Viral Hemorrhagic

Fevers
Samwel Odhiambo
Faith Mwende
Ochung Muge
Viral Hemorrhagic Fevers
 Severe multi-system syndrome (multiple organs
affected).
 Vascular system is damaged and body loses the ability
to regulate itself.
 Accompanied by hemorrhaging.
 Many VHF viruses cause life threatening diseases
 Most have no established treatment or cure.
VHF Caused by Viruses of 4 Families
 Arenaviruses
 Filoviruses (Ebola and Marburg)
 Work with filovirus species requires Biosafety Level 4
(BSL-4) “space suit” containment (HIV requires BSL-2
“space suit” containment).
 Bunyaviruses
 Flaviviruses
 Features of these Viruses
 RNA Viruses, covered in lipid coating
 Humans are not natural reservoir, but can transmit
virus
 Viruses are restricted to areas of their host species
 Envelope- making susceptible to detergents, low pH
environments and household bleach
Viral hemorrhagic fever
 Marburg
 Caused by a zoonotic virus of the filovirus family.
 Mortality Rate 23-25%
 First recognized in 1967 when simultaneous outbreaks
occurred in Marburg and Frankfurt, Germany, and in
Belgrade, Yugoslavia.
 37 people became ill. The ill were mostly
laboratory workers and medical personnel.
 Original people who became ill had been exposed
to the tissues of African green monkeys, which
were imported from Uganda for research.
 Location:
 The area to which the virus is native is unknown, but
it is believed to include parts of Uganda, Western
Kenya, and Zimbabwe.
 Transmission
 The animal host to the Marburg Virus is unknown,
and so is the way that the animal transmits the disease
to humans.
 People who have been exposed to infected monkeys or
their body fluids have become infected in the past.
 The disease is easily transmitted between humans.
Direct contact with an infected person, or exposure to
their body fluids, are both ways by which the disease
is thought to be transmitted.
 Ebola
 Believed to be caused by a zoonotic member of the filovirus
family.
 Believed to be carried by an animal host that is native
to Africa.
 Named after a river in the Democratic Republic of Congo
in Africa (formerly Zaire) where first outbreak occurred in
1976.
 First Ebola outbreak in Zaire (1976)- 318 Human cases,
88% of those people died of the disease.
 4 Types of Ebola Virus
 Ebola-Zaire
 Ebola-Sudan
 Ebola-Ivory Coast
 Ebola Reston (only know to cause disease in no
human primate)
 Location:
 The Ebola Virus has
been reported in the
Democratic Republic
of Congo, Gabon,
Sudan, the Ivory
Coast, and Uganda.

Map of Ebola Outbreaks in Africa

 Ebola-Reston outbreak at primate research facility in
Virginia. Virus was carried by monkeys that had been
imported from the Phillipines.
 4 humans were infected and developed antibodies,
but none of them became sick

Map of Ebola Reston

Infected Monkeys in
Philippines
 Transmission
 It is believed that the first human becomes infected with
Ebola through contact with an infected animal.
 An outbreak of Ebola-Zaire occurred in Gabon in
1996 after people had eaten an infected monkey.
 One Scientist who had conducted an autopsy on a wild
chimpanzee in the Tai Forest in Ivory Coast was
diagnosed with Ebola-Ivory Coast in 1994.
 People can become infected with Ebola if they come into
contact with the blood or secretions of an infected person.
 People can also become infected through contact with
objects, such as needles, that are contaminated with
secretions or blood.
 In 1976, in England, a person became infected
with Ebola-Sudan after being accidentally
pricked with a contaminated needle.
 Pleomorphic
 Definition: having the ability to assume different forms or
shapes
 Four main shapes: long filamentous, U shaped, 6 shaped,
circular
 Structure

• Filoviruses are non-segmented negative strand

viruses
• Composed of a helical ribonucleoprotein complex
(nucleocapsid)
• Covered with a host-cell derived membrane envelope
• Matrix between the envelope and nucleocapsid is
filled with a protein lattice
Viral Genome
 Viral Genome

 Consists of seven genes

 These genes encode seven proteins in the Marburg virus
and eight in the Ebola virus
 Both viruses have a 3’ leader and 5’ trailer sequence that is
highly conserved and has a high degree of
complementarity
 These extragenic seguences are important in the initiation
of transcription and replication
 Viral Proteins

* Ebola virus only

 NP: Nucleoprotein – the primary structural protein

associated with the filovirus nucleocapsid
 Secreted Glycoprotein sGP
 Viral Proteins

* Ebola virus only

 VP35: acts as a cofactor in transcription and replication of

the viral proteins
 Viral Proteins

* Ebola virus only

 VP40: a matrix protein, also the most abundant viral

protein; may facilitate in the budding process
 Viral Proteins

* Ebola virus only

 GP: Glycoprotein – makes up the virion spikes or

peplomers and mediates entry into host cells through
receptor binding
 Viral Proteins

* Ebola virus only

 sGP: secreted from the cell, present in large amounts in

the blood of Ebola victims; may help to inhibit the immune
response
 Viral Proteins

* Ebola virus only

 VP30 – a minor nucleoprotein that may be involved in

securing the RNA to the C terminus of NP
 Viral Proteins

* Ebola virus only

 VP24: unknown function, possibly a matrix protein

 Viral Proteins

* Ebola virus only

 L: Polymerase L – acts as the polymerase and is the

largest and least abundant viral protein
Interactions with Cells
 Entrance into Cells
 Mediated by the Glycoprotein on the envelope surface
 Structure of GP
 Precursor form GP0 is cleaved yielding GP1 and GP2, they
are connected via one disulfide bond
 Form a heterodimer
 Peplomers are then formed by the association of three of
these heterodimers to form a homotrimer
 GP2 is responsible for trimerization, fusion of the envelope
and cell, and has an immunosuppressive motif
 GP1 is the receptor binding domain
 Receptor - Lipid Rafts

 Receptor, while for most cells unknown, appears to be

located in LIPID RAFTS : less fluid areas of the
membrane high in cholesterol and glycosphingolipid; the
cholesterol-binding caveolin is also closely associated with
the rafts
 Endocytosis
 Caveolae are present in the plasma membranes of most
cell types and are thought to form from lipid rafts
 The major structural protein is caveolin, a multipass
protein
 Caveolae invaginate and collect their cargo proteins, but
do not require the assembly of a cytosolic protein coat
Endocytosis
 Transcription
 Takes place in cytoplasm of cell
 The seven genes are transcribed to produce seven
monocistronic polyadenylated mRNA’s
 Each gene has a conserved transcriptional stop and start
sequences
 Transcripts are thought to have 5’ caps
 Gene overlaps - function unknown
 Unusual GP Transcription
 In the Ebola Virus the GP gene codes for GP and sGP
 sGP is the primary gene product
 Full length GP is expressed by transcriptional editing of a
single adenosine at a run of seven uridine residues in the
genomic RNA
 Translation
 sGP and GP are translated by membrane bound ribosomes
and enter the ER and follow the exocytotic transport route
to the cell surface
 All other viral proteins are translated by free ribosomes in
the cytosol
 Replication
 Build up of proteins
signals switch to
replication
 Switch results in synthesis
of + sense RNA as a
template
 Depletion of proteins
causes switch back to
transcription, eventually
equilibrium
Invasion Process
 Immune System Evasion
 Host dies with little evidence of an immune response
 Mitosis of lymphoid cells seen to decrease 2-3 days
postinfection with eventual apoptosis
 Swelling of MPS and stromal cells and eventual lysis
 Dendritic (antigen-presenting) cells also undergo apoptosis
 sGP may bind to neutrophils and inhibit their activation
 sGP as a decoy? – absorb neutralizing antibodies
 VP35 may act as an IFN antagonist
 GP2 may have an immunosuppressive role
 Ebola shown to inhibit induction of immunomodulatory
and antiviral genes in endothelial cells (MHC I, IFN, etc…)
 Cytotoxicity, Hemorrhage, and Shock

 GP expression causes downregulation of the cell-surface

expression of integrins – cell rounding and detachment
seen
 Disruption of cell functions in general
 Release of vasoactive agents (cytokines, chemokines,
histamines and peroxidases) from infected monocytes and
endothelial cells could increase hemorrhaging and induce
shock
 Risk Factors

 Travel to Asia or Africa

 Handling of animal carcasses
 Contact with sick animals or people
 Transmission is highest during latter stages of illness.
 Reservoir Unknown
 Bats?
 Birds?
 Insects?
 Plants?
 Spread of Ebola
 Direct contact with the blood and/or secretions of an
infected person. (Family setting)
 Contact with objects, such as needles that have been
contaminated with infected secretions. (Health care
setting)
 Ebola Invasion
 Effects innate immune system (non-specific responses)
 Enters through broken skin, mucous membrane or
exchange of bodily fluids
 Can also enter through ingestion, inhalation, injection of
infectious material
 Ebola Basics
 Incubation period of 2-21
days
 Mortality rate of 50-90%
 Some primary targets are
hepatocytes and endothelial
cells, which produce the
greatest amounts of furin in
the human body
 Stable at room temperature
but is destroyed at 60 0 C.
 Also destroyed by gamma
and UV radiation, lipid
solvents, and bleach
 Marburg Basics

 Incubation period of 2-14

days
 Mortality rate of 23-25%
 Stable at room temperature
but is destroyed at 60 0 C.
 Also destroyed by gamma and
UV radiation, lipid solvents,
and bleach
 Early Symptoms
The first signs usually are:
 Prolonged fever that does not
respond to antimalarial
treatment or antibiotics
 Joint pains and generalized
body aches
 Headache
 Generalized weakness
 Nausea and vomiting
 Abdominal pain and diarrhea
 Fatigue
 Arthritis
 Sore throat
 Rash
 Hiccups
 After 5-7 Days
The fever may get associated with
spontaneous bleeding e.g.:

 Bleeding from the gums, nose, eyes,

ears
 Eyes may turn red (conjunctivitis)
 Anal bleeding or bloody diarrhea,
gastrointestinal bleeding
 Genital swelling (labia and scrotum)
 Bleeding from the skin
 Difficulty in swallowing and dryness
of the throat
 Increased sense of pain in skin
 Blood does not clot
 Depression
 Hypotensive shock
 Liver damage
 Treatment for Ebola and Marburg
 Isolation and quarantine
 Quick containment
 No standard treatment
 Supportive therapy, which includes balancing the patient’s
fluids and electrolytes, maintaining their oxygen status and
blood pressure, and treating them for complicating
infections.
 Mechanical ventilation, renal dialysis, and antiseizure
therapy may be required.
 What is the key to survival?
 Demise or improvement usually occurs around day 7 to 11,
when humoral antibody response can be detected.
 Known that patients who die usually have NOT developed
a significant immune response to the virus at the time of
death.
 Convalescence and Recovery
 Slow – takes 5 weeks or
more
 Can still harbor infectious
viral particles up to 82 days
after presentation
 Weight loss and amnesia in
early stages of recovery
 Survivors
 Psychosocial disturbances
 Loss of memory
 Central nervous system
disorders
 Loss of hair, hair elasticity
and hair drying
 Permanent hearing loss
 Arthralgia
 Uveitis
 Orchitis
Death and Burial
 Villagers traditionally help sick,
transport and kiss the dead
 Wash and dress body for the
afterlife
 Burial practices last days
 Dead buried near home
 Hiding of bodies
 Clinical Diagnosis of Ebola
 In early stages, it is difficult to diagnose because early
symptoms, such as red eyes and a skin rash, are
nonspecific and are similar to other diseases that occur
much more frequently.
 Use RT-PCR and ELISA to diagnose Ebola and Marburg.
 Challenges to Vaccine Development
 In past, rare occurrences of Ebola and
remote locations of outbreak did not favor
vaccine development.
 Also required industrial support, which was
not feasible since it was predicted there
would be no market for the vaccine.
 However, this changed with the existing
threat of bioterrorism. Now Ebola is
categorized as a ‘List A agent’.
Ebola Protection Using Immunotherapy
 Antibody titers against Ebola virus GPs are detected in
patients who recover. However, serum from recovered
patients did not consistently protect against infection or
exhibit neutralization of virus replication in cell culture.
 Passive transfer of antibodies in animal models only delays
onset of symptoms and does not alter overall survival.
Ebola Protection Using Immunotherapy

 Monoclonal antibodies isolated from bone marrow of

recovered patients confer immune protection in a murine
model of Ebola virus infection and in guinea pigs.
 But it is relatively easy to protect against infection in the
mouse model and protection of guinea pigs required a high
dose of antibody administered very close to the time of
virus challenge.
 Conclusion: antibodies alone do not provide protective
immunity in a natural context. May not be applicable to
humans.
 Antiviral Therapy
 Use of S-adenosyl-L-homocysteine hydrolase inhibitors.
 The drugs are active in vitro and in mouse and nonhuman
primate models.
 Drugs act through accumulation of S-
adenosylhomocysteine and its selective inhibition of virus
methylation reactions.
 Blood Transfusions
 In 1995 Zaire outbreak, 8 patients given blood transfusions
from individuals who recovered from Ebola.
 7 out of 8 patients survived.
 However, study size was small and patients were young so
actual effectiveness remains unknown.
 Vaccine Development
 Vaccine made with heat inactivated virions but level of
protection was inconsistent. Guinea pigs were partially
protected in one study and 4 out of 5 baboons survived
challenge.
 However, inactivated virions did not induce sufficient
immunity in hamadryl baboons against a lethal challenge.
 May not be effective in humans.
 Vaccine with eVLP
 Recently, vaccine developed that is based on a single or
combinations of virus-encoded structural proteins to
induce immunity.
 After vaccination with eVLP (Ebola virus-like particles),
mice developed high titers of Ebola virus-specific
antibodies, including neutralizing antibodies. The mice
were 100% protected from Ebola virus.
 Weaponization
 Characterized as “class A” weapons
because of their:
 High virulence

 Demonstrated aerosol infectivity in the laboratory

 Ability to cause a state of intense fear and anxiety

 Conclusion
 In addition to the sickness and death that it would cause,
a filovirus attack would cause tremendous disruption of
social and economic activity.
 Ebola has the benefit (to terrorists) of having a reputation
for causing horrifying illnesses.
 Increased anxiety would occur if people were to see the
effects of the disease, as well as the full protective gear
that law enforcements officials, doctors, and nurses would
be wearing.