The fifth I give you...[UPDATED]

Senegal. 
According to it's Minister of Health, Awa Marie Coll Seck[1,2], a case of Ebola virus disease (EVD) has been imported from Guinea and it is confirmed by testing at the World Health Organization's collaboration Centre, the Pasteur Institute in Dakar.

Interesting that this occurred one week after Senegal closed its borders (again) with Guinea.[3,4] The infected 21-year old Guinean student travelled on 21-August to Dakar. On the 23rd he presented to a hospital but did not admit to being in contact with known EVD cases; Guinea issued an alert that a person with EVD contact has escaped surveillance 27-Aug; Senegal closed its borders around 22-August.[5,6,7,8].
[WHO Disease Outbreak News places his movements ahead of the closure of the border, arriving in Senegal 20-Aug [8]]

These borders are leaky and so the effect of "closure" essentially hinders aid, trade and economy (all very important to the region, especially right now) but very clearly does may not stop the spread of human hosts-as we have seen here. 

Humans are the variable in outbreaks. 

They behave differently each time. 

They respond differently each time. 

This is why no two outbreaks are identical. 

It's why you're a mug to assume this outbreak will be like the last outbreak.

While it looks like this is now a case study in why closing a border is ineffective, I maintain a position that border closures can't contain infectious disease. And please, do not point me to "temperature measurement" as a way to ensure capture of infected individuals. You could easily be harbouring an infection that does not yet express the symptom of fever. 

Click on image to enlarge. 
Graphic lifted from a great CNN video narrated by
Dr Sanjay Gupta. The video describes an example of
contact tracing and its importance to the fight
to contain EVD.[2] 

The contact tracing starts in Senegal now. A 42-day clock starts for the country and a signs and symptoms watch continues on all this case's contacts for 21-days.

References...

1. http://in.reuters.com/article/2014/08/29/us-health-ebola-senegal-idINKBN0GT1CD20140829?feedType=RSS&feedName=health&utm_source=dlvr.it&utm_medium=twitter&dlvrit=309303
2. http://edition.cnn.com/2014/08/29/health/ebola-outbreak-senegal/
3. http://www.washingtonpost.com/news/world/wp/2014/08/29/the-ebola-virus-has-spread-to-senegal-as-the-deadliest-outbreak-in-history-gets-worse/
4. http://www.washingtonpost.com/world/africa/alarm-grows-as-ebola-outbreak-spurs-more-flight-cancellations-border-closures/2014/08/25/87e6d020-2c66-11e4-994d-202962a9150c_story.html
5. http://www.bbc.com/news/world-africa-28893835
6. http://fox59.com/2014/08/22/senegal-closes-its-borders-with-guinea-over-ebola-fears/
7. https://www.internationalsos.com/ebola/index.cfm?content_id=434&language_id=ENG
8. 
   

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MERS-CoV around the house-yes, it does transmit at home

Click on graph to enlarge.

Some Middle East respiratory syndrome coronavirus (MERS-CoV) questions remain stubbornly unanswered even after two and a half years.

Today comes a study from Prof Christian Drosten and colleagues, including Prof Ziad Memish, released by the New England Journal of Medicine.[1] This study takes a look at MERS-CoV infection among the contacts of MERS cases.

We already know that asymptomatic or "silent" MERS-CoV infections are not rare. At least 17% of detections of this virus have occurred in people with no overt signs or reported symptoms of disease. That's not to say that they didn't have a slightly raised temperature, headache, sniffle or something very mild that got overlooked or forgotten, but nothing noted or noteworthy. I'd love to see a study on asymptomatic MERS-CoV infected people that looked into fine detail signs and symptoms by the way-that might tell a nice little story about "silent" infections.

This new study looks at the contacts of infected cases from 26 different households, each with a single confirmed MERS-CoV infected case, with MERS. These households provided throat swabs from 280 contacts and antibody test results on at least 1 sample (only 44 permitted a second voluntary blood sample be taken-a shame) from the 280 contacts as well.

Some interesting findings included:

• Median age of cases (65.4% male) was 55-years
• Median age of contacts (52% male) was 29-years
• Cases 7 household contacts (2.5%) were viral RNA-positive (RT-PCR) within 2-weeks of the index patient's illness onset. Similar to what PCR-based studies conducted previously have yielded.
• 5 household contacts (1.7%) were considered antibody positive after a series of different tests were used. 3 were positive between 2-3 weeks after the index case's onset, and 1 each before or after that period. 
• some indication that neutralizing antibodies against MERS-CoV might be low level and short lived in mild or asymptomatic infections and that previous antibody studies may have missed some cases if the took blood too long after a mild infection

Overall, 12 (4%) contacts acquired MERS-CoV infection from an index case, across 6 of 26 households (23.1%). 

Among others, one question I'd like answered is whether symptomatic cases being kept in home isolation, which was occurring during the Jeddah-2104 outbreak when they don't need hospital-based supportive care, is the best option for stopping transmission? We don't know whether mild or silent infections can transmit virus, which remains another important question. While 4% seems like a small proportion, it's big enough to perhaps explain some of the sporadic case occurrences. Also, we should be mindful that MERS-CoV infection is associated with the death of a third of the people it infects. I'd want to be pretty sure I wasn't letting a house-bound shedding mild/silent person spread MERS-CoV to a visiting old uncle with a co-morbidity.

References

1. http://www.nejm.org/doi/full/10.1056/NEJMoa1405858
2. If this is what MERS-CoV detections look like with more testing...what is the "normal" community level of virus?? [UPDATED]
   http://newsmedicalnet.blogspot.com.au/2014/04/if-this-is-what-mers-cov-detections.html
3. Guidelines for home isolation related to MERS Corona Virus infections | May 2014http://www.moh.gov.sa/en/Documents/3-Isolation.pdf

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The battle of Ebola gains a second front...the Democratic Republic of Congo (DRC; formerly Zaire) [UPDATE #3]

So there are three reasons for this post. 

• It may be a little while before we get solid confirmed information from the DRC and I think maps are useful for those of us who are ignorant of where countries live! [See below for update from WHO]
• I'm looking for a quick post so I can move the previous post's grisly pictures down the page!
• Mike Reid (see comments below; many thanks) brought to my attention that the range of the hammer-headed bat (Hypsignathus monstrosus; [5]) overlays the current ebolavirus outbreak areas strikingly well. I lifted that range graphic and (imperfectly, in pink) overlaid it onto my map - et voila!

Data for the hammer head bat's (Hypsignathus monstrosus) range come from The International Union for Conservation of Nature (IUCN) Red List of Threatened Species. I adapted the graphic for VDU from Wikipedia [3]

An 24-Aug report quoted the Minster for Heath, Felix Kabange Numbi.[2] This latest outbreak occurs in a country that was the site of the first (known) outbreak of a virus of species Zaire ebolavirus (called Ebola virus [1] or EBOV), and which has had six other battles with Ebola virus disease (EVD).

One of the two viruses was reported to have been genotyped as a member of the species Sudan ebolavirus (SUDV) and the second was a "mixed" infection of SUDV and an EBOV.[2] A mixed natural infection of a human would be very...unheard of. Can't really say much more though, until we get this all clarified. 

A 26-Aug WHO-AFRO update noted that the index case, a woman from Ikanamongo village, died 11-Aug sometime after butchering a bush animal.[6] 24 suspected cases of haemorrhagic fever occurred between 28-Jul and 18-Aug. 

The latest updates define that the outbreak is solely due to viruses from the species Zaire ebolavirus.[7,8,9] The EBOV viral variants share 99% nucleotide identity with the Kikwit lineage of viruses from this same species (not "strain"). Put simply, this is the evidence needed to be able to state that the two concurrent EVD outbreaks (indicated in the map above as distinct events), are indeed due to genetically distinct viral variants of Zaire ebolavirus and are not related outbreaks. 

For more on naming ebolaviruses - check out my earlier post "Behind the naming of ebolaviruses".[10]

This latest outbreak was previously and relatively quickly (too quickly? Perhaps a message in there for all of us) described by the World Health Organization as being due to gastroenteritis with haemorrhaging...

.@Fla_Medic It is febrile gastroenteritis with haemorrhaging. If i can find the notice, I will posting. DRC is definitely not #Ebola. Best
� Gregory H�rtl (@HaertlG) August 21, 2014

SitRep on #DRC and febrile gastroenteritis with haemorrhaging is only available in French. I can send by email if u ask me. It is not #Ebola
� Gregory H�rtl (@HaertlG) August 21, 2014

...but subsequently we learn today that...

.@Potrblog @WHO I was given premature information from the field. National lab has now tested + for #Ebola. Will be confirmed in a 2nd lab.
� Gregory H�rtl (@HaertlG) August 24, 2014

The outbreaks share at least one common potential animal vector range. This is one of three bat species often pointed to as a possible natural host for ebolaviruses.

Since this is not the first time concurrent outbreaks of ebolaviruses have occurred, I was wondering about seasonal factors and whether they attract or affect bats. This new information adds another piece of of the puzzle.

References

1. http://newsmedicalnet.blogspot.com.au/2014/08/behind-naming-of-ebola-virusesnot-yet.html
2. http://www.aljazeera.com/news/africa/2014/08/congo-ebola-outbreak-2014824183430461469.html
3. http://en.wikipedia.org/wiki/File:Hammer-headed_Bat_area.png
4. http://www.iucnredlist.org
5. http://en.wikipedia.org/wiki/Hammer-headed_bat
6. http://www.afro.who.int/en/clusters-a-programmes/dpc/epidemic-a-pandemic-alert-and-response/outbreak-news/4263-ebola-virus-disease-drc.html
7. http://reliefweb.int/report/democratic-republic-congo/update-ebola-virus-disease-drc-no-5-30-august-2014
8. http://www.who.int/mediacentre/news/ebola/2-september-2014/en/
9. http://reliefweb.int/report/democratic-republic-congo/virological-analysis-no-link-between-ebola-outbreaks-west-africa
10. http://newsmedicalnet.blogspot.com.au/2014/08/behind-naming-of-ebola-virusesnot-yet.html

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Fake/wrong Ebola virus disease images...

As if there isn't enough misery in the world that we need add false imagery to the mix.

Fake or hoax or just plain misunderstood images purporting to be from cases of Ebola virus disease are everywhere at the moment. The ones below are images I see regularly in the #ebola Twitter stream. 

I had once before found the real image of the first picture using a reveres image searhc on Tineye or Google's image search, but lost it until I recently downloaded my Twitter history and did a manual search for the words I thought I'd used. Bazinga! 

I'll add to this page as I find references for other fraudulent imagery. Feel free to send me other fake Ebola-related images (with the original source) and please use this page to throw at people using these images.

While I suspect much of this is just retweteed out of a lack of information, I'd ask that people check before they propagate this sort of stuff. It may dissuade others in the affected regions from seeking medical attention if they think they have been exposed because "If I don't look like that then I can't have an Ebola virus infection!"

NOT EBOLA VIRUS DISEASE

Figure 1. This is from a patient with which has haemorrhagic
bullae simulating purpura fulminans...whopping great blood
blisters and tissues that have been bled into. Image comes
from a case of leukaemia cutis published in the Indian Journal
of Dermatology, Venereology and Leprology in 2010 by
Misri and colleagues.
Pubmed

NOT EBOLA VIRUS DISEASE

Figure 2. This is from a boy with smallpox disease. It can be found 

on the Centers for Disease Control and Prevention's Smallpox 

disease images website.

NOT EBOLA VIRUS DISEASE

Figure 3. This is bleeding under the skin in a patient with dengue
hemorrhagic fever. The image can be found on the National Institute
of Health's National Institute (NIH) of Allergy and Infectious
Diseases (NIAID) website.

NOT EBOLA VIRUS DISEASE

Figure 4. This may be an allergic reaction, possibly 
to contact with poison ivy. I'm not as sure about the source
of this one. Some possible places include:
http://poison-ivy.org/
http://gloriousconfusion.squidoo.com/poisonous_plants_lily_of_valley_ivy_foxglove_digitalis
http://en.wikipedia.org/wiki/Contact_dermatitis
http://hardinmd.lib.uiowa.edu/dermnet/poisonivy1.html

UNSURE


Figure 5. I can only find ebolavirus-related results for this. 
If anyone can confirm or debunk it as being a valid EVD image, I'd 
be grateful if you could tell me.

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