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Hours
Hours
2
Course #626
$18.95
Course Material Valid Through/must be completed by
October 2024
October 2024
Ebola and Zika Viruses
About the Authors
James Wittenauer, RN, MSN, MPA, RN-BC has been a registered nurse for 28 years with over 15 years critical care experience as well as experience in same day surgery, primary care, and cardiac care. He is also a 20-year veteran of the United States Air Force.
Mr. Wittenauer received his associate degree and BSN from Lewis-Clark State College, his master’s degree in public administration from Troy State University and his master’s degree in nursing administration from the University of Phoenix. He is board certified in pain management nursing. He serves as an author and peer reviewer for the National Center of Continuing Education, and has written for journals, websites and continuing education series and serves as a peer reviewer for the Federal Practitioner.
Diana Harland, BS, CCRC, received her degree in Microbiology from the University of Texas at El Paso. She worked in pre-clinical research in retrovirology while in undergraduate school, and again later after graduation at the Texas Biomedical Research Institute (formerly Southwest Foundation for Biomedical Research) in San Antonio, Texas. While at SWFBR, she worked in the Department of Virology and Immunology in Biosafety Level 3-4 (BSL-3/BSL-4) labs. She has extensive training in NIH, OSHA, and CDC guidelines for sterility and asepsis in tissue culture and retrovirology. She holds a certificate in bioterrorism from Tulane University School of Public Health and Tropical Medicine and the University of Alabama at Birmingham School of Public Health. She is a member of the Austin Disaster Relief Network (infrastructure for the City of Austin, Texas, Disaster Response) and the Association for Clinical Research Professionals.
Learning Outcomes
By the end of this course the reader will be able to:
- Define Ebola virus with respect to its genera and species classification and its physical characteristics.
- Delineate the predominance of the Ebola virus with regard to epidemiology.
- Describe the methods of transmission of the Ebola virus, and what is meant by a spillover event.
- Discuss treatments for and prevention of Ebola virus.
- Outline the symptoms of Ebola virus disease (EVD) with respect to the progression of the disease.
- Relate how Ebola infection can be distinguished from influenza infection with regard to who is at risk, how the disease is spread, and the signs and symptoms of infection.
- List some infection control measures necessary when working with patients with known or suspected EVD, including the necessary isolation precautions and the proper PPE needed.
- Explain arboviral diseases and establish why Zika virus disease is a disease that is nationally notifiable.
- Describe the symptoms of Zika virus infection and how a diagnosis is made.
- Relate the recent cases of Zika virus in the U.S. and its territories as reported to ArboNET.
- Review the complications of Zika virus infection in both adults and infants including Congenital Zika Syndrome (CZS) in infants.
- Outline the strategies for prevention of Zika virus disease at both the personal and community levels.
Introduction
Over the years, there has been much debate, speculation, and argument regarding infectious viruses such as the Ebola virus disease and the Zika virus. The media has placed various nurses, doctors, and patients in the spotlight with regard to their experience caring for patients, and in the case of Ebola virus disease, speculating on how they themselves think they contracted the disease, and detailing their path to recovery and how it has impacted their lives.
This CE offering will examine Ebola virus disease (EVD) and the Zika virus. We will discuss the characteristics of the viruses, and how the diseases are spread. We will also look at prevention techniques within a community and what healthcare professionals can do to protect themselves, their patients, and their loved ones. For the Zika virus, we will also discuss the potential long-term serious effects in both infants and adults.
Ebola Virus
Characteristics and Epidemiology of the Ebola virus
The Ebola virus is one of three genera of viruses in the virus family called Filoviridae. The other two know genera in the filoviridae family are Marburgvirus and Cuevavirus. These viruses cause viral hemorrhagic fever (VHF) in both humans and non-human primates.
Figure 1
The virus was first recognized in 1976 when epidemics of EVD broke out in the African countries of Zaire and Sudan. The mortality of infected persons during these epidemics was 88% and 53% mortality respectively. It is believed that the epidemic in Zaire was caused by the improper sterilization of needles.
Six species of the Ebola virus have been identified. Each species has been given its name according to where it was first discovered. The six species include Ebola Virus ( Zaire ebolavirus), Sudan virus (*Sudan ebolavirus*), Bundibugyo virus (*Bundibugyo ebolavirus*), Tai Forest virus (*Tai Forest ebolavirus*, formerly known as Côte D’Ivorie ebolavirus), Reston virus (*Reston ebolavirus*) which was isolated in Reston, Virginia in the United States, and Bombali virus ( Bombali ebolavirus). The Reston genus of the virus is lethal to non-human primates and has not been shown to cause disease in humans. However, scientists have found persons with antibodies to the virus after exposure. The Reston species was discovered in 1989 in Reston, Virginia when monkeys that had been imported from the Philippines began to get sick and die. Prior to this, it was thought that the disease was limited to the rain forests within the Congo in Africa (Pugh 2014).
Of the six species, four (Ebola, Sudan, Taï Forest, and Bundibugyo viruses) are known to cause disease in people. Each of those species produces a differing level of morbidity and mortality with the Sudan species showing mortality levels at 50% and the Zaire species showing the highest level of mortality at 70-90% if left untreated. Needless to say, the Zaire species of the virus causes the most deadly form of the disease.
In February 7, 2021, the Democratic Republic of the Congo declared an outbreak with one case identified in the North Kivu province. One week later, an outbreak was announced in the Republic of Guinea. It was the first case in Guinea since 2016. UNICEF reported 16 cases in total, with ten people fully recovered, and five deaths.
Prior to the 2021 outbreaks, according to the World Health Organization (WHO), the Ebola virus had been the most active in the Equateur Province of the Democratic Republic of the Congo. The outbreak started on June 1, 2020, and was declared to be over on November 18, 2020. There were 130 cases and 55 deaths.
In 2016, in the African countries of Guinea, Liberia, and Sierra Leone, there were 28,616 cases that resulted in more than 11,310 deaths. Travel-associated cases have been reported from Mali and Senegal with 2 cases and 2 deaths. Countries with limited transmissions include the United States, Spain, and Nigeria, totalling 25 cases and 10 deaths.
Virus transmission to humans can be by way of an infected animal such as a primate or bat. When this happens, it is called a spillover event because the virus is moving from one species to another species, and viruses are primarily known to be species specific. Although research has shown that three types of African fruit bats are a natural host of Ebola virus, the zoonotic source has not yet been discovered. Scientists continue to study the fruit bat to find conclusive evidence as to their role in the transmission of EVD.
After a human becomes infected, the transmission of Ebola virus by way of human-to-human contact results from direct exposure to someone who has an active infection or from exposure to that person’s blood or body fluids (e.g. sweat, feces, semen, and breast milk). Transmission can also occur from contaminated needles. In April 2021, the US Department of Homeland Security reported that cases of new infections being caused without evidence of direct human-to-human contact have been documented. As such, some virus infection may be spread as a result of exposure to droplets or aerosols
Figure 2
Diagnosis
During the early phase of infection, it is often difficult to distinguish EVD from other infectious diseases such as malaria, meningitis, typhoid fever, or even the common flu. Ebola virus is detected in blood only after onset of symptoms, most notably fever, which accompanies the rise in circulating virus within the patient’s body. It may take up to three days after symptom onset for the virus to reach detectable levels.
Diagnosis of EVD is confirmed by a variety of tests. The type of test performed is dependent on the timeline of the infection. Diagnostic tests performed within a few days of clinical symptom onset include complete blood count (CBC) with differential, liver enzymes, bilirubin, creatinine, blood urea nitrogen (BUN), enzyme-linked immunosorbent assay (ELISA), IgM ELISA, polymerase chain reaction (PCR), virus isolation and electron microscopy examinations. Diagnostic tests performed later in the disease course include IgM and IgG antibody tests. Tests used to detect the presence of the disease postmortem include virus isolation, PCR, and immunohistochemistry testing.
Figure 3
Clinical Manifestations and Disease Progression
Symptoms of EVD can occur from two to twenty-one days after exposure to the virus but, on average EVD manifests clinically 8-10 days post-exposure, with symptoms that present without any warning. The initial symptoms are: fever, myalgia, severe headache, nausea and vomiting, abdominal pain, diarrhea, chest pain, cough, and pharyngitis. Other symptoms include photophobia, lymphadenopathy, jaundice, and pancreatitis. There is also central nervous system involvement marked by somnolence, and the patient can become delirious and slip into a coma.
Progression of EVD is marked by tissue wasting, bruising, petechial and mucous membrane hemorrhage, and a rash around the trunk of the body that can occur around day five.
By the second week, the patient either improves or dies as a result multiple system organ failure (MSOF). Patients that do improve and survive usually have antibodies that remain present for at least 10 years, and possibly longer. There is a possibility that survivors may have some immunity to the species of Ebola virus that infected them, but it is unknown if survivors will have lifetime immunity or if they can become infected with a different species of Ebola virus.
Even after recovery, Ebola virus may still be found in some body fluids, including semen. The time it takes for Ebola to be cleared from semen is different for each man. For some men who have survived Ebola, viral clearing from semen occurred in three months and for other men, viral clearing in semen did not occur for over nine months. Based on the results from limited studies conducted to date, it appears that the amount of virus decreases over time and will eventually be cleared from the semen.
Many survivors of EVD suffer from long term health conditions such as muscle and joint pain, vision and eye problems, loss of appetite, stomach pain, headaches, weight gain, fatigue, memory loss, dry mouth, neck swelling, chest tightness, hair loss, tinnitus and hearing loss, pain or tingling of hands and feet, inflammation of the pericardium, menstrual changes, testicular inflammation, decrease or loss of interest in sex, impotence, difficulty falling asleep, depression, anxiety, and post-traumatic stress disorder (PTSD).
Treatment of EVD
The treatment for EVD is undergoing a change. Outbreaks from 2021 on are able to be handled differently from those in the past. The FDA approved two drugs in 2020 that when administered early in the disease progression, have been shown to improve the survivability rate dramatically. On October 14, 2020 the FDA approved Inmazeb® (REGN-EB3) and on December 21, they approved Ebanga® (ansuvimab or mAb114) both as a treatment and prophylaxis for EVD in adults, children and babies, including neonates where the mother has tested positive.
Treatment of EVD has been primarily aimed at supportive care. Supportive measures include hydration with oral fluids (if tolerated) or large volumes of intravenous fluids, oxygen therapy, treatment of concomitant infections, and medications administered to maintain adequate blood pressure for end organ perfusion, to reduce vomiting and diarrhea, and to manage pain. Blood products such a platelets or frozen plasma may also be used to assist with blood loss. For many patients, especially those with evidence of septic shock, the addition of broad-spectrum antimicrobials is recommended.
Several experimental treatments came about as a result of the Ebola outbreak in Africa in 2014. The first to gain traction as a potentially promising was an experimental treatment that consisted of an antibody cocktail created with the collaboration among companies in the United States and Canada, called ZMapp that consisted of three monoclonal antibodies that had been prepared from the Nicotiana plant. In addition to ZMapp, other treatments clinically tested in the treatment of Ebola included mAb114, a monoclonal antibody; REGN-EB3, a combination of three monoclonal antibodies; and remdesivir, an antiviral medication. When clinical trials for these treatments showed markedly better outcomes for patients who were given REGN-EB3 or mAb-114 versus patients who were given ZMapp or Remdesivir, the clinical trials were cut short in favor of continuing the use of REGN-EB3 and mAb-114, and discontinuing the use of ZMapp and remdisivir (Kupferschmidt 2019).
In response to the Republic of Guinea outbreak announced February 14, 2021, among other efforts international agencies responded by launching a vaccine program within ten days, and inoculated more than 8000 people, 30% of whom were frontline staff. On April 24th, the last confirmed case was discharged.
The biggest gain in the line of defense in the war against Ebola is the world’s first vaccine effective against the Zaire strain. The vaccine, rVSV-ZEBOV, branded as Ervebo® is produced by the pharmaceutical company Merck. It received approval by the United States Food and Drug Administration (FDA) on December 19, 2019. The vaccine performs exceedingly well, and is considered almost 100% effective against the Zaire strain (*Zaire ebolavirus*) of the virus and is not effective against other strains.
This vaccine is considered to be safe and contains no active part of the virus. It functions by using a vesicular stomatitis virus to carry a non-infective Ebola virus gene. This part of the Ebola virus is not disease-causing, but will trigger an immune response for protection against the disease.
Prevention of EVD
Ebola is classified as a Category A agent of bioterrorism.
Category A agents of bioterrorism:
- Are easily transmitted from person to person or easily dispersed
- Result in high morbidity and mortality rates
- Have the potential to cause widespread panic and social disruption of the public
- Require special preparedness to deal with should an outbreak occur
For these reasons, proper infection prevention technique is vital in controlling outbreaks of EVD. Any healthcare workers who are caring for Ebola patients must have received comprehensive training and must demonstrate competency in performing infection control practices and procedures for Ebola. Droplet + Contact + Standard Precautions are the isolation precautions recommended for the entire duration of illness.
Figure 4
Recommended infection control measures for management of Ebola as per CDC guidelines include:
- Use of sterilizing equipment
- Barrier isolation
- Protective clothing including gloves, masks, and gowns. Personal protective equipment (PPE) that covers the clothing and skin and protects mucous membranes is absolutely required
- A trained observer must supervise every step of PPE donning and doffing to ensure that strict PPE protocol is enforced
- Use of N95 or higher respirators are recommended when performing any aerosol generating procedures. Any procedures that can increase environmental contamination with infectious material or create aerosols should be minimized if possible.
- An onsite manager must at all times supervise any healthcare workers caring for patients with known or suspected EVD
- Direct contact with the body of an Ebola patient should be avoided
Additional guidance for healthcare personnel in hospitals managing patients with known or suspected EVD can be found on the CDC website at https://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html
Further prevention of Ebola should include thorough education of patients and their contacts. The CDC graphic (Figure 4) outlines basic patient education for EBV.
Frontline healthcare facilities, in coordination with state and local healthcare authorities, can become prepared for potential Ebola cases. Key points for frontline facilities as outlined by the CDC are:
- Rapid identification and triage of patients with exposure history and signs or symptoms of EVD
- Immediate isolation patients with exposure history or signs and symptoms of EVD
- Immediate notification of hospital or facility infection control or other appropriate staff and state and local public health authorities when a patient has been identified having relevant exposure AND signs or symptoms compatible with EVD
- Frontline facilities in coordination with state and local health authorities should consider transferring the patient to an Ebola assessment hospital
- Patients with confirmed EVD should be transferred to an Ebola treatment center,
Figure 5
With the availability of a vaccine, approved treatments to limit disease progression, supportive care, trained frontline staff, education within communities and collaborative and efficient response across borders, we can look to the future with the goal that we may one day be able to say, “Humans Won, Ebola Zero.”
Zika Virus
 Aedes albopictus |  Aedes aegypti |
There are only two kinds of mosquito in the United States that are able to transmit Zika virus:
- Aedes aegypti (the yellow fever mosquito) and
- Aedes albopictus (the Asian tiger mosquito).
Source: New Mexico Division of Health
Figure 6
Characteristics and Epidemiology of ZIKV
The Zika virus (ZIKV) was first discovered in 1947 and was named after the Zika Forest in Uganda. It is a single-stranded RNA virus of the Flaviviridae family. Zika virus disease is an arboviral disease that is nationally notifiable. An arboviral disease is a disease transmitted to humans primarily through the bite of an infected arthropod including mosquitoes, ticks, sandflies, or midges. Laboratory confirmed cases are reported to the CDC through ArboNET, the national surveillance system for arboviral diseases. The Zika virus is most concerning because of its effects during pregnancy and its potential to cause microcephaly and other severe brain defects in infants when the virus is passed from mother to fetus in utero.
Figure 7
Zika virus is spread primarily through the bite of an infected mosquito in the genus Aedes. These mosquitoes breed in the community in containers that hold water. Female Aedes aegypti mosquitoes, also known as yellow fever mosquitoes, are known to aggressively bite during daylight hours both indoors and outdoors close to residences. Aedes albopictus mosquitos, also known as tiger mosquitoes, are less of a threat to humans because they prefer non-human blood.
During outbreaks, the virus is spread by arthroponotic transmission (human-to-vector[mosquito]-to-human). ZIKV can also be spread by transplacental transmission, sexual transmission, transfusion of blood and blood products, and organ transplantation. According to the CDC, ZIKV has been detected in human milk, but transmission through breastfeeding has not been definitively demonstrated.
Cases of Zika virus disease have been reported mostly in tropical, and subtropical climates, and in temperate areas where warmer microclimates may exist such as in urban areas. The mosquitoes do not thrive well in elevations above 6500ft. In the U.S. and its territories, the greatest risk of local transmission is in Puerto Rico. In 2020, as reported to ArboNET by April 1, 2021, there were 57 locally acquired cases in Puerto Rico and four travel-related cases in the United States.
Figure 8
Symptoms and Diagnosis of Zika Virus Disease
The incubation period from exposure to symptom onset for Zika virus disease is estimated at 3-14 days. Symptoms of Zika infection include headache, low-grade fever, maculopapular rash, muscle pain, arthralgia, malaise, and conjunctival symptoms. The patient’s clinical examination, travel history, and activities are used to make a preliminary diagnosis. Final diagnosis is made by laboratory detection of ZIKV RNA in samples taken from blood, urine, saliva, semen, cerebrospinal fluid (CSF), amniotic fluid, or tissue samples. The WHO recommends the testing of blood and urine to diagnose infection, and the testing of CSF if it is being collected for other diagnostic purposes. Until a definitive diagnosis is made, persons suspected of ZIKV infection should also be evaluated and managed for potential dengue and chikungunya infection because geographic distribution and symptoms are similar.
ZIKV disease is self-limiting and progression usually lasts less than one week with symptoms that are typically not severe enough to require hospitalization. Persons that have recovered from infection are initially protected from future infections, but antibodies and seroprevalence have been shown to decrease over time.
Figure 9
Complications of ZIKV Infection
After the 2015 ZIKV epidemic in the American continent, a new fear arose in affected communities because it was discovered that ZIKV had the potential to produce long-term, late onset neurological complications in both congenitally exposed newborns and adults as a result of infection. Increasing clinical evidence has shown that ZIKV infection in adults may lead to Guillain-Barré syndrome (GBS) and potentially an associated development of chronic pain, as well as encephalitis, acute myelitis, encephalomyelitis, and chronic inflammatory demyelinating polyneuropathy. There is also evidence to suggest that infection with Zika virus may result in reduced fertility in men. Research has shown that even infants who are examined to be healthy at birth can still develop severe long-term neurological complications. It is therefore important for any individuals exposed to ZIKV to be clinically followed on a long-term basis for any potential neurological problems.
Source: New England Journal of Medicine
Figure 10
The main concern for ZIKV is the transmission of the virus from expectant mothers to their unborn children because of the severe birth defects that occur as a result. The main birth defect is microcephaly, but other defects can occur such as eye defects, loss of hearing, and growth retardation. Infants who develop microcephaly from ZIKV exposure show recurrent seizures and neuropsychomotor development that is severely compromised. This condition of severe manifestation in infants is now termed Congenital Zika Syndrome (CZS), and describes a recognized pattern of birth defects. Although cognitive, sensory and motor disabilities are also characteristic of other congenital infections, there are 5 features that appear to be unique to congenital ZIKV infection and these are rarely seen with other congenital syndromes:
- Severe microcephaly with partially collapsed skull and redundant scalp with extra skin folds (rugae)
- Thin cerebral cortices with subcortical calcifications
- Macular scarring and focal pigmentary retinal mottling
- Congenital contractures of major joints
- Marked early hypertonia or spasticity and symptoms of extrapyramidal involvement that is noted in infants with structural brain anomalies only.
Other features that appear to be unique to CZS include paralysis of the diaphragm (low prevalence), hypertensive hydrocephalus following severe microcephaly (low prevalence), and neurogenic bladder (more common).
Primary Zika virus infection of the fetus during the first and early second trimesters of pregnancy is associated with adverse outcomes that are severe. Infection of the fetus during the third trimester is associated with less severe defects in the brain and eyes. Other adverse outcomes are miscarriage, stillbirth, and neonatal death. Learning disabilities have also been reported but are not linked to a specific trimester of exposure.
https://www.cdc.gov/ncbddd/birthdefects/surveillancemanual/chapters/chapter-5/chapter5-4.html
Source: CDC Birth Defects Surveillance Toolkit avail at: https://www.cdc.gov/ncbddd/birthdefects/surveillancemanual/chapters/chapter-5/chapter5-4.html accessed Nov 11, 2021.
Figure 11
Treatment and Vaccines for ZIKV
There are currently no FDA approved anti-viral drugs or vaccines available for either treatment or prevention of Zika virus disease. The primary treatment for Zika virus disease is that of supportive care, such as increasing fluids to prevent dehydration, use of pain-relieving medications such as acetaminophen or ibuprofen, and rest.
At the time of publication, a number of Zika virus vaccines are being studied, including at more than a dozen different Zika virus vaccine candidates that have completed Phase I clinical trials in humans, and one vaccine candidate that completed a Phase II clinical trial. These vaccine candidates utilize a number of different approaches to vaccination including live attenuated vaccines, inactivated virus vaccines, and recombinant virus vaccines to achieve a neutralizing antibody response.
Prevention of Zika Virus Disease
Recommended isolation precautions for Zika virus disease in the healthcare setting are Standard Precautions. No special cleaning or disinfection practices are needed where patients with known or suspected Zika virus disease have been treated. Daily cleaning of patient care areas and surfaces should be done first, and then followed by use of an EPA-registered hospital disinfectant as per manufacturer’s instructions.
“Zika is mainly spread through mosquito bites. Travelers should take steps to prevent mosquito bites for 3 weeks after returning from an area with risk of Zika. This is because you can have Zika in your blood and a mosquito can bite you, get infected with Zika virus, and spread the virus to other people.”
Protecting yourself from mosquito bites is the best way to prevent Zika virus. The main strategy for prevention of Zika virus disease is in the community. Create an environment where mosquitos cannot flourish. This includes elimination of areas of opportunity for standing water and water stagnation in both outdoor and indoor areas. The CDC suggests checking your environment once a week for any places where mosquitos can lay eggs. Empty items of water that has collected and make adjustments if possible, such that water will not continue to pool. Remove open garbage containers and other manufactured and natural containers and cover water storage containers and wastewater systems.
Use EPA-registered insect repellant as directed, that contain one of the following active ingredients:
- DEET
- Picaridin (known as KBR 3023 and icaridin outside the US)
- IR3535
- Oil of lemon eucalyptus (OLE)
- Para-menthane-diol (PMD)
- 2-undecanone
https://www.cdc.gov/zika/prevention/prevent-mosquito-bites.html
Other measures for prevention include wearing loosely-fitted clothing that offers coverage for arms, legs and torso; and using physical barriers such as screens, mosquito nets, and closed windows and doors.
Also of importance is taking protective measures with someone who is known to have traveled to a Zika infected area within the prior three months to avoid passing Zika through sex. Avoid contact with bodily fluids including urine, blood, vaginal fluids, semen, breast milk, and stool and utilize condoms when engaging in sexual activities. While Zika can be detected in the saliva, there are no confirmed transmissions from saliva in humans.
Studies are underway to determine how long the Zika virus can remain in different types of bodily fluids, and the associated transmission risk.
Those planning travel can refer to a CDC-maintained website for up-to-date information regarding Zika. https://wwwnc.cdc.gov/travel/page/zika-information
Fear and Infectious Disease
While fear of infectious disease may motivate people to protect themselves, fear, anxiety, worry, amplification of those as a result of media coverage can have significant deleterious effects on health and well-being. With knowledge and determination, as nurses we can help individuals protect themselves and not give way to fear or ignorance when these the new threats face us.
Summary
Healthcare workers who are well trained and educated in infection control of these viruses can be instrumental in helping prevent further spread of disease. When nurses and healthcare professionals share their knowledge of these illnesses and prevention techniques with patients and others, they help to reduce the spread of infection facing communities when these and other threats emerge.
References and Suggested Readings
Centers for Disease Control and Prevention. (2021, March 18). Ebola (Ebola Virus Disease). https://www.cdc.gov/vhf/ebola/index.html
Centers for Disease Control and Prevention. (2019, November 5). Treatment. Ebola (Ebola Virus Disease).
Centers for Disease Control and Prevention. (2019, May 20). Zika Virus. https://www.cdc.gov/zika/about/index.html
Centers for Disease Control and Prevention. (2020, December 10). Zika Travel Information Travelers’ Health.
Centers for Disease Control and Prevention. (2021, February 25). Ebola Vaccine: Information About Ervebo®. Ebola (Ebola Virus Disease). https://www.cdc.gov/vhf/ebola/clinicians/vaccine/index.html
U.S. Food & Drug Administration. (2019, December 19). First FDA-approved vaccine for the prevention of Ebola virus disease, marking a critical milestone in public health preparedness and response.
Centers for Disease Control and Prevention. (2018, August 30). Guidance on Personal Protective Equipment (PPE) to be Used by Healthcare Workers During Management of Patients With Confirmed Ebola or Persons Under Investigation (PUIs) for Ebola who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea in U.S. Hospitals, Including Procedures for Donning and Doffing PPE. Ebola (Ebola Virus Disease).
Henderson, A. D., Aubry, M., Kama, M., Vanhomwegen, J., Teissier, A., Mariteragi-Helle, T., Paoaafaite, T., Teissier, Y., Manuguerra, J. C., Edmunds, J., Whitworth, J., Watson, C. H., Lau, C. L., Cao-Lormeau, V. M., & Kucharski, A. J. (2020). Zika seroprevalence declines and neutralizing antibodies wane in adults following outbreaks in French Polynesia and Fiji.eLife,9, e48460.
Kupferschmidt K. (2019, August 12). Finally, some good news about Ebola: Two new treatments dramatically lower the death rate in a trial. https://www.sciencemag.org/news/2019/08/finally-some-good-news-about-ebola-two-new-treatments-dramatically-lower-death-rate.
U.S. Food & Drug Administration. (2020, October 22). Drug Trials Snapshots: Inmazeb. https://www.fda.gov/drugs/drug-approvals-and-databases/drug-trials-snapshots-inmazeb
U.S. Food & Drug Administration. (2021, January 13). Drug Trials Snapshot: Ebanga
Regeneron. (2020 October 14.) Regeneron’s Antibody Cocktail REGN-EB3 (Inmazeb®) is First FDA-Approved Treatment for Ebola (Zaire Ebolavirus).
Department of Homeland Security. (2021, April 20). Feature Article: New Tech Makes Detecting Airborne Ebola Virus Possible. Science and Technology.
Baylor College of Medicine Department of Virology and Microbiology. (n.d.). Zika Virus.
World Health Organization. (2018, July 20). Zika virus
World Health Organization. Disease Outbreak News (DONs). Emergencies Retrieved May 2, 2021
Pan American Health Organization. (n.d.). Zika.
Pattnaik, A., Sahoo, B. R., & Pattnaik, A. K. (2020). Current Status of Zika Virus Vaccines: Successes and Challenges. Vaccines, 8(2), 266. https://doi.org/10.3390/vaccines8020266
Pugh, K. (2014, October, 24). Ebola Reston: A look back at the monkey house. InsideNoVa https://www.insidenova.com/headlines/ebola-reston-a-look-back-at-the-monkey-house/article_4aad76c0-5b35-11e4-b9b3-371ac205d748.html
Chang, A. Y., Lynch, R., Martins, K., Encinales, L., Cadena Bonfanti, A. Á., Pacheco, N., Reid, S. P., Lara Sarabia, O. E., González Torres, H. J., Mejia Castillo, S., Barrios Taborda, O., Alarcon Gomez, M., Guerra Duran, B., Martinez Giraldo, V., Benitez Ospino, A., Porras, A., Mendoza, A. R., Mantus, G., Li, G., Peng, J., Simon, G. L. (2018). Long-term clinical outcomes of Zika-associated Guillain-Barré syndrome.Emerging microbes & infections, 7(1), 148.
Souza, I., Barros-Aragão, F., Frost, P. S., Figueiredo, C. P., & Clarke, J. R. (2019). Late Neurological Consequences of Zika Virus Infection: Risk Factors and Pharmaceutical Approaches. Pharmaceuticals (Basel, Switzerland), 12(2), 60.
World Health Organization. (n.d.). Zika virus vaccine product development. Immunization, Vaccines, and Biologicals Retrieved May 2, 2021, from https://www.who.int/immunization/research/development/zika/en/
World Health Organization. (n.d.) Zika virus disease.
(OCHA) United Nations Office for the Coordination of Humanitarian Affairs (2021, April 27). UNICEF Guinea Ebola Situation Report No. 5, 14 - 24 April 2021. reliefweb.
https://reliefweb.int/report/guinea/unicef-guinea-ebola-situation-report-no-5-14-24-april-2021
Yang, C., Dillard, J. P., & Li, R. (2018). Understanding Fear of Zika: Personal, Interpersonal, and Media Influences. Risk analysis: an official publication of the Society for Risk Analysis, 38(12), 2535–2545.
