The Pronk Pops Show 342, October 2, 2014, Story 1: Obama Spreading Communicable Diseases Across United States With Illegal Aliens in Schools and Communities– TB, Virus, Ebola — What’s Next? — Pandemic! — Videos

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The Pronk Pops Show Podcasts

Pronk Pops Show 342: October 2, 2014

Pronk Pops Show 341: October 1, 2014

Pronk Pops Show 340: September 30, 2014

Pronk Pops Show 339: September 29, 2014

Pronk Pops Show 338: September 26, 2014

Pronk Pops Show 337: September 25, 2014

Pronk Pops Show 336: September 24, 2014

Pronk Pops Show 335: September 23 2014

Pronk Pops Show 334: September 22 2014

Pronk Pops Show 333: September 19 2014

Pronk Pops Show 332: September 18 2014

Pronk Pops Show 331: September 17, 2014

Pronk Pops Show 330: September 16, 2014

Pronk Pops Show 329: September 15, 2014

Pronk Pops Show 328: September 12, 2014

Pronk Pops Show 327: September 11, 2014

Pronk Pops Show 326: September 10, 2014

Pronk Pops Show 325: September 9, 2014

Pronk Pops Show 324: September 8, 2014

Pronk Pops Show 323: September 5, 2014

Pronk Pops Show 322: September 4, 2014

Pronk Pops Show 321: September 3, 2014

Pronk Pops Show 320: August 29, 2014

Pronk Pops Show 319: August 28, 2014

Pronk Pops Show 318: August 27, 2014 

Pronk Pops Show 317: August 22, 2014

Pronk Pops Show 316: August 20, 2014

Pronk Pops Show 315: August 18, 2014

Pronk Pops Show 314: August 15, 2014

Pronk Pops Show 313: August 14, 2014

Pronk Pops Show 312: August 13, 2014

Pronk Pops Show 311: August 11, 2014

Pronk Pops Show 310: August 8, 2014

Pronk Pops Show 309: August 6, 2014

Pronk Pops Show 308: August 4, 2014

Pronk Pops Show 307: August 1, 2014 

Pronk Pops Show 306: July 31, 2014

Pronk Pops Show 305: July 30, 2014

Pronk Pops Show 304: July 29, 2014

Pronk Pops Show 303: July 28, 2014

Pronk Pops Show 302: July 24, 2014

Pronk Pops Show 301: July 23, 2014

Pronk Pops Show 300: July 22, 2014

Pronk Pops Show 299: July 21, 2014

Pronk Pops Show 298: July 18, 2014

Pronk Pops Show 297: July 17, 2014

Pronk Pops Show 296: July 16, 2014

Pronk Pops Show 295: July 15, 2014

Pronk Pops Show 294: July 14, 2014

Pronk Pops Show 293: July 11, 2014

Pronk Pops Show 292: July 9, 2014

Pronk Pops Show 291: July 7, 2014

Pronk Pops Show 290: July 3, 2014

Pronk Pops Show 289: July 2, 2014

 

Story 1: Obama Spreading Communicable Diseases Across United States With Illegal Aliens in Schools and Communities– TB, Virus, Ebola — What’s Next? — Pandemic! — Videosgraphic_InfectiousCommunication Diseases - Daysebola-symptoms1Ebola-outbreak-graphicWhat-are-the-symptoms-of-Ebolaillness-flu3EbolaSymptoms3ebola-united-states-dallas-texas-meme-3

symptoms of tbtuberculosis-of-the-lungsCOMMUNICABLEfunny-pictures-barack-obama-talking-about-illegal-aliens-are-now-called-undocumented-democratsobama_bull

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Latest influx of illegal aliens brings disease

Pestilence : Illegal Aliens bringing serious diseases across the U.S. Border

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Experts: Ebola Could Go Airborne, Kill Millions

Medical Experts Warns Ebola Virus May already be Airborne

We Heard the Bells: The Influenza of 1918 (full documentary)

In 1918-1919, the worst flu in recorded history killed an estimated 50 million people worldwide. The U.S. death toll was 675,000 – five times the number of U.S. soldiers killed in World War I. Where did the 1918 flu come from? Why was it so lethal? What did we learn?

Killer Flu Documentary

The Genesis of the 1918 Spanish Influenza Pandemic

US Army: Ebola like FLU needs Winter Weather to go AIRBORNE

Aerosolizing ONE DROP of EBOLA = 1/2 MILLION DEAD

 

COMMENTARY: Health workers need optimal respiratory protection for Ebola

Courtesy of 3M Company
A powered air-purifying respirator (PAPR).

Editor’s Note: Today’s commentary was submitted to CIDRAP by the authors, who are national experts on respiratory protection and infectious disease transmission. In May they published a similar commentary on MERS-CoV. Dr Brosseau is a Professor and Dr Jones an Assistant Professor in the School of Public Health, Division of Environmental and Occupational Health Sciences, at the University of Illinois at Chicago.


 

Healthcare workers play a very important role in the successful containment of outbreaks of infectious diseases like Ebola. The correct type and level of personal protective equipment (PPE) ensures that healthcare workers remain healthy throughout an outbreak—and with the current rapidly expanding Ebola outbreak in West Africa, it’s imperative to favor more conservative measures.
The precautionary principle—that any action designed to reduce risk should not await scientific certainty—compels the use of respiratory protection for a pathogen like Ebola virus that has:
  • No proven pre- or post-exposure treatment modalities
  • A high case-fatality rate
  • Unclear modes of transmission

We believe there is scientific and epidemiologic evidence that Ebola virus has the potential to be transmitted via infectious aerosol particles both near and at a distance from infected patients, which means that healthcare workers should be wearing respirators, not facemasks.1

The minimum level of protection in high-risk settings should be a respirator with an assigned protection factor greater than 10. A powered air-purifying respirator (PAPR) with a hood or helmet offers many advantages over an N95 filtering facepiece or similar respirator, being more protective, comfortable, and cost-effective in the long run.

We strongly urge the US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) to seek funds for the purchase and transport of PAPRs to all healthcare workers currently fighting the battle against Ebola throughout Africa—and beyond.

There has been a lot of on-line and published controversy about whether Ebola virus can be transmitted via aerosols. Most scientific and medical personnel, along with public health organizations, have been unequivocal in their statements that Ebola can be transmitted only by direct contact with virus-laden fluids2,3 and that the only modes of transmission we should be concerned with are those termed “droplet” and “contact.”

These statements are based on two lines of reasoning. The first is that no one located at a distance from an infected individual has contracted the disease, or the converse, every person infected has had (or must have had) “direct” contact with the body fluids of an infected person.

This reflects an incorrect and outmoded understanding of infectious aerosols, which has been institutionalized in policies, language, culture, and approaches to infection control. We will address this below. Briefly, however, the important points are that virus-laden bodily fluids may be aerosolized and inhaled while a person is in proximity to an infectious person and that a wide range of particle sizes can be inhaled and deposited throughout the respiratory tract.

The second line of reasoning is that respirators or other control measures for infectious aerosols cannot be recommended in developing countries because the resources, time, and/or understanding for such measures are lacking.4

Although there are some important barriers to the use of respirators, especially PAPRs, in developing countries, healthcare workers everywhere deserve and should be afforded the same best-practice types of protection, regardless of costs and resources. Every healthcare worker is a precious commodity whose well-being ensures everyone is protected.

If we are willing to offer infected US healthcare workers expensive treatments and experimental drugs free of charge when most of the world has no access to them, we wonder why we are unwilling to find the resources to provide appropriate levels of comparatively less expensive respiratory protection to every healthcare worker around the world.

How are infectious diseases transmitted via aerosols?

Medical and infection control professionals have relied for years on a paradigm for aerosol transmission of infectious diseases based on very outmoded research and an overly simplistic interpretation of the data. In the 1940s and 50s, William F. Wells and other “aerobiologists” employed now significantly out-of-date sampling methods (eg, settling plates) and very blunt analytic approaches (eg, cell culturing) to understand the movement of bacterial aerosols in healthcare and other settings. Their work, though groundbreaking at the time, provides a very incomplete picture.

Early aerobiologists were not able to measure small particles near an infectious person and thus assumed such particles existed only far from the source. They concluded that organisms capable of aerosol transmission (termed “airborne”) can only do so at around 3 feet or more from the source. Because they thought that only larger particles would be present near the source, they believed people would be exposed only via large “droplets” on their face, eyes, or nose.

Modern research, using more sensitive instruments and analytic methods, has shown that aerosols emitted from the respiratory tract contain a wide distribution of particle sizes—including many that are small enough to be inhaled.5,6 Thus, both small and large particles will be present near an infectious person.

The chance of large droplets reaching the facial mucous membranes is quite small, as the nasal openings are small and shielded by their external and internal structure. Although close contact may permit large-droplet exposure, it also maximizes the possibility of aerosol inhalation.

As noted by early aerobiologists, liquid in a spray aerosol, such as that generated during coughing or sneezing, will quickly evaporate,7 which increases the concentration of small particles in the aerosol. Because evaporation occurs in milliseconds, many of these particles are likely to be found near the infectious person.

The current paradigm also assumes that only “small” particles (less than 5 micrometers [mcm]) can be inhaled and deposited in the respiratory tract. This is not true. Particles as large as 100 mcm (and perhaps even larger) can be inhaled into the mouth and nose. Larger particles are deposited in the nasal passages, pharynx, and upper regions of the lungs, while smaller particles are more likely to deposit in the lower, alveolar regions. And for many pathogens, infection is possible regardless of the particle size or deposition site.

It’s time to abandon the old paradigm of three mutually exclusive transmission routes for a new one that considers the full range of particle sizes both near and far from a source. In addition, we need to factor in other important features of infectivity, such as the ability of a pathogen to remain viable in air at room temperature and humidity and the likelihood that systemic disease can result from deposition of infectious particles in the respiratory system or their transfer to the gastrointestinal tract.

We recommend using “aerosol transmissible” rather than the outmoded terms “droplet” or “airborne” to describe pathogens that can transmit disease via infectious particles suspended in air.

Is Ebola an aerosol-transmissible disease?

We recently published a commentary on the CIDRAP site discussing whether Middle East respiratory syndrome (MERS) could be an aerosol-transmissible disease, especially in healthcare settings. We drew comparisons with a similar and more well-studied disease, severe acute respiratory syndrome (SARS).

For Ebola and other filoviruses, however, there is much less information and research on disease transmission and survival, especially in healthcare settings.

Being at first skeptical that Ebola virus could be an aerosol-transmissible disease, we are now persuaded by a review of experimental and epidemiologic data that this might be an important feature of disease transmission, particularly in healthcare settings.

What do we know about Ebola transmission?

No one knows for certain how Ebola virus is transmitted from one person to the next. The virus has been found in the saliva, stool, breast milk, semen, and blood of infected persons.8,9 Studies of transmission in Ebola virus outbreaks have identified activities like caring for an infected person, sharing a bed, funeral activities, and contact with blood or other body fluids to be key risk factors for transmission.10-12

On the basis of epidemiologic evidence, it has been presumed that Ebola viruses are transmitted by contaminated hands in contact with the mouth or eyes or broken skin or by splashes or sprays of body fluids into these areas. Ebola viruses appear to be capable of initiating infection in a variety of human cell types,13,14 but the primary portal or portals of entry into susceptible hosts have not been identified.

Some pathogens are limited in the cell type and location they infect. Influenza, for example, is generally restricted to respiratory epithelial cells, which explains why flu is primarily a respiratory infection and is most likely aerosol transmissible. HIV infects T-helper cells in the lymphoid tissues and is primarily a bloodborne pathogen with low probability for transmission via aerosols.

Ebola virus, on the other hand, is a broader-acting and more non-specific pathogen that can impede the proper functioning of macrophages and dendritic cells—immune response cells located throughout the epithelium.15,16 Epithelial tissues are found throughout the body, including in the respiratory tract. Ebola prevents these cells from carrying out their antiviral functions but does not interfere with the initial inflammatory response, which attracts additional cells to the infection site. The latter contribute to further dissemination of the virus and similar adverse consequences far beyond the initial infection site.

The potential for transmission via inhalation of aerosols, therefore, cannot be ruled out by the observed risk factors or our knowledge of the infection process. Many body fluids, such as vomit, diarrhea, blood, and saliva, are capable of creating inhalable aerosol particles in the immediate vicinity of an infected person. Cough was identified among some cases in a 1995 outbreak in Kikwit, Democratic Republic of the Congo,11 and coughs are known to emit viruses in respirable particles.17The act of vomiting produces an aerosol and has been implicated in airborne transmission of gastrointestinal viruses.18,19 Regarding diarrhea, even when contained by toilets, toilet flushing emits a pathogen-laden aerosol that disperses in the air.20-22

Experimental work has shown that Marburg and Ebola viruses can be isolated from sera and tissue culture medium at room temperature for up to 46 days, but at room temperature no virus was recovered from glass, metal, or plastic surfaces.23 Aerosolized (1-3 mcm) Marburg, Ebola, and Reston viruses, at 50% to 55% relative humidity and 72°F, had biological decay rates of 3.04%, 3.06%. and 1.55% per minute, respectively. These rates indicate that 99% loss in aerosol infectivity would occur in 93, 104, and 162 minutes, respectively.23

In still air, 3-mcm particles can take up to an hour to settle. With air currents, these and smaller particles can be transported considerable distances before they are deposited on a surface.

There is also some experimental evidence that Ebola and other filoviruses can be transmitted by the aerosol route. Jaax et al24 reported the unexpected death of two rhesus monkeys housed approximately 3 meters from monkeys infected with Ebola virus, concluding that respiratory or eye exposure to aerosols was the only possible explanation.

Zaire Ebola viruses have also been transmitted in the absence of direct contact among pigs25 and from pigs to non-human primates,26 which experienced lung involvement in infection. Persons with no known direct contact with Ebola virus disease patients or their bodily fluids have become infected.12

Direct injection and exposure via a skin break or mucous membranes are the most efficient ways for Ebola to transmit. It may be that inhalation is a less efficient route of transmission for Ebola and other filoviruses, as lung involvement has not been reported in all non-human primate studies of Ebola aerosol infectivity.27 However, the respiratory and gastrointestinal systems are not complete barriers to Ebola virus. Experimental studies have demonstrated that it is possible to infect non-human primates and other mammals with filovirus aerosols.25-27

Altogether, these epidemiologic and experimental data offer enough evidence to suggest that Ebola and other filoviruses may be opportunistic with respect to aerosol transmission.28 That is, other routes of entry may be more important and probable, but, given the right conditions, it is possible that transmission could also occur via aerosols.

Guidance from the CDC and WHO recommends the use of facemasks for healthcare workers providing routine care to patients with Ebola virus disease and respirators when aerosol-generating procedures are performed. (Interestingly, the 1998 WHO and CDC infection-control guidance for viral hemorrhagic fevers in Africa, still available on the CDC Web site, recommends the use of respirators.)

Facemasks, however, do not offer protection against inhalation of small infectious aerosols, because they lack adequate filters and do not fit tightly against the face.1 Therefore, a higher level of protection is necessary.

Which respirator to wear?

As described in our earlier CIDRAP commentary, we can use a Canadian control-banding approach to select the most appropriate respirator for exposures to Ebola in healthcare settings.29 (See this document for a detailed description of the Canadian control banding approach and the data used to select respirators in our examples below.)

The control banding method involves the following steps:

  1. Identify the organism’s risk group (1 to 4). Risk group reflects the toxicity of an organism, including the degree and type of disease and whether treatments are available. Ebola is in risk group 4, the most toxic organisms, because it can cause serious human or animal disease, is easily transmitted, directly or indirectly, and currently has no effective treatments or preventive measures.
  2. Identify the generation rate. The rate of aerosol generation reflects the number of particles created per time (eg, particles per second). Some processes, such as coughing, create more aerosols than others, like normal breathing. Some processes, like intubation and toilet flushing, can rapidly generate very large quantities of aerosols. The control banding approach assigns a qualitative rank ranging from low (1) to high (4) (eg, normal breathing without coughing has a rank of 1).
  3. Identify the level of control. Removing contaminated air and replacing it with clean air, as accomplished with a ventilation system, is effective for lowering the overall concentration of infectious aerosol particles in a space, although it may not be effective at lowering concentration in the immediate vicinity of a source. The number of air changes per hour (ACH) reflects the rate of air removal and replacement. This is a useful variable, because it is relatively easy to measure and, for hospitals, reflects building code requirements for different types of rooms. Again, a qualitative ranking is used to reflect low (1) versus high (4) ACH. Even if the true ventilation rate is not known, the examples can be used to select an appropriate air exchange rate.
  4. Identify the respirator assigned protection factor. Respirators are designated by their “class,” each of which has an assigned protection factor (APF) that reflects the degree of protection. The APF represents the outside, environmental concentration divided by the inside, facepiece concentration. An APF of 10 means that the outside concentration of a particular contaminant will be 10 times greater than that inside the respirator. If the concentration outside the respirator is very high, an assigned protection factor of 10 may not prevent the wearer from inhaling an infective dose of a highly toxic organism.

Practical examples

Two examples follow. These assume that infectious aerosols are generated only during vomiting, diarrhea, coughing, sneezing, or similar high-energy emissions such as some medical procedures. It is possible that Ebola virus may be shed as an aerosol in other manners not considered.

Caring for a patient in the early stages of disease (no bleeding, vomiting, diarrhea, coughing, sneezing, etc). In this case, the generation rate is 1. For any level of control (less than 3 to more than 12 ACH), the control banding wheel indicates a respirator protection level of 1 (APF of 10), which corresponds to an air purifying (negative pressure) half-facepiece respirator such as an N95 filtering facepiece respirator. This type of respirator requires fit testing.

Caring for a patient in the later stages of disease (bleeding, vomiting, diarrhea, etc).If we assume the highest generation rate (4) and a standard patient room (control level = 2, 3-6 ACH), a respirator with an APF of at least 50 is needed. In the United States, this would be equivalent to either a full-facepiece air-purifying (negative-pressure) respirator or a half-facepiece PAPR (positive pressure), but standards differ in other countries. Fit testing is required for these types of respirators.

The control level (room ventilation) can have a big effect on respirator selection. For the same patient housed in a negative-pressure airborne infection isolation room (6-12 ACH), a respirator with an assigned protection factor of 25 is required. This would correspond in the United States to a PAPR with a loose-fitting facepiece or with a helmet or hood. This type of respirator does not need fit testing.

Implications for protecting health workers in Africa

Healthcare workers have experienced very high rates of morbidity and mortality in the past and current Ebola virus outbreaks. A facemask, or surgical mask, offers no or very minimal protection from infectious aerosol particles. As our examples illustrate, for a risk group 4 organism like Ebola, the minimum level of protection should be an N95 filtering facepiece respirator.

This type of respirator, however, would only be appropriate only when the likelihood of aerosol exposure is very low. For healthcare workers caring for many patients in an epidemic situation, this type of respirator may not provide an adequate level of protection.

For a risk group 4 organism, any activity that has the potential for aerosolizing liquid body fluids, such as medical or disinfection procedures, should be avoided, if possible. Our risk assessment indicates that a PAPR with a full facepiece (APF = 50) or a hood or helmet (APF = 25) would be a better choice for patient care during epidemic conditions.

We recognize that PAPRs present some logistical and infection-control problems. Batteries require frequent charging (which requires a reliable source of electricity), and the entire ensemble requires careful handling and disinfection between uses. A PAPR is also more expensive to buy and maintain than other types of respirators.

On the other hand, a PAPR with a loose-fitting facepiece (hood or helmet) does not require fit testing. Wearing this type of respirator minimizes the need for other types of PPE, such as head coverings and goggles. And, most important, it is much more comfortable to wear than a negative-pressure respirator like an N95, especially in hot environments.

A recent report from a Medecins Sans Frontieres healthcare worker in Sierra Leone30 notes that healthcare workers cannot tolerate the required PPE for more than 40 minutes. Exiting the workplace every 40 minutes requires removal and disinfection or disposal (burning) of all PPE. A PAPR would allow much longer work periods, use less PPE, require fewer doffing episodes, generate less infectious waste, and be more protective. In the long run, we suspect this type of protection could also be less expensive.

Adequate protection is essential

To summarize, for the following reasons we believe that Ebola could be an opportunistic aerosol-transmissible disease requiring adequate respiratory protection:

  • Patients and procedures generate aerosols, and Ebola virus remains viable in aerosols for up to 90 minutes.
  • All sizes of aerosol particles are easily inhaled both near to and far from the patient.
  • Crowding, limited air exchange, and close interactions with patients all contribute to the probability that healthcare workers will be exposed to high concentrations of very toxic infectious aerosols.
  • Ebola targets immune response cells found in all epithelial tissues, including in the respiratory and gastrointestinal system.
  • Experimental data support aerosols as a mode of disease transmission in non-human primates.

Risk level and working conditions suggest that a PAPR will be more protective, cost-effective, and comfortable than an N95 filtering facepiece respirator.

Acknowledgements

We thank Kathleen Harriman, PhD, MPH, RN, Chief, Vaccine Preventable Diseases Epidemiology Section, Immunization Branch, California Department of Public Health, and Nicole Vars McCullough, PhD, CIH, Manager, Global Technical Services, Personal Safety Division, 3M Company, for their input and review.

References

  1. Oberg L, Brosseau LM. Surgical mask filter and fit performance. Am J Infect Control 2008 May;36(4):276-82 [Abstract]
  2. CDC. Ebola hemorrhagic fever: transmission. 2014 Aug 13 [Full text]
  3. ECDC. Outbreak of Ebola virus disease in West Africa: third update, 1 August 2014. Stockholm: ECDC 2014 Aug 1 [Full text]
  4. Martin-Moreno JM, Llinas G, Hernandez JM. Is respiratory protection appropriate in the Ebola response? Lancet 2014 Sep 6;384(9946):856 [Full text]
  5. Papineni RS, Rosenthal FS. The size distribution of droplets in the exhaled breath of healthy human subjects. J Aerosol Med 1997;10(2):105-16 [Abstract]
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  7. Nicas M, Nazaroff WW, Hubbard A. Toward understanding the risk of secondary airborne infection: emission of respirable pathogens. J Occup Environ Hyg 2005 Mar;2(3):143-54 [Abstract]
  8. Bauchsch DG, Towner JS, Dowell SF, et al. Assessment of the risk of Ebola virus transmission from bodily fluids and fomites. J Infect Dis 2007;196:S142-7 [Full text]
  9. Formenty P, Leroy EM, Epelboin A, et al. Detection of Ebola virus in oral fluid specimens during outbreaks of Ebola virus hemorrhagic fever in the Republic of Congo. Clin Infect Dis 2006 Jun;42(11):1521-6 [Full text]
  10. Francesconi P, Yoti Z, Declich S, et al. Ebola hemorrhagic fever transmission and risk factors of contacts, Uganda. Emerg Infect Dis 2003 Nov;9(11):1430-7 [Full text]
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  12. Roels TH, Bloom AS, Buffington J, et al. Ebola hemorrhagic fever, Kikwit, Democratic Republic of the Congo, 1995: risk factors for patients without a reported exposure. J Infect Dis 1999 Feb;179:S92-7 [Full text]
  13. Kuhl A, Hoffmann M, Muller MA, et al. Comparative analysis of Ebola virus glycoprotein interactions with human and bat cells. J Infect Dis 2011 Nov;204:S840-9 [Full text]
  14. Hunt CL, Lennemann NJ, Maury W. Filovirus entry: a novelty in the viral fusion world. Viruses 2012 Feb;4(2):258-75 [Full text]
  15. Bray M, Geisbert TW. Ebola virus: the role of macrophages and dendritic cells in the pathogenesis of Ebola hemorrhagic fever. Int J Biochem Cell Biol 2005 Aug;37(8):1560-6 [Full text]
  16. Mohamadzadeh M, Chen L, Schmaljohn AL. How Ebola and Marburg viruses battle the immune system. Nat Rev Immunol 2007 Jul;7(7):556-67 [Abstract]
  17. Lindsley WG, Blachere FM, Thewlis RE, et al. Measurements of airborne influenza virus in aerosol particles from human coughs. PLoS One 2010 Nov 30;5(11):e15100 [Full text]
  18. Caul EO. Small round structured viruses: airborne transmission and hospital control. Lancet 1994 May 21;343(8908):1240-2 [Full text]
  19. Chadwick PR, Walker M, Rees AE. Airborne transmission of a small round structured virus. Lancet 1994 Jan 15;343(8890):171 [Full text]
  20. Best EL, Snadoe JA, Wilcox MH. Potential for aerosolization of Clostridium difficile after flushing toilets: the role of toilet lids in reducing environmental contamination. J Hosp Infect 2012 Jan;80(1):1-5 [Full text]
  21. Gerba CP, Wallis C, Melnick JL. Microbiological hazards of household toilets: droplet production and the fate of residual organisms. Appl Microbiol 1975 Aug;30(2):229-37 [Full text]
  22. Barker J, Jones MV. The potential spread of infection caused by aerosol contamination of surfaces after flushing a domestic toilet. J Appl Microbiol 2005;99(2):339-47 [Full text]
  23. Piercy TJ, Smither SJ, Steward JA, et al. The survival of filoviruses in liquids, on solid substrates and in a dynamic aerosol. J Appl Microbiol 2010 Nov;109(5):1531-9 [Full text]
  24. Jaax N, Jahrling P, Geisbert T, et al. Transmission of Ebola virus (Zaire strain) to uninfected control monkeys in a biocontainment laboratory. Lancet 1995 Dec 23-30;346(8991-2):1669-71 [Abstract]
  25. Kobinger GP, Leung A, Neufeld J, et al. Replication, pathogenicity, shedding and transmission of Zaire ebolavirus in pigs. J Infect Dis 2011 Jul 15;204(2):200-8 [Full text]
  26. Weingartl HM, Embury-Hyatt C, Nfon C, et al. Transmission of Ebola virus from pigs to non-human primates. Sci Rep 2012;2:811 [Full text]
  27. Reed DS, Lackemeyer MG, Garza NL, et al. Aerosol exposure to Zaire Ebolavirus in three nonhuman primate species: differences in disease course and clinical pathology. Microb Infect 2011 Oct;13(11):930-6 [Abstract]
  28. Roy CJ, Milton DK. Airborne transmission of communicable infection—the elusive pathway. N Engl J Med 2004 Apr;350(17):1710-2 [Preview]
  29. Canadian Standards Association. Selection, use and care of respirators. CAN/CSA Z94.4-11
  30. Wolz A. Face to face with Ebola—an emergency care center in Sierra Leone. (Perspective) N Engl J Med 2014 Aug 27

 

 

 

Ebola Patient in Dallas Lied on Screening Form, Liberian Airport Official Says

U.S. Patient Aided Ebola Victim in LiberiaOCT. 1, 2014

 

A Hospital From Hell, in a City Swamped by EbolaOCT. 1, 2014

graphic

What Are the Chances Ebola Will Spread in the United States?JULY 31, 2014

Mr. Duncan, who was a family friend and also a tenant in a house owned by the Williams family, rode in the taxi in the front passenger seat while Ms. Williams, her father and her brother, Sonny Boy, shared the back seat, her parents said. Mr. Duncan then helped carry Ms. Williams, who was no longer able to walk, back to the family home that evening, neighbors said.

Photo

The family of Marthalene Williams said Thomas Eric Duncan helped carry her to and from a hospital in the capital, Monrovia, last month. Marthalene died the next day. Liberian health officials said Wednesday that Mr. Duncan was the man who flew to Dallas and was later found to have the Ebola virus. CreditDaniel Berehulak for The New York Times

“He was holding her by the legs, the pa was holding her arms and Sonny Boy was holding her back,” said Arren Seyou, 31, who witnessed the scene and occupies the room next to Mr. Duncan’s.

Sonny Boy, 21, also started getting sick about a week ago, his family said, around the same time that Mr. Duncan first started showing symptoms.

In a sign of how furiously the disease can spread, an ambulance had come to their house on Wednesday to pick up Sonny Boy. Another ambulance picked up a woman and her daughter from the same area, and a team of body collectors came to retrieve the body of yet another woman — all four appeared to have been infected in a chain reaction started by Marthalene Williams.

A few minutes after the ambulance left, the parents got a call telling them that Sonny Boy had died on the way to the hospital.

Photo

Marie Wread, a friend of a neighbor of Marthalene Williams, became ill and was carried away by health workers in Monrovia on Wednesday. CreditDaniel Berehulak for The New York Times

Mr. Duncan had lived in the neighborhood, called 72nd SKD Boulevard, for the past two years, living by himself in a small room that he rented from the Williams couple. He had told that them and his neighbors that his son lived in the United States, played baseball, and was trying to get him to come to America.

For the past year, Mr. Duncan had worked as a driver at Safeway Cargo, the Liberian customs clearance agent for FedEx, said Henry Brunson, the company’s manager.

In an office with a large FedEx sign outside the building in downtown Monrovia, Mr. Brunson said that Mr. Duncan quit abruptly on Sept. 4, giving no reason. But Mr. Brunson said he knew that Mr. Duncan had family members in the United States as well.

“His sister came from the United States and he asked for a day off so that he could go meet her at the Mamba Point Hotel,” Mr. Brunson said, mentioning a hotel popular among foreigners. “He quit a few weeks after that.”

Officials on Tuesday said they were confident that standard procedures for controlling an infection can contain Ebola in the United States. The C.D.C. is sending experts to Texas to trace anyone who may have come in contact with the patient while he was sick with symptoms.

Doctors across the country are being reminded to ask for the travel history of anybody who comes in with a fever. Patients who have been to West Africa are being screened and tested if there seems to be a chance they have been exposed.

It helps that Ebola does not spread nearly as easily as Hollywood movies about contagious diseases might suggest. In 2008, a patient who had contracted Marburg – a virus much like Ebola – in Uganda was treated at a hospital in the United States and could have exposed more than 200 people to the disease before anyone would have known what she had. Yet no one became sick.

When did the man infected with Ebola arrive in the U.S.?
A man who traveled to Dallas from Liberia has been found to have Ebola, the Centers for Disease Control and Prevention reported on Tuesday. He was screened for fever before boarding the plane — a standard airport procedure in Liberia — and showed no symptoms at that time.

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sept. 19

20

After being

checked for

symptoms,

man boards

flight from

Liberia.

Man arrives in

Dallas to visit

family.

21

22

23

24

25

26

27

Man begins

to develop

symptoms.

Man seeks

care at Dallas

hospital but

is sent home.

28

29

30

Man is admitted to Dallas hospital and is placed in isolation.

C.D.C. confirms that man’s blood is positive for

Ebola.

How many people have been infected?
More than 7,000 people in Guinea, Liberia, Nigeria, Senegal and Sierra Leone have contracted Ebola since March, according to the World Health Organization, making this the biggest outbreak on record.More than 3,300 people have died. In the first case diagnosed in the United States, a man who traveled from Liberia to Dallas tested positive for the virus on Sept. 30.
Guinea8001,6002,4003,2004,000MAR 21OCT 1710deaths1,157casesLiberia8001,6002,4003,2004,000MAR 21OCT 11,998deaths3,696casesSierra Leone8001,6002,4003,2004,000MAR 21OCT 1622deaths2,304casesNigeria8001,6002,4003,2004,000MAR 215deaths11cases
Where is the outbreak?
The disease continues to spread in Guinea, Liberia and Sierra Leone. The C.D.C. said Tuesday that Nigeria appears to have contained its outbreak.

EBOLA CASES

SENEGAL

MALI

1

15

150

250

500 or more

GUINEA-

BISSAU

GUINEA

Atlantic Ocean

Guéckédou

SIERRA

LEONE

IVORY COAST

Kenema

WEST AFRICA

Monrovia

150 Miles

NIGERIA

LIBERIA

DETAIL

Source: USAID

Note: Areas affected as of Sept. 29

How big can the outbreak become?
The Centers for Disease Control and Prevention said on Sept. 23 that in a worst-case scenario, cases could reach 1.4 million in four months. The centers’ model is based on data from August and includes cases in Liberia and Sierra Leone, but not Guinea (where counts have been unreliable).Estimates are in line with those made by other groups like the World Health Organization, though the C.D.C. has projected further into the future and offered ranges that account for underreporting of cases.

1,400,000

Cumulative cases in Liberia and Sierra Leone

 

Best-case scenario

Worst-case scenario

1,200,000

11,000-27,000 cases through Jan. 20

537,000-1.4 million cases through Jan. 20

Assumes 70 percent of patients are treated in settings that confine the illness and that the dead are buried safely. About 18 percent of patients in Liberia and 40 percent in Sierra Leone are being treated in appropriate settings.

If the disease continues spreading without effective intervention. Dr. Thomas R. Frieden, the C.D.C. director, said, “My gut feeling is, the actions we’re taking now are going to make that worst-case scenario not come to pass. But it’s important to understand that it could happen.”

1,000,000

800,000

600,000

Range

400,000

200,000

0

Oct.

Nov.

Dec.

Jan.

Oct.

Nov.

Dec.

Jan.

Sept.

Sept.

2014

2015

2014

2015

Source: Centers for Disease Control and Prevention

What is the United States doing to help?
President Obama announced Sept. 16 an expansion of military and medical resources to combat the outbreak. He said that the United States would help Liberia in the construction of as many as 17 Ebola treatment centers in the region, with about 1,700 beds, and will also open a joint command operation to coordinate the international effort to combat the disease. The American response will include the deployment of some 3,000 American military personnel, including doctors, to Liberia and Senegal.
How does this compare to past outbreaks?
It is the deadliest, eclipsing an outbreak in 1976, the year the virus was discovered.

Ebola cases and deaths by year, and countries affected

Cases

Deaths

1976

1995

2000

2007

2014

2nd-worst year

5th

3rd

4th

1st

Sudan, Democratic Republic of Congo

Democratic Republic of Congo

Uganda

Uganda, Democratic Republic of Congo

Guinea, Liberia, Nigeria, Senegal and Sierra Leone

602 cases

431 deaths

315 cases

254 deaths

425 cases

224 deaths

413 cases

224 deaths

6,553 cases

3,083 deaths

as of Sept. 26

Source: World Health Organization

Officials have emphasized that people are only infectious if they have symptoms of Ebola. There is no risk of transmission from people who have been exposed to the virus but are not yet showing symptoms. You are not likely to catch Ebola just by being in proximity to someone who has the virus. It is not spread through the air like the flu or respiratory viruses such as SARS.Instead, Ebola spreads through direct contact with bodily fluids. If an infected person’s blood or vomit gets in another person’s eyes, nose or mouth, the infection may be transmitted. In the current outbreak, most new cases are occurring among people who have been taking care of sick relatives or who have prepared an infected body for burial.Health care workers are at high risk, especially if they have not been properly equipped with protective gear or correctly trained to use and decontaminate it.The virus can survive on surfaces, so any object contaminated with bodily fluids, like a latex glove or a hypodermic needle, may spread the disease.
Why is Ebola so difficult to contain?
The epidemic is growing faster than efforts to keep up with it, and it will take months before governments and health workers in the region can get the upper hand, according to Doctors Without Borders.In some parts of West Africa, there is a belief that simply saying “Ebola” aloud makes the disease appear. Such beliefs have created major obstacles for physicians trying to combat the outbreak. Some people have even blamed physicians for the spread of the virus, opting to turn to witch doctors for treatment instead. Their skepticism is not without a grain of truth: In past outbreaks, hospital staff members who did not take thorough precautions became unwitting travel agents for the virus.

Ahmed Jallanzo/European Pressphoto Agency

Liberian health workers on the way to bury a woman who died of the Ebola virus.

How does the disease progress?
Symptoms usually begin about eight to 10 days after exposure to the virus, but can appear as late as 21 days after exposure, according to the C.D.C. At first, it seems much like the flu: a headache, fever and aches and pains. Sometimes there is also a rash. Diarrhea and vomiting follow.Then, in about half of the cases, Ebola takes a severe turn, causing victims to hemorrhage. They may vomit blood or pass it in urine, or bleed under the skin or from their eyes or mouths. But bleeding is not usually what kills patients. Rather, blood vessels deep in the body begin leaking fluid, causing blood pressure to plummet so low that the heart, kidneys, liver and other organs begin to fail.
How is the disease treated?
There is no vaccine or definitive cure for Ebola, and in past outbreaks the virus has been fatal in 60 percent to 90 percent of cases. The United States government plans to fast-track development of a vaccine shown to protect macaque monkeys, but there is no guarantee it will be effective in humans. The question of who should have access to the scarce supplies of an experimental medicine has become a hotly debated ethical question. Beyond this, all physicians can do is try to nurse people through the illness, using fluids and medicines to maintain blood pressure, and treat other infections that often strike their weakened bodies. A small percentage of people appear to have an immunity to the Ebola virus.
Where does the disease come from?
Ebola was discovered in 1976, and it was once thought to originate in gorillas, because human outbreaks began after people ate gorilla meat. But scientists have since ruled out that theory, partly because apes that become infected are even more likely to die than humans.Scientists now believe that bats are the natural reservoir for the virus, and that apes and humans catch it from eating food that bats have drooled or defecated on, or by coming in contact with surfaces covered in infected bat droppings and then touching their eyes or mouths.The current outbreak seems to have started in a village near Guéckédou, Guinea, where bat hunting is common, according to Doctors Without Borders.
How does Ebola compare with other infectious diseases in the news?
The biggest headlines have tended to involve outbreaks of deadly viruses that medical workers have few, if any, tools to combat. The four most prominent are compared below. No cure is known for any of them, nor has any vaccine yet been approved for human use.
Ebola Marburg MERS SARS
Emerged / identified 1976; latest outbreak in 2014 1967; latest major outbreak in 2005 2012-2013 2002-2003
Locus Originally, Congo Basin and central Africa; latest strain, West Africa Originally, central Europe; latest major outbreak, Angola Arabian peninsula Southern China
Suspected source Fruit bats, by way of monkeys and other animals Fruit bats, sometimes by way of monkeys Bats, by way of camels Bats, by way of civets
Type of virus Filovirus Filovirus Coronavirus Coronavirus
Type of illness Hemorrhagic fever Hemorrhagic fever Respiratory syndrome Respiratory syndrome
Fatality rate in outbreaks 50% to 90% 24% to 88% About 30% About 10%
Known cases 4,000+ 570+ 830+ 8,200+
Known deaths 2700+ 470+ 290+ 775+
Person-to-person transmission Readily by close contact or fluids; not by aerosol Readily by close contact or fluids; not by aerosol Not very readily; mechanism unclear Very readily by aerosol, fluids or close contact
Note: On Sept. 30, officials with the federal Centers for Disease Control and Prevention said Mr. Duncan first went to the hospital on Sept. 26. On Oct. 1, the Texas Health Presbyterian Hospital issued a statement that he first arrived there after 10 p.m. on Sept. 25.

 

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Story 1: First Case of Ebola in United States of America in Dallas, Texas — Videos

Dallas_hospital_monitoring_patienebola-texas

Ebola Dallas Hospitaltexas_hospitalpresb_hospital

What-are-the-symptoms-of-EbolaEbola-outbreak-graphicillness-flu3ebola-symptoms1EbolaSymptoms3ebola_map_fpebola_spread

BREAKING! FIRST EBOLA CASE DIAGNOSED IN THE U.S.! NOW AT DALLAS TEXAS HOSPITAL!

CDC press conference on Dallas Ebola case

What You Need to Know About Ebola

Ebola in Dallas, Texas | The Daily Briefing: 9.30.14

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Obama: Ebola a threat to global security

 

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Ebola’s spread to US “inevitable”

Michael Savage on First Case of U.S Ebola in Dallas Texas – 9-30-14

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Ebola, the Secret Killer

 

 

 

As Ebola confirmed in U.S., CDC vows: ‘We’re stopping it in its tracks’

Months after the deadliest Ebola outbreak in history began ravaging West African countries, a man who flew from Liberia to Dallas became the first case of Ebola to be diagnosed in the United States.

Health officials stressed that they are confident they can control this situation and keep the virus from spreading in the U.S.

“We’re stopping it in its tracks in this country,” Thomas Frieden, director of the Centers for Disease Control and Prevention, declared during a news conference Tuesday afternoon.

The man who is infected, who was not identified, left Liberia on Sept. 19 and arrived in the U.S. the following day to visit family members. Health officials are working to identify everyone who may have been exposed to this man. Frieden said this covered just a “handful” of people, a group that will be watched for three weeks to see if any symptoms emerge.

“The bottom line here is that I have no doubt that we will control this importation, or this case of Ebola, so that it does not spread widely in this country,” Frieden said. “It is certainly possible that someone who had contact with this individual could develop Ebola in the coming weeks. But there is no doubt in my mind that we will stop it here.”

 

There were more than 6,500 reported cases of Ebola in Guinea, Liberia and Sierra Leone as of Tuesday, and the crisis has been blamed for more than 3,000 deaths, according to the World Health Organization. Ebola was first identified in 1976, and the current outbreak in West Africa is considered the largest and most complex in the history of the virus, with more cases and deaths than every other outbreak combined.

Until now, the only known cases of Ebola in the U.S. involved American doctors and aid workers who were infected and returned to the country for treatment. One of them, Richard Sacra, was discharged last week from a Nebraska hospital. Days later, the National Institutes of Health in Bethesdaadmitted an American physician who was exposed to the Ebola virus in Sierra Leone. There were reports of possible Ebola patients in New York,California, New Mexico and Miami, but all of them tested negative for the virus.

The unidentified person with Ebola is being treated in intensive care at Texas Health Presbyterian Hospital Dallas, according to Edward Goodman, the hospital’s epidemiologist.

People who traveled on the same plane as this man are not in danger because he had his temperature checked before the flight and was not symptomatic at the time, Frieden said. Ebola is only contagious if the person has symptoms, and can be spread through bodily fluids or infected animals but not through the air.

“There is zero risk of transmission on the flight,” Frieden said.

 

Still, the fact that the disease has been confirmed on American soil immediately sparked fears in the U.S., turning a public health crisis from a faraway news story to something that makes people reach for Purell and facemasks. But experts said it was impossible to imagine that Ebola, which a CDC estimate projects could infect up to half a million people by January, would remain completely outside the country’s borders.

“It was inevitable once the outbreak exploded,” said Thomas Geisbert, a professor at the University of Texas Medical Branch at Galveston, who has researched the Ebola virus for decades. “Unless you were going to shut down to shut down airports and keep people from leaving [West Africa], it’s hard to stop somebody from getting on a plane.”

But Geisbert quickly underscored how unlikely the virus is to spread in the United States. For starters, he said, officials placed the sick man in quarantine quickly in order to isolate him from potentially infecting others. In addition, health workers are already contacting and monitoring any other people he might have had contact with in recent days.

Two Dallas Fire-Rescue paramedics and one paramedic intern are being monitored for Ebola symptoms after transporting the patient to the hospital. The three EMS workers will remain at home for 21 days, Dallas Fire-Rescue Lt. Joel Lavender said Tuesday night. Their ambulance was decontaminated after they transported the patient, Lavender said.

“The system that was put in place worked the way it was supposed to work,” Geisbert said.

That doesn’t guarantee that no one else will get infected, because the sick person could have transmitted the disease to someone else before being isolated. But that approach almost certainly ensures that the United States will quickly contain the disease.

The deadliest Ebola outbreak in history is centered in the West African countries of Liberia, Sierra Leone and Guinea, though there is a separate outbreak in Congo. Unlike in West Africa, where the affected countries have fragile or barely existent health care systems, where people are being turned away from treatment centers, where family members are caring directly with those sick and dying from Ebola, the U.S. is far more equipped to isolate anyone with the virus and provide the highest level of care.

For months, the CDC has been conducting briefings for hospitals and clinicians about the proper protocol for diagnosing patients suspected of having the virus, as well as the kinds of infection control measures to manage hospitalized patients known or suspected of having the disease. Many procedures involve the same types of infection control that major hospitals are already supposed to have in place.

Early recognition is a critical element of infection control. Symptoms include fever greater than 101.5 degrees Fahrenheit, severe headache, muscle pain, vomiting, diarrhea and contact within 21 days before onset of symptoms with the blood or other bodily fluids or human remains of someone known or suspected of having the disease or travel to an area where transmission is active.

The CDC also has scheduled more training for U.S. workers who either plan on volunteering in West Africa or want to be prepared in the event that cases surface at their own hospitals.

President Obama spoke with Frieden on Tuesday afternoon regarding the way the patient is being isolated and the efforts to scour the man’s contacts to seek out any potential other cases, the White House said.

Frieden said during the news conference that the man who is infected did not develop symptoms until about four days after arriving in the country. This man sought medical treatment on Friday, two days after symptoms developed, but was evaluated and released. He was admitted to the hospital on Sunday before being placed into isolation. Frieden, who would not say if the man was a U.S. citizen, said the man is not believed to have been working as part of the response to the Ebola outbreak.

David Lakey, head of the Texas Department of Health Services, said the state’s laboratory in Austin, Tex., received a blood sample from the patient on Tuesday morning and confirmed the presence of Ebola several hours later. This laboratory was certified to do Ebola testing last month.

http://www.washingtonpost.com/news/to-your-health/wp/2014/09/30/cdc-confirms-first-case-of-ebola-in-the-u-s/

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