YALE- TULANE ESF-8 SPECIAL REPORT

WEST AFRICA – EBOLA 2014

CURRENT SITUATION

3 OCTOBER 2014

NGOs

LIBERIA• MINISTRY OF HEALTH AND SOCIA

L WELFARE NIGERIA • NIGERIA MINISTRY OF HEALTH• NIGERIA EMERGENCY MANAGEM

ENT AGENCY• EBOLA ALERT

SIERRA LEONE• MOHS• MINISTRY OF HEALTH AND SANITA

TION

INTERNATIONAL ORGANIZATIONS• RELIEF WEB• HUMANITARIAN RESPONSE • GLOBBAL EBOLA RESPOINSE • UNICEF • UN NEWS CENTER• LOGISTICS CLUSTER

WHO• WORLD HEALTH ORGANIZATION

– AFRICA• GLOABAL EBOLA RESPONSE COAL

ITION• WHO EBOLA PORTAL• WHO AFRP EPR OUTBREAK NEWS• DISEASE OUTBREAK NEWS• GLOBAL ALERT RESPONSE -

EBOLA• WHO – EBOLA• IFRC NGO• MSF• ACT ALLIANCE• CATHOLIC RELIEF• SAMARITAN'S PURSE

US GOVERNMENT• US EMBASSY MONROVIA – LI

BERIA• US EMBASSY – CONAKRY, GUI

NEA.

• US EMBASSY – SIERRA LEONE• US EMBASSY – NIGERIA• 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 AFRI

CA EBOLA RESPONSE• MEDBOX EBOLA TOOLBOX• VIROLOGY DOWN UNDER BL

OG• H5N1• DISASTER INFORMATION RES

EARCH CENTER• INTERNATIONAL SOS• MAPACTION

NEW SOURCES• ALERTNET• NY TIMES• WASHINGTON POST

IMPACT ON HCW

GUINEA

LIBERIA

SIERRA LEONE

VACCINE DEVELOPMENT

CONFIRMED PROBABLE SUSPECTED TOTALS

CASES3,953 1,863 1341 7157

DEATH1999 871 460 3330

GUINEA | LIBERIANIGERIA| SIERRA LEONE

EBOLA VIRUS DISEASE, WEST AFRICA – UPDATE 1 OCT 2014

CDC

UNITED NATIONS

UNITED STATES

INTERNATIONAL COMMUNITY

EXPERIMENTAL THERAPIES

PROJECTIONS

EUROPEAN UNION

http://www.esf-8-university.org/

CONFIRMED AND PROBABLE CASES OF EBOLA VIRUS DISEASE IN GUINEA, LIBERIA, AND SIERRA LEONE

Data are based on official information reported by Ministries of Health. These numbers are subject to change due to ongoing reclassification, retrospective investigation and availability of laboratory results.

(WHO – 1 OCT)

• Upward epidemic trend continues in Sierra Leone and in Liberia although there is evidence that there is under-reporting of new cases.

• In Liberia, the previously uninfected area of Grand Kru, near the border with Cote d’Ivoire, has now reported six confirmed cases of EVD. (WHO – 1 OCT)

GEOGRAPHICAL DISTRIBUTION OF NEW CASES AND TOTAL CASES IN GUINEA, LIBERIA, AND SIERRA LEONE

(WHO- 1 OCT )

The map shows the location of cases throughout the countries with widespread and intense transmission.

The cumulative number of cases to date in each area is shown (grey circles), together with the number of cases that have occurred within the 21 days (red circles) up to 28 September.

Ten districts in which previous cases were confirmed have reported no cases during the 21 days prior to the end of 28 September (nine districts in Guinea, one in Sierra Leone).

In Guinea, there has been one confirmed case reported in the newly affected Beyla district, on the border with Côte d’Ivoire.

In Liberia, the previously uninfected area of Grand Kru, near the border with Côte d’Ivoire, has now reported six confirmed cases of EVD.

NOTE: This is the largest ever documented outbreak of EVD with a number of reported cases and deaths that exceeds the case and death number of all historical outbreaks. It is also the largest outbreak in terms of geographical spread. THE OUTBREAK HAS NOT YET REACHED ITS PEAK AND IT IS CURRENTLY IN A PHASE OF RAPID SPREAD. Community resistance, inadequate treatment facilities and insufficient human resources in affected areas are among the challenges currently faced by the countries in responding to the EVD outbreak. (ECDC – Sept 26)

CASES AND DEATHS OF EVD BY COUNTRY, AS OF WEEK 39/2014:

SITUATION

DISTRIBUTION OF REPORTED CASES OF EVD BY WEEK IN GUINEA, SIERRA LEONE, LIBERIA, NIGERIA AND SENEGAL WEEK 48/2013 TO 39/2014 (DATA AS OF 21 SEPTEMBER 2014)

• The Ebola virus disease (EVD) outbreak continues to grow, doubling in size approximately every 3 weeks. The latest WHO figures report a total of 7,178 cases and 3,338 deaths up to September 28.

• The current EVD outbreak is unprecedented in scale, geographical reach, and impact on the health care systems of the countries involved.

• The present West Africa outbreak has a higher caseload than all other previous Ebola crises combined.

• An estimated 22.34 million people are living in areas where active EVD transmission has been reported, with 4.29 million people living in areas where twenty or more fatalities have been reported.

• The large number of cases in high-population density settings and simultaneously in remote, hard-to-access villages makes the outbreak particularly difficult to contain.

• The concerning trend of infections among health care workers (HCWs) persists, with 377 cases of which 216 have resulted in death. Of the total cases of EVD-infected HCWs, almost 50% have occurred in Liberia. Because of their role as caregivers, women are experiencing the brunt of the disease, making up 75% of all cases.

• A recent study published by the WHO Ebola Response Team forecasts more than 20,000 (5,740 in Guinea, 9,890 in Liberia and 5,000 in Sierra Leone) by beginning of November 2014.

• In addition to the cases in Guinea, Liberia, Nigeria, Sierra Leone, and one imported case in Senegal (a Guinean citizen who arrived from Guinea), there has now been a documented case in the Unites States of America, of a man returning to the US after visiting his home country of Liberia.

• Travel restrictions and quarantines have been employed by governments across the region, in attempts to reduce disease transmission.

(ECDC – Sept 26 ; UNMEER – Oct 2)

SITUATION

LOCAL EFFORTS AGAINST STEEP ODDS

• Foreign investors and companies have scaled down operations as expatriates depart the country; public and private institutions have also scaled down operations. The IMF predicts that Liberia and Sierra Leone’s economies could decline by 3.5% due to Ebola’s effect on the agriculture, services, and mining sectors. (CPI – SEP 25).

• Fear, misunderstanding, and economic hardship continue to drive tensions within affected populations, even as lack of education and access to hygienic precautions continues to drive virus transmission.

• Burial teams from the Liberian Red Cross have been mobilized across Liberia to provide safe disposal of contagious bodies, which often includes cremation. They face obstacles ranging from broken roads and curfews, to disease and poor care, to direct animosity and violence.

• In southeast Guinea, a team of journalists and health care workers was attacked by villagers and eight people murdered. Outsiders and “visitors” including health workers have been blamed for causing or bringing in the disease to remote communities. (WP – SEP 25)

• Sierra Leone conducted a three-day nation-wide lockdown in an attempt to stem the transmission of disease. Although widely criticized in the country due to limiting citizens’ access to food and employment for three days, the measure was declared “a success” by the government. More than a million households were reported surveyed during it, and 130 new cases discovered. (BBC – SEPT 22)

• At least 3,700 children in Guinea, Liberia and Sierra Leone have lost one or both parents to Ebola since the start of the outbreak in West Africa, according to preliminary UNICEF estimates, and many are being rejected by their surviving relatives for fear of infection. An estimated 2.5 million children under the age of five living in areas affected by the Ebola virus. (UNICEF – Sep 30)

A peacekeeper with the UN Mission in Liberia in Monrovia. (UNMEER)

Military road block in Sierra Leone (BBC)

SITUATION GUINEA

GUINEA CONFIRMED PROBABLE SUSPECT TOTALS

Cases 950 170 37 1157Deaths 535 170 5 710

SOURCE: WHO – 1 OCT

(WHO – AS OF 28 OCT)

BACKGROUND• Guinea was the first nation to report cases in the current West African Ebola

outbreak. The first likely occurred in late 2013, though it was not confirmed/reported to international authorities until March 2014. During that lag, control measures were not enacted and the outbreak was able to spread internationally into Liberia and Sierra Leone.

• 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. (USAID – 20 AUG)

• Several times, the outbreak looked like it might be under control but then would flare again in a different part of the country or would resurge in an area that previously had cases. WHO officials believe the outbreak in Guinea has been re-ignited several times in part due to re-importation from people coming from Liberia and Sierra Leone. (ISOS – 23 SEP)

CURRENT SITUATION• Cases have been identified in 19 of Guinea’s 34 prefectures. Ongoing spread of

Ebola is occurring in Beyla, Conakry, Coyah, Dabola, Dalaba, Dubreka, Forecariah, Gueckedou, Kerouane, Kindia, Kissidougou, Macenta, Nzerekore, and Yomou. (ISOS – 2 OCT)

• The situation in Guinea remains stable, though it must be emphasized that in the context of an outbreak of EVD, a stable pattern of transmission is still of grave concern, and could change quickly. (WHO – 1 OCT)

CASE FATALITY RATE: 61%

http://reliefweb.int/sites/reliefweb.int/files/resources/GIN_A4_L_140929_Ebola_3W_Reponse_0.pdf

SITUATION GUINEA

CASE MANAGEMENT AND INFECTION PREVENTION AND CONTROL• Reports from Guinea show a slight fall in the number of new cases reported

compared with each of the past five weeks (figure 2). This fall is largely attributable to a drop in the number of new cases reported from Macenta district, which had seen a surge in the number of new cases over the past five weeks. (WHO – 1 OCT)

• CDC is working closely with the Guinean Ministry of Health to strengthen contact tracing efforts in the capital city of Conakry. Contact tracing efforts supported by CDC have recently identified cases in Conakry among known contacts, indicating that contact tracing efficacy in Conakry is improving. (USAID – 1 OCT)

• In Guinea, a door-to-door campaign including the delivery of hygiene kits (soap, chlorine) and flyers has reached 71,000 households composed of 486,000 people. The campaign’s messages were reinforced with radio programmes and religious activities. (WHO – 1 OCT)

• The World Bank is helping Guinea-Bissau implement an emergency plan to prevent Ebola from spreading in the country. (ISOS – 30 SEP)

FOOD• In September, WFP delivered 627 mt of food to more than 24,700 people

through targeted and general distributions in Gueckedou, Kissidougou, Macenta and Conakry. (WFP – 30 SEP)

SAFETY AND SECURITY• In Forécariah, about 100 km from Conakry, a hostile youth protest

degenerated into a riot after the Guinean Red Cross sprayed a mortuary. Further, the Prefectural Department of Health was ransacked, causing many injuries. This violent episode demonstrates the resistance against the spraying of homes and villages. UNICEF is currently holding discussions with the national authorities to develop local skills for spraying home. (UNICEF – 26 SEP)

• In the village of Womey, a team of health officials were attacked by a group of local residents with knives and rocks. Eight of the health officials were killed in the attack (AP – 19 SEP)

• Insecurity recently prevented a group of medical students—originally from Guékédou, Macenta, and Yomou prefectures—from returning to their areas of origin to conduct EVD awareness activities, according to the Government of Guinea (USAID – 1 OCT)

RUMORS AND CHALLENGES• The reluctance of rural communities continues, but social mobilization

efforts have helped overcome resistance in the villages of Tonata and Yekini in Yomou and Boffossou in Macenta. (WHO – 1 OCT)

• Community resistance to EVD response efforts continues to inhibit the implementation of comprehensive contact tracing activities and other EVD-related humanitarian assistance, particularly in Macenta, Nzérékoré, and Yamou prefectures. (USAID – 1 OCT)

RISK COMMUNICATIONS• In an effort to reduce resistance and end violence in some Ebola affected

areas, influential nationals will be deployed to their home regions and villages for social mobilization activities. A group of 30 people has been deployed in the area of Macenta and 589 others will be deployed in 12 prefectures. (UNICEF – 26 SEP)

• In addition to the door-to-door campaign, messages were reinforced with radio programmes and religious activities. (WHO – 1 OCT)

SITUATIONLIBERIA

LIBERIA CONFIRMED PROBABLE SUSPECT TOTALS

Cases 927 1656 1113 3696Deaths 280 687 672 1639

SOURCE: WHO – 28 SEPT

GOVERNMENT OF LIBERIA• An international non-governmental organization, Global Communities, has

started to support the Ministry of Health in training to facilitate the safe handling of dead bodies and management of safe burials in the districts of Bomi, Nimba, and Sinoe. EU – 1 OCT

• Surveillance: daily contact tracing achievement was under 90% on average during the week to 28 September in the districts of Grand Cap Mount, Grand Gedeh, Grand Kru, River Ghee, Margibi, Maryland, and Rivercess. EU – 1 OCT

• 97.5 million euros has been promised which is intended to be spent in Budget Support (BS) operations to Liberia and Sierra Leone, to reinforce those governments' capacity to deliver public services - in particular health care - and macro-economic stability, and a further 5 million euros towards providing mobile laboratories for the detection of the virus and training health workers as part of the Instrument contributing to Stability and Peace, IcSP. EU – 1 OCT

• The Ministry of Health and Social Welfare has established hotlines that the public can call to get basic Ebola information: 1333, 4455, 0886229641, 0886397381, and 0776547437. ISOS – 1 OCT

• The Ministry of Health Sit Rep 134 for cases upto 26 September added nearly 70 clinical cases, including 3 suspected cases in a previously unaffected county, Grand Gedeh and a single suspected case in Gbarpolu. If confirmed, these cases will mean that every county in Liberia has reported at least one case of Ebola. ISOS – 29 SEPT

• News sources report that a physician in rural Liberia administered an HIV drug (Lamivudine) to 15 Ebola patients, of which 13 people recovered. The two patients who died had received the drug five days or later after falling ill unlike others who got the medication within first five days of their illness. ISOS – 28 SEPT

• Media sources report that a doctor who is also a deputy health minister has been quarantined after exposure to a confirmed case. The case was one of the doctor's assistants and has died of the disease. ISOS – 28 SEPT

• Few reports state that a confirmed case has been detected in Grand Gedeh county, however this is yet to be confirmed by official sources. ISOS – 28 SEPT

Medical staff members of the Croix Rouge NGO remove the corpse of an Ebola victim from a house in Monrovia, on Sept. 29 (Pascal Guyot/AFP/Getty Images)

CASE FATALITY RATE: 44.3%

SITUATIONLIBERIA

CASE MANAGEMENT AND INFECTION PREVENTION AND CONTROL

• Last week there were no new reported confirmed cases from the capital, Monrovia, which in previous weeks had reported a surge in cases. This week, five new confirmed cases have been reported in Monrovia, but there remains compelling evidence obtained from responders and laboratory staff in the country that there is widespread under-reporting of new cases, and that the situation in Liberia, and in Monrovia in particular, continues to deteriorate. WHO – 1 OCT

• The numbers of probable and suspected cases, together with those confirmed, may be a more accurate reflection of case numbers in Liberia. The counties of Bong, Grand Bassa, Margibi and Nimba continue to report high numbers of new cases. There has been little change in the number of new cases reported in Lofa, which borders Gueckedou in Guinea, for the past three weeks, with 38 confirmed and probable cases reported this week. WHO – 1 OCT

• The previously uninfected area of Grand Kru, near the border with Côte d’Ivoire, has now reported six confirmed cases of EVD. WHO – 1 OCT

• A site has been identified by the Ministry of Health for a referral unit in Grand Kru district 7 (Maryland county): an area in the south of the country which only recently reported its first confirmed cases of EVD. WHO – 1 OCT

• An estimated 1500 beds are required in addition to those in place or soon to be in place; in Sierra Leone, an additional 450 beds are needed. WHO – 1 OCT

• Two US Navy mobile laboratories have now arrived in Liberia. One team will be based in Gbarnga (Bong county), with the other based in Montserrado (the district containing the capital, Monrovia). Both teams will be operational by 5 October. WHO – 1 OCT

• In Liberia, rituals to prepare bodies for burial are contributing to the rapid spread of the virus. The dead body is typically washed and dressed by multiple people before being carried to a grave — a ripe situation for the virus to spread. To stop the spread of Ebola, burial teams have been mobilized across Liberia to provide safe disposal of contagious bodies, which often includes cremation. With the epidemic on the rise, every dead body is now considered an Ebola body. USAID - 1 OCT

HOSPITAL RESPONSE AND ISOLATION/TREATMENT CENTERS

Lofa, Margibi, Bong and Nimba, all have isolation facilities established. As at 5 September, the country has 314 treatment beds, and WHO estimates many more are required (additional 760 beds required in Monrovia).

FOYA, LOFA COUNTY: Borma Hospital Ebola Treatment Unit (ETU) being run by Medecins Sans Frontieres (MSF) has a capacity of 100 beds. 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 and there are plans to expand to 300 beds. The facility in JFK Hospital is functioning as a full ETU. WHO advised on 5 September an additional 40 beds had been opened in Monrovia. There is a Holding Unit at Redemption Hospital. A 150-bed unit has been opened in the western suburb of Duala. A 120-bed Ebola Treatment Centre run by the MoH and WHO opened on 22 September at the Old Island Clinic on the Bushrod Island.

MONTSERRADO: West Point holding unit has been established.

NIMBA: Renovation of the holding facilties at G. W. Harley is underway as at 20 August. Ganta Hospital is functioning.

BONG: A 70-bed Ebola Treatment Unit is functional as at 25 September. A 7-bed Isolation Centre has been added to the Phebe Hospital in Suakoko.

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.

MARGIBI: The United States military has begun construction of a 25-bed hospital for infected healthcare workers.

SOURCE: ISOS – 1 OCT

http://reliefweb.int/sites/reliefweb.int/files/resources/LBR_A4_3W_Ebola_20140929.pdf

SITUATIONLIBERIA

SOURCE: UNOCHA – 1 OCT

SOURCE: WHO – 1 OCT

SITUATIONLIBERIA

SITUATION:• An outbreak of Ebola has been ongoing in Sierra Leone since May 2014. New

cases have been increasing each week for the past 6 weeks (OCT 2).

• 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.

• The situation continues to deteriorate. Port Loko, Bombali and Moyamba have been quarantined following a surge in new cases. Tonkolili has also reported an increase in the number of new cases. The number of cases reported from Kailahun and Kenema has been low. However, it is not clear if this is a genuine fall in case numbers or due to under reporting. An additional 450 beds are needed. Three isolation units in Bombali district have been opened (ISOS – 1 OCT)

GOVERNMENT OF SIERRA LEONE • MoH officials expressed their satisfaction at the outcome of the three-day

lockdown. The campaign achieved 75% of the planned target and Port Loko, Bombali and Moyamba districts have been identified as hot spots for Ebola respons. Reports say the campaign spread Ebola education to over 80% of target households.(GoSL- 24 SEP)

SIERRA LEONE CONFIRMED PROBABLE SUSPECTED TOTALS

Cases 2,155 37 215 2,407Deaths 527 37 11 575

SOURCEOCHA 2 OCT

SITUATIONSIERRA LEONE

GoSL Situation Report--30 Sept

Case Fatality Rate: 24.5%

SITUATIONSIERRA LEONE

• The Government of Sierra Leone placed Bombali, Moyamba, and Port Loko districts—which have a total population of approximately 1.2 million people, according to international media—under quarantine on September 25 (See Press Release Below), raising the total number of districts quarantined in Sierra Leone to five. The GoSL has maintained quarantines around Kailahun and Kenema districts since early August.

The Government of Sierra Leone issued a press release on 24 September detailing several measures to assist in the containment of the Ebola disease including:

• New quarantine restrictions have commenced around the country. Port Loko, Bombali and Moyamba Districts are under immediate isolation. Corridors for travel to and from non-quarantined areas have been established; travel must be between 09:00 and 17:00 and vehicles and passengers must not alight within the quarantine areas

• Any location where the Ebola disease is identified will be quarantined

• The Ministry of Health and Sanitation will work with the Ministries of Local Government and Rural Development, Education, Science and Technology, and Youth Affairs to activate the involvement of Paramount Chiefs, Local Government Authorities, Teachers and Youth Groups within the affected districts in contact tracing and community surveillance activities. (GoSL- - 24 SEP)

ISOLATION / TREATMENT CENTERS (ISOS ASF OF 3 OCT)• KENEMA: The Red Cross isolation facility in Kenema Government Hospital

was relocated outside of the Kenema township, a few miles from Hanga. The facility has 60 beds and was operational as of September 12. Admissions initially staggered to keep healthcare workers safe.

• 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: The 35-bed MSF isolation unit is now functional. A transit centre in Gondama is run by MSF. Construction has begun on an isolation ward at Bo government hospital.

• PORT LOKO: On September 12, officials announced a holding center would be established at the St John of God Hospital and should be “operational anytime”. The hospital reopened September 13 after a 21-day closure. International Medical Corps to establish new Ebola Treatment Unit in Lunsar, Port Loko.

• WESTERN AREA: The Lakka holding facility is currently being used as a treatment center. The Kerry town facility remains under construction. Maculy Street Hospital treatment center opened 15 September. Newton and Hasting police 50-bed isolation centers are open.

• BOMBAll: ADDAX is assisting in the construction of a holding center. Expected completion by the first week of October. Holding centers at Paramedical School, Arab Hospital, and Regional Government Hospital began receiving patients 21 September. Three isolation centers opened at the start of October.

• Ministry of Energy committed to providing electricity to EVD lab in Lakka and Solar Street lights to Kerry Town treatment center

As Government continues to intensify its efforts in the fight against the Ebola virus disease (EVD), President Ernest Bai Koroma on Friday 26th September 2014, commissioned the BSL-3 mobile laboratory at the Sierra Leone-China Friendship Hospital at Jui. (SL- 26 SEP)

http://reliefweb.int/sites/reliefweb.int/files/resources/SLE_A4_L_140929_Ebola_3W_Reponse%281%29.pdf

SITUATIONSIERRA LEONE

Source: International SOS 2 OCT WHO 16 SEPT 2014 GoSL 12 SEPT 2014 WHO 1 OCT

• At the request of the Government of Sierra Leone, the UK is leading an international mission that aims to control, contain and ultimately defeat the disease. At the heart of the plan is a promise to provide and staff 700 treatments beds – tripling current capacity in the country (DIFID – 30 SEP)

• Construction of the first treatment center is well underway in Kerry Town, not far from the country's capital. UK aid is supporting local builders, humanitarian advisers, military engineers and its partner, +Save the Children UK, to get the center up and running as soon as possible :https://www.flickr.com/photos/dfid/sets/7215764756340364

Military engineers from the UK provide expertise treatment center in Kerry Town, (DIFID – 30 SEP)

CASE MANAGEMENT

• Nationally, the situation in Sierra Leone continues to deteriorate, with an increase in the number of new confirmed cases reported over each of the past six weeks.

• The neighboring districts of Port Loko, Bombali, and Moyamba, which are adjacent to the capital, Freetown, have now been quarantined after a surge in new cases over the past four weeks.

• Tonkolili has also reported a rise in the number of new cases this week.

• By contrast, a very low number of new cases have been reported from Kailahun and Kenema for the past two weeks.

These areas had previously reported high levels of transmission. Further investigation will be required to confirm whether this fall is genuine, or a result of under-reporting. At present, the latter appears more likely. (WHO – 1 OCT)

FOODEbola first struck in Sierra Leone during May, the peak season for farm labor. To curb contagion risks, the government of Sierra Leone has restricted movement in five districts, which include centers of food production in the country. “

Key export crops such as coco will be highly impacted. Control measures curtailed the movement of goods and services, including food items, resulting in panic buying, food shortages and soaring food prices. Labor shortages are threatening the impending harvest

In talks hosted by U.S. President Barack Obama last week, FAO Director-General warned that the Ebola epidemic had the potential to cause long-term food insecurity in West Africa, as a result of prolonged disruption of crop harvesting and subsequent planting. (FAO 1-OCT)

ASSITANCE:

HEALTHCARE WORKERS

• Exposure to HCW remains a persistent concern and insufficient numbers of qualified staff.

• Both foreign and local health care workers have been affected as this continues to be a global fight. 12,750 healthcare workers from the African Union, Canada, China, Cuba, DRC, EU, France, Russia, South Africa, UK, US, and Uganda are committed to helping perform mission critical actions. (Ebola Crisis Response - 30 SEPT)

HEALTHCARE WORKERS ARRIVING

• Cuba pledged to train and deploy 165 health professionals to Sierra Leone• Norway pledges to provide physicians and nurses and is considering other support to Sierra

Leone• The Philippines is considering the provision of healthcare workers to Sierra Leone• 26 volunteers are being trained in Geneva to staff an ETC being opened in Sierra Leone

(Defeating Ebola in Sierra Leone - 2 OCT )• The Government’s National AIDS Control Program plans to send 26 teams to 114 health

facilities throughout Liberia starting 15 October • UNICEF supported the MoHSW to hire an additional 60 social workers and 50 mental health

clinicians, who are being trained to provide psychosocial care and support services to children affected by Ebola in Liberia. (UNICEF - 26 SEPT)

• Cuba announced that it will send a further 300 doctors and nurses to Sierra Leone, Guinea and Liberia to help fight the Ebola epidemic (UN Ebola Crisis Center - 27 SEPT)

• Over the next 6 months more than 2,500 Ebola survivors – now immune to the disease – will be trained in Sierra Leone to provide care and support to quarantined children in treatment centers. (UNICEF - 30 SEPT)

• CDC experts are being deployed to non-affected border countries, including Cote d’Ivoire, to conduct assessments of Ebola preparedness in those countries (CDC - 2 OCT)

• 2000 Germans will join the German Red Cross in providing assistance to Sierra Leone, Guinea, and Liberia. They began airlifts to transport volunteers on 25 September (ReliefWeb - 25 SEPT)

As part of a comprehensive and coordinated response, the CDC is continuing to develop an introductory training course for licensed clinicians intending to work in an Ebola Treatment

Unit (ETU) in Africa. This will be a 3-day course held Monday through Wednesday each week beginning on October 6, 2014 in Atlanta, GA in the United States. (CDC - 24 SEPT)

• In Liberia, an International non-governmental organization, Global Communities, has started to support the Ministry of Health in training to facilitate the safe handling of dead bodies and management of safe burials in the districts of Bomi, Nimba, and Sinoe (WHO - 1 OCT)

• the Red Cross is opening the Ebola treatment center to relieve pressure on the local government hospital in Sierra Leone, where several doctors and nurses have fallen victim to the virus. Before admitting an estimated 60 patients over the next few weeks, the clinic’s volunteers will undergo a rigorous training in Geneva, Switzerland. (ReliefWeb - 1 OCT)

• The American Red Cross has deployed 2 IT specialists to Sierra Leone to work with the Humanitarian OpenStreetMap team to provide accurate maps to relief agencies working on the ground (ReliefWeb - 1 OCT)

• UNICEF is currently holding discussions with the national authorities in Guinea to develop local skills for reducing violent episodes while spraying homes (UNICEF - 26 SEPT)

• UNICEF provided technical support to the MoHSW for the finalization of “no-touch guidelines” for Community Health Volunteers (UNICEF - 26 SEPT)

• When safe alternatives to breastfeeding and infant care exist, mothers with probable or confirmed Ebola virus disease should not have close contact with their infants (including breastfeeding). (CDC - 19 SEPT)

• As the death toll from Ebola continues to rise, preliminary reports from Guinea, Liberia and Sierra Leone suggest that the 3,700 children orphaned by Ebola is likely to double by mid-October. (UNICEF - 30 SEPT

UPDATES ON HCW CONDITIONS

GUINEA • In an effort to reduce resistance and end violence in some

Ebola affected areas, influential nationals will be deployed to their home regions and villages for social mobilization activities. A group of 30 people has been deployed in the area of Macenta and 589 others will be deployed in 12 prefectures starting next week. (UNICEF - 26 SEPT)

• In Forécariah, about 100 km from Conakry, a hostile youth protest degenerated into a riot after the Guinean Red Cross sprayed a mortuary. Further, the Prefectural Department of Health was ransacked, causing many injuries. This violent episode demonstrates the resistance against the spraying of homes and villages.

• Community members attacked a group of six Red Cross volunteers attempting to safely collect the body of a deceased person in Forecariah town, western Guinea, on September 23; the attack resulted in at least one injury that required hospitalization(USAID - 1 OCT)

LIBERIA • As of September 28, all components of the DoD-supported 25-

bed field hospital had arrived in Monrovia. A three-person U.S. Public Health Service team plans to assist with establishing the hospital. The hospital will be used specifically to care for HCW (USAID - 1 OCT)

• Soldiers at the Edward Beyan Kesselley Barrack have been quarantined and the facility has been closed for 21 days. The step was initiated after at least seven soldiers from the Liberian army were infected with Ebola. (INTERNATIONAL SOS - 1 OCT)

HEALTHCARE WORKERS

SIERRA LEONE

• the Chinese mobile laboratory team based in Freetown started testing samples on 29 September 2014, with a testing capacity of 20 samples per day. (WHO - 1 OCT)

• The Government of Sierra Leone has mobilized nearly 200 volunteers to deliver EVD prevention messages in densely-populated areas of the capital city of Freetown, aiming to reach 500,000 people by early October. (USAID - 1 OCT)

• Emergency USA, a nonprofit group that builds medical and surgical centers in war zones, recently opened a 22-bed Ebola treatment center in Sierra Leone. The nonprofit wants to open another 90-bed facility, and is worried about finding enough local health workers. (WSJ- 2 OCT)

DEATHS AND NEW INFECTIONS AMONG HCWS

Following the death of her office assistant to Ebola, Liberia’s chief medical officer, a deputy health minister, placed herself under quarantine for 21 days to ensure that she was not infected. While asymptomatic, she also instructed her office staff to remain at home for three weeks. (UN Ebola Crisis Center - 29 SEPT)

A member of EMERGENCY's international staff has contracted the Ebola virus in Sierra Leone. The patient is a Ugandan paediatrician who works at EMERGENCY's Centre for treatment of Ebola patients in Lakka, in the area around the capital Freetown. He has begun the treatment at the Lakka Centre and his overall conditions are stable. He has been transferred today to Germany to continue the treatment (EMEREGENCY – 2 OCT )

In Sierra Leone The impact on "first responders", healthcare workers who attended early cases, was severe with many doctors and nurses dying from Ebola, including the head of the Lassa Fever Programme, Dr Sheik Humarr Kahn. This has critically impaired the nation's capacity to respond. Many more beds are needed in safer treatment centers and teams to undertake contact tracing and safe burial are in desperately short supply.(ISOS – 22 SEP)

NOTICE TO HCWs AND TRAVELLERS The CDC encourages all persons traveling from Ebola outbreak areas to:• Monitor your health for 21 days• Seek medical care IMMEDIATELY if you

develop a fever and additional symptoms• Call the doctor in advance and inform of

recent travel to allow facility preparation• If you get symptoms of Ebola, stay away

from other people and call your doctor right away.

CDC - 2 OCT

HEALTHCARE WORKERS

The above table indicates the total number of probable, confirmed, and suspected cases in healthcare workers in Guinea, Liberia, Sierra Leone, and Nigeria as of 28

September 2014 (WHO Ebola sitrep – 1 OCT)

This sharp increase in HCW cases in Sierra Leone reflects the integration of the results of the retrospective investigation into the official national data. It is

important to emphasize that the additional HCW infections and deaths occurred throughout the course of the outbreak. Any cases of EVD in HCWs are of great concern, but there is currently no evidence to suggest a recent increase in the

incidence of infections of HCWs. (WHO - 24 SEPT)

FIRST CASE DIAGNOSED IN THE UNITED STATES

• On September 30 the CDC confirmed the first case of Ebola to be diagnosed in the United States. A man travelled from West Africa to Dallas, Texas and began displaying symptoms on 24 September, approximately 5 days after arrival. The patient sought medical care on 26 September and was admitted to isolation on 28 September at Texas Health Presbyterian Hospital in Dallas, Texas.

• CDC confirmed positive results for Ebola virus from sample testing the patient. Identification of persons with close contact to the patient is under way to provide daily monitoring for 21 days . (WHO - 1 OCT)

• For further guidance on CDC recommended control practices to prevent the transmission of infectious agents in healthcare settings go to http://www.cdc.gov/hicpac/2007IP/2007ip_part2.html#e

WHO will convene a meeting of the Guideline Development Group on 6–7 October, which will discuss the development of new guidelines on the use of personal protective equipment to control health-care associated Ebola transmission, and to allow satisfactory working conditions in the context of EVD outbreak response (WHO - 1 OCT)

RESPONSE ACTIVITIESUNITED NATIONS

BACKGROUND• In identical letters dated 17 September to the Presidents of the

General Assembly and the Security Council, the Secretary-General stated his intention to establish the United Nations Mission for Ebola Emergency Response (UNMEER) and set forth the Mission’s five objectives, six guiding principles and 12 mission critical actions deemed necessary to stop the outbreak in the affected countries and prevent its further spread. Those steps are estimated to cost almost $1 billion over the next six months.

• On 18 September 2014, the Security Council determined that the outbreak is a "threat to international peace and security" and unanimously adoptedResolution 2177 which was co-sponsored by 134 Member States, the highest number of co-sponsors of any Security Council resolution and only the third time the Council has taken such action on a public health crisis.

• On 19 September 2014, the General Assembly unanimously adopted resolution 69/1 welcoming the Secertary-General's intention to establish UNMEER, and called on all Member States, relevant United Nations bodies and the United Nations system to provide their full support to the United Nations Mission for Ebola Emergency Response (UNMEER).

• Immediately thereafter, the Secretary-General established UNMEER and deployed advance teams to the mission headquarters in Accra, Ghana as well as to the most-affected countries, Guinea, Liberia and Sierra Leone, to accelerate international and regional efforts to support national efforts.

• On 23 September 2014 United Nations Secretary-General Ban Ki-moon announced the appointment of David Nabarro as his Special Envoy for Ebola and Anthony Banbury as his Special Representative and Head of the United Nations Mission for Ebola Emergency Response (UNMEER).

• The first-ever UN emergency health mission, the UN Mission for Ebola Emergency Response (UNMEER) is being set up in response to the unprecedented outbreak.The Mission will be temporary and will respond to immediate needs related to the fight against Ebola.

• RAPID ACTION: • Under the strategic guidance of the SG's Special Envoy, David

Nabarro, and the operational direction of the SG's Special Representative, Anthony Banbury, the mission will harness the capabilities and competencies of all the relevant United Nations actors under a unified operational structure to reinforce unity of purpose, effective ground-level leadership and operational direction, in order to ensure a rapid, effective, efficient and coherent response to the crisis.

• THE SINGULAR STRATEGIC OBJECTIVE AND PURPOSE: to work with others to stop the Ebola outbreak.

• STRATEGIC PRIORITIES OF THE MISSION: 1) stop the spread of the disease 2) treat the infected 3) ensure essential services, preserve stability and prevent the spread to countries currently unaffected.

• IN PARTNERSHIP: UNMEER will work closely with governments and national structures in the affected countries, regional and international actors, such as the African Union (AU) and the Economic Community of West African States (ECOWAS), and with Member States, the private sector and civil society.

• UNITING EXPERTISE: The World Health Organization (WHO) will be responsible for overall health strategy and advice within the Mission, while other UN agencies will act in their area of expertise under the overall leadership and direction of a single Head of Mission. The Mission will leverage the existing presence and expertise of UN country teams, international partners including NGOs on the ground to minimize gaps and ensure leadership.

(UNMEER 30 SEP 2014)

RESPONSE ACTIVITIESUNMEER

PRIORITY REQUESTS (FOR MEMBER STATES) • Air lift, particularly helicopters, and maritime transport capabilities, fuel, vehicles

• Mobile laboratory facilities capable of movement throughout affected countries;

• Static non-Ebola medical clinics;

• Emergency medical evacuation capability for movement of international aid workers potentially exposed to Ebola to locations for appropriate medical care;

• 3.3 million items of high quality personal protective equipment;

• Training

• Provision of Ebola Treatment Centers.

PRIORITY REQUESTS FOR PRIVATE SECTOR ENGAGEMENT(For details see UNMEER-Ebola Business Engagement Guide)

“70 per cent of infected people need to be under treatment, 70 per cent of burials need to be done in a safe way in order to turn this around and we need to do it in 60 days.” SRSG Banbury

• 2 October 2014- SRSG Anthony Banbury met with UN, national, and operational partners in Liberia on the first part of an introductory visit to affected at the National Emergency Operations Centre in Accra, Ghana.

• UNMEER is set to establish operational capacities by providing transportation vehicles, supplies for the health workers, and meeting other needs identified by the national governments.

• Mr. Banbury applauded the work being done by both district health officials and the frontline workers of NGOs such as Médecins Sans Frontières and Samaritan’s Purse. But, he noted, patients continued to arrive in the field hospitals, and the threat of transnational contagion from bordering States remained alive. (UN NEWS CENTER – 2 OCT)

RESPONSE ACTIVITIES

According to WFP’s most recent update, it has delivered 5971 metric tons of food for 430,369 people in Guinea, Liberia and Sierra Leone since April 2014. Meanwhile, UN Humanitarian Response Depots (UNHRD) in Dubai and Accra dispatched 224 metric tons of protective gear, emergency health kits, relief items and equipment to the region thus far.

WFP’s response to the Ebola outbreak includes:• WFP’s food assistance is provided to patients in Ebola treatment centres,

survivors of Ebola discharged from treatment centres and communities with widespread and intense transmission – including the families of people infected with Ebola who are in treatment, deceased, or recovering. This helps to stabilize affected communities by enabling them to limit unnecessary movement.

• Food distributions are ongoing in all three countries, in both urban and rural areas, often house-to-house, one family at a time -- and more food is on the way. WFP has contracted a ship that is currently in Cotonou, Benin, loading 7,000 metric tons of rice to be transported to Monrovia and Freetown.

• The United Nations Humanitarian Air Service (UNHAS), managed by WFP, has opened a new air corridor between Dakar, Accra, Freetown, Monrovia and Conakry to facilitate the rapid deployment of humanitarian staff to the field. UNHAS was already operating between the affected countries and has transported 497 passengers and 6.6 metric tons of light cargo for 25 organizations (NGO, UN, donors, government partners and media), using two fixed-wing aircraft and one helicopter.

• WFP is providing unprecedented logistics support to help medical services to treat and prevent the spread of the virus. In Liberia’s capital Monrovia, WFP field engineers are setting up four Ebola Treatment Units with a capacity of 400 beds.

WORLD FOOD PROGRAM

A WFP distribution center in Monrovia, Liberia. WFP/Rein Skullerud

• WFP is helping to quantify the impact of the health crisis on household food security through an innovative technique called “mVAM,” using mobile phones for surveys that are normally done in person. In Sierra Leone, data collection via SMS has been completed for a sample of 800 households. In Guinea and Liberia, WFP is preparing data collection through interactive voice response.

• The UN Humanitarian Response Depot (UNHRD), managed by WFP, continues to support the response efforts of the World Health Organization, WFP, Irish Aid and Japan International Cooperation Agency. UNHRD depots in Dubai (UAE), Accra (Ghana), and Las Palmas (Spain) have so far dispatched 224 metric tons, worth US$ 1.9 million, of protective gear, emergency health kits and equipment to the region. Weekly dispatches are ongoing.

SOURCE: WFP- 3 OCT

RESPONSE ACTIVITIESUNITED NATIONS CHILDREN'S FUND

In collaboration with partners such as the Red Cross and the WHO, UNICEF is stepping up efforts to design culturally-sensitive communication strategies and raise awareness of Ebola, at the grassroots level, across the seven at-risk or affected countries in West Africa.

In Guinea, Liberia, Sierra Leone, Cote d'Ivoire, Senegal, Mali and Guinea Bissau, mass and digital media and inter-personal communication activities are being carried out to prevent people contracting the Ebola virus amongst communities and health workers in mosques, churches, schools, health centers and markets.

USAID Morgana Wingard)

EVD ORPHANSUNICEF reported on September 30 that the EVD outbreak has orphaned at least 3,700 children in Guinea, Liberia, and Sierra Leone. Many of the children face rejection from extended families. UNICEF reports the number of orphaned children could double by mid-October. (UNICEF -30 SEP)

As it accelerates its Ebola response, UNICEF is looking at traditional and new ways to help provide children with the physical and emotional healing they need:

• In Liberia, UNICEF is helping the government train 400 additional mental health and social workers. UNICEF is also working with local authorities in the most affected counties to help strengthen family and community support to children affected by Ebola and provide care to those who have been rejected by their communities or whose families have died.

• Over the next 6 months more than 2,500 Ebola survivors – now immune to the disease – will be trained in Sierra Leone to provide care and support to quarantined children in treatment centres. UNICEF is also working with partners to reunite separated children with their families through an extensive family tracing network across the country which also provides children with psychosocial support.

• In Guinea, UNICEF and partners will provide about 60,000 vulnerable children and families in Ebola-affected communities with psychosocial support.

HOUSEHOLD PROTECTION KITSUNICEF has sent over 9,000 kits to Liberia. This is the first in a series of airlifts that will see a planned total of 50,000 kits for distribution. Each kit contains protective gowns, gloves and masks, as well as soap, chlorine and a sprayer, along with instructions on the use and safe disposal of materials Along with USAID, funding for the kits is being provided by US-based Paul G. Allen Family Foundation, which has committed a US$3.6 million matching contribution to UNICEF to support the airlift.(UNICEF - 25-SEP)

SCHOOL REOPENINGSIn view of a possible reopening of schools in Guinea in October, although a date has yet to be determined, UNICEF is supporting the Ministry of Education to develop school plans and protocols for referral, teacher training, and a health and wash supply package, thus creating the conditions for a return to school in safe and protective learning environments. (UNECC 1-OCT)

RESPONSE ACTIVITIESUS GOVERNMENT

DECLARATIONS: • On August 4, 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 August 13, U.S. Chargé d’Affaires Kathleen FitzGibbon declared a disaster due to the effects of the EVD outbreak in Sierra Leone.

• On August 15. U.S. Chargé d’Affaires Ervin Massinga declared a disaster due to the magnitude of the EVD outbreak in Guinea

• The Ebola outbreak afflicting West African countries is now an epidemic of unprecedented proportions. President Obama has made combating Ebola a top national security priority and on 25 September, at the United Nations, he called on the world to join the United States in this effort. (WHITE HOUSE -25 SEP)

• The President noted how the public health systems in Sierra Leone, Liberia, and Guinea have collapsed, making the outbreak a regional and potentially global threat. Health workers on the front lines are in desperate need of more aid – from beds, to supplies, to more helping hands. (WHITE HOUSE -25 SEP)

• The Centers for Disease Control and Prevention (CDC) is launching the largest international response in its history. President Obama has also directed the U.S. military to establish a command in Liberia which is now up and running, moving in personnel, equipment, and supplies. The U.S. is working with Sierra Leone to create an air bridge that will get health workers and medical supplies to the region faster, and we’re setting up new treatment centers, a field hospital, and a training facility to help bolster the number of health workers on the ground. (WHITE HOUSE -25 SEP)

President Barack Obama delivers remarks on the Ebola epidemic during a meeting chaired by United Nations Secretary-General Ban Ki-moon at the United Nations in New York, N.Y., Sept. 25, 2014. (Official White House Photo by Pete Souza)

• A high-level USG delegation—including Assistant Administrator for USAID’s Bureau for Democracy, Conflict, and Humanitarian Assistance Nancy Lindborg and DoD Assistant Secretary of Defense Michael Lumpkin—arrived in Liberia’s capital city of Monrovia on September 29 to assess ongoing EVD response efforts. While in Liberia, the 10-person delegation is scheduled to meet with Liberian President Ellen Johnson Sirleaf, Government of Liberia (GoL) and U.N. officials, other USG partners, and EVD-affected community members. (USAID – 1 OCT)

http://reliefweb.int/sites/reliefweb.int/files/resources/10.01.14%20-%20USG%20West%20Africa%20Ebola%20Outbreak%20Program%20Map.pdf

RESPONSE ACTIVITIESUS GOVERNMENT

USAID • CDC and USAID continue to support EVD-affected countries to establish national

and sub-national Emergency Operations Centers (EOC). USG experts have deployed to Guinea, Liberia, and Sierra Leone to provide technical guidance on setting up EOCs. All three countries currently have an incident manager, reporting to the President of the country, to lead EVD response efforts. (USAID – 24 SEP)

• USAID and the U.S. Department of State formalized a $10 million grant—approximately $5 million from each—for the AU Commission to support the deployment of more than 100 health care workers to assist with the ongoing EVD outbreak response. With the USG funding, health personnel from AU member states will receive EVD preparedness training and deployment assistance. The AU Support to Ebola Outbreak in West Africa (ASEOWA) mission will augment on-going efforts to control the outbreak. ASEOWA personnel will directly respond to medical needs in Guinea, Liberia, and Sierra Leone in close cooperation with governments in affected nations, the USAID-led Disaster Assistance Response Team (DART), CDC, and other international responders. (USAID – 1 OCT)

CENTER FOR DISEASE CONTROLCONTROL

TRAINING COURSE FOR LICENSED CLINICIANS• CDC has announced an introductory training course for licensed clinicians—

including nurses, physicians, and other health care providers—intending to deploy to affected countries to support clinical care in ETUs. CDC plans to provide multiple offerings of the three-day course in the U.S. for at least three months, beginning the first week of October. The primary purpose of the course is to ensure that clinicians intending to provide medical care to EVD patients have sufficient knowledge of the disease and its transmission routes to work safely and efficiently in a well designed ETU. (USAID – 1 OCT )

TECHNICAL ASSISTANCE FOR AIRPORT• Since the beginning of August, CDC has worked with airlines, airports, ministries of

health, and other partners in EVD-affected countries to provide technical assistance for airport exit screenings and travel restrictions. Exit screening is recommended in countries with EVD outbreaks because the benefit of screening for illness and exposures is much greater when conducted at or near the source of the outbreak.

• Successful exit screening at the source lessens the need for entry screening in other countries. A well-run exit screening system also aims to increase the confidence of travelers, airline crews, and airline management, allowing affected-counties to continue receiving goods, people, and services via ports. (USAID – 1 OCT )

DEPLOYMENTS• Hundreds of CDC staff members have provided logistics, staffing, communication,

analytics, management, and other support functions for the response. CDC has deployed several teams of public health experts to the West Africa region. CDC staff are deployed to Guinea, Liberia, Nigeria, Senegal, and Sierra Leone to assist with response efforts, including surveillance, contact tracing, data management, laboratory testing, and health education. (CDC- 2 OCT)

• CDC is consulting with WHO to increase laboratory capacity in Cote D’Ivoire, Ghana, Guinea Bissau, and Mali under a USAID cooperative agreement. CDC epidemiologists are also working with teams in Cote d’Ivoire, Ghana, and Guinea Bissau to assess and support preparedness for possible Ebola virus disease. (USAID – 1 OCT)

The Centers for Disease Control and Prevention is sending Epidemic Intelligence Service Officers or disease detectives to try and stop the outbreak of the Ebola virus. And those workers admit there is a long road ahead to stop the disease.(CNN 29 SEP)

MORBIDITY AND MORTALITY WEEKLY REPORT (MMWR)• On September 26, CDC released an MMWR article, “

Estimating the Future Number of Cases in the Ebola Epidemic – Liberia and Sierra Leone, 2014-2015,” which estimated the future number of Ebola cases if current trends continue. The projected numbers were adjusted to account for estimated underreporting of cases.

‒ Without additional interventions or changes in community behavior, CDC estimates that by January 20, 2015, there will be a total of approximately 550,000 Ebola cases in Liberia and Sierra Leone, or 1.4 million if corrections for underreporting are made.

‒ Cases in Liberia are currently doubling every 15-20 days, and those in Sierra Leone and Guinea are doubling every 30-40 days.

‒ A Q&A on the report is available at http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/qa-mmwr-estimating-future-cases.html

FOOD AND DRUG ADMINSTRATION • FDA has issued Warning Letters to three firms marketing products that claim to

prevent, treat or cure infection by the Ebola virus: Natural Solutions Foundation, Young Living, and dōTERRA International LLC. There are currently no FDA-approved vaccines or prescription or over-the-counter drugs to prevent or treat Ebola. Individuals and companies promoting these unapproved and fraudulent products must take immediate action to correct or remove these claims or face potential FDA action. - FDA - 24 SEP

Experimental Ebola vaccines and treatments are in the early stages of product development, have not yet been fully tested for safety or effectiveness, and the supply is very limited. There are no FDA-approved treatments for Ebola available for purchase on the Internet. A claim that a product prevents, treats, or cures a disease requires prior approval by FDA. FDA - 24 SEP

From left, Dr. Joel Montgomery, a team leader with the U.S. Centers for Disease Control and Prevention, adjusts a colleague's personal protective equipment Sept. 17, 2014, before entering the Ebola virus treatment unit in Monrovia, Liberia,.

• The U.S. Food and Drug Administration has authorized Tekmira

Pharmaceuticals Corp. to provide an experimental drug to people with confirmed or suspected Ebola virus infections. In the FDA expanded-access programs, drug developers may provide experimental drugs to patients with serious or life-threatening diseases who don't have satisfactory alternatives. The programs are intended for patients who don't qualify for clinical trials of a drug.(WSJ- 22 SEP)

RESPONSE ACTIVITIESCENTER FOR DISEASE CONTROL

The U.S. Africa Command, through U.S. Army Africa, provides coordination of logistics, training, and engineering support to the U.S. Agency for International Development (USAID) in West Africa to assist in the overall U.S. Government Foreign Humanitarian Assistance/Disaster Relief efforts to contain the spread of the Ebola Virus/Disease, as part of the international assistance effort supporting the Governments of Liberia, Sierra Leone and Guinea. Operation United Assistance personnel also will set up a training facility for health care workers near Monrovia, as well as an intermediate staging base in Senegal.

US MEMBERS IN MONROVIACurrently there are 150 US service members in Liberia conducting a range of activities in support of USAID. (DOD – 30 SEP)

EMEDS EBOLA TREATMENT FACILITY• Airmen from the 633rd Medical Group partnered with representatives from the U.S. Public

Health Service on Sept. 26 to deliver a modular medical treatment center as part of the U.S. whole-of-government effort to support humanitarian relief operations in Ebola-stricken African nations. Airmen from the 633rd Medical Group accompanied the Expeditionary Medical Support System, or EMEDS, to Africa. And while they will not be involved in treatment of patients exposed to the virus, they will be supporting the overall effort by setting up the facility and training international health care workers. (DOD – 26 SEP)

• 15 Seabees from the Naval Mobile Construction Bat talion 133 are handling site preparation for the medical facility (Navy Times -25 SEP).

DEPLOYEMENTSDeployments of U.S. troops to fight the Ebola outbreak in West Africa will accelerate during October when 1,600 soldiers will be dispatched to Liberia. Half of the soldiers are from the headquarters element of the 101st Airborne Division, based at Fort Campbell, Ky., and will form the headquarters staff of a joint forces command led by Maj. Gen. Gary Volesky. The other 700 will include combat engineers from units around the United States, charged with overseeing the construction of 17 Ebola treatment centers with a total of 1,700 beds. Officials with the 1st Armored Division at Fort Bliss, Texas, and Joint Task Force Carson at Fort Carson, Colo., confirmed troops from those installations would deploy this month to Liberia.(STAR-STRIPES – 1 OCT)

Airmen assigned to the 633rd Medical Group board a C-17 Globemaster at Langley Air Force Base, Va., Sept. 26, 2014. The 633rd Medical Group packaged and delivered a modular medical treatment center, as part of a governmentwide effort to support humanitarian relief operations in Ebola-stricken African nations. (SOURCE: U.S. Air Force photo by Senior Airman Kayla Newman)

MOBILE LABORATORY• Two US Navy mobile laboratories have now arrived in Liberia.

One team will be based in Gbarnga (Bong county), with the other based in Montserrado (the district containing the capital, Monrovia). Both teams will be operational by 5 October (WHO - 1 OCT)

• The two additional laboratories will provide quick testing capabilities for ETUs at Bong and Island Clinic. Rapid testing is vital to remove negative cases from facilities and open beds for other suspected cases. (USAID – 1 OCT)

RESPONSE ACTIVITIESUS DEPARTMENT OF DEFENSE – OPERATION UNITED ASSISTANCE

SITUATIONEUROPEAN UNION

EUROPEAN UNION (EU): • The European Commission is establishing an operational hub from which to

coordinate and facilitate air transport for medical evacuations of health workers, and has activated the EU Civil Protection Mechanism to facilitate the provision of assistance on the ground and to coordinate the deliveries of equipment and supplies. (EU – 25 SEP)

• The European Mobile Laboratory (EMlab) will work with the European Commission to establish the European Union West Africa Mobile Lab (EUWAM-Lab), to train more local and EU specialists as well as providing additional equipment. (EU – 29 SEP)

IRELAND: Ireland has pledged 42 tons of supplies, including blankets, tarpaulins, tents, mosquito nets, jerry cans and soap, to be airlifted from Accra to the affected countries. Ireland has also deployed a member of its Rapid Response Corps to Dakar, Senegal to work with WFP to establish an air transit center to be used by the UN Humanitarian Air Service. (Ireland – 22 SEP)

DENMARK: Denmark has pledged maritime transport capacity to move supplies, equipment and personnel to affected countries in West Africa. Denmark will also provide accommodation to healthcare workers responding to the Ebola outbreak, to ensure their accommodations have adequate sanitation, security and opportunities for rest. (Denmark – 25 SEP)

GERMANY: 2,000 Bundeswehr (armed forces) soldiers have volunteered to participate in Germany’s response to the crisis. These volunteers, along with the German Red Cross and the Federal Agency for Technical Relief (THW) will set up and run a mobile hospital in Liberia with 300 beds. The initial airliftof supplies and personnel from Dakar, Senegal was expected to start on 25 September. (Germany – 25 SEP)

FRANCE: France has pledged to establish a 50-bed Ebola treatment center in Guinea, to be run by the French Red Cross with a laboratory run by the Pasteur Institute. (France – 2 OCT)

UNITED KINGDOM:• On 2 October, the UK hosted the Defeating Ebola conference in

London. The conference resulted in additional pledges of funding and other contributions from governments, NGOs, foundations and the private sector, including: 165 health professionals from Cuba, medical treatment facilities from Ireland, personal protection equipment kits from Japan, and physicians and nurses from Norway. (DFID – 2 OCT)

• The UK will undertake rapid trials of community care units in Sierra Leone. These units will give people who suspect they are infected with Ebola to seek swift and accurate diagnosis and appropriate care. If positive, they will be isolated at the center until they can be transferred to a full Ebola treatment center. If the initial pilot is deemed effective, it will be rolled out across the country.

• The Department for International Development (DFID) will partner with Sierra Leone’s Ministry of Health and NGOs to help reduce the risk of infection from traditional burial practices; this will ensure bodies are buried safely while respecting local practices. (DFID – 2 OCT)

• More than 40 military personnel and humanitarian staff from the UK arrived in Freetown to oversee construction of the UK’s medical facility and assist with response to the Ebola crisis. (DFID – 23 SEP)

• DFID published its action plan to defeat Ebola in Sierra Leone, available here.

• The UK has committed to deploying clinicians, epidemiologists and infection control advisors from Public Health England and King’s Health Partners. The UK will also provide vital medical supplies such as chlorine, personal protection equipment and essential water and sanitation facilities in Sierra Leone. (DFID – 1 OCT)

SITUATIONOTHER COUNTRIES

SWITZERLAND: The Swiss Agency for Development and Cooperation (SDC) is supporting the Hospitals of the University of Geneva (HUG), which is supplying medical personnel in Geneva and Liberia for treatment of the infected and for prevention and training projects. (ReliefWeb – 30 SEP)

CANADA:• Canada has deployed a mobile laboratory, along with a rotating team of

scientists, to Sierra Leone.

• Canada donated hundreds of doses of the experimental Ebola vaccine to the WHO. (Canada – 25 SEP)

GHANA: Ghana is hosting the UN’s Mission on Ebola Emergency Response (UNMEER) in Accra, which is deploying 250 UN personnel. (Ghana – 25 SEP) This includes the establishment of an air bridge in Ghana, which will be vital in transporting supplies to affected countries. (UNMEER – 30 SEP)

ECONOMIC COMMUNITY OF WEST AFRICAN STATES (ECOWAS):• The ECOWAS Coordinating Ministerial Group has called for member states

to deploy armed and security forces, including medical personnel, logistics staff and military engineers to help set up Ebola treatment centers in Guinea, Liberia and Sierra Leone. (ECOWAS – 26 SEP)

CUBA• Late Wednesday, 1 OCT , doctors and 103 nurses departed Cuba for Sierra

Leone, as part of the Cuban contribution to global efforts to curb the spread of EVD. Prior to deployment, Cuban health professionals are undergoing more than two weeks of training with international experts at a Havana hospital specializing in tropical diseases.

• Another 296 Cuban doctors and nurses will deploy to Liberia and Guinea once their training has been completed (UNECC- 3 OCT)

CHINA:• The Chinese mobile bio-safety level III laboratory arrived in Sierra

Leone on 25 September (China – 25 SEP)

• SL-3 mobile laboratory has been set up at the Sierra Leone-China Friendship Hospital at Jui. (SL- 26 SEP)

NGO RESPONSE ACTIVITIES MÉDECINS SANS FRONTIÈRES (MSF) - DOCTORS WITHOUT BORDERS

GENERAL UPDATE• MSF has been responding to the epidemic since March, and currently has

248 international and 2,800 locally hired staff on the ground in Guinea, Sierra Leone and Liberia, treating a rapidly increasing number of patients.

• MSF is managing 549 beds in six different Ebola management centers, and has sent more than 553 tons of supplies to the affected countries.

• MSF has admitted 3,299 patients, of whom 2,051 were confirmed cases of Ebola, 650 of whom have survived. (MSF – 25 SEP)

Despite strict safety precautions to prevent the spread of infection in health centers, medical and non-medical staff at these centers remain at risk of infection. Risks of infection at work are as minimized as possible, but the risk of staff becoming infected in their communities remains. The infection of 240 health workers, 120 of whom have died (MSF has had 14 infected and has lost 8 colleagues), makes responding to the crisis even more challenging. (MSF – 25 SEP)

GUINEA• MSF’s team in Guéckédou has an average of 40 cases in its Ebola center. • The MSF team in Macenta continues to manage the transfers from the

transit center to Guéckédou. Several deaths have been reported in and around Macenta. (MSF – 25 SEP)

SIERRA LEONE• MSF’s Ebola management center in Bo opened on 19 September and has

admitted 15 patients, 11 of whom were confirmed cases. • In Kailahun, MSF continues to see a large number of patients from Makeni,

often arriving in overcrowded ambulances. (MSF – 25 SEP)

LIBERIA• The number of people with Ebola in Monrovia continues to rise, with large

numbers seeking treatment at MSF’s ELWA Ebola center, but not all can be accepted because the center is full. A new 120 bed clinic opened in Monrovia, the Island clinic, run by the Ministry of Health and WHO brings the total number of beds in the city to 360.

• MSF plans to start a mass distribution of 50,000 family protection and home disinfection kits, targeting neighborhoods that have a large number of cases over the next two months. The kits are designed to help people protect themselves from infection and disinfect their homes to reduce the risk of transmission should a family member become ill with Ebola.

• In Lofa county, MSF continues to operate a 100-bed Ebola management center in Foya.

• A mental health team recently arrived to provide counselling for patients and their relatives, and is hoping to provide support to negative discharged and recovered patients who often face discrimination in local communities. (MSF – 25 SEP)

Sylvain Cherkaoui/Cosmos

NGO RESPONSE ACTIVITIES

INTERNATIONAL FEDERATION OF RED CROSS AND RED CRESCENT SOCIETIES (IFRC)• The Red Cross is opening a new health facility in Kenema district of

Sierra Leone, which will be staffed by 19 international staff and 80 local workers. IFRC has more than 4,000 volunteers responding to the crisis, working on disease prevention, provision of psychosocial support and management of dead bodies. (IFRC – 23 SEP)

Five Pillars of the Red Cross Red Crescent Response:

(IFRC – 30 SEP)

EMERGENCY• In early September, EMERGENCY opened an Ebola treatment center in

Lakka, Sierra Leone and continues to provide medical care at the Surgical and Paediatric Center in Goderich, in Freetown. (EMERGENCY – 21 SEP)

INTERNATIONAL MEDICAL CORPS (IMC)• IMC is running the Ebola treatment center in Bong county, Liberia, and

should be running at capacity soon with 60 beds and 200 staff.• IMC plans to open a 70-bed Ebola treatment unit in Lunsar, Sierra Leone,

and is in discussions about opening a second Ebola treatment unit in Freetown. (IMC – 29 SEP)

OXFAM• Oxfam provides medical protective materials to case tracking and burial

teams in Sierra Leone and Liberia, and is disseminating educational information via radio and posters on how to recognize and prevent contamination of Ebola.

• Oxfam has provided 1,500 families with Ebola prevention kits and educational materials in Monrovia. (Oxfam – 23 SEP)

INTERNATIONAL RESCUE COMMITTEE (IRC)• In Liberia and Sierra Leone, the IRC is supporting surveillance and

contact tracing efforts, providing protective equipment to health workers, and conducting community sensitization. (IRC – 23 SEP)

SAMARITAN’S PURSE• On 1 October, Samaritan’s Purse airlifted 100 tons of personal protective

gear and supplies to Liberia. • Samaritan’s Purse is launching a community-based care program and

plans to open 15 community care centers that will provide basic support care, starting in Lofa county. Samaritan’s Purse staff will also train and equip people, by distributing 3,000 care kits, to care for their loved ones and protect themselves against infection. (Samaritan’s Purse – 2 OCT)

GOAL• Since GOAL launched an emergency recruitment drive, the organization

has received over 500 applications for medical response team members to staff isolation and treatment centers in Sierra Leone. (GOAL – 2 OCT)

NGO RESPONSE ACTIVITIES

WORLD VISION• World Vision airlifted 4 million pairs of gloves, 8,000 gallons of chlorine

and personal protective equipment to Sierra Leone. (Sierra Leone – 24 SEP)

SAVE THE CHILDREN• Save the Children is building and will manage an Ebola treatment center

in Sierra Leone, and is supporting an interim care center in Kailahun for children who have lost families to Ebola. (Save – 1 OCT)

• Save the Children built a 70-bed Ebola treatment center in Bong county, Liberia, that is now being run by IMC. Save the Children plans to open an additional Ebola treatment unit in Margibi county, Sierra Leone, as well as 10 additional care units in Liberia. (Save the Children – 27 SEP)

AMERICARES• AmeriCares has staff in Liberia coordinating the delivery of humanitarian

assistance, including a recent shipment of 90,000 pairs of gloves, 88,000 face masks, and 28,000 sets of personal protective gear. AmeriCares has is planning a shipment of similar supplies and medicines to Guinea. (AmeriCares – 2 OCT)

DIRECT RELIEF • Direct Relief sent its twelfth shipment of medicines and supplies to West

Africa. This 13-ton shipment was bound for Liberia, and included personal protective gear, antibiotics, oral rehydration salts, beds, gurneys, IV stands and prescription medications. Direct Relief’s 11th shipment, 100 tons of medical aid, was sent to Liberia and Sierra Leone.

• Direct Relief partners with AirLink on shipments of humanitarian aid, creating an air bridge to affected countries. (Direct Relief – 29 SEP)

MEDICAL TEAMS INTERNATIONAL (MTI)• In Liberia, MTI is training and supporting health workers, mobilizing

community health volunteers to educate communities about Ebola, improving infection control measures at health centers and providing personal protective equipment, gloves and body bags. (MTI)

MÉDECINS DU MONDE (MDM)• MDM is supporting five health facilities in Monrovia. (MDM – 30 SEP)

A Direct Relief-chartered Boeing 747 departs John F. Kennedy International with 100 tons of emergency medical assistance for communities gripped by Ebola. (Direct Relief)

VACCINE DEVELOPMENTS

COORDINATION OF EFFORTSThe World Health Organization on Sept 29-30 organized an expert consultation on Ebola vaccines. More than 70 experts attended the meeting to assess the status of work to test and to license two candidate Ebola vaccines. Experts from both affected and neighboring countries in West Africa also attended the event. All participants agreed "to have a fully tested and licensed product that can be scaled up for use in mass vaccination campaigns” (ISOS – Oct 2)

Three strong themes that carried through the meeting were allowing nothing to delay the vaccine work, making sure the products are safe and effective, and solidarity with the people of West Africa (CIDRAP – 1 OCT)

VACCINE CANDIDATES• Two prototype vaccines have been earmarked for Phase I trials to assess safety, immune response,

and side effects, in healthy volunteers.

• These trials will be conducted in small groups of volunteers at more than 10 sites in Africa, Europe and North America, with funding provided by national governments as well as grants by the Wellcome Trust and the Gates Foundation.

• Leading candidates heading into Phase I trials which are currently underway are: 1. cAd3-ZEBOV: Developed by British company GlaxoSmithKline (GSK) with the US National

Institute for Allergy and Infectious Diseases (NIAID). Based on a chimpanzee adenovirus to which an Ebola virus gene has been added in a bid to stimulate an immune response. Trials started in September, among 20 healthy adults in the United States and 60 in Britain. Two groups of 40 people will be enrolled for Phase I trials in Gambia and Mali.

2. rVSV-ZEBOV: Developed by the Public Health Agency of Canada, with the commercial license held by a US company, NewLink Genetics (of Ames, Iowa). Uses a weakened unrelated virus for vesicular stomatitis, a livestock disease, in which one of the genes has been replaced an Ebola virus gene. Trials to start in the United States early October.

• Phase II tests could start as early as January-February 2015. They will involve a larger group of volunteers, and will serve to confirm formulations and doses, as well as identify the need for boosters and intervals between doses.

• At least two other vaccine candidates are in the pipeline but lagging several months behind; they are being developed by the companies Crucell and Inovio respectively. Human safety and efficacy data for these is not yet known.

• If cAd3-ZEBOV passes trials, GSK estimates it could produce 10,000 doses of the vaccine by early 2015. Some doses could be available for a small number of frontline healthcare workers by November, with wider use offered in early 2015.

(NPR – Sept 30; CNBC – Oct 1; AFP – Oct 1; TIME – Oct 1)

EXPERIMENTAL THERAPIES

ZMAPP• ZMapp is the leading candidate for treatment of the current epidemic Ebola

strain. It is a cocktail of three antibodies against the virus, developed by Mapp Biopharmaceutical, a tiny San Diego company, with funding from the US and Canadian governments. It was highly effective in monkeys, however had not yet gone through human clinical trials.

• At this time, ZMapp has been used to treat several patients, including the American doctor and nurse who became infected while working for the humanitarian organization Samaritan’s Purse in Liberia. Their treatment was arranged privately by the organization and was not part of a medical trial.

• Overall, five out of seven patients treated with Zmapp recovered. It is unclear whether it was the drug, additional therapeutics (including transfusion of antibodies from convalescent patients), or supportive care after evacuation to the US, that played the decisive role.

• At this time the supply of Zmapp remains exhausted. The small facility in Kentucky where the original doses were produced is working, but is expected to yield only 10 to 20 treatment courses by the end of the year.

• Plans to scale up production are in progress, likely by multiple manufacturers, with financial backing from the US government, the Bill and Melinda Gates Foundation, and the Wellcome Trust.

• One possibility is scaling up production in plants, which could potentially yield hundreds of doses but is limited by growing conditions and season of the tobacco plants in which they are grown.

• Another option is growing ZMapp in animal cell cultures, which can be scaled up nearly indefinitely in biotechnology facilities. However, this approach involves longer lag time, and may require re-testing for efficacy.

• Despite the new efforts, supplies of the drug are expected to be limited to hundreds or thousands of treatment courses by early next year at best.

(NYT – Oct 1)

TKM-EBOLA• TKM-Ebola (formerly known as Ebola-SNALP) is developed by

Vancouver-based Tekmira Pharmaceuticals. It is a combination of small interfering RNAs (siRNAs) targeting Ebola’s replication.

• A Phase I trial of TKM-Ebola’s safety began in January 2014; it was put on hold by the FDA in July 2014 after some subjects had flu-like responses. More recently, the FDA changed its status to "partial hold", and authorized its release for people infected with Ebola.

• Tekmira said the drug has been given to several patients under emergency protocols and was well tolerated, however it is too early to report recovery rates.

(WSJ – Sept 22)

OTHER NEW MEDICATIONS• BioCryst Pharmaceuticals is developing BCX4430, a novel nucleoside

with broad spectrum antiviral activity including against Ebola. To date, BCX4430 has shown efficacy in animal infection models for Ebola and Marburg viruses. A Phase I trial is expected to begin in early 2015.

• Another drug, AVI-7537, developed by Sarepta Therapeutics in Boston, has likewise showed promising results in monkeys. However, further tests on this drug were stopped in 2012 due to budget cuts. Between 25 and 150 doses of this drug could be available without further scale-up of production.

(NPR – Sept 30)

REPURPOSING EXISTING TREATMENTS• Avigan (favipiravir) is a viral polymerase inhibitor approved as a

seasonal influenza treatment in Japan. It was used in September to treat a French MSF worker; the patient has been reported stable. If effective against Ebola in trials, its developer Fujifilm Corporation reports it may have enough doses for 20,000 patients.

• A clinic in Liberia has reported empirical use of the antiretroviral drug lamivudine, with good outcomes in 13 of 15 Ebola patients. The NIH is now investigating lamivudine and other nucleoside analogs.

(Bloomberg – Sept 29 ; WP – Oct 2)

OVERVIEWAt of this writing, a few candidate drugs are ramping up efforts for Phase I trials. Use of unproven drugs is permitted on an experimental basis during the epidemic, however drug availability remains miniscule.

EXPERIMENTAL THERAPIESCONVALESCENT TREATMENTS• Convalescent therapies involve transfusion of antibody-containing blood

products from patients who have recovered from Ebola virus into acutely ill patients in the early stages of the disease.

• They have been used in a few patients, including two American doctors who recovered and were declared free of disease. However, the numbers are too small to support any conclusions about efficacy. In the case of the American patients, results are confounded by multiple treatments and the additional supportive care after evacuation to the US.

• The WHO has issued an interim guidance document on the use of convalescent whole blood or plasma collected from patients recovered from Ebola virus disease as an empirical treatment option.

• However, there remain major questions regarding the safety and efficacy of convalescent therapies, and the feasibility of their scale-up in countries with shattered health systems and an acute shortage of medical staff.

• In particular, blood product immunological compatibility and infection control are the greatest obstacles to broader use of this treatment modality. Further difficulties will include safe collection, storage, and distribution of blood products. WHO – Sept 26)

PLANS FOR CLINICAL TRIALS• In September, the Gates Foundation announced a $50 million

commitment in support of large-scale emergency efforts to contain the Ebola epidemic. The funding is to be divided between public health and medical relief efforts in affected areas, education, vaccine research, and development of therapeutics.

• The Wellcome Trust is providing a further £3.2 million in grants to multiple partners to quickly establish clinical trials at existing Ebola treatment centers. Partners include the International Severe Acute Respiratory and Emerging Infections Consortium (ISARIC), the University of Oxford, Médecins Sans Frontières (MSF), the World Health Organization (WHO), Institut Pasteur, Fondation Mérieux, and the Global Health Network.

(Forbes – Sept 25; Wellcome Trust – Sept 23)

ETHICS AND OVERSIGHT• Since August, a group of experts convened by the WHO agreed that the

use of experimental medicines and vaccines is ethically permissible under the exceptional circumstances of the Ebola epidemic.

• The WHO will facilitate access to the treatments, rapid ethical review, and implementation of clinical trials, in a way that is acceptable and coordinated with national governments and local communities.

• Organizations with long-standing experience in the area and existing treatment facilities, such as MSF, will continue to play a key role in scaling up of efforts for treatment and containment of the epidemic.

• It is likely that decisions on prioritization of treatment will continue to evolve as treatment and prevention options become available.

(WHO Sept 26; Wellcome Trust – Sept 23)

MSF treatment center near Monrovia (NPR – Sept 30)

PROJECTIONS

• Epidemiologists tracking the spread of Ebola virus disease are increasingly convinced that the current epidemic in West Africa has been growing exponentially for at least 16 weeks, since May 2014 . The number of new cases has been doubling every 20-30 days.

• Epidemiologists at WHO headquarters in Geneva undertook a major re-assessment of all reported data coming from all sources at all outbreak sites. Though confidence in data being reported by Guinea is good, other significant problems were identified.

• In Liberia, for example, data were being reported from 4 different and uncoordinated streams, resulting in several overlaps and duplicated numbers. In other cases, a backlog of unreported cases was detected, thus creating a distorted picture of how the outbreak has been evolving. Many cases and deaths were not being properly registered on standard reporting forms.

• These problems have now been corrected. The results of this data clean-up and re-analysis were published online in the New England Journal of Medicine (23 SEP).

• Nearly 1000 new cases were reported in the week ending 14 September alone – certainly an underestimate of the true burden of disease. If the present rate of increase continues – if nothing is done to intervene – somewhere between 2500 (black line) and 5000 cases (blue line) will occur, each week, just four weeks from now. Affected countries could be seeing more than 10 000 cases weekly by mid-November (GAR - 22 SEP)

Notwithstanding the geographic variation in case incidence within and among Guinea, Liberia, and Sierra Leone, the current epidemiologic outlook is bleak. Forward projections suggest that unless control measures — including improvements in contact tracing, adequate case isolation, increased capacity for clinical management, safe burials, greater community engagement, and support from international partners — improve quickly, these three countries will soon be reporting thousands of cases and deaths each week, projections that are similar to those of the Centers for Disease Control and Prevention. New England Journal of Medicine (23 SEP).