Global & Disaster Medicine

Archive for the ‘Ebola’ Category

The Ebola outbreak in the Democratic Republic of the Congo (DRC) grew by 9 more cases

WHO

“…..As of 18 May 2017, a total of 29 EVD cases [two confirmed, two probable and 25 suspected] have been reported.  To date, three deaths have been reported, giving a case fatality rate of 10%. Most of the cases presented with fever, vomiting, bloody diarrhea and other bleeding symptoms and signs. The cases have been reported from four health areas, namely Nambwa (11 cases and two deaths), Mouma (three cases and one death), Ngayi (13 cases and no deaths), and Azande (two cases and no deaths). According to available ….”


WHO said 2 new suspected Ebola cases are being investigated in the Democratic Republic of Congo (DRC), and a US expert says events are unfolding in ways reminiscent of Guinea in 2014 at the onset of a massive West Africa outbreak.

CIDRAP

1. Situation update
WHO continues to monitor the outbreak of Ebola virus disease (EVD) in Likati Health Zone, Bas Uele Province located in the north-east of the Democratic Republic of the Congo. Between 15 May and 16 May 2017, two new suspected EVD cases were reported in Azande (one case) and Nambwa (1 case) health areas in Lakati Health Zone. As of 16 May 2017, 21 suspected EVD cases including three deaths (case fatality rate of 14.3%) have been reported. Most of the cases presented with fever, vomiting, bloody diarrhoea and other bleeding symptoms and signs. The cases have been reported from four health areas, namely Nambwa (13 cases and two deaths), Mouma (three cases and one death), Ngayi (four cases and no deaths) and Azande (one case and no deaths).
Two of five blood samples collected from the initial cases and analysed at the Institut National de Recherche Biomédicale (INRB) laboratory in Kinshasa tested positive for Zaire ebolavirus. Approximately 400 close contacts have been registered in Likati Health Zone and are being monitored.
This Ebola outbreak in the Democratic Republic of the Congo was notified to WHO by the Ministry of Health on 11 May 2017. The cluster of cases and deaths of previously unidentified illness have been reported since late April 2017. Likati Health Zone shares borders with two provinces in the Democratic Republic of the Congo and with the Central African Republic (Fig. 1). The affected areas are remote and hard to reach, with limited communication and transport networks.
EBOLA VIRUS DISEASE Democratic Republic of Congo
Date of issue: 16 May 2017
The current outbreak is the eighth Ebola outbreak in the Democratic Republic of the Congo since the disease was first discovered in 1976 in Yambuku.
Health Emergency Information and Risk Assessment Health Emergency Information and Risk Assessment 2-19 suspected cases -3 deaths

As this is a rapidly changing situation, the number of reported cases and deaths, contacts under medical observation and the number of laboratory results are subject to change due to enhanced surveillance and contact tracing activities, ongoing laboratory investigations and consolidation of case, contact and laboratory data.
Health Emergency Information and Risk Assessment Health Emergency Information and Risk Assessment 3

Current risk assessment
The risk is high at the national level due to the known impact of Ebola outbreaks, remoteness of the affected area, limited access to health care and suboptimal surveillance. • Risk at the regional level is moderate due to the proximity of international borders and the recent influx of refugees from Central African Republic. •  The risk is low at global level due to the remoteness and inaccessibility of the area to major international ports.
The risk assessment will be revaluated by the three levels of WHO according to the evolution of the situation and the available information. WHO advises against the application of any travel or trade restrictions on the Democratic Republic of the Congo based on the currently available information. WHO continues to monitor reports of measures being implemented at points of entry.
WHO’s strategic approach to the prevention, detection and control of EVD
WHO recommends the implementation of strategies that have proven to be effective in preventing and control of Ebola outbreaks. These strategies include (i) coordination of the response, (ii) enhanced surveillance, (iii) laboratory confirmation, (iv) contact identification and follow-up, (v) case management, (vi) infection prevention and control, (vii) safe burials, (viii) social mobilization and community engagement, (ix) logistics, (x) risk communication, (xi) vaccination, (xii) partner engagement, (xiii) research and (xiv) resource mobilization.
2. Actions to date
Since the declaration of the outbreak, the WHO regional Office for Africa, as well as the other levels of WHO, are providing a high level of support to the country in order to ensure an effective response to this event.
Coordination of the response
• On 15 May 2017, the Minister of Public Health chaired the Health Emergency Management Committee meeting in Kinshasa which was attended by government officials and partners. The attendees reviewed the current situation, discussed strategies and planned the implementation of control interventions. • The national, provincial and zonal response teams, in collaboration with partners, are conducting daily coordination meetings in order to design strategies, plan, implement and monitor progress of the response. • WHO is conducting daily conference calls involving all the three levels of WHO to strategize and provide guidance.
Surveillance
• The national rapid response team arrived in Likati Health Zone on 15 May 2017. The team will conduct detailed epidemiological investigations and support the local response. • Active surveillance is being established and strengthened in the affected region and daily reporting has been implemented. Surveillance is also being enhanced nationwide.
Laboratory confirmation
• By 15 May 2017, five new blood samples have been collected from the affected people and are being transported to the Institut National de Recherche Biomédicale (INRB) laboratory in Kinshasa for testing. • INRB is deploying 2 mobile laboratories to Buta and Likati. There is additional mobile laboratory support available through GOARN/EDPLN for if required. • The available samples will be transported to the WHO Collaborating Centre for further analysis. • Samples transportation mechanism from the field is being improved to enable timely confirmation of suspected cases.
Health Emergency Information and Risk Assessment Health Emergency Information and Risk Assessment 4
Health Emergency Information and Risk Assessment Health Emergency Information and Risk Assessment 5
Infection prevention and control / safe burials
• The disinfection of materials and homes of the cases is ongoing in Likati and Nambwa health zones. • The logistics and capacity to conduct safe burials are being put in place.
Contact identification and follow-up
At least 400 contacts have been identified and are being followed up on a daily basis. Efforts are ongoing to establish and strengthen contact tracing mechanisms.  • Tools for contact identification and follow up are being distributed to health workers.
Case management
• Preparations by the non-governmental organizations Médecins Sans Frontières (MSF) and the Alliance for International Medical Action (ALIMA) are ongoing to support the establishment of proper isolation and treatment facilities in the affected areas.
Social mobilization and community engagement
• National social mobilization and community engagement experts are on the ground to sensitize and engage the communities.
Logistic
• The logistics team in Kinshasa is working closely with logistics partners and stakeholders across the Democratic Republic of the Congo to ensure effective collaboration and coordination. The logistic issues to be addressed include supply, warehousing, transport, setting up of living quarters and operations base(s) in remote zones, setting up medical and isolation facilities, and referral of patients. The international logistics partners include UNICEF, World Food Programme (WFP), MSF, ALIMA, the United States Agency for International Development (USAID) and the United Kingdom Department for International Development (DFID). • WFP/Logistics Cluster and UNICEF have been approach to support warehousing capacity in Buta and eventually Likati. • WHO donated 3,000 sets of personal protective equipment (PPE), enough to support a facility of 30 beds for 30 days. The other supplies donated include 100 body bags, sprayers, chlorine powder for disinfection and infrared thermometers. The supplies have been transported to Likati. • Communication equipment, including satellite phones and data satellite communication devices has been deployed. • Discussions to secure air transport are in advanced stages. The options will include using both helicopter and fixed-wing flights. The United Nations Humanitarian Air Service (UNHAS) will set up a base to operate from Buta. •
Resources Mobilization
• The Ministry of Health has finalized the national Ebola outbreak response plan and budget, amounting to US$ 8 million. The response plan and budget has been presented and discussed with partners. • The WHO Country Office in the Democratic Republic of the Congo finalized a response plan and budget amounting to US$ 1.4 million. •
Risk communication
• Risk communication messages are being aired through local radio channels. Awareness campaigns are also being organized in markets, churches and other public places. • An advocacy meeting was held with the political and administrative authorities
Health Emergency Information and Risk Assessment Health Emergency Information and Risk Assessment 6

Partnership
• WHO continues to mobilize partners to provide technical and logistical support to the country. • GOARN Operational Support Team is coordinating Partner inputs and regular information sharing through teleconferences and secure Knowledge Platform. • MSF and ALIMA are on the ground in Likati to provide technical support.
IHR Travel measures
• As of 16 May 2017, three countries have instituted entry screening at airports and ports of entry (Nigeria, Tanzania, and Zimbabwe), and two countries have issued travel advisories to avoid unnecessary travel to DRC (Rwanda) or to areas around the epicenter of the epidemic (United Kingdom). • The IHR Secretariat, together with ICAO is actively monitoring the travel measures implemented by States Parties in relation to this outbreak. • WHO does not currently recommend any restrictions of travel and trade in relation to this outbreak.
3. Summary of public health risks, needs and gaps
The critical needs currently are access to the affected areas and to enable the timely deployment of required human and logistical resources, including the mobile laboratory and communication tools.
Proposed ways forward include:
• Establishing appropriate Ebola isolation and treatment facilities; • Initiate implementation of response interventions in all the essential pillars; • Continuing with the deployment of national and international experts to the affected areas; • Mobilizing needed resources, including telecommunications and air transport logistics, to ease communication and access to the affected areas.


The WHO and outside experts are making arrangements to send an experimental Ebola vaccine to the Democratic Republic of Congo, should officials there say they need it to quell an outbreak there.

Stat

  • The outbreak has grown to 20 suspected cases.
  • Three of the infected have died.

 


The WHO has identified two more suspected cases of Ebola a day after declaring an outbreak in Congo. The U.N. agency said Saturday there are now 11 suspected cases.

FOX


United Nations officials say at least 11 people have died from a mysterious illness in Liberia and tests have been negative for the Ebola virus.

NY Daily News


The US State Department and the Department of Health and Human Services (HHS) last week conducted an unprecedented inter-agency drill to test the ability to airlift clusters of infected patients to hospitals with special biocontainment units.

AP

“……The State Department and Department of Health and Human Services said Tuesday they led an unprecedented inter-agency drill last week to test their preparedness to deal with a new outbreak of Ebola or another deadly, highly infectious disease. In the drill, 11 simulated patients were flown in specially designed bio-containment containers on a pair of 747s and three smaller Gulfstream jets from Sierra Leone to Washington’s Dulles International Airport.

From Dulles, the purported patients then went to five medical facilities across the U.S – Bellevue Hospital in New York City, Johns Hopkins University in Baltimore, the University of Minnesota Medical Center in Minneapolis, the Denver Health Medical Center in Denver and the University of Nebraska Medical Center in Omaha. The patients were played by non-infected volunteers…..”


Predictive and easy-to-use prognostic tools, which stratify the risk of EVD mortality at or after EVD triage.

PLOS:  Hartley M-A, Young A, Tran A-M, Okoni-Williams HH, Suma M, Mancuso B, et al. (2017) Predicting Ebola Severity: A Clinical Prioritization Score for Ebola Virus Disease. PLoS Negl Trop Dis 11(2): e0005265. doi:10.1371/journal.pntd.0005265

  • 158 Ebola patients:  Study population
  • The authors were able to accurately predict death at triage 91% of the time and death after triage 97% of the time.
  • Co-infection with malaria was associated with a 2.5-fold increase in the odds of death.
  • Disorientation, hiccups, diarrhea, conjunctivitis, shortness of breath, and muscle aches were also strong predictors of death.
  • Age was also a predictor of mortality.
    • The patient group aged between 5 and 24 years had the lowest mortality rate of 42.5%
    • The over-45’s and under-5’s were particularly vulnerable, being 11.6 and 5.4 fold more likely to die, respectively.

Background

Despite the notoriety of Ebola virus disease (EVD) as one of the world’s most deadly infections, EVD has a wide range of outcomes, where asymptomatic infection may be almost as common as fatality. With increasingly sensitive EVD diagnosis, there is a need for more accurate prognostic tools that objectively stratify clinical severity to better allocate limited resources and identify those most in need of intensive treatment.

Methods/Principal Findings

This retrospective cohort study analyses the clinical characteristics of 158 EVD(+) patients at the GOAL-Mathaska Ebola Treatment Centre, Sierra Leone. The prognostic potential of each characteristic was assessed and incorporated into a statistically weighted disease score. The mortality rate among EVD(+) patients was 60.8% and highest in those aged <5 or >25 years (p<0.05). Death was significantly associated with malaria co-infection (OR = 2.5, p = 0.01). However, this observation was abrogated after adjustment to Ebola viral load (p = 0.1), potentially indicating a pathologic synergy between the infections. Similarly, referral-time interacted with viral load, and adjustment revealed referral-time as a significant determinant of mortality, thus quantifying the benefits of early reporting as a 12% mortality risk reduction per day (p = 0.012). Disorientation was the strongest unadjusted predictor of death (OR = 13.1, p = 0.014) followed by hiccups, diarrhoea, conjunctivitis, dyspnoea and myalgia. Including these characteristics in multivariate prognostic scores, we obtained a 91% and 97% ability to discriminate death at or after triage respectively (area under ROC curve).

Conclusions/Significance  This study proposes highly predictive and easy-to-use prognostic tools, which stratify the risk of EVD mortality at or after EVD triage.

Nearly three years after Ebola hit Sierra Leone, millions of dollars in funds raised to fight the deadly virus have still not been accounted for.

BBC

“…..This led to dramatic strike action in late 2014 at the Kenema hospital. Members of the specialist burial teams brought out corpses from the morgue and placed them at the hospital entry points, demanding unpaid allowances. ……”

 


Long-term clinical, psychosocial, and viral outcomes in Ebola survivors in Guinea.

Lancet

Multidisciplinary assessment of post-Ebola sequelae in Guinea (Postebogui): an observational cohort study.                                                                                                                                                                                                                 Etard, Jean-François et al.                                                                                                                                                                                                                       The Lancet Infectious Diseases

img_9577

Findings

Between March 23, 2015, and July 11, 2016, we recruited 802 patients, of whom 360 (45%) were male, 442 (55%) were female; 158 (20%) were younger than 18 years. The median age was 28·4 years (range 1·0–79·9, IQR 19·4–39·8). The median delay after discharge was 350 days (IQR 223–491). The most frequent symptoms were general symptoms (324 [40%] patients), musculoskeletal pain (303 [38%]), headache (278 [35%]), depression (124 [17%] of 713 responses), abdominal pain (178 [22%]), and ocular disorders (142 [18%]). More adults than children had at least one clinical symptom (505 [78%] vs 101 [64%], p<0·0003), ocular complications (124 [19%] vs 18 [11%], p=0·0200), or musculoskeletal symptoms (274 [43%] vs 29 [18%], p<0·0001). A positive RT-PCR in semen was found in ten (5%) of 188 men, at a maximum of 548 days after disease onset. 204 (26%) of 793 patients reported stigmatization. Ocular complications were more frequent at enrolment than at discharge (142 [18%] vs 61 [8%] patients).

Interpretation

Post-EVD symptoms can remain long after recovery and long-term viral persistence in semen is confirmed. The results justify calls for regular check-ups of survivors at least 18 months after recovery.

 


What is the potential role of lung infection in Ebola and can it be a factor in transmission of the virus from one human to another?

Eureka

Biava M, Caglioti C, Bordi L, Castilletti C, Colavita F, Quartu S, et al. (2017) Detection of Viral RNA in Tissues following Plasma Clearance from an Ebola Virus Infected Patient. PLoS Pathog 13(1): e1006065. doi:10.1371/journal.ppat.1006065

http://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1006065


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