EBOLA UPDATE (40): EYE PROBLEMS, GUIDELINES, VACCINE

Posted on 21ST OCT 2017
tagged Ebola, Worldwide

A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

In this update:
[1] Ebola eye problems
[2] Ebola guidelines
[3] Vaccine update

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[1] Ebola eye problems
Date: Thu 19 Oct 2017
Source: New York Times [edited]
https://www.nytimes.com/2017/10/19/health/ebola-survivors-cataracts.html

Hoisted onto the operating table by a nurse, AC, a spunky 8-year-old, crossed her skinny ankles jauntily and held stock-still as doctors numbed her eye and then pierced it with a needle to withdraw a sample of fluid.

Up to 2 years ago, Ebola nearly took AC's life. Now, complications from it are threatening her sight.

She came with her mother to an eye hospital here in late July [2017], hoping for surgery to remove a dense cataract that had clouded the lens of her right eye, erasing most of its vision.

Cataracts usually afflict the old, not the young, but doctors have been shocked to find them in Ebola survivors as young as 5. And for reasons that no one understands, some of those children have the toughest, thickest cataracts that eye surgeons have encountered, along with scarring deep inside the eye.

Before the [Ebola virus disease (EVD)] epidemic in West Africa, from 2013 -- 2016, doctors did not realize how much damage the disease could leave in its wake, because previous outbreaks were small and survivors few. Eye disease, with the specter of blindness, has become a dreaded complication.

There are about 17 000 [EVD] survivors in West Africa, and researchers estimate that 20 percent of them have had a severe inflammation inside the eye, uveitis. It can cause blindness, but even if it resolves and sight returns, cataracts can quickly follow. Usually, just one eye is affected.

Until recently, surgeons have hesitated to remove cataracts from [EVD] survivors, for fear that the insides of their eyes might still harbor the virus. But physicians from Emory University have made a series of visits to West Africa to study eye problems in survivors, treat them and find ways to prevent blindness if more Ebola outbreaks occur. One goal has been to look for the virus in the eyes of survivors with cataracts, to let local surgeons know whether it is safe to operate. 'Hopefully, more patients will get access to cataract surgery, and practitioners will feel safe," said Dr. Jessica Shantha, an ophthalmologist from Emory.

On a Monday morning, AC and her mother joined about 20 other Ebola survivors of all ages at the Kissy/Lowell and Ruth Gess United Methodist Church Eye Hospital, listening as the Emory doctors explained the tests and treatments they would receive. The patients, with their hazy eyes, looked grim and fatigued, old beyond their years.

The team included 2 more ophthalmologists, Dr. Steven Yeh and Dr. Brent Hayek, and Dr. Ian Crozier, an infectious disease specialist who contracted Ebola while treating patients in Sierra Leone in 2014 and who recently joined the National Institutes of Health. "I'm also an Ebola survivor in whom my eye went blind," Dr. Crozier told the group. "The same things you go through today, I went through for the past 2 years, even with the same doctors."

A translator repeated his message in Krio, the country's most widely spoken language. Gesturing to Dr. Yeh, Dr. Crozier said: "Dr. Steve put the needle in my eye. So in a sense we are getting the same care." ...-more

[Byline: Jane Hahn]

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Communicated by:
ProMED-mail Rapporteur Mary Marshall

[This report on the eye problems being encountered by survivors of Ebola virus disease [EVD], particularly young children, is well worth reading for the effective photos and to gain further understanding of the impact of Ebola virus on survivors. The story of Dr. Ian Crozier, an infectious disease specialist who contracted Ebola while treating patients in Sierra Leone in 2014, who was among the 1st to report serious eye problems after recovering from infection, was well publicized. The N Engl J Med reported on the clinical course the disease took in Dr. Crozier where severe, acute, unilateral uveitis developed during the convalescent phase following infection ( JB Varkey et al. Persistence of Ebola Virus in Ocular Fluid during Convalescence. N Engl J Med 2015; 372:2423-2427 DOI: 10.1056/NEJMoa1500306). The authors report they detected viable EBOV in aqueous humor obtained from Dr. Crozier's inflamed eye 14 weeks after the onset of the initial symptoms of EVD and 9 weeks after the clearance of viremia. Virus was not detectable after 18 months, but it is not known at what point before then it became undetectable.

A 2nd doctor, Dr. Richard Sacra, who also contracted Ebola while caring for pregnant women in Liberia during the Ebola outbreak there was declared Ebola-free after spending about a month in the hospital in the US. "But about 2 weeks after he was released from the hospital, Sacra reported vision loss, pain, redness and sensitivity to light in his left eye. An examination showed a slight swelling of his cornea, and there were white blood cells in the space between the outer covering and the iris in his eye," the report said. "Sacra was given a topical corticosteroid to apply to his eye every hour while he was awake. But Sacra's vision worsened, and he was given an oral corticosteroid, prednisone. Within a week, his condition improved, and by March 2015, he had no symptoms and had 20-20 vision," the report said (https://www.livescience.com/52902-ebola-survivor-eye-problems-sacra.html).

Because of cases such as these, the doctors in W Africa have been afraid to operate on the children's eyes without being assured they are virus-free. The children being treated for these severe cataracts following recovery from EVD are initially tested for the presence of Ebola virus to alleviate such fears. But it is important to operate early in the process of the formation of the cataracts as the scarring is likely to worsen with time. The NY Times report states that the "capsule of tissue around the lens [is sometimes] so calcified that it was like cutting through cement."

Some patients have experienced damage worse than cataracts, e.g., "inflammation that caused soaring eye pressure, which damaged the optic nerve and caused permanent blindness and constant pain."

The toll of EVD seems to be never ending for W Africa. It is commendable there are doctors willing to work to help improve the lives of those individuals lucky enough to survive, but who are experiencing serious medical and psychological problems resulting from infection. - Mod.LK]

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[2] Ebola guidelines
Date: Wed 18 Oct 2017
Source: Cidrap [edited]
http://www.cidrap.umn.edu/news-perspective/2017/10/new-ebola-guidelines-...

Up to 2 new studies offer insight into how to care for patients during the next Ebola outbreak, including recommendations for hydration, monitoring, testing, and pain relief as part of supportive care.

A new study based on the 2013--2016 West African [Ebola virus disease (EVD)] outbreak, the world's largest, states that patients need immediate oral hydration when 1st hospitalized for EVD, but that human-to-human transmission is low when personal protective gear is used appropriately.

The study, by a team of international experts, was published yesterday [Tue 17 Oct 2017] in The Lancet. The authors write that at the beginning of the outbreak in 2013, case-fatality rates were 70 percent, but that number was lowered significantly (to 40 percent) as supportive care practices improved over the course of the outbreak. Using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, the authors present evidence-based recommendations for patient care during the next Ebola outbreak.

Oral hydration and intravenous hydration had the strongest recommendation. When administered properly, the measure carries no risk of transmission to healthcare workers, the experts say. and making sure patients, especially the very young, are adequately hydrated is a necessary supportive measure.

Having enough medical staff, at least one doctor for 4 patients, was also strongly suggested. Patients should be assessed 3 times per day and should be continuously monitored.

Finally, the authors also recommended prompt use of analgesics and antibiotics as necessary.

[Citation. Lamontagne F et al. 2017. Evidence-based guidelines for supportive care of patients with Ebola virus disease. The Lancet. 17 Oct 2017 http://dx.doi.org/10.1016/S0140-6736(17)31795-6
Abstract. The 2013-16 Ebola virus disease outbreak in west Africa was associated with unprecedented challenges in the provision of care to patients with Ebola virus disease, including absence of pre-existing isolation and treatment facilities, patients' reluctance to present for medical care, and limitations in the provision of supportive medical care. Case fatality rates in west Africa were initially greater than 70 percent, but decreased with improvements in supportive care. To inform optimal care in a future outbreak of Ebola virus disease, we employed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to develop evidence-based guidelines for the delivery of supportive care to patients admitted to Ebola treatment units. Key recommendations include administration of oral and, as necessary, intravenous hydration; systematic monitoring of vital signs and volume status; availability of key biochemical testing; adequate staffing ratios; and availability of analgesics, including opioids, for pain relief.]

Another study, published in Emerging Infectious Diseases, used retrospective data from 252 Ebola-positive and 172 Ebola-negative patients at a Sierra Leone Ebola treatment center to develop easy-to-use risk scores "based on symptoms and laboratory tests (if available), to stratify triaged patients by their likelihood of having Ebola infection."

Because Ebola patients can have symptoms similar to cholera and yellow fever, among other diseases, the researchers tracked the most common clinical and lab-based markers of Ebola virus. These markers can help quickly help establish an Ebola diagnosis in rural settings, where rapid Ebola testing isn't widely available.

Positive Ebola diagnosis corresponded most often with headache, diarrhea, difficulty breathing, nausea and vomiting, loss of appetite, and conjunctivitis. The laboratory tests most useful were creatinine, creatine kinase, alanine aminotransferase, and total bilirubin. The risk scores developed by the researchers correctly identified 92 percent of Ebola-positive patients as being at high risk for infection.

"Our risk scores cannot replace the WHO case definition or actual diagnostic testing. They can, however, help fill the gap between a broad case definition and an often-lengthy diagnostic process, which is valuable for several reasons," the authors wrote. "Until a reliable rapid [point-of-care] diagnostic for Ebola is readily available in low-resource settings, a flexible risk score that is easy to implement can be a useful tool for further triaging patients."

[Citation 2. Oza S et al. 2017. Symptom- and Laboratory-Based Ebola Risk Scores to Differentiate Likely Ebola Infections. Emerging Infectious Diseases. 23(11) http://www.cdc.gov/eid
Abstract. Rapidly identifying likely Ebola patients is difficult because of a broad case definition, overlap of symptoms with common illnesses, and lack of rapid diagnostics. However, rapid identification is critical for care and containment of contagion. We analyzed retrospective data from 252 Ebola positive and 172 Ebola-negative patients at a Sierra Leone Ebola treatment center to develop easy-to-use risk scores, based on symptoms and laboratory tests (if available), to stratify triaged patients by their likelihood of having Ebola infection. Headache, diarrhea, difficulty breathing, nausea/ vomiting, loss of appetite, and conjunctivitis comprised the symptom-based score. The laboratory-based score also included creatinine, creatine kinase, alanine aminotransferase, and total bilirubin. This risk score correctly identified 92 percent of Ebola-positive patients as high risk for infection; both scores correctly classified >70 percent of Ebola-negative patients as low or medium risk. Clinicians can use these risk scores to gauge the likelihood of triaged patients having Ebola while awaiting laboratory confirmation. ]

[Byline: Stephanie Soucheray]

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Communicated by:
ProMED-mail

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[3] Vaccine update
Date: Fri 20 Oct 2017 17:35:01
Source: Xinhuanet [edited]
http://news.xinhuanet.com/english/2017-10/20/c_136694109.htm

[China has approved a domestically developed Ebola vaccine, according to the China Food and Drug Administration (CFDA) [Fri 20 Oct2017].

The vaccine was developed by the Academy of Military Medical Sciences and CanSino Biologics INC.

Its approval makes China the 3rd country to develop a vaccine against Ebola following the United States and Russia.

The vaccine is based on the 2014 mutant gene type and in the form of freeze-dried powder, which can remain stable for at least 2 weeks in temperatures of up to 37 degrees Celsius [98.6 F] and is suitable for the climate in West Africa.

The vaccine was clinically-approved by the CFDA in Feb 2015 and has undergone clinical trials in Sierra Leone, one of the countries worst hit by Ebola." ...more...]

[Byline: An]

[Compiled by: Celeste Whitlow ]

[Maps of the West African countries affected by the 2014 Ebola outbreak can be accessed at:
Liberia http://healthmap.org/promed/p/54
Guinea http://healthmap.org/promed/p/45
Sierra Leone http://healthmap.org/promed/p/46. - Mod.LK]

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