Friday, October 24, 2014

WHO Ebola Update – Mali Confirms 1st Ebola Case




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Yesterday afternoon, in Reuters: Mali Reports 1st Confirmed Ebola Case, we got confirmation on a positive Ebola test for a toddler – recently in Guinea – making Mali the sixth African nation affected by this current Ebola outbreak.


Through great effort and no small amount of luck, previous introductions into Nigeria and Senegal were successfully contained, but concerns run high anytime a new country is affected.


Today, in short order, we have a detailed update from the World Health Organization, who state the child traveled extensively with a relative while symptomatic – including on public conveyances – and that numerous high-risk exposures may have occurred. 


They consider the situation in Mali an emergency.


Mali confirms its first case of Ebola

Ebola situation assessment - 24 October 2014

Mali’s Ministry of Health has confirmed the country’s first case of Ebola virus disease. The Ministry received positive laboratory results, from PCR testing, on Thursday and informed WHO immediately. In line with standard procedures, samples are being sent to a WHO-approved laboratory for further testing and diagnostic work.

Details about the case

In telephone conversation on Thursday night, health officials gave WHO the following details about the case, which is currently undergoing intense investigation.

The patient is a two-year-old girl, who recently arrived from Guinea accompanied by her grandmother. The child’s first contact with the country’s health services occurred on 20 October, when she was examined by a health care worker at Quartier Plateau in Kayes, a city in western Mali on the Senegal River.

Kayes has a population of around 128 000 people. It is located about 600 kilometres from the capital city of Bamako and lies near the border between Mali and Senegal.

The health-care worker referred the grandmother and child to the Fousseyni Daou Hospital, in the same city, where she was admitted to the paediatric ward on the following day, on 21 October. Symptoms on admission included a fever of 39°C, cough, bleeding from the nose, and blood in the stools.

Test results were negative for malaria, but positive for typhoid fever. The child received paracetamol, but did not improve. Further testing at the country’s SEREFO laboratory confirmed Ebola virus as the causative agent on 23 October.

Initial investigation of this case – the first confirmed in Mali – has revealed the extensive travel history of the child and her grandmother. The grandmother travelled from her home in Mali to attend a funeral in the town of Kissidougou, in southern Guinea.

WHO is seeking confirmation of media reports that the funeral was for the child’s mother, who is said to have shown Ebola-like symptoms before her death. These and other facts will be communicated as they are confirmed.

Additional facts communicated to WHO

On 19 October, the grandmother left Guinea to return to Mali, taking the child with her. The case history revealed that bleeding from the nose began while both were still in Guinea, meaning that the child was symptomatic during their travels through Mali.

Travel was by public transport through Keweni, Kankan, Sigouri, and Kouremale to Bamako. The two stayed in Bamako for two hours before travelling on to Kayes. Multiple opportunities for exposure occurred when the child was visibly symptomatic.

Prompt emergency response

WHO is treating the situation in Mali as an emergency. The child’s symptomatic state during the bus journey is especially concerning, as it presented multiple opportunities for exposures – including high-risk exposures - involving many people.

Continued high-level vigilance is essential, as the government is fully aware.

The child is being treated in isolation and staff have received training in appropriate procedures for safe management. The initial investigation identified 43 close and unprotected contacts, including 10 health-care workers, who are also being monitored in isolation.

(Continue . . .)


WHO MERS Update – Turkey



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Last weekend in Turkey Announces MERS Fatality – ex KSA we first learned of a recently exported case fatal case of MERS to Turkey.  On Wednesday we saw the ECDC’s Epidemiological Update – MERS In Turkey (ex KSA), while today we have the official update from the World Health Organization.


Although the MERS coronavirus has been largely supplanted in the newspaper headlines by Ebola, it continues to simmer on the Arabian peninsula, and occasionally gets exported to other regions of the world.   The concern is that we could see the same kind of winter-spring surge in cases that we saw last year.



Middle East respiratory syndrome coronavirus (MERS-CoV) – Turkey

Disease Outbreak News
24 October 2014

On 17 October 2014, WHO EURO was notified by the National IHR Focal Point for Turkey of a laboratory-confirmed case of infection with Middle East respiratory syndrome coronavirus (MERS-CoV). On 11 October 2014, the patient died. This is the first MERS-CoV case in Turkey.

Details of the case are as follows:

The case is a 42-year-old male, Turkish citizen known to be working in Jeddah, Kingdom of Saudi Arabia (KSA). On 25 September 2014, the patient developed symptoms in Jeddah. Initially, he sought medical care in KSA; however, on 6 October 2014, as symptoms worsened, he travelled with a direct flight from Jeddah to Hatay, Turkey. Upon his arrival, he was admitted to a local hospital. On 8 October, he was transferred to the University Hospital in Hatay.

Public health response

Additional information about the flight and any contacts that may be linked to the same flight are now being investigated; the health condition of the cabin crew is being monitored. Also, contacts of the case during his symptomatic phase (25 September - 6 October 2014) when he was still in Jeddah are being examined, including contacts in health care facilities in KSA. WHO EURO and EMRO IHR Contact Points are facilitating direct communications between the IHR NFP Turkey and KSA.

Globally, WHO has received notification of 883 laboratory-confirmed cases of infection with MERS-CoV, including at least 319 related deaths.

Saudi MOH: New MERS Cases in Riyadh & Taif


MERS reports from 23rd & 24th

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For whatever reason the Saudi MOH didn’t update their English language MERS site yesterday (although the Arabic site showed a new case), but today we have yesterday’s and today’s report now posted.


Yesterday’s case involved a 73 y.o. female from Riyadh, with no known routes of exposure (note the expanded categories added yesterday)



Today’s case, from Taif, is apparently the result of nosocomial transmission at a hospital.  This is the 16th case reported from the Taif region since September 3rd, with many of the cases apparently linked to hospital exposures.


COCA Call: Approaches to Clinical Management for Patients with Ebola



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With a second imported case of Ebola now in a New York hospital, and the potential for seeing more cases arrive in the coming months, the COCA Call held earlier this week on the clinical management of Ebola patients comes at an opportune time.


Primarily of interest to clinicians, the CDC holds frequent COCA (Clinician Outreach Communication Activity) calls which are designed to ensure that practitioners have up-to-date information for their practices.


This particular call is described as being - `. . . not intended for the general US public . . . not intended for the US media and press’  and I suspect that those without a solid medical background will be either be either lost or bored by much of the technical information presented. 

Clinicians, however, will want to check out the transcript or the audio file below:

Approaches to Clinical Management for Patients with Ebola Treated in U.S. Hospitals


Date:Monday, October 20, 2014

Time:2:00 – 3:30 PM (Eastern Time)


Tim Uyeki, MD, MPH, MPP
Clinical Team Lead
CDC Ebola Response

Diana Florescu, MD
Infectious Disease Specialist
Section on Infectious Diseases
University of Nebraska Medical Center

G. Marshall Lyon III MD, MMSc
Associate Professor
Division of Infectious Diseases
Emory University School of Medicine


The 2014 Ebola epidemic is the largest in history, affecting multiple countries in West Africa. A small number of patients with Ebola virus disease (EVD) have been medically evacuated from West Africa to receive care in U.S. hospitals. The first imported case of Ebola was diagnosed in the United States in a person who had traveled from West Africa to Dallas, Texas and two secondary Ebola cases in health care workers have been identified as of October 14, 2014. CDC and our partners are taking precautions to prevent the spread of Ebola by sharing information with clinicians who may provide care for patients with EVD. During this COCA Call, clinicians will learn the clinical features and complications associated with Ebola and recommendations from Emory University Hospital and the University of Nebraska Medical Center on clinical management of patients with EVD.

Call Materials

  • Audio: Listen Now
  • Transcript: Read Now
  • Slides: There are no PowerPoint slides for this call.

MSF Protocols For Volunteers Returning From Ebola Stricken Nations

Health staff dressed in protective clothing constructing a perimeter for the isolation ward.

MSF health staff in protective clothing constructing perimeter for isolation ward.

Credit CDC Ebola Webpage


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Even though we are just beginning to learn the details about New York City’s Ebola case – that of a Médecins Sans Frontières (MSF) volunteer doctor recently returned from Guinea – already the media are attempting to dissect his movements (see WPIX report NYC doctor rode subway before testing positive for Ebola at Bellevue) over the past couple of days.


While we can’t assume that every Ebola infected individual sheds virus on exactly the same timetable, the fact that Thomas Duncan’s family was exposed for several days before he was hospitalized – yet none developed the disease - suggests that Ebola cases are likely far less infectious early in their illness.


Nevertheless, the City of New York will have a huge job ahead doing contact tracing, monitoring, environmental cleanup, and public relations work as a result of this latest Ebola incident.  Some of these steps will be prudent or medically necessary, while others will be employed to reassure a jittery population.

While MSF volunteers treating Ebola cases are quite deservedly viewed as heroes, the societal and economic impact of dealing with this latest imported case will be substantial, and that will doubtless spark further debate over what restrictions should be in place for travelers arriving from Ebola hot zone countries.

Late yesterday MSF released the following statement regarding the protocols used by their staff during the 21 days after leaving Ebola affected nations.


MSF Protocols for Staff Returning from Ebola-Affected Countries

October 23, 2014

Since the beginning of its operations in West Africa in March to combat the Ebola outbreak, Doctors Without Borders/Médecins Sans Frontières (MSF) has put in place stringent protocols to protect its staff from exposure to the Ebola virus and to monitor the health of its returning staff.

MSF has specific guidelines and protocols for staff members returning from Ebola assignments.  These guidelines govern the 21-day incubation period of the virus (it can take up to 21 days to display symptoms of possible Ebola infection). A fever that develops during the 21-day period may also be due to something other than Ebola, such as the flu. A fever that develops after the 21-day-period is not due to Ebola. 

Until today, out of more than 700 expatriate staff deployed so far to West Africa, no MSF staff person has developed confirmed Ebola symptoms after returning to their home country. While some MSF staff members have been exposed in the field, those exposures were detected and the staff members were immediately isolated and treated. Two international staff members have been medically evacuated. They have fully recovered.

MSF pre-identifies health facilities in the United States that can assist and manage the care of our staff members in the event they develop symptoms after their return home. This pre-identification practice is carried out in coordination with the US Centers for Disease Control (CDC) and departments of health at state and local levels.

Upon returning to the United States, each MSF staff member goes through a thorough debriefing process, during which they are informed of our guidelines. 

The guidelines include the following instructions:

1.    Check temperature two times per day
2.    Finish regular course of malaria prophylaxis (malaria symptoms can mimic Ebola symptoms)
3.    Be aware of relevant symptoms, such as fever
4.    Stay within four hours of a hospital with isolation facilities
5.    Immediately contact the MSF-USA office if any relevant symptoms develop

These guidelines are consistent with those provided by the CDC to people returning from one of the Ebola-affected countries in West Africa. MSF is also implementing new federal guidelines outlining reporting requirements for people returning from Ebola affected countries.

Our colleague in New York followed the MSF protocols and guidelines since returning from West Africa. At the immediate detection of fever on the morning of October 23, 2014, he swiftly notified the MSF office in New York.  He did not leave his apartment until paramedics transported him safely to Bellevue Hospital in Manhattan, and he posed no public health threat prior to developing symptoms. 

While MSF is not in a position to comment on his medical condition or the care he is receiving, the organization sincerely wishes for his swift and complete recovery.  

Steps Doctors Without Borders takes to ensure the health and well being of its staff and the community at large:

If returned staff members do not live within four hours of appropriate medical facilities, MSF will ensure they are accommodated appropriately during the 21-day incubation period.

In the unlikely event that a staff person develops Ebola-like symptoms within the 21-day period, he/she is advised to immediately contact MSF and to refrain from traveling on public transportation. Local health authorities are immediately notified.

As long as a returned staff member does not experience any symptoms, normal life can proceed. Family, friends, and neighbors can be assured that a returned staff person who does not present symptoms is not contagious and does not put them at risk. Self-quarantine is neither warranted nor recommended when a person is not displaying Ebola-like symptoms.

However, returned staff members are discouraged from returning to work during the 21-day period.  Field assignments are extremely challenging and people need to regain energy.  In addition, people who return to work too quickly could catch a simple bacterial or viral infection (common cold, bronchitis, flu etc.) that may have symptoms similar to Ebola. This can create needless stress and anxiety for the person involved and his/her colleagues. For this reason, MSF continues to provide salaries to returned staff for the 21-day period.

CDC Statement: Ebola Case Tests Positive In NYC




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A not altogether unexpected statement this evening, given the media reports of this Healthcare Workers symptoms and recent work in Ebola stricken Guinea, but this evening the CDC has announced that local testing indicates he has been infected with the Ebola virus.


Confirmatory testing should come from the CDC in the coming hours, but there seems little doubt in the matter.

The epidemiological investigation is already underway, and potential contacts of this patient will be identified, notified, and monitored for up to 21 days. The good news is, Ebola patients are believed to be less infectious during the early hours and days of showing symptoms.

While many were hopeful as we approached the end of the 21 day incubation period in Dallas without any more cases, this is a reminder that as long as the virus is spreading in West Africa, the rest of the world is at risk from new importations of the virus.


I expect we will get a good many more details in the coming hours.  In the meantime we have the following statement from the CDC’s press room.


New York City Reports Positive Test for Ebola in Volunteer International Aid Work

A hospitalized medical aid worker who volunteered in Guinea, one of the three West African nations experiencing an Ebola epidemic, and since returned to the United States has tested positive for Ebola according to the New York City Health Department laboratory, which is part of the Laboratory Response Network overseen by the Centers for Disease Control and Prevention.

The patient has been notified of the test results and remains in isolation. The patient is currently at Bellevue Hospital in New York City. Bellevue Hospital is one of eight New York State hospitals that Governor Cuomo has designated to treat Ebola patients. A specially trained CDC team determined earlier this week that the hospital has been trained in proper protocols and is well prepared to treat Ebola patients.

Confirmation testing at the Centers for Disease Control and Prevention's laboratory will be done. The healthcare worker had returned through JFK Airport on Oct. 17 and participated in the enhanced screening for all returning travelers from these countries. He went through multiple layers of screening and did not have a fever or other symptoms of illness. The patient reported a fever to local health officials for the first time today. The patient was transported by a specially trained HAZ TAC unit wearing Personal Protective Equipment (PPE) to Bellevue. The New York City Health Department has interviewed the patient regarding close contacts and activities.

CDC is in close communications with the New York City Health Department and Bellevue Hospital, and is providing technical assistance and resources. Three members of CDC's Ebola Response Team will arrive in New York City tonight. This team is deployed when an Ebola case is identified in the United States, or when health officials have a very strong suspicion that a patient has Ebola pending lab results.

In addition, CDC already had a team of Ebola experts in New York City who can offer immediate additional support. The CDC experts were in New York City this week assessing hospital readiness to receive Ebola patients, including Bellevue hospital. CDC's Ebola hospital assessment teams are designed to make sure that hospitals that have volunteered to take Ebola patients are Ebola ready.

These teams assess a facility's infection control readiness and to determine if there are gaps in infection control readiness. They support a facility in developing a comprehensive infection control plan. The principle is to be ready for the patient coming in the front door and everything that happens through the patient's stay in the hospital. CDC's team is a multidisciplinary team of experts. It includes infection control practice specialists, personal protective equipment specialists, worker safety experts, clinical care and diagnostics experts, and laboratory processes experts. New York City and New York State have designated Bellevue as an Ebola treatment hospital. The CDC team, which had completed its assessment of Bellevue, found the facility to be well prepared to care for a patient with Ebola.

Ebola is spread through direct contact with bodily fluids of a sick person or exposure to objects such as needles that have been contaminated. The illness has an average 8-10 day incubation period (although it could be from 2 to 21 days). CDC recommends monitoring exposed people for symptoms a complete 21 days.

Confirmatory CDC laboratory tests will be shared when these tests are done, following appropriate patient notification.