MALI EBOLA CRISIS
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WHO Details Ebola Export From Guinea To Mali
WHO has detailed the history and contacts of the export of Ebola from Guinea to Mali.
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niman
Post subject: Re: WHO Details Ebola Export To Mali
PostPosted: Mon Nov 10, 2014 5:02 pm
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Mali case, Ebola imported from Guinea
Ebola situation assessment - 10 November 2014
Investigations undertaken by Ministries of Health in Mali and Guinea, assisted by WHO, have clarified the early exposure history of Mali’s first Ebola case.
The index case in Mali, a 2-year-old girl who resided with her family in the urban commune of Beyla, Guinea, was diagnosed with Ebola, in Kayes, Mali, on 23 October and died on the following day.
In Guinea: a family devastated by an undiagnosed disease
The child’s history while still residing in Guinea strongly suggests that several members of her family died from Ebola virus disease. Most of the patients described below were buried safely by Red Cross volunteers, but not tested until late in the transmission chains.
The Guinea history reveals many difficult challenges faced by ministries of health, local health officials, WHO and other partners in the Ebola response.
The child’s history begins with the death of her father, of unidentified causes, on 3 October.
The father was a Red Cross worker who also provided care at a private medical clinic owned by his father (the paternal grandfather of the index case). The paternal grandfather was a retired health care worker.
While working at the private medical clinic, the child’s father had contact with a farmer from another village who died, of undiagnosed causes, on 12 September. The farmer sought treatment accompanied by his two daughters. Both daughters died, of undiagnosed causes, in Beyla on 23 September, one at dawn and the other in the evening.
WHO data from Sierra Leone strongly suggest that Ebola care in private health facilities, as opposed to care in publicly-funded or MSF-run Ebola treatment centres, carries a higher risk of infection. In Kenema, for example, 87% of new infections among health care workers have been acquired in privately-run non-Ebola clinics.
Going home to die
The child’s father fell ill sometime during the third week of September. Fellow residents and neighbours in Beyla believed he was the victim of a bad-luck “curse” following an argument with the village chief. Witchcraft, and not Ebola, was suspected.
Shunned by the community, and on the advice of his own father (the paternal grandfather of the index case and the head of the family), the father returned to his native village of Sokodougou, in the sub-prefecture of Moussadou – a trip of more than 70 kilometres. He died there on 3 October.
This pattern of returning to a native village to grow old or die is commonly seen in Guinea, Liberia, Sierra Leone and many other countries around the world.
Such frequent travels by symptomatic Ebola patients, often via public transportation and over long distances, unquestionably create multiple opportunities for high-risk exposures – en route and also when the patient reaches his home and is greeted by family and friends.
Diagnosis: Ebola
Meanwhile in Beyla, the paternal grandfather and family head lost his wife to an unknown disease on 8 October. He then allowed health officials to undertake contact tracing of 16 family members who had been in close contact with his deceased son (the father of the index case in Mali).
On the following day (9 October), two of his other sons were admitted to hospital. The hospital referred them to a MSF-run Ebola transit centre in Macenta.
The first son died the same day en route to Macenta. On 10 October, samples from both sons tested positive for Ebola, strongly suggesting that other family members had also died from Ebola virus disease.
On 16 October, the paternal grandfather travelled to Macenta, seeking treatment for what he told medical staff was “rheumatoid arthritis”. As part of a thorough medical examination, he was tested for Ebola. Positive results were received from the laboratory on 17 October. The paternal grandfather died at an Ebola treatment centre in Gueckedou on 20 October.
Mali’s index case leaves Guinea
Following news of the death of relatives in Guinea, the child’s grand aunt or “Grandma” (the second wife of the maternal grandfather) travelled to Beyla, Guinea, to offer her condolences to her relatives. The “Grandma” resides in Kayes, Mali.
She left Guinea to return to Mali on 19 October, taking the 2-year-old index case and her 5-year-old sister with her. A maternal uncle, the mother’s brother, also accompanied them. The index case was showing haemorrhagic symptoms in Guinea when the three began their extensive travels.
The mother is alive and is in regular telephone contact with the Mali team. She has to remain in the village where her husband was buried for 40 days for the official mourning, before she can leave. Her three-month-old baby is with her in Guinea. Both are under observation and, to date, neither has shown any symptoms.
The family group travelled via public transportation, taking at least one bus and 3 taxi rides as they journeyed more than 1200 kilometres through Mali. The buses made frequent stops for fuel or to let passengers on. The four spent 2 hours in the capital, Bamako, visiting relatives in a household with 25 people.
On 19–20 October, they travelled overnight in one bus from Bamako to Kayes. Between Bamako and Kayes, only two persons left the bus at Niamiga village. Persistent tracking eventually located both at their final destinations, in Dakar, Senegal and Paris, France.
Once in Kayes, the Grandma and index case consulted two traditional healers. The second healer took them to a retired nurse, who was alarmed by the child’s high temperature, which was above 40oC. When he learned they had recently travelled in Guinea, he suspected Ebola and advised them to seek treatment at a hospital.
The child was admitted to the hospital in Kayes on 21 October and diagnosed with Ebola following receipt of positive laboratory results on 23 October. She was hospitalized and treated in isolation, with infection prevention and control equipment and procedures in place. She died on 24 October.
The emergency response in Mali continues
In collaboration with WHO, the Ministry of Health has established an incident command structure to mount a coordinated response that includes surveillance and contact tracing, case management, safe burials, social mobilization and logistics.
To date, Malian health officials, aided by WHO, the US Centers for Disease Control and Prevention (CDC), Mèdecins sans Frontières (MSF), the International Federation of Red Cross and Red Crescent Societies, and several other partners have identified 108 contacts of the symptomatic patient, including 33 health care workers who were exposed. Of the 108 contacts, 25 have been followed for 21 days and have been released from the surveillance system.
Seventy-nine contacts were at the hospital where the child was treated and in the Kayes community. All have been monitored. To date, no one has shown signs of Ebola or tested positive for the disease.
The government has accelerated the completion of an isolation facility at the Center for Vaccine Development in Bamako. Isolation facilities were part of the strategies put in place in Senegal and Nigeria to successfully contain Ebola.
Bamako has a well-functioning biosafety level 3 laboratory, previously established with support from the US National Institutes of Health to carry out diagnostic work with tuberculosis bacteria and HIV. The laboratory has now been repurposed to safely test Ebola samples.
With persistent and thorough contact tracing, isolation and monitoring in place, confidence is growing that no further spread within Mali followed exposure to the index case, who had haemorrhagic symptoms but no diarrhoea or vomiting during her travels.
The last region in Sierra Leone to be struck by Ebola now has had 50 deaths, the United Nations (UN) said today, in the wake of a warning from the top UN official to guard against complacency following reports of declining cases in some areas of the three hard-hit countries.
In other developments, Sierra Leone reported 111 Ebola cases yesterday, the highest daily count since August, according to a media report, while large new funding pledges were made by Japan and by the African Union in association with other African groups.
Also today, the World Health Organization (WHO) reported that the Ebola case in a 2-year-old Guinean girl who became Mali's first case-patient was preceded by a series of fatal cases in her family. The WHO said confidence is growing that her illness did not trigger any further spread in Mali.
Sierra Leone region hit after long resistance
In a situation report today, the UN Mission for Ebola Emergency Response (UNMEER) said Koinadugu, the last area of Sierra Leone to feel Ebola's impact, has had 50 deaths since mid-October. The region is a remote, mountainous, and "largely inaccessible" area in the country's northeast.
Sixty Ebola virus disease (EVD) cases have been confirmed in Koinadugu, and 200 people have been quarantined, UNMEER reported. It said the area previously had taken pride in being the last part of Sierra Leone unaffected by the epidemic.
Meanwhile, Sierra Leone's health ministry said 111 new Ebola cases were reported yesterday, the highest daily count since the ministry started publishing figures in August, the UK's Guardian newspaper reported today. That followed 45 cases reported the day before.
The numbers included a surge of cases in Port Loko, a district northeast of Freetown (the capital) that has no treatment center, the story said. The UN warned recently that up to half of Ebola cases in Sierra Leone were not being reported, the story noted.
Ban Ki-moon cautions against premature exuberance
In a Nov 7 Washington Post commentary, UN Secretary-General Ban Ki-moon warned against the danger of "declaring 'mission accomplished' too soon" in the Ebola crisis.
"The rate of new Ebola cases shows encouraging signs of slowing in some of the hardest-hit parts of Liberia, Guinea and Sierra Leone—and that's good news," Ban wrote. "The full-scale international strategy to attack Ebola through safe burials, treatment facilities, and community mobilization is paying dividends.
"But as caseloads go down in some areas, they are rising in others. Some of the worst-affected areas are now almost free of Ebola while neighboring districts are seeing numbers climb sharply. Beds may be empty in one facility while treatment centers are overflowing elsewhere."
Although the response to the epidemic has accelerated greatly, "huge gaps remain in funding, equipment and, most urgently, medical personnel," Ban wrote. "Each day's delay in intensifying the response adds greatly to the toll in lives, the cost of ending the outbreak, the social and economic impact, and the risk of the disease spreading to other countries."
"Now is no time to let down our guard," he warned. "We must keep fighting the fire until the last ember is out."
Liberian town reeling
Meanwhile in Liberia, a town of 300 people in Grand Cape Mount County near the Sierra Leone border has become a new epicenter for Ebola in the country, the Associated Press (AP) reported today.
The outbreak in the town of Jene-Wonde began when a teacher brought his sick daughter there from Monrovia, the capital, the story said. Soon he and his whole family succumbed to the disease. Momo Sheriff, a resident whose son died of Ebola, said the town has no healthcare and has lost 10% of its inhabitants to Ebola since late September.
Abdullai Kamara, the leader of Burial Team A of Grand Cape Mount County Ebola, said the people of Jene-Wonde have been stubborn and in denial about the disease, which he cites as the reason it is still spreading, according to the AP. Another local resident said he feared that without government help, the town will cease to exist.
Background of case in Mali
In following up on Mali's first Ebola case, the WHO issued a fairly lengthy statement today about earlier cases in the family of the 2-year-old Guinean girl who died of EVD in Mali on Oct 24, after being brought there by a relative.
The girl lived in the urban commune of Beyla, Guinea. The girl's father, a Red Cross worker who provided care at a private clinic owned by his own father (the girl's grandfather), got sick after contact with a sick farmer from another village on Sep 12. The father died of unknown causes on Oct 3, after going back to his native village.
The wife of the little girl's grandfather also fell ill and died of unknown causes on Oct 8, the WHO said. The next day two of the grandfather's other sons also got sick and were referred to an Ebola treatment center in Macenta; one of them died en route, and both subsequently tested positive for EVD, strongly suggesting that the other deaths were also due to Ebola.
The grandfather also got sick a few days after the two sons, and he died of EVD in Gueckedou on Oct 20, the report says.
After news of the deaths in the family, the 2-year-old's "grand aunt" (second wife of her maternal grandfather), who lives in Kayes, Mali, traveled to Beyla to offer condolences, the WHO reported. When she left Guinea on Oct 19, she took the little girl and her 5-year-old sister along, traveling by taxi and bus.
In Kayes the grand aunt took the girl to traditional healers and later to a hospital, where she tested positive for Ebola on Oct 23. She died the next day.
Thus far, Malian health officials and partner groups have identified 108 contacts of the little girl, including 33 healthcare workers, the WHO said. Of the 108, 25 have been followed for 21 days and released from surveillance. None of the contacts have shown signs of disease or tested positive for the virus.
"With persistent and thorough contact tracing, isolation, and monitoring in place, confidence is growing that no further spread within Mali followed exposure to the index case, who had haemorrhagic symptoms but no diarrhoea or vomiting during her travels," the agency said.
New pledges of support from Japan, Africa
On the funding side, Japan announced that it will make available an extra $100 million to aid the fight against EVD, according to today's UNMEER report. The pledge comes on top of a pledge of $40 million made by Prime Minister Shinzo Abe in September.
Japan also decided that, of the earlier $40 million, it will provide $4 million each to the governments of Guinea, Liberia, and Sierra Leone for medical and epidemic prevention equipment, the UN said. In addition, Japan will contribute $6 million to the UN Ebola Response Multi-Partner Trust Fund to support UNMEER's efforts.
On Nov 8 a coalition of African groups, including the African Union (AU), the African Development Bank, and business people announced a funding mechanism to help support African medical workers, with more than $28 million in initial pledges. The AU said in a statement that the funding plan came from a roundtable attended by chief executive officers from several sectors, including banking, telecommunications, mining, energy, services, and manufacturing.
They established the fund under the African Union Foundation through a facility managed by the African Development Bank, aiming to improve efforts to equip, train, and deploy health workers to help battle the disease in Guinea, Liberia, and Sierra Leone.
According to the AU, the business executives also committed logistical support and in-kind contributions. Business participants also agreed to build citizen action around a "United Against Ebola" campaign that would offer individuals in Africa and overseas an opportunity to donate.
DoD fleshes out quarantine details
In the United States, the Department of Defense (DoD) on Nov 7 announced new details about a mandatory 21-day controlled monitoring period for service members returning from West Africa's outbreak countries as part of Operation United Assistance.
As many as 4,000 soldiers could be deployed to assist with the global response. As of late October, about 700 troops had been sent to the region.
On Oct 29 DoD Secretary Chuck Hagel announced the 21-day monitoring period for all troops returning from the region and asked the Joint Chiefs of Staff to announce specifics in 15 days and review the system in 45 days. The DoD program is more stringent than the CDC's recommendations, which don't include mandatory quarantine for asymptomatic people.
Service members will be quarantined at one of seven bases—five in the United States and two in Europe. In a Nov 7 report the DoD said it selected the locations because of their proximity to medical facilities that can treat Ebola, do the required monitoring, and control access. They are:
Fort Bliss, El Paso, Tex.
Joint Base Langley-Eustis, Hampton, Va.
Fort Hood, Killeen, Tex.
Fort Bragg, Fayetteville, N.C.
Joint Base Lewis-McChord, Wa.
US Army Garrison Baumholder, Germany
US Army Garrison Caserma Del Din, Vicenza, Italy
Military officials say the quarantine measures address the needs of service members and their families and that officials will assess and adapt the program as needed, according to the DoD report.
Africa Cup soccer may not have a host
In related news, Morocco has decided not to host the Africa Cup of Nations soccer tournament in January out of fear that fans would bring Ebola into the country, the Canadian Press reported today. The Moroccan government has been asking the Confederation of African Football (CAF) to postpone the tournament until June 2015, the story said.
CAF executives are due to meet tomorrow to decide the tourney's fate and may have to give up on it for 2015, according to the story. Four possible stand-in countries, South Africa, Sudan, Egypt, and Ghana, have also indicated they are not willing to host. It is unclear if any other countries met the Nov 8 deadline to offer to replace Morocco as the host.
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