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1 THE VIRUSES AMONG US NOVEMBER 10, 2014 Alfonso F. Banuelos, Jr. MD Santa Clara Valley Medical Center 11/14/2014 Virus 2 A virus is a small infectious agent that replicates only inside the living cells of other organisms. Viruses can infect all types of life forms, from animals and plants to bacteria. Dmitri Ivanovsky's 1892 article describing a non-bacterial pathogen infecting tobacco plants, and the discovery of the tobacco mosaic virus by Martinus Beijerinck in 1898, about 5,000 viruses have been described in detail, although there are millions of different types. Viruses are found in almost every ecosystem on Earth and are the most abundant type of biological entity. The study of viruses is known as virology, a sub-speciality of microbiology. Virus particles (known as virions) consist of two or three parts: the genetic material made from either DNA or RNA, long molecules that carry genetic information; a protein coat that protects these genes; and in some cases an envelope of lipids that surrounds the protein coat when they are outside a cell. The shapes of viruses range from simple helical and icosahedral forms to more complex structures. The average virus is about one one-hundredth the size of the 11/14/2014 average bacterium. From Wikipedia 2014 Virus vs. Bacteria 3 11/14/2014 http://socratic.org/questions/how-do-bacteria-differ-from-a-virus Viruses vs. Bacteria 4 http://socratic.org/questions/how-do-bacteria-differ-from-a-virus 11/14/2014 Viral vs. Bacterial Reproduction 5 www.microbeworld.org/what-is-a-microbe/viruses 11/14/2014 6 ABOUT INFLUENZA 11/14/2014 Influenza Virus 7 Structure of influenza virus 30 APRIL 2009 The virus particle is 80–120 nanometers in diameter and usually roughly spherical, although filamentous forms can occur. http://www.virology.ws/2009/04/30/structure-of-influenzavirus/ 11/14/2014 Ebola Virus 8 The overall cylinders are generally approximately 80nm in diameter, and having a virally encoded glycoprotein (GP) projecting as 7-10 nm long spikes from its lipid bilayer surface.[7] The cylinders are of variable length,11/14/2014 typically 800 nm, but sometimes up to 1000 nm long. Influenza Symptoms 9 Influenza (also known as the flu) is a contagious respiratory illness caused by flu viruses. It can cause mild to severe illness, and at times can lead to death. The flu is different from a cold. The flu usually comes on suddenly. People who have the flu often feel some or all of these symptoms: Fever* or feeling feverish/chills Cough Sore throat Runny or stuffy nose Muscle or body aches Headaches Fatigue (tiredness) Some people may have vomiting and diarrhea, though this is more common in children than adults. * It's important to note that not everyone with flu will have a fever. 11/14/2014 CDC: Centers for Disease Control and Influenza Complications 10 How many people die from seasonal flu each year in the United States? The number of seasonal influenza-associated (i.e., seasonal flu-related) deaths varies from year to year because flu seasons are unpredictable and often fluctuate in length and severity. Therefore, a single estimate cannot be used to summarize influenza-associated deaths. Instead, a range of estimated deaths is a better way to represent the variability and unpredictability of flu. CDC estimates that from the 1976-1977 season to the 2006-2007 flu season, flu-associated deaths ranged from a low of about 3,000 to a high of about 49,000 people. About 90% of influenza associated deaths occur among adults 65 years and older. CDC has estimated the global death toll from the 2009 H1N1 influenza pandemic at more than 284,000, about 15 times the number of laboratoryconfirmed cases. Estimated that 80% of those who died were younger than 65, which is in accord with previous observations that the pandemic H1N1 burden fell heavily on younger people, unlike the pattern for seasonal flu. CDC: Centers for Disease Control and Prevention 11/14/2014 Influenza Complications 11 Most people who get influenza will recover in a few days to less than two weeks, but some people will develop complications (such as pneumonia) as a result of the flu, some of which can be lifethreatening and result in death. Pneumonia, bronchitis, sinus and ear infections are examples of complications from flu. The flu can make chronic health problems worse. For example, people with asthma may experience asthma attacks while they have the flu, and people with chronic congestive heart failure may experience worsening of this condition that is triggered by the flu. 11/14/2014 CDC: Centers for Disease Control and Prevention Influenza Vaccine 2014-2015 12 Flu vaccines are designed to protect against the main flu viruses that research suggests will be the most common during the upcoming season. Three kinds of flu viruses commonly circulate among people today: Influenza A (H1N1) viruses, influenza A (H3N2) viruses, and influenza B viruses. All of the 2014-2015 influenza vaccine is made to protect against the following three viruses: an A/California/7/2009 (H1N1)pdm09-like virus an A/Texas/50/2012 (H3N2)-like virus a B/Massachusetts/2/2012-like virus. Some of the 2014-2015 flu vaccine also protects against an additional B virus (B/Brisbane/60/2008-like virus). Vaccines that give protection against three viruses are called trivalent vaccines. Vaccines that give protection against four viruses are called quadrivalent vaccines. CDC: Centers for Disease Control and Prevention 2014 11/14/2014 Influenza Vaccine 2014-2015 13 Inactivated and recombinant flu vaccines You are getting an injectable flu vaccine, which is either an "inactivated" or "recombinant" vaccine. These vaccines do not contain any live influenza virus. They are given by injection with a needle, and often called the "flu shot." A different, live, attenuated (weakened) influenza vaccine is sprayed into the nostrils. 11/14/2014 CDC: Centers for Disease Control and Prevention 2014 Influenza Vaccine 2014-2015 14 How does Fluzone High-Dose differ from other flu vaccines? Fluzone High-Dose is an injected flu vaccine formulated for people age 65 years and older. Like other flu vaccines, Fluzone High-Dose is made up of the three flu strains most likely to cause the flu during the upcoming season. The high-dose vaccine, however, contains four times as much flu virus antigen — the part of the vaccine that stimulates the immune system — as regular Fluzone and other standard flu vaccines. Why is it needed? In response to a regular flu shot, older people produce 50 to 75 percent fewer antibodies, which protect against the vaccine antigens, than do younger adults. Evidence that a high-dose flu vaccine can compensate for this difference originally comes from studies that found higher post-vaccine antibody levels in older people who received high-dose flu vaccine than in those who received standard flu vaccine. In addition, one study found almost 25 percent fewer cases of proven influenza in adults age 65 and older who took the high-dose vaccine compared with those who took the standard-dose vaccine. Are there side effects? In the largest of three clinical studies comparing high-dose and standard-dose flu vaccine, those who received the high-dose vaccine were more likely to develop side effects, such as fever and soreness at the injection site, during the week after vaccination. James M. Steckelberg, M.D. www.mayoclinic.org/diseases-conditions/flu/expertanswers/fluzone/faq-20058032 11/14/2014 Influenza Vaccine 2014-2015 15 Are there new recommendations for the 2014-2015 influenza season? Starting in 2014-2015, CDC recommends use of the nasal spray vaccine (LAIV) for healthy* children 2 through 8 years of age, when it is immediately available and if the child has no contraindications or precautions to that vaccine. Recent studies suggest that the nasal spray flu vaccine may work better than the flu shot in younger children. However, if the nasal spray vaccine is not immediately available and the flu shot is, children 2 years through 8 years old should get the flu shot. Don’t delay vaccination to find the nasal spray flu vaccine. It takes about two weeks after vaccination for antibodies to develop in the body and provide protection against the flu. CDC: Centers for Disease Control and Prevention 2014 11/14/2014 Influenza Vaccine 2014-2015 16 Can I get vaccinated and still get the flu? Yes. It’s possible to get sick with the flu even if you have been vaccinated. This is possible for the following reasons: You may be exposed to a flu virus shortly before getting vaccinated or during the period that it takes the body to gain protection after getting vaccinated. This exposure may result in you becoming ill with flu before the vaccine begins to protect you. (About 2 weeks after vaccination, antibodies that provide protection develop in the body.) You may be exposed to a flu virus that is not included in the seasonal flu vaccine. There are many different flu viruses that circulate every year. The flu vaccine is made to protect against the three or four flu viruses that research suggests will be most common. Unfortunately, some people can become infected with a flu virus the flu vaccine is designed to protect against, despite getting vaccinated. Protection provided by flu vaccination can vary widely, based in part on health and age factors of the person getting vaccinated. In general, the flu vaccine works best among healthy younger adults and older children. 11/14/2014 Some older people and people with certain chronic illnesses may develop less immunity after vaccination. Flu vaccination is not a perfect tool, but it is Influenza Vaccine 2014-2015 17 How much flu vaccine will be available this season? As of mid-October, seven influenza vaccine manufacturers are projecting that as many as 151 million to 156 million doses of influenza vaccine will be available for use in the United States during the 2014-2015 influenza season. How much of the flu vaccines for the United States during 2014-2015 will be quadrivalent? Of the 151 million to 156 million doses of influenza vaccine projected to be available for the 20142015 season, manufacturers estimate that 76 million doses will be quadrivalent flu vaccine. 11/14/2014 CDC: Centers for Disease Control and Prevention Influenza Antiviral Medications. 18 Influenza antiviral prescription drugs can be used to treat influenza or to prevent influenza. Four licensed prescription influenza antiviral agents are available in the United States. Two FDA-approved influenza antiviral medications are recommended for use in the United States during the 2013-2014 influenza season: oral oseltamivir (Tamiflu®) and inhaled zanamivir (Relenza®). Oseltamivir and zanamivir are chemically related antiviral medications known as neuraminidase inhibitors that have activity against both influenza A and B viruses. Amantadine and rimantadine are antiviral drugs in a class of medications known as adamantanes. These medications are active against influenza A viruses, but not influenza B viruses. As in recent past seasons, there is a high prevalence (>99%) of influenza A(H3N2) and influenza A(H1N1)pdm09 (2009 H1N1) viruses resistant to adamantanes. Therefore, amantadine and rimantadine are not recommended for antiviral treatment or chemoprophylaxis of currently circulating influenza A viruses. Antiviral resistance to oseltamivir and zanamivir among circulating influenza viruses is currently low, but this might change. Also, antiviral resistance can emerge during or after treatment in certain patients (e.g., immunosuppressed). 11/14/2014 CDC: Centers for Disease Control and Prevention 2014 19 ABOUT ENTEROVIRUS 11/14/2014 Enterovirus 20 Non-enveloped, spherical, about 30 nm in diameter, T=pseudo3 icosahedral capsid surrounding the naked RNA genome. 11/14/2014 Enterovirus 2014 21 General Key Points About Enteroviruses and Enterovirus D68 Enteroviruses are very common viruses; there are more than 100 types. It is estimated that 10 to 15 million enterovirus infections occur in the United States each year. Tens of thousands of people are hospitalized each year for illnesses caused by enteroviruses. Enteroviruses can cause respiratory illness, febrile rash, and neurologic illnesses, such as aseptic meningitis (swelling of the tissue covering the brain and spinal cord), encephalitis (swelling of the brain) and acute flaccid paralysis Most infected people have no symptoms or only mild symptoms, but some infections can be serious. Infants, children, and teenagers are most likely to get infected with enteroviruses and become sick. Adults can get infected with enteroviruses, but they are more likely to have no symptoms or mild symptoms. In general, the spread of enteroviruses is often quite unpredictable, and different types of enteroviruses can be common in different years with no particular pattern. In the United States, people are more likely to get infected with enteroviruses in the summer and fall. From California Department of Public Health and Sara H. Cody, 11/14/2014 MD Health Officer, Santa Clara County Public Health Department Enterovirus 22 Activity of Enterovirus D68-like Illness in States Activity October 26-November 1, 2014. CDC: Centers for Disease Control and Prevention 2014 11/14/2014 Enterovirus 2014 23 From mid-August to October 2, 2014, more than 500 people in 43 states and the District of Columbia were confirmed to have respiratory illness caused by EV-D68. The cases were confirmed by CDC or state public health labs that notified CDC. So far, CDC has found four patients who have tested positive for EV-D68 and have died nationwide. CDC and state health departments are investigating whether EV-D68 was a cause of death in these cases. Testing has primarily been done in children with severe respiratory illness. However, it is likely that EV-D68 is circulating widely. In the United States, people are more likely to get infected with enteroviruses in the summer and fall. We are currently in the middle of the enterovirus season. EV-D68 infections are likely to decline later in the fall. Many other viruses that cause respiratory illness are circulating in the United States during this time of year. Not all clusters or outbreaks of respiratory illness occurring now are due to EV-D68. EV-D68 is not a new type of enterovirus. It is genetically very close to the types of EV-D68 that were previously detected in 2012 and 2013 in the United States, southern Europe, and Asia. The general public can help protect themselves from respiratory illnesses by washing hands with soap and water, avoiding close contact with sick people, and disinfecting frequently touched surfaces. From California Department of Public Health and Sara H. Cody, MD Health Officer, Santa Clara County Public Health Department 11/14/2014 24 ABOUT NOROVIRUS 11/14/2014 25 11/14/2014 Norovirus 26 X-ray crystallographic structure of the Norwalk virus capsid The virus particles demonstrate an amorphous surface structure when visualized usingelectron microscopy and are between 27-38 nm in size. Prasad BV, Crawford S, Lawton JA, Pesavento J, Hardy M, Estes MK (2001). "Structural studies on gastroenteritis viruses". Novartis Found. Symp. Novartis Foundation Symposia 238: 26–37; discussion 37–46. doi:10.1002/0470846534.ch3. ISBN 978-0-470-84653-7. PMID 11444031. Norovirus 27 11/14/2014 Norovirus 28 Norovirus Has Many Names. You may hear norovirus illness called "food poisoning" or "stomach flu." Food poisoning can be caused by noroviruses. But, other germs and chemicals can also cause food poisoning. Norovirus illness is not related to the flu (influenza), which is a respiratory illness caused by influenza virus. Norovirus is a very contagious virus. You can get norovirus from an infected person, contaminated food or water, or by touching contaminated surfaces. The virus causes your stomach or intestines or both to get inflamed (acute gastroenteritis). This leads you to have stomach pain, nausea, and diarrhea and to throw up. Anyone can be infected with norovirus and get sick. Also, you can have norovirus illness many times in your life. Norovirus illness can be serious, especially for young children and older adults. Norovirus is the most common cause of acute gastroenteritis in the United States. Each year, it causes 19-21 million illnesses and contributes to 56,000-71,000 hospitalizations and 570-800 deaths. Norovirus is also the most common cause of foodborne-disease outbreaks in the United States. The best way to help prevent norovirus is to practice proper hand washing and general cleanliness. CDC: Centers for Disease Control and Prevention 2014 11/14/2014 Norovirus 29 Norovirus is a highly contagious virus. Anyone can get infected with norovirus and get sick. Also, you can get norovirus illness many times in your life. One reason for this is that there are many different types of noroviruses. Being infected with one type of norovirus may not protect you against other types. Norovirus can be found in your stool (feces) even before you start feeling sick. The virus can stay in your stool for 2 weeks or more after you feel better. You are most contagious when you are sick with norovirus illness, and during the first few days after you recover from norovirus illness. You can become infected with norovirus by accidentally getting stool or vomit from infected people in your mouth. This usually happens by eating food or drinking liquids that are contaminated with norovirus, touching surfaces or objects contaminated with norovirus then putting your fingers in your mouth, or having contact with someone who is infected with norovirus (for example, caring for or sharing food or eating utensils with someone with norovirus illness). 11/14/2014 CDC: Centers for Disease Control and Prevention 2014 Norovirus 30 Norovirus and food Norovirus is the leading cause of illness and outbreaks from contaminated food in the United States. Most of these outbreaks occur in the food service settings like restaurants. Infected food workers are frequently the source of the outbreaks, often by touching ready-to-eat foods, such as raw fruits and vegetables, with their bare hands before serving them. However, any food served raw or handled after being cooked can get contaminated with norovirus. Norovirus outbreaks can also occur from foods, such as oysters, fruits, and vegetables, that are contaminated at their source. Norovirus can spread quickly in closed places like daycare centers, nursing homes, schools, and cruise ships. Most norovirus outbreaks happen from November to April in the United States. CDC: Centers for Disease Control and Prevention 2014 11/14/2014 ABOUT EBOLA © 2014 Santa Clara County Public Health Department The Public Health Department is owned and operated by the County of Santa Clara 32 11/14/2014 Background Ebola was first identified in a remote area of Africa in 1976. Since then, outbreaks have happened now and again in Africa. Before the current outbreak could be brought under control, it made it into urban areas. Cases of Ebola Virus Disease in Africa, 1976 2014 34 Page last updated: November 7, 2014 11/14/2014 Cases of Ebola Virus Disease in Africa, 1976 - 2014 35 Country Town Cases Multiple countries multiple Uganda Dem. Rep. of Congo Isiro Health Zone 2012 Uganda Kibaale District 11* 4* Sudan ebolavirus 2012 Uganda Luwero District 1 1 Sudan ebolavirus 2011 Dem. Rep. of Congo Luebo Uganda 13241 Luwero District 6* Deaths 4950 Year Zaire ebolavirus 3* Sudan ebolavirus 36* 32 Bundibugyo Species 13* 15 2014 2012 Bundibugyo ebolavirus Zaire ebolavirus 2008 149 37 Bundibugyo ebolavirus 2007 Dem. Rep. of Congo Luebo 264 187 Zaire ebolavirus South Sudan Yambio 17 7 Zaire ebolavirus Republic of Congo Mbomo 35 29 Republic of Congo Mbomo 143 128 Republic of Congo 57 Gabon Libreville 65 53 Zaire ebolavirus 2001 Uganda Gulu 425 224 Zaire ebolavirus 2000 South Africa Johannesburg 2 1 Zaire ebolavirus 1996 Gabon Booue 60 45 Zaire ebolavirus 1996 Gabon Mayibout 37 21 Zaire ebolavirus 1996 Dem. Rep. of Congo Kikwit Côte d'Ivoire (Ivory Coast) Gabon South Sudan Nzara Dem. Rep. of Congo Tandala Not specified 315 Mekouka 52 2004 Zaire ebolavirus Zaire ebolavirus 43 2003 2002 Zaire ebolavirus 250 Tai Forest 2007 2001 Zaire ebolavirus 1 1995 0 Taï Forest ebolavirus 31 Zaire ebolavirus 1994 34 22 Sudan ebolavirus 1979 1 1 Zaire ebolavirus South Sudan Nzara 284 151 Sudan ebolavirus Dem. Rep. of Congo Yambuku 318 280 Zaire ebolavirus 1994 1977 1976 1976 11/14/2014 Background The current outbreak started in Guinea, midMarch, 2014. Then spread to Liberia, Sierra Leone and Nigeria. Nigeria now free of the virus. Mali and Senegal have imported cases without transmission. Spain and U.S. have imported cases with transmission. This is the largest Ebola Virus Disease outbreak to date. Currently there are more cases than all other previous outbreaks 37 Ebola Outbreak Currently in 3 Countries in West Africa 11/14/2014 BOLA RESPONSE SITUATION REPORT 38 World Health Organization EBOLA RESPONSE ROAD MAP SITUATION REPORT UPDATE 7 NOVEMBER 2014 HIGHLIGHTS There have been 13,268 reported Ebola cases in eight affected countries since the outbreak began, with 4960 reported deaths. Case incidence is declining in some districts in Guinea, Liberia and Sierra Leone, while steep rises persist in other districts. Intense transmission in the three most affected countries demands widespread rigorous control measures. Preparedness in unaffected neighbouring countries is also critical. There have been no new cases in Mali, Spain and the USA, but a high level of vigilance is essential in these countries. CASES / DEATHS Guinea 1760 / 1054 Liberia 6619 / 2766 Sierra Leone 4862 / 1130 Mali 1 / 1 Nigeria 20 / 8 Senegal 1 / 0 Spain 1 / 0 United States of America 4 / 1 Total 13268 / 4960 http://apps.who.int/iris/bitstream/10665/137592/1 roadmapsitrep_7Nov2014_eng.pdf 11/14/2014 Many countries in Africa are farther from the outbreak than countries in Europe 39 11/14/2014 What is Ebola? 40 It is a rare and deadly disease caused by one of the Ebola virus strains, which are found in several African countries. Based on evidence and the nature of similar viruses, researchers believe that the virus is started in animal and bats are the most likely source. Ebola can cause disease in humans and primates. 11/14/2014 How does Ebola spread? 41 Animal (bats, primates) to human. Human to human: through direct contact with blood or body fluids (saliva, mucus, vomit, pee and poop), and then touching eyes, nose, mouth or a wound or cut. Common settings for transmission: Healthcare workers taking care of sick; Home caregivers taking care of sick; Traditional funerals that involve touching the body. 11/14/2014 42 11/14/2014 When does Ebola spread? 43 The incubation period for Ebola is the time from being exposed to the disease and beginning of symptoms. Incubation for Ebola ranges from 2 to 21 days, but 8 – 10 days is typical. Exposed/No Symptoms: Not infectious and no risk to the public’s health. Early Symptoms: Low risk for transmitting disease to others. As the symptoms get worse, the patient is more infectious. Symptoms Worsen: High risk for transmitting to others. After Death: Risk of transmission remains high. Who may have Ebola? Have they been in Guinea, Liberia or Sierra Leone in the last 21 days? Have they been exposed to a person with Ebola? Are they ill with symptoms that might indicate Ebola? Ebola Symptoms 45 Starts with common symptoms: Fever (87%), chills, muscle aches (39%), weakness (76%). Day 4 of illness: Severe watery diarrhea (65%), nausea, vomiting (67%), abdominal pain (44%), chest pain, shortness of breath, profound weakness. Day 5 – 7 of illness: May develop rash. Day 6 – 16: Multi-organ failure, septic shock, bleeding (18%). 11/14/2014 Treatment Of Ebola No FDA-approved vaccine or medicine (e.g., antiviral drug) is available for Ebola. Symptoms of Ebola and complications are treated as they appear. The following basic interventions, when used early, can significantly improve the chances of survival: • Providing intravenous fluids (IV) and balancing electrolytes (body salts). • Maintaining oxygen status and blood pressure. • Treating other infections if they occur. Experimental vaccines and treatments for Ebola are under development, but they have not yet been fully tested for safety or effectiveness. Recovery from Ebola depends on good supportive care and the patient’s immune response. People who recover from Ebola infection develop antibodies that last for at least 10 years, possibly longer. It is not known if people who recover are immune for life or if they can become Treatment of Ebola 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-healthcare-settings.html Treatment Centers 48 11/14/2014 Ebola African Community Information 49 From Ministry of Health, and Sanitation, Sierra Leone Used with permission. 11/14/2014 Ebola African Community Information 50 From Ministry of Health, Liberia - Used with permission. 11/14/2014 Ebola African Community Information 51 11/14/2014 Ebola African Community Information 52 From Ministry of Health, Liberia - Used with permission. 11/14/2014 Ebola African Community Information 53 11/14/2014 Ebola African Community Information 54 How to make chlorine solutions from 5% liquid bleach 11/14/2014 Ebola Community Information 55 11/14/2014 Public Health Preparedness 56 Objective #1: Preparing the Health Care System Safe identification and care of a potential Ebola patient includes: Rapid ID of patient in all healthcare settings. Rapid implementation of infection control precautions. Safe transport of ill patient to hospital via Emergency Medical Services Agency. Identification and support of referral hospitals for ongoing care. Effective decontamination of equipment, vehicles and facilities. 11/14/2014 Public Health Preparedness 57 Objective #2: Educating the Public Clear, concise, consistent risk communication with public, partners and other stakeholders. Staying up-to-date and in communication with California Department of Public Health & the Centers for Disease Control and Prevention (CDC). 11/14/2014 Public Health Preparedness 58 Objective #3: Ensuring public health system is ready to respond Rapid identification, risk assessment and implementation of public health actions for any contacts to a confirmed Ebola case to stop the chain of transmission. Protocols in place for followup with recent travelers from affected countries. 11/14/2014 Know the Facts 60 There is no Ebola in Santa Clara County or California. Ebola can only be spread by direct contact with blood or body fluids of a person who is sick with symptoms of the disease. Systems are in place for a quick response from the Public Health Department and medical community to keep the public safe. 11/14/2014 Is it Flu or Ebola? 61 Flu (influenza) The flu is a common contagious respiratory illness caused by flu viruses. The flu is different from a cold. Flu can cause mild to severe illness, and complications can lead to death. Ebola Ebola is a rare and deadly disease caused by infection with an Ebola virus. How Flu Germs Are Spread How Ebola Germs are Spread The flu is spread mainly by droplets made when people who have flu cough, sneeze, or talk. Viruses can also spread on surfaces, but this is less common. People with flu can spread the virus before and during their illness. Ebola can only be spread by direct contact with blood or body fluids from a person who is sick or who has died of Ebola or Objects like needles that have been in contact with the blood or body fluids of a person sick with Ebola. Ebola cannot spread in the air or by water or food. Who Gets The Flu? Who Gets Ebola? Anyone can get the flu. Some people—like very young children, older adults, and people with some health conditions—are at high risk of serious complications. People most at risk of getting Ebola are Healthcare providers taking care of Ebola patients. Friends and family who have had unprotected direct contact with blood or body fluids of a person sick with Ebola. Signs and Symptoms of Flu The signs and symptoms of flu usually develop within 2 days after exposure. Symptoms come on quickly and all • Fever or feeling feverish • Headache • Muscle or body aches • Feeling very tired (fatigue) • Sore throat • Runny or stuffy nose Cough Signs and Symptoms of Ebola The signs and symptoms of Ebola can appear 2 to 21 days after exposure. The average time is 8 to 10 days. Symptoms of Ebola develop over several days and become progressively more severe. • People with Ebola cannot spread the virus until symptoms appear. Fever Severe headache Muscle pain Feeling very tired (fatigue) Vomiting and diarrhea develop after 3–6 days Weakness (can be severe) Stomach pain Unexplained bleeding or bruising 11/14/2014 For more information about the flu and Ebola, visit www.cdc.gov/flu and www.cdc.gov/ebola. 62 Questions? California Hotline 855-421-5921 8:00 a.m. to 5:00 p.m. Monday through Friday 11/14/2014