Friday, August 01, 2014

State Dept. On Ebola Medical Evacuation & CDC Infection Control Guidance



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With two American Missionaries infected with Ebola expected to arrive in the United States as soon as this weekend (see State Department statement below) – and the possibility that infected international travelers might find their way to our shores – it is not altogether surprising that the CDC today has issued Infection Prevention and Control Recommendations for health care facilities treating suspected or confirmed Ebola cases.


First, the statement from the U.S. Department of State.


Citizens From West Africa

Medical Evacuations of Two U.S. Citizens From West Africa

Press Statement

Marie Harf
Deputy Department Spokesperson, Office of the Spokesperson

Washington, DC

August 1, 2014

The State Department, together with the Centers for Disease Control and Prevention (CDC), is facilitating a medical evacuation for two U.S. citizens who have been infected by Ebola in West Africa. The safety and security of U.S. citizens is our paramount concern. Every precaution is being taken to move the patients safely and securely, to provide critical care en route on a non-commercial aircraft, and to maintain strict isolation upon arrival in the United States.

These evacuations will take place over the coming days. CDC protocols and equipment are used for these kinds of medical evacuations so that they are carried out safely, thereby protecting the patient and the American public, as has been done with similar medical evacuations in the past.

Upon arriving in the United States, the patients will be taken to medical facilities with appropriate isolation and treatment capabilities.

Because of privacy considerations, we will not be able to confirm the names or other specific details of these particular cases.

For matters relating to public health precautions in the United States, we would refer to the CDC, which has the overall lead role on those issues within the U.S. Government.



The CDC’s Infection control guidance (h/t @Influenza_bio for tweeting the link) is too lengthy to try to post in it’s entirety, so I’ll just show an excerpt, and ask those with need for the details to follow the link to the CDC website.


Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals

Standard, contact, and droplet precautions are recommended for management of hospitalized patients with known or suspected Ebola hemorrhagic fever (Ebola HF), also referred to as Ebola Viral Disease (EVD) (See Table below). Note that this guidance outlines only those measures that are specific for Ebola HF; additional infection control measures might be warranted if an Ebola HF patient has other conditions or illnesses for which other measures are indicated (e.g., tuberculosis, multi-drug resistant organisms, etc.).

Though these recommendations focus on the hospital setting, the recommendations for personal protective equipment (PPE) and environmental infection control measures are applicable to any healthcare setting. In this guidance healthcare personnel (HCP) refers all persons, paid and unpaid, working in healthcare settings who have the potential for exposure to patients and/or to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air. HCP include, but are not limited to, physicians, nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainees, contractual personnel, home healthcare personnel, and persons not directly involved in patient care (e.g., clerical, dietary, house-keeping, laundry, security, maintenance, billing, chaplains, and volunteers) but potentially exposed to infectious agents that can be transmitted to and from HCP and patients. This guidance is not intended to apply to persons outside of healthcare settings.

As information becomes available, these recommendations will be re-evaluated and updated as needed. These recommendations are based upon available information (as of July 30, 2014) and the following considerations:

  • High rate of morbidity and mortality among infected patients
  • Risk of human-to-human transmission
  • Lack of FDA-approved vaccine and therapeutics

(Continue . . . )

Follow the above link for specific information on Patient Isolation, PPEs, Aerosol Generating Procedures, Environmental Infection control, monitoring potentially exposed personnel . . . and more.


WHO To Convene IHR Emergency Committee Meeting On Ebola


@WHO & Partners Ebola Response In Guinea


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Although WHO Director Margaret Chan announced it earlier today in a speech delivered today to the Presidents of Guinea, Liberia, Sierra Leone, and Cote d’Ivoire, the World Health Organization has sent out a notice to journalists that the IHR Emergency Committee will meet next week to discuss whether the ongoing Ebola outbreak in West Africa constitutes a “public health emergency of international concern” (PHEIC), and if so, what measures to recommend.


The WHO will hold a Virtual Press Conference after the meeting to discuss the results.

  • WHEN: Thursday 7 August, early evening CEST, timing to be confirmed.
  • WHERE: Geneva-based journalists may participate in the Library Room at WHO Headquarters. Journalists outside Geneva may dial in. Dial-in numbers will be sent to all media on Tuesday.

We’ve seen six such meetings called over the ongoing MERS-CoV outbreaks in the Middle East over the past 18 months, but the situation has never been deemed to reach the level of PHEIC.  But three months ago, an IHR committee meeting did decide that to Declare Polio Spread A Public Health Emergency Of International Concern, and recommended new, strict polio vaccination requirements be implemented for those countries with `active polio’.

Although there are no pharmaceutical options currently available for the control of Ebola,  Director Chan outlined some of the steps that might be needed in her speech today, including:

  • Public awareness of the facts about this disease needs to increase dramatically. Messages from presidents and community and religious leaders are important, but this outbreak needs professionally designed and implemented campaigns, again with help from external experts.
  • Depending on the epidemiological situation, your governments may need to impose some restrictions, for example, on population movements and public gatherings.
  • Governments may need to use their police and civil defence forces to guarantee the safety and security of response teams. Some are already doing so.

As CDC Director Frieden said yesterday, the Ebola situation is worsening, and bringing it under control will be more like a running a marathon, than a sprint.

A Revision In the List Of Quarantinable Communicable Diseases


Photo Credit CDC PHIL


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Eighteen months ago, in EID Journal: A Brief History Of Quarantine, we looked at the long and successful use of quarantine in the United States, and around the world, to contain highly infectious diseases. 


Contrary to Hollywood’s draconian portrayal, quarantine usually consists of  having an exposed person stay home, and report to a healthcare worker by phone each day, during a disease’s incubation period.


Just so we are all on the same page, here is how the CDC differentiates between Quarantine and Isolation:

The CDC applies the term "quarantine" to more than just people. It also refers to any situation in which a building, conveyance, cargo, or animal might be thought to have been exposed to a dangerous contagious disease agent and is closed off or kept apart from others to prevent disease spread.

The Centers for Disease Control and Prevention (CDC) is the U.S. government agency responsible for identifying, tracking, and controlling the spread of disease. With the help of the CDC, state and local health departments have created emergency preparedness and response plans. In addition to early detection, rapid diagnosis, and treatment with antibiotics or antivirals, these plans use two main traditional strategies—quarantine and isolation—to contain the spread of illness. These are common health care practices to control the spread of a contagious disease by limiting people's exposure to it.

The difference between quarantine and isolation can be summed up like this:

  • Isolation applies to persons who are known to be ill with a contagious disease.
  • Quarantine applies to those who have been exposed to a contagious disease but who may or may not become ill.


During the SARS outbreak in 2003, then President George Bush via  Executive Order 13295: Revised List Of Quarantinable Communicable Diseases added SARS to the short list of quarantinable diseases.


(a) Cholera; Diphtheria; infectious Tuberculosis; Plague; Smallpox; Yellow Fever; and Viral Hemorrhagic Fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named).

(b) Severe Acute Respiratory Syndrome (SARS), which is a disease associated with fever and signs and symptoms of pneumonia or other respiratory illness, is transmitted from person to person predominantly by the aerosolized or droplet route, and, if spread in the population, would have severe public health consequences.


Two years later, when avian flu became a serious concern, Executive Order 13375  amended this list by adding :


‘‘(c) Influenza caused by novel or reemergent influenza viruses that are causing, or have the potential to cause, a pandemic.’’.

As emerging disease threats evolve, so to must the legalese enabling an adequate response.   Yesterday the White House issued the following executive order (h/t Sharon Sanders & Treyfish on FluTrackers) regarding a subtle change that broadens the scope of SARS and SARS-like diseases.


The White House

Office of the Press Secretary

For Immediate Release

July 31, 2014

Executive Order -- Revised List of Quarantinable Communicable Diseases

- - - - - - -

By the authority vested in me as President by the Constitution and the laws of the United States of America, including section 264(b) of title 42, United States Code, it is hereby ordered as follows:

Section 1.  Amendment to Executive Order 13295.  Based upon the recommendation of the Secretary of Health and Human Services, in consultation with the Acting Surgeon General, and for the purposes set forth in section 1 of Executive Order 13295 of April 4, 2003, as amended by Executive Order 13375 of April 1, 2005, section 1 of Executive Order 13295 shall be further amended by replacing subsection (b) with the following:

"(b)  Severe acute respiratory syndromes, which are diseases that are associated with fever and signs and symptoms of pneumonia or other respiratory illness, are capable of being transmitted from person to person, and that either are causing, or have the potential to cause, a pandemic, or, upon infection, are highly likely to cause mortality or serious morbidity if not properly controlled.  This subsection does not apply to influenza."

Sec. 2.  General Provisions.  (a)  Nothing in this order shall be construed to impair or otherwise affect:
(i) the authority granted by law to an executive department, agency, or the head thereof; or
(ii) the functions of the Director of the Office of Management and Budget relating to budgetary, administrative, or legislative proposals.

(b)  This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person.



The major change here is the removal of the requirement that the disease be transmitted  `predominantly by the aerosolized or droplet route’.   While not specifying why this change was needed, one could speculate that since we don’t have absolute answers regarding how MERS is transmitted, it falls outside of the older SARS definition. 

Quarantines are politically messy, difficult to administer, and lose their value quickly in an outbreak. Once a communicable disease is `in the community’, there is rarely a good  reason to pursue them. 


But implemented early in an outbreak – as was done with SARS in 2003 – they can literally turn the tide against an emerging epidemic.


During the 2003 SARS epidemic, Isolation was used in the United States for patients who were ill, but since transmission of the virus was very limited here, quarantine was not recommended for those exposed (cite).


In other countries, where transmission risks were greater, quarantines were used – quite successfully – in order to contain the virus. 

  • Singapore was one of the first countries to mandate quarantines when more than 800 family members of SARS patients were ordered to stay in their homes. 
  • Hong Kong sealed part of the Amoy Gardens Apartment complex after scores of cases erupted there, and later moved all remaining residents to two holiday camps where they were quarantined.
  • And Toronto, Canada closed schools and quarantined thousands in their bid to contain the virus (see The SARS Experience In Ontario, Canada).

The graph below shows two distinct phases of disease transmission in Canada, both apparently dampened by the implementation of quarantines.



While unlikely to be popular (particularly among those caught up in one) – quarantines are a necessary and often highly effective tool for public health – and likely stopped SARS from becoming a global pandemic in 2003.  

Fair Biosecurity & H3N2 In North Dakota Show Pigs



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County and State Fair season is underway in the northern states and will continue across the nation well into fall. One of the highlights for many visitors are the agricultural exhibits, including livestock exhibitions.  While educational, entertaining, and financially lucrative, there are admittedly some downsides.

Bringing together animals from farms all over the region provides unique opportunities to swap pathogens amongst themselves, and potentially spread them to handlers and the public.


In years past, the concern has centered primarily on swine flu, but the recent emergence of two new swine coronaviruses – PEDV & PDCoV  (see SECD: Another Emerging Coronavirus Threat) have complicated matters as well.  Unlike the swine influenzas, however, SECDs - or Swine Enteric Coronavirus Diseases  are not known to transmit to humans.


While they generally cause mild symptoms in adult pigs, among piglets, the mortality rate can run close to 100%. 


In some regions, fair administrators have implemented a terminal show policy where pigs exhibited at the fair must be sent to market at the show’s end, rather than back home (or worse, to another fair) to prevent the potential spread of porcine diseases. 


This report (and video) from a local Wisconsin TV station.

Terminal show policy in place to control swine virus

The PED virus has had a significant impact on pig populations in the United States in the last two years

Author: Dave Delozier,

Published On: Jul 25 2014 05:44:58 PM CDT


While most pig exhibitors attend county fairs with the expectation their animal will be sold to market, it is now becoming a certainty.  Because of concerns about the spread of a deadly virus, Porcine Epidemic Diarrhea or PED, county fairs have adopted a terminal show policy.  That means a pig shown at a county fair must be sold to market at the shows end and cannot be taken back to a farm.

(Continue . . . )


Beyond the opportunities for porcine diseases to spread between pigs, fairs also provide lots of human-animal contact, which can lead to the spread of infections from humans-to-pigs, and from pigs-to-humans


Illustrating the two-way nature of disease sharing - shortly after the 2009 H1N1 virus emerged in the human population - it began showing up in pig herds around the world (see Study: Reassortants of H1N1pdm & Swine H1 & H3 Viruses in Japan)



With the emergence of several swine variant influenza viruses in the past few years (H1N1v, H1N2v, H3N2v) – all able to jump to humans (albeit, not able to transmit efficiently) -  we are seeing a greater emphasis on fair biosecurity than ever before (see CDC: Measures to Minimize Influenza Transmission at Swine Exhibitions, 2014).

Last week, in EID Journal: H3N2v Swine To Human Transmission At Agricultural Fairs – 2012, we looked at what was the most active year for swine variant transmission to humans, where the authors cautioned:


Swine-to-human transmission and human-to-swine transmission of influenza A virus are known to occur at fairs (28), highlighting the fact that swine in this setting are potentially exposed to multiple lineages of influenza A viruses simultaneously, making fairs ideal locations for genomic reassortment and novel virus formation.


Swine are highly susceptible to a variety of flu viruses (human, swine, avian) - and are viewed as excellent `mixing vessels’, allowing viruses to reassort into new hybrid strains.  This is how the 2009 H1N1 pandemic virus was created, after bouncing around swine herds for a decade or more.

Reassortant pig[6]


State & local  fairs have instituted inspections for any signs of illness in livestock – but as we’ve discussed previously (see Asymptomatic Pigs: Revisited) - pigs can sometimes carry these viruses without showing any outward signs of infection.


While we’ve not seen any reports of human infection with swine variant influenza this summer, fair officials and health departments are understandably on heightened alert, and are taking steps to try to prevent that from happening.  All of which serves as prelude to this announcement (yesterday) by North Dakota’s Department of Health.


Influenza A H3N2 Variant Viruses (H3N2v)

Influenza A H3N2v is a non-human influenza virus that normally circulates in pigs. In 2011, a small number of humans were found to be infected with this virus. From 2011 to 2013, a total of 340 cases of H3N2v was identified in 13 states, resulting in 17 hospitalizations and one death. Most of these cases occured in the summer months, and most reported contact with pigs. Symptoms and severity of H3N2v infections in humans resemble that of seasonal influenza, and include fever, cough, sore throat, body aches, and headache. No cases have been identified at this time for 2014, and no cases in North Dakota have ever been reported.

On July 31, 2014 it was reported that three pigs at the 2014 North Dakota State Fair had been removed for illness and had tested positive for an H3N2 virus. The North Dakota Department of Agriculture put out the following news release:

North Dakota Department of Agriculture
July 31, 2014

For immediate release

Precautions advised regarding influenza

BISMARCK – The North Dakota Department of Agriculture (NDDA) and North Dakota Department of Health (NDDoH) received results from the National Veterinary Services Laboratory confirming that three pigs exhibited at the state fair in Minot have tested positive for an influenza A H3N2 virus strain. Although influenza can be passed from swine to people, there is no evidence at this time that any people have become ill as a result of exposure to these pigs.

NDDA animal health division staff inspects all animals displayed at the North Dakota State Fair. The pigs appeared healthy when they arrived at the fair and became ill thereafter. After being tested, they were removed from the fairgrounds by their owners at the recommendation of veterinarians. This is the first time that an influenza virus has been confirmed in swine at a fair in North Dakota.

“Fairs and exhibits are an excellent way to showcase livestock and expose the public to animal agriculture production,” said Agriculture Commissioner Doug Goehring. “When appropriate precautions are taken, there is minimal risk of spreading disease to the public.”

However, some influenza viruses can spread from pigs to people and from people to pigs. Spread from infected pigs to humans is thought to happen in the same way that seasonal influenza viruses spread between people; mainly through infected respiratory droplets created when an infected pig coughs. Swine influenza has not been shown to be transmissible to people through eating properly handled and prepared pork or other products derived from pigs.

According to the NDDoH, appropriate precautions to prevent the spread of influenza from pigs to people include the same types of measures used to prevent the spread of influenza between people; frequent hand washing and avoiding contact with those that are ill. Other precautions include not eating or drinking around animals and avoiding contact with material, such as bedding material, which has been in contact with pigs. Any exhibitor or visitor at high risk of serious flu complications, who is planning to attend a fair where pigs will be present, should consider avoiding pigs and swine barns. The NDDoH also encourages those who work with pigs to take precautions to avoid the spread of illness. Use masks and gloves when you work with ill animals to protect yourself against transfer of the virus.

“Washing hands prior to working with or handling animals and likewise after working with animals is a good practice,” State Veterinarian, Dr. Susan Keller said. “Swine producers should contact their veterinarians if they have any questions about influenza-like illnesses in their pigs. Vaccines are available that may prevent illness.”

According to the NDDoH, if you experience symptoms of influenza (fever, cough, sore throat, body aches, headache) after contact with animals, report that contact to your primary health care provider. Conversely, if you have influenza, avoid contact with pigs during your illness and for another week after symptoms have disappeared.

For more information about influenza, including the H3N2v flu, visit the health department’s influenza website at or call the North Dakota Department of Health at 701-328-2378. For recommendations for swine producers, visit the NDDA website at or call the State Veterinarian’s office at 701-328-2655.



Although only 19 swine variant flu infections were reported last year,  in 2012 more that 300 cases were reported, with nearly all linked to fairgoers, mostly in Indiana & Ohio.  Given the limits of surveillance, and the likelihood that some number of mild or asymptomatic cases went undetected, both numbers probably under represent the true incidence of the disease.

Nevertheless, these swine variant viruses do no yet appear ready for prime time, as they have yet to show signs of sustained and efficient transmission in the community.  


They do, however, bear watching as research has shown only limited community immunity to these variant strains (see CIDRAP: Children & Middle-Aged Most Susceptible To H3N2v).

Thursday, July 31, 2014

CDC Statement On Travel Warnings & Ebola Situation In West Africa


Credit CDC Ebola Outbreak Website


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In concert with today’s press conference, and travel warnings, the CDC has released the following statement on the Ebola situation – and their response – in Western Africa.



As West Africa Ebola outbreak worsens, CDC issues Level 3 Travel Warning

CDC surge scaling up response in Guinea, Sierra Leone, and Liberia

The Centers for Disease Control and Prevention (CDC) today issued a warning to avoid nonessential travel to the West African nations of Guinea, Liberia, and Sierra Leone. This Level 3 travel warning is a reflection of the worsening Ebola outbreak in this region.

CDC is rapidly increasing its ongoing efforts in the three nations. CDC disease detectives and other staff are on the ground:

  • Tracking the epidemic including using real-time data to improve response
  • Improving case finding
  • Improving contact tracing
  • Improving infection control
  • Improving health communication
  • Advising embassies
  • Coordinating with the World Health Organization (WHO) and other partners
  • Strengthening Ministries of Health and helping them establish emergency management systems

“This is the biggest and most complex Ebola outbreak in history. Far too many lives have been lost already,” said CDC Director Tom Frieden, M.D., M.P.H. “It will take many months, and it won’t be easy, but Ebola can be stopped. We know what needs to be done. CDC is surging our response, sending 50 additional disease control experts to the region in the next 30 days.”

CDC expects its efforts not only to help bring the current outbreak under control, but to leave behind stronger systems to prevent, detect and stop Ebola and other outbreaks before they spread.

In addition to warning travelers to avoid going to the region, CDC is also assisting with active screening and education efforts on the ground in West Africa to prevent sick travelers from getting on planes. On the remote possibility that they do, CDC has protocols in place to protect against further spread of disease. These include notification to CDC of ill passengers on a plane before arrival, investigation of ill travelers, and, if necessary, quarantine. CDC also provides guidance to airlines for managing ill passengers and crew and for disinfecting aircraft. Earlier this week, CDC issued a Health Alert Notice reminding U.S. healthcare workers of the importance of taking steps to prevent the spread of this virus, how to test and isolate suspected patients and how they can protect themselves from infection.

At this time, CDC and its partners at points of entry are not screening passengers traveling from the affected countries. It is important to note that Ebola is not contagious until symptoms appear, and that transmission is through direct contact of bodily fluids of an infected, symptomatic person or exposure to objects like needles that have been contaminated with infected secretions.

Over the next five years the United States has committed to working with at least 30 partner countries (totaling at least 4 billion people) to improve their ability to prevent, detect, and effectively respond to infectious disease threats -- whether naturally occurring or caused by accidental or intentional release of pathogens.

Improving these capabilities for each nation improves health security for all nations. Stopping outbreaks where they occur is the most effective and least expensive way to protect people’s health.

The President’s FY 2015 budget includes a request of $45 million to fund this global health security effort.

CDC: U.S. Issues Travel Warning To West African Nations With Ebola



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Although the CDC updated their Ebola travel advisories (Alert Level 2, Practice Enhanced Precautions) to Guinea, Sierra Leone and Liberia on Monday – today CDC Director Thomas Frieden announced an escalation to a Warning Level 3, Avoid Nonessential Travel – during a press conference.


While exposure to Ebola is a concern in these countries, the degradation of overall medical services in the region due to the Ebola outbreak was also cited as a reason for the decision to raise the alert level.


As of this posting, this travel warning has not been posted on the CDC’s Travel Health Notices website.

UPDATED 1415 hrs:



In describing the situation, Director Frieden stated that Ebola is worsening in Western Africa, and there are no quick or easy solutions, given the challenges in the region.  This outbreak is likely to continue for months to come, and the CDC is preparing to send 50 EIS (Epidemic Intelligence Service) officers to the region in the next month.

While the CDC is preparing for the possibility that an infected individual might arrive in this country via air travel (see CDC Teleconference & HAN Notice On Ebola), they also reassure that any significant spread in this country is unlikely due to its limited transmissibility, and our public health infrastructure.


Dr Frieden ended by stressing three key points (paraphrased).


    • Ebola is worsening in West Africa.  It is the largest and most complex outbreak known to date. 
    • CDC is surging their response in West Africa, and while it won’t be quick ot easy, they know what it takes to stop Ebola.  It will nr a marathon, not a sprint, and it will take 3 to 6 months . . . assuming things go right.
    • We have strong systems in place to detect, isolate, and treat Ebola cases should they show up in the United States.


The CDC will likely have a transcript, and audio recording, from today’s teleconference posted on this website later today.