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Ebola death toll reaches 5,000: actual figure could be triple this, WHO reports
Nigeria declared Ebola-free – Global preparedness at peak
WHO Declares Nigeria Free Of Ebola Virus Disease
How is the end of an Ebola outbreak decided and declared?
Information note – October 2014
Who decides the date?
The WHO Ebola outbreak response team is responsible for establishing the date of the end of the outbreak in collaboration with the affected country’s subcommittee for surveillance, epidemiology and laboratory.
How is the date determined?
An Ebola virus disease outbreak in a country can be declared over once 42 days have passed and no new cases have been detected. The 42 days represents twice the maximum incubation period for Ebola (21 days). This 42-day period starts from the last day that any person in the country had contact with a confirmed or probable Ebola case.
This includes health care workers who have been exposed to patients with Ebola virus disease, even if the health worker was wearing personal protective equipment and followed infection control procedures since such a person could be exposed accidentally without realizing it. In the setting of an Ebola treatment centre, the date of the last infectious contact is defined as the day when the last patient in the treatment centre tested negative for Ebola virus disease, using a real-time reverse-transcriptase polymerase chain reaction (RT-PCR) test.
If no new case has been detected at the end of this 42-day period, the risk of a further case is very low, and the outbreak is declared over.
Why 42 days?
The maximum incubation period for Ebola virus disease is 21 days. The 42-day period set by WHO (twice the maximum incubation period) provides a margin of security to cover any possible missed cases, uncertainty in reporting dates or hidden chains of transmission. (*)
During the 42-day period, the surveillance system should be fully functional, so that all contacts of the last patient are followed to detect possible chains of transmission.
What is the procedure to make the declaration?
The WHO Ebola outbreak response team in collaboration with the affected country’s subcommittee for surveillance, epidemiology and laboratory determines the date of the end of the epidemic. The government of the affected country, in collaboration with WHO and international partners, makes an official declaration of the end of the epidemic.
Are the Ebola outbreaks in Nigeria and Senegal over?
Ebola situation assessment – 14 October 2014
Not quite yet.
If the active surveillance for new cases that is currently in place continues, and no new cases are detected, WHO will declare the end of the outbreak of Ebola virus disease in Senegal on Friday 17 October. Likewise, Nigeria is expected to have passed through the requisite 42 days, with active surveillance for new cases in place and none detected, on Monday 20 October.
For Nigeria, WHO confirms that tracing of people known to have contact with an Ebola patient reached 100% in Lagos and 98% in Port Harcourt. In a piece of world-class epidemiological detective work, all confirmed cases in Nigeria were eventually linked back to the Liberian air traveller who introduced the virus into the country on 20 July.
The anticipated declaration by WHO that the outbreaks in these 2 countries are over will give the world some welcome news in an epidemic that elsewhere remains out of control in 3 West African nations.
In Guinea, Liberia, and Sierra Leone, new cases continue to explode in areas that looked like they were coming under control. An unusual characteristic of this epidemic is a persistent cyclical pattern of gradual dips in the number of new cases, followed by sudden flare-ups. WHO epidemiologists see no signs that the outbreaks in any of these 3 countries are coming under control.
How does WHO declare the end of an Ebola outbreak?
A WHO subcommittee on surveillance, epidemiology, and laboratory testing is responsible for establishing the date of the end of an Ebola outbreak.
The date is fixed according to rigorous epidemiological criteria based on the last day that any person in the country had contact with a confirmed or probable Ebola case.*
According to WHO recommendations, health care workers who have attended patients or cleaned their rooms should be considered as “close contacts” and monitored for 21 days after the last exposure, even if their contact with a patient occurred when they were fully protected by wearing personal protective equipment.
For health care workers, the date of the “last infectious contact” is the day when the last patient in a health facility tests negative using a real-time reverse-transcriptase polymerase chain reaction (RT-PCR) test.
For WHO to declare an Ebola outbreak over, a country must pass through 42 days, with active surveillance demonstrably in place, supported by good diagnostic capacity, and with no new cases detected. Active surveillance is essential to detect chains of transmission that might otherwise remain hidden.
Incubation period
The period of 42 days, with active case-finding in place, is twice the maximum incubation period for Ebola virus disease and is considered by WHO as sufficient to generate confidence in a declaration that an Ebola outbreak has ended.
Recent studies conducted in West Africa have demonstrated that 95% of confirmed cases have an incubation period in the range of 1 to 21 days; 98% have an incubation period that falls within the 1 to 42 day interval. WHO is therefore confident that detection of no new cases, with active surveillance in place, throughout this 42-day period means that an Ebola outbreak is indeed over.
The announcement that the outbreaks are over, in line with the dates fixed by the subcommittee on surveillance, epidemiology, and laboratory testing, is made by the governments of the affected countries in close collaboration with WHO and its international partners.
Official announcements for the 2 countries will be made on the WHO website.
WHO recommendations for testing for Ebola virus disease and confirming a case
WHO is alarmed by media reports of suspected Ebola cases imported into new countries that are said, by government officials or ministries of health, to be discarded as “negative” within hours after the suspected case enters the country.
Such rapid determination of infection status is impossible, casting grave doubts on some of the official information that is being communicated to the public and the media.
For early detection of Ebola virus in suspected or probable cases, detection of viral ribonucleic acid (RNA) or viral antigen are the recommended tests.
Laboratory-confirmed cases must test positive for the presence of the Ebola virus, either by detection of viral RNA by RT-PCR, and/or by detection of Ebola antigen by a specific Antigen detection test, and/or by detection of immunoglobulin M (IgM) antibodies directed against Ebola.
Two negative RT-PCR test results, at least 48 hours apart, are required for a clinically asymptomatic patient to be discharged from hospital, or for a suspected Ebola case to be discarded as testing negative for the virus.
Laboratory results should be communicated to WHO as quickly as possible, in addition to reporting under the requirements and within the timelines set out in the International Health Regulations, which are administered by WHO.
Note
WHO recommends that the first 25 positive cases and 50 negative specimens detected by a country without a recognized national reference viral haemorrhagic fever laboratory should be sent for secondary confirmatory testing to a WHO collaborating centre, designed as specialized in the safe detection (at biosafety level IV) of viral haemorrhagic fevers.
Similarly, for countries with a national reference laboratory for viral haemorrhagic fevers, the initial positive cases should also be sent to a WHO collaborating centre for confirmation.
If results are concordant, laboratory results reported from the national reference laboratory would be accepted by WHO.
President Obama is doing reasonably well on this whole Ebola thing — at least on the public relations front — but another new poll suggests Americans want him to take actions that he has resisted so far.
The poll, from CBS News, shows a whopping 80 percent of people want American citizens and legal residents returning from West Africa to be quarantined until it is determined that they are Ebola-free. Another 17 percent think they should be allowed to enter the country if they are symptom-free at the time.
The poll, notably, did not specify just how long such people would need to be quarantined — about 21 days — or where they would be quarantined. (Such specifics could conceivably reduce support.)
The poll echoes a Washington Post-ABC News poll from earlier this week that showed support for restricting entry from those same countries at 70 percent.
The White House struck a defiant tone on this issue on Wednesday, with Obama saying, “We don’t just react based on our fears. We react based on facts and judgment and making smart decisions.”
That seemed a clear — if indirect — shot at governors of both parties who have instituted quarantines in their states. One of them, New Jersey Gov. Chris Christie (R), released an American nurse from quarantine after the nurse publicly fought against it. The nurse, Kaci Hickox, had returned from treating Ebola patients in Sierra Leone, and Christie said she was ill and they needed to rule out Ebola. She has since reportedly said she will not abide by the government’s quarantine in her home state of Maine.
The White House has stressed repeatedly that such travel restrictions and quarantines would be counter-productive, especially by discouraging medical professionals from traveling to West Africa to fight the disease at its source.
Do Americans believe there should be a quarantine to deal with Ebola?
By Sarah Dutton, Jennifer De Pinto, Anthony Salvanto and Fred Backus
A new CBS News poll finds that Americans overwhelmingly support quarantine for travelers arriving from West Africa. Eighty percent think U.S. citizens and legal residents returning from West Africa should be quarantined upon their arrival in the U.S. until it is certain they don’t have Ebola. Just 17 percent think they should be allowed to enter as long as they do not show symptoms of Ebola.
Polling began on the evening of Oct. 23, the night Dr. Craig Spencer became the first U.S. citizen to be diagnosed with Ebola inside the United States after contracting the disease in West Africa.
Americans are even more stringent when it comes to foreign visitors from West Africa. Just 14 percent think foreign visitors should be allowed to enter the U.S. as long as they show no symptoms of Ebola. Most–56 percent–think they should be quarantined upon arrival, while just over a quarter (27 percent) don’t think they should be allowed to enter the U.S. at all until the Ebola epidemic in West Africa is over.
Americans continue to show concern that the federal government is not adequately prepared to deal with an outbreak of Ebola in the United States. Fifty-six percent do not think the federal government is adequately prepared, and 66 percent feel the same way about their own local hospital.
Sixty-one percent of Americans are at least somewhat concerned that there will be a large outbreak of Ebola inside the United States within the next twelve months. Still, the percentage of Americans who are very concerned has dropped eight points, from 40 percent at the beginning of the month to 32 percent now.
And few Americans believe they or their family are directly at risk. Eighty-three percent of Americans don’t think it is likely that they or a member of their family will get Ebola, including 52 percent who say it is not likely at all.
This poll was conducted by telephone October 23-27, 2014 among 1,269 adults nationwide. The error due to sampling for results based on the entire sample could be plus or minus three percentage points. The error for subgroups may be higher. Data collection was conducted on behalf of CBS News by SSRS of Media, PA. Phone numbers were dialed from samples of both standard land-line and cell phones. Interviews were conducted in English and Spanish. This poll release conforms to the Standards of Disclosure of the National Council on Public Polls.
State Department plans to bring foreign Ebola patients to U.S.
The State Department has quietly made plans to bring Ebola-infected doctors and medical aides to the U.S. for treatment, according to an internal department document that argued the only way to get other countries to send medical teams to West Africa is to promise that the U.S. will be the world’s medical backstop.
Some countries “are implicitly or explicitly waiting for medevac assurances” before they will agree to send their own medical teams to join U.S. and U.N. aid workers on the ground, the State Department argues in the undated four-page memo, which was reviewed by The Washington Times.
“The United States needs to show leadership and act as we are asking others to act by admitting certain non-citizens into the country for medical treatment for Ebola Virus Disease (EVD) during the Ebola crisis,” says the four-page memo, which lists as its author Robert Sorenson, deputy director of the office of international health and biodefense.
More than 10,000 people have become infected with Ebola in Liberia, Sierra Leone and Guinea, and the U.S. has taken a lead role in arguing that the outbreak must be stopped in West Africa. President Obama has committed thousands of U.S. troops and has deployed American medical personnel, but other countries have been slow to follow.
In the memo, officials say their preference is for patients go to Europe, but there are some cases in which the U.S. is “the logical treatment destination for non-citizens.”
The document has been shared with Congress, where lawmakers already are nervous about the administration’s handling of the Ebola outbreak. The memo even details the expected price per patient, with transportation costs at $200,000 and treatment at $300,000.
Nurse Kaci Hickox says she won’t obey Maine’s Ebola quarantine: I won’t be ‘bullied by politicians’
Eun Kyung
Nurse Kaci Hickox — who remains symptom-free after spending three days in a New Jersey isolation tent after flying home from Ebola-stricken West Africa — remains under quarantine at home in Maine, but for only another day, she tells TODAY’s Matt Lauer.
“I truly believe this policy is not scientifically nor constitutionally just, and so I’m not going to sit around and be bullied around by politicians and be forced to stay in my home when I am not a risk to the American public.”
Hickox, who pointed out that top health officials believe a quarantine is unnecessary unless someone develops symptoms, also said:
She will pursue legal action if Maine forces her into continued isolation: “If the restrictions placed on me by the state of Maine are not lifted by Thursday morning, I will go to court to fight for my freedom.”
She plans to return to Africa to help Ebola patients: “My work in Sierra Leone for four weeks was amazing and I feel privileged to have been able to fight this battle and I do plan on going back. It’s not just will I, it’s more of a when.”
State officials should maintain health guidelines but New Jersey officials demonstrated a lack of scientific rationale: Hickox said policies need to be based on evidence, but what she saw at Newark airport showed no such basis. “I saw complete disorganization. I saw no leadership, and if you’re going to put a policy like that in place, that impedes on my civil rights, then you need to have the administrative details worked out before you start detaining me in an airport for no reason.”
Maine Governor Seeks to Make Nurse Abide by Quarantine
By Michelle Kaske
Governor Paul LePage said he would try to force nurse Kaci Hickox to abide by Maine’s Ebola quarantine, escalating the confrontation between the previously little-known aid worker and the political leaders of two states.
Hickox, who has shown no symptoms since a brief fever, was kept in a tent at a New Jersey hospital after returning from treating patients in Sierra Leonebefore being released by Governor Chris Christie. She said today she wouldn’t follow isolation orders in Maine, where she lives. LePage, a 66-year-old Republican facing a re-election fight Nov. 4, said he would try to make her.
“Upon learning the healthcare worker intends to defy the protocols, the Office of the Governor has been working collaboratively with the State health officials within the Department of Health and Human Services to seek legal authority to enforce the quarantine,” he said a statement. “While we certainly respect the rights of one individual, we must be vigilant in protecting 1.3 million Mainers.”
Government officials are struggling to calm fears of contagion while not penalizing aid workers who venture to countries at the center of the still-raging epidemic. In West Africa, the virus has infected about 10,000 people and killed about half, according to the World Health Organization. In the U.S., one man who traveled from Liberia died.
Nurse’s Revolt
Hickox, a 33-year-old volunteer for Doctors Without Borders, said this morning that Maine’s orders were unjust.
“I remain appalled by these home quarantine policies that have been forced upon me, even though I am in perfectly good health and feeling strong and have been this entire time completely symptom free,” Hickox said today in an interview on NBC’s “Today” show.
If the state were to force Hickox to stay home through a court order, she would fight such a move, said Steven Hyman, one of her lawyers.
“If they attempt to get one, Kaci will contest it,” Hyman, a partner in New York at McLaughlin & Stern LLP, said in a telephone interview.
Doctors Without Borders “strongly disagrees with blanket forced quarantine for health care workers returning from Ebola affected countries,” the group said in an e-mailed statement.
Tent Escape
Hickox, who Oct. 26 criticized Christie for her detention, is staying in Fort Kent near the Canadian border. She wouldn’t have emerged from Maine’s 21-day quarantine until Nov. 10.
Hickox was detained for Ebola monitoring at Newark Liberty International Airport after returning from Africa. The nurse was taken to University Hospital in Newark on Oct. 24. She said the fever she registered upon arrival was due to anger.
Christie later allowed her to travel to Maine after she remained asymptomatic.
“I could care less that she hired a lawyer,” Christie said today at a press event in Little Ferry. “I hope that for the public good and for her own good that she decides to comply with the quarantine that they’ve requested in Maine. I think that’s fair to the public and it’s common sense.”
Her home, population 4,090, marks the beginning of 2,328-mile (3,746 kilometer) U.S. Route 1. Fort Kent is at the top of the state’s the northernmost county, Aroostook, across the St. John River fromCanada.
NURSE WHO TREATED EBOLA PATIENTS IN WEST AFRICA RETURNS TO TEXAS, WILL SELF-QUARANTINE
Early Wednesday morning, a nurse who had been treating Ebola patients in Sierra Leone returned to her home in Texas. The nurse, whose name is being withheld for privacy reasons, showed no signs of the disease, but CDC protocols placed her at “some” risk due to her contact with the patients. She has agreed to voluntarily self-quarantine at her home while she waits for the Ebola incubation period to pass.
Texas Governor Rick Perry’s office released a statement Wednesday calling the nurse a “health care hero,” and mentioning that Perry had spoken to her on the phone after her flight landed “to personally thank her for her heroic and selfless work on the front lines of fighting Ebola.”
“In Texas, we have a great tradition of welcoming our heroes back home and this heroic individual deserves our appreciation, our compassion, and our utmost respect,” added Perry. “The tremendous work that she and so many other health care workers are doing in West Africa is making life better for those in afflicted countries and helps protect the rest of the world from the spread of this terrible disease; they are doing vitally important work that makes us all proud.”
The nurse arrived at Austin-Bergstrom Airport, where she was greeted by Dr. David Lakey, the Commissioner of the Texas Department of State Health Services (DSHS) and a member of the Texas Task Force on Infectious Disease Preparedness and Response, which was formed earlier this month by Perry to address the Ebola crisis in Texas. The task force’s initial recommendations included better screening processes for health care workers who may have been exposed to Ebola and taking swift action to isolate such people until they can be sure they have a clean bill of health. Accordingly, at Perry’s request, the nurse agreed to self-quarantine at home, where DSHS will monitor her for fever and other symptoms of Ebola twice a day.
The nurse’s willingness to comply with the Governor’s self-quarantine request stands in sharp contrast to the situation regarding nurse Kaci Hickox, who was ordered into quarantine by New Jersey Governor Chris Christie, and, instead of complying, hired an attorney to fight the order, claiming that her “basic human rights have been violated.” Christie backed down and Hickox returned to her home in Maine, issuing a statement through her attorney that she will not agree to stay confined in her house more than two days.
Perry had additional words of praise for the Texas nurse’s decision to agree to the quarantine request. “This health care hero has made a great sacrifice in traveling abroad to minister to those who are suffering,” he said. “Even now home in Texas, she continues to demonstrate her selflessness by agreeing to quarantine herself and further protect her fellow Texans.”
Ebola virus disease
Fact sheet N°103
Updated September 2014
Key facts
Ebola virus disease (EVD), formerly known as Ebola haemorrhagic fever, is a severe, often fatal illness in humans.
The virus is transmitted to people from wild animals and spreads in the human population through human-to-human transmission.
The average EVD case fatality rate is around 50%. Case fatality rates have varied from 25% to 90% in past outbreaks.
The first EVD outbreaks occurred in remote villages in Central Africa, near tropical rainforests, but the most recent outbreak in west Africa has involved major urban as well as rural areas.
Community engagement is key to successfully controlling outbreaks. Good outbreak control relies on applying a package of interventions, namely case management, surveillance and contact tracing, a good laboratory service, safe burials and social mobilisation.
Early supportive care with rehydration, symptomatic treatment improves survival. There is as yet no licensed treatment proven to neutralise the virus but a range of blood, immunological and drug therapies are under development.
There are currently no licensed Ebola vaccines but 2 potential candidates are undergoing evaluation.
Background
The Ebola virus causes an acute, serious illness which is often fatal if untreated. Ebola virus disease (EVD) first appeared in 1976 in 2 simultaneous outbreaks, one in Nzara, Sudan, and the other in Yambuku, Democratic Republic of Congo. The latter occurred in a village near the Ebola River, from which the disease takes its name.
The current outbreak in west Africa, (first cases notified in March 2014), is the largest and most complex Ebola outbreak since the Ebola virus was first discovered in 1976. There have been more cases and deaths in this outbreak than all others combined. It has also spread between countries starting in Guinea then spreading across land borders to Sierra Leone and Liberia, by air (1 traveller only) to Nigeria, and by land (1 traveller) to Senegal.
The most severely affected countries, Guinea, Sierra Leone and Liberia have very weak health systems, lacking human and infrastructural resources, having only recently emerged from long periods of conflict and instability. On August 8, the WHO Director-General declared this outbreak a Public Health Emergency of International Concern.
A separate, unrelated Ebola outbreak began in Boende, Equateur, an isolated part of the Democratic Republic of Congo.
The virus family Filoviridae includes 3 genera: Cuevavirus, Marburgvirus, and Ebolavirus. There are 5 species that have been identified: Zaire, Bundibugyo, Sudan, Reston and Taï Forest. The first 3, Bundibugyo ebolavirus, Zaire ebolavirus, and Sudan ebolavirus have been associated with large outbreaks in Africa. The virus causing the 2014 west African outbreak belongs to the Zaire species.
Transmission
It is thought that fruit bats of the Pteropodidae family are natural Ebola virus hosts. Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals such as chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead or in the rainforest.
Ebola then spreads through human-to-human transmission via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids.
Health-care workers have frequently been infected while treating patients with suspected or confirmed EVD. This has occurred through close contact with patients when infection control precautions are not strictly practiced.
Burial ceremonies in which mourners have direct contact with the body of the deceased person can also play a role in the transmission of Ebola.
People remain infectious as long as their blood and body fluids, including semen and breast milk, contain the virus. Men who have recovered from the disease can still transmit the virus through their semen for up to 7 weeks after recovery from illness.
Symptoms of Ebola virus disease
The incubation period, that is, the time interval from infection with the virus to onset of symptoms is 2 to 21 days. Humans are not infectious until they develop symptoms. First symptoms are the sudden onset of fever fatigue, muscle pain, headache and sore throat. This is followed by vomiting, diarrhoea, rash, symptoms of impaired kidney and liver function, and in some cases, both internal and external bleeding (e.g. oozing from the gums, blood in the stools). Laboratory findings include low white blood cell and platelet counts and elevated liver enzymes.
Diagnosis
It can be difficult to distinguish EVD from other infectious diseases such as malaria, typhoid fever and meningitis. Confirmation that symptoms are caused by Ebola virus infection are made using the following investigations:
Samples from patients are an extreme biohazard risk; laboratory testing on non-inactivated samples should be conducted under maximum biological containment conditions.
Treatment and vaccines
Supportive care-rehydration with oral or intravenous fluids- and treatment of specific symptoms, improves survival. There is as yet no proven treatment available for EVD. However, a range of potential treatments including blood products, immune therapies and drug therapies are currently being evaluated. No licensed vaccines are available yet, but 2 potential vaccines are undergoing human safety testing.
Prevention and control
Good outbreak control relies on applying a package of interventions, namely case management, surveillance and contact tracing, a good laboratory service, safe burials and social mobilisation. Community engagement is key to successfully controlling outbreaks. Raising awareness of risk factors for Ebola infection and protective measures that individuals can take is an effective way to reduce human transmission. Risk reduction messaging should focus on several factors:
Reducing the risk of wildlife-to-human transmission from contact with infected fruit bats or monkeys/apes and the consumption of their raw meat. Animals should be handled with gloves and other appropriate protective clothing. Animal products (blood and meat) should be thoroughly cooked before consumption.
Reducing the risk of human-to-human transmission from direct or close contact with people with Ebola symptoms, particularly with their bodily fluids. Gloves and appropriate personal protective equipment should be worn when taking care of ill patients at home. Regular hand washing is required after visiting patients in hospital, as well as after taking care of patients at home.
Outbreak containment measures including prompt and safe burial of the dead, identifying people who may have been in contact with someone infected with Ebola, monitoring the health of contacts for 21 days, the importance of separating the healthy from the sick to prevent further spread, the importance of good hygiene and maintaining a clean environment.
Controlling infection in health-care settings:
Health-care workers should always take standard precautions when caring for patients, regardless of their presumed diagnosis. These include basic hand hygiene, respiratory hygiene, use of personal protective equipment (to block splashes or other contact with infected materials), safe injection practices and safe burial practices.
Health-care workers caring for patients with suspected or confirmed Ebola virus should apply extra infection control measures to prevent contact with the patient’s blood and body fluids and contaminated surfaces or materials such as clothing and bedding. When in close contact (within 1 metre) of patients with EBV, health-care workers should wear face protection (a face shield or a medical mask and goggles), a clean, non-sterile long-sleeved gown, and gloves (sterile gloves for some procedures).
Laboratory workers are also at risk. Samples taken from humans and animals for investigation of Ebola infection should be handled by trained staff and processed in suitably equipped laboratories.
WHO response
WHO aims to prevent Ebola outbreaks by maintaining surveillance for Ebola virus disease and supporting at-risk countries to developed preparedness plans. The document provides overall guidance for control of Ebola and Marburg virus outbreaks:
When an outbreak is detected WHO responds by supporting surveillance, community engagement, case management, laboratory services, contact tracing, infection control, logistical support and training and assistance with safe burial practices.
WHO has developed detailed advice on Ebola infection prevention and control:
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