CRS: Ebola Outbreak – Quarantine v. Isolation, Travel Restrictions, Select Legal Issues

— Domani Spero
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On October 25, WaPo reported that the governors of New York Andrew Cuomo and New Jersey Gov. Chris Christie ordered on Friday the imposition of a mandatory 21-day quarantine for medical workers returning from the countries hit hardest by the ebola epidemic. Illinois later in the day imposed similar restrictions. Today, NYT reported that the Obama administration has expressed deep concerns to the governors and is consulting with them to modify their orders to quarantine medical volunteers returning from West Africa.

Ebola CRS report via Secrecy News (pdf):

On August 8th, the World Health Organization declared the outbreak of the Ebola Virus Disease in West Africa a Public Health Emergency of International Concern. The recent arrival in the United States of several health care workers who contracted the disease, combined with the first diagnosis of a case in the U.S. at a hospital in Dallas, has sparked discussion about the appropriate government response. Aside from the various policy considerations at issue, the outbreak has generated several legal questions about the federal government’s authority to restrict specific passengers’ travel and/or contain the outbreak of an infectious disease. These questions include, inter alia, whether the federal government may: (1) restrict which countries U.S. nationals may travel to in the event of a public health crisis; (2) bar the entry into the United States of people who may have been infected by a disease; and (3) impose isolation or quarantine measures in order to control infectious diseases.

Passport restrictions on which countries U.S. citizens may visit can be imposed by the Secretary of State. Pursuant to the Passport Act, the Secretary of State may “grant and issue passports” according to rules designated by the President, and may impose restrictions on the use of passports to travel to countries “where there is imminent danger to the public health or the physical safety of United States travellers” (sic). The Supreme Court has recognized that the authority to “grant and issue” passports includes the power to impose “area restrictions” – limits on travel to specific countries (restrictions must comply with the Due Process Clause of the Constitution). Although passport restrictions are not criminally enforceable, they may prevent travelers from boarding a flight to a restricted area.

Restrictions may also be imposed on who may enter the United States, though the range of applicable restrictions may differ depending upon whether a person seeking entry into the country is a U.S. national. The government enjoys authority under federal immigration law to bar the entry of a foreign national on specific health-related grounds, including when a particular foreign national is determined to have a “communicable disease of public health significance.” More broadly, section 212(f) of the Immigration and Nationality Act authorizes the President, pursuant to proclamation, to direct the denial of entry to any alien or class of aliens whose entry into the country “would be detrimental to the interests of the United States.”

These restrictions do not apply to U.S. citizens, who may enjoy a constitutional right to reenter the country. Nonetheless, certain travel restrictions may impede the ability of any person – regardless of citizenship – from traveling to the United States in a manner that potentially exposes others to a communicable disease. For example, airlines flying to the U.S. are permitted under Department of Transportation regulations to refuse transportation to passengers with infectious diseases who have been determined to pose a “direct threat” to the health and safety of others. In making this determination, airlines may rely on directives from the CDC and other government agencies. Pilots of flights to the United States are also required to report certain illnesses they encounter during flight before arrival into the U.S.

In addition, the Department of Homeland Security and Centers for Disease Control and Prevention (CDC) maintain a public health “Do Not Board” (DNB) list, which contains the names of people who are likely to be contagious with a communicable disease, may not adhere to public health recommendations, and are likely to board an aircraft. Airlines are not permitted to issue a boarding pass to people on the DNB list for flights departing from or arriving into the United States. People placed on the DNB list are also “assigned a public health lookout record,” which will alert Customs and Border Protection officers in the event the person attempts to enter the country through a port of entry. The CDC’s Division of Global Migration and Quarantine (DGMQ) can conduct exit screening at foreign airports to identify travelers with communicable diseases and alert the relevant local authorities.

Finally, both federal and state governments have authority to impose isolation and quarantine measures to help prevent the spread of infectious diseases. While the terms are often used interchangeably, quarantine and isolation are actually two distinct concepts. Quarantine typically refers to separating or restricting the movement of individuals who have been exposed to a contagious disease but are not yet sick. Isolation refers to separating infected individuals from those who are not sick. Historically, the primary authority for quarantine and isolation exists at the state level as an exercise of the state’s police power in accordance with its particular laws and policies.

However, the CDC is also authorized to take measures “to prevent the introduction, transmission, or spread of communicable diseases from foreign countries into the States or possessions, or from one State or possession into any other State or possession.” In order to do so, the implementing regulations “authorize the detention, isolation, quarantine, or conditional release of individuals.” This authority is limited to diseases identified by an Executive Order of the President, a list which currently includes Ebola. Whether an isolation or quarantine order originates with the federal or state government, such orders will presumably be subject to habeas corpus challenges, and must also comport with the Due Process Clause of the Constitution.

View the original CRS Legal Sidebar here (pdf) includes active links.

And that legal challenge may soon be upon us. On October 26, Kaci Hickox, a nurse placed under mandatory quarantine in New Jersey, went on CNN on Sunday and criticized the “knee-jerk reaction by politicians” to Ebola.  According to CNN, Hickox, an epidemiologist who was working to help treat Ebola patients in Sierra Leone, has tested negative twice for Ebola and does not have symptoms.  Norman Siegel, Hickox’s attorney, and a former director of the New York Civil Liberties Union told CNN that he will be filing papers in court for Hickox to have a hearing no later than five days from the start of her confinement. Siegel told CNN that Hickox’s quarantine is based on fear.

Here is the link to the Executive Order 13295 of April 4, 2003 cited above by the CRS brief via:

[T]he following communicable diseases are hereby specified pursuant to section 361(b) of the Public Health Service Act:

(a) Cholera; Diphtheria; infectious Tuberculosis; Plague; Smallpox; Yellow Fever; and Viral Hemorrhagic Fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named).

July 31, 2014 Update

“(b) Severe acute respiratory syndromes, which are diseases that are associated with fever and signs and symptoms of pneumonia or other respiratory illness, are capable of being transmitted from person to person, and that either are causing, or have the potential to cause, a pandemic, or, upon infection, are highly likely to cause mortality or serious morbidity if not properly controlled. This subsection does not apply to influenza.”

A side note, the U.S. Ambassador to the United Nations, Samantha Power is currently traveling to the countries in West Africa hardest hit with the ebola outbreak:

 

 

Now, since Ambassador Power is not a medical worker, she probably will not be subjected to the NJ/NY mandatory quarantine when she gets back. However, on October 22, the Centers for Disease Control and Prevention (CDC) announced that public health authorities will begin active post-arrival monitoring of travelers whose travel originates in Liberia, Sierra Leone, or Guinea.  Active post-arrival monitoring, according to the CDC  means that travelers without febrile illness or symptoms consistent with Ebola will be followed up daily by state and local health departments for 21 days from the date of their departure from West Africa. Except that Ambassador Power’s return trip will not be originating from West Africa but from Belgium, the last stop on this West Africa-Europe trip before returning to the U.S.

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Congressional Research Service (CRS) Reports and Briefs — Published August 2014

— Domani Spero
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Note that some documents are web-accessible but most are in pdf formats.

-08/29/14   Latin America and the Caribbean: Key Issues for the 113th Congress  [598 Kb]
-08/29/14   Organization of American States: Background and Issues for Congress  [433 Kb]
-08/29/14   Special Immigrant Juveniles: In Brief  [317 Kb]
-08/29/14   Taiwan: Major U.S. Arms Sales Since 1990  [646 Kb]
-08/28/14   The “1033 Program,” Department of Defense Support to Law Enforcement  [234 Kb]
-08/28/14   The Islamic State in Syria and Iraq: A Possible Threat to Jordan? – CRS Insights  [84 Kb]
-08/28/14   Unaccompanied Children from Central America: Foreign Policy Considerations  [451 Kb]
-08/27/14   The New START Treaty: Central Limits and Key Provisions  [436 Kb]
-08/27/14   The Quadrennial Diplomacy and Development Review (QDDR)  [53 Kb]
-08/26/14   Conventional Prompt Global Strike and Long-Range Ballistic Missiles: Background and Issues  [452 Kb]
-08/26/14   NATO’s Wales Summit: Expected Outcomes and Key Challenges  [317 Kb]
-08/26/14   The 2014 Ebola Outbreak: International and U.S. Responses  [625 Kb]
-08/21/14   China’s Economic Rise: History, Trends, Challenges, and Implications for the United States  [646 Kb]
-08/20/14   Climate Change and Existing Law: A Survey of Legal Issues Past, Present, and Future  [514 Kb]
-08/20/14   The “Militarization” of Law Enforcement and the Department of Defense’s “1033 Program” – CRS Insights  [66 Kb]
-08/19/14   Cuba: U.S. Restrictions on Travel and Remittances  [504 Kb]
-08/19/14   Iran Sanctions  [709 Kb]
-08/15/14   Domestic Terrorism Appears to Be Reemerging as a Priority at the Department of Justice – CRS Insights  [97 Kb]
-08/15/14   Latin America: Terrorism Issues  [530 Kb]
-08/15/14   Manufacturing Nuclear Weapon “Pits”: A Decisionmaking Approach to Congress [656 Kb]
-08/15/14   Same-Sex Marriage: A Legal Background After United v. Windsor  [234 Kb]
-08/15/14   State, Foreign Operations, and Related Programs: FY2015 Budget and Appropriations  [558 Kb]
-08/14/14   The U.S. Military Presence in Okinawa and Futenma Base Controversy  [654 Kb]
-08/13/14   U.S. – Vietnam Economic and Trade Relations: Issues for the 113th Congress  [408 Kb]
-08/12/14   Iraq: Politics, Governance, and Human Rights  [497 Kb]
-08/08/14   Ebola: 2014 Outbreak in West Africa – CRS In Focus  [243 Kb]
-08/08/14   Iraq Crisis and U.S. Policy  [578 Kb]
-08/08/14   U.S. – Vietnam Nuclear Cooperation Agreement: Issues for Congress  [336 Kb]
-08/07/14   Guatemala: Political, Security, and Socio-Economic Conditions and U.S. Relations [449 Kb]
-08/07/14   India’s New Government and Implications for U.S. Interests  [310 Kb]
-08/07/14   Reducing the Budget Deficit: Overview of Policy Issues  [410 Kb]
-08/07/14   U.S. – EU Cooperation on Ukraine and Russia – CRS Insights  [135 Kb]
-08/06/14   2014 Quadrennial Homeland Security Review: Evolution of Strategic Review – CRS Insights  [243 Kb]
-08/05/14   China Naval Modernization: Implications for U.S. Navy Capabilities – Background and Issues for Congress  [4552 Kb]
-08/05/14   Maritime Territorial and Exclusive Economic Zone (EEZ) Disputes Involving China: Issues for Congress  [1348 Kb]
-08/05/14   Safe at Home? Letting Ebola-Stricken Americans Return – CRS Insights  [195 Kb]
-08/04/14   Indonesia’s 2014 Presidential Election – CRS Insights  [55 Kb]
-08/01/14   “Womenomics” in Japan: In Brief  [232 Kb]
-08/01/14   Gun Control Legislation in the 113th Congress  [539 Kb]
-08/01/14   Turkey: Background and U.S. Relations  [907 Kb] 

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State Dept Awards $4.9 Million Contract to Phoenix Air for Air Ambulance Evacuation #Ebola

Domani Spero
[twitter-follow screen_name=’Diplopundit’ ]

 

Yahoo News reported on September 9 that “an undisclosed number of people who’ve been exposed to the Ebola virus — not just the four patients publicly identified with diagnosed cases — have been evacuated to the U.S. by an air ambulance company contracted by the State Department.”  The report identified Phoenix Air Group as the provider of the air ambulance services. The VP of the company said medical privacy laws and his company’s contract with the State Department prevented him from revealing how many exposed patients have been flown from West Africa to the U.S.  He did tell the reported that Phoenix Air has flown 10 Ebola-related missions in the past six weeks. The report also says that the State Department confirmed the four known Ebola patient transports but couldn’t provide details on any exposure evacuations to the United States.  An unnamed State Department official told Yahoo News that “every precaution is taken to move the patient safely and securely, to provide critical care en route, and to maintain strict isolation upon arrival in the United States.”(See Ebola evacuations to US greater than previously known).

Public records indicate that the State Department awarded the air ambulance contract on August 18, 2014.  The sole source contract was awarded to Phoenix Air for a period of six (6) months at an estimated cost of $4,900,000.00 under FAR 6.302-2  for “unusual and compelling urgency.” The services include among others, air ambulance evacuation, a dedicated on-call aircraft and flight crew, an aero-biological containment system, and emergency recall and mission preparedness:

This requirement is in response to Department of State’s diplomatic mission overseas to provide movement of emergency response personnel into and out of hazardous/non-permissive environments and medical evacuation of critically ill/injured patients, including those infected with unique and high contagious pathogens. This is an immediate response to the Ebola Virus Crisis.

The contract justification says that the movement of patients infected with highly contagious pathogens, as with the current Ebola Virus epidemic, requires the use of an air-transportable biocontainment unit. A unit was designed and built by the Center for Disease Control in 2006 in collaboration with the Phoenix Air Group in Cartersville, GA. The Aeromedical Biological Containment Shelter (ABCS) is the only contagious patient airborne transportation system in the world which allows attending medical personnel to enter the containment vessel in-flight to attend to the patient, thus allowing emergency medical intervention such as new IV lines, intubation, etc.

Yes, the Pentagon has a transport tube but —

“The U.S. Department of Defense has a transport “tube” which a patient is placed into, but once sealed inside the patient is isolated from medical care. It is admittedly (by the DOD) more designed for battlefield causalities than live human transport, especially over long distances. It is also only certified for DOD aircraft and not by the FAA for commercial aircraft which makes this capability not feasible in meeting the Department’s urgent need for the capability to transport contagious patients world-wide.”

Why is this a sole-sourced contract?

Below is part of the justification statement extracted from publicly available documents:

As a matter of standard business practice, Phoenix Air Group does not provide chartered transport of highly contagious patients outside of a standing government contract. As the only vendor with this unique capability, Phoenix Air Group has never offered this service on a one-off basis to private of government entities. The capability was developed on a multi-year contract with the CDC (2006-2011). When the CDC could no longer to afford to maintain the stand-by capability, the equipment was warehoused. While it is technically true that the movement of two American citizens in late July, 2014, was a private transaction, those missions were conducted after the Department requested that PAG consider a break in their standard business practice on a humanitarian basis, with the assurance that the USG would make all necessary arrangements for landing clearances, public health integration, decontamination, and provide press guidance. Simply put, the transportation of this type of patient requires too much international and inter-agency coordination, and incurs too much corporate risk, for PAG to provide the service outside the protection of a federal contract to do so.

The U.S. Department of State has always been responsible for the medical evacuation of official Americans overseas, regardless of their USG agency affiliation. Because of the unique severity and scope of the current Ebola outbreak, and the complete lack of host nation infrastructure to support victims of EVD infection, the international community is finding recruitment of professional staff very difficult without being able to articulate a sound medical evacuation plan. To that end, the Governments of Mexico, Japan, the United Kingdom, Canada, and the United Arab Emirates, as well as the World Health Organization and the United Nations, have separately approached PAG to establish exclusive contracts for this limited resource. Had the Department not moved very quickly to establish its own exclusive use contract, our negotiating position would have shifted, placing USG personnel and private citizens at significant risk.

The availability of the PAG resource is thus a foreign policy issue, placing the U.S. Department of State as the logical arbiter of international agreements to assure equitable coverage while protecting U.S. national interests. The Department is moving to establish Title 607 agreements with these and other eligible entities, allowing coordinated sharing of the resource on a cost-reimbursable basis under 22 U SC 2357 authorities.

Private American citizens responding to this crisis would lack the resources to privately contract for this service, even if it were available on the open market. By establishing the contract through the Department, additional options are provided to American Citizen Services, allowing them to structure the funding as a form of repatriation loan. This would be very difficult to do if not for a Department-level contract; by bringing the resource in-house, the money flow remains within the Department, spreading the financial risk across a much larger budgeting pool. Foreign governments are being encouraged to take similar steps with their own private citizens through high level dialogue that is only possible when the Department is in the lead on this issue.

Given recent CDC guidelines for the movement of asymptomatic contacts, an unprecedented level of control and coordination is necessary to move these individuals that, despite not being contagious or even clearly infected, are nonetheless quarantined. The USG is left with only two options in supporting a CDC scientist that has a high risk exposure to an EVD patient — use the PAG capability to fly the person back to the US for observation and optimum care should disease develop, or leave the person in place where no care is available if the disease develops. The question, then, is not how many EVD patients will be moved, but rather how many contacts and EVD patients will be moved across the entire international response population (as many as three per month). Finally, from a pragmatic stand point, given the limited options for movement of even asymptomatic contacts, it has become clear that an international response to this crisis will not proceed if a reliable mechanism for patient movement cannot be established and centrally managed.

The “special missions” G-111 aircraft, what is it?

 The ABCS was certified by the Federal Air Administration (FAA) under a Supplemental Type Certification (STC) for use in an aircraft. The STC further lists only two (2) air- craft by serial number as approved for the installation and operation of the ABCS. Both aircraft are owned and operated by Phoenix Air.

The two aircraft listed by serial number in the STC are “special missions” Gulfstream G-III jets owned and operated by Phoenix Air. There are only three “special missions” G-111 aircraft in the world and Phoenix Air owns and operates all three. These are unique aircraft converted in the Gulfstream Aerospace factory during the original manufacturing assembly line from standard “executive” aircraft to “special missions” aircraft which includes a large cargo door forward of the wing measuring 81.5” wide X 61” high thus allowing the large components of the ABCS to be installed in the aircraft and post-flight decontamination to be performed, each aircraft has a heavy duty cargo floor allowing the ABCS floor attachment system to be installed, and each aircraft is certified at the factory for passenger, cargo or air ambulance operations.

Phoenix Air holds various DOD Civil Aircraft Landing Permits (CALP’s) from all U.S DOD service branches allowing its aircraft to land at all U.S. military bases and facilities worldwide. For security reasons, all medical evacuations of patients with highly contagious pathogens must land at military airfields. Recent experience reinforces the importance of using military airfields, especially OCONUS where the host nation governments have refused to allow the aircraft access to civil airports in the Azores, but have conceded to allow the aircraft to refuel on USMIL airfields in their country.

All Phoenix Air flight and medical personnel have the Commission on Accreditation of Medical Transport Systems (CAMTS) required accreditation and CDC recommended inoculations for air ambulance missions as well as missions into disease~prone areas around the world providing DOS a unique capability that may not be available with other aviation vendors.

 

Unlike the outbreak of the highly pathogenic avian influenza (H5N1) virus and fears of a pandemic in 2007, one thing we haven’t heard this time is  “shelter-in-place.” Back then, Americans abroad were advised to identify local sources of healthcare and prepare to “shelter-in-place” if necessary. “In those areas with potentially limited water and food availability, Americans living abroad are encouraged to maintain supplies of food and water to last at least two and as long as 12 weeks.” We remember thinking then about the embassy swimming pool and wondering how long it would last if city water runs out. Or what happens if a mob comes into the compound in search of food and water.

That does not seem to be the case here. At least, this time, there will be an air ambulance equipped to evacuate  Americans back home should it come to that. Note that the  justification statement does not include details of how much of the cost will be accounted for as part of the repatriation loan program (pdf) for private Americans.

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Freaking out over the disease that’s “coming for us”? Watch this!

 

 

 

 

 

 

 

 

U.S. Embassy Dakar Issues Security Message on Ebola Virus Disease (EVD) in Senegal

— Domani Spero
[twitter-follow screen_name=’Diplopundit’ ]

 

Today, the U.S. Embassy in Dakar issued a security message to U.S. citizens in Senegal concerning the country’s first confirmed case of Ebola Virus Disease (EVD):

On August 29, the Senegalese Minister of Health and Social Action (MOH) announced the country’s first confirmed case of EVD.  At a press conference, the MOH reported that Guinean authorities reached out to Senegalese authorities to advise them about a young Guinean student who is confirmed to have the virus.  The student is currently placed in isolation at a local hospital and is in stable condition.  At this time, there are no other confirmed cases in Senegal. The Department of State is working with the government of Senegal, the World Health Organization (WHO), and the Centers for Disease Control and Prevention (CDC) to monitor the situation.

 

On August 21, the government of Senegal has closed its borders with Guinea. It has also closed air and sea borders for aircraft and ships from Guinea, Sierra Leone, and Liberia.

The State Department has previously issued travel warnings for two countries in the region – Liberia and Sierra Leone– and warned U.S. citizens against non-essential travel to these countries. Due to the lack of available medical resources in these countries and limited availability of medical evacuation options, the U.S. Department of State ordered the departure of family members residing with Embassy staff in Monrovia and in Freetown. (see U.S. Embassy Sierra Leone Now on Ordered Departure for Family Members #Ebola and U.S. Embassy Liberia Now on Ordered Departure For Family Members, New Travel Warning Issued).

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State Dept Issues Travel Alert on Ebola-Related Screening and Travel Restrictions in West Africa

— Domani Spero
[twitter-follow screen_name=’Diplopundit’ ]

 

On August 28, the State Department issued a Travel Alert for screening and restrictions related to the Ebola outbreak in parts of West Africa:

The Department of State alerts U.S. citizens to screening procedures, travel restrictions, and reduced aviation transportation options in response to the outbreak of Ebola Virus Disease in Guinea, Liberia, Nigeria, and Sierra Leone.   This Travel Alert will expire on February 27, 2015.

Due to an outbreak of Ebola Virus Disease (EVD) in the West African nations of Liberia, Guinea, and Sierra Leone, the Centers for Disease Control and Prevention (CDC) issued  Level 3 Travel Warnings for those three countries advising against non-essential travel and provided guidance to reduce the potential for spread of EVD.  The CDC also issued a Level 2 Travel Alert for Nigeria to notify travelers of the Ebola outbreak in that country.  The Bureau of Consular Affairs’ website prominently features an Ebola Fact Sheet and links to the CDC Health Travel Warnings, Travel Alert, and general guidance about Ebola.

The World Health Organization (WHO) and CDC have also published and provided interim guidance to public health authorities, airlines, and other partners in West Africa for evaluating risk of exposure of persons coming from countries affected by EVD.  Measures can include screening, medical evaluation, movement restrictions up to 21 days, and infection control precautions.  Travelers who exhibit symptoms indicative of possible Ebola infection may be prevented from boarding and restricted from traveling for the 21-day period.  Please note neither the Department of State’s Bureau of Consular Affairs nor the U.S. Embassy have authority over quarantine issues and cannot prevent a U.S. citizen from being quarantined should local health authorities require it.  For questions about quarantine, please visit the CDC website that addresses quarantine and isolation issues.

The cost for a medical evacuation is very expensive.  We encourage U.S. citizens travelling to Ebola-affected countries to purchase travel insurance that includes medical evacuation for Ebola Virus Disease (EVD).  Policy holders should confirm the availability of medical care and evacuation services at their travel destinations prior to travel.

Some local, regional, and international air carriers have curtailed or temporarily suspended service to or from Ebola-affected countries.  U.S. citizens planning travel to or from these countries, in accordance with the CDC Health Travel Warnings and Health Travel Alert, should contact their airline to verify seat availability, confirm departure schedules, inquire about screening procedures, and be aware of other airline options.

The Department is aware that some countries have put in place procedures relating to the travel of individuals from the affected countries, including complete travel bans.  Changes to existing procedures may occur with little or no notice.  Please consult your airline or the embassy of your destination country for additional information.

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According to the WHO’s Outbreak News, the total number of probable and confirmed cases in the current outbreak of Ebola virus disease (EVD) as reported by the respective Ministries of Health of Guinea, Liberia, Nigeria, and Sierra Leone is 3069, with 1552 deaths.  The World Health Organization reports that the outbreak continues to accelerate with more than 40% of the total number of cases occurring within the past 21 days.  The overall case fatality rate is 52%.

A separate outbreak of Ebola virus disease not related to the four-country outbreak was laboratory-confirmed on  August 26 by the Democratic Republic of Congo (DRC). The DRC’s index case was a pregnant woman from a village who butchered a bush animal that had been killed and given to her by her husband. From July 28- August 18, 2014, a total of 24 suspected cases of haemorrhagic fever, including 13 deaths, have been identified in that outbreak.

As of this writing, Senegal also confirmed its first case of Ebola related to the four-country outbreak in West Africa.

 

 

 

 

 

 

 

U.S. Embassy Sierra Leone Now on Ordered Departure for Family Members #Ebola

— Domani Spero
[twitter-follow screen_name=’Diplopundit’ ]

 

On August 14, the State Department  announced the ordered departure of family members not employed at U.S. Embassy Freetown from Sierra Leone. This follows the ordered departure of family members from U.S. Embassy Liberia on August 7. No Travel Warning has yet been issued for Sierra Leone as of this writing but we expect one coming out soon. Below is the statement of the U.S. Embassy Freetown ordered departure:

At the recommendation of the U.S. Embassy in Sierra Leone, the State Department today ordered the departure from Freetown of all eligible family members (EFMs) not employed by post. The Embassy recommended this step out of an abundance of caution, following the determination by the Department’s Medical Office that there is a lack of options for routine health care services at major medical facilities due to the Ebola outbreak.

We are reconfiguring the Embassy staff to be more responsive to the current situation. Our entire effort is currently focused on assisting U.S. citizens in the country, the Government of Sierra Leone, international health organizations, local non-governmental organizations (NGOs), and the Sierra Leonean people to deal with this unprecedented Ebola outbreak.

We remain deeply committed to supporting Sierra Leone and regional and international efforts to strengthen the capacity of the country’s health care infrastructure and system — specifically, the capacity to contain and control the transmission of the Ebola virus, and deliver health care.

According to the World Health Organization, a total of 128 new cases of Ebola virus disease (EVD) (laboratory-confirmed, probable, and suspect cases) as well as 56 deaths were reported from Guinea, Liberia, Nigeria, and Sierra Leone between August 10-11, 2014. See the disease update from the WHO:

via WHO

via WHO

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U.S. Embassy Liberia Now on Ordered Departure For Family Members, New Travel Warning Issued

— Domani Spero
[twitter-follow screen_name=’Diplopundit’ ]

 

On August 7, the State Department ordered the departure of all family members not employed at the U.S. Embassy in Monrovia, Liberia.  The new Travel Warning issued today says that the U.S. government employees in Liberia will remain on active duty at the Embassy and additional staff are being deployed to assist the Government of Liberia in addressing the Ebola Virus Disease outbreak.  This follows the departure of  the U.S. Peace Corps from Liberia on July 30 as a result of the current outbreak of Ebola Virus Disease in the region. Yesterday, the CDC also issued a Level 3 warning urging all US residents to avoid nonessential travel to Sierra Leone, Guinea, and Liberia.  

Full State Department statement below:

At the recommendation of the U.S. Embassy in Liberia, the State Department today ordered the departure from Monrovia of all eligible family members (EFMs) not employed by post in the coming days. The Embassy recommended this step out of an abundance of caution, following the determination by the Department’s Medical Office that there is a lack of options for routine health care services at major medical facilities due to the Ebola outbreak. We are reconfiguring the Embassy staff to be more responsive to the current situation. Our entire effort is currently focused on assisting U.S. citizens in the country, the Government of Liberia, international health organizations, local non-governmental organizations (NGOs), and the Liberian people to deal with this unprecedented Ebola outbreak.

We remain deeply committed to supporting Liberia and regional and international efforts to strengthen the capacity of the Liberian health care infrastructure and system – specifically, their capacity to contain and control the transmission of the Ebola virus, and deliver health care. Additional staff from various government agencies including 12 disease prevention specialists from the Centers for Disease Control and Prevention and a 13-member Disaster Assistance Response Team from USAID are deploying to Liberia to assist the Liberian Government in addressing the Ebola outbreak.

A new Travel Warning for Liberia also came out today indicating that the ordered departure of USG family members will begin tomorrow, August 8. The new warning also advised travelers that some airlines have discontinued service and flights to Liberia and that air carriers chartered by medical evacuation insurance companies may not be able to provide timely services in Liberia or the region. Excerpt below:

In May 2014, a case of Ebola Virus Disease (EVD) was confirmed in Liberia, marking the first case in a second wave of the EVD outbreak. Since then, EVD has continued to spread and intensify. The latest wave of the outbreak has overwhelmed Liberia’s health system and most health facilities lack sufficient staff or resources to address the continuing transmission of EVD.  Options for obtaining routine medical care are severely limited.  For more information concerning EVD, please visit the Centers for Disease Control and Prevention website.  Please direct inquiries regarding U.S. citizens in Liberia to EbolaEmergencyUSC@state.gov. Callers in the United States and Canada may dial the toll free number 1-888-407-4747.  Callers outside the United States and Canada may dial 1-202-501-4444.

If you arrive in Liberia and subsequently need routine or emergency medical care, you should expect limited, if any, options.  Travelers are advised that air carriers chartered by medical evacuation insurance companies may not be able to provide timely services in Liberia or the region.  Policyholders should confirm the availability of medical evacuation services prior to travel.  While commercial flights are still available from Monrovia, some airlines have discontinued service and flights may become more difficult to obtain.  If you plan to visit Liberia despite this warning, you should purchase travel insurance that includes medical evacuation, and confirm that the coverage applies to the circumstances in Liberia.

According to USAID , the deployed staff came from the Agency’s Office of U.S. Foreign Disaster Assistance (OFDA)  and will be overseeing critical areas of the response, such as planning, operations, logistics in coordination with other federal agencies, including the U.S. Departments of Defense and Health and Human Services. Members of the Centers for Disease Control and Prevention (CDC) are also on the DART to lead on public health and medical response activities.

USAID has already provided $2.1 million to the UN World Health Organization and UNICEF for the deployment of more than 30 technical experts and other Ebola response efforts.

Two days ago, USAID also announced an additional $5 million in assistance to help ramp up the international community’s Ebola response efforts. This new funding will support outreach campaigns via radio, text messages, and through local media as well as the expansion of Ebola outbreak programs the Agency is already supporting in Guinea, Sierra Leone, and Liberia. These programs help trace people who may be infected with the disease, as well as provide health clinics and households with hygiene kits, soap, bleach, gloves, masks, and other supplies to help prevent the spread of disease.

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US Embassy Conakry Issues Security Message on Ebola Outbreak in Guinea

— Domani Spero

On March 24, the US Embassy in Conakry, Guinea issued the following message to U.S. citizens in the country:

The Government of Guinea has confirmed the presence of the Ebola virus in the Nzérékoré  (Guinee Forestiere) region, mostly in the administrative district of Gueckedou and in the town of Macenta.  Symptoms include diarrhea, vomiting, a high fever and heavy bleeding.  To date over 80 cases have been recorded with 59 recorded fatalities.
The U.S. mission in Conakry strongly recommends that U.S. citizens avoid contact with individuals exhibiting the symptoms described above until further information becomes available.

Ebola Hemorrhagic Fever (HF) is a deadly disease but is preventable.  It can be spread through DIRECT, unprotected contact with the blood or secretions of an infected person; or through exposure to objects (such as needles) that have been contaminated with infected secretions.  The viruses that cause Ebola HF are often spread through families and friends because they come in close contact with infectious secretions when caring for ill persons.  Ebola HF has a high mortality rate and early evidence suggests that the Guinea strain of Ebola is related to the Zaire Ebola strain that carries a mortality rate of 90%. Some who become sick with Ebola HF are able to recover, while others do not.  The reasons behind this are not yet fully understood. However, it is known that patients who die usually have not developed a significant immune response to the virus at the time of death.
During outbreaks of Ebola HF, the disease can spread quickly within health care settings (such as a clinic or hospital).  Exposure to Ebola viruses can occur in health care settings where hospital staff are not wearing appropriate protective equipment, such as masks, gowns, and gloves.

Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola virus though 8-10 days is most common.  A person suffering from Ebola presents with a sudden onset of high fever with any of the following: headache, vomits blood, has joint or muscle pains, bleeds through the body openings (eyes, nose, gums, ears, anus) and has reduced urine.

Since the virus spreads through direct contact with blood and other body secretions of an infected person those at highest risk include health care workers and the family and friends of an infected individual.

For more information on Ebola hemorrhagic fever, please visit the CDC website at www.cdc.gov/vhf/ebola

CDC map

CDC map

On 25 March 2014, the World Health Organization provided a status update of the outbreak:

The Ministry of Health (MoH) of Guinea has notified WHO of a rapidly evolving outbreak of Ebola haemorrhagic fever in forested areas south eastern Guinea. The cases have been reported in Guekedou, Macenta, and Kissidougou districts. As of 25 March 2014, a total of 86 suspected cases including 60 deaths (case fatality ratio: 69.7%) had been reported. Four health care workers are among the victims. Reports of suspected cases in border areas of Liberia and Sierra Leone are being investigated.

Thirteen of the cases have tested positive for Ebola virus by PCR (six at the Centre International de Recherche en Infectiologie (CIRI) in Lyon, France, and seven at the Institut Pasteur Dakar, Senegal), confirming the first Ebola haemorrhagic fever outbreak in Guinea. Results from sequencing done by CIRI Lyon showed strongest homology of 98% with Zaire Ebolavirus last reported in 2009 in Kasai-Occidental Province of DR Congo. This Ebolavirus species has been associated with high mortality rates during previous outbreaks.

Doctors Without Borders/Médecins Sans Frontières (MSF) has worked in Guinea since 2001. Its March 25 update indicates that the group is reinforcing its teams in Guéckédou and Macenta, two towns in the south of the country where the virus has spread. Thirty staff members are reportedly on the ground and more doctors, nurses, and sanitation specialists will be joining them in the coming days. According to DWB/MSF, thirteen samples to-date have tested positive for the Ebola virus, an extremely deadly viral hemorrhagic fever. Other samples are currently being analyzed. Suspected cases have been identified in neighboring Liberia and Sierra Leone, but none of these have yet been confirmed by laboratory tests.

The CDC has updated its outbreak page with information from WHO and says that it is in regular communication with its international partners WHO and MSF regarding the outbreak, to identify areas where CDC subject matter experts can contribute to the response.

As of March 25, 2014, WHO has not recommended any travel or trade restrictions to Guinea in connection with this outbreak.

U.S. Embassy Conakry is an extreme hardship post receiving 25% COLA and 30% post hardship differential. Post is headed by Ambassador Alexander Laskaris who was sworn in as the 20th U.S. Ambassador to the Republic of Guinea on September 10, 2012.

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US Embassy Uganda: Emergency Msg to US Citizens on Ebola Outbreak, Oops, Scratch Dat — One Confirmed Case of Ebola Virus

On  July 28, the US Embassy in Kampala released the following Emergency Message to U.S. citizens:

Emergency Message for U.S. Citizens | Confirmed Case of Ebola Virus in Uganda

This Emergency Message is to alert U.S. citizens residing and traveling in Uganda of an outbreak of Ebola virus.  On July 27, 2012, local Ugandan press reported 12 deaths due to a “strange illness.”  Laboratory tests conducted by the Uganda Virus Research Institute and the United States Centers for Disease Control and Prevention (CDC) have confirmed, to date, that at least one victim was infected with the Ebola virus (Sudan strain).  The Ugandan Ministry of Health, U.S. CDC, and international partners are investigating the case to determine the extent of the outbreak and if additional cases are present.  At this time, the cases appear to be centered in Nyamarunda Sub County, Kibaale district, although one suspected victim is reported to have traveled to Kampala for treatment at Mulago Hospital where he subsequently died on July 22, 2012.

Ebola is a deadly but preventable disease.  The virus has the potential to spread from person to person, especially among health-care staff and family members who care for patients with Ebola Viral Hemorrhagic Fever. A person suffering from Ebola usually presents with sudden fever, headache, joint and muscle aches, sore throat, and weakness, followed by diarrhea, vomiting, and stomach pain.  A rash, red eyes, hiccups and internal and external bleeding may be seen in some patients. Symptoms become increasingly severe and may include jaundice, severe weight loss, mental confusion, shock, and multi-organ failure. There is no standard treatment for Ebola HF.  Patients receive supportive therapy.

The likelihood of contracting Ebola is considered extremely low unless there has been a direct contact with body fluids like saliva, urine, or blood of an infected person or animal or the body of someone who has died from the disease.  Since the virus spreads through direct contact with blood and other body secretions of an infected person, people living with and caring for Ebola patients are at a higher risk of becoming infected.

The U.S. Mission in Kampala and the CDC office in Uganda recommend that U.S. citizens residing and traveling in Uganda avoid contact with people exhibiting the symptoms described above.  To minimize the risk of contracting Ebola, avoid direct contact with body fluids (blood, saliva, vomit, urine, and stool).  Practice good hygiene, such as washing hands carefully and thoroughly with soap and water, or with alcohol-based hand cleanser if soap and water are unavailable.  Avoid communal washing of hands during funerals or other public gatherings.  Avoid contact with dead animals, especially primates, and refrain from eating “bushmeat.”

Read the whole message here.

English: Biosafety level 4 hazmat suit: resear...

English: Biosafety level 4 hazmat suit: researcher is working with the Ebola virus (Photo credit: Wikipedia)

Here is what the CDC posted about the ebola outbreak on the same date:

2012: Ebola Hemorrhagic Fever Outbreak in Uganda

On July 28th, 2012, the Uganda Ministry of Health reported an outbreak of Ebola Hemorrhagic fever in the Kibaale District of Uganda. A total of 20 probable human cases, including 14 fatalities, have been reported since the beginning of July. Laboratory tests of blood samples, conducted by the Uganda Virus Research Institute (UVRI) and the U. S. Centers for Disease Control and Prevention (CDC), confirmed Ebola virus in five patients, two of whom have died. All reported illnesses and contacts are being investigated.

A team of experts from CDC is traveling Uganda, to work with Ministry of Health and international partners in determining the extent of the outbreak and locating, testing, and treating any additional cases. A laboratory team will also assist in diagnostic testing.

Here is the statement that the Ministry of Health released in Kampala, Uganda:

EBOLA SUSPECTED CASES INCREASE IN KIBAALE DISTRICT
KAMPALA – 07/03/2012 – The Ministry of Health Wishes to inform the public that the number of suspected Ebola cases registered at Kagadi Government Hospital in Kibaale district has since yesterday increased from seven to 18 patients. Currently there are three confirmed cases and 15 suspects admitted at the isolation facility. The patients are receiving the appropriate treatment from the medical team dispatched from the National Task force jointly with local hospital staff. Most of them are responding positively to the treatment administered to them.

The increased number follows the quick response given to suspected alerts from various parts ofthe district. The patients are currently admitted at the hospital isolation facility after they presented with Ebola signs.

There have been no more deaths recorded since the announcement of the outbreak on July 28th, The death toll still remains at 14.

A total of 16 samples have since the outbreak been collected from the suspect cases for investigation at the Uganda Virus Research Institute. The Ministry of Health Surveillance team in Kibaale district is actively and closely following up to 40 people who are suspected to have got into Contact with the dead. These contacts have not shown any signs of the disease but will be monitored for 21 days. After 21 days, they will be declared Ebola-free meaning that they did not contract the disease.

At Mulago National Referral Hospital, a total of eight health workers who attended to the suspect case are closely being monitored. An isolation policy arrangement to last 21 days has been put in place as active monitoring continues.

The Ministry of Health further informs the public that plans are underway to set up Isolation Facility at Mulago National Referral Hospital in readiness for any alerts and suspected cases from Kampala and neighbouring districts.

The public is therefore requested to stay calm as everything is being done to manage the outbreak. The Ministry of Health advises the public to ensure that the recommended safety measures are adhered to and to refer any suspected cases to a nearby health facility for check up. Ebola presents with fever, vomiting, diarrhoea, abdominal pain, headache, measles-like rash, red eyes, and sometimes with bleeding from body openings.

The original statement is online here.

The US Embassy in Kampala cites local press reports which calls the death the result of “strange illness.”  As the Examiner points out, our own CDC has had a long term presence in Uganda and operates a VHF lab in cooperation with the Uganda Virus Research Institute.

So here is what we don’t get —

Why would the embassy emergency message cites press reports about “strange illness” instead of using the information from the CDC?

The embassy emergency message of July 28 cites only one confirmed case infected with the Ebola virus.

The CDC information dated July 28  calls it an outbreak and cites 20 probable human cases, including 14 fatalities, plus, confirmed Ebola virus in five patients, two of whom have died.

The one emergency message with no follow-up message to-date did not mention that the Kibaale district cases have increased from seven to 18 patients. Nor did it mention the three confirmed cases and 15 suspects admitted at the isolation facility. Nor did it mention that the Ministry of Health Surveillance team in Kibaale district is actively and closely following up to 40 people who are suspected to have contact with the dead. Nor did it mention that a total of eight health workers who attended to the suspect case are also closely being monitored under the government’s isolation policy which last for 21 days (the incubation period for Ebola HF ranges from 2 to 21 days).

Although July 28 emergency message is prominently displayed on the embassy’s website, there is no mention of that message on the embassy’s Facebook or Twitter pages. US Embassy Kampala/FB talks about the London Olympics, and the most effective approach Uganda can take to stop terrorists.  Here is what US Embassy Kampala has on Twitter in a 5-day span, not one mention of e-bola:

And so — one more example of just how integrated is the embassy’s social media outreach with its primary consular function.

The Examiner notes the USG presence in the country and the absence of travel restrictions:

Several other U.S. government agencies are active in Uganda and have personnel there. The Peace Corps has about 122 volunteers in the country. U.S. military personnel regularly exercise with their Ugandan counterparts and Special Operations forces have been deployed there since October 2010. The U.S. Agency for International Development participates in 154 projects in that nation.

There is no traveler’s warning from the CDC for Uganda concerning the Ebola outbreak. The U.S. Embassy in Uganda issues a warning message to U.S. citizens in Uganda but has not suggested any travel restrictions.

Just two days before the ebola outbreak, forty-five Peace Corps Volunteers started their service in Uganda.

This is not the first reported instance of ebola outbreak in Uganda in recent history. In 2000/2001, there were 425 reported cases with 53% deaths; in 2007/2008, 131 reported cases with 37% deaths; and a single case in May 2011 which resulted in death.

Domani Spero