H5N1

As Ebola ebbs in Africa, focus turns from death to life

Via The New York Times, a report by Norimitsu Onishi: As Ebola Ebbs in Africa, Focus Turns From Death to Life. Excerpt:

Here in Monrovia, the capital, ambulances and body collection vehicles that once barreled through the streets are a rare sight. Soccer matches are now played throughout the city on weekend mornings. Buckets filled with chlorine water are gone from most entrances, or sit empty. People can be seen shaking hands once again, squeezing into taxis and touching during conversations, as the fear of the virus ebbs and Liberians slip back into their daily, tactile rhythm. 

“We used to be afraid to touch our friends, but the fear is small, small now,” Patrick Chea, 19, said outside Mary Brownell Junior High School, where students horsed around as they cleaned up the schoolyard. Mr. Chea playfully placed his hand on the head of Sonnie Kollie, a 16-year-old girl — who promptly punched him on the shoulder. 

Experts are trying to understand how the disease, which has defied the ominous predictions of the world’s top infectious disease researchers, appears to be extinguishing itself with surprising swiftness. In September, the United States Centers for Disease Control and Prevention had projected that, by Jan. 20, the outbreak could reach 1.4 million cases in Liberia and Sierra Leone alone, but by that date only 21,797 were recorded in all three countries.

While many have emphasized the enormous assistance hauled into the region by the United States and international organizations, there is strong evidence, especially here in Monrovia, that the biggest change came from the precautions taken by residents themselves. 

“Fundamentally, this is about the extent to which societies change their behaviors, how they change them, and the speed at which they change them,” said Dr. David Nabarro, the United Nations special envoy on Ebola, who made frequent trips to the hot zone at the height of the epidemic. “I believe for various reasons people in Liberia changed quickly and dramatically. I believe Sierra Leoneans changed quickly in some areas and less quickly in some areas.” 

When Ebola struck the densely crowded neighborhoods of Monrovia over the summer, the first time a capital city had faced Ebola’s full onslaught, the impact was devastating. Hundreds of new cases appeared around the country every week, hospitals collapsed or overflowed with patients, and sick people lay along the road, sometimes dying before help could reach them.

Disease Watchdogs 

Reeling from the explosion of infections in August, volunteer Ebola watchdog groups sprang up in many neighborhoods, typically overseen by local elders and led by educated youths, drawing from a long history of community organizing to survive war, poverty and government neglect. 

With little or no outside help in the early months, the groups educated their communities about Ebola, a disease new to this part of Africa, and collected money to set up hand-washing stations at key spots. They kept records of the sick and the dead. Many also placed households under quarantine and restricted visits by outsiders. 

As the sick were turned away at the gates of treatment centers because of a lack of beds, people inside homes began protecting themselves better, covering their arms in plastic shopping bags as they cared for ailing relatives. The gear became known as Liberian P.P.E.’s, or personal protective equipment, a reference to the more impermeable suits worn by health workers. 

By mid-October, new cases in Liberia had dropped precipitously, to dozens from hundreds per week. A few clinics run by Liberians and international charities had opened, but the drop took place a solid month before any of the treatment centers built by the American military had even begun accepting patients.

Chimerix scraps testing of experimental Ebola drug in Liberia

Via The Wall Street Journal: Chimerix Scraps Testing of Experimental Ebola Drug in Liberia. Excerpt:

Chimerix Inc. scrapped testing of its experimental antiviral in Ebola patients in Liberia, saying the number of infections had dropped in recent weeks, and that only a handful of patients had been enrolled in the Liberian study. 

The abrupt reversal in Chimerix’s plans could raise questions about whether the declining number of Ebola infections in West Africa could be a problem for other experimental drugs and vaccines currently undergoing testing in the region for safety and efficacy. The World Health Organization said this week the incidence of the deadly disease continues to fall in the three countries that were hardest hit last year—Guinea, Liberia and Sierra Leone. 

More than 22,000 people had been infected with Ebola and more than 8,800 had died as of Jan. 25, primarily in the three West African countries, according to WHO. 

Chimerix, of Durham, N.C., said in a news release issued late Friday that after discussions with the U.S. Food and Drug Administration, the company “is ceasing further participation in all current and future clinical studies of brincidofovir” for Ebola virus disease. This includes a study in Liberia sponsored by the U.K.’s University of Oxford, which began in January. 

Peter Horby, an Oxford researcher who was helping to run the study, said the decision to halt it “arose from bilateral discussions between Chimerix and the FDA.” He said he wasn’t aware of any reasons for the decision beyond declining case numbers. An FDA representative couldn’t immediately be reached.

Ebola in West Africa: A timeline

Via ReliefWeb, a useful AFP report: Ebola: timeline of a ruthless killer.

Here are key dates in the current Ebola epidemic, the worst ever outbreak of the haemorrhagic fever which first surfaced in 1976 in the Democratic Republic of Congo (DRC). 

According to the latest toll given by the World Health Organization (WHO), the epidemic has left 8,810 dead, mainly in the west African states of Guinea, Liberia and Sierra Leone, out of the more than 22,000 cases registered. 

-- DECEMBER 2013 -- - 6: A two-year-old child dies in Meliandou in southern Guinea and is later identified as "patient zero". The virus remains localised until February 2014, when a careworker in a neighbouring province dies. 

-- MARCH 2014 -- - 24: Authorities in Guinea and the WHO say that since January the country has recorded 87 suspected cases of viral haemorrhagic fever, including 61 deaths. Scientists studying samples in the French city of Lyon confirm it is Ebola. 

• 31: Liberia confirms two cases. 

-- MAY -- - 26: Sierra Leone confirms its first case. 

-- JULY -- - 30: Ebola is "out of control" according to the aid group Doctors Without Borders (MSF). The affected countries declare measures including states of emergency and quarantines. Many neighbouring nations close their borders with the affected countries. 

-- AUGUST -- - 8: The WHO declares the Ebola epidemic a "public health emergency of international concern". 

• 12: The WHO authorises the use of experimental drugs in the fight against Ebola after an ethical debate. A Spanish missionary contaminated in Liberia dies in Madrid, the first European fatality. 

-- SEPTEMBER -- - 30: In the United States, a Liberian is hospitalised in Texas, the first Ebola infection diagnosed outside Africa, and dies on October 8. 

-- OCTOBER -- - 6: First infection outside Africa, of a Spanish nurse in a Madrid hospital. She is treated and given the all-clear on the 19th. 

• 17-20: Senegal and Nigeria are declared Ebola-free. 

-- DECEMBER -- - 18-19: UN chief Ban Ki-moon pledges support for Ebola-ravaged countries and to rebuild their health systems on a tour of the three hardest-hit nations. 

It marked the highest-level such tour since the epidemic began. French President Francois Hollande had been the only non-African head of state to visit one of the worst-hit countries with a trip to Guinea on November 29. 

 -- JANUARY 2015 -- 

• 17: The football Africa Cup of Nations begins in Equatorial Guinea after being moved there at the last minute following Morocco's refusal to act as hosts over fears of Ebola.  

• 18: The Malian government and the United Nations declare the country free of Ebola. 

• 23: US health authorities announce that a large-scale trial will start in Liberia with two leading candidate vaccines. Trials in Guinea and Sierra Leone to follow in February. 

• 29: The Ebola epidemic is decreasing but is still present in a third of the areas of the three affected west African nations, UN Ebola coordinator David Nabarro warns.

Hong Kong: CHP closely monitors second human case of avian influenza A(H7N9) in Canada

Via the Centre for Health Protection: CHP closely monitors second human case of avian influenza A(H7N9) in Canada. Excerpt:

The Centre for Health Protection (CHP) of the Department of Health (DH) is today (February 1) closely monitoring the second human case of avian influenza A(H7N9) reported by Canada, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.      

"This is the second case reported in North America to date. We will remain vigilant and work closely with neighbouring and overseas health authorities to monitor the latest developments," a spokesman for the CHP said.

According to the Public Health Agency of Canada, this case and the previous case (reported on January 26) are a couple who are residents of British Columbia. They recently travelled to China together and were not symptomatic during travel. They returned to Canada on January 12 by Air Canada flight AC 008. They only began showing symptoms after arrival in Canada. They did not require hospitalisation and are currently recovering from their illness.

All evidence indicates they were infected following exposure in Mainland China. Since the two cases became symptomatic one day apart, it is likely they were exposed to a common source, rather than one having been infected by the other. All close contacts of them have been identified and their health conditions were being monitored by provincial public health authorities. Public health officials have completed their follow-up of contacts and there has been no further spread.

To date, 523 cases have been reported globally since March 2013, including 504 cases in the Mainland and 19 cases exported to Hong Kong (12 cases), Taiwan (four cases), Malaysia (one case) and Canada (two cases).

US: Vaccine critics turn defensive over measles

Via The New York Times: Vaccine Critics Turn Defensive Over Measles. Excerpt:

Huntington Beach, Calif. -- Their children have been sent home from school. Their families are barred from birthday parties and neighborhood play dates. Online, people call them negligent and criminal. And as officials in 14 states grapple to contain a spreading measles outbreak that began near here at Disneyland, the parents at the heart of America’s anti-vaccine movement are being blamed for incubating an otherwise preventable public-health crisis. 

Measles anxiety rippled thousands of miles beyond its center on Friday as officials scrambled to try to contain a wider spread of the highly contagious disease — which America declared vanquished 15 years ago, before a statistically significant number of parents started refusing to vaccinate their children.  

In recent days, new measles cases popped up in Nebraska and Minnesota, New York and Marin County in California. Officials around the country reported rising numbers of patients who were seeking shots, as well as some pediatricians who were accepting nonvaccinated families but were debating changing their policies. The White House urged parents to listen to the science that supports inoculations. 

In Arizona, health officials warned that 1,000 people could have been exposed to measles and urged anyone displaying symptoms to avoid this weekend’s Super Bowl events in the Phoenix area. In a small planned community where one family became ill after visiting Disneyland, store windows were lined with measles alerts, and a sign on the Pinal County office building warned: “Stop! Measles is in our county!” and asked people with symptoms to wear masks before entering. 

But here in California, anti-vaccine parents whose children have endured bouts of whooping cough and chickenpox largely defended their choice to raise their children on natural foods, essential oils and no vaccinations. 

“There is absolutely no reason to get the shot,” said Crystal McDonald, whose 16-year-old daughter was one of 66 students sent home from Palm Desert High School for the next two weeks because they did not have full measles immunizations. 

After researching the issue and reading information from a national anti-vaccine advocacy group, Ms. McDonald said she and her husband, a chiropractor, decided to raise their four children without vaccines. She said they ate well and had never been to the doctor, and she insisted that her daughter was healthier than many classmates. But when the school sent her home with a letter, Ms. McDonald’s daughter was so concerned about missing two weeks of advanced-placement classes that she suggested simply getting a measles inoculation. 

“I said, ‘No, absolutely not,’ “ Ms. McDonald said. “I said, ‘I’d rather you miss an entire semester than you get the shot.’ “ 

The anti-vaccine movement can largely be traced to a 1998 report in a medical journal that suggested a link between vaccines and autism but was later proved fraudulent and retracted. Today, the waves of parents who shun vaccines include some who still believe in the link and some, like the Amish, who have religious objections to vaccines. 

Then there is a particular subculture of largely wealthy and well-educated families, many living in palmy enclaves around Los Angeles and San Francisco, who are trying to carve out “all-natural” lives for their children.

“Sometimes, I feel like we’re practicing in the 1950s,” said Dr. Eric Ball, a pediatrician in southern Orange County, where some schools report that 50 to 60 percent of their kindergartners are not fully vaccinated and that 20 to 40 percent of parents have sought a personal beliefs exemption to vaccination requirements. “It’s very frustrating. It’s hard to see a kid suffer for something that’s entirely preventable.”

Saudi Arabia: No new MERS cases, no deaths, no recoveries as of noon January 31

Via the KSA Command and Control Center: MOH: 'No New Corona Cases Recorded'. And no deaths or recoveries. So the month ends with six cases under care, 475 recovered, 845 total, and 364 deaths.

MSF Ebola crisis update for January 30

MSF doesn't post Ebola updates as often as I'd like (daily would be nice), but it's always worth the wait. Here's the latest: Ebola crisis update - 30 January 2015. Excerpt:

Guinea 

While the total number of new cases has considerably decreased during the last weeks - reaching 9 confirmed cases over 17 hospitalisations in the whole country - with 13 of the country’s prefectures considered as “active”, the epidemic is still geographically spread out. Moreover, new chains of transmission have been reported in areas previously considered as Ebola-free. 

To respond to this new dynamic, MSF deployed a rapid response team to intervene in the new hotspots. This team is currently intervening in Faranah where new cases have been reported. A second rapid response team should arrive shortly in the country. These teams are able to quickly identify, investigate and follow new cases and contacts, as well as quickly setting up isolation units within existing health structures. 

On January 17th, the government officially launched the “0 cases in 60 days” plan. 

The number and rate of health staff infections remains high, especially in private structures 

Conakry 

There has been a slight increase in cases with 8 new admissions at Donka CTE. MSF continues outreach and community sensitization activities in the city but the level of acceptance remains low. 

Guéckédou 


With 2 admissions (of which 1 confirmed case, the only one in the ETC) during the last days, the number of patients remains low. MSF launched a support intervention in the nearby town of Kissidougou, where new cases have been reported. 

The favipiravir trial led by INSERM is ongoing. 

Liberia 

Liberia has seen a sharp decline in Ebola cases. Due to the overall improvement of the situation in the country, MSF has progressively reduced its activities, and is working today in Monrovia in two facilities: the Redemption Hospital transit centre and ELWA 3. The main focus is now on surveillance, infection control and prevention, health promotion and training activities. Support of non-Ebola healthcare remains a priority. 

Monrovia: ELWA 3 ETC 

On 17 January, there were no Ebola patients in ELWA 3 for the first time since it opened.  Currently this ETC hosts only one patient. The downsizing of the centre has begun with a first reduction from 200 to 60 beds. An additional downsizing to 30 beds is planned for the beginning of February. 

In the meantime, MSF started the decommissioning of an old part of the ETC. A survivors’ clinic, aiming to offer psychosocial support, health screening and primary health care to Ebola survivors started this week. 

The brincidofovir trial: The trial group is following a case by case approach for the inclusion of new patients. Trial may be resumed sooner than expected due the reduced number of patients.

I'm really happy to see that MSF is providing follow-through care for Ebola survivors. When the outbreak is over, the survivors are likely to be carefully forgotten.

Ebola reveals flaws of African solidarity

Via The Manila Times, an AFP report: Ebola reveals flaws of African solidarity. Excerpt:

ADDIS ABABA: As Africa’s leaders meet in Ethiopia to discuss the Ebola crisis, expectations of firm action will be tempered by criticism over the continent’s poor record in the early stages of the epidemic. 

The outbreak is a priority on the agenda of the 54-nation African Union (AU) summit in Addis Ababa on Saturday, yet the bloc is still smarting from criticism that it reacted too slowly to the outbreak. 

Health workers and cash have flooded in from the United States, Britain and even Cuba as part of a UN-led surge to battle an epidemic which has seen nearly 9,000 deaths in Liberia, Guinea and Sierra Leone. 

Yet it was only in September — 10 months after the virus emerged and a month after it was declared a “health emergency of international concern” —that the AU held an emergency summit. 

The three hardest-hit nations have expressed disappointment that their continental neighbors seemed initially to be much quicker to shut borders and ban flights than to deploy resources. 

Sierra Leone President Ernest Bai Koroma hinted at his disillusionment in August when he greeted a $500,000 donation from Gambia with an ill-disguised dig at his other African neighbors. 

“In moments like this, we will remember our friends including those that are rallying round us and those that show true spirit of African solidarity,” he said. 

He added that “we expect African countries and organizations including ECOWAS and the African Union to rally round and show solidarity which the Gambian president has demonstrated”. 

A week earlier Ibrahim Ben Kargbo, a senior official, had expressed “shock” that South Africa had donated a mobile testing laboratory on one hand while banning Sierra Leoneans on the other. 

The hurt was shared in Liberia where Musa Bility, head of the national football association, told AFP in August that travel bans imposed by several neighbors were “un-African”. 

Nelson Mandela’s widow Graca Machel was more explicit when she blasted African leaders in November for an “inadequate” response to Ebola which demonstrated a lack of regard for human life. 

The AU itself has recognized its shortcomings. At the height of the epidemic, members had deployed just 100 volunteers to west Africa, a quarter of the number provided by Cuba alone.

Ebola: Military healthcare worker returns to UK after needle injury

Via The Guardian: Ebola: military healthcare worker returns to UK after needle injury. Excerpt:

A British military healthcare worker who suffered a needlestick injury while treating an Ebola patient in Sierra Leone has been evacuated to the UK. 

The healthcare worker arrived back in the UK on Saturday on an RAF flight and is being assessed at the specialist isolation unit at the Royal Free hospital in north London. 

The hospital said the patient has not tested positive for Ebola and was showing no signs of the deadly virus. 

“We can confirm that a UK military healthcare worker has been admitted to the Royal Free hospital today following a needlestick injury while treating a person with Ebola in Sierra Leone,” it said in a statement. 

“The individual is likely to have been exposed to the Ebola virus but has not been diagnosed with Ebola and does not have symptoms.” 

Public Health England (PHE) said the individual had been exposed to the virus in a “frontline care setting”. The patient will be monitored for the remainder of their 21-day incubation period. Next of kin have been informed. 

PHE’s director for health protection and medical director, Prof Paul Cosford, expressed confidence that all appropriate precautionary measures had been taken.

How bad data fed the Ebola epidemic

Via The New York Times, an op-ed worth reading and pondering: How Bad Data Fed the Ebola Epidemic. Excerpt (but read the whole thing) and then a comment:

The West African Ebola outbreak first hit Sierra Leone in May 2014, followed by an explosion of cases in the capital Freetown in the autumn. The epidemic now counts more than 10,500 cases across Sierra Leone, with signs that the spread is slowing. 

The early days of the crisis were characterized by a sense of immense fear, anxiety and alarm, regionally and globally. In Sierra Leone, a three-day, countrywide, military-led lockdown in September fed the fear in West Africa and beyond. Many flights originating in unaffected African countries were restricted. African students were prevented from attending some American schools, and there were countless reports of discrimination against Africans across the globe. Pictures of health workers in full protective suits became a ubiquitous symbol of the panic. 

Misleading reports, speculation and poor projections from international agencies, government ministries and the media about the Ebola outbreak exacerbated the problem. The fear that was spread by the dramatic reports that accentuated the negative, undermined confidence, made it harder to encourage people to seek care, and misdirected attention away from Sierra Leone’s urban areas, where data suggest the economic effects of Ebola have been concentrated. 

Valid, credible and timely data is essential during a global crisis. Without reliable data, efforts to assist affected people and to rebuild damaged communities can be misdirected and inefficient. 

An early example of how data were presented misleadingly was the World Health Organization’s choice to report from April through August that the death rate from Ebola was “up to 90 percent,” when the actual death rate of this outbreak from confirmed cases, even in the early days in March 2014 in Guinea, was about 70 percent — still hardly reassuring, but better than almost-certain death. Warning people of likely death is not a good way to encourage them to seek care. 

Both the W.H.O. and the Centers for Disease Control and Prevention misjudged how the disease would evolve. Initially slow to appreciate the severity of the outbreak, the W.H.O. and the C.D.C. subsequently overestimated likely cases. The C.D.C. projected that up to 1.4 million people in Liberia and Sierra Leone could be infected by January 2015. (As of Jan. 27, 19,140 cases have been reported across the two countries.) 

Inaccurate and implausible claims about the economic impact further reduced the public’s confidence, which had its own economic consequences. 

For example, in August, a senior Sierra Leonean government official was reported as saying his country’s Gross Domestic Product had fallen by 30 percent, a figure that was implausible considering the crisis was only a few months old and that even during Sierra Leone’s devastating civil war real G.D.P. fell only by an average of 5 percent a year. 

In October, the World Bank estimated that the costs associated with Ebola for West Africa as a whole may be as high as $32.6 billion, an estimate that was revised down this month to be at most $6 billion. When the public anticipates bad times, they cut back on discretionary purchases and save more, compounding the effects of the shock.

Meanwhile, the local and international press was full of reports of skyrocketing food prices, while surveys undertaken by the International Growth Center and Innovations for Poverty Action of markets across Sierra Leone (conducted monthly from August through December 2014) showed food prices in line with previous years. 

One problem with doomsday scenarios is that when reliable data is finally released — as they were this month — the real figures can seem small and insignificant relative to earlier predictions. 

They are not. In Sierra Leone, the urban areas in particular have been badly hit. The percentage of household heads “not working in the previous week” rose from 25 percent in July/August to 33 percent in November. This reduction in employment is taking place in one of the poorest countries in the world with few formal safety nets. Just over a quarter of household heads work in non-farm household enterprises in which revenues are down by 40 percent over this period, and the six-month failure rate of these businesses tripled.

With people still falling ill with Ebola, the analysis is already under way. And it should be. In fairness, WHO's scary projection of 1.4 million cases was based on the premise that the rest of the world would do nothing. At least it got our attention; the world's collective concern threshold seems to require at least a megadeath.

I have my issues with WHO (and with its member nations' underfunding of it), but the organization took a beating after declaring an H1N1 pandemic in 2009. A lot of people died, but not enough to hit the threshold (and not a zombie to be found worldwide).

 

That may explain why WHO took so long to declare a Public Health Emergency of International Concern over Ebola: crying wolf twice in five years would cause a lot of political grief.

 

The hazards of a bowl of spicy bat soup, and the kissing of corpses, are far less dangerous to global health than the public attitudes of the self-styled "advanced" nations. The only numbers we respect are six-digit body counts (three digits if the bodies are white), preferably from a really gross disease. After all, we've grown up on depictions of tidy deaths in movies where a bullet doesn't even puncture the victim's shirt—he just folds up in a tidy heap. To impress us, a real splatter is required.

 

Given our attitude, WHO and other health agencies must see the West Africans' culture as far more rational than ours. We created a superb public-health system in a fit of absent-mindedness, and now its beneficiaries won't even vaccinate their wretched kids. To get us even dimly aware of a problem requires percussive maintenance on our collective skull. Once aroused, we're as likely to walk into the wall as get through the open door beside it. 

 

Compounding the problem, we can handle only so many mortal threats at one time. Ebola? Forget malaria. Ukraine? Forget Ebola. Someone gets killed by a terrorist and we wet ourselves, ignoring the more than one million deaths from communicable diseases already suffered this year.

 

Ebola may indeed wrap up in West Africa this year, or may simmer on for years like Haiti's cholera. Or we'll learn of some new and mysterious outbreak tomorrow. Whatever happens, the real health communication challenge will be dealing not with the victims but with us, the people who have the material resources to fight it. If only we had the cultural resources as well.