Viral Hemorrhagic Diseases

Learning Outcomes
• At the end of this lecture you should be able to:

– describe ‘viral hemorrhagic disease’ and different viruses causing them (aetiology)

– Identify the major modes of transmission of specified viral hemorrhagic diseases

– Explain the clinical signs/symptoms, and pathophysiology of viral hemorrhagic

diseases/viral hemorrhagic fever

– Justify the choice of laboratory investigations for their diagnosis

– outline a general treatment plan, and prevention/control of viralhemorrhagic

diseases

– describe the epidemiology, pathogenesis, and laboratory diagnosis of Dengue

hemorrhagic fever in detail
 Overview of the lecture
Part-1 Part-2 Part-3

• Introduction to viral • Clinical diseases & • Dengue virus & dengue

hemorrhagic Pathogenesis of viral hemorrhagic fever
diseases and hemorrhagic
causative viruses diseases/viral
hemorrhagic fever o Epidemiology/transmission
• Global distribution
• Laboratory o Clinical disease and symptoms
• Major modesof investigations for their o Laboratory diagnosis
transmission diagnosis o Management (overview)
o Prevention
• Biosafety issues with
Viruses causing HF
• Treatment outline, and
prevention/control

2
 Part-1

Introduction to VHF & causativeviruses

Global distribution & modes of transmission

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 Viral Hemorrhagic Diseases
or
Viral Hemorrhagic Fevers (VHFs)
• A group of illnesses that are caused byseveral
distinct families of viruses
• A severe multisystem syndrome-
– (multiple organ affected)

• Symptoms are often accompanied by hemorrhage

(bleeding)
• While some types of hemorrhagic fever viruses can
cause relatively mild illnesses, many of theseviruses
cause severe, life-threatening disease
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 Viral Hemorrhagic Fever: Aetiology

Viruses of four distinct families:

1. Arenaviruses (Arenaviridae)
2. Bunyaviruses (Bunyaviridae)
3. Filoviruses (Filoviridae)
4. Flaviviruses (Flaviviridae)

Each of these families share a number of features in common

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Common Features of Hemorrhagic fever viruses

• ALLRNA viruses, and enveloped

• Survival dependent on an animal/insect host,- natural reservoir

• Geographically restricted to areas where their hostspecies live

• Humans: NOT the natural reservoir for any of theseviruses

• Human cases or outbreaks occur sporadically and irregularly

• There is NO cure or established drug treatment for VHFs.

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 Epidemiology of viral hemorrhagic
diseases
• Global distribution:
– Geographically restricted to areas where their host specieslive

• Occasionally man becomes infected in an area:

– by a host that has been exported from its nativehabitat
– where the virus occurs naturally and then travels elsewherefor
further spread

• Person-to-person contact- traveler could infect other people

– outbreaks of these diseases are becoming an increasing threat in
places where they rarely, if ever, have been seenbefore

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 Epidemiology of viral hemorrhagicdiseases
VHF Viruses and their geographicdistribution
1 2 3 4
Arenaviridae Bunyaviridae Filoviridae Flaviviridae
Ebola virus-
CCHFvirus- Crimean Zaire, Sudan, Italy, KFDvirus - India
Junin virus-Argentina peninsula Philippines

Marburg virus-
Germany, Yugoslavia, OHF virus - Europe
Machupo virus- Bolivia
Congo, Netherlands

Sabia virus- South Hantaan virus - Korea

TBEvirus
America
YFvirus - Africa and
Guanarito virus- RVFvirus- Egypt
Americas
Venezuela
Dengue virus - Asia, Africa,
Lassa virus - Nigeria Australia, and Americas
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 Bas-Congo virus, or BASV New

• A Deep sequencing was used

to discover a NOVEL
Rhabdovirus associated
with a 2009 outbreak of 3
human cases of acute
hemorrhagic fever in
Mangala village, Democratic
Republic of Congo (DRC),
Africa.

Grard G, Fair JN, Lee D, Slikas E, et al. (2012) A Novel Rhabdovirus Associated with Acute Hemorrhagic Fever in Central Africa. PLoS Pathog 8(9):
e1002924. doi:10.1371/journal.ppat.1002924
http://www.plospathogens.org/article/info:doi/10.1371/journal.ppat.1002924
9
 Transmission of hemorrhagic feverviruses
Spread from one personto

Arthropod vectors
Rodent reservoirs

Human-to-human transmission
another, once an initial
person has become infected.
The viruses associated with
Examples:
arthropod vectors arespread
most often when the vector Ebola, Marburg, Lassa and
mosquito or tick bites a Crimean-Congohemorrhagic
human, or when a human fever viruses.
crushes a tick. This type of secondary
The viruses carried in rodent
reservoirs are transmitted Some of these vectorsmay transmission ofthe virus can
when humans have contact spread virus to animals, occur directly, through close
with urine, fecal matter, livestock, for example. contact with infectedpeople
saliva, or other body Humans then become or their bodyfluids.
excretions from infected infected when they care foror It can also occur indirectly,
rodents. slaughter the animals. through contact with objects
contaminated with infected
body fluids.
Example:
Calomys callosus
Contaminated syringes &
needles play an important
role in spreading infectionin
outbreaks of Ebola & Lassa
Hyalomma tick hemorrhagic fever.
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 Transmission of hemorrhagic feverviruses
The first outbreaks of
Marburg
hemorrhagic fever, in
Bat as reservoir host

Monkey/Chimpanzee as reservoir host

Marburg and
Frankfurt, and in
Yugoslavia, occurred
when laboratory
workers handled
imported monkeys
infected with
Three species of fruit Marburg virus.
bats (suborder Ebola seems to be
Megachiroptera) are contracted from contact
found asymptomatically with infected animals
such as chimpanzees.
and naturally infected
with Ebola virus:
Hypsignathus monstrosus
(hammer-headed fruit
beats),
Epomops franqueti
(singing fruit bats
Myonycteris torquata
(little collared fruit 11
bats)
Vectors for transmission of VHFs

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13
2014 Ebola Outbreak in West Africa

14
 Part-2

Clinical diseases & Pathogenesis

Laboratory investigations for diagnosis

Biosafety issues with Viruses causing HF

Treatment outline, and prevention/control

15
 Symptoms of viral hemorrhagic feverillnesses
• Differ slightly depending on the virus
• Characteristics in common:
– overall vascular system is
damaged
– body's ability to regulate itself is
impaired
More severely
Severe cases ill cases
Initial • Increased
presentation • Multisystem
permeability
(Acute infection) failure (varies
& cellular
• Marked fever, with
damage
fatigue, pathogen)
• Signs of • Shock,
dizziness, bleeding nervous
muscle aches, under skin, in system
loss of internal malfunction,
strength, organs, or coma,
& exhaustion from body delirium, and
orifices seizures 17
 Symptoms of viral hemorrhagic feverillnesses

Severe cases of VHF:

• Bleeding under skin causes:
• Petechiae, Purpura, &
Ecchymoses Petechiae, Purpura, & Conjunctivitis
• Conjunctivitis Ecchymoses
• Thrombotic
thrombocytopenia
purpura

– Patients rarely die becauseof

blood loss.

Bleeding under skin or from bodyorifices

Micrograph showing an acute thrombotic
microangiopathy, as may be seen in TTP
A thrombus is present in the hilumof
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the glomerulus (center of image)
 Pathogenesis

SHOCK
Dysregulation
Unregulated &
┼
Impairment
┼ ┼ ┼ Hypotension ═
virus spread of host Coagulation
of vascular
and
replication
immune
responses
abnormalities
system MULTI-
ORGAN
FAILURE

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 Prognosis
• According to the World Health Organization,
Marburg hemorrhagic fever has a fatality rate of
up to 80 percent, while Ebola fever has afatality
rate of up to 90 percent.
[ ]
http:// nihrecord.od.nih.gov/newsletters/2010/07_09_2010/ digest.htm

• Poor prognosis associated with:

– Shock
– Encephalopathy
– extensive hemorrhage
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20
 Diagnosis
Laboratory Findings:
• Thrombocytopenia
• Leukopenia
• Elevated LFTs
• Prolonged PT,PTT,INR
• Disseminated Intravascular
Coagulation (DIC)
Differential Diagnosis:
• Other febrile tropical
illnesses-
– Malaria
– Typhoid fever
– Bacterial gastro-enteritis
– Rickettsial diseases
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 Diagnosis
• Test specimens:
• specimen types
• must be sent to a
designated referral center
• Referral centers:
• Centre for DiseaseControl
(CDC)
• U.S.Army Medical
Research Institute of
Infectious Disease
(USAMRIID)
• Tests performed to
diagnose:
• Serology
• Immunohistochemistry
(IHC)
• Polymerase chain
Ebola reaction (PCR)
virus • Viral isolation & Electron
microscopy
• Guidelines for
Submitting Specimens
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 Guidelines for Submitting Specimens
The following specimen Specimen
types may be submitted: packaging
– Serum drawn near requirements:
admission with clots
retained from redtop tube – Minimum volume:
1ml serum (2.5 ml
Serology

– As late a serum as available preferred)

– Convalescent serum drawn – Serum samples must

approximately 21 days after be shipped with a cold
first specimen pack, or on dry ice in a
plastic tube.
– Post-mortem heart blood

Source: http://www.cdc.gov/ncidod/dvrd/spb/mnpages/specguide.htm 23
 Guidelines for Submitting Specimens
Types of formalin-fixedor Specimen packaging
paraffin-embedded tissues: requirements:
– Lung, kidney, and spleen tissues – Paraffin blocks are preferred,
Immunohistochemistry (IHC)

are preferred. particularly if death was not recent.

– Other tissues that may be sent – If paraffin blocks are not available,
include lymph nodes, heart, formalin-fixed tissues may be sent.
pancreas, pituitary, brain, or liver.
– Ship paraffin blocks or formalin-fixed
Denguevirus
infected cells tissue at room temperature--do NOT
freeze.

– An autopsy or surgical report must

accompany the specimen.

Source: http://www.cdc.gov/ncidod/dvrd/spb/mnpages/specguide.htm 24
 Guidelines for Submitting Specimens
Specimen
packaging
Types ofsamples: requirements:
– Ante-mortem:
– Clots must be sent on dry ice
You may submit biopsy in a
PCR/ Virus isolation

material of the lung or plastic tube.

bone marrow aspirate
– Acute blood for virus
or clot.
isolation must be sent on
dry ice in a plastic tube.
– Post-mortem:
spleen, lung, kidney, liver, – Tissues should be ideally
lymph nodes, heart, 1cm3.
pancreas, pituitary, brain,
or liver tissue, or heart
blood. – Buffy coat and fresh tissues
must be shipped on dry ice.
Source: http://www.cdc.gov/ncidod/dvrd/spb/mnpages/specguide.htm 25
Global Disease Detection: Regional
Centers of CDC

Source: http://www.cdc.gov/globalhealth/gdder/gdd/regionalcenters.htm 27
 VHF Agents as Biological Weapons

• They are candidates for biological warfare agents

• Marburg and Ebola have high case fatality rates

• Rift Valley is the most stable VHF in liquid or frozenstate

• Introduction of these agents into nonendemic countries

poses a major public health threat to thatcountry

• Weapons disseminating a number of HFVscould cause an

outbreak

Source: Borio et al., The Journal of the American Medical Association (JAMA).2002;287(18):2391-2405
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 Working with VHF viruses needs high grade
containment facility
• Hemorrhagic fever causing viruses are classified as:
biosafety level four (BSL-4)pathogens

A researcher at work in BSL-4laboratory in CDC

(http://www.cdc.gov)

• The Special Pathogens Branch (SPB) of CDCprimarily works

with BSL-4pathogens
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 Safety concern while transferring VHFpatients

• Patients should be transferred to facilities with the following:

– Specialized and skilled staff
– Appropriate isolation space
– Sufficient laboratory and testing facilities

• Increase the chances of nosocomial transmission

• A negative pressure room is used to isolate or treat infected patients.

Negative pressure
isolation chamber

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 Treatment & Management
• Patients receive supportive therapy

• Patients may require treatment for secondary infectionsthat

may arise

• Strict isolation of affected patientsis required

• Intensive care management may be required for viral

hemorrhagic fevers

• Report to health authorities

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 Treatment & Management
• Ribavirin- an anti-viral drug,
has been effective in
treating some individuals
with:
– Lassa fever
(Arenaviridae)
– Hemorrhagic fever with
renal syndrome or HFRS
(Bunyaviridae)
– NOTapproved byFDA
• There is NO other treatment or established cure forVHFs
• Treatment with
‘convalescent-phase plasma’
has been used with success
in some patients with:
– Argentine HF
– Bolivian HF
– Ebola virus HF
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 Prevention & Control of VHF in general
HFVstransmitted by HFVsspreadby HFVstransmitted
rodents: arthropod vectors: from human-human:
• controlling rodent • Efforts focusing on • Avoiding close
populations community-wide contact with
insect & arthropod infected people &
• discouraging control body fluids
rodents from
entering or living • Encouraging to use • Barrier nursing or
in homes or insect repellant, infection control
workplaces proper clothing, techniques
bednets, window
• encouraging safe screens, & other
cleanup of rodent insect barriers
nests and
droppings 33
 Prevention & Control of VHF in general
• Protective clothing for healthcareworkers:
• Suspected VHF patients must use a chemicaltoilet
• Other infection control recommendations
Source: WHO and CDCdeveloped manual on “Infection Control for Viral Hemorrhagic Fevers In the African Health Care Setting”

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PART 3 Dengue virus & dengue hemorrhagic fever

Information about the Virus

Epidemiology/transmission
(vectors)

Clinical disease &

symptoms

Laboratory diagnosis

Management / Rx
(overview only)

Prevention
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 General Information on ‘Dengue virus’
• Family Flaviviridae
• 4 viral serotypes
• DEN-1, DEN-2, DEN-3, & DEN-4

• Spherical particles with anenvelope

• Single strand positive RNAGenome

• approximately 11 kb in length
• Genome encodes single open reading frame

Intracellular life
cycle of the virus
http://www.microbiologybytes.com/virology/3035pics/dengue.jpg

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 General Information on ‘Dengue virus’
Dengue virus infection: Dengue Transmission Vectors
Aedesaegypti
• A leading cause of illness and • Yellow fever mosquito
death in the tropics andsubtropics. • transmitted by the bite
of infected mosquitoes
• It is also known as:
– Dengue fever • originated in Africa
– Break bone fever
– Dengue hemorrhagic fever

• A mosquito is the biologicalvector Aedes albopictus

• Asian tiger mosquito
• More than one-third of the world’s • an invasive species
population living in areas at risk for originally fromAsia
transmission of Dengue

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 Immunological Response to Dengue
Infection
• Acquired immune response:
– IgM & IgG antibodies directed
against the envelope proteins

• Immune response varies

depending on:
– Primary infection
– Secondary infection

• Diagnosis is dependent on phase

of the infection

Recovery from infection by one serotype provides lifelong immunity against thatvirus, confers
only partial and transient protection against subsequent infection by the other three viruses
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 The Real Problem:
Dengue Hemorrhagic Fever
• Sequential infection increases risk of developing dengue hemorrhagicfever

• Symptoms (WARNING signs):

– Significant damage to blood and lymphvessels
– Increase in HCTconcurrent with rapid decrease in platelet count
– Mucosal bleed- Bleeding from nose andmouth
– Bleeding under the skin, which gives the appearance of‘bruising’
– Hepatomegaly- Liver enlargement >2cm
– Abdominal pain or tenderness-vomiting
– Lethargy

• Hypovolemic shock due to ‘low bloodpressure’

• Death
Mayo clinic-, (2010). Dengue fever symptoms. Retrieved April 19, 2010from
http://www.mayoclinic.com/health/dengue_fever/DS01028/DSECTION=symptoms 40
 Dengue shock syndrome (DSS)
• Signs of circulatory failure
• Signs of impending shock
– Hypovolaemia
– Intense abdominal pain,
vomiting
– Restlessness / agitation
– Lethargy / prostration
– Hypothermia
– Sweating
– Cold/clammy extremities
• Signs of poor prognosis
– purpura, ecchymoses
– epistaxis, haematemesis,
melaena
– coma, convulsion and
severe shock
• Mortality rate of 10%
• Recovery
– complete with rapid
treatment
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 Laboratory diagnosis
• How to suspect Dengue during an
epidemic?
– Fever
– Rash
– Severe headache, back pain
– Musculoskeletal pains
(break bone fever)
• Testing serum samples during the
first 5 days of symptoms and/or
early convalescent phase.
• Dengue can be diagnosed by:
– Isolation of thevirus
– Serological tests
– Molecular methods
Molecular methods:
• PCR
– Employed to detect theviral
genome in serum
• Sequencing
– Virus can be isolated and
sequenced for additional
characterization and confirmation
• Real time PCR(RT–PCR)
– Assays have been developed and
automated
• MOST of the above tests areyet
commercially available
40
 Dengue CaseManagement

• There is no specific treatment for DHF

• Can only treat the symptoms (supportive Rx)
• Therapy for pain
• avoid aspirin because of exacerbating hemorrhagic tendencies
• Medication to reducefever
• Fluid replacement through IV
• Blood transfusion
• Platelet transfusion

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 Prevention
• Vaccines to prevent infection with dengue virus- Nothing yetbut
progress is being made

• There is NO specific medications to prevent a dengue virusinfection

• The most effective protective measures are those that to reduce your
risk of dengueinfection

– Avoid mosquito bites (Mosquito control)

• All insect control measures

• When infected, early recognition and prompt supportivetreatment

can substantially lower the risk of developingsevere disease.

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