Overview of Emerging Infectious Disease Threats Infectious Disease Epidemiology Section Office of Public Health Louisiana Department of Health and Hospitals 800-256-2748 Transmission of Infectious Diseases Main Modes of Transmission

AIRBORNE

DROPLET

AND Vector borne, Common source: CONTACT Water, Food, Direct Indirect Equipment, Rx Droplet

Droplets above 10 µ m are trapped in the nose and usually do not make it to the A droplet of will fall in bronchi

100 µm 10 seconds 40 µm 1 minute 20 µm 4 minutes 10 µm 20 minutes 5-10 µm 30-45 minutesMay reach lower respiratory tract

≤ 5 µm Droplet nuclei May be inhaled Only ones able to reach to alveoli alveoli Cough produces good droplet nuclei

Cough 1 good cough  465 DN after 30 minutes  228 DN (49%)

Speech: count from 1 to 100  1764 DN after 30 minutes  106 DN ( 6%) Airborne Transmission

• Droplet nuclei = droplets less than 5 µ in diameter • from evaporation of larger droplets • or from direct formation during coughing, speaking, singing • Transmission may occur over long distance

Transmitted by D.N.  Tuberculosis (Infectious) Without air flow  Suspects of TB: request sputum control DN spread smear throughout the building  Measles  Varicella  Smallpox (hemorrhagic) Droplet Transmission • Haemophilus influenzae • Meningococci • Pneumococcal infections (invasive, resistant) • BACTERIAL RESPIRATORY Infections • Diphtheria, Pertussis, pneumonic plague, Mycoplasma pneumoniae • Strepto pharyngitis, pneumonia, scarlet fever • VIRAL RESPIRATORY Infections • Adenovirus, Influenza, Mumps, Parvovirus, Rubella • ANY PAROXYSMAL COUGH (Pertussis?) Droplet & Contact Precautions Most agents transmitted by droplets can also be transmitted by contact Contact: Fecal Oral Second most important mode of transmission after the respiratory tract

• excreted by the feces Viruses with envelopes do • transmitted to the oral portal of entry through not survive exposure to hydrochloric acid in the • contaminated food, stomach, bile acids in the • contaminated water, milk, drinks duodenum, salts and • hands enzymes of the gut. • flies Small enterovirus without envelope (Norovirus, • Site of entry: rotavirus, polio & coxsackie • oropharynx for some microorganisms able to resist. • intestinal tract for most viruses. • Surviving through the upper GI tract is essential. Contact: Fecal-Oral

• Typhoid fever • Shigella • Cholera • Polio • Coxsackie, Echo, Reo • Norovirus • Rotavirus • Hepatitis A, Hepatitis E Transmission Through Skin /Mucous Membrane

Transmission through the skin is the third most common mode of transmission of infection. Penetration through the intact skin is unlikely. Break in the skin barrier may result from: • Needle injection, cut during a surgical procedure, accidental cut, crushing injury… • Bite: rabies • Arthropod bite for vector borne infections: malaria, filariasis…

Some parasites are able to penetrate directly through the intact skin: larvae of hookworm, cercariae of schistosoma. Blood & Tissue Exposure: Skin Penetration, Mucosal Membranes • Blood borne pathogens ( HBV, HCB, HIV) does not penetrate if blood was splashed exclusively on intact skin. • Need injury to the skin: with a hollow bore needle or other sharp object (lancet, glass, scalpel) contaminated with blood to cause an infection. • Solid needles do not carry sufficient quantities of blood to cause an infection ( ± ). • Viral titer is best predictor of risk of infection. • Mucosal membranes allow BBP penetration. Data from 21 studies worldwide on mucosal Risk of infection after membrane exposure of 1107 HCW to HIV percutaneous exposure to blood from infected showed only one conversion: risk of 0.09%, patients, 95%CI = 0.006% to 0.5%. •HBV 30% •HCV 3% •HIV 0.3% Emerging Diseases The Concept of Emergence

Emerging infectious diseases are diseases of infectious origin whose incidence in humans has increased within the past two decades or threatens to increase in the near future

Menu of Emerging Diseases • Really NEW infectious disease • Changing patterns of infectious diseases • Old infectious diseases NEWLY IDENTIFIED • Old infectious disease with NEW ENERGY • Old infectious disease SWINGING BACK & FORTH • Old infectious disease which REFUSE TO GO AWAY How Migrations from Rural to Urban Areas in Africa Triggered a Pandemic Once upon a time in Africa… Two different monkeys, the red-capped mangabey (Cercocebus torquatus) and the greater spot-nosed monkey Cercopithecus nictitans) were infected with the Simian Immunodeficiency Virus (SIV).

The chimpanzees ate the monkeys so they acquired the monkey viruses. The hybrid virus then spread through the chimpanzee species to become “SIVcpz”. The chimpanzees are not known to develop any disease symptoms.

Then humans ate the chimps and acquires the SIVcpz. The virus evolved into the HIV virus… In the 1950s, HIV became a rare infection among dwellers in African villages… Then HIV stayed in the villages: Prevalence of Infection over a 10 Year Period in Zaire

• 1976: 659 serum samples collected in Equateur Province, Zaire because of Ebola epidemic at Yanbuku Mission Hospital • 1985: samples examined for HIV antibodies: 5/659 Pos = 0.8% • 1986: cluster sample of Yambuku population + selected groups re-surveyed: • Of the 5 positive in 1976: 2 alive & well, 3 died of AIDS-like disease • Only 1 of the 5 had traveled outside of the village • Population sample: 3/388 Pos = 0.8% • Femmes Libres: 32/283 Pos = 11.3% • Pregnant women: 3/136 Pos = 2.2% • STABLE HIV IN VILLAGE: present in 1976, No major change in 10 years • In Kinshasa meanwhile HIV prevalence among pregnant women was x10 Nzilambi N 1988. NEJM 318:276 Finally HIV moved to town and started to travel worldwide • 1950: From African forest monkeys  Humans • 1950-60: Stable among isolated villages in forest • 1960-70: Moving to town • 1970-80: Build up among STD core transmission groups Few cases among travelers to Africa, all missed • 1981: the first cases recognized • Few cases of Pneumocystis carinii pneumonia clustered among homosexual men in Los Angeles (CDC 1981. Pneumocystis pneumonia, Los Angeles. MMWR 30 [33]: 409-420) • Outbreak of Kaposi’s sarcoma also among homosexual men • Common thread = profound immunodeficiency  Acquired Immune Deficiency Syndrome (AIDS) The phylogenetic tree shows the progression of the different types. The birth place of the virus is the one with most subtypes Dengue GOOD OLD DAYS • 1779-1780 in Asia, Africa, & N. America: outbreaks • dengue fever = benign, nonfatal disease of visitors to tropics • long intervals (10-40 y) between major epidemics

• MEAN NEW DAYS • global pandemic started in SE Asia after World War II intensified during the last 15 years. • Before 1970 DHF epidemics in 9 countries • Since 1970s: endemic in 100+ countries in Africa, the Americas, the Eastern Mediterranean, South-East Asia and the Western Pacific • 1995 endemic in 41 countries • 2.5 billion (2/5 world) at risk, 50 million cases /yr • 1995 Americas: 275,000 cases, 7,715 cases DHF • attack rates = 6.4 per 100 persons exposed Geographic Distribution

• Tropical regions, in urban & peri-urban • Transmitted by Aedes aegypti & Aedes albopictus • Breeding in peridomestic waters (flower pots, tin cans, discarded tires, barrels, buckets, cisterns) • Bite during day

Dengue Endemic Dengue risk Chikungunya

• 1953 - Isolated in Tanzania • 1960s – 1980s virus isolated from Western, Central, Southern Africa, and many areas of Asia • Since 1980s numerous epidemics in both Africa and Southeast Asia involving 100,000s of people • Late 2013 – first local transmission in the Americas was identified in Caribbean countries and territories • Local transmission now in 37 countries or territories in Caribbean, Central America, South America, and North America o 780,206 suspected cases, 15,246 lab confirmed • In the United States o 1,627 cases, 11 locally transmitted in Florida o Louisiana has had 12 travel associated cases

West Nile Virus • First isolated in 1937 in Uganda (West Nile Province) from blood of a febrile woman. • Transmitted by mosquitoes, reservoir in birds • Originally a Fever

•Moved to Europe in the 1950s •Became neurotropic •Israel 1951,1954,1957(Nursing homes), France 1962, South Africa 1974, Romania 1996 (393 cases), Italy 1998, Russia1999, Israel 2000, France 2000

•Imported from Mid/East in 1999 in NY •In Louisiana in 2001 •Moved throughout the US, reached West Coast in 2004 Influenza… and some other newsworthy respiratory stuff Influenza Virus PB2

PB1 PA

HA

NP NA M

NS Transmission Transmissibility Period

Incubation Disease 1-5 days 3-8 days

TRANSMISSIBLE Does Shedding = Infectious??? Asymptomatic cases ??? Infectious Period • 1 day before symptom onset • Peak shedding 1st day of symptoms • Adults shed 4-6 days • Infants and children may shed longer • Immunocompromised PB2 PB2 PB1 PB1 Human PA PA HA HA NP NP Classical Swine NA NA M M Eurasian Swine NS NS Avian trH1N1 trH1N2

PB2 PB2 PB2 PB1 PB1 PB1 PA PA PA HA HA HA NP NP NP NA NA NA M M M NS NS NS

2009 H1N1 2011 H3N2 trH3N2 H3N2v

• Variant viruses normally circulate in pigs • Localized outbreaks • Swine-to-human transmission • Rare, limited human-human transmission • No sustained or community transmission • Susceptible to neuraminidase inhibitors • Since 2011: 343 cases in 13 states, 18 hospitalizations, 1 death

Avian Influenza A (H7N9)

• Reassortment of 3 avian influenza viruses • 1st time that humans have been infected with H7N9 • Low Pathogenic Avian Influenza (LPAI) viruses usually cause uncomplicated ILI or conjunctivitis in humans • Only 1 recorded death from a LPAI, H7N7 • Little to no immunity in humans • H7N9 does not sicken birds = silent spread • Gene sequences of the virus indicate it is better adapted to infecting mammals and an enhanced ability to bind to receptors in the upper respiratory tract • Susceptible to neuraminidase inhibitors Avian Influenza A (H7N9)

• 453 cases*, 175 deaths • 38.6% case fatality rate • >80% of human cases have a link to live bird market • 14 clusters of human-human transmission • 13 clusters involving 2 family members • 1 cluster involving 3 family members

*as of 10/2/14 Unknowns??? 1. Animal reservoir(s) 2. Main exposures and routes of transmission to humans 3. Distribution and prevalence of this virus among people and animals (including distribution in wild birds) Avian Influenza A (H5N1)

• 1997 – 1st infected humans during poultry outbreak • 2003-2004 – widespread reemergence in Asia, Europe, & Africa • 2011 – considered endemic in Bangladesh, China, Egypt, India, Indonesia, & Vietnam • 2014* - 668 cases; 393 deaths; 59% case fatality

* As of 10/2/14 Avian Influenza A (H5N1)

• Monitor genetic changes to the virus: • Susceptibility • Transmissibility • Inventory of genetic changes • Detected in other animals: • Pigs • Domestic cats • Domestic dogs • Tigers & Leopards (at zoos in Thailand) • Majority of cases among children and adults <40 • Most have direct or close contact with sick or dead poultry • Clusters range from 2-8 cases • Mortality highest in 10-19 year old group • Person-person spread very rare and NOT sustained H5N1 is considered the world’s largest pandemic threat 1. High lethality & virulence 2. Endemic presence 3. Increasing large host reservoir 4. Significant ongoing mutations H5N1 Treatment & Vaccine Issues • Treatment • No standardized approach for clinical management • Oseltamivir remains primary recommended treatment

• Vaccine Development • 12 companies; 17 governments • Sample sharing controversy • Pre-pandemic vaccines in 28 different trials • Full scale production - 3 months Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

• Coronaviruses common worldwide • Usually cause colds • Named for the crown-like spikes on their surfaces • MERS-CoV is different than any other coronavirus previously found in people including SARS • Most people confirmed with MERS-CoV infection have Severe Acute Respiratory Illness MERS-CoV • Nosocomial outbreaks with transmission to healthcare workers • Documented patient-to-patient nosocomial transmission in France • Ongoing risk of transmission to humans in the Arabian Peninsula • Concerns about importation to other geographic areas • Two U.S. Cases – Indiana & Florida Since April 2012 909 cases including 331 deaths* Countries in or near the Arabian Countries with travel- Peninsula with Cases associated cases  Saudi Arabia  United Kingdom  France  United Arab Emirates  Tunisia (UAE)  Italy  Qatar  Malaysia  Oman  Philippines  Greece  Jordan  Egypt  Kuwait  United States of America  Yemen  Netherlands  Algeria  Lebanon  Austria  Iran  Turkey * As of 11/7/14 MERS-CoV MERS-CoV • Unknown • Source • Route of transmission to humans • Mode(s) of human-to-human transmission • No vaccine • No specific treatment

Enterovirus D-68

• Non-polio enteroviruses • >100 types • First identified in 1962 in California • Small numbers have circulated since 1987 • Almost all cases among children • Children with asthma at higher risk Enterovirus D-68 • Mid August – November 6 • 1,116 cases from 47 states • 11 deaths • No treatment • No vaccine

• Neurologic Illness with Limb Weakness • 64 reports, 28 states What do they have in common?

•HIV •Influenza •West Nile •MERS-CoV •Chikungunya •EV-D68 •Dengue •Ebola Ebola Virus Disease (EVD)

• Ebola Virus Disease (EVD) is a severe viral disease, caused by an infection with the Ebola virus.

• In 1976, the first Ebola Source: Public Health Image Library virus species was discovered in what is now the Democratic Republic of the Congo, near the Ebola River. • Since 1976, outbreaks have appeared sporadically. Classification . Order Mononegavirales Enveloped, nonsegmented, Negative strand RNA viruses

. Family Filoviridae contains 3 genera: . Ebolavirus (1976) . Marburgvirus – Lake Victoria marburgvirus (1967) . Cuevavirus – Lloviu virus (bats, Spain, 2002) . Species: . Zaire ebolavirus: 1976, Democratic Republic of Congo. . Sudan ebolavirus: 1976, Sudan. . Bundibugyo ebolavirus: 2007, Uganda. . Taї Forest ebolavirus (formerly Côte d’Ivoire ebolavirus): 1994, Ivory Coast, Single case, veterinary worker handling primate. . Reston ebolavirus: 1989, Philippines: Macaques, swine, Human laboratory workers seropositive but no clinical disease. Transmission

Transmission from the Forest to Humans

. Fruit bats reservoir of virus - Drop partially eaten fruits . Bats infect chimpanzees, gorillas, forest antelopes, porcupines . Humans handle bush meat (bats, chimpanzees, gorillas)

Centers for Disease Control and Prevention; Virus Ecology Graphic http://www.cdc.gov/vhf/ebola/resources/virus-ecology.html Human to Human Transmission

• Ebola is spread by direct contact with: . Blood and body fluids of a symptomatic person . Objects contaminated with the virus (Needles or medical supplies)

Blood & Internal body fluids • Saliva, Tears • Sweat • Vomitus • Urine • Stools • Vaginal fluid, semen Ebola Mutation to Airborne Transmission?

• Ebola virus attaches to macrophages while Influenza virus attaches to respiratory tract cells • To become airborne EV would have to switch attachment site from protein on macrophage to protein on the respiratory tract • Then EV would have to be expelled by respiratory tract cells • Meanwhile it would also have to keep his cythopathic effects on the macrophages • In a 100,000 years neither HBV, HCV and HIV manage to do this acrobatic feat • The probability of EV becoming airborne is similar to the of chicken regaining teeth their dinosaur ancestors had. Transmission . Among 173 household contacts of 27 patients with confirmed Ebola, the transmission rate was only 16% despite none of the standard infection control precautions routinely employed in U.S. hospitals being used

. Of 78 contacts who reported no physical contact with the infected patient, none became infected

. Among those who did have physical contact, risk for Ebola was highest after contact with the patients’ blood

Dowell SF et al Transmission of Ebola hemorrhagic fever: A study of risk factors in family members, Kikwit, Democratic Republic of the Congo, 1995 The Journal of Infectious Diseases 1999;179(Suppl 1):S87–91

• Ebola is not spread through the air, food, or by water • There is no evidence that mosquitos or other insects can transmit EVD Epidemiologic Parameters

 Incubation period = time between exposure to the virus until the appearance of the first symptom. . Incubation period may vary:

 often multiple possible exposures,

 Disease onset vary according to individuals . Incubation period for Ebola is from 2 to 21 days (average is 8-10 days)  Latent Period = Time between infection and infectiousness . Less than incubation period if person become infectious before onset  R0 = basic reproduction number or basic reproductive ratio. . Number of cases one case generates on average over the course of its infectious period, in an otherwise uninfected population. . When R0<1, the infection will eventually die out in the population . When R0>1, the infection will continue spreading in the population . Ebola R0 = 1.4 to 2.2  Serial Interval = time between successive cases in a chain of transmission. . Generally estimated from the interval between clinical onsets, in which case it is the 'clinical onset serial interval' when these quantities are observable . Ebola serial interval 15 days Ebola Epidemiologic Parameters

Basic R0 CI SI Doubling Doubling R0 Time Time CI Guinea 1.71 1.44-2.01 15.3 15.7 12.9-20.3 Sierra Leone 1.83 1.72-1.94 24.0 23.6 20.2-28.2 Liberia 2.02 1.79-2.26 30.0 30.2 23.6-42.3

Disease Transmission R0 Measles Airborne 12–18 Pertussis Airborne droplet 12–17 Smallpox Airborne droplet 5–7 Polio Fecal-oral route 5–7 Rubella Airborne droplet 5–7 Mumps Airborne droplet 4–7 HIV/AIDS Sexual contact 2–5 SARS Airborne droplet 2–5 Influenza (1918) Airborne droplet 2–3 Ebola (2014) Bodily fluids 1.5-2.5 Ebola Spread Ebola Spread Pathogenesis: How does Ebola Virus Causes Disease

. Virus enters the body via infected blood/body fluid in contact with a mucosal surface or a break in intact skin. . Virus replicates preferentially in monocytes/macrophages and dendritic cells which facilitate dissemination of the virus throughout the body via lymphatic system. . Other cells are secondarily infected and there is rapid viral growth in hepatocytes, endothelial and epithelial tissues. . There is strong cytokine/inflammatory mediator release of TNF-a and inflammatory cascade. Pathogenesis: How does Ebola Virus Causes Disease

. Leads to endothelial damage, increased vascular permeability and shock. . This results in the end organ damage and multi-organ dysfunction . Diffuse intravascular coagulopathy(DIC) with platelet and coagulation factor consumption which leads to hemorrhage. . IgM starts forming in 2 day and IgG in 5-8 days post infection . . Immunologic response correlates with survival. . Thus the observation that those who live >1 week are more likely to survive. Clinical Presentation

• Acute onset: • Typically 8–10 days after exposure (range 2–21 days) • Signs and symptoms: • Initial: Fever (greater than 100.4 F) , chills, myalgia, malaise, anorexia ⁰ • After 5 days: GI symptoms, such as nausea, vomiting, watery diarrhea, abdominal pain • Advanced symptoms: mental confusion, hemorrhage, shock, multi-organ failure • Other: Headache, conjunctivitis, hiccups, rash, chest pain, shortness of breath, seizures • Other possible infections with similar symptoms: Malaria, typhoid fever, meningococcemia, Lassa fever and other bacterial infections (e.g., pneumonia) – all very common in Africa

63 Clinical Manifestations by Organ System in West African Ebola Outbreak Organ System Clinical Manifestation

General Fever (87%), fatigue (76%), arthralgia (39%), myalgia (39%)

Neurological Headache (53%), confusion (13%), eye pain (8%), coma (6%)

Cardiovascular Chest pain (37%)

Pulmonary Cough (30%), dyspnea (23%), sore throat (22%), hiccups (11%)

Gastrointestinal Vomiting (68%), diarrhea (66%), anorexia (65%), abdominal pain (44%), dysphagia (33%), jaundice (10%)

Hematological Any unexplained bleeding (18%), melena/hematochezia (6%), hematemesis (4%), vaginal bleeding (3%), gingival bleeding (2%), hemoptysis (2%), epistaxis (2%), bleeding at injection site (2%), hematuria (1%), petechiae/ecchymoses (1%)

Integumentary Conjunctivitis (21%), rash (6%)

WHO Ebola Response team. NEJM. 2014 64 Viral Load

Log(Viral copies/mL serum)=8 or Number viral copies/mL=100,000,000 Detection of Ebola Virus in Different Human Body Fluids over Time

Source: CDC

66 Treatment

• Symptoms of Ebola are treated as they appear • Early interventions can significantly improve the chances of survival: • Providing intravenous fluids (IV)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. • No FDA approved vaccine or medication is available Recovery

• Recovery from Ebola depends on supportive clinical care and a patient’s immune system • A person who recovers from Ebola infections will develop antibodies that last for at least 10 years • Some people who have recovered from Ebola have developed long-term complications, such as • joint and muscle pain • vision problems Fatality Rate Ebola Outbreaks 1976-2014 Ebola Outbreaks 1976-2014

Source: CDC Year Country Virus species Cases Deaths Case fatality 2012 DRC /Zaire Bundibugyo 57 29 51% 2012 Uganda Sudan 7 4 57% 2012 Uganda Sudan 24 17 71% 2011 Uganda Sudan 1 1 100% 2008 DRC /Zaire Zaire 32 14 44% 2007 Uganda Bundibugyo 149 37 25% 2007 DRC /Zaire Zaire 264 187 71% 2005 Congo Zaire 12 10 83% 2004 Sudan Sudan 17 7 41% 2003 11/12 Congo Zaire 35 29 83% 2003 01/04 Congo Zaire 143 128 90% 2001-2002 Congo Zaire Past 59 44 75% 2001-2002 Gabon Zaire Outbreaks 65 53 82% 2000 Uganda Sudan 425 224 53% 1996 SAfrica (Gabon) Zaire 1 1 100% 1996 07/12 Gabon Zaire 60 45 75% 199601/04 Gabon Zaire 31 21 68% 1995 DRC /Zaire Zaire 315 254 81% 1994 Cote d'Ivoire Taï Forest 1 0 0% 1994 Gabon Zaire 52 31 60% 1979 Sudan Sudan 34 22 65% 1977 DRC /Zaire Zaire 1 1 100% 1976 Sudan Sudan 284 151 53% 1976 DRC/Zaire Zaire 318 280 88% 2014 Outbreak Meliandou Village, December 2013 Initial Spread

. Initial (suspect) cases Initial report March 24, 2014 occurred in a family in According to the World Health Organization Guéckédou, Guinea: (WHO), the Ministry of Health (MoH) of Guinea December 2013 / has reported an outbreak of Ebola hemorrhagic January 2014 fever in four southeastern districts: . Spread to a number of Guekedou, Macenta, Nzerekore and health care workers and Kissidougou. Reports of suspected cases in the then among their family neighboring countries of Liberia and Sierra members: January to March Leone are being investigated. In Guinea, a total 2014 of 86 suspected cases, including 59 deaths (case . Not all initial cases were fatality ratio: 68.5%), had been reported as of definitively linked March 24, 2014. Preliminary results from the Pasteur Institute in Lyon, France suggest Zaire ebolavirus as the causative agent. Médecins sans Frontières (MSF/Doctors without Borders) is helping the Ministry of Health of Guinea in establishing Ebola treatment centers in the epicenter of the outbreak. CDC is in regular communication with its international partners WHO and MSF regarding the outbreak, to identify areas where CDC subject matter experts can contribute to the response. The Beginnings

• March 27, 2014: Guinea's capital of Conakry (2 million people) • Bernhard-Nocht Institute of Tropical Medicine in Hamburg, Germany, and Institut Pasteur in Dakar, Senegal confirm the virus is a strain of Ebola originally from Zaire (DRC) in 1976. • March 29, 2014: The virus is confirmed to have reached Liberia. August 25, 2014 Cases to August 25, 2014

Country Cases Deaths Guinea 648 430 Liberia 1378 694 Sierra Leone 1026 422 Cases to September 28, 2014

Country Cases Deaths Guinea 1157 710 Liberia 3696 1998 Sierra Leone 2304 622 Current Ebola Situation Cases to November 16, 2014 Current Ebola Situation

As of November 16, 2014 Recent Updates • WHO officially declared Senegal and Nigeria free of Ebola virus transmission on October 17 and 20, respectively. • On November 5, WHO reported that all 83 contacts of the health worker infected in Madrid, Spain have completed the 21-day follow-up period. Mali Cases

• On October 23, Mali reported its first confirmed case of Ebola in a child who had traveled there from Guinea. The child passed away on October 24. 85 contacts were identified and monitored, no additional cases identified. • On October 27, a man who had traveled from Guinea died in Mali’s capital, Bamako. His body was washed at a mosque and then returned for burial to Guinea. He was not tested for or diagnosed with Ebola. • On November 10, a nurse who had treated the man tested positive for Ebola and died. It was then that Ebola was suspected for the man who died. Other family members and contacts of his were reported to be ill. • 3 more cases identified, 384 contacts being monitored • Mali added to CDC’s Guidance for Monitoring and Movement, flights from Mali routed through 5 main airports in U.S. and added to airport screening The Concerns about Nigeria • Nigeria first Ebola case, in Lagos, announced on July 23 2014. • The Ebola virus entered Lagos on 20 July via an infected Liberian air traveler, who died 5 days later. At the departure airport, he was visibly very ill, lying on the floor of the waiting room while awaiting the flight. • He told staff that he had malaria and no contact with Ebola patient. In fact he had visited his sister in hospital and attended her traditional funeral and burial ceremony. She was a confirmed case. • Suspecting malaria no staff at the hospital took protective precautions. 9 physicians and nurses became infected and 4 died. The Concerns about Nigeria • Lagos, Africa’s largest city, is also characterized by a large population living in crowded and unsanitary conditions in many slums. • Thousands of people move in and out of Lagos every day, constantly looking for work or markets for their products in a busy metropolis with frequent gridlocks of vehicle traffic. • An “apocalyptic urban outbreak” was expected The Concerns About Nigeria How Nigeria Did It • Epidemiologists from the Nigerian NCDC, the Nigeria Field Epidemiology and Laboratory Training Program, State MOH, WHO detected numerous high-risk exposures for hundreds of people. • Isolation wards were immediately constructed, as were designated Ebola treatment facilities, though more slowly. Vehicles and mobile phones, with specially adapted programs, were made available to aid real-time reporting as the investigations moved forward. • With assistance from WHO, CDC and others officials reached 100% of known contacts in Lagos and 99.8% at the second outbreak site, in Port Harcourt, Nigeria’s oil hub. • 20 cases total and 8 deaths End of Ebola in Nigeria

20 October 2014 -- WHO officially declares that Nigeria is now free of Ebola virus transmission. This is a spectacular success story that shows that Ebola can be contained. The story of how Nigeria ended what many believed to be potentially the most explosive Ebola outbreak imaginable is worth telling in detail. First US Case Imported

• Thomas Eric Duncan (1972 – October 8, 2014) • Liberian who traveled to the US to visit his family • Emergency Dept visit September 24, 10pm, sent back home • Home with family for 4 days • Sicker, transported to the same ED on September 28 to the same Texas Health Presbyterian Hospital emergency room by ambulance • Diagnosed on September 30, 2014. • Treated at Texas Health Presbyterian Hospital in Dallas • October 4, condition had deteriorated from "serious but stable" to "critical". • October 8, Duncan died of Ebola. First US Cases

On the night of October 10, Nina Pham, a 26-year-old nurse who had treated Duncan reported a low-grade fever and was placed in isolation. On October 11, she tested positive for Ebola virus.

On October 14, Amber Vinson, a 29-year-old, who had provided treatment for Duncan, reported a fever. Vinson was isolated within 90 minutes of reporting the fever. By the next day, Vinson had tested positive for Ebola virus. United States EVD Cases

• Four U.S. health workers and one journalist who were infected with Ebola virus in West Africa were transported to hospitals in the United States for care. • All the patients have recovered and have been released from the hospital after laboratory testing confirmed that they no longer have Ebola virus in their blood. • 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. He recovered and was released on November 11.

92 Non-Health Care Contacts

Louise Troh, her 13-year-old son and two adult nephews stayed with Duncan in the same apartment for 4 days. Their 21-days of quarantine ended.

Oct 2, 2014 - Public health officials in Texas said Thursday that as many as 100 people may have had contact with the Liberian man diagnosed with Ebola.

Vinson got on Frontier Airlines Flight 1143, with 132 other passengers other passengers. She landed in Dallas at 8:16 P.M. The passengers in the same gate and up to 12 gates away were warned. The next morning, her fever was worse; around midnight, she tested positive for Ebola.

Nina Pham was reunited Saturday with her beloved King Charles spaniel and "best friend," Bentley.

Craig Spencer the doctor with Ebola who returned to Guinea deadly virus. Following visits to a Brooklyn bowling alley, the subway, a taxi, his home in 147th Street in Harlem and other parts of the city. Prevention Prevention

• Avoid contact with blood and body fluids of an infected, symptomatic person

Avoid Body Contact

• Wash hands regularly with soap and water or an alcohol- based hand sanitizer • Do not handle items that have come in contact with an infected, symptomatic person’s blood or body fluids( clothes, bedding, towels, needles…) • Use protective clothing such as gloves, masks, gowns when caring for an infected person Preparedness http://www.cdc.gov/vhf/ebola/pdf/ed-algorithm-management-patients-possible-ebola.pdf Laboratory Guidance

• CDC has developed interim guidance for U.S. laboratory workers and other healthcare personnel who collect or handle specimens. • This guidance includes information about the appropriate steps for collecting, transporting, and testing specimens from patients who are suspected to be infected with Ebola. • The State PH Lab can test specimens for Ebola • Specimens should NOT be shipped to LA PH Lab or CDC without consulting IDEpi

Information available at: http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-specimen- collection-submission-patients-suspected-infection-ebola.html 98 Airport Screening • Exit Screening: Affected countries screen departing travelers looking for sick travelers or travelers exposed to Ebola • Screened: temp taken, look for symptoms, questions regarding risk • Symptoms or exposures, not allowed to travel • Entry Screening: CDC and Customs and Border Patrol (CBP) have implemented enhanced entry screening at five U.S. airports that receive all travelers from Guinea, Liberia, Sierra Leone and Mali • JFK, Washington-Dulles, Newark, Chicago-O’Hare, Atlanta • Ebola information given to each traveler – CARE kits • Screened: temp taken, look for symptoms, questions regarding risk • Local/state public health jurisdiction notified to begin active monitoring of returned travelers Post-Arrival Monitoring of Returned Travelers • State and local health departments follow-up with returned travelers for 21 days from date of departure to monitor for fever and symptoms • If symptomatic, public health officials implement isolation and evaluation plan to limit exposure and direct the individual to a local hospital • Began October 27 in NY, PA, MD, VA, NJ, GA – receives 70% of incoming travelers • Louisiana has implemented voluntary self-quarantine for all returning travelers with twice daily direct monitoring by public health officials • Temp and symptoms evaluated 2xday by PH staff • Limit travel, coordinate any necessary travel with OPH • No public transportation • Avoid public places (restaurants, grocery stores, malls, places of worship, etc. Louisiana’s Oil Workers • IDEpi has received numerous calls about oil workers returning from Malabo, an island of Equatorial Guinea • There are 3 confusing countries: Guinea, Equatorial Guinea, and Guinea-Bissau • ONLY Guinea is an Ebola-effected country Guinea-Bissau Travel to Equatorial Guinea or • Guinea Guinea-Bissau is not a risk for exposure to Ebola Equatorial Guinea • Many oil workers also fly through Nigeria – this is not a risk of Ebola exposure • We have not received any notifications of oil workers returning from one of the Ebola-affected countries Louisiana Prepared for A Suspect Case

• LA DHH, GOHSEP, EMS, Hospitals, Fire, Police, other partners prepared to handle a suspect Ebola case • If a suspect case is identified: 1. Consult with IDEpi (1-800-256-2748) 2. Isolate patient at hospital 3. IDEpi and hospital coordinate testing 4. IDEpi begins contact tracing and monitoring

Community Education • Community engagement is key to successfully controlling outbreaks • Raising awareness of risk factors for Ebola infection and protective measures that individuals can take is an effective

way to reduce Source: Public Health Image Library human transmission Current Guidance http://www.cdc.gov/vhf/ebola/

• Signs and Symptoms • Transport • Transmission • Personal Protective • Risk of Exposure Equipment • Prevention • Hospitals • Diagnosis • Environmental Cleaning • Treatment • EMS/911 • Infection Control • Human Remains • Laboratory Testing • Info for parents, • Monitoring and schools, pediatrics Movement Notification

Contact the Louisiana Office of Public Health immediately at 504-568-8313(Monday – Friday 8am-4:30pm) or 800- 256-2748(weekdays after 4:30pm and weekends) to discuss a possible exposure, request laboratory testing, or report a suspected case…

Or any other infectious disease question!