Modest Fissure Eruption Near Bárðarbunga

Source Icelandic Met Office 

 

UPDATED:  See update at bottom.

 

# 9022

 

The on again, off again RED aviation alert for the Bárðarbunga volcano is on again after a 1.5 km long fissure eruption overnight, but right now it is impossible to know just how disruptive this event is likely to become.  That said, this  eruption appears to be much larger than the small fissure eruption on Friday.

 

For now, a long dyke of sub-surface magma stretches north from the volcano to Askja to the north, which is now on Yellow Alert.

 

A tweet from a team on site from the University of Iceland describes the event:

 

An Olympic-sized pool contains about 2500 cubic meters of water, so the estimated lava flow at this time would fill about 24 pools a minute, or 1440 pools an hour.  Impressive, but at this time, this eruption appears to be smooth, non-explosive, and producing little or no ash.

The Icelandic Met Office – which warned yesterday that an eruption appeared more likely – describes the overnight event as:

 

31st August 2014 08:40 - Eruption in Holuhraun observed 05:15

Observation from scientists in the field (05:15): It appears that the eruptive fissure is longer than in the last eruption. It is extending north and south on the same fissure. The eruption is a very calm lava eruption and can hardly be seen on seismometers (almost no gosórói). Visual observation confirm it is calm, but continuous.

 

Several of the webcams monitoring the event I’ve mentioned in the past appear to be offline right now, but you can watch live (from a distance) on this webcam.

 

Seismic activity in and around  Bárðarbunga continues, with a M5.1 reported within the past hour.

We should see an update from the

Scientific Advisory Board of the Icelandic Civil Protection later today.  Yesterday a fissure eruption was deemed one of the more likely scenarios, although an explosive eruption of Bárðarbunga could not be discounted.

Stay tuned.

UPDATE:  1100 hrs EDT

Although weather conditions are hindering observations, the Scientific Advisory board has released the following update:

 

31st August 2014 12:07 - from the Scientific Advisory Board

Scientists from the Icelandic Met Office and the Institute of Earth Sciences and representatives of the Civil Protection in Iceland attend the meetings of the Scientific Advisory Board of the Icelandic Civil Protection.

Conclusions of the Scientific Advisory Board of the Icelandic Civil Protection:

• A lava eruption started in Holuhraun shortly after 04 AM, on the same volcanic fissure, which erupted earlier this week. The fissure is estimated to be 1,5 km long. It was detected on Míla´s web-camera at 05:51 AM. Fewer earthquakes seem to follow the event than in the previous eruption, but more lava is being extruded.
• At 07 AM the lava flow was around 1 km wide and 3 km long towards northeast. The thickness was estimated a few meters, the flow about 1000 m³ pr second.
• Approximately 500 earthquakes were detected in the area and smaller than before. The strongest earthquake, M3.8 was in the Bárðarbunga caldera. Poor weather conditions prevail in the area, which makes detection of smaller earthquakes difficult.
• GPS measurements show continued movements north of Dyngjujökull.
• Gas emissions rise to a few hundred meters above the fissure.
• Weather conditions make it difficult to follow the progression of the eruption, but scientists are in the area, using every opportunity to acquire information on gas and lava outflow.
• Weather conditions do not allow overflight at this time. The opportunity to fly over the area will be assessed later today.

From the Icelandic Met Office:

The Aviation Colour Code for Bárðarbunga is at ‘red' and the code for Askja at ‘yellow'.

I would note that the latest Aviation Color code map has just recently been changed back to Orange.

Mackay On Ebola: Blood, Sweat & Tears

Credit CDC PHIL

 

# 9022

 

 

Ian Mackay, in a follow up to his seminal post on Ebola ten days ago, writes today on the level of EBOV detection (often via RNA, or Antigens) in various human body fluids. 

 

While the blood of  viremic patients is infamously teeming with the virus, Ian describes the (somewhat limited) research to date on the level of EBOV detection in other body fluids – like tears, sweat and saliva.

 

Although the level of EBOV detection in these fluids have been far lower –and  often even undetectable -  given the believed low infectious dose for contracting viral hemorrhagic fevers and the likely variability of virus shedding across numerous cases, any hint of the virus in these body fluids is deserving of our attention and respect.

 

Follow the link to read.

 

Sunday, 31 August 2014

Ebola: Blood, sweat and tears...

This post follows up the recent one on convalescent semen being able to harbour infectious Ebola virus (EBOV; although I am not aware of any infection resulting from this route of transmission there has been at least one report for Marburg virus [4]).

I thought I'd give the same treatment to tears and sweat which are also fluids intermittently listed as possible sources of EBOV infection for humans. Some examples of the scientific literature which support the risk messaging, follow.

(Continue . . .)

WHO Update & Timeline On Senegal’s 1st Ebola Case

 

 

# 9022

 

On Friday we learned that a fifth African nation had been touched by the Ebola outbreak in Senegal Reports 1st Imported Case Of Ebola.  Initial details were sketchy, particularly concerning the timing of the index cases' arrival and diagnosis.

 

Today the World Health Organization has released an update that, unfortunately, shows this patient was symptomatic, and living with relatives in Dakar for several days before being admitted to the hospital.

 

All of which makes the identification and observation of all of this patient’s contacts during that period of paramount importance. It also appears that this person entered the country prior to last week’s (Aug. 21st) border closing with Guinea.

 

WHO Ebola Disease Outbreak News: Senegal

30/08/2014

Epidemiology and surveillance

On 30 August 2014, Senegal’s Ministry of Public Health and Social Affairs provided WHO with details about a case of Ebola virus disease (EVD) announced in that country on 29 August.

WHO has also received details of the emergency investigation immediately launched by the Government. Testing and confirmation of Ebola were undertaken by a laboratory at the Institut Pasteur in Dakar.

The case is a 21-year-old male native of Guinea, who arrived in Dakar, by road, on 20 August and stayed with relatives at a home in the outskirts of the city.

On 23 August, he sought medical care for symptoms that included fever, diarrhoea, and vomiting. He received treatment for malaria, but did not improve and left the facility.

After leaving the facility, he continued to reside with his relatives. Though the investigation is in its early stages, he is not presently known to have travelled elsewhere.

On 26 August, he was referred to a specialized facility for infectious diseases, still showing the same symptoms, and was hospitalized.

On 27 August, authorities in Conakry, Guinea, issued an alert, informing medical services in Guinea and neighbouring countries, that a person, who was a close contact of a confirmed EVD patient, had escaped the surveillance system.

That alert prompted testing at the Dakar laboratory, launched an investigation, and triggered urgent contact tracing.

Health sector response

WHO is treating this first case in Senegal as a top priority emergency. Key operational personnel were dispatched to Dakar today; others will follow.

The Government of Senegal has informed WHO of the urgent need for epidemiological support, personal protective equipment, and hygiene kits. These needs will be met with the fastest possible speed.

PAHO/WHO: Epidemiological Alert On Chikungunya & Dengue In the Americas

 

 

# 9020

 

While Ebola garners the bulk of the headlines, other serious disease threats like Chikungunya and Dengue continue their inexorable spread across the globe, infecting hundreds of times more people than does Ebola, albeit with a far lower morality rate.   

 

For 2013, PAHO provides the following assessment for Dengue in the Americas:

 

In 2013, dengue behaved like a classic epidemic for the Americas region, with the largest historical cases reported. In total, countries in the Americas reported more than 2.3 million cases of dengue, with 37,692 cases of severe dengue and 1,280 deaths, for a mortality rate of about 0.05%.

 

This year, for the first time, the Americas are also dealing with Chikungunya – which arrived late last fall in the Caribbean, and has spread rapidly since then.  PAHO’s most recent report (Week 34) indicates just over 650,000 CHKV infections in the Americas, and 37 deaths.

 

The arrival of Chikungunya to the Americas has been anticipated for some time, and the CDC & PAHO produced a 161 page guide on preparing for its arrival 3 years ago (see Preparedness and Response for Chikungunya Virus Introduction in the Americas).

 

Last May, in Florida Prepares For Chikungunya we looked at local preparations for its arrival.  Given its climate, its position as the gateway to the Caribbean, and that it receives millions of tourists every year -  Florida was considered a likely first US battleground against any CHKV invasion.  

 

And indeed, the first first locally acquired case in Florida was reported in July.

 

For now, the major concern is in the Caribbean, Central & South America where both Dengue and CHKV co-circulate, and where the burden of these diseases is infinitely higher than it is in the United States. As the height of the Dengue season generally occurs in the second half the year, the next few months are considered a critical time for mosquito control programs.

 

Yesterday PAHO and the World Health Organization released an 8-page PDF Epidemiological Alert for the Americas on these co-circulating mosquito-borne diseases.  Follow the link to read the entire document:

 

Epidemiological Alert

Chikungunya & Dengue Fever In the Americas

29 August 2014

Situation summary

The first evidence of autochthonous chikungunya transmission in the Americas was recorded in December 2013, since then, autochthonous transmission has been detected in 33 countries and territories of the Americas (27 countries and territories in the Caribbean, 3 countries in Central America, 1 country and 1 territory in South America and 1 country in North America).1,2 As of epidemiological week (EW) 35 of 2014, the Pan American Health Organization / World Health Organization (PAHO/WHO) has been informed of a total of 659,367 cases, including 37 deaths, in the Americas.

Usually during the second semester of the year, Central America, Mexico and the Caribbean experience a seasonal increase in dengue fever transmission. Currently, the Dominican Republic, El Salvador, Guatemala, and Honduras, are recording increases in cases coinciding with this period of greater transmission.

The threats posed by the seasonal increase of dengue transmission and the introduction, or risks of introduction of the chikungunya virus in the Region require an integrated approach of prevention and vector control activities of both diseases. With the rapid spread of the chikungunya virus observed in some countries of the Americas, simultaneous dengue and chikungunya outbreaks may occur, which would result in increased health care demand. Accordingly, health care services must be prepared to meet expected increased demand without compromising quality of care; preparations should be guided by the PAHO/WHO recommendations for clinical management of patients with dengue or chikungunya.
 

(Continue . . . . .)

 

 

With the rapid expansion of both Dengue and Chikungunya around the globe, Europe and the United States are seeing signifcant increases in the number of imported cases every year – each with at least the potential to seed local mosquito populations with the virus. So far locally acquired infections in both regions remain relatively rare.

 

The lack of an abundant non-human animal reservoir for the virus is likely partly responsible. But in 2003, a CDC EID study also found that economics and lifestyle may have a lot to do to with our lack of locally transmitted Dengue (see Texas Lifestyle Limits Transmission of Dengue Virus).

 

But given the availability of two competent mosquito vectors (Aedes Aegypti & Aedes Albopictus), and repeated introductions of the virus from travelers coming from regions where the virus is endemic, our luck in this matter may not last forever.

 

The good news is that these mosquito-borne illnesses (and others, including WNV, SLEV, EEE, etc.) are largely preventable.

 

Florida’s Health department reminds people to always follow the `5 D’s’:

Referral: Mackay On The Expansion Of Ebola Into Senegal

Credit Dr. Ian Mackay VDU Blog

 

# 9019

 

In his blog overnight, Dr. Ian Mackay adds Senegal to his Ebola outbreak map, and makes an important point about the uniqueness of each disease outbreak, the human variables that drive them, and the danger of assuming that the public health responses of the past will always suffice in the future.

 

First a link to Ian’s blog, then I’ll be back with a comment.

 

The fifth I give you...

Senegal.

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

Interesting that this occurred one week after Senegal closed its borders (again) with Guinea.[3,4] The infected Guinean student travelled on 29-August to Dakar where he presented to a hospital but did not admit to being in contact with known EVD cases. Senegal had closed its borders around 22-August.[5,6].

 

(Continue . . . )

 

 

After forty years of outbreaks – all of which were geographically limited and comparatively small – Ebola had gained the reputation of being a horrific killer – but basically only of `local concern’. 

 

Conventional wisdom said that it killed too quickly to allow those infected to spread the disease far. The virus simply didn’t have the `legs’ to spark a major outbreak.

 

Fast forward to 2014, and those assumptions are taking it on the chin.  Not because the virus has changed, but because Africa has changed (a major point made in Michael Osterholm’s WaPo Article  Aug. 1st).  

 

Remote villages aren’t nearly as remote as they once were. Cars, busses, trains, even airplanes are far more common today in Africa than they were in 1976 when the virus was first detected.  Society is more mobile today than ever before, and that applies to just about everywhere on this planet.

 

The world was caught flat-footed in its initial response to this Ebola outbreak – no doubt lulled by earlier successes in containing the virus -  and that has allowed it to spread unchecked. Given its lack of `airborne’ transmission, I fully expect it will eventually be brought under control, albeit at a terrible cost. 

 

The takeaway lesson here goes beyond Ebola, and well beyond the continent of Africa.

 

As the world changes, so do the capabilities of its pathogens. A side effect of modern society is that it has become the great enabler of infectious disease.  A novel virus or resistant bacteria can hitch a ride in New Delhi or Shanghai this morning and can be in London, or New York by tonight.

 

Which means that we no longer have the luxury of ignoring `small disease outbreaks’  anywhere in the world, no matter how remote. 

 

Because the next pathogen to crawl out of the woodwork may be far more `pandemic-ready’  than Ebola could ever be. 

Nature: 100% Of Ebola Infected Macaques Recovered With ZMapp

 

 

# 9018

 

 

The wires are buzzing this afternoon with details on a freshly published study in the Journal Nature that looks at the outcome of 21 Ebola-infected Rhesus Macaques – 18 of which received the ZMapp monoclonal antibody cocktail. Incredibly, 100% of the treated monkeys – even those treated 5 days post exposure and already symptomatic – recovered.

 

First a link to the study, then I’ll be back with more.

 

Reversion of advanced Ebola virus disease in nonhuman primates with ZMapp

Xiangguo Qiu, Gary Wong, Jonathan Audet, Alexander Bello, Lisa Fernando, Judie B. Alimonti, Hugues  Fausther-Bovendo, Haiyan Wei, Jenna Aviles, Ernie Hiatt, Ashley Johnson, Josh Morton,  Kelsi Swope, Ognian Bohorov, Natasha Bohorova, Charles Goodman, Do Kim, Michael H. Pauly, Jesus Velasco, James Pettitt, Gene G. Olinger, Kevin Whaley, Bianli Xu, James E. Strong, Larry Zeitlin et al.

 (2014) doi:10.1038/nature13777

Published online 29 August 2014

ABSTRACT

Without an approved vaccine or treatment, Ebola outbreak management has been limited to palliative care and barrier methods to prevent transmission. These approaches, however, have yet to end the 2014 outbreak of Ebola after its prolonged presence in West Africa. Here we show that a combination of monoclonal antibodies (ZMapp), optimized from two previous antibody cocktails, is able to rescue 100% of rhesus macaques when treatment is initiated up to 5 days post-challenge. High fever, viraemia and abnormalities in blood count and blood chemistry were evident in many animals before ZMapp intervention. Advanced disease, as indicated by elevated liver enzymes, mucosal haemorrhages and generalized petechia could be reversed, leading to full recovery. ELISA and neutralizing antibody assays indicate that ZMapp is cross-reactive with the Guinean variant of Ebola. ZMapp exceeds the efficacy of any other therapeutics described so far, and results warrant further development of this cocktail for clinical use.

(Continue . . . )

 

Quite simply, a remarkable success rate by any measure. And while you can’t guarantee you’d see the same kind of results in human patients, it is highly encouraging.

 

That said, this news must also be tempered by fact that the existing limited supply of ZMapp has been exhausted, and it is expected that it will take weeks or even months to produce even a small quantity of the drug.

 

A pair of reports on this from two of the best science writers in the business. First this from Maggie Fox of NBC news.

 

ZMapp Saves Sick Monkeys From Ebola, Study Finds

By Maggie Fox

An experimental treatment used to treat two sick American missionaries saved a batch of monkeys infected with Ebola virus, even days after they got sick, researchers reported on Friday.

What works in monkeys doesn’t always work in humans, but it’s a piece of good news for the makers of ZMapp, a cocktail of engineered antibodies meant to boost the body’s defenses against the virus. ZMapp, made by California-based Mapp Biopharmaceutical, is grown in tobacco plants and is meant to improve on an old-fashioned approach that uses transfusions of blood from people who have survived an infection.

(Continue . . . )

 

 

And this from Helen Branswell of the Canadian Press.

 

Winnipeg lab created, tested Ebola drug ZMapp

By Helen Branswell The Canadian Press

 TORONTO – The experimental Ebola drug ZMapp was able to save infected monkeys even when treatment was only begun five days after the animals were infected, a new study shows.

This is the first research to demonstrate that an Ebola therapy could save primates if given so late in the course of their illness — a circumstance that more closely reflects how an Ebola drug would be used in people in an outbreak.

(Continue . . .)

 

For more on ZMapp you may wish to revisit  CDC FAQ On Experimental Ebola Treatments & Vaccine Development.

Senegal Reports 1st Imported Case Of Ebola

UPDATED: 10:00 Hrs EDT

 

The AP is now reporting this patient is a young man who appears to have been the subject of epidemiological surveillance team who were doing contact tracing of Ebola cases in Guinea, but he evaded them and crossed the border into Senegal. 

The patient sought medical care earlier this week in Dakar after falling ill, and told doctors he’d had contact with Ebola cases. His tests have come back positive for the virus and the WHO have been notified. 

 

 

# 9017

 

 

Senegal, which last week Closed its Border With Guinea Over Ebola Concerns, is reporting this morning an important case in a visitor from Guinea. Details at this time are scant,  and I’ve found nothing posted on the Senegalese Ministry Of Health website.

Gert van der Hoek on Flutrackers has translated article from PressAfrik

 

Urgent - the Senegal recorded his first Ebola case

This is confirmed Senegal recorded its first case of Ebola patient. This is a Guinean national who is on vacation on our soil. He is currently detained at the Department of Infectious Diseases Fann. The Minister of Health, Awa Marie Coll Seck will soon give the details of this unfortunate news.

(Continue . . .)

The following report from Reuters is fairly representative of what is currently in the English press.

  

First case of Ebola confirmed in Senegal - health minister

Fri Aug 29, 2014 12:31pm GMT

 

DAKAR Aug 29 (Reuters) - The first case of Ebola has been confirmed in Senegal, a major hub for the business and aid community in West Africa, Health Minister Awa Marie Coll Seck told a news conference on Friday.

The minister said the case was a Guinean national who had arrived from the neighbouring West African country, where the deadly virus was first detected in March. (Reporting by Diadie Ba; Writing by Daniel Flynn; Editing by Emma Farge)

I’ll update this story as more information comes in.

WHO: Ebola Response Roadmap Situation Report # 1

# 9017

 

This morning the World Health Organization has released as 7 page PDF SitRep (Situation Report) on the Ebola Outbreak in Western Africa.   This comes one day after releasing their Ebola Response Roadmap, which calls for a massive international effort and nearly 500 million dollars to respond to the crisis.

 

A few excerpts from the report, but follow the link to download and read it in its entirety.

 

 

WHO: Ebola Response Roadmap Situation Report 1

29 August 2014

(Excerpt)

The figures below show the distribution of confirmed and probable cases in each of these countries, accompanied by numbers of cases over time in capital cities.

GUINEA

These data indicate that the reporting of cases in Guinea appears to have been relatively stable, but with a marked increase in the recent week. Priorities continue to be to reduce incidence in the epicentre (Gueckedou), and to address threatening foci in Conakry.
LIBERIA

LIBERIA

By contrast, in Liberia, cases are increasing in the epicentre (Lofa) and in the capital, Monrovia.

SIERRA LEONE

The incidence of cases in Sierra Leone has been relatively flat, although with increases in the past week. Problems in scaling up response measures persist, notably in two districts, Kenema and Kailahun. Numbers of cases increased in the capital, Freetown.

 

Regarding Nigeria, the news yesterday that two new cases (1 confirmed, 1 suspected) had turned up in Port Harcourt means that containment of the virus has yet to be accomplished.

 

COUNTRIES WITH AN INITIAL CASE OR CASES, OR WITH LOCALIZED TRANSMISSION

To date, the only country with cases linked to a case imported from a country with widespread and intense transmission is Nigeria. The table below shows the distribution of cases in that country.

 

The first 14 confirmed cases were all linked to persons, including health care workers, in close contact with an air traveller from Liberia, who entered Lagos on 20 July and died five days later. On 27 August, 1 additional case was confirmed in Port Harcourt by the Ministry of Health. A Ministry of Health and WHO team is in Port Harcourt supporting contact tracing and further investigation of the incident.

 

And lastly, a look at some of the response challenges on the ground.

 

There are serious problems with case management and infection prevention and control. The situation is worsening in Liberia and Sierra Leone.

• In Guinea, the capacity to manage the current load of EVD cases is currently adequate in Gueckedou and in Conakry.
• In Liberia, the capacity to cope with the increasing caseload remains dramatically low, especially in the capital, Monrovia, as well as in Bong and Nimba counties.
• In Nigeria, a 40-bed isolation unit has been set up in the Mainland Hospital, and is sufficient to accommodate the patients currently isolated. The Ministry of Health has set up an isolation unit in Lagos town to care for cases.
• In Sierra Leone, there is inadequate capacity to accommodate patients in Freetown. Patients must be transferred to Kenema, which is already overwhelmed by local demand.
• Health care workers continue to be seriously affected in all countries, especially in Liberia and Nigeria.
  

Laboratory capacity

In Guinea, laboratory capacity currently appears to be sufficient. Support is being provided by the Pasteur Institute Dakar in Conakry, the European Union Mobile Laboratory in Gueckedou, and WHO.

• In Liberia, specimens from Lofa county are tested in Guinea. Additional laboratory support is needed in Lofa to alleviate this burden. Specimens from other counties far from Lofa are sent to Monrovia, where laboratory capacity, supported by the United States Army Medical Research Institute of Infectious Diseases, US National Institutes of Health, and US Centers for Disease Control and Prevention, is stretched. The need for more laboratory support is being assessed in Bong (Pheebe hospital), Nimba and Bomi counties.
  
• In Sierra Leone, additional laboratory support is needed in addition to the Kenema laboratory (supported by Metabiota and the US Department of Defense Critical Reagent Team) to cope with the increasing disease burden. A mobile laboratory from South Africa has been deployed to Freetown, where Ebola treatment centres are being constructed to care for patients locally and in better conditions, rather than referring them to Kenema.
  
• In Nigeria, the Lagos University Teaching Hospital virology lab and the Lagos University Laboratory are being supported by WHO and an EU mobile team from the WHO Collaborating Centre in Hamburg, Germany.
  

 

Kansas City Outbreak Identified As HEV 68

Credit CDC – Non Polio-Enteroviruses

 

See Update Sept 6th:  Enterovirus D-68 (HEV-D68) Update

 

# 9016

 

Local media reports (see Unusual respiratory virus strikes metro kids) from Kansas City, Mo. indicate that a rarely seen – and not yet well understood – respiratory virus called HEV 68 (Human Enterovirus 68) has sickened hundreds of kids in the region this week, and that the local Children’s Hospital is unusually at full census in late August.

Without specifying the pathogen, Children’s Mercy Hospital posted the following notice yesterday on their website: Viruses in the Community Prompt Inpatient Visiting Restrictions.

 

I’ve checked the local and state Health departments but can find no official statement regarding this respiratory outbreak.  Hopefully we’ll get some official confirmation soon, but assuming local media reports are correct . . .

 

Enteroviruses encompass a large family of small RNA viruses that include the three Polioviruses, along with myriad non-polio serotypes of Human Rhinovirus, Coxsackievirus, echovirus, and human, porcine, and simian enteroviruses.  We’ve looked at EV-71 and the Coxsackieviruses on numerous occasions in regards to AFP (Acute Flaccid Paralysis) and HFMD (see here,  here & here).

 

According to the CDC  Non-Polio Enteroviruses (NPEVs) cause 10 to 15 million – mostly mild and often asymptomatic – infections in the United States each year, primarily among infants, children, and teenagers. Fever, runny nose, sneezing, coughing, a skin rash or mouth blisters, and body and muscle aches are the most commonly reported symptoms.

 

First isolated in 1962, EV 68 (genus Enterovirus - family Picornaviridae – species HEV-D) has only rarely been identified over the years.  In 2011 – in MMWR: Clusters Of HEV68 Respiratory Infections 2008-2010 – we looked at a half dozen  HV 68 associated clusters which occurred in Asia, Europe, and the United States during 2008--2010.

A few excerpts from that report:

 

HEV68 infection was associated with respiratory illness ranging from relatively mild illness that did not require hospitalization to severe illness requiring intensive care and mechanical ventilation. Three cases, two in the Philippines and one in Japan, were fatal. In these six clusters, HEV68 disproportionately occurred among children.

<SNIP>

This report highlights HEV68 as an increasingly recognized cause of respiratory illness. Clinicians should be aware of HEV68 as one of many causes of viral respiratory disease and should report clusters of unexplained respiratory illness to the appropriate public health agency.

<SNIP>

The spectrum of illness caused by HEV68 remains unclear. HEV68, like other enteroviruses, has been associated with central nervous system disease (9). Further investigation could help clarify the epidemiology and spectrum of disease caused by HEV68. Some diagnostic tests might not detect HEV68 or might misidentify it as an HRV

Unlike influenza, classic enteroviruses tend to break out in summer-to-fall, although EV 68 has been observed to occur well into the winter season. The largest outbreak characterized by this MMWR report involved 28 children and adolescents from Pennsylvania in the fall of 2009. 

Since the vast majority of  mild-to-moderate respiratory infections are never tested, the actual incidence of this viral infection isn’t well understood, but it tends to be among the least commonly identified enteroviruses.

 

In recent years, with advances in microbiology and sequence-independent amplification of viral genomes, the ability of laboratories to identify new or rarely seen viruses has steadily improved, and so it is hard to know whether these recent clusters indicate that the incidence of EV 68 is increasing, or they are a result of better surveillance and testing.

 

Unlike other enteroviruses which can produce a wide spectrum of respiratory, gastrointestinal, and neurological symptoms – EV 68 is mainly associated with respiratory symptoms – although it was tentatively linked to two of five children (see Acute Flaccid Paralysis Cases In California) who developed a rare polio-like syndrome last winter.

 

Whether EV-68 was actually the cause of these paralysis cases, or simply an incidental finding, is something that will require more research to establish.

 

Although there is no vaccine and no specific treatment for this virus, there are things that can be done to protect yourself.  In addition to the standard `flu’ etiquette urged every year (hand washing, covering coughs, sneezes, staying home when sick), the CDC’s recommendations to prevent NPEV transmission include:

 

You can help protect yourself and others from non-polio enterovirus infections by—

• Washing your hands often with soap and water, especially after using the toilet and changing diapers,
• Avoiding close contact, such as touching and shaking hands, with people who are sick, and
• Cleaning and disinfecting frequently touched surfaces.

According to Dr. Mary Anne Jackson, an infectious disease specialist interviewed yesterday by local media, roughly 10%-15% of the children currently affected in Kansas City are experiencing serious illness, and that it is hitting kids with asthma particularly hard.

 

With schools just letting in for the fall, we’ll want to keep a close eye on this outbreak to see how it progresses, and if it spreads to other areas of the country.

Study: Ebola Virus Is Rapidly Evolving

Credit CDC PHIL

 

# 9015

 

One of the concerns we have when any zoonotic virus spills over into the human population is that over time, as it passes from one person to the next, it could pick up host adaptations – mutations – that could make the virus a greater threat over time.

 

In the laboratory, researchers will often conduct serial passage experiments (see Serial Passage Of H5N2 In Mice) to observe these evolutionary changes, and try to figure out what they mean.

 

Often, these genetic changes are of little or no effect, and can sometimes even be detrimental to the `biological fitness’ of the virus. Those that favor replication in the new found host, however, tend to carry on to produce more progeny, advancing their new lineage forward,  drowning out the earlier `wild type’ virus in the host.

 

A recent concern has been that Ebola - which up until now has never really spread in kind of long chains of human cases that we are seeing now – could better adapt to human physiology over time.

 

Today we’ve a study appearing in the Journal Science where scientists sequenced 99 Ebola viruses taken from 78 people from Sierra Leone during the month of June, and found that the virus is showing a marked propensity to accumulate `interhost and intrahost genetic variation’ as it passages through the population.

 

First a bit from the study, then I’ll be back with more.

Published Online August 28 2014

Science DOI: 10.1126/science.1259657

Genomic surveillance elucidates Ebola virus origin and transmission during the 2014 outbreak

Stephen K. Gire¹,²,*, Augustine Goba³,*,†, Kristian G. Andersen¹,²,*,†, Rachel S. G. Sealfon²,⁴,*, Daniel J. Park²,*, Lansana Kanneh³, Simbirie Jalloh³, Mambu Momoh³,⁵, Mohamed Fullah³,⁵,‡, Gytis Dudas⁶, Shirlee Wohl¹,²,⁷, Lina M. Moses⁸, Nathan L. Yozwiak¹,², Sarah Winnicki¹,², Christian B. Matranga², Christine M. Malboeuf², James Qu², Adrianne D. Gladden², Stephen F. Schaffner¹,², Xiao Yang², Pan-Pan Jiang¹,², Mahan Nekoui¹,², Andres Colubri¹, Moinya Ruth Coomber³, Mbalu Fonnie³,‡, Alex Moigboi³,‡, Michael Gbakie³, Fatima K. Kamara³, Veronica Tucker³, Edwin Konuwa³, Sidiki Saffa³, Josephine Sellu³, Abdul Azziz Jalloh³, Alice Kovoma³,‡, James Koninga³, Ibrahim Mustapha³, Kandeh Kargbo³, Momoh Foday³, Mohamed Yillah³, Franklyn Kanneh³, Willie Robert³, James L. B. Massally³, Sinéad B. Chapman², James Bochicchio², Cheryl Murphy², Chad Nusbaum², Sarah Young², Bruce W. Birren², Donald S. Grant³, John S. Scheiffelin⁸, Eric S. Lander²,⁷,⁹, Christian Happi¹⁰, Sahr M. Gevao¹¹, Andreas Gnirke²,§, Andrew Rambaut⁶,¹²,¹³,§, Robert F. Garry⁸,§, S. Humarr Khan³,‡§, Pardis C. Sabeti¹,²,†§

 

In its largest outbreak, Ebola virus disease is spreading through Guinea, Liberia, Sierra Leone, and Nigeria. We sequenced 99 Ebola virus genomes from 78 patients in Sierra Leone to ~2,000x coverage. We observed a rapid accumulation of interhost and intrahost genetic variation, allowing us to characterize patterns of viral transmission over the initial weeks of the epidemic. This West African variant likely diverged from Middle African lineages ~2004, crossed from Guinea to Sierra Leone in May 2014, and has exhibited sustained human-to-human transmission subsequently, with no evidence of additional zoonotic sources. Since many of the mutations alter protein sequences and other biologically meaningful targets, they should be monitored for impact on diagnostics, vaccines, and therapies critical to outbreak response.

• In Depth Infectious Disease Genomes reveal start of Ebola outbreak

  • Gretchen Vogel
  Science 29 August 2014: 989-990.
  • Summary
  • Full Text
  • Full Text (PDF)

These researchers found that the virus had evolved into three distinct lineages in Sierra Leone during the month of June (one of which appears to have died out), along with accumulating scores of amino acid changes to its genome.

 

It should be noted that while scientists have the ability to sequence and compare these variant viruses, they don’t necessarily know what these individual mutations (or their aggregate) means to the virus, or how it might change its behavior. 

 

Based on the location of some these changes, there are concerns that the PCR primers currently used to detect it patients may need adjusting, and that some of the antiviral drugs being developed could be impacted as well. 

 

And while it is theoretically possible that changes to the genome could affect the transmissibility of the virus, we haven’t seen any evidence of that happening.

 

Unknown at this time are what genetic changes might be occurring in the virus in Liberia and Guinea, or even Nigeria. The bottom line, however, is that the longer this virus circulates in humans, the better chance it has of producing a mutation we really don’t want to see.

 

For some more coverage on this report, NPR’s Goats & Soda Blog has:

 

Ebola Is Rapidly Mutating As It Spreads Across West Africa

by Michaeleen Doucleff

 

 

This from Scientific American:

 

Patient Zero Believed to be Sole Source of Ebola Outbreak

By pinpointing the virus’s source, a new report validates steps health care workers are taking to battle the disease

Aug 28, 2014 |By Dina Fine Maron

And this from Nature News. 

 

Ebola virus mutating rapidly as it spreads

Outbreak likely originated with a single animal-to-human transmission.

UK Govt. Strongly Advises Against Travel To Sierra Leone, Liberia & Guinea

Source OCHA

 

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A change in the advice  by the UK’s Foreign Office today now advises against all but essential travel to the three primary Ebola-stricken nations, and warns that as conditions deteriorate and air service to the region diminishes, it may become increasingly difficult for people to leave.

 

 

Foreign Office Sierra Leone, Guinea and Liberia travel advice update

Published 28 August 2014

The UK has changed its travel advice to Sierra Leone, Guinea and Liberia. Foreign Office advises against all but essential travel to these countries.

The UK advises against all but essential travel to Sierra Leone, Guinea and Liberia due to the ongoing Ebola outbreak and the impact this is having on commercial flights and medical facilities. British Airways have suspended flights to Sierra Leone and Liberia until 31 December due to the deteriorating public health situation and some other airlines have also suspended flights to these countries.

If you are a British national in these countries, you should stay in contact with your employer or host organisation about the support that they can provide to you while you are in the country or should you wish to leave. You should be aware that the narrowing range of commercial flight options and growing restrictions on travel in the region may make it difficult to leave, particularly at short notice, and consider your own plans in this context.

Full travel advice to these countries can be found here.

 

The entry for Liberia reads (in part):

 

Due to the narrowing commercial options for flights and the impact on medical facilities, the FCO advise against all but essential travel to these countries, except for those involved in the direct response to the Ebola outbreak.

 

The CDC has issued strong travel warnings to the region as well, and updated their advice on August 26th.

Updated: August 26, 2014

CDC urges all US residents to avoid nonessential travel to Liberia, Guinea, and Sierra Leone because of unprecedented outbreaks of Ebola in those countries. CDC recommends that travelers to these countries protect themselves by avoiding contact with the blood and body fluids of people who are sick with Ebola.

Warning Level 3, Avoid Nonessential Travel

• Updated Ebola in Sierra Leone Updated August 26, 2014 CDC urges all US residents to avoid nonessential travel to Sierra Leone, Guinea, and Liberia because of unprecedented outbreaks of Ebola in those countries. CDC recommends that travelers to these countries protect themselves by avoiding contact with the blood and body fluids of people who are sick with Ebola. Read More >>
• Updated Ebola in Liberia Updated August 26, 2014 CDC urges all US residents to avoid nonessential travel to Liberia, Guinea, and Sierra Leone because of unprecedented outbreaks of Ebola in those countries. CDC recommends that travelers to these countries protect themselves by avoiding contact with the blood and body fluids of people who are sick with Ebola. Read More >>
• Updated Ebola in Guinea Updated August 26, 2014 CDC urges all US residents to avoid nonessential travel to Guinea, Liberia, and Sierra Leone because of unprecedented outbreaks of Ebola in those countries. CDC recommends that travelers to these countries protect themselves by avoiding contact with the blood and body fluids of people who are sick with Ebola. Read More >>

NIH To Launch Trials On Ebola Vaccine Candidate

Credit CDC PHIL

 

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The story has been filtering through the news wires for a couple of hours, but the embargo has just come off the following NIH press release, which outlines the plans for testing this (and other) experimental vaccine candidates.

 

NIH to Launch Human Safety Study of Ebola Vaccine Candidate

Trial is First in Series of Accelerated Safety Studies of Ebola Vaccines

Embargoed for Release: Thursday, August 28, 2014, 9:30 a.m. EDT

 

Initial human testing of an investigational vaccine to prevent Ebola virus disease will begin next week by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health.

 

The early-stage trial will begin initial human testing of a vaccine co-developed by NIAID and GlaxoSmithKline (GSK) and will evaluate the experimental vaccine’s safety and ability to generate an immune system response in healthy adults. Testing will take place at the NIH Clinical Center in Bethesda, Maryland.

 

The study is the first of several Phase 1 clinical trials that will examine the investigational NIAID/GSK Ebola vaccine and an experimental Ebola vaccine developed by the Public Health Agency of Canada and licensed to NewLink Genetics Corp. The others are to launch in the fall. These trials are conducted in healthy adults who are not infected with Ebola virus to determine if the vaccine is safe and induces an adequate immune response.

 

In parallel, NIH has partnered with a British-based international consortium that includes the Wellcome Trust and Britain’s Medical Research Council and Department for International Development to test the NIAID/GSK vaccine candidate among healthy volunteers in the United Kingdom and in the West African countries of Gambia (after approval from the relevant authorities) and Mali.

 

Additionally, the U.S. Centers for Disease Control and Prevention has initiated discussions with Ministry of Health officials in Nigeria about the prospects for conducting a Phase 1 safety study of the vaccine among healthy adults in that country.

<SNIP>

 

The investigational vaccine now entering Phase 1 trials was designed by Nancy J. Sullivan, Ph.D., chief of the Biodefense Research Section in NIAID’s Vaccine Research Center (VRC). She worked in collaboration with researchers at the VRC, the U.S. Army Medical Research Institute of Infectious Diseases, and Okairos, a Swiss-Italian biotechnology company acquired by GSK in 2013.

 

Phase 1 clinical trials are the first step in what is typically a multi-stage clinical trials process). During Phase 1 studies, researchers test an investigational vaccine in a small group of people to evaluate its safety and the immune response it provokes. Phase 2 clinical trials of investigational vaccines are designed to further assess safety and immune response in larger numbers of volunteers. Under certain circumstances, the vaccine’s ability to prevent infection or disease (called efficacy) can be determined in a Phase 2 trial. Phase 3 clinical trials are directed predominantly at determining efficacy.

 

The NIAID/GSK Ebola vaccine candidate is based on a type of chimpanzee cold virus, called chimp adenovirus type 3 (ChAd3). The adenovirus is used as a carrier, or vector, to deliver segments of genetic material derived from two Ebola virus species: Zaire Ebola and Sudan Ebola. Hence, this vaccine is referred to as a bivalent vaccine. The Zaire species of the virus is responsible for the current Ebola outbreak in West Africa.

 

The vaccine candidate delivers one part of Ebola’s genetic material to human cells, but the adenovirus vector does not replicate. Rather, the Ebola gene that it carries allows the cells of the vaccine recipient to express a single Ebola protein, and that protein prompts an immune response in the individual. It is important to know that the Ebola genetic material contained in the investigational vaccine cannot cause a vaccinated individual to become infected with Ebola.

 

“The experimental NIAID/GSK vaccine performed extremely well in protecting nonhuman primates from Ebola infection,” Dr. Fauci noted.

 

The candidate vaccine builds upon three earlier NIAID-developed investigational Ebola vaccines that began Phase 1 clinical trial testing in 2003.

 

“The knowledge gained from each of those trials has contributed to the development of the candidate vaccine we are now studying, as well as our improved understanding of human immune responses to investigational Ebola vaccines,” said John R. Mascola, M.D., director of NIAID’s Vaccine Research Center.

 

The Phase 1 clinical trial, called VRC 207, will be led by principal investigator Julie E. Ledgerwood, D.O., chief of the VRC’s clinical trials program, and will be conducted among 20 healthy adults ages 18 to 50 years. Participants will be divided into two groups of 10 participants each. One group will receive an intramuscular injection of the NIAID/GSK experimental vaccine. The second group will receive a single injection of the same vaccine but at a higher dose.

 

A number of safety features are built into the study’s design, including daily and weekly reviews of patient data by clinical staff and the study protocol team. Additionally, the trial features a staged enrollment plan that requires interim safety reviews after three participants have been vaccinated and have undergone three days of follow up before enrolling additional study participants into the group. Participants in both groups will be seen and evaluated by clinical staff nine times over a 48-week period.

Additional Phase 1 Tests of the NIAID/GSK Vaccine

As part of the VRC 207 trial, NIAID will also test a version of the NIAID/GSK vaccine that contains genetic material from only the Zaire Ebola species. Hence, this vaccine is referred to as a monovalent vaccine. This portion of the Phase 1 safety study, which will also involve 20 healthy adults, is expected to begin in October at the NIH Clinical Center and potentially another U.S. location. Dr. Ledgerwood will also lead that effort. The VRC 207 clinical trial is being conducted based on expedited review and approval by the U.S. Food and Drug Administration.

 

In parallel, NIH has partnered with an international consortium that includes the British-based Wellcome Trust, as well as Britain’s Medical Research Council and Department for International Development to test the same NIAID/GSK monovalent vaccine candidate. The vaccine candidate will be tested among 60 healthy volunteers at the University of Oxford in England and among 40 healthy volunteers in Mali by the University of Maryland School of Medicine Center for Vaccine Development and its Center for Vaccine Development in Mali (a joint enterprise of the University of Maryland School of Medicine and the Ministry of Health of Mali). Additionally, the vaccine candidate is expected to be tested among 40 healthy volunteers in Gambia after approval from the relevant authorities.

 

The Oxford trial is expected to launch in mid-September pending ethical and regulatory approval.

“Today’s announcement shows how private and public partners can pull together to quickly respond to this critical public health emergency. Developing a new vaccine is complex with no guarantees of success, and we are still in the early days for our Ebola vaccine candidate. But we are encouraged by progress so far and will do the best we can, along with WHO and our partners, to speed up development and explore ways in which the vaccine could contribute to this or future Ebola outbreaks,” said Dr. Moncef Slaoui, chairman of Global R&D and Vaccines at GSK.

 

Initial safety and immunogenicity data from the Phase 1 trials of the NIAID/GSK investigational Ebola vaccine are expected in late 2014.

Vesicular Stomatitis Virus (VSV) Ebola Vaccine Testing

The NIH will also collaborate with the U.S. Department of Defense in support of efforts by NewLink Genetics Corp., a biopharmaceutical company in Ames, Iowa, to conduct Phase 1 safety studies of the investigational recombinant vesicular stomatitis virus Ebola vaccine (called VSV-EBOV) developed by and licensed from the Public Health Agency of Canada. Those clinical trials are expected to begin in the fall at the Clinical Trials Center of Walter Reed Army Institute of Research in Silver Spring, Maryland.

 

For more information about these early-stage Ebola vaccine clinical trials, see Questions and Answers: Phase 1 Clinical Trials of NIAID/GSK Investigational Ebola Vaccine.

 

NIAID conducts and supports research — at NIH, throughout the United States, and worldwide — to study the causes of infectious and immune-mediated diseases, and to develop better means of preventing, diagnosing and treating these illnesses. News releases, fact sheets and other NIAID-related materials are available on the NIAID Web site at http://www.niaid.nih.gov.

WHO Ebola Response Roadmap

 

 

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With the Ebola outbreak in Western Africa continuing to accelerate, and the breadth and scope of the outbreak already greater than all previously described outbreaks combined, the World Health Organization has today released a 27 page PDF file outlining a roadmap to contain the outbreak over the next 6 to 9 months.

This roadmap contains a number of assumptions, including:

 

This Roadmap assumes that in many areas of intense transmission the actual number of cases may be 2-4 fold higher than that currently reported. It acknowledges that the aggregate case load of EVD could exceed 20,000 over the course of this emergency. The Roadmap assumes that a rapid escalation of the complementary strategies in intense transmission, resource-constrained areas will allow the comprehensive application of more standard containment strategies within 3 months. This plan recognizes that a number of currently unaffected countries could be exposed to EVD, but assumes that the emergency application of the standard control strategies will stop any new transmission within 8 weeks of the index case.

 

Below you’ll find the WHO press release on this Ebola response document.

 

WHO issues roadmap for scaled-up response to the Ebola outbreak

28 August 2014

The World Health Organization is today issuing a roadmap to guide and coordinate the international response to the outbreak of Ebola virus disease in West Africa.

The roadmap aims to stop ongoing Ebola transmission worldwide within 6–9 months, while rapidly managing the consequences of any further international spread. It also recognizes the need to address, in parallel, the outbreak’s broader socioeconomic impact.

It responds to the urgent need to dramatically scale up the international response. Nearly 40% of the total number of reported cases have occurred within the past three weeks.

The roadmap was informed by comments received from a large number of partners, including health officials in the affected countries, the African Union, development banks, other UN agencies, Médecins Sans Frontières (MSF), and countries providing direct financial support.

The roadmap will serve as a framework for updating detailed operational plans. Priority is being given to needs for treatment and management centres, social mobilization, and safe burials. These plans will be based on site-specific data that are being set out in regular situation reports, which will begin this week.

The situation reports map the hotspots and hot zones, present epidemiological data showing how the outbreak is evolving over time, and communicate what is known about the location of treatment facilities and laboratories, together with data needed to support other elements of the roadmap.

The roadmap covers the health dimensions of the international response. These dimensions include key potential bottlenecks requiring international coordination, such as the supply of personal protective equipment, disinfectants, and body bags.

The WHO roadmap will be complemented by the development of a separate UN-wide operational platform that brings in the skills and capacities of other agencies, including assets in the areas of logistics and transportation. The UN-wide platform aims to facilitate the delivery of essential services, such as food and other provisions, water supply and sanitation, and primary health care.

Resource flows to implement the roadmap will be tracked separately, with support from the World Bank.

This is a fast-moving outbreak with a number of unprecedented dimensions. The roadmap being issued today is sufficiently flexible to accommodate rapid changes in the outbreak’s epidemiology and the needs this creates.

Nigerian Setback: Two More Ebola Cases

 

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Two days ago the Nigerian Ministry of Health was all but proclaiming victory over the introduction of Ebola to his country (see media report  Nigeria Has Contained Ebola, Minister of Health Says), but this morning is now facing fresh challenges as two new cases have been reported in the port city of Harcourt.

 

These two cases involve a doctor (now deceased) who treated a contact of the index case Patrick Sawyer, and his wife.  The MOH indicates that another 70 people are under surveillance.

This report from VOA News.

 

Nigeria Reports 2 New Ebola Cases

VOA News

August 28, 2014 5:43 AM

Nigeria's health ministry has reported two more cases of Ebola, bringing the country's total to 15.

Officials said Thursday that a man working for the Economic Community of West African States recovered from an Ebola infection without treatment, but that his doctor died last week from the virus.

Six people have now died from Ebola in Nigeria during the latest outbreak.

The World Health Organization (WHO) reported Thursday the virus has killed at least 1,550 people and infected more than 3,000. The majority of cases have been in Liberia, Sierra Leone and Guinea.

(continue . . .)

 

 

In a related story, Nigeria has announced the delay of the opening of schools across their nation until mid-October (see BBC report Ebola outbreak: Nigeria closes all schools until October).

WHO Ebola Update – August 28th

 

 

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It has been more than a week since the last World Health Organization update on the Ebola situation in Africa, and so as one might expect, today’s catch-up report presents some pretty big numbers.

 

Between the 20th and 26th, nearly 600 new cases have been reported, and just over 200 additional deaths.

 

The situation in Liberia and Sierra Leone remains chaotic and confused, and these numbers should not be perceived as a full accounting of the outbreak.   As the WHO notes in today’s update, the outbreak is still accelerating, with more than 40% of all cases reported in the past 21 days.

 

We also have a new – apparently unrelated – outbreak of Ebola in the DRC, whose full scope is not yet known.

 

And finally, after hopes were raised earlier this week that Nigeria had successfully contained their Ebola outbreak, this morning there are reports of two new cases in Nigeria (see ABC News report Nigeria Ebola Patient Hid From Government), which effectively resets the clock and requires a new round of contact tracing.

 

 

Ebola virus disease update - west Africa

Disease outbreak news
28 August 2014

Epidemiology and surveillance

• The total number of probable and confirmed cases in the current outbreak of Ebola virus disease (EVD) in the four affected countries as reported by the respective Ministries of Health of Guinea, Liberia, Nigeria, and Sierra Leone is 3069, with 1552 deaths.
• The outbreak continues to accelerate. More than 40% of the total number of cases have occurred within the past 21 days. However, most cases are concentrated in only a few localities.
• The overall case fatality rate is 52%. It ranges from 42% in Sierra Leone to 66% in Guinea.
• A separate outbreak of Ebola virus disease, which is not related to the outbreak in West Africa, was reported on 24 August by the Democratic Republic of Congo (DRC) and is detailed in a separate edition of the Disease Outbreak News (http://who.int/csr/don/2014_08_27_ebola/en/)

Health sector response

A full understanding of the outbreak that will lead to improved response requires detailed analysis of exactly where transmission is occurring (by district level) and of time trends. This analysis is ongoing. Preliminary results show that cases are still concentrated (62% of all reported cases since the beginning of the outbreak) in the epicentre of the outbreak in Gueckedou (Guinea); Lofa (Liberia), where cases continue to rise; and Kenema and Kailahun (Sierra Leone). Capital cities are of particular concern, owing to their population density and repercussions for travel and trade.

WHO and its partners are on the ground establishing Ebola treatment centres and strengthening capacity for laboratory testing, contact tracing, social mobilization, safe burials, and non-Ebola health care.

WHO continues to monitor for reports of rumoured or suspected cases from countries around the world and systematic verification of these cases is ongoing. Countries are encouraged to continue engaging in active surveillance and preparedness activities. Cases of EVD have been reported from the Democratic Republic of Congo. The cases in DRC are not related to the outbreak in West Africa. Outside of the four affected countries in West Africa and DRC, no new cases have been confirmed in other countries.

WHO does not recommend any travel or trade restrictions be applied except in cases where individuals have been confirmed or are suspected of being infected with EVD or where individuals have had contact with cases of EVD. (Contacts do not include properly-protected health-care workers and laboratory staff.) Temporary recommendations from the Emergency Committee with regard to actions to be taken by countries can be found at http://who.int/mediacentre/news/statements/2014/ebola-20140808/en/.

Disease update

As of 26 August 2014, the cumulative number of cases attributed to EVD in the four countries stands at 3 069, including 1552 deaths. The distribution and classification of the cases are as follows: Guinea, 647 cases (482 confirmed, 141 probable, and 25 suspected), including 430 deaths; Liberia, 1378 cases (322 confirmed, 674 probable, and 382 suspected), including 694 deaths; Nigeria, 17 cases (13 confirmed, 1 probable, and 3 suspected), including 6 deaths; and Sierra Leone, 1026 cases (935 confirmed, 37 probable, and 54 suspected), including 422 deaths.