Ebola outbreak in West Africa Last updated 15 September 2014.

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Ebola outbreak in West Africa Last updated 15 September 2014

Transcript of Ebola outbreak in West Africa Last updated 15 September 2014.

Ebola outbreak in West Africa

Ebola outbreak in West Africa

Last updated 15 September 2014

Pandemic and Epidemic Diseases department2 |

●Introduction to Ebola Virus Disease●Global Update●Essential Element for Control of On-going Outbreak●WHO response to the Outbreak

Ebola Virus DiseaseEbola Virus Disease

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Introduction to Ebola Virus DiseaseIntroduction to Ebola Virus Disease

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History of Ebola Virus OutbreaksHistory of Ebola Virus Outbreaks

● 1976, Ebola first appeared in 2 simultaneous outbreaks in Sudan and in Democratic Republic of Congo

● Since Ebola discovery in 1976 until December 2013:

23 outbreaks, 2388 human cases including 1590 deaths

● The 2014 current Ebola outbreak began in Guinea in December 2013. This outbreak now involves transmission in Guinea, Liberia, Nigeria, and Sierra Leone.

● As of 21 August 2014, countries have reported 2550 cases (1490 confirmed, 718 probable, 342 suspect), including 1339 deaths. Currently the largest EVD outbreak ever recorded.

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Ebola and Marburg virusesEbola and Marburg virusesFamily Filoviridae, single-strand, negative-sense RNA virus

Genus Marburgvirus, 1 species Marburg marburgvirus– Virus 1: Marburg virus (MARV)– Virus 2: Ravn virus (RAVV)

Genus Ebolavirus, 5 distinct species– Species Taï Forest ebolavirus, virus: Taï Forest virus (TAFV)– Species Reston ebolavirus, virus: Reston virus (RESTV)– Species Sudan ebolavirus, virus: Sudan virus (SUDV)– Species Zaire ebolavirus, virus: Ebola virus (EBOV)– Species Bundibugyo ebolavirus, virus: Bundibugyo virus (BDBV)

Genus Cuevavirus*, Species Lloviu cuevavirus*– virus: Lloviu virus (LLOV)

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Disease in animalsDisease in animals In Africa, since 1994, outbreaks from the EBOV and TAFV

observed in chimpanzees and gorillas

In Philippines, RESTV has caused severe EVD outbreaks in macaque monkeys farmed and was detected in monkeys imported into the USA in 1989, 1990 and 1996, and in monkeys imported to Italy from Philippines in 1992

Since 2008, RESTV viruses detected during several outbreaks of a deadly disease in pigs in Philippines and People’s Republic of China

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● Incubation 2-21 days● Case Fatality Ratio 24-89%● Handling specimens requires BSL 4 ● Treatment is supportive but effective in reducing mortality

Rehydration, intensive care● Some potential specific treatment

Monoclonal antibodies• Very limited availability• Limited information on safety & efficacy

Other candidate drugs also in early stages of testing

● Vaccines in development

Ebola Virus DiseaseEbola Virus Disease

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How Ebola Outbreaks Start

● First human cases start with infection by an animal Chimpanzes, gorillas, monkeys, forest antelopes, fruit bats,

porcupine... How 2014 outbreak in West Africa started is unknown

● Infection from person-to-person creates an outbreak Direct or indirect physical contact with body fluids of

infected person (blood, saliva, vomitus, urine, stool, semen)

● Well known locations where transmission occurs Hospital: health care workers, other patients, unsafe injections Communities: Family, friends, contacts caring for ill, through

funeral practices

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Diagnosis Diagnosis ● Diseases that should be ruled out include: malaria, typhoid fever,

shigellosis, cholera, leptospirosis, plague, rickettsiosis, relapsing fever, meningitis, hepatitis and other viral haemorrhagic fevers

● Essential role of patient history; exposure to area/village with ongoing outbreak and/or contact with confirmed cases

● Diagnostic tests: ● Antibody-capture enzyme-linked immunosorbent assay (ELISA)● Antigen detection tests● Reverse transcriptase polymerase chain reaction (RT-PCR) assay● Electron microscopy● Virus isolation by cell culture

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Short Duration ViraemiaShort Duration Viraemia

Time3-7 days

3-15 days

Fever

Virus / Antigen

Neutralizing /IgG ELISA Antibodies

IgM Antibodies

Incubation Disease(Figure adapted from T Ksiazek CDC/Atlanta)

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● Preferred specimens Whole blood preserved with EDTA: see WHO guide

“How to safely collect blood samples from persons suspected to be infected with Ebola” on WHO website

Oral swabs from deceased patients● Laboratory diagnosis: Extreme biohazard risk; testing

should be conducted under maximum biological containment conditions. Samples handled by trained staff & processed in suitably equipped laboratories (BSL4).

Sample CollectionSample Collection

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● Shipment of specimens should follow international standards shipping procedures for “transport of category A infectious substances” (triple packaging system)

● Shipping logistics coordinated through EDPLN network

● Category A for live virus● Category B for inactivated specimens

Specimens ShipmentSpecimens Shipment

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● A network of high security diagnostic laboratories Human and Animal High Security Laboratories BSL-4 and selected

BSL-3

● Supports rapid response to detect, diagnose and control novel disease threats Laboratory response

Assay and reagent development

Technology transfer and training

Applied research

Global coordination and information exchange

Emerging and Dangerous Pathogens Laboratory Network (EDPLN)

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EDPLN - 23 members globally

EDPLN - 23 members globally

Region of the Americas

WHO regions

African Region

South-East Asia Region

European Region

Eastern Mediterranean Region

Western Pacific Region

EDPLN member (6 members)

EDPLN member and WHO CC (15 members)

EDPLN member and veterinary laboratory (2 members)

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Disease in humans: Clinical SymptomsDisease in humans: Clinical Symptoms

● Incubation period: 2 – 21 days

● Start with feverish syndrome: often characterized by the sudden onset of fever, intense weakness, muscle pain, headache and sore throat

● Followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases, both internal and external bleeding

● Laboratory findings include low white blood cell and platelet counts and elevated liver enzymes

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Disease in Humans: Treatment Disease in Humans: Treatment

● Intensive supportive care is required

● Supportive care: monitor fluid and electrolyte balance and renal function, careful rehydration

● Provide supportive drug therapy : painkillers, antiemetic for vomiting, anxiolytic for agitation, +/-antibiotics and/or antimalarial drugs

● Some potential specific treatment Monoclonal antibodies Other candidate drugs also in early stages of testing

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Global Update Global Update

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Status of Ebola Outbreak 2014 as of 5 September 2014Status of Ebola Outbreak 2014 as of 5 September 2014

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Geographical location of confirmed an probable cases in West Africa

15 September 2014

Geographical location of confirmed an probable cases in West Africa

15 September 2014

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Ebola West Africa- Distribution of cases by week of onset

as of 15 September 2014

Ebola West Africa- Distribution of cases by week of onset

as of 15 September 2014

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Ebola West Africa- Distribution of cases by week of onset and by country (1)

as of 15 September 2014

Ebola West Africa- Distribution of cases by week of onset and by country (1)

as of 15 September 2014

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Ebola West Africa- Distribution of cases by week of onset and by country (2)

as of 15 September 2014

Ebola West Africa- Distribution of cases by week of onset and by country (2)

as of 15 September 2014

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Ebola West Africa- Distribution of cases by week of onset and by country (3)

as of 15 September 2014

Ebola West Africa- Distribution of cases by week of onset and by country (3)

as of 15 September 2014

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Response in countries with widespread and intense transmission

Response in countries with widespread and intense transmission

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Essential Elements for Control of On-going Outbreak

Essential Elements for Control of On-going Outbreak

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Essential components for controlEssential components for control

● Interim manual - Ebola and Marburg virus disease epidemics: preparedness, alert, control, and evaluation

● This document describes preparedness, prevention, and control measures that have been implemented successfully during previous epidemics

http://www.who.int/csr/disease/ebola/manual_EVD/en/

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●National leadership and risk communication

●Outbreak control measures to stop transmission:

- Clinical Management and IPC

- Epidemiological investigation, surveillance and laboratories

- Behavioral and social interventions

- Logistics

Control the outbreakControl the outbreak

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Psycho-social

support

Control of vectors and

reservoirs in nature

Triage In/out

Barriernursing

Clinical trialsEthics committee

Organizefunerals

Anthropologicalevaluation

SpecimensLaboratory

testing

Follow-upof contacts

Active case-finding

Infection

control

Social and Epidemiological

mobile teams

SecurityPolice

Lodging

Food

Formal and informal modes of

communication

Search the source

Databaseanalysis

FinancesSalaries

TransportVehicles

Epidemiological investigation,surveillance

and laboratory

Logistics

Clinical caseManagement

Behavioural and

social

interventions

Ethical aspects

Duty of careResearchCoordinationMedias

Communication Press

Journalists

Social andCultural

practices

Women, associations Traditional healersOpinion leaders

General strategy to CONTROL Ebola outbreak

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Clinical Management and IPCClinical Management and IPC

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Clinical Management and Patient Care

Clinical Management and Patient Care

● The diagnosis is based on 3 components:

– History of exposure: 2-21 days (e.g., caring for family members, attending funeral, investigate network).

– Detailed clinical assessment (maintain high level of suspicion, differential diagnosis).– Laboratory investigations (false negatives in early phase possible).

● Early clinical features:

– Flu-like symptoms: weakness, malaise, fever, headache, hiccups.– Gastrointestinal: diarrhea, nausea, vomiting, difficulty swallowing. – Bleeding not usually an early sign.

● Observe case definitions for alert, suspect, and probable cases. Confirmation by laboratory results.

●Clinical management: predominantly supportive, symptom control, identification and treatment of comorbidities, co-infections.

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Patient Care: New Medicines and vaccines (1)Patient Care: New Medicines and vaccines (1)

● Several new treatment options are under development, among which: ZMap: a cocktail of three monoclonal antibodies

produced in plants Convalescent plasma Hyperimmune globulins made in horses or cattle siRNA (Lipid Nanoparticle Small interfering RNAs) BCX4430: a chemical which blocks viral replication T705: chemical substitution of constituent needed for

viral replication

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Patient Care: New medicines and vaccines (2)Patient Care: New medicines and vaccines (2)

● Two recombinant vaccines, based on a non-replicative Chimpanzee

adenovirus 3 vector or a VSV attenuated vector, have been shown

to protect non-human primates against Ebola virus infection. Their

development is being fast-tracked, with first-in-man Phase 1 clinical

likely to start in September 2014 in the USA

● None of the above products is currently registered for use in EVD,

which warrants an ethical discussion on how quickly they can be

made available to those in needs.

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Infection Prevention and Control Infection Prevention and Control

● Avoid shaking hands

●Personal Protective Equipment (PPE) not required if all below apply:

– Distance >1 meter from interviewee– Interviewing asymptomatic people– No contact with potentially contaminated environment

●Provide alcohol-based handrub solutions and instructions to perform hand hygiene

WHO Interim IPC Guidance - 2014 Updatehttp://www.who.int/csr/resources/who-ipc-guidance-ebolafinal-09082014.pdf

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IPC Essential Precautions in Healthcare Facilities

IPC Essential Precautions in Healthcare Facilities

● Standard precautions for all patients at all times

●Isolation of suspected and confirmed cases in separated rooms/areas with restricted access

●Exclusively dedicated staff and equipment for isolation rooms/areas

●Hand hygiene with alcohol-based handrub or water and soap

●Use of PPE (see next slide)

●Rigorous environmental cleaning and surfaces/objects decontamination

●Safe injection practices and sharps handling

●Post-exposure evaluation and care following professional accidentsWHO Interim IPC Guidance - 2014 Update

http://www.who.int/csr/resources/who-ipc-guidance-ebolafinal-09082014.pdf

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PPE for patient care and non clinical carePPE for patient care and non clinical care

● For visitors, health-care workers, cleaners, laboratory staff, anyone providing patient care and/or having contact with contaminated surfaces, blood or body fluids, clinical samples, infectious waste, dead bodies

●At least: gloves, gown, rubber boots/closed shoes with overshoes, and mask and eye protection for splashes

●Impermeable gown or plastic apron over gown and double gloves for any strenuous activity or tasks with contact with blood and body fluids

●Respirators needed only for aerosol-generating procedures

WHO Interim IPC Guidance - 2014 Updatehttp://www.who.int/csr/resources/who-ipc-guidance-ebolafinal-09082014.pdf

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Epidemiological Investigation, surveillance and laboratories

Epidemiological Investigation, surveillance and laboratories

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Any person that has travelled or/and has stayed, in a country that has reported at least one confirmed case of Ebola Virus Disease, within a period of 21 days before onset of symptoms, and :- with sudden onset of high fever and at least three of the following symptoms : headaches, vomiting, anorexia/loss of appetite, diarrhoea, lethargy, stomach pain, aching muscles or joints, difficulty swallowing, breathing difficulties, hiccupOR - with inexplicable bleedingOR- that died suddendly and inexplicably

Case definition (1): SUSPECTED CASECase definition (1): SUSPECTED CASE

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PROBABLE CASEAny suspected case evaluated by a clinician that has had an epidemiological link with a confirmed case

LABORATORY-CONFIRMED CASESAny suspected or probable cases with a positive laboratory result. Laboratory-confirmed cases must test positive for the virus antigen, either by detection of virus RNA by reverse transcriptase-polymerase chain reaction (RT-PCR), or by detection of IgM antibodies directed against Ebola virus

NON-CASEAny suspected or probable case with a negative laboratory result. Non-cases are those which showed no specific antibodies, RNA or specific detectable antigens.

Case definition (2)Case definition (2)

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- Report the case to the surveillance team- After obtaining express consent, collect a biological sample- Fill in a case notification form-Create a list of contacts of the suspected case-If subject is alive: explain to the patient (and family the need to go to hospital to receive adequate medical care) and arrange for hospital transfer-If subject has passed away, explain to the family the need for conducting a safe burial

Instructions when suspected case identified

Instructions when suspected case identified

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- To be completed soon

Contact tracingContact tracing

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Behavioral and Social Interventions

Behavioral and Social Interventions

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An informed and engaged population is empowered to make the decisions to best protect themselves, their families and communities from the spread of Ebola virus

Experience has taught us that early and sustained engagement with affected communities is critical for effective disease outbreak control and can limit the spread of disease and lower mortality and morbidity

People at risk of contracting Ebola need to know:

- What is Ebola?

- How does it spread?

- What behaviors they need to change or adopt to best protect them selves and their families?

- Where they can get additional information?

It is critical that communities receive these messages from local trusted leaders, in language and voices they can relate to and understand

The importance of an informed and engaged population

The importance of an informed and engaged population

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There are a number of important steps and processes that need to be followed to ensure behavioral change/engagement strategies are delivered effectively:

1. They must be data driven – To design effective messaging, tools and products local community knowledge, attitudes, practices and behaviors must be understood – these variables will effect the messaging, strategies and tools needed to engage a community

2. There must be local input into the strategies and messaging - Local community leaders and influencers must be consulted and should contribute to the designing of messages and suitable channels to best reach affected communities - People are more likely to pay attention to information from others that they already know, trust and who they feel are concerned about their well-being.

3. There should be a mix of strategies and approaches - Communities need to hear messages from multiple trusted channels which will lead to faster adoption of the desired protective behaviors

4. There should be robust and regular evaluation – It is critical that community engagement efforts are regularly evaluated for their impact and effectiveness

Establishing the processes to deliver an effective engagement strategy

Establishing the processes to deliver an effective engagement strategy

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There are a number of priority actions that Ebola affected countries should take to inform and empower populations

1.The President should address the nation declaring Ebola a national health emergency – This address should be widely distributed through TV and radio channels

2.Senior government and UN leadership should travel to affected areas to demonstrate their leadership and support for these communities

3.A coordinating task team for community engagement should be established at national and appropriate sub-national levels with appropriate membership from all ministries, UN partners, International and National NGO Groups, Community Groups

4.Dialogue with local community leaders should be established to identify local, provincial and national leadership that can assist mobilization and engagement of local communities

5.Messages should be crafted and endorsed by this group that address the key behavioral practices relating to health facility patient care, home based care, safe burial and early reporting of cased to treatment centres

6.Rumors should be tracked closely with efforts established to correct and inform with appropriate information

Priority actions to quickly inform and empower populations

Priority actions to quickly inform and empower populations

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WHO is responsible for ensuring messaging developed at all levels is technically accurate and matches the recommended Ebola outbreak containment strategies and priorities

WHO should support UNICEF and relevant government agencies, particularly the MoH, develop, role out and evaluate evidence based strategies to mobilize and engage with affected communities ensuring that these strategies match Ebola outbreak containment strategies and priorities

WHO should support UNICEF coordinate global partner support especially with agencies or organizations with the ability to support or deliver effective community engagement strategies in affected or at risk countries

The Role of WHOThe Role of WHO

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Points of entry – International travel and transport

Points of entry – International travel and transport

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States with EVD transmission:

Develop standard operational procedures and conduct exit screening of all persons at international airports, seaports and major land crossings: for unexplained febrile illness consistent with potential Ebola infection.

– The exit screening should consist of, at a minimum, a questionnaire, a temperature measurement and, if there is a fever, an assessment of the risk that the fever is caused by EVD.

For all points of entry:Ensure public health contingency emergency plan is in place at designated PoEAllocate space at PoE for health assessments in the event of suspected ill travellers is detected. Establish standard operation procedures when ill travellers need to be referred to designated hospitals including identification of adequate ambulance service.Ensure sufficient trained staff with appropriate and sufficient Personal Protective Equipment (PPE) and disinfectants.Raise awareness among conveyance operators for the need of immediate notification to PoE health authorities prior to arrival of any suspected case(s). In regard to air travel, coordinate health sector and stakeholders with civil aviation authorities, airport operators and airlines to facilitate contact tracing and event management, ensuring passenger locator form is on board and at airport and airport ground staff and crew trained for managing EVD and environmental contaminants in flight and at airport.Ensure timely communication between PoE and national health surveillance system Disseminate health information and raise awareness among PoE stakeholders of EVD

PoE - ITTPoE - ITT

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WHO Response to the OutbreakWHO Response to the Outbreak

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2-3 July: Emergency Ministerial meeting in Accra, Ghana operations coordination centre in Conakry, Guinea

31 July: Launch of Ebola Outbreak Response Plan Main pillars of activities; initial resource estimates

8 August: DG/WHO declares Public Health Emergency of International Concern Issues IHR Temporary Recommendations

BackgroundBackground

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Unprecedented nature of event

Responds to demand for comprehensive guidance on Ebola response

The Roadmap consolidates country-specific experience & knowledge into a common framework to:

1. Assist governments & partners in revising/resourcing country-specific plans

2. coordinate international support to implement plans

Need for Updated Response RoadmapNeed for Updated Response Roadmap

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GOAL:

Stop Ebola transmission globally within 6-9 months, while addressing the broader socioeconomic impact in intense transmission areas & rapidly managing consequences of international spread

Ebola Response RoadmapEbola Response Roadmap

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Ebola Response RoadmapEbola Response Roadmap

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Full Ebola intervention package (case mgmt, lab, contact tracing, safe burials, social mobilization)

Develop & apply complementary approaches for intense transmission areas

Institute short-term measures to limit national spread

Implement IHR recs to prevent international spread

Essential services & foundation for sector recovery

OBJ. 1 – PRIORITY ACTIVITIESOBJ. 1 – PRIORITY ACTIVITIES

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OBJ 2. Emergency Response Countries Initiate emergency health procedures Immediately activate Ebola response

protocols/facilities Implement IHR Recs to prevent international spread

OBJ 3. Preparedness all unaffected countries countries bordering Ebola-infected areas countries international transportation hub(s)

OBJ. 2&3 – PRIORITY ACTIVITIESOBJ. 2&3 – PRIORITY ACTIVITIES

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OPERATIONALIZING THE ROAD MAPOPERATIONALIZING THE ROAD MAP

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MAJOR ROLES & RESPONSABILITIESMAJOR ROLES & RESPONSABILITIES

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EBOLA WHO websiteEBOLA WHO website

http://www.who.int/csr/disease/ebola/en/

● Technical information Infection control Social mobilization Epidemiology Preparedness and response Patient care

● Guidelines

● Meeting reports

● Disease outbreak news

THANK YOU