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Thursday, October 30, 2014

CDC REVISES GUIDANCE FOR MONITORING & MOVEMENT OF PERSONS WITH POTENTIAL EBOLA EXPOSURE


CDC Issues Revised Interim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure

The Centers for Disease Control and Prevention (CDC) issued revised Interim U.S. Guidance for Monitoring and Movement of Persons with Ebola Virus Exposure.  This guidance provides new information public health authorities and other partners can use to determine appropriate public health actions based on Ebola exposure risk factors and clinical presentation. It also includes criteria for monitoring exposed people and for when movement restrictions may be needed.
A fact sheet describing this revised interim guidance can be found here.
The updated guidance can be found here.
The press release can be found here.
The transcript and audio of the press briefing.

CDC Main Campus

Ebola Cases and Deaths (West Africa)

As of October 27, 2014*

  • Total Cases: 13703
  • Laboratory-Confirmed Cases: 7637
  • Total Deaths: 4922
Updates on cases and deaths can be found on the CDC website.
*Case counts updated in conjunction with World Health Organization updates and are based on information reported by the Ministries of Health.

Online Resources


General Outbreak Information


New or Updated Guidance Documents

(Full range of guidance documents can be found at the CDC Ebola Web site)

Multimedia Resources


Content Syndication

Put CDC content on Ebola on your website that will update automatically.
Add a CDC Ebola Microsite to your web page.  The embed code for this microsite is available in CDC’s new syndication site, the Public Health Media Library.  Ebola HTML content, images, and other media are being added and also available for syndication from this site.
Please contact IMTech@cdc.gov for technical support.

CDC Key Messages

*Please Note that NEW Information is italicized and bold.


Outbreak Summary

On August 8, the World Health Organization (WHO) declared the current Ebola outbreak a Public Health Emergency of International Concern. 
The 2014 Ebola epidemic is the largest in history, affecting multiple countries in West Africa.
---Most of the cases have been reported in three countries: Guinea, Liberia, and Sierra Leone.
---WHO officially declared Senegal and Nigeria free of Ebola virus transmission on October 17 and 20, respectively.
---On October 23, the Mali Ministry of Health reported a case of Ebola in a child who had recently traveled from Guinea. Public health officials are investigating.
Spain has had one confirmed case of Ebola in a healthcare worker who had treated a patient repatriated from West Africa.
Two imported cases, including one death, and two locally acquired cases in healthcare workers have been reported in the United States.
---On October 23, the New York City Department of Health and Mental Hygiene reported a case of Ebola in a medical aid worker who had returned to New York City from Guinea, where the medical aid worker had served with Doctors Without Borders. The diagnosis was confirmed by CDC on October 24. 
  • The patient is in isolation in a New York City hospital.  Public health officials are investigating and conducting contact tracing. A CDC team was deployed to assist with the investigation.
An outbreak of Ebola is occurring in the Democratic Republic of the Congo that is unrelated to the outbreak in West Africa. For more information, see http://www.cdc.gov/vhf/ebola/outbreaks/drc/2014-august.html.
On September 23, CDC released an MMWR article, “Estimating the Future Number of Cases in the Ebola Epidemic – Liberia and Sierra Leone, 2014-2015,” which estimated the future number of Ebola cases if current trends continue. The projected numbers were adjusted to account for estimated underreporting of cases.
CDC’s response to the Ebola epidemic is the agency’s largest international outbreak response ever.
---CDC is partnering with the U.S. Agency for International Development (USAID) in support of the United States’ overseas response to the Ebola outbreak. Together with the Department of Defense, Department of State, and other U.S. departments and agencies, CDC is part of a whole-of-government approach to this national security priority.
---In the United States, the Department of Health and Human Services, including CDC, is in charge of the strategic effort to fortify the U.S. public health and treatment infrastructure. The National Institutes of Health (NIH) and the Food and Drug Administration (FDA) are leading the effort to develop and test vaccines and new treatments.
On September 16, President Obama announced additional U.S. government support for the response in West Africa, including significant U.S. military funding and engagement.
---U.S. Africa Command (AFRICOM) is setting up a regional command in Monrovia, Liberia, to facilitate the coordination of the response and to expedite the transportation of equipment, supplies, and personnel.
---Additional Ebola treatment units are being established in the affected areas, as well as a site to train up to 500 health workers per week to care for patients.
---The U.S. Public Health Service Commissioned Corps has deployed 65 health workers to support a state-of-the-art Department of Defense hospital that will be placed in Monrovia to provide care to health workers who become sick.
---The Department of Defense has established a 30-member medical Ebola support team to provide short-notice assistance to civilian medical professionals in the United States. The formation of the team is an added prudent measure to ensure that the nation is ready to respond quickly, effectively, and safely if there are new Ebola cases in the United States. 

Ebola and the United States

On September 30, CDC confirmed the first case of Ebola to be diagnosed in the United States in a person who had traveled from Liberia to Dallas, Texas. The patient died on October 8.
On October 10, a healthcare worker who provided care for the index patient at Texas Health Presbyterian Hospital tested positive for Ebola.
---The healthcare worker was isolated after initial reports of fever and subsequently moved to the NIH Clinical Center in Bethesda, Maryland.
---The patient has recovered and was discharged from the NIH Clinical Center on October 24.
On October 15, a second healthcare worker who provided care for the index patient at Texas Health Presbyterian Hospital tested positive for Ebola.
---On the morning of October 14, the healthcare worker reported to the hospital with a low-grade fever and was isolated. The patient was later transferred to Emory Hospital in Atlanta, Georgia.
---The patient has recovered and was discharged from the hospital on October 28.
---The healthcare worker had traveled by air on October 10 from Dallas to Cleveland and October 13 from Cleveland to Dallas.
--CDC worked to ensure that all passengers and crew on the two flights were contacted by public health professionals to answer their questions and arrange follow up as necessary.
---For answers to frequently asked questions related to this incident, visithttp://www.cdc.gov/media/releases/2014/faq1017-ebola-investigation-frequently-asked-questions.html.
On October 23, the New York City Department of Health and Mental Hygiene reported a case of Ebola in a medical aid worker who had returned to New York City from Guinea, where the medical aid worker had served with Doctors Without Borders. The diagnosis was confirmed by laboratory testing at CDC on October 24.
---The patient is in isolation in a New York City hospital.  Public health officials are investigating and conducting contact tracing. A CDC team was deployed to assist with the investigation.
Teams from CDC are deployed to Dallas, Ohio, and New York to assist with the investigations.They are supported 24/7 by CDC’s Emergency Operations Center and Ebola experts at CDC’s Atlanta headquarters.
---The teams work closely with state and local health departments in finding, assessing, and assisting everyone who came into contact with the Ebola patients.
Although the risk of rapid spread of Ebola in the United States is very low, CDC and partners are taking precautions to isolate any cases of Ebola and prevent the spread of the disease.
CDC and partners are taking precautions to prevent the spread of Ebola.
---CDC has issued a Warning, Level 3 (the highest level) travel notice for three countries where the Ebola outbreak is severe. U.S. citizens should avoid all nonessential travel to Guinea, Liberia, and Sierra Leone.
---Exit screening efforts in West Africa help prevent travelers who have been exposed to Ebola or who are sick with Ebola from getting on commercial planes, buses, trains, or ships. 
---Every day, CDC works closely with partners at U.S. international airports and other ports of entry to look for sick travelers with possible contagious diseases.
---CDC has enhanced its outreach with the Department of Homeland Security (DHS) and other partners at ports of entry (primarily international airports) to use routine procedures for identifying and reporting travelers who show signs of infectious disease.
---CDC and DHS are conducting enhanced entry screening at five U.S. airports (New York’s JFK International, Washington-Dulles, Newark, Chicago-O’Hare, and Atlanta) for all U.S.-bound air travelers who have been in Liberia, Sierra Leone, or Guinea.
  • Entry screening helps to prevent further spread of Ebola and protect the health of all  Americans by identifying travelers who may be sick with Ebola or may have had an exposure to Ebola and by ensuring that these travelers are directed to appropriate care.
  • These inbound travelers receive Check and Report Ebola (Care) Kits that contain further information about Ebola. This kit includes a health advisory infographic about monitoring for Ebola symptoms for 21 days, pictorial descriptions of symptoms, a thermometer with instructions for how to use it, a symptom log, and a wallet-sized card that reminds travelers to monitor their health and provides information about who to call if they have symptoms. See http://www.cdc.gov/media/DPK/2014/Ebola-Care-Kit.html.   
  • A post-arrival active monitoring program began October 27 in the six states (New York, Pennsylvania, Maryland, Virginia, New Jersey, and Georgia) where approximately 70% of incoming travelers are located. Active post-arrival monitoring will begin in the other states in the days following.
  • CDC will provide assistance, support, and tools to state and local health departments as needed. Once fully operational, CDC estimates that state and local public health departments will be tracking approximately 3,000 travelers across the country, and that every state will participate in active monitoring. Since both state and local health departments will conduct the monitoring, the responsibility will be distributed across the country.
  • CDC continues to believe that the screening of outbound passengers in West Africa is the most effective measure. The post-arrival active monitoring activities are an additional safety-net on top of the already comprehensive exit screening measures that have previously been implemented at relevant West African airports and domestic entry screening measures for inbound travelers.
---CDC has updated its interim guidance for monitoring people potentially exposed to Ebola and for evaluating their intended travel, including the application of movement restrictions when indicated. The guidance, Interim Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure, is available at www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html.
---CDC is tightening previous infection control guidance for healthcare workers caring for patients with Ebola. The revised guidance, issued October 20, focuses on specific personal protective equipment (PPE) that healthcare workers should use and offers detailed step-by-step instructions for how to put the equipment on and take it off safely.            
Ebola virus is not spread through air or by water, or by any food grown or legally purchased in the United States.
---There is a small chance that Ebola could be spread by handling or eating bushmeat (wild animals hunted for food) that has been illegally imported from Africa; however, to date, there have been no reports of human illness in the United States from preparing or consuming illegally imported bushmeat.
---CDC encourages all U.S. healthcare providers to do the following when patients present with Ebola-like symptoms:
        Assess patients for:
  • Elevated body temperature or subjective fever; or
  • Severe headache, muscle pain, vomiting, diarrhea, abdominal (stomach) pain, or unexplained hemorrhage (bleeding or bruising).
  • Ask patients with Ebola-like symptoms about their travel histories to determine if they have traveled to West Africa within the last 3 weeks.
  • Contact the state or local health department if Ebola is suspected.

Ebola Cases and Deaths

As of October 27, 2014, a total of 13,703* cases of Ebola (7,637 laboratory-confirmed) and 4,922 deaths have been reported.
For specific areas where cases have been identified, see CDC’s Ebola outbreak webpage(http://www.cdc.gov/vhf/ebola/outbreaks/guinea/index.html).

Countries with Widespread Transmission

Country: Guinea 
Total Cases: 1906
Laboratory-Confirmed Cases: 1391
Total Deaths: 997

Country: Liberia
Total Cases: 6535
Laboratory-Confirmed Cases: 2515
Total Deaths: 2413

Country: Sierra Leone
Total Cases: 5235
Laboratory-Confirmed Cases: 3700
Total Deaths: 1500

Total
Total Cases: 13676*
Laboratory-Confirmed Cases: 7606
Total Deaths: 4910

Countries with Travel-associated Cases

Country: Mali
Total Cases: 1
Laboratory-Confirmed Cases: 1
Total Deaths: 1

Country: Senegal
Total Cases: 1**
Laboratory-Confirmed Cases: 1**
Total Deaths: 0

Total
Total Cases: 2
Laboratory-Confirmed Cases: 2
Total Deaths: 1


Countries with Limited Transmission

Country: Nigeria 
Total Cases: 20** 
Laboratory-Confirmed Cases: 19**
Total Deaths: 

Country: Spain
Total Cases: 1
Laboratory-Confirmed Cases: 1
Total Deaths: 0

Country: United States
Total Cases: 4
Laboratory-Confirmed Cases: 4
Total Deaths: 1

Total
Total Cases: 25
Laboratory-Confirmed Cases: 24
Total Deaths: 9
*The increase in the total cases compared with the total released on October 25, 2014, results from a more comprehensive assessment of patient databases. The additional 3,792 cases have occurred throughout the epidemic period.
**The outbreaks of Ebola Virus Disease (EVD) in Senegal and Nigeria were declared over on 17 October and 19 October 2014, respectively. A national EVD outbreak is considered to be over when 42 days (double the 21-day incubation period of the Ebola virus) has elapsed since the last patient in isolation became laboratory negative for EVD.

Ebola in U.S. Health Workers (in West Africa)

During July-October 2014, four U.S. health workers and one journalist were infected with Ebola virus in West Africa and transported to hospitals in the United States.  All four have recovered and been released from the hospital after laboratory testing confirmed that they no longer have Ebola virus in their blood. CDC has advised the hospitals that there is no public health concern with their release and that they do not pose a risk to household contacts or to the public.
CDC has received many calls from health departments and hospitals about patients under investigation for possible Ebola. These calls have been triaged appropriately and samples have been sent to CDC for testing.

Background on Ebola

Ebola virus disease, previously known as Ebola hemorrhagic fever, is a rare and deadly disease caused by infection with one of the Ebola virus species (Zaire, Sudan, Bundibugyo, or Tai Forest
Ebola viruses are found in several African countries. The first Ebola virus was discovered in 1976 near the Ebola River in what is now the Democratic Republic of the Congo. Since then, outbreaks have appeared sporadically in Africa.
Based on evidence and the nature of other similar viruses, researchers believe that Ebola virus disease is animal-borne (zoonotic) and that bats are the most likely reservoir.
CDC and partners have 38 years of experience in stopping Ebola outbreaks.

Transmission

Ebola virus is spread through direct contact with the blood or body fluids (including but not limited to feces, saliva, sweat, urine, vomit, and semen) of a person who is sick with Ebola. The virus in blood and body fluids can enter another person’s body through broken skin or unprotected mucous membranes in, for example, the eyes, nose, or mouth.
---The virus also can be spread through contact with objects (like needles and syringes) that have been contaminated with the virus, or with infected fruit bats or primates (monkeys and apes).
---Ebola is not spread through the air or by water or, in general, by food. However, in Africa, Ebola may be spread as a result of handling bushmeat (wild animals hunted for food) and contact with infected bats.
---There is no evidence that mosquitos or other insects can transmit Ebola virus. Only mammals (for example, humans, bats, monkeys and apes) have shown the ability to become infected with and spread Ebola virus.
---Although Ebola virus has been detected in breast milk, it is not known if the virus can be transmitted from mothers to their infants through breastfeeding. When safe alternatives to breastfeeding and infant care exist, mothers with probable or confirmed Ebola should not have close contact with their infants (including breastfeeding).
---Ebola is not easy to spread because people are only contagious when they have symptoms, and people with symptoms are likely to be too sick to travel or hide their symptoms.
Once people recover from Ebola, they can no longer spread the virus to people in the community. However, because Ebola can stay in semen after recovery, men should abstain from sex (including oral sex) for at least three months. If abstinence is not possible, condoms may help prevent the spread of disease. There is no evidence that people can get sick from Ebola through sex (or oral sex) before symptoms appear.
People with Ebola symptoms become more infectious as their symptoms worsen. This is partly because exposure to the virus is more likely when someone is bleeding or vomiting, but also because the amount of virus present increases dramatically as a person with Ebola becomes more seriously ill.
Ebola virus is killed with hospital-grade disinfectants (such as household bleach). Ebola on dry surfaces, such as doorknobs and countertops, can survive for several hours; however, virus in body fluids (such as blood) can survive up to several days at room temperature.
While available information suggests the virus may be found in several kinds of animals, it is not believed that pets (like dogs and cats) are at significant risk for Ebola. Only a few species of mammals (for example, humans, monkeys, and apes) have shown the ability to become infected with and spread Ebola virus.
The incubation period, from exposure to when signs or symptoms appear, is 2 to 21 days, but the average is 8 to 10 days.
Genetic analysis of the virus in the current outbreak indicates it is closely related to variants of Ebola virus (species Zaire ebolavirus) identified earlier in the Democratic Republic of the Congo and Gabon.

Signs and Symptoms

Signs of Ebola include fever and symptoms such as severe headache, fatigue, muscle pain, vomiting, diarrhea, abdominal (stomach) pain, or unexplained hemorrhage (bleeding or bruising).

Risk

Health workers caring for Ebola patients and the family and friends in close contact with Ebola patients are at the highest risk of getting sick because they may come in contact with the blood or body fluids of sick patients, for example, by changing sheets after an ill person has vomited. Human-to-human transmission is the way that most people are now getting Ebola in West Africa.
People also can become sick with Ebola after coming in contact with infected wildlife. For example, in Africa, Ebola may be spread as a result of handling bushmeat (wild animals hunted for food) and contact with infected bats.
Ebola poses little risk to travelers or the general public who have not cared for or been in close contact (within 3 feet or 1 meter) with someone sick with Ebola for a prolonged period.

Prevention

There is no FDA-approved vaccine available for Ebola.
If you must travel to or are in an area affected by the Ebola outbreak, make sure to do the following:
---Practice careful hygiene. For example, wash your hands with soap and water or an alcohol-based hand sanitizer and avoid contact with blood and body fluids (including but not limited to feces, saliva, sweat, urine, vomit, and semen).
---Avoid handling items that may have come in contact with an infected person’s blood or body fluids (such as clothes, bedding, needles, and medical equipment).
---Avoid funeral or burial rituals that require handling the body of someone who has died from Ebola.
---Avoid contact with bats and nonhuman primates or blood, fluids, and raw meat prepared from these animals.
---Avoid facilities in West Africa where Ebola patients are being treated. The U.S. Embassy or consulate is often able to provide advice on healthcare facilities.
---Seek medical care immediately if you develop fever, severe headache, muscle pain, diarrhea, vomiting, stomach pain, or unexplained bruising or bleeding.
  • Call in advance to tell the doctor about recent travel and symptoms before going to the office or emergency room. Advance notice will help the doctor provide care and protect other people who may be in the office.
  • Limit your contact with other people when you go to the doctor. Do not travel anywhere else.

Treatment

No FDA-approved vaccine or specific treatment (e.g., antiviral drug) is available for Ebola.
Symptoms of Ebola and complications are treated as they appear. The following basic interventions, when used early, can significantly improve the chances of survival:
---Providing intravenous fluids and balancing electrolytes (body salts)
---Maintaining oxygen status and blood pressure
---Treating other infections if they occur
Experimental vaccines and treatments for Ebola are under development, but they have not yet been fully tested for safety or effectiveness.
---ZMapp, developed by Mapp Biopharmaceutical Inc., is an experimental treatment for use with individuals infected with Ebola virus. The product is a combination of three different monoclonal antibodies that bind to the protein of the Ebola virus. It has been effective in treating macaque monkeys with Ebola.
---It is too early to know if ZMapp can benefit Ebola patients because the drug is still in an experimental stage and has not yet been tested in humans for safety or effectiveness in clinical trials. Some patients infected with Ebola virus do get better spontaneously or with supportive care.
  • The best way to know if treatment with the product is effective is to conduct a randomized controlled clinical trial in people to compare outcomes of patients who received the treatment to patients who did not. No such studies have been conducted to date.
  • On September 2, HHS announced a contract with Mapp Biopharmaceutical Inc. to develop and manufacture ZMapp toward the goal of U.S. Food and Drug Administration approval. As part of the project, Mapp Biopharmaceutical will manufacture a small amount of the drug for early stage clinical safety studies and nonclinical studies needed to demonstrate the drug’s safety and effectiveness in people.
---Some investigational Ebola vaccines have been developed. NIH has begun initial human testing to assess the safety and immune response of an investigational vaccine to prevent Ebola virus disease. The Department of Defense (DoD) has also begun human testing of a different investigational vaccine.
  • On October 21, WHO announced that testing of two experimental Ebola vaccines will begin as early as January in more than 20,000 front-line healthcare workers and others in West Africa.
---Two companies, Tekmira and BioCryst Pharmaceuticals, have received funding from the DoD to develop potential drugs to treat Ebola. BioCryst, with NIH support, is working to develop an antiviral drug to treat Ebola; the first phase of (human) safety testing is expected to begin later this year.

Recovery

Recovery from Ebola depends on good supportive clinical care and the patient’s immune response. Available evidence shows that people who recover from Ebola infection develop antibodies that last for at least 10 years, and possibly longer. It isn’t known if people who recover are immune for life or if they can become infected with a different species of Ebola.
Some people who have recovered from Ebola have developed long-term complication