Ebola cases in W Africa reach 20,000

The World Health Organisation on Wednesday said that the number of people infected by the Ebola outbreak in the three west African countries has passed 20,000, even as the death toll from the deadly-disease reached 7,842.

Cumulative Ebola cases in the three west African countries — Sierra Leone,Liberia and Guinea — stood at 20,081, the WHO said in a statement.

Despite various missions launched by the UN, after it declared the outbreak a “public health emergency of international concern” in August, the disease has continued to spread and experts warn the epidemic will last a full second year.

Meanwhile, the UN Population Fund (UNFPA) today announced that the so—called “CommCare” technology has been chosen to support the Guinean Government Response Plan against Ebola in order to obtain timely and reliable information on patients as well as facilitate contact tracing.

UNFPA said the innovative and time—saving application will be used to locate the contacts and to transfer, in real time, the data collected by the community workers.

Nearly, 158 community workers have already been using these phones to retrieve the data collected in the field.

The UNFPA office in Guinea has been organising training sessions for community workers and supervisors throughout the territory.



CDC Lab Tech Exposed to Ebola?

Lapse in biosafety troubles agency chief.

A CDC lab technician is being monitored for Ebola after possible exposure to what might have been live virus.

A small amount of material in a sealed plate was moved from a biosafety level-4 lab biosafety level-2 lab within CDC headquarters in Atlanta, the agency said in a statement Dec. 24.

Both labs were approved to handle select agents,any of a group of toxins and pathogens thought to pose a “severe threat” to human or animal health, the agency said, and there was no exposure outside the labs.

Nevertheless, the CDC statement said, the material should not have been moved to the lower level lab. The agency said it can’t rule out the possibility a lab tech there was exposed.

The material was destroyed and the lower-level lab decontaminated as part of a routine procedures before the error was discovered Dec. 23, the CDC said, but the lab has been decontaminated again and closed; transfers from the level-4 lab have been halted during an internal investigation.

The technician has no signs of illness but will be monitored for 21 days, the incubation period of the virus.

In the statement, CDC Director Tom Frieden, MD, said he is “troubled by this incident in our Ebola research laboratory in Atlanta.”

He added he has ordered a full review of the incident, which comes after two highly publicized lapses in biosafety earlier this year — one involving anthrax and the other highly pathogenic H5N1 avian influenza.

“Thousands of laboratory scientists in more than 150 labs throughout CDC have taken extraordinary steps in recent months to improve safety,” Frieden said, adding: “no risk to staff is acceptable, and our efforts to improve lab safety are essential — the safety of our employees is our highest priority.”

Meanwhile, a report from the World Health Organization says that Ebola control measures have had “uneven” success — keeping the total incidence stable, while the geographic footprint of the epidemic grows.

In Guinea, Liberia, and Sierra Leone, the first week of December saw 625 confirmed or probable cases, the WHO Ebola Response Team reported online in the New England Journal of Medicine.

That’s similar to the average of 667 new cases weekly for the preceding 10 weeks, the investigators noted.

 The case reproduction numbers for all three countries, averaged across all districts, have now fallen to values close to 1 — the level at which an epidemic begins to slow and stop.

But the average is misleading, the investigators noted, because the places where incidence is greatest have changed over time.

For instance, in Guinea the incidence in Guéckédou, where the epidemic began, averaged 11 confirmed or probable cases weekly between March and September. But incidence in Gueckedou has fallen two cases a week since the beginning of October, while it has “increased sharply” in neighboring districts of Kerouané, Macenta, and N’zerekore, the investigators reported.

Similar geographic shifts have been seen in the other countries as well, they noted.

Indeed, in its midweek situation report, the WHO noted that Guinea had a record 156 confirmed cases in the week ending Dec. 21 — largely due to 58 cases in the province of Kissidougou, which had never before reported more than five a week.

In general, the midweek report said, reported case incidence is fluctuating in Guinea and declining in Liberia, while in Sierra Leone, there are hints that incidence may no longer be increasing.

In NEJM the WHO team wrote that it’s not clear why the overall numbers have stabilized, but one factor might be that infected people are getting into care more quickly.

When they compared the periods before and after Oct. 1, the average time from symptom onset to hospital admission fell from 5.3 days to 4.3 days, which might mean “a reduction in opportunities for transmission in communities.”

By Dec. 14, they noted, there were more than 2,000 beds available in Ebola treatment centers across the three countries — far in excess of the number of new patients being reported — although there were “substantial gaps” in treatment capacity in some places in each nation.

The evidence shows, they concluded, that the “worst fears” — continuing exponential growth — did not become reality. “Nevertheless, Ebola still presents a huge challenge as we move into the second year of the epidemic in West Africa,” they wrote.

Elsewhere in the Journal, investigators on the ground in Sierra Leone report that in their experience, the fatality rate from Ebola does not have to be as high as is commonly reported.

Overall, the WHO midweek report says, the reported case fatality rate in Guinea, Liberia, and Sierra Leone is about 70% among all cases for whom a definitive outcome is known.

And a case series reported in November, also from Sierra Leone, reported that 74% of patients were dying.

But in one clinic, the fatality rate was much lower, according to investigators led by Rashid Ansumana, MSc, of the Mercy Hospital Research Laboratory in Bo, Sierra Leone.

Analysis of 581 patients admitted to the Ebola treatment center at the Hastings Police Training School near Freetown after it opened Sept. 20 showed that just 183 died, they reported.

All told, 631 patients have been admitted to the center, but 50 remain under care. Of the remaining 581, 38 were dead on arrival, 145 died in care, and the rest were discharged, for a case-fatality rate of 31.5%.

Patients were admitted, on average, within 3 or 4 days of symptom inset, they reported. Deaths usually occurred within 3 or 4 days of admission, while survivors usually were in hospital for about 2 weeks.

“It is unclear why the case fatality rate is decreasing at Hastings,” the investigators admitted, noting that they can’t single out any particular component of their protocol.

The treatment protocol, Ansumana and colleagues reported, includes antibiotics (ceftriaxone and metronidazole) for 72 hours as well as fluid replenishment with Ringer’s lactate and dextrose saline. Patients also get vitamin K and an antimalarial drug on admission, as well as zinc sulfate tablet daily, ibuprofen every 12 hours, and metoclopramide intravenously as needed for nausea or vomiting.

After the first 3 days, therapy includes more antibiotics and anti-malarials, as well as a nutrition supplement and oral rehydration solution and juice drinks.

The WHO reported that the West African epidemic has now caused some 19,695 confirmed, probable, or suspected cases, with 7,693 deaths.

Ebola cases in west Africa could rise to 20,000 says WHO

UN health agency say outbreak is accelerating in the region while the death toll has now exceeded 1,500
The WHO’s assistant director-general Bruce Aylward estimates the Ebola outbreak in Liberia will require help from 750 international volunteers. Photograph: EPA

The World Health Organisation (WHO) has warned the number of Ebolacases could rise to 20,000 as doctors in Liberia say the deadly virus is now spreading so rapidly they can no longer deal with the crisis.

The UN health agency said the outbreak is accelerating in west Africa, where the death toll has now reached 1,552, and it believes the numbers who have been hit by Ebola could be two to four times higher than the current 3,069 cases currently reported.

“[It] is a scale that I think has not ever been anticipated in terms of an Ebola outbreak,” said Bruce Aylward, assistant director general of WHO.

He said the increase came from cities including the Liberian capital Monrovia, where a slum was quarantined last week, leading to food shortages and civil unrest.

“It’s really just some urban areas that have outstripped the reporting capacity,” he said. Up to now most efforts have concentrated on rural areas close to the Guinea border. His remarks come as Medecins sans Frontieres said it was struggling to cope with the caseload in Monrovia. MSF has just opened a new Ebola hospital in the Liberian capital and after one week it’s already at capacity of 120 patients.

“The number of patients we are treating is unlike anything we’ve seen in previous outbreaks,” said Lindis Hurum, MSF’s emergency coordinator in Monrovia. “This is not an Ebola outbreak, it is a humanitarian emergency and it needs a full-scale humanitarian response.”

The Ebola outbreak started in Guinea in March and is the 26th since 1976 when the virus was first identified, but is widely recognised to be out of control.

“It is simply unacceptable that, five months after the declaration of this outbreak, serious discussions are only now starting about international leadership and co-ordination,” said MSF director of operations Brice de la Vigne.

MSF said the number of people seeking care at its new Monrovia centre is “growing faster than we can handle both in terms of the number of beds and the capacity of the staff”. It said patients are coming from nearly every district of the city and healthcare workers were “struggling to screen new arrivals, care for admitted patients, safely remove dead bodies and transport them to the crematorium”.

It said it is so overwhelmed it can no longer administer intravenous treatments. MSF has five field hospitals in west Africa, plugging a gap left by the fragile health care systems. It says most of the medical facilities in Monrovia have shut down over fears of the virus among staff, leaving many people with no healthcare at all. This is leading to fears of a secondary health crisis with expectant mothers and malaria patients now going untreated too.

Tom Dannatt is founder of British charity Street Child, which has 650 volunteers in two of the worst stricken countries, Sierra Leone and Liberia. He says the catastrophic spread was not to do with the strength of the virus but the lack of “anti-Ebola measures” being put in place. He also said a food aid programme to help feed those in quarantined areas in eastern Sierra Leone is completely inadequate.

“They are providing food for a standard World Food Programme five heads per household. But in Sierra Leone there are 12 to 15 people living in the majority of households,” said Dannatt. He is offering to lend Street Child’s workers to government task forces to help contain the disease and is launching an emergency appeal later this week.

Dr Anthony Fauci, director of the US National Institute of Allergy and Infectious Diseases told the Guardian that containment could be achieved by “low tech public protection measures”.

“What we have here is porous borders, poverty and big cities. It is the perfect storm. What we need is a massive influx of resources from WHO, from the US, from the UK,” he said.

WHO said it is launching a new $489m (£294m) initiative to try to contain Ebola within six to nine months.

Aylward said it would require the assistance of 750 international workers and 12,000 national workers. He urged airlines, including British Airways, Air France and Gambia Bird, who have suspended flights to the affected countries, to restart services.

The International Ebola Emergency

On August 8, 33 weeks into the longest, largest, and most widespread Ebola outbreak on record, the World Health Organization (WHO) declared the epidemic to be a Public Health Emergency of International Concern (PHEIC). This declaration was not made lightly. A PHEIC is an instrument of the International Health Regulations (IHR) — a legally binding agreement made by 196 countries on containment of major international health threats.

The August 8 statement made by WHO Director-General Margaret Chan followed advice from the independent IHR Emergency Committee. Reviewing all the available evidence, the committee concluded that further international spread of Ebola could have serious consequences. Their concern was based on the continuing transmission of Ebola in West African communities and health facilities, the high case fatality rate of Ebola virus disease (EVD), and the weak health services of Guinea, Liberia, Sierra Leone, Nigeria, and other neighboring countries at risk for infection.

A Public Health Emergency carries immediate consequences for all IHR signatories (see Box 1 in the Supplementary Appendix, available with the full text of this article at NEJM.org). For the four currently affected countries, the Emergency Committee made several recommendations. Heads of state should declare a national emergency, activate national disaster-management mechanisms, and establish emergency operations centers. There should be no international travel of infected persons or their contacts. In areas of intense transmission — especially the border areas of Sierra Leone, Guinea, and Liberia — the provision of clinical care to affected populations could be used as a basis for reducing people’s movement. Funerals and burials should be conducted in the presence of fully trained personnel so as to reduce the risk of spreading infection. And extraordinary supplementary measures, such as quarantine, may be implemented if necessary. These recommendations constitute a robust response to an extraordinary event but are not intended to be coercive. Rather, they should be introduced with the understanding and collaboration of affected communities.

The current outbreak has caused more cases and deaths than any previous EVD epidemic (see graph in the Supplementary Appendix). It appears to have started in the Guéckédou district of Guinea. The first case was recorded in December 2013, but that case was probably not the first in this outbreak.1,2 Until the end of April 2014, most cases were reported from Guinea, with a small number in bordering parts of Liberia and Sierra Leone. (see graph)


Numbers of Confirmed and Probable Ebola Cases Reported Weekly from Guinea, Sierra Leone, and Liberia from December 23, 2013, to August 11, 2014.). In late April, a dip in reported cases in Guinea gave hope that the epidemic was beginning to subside and could be confined largely to one country. That hope was abandoned as the number of confirmed cases in Liberia and Sierra Leone rose sharply during May. By August 16, the cumulative number of confirmed, probable, and suspected cases of EVD in the three worst-affected countries plus Nigeria was 2240, with 1229 deaths. The ratio of deaths to cases implies a case fatality rate of 55%. However, this estimate is approximate, since some cases and deaths (perhaps many) have been missed; in particular, contact tracing in Guinea during the initial period was far from adequate, allowing further opportunities for transmission. Moreover, the fatality rate varies markedly among geographic sites, ranging from 30 to 90% in this epidemic.

Although the largest number of cases was reported in the week starting July 28, the data compiled from Guinea, Liberia, and Sierra Leone give little indication that incidence has begun systematically to decline (see graph). As yet, there is no persuasive evidence that the epidemic is under control. And the recent discovery of cases in Nigeria, which shares no border with Guinea, Liberia, or Sierra Leone, highlights the risk of wider spread across Africa and to other continents. Beyond the immediate health concerns, Ebola is also becoming a humanitarian and economic emergency: schools are being closed, agriculture and mining are under threat as workers leave the affected areas, and cross-border commerce has slowed.

We do not yet have an Ebola vaccine or specific antiviral treatments (see Box 2 in theSupplementary Appendix), but evidence from the current and previous epidemics indicates that transmission can be interrupted by infection-control measures. The mode of transmission is well known: the chance of infection is high if there is direct contact with blood, secretions, organs, or other body fluids of infected persons. Patients become infectious once they are symptomatic (2 to 21 days after infection; see boxManagement of Suspected Cases of Ebola Virus Disease (EVD).), and may remain infectious even after symptoms subside (virus persists in body fluids). The primary animal reservoirs of Ebola are probably fruit bats, and human infection can be acquired from intermediate mammalian hosts, including domestic pigs and primates. But this epidemic is almost certainly being sustained by person-to-person transmission through physical contact. Although contact with infected body fluids carries great risk, Ebola virus does not usually spread rapidly through large populations. From previous epidemics it has been calculated that 1 primary human case generates only 1 to 3 secondary cases on average,3 as compared with 14 to 17 for measles in West Africa.4

These observations point to immediate priorities for control: early diagnosis with patient isolation, contact tracing, strict adherence to biosafety guidelines in laboratories, barrier nursing procedures and use of personal protective equipment by all health care workers, disinfection of contaminated objects and areas, and safe burials. Patients with Ebola require symptomatic treatment and intensive care, and clinical reports suggest that better supportive care improves patients’ chances of survival. The establishment of emergency operations centers is critical, as are communication and social mobilization programs, both to help affected populations understand and comply with control measures and to help health authorities understand how these measures can be introduced in a culturally sensitive way.

These recommended control methods are, of course, more easily recited than implemented. Extraordinary resources are required by any health service confronted by Ebola; those in Guinea, Liberia, and Sierra Leone are severely stretched. Health services are understaffed. Essential personal protective equipment is in short supply. Capacities for laboratory diagnosis, clinical management, and surveillance are limited, and delays in diagnosis impede contact tracing.

On top of these problems, health services are operating in a climate of fear and discrimination. Some contacts of patients with confirmed cases have evaded follow-up by medical teams (which ideally covers the full incubation period of 3 weeks). Some patients and their contacts have been ostracized in areas where Ebola is thought to be a product of witchcraft. Health care workers are aware of the risks they face: more than 150 health care workers have already been infected, and at least 80 have died. Fear has also turned to hostility against national and international response teams and has compromised care delivery and transport of essential equipment and samples to laboratories.

This epidemic’s unprecedented scale has been a surprise, but the response is now firmly under way. The August 8 declaration kick-started a plan to stop the epidemic that will cost at least $100 million to enact in Guinea, Liberia, Sierra Leone, and Nigeria between now and the end of 2014.5Key elements of the plan are to strengthen the field response through surveillance, case investigation, patient care, and contact tracing; activate and test preparedness plans in countries at risk; and coordinate the response internationally (see Box 1 in the Supplementary Appendix). Supporting national governments, the World Bank has pledged to help fill the funding gap.

At the national level, Liberia and Nigeria have declared national emergencies and are screening people arriving at and departing from airports and seaports. Guinea has closed its borders with Liberia and Sierra Leone. Members of Liberia’s National Traditional Council have addressed their communities throughout the country. The engagement of local communities is vital. We have already seen how, in Télimélé, site of a cluster of cases in Guinea, transmission was rapidly curtailed with the support of community leaders.

Monitoring of funds raised and disbursed, and of control measures implemented, is now intense. Above all, we are looking for a sustained decrease in incidence, from week to week and district by district, with no sign of further geographic spread. In the coming days and weeks, that will be our primary measure of success in preventing infections and saving lives.