Showing posts with label EVD. Show all posts
Showing posts with label EVD. Show all posts
Ebola mysteriously returns to Liberia...[UPDATED]
In a gut-wrenching, but not wholly unexpected event, a new case of Ebola virus disease (EVD) has popped up in a town called Nedowein (or Nedowian [8]), about 50km south west of Liberia's capital, Monrovia.
Liberia had been declared a country free of EVD on 9-May-2015 - 52 days ago, or 1 month, 21-days, or 1248 hours.
The 17 year old male (17M) died on Wednesday (about 6 days ago) and has already been buried by all accounts. Samples from his corpse tested positive at least twice.[3]
It's not an unexpected event because both Guinea and Sierra Leone, adjoining countries, continue to struggle with EVD and have been unable to stop the disease from spreading, even though in relatively small numbers compared to what was occurring in 2014. What makes this new case in Liberia a little mysterious is that 17M died far from the border with either of these countries; approximately 150km from Sierra Leone's south-eastern border and about 200km from the nearest Guinean border. Sure, these are not insurmountable distances to travel while incubating an Ebola virus infection, but it would have been a simpler call that this was an imported case if it had occurred on or nearer to the border of one of the two countries with ongoing disease. However, it seems the young man did not travel outside Liberia.[8]
Hopefully the contact tracing and investigations that are going on now will find that 17M simply made contact with someone who had traveled from outside of Liberia, perhaps to Nedowein, which is described as the home town of 17M.[2,7] If this is not an imported case then one is left to wonder about various other scenarios including:
- sexual or other less common transmission of Ebola virus from an as yet undiscovered convalescent EVD case
- contact with an unknown case who had traveled across the border from a country with EVD
- a new zoonotic acquisition of a different Ebola virus variant
- there may still be clusters of EVD within Liberia that have been smouldering on without the knowledge of any authorities
Time and further hard work will no doubt tell.
UPDATE: A second case, associated with 17M ("Abraham") has been diagnosed.[9] Some discussion is evolving around the consumption of dog meat by 17M,[11] however, the same questions around how a dog would become infected (no record of the detection of active replication in a dog have been recorded to date, although antibodies have suggested the possibility in earlier outbreaks) will apply.
Further reading...
- http://www.frontpageafricaonline.com/index.php/news/5660-ebola-back-in-liberia-1-month-20-days-after-free-declaration
- http://www.bbc.com/news/world-africa-33323664
- http://www.ibtimes.com/ebola-liberia-corpse-tests-positive-deadly-virus-weeks-after-liberia-declared-ebola-1989248
- http://bigstory.ap.org/article/581e523aeb1144f68aa1a1629b0e9252/liberian-official-says-corpse-tests-positive-ebola
- http://news.yahoo.com/liberia-announces-return-ebola-one-death-094057018.html
- http://www.nytimes.com/2015/06/30/world/africa/liberia-new-ebola-death-is-reported.html
- http://newsworldmap.com/ebola-returns-to-liberia-but-health-minister-tells-public-no-need-to-panic-washington-post/
- http://news.sciencemag.org/africa/2015/06/liberias-puzzle-how-did-new-ebola-patient-become-infected
- http://www.nytimes.com/2015/07/01/world/africa/liberia-ebola-epidemic.html?partner=rss&emc=rss&smid=tw-nytimesscience&_r=0
- http://frontpageafricaonline.com/index.php/health-sci/5667-ebola-mystery-dog-meat-story-eclipses-border-lapse-theory
- New links added; town name variation added from Science report; hypothesis of contact with another imported case - #2; note on lack of travel outside of Liberia; announcmene tof a 2nd case
Guinea EVD cases rise - but not like they have before...
Edited for clarity 24MAY2015 AEST
The uptick in cases this week from, in particular, Guinea interrupted what was looking promisingly like a continuous downward trend in cases all the way to zero - yes, that was too much to hope for.However, it's worth keeping some context around this:
- Everyone actually working in this space has forewarned us that getting to zero Ebola virus disease (EVD) cases was never going to be an easy journey.
- The indicators have consistently shown more reluctance in Guinea to "kick out Ebola" than in Liberia or Sierra Leone. What caused that reluctance, I don't fully understand from my totally uninvolved chair a million miles away.
I know right? Surprising.
Yes-I'd like a specific reason, all wrapped up and presented to me. I'm simplistic and selfish that way. Get that for me will you?? 'Cause I'm totes sure you haven't been trying your collective butts off all this time. - There were fewer new confirmed EVD cases this past week than in the tally for the week before or for other weeks - look back at January 2015, or October 2014 or June 2014, or any of a number of other dates when cases were accruing at a much faster rate than now (graph below).
That is a silver lining. It's far from ideal, but it's not a return to the worst of it.
All along there has been something different about Guinea and that is now a clear sticking point in the final push to rid its people of Ebola virus|Makona. It never reported, as Sierra Leone did, days with averages of more than 100 cases.
If we knew what was different about the people, communication, geography, weather, traditions, habits, thinking, ETUs, labs, government...or whatever..then we could perhaps better target the problem(s) and get to zero sooner.
That will be core business for the next step to occur.
If we knew what was different about the people, communication, geography, weather, traditions, habits, thinking, ETUs, labs, government...or whatever..then we could perhaps better target the problem(s) and get to zero sooner.
That will be core business for the next step to occur.
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| Click on graph to enlarge. |
A good week for viruses...not so great for humans...
Edited for clarity 25MAY2015
Middle East respiratory syndrome coronavirus (MERS-CoV) managed to get out for some sightseeing - travelling to South Korea this week - and Ebola virus|Makona was given a helping hand to spread to new people in Guinea and Sierra Leone with a small splurge of new confirmed cases.MERS has now trickled into 24 countries world wide as shown in the European Centre for Disease Prevention and Control's (ECDC) epic 'travel-by-plane' map.
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| The original of this is created by the ECDC and is presented here. Click on image to enlarge. |
Meanwhile, a crude extrapolation from current Ebola virus disease (EVD) case numbers saw the predicted date when we might reach zero cases, move further into June.
This could pull back again or it could move further away if the EVD clusters and sporadic cases continue to spread. We can't model that because it's entirely down to unpredictable human variables. We can list what those are, we can better prepare for them, we can educate about them and how to prevent them and we can acknowledge that they are real, but we cannot know when and in what mix they will come into play.
This could pull back again or it could move further away if the EVD clusters and sporadic cases continue to spread. We can't model that because it's entirely down to unpredictable human variables. We can list what those are, we can better prepare for them, we can educate about them and how to prevent them and we can acknowledge that they are real, but we cannot know when and in what mix they will come into play.
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| Extrapolation of the public data for confirmed Ebola virus disease cases from WHO. The most recent week is boxed in red and bucked the trend of declining cases. To see how I made this please visit here. Click on image to enlarge. |
The newest EVD cases remain mostly clustered around the Forecariah prefecture of western Guinea, on the north west border with Sierra Leone but also 5 new cases appeared in the north west of Guinea in Boke prefecture, which borders Guinea-Bissau.
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| From the World Health Organization's Ebola virus disease Situation Report, 20MAY2015. Click on image to enlarge. |
Since the last EVD SitRep, two days of reporting have seen fewer cases than in the same two days of the week before.
So there's that.
Quickly reporting what is actually happening is invaluable for all sorts of reasons. Modelling and prediction allow us to get ahead of the virus. But having the data, and having them available publicly remains a challenge for every country and for every outbreak.
So there's that.
Quickly reporting what is actually happening is invaluable for all sorts of reasons. Modelling and prediction allow us to get ahead of the virus. But having the data, and having them available publicly remains a challenge for every country and for every outbreak.
Public health data are about the public's health. If it has been considered worth collecting and collating, why not communicate it too?
Liberia gave Ebola the boot...and a virus may soon be removed from the wild
The people of Liberia have earned our respect, some time for national celebrations and frankly any other rewards that may flow from denying the Makona variant of Ebola virus any hosts among their community.
The world considered this viral species to be one of the list-toppers when it came to ranking the causes of the most scary acute infectious diseases. Ebola virus has been the basis for all sorts of 'end-of 'the-world' mutating virus horror movies, books, and TV shows. It's not at all surprising that the public view of an Ebola virus infection had long been one of blood, fear and terror.
Behavioural change was a major factor in reducing virus transmission in Liberia. Alongside that was a broad range of aid given from within and beyond Africa's nations. By working together, a widespread outbreak that was not initially thought likely to happen at all, was routed.
For now.
Liberia is not immune to new cases of Ebola virus disease (EVD) crossing its borders or popping up due to a new animal-to-human jump (a zoonosis). That could happen any day - it might be happening now. But those who are still on watch will be searching out new cases while the remaining sites of transmission - Guinea and Liberia - do their best to deny Ebola virus a chance to replicate and spread. The people of Liberia will keep watch help because they have learned very tough lessons about viruses, epidemiology and communication. At least 10,604 suspect, probable and confirmed EVD cases, 4,769 deaths and way too many stories of sadness and families destroyed are a very strict teacher.
The crude prediction in Figure 1 suggests that zero cases across all three countries could happen at the end of May, but many stars must align for that to be a real event.
Human factors - the causal and sustaining variables of any outbreak of infectious disease in humans and sometimes animals - remain very much in play. But once that tri-country zero case value is attained, we have 42 days of watching and waiting - from the time the final case tests negative.
New cases may arise from sources as-yet-unknown. But even if they do keep popping up, it seems very unlikely that widespread transmission will amplify to earlier levels (see the steep slopes in Figure 2) unless a major lapse in attention occurs. Hence,the need for continued vigilance - and Liberia remains on alert for a further 90 days. That more recent figure comes about because we know that infectious Ebola virus can persist in some body sites for many weeks after signs of disease have passed. Whether that virus reservoir is present in every person and whether it actually does cause new Ebola virus infections remain unproven. When you consider what can happen when one person gets infected by an Ebola virus in a tiny remote village in a country that is ill prepared to cope with it and has traditions that lend themselves to its spread...even minor risks rightly come under more intense scrutiny.
What next for this particular virus though? The only place where the Makona variant of this member of the Zaire ebolavirus species will soon exist, is in the freezer of (hopefully) very biosecure laboratories in the US, UK, Africa, Russia, China and probably other laboratories in countries that hosted, evacuated or repatriated cases of EVD.
There is no sign at all - and this is because of the continued efforts and focus of many currently working throughout west Africa - of the fabled "endemic Ebola" becoming a reality. Unless you mean enzootic 'Ebola'- in which case , it already is, I suspect. It seems very, very likely that the forests of west Africa continue to shelter animal hosts with less mutated versions of this and other ebolaviruses (and filoviruses and who-knows-what else). The host species and route(s) of transmission to humans are yet to be confirmed but for now, we are not too far off eradicating one unwanted viral scourge from the wild. Impressive what we can do when we pull together.
The world considered this viral species to be one of the list-toppers when it came to ranking the causes of the most scary acute infectious diseases. Ebola virus has been the basis for all sorts of 'end-of 'the-world' mutating virus horror movies, books, and TV shows. It's not at all surprising that the public view of an Ebola virus infection had long been one of blood, fear and terror.
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| Figure 1. The decline of the Makona variant of Ebola virus in Guinea, Sierra Leone and Liberia (now free of EVD transmission). Click on image to enlarge. |
For now.
Liberia is not immune to new cases of Ebola virus disease (EVD) crossing its borders or popping up due to a new animal-to-human jump (a zoonosis). That could happen any day - it might be happening now. But those who are still on watch will be searching out new cases while the remaining sites of transmission - Guinea and Liberia - do their best to deny Ebola virus a chance to replicate and spread. The people of Liberia will keep watch help because they have learned very tough lessons about viruses, epidemiology and communication. At least 10,604 suspect, probable and confirmed EVD cases, 4,769 deaths and way too many stories of sadness and families destroyed are a very strict teacher.
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| Figure 2. The number of confirmed EVD cases (yellow) grinds to a standstill. Only 9 cases in the week to 10th May 2015. Click on image to enlarge. |
Human factors - the causal and sustaining variables of any outbreak of infectious disease in humans and sometimes animals - remain very much in play. But once that tri-country zero case value is attained, we have 42 days of watching and waiting - from the time the final case tests negative.
New cases may arise from sources as-yet-unknown. But even if they do keep popping up, it seems very unlikely that widespread transmission will amplify to earlier levels (see the steep slopes in Figure 2) unless a major lapse in attention occurs. Hence,the need for continued vigilance - and Liberia remains on alert for a further 90 days. That more recent figure comes about because we know that infectious Ebola virus can persist in some body sites for many weeks after signs of disease have passed. Whether that virus reservoir is present in every person and whether it actually does cause new Ebola virus infections remain unproven. When you consider what can happen when one person gets infected by an Ebola virus in a tiny remote village in a country that is ill prepared to cope with it and has traditions that lend themselves to its spread...even minor risks rightly come under more intense scrutiny.
What next for this particular virus though? The only place where the Makona variant of this member of the Zaire ebolavirus species will soon exist, is in the freezer of (hopefully) very biosecure laboratories in the US, UK, Africa, Russia, China and probably other laboratories in countries that hosted, evacuated or repatriated cases of EVD.
There is no sign at all - and this is because of the continued efforts and focus of many currently working throughout west Africa - of the fabled "endemic Ebola" becoming a reality. Unless you mean enzootic 'Ebola'- in which case , it already is, I suspect. It seems very, very likely that the forests of west Africa continue to shelter animal hosts with less mutated versions of this and other ebolaviruses (and filoviruses and who-knows-what else). The host species and route(s) of transmission to humans are yet to be confirmed but for now, we are not too far off eradicating one unwanted viral scourge from the wild. Impressive what we can do when we pull together.
Outbreak resources: more expert detail presented simply, to more people, at a trusted site, quickly, and for free...
Many, many of us have learned a lot about Ebola virus and Ebola virus disease (EVD) over the past 61 weeks - some more than others.
Some have paid very dearly for their new knowledge and some few have leveraged the event to try and make a buck or draw more attention to themselves or their trade.
Many have been scared - few outside Guinea, Sierra Leone and Liberia have had a real need to be - but fear of this tiny killer is understandable. I stand by my comments on that from back in August when the United States woke up to what had been happening in west Africa for five months, and promptly started freaking out...without evidence of any widespread threat or danger.
For all of the unwanted, unnecessary and often inflammatory commentary, hypotheses, guesses and conspiracy theories, there was some good information to be found about EVD. Sometimes it was only able to be found by academics or others with access to journals that sit behind fee-for-view virtual walls (paywalls). Sometimes the science was too dense for the public to follow - even when they could access it. But most of the time it just took far more digging to unearth the basics than it should have. It would have been good if more of those who could access and interpret that information, had proactively done so.
EVD in west Africa helped generate a lot of publicly accessible descriptive information about some of the technical language of infectious disease outbreaks. But there could be more. New information for public consumption should be...
There will always be a portion of the public who seek their news and detail from the loudest and most garish 'news' source. There are also many who would like to be the smartest person at water cooler - but not if that comes at the expense of trying to locate and then wade through reams of technical guff.
More expert detail, simply presented, to more people, from a trusted site, quickly and for free.
The next 'Ebola' might have a much harder time getting traction in a territory if its population is ready for it, or can get up to speed quickly.
Some have paid very dearly for their new knowledge and some few have leveraged the event to try and make a buck or draw more attention to themselves or their trade.
Many have been scared - few outside Guinea, Sierra Leone and Liberia have had a real need to be - but fear of this tiny killer is understandable. I stand by my comments on that from back in August when the United States woke up to what had been happening in west Africa for five months, and promptly started freaking out...without evidence of any widespread threat or danger.
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| Not everyone has a library on everything |
EVD in west Africa helped generate a lot of publicly accessible descriptive information about some of the technical language of infectious disease outbreaks. But there could be more. New information for public consumption should be...
- Clear, simple information that can be easily read and shared using today's short, punchy and graphic-laden social media communication tools
- Information that is quick and easily found or can be found using (way more) friendly search engines. A page of 2,000+ poorly descriptive results returned from a keyword search...is not helpful
- Broad descriptions about broad topics - not just narrow descriptions for one aspect of one outbreak caused by one virus. We need to explain the wider patterns that are shared among many outbreaks and by many viruses. Ebola virus is not the first bloodborne virus, not the first sexually transmitted virus, not the first virus to spread in vomit and faces or by droplets, or to survive on surfaces, or to mutate, or to have an RNA genome, or to be detected by RT-PCR, or to have its genome sequenced, or to be the trigger for contact tracing, or to have just appeared in west Africa in 2014...etc. Start tying these patterns together to give the public a better sense of what we live with every day, instead of responding to the now and the scary.
- A single online, well formatted (for multiple devices) site that hosts all this information provided, checked, updated and agreed upon by experts in the fields, written by communicators and hosted by the new and improved World Health Organization (WHO). The world needs a one-stop outbreak info shop that it can rely on. And that shop should be staffed by assistants who are available to answer questions or direct customers to the aisles best suited to their needs. We expect access to information and answers to questions from our phone company, so why not from our World's health experts?
- Using better citation to acknowledge the reference material in public health information - what is so wrong with letting everyone know what the guidelines are guided by? Anecdotal is not enough.
- Date stamped to make it clear when it was written and when it was updated. Am I looking at contemporary thinking - or something from 2 days ago before that major discovery/event changed everything we knew about virus X?
There will always be a portion of the public who seek their news and detail from the loudest and most garish 'news' source. There are also many who would like to be the smartest person at water cooler - but not if that comes at the expense of trying to locate and then wade through reams of technical guff.
More expert detail, simply presented, to more people, from a trusted site, quickly and for free.
The next 'Ebola' might have a much harder time getting traction in a territory if its population is ready for it, or can get up to speed quickly.
Yes, there were signs that Ebola was in west Africa, perhaps as far back as 1973...
Apparently, it now does. The New York times [3] has found that there were studies reporting signs of Ebola virus antibodies in humans in Liberia in samples collected back in 1982.
I'll see your 1982 and raise you 1973! [1] That's when some other samples were collected that were found to contain antibodies to Ebola virus. This doesn't come up in the abstract for this article, but is buried in the Methods and Materials section.
"..antibodies specific for Marburg virus and Ebola virus antigens tested by immunoblotting (21% and 14%,respectively)"We noted this paper in 2014 - in a piece for the Conversation [2] - and listed some other articles which found similar signs of prior human exposure to Ebola virus or something related. The NYT piece has also captured some of these papers by the looks of it.
In many (most?) cases, these scientific papers can only be reached after paying a fee, or being affiliated with an Institutions that has a good library. Many researchers, clinicians and public health professionals can be described as such.
For me, it seems clear that there were many people aware of the possibility the Ebola virus was pretty much "always" (in the context of our history with Ebola virus disease[EVD]) in the forests within the regions underneath the flyways of some likely filovirus-host bat species.
But seemingly no action was taken on these reports. Was that because...
- the serology assays were perhaps too non-specific or otherwise unreliable (were they cross-reacting with as-yet unknown filoviruses perhaps (h/t Stephen Goldstein)
- no-one thought much of EVD's capacity to cause a big outbreak?
- we didn't care about smaller outbreaks because they had always been controlled previously?
- we just didn't care because it was "over there" (in Africa)?
- we just forgot about it as soon as it was published?
This is not a problem specific to EVD of course. Trying to stay ahead of infectious threats will take much more devotion than the world has shown it can muster to date. Even when we can see their potential for harm, there are only so many resources we will mobilize for an infectious threat that is not knocking on our specific door.
References...
- Neppert J, G�hring S, Schneider W, Wernet P.
No evidence of LAV infection in the Republic of Liberia, West Africa, in the year 1973.
http://www.ncbi.nlm.nih.gov/pubmed/3015288 - How Ebola started, spread and spiralled out of control
https://theconversation.com/how-ebola-started-spread-and-spiralled-out-of-control-32137 - Yes, We Were Warned About Ebola
http://www.nytimes.com/2015/04/08/opinion/yes-we-were-warned-about-ebola.html
Ebola - the lesser transmission risks are still risks...
The United Nations (UN) Foundation blog has used some pretty strong language in their latest post of the 5 Things to Know on Ebola This Week.
Number 2 on their list stated (by highlighting)...
Perhaps the results are known behind closed doors and perhaps that testing has firmly pointed to a sexual transmission route. The UN post above certainly seems very sure and it also seems that this event has triggered an update to recommendations. There is solid literature about the presence of infectious Ebola virus in seminal fluids so the possibility shouldn't be far beyond belief.[4]
Another possible, albeit also unproven, transmission route is urine. This fluid seems to me to be a far more likely source of trouble. One cannot abstain from urination. So why worry about urine as a risk for transmission of Ebola virus? An EVD case study last year showed very nicely that infectious Ebola virus could be cultured from urine for about 12 days longer than it could be from blood.[1] Viral RNA has also been found in urine for four weeks.[1,2]
Perhaps urine should be a more noteworthy concern for its potential to remain infectious after blood test become negative. This concern might be greater wherever toilet and hand-washing facilities and sewers, are minimal or poorly maintained.
Urine and seminal fluids are not considered to be major transmission routes for Ebola virus. But let's not forget that it was probably an unlikely transmission event, and route - a single jump from an animal to a human - that triggered >25,000 EVD cases in this epidemic. Even a rare risk must be given serious consideration when such a large public health impact can realistically result.
References...
Number 2 on their list stated (by highlighting)...
First detected case of Ebola transmitted through sexual intercourseWhile there is reported to be ongoing testing (and presumably virus genotyping), I've yet to hear publicly the outcome of such testing.
Earlier research suggested that three months of abstinence or condom use among male survivors would suffice to prevent the transmission of Ebola through intercourse. But an Ebola patient in Liberia who died last week had just one known risk factor: her boyfriend was an Ebola survivor, treated last September. This is the first case detected of the Ebola virus being transmitted through sexual intercourse, which has necessitated updated recommendations. Read the full story here: http://unfoundationblog.org/ebola/5-things-to-know-on-ebola-this-week-10/#sthash.2HkUbbYT.dpuf
Perhaps the results are known behind closed doors and perhaps that testing has firmly pointed to a sexual transmission route. The UN post above certainly seems very sure and it also seems that this event has triggered an update to recommendations. There is solid literature about the presence of infectious Ebola virus in seminal fluids so the possibility shouldn't be far beyond belief.[4]
Another possible, albeit also unproven, transmission route is urine. This fluid seems to me to be a far more likely source of trouble. One cannot abstain from urination. So why worry about urine as a risk for transmission of Ebola virus? An EVD case study last year showed very nicely that infectious Ebola virus could be cultured from urine for about 12 days longer than it could be from blood.[1] Viral RNA has also been found in urine for four weeks.[1,2]
Perhaps urine should be a more noteworthy concern for its potential to remain infectious after blood test become negative. This concern might be greater wherever toilet and hand-washing facilities and sewers, are minimal or poorly maintained.
Urine and seminal fluids are not considered to be major transmission routes for Ebola virus. But let's not forget that it was probably an unlikely transmission event, and route - a single jump from an animal to a human - that triggered >25,000 EVD cases in this epidemic. Even a rare risk must be given serious consideration when such a large public health impact can realistically result.
References...
- Kreuels B, Wichmann D, Emmerich P et al. A Case of Severe Ebola Virus Infection Complicated by Gram-Negative Septicemia. N Engl J Med. 2014 Oct 22. 371:2394-2401
- Lyon GM, Mehta AK, Varkey JB et al. Clinical Care of Two Patients with Ebola Virus Disease in the United States. N Engl J Med. 2014 Nov 12. 371:2401-2409
- Ebola Virus Disease (EVD). Key questions and answers concerning water, sanitation and hygiene. World Health Organization. http://apps.who.int/iris/bitstream/10665/137181/1/WHO_EVD_WSH_14_eng.pdf?ua=1
- Mackay IM, Arden KE. Ebola virus in the semen of convalescent men. Lancet Infect Dis. 2015 Feb;15(2):149-50.
Publishing on 'ebola' is a booming pastime...
One of my jobs since October last year has been to keep up on the literature for Ebola virus and Ebola virus disease.
At this stage I have a lot of reading to catch up on.
There were 1,858 publications during the 37 years including 1977 to 2013. In 2014 and 2015 (so far), there have been 1,485 publications.
According to a basic search of PubMed using the term 'ebola' - there have been over 1,500 publications - and those are the ones captured by PubMed - to be found using that search term.
At this stage I have a lot of reading to catch up on.
There were 1,858 publications during the 37 years including 1977 to 2013. In 2014 and 2015 (so far), there have been 1,485 publications.
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| Click on image to enlarge. |
Hans Rosling, a micro-outbreak of Ebola in Liberia and trust issues in Guinea...
As is always the case, Prof Rosling can be seen in front of an audience here, providing a beautifully articulated example of how trust in the Ebola virus disease (EVD) treatment centre/unit plays such a pivotal role in (a) the containment of EVD, even witting a family and its contacts, and (b), the likelihood of survival of EVD patients.
In this example, which you can listen to in its entirety here, as time went on, trust grew and this fewer transmission occurred and more f those infected, survived.
This would seem to be a great example of what is lacking in Guinea - trust - a lack of trust that others are be able to stop the spread of virus and to save the lives of those infected. Thus people are not presenting for help at all and still being managed in the community - possibly infecting others - or else they are not presenting early enough, before the disease has done too much damage to the person. Trust and communication is increasingly seen as being as important to the successful reduction of cases in Liberia and Sierra Leone as the building of treatment centres - the two must co-occur.
Trust comes from understanding, and that is heavily influenced by communication. Communication of accurate information, of clear and digestible information. Communication to the right people using the moist effective channels is also essential.
It still feels like communication, or at least accurate and successful communication accessing the key important and influential people, may be the weakest part of the response in Guinea. It seems to have been better implemented in Liberia and Sierra Leone - or maybe just better received. Is it a groundwork thing? Difference in the way science is presented in different countries? I know far too little to guess further.
There continue to be more security incidents and other types of refusal to cooperate in Guinea compared to the other two countries afflicted with the Makona variant of Ebola virus. These incidents are a marker of a community that does not believe or trust those claiming to be here to help. And that's a problem for stopping the constant rivulet of EVD cases in Guinea; a rivulet that never became the river of hundreds of EVD cases per week seen in Liberia or Sierra Leone, but was still a flow that seeded infection across the region and the world. A case anywhere is a threat everywhere, to paraphrase others.
But there may be other issues to consider and question.
There are fewer treatment centres and laboratories in Guinea than in Liberia or Sierra Leone - strange given that Guinea is larger and that it still has a geographically widespread distribution of cases.
While it has lately been noted that new cases in Guinea could be adding to the tally more simply because of success in reaching more remote areas, this seems only to add support to the need for better communication and to provide more of a presence in these remote areas. Hopefully, now that this happening through the efforts of the US CDC and others, we will soon see the pay off as a reduction of EVD cases. But the rainy season is near and travel will be made into a muddy mess by that. Time has never been on the side of those trying to stop this epidemic.
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| Frame taken from a BBC News video which was being hosted in an African Geographic Magazine story here. Red dots are survivors, black dots are deaths Click on image to enlarge. |
This would seem to be a great example of what is lacking in Guinea - trust - a lack of trust that others are be able to stop the spread of virus and to save the lives of those infected. Thus people are not presenting for help at all and still being managed in the community - possibly infecting others - or else they are not presenting early enough, before the disease has done too much damage to the person. Trust and communication is increasingly seen as being as important to the successful reduction of cases in Liberia and Sierra Leone as the building of treatment centres - the two must co-occur.
Trust comes from understanding, and that is heavily influenced by communication. Communication of accurate information, of clear and digestible information. Communication to the right people using the moist effective channels is also essential.
It still feels like communication, or at least accurate and successful communication accessing the key important and influential people, may be the weakest part of the response in Guinea. It seems to have been better implemented in Liberia and Sierra Leone - or maybe just better received. Is it a groundwork thing? Difference in the way science is presented in different countries? I know far too little to guess further.
There continue to be more security incidents and other types of refusal to cooperate in Guinea compared to the other two countries afflicted with the Makona variant of Ebola virus. These incidents are a marker of a community that does not believe or trust those claiming to be here to help. And that's a problem for stopping the constant rivulet of EVD cases in Guinea; a rivulet that never became the river of hundreds of EVD cases per week seen in Liberia or Sierra Leone, but was still a flow that seeded infection across the region and the world. A case anywhere is a threat everywhere, to paraphrase others.
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| Location of laboratories in Guinea, Liberia, and Sierra Leone. From WHO SitRep 01APR2015. |
There are fewer treatment centres and laboratories in Guinea than in Liberia or Sierra Leone - strange given that Guinea is larger and that it still has a geographically widespread distribution of cases.
While it has lately been noted that new cases in Guinea could be adding to the tally more simply because of success in reaching more remote areas, this seems only to add support to the need for better communication and to provide more of a presence in these remote areas. Hopefully, now that this happening through the efforts of the US CDC and others, we will soon see the pay off as a reduction of EVD cases. But the rainy season is near and travel will be made into a muddy mess by that. Time has never been on the side of those trying to stop this epidemic.
The weakening pulse of the Ebola monster...
As of this post, some of the most comprehensive publicly available data on an emerging virus is coming out of the Kingdom of Saudi Arabia in relation to the Middle East respiratory syndrome coronavirus (MERS-CoV). Yeah-that's what I said. Even with all the issues I complain about, its more detailed than for other current outbreaks.
In 2015, China became a major disappointment in its poor publication of data for the avian influenza A(H7N9) virus's 3rd outbreak - choosing to release bulk updates and little to no detail on who, where or when.
The continuing avian influenza A(H5N1) virus outbreak in Egypt is also a mystery to all but a very few. Something that is a concern I think, for a much larger number.
Data from the Ebola virus hotzone countries in western Africa has also had many ups and downs. This is not at all surprising given the conditions, the extent of mobile communications, the history of the region, the political and social issues, the poor health infrastructure and the speed with which Ebola virus disease (EVD) spread through Guinea, Liberia and Sierra Leone in 2014. Many different patterns have emerged over the past year among these numbers.
One pattern is the "heartbeat" of EVD cases - the difference in number between update and summary tallies - seen when plotting the data reported by the World Health Organization.
The peaks (Wednesdays and Mondays) and troughs in this chart both hide and reveal all sorts of tales. Principal among these is that the pulse is slowing. The life of the EVD epidemic monster is steadily draining away as the courageous aid workers in western Africa, those from within and from outside each afflicted nation, track the monster to its every hideout and starve it of its avenues for escape and further spread.
It is perhaps the slowest and most painstaking of the phases of this epidemic, but the process still moves forward towards the goal of zero cases and the complete eradication of these particular variants of Zaire ebolavirus, from the planet.
In 2015, China became a major disappointment in its poor publication of data for the avian influenza A(H7N9) virus's 3rd outbreak - choosing to release bulk updates and little to no detail on who, where or when.
The continuing avian influenza A(H5N1) virus outbreak in Egypt is also a mystery to all but a very few. Something that is a concern I think, for a much larger number.
Data from the Ebola virus hotzone countries in western Africa has also had many ups and downs. This is not at all surprising given the conditions, the extent of mobile communications, the history of the region, the political and social issues, the poor health infrastructure and the speed with which Ebola virus disease (EVD) spread through Guinea, Liberia and Sierra Leone in 2014. Many different patterns have emerged over the past year among these numbers.
One pattern is the "heartbeat" of EVD cases - the difference in number between update and summary tallies - seen when plotting the data reported by the World Health Organization.
 |
| Click on image to enlarge. |
It is perhaps the slowest and most painstaking of the phases of this epidemic, but the process still moves forward towards the goal of zero cases and the complete eradication of these particular variants of Zaire ebolavirus, from the planet.
Useful Ebola virus disease graphics...
Good graphics can be really helpful to convey information quickly - and no-one has time to read words anymore right?
The one above came from CNN [1] and presents the number of cases that have been treated in the United States prior to the 11 or so contacts/associates of the last unidentified case being evacuated.
The second one, above, came form the European Centre for Disease Control and Prevention (ECDC).[2] These guys make excellent plane travel/infectious disease maps. This one shows that the UK has kept pace with the US in medical evacuations or repatriations of EVD cases, or suspected cases, from the hotzone in west Africa.
References..
Liberia enters the next phase of Ebola virus disease (EVD) eradication with a new case...
version 2
What a heartbreaking disappointment this is for the people of Liberia, with a reported new case of EVD in a 44-year old woman who showed signs of disease 15th March and tested positive for Ebola virus on Friday 20th in Monrovia, Liberia.[2,7,8] after more then 3-weeks (28 days or more[6]) with zero new cases and no ongoing, known, transmission of Ebola virus in any county in the country.[5] The previous final case in Liberia tested negative around the 3rd of March (about 17-days ago), when the 42-day clock was started.[5]
Now it has been stopped.
Starting it again will await this new case returning a negative test as well as all their contacts (who will be monitored for 21-days) being declared infection- (actually disease-, but I say infection intentionally) free.
And thus we enter the next phase � that of a different type of frustration and heartbreak as countries within the tri-nation hotzone come tantalisingly close to being declared free of known cases of Ebola virus disease (EVD; see how those seemingly pedantic words [1] have added meaning now?) or virus transmission, or in fact succeed only to have a random case pop up from somewhere unexpected or travel across a border causing disappointment for the people of the country, the aid workers and the family and friends of the new case.
A random case will also trigger all new contact tracing efforts to try and find the source and lock down further spread as quickly as possible.
There is noise on twitter (see Tweet below) and in the media quoting authorities [6] noting that the case may have been from a sexual contact with a previously infected male. Infectious virus has been found in semen in the past in which it can linger for more than a month [3,4], but this has not been a factor in the timing of release of convalescent males in the recent epidemic. If this is the route of acquisition, then the ensuing costs, scope of the response, risk to a country that had nearly cleared the virus and to the stamina of an Ebola-ravaged country may serve to justify additional testing the future.
#Liberia Min of Info says 'initial suspicions' are that country's 1st #Ebola victim in 28 days could have had sex w/ ebola survivorThe route of acquisition in this latest case remains totally unconfirmed at writing.[7] I'll update this post as I find more details.
� Katerina Vittozzi (@kvittozzi) March 20, 2015
My thoughts are with you Liberians � stay strong � it�s a setback to be sure, but you were very close this time and will get there.
References...
- http://unfoundationblog.org/mali-42-days-free-of-ebola-transmission/
- http://www.bbc.com/news/world-africa-31991748?ocid=socialflow_twitter
- http://www.ncbi.nlm.nih.gov/pubmed/25467652
- http://newsmedicalnet.blogspot.com.au/2014/08/ebola-virus-in-semen-is-real-deal.html
- http://apps.who.int/ebola/current-situation/ebola-situation-report-18-march-2015
- http://www.aljazeera.com/news/2015/03/ebola-case-ends-liberia-countdown-virus-free-150321003004879.html
- http://time.com/3753233/ebola-liberia-new-patient/
- http://www.nytimes.com/2015/03/21/world/africa/liberia-reports-first-ebola-case-in-weeks.html
Catching Ebola: mistakes, messages and madness [amended]
Written by Dr. Ian M. Mackay and Dr. Katherine E. Arden
Despite obvious community and media fear, speculation and exclamation that Ebola virus would enter and spread widely within countries outside the hotzone, such an event did not come to pass in 2014. The early public health messaging on Ebola virus and disease were, for the most part, spot on.
In 2014 and 2015, thousands of cases of Ebola virus disease (EVD) ravaged Guinea, Sierra Leone and Liberia in 2014 (the "hotzone"). A smaller outbreak was defeated in Nigeria [8] and another distinct Ebola virus variant drove an outbreak of EVD in the Democratic Republic of the Congo[7] - they too controlled spread of the virus. Ebola virus travelled from the hotzone to other countries including Senegal, Nigeria, the United States of America (USA), Mali and most recently, the United Kingdom. It did this by hitching a ride in a usually unknowingly infected human host.
Over 40 people have been intentionally evacuated or repatriated for observation or more aggressive supportive care - and perhaps the use of experimental therapies - to France, the USA, Spain, Sweden, Norway, Denmark, Germany, Netherlands, Italy, Switzerland and the United Kingdom.[1,18]
Recently, the last country outside of Africa to have unintentionally acquired a case of EVD, the United Kingdom, passed a milestone; 42 days since the last ill patient tested negative for Ebola virus. They were declared free of known virus transmission.[17]
Containing the spread of each imported case has relied upon stringent infection prevention and control measures and the identification and monitoring of each and every contact of an Ebola virus infected person. And these have been used with great success. No country, apart from the three in which transmission has been widespread and intense, has seen the appearance of multiple and continuing rounds of new EVD cases. A rough calculation of the numbers of contacts falling ill from each EVD index case who travelled outside the hotzone is shown in the table. It only includes those with data available publicly.
On average, fewer than 1 in 100 contacts (0.8%) came down with EVD. Not the easiest virus to catch? If you compare that to measles, 9 in 10 non-immune people close to an infectious measles case will acquire disease (90%).[19]
Table 1. Index cases and the proportion of contacts they infected
 |
a-man travelled overland from Guinea while infected; b-man with EVD repatriated from Liberia; c-man who flew while symptomatic to Lagos, Nigeria with a stopover in Lome, Togo; d-man flew from Liberia while infected; e-male healthcare worker returned from Guinea; f-a 2 year old girl travelling overland while infected; g-male travelled by car to a clinic in Bamako, Mali from Guinea (assumed Ebola case); h-female healthcare worker returning from deployment in Sierra Leone; i-this figure may indicate all contacts for both Mali cases |
Some of the heat may have been taken out of the emotional response to Ebola outside Africa because it is now clear that a catastrophic pandemic is not going to happen. Kinda like we were told. I know; it;s so uncool to be reminded that you were told something by a grown up - and it was right!
Well...THEY TOLD YOU SO!!!
Nations with better (some!) healthcare infrastructure, preparedness, healthcare to patient ratios and those who got advice and help quickly, curtailed the spread of EVD. Kicked it out. Stomped on it. Terminated it. This was true even when contacts had been classified as at high risk of getting sick.[15]
Public health messaging made some big calls early on. Some examples include tweets by Head of Public Relations for the WHO, Gregory H�rtl, and later by the Centers for Disease Control and Prevention�s Director, Dr Tom Freiden.[11] They made it clear that Ebola virus was not easy to catch and that measures to stop an outbreak were known.[16] At the time, this didn't jibe with other voices and the unprecedented number of EVD cases and deaths, especially from August onwards, that were tallying up at an exponential rate in west Africa. But those messages, while technically correct, probably didn't convey enough of some of the biggest factors in a disease outbreak - fear, ignorance (meant only in the sense of no specific knowledge of Ebola virus and EVD), tradition and history - the human factors rather than the viral ones. Some comments about transmission suggested essentially no chance of even a single new case happening on the home soil of richer countries - they were overly enthusiastic. They were unjustifiable and when some hospital workers in non-African countries became infected, they were ultimately seen for the mistake in message crafting that they were.
Much of the science of the Ebola epidemic is yet to be written, but what we know today is that it is unlikely that Ebola transmission is any different from what was observed decades ago. Direct, physical contact with a very ill person�s fluids is the overwhelmingly biggest risk factor to target in reducing disease spread. And even then there's no guarantee that disease will result from all instances of contact. We still have much to learn.
What has changed since the bad old days? We�ve learned how to better manage and support EVD cases. EVD is a disease that caught us a little unawares in its combination of "skills" - it spreads by care and through direct contact, accrues a lot of virus in the blood but also vast quantities in explosively propelled fluids produced from "both ends"; virus that remains infectious for even longer in urine and semen than in blood. Quite the mix of issues to deal with.
EVD is no longer a death sentence, and this needs to become part of the new messaging paradigm. It's a message that may still be highly relevant to those in Guinea and Sierra Leone who seemingly would still rather risk death than seek care at a treatment unit. Post-mortem detection of EVD cases is ongoing, although may be on the decrease but also nearly a third of cases in Guinea and Sierra Leone are arising from unknown human sources.[21] Contextual communication is needed from within each country and region. That aspect cannot be allowed to wane.
With early care, and active care, rather than the palliative model that seemed to occur when the ratio of EVD cases to healthcare workers was too high, patients mostly survive. The EVD treatment center at the Hastings Police Training School near Freetown, Sierra Leone stands as a model for successful life saving and is the best described example of this from the west Africa epidemic to date.[20]
Ebola virus infection is not easy to catch, it can be survived much more often than was generally accepted and its spread can indeed be stopped. Stopping an Ebola outbreak quickly seems to be helped mostly by prior education, ongoing communication, forewarning and preparation but also needs ongoing surveillance, functional healthcare infrastructure, a range of experienced workers and all of that must all be under-written by money.
But even with all that help in place, mistakes will be made and lessons will be learned, by everyone, all the time. Embrace that. We're all human.
References
Ebola virus infection is not easy to catch, it can be survived much more often than was generally accepted and its spread can indeed be stopped. Stopping an Ebola outbreak quickly seems to be helped mostly by prior education, ongoing communication, forewarning and preparation but also needs ongoing surveillance, functional healthcare infrastructure, a range of experienced workers and all of that must all be under-written by money.
But even with all that help in place, mistakes will be made and lessons will be learned, by everyone, all the time. Embrace that. We're all human.
References
- http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html
- http://apps.who.int/iris/bitstream/10665/137510/1/roadmapsitrep_5Nov14_eng.pdf
- http://www.who.int/mediacentre/news/ebola/20-november-2014-mali/en/
- http://www.who.int/mediacentre/news/ebola/17-october-2014/en/
- http://www.nyc.gov/html/doh/html/pr/press-statements.shtml
- http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/united-states-imported-case.html
- http://www.nejm.org/doi/full/10.1056/NEJMoa1411099
- http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20920
- http://apps.who.int/ebola/en/status-outbreak/situation-reports/ebola-situation-report-14-january-2015
- http://www.symplur.com/blog/the-life-cycle-of-ebola-on-twitter/
- http://www.foxnews.com/opinion/2014/08/09/truth-about-ebola-us-risks-and-how-to-stop-it/
- http://www.nytimes.com/interactive/2014/10/20/us/cascade-of-contacts-from-ebola-case.html
- https://www.gov.uk/government/news/ebola-contact-tracing-underway
- http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(14)62016-X.pdf
- http://www.who.int/mediacentre/news/ebola/3-september-2014/en/
- http://www.bloomberg.com/news/videos/b/4a798222-3666-446d-81ff-f21412a3f068?cmpid=yhoo
- http://www.euro.who.int/en/health-topics/emergencies/pages/news/news/2015/03/united-kingdom-is-declared-free-of-ebola-virus-disease/_recache
- http://ecdc.europa.eu/en/healthtopics/ebola_marburg_fevers/Pages/medical-evacuations.aspx
- http://www.cdc.gov/measles/about/transmission.html
- http://www.nejm.org/doi/full/10.1056/NEJMc1413685
- http://apps.who.int/iris/bitstream/10665/156273/1/roadmapsitrep_18Mar2015_eng.pdf?ua=1&ua=1
Last country outside the hotzone to pass 42-day period-awaits official announcement...
The United Kingdom (UK) reached the 42-day mark, during which no new known cases resulted from the index case, on the 6th March 2015.
The UK's accidentally imported Ebola virus disease (EVD) case, a female healthcare worker returning from deployment in Sierra Leone [1], last tested negative for Ebola virus on 23rd of January. She was discharged from hospital on 24th of January.[2]
All that remains now is for an official announcement...from someone (else) official, singing this achievement from the rooftops.
A Public Health England report (below), posted on the UK government website has already acknowledged the 42 day mark.
A bit understated even for the mother country!
References...
The UK's accidentally imported Ebola virus disease (EVD) case, a female healthcare worker returning from deployment in Sierra Leone [1], last tested negative for Ebola virus on 23rd of January. She was discharged from hospital on 24th of January.[2]
 |
| Timeline of the UK EVD case. Green=onset; pink=hospitalization; blue=date of final NEG test on which the 42-day clock started; grey box=country considered, if not yet declared, free of known ongoing Ebola virus transmission. Click on image to enlarge |
All that remains now is for an official announcement...from someone (else) official, singing this achievement from the rooftops.
A Public Health England report (below), posted on the UK government website has already acknowledged the 42 day mark.
A bit understated even for the mother country!
 |
| From here Click on image to enlarge. |
- World Health Organization Disease Outbreak News (DON)
http://www.who.int/csr/don/30-december-2014-ebola/en/ - Ebola Situation Report - 4 March 2015
http://apps.who.int/ebola/current-situation/ebola-situation-report-4-march-2015
