Friday, October 31, 2014

The Return Of The CDC’s `How Ebola Spreads’ Infographic


Droplet Spread – Credit CDC


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Earlier today I mentioned that an infographic showing that Ebola can potentially spread over short distances via droplets had been temporarily pulled by the CDC, just 5 days after first releasing it (see Guidance Gone, But Not Forgotten).   Since this removal was causing such a stir online and in the media, I expressed hopes it would be reinstated soon.


Well, I very pleased to say that a slightly modified (and not in a bad way) version of the original poster has now been uploaded to the CDC’s website (PDF LINK).


The central messages remain the same.  Ebola isn’t an airborne virus – but it can potentially be spread over short distance via droplets propelled by coughs or sneezes.   Exactly why it was deemed necessary to pull the old version escapes me, but I am happy to see the information back online.

Kudos to the CDC for getting this done.




WHO Ebola Response Situation Report – Oct 31st


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The numbers coming out of West Africa continue to bounce around, with the total number of cases actually down by nearly 200 over the report from October 29th, but the number of fatalities slightly higher.

This drop in cases was attributed to some suspected cases in Guinea being ruled out.


Given the limits of surveillance and reporting in these three countries, there’s not a great deal of faith that the numbers we are getting truly represent the size or scope of this epidemic.




total of 13 567 confirmed, probable, and suspected cases of Ebola virus disease (EVD) have been reported in six affected countries (Guinea, Liberia, Mali, Sierra Leone, Spain, and the United States of America) and two previously affected countries (Nigeria, Senegal) up to the end of 29 October. There have been 4951 reported deaths. The cases reported are fewer than those reported in the Situation Report of 29 October, due mainly to suspected cases in Guinea being discarded.

Following the WHO Ebola Response Roadmap structure1, country reports fall into two categories: 1) those with widespread and intense transmission (Guinea, Liberia, and Sierra Leone); and 2) those with or that have had an initial case or cases, or with localized transmission (Mali, Nigeria, Senegal, Spain, and the United States of America). An overview of the situation in the Democratic Republic of the Congo, where a separate, unrelated outbreak of EVD is occurring, is also provided (see Annex 2).


A total of 13 540 confirmed, probable, and suspected cases of EVD and 4941 deaths have been reported up to the end of the 29 October 2014 by the ministries of health of Guinea and Sierra Leone, and 25 October by the Ministry of Health of Liberia (table 1). All districts in Liberia and Sierra Leone have now reported at least one case of EVD since the start of the outbreak (figure 1). Of the eight Guinean and Liberian districts that share a border with Cote d Ivoire, only one in Guinea is yet to report a confirmed or probable case of EVD.

A total of 523 health-care workers (HCWs) are known to have been infected with EVD up to the end of 29 October: 82 in Guinea; 299 in Liberia; 11 in Nigeria; 127 in Sierra Leone; one in Spain; and three in the United States of America (two were infected in the USA and one in Guinea). A total of 269 HCWs have died.

WHO is undertaking extensive investigations to determine the cause of infection in each case. Early indications are that a substantial proportion of infections occurred outside the context of Ebola treatment and care. Infection prevention and control quality assurance checks are now underway at every Ebola treatment unit in the three intense-transmission countries. At the same time, exhaustive efforts are ongoing to ensure an ample supply of optimal personal protective equipment to all Ebola treatment facilities, along with the provision of training and relevant guidelines to ensure that all HCWs are exposed to the minimum possible level of risk.


(Continue . . .)

WHO Updates Personal Protective Equipment Guidelines for Ebola response




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Earlier today in WHO Video: Updated Recommendations For PPEs For Current Ebola Outbreak, we looked at a 40 minute video press briefing by Dr. Edward Kelley, Director, Service Delivery and Safety, at the World Health Organization on updated  Ebola PPE recommendations.


The PDF file has now gone live on the WHO site, and can be downloaded from:


Accompanying this guidance document we get the following (emailed) press release from WHO.


WHO Updates Personal Protective Equipment Guidelines for Ebola response

31 October 2014 ¦ GENEVA   As part of the World Health Organization’s commitment to safety and protection of healthcare workers and patients from transmission of Ebola virus disease, WHO has conducted a formal review of personal protective equipment (PPE) guidelines for healthcare workers and is updating its guidelines in context of the current outbreak.

These updated guidelines aim to clarify and standardize  safe and effective PPE options to protect health care workers and patients, as well as provide information for procurement of PPE stock in the current Ebola outbreak.

The guidelines are based on a review of evidence of PPE use during care of suspected and confirmed Ebola virus disease patients.  The Guidelines Development Group convened by WHO included participation of a wide range of experts from developed and developing countries, and international organizations including the United States Centers for Disease Control and Prevention,  Médecins Sans Frontières, the Infection Control Africa Network and others.

“These guidelines hold an important role in clarifying effective personal protective equipment options that protect the safety of healthcare workers and patients from Ebola virus disease transmission,” says Edward Kelley, WHO Director for Service Delivery and Safety.  “Paramount to the guidelines’ effectiveness is the inclusion of mandatory training on the putting on, taking off and decontaminating of PPE, followed by mentoring for all users before engaging in any clinical care.”

Guidelines were developed from an accelerated development process that meets WHO’s standards for scientific rigour and serves as a complement to the Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola, published by WHO in August 2014.

Experts agreed that it was most important to have PPE that protects the mucosae – mouth, nose and eyes – from contaminated droplets and fluids. Given that hands are known to transmit pathogens to other parts of the body, as well as to other individuals, hand hygiene and gloves are essential, both to protect the health worker and to prevent transmission to others. Face cover, protective foot wear, gowns or coveralls, and head cover were also considered essential to prevent transmission to healthcare workers.

“Although PPE is the most visible control used to prevent transmission, it is effective only if applied together with other controls including facilities for barrier nursing and work organization, water and sanitation, hand hygiene, and waste management,” says Marie-Paule Kieny, Assistant Director General of Health Systems and Innovation.  Benefits derived from PPE depend not only on choice of PPE, but also adherence to protocol on use of the equipment.

A fundamental principle guiding the selection of different types of PPE was the effort to strike a balance between the best possible protection against infection while allowing health workers to provide the best possible care to patients with maximum ease, dexterity, comfort and minimal heat-associated stress. In this situation where evidence is still being collected, to see what works best and on an effective sustainable basis, it was considered prudent to provide options for selecting PPE. In most cases, there was no evidence to show that any one of the options recommended is superior to other options available for healthcare worker safety.

Further work is needed to gather scientific experience and data from the field in systematic studies, in order to understand why some health workers are infected in the current outbreak and to increase effective clinical care.  WHO is committed to working with international partners on these issues to build this evidence base.


WHO Video: Updated Recommendations For PPEs For Current Ebola Outbreak



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Dr. Edward Kelley, Director, Service Delivery and Safety, at the World Health Organization held a 40 minute press conference in Geneva today to preview some upcoming changes to the WHO’s recommendations for HCWs Personal Protective Equipment (PPEs) when dealing with Ebola.

With well over 500 healthcare workers already infected (albeit, not all while working with patients), finding practical ways to protect those working (often in resource limited places) with Ebola patients becomes a major priority.


While stressing that PPEs are only part of a layered IPC (Infection Protection Control) system, Dr. Kelley cited several areas of PPE safety. The new guidance (which should be posted later today on the WHO website) also stresses training in the donning and doffing of PPEs.


  1. Protection of the mucosa of the eyes, nose and mouth – with an emphasis on masks that do not lie flat against the face, which tend to get moist and deteriorate in high heat environments.
  2. Hand Hygiene including strongly recommending double gloving.
  3. New guidance on the use of gowns and coveralls
  4. Guidance on footwear
  5. Guidance on head covers


Many of these recommendations are clarifications, or incremental changes, but some are clearly more stringent – such as the recommendation for double gloving (nitrile),  the need for masks that are structured to lie away from the face, and recommendations (where appropriate) to provide cover for the head and neck.


I’ll update this blog post with the links to the new guidance documents when they become available.

Note: The PDF File is now online, click the image below:



You can watch the press conference by clicking this link, or the image below:



Guidance Gone, But Not Forgotten



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Generally speaking, I’m very supportive of the CDC in this blog. Like most Americans, I recognize that they have a tough job to do, and have consistently viewed them more favorably than any other Federal agency.


While I’ve occasionally been critical of their messaging, I’ve always tried to convey my concerns with respect – not scorn.  

Last Saturday, when the CDC released the following infographic (see CDC: Ebola May Be Spread By Droplets, But Is Not Airborne), I praised them for replacing the tired (and less than entirely believable) `You can’t get Ebola Through Air’  meme, for something far more reasonable.


The idea that large droplets from coughs or sneezes pose a potential Ebola infection risk isn’t a new admission, but it has been largely downplayed by the CDC over the past few months.  This new poster was, in my opinion, a major step forward in improving the messaging. 


Inevitably,some in the media used this infographic to beat the CDC up over their earlier messaging.  A not unexpected reaction, and one I believe would likely have blown over in a couple of days. 

Regrettably, late yesterday this infographic was abruptly removed from the CDC website. Overnight the Daily Mail, Huffington Post, and others have been having a field day, as now when you hit the link you get this message:


The What’s the difference between infections spread through air or by droplets? Fact sheet is being updated and is currently unavailable. Please visit for up-to-date information on Ebola.

Frankly, if you were looking for the best way to re-energize the conspiracy theorists, nut cases, and agency haters out there – I can’t envision a more successful ploy.  Even those of us who aren’t completely certifiable are likely to see this action and go, `hmmmm’.


I can only hope someone will do a minor edit (free suggestion: change `pee & poop’ to `urine and feces’) and have it uploaded back onto your site in short order. 


Whether they have `poster’s regret’  over putting this infographic out or not (and they shouldn’t, it is the best one they’ve produced on Ebola transmission to date), pulling it off  their site after 5 days just makes the CDC look indecisive …  or worse.

Thursday, October 30, 2014

CDC Guidance: Considerations For Discharging Persons Under Investigation For Ebola


CDC Infographic: Is it flu, or Ebola?


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As has already been demonstrated, while a fair number of people may be initially suspected of having Ebola, few will actually end up being infected with the virus. The CDC has fielded calls on scores of `suspected’ Ebola cases from hospitals around the country – performed testing on dozens – and yet only small handful have tested positive for the virus. 


Today the CDC has issued guidance on the steps hospitals and clinicians should take when deciding whether to discharge someone who is (or was) a  PUI (Patient Under Investigation) for Ebola infection.


As you will see, Ebola cannot be ruled out by laboratory testing early in the symptomatic phase of the illness. It can take as long as 72 hours after symptoms appear for rt-PRC testing to pick up the virus. Which explains why some patients have been isolated – and retested – for 2 or 3 days before a final determination can be made. 


A negative test or no test conducted, and a change in symptoms inconsistent with Ebola infection, however, can be used – assuming the patient can be properly monitored after discharge.  

Considerations for Discharging Persons Under Investigation (PUI) for Ebola Virus Disease (Ebola)

The decision to discharge a patient being evaluated as a Person Under Investigation (PUI) for Ebola who has not had a negative RT-PCR test for Ebola (RT-PCR testing for Ebola virus infection has not yet been performed or RT-PCR test result on a blood specimen collected less than 72 hours after onset of symptoms is negative) should be based on clinical and laboratory criteria and on the ability to monitor the PUI after discharge, and made by the medical providers caring for the PUI, along with the local and state health departments.

Health care providers evaluating a PUI should consider these criteria when deciding to discharge a PUI:
  1. In the clinical judgment of the medical team, the PUI’s illness no longer appears consistent with Ebola.
  2. The PUI is afebrile off antipyretics for 24 hours, or there is an alternative explanation for fever.
  3. All symptoms that are compatible with Ebola (e.g., diarrhea or vomiting) have either resolved or can be accounted for by an alternative diagnosis.
  4. The PUI has no clinical laboratory results consistent with Ebola, or those that could be consistent with Ebola have been otherwise explained.
  5. The PUI is able to self-monitor (or to monitor a child, if the PUI is a child) and comply fully with active monitoring and controlled movement.
  6. There is a plan in place for the PUI to return for medical care if symptoms recur, which has been explained to the PUI, and the PUI understands what to do if symptoms recur.
  7. Local and state health departments have been engaged and concur.
  8. Active monitoring and controlled movement still apply for persons who have had Ebola virus exposures and are under follow-up as contacts for the full 21-day period following their last exposure.
Important information about RT-PCR testing for Ebola virus:
  • A negative RT-PCR test result for Ebola virus from a blood specimen collected less than 72 hours after onset of symptoms does not necessarily rule out Ebola virus infection.
    • If the patient is still symptomatic after 72 hours, the test should be repeated.
    • If the patient has recovered from the illness that brought them to medical attention, a repeat test is not required.
  • A negative RT-PCR test result for Ebola virus from a blood specimen collected more than 72 hours after symptom onset rules out Ebola virus infection.
  • Positive Ebola virus RT-PCR results are considered presumptive until confirmed by CDC.