Wednesday, October 01, 2014

WHO: Ebola Response Roadmap Situation Report 1 October 2014

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# 9036

 

The numbers coming out of West Africa’s Ebola outbreak are bad, and getting worse – with 7178 cases reported and 3338 deaths – as of September 28th.   A jump of nearly 1,000 cases since the last report.

More sobering, the best guesses are that the actual number of cases could be between 2 and 3 times higher.


Here are excerpts from the World Health Organization’s latest Ebola Roadmap SitRep.

 

WHO: Ebola Response Roadmap Situation Report 1 October 2014


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OVERVIEW


The total number of probable, confirmed and suspected cases (see Annex 1) in the current outbreak of Ebola virus disease (EVD) in West Africa reported up to 28 September 2014 is 7178, with 3338 deaths. Countries affected are Guinea, Liberia, Nigeria, Senegal and Sierra Leone. Figure 1 shows the total number of confirmed and probable cases in the three high-transmission countries (Guinea, Liberia, and Sierra Leone) reported in each epidemiological week between 30 December 2013 (start of epidemiological week 1) and 28 September 2014 (end of epidemiological week 39). For the second week in a row the total number of reported new cases has fallen. It is clear, however, that EVD cases are under-reported from several key locations. Transmission remains persistent and widespread in Guinea, Liberia and Sierra Leone, with strong evidence of increasing case incidence in several districts. There are few signs yet that the EVD epidemic in West Africa is being brought under control.

1. COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION


The upward epidemic trend continues in Sierra Leone and most probably also in Liberia. By contrast, the situation in Guinea appears to be more stable, though it must be emphasized that in the context of an outbreak of EVD, a stable pattern of transmission is still of grave concern, and could change quickly (figure 1; table 1).

GUINEA
Reports from Guinea show a slight fall in the number of new cases reported compared with each of the past five weeks (figure 2). This fall is largely attributable to a drop in the number of new cases reported from Macenta district, which had seen a surge in the number of new cases over the past five weeks.

Transmission is persistent in Gueckedou, the region in which the outbreak originated, which has reported between five and 20 new cases over the past 10 weeks. There has been a slight increase in the number of new cases reported in the capital, Conakry, with 27 new confirmed cases reported this week. Beyla district, which borders Côte d’Ivoire, has now reported its first confirmed case.


LIBERIA
The continued fall in the number of reported new cases shown in figure 1 is largely attributable to the sharp drop in the number of confirmed new cases reported from Liberia over the past two weeks. Last week there were no new reported confirmed cases from the capital, Monrovia, which in previous weeks had reported a surge in cases. This week, five new confirmed cases have been reported in Monrovia, but there remains compelling evidence obtained from responders and laboratory staff in the country that there is widespread under-reporting of new cases, and that the situation in Liberia, and in Monrovia in particular, continues to deteriorate.

A large number of suspected new cases (and deaths among suspected cases) have been reported from Liberia over the past week. It is very likely that a substantial proportion of these suspected cases are genuine cases of EVD, and that the reported fall in confirmed cases reflects delays in matching laboratory results with clinical surveillance data. Efforts are being made to urgently address this problem, and it is likely that the figures will be revised upwards in due course. At the present time, the numbers of probable and suspected cases, together with those confirmed, may be a more accurate reflection of case numbers in Liberia. The counties of Bong, Grand Bassa, Margibi and Nimba continue to report high numbers of new cases. There has been little change in the number of new cases reported in Lofa, which borders Gueckedou in Guinea, for the past three weeks, with 38 confirmed and probable cases reported this week.


SIERRA LEONE
Nationally, the situation in Sierra Leone continues to deteriorate, with an increase in the number of new confirmed cases reported over each of the past six weeks. The neighbouring districts of Port Loko, Bombali, and Moyamba, which are adjacent to the capital, Freetown, have now been quarantined after a surge in new cases over the past four weeks. Tonkolili has also reported a rise in the number of new cases this week. By contrast, a very low number of new cases have been reported from Kailahun and Kenema for the past two weeks. These areas had previously reported high levels of transmission. Further investigation will be required to confirm whether this fall is genuine, or a result of under-reporting. At present, the latter appears more likely.

HEALTH-CARE WORKERS
The high number of EVD infections in health-care workers (HCWs) continues to be a cause of great concern. 377 HCWs have now been infected with EVD as of 28 September, 216 of whom have died (table 2).

(Continue . . . )

WHO Ebola Situation Report - Experimental Vaccines Expert Consultation

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# 9135

 

With West Africa’s Ebola epidemic spiraling out of control, and the traditional methods of quashing outbreaks – isolation of all cases, contact tracing and monitoring, and stringent infection control – all currently overwhelmed by the sheer volume of cases, there are many who believe the best hopes for containment may lie in the development and deployment of a safe and effective vaccine.

 

The problem is, it normally takes years of testing for a vaccine candidate to be certified both safe and effective. 

 

With the number of Ebola cases doubling every three-to-four weeks, Africa doesn’t have years to wait. 

 

Other interventions, including therapeutics like ZMapp or the use of convalescent serum,  might help slow the spread, but realistically – without an awful lot of luck  – a vaccine is the only thing likely to put an end to this epidemic (and prevent future ones as well).  

 

With a worst-case forecast of more than a million cases possible by the end of January (see MMWR: Estimating The Future Number of Cases In The Ebola Epidemic), the stakes for Africa – and for the rest of the world – are enormous.

 

Even so, it will take months to know whether either of the two selected vaccine candidates work well in humans – and that they are also safe.  Limited use in the field might begin by the end of the year – probably first among healthcare workers and caregivers – but we should not expect to see any mass vaccination campaigns for quite some time. 

 

Today, in a lengthy release from the World Health Organization, officials warned:

 

Vaccine development normally takes a long time and is notoriously costly. Even under the best conditions and with the massive efforts of many partners, a significant number of doses will not be available until late in the first quarter of 2015.


Furthermore, having a vaccine in available quantity and delivering them into the arms of millions of people who – at this time have very little trust in western medicine – will pose many additional challenges.  Rolling out an experimental vaccine in record time is an ambitious endeavor, with no guarantees of timely success.

A quick primer: 

  • Phase I trials are small-scale studies used to assess whether the vaccine is safe in humans and what immune response it evokes.
  • Phase II  trials involve a greater number of participants and look mainly to determine the efficacy of the vaccine (along with safety issues).


Efficacy testing of a vaccine that protects against a deadly virus provides additional challenges, as you cannot simply vaccinate a group of subjects and then challenge them with the virus. The FDA allows for animal testing in these type of cases, but that doesn’t guarantee the same response in humans.

 

All of which brings us to this emailed WHO Situation assessment , outlining the enormous efforts that need to be done to get a viable vaccine into the field.

 

Situation assessment


Experimental Ebola vaccines: outcome of a WHO expert consultation


1 October

WHO Consultation on Ebola vaccines: beyond phase 1 clinical trials

From 29–30 September, WHO organized an expert consultation to assess the status of work to test and eventually license two candidate Ebola vaccines. More than 70 experts, including many from affected and neighbouring countries in West Africa, attended the event.


The expertise represented among participants ranged from the virology of emerging infections, to regulatory requirements that must be met, to medical ethics, public health, and infectious diseases. Heads of clinical research and other executives from the pharmaceutical industry also presented their views.

Some non-African participants came with more than 3 decades of experience working in Africa on other infectious diseases.


Experts on the use of innovative, cutting-edge trial designs also shared their most recent work.


The overarching objective was to take stock of the many efforts currently under way to rapidly evaluate Ebola vaccines for safety and efficacy. The next step is to make these vaccines available as soon as possible – and in sufficient quantities – to protect critical frontline workers and to make a difference in the epidemic’s future evolution.


All agreed on the ultimate goal: to have a fully tested and licensed product that can be scaled up for use in mass vaccination campaigns.


Two promising candidate vaccines
Given the public health need for safe and effective Ebola interventions, WHO regards the expedited evaluation of all Ebola vaccines with clinical grade material as a high priority.


Two candidate vaccines have clinical-grade vials available for phase 1 pre-licensure clinical trials.

One (cAd3-ZEBOV) has been developed by GlaxoSmithKline in collaboration with the US National Institute of Allergy and Infectious Diseases. It uses a chimpanzee-derived adenovirus vector with an Ebola virus gene inserted.


The second (rVSV-ZEBOV) was developed by the Public Health Agency of Canada in Winnipeg. The license for commercialization of the Canadian vaccine is held by an American company, the NewLink Genetics company, located in Ames, Iowa. The vaccine uses an attenuated or weakened vesicular stomatitis virus, a pathogen found in livestock; one of its genes has been replaced by an Ebola virus gene.


Phase 1 trials

WHO and other partners have helped facilitate expedited evaluation of these two vaccines in order to generate phase 1 safety and immunogenicity data for decision-making. A series of coordinated phase 1 trials is currently under way or will soon be initiated with international consortia at more than 10 sites in Africa, Europe and North America.


These studies aim to ensure good communication and harmonization of key design elements to allow for merging of data from different trials of the same candidate products.


The trials, which are being conducted in healthy human volunteers, are designed to test safety and immunogenicity and select the appropriate dose. Two phase 1 trials of the cAd3-ZEBOV started in September 2014 in USA and UK, and the first Phase 1 trial of VSV-ZEBOV is due to start early in October in USA.


The government of Canada has donated 800 vials of rVSV-ZEBOV to WHO. Once data on dosing from phase 1 trials become available, this donation could translate into about 1500 to 2000 doses of vaccine.


Both companies are working to augment their manufacturing capacity. The goal is a very significant increase in scale during the first half of 2015.

No delays

One shared mindset was readily apparent during the two-day discussions. Nothing must be allowed to slow down the goal of making vaccines accessible to people in affected West African countries. The phrase, “Nothing can be allowed to delay this work”, was heard over and over again.

The ambition: to accomplish, within a matter of months, work that normally takes from two to four years, without compromising international standards for safety and efficacy.

In other words: to give the African people and their health authorities the best product that the world’s scientists, working collectively, have to offer.

What the experts considered

Against this background, the meeting looked specifically at the objectives and key design elements for moving in an expedited manner to conduct additional clinical trials (phase 2 trial designs) that will generate additional safety data and evidence that the vaccine confers protection.


Parallel pathways for emergency use of experimental candidate vaccines with data collection, among frontline health care workers and other critical personnel, were also explored.


Apart from the great sense of urgency, the overall spirit of the discussions was characterized by a strong sense of solidarity with the people of West Africa, their governments, and their medical, scientific, and public health communities.


Equally strong was the insistence on ensuring that evidence on safety, immunogenicity, and efficacy of the vaccines is collected properly.

Multiple challenges


Multiple potential challenges and uncertainties were put forward and assessed. Issues ranging from barriers to rapid implementation of R&D, to the design of trials and their use to guide eventual widespread vaccination, were discussed together with proposed ways to overcome them.


Some of the practical issues discussed included how to address communities’ perceptions regarding vaccines in general, and vaccine studies more specifically, public expectations for vaccine availability for widespread use, and whether there is an adequate infrastructure in place to rapidly and safely evaluate and distribute vaccines.

One important technical challenge is the fact that the candidate vaccines must be stored at a temperature of minus 80o C.

Further issues that need to be urgently addressed include identifying staff who can conduct trials meeting international standards, logistical issues (such as cold chain needs for the vaccines), and the resources needed to start the studies quickly.


Some of the scientific challenges include how to conduct studies as safely and rapidly as possible to inform decisions about mass production of vaccines and their administration.


Key questions

Discussions focused on the main questions that studies should help address, which part of the research should be conducted in non-affected areas and which part in affected areas, and how such decisions could either help expedite or delay the availability of robust evidence.


One overarching conclusion was that the international community, joining the affected countries as a whole, has a responsibility and a role to play in accelerating the evaluation, licensing, and availability of the candidate vaccines – if proven safe and effective.


For all these reasons, the actions emerging from the consultation clearly identify a role for each of the main stakeholders.

Randomized controlled trials


Regarding the issue of how to accelerate the assessment and licensure of the vaccines, experts reiterated that, if feasible, randomized controlled trials are the design of choice because they provide the most robust data, in the shortest amount of time, to judge whether a vaccine is safe and induces protection.


Trials must be expedited, while preserving ethical and safety standards. Efficacy data of high quality must be gathered. Trials need to be carefully designed so that they concomitantly address the most important questions regarding safety, immunogenicity, and efficacy.


While individually randomized controlled trials provide the most robust data, alternative designs should be considered when these trials are not judged feasible. These include cluster-randomized and stepped-wedge designs. As long as the amount of vaccine remains limited, units – such as health or treatment facilities – can be randomized. Regardless of the design chosen, trials should move forward as quickly as possible.


Alternative study designs

Alternative study designs will not delay deployment of vaccine to those who need it. Instead, they will influence the choice of people who receive the vaccine. For some months to come, the critical limiting factor is extremely restricted vaccine supply, and not the need to conduct studies using alternative designs.


Descriptions of the so-called “randomized stepped wedge” design attracted lively interest and much discussion. In this design, a “wedge” (like a slice of a pie or a cake) of the study population is selected for step-wise inclusion in the trials.
As each “wedge” receives the vaccine, all lessons learned or needed to adjust the study design are then applied to the next group to be included in the study. The selection of study populations can be randomized by units, as described above; the entire study population eventually receives the vaccine if trials demonstrate sufficient efficacy.

Such a design makes it possible to roll out vaccinations and evaluate efficacy at the same time. It further has features that meet the explicit objective of fairness.


Other designs will be more relevant when large numbers of vaccine doses are available.

Involving countries

Decisions on study designs and target populations must be made with the active participation of experts from the three hardest-hit countries. Consultations with frontline health workers should be undertaken as a matter of urgency to identify the most feasible approaches to evaluate vaccine efficacy and identify factors influencing acceptability of randomized trials.

The experts discussed the importance of making sure that the trials are appropriately designed to inform the use of these vaccines in all populations, including children, pregnant women, and immunocompromised populations, including people who are HIV positive.

The group also discussed how best to use the doses of experimental vaccine donated by Canada and additional doses that may be available later this year and in 2015.

If vaccine doses are used in the short term, vaccines should be deployed to consenting frontline health workers.
The decision to initiate such deployment should be informed by data emerging from the phase 1 studies, and will occur with data collection on the deployment itself.

Equity is important and therefore vaccine should be made available in an equitable and consensual manner to the affected countries. Maximizing the information gained from the use of these vaccines during this phase is critical.

Information sharing

A crosscutting issue is the need for data sharing – in real time – among the research, medical, and public health communities, coordinated by WHO. This was considered of paramount importance to inform decisions on future studies and scaling up the production of those experimental vaccines that look most promising.


Vaccine development normally takes a long time and is notoriously costly. Even under the best conditions and with the massive efforts of many partners, a significant number of doses will not be available until late in the first quarter of 2015.

One important factor for the completion of all the above steps is to secure the funding to ensure the production of the vaccine and to support priority studies. Major international funding partners should promptly pledge or commit the necessary funding so that this critical research is completed without further delay.

The African perspective
The presence of West African researchers, scientists, clinicians, and health officials vastly enriched the discussions, especially concerning the practical dimensions of trial design.


These experts further underscored the importance of communicating with communities and engaging their views, and called for qualitative studies to begin immediately. For example, some cultures are deeply distrustful of “Western” medicine and foreign medical staff in general, and of vaccines in particular.


Interventions from the three hardest-hit countries, Guinea, Liberia, and Sierra Leone, clearly stated that international assistance is both greatly needed and fully welcomed.


Families and entire villages have been shattered. Some communities are on the verge of hopelessness and helplessness. Many do not comprehend what hit them and why, especially as this is the first time that the Ebola virus and Ebola virus disease have been seen in West Africa.


Governments are on board. Clinicians are on board. Researchers and their institutes are on board.


Statements made by West Africans reminded all participants of what life is really like in these countries. Children do not play in school yards, play pens, fenced back yards, or terraced gardens. They play in the bush.


These realities of daily African life need to be kept in mind when high-risk exposures are considered and defined.

Health workers

Participants were further reminded that the definition of “health care workers” in these African countries includes doctors, nurses, and laboratory technicians but also hospital cleaners, ambulance drivers, burial teams, mortuary attendants, and in some instances, traditional healers.


As hospitals in many areas are overflowing or closed, the number of treatment beds in all three countries is woefully inadequate, and people frequently do not trust the health care system, more and more patients are being cared for by their loved ones in homes or within the community.


These people are also at very high risk of infection and should be considered when priorities for support – in all its forms – are being set. The importance of community engagement cannot be overstated.


Operational changes made since the unprecedented resolutions on Ebola virus disease were adopted by an emergency session of the UN Security Council (on 18 September) and by a UN General Assembly high-level session on Ebola (on 25 September) involve a vast ground-swell scaling-up of international support to affected countries. This support includes a much larger number of medical staff working in countries, thanks to generous support from the governments of China, Cuba, and many others.


Lessons learned

Participants also drew heavily on lessons learned, in the African setting, during trials for candidate malaria, HIV/AIDS, cholera, epidemic meningitis, hepatitis B, and other vaccines.


As some experts noted, never again can the international community allow what boils down to “market failure” to create such catastrophic suffering for humanity in any country, in any region of the world.


The sense of urgency and need for speed, without compromising the integrity of studies or the quality of their data, are fully justified by the dire situation in affected countries and the risk that other countries may soon experience their first imported cases.


The Ebola outbreak currently ravaging parts of West Africa is the most severe acute public health emergency in modern times. Never before in recent history has a biosafety level 4 pathogen infected so many people so quickly, over such a wide geographical area, for so long.

Key expected milestones


October 2014:

Mechanisms for evaluating and sharing data in real time must be prepared and agreed upon and the remainder of the phase 1 trials must be started

October–November 2014:
Agreed common protocols (including for phase 2 studies) across different sites must be developed

October–November 2014:
Preparation of sites in affected countries for phase 2 b should start as soon as possible

November–December 2014:
Initial safety data from phase 1 trials will be available

January 2015:
GMP (Good Manufacturing Practices) grade vaccine doses will be available for phase 2 as soon as possible

January–February 2015:

Phase 2 studies to be approved and initiated in affected and non-affected countries (as appropriate)
As soon as possible after data on efficacy become available:

Planning for large-scale vaccination, including systems for vaccine financing, allocation, and use.

 

ECDC Epidemiological Update On MERS-CoV

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Credit Wikipedia

 


# 9134

 

The ECDC has released a new epidemiological update on the MERS-CoV outbreak on the Arabian peninsula in light of yesterday’s announced imported case in Austria, and the Hajj which occurs during the first week of October. 


Between concerns over Ebola, MERS-CoV, and the anticipated seasonal uptick in avian flu cases that arise during the winter and spring, public health officials expect to have their hands full over the next few months.

 

While the number of new MERS case announcements remains fairly low, the ECDC is emphasizing epidemic intelligence work during, and after the Hajj in order to detect any potential cases imported into the EU.

 

 

Epidemiological update: Middle East respiratory syndrome coronavirus (MERS-CoV)

  •  01 Oct 2014

​On 29 September, the Austrian Department of Health reported a confirmed case of MERS-CoV infection in a citizen of the Kingdom of Saudi Arabia recently arrived in Austria. The patient is isolated in a medical facility in Vienna. Tracing of contacts is currently underway.

Since the last ECDC rapid risk assessment of 21 August and as of 30 September 2014, 31 additional cases have been reported in Saudi Arabia. Of these 31, 19 are retrospective cases with date of onset prior to 3 June 2014 reported on 18 September 2014.


Overall, 887 laboratory-confirmed cases of MERS-CoV have been reported to public health authorities worldwide, including 352 deaths (Figure 1). Most of the cases have occurred in the Middle East (Saudi Arabia, United Arab Emirates, Qatar, Jordan, Oman, Kuwait, Egypt, Yemen, Lebanon and Iran) (Table 1). All cases reported outside of the Middle East have had recent travel history to the Middle East or contact with a case who had travelled from the Middle East (Figure 2).

In September 2014, the World Health Organization (WHO) revised the interim recommendations for laboratory testing for MERS-CoV.

Case definitions and surveillance guidance updated in July 2014 are now available on the WHO website.

On 22 September 2014, the Saudi Ministry of Health published a revised version of the MERS-CoV case definition.

The Hajj is taking place between 1 and 6 October. Those travelling from the EU to Saudi Arabia for the Hajj pilgrimage should consult the recommendations made by the Saudi Ministry of Health under Health Regulations for travellers to Saudi Arabia, which provide a comprehensive overview of the measures implemented by the local health authorities in the preparation of this event attended by over 3 million pilgrims.

The number of cases reported in the last months has decreased in Saudi Arabia, likely reflecting decreased transmission of the virus in the community compared to the previous year. However, general travel health advice, including avoiding unsafe water, undercooked meats, and raw fruits and vegetables unless freshly peeled and washed, remain important for those travelling in the Middle East.

ECDC will enhance the epidemic intelligence activities during and after the Hajj to detect possible events posing a threat to Europe. Currently the advice presented in the last ECDC rapid risk assessment remain valid.

Figure 1. Distribution of confirmed cases of MERS-CoV reported September 2012–30 September 2014, by date and reporting country (n=887)

(Continue . . . )

Referral: Ronan Kelly On AES In India

 

 

# 9033

 

One of the great things about this little part of the internet called Flublogia is that we are blessed with a great many very  smart, dedicated, and talented participants.  I’ve written in the past about the work done by volunteers on the  flu forums (see Newshounds: They Cover The Pandemic Front), but they often do far more than just surf the internet and post reports.


Ronan Kelly, who is a senior moderator at FluTrackers, has devoted an incredible amount of time and effort focusing primarily on infectious diseases on the Indian Subcontinent.

 

He was recently contacted by the University of New South Wales and invited to put together a blog post on the – as yet unidentified and complicated AES (Acute Encephalitis Syndrome) epidemic– which occurs in the Northeastern states of that country every year. 

 

So, without further ado, I invite you to follow the link below to read:

 

Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle.

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By Ronan Kelly.

Ronan Kelly (USA) is a Senior Moderator at www.FluTrackers.com, with an interest in outbreaks in India.

Past history of AES in India

Acute Encephalitis Syndrome (AES) is a growing problem in India. The first major outbreak was in West Bengal in 1973 involving 700 cases and over 300 deaths. Subsequent serological studies identified the Japanese Encephalitis (JE) virus as the cause. (1,2) Between 1978 and 2007, over 100,000 cases of AES with a case fatality rate (CFR) of almost 33% were reported from 13 different states. It was widely presumed that JE was the predominant aetiological agent in these outbreaks. (3,4) However, a study of patients admitted between 1985-1988 at King George’s Medical College (now Shahuji Maharaj Medical University) in Lucknow revealed bacterial meningitis as a diagnosis in 18% of apparent AES patients with JE indicated in only 12% of cases. Measles, Mumps, Malaria also played a part to some smaller degree, but 50% of the cases remained undiagnosed. Reye’s Syndrome was not found in any case.(5) An investigation of repeated AES outbreaks in Saharanpur in the early 2000s found that children were eating beans of the Cassia occidentalis plant which was causing acute hepatomyoencephalopathy. These patients were being misdiagnosed as AES cases. Local government organized removal of the plants and provided information programs for residents. As a result, fatalities in the district dropped from around 100 per year to zero in 2010. (6,7)

(Continue . . . )

Why Airport Screening Can’t Stop MERS, Ebola or Avian Flu

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Scheduled airline traffic around the world, circa June 2009 – Credit Wikipedia

 

# 9132

 

Whenever there is an outbreak of a potentially deadly, highly infectious disease somewhere in the world - and cases begin to show up elsewhere as a result of modern air travel -  the question is always raised:

Why can’t we stop infected individuals from entering the country by screening at airports and the border?

 

It is, after all, an idea that is promoted by the manufacturers of thermal scanning devices, and often pulled out of the rabbit hat by governments around the world when a disease threat appears. 

 

During the SARS epidemic of 2003, the H1N1 pandemic, and more recently with MERS and H7N9, many countries have employed fever scanning technology on incoming passengers.

 

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Thermal Scanner – Credit Wikipedia

 

Last year, in Head ‘Em Off At The Passenger Gate?, we looked at a Reuters story called Support high for travel screening to stem MERS spread: poll, that found:

 

More than 80 percent of people questioned in developed countries said inbound travelers from countries with cases of MERS should be screened for the illness. The number rose to 90 percent in less industrialized countries.

 

The problem is, while the technology can detect (most) people with fevers, their track record of detecting and preventing infected individuals from entering a country has been only slightly better than dismal.  The biggest obstacle being:  not everyone who is infected with the fear du jour will exhibit a fever.

 

  • Some may be silently incubating the virus, and will become symptomatic hours or days after arrival
  • Others may have other symptoms, but no fever
  • Some may be taking antipyretics (fever reducers) to ease symptoms or evade detection
  • And some may simply be asymptomatic carriers of the virus.


And since MERS, Avian Flu, and Ebola outbreaks don’t happen in a vacuum – and there are likely to be a far greater number of passengers less dire fever producing infections (colds, flu, WNV, teething babies, etc.) – trying to determine who to quarantine and who to let through becomes a nightmare.


A strict `any fever=no entry’ policy would quickly turn any busy airport or entry point into a shambles, cause massive travel delays for everyone, and incur great economic costs. 

All the while `silent’ infections would  pass through undetected.

 

We know this because previous attempts to interdict SARS and H1N1 using airport screeners and/or thermal scanners have been well studied. In 2010, in  Japan: Quarantine At Ports Ineffective Against Pandemic Flu, I wrote about a study that found between asymptomatic or mild infections, and a silent incubation period of several days, there wasn’t much chance of long-term success.

 

For every person identified, and quarantined, by port authorities  - researchers estimate 14 others infected by the virus entered undetected.

 

In April of 2012, in EID Journal: Airport Screening For Pandemic Flu In New Zealand, we looked at a study that found that the screening methods used at New Zealand’s airport were inadequate to slow the entry of the 2009 pandemic flu into their country, detecting less than 6% of those infected.

 

Unlike some other countries in 2009, New Zealand did not employ thermal scanners, which look for arriving passengers or crew with elevated temperatures.  But even countries that employed thermal scanners and far more strict interdiction techniques during the summer of 2009 failed to keep the flu out.

 

Since there is nothing worse than being sick away from your own country and your own doctor, to little surprise in Vietnam Discovers Passengers Beating Thermal Scanners, we saw evidence of flyers taking fever-reducers to beat the airport scanners in order to get home.

 

In December of 2009, in Travel-Associated H1N1 Influenza in Singapore, I wrote about a a study in the CDC’s  EID Journal  entitled: Epidemiology of travel-associated pandemic (H1N1) 2009 infection in 116 patients, Singapore that determined that airport thermal scanners detected only 12% of travel-associated flu, and that many travelers boarded flights despite already experiencing symptoms.

 

And in June of 2010 CIDRAP carried a piece on a study of thermal scanners in New Zealand in 2008 (before the pandemic) presented at 2010’s ICEID called Thermal scanners are poor flu predictors.

 

The world’s airlines carry 2.6 billion passengers each year, on more than 17 million flights.  And as the graphic at the top of this post indicates, millions of these are international flights.

 

With most viral diseases having an incubation period that ranges from a couple of days to a week or longer, someone who is newly infected with a virus could easily change planes and continents several times before ever they ever show signs of illness.

 

It should be stressed that there is a role for screening passengers departing a known outbreak location for fever or other signs of illness, and that passengers who are visibly ill should always be attended to, and isolated if necessary. 

 

The WHO’s advice in their August 18th Statement on travel and transport in relation to Ebola virus disease (EVD) outbreak.

Affected countries are requested to conduct exit screening of all persons at international airports, seaports and major land crossings, for unexplained febrile illness consistent with potential Ebola infection. Any person with an illness consistent with EVD should not be allowed to travel unless the travel is part of an appropriate medical evacuation. There should be no international travel of Ebola contacts or cases, unless the travel is part of an appropriate medical evacuation

 

And finally,  a statement  I wrote about last June in  WHO: IHR Committee Statement On Thermal Screening For MERS-CoV, which said:

 

Finally, the Committee indicated that there was no solid information to support the use of thermal screening as a means to stop or slow the entry of MERS-CoV infections, and that resources for supporting such screening could be better used to strengthen surveillance, infection control and prevention or other effective public health measures.

 

Airport screening isn’t useless, as it can identify acutely ill individuals when they are likely to be the most contagious so they can be promptly isolated,  and it can provide important surveillance information. And it might even help slow the rate of entry of an emerging disease into a region, allowing additional time to mount public health interventions. 

 

But as far as preventing an infectious disease like MERS, Ebola or Avian Flu from entering this - or any other country -  airport screening is apt to prove a major disappointment.

Tuesday, September 30, 2014

CDC Statement On Dallas Ebola Case

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# 9031

 


The CDC has posted the following statement on today’s announced Ebola case in Dallas, Tx.

 

First Imported Case of Ebola Diagnosed in the United States

 

CDC confirmed on September 30, 2014, through laboratory tests, the first case of Ebola to be diagnosed in the United States in a person who had traveled to Dallas, Texas from West Africa. The patient did not have symptoms when leaving West Africa, but developed symptoms approximately five days after arriving in the United States.

The person sought medical care at Texas Health Presbyterian Hospital of Dallas after developing symptoms consistent with Ebola. Based on the person’s travel history and symptoms, CDC recommended testing for Ebola. The medical facility isolated the patient and sent specimens for testing at CDC and at a Texas lab participating in CDC’s Laboratory Response Network. CDC and the Texas Health Department reported the laboratory test results to the medical center to inform the patient. Local public health officials have begun identifying close contacts of the person for further daily monitoring for 21 days after exposure.

The ill person did not exhibit symptoms of Ebola during the flights from West Africa and CDC does not recommend that people on the same commercial airline flights undergo monitoring, as Ebola is only contagious if the person is experiencing active symptoms. The person reported developing symptoms several days after the return flight.

CDC recognizes that even a single case of Ebola diagnosed in the United States raises concerns. Knowing the possibility exists, medical and public health professionals across the country have been preparing to respond. CDC and public health officials in Texas are taking precautions to identify people who have had close personal contact with the ill person and health care professionals have been reminded to use meticulous infection control at all times.

We know how to stop Ebola’s further spread: thorough case finding, isolation of ill people, contacting people exposed to the ill person, and further isolation of contacts if they develop symptoms. The U.S. public health and medical systems have had prior experience with sporadic cases of diseases such as Ebola. In the past decade, the United States had 5 imported cases of Viral Hemorrhagic Fever (VHF) diseases similar to Ebola (1 Marburg, 4 Lassa). None resulted in any transmission in the United States.