22 Sep 2014

#Nigeria and #Senegal: #stable – for the moment (@WHO, September 22 2014)

[Source: World Health Organization, full page: (LINK).]

Nigeria and Senegal: stable – for the moment [      ]

Ebola at 6 months

Nigeria’s stable situation – with cases confirmed in Lagos, Africa’s most populous city, characterized by a vastly inadequate and fragile infrastructure, and in Port Harcourt, the country’s restive oil and energy hub – astonished experts at WHO and probably everywhere else in the world as well. No one expected an outcome as good as this one.

 

Rapid reaction

After the country’s first case, imported by an air traveller to Lagos on 20 July, was confirmed, the Ministry of Health responded urgently, dramatically, appropriately and effectively.

Contact tracing by highly-trained local health workers, aided by staff from WHO and the United States Centers for Disease Control and Prevention, would eventually reach nearly 100% of all exposed persons. Unlike the case in the three hardest-hit countries, Nigeria’s Ministry of Health created the facilities to isolate exposed persons during the requisite 21-day monitoring period. The government also built two new Ebola-specific treatment centres, one in Lagos and a second in Port Harcourt.

For its part, WHO supported the government’s response with several clinicians and with an epidemiological investigative team headed by one of its most experienced field epidemiologists, Dr William Perea Caro. Dr Perea Caro worked shoulder-to-shoulder with Nigerian health officials. The head of WHO’s country office, Dr Rui Vaz, another highly respected and experienced epidemiologist, likewise participated in the two investigations.

 

Linked infections

When a Lagos contact escaped the monitoring system and fled to Port Harcourt for treatment, the hundreds of high-risk exposures that followed were – once again – expected to lead to a rapid explosion of cases and spread of the virus to other Nigerian states.

But Nigeria has confined the outbreak to only 15 confirmed cases in Lagos and 4 in Port Harcourt. Altogether, seven deaths were reported. Sadly, five of these deaths occurred among doctors and nurses tending the ill. All of the country’s cases were linked back to the index case, the air traveller from Liberia.

 

Two key lessons

The fact that the worst-case scenario never happened supports two important lessons.

First, conventional control tools – like early detection, contact tracing, isolation and monitoring of those exposed, adequate supplies of personal protective equipment for medical and nursing staff, and strict procedures for infection prevention and control – are indeed highly effective when a country’s first imported case is detected early enough and managed as recommended by WHO.

Second, if Nigeria can control an outbreak caused by such a deadly and highly contagious virus, right from the start, any country in the world can do the same.

 

The Senegal case

These lessons were borne out when Senegal confirmed its first case in a Guinean national who entered Senegal by road on 29 August. To support the government, WHO immediately responded in emergency mode, with a risk assessment, airlifting of adequate quantities of medical supplies, and the deployment, within a day, of three of its most senior epidemiologists, Dr Guénaël Rodier, Dr Florimont Tshioko and Dr Amada Berthe.

Contact tracing was excellent. Numerous suspected cases were identified, tested, and then discarded as all test results came back negative. Dakar further benefitted from the presence of an Institut Pasteur laboratory with world-class diagnostic capacity. The first case has remained the country’s only one. He received excellent supportive care, completely recovered, and was released from the hospital with full confidence that he poses no risk to others.

The first 21-day period with no cases has passed and Senegal has entered the second 21-day period. If vigilance stays high and the country remains Ebola-free over the next three weeks, WHO will be able to announce that Senegal’s outbreak has ended.

However, as WHO Assistant Director-General Dr Bruce Aylward has noted, “This health crisis we’re facing is unparalleled in modern times.”

No one can predict with certainty how the outbreaks in these two countries will evolve.

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#Groundzero in #Guinea: the #outbreak smoulders – undetected – for more than 3 months (@WHO, September 22 2014)

[Source: World Health Organization, full page: (LINK).]

Ground zero in Guinea: the outbreak smoulders – undetected – for more than 3 months [      ]

Ebola at 6 months

On 26 December 2013, a two-year-old boy in the remote Guinean village of Meliandou fell ill with a mysterious illness characterized by fever, black stools, and vomiting. He died two days later. Retrospective case-finding by WHO would later identify that child as West Africa’s first case of Ebola virus disease. The circumstances surrounding his illness were ominous.

 

The forest background

During the country’s long years of civil war, natural resources were exploited by mining and timber companies. The ecology in the densely-forested area changed. Fruit bats, which are thought by most scientists to be the natural reservoir of the virus, moved closer to human settlements.

Hunters, who depend on bushmeat for their food security and survival, almost certainly slaughtered infected wild animals – most likely monkeys, forest antelope, or squirrels. (WHO investigations into the origins of previous Ebola outbreaks have often found dead primates and other wild animals in jungles and forests). The wives of the hunters prepared the meat for family meals.

Though no one knew it at the time, the Ebola virus had found a new home in a highly vulnerable population.

Meliandou is located in what is today designated as the outbreak’s “hot zone”: a triangle-shaped forested area where the borders of Guinea, Liberia and Sierra Leone converge. All three countries were deeply impoverished, and their health infrastructures severely damaged, during years of civil war.

Poverty is pervasive. Large numbers of people do not have steady, salaried employment. Their quest to find work contributes to fluid population movements across extremely porous borders – a dream situation for a highly contagious virus.

Following the young boy’s death, the mysterious disease continued to smoulder undetected, causing several chains of deadly transmission.

 

Unclear beginnings

Later – in May this year – after the causative agent had been identified, a retrospective WHO investigation of that earliest event, headed by the Organization’s senior Ebola expert, Dr Pierre Formenty, traced the first 14 cases in great detail.

As Dr Formenty observed, these first cases yielded no strong or convincing hints, either from clinical features of the illness or the pattern of its transmission, of just what the causative agent might be, especially in a country with so much background noise from multiple other killer diseases.

But it was deadly, for sure: all 14 patients died, most within days after symptom onset. High-risk exposures were apparent (caring for a sick relative, preparing a body for burial, or delivering a baby) but again yielded no decisive clues. Alarm bells might have gone off had any doctor or health official in the country ever seen a case of Ebola. No one had. No alarm bells rang for the government or, for that matter, for the international public health community either.

As Dr Formenty noted, no one unfamiliar with the Ebola virus could have guessed so early on that this might be the cause. The WHO investigation also revealed a feature that would become a major driving force as the outbreaks in Guinea and elsewhere evolved: the very rapid movement of people from villages to Guinea’s capital and across the border into Sierra Leone. In an ominous hint of what would come, one of these first cases died in Sierra Leone.

The villagers were frightened and baffled. Their doctors were, too. The area is notorious for outbreaks of cholera and many other infectious diseases. Though cases of malaria have dropped in recent years, that disease remains the country’s most persistent and prevalent killer. Health authorities were on high alert but the causative agent still eluded them, camouflaged by early symptoms that mimic those of many other endemic diseases. Meanwhile the outbreak continued to spread, its causative agent still hidden.

 

Virus on the move

Further retrospective investigations by WHO revealed how the earliest Meliandou cluster of cases ignited spread of the virus to other places. Chains of transmission that began with the illness and death of two midwives put more villages in crisis mode.

Cases began to appear at a hospital in Gueckedou – a city in the same hot zone. At that hospital, the initial suspicions of the attending physicians focused on cholera. Of the nine patient samples tested for cholera, seven came back positive. It didn’t look exactly like cholera, but the tests used were sensitive and specific, and – once again – Ebola eluded detection.

As the investigation continued, links began to emerge between mysterious deaths in different locations. The dots of hotspots were becoming connected. Some single pathogen was likely at work, but which one?

Fortunately, staff from Médecins Sans Frontières (MSF) were already in the country, responding to a serious malaria outbreak. Later, MSF doctors would quickly shift gears to manage clinical care for the swelling number of Ebola patients.

By early March, Guinea’s health officials, MSF staff and WHO knew something strange and very worrisome was going on, but no one knew exactly what. More than three months after that end-December death, Ebola was nowhere on the radar screen of suspects for mysterious deaths in West Africa.

Deeply worried, MSF sent a report in mid-March to one of its most experienced and intuitive disease detectives at its office in Geneva. That expert immediately suspected a haemorrhagic fever, possibly caused by the Marburg virus (the largest-ever outbreak occurred in Angola in 2004–2005), or even Ebola – an unheard event for this part of the world.

 

Diagnosis

The Ministry of Health sent samples to the Institut Pasteur in Paris. The first news was shocking: the causative agent was indeed the Ebola virus. Who could ever have guessed that such a notorious disease, previously confined to Central Africa and Gabon, would crop up in another distant part of the continent? The news from subsequent virological analyses was even worse: this was Ebola Zaire, the most lethal in the family of five distinct Ebola species.

WHO published the official notification of Ebola on its website on 23 March. By that time, WHO had already shipped supplies of personal protective equipment to Conakry and activated its state-of-the-art centre for real-time outbreak tracking and response. The first medical teams, under the WHO Global Outbreak Alert and Response Network (GOARN) umbrella, were on the ground by 25 March.

 

Relentless spread

In the meantime, the virus had continued its relentless spread. The bad news got even worse as the virus successfully marched into Conakry and the first cases – which multiplied quickly – were confirmed there on 27 March. In Conakry and elsewhere, new cases hit like sparks from a fire landing on dry grass.

The brushfire had begun. By that time, flare-ups, as new transmission chains were ignited, could no longer be stamped out, even as foreign medical teams from the WHO GOARN umbrella and other partners continued to pour in.

The pattern that followed was heart-breaking as the all-out national and international response escalated and pressure to stop the virus became increasingly intense. On at least three occasions, prospects for nationwide control looked good and the countdown for a case-free 21-day incubation period began.

Breaths were held as Guinea looked ready to enter the second 21-day Ebola-free period required before WHO can declare the end of an Ebola outbreak. On each occasion, vigilance eased and the sense of emergency lapsed as local health officials assumed the outbreak was over.

The country never made it. As the deadline approached, cases suddenly flared up again in previously controlled villages and cities. In other instances, the virus marched on to infect previously untouched areas.

 

A regional challenge

Some observers have speculated that these tragic up-and-down cycles of apparent control followed by flare-ups demonstrate just how strong this Ebola Zaire virus has become. More likely, these events represent re-introductions of the virus into Guinea – with its notoriously porous borders – from the large outbreaks in neighbouring Liberia and Sierra Leone.

This more realistic explanation strongly suggests that control in Guinea will not be feasible until the Ebola caseload in its neighbours goes down. On current trends, the prospects that this will happen anytime in the near future are distinctly not good at all.

 

The fear factor

Today, one of the biggest barriers to control is violence from an impoverished, terrified and shattered population that does not understand what hit it and fights back the only way it can.

Last week, health workers in several parts of the country were viciously attacked by angry mobs, forcing some medical teams to flee for their lives. One team hid in the bush for more than a day. Others saw their vehicles vandalized and their medicines and equipment collected and publicly burned, as though such acts might work as a “cleansing” ritual.

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Six #months after the #Ebola #outbreak was declared: What happens when a deadly virus hits the destitute? (@WHO, September 22 2014)

[Source: World Health Organization, full page: (LINK).]

Six months after the Ebola outbreak was declared: What happens when a deadly virus hits the destitute? [      ]

On 23 March, the World Health Organization published formal notification of an outbreak of Ebola virus disease in Guinea on its website. On 8 August, WHO declared the epidemic to be a “public health emergency of international concern.”

This assessment traces the early origins and subsequent evolution of the epidemic, and considers where we stand today, looking at current outbreaks in each affected country and some overarching trends – and surprises – in the overall epidemic. It also gives epidemiological projections of how the epidemic is likely to evolve.

 

Looking ahead

WHO is currently conducting systematic risk assessments to identify preparedness needs in neighbouring countries that are extremely worried about their susceptibility to an imported case and their capacity to respond. The results of the assessment, which will be made public soon, will guide preparedness support provided by WHO and its many partners in the Ebola response.

Theoretically, given the speed and volume of air travel, any city with an international airport is at risk of an imported case of Ebola. At the same time, worldwide vigilance is exceptionally high: WHO investigates around 20 to 30 rumoured cases each day. To date, all rumoured cases have been discarded.

Moreover, countries with well-developed health systems and services are unlikely to see much – if any – onward transmission of Ebola virus disease following an imported case. As today’s assessment of the situation in Nigeria and Senegal shows, conventional control tools can be highly effective at the start of an outbreak, even under some extremely challenging conditions.

This six-month situation assessment is dedicated to the scores of health workers treating Ebola patients in the Democratic Republic of Congo, Guinea, Liberia, Nigeria, and Sierra Leone, who, as an expression of our innately shared human compassion, risked their lives, and lost them.

 

Cumulative number of cases and deaths

The cumulative number of cases and deaths, officially reported to WHO from 23 March to 22 September, is 5,843 cases and 2,803 deaths. To date, 337 health care workers have been infected, and more than 181 of them have died.

 

Six-month assessments by country

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#España, En busca de un superviviente para tratar al #religioso infectado de #ébola (El Pais, September 22 2014)

[Source: El Pais, full page: (LINK).]

En busca de un superviviente para tratar al religioso infectado de ébola [      ]

by Elena G. Sevillano  

El ébola no tiene cura. La única terapia posible es controlar los síntomas que la enfermedad produce en los infectados: deshidratación y fiebre en una primera fase, posibles infecciones y, a medida que avanza, el fallo de distintos órganos vitales.

(…)

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Newly-detected #bird #flu [#H5N6] in Southeast #Asia poses #threat to #animal #health, people’s livelihoods (UN, September 22 2014)

[Source: United Nations, full page: (LINK).]

Newly-detected bird flu in Southeast Asia poses threat to animal health, people’s livelihoods [      ]

22 September 2014 – The United Nations Food and Agriculture Organization (FAO) today warned that a recently-emerged strain of avian influenza virus detected in poultry in Southeast Asia presents a new threat to animal health and livelihoods and must be closely monitored.

The virus known as A(H5N6) has so far been detected in poultry in China, the Lao People’s Democratic Republic and Viet Nam, according to a statement released by the Rome-based FAO. The A(H5N6) bird flu is highly contagious in chickens, geese, and other poultry, which hundreds of millions of people rely on for their livelihood.

“Influenza viruses are constantly mixing and recombining to form new threats,” FAO’s Chief Veterinary Officer, Juan Lubroth, said in a statement from the Rome-based agency.

“However, H5N6 is particularly worrisome, since it has been detected in several places so far from one another, and because it is so highly pathogenic, meaning infected poultry quickly become sick and, within 72 hours, death rates are very high.”

Only one case of H5N6 has been reported in humans after contact with infected poultry in China. The person later died. And thus far, there have been no other reported human cases.

“It’s been detected in multiple places in poultry, yet we only have one human infection reported,” said World Health Organization (WHO) epidemiologist Elizabeth Mumford. “This suggests that the virus does not easily jump from animals to humans. Of course, we still need to remain vigilant, because prevalence in poultry and therefore human exposure could increase during the winter.”

Even if the health risks posed by H5N6 currently appear to be low, other pathogens, including subtypes of influenza viruses such as H5N1 and H7N9, still can present cause for concern, warns WHO.

FAO and WHO recommend people follow appropriate hygiene, food preparation and food safety guidelines. These include: washing hands often, cleaning utensils and surfaces used during food preparation, and eating only well-cooked poultry meat products. People should also avoid handling sick birds or those that have died of illness.

Countries in Southeast and East Asia – especially those with links to poultry production and trade – must ramp up efforts to detect and report influenza viruses in poultry and monitor for any human infections. The focus must be on prevention, early detection, immediate reporting and rapid response, said FAO.

An H5N6 outbreak could potentially overwhelm animal health systems in Southeast Asia. An earlier strain of the virus, H5N1, had impacted the livelihoods of millions of people and caused billions of dollars of damage.

News Tracker: past stories on this issue: Humans with bird flu pose no threat to poultry populations, says UN agency

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#Climate #Change: #Challenges and #Opportunities for Global #Health (#JAMA, abstract, edited)

[Source: The Journal of the American Medical Association, full page: (LINK). Abstract, edited.]

Special Communication | September 22, 2014

Climate Change: Challenges and Opportunities for Global Health [      ]

FREE / ONLINE FIRST

Jonathan A. Patz, MD, MPH1,2,3; Howard Frumkin, MD, DrPH4; Tracey Holloway, PhD2,5; Daniel J. Vimont, PhD5,6; Andrew Haines, MBBS, MD7,8

Author Affiliations: 1Global Health Institute, Nelson Institute, Madison, Wisconsin  2Nelson Institute for Environmental Studies, University of Wisconsin, Madison 3Department of Population Health Sciences, University of Wisconsin, Madison 4School of Public Health, University of Washington, Seattle 5Department of Atmospheric/Oceanic Sciences, University of Wisconsin, Madison 6Nelson Institute, Center for Climatic Research, University of Wisconsin, Madison 7Department of Social and Environmental Health Research and Population Health, London School of Hygiene & Tropical Medicine, London, England 8Department of Population Health, London School of Hygiene & Tropical Medicine, London, England

JAMA. Published online September 22, 2014. doi:10.1001/jama.2014.13186 - Published online

 

ABSTRACT

Importance

Health is inextricably linked to climate change. It is important for clinicians to understand this relationship in order to discuss associated health risks with their patients and to inform public policy.

Objectives

To provide new US-based temperature projections from downscaled climate modeling and to review recent studies on health risks related to climate change and the cobenefits of efforts to mitigate greenhouse gas emissions.

Data Sources, Study Selection, and Data Synthesis

We searched PubMed from 2009 to 2014 for articles related to climate change and health, focused on governmental reports, predictive models, and empirical epidemiological studies. Of the more than 250 abstracts reviewed, 56 articles were selected. In addition, we analyzed climate data averaged over 13 climate models and based future projections on downscaled probability distributions of the daily maximum temperature for 2046-2065. We also compared maximum daily 8-hour average with air temperature data taken from the National Oceanic and Atmospheric Administration National Climate Data Center.

Results

By 2050, many US cities may experience more frequent extreme heat days. For example, New York and Milwaukee may have 3 times their current average number of days hotter than 32°C (90°F). The adverse health aspects related to climate change may include heat-related disorders, such as heat stress and economic consequences of reduced work capacity; and respiratory disorders, including those exacerbated by fine particulate pollutants, such as asthma and allergic disorders; infectious diseases, including vectorborne diseases and water-borne diseases, such as childhood gastrointestinal diseases; food insecurity, including reduced crop yields and an increase in plant diseases; and mental health disorders, such as posttraumatic stress disorder and depression, that are associated with natural disasters. Substantial health and economic cobenefits could be associated with reductions in fossil fuel combustion. For example, the cost of greenhouse gas emission policies may yield net economic benefit, with health benefits from air quality improvements potentially offsetting the cost of US carbon policies.

Conclusions and Relevance

Evidence over the past 20 years indicates that climate change can be associated with adverse health outcomes. Health care professionals have an important role in understanding and communicating the related potential health concerns and the cobenefits from reducing greenhouse gas emissions.

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#Climate #Change: A Continuing #Threat to the #Health of the #World’s #Population (#JAMA, extract)

[Source: The Journal of the American Medical Association, full page: (LINK). Extract.]

Editorial | September 22, 2014

Climate Change: A Continuing Threat to the Health of the World’s Population [      ]

FREE / ONLINE FIRST

Howard Bauchner, MD1; Phil B. Fontanarosa, MD, MBA2

Author Affiliations: 1Editor in Chief, JAMA 2Executive Editor, JAMA

JAMA. Published online September 22, 2014. doi:10.1001/jama.2014.13094 - Published online

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Poverty and war are among the two greatest threats to health and well-being. In virtually every study, poverty emerges as a major risk factor for most diseases. The tragedies of 9/11 and the current conflicts in the Middle East are painful reminders of the human toll and societal cost of war. Yet poverty and war are seldom addressed by most national and international medical organizations. They have generally focused on the advancement of science, public and individual health, access to care, and more recently the importance of noncommunicable diseases.

(…)

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#Assessment and #planning for medical #evacuation by #air to the #EU of #patients with #Ebola virus disease and people exposed to Ebola virus, 19 September 2014 (@ECDC_EU, edited)

[Source: European Centre for Disease Prevention and Control (ECDC), full PDF document: (LINK). Edited.]

Assessment and planning for medical evacuation by air to the EU of patients with Ebola virus disease and people exposed to Ebola virus, 19 September 2014 [      ]

 

Background

The outbreak of Ebola virus disease (EVD) in West Africa is raising questions related to the evacuation of people who have been exposed to or infected with Ebola virus.

As of 11 September 2014, there have been seven officially reported medical evacuations by air (air MEDEVAC)* of Ebola-infected healthcare workers from West Africa: four to the USA, one to Spain, one to the United Kingdom and one to Germany. The media have also reported that an unknown number of people have been transported to the USA and Canada after exposure to Ebola virus in West Africa.

Within the EU, there are currently no commonly-agreed criteria for deciding when medical evacuation by air is recommended and there is no guidance on how such evacuations should be carried out. The capacity for medically evacuating EVD patients and people exposed to Ebola virus by air varies among Member States and overall experience within the EU, both civil and military, remains limited.

 

Aim

The aim of this document is to guide decision-making when there is a perceived need for medical evacuation by air of an infected or exposed person from an Ebola-affected country to an EU Member State. The decision to evacuate must be based on:

  • The likelihood of the person being infected with Ebola virus;
  • The potential benefits of evacuation for the concerned person/patient;
  • The risks associated with medical evacuation by air for the person/patient;
  • The risk of transmission to the crew and accompanying medical staff.

This document refers to the Ebola virus disease case definition for reporting in EU which is available on the ECDC website.

 

Likelihood of being infected with the Ebola virus

Exposed person

  • An exposed person refers to an asymptomatic person who has been in contact with a probable or confirmed case of EVD.
  • An exposed person should be considered for medical evacuation by air on the basis of the risk associated with the exposure.
  • An asymptomatic person with high-risk exposure should be considered for medical evacuation by air while an asymptomatic person with low-risk exposure should not. This is because there is less probability of infection after low-risk exposure than high-risk exposure.

 

Probable case

  • A probable case is a person who has been subjected to high-risk exposure and has symptoms compatible with EVD, as per the ECDC case definition.
  • A probable case is therefore more likely to be infected with Ebola virus than an exposed person.
  • Where possible, a probable case should be laboratory-confirmed before being medically evacuated by air.
  • If appropriate tests for Ebola are not available, evacuation should be considered for a probable case in accordance with the options listed for a confirmed case.

 

Confirmed case

  • A confirmed case should always be considered for medical evacuation by air.

 

Benefits for the patient

Exposed persons

  • A person subjected to high-risk exposure who is evacuated to the EU may benefit from post-exposure prophylactic treatment (currently experimental) that is not available in the countries affected by EVD (e.g. passive or active vaccination).
  • In the event of the exposed person developing EVD, supportive treatment can be provided to EU standards earlier than if the person had remained in the EVD-affected country.

 

Confirmed cases

  • The rationale for medical evacuation by air of confirmed cases is the assumption that better medical care can be offered to the person in the EU/EEA than that available in the EVD-affected countries.

 

Risk for the patient

Exposed persons

  • For an exposed but asymptomatic person, the risk associated with medical evacuation by air is not considered higher than for comparable commercial air travel.
  • Should the person develop symptoms during transportation, the probability is very low that the condition would deteriorate to become life-threatening during the flight, and medical evacuation by air therefore does not represent a significantly increased risk for the exposed person.

 

Confirmed cases

  • Medical evacuation by air represents a risk for an EVD patient who is not in stable condition, and for patients who are stable but require uninterrupted intensive supportive treatment during transportation.
  • It is the responsibility of the medical team in the EVD-affected country to assess the risks and benefits of medical evacuation by air to the individual patient in close consultation with the experts in the receiving country.
  • The possible outcomes of the assessment are:
    • The patient is unfit for medical evacuation by air because the risks of the evacuation outweigh the benefits.
    • The patient is fit for medical evacuation by air but requires uninterrupted supportive treatment of intensive-care standard during the evacuation. In this case, the ‘Open isolation’ approach is recommended for the evacuation (Annex 1).
    • The patient is fit for medical evacuation by air but requires limited supportive treatment during the evacuation. In this case, the ‘Closed isolation’ approach is recommended for the evacuation (Annex 1)

 

Risk to the crew and accompanying medical staff

Exposed persons

  • Exposed asymptomatic persons are not infectious and therefore do not represent an infection risk for crew, medical staff and/or any other passengers.
  • Because the documented minimum incubation period for EVD is 48 hours, an exposed person who reaches the final destination within 48 hours after exposure to the virus does not pose a threat to other people during transportation and could, theoretically, travel in an ordinary aircraft (i.e. a regular aircraft without specific equipment although this does not indicate a commercial flight).
  • A person whose high-risk exposure occurred more than 48 hours before the expected time of arrival at the final destination should be evacuated using a closed isolation approach because it cannot be excluded that symptoms may develop during the flight.
  • If still asymptomatic at the time of departure, the person could be evacuated in a normal airplane seat, with the isolation stretcher ready in case he/she develops symptoms.

 

Confirmed cases

  • A confirmed case must be isolated during medical evacuation by air in order to prevent transmission to the crew and accompanying medical staff.

(...)

 

References and further reading

  1. CDC guidance on air transport of EVD patients, 14 August 2014: http://www.cdc.gov/vhf/ebola/hcp/guidance-air-medical-transport-patients.html
  2. Schilling S, Follin P, Jarhall B, Tegnell A, Lastilla M, Bannister B et al. European concepts for the domestic transport of highly infectious patients European Society of Clinical Microbiology and Infectious Diseases CMI 2009;15:727–733. Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1469-0691.2009.02871.x/pdf
  3. C.Bartels, R.Steffler. Sonderisoliertransport - Mit gemeingefährlichen Infektionskrankheiten unterwegs; Biologische Gefahren Handbuch zum Bevölkerungsschutz BBK 2007;434-456 (in German). Available at: http://www.bmi.bund.de/cae/servlet/contentblob/432922/publicationFile/19597/biologische_gefahren.pdf
  4. Ebola virus disease case definition for reporting in EU. ECDC August 2014. Available at: http://ecdc.europa.eu/en/healthtopics/ebola_marburg_fevers/EVDcasedefinition/Pages/default.aspx
  5. Protocol to be followed in medical air evacuation of patients suffering from the Ebola virus. Available at: http://www.msssi.gob.es/profesionales/saludPublica/ccayes/alertasActual/ebola/docs/Protocolo_aeroevacuacion_05092014.pdf
  6. Guide to Air Ambulance Operations, Canada. Available at: http://www.tc.gc.ca/Publications/en/tp10839/pdf/hr/tp10839e.pdf
  7. AIRSAN Project. Coordinated action in the aviation sector to control public health threats. Available at: http://www.airsan.eu/
  8. Air transport of infectious disease patients – Glossary http://www.ecdc.europa.eu/en/activities/response/Pages/Air-transport-infectious-disease-patients-glossary.aspx

 

Annex 1. Mitigation of transmission risks in air MEDEVAC

  • During MEDEVAC by air, medical staff and flight crew have to be seen as personnel at risk of transmission. This risk can be minimised by isolating the patient during transportation. Basically there are two possible isolation approaches:
    • Closed isolation approach
      • The patient is placed inside a physical containment, normally an isolation stretcher. Depending on the type, it is equipped with integrated gloves with long gauntlets, which allow some basic patient handling from outside.
      • Most models will have negative pressure inside, with the exhaust air being purified by an HEPA filter system.
      • Medical staff will be outside the isolator and will not need further protection. The flight crew furthermore is protected by remaining separated in the cockpit
        • Advantages:
          • Excellent level of protection for the personnel involved and for the community; easy to implement.
        • Drawbacks:
          • Any enhanced monitoring or treatment interventions for patients with unstable or deteriorating conditions are obstructed. This treatment option is cost-intensive.
    • Open isolation approach
      • The patient and the medical staff are placed inside a mobile isolation unit (e.g. tent, container, ambulance).
      • The medical staff inside are protected by personal protective equipment.
      • Most types of isolator will have negative pressure inside, with the exhaust air being purified by an HEPA filter system.
      • The unit is provided with all the medical equipment necessary for enhanced monitoring and treatment interventions, such as mechanical ventilation and fluid management.
      • Additional medical staff will be located in the cabin outside the unit to replace the staff working in personal protective equipment according to a defined schedule.
      • The isolation unit is connected to the exterior cabin by a sluice. Staff leaving the unit need be decontaminated before taking off the personal protective equipment and entering the cabin.
        • Advantages:
          • Full access to the patient throughout transportation enables seamless medical care up to ICU level throughout the flight.
        • Drawbacks:
          • Highly complex logistics, labour- intensive and very cost intensive.

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* Since the evacuation of healthcare workers infected with Ebola virus disease and healthcare workers exposed to Ebola virus out of West Africa has so far been carried out by medical teams in specially-equipped aircrafts, this document uses the term ‘medical evacuation by air’ rather than ‘air transport’.

© European Centre for Disease Prevention and Control, Stockholm, 2014

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#EBOLA #RESPONSE ROADMAP #UPDATE, 22 September 2014 (@WHO, edited)

[Source: World Health Organization, full PDF document: (LINK). Edited.]

WHO: EBOLA RESPONSE ROADMAP UPDATE, 22 September 2014 [      ]

Following the roadmap structure, country reports fall into two categories: those with widespread and intense transmission (Guinea, Liberia, and Sierra Leone); and those with an initial case or cases, or with localized transmission (Nigeria, Senegal). An overview of the situation in the Democratic Republic of the Congo, where a separate, unrelated outbreak of Ebola virus disease (EVD) is occurring, is also provided (see Annex 1).

 

1. COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

5843 (probable, confirmed and suspected; see Annex 2) cases and 2803 deaths have been reported in the current outbreak of EVD as at 20 September 2014 by the Ministry of Health of Guinea, as at 17 September 2014 by the Ministry of Health of Liberia, and as at 19 September 2014 by the Ministry of Health of Sierra Leone (table 1).

 

Table 1: Cases of Ebola virus disease in Guinea, Liberia, and Sierra Leone

[Country - Case definition – Cases – Deaths]

  • Guinea
    • Confirmed – 818 – 465
    • Probable – 162 – 162
    • Suspected – 28 – 5
      • All – 1008 – 632
  • Liberia
    • Confirmed – 863 – 670
    • Probable – 1342 – 544
    • Suspected – 817 – 364
      • All – 3022 – 1578
  • Sierra Leone
    • Confirmed – 1640 – 545
    • Probable – 37 – 37
    • Suspected – 136 – 11
      • All – 1813 – 593
  • Total – 5843 – 2803

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Data are based on official information reported by Ministries of Health up to the end of 20 September 2014 for Guinea, 17 September for Liberia, and 19 September for Sierra Leone. These numbers are subject to change due to on-going reclassification, retrospective investigation and availability of laboratory results.

Figure 1 shows the location of cases throughout the countries with widespread and intense transmission. The cumulative numbers of cases of EVD in each area are shown (grey circles). In Guinea, one confirmed case of EVD was reported in Kindia district; the first time an EVD case has been reported from the area.

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Exposure of health-care workers (HCWs) to EVD continues to be an alarming feature of this outbreak. As of 22 September 2014, 348 HCWs are known to have developed EVD (67 in Guinea, 174 in Liberia, 11 in Nigeria, and 96 in Sierra Leone). 186 HCWs have died as a result of EVD infection (35 in Guinea, 85 in Liberia, 5 in Nigeria, and 61 in Sierra Leone).

 

2. COUNTRIES WITH AN INITIAL CASE OR CASES, OR WITH LOCALIZED TRANSMISSION

Two countries, Nigeria and Senegal, have now reported a case or cases imported from a country with widespread and intense transmission.

In Nigeria, there have been 20 cases and eight deaths.

In Senegal, there has been one case, but as yet there have been no deaths or further suspected cases attributable to Ebola (table 2).

Contact tracing and follow-up is ongoing.

In Nigeria, 696 contacts have now completed 21-day follow-up (348 contacts in Lagos, 348 contacts in Port Harcourt). Of the three contacts who are still being monitored in Lagos, all were seen on 20 September. Of the 175 contacts who are still being monitored in Port Harcourt, 165 (94%) were seen on 20 September.

In Senegal, all contacts have now completed 21-day follow-up, with no further cases of EVD reported.

 

Table 2: Cases of Ebola virus disease in Nigeria and Senegal

[Country - Case definition – Cases – Deaths]

  • Nigeria
    • Confirmed – 19 – 7
    • Probable – 1 – 1
    • Suspected – 0 – 0
      • All – 20 – 8
  • Senegal
    • Confirmed – 1 – 0
    • Probable – 0 – 0
    • Suspected – 0 – 0
      • All – 1 – 0
  • Total – 21 – 8

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Data reported are based on official information reported by Ministries of Health. These numbers are subject to change due to on-going reclassification, retrospective investigation and availability of laboratory results.

There are several points to be considered when interpreting epidemiological data for the EVD outbreak.

Many of the deaths attributed to EVD in this outbreak occurred in people who were suspected, but not confirmed, to have died from the disease. EVD cases are only confirmed when a sample tests positive in the laboratory. If samples taken from a body test negative for EVD, that person is no longer counted among EVD deaths and the figures are adjusted accordingly. However, because laboratory services and treatment centres are currently overwhelmed in several countries, the numbers of probable and suspected cases, together with those confirmed, may be a more accurate reflection of case numbers. Work is also on going to resolve discrepancies between different sources of data, which may lead to a revision of the numbers of cases and deaths in the future.

 

ANNEX 1. EBOLA OUTBREAK IN THE DEMOCRATIC REPUBLIC OF THE CONGO

As at 18 September 2014, there have been 68 cases (28 confirmed, 26 probable, 14 suspected) of Ebola virus disease (EVD) reported in the Democratic Republic of the Congo, including eight among health-care workers (HCWs). In total, 41 deaths have been reported, including eight among HCWs.

432 contacts have now completed 21-day follow-up. Of 488 contacts currently being monitored, 468 (96%) were seen on 18 September, the last date for which data has been reported. This outbreak is unrelated to that affecting Guinea, Liberia, Nigeria, Senegal and Sierra Leone.

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#Man bitten by #Ebola #patient flown to #Switzerland (Yahoo!, September 22 2014)

[Source: Yahoo!, full page: (LINK).]

Man bitten by Ebola patient flown to Switzerland [      ]

GENEVA (AP) — Swiss authorities say a male nurse who was bitten by an Ebola patient while working in West Africa has been flown to Switzerland as a precaution.

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