In that moment you thought that Human Immunodeficiency Virus (HIV) is ravaging people all over the world in an pandemic scale, Ebola Virus Disease (EVD) suddenly props up dealing mortal blows at its victims, creating an epidemic!
What is EVD?
EVD, formerly called Ebola hemorrhagic fever, is a severe and often fatal virus infection in humans and primates. It is a form of hemorrhagic fever caused by genus Ebolavirus, a member of Filoviridae family according to a WHO publication.
Filoviridae is a family of single-stranded RNA viruses that infect vertebrates, that have a pleomorphic usually bacilliform or filamentous shape with a helical nucleocapsid and a lipoprotein envelope with glycoprotein projections, and that include the Ebola viruses and the Margburg virus.{1}
Viral hemorrhagic fever (VHF) is an acute febrile syndrome characterized by systemic involvement, which includes generalized bleeding and severe infections.{2}
According to a world health organization (WHO) publication, the genus Ebolavirus comprises 5 distinct species:
- Bundibugyo ebolavirus (BDBV)
- Zaire ebolavirus (EBOV)
- Reston ebolavirus (RESTV)
- Sudan ebolavirus (SUDV)
- Taï Forest ebolavirus (TAFV).
BDBV, EBOV, and SUDV have been associated with large EVD outbreaks in Africa, whereas RESTV and TAFV have not. The RESTV species, found in Philippines and the People’s Republic of China, can infect humans, but no illness or death in humans from this species has been reported to date. {3}
EBOV has a mortality rate of between (77-100)%; SUDV has a mortality rate of between (53-65)%; and the Margburg virus has a mortality rate of between (20-50)% .{4}
BDBV has a mortality rate of between (34-47)%. {5}
BDBV has a mortality rate of between (34-47)%. {5}
What we need to know:
Biomedical science first encountered the virus family Filoviridae when Margburg virus appeared in 1967 in Margburg, Germany. {6}
According to a world health organization publication, Ebola first appeared in 1976 in 2 simultaneous outbreaks, in Nzara, Sudan, and in Yambuku, Democratic Republic of Congo. The latter was in a village situated near the Ebola River, from which the disease takes its name.
between 1976, when it was first seen in Africa, till date EVD had affected people within some African regions:{4}
In 1976, Sudan had 285 reported cases with 53% mortality rate.
In 1976, Congo Democratic Republic (formerly Zaire) reported 318 cases with 88% mortality rate.
1977, CDR, reported one case with 100% mortality rate.
In 1979, Sudan had 34 cases with 65% mortality rate.
1994, Gabon recorded 44 cases with 64% mortality rate.
Same year, Ivory Coast had one reported case with 0% mortality rate.
CDR had another major outbreak with a reported case of 315 and 77% mortality rate in 1995!
In 1996, 37 cases were reported in Gabon with 57% mortality rate.
In 1997, 60 cases were reported in Gabon with 75% mortality rate.
In 2000, Uganda had a reported case of 425 with 53% mortality rate!
In 2001, it was Gabon again with 65 cases and 82% mortality rate reported.
2002, CDR, cases reported were 8 with 83% mortality rate. 2003, CDR, cases reported was 143 with 90% mortality rate. Same year, CDR reported another 42 cases with 69% mortality rate.
EVD is not a death sentence, but a highly contagious disease due to the virulent nature of the causative agent.
Re-emergence
The re-emergence of the Ebola outbreak started in a village in Guinea with a total number of 543 suspects and confirmed cases of EVD, including 396 laboratory confirmed and 394 deaths since it re-emerged this year it then spread to Liberia (834 suspects and confirmed EVD cases, including 200 laboratory confirmations and 466 deaths) and Sierra Leone (WHO reported a cumulative total of 848 suspects and confirmed cases, including 775 laboratory confirmed cases and 365 deaths) according to a Centre for Disease control and prevention (CDC), 2014 Ebola outbreak in West Africa: Ebola Hemorrhagic fever, highlight.
Patrick Sawyer, a U.S citizen, became the first known victim of Ebola to die in Nigeria. As at the last count, the country has recorded 4 deaths including that of Patrick Sawyer. A Doctor, who attended to late Patrick Sawyer, was released from a quarantine of 10 persons after she spontaneously recovered. There are 177 direct and indirect contacts to late Mr Sawyer being observated in Lagos and 21 in Enugu state.
Transmission
Ebola is extremely contagious, it transmitted by contact with blood, feces or body fluids from an infected person or by direct contact with the virus, as in a laboratory. People can be exposed to Ebola virus from direct contact with the blood or secretions of an infected person.
This is why the virus has often been spread through the families and friends of infected persons: in the course of feeding, holding, or otherwise caring for them, family members, health workers who "treat" the victims and friends would come into close contact with such secretions. People can also be exposed to Ebola virus through contact with objects, such as needles, that have been contaminated with infected secretions.
The fruit bats of the Pteropodidae family particularly species of the genera Hypsignathus monstrosus, Epomops franqueti and Myonycteris torquata, are considered possible natural hosts for EVD.
Other carriers of this virus are the green monkeys, great Apes, gorillas and even dead or wounded animals. Any contact with those affected animals likely leads to transmission to a human host!
This virus has been isolated from dead bodies, hence people are advised to handle dead bodies suspected to be victims of EVD with care.
Treatment
Currently, there is no proven cure for Ebola.Victims are treated with supportive therapy with the hope that they will recover, though Zmapp and the controversial Nano Silver has been trending recently. Zmapp was administered to two American "Doctors" infected with EVD and another Spanish priest. The later did not survive though.
Nano Silver is promoted by Dr Rimi for its "strong" anti-pathogenic effect at the cellular level but in some quarters, this cocktail's efficacy has been questioned.{7}
Meanwhile, the best way not to be infected with EVD is not contacting it. The research continues though.
Symptoms
The early symptoms of the virus are said to mimic the symptoms of malaria or flu at first. They include high fever, headache, muscle aches, stomach pain, and diarrhea.
Symptoms
The early symptoms of the virus are said to mimic the symptoms of malaria or flu at first. They include high fever, headache, muscle aches, stomach pain, and diarrhea.
There may also be sore throat, hiccups, and red and itchy eyes ( allergic conjunctivitis, tangelesias, sub-conjunctival hemorrhage, conjunctival hyperemia). A study in Kikwit, CDR, after a 1995 major outbreak infecting 103 people with 84 deaths and only 19 survivors, conjunctivitis was reported in 42% of those that died and 47% of those that survived. Further more, it was noted that 3 of the early onset manifestation that appears to be more suggestive EVD include: bilateral conjunctival injection, maculopapular rash and sore throat with odynophagia (pains on trying to swallow), and always associated with fever [temp: >37.5*C] as the most common symptoms (93% of the time there is fever!).
"Am therefore of the opinion to handle patients with acute red eyes and presented with sudden onset of fever with utmost care! I advice we refer such to a general practitioner to rule out EVD."
The symptoms that tend to follow include vomiting and rash and bleeding problems with bloody nose (epistaxis), spitting up blood from the lungs (hemoptysis) and vomiting it up from the stomach (hematemesis), chest pains and bloody eyes (conjunctival hemorrhages).
“Hemorrhaging symptoms" begin 4 – 5 days after onset, which includes hemorrhagic conjunctivitis, pharyngitis, bleeding gums, oral/lip ulceration, hematemesis, melena, hematuria, epistaxis, and vaginal bleeding,” reports the Pathogen Safety Data Sheet from the Public Health Agency of Canada. {8}
In its late stages, Your bloodstream starts to fill with small blood clots, which slows the blood. Some of these clots stick to blood vessels' sides. (This is called pavementing, because the clots resemble a mosaic).
These clots are very dangerous; they clog up capillaries, which shuts off blood supply various parts of the body, such as the kidneys, lungs, intestines, liver, brain, and throughout the skin. Your skin starts to get these little red dots all over it, which are hemorrhages under the skin (petechiae). It attacks connective tissues that hold your organs together, destroys collagen, and liquefies the under layers of the skin. White blisters appear alongside the red dots (called a maculopapular rash, and looks like tapioca pudding). Rips easily occur in the skin, and hemorrhagic blood spills out. The rash develops into bruises, and the skin becomes pulpy and soft. Your connective face tissues are destroyed, and your face takes on hollow, mask-like look.
These clots are very dangerous; they clog up capillaries, which shuts off blood supply various parts of the body, such as the kidneys, lungs, intestines, liver, brain, and throughout the skin. Your skin starts to get these little red dots all over it, which are hemorrhages under the skin (petechiae). It attacks connective tissues that hold your organs together, destroys collagen, and liquefies the under layers of the skin. White blisters appear alongside the red dots (called a maculopapular rash, and looks like tapioca pudding). Rips easily occur in the skin, and hemorrhagic blood spills out. The rash develops into bruises, and the skin becomes pulpy and soft. Your connective face tissues are destroyed, and your face takes on hollow, mask-like look.
Your eyes also turn bright red, and may be fixed in one position (optometrists take note). Your gums, mouth linings, and salivary glands start hemorrhaging. The surface of the tongue turns bright red, and dissolves. The lining of your throat also dissolves. Then the black vomit starts... Your heart starts bleeding in itself, and blood starts to fill the chest cavity. Blood clots in the brain kill brain cells, which is known as sludging of the brain. The linings of the eyeballs may fill with blood, and you could go blind. You may even weep blood.
You could possibly have a hemispherical stroke, in which parts of your body may become paralyzed, or could be fatal.
Since your organs are clogged with coagulated blood, the blood that you bleed does not clog, the red blood cells having been destroyed, those organs/tissues die while you are still alive... The liver turns yellow, bulges, and may start to dissolve. The kidneys may fail, the spleen hardens, and the intestines fill with blood. If the victim is pregnant, she will abort her baby, which is filled with Ebola virus particles and has red eyes.
EVD destroys the brain thoroughly, and you would probably have epileptic convulsions, or grand Mal-seizures. The entire body violently shakes. If you don't die from a stroke or organ failure, then you will have to suffer from "crash and bleed".... like you might see depicted in some horror zombie flick! You hemorrhage through almost every opening of your body. Your body, already damaged from shock, heated by fever, and slowly being destroyed tissue by tissue, quickly "crashes" from blood loss. After the body is clinically dead, body tissues (skin, organs, etc.) liquefy, and the fluids are filled with Ebola virus particles.{4}
In general, it takes about 2-21 days (average incubation period) for symptoms to become visible.
According to reports, people who have the virus aren’t contagious until symptoms become visible.
What do we need to do?
Every patient that reports for eye check should be requested to have his or her body temperature checked among other parameters like the blood pressure, weight, pulse etc. Anyone with fever and sudden conjunctival hyperemia should be watched and preferably accessed by a general practitioner.
In absence of a general practitioner, the person's full blood count (FBC) is requested cos it often gives clue to EVD. The first line of defense in our body, the macrophages, neutrophils, monocytes etc are highly suppressed in hemorrhagic fever.
EVD is not airborne, though it has been isolated borne on aerosol suspended in the air!{9} .
It is highly advised that we should wear a nose/mouth mask while performing direct ophthalmoscopic examination, hand-held Goldman applanation tonometry or even Schiotz type of tonometer! The air puff tonometry should be the more appropriate in this type of scenario.
EVD is a contact disease. The virus can be transmitted when it comes in direct or indirect contact with a new host. It is therefore advised to ensure we wear re-useable gloves that can be disinfected immediately after attending to a patient. Always wash your hands with disinfectant soap after attending to a patient. Our trial lens frame or the phoropter head should be disinfected with methylated spirit after seeing every patient. When contact equipments are used in the clinic, the least you can do is to disinfect it with methylated spirit.
Do not send home someone you suspect of any of the above symptoms. Let the fever component be of particular interest, others like conjunctivitis and the acute onset of this fever be very suggestive for further action.
The Public Health Agency of Canada explains that virus can survive in liquid or dried material for a number of days. Infectivity is found to be stable at room temperature or at 4 C for several days, and indefinitely stable at -70 C. There is need therefore to disinfect our door knobs, in the clinic and at home.
A message to Optometrists:
What could be faulted as the pathophysiology of conjunctival hyperemia often associated with proven cases of EVD? Does conjunctival involvement predict survival or death in those with EVD? Can ocular involvement and fever be consistent enough for EVD diagnosis?
There is certainly much work to be done, researches to be carried out, bearing in mind that most survivors of EVD end up with chronic ocular complication. As the window of the body to the world, can't some unknown be revealed of this deadly virus since our country is not fully equipped to identify this deadly virus.
It is important as primary eye care professional to develop visual"clues" that may be very helpful... This writeup is retrospective because there has not been any active research work to this end. The onus of proof lies with us.
EVD is a national emergency situation, we should stay prepared and be
ready to help in containing this virus and learning more about it.
Ebola is real, a real manace to humanity. We should confront it with ferocity it deserves...
Dr Victor Ezebuiroh.
{1} (http://www.merriam-webster.com/medical/filoviridae)
{2} (Peter B. Jarhling, PhD*; Aileen M. Marty, MD†; and THOMAS W. Geisbert, PhD: Viral Hemorrhagic fevers. Medical aspects of biological warfare Chapter 13; p272)
{4} http://www.tpida.org/files/Filoviridae.pdf)
{5} http://en.m.wikipedia.org/wiki/Bundibugyo_virus].
{6} Martin GA, Siegert R, eds. Marburg virus disease. Berlin: Springer Verlag, 1971.)
{7} http://drrimatruthreports.com/dtra-confirma-ebola-nano-study/)
{8} (http://www.phac-aspc.gc.ca/lab-bio/res/psds-)
{9} Peters and LeDuc. Ebola: The virus and the disease. The Journal of Infectious diseases 1999; 179(Suppl1): xi.]
