Communicable diseases control special campaign-Training to SHG Volunteers

മഴക്കാല പൂര്‍വ്വ ശുചീകരണപ്രവര്‍ത്തനങ്ങളുടെ ഉദ്ഘാടനം  ബഹുമാനപ്പെട്ട ഏറ്റുമാനൂര്‍ നിയജക മണ്ഡലം  എം,എല്‍ .എ. ശ്രീ.സുരേഷ്കുറുപ്പ് അവര്‍കള്‍ നിവ്വഹിച്ചു 

HINI INFLUENZA

DON'T HAVE TO BE PANIC BUT'VE TO TAKE CARE

ABC GUIDELINES

Category A- mild fever plus cough / sore throat with or without body ache, headache, diarrhoea and
vomiting
--No Oseltamivir required
--Symptomatic treatment
--Good supportive measures
 Plenty of warm nourishing oral fluids,
 Good food intake
 Complete rest
Category-B
(Bi) Category-A plus high grade fever and severe sore throat
        ---Home isolation
        ---Oseltamivir to be started as per clinical assessment;
(Bii) Category- Any mild ILI in people with co-morbidities
 Pregnant women
 Lung/ heart / liver/ kidney / neurological disease, blood disorders/ diabetes/ cancer /HIVAIDS
 On long term steroids
 Children -- mild illness but with predisposing risk factors.
 Age 65 years+.
        ----Start Oseltamivir immediately
        ----Self isolation at home, and telephone follow up for the next 2-3 days
        ----Any suggestion of deterioration/ failure to improve?-- report in person stat.
Category-C
 · Breathlessness, chest pain, drowsiness, fall in blood pressure, haemoptysis, cyanosis
 · Children with ILI (influenza like illness) with red flag signs
 (Somnolence, high/persistent fever, inability to feed well, convulsions, dyspnoea
/respiratory distress, etc).
 · Worsening of underlying chronic conditions.
     -------Hospitalization stat
     -------Start Oseltamivir immediately, without waiting for test results
     -------Intensive supportive management is usually necessary.
Pregnancy is an extreme high risk category
Any Influenza Like Illness (ILI) in pregnancy (both antenatal and post natal) – suspect H1N1, START OSELTAMIVIR IMMEDIATELY
Early referral to appropriate centre to start Oseltamivir / If any delay in transit expected, start Oseltamivir, then refer.
Oseltamivir in pregnancy is considered sa

 H1N1 TESTING

ILI- Cat- A- No testing needed
ILI -Cat-B- No testing for Category-B (i) and (ii)
Cat-C- Test may be needed**, but do not wait for test results .
** (Sentinel type Testing now needs to be done only for epidemiological purposes, eg.- unusual in presentation, failure to respond even after 5 days extension of Oseltamivir therapy, institutional spread, etc)
If testing is indicated -
Contact your hospital Nodal MO, DSO / Nodal MO of District Hospital
Specimen required - 1 throat swab and 1 nasal swab, using Dacron swab, and immersed in VTM (Viral Transport Medium) tube, immediately put in cold chain/ refrigerated till dispatch at 2-8 deg C .
Testing centres – Three** authorized testing centres for Kerala,
1. Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram,
2.Virology Division, MCVR, KMC Hospital, Manipal, Karnataka State.
3. NIV Unit, Medical College, Alappuzha
Chemoprophylaxis to family, school and social contacts of a positive case-
 No mass contact prophylaxis advised
 For those with high risk Eg. pregnancy/ diabetes/ Asthma/immuno-suppressed/ very low or high age-- Start OD dose Oseltamivir x 10 days
 Others – assess category, if and when symptomatic, then treat as per ABC guidelines
Oseltamivir dosage schedule
 Dose for treatment is as follows:
 By Weight:
- For weight <15kg 30 mg BD for 5 days
- 15-23kg 45 mg BD for 5 days
- 24-<40kg 60 mg BD for 5 days
- >40kg 75 mg BD for 5 days
 For infants:
- < 3 months 12 mg BD for 5 days
- 3-5 months 20 mg BD for 5 days
- 6-11 months 25 mg BD for 5 days
- It is also available as syrup (12mg per ml )
- If needed dose & duration can be modified as per clinical condition.
- In case suspension is not in stock, the contents of the capsule can be divided and administered in powdered sugar, sugar syrup, or honey.
-
***Dose by weight for chemoprophylaxis (only in special circumstances-see section 2) is similar, except that it is Once daily, for 10 days

                          PULSE POLIO IMMUNIZATION

Poliomyelitis---The words polio (grey) and myelon (marrow, indicating the spinal cord) are derived from the Greek. It is the effect of poliomyelitis virus on the spinal cord that leads to the classic manifestation of paralysis. Poliomyelitis or poliio is a crippling and potentially deadly infectious disease caused by poliovirus that spreads from person to person invading the brain and spinal cord resulting into paralysis. Humans are the only known reservoir of poliovirus, which is transmitted most frequently by persons having infection.Due to unavailability of any cure till date vaccination is the best way of protection and the only way to control the spread of disease.Generally ,two basic patterns of polio infection are :

• Minor illness which does not involve the central nervous system (CNS), sometimes called abortive poliomyelitis,
• A major illness involving the CNS, which may be paralytic or nonparalytic

Poliomyelitis generally spreads via the fecal-oral route by ingesting contaminated food or water and the oral-oral  route. In endemic areas, polioviruses can affect the entire human population. The disease has a seasonal transmission in temperate climates, with a peak occurrence during summer and autumn.

With the global initiative of eradication of polio in 1988 following World Health Assembly resolution in 1988, Pulse Polio Immunization programme was launched in India in 1995. Children in the age group of 0-5 years administered polio drops during National and Sub-national immunization rounds (in high risk areas) every year. About 172 million children are immunized during each National Immunization Day (NID).

The last polio case in the country was reported from Howrah district of West Bengal with date of onset 13th January 2011. Thereafter no polio case has been reported in the country (25th May 2012).

WHO on 24th February 2012 removed India from the list of countries with active endemic wild polio virus transmission.

1.South-East Asia Region of WHO has been certified polio free. The Regional Certification Commission (RCC) on 27th March 2014 issued certificate which states that “The Commission concludes, from the evidence provided by the National Certificate Committees of the 11 Member States, that the transmission of indigenous wild poliovirus has been interrupted in all countries of the Region.”

2. India has achieved the goal of polio eradication as no polio case has been reported for more than 3 years after last case reported on 13th January, 2011.

3. WHO on 24th February 2012 removed India from the list of countries with active endemic wild polio virus transmission

Last Reported Polio Case in Country
Polio Virus Type	Date of last case	Location
P1	13 January 2011	Howrah (Panchla), WB
P2	24 October 1999	Aligarh, UP
P3	22 October 2010	Pakur (Pakur), Jharkhand

Year	Cases of Polio	Number of districts
2005	66	35
2006	676	114
2007	874	99
2008	559	90
2009	741	56
2010	42	17
2011	01	1
2012	0	0
2013	0	0
2014	0	0

AVIAN  FLUE  SURVEILLANCE ACTIVITIES 

 CENTRAL TEAM & DMO

           at KUMARAKOM on 4/12/2014 

Key facts

• Avian influenza (AI), commonly called bird flu, is an infectious viral disease of birds.
• Most avian influenza viruses do not infect humans; however some, such as A(H5N1) and A(H7N9), have caused serious infections in people.
• Outbreaks of AI in poultry may raise global public health concerns due to their effect on poultry populations, their potential to cause serious disease in people, and their pandemic potential.
• Reports of highly pathogenic AI epidemics in poultry, such as A(H5N1), can seriously impact local and global economies and international trade.
• The majority of human cases of A(H5N1) and A(H7N9) infection have been associated with direct or indirect contact with infected live or dead poultry. There is no evidence that the disease can be spread to people through properly cooked food.
• Controlling the disease in animals is the first step in decreasing risks to humans.

Avian influenza (AI) is an infectious viral disease of birds (especially wild water fowl such as ducks and geese), often causing no apparent signs of illness. AI viruses can sometimes spread to domestic poultry and cause large-scale outbreaks of serious disease. Some of these AI viruses have also been reported to cross the species barrier and cause disease or subclinical infections in humans and other mammals.

AI viruses are divided into 2 groups based on their ability to cause disease in poultry: high pathogenicity or low pathogenicity. Highly pathogenic viruses result in high death rates (up to 100% mortality within 48 hours) in some poultry species. Low pathogenicity viruses also cause outbreaks in poultry but are not generally associated with severe disease.

Avian influenza A(H5N1) and A(H7N9) background-The A(H5N1) virus subtype, a highly pathogenic AI virus, first infected humans in 1997 during a poultry outbreak in Hong Kong SAR, China. Since its widespread re-emergence in 2003 and 2004, this avian virus has spread from Asia to Europe and Africa and has become entrenched in poultry in some countries, resulting in millions of poultry infections, several hundred human cases, and many human deaths. Outbreaks in poultry have seriously impacted livelihoods, the economy and international trade in affected countries.

The A(H7N9) virus subtype, a low pathogenic AI virus, first infected 3 humans – 2 residents of the city of Shanghai and 1 resident of Anhui province - in March 2013. No cases of A(H7N9) outside of China have been reported. Containment measures, including the closure of live bird markets for several months, have impacted the agriculture sectors of affected countries and international trade. Continued surveillance for A(H7N9) will be necessary to detect and control the spread of the virus.

Ongoing circulation of A(H5N1) and A(H7N9) viruses in poultry, especially where endemic, continues to pose threats to public health, as these viruses have both the potential to cause serious disease in people and may have the potential to change into a form that is more transmissible among humans. Other influenza virus subtypes also circulate in poultry and other animals, and may also pose potential threats to public health.

Avian influenza A(H5N1) and A(H7N9) infections and clinical features in humans

The case fatality rate for A(H5N1) and A(H7N9) virus infections in people is much higher compared to that of seasonal influenza infections. The A(H7N9) virus particularly affects people with underlying medical conditions.

Clinical features---------In many patients, the disease caused by the A(H5N1) virus follows an unusually aggressive clinical course, with rapid deterioration and high fatality. Like most emerging disease, A(H5N1) influenza in humans is not well understood.

The incubation period for A(H5N1) avian influenza may be longer than that for normal seasonal influenza, which is around 2 to 3 days. Current data for A(H5N1) infection indicate an incubation period ranging from 2 to 8 days and possibly as long as 17 days. Current data for A(H7N9) infection indicate an incubation period ranging from 2 to 8 days, with an average of five days.¹ WHO currently recommends that an incubation period of 7 days be used for field investigations and the monitoring of patient contacts.Initial symptoms include high fever, usually with a temperature higher than 38°C, and other influenza-like symptoms (cough or sore throat). Diarrhea, vomiting, abdominal pain, chest pain, and bleeding from the nose and gums have also been reported as early symptoms in some patients.

One feature seen in many patients is the development of lower respiratory tract early in the illness. Respiratory distress, a hoarse voice, and a crackling sound when inhaling are commonly seen. Sputum production is variable and sometimes bloody.²Complications of A(H5N1) and A(H7N9) infection include hypoxemia, multiple organ dysfunction, and secondary bacterial and fungal infections.³

Antiviral treatment-Evidence suggests that some antiviral drugs, notably oseltamivir, can reduce the duration of viral replication and improve prospects of survival.In suspected cases, oseltamivir should be prescribed as soon as possible (ideally, within 48 hours following symptom onset) to maximize its therapeutic benefits. However, given the significant mortality currently associated with A(H5N1) and A(H7N9) infection and evidence of prolonged viral replication in this disease, administration of the drug should also be considered in patients presenting later in the course of illness. The use of corticosteroids is not recommended.In cases of severe infection with the A(H5N1) or A(H7N9) virus, clinicians may need to consider increasing the recommended daily dose or/and the duration of treatment.In severely ill A(H5N1) or A(H7N9) patients or in patients with severe gastrointestinal symptoms, drug absorption may be impaired. This possibility should be considered when managing these patients.⁴ Moreover, most A(H5N1) and A(H7N9) viruses are predicated to be resistant to adamantine antiviral drugs, which are therefore not recommended for use.

Risk factors for human infection-The primary risk factor for human infection appears to be direct or indirect exposure to infected live or dead poultry or contaminated environments, such as live bird markets. Controlling circulation of the A(H5N1) and A(H7N9) viruses in poultry is essential to reducing the risk of human infection. Given the persistence of the A(H5N1) and A(H7N9) viruses in some poultry populations, control will require long-term commitments from countries and strong coordination between animal and public health authorities.There is no evidence to suggest that the A(H5N1)and A(H7N9) viruses can be transmitted to humans through properly prepared poultry or eggs. A few A(H5N1) human cases have been linked to consumption of dishes made of raw, contaminated poultry blood. However, slaughter, defeathering, handling carcasses of infected poultry, and preparing poultry for consumption, especially in household settings, are likely to be risk factors.

Human pandemic potential-Influenza pandemics (outbreaks that affect a large proportion of the world due to a novel virus) are unpredictable but recurring events that can have health, economic and social consequences worldwide. An influenza pandemic occurs when key factors converge: an influenza virus emerges with the ability to cause sustained human-to-human transmission, and the human population has little to no immunity against the virus. With the growth of global trade and travel, a localized epidemic can transform into a pandemic rapidly, with little time to prepare a public health response.The A(H5N1) and A(H7N9) AI viruses remain two of the influenza viruses with pandemic potential, because they continue to circulate widely in some poultry populations, most humans likely have no immunity to them, and they can cause severe disease and death in humans.

However, whether the influenza A(H7N9) virus could actually cause a pandemic is unknown. Experience has shown that some animal influenza viruses that have been found to occasionally infect people have not gone on to cause a pandemic while others have done so. Surveillance and the investigations now underway will provide some of the information needed to make this determination.

In addition to A(H5N1) and A(H7N9), other animal influenza virus subtypes reported to have infected people include avian H9, and swine H1 and H3 viruses. H2 viruses may also pose a pandemic threat. Therefore, pandemic planning should consider risks of emergence of a variety of influenza subtypes from a variety of sources.

LEFT FOR HER ETERNAL REST ON 17/11/2014

                        ആദരാഞ്ജലികള്‍

HIV pandemic's origins located: It may have emerged in Congo in 1920s?

Scanning electron micrograph of an HIV-infected H9 T cell. Credit: NIAID

The HIV pandemic with us today is almost certain to have begun its global spread from Kinshasa, the capital of the Democratic Republic of the Congo (DRC), according to a new study.

An international team, led by Oxford University and University of Leuven scientists, has reconstructed the genetic history of the HIV-1 group M pandemic, the event that saw HIV spread across the African continent and around the world, and concluded that it originated in Kinshasa. The team's analysis suggests that the common ancestor of group M is highly likely to have emerged in Kinshasa around 1920 (with 95% of estimated dates between 1909 and 1930).

HIV is known to have been transmitted from primates and apes to humans at least 13 times but only one of these transmission events has led to a human pandemic. It was only with the event that led to HIV-1 group M that a pandemic occurred, resulting in almost 75 million infections to date. The team's analysis suggests that, between the 1920s and 1950s, a 'perfect storm' of factors, including urban growth, strong railway links during Belgian colonial rule, and changes to the sex trade, combined to see HIV emerge from Kinshasa and spread across the globe.

A report of the research is published in this week's Science.

'Until now most studies have taken a piecemeal approach to HIV's genetic history, looking at particular HIV genomes in particular locations,' said Professor Oliver Pybus of Oxford University's Department of Zoology, a senior author of the paper. 'For the first time we have analysed all the available evidence using the latest phylogeographic techniques, which enable us to statistically estimate where a virus comes from. This means we can say with a high degree of certainty where and when the HIV pandemic originated. It seems a combination of factors in Kinshasa in the early 20th Century created a 'perfect storm' for the emergence of HIV, leading to a generalised epidemic with unstoppable momentum that unrolled across sub-Saharan Africa.'

'Our study required the development of a statistical framework for reconstructing the spread of viruses through space and time from their genome sequences,' said Professor Philippe Lemey of the University of Leuven's Rega Institute, another senior author of the paper. 'Once the pandemic's spatiotemporal origins were clear they could be compared with historical data and it became evident that the early spread of HIV-1 from Kinshasa to other population centres followed predictable patterns.'

BIO MEDICAL WASTE MANAGEMENT

                         
                         WELCOME SIR,

WARM WELCOME TO OUR UNION HEALTH MINISTER TO GOD'S OWN COUNTRY

West Africa - Ebola virus disease

2014 Ebola Virus Disease (EVD) outbreak in West Africa

Travel and transport risk assessment: Recommendations for public health authorities and transport sector

---

1. Summary of epidemiological facts and experience

• The incubation period of Ebola virus disease (EVD) varies from 2 to 21 days. Person-to-person transmission by means of direct contact with infected persons or their body fluids/secretions is considered the principal mode of transmission. In a household study, secondary transmission took place only if direct physical contact occurred. No transmission was reported without this direct contact. Airborne transmission has not been documented during previous EVD outbreaks.
• There is no risk of transmission during the incubation period and only low risk of transmission in the early phase of symptomatic patients. The risk of infection during transport of persons can be further reduced through use of infection control precautions (see paragraphs 3.2 and 3.3).
• In the current outbreak, infected travellers have crossed land borders with neighbouring countries and there is a possibility that other cases might occur in neighbouring countries.
• Historically, several cases of haemorrhagic fever (Ebola, Marburg, Lassa, Crimean Congo haemorrhagic fever) disease were diagnosed after long distance travel but none developed the symptoms during the international travel. Long-distance travellers (e.g. between continents) infected in affected areas could arrive while incubating the disease and develop symptoms compatible with EVD, after arrival.

2. Risk of EVD for different groups

2.1. Tourists and businessmen/women returning from affected areas in a country

The risk of a tourist or businessman/woman becoming infected with Ebola virus during a visit to the affected areas and developing disease after returning is extremely low, even if the visit included travel to the local areas from which primary cases have been reported. Transmission requires direct contact with blood, secretions, organs or other body fluids of infected living or dead persons or animal, all unlikely exposures for the average traveller. Tourists are in any event advised to avoid all such contacts.

2.2. Visiting families and relatives

The risk for travellers visiting friends and relatives in affected countries is similarly low, unless the traveller has direct physical contact with a sick or dead person or animal infected with Ebola virus. In such a case, contact tracing should confirm the exposure and prevent further spread of the disease through monitoring the exposed traveller.

2.3. Patients travelling with symptoms and fellow travellers

There is a possibility that a person who had been exposed to Ebola virus and developed symptoms may board a commercial flight, or other mode of transport, without informing the transport company of his status. It is highly likely that such patients would seek immediate medical attention upon arrival, especially if well informed, and then should be isolated to prevent further transmission. Although the risk to fellow travellers in such a situation is very low, contact tracing is recommended in such circumstances.

2.4. Risk for health care workers posted in affected areas

There is a risk for healthcare workers and volunteers, especially if involved in caring for EVD patients. However, if the recommended level of precaution for such settings is implemented, transmission of the disease should be prevented. The risk level can be considered very low to low unless these precautions are not followed, e.g. no personal protective equipment, needle stick injury etc.

3. Recommendations for public health authorities and transport sectors

3.1. Recommendations for countries

3.1.1. Raise the awareness and knowledge of travellers

Travellers leaving for or arriving in an area where EVD is occurring should be provided at points of entry (e.g. in airports or ports on boarding or arrival areas or at ground crossing points) with information on the potential risk of EVD (see proposed template below). Information should also be spread among communities that may include cross-border travellers and near all relevant international borders.

The information provided should emphasize that travellers or residents in the affected areas of countries can minimize any risk of getting infected if they avoid:

• Contact with blood or bodily fluids of a person or corpse infected with the Ebola virus.
• Contact with or handling of wild animals, alive or dead or their raw or undercooked meat.
• Having sexual intercourse with a sick person or a person recovering from EVD for at least 7 weeks.
• Having contact with any object, such as needles, that has been contaminated with blood or bodily fluids.

Travellers should be informed where to obtain medical assistance at the destination and who to inform (e.g. through hotline telephone numbers).

Returning visitors from the affected areas should be alerted that if they develop infectious disease symptoms (such as fever, weakness, muscle pain, headache, sore throat, vomiting, diarrhoea, rash, or bleeding) within three weeks after return or if they suspect that they have been exposed to Ebola virus (e.g. volunteers who worked in healthcare settings) in the affected areas, they should seek rapid medical attention and mention their recent travel to the attending physician.

Template message for travellers and EVD

• Ebola Virus Disease is rare.
• Infection is by contact with blood or body fluids of an infected person or an animal infected or by contact with contaminated objects.
• Symptoms include fever, weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhoea, rash, and in some cases, bleeding.
• Cases of Ebola have recently been confirmed in XXX and YYY.
• Persons who come into direct contact with body fluids of an infected person or animal are at risk.
• There is no licenced vaccine.
• Practice careful hygiene.
• Avoid all contact with blood and body fluids of infected people or animals.
• Do not handle items that may have come in contact with an infected person’s blood or body fluids.
• If you stayed in the areas where Ebola cases have been recently reported seek medical attention if you feel sick ( fever, headache, achiness, sore throat, diarrhoea, vomiting, stomach pain, rash, or red eyes).

3.1.2. Raise the awareness and knowledge of health care providers

Health care providers managing returning travellers need to question them on travel history and consider the possibility of EVD in person coming back from affected areas. A person suspected of having been exposed to Ebola virus should be evaluated regarding the risk of exposure .

If the risk of exposure is considered very low, the person should be reassured, asked to monitor his/her temperature and symptoms for 21 days and seek immediately care if developing symptoms. Other pathologies (e.g. malaria) should be investigated and the patient monitored regularly. Admission to hospital in these observation phases is not necessary.

Essential information to be provided to health care providers should include the following:

• The most common symptoms experienced by persons infected with the virus are the sudden onset of fever, intense weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and at advanced stage, both internal and external bleeding. Laboratory findings include low white blood cells and platelet counts and elevated liver enzymes.
• The incubation period (interval from infection to onset of symptoms) varies between 2 to 21 days.
• People are infectious as long as their blood and secretions contain the virus. Men who have recovered from the disease can still transmit the virus through their semen for up to seven weeks after recovery from illness.
• Malaria, typhoid fever, shigellosis, leptospirosis, yellow fever, dengue and other viral haemorrhagic fevers are differential diagnoses to consider in these patients.
• If the risk of exposure is deemed high, (e.g. a healthcare worker having experienced a needle stick injury with a potentially contaminated needle) a transfer to a specialized centre should be considered.
• More information can be obtained at:
  • Disease Outbreak News (DON) on Ebola
  • Ebola virus disease fact sheet

3.1.3. Prepare health system response

In anticipation of EVD introduction, public health authorities need to:

• Sensitise staff working at “points of entry”, in healthcare settings or involved in first response (emergency departments, ambulance services, GP offices, fire department, civil defence, airport operators, aircraft operators, port health authority) for early and advanced symptoms of viral haemorrhagic fever.
• Emphasize systematic recording in health clinics of travel history of those with relevant symptoms.
• Establish a standard diagnostic procedure for EVD and for common differential diagnoses at an early stage (e.g. malaria, dengue, typhoid fever, shigellosis, cholera, leptospirosis, plague, rickettsiosis, relapsing fever, meningitis, hepatitis, yellow fever and other viral haemorrhagic fevers).
• Establish a protocol for notification to the competent public health authorities at an early stage if an EVD case is suspected.
• Identify and establish laboratory procedures and operational channels to perform Ebola virus diagnostic testing in the country or refer to the closest WHO Collaborating Centre or reference laboratories able to perform viral haemorrhagic fever diagnostics if cases are suspected.
• Ensure basic training of health care workers on principles of provisional barrier and use of personal protective equipment.
• Emphasize to personnel working in the travel sector the importance of infection control methods.
• Keep the regulatory authorities (e.g. national civil aviation authority) informed and involved in decision-making.

If a case of EVD is suspected in a traveller, health care facilities attending the individual should apply the same procedures as if the EVD has already been confirmed. This includes:

• Implementing contact tracing among staff and patients who have been in direct contact with the suspected patient.
• Setting up medical monitoring of identified contacts (fever and prodromal symptoms);
• Notifying immediately to the competent public health authorities.
• Ensuring barrier management in all areas where the suspected patient has been treated (contaminated zone, transition or sluicing zone, “clean” zone).
• Retaining waste and any type of body fluids from patient’s side in the contaminated zone until appropriate decontamination and disposal provisions are in place.
• Handling and shipping patient’s samples according to the international procedures for “transport of category A infectious substances”.

Suspect cases coming from areas affected (e.g. returning travellers with symptoms) identified on an aircraft) should immediately receive medical attention and be isolated to prevent further transmission (see 3.2).

3.1.4. Screening passengers at points of entry ( ports , airports or ground crossing) is not recommended

Screening of passengers at points of entry (arrival or departure) is costly and expected to have very limited impact because it is very unlikely to detect any arriving person infected with EVD. This is particularly true for EVD with its incubation period of 2 to 21 days and symptoms that are not specific. As part of this, the use of thermal scanners that rely on the presence of ‘fever’ in arriving passengers is costly, unlikely to detect any arriving person infected with EVD and is not encouraged.

Travel restrictions, closure of borders at points of entry are not recommended

3.2. Recommendations for international air transport

In case of a passenger presenting with symptoms compatible with EVD (fever, weakness, muscle pain, headache, sore throat, vomiting, diarrhoea, bleeding) on board of an aircraft, the following measures should be immediately considered, in accordance with operational procedures recommended by the International Air Transport Association (IATA):

• Distancing of other passengers if possible from the symptomatic passenger (re-seating); with the ill travellers preferably near a toilet, for his/her exclusive use.
• Covering nose and mouth of the patient with a surgical facemask (if tolerated).
• Limiting contacts to the passenger to the minimum necessary. More specifically, only one or two (if ill passenger requires more assistance) cabin crew should be taking care of the ill passenger and preferably only the cabin crew that have already been in contact with that passenger. This cabin crew should be using the Universal Precaution Kit (see below).
• Hand washing with soap after any direct or indirect contact with the passenger.
• Immediate notification of authorities at the destination airport in accordance with procedures promulgated by the International Civil Aviation Organization (ICAO).
• Immediate isolation of passenger upon arrival.

Dedicated crew member to assist the ill traveller, should be using suitable personal protection equipment (PPE) such as that recommended by ICAO Universal Precaution Kit (http://www.capsca.org/CAPSCARefs.html) for dealing with the traveller and for cleaning procedures on board as needed.

The possibility of transmission to other co-passengers and crew on board the aircraft should be assessed by health care providers on arrival. If the investigation concludes that the passenger has symptoms compatible with EVD and had a risk exposure in affected countries in the past 21 days, passengers as well as crew members may be at risk if they have been in direct contact with body fluids or heavily contaminated objects.

The following epidemiological measures based upon proximity to the index patient should be considered:

• Passengers and crew with reported direct contact 
  To gather this information, any records of significant events on the flight should be obtained from the airline. Co-travellers and crew members who report direct body contact with the index case should undergo contact tracing.
• Passengers seated in an adjacent seat to the index patient
  As direct contact is the main route of transmission for Ebola virus, only passengers who were seated in an adjacent seat to the index case on the side, in front or behind, including across an aisle, should be included in contact tracing.
• Cleaning staff of affected aircraft section
  If the case is suspected or diagnosed after leaving the aircraft, the staff who cleaned the section and seat where the index case was seated should also undergo contact tracing.

At the request of airport or port health authority, airlines may also ask some or all passengers to provide information on their itinerary and their contact details where there is a particular reason to believe they may have been exposed to infection on board of aircraft (e.g. per the ICAO public health passenger locator form)1. Additionally, countries may consider requiring arriving aircraft to complete and deliver the health part of the aircraft general declaration (in those cases where the information is not communicated to the airport of arrival while in flight) concerning persons on board with communicable diseases or sources of infection (IHR Annex 9).

Passengers, crew members and cleaning staff who have been identified through contact tracing should be assessed for their specific level of exposure. Passive self-monitoring of temperature (e.g. monitoring temperature only if feeling feverish) and symptoms or active self-monitoring (e.g. by regular temperature measurement twice a day) for those at higher risk level should be continued for 21 days.

These measures should also be considered if an individual, who experienced symptoms during the flight, has been identified as a suspect of EVD after arrival.

References

• IATA guidelines for air crew to manage a suspected communicable disease or other public health emergency on board
• IATA guideline for cleaning crew for an arriving aircraft with a suspected case of communicable disease
• ICAO Health related documents (1) Procedures for Air Navigation Services; (2) Annex 6 – Medical Supplies
• WHO Aviation Guide which includes information on sanitizing of aircraft

3.3. Recommendations for ships

In case of a passenger presenting with symptoms compatible with EVD (fever, weakness, muscle pain, headache, sore throat, vomiting, diarrhoea, bleeding) on board of a ship, the following precautions must be applied:

• Keep his/her cabin doors closed, if not placed in an medical isolation room on board.
• Provide information about the risk of Ebola transmission to persons who will take care of the patient or enter the isolation area.
• A log listing all people entering the cabin should be maintained.
• Anyone who enters the cabin to provide care to the person in isolation or to clean the cabin must wear PPE with :
• A surgical protection mask; and eye protection or a face shield
• Non-sterile examination gloves or surgical gloves;
• Disposable impermeable gown to cover clothing and exposed skin. A waterproof apron should be worn over a non-impermeable gown or when coming in close contact with the person in isolation
• Before exiting the isolation the PPE should be removed in such a way as to avoid contact with the soiled items and any area of the face.
• Limit the movement and transport of the patient from the cabin for essential purposes only. If transport is necessary, the patient should wear a surgical mask.
• Clean and disinfect spills without spraying or creating aerosol. Used linen, cloths, eating utensils laundry and any other item in contact with a patient’s body fluids should be collected separately and disinfected in such a way as to avoid any creation of aerosol or any contact with persons or contamination of the environment. Effective disinfectant is a dilution of sodium hypochlorite at 0.05 or 500 ppm available chlorine, with a recommended contact time of 30 minutes.
• All waste produced in the isolation cabin must be handled according to the protocol of the ship for clinical waste. If incinerator is available on board, then waste must be incinerated. If waste must be delivered ashore, then special precautions are needed and the port authority should be informed before waste delivery.
• Start case investigation immediately. Protective equipment is not required when interviewing asymptomatic individuals, when a distance of one metre is maintained.
• Close contacts should be identified and asked to do passive self-monitoring of temperature (e.g. monitoring temperature only if feeling feverish) and symptoms or active self-monitoring (e.g. by regular temperature measurement twice a day and for 21 days.

In the event of a suspected diagnosis of EVD on a ship, immediate expert medical opinion should be sought and the event must be reported as soon as possible to the next port of call by the Captain.

The patient should disembark in such a way as to avoid any contact with healthy travellers and wearing a surgical mask. Personnel in contact with the patient during the medical evacuation should wear a surgical protection mask and PPE.

The competent authority at port may need to arrange depending on the situation: medical evacuation or special arrangements for disembarkation and hospitalization of the patient and laboratory diagnosis.

Passengers, crew members and cleaning staff who have been identified through contact tracing should be assessed for their specific level of exposure. Passive self-monitoring of temperature (e.g. monitoring temperature only if feeling feverish) and symptoms or active self-monitoring (e.g. by regular temperature measurement twice a day) for those at higher risk level should be continued for 21 days.

At the request of a governmental port health authority, ship operators shall also facilitate obtaining, from some or all passengers, to provide information on their itinerary and their contact details (should they need to be contacted) when there is a particular reason to believe they may have been exposed to infection on board of the ship. Additionally, countries may consider requiring arriving ships to complete and deliver the Maritime Declaration of Health (IHR Annex 8). Measures taken on board should also be noted on the IHR Ship sanitation control certificate (IHR Annex 3