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admin 14.09.2013

I will try to keep new information and updates in the same post for a while until I have a chance to do a comprehensive re-overview of everything.
First, while the cures and vaccines are truly not deployed as you point out, you are more negative than necessary.
Yesterday I made the optimistic statement that the number of new cases a day may be leveling off, as for two reporting periods in a row, representing five days, the new cases were about half of the previous reporting period, normalized to a per-day estimate. Today’s report from WHO covers two days and indicates 128 more cases, so the number of new cases per day for the latest known period is actually higher than at any previous time during this outbreak. The latest two updates from WHO indicate that the Ebola outbreak may be leveling off now, tough it is too early to be certain.
Note that what appears to have been a fairly steady increase in number of cases, with about the same number of ups as downs but with the ups adding to a higher sum, since late June, has been followed by two reporting periods with decreases in numbers of new cases.
The mortality rate for this outbreak continues to decrease slightly, which is probably a result of increase effectiveness of the response to the outbreak, despite all the news stories about how things seem out of control. The current mortality rate is dropping below 55% given confirmed, probable, and suspected cases and deaths. Currently there are over 1,800 confirmed, probable, or suspected cases reported in the West African outbreak, and 1176 confirmed cases. Patient Zero, who we assume is the person to whom the disease jumped from its usual animal reservoir, directly or indirectly, may have been a toddler in Guinea.
I’ve long maintained that a likely way for Ebola to get into other species is from ground dwelling mammals, such as chimps, gorillas, or forest antelopes and duikers, ingesting or mouthing the discarded wadges of fruit previously handled by Ebola-carrying fruit bats. In the case of the treatment now given to three patients (two survived one died), the cure was developed for Ebola based on some pretty solid science and prior experience with similar type cures working for similar diseases, successfully, in the past.
Regarding the decrease in mortality, I think that this is partly artifact—a math thing. Addendum: I am assuming that the majority of Ebola victims are being cared for at this time by family members.
Regarding the artifact, I discussed that in my earlier post that dealt more with mortality, suggesting the very effect you mention. My impression is that there are perhaps thousands who have risked exposure and who remain so far undiscovered across the affected areas.
Lagos is theoretically scary, but not empirically scary, but many are empirically scared because there have been some cases there. It isn’t clear how many cases make an outbreak, and it is certainly possible to say that they HAD a tiny outbreak (smaller than any previous instance).
Kuching – PKR vice-president Nurul Izzah Anwar has been banned from entering Sarawak. Phnom Penh – Cambodia health officials on Monday were screening hundreds of villagers for HIV after 14 locals tested positive for the virus, sparking fears of a fresh outbreak.
Nervous villagers from Peam, an hour north of the capital Phnom Penh, have flocked to a house where a team of health officials were taking blood samples.
Ly Peng Sun, the director of the National Centre for HIV, said moves to test the entire village were made after 14 people screened positive earlier this month. HIV rates are high in impoverished Cambodia but the country has made significant gains against the virus in recent years.
However fears are running high after a recent outbreak in another village left more than 200 infected.
That outbreak was traced to an unlicensed doctor reusing dirty needles who has since been jailed. Some of those testing positive in Peam believe they may have been infected by a doctor, locals said. The doctor at the centre of the previous outbreak in the western province of Battambang was jailed for 25 years, partly because some of his patients died after being infected. The case shone a spotlight on the chronically underfunded healthcare system in the impoverished nation. Enter your email address to subscribe to this Kualalumpurpost and receive notifications of new posts by email. Health authorities quarantined hundreds of people in northern Sierra Leone on Monday after a 16-year-old girl died of Ebola in an apparent case of sexual transmission, the first confirmed death from the virus in the district for nearly six months. Health authorities quarantined hundreds of people in northern Sierra Leone on Monday after a 16-year-old girl died of Ebola in an apparent case of sexual transmission, the first confirmed death from the virus in the district for nearly six months.Sierra Leone celebrated last month when it discharged the last remaining Ebola patient from its treatment centers.
A case definition is a standard set of criteria for deciding whether an individual should be classified as having the health condition of interest. A three-year-old boy is fighting for his life in hospital after he was found almost drowned in his neighbour’s pond at Ingleside.
THAT annoying delivery slip you find in the mailbox instead of your package will now come with a price tag.
BEAUTY queen Lucille Butterworth has been missing almost 50 years, but only now are questions being answered about her disappearance.
A CORONER has found missing Hobart woman Lucille Butterworth was strangled and dumped on the day she went missing in August 1969. HEALTH authorities are investigating a suspected scabies outbreak at a Rivervale hotel, where country police officers are staying during the Commonwealth Heads of Government Meeting. Officials were alerted to the suspected contamination yesterday after a Northam policewoman presented with a rash. A NOTE ABOUT RELEVANT ADVERTISING: We collect information about the content (including ads) you use across this site and use it to make both advertising and content more relevant to you on our network and other sites. The bird flu was last a major concern in 2006, when infection rates among humans were at an all time high.
The major cause for concern now, rather than in the years since 2008, is that the new, mutant strain first seen in China and Vietnam appears to be resistant to current vaccines against bird flu.
The best thing to do right now is to stay informed of what is going on with bird flu around the world, and to be prepared. Conditions for a Public Health Emergency of International Concern (PHEIC) have not been met by the MERS-CoV outbreak, according to the World Health Organization (WHO). Since April 2012, 992 cases of Middle East respiratory syndrome coronavirus (MERS-CoV) have been reported by local health authorities worldwide, including 401 deaths.Incidence shows a decrease after the surge in October 2014 and the majority of cases are still reported from the Arabian Peninsula, mainly from Saudi Arabia, said the European Centers for Disease Control and Prevention (ECDC) in an update last week.
Get FREE access to authoritative breaking news, videos, podcasts, webinars and white papers. It was your book, based on your Thesis at the Kennedy School, that got me interested in tropical diseases. First, all of the health care molecules have moved to one corner of the proverbial room suffocating other health care efforts in the affected countries.
You went for breathless, and you got to breathless, and that’s probably a good choice, you have the credibility to pull it off and people need to hear much of what you said. I did not address the effect of Ebola victims being taken to receive professional health care, which could either serve to slow or speed its spread, depending on knowledge of infection control and on available resources. But Nigeria simply isn’t having an EBOV outbreak, so one could have used any large densely populated city with certain other characteristics connected to the affected area by airplane. But, at least one case was not infected in Nigeria, and the other cases are all closely related to that one case, and there are no new cases.
They suspect the doctor might have spread HIV,” Phy Sobin, 33, told AFP by telephone after she tested negative. I and my two kids tested negative for HIV, but my husband has not tested yet,” she said, adding that her 67-year old aunt had been confirmed HIV-positive.
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Additional information from studies is also required to better understand the risk factors for infection and transmission.
Well, that and at the same time going to the tropics, running a makeshift health clinic there, and getting some of the diseases. It also explains how you can access or seek correction of your personal information, how you can complain about a breach of the Australian Privacy Principles and how we will deal with a complaint of that nature.
As long as there is an available pool of uninfected individuals, Ebola will continue to burn on until it is put out.
For example, the order of the first three listed steps is highly variable — a health department often verifies the diagnosis and establishes the existence of an outbreak before deciding that a field investigation is warranted.

To get a more accurate (but still hugely ballpark) death rate you would compare the # of cases from, lets say, a couple of weeks ago with the current # of deaths. Whatever the criteria, they must be applied consistently to all persons under investigation.The case definition must not include the exposure or risk factor you are interested in evaluating. The Palestinian Territories, Bulgaria, Romania, Nepal, and Mongolia have also seen some infections recently. First, even if there is a long term upward or downward trend, there is likely to be a lot of randomness in the data. Only occasionally do public health officials decide to conduct a field investigation before confirming an increase in cases and verifying the diagnosis.
More commonly, officials discover an increase in the number of cases of a particular disease and then decide that a field investigation is warranted. Sometimes investigators collect enough information to perform descriptive epidemiology without leaving their desks, and decide that a field investigation is necessary only if they cannot reach a convincing conclusion without one.Regardless of when the decision to conduct a field investigation is made, you should be well prepared before leaving for the field.
As a result, investigators often create different categories of a case definition, such as confirmed, probable, and possible or suspect, that allow for uncertainty. Those who died of Ebola did so in West Africa, but they are still neighbors who live here part time or African-based relatives of neighbors who live here full or part time.
The preparations can be grouped into two broad categories: (a) scientific and investigative issues, and (b) management and operational issues. Over several reporting periods this would, obviously, even out, but a given number of days in a reporting period may be off by a day or so. Good preparation in both categories is needed to facilitate a smooth field experience.Scientific and investigative issuesAs a field investigator, you must have the appropriate scientific knowledge, supplies, and equipment to carry out the investigation before departing for the field. A case classified as probable usually has typical clinical features of the disease without laboratory confirmation. Discuss the situation with someone knowledgeable about the disease and about field investigations, and review the applicable literature. In previous similar outbreaks, what have been the sources, modes of transmission, and risk factors for the disease?
Assemble useful references such as journal articles and sample questionnaires.Before leaving for a field investigation, consult laboratory staff to ensure that you take the proper laboratory material and know the proper collection, storage, and transportation techniques. By talking with the laboratory staff you are also informing them about the outbreak, and they can anticipate what type of laboratory resources will be needed.You also need to know what supplies or equipment to bring to protect yourself.
Some outbreak investigations require no special equipment while an investigation of SARS or Ebola hemorrhagic fever may require personal protective equipment such as masks, gowns, and gloves.Finally, before departing, you should have a plan of action.
For example, if investigating an epidemic of meningococcal meningitis in Bamako, the case definition might be the clinical features as described in the box with onset between January and April of this year among residents and visitors of Bamako.Classifications such as confirmed-probable-possible are helpful because they provide flexibility to the investigators.
A case might be temporarily classified as probable or possible while laboratory results are pending. Alternatively, a case may be permanently classified as probable or possible if the patient's physician decided not to order the confirmatory laboratory test because the test is expensive, difficult to obtain, or unnecessary.
For example, while investigating an outbreak of diarrhea on a cruise ship, investigators usually try to identify the causative organism from stool samples from a few afflicted persons.
The team members must be selected before departure and know their expected roles and responsibilities in the field. If the tests confirm that all of those case-patients were infected with the same organism, for example norovirus, the other persons with compatible clinical illness are all presumed to be part of the same outbreak and to be infected with the same organism.
Note that while this approach is typical in the United States, some countries prefer to acquire laboratory samples from every affected person, and only those with a positive laboratory test are counted as true cases.A case definition is a tool for classifying someone as having or not having the disease of interest, but few case definitions are 100% accurate in their classifications. Some persons with mild illness may be missed, and some persons with a similar but not identical illness may be included.
Generally, epidemiologists strive to ensure that a case definition includes most if not all of the actual cases, but very few or no false-positive cases. If you have been invited to participate but do not work for the local health agency, are you expected to lead the investigation, provide consultation to the local staff who will conduct the investigation, or simply lend a hand to the local staff? And who are your local contacts?Depending on the type of outbreak, the number of involved agencies may be quite large.
The strategy of being more inclusive early on is especially useful in investigations that require travel to different hospitals, homes, or other sites to gather information, because collecting extra data while you are there is more efficient than having to return a second time.
If criminal or bioterrorist intent is suspected, law enforcement agencies and the Federal Bureau of Investigation (FBI) may be in charge, or at least involved.
In a natural disaster (hurricane or flood), the Federal Emergency Management Agency (FEMA) may be the lead. Staff from different agencies have different perspectives, approaches, and priorities that must be reconciled. In analytic epidemiology, inclusion of false-positive cases can produce misleading results.
For example, whereas the public health investigation may focus on identifying a pathogen, source, and mode of transmission, a criminal investigation is likely to focus on finding the perpetrator. Therefore, to test these hypotheses by using analytic epidemiology (see Step 8), specific or tight case definitions are recommended.Other investigations, particularly those of a newly recognized disease or syndrome, begin with a relatively specific or narrow case definition.
Sorting out roles and responsibilities in such multi-agency investigations is critical to accomplishing the disparate objectives of the different agencies.A communications plan must be established. For example, acquired immunodeficiency syndrome (AIDS) and severe acute respiratory syndrome (SARS) both began with relatively specific case definitions. The need for communicating with the public health and clinical community has long been acknowledged, but the need for communicating quickly and effectively with elected officials and the public became obvious during the epidemics of West Nile Virus encephalitis, SARS, and anthrax. This ensures that persons whose illness meets the case definition truly have the disease in question. The plan should include how often and when to have conference calls with involved agencies, who will be the designated spokesperson, who will prepare health alerts and press releases, and the like. As a result, investigators could accurately characterize the typical clinical features of the illness, risk factors for illness, and cause of the illness.
After the cause was known and diagnostic tests were developed, investigators could use the laboratory test to learn about the true spectrum of illness, and could broaden the case definition to include those with early infection or mild symptoms. If you are arriving from outside the area, you should arrange in advance when and where you are to meet with local officials and contacts when you arrive in the field. This condition was characterized by severe myalgias (muscle pains) and an elevated number of a particular type of white blood cell called an eosinophil. Many agencies and organizations have strict approval processes and budgetary limits that you must follow. Usually, the cases are presumed to have a common cause or to be related to one another in some way. Many epidemiologists use the terms outbreak and epidemic interchangeably, but the public is more likely to think that epidemic implies a crisis situation. Exercise 6.4In December 2003, an outbreak of gastroenteritis occurred among tenth-grade students who had participated in a city-wide field trip.
Some epidemiologists apply the term epidemic to situations involving larger numbers of people over a wide geographic area. Half of the students traveled from December 2 to December 7 (Tour A); the other half traveled from December 3 to December 8 (Tour B). This aggregation of cases seems to be unusual, but frequently the public (and sometimes the health agency) does not know the denominator. Although teachers and other adult chaperones accompanied the students on both tours, no adult reported illness. For example, the diagnosis in one neighborhood of four adults with cancer may be disturbing to residents but may well be within the expected level of cancer occurrence, depending on the size of the population, the types of cancer, and the prevalence of risk factors among the residents.One of the first tasks of the field investigator is to verify that a cluster of cases is indeed an outbreak.
In addition, no illness was reported among students who did not go on the field trip, and no cases of E.
Some clusters turn out to be true outbreaks with a common cause, some are sporadic and unrelated cases of the same disease, and others are unrelated cases of similar but unrelated diseases.Even if the cases turn out to be the same disease, the number of cases may not exceed what the health department normally sees in a comparable time period. Using the information in the line listing, develop a case definition that you might use for the outbreak investigation.
The expected number is usually the number from the previous few weeks or months, or from a comparable period during the previous few years.
For a notifiable disease, the expected number is based on health department surveillance records. For other diseases and conditions, the expected number may be based on locally available data such as hospital discharge records, mortality statistics, or cancer or birth defect registries.

When local data are not available, a health department may use rates from state or national data, or, alternatively, conduct a telephone survey of physicians to determine whether they are seeing more cases of the disease than usual. Finally, a survey of the community may be conducted to establish the background or historical level of disease.Even if the current number of reported cases exceeds the expected number, the excess may not necessarily indicate an outbreak.
Reporting may rise because of changes in local reporting procedures, changes in the case definition, increased interest because of local or national awareness, or improvements in diagnostic procedures.
A new physician, infection control nurse, or healthcare facility may more consistently report cases, when in fact there has been no change in the actual occurrence of the disease. Finally, particularly in areas with sudden changes in population size such as resort areas, college towns, and migrant farming areas, changes in the numerator (number of reported cases) may simply reflect changes in the denominator (size of the population).Whether an apparent problem should be investigated further is not strictly tied to verifying the existence of an epidemic (more cases than expected). Sometimes, health agencies respond to small numbers of cases, or even a single case of disease, that may not exceed the expected or usual number of cases.
As noted earlier, the severity of the illness, the potential for spread, availability of control measures, political considerations, public relations, available resources, and other factors all influence the decision to launch a field investigation. Exercise 6.2For the month of August, 12 new cases of tuberculosis and 12 new cases of West Nile virus infection were reported to a county health department. If you have questions about the laboratory findings (for example, if the laboratory tests are inconsistent with the clinical and epidemiologic findings), ask a qualified laboratorian to review the laboratory techniques being used. If you do not have the clinical background to verify the diagnosis, bring a qualified clinician with you.
Talking directly with some patients gives you a better understanding of the clinical features, and helps you to develop a mental image of the disease and the patients affected by it. In addition, conversations with patients are very useful in generating hypotheses about disease etiology and spread. They may be able to answer some critical questions: What were their exposures before becoming ill? Do they have anything in common with others who have the disease?Third, summarize the clinical features using frequency distributions. Frequency distributions of the clinical features are useful in characterizing the spectrum of illness, verifying the diagnosis, and developing case definitions. However, the cases that prompt the concern are often only a small and unrepresentative fraction of the total number of cases.
Investigators may conduct what is sometimes called stimulated or enhanced passive surveillance by sending a letter describing the situation and asking for reports of similar cases. Alternatively, they may conduct active surveillance by telephoning or visiting the facilities to collect information on any additional cases.In some outbreaks, public health officials may decide to alert the public directly, usually through the local media.
For example, in an outbreak of listeriosis in 2002 caused by contaminated sliceable turkey deli meat, announcements in the media alerted the public to avoid the implicated product and instructed them to see a physician if they developed symptoms compatible with the disease in question.(27)If an outbreak affects a restricted population such as persons on a cruise ship, in a school, or at a work site, and if many cases are mild or asymptomatic and therefore undetected, a survey of the entire population is sometimes conducted to determine the extent of infection. A questionnaire could be distributed to determine the true occurrence of clinical symptoms, or laboratory specimens could be collected to determine the number of asymptomatic cases.Finally, investigators should ask case-patients if they know anyone else with the same condition.
Frequently, one person with an illness knows or hears of others with the same illness.In some investigations, investigators develop a data collection form tailored to the specific details of that outbreak.
Regardless of which form is used, the data collection form should include the following types of information about each case.Identifying information. A name, address, and telephone number is essential if investigators need to contact patients for additional questions and to notify them of laboratory results and the outcome of the investigation. Names also help in checking for duplicate records, while the addresses allow for mapping the geographic extent of the problem.Demographic information.
Supplementary clinical information, such as duration of illness and whether hospitalization or death occurred, helps characterize the spectrum of illness.Risk factor information.
For example, since food and water are common vehicles for hepatitis A but not hepatitis B, exposure to food and water sources must be ascertained in an outbreak of the former but not the latter.Reporter information. The case report must include the reporter or source of the report, usually a physician, clinic, hospital, or laboratory. Investigators will sometimes need to contact the reporter, either to seek additional clinical information or report back the results of the investigation.Traditionally, the information described above is collected on a standard case report form, questionnaire, or data abstraction form.
Investigators then abstract selected critical items onto a form called a line listing (See Lesson 2 for more information on line listings.
Thus, a line listing contains key information on every case and can be scanned and updated as necessary. Investigation of bioterrorism-related anthrax, United States, 2001: epidemiologic findings. This process, in which the outbreak is characterized by time, place, and person, is called descriptive epidemiology. This graph, called an epidemic curve, or epi curve for short, provides a simple visual display of the outbreak's magnitude and time trend.
A large outbreak of Salmonella Enteritidis infections associated with crabcakes at a church fundraiser–Maryland, 2003. This information forms the basis for predicting whether more or fewer cases will occur in the near future.The curve can be used for evaluation, answering questions like: How long did it take for the health department to identify a problem? In that situation, it may be useful to draw several epidemic curves with different units on the x-axis to find one that best portrays the data. The shape of the epidemic curve is determined by the epidemic pattern (for example, common source versus propagated), the period of time over which susceptible persons are exposed, and the minimum, average, and maximum incubation periods for the disease.An epidemic curve that has a steep upslope and a more gradual down slope (a so-called log-normal curve) is characteristic of a point-source epidemic in which persons are exposed to the same source over a relative brief period. If the duration of exposure is prolonged, the epidemic is called a continuous common-source epidemic, and the epidemic curve has a plateau instead of a peak. An intermittent common-source epidemic (in which exposure to the causative agent is sporadic over time) usually produces an irregularly jagged epidemic curve reflecting the intermittence and duration of exposure and the number of persons exposed.
Consider the epidemic curve of acute hemorrhagic conjunctivitis in Puerto Rico, shown in Figure 6.4.
If you only had data through Week 35, that is, through point A, you might conclude that the outbreak is still on the upswing, with more cases to come.
On the other hand, if you had data through point B, you might judge that the outbreak has peaked and may soon be over.The cases that stand apart may be just as informative as the overall pattern.
An early case may represent a background or unrelated case, a source of the epidemic, or a person who was exposed earlier than most of the cases (for example, the cook who tasted a dish hours before bringing it to the big picnic). Similarly, late cases may represent unrelated cases, cases with long incubation periods, secondary cases, or persons exposed later than most others (for example, someone eating leftovers).
All outliers are worth examining carefully because if they are part of the outbreak, they may have an easily identifiable exposure that may point directly to the source.In a point-source epidemic of a known disease with a known incubation period, the epidemic curve can be used to identify a likely period of exposure.
This information can be found on disease fact sheets available on the Internet or in the Control of Communicable Diseases Manual.(29)Identify the peak of the outbreak or the median case and count back on the x-axis one average incubation period. Since this technique is not precise, widen the probable period of exposure by, say, 20% to 50% on either side of these dates, and then ask about exposures during this widened period in an attempt to identify the source.In a similar fashion, if the time of exposure and the times of onset of illness are known but the cause has not yet been identified, the incubation period can be estimated from the epidemic curve. Subtract the time of onset of the earliest cases from the time of exposure to estimate the minimum incubation period. Subtract the time of onset of the median case from the time of exposure to estimate the median incubation period. The incubation period for hepatitis A ranges from 15 to 50 days (roughly 2 to 7 weeks), with an average incubation period of 28–30 days (roughly one month). The date of onset of the last known case was during the week of November 18, less than one month later. All of the cases occur within the range of incubation periods expected for a point source exposure. This turned out to be the exact period during which a restaurant employee, diagnosed with hepatitis A in mid-October, would have been shedding virus while still working.
In summary, the graph reflects an outbreak (number of cases clearly in excess of usual) beginning during the week of October 28, peaking during the week of November 4, and ending during the week of November 18. Based on these data and knowledge of the incubation period of hepatitis A, the period of exposure was probably in early to mid-October.
If the map shows a cluster or other pattern (such as cases along a road), the investigator must consider possible explanations — perhaps water supplies, wind currents, or proximity to a restaurant or grocery.
In an outbreak of pneumococcal pneumonia in a nursing home in New Jersey, cases were more common in the north wing than in the south wing (Figure 6.6). A preventable outbreak of pneumococcal pneumonia among unvaccinated nursing home residents in New Jersey during 2001.

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