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  • Its PANIC time (Ebola in the UK)

    Ebola crisis: disease may already be in Britain as man dies on business trip

    The death of a businessman in Macedonia from suspected Ebola has led to fears that the disease may already be in Britain

    A Public Health Center vehicle is parked in front of the hotel where a 58-year-old man was taken to hospital and died of severe internal bleeding, in Skopje Photo: Boris Grdanoski/AP









    By Sarah Knapton, Science Editor

    10:00PM BST 09 Oct 2014



    Ebola may already be in Britain, it was feared last night, after a businessman who had travelled to Macedonia became the first Briton to die from the disease.

    Macedonian officials confirmed that the 56-year-old, who has not been named, had been suffering from fever, vomiting and internal bleeding and that his condition had deteriorated rapidly.

    "These are all symptoms of Ebola, which raises suspicions with this patient," said Dr. Jovanka Kostovska of the health ministry's commission for infectious diseases.




    A second man who had travelled from London with the victim on October 2 has also been isolated and the hotel they were staying in the Macdeonian capital of Skopje has been sealed off.

    Related Articles



    Sampling has been sent to Germany to confirm the cause of death but the disease has an incubation period of up to 21 days, which means the dead man could have been infected in Britain.
    Officials said he had not travelled to any country caught up in the outbreak before arriving in Macedonia, but he may have been making his way to Nigeria.

    Before his death, the victim had been complaining of a severe stomach ache and had stayed in his hotel for three days. At around 3pm yesterday he was taken to hospital, but he died just 90 minutes after being admitted.

    The ambulance crew who took him to hospital have also been isolated.

    Elsewhere in Europe, a Prague hospital said it was testing a 56-year-old Czech man with symptoms of the Ebola virus, while the health of an infected Spanish nurse worsened in Madrid, where a total of seven people are in isolation.

    Yesterday Downing Street announced that enhanced screening will be brought in at the London airports of Heathrow and Gatwick and at Eurostar Terminals.

    The Government, which has up until now insisted additional checks were not necessary, changed guidance following new advice from the Chief Medical Officer, Dame Sally Davies.

    Under new guidelines, people travelling from Liberia, Sierra Leone and Guinea will be questioned about travel arrangements and recent contacts. They may also face medical checks.

    A Downing Street spokesman said: "These measures will help to improve our ability to detect and isolate Ebola cases. However, it is important to stress that given the nature of this disease, no system could offer 100 per cent protection from non-symptomatic cases.

    “It is important to remember that the overall risk to the public in the UK continues to be very low, and the UK has some of the best public health protection systems in the world with well-developed and well-tested systems for managing infectious diseases when they arise. Contingency planning is also underway including a national exercise and wider resilience training to ensure the UK is fully prepared.”

    Dame Sally said that 'further measures' were necessary to protect the public.
    “In view of the concern about the growing number of cases, it is right to consider what further measures could be taken, to ensure that any potential cases arriving in the UK are identified as quickly as possible.

    “We remain alert and prepared, should an Ebola case be identified here.”
    However Britain is not yet following the lead of America and South Africa by bringing in temperature checks to detect passengers suffering from fevers.

    And experts warned that passengers are unlikely to be truthful if they had visited infected areas.
    Professor David Mabey, a physician specialising in infectious diseases at the London School of Hygiene & Tropical Medicine, said he believed that questionnaires asking passengers about their recent travel, were a waste of time".

    He said: "I think people will lie. They don't want to be subjected to the inconvenience. Why would people tell the truth?

    "If last week your aunt died of Ebola but you feel fine, are you going to be honest when you get to the airport and risk being detained and missing your holiday?”

    Professor Julian Hiscox, from the Institute of Infection and Global Health at the University of Liverpool, said public information was key to prevent the spread of Ebola.
    "What we need to see is information handed to people as they step off planes and a phone number people can call if they start to develop symptoms.

    "The main thing is not to panic about this or to drive people coming to the UK underground.”
    Prof David Evans, Professor of Virology, University of Warwick, said that enhanced screening of inbound passengers was the most that can be done 'to balance practicality and effectiveness with the need to reassure the UK public that their health is being protected.'

    However Dr Ben Neuman, Lecturer in Virology, University of Reading, said: "I don't think there is a strong scientific case that airport screening will help keep Ebola out of the UK, but it’s a step that will reassure some people."

    Professor Peter Piot, who was part of the team that identified Ebola in 1976, said that more European cases were ‘unavoidable’

    The Foreign Office said it was still working to confirm that the men were British.
    Last night former foreign secretary David Miliband said there is no question that the West has been slow in its response to the Ebola crisis.

    Mr Miliband, who is in Sierra Leone with the International Rescue Committee which he heads, called on the "big guns" of the world to lend more support.

    "There's no question that there's been a tardiness, a slowness, a lateness of response,” he told Channel 4 news.

    Dr Marc Sprenger, director of the European Centre for Disease Prevention and Control, said current models predicted between 500,000 and 1,500,000 cases in West Africa by the end of January if no action is taken.

    He said while official figures put the number of cases so far at around 8,000, in reality the collapse of West African health care meant the true scale was unknown and could be two-and-a-half times higher.

    He told the Telegraph that good exit screening from affected regions was higher priority than entry screening at British airports.

    He said: “First of all you need to have exit screening. If exit screening is well done, and the flight is not that long, then in fact it’s not necessary to have the person checked on arrival.
    But while it may be simple to screen flights coming direct from West Africa, he said it would be far more difficult to track and screen connecting passengers.

    And he warned they were of limited use. He said: “You only catch the people who have fever but a lot of people are in an incubation period and will develop later and become infectious.”

  • #2
    Re: Its PANIC time (Ebola in the UK)

    If this guy turns out to be WHITE all hell will break lose.........

    After all a few thousand BLACK people dying, why thats "Sad"..............But a few WHITE people !!!!!!!!!
    Watch how quickly this goes into hyperdrive!........
    Mike

    Comment


    • #3
      Re: Its PANIC time (Ebola in the UK)

      The new and improved TSA of the Dominican Republic is here to help!

      Lesson is don't sneeze on a plane if you have an African name and are actually black!

      Skip to 7:30 if you don't want to watch the whole thing.

      Comment


      • #4
        Re: Its PANIC time (Ebola in the UK)

        Ebola... Just in time to take the blame for the next financial crisis ;-) ;-) ;-). But I supposed it's all a moot point if we're all dead by Q2 2015. I'd link an exponential graph, except it seems oddly hard to find a credible one that goes out beyond Oct 2014.

        Confirmed Ebola Cases as of Oct 9, 2014:

        * 3 in Germany: http://www.dw.de/third-ebola-patient...ica/a-17983734
        * 3 in Spain: http://www.cbc.ca/news/world/ebola-o...cted-1.2789848
        * 1 in UK: http://www.dailymail.co.uk/news/arti...thousands.html
        * 1 in USA: http://www.reuters.com/article/2014/...0HX1OK20141008
        * 8 in Nigeria: http://www.bbc.com/news/world-africa-28755033
        * 879 in Sierra Leone
        * 769 in Guinea
        * 2210 in Liberia

        Dodged Bullets so far:
        * 11 tested in Australia: http://www.dailytelegraph.com.au/new...c9b734ef59ff55
        * 1 in Canada: http://www.vancouversun.com/health/S...955/story.html

        2014 Ebola World Maps:
        http://healthmap.org/ebola/#timeline


        EDIT: Found an exponential chart citing the CDC's "Worst case scenario of 1.4 Million projection by Jan 20, 2015 if the way ebola patients are handled isn't changed":
        Last edited by Adeptus; October 09, 2014, 08:12 PM.
        Warning: Network Engineer talking economics!

        Comment


        • #5
          Re: Its PANIC time (Ebola in the UK)

          Comment


          • #6
            Re: Its PANIC time (Ebola in the UK)

            Nice clip, Mike. Think Scott-Heron is on the Prez's song list

            Comment


            • #7
              Re: Its PANIC time (Ebola in the UK)

              Here you go Mega,
              Just found these on reddit...

              Lots more Ebola (I'll be laughing until I or somebody I know gets it) HAHA's here:
              https://www.google.ca/search?q=ebola...ed=0CAYQ_AUoAQ







              Last edited by Adeptus; October 10, 2014, 07:27 AM.
              Warning: Network Engineer talking economics!

              Comment


              • #8
                Re: Its PANIC time (Ebola in the UK)

                Mean time in Liverpool:-

                Liverpool coach station at the centre of Ebola scare



                Medical staff in protective clothing mobilised, but collapsed woman did not have deadly disease






                James Maloney
                National Express coach station in Norton Street, Liverpool, where a woman collapsing from a stroke triggered fears of an Bbola outbreak in Merseyside. Photo by James Maloney
                A Liverpool coach station was at the centre of an Ebola scare after a passenger arriving from London collapsed.
                It sparked a dramatic mobilising of medical staff in protective clothing at the National Express station on Norton Street, off London Road.

                Witnesses described panic among passengers as the coach arrived around 9.30pm on Wednesday with ambulance and police waiting.

                National Express confirmed the station was closed for half-an-hour as a precautionary measure.

                Medical staff entered the coach in protective gear and removed the woman in a protective garment and face mask.
                A spokesman for the Royal Liverpool Hospital confirmed they had received a patient but it swiftly became apparent that she did not have Ebola.
                What is Ebola? Your questions answered

                An onlooker said: “There were loads of people on the coach and people were running and panicking when they got off.
                “The ambulance service and police were there to meet it so I think the driver must have telephoned ahead. It was coming in from London.

                “People wearing protective clothing got on to the coach and after a time brought the woman off. They put her in some sort of protective garment and a mask. It looked like a full alert.”

                North West Ambulance Service confirmed they had been called to reports that a woman had collapsed on a coach.
                It is understood the woman had been to Africa, was feeling feverish and also had stroke symptoms.

                A National Express spokesman said: “On the advice of attending paramedics, police last night closed Liverpool Coach Station as a precautionary measure for around half an hour (Wednesday, October 8).
                “The station was quickly up-and-running the same night with minimal disruption to customers.”
                The Royal is one of four hospitals across the country that is on standby in case of an outbreak of Ebola.
                The Royal Liverpool University Hospital

                Friday, the Royal will stage a local mock exercise for dealing with isolating and managing an Ebola case.
                Dr Peter Williams, medical director said: “Our Tropical and Infectious Disease Unit is an established and widely recognised specialist unit for managing patients with a variety of infectious diseases.

                "As such we are on stand-by to assist the Royal Free Hospital in London in managing patients with Ebola, should the need arise.

                “We have been working with NHS England and other colleagues across the country to prepare for this, as part of long-standing national contingency plans.

                “Our unit has a wide range of specialist protective equipment and facilities and the staff on the unit are highly trained in managing patients with infectious diseases.

                “We run regular training exercises for our staff and have been planning for weeks to run a local simulation exercise this Friday on isolating and managing a ‘patient’ with suspected Ebola.

                “We regularly manage patients with a variety of suspected infectious diseases, using robust, evidence based methods for the isolation, diagnostic testing and care of patients with infection.

                "Whilst we are planning for the possibility of caring for patients with Ebola we do not expect to do so at present, as currently any patient with proven Ebola infection will be cared for at the Royal Free Hospital.

                “I would like to reiterate that there is no risk to members of staff or the general public and anybody coming to the Royal as a patient or visitor should not be concerned.”

                Comment


                • #9
                  Re: Its PANIC time (Ebola in the UK)

                  Gee i do "Hope" those Naz...i mean nice TSA people don't catch it
                  ;))
                  Mike

                  Comment


                  • #10
                    Re: Its PANIC time (Ebola in the UK)

                    Comment


                    • #11
                      Re: Its PANIC time (Ebola in the UK)

                      It's a different world. The global economy means more travel, more difficulty in containing disease. This could get bad.

                      Comment


                      • #12
                        Re: Its PANIC time (Ebola in the UK)

                        W.H.O. Chief Calls Ebola Outbreak a ‘Crisis for International Peace’

                        By NICK CUMMING-BRUCEFiloviruses like Ebola have been of interest to the Pentagon since the late 1970s, mainly because Ebola and its fellow viruses have high mortality rates — in the current outbreak, roughly 60 percent to 72 percent of those who have contracted the disease have died — and its stable nature in aerosol make it attractive as a potential biological weapon.

                        Since the late 1970s and early 1980s, researchers at the U.S. Army Medical Research Institute of Infectious Diseases have sought to develop a vaccine or treatment for the disease.

                        Last year, USAMRIID scientists used a treatment, MB-003, on primates infected with Ebola after they became symptomatic; the treatment fully protected the animals when given one hour after exposure.

                        Two-thirds of infected primates were protected when treated 48 hours after exposure, according to a report published last August in Science Translational Medicine.

                        The Defense Department earlier this week issued a statement, which said:

                        A small group of military and civilian personnel assigned to the U.S. Army Medical Research Institute of Infectious Diseases, or USAMRIID, is in Liberia as part of a larger U.S. interagency response to the world’s worst outbreak of the Ebola virus which continues to spread in West Africa, a Defense Department spokesman said today.

                        Army Col. Steve Warren told reporters that personnel assigned to USAMRIID have established diagnostic laboratories in Liberia and Sierra Leone, two of three countries where the outbreak has been spreading in recent months.

                        “We also evaluate and develop diagnostic instruments and technologies for use in forward field medical laboratories and with the Joint Biological Agent Identification and Detection System, called JBAIDS, the diagnostics platform used across the DoD,” the statement added.




                        Research

                        Undiagnosed Acute Viral Febrile Illnesses, Sierra Leone

                        http://wwwnc.cdc.gov/eid/article/20/7/13-1265_article

                        July, 2014:

                        Analysis of clinical samples from suspected Lassa fever cases in Sierra Leone showed that about two-thirds of the patients had been exposed to other emerging diseases, and nearly nine percent tested positive for Ebola virus.

                        The findings, published in this month’s edition of Emerging Infectious Diseases, demonstrates that Ebola virus has been circulating in the region since at least 2006—well before the current outbreak.

                        First author Randal J. Schoepp, Ph.D., recently returned from Liberia and Sierra Leone, where he spent six weeks helping to set up an Ebola testing laboratory and training local personnel to run diagnostic tests on suspected Ebola hemorrhagic fever clinical samples. He is part of a team from the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) that has been providing assistance to the Ebola outbreak in West Africa since March.

                        Three other USAMRIID personnel also have been involved in this ongoing effort: Wes Carter, who traveled with Schoepp to Liberia; Aileen O’Hearn, Ph.D., who recently returned from providing laboratory support to Kenema Government Hospital (KGH) in Sierra Leone; and Matthew Voorhees, who is currently onsite at KGH.

                        USAMRIID has been working in the region since 2006, when it began a collaborative project to develop and refine diagnostic tests for the Lassa fever virus endemic to Sierra Leone, Liberia and Guinea. As those assays have matured, the scientists have begun to optimize additional tests for a number of emerging diseases.

                        Because the team was working on disease identification and diagnostics, and had pre-positioned assays in the region, said Schoepp, “We had people on hand who were already evaluating samples and volunteered to start testing right away when the current Ebola outbreak started.”

                        According to the publication’s authors, between 500 and 700 samples are submitted each year to the KGH Lassa Diagnostic Laboratory in Sierra Leone. Generally, only 30 to 40 percent of the samples test positive for Lassa fever, so the aim of this study was to determine which other viruses had been causing serious illnesses in the region.

                        Using assays developed at USAMRIID that detect the presence of IgM, an early protein produced by the body to ward off infection, the research team found evidence of dengue fever, West Nile, yellow fever, Rift Valley fever, chikungunya, Ebola, and Marburg viruses in the samples collected between 2006 and 2008.

                        In addition, of the samples that tested positive for Ebola, the vast majority reacted to the Zaire strain, which was unexpected, according to the authors.

                        “Prior to the current outbreak, only one case of Ebola had ever been officially reported in this region, and it was from the Ivory Coast strain,” said Schoepp. “We were surprised to see that Zaire—or a variant of Zaire—was causing infection in West Africa several years ago.”

                        The laboratory testing site in Kenema is supported by the Armed Forces Health Surveillance Center-Global Emerging Infections Surveillance and Response System. In collaboration with the host country, the site enables collection of samples that can be used in research toward new medical countermeasures, and allows USAMRIID to evaluate the performance of previously developed laboratory tests using samples collected on-site. The Institute hopes to eventually obtain viral isolates for medical countermeasure development and receive data on the performance of the diagnostic assays.

                        In addition to providing laboratory testing and training support for the current outbreak, USAMRIID has provided more than 10,000 Ebola assays to support laboratory capabilities in Sierra Leone and Liberia. The Institute also supplied personal protective equipment to Metabiota Inc., a non-government organization (NGO) involved in the testing.

                        Other contributors to the work include the Department of Defense Joint Program Executive Office-Critical Reagents Program, the Defense Threat Reduction Agency (DTRA) Cooperative Biological Engagement Program, and the DTRA Joint Science and Technology Office.

                        COL Erin P. Edgar, commander of USAMRIID, called the project “a great example of medical diplomacy at work.”

                        “This collaboration allows USAMRIID to bring our expertise to bear in responding to an international health crisis,” he said. “In addition, it enables us to test the medical diagnostics that we develop in a real-world setting where these diseases naturally occur.”

                        Comment


                        • #13
                          Re: Its PANIC time (Ebola in the UK)

                          Ebola not airborne? Think again:

                          Source:http://www.cidrap.umn.edu/news-persp...otection-ebola


                          COMMENTARY: Health workers need optimal respiratory protection for Ebola

                          Lisa M Brosseau, ScD, and Rachael Jones, PhD

                          | Sep 17, 2014



                          Editor's Note: Today's commentary was submitted to CIDRAP by the authors, who are national experts on respiratory protection and infectious disease transmission. In May they published a similar commentary on MERS-CoV. Dr Brosseau is a Professor and Dr Jones an Assistant Professor in the School of Public Health, Division of Environmental and Occupational Health Sciences, at the University of Illinois at Chicago.


                          Healthcare workers play a very important role in the successful containment of outbreaks of infectious diseases like Ebola. The correct type and level of personal protective equipment (PPE) ensures that healthcare workers remain healthy throughout an outbreak—and with the current rapidly expanding Ebola outbreak in West Africa, it's imperative to favor more conservative measures.

                          The precautionary principle—that any action designed to reduce risk should not await scientific certainty—compels the use of respiratory protection for a pathogen like Ebola virus that has:

                          • No proven pre- or post-exposure treatment modalities
                          • A high case-fatality rate
                          • Unclear modes of transmission

                          We believe there is scientific and epidemiologic evidence that Ebola virus has the potential to be transmitted via infectious aerosol particles both near and at a distance from infected patients, which means that healthcare workers should be wearing respirators, not facemasks.1
                          The minimum level of protection in high-risk settings should be a respirator with an assigned protection factor greater than 10. A powered air-purifying respirator (PAPR) with a hood or helmet offers many advantages over an N95 filtering facepiece or similar respirator, being more protective, comfortable, and cost-effective in the long run.
                          We strongly urge the US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) to seek funds for the purchase and transport of PAPRs to all healthcare workers currently fighting the battle against Ebola throughout Africa—and beyond.

                          There has been a lot of on-line and published controversy about whether Ebola virus can be transmitted via aerosols. Most scientific and medical personnel, along with public health organizations, have been unequivocal in their statements that Ebola can be transmitted only by direct contact with virus-laden fluids2,3 and that the only modes of transmission we should be concerned with are those termed "droplet" and "contact."

                          These statements are based on two lines of reasoning.

                          The first is that no one located at a distance from an infected individual has contracted the disease, or the converse, every person infected has had (or must have had) "direct" contact with the body fluids of an infected person.
                          This reflects an incorrect and outmoded understanding of infectious aerosols, which has been institutionalized in policies, language, culture, and approaches to infection control. We will address this below. Briefly, however, the important points are that virus-laden bodily fluids may be aerosolized and inhaled while a person is in proximity to an infectious person and that a wide range of particle sizes can be inhaled and deposited throughout the respiratory tract.

                          The second line of reasoning is that respirators or other control measures for infectious aerosols cannot be recommended in developing countries because the resources, time, and/or understanding for such measures are lacking.4
                          Although there are some important barriers to the use of respirators, especially PAPRs, in developing countries, healthcare workers everywhere deserve and should be afforded the same best-practice types of protection, regardless of costs and resources. Every healthcare worker is a precious commodity whose well-being ensures everyone is protected.

                          If we are willing to offer infected US healthcare workers expensive treatments and experimental drugs free of charge when most of the world has no access to them, we wonder why we are unwilling to find the resources to provide appropriate levels of comparatively less expensive respiratory protection to every healthcare worker around the world.
                          How are infectious diseases transmitted via aerosols?

                          Medical and infection control professionals have relied for years on a paradigm for aerosol transmission of infectious diseases based on very outmoded research and an overly simplistic interpretation of the data. In the 1940s and 50s, William F. Wells and other "aerobiologists" employed now significantly out-of-date sampling methods (eg, settling plates) and very blunt analytic approaches (eg, cell culturing) to understand the movement of bacterial aerosols in healthcare and other settings. Their work, though groundbreaking at the time, provides a very incomplete picture.
                          Early aerobiologists were not able to measure small particles near an infectious person and thus assumed such particles existed only far from the source. They concluded that organisms capable of aerosol transmission (termed "airborne") can only do so at around 3 feet or more from the source. Because they thought that only larger particles would be present near the source, they believed people would be exposed only via large "droplets" on their face, eyes, or nose.
                          Modern research, using more sensitive instruments and analytic methods, has shown that aerosols emitted from the respiratory tract contain a wide distribution of particle sizes—including many that are small enough to be inhaled.5,6 Thus, both small and large particles will be present near an infectious person.

                          The chance of large droplets reaching the facial mucous membranes is quite small, as the nasal openings are small and shielded by their external and internal structure. Although close contact may permit large-droplet exposure, it also maximizes the possibility of aerosol inhalation.
                          As noted by early aerobiologists, liquid in a spray aerosol, such as that generated during coughing or sneezing, will quickly evaporate,7 which increases the concentration of small particles in the aerosol. Because evaporation occurs in milliseconds, many of these particles are likely to be found near the infectious person.

                          The current paradigm also assumes that only "small" particles (less than 5 micrometers [mcm]) can be inhaled and deposited in the respiratory tract. This is not true. Particles as large as 100 mcm (and perhaps even larger) can be inhaled into the mouth and nose. Larger particles are deposited in the nasal passages, pharynx, and upper regions of the lungs, while smaller particles are more likely to deposit in the lower, alveolar regions. And for many pathogens, infection is possible regardless of the particle size or deposition site.
                          It's time to abandon the old paradigm of three mutually exclusive transmission routes for a new one that considers the full range of particle sizes both near and far from a source. In addition, we need to factor in other important features of infectivity, such as the ability of a pathogen to remain viable in air at room temperature and humidity and the likelihood that systemic disease can result from deposition of infectious particles in the respiratory system or their transfer to the gastrointestinal tract.
                          We recommend using "aerosol transmissible" rather than the outmoded terms "droplet" or "airborne" to describe pathogens that can transmit disease via infectious particles suspended in air.

                          Is Ebola an aerosol-transmissible disease?

                          We recently published a commentary on the CIDRAP site discussing whether Middle East respiratory syndrome (MERS) could be an aerosol-transmissible disease, especially in healthcare settings. We drew comparisons with a similar and more well-studied disease, severe acute respiratory syndrome (SARS).

                          For Ebola and other filoviruses, however, there is much less information and research on disease transmission and survival, especially in healthcare settings.
                          Being at first skeptical that Ebola virus could be an aerosol-transmissible disease, we are now persuaded by a review of experimental and epidemiologic data that this might be an important feature of disease transmission, particularly in healthcare settings.
                          What do we know about Ebola transmission?

                          No one knows for certain how Ebola virus is transmitted from one person to the next. The virus has been found in the saliva, stool, breast milk, semen, and blood of infected persons.8,9 Studies of transmission in Ebola virus outbreaks have identified activities like caring for an infected person, sharing a bed, funeral activities, and contact with blood or other body fluids to be key risk factors for transmission.10-12

                          On the basis of epidemiologic evidence, it has been presumed that Ebola viruses are transmitted by contaminated hands in contact with the mouth or eyes or broken skin or by splashes or sprays of body fluids into these areas. Ebola viruses appear to be capable of initiating infection in a variety of human cell types,13,14 but the primary portal or portals of entry into susceptible hosts have not been identified.

                          Some pathogens are limited in the cell type and location they infect. Influenza, for example, is generally restricted to respiratory epithelial cells, which explains why flu is primarily a respiratory infection and is most likely aerosol transmissible. HIV infects T-helper cells in the lymphoid tissues and is primarily a bloodborne pathogen with low probability for transmission via aerosols.

                          Ebola virus, on the other hand, is a broader-acting and more non-specific pathogen that can impede the proper functioning of macrophages and dendritic cells—immune response cells located throughout the epithelium.15,16 Epithelial tissues are found throughout the body, including in the respiratory tract. Ebola prevents these cells from carrying out their antiviral functions but does not interfere with the initial inflammatory response, which attracts additional cells to the infection site. The latter contribute to further dissemination of the virus and similar adverse consequences far beyond the initial infection site.

                          The potential for transmission via inhalation of aerosols, therefore, cannot be ruled out by the observed risk factors or our knowledge of the infection process. Many body fluids, such as vomit, diarrhea, blood, and saliva, are capable of creating inhalable aerosol particles in the immediate vicinity of an infected person. Cough was identified among some cases in a 1995 outbreak in Kikwit, Democratic Republic of the Congo,11 and coughs are known to emit viruses in respirable particles.17The act of vomiting produces an aerosol and has been implicated in airborne transmission of gastrointestinal viruses.18,19 Regarding diarrhea, even when contained by toilets, toilet flushing emits a pathogen-laden aerosol that disperses in the air.20-22

                          Experimental work has shown that Marburg and Ebola viruses can be isolated from sera and tissue culture medium at room temperature for up to 46 days, but at room temperature no virus was recovered from glass, metal, or plastic surfaces.23 Aerosolized (1-3 mcm) Marburg, Ebola, and Reston viruses, at 50% to 55% relative humidity and 72°F, had biological decay rates of 3.04%, 3.06%. and 1.55% per minute, respectively. These rates indicate that 99% loss in aerosol infectivity would occur in 93, 104, and 162 minutes, respectively.23

                          In still air, 3-mcm particles can take up to an hour to settle. With air currents, these and smaller particles can be transported considerable distances before they are deposited on a surface.
                          There is also some experimental evidence that Ebola and other filoviruses can be transmitted by the aerosol route. Jaax et al24 reported the unexpected death of two rhesus monkeys housed approximately 3 meters from monkeys infected with Ebola virus, concluding that respiratory or eye exposure to aerosols was the only possible explanation.

                          Zaire Ebola viruses have also been transmitted in the absence of direct contact among pigs25 and from pigs to non-human primates,26 which experienced lung involvement in infection. Persons with no known direct contact with Ebola virus disease patients or their bodily fluids have become infected.12

                          Direct injection and exposure via a skin break or mucous membranes are the most efficient ways for Ebola to transmit. It may be that inhalation is a less efficient route of transmission for Ebola and other filoviruses, as lung involvement has not been reported in all non-human primate studies of Ebola aerosol infectivity.27 However, the respiratory and gastrointestinal systems are not complete barriers to Ebola virus. Experimental studies have demonstrated that it is possible to infect non-human primates and other mammals with filovirus aerosols.25-27
                          Altogether, these epidemiologic and experimental data offer enough evidence to suggest that Ebola and other filoviruses may be opportunistic with respect to aerosol transmission.28 That is, other routes of entry may be more important and probable, but, given the right conditions, it is possible that transmission could also occur via aerosols.

                          Guidance from the CDC and WHO recommends the use of facemasks for healthcare workers providing routine care to patients with Ebola virus disease and respirators when aerosol-generating procedures are performed. (Interestingly, the 1998 WHO and CDC infection-control guidance for viral hemorrhagic fevers in Africa, still available on the CDC Web site, recommends the use of respirators.)
                          Facemasks, however, do not offer protection against inhalation of small infectious aerosols, because they lack adequate filters and do not fit tightly against the face.1 Therefore, a higher level of protection is necessary.
                          Which respirator to wear?

                          As described in our earlier CIDRAP commentary, we can use a Canadian control-banding approach to select the most appropriate respirator for exposures to Ebola in healthcare settings.29 (See this document for a detailed description of the Canadian control banding approach and the data used to select respirators in our examples below.)
                          The control banding method involves the following steps:
                          1. Identify the organism's risk group (1 to 4). Risk group reflects the toxicity of an organism, including the degree and type of disease and whether treatments are available. Ebola is in risk group 4, the most toxic organisms, because it can cause serious human or animal disease, is easily transmitted, directly or indirectly, and currently has no effective treatments or preventive measures.
                          2. Identify the generation rate. The rate of aerosol generation reflects the number of particles created per time (eg, particles per second). Some processes, such as coughing, create more aerosols than others, like normal breathing. Some processes, like intubation and toilet flushing, can rapidly generate very large quantities of aerosols. The control banding approach assigns a qualitative rank ranging from low (1) to high (4) (eg, normal breathing without coughing has a rank of 1).
                          3. Identify the level of control. Removing contaminated air and replacing it with clean air, as accomplished with a ventilation system, is effective for lowering the overall concentration of infectious aerosol particles in a space, although it may not be effective at lowering concentration in the immediate vicinity of a source. The number of air changes per hour (ACH) reflects the rate of air removal and replacement. This is a useful variable, because it is relatively easy to measure and, for hospitals, reflects building code requirements for different types of rooms. Again, a qualitative ranking is used to reflect low (1) versus high (4) ACH. Even if the true ventilation rate is not known, the examples can be used to select an appropriate air exchange rate.
                          4. Identify the respirator assigned protection factor. Respirators are designated by their "class," each of which has an assigned protection factor (APF) that reflects the degree of protection. The APF represents the outside, environmental concentration divided by the inside, facepiece concentration. An APF of 10 means that the outside concentration of a particular contaminant will be 10 times greater than that inside the respirator. If the concentration outside the respirator is very high, an assigned protection factor of 10 may not prevent the wearer from inhaling an infective dose of a highly toxic organism.

                          Practical examples

                          Two examples follow. These assume that infectious aerosols are generated only during vomiting, diarrhea, coughing, sneezing, or similar high-energy emissions such as some medical procedures. It is possible that Ebola virus may be shed as an aerosol in other manners not considered.
                          Caring for a patient in the early stages of disease (no bleeding, vomiting, diarrhea, coughing, sneezing, etc). In this case, the generation rate is 1. For any level of control (less than 3 to more than 12 ACH), the control banding wheel indicates a respirator protection level of 1 (APF of 10), which corresponds to an air purifying (negative pressure) half-facepiece respirator such as an N95 filtering facepiece respirator. This type of respirator requires fit testing.
                          Caring for a patient in the later stages of disease (bleeding, vomiting, diarrhea, etc).If we assume the highest generation rate (4) and a standard patient room (control level = 2, 3-6 ACH), a respirator with an APF of at least 50 is needed. In the United States, this would be equivalent to either a full-facepiece air-purifying (negative-pressure) respirator or a half-facepiece PAPR (positive pressure), but standards differ in other countries. Fit testing is required for these types of respirators.
                          The control level (room ventilation) can have a big effect on respirator selection. For the same patient housed in a negative-pressure airborne infection isolation room (6-12 ACH), a respirator with an assigned protection factor of 25 is required. This would correspond in the United States to a PAPR with a loose-fitting facepiece or with a helmet or hood. This type of respirator does not need fit testing.
                          Implications for protecting health workers in Africa

                          Healthcare workers have experienced very high rates of morbidity and mortality in the past and current Ebola virus outbreaks. A facemask, or surgical mask, offers no or very minimal protection from infectious aerosol particles. As our examples illustrate, for a risk group 4 organism like Ebola, the minimum level of protection should be an N95 filtering facepiece respirator.
                          This type of respirator, however, would only be appropriate only when the likelihood of aerosol exposure is very low. For healthcare workers caring for many patients in an epidemic situation, this type of respirator may not provide an adequate level of protection.
                          For a risk group 4 organism, any activity that has the potential for aerosolizing liquid body fluids, such as medical or disinfection procedures, should be avoided, if possible. Our risk assessment indicates that a PAPR with a full facepiece (APF = 50) or a hood or helmet (APF = 25) would be a better choice for patient care during epidemic conditions.
                          We recognize that PAPRs present some logistical and infection-control problems. Batteries require frequent charging (which requires a reliable source of electricity), and the entire ensemble requires careful handling and disinfection between uses. A PAPR is also more expensive to buy and maintain than other types of respirators.

                          On the other hand, a PAPR with a loose-fitting facepiece (hood or helmet) does not require fit testing. Wearing this type of respirator minimizes the need for other types of PPE, such as head coverings and goggles. And, most important, it is much more comfortable to wear than a negative-pressure respirator like an N95, especially in hot environments.
                          A recent report from a Medecins Sans Frontieres healthcare worker in Sierra Leone30 notes that healthcare workers cannot tolerate the required PPE for more than 40 minutes. Exiting the workplace every 40 minutes requires removal and disinfection or disposal (burning) of all PPE. A PAPR would allow much longer work periods, use less PPE, require fewer doffing episodes, generate less infectious waste, and be more protective. In the long run, we suspect this type of protection could also be less expensive.
                          Adequate protection is essential

                          To summarize, for the following reasons we believe that Ebola could be an opportunistic aerosol-transmissible disease requiring adequate respiratory protection:
                          • Patients and procedures generate aerosols, and Ebola virus remains viable in aerosols for up to 90 minutes.
                          • All sizes of aerosol particles are easily inhaled both near to and far from the patient.
                          • Crowding, limited air exchange, and close interactions with patients all contribute to the probability that healthcare workers will be exposed to high concentrations of very toxic infectious aerosols.
                          • Ebola targets immune response cells found in all epithelial tissues, including in the respiratory and gastrointestinal system.
                          • Experimental data support aerosols as a mode of disease transmission in non-human primates.

                          Risk level and working conditions suggest that a PAPR will be more protective, cost-effective, and comfortable than an N95 filtering facepiece respirator.
                          Acknowledgements
                          We thank Kathleen Harriman, PhD, MPH, RN, Chief, Vaccine Preventable Diseases Epidemiology Section, Immunization Branch, California Department of Public Health, and Nicole Vars McCullough, PhD, CIH, Manager, Global Technical Services, Personal Safety Division, 3M Company, for their input and review.
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                          Last edited by Adeptus; October 14, 2014, 04:02 AM.
                          Warning: Network Engineer talking economics!

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