Epidemiologia, clinica e terapia della Malattia da Virus Ebola Prof. Francesco Castelli Chair of Infectious Diseases UNESCO Chair University of Brescia (Italy) Director, WHO Collaborating Center for TB/HIV co-infection and TB elimination strategy Presidente, Società Italiana di Medicina Tropicale e Salute Globale … it is time to close the book on infectious diseases. The war against pestilence is over… William Stewart, Surgeon General in a message to Congress, 1969 People are not just people. They are an awful lot of microbes, too 90 percent of the cells in the body are microbial and only the remaining 10 percent are human Fattori favorenti l’emergenza di nuove infezioni • • • • • • • • • Crescita popolazione, urbanizzazione Aumentata produzione animale Alterazioni habitat vettori / animali Mobilità umana, vettori, germi, reservoir animale Modificazioni dell’ecosistema (deforestazione, clima, etc.) Comportamento umano Pressione farmacologica (uomo e animale) Adattamento microbico Bioterrorismo ? Incremento demografico Urbanizzazione 80% : Latina America, Northern America 73% : Europe 48% : Asia 64% by 2050 40% : Africa 56% by 2050 https://www.google.it/search?q=world+population+and+animal+production&newwindow=1&rlz=1C1GGGE_itIT459IT526&espv=2&tbm=isch&imgil=M_S OiDQYxgpObM%253A%253B_w12vKrYX8d9rM%253Bhttp%25253A%25252F%25252Fna.unep.net%25252Fgeas%25252FgetUNEPPageWithArticleI DScript.php%25253Farticle_id%2525253D92&source=iu&pf=m&fir=M_SOiDQYxgpObM%253A%252C_w12vKrYX8d9rM%252C_&usg=__hS0kEDZ29 zihAQOEWWGpxmdRPZ4%3D&biw=1093&bih=499&ved=0CE0Qyjc&ei=i_lUVP7bFZaxaf7fgrgN#facrc=_&imgdii=_&imgrc=M_SOiDQYxgpObM%253A %3B_w12vKrYX8d9rM%3Bhttp%253A%252F%252Fna.unep.net%252Fgeas%252FarticleImages%252FOct-12-figure1.png%3Bhttp%253A%252F%252Fna.unep.net%252Fgeas%252FgetUNEPPageWithArticleIDScript.php%253Farticle_id%253D92%3B1509%3B973 Examples of recent emerging diseases NATURE; Vol 430; July 2004; www.nature.com/nature Geosentinel http://healthmap.org/en/ Outbreak Detection and Response without Preparedness First Case Late Detection Delayed Response 90 80 60 Opportunity for control 50 40 30 20 10 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 Cases 70 Day Outbreak Detection and Response with Preparedness Early Detection Rapid Response 90 80 Potential Cases Prevented 60 50 40 30 20 10 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 Cases 70 Day Il mestiere del guardiabosco … Malattia da Virus Ebola: • le vecchie epidemie • quadro epidemiologico attuale • modalità trasmissione • aspetti clinici Flying along the Zaire River to Yambuku, DR Congo (Zaire), October 1976 Epidemiologists in Yambuku, DR Congo (Zaire), 1976 Peace Corps Volunteer, Joel Breman, Peter Piot, Pierre Sureau Country Dem. Rep. of Congo Town Yambuku Cases 318 Deaths 280 Species Zaire ebolavirus Year 1976 South Sudan Dem. Rep. of Congo Nzara Tandala 284 1 151 1 Sudan ebolavirus Zaire ebolavirus 1976 1977 South Sudan Gabon Ivory Coast Nzara Mekouka Tai Forest 34 52 1 22 31 0 Sudan ebolavirus Zaire ebolavirus Taï Forest ebolavirus 1979 1994 1994 Dem. Rep. of Congo Kikwit 315 250 Zaire ebolavirus 1995 Gabon Gabon South Africa Uganda Gabon Republic of Congo Republic of Congo Republic of Congo South Sudan Dem. Rep. of Congo Mayibout Booue Johannesburg Gulu Libreville Not specified Mbomo Mbomo Yambio Luebo 37 60 2 425 65 57 143 35 17 264 21 45 1 224 53 43 128 29 7 187 Zaire ebolavirus Zaire ebolavirus Zaire ebolavirus Zaire ebolavirus Zaire ebolavirus Zaire ebolavirus Zaire ebolavirus Zaire ebolavirus Zaire ebolavirus Zaire ebolavirus 1996 1996 1996 2000 2001 2001 2002 2003 2004 2007 Uganda Bundibugyo 149 37 Bundibugyo ebolavirus 2007 Dem. Rep. of Congo Luebo 32 15 Zaire ebolavirus 2008 Uganda Luwero District 1 1 Sudan ebolavirus 2011 Uganda Kibaale District 11* 4* Sudan ebolavirus 2012 Dem. Rep. of Congo Isiro Health Zone 36* 13* Bundibugyo ebolavirus 2012 Uganda Luwero District 6* 3* Sudan ebolavirus 2012 Malattia da Virus Ebola: • le vecchie epidemie • quadro epidemiologico attuale • modalità trasmissione • aspetti clinici Attuale epidemia: paziente zero Bimbo di 2 anni, originario del piccolo villaggio di Guéckédou, nella Guinea sudorientale, morto il 6 dicembre scorso e probabilmente infettatosi mangiando la frutta non cotta contaminata dai pipistrelli della frutta. La particolare collocazione del villaggio, in una regione lungo il confine tra Liberia, Sierra Leone e la stessa Guinea, ha contribuito alla creazione di corridoi iniziali di trasmissione in questi tre Paesi. I primi ad ammalarsi e morire sarebbero stati i familiari del bimbo: la madre, la sorellina di tre anni e la nonna. Due partecipanti al funerale delle prime vittime avrebbero poi contribuito alla trasmissione del contagio ai loro rispettivi villaggi e da lì, attraverso i parenti stretti e alcuni operatori sanitari, ad altri centri. Origine e diffusione dell’epidemia monrovia N Engl J Med 2014; 371:1481-1495. DOI: 10.1056/NEJMoa1411100 Le date «chiave» della epidemia 6 dicembre 2013 : inizio della epidemia in Guinea Conakry 23 marzo 2014 : l’OMS viene ufficialmente informata della rapida evoluzione della epidemia di Ebola 8 agosto 2014 : l’OMS dichiara la attuale epidemia di Ebola una emergenza globale 17 settembre 2014 : le Nazioni Unite dichiarano Ebola in Africa Occidentale una minaccia per la pace e la sicurezza UK(29/12->) Confirmed: 1 Deaths: 0 Contacts identified: ? USA (1Texas- 1NY) (24/9->) Total: 2+2 confirmed case Deaths: 1 Contacts identified: 470 SENEGAL (20/8->19/10) Total: 1 confirmed case Deaths: 0 Contacts identified: 74 MALI (22/10->) Confirmed: 7 Probable: 1 Deaths: 6 Contacts identified: 327 NIGERIA (20/7->20/10) Total: 1 +19 clinical cases Confirmed: 19 (Lagos 15, Port Harcourt 4) Probable: 1 Deaths: 8 (7 confirmed, 1 probable) ECDC 18 Dec 2014 Date of Evacuation Evacuated from Evacuated to Profession Status 02 August 2014 Liberia Atlanta (USA) Healthcare worker Discharged Yes USA 05 August 2014 Liberia Atlanta (USA) Healthcare worker Discharged Yes USA 06 August 2014 Liberia Madrid (Spain) Healthcare worker Death Spain 24 August 2014 Sierra Leone London (United Healthcare Kingdom) worker 27 August 2014 Sierra Leone Hamburg (Germany) Epidemiologist Recovered Yes Senegal Omaha (USA) Physician Discharged Yes (obstetrician) USA 09 September 2014 Kenema, Sierra Atlanta (USA) Leone Physician Discharged Yes USA 14 September 2014 Sierra Leone Leiden (the Netherlands) Healthcare worker Discharged No Netherland s 14 September 2014 Sierra Leone Leiden (the Netherlands) Healthcare worker Discharged No Netherland s 19 September 2014 Liberia Paris (France) Healthcare worker Discharged Yes France 22 September 2014 Sierra Leone Madrid (Spain) Healthcare worker Death Yes Spain 22 September 2014 Sierra Leone Geneva (Switzerland) Healthcare worker Admitted Unknow Non-Swiss n 28 September 2014 Sierra Leone Maryland (USA) Healthcare worker Admitted Unknow USA n 02 October 2014 Sierra Leone Frankfurt (Germany) Healthcare worker Stable Yes 02 October 2014 Liberia Omaha (USA) Cameraman Discharged Yes USA 06 October 2014 Sierra Leone Oslo (Norway) Healthcare worker Discharged Yes Norway 08 October 2014 Liberia Leipzig (Germany) Laboratory worker Death Yes Sudan 01 November 2014 Sierra Leone Paris (France) UN worker Unknown Yes Sierra Leone 15 November 2014 Sierra Leone Nebraska (USA) Healthcare worker Death Yes USA 20 November 2014 Sierra Leone Geneva (Switzerland) Healthcare worker Unknown Yes Cuba 21 November 2014 Mali Madrid (Spain) Healthcare worker Unknown No Spain 24 November 2014 Sierra Leone Rome (Italy) Healthcare worker Admitted Yes Italy 04 September 2014 Monrovia, Liberia Confirm Citizenship Yes Discharged Yes UK Uganda Guinea 74 confirmed cases were reported in the 7 days to 4 January 2015 There is no discernible upward or downward trend. However, EVD continues to spread geographically, with the western prefecture of Fria reporting confirmed cases for the first time 19 districts have reported a confirmed or probable case in the 21 days to 4 January. Liberia Case incidence has declined from a peak of over 300 new confirmed cases per week in August and September to 8 new confirmed cases and 40 probable cases in the 5 days to 2 January, 2015. The district of Montserrado, which includes the capital Monrovia, continues to account for most cases in the country, with 6 confirmed and 33 probable cases reported in the 5 days to 2 January. Sierra Leone There are signs that case incidence may have levelled off in Sierra Leone, although with 248 new confirmed cases reported in the week to 4 January 2015, it remains by far the worst-affected country at present. Fattori che hanno favorito la comparsa dell’epidemia • • • • Commistione habitat uomo-animale Crescita demografica ed inurbamento Comportamenti tradizionali (lavaggio cadavere) Assenza di immunità nella popolazione Repubblica Democratica del Congo (ex-Zaire) 24 agosto 2014: notificata epidemia in RD Congo (Boende, prov. Equateur), causata da variante diversa da quella dell’Africa occidentale ma sempre della specie Zaire ebolavirus); al 7 ottobre: 69 pts con MVE (38 confermati, 28 probabili, 3 sospetti), 49 decessi, letalità del 74% tra casi probabili e confermati N Engl J Med, October 15, 2014; DOI: 10.1056/NEJMoa1411099 Malattia da Virus Ebola: • le vecchie epidemie • quadro epidemiologico attuale • modalità trasmissione • aspetti clinici Towards detecting the natural host of the virus Modalità contagio umano: •Contatto con pipistrelli o loro ambiente (grotte, alberi da frutto infestati…) •Contatto con animali (primati o mammiferi) (carcasse, sangue, carne cruda) (luoghi infestati da ratti) •Contatto diretto o indiretto con sangue o liquidi biologici o tessuti di malati o morti No trasmissione per via aerea No trasmissione da soggetti infetti asintomatici Trasmissione interumana TRASMISSIONE DA DROPLETS • MANTENERE ALMENO 1 METRO DI DISTANZA • MASCHERINA CHIRURGICA • STANZA SINGOLA • infezione meningococcica • infezioni virali • Inf. batteriche respiratorie Carica infettante: 1-10 virus (dati sperimentali su primati) Rilevabilità di RNA di Virus Ebola dopo comparsa di sintomi 101 gg in seme 33 in secrezioni vaginali 29 nel retto 23 in urine 22 in tampone congiuntivale 21 in sangue 15 in latte 8 in saliva 6 su pelle Numero di casi secondari prodotti da ogni caso (Ro) 1.81 (95% CI, 1.60 to 2.03) for Guinea 1.51 (95% CI, 1.41 to 1.60) for Liberia 1.38 (95% CI, 1.27 to 1.51) for Sierra Leone Periodo incubazione: media 4-10, IC95% 2-21 Malattia da Virus Ebola: • le vecchie epidemie • quadro epidemiologico attuale • modalità trasmissione • aspetti clinici Patogenesi Poco nota: Infezione di monociti, macrofagi e cellule dendritiche Depressione immunità Danno diretto del sistema vascolare Danno diretto di cellule parenchimali di organi bersaglio (fegato, milza, linfonodi, surrenali) Danno da mediatori solubili (citochine, complemento) risposta infiammatoria sistemica Fase acuta: -Replicazione virale e viremia -Risposta immune Ebola pathogenesis Feldman et al., NATURE Reviews, 2003; 3: 677-85 Low risk of transmission High risk of transmission Filovirus activity among selected ethnic groups inhabiting the tropical forest of equatorial Africa. Johnson ED1, Gonzalez JP, Georges A. Seroepidemiological surveys were conducted to determine the frequency and distribution of filovirus activity among selected ethnic groups inhabiting the tropical forests of the Central African Republic. 427 serum specimens were collected from hunter-gatherers and subsistence farmers living in forest environs in the Lobaye District south of the river Lobaye and west of the river Oubangui. Striking serological evidence for filovirus activity was found in both populations. Ebola virus appears to be the most active filovirus; 17.6% (75/427) of the Lobaye survey population were seropositive forEbola virus reactive antibody while 1.2% (5/427) were seroreactive with Marburg viral antigens. Ethnic background appeared to be an important risk factor influencing filovirus exposure in the forest communities. The filovirus antibody prevalence among 2140 years old male Aka Pygmy hunter-gatherers was significantly (P = 0.03) 3 times higher (37.5%) than that in similarly aged male Monzombo and Mbati subsistence farmers (13.2%). Continued epidemiological investigations are needed to define ethnic-related events influencing human filovirus activity in the Congo basin of equatorial Africa. Trans R Soc Trop Med Hyg. 1993 Sep-Oct;87(5):536-8 Treatment of Ebola • • There are no approved treatments available for EVD. Clinical management focus - supportive care of complications: – hypovolemia, electrolyte abnormalities, hematologic abnormalities, refractory shock, hypoxia, hemorrhage, septic shock, multi-organ failure, and DIC. • Recommended care includes: – volume repletion – maintenance of blood pressure (with vasopressors if needed) – maintenance of oxygenation – pain control – nutritional support – treating secondary bacterial infections and pre-existing comorbidities • Among patients from West Africa, large volumes of intravenous fluids have often been required to correct dehydration due to diarrhea and vomiting. • Several investigational therapeutics for Ebola virus disease are in development. There are no approved vaccines available for EVD. Several investigational Ebola vaccines are in development, and Phase I trials are underway for some vaccine candidates. Source: Centers for Disease Control and Prevention. http://www.cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcaresettings.html Accessed Oct. 14, 2014 1) Mouse chimeric antibodies ch133, ch226 2) Ab cocktail: Zmab, MB-003 3) Zmapp: 1 Ab from MB-003 and 2 Abs from Zmab Reversion of advanced Ebola virus disease in non human primates with ZMapp. Qiu X1, et al. Mapp Biopharmaceutical Inc., San Diego, California 92121, USA. ………. Here we show that a combination of monoclonal antibodies (ZMapp), optimized from two previous antibody cocktails, is able to rescue 100% of rhesus macaques when treatment is initiated up to 5 days post-challenge. High fever, viraemia and abnormalities in blood count and blood chemistry were evident in many animals before ZMapp intervention. Advanced disease, as indicated by elevated liver enzymes, mucosal haemorrhages and generalized petechia could be reversed, leading to full recovery. ELISA and neutralizing antibody assays indicate that ZMapp is crossreactive with the Guinean variant of Ebola. ZMapp exceeds the efficacy of any other therapeutics described so far, and results warrant further development of this cocktail for clinical use amiodarone favipravir Phase II trials in west Africa in the next 2-4 weeks ChAd3-EBO-Z (GSK Biologicals/NIAID) chimpanzee adenovirus (ChAd3), genetically engineered to express gycoproteins from the Zaire specie rVSV-ZEBOV (NewLink/Merck) vesicular stomatitis virus (VSV), genetically engineered to express gycoproteins from the Zaire specie Liberia: 3 arms (ChAd3-EBO-Z; rVSV-ZEBOV; control vaccine): 9000x 3 pts Guinea: ring design study Sierra Leone: one vaccine with a stepped wedge approach MALATTIA DA VIRUS EBOLA DIREZIONE MEDICA 29-30-31 OTTOBRE 2014 Ci ricorderemo di loro dopo la epidemia? 1. Cuba : 2. Greece : 3. Monaco : 4. Belarus : 5. Austria 6. Georgia . 7. Italy : 8. Norway : 9. Switzerland : 10. …….. 11 …….. 640 604 581 487 475 454 424 408 407 http://www.worldmapper.org/display.php?selected=219 160. Guinea : 161. ….. 10 186. Sierra Leone: 2 187. Liberia : 1 188. Tanzania : 1 A total of 820 health-care workers (HCWs) are known to have been infected with EVD up to the end of 7 November: 154 in Guinea; 370 in Liberia; 11 in Nigeria; 296 in Sierra Leone; one in Spain; and three in the United States of America (two were infected in the USA and one in Guinea). A total of 488 HCWs have died (WHO; 7th Jan 2015) http://www.indexmundi.com/map/?v=2226&l=it Prof. Francesco Castelli Chair of Infectious Diseases UNESCO Chair University of Brescia (Italy) Harrison’s Principles of Internal Medicine, 18 18° edition, 2012 Chapers Part 1. Introduction to clinical medicine Part 2. Cardinal manifestations and presentations of diseases Pages Pages for ID 92 379 Part 3. Genes, the environment and diseases 40 Part 4. Regenerative medicine 20 Part 5. Aging 32 Part 6. Nutrition 58 12 Part 7. Oncology and hematology 361 11 Part 8. Infectious diseases 761 761 30 11 Part 9. Terrosism and clinical medicine Part 10. Disorders of the cardiovascular system 286 Part 11. Disorders of the respiratory system 112 12 84 9 Part 13. Disorders of the kidney and urinary tract 122 9 Part 14. Disorders of the gastrointestinal system 248 23 Part 15. Disorders of the joints and adjacent tissues 216 7 Part 16. Endocrinology and metabolism 358 Part 17. Neurologic disorders 342 Part 18. Poisoning, drug overdose and evenomations 19 Part 12. Critical care medicine 3585 38 893 (24.9%) Substantiated public health events of potential international concern by hazard Jan 2001-14 June 2011 (n=2,448; 477 (19%) in AMRO) 85% Aldighieri, PAHO, 2012