Saturday, October 25, 2014

CDC: Ebola May Be Spread By Droplets, But Is Not Airborne




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Over the past few months Dr. Ian Mackay and others (including this humble blogger) have taken pains to explain that Ebola is not an `airborne virus’, but that it can be spread over short distances via large droplets that might be coughed, sneezed, or otherwise propelled from an infectious patient.   


Some of Ian’s efforts include:

It's what falls out of the aerosol that matters....

The wind beneath my Ebola virus....


What I’ve often referred to as being within `spittle range’  (see Ebola Risk Communications & Ebola: Parsing The CDC’s Low Risk vs High Risk Exposures).  



The CDC’s initial meme (see above) – that `You can’t get Ebola through Air’ – while technically true –  I felt was lacking in that it never quite spelled out the potential risks of droplet transmission. 


Which is why I’m very pleased to see the following, far more informative graphic appear on the CDC’s Ebola website yesterday.



Saudi MOH Announces A New MERS Case In Taif



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The Taif MERS outbreak – which appears to have been exacerbated by exposures within their healthcare system – continues with the 17th reported case since early September. 


Today’s case is an elderly male who appears to have been exposed in the hospital.



On Monday the Saudi MOH announced new, aggressive measures were being taken to try to bring this outbreak to a halt (see Saudi MOH Statement On Recent MERS Cases In Taif).

NYC Health: Ebola Patient Timeline


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Although the evidence strongly suggests that those infected with the Ebola virus are unlikely to transmit the virus in the early-symptomatic phase of their illness - the risks of transmission, while low, are probably not zero.  


While reassuring, much of our evidence for this is anecdotal, and the question of the variability of viral shedding that might occur among patients early in their illness probably deserves more scrutiny.


So the New York City public Health Department – while stressing that it is unlikely anyone was infected by this patient prior to his going into isolation - is making public a timeline of their index case’s public movements since his arrival on the 17th. 


Health Department Releases Ebola Patient Timeline

  • Patient is a 33-year-old male Medecins Sans Frontieres (Doctor Without Borders) medical doctor who last worked in Guinea on 10/12. While treating patients in Guinea, he always wore personal protective equipment (PPE), and there were no known breaches in protocol.
  • 10/14, the patient departed Guinea on a flight to Brussels. Patient reported no symptoms.
  • On 10/17, the patient boarded a flight to the U.S. on Brussels Airlines Flight SN0501. Patient reported no symptoms.
  • On 10/17, the patient arrived at JFK. The patient was screened at JFK and had no symptoms upon arrival.
  • On 10/21 at 7 AM, the patient reported fatigue and exhaustion. No fever, vomiting, diarrhea.

Ebola Patient Timeline

  • 10/14  Patient departed Guinea. Patient reported no symptoms.
  • 10/17 Patient boarded a flight to JFK on Brussels Airlines Flight SN0501. Patient reported no symptoms.
  • 10/21 Patient reported fatigue and exhaustion. Patient visited High Line and The Meatball Shop.
  • 10/22 Patient went running on Riverside Drive and Westside Highway and also visited The Gutter.
  • 10/23 Patient first reported a fever. He was immediately taken to Bellevue by FDNY EMS for testing.
    • Fatigue is a symptom of Ebola, but it is very unlikely that people he came into close contact with on 10/21 are at risk. Out of an abundance of caution, we are actively monitoring the health of these close contacts.
  • On 10/21, around 3:00 PM, the patient visited The Meatball Shop. The Meatball Shop is located at 64 Greenwich Avenue.
  • Spent 40 minutes at The Meatball Shop.
  • On 10/21, around 4:30 PM, the patient visited the High Line.
  • Walked on High Line and stopped at the Blue Bottle Coffee stand (10th Ave & W 16th St)
  • On 10/21, around 5:30 PM, the patient got off the High Line at 34th Street and took the 1 train to the 145th Street station.
  • On 10/22, around 1:00 PM, the patient went running along Riverside Drive and Westside Highway
  • On 10/22, around 2:00 PM, the patient went to pick up Community Supported Agriculture (CSA) farm share at 143rd St and Amsterdam Avenue (Corbin Hill Farm)
    • Patient picked up box and brought back to apartment
  • On 10/22, around 5:30 PM, the patient left for The Gutter bowling alley in Williamsburg, Brooklyn with two friends. For his arrival at Gutter, the patient took the A train at 145th Street and transferred at 14th Street and took the L train to Bedford Avenue.
  • On 10/22, around 8:30 PM, the patient left The Gutter. For his return trip, the patient used Uber as his means of transportation.
  • On 10/23, around 10:15AM, the patient first reported a fever. At this point, the patient called Medecins Sans Frontieres and the New York City Health Department. He was immediately taken to Bellevue by FDNY EMS.
  • The patient was tested for Ebola at the Health Department’s Public Health Lab. Test results are presumptive positive for Ebola. A confirmatory test will be conducted by the CDC; results will be available within the next 24 hours.

Additional Notes:

  • The patient’s three contacts are healthy and are being quarantined.
  • There is a difference between “quarantine” and “isolation.”

Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick.

Isolation separates sick people with a contagious disease from people who are not sick.

WHO Ebola Roadmap Update – Oct 25th



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Delayed a day, I suspect, because of the fast breaking news about NYC and Mali, the World Health Organization has released their latest end-of-week situation report on the Ebola outbreak in West Africa, showing an increase of 950 cases over the past week. 

About a 15% increase over the previous week’s tally (n=820).


Exactly how representative these numbers really are of the situation in the these hot zone countries is a matter of some debate, although it is widely assumed they are significant undercounts. While the total number of cases reported is just over 10,000 – many observers peg the actual number as likely being 2 or even 3 times higher. 


Media reports suggest many cases are hidden from view, in part over family’s fears that their loved ones would be cremated if they did not survive. We’ve also seen variations in reporting on this outbreak in the past that has led – prematurely and erroneously – to speculation that this outbreak could be on the wane. 




A total of 10 141 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 23 October. There have been 4922 reported deaths.

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 1).


A total of 10 114 confirmed, probable, and suspected cases of EVD and 4912 deaths have been reported up to the end of 18 October 2014 by the Ministry of Health of Liberia, 21 October by the Ministry of Health of Guinea, and 22 October by the Ministry of Health of Sierra Leone (table 1). All but one district in Liberia and all districts in 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 C te d voire, only two are yet to report a confirmed or probable case of EVD.

A total of 450 health-care workers (HCWs) are known to have been infected with EVD up to the end of 23 October: 80 in Guinea; 228 in Liberia; 11 in Nigeria; 127 in Sierra Leone; one in Spain; and three in the United States of America. A total of 244 HCWs have died.

(Continue . . .)

While a separate event with no connection to the West African epidemic, the outbreak in the DRC (Democratic Republic of Congo) is also updated in this report.   Unlike in West Africa, this outbreak appears to have been quickly brought under control.



As at 21 October 2014 there have been 67 cases (38 confirmed, 28 probable, 1 suspected) of Ebola virus disease (EVD) reported in the Democratic Republic of the Congo, including eight among health-care workers (HCWs). In total, 49 deaths have been reported, including eight among HCWs.

Of 1121 total contacts, 1116 have now completed 21-day follow-up. Of five contacts currently being monitored, all were seen on 21 October, the last date for which data has been reported. On 10 October, the last reported case tested negative for the second time and was discharged. The Democratic Republic of the Congo will therefore be declared free of EVD 42 days after the date of the second negative test if no new cases are reported. This outbreak is unrelated to the outbreak that originated in West Africa.


Friday, October 24, 2014

WHO Ebola Update – Mali Confirms 1st Ebola Case




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Yesterday afternoon, in Reuters: Mali Reports 1st Confirmed Ebola Case, we got confirmation on a positive Ebola test for a toddler – recently in Guinea – making Mali the sixth African nation affected by this current Ebola outbreak.


Through great effort and no small amount of luck, previous introductions into Nigeria and Senegal were successfully contained, but concerns run high anytime a new country is affected.


Today, in short order, we have a detailed update from the World Health Organization, who state the child traveled extensively with a relative while symptomatic – including on public conveyances – and that numerous high-risk exposures may have occurred. 


They consider the situation in Mali an emergency.


Mali confirms its first case of Ebola

Ebola situation assessment - 24 October 2014

Mali’s Ministry of Health has confirmed the country’s first case of Ebola virus disease. The Ministry received positive laboratory results, from PCR testing, on Thursday and informed WHO immediately. In line with standard procedures, samples are being sent to a WHO-approved laboratory for further testing and diagnostic work.

Details about the case

In telephone conversation on Thursday night, health officials gave WHO the following details about the case, which is currently undergoing intense investigation.

The patient is a two-year-old girl, who recently arrived from Guinea accompanied by her grandmother. The child’s first contact with the country’s health services occurred on 20 October, when she was examined by a health care worker at Quartier Plateau in Kayes, a city in western Mali on the Senegal River.

Kayes has a population of around 128 000 people. It is located about 600 kilometres from the capital city of Bamako and lies near the border between Mali and Senegal.

The health-care worker referred the grandmother and child to the Fousseyni Daou Hospital, in the same city, where she was admitted to the paediatric ward on the following day, on 21 October. Symptoms on admission included a fever of 39°C, cough, bleeding from the nose, and blood in the stools.

Test results were negative for malaria, but positive for typhoid fever. The child received paracetamol, but did not improve. Further testing at the country’s SEREFO laboratory confirmed Ebola virus as the causative agent on 23 October.

Initial investigation of this case – the first confirmed in Mali – has revealed the extensive travel history of the child and her grandmother. The grandmother travelled from her home in Mali to attend a funeral in the town of Kissidougou, in southern Guinea.

WHO is seeking confirmation of media reports that the funeral was for the child’s mother, who is said to have shown Ebola-like symptoms before her death. These and other facts will be communicated as they are confirmed.

Additional facts communicated to WHO

On 19 October, the grandmother left Guinea to return to Mali, taking the child with her. The case history revealed that bleeding from the nose began while both were still in Guinea, meaning that the child was symptomatic during their travels through Mali.

Travel was by public transport through Keweni, Kankan, Sigouri, and Kouremale to Bamako. The two stayed in Bamako for two hours before travelling on to Kayes. Multiple opportunities for exposure occurred when the child was visibly symptomatic.

Prompt emergency response

WHO is treating the situation in Mali as an emergency. The child’s symptomatic state during the bus journey is especially concerning, as it presented multiple opportunities for exposures – including high-risk exposures - involving many people.

Continued high-level vigilance is essential, as the government is fully aware.

The child is being treated in isolation and staff have received training in appropriate procedures for safe management. The initial investigation identified 43 close and unprotected contacts, including 10 health-care workers, who are also being monitored in isolation.

(Continue . . .)


WHO MERS Update – Turkey



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Last weekend in Turkey Announces MERS Fatality – ex KSA we first learned of a recently exported case fatal case of MERS to Turkey.  On Wednesday we saw the ECDC’s Epidemiological Update – MERS In Turkey (ex KSA), while today we have the official update from the World Health Organization.


Although the MERS coronavirus has been largely supplanted in the newspaper headlines by Ebola, it continues to simmer on the Arabian peninsula, and occasionally gets exported to other regions of the world.   The concern is that we could see the same kind of winter-spring surge in cases that we saw last year.



Middle East respiratory syndrome coronavirus (MERS-CoV) – Turkey

Disease Outbreak News
24 October 2014

On 17 October 2014, WHO EURO was notified by the National IHR Focal Point for Turkey of a laboratory-confirmed case of infection with Middle East respiratory syndrome coronavirus (MERS-CoV). On 11 October 2014, the patient died. This is the first MERS-CoV case in Turkey.

Details of the case are as follows:

The case is a 42-year-old male, Turkish citizen known to be working in Jeddah, Kingdom of Saudi Arabia (KSA). On 25 September 2014, the patient developed symptoms in Jeddah. Initially, he sought medical care in KSA; however, on 6 October 2014, as symptoms worsened, he travelled with a direct flight from Jeddah to Hatay, Turkey. Upon his arrival, he was admitted to a local hospital. On 8 October, he was transferred to the University Hospital in Hatay.

Public health response

Additional information about the flight and any contacts that may be linked to the same flight are now being investigated; the health condition of the cabin crew is being monitored. Also, contacts of the case during his symptomatic phase (25 September - 6 October 2014) when he was still in Jeddah are being examined, including contacts in health care facilities in KSA. WHO EURO and EMRO IHR Contact Points are facilitating direct communications between the IHR NFP Turkey and KSA.

Globally, WHO has received notification of 883 laboratory-confirmed cases of infection with MERS-CoV, including at least 319 related deaths.