Yale-Tulane Special Report - Ebola - West Africa - 5 September 2014

1. YALE- TULANE ESF-8 SPECIAL REPORT WEST AFRICA - EBOLA CONFIRMED PROBABLE SUSPECTED TOTALS CASES 2383 1078 506 3, 967 DEATH 1,243 591 271 2,105 BACKGROUND RISK CURRENT SITUATION 5 SEPTEMBER 2014 GUINEA LIBERIA NIGERIA SIERRA LEON SENEGAL CONGO BIOSECURITY MEASURES LIBERIA • MINISTRY OF HEALTH AND SOCIAL WELFARE NIGERIA • NIGERIA MINISTRY OF HEALTH • NIGERIA EMERGENCY MANAGEMENT AGENCY • EBOLA ALERT SIERRA LEONE • MOHS • MINISTRY OF HEALTH AND SANITATION INTERNATIONAL ORGANIZATIONS • RELIEF WEB • HUMANITARIAN RESPONSE • UNICEF • UN NEWS CENTER WHO • WORLD HEALTH ORGANIZATION - AFRICA • WHO AFRP EPR OUTBREAK NEWS • DISEASE OUTBREAK NEWS • GLOBAL ALERT RESPONSE - EBOLA • WHO – EBOLA • IFRC NGO • MSF • ACT ALLIANCE • CATHOLIC RELIEF • SAMARITAN'S PURSE RESPONSE ACTIVITIES GUINEA | LIBERIA NIGERIA| SIERRA LEONE | SENEGAL US GOVERNMENT • US EMBASSY MONROVIA – LIBERIA • US EMBASSY – CONAKRY, GUINEA. • US EMBASSY – SIERRA LEONE • US EMBASSY – NIGERIA CDC • CDC EBOLA HEMORRHAGIC FEVER • CDC – OUTBREAK OF EBOLA IN WEST AFRICA • USAID EU • ECDC • NaTHNac PORTALS, BLOGS, AND RESOURCES • CIDRAP • PROMED MAIL • EBOLA ALERTS ON HEALTHMAP • OPENSTREETMAP WEST AFRICA EBOLA RESPONSE • MEDBOX EBOLA TOOLBOX • VIROLOGY DOWN UNDER BLOG • H5N1 • DISASTER INFORMATION RESEARCH CENTER • INTERNATIONAL SOS NEW SOURCES • ALERTNET • NY TIMES • WASHINGTON POST EBOLA VIRUS DISEASE, WEST AFRICA – UPDATE 5 SEPTEMBER 2014 ON AUGUST 8, THE WORLD HEALTH ORGANIZATION (WHO) DECLARED THAT THE CURRENT EBOLA OUTBREAK IS A PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN (PHEIC). IMPACT ON HCW ECCD – 29 AUG VACCINE AND TREATMENT DEVLOPMENT

2. BACKGROUND SITUATION: EBOLA OUTBREAK - WEST AFRICA. • An uncontrolled outbreak of Ebola virus is currently underway in several countries in West Africa (Guinea, Liberia, and Sierra Leone, with limited cases reported in Nigeria, and a single case reported in Senegal). • This is the largest Ebola outbreak ever reported, both in terms of case numbers and geographical spread. It's also the first time the disease has affected large cities. Capital cities of these nations are affected. (Note that the Ebola cases in the Democratic Republic of Congo, as of 26 August, appear unrelated to the outbreak in Western Africa.) • The disease is spreading person to person, causing significant international concern and disrupting both the health and economy of these countries as well as neighboring nations. • In late July, the World Health Organization (WHO) declared the outbreak a Grade 3 emergency, its highest level of any emergency response. In early August, they declared it a Public Health Emergency of International Concern, meaning it is a serious public health event that endangers international public health DEVELOPMENT OF THE OUTBREAK: • On 22 March 2014, the Guinea Ministry of Health notified WHO about a rapidly evolving outbreak of EVD. Retrospective epidemiological investigations indicate that the first case of EVD probably occurred as early as December 2013 when a two-year-old girl from Guéckédou prefecture in the forested region of south-eastern Guinea died from symptoms compatible with EVD. • Researchers confirmed that the virus is a member of the Zaire species, which kills most of its victims. Strains of that virus have caused outbreaks previously in Gabon and the Democratic Republic of Congo. SOURCE: THE NEW ENGLAND JOURNAL OF MEDICINE. CDC WHO KEY POINTS – EBOLA VIRUS DISEASE, WEST AFRICA ECDC, INTERNATIONAL SOS SUBSEQUENT SPREAD • LIBERIA: In Liberia, the disease was reported in Lofa and Nimba counties in late March and by mid-April, the Ministry of Health and Social Welfare had recorded possible cases in Margibi and Montserrado counties. • SIERRA LEONE: The outbreak progressed rapidly in Sierra Leone. The first cases were reported on 25 May in the Kailahun District, near the border with Guéckédou in Guinea. By 20 June, there were 158 suspected cases, mainly in Kailahun and the adjacent district of Kenema, but also in the Kambia,Port Loko and Western districts in the north west of the country. By 17 July, the total number of suspected cases in the country stood at 442, and had overtaken those in Guinea and Liberia. By 20 July, additional cases had been reported in the Bo District the first case in Freetown, Sierra Leone's capital. • NIGERIA: At the end of July 2014, a symptomatic case travelled by air to Lagos, Nigeria where he infected a number of healthcare workers and airport contacts before his condition was recognized to be EVD. This cluster in Nigeria, initiated by air travel of an infectious person, has now resulted in tertiary cases in Nigeria and recently a new cluster in Port Harcourt, Rivers State with three confirmed cases. Therefore, Rivers State is now considered as an affected area. • SENEGAL: On 29 August, the Ministry of Health in Senegal reported a confirmed case of EVD in a 21-year-old male native of Guinea. He arrived in Dakar, by road, on 20 August and was hospitalized on 26 August after having initially been treated for malaria. On 27 August 2014, the Ministry of Health was informed that the patient was a contact of a known Ebola patient in Guinea and the patient was immediately isolated The current outbreak in West Africa is caused by Zaïre Ebola virus. A concurrent EVD outbreak was declared on 26 August 2014 in the Democratic Republic of Congo. The two outbreaks are not connected

3. MAP OF AFFECTED AREAS IN AFRICA The largest ever Ebola outbreak is underway in several countries in West Africa. The epidemic continues to grow and spread into new areas, threatening more lives and potentially the economies of affected countries. • 29 August: The Senegalese Ministry of Health announced the first imported case of Ebola in Senegal. • 25 August: A separate outbreak has been identified in Democratic Republic of the Congo.

4. COMBINED EPIDEMIOLOGICAL CURVES – WEST AFRICA In the past three weeks, cases have dramatically increased in the three countries with widespread and intense transmission, both inland and in the capitals. This highlights the urgent need to reinforce control measures and increase capacity for case management, safe burials, contact tracing, and social mobilization. SOURCE: WHO – 5 SEPT 2014 WEST AFRICA

5. LOCATION OF CASES THROUGHOUT THE COUNTRIES WITH MOST INTENSE TRANSMISSION The map shows the location of cases throughout the countries with most intense transmission, differentiating the cumulative number of cases to date in each area, and the number occurring within the past 21 days (i.e. corresponding to the incubation period for Ebola) preceding 31 August. A full understanding of the outbreak that will lead to improved response requires detailed analysis of exactly where transmission is occurring by subdistrict level over. This analysis is ongoing. The outbreak continues to expand geographically. For the first time since the outbreak began, the majority of cases (55.3 %) have been reported outside Gueckedou and Macenta (Guinea); Lofa (Liberia), and Kenema and Kailahun (Sierra Leone). Three districts in Guinea have been affected for the first time. The outbreak continues to escalate. Most cases are concentrated in only a few places: more than 80% of cases have occurred in 9 out of the 42 districts in Guinea, Liberia, and Sierra Leone that have reported cases (Lofa, Kailahun, Kenema, Gueckedou, Montserrado, Macenta, Conakry, Margibi, and Nimba). The overall case fatality rate (ratio of deaths to cases) is 53%. It ranges from 39% in Sierra Leone to 64% in Guinea. SOURCE: WHO – 5 SEPT 2014

6. RISK OF HUMAN TO HUMAN TRANSMISSION  Transmission of EVD requires direct contact with blood, secretions, organs or other bodily fluids of dead or living infected persons or animals or with material or utensils heavily contaminated with such fluids.  This includes unprotected sexual contacts with patients who have recently recovered from the disease. RISK ASSESSMENT • European Centre for Disease Prevention and Control (1 August 2014) • European Centre for Disease Prevention and Control (8 April March 2014) • European Centre for Disease Prevention and Control (23 March 2014) GENERAL INFORMATION • The current outbreak in West Africa has become an epidemic and is not under control • WHO categorizes Guinea, Liberia, and Sierra Leone as having widespread and intense EVD transmission and Nigeria as having localized transmission. to date have been inadequate. THREE RISK ASSESSMENT HAVE BEEN PUBLISHED: CURRENT OUTBREAK  The evolving outbreak of EVD in West Africa over the last weeks increases the likelihood that residents and travelers to the EVD-affected countries will be exposed to infected or ill persons. The risk of infection for residents and visitors to the affected countries through exposure in the community is considered low if they adhere to the recommended precautions.  People visiting friends and relatives in the affected countries tend to have more and closer contacts in the community, and they are more likely than other visitors to participate in burial ceremonies – an activity known to be associated with transmission of the Ebola virus.  Residents and visitors to the affected areas run a high risk of exposure to EVD in healthcare facilities. The risk of being exposed to the Ebola virus is higher for healthcare workers, e.g. volunteers from NGOs who work in settings where appropriate infection control measures have not been implemented. (ECDC - 3 SEPT) RISK TYPE OF CONTACT LOW • Casual contact with a feverish but ambulant and self-caring patient, e.g. sharing a sitting area or public transportation; receptionist tasks. HIGH • Close face-to-face contact (e.g. within one meter) without appropriate personal protective equipment (including eye protection) with a probable or confirmed case who is coughing, vomiting, bleeding, or who has diarrhea; or has had unprotected sexual contact with a case up to three months after recovery • Direct contact with any material soiled by body fluids from a probable or confirmed case • Percutaneous injury (e.g. with needle) or mucosal exposure to bodily fluids, tissues or laboratory specimens of a probable or confirmed case • Participation in funeral rites with direct exposure to human remains in or from affected area without appropriate personal protective equipment • Direct contact with bush meat or bats, rodents, primates, living or dead in/from affected areas (ECDC - 3 SEPT)

7. SITUATION NOTE: The bar for week 35/2014 does not represent a complete week. The solid green line represents the outbreak trends based on a five week moving average plotted on the fifth week of the moving average window. OVERALL ASSESSMENT • The outbreak control measures implemented so far have failed to control the outbreak, in particular in Liberia and Sierra Leone where the outbreak is now accelerating rapidly. • Transmission seems to be primarily driven by direct contact with EVD cases and dead bodies, and the wide geographical spread is the result of ineffective contact tracing and monitoring which has allowed infected people to travel during the incubation period. • 50% survive - In this Ebola outbreak, the survival rate has been higher than previous outbreaks. (WHO) • The epidemiological data coming out from the EVD-affected countries has improved over recent months but it is still far from reliable. It is expected that the rate of new cases will continue to rise in Sierra Leone and Liberia in the coming weeks and possibly months. • The complexity of the outbreak, the weak public health systems in the affected countries and the magnitude of this outbreak make it difficult to predict when the spread is likely to peak and start to decelerate. (ECDC 3 SEPT 2014) • The actual number of cases may be two to four fold higher than currently reported, and it is estimated that the aggregate count could exceed 20,000 EVD cases over the course of the outbreak (WHO Ebola Response Roadmap – 28 AUG 2014) • CURRENTLY THERE ARE NOT ENOUGH HEALTH WORKERS, DOCTORS, NURSES, DRIVERS, AND CONTACT TRACERS ON THE GROUND TO HANDLE THE INCREASING NUMBER OF CASES. Most of the infections are happening in the community, and many people are unwilling to identify themselves as ill. When people do identify themselves as ill there are not enough ambulances to transport them or beds to treat them (WHO 4 SEPT 2014 ) SINCE DECEMBER 2013 AND AS OF 26 AUGUST 2014, 3 071 CASES OF EVD, INCLUDING 1 553 DEATHS HAVE BEEN REPORTED BY WHO CASES, DEATHS AND CASE-FATALITY RATIOS IN WEST AFRICAN EVD-AFFECTED COUNTRIES, AS OF 26 AUGUST 2014 (ECDC 3 SEPT 2014)

8. SITUATION Nurses wearing protective suits escort a man infected with the Ebola virus to a hospital in Monrovia, Liberia. SOURCE: Zoom Doso AFP TRAVEL RESTRICTIONS • There is an urgent need to open up airline routes that have been closed to affected countries. These closures have had a huge impact impeding the flow of experts and supplies into Africa, and the outbreak itself is having a negative impact on the economies of Guinea, Liberia and Sierra Leone. (WHO 4 SEPT 2014 ) • WHO does not recommend any travel or trade restrictions be applied except in cases where individuals have been confirmed or are suspected of being infected with Ebola Virus Disease or where individuals have had contact with cases of Ebola. (WHO 4 SEPT 2014 ) The implemented measures have so far been unsuccessful in controlling the outbreak. The biggest challenges have been encountered in Sierra Leone and Liberia, the two countries where the spread is currently accelerating the fastest. Médecins Sans Frontières (MSF) announced on 2 September in a special briefing at the United Nations organized by the office of the UN Secretary General and the World Health Organization (WHO) that world leaders are failing to address the world's worst Ebola epidemic, and states with biological-disaster response capacity, including civilian and military medical capability, must immediately dispatch assets and personnel to West Africa. The further spread of the virus will not be prevented without a massive deployment of such specialized medical units to bolster epidemic control efforts in affected countries. (MSF, 2 SEP 2014) The Director of CDC is calling for a rapid escalation of the world’s response to the Ebola epidemic in West Africa and says “the window is closing” on the opportunity to bring the unprecedented outbreak under control. (CDC – 2 Sept 2014) • There are still critical shortages of Ebola treatment center beds in Guinea, Liberia, and Sierra Leone, the three countries that have intense and widespread transmission. (WHO 5 SEPT 2014) • Laboratory capacity is gradually expanding; however, there are still critical needs in a number of locations. Increased laboratory capacity is essential for proper screening and triage of patients. • Contact tracing and safe burials continue to be of concern in light of increasing cases and deaths. Of particular concern is the safety of community burials and mass cremation. MSF is putting in place increased capacity for cremation services in Monrovia. WHO is rapidly scaling up numbers of safe burial teams in Liberia and Sierra Leone. (WHO 5 SEPT 2014)

9. SITUATION GUINEA GUINEA CONFIRMED PROBABLE SUSPECT TOTALS Cases 604 152 56 812 Deaths 362 152 3 517 EBOLA VIRUS DISEASE, WEST AFRICA – UPDATE 5 SEPTEMBER 2014 BACKGROUND • Affected districts include Conakry, Guéckédou, Macenta, Kissidougou, Dabola, Djingaraye, Télimélé, Boffa, Kouroussa, Dubreka, Fria, Siguiri, Pita, Coyah, Forecariah, N’zerekore, Gueckédou, Kérouané and Yamou; several are no longer active areas of EVD transmission • 11-13 August: Guinea imposed health checks at its borders with Sierra Leone and Liberia (ECHO) while Guinea-Bissau also decided to close its border with Guinea in a bid to prevent the entry of the virus (Reuters). • U.S. Chargé d’Affaires Ervin Massinga declared a disaster due to the magnitude of the EVD outbreak in Guinea on August 15. DART staff in Conakry are coordinating with government officials, U.N. agencies, and other stakeholders to assess the situation and identify gaps where USG assistance will be most effective. (USAID – 20 AUG) GOVERNMENT OF GUINEA • The Government of Guinea (GoG) declared a public health emergency on August 14 and announced the implementation of preventive measures, including travel restrictions and a ban on transporting human remains between towns, according to international media. Guinean President Alpha Condé also stated that health authorities would hospitalize anyone suspected of EVD infection pending laboratory test results. • The GoG has implemented strict border controls, with health care workers checking individuals—and isolating any suspected EVD cases—at points along Guinea’s borders with Liberia and Sierra Leone, international media report. (USAID – 20 AUG) SOURCE: OCHA 4 SEP 2014

10. SITUATION GUINEA CASE MANAGEMENT AND INFECTION PREVENTION AND CONTROL • The marked increase in the past week shows more than 100 cases newly reported, mainly in the epicenter of the outbreak (Macenta, Gueckedou), as well as in Dubreka, a district close to Conakry. ( WHO - 5 SEP) • According to CDC experts, the current EVD situation in Guinea is deteriorating and the caseload in Macenta Prefecture continues to rise. As of August 26, Guinea’s two ETUs—one in the capital of Conakry and the other in Guékédou—reported the highest number of patients since the outbreak began in March. Community resistance continues to limit contact tracing in Macenta, where public health experts predict that the caseload will likely continue to rise in the coming weeks. (USAID - 3 SEPT) • Reports shows case management capability in Gueckedou and Conakry is mostly adequate, with lab support by the Pasteur Institute Dakar aiding in Conakry, and the European Union Mobile Laboratory in Gueckedou. (29 AUG-WHO) • Guinea-Bissau launched a nationwide hygiene drive, cleaning and disinfection of public places the last Saturday of every month, according to the office of Prime Minister Domingos Simoes Pereira (30 AUG-Agence France-Presse) FOOD: Guinea: WFP began food distributions because of Ebola four months ago and has reached around 40,000 people (in Biffa, Fria, Télémélé, N’Zerekore, Macenta and Guekedo). Preparations are being made to gradually increase distributions to 464,000 people over a period of three months. (WFP 3 SEP) RIOTS/ DEMONSTRATIONS • In Nzérékoré, Guinea’s second largest city, on 28 AUG, riots occurred The cause was a rumor that officers reportedly went into the local market to spray against Ebola. • People panicked, looted, and attacked the Regional Hospital of Nzérékoré. Groups of youths armed with stones, sticks and other sharp objects chanted “Ebola, it's wrong, there is no Ebola.” • Regional and prefectural authorities, elders, religious leaders and local representatives of the UN system, including UNICEF, are conducting advocacy to find lasting solutions to this situation. (29 AUG UNICEF BBC RUMORS AND CHALLENGES • In reluctant villages in Guékédou it was notable to see the fear caused by the bottles of chlorine among villagers who consider the chlorine to be poison used to introduce the virus or disease. (29 AUG UNICEF) • The reluctance of people makes it very difficult to undertake interpersonal communication and sensitize community leaders. Community sensitizers often face danger and their activities in the field are routinely suspended. Local media is an essential compliment in these cases, but their lack of coverage limits their actions (29 AUG UNICEF) RISK COMMUNICATIONS • Community sensitization activities continue in Conakry, Nzérékoré Macenta Yomou, Siguiri and Kouroussa continue. • 220 new religious leaders were trained and gave sermons in 220 places of worship in Conakry and Nzérékoré; 11,050 households we re sensitized through door to door visits and public events. This included the distribution of 28.066 pieces of soap, chlorine 15.084 bottles, and thousands of flyers. (UNICEF 29 AUG)

11. SITUATION LIBERIA LIBERIA CONFIRMED PROBABLE SUSPECT TOTALS Cases 614 888 369 1871 Deaths 431 401 257 1089 GOVERNMENT OF LIBERIA The MoHSWreports that the ongoing EVD outbreak had spread to 11 of Liberia’s 15 counties, leaving only the southwestern counties of Grand Gedeh, Grand Kru, River Gee and Maryland with no reported EVD cases. As of September 1, MoHSWreported that the case fatality rate for confirmed and probable cases in Liberia was nearly 62 percent. (USAID, 3 SEPT 2014) • On 01 September, the Liberian President released a statement ordering all non-essential civil servants to stay home another month in an attempt to mitigate the spread of the Ebola virus. • On 01 September in Monrovia, Liberia, USAID announced it will provide an additional $5 million in aid to assist in the Ebola response, raising the total USAID commitment to $19.6 million. The announcement came shortly after USAID delivered more than 16 tons of emergency medical equipment to Liberia, including water treatment systems, personal protective equipment, plastic sheeting to treatment units. SOURCE: Beloit- 1 SEP 14 ; AA 1 SEPT 14 ; CDC 26 AUG 14 • On 20 August, the Liberian government issued a statement saying it would deny permission for any vessel to disembark from Liberian ports until future notice. Likewise, shore passes, which allow sailors on arriving commercial ships to access Liberian ports, will be canceled. (AFP 30 AUG 14) • On 27 August, the Liberian Minister of Foreign Affairs expressed frustration with the travel restrictions imposed by many African countries in the region. The minister agues that “disproportionate and exaggerated” actions may unjustly stigmatize citizens of Liberia and hinder the ability of effected countries to handle the Ebola outbreak. The World Health Organizations issued a similar statement, arguing that overbearing restrictions create supply shortages and may indirectly harm containment efforts. (BBC 28 AUG 14; All Africa 27 AUG 14 ) • On 26 August, the Liberian President fired government ministers and senior officials operating overseas that defined the order to return to Liberia to assist in the Ebola response. (AFP 26 Aug 14) • On 30 August, the GoL lifted the quarantine imposed on Monrovia’s densely populated West Point neighborhood. The reversal of the West Point quarantine—instated by the GoL on 20 August —follows robust advocacy by MSF and other health actors against the use of quarantines as a tool to prevent the spread of EVD. The GoL has yet to lift the quarantine of Margibi County’s Dolo town, also instated on 20 August. (USAID, 3 SEPT 2014) The WHO says that travel band are jeopardizing efforts to beat the epidemic (BBC) EBOLA VIRUS DISEASE, WEST AFRICA – UPDATE 5 SEPTEMBER 2014

12. SITUATION LIBERIA SOURCE: OCHA 4 SEP 2014 • The Liberian government has recently instituted enhanced measures to combat the spread of Ebola, many of which will likely make travel to, from, and within the country difficult. The government has taken the following steps: • Closed all borders except major entry points (Roberts International Airport, James Spriggs Payne Airport, Foya Crossing, Bo Waterside Crossing, and Ganta Crossing). • Instituted prevention and screening measures at entry points that remain open. This new travel policy will affect incoming and outgoing travelers. • Instituted restrictions on public and other mass gatherings. • Instituted quarantine measures for communities heavily affected by Ebola; travel in and out of those communities will be restricted. • Authorized military personnel to aid in enforcing these and other prevention and control measures. (CDC – 26 AUG)

13. SITUATION LIBERIA CASE MANAGEMENT AND INFECTION PREVENTION AND CONTROL • In Liberia, the capacity to cope with the increasing caseload remains dramatically low, especially in the capital, Monrovia, as well as in Bong and Nimba counties. (WHO 29 AUG 2014) • Liberia continues to be the most affected country, reporting more than 200 cases a week for the past three weeks. Transmission remains very intense in Lofa county, as well as in Montserrado county, which includes the capital, Monrovia. ( WHO 5 SEP 2014) HOSPITAL RESPONSE AND ISOLATION/TREATMENT CENTERS Lofa, Margibi, Bong and Nimba, all have isolation facilities established. • FOYA, LOFA COUNTY: Borma Hospital Ebola Treatment Unit (ETU) is being run by Medecins Sans Frontieres (MSF) as at 15 August. It has a capacity of 40 beds, with expansion to 80 beds underway. No date for completion has been announced. A "mid-level isolation unit" has been established in Telewowan Hospital, Voinjama, managed by MSF. The centre will expand to 40 beds although no estimated date for completion has been set. • MONROVIA: ELWA hospital ETU is being run by MSF. The new 120-bed facility opened on 17 August. There are plans to expand to 300 beds by 2nd September. The facility in JFK Hospital is functioning as a full ETU. There is a Holding Unit at Redemption Hospital. • MONTSERRADO:West Point holding unit has been established. The JFK ETU is open as of 19 August. • NIMBA: Renovation of the holding facilties at G. W. Harley and Ganta Hospitals is underway as at 20 August. • BONG: as at 22 August, a new ETU is being constructed however it is not determined how the clinic services will be run • BOMI: Bomi County Health Team (CHT) opened three, two-room quarantine units with a 12-bed capacity for Ebola patients. There is a holding centre in Tubmanburg. INTERNATIONAL SOS • Doctors Without Borders/Médecins Sans Frontières (MSF) recently opened a new ETU—named ELWA Three—with a 120-bed capacity in Monrovia. However, as of August 27th, the facilities are already reported to be overwhelmed and at max capacity. MSF has issued plans to expand their facilities to accommodate an additional 120 beds in three large tents. Throughout the entire county, MSF operated four facilities and has admitted 1,885 patients since March. (AA 27 Aug 14)

14. SITUATION LIBERIA CUMULATIVE CASES OF THE EBOLA VIRUS DISEASE AMONG HEALTHCARE WORKERS IN LIBERIA SINCE MAY 29 TO SEPTEMBER 2, 2014 SOURCE: LIBERIA MINISTRY OF HEALTH AND SOCIAL WELFARE – 3 SEPT 2014

15. SITUATION NIGERA NIGERIA CONFIRMED PROBABLE SUSPECT TOTALS Cases 18 1 3 22 Deaths 7 1 0 8 CHALLENGES • While the government hoped to contain the disease within Lagos, new cases have been confirmed in the oil producing city of Port Harcourt, raising concerns that the disease may appear elsewhere as well. • Nigeria is experiencing Ebola for the first time and thus has limited knowledge of mode of transmission and preventive measures. In some places, false information about the Ebola virus is being spread therefore, there is a clear need for training of volunteers to support the Ebola operation in Nigeria. • At the moment the human resource capacity is inadequate to fully support the efforts of the Federal and State governments. The government is appealing for more volunteers both clinical and those that can do dissemination of information as well as conducting contact tracing. • To limit the spread of the outbreak, it is necessary to provide timely and accurate information to the population in Nigeria through leaflets, posters, in markets schools, to religious and community leaders. • On 31 August, Nigeria officials confirmed a new case of Ebola contracted by a doctor. The doctor’s spouse, also a doctor, died after treating a patient that had primary contact with the Liberian American that crossed into Nigeria in July. Of the six Ebola attributed deaths in Nigeria, four have been healthcare workers. (REUTERS - 28 AUG) • During the 25 August, the Nigerian Medical Association reached agreement with Nigerian Health Officials to end its strike. This reconciliation allowed doctors return to work the following morning. • On 28 August, the United States National Institute of Health announced they would conduct trials of a new Ebola vaccine in Nigeria. • The Nigerian government announced the closure of all public and private elementary schools through 13 October as a preventative measure to control the spread of Ebola. SOURCE: IFRC ECDC WASHINGTON POST REUTERS HOSPITAL RESPONSE AND ISOLATION/TREATMENT CENTERS • Lagos: Infectious Disease Hospital (also known as Mainland Hospital), Yaba, has a 40-bed isolation facility for Ebola cases • Delta State: seven hospitals have been identified to be isolation centers for Ebola cases, including Warri Central Hospitals, Ughelli Central Hospital, Sapele Central Hospital, Agbor Central Hsopital, Oleh Central Hospital, Eku Baptist Government Hospital and Delta State University Teaching Hospital Oghara. • Niger State: a quarantine centre is being established in Minna. "Containment Center" will be established in the three Senatorial Districts. • Rivers State: an isolation unit has been established at Oduoha, Emohua. EBOLA VIRUS DISEASE, WEST AFRICA – UPDATE 5 SEPTEMBER 2014

16. SIERRA LEONE CONFIRMED PROBABLE SUSPECT TOTALS Cases 1146 37 78 1261 Deaths 443 37 11 491 BACKGROUND: • An outbreak of Ebola has been ongoing in Sierra Leone since May 2014. • Affected districts in Sierra Leone include Bo, Bombali, Bonthe, Kailahun, Kambia, Kenema, Kono, Moyamba, Port Loko, Pujehun, Tonkolili, and Western Area, including the capital of Freetown. • On 13 August, U.S. Chargé d’Affaires Kathleen FitzGibbon declared a disaster due to the effects of the EVD outbreak in Sierra Leone. DART staff in Freetown are coordinating with government officials, U.N. agencies, and other stakeholders to assess the situation and identify gaps where USG assistance will be most effective. GOVERNMENT OF SIERRA LEONE • On 29 August, Government of Sierra Leone (GoSL) President Ernest Bai Koroma dismissed GoSL’s Minister of Health Miatta Kargbo, citing her ineffective management of the ongoing EVD outbreak, according to international media. • Parliament in Sierra Leone has passed a law that imposes jail time (up to two years) for concealing Ebola-infected patients. Legislation also passed that imposes up to 6-month jail sentence to individuals entering or leaving Ebola affected areas who are not authorized (30 AUG-ACAPS) SOURCE: OCHA 4 SEP SITUATION SIERRA LEONE EBOLA VIRUS DISEASE, WEST AFRICA – UPDATE 5 SEPTEMBER 2014

17. ISOLATION / TREATMENT CENTERS • Kenema: The isolation facility in Kenema Government Hospital, is to be re-located outside the township of Kenema, a few miles from Hanga. All new cases will be treated at the centre in Kailahun until the new centre is ready. The Red Cross is establishing the new facility, which, on 22 August, was expected to be functional "soon" . • Kailahun: There is an 80-bed facility, operated by MSF. The villages of Koindu and Buedu have "referral units", where patients who have symptoms of Ebola are isolated and evaluated. If they are determined to have Ebola they are then transferred to the isolation facility. • Freetown: An isolation unit has been established at Connaught Hospital, with assistance from a medical team from King's Health Partners, UK. • Bo: MSF is constructing a 35-bed isolation centre which is expected to be functional by 28 August. A transit centre in Gondama is run by MSF. • Western Area: A holding facility is being established in Lakka, and a facility is being constructed in Kerry Town. SITUATION SIERRA LEONE • There is inadequate capacity to accommodate patients in Freetown. Patients must be transferred to Kenema, which is already overwhelmed by local demand. (WHO 29 AUG) • The GoSL Ministry of Health and Sanitation (MoHS) reported that as of 01 September, the EVD case fatality rate in Sierra Leone for confirmed cases was nearly 36 percent. There are currently 75 patients in the Kenema Isolation Unit. (USAID, 3 SEP) LABORATORY CAPACITY • Additional laboratory support is needed in addition to the Kenema laboratory (supported by Metabiota and the US Department of Defense Critical Reagent Team) to cope with the increasing disease burden. (WHO, 29 AUG) • A mobile laboratory from South Africa has been deployed to Freetown, where Ebola treatment centers are being constructed to care for patients locally and in better conditions, rather than referring them to Kenema. (WHO 29 AUG) CASE MANAGEMENT AND INFECTION PREVENTION AND CONTROL • In the last two weeks, the incidence in Sierra Leone has remained very high, with more than 150 cases reported each week. Kenema and Kailahun show active, persistent transmission, while the incidence in the capital, Freetown, continues to increase. ( WHO 5 SEP 2014) MOST URGENT HUMANITARIAN NEEDS In order to be more effective in the Ebola response there is a continued urgent need for the following: • Additional Health Workers (doctors & nurses), • Additional Transport – Ambulances (4x4), Pick-ups (4x4), motorcycles • Medical supplies (including personal protective equipment), • Continued Nation-wide community outreach/social mobilization programs, • Scaling-up of quality Contact Tracing • Support to survivors & affected communities (including Family Tracing & Reunification and PsychoSocial Support).

18. SITUATION SENEGAL SENEGAL CONFIRMED PROBABLE SUSPECT TOTALS Cases 1 1 Deaths 0 RESPONSE • The alert of a case in Senegal launched an investigation, and triggered urgent contact tracing. • WHO is treating this first case in Senegal as a top priority emergency. Key operational personnel were dispatched to Dakar on 30 August; others will follow. • The Government of Senegal has informed WHO of the urgent need for epidemiological support, personal protective equipment, and hygiene kits. These needs will be met with the fastest possible speed. • The CDC is not currently warning US residents to avoid travel to Senegal. SITUATION • On 29 August 2014, Senegal’s Ministry of Health confirmed the first case of Ebola virus in the country. • The case is a 21-year-old male native of Guinea who arrived in Dakar by road on 20 August and stayed with relatives on the outskirts of the city. • On 23 August, he sought medical care for symptoms that included fever, diarrhea, and vomiting. He was initially treated for malaria, but was referred to a Dakar hospital on 26 August when symptoms did not improve. SOURCE: WHO – 30 AUG, US NEWS & WORLD REPORT – 1 SEP , CDC Source: CDC EBOLA VIRUS DISEASE, WEST AFRICA – UPDATE 5 SEPTEMBER 2014

19. SITUATION DEMOCRATIC REPUBLIC OF THE CONGO Democratic Republic of the Congo CONFIRMED PROBABLE SUSPECT TOTALS Cases 13 21 19 534 Deaths 311 OUTBREAK DEVELOPMENT The first person to contract Ebola in the DRC was a pregnant woman who butchered a bush animal given to her by her husband. She was taken to a clinic after she started displaying symptoms of EVD and died on Aug. 11 of suspected hemorrhagic fever. The health care workers who cared for the woman, which included one doctor, two nurses, a hygienist and a ward boy, all developed similar symptoms and died. Similar deaths were discovered among relatives of this patient, people who were in contact with the health care workers, and people who were involved in the burial process of all the men and women who died. According to the WHO, from July 28 to Sept 2 there have been 31 deaths and 53 cases. Healthcare workers are now tracing 160 contacts.1 WHO confirmed that “the outbreak in DRC is a distinct and independent event, with no relationship to the outbreak in west Africa.” 1 This outbreak marks the seventh in the DRC since EVD was discovered in the country in 1976. FINANCIAL SUPPORT In order to effectively address this outbreak, the United Nations (UN) mission in the DRC allocated US$1.5 million according to Agence France-Presse (AFP) report.3 The World Health Organization (WHO) reported that the Ministry of Health (MoH) in the DRC reported an outbreak of Ebola in Equateur Province.1 REFERENCES DRC Ebola map image from UN OCHA 25 Aug 14: http://reliefweb.int/map/democratic-republic- congo/rd-congo-ebola-outbreak-equateur-25-aug-2014 1World Health Organization 2 Sept 14: http://who.int/mediacentre/news/ebola/2-september- 2014/en/ 2-3Voice of America News and Reuters: http://www.voanews.com/content/dozens-monitored-for- possible-ebola-in-drc/2430146.html https://news.yahoo.com/death-toll-congo-ebola-outbreak-rises-31-120522508.html 4United Nations 30 Aug 14: https://wca.humanitarianresponse.info/fr/system/files/documents/files/EBOLA%20- %20Update%20du%2030%20aout%202014%20-%20No.%205_0.pdf Bush meat image from Casimir Nebesse (2009): http://theiufroblog.wordpress.com/2010/02/15/bushmeat-beyond-the-ecological-crisis/ photo3-2/ Young woman selling bushmeat in DRC

20. HEATHCARE WORKERS • More than 130 health workers have died during the Ebola outbreak amid shortages of equipment and trained staff in the region. That is nearly a 10th of the total 1,550 killed by the disease, mostly in Liberia, Sierra Leone and Guinea and it does not include those who died in the recently announced outbreak in the DRC. Additionally, more than 260 have been infected. (NPR: 1 SEPT 2014 ) • Several factors help explain the high proportion of infected medical staff. (nearly 10% of the cases) These factors include shortages of personal protective equipment or its improper use, far too few medical staff for such a large outbreak, and the compassion that causes medical staff to work in isolation wards far beyond the number of hours recommended as safe. (WHO, 25 AUG 2014) DEATHS and NEW INFECTIONS AMONG HCWs • SIM announced on 2 Sept 2014 that a U.S. doctor treating obstetric patients at ELWA hospital in Monrovia is infected. The doctor had not been working within the Ebola isolation unit before becoming infected. • The 2 U.S. aid workers, Dr. Kent Brantley and Nancy Writebol were discharged from the hospital on 19 Aug 2014. • Three more doctors: Zukunis Ireland, Abraham Borbor from Liberia and Aroh Cosmos Izchukwu from Nigeria have contracted the virus. Dr. Abraham Borbor succumbed to the disease on Sunday 24 August. • A British nurse, William Poolley, who tested positive for Ebola in Sierra Leone was on 24 Aug 2014, was discharged from a London hospital on 3 Sept 2014. • On 29 July, leading Ebola doctor Sheik Umar Khan from Sierra Leone died in the outbreak and Dr Modupe Cole, a senior physician at the country`s main referral facility, Connaught Hospital, died after contracting the virus from an infected patient • Samuel Brisbane, a former advisor to the Liberian Ministry of Health and Social Welfare described as "one of Liberia's most high-profile doctors” died on 27 July 2014. WHY HAVE SO MANY HEALTHCARE WORKERS BEEN INFECTED? • Capital cities as well as remote rural areas are affected, vastly increasing opportunities for undiagnosed cases to have contact with hospital staff. • Neither doctors nor the public are familiar with the disease. • Several infectious diseases endemic in the region, like malaria, typhoid fever, and Lassa fever, mimic the initial symptoms of Ebola virus disease. • Patients infected with these diseases will often need emergency care. Their doctors and nurses may see no reason to suspect Ebola and see no need to take protective measures. • Some documented infections have occurred when unprotected doctors rushed to aid a waiting patient who was visibly very ill. • In many cases, medical staff are at risk because no protective equipment is available – not even gloves and face masks. Even in dedicated Ebola wards, personal protective equipment is often scarce or not being properly used. • Personal protective equipment is hot and cumbersome, especially in a tropical climate, and this severely limits the time that doctors and nurses can work in an isolation ward. • Some doctors work beyond their physical limits, trying to save lives in 12-hour shifts, every day of the week. Staff who are exhausted are more prone to make mistakes.

21. HEATHCARE WORKERS UPDATES ON HCW CONDITIONS Both foreign and local health care workers have been affected as this continues to be a global fight. MSF has 1,800 HCWs working on Ebola in Guinea, Sierra Leone, Liberia and Nigeria. Of those, 184 are foreign volunteers. WHO has both foreign and local people on the ground and the U.S. CDC announced it will be sending 50 staffers to West Africa. LIBERIA--HCWs in Liberia’s JFK Memorial Medical Center strike on 2 Sept 14 following a protest on the previous day over unpaid wages from the last two months. This comes amidst food shortages and steep inflation due to border closings from the EBV. SIERRA LEONE--On 31 August, health workers went on strike at a major state-run Ebola treatment center, protesting over pay and working conditions (international media, 30/08/2014). On 26 August, WHO temporarily withdrew its health workers from Kailahun post after one of them was infected with the virus (WHO, 26/08/2014).There are continued cases of infected people leaving treatment centers. Some infected people, including medical personnel, are disappearing with their families, leading to fear and tension in the communities and great uncertainty in the control of the disease. Health workers are refusing to work in isolation wards and Ebola treatment hospital (UNICEF, 26/08/2014). NIGERIA--Of the six people who have died of EBV in Nigeria, four have been healthcare workers—two doctors and two nurses. Additionally, a doctor and a pharmacist are in isolation under observation. The Nigerian health ministry met on 1 Sept 2014 to discuss how patients can be properly treated while at the same time protecting health care works. GUINEA--Nurses told the press they lacked basic medical equipment to treat patients. Some bring protective items such as gloves and clothing to work themselves. Nursing students in Freetown, Sierra Leone, wait to take their final qualifying exams so they can join the fight against Ebola. A Red Cross worker puts on protective gear before entering the house of a suspected Ebola victim in Gbeka, Sierra Leone. Photo credits: Samuel Aranda, National Geographic, 29 Aug 14 http://news.nationalgeographic.com/news/speci al-features/2014/08/140829-Ebola-caregivers-doctors- nurses-west-africa-sierra-leone/

22. BIOSECURITY MEASURES • Human-to-human transmission of the Ebola virus is associated with direct or indirect contact with blood and body fluids. • Close physical contact with Ebola patients should be avoided. Gloves and appropriate personal protective equipment should be worn when taking care of ill patients at home. • Regular hand washing is required after visiting patients in hospital, as well as after taking care of patients at home. • People who have died from Ebola should be promptly and safely buried. World Health Organization • Health-care workers caring for patients with suspected or confirmed Ebola virus should apply, in addition to standard precautions, other infection control measures to avoid any exposure to the patient’s blood and body fluids and direct unprotected contact with the possibly contaminated environment. • When in close contact (within 1 meter) of patients, health-care workers should wear face protection (a face shield or a medical mask and goggles), a clean, non-sterile long-sleeved gown, and gloves (sterile gloves for some procedures). • Ebola viruses are considered Risk Group 4 Pathogens by WHO, requiring Biosafety Level 4 equipment in laboratories. World Health Organization The World Health Organization has just released an Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola. If carefully implemented, infection prevention and control (IPC) measures will reduce or stop the spread of the virus and protect health-care workers (HCWs) and others. During an Ebola outbreak, funeral rituals are the most important contamination vectors. Here, body bags are incinerated in a crematorium.(MSF)

23. RESPONSE IN COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION BEDS: There are still critical shortages of Ebola treatment center beds in Guinea, Liberia, and Sierra Leone, the three countries that have intense and widespread transmission. • In the past week, an additional 40 beds have been established by Médecins Sans Frontières (MSF) in Monrovia; a further 40 beds will soon be available in Bong, Liberia. • Total Ebola Treatment Centre bed capacity for these three countries are: Guinea, 130; Liberia, 314; and Sierra Leone, 130. • Another 170 beds are expected to be available soon in Sierra Leone. Based on current capacity and needs, an additional 980 Ebola treatment center beds are required, with 760 of these in Monrovia alone. • Although plans are in place to build such facilities, there are challenges related to site selection as well as a critical shortage of clinical teams available to manage these facilities. MSF and Ministries of Health are being supported by WHO to resolve these issues SOCIAL MOBILIZATION • Responsible agencies are rapidly improving the coordination and scale of social mobilization efforts in affected countries. • National Social Mobilization Task Forces have been established, additional human resources are being identified and deployed. • Additional work is needed to ensure the quality of social mobilization national and sub-national plans and efforts at district level are coordinated with the overall response SOURCE: WHO - 5 SEP 2014

24. RESPONSE ACTIVITIES WHO SURVEILLANCE: WHO, the Global Alert and Response Network (GOARN), and its partners are providing guidance and support and have deployed teams of experts to West African countries, including epidemiologists to work with the countries in surveillance and monitoring of the outbreak and laboratory experts to support mobile field laboratories for early confirmation of Ebola cases. DEPLOYED ASSETS: WHO has deployed clinical management experts to help health-care facilities treat affected patients, infection and prevention control experts to help the countries stop community and health-care facility transmission of the virus, and logisticians to dispatch needed equipment and materials. EXPERIMENTAL MEDICINES AND VACCINES • WHO has advised that the use of experimental medicines and vaccines under the exceptional circumstances of this outbreak is ethically acceptable. However, existing supplies of all experimental medicines are either extremely limited or exhausted. • WHO welcomes the decision by the Canadian government to donate several hundred doses of an experimental vaccine to support the outbreak response. A fully tested and licensed vaccine is not expected before EBOLA RESPONSE ROADMAP • On 28 August 2014 WHO is issued a roadmap to guide and coordinate the international response to the outbreak of Ebola virus disease in west Africa. • The aim is to stop ongoing Ebola transmission worldwide within 6–9 months, while rapidly managing the consequences of any further international spread. • The roadmap will assist governments and partners in the revision and resourcing of country-specific operational plans for Ebola response, and the coordination of international support for their full implementation. The objectives are: o to achieve full geographic coverage with complementary Ebola response activities in countries with widespread and intense transmission o to ensure emergency and immediate application of comprehensive Ebola response interventions in countries with an initial case(s) or with localized transmission o to strengthen preparedness of all countries to rapidly detect and respond to an Ebola exposure, especially those sharing land borders with an intense transmission area and those with international transportation hubs. SOURCE: EBOLA ROAD MAP TECHNICAL INFORMATION Information resources on Ebola virus disease Ebola: Protective measures for general public Ebola: Protective measures for medical staff

25. RESPONSE ACTIVITIES UNICEF UNICEF is working closely with WHO, The Centres for Disease Control and Prevention (CDC), Médecins Sans Frontières (MSF) and the International Federation of Red Cross and Red Crescent Societies (IFRC), as well as other partners and communities on outbreak response as well as to share information on how to prevent the further spread of EVD and care for those already affected. The latest updated information and materials critical to assist countries dealing with EVD and outbreak response management is available here. PPE • In the absence of a harmonized EVD response kit, UNICEF has been identifying, sourcing and supplying personal protective equipment for use in outbreak response. A suite of PPE products should • cover the needs of staff (both medical and non-medical) for use in all high- and low-risk treatment settings. • The selection of PPE depends on the risk hazard assessment identified by each treatment center and the infectious agent transmission in each facility during medical intervention and care. • “High-risk” areas include treatment or isolation facilities accommodating patients (suspected or confirmed), laboratories and morgues. “Low-risk” areas include facilities used for service preparation, stores, laundry and • disinfection. • UNICEF is working with WHO, CDC and MSF to identify appropriate PPE technical specifications, standards and guidance to determine and define appropriate context and end-use function of the equipment. UNICEF has procured emergency medical and principally low-risk PPE supplies in response to EVD in Liberia and Sierra Leone, in addition to water treatment and temporary structures. UNICEF has also been in close communication with manufacturers (Kimberly-Clark, DuPont and 3M) to source additional high-risk PPE, in particular to fill the gaps in high-risk product availability. Based on the high volume of demand and lack of manufacturer inventory and capacity, UNICEF is working with suppliers to identify lead times for delivery, and as a result, countries may also be asked to split deliveries over time. Body bags and coveralls designed for high risk and high exposure setting, in particular, are in short supply owing to sudden high demand outside normal industry offtake. SOURCE: UNICEF SUPPLY DIVISION – 1 SEPT

26. RESPONSE ACTIVITIES WORLD FOOD PROGRAM • The UN World Food Programme is responding to the Ebola virus outbreak in West Africa with an operation that aims to provide food to 1.3 million people in Guinea, Liberia and Sierra Leone. WFP is also assisting the wider humanitarian community with logistics, helping other organizations to get aid workers and critical supplies into the affected areas. • WFP has launched a regional emergency operation which will provide food assistance to around 1.3 million people in the three most affected countries: Guinea, Liberia and Sierra Leone. Food is being distributed to people under medical quarantine, people under treatment, and their relatives. We are working alongside national governments, the World Health Organization (WHO) and other partners. • The objective is to prevent a health crisis from becoming a food crisis. In the three countries, the food chain is threatened at many levels, starting with production. Farmers are leaving behind their crops and livestock as they seek areas they perceive as safer from exposure to the virus. Travel restrictions and displacements are likely to affect food prices. • The bans on eating traditional protein sources, such as bush meat, may also have implications for the food security and nutrition of people in these communities. Some of the animals that people normally hunt for food, such as bats and apes, are known to be potential carriers of the Ebola virus. • On the top of that, hundreds of households have already lost one or more of their members. The majority of Ebola victims fall within the 15-45 year bracket and are therefore frequently the main income providers. The reduction of household income coupled with the already observed food price rise will further deteriorate the food security situation. SOURCE: UNICEF SUPPLY DIVISION – 1 SEPT FOOD ASSISTANCE • GUINEA: WFP began food distributions because of Ebola four months ago and has reached around 40,000 people (in Biffa, Fria, Télémélé, N’Zerekore, Macenta and Guekedo). Preparations are being made to gradually increase distributions to 464,000 people over a period of three months. • SIERRA LEONE: WFP is reaching Ebola patients in health centers and affected households in the epicenters of Kenema and Kailahun as well as houses that are under quarantine in 12 out of 13 districts in Sierra Leone. Up to 400,000 people in Sierra Leone are targeted under the regional response for the next 3 months. • LIBERIA: Between 1 July and the end of August, WFP delivered food to some 43,700 people at Ebola case management centers and in quarantined communities. The distributions have covered nine of Liberia’s 15 counties, including the West Point slum community in the capital Monrovia and the Ebola epicenter of Foya District in Liberia’s northern Lofa County. LOGISTICS Because of its expertise in logistics, WFP has been given the job of coordinating logistics for the entire humanitarian community involved in the Ebola response. This happens through the Logistics Cluster WFP also manages the UN Humanitarian Response Depots (UNHRD), which store emergency supplies that can be transported within 48 hours. In addition, it manages the UN Humanitarian Air Service (UNHAS), which transports humanitarian workers and light cargo to emergencies around the world. UNHAS is currently operating in West Africa and has flown more than 100 passengers from organizations like WHO, UNICEF, MSF and WFP into and out of the Ebola affected areas since 16 August.

27. RESPONSE ACTIVITIES MÉDECINS SANS FRONTIÈRES (MSF) - DOCTORS WITHOUT BORDERS HUMANITARIAN AGENCIES REACHING LIMITS • Emergency teams from the international medical organization Médecins Sans Frontières (MSF) are continuing all their efforts to fight the Ebola epidemic. • Working in response to the epidemic since March, MSF currently has 1,086 staff operating in Guinea, Sierra Leone and Liberia, treating a rapidly increasing number of patients. • MSF’s top priority is to provide care for patients infected with the virus and we have already deployed the maximum number of our experienced human resources. • In Liberia and Sierra Leone, many health facilities are closed or empty. People are not seeking care for regular illnesses for fear of being infected with Ebola. Some health workers have been infected or have died. Many are therefore too afraid to come to work. The epidemic is further straining weak health systems already trying to cope with existing health crises like malaria and maternal mortality. CARE CENTERS OVERCROWDED • MSF’s care centers in Liberia and Sierra Leone are overcrowded with suspected Ebola patients. People continue to become ill and are dying in their villages and communities. In Sierra Leone, highly infectious bodies are rotting in the streets. • A multiplication of high quality isolation facilities would allow for earlier referral and admission, leading to a significant impact on mortality. MSF teams have been able to save more lives when people infected with Ebola seek treatment as early as possible. Increased isolation capacity will also relieve the affected countries’ health systems, some of which are on the verge of collapse. HEALTH AND HYGIENE PROMOTION NEEDED Additionally, triage centers must be set up, systems for management of corpses must be increased, and hygiene items must be distributed at a mass scale, along with an increase of active surveillance capacities. Disinfection campaigns are needed, as well as health and hygiene promotion among the populations and within health facilities. The president of MSF-USA (Doctors Without Borders) and MSF International announced the world was losing the battle against Ebola on 2 Sept 2014 and urged for an increased response from states and nations. MSF began its Ebola intervention in West Africa in March 2014 and is now operating in Guinea, Liberia, Nigeria, and Sierra Leone. The organization runs five Ebola case management centers with a total capacity of 480 beds. Since March, MSF has admitted 2,077 people, of whom 1,038 tested positive for Ebola and 241 have recovered. MSF has deployed 156 international staff to the region and employs 1,700 nationally hired personnel. (MSF - 2 SEPT) Click here to see an interactive guide to an MSF Ebola Treatment center

28. RESPONSE ACTIVITIES MÉDECINS SANS FRONTIÈRES (MSF) - DOCTORS WITHOUT BORDERS LIBERIA • In Monrovia, Liberia, for example, new Ebola management centers with adequate isolation facilities and qualified staff are urgently needed. The queue of patients continues to increase in front of MSF’s ever growing ELWA 3 center, which now contains 160 beds. It is estimated that 800 additional beds are needed in Monrovia alone. The MSF team is overwhelmed and cannot offer more than palliative care. • The situation is catastrophic and is deteriorating on daily in Liberia’s capital, Monrovia. At one point last week, all five of the main hospitals in the city were closed. Some have since reopened but are barely functioning. • There has been no improvement in the overall coordination of the response to the epidemic. Hospitals and almost all health centers in the city of close to one million inhabitants remain closed. The number of dead is outstripping the capacity for health officials to manage safe burials, and more and more health workers have been infected with Ebola over recent weeks. There is a dire need for the WHO, countries, and other international organizations to mobilize to support the Liberian Ministry of Health. • MSF has completed the construction of a new 120-bed case management center in Monrovia called ELWA3, which will received its first patients by this weekend. It is one of the largest Ebola treatment centers ever built by MSF. The team also continues to provide technical support and training to the Ministry of Health. • MSF has recently launched a response in Liberia’s Lofa region, alongside the Guinean border, which has been badly affected by Ebola. In Foya, a team has rehabilitated the isolation center with 40 beds, in line with MSF standards for the management of the disease. After two weeks of intervention, the team currently has 137 suspected Ebola patients in its care. GUINEA • In Guinea, MSF is running two Ebola treatment centers – one in the capital, Conakry, and one inGuéckédou, in the southwest of the country, where the outbreak began. Currently, there are 4 patients in MSF’s treatment center in Conakry and 11 in Guéckédou. • In Macenta transit center in southwest Guinea near the Liberian border, MSF supported the ministry of health by transferring Ebola patients by ambulance for treatment in either Conakry or Guékédou and has handed it over completely to the ministry of health and the WHO. Patients are arriving from a wide area, including the region around Nzerekore. SIERRA LEONE • Between five and ten new patients are being admitted each day to MSF’s 80-bed Ebola treatment center in Kailahun, near the border with Guinea. There are currently 50 patients in the center. • MSF is building a 35-bed isolation center in Bo Town. Near the village of Gondama, MSF also runs a transit capacity center where people suspected to be infected with Ebola are isolated and then transferred for further care. MSF-15 AUG 2014 MSF 2 SEPT 2014 MSF 29 AUG 2014: One of the MSF staff members at the Ebola treatment Centre in Monrovia. At the moment, MSF deployed a team of 350 people in Liberia only. A number which should increase in the days / weeks to come.

29. RESPONSE ACTIVITIES MÉDECINS SANS FRONTIÈRES (MSF) - DOCTORS WITHOUT BORDERS HUMANITARIAN AGENCIES REACHING LIMITS • Emergency teams from the international medical organization Médecins Sans Frontières (MSF) are continuing all their efforts to fight the Ebola epidemic. • Working in response to the epidemic since March, MSF currently has 1,086 staff operating in Guinea, Sierra Leone and Liberia, treating a rapidly increasing number of patients. • MSF’s top priority is to provide care for patients infected with the virus and we have already deployed the maximum number of our experienced human resources. • In Liberia and Sierra Leone, many health facilities are closed or empty. People are not seeking care for regular illnesses for fear of being infected with Ebola. Some health workers have been infected or have died. Many are therefore too afraid to come to work. The epidemic is further straining weak health systems already trying to cope with existing health crises like malaria and maternal mortality. LIBERIA • In Monrovia, Liberia, for example, new Ebola management centres with adequate isolation facilities and qualified staff are urgently needed. The queue of patients continues to increase in front of MSF’s ever growing ELWA 3 centre, which now contains 160 beds. It is estimated that 800 additional beds are needed in Monrovia alone. The MSF team is overwhelmed and cannot offer more than palliative care. • The situation is catastrophic and is deteriorating on daily in Liberia’s capital, Monrovia. At one point last week, all five of the main hospitals in the city were closed. Some have since reopened but are barely functioning. • There has been no improvement in the overall coordination of the response to the epidemic. Hospitals and almost all health centers in the city of close to one million inhabitants remain closed. The number of dead is outstripping the capacity for health officials to manage safe burials, and more and more health workers have been infected with Ebola over recent weeks. There is a dire need for the WHO, countries, and other international organizations to mobilize to support the Liberian Ministry of Health. • MSF has completed the construction of a new 120-bed case management center in Monrovia called ELWA3, which will received its first patients by this weekend. It is one of the largest Ebola treatment centers ever built by MSF. The team also continues to provide technical support and training to the Ministry of Health. • MSF has recently launched a response in Liberia’s Lofa region, alongside the Guinean border, which has been badly affected by Ebola. In Foya, a team has rehabilitated the isolation center with 40 beds, in line with MSF standards for the management of the disease. After two weeks of intervention, the team currently has 137 suspected Ebola patients in its care. SIERRA LEONE Between five and ten new patients are being admitted each day to MSF’s 80-bed Ebola treatment center in Kailahun, near the border with Guinea. There are currently 50 patients in the center. MSF is building a 35-bed isolation center in Bo Town. Near the village of Gondama, MSF also runs a transit capacity center where people suspected to be infected with Ebola are isolated and then transferred for further care. GUINEA • In Guinea, MSF is running two Ebola treatment centers – one in the capital, Conakry, and one inGuéckédou, in the southwest of the country, where the outbreak began. Currently, there are 4 patients in MSF’s treatment center in Conakry and 11 in Guéckédou. • In Macenta transit center in southwest Guinea near the Liberian border, MSF supported the ministry of health by transferring Ebola patients by ambulance for treatment in either Conakry or Guékédou and has handed it over completely to the ministry of health and the WHO. Patients are arriving from a wide area, including the region around Nzerekore. .

30. RESPONSE ACTIVITY US GOVERNMENT DECLARATIONS: • On 04 August, the U.S. Ambassador to Liberia declared a disaster due to the effects of the Ebola outbreak. In response, USAID has activated a Disaster Assistance Response Team (DART). • On 13 August, U.S. Chargé d’Affaires Kathleen FitzGibbon declared a disaster due to the effects of the EVD outbreak in Sierra Leone. U.S. Chargé d’Affaires Ervin Massinga declared a disaster due to the magnitude of the EVD outbreak in Guinea on 15 August. The United States has stepped up assistance to the affected countries and to international organizations responding to the outbreak. Multiple U.S. agencies have been involved in the response to the crisis, including the State Department, the Department of Health and Human Services (HHS), U.S. Agency for International Development (USAID), and the Department of Defense (DOD). Since the CDC ramped up its Ebola response in early July, more than 500 CDC staff members have provided logistics, staffing, communication, analytics, management, and other support functions. As of September 2, roughly 100 U.S. government personnel have been deployed and are working in the affected countries responding to the outbreak, this includes more than 70 CDC staff deployed in Guinea, Liberia, Nigeria, and Sierra Leone assisting with various vital response efforts such as surveillance, contact tracing, database management, and health education. The U.S. Agency for International Development (USAID) has committed more than $21 million for the response since the outbreak was first reported in March 2014. This funding is being used to provide health equipment and emergency supplies, food assistance, train and support healthcare workers on infection control and case management, support public outreach campaigns, and build the capacity of local health care and emergency response systems. On August 23, a charter flight funded by USAID and UNICEF brought in more than 40 tons of chlorine and 400-thousand pairs of medical gloves into Monrovia. On August 24, USAID airlifted more than 16 tons of medical supplies and emergency equipment to Monrovia, Liberia. The U.S. government will continue to provide materials, experts and leadership to this epidemic response. CDC is assisting the World Health Organization with setting up an emergency response structure, conducting Ebola surveillance and contact tracing, providing advice on exit screening and infection control at airports, and providing training and education in the affected countries. The official case count and death toll in the current outbreak exceeds cases and deaths from all previous Ebola outbreaks combined. Yet these official numbers greatly underestimate the actual numbers of cases and deaths and do not adequately describe the outbreak’s toll in human lives, health care and societal disruption, and economic loss. CDC Director’s Brief - 2 SEPT 2014 – CDC Warns Ebola Epidemic in West Africa is Outpacing Current Response

31. RESPONSE ACTIVITY US GOVERNMENT FDA 05 August 2014 – FDA authorized the use of a diagnostic test developed by the U.S. Department of Defense (DoD) to detect the Ebola Zaire virus in laboratories designated by the DoD to help facilitate effective response to the ongoing Ebola outbreak in West Africa. • The test is designed for use in individuals, including DoD personnel and responders, who may be at risk of infection as a result of the outbreak. • Specifically, the test is intended for use in individuals with signs and symptoms of infection with Ebola Zaire virus, who are at risk for exposure to the virus or who may have been exposed to the virus. (See also: August 12, 2014 Federal Register notice from HHS: Declaration Regarding Emergency Use of In Vitro Diagnostics for Detection of Ebola Virus) • There are currently no FDA approved drugs or vaccines for Ebola. However, the FDA authorized an emergency investigation new drug (EIND) application for the treatment of US Ebola victims at Emory. They are working with the CDC, DOD, NIH, and HHS to develop new medical products. • FDA signed an agreement on August 25 with WHO EMP to share non-public information that may be useful to combat international public health crises. FDA monitors fraudulent Ebola products and responds to customer complaints. DOD • 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 • USAMRIID has established diagnostic laboratories in Liberia and Sierra Leone, two of three countries where the outbreak has been spreading in recent months. (DOD 4 AUG) USAID DART • The USAID-led Disaster Assistance Response Team (DART)—comprising disaster response and public health experts from USAID/OFDA, CDC, and the U.S. Department of Defense (DoD)—continues to operate in Monrovia, Liberia. USAID/OFDA and CDC have deployed additional DART staff to Conakry, Guinea, and Freetown, Sierra Leone, to support the U.S. Government (USG) regional EVD response. • USAID/OFDA recently committed approximately $760,000 through the non-governmental HHS • 02 September —HHS announced it will give $24.9 million contract to Mapp Biopharmaceutical, Inc. for Zmapp drug (used in US citizen Ebola cases) development, manufacture, and regulatory approval. NIH • Vaccine Research Center will begin Phase 1 human clinical trials of two vaccines the week of August 31. NIH will work with the DOD on Phase 1 clinical trials of a VSV-Ebola vaccine developed by the Public Health Agency of Canada in fall 2014. • NIH is also working on developing therapeutic drugs and new diagnostic techniques. organization (NGO) Global Communities to conduct public outreach, educate households and community leaders, and support county health teams to safely remove and bury bodies of deceased EVD patients in Liberia. As of 27 August, USAID sent $195,500,000 in total assistance for the outbreak. On 27 August an additional $5 million in aid was announced. • USAID airlifted more than 16 tons of medical supplies and emergency equipment to Monrovia, Liberia on August 24 as part of its ongoing efforts to combat the West Africa Ebola outbreak. The shipment came from USAID’s warehouse in Dubai, United Arab Emirates, and included 10,000 sets of personal protective equipment (PPE), two water treatment systems, two portable water tanks capable of storing 10,000 liters each, and 100 rolls of plastic sheeting, which can be used in the construction of Ebola treatment centers. The critical commodities will be distributed to affected areas throughout Liberia. SOURCE: USAID Airlifts Medical Supplies, Emergency Equipment for Ebola Response West Africa – Ebola Outbreak Fact Sheet #2 West Africa – Ebola Outbreak Fact Sheet #1; West Africa--Ebola Outbreak Fact Sheet #3 FDAMedscape NIH NIH EBOLA RESPONSE HHS FDAMedscape

32. USG PROGRAMS FOR EBOLA OUTBREAK IN WEST AFRICA http://reliefweb.int/sites/reliefweb.int/files/resources/09.03.14%20-%20USG%20West%20Africa%20Ebola%20Outbreak%20Program%20Map.pdf

33. RESPONSE ACTIVITIES US CENTER FOR DISEASE CONRTOL • CDC has activated its Emergency Operations Center (EOC) to help coordinate technical assistance and control activities with partners. o On 06 August, CDC elevated the EOC to a Level 1 activation, its highest level, because of the significance of the outbreak. o CDC is in regular communication with other U.S. government agencies that are participating in the response, the ministries of health of the affected countries, the World Health Organization (WHO), and other international partners. • CDC has deployed several teams of public health experts to the West Africa region. As of 22 August, more than 60 CDC staff deployed in Guinea, Liberia, Nigeria, and Sierra Leone are assisting with various response efforts, including surveillance, contact tracing, database management, and health education. On 20 August the CDC opened Liberia’s second mobile testing laboratory in Monrovia. The facility was at full capacity as of 22 August. o CDC plans to send additional public health experts to the affected countries to expand current response activities. o CDC staff are assisting with setting up an emergency response structure, contact tracing, providing advice on exit screening and infection control at major airports, and providing training and education in the affected countries. AS OF AUGUST 22, EIGHT HEALTH COMMUNICATORS ARE DEPLOYED TO GUINEA, LIBERIA, AND SIERRA LEONE. o CDC health communicators in Sierra Leone, Guinea, and Liberia are working closely with country embassies, UNICEF, and ministries of health to develop public health messages and plan social mobilization activities. o Africell, a telecommunications company in Sierra Leone, is broadcasting radio programs on Ebola supported by CDC, the US Embassy, and the nongovernmental organization, BBC Media Action. o In Kenema, Sierra Leone, CDC and the international non-governmental organization GOAL are conducting a 2-day training for police and security personnel on Ebola risk mitigation and response activities. • CDC is working closely with U.S. Agency for International Development (USAID), Office of Foreign Disaster Assistance (OFDA), on deployment of a Disaster Assistance Response Team (DART), which is overseeing the U.S. government’s Ebola response in West Africa. • On 29 August, the CDC issued a level 2 travel alert for Ebola in the DRC. Level 3 alerts are in effect for Guinea, Liberia, and Sierra Leone, and a level 2 alert is in place for Nigeria. SOURCE: CDC CDC Travel Advisory- West Africa CDC Travel Advisory-DRC West Africa- Ebola Outbreak Fact Sheet #3

34. RESPONSE ACTIVITY EUROPEAN UNION EUROPEAN COMMISSION HUMANITARIAN AID (ECHO): • Since March 2014, ECHO has pledged a total of EUR 11.9 million in humanitarian funding to respond to the outbreak of the Ebola virus disease (EVD) in West Africa. This funding is currently supporting Médecins Sans Frontières (MSF), the World Health Organization (WHO) and the International Federation of Red Cross and Red Crescent (IFRC), and ECHO is considering funding other humanitarian partners to scale up the response. (ECHO Factsheet, 28 August) • The European Mobile Laboratory (EMlab) project for dangerous infectious diseases established a field laboratory in Guéckédou, Guinea in March 2014. Eight teams of European specialists have since been deployed to the laboratory, assisting with rapid diagnostics, sample analysis and case confirmation. (EMlab, 20 August) A second EMlab is expected to be deployed, likely to Freetown, Sierra Leone. (European Commission, 8 August) EUROPEAN CENTER FOR DISEASE CONTROL (ECDC): • ECDC has not recommended travel restrictions to countries affected by the EVD outbreak, instead recommending preventative measures be taken when traveling to affected countries. (ECDC, 1 August) FRANCE: • Through the Pasteur and Mérieux Institutes, France has sent five experts to support the Guinean Health Ministry, and supports mobile laboratory projects with technical expertise. (MOFA, 30 July) • Through the EPRUS Institute, France will send 20 specialists in biological disasters to support Guinea for the next three months. (Reuters, 3 Sept) NORWAY: • The Government of Norway has pledged a total of NOK 19 million (approximately $3.1 million) to combat the EVD outbreak. (MOFA, 31 July) IRELAND • Ireland’s Department of Foreign Affairs (DFA) has provided EUR 350,000 to support EVD response, mostly in Liberia and Sierra Leone. (DFA, 6 August) UNITED KINGDOM: • The Department for International Development (DFID) has provided emergency kits of clean blankets, clothing, sleeping mats and food for affected families, as well as hygiene and sanitation materials such as chlorine in Liberia. DFID has committed GBP 5 million (approximately $8.3 million) to support EVD response in West Africa. (DFID, 7 August) • DFID and the Wellcome Trust has put out an emergency research call for proposals that will help inform management of EVD outbreaks, and that can help tackle the current outbreak in West Africa. GBP 6.5 million (approximately USD 10.7 million) in funding will be managed by Enhancing Learning & Research for Humanitarian Assistance (ELRHA). This funding, from the Research for Health in Humanitarian Crisis (R2HC) initiative, will be awarded in areas such as anthropology, clinical management, diagnosis, disease control and prevention, ethics, health systems, social mobilization, surveillance and treatment. The initial call for proposals closes on 8 September 2014 at this link: Ebola Health Research Call (DFID, 21 August) GERMANY • Germany’s Foreign Office has provided EUR 760,000 (Foreign Office, 4 July), and the Federal Ministry for Economic Cooperation and Development (BMZ) recently pledged an additional EUR 1 million to support EVD response. (BMZ, 5 August) ITALY: • The Ministry of Foreign Affairs and International Cooperation has outlined a plan of approximately EUR 1.6 million to respond to the EVD epidemic in West Africa, including sending specialized Italian personnel, namely from the Spallazani Hospital in Rome, support to WHO and to Italian NGOs working in the region, especially Sierra Leone. (MOFA, 29 August)

35. RESPONSE ACTIVITY OTHER COUNTRIES CANADA • The Canadian government will donate between 800 and 1,000 doses of an experimental Ebola vaccine, VSV-EBOV, to WHO. Scientists at the National Microbiology Laboratory developed the vaccine, which has proven effective in animals, but has never been tested in humans. After a WHO panel of medical ethical experts decided that, in response to the EVD outbreak in West Africa, it is ethical to offer untested medical interventions, the vaccine will be distributed, most likely to health workers. VSV-EBOV has been licensed to the U.S. firm BioProtection Systems to bring the vaccine closer to human testing. (Government of Canada, 12 August) • To date, Canada has contributed $5 million to the EVD response and the Public Health Agency of Canada (PHAC) is providing laboratory support on the ground in West Africa. (Government of Canada, 8 August) JAPAN: • The Government of Japan has pledged a total of $2 million to organizations responding to EVD in West Africa. (MOFA, 15 August) BRAZIL: • Brazil’s Health Ministry has sent four supply kits to Guinea and five supply kits to Sierra Leone. Each kit contains medication and first-aid tools, such as masks and gloves, and are designed to serve 500 people for three months. Five kits are expected to be sent to Liberia. (ReliefWeb, 28 August) ECONOMIC COMMUNITY OF WEST AFRICAN STATES (ECOWAS): • ECOWAS has pledged to deploy health personnel to support the affected countries, provide materials and equipment as well as financial support, to strengthen epidemiological surveillance in the region, and to harmonize communication on the EVD outbreak and prevention. In coordination with the West African Health Organization (WAHO), ECOWAS will work to keep travel, humanitarian and economic corridors open, only imposing border closures or travel restrictions in exceptional case, and in consultation with WAHO and WHO. (ECOWAS, 28 August) MANO RIVER UNION: • All member states – Cote d’Ivoire, Guinea, Liberia and Sierra Leone – pledged a coordinated response including: strengthened health care services; isolating affected communities and providing those communities with material support to reduce the spread of EVD; improve preventative precautions in health facilities to prevent the spread of infection to health care workers; and improve surveillance, contact tracing and case management. (WAHO, 1 August) AFRICAN DEVELOPMENT BANK (AFDB): • AfDB has pledged $210 million to support response to EVD outbreak in West Africa, through both grants and loans, aimed at addressing immediate needs and improving health systems in the long term (2015 – 2017). (AfDB, 19 August) The AfDB funding includes $2 million for WAHO, (WAHO, 19 May) and a $60 million grant to the WHO Regional Office for Africa. (WHO, 26 August) SWITZERLAND: • Swiss Humanitarian Aid and the Swiss Agency for Development and Cooperation (SDC) have committed CHF 1.65 million (approximately USD 1.8 million) to EVD response in West Africa. On 1 September, Swiss Humanitarian Aid sent a chartered plane with 14 tons of medical supplies, including 31,000 bottles of disinfectant, 300,000 protective gloves, 100,000 masks, 200 body bags, 5,840 intravenous drips and 3,000 rehydration solutions to Liberia, along with specialists from the University Hospitals of Geneva. (Federal Department of Foreign Affairs, 1 September)

36. VACCINE DEVELOPMENTS There are currently no FDA approved vaccines for Ebola. The NIH's National Institute of Allergy and Infectious Diseases is working on developing an Ebola vaccine. NIH recently announced they are expediting their work, and aiming to launch PHASE 1 clinical trials of an Ebola this week. The early-stage trial will begin initial human testing of a vaccine co-developed by NIAID and GlaxoSmithKline (GSK) and will evaluate the experimental vaccine’s safety and ability to generate an immune system response in healthy adults. The study is the first of several Phase 1 clinical trials that will examine the investigational NIAID/GSK Ebola vaccine and an experimental Ebola vaccine developed by the Public Health Agency of Canada and licensed to NewLink Genetics Corp. The study is the first of several Phase 1 clinical trials that will examine the investigational NIAID/GSK Ebola vaccine and an experimental Ebola vaccine developed by the Public Health Agency of Canada and licensed to NewLink Genetics Corp. (CDC) Testing in humans for a vaccine against Ebola is scheduled to begin this week, and though researchers aim to complete the first phase of clinical trials by the end of 2014, two more phases will remain before the treatment can be widely used. The National Institute of Allergy and Infectious Diseases, part of the National Institutes of Health, developed the vaccine with pharmaceutical giant GlaxoSmithKline. Experiments with the vaccine already have been evaluated in primates and showed promising protection. The candidate vaccine is against the Zaire species of Ebola - the one circulating in West Africa - and uses a single Ebola virus protein to generate an immune response. As it does not contain infectious virus material, it cannot cause a person who is vaccinated to become infected with Ebola. Pre-clinical research by the NIH and Okairos, a biotechnology company acquired last year by GSK, has indicated that it provides promising protection in non-human primates exposed to Ebola, without significant adverse effects. PHASE I: • Phase I of the clinical trial will take place in the U.S. at the NIH Clinical Center in Bethesda, Maryland, and will involve 20 healthy human adults. Researchers will be assessing the safety of the vaccine and watching participants' immune responses for side effects. No one will be infected with Ebola. The vaccine reportedly uses a single Ebola virus protein to generate an immune response. • The vaccine also will be tested in the United Kingdom, Gambia and Mali, and officials in Nigeria are discussing conducting another trial with the Centers for Disease Control and Prevention. Professor Adrian Hill, director of the Jenner Institute at the University of Oxford is leading the parallel tests . PHASE 2: The second phase of the clinical trial for the vaccine likely will involve a larger group and serve to confirm formulations and doses, as well as identify the need for boosters and the best intervals between each dose. PHASE 3: A third phase could evaluate the protection given to several thousand volunteers who are at risk from the disease. A $4.6 million grant from the Wellcome Trust, the Medical Research Council and the UK Department for International Development is funding the trial overseas SOURCE: WELLCOME TRUST WASHINGTON POST USA NEWS AND WORLD REPORT

37. WHAT IS ZMAPP? WHAT IS ZMAPP? • ZMapp, being developed by Mapp Biopharmaceutical Inc., is an experimental treatment, for use with individuals infected with Ebola virus. It has not yet been tested in humans for safety or effectiveness. • The product is a combination of three different monoclonal antibodies that bind to the protein of the Ebola virus. HOW EFFECTIVE IS THE EXPERIMENTAL TREATMENT? • It is too early to know whether ZMapp is effective, since it is still in an experimental stage and has not yet been tested in humans for safety or effectiveness. • Some patients infected with Ebola virus do get better spontaneously or with supportive care. However, the best way to know if treatment with the product is efficacious is to conduct a randomized controlled clinical trial in people to compare outcomes of patients who receive the treatment to untreated patients. No such studies have been conducted. SOURCE: CDC WHY AREN'T MORE PEOPLE GETTING ZMAPP? • At this time, very few courses of this experimental treatment have been manufactured. Since the product is still in an experimental stage, it is too early to know whether ZMapp is effective. The manufacturer of this experimental treatment continues to research and evaluate the product's safety and effectiveness. It has not yet been tested in humans for safety or effectiveness and much more study is needed. DID THE NIH PLAY A ROLE IN GETTING THE EXPERIMENTAL THERAPY TO THE TWO U.S. PATIENTS IN LIBERIA? • This experimental treatment was arranged privately by Samaritan's Purse, the private humanitarian organization, which employed one of the Americans who contracted the virus in Liberia. Samaritan's Purse contacted the Centers for Disease Control and Prevention (CDC), who referred them to the National Institutes of Health (NIH). NIH was able to provide the organization with the appropriate contacts at the private company developing this treatment. The NIH was not involved with procuring, transporting, approving, or administering the experimental treatments. WILL PATIENTS IN WEST AFRICA BE ABLE TO ACCESS THIS EXPERIMENTAL TREATMENT? HOW MUCH SUPPLY IS THERE? • The product is still in an experimental stage, and the manufacturer reports that there is a very limited supply, so it cannot be purchased and is not available for general use. • The manufacturer has been planning for phase 1 clinical trials and does not have the capacity to manufacture large quantities of the treatment. The drug has not gone through clinical trials, meaning its safety and effectiveness has not yet been tested in humans. • The manufacturer of the experimental treatment continues to research and evaluate the product's safety and effectiveness. The U.S. Department of Health and Human Services (HHS) signed a $24.9 million, 18-month contract with Mapp Biopharmaceutical to support the development, manufacture, and FDA approval of the medication ZMapp for the treatment of Ebola disease. The deal can be extended up to a total of $42.3 million. To speed the development of ZMapp, officials at the Biomedical Advanced Research and Development Authority (BARDA) said they will work closely with the Defense Threat Reduction Agency within the Department of Defense and the National Institute of Allergy and Infectious Diseases. BARDA also will work with the company to optimize and accelerate the manufacturing of ZMapp so testing can be done as soon as possible. (GEN 3 SEP 2014)

Yale-Tulane Special Report - Ebola - West Africa - 5 September 2014

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