or non-severe illness;
– (ii) Signs and symptoms of progression to severe
illness; (Moderate)
– (iii) Severe illness.
 Mild illness (Non severe)
Patients with mild Influenza-like illness may present with
some or all of the following symptoms:

• Fever (Between 38 to 39 0C), dry cough, sore

throat, rhinorrhea, headache, muscle pain, malaise, but
no shortness of breath or dyspnoea.
• Gastrointestinal illness, such as diarrhoea and/or
vomiting, especially in children, but without any
evidence of dehydration.
• The general condition of these patients will be good
without any signs of hypotension or mental confusion.
 Signs and symptoms of progression to severe
illness

• Patients presenting initially with mild

influenza-like illness may rapidly progress to
more severe illness in the course of the disease.

• The followings are some of the clinical signs

and symptoms indicating rapid progression of
a patient to severe illness, which would
necessitate an urgent review of patient’s
clinical management:
• Symptoms and signs suggesting oxygen impairment or
cardiopulmonary insufficiency:
– Shortness of breath (with activity or at rest), difficulty in
breathing, turning blue, bloody or coloured sputum, chest pain, low blood
pressure;
– Fast or laboured breathing in children less than 5 years of age;
– Hypoxia as indicated by pulse oximetry, if available (Oxygen saturation ≤
90%)
• Symptoms and signs suggesting CNS complications:
– Altered mental status, unconscious, drowsiness, or difficult to awaken;
recurring or persistent convulsions (seizures), confusion, severe weakness
or paralysis.
• Evidence of sustained virus replication or invasive secondary bacterial
infection:
– Based on laboratory testing or clinical signs (e.g. persistent or recurrent
high fever and other symptoms beyond three days even when under
treatment with analgesics or antipyretics).
• Severe dehydration:
– Decreased activity, dizziness, decreased urine output, lethargy.
 Severe illness
Patients showing any of the following clinical signs and symptoms would
be considered as suffering from severe illness due to influenza:

• Severe respiratory distress:

– Severe breathlessness, e.g. unable to complete sentences in one breath.
Use of accessory muscles, supra-clavicular recession, tracheal tug or
feeling of suffocation (For adult patients)
– Lower chest in-drawing, sternal recession or noisy breathing when
calm (For paediatric patients)
• Increased respiratory rate measured over at least 30 seconds:
– Over 30 breaths per minute (For adult patients)
– ≥ 50 breaths per minute if under 1 year or ≥40 breaths per minute if ≥ 1
year (For paediatric patients)
• Oxygen saturation ≤92% on pulse oximetry, breathing
air or on oxygen:
– Absence of cyanosis is a poor discriminator for severe illness.
• Respiratory exhaustion
– New abnormal breathing pattern, e.g. alternating fast and slow
rate or long pauses between breaths (For adult patients)
– Apnoea defined as a ≥ 20 second pause in breathing (For
paediatric patients)
• Evidence of severe clinical dehydration or clinical
shock
– Systolic blood pressure <90mmHg and/or diastolic blood
pressure <60mmHg. Sternal capillary refill time >2
seconds, reduced skin turgor (For adult patients)
– Sternal capillary refill time >2 seconds, reduced skin
turgor, sunken eyes or fontanelle (For paediatric patients)
• Altered conscious level
– New confusion, striking agitation or seizures (For
adult patients)
– Strikingly agitated or irritable, seizures, or floppy
infant (For paediatric patients)

• Causing other clinical concern to the

clinician or to the specialist doctor
– e.g. a rapidly progressive or an unusually
prolonged illness.
 Groups at high risk for complications
• Pregnant women
• Adults 65 years of age and older;
• Children younger than 5 years old (In particular less than 2 years);
• Persons with the following underlying conditions at any age:
– Chronic Broncho-pulmonary disease (Including asthma),
– Chronic cardiovascular disease (except hypertension)
– Chronic neurologic disorder (Cerebral palsy, stroke, multiple
sclerosis, muscular dystrophy, etc)
– Immune suppressed patients
– Haematological disorder
– Chronic liver or renal failure
– Metabolic disorder (specially Diabetes mellitus),
– Morbid obesity
• Healthcare personnel in the hospital settings caring for patients
infected with A(H1N1) 2009 influenza virus;
 Mild cases

Home Isolation
Symptomatic treatment
progress
Improvement
Hospital isolation
Tamiflu
Samples
Positive
Negative
Continue Tamiflue
, assessment after 5 days
Discharge , treat according to
the case Progress Improved

Continue isolation , doubling tamiflu dose , assess for Discharge , stop Tamiflu , Treat
hospital or ICU admission according to the case
 Mild case with risk factors

Home isolation
Tamiflu
No samples

progress Improved

•Hospital isolation • Continue Tamifue for 5

•Doubling tamiflu dose days
•Samples • Stop isolation 24 hs after
•Assessment after 5 days symptoms disappear
 Sever cases

1. Hospital Isolation
2. Tamiflu ‫االطفا‬
‫البالغي‬
3. Samples
‫ن‬ ( throat – naso‫ل‬

pharyngeal )
4. Cultute for secretion )
 criteria for consideration of patients’
admission at the ICU
Patient showing no signs of improvement and remain
non-responsive to antiviral treatment using oseltamivir
as evidenced by the followings:
•Signs of progressive infiltrates on chest x-ray
•Persistent hypoxia ( SpO2 < 85%) despite maximum
oxygen saturation;
•Progressive hypercapnoea;
•Presence of compromised haemodynamics;
A •Signs of sepsis
higher dose regimenand imminent
of Oseltamivir (150shock
mg twice daily for up to 10 days)
may be considered in adult patients admitted in the Intensive Care Unit
A higher dose regimen (double the normal dose regimen) may also be
considered in children as well.
 antiviral agents for influenza
• Neuraminidase Hemaggluti
inhibitors nin
– Oseltamivir (including
Tamiflu™, Antiflu™) Neuraminidase
– Zanamivir (including
Relenza™) M2 ion channel
– Peramivir (not registered in
most countries)
M2 Inhibitors
 Amantadin
e
Lipid bilayer
 Rimantadin
e
Other antiviral and
adjunctive
treatments
include M1 matrix protein
Ribavirin
Arbidol
Interferon
Immune plasma
 Treatment protocol for antiviral treatment
Dosage recommendations for antiviral treatment using oseltamivir
Agent Age groups
Duration 1-4 5-9 10-12 13-64 =>65

Oseltamivir
Weight-adjusted doses: 75 mg 75 mg
5 days twice daily twice daily
30 mg twice daily for ≤ 15 kg
45 mg twice daily for >15 to 23 kg
60 mg twice daily for >23 to 40 kg

75 mg twice daily for >40 kg

Zanamivir (In situations where oseltamivir is not available or if the virus is resistant to oseltamivir but known
or likely to be susceptible to zanamivir,

5 days 10 mg , (2 inhalations) twice daily

 Use of antibiotics, corticosteroids and other supporting treatment for
hospitalized patients

In addition to antiviral treatment using oseltamivir , the following

supportive treatment should be considered :
• Supportive cares (antipyretics like acetaminophen for fever, adequate
rehydration for correcting dehydration, etc) are sufficient in the majority of
patients.
• Oxygen Therapy: oxygen saturation should be monitored by pulse
oximetry whenever possible. Supplemental oxygen should be provided to
correct hypoxemia depending on the severity (nasal
cannula, facemask, facemask with reservoir, intubation and assisted
ventilation).
• Corticosteroids: Corticosteroids should not be routinely used.
• Antibiotics: Antibiotic chemoprophylaxis should not be used. When
secondary bacterial pneumonia is suspected, treatment with antibiotics
should follow recommendations from national guidelines for community-
acquired pneumonia.
 Hospital discharge criteria for patients with either
confirmed, probable or suspected H1N1 infection
• Patient becomes afebrile;
• Absence of dyspnoea;
• Satisfactory oral fluid tolerance;
• No signs of dehydration;
• Respiratory rate  30 bpm;
• Oxygen saturation  92%
• Underlying chronic health conditions not exacerbated in patients in high-
risk group for complication.
Patients should be discharged after receiving the full five day course of
oseltamivir or 24 hours after becoming afebrile, whichever is earlier.
 Antiviral Treatment using Oseltamivir for
patients admitted at the ICU
• A higher dose regimen of Oseltamivir (150 mg twice daily for up to
10 days) may be considered in adult patients admitted in the ICU
• A higher dose regimen (double the normal dose regimen) may also
be considered in children as well.
• patients with severe or progressive illness not responding to normal
antiviral treatment regimen, higher doses of oseltamivir and longer
duration of treatment may be appropriate, although there is no
clinical trial evidence to show benefit.
• An adult dose of 150 mg bd for up to 10 days is being used in some
situations.
 Middle East Respiratory
Syndrome Corona-virus (MERS-CoV)
• Middle East Respiratory Syndrome
Coronavirus (MERS-CoV) is a novel
coronavirus, which was first described in
September 2012.

• The virus causes respiratory tract infections

ranging from asymptomatic or mild disease to
severe pneumonia associated with multi-
organ failure and death
• The first case of a novel
coronavirus, now called
Middle East respiratory
syndrome coronavirus
(MERS-CoV), was
identified in a patient
with acute pneumonia
and renal failure in
Jeddah, Kingdom of Saudi
Arabia (KSA) in June 2012
 Corona Cases and deaths 8/11/2014
Country cases Deaths )%(
Saudi Arabia 796 340 42.7%
Emirate 33 9 27%
Qatar 7 4 57%
Jordan 9 5 56%
United Kingdom 4 3 75%
Kuwait 3 1 33%
Tunisia 3 1 33%
Oman 2 2 100%
France 2 1 50%
Germany 2 1 50%
Malaysia 1 1 100%
Italy 1 0 0%
Philippine 1 0 0%
Spain 1 0 0%
Grace 1 0 0%
Egypt 1 0 0%
Netherland 2 0 0%
Iran 1 1 100%
Algeria 2 1 50%
Total 867 364 42%
Transmission of MERS-CoV

• The exact mechanism through which MERS-CoV

infection is acquired remains uncertain.
• Primary cases, The majority of infections are sporadic

• but human to human transmission has been

documented both in hospital and in community settings
• Pneumonia has been the most common clinical presentation;

• five patients developed Acute Respiratory Distress Syndrome

(ARDS).

• Renal failure, pericarditis and disseminated intravascular

coagulation (DIC) have also occurred.

• no virus-specific prevention or treatment (e.g. vaccine or antiviral

drugs) is available.

• As all confirmed cases reported to date have occurred in adults

1. focuses on the early recognition and management of
patients with SARI and includes early initiation of
supportive and infection prevention and control
measures, and therapeutics.

2. focuses on management of patients who deteriorate

and develop severe respiratory distress and ARDS.

3. focuses on the management of patients who deteriorate

and develop septic shock.

4. focuses on ongoing care of the critically ill patient and

best practices to prevent complications.
 1. Recognize severe
manifestations of acute
respiratory infections

Definitions of clinical syndromes

 “Patient under investigation” for
novel coronavirus infection Suspect
• A person with an acute respiratory infection, which may include
history of fever or measured fever (≥ 38 °C,) and cough;
– AND suspicion of pulmonary parenchymal disease (e.g. pneumonia
or ARDS), based on clinical or radiological evidence of consolidation:
– AND residence in or history of travel to the Arabian Peninsula or
neighboring countries within 10 - 14 days before onset of illness:
– AND not already explained by any other infection or
aetiology, including all clinically indicated tests for community-
acquired pneumonia according to local management guidelines.
– It is not necessary to wait for test results for other pathogens
before testing for novel coronavirus.
 Initiate infection prevention and control measures

• Droplet precautions
– These infection prevention and control measures should
be started when the patient enters triage with symptoms
of acute febrile respiratory illness.
– Organize the space and process to permit spatial
separation (at least 1 meter) between each patient with
acute respiratory infections and other individuals not
wearing PPE.
– Ensure that triage and waiting areas are adequately
ventilated.
– Encourage the use of respiratory hygiene (i.e. covering
the mouth and nose during coughing or sneezing with a
medical mask, cloth mask, tissue or flexed
elbow), followed by hand hygiene.
• Airborne precautions should be used for
aerosol-generating procedures, which have
been consistently associated with an increased
risk of pathogen transmission .
– The most consistent association of increased risk of
transmission to healthcare workers (based on
studies done during the SARS outbreaks of 2002–
2003) was found for tracheal intubation.
– Increased risk of SARS transmission was also
reported when performing non-invasive
ventilation, tracheotomy and manual ventilation
before intubation; however, these findings were
identified from a limited number of very low-quality
studies.
 Then
1. Give supplemental oxygen therapy to patients with SARI
2. Collect respiratory and other specimens for laboratory
testing
3. Give empiric antimicrobials to treat suspected
pathogens, including community-acquired pathogens
4. Use conservative fluid management in patients with SARI
when there is no evidence of shock
5. Do not give high-dose systemic corticosteroids or other
adjunctive therapies for viral pneumonitis outside the
context of clinical trials
6. Closely monitor patients with SARI for signs of clinical
deterioration, such as severe respiratory distress/respiratory
failure or tissue hypoperfusion/shock, and apply supportive
care interventions
2. Management of severe respiratory
distress,
hypoxemia and ARDS

3. Management of septic shock

4. Prevention of complications
A number of therapeutic interventions for
coronavirus were investigated during the large
multi-national outbreak of Severe Acute
Respiratory Syndrome (SARS) in 2003
• To date, no antiviral therapy has been approved for
treatment of patients with MERS-CoV infection.

• Reviews of the available literature suggest that a

combination of ribavirin and pegylated interferon may
be of benefit to patients with severe MERS-CoV
infection.
• Furthermore, the combination was shown to inhibit
MERS-CoV in cell culture and appeared to improve
clinical outcome in animal studies.
• Both agents are associated with significant potential
adverse effects and hence their unlicensed use should
be carefully balanced against any potential harm.
To be considered eligible for oral ribavirin
and subcutaneous pegylated interferon
therapy, the patient must fulfill ALL the
following criteria:
1. Laboratory-confirmed MERS-CoV infection
2. Clinical and radiological evidence of pneumonia
3. The patient requires invasive or non-invasive
ventilatory support or showing progressive hypoxemia
4. Approval by one consultants in Adult Infectious
Diseases
1. Patients who do not consent to the proposed
treatment regimen.

2. Patients who have known allergy to any agent

in the treatment protocol.
Administration Protocol:
Monitoring:
1. Both ribavirin and Peg-interferon are associated
with considerable potential adverse effects. In
addition to any clinical or laboratory monitoring
that is dictated by the patient’s condition,
2. the following investigations are essential before
starting pegylated interferon 2-alfa therapy and
ribavirin and on daily basis throughout the
treatment course
3. Conscious patients must have a formal
psychiatric assessment if there is any clinical
evidence of psychosis or acute confusion
 Changes to the treatment protocol:

• Changes in the treatment protocol in

response to toxicity or clinical
developments are permitted.
• A consultant in adult infectious
diseases must approve all such
changes.
Ebola Outbreaks 1976-2014
 Historical Background
in 2 simultaneous
outbreaks, first in Nzara which is small town in south
of Sudan which infected over 284 people, with a
mortality rate of 53%.

• After view month another out break occurred in

Yambuku in Democratic Republic of Congo. The latter
was in a village situated near the from
which the disease takes its name

• In Congo outbreak 318 people infected with highest

mortality rate of 88% .
• 24 outbreaks reported by WHO from 1976 till
2012 .
• first outbreak occurred in Sudan ( Newly south
of Sudan ) and Democratic Republic of Congo
with mortality rate of 53% and 88% respectively .
• Countries involved in outbreaks was , Sudan
, Congo , Uganda ,Gabon , South Africa ( one case
in 1996 ) and Cote d'Ivoire ( one case in 1994).
• No case reported out of Africa till 2012 .
• The maximum No of infected patients was 425 in
Uganda outbreak 2000 .
 August 1, 2014, the Guinea Ministry of Health
announced a total of 485 suspect and confirmed cases
of Ebola virus disease (EVD), including 358 fatal cases.

• 340 cases across Guinea have been confirmed by

laboratory testing to be positive for Ebola virus
infection.

• August 1, 2014, the Ministry of Health and Sanitation

of Sierra Leone and WHO reported a cumulative total
of 646 suspect and confirmed cases, including 540
laboratory confirmations and 273 reported fatal cases
• August 1, 2014, the Ministry of Health and Social
Welfare of Liberia and WHO have reported 468
suspect and confirmed EHF cases (including 129
laboratory confirmations) and 255 reported
fatalities.

• August 1, 2014, the Nigerian Ministry of Health

and WHO reported 4 suspect and probable cases
and 1 fatal probable case.

• Nigerian Suspected and Confirmed Case Count

are 4 .
What is Ebola virus disease (EVD)?
• Ebola virus disease (formerly known as Ebola haemorrhagic
fever) is a severe, often fatal illness, with a death rate of up
to 90%.

• The illness affects humans and nonhuman primates

(monkeys, gorillas, and chimpanzees).

• Ebola first appeared in 1976 in two simultaneous

outbreaks, one in a village near the Ebola River in the
Democratic Republic of Congo, and the other in a remote
area of Sudan.

• The origin of the virus is unknown but are

considered the likely host of the Ebola virus, based on
available evidence.
Case counts October 24, 2014
 Countries with widespread
transmission
Country Total cases Lab. Conf. Total
cases deaths

Guinea 1760 1479 1054

Liberia 6919 2514 2766
Sierra 4862 4149 1130
Leone

Total 13241 8142 4950

08 November 2014
 Countries with travel associated cases
Country Total cases Lab. Conf. cases Total deaths
Mali 1 1 1
Senegal 1 1 0
2 2 1

Country Total cases Lab. Conf. cases Total deaths

Nigeria 20 19 8
Spain 1 1 0
United State 4 4 1
25 24 9
• The outbreak of Ebola Virus in Nigeria and
Senegal were declared over on 17 October
and 19 October 2014.

• A national EVD outbreak is considered to be

over when 42 days ( Double the 21 days
incubation period ) has elapsed since the last
patient in isolation became laboratory
negative for EVD
How many people could become
infected?
 2. How do people become infected
with the virus?
• In the current outbreak in West Africa, the majority of
cases in humans have occurred as a result of

• Infection occurs from through broken skin

or mucous membranes with the blood, or other bodily
fluids or secretions (stool, urine, saliva, semen) of
infected people.

• Infection can also occur if broken skin or mucous

membranes of a healthy person come into
such as soiled
clothing, bed linen, or used needles.
• More than 200 health-care workers have been
exposed to the virus while caring for Ebola
patients.

• This happens because they

or were
not properly applying
when caring for the patients.

• Health-care providers at all levels of the health

system – hospitals, clinics, and health posts –
should be briefed on the nature of the disease
and how it is transmitted, and strictly follow
recommended infection control precautions.
• People are infectious as long as their blood and
secretions contain the virus. For this reason, infected
patients receive close monitoring from medical
professionals and receive laboratory tests to ensure the
virus is no longer circulating in their systems

• Men who
to their partner through their semen for
up to 7 weeks after recovery. For this reason, it is
important for men to avoid sexual intercourse for at least
7 weeks after recovery or to wear condoms if having
sexual intercourse during 7 weeks after recovery.

• Generally, a person must come into contact with an

animal that has Ebola and it can then spread within the
community from human to human.
 Who is most at risk?
During an outbreak, those at higher risk of
infection are:
• health workers;
• family members or others in close contact with
infected people;
• mourners who have direct contact with the
bodies.
• More research is needed to understand if some
groups, such as immuno-compromised people or
those with other underlying health
conditions, are more susceptible than others to
contracting the virus.
 incubation period
2 to 21 days
• The incubation period from time of infection
to symptoms is 2 to 21 days.
What are typical signs and symptoms
of infection?
• Sudden onset of fever, intense
weakness, muscle pain, headache and sore
throat are typical signs and symptoms.
• This is followed by
vomiting, diarrhoea, rash, impaired kidney
and liver function, and in some cases, both
internal and external bleeding.
• Laboratory findings include low white blood
cell and platelet counts, and elevated liver
enzymes.
• The patients become infectious once they
begin to show symptoms.
• They are not contagious during the incubation
period.( 2- 21 days)
• Ebola virus disease infections can only be
confirmed through laboratory testing.
 What is the treatment?
• There is currently no specific treatment to cure the
disease.

• Severely ill patients require intensive supportive care.

They are frequently dehydrated and need intravenous
fluids or oral rehydration with solutions that contain
electrolytes.

• Some patients will recover with the appropriate

medical care.

• Isolation from other patients and treated by health

workers using strict infection control precautions.
 Should patients with suspected or confirmed
Ebola virus be separated from other patients?
• Isolating patients with suspected or confirmed
Ebola virus disease in single isolation rooms is
recommended.
• Where isolation rooms are not available, it is
important to assign designated areas, separate
from other patients, for suspected and confirmed
cases.
• Access to these areas should be
restricted, needed equipment should be
dedicated strictly to suspected and confirmed
EVD treatment areas, and clinical and non-clinical
personnel should be exclusively assigned to
isolation rooms and dedicated areas.
Stopping visitor access to patients infected with
EVD is preferred.

If this is not possible, access should be given

only to those individuals who are necessary
for the patient’s well-being and care, such as a
child’s parent.
 Is hand hygiene important?
Hand hygiene is essential and should be performed:
• before donning gloves and wearing PPE on entry to
the isolation room/area;
• before any clean or aseptic procedures is being
performed on a patient;
• after any exposure risk or actual exposure with a
patient’s blood or body fluids;
• after touching (even potentially) contaminated
surfaces, items, or equipment in the patient’s
surroundings; and
• after removal of PPE, upon leaving the isolation
area.
• Either an alcohol-based hand rub or soap and
running water can be used for hand hygiene.
• It is important to always perform hand hygiene
with soap and running water when hands are
visibly soiled.
• Alcohol-based hand rubs should be made
available at every point of care (at the entrance
and within the isolation rooms and areas);
running water, soap, and single use towels should
also be always available.
 Keeping Healthy
• Maintain a healthy lifestyle; attention
to rest, diet, exercise, and relaxation
helps maintain physical and emotional
health.
• Resilience