Economic Signs and Wonders

SUBHEAD: All that remains are various three card monte maneuvers, hot potato games, and musical chair tournaments.

By James Kunstler on 3 November 2014 for Kunstler.com -
(http://kunstler.com/clusterfuck-nation/signs-and-wonders/)


Image above: The 2012 Musical Chairs World Championship with a $10K prize was coverefd by ESPN. From (http://espn.go.com/espn/story/_/id/8910212/thousands-contestants-battle-high-stakes-musical-chairs-championship-espn-magazine).

“Holy smokes,” Janet Yellen must have barked last week when Japan stepped up to plug the liquidity hole left by the US Federal Reserve’s final taper trot to the zero finish line of Quantitative Easing 3. 

The gallant samurai Haruhiko Kuroda (of Japan’s central bank) announced that his grateful nation had accepted the gift of inflation from the generous American people, which will allow the island nation to fall on its wakizashi and exit the dream-world of industrial modernity it has struggled through for a scant 200 years.

Money-printing turns out to be the grift that keeps on giving. The US stock markets retraced all their October jitter lines, and bonds plumped up nicely in anticipation of hot so-called “money” wending its digital way from other lands to American banks. Euroland, too, accepted some gift inflation as its currency weakened. 

The world seems to have forgotten for a long moment that all this was rather the opposite of what America’s central bank has been purported to seek lo these several years of QE heroics — namely, a little domestic inflation of its own to simulate if not stimulate the holy grail of economic growth. Of course all that has gotten is the Potemkin stock market, a fragile, one-dimensional edifice concealing the post-industrial slum that the on-the-ground economy has become behind it.

Then, as if cued by some Satanic invocation, who marched onstage but the old Maestro himself, Alan Greenspan, Fed chief from 1987 to 2007, who had seen many a sign and wonder himself during that hectic tenure, and he just flat-out called QE a flop. He stuck a cherry on top by adding that the current Fed couldn’t possibly end its ZIRP policy, either. 

All of which rather left America’s central bank in a black box wrapped in an enigma, shrouded by a conundrum, off-gassing hydrogen sulfide like a roadkill ‘possum. Incidentally, Greenspan told everybody to go out and buy gold — which naturally sent the price of gold spiraling down through its previous bottom into the uncharted territory of worthlessness. 

Gold is now the most unloved substance in the history of trade, made even uglier by the overtures of Mr. Greenspan. Personally, I think the more violently gold devalues for the moment, the more extreme the reaction will be when the first glimpses of reality pierce the twilight’s last gleaming of official US market intervention shenanigans.

All this goes on, by the way, because an essential problem remains: the world cannot pay back its accumulated debt and the money maestros of world finance don’t dare even try to unwind it in an orderly manner, fearing they will open up an international monetary sucking chest wound of deflationary doom. 

And this does nothing to brighten the prospect that evermore new debt can ever be repaid. All that remains are various three card monte maneuvers, hot potato games, and musical chair tournaments using the last kinetic rocket thrusts of global credulity to pretend that contraction is not already here, walking amongst us, like the ancient Harvestman of yore, swinging his scythe.
 
Of course, few doubt the reality of Ebola. And ISIS (or whatever it’s called) also works its ghastly hoodoo in the gummiest region of the world, and they both share an interesting feature these days: reporters are discouraged from going into either hot zone where the threat is that they will bleed out through all the orifices from Ebola or have their heads hacked off on video by ISIS. 

So we are not getting the best information out of Ebola West Africa and those parts of the Middle East where ISIS is at large. The situation is apt to be rather worse than we are being told. 

The financial markets shrugged off both these threats by the time Halloween rolled around, but I wouldn’t be so confident that story is over for either of these two ugly influences. If the world had a face, it would have fragility written all over it.

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DOD says Ebola is Aerostable

SUBHEAD: The Army has found is that sewer systems also offer an ideal environment for longer term Ebola persistence.

By Ms. X on 27 October 2014 for Pissin' On The Roses -
(http://pissinontheroses.blogspot.com/2014/10/department-of-defense-says-ebola-is.html)


Image above: Indications the Feds fear airborne Ebola. From (http://www.wnd.com/2014/10/document-shows-feds-fear-airborne-ebola/).

The Defense Threat Reduction Agency [DTRA], in a just released a broad agency announcement last Friday seeking rapid assistance against Ebola's weapon of mass destruction [WMD] capability, stated that:

  "Ebola is aerostable in an enclosed controlled system in the dark and can survive for long periods in different liquid media"

The short of it is that DTRA's WMD arm sees a massive potential for Ebola to persist in sewage systems in Airborne, Waterborne, and BioFilm form.

The obvious dangers are multifold.

1. Severe Acute Respiratory Syndrome (SARS) spread in the Amoy Gardens high-rise apartment complex via a similar plumbing related infectious route.
   
2. CDC's current guidance encourages untreated EBOLA waste discharge into sewer systems.
   
3. Dr. Craig Spencer has already potentially infected NYC sewer system despite his 21 day "home quarantine".
   
4. Sewers may be a reoccurring source on #Ebola infection.
   
5. CDC's assurances that Ebola can not be spread via Air, Water, or Sewer places people at great risk.

Specifically, DTRA wants answers in 3 to 6 months regarding environmental conditions that allow to Ebola to persist in an airborne state, and persist on surfaces after precipitating out of the air.
DTRA is also looking for genetic weaponization markers that elucidate that persistence.

Interestingly enough, DTRA's solicitation also seeks Africa specific data that will allow them to use a a NATO Biowarfare Ebola simulation to predict the flow Ebola infection in Africa; we'll have more on that in a separate video analysis.


Video above: This article is available as video on YouTube. From (http://youtu.be/XFv5XuTnfHI).

As we have reported in previous posts, the US Army says that Ebola has an airborne stability similar to Influenza and that winter weather conditions may allow to spread via the airborne route.See (http://islandbreath.blogspot.com/2014/09/ebola-to-be-airborne-in-cold.html).

Apparently what the Army has found is that sewer systems also offer an ideal environment for longer term Ebola persistence.

Sources:
Chemical/Biological Technologies Department Ebola Broad Agency Announcement

Defense Threat Reduction Agency Announcemnet

Aerosolizing ONE DROP of Ebola Infected Blood Can Kill 500,000 People

US ARMY Says EBOLA = FLU in Airborne Stability, Needs Winter Weather To Go Airborne

Inadequate plumbing systems likely contributed to SARS transmission

Hong Kong seals apartment building to contain SARS

http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html

---

 Fever removed from Ebola case definition

SUBHEAD: CDC removes FEVER from Ebola Case Definition & adds FATIGUE as a symptom

By Ms. X on 28 October 2014 for Pissin' On The Roses -
(http://pissinontheroses.blogspot.com/2014/10/alert-cdc-removes-fever-from-ebola-case.html)

The CDC has removed fever from the Ebola Case Definition, and replaced it with the a more nebulous definition of:

 "Elevated body temperature or subjective fever or symptoms". 

 The CDC has also added "Fatigue" to the case definition. 

Here is the relevant part of the PRIOR case definition:

Person Under Investigation (PUI)
A person who has both consistent symptoms and risk factors as follows:

1. Clinical criteria, which includes fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage; AND

1. epidemiologic risk factors within the past 21 days before the onset of symptoms, such as contact with blood or other body fluids or human remains of a patient known to have or suspected to have EVD; residence in—or travel to—an area where EVD transmission is active*; or direct handling of bats or non-human primates from disease-endemic areas.

Here is the relevant part of the CURRENT case definition:

Person Under Investigation (PUI)
A person who has both consistent symptoms and risk factors as follows:

1. Elevated body temperature or subjective fever or symptoms, including severe headache, fatigue, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage; AND

1. An epidemiologic risk factor within the 21 days before the onset of symptoms.

Other important changes have also been made to loosen up CDC's Ebola case definition; we will update this post as time permits:

UPDATE: 10/28
The CDC's new Ebola case definition greatly increase the category of persons who may be forcefully quarantined to anyone who was in proximity of an Ebola case even if the Ebola victim was not actively showing symptoms at the time of proximity. (more to follow).

UPDATE 1: 10/29
The CDC's new Ebola case definition greatly increase the category of persons who may be forcefully quarantined to anyone who was in proximity of an Ebola case even if the Ebola victim was not actively showing symptoms at the time of proximity. (more to follow)

UPDATE 2: 10/29
After a more detail reading, the CDC has greatly increased the at risk Ebola category to include the following:

1. Direct contact (hand shake) with Ebola victim 21 days PRIOR to symptom onset
   
2. Airborne contact, that is even "brief proximity" (such as being in the same room for a brief period of time) with an Ebola victim AFTER their symptom onset

Any person who meets those two above definitions and in the subject eyes of an examiner has any "signs" of concern such as elevated body temperature (98.7 deg F) is now defined as a "Person Under Investigation" for Ebola. And as such, that person is subject to forceful quarantine

Nurse flew with Ebola symptom

SUBHEAD: Amber Vinson, 2nd nurse from Dallas to be infected, flew to and from Cleveland.

By Alan Horowitz on 15 October 2014 for Huffington Post -
(http://www.huffingtonpost.com/2014/10/15/amber-vinson-cdc-ebola_n_5993486.html)


Image above: Photo of the three people diagnosed with Ebola from Texas Health Presbyterian Hospital; (l-r) Thomas Eric Duncan (deseased), nurse Nina Pham and nurse Amber Joy Vinson. CDC let Vinson fly from Cleveland to Dallas with low grade fever later determined to be from Ebola. From (http://www.11alive.com/story/news/nation-now/2014/10/15/ebola-nurse-amber-joy-vinson-flew-plan-wedding/17313413/).

[IB Publisher's note: "Brownie You're Doing A Heck Of A Job", George W. Bush to FEMA head. It is beginning to look like the CDC (Center for Disease Control) is handling the Ebola outbreak in 2014 as badly as FEMA (Federal Emergency Management Agency) handled Hurricane Katrina in 2005, and the EPA (Environmental Protection Agency) handled BP oil spill in 2010. ]

A Dallas nurse who took a commercial flight from Cleveland hours before reporting symptoms of Ebola says that the Center for Disease Control and Prevention told her it was okay to fly.
Amber Vinson helped treat Thomas Eric Duncan, the Liberian man who died in Dallas of the Ebola virus earlier this month. On Wednesday, the CDC announced that she had contracted the virus as well.

The CDC also revealed that she had taken a flight to Dallas on Monday, though it said that it was extremely unlikely that any other passengers were exposed.

Vinson told CBS Dallas Fort Worth that she was feeling ill before boarding her flight. She had a low grade fever, but she said that officials told her it was okay to get on the plane. Vinson told CBS that she called the CDC several times with concerns.

is only contagious when a patient is symptomatic. Vinson's 99.5 degrees Fahrenheit fever wasn't high enough to be considered a symptom.

The CDC confirmed to FOX 4 News that they gave Vinson the green light to fly. "Vinson was not told that she could not fly," a government spokesperson told NBC News.

Vinson's comments contradict remarks made earlier today by CDC Director Tom Freiden, who said that she never should have gotten on the plane.

On Wednesday night, a letter from Frontier Airlines CEO Dave Siegel to airline employees claimed that the CDC had notified the airline that Vinson may have had symptoms while on the flight, the Denver Channel reported. "At 1:55 p.m. MDT (Wednesday) Frontier was notified by the CDC that the passenger may have been symptomatic earlier than initially suspected; including the possibility of possessing symptoms while onboard the flight," the letter said.

This would conflict with CDC's earlier statement that she didn't have symptoms of the illness while she was on the flight and didn't start showing symptoms until Tuesday.

After Vinson reported symptoms of Ebola on Tuesday, she was placed in isolation. On Wednesday, she was transported to Emory Hospital in Atlanta, where she will continue to receive treatment. She is in stable condition.

The 29-year-old nurse is the second person to contract Ebola in the United States. The first was Nina Pham, who is also a nurse at Texas Health Presbyterian Hospital Dallas, where Duncan was being treated. Duncan is the first person to have died of Ebola in the United States.

The CDC is trying to locate the 132 passengers that were on the Frontier Airlines flight 1143 with Vinson to determine their potential risk of Ebola. On Wednesday night, an official said that a Fort Worth family with a child had been isolated after a member of the family boarded a Frontier airline with Vinson, according to NBC DFW's Brian Curtis.

After a scheduled trip to Denver, Frontier Airlines said that the plane that Vinson flew on was taken out of service. The seat covers and carpeting are to be replaced, the crew placed on paid leave, according to Marc Stewart of KMGH.

---

Frontier plane flew 5 more times

SUBHEAD: Carrier completed five more flights after carrying Ebola stricken nurse from Cleveland to Dallas.

By Hugo Martin & Dan Weinkel on 15 October 2014 for LA Times -
(http://www.latimes.com/business/la-fi-frontier-airline-ebola-patient-20141015-story.html)


Image above: The Frontier Airlines plane that Amber Vinson flew from Cleveland to Dallas on Monday, rests at a terminal at Cleveland Hopkins International Airport, Wednesday, October 15, 2104. From original article.

The Frontier Airlines jet that carried a Dallas healthcare worker diagnosed with Ebola made five additional flights after her trip before it was taken out of service, according to a flight-monitoring website.

Denver-based Frontier said in a statement that it grounded the plane immediately after the carrier was notified late Tuesday night by the Centers for Disease Control and Prevention about the Ebola patient.

Flight 1143, on which the woman flew from Cleveland to Dallas/Fort Worth, was the last trip of the day Monday for the Airbus A320.

But Tuesday morning the plane was flown back to Cleveland and then to Fort Lauderdale, Fla., back to Cleveland and then to Atlanta and finally back to Cleveland again, according to Daniel Baker, chief executive of the flight-monitoring site Flightaware.com.

He said his data did not include any passenger manifests, so he could not tell how many total passengers flew on the plane Tuesday.

The passenger "exhibited no symptoms or sign of illness while on Flight 1143, according to the crew," Frontier said.

The plane went through a routine but "thorough" cleaning Monday night, Frontier said. Airline industry experts said routine overnight cleaning includes wiping down tray tables, vacuuming carpet and disinfecting restrooms.

The healthcare worker also had flown to Cleveland from Dallas three days earlier on Frontier Flight 1142, the airline reported.

An official with the union that represents Frontier pilots said members were so concerned about possible exposure to the deadly virus that they began reaching out to doctors and other experts Wednesday for information about Ebola.


The airline said it was working with the CDC to contact all 132 passengers on the Monday flight that carried the Ebola patient.

Frontier could not be reached to confirm the FlightAware data, and it was unclear whether passengers on the additional flights were being contacted.

“It seems like it’s not that big of a risk, but it’s pretty scary,” said the union official, who asked to remain anonymous because he was not authorized to speak for the group.

The union official also said that Frontier sent pilots information Wednesday morning outlining the cleaning procedures the carrier was using to make sure the disease did not spread.

In response to the news that another Ebola patient had flown on a commercial flight, the union that represents 60,000 flight attendants on 19 airlines is asking the CDC to monitor and care for the four flight attendants who were on the Frontier flight from Cleveland to Dallas/Fort Worth.

The Assocciation. of Flight Attendants “will continue to press that crew members are regularly monitored and provided with any additional resources that may be required,” the group said.

The Ebola scare prompted the union last week to call for better measures to protect flight attendants from exposure to the deadly virus.

The group's international president, Sara Nelson, suggested that flight attendants are being asked to do too much in the fight against Ebola.

"We are not, however, professional healthcare providers and our members have neither the extensive training nor the specialized personal protective equipment required for handling an Ebola patient," she said in a statement.

Amber Joy Vinson of Dallas, traveled by air on October 13th, the day before she first reported symptoms.

Meanwhile, the trade group for the nation’s largest airlines said carriers were working with federal heath officials “to ensure we are doing all we can to protect the well-being of our passengers, our crew members and the American public.”

Airlines for America, whose members do not include Frontier, said its airlines are all equipped with “universal precautions kits” that include gloves, masks, aprons and biological waste bags to clean up any medical spill or accident on a plane.

Earlier this month, United Airlines was rushing to contact passengers who flew on two flights that carried a Liberian man infected with Ebola from Brussels to Washington, D.C., and then to Dallas.

The Ebola-stricken healthcare worker who flew on Frontier had been treating the Liberian man, Thomas Eric Duncan, who has since died.

The latest scare has forced some air travelers to think twice about flying.

“It is very scary and my travel is now very, very limited,” Bruce Remick of Hollywood said. “I prefer Skype conferencing.”

Airline-industry stock prices have taken a beating in recent weeks, with some analysts blaming the Ebola scare.

On Wednesday, stocks of Delta Air Lines and United Airlines fell more than 1%. A New York Stock Exchange index of airline stock is down 11.57% over the last month. Frontier is privately held.




.

Ebola maybe airborne

SUBHEAD: CIDRAP believes there is scientific evidence Ebola has potential to infect as aerosol.

By Tyler Durden on 13 October 2014 for Zero Hedge -
(http://www.zerohedge.com/news/2014-10-13/cidrap-we-believe-there-scientific-evidence-ebola-has-potential-be-airborne)


Image above: Self contained breathing apparati for highly contagious health environments. From (http://www.approvedgasmasks.com/msa-optimairHC.htm).

When CDC Director Tim Frieden first announced, just a week ago and very erroneously, that he was "confident we will stop Ebola in its tracks here in the United States", he hardly anticipated facing the double humiliation of not only having the first person-to-person transmission of Ebola on US soil taking place within a week, but that said transmission would impact a supposedly protected healthcare worker. He certainly did not anticipate the violent public reaction that would result when, instead of taking blame for another epic CDC blunder, one which made many wonder if last night's Walking Dead season premier was in fact non-fiction, he blamed health workers for "not following protocol."

And yet, while once again casting scapegoating and blame, the CDC sternly refuses to acknowledge something others, and not just tingoil blog sites, are increasingly contemplating as a distinct possibility: namely that Ebola is, contrary to CDC "protocol", in fact airborne. Or as, an article posted by CIDRAP defines it, "aerosolized."

Who is CIDRAP?  "The Center for Infectious Disease Research and Policy (CIDRAP; "SID-wrap") is a global leader in addressing public health preparedness and emerging infectious disease response. Founded in 2001, CIDRAP is part of the Academic Health Center at the University of Minnesota."

The full punchline from the CIDRAP report:

We believe there is scientific and epidemiologic evidence that Ebola virus has the potential to be transmitted via infectious aerosol particles both near and at a distance from infected patients, which means that healthcare workers should be wearing respirators, not facemasks.

In other words, airborne. And now the search for the next LAKE, i.e., a public company maker of powered air-purifying respirator (PAPR), begins.

Here is the full note: we hope the CDC will take the time to read it.

Health workers need optimal respiratory protection for Ebola
Today's commentary was submitted to CIDRAP by the authors, who are national experts on respiratory protection and infectious disease transmission. In May they published a similar commentary on MERS-CoV. Dr Brosseau is a Professor and Dr Jones an Assistant Professor in the School of Public Health, Division of Environmental and Occupational Health Sciences, at the University of Illinois at Chicago.

Healthcare workers play a very important role in the successful containment of outbreaks of infectious diseases like Ebola. The correct type and level of personal protective equipment (PPE) ensures that healthcare workers remain healthy throughout an outbreak—and with the current rapidly expanding Ebola outbreak in West Africa, it's imperative to favor more conservative measures.

The precautionary principle—that any action designed to reduce risk should not await scientific certainty—compels the use of respiratory protection for a pathogen like Ebola virus that has:

• No proven pre- or post-exposure treatment modalities
• A high case-fatality rate
• Unclear modes of transmission

We believe there is scientific and epidemiologic evidence that Ebola virus has the potential to be transmitted via infectious aerosol particles both near and at a distance from infected patients, which means that healthcare workers should be wearing respirators, not facemasks.¹

The minimum level of protection in high-risk settings should be a respirator with an assigned protection factor greater than 10. A powered air-purifying respirator (PAPR) with a hood or helmet offers many advantages over an N95 filtering facepiece or similar respirator, being more protective, comfortable, and cost-effective in the long run.

We strongly urge the US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) to seek funds for the purchase and transport of PAPRs to all healthcare workers currently fighting the battle against Ebola throughout Africa—and beyond.

There has been a lot of on-line and published controversy about whether Ebola virus can be transmitted via aerosols. Most scientific and medical personnel, along with public health organizations, have been unequivocal in their statements that Ebola can be transmitted only by direct contact with virus-laden fluids^2,3 and that the only modes of transmission we should be concerned with are those termed "droplet" and "contact."

These statements are based on two lines of reasoning. The first is that no one located at a distance from an infected individual has contracted the disease, or the converse, every person infected has had (or must have had) "direct" contact with the body fluids of an infected person.

This reflects an incorrect and outmoded understanding of infectious aerosols, which has been institutionalized in policies, language, culture, and approaches to infection control. We will address this below. Briefly, however, the important points are that virus-laden bodily fluids may be aerosolized and inhaled while a person is in proximity to an infectious person and that a wide range of particle sizes can be inhaled and deposited throughout the respiratory tract.

The second line of reasoning is that respirators or other control measures for infectious aerosols cannot be recommended in developing countries because the resources, time, and/or understanding for such measures are lacking.⁴

Although there are some important barriers to the use of respirators, especially PAPRs, in developing countries, healthcare workers everywhere deserve and should be afforded the same best-practice types of protection, regardless of costs and resources. Every healthcare worker is a precious commodity whose well-being ensures everyone is protected.

If we are willing to offer infected US healthcare workers expensive treatments and experimental drugs free of charge when most of the world has no access to them, we wonder why we are unwilling to find the resources to provide appropriate levels of comparatively less expensive respiratory protection to every healthcare worker around the world.

How are infectious diseases transmitted via aerosols?
Medical and infection control professionals have relied for years on a paradigm for aerosol transmission of infectious diseases based on very outmoded research and an overly simplistic interpretation of the data. In the 1940s and 50s, William F. Wells and other "aerobiologists" employed now significantly out-of-date sampling methods (eg, settling plates) and very blunt analytic approaches (eg, cell culturing) to understand the movement of bacterial aerosols in healthcare and other settings. Their work, though groundbreaking at the time, provides a very incomplete picture.

Early aerobiologists were not able to measure small particles near an infectious person and thus assumed such particles existed only far from the source. They concluded that organisms capable of aerosol transmission (termed "airborne") can only do so at around 3 feet or more from the source. Because they thought that only larger particles would be present near the source, they believed people would be exposed only via large "droplets" on their face, eyes, or nose.

Modern research, using more sensitive instruments and analytic methods, has shown that aerosols emitted from the respiratory tract contain a wide distribution of particle sizes—including many that are small enough to be inhaled.^5,6 Thus, both small and large particles will be present near an infectious person.

The chance of large droplets reaching the facial mucous membranes is quite small, as the nasal openings are small and shielded by their external and internal structure. Although close contact may permit large-droplet exposure, it also maximizes the possibility of aerosol inhalation.

As noted by early aerobiologists, liquid in a spray aerosol, such as that generated during coughing or sneezing, will quickly evaporate,⁷ which increases the concentration of small particles in the aerosol. Because evaporation occurs in milliseconds, many of these particles are likely to be found near the infectious person.

The current paradigm also assumes that only "small" particles (less than 5 micrometers [mcm]) can be inhaled and deposited in the respiratory tract. This is not true. Particles as large as 100 mcm (and perhaps even larger) can be inhaled into the mouth and nose. Larger particles are deposited in the nasal passages, pharynx, and upper regions of the lungs, while smaller particles are more likely to deposit in the lower, alveolar regions. And for many pathogens, infection is possible regardless of the particle size or deposition site.

It's time to abandon the old paradigm of three mutually exclusive transmission routes for a new one that considers the full range of particle sizes both near and far from a source. In addition, we need to factor in other important features of infectivity, such as the ability of a pathogen to remain viable in air at room temperature and humidity and the likelihood that systemic disease can result from deposition of infectious particles in the respiratory system or their transfer to the gastrointestinal tract.
We recommend using "aerosol transmissible" rather than the outmoded terms "droplet" or "airborne" to describe pathogens that can transmit disease via infectious particles suspended in air.


Is Ebola an aerosol-transmissible disease?
We recently published a commentary on the CIDRAP site discussing whether Middle East respiratory syndrome (MERS) could be an aerosol-transmissible disease, especially in healthcare settings. We drew comparisons with a similar and more well-studied disease, severe acute respiratory syndrome (SARS).

For Ebola and other filoviruses, however, there is much less information and research on disease transmission and survival, especially in healthcare settings.

Being at first skeptical that Ebola virus could be an aerosol-transmissible disease, we are now persuaded by a review of experimental and epidemiologic data that this might be an important feature of disease transmission, particularly in healthcare settings.

What do we know about Ebola transmission?
No one knows for certain how Ebola virus is transmitted from one person to the next. The virus has been found in the saliva, stool, breast milk, semen, and blood of infected persons.^8,9 Studies of transmission in Ebola virus outbreaks have identified activities like caring for an infected person, sharing a bed, funeral activities, and contact with blood or other body fluids to be key risk factors for transmission.^10-12

On the basis of epidemiologic evidence, it has been presumed that Ebola viruses are transmitted by contaminated hands in contact with the mouth or eyes or broken skin or by splashes or sprays of body fluids into these areas. Ebola viruses appear to be capable of initiating infection in a variety of human cell types,^13,14 but the primary portal or portals of entry into susceptible hosts have not been identified.

Some pathogens are limited in the cell type and location they infect. Influenza, for example, is generally restricted to respiratory epithelial cells, which explains why flu is primarily a respiratory infection and is most likely aerosol transmissible. HIV infects T-helper cells in the lymphoid tissues and is primarily a bloodborne pathogen with low probability for transmission via aerosols.

Ebola virus, on the other hand, is a broader-acting and more non-specific pathogen that can impede the proper functioning of macrophages and dendritic cells—immune response cells located throughout the epithelium.^15,16 Epithelial tissues are found throughout the body, including in the respiratory tract. Ebola prevents these cells from carrying out their antiviral functions but does not interfere with the initial inflammatory response, which attracts additional cells to the infection site. The latter contribute to further dissemination of the virus and similar adverse consequences far beyond the initial infection site.

The potential for transmission via inhalation of aerosols, therefore, cannot be ruled out by the observed risk factors or our knowledge of the infection process. Many body fluids, such as vomit, diarrhea, blood, and saliva, are capable of creating inhalable aerosol particles in the immediate vicinity of an infected person. Cough was identified among some cases in a 1995 outbreak in Kikwit, Democratic Republic of the Congo,¹¹ and coughs are known to emit viruses in respirable particles.¹⁷

The act of vomiting produces an aerosol and has been implicated in airborne transmission of gastrointestinal viruses.^18,19 Regarding diarrhea, even when contained by toilets, toilet flushing emits a pathogen-laden aerosol that disperses in the air.^20-22

Experimental work has shown that Marburg and Ebola viruses can be isolated from sera and tissue culture medium at room temperature for up to 46 days, but at room temperature no virus was recovered from glass, metal, or plastic surfaces.²³ Aerosolized (1-3 mcm) Marburg, Ebola, and Reston viruses, at 50% to 55% relative humidity and 72°F, had biological decay rates of 3.04%, 3.06%. and 1.55% per minute, respectively. These rates indicate that 99% loss in aerosol infectivity would occur in 93, 104, and 162 minutes, respectively.²³

In still air, 3-mcm particles can take up to an hour to settle. With air currents, these and smaller particles can be transported considerable distances before they are deposited on a surface.
There is also some experimental evidence that Ebola and other filoviruses can be transmitted by the aerosol route. Jaax et al²⁴ reported the unexpected death of two rhesus monkeys housed approximately 3 meters from monkeys infected with Ebola virus, concluding that respiratory or eye exposure to aerosols was the only possible explanation.

Zaire Ebola viruses have also been transmitted in the absence of direct contact among pigs²⁵ and from pigs to non-human primates,²⁶ which experienced lung involvement in infection. Persons with no known direct contact with Ebola virus disease patients or their bodily fluids have become infected.¹²

Direct injection and exposure via a skin break or mucous membranes are the most efficient ways for Ebola to transmit. It may be that inhalation is a less efficient route of transmission for Ebola and other filoviruses, as lung involvement has not been reported in all non-human primate studies of Ebola aerosol infectivity.²⁷ However, the respiratory and gastrointestinal systems are not complete barriers to Ebola virus. Experimental studies have demonstrated that it is possible to infect non-human primates and other mammals with filovirus aerosols.^25-27

Altogether, these epidemiologic and experimental data offer enough evidence to suggest that Ebola and other filoviruses may be opportunistic with respect to aerosol transmission.²⁸ That is, other routes of entry may be more important and probable, but, given the right conditions, it is possible that transmission could also occur via aerosols.

Guidance from the CDC and WHO recommends the use of facemasks for healthcare workers providing routine care to patients with Ebola virus disease and respirators when aerosol-generating procedures are performed. (Interestingly, the 1998 WHO and CDC infection-control guidance for viral hemorrhagic fevers in Africa, still available on the CDC Web site, recommends the use of respirators.)

Facemasks, however, do not offer protection against inhalation of small infectious aerosols, because they lack adequate filters and do not fit tightly against the face.¹ Therefore, a higher level of protection is necessary.

Which respirator to wear?
As described in our earlier CIDRAP commentary, we can use a Canadian control-banding approach to select the most appropriate respirator for exposures to Ebola in healthcare settings.²⁹ (See this document for a detailed description of the Canadian control banding approach and the data used to select respirators in our examples below.)

The control banding method involves the following steps:

1. Identify the organism's risk group (1 to 4). Risk group reflects the toxicity of an organism, including the degree and type of disease and whether treatments are available. Ebola is in risk group 4, the most toxic organisms, because it can cause serious human or animal disease, is easily transmitted, directly or indirectly, and currently has no effective treatments or preventive measures.
2. Identify the generation rate. The rate of aerosol generation reflects the number of particles created per time (eg, particles per second). Some processes, such as coughing, create more aerosols than others, like normal breathing. Some processes, like intubation and toilet flushing, can rapidly generate very large quantities of aerosols. The control banding approach assigns a qualitative rank ranging from low (1) to high (4) (eg, normal breathing without coughing has a rank of 1).
3. Identify the level of control. Removing contaminated air and replacing it with clean air, as accomplished with a ventilation system, is effective for lowering the overall concentration of infectious aerosol particles in a space, although it may not be effective at lowering concentration in the immediate vicinity of a source. The number of air changes per hour (ACH) reflects the rate of air removal and replacement. This is a useful variable, because it is relatively easy to measure and, for hospitals, reflects building code requirements for different types of rooms. Again, a qualitative ranking is used to reflect low (1) versus high (4) ACH. Even if the true ventilation rate is not known, the examples can be used to select an appropriate air exchange rate.
4. Identify the respirator assigned protection factor. Respirators are designated by their "class," each of which has an assigned protection factor (APF) that reflects the degree of protection. The APF represents the outside, environmental concentration divided by the inside, facepiece concentration. An APF of 10 means that the outside concentration of a particular contaminant will be 10 times greater than that inside the respirator. If the concentration outside the respirator is very high, an assigned protection factor of 10 may not prevent the wearer from inhaling an infective dose of a highly toxic organism.

Practical examples
Two examples follow. These assume that infectious aerosols are generated only during vomiting, diarrhea, coughing, sneezing, or similar high-energy emissions such as some medical procedures. It is possible that Ebola virus may be shed as an aerosol in other manners not considered.

Caring for a patient in the early stages of disease (no bleeding, vomiting, diarrhea, coughing, sneezing, etc). In this case, the generation rate is 1. For any level of control (less than 3 to more than 12 ACH), the control banding wheel indicates a respirator protection level of 1 (APF of 10), which corresponds to an air purifying (negative pressure) half-facepiece respirator such as an N95 filtering facepiece respirator. This type of respirator requires fit testing.

Caring for a patient in the later stages of disease (bleeding, vomiting, diarrhea, etc). If we assume the highest generation rate (4) and a standard patient room (control level = 2, 3-6 ACH), a respirator with an APF of at least 50 is needed. In the United States, this would be equivalent to either a full-facepiece air-purifying (negative-pressure) respirator or a half-facepiece PAPR (positive pressure), but standards differ in other countries. Fit testing is required for these types of respirators.
The control level (room ventilation) can have a big effect on respirator selection. For the same patient housed in a negative-pressure airborne infection isolation room (6-12 ACH), a respirator with an assigned protection factor of 25 is required. This would correspond in the United States to a PAPR with a loose-fitting facepiece or with a helmet or hood. This type of respirator does not need fit testing.

Implications for protecting health workers in Africa
Healthcare workers have experienced very high rates of morbidity and mortality in the past and current Ebola virus outbreaks. A facemask, or surgical mask, offers no or very minimal protection from infectious aerosol particles. As our examples illustrate, for a risk group 4 organism like Ebola, the minimum level of protection should be an N95 filtering facepiece respirator.

This type of respirator, however, would only be appropriate only when the likelihood of aerosol exposure is very low. For healthcare workers caring for many patients in an epidemic situation, this type of respirator may not provide an adequate level of protection.

For a risk group 4 organism, any activity that has the potential for aerosolizing liquid body fluids, such as medical or disinfection procedures, should be avoided, if possible. Our risk assessment indicates that a PAPR with a full facepiece (APF = 50) or a hood or helmet (APF = 25) would be a better choice for patient care during epidemic conditions.

We recognize that PAPRs present some logistical and infection-control problems. Batteries require frequent charging (which requires a reliable source of electricity), and the entire ensemble requires careful handling and disinfection between uses. A PAPR is also more expensive to buy and maintain than other types of respirators.

On the other hand, a PAPR with a loose-fitting facepiece (hood or helmet) does not require fit testing. Wearing this type of respirator minimizes the need for other types of PPE, such as head coverings and goggles. And, most important, it is much more comfortable to wear than a negative-pressure respirator like an N95, especially in hot environments.

A recent report from a Medecins Sans Frontieres healthcare worker in Sierra Leone³⁰ notes that healthcare workers cannot tolerate the required PPE for more than 40 minutes. Exiting the workplace every 40 minutes requires removal and disinfection or disposal (burning) of all PPE. A PAPR would allow much longer work periods, use less PPE, require fewer doffing episodes, generate less infectious waste, and be more protective. In the long run, we suspect this type of protection could also be less expensive.

Adequate protection is essentialTo summarize, for the following reasons we believe that Ebola could be an opportunistic aerosol-transmissible disease requiring adequate respiratory protection:

• Patients and procedures generate aerosols, and Ebola virus remains viable in aerosols for up to 90 minutes.
• All sizes of aerosol particles are easily inhaled both near to and far from the patient.
• Crowding, limited air exchange, and close interactions with patients all contribute to the probability that healthcare workers will be exposed to high concentrations of very toxic infectious aerosols.
• Ebola targets immune response cells found in all epithelial tissues, including in the respiratory and gastrointestinal system.
• Experimental data support aerosols as a mode of disease transmission in non-human primates.

Risk level and working conditions suggest that a PAPR will be more protective, cost-effective, and comfortable than an N95 filtering facepiece respirator.

Acknowledgements
We thank Kathleen Harriman, PhD, MPH, RN, Chief, Vaccine Preventable Diseases Epidemiology Section, Immunization Branch, California Department of Public Health, and Nicole Vars McCullough, PhD, CIH, Manager, Global Technical Services, Personal Safety Division, 3M Company, for their input and review.
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See also:
Ea O Ka Aina: Ebola may be airborne in cold 9/16/14


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