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Original antigenic sin

Original antigenic sin , also known as antigenic imprinting , the Hoskins effect , immunological imprinting , or primary addiction is the propensity of the immune system to preferentially use immunological memory based on a previous infection when a second slightly different version of that foreign pathogen (e.g. a virus or bacterium ) is encountered. This leaves the immune system "trapped" by the first response it has made to each antigen , and unable to mount potentially more effective responses during subsequent infections. Antibodies or T-cells induced during infections with the first variant of the pathogen are subject to repertoire freeze, a form of original antigenic sin. The phenomenon has been described in relation to influenza virus , SARS-CoV-2 , dengue fever , human immunodeficiency virus (HIV) and to several other viruses. This phenomenon was first described in 1960 by Thomas Francis Jr. in the article "On the Doctrine of Original Antigenic Sin". It is named by analogy to the Christian theological concept of original sin . According to Francis as cited by Richard Krause : The antibody of childhood is largely a response to dominant antigen of the virus causing the first type A influenza infection of the lifetime. [...] The imprint established by the original virus infection governs the antibody response thereafter. This we have called the Doctrine of the Original Antigenic Sin.During a primary infection , long-lived memory B cells are generated, which remain in the body and protect from subsequent infections. These memory B cells respond to specific epitopes on the surface of viral proteins to produce antigen-specific antibodies and can respond to infection much faster than naive B cells can to novel antigens. This effect lessens time needed to clear subsequent infections. Between primary and secondary infections or following vaccination , a virus may undergo antigenic drift , in which the viral surface proteins (the epitopes) change through natural mutation. This allows the virus to escape the immune system. The altered virus preferentially reactivates previously activated high-affinity memory B cells and spurs antibody production. However, the antibodies produced generally ineffectively bind to the altered epitopes. In addition, these antibodies inhibit activation of naive B cells that could make more effective antibodies to the second virus. This leads to a less effective immune response and recurrent infections may take longer to clear. Original antigenic sin has important implications for vaccine development . In dengue fever , for example, once a response against one serotype has been established, it is unlikely that vaccination against a second will be effective. This implies that balanced responses against all four virus serotypes must be established with the first vaccine dose. Activation of naive B cells that recognize novel epitopes may be attenuated with repeated infection with variant influenza viruses. However, the impact of antigenic sin on protection has not been well established and appears to differ with each infectious agent vaccine, geographic location, and age. Research done in 2011 found reduced antibody responses to the 2009 pandemic H1N1 influenza vaccine in individuals who had been vaccinated against the seasonal A/Brisbane/59/2007 (H1N1) within the previous three months. The relative ineffectiveness of the bivalent booster against the SARS-CoV-2 Omicron variant in patients who had previously received COVID-19 vaccines has been attributed to immunological imprinting. A similar phenomenon has been described in cytotoxic T cells (CTL). It has been demonstrated that during a second infection by a different strain of dengue virus, the CTLs prefer to release cytokines instead of causing cell lysis . As a result, the production of these cytokines is thought to increase vascular permeability and exacerbate damage to endothelial cells, resulting in dengue hemorrhagic fever . Several groups have attempted to design vaccines for HIV and hepatitis C based on induction of CTL response. The finding that the CTL response may be biased by original antigenic sin may help to explain the limited effectiveness of these vaccines. Viruses like HIV are highly variable and undergo mutation frequently; due to original antigenic sin, HIV infection induced by viruses that express slightly different epitopes (than those in a viral vaccine) might fail to be controlled by the vaccine. It has been hypothesized that: if original antigenic sin is a common phenomenon, a naively designed single-component vaccine could conceivably make an infection even worse than if no vaccination at all had occurred. The hypothesized mechanism is that the immune response would be "trapped" in a less effective response. Therefore, a recommendation was made for vaccines with multiple components or that target conserved epitopes.

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Dengue fever

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Aedes albopictus

Culex albopictus Skuse , 1894 Aedes albopictus ( Stegomyia albopicta ), from the mosquito (Culicidae) family , also known as the (Asian) tiger mosquito or forest mosquito , is a mosquito native to the tropical and subtropical areas of Southeast Asia. In the past few centuries, however, this species has spread to many countries through the transport of goods and international travel. It is characterized by the white bands on its legs and body. This mosquito has become a significant pest in many communities because it closely associates with humans (rather than living in wetlands), and typically flies and feeds in the daytime in addition to at dusk and dawn. The insect is called a tiger mosquito for its striped appearance, which resembles that of the tiger . Ae. albopictus is an epidemiologically important vector for the transmission of many viral pathogens , including the yellow fever virus , dengue fever , and Chikungunya fever , as well as several filarial nematodes such as Dirofilaria immitis . Aedes albopictus is capable of hosting the Zika virus and is considered a potential vector for Zika transmission among humans.In 1894, a British-Australian entomologist, Frederick A. Askew Skuse , was the first to scientifically describe the Asian tiger mosquito, which he named Culex albopictus ( lat. culex "gnat", "midge" and albopictus "white-painted"). Later, the species was assigned to the genus Aedes ( gr. άηδής , "unpleasant") and referred to as Aedes albopictus . Like the yellow fever mosquito , it belongs to the subgenus Stegomyia (Gr. στέγος , "covered, roofed", referring to the scales that completely cover the dorsal surface in this subgenus, and Î¼Ï Î¯Î± , "fly") within the genus Aedes . In 2004, scientists explored higher-level relationships and proposed a new classification within the genus Aedes and Stegomyia was elevated to the genus level, making Aedes albopictus now Stegomyia albopicta . This is, however, a controversial matter, and the use of Stegomyia albopicta versus Aedes albopictus is continually debated. The adult Asian tiger mosquito is less than 10 mm (0.39 in) long from end to end with a striking white and black pattern. The variation of the body size in adult mosquitoes depends on the density of the larval population and food supply within the breeding water. Since these circumstances are seldom optimal, the average body size of adult mosquitoes is considerably smaller than 10 mm. For example, the average length of the abdomen was calculated to be 2.63 mm (0.104 in) , the wings 2.7 mm (0.11 in) , and the proboscis 1.88 mm (0.074 in) . The males are roughly 20% smaller than the females, but they are morphologically very similar. However, as in all mosquito species, the antennae of the males in comparison to the females are noticeably bushier and contain auditory receptors to detect the characteristic whine, almost inaudible to humans, of the female. The maxillary palps of the males are also longer than their proboscis, whereas the females' maxillary palps are much shorter. (This is typical for the males of the Culicinae .) In addition, the tarsus of the hind legs of the males is more silvery. Tarsomere IV is roughly 75% silver in the males whereas the females' is only about 60% silver. [ citation needed ] The other characteristics do not differentiate between sexes. A single silvery-white line of tight scales begins between the eyes and continues down the dorsal side of the thorax. This characteristic marking is the easiest and surest way to identify the Asian tiger mosquito. [ citation needed ] The proboscis is dark colored, the upper surface of the end segment of the palps is covered in silvery scales, and the labium does not feature a light line on its underside. The compound eyes are distinctly separated from one another. The scute , the dorsal portion of an insect's thoracic segment, is black alongside the characteristic white midline. On the side of the thorax, the scutellum , and the abdomen are numerous spots covered in white-silvery scales. [ citation needed ] Such white-silvery scales can also be found on the tarsus, particularly on the hind legs that are commonly suspended in the air. The bases of tarsomeres I through IV have a ring of white scales, creating the appearance of white and black rings. On the forelegs and middle legs, only the first three tarsomeres have the ring of white scales, whereas tarsomere V on the hind legs is completely white. The femur of each leg is also black with white scales on the end of the "knee". The femora of the middle legs do not feature a silver line on the base of the upper side, whereas, the femora on the hind legs have short white lines on base of the upper side. The tibiae are black on the base and have no white scales. [ citation needed ] The terga on segments II through VI of the abdomen are dark and have an almost triangular silvery-white marking on the base that is not aligned with the silvery bands of scales on the ventral side of the abdomen. The triangular marking and the silvery band are only aligned on abdominal segment VII. The transparent wings have white spots on the base of the costae. With older mosquito specimens, the scales could be partially worn off, making these characteristics not stand out as much. As with other members of the mosquito family, the female is equipped with an elongated proboscis that she uses to collect blood to feed her eggs. The Asian tiger mosquito has a rapid bite and an agility that allows it to escape most attempts by people to swat it. By contrast, the male member of the species primarily feeds on nectar and does not bite. The female lays her eggs near water, not directly into it as other mosquitoes do, but typically near a stagnant pool. However, any open container containing water will suffice for larvae development, even with less than one US fl oz (30 ml) of water. It can also breed in running water, so stagnant pools of water are not its only breeding sites. It is more likely to lay eggs in water sources near flowers than in water sources without flowers. It has a short flight range (less than 200 m (220 yd) ), so breeding sites are likely to be close to where this mosquito is found. Other mosquito species may be visually confused with the tiger mosquito. Comparison with approved pictures is the best way to determine the species with certainty. Behavioral cues like almost-silent flight and difficulty in catching combined with knowledge of the range of local endemic mosquitoes may also aid this process. Some mosquitoes in North America, such as Ochlerotatus canadensis , have a similar leg pattern. In North and South America, Ae. albopictus can be distinguished from Aedes taeniorhynchus since only Ae. albopictus has back markings. In Europe, the mosquito Culiseta annulata , which is very common, but does not occur in high densities, can be mistaken for an Asian tiger mosquito because of its black-and-white-ringed legs. However, this species is missing the distinctive white line that runs from the middle of its head and down the thorax. It is also considerably larger than Ae. albopictus , is not black and white, but rather beige and grey striped, and has wings with noticeable veins and four dark, indistinct spots. The Tree Hole mosquito or Aedes geniculatus – a native to Europe and North Africa – has also been mistaken for Ae. albopictus. This is because the Tree Hole mosquito has very white scales on a very similar body. In the eastern Mediterranean area, Ae. albopictus species can be mistaken for Aedes cretinus , which also belongs to the subgenus Stegomyia and uses similar breeding waters. Aedes cretinus also has a white stripe on the scute , but it ends shortly before the abdomen, and also has two additional stripes to the left and right of the middle stripe. So far Aedes cretinus is only located in Cyprus, Greece, North Macedonia, Georgia and Turkey. In Asia, the Asian tiger mosquito can be mistaken for other members of the subgenus Stegomyia , particularly the yellow fever mosquito Aedes aegypti (the most prevalent species in the tropics and subtropics), because both species display a similar black and white pattern. It can be hard to distinguish Ae. albopictus from the closely related Aedes scutellaris (India, Indonesia, Papua New Guinea , and the Philippines ), Aedes pseudoalbopictus ( India , Indonesia, Malaysia , Myanmar , Nepal, Taiwan , Thailand, and Vietnam ) and Aedes seatoi (Thailand). Like other mosquito species, only the females require a blood meal to develop their eggs. Apart from that, they feed on nectar and other sweet plant juices just as the males do. In regards to host location, carbon dioxide and organic substances produced from the host, humidity, and optical recognition play important roles. [ citation needed ] The search for a host takes place in two phases. First, the mosquito exhibits a nonspecific searching behavior until it perceives host stimulants, whereupon it secondly takes a targeted approach. For catching tiger mosquitoes with special traps, carbon dioxide and a combination of chemicals that naturally occur in human skin ( fatty acids , ammonia , and lactic acid ) are the most attractive. The Asian tiger mosquito particularly bites in forests during the day, so has been known as the forest day mosquito. Depending upon region and biotype, activity peaks differ, but for the most part, they rest during the morning and night hours. They search for their hosts inside and outside human dwellings, but are particularly active outside. The size of the blood meal depends upon the size of the mosquito, but it is usually around 2 μl. Their bites are not necessarily painful, but they are more noticeable than those from other kinds of mosquitoes. Tiger mosquitoes generally tend to bite a human host more than once if they are able to. Ae. albopictus also bites other mammals besides humans, as well as birds. The females are always on the search for a host and are persistent but cautious when it comes to their blood meal and host location. Their blood meal is often broken off before enough blood has been ingested for the development of their eggs, so Asian tiger mosquitoes bite multiple hosts during their development cycle of the egg, making them particularly efficient at transmitting diseases. The mannerism of biting diverse host species enables the Asian tiger mosquito to be a potential bridge vector for certain pathogens that can jump species boundaries, for example the West Nile virus . [ citation needed ] Primarily, other mosquito larvae, flatworms , swimming beetles, fungi , ciliates , paramecia , protozoans which act as parasites, predatory copepods , and spiders are natural enemies of the larval stage of Asian tiger mosquitoes. [ citation needed ] Toxorhynchites larvae, a mosquito genus that does not suck blood, feeds upon other mosquito larvae and are often found with tiger mosquito larvae. Flatworms and small swimming beetles are considered natural predators. Fungi from the genus Coelomomyces (order Blastocladiales ) develop inside the visceral cavity of mosquito larvae. The species Coelomomyces stegomyiae was first found on the Asian tiger mosquito. Paramecia , or ciliates, can also affect Ae. albopictus larvae, and the first detected species was Lambornella stegomyiae (Hymenostomatida: Tetrahymenidae). The virulence, mortality rate, and subsequent possibilities of Lambornella being implemented as a biological remedy to control Ae. albopictus , however, has conflicting views. Sporozoans of the genus Ascogregarina ( Lecudinidae ) infect the larval stage of mosquitoes. The species Ascogregarina taiwanensis was found in Asian tiger mosquitoes. When the adult mosquitoes emerge from their pupal case, they leave the infectious intermediary stage of parasites in the water and close off the infection cycle. Infected adults are generally smaller than non-infected adults and have an insignificantly higher mortality rate; therefore, food supply and larval density apparently play a role. In competitive situations, an infection with sporozoans can also reduce the biological fitness of other uninfected mosquitoes. However, the use of the parasites as an effective biological remedy to control mosquito populations is implausible because the host must reach the adult stage for the transmission of the parasites. Though they do not commonly occur in the natural habitats of Asian tiger mosquitoes, predatory copepods from the family Cyclopidae seem to willingly feed on them given the opportunity. Relatives of different genera could therefore present a possibility in the control of tiger mosquitoes. Predators of adult Ae. albopictus in Malaysia include various spider species. Up to 90% of the gathered spiders from rubber plantations and a cemetery fed upon Asian tiger mosquitoes. Whether the spiders would have an effect on the mosquito population is still unclear. Tiger mosquitoes were abundantly present despite the existence of the spiders. In 1894, a British-Australian entomologist, Frederick A. Askew Skuse , was the first to scientifically describe the Asian tiger mosquito, which he named Culex albopictus ( lat. culex "gnat", "midge" and albopictus "white-painted"). Later, the species was assigned to the genus Aedes ( gr. άηδής , "unpleasant") and referred to as Aedes albopictus . Like the yellow fever mosquito , it belongs to the subgenus Stegomyia (Gr. στέγος , "covered, roofed", referring to the scales that completely cover the dorsal surface in this subgenus, and Î¼Ï Î¯Î± , "fly") within the genus Aedes . In 2004, scientists explored higher-level relationships and proposed a new classification within the genus Aedes and Stegomyia was elevated to the genus level, making Aedes albopictus now Stegomyia albopicta . This is, however, a controversial matter, and the use of Stegomyia albopicta versus Aedes albopictus is continually debated. The adult Asian tiger mosquito is less than 10 mm (0.39 in) long from end to end with a striking white and black pattern. The variation of the body size in adult mosquitoes depends on the density of the larval population and food supply within the breeding water. Since these circumstances are seldom optimal, the average body size of adult mosquitoes is considerably smaller than 10 mm. For example, the average length of the abdomen was calculated to be 2.63 mm (0.104 in) , the wings 2.7 mm (0.11 in) , and the proboscis 1.88 mm (0.074 in) . The males are roughly 20% smaller than the females, but they are morphologically very similar. However, as in all mosquito species, the antennae of the males in comparison to the females are noticeably bushier and contain auditory receptors to detect the characteristic whine, almost inaudible to humans, of the female. The maxillary palps of the males are also longer than their proboscis, whereas the females' maxillary palps are much shorter. (This is typical for the males of the Culicinae .) In addition, the tarsus of the hind legs of the males is more silvery. Tarsomere IV is roughly 75% silver in the males whereas the females' is only about 60% silver. [ citation needed ] The other characteristics do not differentiate between sexes. A single silvery-white line of tight scales begins between the eyes and continues down the dorsal side of the thorax. This characteristic marking is the easiest and surest way to identify the Asian tiger mosquito. [ citation needed ] The proboscis is dark colored, the upper surface of the end segment of the palps is covered in silvery scales, and the labium does not feature a light line on its underside. The compound eyes are distinctly separated from one another. The scute , the dorsal portion of an insect's thoracic segment, is black alongside the characteristic white midline. On the side of the thorax, the scutellum , and the abdomen are numerous spots covered in white-silvery scales. [ citation needed ] Such white-silvery scales can also be found on the tarsus, particularly on the hind legs that are commonly suspended in the air. The bases of tarsomeres I through IV have a ring of white scales, creating the appearance of white and black rings. On the forelegs and middle legs, only the first three tarsomeres have the ring of white scales, whereas tarsomere V on the hind legs is completely white. The femur of each leg is also black with white scales on the end of the "knee". The femora of the middle legs do not feature a silver line on the base of the upper side, whereas, the femora on the hind legs have short white lines on base of the upper side. The tibiae are black on the base and have no white scales. [ citation needed ] The terga on segments II through VI of the abdomen are dark and have an almost triangular silvery-white marking on the base that is not aligned with the silvery bands of scales on the ventral side of the abdomen. The triangular marking and the silvery band are only aligned on abdominal segment VII. The transparent wings have white spots on the base of the costae. With older mosquito specimens, the scales could be partially worn off, making these characteristics not stand out as much. As with other members of the mosquito family, the female is equipped with an elongated proboscis that she uses to collect blood to feed her eggs. The Asian tiger mosquito has a rapid bite and an agility that allows it to escape most attempts by people to swat it. By contrast, the male member of the species primarily feeds on nectar and does not bite. The female lays her eggs near water, not directly into it as other mosquitoes do, but typically near a stagnant pool. However, any open container containing water will suffice for larvae development, even with less than one US fl oz (30 ml) of water. It can also breed in running water, so stagnant pools of water are not its only breeding sites. It is more likely to lay eggs in water sources near flowers than in water sources without flowers. It has a short flight range (less than 200 m (220 yd) ), so breeding sites are likely to be close to where this mosquito is found. Other mosquito species may be visually confused with the tiger mosquito. Comparison with approved pictures is the best way to determine the species with certainty. Behavioral cues like almost-silent flight and difficulty in catching combined with knowledge of the range of local endemic mosquitoes may also aid this process.Some mosquitoes in North America, such as Ochlerotatus canadensis , have a similar leg pattern. In North and South America, Ae. albopictus can be distinguished from Aedes taeniorhynchus since only Ae. albopictus has back markings. In Europe, the mosquito Culiseta annulata , which is very common, but does not occur in high densities, can be mistaken for an Asian tiger mosquito because of its black-and-white-ringed legs. However, this species is missing the distinctive white line that runs from the middle of its head and down the thorax. It is also considerably larger than Ae. albopictus , is not black and white, but rather beige and grey striped, and has wings with noticeable veins and four dark, indistinct spots. The Tree Hole mosquito or Aedes geniculatus – a native to Europe and North Africa – has also been mistaken for Ae. albopictus. This is because the Tree Hole mosquito has very white scales on a very similar body. In the eastern Mediterranean area, Ae. albopictus species can be mistaken for Aedes cretinus , which also belongs to the subgenus Stegomyia and uses similar breeding waters. Aedes cretinus also has a white stripe on the scute , but it ends shortly before the abdomen, and also has two additional stripes to the left and right of the middle stripe. So far Aedes cretinus is only located in Cyprus, Greece, North Macedonia, Georgia and Turkey. In Asia, the Asian tiger mosquito can be mistaken for other members of the subgenus Stegomyia , particularly the yellow fever mosquito Aedes aegypti (the most prevalent species in the tropics and subtropics), because both species display a similar black and white pattern. It can be hard to distinguish Ae. albopictus from the closely related Aedes scutellaris (India, Indonesia, Papua New Guinea , and the Philippines ), Aedes pseudoalbopictus ( India , Indonesia, Malaysia , Myanmar , Nepal, Taiwan , Thailand, and Vietnam ) and Aedes seatoi (Thailand). Like other mosquito species, only the females require a blood meal to develop their eggs. Apart from that, they feed on nectar and other sweet plant juices just as the males do. In regards to host location, carbon dioxide and organic substances produced from the host, humidity, and optical recognition play important roles. [ citation needed ] The search for a host takes place in two phases. First, the mosquito exhibits a nonspecific searching behavior until it perceives host stimulants, whereupon it secondly takes a targeted approach. For catching tiger mosquitoes with special traps, carbon dioxide and a combination of chemicals that naturally occur in human skin ( fatty acids , ammonia , and lactic acid ) are the most attractive. The Asian tiger mosquito particularly bites in forests during the day, so has been known as the forest day mosquito. Depending upon region and biotype, activity peaks differ, but for the most part, they rest during the morning and night hours. They search for their hosts inside and outside human dwellings, but are particularly active outside. The size of the blood meal depends upon the size of the mosquito, but it is usually around 2 μl. Their bites are not necessarily painful, but they are more noticeable than those from other kinds of mosquitoes. Tiger mosquitoes generally tend to bite a human host more than once if they are able to. Ae. albopictus also bites other mammals besides humans, as well as birds. The females are always on the search for a host and are persistent but cautious when it comes to their blood meal and host location. Their blood meal is often broken off before enough blood has been ingested for the development of their eggs, so Asian tiger mosquitoes bite multiple hosts during their development cycle of the egg, making them particularly efficient at transmitting diseases. The mannerism of biting diverse host species enables the Asian tiger mosquito to be a potential bridge vector for certain pathogens that can jump species boundaries, for example the West Nile virus . [ citation needed ]Primarily, other mosquito larvae, flatworms , swimming beetles, fungi , ciliates , paramecia , protozoans which act as parasites, predatory copepods , and spiders are natural enemies of the larval stage of Asian tiger mosquitoes. [ citation needed ] Toxorhynchites larvae, a mosquito genus that does not suck blood, feeds upon other mosquito larvae and are often found with tiger mosquito larvae. Flatworms and small swimming beetles are considered natural predators. Fungi from the genus Coelomomyces (order Blastocladiales ) develop inside the visceral cavity of mosquito larvae. The species Coelomomyces stegomyiae was first found on the Asian tiger mosquito. Paramecia , or ciliates, can also affect Ae. albopictus larvae, and the first detected species was Lambornella stegomyiae (Hymenostomatida: Tetrahymenidae). The virulence, mortality rate, and subsequent possibilities of Lambornella being implemented as a biological remedy to control Ae. albopictus , however, has conflicting views. Sporozoans of the genus Ascogregarina ( Lecudinidae ) infect the larval stage of mosquitoes. The species Ascogregarina taiwanensis was found in Asian tiger mosquitoes. When the adult mosquitoes emerge from their pupal case, they leave the infectious intermediary stage of parasites in the water and close off the infection cycle. Infected adults are generally smaller than non-infected adults and have an insignificantly higher mortality rate; therefore, food supply and larval density apparently play a role. In competitive situations, an infection with sporozoans can also reduce the biological fitness of other uninfected mosquitoes. However, the use of the parasites as an effective biological remedy to control mosquito populations is implausible because the host must reach the adult stage for the transmission of the parasites. Though they do not commonly occur in the natural habitats of Asian tiger mosquitoes, predatory copepods from the family Cyclopidae seem to willingly feed on them given the opportunity. Relatives of different genera could therefore present a possibility in the control of tiger mosquitoes. Predators of adult Ae. albopictus in Malaysia include various spider species. Up to 90% of the gathered spiders from rubber plantations and a cemetery fed upon Asian tiger mosquitoes. Whether the spiders would have an effect on the mosquito population is still unclear. Tiger mosquitoes were abundantly present despite the existence of the spiders. The Asian tiger mosquito originally came from Southeast Asia. In 1966, parts of Asia and the island worlds of India and the Pacific Ocean were denoted as the area of circulation for the Asian tiger mosquito. Ae. albopictus as a native to tropical and subtropical regions with warm and humid climate, is active all year long; however, it has been adapting successfully to cooler, temperate regions, where they hibernate over winter. Eggs from strains in the temperate zones are more tolerant to the cold than ones from warmer regions. The species can even tolerate snow and temperatures under freezing. Adult tiger mosquitoes can survive throughout winter in suitable microhabitats. Since the mid-1960s, the tiger mosquito has spread to Europe, the Americas, the Caribbean, Africa, and the Middle East. As of 2008 Ae. albopictus was one of the 100 world's worst invasive species according to the Global Invasive Species Database. As of 2006, Ae. albopictus was not native to Australia and New Zealand. The species was introduced there multiple times, but has yet to establish itself. This is due to the well-organized entomological surveillance programs in the harbors and airports of these countries. Nevertheless, as of 2006 it has become domestic on the islands in the Torres Strait between Queensland, Australia, and New Guinea. In Europe, Asian tiger mosquitos first emerged in Albania in 1979, introduced through a shipment of goods from China. In 1990–1991, they were most likely brought to Italy in used tires from Georgia (USA), and since then have spread throughout the entire mainland of Italy, as well as parts of Sicily and Sardinia . Since 1999, they have established themselves on the mainland of France, primarily southern France. In 2002, they were also discovered in a vacation town on the island of Corsica , but did not completely establish themselves there until 2005. In Belgium , they were detected in 2000 and 2013, in 2001 in Montenegro, 2003 in Canton Ticino in southern Switzerland , and Greece , 2004 in Spain and Croatia , 2005 in the Netherlands and Slovenia , 2006 in Bosnia and Herzegovina and 2022 in Cyprus. In the fall of 2007, the first tiger mosquito eggs were discovered in Rastatt ( Baden-Wuerttemberg , Germany). Shortly before, they were found in the northern Alps of Switzerland in Canton Aargau. Since 2010, it has also been sighted increasingly in Malta during summer. [ citation needed ] In September 2016, Public Health England found eggs, though no mosquitos, in a lorry park at Folkestone service station on the M20 , near Westenhanger , which is 6 miles West of the Eurotunnel. The Swiss Autobahns are especially of concern. Governments and universities in Switzerland cooperate every year to monitor the invasion using traps at Autobahn rest stations, and also at airports and commercial hubs. In Slovakia , two independent observations events have been observed in recent years: first in 2012 near KoÅ¡ice and the second in 2023 in the populated Ružinov borough of Bratislava . The species had failed to settle during the first occurrence but had likely settled in the latter, increasing the risk of concern for public health and safety. In the United States, this species invaded the Southern United States in the 1980s and rapidly spread northward into novel climate compared to its native range. It was initially found in 1983 in Memphis, Tennessee . then at the Port of Houston in a 1985 shipment of used tires, and spread across the South up the East Coast to become prevalent in the Northeast . It was not discovered in Southern California until 2001, then eradicated for over a decade; however, by 2011, it was again being found in Los Angeles County traps, then over the next two years expanded its range to Kern County and San Diego County . As of 2013 [ update ] , North American land favoring the environmental conditions of the Asian tiger mosquito was expected to more than triple in size in the coming 20 years, especially in urban areas. As of 2017 [ update ] Aedes albopictus mosquitoes have been identified in 1,368 counties in 40 U.S states. A 2019 study in Nature Microbiology that modeled expansion of Aedes albopictus due to climate change, urbanization, and human movement found that the species would likely continue to spread throughout the coming decades. In Latin America, the Asian tiger mosquito was first discovered 1986 in Brazil and in 1988 in Argentina and Mexico , as well. Other parts of Latin America where the Asian tiger mosquito was discovered are the Dominican Republic in 1993, Bolivia , Cuba, Honduras , and Guatemala in 1995, El Salvador in 1996, Paraguay in 1999, Panama in 2002, and Uruguay and Nicaragua in 2003. In Africa, the species was first detected in 1990 in South Africa. In Nigeria , it has been domestic since at least 1991. It spread to Cameroon in 1999/2000, to the Bioko Island of Equatorial Guinea in 2001, and to Gabon in 2006. In the Middle East, the species was detected in Lebanon in 2003 and in Syria in 2005; the first record in Israel was published in 2003. Ae. albopictus can outcompete and even eradicate other species with similar breeding habitats from the very start of its dispersal to other regions and biotopes. In Kolkata , for example, it was observed in the 1960s that egg depositing containers were being settled by the Asian tiger mosquito in city districts where the malaria mosquito (genus Anopheles ) and yellow fever mosquito ( Aedes aegypti ) had both been eliminated by the application of DDT . This may be because primarily the inner walls of the houses were treated with DDT to kill the mosquitoes resting there and fight the malaria mosquito. The yellow fever mosquito also lingers particularly in the inside of buildings and would have been also affected. The Asian tiger mosquito rests in the vicinity of human dwellings would therefore have an advantage over the other two species. In other cases where the yellow fever mosquito was repressed by the Asian tiger mosquito, for instance in Florida, this explanation does not fit. Other hypotheses include competition in the larval breeding waters, differences in metabolism and reproductive biology, or a major susceptibility to sporozoans (Apicomplexa). Another species which was suppressed by the migrating Ae. albopictus was Ae. guamensis in Guam . The Asian tiger mosquito is similar, in terms of its close socialization with humans, to the common house mosquito ( Culex pipiens ). Among other differences in their biology, Culex pipiens prefers larger breeding waters and is more tolerant to cold. In this respect, no significant competition or suppression between the two species likely occurs. A possible competition among mosquito species that all lay their eggs in knotholes and other similar places ( Ae. cretinus , Ae. geniculatus , and Anopheles plumbeus ) has yet to be observed. [ citation needed ] In Europe, the Asian tiger mosquito apparently covers an extensive new niche. This means that no native, long-established species conflict with the dispersal of Ae. albopictus . [ citation needed ]The Asian tiger mosquito originally came from Southeast Asia. In 1966, parts of Asia and the island worlds of India and the Pacific Ocean were denoted as the area of circulation for the Asian tiger mosquito. Ae. albopictus as a native to tropical and subtropical regions with warm and humid climate, is active all year long; however, it has been adapting successfully to cooler, temperate regions, where they hibernate over winter. Eggs from strains in the temperate zones are more tolerant to the cold than ones from warmer regions. The species can even tolerate snow and temperatures under freezing. Adult tiger mosquitoes can survive throughout winter in suitable microhabitats. Since the mid-1960s, the tiger mosquito has spread to Europe, the Americas, the Caribbean, Africa, and the Middle East. As of 2008 Ae. albopictus was one of the 100 world's worst invasive species according to the Global Invasive Species Database. As of 2006, Ae. albopictus was not native to Australia and New Zealand. The species was introduced there multiple times, but has yet to establish itself. This is due to the well-organized entomological surveillance programs in the harbors and airports of these countries. Nevertheless, as of 2006 it has become domestic on the islands in the Torres Strait between Queensland, Australia, and New Guinea. In Europe, Asian tiger mosquitos first emerged in Albania in 1979, introduced through a shipment of goods from China. In 1990–1991, they were most likely brought to Italy in used tires from Georgia (USA), and since then have spread throughout the entire mainland of Italy, as well as parts of Sicily and Sardinia . Since 1999, they have established themselves on the mainland of France, primarily southern France. In 2002, they were also discovered in a vacation town on the island of Corsica , but did not completely establish themselves there until 2005. In Belgium , they were detected in 2000 and 2013, in 2001 in Montenegro, 2003 in Canton Ticino in southern Switzerland , and Greece , 2004 in Spain and Croatia , 2005 in the Netherlands and Slovenia , 2006 in Bosnia and Herzegovina and 2022 in Cyprus. In the fall of 2007, the first tiger mosquito eggs were discovered in Rastatt ( Baden-Wuerttemberg , Germany). Shortly before, they were found in the northern Alps of Switzerland in Canton Aargau. Since 2010, it has also been sighted increasingly in Malta during summer. [ citation needed ] In September 2016, Public Health England found eggs, though no mosquitos, in a lorry park at Folkestone service station on the M20 , near Westenhanger , which is 6 miles West of the Eurotunnel. The Swiss Autobahns are especially of concern. Governments and universities in Switzerland cooperate every year to monitor the invasion using traps at Autobahn rest stations, and also at airports and commercial hubs. In Slovakia , two independent observations events have been observed in recent years: first in 2012 near KoÅ¡ice and the second in 2023 in the populated Ružinov borough of Bratislava . The species had failed to settle during the first occurrence but had likely settled in the latter, increasing the risk of concern for public health and safety. In the United States, this species invaded the Southern United States in the 1980s and rapidly spread northward into novel climate compared to its native range. It was initially found in 1983 in Memphis, Tennessee . then at the Port of Houston in a 1985 shipment of used tires, and spread across the South up the East Coast to become prevalent in the Northeast . It was not discovered in Southern California until 2001, then eradicated for over a decade; however, by 2011, it was again being found in Los Angeles County traps, then over the next two years expanded its range to Kern County and San Diego County . As of 2013 [ update ] , North American land favoring the environmental conditions of the Asian tiger mosquito was expected to more than triple in size in the coming 20 years, especially in urban areas. As of 2017 [ update ] Aedes albopictus mosquitoes have been identified in 1,368 counties in 40 U.S states. A 2019 study in Nature Microbiology that modeled expansion of Aedes albopictus due to climate change, urbanization, and human movement found that the species would likely continue to spread throughout the coming decades. In Latin America, the Asian tiger mosquito was first discovered 1986 in Brazil and in 1988 in Argentina and Mexico , as well. Other parts of Latin America where the Asian tiger mosquito was discovered are the Dominican Republic in 1993, Bolivia , Cuba, Honduras , and Guatemala in 1995, El Salvador in 1996, Paraguay in 1999, Panama in 2002, and Uruguay and Nicaragua in 2003. In Africa, the species was first detected in 1990 in South Africa. In Nigeria , it has been domestic since at least 1991. It spread to Cameroon in 1999/2000, to the Bioko Island of Equatorial Guinea in 2001, and to Gabon in 2006. In the Middle East, the species was detected in Lebanon in 2003 and in Syria in 2005; the first record in Israel was published in 2003. Ae. albopictus can outcompete and even eradicate other species with similar breeding habitats from the very start of its dispersal to other regions and biotopes. In Kolkata , for example, it was observed in the 1960s that egg depositing containers were being settled by the Asian tiger mosquito in city districts where the malaria mosquito (genus Anopheles ) and yellow fever mosquito ( Aedes aegypti ) had both been eliminated by the application of DDT . This may be because primarily the inner walls of the houses were treated with DDT to kill the mosquitoes resting there and fight the malaria mosquito. The yellow fever mosquito also lingers particularly in the inside of buildings and would have been also affected. The Asian tiger mosquito rests in the vicinity of human dwellings would therefore have an advantage over the other two species. In other cases where the yellow fever mosquito was repressed by the Asian tiger mosquito, for instance in Florida, this explanation does not fit. Other hypotheses include competition in the larval breeding waters, differences in metabolism and reproductive biology, or a major susceptibility to sporozoans (Apicomplexa). Another species which was suppressed by the migrating Ae. albopictus was Ae. guamensis in Guam . The Asian tiger mosquito is similar, in terms of its close socialization with humans, to the common house mosquito ( Culex pipiens ). Among other differences in their biology, Culex pipiens prefers larger breeding waters and is more tolerant to cold. In this respect, no significant competition or suppression between the two species likely occurs. A possible competition among mosquito species that all lay their eggs in knotholes and other similar places ( Ae. cretinus , Ae. geniculatus , and Anopheles plumbeus ) has yet to be observed. [ citation needed ] In Europe, the Asian tiger mosquito apparently covers an extensive new niche. This means that no native, long-established species conflict with the dispersal of Ae. albopictus . [ citation needed ]Ae. albopictus is known to transmit pathogens and viruses, such as the yellow fever virus, dengue fever , Chikungunya fever, and Usutu virus . There is some evidence supporting the role of Ae. albopictus in the transmission of Zika virus , which is primarily transmitted by the related Ae. aegypti . The Asian tiger mosquito was responsible for the Chikungunya epidemic on the French Island La Réunion in 2005–2006. By September 2006, an estimated 266,000 people were infected with the virus, and 248 fatalities occurred on the island. The Asian tiger mosquito was also the transmitter of the virus in the first outbreak of Chikungunya fever on the European continent. This outbreak occurred in the Italian province of Ravenna in the summer of 2007, and infected over 200 people. Evidently, mutated strains of the Chikungunya virus are being directly transmitted through Ae. albopictus particularly well and in such a way that another dispersal of the disease in regions with the Asian tiger mosquito is feared. On the basis of experimental evidence and probability estimates, the likelihood of mechanical or biological transmission of HIV by insects is virtually nonexistent. The tiger mosquito is relevant to veterinary medicine. For example, tiger mosquitoes are transmitters of Dirofilaria immitis , a parasitic roundworm that causes heart failure in dogs and cats. Wolbachia infection are the most common infection in arthropods today, and over 40% of arthropods have contracted it. Wolbachia can be transmitted from parent to offspring or between breeding individuals. Wolbachia is easily transmitted within the Ae. albopictus mosquito due to the effects it has on fecundity in females. Once female Asian tiger mosquitos have contracted the infection, they produce more eggs, give birth more frequently, and live longer than uninfected females. In this way, Wolbachia provides a fitness advantage to the infected females and prevents uninfected females from reproducing. This allows control of the spread of diseases that many species carry by suppressing reproduction of the individuals with the harmful disease, but without the Wolbachia infection. Wolbachia can also be used to transfer certain genes into the population to further control the spread of diseases. In the natural environment, Wolbachia and the Asian tiger mosquito are in a symbiotic relationship, so both species benefit from each other and can evolve together. The relationship between Wolbachia and its host might not have always been mutualistic, as Drosophila populations once experienced decreased fecundity in infected females, suggesting that Wolbachia evolved over time so that infected individuals would actually reproduce much more. The mechanism by which Wolbachia is inherited through maternal heredity is called cytoplasmic incompatibility . This changes the gamete cells of males and females, making some individuals unable to mate with each other. Although little is known about why cytoplasmic incompatibility exists, Wolbachia infection creates a fitness advantage for infected females, as they can mate with either infected or uninfected males. Despite this, infected males cannot reproduce with uninfected females. Therefore, over time, a population exposed to Wolbachia transitions from a few infected individuals to all individuals becoming infected, as the males that cannot reproduce successfully do not contribute to future generations. This is called population replacement, where the population's overall genotype is replaced by a new genotype. This shows how populations of Asian tiger mosquitoes can vary in number of Wolbachia -infected individuals, based on how often the infection is transmitted. Due to Wolbachia's ability to transmit from one host to the next, it can change the average genotype of a population, potentially reducing the population's gene flow with other nearby populations. [ citation needed ] This type of cytoplasmic incompatibility where an infected male cannot reproduce successfully with an uninfected female is called unidirectional cytoplasmic incompatibility. It occurs because Wolbachia modifies the paternal chromosomes during sperm development, leading to complications for these offspring during embryonic development. Also, bidirectional cytoplasmic incompatibility occurs when an infected male carrying one strain of Wolbachia reproduces with an infected female carrying a different strain of Wolbachia . This also results in failed reproduction. Bidirectional cytoplasmic incompatibility also has evolutionary implications for populations of Ae. albopictus and other vectors of the infection. This is because bidirectional cytoplasmic incompatibility in Wolbachia creates unviable offspring, reducing gene flow between two populations, which can eventually lead to speciation . [ citation needed ]Ae. albopictus is known to transmit pathogens and viruses, such as the yellow fever virus, dengue fever , Chikungunya fever, and Usutu virus . There is some evidence supporting the role of Ae. albopictus in the transmission of Zika virus , which is primarily transmitted by the related Ae. aegypti . The Asian tiger mosquito was responsible for the Chikungunya epidemic on the French Island La Réunion in 2005–2006. By September 2006, an estimated 266,000 people were infected with the virus, and 248 fatalities occurred on the island. The Asian tiger mosquito was also the transmitter of the virus in the first outbreak of Chikungunya fever on the European continent. This outbreak occurred in the Italian province of Ravenna in the summer of 2007, and infected over 200 people. Evidently, mutated strains of the Chikungunya virus are being directly transmitted through Ae. albopictus particularly well and in such a way that another dispersal of the disease in regions with the Asian tiger mosquito is feared. On the basis of experimental evidence and probability estimates, the likelihood of mechanical or biological transmission of HIV by insects is virtually nonexistent. The tiger mosquito is relevant to veterinary medicine. For example, tiger mosquitoes are transmitters of Dirofilaria immitis , a parasitic roundworm that causes heart failure in dogs and cats. Wolbachia infection are the most common infection in arthropods today, and over 40% of arthropods have contracted it. Wolbachia can be transmitted from parent to offspring or between breeding individuals. Wolbachia is easily transmitted within the Ae. albopictus mosquito due to the effects it has on fecundity in females. Once female Asian tiger mosquitos have contracted the infection, they produce more eggs, give birth more frequently, and live longer than uninfected females. In this way, Wolbachia provides a fitness advantage to the infected females and prevents uninfected females from reproducing. This allows control of the spread of diseases that many species carry by suppressing reproduction of the individuals with the harmful disease, but without the Wolbachia infection. Wolbachia can also be used to transfer certain genes into the population to further control the spread of diseases. In the natural environment, Wolbachia and the Asian tiger mosquito are in a symbiotic relationship, so both species benefit from each other and can evolve together. The relationship between Wolbachia and its host might not have always been mutualistic, as Drosophila populations once experienced decreased fecundity in infected females, suggesting that Wolbachia evolved over time so that infected individuals would actually reproduce much more. The mechanism by which Wolbachia is inherited through maternal heredity is called cytoplasmic incompatibility . This changes the gamete cells of males and females, making some individuals unable to mate with each other. Although little is known about why cytoplasmic incompatibility exists, Wolbachia infection creates a fitness advantage for infected females, as they can mate with either infected or uninfected males. Despite this, infected males cannot reproduce with uninfected females. Therefore, over time, a population exposed to Wolbachia transitions from a few infected individuals to all individuals becoming infected, as the males that cannot reproduce successfully do not contribute to future generations. This is called population replacement, where the population's overall genotype is replaced by a new genotype. This shows how populations of Asian tiger mosquitoes can vary in number of Wolbachia -infected individuals, based on how often the infection is transmitted. Due to Wolbachia's ability to transmit from one host to the next, it can change the average genotype of a population, potentially reducing the population's gene flow with other nearby populations. [ citation needed ] This type of cytoplasmic incompatibility where an infected male cannot reproduce successfully with an uninfected female is called unidirectional cytoplasmic incompatibility. It occurs because Wolbachia modifies the paternal chromosomes during sperm development, leading to complications for these offspring during embryonic development. Also, bidirectional cytoplasmic incompatibility occurs when an infected male carrying one strain of Wolbachia reproduces with an infected female carrying a different strain of Wolbachia . This also results in failed reproduction. Bidirectional cytoplasmic incompatibility also has evolutionary implications for populations of Ae. albopictus and other vectors of the infection. This is because bidirectional cytoplasmic incompatibility in Wolbachia creates unviable offspring, reducing gene flow between two populations, which can eventually lead to speciation . [ citation needed ]In the natural environment, Wolbachia and the Asian tiger mosquito are in a symbiotic relationship, so both species benefit from each other and can evolve together. The relationship between Wolbachia and its host might not have always been mutualistic, as Drosophila populations once experienced decreased fecundity in infected females, suggesting that Wolbachia evolved over time so that infected individuals would actually reproduce much more. The mechanism by which Wolbachia is inherited through maternal heredity is called cytoplasmic incompatibility . This changes the gamete cells of males and females, making some individuals unable to mate with each other. Although little is known about why cytoplasmic incompatibility exists, Wolbachia infection creates a fitness advantage for infected females, as they can mate with either infected or uninfected males. Despite this, infected males cannot reproduce with uninfected females. Therefore, over time, a population exposed to Wolbachia transitions from a few infected individuals to all individuals becoming infected, as the males that cannot reproduce successfully do not contribute to future generations. This is called population replacement, where the population's overall genotype is replaced by a new genotype. This shows how populations of Asian tiger mosquitoes can vary in number of Wolbachia -infected individuals, based on how often the infection is transmitted. Due to Wolbachia's ability to transmit from one host to the next, it can change the average genotype of a population, potentially reducing the population's gene flow with other nearby populations. [ citation needed ]This type of cytoplasmic incompatibility where an infected male cannot reproduce successfully with an uninfected female is called unidirectional cytoplasmic incompatibility. It occurs because Wolbachia modifies the paternal chromosomes during sperm development, leading to complications for these offspring during embryonic development. Also, bidirectional cytoplasmic incompatibility occurs when an infected male carrying one strain of Wolbachia reproduces with an infected female carrying a different strain of Wolbachia . This also results in failed reproduction. Bidirectional cytoplasmic incompatibility also has evolutionary implications for populations of Ae. albopictus and other vectors of the infection. This is because bidirectional cytoplasmic incompatibility in Wolbachia creates unviable offspring, reducing gene flow between two populations, which can eventually lead to speciation . [ citation needed ]Ae. albopictus is very difficult to suppress or to control due to its remarkable ability to adapt to various environments, its close contact with humans, and its reproductive biology. [ citation needed ] The containment of infestations is generally effected by public health services through area-wide integrated control plans, which aim to reduce the nuisance perceived by populations and the risks of viraemic transmission. Such plans consist of different activities that include entomological surveillance, larvicide treatments in public and private areas, information campaigns, and treatments against adult mosquitoes in the zones affected by suspected cases of transmissible viruses. Efficient monitoring or surveillance is essential to prevent the spread and establishment of this species. In addition to the monitoring of ports, warehouses with imported plants, and stockpiles of tires, rest areas on highways and train stations should be monitored with appropriate methods. The control of Asian tiger mosquitoes begins with destroying the places where they lay their eggs, which are never far from where people are being bitten, since they are weak fliers, with only about a 180-metre (590 ft) lifetime flying radius. Puddles that last more than three days, sagging or plugged roof gutters, old tires holding water, litter, and any other possible containers or pools of standing water should be drained or removed. Bird baths, inlets to sewers and drainage systems holding stagnant water, flower pots, standing flower vases, knotholes, and other crevices that can collect water should be filled with sand or fine gravel to prevent mosquitoes from laying their eggs in them. [ citation needed ] Any standing water in pools, catchment basins, etc., that cannot be drained, or dumped, can be periodically treated with properly labeled insecticides or Bacillus thuringiensis israelensis (Bti), often formed into doughnut-shaped "mosquito dunks". Bti produces toxins which are effective in killing larvae of mosquitoes and certain other dipterans , while having almost no effect on other organisms. Bti preparations are readily available at farm, garden, and pool suppliers. [ citation needed ] Flowing water will not be a breeding spot, [ contradictory ] and water that contains minnows is not usually a problem, because the fish eat the mosquito larvae. [ citation needed ] Adult and nymphal dragonflies have been proposed as biological control of mosquito species. Dragonfly nymphs eat mosquito larvae, at least in laboratory conditions, though studies of wild dragonfly diets have not shown mosquitoes to be part of dragonfly nymph diets. A study of adult dragonfly diets in Europe showed that adult mosquitoes were not an important food source. In any case, an efficient surveillance is essential to monitor the presence of tiger mosquitoes and the effect of control programs. Ovitraps are normally used for the monitoring of Ae. albopictus . They are black water containers with floating Styrofoam blocks or small wooden paddles that are in contact with the surface of the water. Female tiger mosquitoes lay their eggs on these surfaces. Through the identification of these eggs or of the larvae that hatch from these eggs in the laboratory, the presence and abundance of mosquito species can be estimated. Versions of these traps with an adhesive film (sticky traps) that catch the egg-depositing mosquitoes make the analysis much easier and quicker, but are more complicated in terms of handling. The results of ovitraps are often variable and depend on the availability of alternative egg-depositing waters. Due to this, it is best to use them in large numbers and in conjunction with other monitoring methods. [ citation needed ] To date, few effective traps for adult Asian tiger mosquitoes are available. Those traps that catch other species of mosquitoes do not catch tiger mosquitoes efficiently. A form of an ovitrap called a lethal ovitrap mimics the breeding site for Ae. albopictus just like the monitoring tool, but it has the added benefit of containing chemicals that are toxic to the mosquitoes when they enter, but do not harm humans. These traps have had success in some countries to control Aedes mosquito populations. A new trap type has now been shown to catch significant numbers of Ae. albopictus . This device, with the help of a ventilator, produces an upward air current of ammonia , fatty acids , and lactic acids that takes a similar form and smell of a human body. With the addition of carbon dioxide , the efficacy of the trap is increased. This means a suitable tool is available for trapping adult tiger mosquitoes, and for example, examining the existence of viruses in the trapped mosquitoes. Previously, the mosquitoes had to be collected from volunteers to be studied, which is ethically questionable, especially during epidemics. Recent research also indicates this trap type may also have a use as a control tool; in a study in Cesena , Italy , the number of biting tiger mosquitoes was reduced in places where traps were installed. An amino acid substitution mutation – F1534C – is overwhelmingly the most common voltage-gated sodium channel in A. albopictus in Singapore . This channel being the target of pyrethroids , this is suspected to be a knockdown resistance ( kdr ) mutation, and that that is the reason for its prevalence. The control of Asian tiger mosquitoes begins with destroying the places where they lay their eggs, which are never far from where people are being bitten, since they are weak fliers, with only about a 180-metre (590 ft) lifetime flying radius. Puddles that last more than three days, sagging or plugged roof gutters, old tires holding water, litter, and any other possible containers or pools of standing water should be drained or removed. Bird baths, inlets to sewers and drainage systems holding stagnant water, flower pots, standing flower vases, knotholes, and other crevices that can collect water should be filled with sand or fine gravel to prevent mosquitoes from laying their eggs in them. [ citation needed ] Any standing water in pools, catchment basins, etc., that cannot be drained, or dumped, can be periodically treated with properly labeled insecticides or Bacillus thuringiensis israelensis (Bti), often formed into doughnut-shaped "mosquito dunks". Bti produces toxins which are effective in killing larvae of mosquitoes and certain other dipterans , while having almost no effect on other organisms. Bti preparations are readily available at farm, garden, and pool suppliers. [ citation needed ] Flowing water will not be a breeding spot, [ contradictory ] and water that contains minnows is not usually a problem, because the fish eat the mosquito larvae. [ citation needed ]Adult and nymphal dragonflies have been proposed as biological control of mosquito species. Dragonfly nymphs eat mosquito larvae, at least in laboratory conditions, though studies of wild dragonfly diets have not shown mosquitoes to be part of dragonfly nymph diets. A study of adult dragonfly diets in Europe showed that adult mosquitoes were not an important food source. In any case, an efficient surveillance is essential to monitor the presence of tiger mosquitoes and the effect of control programs. Ovitraps are normally used for the monitoring of Ae. albopictus . They are black water containers with floating Styrofoam blocks or small wooden paddles that are in contact with the surface of the water. Female tiger mosquitoes lay their eggs on these surfaces. Through the identification of these eggs or of the larvae that hatch from these eggs in the laboratory, the presence and abundance of mosquito species can be estimated. Versions of these traps with an adhesive film (sticky traps) that catch the egg-depositing mosquitoes make the analysis much easier and quicker, but are more complicated in terms of handling. The results of ovitraps are often variable and depend on the availability of alternative egg-depositing waters. Due to this, it is best to use them in large numbers and in conjunction with other monitoring methods. [ citation needed ] To date, few effective traps for adult Asian tiger mosquitoes are available. Those traps that catch other species of mosquitoes do not catch tiger mosquitoes efficiently. A form of an ovitrap called a lethal ovitrap mimics the breeding site for Ae. albopictus just like the monitoring tool, but it has the added benefit of containing chemicals that are toxic to the mosquitoes when they enter, but do not harm humans. These traps have had success in some countries to control Aedes mosquito populations. A new trap type has now been shown to catch significant numbers of Ae. albopictus . This device, with the help of a ventilator, produces an upward air current of ammonia , fatty acids , and lactic acids that takes a similar form and smell of a human body. With the addition of carbon dioxide , the efficacy of the trap is increased. This means a suitable tool is available for trapping adult tiger mosquitoes, and for example, examining the existence of viruses in the trapped mosquitoes. Previously, the mosquitoes had to be collected from volunteers to be studied, which is ethically questionable, especially during epidemics. Recent research also indicates this trap type may also have a use as a control tool; in a study in Cesena , Italy , the number of biting tiger mosquitoes was reduced in places where traps were installed. An amino acid substitution mutation – F1534C – is overwhelmingly the most common voltage-gated sodium channel in A. albopictus in Singapore . This channel being the target of pyrethroids , this is suspected to be a knockdown resistance ( kdr ) mutation, and that that is the reason for its prevalence. Although the Wolbachia infection is prevalent in arthropod species, especially the Asian tiger mosquito, it is a useful mechanism for inhibiting the spread of dengue . Ae. aegypti individuals, a close relative of Ae. albopictus , with an artificial Wolbachia infection, cannot transmit dengue, an infectious virus, but they can pass on the Wolbachia infection to other populations. This could lead to many more discoveries in disease control for Ae. albopictus and other mosquito species. In addition, due to the cytoplasmic incompatibility caused by Wolbachia , the artificial infection of males can serve as a biological control as they are unable to reproduce successfully with uninfected females (unidirectional CI). When artificially infected males are unable to reproduce, the population size can be controlled, thereby reducing the transmission of the harmful disease of interest. Artificial infection of males is achieved by the removal of cytoplasm from infected oocytes, which is then transferred into embryos prior to the blastoderm stage. [ citation needed ]

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Dengue fever

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UFC on ESPN: Ribas vs. Namajunas

UFC on ESPN: Ribas vs. Namajunas (also known as UFC on ESPN 53 and UFC Vegas 89 ) was a mixed martial arts event produced by the Ultimate Fighting Championship that took place on March 23, 2024, at UFC Apex in Enterprise, Nevada , United States. A women's flyweight bout between Amanda Ribas and former two-time UFC Women's Strawweight Champion Rose Namajunas headlined the event. A heavyweight bout between Chris Barnett and The Ultimate Fighter: Team Peña vs. Team Nunes heavyweight winner Mohammed Usman was scheduled for this event. However, Barnett withdrew due to unknown reason and was replaced by Mick Parkin. Edmen Shahbazyan and Duško Todorović were expected to meet in a middleweight bout at the event. However, Todorović pulled out due to a serious knee injury and was replaced by A.J. Dobson. A women's strawweight bout between Shauna Bannon and Stephanie Luciano was expected to take place at this event. However, Bannon pulled out for unknown reasons and was replaced by Julia Polastri. In turn, the bout was cancelled when Luciano was forced to withdraw due to falling ill with dengue fever . A heavyweight bout between Junior Tafa and Karl Williams was expected to take place at the event. However, Tafa stepped in on short notice as a replacement for his brother Justin Tafa against Marcos Rogério de Lima at UFC 298 and was eventually unable to compete at this event after losing via TKO. He was eventually replaced by Justin at this event. A featherweight bout between Billy Quarantillo and Gabriel Miranda was expected to take place at the event. However, Miranda was replaced by Youssef Zalal for unknown reasons. A bantamweight bout between Cody Gibson and Davey Grant was expected to take place at the event. However, Grant withdrew due to injury and was replaced by former LFA Bantamweight Champion Miles Johns . The following fighters received $50,000 bonuses. Fight of the Night: Jarno Errens vs. Steven Nguyen Performance of the Night: Payton Talbott and Fernando PadillaAfter the first ever disqualification due to biting took place at this event, UFC CEO Dana White gave a Bite of the Night $50,000 bonus to André Lima whose bout ended prematurely as a result of being bit on the arm by opponent Igor Severino. Severino was subsequently released from his contract with the promotion. The Nevada Athletic Commission also announced that it would withhold Severino's purse and he is expected to receive a heavy fine and lengthy suspension when the NAC holds its monthly meeting in April.

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Dengue fever

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Flaviviridae

Flaviviridae is a family of enveloped positive-strand RNA viruses which mainly infect mammals and birds . They are primarily spread through arthropod vectors (mainly ticks and mosquitoes ). The family gets its name from the yellow fever virus; flavus is Latin for "yellow", and yellow fever in turn was named because of its propensity to cause jaundice in victims. There are 89 species in the family divided among four genera. Diseases associated with the group include: hepatitis ( hepaciviruses ), hemorrhagic syndromes , fatal mucosal disease ( pestiviruses ), hemorrhagic fever , encephalitis , and the birth defect microcephaly ( flaviviruses ). Virus particles are enveloped and spherical with icosahedral-like geometries that have pseudo T=3 symmetry. They are about 40–60 nm in diameter. Members of the family Flaviviridae have monopartite, linear, single-stranded RNA genomes of positive polarity, and 9.6 to 12.3 kilobase in total length. The 5'-termini of flaviviruses carry a methylated nucleotide cap, while other members of this family are uncapped and encode an internal ribosome entry site. The genome encodes a single polyprotein with multiple transmembrane domains that is cleaved, by both host and viral proteases, into structural and non-structural proteins. Among the non-structural protein products (NS), the locations and sequences of NS3 and NS5, which contain motifs essential for polyprotein processing and RNA replication respectively, are relatively well conserved across the family and may be useful for phylogenetic analysis.Viral replication is cytoplasmic. Entry into the host cell is achieved by attachment of the viral envelope protein E to host receptors, which mediates clathrin -mediated endocytosis. Replication follows the positive-stranded RNA virus replication model. Positive-stranded RNA virus transcription is the method of transcription. Translation takes place by viral initiation. The virus exits the host cell by budding. Humans and mammals serve as the natural hosts. The virus is transmitted via vectors (ticks and mosquitoes). The family has four genera: Other Orthoflaviviruses are known that have yet to be classified. These include Wenling shark virus. Jingmenvirus is a group of unclassified viruses in the family which includes Alongshan virus , Guaico Culex virus, Jingmen tick virus and Mogiana tick virus. These viruses have a segmented genome of 4 or 5 pieces. Two of these segments are derived from flaviviruses. A number of viruses may be related to the flaviviruses, but have features that are atypical of the flaviviruses. These include citrus Jingmen-like virus, soybean cyst nematode virus 5, Toxocara canis larva agent, Wuhan cricket virus, and possibly Gentian Kobu-sho-associated virus.Major diseases caused by members of the family Flaviviridae include:

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Dengue fever

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Dengue pandemic in Sri Lanka

The dengue pandemic in Sri Lanka is part of the tropical disease dengue fever pandemic. Dengue fever is caused by Dengue virus , first recorded in the 1960s. It is not a native disease in this island. Present-day dengue has become a major public health problem. Aedes aegypti and Aedes albopictus are both mosquito species native to Sri Lanka. However, the disease did not emerge until the early 1960s. Dengue was first serologically confirmed in the country in 1962. A Chikungunya outbreak followed in 1965. In the early 1970s two type of dengue dominated in Sri Lanka: DENV-1 type1 and DENV-2 type 2. A total of 51 cases and 15 deaths were reported in 1965–1968. From 1989 onward, dengue fever has become endemic in Sri Lanka. Dengue outbreaks started to emerge in Sri Lanka in the 1960s, with the Ministry of Health first serologically confirming the disease in Sri Lanka in 1962. However, unofficial British Ceylon clinical studies recorded dengue-like cases in Sri Lanka in the early 20th century. The first outbreak was confirmed in 1965 and was associated with DEN types 1 and 2, with 51 cases of 15 deaths between 1965 and 1968. Since 1989 dengue has become a major problem in Sri Lanka. From 1970 to 1990, multiple outbreaks with endemic were reported in Western Province urban areas. In 1990 dengue cases rose 1,350 of 54 deaths. [ clarification needed ] In the early 1990s, annual dengue cases were reported as being up to 1,000. [ clarification needed ] In 2002 the largest outbreak in recent years was recorded, with 8,931 cases and 64 deaths. The following year, 2003, was one of relatively low endemicity, with only 4,749 suspected cases and 32 deaths reported. In 2004 there were 15,463 suspected cases and 88 deaths reported to the Epidemiological Unit of the Ministry of Health. During the year 2005, 5,211 cases of suspected cases of DF/DHF and 26 deaths were reported to the Epidemiological Unit. Most dengue cases reported dominated in Western Province . Outbreaks from 2005 to 2008 were attributed to a new mutation DEN type 3. Almost all the districts in Sri Lanka have reported cases and posed a threat to the health of the people. Colombo , Gampaha , Kalutara and Kandy districts have recorded highest number of cases. Sri Lanka is a tropical and warm country. Mean temperatures range from 28 °C. The rainfall pattern is influenced by monsoon winds from the Indian Ocean and Bay of Bengal. Average rain at 800 to 1,200 mm per year. Average humidity from 75% during different seasons and in the different regions of the country. Tropical region humidity ranges from 75% to 90%. Sri Lanka is a tropical country with two monsoons: the northeast monsoon (December to March) and the southwest monsoon (May to September). Two annual peaks have been identified in the occurrence of dengue cases in the country in association with the monsoon rain.

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Dengue fever

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Antibody-dependent enhancement

Antibody-dependent enhancement ( ADE ), sometimes less precisely called immune enhancement or disease enhancement , is a phenomenon in which binding of a virus to suboptimal antibodies enhances its entry into host cells , followed by its replication . The suboptimal antibodies can result from natural infection or from vaccination. ADE may cause enhanced respiratory disease , but is not limited to respiratory disease . It has been observed in HIV , RSV virus and Dengue virus and is monitored for in vaccine development. In ADE, antiviral antibodies promote viral infection of target immune cells by exploiting the phagocytic FcγR or complement pathway . After interaction with a virus, the antibodies bind Fc receptors (FcR) expressed on certain immune cells or complement proteins. FcγRs bind antibodies via their fragment crystallizable region (Fc) . The process of phagocytosis is accompanied by virus degradation, but if the virus is not neutralized (either due to low affinity binding or targeting to a non-neutralizing epitope ), antibody binding may result in virus escape and, therefore, more severe infection. Thus, phagocytosis can cause viral replication and the subsequent death of immune cells. Essentially, the virus "deceives" the process of phagocytosis of immune cells and uses the host's antibodies as a Trojan horse . ADE may occur because of the non-neutralizing characteristic of an antibody, which binds viral epitopes other than those involved in host-cell attachment and entry. It may also happen when antibodies are present at sub-neutralizing concentrations (yielding occupancies on viral epitopes below the threshold for neutralization), or when the strength of antibody-antigen interaction is below a certain threshold. This phenomenon can lead to increased viral infectivity and virulence . ADE can occur during the development of a primary or secondary viral infection, as well as with a virus challenge after vaccination. It has been observed mainly with positive-strand RNA viruses , including flaviviruses such as dengue , yellow fever , and Zika ; alpha- and betacoronaviruses ; orthomyxoviruses such as influenza ; retroviruses such as HIV ; and orthopneumoviruses such as RSV. The viruses that cause it frequently share common features such as antigenic diversity, replication ability, or ability to establish persistence in immune cells. The mechanism that involves phagocytosis of immune complexes via the FcγRII / CD32 receptor is better understood compared to the complement receptor pathway. Cells that express this receptor are represented by monocytes , macrophages , and some categories of dendritic cells and B-cells . ADE is mainly mediated by IgG antibodies , but IgM and IgA antibodies have also been shown to trigger it.Prior to the COVID-19 pandemic , ADE was observed in animal studies of laboratory rodents with vaccines for SARS-CoV , the virus that causes severe acute respiratory syndrome ( SARS ). As of 27 January 2022 [ update ] , there have been no observed incidents with vaccines for COVID-19 in trials with nonhuman primates, in clinical trials with humans, or following the widespread use of approved vaccines. Prior to the COVID-19 pandemic , ADE was observed in animal studies of laboratory rodents with vaccines for SARS-CoV , the virus that causes severe acute respiratory syndrome ( SARS ). As of 27 January 2022 [ update ] , there have been no observed incidents with vaccines for COVID-19 in trials with nonhuman primates, in clinical trials with humans, or following the widespread use of approved vaccines. Prior receipt of 2008–09 TIV (Trivalent Inactivated Influenza Vaccine) was associated with an increased risk of medically attended pH1N1 illness during the spring-summer 2009 in Canada. The occurrence of bias (selection, information) or confounding cannot be ruled out. Further experimental and epidemiological assessment is warranted. Possible biological mechanisms and immunoepidemiologic implications are considered. Natural infection and the attenuated vaccine induce antibodies that enhance the update of the homologous virus and H1N1 virus isolated several years later, demonstrating that a primary influenza A virus infection results in the induction of infection enhancing antibodies. ADE was suspected in infections with influenza A virus subtype H7N9 , but knowledge is limited.The most widely known ADE example occurs with dengue virus . Dengue is a single-stranded positive-polarity RNA virus of the family Flaviviridae . It causes disease of varying severity in humans, from dengue fever (DF), which is usually self-limited, to dengue hemorrhagic fever and dengue shock syndrome, either of which may be life-threatening. It is estimated that as many as 390 million individuals contract dengue annually. ADE may follow when a person who has previously been infected with one serotype becomes infected months or years later with a different serotype, producing higher viremia than in first-time infections. Accordingly, while primary (first) infections cause mostly minor disease (dengue fever) in children, re-infection is more likely to be associated with dengue hemorrhagic fever and/or dengue shock syndrome in both children and adults. Dengue encompasses four antigenically different serotypes (dengue virus 1–4). In 2013 a fifth serotype was reported. Infection induces the production of neutralizing homotypic immunoglobulin G (IgG) antibodies that provide lifelong immunity against the infecting serotype. Infection with dengue virus also produces some degree of cross-protective immunity against the other three serotypes. Neutralizing heterotypic ( cross-reactive ) IgG antibodies are responsible for this cross-protective immunity, which typically persists for a period of months to a few years. These heterotypic titers decrease over long time periods (4 to 20 years). While heterotypic titers decrease, homotypic IgG antibody titers increase over long time periods. This could be due to the preferential survival of long-lived memory B cells producing homotypic antibodies. In addition to neutralizing heterotypic antibodies, an infection can also induce heterotypic antibodies that neutralize the virus only partially or not at all. The production of such cross-reactive, but non-neutralizing antibodies could enable severe secondary infections. By binding to but not neutralizing the virus, these antibodies cause it to behave as a " trojan horse ", where it is delivered into the wrong compartment of dendritic cells that have ingested the virus for destruction. Once inside the white blood cell , the virus replicates undetected, eventually generating high virus titers and severe disease. A study conducted by Modhiran et al. attempted to explain how non-neutralizing antibodies down-regulate the immune response in the host cell through the Toll-like receptor signaling pathway. Toll-like receptors are known to recognize extra- and intracellular viral particles and to be a major basis of the cytokines' production. In vitro experiments showed that the inflammatory cytokines and type 1 interferon production were reduced when the ADE-dengue virus complex bound to the Fc receptor of THP-1 cells . This can be explained by both a decrease of Toll-like receptor production and a modification of its signaling pathway. On the one hand, an unknown protein induced by the stimulated Fc receptor reduces Toll-like receptor transcription and translation, which reduces the capacity of the cell to detect viral proteins. On the other hand, many proteins ( TRIF , TRAF6 , TRAM, TIRAP , IKKα, TAB1 , TAB2, NF-κB complex) involved in the Toll-like receptor signaling pathway are down-regulated, which led to a decrease in cytokine production. Two of them, TRIF and TRAF6, are respectively down-regulated by 2 proteins SARM and TANK up-regulated by the stimulated Fc receptors. One example occurred in Cuba , lasting from 1977 to 1979. The infecting serotype was dengue virus-1. This epidemic was followed by outbreaks in 1981 and 1997. In those outbreaks; dengue virus-2 was the infecting serotype. 205 cases of dengue hemorrhagic fever and dengue shock syndrome occurred during the 1997 outbreak, all in people older than 15 years. All but three of these cases were demonstrated to have been previously infected by dengue virus-1 during the first outbreak. Furthermore, people with secondary infections with dengue virus-2 in 1997 had a 3-4 fold increased probability of developing severe disease than those with secondary infections with dengue virus-2 in 1981. This scenario can be explained by the presence of sufficient neutralizing heterotypic IgG antibodies in 1981, whose titers had decreased by 1997 to the point where they no longer provided significant cross-protective immunity.ADE of infection has also been reported in HIV. Like dengue virus, non-neutralizing level of antibodies have been found to enhance the viral infection through interactions of the complement system and receptors. The increase in infection has been reported to be over 350 fold which is comparable to ADE in other viruses like dengue virus. ADE in HIV can be complement-mediated or Fc receptor-mediated. Complements in the presence of HIV-1 positive sera have been found to enhance the infection of the MT-2 T-cell line. The Fc-receptor mediated enhancement was reported when HIV infection was enhanced by sera from HIV-1 positive guinea pig enhanced the infection of peripheral blood mononuclear cells without the presence of any complements. Complement component receptors CR2, CR3 and CR4 have been found to mediate this Complement-mediated enhancement of infection. The infection of HIV-1 leads to activation of complements. Fragments of these complements can assist viruses with infection by facilitating viral interactions with host cells that express complement receptors. The deposition of complement on the virus brings the gp120 protein close to CD4 molecules on the surface of the cells, thus leading to facilitated viral entry. Viruses pre-exposed to non-neutralizing complement system have also been found to enhance infections in interdigitating dendritic cells. Opsonized viruses have not only shown enhanced entry but also favorable signaling cascades for HIV replication in interdigitating dendritic cells. HIV-1 has also shown enhancement of infection in HT-29 cells when the viruses were pre-opsonized with complements C3 and C9 in seminal fluid. This enhanced rate of infection was almost 2 times greater than infection of HT-29 cells with the virus alone. Subramanian et al. , reported that almost 72% of serum samples out of 39 HIV-positive individuals contained complements that were known to enhance the infection. They also suggested that the presence of neutralizing antibody or antibody-dependent cellular cytotoxicity-mediating antibodies in the serum contains infection-enhancing antibodies. The balance between the neutralizing antibodies and infection-enhancing antibodies changes as the disease progresses. During advanced stages of the disease, the proportion of infection-enhancing antibodies are generally higher than neutralizing antibodies. Increase in viral protein synthesis and RNA production have been reported to occur during the complement-mediated enhancement of infection. Cells that are challenged with non-neutralizing levels of complements have been found to have accelerated release of reverse transcriptase and viral progeny. The interaction of anti-HIV antibodies with non-neutralizing complement exposed viruses also aid in binding of the virus and the erythrocytes which can lead to the more efficient delivery of viruses to the immune-compromised organs. ADE in HIV has raised questions about the risk of infections to volunteers who have taken sub-neutralizing levels of vaccine just like any other viruses that exhibit ADE. Gilbert et al. , in 2005 reported that there was no ADE of infection when they used the rgp120 vaccine in phase 1 and 2 trials. It has been emphasized that much research needs to be done in the field of the immune response to HIV-1, information from these studies can be used to produce a more effective vaccine.Interaction of a virus with antibodies must prevent the virus from attaching to the host cell entry receptors. However, instead of preventing infection of the host cell, this process can facilitate viral infection of immune cells, causing ADE. After binding the virus, the antibody interacts with Fc or complement receptors expressed on certain immune cells. These receptors promote virus-antibody internalization by the immune cells, which should be followed by the virus destruction. However, the virus might escape the antibody complex and start its replication cycle inside the immune cell avoiding the degradation. This happens if the virus is bound to a low-affinity antibody. There are several possibilities to explain the phenomenon of enhancing intracellular virus survival: 1) Antibodies against a virus of one serotype binds to a virus of a different serotype. The binding is meant to neutralize the virus from attaching to the host cell, but the virus-antibody complex also binds to the Fc-region antibody receptor ( FcγR ) on the immune cell. The cell internalizes the virus for programmed destruction but the virus avoids it and starts its replication cycle instead. 2) Antibodies against a virus of one serotype binds to a virus of a different serotype, activating the classical pathway of the complement system . The complement cascade system binds C1Q complex attached to the virus surface protein via the antibodies, which in turn bind C1q receptor found on cells, bringing the virus and the cell close enough for a specific virus receptor to bind the virus, beginning infection. This mechanism has been shown for Ebola virus in vitro and some flaviviruses in vivo . When an antibody to a virus is unable to neutralize the virus, it forms sub-neutralizing virus-antibody complexes. Upon phagocytosis by macrophages or other immune cells, the complex may release the virus due to poor binding with the antibody. This happens during acidification and eventual fusion of the phagosome with lysosomes . The escaped virus begins its replication cycle within the cell, triggering ADE. There are several possibilities to explain the phenomenon of enhancing intracellular virus survival: 1) Antibodies against a virus of one serotype binds to a virus of a different serotype. The binding is meant to neutralize the virus from attaching to the host cell, but the virus-antibody complex also binds to the Fc-region antibody receptor ( FcγR ) on the immune cell. The cell internalizes the virus for programmed destruction but the virus avoids it and starts its replication cycle instead. 2) Antibodies against a virus of one serotype binds to a virus of a different serotype, activating the classical pathway of the complement system . The complement cascade system binds C1Q complex attached to the virus surface protein via the antibodies, which in turn bind C1q receptor found on cells, bringing the virus and the cell close enough for a specific virus receptor to bind the virus, beginning infection. This mechanism has been shown for Ebola virus in vitro and some flaviviruses in vivo . When an antibody to a virus is unable to neutralize the virus, it forms sub-neutralizing virus-antibody complexes. Upon phagocytosis by macrophages or other immune cells, the complex may release the virus due to poor binding with the antibody. This happens during acidification and eventual fusion of the phagosome with lysosomes . The escaped virus begins its replication cycle within the cell, triggering ADE.

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Dengue fever

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Orthohantavirus

Hantavirus Orthohantavirus is a genus of single-stranded, enveloped, negative-sense RNA viruses in the family Hantaviridae within the order Bunyavirales . Members of this genus may be called orthohantaviruses or simply hantaviruses . Orthohantaviruses typically cause chronic asymptomatic infection in rodents . Humans may become infected with hantaviruses through contact with rodent urine, saliva, or feces. Some strains cause potentially fatal diseases in humans, such as hantavirus hemorrhagic fever with renal syndrome (HFRS), or hantavirus pulmonary syndrome (HPS), also known as hantavirus cardiopulmonary syndrome (HCPS), while others have not been associated with known human disease (e.g. Prospect Hill virus ). HPS (HCPS) is a "rare respiratory illness associated with the inhalation of aerosolized rodent excreta (urine and feces) contaminated by hantavirus particles". Human infections of hantaviruses have almost entirely been linked to human contact with rodent excrement; however, in 2005 and 2019, human-to-human transmission of the Andes virus was reported in South America. Orthohantaviruses are named for the Greek word ortho - meaning "straight" or "true" and for the Hantan River in South Korea , where the first member species ( Hantaan virus ) was identified and isolated in 1976 by Ho Wang Lee . Hantavirus infections in humans are associated with two diseases: hemorrhagic fever with renal syndrome (HFRS) and hantavirus pulmonary syndrome (HPS), caused by Old World and New World hantaviruses, respectively. A common feature of the two diseases is increased vascular permeability, which causes hypotension , thrombocytopenia , and leukocytosis . The pulmonary illness is the more fatal of the two, whereas the hemorrhagic fever is much more common. Treatment for both is primarily supportive as there is no specific treatment for hantavirus infections. While many hantaviruses cause either of the two diseases, some are not known to cause illness, such as the Prospect Hill orthohantavirus . Hemorrhagic fever with renal syndrome (HFRS) is caused chiefly by hantaviruses in Asia and Europe. Clinical presentation varies from subclinical to fatal, depending on the virus. After an incubation period of 2–4 weeks, the typical illness starts with non-specific symptoms such as high fever, chills, headache, backache, abdominal pains, nausea, and vomiting. After the initial period, bleeding under the skin begins, often paired with low blood pressure, followed by further internal bleeding throughout the body. Renal dysfunction leading to further health issues begins thereafter, which may cause death. A more mild form of HFRS that occurs in Europe is called "nephropathia epidemica" (NE). Trench nephritis during World War I is now thought to have been HFRS. [ citation needed ] Hantavirus pulmonary syndrome (HPS), also called hantavirus cardiopulmonary syndrome (HCPS), is usually caused by hantaviruses in the Americas. Its incubation period ranges from 16 to 24 days. Illness initially shows similar symptoms as HFRS. After a few days of non-specific symptoms, sudden onset of progressive, or productive, coughing, shortness of breath, and elevated heart rate occur due to fluid buildup in the lungs . These symptoms are accompanied by impairment of lymphoid organs . Death from cardiovascular shock may occur rapidly after the appearance of severe symptoms. While HCPS is typically associated with New World hantaviruses, the Puumala orthohantavirus in Europe has also caused the syndrome on rare occasions. Hantaviruses are transmitted by contact with the bodily fluids of rodents, particularly from saliva from bites and especially from inhalation of viral particles from urine and feces in aerosols . The manner of transmission is the same for both diseases caused by hantaviruses. Among the HCPS-causing hantaviruses is the Andes orthohantavirus , which is the only hantavirus confirmed to be capable of spreading from person to person, though this is rare. Hemorrhagic fever with renal syndrome (HFRS) is caused chiefly by hantaviruses in Asia and Europe. Clinical presentation varies from subclinical to fatal, depending on the virus. After an incubation period of 2–4 weeks, the typical illness starts with non-specific symptoms such as high fever, chills, headache, backache, abdominal pains, nausea, and vomiting. After the initial period, bleeding under the skin begins, often paired with low blood pressure, followed by further internal bleeding throughout the body. Renal dysfunction leading to further health issues begins thereafter, which may cause death. A more mild form of HFRS that occurs in Europe is called "nephropathia epidemica" (NE). Trench nephritis during World War I is now thought to have been HFRS. [ citation needed ]Hantavirus pulmonary syndrome (HPS), also called hantavirus cardiopulmonary syndrome (HCPS), is usually caused by hantaviruses in the Americas. Its incubation period ranges from 16 to 24 days. Illness initially shows similar symptoms as HFRS. After a few days of non-specific symptoms, sudden onset of progressive, or productive, coughing, shortness of breath, and elevated heart rate occur due to fluid buildup in the lungs . These symptoms are accompanied by impairment of lymphoid organs . Death from cardiovascular shock may occur rapidly after the appearance of severe symptoms. While HCPS is typically associated with New World hantaviruses, the Puumala orthohantavirus in Europe has also caused the syndrome on rare occasions. Hantaviruses are transmitted by contact with the bodily fluids of rodents, particularly from saliva from bites and especially from inhalation of viral particles from urine and feces in aerosols . The manner of transmission is the same for both diseases caused by hantaviruses. Among the HCPS-causing hantaviruses is the Andes orthohantavirus , which is the only hantavirus confirmed to be capable of spreading from person to person, though this is rare. Hantavirus virions are about 80–120 nm in diameter. The lipid bilayer of the viral envelope is about 5 nm thick and is embedded with viral surface proteins to which sugar residues are attached. These glycoproteins, known as Gn and Gc, are encoded by the M segment of the viral genome. They tend to associate ( heterodimerize ) with each other and have both an interior tail and an exterior domain that extends to about 6 nm beyond the envelope surface. [ citation needed ] Inside the envelope are the nucleocapsids. These are composed of many copies of the nucleocapsid protein N, which interact with the three segments of the viral genome to form helical structures. The virally encoded RNA polymerase is also found in the interior. By mass, the virion is greater than 50% protein, 20–30% lipid, and 2–7% carbohydrate. The density of the virions is 1.18 g/cm 3 . These features are common to all members of the family Hantaviridae . [ citation needed ] The genome of hantaviruses is negative-sense, single-stranded RNA . Their genomes are composed of three segments: the small (S), medium (M), and large (L) segments. The S segment, 1–3 kilobases (kb) in length, encodes for the nucleocapsid (N) protein. The M segment, 3.2–4.9 kb in length, encodes a glycoprotein precursor polyprotein that is co-translationally cleaved into the envelope glycoproteins Gn and Gc, alternatively called G1 and G2. The L segment, 6.8–12 kb in length, encodes the L protein which functions primarily as the viral RNA-dependent RNA polymerase used for transcription and replication. Within virions , the genomic RNAs of hantaviruses are thought to complex with the N protein to form helical nucleocapsids, the RNA component of which circularizes due to sequence complementarity between the 5′ and 3′ terminal sequences of genomic segments. [ citation needed ] As with other Bunyavirales , each of the three segments has a consensus 3′-terminal nucleotide sequence (AUCAUCAUC), which is complementary to the 5′-terminal sequence and is distinct from those of the other four genera in the family. These sequences appear to form panhandle structure which seem likely to play a role in replication and encapsidation facilitated by binding with the viral nucleocapsid (N) protein. The large segment is 6530–6550 nucleotides (nt) in length, the medium is 3613–3707 nt in length and the small is 1696–2083 nt in length. [ citation needed ] No nonstructural proteins are known, unlike the other genera in this family. At the 5′ and 3′ of each segment are short noncoding sequences: the noncoding segment in all sequences at the 5′ end is 37–51 nt. The 3′ noncoding regions differ: L segment 38–43 nt; M segment 168–229 nt; and S segment 370–730 nt. The 3′ end of the S segment is conserved between the genera suggesting a functional role. [ citation needed ] Viral entry into host cells initiates by binding to surface cell receptors. Integrins are considered to be the main receptors for hantaviruses in vitro , but complement decay-accelerating factor (DAF) and globular heads of complement C1q receptor (gC1qR) have mediated attachment in cultured cells too. Entry may proceed through a number of possible routes, including clathrin -dependent endocytosis , clathrin-independent receptor-mediated endocytosis, and micro pinocytosis . Viral particles are then transported to late endosomes . Gc-mediated membrane fusion with the endosomal membrane , triggered by low pH , releases the nucleocapsid into the cytoplasm . After the release of the nucleocapsids into cytoplasm, the complexes are targeted to the endoplasmic reticulum–Golgi intermediate compartments (ERGIC) through microtubular -associated movement resulting in the formation of viral factories at ERGIC. [ citation needed ] These factories then facilitate transcription and subsequent translation of the viral proteins. Transcription of viral genes must be initiated by association of the L protein with the three nucleocapsid species. In addition to transcriptase and replicase functions, the viral L protein is also thought to have an endonuclease activity that cleaves cellular messenger RNAs (mRNAs) for the production of capped primers used to initiate transcription of viral mRNAs. As a result of this cap snatching , the mRNAs of hantaviruses are capped and contain nontemplated 5′-terminal extensions. The G1 (or Gn) and G2 (Gc) glycoproteins form hetero-oligomers and are then transported from the endoplasmic reticulum to the Golgi complex , where glycosylation is completed. The L protein produces nascent genomes by replication via a positive-sense RNA intermediate. Hantavirus virions are believed to assemble by association of nucleocapsids with glycoproteins embedded in the membranes of the Golgi, followed by budding into the Golgi cisternae . Nascent virions are then transported in secretory vesicles to the plasma membrane and released by exocytosis . [ citation needed ] The pathogenesis of hantavirus infections is unclear as there is a lack of animal models to describe it (rats and mice do not seem to acquire severe disease). While the primary site of viral replication in the body is not known, in HFRS the main effect is in the blood vessels while in HPS most symptoms are associated with the lungs. In HFRS, there are increased vascular permeability and decreased blood pressure due to endothelial dysfunction and the most dramatic damage is seen in the kidneys, whereas in HPS, the lungs, spleen, and gall bladder are most affected. Early symptoms of HPS tend to present similarly to the flu (muscle aches, fever and fatigue) and usually appear around 2 to 3 weeks after exposure. Later stages of the disease (about 4 to 10 days after symptoms start) include difficulty breathing, shortness of breath and coughing. Findings of significant congruence between phylogenies of hantaviruses and phylogenies of their rodent reservoirs have led to the theory that rodents, although infected by the virus, are not harmed by it because of long-standing hantavirus–rodent host coevolution , although findings in 2008 led to new hypotheses regarding hantavirus evolution. Various hantaviruses have been found to infect multiple rodent species, and cases of cross-species transmission ( host switching ) have been recorded. Additionally, rates of substitution based on nucleotide sequence data reveal that hantavirus clades and rodent subfamilies may not have diverged at the same time. Furthermore, as of 2007 hantaviruses have been found in multiple species of non-rodent shrews and moles. Taking into account the inconsistencies in the theory of coevolution, it was proposed in 2009 that the patterns seen in hantaviruses in relation to their reservoirs could be attributed to preferential host switching directed by geographical proximity and adaptation to specific host types. Another proposal from 2010 is that geographical clustering of hantavirus sequences may have been caused by an isolation-by-distance mechanism. Upon comparison of the hantaviruses found in hosts of orders Rodentia and Eulipotyphla , it was proposed in 2011 that the hantavirus evolutionary history is a mix of both host switching and codivergence and that ancestral shrews or moles, rather than rodents, may have been the early original hosts of ancient hantaviruses. A Bayesian analysis in 2014 suggested a common origin for these viruses ~2000 years ago. The association with particular rodent families appears to have been more recent. The viruses carried by the subfamilies Arvicolinae and Murinae originated in Asia 500–700 years ago. These subsequently spread to Africa , Europe , North America and Siberia possibly carried by their hosts. The species infecting the subfamily Neotominae evolved 500–600 years ago in Central America and then spread toward North America. The species infecting Sigmodontinae evolved in Brazil 400 years ago. Their ancestors may have been a Neotominae-associated virus from northern South America. The evolution of shrew -borne hantaviruses appears to have involved natural occurrences of homologous recombination events and the reassortment of genome segments. The evolution of Tula orthohantavirus carried by the European common vole also appears to have involved homologous recombination events. Hantavirus virions are about 80–120 nm in diameter. The lipid bilayer of the viral envelope is about 5 nm thick and is embedded with viral surface proteins to which sugar residues are attached. These glycoproteins, known as Gn and Gc, are encoded by the M segment of the viral genome. They tend to associate ( heterodimerize ) with each other and have both an interior tail and an exterior domain that extends to about 6 nm beyond the envelope surface. [ citation needed ] Inside the envelope are the nucleocapsids. These are composed of many copies of the nucleocapsid protein N, which interact with the three segments of the viral genome to form helical structures. The virally encoded RNA polymerase is also found in the interior. By mass, the virion is greater than 50% protein, 20–30% lipid, and 2–7% carbohydrate. The density of the virions is 1.18 g/cm 3 . These features are common to all members of the family Hantaviridae . [ citation needed ]The genome of hantaviruses is negative-sense, single-stranded RNA . Their genomes are composed of three segments: the small (S), medium (M), and large (L) segments. The S segment, 1–3 kilobases (kb) in length, encodes for the nucleocapsid (N) protein. The M segment, 3.2–4.9 kb in length, encodes a glycoprotein precursor polyprotein that is co-translationally cleaved into the envelope glycoproteins Gn and Gc, alternatively called G1 and G2. The L segment, 6.8–12 kb in length, encodes the L protein which functions primarily as the viral RNA-dependent RNA polymerase used for transcription and replication. Within virions , the genomic RNAs of hantaviruses are thought to complex with the N protein to form helical nucleocapsids, the RNA component of which circularizes due to sequence complementarity between the 5′ and 3′ terminal sequences of genomic segments. [ citation needed ] As with other Bunyavirales , each of the three segments has a consensus 3′-terminal nucleotide sequence (AUCAUCAUC), which is complementary to the 5′-terminal sequence and is distinct from those of the other four genera in the family. These sequences appear to form panhandle structure which seem likely to play a role in replication and encapsidation facilitated by binding with the viral nucleocapsid (N) protein. The large segment is 6530–6550 nucleotides (nt) in length, the medium is 3613–3707 nt in length and the small is 1696–2083 nt in length. [ citation needed ] No nonstructural proteins are known, unlike the other genera in this family. At the 5′ and 3′ of each segment are short noncoding sequences: the noncoding segment in all sequences at the 5′ end is 37–51 nt. The 3′ noncoding regions differ: L segment 38–43 nt; M segment 168–229 nt; and S segment 370–730 nt. The 3′ end of the S segment is conserved between the genera suggesting a functional role. [ citation needed ]Viral entry into host cells initiates by binding to surface cell receptors. Integrins are considered to be the main receptors for hantaviruses in vitro , but complement decay-accelerating factor (DAF) and globular heads of complement C1q receptor (gC1qR) have mediated attachment in cultured cells too. Entry may proceed through a number of possible routes, including clathrin -dependent endocytosis , clathrin-independent receptor-mediated endocytosis, and micro pinocytosis . Viral particles are then transported to late endosomes . Gc-mediated membrane fusion with the endosomal membrane , triggered by low pH , releases the nucleocapsid into the cytoplasm . After the release of the nucleocapsids into cytoplasm, the complexes are targeted to the endoplasmic reticulum–Golgi intermediate compartments (ERGIC) through microtubular -associated movement resulting in the formation of viral factories at ERGIC. [ citation needed ] These factories then facilitate transcription and subsequent translation of the viral proteins. Transcription of viral genes must be initiated by association of the L protein with the three nucleocapsid species. In addition to transcriptase and replicase functions, the viral L protein is also thought to have an endonuclease activity that cleaves cellular messenger RNAs (mRNAs) for the production of capped primers used to initiate transcription of viral mRNAs. As a result of this cap snatching , the mRNAs of hantaviruses are capped and contain nontemplated 5′-terminal extensions. The G1 (or Gn) and G2 (Gc) glycoproteins form hetero-oligomers and are then transported from the endoplasmic reticulum to the Golgi complex , where glycosylation is completed. The L protein produces nascent genomes by replication via a positive-sense RNA intermediate. Hantavirus virions are believed to assemble by association of nucleocapsids with glycoproteins embedded in the membranes of the Golgi, followed by budding into the Golgi cisternae . Nascent virions are then transported in secretory vesicles to the plasma membrane and released by exocytosis . [ citation needed ]The pathogenesis of hantavirus infections is unclear as there is a lack of animal models to describe it (rats and mice do not seem to acquire severe disease). While the primary site of viral replication in the body is not known, in HFRS the main effect is in the blood vessels while in HPS most symptoms are associated with the lungs. In HFRS, there are increased vascular permeability and decreased blood pressure due to endothelial dysfunction and the most dramatic damage is seen in the kidneys, whereas in HPS, the lungs, spleen, and gall bladder are most affected. Early symptoms of HPS tend to present similarly to the flu (muscle aches, fever and fatigue) and usually appear around 2 to 3 weeks after exposure. Later stages of the disease (about 4 to 10 days after symptoms start) include difficulty breathing, shortness of breath and coughing. Findings of significant congruence between phylogenies of hantaviruses and phylogenies of their rodent reservoirs have led to the theory that rodents, although infected by the virus, are not harmed by it because of long-standing hantavirus–rodent host coevolution , although findings in 2008 led to new hypotheses regarding hantavirus evolution. Various hantaviruses have been found to infect multiple rodent species, and cases of cross-species transmission ( host switching ) have been recorded. Additionally, rates of substitution based on nucleotide sequence data reveal that hantavirus clades and rodent subfamilies may not have diverged at the same time. Furthermore, as of 2007 hantaviruses have been found in multiple species of non-rodent shrews and moles. Taking into account the inconsistencies in the theory of coevolution, it was proposed in 2009 that the patterns seen in hantaviruses in relation to their reservoirs could be attributed to preferential host switching directed by geographical proximity and adaptation to specific host types. Another proposal from 2010 is that geographical clustering of hantavirus sequences may have been caused by an isolation-by-distance mechanism. Upon comparison of the hantaviruses found in hosts of orders Rodentia and Eulipotyphla , it was proposed in 2011 that the hantavirus evolutionary history is a mix of both host switching and codivergence and that ancestral shrews or moles, rather than rodents, may have been the early original hosts of ancient hantaviruses. A Bayesian analysis in 2014 suggested a common origin for these viruses ~2000 years ago. The association with particular rodent families appears to have been more recent. The viruses carried by the subfamilies Arvicolinae and Murinae originated in Asia 500–700 years ago. These subsequently spread to Africa , Europe , North America and Siberia possibly carried by their hosts. The species infecting the subfamily Neotominae evolved 500–600 years ago in Central America and then spread toward North America. The species infecting Sigmodontinae evolved in Brazil 400 years ago. Their ancestors may have been a Neotominae-associated virus from northern South America. The evolution of shrew -borne hantaviruses appears to have involved natural occurrences of homologous recombination events and the reassortment of genome segments. The evolution of Tula orthohantavirus carried by the European common vole also appears to have involved homologous recombination events. Orthohantaviruses belong to the family Hantaviridae and members of both the genus and the family are called hantaviruses. The genus also belongs to the subfamily Mammantavirinae , the mammalian hantaviruses, with three other genera. Orthohantaviruses specifically are mammalian hantaviruses that are transmitted among rodents. The genus contains these 38 species: Hantaviruses that were formerly classified as species in this genus and which were not reassigned as member viruses of any existing species include: Isla Vista hantavirus , also called Isla Vista virus Muleshoe hantavirus , also called Muleshoe virus Rio Segundo hantavirus , also called Rio Segundo virusAccording to the U.S. CDC, the best prevention against contracting hantavirus is to eliminate or minimize contact with rodents in the home, workplace, or campsite. As the virus can be transmitted by rodent saliva, excretions, and bites, control of rats and mice in areas frequented by humans is key for disease prevention. General prevention can be accomplished by disposing of rodent nests, sealing any cracks and holes in homes where mice or rats could enter, setting traps, or laying down poisons or using natural predators such as cats in the home. The duration that hantaviruses remain infectious in the environment varies based on factors such as the rodent's diet, temperature, humidity, and whether indoors or outdoors. The viruses have been demonstrated to remain active for 2–3 days at normal room temperature, while ultraviolet rays in direct sunlight kill them within a few hours. Rodent droppings or urine of indeterminate age, though, should always be treated as infectious. As of 2021 [ update ] , no vaccines against hantaviruses have been approved by the U.S. FDA, but whole virus inactivated bivalent vaccines against Hantaan virus and Seoul virus are available in China and South Korea. In both countries, the use of the vaccine, combined with other preventive measures, has significantly reduced the incidence of hantavirus infections. Apart from these vaccines, four types of vaccines have been researched: DNA vaccines targeting the M genome segment and the S genome segment, subunit vaccines that use recombinant Gn, Gc, and N proteins of the virus, virus vector vaccines that have recombinant hantavirus proteins inserted in them, and virus-like particle vaccines that contain viral proteins, but lack genetic material. Of these, only DNA vaccines have entered into clinical trials. As of 2021 [ update ] , no vaccines against hantaviruses have been approved by the U.S. FDA, but whole virus inactivated bivalent vaccines against Hantaan virus and Seoul virus are available in China and South Korea. In both countries, the use of the vaccine, combined with other preventive measures, has significantly reduced the incidence of hantavirus infections. Apart from these vaccines, four types of vaccines have been researched: DNA vaccines targeting the M genome segment and the S genome segment, subunit vaccines that use recombinant Gn, Gc, and N proteins of the virus, virus vector vaccines that have recombinant hantavirus proteins inserted in them, and virus-like particle vaccines that contain viral proteins, but lack genetic material. Of these, only DNA vaccines have entered into clinical trials. Ribavirin may be a drug for HPS and HFRS, but its effectiveness remains unknown; still, spontaneous recovery is possible with supportive treatment. People with suspected hantavirus infection may be admitted to a hospital, and given oxygen and mechanical ventilation support to help them breathe during the acute pulmonary stage with severe respiratory distress. Immunotherapy, administration of human neutralizing antibodies during acute phases of hantavirus, has been studied only in mice, hamsters, and rats. No controlled clinical trials have been reported. Hantavirus infections have been reported from all continents except Australia. Regions especially affected by HFRS include China , the Korean Peninsula , Russia (Hantaan, Puumala, and Seoul viruses), and Northern and Western Europe ( Puumala and Dobrava virus). Regions with the highest incidences of hantavirus pulmonary syndrome include Argentina , Chile , Brazil , the United States , Canada , and Panama . [ citation needed ] In 2010, a novel hantavirus, Sangassou virus , was isolated in Africa, which causes HFRS. In China, Hong Kong, the Korean Peninsula, and Russia, HFRS is caused by Hantaan, Puumala, and Seoul viruses. In March 2020, a man from Yunnan tested positive for hantavirus. He died while travelling to Shandong for work on a chartered bus. According to the Global Times reports, around 32 other people have been tested for the virus. As of 2005 [ update ] , no human infections have been reported in Australia, though rodents were found to carry antibodies. In Europe, two hantaviruses – Puumala and Dobrava-Belgrade viruses – are known to cause HFRS. Puumala usually causes a generally mild disease, nephropathia epidemica , which typically presents with fever, headache, gastrointestinal symptoms, impaired renal function, and blurred vision. Dobrava infections are similar, except that they often also have hemorrhagic complications. [ citation needed ] Puumala virus is carried by its rodent host, the bank vole ( Clethrionomys glareolus ), and is present throughout most of Europe, except for the Mediterranean region. Four Dobrava virus genotypes are known, each carried by a different rodent species. Genotype Dobrava is found in the yellow-necked mouse ( Apodemus flavicollis ), genotypes Saaremaa and Kurkino in the striped field mouse ( Apodemus agrarius ), and genotype Sochi in the Black Sea field mouse ( Apodemus ponticus ). [ citation needed ] In 2017 alone, the Robert Koch Institute (RKI) in Germany received 1,713 notifications of hantavirus infections. The primary cause of the disease in Canada is Sin Nombre virus-infected deer mice. Between 1989 and 2014, 109 confirmed cases were reported, with the death rate estimated at 29%. The virus exists in deer mice nationwide, but cases were concentrated in western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) with only one case in eastern Canada. In Canada, "[a]ll cases occurred in rural settings and approximately 70% of the cases have been associated with domestic and farming activities." In the United States, minor cases of HPS include Sin Nombre orthohantavirus , New York orthohantavirus , Bayou orthohantavirus , and possibly Black Creek Canal orthohantavirus . [ citation needed ] As of January 2017 [ update ] , 728 cases of hantavirus had been reported in the United States cumulatively since 1995, across 36 states, not including cases with presumed exposure outside the United States. More than 96% of cases have occurred in states west of the Mississippi River . The top 10 states by number of cases reported (which differs slightly from a count ordered by the state of original exposure ) were New Mexico (109), Colorado (104), Arizona (78), California (61), Washington (50), Texas (45), Montana (43), Utah (38), Idaho (21), and Oregon (21); 36% of the total reported cases have resulted in death. In Mexico, rodents have been found to carry hantaviruses include Thomas's giant deer mouse (Megadontomys thomasi) , the pack rat Neotoma picta , Orizaba deer mouse (Peromyscus beatae) , Western harvest mouse (Reithrodontomys megalotis) and Sumichrast's harvest mouse (Reithrodontomys sumichrasti) . Agents of HPS found in South America include the Andes virus (also called Oran, Castelo de Sonhos – Portuguese for "Castle of Dreams", Lechiguanas, Juquitiba, Araraquara, and Bermejo virus, among many other synonyms), which is the only hantavirus that has shown an interpersonal form of transmission, and the Laguna Negra virus , an extremely close relative of the previously known Rio Mamore virus. [ citation needed ] Rodents that have been shown to carry hantaviruses include Abrothrix longipilis and Oligoryzomys longicaudatus . In 2010, a novel hantavirus, Sangassou virus , was isolated in Africa, which causes HFRS. In China, Hong Kong, the Korean Peninsula, and Russia, HFRS is caused by Hantaan, Puumala, and Seoul viruses. In March 2020, a man from Yunnan tested positive for hantavirus. He died while travelling to Shandong for work on a chartered bus. According to the Global Times reports, around 32 other people have been tested for the virus. In March 2020, a man from Yunnan tested positive for hantavirus. He died while travelling to Shandong for work on a chartered bus. According to the Global Times reports, around 32 other people have been tested for the virus. As of 2005 [ update ] , no human infections have been reported in Australia, though rodents were found to carry antibodies. In Europe, two hantaviruses – Puumala and Dobrava-Belgrade viruses – are known to cause HFRS. Puumala usually causes a generally mild disease, nephropathia epidemica , which typically presents with fever, headache, gastrointestinal symptoms, impaired renal function, and blurred vision. Dobrava infections are similar, except that they often also have hemorrhagic complications. [ citation needed ] Puumala virus is carried by its rodent host, the bank vole ( Clethrionomys glareolus ), and is present throughout most of Europe, except for the Mediterranean region. Four Dobrava virus genotypes are known, each carried by a different rodent species. Genotype Dobrava is found in the yellow-necked mouse ( Apodemus flavicollis ), genotypes Saaremaa and Kurkino in the striped field mouse ( Apodemus agrarius ), and genotype Sochi in the Black Sea field mouse ( Apodemus ponticus ). [ citation needed ] In 2017 alone, the Robert Koch Institute (RKI) in Germany received 1,713 notifications of hantavirus infections. The primary cause of the disease in Canada is Sin Nombre virus-infected deer mice. Between 1989 and 2014, 109 confirmed cases were reported, with the death rate estimated at 29%. The virus exists in deer mice nationwide, but cases were concentrated in western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) with only one case in eastern Canada. In Canada, "[a]ll cases occurred in rural settings and approximately 70% of the cases have been associated with domestic and farming activities." In the United States, minor cases of HPS include Sin Nombre orthohantavirus , New York orthohantavirus , Bayou orthohantavirus , and possibly Black Creek Canal orthohantavirus . [ citation needed ] As of January 2017 [ update ] , 728 cases of hantavirus had been reported in the United States cumulatively since 1995, across 36 states, not including cases with presumed exposure outside the United States. More than 96% of cases have occurred in states west of the Mississippi River . The top 10 states by number of cases reported (which differs slightly from a count ordered by the state of original exposure ) were New Mexico (109), Colorado (104), Arizona (78), California (61), Washington (50), Texas (45), Montana (43), Utah (38), Idaho (21), and Oregon (21); 36% of the total reported cases have resulted in death. In Mexico, rodents have been found to carry hantaviruses include Thomas's giant deer mouse (Megadontomys thomasi) , the pack rat Neotoma picta , Orizaba deer mouse (Peromyscus beatae) , Western harvest mouse (Reithrodontomys megalotis) and Sumichrast's harvest mouse (Reithrodontomys sumichrasti) . The primary cause of the disease in Canada is Sin Nombre virus-infected deer mice. Between 1989 and 2014, 109 confirmed cases were reported, with the death rate estimated at 29%. The virus exists in deer mice nationwide, but cases were concentrated in western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) with only one case in eastern Canada. In Canada, "[a]ll cases occurred in rural settings and approximately 70% of the cases have been associated with domestic and farming activities." In the United States, minor cases of HPS include Sin Nombre orthohantavirus , New York orthohantavirus , Bayou orthohantavirus , and possibly Black Creek Canal orthohantavirus . [ citation needed ] As of January 2017 [ update ] , 728 cases of hantavirus had been reported in the United States cumulatively since 1995, across 36 states, not including cases with presumed exposure outside the United States. More than 96% of cases have occurred in states west of the Mississippi River . The top 10 states by number of cases reported (which differs slightly from a count ordered by the state of original exposure ) were New Mexico (109), Colorado (104), Arizona (78), California (61), Washington (50), Texas (45), Montana (43), Utah (38), Idaho (21), and Oregon (21); 36% of the total reported cases have resulted in death. In Mexico, rodents have been found to carry hantaviruses include Thomas's giant deer mouse (Megadontomys thomasi) , the pack rat Neotoma picta , Orizaba deer mouse (Peromyscus beatae) , Western harvest mouse (Reithrodontomys megalotis) and Sumichrast's harvest mouse (Reithrodontomys sumichrasti) . Agents of HPS found in South America include the Andes virus (also called Oran, Castelo de Sonhos – Portuguese for "Castle of Dreams", Lechiguanas, Juquitiba, Araraquara, and Bermejo virus, among many other synonyms), which is the only hantavirus that has shown an interpersonal form of transmission, and the Laguna Negra virus , an extremely close relative of the previously known Rio Mamore virus. [ citation needed ] Rodents that have been shown to carry hantaviruses include Abrothrix longipilis and Oligoryzomys longicaudatus . Hantavirus HFRS was likely first referenced in China in the 12th century. The first clinical recognition was in 1931 in northeast China. Around the same time in the 1930s, NE was identified in Sweden. HFRS came to the recognition of western physicians during the Korean War between 1951 and 1954 when more than 3,000 United Nations soldiers fell ill in an outbreak. In 1976, the first pathogenic hantavirus, the Hantaan orthohantavirus , was isolated from rodents near the Hantan River in South Korea . Other prominent hantaviruses that cause HFRS, including the Dobrava-Belgrade orthohantavirus , Puumala orthohantavirus , and Seoul orthohantavirus , were identified in the years after then and are collectively referred to as the Old World hantaviruses. In 1993, an outbreak of HCPS , then unrecognized, occurred in the Four Corners region of the United States and led to the discovery of the Sin Nombre orthohantavirus . Since then, approximately 43 hantavirus strains, of which 20 are pathogenic, have been found in the Americas and are referred to as the New World hantaviruses. This includes the Andes orthohantavirus , one of the primary causes of HCPS in South America and the only hantavirus known to be capable of person-to-person transmission. In late medieval England a mysterious sweating sickness swept through the country in 1485 just before the Battle of Bosworth Field . Noting that the symptoms overlap with hantavirus pulmonary syndrome, several scientists have theorized that the virus may have been the cause of the disease. The hypothesis was criticized because sweating sickness was recorded as being transmitted from human to human, whereas hantaviruses were not known to spread in this way.

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Impetigore

Shanty Harmayn Tia Hasibuan Aoura Lovenson Chandra Ben Soebiakto Bembi Gusti Mian Tiara Tony Merle Aghi Narottama Rapi Films Base Entertainment CJ Entertainment Ivanhoe Pictures Rapi Films (Indonesia) Shudder Originals (United States) 17 October 2019 ( 2019-10-17 ) Impetigore ( Indonesian : Perempuan Tanah Jahanam , lit. ' Woman of the damned land ' ) is a 2019 horror film written and directed by Joko Anwar . The film stars Tara Basro , Marissa Anita , Christine Hakim , Asmara Abigail, and Ario Bayu . The film follows Maya (Basro), who travels with her friend Dini (Anita) to her remote ancestral village seeking an inheritance . Almost a decade in development, the film was announced in 2011 but was shelved. Seven years later, Impetigore was secured as an international co-production between Indonesian, South Korean and American production houses. Filming took place on location at various sites in East Java , facing challenges due to the remoteness of the main village location and Anwar being hospitalised with dengue fever . Impetigore premiered in Indonesia on 17 October 2019 and internationally at the 2020 Sundance Film Festival . It was later acquired by Shudder for international streaming. The film was a box office success in Indonesia and received favourable reviews internationally, with critics praising its cinematography, sound design and use of Indonesian folklore . It was selected as the Indonesian official entry for the Best International Feature Film at the 93rd Academy Awards , but was not nominated. At the 40th Citra Awards , Indonesia's top film honours, the film received a record-breaking 17 nominations and won 6, including Best Picture , a second Best Director for Anwar, and a third supporting actress and ninth overall win for screen veteran Christine Hakim .Best friends Maya and Dini work as tollbooth collectors in Jakarta . On a night shift, Maya is attacked by a man wielding a golok , who says he is from a village called Harjosari and calls Maya "Rahayu". Maya narrowly avoids being killed before the attacker is shot dead by police. Later, Maya shows Dini an old photograph given by her aunt, who has raised her in the city since her parents' mysterious deaths. The photograph shows a young Maya, who is identified as Rahayu, with her deceased parents Donowongso and Shinta, in front of a large house. Maya and Dini travel to the remote Harjosari village to look for the house in the hope of selling it as inheritance . Posing as student researchers in Harjosari, the pair find the long-abandoned house and encounter cold, suspicious villagers. They witness daily funerals for children taking place and observe that many headstones in the cemetery belong to newborns. Dini is lured away by villagers, who slit her throat and flay her, mistaking her for Rahayu. While looking for Dini that evening, Maya spies village chief and dalang Saptadi attending the birth of a skinless baby, whom he proceeds to drown. A sympathetic villager Ratih tells her that 20 years ago, Donowongso, a rich dalang, made a pact with the devil and murdered three girls to heal his daughter Rahayu, who was born without skin. Since then, all babies in the village have been born skinless. The ghost of one of the girls reveals to Maya that, to end the curse, she must bury the slain girls' skin, which had been made into wayang kulit puppets by Donowongso. The ghost also reveals that Maya was born out of the extramarital relations between Shinta and Saptadi. Disapproving of the affair, Saptadi's dukun mother Misni jinxed Saptadi to forget Shinta, and cursed Maya, who was named Rahayu at birth, to be born skinless. Donowongso then sacrificed three girls to cure Rahayu's skin and, in doing so, cursed the entire village. Saptadi then killed Donowongso, Shinta, and a group of wayang musicians during a performance in front of all the villagers, and framed Donowongso for the massacre. Misni then convinced the villagers that the curse can only be undone by flaying Rahayu and making puppets out of her skin. Rahayu was evacuated by her 'aunt', who in fact was one of Donowongso's servants, and renamed Maya to conceal her identity. Maya and Ratih bury the puppets made from the three girls' skin and their spirits are pacified. Misni arrives with the villagers and they capture Maya. Maya appeals to Saptadi by telling him the truth, and Misni reveals that Saptadi was born out of her own extramarital affair with Donowongso's father, making him Donowongso's half-brother. As Misni moves to flay Maya, a remorseful Saptadi takes her hand to slit his throat instead. Horrified, Misni slits her own throat to join her son. As a villager announces the birth of the first healthy baby in 20 years, Maya escapes. One year later, a villager suffers a violent miscarriage and it is shown that Misni's ghost has extracted the fetus and devoured it.Cast adapted from RogerEbert.com . Tara Basro as Maya / Rahayu Christine Hakim as Nyi Misni Ario Bayu as Ki Saptadi Marissa Anita as Dini Asmara Abigail as Ratih Zidni Hakim as Ki Donowongso Faradina Mufti as Nyai Shinta Kiki Narendra as BambangDirector and writer Joko Anwar described the film's concept as originating from a story his older brother had told him as a child; that the leather for Indonesian shadow puppets came from human skin. To form the concept for the film, he combined this with the idea of a strong but intimidating maternal character inspired by his own mother, and various Indonesian social and political issues. On the inclusion of Indonesian folklore elements, Anwar said "It's not a choice, it comes naturally. I grew up reading and being told about this type of folklore all the time. It's even taught in schoolbooks in Indonesia". In 2011, a poster and Twitter account were made to promote the film, which was set to be produced by Lifelike Pictures, but the project was cancelled. Anwar also said difficulties finding a filming location that matched the script and a lack of budget led to the project being shelved. He later said he "kept fixing the story each year while at the same time also searching for the right partner to make this film". The project was revived seven years later, when Ivanhoe Pictures announced a three-film collaboration with Anwar which includes Impetigore , Ghost in the Cell , and The Vow . The film was an international co-production between Indonesia's Rapi Films and BASE Entertainment, South Korea's CJ Entertainment and American company Ivanhoe Pictures. CJ Entertainment had previously had major international success with Crazy Rich Asians (2018), and intended to increase their presence in Southeast Asia. Anwar announced on Instagram that the film would be called Perempuan Tanah Jahanam on 31 December 2018. In February 2019, Anwar announced the cast members, including frequent collaborators Tara Basro , Marissa Anita , Asmara Abigail, Ario Bayu , and Arswendi Nasution. Christine Hakim 's casting, announced at the same time, represented the first time she had appeared in a horror film in her 46-year career. Although the film is primarily in Indonesian , some older characters speak Javanese . Filming began in March 2019, and was primarily shot on location in Banyuwangi , Lumajang and Ijen in East Java . The film crew spent three months searching for a village that matched the location described in the script. The village chosen, which was established in 1941 for workers on Dutch plantations, was so remote that the crew had to construct a path for vehicles and equipment to reach it. Anwar said that "due to the difficult terrain, the entire crew and cast members had to stay in the village throughout the filming. [Fortunately] the villagers warmly welcomed us, even cooked every day for us." Many local villagers appear as extras in the film. Filming was expected to take 29 days, but experienced difficulties when Anwar contracted dengue fever on the first day and was hospitalised for 8 days. Anwar later reflected that he had almost died during the illness, and that the shoot was "probably the most adventurous time" of his life. The film crew had to construct the village's first toilets themselves, as well as the house that was used for the main set. After filming, this infrastructure was left by the crew for use by village residents, with the house set converted into a public library with books provided by the crew. Sound mixing was conducted by the same team used by Thai filmmaker Apichatpong Weerasethakul , who won the 2010 Palme d'Or . BASE Entertainment announced that production had wrapped by April 2019. A teaser poster and trailer were released in August 2019. Titled Perumpuan Tanah Janah in Indonesia, the film's internationally marketed name Impetigore is a made-up word to name the disease suffered by the children in the film. Director and writer Joko Anwar described the film's concept as originating from a story his older brother had told him as a child; that the leather for Indonesian shadow puppets came from human skin. To form the concept for the film, he combined this with the idea of a strong but intimidating maternal character inspired by his own mother, and various Indonesian social and political issues. On the inclusion of Indonesian folklore elements, Anwar said "It's not a choice, it comes naturally. I grew up reading and being told about this type of folklore all the time. It's even taught in schoolbooks in Indonesia". In 2011, a poster and Twitter account were made to promote the film, which was set to be produced by Lifelike Pictures, but the project was cancelled. Anwar also said difficulties finding a filming location that matched the script and a lack of budget led to the project being shelved. He later said he "kept fixing the story each year while at the same time also searching for the right partner to make this film". The project was revived seven years later, when Ivanhoe Pictures announced a three-film collaboration with Anwar which includes Impetigore , Ghost in the Cell , and The Vow . The film was an international co-production between Indonesia's Rapi Films and BASE Entertainment, South Korea's CJ Entertainment and American company Ivanhoe Pictures. CJ Entertainment had previously had major international success with Crazy Rich Asians (2018), and intended to increase their presence in Southeast Asia. Anwar announced on Instagram that the film would be called Perempuan Tanah Jahanam on 31 December 2018. In February 2019, Anwar announced the cast members, including frequent collaborators Tara Basro , Marissa Anita , Asmara Abigail, Ario Bayu , and Arswendi Nasution. Christine Hakim 's casting, announced at the same time, represented the first time she had appeared in a horror film in her 46-year career. Although the film is primarily in Indonesian , some older characters speak Javanese . Filming began in March 2019, and was primarily shot on location in Banyuwangi , Lumajang and Ijen in East Java . The film crew spent three months searching for a village that matched the location described in the script. The village chosen, which was established in 1941 for workers on Dutch plantations, was so remote that the crew had to construct a path for vehicles and equipment to reach it. Anwar said that "due to the difficult terrain, the entire crew and cast members had to stay in the village throughout the filming. [Fortunately] the villagers warmly welcomed us, even cooked every day for us." Many local villagers appear as extras in the film. Filming was expected to take 29 days, but experienced difficulties when Anwar contracted dengue fever on the first day and was hospitalised for 8 days. Anwar later reflected that he had almost died during the illness, and that the shoot was "probably the most adventurous time" of his life. The film crew had to construct the village's first toilets themselves, as well as the house that was used for the main set. After filming, this infrastructure was left by the crew for use by village residents, with the house set converted into a public library with books provided by the crew. Sound mixing was conducted by the same team used by Thai filmmaker Apichatpong Weerasethakul , who won the 2010 Palme d'Or . BASE Entertainment announced that production had wrapped by April 2019. A teaser poster and trailer were released in August 2019. Titled Perumpuan Tanah Janah in Indonesia, the film's internationally marketed name Impetigore is a made-up word to name the disease suffered by the children in the film. Impetigore was released in Indonesia on 17 October 2019. Plans to screen the film for free at abandoned 1920s cinema Bioskop Grand Senen in Jakarta, as part of an effort to revive historic Indonesian cinemas, were later abandoned due to permit issues; demand was so high tickets had sold out within five minutes of the announcement. It premiered internationally at the Sundance Film Festival on 26 January 2020, and was later screened at the Rotterdam and Gothenburg Film Festivals . It also had theatrical releases in Malaysia, Hong Kong, Singapore, Brunei, Cambodia, Laos, Thailand, Macau and Myanmar. In May 2020, it was released for streaming on Indonesian service GoPlay and was released in the United States, Canada and the UK on horror streaming service Shudder on 23 July 2020, after its distribution rights were acquired by the network as a Shudder original . This marked another collaboration of Anwar and Shudder, after Satan's Slaves became one of the network's biggest hits. Impetigore was a box office success in Indonesia. It opened in first place in the local box office with an audience of 117,000 on its opening day and attracted 700,000 admissions in its first week of release. At the end of its domestic theatrical run, it ended up with 1.7 million admissions, making it the seventh highest grossing domestic film in 2019. The film's soundtrack was created with the involvement of composer Rahayu Supanggah , and musical arrangers Aghi Narottama, Bemby Gusti and Tony Merle. On review aggregator Rotten Tomatoes , the film holds a 92% approval rating based on 39 reviews, with an average rating of 7.2/10 . The site's critics consensus reads, " Impetigore uses its folk horror setting as the brutally effective backdrop for a supernatural story that sinks its hooks into the viewer and refuses to let go." In The Jakarta Post , Reyzando Nawara gave a positive review, commenting on the film's relevance to Indonesian society, saying it "makes a very compelling argument about the evils of abused power and the danger it presents" across multiple generations. In Kompas , Mohammad Hilmi Faiq described the film as a new peak for Anwar. Some reviewers in American publications commented that Impetigore was not too scary as it instead put emphasis on Indonesian cultural elements. Dennis Harvey wrote a positive review in Variety , praising the film's production design and sound, calling it a "handsome and atmospheric production" and "good, sometimes grisly fun that's not terribly scary, particularly once hectic climactic events prove less suspenseful than the slow-burn buildup". Harvey critiqued the film's later acts, saying that the "convoluted later mix of chase scenes and explanatory flashbacks [feel] more like an awkward pileup of miscellaneous genre tropes ". On RogerEbert.com , Peter Sobczynski gave the film three and a half out of four stars, commending film's style and use of Indonesian folklore , but criticised the flashback sequence and epilogue. He particularly highlighted the film's opening sequence, calling it "electrifying" and "absolutely spellbinding". In Screen Daily , Wendy Ide commended the film's atmosphere but critiqued its use of exposition , calling it "entertaining, pulpy horror, [that] focuses more on incorporating Indonesian cultural elements rather than delivering neatly packaged scares". Jacob Stolworthy in The Independent called the film "a must-watch for fans of scary films". In a more mixed review, James Marsh in South China Morning Post rated the film 2.5 out of 5 stars and said the film was "unevenly paced and fails to capitalise on its grisly premise", but praised Basro's performance. Marco Ferrarese in Al Jazeera highlighted Impetigore as part of a new wave of low-budget horror films bringing increased international attention to Southeast Asia's film industry , alongside Malaysian film Roh . Distributed internationally by streaming services , Ferrarese highlighted it as one of several recent horror films from the region that received critical acclaim and festival attention beyond their native countries. Impetigore received a record 17 nominations and went on to be the biggest winner at the 2020 Indonesian Film Festival , the first for a horror film in the history of the Citra Awards. In accepting the award for Best Director, Anwar expressed his hope that the Indonesian film industry could raise its international profile, and said he believed that the COVID-19 pandemic had halted its progress when Indonesian film was "at its peak". Anwar won his second Citra Award for Best Director , and Hakim won the third Best Supporting Actress and ninth award overall of her career. In November 2020, it was selected as the Indonesian official entry for the Best International Feature Film at the 93rd Academy Awards , but it was not nominated. When announcing the submission, Garin Nugroho , head of the Indonesian Academy Awards Selection Committee, cited the film's showcasing of Indonesian values and culture, as well as for its direction and script. The film was also submitted to the Best Foreign Language Film at the 78th Golden Globe Awards and was also not nominated. On review aggregator Rotten Tomatoes , the film holds a 92% approval rating based on 39 reviews, with an average rating of 7.2/10 . The site's critics consensus reads, " Impetigore uses its folk horror setting as the brutally effective backdrop for a supernatural story that sinks its hooks into the viewer and refuses to let go." In The Jakarta Post , Reyzando Nawara gave a positive review, commenting on the film's relevance to Indonesian society, saying it "makes a very compelling argument about the evils of abused power and the danger it presents" across multiple generations. In Kompas , Mohammad Hilmi Faiq described the film as a new peak for Anwar. Some reviewers in American publications commented that Impetigore was not too scary as it instead put emphasis on Indonesian cultural elements. Dennis Harvey wrote a positive review in Variety , praising the film's production design and sound, calling it a "handsome and atmospheric production" and "good, sometimes grisly fun that's not terribly scary, particularly once hectic climactic events prove less suspenseful than the slow-burn buildup". Harvey critiqued the film's later acts, saying that the "convoluted later mix of chase scenes and explanatory flashbacks [feel] more like an awkward pileup of miscellaneous genre tropes ". On RogerEbert.com , Peter Sobczynski gave the film three and a half out of four stars, commending film's style and use of Indonesian folklore , but criticised the flashback sequence and epilogue. He particularly highlighted the film's opening sequence, calling it "electrifying" and "absolutely spellbinding". In Screen Daily , Wendy Ide commended the film's atmosphere but critiqued its use of exposition , calling it "entertaining, pulpy horror, [that] focuses more on incorporating Indonesian cultural elements rather than delivering neatly packaged scares". Jacob Stolworthy in The Independent called the film "a must-watch for fans of scary films". In a more mixed review, James Marsh in South China Morning Post rated the film 2.5 out of 5 stars and said the film was "unevenly paced and fails to capitalise on its grisly premise", but praised Basro's performance. Marco Ferrarese in Al Jazeera highlighted Impetigore as part of a new wave of low-budget horror films bringing increased international attention to Southeast Asia's film industry , alongside Malaysian film Roh . Distributed internationally by streaming services , Ferrarese highlighted it as one of several recent horror films from the region that received critical acclaim and festival attention beyond their native countries. Impetigore received a record 17 nominations and went on to be the biggest winner at the 2020 Indonesian Film Festival , the first for a horror film in the history of the Citra Awards. In accepting the award for Best Director, Anwar expressed his hope that the Indonesian film industry could raise its international profile, and said he believed that the COVID-19 pandemic had halted its progress when Indonesian film was "at its peak". Anwar won his second Citra Award for Best Director , and Hakim won the third Best Supporting Actress and ninth award overall of her career. In November 2020, it was selected as the Indonesian official entry for the Best International Feature Film at the 93rd Academy Awards , but it was not nominated. When announcing the submission, Garin Nugroho , head of the Indonesian Academy Awards Selection Committee, cited the film's showcasing of Indonesian values and culture, as well as for its direction and script. The film was also submitted to the Best Foreign Language Film at the 78th Golden Globe Awards and was also not nominated.

Wiki

Dengue fever

https://api.wikimedia.org/core/v1/wikipedia/en/page/Pocari_Sweat/html

Pocari Sweat

Pocari Sweat ( Japanese : ポカリスエット , Pokari Suetto ) is a Japanese sports drink , manufactured by Otsuka Pharmaceutical . It was launched in 1980, and is mostly well known across Asia and the Middle East; it is also available in East Asia , Southeast Asia , Australia and Mexico . Pocari Sweat is a mild-tasting, relatively light, non-carbonated sweet beverage and is advertised as an "ion supply drink", "refreshment water" (1992), "body request" (1999), and "electrolyte beverage" in Thailand . It has a mild grapefruit flavor with little aftertaste. Ingredients listed are water, sugar, citric acid , trisodium citrate , sodium chloride , potassium chloride , calcium lactate , magnesium carbonate , and flavoring. It is sold in aluminium cans , PET bottles , and as a powder for mixing with water. An artificially sweetened version with reduced sugar called Pocari Sweat Ion Water ( ポカリスエット イオンウォーター , Pokari Suetto Ion Wōtā ) is also sold. Pocari Sweat was launched in 1980 in Japan by Rokuro Harima, an Otsuka Pharmaceutical employee who came up with the idea after observing a doctor drink IV solution to rehydrate. Harima had taken a trip to the hospital after getting diarrhea during a business trip to Mexico, and wondered if a drink could provide both the water and nutrients he needed to recover. Wary of Gatorade 's dominance of the United States market, Pocari Sweat focused on expansion into Asia and the Middle East. In 1982, it was exported overseas for the first time, to Hong Kong and Taiwan, followed the next year by Singapore, Bahrain, Oman and Saudi Arabia. By the mid-1990s, Pocari Sweat had become Japan's first domestically produced non-alcoholic drink to ship over $1 billion in product. The reference to sweat in the name of the beverage might have a somewhat off-putting or mildly humorous connotation for some English speakers. However, the name was chosen by the manufacturers originally for the purpose of marketing the product as a sports drink in Japan, where English words are used differently . It was largely derived from the notion of what it is intended to supply to the drinker: all of the nutrients and electrolytes lost when sweating. The first part of the name, Pocari , gives a refreshing impression. Otsuka Pharmaceutical's website states: " ' Pocari' was named for its light nuance and bright sound, and it has no particular meaning." Pocari Sweat has maintained the same blue-and-white color scheme since its inception in 1980. Originally sold in a 245 mL can, it has been sold primarily in bottle form since 1990. Otsuka began a targeted marketing campaign in Indonesia after an outbreak of dengue fever in 2010, promoting the drink to prevent dehydration, a common symptom of the disease. On 15 May 2014, Pocari Sweat started a project to send a "dream capsule" to the Moon. The capsule will have the same shape as a Pocari Sweat can and will be filled with Pocari Sweat powder. Once it arrives, Pocari Sweat will be the first commercial product advertised on the Moon. Originally scheduled to launch on a SpaceX Falcon 9 rocket in October 2015, it is currently onboard an Astrobotic Technology lander that launched in January 2024. The company also has done extensive advertising through anime . The technical director for the film Your Name helped create a 2019 anime-styled advertisement. Pocari Sweat released a January 2021 special episode of the Cells at Work! anime promoting the drink as a way to prevent heat stroke .

Wiki

Dengue fever

https://api.wikimedia.org/core/v1/wikipedia/en/page/Paracetamol/html

Paracetamol

N -(4-hydroxyphenyl)ethanamide CC(=O)Nc1ccc(O)cc1 InChI=1S/C8H9NO2/c1-6(10)9-7-2-4-8(11)5-3-7/h2-5,11H,1H3,(H,9,10) Y Key:RZVAJINKPMORJF-UHFFFAOYSA-N Y Paracetamol ( acetaminophen [lower-alpha 1] or para -hydroxyacetanilide ) is a non-opioid analgesic and antipyretic agent used to treat fever and mild to moderate pain . It is a widely used over the counter medication . Common brand names include Tylenol and Panadol . At a standard dose, paracetamol slightly decreases body temperature; it is inferior to ibuprofen in that respect, and the benefits of its use for fever are unclear, particularly in the context of fever of viral origins. Paracetamol relieves pain in both acute mild migraine and episodic tension headache . The aspirin/paracetamol/caffeine combination also helps with both conditions where the pain is mild and is recommended as a first-line treatment for them. Paracetamol is effective for post- surgical pain, but it is inferior to ibuprofen. The paracetamol/ibuprofen combination provides further increase in potency and is superior to either drug alone. The pain relief paracetamol provides in osteoarthritis is small and clinically insignificant. The evidence in its favor for the use in low back pain, cancer pain , and neuropathic pain is insufficient. In the short term, paracetamol is safe and effective when used as directed. Short term adverse effects are uncommon and similar to ibuprofen , but paracetamol is typically safer than non-steroidal anti-inflammatory drugs (NSAID) for long term use. Paracetamol is also often used in patients who cannot tolerate NSAIDs like ibuprofen . Chronic consumption of paracetamol may result in a drop in hemoglobin level, indicating possible gastrointestinal bleeding , and abnormal liver function tests . The recommended maximum daily dose for an adult is three to four grams. Higher doses may lead to toxicity, including liver failure . Paracetamol poisoning is the foremost cause of acute liver failure in the Western world , and accounts for most drug overdoses in the United States, the United Kingdom, Australia, and New Zealand. Paracetamol was first made in 1878 by Harmon Northrop Morse or possibly 1852 by Charles Frédéric Gerhardt . It is the most commonly used medication for pain and fever in both the United States and Europe. It is on the World Health Organization's List of Essential Medicines . Paracetamol is available as a generic medication , with brand names including Tylenol and Panadol among others . In 2021, it was the 113th most commonly prescribed medication in the United States, with more than 5 million prescriptions. Paracetamol is a drug of choice for reducing fever . However, there has been a lack of research on its antipyretic properties, particularly in adults. The most recent review on paracetamol and management of fever in the general practice (2008) argued that its benefits are unclear. In addition, when used for the common cold, paracetamol may relieve a stuffed or runny nose, but not other cold symptoms such as a sore throat, malaise, sneezing, or cough; however, these data are of poor quality. For patients in critical care, paracetamol decreased body temperature by only 0.2 – 0.3 °C more than control interventions; there was no difference in mortality. It did not change the outcome in febrile patients with stroke. The results are contradictory for paracetamol use in sepsis: higher mortality, lower mortality, and no change in mortality were all reported. Paracetamol offered no benefit in the treatment of dengue fever and was accompanied by a higher rate of liver enzyme elevation: a sign of a potential liver damage. Overall, there is no support for a routine administration of antipyretic drugs, including paracetamol, to hospitalized patients with fever and infection. The efficacy of paracetamol in children with fever is unclear. Paracetamol should not be used solely with the aim of reducing body temperature; however, it may be considered for children with fever who appear distressed. It does not prevent febrile seizures and should not be used for that purpose. It appears that 0.2 °C decrease of the body temperature in children after a standard dose of paracetamol is of questionable value, particularly in emergency situations. Based on this, some physicians advocate using higher doses that may decrease the temperature by as much as 0.7 °C. Meta-analyses showed that paracetamol is less effective than ibuprofen in children (marginally less effective, according to another analysis ), including children younger than 2 years old, with equivalent safety. Exacerbation of asthma occurs with similar frequency for both medications. Giving paracetamol and ibuprofen together at the same time to children under 5 is not recommended, however doses may be alternated if required. Paracetamol is used for the relief of mild to moderate pain such as headache, muscle aches, minor arthritis pain, toothache as well as pain caused by cold, flu, sprains, and dysmenorrhea . It is recommended, in particular, for acute mild to moderate pain, since the evidence for the treatment of chronic pain is insufficient. The benefits of paracetamol in musculoskeletal conditions, such as osteoarthritis and backache, are uncertain. It appears to provide only small and not clinically important benefits in osteoarthritis . American College of Rheumatology and Arthritis Foundation guideline for the management of osteoarthritis notes that the effect size in clinical trials of paracetamol has been very small, which suggests that for most individuals it is ineffective. The guideline conditionally recommends paracetamol for short-term and episodic use to those who do not tolerate nonsteroidal anti-inflammatory drugs . For people taking it regularly, monitoring for liver toxicity is required. Essentially the same recommendation was issued by EULAR for hand osteoarthritis. Similarly, the ESCEO algorithm for the treatment of knee osteoarthritis recommends limiting the use of paracetamol to short-term rescue analgesia only. Paracetamol is ineffective for acute low back pain. No randomized clinical trials evaluated its use for chronic or radicular back pain, and the evidence in favor of paracetamol is lacking. Paracetamol is effective for acute migraine : 39% of people experience pain relief at one hour compared with 20% in the control group. The aspirin/paracetamol/caffeine combination also "has strong evidence of effectiveness and can be used as a first-line treatment for migraine". Paracetamol on its own only slightly alleviates episodic tension headache in those who have them frequently. However, the aspirin/paracetamol/caffeine combination is superior to both paracetamol alone and placebo and offers meaningful relief of tension headache: 2 hours after administering the medication, 29% of those who took the combination were pain-free as compared with 21% on paracetamol and 18% on placebo. The German, Austrian, and Swiss headache societies and the German Society of Neurology recommend this combination as a "highlighted" one for self-medication of tension headache, with paracetamol/caffeine combination being a "remedy of first choice", and paracetamol a "remedy of second choice". Pain after a dental surgery provides a reliable model for the action of analgesics on other kinds of acute pain. For the relief of such pain, paracetamol is inferior to ibuprofen. Full therapeutic doses of non-steroidal anti-inflammatory drugs (NSAIDs) ibuprofen, naproxen or diclofenac are clearly more efficacious than the paracetamol/codeine combination which is frequently prescribed for dental pain. The combinations of paracetamol and NSAIDs ibuprofen or diclofenac are promising, possibly offering better pain control than either paracetamol or the NSAID alone. Additionally, the paracetamol/ibuprofen combination may be superior to paracetamol/codeine and ibuprofen/codeine combinations. A meta-analysis of general post-surgical pain, which included dental and other surgery, showed the paracetamol/codeine combination to be more effective than paracetamol alone: it provided significant pain relief to as much as 53% of the participants, while the placebo helped only 7%. Paracetamol fails to relieve procedural pain in newborn babies . For perineal pain postpartum paracetamol appears to be less effective than non-steroidal anti-inflammatory drugs (NSAIDs). The studies to support or refute the use of paracetamol for cancer pain and for neuropathic pain are lacking. There is limited evidence in favor of the use of the intravenous form of paracetamol for acute pain control in the emergency department. The combination of paracetamol with caffeine is superior to paracetamol alone for the treatment of acute pain. Paracetamol helps ductal closure in patent ductus arteriosus . It is as effective for this purpose as ibuprofen or indomethacin , but results in less frequent gastrointestinal bleeding than ibuprofen. Its use for extremely low birth weight and gestational age infants however requires further study. Paracetamol is a drug of choice for reducing fever . However, there has been a lack of research on its antipyretic properties, particularly in adults. The most recent review on paracetamol and management of fever in the general practice (2008) argued that its benefits are unclear. In addition, when used for the common cold, paracetamol may relieve a stuffed or runny nose, but not other cold symptoms such as a sore throat, malaise, sneezing, or cough; however, these data are of poor quality. For patients in critical care, paracetamol decreased body temperature by only 0.2 – 0.3 °C more than control interventions; there was no difference in mortality. It did not change the outcome in febrile patients with stroke. The results are contradictory for paracetamol use in sepsis: higher mortality, lower mortality, and no change in mortality were all reported. Paracetamol offered no benefit in the treatment of dengue fever and was accompanied by a higher rate of liver enzyme elevation: a sign of a potential liver damage. Overall, there is no support for a routine administration of antipyretic drugs, including paracetamol, to hospitalized patients with fever and infection. The efficacy of paracetamol in children with fever is unclear. Paracetamol should not be used solely with the aim of reducing body temperature; however, it may be considered for children with fever who appear distressed. It does not prevent febrile seizures and should not be used for that purpose. It appears that 0.2 °C decrease of the body temperature in children after a standard dose of paracetamol is of questionable value, particularly in emergency situations. Based on this, some physicians advocate using higher doses that may decrease the temperature by as much as 0.7 °C. Meta-analyses showed that paracetamol is less effective than ibuprofen in children (marginally less effective, according to another analysis ), including children younger than 2 years old, with equivalent safety. Exacerbation of asthma occurs with similar frequency for both medications. Giving paracetamol and ibuprofen together at the same time to children under 5 is not recommended, however doses may be alternated if required. Paracetamol is used for the relief of mild to moderate pain such as headache, muscle aches, minor arthritis pain, toothache as well as pain caused by cold, flu, sprains, and dysmenorrhea . It is recommended, in particular, for acute mild to moderate pain, since the evidence for the treatment of chronic pain is insufficient. The benefits of paracetamol in musculoskeletal conditions, such as osteoarthritis and backache, are uncertain. It appears to provide only small and not clinically important benefits in osteoarthritis . American College of Rheumatology and Arthritis Foundation guideline for the management of osteoarthritis notes that the effect size in clinical trials of paracetamol has been very small, which suggests that for most individuals it is ineffective. The guideline conditionally recommends paracetamol for short-term and episodic use to those who do not tolerate nonsteroidal anti-inflammatory drugs . For people taking it regularly, monitoring for liver toxicity is required. Essentially the same recommendation was issued by EULAR for hand osteoarthritis. Similarly, the ESCEO algorithm for the treatment of knee osteoarthritis recommends limiting the use of paracetamol to short-term rescue analgesia only. Paracetamol is ineffective for acute low back pain. No randomized clinical trials evaluated its use for chronic or radicular back pain, and the evidence in favor of paracetamol is lacking. Paracetamol is effective for acute migraine : 39% of people experience pain relief at one hour compared with 20% in the control group. The aspirin/paracetamol/caffeine combination also "has strong evidence of effectiveness and can be used as a first-line treatment for migraine". Paracetamol on its own only slightly alleviates episodic tension headache in those who have them frequently. However, the aspirin/paracetamol/caffeine combination is superior to both paracetamol alone and placebo and offers meaningful relief of tension headache: 2 hours after administering the medication, 29% of those who took the combination were pain-free as compared with 21% on paracetamol and 18% on placebo. The German, Austrian, and Swiss headache societies and the German Society of Neurology recommend this combination as a "highlighted" one for self-medication of tension headache, with paracetamol/caffeine combination being a "remedy of first choice", and paracetamol a "remedy of second choice". Pain after a dental surgery provides a reliable model for the action of analgesics on other kinds of acute pain. For the relief of such pain, paracetamol is inferior to ibuprofen. Full therapeutic doses of non-steroidal anti-inflammatory drugs (NSAIDs) ibuprofen, naproxen or diclofenac are clearly more efficacious than the paracetamol/codeine combination which is frequently prescribed for dental pain. The combinations of paracetamol and NSAIDs ibuprofen or diclofenac are promising, possibly offering better pain control than either paracetamol or the NSAID alone. Additionally, the paracetamol/ibuprofen combination may be superior to paracetamol/codeine and ibuprofen/codeine combinations. A meta-analysis of general post-surgical pain, which included dental and other surgery, showed the paracetamol/codeine combination to be more effective than paracetamol alone: it provided significant pain relief to as much as 53% of the participants, while the placebo helped only 7%. Paracetamol fails to relieve procedural pain in newborn babies . For perineal pain postpartum paracetamol appears to be less effective than non-steroidal anti-inflammatory drugs (NSAIDs). The studies to support or refute the use of paracetamol for cancer pain and for neuropathic pain are lacking. There is limited evidence in favor of the use of the intravenous form of paracetamol for acute pain control in the emergency department. The combination of paracetamol with caffeine is superior to paracetamol alone for the treatment of acute pain. The benefits of paracetamol in musculoskeletal conditions, such as osteoarthritis and backache, are uncertain. It appears to provide only small and not clinically important benefits in osteoarthritis . American College of Rheumatology and Arthritis Foundation guideline for the management of osteoarthritis notes that the effect size in clinical trials of paracetamol has been very small, which suggests that for most individuals it is ineffective. The guideline conditionally recommends paracetamol for short-term and episodic use to those who do not tolerate nonsteroidal anti-inflammatory drugs . For people taking it regularly, monitoring for liver toxicity is required. Essentially the same recommendation was issued by EULAR for hand osteoarthritis. Similarly, the ESCEO algorithm for the treatment of knee osteoarthritis recommends limiting the use of paracetamol to short-term rescue analgesia only. Paracetamol is ineffective for acute low back pain. No randomized clinical trials evaluated its use for chronic or radicular back pain, and the evidence in favor of paracetamol is lacking. Paracetamol is effective for acute migraine : 39% of people experience pain relief at one hour compared with 20% in the control group. The aspirin/paracetamol/caffeine combination also "has strong evidence of effectiveness and can be used as a first-line treatment for migraine". Paracetamol on its own only slightly alleviates episodic tension headache in those who have them frequently. However, the aspirin/paracetamol/caffeine combination is superior to both paracetamol alone and placebo and offers meaningful relief of tension headache: 2 hours after administering the medication, 29% of those who took the combination were pain-free as compared with 21% on paracetamol and 18% on placebo. The German, Austrian, and Swiss headache societies and the German Society of Neurology recommend this combination as a "highlighted" one for self-medication of tension headache, with paracetamol/caffeine combination being a "remedy of first choice", and paracetamol a "remedy of second choice". Pain after a dental surgery provides a reliable model for the action of analgesics on other kinds of acute pain. For the relief of such pain, paracetamol is inferior to ibuprofen. Full therapeutic doses of non-steroidal anti-inflammatory drugs (NSAIDs) ibuprofen, naproxen or diclofenac are clearly more efficacious than the paracetamol/codeine combination which is frequently prescribed for dental pain. The combinations of paracetamol and NSAIDs ibuprofen or diclofenac are promising, possibly offering better pain control than either paracetamol or the NSAID alone. Additionally, the paracetamol/ibuprofen combination may be superior to paracetamol/codeine and ibuprofen/codeine combinations. A meta-analysis of general post-surgical pain, which included dental and other surgery, showed the paracetamol/codeine combination to be more effective than paracetamol alone: it provided significant pain relief to as much as 53% of the participants, while the placebo helped only 7%. Paracetamol fails to relieve procedural pain in newborn babies . For perineal pain postpartum paracetamol appears to be less effective than non-steroidal anti-inflammatory drugs (NSAIDs). The studies to support or refute the use of paracetamol for cancer pain and for neuropathic pain are lacking. There is limited evidence in favor of the use of the intravenous form of paracetamol for acute pain control in the emergency department. The combination of paracetamol with caffeine is superior to paracetamol alone for the treatment of acute pain. Paracetamol helps ductal closure in patent ductus arteriosus . It is as effective for this purpose as ibuprofen or indomethacin , but results in less frequent gastrointestinal bleeding than ibuprofen. Its use for extremely low birth weight and gestational age infants however requires further study. Gastrointestinal adverse effects such as nausea and abdominal pain are common, and their frequency is similar to that of ibuprofen . Increase in risk-taking behavior is possible. According to the US Food and Drug Administration , the drug may cause rare and possibly fatal skin reactions such as Stevens–Johnson syndrome and toxic epidermal necrolysis , Rechallenge tests and an analysis of American but not French pharmacovigilance databases indicated a risk of these reactions. In clinical trials for osteoarthritis , the number of participants reporting adverse effects was similar for those on paracetamol and on placebo . However, the abnormal liver function tests (meaning there was some inflammation or damage to the liver) were almost four times more likely in those on paracetamol, although the clinical importance of this effect is uncertain. After 13 weeks of paracetamol therapy for knee pain, a drop in hemoglobin level indicating gastrointestinal bleeding was observed in 20% of participants, this rate being similar to ibuprofen group. Due to the absence of controlled studies , most of the information about the long-term safety of paracetamol comes from observational studies . These indicate a consistent pattern of increased mortality as well as cardiovascular ( stroke , myocardial infarction ), gastrointestinal ( ulcers , bleeding ) and renal adverse effects with increased dose of paracetamol. Use of paracetamol is associated with 1.9 times higher risk of peptic ulcer. Those who take it regularly at a higher dose (more than 2 – 3 g daily) are at much higher risk (3.6 – 3.7 times) of gastrointestinal bleeding and other bleeding events. Meta-analyses suggest that paracetamol may increase the risk of kidney impairment by 23% and kidney cancer by 28%. Paracetamol slightly but significantly increases blood pressure and heart rate. A 2022 double-blind, placebo-controlled, crossover study has provided evidence that daily, high-dose use (4 g per day) of paracetamol increases systolic BP. A review of available research has suggested that increase in systolic blood pressure and increased risk of gastrointestinal bleeding associated with chronic paracetamol use shows a degree of dose dependence. The association between paracetamol use and asthma in children has been a matter of controversy. However, the most recent research suggests that there is no association, and that the frequency of asthma exacerbations in children after paracetamol is the same as after another frequently used pain killer ibuprofen. Paracetamol safety in pregnancy has been under increased scrutiny. There appears to be no link between paracetamol use in the first trimester and adverse pregnancy outcomes or birth defects . However, indications exist of a possible increase of asthma and developmental and reproductive disorders in the offspring of women with prolonged use of paracetamol during pregnancy. Paracetamol use by the mother during pregnancy is associated with an increased risk of childhood asthma , but so are the maternal infections for which paracetamol may be used, and separating these influences is difficult. Paracetamol, in a small scale meta-analysis was also associated with 20 – 30% increase in autism spectrum disorder , attention deficit hyperactivity disorder , hyperactivity symptoms, and conduct disorder , with the association being lower in a meta-analysis where a larger demographic was used, but it is unclear whether this is a causal relationship and there was potential bias in the findings. There is also an argument that the large number, consistency, and the robust designs of the studies provide a strong evidence in favor of paracetamol causing the increased risk of these neurodevelopmental disorders. In animal experiments, paracetamol disrupts fetal testosterone production, and several epidemiological studies linked cryptorchidism with mother's paracetamol use for more than two weeks in the second trimester. On the other hand, several studies did not find any association. The consensus recommendation appears to be to avoid prolonged use of paracetamol in pregnancy and use it only when necessary, at the lowest effective dosage and for the shortest time. Paracetamol safety in pregnancy has been under increased scrutiny. There appears to be no link between paracetamol use in the first trimester and adverse pregnancy outcomes or birth defects . However, indications exist of a possible increase of asthma and developmental and reproductive disorders in the offspring of women with prolonged use of paracetamol during pregnancy. Paracetamol use by the mother during pregnancy is associated with an increased risk of childhood asthma , but so are the maternal infections for which paracetamol may be used, and separating these influences is difficult. Paracetamol, in a small scale meta-analysis was also associated with 20 – 30% increase in autism spectrum disorder , attention deficit hyperactivity disorder , hyperactivity symptoms, and conduct disorder , with the association being lower in a meta-analysis where a larger demographic was used, but it is unclear whether this is a causal relationship and there was potential bias in the findings. There is also an argument that the large number, consistency, and the robust designs of the studies provide a strong evidence in favor of paracetamol causing the increased risk of these neurodevelopmental disorders. In animal experiments, paracetamol disrupts fetal testosterone production, and several epidemiological studies linked cryptorchidism with mother's paracetamol use for more than two weeks in the second trimester. On the other hand, several studies did not find any association. The consensus recommendation appears to be to avoid prolonged use of paracetamol in pregnancy and use it only when necessary, at the lowest effective dosage and for the shortest time. Overdose of paracetamol is caused by taking more than the recommended maximum daily dose of paracetamol for healthy adults (three or four grams), and can cause potentially fatal liver damage . A single dose should not exceed 1000 mg, and doses should be taken no sooner than four hours apart. While a majority of adult overdoses are linked to suicide attempts, many cases are accidental, often due to the use of more than one paracetamol-containing product over an extended period. Paracetamol toxicity is the foremost cause of acute liver failure in the Western world , and accounts for most drug overdoses in the United States, the United Kingdom, Australia, and New Zealand. [ when? ] Paracetamol overdose results in more calls to poison control centers in the US than overdose of any other pharmacological substance. According to the FDA, in the United States, "56,000 emergency room visits, 26,000 hospitalizations, and 458 deaths per year [were] related to acetaminophen-associated overdoses during the 1990s. Within these estimates, unintentional acetaminophen overdose accounted for nearly 25% of the emergency department visits, 10% of the hospitalizations, and 25% of the deaths." [ needs update ] Overdoses are frequently related to high-dose recreational use of prescription opioids , as these opioids are most often combined with paracetamol. The overdose risk may be heightened by frequent consumption of alcohol. Untreated paracetamol overdose results in a lengthy, painful illness. Signs and symptoms of paracetamol toxicity may initially be absent or non-specific symptoms . The first symptoms of overdose usually begin several hours after ingestion, with nausea , vomiting , sweating, and pain as acute liver failure starts. People who take overdoses of paracetamol do not fall asleep or lose consciousness, although most people who attempt suicide with paracetamol wrongly believe that they will be rendered unconscious by the drug. Treatment is aimed at removing the paracetamol from the body and replenishing glutathione . Activated charcoal can be used to decrease absorption of paracetamol if the person comes to the hospital soon after the overdose. While the antidote, acetylcysteine (also called N -acetylcysteine or NAC), acts as a precursor for glutathione, helping the body regenerate enough to prevent or at least decrease the possible damage to the liver; a liver transplant is often required if damage to the liver becomes severe. NAC was usually given following a treatment nomogram (one for people with risk factors, and one for those without), but the use of the nomogram is no longer recommended as evidence to support the use of risk factors was poor and inconsistent, and many of the risk factors are imprecise and difficult to determine with sufficient certainty in clinical practice. Toxicity of paracetamol is due to its quinone metabolite NAPQI and NAC also helps in neutralizing it. Kidney failure is also a possible side effect. Prokinetic agents such as metoclopramide accelerate gastric emptying, shorten time (t max ) to paracetamol peak blood plasma concentration (C max ), and increase C max . Medications slowing gastric emptying such as propantheline and morphine lengthen t max and decrease C max . The interaction with morphine may result in patients failing to achieve the therapeutic concentration of paracetamol; the clinical significance of interactions with metoclopramide and propantheline is unclear. There have been suspicions that cytochrome inducers may enhance the toxic pathway of paracetamol metabolism to NAPQI (see Paracetamol#Pharmacokinetics ). By and large, these suspicions have not been confirmed. Out of the inducers studied, the evidence of potentially increased liver toxicity in paracetamol overdose exists for phenobarbital , primidone , isoniazid , and possibly St John's wort . On the other hand, the anti-tuberculosis drug isoniazid cuts the formation of NAPQI by 70%. Ranitidine increased paracetamol area under the curve (AUC) 1.6-fold. AUC increases are also observed with nizatidine and cisapride . The effect is explained by these drugs inhibiting glucuronidation of paracetamol. Paracetamol raises plasma concentrations of ethinylestradiol by 22% by inhibiting its sulfation. Paracetamol increases INR during warfarin therapy and should be limited to no more than 2 g per week. Paracetamol appears to exert its effects through two mechanisms: the inhibition of cyclooxygenase and actions of its metabolite N-arachidonoylphenolamine (AM404). Supporting the first mechanism, pharmacologically and in its side effects, paracetamol is close to classical nonsteroidal anti-inflammatory drugs (NSAIDs) that act by inhibiting COX-1 and COX-2 enzymes and especially similar to selective COX-2 inhibitors . Paracetamol inhibits prostaglandin synthesis by reducing the active form of COX-1 and COX-2 enzymes. This occurs only when the concentration of arachidonic acid and peroxides is low. Under these conditions, COX-2 is the predominant form of cyclooxygenase, which explains the apparent COX-2 selectivity of paracetamol. Under the conditions of inflammation, the concentration of peroxides is high, which counteracts the reducing effect of paracetamol. Accordingly, the anti-inflammatory action of paracetamol is slight. The anti-inflammatory action of paracetamol (via COX inhibition) has also been found to primarily target the central nervous system and not peripheral areas of the body, explaining the lack of side effects associated with conventional NSAIDs such as gastric bleeding. The second mechanism centers on the paracetamol metabolite AM404 . This metabolite has been detected in the brains of animals and cerebrospinal fluid of humans taking paracetamol. It is formed in the brain from another paracetamol metabolite 4-aminophenol by action of fatty acid amide hydrolase . AM404 is a weak agonist of cannabinoid receptors CB1 and CB2 , an inhibitor of endocannabinoid transporter , and a potent activator of TRPV1 receptor. This and other research indicate that cannabinoid system and TRPV1 may play an important role in the analgesic effect of paracetamol. In 2018, Suemaru et al . found that, in mice, paracetamol exerts anticonvulsant effect by activation of TRPV1 receptors and decrease in neuronal excitability by hyperpolarization of neurons. The exact mechanism of the anticonvulsant effect of acetaminophen is not clear. According to Suemaru et al ., acetaminophen and its active metabolite AM404 show a dose-dependent anticonvulsant activity against pentylenetetrazol-induced seizures in mice. After being taken by mouth, paracetamol is rapidly absorbed from the small intestine , while absorption from the stomach is negligible. Thus, the rate of absorption depends on stomach emptying. Food slows the stomach emptying and absorption, but the total amount absorbed stays the same. In the same subjects, the peak plasma concentration of paracetamol was reached after 20 minutes when fasting versus 90 minutes when fed. High carbohydrate (but not high protein or high fat) food decreases paracetamol peak plasma concentration by four times. Even in the fasting state, the rate of absorption of paracetamol is variable and depends on the formulation, with maximum plasma concentration being reached after 20 minutes to 1.5 hours. Paracetamol's bioavailability is dose-dependent: it increases from 63% for 500 mg dose to 89% for 1000 mg dose. Its plasma terminal elimination half-life is 1.9 – 2.5 hours, and volume of distribution is roughly 50 L. Protein binding is negligible, except under the conditions of overdose, when it may reach 15 – 21%. The concentration in serum after a typical dose of paracetamol usually peaks below 30 μg/mL (200 μmol/L). After 4 hours, the concentration is usually less than 10 μg/mL (66 μmol/L). Paracetamol is metabolized primarily in the liver, mainly by glucuronidation and sulfation , and the products are then eliminated in the urine (see the Scheme on the right). Only 2 – 5% of the drug is excreted unchanged in the urine. Glucuronidation by UGT1A1 and UGT1A6 accounts for 50 – 70% of the drug metabolism. Additional 25 – 35% of paracetamol is converted to sulfate by sulfation enzymes SULT1A1 , SULT1A3 , and SULT1E1 . A minor metabolic pathway (5–15%) of oxidation by cytochrome P450 enzymes, mainly by CYP2E1 , forms a toxic metabolite known as NAPQI ( N -acetyl- p -benzoquinone imine). NAPQI is responsible for the liver toxicity of paracetamol. At usual doses of paracetamol, NAPQI is quickly detoxified by conjugation with glutathione . The non-toxic conjugate APAP-GSH is taken up in the bile and further degraded to mercapturic and cysteine conjugates that are excreted in the urine. In overdose, glutathione is depleted by the large amount of formed NAPQI, and NAPQI binds to mitochondria proteins of the liver cells causing oxidative stress and toxicity. Yet another minor but important direction of metabolism is deacetylation of 1 – 2% of paracetamol to form p -aminophenol . p -Aminophenol is then converted in the brain by fatty acid amide hydrolase into AM404 , a compound that may be partially responsible for the analgesic action of paracetamol. Paracetamol appears to exert its effects through two mechanisms: the inhibition of cyclooxygenase and actions of its metabolite N-arachidonoylphenolamine (AM404). Supporting the first mechanism, pharmacologically and in its side effects, paracetamol is close to classical nonsteroidal anti-inflammatory drugs (NSAIDs) that act by inhibiting COX-1 and COX-2 enzymes and especially similar to selective COX-2 inhibitors . Paracetamol inhibits prostaglandin synthesis by reducing the active form of COX-1 and COX-2 enzymes. This occurs only when the concentration of arachidonic acid and peroxides is low. Under these conditions, COX-2 is the predominant form of cyclooxygenase, which explains the apparent COX-2 selectivity of paracetamol. Under the conditions of inflammation, the concentration of peroxides is high, which counteracts the reducing effect of paracetamol. Accordingly, the anti-inflammatory action of paracetamol is slight. The anti-inflammatory action of paracetamol (via COX inhibition) has also been found to primarily target the central nervous system and not peripheral areas of the body, explaining the lack of side effects associated with conventional NSAIDs such as gastric bleeding. The second mechanism centers on the paracetamol metabolite AM404 . This metabolite has been detected in the brains of animals and cerebrospinal fluid of humans taking paracetamol. It is formed in the brain from another paracetamol metabolite 4-aminophenol by action of fatty acid amide hydrolase . AM404 is a weak agonist of cannabinoid receptors CB1 and CB2 , an inhibitor of endocannabinoid transporter , and a potent activator of TRPV1 receptor. This and other research indicate that cannabinoid system and TRPV1 may play an important role in the analgesic effect of paracetamol. In 2018, Suemaru et al . found that, in mice, paracetamol exerts anticonvulsant effect by activation of TRPV1 receptors and decrease in neuronal excitability by hyperpolarization of neurons. The exact mechanism of the anticonvulsant effect of acetaminophen is not clear. According to Suemaru et al ., acetaminophen and its active metabolite AM404 show a dose-dependent anticonvulsant activity against pentylenetetrazol-induced seizures in mice. After being taken by mouth, paracetamol is rapidly absorbed from the small intestine , while absorption from the stomach is negligible. Thus, the rate of absorption depends on stomach emptying. Food slows the stomach emptying and absorption, but the total amount absorbed stays the same. In the same subjects, the peak plasma concentration of paracetamol was reached after 20 minutes when fasting versus 90 minutes when fed. High carbohydrate (but not high protein or high fat) food decreases paracetamol peak plasma concentration by four times. Even in the fasting state, the rate of absorption of paracetamol is variable and depends on the formulation, with maximum plasma concentration being reached after 20 minutes to 1.5 hours. Paracetamol's bioavailability is dose-dependent: it increases from 63% for 500 mg dose to 89% for 1000 mg dose. Its plasma terminal elimination half-life is 1.9 – 2.5 hours, and volume of distribution is roughly 50 L. Protein binding is negligible, except under the conditions of overdose, when it may reach 15 – 21%. The concentration in serum after a typical dose of paracetamol usually peaks below 30 μg/mL (200 μmol/L). After 4 hours, the concentration is usually less than 10 μg/mL (66 μmol/L). Paracetamol is metabolized primarily in the liver, mainly by glucuronidation and sulfation , and the products are then eliminated in the urine (see the Scheme on the right). Only 2 – 5% of the drug is excreted unchanged in the urine. Glucuronidation by UGT1A1 and UGT1A6 accounts for 50 – 70% of the drug metabolism. Additional 25 – 35% of paracetamol is converted to sulfate by sulfation enzymes SULT1A1 , SULT1A3 , and SULT1E1 . A minor metabolic pathway (5–15%) of oxidation by cytochrome P450 enzymes, mainly by CYP2E1 , forms a toxic metabolite known as NAPQI ( N -acetyl- p -benzoquinone imine). NAPQI is responsible for the liver toxicity of paracetamol. At usual doses of paracetamol, NAPQI is quickly detoxified by conjugation with glutathione . The non-toxic conjugate APAP-GSH is taken up in the bile and further degraded to mercapturic and cysteine conjugates that are excreted in the urine. In overdose, glutathione is depleted by the large amount of formed NAPQI, and NAPQI binds to mitochondria proteins of the liver cells causing oxidative stress and toxicity. Yet another minor but important direction of metabolism is deacetylation of 1 – 2% of paracetamol to form p -aminophenol . p -Aminophenol is then converted in the brain by fatty acid amide hydrolase into AM404 , a compound that may be partially responsible for the analgesic action of paracetamol. The classical methods for the production of paracetamol involve the acetylation of 4-aminophenol with acetic anhydride as the last step. They differ in how 4-aminophenol is prepared. In one method, nitration of phenol with nitric acid affords 4-nitrophenol , which is reduced to 4-aminophenol by hydrogenation over Raney nickel . In another method, nitrobenzene is reduced electrolytically giving 4-aminophenol directly. Additionally, 4-nitrophenol can be selectively reduced by Tin(II) Chloride in absolute ethanol or ethyl acetate to produce a 91% yield of 4-aminophenol. An alternative industrial synthesis developed at Celanese involves firstly direct acylation of phenol with acetic anhydride in the presence of hydrogen fluoride to a ketone, then the conversion of the ketone with hydroxylamine to a ketoxime , and finally the acid-catalyzed Beckmann rearrangement of the cetoxime to the para-acetylaminophenol product. 4 -Aminophenol may be obtained by the amide hydrolysis of paracetamol. This reaction is also used to determine paracetamol in urine samples: After hydrolysis with hydrochloric acid, 4 -aminophenol reacts in ammonia solution with a phenol derivate, e.g. salicylic acid, to form an indophenol dye under oxidization by air. The classical methods for the production of paracetamol involve the acetylation of 4-aminophenol with acetic anhydride as the last step. They differ in how 4-aminophenol is prepared. In one method, nitration of phenol with nitric acid affords 4-nitrophenol , which is reduced to 4-aminophenol by hydrogenation over Raney nickel . In another method, nitrobenzene is reduced electrolytically giving 4-aminophenol directly. Additionally, 4-nitrophenol can be selectively reduced by Tin(II) Chloride in absolute ethanol or ethyl acetate to produce a 91% yield of 4-aminophenol. An alternative industrial synthesis developed at Celanese involves firstly direct acylation of phenol with acetic anhydride in the presence of hydrogen fluoride to a ketone, then the conversion of the ketone with hydroxylamine to a ketoxime , and finally the acid-catalyzed Beckmann rearrangement of the cetoxime to the para-acetylaminophenol product. The classical methods for the production of paracetamol involve the acetylation of 4-aminophenol with acetic anhydride as the last step. They differ in how 4-aminophenol is prepared. In one method, nitration of phenol with nitric acid affords 4-nitrophenol , which is reduced to 4-aminophenol by hydrogenation over Raney nickel . In another method, nitrobenzene is reduced electrolytically giving 4-aminophenol directly. Additionally, 4-nitrophenol can be selectively reduced by Tin(II) Chloride in absolute ethanol or ethyl acetate to produce a 91% yield of 4-aminophenol. An alternative industrial synthesis developed at Celanese involves firstly direct acylation of phenol with acetic anhydride in the presence of hydrogen fluoride to a ketone, then the conversion of the ketone with hydroxylamine to a ketoxime , and finally the acid-catalyzed Beckmann rearrangement of the cetoxime to the para-acetylaminophenol product. 4 -Aminophenol may be obtained by the amide hydrolysis of paracetamol. This reaction is also used to determine paracetamol in urine samples: After hydrolysis with hydrochloric acid, 4 -aminophenol reacts in ammonia solution with a phenol derivate, e.g. salicylic acid, to form an indophenol dye under oxidization by air. Acetanilide was the first aniline derivative serendipitously found to possess analgesic as well as antipyretic properties, and was quickly introduced into medical practice under the name of Antifebrin by Cahn & Hepp in 1886. But its unacceptable toxic effects — the most alarming being cyanosis due to methemoglobinemia , an increase of hemoglobin in its ferric [Fe 3+ ] state, called methemoglobin , which cannot bind oxygen, and thus decreases overall carriage of oxygen to tissue — prompted the search for less toxic aniline derivatives. Some reports state that Cahn & Hepp or a French chemist called Charles Gerhardt first synthesized paracetamol in 1852. Harmon Northrop Morse synthesized paracetamol at Johns Hopkins University via the reduction of p -nitrophenol with tin in glacial acetic acid in 1877, but it was not until 1887 that clinical pharmacologist Joseph von Mering tried paracetamol on humans. In 1893, von Mering published a paper reporting on the clinical results of paracetamol with phenacetin , another aniline derivative. Von Mering claimed that, unlike phenacetin, paracetamol had a slight tendency to produce methemoglobinemia . Paracetamol was then quickly discarded in favor of phenacetin . The sales of phenacetin established Bayer as a leading pharmaceutical company. Von Mering's claims remained essentially unchallenged for half a century, until two teams of researchers from the United States analyzed the metabolism of acetanilide and phenacetin. In 1947, David Lester and Leon Greenberg found strong evidence that paracetamol was a major metabolite of acetanilide in human blood, and in a subsequent study they reported that large doses of paracetamol given to albino rats did not cause methemoglobinemia. In 1948, Bernard Brodie , Julius Axelrod and Frederick Flinn confirmed that paracetamol was the major metabolite of acetanilide in humans, and established that it was just as efficacious an analgesic as its precursor. They also suggested that methemoglobinemia is produced in humans mainly by another metabolite, phenylhydroxylamine . A follow-up paper by Brodie and Axelrod in 1949 established that phenacetin was also metabolized to paracetamol. This led to a "rediscovery" of paracetamol. Paracetamol was first marketed in the United States in 1950 under the name Triagesic, a combination of paracetamol, aspirin , and caffeine. Reports in 1951 of three users stricken with the blood disease agranulocytosis led to its removal from the marketplace, and it took several years until it became clear that the disease was unconnected. The following year, 1952, paracetamol returned to the US market as a prescription drug. In the United Kingdom, marketing of paracetamol began in 1956 by Sterling-Winthrop Co. as Panadol, available only by prescription, and promoted as preferable to aspirin since it was safe for children and people with ulcers. In 1963, paracetamol was added to the British Pharmacopoeia , and has gained popularity since then as an analgesic agent with few side-effects and little interaction with other pharmaceutical agents. Concerns about paracetamol's safety delayed its widespread acceptance until the 1970s, but in the 1980s paracetamol sales exceeded those of aspirin in many countries, including the United Kingdom. This was accompanied by the commercial demise of phenacetin, blamed as the cause of analgesic nephropathy and hematological toxicity. Available in the US without a prescription since 1955 (1960, according to another source ) paracetamol has become a common household drug. In 1988, Sterling Winthrop was acquired by Eastman Kodak which sold the over the counter drug rights to SmithKline Beecham in 1994. In June 2009, an FDA advisory committee recommended that new restrictions be placed on paracetamol use in the United States to help protect people from the potential toxic effects. The maximum single adult dosage would be decreased from 1000 mg to 650 mg, while combinations of paracetamol and other products would be prohibited. Committee members were particularly concerned by the fact that the then-present maximum dosages of paracetamol had been shown to produce alterations in liver function. In January 2011, the FDA asked manufacturers of prescription combination products containing paracetamol to limit its amount to no more than 325 mg per tablet or capsule and began requiring manufacturers to update the labels of all prescription combination paracetamol products to warn of the potential risk of severe liver damage. Manufacturers had three years to limit the amount of paracetamol in their prescription drug products to 325 mg per dosage unit. In November 2011, the Medicines and Healthcare products Regulatory Agency revised UK dosing of liquid paracetamol for children. In September 2013, "Use Only as Directed", an episode of the radio program This American Life highlighted deaths from paracetamol overdose. This report was followed by two reports by ProPublica alleging that the "FDA has long been aware of studies showing the risks of acetaminophen. So has the maker of Tylenol, McNeil Consumer Healthcare, a division of Johnson & Johnson" and "McNeil, the maker of Tylenol, ... has repeatedly opposed safety warnings, dosage restrictions and other measures meant to safeguard users of the drug." During the COVID-19 pandemic it was considered by some in the scientific community that it was an effective analgesic medication to treat symptoms of COVID-19 , but this was found to be unsubstantiated. Paracetamol is the Australian Approved Name and British Approved Name as well as the international nonproprietary name used by the WHO and in many other countries; acetaminophen is the United States Adopted Name and Japanese Accepted Name and also the name generally used in Canada, Venezuela, Colombia, and Iran. Both paracetamol and acetaminophen are contractions of para -acetylaminophenol, a chemical name for the compound. The word "acetaminophen" is a shortened form of N- acet yl aminophen ol, and was coined and first marketed by McNeil Laboratories in 1955. The word "paracetamol" is a shortened form of par a- acet yl- am ino-phen ol , and was coined by Frederick Stearns & Co in 1956. The initialism APAP used by dispensing pharmacists in the United States comes from the alternative chemical name [ N -]acetyl- para -aminophenol. Paracetamol is available in oral, suppository, and intravenous forms. Intravenous paracetamol is sold under the brand name Ofirmev in the United States. In some formulations, paracetamol is combined with the opiate codeine , sometimes referred to as co-codamol ( BAN ) and Panadeine in Australia. In the US, this combination is available only by prescription. As of 1 February 2018, medications containing codeine also became prescription-only in Australia. Paracetamol is also combined with other opioids such as dihydrocodeine , referred to as co-dydramol ( British Approved Name (BAN)), oxycodone or hydrocodone . Another very commonly used analgesic combination includes paracetamol in combination with propoxyphene napsylate . A combination of paracetamol, codeine, and the doxylamine succinate is also available. Paracetamol is sometimes combined with phenylephrine hydrochloride . Sometimes a third active ingredient, such as ascorbic acid , caffeine , chlorpheniramine maleate , or guaifenesin is added to this combination.Paracetamol is the Australian Approved Name and British Approved Name as well as the international nonproprietary name used by the WHO and in many other countries; acetaminophen is the United States Adopted Name and Japanese Accepted Name and also the name generally used in Canada, Venezuela, Colombia, and Iran. Both paracetamol and acetaminophen are contractions of para -acetylaminophenol, a chemical name for the compound. The word "acetaminophen" is a shortened form of N- acet yl aminophen ol, and was coined and first marketed by McNeil Laboratories in 1955. The word "paracetamol" is a shortened form of par a- acet yl- am ino-phen ol , and was coined by Frederick Stearns & Co in 1956. The initialism APAP used by dispensing pharmacists in the United States comes from the alternative chemical name [ N -]acetyl- para -aminophenol. Paracetamol is available in oral, suppository, and intravenous forms. Intravenous paracetamol is sold under the brand name Ofirmev in the United States. In some formulations, paracetamol is combined with the opiate codeine , sometimes referred to as co-codamol ( BAN ) and Panadeine in Australia. In the US, this combination is available only by prescription. As of 1 February 2018, medications containing codeine also became prescription-only in Australia. Paracetamol is also combined with other opioids such as dihydrocodeine , referred to as co-dydramol ( British Approved Name (BAN)), oxycodone or hydrocodone . Another very commonly used analgesic combination includes paracetamol in combination with propoxyphene napsylate . A combination of paracetamol, codeine, and the doxylamine succinate is also available. Paracetamol is sometimes combined with phenylephrine hydrochloride . Sometimes a third active ingredient, such as ascorbic acid , caffeine , chlorpheniramine maleate , or guaifenesin is added to this combination.Paracetamol is extremely toxic to cats, which lack the necessary UGT1A6 enzyme to detoxify it. Initial symptoms include vomiting, salivation, and discoloration of the tongue and gums. Unlike an overdose in humans, liver damage is rarely the cause of death; instead, methemoglobin formation and the production of Heinz bodies in red blood cells inhibit oxygen transport by the blood, causing asphyxiation ( methemoglobinemia and hemolytic anemia ). Treatment of the toxicosis with N-acetylcysteine is recommended. Paracetamol has been reported to be as effective as aspirin in the treatment of musculoskeletal pain in dogs. A paracetamol–codeine product (brand name Pardale-V) licensed for use in dogs is available for purchase under supervision of a vet, pharmacist or other qualified person. It should be administered to dogs only on veterinary advice and with extreme caution. The main effect of toxicity in dogs is liver damage, and GI ulceration has been reported. N-acetylcysteine treatment is efficacious in dogs when administered within two hours of paracetamol ingestion. Paracetamol is lethal to snakes and has been suggested as a chemical control program for the invasive brown tree snake ( Boiga irregularis ) in Guam . Doses of 80 mg are inserted into dead mice that are scattered by helicopter as lethal bait to be consumed by the snakes.Paracetamol is extremely toxic to cats, which lack the necessary UGT1A6 enzyme to detoxify it. Initial symptoms include vomiting, salivation, and discoloration of the tongue and gums. Unlike an overdose in humans, liver damage is rarely the cause of death; instead, methemoglobin formation and the production of Heinz bodies in red blood cells inhibit oxygen transport by the blood, causing asphyxiation ( methemoglobinemia and hemolytic anemia ). Treatment of the toxicosis with N-acetylcysteine is recommended. Paracetamol has been reported to be as effective as aspirin in the treatment of musculoskeletal pain in dogs. A paracetamol–codeine product (brand name Pardale-V) licensed for use in dogs is available for purchase under supervision of a vet, pharmacist or other qualified person. It should be administered to dogs only on veterinary advice and with extreme caution. The main effect of toxicity in dogs is liver damage, and GI ulceration has been reported. N-acetylcysteine treatment is efficacious in dogs when administered within two hours of paracetamol ingestion. Paracetamol is lethal to snakes and has been suggested as a chemical control program for the invasive brown tree snake ( Boiga irregularis ) in Guam . Doses of 80 mg are inserted into dead mice that are scattered by helicopter as lethal bait to be consumed by the snakes.

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Dengue fever

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2005 dengue outbreak in Singapore

In the 2005 dengue outbreak in Singapore , a significant rise in the number of dengue fever cases was reported in Singapore, becoming the country's worst health crisis since the 2003 SARS epidemic. In October 2005, there were signs that the dengue fever outbreak had peaked, as the number of weekly cases had declined and the outbreak of this infectious disease declined by the end of 2005.In 2005, there were a total of 14,209 dengue fever cases and 27 people died, a record death toll that would not be surpassed until 2020 . The outbreak peaked in the months of September and October, when it caused hospitals to cancel some elective surgery due to the need to allocate more beds for dengue patients. [ citation needed ] Singapore's health-care system is helping to maintain a low fatality rate at 0.2% (2005), which is lower than Southeast Asia's regional average of 0.8% in 2004, according to the World Health Organization . [ citation needed ] The National Environment Agency (NEA) said that the dengue fever problem may be worsening because of higher temperatures and changes in viral strains. The mean temperature has risen to 28.2 °C (82.8 °F) from 27.8 °C in 2003. [ citation needed ] In the second week of September, more than 100 new cases were reported daily and many were admitted to public hospitals. Health Minister Khaw Boon Wan said that one of the concerns is that more Singaporeans are infected with Dengue Type 3, which is a new strain of the dengue virus. [ citation needed ] Some experts, such as Dr Paul Reiter , Professor of Entomology at the Pasteur Institute in France, suggested that Singapore's success in suppressing the dengue has partly contributed to this year sudden increase in dengue cases. The population born over the last two decades has a low herd immunity and therefore more susceptible to the virus. In January 2006, Environment and Water Resources Minister Yaacob Ibrahim declared the dengue outbreak is under control with average 84 cases weekly compared to a peak of more than 700. In September, an inter-ministerial committee headed by Minister for the Environment and Water Resources , Yaacob Ibrahim , was formed to tackle the dengue outbreak. Yaacob Ibrahim delivered a ministerial statement on the issue in the parliament on 19 September. An inter-agency Dengue Coordination Committee and a community-centred Dengue Watch Committee have also been established. The Dengue Coordination Committee involves the permanent secretaries of the Environment, Health, and National Development ministries, and Chief Executive Officers of key government statutory boards, and it aims to ensure that the various policy initiatives by the various ministries are well-coordinated. Land Transport Authority (LTA) would make sure that bus-stops, Mass Rapid Transit stations, construction sites are free of mosquito breeding. Singapore Land Authority (SLA) were also stepping up their checks on vacant state land and properties, while the Housing and Development Board (HDB) and town councils are stepping up the cleaning of common areas. The Dengue Watch Committee is chaired by Khoo Tsai Kee who is the Senior Parliamentary Secretary for the Environment and Water Resources. He will co-ordinate with the five mayors in Singapore to reach out to the 84 advisers and the town councils, to oversee dengue prevention measures at the community level. [ citation needed ] A panel of experts had also been set up to advise the government on anti-dengue measures. The panel is chaired by Dr Chee Yam Cheng , Clinical Professor and Assistant chief executive officer of National Healthcare Group . [ citation needed ]Singapore launched a number of measures to contain the dengue outbreak, including public awareness campaigns and regular fogging with insecticides . 4,200 volunteers, 970 environmental control officers hired by construction sites, 350 so-called "mozzie busters" made up of girl guides and scouts, have participated in the preventive efforts. [ citation needed ] The Ministry of Health stepped up its monitoring of common mosquito breeding sites and launched an online map listing "hotspots" for the insects. Residents who allow mosquitoes to breed in their homes can be fined between S$100 to S$200, and heavier penalties may be issued for construction sites found with standing water. The number of officers conducting such checks have tripled since the start of the year to 360, and may increase to 510 by December. [ citation needed ] The National Environment Agency has allocated an additional S$7.5 million on top of its existing S$2.5 million budget to clear drains of stagnant water where mosquitoes breed. Singapore Land Authority has also stepped up its checks on vacant state properties. [ citation needed ] On 10 September, National Environment Agency started collecting blood samples from residents of Sims Avenue , a dengue hotspot, to help track the infection. The residents were asked to provide voluntarily 5 millilitres of blood sample and a swab of saliva for the study. The samples were to be analysed for antibodies against dengue infection in the last 2 months. The National Parks Board (NParks) is considering removing broad-leafed plants which may breed mosquitoes. These plants like palm trees or any plants with axils capable of trapping water, are potential breeding sites. Some town councils had removed some or all palm trees in their jurisdictions. Additional trimming of palm trees had been done by NParks to reduce potential breeding sites. As holes in tree trunks are also a concern, NParks had regularly filling these holes with sands. NParks has engaged 16 pest companies to prevent mosquito breeding in the parks it manages. Due to the dengue threat, some schools are cancelling excursions to the parks. By end of October, town councils are to employ dedicated pest control officers and engage in more frequent drain cleanings. Health Minister Khaw Boon Wan urged the public to help in the fight against the disease. As households are common breeding grounds for mosquitos and are less accessible for fogging, residents can help by checking for stagnant water in their households and neighbourhood and ensuring no blockage of drains. Due to the short life cycle of Aedes aegypti mosquitos (7 to 10 days), frequent checks are necessary to eradicate dengue. These checks only take several minutes and could potentially save lives. [ citation needed ] Dr Kevin Palmer, World Health Organization 's regional adviser for mosquito-borne diseases, said that it is important for ordinary residents to play their part. He added that fogging alone was not effective as winds could blow the insecticide away. Yaacob Ibrahim also said that fogging only kills adult mosquitoes, but not the larva and therefore less effective compared to removing breeding sites. Singapore residents are also arming themselves with anti-mosquito products including insecticides , repellents and electronic mosquito traps. For repellents, experts are recommending those with an active ingredients, such as DEET which provide more effective and lasting protection. [ citation needed ] As a preventive measure, some residents bought a perennial grass plant, Citronella , and placing it at their home to repel mosquitos. The plant gives off a strong lemon-like fragrance which supposedly repels mosquitoes. To prevent the spread of the virus, those who are already infected with dengue are encouraged to use mosquito repellents, wear long-sleeved clothing and sleep under mosquito nets to prevent mosquitoes from biting them again and spreading the virus to others. [ citation needed ] Minister for the Environment and Water Resources Yaacob Ibrahim informed Parliament that NEA officers with volunteers would conduct weekend blitz campaigns over six weeks, covering all estates, to destroy mosquito-breeding sites. On the weekend of 17–18 September, more than 700 officers and volunteers launched a house-to-house campaign to remove breeding sites at four neighbourhoods, in what Minister Mah Bow Tan described as "sort of a carpet-combing exercise" . The four neighbourhoods involved in the weekend blitz are Ang Mo Kio , Yishun , Hougang and Marsiling , which are among the worst affected regions. [ citation needed ] In this "search-and-destroy" operation, mosquito-fighting "commandos" combed the streets, checked the drains, looked at the bins and the roof structures at all estates to seek and destroy breeding sites. They found 172 mosquito-breeding sites, mainly flower pot trays, water containers, litter in open area and tree holes. In the following weekend, the blitz was continued and covered five other areas such as Toa Payoh / Bishan , Tampines , Choa Chu Kang , Bedok and Boon Lay / Jurong , and 220 breeding sites were found and destroyed. More than one thousand volunteers were involved in this third blitz to cover areas including Kallang , West Coast and Jurong East . 187 breeding sites were found and removed. Health Minister Khaw Boon Wan urged the public to help in the fight against the disease. As households are common breeding grounds for mosquitos and are less accessible for fogging, residents can help by checking for stagnant water in their households and neighbourhood and ensuring no blockage of drains. Due to the short life cycle of Aedes aegypti mosquitos (7 to 10 days), frequent checks are necessary to eradicate dengue. These checks only take several minutes and could potentially save lives. [ citation needed ] Dr Kevin Palmer, World Health Organization 's regional adviser for mosquito-borne diseases, said that it is important for ordinary residents to play their part. He added that fogging alone was not effective as winds could blow the insecticide away. Yaacob Ibrahim also said that fogging only kills adult mosquitoes, but not the larva and therefore less effective compared to removing breeding sites. Singapore residents are also arming themselves with anti-mosquito products including insecticides , repellents and electronic mosquito traps. For repellents, experts are recommending those with an active ingredients, such as DEET which provide more effective and lasting protection. [ citation needed ] As a preventive measure, some residents bought a perennial grass plant, Citronella , and placing it at their home to repel mosquitos. The plant gives off a strong lemon-like fragrance which supposedly repels mosquitoes. To prevent the spread of the virus, those who are already infected with dengue are encouraged to use mosquito repellents, wear long-sleeved clothing and sleep under mosquito nets to prevent mosquitoes from biting them again and spreading the virus to others. [ citation needed ]Minister for the Environment and Water Resources Yaacob Ibrahim informed Parliament that NEA officers with volunteers would conduct weekend blitz campaigns over six weeks, covering all estates, to destroy mosquito-breeding sites. On the weekend of 17–18 September, more than 700 officers and volunteers launched a house-to-house campaign to remove breeding sites at four neighbourhoods, in what Minister Mah Bow Tan described as "sort of a carpet-combing exercise" . The four neighbourhoods involved in the weekend blitz are Ang Mo Kio , Yishun , Hougang and Marsiling , which are among the worst affected regions. [ citation needed ] In this "search-and-destroy" operation, mosquito-fighting "commandos" combed the streets, checked the drains, looked at the bins and the roof structures at all estates to seek and destroy breeding sites. They found 172 mosquito-breeding sites, mainly flower pot trays, water containers, litter in open area and tree holes. In the following weekend, the blitz was continued and covered five other areas such as Toa Payoh / Bishan , Tampines , Choa Chu Kang , Bedok and Boon Lay / Jurong , and 220 breeding sites were found and destroyed. More than one thousand volunteers were involved in this third blitz to cover areas including Kallang , West Coast and Jurong East . 187 breeding sites were found and removed. On the weekend of 17–18 September, more than 700 officers and volunteers launched a house-to-house campaign to remove breeding sites at four neighbourhoods, in what Minister Mah Bow Tan described as "sort of a carpet-combing exercise" . The four neighbourhoods involved in the weekend blitz are Ang Mo Kio , Yishun , Hougang and Marsiling , which are among the worst affected regions. [ citation needed ] In this "search-and-destroy" operation, mosquito-fighting "commandos" combed the streets, checked the drains, looked at the bins and the roof structures at all estates to seek and destroy breeding sites. They found 172 mosquito-breeding sites, mainly flower pot trays, water containers, litter in open area and tree holes. In the following weekend, the blitz was continued and covered five other areas such as Toa Payoh / Bishan , Tampines , Choa Chu Kang , Bedok and Boon Lay / Jurong , and 220 breeding sites were found and destroyed. More than one thousand volunteers were involved in this third blitz to cover areas including Kallang , West Coast and Jurong East . 187 breeding sites were found and removed. In September, Singapore experienced a drastic rise of dengue cases. In the first week alone, 547 new cases were reported and many required hospital care. As the treatment lasts about 10 days, many hospitals across Singapore are experiencing shortage of hospitals beds. To cope with the strain, hospitals are postponing non-emergency operations to accommodate the dengue patients. General practitioners and polyclinics are on high alert to check for cases of dengue and are ordering more patients to have their blood tested for suspected dengue. The test, which takes fifteen minutes, is based on platelet count; dengue sufferers have 100,000 or lower platelet count as compared to 140,000 to 400,000 of a healthy person. If a suspected dengue patient is diagnosed, the patient will be referred to a hospital for more accurate testing. [ citation needed ]In July 2005, a Singapore life science start-up company Veredus Laboratories launched a DNA- and RNA-based diagnostic kits for dengue, avian influenza and malaria . The kit is based on technologies licensed from A*STAR and the National University of Singapore . Another Singapore company Attogenix Biosystems has also developed a biochip called AttoChip which has successfully undergone an independent clinical trial conducted by Tan Tock Seng Hospital and is 98 percent accurate. The AttoChip identifies genes, viruses and bacteria-causing diseases from a blood sample. It can detect the presence of the dengue virus within two to three days of the onset of the virus.

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Dengue fever

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Manu Toigo

Survival TV Star Environmental Activism Manu Toigo is a survivalist from Queensland , Australia, who was featured on Discovery Channel 's TV show Naked and Afraid and Curiosity . Manu was born in Queensland and lived on her parents' farm. At the age of 17 she joined the Infantry Reserve Unit in the Australian Army and served for eight years until she sustained an injury. In 1998 Manu moved to Seattle, where she graduated college. Manu appeared on the Discovery Channel series Curiosity during the "I, Caveman" episode which aired on October 2, 2011. In 2013, Manu was featured on the second season of Discovery Channel's Naked and Afraid for a special double episode titled "Double Jeopardy" which took place in the Panama Jungle . The episode premiered on December 10, 2013, and attracted 2.4 million viewers. Manu made it through the 21 day challenge but contracted dengue fever from a mosquito bite and went to the hospital three days after she finished the challenge. Manu said that she got to the hospital just in time — any later and she might have died. Manu spent a total of two weeks in the hospital and several months in physical therapy. She finished with a Primitive Survival Rating (PSR) of 8.0. In 2019, Manu returned to the Naked Afraid series as she was cast with 14 other survivalists for Naked and Afraid XL . For this challenge the survivalists had to survive 40 days in the Palawan in the Philippines. Manu was partnered in a group with Rylie Parlett and Christina McQueen, but tapped out on Day 7 due to her brother receiving treatments for jaw cancer. Manu appeared on National Geographic 's show Mygrations in 2016. The National Geographic team originally contacted Manu via Twitter and asked her if she would like to be featured in the show. Manu said she enjoyed being on the show, but commented on the show's large production, which took much of the wilderness experience away from her.Manu appeared on the Discovery Channel series Curiosity during the "I, Caveman" episode which aired on October 2, 2011. In 2013, Manu was featured on the second season of Discovery Channel's Naked and Afraid for a special double episode titled "Double Jeopardy" which took place in the Panama Jungle . The episode premiered on December 10, 2013, and attracted 2.4 million viewers. Manu made it through the 21 day challenge but contracted dengue fever from a mosquito bite and went to the hospital three days after she finished the challenge. Manu said that she got to the hospital just in time — any later and she might have died. Manu spent a total of two weeks in the hospital and several months in physical therapy. She finished with a Primitive Survival Rating (PSR) of 8.0. In 2019, Manu returned to the Naked Afraid series as she was cast with 14 other survivalists for Naked and Afraid XL . For this challenge the survivalists had to survive 40 days in the Palawan in the Philippines. Manu was partnered in a group with Rylie Parlett and Christina McQueen, but tapped out on Day 7 due to her brother receiving treatments for jaw cancer. Manu appeared on National Geographic 's show Mygrations in 2016. The National Geographic team originally contacted Manu via Twitter and asked her if she would like to be featured in the show. Manu said she enjoyed being on the show, but commented on the show's large production, which took much of the wilderness experience away from her.Manu currently runs a wilderness camp in California to educate youth about the environment called camp Manu. She also runs an organization called Walk-about that gives survival tips and tells people how to respect the environment. The organization is partnered with Leave No Trace and Women Owned. On November 9, 2019, Manu released a song titled "Plastic Solution" with Two Roads Plastic Project. 100% of the song profits will go to efforts in fighting against plastic pollution .

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Dengue fever

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Andy Irons

Philip Andrew Irons (July 24, 1978 – November 2, 2010) was an American professional surfer . Irons began surfing with his brother Bruce on the shallow and dangerous waves of Kauai, Hawaii, before being spotted by a local surfboard brand and flown to North Shore, Oahu, Hawaii , to compete and develop his skill. Over the course of his professional career, he won three world titles (2002, 2003, 2004), three Quiksilver Pro France titles (2003, 2004, 2005), two Rip Curl Pro Search titles (2006 and 2007), and 20 elite-tour victories, including the Vans Triple Crown of Surfing four times from 2002 to 2006. He won at nearly every venue on the ASP calendar, only missing Gold Coast, Brazil, and Portugal. His younger brother Bruce Irons is a former competitor on the World Championship Tour of Surfing . During his childhood, Andy regularly lost to Bruce in contests, but that changed once he entered the World Championship Tour. During his professional career, he won three world titles (2002, 2003, 2004), three Quiksilver Pro France titles (2003, 2004, 2005), two Rip Curl Pro Search titles (2006 and 2007) and 20 elite-tour victories, including the Vans Triple Crown of Surfing four times from 2002 to 2006. On September 3, 2010, he won the Billabong Pro Teahupoo in Tahiti. In 2009, Irons withdrew from doing the full ASP World Tour season for personal reasons, though he did participate in a few events. He requested a wildcard entry for the 2010 ASP World Tour season, which was granted by ASP President Wayne Bartholomew . As a result, Irons did not have to re-qualify in 2010 via the World Qualifying Series (WQS). Irons won the Billabong Pro Tahiti 2010. He was inducted into the Surfing Walk of Fame in Huntington Beach, California , in 2008. The Governor of Hawaii declared February 13 forever "Andy Irons Day". Billabong produced an Andy Irons line of board shorts.Irons died on November 2, 2010. He was found by two hotel staff lying in bed on his back with the sheets pulled up to his chin after he had failed to respond to knocks on the door and they went in to investigate. The Tarrant County Medical Examiner's Office concludes that Irons died from a cardiac arrest due to a severe blockage of a main artery of the heart . The official autopsy report lists also a second cause of death as " acute mixed drug ingestion ", listing alprazolam , methadone , benzoylecgonine (a metabolite of cocaine), and traces of methamphetamine as the drugs found in Andy's body at the time of his death. Initial press releases cited Dengue fever as the cause of Irons' death; however, the autopsy report conducted by the Tarrant County Medical Examiner's office were negative for Dengue and other flavivirus . It is unclear why rumors that Dengue fever contributed to Irons' death proliferated. In response to Irons' death, a World Championship Tour event in Puerto Rico was postponed for two days with competitors holding a "paddle out" memorial service for Irons. Irons had withdrawn from the event citing ill health and was flying back to his home in Hawaii during a stopover in Grapevine, Texas , near Dallas-Fort Worth International Airport . He had reportedly stopped in Miami after leaving Puerto Rico, and early reports said he was put on a saline drip. He was reported to have been vomiting on the Hawaii-bound plane before being removed prior to takeoff. In the days immediately following his death, it was reported that in Dallas, an extremely ill Irons had attempted to board his connecting flight to Honolulu at 11:30 a.m. but was turned away at an American Airlines gate—a claim the company denies. A memorial service was held November 14, 2010, in Hanalei Bay , Kauai . His wife, Lyndie, and brother, Bruce , scattered his ashes outside Hanalei Bay, where thousands of family, friends, and admirers said their last goodbyes. Friend and rival surfer Kelly Slater dedicated his November 6, 2010, victory to Irons. "I just want to send my condolences to Andy's family," Slater said: Slater also wrote a candid remembrance honoring the life of Andy Irons on the anniversary of his death; it was also the same day that Slater claimed his 11th ASP World Title in San Francisco.Irons married Lyndie Dupuis on November 25, 2007, in Princeville, Kauai . She was seven months pregnant with their first child at the time of his death. Lyndie gave birth to their son, Andy Axel Irons, in Kauai on the opening day of the Pipeline Masters in Memory of Andy Irons on December 8, 2010. Lyndie and Axel continue to live on Kauai, where she and Andy shared a home.The 2018 movie Andy Irons: Kissed by God (directed by adventure-sport documentarians Steve and Todd Jones) is about the three-time world champion who died at 32 after a lifelong struggle with bipolar disorder and addiction . The film features in-depth interviews with Andy's brother Bruce Irons , his wife Lyndie Irons, Joel Parkinson , Nathan Fletcher, Sunny Garcia , and Kelly Slater . In 2009, Irons Brothers Productions released A fly in the champagne , a documentary of the rivalry that arose between Irons and Slater in the early 2000s. The movie ends with a trip to Indonesia Kelly Slater and Andy Irons went on together. The 2005 movie Blue Horizon (directed by surfing filmmaker Jack McCoy) paralleled his life on the WCT tour with that of free surfer David Rastovich. The film also touched on his long-time rivalry with 11-time world champion Kelly Slater . Although the film was created in a documentary-like style, there has been some debate over whether or not the film offered an accurate and fair portrayal of Irons' surfing lifestyle. In addition to Blue Horizon , Irons was also a subject of many other surf films, including his screen appearance in Trilogy , which starred himself, Joel Parkinson , and Taj Burrow . Irons had a much-publicized, and, according to him, overhyped, rivalry with fellow professional surfer Kelly Slater . In an interview, Irons said: For me, just being affiliated with Kelly--to be next to him--I mean, that's awesome. He's the ultimate surfer. He's the best surfer in the world. Ever. Best competitive, best free surfer, you name it, and to have my name put next to his everywhere really is flattering. He's the Michael Jordan of our sport. Kelly knows how I feel about him. Despite all the media hype that comes out of a rivalry there's a lot of respect given both ways. People don't realize there are times when we hang out. We'll go check the waves together. We talk about boards. He invited me personally to his contest on Tavarua. There's a ton of respect there. Slater himself was quoted in a Surfer Magazine tribute for Irons: Andy was an absolutely gifted individual. I'm lucky to have known him and had the times we had together. I feel blessed that we worked through the differences we had and I was able to learn what I'm made of because of Andy. I got to know a happy, funny, innocent kid who was happy to live every second with the people he loved. I'm so sad. My thoughts are with Bruce and Lyndie and their parents and all of his many friends around the world. It's a huge and far too premature loss for all of us. He was the most intense competitor I've ever known and one of the most sensitive people. He had so much life left in him and it hurts to think about. We look forward to his memory living on with our memories of him and his child on the way. There are a lot of uncles awaiting his arrival. I really miss Andy. He had a really good heart. A 2018 documentary titled Andy Irons: Kissed by God chronicled Irons' surfing career and his struggles with bipolar disorder and substance abuse. Irons' family runs the Andy Irons Foundation in his memory which focuses on community programs for youth struggling with mental illness. In 2019, Metallica and Billabong released the "Metallica x AI Forever" collection, with a portion of the proceeds benefiting the Andy Irons Foundation. Irons had previously collaborated with Metallica and Billabong for a clothing collection in 2007. Pipe (2011) Still Filthy (2009) A Fly in the Champagne (2009) Trilogy (2007) A Fistful of Barrels (2006)

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Dengue fever

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West Nile virus

West Nile virus ( WNV ) is a single-stranded RNA virus that causes West Nile fever . It is a member of the family Flaviviridae , from the genus Flavivirus , which also contains the Zika virus , dengue virus , and yellow fever virus. The virus is primarily transmitted by mosquitoes , mostly species of Culex . The primary hosts of WNV are birds, so that the virus remains within a "bird–mosquito–bird" transmission cycle. The virus is genetically related to the Japanese encephalitis family of viruses. Humans and horses both exhibit disease symptoms from the virus, and symptoms rarely occur in other animals.Contrary to popular belief, West Nile virus was not named after the Nile River , rather, the West Nile district of Uganda where the virus was first isolated in 1937. After its original discovery in this region, it was found in many other parts of the world. Most likely, it spread from the original West Nile district.Like most other flaviviruses, WNV is an enveloped virus with icosahedral symmetry . Electron microscope studies reveal a 45–50 nm virion covered with a relatively smooth protein shell; this structure is similar to the dengue fever virus, another Flavivirus . The protein shell is made of two structural proteins: the glycoprotein E and the small membrane protein M. Protein E has numerous functions including receptor binding, viral attachment, and entry into the cell through membrane fusion . The outer protein shell is covered by a host-derived lipid membrane , the viral envelope . The flavivirus lipid membrane has been found to contain cholesterol and phosphatidylserine , but other elements of the membrane have yet to be identified. The lipid membrane has many roles in viral infection , including acting as signaling molecules and enhancing entry into the cell. Cholesterol, in particular, plays an integral part in WNV entering a host cell. The two viral envelope proteins, E and M, are inserted into the membrane. The RNA genome is bound to capsid (C) proteins, which are 105 amino-acid residues long, to form the nucleocapsid . The capsid proteins are one of the first proteins created in an infected cell; the capsid protein is a structural protein whose main purpose is to package RNA into the developing viruses. The capsid has been found to prevent apoptosis by affecting the Akt pathway. WNV is a positive-sense, single-stranded RNA virus . Its genome is approximately 11,000 nucleotides long and is flanked by 5′ and 3′ non-coding stem loop structures. The coding region of the genome codes for three structural proteins and seven nonstructural (NS) proteins , proteins that are not incorporated into the structure of new viruses. The WNV genome is first translated into a polyprotein and later cleaved by virus and host proteases into separate proteins (i.e. NS1, C, E). Structural proteins (C, prM/M, E) are capsid, precursor membrane proteins, and envelope proteins, respectively. The structural proteins are located at the 5′ end of the genome and are cleaved into mature proteins by both host and viral proteases. [ citation needed ] Nonstructural proteins consist of NS1, NS2A, NS2B, NS3, NS4A, NS4B, and NS5. These proteins mainly assist with viral replication or act as proteases. The nonstructural proteins are located near the 3′ end of the genome.WNV is a positive-sense, single-stranded RNA virus . Its genome is approximately 11,000 nucleotides long and is flanked by 5′ and 3′ non-coding stem loop structures. The coding region of the genome codes for three structural proteins and seven nonstructural (NS) proteins , proteins that are not incorporated into the structure of new viruses. The WNV genome is first translated into a polyprotein and later cleaved by virus and host proteases into separate proteins (i.e. NS1, C, E). Structural proteins (C, prM/M, E) are capsid, precursor membrane proteins, and envelope proteins, respectively. The structural proteins are located at the 5′ end of the genome and are cleaved into mature proteins by both host and viral proteases. [ citation needed ]Nonstructural proteins consist of NS1, NS2A, NS2B, NS3, NS4A, NS4B, and NS5. These proteins mainly assist with viral replication or act as proteases. The nonstructural proteins are located near the 3′ end of the genome.Once WNV has successfully entered the bloodstream of a host animal, the envelope protein, E, binds to attachment factors called glycosaminoglycans on the host cell. These attachment factors aid entry into the cell, however, binding to primary receptors is also necessary. Primary receptors include DC-SIGN , DC-SIGN-R, and the integrin α v β 3 . By binding to these primary receptors, WNV enters the cell through clathrin-mediated endocytosis . As a result of endocytosis, WNV enters the cell within an endosome . [ citation needed ] The acidity of the endosome catalyzes the fusion of the endosomal and viral membranes, allowing the genome to be released into the cytoplasm. Translation of the positive-sense single-stranded RNA occurs at the endoplasmic reticulum ; the RNA is translated into a polyprotein which is then cleaved by both host and viral proteases NS2B-NS3 to produce mature proteins. In order to replicate its genome, NS5, a RNA polymerase , forms a replication complex with other nonstructural proteins to produce an intermediary negative-sense single-stranded RNA ; the negative-sense strand serves as a template for synthesis of the final positive-sense RNA. Once the positive-sense RNA has been synthesized, the capsid protein, C, encloses the RNA strands into immature virions. The rest of the virus is assembled along the endoplasmic reticulum and through the Golgi apparatus , and results in non-infectious immature virions. The E protein is then glycosylated and prM is cleaved by furin , a host cell protease, into the M protein, thereby producing an infectious mature virion. The mature viruses are then secreted out of the cell. [ citation needed ]WNV is one of the Japanese encephalitis antigenic serocomplex of viruses, together with Japanese encephalitis virus, Murray Valley encephalitis virus , Saint Louis encephalitis virus and some other flaviviruses. Studies of phylogenetic lineages have determined that WNV emerged as a distinct virus around 1000 years ago. This initial virus developed into two distinct lineages. Lineage 1 and its multiple profiles is the source of the epidemic transmission in Africa and throughout the world. Lineage 2 was considered an African zoonosis . However, in 2008, lineage 2, previously only seen in horses in sub-Saharan Africa and Madagascar, began to appear in horses in Europe, where the first known outbreak affected 18 animals in Hungary. Lineage 1 West Nile virus was detected in South Africa in 2010 in a mare and her aborted fetus ; previously, only lineage 2 West Nile virus had been detected in horses and humans in South Africa. Kunjin virus is a subtype of West Nile virus endemic to Oceania . A 2007 fatal case in a killer whale in Texas broadened the known host range of West Nile virus to include cetaceans . Since the first North American cases in 1999, the virus has been reported throughout the United States, Canada, Mexico, the Caribbean, and Central America. There have been human cases and equine cases, and many birds are infected. The Barbary macaque , Macaca sylvanus , was the first nonhuman primate to contract WNV. Both the American and Israeli strains are marked by high mortality rates in infected avian populations; the presence of dead birds—especially Corvidae —can be an early indicator of the arrival of the virus. [ citation needed ]The natural hosts for WNV are birds and mosquitoes. Over 300 different species of bird have been shown to be infected with the virus. Some birds, including the American crow ( Corvus brachyrhynchos ), blue jay ( Cyanocitta cristata ) and greater sage-grouse ( Centrocercus urophasianus ), are killed by the infection, but others survive. The American robin ( Turdus migratorius ) and house sparrow ( Passer domesticus ) are thought to be among the most important reservoir species in N. American and European cities. Brown thrashers ( Toxostoma rufum ), gray catbirds ( Dumetella carolinensis ), northern cardinals ( Cardinalis cardinalis ), northern mockingbirds ( Mimus polyglottos ), wood thrushes ( Hylocichla mustelina ) and the dove family are among the other common N. American birds in which high levels of antibodies against WNV have been found. WNV has been demonstrated in a large number of mosquito species, but the most significant for viral transmission are Culex species that feed on birds, including Culex pipiens , C. restuans , C. salinarius , C. quinquefasciatus , C. nigripalpus , C. erraticus and C. tarsalis . Experimental infection has also been demonstrated with soft tick vectors, but is unlikely to be important in natural transmission. WNV has a broad host range, and is also known to be able to infect at least 30 mammalian species, including humans, some non-human primates, horses, dogs and cats. Some infected humans and horses experience disease but dogs and cats rarely show symptoms. Reptiles and amphibians can also be infected, including some species of crocodiles, alligators, snakes, lizards and frogs. Mammals are considered incidental or dead-end hosts for the virus: they do not usually develop a high enough level of virus in the blood ( viremia ) to infect another mosquito feeding on them and carry on the transmission cycle; some birds are also dead-end hosts. In the normal rural or enzootic transmission cycle, the virus alternates between the bird reservoir and the mosquito vector. It can also be transmitted between birds via direct contact, by eating an infected bird carcass or by drinking infected water. Vertical transmission between female and offspring is possible in mosquitoes, and might potentially be important in overwintering. In the urban or spillover cycle, infected mosquitoes that have fed on infected birds transmit the virus to humans. This requires mosquito species that bite both birds and humans, which are termed bridge vectors. The virus can also rarely be spread through blood transfusions, organ transplants, or from mother to baby during pregnancy, delivery, or breastfeeding. Unlike in birds, it does not otherwise spread directly between people. West Nile fever is an infection by the West Nile virus, which is typically spread by mosquitoes . In about 80% of infections people have few or no symptoms . About 20% of people develop a fever , headache, vomiting, or a rash. In less than 1% of people, encephalitis or meningitis occurs, with associated neck stiffness, confusion, or seizures. Recovery may take weeks to months. The risk of death among those in whom the nervous system is affected is about 10 percent. West Nile virus (WNV) is usually spread by mosquitoes that become infected when they feed on infected birds, which often carry the disease . Rarely the virus is spread through blood transfusions, organ transplants, or from mother to baby during pregnancy, delivery, or breastfeeding, but it otherwise does not spread directly between people. Risks for severe disease include being over 60 years old and having other health problems. Diagnosis is typically based on symptoms and blood tests. There is no human vaccine . The best way to reduce the risk of infection is to avoid mosquito bites. Mosquito populations may be reduced by eliminating standing pools of water, such as in old tires, buckets, gutters, and swimming pools. When mosquitoes cannot be avoided, mosquito repellent , window screens , and mosquito nets reduce the likelihood of being bitten. There is no specific treatment for the disease; pain medications may reduce symptoms. Severe disease may also occur in horses. Several vaccines for these animals are now available. Before the availability of veterinary vaccines, around 40% of horses infected in North America died. West Nile fever is an infection by the West Nile virus, which is typically spread by mosquitoes . In about 80% of infections people have few or no symptoms . About 20% of people develop a fever , headache, vomiting, or a rash. In less than 1% of people, encephalitis or meningitis occurs, with associated neck stiffness, confusion, or seizures. Recovery may take weeks to months. The risk of death among those in whom the nervous system is affected is about 10 percent. West Nile virus (WNV) is usually spread by mosquitoes that become infected when they feed on infected birds, which often carry the disease . Rarely the virus is spread through blood transfusions, organ transplants, or from mother to baby during pregnancy, delivery, or breastfeeding, but it otherwise does not spread directly between people. Risks for severe disease include being over 60 years old and having other health problems. Diagnosis is typically based on symptoms and blood tests. There is no human vaccine . The best way to reduce the risk of infection is to avoid mosquito bites. Mosquito populations may be reduced by eliminating standing pools of water, such as in old tires, buckets, gutters, and swimming pools. When mosquitoes cannot be avoided, mosquito repellent , window screens , and mosquito nets reduce the likelihood of being bitten. There is no specific treatment for the disease; pain medications may reduce symptoms. Severe disease may also occur in horses. Several vaccines for these animals are now available. Before the availability of veterinary vaccines, around 40% of horses infected in North America died. According to the Center for Disease Control , infection with West Nile Virus is seasonal in temperate zones. Climates that are temperate, such as those in the United States and Europe, see peak season from July to October. Peak season changes depending on geographic region and warmer and humid climates can see longer peak seasons. All ages are equally likely to be infected but there is a higher amount of death and neuroinvasive West Nile Virus in people 60–89 years old. People of older age are more likely to have adverse effects. [ citation needed ] There are several modes of transmission, but the most common cause of infection in humans is by being bitten by an infected mosquito. Other modes of transmission include blood transfusion, organ transplantation, breast-feeding, transplacental transmission, and laboratory acquisition. These alternative modes of transmission are extremely rare. Prevention efforts against WNV mainly focus on preventing human contact with and being bitten by infected mosquitoes. This is twofold, first by personal protective actions and second by mosquito-control actions. When a person is in an area that has WNV, it is important to avoid outdoor activity, and if they go outside they should use a mosquito repellent with DEET. A person can also wear clothing that covers more skin, such as long sleeves and pants. Mosquito control can be done at the community level and include surveillance programs and control programs including pesticides and reducing mosquito habitats. This includes draining standing water. Surveillance systems in birds is particularly useful. If dead birds are found in a neighborhood, the event should be reported to local authorities. This may help health departments do surveillance and determine if the birds are infected with West Nile Virus. Despite the commercial availability of four veterinary vaccines for horses, no human vaccine has progressed beyond phase II clinical trials . Efforts have been made to produce a vaccine for human use and several candidates have been produced but none are licensed to use. The best method to reduce the risk of infections is avoiding mosquito bites. This may be done by eliminating standing pools of water, such as in old tires, buckets, gutters, and swimming pools. Mosquito repellent , window screens , mosquito nets , and avoiding areas where mosquitoes occur may also be useful. Like other tropical diseases which are expected to have increased spread due to climate change, there is concern that changing weather conditions will increase West Nile Virus spread. Climate change will affect disease rates, ranges, and seasonality and affects the distribution of West Nile Virus. Projected changes in flood frequency and severity can bring new challenges in flood risk management , allowing for increased mosquito populations in urban areas. Weather conditions affected by climate change including temperature, precipitation and wind may affect the survival and reproduction rates of mosquitoes, suitable habitats, distribution, and abundance. Ambient temperatures drive mosquito replication rates and transmission of WNV by affecting the peak season of mosquitoes and geographic variations. For example, increased temperatures can affect the rate of virus replication, speed up the virus evolution rate, and viral transmission efficiency. Furthermore, higher winter temperatures and warmer spring may lead to larger summer mosquito populations, increasing the risk for WNV. Similarly, rainfall may also drive mosquito replication rates and affect the seasonality and geographic variations of the virus. Studies show an association between heavy precipitation and higher incidence of reported WNV. Likewise, wind is another environmental factor that serves as a dispersal mechanism for mosquitoes. Mosquitoes have extremely wide environmental tolerances and a nearly ubiquitous geographical distribution, being present on all major land masses except Antarctica and Iceland. Nevertheless, changes in climate and land use on ecological timescales can variously expand or fragment their distribution patterns, raising consequent concerns for human health.

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Dengue fever

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Hess test

The Hess test or Rumpel-Leede test is a medical test used to assess capillary fragility. It is also called the Tourniquet test . To perform the test, pressure is applied to the forearm with a blood pressure cuff inflated to between systolic and diastolic blood pressure for 10 minutes. After removing the cuff, the number of petechiae in a 5 cm diameter circle of the area under pressure is counted. Normally less than 15 petechiae are seen. 15 or more petechiae indicate capillary fragility, which occurs due to poor platelet function, bleeding diathesis or thrombocytopenia , and can be seen in cases of scurvy , and Dengue fever . The test is named after Alfred Fabian Hess .

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Dengue fever

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Leptospirosis

Leptospirosis is a blood infection caused by the bacteria Leptospira that can infect humans, dogs, rodents and many other wild and domesticated animals. Signs and symptoms can range from none to mild ( headaches , muscle pains , and fevers ) to severe ( bleeding in the lungs or meningitis ). Weil's disease ( / ˈ v aɪ l z / VILES ), the acute, severe form of leptospirosis, causes the infected individual to become jaundiced (skin and eyes become yellow), develop kidney failure , and bleed. Bleeding from the lungs associated with leptospirosis is known as severe pulmonary haemorrhage syndrome . More than ten genetic types of Leptospira cause disease in humans. Both wild and domestic animals can spread the disease, most commonly rodents. The bacteria are spread to humans through animal urine or feces , or water or soil contaminated with animal urine and feces, coming into contact with the eyes, mouth, nose or breaks in the skin. In developing countries, the disease occurs most commonly in pest control, farmers and low-income people who live in areas with poor sanitation. In developed countries, it occurs during heavy downpours and is a risk to pest controllers, sewage workers and those involved in outdoor activities in warm and wet areas. Diagnosis is typically by testing for antibodies against the bacteria or finding bacterial DNA in the blood. Efforts to prevent the disease include protective equipment to block contact when working with potentially infected animals, washing after contact, and reducing rodents in areas where people live and work. The antibiotic doxycycline is effective in preventing leptospirosis infection. Human vaccines are of limited usefulness; vaccines for other animals are more widely available. Treatment when infected is with antibiotics such as doxycycline, penicillin , or ceftriaxone . The overall risk of death is 5–10%. However, when the lungs are involved, the risk of death increases to the range of 50–70%. It is estimated that one million severe cases of leptospirosis in humans occur every year, causing about 58,900 deaths. The disease is most common in tropical areas of the world but may occur anywhere. Outbreaks may arise after heavy rainfall. The disease was first described by physician Adolf Weil in 1886 in Germany. Infected animals may have no, mild or severe symptoms. These may vary by the type of animal. In some animals Leptospira live in the reproductive tract, leading to transmission during mating. The symptoms of leptospirosis usually appear one to two weeks after infection, but the incubation period can be as long as a month. The illness is biphasic in a majority of symptomatic cases. Symptoms of the first phase (acute or leptospiremic phase) last five to seven days. In the second phase (immune phase), the symptoms resolve as antibodies against the bacteria are produced. Additional symptoms develop in the second phase. The phases of illness may not be distinct, especially in patients with severe illness. 90% of those infected experience mild symptoms while 10% experience severe leptospirosis. Leptospiral infection in humans causes a range of symptoms , though some infected persons may have none. The disease begins suddenly with fever accompanied by chills, intense headache, severe muscle aches and abdominal pain. A headache brought on by leptospirosis causes throbbing pain and is characteristically located at the head's bilateral temporal or frontal regions. The person could also have pain behind the eyes and a sensitivity to light . Muscle pain usually involves the calf muscle and the lower back. The most characteristic feature of leptospirosis is the conjunctival suffusion ( conjunctivitis without exudate ) which is rarely found in other febrile illnesses. Other characteristic findings on the eye include subconjunctival bleeding and jaundice . A rash is rarely found in leptospirosis. When one is found alternative diagnoses such as dengue fever and chikungunya fever should be considered. Dry cough is observed in 20–57% of people with leptospirosis. Thus, this clinical feature can mislead a doctor to diagnose the disease as a respiratory illness. Additionally, gastrointestinal symptoms such as nausea , vomiting, abdominal pain, and diarrhoea frequently occur. Vomiting and diarrhea may contribute to dehydration . The abdominal pain can be due to acalculous cholecystitis or inflammation of the pancreas . Rarely, the lymph nodes , liver , and spleen may be enlarged and palpable. There will be a resolution of symptoms for one to three days. The immune phase starts after this and can last from four to 30 days and can be anything from brain to kidney complications. The hallmark of the second phase is inflammation of the membranes covering the brain . Signs and symptoms of meningitis include severe headache and neck stiffness. Kidney involvement is associated with reduced or absent urine output. The classic form of severe leptospirosis, known as Weil's disease, is characterised by liver damage (causing jaundice), kidney failure , and bleeding, which happens in 5–10% of those infected. Lung and brain damage can also occur. For those with signs of inflammation of membranes covering the brain and the brain itself , altered level of consciousness can happen. A variety of neurological problems such as paralysis of half of the body , complete inflammation of a whole horizontal section of spinal cord , and muscle weakness due to immune damage of the nerves supplying the muscles are the complications. Signs of bleeding such as non-traumatic bruises at 1 mm (0.039 in) , non-traumatic bruises more than 1 cm (0.39 in) , nose bleeding , blackish stools due to bleeding in the stomach , vomiting blood and bleeding from the lungs can also be found. Prolongation of prothrombin time in coagulation testing is associated with severe bleeding manifestation. However, low platelet count is not associated with severe bleeding. Pulmonary haemorrhage is alveolar haemorrhage (bleeding into the alveoli of the lungs) leading to massive coughing up of blood , and causing acute respiratory distress syndrome , where the risk of death is more than 50%. Rarely, inflammation of the heart muscles , inflammation of membranes covering the heart , abnormalities in the heart's natural pacemaker and abnormal heart rhythms may occur. Leptospirosis is caused by spirochaete bacteria that belong to the genus Leptospira , which are aerobic , right-handed helical , and 6–20 micrometers long. Like Gram-negative bacteria, Leptospira have an outer membrane studded with lipopolysaccharide (LPS) on the surface, an inner membrane and a layer of peptidoglycan cell wall. However, unlike Gram-negative bacteria, the peptidoglycan layer in Leptospira lies closer to the inner than the outer membrane. This results in a fluid outer membrane loosely associated with the cell wall. In addition, Leptospira have a flagellum located in the periplasm , associated with corkscrew style movement. Chemoreceptors at the poles of the bacteria sense various substrates and change the direction of its movement. The bacteria are traditionally visualised using dark-field microscopy without staining. A total of 66 species of Leptospira has been identified. Based on their genomic sequence, they are divided into two clades and four subclades: P1, P2, S1, and S2. The 19 members of the P1 subclade include the 8 species that can cause severe disease in humans: L. alexanderi , L. borgpetersenii , L. interrogans , L. kirschneri , L. mayottensis , L. noguchii , L. santarosai , and L. weilii . The P2 clade comprises 21 species that may cause mild disease in humans. The remaining 26 species comprise the S1 and S2 subclades, which include "saprophytes" known to consume decaying matter ( saprotrophic nutrition ). Pathogenic Leptospira do not multiply in the environment. Leptospira require high humidity for survival but can remain alive in environments such as stagnant water or contaminated soil. The bacterium can be killed by temperatures of 50 °C (122 °F) and can be inactivated by 70% ethanol , 1% sodium hypochlorite , formaldehyde , detergents and acids. Leptospira are also classified based on their serovar . The diverse sugar composition of the lipopolysaccharide on the surface of the bacteria is responsible for the antigenic difference between serovars. About 300 pathogenic serovars of Leptospira are recognised. Antigenically related serovars (belonging to the same serogroup) may belong to different species because of horizontal gene transfer of LPS biosynthetic genes between different species. Currently, the cross agglutination absorption test and DNA-DNA hybridisation are used to classify Leptospira species, but are time-consuming. Therefore, total genomic sequencing could potentially replace these two methods as the new gold standard of classifying Leptospira species. The bacteria can be found in ponds, rivers, puddles, sewers, agricultural fields and moist soil. Pathogenic Leptospira have been found in the form of aquatic biofilms , which may aid survival in the environment. The number of cases of leptospirosis is directly related to the amount of rainfall, making the disease seasonal in temperate climates and year-round in tropical climates. The risk of contracting leptospirosis depends upon the risk of disease carriage in the community and the frequency of exposure. In rural areas, farming and animal husbandry are the major risk factors for contracting leptospirosis. Poor housing and inadequate sanitation also increase the risk of infection. In tropical and semi-tropical areas, the disease often becomes widespread after heavy rains or after flooding. Leptospira are found mostly in mammals. However, reptiles and cold-blooded animals such as frogs, snakes, turtles, and toads have been shown to have the infection. Whether there are reservoirs of human infection is unknown. Rats, mice, and moles are important primary hosts , but other mammals including dogs, deer, rabbits, hedgehogs, cows, sheep, swine, raccoons, opossums, and skunks can also carry the disease. In Africa, a number of wildlife hosts have been identified as carriers, including the banded mongoose , Egyptian fox , Rusa deer , and shrews . There are various mechanisms whereby animals can infect each other. Dogs may lick the urine of an infected animal off the grass or soil , or drink from an infected puddle. House-bound domestic dogs have contracted leptospirosis, apparently from licking the urine of infected mice in the house. Leptospirosis can also be transmitted via the semen of infected animals. The duration of bacteria being consistently present in animal urine may persist for years. Humans are the accidental host of Leptospira . Humans become infected through contact with water or moist soil that contains urine & feces from infected animals. The bacteria enter through cuts, abrasions, ingestion of contaminated food, or contact with mucous membrane of the body (e.g. mouth, nose, and eyes). Occupations at risk of contracting leptospirosis include farmers, fishermen, garbage collectors and sewage workers. The disease is also related to adventure tourism and recreational activities. It is common among water-sports enthusiasts in specific areas, including triathlons , water rafting , canoeing and swimming, as prolonged immersion in water promotes the entry of the bacteria. However, Leptospira are unlikely to penetrate intact skin. The disease is not known to spread between humans, and bacterial dissemination in recovery period is extremely rare in humans. Once humans are infected, bacterial shedding from the kidneys usually persists for up to 60 days. Rarely, leptospirosis can be transmitted through an organ transplant. Infection through the placenta during pregnancy is also possible. It can cause miscarriage and infection in infants . Leptospirosis transmission through eating raw meat of wildlife animals have also been reported (e.g. psychiatric patients with allotriophagy). Leptospirosis is caused by spirochaete bacteria that belong to the genus Leptospira , which are aerobic , right-handed helical , and 6–20 micrometers long. Like Gram-negative bacteria, Leptospira have an outer membrane studded with lipopolysaccharide (LPS) on the surface, an inner membrane and a layer of peptidoglycan cell wall. However, unlike Gram-negative bacteria, the peptidoglycan layer in Leptospira lies closer to the inner than the outer membrane. This results in a fluid outer membrane loosely associated with the cell wall. In addition, Leptospira have a flagellum located in the periplasm , associated with corkscrew style movement. Chemoreceptors at the poles of the bacteria sense various substrates and change the direction of its movement. The bacteria are traditionally visualised using dark-field microscopy without staining. A total of 66 species of Leptospira has been identified. Based on their genomic sequence, they are divided into two clades and four subclades: P1, P2, S1, and S2. The 19 members of the P1 subclade include the 8 species that can cause severe disease in humans: L. alexanderi , L. borgpetersenii , L. interrogans , L. kirschneri , L. mayottensis , L. noguchii , L. santarosai , and L. weilii . The P2 clade comprises 21 species that may cause mild disease in humans. The remaining 26 species comprise the S1 and S2 subclades, which include "saprophytes" known to consume decaying matter ( saprotrophic nutrition ). Pathogenic Leptospira do not multiply in the environment. Leptospira require high humidity for survival but can remain alive in environments such as stagnant water or contaminated soil. The bacterium can be killed by temperatures of 50 °C (122 °F) and can be inactivated by 70% ethanol , 1% sodium hypochlorite , formaldehyde , detergents and acids. Leptospira are also classified based on their serovar . The diverse sugar composition of the lipopolysaccharide on the surface of the bacteria is responsible for the antigenic difference between serovars. About 300 pathogenic serovars of Leptospira are recognised. Antigenically related serovars (belonging to the same serogroup) may belong to different species because of horizontal gene transfer of LPS biosynthetic genes between different species. Currently, the cross agglutination absorption test and DNA-DNA hybridisation are used to classify Leptospira species, but are time-consuming. Therefore, total genomic sequencing could potentially replace these two methods as the new gold standard of classifying Leptospira species. The bacteria can be found in ponds, rivers, puddles, sewers, agricultural fields and moist soil. Pathogenic Leptospira have been found in the form of aquatic biofilms , which may aid survival in the environment. The number of cases of leptospirosis is directly related to the amount of rainfall, making the disease seasonal in temperate climates and year-round in tropical climates. The risk of contracting leptospirosis depends upon the risk of disease carriage in the community and the frequency of exposure. In rural areas, farming and animal husbandry are the major risk factors for contracting leptospirosis. Poor housing and inadequate sanitation also increase the risk of infection. In tropical and semi-tropical areas, the disease often becomes widespread after heavy rains or after flooding. Leptospira are found mostly in mammals. However, reptiles and cold-blooded animals such as frogs, snakes, turtles, and toads have been shown to have the infection. Whether there are reservoirs of human infection is unknown. Rats, mice, and moles are important primary hosts , but other mammals including dogs, deer, rabbits, hedgehogs, cows, sheep, swine, raccoons, opossums, and skunks can also carry the disease. In Africa, a number of wildlife hosts have been identified as carriers, including the banded mongoose , Egyptian fox , Rusa deer , and shrews . There are various mechanisms whereby animals can infect each other. Dogs may lick the urine of an infected animal off the grass or soil , or drink from an infected puddle. House-bound domestic dogs have contracted leptospirosis, apparently from licking the urine of infected mice in the house. Leptospirosis can also be transmitted via the semen of infected animals. The duration of bacteria being consistently present in animal urine may persist for years. Humans are the accidental host of Leptospira . Humans become infected through contact with water or moist soil that contains urine & feces from infected animals. The bacteria enter through cuts, abrasions, ingestion of contaminated food, or contact with mucous membrane of the body (e.g. mouth, nose, and eyes). Occupations at risk of contracting leptospirosis include farmers, fishermen, garbage collectors and sewage workers. The disease is also related to adventure tourism and recreational activities. It is common among water-sports enthusiasts in specific areas, including triathlons , water rafting , canoeing and swimming, as prolonged immersion in water promotes the entry of the bacteria. However, Leptospira are unlikely to penetrate intact skin. The disease is not known to spread between humans, and bacterial dissemination in recovery period is extremely rare in humans. Once humans are infected, bacterial shedding from the kidneys usually persists for up to 60 days. Rarely, leptospirosis can be transmitted through an organ transplant. Infection through the placenta during pregnancy is also possible. It can cause miscarriage and infection in infants . Leptospirosis transmission through eating raw meat of wildlife animals have also been reported (e.g. psychiatric patients with allotriophagy). When animals ingest the bacteria, they circulate in the bloodstream, then lodge themselves into the kidneys through the glomerular or peritubular capillaries . The bacteria then pass into the lumens of the renal tubules and colonise the brush border and proximal convoluted tubule . This causes the continuous shedding of bacteria in the urine without the animal experiencing significant ill effects. This relationship between the animal and the bacteria is known as a commensal relationship , and the animal is known as a reservoir host . Humans are the accidental host of Leptospira . The pathogenesis of leptospirosis remains poorly understood despite research efforts. The bacteria enter the human body through either breaches in the skin or the mucous membrane, then into the bloodstream. The bacteria later attach to the endothelial cells of the blood vessels and extracellular matrix (complex network of proteins and carbohydrates present between cells). The bacteria use their flagella for moving between cell layers. They bind to cells such as fibroblasts , macrophages , endothelial cells, and kidney epithelial cells. They also bind to several human proteins such as complement proteins, thrombin , fibrinogen , and plasminogen using surface leptospiral immunoglobulin-like (Lig) proteins such as LigB and LipL32, whose genes are found in all pathogenic species. Through the innate immune system , endothelial cells of the capillaries in the human body are activated by the presence of these bacteria. The endothelial cells produce cytokines and antimicrobial peptides against the bacteria. These products regulate the coagulation cascade and movements of white blood cells. Macrophages presented in humans are able to engulf Leptospira . However, Leptospira are able to reside and proliferate in the cytoplasmic matrix after being ingested by macrophages. Those with severe leptospirosis can experience a high level of cytokines such as interleukin 6 , tumor necrosis factor alpha (TNF-α), and interleukin 10 . The high level of cytokines causes sepsis -like symptoms which is life-threatening instead of helping to fight against the infection. Those who have a high risk of sepsis during a leptospirosis infection are found to have the HLA-DQ6 genotype , possibly due to superantigen activation, which damages bodily organs. Leptospira LPS only activates toll-like receptor 2 (TLR2) in monocytes in humans. The lipid A molecule of the bacteria is not recognised by human TLR4 receptors. Therefore, the lack of Leptospira recognition by TLR4 receptors probably contributes to the leptospirosis disease process in humans. Although there are various mechanisms in the human body to fight against the bacteria, Leptospira is well adapted to such an inflammatory condition created by it. In the bloodstream, it can activate host plasminogen to become plasmin that breaks down extracellular matrix, degrades fibrin clots and complemental proteins ( C3b and C5 ) to avoid opsonisation . It can also recruit complement regulators such as Factor H , C4b -binding protein, factor H-like binding protein, and vitronectin to prevent the activation of membrane attack complex on its surface. It also secretes proteases to degrade complement proteins such as C3 . It can bind to thrombin that decreases the fibrin formation. Reduced fibrin formation increases the risk of bleeding. Leptospira also secretes sphingomyelinase and haemolysin that target red blood cells. Leptospira spreads rapidly to all organs through the bloodstream. They mainly affect the liver. They invade spaces between hepatocytes , causing apoptosis. The damaged hepatocytes and hepatocyte intercellular junctions cause leakage of bile into the bloodstream, causing elevated levels of bilirubin , resulting in jaundice. Congested liver sinusoids and perisinusoidal spaces have been reported. Meanwhile, in the lungs, petechiae or frank bleeding can be found at the alveolar septum and spaces between alveoli. Leptospira secretes toxins that cause mild to severe kidney failure or interstitial nephritis . The kidney failure can recover completely or lead to atrophy and fibrosis . Rarely, inflammation of the heart muscles, coronary arteries, and aorta are found. For those who are infected, a complete blood count may show a high white cell count and a low platelet count. When a low haemoglobin count is present together with a low white cell count and thrombocytopenia , bone marrow suppression should be considered. Erythrocyte sedimentation rate and C-reactive protein may also be elevated. The kidneys are commonly involved in leptospirosis. Blood urea and creatinine levels will be elevated. Leptospirosis increases potassium excretion in urine, which leads to a low potassium level and a low sodium level in the blood. Urinalysis may reveal the presence of protein , white blood cells , and microscopic haematuria . Because the bacteria settle in the kidneys, urine cultures will be positive for leptospirosis starting after the second week of illness until 30 days of infection. For those with liver involvement, transaminases and direct bilirubin are elevated in liver function tests . The Icterohaemorrhagiae serogroup is associated with jaundice and elevated bilirubin levels. Hemolytic anemia contributes to jaundice. A feature of leptospirosis is acute haemolytic anaemia and conjugated hyperbilirubinemia, especially in patients with glucose-6-phosphate dehydrogenase deficiency . Abnormal serum amylase and lipase levels (associated with pancreatitis) are found in those who are admitted to hospital due to leptospirosis. Impaired kidney function with creatinine clearance less than 50 ml/min is associated with elevated pancreatic enzymes. For those with severe headache who show signs of meningitis, a lumbar puncture can be attempted. If infected, cerebrospinal fluid (CSF) examination shows lymphocytic predominance with a cell count of about 500/mm 3 , protein between 50 and 100 mg/ml and normal glucose levels. These findings are consistent with aseptic meningitis . Rapid detection of Leptospira can be done by quantifying the IgM antibodies using an enzyme-linked immunosorbent assay (ELISA) . Typically, L. biflexa antigen is used to detect the IgM antibodies. This test can quickly determine the diagnosis and help in early treatment. However, the test specificity depends upon the type of antigen used and the presence of antibodies from previous infections. The presence of other diseases such as Epstein–Barr virus infection, viral hepatitis , and cytomegalovirus infection can cause false-positive results. Other rapid screening tests have been developed such as dipsticks, latex and slide agglutination tests. The microscopic agglutination test (MAT) is the reference test for the diagnosis of leptospirosis. MAT is a test where serial dilutions of patient sera are mixed with different serovars of Leptospira . The mixture is then examined under a dark field microscope to look for agglutination . The highest dilution where 50% agglutination occurs is the result. MAT titres of 1:100 to 1:800 are diagnostic of leptospirosis. A fourfold or greater rise in titre of two sera taken at symptoms' onset and three to 10 days of disease onset confirms the diagnosis. During the acute phase of the disease, MAT is not specific in detecting a serotype of Leptospira because of cross-reactivity between the serovars. In the convalescent phase, MAT is more specific in detecting the serovar types. MAT requires a panel of live antigens and requires laborious work. Leptospiral DNA can be amplified by using polymerase chain reaction (PCR) from serum, urine, aqueous humour , CSF, and autopsy specimens. It detects the presence of bacteria faster than MAT during the first few days of infection without waiting for the appearance of antibodies. As PCR detects the presence of leptospiral DNA in the blood it is useful even when the bacteria is killed by antibiotics. In those who have lung involvement, a chest X-ray may demonstrate diffuse alveolar opacities. In 1982, the World Health Organization (WHO) proposed the Faine's criteria for the diagnosis of leptospirosis. It consists of three parts: A (clinical findings), B (epidemiological factors), and C (lab findings and bacteriological data). Since the original Faine's criteria only included culture and MAT in part C, which is difficult and complex to perform, the modified Faine's criteria were proposed in 2004 to include ELISA and slide agglutination tests which are easier to perform. In 2012, modified Faine's criteria (with amendment) was proposed to include shortness of breath and coughing up blood in the diagnosis. In 2013, India recommended modified Faine's criteria in the diagnosis of leptospirosis. For those who are infected, a complete blood count may show a high white cell count and a low platelet count. When a low haemoglobin count is present together with a low white cell count and thrombocytopenia , bone marrow suppression should be considered. Erythrocyte sedimentation rate and C-reactive protein may also be elevated. The kidneys are commonly involved in leptospirosis. Blood urea and creatinine levels will be elevated. Leptospirosis increases potassium excretion in urine, which leads to a low potassium level and a low sodium level in the blood. Urinalysis may reveal the presence of protein , white blood cells , and microscopic haematuria . Because the bacteria settle in the kidneys, urine cultures will be positive for leptospirosis starting after the second week of illness until 30 days of infection. For those with liver involvement, transaminases and direct bilirubin are elevated in liver function tests . The Icterohaemorrhagiae serogroup is associated with jaundice and elevated bilirubin levels. Hemolytic anemia contributes to jaundice. A feature of leptospirosis is acute haemolytic anaemia and conjugated hyperbilirubinemia, especially in patients with glucose-6-phosphate dehydrogenase deficiency . Abnormal serum amylase and lipase levels (associated with pancreatitis) are found in those who are admitted to hospital due to leptospirosis. Impaired kidney function with creatinine clearance less than 50 ml/min is associated with elevated pancreatic enzymes. For those with severe headache who show signs of meningitis, a lumbar puncture can be attempted. If infected, cerebrospinal fluid (CSF) examination shows lymphocytic predominance with a cell count of about 500/mm 3 , protein between 50 and 100 mg/ml and normal glucose levels. These findings are consistent with aseptic meningitis . Rapid detection of Leptospira can be done by quantifying the IgM antibodies using an enzyme-linked immunosorbent assay (ELISA) . Typically, L. biflexa antigen is used to detect the IgM antibodies. This test can quickly determine the diagnosis and help in early treatment. However, the test specificity depends upon the type of antigen used and the presence of antibodies from previous infections. The presence of other diseases such as Epstein–Barr virus infection, viral hepatitis , and cytomegalovirus infection can cause false-positive results. Other rapid screening tests have been developed such as dipsticks, latex and slide agglutination tests. The microscopic agglutination test (MAT) is the reference test for the diagnosis of leptospirosis. MAT is a test where serial dilutions of patient sera are mixed with different serovars of Leptospira . The mixture is then examined under a dark field microscope to look for agglutination . The highest dilution where 50% agglutination occurs is the result. MAT titres of 1:100 to 1:800 are diagnostic of leptospirosis. A fourfold or greater rise in titre of two sera taken at symptoms' onset and three to 10 days of disease onset confirms the diagnosis. During the acute phase of the disease, MAT is not specific in detecting a serotype of Leptospira because of cross-reactivity between the serovars. In the convalescent phase, MAT is more specific in detecting the serovar types. MAT requires a panel of live antigens and requires laborious work. Leptospiral DNA can be amplified by using polymerase chain reaction (PCR) from serum, urine, aqueous humour , CSF, and autopsy specimens. It detects the presence of bacteria faster than MAT during the first few days of infection without waiting for the appearance of antibodies. As PCR detects the presence of leptospiral DNA in the blood it is useful even when the bacteria is killed by antibiotics. Rapid detection of Leptospira can be done by quantifying the IgM antibodies using an enzyme-linked immunosorbent assay (ELISA) . Typically, L. biflexa antigen is used to detect the IgM antibodies. This test can quickly determine the diagnosis and help in early treatment. However, the test specificity depends upon the type of antigen used and the presence of antibodies from previous infections. The presence of other diseases such as Epstein–Barr virus infection, viral hepatitis , and cytomegalovirus infection can cause false-positive results. Other rapid screening tests have been developed such as dipsticks, latex and slide agglutination tests. The microscopic agglutination test (MAT) is the reference test for the diagnosis of leptospirosis. MAT is a test where serial dilutions of patient sera are mixed with different serovars of Leptospira . The mixture is then examined under a dark field microscope to look for agglutination . The highest dilution where 50% agglutination occurs is the result. MAT titres of 1:100 to 1:800 are diagnostic of leptospirosis. A fourfold or greater rise in titre of two sera taken at symptoms' onset and three to 10 days of disease onset confirms the diagnosis. During the acute phase of the disease, MAT is not specific in detecting a serotype of Leptospira because of cross-reactivity between the serovars. In the convalescent phase, MAT is more specific in detecting the serovar types. MAT requires a panel of live antigens and requires laborious work. Leptospiral DNA can be amplified by using polymerase chain reaction (PCR) from serum, urine, aqueous humour , CSF, and autopsy specimens. It detects the presence of bacteria faster than MAT during the first few days of infection without waiting for the appearance of antibodies. As PCR detects the presence of leptospiral DNA in the blood it is useful even when the bacteria is killed by antibiotics. In those who have lung involvement, a chest X-ray may demonstrate diffuse alveolar opacities. In 1982, the World Health Organization (WHO) proposed the Faine's criteria for the diagnosis of leptospirosis. It consists of three parts: A (clinical findings), B (epidemiological factors), and C (lab findings and bacteriological data). Since the original Faine's criteria only included culture and MAT in part C, which is difficult and complex to perform, the modified Faine's criteria were proposed in 2004 to include ELISA and slide agglutination tests which are easier to perform. In 2012, modified Faine's criteria (with amendment) was proposed to include shortness of breath and coughing up blood in the diagnosis. In 2013, India recommended modified Faine's criteria in the diagnosis of leptospirosis. Rates of leptospirosis can be reduced by improving housing, infrastructure, and sanitation standards. Rodent abatement efforts and flood mitigation projects can also help to prevent it. Proper use of personal protective equipment (PPE) by people who have a high risk of occupational exposure can prevent leptospirosis infections in most cases. There is no human vaccine suitable for worldwide use. Only a few countries such as Cuba, Japan, France, and China have approved the use of inactivated vaccines with limited protective effects. Side effects such as nausea, injection site redness and swelling have been reported after the vaccine was injected. Since the immunity induced by one Leptospira serovar is only protective against that specific one, trivalent vaccines have been developed. However, they do not confer long-lasting immunity to humans or animals. Vaccines for other animals are more widely available. Doxycycline is given once a week as a prophylaxis and is effective in reducing the rate of leptospirosis infections amongst high-risk individuals in flood-prone areas. In one study, it reduced the number of leptospirosis cases in military personnel undergoing exercises in the jungles. In another study, it reduced the number of symptomatic cases after exposure to leptospirosis under heavy rainfall in endemic areas. The prevention of leptospirosis from the environmental sources like contaminated waterways, soil, sewers, and agricultural fields, is disinfection used by effective microorganisms , which is mixed with bokashi mudballs for the infected waterways & sewers.Most leptospiral cases resolve spontaneously. Early initiation of antibiotics may prevent the progression to severe disease. Therefore, in resource-limited settings, antibiotics can be started once leptospirosis is suspected after history taking and examination. For mild leptospirosis, antibiotic recommendations such as doxycycline, azithromycin , ampicillin and amoxicillin were based solely on in vitro testing. In 2001, the WHO recommended oral doxycycline (2 mg/kg up to 100 mg every 12 hours) for five to seven days for those with mild leptospirosis. Tetracycline , ampicillin, and amoxicillin can also be used in such cases. However, in areas where both rickettsia and leptospirosis are endemic, azithromycin and doxycycline are the drugs of choice. It should be noted doxycycline is not used in cases where the patient suffers from liver damage as it has been linked to hepatotoxicity. Based on a 1988 study, intravenous (IV) benzylpenicillin (also known as penicillin G) is recommended for the treatment of severe leptospirosis. Intravenous benzylpenicillin (30 mg/kg up to 1.2 g every six hours) is used for five to seven days. Amoxicillin, ampicillin, and erythromycin may also be used for severe cases. Ceftriaxone (1 g IV every 24 hours for seven days) is also effective for severe leptospirosis. Cefotaxime (1 g IV every six hours for seven days) and doxycycline (200 mg initially followed by 100 mg IV every 12 hours for seven days) are equally effective as benzylpenicillin (1.5 million units IV every six hours for seven days). Therefore, there is no evidence on differences in death reduction when benzylpenicillin is compared with ceftriaxone or cefotaxime. Another study conducted in 2007 also showed no difference in efficacy between doxycycline (200 mg initially followed by 100 mg orally every 12 hours for seven days) or azithromycin (2 g on day one followed by 1 g daily for two more days) for suspected leptospirosis. There was no difference in the resolution of fever and azithromycin is better tolerated than doxycycline. Outpatients are given doxycycline or azithromycin. Doxycycline can shorten the duration of leptospirosis by two days, improve symptoms, and prevent the shedding of organisms in their urine. Azithromycin and amoxicillin are given to pregnant women and children. Rarely, a Jarisch–Herxheimer reaction can develop in the first few hours after antibiotic administration. However, according to a meta-analysis done in 2012, the benefit of antibiotics in the treatment of leptospirosis was unclear although the use of antibiotics may reduce the duration of illness by two to four days. Another meta-analysis done in 2013 reached a similar conclusion. For those with severe leptospirosis, including potassium wasting with high kidney output dysfunction, intravenous hydration and potassium supplements can prevent dehydration and hypokalemia . When acute kidney failure occurs, early initiation of haemodialysis or peritoneal dialysis can help to improve survival. For those with respiratory failure, tracheal intubation with low tidal volume improves survival rates. Corticosteroids have been proposed to suppress inflammation in leptospirosis because Leptospira infection can induce the release of chemical signals which promote inflammation of blood vessels in the lungs. However, there is insufficient evidence to determine whether the use of corticosteroids is beneficial. The overall risk of death for leptospirosis is 5–10%. For those with jaundice, the case fatality can increase up to 15%. For those infected who present with confusion and neurological signs, there is a high risk of death. Other factors that increase the risk of death include reduced urine output, age more than 36 years, and respiratory failure. With proper care, most of those infected will recover completely. Those with acute kidney failure may develop persistent mild kidney impairment after they recover. In those with severe lung involvement, the risk of death is 50–70%. Thirty percent of people with acute leptospirosis complained of long-lasting symptoms characterised by weakness, muscle pain, and headaches. Eye problems can occur in 10% of those who recovered from leptospirosis in the range from two weeks to a few years post-infection. Most commonly, eye complications can occur at six months after the infection. This is due to the immune privilege of the eye which protects it from immunological damage during the initial phase of leptospiral infection. These complications can range from mild anterior uveitis to severe panuveitis (which involves all three vascular layers of the eye). The uveitis is more commonly happen in young to middle-aged males and those working in agricultural farming. In up to 80% of those infected, Leptospira DNA can be found in the aqueous humour of the eye. Eye problems usually have a good prognosis following treatment or they are self-limiting. In anterior uveitis, only topical steroids and mydriatics (an agent that causes dilation of the pupil) are needed while in panuveitis, it requires periocular corticosteroids. Leptospiral uveitis is characterised by hypopyon , rapidly maturing cataract , free floating vitreous membranes, disc hyperemia and retinal vasculitis . Eye problems can occur in 10% of those who recovered from leptospirosis in the range from two weeks to a few years post-infection. Most commonly, eye complications can occur at six months after the infection. This is due to the immune privilege of the eye which protects it from immunological damage during the initial phase of leptospiral infection. These complications can range from mild anterior uveitis to severe panuveitis (which involves all three vascular layers of the eye). The uveitis is more commonly happen in young to middle-aged males and those working in agricultural farming. In up to 80% of those infected, Leptospira DNA can be found in the aqueous humour of the eye. Eye problems usually have a good prognosis following treatment or they are self-limiting. In anterior uveitis, only topical steroids and mydriatics (an agent that causes dilation of the pupil) are needed while in panuveitis, it requires periocular corticosteroids. Leptospiral uveitis is characterised by hypopyon , rapidly maturing cataract , free floating vitreous membranes, disc hyperemia and retinal vasculitis . It is estimated that one million severe cases of leptospirosis occur annually, with 58,900 deaths. Severe cases account for 5–15% of all leptospirosis cases. Leptospirosis is found in both urban and rural areas in tropical , subtropical , and temperate regions. The global health burden for leptospirosis can be measured by disability-adjusted life year (DALY). The score is 42 per 100,000 people per year, which is more than other diseases such as rabies and filariasis . The disease is observed persistently in parts of Asia, Oceania, the Caribbean, Latin America and Africa. Antarctica is the only place not affected by leptospirosis. In the United States, there were 100 to 150 leptospirosis cases annually. In 1994, leptospirosis ceased to be a notifiable disease in the United States except in 36 states/territories where it is prevalent such as Hawaii, Texas, California, and Puerto Rico. About 50% of the reported cases occurred in Puerto Rico. In January 2013, leptospirosis was reinstated as a nationally notifiable disease in the United States. Research on epidemiology of leptospirosis in high-risk groups and risk factors is limited in India. The global rates of leptospirosis have been underestimated because most affected countries lack notification or notification is not mandatory. Distinguishing clinical signs of leptospirosis from other diseases and lack of laboratory diagnostic services are other problems. The socioeconomic status of many of the world's population is closely tied to malnutrition; subsequent lack of micronutrients may lead to increased risk of infection and death due to leptospirosis infection. Micronutrients such as iron , calcium , and magnesium represent important areas for future research. The disease was first described by Adolf Weil in 1886 when he reported an "acute infectious disease with enlargement of spleen, jaundice, and nephritis ." Before Weil's description, the disease was known as "rice field jaundice " in ancient Chinese text, "autumn fever", "seven-day fever", and " nanukayami fever" in Japan; in Europe and Australia, the disease was associated with certain occupations and given names such as "cane-cutter's disease", "swine-herd's disease", and " Schlammfieber " (mud fever). It has been known historically as "black jaundice", or "dairy farm fever" in New Zealand. Leptospirosis was postulated as the cause of an epidemic among Native Americans along the coast of what is now New England during 1616–1619. The disease was most likely brought to the New World by Europeans. Leptospira was first observed in 1907 in a post mortem kidney tissue slice by Arthur Stimson using silver deposition staining technique. He called the organism Spirocheta interrogans because the bacteria resembled a question mark. In 1908, a Japanese research group led by Ryukichi Inada and Yutaka Ito first identified this bacterium as the causative agent of leptospirosis and noted its presence in rats in 1916. Japanese coal mine workers frequently contracted leptospirosis. In Japan, the organism was named Spirocheta icterohaemorrhagiae . The Japanese group also experimented with the first leptospiral immunisation studies in guinea pigs. They demonstrated that by injecting the infected guinea pigs with sera from convalescent humans or goats, passive immunity could be provided to the guinea pigs. In 1917, the Japanese group discovered rats as the carriers of leptospirosis. Unaware of the Japanese group's work, two German groups independently and almost simultaneously published their first demonstration of transmitting leptospiral infection in guinea pigs in October 1915. They named the organism Spirochaeta nodosa and Spirochaeta Icterogenes respectively. Leptospirosis was subsequently recognised as a disease of all mammalian species. In 1933, Dutch workers reported the isolation of Leptospira canicola which specifically infects dogs. In 1940, the strain that specifically infects cattle was first reported in Russia. In 1942, soldiers at Fort Bragg , North Carolina , were recorded to have an infectious disease which caused a rash over their shinbones . This disease was later known to be caused by leptospirosis. By the 1950s, the number of serovars that infected various mammals had expanded significantly. In the 1980s, leptospirosis was recognised as a veterinary disease of major economic importance. In 1982, there were about 200 serovars of Leptospira available for classification. The International Committee on Systematic Bacteriology 's subcommittee on taxonomy of Leptospira proposed classifying these serovars into two big groups: L. interrogans containing pathogenic serovars and L. biflexa containing saprophytic serovars. In 1979, the leptospiral family of Leptospiraceae was proposed. In the same year, Leptospira illini was reclassified as the new genus Leptonema . In 2002, "Lepthangamushi syndrome" was coined to describe a series of overlapping symptoms of leptospirosis with Hantavirus hemorrhagic fever with renal syndrome , and scrub typhus caused by Orientia tsutsugamushi . In 2005, Leptospira parva was classified as Turneriella . With DNA-DNA hybridisation technology, L. interrogans was divided into seven species. More Leptospira species have been discovered since then. The WHO established the Leptospirosis Burden Epidemiology Reference Group (LERG) to review the latest disease epidemiological data of leptospirosis, formulate a disease transmission model, and identify gaps in knowledge and research. The first meeting was convened in 2009. In 2011, LERG estimated that the global yearly rate of leptospirosis is five to 14 cases per 100,000 population. Infected animals can have no, mild, or severe symptoms; the presenting symptoms may vary by the type of animal. In some animals the bacteria live in the reproductive tract, leading to transmission during mating. Animals also present with similar clinical features when compared to humans. Clinical signs can appear in 5–15 days in dogs. The incubation period can be prolonged in cats. Leptospirosis can cause abortions after 2–12 weeks in cattle, and 1–4 weeks of infection in pigs. The illness tends to be milder in reservoir hosts. The most commonly affected organs are the kidneys, liver, and reproductive system, but other organs can be affected. In dogs, the acute clinical signs include fever, loss of appetite , shivering, muscle pain, weakness, and urinary symptoms. Vomiting, diarrhea, and abdominal pain may also present. Petechiae and ecchymoses may be seen on mucous membranes. Bleeding from the lungs may also be seen in dogs. In chronic presentations, the affected dog may have no symptoms. In animals that have died of leptospirosis, their kidneys may be swollen with grey and white spots, mottling , or scarring. Their liver may be enlarged with areas of cell death . Petechiae and ecchymoses may be found in various organs. Inflammation of the blood vessels , inflammation of the heart, meningeal layers covering the brain and spinal cord, and uveitis are also possible. Equine recurrent uveitis (ERU) is the most common disease associated with Leptospira infection in horses in North America and may lead to blindness. ERU is an autoimmune disease involving antibodies against Leptospira proteins LruA and LruB cross-reacting with eye proteins. Live Leptospira can be recovered from the aqueous or vitreous fluid of many horses with Leptospira -associated ERU. Risk of death or disability in infected animals varies depending upon the species and age of the animals. In adult pigs and cattle, reproductive signs are the most common signs of leptospirosis. Up to 40% of cows may have a spontaneous abortion. Younger animals usually develop more severe disease. About 80% of dogs can survive with treatment, but the survival rate is reduced if the lungs are involved. ELISA and microscopic agglutination tests are most commonly used to diagnose leptospirosis in animals. The bacteria can be detected in blood, urine, and milk or liver, kidney, or other tissue samples by using immunofluorescence or immunohistochemical or polymerase chain reaction techniques. Silver staining or immunogold silver staining is used to detect Leptospira in tissue sections. The organisms stain poorly with Gram stain . Dark-field microscopy can be used to detect Leptospira in body fluids, but it is neither sensitive nor specific in detecting the organism. A positive culture for leptospirosis is definitive, but the availability is limited, and culture results can take 13–26 weeks for a result, limiting its utility. Paired acute and convalescent samples are preferred for serological diagnosis of leptospirosis in animals. A positive serological sample from an aborted fetus is also diagnostic of leptospirosis. Various antibiotics such as doxycycline, penicillins, dihydrostreptomycin , and streptomycin have been used to treat leptospirosis in animals. Fluid therapy, blood transfusion, and respiratory support may be required in severe disease. For horses with ERU, the primary treatment is with anti-inflammatory drugs. Leptospirosis vaccines are available for animals such as pigs, dogs, cattle, sheep, and goats. Vaccines for cattle usually contain Leptospira serovar Hardjo and Pomona, for dogs, the vaccines usually contain serovar Icterohaemorrhagiae and Canicola. Vaccines containing multiple serovars do not work for cattle as well as vaccines containing a single serovar, yet the multivalent vaccines continue to be sold. Isolation of infected animals and prophylactic antibiotics are also effective in preventing leptospirosis transmission between animals. Environmental control and sanitation also reduce transmission rates.

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Cambodian rock (1960s–1970s)

Electric guitar bass drums organ horns vocals Cambodian rock of the 1960s and 1970s was a thriving and prolific music scene based in Phnom Penh , Cambodia , in which musicians created a unique sound by combining traditional Cambodian music forms with rock and pop influences from records imported into the country from Latin America, Europe, and the United States. U.S. armed forces radio that had been broadcast to troops stationed nearby during the Vietnam War was also a primary influence. This music scene was abruptly crushed by the Khmer Rouge communists in 1975, and many of its musicians disappeared or were executed during the ensuing Cambodian genocide . Due to its unique sounds and the tragic fate of many of its performers, the Cambodian rock scene has attracted the interest of music historians and record collectors, and the genre gained new popularity upon the international release of numerous compilation albums starting in the late 1990s.Cambodia gained independence from France in 1953, under the leadership of young king Norodom Sihanouk . Sihanouk was a musician and songwriter, and fostered the development of homegrown popular music in the newly independent country. Under Sihanouk's rule, it was common for government ministries to have their own orchestras or singing groups to perform at official state functions and royal receptions. For example, Sihanouk's mother, Queen Sisowath Kossamak , sponsored the Vong Phleng Preah Reach Troap (the classical ensemble of the Royal Treasury), and in approximately 1957 invited the young Sinn Sisamouth to join the ensemble as his first professional music job. Cambodia's international relations with France and various countries in Latin America fostered the importation of pop records into the country, while children from wealthy Cambodian families often attended school in France and returned with French pop records that were widely traded among fans in Phnom Penh . French pop singers Sylvie Vartan and Johnny Hallyday were particularly popular. Latin jazz , cha cha cha , and À gogo records imported from Latin America also became popular in the capital city. By the late 1950s, these genres inspired a flourishing pop music scene in Phnom Penh, featuring singers who created a unique sound by combining traditional Cambodian music forms with these new international influences. Sinn Sisamouth , Mao Sareth , So Savoeun , Chhuon Malay, Sieng Di, and Sos Math were among the earliest stars in this pop scene, with Sisamouth in particular becoming a leader of popular trends in which Cambodian musicians absorbed more international influences, eventually leading to the development of Cambodian rock music. By 1959, American and British pop and early rock and roll records began to appear in Cambodia, inspiring teenage fans in particular. That year, teen brothers Mol Kagnol and Mol Kamach formed Baksey Cham Krong , widely considered to be Cambodia's first rock band. The band originally performed crooning vocal music inspired by Paul Anka and Pat Boone , then added inspiration from the guitar-driven music of The Ventures and Chuck Berry . They likened themselves to Cliff Richard and The Shadows , and modeled their stage presence after Richard's 1961 movie The Young Ones . Baksey Cham Krong exerted a wide influence on the Cambodian rock and pop scene, and their popularity inspired older singers like Sinn Sisamouth to add rock songs to their repertoires. Many later Cambodian rock musicians cited the band as a formative influence. By the mid-1960s, Sinn Sisamouth had become Cambodia's most well-known pop music performer, and his music increasingly incorporated rock influences, including psychedelic rock and garage rock . By this time, the Cambodian music scene was further influenced by Western rock and soul music via U.S. armed forces radio that had been broadcast to troops stationed nearby during the Vietnam War . Sisamouth fostered the careers of younger singers and musicians, writing songs for them while also utilizing them in many of his own songs. Pen Ran (also known as Pan Ron) was one of the earliest rock-oriented female singers in the Cambodian scene, first emerging in 1963 with traditional pop songs but moving into rock music by 1966 via duets with Sisamouth as well as her own songs. Pen Ran was particularly influential, known for her flirtatious dancing and risque lyrics that subverted traditional Khmer gender roles. Sisamouth was also instrumental in launching the career of Ros Serey Sothea , who had been singing at weddings and quickly became the leading female singer in the Cambodian rock scene after her emergence in 1967. Sothea received wide recognition for her high and clear singing voice, and her ability to convey emotions from mischief and flirtation to heartbreak and tragedy. Sothea was also one of many female singers in the rock scene to utilize the traditional "ghost voice" Cambodian singing technique, featuring a high register with quick jumps among octaves, creating an effect that has been compared to yodeling . This was another factor in the genre's unique sound. Sothea maintained an active career with her own songs as well as many popular duets with Sisamouth. In a reflection of her popularity with the Cambodian people, Sothea was honored by Head of State Norodom Sihanouk with the royal title of Preah Reich Theany Somlang Meas , the "Queen with the Golden Voice". Sihanouk continued to support the Cambodian music scene through his patronage of the national radio station, allowing the station to promote local music. A regular rock music show hosted by DJ Huoy Meas was popular with teenagers and college students, making Meas a national celebrity. She became a popular singer as well, known particularly for highly personal lyrics that subverted the social expectations placed on Khmer women, and a melancholic voice that Sihanouk compared to Édith Piaf . The Cambodian rock scene was also notable for its prolific nature, with musicians recording large numbers of songs that were continuously released as singles. For example, Sinn Sisamouth is confirmed to have written more than one thousand songs, and the true total is likely to be much higher. Sisamouth, Ros Serey Sothea, Pen Ran and others also maintained separate music careers concurrently. Their rock n' roll records, which were popular with younger people, were released alongside works in other genres including traditional Cambodian music, romantic ballads, and film music , with those latter genres remaining popular with the country's older music fans. Ros Serey Sothea and Pen Ran are both believed to have sung on hundreds of songs, and Pen Ran wrote many of her songs herself. By 1969, Norodom Sihanouk had lost the support of many urban and educated Cambodians due to his inability to keep the hostilities of the Vietnam War from spilling across the country's borders. In March 1970, Sihanouk was deposed by the Cambodian National Assembly and replaced by military leader Lon Nol , thus forming the right-wing, pro-American Khmer Republic . Rock musicians in Phnom Penh generally favored the new Khmer Republic government and turned against Sihanouk, particularly after he attempted to maintain his support in Cambodia's rural countryside by aligning with the communist Khmer Rouge insurgents. Many singers, including Sinn Sisamouth, released patriotic songs and made public appearances to support the Khmer Republic military. Ros Serey Sothea released a song called "The Traitor" that directly criticized Sihanouk, her former patron. Sothea also directly participated in the Khmer Republic military; a film of her parachuting out of a plane during a paratrooper exercise is the only known video footage of her to have survived. The Khmer Republic 's increased relations with the United States, plus the prevalence of U.S. Armed Forces Radio that had been broadcast to troops in nearby South Vietnam and could be picked up in Phnom Penh, allowed new musical influences to infiltrate the Cambodian rock scene. This inspired a diversification in that scene's sounds, fashions, and lyrical content starting in about 1970. For example, singer/guitarist Yol Aularong was influenced by garage rock and specialized in sarcastic lyrics that poked fun at conservative Cambodian society. Aularong has been described as a " proto-punk " by the New York Times . Additional examples of this new wave of Cambodian rock musicians include Meas Samon , who combined the showmanship of a comedian with satirical lyrics and psychedelic rock sounds. Liev Tuk adopted American soul and funk , with a belting vocal style that has been compared to Wilson Pickett and James Brown . Pou Vannary , unusually for a female singer in the genre, was also an instrumentalist who could accompany herself on acoustic guitar in the mode of an American singer-songwriter, displaying a vocal style that was much more relaxed and intimate than her contemporaries. The self-contained band Drakkar played hard rock music that has been compared to Santana and Led Zeppelin . These musicians also adopted hippie hairstyles and fashions, as further indicators of American influence in Cambodia at the time. This latest wave of rock musicians, plus established stars like Sinn Sisamouth and Ros Serey Sothea, continued their music careers throughout the early 1970s. However, the Cambodian Civil War took its toll on the country, as did American bombing campaigns associated with the Vietnam War. Due to wartime curfews, musicians often had to play in clubs during the day and often heard nearby gunfire and explosions during their performances. The Cambodian rock scene persevered in this fashion until the fall of the Khmer Republic in April 1975.The Cambodian Civil War ended in April 1975 when the communist Khmer Rouge defeated the Khmer Republic and gained control of the country. The Khmer Rouge ordered the two million residents of Phnom Penh to evacuate the city and move to prison farms and labor camps, The city's musicians were included in this forced exodus. The Khmer Rouge regime, led by Pol Pot , wanted to return the nation of Cambodia to an idyllic notion of the past by implementing a radical form of agrarian socialism while simultaneously shunning outside aid and influence. In order to build and protect their utopian goals, the Khmer Rouge perceived enmity in anyone tied to the previous Cambodian governments, ethnic and religious minorities, intellectuals, and members of certain professions. In the ensuing Cambodian genocide , about 25 percent of the Cambodian population perished. More than half of those who died during the genocide are believed to have been directly executed. The rest died through forced labor, malnutrition, and disease due to the Khmer Rouge's cruelty and poor management of its utopian project. Musicians posed an apparent threat to the Khmer Rouge regime due to their influence on culture, incompatibility with an agrarian lifestyle, and foreign influences. Many of Cambodia's rock musicians disappeared during the genocide and their exact fates have never been confirmed. Due to these musicians' enduring popularity with the Cambodian people, reports differ on how some of them died. Sinn Sisamouth and Ros Serey Sothea are both believed to have been summarily executed by Khmer Rouge soldiers out of fear that their popularity could foment resistance among the population. However, these reports have never been confirmed. Meas Samon is believed to have been executed at a work site after refusing to stop playing music during breaks. Other musicians like Pen Ran, Yol Aularong, and Pou Vannary simply disappeared sometime between 1975 and 1979 with no information available about their fates, as is the case with most of the ordinary Cambodians who perished during the genocide. Some Cambodian rock musicians survived the genocide through various hardships. For example, Drakkar guitarist Touch Chhatha was among many professional musicians who were forced to play traditional and patriotic music every day to Khmer Rouge troops. Chhatha's bandmate Touch Seang Tana survived several years' imprisonment at a work camp by pretending to be a common peasant. During the Khmer Rouge takeover of Phnom Penh, singer Sieng Vannthy was confronted by insurgents who demanded to know her occupation. She lied and said she was a banana seller, which probably saved her life as the Khmer Rouge were already known to target musicians for imprisonment or execution. As with many other aspects of pre-Khmer Rouge Cambodian culture, much of the country's rock music and information about the musicians was lost during the chaos of the regime. In their attempt to "purify" Cambodian society and culture, Khmer Rouge soldiers were known to destroy records and master tapes containing any Western-influenced music genres, and often forced residents to burn their record collections. The only Cambodian rock records to survive were the few that citizens managed to hide in personal collections, and many of those were damaged to the point at which artist names or song titles had been lost. Therefore, except for fans' personal memories, much of the 1960s–1970s rock music of Cambodia was lost until it was slowly rediscovered starting in the 1990s. Relations between the Khmer Rouge regime and neighboring Vietnam collapsed in late 1978, igniting the Cambodian–Vietnamese War . Vietnam launched a full-scale military invasion of Cambodia in December 1978 and captured Phnom Penh the following month, thus ending the Khmer Rouge regime and the Cambodian genocide. Vietnamese forces sent the Khmer Rouge into exile in Thailand and installed Heng Samrin as the new leader of the restored Cambodia. Residents who had been exiled to farm camps and other Khmer Rouge installations were invited to return to Phnom Penh. Singer Sieng Vannthy, who had survived the genocide, was invited to make an announcement on Cambodia's national radio station that residents were welcome to return to the city. Those who did not return were considered dead, including musicians. After the fall of the Khmer Rouge, surviving Cambodian rock musicians regrouped and attempted to locate missing colleagues. Many musicians contacted Ros Saboeut , older sister of Ros Serey Sothea, to inquire about Sothea's fate. Sothea did not survive the genocide but Saboeut took the opportunity to reunite Cambodia's surviving rock musicians, maintaining a list of contacts. Saboeut's efforts are widely credited with reviving Cambodian popular music in the aftermath of the genocide. According to Youk Chhang, the executive director of the Documentation Center of Cambodia, Saboeut sought to restore Cambodian music as a tribute to her sister, saying "I think she was bound by the legacy of her sister to help." As with all other aspects of Cambodian society and culture, the country's music scene faced a tough but relatively fast recovery. The post-Khmer Rouge government made specific moves to re-establish the country's radio industry, allowing surviving singers and musicians to resume their careers by creating new entertainment content. For example, Drakkar drummer Ouk Sam Art and guitarist Touch Chhatha were able to return to music work at Cambodia's national radio station. [ better source needed ] The Cambodian music scene moved on to more modern pop forms, consigning the country's 1960s–1970s rock music to the memories of older fans who had survived the genocide. In the ensuing years, fans of Cambodian rock music found and reproduced the few records and master tapes that survived the chaos of the Khmer Rouge regime. A black market in remixed and reprinted works by popular but now-deceased (and some still-living) musicians developed, with little regard for intellectual property rights, which were not enforced in Cambodia until 2003. Black marketeers were known to remix songs by artists like Ros Serey Sothea and Pen Ran to make them more dance-able for current music fans, often with unknown musicians adding stronger drum beats and other effects; some songs were also artificially sped up so more could be squeezed onto inexpensive cassettes to be sold on the street. This unauthorized marketplace allowed Cambodian rock songs to remain popular well into the 1990s; original and authentic master recordings are highly sought by collectors and preservationists, though few are known to have survived the Khmer Rouge regime. The Cambodian rock genre of the 1960s–1970s remained largely unknown to the outside world until the late 1990s. While on a tourist trip to Cambodia in 1994, American Paul Wheeler became interested in music he had been hearing around Siem Reap . He purchased some unmarked cassettes from a market vendor and assembled a mixtape of his favorite tracks. The Parallel World label, upon hearing Wheeler's mixtape, assembled the 13-track compilation album Cambodian Rocks and released 1,000 copies on vinyl in 1996. When those sold out, the label issued the much more widely known CD version with 22 tracks. Wheeler made no effort to discover the song titles or the names of the artists, and Cambodian Rocks was released with no supporting information, thus giving it the appearance of a bootleg . In the years since the CD's release, interested listeners have collaborated on the Internet to confirm the artist names and song titles, discovering that ten of the album's 22 songs were by Ros Serey Sothea, with other tracks by Sinn Sisamouth, Pen Ran, Yol Aularong, Meas Samon, and Liev Tuk. Cambodian Rocks was widely praised by the Western rock community. Rolling Stone called it "a marvel of cultural appropriation," and Far East Audio called it an "instant classic." Further illustrating the unique nature of the music to Western ears, writer Nick Hanover called the album "a continuous surprise, a fusion of elements that should be contradictory but somehow strike a balance of West and East." The New York Times said the album and the circumstances of its release "established a lasting aura of mystery around the music." Cambodian Rocks was the first release of its kind, followed by a number of similar compilations like Cambodian Cassette Archives and others with similar titles. The 2002 film City of Ghosts , a crime thriller that takes place in Cambodia, featured songs by Sinn Sisamouth, Pen Ran, Ros Serey Sothea, Meas Samon, and Chhuon Malay on its soundtrack. American filmmaker John Pirozzi, a production assistant for City of Ghosts , was given a copy of Cambodian Rocks while working in the country and decided to research the musicians on the album and their fates at the hands of the Khmer Rouge. His research ultimately resulted in the 2015 film Don't Think I've Forgotten , which was named after a Sinn Sisamouth song. Pirozzi's first film project on Cambodian rock music was the 2009 documentary Sleepwalking Through the Mekong that covered a 2005 Cambodian tour by the band Dengue Fever . The film finds that the 1960s–1970s Cambodian rock music played by the band was still popular with the country's people, and fans were interested in seeing a mostly American band perform the songs. Dengue Fever also released a charity compilation of 1960s–1970s Cambodian rock songs called Electric Cambodia in 2010. After ten years of research in conjunction with Cambodian-born artist and sociology professor LinDa Saphan , Pirozzi completed the documentary Don't Think I've Forgotten in 2015, featuring in-depth profiles of many of the Cambodian rock scene's most influential performers. The film received almost universally positive reviews, further igniting worldwide interest in the Cambodian rock music scene. The film's international release inspired reunion concerts by surviving members of Drakkar, and concerts celebrating the legacy of Sinn Sisamouth and his contemporaries. The film's soundtrack album contained many professionally restored songs that had not been available on other compilations, including some by rarely compiled artists like Baksey Cham Krong, Pou Vannary, Huoy Meas, and Sieng Vannthy. The Cambodian Rocks album and similar compilations are believed to have inspired the formation of several modern bands who perform cover versions of original Cambodian rock songs and create new music based on that genre. For example, in the late 1990s American rock keyboardist Ethan Holtzman discovered the genre while traveling in Cambodia, and his guitarist brother Zac Holtzman had coincidentally discovered the same music while working at a California record store. In 2001, the brothers formed the band Dengue Fever with Cambodian-born Chhom Nimol , who had previously been a well-known singer in her native country before emigrating to the United States. Dengue Fever first performed covers of original Cambodian rock songs discovered by the Holtzman brothers, but have since released several albums of original material inspired by the genre. Meanwhile, the band Cambodian Space Project was formed in 2009 in Cambodia by singer Kak Channthy and Australian enthusiast Julien Poulson; that band released five albums of covers of 1960s–1970s Cambodian rock songs and original songs inspired by the genre. Cambodian Space Project disbanded in March 2018 when Channthy was killed in a car accident. The Cambodian rock scene of the 1960s–1970s has also become a matter of interest to record collectors around the world, while specialists like Dust-to-Digital have embarked on projects to locate and restore surviving records. In addition to enthusiasts like Dengue Fever, other western musicians have become fans of the genre. One example is hip-hop songwriter/producer Danger Mouse , who noted "There were these groups... who took Beatles songs and whatever else, put their own lyrics in and called it whatever they wanted to. [...] It sounds like nothing you've ever heard." Cambodian-American singer Bochan Huy is one of a new generation of musicians from that culture who are revisiting 1960s–1970s Cambodian rock with the goal of preserving the music and addressing its troubled history. Singer-songwriter Sin Setsochhata, a granddaughter of Sinn Sisamouth, has gained international notice for combining Cambodian rock influences with modern pop sounds. Cambodian rapper VannDa regularly references the country's 1960s–1970s rock musicians in his lyrics. The 2018 off-Broadway musical Cambodian Rock Band by Lauren Yee is inspired by the genre and its historical backdrop. The Cambodian rock scene of the 1960s–1970s was very robust, with hundreds of active performers. Information on many of them remains lost after the chaos of the Khmer Rouge regime, while some others remain to be discovered by Western journalists and enthusiasts. The list below includes those musicians whose works have become available in the West. Baksey Cham Krong Chhun Vanna Chhuon Malay Dara Jamchan Drakkar Eng Nary Huoy Meas Im Song Seum Sieng Di Sieng Vannthy Sinn Sisamouth So Savoeun Sos Math Voa Saroun Yol Aularong

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Myalgia

Myalgia is the medical term for muscle pain . Myalgia is a symptom of many diseases . The most common cause of acute myalgia is the overuse of a muscle or group of muscles ; another likely cause is viral infection , especially when there has been no trauma . Long-lasting myalgia can be caused by metabolic myopathy , some nutritional deficiencies , chronic fatigue syndrome , fibromyalgia , and amplified musculoskeletal pain syndrome .The most common causes of myalgia are overuse , injury , and strain . Myalgia might also be caused by allergies, diseases, medications, or as a response to a vaccination . Dehydration at times results in muscle pain as well, especially for people involved in extensive physical activities such as workout . Muscle pain is also a common symptom in a variety of diseases, including infectious diseases, such as influenza, muscle abscesses, Lyme disease, malaria, trichinosis or poliomyelitis; autoimmune diseases, such as celiac disease, systemic lupus erythematosus, Sjögren's syndrome or polymyositis; gastrointestinal diseases , such as non-celiac gluten sensitivity (which can also occur without digestive symptoms) and inflammatory bowel disease (including Crohn's disease and ulcerative colitis). The most common causes are: [ citation needed ] Injury or trauma, including sprains, hematoma Overuse: using a muscle too much, too often, including protecting a separate injury Chronic tension Muscle pain occurs with: Overuse of a muscle is using it too much, too soon or too often. One example is repetitive strain injury . See also: The most common causes of myalgia by injury are: sprains and strains . Sudden cessation of high-dose corticosteroids , opioids , barbiturates , benzodiazepines , caffeine , or alcohol can induce myalgia. [ citation needed ]Overuse of a muscle is using it too much, too soon or too often. One example is repetitive strain injury . See also: The most common causes of myalgia by injury are: sprains and strains . The most common causes of myalgia by injury are: sprains and strains . Sudden cessation of high-dose corticosteroids , opioids , barbiturates , benzodiazepines , caffeine , or alcohol can induce myalgia. [ citation needed ]When the cause of myalgia is unknown, it should be treated symptomatically. Common treatments include heat , rest, paracetamol , NSAIDs , massage , cryotherapy and muscle relaxants .

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Himalayas

The Himalayas , or Himalaya ( / ˌ h ɪ m ə ˈ l eɪ . ə , h ɪ ˈ m ɑː l ə j ə / HIM -ə- LAY -ə, hih- MAH -lə-yə ) [lower-alpha 2] is a mountain range in Asia, separating the plains of the Indian subcontinent from the Tibetan Plateau . The range has some of the Earth 's highest peaks, including the highest, Mount Everest ; more than 100 peaks exceeding elevations of 7,200 m (23,600 ft) above sea level lie in the Himalayas. The Himalayas abut or cross five countries : Nepal , China , Pakistan , Bhutan and India . The sovereignty of the range in the Kashmir region is disputed among India, Pakistan , and China. The Himalayan range is bordered on the northwest by the Karakoram and Hindu Kush ranges, on the north by the Tibetan Plateau, and on the south by the Indo-Gangetic Plain . Some of the world's major rivers , the Indus , the Ganges , and the Tsangpo – Brahmaputra , rise in the vicinity of the Himalayas, and their combined drainage basin is home to some 600 million people; 53 million people live in the Himalayas. The Himalayas have profoundly shaped the cultures of South Asia and Tibet . Many Himalayan peaks are sacred in Hinduism and Buddhism . The summits of several — Kangchenjunga (from the Indian side), Gangkhar Puensum , Machapuchare , Nanda Devi , and Kailash in the Tibetan Transhimalaya — are off-limits to climbers. Lifted by the subduction of the Indian tectonic plate under the Eurasian Plate , the Himalayan mountain range runs west-northwest to east-southeast in an arc 2,400 km (1,500 mi) long. Its western anchor, Nanga Parbat , lies just south of the northernmost bend of the Indus river. Its eastern anchor, Namcha Barwa , lies immediately west of the great bend of the Yarlung Tsangpo River . The range varies in width from 350 km (220 mi) in the west to 150 km (93 mi) in the east. The name of the range hails from the Sanskrit Himālaya ( हिमालय 'abode of snow' ), from hima ( हिम 'frost/cold' ) and ālaya ( आलय 'dwelling/house' ). They are now known as " the Himalaya Mountains ", usually shortened to "the Himalayas". The mountains are known as the Himālaya in Nepali and Hindi (both written हिमालय ), Himāl (हिमाल) in Kumaoni , the Himalaya ( ཧི་མ་ལ་ཡ་ ) or 'The Land of Snow' ( གངས་འན་ལྗོངས་ ) in Tibetan , also known as Himālaya in Sinhala (written as හිමාලය ), the Himāliya Mountain Range ( سلسلہ کوہ ہ٠الیہ ) in Urdu , the Himaloy Parvatmala ( হিমালয় পর্বতমালা ) in Bengali , and the Ximalaya Mountain Range ( simplified Chinese : å–œé©¬æ‹‰é› å±±è„‰ ; traditional Chinese : å–œé¦¬æ‹‰é› å±±è„‰ ; pinyin : Xǐmǎlāyǎ Shānmà i ) in Chinese . The name of the range is sometimes also given as Himavan in older writings, including the Sanskrit epic Mahabharata . Himavat ( Sanskrit : हिमवत् ) or Himavan Himavān ( Sanskrit : हिमवान्) is a Hindu deity who is the personification of the Himalayan Mountain Range. Other epithets include Himaraja ( Sanskrit : हिमराज, lit. ' king of snow ' ) or Parvateshwara ( Sanskrit : पर्वतेश्वर, lit. ' lord of mountains ' ). In western literature, some writers refer to it as the Himalaya . This was also previously transcribed as Himmaleh , as in Emily Dickinson 's poetry and Henry David Thoreau 's essays. The Himalayas consists of four parallel mountain ranges from south to north: the Sivalik Hills on the south; the Lower Himalayan Range ; the Great Himalayas , which is the highest and central range; and the Tibetan Himalayas on the north. The Karakoram are generally considered separate from the Himalayas. In the middle of the great curve of the Himalayan mountains lie the 8,000 m (26,000 ft) peaks of Dhaulagiri and Annapurna in Nepal , separated by the Kali Gandaki Gorge . The gorge splits the Himalayas into Western and Eastern sections, both ecologically and orographically – the pass at the head of the Kali Gandaki, the Kora La , is the lowest point on the ridgeline between Everest and K2 (the highest peak of the Karakoram range). To the east of Annapurna are the 8,000 m (5.0 mi) peaks of Manaslu and across the border in Tibet, Shishapangma . To the south of these lies Kathmandu , the capital of Nepal and the largest city in the Himalayas. East of the Kathmandu Valley lies the valley of the Bhote/ Sun Kosi river which rises in Tibet and provides the main overland route between Nepal and China – the Araniko Highway / China National Highway 318 . Further east is the Mahalangur Himal with four of the world's six highest mountains, including the highest: Cho Oyu , Everest , Lhotse , and Makalu . The Khumbu region, popular for trekking, is found here on the south-western approaches to Everest. The Arun river drains the northern slopes of these mountains, before turning south and flowing to the range to the east of Makalu. In the far east of Nepal, the Himalayas rise to the Kangchenjunga massif on the border with India, the third-highest mountain in the world, the most easterly 8,000 m (26,000 ft) summit and the highest point of India . The eastern side of Kangchenjunga is in the Indian state of Sikkim . Formerly an independent Kingdom, it lies on the main route from India to Lhasa , Tibet, which passes over the Nathu La pass into Tibet. East of Sikkim lies the ancient Buddhist Kingdom of Bhutan . The highest mountain in Bhutan is Gangkhar Puensum , which is also a strong candidate for the highest unclimbed mountain in the world. The Himalayas here are becoming increasingly rugged, with heavily forested steep valleys. The Himalayas continue, turning slightly northeast, through the Indian State of Arunachal Pradesh as well as Tibet, before reaching their easterly conclusion in the peak of Namche Barwa , situated in Tibet, inside the great bend of the Yarlang Tsangpo river. On the other side of the Tsangpo, to the east, are the Kangri Garpo mountains. The high mountains to the north of the Tsangpo, including Gyala Peri , however, are also sometimes included in the Himalayas. Going west from Dhaulagiri, Western Nepal is somewhat remote and lacks major high mountains, but is home to Rara Lake , the largest lake in Nepal. The Karnali River rises in Tibet but cuts through the centre of the region. Further west, the border with India follows the Sarda River and provides a trade route into China, where on the Tibetan plateau lies the high peak of Gurla Mandhata . Just across Lake Manasarovar from this lies the sacred Mount Kailash in the Kailash Ranges , which stands close to the source of the four main rivers of Himalayas and is revered in Hinduism, Jainism , Buddhism , Sufism and Bonpo. In Uttarakhand , the Himalayas are regionally divided into the Kumaon and Garhwal Himalayas with the high peaks of Nanda Devi and Kamet . The state is also home to the important pilgrimage destinations of Chota Chaar Dhaam , with Gangotri , the source of the holy river Ganges , Yamunotri , the source of the river Yamuna , and the temples at Badrinath and Kedarnath . The next Himalayan Indian state, Himachal Pradesh , is noted for its hill stations, particularly Shimla , the summer capital of the British Raj , and Dharamsala , the centre of the Tibetan community and government in exile in India. This area marks the start of the Punjab Himalaya and the Sutlej river , the most easterly of the five tributaries of the Indus , cuts through the range here. Further west, the Himalayas form much of the disputed Indian-administered union territory of Jammu and Kashmir where lie the mountainous Jammu region and the renowned Kashmir Valley with the town and lakes of Srinagar . The Himalayas form most of the south-west portion of the disputed Indian-administered union territory of Ladakh . The twin peaks of Nun Kun are the only mountains over 7,000 m (4.3 mi) in this part of the Himalayas. Finally, the Himalayas reach their western end in the dramatic 8000 m peak of Nanga Parbat , which rises over 8,000 m (26,000 ft) above the Indus valley and is the most westerly of the 8000 m summits. The western end terminates at a magnificent point near Nanga Parbat where the Himalayas intersect with the Karakoram and Hindu Kush ranges, in the disputed Pakistani-administered territory of Gilgit-Baltistan . Some portion of the Himalayas, such as the Kaghan Valley , Margalla Hills , and Galyat tract, extend into the Pakistani provinces of Khyber Pakhtunkhwa and Punjab .The Himalayan range is one of the youngest mountain ranges on the planet and consists mostly of uplifted sedimentary and metamorphic rock . According to the modern theory of plate tectonics , its formation is a result of a continental collision or orogeny along the convergent boundary ( Main Himalayan Thrust ) between the Indo-Australian Plate and the Eurasian Plate . The Arakan Yoma highlands in Myanmar and the Andaman and Nicobar Islands in the Bay of Bengal were also formed as a result of this collision. During the Upper Cretaceous , about 70 million years ago, the north-moving Indo-Australian Plate (which has subsequently broken into the Indian Plate and the Australian Plate ) was moving at about 15 cm (5.9 in) per year. About 50 million years ago this fast-moving Indo-Australian Plate had completely closed the Tethys Ocean , the existence of which has been determined by sedimentary rocks settled on the ocean floor and the volcanoes that fringed its edges. Since both plates were composed of low density continental crust , they were thrust faulted and folded into mountain ranges rather than subducting into the mantle along an oceanic trench . An often-cited fact used to illustrate this process is that the summit of Mount Everest is made of unmetamorphosed marine Ordovician limestone with fossil trilobites , crinoids , and ostracods from this ancient ocean. Today, the Indian plate continues to be driven horizontally at the Tibetan Plateau, which forces the plateau to continue to move upwards. The Indian plate is still moving at 67 mm (2.6 in) per year, and over the next 10 million years, it will travel about 1,500 km (930 mi) into Asia. About 20 mm per year of the India-Asia convergence is absorbed by thrusting along the Himalaya southern front . This leads to the Himalayas rising by about 5 mm per year, making them geologically active. The movement of the Indian plate into the Asian plate also makes this region seismically active, leading to earthquakes from time to time. During the last ice age , there was a connected ice stream of glaciers between Kangchenjunga in the east and Nanga Parbat in the west. In the west, the glaciers joined with the ice stream network in the Karakoram , and in the north, they joined with the former Tibetan inland ice. To the south, outflow glaciers came to an end below an elevation of 1,000–2,000 m (3,300–6,600 ft) . While the current valley glaciers of the Himalaya reach at most 20 to 32 km (12 to 20 mi) in length, several of the main valley glaciers were 60 to 112 km (37 to 70 mi) long during the ice age. The glacier snowline (the altitude where accumulation and ablation of a glacier are balanced) was about 1,400–1,660 m (4,590–5,450 ft) lower than it is today. Thus, the climate was at least 7.0 to 8.3 °C (12.6 to 14.9 °F) colder than it is today. Despite their scale, the Himalayas do not form a major continental divide , and a number of rivers cut through the range, particularly in the eastern part of the range. As a result, the main ridge of the Himalayas is not clearly defined, and mountain passes are not as significant for traversing the range as with other mountain ranges. Himalayas' rivers drain into two large systems: The northern slopes of Gyala Peri and the peaks beyond the Tsangpo , sometimes included in the Himalayas, drain into the Irrawaddy River , which originates in eastern Tibet and flows south through Myanmar to drain into the Andaman Sea . The Salween , Mekong , Yangtze , and Yellow River all originate from parts of the Tibetan Plateau that are geologically distinct from the Himalaya mountains and are therefore not considered true Himalayan rivers. Some geologists refer to all the rivers collectively as the circum-Himalayan rivers . The great ranges of central Asia, including the Himalayas, contain the third-largest deposit of ice and snow in the world, after Antarctica and the Arctic . Some even refer to this region as the "Third Pole". The Himalayan range encompasses about 15,000 glaciers, which store about 12,000 km 3 (2,900 cu mi) , or 3600–4400 Gt (10 12 kg) of fresh water. Its glaciers include the Gangotri and Yamunotri ( Uttarakhand ) and Khumbu glaciers ( Mount Everest region), Langtang glacier ( Langtang region), and Zemu ( Sikkim ). Owing to the mountains' latitude near the Tropic of Cancer , the permanent snow line is among the highest in the world, at typically around 5,500 m (18,000 ft) . In contrast, equatorial mountains in New Guinea , the Rwenzoris , and Colombia have a snow line some 900 m (2,950 ft) lower. The higher regions of the Himalayas are snowbound throughout the year, in spite of their proximity to the tropics, and they form the sources of several large perennial rivers . In recent years, scientists have monitored a notable increase in the rate of glacier retreat across the region as a result of climate change. For example, glacial lakes have been forming rapidly on the surface of debris-covered glaciers in the Bhutan Himalaya during the last few decades. Studies have measured an approximately 13% overall decrease in glacial coverage in the Himalayas over the last 40–50 years. Local conditions play a large role in glacial retreat, however, and glacial loss can vary locally from a few m/yr to 61 m/yr. A marked acceleration in glacial mass loss has also been observed since 1975, from about 5–13 Gt/yr to 16–24 Gt/yr. Although the effect of this will not be known for many years, it potentially could mean disaster for the hundreds of millions of people who rely on the glaciers to feed the rivers during the dry seasons. The global climate change will affect the water resources and livelihoods of the Greater Himalayan region. The Himalayan region is dotted with hundreds of lakes. Pangong Tso , which is spread across the border between India and China, at the far western end of Tibet, is among the largest with a surface area of 700 km 2 (270 sq mi) . South of the main range, the lakes are smaller. Tilicho Lake in Nepal, in the Annapurna massif, is one of the highest lakes in the world. Other lakes include Rara Lake in western Nepal, She-Phoksundo Lake in the Shey Phoksundo National Park of Nepal, Gurudongmar Lake , in North Sikkim , Gokyo Lakes in Solukhumbu district of Nepal , and Lake Tsongmo , near the Indo-China border in Sikkim. Some of the lakes present the danger of a glacial lake outburst flood . The Tsho Rolpa glacier lake in the Rowaling Valley , in the Dolakha District of Nepal, is rated as the most dangerous. The lake, which is located at an altitude of 4,580 m (15,030 ft) , has grown considerably over the last 50 years due to glacial melting. The mountain lakes are known to geographers as tarns if they are caused by glacial activity. Tarns are found mostly in the upper reaches of the Himalaya, above 5,500 m (18,000 ft) . Temperate Himalayan wetlands provide important habitat and layover sites for migratory birds. Many mid and low altitude lakes remain poorly studied in terms of their hydrology and biodiversity, like Khecheopalri in the Sikkim Eastern Himalayas. The great ranges of central Asia, including the Himalayas, contain the third-largest deposit of ice and snow in the world, after Antarctica and the Arctic . Some even refer to this region as the "Third Pole". The Himalayan range encompasses about 15,000 glaciers, which store about 12,000 km 3 (2,900 cu mi) , or 3600–4400 Gt (10 12 kg) of fresh water. Its glaciers include the Gangotri and Yamunotri ( Uttarakhand ) and Khumbu glaciers ( Mount Everest region), Langtang glacier ( Langtang region), and Zemu ( Sikkim ). Owing to the mountains' latitude near the Tropic of Cancer , the permanent snow line is among the highest in the world, at typically around 5,500 m (18,000 ft) . In contrast, equatorial mountains in New Guinea , the Rwenzoris , and Colombia have a snow line some 900 m (2,950 ft) lower. The higher regions of the Himalayas are snowbound throughout the year, in spite of their proximity to the tropics, and they form the sources of several large perennial rivers . In recent years, scientists have monitored a notable increase in the rate of glacier retreat across the region as a result of climate change. For example, glacial lakes have been forming rapidly on the surface of debris-covered glaciers in the Bhutan Himalaya during the last few decades. Studies have measured an approximately 13% overall decrease in glacial coverage in the Himalayas over the last 40–50 years. Local conditions play a large role in glacial retreat, however, and glacial loss can vary locally from a few m/yr to 61 m/yr. A marked acceleration in glacial mass loss has also been observed since 1975, from about 5–13 Gt/yr to 16–24 Gt/yr. Although the effect of this will not be known for many years, it potentially could mean disaster for the hundreds of millions of people who rely on the glaciers to feed the rivers during the dry seasons. The global climate change will affect the water resources and livelihoods of the Greater Himalayan region. The Himalayan region is dotted with hundreds of lakes. Pangong Tso , which is spread across the border between India and China, at the far western end of Tibet, is among the largest with a surface area of 700 km 2 (270 sq mi) . South of the main range, the lakes are smaller. Tilicho Lake in Nepal, in the Annapurna massif, is one of the highest lakes in the world. Other lakes include Rara Lake in western Nepal, She-Phoksundo Lake in the Shey Phoksundo National Park of Nepal, Gurudongmar Lake , in North Sikkim , Gokyo Lakes in Solukhumbu district of Nepal , and Lake Tsongmo , near the Indo-China border in Sikkim. Some of the lakes present the danger of a glacial lake outburst flood . The Tsho Rolpa glacier lake in the Rowaling Valley , in the Dolakha District of Nepal, is rated as the most dangerous. The lake, which is located at an altitude of 4,580 m (15,030 ft) , has grown considerably over the last 50 years due to glacial melting. The mountain lakes are known to geographers as tarns if they are caused by glacial activity. Tarns are found mostly in the upper reaches of the Himalaya, above 5,500 m (18,000 ft) . Temperate Himalayan wetlands provide important habitat and layover sites for migratory birds. Many mid and low altitude lakes remain poorly studied in terms of their hydrology and biodiversity, like Khecheopalri in the Sikkim Eastern Himalayas. The physical factors determining the climate in any location in the Himalayas include latitude, altitude, and the relative motion of the Southwest monsoon . From north to south, the mountains cover more than eight degrees of latitude, spanning temperate to subtropical zones. The colder air of Central Asia is prevented from blowing down into South Asia by the physical configuration of the Himalayas. This causes the tropical zone to extend farther north in South Asia than anywhere else in the world. The evidence is unmistakable in the Brahmaputra valley as the warm air from the Bay of Bengal bottlenecks and rushes up past Namcha Barwa , the eastern anchor of the Himalayas, and into southeastern Tibet. Temperatures in the Himalayas cool by 2.0 degrees C (3.6 degrees F) for every 300 metres (980 ft) increase of altitude. As the physical features of mountains are irregular, with broken jagged contours, there can be wide variations in temperature over short distances. Temperature at a location on a mountain depends on the season of the year, the bearing of the sun with respect to the face on which the location lies, and the mass of the mountain, i.e. the amount of matter in the mountain. As the temperature is directly proportional to received radiation from the sun, the faces that receive more direct sunlight also have a greater heat buildup. In narrow valleys — lying between steep mountain faces — there can be dramatically different weather along their two margins. The side to the north with a mountain above facing south can have an extra month of the growing season. The mass of the mountain also influences the temperature, as it acts as a heat island , in which more heat is absorbed and retained than the surroundings, and therefore influences the heat budget or the amount of heat needed to raise the temperature from the winter minimum to the summer maximum. The immense scale of the Himalayas means that many summits can create their own weather, the temperature fluctuating from one summit to another, from one face to another, and all may be quite different from the weather in nearby plateaus or valleys. A critical influence on the Himalayan climate is the Southwest Monsoon . This is not so much the rain of the summer months as the wind that carries the rain. Different rates of heating and cooling between the Central Asian continent and the Indian Ocean create large differences in the atmospheric pressure prevailing above each. In the winter, a high-pressure system forms and remains suspended above Central Asia, forcing air to flow in the southerly direction over the Himalayas. But in Central Asia, as there is no substantial source for water to be diffused as vapour, the winter winds blowing across South Asia are dry. In the summer months, the Central Asian plateau heats up more than the ocean waters to its south. As a result, the air above it rises higher and higher, creating a thermal low . Off-shore high-pressure systems in the Indian Ocean push the moist summer air inland toward the low-pressure system. When the moist air meets mountains, it rises and upon subsequent cooling, its moisture condenses and is released as rain, typically heavy rain. The wet summer monsoon winds cause precipitation in India and all along the layered southern slopes of the Himalayas. This forced lifting of air is called the orographic effect . The vast size, huge altitude range, and complex topography of the Himalayas mean they experience a wide range of climates, from humid subtropical in the foothills, to cold and dry desert conditions on the Tibetan side of the range. For much of the Himalayas—in the areas to the south of the high mountains, the monsoon is the most characteristic feature of the climate and causes most of the precipitation, while the western disturbance brings winter precipitation, especially in the west. Heavy rain arrives on the southwest monsoon in June and persists until September. The monsoon can seriously impact transport and cause major landslides. It restricts tourism – the trekking and mountaineering season is limited to either before the monsoon in April/May or after the monsoon in October/November (autumn). In Nepal and Sikkim, there are often considered to be five seasons: summer, monsoon , autumn, (or post-monsoon), winter, and spring. Using the Köppen climate classification , the lower elevations of the Himalayas, reaching in mid-elevations in central Nepal (including the Kathmandu valley), are classified as Cwa , Humid subtropical climate with dry winters. Higher up, most of the Himalayas have a subtropical highland climate ( Cwb ) . [ citation needed ] The intensity of the southwest monsoon diminishes as it moves westward along the range, with as much as 2,030 mm (80 in) of rainfall in the monsoon season in Darjeeling in the east, compared to only 975 mm (38.4 in) during the same period in Shimla in the west. The northern side of the Himalayas, also known as the Tibetan Himalaya, is dry, cold, and generally windswept, particularly in the west where it has a cold desert climate . The vegetation is sparse and stunted and the winters are severely cold. Most of the precipitation in the region is in the form of snow during the late winter and spring months. Local impacts on climate are significant throughout the Himalayas. Temperatures fall by 0.2 to 1.2 °C for every 100 m (330 ft) rise in altitude. This gives rise to a variety of climates, from a nearly tropical climate in the foothills, to tundra and permanent snow and ice at higher elevations. Local climate is also affected by the topography: The leeward side of the mountains receive less rain while the well-exposed slopes get heavy rainfall and the rain shadow of large mountains can be significant, for example, leading to near desert conditions in the Upper Mustang , which is sheltered from the monsoon rains by the Annapurna and Dhaulagiri massifs and has annual precipitation of around 300 mm (12 in) , while Pokhara on the southern side of the massifs has substantial rainfall ( 3,900 mm or 150 in a year). Thus, although annual precipitation is generally higher in the east than in the west, local variations are often more important. [ citation needed ] The Himalayas have a profound effect on the climate of the Indian subcontinent and the Tibetan Plateau. They prevent frigid, dry winds from blowing south into the subcontinent, which keeps South Asia much warmer than corresponding temperate regions in the other continents. It also forms a barrier for the monsoon winds, keeping them from traveling northwards, and causing heavy rainfall in the Terai region. The Himalayas are also believed to play an important part in the formation of Central Asian deserts, such as the Taklamakan and Gobi . The 2019 Hindu Kush Himalaya Assessment concluded that between 1901 and 2014, the Hindu Kush Himalaya (or HKH) region had already experienced warming of 0.1 °C per decade, with the warming rate accelerating to 0.2 °C per decade over the past 50 years. Over the past 50 years, the frequency of warm days and nights had also increased by 1.2 days and 1.7 nights per decade, while the frequency of extreme warm days and nights had increased by 1.26 days and 2.54 nights per decade. There was also a corresponding decline of 0.5 cold days, 0.85 extreme cold days, 1 cold night, and 2.4 extreme cold nights per decade. The length of the growing season has increased by 4.25 days per decade. There is less conclusive evidence of light precipitation becoming less frequent while heavy precipitation became both more frequent and more intense. Finally, since 1970s glaciers have retreated everywhere in the region beside Karakoram , eastern Pamir , and western Kunlun , where there has been an unexpected increase in snowfall. Glacier retreat had been followed by an increase in the number of glacial lakes , some of which may be prone to dangerous floods. In the future, if the Paris Agreement goal of 1.5 °C of global warming is not exceeded, warming in the HKH will be at least 0.3 °C higher, and at least 0.7 °C higher in the hotspots of northwest Himalaya and Karakoram. If the Paris Agreement goals are broken, then the region is expected to warm by 1.7–2.4 °C in the near future (2036–2065) and by 2.2–3.3 °C (2066–2095) near the end of the century under the "intermediate" Representative Concentration Pathway 4.5 (RCP4.5). Under the high-warming RCP8.5 scenario where the annual emissions continue to increase for the rest of the century, the expected regional warming is 2.3–3.2 °C and 4.2–6.5 °C, respectively. Under all scenarios, winters will warm more than the summers, and the Tibetan Plateau, the central Himalayan Range, and the Karakoram will continue to warm more than the rest of the region. Climate change will also lead to the degradation of up to 81% of the region's permafrost by the end of the century. Future precipitation is projected to increase as well, but CMIP5 models struggle to make specific projections due to the region's topography: the most certain finding is that the monsoon precipitation in the region will increase by 4–12% in the near future and by 4–25% in the long term. There has also been modelling of the changes in snow cover, but it is limited to the end of century under the RCP 8.5 scenario: it projects declines of 30–50% in the Indus Basin, 50–60% in the Ganges basin, and 50–70% in the Brahmaputra Basin, as the snowline elevation in these regions will rise by between 4.4 and 10.0 m/yr. There has been more extensive modelling of glacier trends: it is projected that one third of all glaciers in the extended HKH region will be lost by 2100 even if the warming is limited to 1.5 °C (with over half of that loss in the Eastern Himalaya region), while RCP 4.5 and RCP 8.5 are likely to lead to the losses of 50% and >67% of the region's glaciers over the same timeframe.The physical factors determining the climate in any location in the Himalayas include latitude, altitude, and the relative motion of the Southwest monsoon . From north to south, the mountains cover more than eight degrees of latitude, spanning temperate to subtropical zones. The colder air of Central Asia is prevented from blowing down into South Asia by the physical configuration of the Himalayas. This causes the tropical zone to extend farther north in South Asia than anywhere else in the world. The evidence is unmistakable in the Brahmaputra valley as the warm air from the Bay of Bengal bottlenecks and rushes up past Namcha Barwa , the eastern anchor of the Himalayas, and into southeastern Tibet. Temperatures in the Himalayas cool by 2.0 degrees C (3.6 degrees F) for every 300 metres (980 ft) increase of altitude. As the physical features of mountains are irregular, with broken jagged contours, there can be wide variations in temperature over short distances. Temperature at a location on a mountain depends on the season of the year, the bearing of the sun with respect to the face on which the location lies, and the mass of the mountain, i.e. the amount of matter in the mountain. As the temperature is directly proportional to received radiation from the sun, the faces that receive more direct sunlight also have a greater heat buildup. In narrow valleys — lying between steep mountain faces — there can be dramatically different weather along their two margins. The side to the north with a mountain above facing south can have an extra month of the growing season. The mass of the mountain also influences the temperature, as it acts as a heat island , in which more heat is absorbed and retained than the surroundings, and therefore influences the heat budget or the amount of heat needed to raise the temperature from the winter minimum to the summer maximum. The immense scale of the Himalayas means that many summits can create their own weather, the temperature fluctuating from one summit to another, from one face to another, and all may be quite different from the weather in nearby plateaus or valleys. A critical influence on the Himalayan climate is the Southwest Monsoon . This is not so much the rain of the summer months as the wind that carries the rain. Different rates of heating and cooling between the Central Asian continent and the Indian Ocean create large differences in the atmospheric pressure prevailing above each. In the winter, a high-pressure system forms and remains suspended above Central Asia, forcing air to flow in the southerly direction over the Himalayas. But in Central Asia, as there is no substantial source for water to be diffused as vapour, the winter winds blowing across South Asia are dry. In the summer months, the Central Asian plateau heats up more than the ocean waters to its south. As a result, the air above it rises higher and higher, creating a thermal low . Off-shore high-pressure systems in the Indian Ocean push the moist summer air inland toward the low-pressure system. When the moist air meets mountains, it rises and upon subsequent cooling, its moisture condenses and is released as rain, typically heavy rain. The wet summer monsoon winds cause precipitation in India and all along the layered southern slopes of the Himalayas. This forced lifting of air is called the orographic effect . The vast size, huge altitude range, and complex topography of the Himalayas mean they experience a wide range of climates, from humid subtropical in the foothills, to cold and dry desert conditions on the Tibetan side of the range. For much of the Himalayas—in the areas to the south of the high mountains, the monsoon is the most characteristic feature of the climate and causes most of the precipitation, while the western disturbance brings winter precipitation, especially in the west. Heavy rain arrives on the southwest monsoon in June and persists until September. The monsoon can seriously impact transport and cause major landslides. It restricts tourism – the trekking and mountaineering season is limited to either before the monsoon in April/May or after the monsoon in October/November (autumn). In Nepal and Sikkim, there are often considered to be five seasons: summer, monsoon , autumn, (or post-monsoon), winter, and spring. Using the Köppen climate classification , the lower elevations of the Himalayas, reaching in mid-elevations in central Nepal (including the Kathmandu valley), are classified as Cwa , Humid subtropical climate with dry winters. Higher up, most of the Himalayas have a subtropical highland climate ( Cwb ) . [ citation needed ] The intensity of the southwest monsoon diminishes as it moves westward along the range, with as much as 2,030 mm (80 in) of rainfall in the monsoon season in Darjeeling in the east, compared to only 975 mm (38.4 in) during the same period in Shimla in the west. The northern side of the Himalayas, also known as the Tibetan Himalaya, is dry, cold, and generally windswept, particularly in the west where it has a cold desert climate . The vegetation is sparse and stunted and the winters are severely cold. Most of the precipitation in the region is in the form of snow during the late winter and spring months. Local impacts on climate are significant throughout the Himalayas. Temperatures fall by 0.2 to 1.2 °C for every 100 m (330 ft) rise in altitude. This gives rise to a variety of climates, from a nearly tropical climate in the foothills, to tundra and permanent snow and ice at higher elevations. Local climate is also affected by the topography: The leeward side of the mountains receive less rain while the well-exposed slopes get heavy rainfall and the rain shadow of large mountains can be significant, for example, leading to near desert conditions in the Upper Mustang , which is sheltered from the monsoon rains by the Annapurna and Dhaulagiri massifs and has annual precipitation of around 300 mm (12 in) , while Pokhara on the southern side of the massifs has substantial rainfall ( 3,900 mm or 150 in a year). Thus, although annual precipitation is generally higher in the east than in the west, local variations are often more important. [ citation needed ] The Himalayas have a profound effect on the climate of the Indian subcontinent and the Tibetan Plateau. They prevent frigid, dry winds from blowing south into the subcontinent, which keeps South Asia much warmer than corresponding temperate regions in the other continents. It also forms a barrier for the monsoon winds, keeping them from traveling northwards, and causing heavy rainfall in the Terai region. The Himalayas are also believed to play an important part in the formation of Central Asian deserts, such as the Taklamakan and Gobi . The 2019 Hindu Kush Himalaya Assessment concluded that between 1901 and 2014, the Hindu Kush Himalaya (or HKH) region had already experienced warming of 0.1 °C per decade, with the warming rate accelerating to 0.2 °C per decade over the past 50 years. Over the past 50 years, the frequency of warm days and nights had also increased by 1.2 days and 1.7 nights per decade, while the frequency of extreme warm days and nights had increased by 1.26 days and 2.54 nights per decade. There was also a corresponding decline of 0.5 cold days, 0.85 extreme cold days, 1 cold night, and 2.4 extreme cold nights per decade. The length of the growing season has increased by 4.25 days per decade. There is less conclusive evidence of light precipitation becoming less frequent while heavy precipitation became both more frequent and more intense. Finally, since 1970s glaciers have retreated everywhere in the region beside Karakoram , eastern Pamir , and western Kunlun , where there has been an unexpected increase in snowfall. Glacier retreat had been followed by an increase in the number of glacial lakes , some of which may be prone to dangerous floods. In the future, if the Paris Agreement goal of 1.5 °C of global warming is not exceeded, warming in the HKH will be at least 0.3 °C higher, and at least 0.7 °C higher in the hotspots of northwest Himalaya and Karakoram. If the Paris Agreement goals are broken, then the region is expected to warm by 1.7–2.4 °C in the near future (2036–2065) and by 2.2–3.3 °C (2066–2095) near the end of the century under the "intermediate" Representative Concentration Pathway 4.5 (RCP4.5). Under the high-warming RCP8.5 scenario where the annual emissions continue to increase for the rest of the century, the expected regional warming is 2.3–3.2 °C and 4.2–6.5 °C, respectively. Under all scenarios, winters will warm more than the summers, and the Tibetan Plateau, the central Himalayan Range, and the Karakoram will continue to warm more than the rest of the region. Climate change will also lead to the degradation of up to 81% of the region's permafrost by the end of the century. Future precipitation is projected to increase as well, but CMIP5 models struggle to make specific projections due to the region's topography: the most certain finding is that the monsoon precipitation in the region will increase by 4–12% in the near future and by 4–25% in the long term. There has also been modelling of the changes in snow cover, but it is limited to the end of century under the RCP 8.5 scenario: it projects declines of 30–50% in the Indus Basin, 50–60% in the Ganges basin, and 50–70% in the Brahmaputra Basin, as the snowline elevation in these regions will rise by between 4.4 and 10.0 m/yr. There has been more extensive modelling of glacier trends: it is projected that one third of all glaciers in the extended HKH region will be lost by 2100 even if the warming is limited to 1.5 °C (with over half of that loss in the Eastern Himalaya region), while RCP 4.5 and RCP 8.5 are likely to lead to the losses of 50% and >67% of the region's glaciers over the same timeframe.The flora and fauna of the Himalayas vary with climate, rainfall, altitude, and soils. The climate ranges from tropical at the base of the mountains to permanent ice and snow at the highest elevations. The amount of yearly rainfall increases from west to east along the southern front of the range. This diversity of altitude, rainfall, and soil conditions, combined with the very high snow line, supports a variety of distinct plant and animal communities. The extremes of high altitude (low atmospheric pressure), combined with extreme cold, favor extremophile organisms. At high altitudes, the elusive and previously endangered snow leopard is the main predator. Its prey includes members of the goat family grazing on the alpine pastures and living on the rocky terrain, notably the endemic bharal or Himalayan blue sheep. The Himalayan musk deer is also found at high altitudes. Hunted for its musk, it is now rare and endangered. Other endemic or near-endemic herbivores include the Himalayan tahr , the takin , the Himalayan serow , and the Himalayan goral . The critically endangered Himalayan subspecies of the brown bear is found sporadically across the range, as is the Asian black bear . In the mountainous mixed deciduous and conifer forests of the eastern Himalayas, red pandas feed in the dense understories of bamboo. Lower down, the forests of the foothills are inhabited by several different primates, including the endangered Gee's golden langur and the Kashmir gray langur , with highly restricted ranges in the east and west of the Himalayas, respectively. The unique floral and faunal wealth of the Himalayas is undergoing structural and compositional changes due to climate change . Hydrangea hirta is an example of floral species that can be found in this area. The increase in temperature is shifting various species to higher elevations. The oak forest is being invaded by pine forests in the Garhwal Himalayan region. There are reports of early flowering and fruiting in some tree species, especially rhododendron , apple, and box myrtle . The highest known tree species in the Himalayas is Juniperus tibetica , located at 4,900 m (16,080 ft) in Southeastern Tibet. Similar to the mountains, the communities living near the Himalayas are experiencing climate change and its negative impacts significantly more than other parts of the world. Some of the impacts that the communities are facing include erratic rainfall, flooding, rising temperatures, and landslides. These impacts can have extreme negative effects on the villages living in the area especially as the temperatures rise at higher rates than many other places in the world (Alexander et al., 2014). There are more than 1.9 million people who are highly vulnerable due to climate change with an additional 10 million people at risk in Nepal. Nepal is among the top ten most vulnerable Global South countries due to climate change in the world, standing at number 4 as of 2010 according to the climate change risk atlas. According to NAPA (National Adaptation Program of Action) of Nepal, many threats including floods, droughts, and landslides are an imminent threat to the glacial lake area. With this in consideration, climate change policy and framework for LAPA (Local Adaptation Plans of Action) were prepared in 2011 primarily focusing on addressing climatic hazards. Local communities are suffering from food scarcity and malnutrition as well as an increasing risk to diseases such as malaria and dengue fever as temperatures rise and allow these diseases to migrate further north. There is also an increasing risk of water borne illnesses accompanied by an increasing lack of safe drinking water. Illness is not the only danger to the communities as temperatures sky rocket. With the climate changing weather patterns are also changing and more extreme weather events are occurring putting local communities more at risk to physical harm and death during erratic weather events. Marginalized groups including children and women are experiencing more severe impacts from climate change and are often more exposed to disease and injury. Over the last couple years these health impacts have gotten increasingly worse and more common. Recent studies have shown that dengue fever has had a consistent pattern of epidemic in Nepal in the years 2010, 2013, 2016, 2017, 2019, 2022 with the largest in terms of severity occurring in 2022. 54,784 reported cases were recorded from all 77 districts in seven provinces. These diseases are simply in addition to other diseases that can be seen with the rise of global temperatures and air pollution. Many vulnerable groups are experiencing an increase in respiratory illness, cardiac illnesses, and asthma. The heat can lead to issues such as a strain on respiratory illnesses, heat stroke, and fever. There is also the increased risk of cancer. Many lower income communities such as the himalayan villages suffer from exposure to more pollution or in some cases exposure to toxic chemicals which has led to an increased rate of cancer in these communities as well as an increased risk of death. The increasing temperatures are also leading to a decrease in territory for local wildlife. This has led to a decrease in prey for at risk predators such as snow leopards. This has led to a negative relationship between local farmers and the wildlife as snow leopards and other predators attack the farmers' livestock. This livestock consists of yaks, oxen, horses, and goats. Snow leopards have killed about 2.6% of the local livestock per year in response to their decreasing habitat. This has had a major impact on the local economy leading to the loss of about a quarter of the average annual income of the local farmers. This has led to farmers then killing the snow leopards in retaliation in order to protect their livestock and their livelihoods. Nepal is a part of the Paris agreement and thus is required to have a climate action plan and is being tracked by the Climate Action Tracker. According to the Climate Action Tracker, Nepal is "almost sufficient" on its track to reach the goals set by the Paris Agreement. There are two factors that hold Nepal back from reaching sufficient status and thus stand out. There is no Climate Finance Plan and emissions and temperature rising rate ranking at critically insufficient. Nepal has many goals, however, that are on track with the Paris Agreement. The first of note being a goal of net-zero emissions by 2045. To reach this goal Nepal submitted two separate plans to account for whatever future they experience the first being WAM (with additional measures) and the second being WEM (with existing measures). WEM is based primarily on already existing policies and highlights the energy sector as the main target for CO2 reduction. The WAM scenario introduces a far more ambitious strategy for reducing emissions. In this scenario the focus is primarily on an intervention method and disruption of the energy sector reducing the use of fossil fuels and the incorporation of renewable energy sources. This pathway heavily relies on reducing emissions from energy sources while preserving the carbon-absorbing capacity of the LULUCF (Land Use, Land-Use Change and Forestry) sector. Under this scenario, it is anticipated that net CO2 emissions will remain negative from 2020 to 2030, approach 'zero' between 2035 and 2045, and then revert to negative values by 2050. The goal of this scenario is to accelerate the journey toward achieving carbon neutrality before 2045. These policies along with many more have Nepal on track to stay beneath the 1.5 threshold set by the Paris Agreement. In recent years many citizens of these Himalayan communities have started to notice the extreme effects of climate change by experiencing nature itself. They have noticed a decrease in precipitation especially in lowland districts, fluctuating temperatures during months of the year that are typically cooler, and changes in weather patterns even compared to early 2000s weather. Many local villagers have identified climate change simply through the availability of certain native plants decreasing or shifting seasons. The concept of climate change has now been aligned with the risk of natural disasters and has increased awareness in the local communities. These impacts of climate change have greatly affected agriculture in the area and has forced farmers to change crops and when they plant them. In response to this rather than push for policy change, citizens have begun to adapt to climate change. According to Dhungana, 91.94% of the respondents experienced drought as major climatic hazards then floods at 83.87%, landslides at 70.97%, and forest fires at 67.74%. In response to this citizens have begun adapting and adopting new practices. As a response to drought at the high altitudes, plantations are planting more protective trees, drought resistant plants, and have begun adopting irrigation practices drawing from nearby streams. In response to flooding, farmers have created more basins, dam construction, and small drainage canals. The response to landslides includes plantation grasses in previously barren areas, Gabion wall construction, avoiding livestock grazing in landslide-prone areas, and a prohibition on tillage in areas at risk of landslides. To fight the increased rate of forest fires, citizens have begun beating the fires with green branches and mud, construction of fire lines, and are raising awareness about the wildfires. Fire lines are lines of varying width built through the leaf litter of a forest floor down to the soil and minerals to prevent a spread of fire past the line. The main reason for these adaptations is to decrease the risk that climate change poses over these marginalized communities while taking advantage of the moment and allowing for a positive change towards a more sustainable or adaptable future. Major barriers to these adaptations include a lack of funds, a lack of knowledge, a lack of technology, a lack of time, and lack of mandatory policy. Local communities are suffering from food scarcity and malnutrition as well as an increasing risk to diseases such as malaria and dengue fever as temperatures rise and allow these diseases to migrate further north. There is also an increasing risk of water borne illnesses accompanied by an increasing lack of safe drinking water. Illness is not the only danger to the communities as temperatures sky rocket. With the climate changing weather patterns are also changing and more extreme weather events are occurring putting local communities more at risk to physical harm and death during erratic weather events. Marginalized groups including children and women are experiencing more severe impacts from climate change and are often more exposed to disease and injury. Over the last couple years these health impacts have gotten increasingly worse and more common. Recent studies have shown that dengue fever has had a consistent pattern of epidemic in Nepal in the years 2010, 2013, 2016, 2017, 2019, 2022 with the largest in terms of severity occurring in 2022. 54,784 reported cases were recorded from all 77 districts in seven provinces. These diseases are simply in addition to other diseases that can be seen with the rise of global temperatures and air pollution. Many vulnerable groups are experiencing an increase in respiratory illness, cardiac illnesses, and asthma. The heat can lead to issues such as a strain on respiratory illnesses, heat stroke, and fever. There is also the increased risk of cancer. Many lower income communities such as the himalayan villages suffer from exposure to more pollution or in some cases exposure to toxic chemicals which has led to an increased rate of cancer in these communities as well as an increased risk of death. The increasing temperatures are also leading to a decrease in territory for local wildlife. This has led to a decrease in prey for at risk predators such as snow leopards. This has led to a negative relationship between local farmers and the wildlife as snow leopards and other predators attack the farmers' livestock. This livestock consists of yaks, oxen, horses, and goats. Snow leopards have killed about 2.6% of the local livestock per year in response to their decreasing habitat. This has had a major impact on the local economy leading to the loss of about a quarter of the average annual income of the local farmers. This has led to farmers then killing the snow leopards in retaliation in order to protect their livestock and their livelihoods. Nepal is a part of the Paris agreement and thus is required to have a climate action plan and is being tracked by the Climate Action Tracker. According to the Climate Action Tracker, Nepal is "almost sufficient" on its track to reach the goals set by the Paris Agreement. There are two factors that hold Nepal back from reaching sufficient status and thus stand out. There is no Climate Finance Plan and emissions and temperature rising rate ranking at critically insufficient. Nepal has many goals, however, that are on track with the Paris Agreement. The first of note being a goal of net-zero emissions by 2045. To reach this goal Nepal submitted two separate plans to account for whatever future they experience the first being WAM (with additional measures) and the second being WEM (with existing measures). WEM is based primarily on already existing policies and highlights the energy sector as the main target for CO2 reduction. The WAM scenario introduces a far more ambitious strategy for reducing emissions. In this scenario the focus is primarily on an intervention method and disruption of the energy sector reducing the use of fossil fuels and the incorporation of renewable energy sources. This pathway heavily relies on reducing emissions from energy sources while preserving the carbon-absorbing capacity of the LULUCF (Land Use, Land-Use Change and Forestry) sector. Under this scenario, it is anticipated that net CO2 emissions will remain negative from 2020 to 2030, approach 'zero' between 2035 and 2045, and then revert to negative values by 2050. The goal of this scenario is to accelerate the journey toward achieving carbon neutrality before 2045. These policies along with many more have Nepal on track to stay beneath the 1.5 threshold set by the Paris Agreement. In recent years many citizens of these Himalayan communities have started to notice the extreme effects of climate change by experiencing nature itself. They have noticed a decrease in precipitation especially in lowland districts, fluctuating temperatures during months of the year that are typically cooler, and changes in weather patterns even compared to early 2000s weather. Many local villagers have identified climate change simply through the availability of certain native plants decreasing or shifting seasons. The concept of climate change has now been aligned with the risk of natural disasters and has increased awareness in the local communities. These impacts of climate change have greatly affected agriculture in the area and has forced farmers to change crops and when they plant them. In response to this rather than push for policy change, citizens have begun to adapt to climate change. According to Dhungana, 91.94% of the respondents experienced drought as major climatic hazards then floods at 83.87%, landslides at 70.97%, and forest fires at 67.74%. In response to this citizens have begun adapting and adopting new practices. As a response to drought at the high altitudes, plantations are planting more protective trees, drought resistant plants, and have begun adopting irrigation practices drawing from nearby streams. In response to flooding, farmers have created more basins, dam construction, and small drainage canals. The response to landslides includes plantation grasses in previously barren areas, Gabion wall construction, avoiding livestock grazing in landslide-prone areas, and a prohibition on tillage in areas at risk of landslides. To fight the increased rate of forest fires, citizens have begun beating the fires with green branches and mud, construction of fire lines, and are raising awareness about the wildfires. Fire lines are lines of varying width built through the leaf litter of a forest floor down to the soil and minerals to prevent a spread of fire past the line. The main reason for these adaptations is to decrease the risk that climate change poses over these marginalized communities while taking advantage of the moment and allowing for a positive change towards a more sustainable or adaptable future. Major barriers to these adaptations include a lack of funds, a lack of knowledge, a lack of technology, a lack of time, and lack of mandatory policy. There are many cultural and mythological aspects associated with the Himalayas. In Jainism , Mount Ashtapada of the Himalayan mountain range is a sacred place where the first Jain tirthankara , Rishabhanatha , attained moksha . It is believed that after Rishabhanatha attained nirvana , his son, Bharata , had constructed three stupas and twenty four shrines of the 24 tirthankara s with their idols studded with precious stones over there and named it Sinhnishdha . For the Hindus, the Himalayas are personified as Himavat , the king of all mountains and the father of the goddess Parvati . The Himalayas are also considered to be the father of the goddess Ganga (the personification of river Ganges). Two of the most sacred places of pilgrimage for the Hindus are the temple complex in Pashupatinath and Muktinath , also known as Shaligrama because of the presence of the sacred black rocks called shaligrams . The Buddhists also lay a great deal of importance on the Himalayas. Paro Taktsang is the holy place where Buddhism started in Bhutan . The Muktinath is also a place of pilgrimage for the Tibetan Buddhists. They believe that the trees in the poplar grove came from the walking sticks of eighty-four ancient Indian Buddhist magicians or mahasiddhas . They consider the saligrams to be representatives of the Tibetan serpent deity known as Gawo Jagpa. The Himalayan people's diversity shows in many different ways. It shows through their architecture, their languages, and dialects, their beliefs and rituals, as well as their clothing. The shapes and materials of the people's homes reflect their practical needs and beliefs. Another example of the diversity amongst the Himalayan peoples is that handwoven textiles display colors and patterns unique to their ethnic backgrounds. Finally, some people place great importance on jewelry. The Rai and Limbu women wear big gold earrings and nose rings to show their wealth through their jewelry. Several places in the Himalayas are of religious significance in Hinduism , Buddhism , Jainism , and Sikhism . A notable example of a religious site is Paro Taktsang , where Padmasambhava is said to have founded Buddhism in Bhutan . A number of Vajrayana Buddhist sites are situated in the Himalayas, in Tibet , Bhutan , and in the Indian regions of Ladakh , Sikkim, Arunachal Pradesh , Spiti , and Darjeeling . There were over 6,000 monasteries in Tibet, including the residence of the Dalai Lama . Bhutan , Sikkim , and Ladakh are also dotted with numerous monasteries. The Himalayas are home to a diversity of medicinal resources. Plants from the forests have been used for millennia to treat conditions ranging from simple coughs to snake bites. Different parts of the plants – root, flower, stem, leaves, and bark – are used as remedies for different ailments. For example, a bark extract from an Abies pindrow tree is used to treat coughs and bronchitis. Leaf and stem paste from an Andrachne cordifolia is used for wounds and as an antidote for snake bites. The bark of a Callicarpa arborea is used for skin ailments. Nearly a fifth of the gymnosperms , angiosperms , and pteridophytes in the Himalayas are found to have medicinal properties, and more are likely to be discovered. Most of the population in some Asian and African countries depends on medicinal plants rather than prescriptions and such. Since so many people use medicinal plants as their only source of healing in the Himalayas, the plants are an important source of income. This contributes to economic and modern industrial development both inside and outside the region. The only problem is that locals are rapidly clearing the forests on the Himalayas for wood, often illegally.

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Dengue fever

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Mosquito control

Mosquito control manages the population of mosquitoes to reduce their damage to human health, economies, and enjoyment. Mosquito control is a vital public-health practice throughout the world and especially in the tropics because mosquitoes spread many diseases, such as malaria and the Zika virus . Mosquito-control operations are targeted to multiple problems: Disease organisms transmitted by mosquitoes include West Nile virus , Saint Louis encephalitis virus , Eastern equine encephalomyelitis virus , Everglades virus , Highlands J virus , La Crosse Encephalitis virus in the United States; dengue fever , yellow fever , Ilheus virus, malaria , Zika virus and filariasis in the American tropics ; Rift Valley fever , Wuchereria bancrofti , Japanese encephalitis , chikungunya and filariasis in Africa and Asia; and Murray Valley encephalitis in Australia. Vertical transmission from adult mosquitos to larvae is possible. Depending on the situation, source reduction, biocontrol, larviciding (killing of larvae ), or adulticiding (killing of adults) may be used to manage mosquito populations. These techniques are accomplished using habitat modification, pesticide , biological-control agents, and trapping. The advantage of non-toxic methods of control is they can be used in Conservation Areas . Integrated pest management (IPM) is the use of the most environmentally appropriate method or combination of methods to control pest populations. Typical mosquito-control programs using IPM first conduct surveys, in order to determine the species composition , relative abundance and seasonal distribution of adult and larval mosquitoes, and only then is a control strategy defined.Adult mosquito populations may be monitored by landing rate counts, mechanical traps or by, lidar technology For landing rate counts, an inspector visits a set number of sites every day, counting the number of adult female mosquitoes that land on a part of the body, such as an arm or both legs, within a given time interval. Mechanical traps use a fan to blow adult mosquitoes into a collection bag that is taken back to the laboratory for analysis of catch. The mechanical traps use visual cues (light, black/white contrasts) or chemical attractants that are normally given off by mosquito hosts (e.g., carbon dioxide , ammonia , lactic acid , octenol ) to attract adult female mosquitoes. These cues are often used in combination. Entomology lidar detection has the possibility of showing the difference between male and female mosquitoes. Monitoring larval mosquito populations involves collecting larvae from standing water with a dipper or a turkey baster . The habitat, approximate total number of larvae and pupae , and species are noted for each collection. An alternative method works by providing artificial breeding spots ( ovitraps ) and collecting and counting the developing larvae at fixed intervals. Monitoring these mosquito populations is crucial to see what species are present, if mosquito numbers are rising or falling, and detecting any diseases they carry. Mosquito Alert is a cooperative citizen science project, currently run as a non-profit and coordinated by four public research centers in Spain. The aim of the project is to study, monitor, and fight the spread of invasive mosquitos. The project provided the first detection of the Asian bush mosquito Aedes japonicus in Spain in 2018, providing the first report of a population of mosquitos that were located 1,300 km from their previously nearest known location in Europe. Mechanical control is the management and control using physical means. Since many mosquitoes breed in standing water , source reduction can be as simple as emptying water from containers around the home. This is something that homeowners can accomplish. Mosquito breeding grounds can be eliminated at home by removing unused plastic pools , old tires , or buckets ; by clearing clogged gutters and repairing leaks around faucets ; by regularly (at most every 4 days) changing water in bird baths ; and by filling or draining puddles, swampy areas, and tree stumps. Eliminating such mosquito breeding areas can be an extremely effective and permanent way to reduce mosquito populations without resorting to insecticides. However, this may not be possible in parts of the developing world where water cannot be readily replaced due to irregular water supply. Many individuals also believe mosquito control is the government's responsibility, so if these methods are not done regularly by homeowners then the effectiveness is reduced. Open water marsh management (OWMM) involves the use of shallow ditches, to create a network of water flow within marshes and to connect the marsh to a pond or canal. The network of ditches drains the mosquito habitat and lets in fish which will feed on mosquito larvae. This reduces the need for other control methods such as pesticides . Simply giving the predators access to the mosquito larvae can result in long-term mosquito control. Open-water marsh management is used on both the eastern and western coasts of the United States. [ citation needed ] Rotational impoundment management (RIM) involves the use of large pumps and culverts with gates to control the water level within an impounded marsh. RIM allows mosquito control to occur while still permitting the marsh to function in a state as close to its natural condition as possible. Water is pumped into the marsh in the late spring and summer to prevent the female mosquito from laying her eggs on the soil. The marsh is allowed to drain in the fall, winter, and early spring. Gates in the culverts are used to permit fish, crustaceans, and other marsh organisms to enter and exit the marsh. RIM allows the mosquito-control goals to be met while at the same time reducing the need for pesticide use within the marsh. Rotational impoundment management is used to a great extent on the east coast of Florida. A 2019 study also explored the idea of using unmanned aerial vehicles as a valid strategy to identify and prioritize water bodies where disease vectors such as Ny . darlingi are most likely to breed. An oil drip can or oil drip barrel was a common and nontoxic anti-mosquito measure. The thin layer of oil on top of the water prevents mosquito breeding in two ways: mosquito larvae in the water cannot penetrate the oil film with their breathing tube, and so drown and die; also adult mosquitoes do not lay eggs on the oiled water. A traditional approach to controlling mosquito populations is the use of ovitraps or lethal ovitraps , which provide artificial breeding spots for mosquitoes to lay their eggs. While ovitraps only trap eggs, lethal ovitraps usually contain a chemical inside the trap that is used to kill the adult mosquito and/or the larvae in the trap. Studies have shown that with enough of these lethal ovitraps, Aedes mosquito populations can be controlled. A recent approach is the automatic lethal ovitrap, which works like a traditional ovitrap but automates all steps needed to provide the breeding spots and to destroy the developing larvae. In 2016 researchers from Laurentian University released a design for a low cost trap called an Ovillanta which consists of attractant-laced water in a section of discarded rubber tire. At regular intervals the water is run through a filter to remove any deposited eggs and larva. The water, which then contains an 'oviposition' pheromone deposited during egg-laying, is reused to attract more mosquitoes. Two studies have shown that this type of trap can attract about seven times as many mosquito eggs as a conventional ovitrap. Some newer mosquito traps or known mosquito attractants emit a plume of carbon dioxide together with other mosquito attractants such as sugary scents, lactic acid , octenol , warmth, water vapor and sounds. By mimicking a mammal's scent and outputs, the trap draws female mosquitoes toward it, where they are typically sucked into a net or holder by an electric fan where they are collected. According to the American Mosquito Control Association, the trap will kill some mosquitoes, but their effectiveness in any particular case will depend on a number of factors such as the size and species of the mosquito population and the type and location of the breeding habitat. They are useful in specimen collection studies to determine the types of mosquitoes prevalent in an area but are typically far too inefficient to be useful in reducing mosquito populations. This is a process of achieving sustainable mosquito control in an eco friendly manner by providing artificial breeding grounds with an ovitrap or an ovillanta utilizing common household utensils and destroying larvae by non-hazardous natural means such as throwing them in dry places or feeding them to larvae eating fishes like Gambusia affinis , or suffocating them by spreading a thin plastic sheet over the entire water surface to block atmospheric air. Shifting the water with larvae to another vessel and pouring a few drops of kerosene oil or insecticide/larvicide in it is another option for killing wrigglers, but not preferred due to its environmental impact . Most of the ornamental fishes eat mosquito larvae. [ citation needed ]Since many mosquitoes breed in standing water , source reduction can be as simple as emptying water from containers around the home. This is something that homeowners can accomplish. Mosquito breeding grounds can be eliminated at home by removing unused plastic pools , old tires , or buckets ; by clearing clogged gutters and repairing leaks around faucets ; by regularly (at most every 4 days) changing water in bird baths ; and by filling or draining puddles, swampy areas, and tree stumps. Eliminating such mosquito breeding areas can be an extremely effective and permanent way to reduce mosquito populations without resorting to insecticides. However, this may not be possible in parts of the developing world where water cannot be readily replaced due to irregular water supply. Many individuals also believe mosquito control is the government's responsibility, so if these methods are not done regularly by homeowners then the effectiveness is reduced. Open water marsh management (OWMM) involves the use of shallow ditches, to create a network of water flow within marshes and to connect the marsh to a pond or canal. The network of ditches drains the mosquito habitat and lets in fish which will feed on mosquito larvae. This reduces the need for other control methods such as pesticides . Simply giving the predators access to the mosquito larvae can result in long-term mosquito control. Open-water marsh management is used on both the eastern and western coasts of the United States. [ citation needed ] Rotational impoundment management (RIM) involves the use of large pumps and culverts with gates to control the water level within an impounded marsh. RIM allows mosquito control to occur while still permitting the marsh to function in a state as close to its natural condition as possible. Water is pumped into the marsh in the late spring and summer to prevent the female mosquito from laying her eggs on the soil. The marsh is allowed to drain in the fall, winter, and early spring. Gates in the culverts are used to permit fish, crustaceans, and other marsh organisms to enter and exit the marsh. RIM allows the mosquito-control goals to be met while at the same time reducing the need for pesticide use within the marsh. Rotational impoundment management is used to a great extent on the east coast of Florida. A 2019 study also explored the idea of using unmanned aerial vehicles as a valid strategy to identify and prioritize water bodies where disease vectors such as Ny . darlingi are most likely to breed. An oil drip can or oil drip barrel was a common and nontoxic anti-mosquito measure. The thin layer of oil on top of the water prevents mosquito breeding in two ways: mosquito larvae in the water cannot penetrate the oil film with their breathing tube, and so drown and die; also adult mosquitoes do not lay eggs on the oiled water. A traditional approach to controlling mosquito populations is the use of ovitraps or lethal ovitraps , which provide artificial breeding spots for mosquitoes to lay their eggs. While ovitraps only trap eggs, lethal ovitraps usually contain a chemical inside the trap that is used to kill the adult mosquito and/or the larvae in the trap. Studies have shown that with enough of these lethal ovitraps, Aedes mosquito populations can be controlled. A recent approach is the automatic lethal ovitrap, which works like a traditional ovitrap but automates all steps needed to provide the breeding spots and to destroy the developing larvae. In 2016 researchers from Laurentian University released a design for a low cost trap called an Ovillanta which consists of attractant-laced water in a section of discarded rubber tire. At regular intervals the water is run through a filter to remove any deposited eggs and larva. The water, which then contains an 'oviposition' pheromone deposited during egg-laying, is reused to attract more mosquitoes. Two studies have shown that this type of trap can attract about seven times as many mosquito eggs as a conventional ovitrap. Some newer mosquito traps or known mosquito attractants emit a plume of carbon dioxide together with other mosquito attractants such as sugary scents, lactic acid , octenol , warmth, water vapor and sounds. By mimicking a mammal's scent and outputs, the trap draws female mosquitoes toward it, where they are typically sucked into a net or holder by an electric fan where they are collected. According to the American Mosquito Control Association, the trap will kill some mosquitoes, but their effectiveness in any particular case will depend on a number of factors such as the size and species of the mosquito population and the type and location of the breeding habitat. They are useful in specimen collection studies to determine the types of mosquitoes prevalent in an area but are typically far too inefficient to be useful in reducing mosquito populations.This is a process of achieving sustainable mosquito control in an eco friendly manner by providing artificial breeding grounds with an ovitrap or an ovillanta utilizing common household utensils and destroying larvae by non-hazardous natural means such as throwing them in dry places or feeding them to larvae eating fishes like Gambusia affinis , or suffocating them by spreading a thin plastic sheet over the entire water surface to block atmospheric air. Shifting the water with larvae to another vessel and pouring a few drops of kerosene oil or insecticide/larvicide in it is another option for killing wrigglers, but not preferred due to its environmental impact . Most of the ornamental fishes eat mosquito larvae. [ citation needed ]Chemical control is the management and control using chemical means. Control of larvae can be accomplished through use of contact poisons, growth regulators, surface films, stomach poisons (including bacterial agents), and biological agents such as fungi, nematodes, copepods, and fish. A chemical commonly used in the United States is methoprene , considered slightly toxic to larger animals, which mimics and interferes with natural growth hormones in mosquito larvae, preventing development. Methoprene is frequently distributed in time-release briquette form in breeding areas. Another chemical is Temefos or temephos , a sand granular insecticide is used to treat water infected with disease carrying insects. It is believed by some researchers that the larvae of Anopheles gambiae (important vectors of malaria) can survive for several days on moist mud, and that treatments should therefore include mud and soil several meters from puddles. Control of adult mosquitoes is the most familiar aspect of mosquito control to most of the public. It is accomplished by ground-based applications or via aerial application of residual chemical insecticides such as Duet . Generally modern mosquito-control programs in developed countries use low-volume applications of insecticides, although some programs may still use thermal fogging. Beside fogging there are some other insect repellents for indoors and outdoors. An example of a synthetic insect repellent is DEET . A naturally occurring repellent is citronella . Indoor Residual Spraying ( IRS ) is another method of adulticide. Walls of properties are sprayed with an insecticide, the mosquitoes die when they land on the surface covered in insecticide. To control adult mosquitoes in India, van mounted fogging machines and hand fogging machines are used. DDT was formerly used throughout the world for large area mosquito control, but it is now banned in most developed countries. Controversially, DDT remains in common use in many developing countries (14 countries were reported to be using it in 2009 ), which claim that the public-health cost of switching to other control methods would exceed the harm caused by using DDT. It is sometimes approved for use only in specific, limited circumstances where it is most effective, such as application to walls. [ citation needed ] The role of DDT in combating mosquitoes has been the subject of considerable controversy. Although DDT has been proven to affect biodiversity and cause eggshell thinning in birds such as the bald eagle, some say that DDT is the most effective weapon in combating mosquitoes, and hence malaria. While some of this disagreement is based on differences in the extent to which disease control is valued as opposed to the value of biodiversity, [ citation needed ] there is also genuine disagreement amongst experts about the costs and benefits of using DDT. [ dubious – discuss ] Notwithstanding, DDT-resistant mosquitoes have started to increase in numbers, especially in tropics due to mutations, reducing the effectiveness of this chemical; these mutations can rapidly spread over vast areas if pesticides are applied indiscriminately (Chevillon et al. 1999). In areas where DDT resistance is encountered, malathion , propoxur or lindane is used.Control of larvae can be accomplished through use of contact poisons, growth regulators, surface films, stomach poisons (including bacterial agents), and biological agents such as fungi, nematodes, copepods, and fish. A chemical commonly used in the United States is methoprene , considered slightly toxic to larger animals, which mimics and interferes with natural growth hormones in mosquito larvae, preventing development. Methoprene is frequently distributed in time-release briquette form in breeding areas. Another chemical is Temefos or temephos , a sand granular insecticide is used to treat water infected with disease carrying insects. It is believed by some researchers that the larvae of Anopheles gambiae (important vectors of malaria) can survive for several days on moist mud, and that treatments should therefore include mud and soil several meters from puddles. Control of adult mosquitoes is the most familiar aspect of mosquito control to most of the public. It is accomplished by ground-based applications or via aerial application of residual chemical insecticides such as Duet . Generally modern mosquito-control programs in developed countries use low-volume applications of insecticides, although some programs may still use thermal fogging. Beside fogging there are some other insect repellents for indoors and outdoors. An example of a synthetic insect repellent is DEET . A naturally occurring repellent is citronella . Indoor Residual Spraying ( IRS ) is another method of adulticide. Walls of properties are sprayed with an insecticide, the mosquitoes die when they land on the surface covered in insecticide. To control adult mosquitoes in India, van mounted fogging machines and hand fogging machines are used. DDT was formerly used throughout the world for large area mosquito control, but it is now banned in most developed countries. Controversially, DDT remains in common use in many developing countries (14 countries were reported to be using it in 2009 ), which claim that the public-health cost of switching to other control methods would exceed the harm caused by using DDT. It is sometimes approved for use only in specific, limited circumstances where it is most effective, such as application to walls. [ citation needed ] The role of DDT in combating mosquitoes has been the subject of considerable controversy. Although DDT has been proven to affect biodiversity and cause eggshell thinning in birds such as the bald eagle, some say that DDT is the most effective weapon in combating mosquitoes, and hence malaria. While some of this disagreement is based on differences in the extent to which disease control is valued as opposed to the value of biodiversity, [ citation needed ] there is also genuine disagreement amongst experts about the costs and benefits of using DDT. [ dubious – discuss ] Notwithstanding, DDT-resistant mosquitoes have started to increase in numbers, especially in tropics due to mutations, reducing the effectiveness of this chemical; these mutations can rapidly spread over vast areas if pesticides are applied indiscriminately (Chevillon et al. 1999). In areas where DDT resistance is encountered, malathion , propoxur or lindane is used.Biological control is the management and control using biological means. Biological pest control , or "biocontrol", is the use of the natural enemies of pests like mosquitoes to manage the pest's populations. There are several types of biocontrol, including the direct introduction of parasites, pathogens, and predators to target mosquitoes. Effective biocontrol agents include predatory fish that feed on mosquito larvae such as mosquitofish ( Gambusia affinis ) and some cyprinids (carps and minnows) and killifish . Tilapia also consume mosquito larvae. Direct introduction of tilapia and mosquitofish into ecosystems around the world have had disastrous consequences. However, utilizing a controlled system via aquaponics provides the mosquito control without the adverse effects to the ecosystem. Other predators include dragonfly (fly) naiads , which consume mosquito larvae in the breeding waters, adult dragonflies , which eat adult mosquitoes, and some species of lizard and gecko . Biocontrol agents that have had lesser degrees of success include the predator mosquito Toxorhynchites and predator crustaceans — Mesocyclops copepods , nematodes and fungi . Predators such as birds, bats, lizards, and frogs have been used, but their effectiveness is only anecdotal. Instead of chemical insecticides, some researchers are studying biocides. Like all animals, mosquitoes are subject to disease. Invertebrate pathologists study these diseases in the hope that some of them can be utilized for mosquito management. Microbial pathogens of mosquitoes include viruses, bacteria, fungi, protozoa, nematodes and microsporidia. [ page needed ] Most notably, scientists in Burkina Faso were studying the Metarhizium fungal species. This fungus in a high concentration can slowly kill mosquitoes. To increase the lethality of the fungus, a gene from a spider was inserted into the fungus causing it to produce a neurotoxin . But it is only activated when in mosquito hemolymph. Research was done to show the fungi would not affect other insects or humans. Two other species of fungi that can kill adult mosquitoes are Metarhizium anisopliae and Beauveria bassiana . Dead spores of the soil bacterium Bacillus thuringiensis , especially Bt israelensis (BTI) interfere with dipteran larval digestive systems. It can be dispersed by hand or dropped by helicopter in large areas. BTI loses effectiveness after the larvae turn into pupae, because they stop eating. [ citation needed ] BTI was reported to be widely applied in West Africa with limited adverse effects, and may pose lesser risk than chemical pesticides. In the Wolbachia method, both male and female mosquitos that carry the Wolbachia bacterium are released into natural populations. Wolbachia boosts the natural immune response of the mosquito so that it does not easily get infected and become a host vector for mosquito-borne diseases. Therefore it is unable to easily transmit those viruses to people. This is known as replacement strategy as it aims to replace the natural population with Wolbachia -carrying ones. Since 2011, the World Mosquito Program has conducted several trials and projects, in 14 countries across Asia, Latin America and Oceania. This approach also uses Wolbachia but involves the release of only male mosquitos that carry the Wolbachia bacterium. When these male mosquitos mate with wild female mosquitos, her eggs do not hatch due to lack of biocompatibility. Wolbachia is not endemic to wild mosquito populations although it is endemic in 50% of all insect species. This is known as suppression strategy as it aims to suppress the natural reproduction cycle. Wolbachia-Aedes suppression has been piloted in various countries such as Myanmar (1967), French Polynesia (2009, 2012), USA (2014-2016, 2018), Thailand (2016), Australia (2017), Singapore (since 2016) and Puerto Rico (2020). Maui and Kuai, Hawaii - A series of IIT projects were planned to protect endangered bird species from avian malaria . The projects involve the release of large numbers of male mosquitos infected with a strain of Wolbachia that is incompatible with the strain carried by resident females. These mosquitos would not be irradiated or subject to genetic modification. Introducing large numbers of sterile males is another approach to reducing mosquito numbers. This is called Sterile Insect Technique (SIT). Radiation is used to disrupt DNA in the mosquitoes and randomly create mutations. Males with mutations that disrupt their fertility are selected and released in mass into the wild population. These sterile males mate with wild type females and no offspring is produced, reducing the population size. Guangzhou, China - A combination of SIT with IIT, were used in a mosquito control program in Guangzhou, China. The pilot trial was carried out with the support of the IAEA in cooperation with the Food and Agriculture Organization of the United Nations (FAO). The pilot demonstrated the successful near-elimination of field populations of the world's most invasive mosquito species, Aedes albopictus (Asian tiger mosquito). The two-year trial (2016–2017) covered a 32.5-hectare area on two relatively isolated islands in the Pearl River in Guangzhou. It involved the release of about 200 million irradiated mass-reared adult male mosquitoes exposed to Wolbachia bacteria. Biological pest control , or "biocontrol", is the use of the natural enemies of pests like mosquitoes to manage the pest's populations. There are several types of biocontrol, including the direct introduction of parasites, pathogens, and predators to target mosquitoes. Effective biocontrol agents include predatory fish that feed on mosquito larvae such as mosquitofish ( Gambusia affinis ) and some cyprinids (carps and minnows) and killifish . Tilapia also consume mosquito larvae. Direct introduction of tilapia and mosquitofish into ecosystems around the world have had disastrous consequences. However, utilizing a controlled system via aquaponics provides the mosquito control without the adverse effects to the ecosystem. Other predators include dragonfly (fly) naiads , which consume mosquito larvae in the breeding waters, adult dragonflies , which eat adult mosquitoes, and some species of lizard and gecko . Biocontrol agents that have had lesser degrees of success include the predator mosquito Toxorhynchites and predator crustaceans — Mesocyclops copepods , nematodes and fungi . Predators such as birds, bats, lizards, and frogs have been used, but their effectiveness is only anecdotal.Instead of chemical insecticides, some researchers are studying biocides. Like all animals, mosquitoes are subject to disease. Invertebrate pathologists study these diseases in the hope that some of them can be utilized for mosquito management. Microbial pathogens of mosquitoes include viruses, bacteria, fungi, protozoa, nematodes and microsporidia. [ page needed ] Most notably, scientists in Burkina Faso were studying the Metarhizium fungal species. This fungus in a high concentration can slowly kill mosquitoes. To increase the lethality of the fungus, a gene from a spider was inserted into the fungus causing it to produce a neurotoxin . But it is only activated when in mosquito hemolymph. Research was done to show the fungi would not affect other insects or humans. Two other species of fungi that can kill adult mosquitoes are Metarhizium anisopliae and Beauveria bassiana . Dead spores of the soil bacterium Bacillus thuringiensis , especially Bt israelensis (BTI) interfere with dipteran larval digestive systems. It can be dispersed by hand or dropped by helicopter in large areas. BTI loses effectiveness after the larvae turn into pupae, because they stop eating. [ citation needed ] BTI was reported to be widely applied in West Africa with limited adverse effects, and may pose lesser risk than chemical pesticides. In the Wolbachia method, both male and female mosquitos that carry the Wolbachia bacterium are released into natural populations. Wolbachia boosts the natural immune response of the mosquito so that it does not easily get infected and become a host vector for mosquito-borne diseases. Therefore it is unable to easily transmit those viruses to people. This is known as replacement strategy as it aims to replace the natural population with Wolbachia -carrying ones. Since 2011, the World Mosquito Program has conducted several trials and projects, in 14 countries across Asia, Latin America and Oceania.This approach also uses Wolbachia but involves the release of only male mosquitos that carry the Wolbachia bacterium. When these male mosquitos mate with wild female mosquitos, her eggs do not hatch due to lack of biocompatibility. Wolbachia is not endemic to wild mosquito populations although it is endemic in 50% of all insect species. This is known as suppression strategy as it aims to suppress the natural reproduction cycle. Wolbachia-Aedes suppression has been piloted in various countries such as Myanmar (1967), French Polynesia (2009, 2012), USA (2014-2016, 2018), Thailand (2016), Australia (2017), Singapore (since 2016) and Puerto Rico (2020). Maui and Kuai, Hawaii - A series of IIT projects were planned to protect endangered bird species from avian malaria . The projects involve the release of large numbers of male mosquitos infected with a strain of Wolbachia that is incompatible with the strain carried by resident females. These mosquitos would not be irradiated or subject to genetic modification. Maui and Kuai, Hawaii - A series of IIT projects were planned to protect endangered bird species from avian malaria . The projects involve the release of large numbers of male mosquitos infected with a strain of Wolbachia that is incompatible with the strain carried by resident females. These mosquitos would not be irradiated or subject to genetic modification. Introducing large numbers of sterile males is another approach to reducing mosquito numbers. This is called Sterile Insect Technique (SIT). Radiation is used to disrupt DNA in the mosquitoes and randomly create mutations. Males with mutations that disrupt their fertility are selected and released in mass into the wild population. These sterile males mate with wild type females and no offspring is produced, reducing the population size. Guangzhou, China - A combination of SIT with IIT, were used in a mosquito control program in Guangzhou, China. The pilot trial was carried out with the support of the IAEA in cooperation with the Food and Agriculture Organization of the United Nations (FAO). The pilot demonstrated the successful near-elimination of field populations of the world's most invasive mosquito species, Aedes albopictus (Asian tiger mosquito). The two-year trial (2016–2017) covered a 32.5-hectare area on two relatively isolated islands in the Pearl River in Guangzhou. It involved the release of about 200 million irradiated mass-reared adult male mosquitoes exposed to Wolbachia bacteria. Guangzhou, China - A combination of SIT with IIT, were used in a mosquito control program in Guangzhou, China. The pilot trial was carried out with the support of the IAEA in cooperation with the Food and Agriculture Organization of the United Nations (FAO). The pilot demonstrated the successful near-elimination of field populations of the world's most invasive mosquito species, Aedes albopictus (Asian tiger mosquito). The two-year trial (2016–2017) covered a 32.5-hectare area on two relatively isolated islands in the Pearl River in Guangzhou. It involved the release of about 200 million irradiated mass-reared adult male mosquitoes exposed to Wolbachia bacteria. These techniques share the characteristic of introducing lethal genes and reducing the size of the mosquito population over time. Another control approach under investigation for Aedes aegypti uses a strain that is genetically modified to require the antibiotic tetracycline to develop beyond the larval stage. Modified males develop normally in a nursery while they are supplied with this chemical and can be released into the wild. However, their subsequent offspring will lack tetracycline in the wild and never mature. Field trials were conducted in the Cayman Islands, Malaysia and Brazil to control the mosquitoes that cause dengue fever. In April 2014, Brazil's National Technical Commission for Biosecurity approved the commercial release of the modified mosquito. The FDA is the lead agency for regulating genetically-engineered mosquitoes in the United States. In 2014 and 2018 research was reported into other genetic methods including cytoplasmic incompatibility, chromosomal translocations, sex distortion and gene replacement. Although several years away from the field trial stage, if successful these other methods have the potential to be cheaper and to eradicate the Aedes aegypti mosquito more efficiently. A pioneering experimental demonstration of the gene drive method eradicated small populations of Anopheles gambiae . In 2020, Oxitec 's non-biting Friendly Aedes aegypti mosquito was approved for release by the US EPA and Florida state authorities. Malaysia - In several experiments, researchers released batches of male adult Aedes mosquitos with genetic modifications to study the effects of dispersal and reproduction in natural populations. Mosquito traps were ultilized for the purpose of these studies. The process allowed for the opportunity to determine which mosquitoes were affected, and provided a group to be re-released with genetic modifications resulting in the OX513A variant to reduce reproduction. Adult mosquitoes are attracted inside the traps where they died of dehydration. Research is being conducted that indicates that dismantling a protein associated with eggshell organization, factor EOF1 (factor 1), which may be unique to mosquitoes, may be a means to hamper their reproduction effectively in the wild without creating a resistant population or affecting other animals. Another control approach under investigation for Aedes aegypti uses a strain that is genetically modified to require the antibiotic tetracycline to develop beyond the larval stage. Modified males develop normally in a nursery while they are supplied with this chemical and can be released into the wild. However, their subsequent offspring will lack tetracycline in the wild and never mature. Field trials were conducted in the Cayman Islands, Malaysia and Brazil to control the mosquitoes that cause dengue fever. In April 2014, Brazil's National Technical Commission for Biosecurity approved the commercial release of the modified mosquito. The FDA is the lead agency for regulating genetically-engineered mosquitoes in the United States. In 2014 and 2018 research was reported into other genetic methods including cytoplasmic incompatibility, chromosomal translocations, sex distortion and gene replacement. Although several years away from the field trial stage, if successful these other methods have the potential to be cheaper and to eradicate the Aedes aegypti mosquito more efficiently. A pioneering experimental demonstration of the gene drive method eradicated small populations of Anopheles gambiae . In 2020, Oxitec 's non-biting Friendly Aedes aegypti mosquito was approved for release by the US EPA and Florida state authorities. Malaysia - In several experiments, researchers released batches of male adult Aedes mosquitos with genetic modifications to study the effects of dispersal and reproduction in natural populations. Mosquito traps were ultilized for the purpose of these studies. The process allowed for the opportunity to determine which mosquitoes were affected, and provided a group to be re-released with genetic modifications resulting in the OX513A variant to reduce reproduction. Adult mosquitoes are attracted inside the traps where they died of dehydration.Malaysia - In several experiments, researchers released batches of male adult Aedes mosquitos with genetic modifications to study the effects of dispersal and reproduction in natural populations. Mosquito traps were ultilized for the purpose of these studies. The process allowed for the opportunity to determine which mosquitoes were affected, and provided a group to be re-released with genetic modifications resulting in the OX513A variant to reduce reproduction. Adult mosquitoes are attracted inside the traps where they died of dehydration.Research is being conducted that indicates that dismantling a protein associated with eggshell organization, factor EOF1 (factor 1), which may be unique to mosquitoes, may be a means to hamper their reproduction effectively in the wild without creating a resistant population or affecting other animals. In Singapore , under the Control of Vectors and Pesticides Act there a legal duty on occupiers to prevent Aedes mosquitos from breeding in their homes. If breeding mosquitos are found by inspectors, occupiers are subject to a fine of 5,000 Singapore dollars or imprisonment for a term not exceeding 3 months or both. Some biologists have proposed the deliberate extinction of certain mosquito species. Biologist Olivia Judson has advocated " specicide " of thirty mosquito species by introducing a genetic element which can insert itself into another crucial gene, to create recessive " knockout genes ". She says that the Anopheles mosquitoes (which spread malaria ) and Aedes mosquitoes (which spread dengue fever , yellow fever , elephantiasis , zika , and other diseases) represent only 30 out of some 3,500 mosquito species; eradicating these would save at least one million human lives per year, at a cost of reducing the genetic diversity of the family Culicidae by 1%. She further argues that since species become extinct "all the time" the disappearance of a few more will not destroy the ecosystem : "We're not left with a wasteland every time a species vanishes. Removing one species sometimes causes shifts in the populations of other species — but different need not mean worse." In addition, anti-malarial and mosquito control programs offer little realistic hope to the 300 million people in developing nations who will be infected with acute illnesses each year. Although trials are ongoing, she writes that if they fail: "We should consider the ultimate swatting." Biologist E. O. Wilson has advocated the extinction of several species of mosquito, including malaria vector Anopheles gambiae . Wilson stated, "I'm talking about a very small number of species that have co-evolved with us and are preying on humans, so it would certainly be acceptable to remove them. I believe it's just common sense." Insect ecologist Steven Juliano has argued that "it's difficult to see what the downside would be to removal, except for collateral damage". Entomologist Joe Conlon stated that "If we eradicated them tomorrow, the ecosystems where they are active will hiccup and then get on with life. Something better or worse would take over." However, David Quammen has pointed out that mosquitoes protect forests from human exploitation and may act as competitors for other insects. In terms of malaria control, if populations of mosquitoes were temporarily reduced to zero in a region, then this would exterminate malaria, and the mosquito population could then be allowed to rebound.

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Dengue fever

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Ghulam Muhammad Sultan Sahib

Prince Sahibzada Sayyid Shareef Ghulam Muhammad Sultan Khan Sahib , KCSI (March 1795 in Srirangapatnam – 11 August 1872 in Tollygunge, Calcutta ) was the youngest son of Tipu Sultan . Deported to Calcutta in 1806 along with the remainder of his family 7 years after the defeat and death of his father, he was eventually recognised by the Government of India as the official head of the family and successor to his father. Known as the last surviving son of Tipu Sultan and Knighted in 1870, he died 2 years later, aged 77, of dengue fever .

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Dengue fever

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Mosquito net

A mosquito net is a type of meshed curtain that is circumferentially draped over a bed or a sleeping area, to offer the sleeper barrier protection against bites and stings from mosquitos , flies , and other pest insects , and thus against the diseases they may carry. Examples of such preventable insect-borne diseases include malaria , dengue fever , yellow fever , zika virus , Chagas disease and various forms of encephalitis , including the West Nile virus . To be effective, the mesh of a mosquito net must be fine enough to exclude such insects without obscuring visibility or ventilation to unacceptable levels. It is possible to increase the effectiveness of a mosquito net greatly by pretreating it with an appropriate insecticide or insect repellent . Research has shown mosquito nets to be an extremely effective method of malaria prevention, averting approximately 663 million cases of malaria over the period 2000–2015. Mosquito netting is mainly used for the protection against the malaria transmitting vector, Anopheles gambiae . The first record of malaria-like symptoms occurred as early as 2700 BCE from China . The vector for this disease was not identified until 1880 when Sir Ronald Ross identified mosquitoes as a vector for malaria. Conopeum or Conopium ( Ancient Greek : κωνώπιον or κωνόπιον or κωνωπεῖον ) was a mosquito-curtain. It was made to keep away mosquitos and other flying insects. It took its name from κώνωψ, which means mosquito in Greek, and is the origin of the English word canopy. These curtains were especially used in Egypt because of the mosquitoes which infest the Nile. The Scholiast on Juvenal mention that at Rome they were called cubiculare . They are still used in Greece and other countries surrounding the Mediterranean. Mosquito netting has a long history. Though use of the term dates from the mid-18th century, Indian literature from the late medieval period has references to the usage of mosquito nets in ritual Hindu worship. Poetry composed by Annamayya , the earliest known Telugu musician and poet, references domatera , which means "mosquito net" in Telugu . Use of mosquito nets has been dated to prehistoric times. It is said that Cleopatra , the last active pharaoh of Ancient Egypt , also slept under a mosquito net. Mosquito nets were used during the malaria-plagued construction of the Suez Canal . Mosquito netting can be made from cotton , polyethylene , polyester , polypropylene , or nylon . A mesh size of 1.2 millimetres (0.047 in) stops mosquitoes, and smaller, such as 0.6 millimetres (0.024 in) , stops other biting insects such as biting midges/no-see-ums . A mosquito bar is an alternate form of a mosquito net. It is constructed of a fine see-through mesh fabric mounted on and draped over a box-shaped frame. It is designed to fit over an area or item such as a sleeping bag to provide protection from insects. A mosquito bar could be used to protect oneself from mosquitoes and other insects while sleeping in jungle areas. The mesh is woven tightly enough to stop insects from entering but loosely enough to not interfere with ventilation. The frame is usually self-supporting or freestanding although it can be designed to be attached from the top to an alternative support such as tree limbs. Mosquito nets are often used where malaria or other insect-borne diseases are common, especially as a tent-like covering over a bed. For effectiveness, it is important that the netting not have holes or gaps large enough to allow insects to enter. It is also important to 'seal' the net properly because mosquitoes are able to 'squeeze' through improperly secured nets. Because an insect can bite a person through the net, the net must not rest directly on the skin. Mosquito netting can be hung over beds from the ceiling or a frame, built into tents , or installed in windows and doors. When hung over beds, rectangular nets provide more room for sleeping without the danger of netting contacting skin, at which point mosquitoes may bite through untreated netting. Some newer mosquito nets are designed to be both easy to deploy and foldable after use. Where mosquito nets are freely or cheaply distributed, local residents sometimes opportunistically use them inappropriately, for example as fishing nets . When used for fishing, mosquito nets have harmful ecological consequences because the fine mesh of a mosquito net retains almost all fish, including bycatch such as immature or small fish and fish species that are not suitable for consumption. In addition, insecticides with which the mesh has been treated, such as permethrin , may be harmful to the fish and other aquatic fauna . Mosquito nets treated with insecticides—known as insecticide-treated nets (ITNs) or bednets—were developed and tested in the 1980s for malaria prevention by P. Carnevale and his team in Bobo-Dioulasso, Burkina Faso . ITNs are estimated to be twice as effective as untreated nets, and offer greater than 70% protection compared with no net. These nets are dip-treated using a synthetic pyrethroid insecticide such as deltamethrin or permethrin which will double the protection over a non-treated net by killing and repelling mosquitoes. For maximum effectiveness, ITNs should be re-impregnated with insecticide every six months. This process poses a significant logistical problem in rural areas. Newer, long-lasting insecticidal nets (LLINs) have now replaced ITNs in most countries. The distribution of mosquito nets or bednets treated with insecticides such as permethrin or deltamethrin has been shown to be an extremely effective method of malaria prevention. According to a 2015 Nature study, mosquito nets averted 68% of an estimated 663 million averted cases of malaria infection since 2000. It is also one of the most cost-effective methods of prevention. These nets can often be obtained for around $2.50–$3.50 (2–3 euros) from the United Nations , the World Health Organization (WHO), and others. ITNs have been shown to be the most cost-effective prevention method against malaria and are part of WHO's Millennium Development Goals (MDGs). Generally LLINs are purchased by donor groups and delivered through in-country distribution networks. ITNs protect people sleeping under them and simultaneously kill mosquitoes that contact the nets. Some protection is provided to others by this method, including people sleeping in the same room but not under the net. However, mathematical modeling has suggested that disease transmission may be exacerbated after bed nets have lost their insecticidal properties under certain circumstances. Although ITN users are still protected by the physical barrier of the netting, non-users could experience an increased bite rate as mosquitoes are deflected away from the non-lethal bed net users. The modeling suggests that this could increase transmission when the human population density is high or at lower human densities when mosquitoes are more adept at locating their blood meals. In December 2019 it was reported that West African populations of Anopheles gambiae include mutants with higher levels of sensory appendage protein 2 (a type of chemosensory protein in the legs), which binds to pyrethroids, sequestering them and so preventing them from functioning, thus making the mosquitoes with this mutation more likely to survive contact with bednets. While some experts argue that international organizations should distribute ITNs and LLINs to people for free to maximize coverage (since such a policy would reduce price barriers), others insist that cost-sharing between the international organization and recipients would lead to greater use of the net (arguing that people will value a good more if they pay for it). Additionally, proponents of cost-sharing argue that such a policy ensures that nets are efficiently allocated to the people who most need them (or are most vulnerable to infection). Through a "selection effect", they argue, the people who most need the bed nets will choose to purchase them, while those less in need will opt out. However, a randomized controlled trial study of ITNs uptake among pregnant women in Kenya , conducted by economists Pascaline Dupas and Jessica Cohen, found that cost-sharing does not necessarily increase the usage intensity of ITNs nor does it induce uptake by those most vulnerable to infection, as compared to a policy of free distribution. In some cases, cost-sharing can decrease demand for mosquito nets by erecting a price barrier. Dupas and Cohen's findings support the argument that free distribution of ITNs can be more effective than cost-sharing in increasing coverage and saving lives. In a cost-effectiveness analysis, Dupas and Cohen note that "cost-sharing is at best marginally more cost-effective than free distribution, but free distribution leads to many more lives saved." The researchers base their conclusions about the cost-effectiveness of free distribution on the proven spillover benefits of increased ITN usage. ITNs protect the individuals or households that use them, and they protect people in the surrounding community in one of two ways. When a large number of nets are distributed in one residential area, their chemical additives help reduce the number of mosquitoes in the environment. With fewer mosquitoes, the chances of malaria infection for recipients and non-recipients are significantly reduced. (In other words, the importance of the physical barrier effect of ITNs decreases relative to the positive externality effect [ clarification needed ] of the nets in creating a mosquito-free environment when ITNs are highly concentrated in one residential cluster or community.) Standard ITNs must be replaced or re-treated with insecticide after six washes and, therefore, are not seen as a convenient, effective long-term solution to the malaria problem. As a result, the mosquito netting and pesticide industries developed so-called long-lasting insecticidal mosquito nets, which also use pyrethroid insecticides. There are three types of LLINs — polyester netting which has insecticide bound to the external surface of the netting fibre using a resin; polyethylene which has insecticide incorporated into the fibre and polypropylene which has insecticide incorporated into the fibre. All types can be washed at least 20 times, but physical durability will vary. A survey carried out in Tanzania concluded that effective life of polyester nets was 2 to 3 years; with polyethylene LLINs there are data to support over 5 years of life with trials in showing nets which were still effective after 7 years. A review of 22 randomized controlled trials of ITNs found (for Plasmodium falciparum malaria) that ITNs can reduce deaths in children by one fifth and episodes of malaria by half. More specifically, in areas of stable malaria "ITNs reduced the incidence of uncomplicated malarial episodes by 50% compared to no nets, and 39% compared to untreated nets" and in areas of unstable malaria "by 62% compared to no nets and 43% compared to untreated nets". As such the review calculated that for every 1000 children protected by ITNs, 5.5 lives would be saved each year. Through the years 1999 and 2010 the abundance of female anopheles gambiae densities in houses throughout western Kenya were recorded. This data set was paired with the spatial data of bed net usage in order to determine correlation. Results showed that from 2008 to 2010 the relative population density of the female anopheles gambiae decreased from 90.6% to 60.7%. The conclusion of this study showed that as the number of houses which used insecticide treated bed nets increased the population density of female anopheles gambiae decreased. This result did however vary from region to region based on the local environment. A 2019 study in PLoS ONE found that a campaign to distribute mosquito bednets in the Democratic Republic of Congo led to a 41% decline mortality for children under five who lived in areas with a high malaria risk. While some experts argue that international organizations should distribute ITNs and LLINs to people for free to maximize coverage (since such a policy would reduce price barriers), others insist that cost-sharing between the international organization and recipients would lead to greater use of the net (arguing that people will value a good more if they pay for it). Additionally, proponents of cost-sharing argue that such a policy ensures that nets are efficiently allocated to the people who most need them (or are most vulnerable to infection). Through a "selection effect", they argue, the people who most need the bed nets will choose to purchase them, while those less in need will opt out. However, a randomized controlled trial study of ITNs uptake among pregnant women in Kenya , conducted by economists Pascaline Dupas and Jessica Cohen, found that cost-sharing does not necessarily increase the usage intensity of ITNs nor does it induce uptake by those most vulnerable to infection, as compared to a policy of free distribution. In some cases, cost-sharing can decrease demand for mosquito nets by erecting a price barrier. Dupas and Cohen's findings support the argument that free distribution of ITNs can be more effective than cost-sharing in increasing coverage and saving lives. In a cost-effectiveness analysis, Dupas and Cohen note that "cost-sharing is at best marginally more cost-effective than free distribution, but free distribution leads to many more lives saved." The researchers base their conclusions about the cost-effectiveness of free distribution on the proven spillover benefits of increased ITN usage. ITNs protect the individuals or households that use them, and they protect people in the surrounding community in one of two ways. When a large number of nets are distributed in one residential area, their chemical additives help reduce the number of mosquitoes in the environment. With fewer mosquitoes, the chances of malaria infection for recipients and non-recipients are significantly reduced. (In other words, the importance of the physical barrier effect of ITNs decreases relative to the positive externality effect [ clarification needed ] of the nets in creating a mosquito-free environment when ITNs are highly concentrated in one residential cluster or community.) Standard ITNs must be replaced or re-treated with insecticide after six washes and, therefore, are not seen as a convenient, effective long-term solution to the malaria problem. As a result, the mosquito netting and pesticide industries developed so-called long-lasting insecticidal mosquito nets, which also use pyrethroid insecticides. There are three types of LLINs — polyester netting which has insecticide bound to the external surface of the netting fibre using a resin; polyethylene which has insecticide incorporated into the fibre and polypropylene which has insecticide incorporated into the fibre. All types can be washed at least 20 times, but physical durability will vary. A survey carried out in Tanzania concluded that effective life of polyester nets was 2 to 3 years; with polyethylene LLINs there are data to support over 5 years of life with trials in showing nets which were still effective after 7 years. A review of 22 randomized controlled trials of ITNs found (for Plasmodium falciparum malaria) that ITNs can reduce deaths in children by one fifth and episodes of malaria by half. More specifically, in areas of stable malaria "ITNs reduced the incidence of uncomplicated malarial episodes by 50% compared to no nets, and 39% compared to untreated nets" and in areas of unstable malaria "by 62% compared to no nets and 43% compared to untreated nets". As such the review calculated that for every 1000 children protected by ITNs, 5.5 lives would be saved each year. Through the years 1999 and 2010 the abundance of female anopheles gambiae densities in houses throughout western Kenya were recorded. This data set was paired with the spatial data of bed net usage in order to determine correlation. Results showed that from 2008 to 2010 the relative population density of the female anopheles gambiae decreased from 90.6% to 60.7%. The conclusion of this study showed that as the number of houses which used insecticide treated bed nets increased the population density of female anopheles gambiae decreased. This result did however vary from region to region based on the local environment. A 2019 study in PLoS ONE found that a campaign to distribute mosquito bednets in the Democratic Republic of Congo led to a 41% decline mortality for children under five who lived in areas with a high malaria risk. Malaria and other arboviruses are known to contribute to economic disparity within that country and vice versa. This opens the stage for corruption associated to the distribution of self-protection aides. The least wealthy members of society are both more likely to be in closer proximity to the vectors' prime habitat and less likely to be protected from the vectors. This increase in probability of being infected increases the demand for self-protection which therefore allows for higher pricing and uneven distribution of self-protection means. A decrease in per capita income exaggerates a high demand for resources such as water and food resulting in civil unrest among communities. Protecting resources as well as attempting to obtain resources are both a cause for conflict. Mosquito nets have been observed to be used in fisheries across the world, where their strength, light weight and free or cheap accessibility make them an attractive tool for fishing. People who use them for fishing catch vast numbers of juvenile fish. Mosquito nets do reduce air flow to an extent and sleeping under a net is hotter than sleeping without one, which can be uncomfortable in tropical areas without air-conditioning . Some alternatives are:

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Dengue fever

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Tropical disease

Tropical diseases are diseases that are prevalent in or unique to tropical and subtropical regions. The diseases are less prevalent in temperate climates , due in part to the occurrence of a cold season , which controls the insect population by forcing hibernation . However, many were present in northern Europe and northern America in the 17th and 18th centuries before modern understanding of disease causation. The initial impetus for tropical medicine was to protect the health of colonial settlers, notably in India under the British Raj . Insects such as mosquitoes and flies are by far the most common disease carrier, or vector . These insects may carry a parasite , bacterium or virus that is infectious to humans and animals. Most often disease is transmitted by an insect bite , which causes transmission of the infectious agent through subcutaneous blood exchange. Vaccines are not available for most of the diseases listed here, and many do not have cures . Human exploration of tropical rainforests , deforestation , rising immigration and increased international air travel and other tourism to tropical regions has led to an increased incidence of such diseases to non-tropical countries. Of particular concern is the habitat loss of reservoir host species. In 1975 the Special Programme for Research and Training in Tropical Diseases (TDR) was established to focus on neglected infectious diseases which disproportionately affect poor and marginalized populations in developing regions of Africa , Asia , Central America and North South America . It was established at the World Health Organization , which is the executing agency, and is co-sponsored by the United Nations Children's Fund , United Nations Development Programme , the World Bank and the World Health Organization . [ citation needed ] TDR's vision is to foster an effective global research effort on infectious diseases of poverty in which disease endemic countries play a pivotal role. It has a dual mission of developing new tools and strategies against these diseases, and to develop the research and leadership capacity in the countries where the diseases occur. The TDR secretariat is based in Geneva, Switzerland, but the work is conducted throughout the world through many partners and funded grants. [ citation needed ] Some examples of work include helping to develop new treatments for diseases, such as ivermectin for onchocerciasis (river blindness); showing how packaging can improve use of artemesinin-combination treatment (ACT) for malaria; demonstrating the effectiveness of bednets to prevent mosquito bites and malaria; and documenting how community-based and community-led programmes increases distribution of multiple treatments. TDR history The current TDR disease portfolio includes the following entries: second stage: insomnia , confusion , ataxia , hemiparesis , paralysis 2 billion (latent, 2018)Additional neglected tropical diseases include: Some tropical diseases are very rare, but may occur in sudden epidemics , such as the Ebola hemorrhagic fever, Lassa fever and the Marburg virus . There are hundreds of different tropical diseases which are less known or rarer, but that, nonetheless, have importance for public health .The so-called "exotic" diseases in the tropics have long been noted both by travelers, explorers, etc., as well as by physicians. One obvious reason is that the hot climate present during all the year and the larger volume of rains directly affect the formation of breeding grounds, the larger number and variety of natural reservoirs and animal diseases that can be transmitted to humans ( zoonosis ), the largest number of possible insect vectors of diseases. It is possible also that higher temperatures may favor the replication of pathogenic agents both inside and outside biological organisms. Socio-economic factors may be also in operation, since most of the poorest nations of the world are in the tropics. Tropical countries like Brazil , which have improved their socio-economic situation and invested in hygiene , public health and the combat of transmissible diseases have achieved dramatic results in relation to the elimination or decrease of many endemic tropical diseases in their territory. [ citation needed ] Climate change , global warming caused by the greenhouse effect , and the resulting increase in global temperatures , are possibly causing tropical diseases and vectors to spread to higher altitudes in mountainous regions, and to higher latitudes that were previously spared, such as the Southern United States , the Mediterranean area, etc. For example, in the Monteverde cloud forest of Costa Rica, global warming enabled Chytridiomycosis, a tropical disease, to flourish and thus force into decline amphibian populations of the Monteverde Harlequin frog. Here, global warming raised the heights of orographic cloud formation, and thus produced cloud cover that would facilitate optimum growth conditions for the implicated pathogen, B. dendrobatidis. [ citation needed ]Vectors are living organisms that pass disease between humans or from animal to human. The vector carrying the highest number of diseases is the mosquito, which is responsible for the tropical diseases dengue and malaria. Many different approaches have been taken to treat and prevent these diseases. NIH-funded research has produced genetically modify mosquitoes that are unable to spread diseases such as malaria. An issue with this approach is global accessibility to genetic engineering technology; Approximately 50% of scientists in the field do not have access to information on genetically modified mosquito trials being conducted. Other prevention methods include: Assisting with economic development in endemic regions can contribute to prevention and treatment of tropical diseases. For example, microloans enable communities to invest in health programs that lead to more effective disease treatment and prevention technology. Educational campaigns can aid in the prevention of various diseases. Educating children about how diseases spread and how they can be prevented has proven to be effective in practicing preventative measures. Educational campaigns can yield significant benefits at low costs. [ citation needed ]Vectors are living organisms that pass disease between humans or from animal to human. The vector carrying the highest number of diseases is the mosquito, which is responsible for the tropical diseases dengue and malaria. Many different approaches have been taken to treat and prevent these diseases. NIH-funded research has produced genetically modify mosquitoes that are unable to spread diseases such as malaria. An issue with this approach is global accessibility to genetic engineering technology; Approximately 50% of scientists in the field do not have access to information on genetically modified mosquito trials being conducted. Other prevention methods include:Assisting with economic development in endemic regions can contribute to prevention and treatment of tropical diseases. For example, microloans enable communities to invest in health programs that lead to more effective disease treatment and prevention technology. Educational campaigns can aid in the prevention of various diseases. Educating children about how diseases spread and how they can be prevented has proven to be effective in practicing preventative measures. Educational campaigns can yield significant benefits at low costs. [ citation needed ]

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Dengue fever

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Naval Medical Research Unit South

Naval Medical Research Unit SOUTH , formerly known as Naval Medical Research Unit Six , is a biomedical research laboratory of the U.S. Navy located in Lima , Peru. It is the only U.S. military command located in South America. Its mission is to identify infectious disease threats of military and public health importance and to develop and evaluate interventions and products to mitigate those threats. NAMRU SOUTH consists of 143,182 square feet (13,302.0 m 2 ) of laboratory and office space in Lima and 5000 square feet of lab space in Iquitos, Peru. The Lima facility includes Biosafety Level 3 (BSL-3) facilities, while the other two laboratories are only biosafety level 2 rated. The Lima facility also contains a vivarium for animal research that is Association for Assessment and Accreditation of Laboratory Animal Care International (AAALAC) certified.Implementation of NAMRU SOUTH's mission is via threefold means: to investigate prophylactic agents such as vaccines and pharmaceuticals against tropical infectious diseases which cause severe mortality or morbidity to the US military member in the deployed environment. Generally the focus of study is "orphan" illnesses with little or no investment by major pharmaceutical companies and includes parasitic infection such as malaria and leishmaniasis, viral diseases such as dengue fever and other arboviruses, and bacterial illnesses like traveler's diarrhea ( ETEC , campylobacter, shigella). to augment public health and military medical infrastructure of host and partner nations by assisting in surveillance of outbreaks and providing laboratory surge capacity during pandemics. to provide assistance in training host nation scientists in epidemiologic techniques or modern laboratory molecular biology methods. Via these collaborations with partner nations, the NAMRU gets to conduct research on diseases that threaten troops on deployment but are not commonly seen in the US, and to get advanced notice of impending pandemics such as avian influenza that might affect military operational readiness. The host nation benefits by getting access to state of the art treatments and protection against diseases endemic to their country and a more robust public health infrastructure and better trained microbiology and physician population. This results in both military and political benefits to both nations and as such all NAMRU personnel are considered diplomats and counted as members of the US embassy in the host country. Partner nations include ministries of Defense or Health in Honduras, El Salvador, Nicaragua, Venezuela, Ecuador, Argentina, Bolivia, Paraguay and Colombia. The lab conducts research throughout Peru including the cities and districts of Arequipa, Cuzco, Junin, La Libertad, Lambayeque, Madre De Dios, Piura, San Martin, Tumbes, Puno, Lima, Loreto and Ucayali. All animal research conducted at NAMRU SOUTH is subject to approval by an Institutional Animal Care and Use Committee (IACUC)and all human research conducted by NAMRU SOUTH is conducted under supervision of duly constituted Institutional Review Board (IRB).The idea for what would become NAMRU South originated in 1978 with an idea of ADM Dileo-Paoli, the Peruvian Surgeon General, who proposed to the US Navy Surgeon General to establish a program of tropical medicine with joint participation between the US and Peruvian Navies. The command began with the arrival of 4 US Navy Active duty members under the Officer in Charge, CDR Michael Kilpatrick on January 20, 1983. The detachment was signed into agreement on October 21, 1983, in Lima between Fernando Schwalb Lopez Aldan, Minister of Foreign Affairs of Peru and Ambassador Frank V. Ortiz. This agreement was further signed by RADM Jorge Tenorio De la Fuente, the Peruvian Surgeon General and VADM Lewis H. Seaton the US Navy Surgeon General in Washington, D.C., on November 14, 1983. On Jan 6th 1984, The US Chief of Naval Operations established the laboratory as a detachment of Naval Medical Research Institute , Bethesda, Maryland, it was then known as the acronym NMRID . In December 1983, Rear Admiral Roger F Milnes represented the US Navy Surgeon General in a ceremony laying the cornerstone of the new 7330 meter facility, jointly funded by the Peruvian and US Navies. This first building was inaugurated on July 4, 1985, by the President of Peru, the Architect Fernando Belaunde Terry and the US Ambassador David Jordan. An annex building for animal research was inaugurated in 1987. The facility was one of the first in Peru to be able to work with BSL-3 agents such as Brucella melitensis , Yersinia pestis and Venezuelan Equine Encephalitis . Additionally in July 1985, the first clinics of investigation were inaugurated on the grounds of the Naval Clinic in Iquitos, Peru. In 1998, NMRID became part of the newly reorganized Naval Medical Research Command . The Base Re-alignment and Closure (BRAC) process had ordered the closure of NMRI on the Bethesda campus and its relocation to the Walter Reed Forest Glen Annex with Walter Reed Army Institute of Research , where it was established as Naval Medical Research Center (NMRC), NAMRID was subsequently renamed as NMRCD to reflect the change of name of its parent command. On 16 November 2010, NMRCD officially changed its command status from a detachment of NMRC with an officer-in-charge, to a full command, U.S. Naval Medical Research Unit No. 6 (NAMRU-6), with a commanding officer. A modern laboratory facility was constructed and inaugurated in Iquitos in July 2005 by US Ambassador Curtis Struble and Vice Admiral Jose Ricardo Rafael Aste Daffos, the head of Amazonian Operations for the Peruvian Navy. The civilian staff has been awarded the Department of the Navy Award of Merit for Group Achievement twice, once in 1990 and again from 1995 to 1997. Important scientific achievements include completing a Cholera vaccine field efficacy trial on 18,000 volunteers in Peru in 1993, development of an FDA approved rapid malaria diagnostic test (BinaxNow) from 1996 to 2001, the first clinical descriptions of Mayaro virus in 1999, the first identification of novel strains of dengue in Peru in 2000-1, investigations of HIV and hepatitis , conducting field efficacy trials resulting in region specific national malaria treatment guidelines in 2000, association of spotted fever rickettsia with an outbreak of febrile illness in 2004, demonstrating superiority of glucantime to pentamidine therapy for cutaneous leishmaniasis in 2005, developing non-human primate models of campylobacter and Enterotoxigenic Escherichia coli diarrhea, a field trial of two yellow fever vaccines in children in 2005, and the discovery of Iquitos virus in 2010. In 2023, the laboratory was renamed U.S. Naval Medical Research Unit SOUTH to better reflect its geographical mission and commitment to Navy and regional partners in Central and South America.Surveillance of influenza: NAMRU SOUTH is active in the global response to the threat of avian and pandemic influenza including an outbreak of H1N1 on Peruvian ship Mollendo in 2009. Surveillance of febrile illness in four countries. Electronic Surveillance in militaries of Peru, Paraguay, Uruguay, and Ecuador using the Vigilia open-source system developed by Johns' Hopkins Applied Physics lab Investigation of Multi-drug resistant Nosocomial bacterial infection Surveillance of traveler's diarrhea at a Spanish school in Cuzco Peru. Pre-clinical investigation of vaccines for Enterotoxigenic E. coli, Shigella, Campylobacter jejuni, Dengue, malaria in an Aotus nancymaae model of infection Development of a point of care diagnostic assay for Dengue fever Evaluation of insecticide treated curtains Evaluation of lethal ovitraps for mosquito control Developing a Plasmodium vivax infected mosquito model Evaluation of the trans-oceanic highway on disease ecology in the Amazon rainforest. Training in outbreak investigation methods Joint training in a Master's of epidemiology program

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Dengue fever

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2020 dengue outbreak in Singapore

In the 2020 dengue outbreak in Singapore , a record-breaking number of dengue fever cases was reported in Singapore. This was part of the wider 2019–2020 dengue fever epidemic which also affected several neighbouring countries in Southeast Asia. A locally uncommon strain of the dengue virus — one that the local populace would be more susceptible to – had begun to reemerge toward the end of 2019. This contributed to a four-year high in the number of people infected in the first six weeks of 2020, establishing a high baseline for disease incidence even before the onset of the peak dengue season in the middle of the year. There was a steep climb in the rate of infection beginning in May, and by early July the total number of cases for the year was projected to surpass the previous high of 22,170 recorded in the 2013 outbreak . The weekly disease incidence would reach a historic peak of 1,792 new cases during the week of 19–25 July. This surge of infections drove the cumulative number of cases to 22,403 on 5 August 2020, breaking the 2013 record. On 14 October, the number of deaths due to dengue reached 28, surpassing the previous record from the 2005 outbreak . The year ended with a total of 35,315 dengue fever cases, including 54 instances of dengue haemorrhagic fever, a more severe form of the disease. 32 deaths were attributed to the disease. There are four strains of dengue virus, DENV-1 to DENV-4. Infection with one serotype confers immunity against it, but not the others. Since 2016, DENV-2 had been the dominant strain in Singapore, causing the majority of infections. There had not been an outbreak of the less common DENV-3 in Singapore for nearly three decades, so the local population had lower immunity against it and was more susceptible to infection when DENV-3 returned as the dominant strain from January to April 2020. This contributed to an unusually high number of infections even before the start of the mid-year peak dengue season, which in turn increased the momentum of dengue transmission. Response against the dengue outbreak was complicated by the concurrent COVID-19 pandemic (and vice versa), with the simultaneous outbreaks putting strain on the local healthcare system . Before the development and widespread availability of accurate COVID-19 tests , doctors faced challenges in rendering the correct diagnosis, as the two diseases share some of the same early symptoms, and have clinical and laboratory characteristics in common. In February, during the early stages of the coronavirus pandemic, two patients in Singapore initially recorded false-positive test results for dengue and were thus misdiagnosed before later being found to actually have COVID-19 ; this included one patient who was originally reported as the first to have been infected with both diseases. The discovery of such false-positive cases uncovered the risk of healthcare-associated infections , since mistaking COVID-19 for dengue could lead to the adoption of a lower level of infection control than would actually be required. Consequently, additional care had to be taken during the hospital triage process, with full precautions taken when screening patients, until COVID-19 could be eliminated as a possibility. Conversely, protective measures against COVID-19 can create bottlenecks in healthcare systems and lead to delays in diagnosis; confirmation that a patient does not pose a COVID-19 risk requires two consecutive negative test results obtained at least 24 hours apart. However, dengue fever is also potentially deadly, and failure to treat it promptly during its critical phase can negatively impact survival outcomes. Therefore, "detailed and strict" protocols needed to be developed and implemented to distinguish between the two diseases and conduct necessary treatment while managing the risk of COVID-19 transmission. The "circuit breaker" measures implemented by the Government of Singapore to contain the spread of COVID-19 contributed to an increase in dengue cases among the general population between April and June. The Aedes aegypti mosquito , the primary vector for dengue, is a daytime feeder that dwells in indoor environments. When all schools and 95% of workplaces were closed due to the stay-at-home-order, it forced a dramatic shift in the mobility patterns of all school-aged children and a majority of working-age adults. As more people remained at home during the day due to the lockdown, this increased the number of prospective hosts for mosquitoes to target, helping fuel an increase in disease spread. A study carried out by the NEA and the School of Public Health at the National University of Singapore performed difference in differences statistical analysis to determine how changes in mobility patterns during the circuit breaker period impacted dengue infection rates. After compensating for other factors such as weather (which affects mosquito breeding and activity), seasonal effects (a surge of dengue infections is usually observed in the mid-year peak season), and the higher initial number of cases at the beginning of 2020, the study found that there were 37.2% more dengue infections (with a 95% confidence interval of 19.9%–49.8%) than would have otherwise occurred without the stay-at-home-order. Working-age adults represented the bulk of the additional infections, as they spent more time working from homes with natural ventilation, rather than at their workplaces, most of which are better protected against mosquitoes due to air-conditioning. Schoolchildren were affected to a lesser extent, experiencing a 12% increase in the number of cases compared to the norm. The reopening of schools partway through the circuit breaker has been postulated as a possible reason, as well as the fact that students would usually be home before dusk, a time of peak mosquito biting activity. The COVID-19 lockdown also had an undesirable effect on mosquito breeding. The stoppage of construction work meant that construction sites were maintained only by skeleton crews and as such more prone to accumulation of stagnant water from regular rainfall, leading to more mosquito breeding sites. Vector control inspections conducted at construction sites from April to June 2020 found that 18% them harboured mosquito breeding areas, triple the amount compared to the prior three months. A labour shortage caused by COVID-19 infections among the migrant worker population forced some landscaping works to be deferred, leading to an increase in untrimmed vegetation that provided a hospitable environment for mosquitoes. Residential areas also experienced an increase in mosquito breeding throughout the stay-at-home-order, with a sharp rise in the number of mosquito breeding sites found by vector control inspectors in homes and common areas of public housing blocks during this period, amounting to five times that of the two months prior. This was despite a sustained publicity campaign that exhorted the community to take preventive measures to eliminate potential breeding habitats, and contrary to expectations that residents, being confined to their homes, would be better able to implement the necessary steps. Public health experts have suggested that this could be because housekeeping demands actually increased during this period, with residents having to divide their time between remote work and child care , along with the need to prepare additional meals. On the other hand, the circuit breaker period led to a decrease in dengue infections among the migrant workforce population in Singapore. This demographic group mostly lives in densely-packed shared dormitories, and were thus disproportionately impacted by COVID-19. To help contain the spread of COVID-19, strict quarantine protocols were implemented to confine workers to their dormitories, with several being declared as "isolation areas". These measures are estimated to have led to a 68.5% reduction in the risk of contracting dengue fever for these foreign workers, or about 432 fewer cases over the duration of the quarantine, highlighting the elevated risk of dengue that migrant workers routinely face when at work. There are four strains of dengue virus, DENV-1 to DENV-4. Infection with one serotype confers immunity against it, but not the others. Since 2016, DENV-2 had been the dominant strain in Singapore, causing the majority of infections. There had not been an outbreak of the less common DENV-3 in Singapore for nearly three decades, so the local population had lower immunity against it and was more susceptible to infection when DENV-3 returned as the dominant strain from January to April 2020. This contributed to an unusually high number of infections even before the start of the mid-year peak dengue season, which in turn increased the momentum of dengue transmission. Response against the dengue outbreak was complicated by the concurrent COVID-19 pandemic (and vice versa), with the simultaneous outbreaks putting strain on the local healthcare system . Before the development and widespread availability of accurate COVID-19 tests , doctors faced challenges in rendering the correct diagnosis, as the two diseases share some of the same early symptoms, and have clinical and laboratory characteristics in common. In February, during the early stages of the coronavirus pandemic, two patients in Singapore initially recorded false-positive test results for dengue and were thus misdiagnosed before later being found to actually have COVID-19 ; this included one patient who was originally reported as the first to have been infected with both diseases. The discovery of such false-positive cases uncovered the risk of healthcare-associated infections , since mistaking COVID-19 for dengue could lead to the adoption of a lower level of infection control than would actually be required. Consequently, additional care had to be taken during the hospital triage process, with full precautions taken when screening patients, until COVID-19 could be eliminated as a possibility. Conversely, protective measures against COVID-19 can create bottlenecks in healthcare systems and lead to delays in diagnosis; confirmation that a patient does not pose a COVID-19 risk requires two consecutive negative test results obtained at least 24 hours apart. However, dengue fever is also potentially deadly, and failure to treat it promptly during its critical phase can negatively impact survival outcomes. Therefore, "detailed and strict" protocols needed to be developed and implemented to distinguish between the two diseases and conduct necessary treatment while managing the risk of COVID-19 transmission. The "circuit breaker" measures implemented by the Government of Singapore to contain the spread of COVID-19 contributed to an increase in dengue cases among the general population between April and June. The Aedes aegypti mosquito , the primary vector for dengue, is a daytime feeder that dwells in indoor environments. When all schools and 95% of workplaces were closed due to the stay-at-home-order, it forced a dramatic shift in the mobility patterns of all school-aged children and a majority of working-age adults. As more people remained at home during the day due to the lockdown, this increased the number of prospective hosts for mosquitoes to target, helping fuel an increase in disease spread. A study carried out by the NEA and the School of Public Health at the National University of Singapore performed difference in differences statistical analysis to determine how changes in mobility patterns during the circuit breaker period impacted dengue infection rates. After compensating for other factors such as weather (which affects mosquito breeding and activity), seasonal effects (a surge of dengue infections is usually observed in the mid-year peak season), and the higher initial number of cases at the beginning of 2020, the study found that there were 37.2% more dengue infections (with a 95% confidence interval of 19.9%–49.8%) than would have otherwise occurred without the stay-at-home-order. Working-age adults represented the bulk of the additional infections, as they spent more time working from homes with natural ventilation, rather than at their workplaces, most of which are better protected against mosquitoes due to air-conditioning. Schoolchildren were affected to a lesser extent, experiencing a 12% increase in the number of cases compared to the norm. The reopening of schools partway through the circuit breaker has been postulated as a possible reason, as well as the fact that students would usually be home before dusk, a time of peak mosquito biting activity. The COVID-19 lockdown also had an undesirable effect on mosquito breeding. The stoppage of construction work meant that construction sites were maintained only by skeleton crews and as such more prone to accumulation of stagnant water from regular rainfall, leading to more mosquito breeding sites. Vector control inspections conducted at construction sites from April to June 2020 found that 18% them harboured mosquito breeding areas, triple the amount compared to the prior three months. A labour shortage caused by COVID-19 infections among the migrant worker population forced some landscaping works to be deferred, leading to an increase in untrimmed vegetation that provided a hospitable environment for mosquitoes. Residential areas also experienced an increase in mosquito breeding throughout the stay-at-home-order, with a sharp rise in the number of mosquito breeding sites found by vector control inspectors in homes and common areas of public housing blocks during this period, amounting to five times that of the two months prior. This was despite a sustained publicity campaign that exhorted the community to take preventive measures to eliminate potential breeding habitats, and contrary to expectations that residents, being confined to their homes, would be better able to implement the necessary steps. Public health experts have suggested that this could be because housekeeping demands actually increased during this period, with residents having to divide their time between remote work and child care , along with the need to prepare additional meals. On the other hand, the circuit breaker period led to a decrease in dengue infections among the migrant workforce population in Singapore. This demographic group mostly lives in densely-packed shared dormitories, and were thus disproportionately impacted by COVID-19. To help contain the spread of COVID-19, strict quarantine protocols were implemented to confine workers to their dormitories, with several being declared as "isolation areas". These measures are estimated to have led to a 68.5% reduction in the risk of contracting dengue fever for these foreign workers, or about 432 fewer cases over the duration of the quarantine, highlighting the elevated risk of dengue that migrant workers routinely face when at work. Response against the dengue outbreak was complicated by the concurrent COVID-19 pandemic (and vice versa), with the simultaneous outbreaks putting strain on the local healthcare system . Before the development and widespread availability of accurate COVID-19 tests , doctors faced challenges in rendering the correct diagnosis, as the two diseases share some of the same early symptoms, and have clinical and laboratory characteristics in common. In February, during the early stages of the coronavirus pandemic, two patients in Singapore initially recorded false-positive test results for dengue and were thus misdiagnosed before later being found to actually have COVID-19 ; this included one patient who was originally reported as the first to have been infected with both diseases. The discovery of such false-positive cases uncovered the risk of healthcare-associated infections , since mistaking COVID-19 for dengue could lead to the adoption of a lower level of infection control than would actually be required. Consequently, additional care had to be taken during the hospital triage process, with full precautions taken when screening patients, until COVID-19 could be eliminated as a possibility. Conversely, protective measures against COVID-19 can create bottlenecks in healthcare systems and lead to delays in diagnosis; confirmation that a patient does not pose a COVID-19 risk requires two consecutive negative test results obtained at least 24 hours apart. However, dengue fever is also potentially deadly, and failure to treat it promptly during its critical phase can negatively impact survival outcomes. Therefore, "detailed and strict" protocols needed to be developed and implemented to distinguish between the two diseases and conduct necessary treatment while managing the risk of COVID-19 transmission. The "circuit breaker" measures implemented by the Government of Singapore to contain the spread of COVID-19 contributed to an increase in dengue cases among the general population between April and June. The Aedes aegypti mosquito , the primary vector for dengue, is a daytime feeder that dwells in indoor environments. When all schools and 95% of workplaces were closed due to the stay-at-home-order, it forced a dramatic shift in the mobility patterns of all school-aged children and a majority of working-age adults. As more people remained at home during the day due to the lockdown, this increased the number of prospective hosts for mosquitoes to target, helping fuel an increase in disease spread. A study carried out by the NEA and the School of Public Health at the National University of Singapore performed difference in differences statistical analysis to determine how changes in mobility patterns during the circuit breaker period impacted dengue infection rates. After compensating for other factors such as weather (which affects mosquito breeding and activity), seasonal effects (a surge of dengue infections is usually observed in the mid-year peak season), and the higher initial number of cases at the beginning of 2020, the study found that there were 37.2% more dengue infections (with a 95% confidence interval of 19.9%–49.8%) than would have otherwise occurred without the stay-at-home-order. Working-age adults represented the bulk of the additional infections, as they spent more time working from homes with natural ventilation, rather than at their workplaces, most of which are better protected against mosquitoes due to air-conditioning. Schoolchildren were affected to a lesser extent, experiencing a 12% increase in the number of cases compared to the norm. The reopening of schools partway through the circuit breaker has been postulated as a possible reason, as well as the fact that students would usually be home before dusk, a time of peak mosquito biting activity. The COVID-19 lockdown also had an undesirable effect on mosquito breeding. The stoppage of construction work meant that construction sites were maintained only by skeleton crews and as such more prone to accumulation of stagnant water from regular rainfall, leading to more mosquito breeding sites. Vector control inspections conducted at construction sites from April to June 2020 found that 18% them harboured mosquito breeding areas, triple the amount compared to the prior three months. A labour shortage caused by COVID-19 infections among the migrant worker population forced some landscaping works to be deferred, leading to an increase in untrimmed vegetation that provided a hospitable environment for mosquitoes. Residential areas also experienced an increase in mosquito breeding throughout the stay-at-home-order, with a sharp rise in the number of mosquito breeding sites found by vector control inspectors in homes and common areas of public housing blocks during this period, amounting to five times that of the two months prior. This was despite a sustained publicity campaign that exhorted the community to take preventive measures to eliminate potential breeding habitats, and contrary to expectations that residents, being confined to their homes, would be better able to implement the necessary steps. Public health experts have suggested that this could be because housekeeping demands actually increased during this period, with residents having to divide their time between remote work and child care , along with the need to prepare additional meals. On the other hand, the circuit breaker period led to a decrease in dengue infections among the migrant workforce population in Singapore. This demographic group mostly lives in densely-packed shared dormitories, and were thus disproportionately impacted by COVID-19. To help contain the spread of COVID-19, strict quarantine protocols were implemented to confine workers to their dormitories, with several being declared as "isolation areas". These measures are estimated to have led to a 68.5% reduction in the risk of contracting dengue fever for these foreign workers, or about 432 fewer cases over the duration of the quarantine, highlighting the elevated risk of dengue that migrant workers routinely face when at work. The NEA conducted public communications and outreach campaigns to increase awareness and encourage the community to take preventive steps to prevent the spread of dengue. In light of the outbreak, its annual National Dengue Prevention Campaign, which usually takes place during the mid-year peak dengue season, was brought forward to March, and extended to cover a two-month duration until May. NEA also took preventive vector control measures against the Aedes aegypti mosquito, working with town councils to eliminate stagnant water and prevent mosquito breeding and coordinate chemical treatment with insecticides and larvicides in dengue clusters to reduce the mosquito population. This included an "intensive" two-week exercise as the outbreak peaked in July. Over the course of the year, about 1 million inspections were conducted of homes, common areas of housing estates, construction sites and other premises to root out mosquito breeding habitats, uncovering about 23,400 instances. After the number of mosquito breeding sites found in home inspections quintupled during the COVID-19 circuit breaker period, the NEA further tightened enforcement with increased fines from 15 July onward. During the peak dengue season between June and October, the Ministry of Health and NEA distributed over 300,000 bottles of mosquito repellent to dengue patients to prevent them from getting bitten, thus helping to break the chain of transmission and protect others around them. In August, another 46,000 bottles were given to students of 37 schools in dengue-hit areas. The NEA expanded ongoing studies of new vector control methods involving the release of male mosquitoes carrying the Wolbachia bacteria into the field to mate with wild (non- Wolbachia -carrying) females. The resulting eggs are unable to hatch, leading to a decline in the mosquito population, with a reduction of up to 90% being observed.

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Dengue fever

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Rickettsia

R. conorii subsp. caspia R. conorii subsp. conorii R. conorii subsp. indica R. conorii subsp. israelensis Rickettsia is a genus of nonmotile , gram-negative , nonspore-forming , highly pleomorphic bacteria that may occur in the forms of cocci (0.1 μm in diameter), bacilli (1–4 μm long), or threads (up to about 10 μm long). The genus was named after Howard Taylor Ricketts in honor of his pioneering work on tick-borne spotted fever . Properly, Rickettsia is the name of a single genus, but the informal term "rickettsia", plural "rickettsias", usually not capitalised, commonly applies to any members of the order Rickettsiales . Being obligate intracellular bacteria , rickettsias depend on entry, growth, and replication within the cytoplasm of living eukaryotic host cells (typically endothelial cells). Accordingly, Rickettsia species cannot grow in artificial nutrient culture; they must be grown either in tissue or embryo cultures; typically, chicken embryos are used, following a method developed by Ernest William Goodpasture and his colleagues at Vanderbilt University in the early 1930s. Many new strains or species of Rickettsia are described each year. Some Rickettsia species are pathogens of medical and veterinary interest, but many Rickettsia are non-pathogenic to vertebrates, including humans, and infect only arthropods, often non-hematophagous, such as aphids or whiteflies. Many Rickettsia species are thus arthropod-specific symbionts, but are often confused with pathogenic Rickettsia (especially in medical literature), showing that the current view in rickettsiology has a strong anthropocentric bias. Pathogenic Rickettsia species are transmitted by numerous types of arthropods , including chigger , ticks , fleas , and lice , and are associated with both human and plant diseases. Most notably, Rickettsia species are the pathogens responsible for typhus , rickettsialpox , boutonneuse fever , African tick-bite fever , Rocky Mountain spotted fever , Flinders Island spotted fever , and Queensland tick typhus ( Australian tick typhus). The majority of pathogenic Rickettsia bacteria are susceptible to antibiotics of the tetracycline group.The classification of Rickettsia into three groups (spotted fever, typhus, and scrub typhus ) was initially based on serology . This grouping has since been confirmed by DNA sequencing . All three of these groups include human pathogens . The scrub typhus group has been reclassified as a related new genus, Orientia , but they still are in the order Rickettsiales and accordingly still are grouped with the rest of the rickettsial diseases. [ citation needed ] Rickettsias are more widespread than previously believed and are known to be associated with arthropods , leeches , and protists . Divisions have also been identified in the spotted fever group and this group likely should be divided into two clades . Arthropod-inhabiting rickettsiae are generally associated with reproductive manipulation (such as parthenogenesis ) to persist in host lineage. In March 2010, Swedish researchers reported a case of bacterial meningitis in a woman caused by Rickettsia helvetica previously thought to be harmless. Magnetococcus marinus Holosporales Hyphomicrobiales , Rhodobacteraceae , Rhodospirillales , Sphingomonadales , etc . Pelagibacter Subgroups Ib, II, IIIa, IIIb, IV and V Proto-mitochondria Neorickettsia Wolbachia Anaplasma Ehrlichia Midichloria Orientia RickettsiaMagnetococcus marinus Holosporales Hyphomicrobiales , Rhodobacteraceae , Rhodospirillales , Sphingomonadales , etc . Pelagibacter Subgroups Ib, II, IIIa, IIIb, IV and V Proto-mitochondria Neorickettsia Wolbachia Anaplasma Ehrlichia Midichloria Orientia RickettsiaPlant diseases have been associated with these Rickettsia -like organisms (RLOs): Infection occurs in nonhuman mammals; for example, species of Rickettsia have been found to afflict the South American guanaco , Lama guanacoe potentially marsupials and reptiles. Rickettsial organisms are obligate intracellular parasites and invade vascular endothelial cells in target organs, damaging them and producing increased vascular permeability with consequent oedema , hypotension , and hypoalbuminaemia . Certain segments of rickettsial genomes resemble those of mitochondria . The deciphered genome of R. prowazekii is 1,111,523 bp long and contains 834 genes . Unlike free-living bacteria, it contains no genes for anaerobic glycolysis or genes involved in the biosynthesis and regulation of amino acids and nucleosides . In this regard, it is similar to mitochondrial genomes; in both cases, nuclear (host) resources are used. ATP production in Rickettsia is the same as that in mitochondria. In fact, of all the microbes known, the Rickettsia is probably the closest relative (in a phylogenetic sense) to the mitochondria. Unlike the latter, the genome of R. prowazekii , however, contains a complete set of genes encoding for the tricarboxylic acid cycle and the respiratory chain complex. Still, the genomes of the Rickettsia , as well as the mitochondria, are frequently said to be "small, highly derived products of several types of reductive evolution". The recent discovery of another parallel between Rickettsia and viruses may become a basis for fighting HIV infection. Human immune response to the scrub typhus pathogen, Orientia tsutsugamushi , appears to provide a beneficial effect against HIV infection progress, negatively influencing the virus replication process. A probable reason for this actively studied phenomenon is a certain degree of homology between the rickettsiae and the virus, namely, common epitope (s) due to common genome fragment(s) in both pathogens. Surprisingly, the other infection reported to be likely to provide the same effect (decrease in viral load) is the virus-caused illness dengue fever . Comparative analysis of genomic sequences have also identified five conserved signature indels in important proteins, which are uniquely found in members of the genus Rickettsia . These indels consist of a four-amino-acid insertion in transcription repair coupling factor Mfd, a 10-amino-acid insertion in ribosomal protein L19, a one-amino-acid insertion in FtsZ , a one-amino-acid insertion in major sigma factor 70, and a one-amino-acid deletion in exonuclease VII . These indels are all characteristic of the genus and serve as molecular markers for Rickettsia . Bacterial small RNAs play critical roles in virulence and stress/adaptation responses. Although their specific functions have not been discovered in Rickettsia , few studies showed the expression of novel sRNA in human microvascular endothelial cells (HMEC) infected with Rickettsia . Genomes of intracellular or parasitic bacteria undergo massive reduction compared to their free-living relatives. Examples include Rickettsia for alpha proteobacteria, T. whipplei for Actinobacteria, Mycoplasma for Firmicutes (the low G+C content Gram-positive), and Wigglesworthia and Buchnera for gamma proteobacteria. The genus Rickettsia is named after Howard Taylor Ricketts (1871–1910), who studied Rocky Mountain spotted fever in the Bitterroot Valley of Montana, and eventually died of typhus after studying that disease in Mexico City. In his early part of career, he undertook research at Northwestern University on blastomycosis. He later worked on Rocky Mountain spotted fever at the University of Chicago and Bitterroot Valley of Montana. He was so devoted to his research that on several occasions,he injected himself with pathogens to study their effects. On account of the apparent similarity between Rocky Mountain fever and typhus fever, he became occupied in investigating the latter in Chicago where the disease was epidemic, and became a victim of the epidemic in 1910. His investigations and discoveries added materially to the sum of medical knowledge.

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Dengue fever

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Tick-borne encephalitis

Tick-borne encephalitis ( TBE ) is a viral infectious disease involving the central nervous system . The disease most often manifests as meningitis , encephalitis or meningoencephalitis . Myelitis and spinal paralysis also occurs. In about one third of cases sequelae , predominantly cognitive dysfunction, persist for a year or more. The number of reported cases has been increasing in most countries. TBE is posing a concerning health challenge to Europe, as the number of reported human cases of TBE in all endemic regions of Europe have increased by almost 400% within the last three decades. The tick-borne encephalitis virus is known to infect a range of hosts including ruminants , birds , rodents , carnivores, horses , and humans. The disease can also be spread from animals to humans , with ruminants and dogs providing the principal source of infection for humans. The disease is most often biphasic . After an incubation period of approximately one week (range: 4–28 days) from exposure (tick bite) non-specific symptoms occurs. These symptoms are fever, malaise, headache, nausea, vomiting and myalgias that persist for about 5 days. Then, after approximately one week without symptoms, some of the infected develop neurological symptoms, i.e. meningitis, encephalitis or meningoencephalitis. Myelitis also occurs with or without encephalitis. Sequelae persist for a year or more in approximately one third of people who develop neurological disease. Most common long-term symptoms are headache, concentration difficulties, memory impairment and other symptoms of cognitive dysfunction. Mortality depends on the subtype of the virus. For the European subtype mortality rates are 0.5% to 2% for people who develop neurological disease. In dogs, the disease also manifests as a neurological disorder with signs varying from tremors to seizures and death. In ruminants, neurological disease is also present, and animals may refuse to eat, appear lethargic, and also develop respiratory signs. TBE is caused by tick-borne encephalitis virus , a member of the genus Flavivirus in the family Flaviviridae . It was first isolated in 1937. Three virus sub-types also exist: The former Soviet Union conducted research on tick-borne diseases, including the TBE viruses. It is transmitted by the bite of several species of infected woodland ticks , including Ixodes scapularis , I. ricinus and I. persulcatus , or (rarely) through the non-pasteurized milk of infected cows. Infection acquired through goat milk consumed as raw milk or fresh cheese (Frischkäse) has been documented in 2016 and 2017 in the German state of Baden-Württemberg . None of the infected had neurological disease. It is transmitted by the bite of several species of infected woodland ticks , including Ixodes scapularis , I. ricinus and I. persulcatus , or (rarely) through the non-pasteurized milk of infected cows. Infection acquired through goat milk consumed as raw milk or fresh cheese (Frischkäse) has been documented in 2016 and 2017 in the German state of Baden-Württemberg . None of the infected had neurological disease. Detection of specific IgM and IgG antibodies in patients' sera combined with typical clinical signs, is the principal method for diagnosis. In more complicated situations, e.g. after vaccination, testing for presence of antibodies in cerebrospinal fluid may be necessary. It has been stated that lumbar puncture always should be performed when diagnosing TBE and that pleocytosis in cerebrospinal fluid should be added to the diagnostic criteria. PCR ( polymerase chain reaction ) method is rarely used, since TBE virus RNA is most often not present in patient sera or cerebrospinal fluid at the time of neurological symptoms. Prevention includes non-specific (tick-bite prevention) and specific prophylaxis in the form of a vaccination . Tick checks, while useful for preventing some other tick-borne diseases such as Lyme borreliosis , would not be expected to be effective in the prevention of tick-borne encephalitis as the virus is transmitted within minutes of attachment by the tick. Tick-borne encephalitis vaccines are very effective and available in many disease endemic areas and in travel clinics. Trade names are Encepur N and FSME-Immun CC . There is no specific antiviral treatment for TBE. Symptomatic brain damage requires hospitalization and supportive care based on syndrome severity. Anti-inflammatory drugs , such as corticosteroids , may be considered under specific circumstances for symptomatic relief. Tracheal intubation and respiratory support may be necessary.As of 2011, the disease was most common in Central and Eastern Europe, and Northern Asia. About ten to twelve thousand cases are documented a year but the rates vary widely from one region to another. Most of the variation has been the result of variation in host population, particularly that of deer. In Austria, an extensive vaccination program since the 1970s reduced the incidence in 2013 by roughly 85%. In Germany, during the 2010s, there have been a minimum of 95 (2012) and a maximum of 584 cases (2018) of TBE (or FSME as it is known in German). More than half of the reported cases from 2019 had meningitis , encephalitis or myelitis . The risk of infection was noted to be increasing with age, especially in people older than 40 years and it was greater in men than women. Most cases were acquired in Bavaria (46%) and Baden-Württemberg (37%), much less in Saxony, Hesse, Lower Saxony and other states. Altogether 164 Landkreise are designated TBE-risk areas, including all of Baden-Württemberg except for the city of Heilbronn. In Sweden, most cases of TBE occur in a band running from Stockholm to the west, especially around lakes and the nearby region of the Baltic sea. It reflects the greater population involved in outdoor activities in these areas. Overall, for Europe, the estimated risk is roughly 1 case per 10,000 human-months of woodland activity. Although in some regions of Russia and Slovenia, the prevalence of cases can be as high as 70 cases per 100,000 people per year. Travelers to endemic regions do not often become cases, with only 8 cases reported among U.S. travelers returning from Eurasia between 2000 and 2017, a rate so low that as of 2020 the U.S. Centers for Disease Control and Prevention recommended vaccination only for those who will be extensively exposed in high risk areas.

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Dengue fever

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World Health Day

World Health Day is a global health awareness day celebrated every year on 7 April, under the sponsorship of the World Health Organization (WHO), as well as other related organizations. In 1948, the WHO held the First World Health Assembly . The Assembly decided to celebrate 7 April of each year, with effect from 1950, as the World Health Day. The World Health Day is held to mark WHO's founding and is seen as an opportunity by the organization to draw worldwide attention to a subject of major importance to global health each year. The WHO organizes international, regional and local events on the Day related to a particular theme. World Health Day is acknowledged by various governments and non-governmental organizations with interests in public health issues, who also organize activities and highlight their support in media reports, such as the Global Health Council . World Health Day is one of 11 official global health campaigns marked by WHO, along with World Tuberculosis Day , World Immunization Week , World Malaria Day , World No Tobacco Day , World AIDS Day , World Blood Donor Day , World Chagas Disease Day , World Patient Safety Day , World Antimicrobial Awareness Week and World Hepatitis Day . 1991: Should Disaster Strike, be prepared 1992: Heart beat: A rhythm of Health 1993: Handle life with care: Prevent violence and Negligence 1994: Oral Health for a Healthy Life 1995: Global Polio Eradication 1996: Healthy Cities for better life 1997: Emerging infectious diseases 1998: Safe motherhood 1999: Active aging makes the difference 2000: Safe Blood starts with me 2001: Mental Health : stop exclusion, dare to care 2002: Move for health 2003: Shape the future of life: healthy environments for children 2004: Road safety 2005: Make every mother and child count 2006: Working together for health In 2006, World Health Day was devoted to the health workforce crisis, or chronic shortages of health workers around the world due to decades of underinvestment in their education, training, salaries, working environment and management. The day was also meant to celebrate individual health workers – the people who provide health care to those who need it, in other words those at the heart of health systems . The Day also marked the launch of the WHO's World Health Report 2006 , which focused on the same theme. The report contained an assessment of the current crisis in the global health workforce, revealing an estimated shortage of almost 4.3 million physicians, midwives, nurses and other health care providers worldwide, and further proposed a series of actions for countries and the international community to tackle it. In 2008, World Health Day focused on the need to protect health from the adverse effects of climate change and establish links between climate change and health and other development areas such as environment, food, energy, transport. The theme "protecting health from climate change" put health at the centre of the global dialogue about climate change. WHO selected this theme in recognition that climate change is posing ever growing threats to global public health security. World Health Day 2009 focused on the safety of health facilities and the readiness of health workers who treat those affected by emergencies. Health centres and staff are critical lifelines for vulnerable people in disasters – treating injuries , preventing illnesses and caring for people's health needs. Often, already fragile health systems are unable to keep functioning through a disaster, with immediate and future public health consequences. For this year's World Health Day campaign, WHO and international partners underscored the importance of investing in health infrastructure that can withstand hazards and serve people in immediate need, and urged health facilities to implement systems to respond to internal emergencies, such as fires, and ensure the continuity of care. With the campaign "1000 cities, 1000 lives", events were organized worldwide during the week starting 7 April 2010. The global goals of the campaign were: 1000 cities : to open up public spaces to health, whether it be activities in parks, town hall meetings, clean-up campaigns, or closing off portions of streets to motorized vehicles. 1000 lives : to collect 1000 stories of urban health champions who have taken action and had a significant impact on health in their cities. The theme of World Health Day 2011, marked on 7 April 2011, was " antimicrobial resistance and its global spread" and focused on the need for governments and stakeholders to implement the policies and practices needed to prevent and counter the emergence of highly resistant microorganisms . When infections caused by resistant microorganisms fail to respond to standard treatments, including antibiotics and other antimicrobial medicines – also known as drug resistance – this may result in prolonged illness and greater risk of death. On World Health Day 2011, WHO called for intensified global commitment to safeguard antimicrobial medicines for future generations. The organization introduced a six-point policy package to combat the spread of antimicrobial resistance: Commit to a comprehensive, financed national plan with accountability and civil society engagement. Strengthen surveillance and laboratory capacity. Ensure uninterrupted access to essential medicines of assured quality. Regulate and promote rational use of medicines, including in animal husbandry, and ensure proper patient care; reduce use of antimicrobials in food-producing animals. Enhance infection prevention and control. Foster innovations and research and development for new tools. World Health Day 2012 was marked with the slogan "Good health adds life to years". Life expectancy is going up in most countries, meaning more and more people live longer and enter an age when they may need health care . Meanwhile, birth rates are generally falling. Countries and health care systems need to find innovative and sustainable ways to cope with the demographic shift. As stated by John Beard, director of the WHO Department of Ageing and Life Course, "With the rapid ageing of populations, finding the right model for long-term care becomes more and more urgent". Different activities were organized by WHO as well as non-governmental and community organizations around the world to mark World Health Day 2012. The theme of World Health Day 2013, marked on 7 April 2013, was the need to control raised blood pressure (hypertension) as a "silent killer, global public health crisis". The slogan for the campaign was "Healthy Heart Beat, Healthy Blood Pressure". The WHO reports hypertension – which is both preventable and treatable – contributes to the burden of heart disease , stroke and kidney failure, and is an important cause of premature death and disability. The organization estimates one in 3 adults has raised blood pressure. Specific objectives of the World Health Day 2013 campaign were to: raise awareness of the causes and consequences of high blood pressure; provide information on how to prevent high blood pressure and related complications; encourage adults to check their blood pressure and follow the advice of healthcare professionals; encourage self care to prevent high blood pressure; to make blood pressure measurement affordable to all; to incite national and local authorities to create enabling environments for healthy behaviours . World Health Day 2014 put the spotlight on some of the most commonly known vectors – such as mosquitoes, sandflies, bugs, ticks and snails – responsible for transmitting a wide range of parasites and pathogens that can cause many different illnesses. Mosquitoes, for example, transmit malaria – the most deadly vector-borne disease, causing an estimated 660 000 deaths annually worldwide – as well as dengue fever , lymphatic filariasis , chikungunya , Japanese encephalitis , and yellow fever . More than half of the world's population is at risk of these diseases. The goal of the World Health Day 2014 campaign was better protection from vector-borne diseases, especially for families living in areas where diseases are transmitted by vectors, and travelers to countries where they pose a health threat. The campaign advocated for health authorities in countries where vector-borne diseases are a public health problem or emerging threat, to put in place measures to improve surveillance and protection. The WHO promoted improvement of food safety as part of the 2015 World Health Day campaign. Unsafe food — food containing harmful bacteria, viruses, parasites or chemical substances — is responsible for more than 200 diseases, and is linked to the deaths of some 2 million people annually, mostly children. Changes in food production , distribution and consumption ; changes to the environment; new and emerging pathogens; and antimicrobial resistance all pose challenges to food safety systems. The WHO works with countries and partners to strengthen efforts to prevent, detect and respond to foodborne disease outbreaks in line with the Codex Alimentarius , advocating that food safety is a shared responsibility — from farmers and manufacturers to vendors and consumers — and raising awareness about the importance of the part everyone can play in ensuring that the food on our plate is safe to eat. The WHO focused World Health Day 2016, on diabetes – a largely preventable and treatable non-communicable disease that is rapidly increasing in numbers in many countries, most dramatically in low- and middle-income countries . Simple lifestyle measures have been shown to be effective in preventing or delaying the onset of type 2 diabetes, including maintaining normal body weight , engaging in regular physical activity, and eating a healthy diet. Diabetes can be controlled and managed to prevent complications through diagnosis, self-management education, and affordable treatment. The WHO estimates about 422 million people in the world have diabetes, with the disease the direct cause of some 1.5 million deaths. The goals of WHD 2016 are (1) scale up prevention, (2) strengthen care, and (3) enhance surveillance. World Health Day 2017, celebrated on 7 April, aims to mobilize action on depression . This condition affects people of all ages, from all walks of life, in all countries. It impacts on people's ability to carry out everyday tasks, with consequences for families, friends, and even communities, workplaces, and health care systems. At worst, depression can lead to self-inflicted injury and suicide . A better understanding of depression – which can be prevented and treated – will help reduce the stigma associated with the illness, and lead to more people seeking help. World Health Day 2018 theme, "Universal Health Coverage: Everyone, Everywhere", emphasized the idea that health is a fundamental human right, and that all people should be able to have access to health care. The slogan for the day was "Health For All". Several events were held including a panel discussion on universal health coverage which was live streamed . 2018 marked the 70th anniversary of the World Health Organization's founding. The 2019 World Health Day theme was "Universal Health Coverage: Everyone, Everywhere", a repeat of the 2018 theme, with an emphasis on the idea that "Universal Health Coverage is the WHO's number one goal". To commemorate the 2019 World Health Day theme, the World Health Organization launched a campaign to sign a petition for health for all, held a Facebook live event, and shared information about primary health care and universal health coverage "statistics and facts". The 2020 World Health Day theme took place in the context of the COVID-19 global pandemic and was therefore launched as 'Support Nurses and Midwives". Around the world, people spent the day thanking the nurses and health care workers on the frontlines battling the COVID-19 coronavirus. The US White House released a presidential message emphasizing the role public health plays in "building strong, prosperous, and free societies around the world". The celebration of 2020 World Health Day took place around the world in a mostly virtual environment through online press conferences, announcements, and social media due to the worldwide, broad based, "stay at home" order due to the COVID-19 coronavirus pandemic. Much of the efforts were focused on raising funds for the COVID-19 solidarity response fund. In 2006, World Health Day was devoted to the health workforce crisis, or chronic shortages of health workers around the world due to decades of underinvestment in their education, training, salaries, working environment and management. The day was also meant to celebrate individual health workers – the people who provide health care to those who need it, in other words those at the heart of health systems . The Day also marked the launch of the WHO's World Health Report 2006 , which focused on the same theme. The report contained an assessment of the current crisis in the global health workforce, revealing an estimated shortage of almost 4.3 million physicians, midwives, nurses and other health care providers worldwide, and further proposed a series of actions for countries and the international community to tackle it. In 2008, World Health Day focused on the need to protect health from the adverse effects of climate change and establish links between climate change and health and other development areas such as environment, food, energy, transport. The theme "protecting health from climate change" put health at the centre of the global dialogue about climate change. WHO selected this theme in recognition that climate change is posing ever growing threats to global public health security. World Health Day 2009 focused on the safety of health facilities and the readiness of health workers who treat those affected by emergencies. Health centres and staff are critical lifelines for vulnerable people in disasters – treating injuries , preventing illnesses and caring for people's health needs. Often, already fragile health systems are unable to keep functioning through a disaster, with immediate and future public health consequences. For this year's World Health Day campaign, WHO and international partners underscored the importance of investing in health infrastructure that can withstand hazards and serve people in immediate need, and urged health facilities to implement systems to respond to internal emergencies, such as fires, and ensure the continuity of care.With the campaign "1000 cities, 1000 lives", events were organized worldwide during the week starting 7 April 2010. The global goals of the campaign were: 1000 cities : to open up public spaces to health, whether it be activities in parks, town hall meetings, clean-up campaigns, or closing off portions of streets to motorized vehicles. 1000 lives : to collect 1000 stories of urban health champions who have taken action and had a significant impact on health in their cities.The theme of World Health Day 2011, marked on 7 April 2011, was " antimicrobial resistance and its global spread" and focused on the need for governments and stakeholders to implement the policies and practices needed to prevent and counter the emergence of highly resistant microorganisms . When infections caused by resistant microorganisms fail to respond to standard treatments, including antibiotics and other antimicrobial medicines – also known as drug resistance – this may result in prolonged illness and greater risk of death. On World Health Day 2011, WHO called for intensified global commitment to safeguard antimicrobial medicines for future generations. The organization introduced a six-point policy package to combat the spread of antimicrobial resistance: Commit to a comprehensive, financed national plan with accountability and civil society engagement. Strengthen surveillance and laboratory capacity. Ensure uninterrupted access to essential medicines of assured quality. Regulate and promote rational use of medicines, including in animal husbandry, and ensure proper patient care; reduce use of antimicrobials in food-producing animals. Enhance infection prevention and control. Foster innovations and research and development for new tools.World Health Day 2012 was marked with the slogan "Good health adds life to years". Life expectancy is going up in most countries, meaning more and more people live longer and enter an age when they may need health care . Meanwhile, birth rates are generally falling. Countries and health care systems need to find innovative and sustainable ways to cope with the demographic shift. As stated by John Beard, director of the WHO Department of Ageing and Life Course, "With the rapid ageing of populations, finding the right model for long-term care becomes more and more urgent". Different activities were organized by WHO as well as non-governmental and community organizations around the world to mark World Health Day 2012. The theme of World Health Day 2013, marked on 7 April 2013, was the need to control raised blood pressure (hypertension) as a "silent killer, global public health crisis". The slogan for the campaign was "Healthy Heart Beat, Healthy Blood Pressure". The WHO reports hypertension – which is both preventable and treatable – contributes to the burden of heart disease , stroke and kidney failure, and is an important cause of premature death and disability. The organization estimates one in 3 adults has raised blood pressure. Specific objectives of the World Health Day 2013 campaign were to: raise awareness of the causes and consequences of high blood pressure; provide information on how to prevent high blood pressure and related complications; encourage adults to check their blood pressure and follow the advice of healthcare professionals; encourage self care to prevent high blood pressure; to make blood pressure measurement affordable to all; to incite national and local authorities to create enabling environments for healthy behaviours .World Health Day 2014 put the spotlight on some of the most commonly known vectors – such as mosquitoes, sandflies, bugs, ticks and snails – responsible for transmitting a wide range of parasites and pathogens that can cause many different illnesses. Mosquitoes, for example, transmit malaria – the most deadly vector-borne disease, causing an estimated 660 000 deaths annually worldwide – as well as dengue fever , lymphatic filariasis , chikungunya , Japanese encephalitis , and yellow fever . More than half of the world's population is at risk of these diseases. The goal of the World Health Day 2014 campaign was better protection from vector-borne diseases, especially for families living in areas where diseases are transmitted by vectors, and travelers to countries where they pose a health threat. The campaign advocated for health authorities in countries where vector-borne diseases are a public health problem or emerging threat, to put in place measures to improve surveillance and protection.The WHO promoted improvement of food safety as part of the 2015 World Health Day campaign. Unsafe food — food containing harmful bacteria, viruses, parasites or chemical substances — is responsible for more than 200 diseases, and is linked to the deaths of some 2 million people annually, mostly children. Changes in food production , distribution and consumption ; changes to the environment; new and emerging pathogens; and antimicrobial resistance all pose challenges to food safety systems. The WHO works with countries and partners to strengthen efforts to prevent, detect and respond to foodborne disease outbreaks in line with the Codex Alimentarius , advocating that food safety is a shared responsibility — from farmers and manufacturers to vendors and consumers — and raising awareness about the importance of the part everyone can play in ensuring that the food on our plate is safe to eat. The WHO focused World Health Day 2016, on diabetes – a largely preventable and treatable non-communicable disease that is rapidly increasing in numbers in many countries, most dramatically in low- and middle-income countries . Simple lifestyle measures have been shown to be effective in preventing or delaying the onset of type 2 diabetes, including maintaining normal body weight , engaging in regular physical activity, and eating a healthy diet. Diabetes can be controlled and managed to prevent complications through diagnosis, self-management education, and affordable treatment. The WHO estimates about 422 million people in the world have diabetes, with the disease the direct cause of some 1.5 million deaths. The goals of WHD 2016 are (1) scale up prevention, (2) strengthen care, and (3) enhance surveillance. World Health Day 2017, celebrated on 7 April, aims to mobilize action on depression . This condition affects people of all ages, from all walks of life, in all countries. It impacts on people's ability to carry out everyday tasks, with consequences for families, friends, and even communities, workplaces, and health care systems. At worst, depression can lead to self-inflicted injury and suicide . A better understanding of depression – which can be prevented and treated – will help reduce the stigma associated with the illness, and lead to more people seeking help. World Health Day 2018 theme, "Universal Health Coverage: Everyone, Everywhere", emphasized the idea that health is a fundamental human right, and that all people should be able to have access to health care. The slogan for the day was "Health For All". Several events were held including a panel discussion on universal health coverage which was live streamed . 2018 marked the 70th anniversary of the World Health Organization's founding. The 2019 World Health Day theme was "Universal Health Coverage: Everyone, Everywhere", a repeat of the 2018 theme, with an emphasis on the idea that "Universal Health Coverage is the WHO's number one goal". To commemorate the 2019 World Health Day theme, the World Health Organization launched a campaign to sign a petition for health for all, held a Facebook live event, and shared information about primary health care and universal health coverage "statistics and facts". The 2020 World Health Day theme took place in the context of the COVID-19 global pandemic and was therefore launched as 'Support Nurses and Midwives". Around the world, people spent the day thanking the nurses and health care workers on the frontlines battling the COVID-19 coronavirus. The US White House released a presidential message emphasizing the role public health plays in "building strong, prosperous, and free societies around the world". The celebration of 2020 World Health Day took place around the world in a mostly virtual environment through online press conferences, announcements, and social media due to the worldwide, broad based, "stay at home" order due to the COVID-19 coronavirus pandemic. Much of the efforts were focused on raising funds for the COVID-19 solidarity response fund.

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Dengue fever

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Natural hazards in Colombia

Natural disasters in Colombia are the result of several different natural hazards that affect the country according to its particular geographic and geologic features. Human vulnerability, exacerbated by the lack of planning or lack of appropriate emergency management , and the fragility of the economy and infrastructure contribute to a high rate of financial, structural, and human losses. Some of the natural hazards present in Colombia are: Earthquakes Floods Landslides Volcanoes Colombia is part of the Pacific Ring of Fire and Andean Volcanic Belt due to the collision of the South American Plate and the Nazca Plate . This produces an increased risk of earthquakes and volcanic eruptions . Some natural disasters of this type are:Rainfall is heaviest in the Pacific lowlands and in parts of eastern Colombia, where rain is almost a daily occurrence and rain forests predominate. Precipitation exceeds 760 centimeters annually in most of the Pacific lowlands, making this one of the wettest regions in the world. The highest average annual precipitation in the world is estimated to be in Lloro, Colombia, with 13,299 mm (523.9 inches). In eastern Colombia, it decreases from 635 centimeters in portions of the Andean piedmont to 254 centimeters eastward. Extensive areas of the Caribbean interior are permanently flooded, more because of poor drainage than because of the moderately heavy precipitation during the rainy season. The Caribbean Region of Colombia , valleys of Magdalena river and Cauca river and the eastern savannahs are prone to floods during the two main monsoon seasons (April and November). The opposite phenomenon of drought is also frequent. January through March and July through September are the dry seasons, when abnormally dry periods cause shortage in the water supply to crops and urban centers.The presence of coastal regions both in the Atlantic and the Pacific oceans increases the risk of hurricanes and tropical storms . Waves in the trade winds in the Atlantic Ocean—areas of converging winds that move along the same track as the prevailing wind—create instabilities in the atmosphere that may lead to the formation of hurricanes . Some of the events of this type that have affected the country are:Some of the main public health issues in Colombia are: malnutrition , pregnancy -related deaths, neonatal deaths, acute respiratory disease-related deaths in children under 5 years, diarrhea -related deaths in children under 5 years, lack of vaccinations , tropical diseases such as malaria , dengue fever , hemorrhagic dengue fever, yellow fever , Chagas disease and leishmaniasis , poly- parasitism , snakebites and violence related causes of mortality.

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Dengue fever

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Muhammad Abdul Wahhab

Haji Muhammad Abdul Wahhab ( Urdu : حاجی راو ٠ح٠د عبد الوہاب , Ḥājī Muḥammad 'Abdul-Wahhāb (1 January 1923 – 18 November 2018 ) was an Islamic preacher and the emir of Tablighi Jamaat in Pakistan .Muhammad Abdul Wahhab was born in Delhi , British India , in 1923 into a Rajput family originally from Saharanpur in Uttar Pradesh . The family moved to Lahore following the 1947 partition , where he graduated from the Islamia College and became a government employee. After graduation he worked as a tehsildar in pre-partition India. In his youth he also worked for Majlis-e-Ahrar-e-Islam , and was influenced by Abdul Qadir Raipuri (1878–1962). He was the president of Majlis-e-Ahrar Burewala. [ citation needed ]Abdul Wahhab joined the Tabligh Jamaat during the life of its founder, Muhammad Ilyas Kandhlawi . He arrived at Nizamuddin markaz on 1 January 1944. He got the sohbah of Maulana Ilyas for six months. [ dubious – discuss ] [ citation needed ] He left his job to devote his time and effort to the Jamaat, and he was one of the first five people in Pakistan who offered their entire life for doing Tabligh work. He was a direct companion of Maulana Muhammad Ilyas Kandhlawi , Yusuf Kandhlawi , and Inamul Hasan Kandhlawi . [ citation needed ] Muhammad Shafi Quraishi (1903–1971) was the first regular amir of the Tablighi Jamaat in Pakistan; he was succeeded by Haji Muhammad Bashir (1919–1992). Abdul Wahhab succeeded Bashir as the third regular amir for Pakistan. He was based at Raiwind Markaz , the movement's headquarters in the country, where he headed a shura (council). He was also a member of the movement's alami shura (world council) based in Nizamuddin , Delhi, India. He was also related with the Qadiriyah Sufi order through his mentor, Shaykh Abdul Qadir Raipuri. In October 2013 it was reported that the name of Haji Abdul Wahhab was suggested to head a Loya Jirga in preparation for peace talks with the Pakistani Taliban . In February 2014 it was reported that during consultations with a committee, TTP commanders of different factions recommended that the names of Haji Abdul Wahhab, Maulana Sami'ul Haq , Dr. Abdul Qadeer Khan , and other leaders be added in the government peace committee. Abdul Wahhab joined the Tabligh Jamaat during the life of its founder, Muhammad Ilyas Kandhlawi . He arrived at Nizamuddin markaz on 1 January 1944. He got the sohbah of Maulana Ilyas for six months. [ dubious – discuss ] [ citation needed ] He left his job to devote his time and effort to the Jamaat, and he was one of the first five people in Pakistan who offered their entire life for doing Tabligh work. He was a direct companion of Maulana Muhammad Ilyas Kandhlawi , Yusuf Kandhlawi , and Inamul Hasan Kandhlawi . [ citation needed ] Muhammad Shafi Quraishi (1903–1971) was the first regular amir of the Tablighi Jamaat in Pakistan; he was succeeded by Haji Muhammad Bashir (1919–1992). Abdul Wahhab succeeded Bashir as the third regular amir for Pakistan. He was based at Raiwind Markaz , the movement's headquarters in the country, where he headed a shura (council). He was also a member of the movement's alami shura (world council) based in Nizamuddin , Delhi, India. He was also related with the Qadiriyah Sufi order through his mentor, Shaykh Abdul Qadir Raipuri. In October 2013 it was reported that the name of Haji Abdul Wahhab was suggested to head a Loya Jirga in preparation for peace talks with the Pakistani Taliban . In February 2014 it was reported that during consultations with a committee, TTP commanders of different factions recommended that the names of Haji Abdul Wahhab, Maulana Sami'ul Haq , Dr. Abdul Qadeer Khan , and other leaders be added in the government peace committee. As of the 2014/2015 issue, he was ranked #10 in The Muslim 500 , a list of the 500 most influential Muslims in the world, due to his leadership of the Tablighi Jamaat. Haji Abdul Wahab died on 18 November 2018 . He was buried in a graveyard adjacent to Tableeghi Markaz (Headquarter) at Raiwind the same day.

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Dengue fever

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Maculopapular rash

A maculopapular rash is a type of rash characterized by a flat, red area on the skin that is covered with small confluent bumps. It may only appear red in lighter-skinned people. The term "maculopapular" is a compound: macules are small, flat discolored spots on the surface of the skin; and papules are small, raised bumps. It is also described as erythematous , or red. This type of rash is common in several diseases and medical conditions, including scarlet fever , measles , Ebola virus disease , rubella , HIV , secondary syphilis (Congenital syphilis, which is asymptomatic, the newborn may present this type of rash), erythrovirus ( parvovirus B19 ), chikungunya (alphavirus), zika , smallpox (which has been eradicated), varicella (when vaccinated persons exhibit symptoms from the modified form), heat rash , and sometimes in Dengue fever . It is also a common manifestation of a skin reaction to the antibiotic amoxicillin or chemotherapy drugs. Cutaneous infiltration of leukemic cells may also have this appearance. Maculopapular rash is seen in graft-versus-host disease (GVHD) developed after a hematopoietic stem cell transplant (bone marrow transplant), which can be seen within one week or several weeks after the transplant. In the case of GVHD, the maculopapular lesions may progress to a condition similar to toxic epidermal necrolysis . In addition, this is the type of rash that some patients presenting with Ebola virus hemorrhagic (EBO-Z) fever will reveal but can be hard to see on dark skin people. It is also seen in patients with Marburg hemorrhagic fever , a filovirus not unlike Ebola. This type of rash can be as a result of large doses of niacin or no-flush niacin (2000 – 2500 mg), [ citation needed ] used for the management of low HDL cholesterol. This type of rash can also be a symptom of Sea bather's eruption . This stinging, pruritic, maculopapular rash affects swimmers in some Atlantic locales (e.g., Florida, Caribbean, Long Island). It is caused by hypersensitivity to stings from the larvae of the sea anemone (e.g., Edwardsiella lineate ) or the thimble jellyfish ( Linuche unguiculata ). The rash appears where the bathing suit contacts the skin. This type of rash can also be a symptom of acute arsenic intoxication, appearing 2 weeks later.

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Dengue fever

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2013 dengue outbreak in Singapore

In the 2013 dengue outbreak in Singapore , a significant rise in the number of dengue fever cases was reported in Singapore. The outbreak began in January, with the number of infections beginning to surge in April, before eventually reaching a peak of 842 dengue cases in the week of 16–22 June 2013. This figure was far beyond the highest number of cases per week in the previous three years. Although there were concerns that the rate of infection could exceed 1,000 per week, these fears did not materialize. As official data showed, more than 13,000 people were infected with dengue as of mid-July in 2013, fast nearing the total of 14,209 infections in the 2005 dengue outbreak , the worst year on record. The 2005 record was surpassed in the week of 4–10 August, when the total number of cases of reached 14,217. The year ended with a total of 22,170 people infected with the disease, a record that would stand until 2020 . 29 May : Dengue claimed its first death in Singapore in 2013. 25 June : Two deaths due to dengue were reported. 8 July : A fifth person dies from dengue. 13 August : A 52-year-old Chinese male becomes the sixth death due to dengue. 30 September :A 35-year-old Chinese woman died of dengue on Monday, becoming the seventh death in 2013. 16 November : A 53-year-old woman became the seventh local dengue death case this year, and the overall eighth death.29 May : Dengue claimed its first death in Singapore in 2013.25 June : Two deaths due to dengue were reported.8 July : A fifth person dies from dengue.13 August : A 52-year-old Chinese male becomes the sixth death due to dengue.30 September :A 35-year-old Chinese woman died of dengue on Monday, becoming the seventh death in 2013.16 November : A 53-year-old woman became the seventh local dengue death case this year, and the overall eighth death.In March, multiple warning signs surfaced of the impending outbreak. The less common DENV-1 serotype of the dengue virus supplanted DENV-2 as the dominant strain of the virus in circulation, jumping from around 20–30% to over half of new infections. This switch threatened to drive a strong surge in infections during the upcoming mid-year dengue peak season. Epidemiological modelling provided corroboration, forecasting a peak of up to 800 cases per week in June. Based on this, warnings about the epidemic risk were issued through the government's Inter-Agency Dengue Task Force. NEA stepped up vector control measures, and a community awareness campaign was initiated. The amount of government budget allocated to combat dengue would eventually be increased by more than 20% compared to recent years. In April, the NEA began using a new community alert system. Colour-coded banners would be put up in dengue-hit areas, using the three traffic light colours green, yellow and red to indicate the number of cases in the neighbourhood. As part of NEA's vector control measures, routine inspections were conducted to check for potential mosquito breeding sites in homes, public areas of housing estates, and construction sites. On 14 June 2013, the head of NEA announced that more officers would be recruited to conduct these checks. NEA also indicated that it would resort to hiring a locksmith to forcibly gain access to conduct inspections if homeowners fail to cooperate; this happened to ten homes after the residents did not respond to notices sent to them. The People's Association (PA) announced that they would recruit 10,000 volunteer "dengue fighters" to assist NEA officers during house visits. Penalties were levied as a consequence of these inspections, even government organizations were not exempt. On 5 June 2013, Sembawang-Nee Soon Town Council was fined S$ 200 for allowing mosquitoes to breed in water tanks the council controlled. Officers from the NEA found mosquito larvae in water tanks at the rooftops of Blocks 896C and 899A in Woodlands. The Singapore Land Authority incurred S$2000 in fines for ten breeding spots discovered in vacant buildings and plots of land under its management from January to June 2013. NEA also announced that insect repellent would be distributed to every household in the country in July and August, to "help residents protect themselves from mosquito bites and thus break the chain of transmission."

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Dengue fever

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Rice-fish system

A rice-fish system is a polyculture practice that integrates rice agriculture with aquaculture , most commonly with freshwater fish . It is based on a mutually beneficial relationship between rice and fish in the same agroecosystem . The benefits of rice-fish systems include increased rice yield, the production of an additional (fish) crop on the same land, diversification of farm production , increased food security , and reduced need for inputs of fertilizer and pesticide . Because fish eat insects and snails, the systems may reduce mosquito-borne diseases such as malaria and dengue fever , and snail-born parasites such as the trematodes which cause schistosomiasis . The reduction in chemical inputs may reduce environmental harms caused by their release into the environment. The increased biodiversity may reduce methane emissions from rice fields.The simultaneous cultivation of rice and fish is thought to be over 2,000 years old. Ancient clay models of rice fields , containing miniature models of fish such as the common carp , have been found in Han dynasty tombs in China . The system originated somewhere in continental Asia such as in India , Thailand , northern Vietnam and southern China . The practice likely started in China since they were early practitioners of aquaculture. Common carp were probably among the first fish used in rice-fish systems. Wei dynasty records from 220 to 265 AD mention that "a small fish with yellow scales and a red tail, grown in the rice fields of Pi County northeast of Chengdu , Sichuan Province , can be used for making sauce". Liu Xun wrote the first descriptions of the system, with texts written during 900 AD during the Tang dynasty . Rice-fish systems may have evolved from pond culture in China; one theory proposes that the practice started when farmers decided to place excess fry in their ponds and found the results beneficial. It is possible that the practice developed independently from China in other Asian countries. It appears to have spread from India to neighbouring Asian countries over 1500 years ago. The practice slowly gained popularity among farmers, and by the mid-1900s, over 28 countries on all continents except Antarctica used rice-fish systems. Historically, the common carp was the most commonly used fish, with the Mozambique tilapia ( Oreochromis mossambicus ) in second place. As the practice spread throughout the world, new species were adopted. For example, Malaysia introduced the snakeskin gourami ( Trichogaster pectoralis ) and Egypt used the Nile tilapia ( Oreochromis niloticus ). An early study, in Jiangsu Province in 1935, found that growing black carp ( Mylopharyngodon piceus ), grass carp , silver carp , bighead carp ( Aristichthys nobilis ) and common carp together with rice was beneficial. Rice-fish systems were traditionally low maintenance, growing additional animal protein alongside the staple food , rice. From the 1980s on, Chinese systems developed rapidly with new species such as the Chinese mitten crab , the red swamp crayfish , and softshell turtles . The space used for fish-rice systems in China grew from 441,027 hectares (1,089,800 acres ) to 853,150 hectares (2,108,200 acres) and the production increased dramatically, going from 36,330 tonnes to 206,915 tonnes between 1983 and 1994. Rice-fish systems are polycultures based on the concept of mutual benefit. Both rice (a semiaquatic wetland crop) and fish are grown in the same aquatic ecosystem and both benefit from this, creating a mutualistic relationship. The principle has evolved through the years and major technological advances allowed for the popularisation of the practice. A notable improvement was the addition of channels in the previously flat rice fields that allowed for the fish to continue growing even during rice harvest and dry seasons. Before creating the rice field, the field is treated with 4.5–5.25 tonnes per hectare (2.0–2.3 short ton/acre) of organic manure . Organic manure is applied again during the main growing season, with about 1.5 tonnes per hectare (0.7 short ton/acre) applied every 15 days. This provides nutrients for rice and the added cultures of plankton and benthos that feed the fish. During the main growing season, supplementary feeds complement the plankton and benthos culture and are used once or twice a day. The supplementary feeds include fish meal , soybean cake, rice bran and wheat bran. Fish are stocked at a rate between 0.25 and 1 per square metre (1,000–4,000/acre) . Unwanted fish or invasive species can threaten the mutualistic relationship between rice and fish, and therefore reduce the food production. For example, in the integrated Rice-Swamp Loach Aquaculture Model, catfish , snakeheads ( Channa argus ) and paddy eels ( Monopterus albus ) are considered as unwanted species. Predatory birds can be considered a threat: adding nets to the rice fields can prevent these birds from eating the wanted fish. Rice-fish systems are the most common type of integrated rice-field system. However, some 19 other models exist, including rice- crayfish , rice- crab and rice- turtle . Rice and fish form a mutualistic relationship : they both benefit from growing together. The rice provides the fish with shelter and shade and a reduced water temperature, along with herbivorous insects and other small animals that feed on the rice. Rice benefits from nitrogenous waste from the fish, while the fish reduce insect pests such as brown planthoppers , diseases such as sheath blight of rice , and weeds. By controlling weeds, competition for nutrients is decreased. CO 2 released by the fish may be used in photosynthesis by the rice. The constant fish movements allow for the loosening of the surface soil which can: Soil fertility is improved by the integration of fish, whose manure is a fertilizer recycling organic matter, nitrogen, phosphorus and potassium . The inclusion of fish in rice-fields helps to maintain soil health , biodiversity, and productivity. The aquatic diversity in rice-fish systems includes plankton (both phytoplankton and zooplankton ), soil benthic fauna and microbial populations that all play a role in the enhanced soil fertility and the sustainability of production. However, benthic communities may be disturbed by constant grazing from the fish. Net gains vary between and within countries. Overall, integrated rice-fish fields have a positive impact on net returns. In Bangladesh , net returns are over 50% greater than in rice monocultures. In China , the net return by region is between 45 and 270% greater. A case of loss in net returns was found in Thailand with only 80% of the profitability of rice monocultures. This might be caused by the initial investment needed when starting the system. The use of rice-fish systems has resulted in an increase in rice yields and productivity from 6.7 tons to 7.5 tons of rice per hectare and simultaneously also from 0.75 tons to 2.25 tons of fish per hectare. The landscapes created by rice-fish systems form a possible tourist attraction, as it creates a distinctive landscape. The addition of fish diversifies the farm's production, increases food security, and generates income; Halwart and Gupta comment that if it also increases rice yield and cuts the need for fertilizer and pesticide inputs, these are "added bonus[es]". Rice-fish farming was one of the first systems to be considered as a "Globally Important Agricultural Heritage System" according to the FAO 's Global Environment Facility . In 1981, the Health Commission of China recognised integrated rice fields as a possible measure to decrease the population of mosquitoes , which carry diseases such as malaria and dengue fever . The larvae density is reduced in integrated rice fields since freshwater fishes routinely prey on the larvae. Rice-fish systems may decrease the number of snails , known to carry trematodes which in turn cause schistosomiasis . Farmers' diets may improve with the addition of fish protein. Reduced antibiotic resistance is another possible benefit. Rice-crayfish systems have lower abundance and diversity of antibiotic resistance genes in bacteria than aquaculture systems without rice. As fish control pests and weeds, fewer chemicals (such as pesticides and herbicides ) are used, reducing the release of these agricultural chemicals into the environment. In addition, farmers often choose not to use pesticides, to avoid harming the fish. In turn, biodiversity is increased. Rice-fish systems can reduce methane emissions compared to rice monoculture. Net gains vary between and within countries. Overall, integrated rice-fish fields have a positive impact on net returns. In Bangladesh , net returns are over 50% greater than in rice monocultures. In China , the net return by region is between 45 and 270% greater. A case of loss in net returns was found in Thailand with only 80% of the profitability of rice monocultures. This might be caused by the initial investment needed when starting the system. The use of rice-fish systems has resulted in an increase in rice yields and productivity from 6.7 tons to 7.5 tons of rice per hectare and simultaneously also from 0.75 tons to 2.25 tons of fish per hectare. The landscapes created by rice-fish systems form a possible tourist attraction, as it creates a distinctive landscape. The addition of fish diversifies the farm's production, increases food security, and generates income; Halwart and Gupta comment that if it also increases rice yield and cuts the need for fertilizer and pesticide inputs, these are "added bonus[es]". Rice-fish farming was one of the first systems to be considered as a "Globally Important Agricultural Heritage System" according to the FAO 's Global Environment Facility . In 1981, the Health Commission of China recognised integrated rice fields as a possible measure to decrease the population of mosquitoes , which carry diseases such as malaria and dengue fever . The larvae density is reduced in integrated rice fields since freshwater fishes routinely prey on the larvae. Rice-fish systems may decrease the number of snails , known to carry trematodes which in turn cause schistosomiasis . Farmers' diets may improve with the addition of fish protein. Reduced antibiotic resistance is another possible benefit. Rice-crayfish systems have lower abundance and diversity of antibiotic resistance genes in bacteria than aquaculture systems without rice. As fish control pests and weeds, fewer chemicals (such as pesticides and herbicides ) are used, reducing the release of these agricultural chemicals into the environment. In addition, farmers often choose not to use pesticides, to avoid harming the fish. In turn, biodiversity is increased. Rice-fish systems can reduce methane emissions compared to rice monoculture. Rice-fish systems are being exported to less developed countries with the FAO /China Trust fund. About 80 Chinese rice-fish experts were sent to underdeveloped countries in diverse regions of the world such as certain African countries, other parts of Asia and in the South Pacific to implement the rice-fish systems and their benefits as well as share their agriculture knowledge. For example, the China-Nigeria South-South Cooperation programme integrated over 10,000 hectares of rice-fish fields in Nigeria , which has allowed for the production of rice and tilapia to almost double. Climate change threatens global food production as it creates numerous changes to regional weather, such as higher temperatures, heavy rainfall, and storms. These changes may cause outbreaks of pests with, for example, an increase in the number of plant hoppers and stem borers . Rice-fish systems should be beneficial in future climates because they have higher reliability and stability than rice monoculture. Rice-fish systems are being exported to less developed countries with the FAO /China Trust fund. About 80 Chinese rice-fish experts were sent to underdeveloped countries in diverse regions of the world such as certain African countries, other parts of Asia and in the South Pacific to implement the rice-fish systems and their benefits as well as share their agriculture knowledge. For example, the China-Nigeria South-South Cooperation programme integrated over 10,000 hectares of rice-fish fields in Nigeria , which has allowed for the production of rice and tilapia to almost double. Climate change threatens global food production as it creates numerous changes to regional weather, such as higher temperatures, heavy rainfall, and storms. These changes may cause outbreaks of pests with, for example, an increase in the number of plant hoppers and stem borers . Rice-fish systems should be beneficial in future climates because they have higher reliability and stability than rice monoculture.

Wiki

Dengue fever

https://api.wikimedia.org/core/v1/wikipedia/en/page/Central_Epidemic_Command_Center/html

Central Epidemic Command Center

The Central Epidemic Command Center ( CECC ; Chinese : åœ‹å®¶è¡›ç”ŸæŒ‡æ®ä¸­å¿ƒä¸­å¤®æµè¡Œç–«æƒ æŒ‡æ®ä¸­å¿ƒ ) is an agency of the National Health Command Center [ fr ] (NHCC). It has been activated by the government of Taiwan for several disease outbreaks, such as the 2009 swine flu pandemic and the COVID-19 pandemic . The head of the agency is Chen Shih-chung , the minister of health and welfare. The CECC is associated with the Taiwan Centers for Disease Control (Taiwan CDC). A temporary command center was first established in 2003 during the SARS epidemic, which caused 71 deaths in Taiwan. Then, as a result of lessons learned from this epidemic, a permanent National Health Command Center was approved as a project on 16 August 2004; NHCC offices opened in the CDC building on 18 January 2005. The CECC is one of the command centers that are part of the NHCC. On 28 April 2009, the CECC held its first meeting hosted by the Minister of Health, Yeh Ching-chuan . Participating agencies included the Department of Health, the Ministry of Interior, the Ministry of Foreign Affairs and the Ministry of Economic Affairs. On 20 May 2009, the CECC confirmed Taiwan's first imported case of H1N1 influenza . The CDC immediately reported to the WHO and other countries through International Health Regulations Focal Points. On 24 May, the first indigenous case was confirmed. These precautionary measures triggered many different policy responses in Taiwan. On 3 April 2013, the Executive Yuan activated the CECC in response to the H7N9 influenza (avian influenza or bird flu virus) epidemic in mainland China. The Executive Yuan deactivated the CECC for H7N9 influenza on 11 April 2014. The CECC convened 24 meetings with government agencies including the Council of Agriculture, the Ministry of Transportation and Communications, and the Ministry of Education. It also convened meetings with 22 city and local governments. In addition, regional and deputy commanding officers of the Communicable Disease Control Network attended these meetings. On 17 May 2013, the slaughtering of live poultry was banned at traditional wet markets, eliminating risk of avian influenza being transmitted from animals to humans. Dengue fever is caused by the dengue virus, and is common in tropical and sub-tropical climates. Outbreaks occur from time to time in Taiwan, and the CECC was activated on 14 September 2015. There were 43,784 cases reported in total, most of these being in the tropical climate of the southern cities of Tainan and Kaohsiung with 52% and 45% respectively. Taiwan experienced consecutive outbreaks of dengue fever in both 2014 and 2015. CECC was activated on 2 February 2016. In response to the coronavirus pandemic, the CECC was activated on 20 January 2020. The Executive Yuan approved the deactivation of the CECC in response to COVID-19 effective 1 May 2023. The CECC has the authority to coordinate work across government departments and enlist additional personnel during an emergency. The CECC has coordinated government response measures across areas including logistics for citizens on the Diamond Princess , disinfection of public spaces around schools, and daily briefings from Minister of Health Chen Shih-chung , which are regularly aired on large news channels in Taiwan . Originally established as a level 3 government entity, the CECC was promoted to level 1 on 28 February 2020. In January, Taiwan closed its borders to all residents of Wuhan amid concerns that the country was not receiving timely updates, because it was excluded from the World Health Organization (WHO). The agency has sent warning text messages target to mobile phones in specific areas, urging people to practice social distancing, especially by avoiding crowded scenic areas. On 18 March, the CECC raised its travel notice for the United States, Canada, Australia, and New Zealand and advised against all nonessential travel to these countries. It also announced that certain exempted foreign nationals must observe a 14-day home quarantine upon arrival from overseas. On 25 March, even as Taiwan saw zero new confirmed cases on that day, the CECC announced recommendations that indoor events which would be attended by more than 100 people should be suspended, while outdoor gatherings of more than 500 people should also do so. Taiwan's response has been praised in JAMA , the journal of the American Medical Association . According to JAMA , Taiwan should have seen the second-largest outbreak of COVID-19 in the world, but has instead effectively eliminated community transmission. Taiwan has done this without ordering people to stay home or shutting down schools, restaurants, shops and other businesses. As a result, Taiwan's economy is not suffering the same economic damage as countries under lockdown. The CECC has the authority to coordinate work across government departments and enlist additional personnel during an emergency. The CECC has coordinated government response measures across areas including logistics for citizens on the Diamond Princess , disinfection of public spaces around schools, and daily briefings from Minister of Health Chen Shih-chung , which are regularly aired on large news channels in Taiwan . Originally established as a level 3 government entity, the CECC was promoted to level 1 on 28 February 2020. In January, Taiwan closed its borders to all residents of Wuhan amid concerns that the country was not receiving timely updates, because it was excluded from the World Health Organization (WHO). The agency has sent warning text messages target to mobile phones in specific areas, urging people to practice social distancing, especially by avoiding crowded scenic areas. On 18 March, the CECC raised its travel notice for the United States, Canada, Australia, and New Zealand and advised against all nonessential travel to these countries. It also announced that certain exempted foreign nationals must observe a 14-day home quarantine upon arrival from overseas. On 25 March, even as Taiwan saw zero new confirmed cases on that day, the CECC announced recommendations that indoor events which would be attended by more than 100 people should be suspended, while outdoor gatherings of more than 500 people should also do so. Taiwan's response has been praised in JAMA , the journal of the American Medical Association . According to JAMA , Taiwan should have seen the second-largest outbreak of COVID-19 in the world, but has instead effectively eliminated community transmission. Taiwan has done this without ordering people to stay home or shutting down schools, restaurants, shops and other businesses. As a result, Taiwan's economy is not suffering the same economic damage as countries under lockdown.

Wiki

Dengue fever

https://api.wikimedia.org/core/v1/wikipedia/en/page/Q_fever/html

Q fever

Q fever or query fever is a disease caused by infection with Coxiella burnetii , a bacterium that affects humans and other animals. This organism is uncommon, but may be found in cattle , sheep , goats , and other domestic mammals , including cats and dogs . The infection results from inhalation of a spore-like small-cell variant, and from contact with the milk , urine , feces , vaginal mucus , or semen of infected animals. Rarely, the disease is tick -borne. The incubation period can range from 9 to 40 days . Humans are vulnerable to Q fever, and infection can result from even a few organisms. The bacterium is an obligate intracellular pathogenic parasite .The incubation period is usually two to three weeks. The most common manifestation is flu-like symptoms : abrupt onset of fever , malaise , profuse perspiration , severe headache , muscle pain , joint pain , loss of appetite , upper respiratory problems, dry cough, pleuritic pain , chills, confusion , and gastrointestinal symptoms , such as nausea , vomiting, and diarrhea . About half of infected individuals exhibit no symptoms. During its course, the disease can progress to an atypical pneumonia , which can result in a life-threatening acute respiratory distress syndrome , usually occurring during the first four to five days of infection. Less often, Q fever causes (granulomatous) hepatitis , which may be asymptomatic or become symptomatic with malaise, fever, liver enlargement , and pain in the right upper quadrant of the abdomen . This hepatitis often results in the elevation of transaminase values , although jaundice is uncommon. Q fever can also rarely result in retinal vasculitis . The chronic form of Q fever is virtually identical to endocarditis (i.e. inflammation of the inner lining of the heart), which can occur months or decades following the infection. It is usually fatal if untreated. However, with appropriate treatment, the mortality falls to around 10%. [ citation needed ] A minority of Q fever survivors develops Q fever fatigue syndrome after acute infection, one of the more well-studied post-acute infection syndromes . Q fever fatigue syndrome is characterised by post-exertional malaise and debilitating fatigue. People with Q fever fatigue syndrome frequently meet the diagnostic criteria for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Symptoms often persist years after the initial infection. Diagnosis is usually based on serology (looking for an antibody response) rather than looking for the organism itself. Serology allows the detection of chronic infection by the appearance of high levels of the antibody against the virulent form of the bacterium. Molecular detection of bacterial DNA is increasingly used. Contrary to most obligate intracellular parasites, Coxiella burnetii can be grown in an axenic culture, but its culture is technically difficult and not routinely available in most microbiology laboratories. Q fever can cause endocarditis (infection of the heart valves) which may require transoesophageal echocardiography to diagnose. Q fever hepatitis manifests as an elevation of alanine transaminase and aspartate transaminase , but a definitive diagnosis is only possible on liver biopsy , which shows the characteristic fibrin ring granulomas . Research done in the 1960s – 1970s by French Canadian-American microbiologist and virologist Paul Fiset was instrumental in the development of the first successful Q fever vaccine . Protection is offered by Q-Vax, a whole-cell, inactivated vaccine developed by an Australian vaccine manufacturing company, CSL Limited . The intradermal vaccination is composed of killed C. burnetii organisms. Skin and blood tests should be done before vaccination to identify pre-existing immunity, because vaccinating people who already have immunity can result in a severe local reaction. After a single dose of vaccine, protective immunity lasts for many years. Revaccination is not generally required. Annual screening is typically recommended. In 2001, Australia introduced a national Q fever vaccination program for people working in "at risk" occupations. Vaccinated or previously exposed people may have their status recorded on the Australian Q Fever Register, which may be a condition of employment in the meat processing industry or in veterinary research . An earlier killed vaccine had been developed in the Soviet Union, but its side effects prevented its licensing abroad. [ citation needed ] Preliminary results suggest vaccination of animals may be a method of control. Published trials proved that use of a registered phase vaccine (Coxevac) on infected farms is a tool of major interest to manage or prevent early or late abortion, repeat breeding, anoestrus , silent oestrus, metritis , and decreases in milk yield when C. burnetii is the major cause of these problems. Treatment of acute Q fever with antibiotics is very effective. Commonly used antibiotics include doxycycline , tetracycline , chloramphenicol , ciprofloxacin , and ofloxacin ; the antimalarial drug hydroxychloroquine is also used. Chronic Q fever is more difficult to treat and can require up to four years of treatment with doxycycline and quinolones or doxycycline with hydroxychloroquine. If a person has chronic Q fever, doxycycline and hydroxychloroquine will be prescribed for at least 18 months. Q fever in pregnancy is especially difficult to treat because doxycycline and ciprofloxacin are contraindicated in pregnancy. The preferred treatment for pregnancy and children under the age of eight is co-trimoxazole . Q fever is a globally distributed zoonotic disease caused by a highly sustainable and virulent bacterium. The pathogenic agent is found worldwide, with the exception of New Zealand and Antarctica. Understanding the transmission and risk factors of Q fever is crucial for public health due to its potential to cause widespread infection. Transmission primarily occurs through the inhalation of contaminated dust, contact with contaminated milk, meat, or wool, and particularly birthing products. Ticks can transfer the pathogenic agent to other animals. While human-to-human transmission is rare, often associated with the transmission of birth products, sexual contact, and blood transfusion, certain occupations pose higher risks for Q fever: It is important to note that anyone who has contact with animals infected with Q fever bacteria, especially people who work on farms or with animals, is at an increased risk of contracting the disease. Understanding these occupational risks is crucial for public health. Studies indicate a higher prevalence of Q fever in men than in women, potentially linked to occupational exposure rates. Other contributing risk factors include geography, age, and occupational exposure. Diagnosis relies on blood compatibility testing , with treatment varying for acute and chronic cases. Acute disease often responds to doxycycline , while chronic cases may require a combination of doxycycline and hydroxychloroquine . It is worth noting that Q fever was officially reported in the United States as a notifiable disease in 1999 due to its potential biowarfare agent status. Q fever exhibits global epidemiological patterns, with higher incidence rates reported in certain countries. In Africa, wild animals in rainforests primarily transmit the disease, making it endemic . Unique patterns are observed in Latin America, but reporting is sporadic and inconsistent between and among countries, making it difficult to track and address. Recent outbreaks in European countries, including the Netherlands and France, have been linked to urbanized goat farming , raising concerns about the safety of intensive livestock farming practices and the potential risks of zoonotic diseases. Similarly, in the United States, Q fever is more common in livestock farming regions, especially in the West and the Great Plains. California, Texas, and Iowa account for almost 40% of reported cases, with a higher incidence during the spring and early summer when livestock are breeding, regardless of whether the infection is acute or chronic. These outbreaks have affected a significant number of people, with immunocompromised individuals being more severely impacted. The global nature of Q fever and its association with livestock farming highlight the importance of implementing measures to prevent and control the spread of the disease, particularly in high-risk regions. Older men in the West and Great Plains regions, involved in close contact with livestock management, are at a higher risk of contracting chronic Q fever. This risk may be further increased for those with a history of cardiac problems. The disease can manifest years after the initial infection, presenting symptoms such as non-specific fatigue, fever, weight loss, and endocarditis . Additionally, certain populations have been found to be more vulnerable to Q fever, including children living in farming communities, who may experience similar symptoms as adults. There have also been reported cases of Q fever among United States military service members , particularly those deployed to Iraq or Afghanistan, which further highlights the importance of understanding and addressing the occupational risks associated with Q fever. Proper public health education is crucial in reducing the number of Q fever cases. Raising awareness about transmission routes, occupational risks, and preventive measures, such as eliminating unpasteurized milk products from the diet, can help prevent the spread of disease. Interdisciplinary collaboration between medical personnel and farmers is critical when developing strategies for control and prevention in a community. Awareness campaigns should particularly target occupations that work with livestock, focusing on risk-reduction procedures such as herd monitoring, implementing sanitation practices and personal protective equipment, and vaccinating animals. Locating livestock farms at least 500 meters away from residential areas can also help reduce animal-to-human transmission. Transmission primarily occurs through the inhalation of contaminated dust, contact with contaminated milk, meat, or wool, and particularly birthing products. Ticks can transfer the pathogenic agent to other animals. While human-to-human transmission is rare, often associated with the transmission of birth products, sexual contact, and blood transfusion, certain occupations pose higher risks for Q fever: It is important to note that anyone who has contact with animals infected with Q fever bacteria, especially people who work on farms or with animals, is at an increased risk of contracting the disease. Understanding these occupational risks is crucial for public health.Studies indicate a higher prevalence of Q fever in men than in women, potentially linked to occupational exposure rates. Other contributing risk factors include geography, age, and occupational exposure. Diagnosis relies on blood compatibility testing , with treatment varying for acute and chronic cases. Acute disease often responds to doxycycline , while chronic cases may require a combination of doxycycline and hydroxychloroquine . It is worth noting that Q fever was officially reported in the United States as a notifiable disease in 1999 due to its potential biowarfare agent status. Q fever exhibits global epidemiological patterns, with higher incidence rates reported in certain countries. In Africa, wild animals in rainforests primarily transmit the disease, making it endemic . Unique patterns are observed in Latin America, but reporting is sporadic and inconsistent between and among countries, making it difficult to track and address. Recent outbreaks in European countries, including the Netherlands and France, have been linked to urbanized goat farming , raising concerns about the safety of intensive livestock farming practices and the potential risks of zoonotic diseases. Similarly, in the United States, Q fever is more common in livestock farming regions, especially in the West and the Great Plains. California, Texas, and Iowa account for almost 40% of reported cases, with a higher incidence during the spring and early summer when livestock are breeding, regardless of whether the infection is acute or chronic. These outbreaks have affected a significant number of people, with immunocompromised individuals being more severely impacted. The global nature of Q fever and its association with livestock farming highlight the importance of implementing measures to prevent and control the spread of the disease, particularly in high-risk regions.Older men in the West and Great Plains regions, involved in close contact with livestock management, are at a higher risk of contracting chronic Q fever. This risk may be further increased for those with a history of cardiac problems. The disease can manifest years after the initial infection, presenting symptoms such as non-specific fatigue, fever, weight loss, and endocarditis . Additionally, certain populations have been found to be more vulnerable to Q fever, including children living in farming communities, who may experience similar symptoms as adults. There have also been reported cases of Q fever among United States military service members , particularly those deployed to Iraq or Afghanistan, which further highlights the importance of understanding and addressing the occupational risks associated with Q fever. Proper public health education is crucial in reducing the number of Q fever cases. Raising awareness about transmission routes, occupational risks, and preventive measures, such as eliminating unpasteurized milk products from the diet, can help prevent the spread of disease. Interdisciplinary collaboration between medical personnel and farmers is critical when developing strategies for control and prevention in a community. Awareness campaigns should particularly target occupations that work with livestock, focusing on risk-reduction procedures such as herd monitoring, implementing sanitation practices and personal protective equipment, and vaccinating animals. Locating livestock farms at least 500 meters away from residential areas can also help reduce animal-to-human transmission. Q fever was first described in 1935 by Edward Holbrook Derrick in slaughterhouse workers in Brisbane , Queensland . The "Q" stands for "query" and was applied at a time when the causative agent was unknown; it was chosen over suggestions of abattoir fever and Queensland rickettsial fever, to avoid directing negative connotations at either the cattle industry or the state of Queensland. The pathogen of Q fever was discovered in 1937, when Frank Macfarlane Burnet and Mavis Freeman isolated the bacterium from one of Derrick's patients. It was originally identified as a species of Rickettsia . H.R. Cox and Gordon Davis elucidated the transmission when they isolated it from ticks found in the US state of Montana in 1938. It is a zoonotic disease whose most common animal reservoirs are cattle, sheep, and goats. Coxiella burnetii – named for Cox and Burnet – is no longer regarded as closely related to the Rickettsiae , but as similar to Legionella and Francisella , and is a Gammaproteobacterium . [ citation needed ]An early mention of Q fever was important in one of the early Dr. Kildare films (1939, Calling Dr. Kildare ). Kildare's mentor Dr. Gillespie ( Lionel Barrymore ) tires of his protégé working fruitlessly on "exotic diagnoses" ("I think it's Q fever!") and sends him to work in a neighborhood clinic, instead. Q fever was also highlighted in an episode of the U.S. television medical drama House (" The Dig ", season seven, episode 18). [ citation needed ] C. burnetii has been used to develop biological weapons . The United States investigated it as a potential biological warfare agent in the 1950s, with eventual standardization as agent OU. At Fort Detrick and Dugway Proving Ground, human trials were conducted on Whitecoat volunteers to determine the median infective dose (18 MICLD 50 /person i.h.) and course of infection. The Deseret Test Center dispensed biological Agent OU with ships and aircraft, during Project 112 and Project SHAD . As a standardized biological, it was manufactured in large quantities at Pine Bluff Arsenal , with 5,098 gallons in the arsenal in bulk at the time of demilitarization in 1970. [ citation needed ] C. burnetii is currently ranked as a " category B " bioterrorism agent by the CDC . It can be contagious, and is very stable in aerosols in a wide range of temperatures. Q fever microorganisms may survive on surfaces up to 60 days. It is considered a good agent in part because its ID 50 (number of bacilli needed to infect 50% of individuals) is considered to be one, making it the lowest known. [ dubious – discuss ]C. burnetii has been used to develop biological weapons . The United States investigated it as a potential biological warfare agent in the 1950s, with eventual standardization as agent OU. At Fort Detrick and Dugway Proving Ground, human trials were conducted on Whitecoat volunteers to determine the median infective dose (18 MICLD 50 /person i.h.) and course of infection. The Deseret Test Center dispensed biological Agent OU with ships and aircraft, during Project 112 and Project SHAD . As a standardized biological, it was manufactured in large quantities at Pine Bluff Arsenal , with 5,098 gallons in the arsenal in bulk at the time of demilitarization in 1970. [ citation needed ] C. burnetii is currently ranked as a " category B " bioterrorism agent by the CDC . It can be contagious, and is very stable in aerosols in a wide range of temperatures. Q fever microorganisms may survive on surfaces up to 60 days. It is considered a good agent in part because its ID 50 (number of bacilli needed to infect 50% of individuals) is considered to be one, making it the lowest known. [ dubious – discuss ]Q fever can affect many species of domestic and wild animals, including ruminants (cattle, sheep, goats, bison, deer species ...), carnivores (dogs, cats, seals ...), rodents, reptiles and birds. However, ruminants (cattle, goats, and sheep) are the most frequently affected animals, and can serve as a reservoir for the bacteria. In contrast to humans, though a respiratory and cardiac infection could be experimentally reproduced in cattle, the clinical signs mainly affect the reproductive system. Q fever in ruminants is, therefore, mainly responsible for abortions, metritis, retained placenta, and infertility. The clinical signs vary between species. In small ruminants (sheep and goats), it is dominated by abortions, premature births, stillbirths, and the birth of weak lambs or kids. One of the characteristics of abortions in goats is that they are very frequent and clustered in the first year or two after contamination of the farm. This is known as an abortion storm. In cattle, although abortions also occur, they are less frequent and more sporadic. The clinical picture is rather dominated by nonspecific signs such as placental retentions, metritis, and consequent fertility disorders. With the exception of New Zealand, which is currently free of Q fever, the disease is present throughout the world. Numerous epidemiological surveys have been carried out. They have shown that about one in three cattle farms and one in four sheep or goat farms are infected, but wide variations are seen between studies and countries. In China, Iran, Great Britain, Germany, Hungary, the Netherlands, Spain, the US, Belgium, Denmark, Croatia, Slovakia, the Czech Republic, Serbia, Slovenia, and Jordan, for example, more than 50% of cattle herds were infected with Q fever. Infected animals shed the bacteria by three routes - genital discharge, faeces, and milk. Excretion is greatest at the time of parturition or abortion, and placentas and aborted fetuses are the main sources of bacteria, particularly in goats. As C. burnetii is small and resistant in the environment, it is easily airborne and can be transmitted from one farm to another, even if several kilometres away. Based on the epidemiological data, biosecurity measures can be derived: The spread of manure from infected farm should be avoided in windy conditions The level of hygiene must be very high during parturition and fetal annexes, and fetuses must be collected and destroyed as soon as possible A vaccine for cattle, goats and sheep exists. It reduces clinical expression such as abortions and decreases excretion of the bacteria by the animals leading to control of Q fever in herds. In addition, vaccination of herds against Q fever has been shown to reduce the risk of human infection. In contrast to humans, though a respiratory and cardiac infection could be experimentally reproduced in cattle, the clinical signs mainly affect the reproductive system. Q fever in ruminants is, therefore, mainly responsible for abortions, metritis, retained placenta, and infertility. The clinical signs vary between species. In small ruminants (sheep and goats), it is dominated by abortions, premature births, stillbirths, and the birth of weak lambs or kids. One of the characteristics of abortions in goats is that they are very frequent and clustered in the first year or two after contamination of the farm. This is known as an abortion storm. In cattle, although abortions also occur, they are less frequent and more sporadic. The clinical picture is rather dominated by nonspecific signs such as placental retentions, metritis, and consequent fertility disorders. With the exception of New Zealand, which is currently free of Q fever, the disease is present throughout the world. Numerous epidemiological surveys have been carried out. They have shown that about one in three cattle farms and one in four sheep or goat farms are infected, but wide variations are seen between studies and countries. In China, Iran, Great Britain, Germany, Hungary, the Netherlands, Spain, the US, Belgium, Denmark, Croatia, Slovakia, the Czech Republic, Serbia, Slovenia, and Jordan, for example, more than 50% of cattle herds were infected with Q fever. Infected animals shed the bacteria by three routes - genital discharge, faeces, and milk. Excretion is greatest at the time of parturition or abortion, and placentas and aborted fetuses are the main sources of bacteria, particularly in goats. As C. burnetii is small and resistant in the environment, it is easily airborne and can be transmitted from one farm to another, even if several kilometres away. Based on the epidemiological data, biosecurity measures can be derived: The spread of manure from infected farm should be avoided in windy conditions The level of hygiene must be very high during parturition and fetal annexes, and fetuses must be collected and destroyed as soon as possible A vaccine for cattle, goats and sheep exists. It reduces clinical expression such as abortions and decreases excretion of the bacteria by the animals leading to control of Q fever in herds. In addition, vaccination of herds against Q fever has been shown to reduce the risk of human infection. Based on the epidemiological data, biosecurity measures can be derived: The spread of manure from infected farm should be avoided in windy conditions The level of hygiene must be very high during parturition and fetal annexes, and fetuses must be collected and destroyed as soon as possibleA vaccine for cattle, goats and sheep exists. It reduces clinical expression such as abortions and decreases excretion of the bacteria by the animals leading to control of Q fever in herds. In addition, vaccination of herds against Q fever has been shown to reduce the risk of human infection.

Wiki

Dengue fever

https://api.wikimedia.org/core/v1/wikipedia/en/page/Neil_Ferguson_(epidemiologist)/html

Neil Ferguson (epidemiologist)

Neil Morris Ferguson OBE FMedSci (born 1968) is a British epidemiologist and professor of mathematical biology , who specialises in the patterns of spread of infectious disease in humans and animals. He is the director of the Jameel Institute , and of the MRC Centre for Global Infectious Disease Analysis , and head of the Department of Infectious Disease Epidemiology in the School of Public Health and Vice-Dean for Academic Development in the Faculty of Medicine , all at Imperial College London . Ferguson has used mathematical modelling to provide data on several disease outbreaks including the 2001 United Kingdom foot-and-mouth outbreak , the swine flu outbreak in 2009 in the UK , the 2012 Middle East respiratory syndrome coronavirus outbreak and the ebola epidemic in Western Africa in 2016. His work has also included research on mosquito-borne diseases including zika fever , yellow fever , dengue fever and malaria . In February 2020, during the COVID-19 pandemic , which was first detected in China, Ferguson and his team used statistical models to estimate that cases of coronavirus disease 2019 (COVID-19) were significantly under-detected in China. He is part of the Imperial College COVID-19 Response Team .Ferguson was born in Whitehaven , Cumberland , but grew up in Mid Wales , where he attended Llanidloes High School . His father was an educational psychologist , while his mother was a librarian who later became an Anglican priest . He received his Bachelor of Arts degree in Physics in 1990 at Lady Margaret Hall, Oxford , and his Doctor of Philosophy degree in theoretical physics in 1994 at Linacre College, Oxford . His doctoral research investigated interpolations from crystalline to dynamically triangulated random surfaces and was supervised by John Wheater . It was there that he attended a lecture by Robert May on modelling the HIV epidemic , which together with the death of a friend's brother from AIDS , interested him in pursuing the mathematical modelling of infectious diseases. Using mathematical and statistical models he studies the processes that influence the development , evolution and transmission of infectious diseases. These have included SARS, pandemic influenza, BSE / vCJD , foot-and-mouth disease, HIV and smallpox , in addition to bioterrorism . Ferguson was part of Roy Anderson 's group of infectious disease scientists who moved from the University of Oxford to Imperial College in November 2000, and started working on modelling the 2001 United Kingdom foot-and-mouth outbreak a few months later. Ferguson and colleagues founded the Medical Research Council (MRC) Centre for Global Infectious Disease Analysis in 2008. He advises the World Health Organization (WHO), the European Union, and the governments of the UK and United States, on the dynamics of infectious disease. He is an international member of the National Academy of Medicine , a fellow of the Royal Statistical Society , and is on the editorial boards of PLOS Computational Biology and Journal of the Royal Society Interface . He is a founding editor of the journal Epidemics . Since 2014 he is the director of the National Institute for Health Research (NIHR) Health Protection Research Unit for Modelling Methodology. Together with a number of other persons, in 2016 he proposed a World Serum Bank as a means of helping combat epidemics . In October 2019, Ferguson was appointed inaugural director of the Jameel Institute for Disease and Emergency Analytics (J-IDEA), a research institute at Imperial College London in the fields of epidemiology , mathematical modelling of infectious diseases and emergencies, environmental health , and health economics . The Jameel Institute was part of the Imperial College COVID-19 Response Team. As of February 2020, at Imperial College, London, he was a professor of mathematical biology , director of the Jameel Institute (J-IDEA), head of the Department of Infectious Disease Epidemiology in the School of Public Health and Vice-Dean for Academic Development in the Faculty of Medicine. As of March 2020, Ferguson was a member of the UK Department of Health advisory body called the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG), which advises the CMOUK . During the 2001 United Kingdom foot-and-mouth outbreak Ferguson worked on the team, led by Roy M. Anderson of Imperial College, creating mathematical models used to inform the UK Government of the most effective methods of preventing the spread of foot-and-mouth-disease . Ferguson published a journal article in Science magazine in April 2001 describing the mathematical models that were relied upon by the UK government to recommend the mass slaughter of millions of cows, sheep and pigs in the UK in order to stop the spread of the disease; over a decade later, the BBC would remind its readers Ferguson "was among those advising government on how to control the epidemic a decade ago." In August 2005, Neil Ferguson said in an interview that bird flu could kill as many as 200 million people worldwide. He stated that "Around 40 million people died in 1918 Spanish flu outbreak" and that "There are six times more people on the planet now so you could scale it [the death toll from bird flu] up to around 200 million people probably". In the interview, he warned that failure to take swift action would be catastrophic for the United Kingdom, saying that "If the virus got as far as Britain, it would effectively be too late". The virus did not reach Britain and 74 persons worldwide died of bird flu in 2005. During the swine flu outbreak in 2009 in the UK , in an article titled "Closure of schools during an influenza pandemic" published in the Lancet Infectious Diseases , Ferguson and colleagues endorsed the closure of schools to interrupt the course of the infection, slow further spread and buy time to research and produce a vaccine. Ferguson's team reported on the economic and workforce effect school closure would have, particularly with a large percentage of doctors and nurses being women, of whom half had children under the age of 16. They studied previous influenza pandemics including the 1918 flu pandemic , the influenza pandemic of 1957 and the 1968 flu pandemic . They also looked at the dynamics of the spread of influenza in France during French school holidays and noted that cases of flu dropped when schools closed and re-emerged when they reopened. They noted that when teachers in Israel went on strike during the flu season of 1999–2000, visits to doctors and the number of respiratory infections, fell by more than a fifth and more than two-fifths respectively. In the House of Lords Science and Technology Committee 's "follow-up" to the swine flu epidemic in 2009, Ferguson recommended that to halt transmission of swine flu, actions would need to include "treating isolated cases with antivirals, public health measures such as school closures, travel restrictions around the region, mass use of antiviral prophylaxis in the population and possible use of vaccines". He was also asked why there was not a policy for vaccinating frontline healthcare workers at that time. In 2013, he contributed to research on MERS-CoV during the first MERS outbreak in the Middle East , and its link with dromedary camels . In 2014, as the director of the UK Medical Research Council's centre for outbreak analysis and modelling at Imperial, Ferguson provided data analysis for the WHO, on Ebola during the ebola epidemic in Western Africa . In the same year, he co-wrote a paper with Christopher J. M. Whitty and Jeremy Farrar , published in Nature , titled "Infectious disease: Tough choices to reduce Ebola transmission", explaining the UK government's response to ebola in Sierra Leone, including the proposal to build and support centres where people could self-isolate voluntarily if they suspected they had the disease. Ferguson's work has included research on several mosquito-borne diseases including zika fever , yellow fever , dengue fever and malaria . In 2016, he co-wrote a paper titled "Countering the Zika epidemic in Latin America", published in Science . Although disputed by at least one other biostatistician, Ferguson and his team concluded that the age distribution of future outbreaks of zika will likely differ and that a new large epidemic would be delayed for "at least a decade". Cases of zika dropped after 2016. That year, he predicted that the zika outbreak in the Americas would be over within three years, and clarified that "viruses tend to return when there are enough susceptible people, such as children, to sustain a new outbreak". Wolbachia is a bacterium frequently found in insects but not in the Aedes aegypti mosquito, which carries the dengue virus . In 2015, Ferguson published a paper titled "Modeling the impact on virus transmission of Wolbachia -mediated blocking of dengue virus infection of Aedes aegypti ", in which he and his team presented their experiments and used a mathematical model to show that one strain of Wolbachia , could reduce the ability of the Aedes aegypti mosquito to transmit dengue, with a 66–75% reduction in the basic reproduction number . During the COVID-19 pandemic , Neil Ferguson headed the Imperial College COVID-19 Response Team . In February 2020, during the COVID-19 pandemic , using statistical models that considered data on the number of deaths and recoveries inside China, travellers outside China and in those affected that had returned home, Ferguson, Azra Ghani and their team estimated that detected cases of COVID-19 had significantly underestimated the actual spread of the disease in China. That month he stated that only 10% of cases were being detected in China. At the same time, it was noted that the number of available testing kits had come into question, and Ferguson calculated that only one in three cases coming into the UK was being detected. He stated "that approximately two-thirds of cases in travellers from China have not yet been detected. It is highly likely that some of these undetected cases will have started chains of transmission within the countries they entered." He said that the new coronavirus could affect up to 60% of the UK's population, in the worst-case scenario, and "suggest(ed) that the impact of the unfolding epidemic may be comparable to the major influenza pandemics of the twentieth century." His team's publication in mid-March of the projections that the UK could face hundreds of thousands of deaths from COVID-19 without strict social distancing measures, gained widespread media attention. In late March, he calculated that with "strict social distancing , testing and isolation of infected cases", deaths in the UK could fall to less than 20,000. Ferguson's research has raised questions by virologist Hendrik Streeck . Ferguson is the corresponding author for a paper titled "Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand", which describes itself as having "informed policymaking in the UK and other countries in recent weeks". Streeck stated in reference to the paper "In the – really good – model studies by the Imperial College about the progress of the epidemic, the authors assume, for example, that 50 percent of households in which there is a case do not comply with the voluntary quarantine. Where does such an assumption come from? I think we should establish more facts." The COVID-19 computer model which Ferguson authored (see CovidSim ) was initially criticised as "unreliable" and "a buggy mess," but subsequent efforts to reproduce the results were successful. Ferguson has been a regular guest on BBC Radio 4 's morning programme Today during the pandemic. On 5 May 2020, it emerged that Ferguson had resigned from his position as a government advisor on the Scientific Advisory Group for Emergencies (SAGE) committee after admitting to "undermining" the government's messages on social distancing by trysting with a married woman, Antonia Staats. The Telegraph reported that she had visited his home at least two times. After resigning, Ferguson said "I acted in the belief that I was immune, having tested positive for coronavirus and completely isolated myself for almost two weeks after developing symptoms", adding that he regretted undermining "clear messages" about the need for social distancing. The Secretary of State for Health and Social Care , Matt Hancock , said that he was right to resign from his advisory position. Ferguson did not receive a fine or prosecution for his actions, as at the time it was not illegal as he had not left his home; this legal loophole was later closed. It was subsequently revealed that Ferguson had remained a member of the SAGE sub-committee NERVTAG and continued to contribute to the advisory committee SPI-M. In August 2022, after revelations by former Chancellor Rishi Sunak , retired Supreme Court judge Jonathan Sumption blamed " Report 9 " of Ferguson's Imperial College COVID-19 Response Team in 2020 for "one of the gravest governmental failures of modern times". Ferguson was appointed an Officer of the British Empire (OBE) in the 2002 New Year Honours for his work modelling the 2001 United Kingdom foot-and-mouth outbreak . He was elected a Fellow of the Academy of Medical Sciences (FMedSci) in 2005. He is also an International Member of the US National Academy of Medicine . In recognition of his policy work on non-pharmaceutical intervention measures to address the COVID-19 pandemic, Ferguson received an Emergent Ventures award and associated grant money from the Mercatus Center . Ferguson's publications include:During the 2001 United Kingdom foot-and-mouth outbreak Ferguson worked on the team, led by Roy M. Anderson of Imperial College, creating mathematical models used to inform the UK Government of the most effective methods of preventing the spread of foot-and-mouth-disease . Ferguson published a journal article in Science magazine in April 2001 describing the mathematical models that were relied upon by the UK government to recommend the mass slaughter of millions of cows, sheep and pigs in the UK in order to stop the spread of the disease; over a decade later, the BBC would remind its readers Ferguson "was among those advising government on how to control the epidemic a decade ago." In August 2005, Neil Ferguson said in an interview that bird flu could kill as many as 200 million people worldwide. He stated that "Around 40 million people died in 1918 Spanish flu outbreak" and that "There are six times more people on the planet now so you could scale it [the death toll from bird flu] up to around 200 million people probably". In the interview, he warned that failure to take swift action would be catastrophic for the United Kingdom, saying that "If the virus got as far as Britain, it would effectively be too late". The virus did not reach Britain and 74 persons worldwide died of bird flu in 2005. During the swine flu outbreak in 2009 in the UK , in an article titled "Closure of schools during an influenza pandemic" published in the Lancet Infectious Diseases , Ferguson and colleagues endorsed the closure of schools to interrupt the course of the infection, slow further spread and buy time to research and produce a vaccine. Ferguson's team reported on the economic and workforce effect school closure would have, particularly with a large percentage of doctors and nurses being women, of whom half had children under the age of 16. They studied previous influenza pandemics including the 1918 flu pandemic , the influenza pandemic of 1957 and the 1968 flu pandemic . They also looked at the dynamics of the spread of influenza in France during French school holidays and noted that cases of flu dropped when schools closed and re-emerged when they reopened. They noted that when teachers in Israel went on strike during the flu season of 1999–2000, visits to doctors and the number of respiratory infections, fell by more than a fifth and more than two-fifths respectively. In the House of Lords Science and Technology Committee 's "follow-up" to the swine flu epidemic in 2009, Ferguson recommended that to halt transmission of swine flu, actions would need to include "treating isolated cases with antivirals, public health measures such as school closures, travel restrictions around the region, mass use of antiviral prophylaxis in the population and possible use of vaccines". He was also asked why there was not a policy for vaccinating frontline healthcare workers at that time. In 2013, he contributed to research on MERS-CoV during the first MERS outbreak in the Middle East , and its link with dromedary camels . In 2014, as the director of the UK Medical Research Council's centre for outbreak analysis and modelling at Imperial, Ferguson provided data analysis for the WHO, on Ebola during the ebola epidemic in Western Africa . In the same year, he co-wrote a paper with Christopher J. M. Whitty and Jeremy Farrar , published in Nature , titled "Infectious disease: Tough choices to reduce Ebola transmission", explaining the UK government's response to ebola in Sierra Leone, including the proposal to build and support centres where people could self-isolate voluntarily if they suspected they had the disease. Ferguson's work has included research on several mosquito-borne diseases including zika fever , yellow fever , dengue fever and malaria . In 2016, he co-wrote a paper titled "Countering the Zika epidemic in Latin America", published in Science . Although disputed by at least one other biostatistician, Ferguson and his team concluded that the age distribution of future outbreaks of zika will likely differ and that a new large epidemic would be delayed for "at least a decade". Cases of zika dropped after 2016. That year, he predicted that the zika outbreak in the Americas would be over within three years, and clarified that "viruses tend to return when there are enough susceptible people, such as children, to sustain a new outbreak". Wolbachia is a bacterium frequently found in insects but not in the Aedes aegypti mosquito, which carries the dengue virus . In 2015, Ferguson published a paper titled "Modeling the impact on virus transmission of Wolbachia -mediated blocking of dengue virus infection of Aedes aegypti ", in which he and his team presented their experiments and used a mathematical model to show that one strain of Wolbachia , could reduce the ability of the Aedes aegypti mosquito to transmit dengue, with a 66–75% reduction in the basic reproduction number . In 2016, he co-wrote a paper titled "Countering the Zika epidemic in Latin America", published in Science . Although disputed by at least one other biostatistician, Ferguson and his team concluded that the age distribution of future outbreaks of zika will likely differ and that a new large epidemic would be delayed for "at least a decade". Cases of zika dropped after 2016. That year, he predicted that the zika outbreak in the Americas would be over within three years, and clarified that "viruses tend to return when there are enough susceptible people, such as children, to sustain a new outbreak". Wolbachia is a bacterium frequently found in insects but not in the Aedes aegypti mosquito, which carries the dengue virus . In 2015, Ferguson published a paper titled "Modeling the impact on virus transmission of Wolbachia -mediated blocking of dengue virus infection of Aedes aegypti ", in which he and his team presented their experiments and used a mathematical model to show that one strain of Wolbachia , could reduce the ability of the Aedes aegypti mosquito to transmit dengue, with a 66–75% reduction in the basic reproduction number . During the COVID-19 pandemic , Neil Ferguson headed the Imperial College COVID-19 Response Team . In February 2020, during the COVID-19 pandemic , using statistical models that considered data on the number of deaths and recoveries inside China, travellers outside China and in those affected that had returned home, Ferguson, Azra Ghani and their team estimated that detected cases of COVID-19 had significantly underestimated the actual spread of the disease in China. That month he stated that only 10% of cases were being detected in China. At the same time, it was noted that the number of available testing kits had come into question, and Ferguson calculated that only one in three cases coming into the UK was being detected. He stated "that approximately two-thirds of cases in travellers from China have not yet been detected. It is highly likely that some of these undetected cases will have started chains of transmission within the countries they entered." He said that the new coronavirus could affect up to 60% of the UK's population, in the worst-case scenario, and "suggest(ed) that the impact of the unfolding epidemic may be comparable to the major influenza pandemics of the twentieth century." His team's publication in mid-March of the projections that the UK could face hundreds of thousands of deaths from COVID-19 without strict social distancing measures, gained widespread media attention. In late March, he calculated that with "strict social distancing , testing and isolation of infected cases", deaths in the UK could fall to less than 20,000. Ferguson's research has raised questions by virologist Hendrik Streeck . Ferguson is the corresponding author for a paper titled "Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand", which describes itself as having "informed policymaking in the UK and other countries in recent weeks". Streeck stated in reference to the paper "In the – really good – model studies by the Imperial College about the progress of the epidemic, the authors assume, for example, that 50 percent of households in which there is a case do not comply with the voluntary quarantine. Where does such an assumption come from? I think we should establish more facts." The COVID-19 computer model which Ferguson authored (see CovidSim ) was initially criticised as "unreliable" and "a buggy mess," but subsequent efforts to reproduce the results were successful. Ferguson has been a regular guest on BBC Radio 4 's morning programme Today during the pandemic. On 5 May 2020, it emerged that Ferguson had resigned from his position as a government advisor on the Scientific Advisory Group for Emergencies (SAGE) committee after admitting to "undermining" the government's messages on social distancing by trysting with a married woman, Antonia Staats. The Telegraph reported that she had visited his home at least two times. After resigning, Ferguson said "I acted in the belief that I was immune, having tested positive for coronavirus and completely isolated myself for almost two weeks after developing symptoms", adding that he regretted undermining "clear messages" about the need for social distancing. The Secretary of State for Health and Social Care , Matt Hancock , said that he was right to resign from his advisory position. Ferguson did not receive a fine or prosecution for his actions, as at the time it was not illegal as he had not left his home; this legal loophole was later closed. It was subsequently revealed that Ferguson had remained a member of the SAGE sub-committee NERVTAG and continued to contribute to the advisory committee SPI-M. In August 2022, after revelations by former Chancellor Rishi Sunak , retired Supreme Court judge Jonathan Sumption blamed " Report 9 " of Ferguson's Imperial College COVID-19 Response Team in 2020 for "one of the gravest governmental failures of modern times". On 5 May 2020, it emerged that Ferguson had resigned from his position as a government advisor on the Scientific Advisory Group for Emergencies (SAGE) committee after admitting to "undermining" the government's messages on social distancing by trysting with a married woman, Antonia Staats. The Telegraph reported that she had visited his home at least two times. After resigning, Ferguson said "I acted in the belief that I was immune, having tested positive for coronavirus and completely isolated myself for almost two weeks after developing symptoms", adding that he regretted undermining "clear messages" about the need for social distancing. The Secretary of State for Health and Social Care , Matt Hancock , said that he was right to resign from his advisory position. Ferguson did not receive a fine or prosecution for his actions, as at the time it was not illegal as he had not left his home; this legal loophole was later closed. It was subsequently revealed that Ferguson had remained a member of the SAGE sub-committee NERVTAG and continued to contribute to the advisory committee SPI-M. In August 2022, after revelations by former Chancellor Rishi Sunak , retired Supreme Court judge Jonathan Sumption blamed " Report 9 " of Ferguson's Imperial College COVID-19 Response Team in 2020 for "one of the gravest governmental failures of modern times". Ferguson was appointed an Officer of the British Empire (OBE) in the 2002 New Year Honours for his work modelling the 2001 United Kingdom foot-and-mouth outbreak . He was elected a Fellow of the Academy of Medical Sciences (FMedSci) in 2005. He is also an International Member of the US National Academy of Medicine . In recognition of his policy work on non-pharmaceutical intervention measures to address the COVID-19 pandemic, Ferguson received an Emergent Ventures award and associated grant money from the Mercatus Center . Ferguson's publications include:Ferguson reported on 18 March 2020 that he had developed the symptoms of COVID-19, and self-isolated. He recovered after a mild illness. Ferguson is separated from his wife and has one son.

Wiki

Dengue fever

https://api.wikimedia.org/core/v1/wikipedia/en/page/Aedes/html

Aedes

List of Aedes species Aedes (also known as the tiger mosquito ) is a genus of mosquitoes originally found in tropical and subtropical zones , but now found on all continents except Antarctica . Some species have been spread by human activity : Aedes albopictus , a particularly invasive species , was spread to the Americas , including the United States , in the 1980s, by the used-tire trade . First described and named by German entomologist Johann Wilhelm Meigen in 1818, the generic name comes from the Ancient Greek ἀηδής , aēdēs , meaning 'unpleasant' or 'odious'. The type species for Aedes is Aedes cinereus . The genus was named by Johann Wilhelm Meigen in 1818. The generic name comes from the Ancient Greek ἀηδής , aēdēs , meaning 'unpleasant' or 'odious'. As historically defined, the genus contains over 700 species (see the list of Aedes species ). The genus has been divided into several subgenera ( Aedes , Diceromyia , Finlaya , Stegomyia , etc.), most of which have been recently treated by some authorities as full genera. The classification was revised in 2009. Aedes mosquitoes are visually distinctive because they have noticeable black and white markings on their bodies and legs. Unlike most other mosquitoes, they are active and bite only during the daytime . The peak biting periods are early in the morning and in the evening before dusk. The genus contains 28 species that are not placed in a further subgenus: Members of the genus Aedes are known vectors for numerous viral infections, including dengue fever , yellow fever , the Zika virus , and chikungunya , which are transmitted by species in the subgenus Stegomyia , and by A. aegypti and A. albopictus . Infections with these viruses are typically accompanied by a fever, and in some cases, encephalitis, which can lead to death . A vaccine to provide protection from yellow fever exists, and measures to prevent mosquito bites include insecticides such as DDT , mosquito traps , insect repellents , mosquito nets , and pest control using genetically modified insects . In Polynesia , the species Aedes polynesiensis is responsible for the transmission of human lymphatic filariasis . Aedes can be detected and monitored by ovitraps .The genome of the yellow fever mosquito ( Aedes aegypti ) was sequenced by the Broad Institute and the Institute for Genomic Research . The initial assembly was released in August 2005; a draft sequence of the genome and preliminary analysis was published in June 2007. The annotated genome is available at VectorBase . An updated and improved version of the Aedes aegypti genome was released in 2018.

Wiki

Dengue fever

https://api.wikimedia.org/core/v1/wikipedia/en/page/Eupatorium_perfoliatum/html

Eupatorium perfoliatum

Cunigunda perfoliata (L.) Lunell Uncasia perfoliata (L.) Greene Eupatorium chapmanii Small Eupatorium connatum Michaux Eupatorium salviifolium Sims Eupatorium truncatum Muhl. ex Willd. Eupatorium × truncatum Muhl. ex Willd. Eupatorium cuneatum Engelm. ex Torr. & A.Gray Uncasia cuneata (Engelm. ex Torr. & A.Gray) Greene Uncasia truncata (Mühlenb. ex Willd.) Greene Eupatorium perfoliatum , known as common boneset or just boneset , is a North American perennial plant in the family Asteraceae . It is a common native to the Eastern United States and Canada , widespread from Nova Scotia to Florida , west as far as Texas , Nebraska , the Dakotas , and Manitoba . It is also called agueweed , feverwort , or sweating-plant . In herbal medicine , the plant is a diaphoretic , or an agent to cause sweating. It was introduced to American colonists by natives who used the plant for breaking fevers by means of heavy sweating, and commonly used to treat fever by the African-American population of the southern United States. The name "boneset" comes from the use of the plant to treat dengue fever , which is also called "break-bone fever." It is nearly always found in low, wet areas. Eupatorium perfoliatum grows up to 100 cm (39 inches) tall, with opposite, serrate leaves that clasp the stems ( perfoliate ). The stem is hairy. The plant produces dense clusters of tiny white flower heads held above the foliage. In Illinois, the plant blooms during late summer and early fall. Its native habitats include damp prairies, bogs, and alluvial woods. Eupatorium perfoliatum can form hybrids with other species of the genus Eupatorium , for example Eupatorium serotinum . Eupatorium perfoliatum leaves and roots contain mixed phytochemicals , including polysaccharides (containing xylose and glucuronic acid ), tannins , volatile oil , sesquiterpene lactones , sterols , triterpenes , alkaloids , and various flavonoids , such as quercetin , kaempferol , and caffeic acid derivatives. E. perfoliatum and several of its related species are listed on the Poisonous Plants Database of the US Food and Drug Administration , with E. perfoliatum described as an "unapproved homeopathic medicine" with unknown safety by the US National Library of Medicine . Holistic health companies marketing fraudulent supplement products that contained E. perforliatum with claims of benefit against COVID-19 were warned by the US Food and Drug Administration in 2020 about making illegal health claims and scamming consumers from their money. Eupatorium perfoliatum (also called boneset ) was used in traditional medicine by Native Americans who applied extracts for fever and common colds . By the early 20th century, it was reported as commonly used by rural African-Americans in the Deep South to treat fever, including dengue fever , though it was considered less effective for yellow fever and typhoid fever . Possible effects of E. perfoliatum for these uses remain undefined by adequate scientific research , and are unconfirmed by high-quality clinical research . If consumed in large amounts, tea made from its leaves may cause diarrhea . Eupatorium perfoliatum (also called boneset ) was used in traditional medicine by Native Americans who applied extracts for fever and common colds . By the early 20th century, it was reported as commonly used by rural African-Americans in the Deep South to treat fever, including dengue fever , though it was considered less effective for yellow fever and typhoid fever . Possible effects of E. perfoliatum for these uses remain undefined by adequate scientific research , and are unconfirmed by high-quality clinical research . If consumed in large amounts, tea made from its leaves may cause diarrhea .

Wiki

Dengue fever

https://api.wikimedia.org/core/v1/wikipedia/en/page/Kizzmekia_Corbett/html

Kizzmekia Corbett

Kizzmekia " Kizzy " Shanta Corbett (born January 26, 1986) is an American viral immunologist . She is an Assistant Professor of Immunology and Infectious Diseases at Harvard T.H. Chan School of Public Health and the Shutzer Assistant Professor at the Harvard Radcliffe Institute since June 2021. She joined Harvard following six years at the Vaccine Research Center (VRC) at the National Institute of Allergy and Infectious Diseases , National Institutes of Health (NIAID NIH) based in Bethesda, Maryland . She earned a PhD in microbiology and immunology from the University of North Carolina at Chapel Hill (UNC-Chapel Hill) in 2014. Appointed to the VRC in 2014, Corbett was a postdoctoral scientist of the VRC's COVID-19 Team, with research efforts aimed at COVID-19 vaccines . In February 2021, Corbett was highlighted in the Time's "Time100 Next" list under the category of Innovators , with a profile written by Anthony Fauci . Corbett was born in Hurdle Mills, North Carolina on January 26, 1986, to Rhonda Brooks. She grew up in Hillsborough, North Carolina , where she had a large family of step-siblings and foster siblings. Corbett went to Oak Lane Elementary School in Roxboro and A.L. Stanback Middle School in Hillsborough. Her fourth grade teacher, Myrtis Bradsher, recalls recognizing Corbett's talent at an early age and encouraging Kizzy's mother to place her in advanced classes. "I always thought she is going to do something one day. She dotted i's and crossed t's. The best in my 30 years of teaching," Bradsher said in a 2020 interview with The Washington Post . In 2004, Corbett graduated from Orange High School in Hillsborough, North Carolina. In 2008, Corbett received a B.S. in biological sciences and sociology from the University of Maryland, Baltimore County (UMBC), as a student in the Meyerhoff Scholars Program . Corbett is among a cohort of recent UMBC graduates (also including Kaitlyn Sadtler ) who have risen to prominence in biomedicine during the COVID-19 pandemic. In 2014, Corbett received a PhD in microbiology and immunology from the University of North Carolina at Chapel Hill . For her doctoral work, Corbett worked in Sri Lanka to study the role of human antibodies in dengue virus pathogenesis . While in high school, Corbett realized that she wanted to pursue a scientific career, and as part of an American Chemical Society -sponsored program called Project SEED, spent her summer holiday working in research laboratories, one of which was at UNC's Kenan Labs with organic chemist James Morkin. In 2005, she was a summer intern at Stony Brook University in Gloria Viboud's lab where she studied Yersinia pseudotuberculosis pathogenesis. From 2006 to 2007, she worked as a lab tech in Susan Dorsey's lab at the University of Maryland School of Nursing . After earning her bachelor's degree, from 2006 to 2009, Corbett was a biological sciences trainer at the National Institutes of Health (NIH), where she worked alongside Dr. Barney S. Graham . At the NIH, Corbett worked on the pathogenesis of respiratory syncytial virus as well as on a project focused on innovative vaccine platform advancement. From 2009 to 2014, Corbett studied human antibody responses to dengue virus in Sri Lankan children under the supervision of Aravinda de Silva at University of North Carolina at Chapel Hill (UNC-Chapel Hill). She studied how people produce antibodies in response to dengue fever, and how the genetics of dengue fever impact the severity of a disease. From April to May 2014, as part of her research for her dissertation, Corbett worked as a visiting scholar at Genetech Research Institute in Colombo, Sri Lanka . In October 2014, Corbett became a research fellow working as a viral immunologist at the NIH. Her research aims to uncover mechanisms of viral pathogenesis and host immunity. She specifically focuses on development of novel vaccines for coronaviridae . Her early research considered the development of Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) vaccine antigens. During this time, she identified a simple way to make coronavirus spike proteins that are stabilized in a conformation that renders them more immunogenic and manufacturable, in collaboration with researchers at Scripps Research Institute and Dartmouth College. In December 2021, Corbett was assigned to Boston's COVID-19 advisory committee by mayor Wu . At the onset of the COVID-19 pandemic , Corbett started working on a vaccine to protect people from coronavirus disease . Recognizing that the virus was similar to severe acute respiratory syndrome coronavirus , Corbett's team utilized previous knowledge of optimal coronavirus proteins to tackle COVID-19. S proteins form a "crown" on the surface of coronaviruses and are crucial for engagement of host cell receptors and the initiation of membrane fusion in coronavirus disease. This makes them a particularly vulnerable target for coronavirus prophylactics and therapeutics. Based on her previous research, Corbett's team, in collaboration with Jason McLellan and other investigators at The University of Texas at Austin , transplanted stabilizing mutations from SARS-CoV S protein into SARS-CoV-2 spike protein. She was part of the NIH team who helped solve the cryogenic electron microscopy (CryoEM) structure of the SARS-CoV-2 spike protein. Her prior research suggested that messenger RNA (mRNA) encoding S protein could be used to excite the immune response to produce protective antibodies against coronavirus disease 2019. To manufacture and test the COVID-19 vaccine Corbett's team partnered with Moderna , a biotechnology company, to rapidly enter animal studies. Subsequently, the vaccine entered Phase 1 clinical trial only 66 days after the virus sequence was released. The trial, to be completed in at least 45 people, is a dose escalation study in the form of two injections separated by 28 days. In December 2020, the Institute's Director, Anthony Fauci said: "Kizzy is an African American scientist who is right at the forefront of the development of the vaccine." In the Time's profile, Fauci wrote that Corbett has "been central to the development of the Moderna mRNA vaccine and the Eli Lilly therapeutic monoclonal antibody that were first to enter clinical trials in the U.S." and that "her work will have a substantial impact on ending the worst respiratory-disease pandemic in more than 100 years." Corbett's work afforded her the opportunity to be a part of the National Institutes of Health team that had Donald Trump at the Dale and Betty Bumpers Vaccine Research Center in March 2020. When asked about her involvement with the development of the COVID-19 vaccine, Corbett said, "To be living in this moment where I have the opportunity to work on something that has imminent global importance…it's just a surreal moment for me". Corbett stated she cried when the efficacy results showed the mRNA-1273 Moderna vaccine worked. Corbett has called for the public to be cautious and respectful of one another during the COVID-19 pandemic, explaining that regular hand washing and sneezing into one's elbow can help to minimize the spread of the virus. She has also emphasized that we should not stigmatize people who may be from areas where the virus started. Corbett has worked to rebuild trust with vaccine-hesitant populations such as the Black community. For example, she presented education about the COVID-19 vaccine development to Black Health Matters in October 2020. Her race has been a focus of government outreach; after a study released by the NAACP and others revealed that only 14% of black Americans believe a COVID-19 vaccine will be safe, NIAID Director Fauci was explicit: "the first thing you might want to say to my African American brothers and sisters is that the vaccine that you're going to be taking was developed by an African American woman." In May 2020, The Washington Post reported that Corbett had been scrutinized for tweets lamenting the lack of diversity on the White House Coronavirus Task Force , as well as for her responses to other tweets about data that African Americans were disproportionately dying from the virus. Responding to a tweet in which someone else claimed that the virus "is a way to get rid of us," Corbett responded: "Some have gone as far to call it genocide. I plead the fifth.". Fox News news host Tucker Carlson read several of Corbett's tweets on his show, accusing her of "spouting lunatic conspiracy theories." Another Fox News article said she "adopts a strikingly casual and conspiratorial tone." After the controversy, Corbett scaled back her use of social media and stopped appearing on television. Texas Southern University professor Robert Bullard and president of the National Medical Association (an organization of Black physicians) Oliver Brooks defended Corbett overall, although Brooks expressed concern about her tweet on genocide, saying "It's subjective. I wouldn't want to go there. I really don't believe that. We're dying at a higher rate but … that one just doesn't fit.". At the onset of the COVID-19 pandemic , Corbett started working on a vaccine to protect people from coronavirus disease . Recognizing that the virus was similar to severe acute respiratory syndrome coronavirus , Corbett's team utilized previous knowledge of optimal coronavirus proteins to tackle COVID-19. S proteins form a "crown" on the surface of coronaviruses and are crucial for engagement of host cell receptors and the initiation of membrane fusion in coronavirus disease. This makes them a particularly vulnerable target for coronavirus prophylactics and therapeutics. Based on her previous research, Corbett's team, in collaboration with Jason McLellan and other investigators at The University of Texas at Austin , transplanted stabilizing mutations from SARS-CoV S protein into SARS-CoV-2 spike protein. She was part of the NIH team who helped solve the cryogenic electron microscopy (CryoEM) structure of the SARS-CoV-2 spike protein. Her prior research suggested that messenger RNA (mRNA) encoding S protein could be used to excite the immune response to produce protective antibodies against coronavirus disease 2019. To manufacture and test the COVID-19 vaccine Corbett's team partnered with Moderna , a biotechnology company, to rapidly enter animal studies. Subsequently, the vaccine entered Phase 1 clinical trial only 66 days after the virus sequence was released. The trial, to be completed in at least 45 people, is a dose escalation study in the form of two injections separated by 28 days. In December 2020, the Institute's Director, Anthony Fauci said: "Kizzy is an African American scientist who is right at the forefront of the development of the vaccine." In the Time's profile, Fauci wrote that Corbett has "been central to the development of the Moderna mRNA vaccine and the Eli Lilly therapeutic monoclonal antibody that were first to enter clinical trials in the U.S." and that "her work will have a substantial impact on ending the worst respiratory-disease pandemic in more than 100 years." Corbett's work afforded her the opportunity to be a part of the National Institutes of Health team that had Donald Trump at the Dale and Betty Bumpers Vaccine Research Center in March 2020. When asked about her involvement with the development of the COVID-19 vaccine, Corbett said, "To be living in this moment where I have the opportunity to work on something that has imminent global importance…it's just a surreal moment for me". Corbett stated she cried when the efficacy results showed the mRNA-1273 Moderna vaccine worked. Corbett has called for the public to be cautious and respectful of one another during the COVID-19 pandemic, explaining that regular hand washing and sneezing into one's elbow can help to minimize the spread of the virus. She has also emphasized that we should not stigmatize people who may be from areas where the virus started. Corbett has worked to rebuild trust with vaccine-hesitant populations such as the Black community. For example, she presented education about the COVID-19 vaccine development to Black Health Matters in October 2020. Her race has been a focus of government outreach; after a study released by the NAACP and others revealed that only 14% of black Americans believe a COVID-19 vaccine will be safe, NIAID Director Fauci was explicit: "the first thing you might want to say to my African American brothers and sisters is that the vaccine that you're going to be taking was developed by an African American woman." In May 2020, The Washington Post reported that Corbett had been scrutinized for tweets lamenting the lack of diversity on the White House Coronavirus Task Force , as well as for her responses to other tweets about data that African Americans were disproportionately dying from the virus. Responding to a tweet in which someone else claimed that the virus "is a way to get rid of us," Corbett responded: "Some have gone as far to call it genocide. I plead the fifth.". Fox News news host Tucker Carlson read several of Corbett's tweets on his show, accusing her of "spouting lunatic conspiracy theories." Another Fox News article said she "adopts a strikingly casual and conspiratorial tone." After the controversy, Corbett scaled back her use of social media and stopped appearing on television. Texas Southern University professor Robert Bullard and president of the National Medical Association (an organization of Black physicians) Oliver Brooks defended Corbett overall, although Brooks expressed concern about her tweet on genocide, saying "It's subjective. I wouldn't want to go there. I really don't believe that. We're dying at a higher rate but … that one just doesn't fit.". Corbett regularly shares information on Twitter and takes part in programs to inspire youth in underserved communities.

Wiki

Dengue fever

https://api.wikimedia.org/core/v1/wikipedia/en/page/2017_dengue_outbreak_in_Sri_Lanka/html

2017 dengue outbreak in Sri Lanka

In the 2017 dengue epidemic in Sri Lanka , a rise in the number of dengue fever cases was reported on the island country of Sri Lanka . The peak of the outbreak was in the mid-year monsoon rain season , when there was record of over 40,000 cases in July. This figure was far beyond the historical highest number of cases per month in Sri Lanka. Year end total dengue cases rose to 186,101. Most cases (43%) were recorded in Western Province urban areas such as the Colombo district (table 1). Most dengue cases were young people and school children. Year end Sri Lanka's total dengue related deaths was 440 . The Government of Sri Lanka spend more than US$12 million on outbreak control and was supported by NGOs such as the Red Cross . In 2017 Sri Lanka experienced its largest neglected tropical disease outbreak of dengue fever since the first recorded Sri Lankan case in 1962. This biological hazard , transmitted via female mosquito bites, caused 186,101 dengue cases , significantly higher than in previous years (table 2), and 440 deaths . Sri Lanka's Ministry of Health (MoH) reported a rise in cases from January, with the highest number of cases reported in July (table 3). Most cases were recorded in the west and north of the country, specifically in the urban Colombo district. Climate change models suggest that Sri Lanka's climate is becoming more conducive to mosquito breeding, this combined with economic instability could trigger a future epidemic . There is a possibility of a cycle of disease, poverty and food insecurity which may be challenging to break. However, this could be mitigated if the MoH, supported by institutions like WHO , engage in proactive strategies. At the cost of US$78 per person a licensed vaccine is now available - Dengvaxia - with five more in development. However, Sri Lanka's current expenditure is US$161 per capita on healthcare (2021), the vaccine is a significant proportion of that budget and in uncertain economic times may not be a priority. Climate change models suggest that Sri Lanka's climate is becoming more conducive to mosquito breeding, this combined with economic instability could trigger a future epidemic . There is a possibility of a cycle of disease, poverty and food insecurity which may be challenging to break. However, this could be mitigated if the MoH, supported by institutions like WHO , engage in proactive strategies. At the cost of US$78 per person a licensed vaccine is now available - Dengvaxia - with five more in development. However, Sri Lanka's current expenditure is US$161 per capita on healthcare (2021), the vaccine is a significant proportion of that budget and in uncertain economic times may not be a priority.

Wiki

Dengue fever

https://api.wikimedia.org/core/v1/wikipedia/en/page/Ebola/html

Ebola

Ebola , also known as Ebola virus disease ( EVD ) and Ebola hemorrhagic fever ( EHF ), is a viral hemorrhagic fever in humans and other primates , caused by ebolaviruses . Symptoms typically start anywhere between two days and three weeks after infection. The first symptoms are usually fever , sore throat , muscle pain , and headaches . These are usually followed by vomiting , diarrhoea , rash and decreased liver and kidney function, at which point some people begin to bleed both internally and externally. It kills between 25% and 90% of those infected – about 50% on average. Death is often due to shock from fluid loss , and typically occurs between six and 16 days after the first symptoms appear. Early treatment of symptoms increases the survival rate considerably compared to late start. An Ebola vaccine was approved by the US FDA in December 2019. The virus spreads through direct contact with body fluids , such as blood from infected humans or other animals, or from contact with items that have recently been contaminated with infected body fluids. There have been no documented cases, either in nature or under laboratory conditions, of spread through the air between humans or other primates . After recovering from Ebola, semen or breast milk may continue to carry the virus for anywhere between several weeks to several months. Fruit bats are believed to be the normal carrier in nature ; they are able to spread the virus without being affected by it. The symptoms of Ebola may resemble those of several other diseases, including malaria , cholera , typhoid fever , meningitis and other viral hemorrhagic fevers. Diagnosis is confirmed by testing blood samples for the presence of viral RNA , viral antibodies or the virus itself. Control of outbreaks requires coordinated medical services and community engagement, including rapid detection, contact tracing of those exposed, quick access to laboratory services, care for those infected, and proper disposal of the dead through cremation or burial. Prevention measures involve wearing proper protective clothing and washing hands when in close proximity to patients and while handling potentially infected bushmeat , as well as thoroughly cooking bushmeat. An Ebola vaccine was approved by the US FDA in December 2019. While there is no approved treatment for Ebola as of 2019 [ update ] , two treatments ( atoltivimab/maftivimab/odesivimab and ansuvimab ) are associated with improved outcomes. Supportive efforts also improve outcomes. These include oral rehydration therapy (drinking slightly sweetened and salty water) or giving intravenous fluids , and treating symptoms. In October 2020, atoltivimab/maftivimab/odesivimab (Inmazeb) was approved for medical use in the United States to treat the disease caused by Zaire ebolavirus . Ebola was first identified in 1976, in two simultaneous outbreaks, one in Nzara (a town in South Sudan ) and the other in Yambuku ( the Democratic Republic of the Congo ), a village near the Ebola River , for which the disease was named. Ebola outbreaks occur intermittently in tropical regions of sub-Saharan Africa . Between 1976 and 2012, according to the World Health Organization , there were 24 outbreaks of Ebola resulting in a total of 2,387 cases, and 1,590 deaths . The largest Ebola outbreak to date was an epidemic in West Africa from December 2013 to January 2016, with 28,646 cases and 11,323 deaths. On 29 March 2016, it was declared to no longer be an emergency. Other outbreaks in Africa began in the Democratic Republic of the Congo in May 2017, and 2018. In July 2019, the World Health Organization declared the Congo Ebola outbreak a world health emergency . The length of time between exposure to the virus and the development of symptoms ( incubation period ) is between 2 and 21 days, and usually between 4 and 10 days. However, recent estimates based on mathematical models predict that around 5% of cases may take longer than 21 days to develop. Symptoms usually begin with a sudden influenza -like stage characterised by fatigue , fever , weakness , decreased appetite , muscular pain , joint pain , headache, and sore throat. The fever is usually higher than 38.3 °C (101 °F) . This is often followed by nausea, vomiting, diarrhoea , abdominal pain, and sometimes hiccups . The combination of severe vomiting and diarrhoea often leads to severe dehydration . Next, shortness of breath and chest pain may occur, along with swelling , headaches , and confusion . In about half of the cases, the skin may develop a maculopapular rash , a flat red area covered with small bumps, five to seven days after symptoms begin. In some cases, internal and external bleeding may occur. This typically begins five to seven days after the first symptoms. All infected people show some decreased blood clotting . Bleeding from mucous membranes or from sites of needle punctures has been reported in 40–50% of cases. This may cause vomiting blood , coughing up of blood , or blood in stool . Bleeding into the skin may create petechiae , purpura , ecchymoses or haematomas (especially around needle injection sites). Bleeding into the whites of the eyes may also occur. Heavy bleeding is uncommon; if it occurs, it is usually in the gastrointestinal tract . The incidence of bleeding into the gastrointestinal tract was reported to be ~58% in the 2001 outbreak in Gabon, but in the 2014–15 outbreak in the US it was ~18%, possibly due to improved prevention of disseminated intravascular coagulation . Recovery may begin between seven and 14 days after first symptoms. Death, if it occurs, follows typically six to sixteen days from first symptoms and is often due to shock from fluid loss . In general, bleeding often indicates a worse outcome, and blood loss may result in death. People are often in a coma near the end of life. Those who survive often have ongoing muscular and joint pain, liver inflammation , and decreased hearing, and may have continued tiredness, continued weakness, decreased appetite, and difficulty returning to pre-illness weight. Problems with vision may develop. It is recommended that survivors of EVD wear condoms for at least twelve months after initial infection or until the semen of a male survivor tests negative for Ebola virus on two separate occasions. Survivors develop antibodies against Ebola that last at least 10 years, but it is unclear whether they are immune to additional infections. The length of time between exposure to the virus and the development of symptoms ( incubation period ) is between 2 and 21 days, and usually between 4 and 10 days. However, recent estimates based on mathematical models predict that around 5% of cases may take longer than 21 days to develop. Symptoms usually begin with a sudden influenza -like stage characterised by fatigue , fever , weakness , decreased appetite , muscular pain , joint pain , headache, and sore throat. The fever is usually higher than 38.3 °C (101 °F) . This is often followed by nausea, vomiting, diarrhoea , abdominal pain, and sometimes hiccups . The combination of severe vomiting and diarrhoea often leads to severe dehydration . Next, shortness of breath and chest pain may occur, along with swelling , headaches , and confusion . In about half of the cases, the skin may develop a maculopapular rash , a flat red area covered with small bumps, five to seven days after symptoms begin. In some cases, internal and external bleeding may occur. This typically begins five to seven days after the first symptoms. All infected people show some decreased blood clotting . Bleeding from mucous membranes or from sites of needle punctures has been reported in 40–50% of cases. This may cause vomiting blood , coughing up of blood , or blood in stool . Bleeding into the skin may create petechiae , purpura , ecchymoses or haematomas (especially around needle injection sites). Bleeding into the whites of the eyes may also occur. Heavy bleeding is uncommon; if it occurs, it is usually in the gastrointestinal tract . The incidence of bleeding into the gastrointestinal tract was reported to be ~58% in the 2001 outbreak in Gabon, but in the 2014–15 outbreak in the US it was ~18%, possibly due to improved prevention of disseminated intravascular coagulation . Recovery may begin between seven and 14 days after first symptoms. Death, if it occurs, follows typically six to sixteen days from first symptoms and is often due to shock from fluid loss . In general, bleeding often indicates a worse outcome, and blood loss may result in death. People are often in a coma near the end of life. Those who survive often have ongoing muscular and joint pain, liver inflammation , and decreased hearing, and may have continued tiredness, continued weakness, decreased appetite, and difficulty returning to pre-illness weight. Problems with vision may develop. It is recommended that survivors of EVD wear condoms for at least twelve months after initial infection or until the semen of a male survivor tests negative for Ebola virus on two separate occasions. Survivors develop antibodies against Ebola that last at least 10 years, but it is unclear whether they are immune to additional infections. EVD in humans is caused by four of six viruses of the genus Ebolavirus . The four are Bundibugyo virus (BDBV), Sudan virus (SUDV), Taï Forest virus (TAFV) and one simply called Ebola virus (EBOV, formerly Zaire Ebola virus). EBOV, species Zaire ebolavirus , is the most dangerous of the known EVD-causing viruses, and is responsible for the largest number of outbreaks. The fifth and sixth viruses, Reston virus (RESTV) and Bombali virus (BOMV), are not thought to cause disease in humans, but have caused disease in other primates. All five viruses are closely related to marburgviruses . Ebolaviruses contain single-stranded, non-infectious RNA genomes . Ebolavirus genomes contain seven genes including 3'-UTR - NP - VP35 - VP40 - GP - VP30 - VP24 - L - 5'-UTR . The genomes of the five different ebolaviruses (BDBV, EBOV, RESTV, SUDV and TAFV) differ in sequence and the number and location of gene overlaps. As with all filoviruses , ebolavirus virions are filamentous particles that may appear in the shape of a shepherd's crook, of a "U" or of a "6," and they may be coiled, toroid or branched. In general, ebolavirions are 80 nanometers (nm) in width and may be as long as 14,000 nm. Their life cycle is thought to begin with a virion attaching to specific cell-surface receptors such as C-type lectins , DC-SIGN , or integrins , which is followed by fusion of the viral envelope with cellular membranes . The virions taken up by the cell then travel to acidic endosomes and lysosomes where the viral envelope glycoprotein GP is cleaved. This processing appears to allow the virus to bind to cellular proteins enabling it to fuse with internal cellular membranes and release the viral nucleocapsid . The Ebolavirus structural glycoprotein (known as GP1,2) is responsible for the virus' ability to bind to and infect targeted cells. The viral RNA polymerase , encoded by the L gene, partially uncoats the nucleocapsid and transcribes the genes into positive-strand mRNAs , which are then translated into structural and nonstructural proteins. The most abundant protein produced is the nucleoprotein, whose concentration in the host cell determines when L switches from gene transcription to genome replication. Replication of the viral genome results in full-length, positive-strand antigenomes that are, in turn, transcribed into genome copies of negative-strand virus progeny. Newly synthesised structural proteins and genomes self-assemble and accumulate near the inside of the cell membrane . Virions bud off from the cell, gaining their envelopes from the cellular membrane from which they bud. The mature progeny particles then infect other cells to repeat the cycle. The genetics of the Ebola virus are difficult to study because of EBOV's virulent characteristics. It is believed that between people, Ebola disease spreads only by direct contact with the blood or other body fluids of a person who has developed symptoms of the disease. Body fluids that may contain Ebola viruses include saliva, mucus, vomit, feces, sweat, tears, breast milk, urine and semen . The WHO states that only people who are very sick are able to spread Ebola disease in saliva , and the virus has not been reported to be transmitted through sweat. Most people spread the virus through blood, feces and vomit. Entry points for the virus include the nose, mouth, eyes, open wounds, cuts and abrasions. Ebola may be spread through large droplets ; however, this is believed to occur only when a person is very sick. This contamination can happen if a person is splashed with droplets. Contact with surfaces or objects contaminated by the virus, particularly needles and syringes, may also transmit the infection. The virus is able to survive on objects for a few hours in a dried state, and can survive for a few days within body fluids outside of a person. The Ebola virus may be able to persist for more than three months in the semen after recovery, which could lead to infections via sexual intercourse . Virus persistence in semen for over a year has been recorded in a national screening programme. Ebola may also occur in the breast milk of women after recovery, and it is not known when it is safe to breastfeed again. The virus was also found in the eye of one patient in 2014, two months after it was cleared from his blood. Otherwise, people who have recovered are not infectious. The potential for widespread infections in countries with medical systems capable of observing correct medical isolation procedures is considered low. Usually when someone has symptoms of the disease, they are unable to travel without assistance. Dead bodies remain infectious; thus, people handling human remains in practices such as traditional burial rituals or more modern processes such as embalming are at risk. Of the cases of Ebola infections in Guinea during the 2014 outbreak, 69% are believed to have been contracted via unprotected (or unsuitably protected) contact with infected corpses during certain Guinean burial rituals. Health-care workers treating people with Ebola are at greatest risk of infection. The risk increases when they do not have appropriate protective clothing such as masks, gowns, gloves and eye protection; do not wear it properly; or handle contaminated clothing incorrectly. This risk is particularly common in parts of Africa where the disease mostly occurs and health systems function poorly. There has been transmission in hospitals in some African countries that reuse hypodermic needles. Some health-care centres caring for people with the disease do not have running water. In the United States the spread to two medical workers treating infected patients prompted criticism of inadequate training and procedures. Human-to-human transmission of EBOV through the air has not been reported to occur during EVD outbreaks, and airborne transmission has only been demonstrated in very strict laboratory conditions, and then only from pigs to primates , but not from primates to primates. Spread of EBOV by water, or food other than bushmeat, has not been observed. No spread by mosquitos or other insects has been reported. Other possible methods of transmission are being studied. Airborne transmission among humans is theoretically possible due to the presence of Ebola virus particles in saliva, which can be discharged into the air with a cough or sneeze, but observational data from previous epidemics suggests the actual risk of airborne transmission is low. A number of studies examining airborne transmission broadly concluded that transmission from pigs to primates could happen without direct contact because, unlike humans and primates, pigs with EVD get very high ebolavirus concentrations in their lungs, and not their bloodstream. Therefore, pigs with EVD can spread the disease through droplets in the air or on the ground when they sneeze or cough. By contrast, humans and other primates accumulate the virus throughout their body and specifically in their blood, but not very much in their lungs. It is believed that this is the reason researchers have observed pig to primate transmission without physical contact, but no evidence has been found of primates being infected without actual contact, even in experiments where infected and uninfected primates shared the same air. Although it is not entirely clear how Ebola initially spreads from animals to humans, the spread is believed to involve direct contact with an infected wild animal or fruit bat. Besides bats, other wild animals that are sometimes infected with EBOV include several species of monkeys such as baboons , great apes ( chimpanzees and gorillas ), and duikers (a species of antelope ). Animals may become infected when they eat fruit partially eaten by bats carrying the virus. Fruit production, animal behavior and other factors may trigger outbreaks among animal populations. Evidence indicates that both domestic dogs and pigs can also be infected with EBOV. Dogs do not appear to develop symptoms when they carry the virus, and pigs appear to be able to transmit the virus to at least some primates. Although some dogs in an area in which a human outbreak occurred had antibodies to EBOV, it is unclear whether they played a role in spreading the disease to people. The natural reservoir for Ebola has yet to be confirmed; however, bats are considered to be the most likely candidate. Three types of fruit bats ( Hypsignathus monstrosus , Epomops franqueti and Myonycteris torquata ) were found to possibly carry the virus without getting sick. As of 2013 [ update ] , whether other animals are involved in its spread is not known. Plants, arthropods , rodents , and birds have also been considered possible viral reservoirs. Bats were known to roost in the cotton factory in which the first cases of the 1976 and 1979 outbreaks were observed, and they have also been implicated in Marburg virus infections in 1975 and 1980. Of 24 plant and 19 vertebrate species experimentally inoculated with EBOV, only bats became infected. The bats displayed no clinical signs of disease, which is considered evidence that these bats are a reservoir species of EBOV. In a 2002–2003 survey of 1,030 animals including 679 bats from Gabon and the Republic of the Congo , immunoglobulin G (IgG) immune defense molecules indicative of Ebola infection were found in three bat species; at various periods of study, between 2.2 and 22.6% of bats were found to contain both RNA sequences and IgG molecules indicating Ebola infection. Antibodies against Zaire and Reston viruses have been found in fruit bats in Bangladesh , suggesting that these bats are also potential hosts of the virus and that the filoviruses are present in Asia. Between 1976 and 1998, in 30,000 mammals, birds, reptiles, amphibians and arthropods sampled from regions of EBOV outbreaks, no Ebola virus was detected apart from some genetic traces found in six rodents (belonging to the species Mus setulosus and Praomys ) and one shrew ( Sylvisorex ollula ) collected from the Central African Republic . However, further research efforts have not confirmed rodents as a reservoir. Traces of EBOV were detected in the carcasses of gorillas and chimpanzees during outbreaks in 2001 and 2003, which later became the source of human infections. However, the high rates of death in these species resulting from EBOV infection make it unlikely that these species represent a natural reservoir for the virus. Deforestation has been mentioned as a possible contributor to recent outbreaks, including the West African Ebola virus epidemic . Index cases of EVD have often been close to recently deforested lands. Ebolaviruses contain single-stranded, non-infectious RNA genomes . Ebolavirus genomes contain seven genes including 3'-UTR - NP - VP35 - VP40 - GP - VP30 - VP24 - L - 5'-UTR . The genomes of the five different ebolaviruses (BDBV, EBOV, RESTV, SUDV and TAFV) differ in sequence and the number and location of gene overlaps. As with all filoviruses , ebolavirus virions are filamentous particles that may appear in the shape of a shepherd's crook, of a "U" or of a "6," and they may be coiled, toroid or branched. In general, ebolavirions are 80 nanometers (nm) in width and may be as long as 14,000 nm. Their life cycle is thought to begin with a virion attaching to specific cell-surface receptors such as C-type lectins , DC-SIGN , or integrins , which is followed by fusion of the viral envelope with cellular membranes . The virions taken up by the cell then travel to acidic endosomes and lysosomes where the viral envelope glycoprotein GP is cleaved. This processing appears to allow the virus to bind to cellular proteins enabling it to fuse with internal cellular membranes and release the viral nucleocapsid . The Ebolavirus structural glycoprotein (known as GP1,2) is responsible for the virus' ability to bind to and infect targeted cells. The viral RNA polymerase , encoded by the L gene, partially uncoats the nucleocapsid and transcribes the genes into positive-strand mRNAs , which are then translated into structural and nonstructural proteins. The most abundant protein produced is the nucleoprotein, whose concentration in the host cell determines when L switches from gene transcription to genome replication. Replication of the viral genome results in full-length, positive-strand antigenomes that are, in turn, transcribed into genome copies of negative-strand virus progeny. Newly synthesised structural proteins and genomes self-assemble and accumulate near the inside of the cell membrane . Virions bud off from the cell, gaining their envelopes from the cellular membrane from which they bud. The mature progeny particles then infect other cells to repeat the cycle. The genetics of the Ebola virus are difficult to study because of EBOV's virulent characteristics. It is believed that between people, Ebola disease spreads only by direct contact with the blood or other body fluids of a person who has developed symptoms of the disease. Body fluids that may contain Ebola viruses include saliva, mucus, vomit, feces, sweat, tears, breast milk, urine and semen . The WHO states that only people who are very sick are able to spread Ebola disease in saliva , and the virus has not been reported to be transmitted through sweat. Most people spread the virus through blood, feces and vomit. Entry points for the virus include the nose, mouth, eyes, open wounds, cuts and abrasions. Ebola may be spread through large droplets ; however, this is believed to occur only when a person is very sick. This contamination can happen if a person is splashed with droplets. Contact with surfaces or objects contaminated by the virus, particularly needles and syringes, may also transmit the infection. The virus is able to survive on objects for a few hours in a dried state, and can survive for a few days within body fluids outside of a person. The Ebola virus may be able to persist for more than three months in the semen after recovery, which could lead to infections via sexual intercourse . Virus persistence in semen for over a year has been recorded in a national screening programme. Ebola may also occur in the breast milk of women after recovery, and it is not known when it is safe to breastfeed again. The virus was also found in the eye of one patient in 2014, two months after it was cleared from his blood. Otherwise, people who have recovered are not infectious. The potential for widespread infections in countries with medical systems capable of observing correct medical isolation procedures is considered low. Usually when someone has symptoms of the disease, they are unable to travel without assistance. Dead bodies remain infectious; thus, people handling human remains in practices such as traditional burial rituals or more modern processes such as embalming are at risk. Of the cases of Ebola infections in Guinea during the 2014 outbreak, 69% are believed to have been contracted via unprotected (or unsuitably protected) contact with infected corpses during certain Guinean burial rituals. Health-care workers treating people with Ebola are at greatest risk of infection. The risk increases when they do not have appropriate protective clothing such as masks, gowns, gloves and eye protection; do not wear it properly; or handle contaminated clothing incorrectly. This risk is particularly common in parts of Africa where the disease mostly occurs and health systems function poorly. There has been transmission in hospitals in some African countries that reuse hypodermic needles. Some health-care centres caring for people with the disease do not have running water. In the United States the spread to two medical workers treating infected patients prompted criticism of inadequate training and procedures. Human-to-human transmission of EBOV through the air has not been reported to occur during EVD outbreaks, and airborne transmission has only been demonstrated in very strict laboratory conditions, and then only from pigs to primates , but not from primates to primates. Spread of EBOV by water, or food other than bushmeat, has not been observed. No spread by mosquitos or other insects has been reported. Other possible methods of transmission are being studied. Airborne transmission among humans is theoretically possible due to the presence of Ebola virus particles in saliva, which can be discharged into the air with a cough or sneeze, but observational data from previous epidemics suggests the actual risk of airborne transmission is low. A number of studies examining airborne transmission broadly concluded that transmission from pigs to primates could happen without direct contact because, unlike humans and primates, pigs with EVD get very high ebolavirus concentrations in their lungs, and not their bloodstream. Therefore, pigs with EVD can spread the disease through droplets in the air or on the ground when they sneeze or cough. By contrast, humans and other primates accumulate the virus throughout their body and specifically in their blood, but not very much in their lungs. It is believed that this is the reason researchers have observed pig to primate transmission without physical contact, but no evidence has been found of primates being infected without actual contact, even in experiments where infected and uninfected primates shared the same air. Although it is not entirely clear how Ebola initially spreads from animals to humans, the spread is believed to involve direct contact with an infected wild animal or fruit bat. Besides bats, other wild animals that are sometimes infected with EBOV include several species of monkeys such as baboons , great apes ( chimpanzees and gorillas ), and duikers (a species of antelope ). Animals may become infected when they eat fruit partially eaten by bats carrying the virus. Fruit production, animal behavior and other factors may trigger outbreaks among animal populations. Evidence indicates that both domestic dogs and pigs can also be infected with EBOV. Dogs do not appear to develop symptoms when they carry the virus, and pigs appear to be able to transmit the virus to at least some primates. Although some dogs in an area in which a human outbreak occurred had antibodies to EBOV, it is unclear whether they played a role in spreading the disease to people. The natural reservoir for Ebola has yet to be confirmed; however, bats are considered to be the most likely candidate. Three types of fruit bats ( Hypsignathus monstrosus , Epomops franqueti and Myonycteris torquata ) were found to possibly carry the virus without getting sick. As of 2013 [ update ] , whether other animals are involved in its spread is not known. Plants, arthropods , rodents , and birds have also been considered possible viral reservoirs. Bats were known to roost in the cotton factory in which the first cases of the 1976 and 1979 outbreaks were observed, and they have also been implicated in Marburg virus infections in 1975 and 1980. Of 24 plant and 19 vertebrate species experimentally inoculated with EBOV, only bats became infected. The bats displayed no clinical signs of disease, which is considered evidence that these bats are a reservoir species of EBOV. In a 2002–2003 survey of 1,030 animals including 679 bats from Gabon and the Republic of the Congo , immunoglobulin G (IgG) immune defense molecules indicative of Ebola infection were found in three bat species; at various periods of study, between 2.2 and 22.6% of bats were found to contain both RNA sequences and IgG molecules indicating Ebola infection. Antibodies against Zaire and Reston viruses have been found in fruit bats in Bangladesh , suggesting that these bats are also potential hosts of the virus and that the filoviruses are present in Asia. Between 1976 and 1998, in 30,000 mammals, birds, reptiles, amphibians and arthropods sampled from regions of EBOV outbreaks, no Ebola virus was detected apart from some genetic traces found in six rodents (belonging to the species Mus setulosus and Praomys ) and one shrew ( Sylvisorex ollula ) collected from the Central African Republic . However, further research efforts have not confirmed rodents as a reservoir. Traces of EBOV were detected in the carcasses of gorillas and chimpanzees during outbreaks in 2001 and 2003, which later became the source of human infections. However, the high rates of death in these species resulting from EBOV infection make it unlikely that these species represent a natural reservoir for the virus. Deforestation has been mentioned as a possible contributor to recent outbreaks, including the West African Ebola virus epidemic . Index cases of EVD have often been close to recently deforested lands. Like other filoviruses , EBOV replicates very efficiently in many cells , producing large amounts of virus in monocytes , macrophages , dendritic cells and other cells including liver cells , fibroblasts , and adrenal gland cells . Viral replication triggers high levels of inflammatory chemical signals and leads to a septic state . EBOV is thought to infect humans through contact with mucous membranes or skin breaks. After infection, endothelial cells (cells lining the inside of blood vessels), liver cells, and several types of immune cells such as macrophages, monocytes , and dendritic cells are the main targets of attack. Following infection, immune cells carry the virus to nearby lymph nodes where further reproduction of the virus takes place. From there the virus can enter the bloodstream and lymphatic system and spread throughout the body. Macrophages are the first cells infected with the virus, and this infection results in programmed cell death . Other types of white blood cells , such as lymphocytes , also undergo programmed cell death leading to an abnormally low concentration of lymphocytes in the blood. This contributes to the weakened immune response seen in those infected with EBOV. Endothelial cells may be infected within three days after exposure to the virus. The breakdown of endothelial cells leading to blood vessel injury can be attributed to EBOV glycoproteins . This damage occurs due to the synthesis of Ebola virus glycoprotein (GP), which reduces the availability of specific integrins responsible for cell adhesion to the intercellular structure and causes liver damage, leading to improper clotting . The widespread bleeding that occurs in affected people causes swelling and shock due to loss of blood volume . The dysfunctional bleeding and clotting commonly seen in EVD has been attributed to increased activation of the extrinsic pathway of the coagulation cascade due to excessive tissue factor production by macrophages and monocytes. After infection, a secreted glycoprotein , small soluble glycoprotein (sGP or GP) is synthesised. EBOV replication overwhelms protein synthesis of infected cells and the host immune defences. The GP forms a trimeric complex , which tethers the virus to the endothelial cells. The sGP forms a dimeric protein that interferes with the signalling of neutrophils , another type of white blood cell. This enables the virus to evade the immune system by inhibiting early steps of neutrophil activation. [ medical citation needed ] Furthermore, the virus is capable of hijacking cellular metabolism. Studies have shown that Ebola virus-like particles can reprogram metabolism in both vascular and immune cells. Filoviral infection also interferes with proper functioning of the innate immune system . EBOV proteins blunt the human immune system's response to viral infections by interfering with the cells' ability to produce and respond to interferon proteins such as interferon-alpha , interferon-beta , and interferon gamma . The VP24 and VP35 structural proteins of EBOV play a key role in this interference. When a cell is infected with EBOV, receptors located in the cell's cytosol (such as RIG-I and MDA5 ) or outside of the cytosol (such as Toll-like receptor 3 (TLR3) , TLR7 , TLR8 and TLR9 ) recognise infectious molecules associated with the virus. On TLR activation, proteins including interferon regulatory factor 3 and interferon regulatory factor 7 trigger a signalling cascade that leads to the expression of type 1 interferons . The type 1 interferons are then released and bind to the IFNAR1 and IFNAR2 receptors expressed on the surface of a neighbouring cell. Once interferon has bound to its receptors on the neighbouring cell, the signalling proteins STAT1 and STAT2 are activated and move to the cell's nucleus . This triggers the expression of interferon-stimulated genes , which code for proteins with antiviral properties. EBOV's V24 protein blocks the production of these antiviral proteins by preventing the STAT1 signalling protein in the neighbouring cell from entering the nucleus. The VP35 protein directly inhibits the production of interferon-beta. By inhibiting these immune responses, EBOV may quickly spread throughout the body. Filoviral infection also interferes with proper functioning of the innate immune system . EBOV proteins blunt the human immune system's response to viral infections by interfering with the cells' ability to produce and respond to interferon proteins such as interferon-alpha , interferon-beta , and interferon gamma . The VP24 and VP35 structural proteins of EBOV play a key role in this interference. When a cell is infected with EBOV, receptors located in the cell's cytosol (such as RIG-I and MDA5 ) or outside of the cytosol (such as Toll-like receptor 3 (TLR3) , TLR7 , TLR8 and TLR9 ) recognise infectious molecules associated with the virus. On TLR activation, proteins including interferon regulatory factor 3 and interferon regulatory factor 7 trigger a signalling cascade that leads to the expression of type 1 interferons . The type 1 interferons are then released and bind to the IFNAR1 and IFNAR2 receptors expressed on the surface of a neighbouring cell. Once interferon has bound to its receptors on the neighbouring cell, the signalling proteins STAT1 and STAT2 are activated and move to the cell's nucleus . This triggers the expression of interferon-stimulated genes , which code for proteins with antiviral properties. EBOV's V24 protein blocks the production of these antiviral proteins by preventing the STAT1 signalling protein in the neighbouring cell from entering the nucleus. The VP35 protein directly inhibits the production of interferon-beta. By inhibiting these immune responses, EBOV may quickly spread throughout the body. When EVD is suspected, travel, work history, and exposure to wildlife are important factors with respect to further diagnostic efforts. Possible non-specific laboratory indicators of EVD include a low platelet count ; an initially decreased white blood cell count followed by an increased white blood cell count ; elevated levels of the liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST); and abnormalities in blood clotting often consistent with disseminated intravascular coagulation (DIC) such as a prolonged prothrombin time , partial thromboplastin time , and bleeding time . Filovirions such as EBOV may be identified by their unique filamentous shapes in cell cultures examined with electron microscopy . The specific diagnosis of EVD is confirmed by isolating the virus, detecting its RNA or proteins, or detecting antibodies against the virus in a person's blood. Isolating the virus by cell culture , detecting the viral RNA by polymerase chain reaction (PCR) and detecting proteins by enzyme-linked immunosorbent assay (ELISA) are methods best used in the early stages of the disease and also for detecting the virus in human remains. Detecting antibodies against the virus is most reliable in the later stages of the disease and in those who recover. IgM antibodies are detectable two days after symptom onset and IgG antibodies can be detected six to 18 days after symptom onset. During an outbreak, isolation of the virus with cell culture methods is often not feasible. In field or mobile hospitals, the most common and sensitive diagnostic methods are real-time PCR and ELISA. In 2014, with new mobile testing facilities deployed in parts of Liberia, test results were obtained 3–5 hours after sample submission. In 2015, a rapid antigen test which gives results in 15 minutes was approved for use by WHO. It is able to confirm Ebola in 92% of those affected and rule it out in 85% of those not affected. Early symptoms of EVD may be similar to those of other diseases common in Africa, including malaria and dengue fever . The symptoms are also similar to those of other viral haemorrhagic fevers such as Marburg virus disease , Crimean–Congo haemorrhagic fever , and Lassa fever . The complete differential diagnosis is extensive and requires consideration of many other infectious diseases such as typhoid fever , shigellosis , rickettsial diseases , cholera , sepsis , borreliosis , EHEC enteritis , leptospirosis , scrub typhus , plague , Q fever , candidiasis , histoplasmosis , trypanosomiasis , visceral leishmaniasis , measles , and viral hepatitis among others. Non-infectious diseases that may result in symptoms similar to those of EVD include acute promyelocytic leukaemia , haemolytic uraemic syndrome , snake envenomation , clotting factor deficiencies/platelet disorders, thrombotic thrombocytopenic purpura , hereditary haemorrhagic telangiectasia , Kawasaki disease , and warfarin poisoning. Possible non-specific laboratory indicators of EVD include a low platelet count ; an initially decreased white blood cell count followed by an increased white blood cell count ; elevated levels of the liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST); and abnormalities in blood clotting often consistent with disseminated intravascular coagulation (DIC) such as a prolonged prothrombin time , partial thromboplastin time , and bleeding time . Filovirions such as EBOV may be identified by their unique filamentous shapes in cell cultures examined with electron microscopy . The specific diagnosis of EVD is confirmed by isolating the virus, detecting its RNA or proteins, or detecting antibodies against the virus in a person's blood. Isolating the virus by cell culture , detecting the viral RNA by polymerase chain reaction (PCR) and detecting proteins by enzyme-linked immunosorbent assay (ELISA) are methods best used in the early stages of the disease and also for detecting the virus in human remains. Detecting antibodies against the virus is most reliable in the later stages of the disease and in those who recover. IgM antibodies are detectable two days after symptom onset and IgG antibodies can be detected six to 18 days after symptom onset. During an outbreak, isolation of the virus with cell culture methods is often not feasible. In field or mobile hospitals, the most common and sensitive diagnostic methods are real-time PCR and ELISA. In 2014, with new mobile testing facilities deployed in parts of Liberia, test results were obtained 3–5 hours after sample submission. In 2015, a rapid antigen test which gives results in 15 minutes was approved for use by WHO. It is able to confirm Ebola in 92% of those affected and rule it out in 85% of those not affected. Early symptoms of EVD may be similar to those of other diseases common in Africa, including malaria and dengue fever . The symptoms are also similar to those of other viral haemorrhagic fevers such as Marburg virus disease , Crimean–Congo haemorrhagic fever , and Lassa fever . The complete differential diagnosis is extensive and requires consideration of many other infectious diseases such as typhoid fever , shigellosis , rickettsial diseases , cholera , sepsis , borreliosis , EHEC enteritis , leptospirosis , scrub typhus , plague , Q fever , candidiasis , histoplasmosis , trypanosomiasis , visceral leishmaniasis , measles , and viral hepatitis among others. Non-infectious diseases that may result in symptoms similar to those of EVD include acute promyelocytic leukaemia , haemolytic uraemic syndrome , snake envenomation , clotting factor deficiencies/platelet disorders, thrombotic thrombocytopenic purpura , hereditary haemorrhagic telangiectasia , Kawasaki disease , and warfarin poisoning. An Ebola vaccine , rVSV-ZEBOV , was approved in the United States in December 2019. It appears to be fully effective ten days after being given. It was studied in Guinea between 2014 and 2016. More than 100,000 people have been vaccinated against Ebola as of 2019 [ update ] . The WHO reported that approximately 345,000 people were given the vaccine during the Kivu Ebola epidemic from 2018 to 2020. Community awareness of the benefits on survival chances of admitting cases early is important for the infected and infection control People who care for those infected with Ebola should wear protective clothing including masks, gloves, gowns and goggles. The U.S. Centers for Disease Control (CDC) recommend that the protective gear leaves no skin exposed. These measures are also recommended for those who may handle objects contaminated by an infected person's body fluids. In 2014, the CDC began recommending that medical personnel receive training on the proper suit-up and removal of personal protective equipment (PPE); in addition, a designated person, appropriately trained in biosafety, should be watching each step of these procedures to ensure they are done correctly. In Sierra Leone, the typical training period for the use of such safety equipment lasts approximately 12 days. In 2022 in Uganda, lighter personal protection equipment has become available as well as possibilities to monitor and communicate with patients from windows in the treatment tents until it is necessary to enter if e.g. a patient's oxygen levels drop. The infected person should be in barrier-isolation from other people. All equipment, medical waste, patient waste and surfaces that may have come into contact with body fluids need to be disinfected . During the 2014 outbreak, kits were put together to help families treat Ebola disease in their homes, which included protective clothing as well as chlorine powder and other cleaning supplies. Education of caregivers in these techniques, and providing such barrier-separation supplies has been a priority of Doctors Without Borders . Ebolaviruses can be eliminated with heat (heating for 30 to 60 minutes at 60 °C or boiling for five minutes). To disinfect surfaces, some lipid solvents such as some alcohol-based products, detergents, sodium hypochlorite (bleach) or calcium hypochlorite (bleaching powder), and other suitable disinfectants may be used at appropriate concentrations. Education of the general public about the risk factors for Ebola infection and of the protective measures individuals may take to prevent infection is recommended by the World Health Organization . These measures include avoiding direct contact with infected people and regular hand washing using soap and water. Bushmeat , an important source of protein in the diet of some Africans, should be handled and prepared with appropriate protective clothing and thoroughly cooked before consumption. Some research suggests that an outbreak of Ebola disease in the wild animals used for consumption may result in a corresponding human outbreak. Since 2003, such animal outbreaks have been monitored to predict and prevent Ebola outbreaks in humans. If a person with Ebola disease dies, direct contact with the body should be avoided. Certain burial rituals , which may have included making various direct contacts with a dead body, require reformulation so that they consistently maintain a proper protective barrier between the dead body and the living. Social anthropologists may help find alternatives to traditional rules for burials. Transportation crews are instructed to follow a certain isolation procedure, should anyone exhibit symptoms resembling EVD. As of August 2014 [ update ] , the WHO does not consider travel bans to be useful in decreasing spread of the disease. In October 2014, the CDC defined four risk levels used to determine the level of 21-day monitoring for symptoms and restrictions on public activities. In the United States, the CDC recommends that restrictions on public activity, including travel restrictions, are not required for the following defined risk levels: having been in a country with widespread Ebola disease transmission and having no known exposure (low risk); or having been in that country more than 21 days ago (no risk) encounter with a person showing symptoms; but not within three feet of the person with Ebola without wearing PPE; and no direct contact with body fluids having had brief skin contact with a person showing symptoms of Ebola disease when the person was believed to be not very contagious (low risk) in countries without widespread Ebola disease transmission: direct contact with a person showing symptoms of the disease while wearing PPE (low risk) contact with a person with Ebola disease before the person was showing symptoms (no risk). The CDC recommends monitoring for the symptoms of Ebola disease for those both at "low risk" and at higher risk. In laboratories where diagnostic testing is carried out, biosafety level 4-equivalent containment is required. Laboratory researchers must be properly trained in BSL-4 practices and wear proper PPE. Isolation refers to separating those who are sick from those who are not. Quarantine refers to separating those who may have been exposed to a disease until they either show signs of the disease or are no longer at risk. Quarantine, also known as enforced isolation, is usually effective in decreasing spread. Governments often quarantine areas where the disease is occurring or individuals who may transmit the disease outside of an initial area. In the United States, the law allows quarantine of those infected with ebolaviruses. Contact tracing is considered important to contain an outbreak. It involves finding everyone who had close contact with infected individuals and monitoring them for signs of illness for 21 days. If any of these contacts comes down with the disease, they should be isolated, tested and treated. Then the process is repeated, tracing the contacts' contacts. An Ebola vaccine , rVSV-ZEBOV , was approved in the United States in December 2019. It appears to be fully effective ten days after being given. It was studied in Guinea between 2014 and 2016. More than 100,000 people have been vaccinated against Ebola as of 2019 [ update ] . The WHO reported that approximately 345,000 people were given the vaccine during the Kivu Ebola epidemic from 2018 to 2020. Community awareness of the benefits on survival chances of admitting cases early is important for the infected and infection control People who care for those infected with Ebola should wear protective clothing including masks, gloves, gowns and goggles. The U.S. Centers for Disease Control (CDC) recommend that the protective gear leaves no skin exposed. These measures are also recommended for those who may handle objects contaminated by an infected person's body fluids. In 2014, the CDC began recommending that medical personnel receive training on the proper suit-up and removal of personal protective equipment (PPE); in addition, a designated person, appropriately trained in biosafety, should be watching each step of these procedures to ensure they are done correctly. In Sierra Leone, the typical training period for the use of such safety equipment lasts approximately 12 days. In 2022 in Uganda, lighter personal protection equipment has become available as well as possibilities to monitor and communicate with patients from windows in the treatment tents until it is necessary to enter if e.g. a patient's oxygen levels drop. The infected person should be in barrier-isolation from other people. All equipment, medical waste, patient waste and surfaces that may have come into contact with body fluids need to be disinfected . During the 2014 outbreak, kits were put together to help families treat Ebola disease in their homes, which included protective clothing as well as chlorine powder and other cleaning supplies. Education of caregivers in these techniques, and providing such barrier-separation supplies has been a priority of Doctors Without Borders . Ebolaviruses can be eliminated with heat (heating for 30 to 60 minutes at 60 °C or boiling for five minutes). To disinfect surfaces, some lipid solvents such as some alcohol-based products, detergents, sodium hypochlorite (bleach) or calcium hypochlorite (bleaching powder), and other suitable disinfectants may be used at appropriate concentrations. Education of the general public about the risk factors for Ebola infection and of the protective measures individuals may take to prevent infection is recommended by the World Health Organization . These measures include avoiding direct contact with infected people and regular hand washing using soap and water. Bushmeat , an important source of protein in the diet of some Africans, should be handled and prepared with appropriate protective clothing and thoroughly cooked before consumption. Some research suggests that an outbreak of Ebola disease in the wild animals used for consumption may result in a corresponding human outbreak. Since 2003, such animal outbreaks have been monitored to predict and prevent Ebola outbreaks in humans. If a person with Ebola disease dies, direct contact with the body should be avoided. Certain burial rituals , which may have included making various direct contacts with a dead body, require reformulation so that they consistently maintain a proper protective barrier between the dead body and the living. Social anthropologists may help find alternatives to traditional rules for burials. Transportation crews are instructed to follow a certain isolation procedure, should anyone exhibit symptoms resembling EVD. As of August 2014 [ update ] , the WHO does not consider travel bans to be useful in decreasing spread of the disease. In October 2014, the CDC defined four risk levels used to determine the level of 21-day monitoring for symptoms and restrictions on public activities. In the United States, the CDC recommends that restrictions on public activity, including travel restrictions, are not required for the following defined risk levels: having been in a country with widespread Ebola disease transmission and having no known exposure (low risk); or having been in that country more than 21 days ago (no risk) encounter with a person showing symptoms; but not within three feet of the person with Ebola without wearing PPE; and no direct contact with body fluids having had brief skin contact with a person showing symptoms of Ebola disease when the person was believed to be not very contagious (low risk) in countries without widespread Ebola disease transmission: direct contact with a person showing symptoms of the disease while wearing PPE (low risk) contact with a person with Ebola disease before the person was showing symptoms (no risk). The CDC recommends monitoring for the symptoms of Ebola disease for those both at "low risk" and at higher risk. In laboratories where diagnostic testing is carried out, biosafety level 4-equivalent containment is required. Laboratory researchers must be properly trained in BSL-4 practices and wear proper PPE. People who care for those infected with Ebola should wear protective clothing including masks, gloves, gowns and goggles. The U.S. Centers for Disease Control (CDC) recommend that the protective gear leaves no skin exposed. These measures are also recommended for those who may handle objects contaminated by an infected person's body fluids. In 2014, the CDC began recommending that medical personnel receive training on the proper suit-up and removal of personal protective equipment (PPE); in addition, a designated person, appropriately trained in biosafety, should be watching each step of these procedures to ensure they are done correctly. In Sierra Leone, the typical training period for the use of such safety equipment lasts approximately 12 days. In 2022 in Uganda, lighter personal protection equipment has become available as well as possibilities to monitor and communicate with patients from windows in the treatment tents until it is necessary to enter if e.g. a patient's oxygen levels drop. The infected person should be in barrier-isolation from other people. All equipment, medical waste, patient waste and surfaces that may have come into contact with body fluids need to be disinfected . During the 2014 outbreak, kits were put together to help families treat Ebola disease in their homes, which included protective clothing as well as chlorine powder and other cleaning supplies. Education of caregivers in these techniques, and providing such barrier-separation supplies has been a priority of Doctors Without Borders . Ebolaviruses can be eliminated with heat (heating for 30 to 60 minutes at 60 °C or boiling for five minutes). To disinfect surfaces, some lipid solvents such as some alcohol-based products, detergents, sodium hypochlorite (bleach) or calcium hypochlorite (bleaching powder), and other suitable disinfectants may be used at appropriate concentrations. Education of the general public about the risk factors for Ebola infection and of the protective measures individuals may take to prevent infection is recommended by the World Health Organization . These measures include avoiding direct contact with infected people and regular hand washing using soap and water. Bushmeat , an important source of protein in the diet of some Africans, should be handled and prepared with appropriate protective clothing and thoroughly cooked before consumption. Some research suggests that an outbreak of Ebola disease in the wild animals used for consumption may result in a corresponding human outbreak. Since 2003, such animal outbreaks have been monitored to predict and prevent Ebola outbreaks in humans. If a person with Ebola disease dies, direct contact with the body should be avoided. Certain burial rituals , which may have included making various direct contacts with a dead body, require reformulation so that they consistently maintain a proper protective barrier between the dead body and the living. Social anthropologists may help find alternatives to traditional rules for burials. Transportation crews are instructed to follow a certain isolation procedure, should anyone exhibit symptoms resembling EVD. As of August 2014 [ update ] , the WHO does not consider travel bans to be useful in decreasing spread of the disease. In October 2014, the CDC defined four risk levels used to determine the level of 21-day monitoring for symptoms and restrictions on public activities. In the United States, the CDC recommends that restrictions on public activity, including travel restrictions, are not required for the following defined risk levels: having been in a country with widespread Ebola disease transmission and having no known exposure (low risk); or having been in that country more than 21 days ago (no risk) encounter with a person showing symptoms; but not within three feet of the person with Ebola without wearing PPE; and no direct contact with body fluids having had brief skin contact with a person showing symptoms of Ebola disease when the person was believed to be not very contagious (low risk) in countries without widespread Ebola disease transmission: direct contact with a person showing symptoms of the disease while wearing PPE (low risk) contact with a person with Ebola disease before the person was showing symptoms (no risk). The CDC recommends monitoring for the symptoms of Ebola disease for those both at "low risk" and at higher risk. In laboratories where diagnostic testing is carried out, biosafety level 4-equivalent containment is required. Laboratory researchers must be properly trained in BSL-4 practices and wear proper PPE. Isolation refers to separating those who are sick from those who are not. Quarantine refers to separating those who may have been exposed to a disease until they either show signs of the disease or are no longer at risk. Quarantine, also known as enforced isolation, is usually effective in decreasing spread. Governments often quarantine areas where the disease is occurring or individuals who may transmit the disease outside of an initial area. In the United States, the law allows quarantine of those infected with ebolaviruses. Contact tracing is considered important to contain an outbreak. It involves finding everyone who had close contact with infected individuals and monitoring them for signs of illness for 21 days. If any of these contacts comes down with the disease, they should be isolated, tested and treated. Then the process is repeated, tracing the contacts' contacts. As of 2019 [ update ] two treatments ( atoltivimab/maftivimab/odesivimab and ansuvimab ) are associated with improved outcomes. The U.S. Food and Drug Administration (FDA) advises people to be careful of advertisements making unverified or fraudulent claims of benefits supposedly gained from various anti-Ebola products. In October 2020, the U.S. Food and Drug Administration (FDA) approved atoltivimab/maftivimab/odesivimab with an indication for the treatment of infection caused by Zaire ebolavirus . Treatment is primarily supportive in nature. Early supportive care with rehydration and symptomatic treatment improves survival. Rehydration may be via the oral or intravenous route. These measures may include pain management , and treatment for nausea , fever , and anxiety . The World Health Organization (WHO) recommends avoiding aspirin or ibuprofen for pain management, due to the risk of bleeding associated with these medications. Blood products such as packed red blood cells , platelets , or fresh frozen plasma may also be used. Other regulators of coagulation have also been tried including heparin in an effort to prevent disseminated intravascular coagulation and clotting factors to decrease bleeding. Antimalarial medications and antibiotics are often used before the diagnosis is confirmed, though there is no evidence to suggest such treatment helps. Several experimental treatments are being studied . Where hospital care is not possible, the WHO's guidelines for home care have been relatively successful. Recommendations include using towels soaked in a bleach solution when moving infected people or bodies and also applying bleach on stains. It is also recommended that the caregivers wash hands with bleach solutions and cover their mouth and nose with a cloth. Intensive care is often used in the developed world. This may include maintaining blood volume and electrolytes (salts) balance as well as treating any bacterial infections that may develop. Dialysis may be needed for kidney failure , and extracorporeal membrane oxygenation may be used for lung dysfunction. Treatment is primarily supportive in nature. Early supportive care with rehydration and symptomatic treatment improves survival. Rehydration may be via the oral or intravenous route. These measures may include pain management , and treatment for nausea , fever , and anxiety . The World Health Organization (WHO) recommends avoiding aspirin or ibuprofen for pain management, due to the risk of bleeding associated with these medications. Blood products such as packed red blood cells , platelets , or fresh frozen plasma may also be used. Other regulators of coagulation have also been tried including heparin in an effort to prevent disseminated intravascular coagulation and clotting factors to decrease bleeding. Antimalarial medications and antibiotics are often used before the diagnosis is confirmed, though there is no evidence to suggest such treatment helps. Several experimental treatments are being studied . Where hospital care is not possible, the WHO's guidelines for home care have been relatively successful. Recommendations include using towels soaked in a bleach solution when moving infected people or bodies and also applying bleach on stains. It is also recommended that the caregivers wash hands with bleach solutions and cover their mouth and nose with a cloth. Intensive care is often used in the developed world. This may include maintaining blood volume and electrolytes (salts) balance as well as treating any bacterial infections that may develop. Dialysis may be needed for kidney failure , and extracorporeal membrane oxygenation may be used for lung dysfunction. EVD has a risk of death in those infected of between 25% and 90%. As of September 2014 [ update ] , the average risk of death among those infected is 50%. The highest risk of death was 90% in the 2002–2003 Republic of the Congo outbreak. Early admission significantly increases survival rates Death, if it occurs, follows typically six to sixteen days after symptoms appear and is often due to low blood pressure from fluid loss . Early supportive care to prevent dehydration may reduce the risk of death. If an infected person survives, recovery may be quick and complete. However, a large portion of survivors develop post-Ebola virus syndrome after the acute phase of the infection. Prolonged cases are often complicated by the occurrence of long-term problems, such as inflammation of the testicles , joint pains , fatigue, hearing loss, mood and sleep disturbances, muscular pain , abdominal pain, menstrual abnormalities , miscarriages , skin peeling , or hair loss . Inflammation and swelling of the uveal layer of the eye is the most common eye complication in survivors of Ebola virus disease. Eye symptoms, such as light sensitivity , excess tearing , and vision loss have been described. Ebola can stay in some body parts like the eyes, breasts, and testicles after infection. Sexual transmission after recovery has been suspected. If sexual transmission occurs following recovery it is believed to be a rare event. One case of a condition similar to meningitis has been reported many months after recovery, as of October 2015 [ update ] . If an infected person survives, recovery may be quick and complete. However, a large portion of survivors develop post-Ebola virus syndrome after the acute phase of the infection. Prolonged cases are often complicated by the occurrence of long-term problems, such as inflammation of the testicles , joint pains , fatigue, hearing loss, mood and sleep disturbances, muscular pain , abdominal pain, menstrual abnormalities , miscarriages , skin peeling , or hair loss . Inflammation and swelling of the uveal layer of the eye is the most common eye complication in survivors of Ebola virus disease. Eye symptoms, such as light sensitivity , excess tearing , and vision loss have been described. Ebola can stay in some body parts like the eyes, breasts, and testicles after infection. Sexual transmission after recovery has been suspected. If sexual transmission occurs following recovery it is believed to be a rare event. One case of a condition similar to meningitis has been reported many months after recovery, as of October 2015 [ update ] . The disease typically occurs in outbreaks in tropical regions of Sub-Saharan Africa . From 1976 (when it was first identified) through 2013, the WHO reported 2,387 confirmed cases with 1,590 overall fatalities. The largest outbreak to date was the Ebola virus epidemic in West Africa , which caused a large number of deaths in Guinea , Sierra Leone , and Liberia . The first known outbreak of EVD was identified only after the fact. It occurred between June and November 1976, in Nzara, South Sudan (then part of Sudan ), and was caused by Sudan virus (SUDV). The Sudan outbreak infected 284 people and killed 151. The first identifiable case in Sudan occurred on 27 June in a storekeeper in a cotton factory in Nzara , who was hospitalised on 30 June and died on 6 July. Although the WHO medical staff involved in the Sudan outbreak knew that they were dealing with a heretofore unknown disease, the actual "positive identification" process and the naming of the virus did not occur until some months later in Zaire . On 26 August 1976, the second outbreak of EVD began in Yambuku , a small rural village in Mongala District in northern Zaire (now known as the Democratic Republic of the Congo ). This outbreak was caused by EBOV, formerly designated Zaire ebolavirus , a different member of the genus Ebolavirus than in the first Sudan outbreak. The first person infected with the disease was the village school's headmaster Mabalo Lokela , who began displaying symptoms on 26 August 1976. Lokela had returned from a trip to Northern Zaire near the border of the Central African Republic , after visiting the Ebola River between 12 and 22 August. He was originally believed to have malaria and was given quinine . However, his symptoms continued to worsen, and he was admitted to Yambuku Mission Hospital on 5 September. Lokela died on 8 September 14 days after he began displaying symptoms. Soon after Lokela's death, others who had been in contact with him also died, and people in Yambuku began to panic. The country's Minister of Health and Zaire President Mobutu Sese Seko declared the entire region, including Yambuku and the country's capital, Kinshasa , a quarantine zone. No-one was permitted to enter or leave the area, and roads, waterways, and airfields were placed under martial law . Schools, businesses and social organisations were closed. The initial response was led by Congolese doctors, including Jean-Jacques Muyembe-Tamfum , one of the discoverers of Ebola. Muyembe took a blood sample from a Belgian nun; this sample would eventually be used by Peter Piot to identify the previously unknown Ebola virus. Muyembe was also the first scientist to come into direct contact with the disease and survive. Researchers from the Centers for Disease Control and Prevention (CDC), including Piot, co-discoverer of Ebola, later arrived to assess the effects of the outbreak, observing that "the whole region was in panic." Piot concluded that Belgian nuns had inadvertently started the epidemic by giving unnecessary vitamin injections to pregnant women without sterilizing the syringes and needles. The outbreak lasted 26 days and the quarantine lasted two weeks. Researchers speculated that the disease disappeared due to the precautions taken by locals, the quarantine of the area, and discontinuing of the injections. During this outbreak, Ngoy Mushola recorded the first clinical description of EVD in Yambuku , where he wrote the following in his daily log: "The illness is characterised with a high temperature of about 39 °C (102 °F) , haematemesis , diarrhoea with blood, retrosternal abdominal pain, prostration with 'heavy' articulations, and rapid evolution death after a mean of three days." The virus responsible for the initial outbreak, first thought to be the Marburg virus , was later identified as a new type of virus related to the genus Marburgvirus . Virus strain samples isolated from both outbreaks were named "Ebola virus" after the Ebola River , near the first-identified viral outbreak site in Zaire. Reports conflict about who initially coined the name: either Karl Johnson of the American CDC team or Belgian researchers. Subsequently, a number of other cases were reported, almost all centred on the Yambuku mission hospital or close contacts of another case. In all, 318 cases and 280 deaths (an 88% fatality rate) occurred in Zaire. Although the two outbreaks were at first believed connected, scientists later realised that they were caused by two distinct ebolaviruses, SUDV and EBOV. The second major outbreak occurred in Zaire (now the Democratic Republic of the Congo , DRC), in 1995, affecting 315 and killing 254. In 2000, Uganda had an outbreak infecting 425 and killing 224; in this case, the Sudan virus was found to be the Ebola species responsible for the outbreak. In 2003, an outbreak in the DRC infected 143 and killed 128, a 90% death rate, the highest of a genus Ebolavirus outbreak to date. In 2004, a Russian scientist died from Ebola after sticking herself with an infected needle. Between April and August 2007, a fever epidemic in a four-village region of the DRC was confirmed in September to have been cases of Ebola. Many people who attended the recent funeral of a local village chief died. The 2007 outbreak eventually infected 264 individuals and killed 187. On 30 November 2007, the Uganda Ministry of Health confirmed an outbreak of Ebola in the Bundibugyo District in Western Uganda. After confirming samples tested by the United States National Reference Laboratories and the Centers for Disease Control, the World Health Organization (WHO) confirmed the presence of a new species of genus Ebolavirus , which was tentatively named Bundibugyo. The WHO reported 149 cases of this new strain and 37 of those led to deaths. The WHO confirmed two small outbreaks in Uganda in 2012, both caused by the Sudan variant. The first outbreak affected seven people, killing four, and the second affected 24, killing 17. On 17 August 2012, the Ministry of Health of the DRC reported an outbreak of the Ebola-Bundibugyo variant in the eastern region. Other than its discovery in 2007, this was the only time that this variant has been identified as responsible for an outbreak. The WHO revealed that the virus had sickened 57 people and killed 29. The probable cause of the outbreak was tainted bush meat hunted by local villagers around the towns of Isiro and Viadana. In 2014, an outbreak occurred in the DRC. Genome-sequencing showed that this outbreak was not related to the 2014–15 West Africa Ebola virus outbreak , but was the same EBOV species, the Zaire species. It began in August 2014, and was declared over in November with 66 cases and 49 deaths. This was the 7th outbreak in the DRC, three of which occurred during the period when the country was known as Zaire . In March 2014, the World Health Organization (WHO) reported a major Ebola outbreak in Guinea , a West African nation. Researchers traced the outbreak to a one-year-old child who died in December 2013. The disease rapidly spread to the neighbouring countries of Liberia and Sierra Leone . It was the largest Ebola outbreak ever documented, and the first recorded in the region. On 8 August 2014, the WHO declared the epidemic an international public health emergency. Urging the world to offer aid to the affected regions, its Director-General said, "Countries affected to date simply do not have the capacity to manage an outbreak of this size and complexity on their own. I urge the international community to provide this support on the most urgent basis possible." By mid-August 2014, Doctors Without Borders reported the situation in Liberia's capital, Monrovia , was "catastrophic" and "deteriorating daily". They reported that fears of Ebola among staff members and patients had shut down much of the city's health system, leaving many people without medical treatment for other conditions. In a 26 September statement, WHO said, "The Ebola epidemic ravaging parts of West Africa is the most severe acute public health emergency seen in modern times. Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over such a broad geographical area, for so long." Intense contact tracing and strict isolation largely prevented further spread of the disease in the countries that had imported cases. It caused significant mortality, with a considerable case fatality rate . [note 1] By the end of the epidemic, 28,616 people had been infected; of these, 11,310 had died, for a case-fatality rate of 40%. As of 8 May 2016 [ update ] , 28,646 suspected cases and 11,323 deaths were reported; however, the WHO said that these numbers may be underestimated. Because they work closely with the body fluids of infected patients, healthcare workers were especially vulnerable to infection; in August 2014, the WHO reported that 10% of the dead were healthcare workers. In September 2014, it was estimated that the countries' capacity for treating Ebola patients was insufficient by the equivalent of 2,122 beds; by December there were a sufficient number of beds to treat and isolate all reported Ebola cases, although the uneven distribution of cases was causing serious shortfalls in some areas. On 28 January 2015, the WHO reported that for the first time since the week ending 29 June 2014, there had been fewer than 100 new confirmed cases reported in a week in the three most-affected countries. The response to the epidemic then moved to a second phase, as the focus shifted from slowing transmission to ending the epidemic. On 8 April 2015, the WHO reported only 30 confirmed cases, the lowest weekly total since the third week of May 2014. On 29 December 2015, 42 days after the last person tested negative for a second time, Guinea was declared free of Ebola transmission. At that time, a 90-day period of heightened surveillance was announced by that agency. "This is the first time that all three countries – Guinea, Liberia and Sierra Leone – have stopped the original chains of transmission ...", the organisation stated in a news release. A new case was detected in Sierra Leone on 14 January 2016. However, the outbreak was declared no longer an emergency on 29 March 2016. On 19 September, Eric Duncan flew from his native Liberia to Texas; five days later he began showing symptoms and visited a hospital but was sent home. His condition worsened and he returned to the hospital on 28 September, where he died on 8 October. Health officials confirmed a diagnosis of Ebola on 30 September – the first case in the United States. In early October, Teresa Romero, a 44-year-old Spanish nurse, contracted Ebola after caring for a priest who had been repatriated from West Africa. This was the first transmission of the virus to occur outside Africa. Romero tested negative for the disease on 20 October, suggesting that she may have recovered from Ebola infection. On 12 October, the Centers for Disease Control and Prevention (CDC) confirmed that a nurse in Texas, Nina Pham , who had treated Duncan tested positive for the Ebola virus, the first known case of transmission in the United States. On 15 October, a second Texas health-care worker who had treated Duncan was confirmed to have the virus. Both of these people recovered. An unrelated case involved a doctor in New York City, who returned to the United States from Guinea after working with Médecins Sans Frontières and tested positive for Ebola on 23 October. The person recovered and was discharged from Bellevue Hospital on 11 November. On 24 December 2014, a laboratory in Atlanta , Georgia reported that a technician had been exposed to Ebola. On 29 December 2014, Pauline Cafferkey , a British nurse who had just returned to Glasgow from Sierra Leone, was diagnosed with Ebola at Glasgow's Gartnavel General Hospital . After initial treatment in Glasgow, she was transferred by air to RAF Northolt , then to the specialist high-level isolation unit at the Royal Free Hospital in London for longer-term treatment. On 11 May 2017, the DRC Ministry of Public Health notified the WHO about an outbreak of Ebola. Four people died, and four people survived; five of these eight cases were laboratory-confirmed. A total of 583 contacts were monitored. On 2 July 2017, the WHO declared the end of the outbreak. On 14 May 2018, the World Health Organization reported that "the Democratic Republic of Congo reported 39 suspected, probable or confirmed cases of Ebola between 4 April and 13 May, including 19 deaths." Some 393 people identified as contacts of Ebola patients were being followed up. The outbreak centred on the Bikoro , Iboko, and Wangata areas in Equateur province, including in the large city of Mbandaka . The DRC Ministry of Public Health approved the use of an experimental vaccine. On 13 May 2018, WHO Director-General Tedros Adhanom Ghebreyesus visited Bikoro. Reports emerged that maps of the area were inaccurate, not so much hampering medical providers as epidemiologists and officials trying to assess the outbreak and containment efforts. The 2018 outbreak in the DRC was declared over on 24 July 2018. On 1 August 2018, the world's 10th Ebola outbreak was declared in North Kivu province of the Democratic Republic of the Congo. It was the first Ebola outbreak in a military conflict zone, with thousands of refugees in the area. By November 2018, nearly 200 Congolese had died of Ebola, about half of them from the city of Beni , where armed groups are fighting over the region's mineral wealth, impeding medical relief efforts. By March 2019, this became the second largest Ebola outbreak ever recorded, with more than 1,000 cases and insecurity continuing to be the major resistance to providing an adequate response. As of 4 June 2019 [ update ] , the WHO reported 2025 confirmed and probable cases with 1357 deaths. In June 2019, two people died of Ebola in neighbouring Uganda . In July 2019, an infected man travelled to Goma , home to more than two million people. One week later, on 17 July 2019, the WHO declared the Ebola outbreak a global health emergency , the fifth time such a declaration has been made by the organisation. A government spokesman said that half of the Ebola cases are unidentified, and he added that the current outbreak could last up to three years. On 25 June 2020, the second biggest EVD outbreak ever was declared over. On 1 June 2020, the Congolese health ministry announced a new DRC outbreak of Ebola in Mbandaka , Équateur Province , a region along the Congo River. Genome sequencing suggests that this outbreak, the 11th outbreak since the virus was first discovered in the country in 1976, is unrelated to the one in North Kivu Province or the previous outbreak in the same area in 2018. It was reported that six cases had been identified; four of the people had died. It is expected that more people will be identified as surveillance activities increase. By 15 June the case count had increased to 17 with 11 deaths, with more than 2,500 people having been vaccinated. The 11th EVD outbreak was officially declared over on 19 November 2020. By the time the Équateur outbreak ended, it had 130 confirmed cases with 75 recoveries and 55 deaths. On 7 February 2021, the Congolese health ministry announced a new case of Ebola near Butembo, North Kivu detected a day before. The case was a 42-year-old woman who had symptoms of Ebola in Biena on 1 February 2021. A few days after, she died in a hospital in Butembo. The WHO said that more than 70 people with contact with the woman had been tracked. On 11 February 2021, another woman who had contact with the previous woman died in the same town, and the number of traced contacts increased to 100. A day after, a third case was detected in Butembo. On 3 May 2021, the 12th EVD outbreak was declared over, resulting in 12 cases and six deaths. Heightened surveillance will continue for 90 days after the declaration, in case of resurgence. In February 2021, Sakoba Keita, head of Guinea's national health agency confirmed that three people had died of Ebola in the south-eastern region near the city of Nzérékoré. A further five people also tested positive. Keita also confirmed more testing was underway, and attempts to trace and isolate further cases had begun. On 14 February, the Guinean government declared an Ebola epidemic. The outbreak may have started following reactivation of a latent case in a survivor of an earlier outbreak. As of 4 May 2021, 23 cases were reported, with no new cases or deaths since 3 April 2021. A 42-day countdown period was started on 8 May 2021, and on 19 June, the outbreak was declared over. On 14 August 2021, The Ministry of Health of Cote d'Ivoire confirmed the country's first case of Ebola since 1994. This came after the Institut Pasteur in Cote d'Ivoire confirmed the Ebola Virus Disease in samples collected from a patient, who was hospitalized in the commercial capital of Abidjan , after arriving from Guinea. However, on 31 August 2021, the WHO found that, after further tests in a laboratory in Lyon , the patient did not have Ebola. The cause of her disease is still being analyzed. On 23 April 2022, a case of Ebola was confirmed in the DRC in the Equateur province. The case was a 31-year-old man whose symptoms began on 5 April, but did not seek treatment for over a week. On 21 April, he was admitted to an Ebola treatment centre and died later that day. By 24 May 2022, there were 5 recorded deaths in the DRC. On 15 August, the fifth case was buried, and the outbreak was declared over, 42 days after, on 4 July 2022. In September 2022, Uganda reported 7 cases infected with the Ebola Sudan strain , but by mid-October the count had increased to 63. In November 2022, the outbreak in Uganda continued - still without a vaccine. On 10 January 2023, the outbreak was considered over after no new cases had been reported for 42 days; the outbreak killed nearly 80 people. The first known outbreak of EVD was identified only after the fact. It occurred between June and November 1976, in Nzara, South Sudan (then part of Sudan ), and was caused by Sudan virus (SUDV). The Sudan outbreak infected 284 people and killed 151. The first identifiable case in Sudan occurred on 27 June in a storekeeper in a cotton factory in Nzara , who was hospitalised on 30 June and died on 6 July. Although the WHO medical staff involved in the Sudan outbreak knew that they were dealing with a heretofore unknown disease, the actual "positive identification" process and the naming of the virus did not occur until some months later in Zaire . On 26 August 1976, the second outbreak of EVD began in Yambuku , a small rural village in Mongala District in northern Zaire (now known as the Democratic Republic of the Congo ). This outbreak was caused by EBOV, formerly designated Zaire ebolavirus , a different member of the genus Ebolavirus than in the first Sudan outbreak. The first person infected with the disease was the village school's headmaster Mabalo Lokela , who began displaying symptoms on 26 August 1976. Lokela had returned from a trip to Northern Zaire near the border of the Central African Republic , after visiting the Ebola River between 12 and 22 August. He was originally believed to have malaria and was given quinine . However, his symptoms continued to worsen, and he was admitted to Yambuku Mission Hospital on 5 September. Lokela died on 8 September 14 days after he began displaying symptoms. Soon after Lokela's death, others who had been in contact with him also died, and people in Yambuku began to panic. The country's Minister of Health and Zaire President Mobutu Sese Seko declared the entire region, including Yambuku and the country's capital, Kinshasa , a quarantine zone. No-one was permitted to enter or leave the area, and roads, waterways, and airfields were placed under martial law . Schools, businesses and social organisations were closed. The initial response was led by Congolese doctors, including Jean-Jacques Muyembe-Tamfum , one of the discoverers of Ebola. Muyembe took a blood sample from a Belgian nun; this sample would eventually be used by Peter Piot to identify the previously unknown Ebola virus. Muyembe was also the first scientist to come into direct contact with the disease and survive. Researchers from the Centers for Disease Control and Prevention (CDC), including Piot, co-discoverer of Ebola, later arrived to assess the effects of the outbreak, observing that "the whole region was in panic." Piot concluded that Belgian nuns had inadvertently started the epidemic by giving unnecessary vitamin injections to pregnant women without sterilizing the syringes and needles. The outbreak lasted 26 days and the quarantine lasted two weeks. Researchers speculated that the disease disappeared due to the precautions taken by locals, the quarantine of the area, and discontinuing of the injections. During this outbreak, Ngoy Mushola recorded the first clinical description of EVD in Yambuku , where he wrote the following in his daily log: "The illness is characterised with a high temperature of about 39 °C (102 °F) , haematemesis , diarrhoea with blood, retrosternal abdominal pain, prostration with 'heavy' articulations, and rapid evolution death after a mean of three days." The virus responsible for the initial outbreak, first thought to be the Marburg virus , was later identified as a new type of virus related to the genus Marburgvirus . Virus strain samples isolated from both outbreaks were named "Ebola virus" after the Ebola River , near the first-identified viral outbreak site in Zaire. Reports conflict about who initially coined the name: either Karl Johnson of the American CDC team or Belgian researchers. Subsequently, a number of other cases were reported, almost all centred on the Yambuku mission hospital or close contacts of another case. In all, 318 cases and 280 deaths (an 88% fatality rate) occurred in Zaire. Although the two outbreaks were at first believed connected, scientists later realised that they were caused by two distinct ebolaviruses, SUDV and EBOV. The first known outbreak of EVD was identified only after the fact. It occurred between June and November 1976, in Nzara, South Sudan (then part of Sudan ), and was caused by Sudan virus (SUDV). The Sudan outbreak infected 284 people and killed 151. The first identifiable case in Sudan occurred on 27 June in a storekeeper in a cotton factory in Nzara , who was hospitalised on 30 June and died on 6 July. Although the WHO medical staff involved in the Sudan outbreak knew that they were dealing with a heretofore unknown disease, the actual "positive identification" process and the naming of the virus did not occur until some months later in Zaire . On 26 August 1976, the second outbreak of EVD began in Yambuku , a small rural village in Mongala District in northern Zaire (now known as the Democratic Republic of the Congo ). This outbreak was caused by EBOV, formerly designated Zaire ebolavirus , a different member of the genus Ebolavirus than in the first Sudan outbreak. The first person infected with the disease was the village school's headmaster Mabalo Lokela , who began displaying symptoms on 26 August 1976. Lokela had returned from a trip to Northern Zaire near the border of the Central African Republic , after visiting the Ebola River between 12 and 22 August. He was originally believed to have malaria and was given quinine . However, his symptoms continued to worsen, and he was admitted to Yambuku Mission Hospital on 5 September. Lokela died on 8 September 14 days after he began displaying symptoms. Soon after Lokela's death, others who had been in contact with him also died, and people in Yambuku began to panic. The country's Minister of Health and Zaire President Mobutu Sese Seko declared the entire region, including Yambuku and the country's capital, Kinshasa , a quarantine zone. No-one was permitted to enter or leave the area, and roads, waterways, and airfields were placed under martial law . Schools, businesses and social organisations were closed. The initial response was led by Congolese doctors, including Jean-Jacques Muyembe-Tamfum , one of the discoverers of Ebola. Muyembe took a blood sample from a Belgian nun; this sample would eventually be used by Peter Piot to identify the previously unknown Ebola virus. Muyembe was also the first scientist to come into direct contact with the disease and survive. Researchers from the Centers for Disease Control and Prevention (CDC), including Piot, co-discoverer of Ebola, later arrived to assess the effects of the outbreak, observing that "the whole region was in panic." Piot concluded that Belgian nuns had inadvertently started the epidemic by giving unnecessary vitamin injections to pregnant women without sterilizing the syringes and needles. The outbreak lasted 26 days and the quarantine lasted two weeks. Researchers speculated that the disease disappeared due to the precautions taken by locals, the quarantine of the area, and discontinuing of the injections. During this outbreak, Ngoy Mushola recorded the first clinical description of EVD in Yambuku , where he wrote the following in his daily log: "The illness is characterised with a high temperature of about 39 °C (102 °F) , haematemesis , diarrhoea with blood, retrosternal abdominal pain, prostration with 'heavy' articulations, and rapid evolution death after a mean of three days." The virus responsible for the initial outbreak, first thought to be the Marburg virus , was later identified as a new type of virus related to the genus Marburgvirus . Virus strain samples isolated from both outbreaks were named "Ebola virus" after the Ebola River , near the first-identified viral outbreak site in Zaire. Reports conflict about who initially coined the name: either Karl Johnson of the American CDC team or Belgian researchers. Subsequently, a number of other cases were reported, almost all centred on the Yambuku mission hospital or close contacts of another case. In all, 318 cases and 280 deaths (an 88% fatality rate) occurred in Zaire. Although the two outbreaks were at first believed connected, scientists later realised that they were caused by two distinct ebolaviruses, SUDV and EBOV. The second major outbreak occurred in Zaire (now the Democratic Republic of the Congo , DRC), in 1995, affecting 315 and killing 254. In 2000, Uganda had an outbreak infecting 425 and killing 224; in this case, the Sudan virus was found to be the Ebola species responsible for the outbreak. In 2003, an outbreak in the DRC infected 143 and killed 128, a 90% death rate, the highest of a genus Ebolavirus outbreak to date. In 2004, a Russian scientist died from Ebola after sticking herself with an infected needle. Between April and August 2007, a fever epidemic in a four-village region of the DRC was confirmed in September to have been cases of Ebola. Many people who attended the recent funeral of a local village chief died. The 2007 outbreak eventually infected 264 individuals and killed 187. On 30 November 2007, the Uganda Ministry of Health confirmed an outbreak of Ebola in the Bundibugyo District in Western Uganda. After confirming samples tested by the United States National Reference Laboratories and the Centers for Disease Control, the World Health Organization (WHO) confirmed the presence of a new species of genus Ebolavirus , which was tentatively named Bundibugyo. The WHO reported 149 cases of this new strain and 37 of those led to deaths. The WHO confirmed two small outbreaks in Uganda in 2012, both caused by the Sudan variant. The first outbreak affected seven people, killing four, and the second affected 24, killing 17. On 17 August 2012, the Ministry of Health of the DRC reported an outbreak of the Ebola-Bundibugyo variant in the eastern region. Other than its discovery in 2007, this was the only time that this variant has been identified as responsible for an outbreak. The WHO revealed that the virus had sickened 57 people and killed 29. The probable cause of the outbreak was tainted bush meat hunted by local villagers around the towns of Isiro and Viadana. In 2014, an outbreak occurred in the DRC. Genome-sequencing showed that this outbreak was not related to the 2014–15 West Africa Ebola virus outbreak , but was the same EBOV species, the Zaire species. It began in August 2014, and was declared over in November with 66 cases and 49 deaths. This was the 7th outbreak in the DRC, three of which occurred during the period when the country was known as Zaire . In March 2014, the World Health Organization (WHO) reported a major Ebola outbreak in Guinea , a West African nation. Researchers traced the outbreak to a one-year-old child who died in December 2013. The disease rapidly spread to the neighbouring countries of Liberia and Sierra Leone . It was the largest Ebola outbreak ever documented, and the first recorded in the region. On 8 August 2014, the WHO declared the epidemic an international public health emergency. Urging the world to offer aid to the affected regions, its Director-General said, "Countries affected to date simply do not have the capacity to manage an outbreak of this size and complexity on their own. I urge the international community to provide this support on the most urgent basis possible." By mid-August 2014, Doctors Without Borders reported the situation in Liberia's capital, Monrovia , was "catastrophic" and "deteriorating daily". They reported that fears of Ebola among staff members and patients had shut down much of the city's health system, leaving many people without medical treatment for other conditions. In a 26 September statement, WHO said, "The Ebola epidemic ravaging parts of West Africa is the most severe acute public health emergency seen in modern times. Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over such a broad geographical area, for so long." Intense contact tracing and strict isolation largely prevented further spread of the disease in the countries that had imported cases. It caused significant mortality, with a considerable case fatality rate . [note 1] By the end of the epidemic, 28,616 people had been infected; of these, 11,310 had died, for a case-fatality rate of 40%. As of 8 May 2016 [ update ] , 28,646 suspected cases and 11,323 deaths were reported; however, the WHO said that these numbers may be underestimated. Because they work closely with the body fluids of infected patients, healthcare workers were especially vulnerable to infection; in August 2014, the WHO reported that 10% of the dead were healthcare workers. In September 2014, it was estimated that the countries' capacity for treating Ebola patients was insufficient by the equivalent of 2,122 beds; by December there were a sufficient number of beds to treat and isolate all reported Ebola cases, although the uneven distribution of cases was causing serious shortfalls in some areas. On 28 January 2015, the WHO reported that for the first time since the week ending 29 June 2014, there had been fewer than 100 new confirmed cases reported in a week in the three most-affected countries. The response to the epidemic then moved to a second phase, as the focus shifted from slowing transmission to ending the epidemic. On 8 April 2015, the WHO reported only 30 confirmed cases, the lowest weekly total since the third week of May 2014. On 29 December 2015, 42 days after the last person tested negative for a second time, Guinea was declared free of Ebola transmission. At that time, a 90-day period of heightened surveillance was announced by that agency. "This is the first time that all three countries – Guinea, Liberia and Sierra Leone – have stopped the original chains of transmission ...", the organisation stated in a news release. A new case was detected in Sierra Leone on 14 January 2016. However, the outbreak was declared no longer an emergency on 29 March 2016. On 19 September, Eric Duncan flew from his native Liberia to Texas; five days later he began showing symptoms and visited a hospital but was sent home. His condition worsened and he returned to the hospital on 28 September, where he died on 8 October. Health officials confirmed a diagnosis of Ebola on 30 September – the first case in the United States. In early October, Teresa Romero, a 44-year-old Spanish nurse, contracted Ebola after caring for a priest who had been repatriated from West Africa. This was the first transmission of the virus to occur outside Africa. Romero tested negative for the disease on 20 October, suggesting that she may have recovered from Ebola infection. On 12 October, the Centers for Disease Control and Prevention (CDC) confirmed that a nurse in Texas, Nina Pham , who had treated Duncan tested positive for the Ebola virus, the first known case of transmission in the United States. On 15 October, a second Texas health-care worker who had treated Duncan was confirmed to have the virus. Both of these people recovered. An unrelated case involved a doctor in New York City, who returned to the United States from Guinea after working with Médecins Sans Frontières and tested positive for Ebola on 23 October. The person recovered and was discharged from Bellevue Hospital on 11 November. On 24 December 2014, a laboratory in Atlanta , Georgia reported that a technician had been exposed to Ebola. On 29 December 2014, Pauline Cafferkey , a British nurse who had just returned to Glasgow from Sierra Leone, was diagnosed with Ebola at Glasgow's Gartnavel General Hospital . After initial treatment in Glasgow, she was transferred by air to RAF Northolt , then to the specialist high-level isolation unit at the Royal Free Hospital in London for longer-term treatment. On 19 September, Eric Duncan flew from his native Liberia to Texas; five days later he began showing symptoms and visited a hospital but was sent home. His condition worsened and he returned to the hospital on 28 September, where he died on 8 October. Health officials confirmed a diagnosis of Ebola on 30 September – the first case in the United States. In early October, Teresa Romero, a 44-year-old Spanish nurse, contracted Ebola after caring for a priest who had been repatriated from West Africa. This was the first transmission of the virus to occur outside Africa. Romero tested negative for the disease on 20 October, suggesting that she may have recovered from Ebola infection. On 12 October, the Centers for Disease Control and Prevention (CDC) confirmed that a nurse in Texas, Nina Pham , who had treated Duncan tested positive for the Ebola virus, the first known case of transmission in the United States. On 15 October, a second Texas health-care worker who had treated Duncan was confirmed to have the virus. Both of these people recovered. An unrelated case involved a doctor in New York City, who returned to the United States from Guinea after working with Médecins Sans Frontières and tested positive for Ebola on 23 October. The person recovered and was discharged from Bellevue Hospital on 11 November. On 24 December 2014, a laboratory in Atlanta , Georgia reported that a technician had been exposed to Ebola. On 29 December 2014, Pauline Cafferkey , a British nurse who had just returned to Glasgow from Sierra Leone, was diagnosed with Ebola at Glasgow's Gartnavel General Hospital . After initial treatment in Glasgow, she was transferred by air to RAF Northolt , then to the specialist high-level isolation unit at the Royal Free Hospital in London for longer-term treatment. On 11 May 2017, the DRC Ministry of Public Health notified the WHO about an outbreak of Ebola. Four people died, and four people survived; five of these eight cases were laboratory-confirmed. A total of 583 contacts were monitored. On 2 July 2017, the WHO declared the end of the outbreak. On 14 May 2018, the World Health Organization reported that "the Democratic Republic of Congo reported 39 suspected, probable or confirmed cases of Ebola between 4 April and 13 May, including 19 deaths." Some 393 people identified as contacts of Ebola patients were being followed up. The outbreak centred on the Bikoro , Iboko, and Wangata areas in Equateur province, including in the large city of Mbandaka . The DRC Ministry of Public Health approved the use of an experimental vaccine. On 13 May 2018, WHO Director-General Tedros Adhanom Ghebreyesus visited Bikoro. Reports emerged that maps of the area were inaccurate, not so much hampering medical providers as epidemiologists and officials trying to assess the outbreak and containment efforts. The 2018 outbreak in the DRC was declared over on 24 July 2018. On 1 August 2018, the world's 10th Ebola outbreak was declared in North Kivu province of the Democratic Republic of the Congo. It was the first Ebola outbreak in a military conflict zone, with thousands of refugees in the area. By November 2018, nearly 200 Congolese had died of Ebola, about half of them from the city of Beni , where armed groups are fighting over the region's mineral wealth, impeding medical relief efforts. By March 2019, this became the second largest Ebola outbreak ever recorded, with more than 1,000 cases and insecurity continuing to be the major resistance to providing an adequate response. As of 4 June 2019 [ update ] , the WHO reported 2025 confirmed and probable cases with 1357 deaths. In June 2019, two people died of Ebola in neighbouring Uganda . In July 2019, an infected man travelled to Goma , home to more than two million people. One week later, on 17 July 2019, the WHO declared the Ebola outbreak a global health emergency , the fifth time such a declaration has been made by the organisation. A government spokesman said that half of the Ebola cases are unidentified, and he added that the current outbreak could last up to three years. On 25 June 2020, the second biggest EVD outbreak ever was declared over. On 1 June 2020, the Congolese health ministry announced a new DRC outbreak of Ebola in Mbandaka , Équateur Province , a region along the Congo River. Genome sequencing suggests that this outbreak, the 11th outbreak since the virus was first discovered in the country in 1976, is unrelated to the one in North Kivu Province or the previous outbreak in the same area in 2018. It was reported that six cases had been identified; four of the people had died. It is expected that more people will be identified as surveillance activities increase. By 15 June the case count had increased to 17 with 11 deaths, with more than 2,500 people having been vaccinated. The 11th EVD outbreak was officially declared over on 19 November 2020. By the time the Équateur outbreak ended, it had 130 confirmed cases with 75 recoveries and 55 deaths.On 7 February 2021, the Congolese health ministry announced a new case of Ebola near Butembo, North Kivu detected a day before. The case was a 42-year-old woman who had symptoms of Ebola in Biena on 1 February 2021. A few days after, she died in a hospital in Butembo. The WHO said that more than 70 people with contact with the woman had been tracked. On 11 February 2021, another woman who had contact with the previous woman died in the same town, and the number of traced contacts increased to 100. A day after, a third case was detected in Butembo. On 3 May 2021, the 12th EVD outbreak was declared over, resulting in 12 cases and six deaths. Heightened surveillance will continue for 90 days after the declaration, in case of resurgence. In February 2021, Sakoba Keita, head of Guinea's national health agency confirmed that three people had died of Ebola in the south-eastern region near the city of Nzérékoré. A further five people also tested positive. Keita also confirmed more testing was underway, and attempts to trace and isolate further cases had begun. On 14 February, the Guinean government declared an Ebola epidemic. The outbreak may have started following reactivation of a latent case in a survivor of an earlier outbreak. As of 4 May 2021, 23 cases were reported, with no new cases or deaths since 3 April 2021. A 42-day countdown period was started on 8 May 2021, and on 19 June, the outbreak was declared over. On 14 August 2021, The Ministry of Health of Cote d'Ivoire confirmed the country's first case of Ebola since 1994. This came after the Institut Pasteur in Cote d'Ivoire confirmed the Ebola Virus Disease in samples collected from a patient, who was hospitalized in the commercial capital of Abidjan , after arriving from Guinea. However, on 31 August 2021, the WHO found that, after further tests in a laboratory in Lyon , the patient did not have Ebola. The cause of her disease is still being analyzed. On 7 February 2021, the Congolese health ministry announced a new case of Ebola near Butembo, North Kivu detected a day before. The case was a 42-year-old woman who had symptoms of Ebola in Biena on 1 February 2021. A few days after, she died in a hospital in Butembo. The WHO said that more than 70 people with contact with the woman had been tracked. On 11 February 2021, another woman who had contact with the previous woman died in the same town, and the number of traced contacts increased to 100. A day after, a third case was detected in Butembo. On 3 May 2021, the 12th EVD outbreak was declared over, resulting in 12 cases and six deaths. Heightened surveillance will continue for 90 days after the declaration, in case of resurgence. In February 2021, Sakoba Keita, head of Guinea's national health agency confirmed that three people had died of Ebola in the south-eastern region near the city of Nzérékoré. A further five people also tested positive. Keita also confirmed more testing was underway, and attempts to trace and isolate further cases had begun. On 14 February, the Guinean government declared an Ebola epidemic. The outbreak may have started following reactivation of a latent case in a survivor of an earlier outbreak. As of 4 May 2021, 23 cases were reported, with no new cases or deaths since 3 April 2021. A 42-day countdown period was started on 8 May 2021, and on 19 June, the outbreak was declared over. On 14 August 2021, The Ministry of Health of Cote d'Ivoire confirmed the country's first case of Ebola since 1994. This came after the Institut Pasteur in Cote d'Ivoire confirmed the Ebola Virus Disease in samples collected from a patient, who was hospitalized in the commercial capital of Abidjan , after arriving from Guinea. However, on 31 August 2021, the WHO found that, after further tests in a laboratory in Lyon , the patient did not have Ebola. The cause of her disease is still being analyzed. On 23 April 2022, a case of Ebola was confirmed in the DRC in the Equateur province. The case was a 31-year-old man whose symptoms began on 5 April, but did not seek treatment for over a week. On 21 April, he was admitted to an Ebola treatment centre and died later that day. By 24 May 2022, there were 5 recorded deaths in the DRC. On 15 August, the fifth case was buried, and the outbreak was declared over, 42 days after, on 4 July 2022. In September 2022, Uganda reported 7 cases infected with the Ebola Sudan strain , but by mid-October the count had increased to 63. In November 2022, the outbreak in Uganda continued - still without a vaccine. On 10 January 2023, the outbreak was considered over after no new cases had been reported for 42 days; the outbreak killed nearly 80 people. Ebolavirus is classified as a biosafety level 4 agent, as well as a Category A bioterrorism agent by the Centers for Disease Control and Prevention. It has the potential to be weaponised for use in biological warfare , and was investigated by Biopreparat for such use, but might be difficult to prepare as a weapon of mass destruction because the virus becomes ineffective quickly in open air. Fake emails pretending to be Ebola information from the WHO or the Mexican government have, in 2014, been misused to spread computer malware. The BBC reported in 2015 that "North Korean state media has suggested the disease was created by the U.S. military as a biological weapon." Richard Preston 's 1995 best-selling book, The Hot Zone , dramatised the Ebola outbreak in Reston, Virginia. William Close 's 1995 Ebola: A Documentary Novel of Its First Explosion and 2002 Ebola: Through the Eyes of the People focused on individuals' reactions to the 1976 Ebola outbreak in Zaire. Tom Clancy 's 1996 novel, Executive Orders , involves a Middle Eastern terrorist attack on the United States using an airborne form of a deadly Ebola virus strain named "Ebola Mayinga" (see Mayinga N'Seka ). As the Ebola virus epidemic in West Africa developed in 2014, a number of popular self-published and well-reviewed books containing sensational and misleading information about the disease appeared in electronic and printed formats. The authors of some such books admitted that they lacked medical credentials and were not technically qualified to give medical advice. The World Health Organization and the United Nations stated that such misinformation had contributed to the spread of the disease. Ebolavirus is classified as a biosafety level 4 agent, as well as a Category A bioterrorism agent by the Centers for Disease Control and Prevention. It has the potential to be weaponised for use in biological warfare , and was investigated by Biopreparat for such use, but might be difficult to prepare as a weapon of mass destruction because the virus becomes ineffective quickly in open air. Fake emails pretending to be Ebola information from the WHO or the Mexican government have, in 2014, been misused to spread computer malware. The BBC reported in 2015 that "North Korean state media has suggested the disease was created by the U.S. military as a biological weapon." Richard Preston 's 1995 best-selling book, The Hot Zone , dramatised the Ebola outbreak in Reston, Virginia. William Close 's 1995 Ebola: A Documentary Novel of Its First Explosion and 2002 Ebola: Through the Eyes of the People focused on individuals' reactions to the 1976 Ebola outbreak in Zaire. Tom Clancy 's 1996 novel, Executive Orders , involves a Middle Eastern terrorist attack on the United States using an airborne form of a deadly Ebola virus strain named "Ebola Mayinga" (see Mayinga N'Seka ). As the Ebola virus epidemic in West Africa developed in 2014, a number of popular self-published and well-reviewed books containing sensational and misleading information about the disease appeared in electronic and printed formats. The authors of some such books admitted that they lacked medical credentials and were not technically qualified to give medical advice. The World Health Organization and the United Nations stated that such misinformation had contributed to the spread of the disease. Ebola has a high mortality rate among primates. Frequent outbreaks of Ebola may have resulted in the deaths of 5,000 gorillas. Outbreaks of Ebola may have been responsible for an 88% decline in tracking indices of observed chimpanzee populations in the 420 km 2 Lossi Sanctuary between 2002 and 2003. Transmission among chimpanzees through meat consumption constitutes a significant risk factor, whereas contact between the animals, such as touching dead bodies and grooming, is not. Recovered gorilla carcasses have contained multiple Ebola virus strains, suggesting multiple introductions of the virus. Bodies decompose quickly and carcasses are not infectious after three to four days. Contact between gorilla groups is rare, suggesting that transmission among gorilla groups is unlikely, and that outbreaks result from transmission between viral reservoirs and animal populations. In 2012, it was demonstrated that the virus can travel without contact from pigs to nonhuman primates, although the same study failed to achieve transmission in that manner between primates. Dogs may become infected with EBOV but not develop symptoms. Dogs in some parts of Africa scavenge for food, and they sometimes eat EBOV-infected animals and also the corpses of humans. A 2005 survey of dogs during an EBOV outbreak found that although they remain asymptomatic, about 32 percent of dogs closest to an outbreak showed a seroprevalence for EBOV versus nine percent of those farther away. The authors concluded that there were "potential implications for preventing and controlling human outbreaks." In late 1989, Hazelton Research Products' Reston Quarantine Unit in Reston, Virginia , had an outbreak of fatal illness amongst certain lab monkeys. This lab outbreak was initially diagnosed as simian haemorrhagic fever virus (SHFV) and occurred amongst a shipment of crab-eating macaque monkeys imported from the Philippines. Hazelton's veterinary pathologist in Reston sent tissue samples from dead animals to the United States Army Medical Research Institute of Infectious Diseases (USAMRIID) at Fort Detrick, Maryland , where an ELISA test indicated the antibodies present in the tissue were a response to Ebola virus and not SHFV. An electron microscopist from USAMRIID discovered filoviruses similar in appearance, in crystalloid aggregates and as single filaments with a shepherd's hook, to Ebola in the tissue samples sent from Hazelton Research Products' Reston Quarantine Unit. A US Army team headquartered at USAMRIID euthanised the surviving monkeys, and brought all the dead monkeys to Fort Detrick for study by the Army's veterinary pathologists and virologists, and eventual disposal under safe conditions. Blood samples were taken from 178 animal handlers during the incident. Of those, six animal handlers eventually seroconverted , including one who had cut himself with a bloody scalpel. Despite its status as a Level‑4 organism and its apparent pathogenicity in monkeys, when the handlers did not become ill, the CDC concluded that the virus had a very low pathogenicity to humans. The Philippines and the United States had no previous cases of Ebola infection, and upon further isolation, researchers concluded it was another strain of Ebola, or a new filovirus of Asian origin, which they named Reston ebolavirus (RESTV) after the location of the incident. Reston virus (RESTV) can be transmitted to pigs. Since the initial outbreak it has since been found in nonhuman primates in Pennsylvania, Texas, and Italy, where the virus had infected pigs. According to the WHO, routine cleaning and disinfection of pig (or monkey) farms with sodium hypochlorite or detergents should be effective in inactivating the Reston ebolavirus . Pigs that have been infected with RESTV tend to show symptoms of the disease. Ebola has a high mortality rate among primates. Frequent outbreaks of Ebola may have resulted in the deaths of 5,000 gorillas. Outbreaks of Ebola may have been responsible for an 88% decline in tracking indices of observed chimpanzee populations in the 420 km 2 Lossi Sanctuary between 2002 and 2003. Transmission among chimpanzees through meat consumption constitutes a significant risk factor, whereas contact between the animals, such as touching dead bodies and grooming, is not. Recovered gorilla carcasses have contained multiple Ebola virus strains, suggesting multiple introductions of the virus. Bodies decompose quickly and carcasses are not infectious after three to four days. Contact between gorilla groups is rare, suggesting that transmission among gorilla groups is unlikely, and that outbreaks result from transmission between viral reservoirs and animal populations. In 2012, it was demonstrated that the virus can travel without contact from pigs to nonhuman primates, although the same study failed to achieve transmission in that manner between primates. Dogs may become infected with EBOV but not develop symptoms. Dogs in some parts of Africa scavenge for food, and they sometimes eat EBOV-infected animals and also the corpses of humans. A 2005 survey of dogs during an EBOV outbreak found that although they remain asymptomatic, about 32 percent of dogs closest to an outbreak showed a seroprevalence for EBOV versus nine percent of those farther away. The authors concluded that there were "potential implications for preventing and controlling human outbreaks."In late 1989, Hazelton Research Products' Reston Quarantine Unit in Reston, Virginia , had an outbreak of fatal illness amongst certain lab monkeys. This lab outbreak was initially diagnosed as simian haemorrhagic fever virus (SHFV) and occurred amongst a shipment of crab-eating macaque monkeys imported from the Philippines. Hazelton's veterinary pathologist in Reston sent tissue samples from dead animals to the United States Army Medical Research Institute of Infectious Diseases (USAMRIID) at Fort Detrick, Maryland , where an ELISA test indicated the antibodies present in the tissue were a response to Ebola virus and not SHFV. An electron microscopist from USAMRIID discovered filoviruses similar in appearance, in crystalloid aggregates and as single filaments with a shepherd's hook, to Ebola in the tissue samples sent from Hazelton Research Products' Reston Quarantine Unit. A US Army team headquartered at USAMRIID euthanised the surviving monkeys, and brought all the dead monkeys to Fort Detrick for study by the Army's veterinary pathologists and virologists, and eventual disposal under safe conditions. Blood samples were taken from 178 animal handlers during the incident. Of those, six animal handlers eventually seroconverted , including one who had cut himself with a bloody scalpel. Despite its status as a Level‑4 organism and its apparent pathogenicity in monkeys, when the handlers did not become ill, the CDC concluded that the virus had a very low pathogenicity to humans. The Philippines and the United States had no previous cases of Ebola infection, and upon further isolation, researchers concluded it was another strain of Ebola, or a new filovirus of Asian origin, which they named Reston ebolavirus (RESTV) after the location of the incident. Reston virus (RESTV) can be transmitted to pigs. Since the initial outbreak it has since been found in nonhuman primates in Pennsylvania, Texas, and Italy, where the virus had infected pigs. According to the WHO, routine cleaning and disinfection of pig (or monkey) farms with sodium hypochlorite or detergents should be effective in inactivating the Reston ebolavirus . Pigs that have been infected with RESTV tend to show symptoms of the disease. As of July 2015 [ update ] , no medication has been proven safe and effective for treating Ebola. By the time the Ebola virus epidemic in West Africa began in 2013, there were at least nine different candidate treatments. Several trials were conducted in late 2014, and early 2015, but some were abandoned due to lack of efficacy or lack of people to study. As of August 2019 [ update ] , two experimental treatments known as atoltivimab/maftivimab/odesivimab and ansuvimab were found to be 90% effective. The diagnostic tests currently available require specialised equipment and highly trained personnel. Since there are few suitable testing centres in West Africa, this leads to delay in diagnosis. On 29 November 2014, a new 15-minute Ebola test was reported that if successful, "not only gives patients a better chance of survival, but it prevents transmission of the virus to other people." The new equipment, about the size of a laptop and solar-powered, allows testing to be done in remote areas. On 29 December 2014, the U.S. Food and Drug Administration (FDA) approved the LightMix Ebola Zaire rRT-PCR test for patients with symptoms of Ebola. Animal models and in particular non-human primates are being used to study different aspects of Ebola virus disease. Developments in organ-on-a-chip technology have led to a chip-based model for Ebola haemorrhagic syndrome. As of July 2015 [ update ] , no medication has been proven safe and effective for treating Ebola. By the time the Ebola virus epidemic in West Africa began in 2013, there were at least nine different candidate treatments. Several trials were conducted in late 2014, and early 2015, but some were abandoned due to lack of efficacy or lack of people to study. As of August 2019 [ update ] , two experimental treatments known as atoltivimab/maftivimab/odesivimab and ansuvimab were found to be 90% effective. The diagnostic tests currently available require specialised equipment and highly trained personnel. Since there are few suitable testing centres in West Africa, this leads to delay in diagnosis. On 29 November 2014, a new 15-minute Ebola test was reported that if successful, "not only gives patients a better chance of survival, but it prevents transmission of the virus to other people." The new equipment, about the size of a laptop and solar-powered, allows testing to be done in remote areas. On 29 December 2014, the U.S. Food and Drug Administration (FDA) approved the LightMix Ebola Zaire rRT-PCR test for patients with symptoms of Ebola. Animal models and in particular non-human primates are being used to study different aspects of Ebola virus disease. Developments in organ-on-a-chip technology have led to a chip-based model for Ebola haemorrhagic syndrome.

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Effects of climate change on human health

The effects of climate change on human health are increasingly well studied and quantified. Rising temperatures and changes in weather patterns are increasing the severity of heat waves , extreme weather and other causes of illness, injury or death. Heat waves and extreme weather events have a big impact on health both directly and indirectly. When people are exposed to higher temperatures for longer time periods they might experience heat illness and heat-related death . In addition to direct impacts, climate change and extreme weather events cause changes in the biosphere . Certain diseases that are carried by vectors or spread by climate-sensitive pathogens may become more common in some regions. Examples include mosquito-borne diseases such as dengue fever , and waterborne diseases such as diarrhoeal disease . Climate change will impact where infectious diseases are able to spread in the future. Many infectious diseases will spread to new geographic areas where people have not previously been exposed to them. Changes in climate can cause decreasing yields for some crops and regions, resulting in higher food prices , food insecurity , and undernutrition . Climate change can also reduce water security . These factors together can lead to increasing poverty, human migration , violent conflict, and mental health issues. Climate change affects human health at all ages, from infancy through adolescence, adulthood and old age. Factors such as age, gender and socioeconomic status influence to what extent these effects become wide-spread risks to human health. : 1867 Extreme weather creates climate hazards for whole families, particularly those headed by women. It can also reduce the earning capacity and economic stability of people. Populations over 65 years of age are particularly vulnerable to heat and other health effects of climate change. Health risks are unevenly distributed across the world. Disadvantaged people are particularly vulnerable to climate change . : 15 The health effects of climate change are increasingly a matter of concern for the international public health policy community. In 2009, a publication in the general medical journal The Lancet stated that "Climate change is the biggest global health threat of the 21st century". The World Health Organization reiterated this in 2015. Research shows that health professionals around the world agree that climate change is real, is caused by humans, and is causing increased health problems in their communities. Studies also show that taking action to address climate change improves public health. Health professionals can act by informing people about health harms and ways to address them, by lobbying leaders to take action, and by taking steps to decarbonize their own homes and workplaces. Studies have found that communications on climate change that present it as a health concern rather than just an environmental matter are more likely to engage the public. The effects of climate change on human health can be grouped into direct and indirect effects. : 1867 Both types of effects interact with social dynamics. The combination of effects and social dynamics determines the eventual health outcomes. Mechanisms and social dynamics are explained further below: These health risks vary across the world and between different groups of people. For example, differences in health service provision or economic development will result in different health risks for people in different regions, with less developed countries facing greater health risks. In many places, the combination of lower socioeconomic status and cultural gender roles result in increased health risks to women and girls as a result of climate change, compared to those faced by men and boys (although the converse may apply in other instances). The following health effects that are related to climate change have been identified: cardiovascular diseases , respiratory diseases , infectious diseases , undernutrition , mental illness , allergies , injuries and poisoning . : Figure 2 Health and health care provision can also be impacted by the collapse of health systems and damage to infrastructure due to climate-induced events such as flooding. Therefore, building health systems that are climate resilient is a priority. : 15Impact of higher global temperatures will have ramifications for the following aspects: vulnerability to extremes of heat, exposure of vulnerable populations to heatwaves , heat and physical activity, change in labor capacity, heat and sentiment (mental health), heat-related mortality. The global average and combined land and ocean surface temperature show a warming of 1.09 °C (range: 0.95 to 1.20 °C) from 1850–1900 to 2011–2020, based on multiple independently produced datasets. The trend is faster since the 1970s than in any other 50-year period over at least the last 2000 years. A 2023 study estimated that climate change since 1960–1990 has put over 600 million people (9% of the global population) outside the "temperature niche" - the average temperature range at which humans flourish. A 2020 study projects that regions inhabited by a third of the human population could become as hot as the hottest parts of the Sahara within 50 years without a change in patterns of population growth and without migration , unless greenhouse gas emissions are reduced . The projected annual average temperature of above 29 °C for these regions would be outside the "human temperature niche" – a suggested range for climate biologically suitable for humans based on historical data of mean annual temperatures (MAT) – and the most affected regions have little adaptive capacity as of 2020. The UK Met Office came to similar conclusions, reporting that the "numbers of people in regions across the world affected by extreme heat stress – a potentially fatal combination of heat and humidity – could increase" "from 68 million today to around one billion" if the world's temperature rise reaches 2°C, albeit it is unclear if that limit or the 1.5 °C goal of the Paris Agreement is achieved. Vulnerable people with regard to heat illnesses include people with low incomes, minority groups, women (in particular pregnant women), children, older adults (over 65 years old), people with chronic diseases, disabilities and co-morbidities . : 13 Other people at risk include those in urban environments (due to the urban heat island effect ), outdoor workers and people who take certain prescription drugs . Exposure to extreme heat poses an acute health hazard for many of the people deemed as vulnerable. Climate change increases the frequency and severity of heatwaves and thus heat stress for people. Human responses to heat stress can include heat stroke and hyperthermia . Extreme heat is also linked to low quality sleep , acute kidney injury and complications with pregnancy . Furthermore, it may cause the deterioration of pre-existing cardiovascular and respiratory disease . : 1624 Adverse pregnancy outcomes due to high ambient temperatures include for example low birth weight and pre-term birth . : 1051 Heat waves have also resulted in epidemics of chronic kidney disease (CKD). Prolonged heat exposure, physical exertion, and dehydration are sufficient factors for the development of CKD. The human body requires evaporative cooling to prevent overheating, even with a low activity level. With excessive ambient heat and humidity during heatwaves , adequate evaporative cooling might be compromised. A wet-bulb temperature that is too high means that human bodies would no longer be able to adequately cool the skin. A wet bulb temperature of 35 °C is regarded as the limit for humans (called the "physiological threshold for human adaptability" to heat and humidity). : 1498 As of 2020, only two weather stations had recorded 35 °C wet-bulb temperatures, and only very briefly, but the frequency and duration of these events is expected to rise with ongoing climate change. Global warming above 1.5 degrees risks making parts of the tropics uninhabitable because the threshold for the wet bulb temperature may be passed. Further study found that even a wet bulb temperature of 31 degrees is dangerous, even for young and healthy people. This threshold is not uniform for all and depend on many factors including environmental factors, activity and age. If the global temperature will rise by 3 degrees (the most likely scenario if things will not change), temperatures will exceed this limit at large areas in Pakistan, India, China, Sub Saharan Africa, United States, Australia, South America. People with cognitive health issues (e.g. depression , dementia , Parkinson's disease ) are more at risk when faced with high temperatures and ought to be extra careful as cognitive performance has been shown to be differentially affected by heat. People with diabetes and those who are overweight, have sleep deprivation, or have cardiovascular/cerebrovascular conditions should avoid too much heat exposure. The risk of dying from chronic lung disease during a heat wave has been estimated at 1.8-8.2% higher compared to average summer temperatures. An 8% increase in hospitalization rate for people with Chronic Obstructive Pulmunary Disease has been estimated for every 1 °C increase in temperatures above 29 °C. The effects of heatwaves tend to be more pronounced in urban areas because they are typically warmer than surrounding rural areas due to the urban heat island effect. : 2926 This is caused from the way many cities are built. For example, they often have extensive areas of asphalt, reduced greenery along with many large heat-retaining buildings that physically block cooling breezes and ventilation. Lack of water features are another cause. : 2926 Extreme heat exposure in cities with a wet bulb globe temperature above 30 °C tripled between 1983 and 2016. It increased by about 50% when the population growth in these cities is not taken into account. Cities are often on the front-line of climate change due to their densely concentrated populations, the urban heat island effect, their frequent proximity to coasts and waterways, and reliance on ageing physical infrastructure networks. Health experts warn that "exposure to extreme heat increases the risk of death from cardiovascular , cerebrovascular , and respiratory conditions and all-cause mortality. Heat-related deaths in people older than 65 years reached a record high of an estimated 345 000 deaths in 2019". : 9 More than 70,000 Europeans died as a result of the 2003 European heat wave . Also more than 2,000 people died in Karachi , Pakistan in June 2015 due to a severe heat wave with temperatures as high as 49 °C (120 °F) . Increasing access to indoor cooling ( air conditioning ) will help prevent heat-related mortality but current air conditioning technology is generally unsustainable as it contributes to greenhouse gas emissions , air pollution , peak electricity demand , and urban heat islands. : 17 Mortality due to heat waves could be reduced if buildings were better designed to modify the internal climate, or if the occupants were better educated about the issues, so they can take action on time. Heatwave early warning and response systems are important elements of heat action plans. Heat exposure can affect people's ability to work. : 8 The annual Countdown Report by The Lancet investigated change in labour capacity as an indicator. It found that during 2021, high temperature reduced global potential labour hours by 470 billion - a 37% increase compared to the average annual loss that occurred during the 1990s. Occupational heat exposure especially affects laborers in the agricultural sector of developing countries . In those countries, the vast majority of these labour hour losses (87%) were in the agricultural sector. : 1625 Working in extreme heat can lead to labor force productivity decreases as well as participation because employees' health may be weaker due to heat related health problems, such as dehydration, fatigue, dizziness, and confusion. : 1073–1074 With regards to sporting activities, it has been observed that "hot weather reduces the likelihood of engaging in exercise". : 1625 Furthermore, participating in sports during excessive heat can lead to injury or even death. : 1073–1074 It is also well established that regular physical activity is beneficial for human health, including mental health. : 1625 Therefore, an increase in hot days due to climate change could indirectly affect health due to people exercising less.Vulnerable people with regard to heat illnesses include people with low incomes, minority groups, women (in particular pregnant women), children, older adults (over 65 years old), people with chronic diseases, disabilities and co-morbidities . : 13 Other people at risk include those in urban environments (due to the urban heat island effect ), outdoor workers and people who take certain prescription drugs . Exposure to extreme heat poses an acute health hazard for many of the people deemed as vulnerable. Climate change increases the frequency and severity of heatwaves and thus heat stress for people. Human responses to heat stress can include heat stroke and hyperthermia . Extreme heat is also linked to low quality sleep , acute kidney injury and complications with pregnancy . Furthermore, it may cause the deterioration of pre-existing cardiovascular and respiratory disease . : 1624 Adverse pregnancy outcomes due to high ambient temperatures include for example low birth weight and pre-term birth . : 1051 Heat waves have also resulted in epidemics of chronic kidney disease (CKD). Prolonged heat exposure, physical exertion, and dehydration are sufficient factors for the development of CKD. The human body requires evaporative cooling to prevent overheating, even with a low activity level. With excessive ambient heat and humidity during heatwaves , adequate evaporative cooling might be compromised. A wet-bulb temperature that is too high means that human bodies would no longer be able to adequately cool the skin. A wet bulb temperature of 35 °C is regarded as the limit for humans (called the "physiological threshold for human adaptability" to heat and humidity). : 1498 As of 2020, only two weather stations had recorded 35 °C wet-bulb temperatures, and only very briefly, but the frequency and duration of these events is expected to rise with ongoing climate change. Global warming above 1.5 degrees risks making parts of the tropics uninhabitable because the threshold for the wet bulb temperature may be passed. Further study found that even a wet bulb temperature of 31 degrees is dangerous, even for young and healthy people. This threshold is not uniform for all and depend on many factors including environmental factors, activity and age. If the global temperature will rise by 3 degrees (the most likely scenario if things will not change), temperatures will exceed this limit at large areas in Pakistan, India, China, Sub Saharan Africa, United States, Australia, South America. People with cognitive health issues (e.g. depression , dementia , Parkinson's disease ) are more at risk when faced with high temperatures and ought to be extra careful as cognitive performance has been shown to be differentially affected by heat. People with diabetes and those who are overweight, have sleep deprivation, or have cardiovascular/cerebrovascular conditions should avoid too much heat exposure. The risk of dying from chronic lung disease during a heat wave has been estimated at 1.8-8.2% higher compared to average summer temperatures. An 8% increase in hospitalization rate for people with Chronic Obstructive Pulmunary Disease has been estimated for every 1 °C increase in temperatures above 29 °C. The effects of heatwaves tend to be more pronounced in urban areas because they are typically warmer than surrounding rural areas due to the urban heat island effect. : 2926 This is caused from the way many cities are built. For example, they often have extensive areas of asphalt, reduced greenery along with many large heat-retaining buildings that physically block cooling breezes and ventilation. Lack of water features are another cause. : 2926 Extreme heat exposure in cities with a wet bulb globe temperature above 30 °C tripled between 1983 and 2016. It increased by about 50% when the population growth in these cities is not taken into account. Cities are often on the front-line of climate change due to their densely concentrated populations, the urban heat island effect, their frequent proximity to coasts and waterways, and reliance on ageing physical infrastructure networks. The effects of heatwaves tend to be more pronounced in urban areas because they are typically warmer than surrounding rural areas due to the urban heat island effect. : 2926 This is caused from the way many cities are built. For example, they often have extensive areas of asphalt, reduced greenery along with many large heat-retaining buildings that physically block cooling breezes and ventilation. Lack of water features are another cause. : 2926 Extreme heat exposure in cities with a wet bulb globe temperature above 30 °C tripled between 1983 and 2016. It increased by about 50% when the population growth in these cities is not taken into account. Cities are often on the front-line of climate change due to their densely concentrated populations, the urban heat island effect, their frequent proximity to coasts and waterways, and reliance on ageing physical infrastructure networks. Health experts warn that "exposure to extreme heat increases the risk of death from cardiovascular , cerebrovascular , and respiratory conditions and all-cause mortality. Heat-related deaths in people older than 65 years reached a record high of an estimated 345 000 deaths in 2019". : 9 More than 70,000 Europeans died as a result of the 2003 European heat wave . Also more than 2,000 people died in Karachi , Pakistan in June 2015 due to a severe heat wave with temperatures as high as 49 °C (120 °F) . Increasing access to indoor cooling ( air conditioning ) will help prevent heat-related mortality but current air conditioning technology is generally unsustainable as it contributes to greenhouse gas emissions , air pollution , peak electricity demand , and urban heat islands. : 17 Mortality due to heat waves could be reduced if buildings were better designed to modify the internal climate, or if the occupants were better educated about the issues, so they can take action on time. Heatwave early warning and response systems are important elements of heat action plans.Heat exposure can affect people's ability to work. : 8 The annual Countdown Report by The Lancet investigated change in labour capacity as an indicator. It found that during 2021, high temperature reduced global potential labour hours by 470 billion - a 37% increase compared to the average annual loss that occurred during the 1990s. Occupational heat exposure especially affects laborers in the agricultural sector of developing countries . In those countries, the vast majority of these labour hour losses (87%) were in the agricultural sector. : 1625 Working in extreme heat can lead to labor force productivity decreases as well as participation because employees' health may be weaker due to heat related health problems, such as dehydration, fatigue, dizziness, and confusion. : 1073–1074With regards to sporting activities, it has been observed that "hot weather reduces the likelihood of engaging in exercise". : 1625 Furthermore, participating in sports during excessive heat can lead to injury or even death. : 1073–1074 It is also well established that regular physical activity is beneficial for human health, including mental health. : 1625 Therefore, an increase in hot days due to climate change could indirectly affect health due to people exercising less.Climate change is increasing the periodicity and intensity of some extreme weather events. Confidence in the attribution of extreme weather to anthropogenic climate change is highest in changes in frequency or magnitude of extreme heat and cold events with some confidence in increases in heavy precipitation and increases in the intensity of droughts. Extreme weather events, such as floods, hurricanes, droughts and wildfires can result in injuries, death and the spread of infectious diseases . For example, local epidemics can occur due to loss of infrastructure, such as hospitals and sanitation services, but also because of changes in local ecology and environment. Examples include:Global climate change has increased the occurrence of some infectious diseases . Infectious diseases whose transmission is impacted by climate change include, for example, vector-borne diseases like dengue fever , malaria , tick-borne diseases , leishmaniasis , zika fever , chikungunya and Ebola . One mechanism contributing to increased disease transmission is that climate change is altering the geographic range and seasonality of the insects (or disease vectors ) that can carry the diseases. Scientists stated a clear observation in 2022: "the occurrence of climate-related food-borne and waterborne diseases has increased (very high confidence)." : 11 Infectious diseases that are sensitive to climate can be grouped into: vector-borne diseases (transmitted via mosquitos , ticks etc.), waterborne diseases (transmitted via viruses or bacteria through water), and food-borne diseases. : 1107 Climate change is affecting the distribution of these diseases due to the expanding geographic range and seasonality of these diseases and their vectors. : 9 Like other ways in which climate change affects on human health, climate change exacerbates existing inequalities and challenges in managing infectious disease.Climate change affects many aspects of food security through "multiple and interconnected pathways". : 1619 Many of these are related to the effects of climate change on agriculture , for example failed crops due to more extreme weather events. This comes on top of other coexisting crises that reduce food security in many regions. Less food security means more undernutrition with all its associated health problems. Food insecurity is increasing at the global level (some of the underlying causes are related to climate change, others are not) and about 720–811 million people suffered from hunger in 2020. : 1629 The number of deaths resulting from climate change-induced changes to food availability are difficult to estimate. The 2022 IPCC Sixth Assessment Report does not quantify this number in its chapter on food security. A modelling study from 2016 found "a climate change–associated net increase of 529,000 adult deaths worldwide [...] from expected reductions in food availability (particularly fruit and vegetables) by 2050, as compared with a reference scenario without climate change." A headline finding in 2021 regarding marine food security stated that: "In 2018–20, nearly 70% of countries showed increases in average sea surface temperature in their territorial waters compared within 2003–05, reflecting an increasing threat to their marine food productivity and marine food security". : 14 (see also climate change and fisheries ). A warming climate can lead to increases of pollen season lengths and concentrations in some regions of the world. For example, in northern mid-latitudes regions, the spring pollen season is now starting earlier. : 1049 This can affect people with pollen allergies (hay fever). The rise in pollen also comes from rising CO 2 concentrations in the atmosphere and resulting CO 2 fertilisation effects . : 1096 The relationship between surface ozone (also called ground-level ozone ) and ambient temperature is complex. Changes in air temperature and water content affect the air's chemistry and the rates of chemical reactions that create and remove ozone. Many chemical reaction rates increase with temperature and lead to increased ozone production. Climate change projections show that rising temperatures and water vapour in the atmosphere will likely increase surface ozone in polluted areas like the eastern United States. On the other hand, ozone concentrations could decrease in a warming climate if anthropogenic ozone-precursor emissions (e.g., nitrogen oxides) continue to decrease through implementation of policies and practices. Therefore, future surface ozone concentrations depend on the climate change mitigation steps taken (more or less methane emissions) as well as air pollution control steps taken. : 884 High surface ozone concentrations often occur during heat waves in the United States. Throughout much of the eastern United States, ozone concentrations during heat waves are at least 20% higher than the summer average. Broadly speaking, surface ozone levels are higher in cities with high levels of air pollution. : 876 Ozone pollution in urban areas affects denser populations, and is worsened by high populations of vehicles, which emit pollutants NO 2 and VOCs , the main contributors to problematic ozone levels. There is a great deal of evidence to show that surface ozone can harm lung function and irritate the respiratory system . Exposure to ozone (and the pollutants that produce it) is linked to premature death , asthma , bronchitis , heart attack , and other cardiopulmonary problems. High ozone concentrations irritate the lungs and thus affect respiratory function, especially among people with asthma. People who are most at risk from breathing in ozone air pollution are those with respiratory issues, children, older adults and those who typically spend long periods of time outside such as construction workers. The warming oceans and lakes are leading to more frequent harmful algal blooms . Also, during droughts, surface waters are even more susceptible to harmful algal blooms and microorganisms. Algal blooms increase water turbidity, suffocating aquatic plants, and can deplete oxygen, killing fish. Some kinds of blue-green algae (cyanobacteria) create neurotoxins , hepatoxins, cytotoxins or endotoxins that can cause serious and sometimes fatal neurological, liver and digestive diseases in humans. Cyanobacteria grow best in warmer temperatures (especially above 25 degrees Celsius), and so areas of the world that are experiencing general warming as a result of climate change are also experiencing harmful algal blooms more frequently and for longer periods of time. One of these toxin producing algae is Pseudo-nitzschia fraudulenta. This species produces a substance called domoic acid which is responsible for amnesic shellfish poisoning . The toxicity of this species has been shown to increase with greater CO 2 concentrations associated with ocean acidification. Some of the more common illnesses reported from harmful algal blooms include; Ciguatera fish poisoning , paralytic shellfish poisoning , azaspiracid shellfish poisoning, diarrhetic shellfish poisoning , neurotoxic shellfish poisoning and the above-mentioned amnesic shellfish poisoning. Climate change affects many aspects of food security through "multiple and interconnected pathways". : 1619 Many of these are related to the effects of climate change on agriculture , for example failed crops due to more extreme weather events. This comes on top of other coexisting crises that reduce food security in many regions. Less food security means more undernutrition with all its associated health problems. Food insecurity is increasing at the global level (some of the underlying causes are related to climate change, others are not) and about 720–811 million people suffered from hunger in 2020. : 1629 The number of deaths resulting from climate change-induced changes to food availability are difficult to estimate. The 2022 IPCC Sixth Assessment Report does not quantify this number in its chapter on food security. A modelling study from 2016 found "a climate change–associated net increase of 529,000 adult deaths worldwide [...] from expected reductions in food availability (particularly fruit and vegetables) by 2050, as compared with a reference scenario without climate change." A headline finding in 2021 regarding marine food security stated that: "In 2018–20, nearly 70% of countries showed increases in average sea surface temperature in their territorial waters compared within 2003–05, reflecting an increasing threat to their marine food productivity and marine food security". : 14 (see also climate change and fisheries ).A warming climate can lead to increases of pollen season lengths and concentrations in some regions of the world. For example, in northern mid-latitudes regions, the spring pollen season is now starting earlier. : 1049 This can affect people with pollen allergies (hay fever). The rise in pollen also comes from rising CO 2 concentrations in the atmosphere and resulting CO 2 fertilisation effects . : 1096The relationship between surface ozone (also called ground-level ozone ) and ambient temperature is complex. Changes in air temperature and water content affect the air's chemistry and the rates of chemical reactions that create and remove ozone. Many chemical reaction rates increase with temperature and lead to increased ozone production. Climate change projections show that rising temperatures and water vapour in the atmosphere will likely increase surface ozone in polluted areas like the eastern United States. On the other hand, ozone concentrations could decrease in a warming climate if anthropogenic ozone-precursor emissions (e.g., nitrogen oxides) continue to decrease through implementation of policies and practices. Therefore, future surface ozone concentrations depend on the climate change mitigation steps taken (more or less methane emissions) as well as air pollution control steps taken. : 884 High surface ozone concentrations often occur during heat waves in the United States. Throughout much of the eastern United States, ozone concentrations during heat waves are at least 20% higher than the summer average. Broadly speaking, surface ozone levels are higher in cities with high levels of air pollution. : 876 Ozone pollution in urban areas affects denser populations, and is worsened by high populations of vehicles, which emit pollutants NO 2 and VOCs , the main contributors to problematic ozone levels. There is a great deal of evidence to show that surface ozone can harm lung function and irritate the respiratory system . Exposure to ozone (and the pollutants that produce it) is linked to premature death , asthma , bronchitis , heart attack , and other cardiopulmonary problems. High ozone concentrations irritate the lungs and thus affect respiratory function, especially among people with asthma. People who are most at risk from breathing in ozone air pollution are those with respiratory issues, children, older adults and those who typically spend long periods of time outside such as construction workers. The warming oceans and lakes are leading to more frequent harmful algal blooms . Also, during droughts, surface waters are even more susceptible to harmful algal blooms and microorganisms. Algal blooms increase water turbidity, suffocating aquatic plants, and can deplete oxygen, killing fish. Some kinds of blue-green algae (cyanobacteria) create neurotoxins , hepatoxins, cytotoxins or endotoxins that can cause serious and sometimes fatal neurological, liver and digestive diseases in humans. Cyanobacteria grow best in warmer temperatures (especially above 25 degrees Celsius), and so areas of the world that are experiencing general warming as a result of climate change are also experiencing harmful algal blooms more frequently and for longer periods of time. One of these toxin producing algae is Pseudo-nitzschia fraudulenta. This species produces a substance called domoic acid which is responsible for amnesic shellfish poisoning . The toxicity of this species has been shown to increase with greater CO 2 concentrations associated with ocean acidification. Some of the more common illnesses reported from harmful algal blooms include; Ciguatera fish poisoning , paralytic shellfish poisoning , azaspiracid shellfish poisoning, diarrhetic shellfish poisoning , neurotoxic shellfish poisoning and the above-mentioned amnesic shellfish poisoning. It is possible that a potential health benefit from global warming could result from fewer cold days in winter: : 1099 This could lead to some mental health benefits. However, the evidence on this correlation is regarded as inconsistent in 2022. : 1099 The potential health benefits (also called "co-benefits") from climate change mitigation and adaptation measures are significant, having been described as "the greatest global health opportunity" of the 21st century. : 1861 Measures can not only mitigate future health effects from climate change but also improve health directly. Climate change mitigation is interconnected with various co-benefits (such as reduced air pollution and associated health benefits) and how it is carried out (in terms of e.g. policymaking) could also determine its effect on living standards (whether and how inequality and poverty are reduced). There are many health co-benefits associated with climate action. These include those of cleaner air, healthier diets (e.g. less red meat), more active lifestyles , and increased exposure to green urban spaces. : 26 Access to urban green spaces provides benefits to mental health as well. : 18 Biking reduces greenhouse gas emissions while reducing the effects of a sedentary lifestyle at the same time According to PLoS Medicine : "obesity, diabetes, heart disease, and cancer, which are in part related to physical inactivity, may be reduced by a switch to low-carbon transport—including walking and cycling." Compared with the current pathways scenario (with regards to greenhouse gas emissions and mitigation efforts), the sustainable pathways scenario will likely result in an annual reduction of 1.18 million air pollution-related deaths, 5.86 million diet-related deaths, and 1.15 million deaths due to physical inactivity, across the nine countries, by 2040. These benefits were attributable to the mitigation of direct greenhouse gas emissions and the commensurate actions that reduce exposure to harmful pollutants, as well as improved diets and safe physical activity. Air pollution generated by fossil fuel combustion is both a major driver of global warming and the cause of a large number of annual deaths with some estimates as high as 8.7 million excess deaths during 2018. Climate change mitigation policies can lead to lower emissions of co-emitted air pollutants, for instance by shifting away from fossil fuel combustion. Gases such as black carbon and methane contribute both to global warming and to air pollution. Their mitigation can bring benefits in terms of limiting global temperature increases as well as improving air quality. Implementation of the climate pledges made in the run-up to the Paris Agreement could therefore have significant benefits for human health by improving air quality. The replacement of coal-based energy with renewables can lower the number of premature deaths caused by air pollution. A higher share of renewable energy and consequently less coal-related respiratory diseases can decrease health costs. The potential health benefits (also called "co-benefits") from climate change mitigation and adaptation measures are significant, having been described as "the greatest global health opportunity" of the 21st century. : 1861 Measures can not only mitigate future health effects from climate change but also improve health directly. Climate change mitigation is interconnected with various co-benefits (such as reduced air pollution and associated health benefits) and how it is carried out (in terms of e.g. policymaking) could also determine its effect on living standards (whether and how inequality and poverty are reduced). There are many health co-benefits associated with climate action. These include those of cleaner air, healthier diets (e.g. less red meat), more active lifestyles , and increased exposure to green urban spaces. : 26 Access to urban green spaces provides benefits to mental health as well. : 18 Biking reduces greenhouse gas emissions while reducing the effects of a sedentary lifestyle at the same time According to PLoS Medicine : "obesity, diabetes, heart disease, and cancer, which are in part related to physical inactivity, may be reduced by a switch to low-carbon transport—including walking and cycling." Compared with the current pathways scenario (with regards to greenhouse gas emissions and mitigation efforts), the sustainable pathways scenario will likely result in an annual reduction of 1.18 million air pollution-related deaths, 5.86 million diet-related deaths, and 1.15 million deaths due to physical inactivity, across the nine countries, by 2040. These benefits were attributable to the mitigation of direct greenhouse gas emissions and the commensurate actions that reduce exposure to harmful pollutants, as well as improved diets and safe physical activity. Air pollution generated by fossil fuel combustion is both a major driver of global warming and the cause of a large number of annual deaths with some estimates as high as 8.7 million excess deaths during 2018. Climate change mitigation policies can lead to lower emissions of co-emitted air pollutants, for instance by shifting away from fossil fuel combustion. Gases such as black carbon and methane contribute both to global warming and to air pollution. Their mitigation can bring benefits in terms of limiting global temperature increases as well as improving air quality. Implementation of the climate pledges made in the run-up to the Paris Agreement could therefore have significant benefits for human health by improving air quality. The replacement of coal-based energy with renewables can lower the number of premature deaths caused by air pollution. A higher share of renewable energy and consequently less coal-related respiratory diseases can decrease health costs. Air pollution generated by fossil fuel combustion is both a major driver of global warming and the cause of a large number of annual deaths with some estimates as high as 8.7 million excess deaths during 2018. Climate change mitigation policies can lead to lower emissions of co-emitted air pollutants, for instance by shifting away from fossil fuel combustion. Gases such as black carbon and methane contribute both to global warming and to air pollution. Their mitigation can bring benefits in terms of limiting global temperature increases as well as improving air quality. Implementation of the climate pledges made in the run-up to the Paris Agreement could therefore have significant benefits for human health by improving air quality. The replacement of coal-based energy with renewables can lower the number of premature deaths caused by air pollution. A higher share of renewable energy and consequently less coal-related respiratory diseases can decrease health costs. Estimating deaths ( mortality ) or DALYs ( morbidity ) from the effects of climate change at the global level is very difficult. A 2014 study by the World Health Organization estimated the effect of climate change on human health, but not all of the effects of climate change were included. For example, the effects of more frequent and extreme storms were excluded. The study assessed deaths from heat exposure in elderly people, increases in diarrhea , malaria, dengue, coastal flooding , and childhood undernutrition. The authors estimated that climate change was projected to cause an additional 250,000 deaths per year between 2030 and 2050 but also stated that "these numbers do not represent a prediction of the overall impacts of climate change on health, since we could not quantify several important causal pathways". Climate change was responsible for 3% of diarrhoea , 3% of malaria , and 3.8% of dengue fever deaths worldwide in 2004. Total attributable mortality was about 0.2% of deaths in 2004; of these, 85% were child deaths. The effects of more frequent and extreme storms were excluded from this study. The health effects of climate change are expected to rise in line with projected ongoing global warming for different climate change scenarios . A review found if warming reaches or exceeds 2 °C this century, roughly 1 billion premature deaths would be caused by anthropogenic global warming. A 2021 report published in The Lancet found that climate change does not affect people's health in an equal way. The greatest impact tends to fall on the most vulnerable such as the poor, women, children, the elderly, people with pre-existing health concerns, other minorities and outdoor workers. : 13 The social vulnerability of people is related to certain health patterns. For example there are "demographic, socioeconomic, housing, health (such as pre-existing health conditions), neighbourhood, and geographical factors". Much of the health burden associated with climate change falls on vulnerable people (e.g. indigenous peoples and economically disadvantaged communities). As a result, people of disadvantaged sociodemographic groups experience unequal risks. Often these people will have made a disproportionately low contribution toward man-made global warming, thus leading to concerns over climate justice . Climate change has diverse effects on migration activities, and can lead to decreases or increases in the number of people who migrate. : 1079 Migration activities can have an effect on health and well-being, in particular for mental health . Migration in the context of climate change can be grouped into four types: adaptive migration (see also climate change adaptation ), involuntary migration, organised relocation of populations, and immobility (which is when people are unable or unwilling to move even though it is recommended). : 1079 The observed contribution of climate change to conflict risk is small in comparison with cultural, socioeconomic, and political causes. There is some evidence that rural-to-urban migration within countries worsens the conflict risk in violence prone regions. But there is no evidence that migration between countries would increase the risk of violence. : 1008, 1128 Studies have found that when communicating climate change with the public , it can help encourage engagement if it is framed as a health concern, rather than as an environmental issue. This is especially the case when comparing a health related framing to one that emphasised environmental doom, as was common in the media at least up until 2017. Communicating the co-benefits to health helps underpin greenhouse gas reduction strategies . Safeguarding health—particularly of the most vulnerable—is a frontline local climate change adaptation goal. In 2019, the Australian Medical Association formally declared climate change as a health emergency . Due to its significant impact on human health, climate change has become a major concern for public health policy . The United States Environmental Protection Agency had issued a 100-page report on global warming and human health back in 1989. By the early years of the 21st century, climate change was increasingly addressed as a public health concern at a global level, for example in 2006 at Nairobi by UN secretary general Kofi Annan . Since 2018, factors such as the 2018 heat wave , the Greta effect and the IPCC's 2018 Special Report on Global Warming of 1.5 °C further increased the urgency for responding to climate change as a global health issue. The World Bank has suggested a framework that can strengthen health systems to make them more resilient and climate-sensitive . Placing health as a key focus of the Nationally Determined Contributions could present an opportunity to increase ambition and realize health co-benefits. A 2021 report published in The Lancet found that climate change does not affect people's health in an equal way. The greatest impact tends to fall on the most vulnerable such as the poor, women, children, the elderly, people with pre-existing health concerns, other minorities and outdoor workers. : 13 The social vulnerability of people is related to certain health patterns. For example there are "demographic, socioeconomic, housing, health (such as pre-existing health conditions), neighbourhood, and geographical factors". Much of the health burden associated with climate change falls on vulnerable people (e.g. indigenous peoples and economically disadvantaged communities). As a result, people of disadvantaged sociodemographic groups experience unequal risks. Often these people will have made a disproportionately low contribution toward man-made global warming, thus leading to concerns over climate justice . Climate change has diverse effects on migration activities, and can lead to decreases or increases in the number of people who migrate. : 1079 Migration activities can have an effect on health and well-being, in particular for mental health . Migration in the context of climate change can be grouped into four types: adaptive migration (see also climate change adaptation ), involuntary migration, organised relocation of populations, and immobility (which is when people are unable or unwilling to move even though it is recommended). : 1079 The observed contribution of climate change to conflict risk is small in comparison with cultural, socioeconomic, and political causes. There is some evidence that rural-to-urban migration within countries worsens the conflict risk in violence prone regions. But there is no evidence that migration between countries would increase the risk of violence. : 1008, 1128Studies have found that when communicating climate change with the public , it can help encourage engagement if it is framed as a health concern, rather than as an environmental issue. This is especially the case when comparing a health related framing to one that emphasised environmental doom, as was common in the media at least up until 2017. Communicating the co-benefits to health helps underpin greenhouse gas reduction strategies . Safeguarding health—particularly of the most vulnerable—is a frontline local climate change adaptation goal. In 2019, the Australian Medical Association formally declared climate change as a health emergency . Due to its significant impact on human health, climate change has become a major concern for public health policy . The United States Environmental Protection Agency had issued a 100-page report on global warming and human health back in 1989. By the early years of the 21st century, climate change was increasingly addressed as a public health concern at a global level, for example in 2006 at Nairobi by UN secretary general Kofi Annan . Since 2018, factors such as the 2018 heat wave , the Greta effect and the IPCC's 2018 Special Report on Global Warming of 1.5 °C further increased the urgency for responding to climate change as a global health issue. The World Bank has suggested a framework that can strengthen health systems to make them more resilient and climate-sensitive . Placing health as a key focus of the Nationally Determined Contributions could present an opportunity to increase ambition and realize health co-benefits.

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Dengue fever

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Incubation period

Incubation period (also known as the latent period or latency period ) is the time elapsed between exposure to a pathogenic organism, a chemical, or radiation , and when symptoms and signs are first apparent. In a typical infectious disease, the incubation period signifies the period taken by the multiplying organism to reach a threshold necessary to produce symptoms in the host. While latent or latency period may be synonymous, a distinction is sometimes made whereby the latent period is defined as the time from infection to infectiousness. Which period is shorter depends on the disease. A person may carry a disease, such as Streptococcus in the throat, without exhibiting any symptoms. Depending on the disease, the person may or may not be contagious during the incubation period. During latency, an infection is subclinical . With respect to viral infections , in incubation the virus is replicating. This is in contrast to viral latency , a form of dormancy in which the virus does not replicate. An example of latency is HIV infection. HIV may at first have no symptoms and show no signs of AIDS , despite HIV replicating in the lymphatic system and rapidly accumulating a large viral load . People with HIV in this stage may be infectious .The terms "intrinsic incubation period" and "extrinsic incubation period" are used in vector-borne diseases . The intrinsic incubation period is the time taken by an organism to complete its development in the definitive host . The extrinsic incubation period is the time taken by an organism to develop in the intermediate host . [ citation needed ] For example, once ingested by a mosquito, malaria parasites must undergo development within the mosquito before they are infectious to humans. The time required for development in the mosquito ranges from 10 to 28 days, depending on the parasite species and the temperature. This is the extrinsic incubation period of that parasite. If a female mosquito does not survive longer than the extrinsic incubation period, then she will not be able to transmit any malaria parasites. [ citation needed ] But if a mosquito successfully transfers the parasite to a human body via a bite, the parasite starts developing. The time between the injection of the parasite into the human and the development of the first symptoms of malaria is its intrinsic incubation period. The specific incubation period for a disease process is the result of multiple factors, including: [ citation needed ] Dose or inoculum of an infectious agent Route of inoculation Rate of replication of infectious agent Host susceptibility Immune responseDue to inter-individual variation, the incubation period is always expressed as a range. When possible, it is best to express the mean and the 10th and 90th percentiles, though this information is not always available. For many conditions, incubation periods are longer in adults than they are in children or infants.

Wiki

Dengue fever

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Hematocrit

The hematocrit ( / h ɪ ˈ m æ t ə k r ɪ t / ) ( Ht or HCT ), also known by several other names , is the volume percentage (vol%) of red blood cells (RBCs) in blood , measured as part of a blood test . The measurement depends on the number and size of red blood cells. It is normally 40.7–50.3% for males and 36.1–44.3% for females. It is a part of a person's complete blood count results, along with hemoglobin concentration, white blood cell count and platelet count. Because the purpose of red blood cells is to transfer oxygen from the lungs to body tissues, a blood sample's hematocrit—the red blood cell volume percentage—can become a point of reference of its capability of delivering oxygen. Hematocrit levels that are too high or too low can indicate a blood disorder, dehydration , or other medical conditions. An abnormally low hematocrit may suggest anemia , a decrease in the total amount of red blood cells, while an abnormally high hematocrit is called polycythemia . Both are potentially life-threatening disorders.There are other names for the hematocrit, such as packed cell volume (PCV), volume of packed red cells (VPRC), or erythrocyte volume fraction (EVF). The term hematocrit (or haematocrit in British English ) comes from the Ancient Greek words haima ( αἷμα , "blood") and kritēs ( κριτής , "judge"), and hematocrit means "to separate blood". It was coined in 1891 by Swedish physiologist Magnus Blix as haematokrit , modeled after lactokrit .With modern lab equipment, the hematocrit can be calculated by an automated analyzer or directly measured, depending on the analyzer manufacturer. Calculated hematocrit is determined by multiplying the red cell count by the mean cell volume . The hematocrit is slightly more accurate, as the PCV includes small amounts of blood plasma trapped between the red cells. An estimated hematocrit as a percentage may be derived by tripling the hemoglobin concentration in g / dL and dropping the units. The packed cell volume (PCV) can be determined by centrifuging EDTA -treated or heparinized blood in a capillary tube (also known as a microhematocrit tube) at 10,000 RPM for five minutes. This separates the blood into layers. The volume of packed red blood cells divided by the total volume of the blood sample gives the PCV. Since a tube is used, this can be calculated by measuring the lengths of the layers. Another way of measuring hematocrit levels is by optical methods such as spectrophotometry . Through differential spectrophotometry, the differences in optical densities of a blood sample flowing through small-bore glass tubes at isosbestic wavelengths for deoxyhemoglobin and oxyhemoglobin and the product of the luminal diameter and hematocrit create a linear relationship that is used to measure hematocrit levels. Other than potential bruising at the puncture site, and/or dizziness, there are no complications associated with this test. While known hematocrit levels are used in detecting conditions, it may fail at times due to hematocrit being the measure of concentration of red blood cells through volume in a blood sample. It does not account for the mass of the red blood cells, and thus the changes in mass can alter a hematocrit level or go undetected while affecting a subject's condition. Additionally, there have been cases in which the blood for testing was inadvertently drawn proximal to an intravenous line that was infusing packed red cells or fluids. In these situations, the hemoglobin level in the blood sample will not be the true level for the patient because the sample will contain a large amount of the infused material rather than what is diluted into the circulating whole blood. That is, if packed red cells are being supplied, the sample will contain a large amount of those cells and the hematocrit will be artificially very high.Hematocrit can vary from the determining factors of the number of red blood cells. These factors can be from the age and sex of the subject. [ clarification needed ] Typically, a higher hematocrit level signifies the blood sample's ability to transport oxygen, which has led to reports that an "optimal hematocrit level" may exist. Optimal hematocrit levels have been studied through combinations of assays on blood sample's hematocrit itself, viscosity, and hemoglobin level. Hematocrit levels also serve as an indicator of health conditions. Thus, tests on hematocrit levels are often carried out in the process of diagnosis of such conditions, and may be conducted prior to surgery. Additionally, the health conditions associated with certain hematocrit levels are the same as ones associated with certain hemoglobin levels. As blood flows from the arterioles into the capillaries, a change in pressure occurs. In order to maintain pressure, the capillaries branch off to a web of vessels that carry blood into the venules. Through this process blood undergoes micro-circulation. In micro-circulation, the Fåhræus effect will take place, resulting in a large change in hematocrit. As blood flows through the arterioles, red cells will act a feed hematocrit (Hf), while in the capillaries, a tube hematocrit (Ht) occurs. In tube hematocrit, plasma fills most of the vessel while the red cells travel through in somewhat of a single file line. From this stage, blood will enter the venules increasing in hematocrit, in other words the discharge hematocrit (Hd).In large vessels with low hematocrit, viscosity dramatically drops and red cells take in a lot of energy. While in smaller vessels at the micro-circulation scale, viscosity is very high. With the increase in shear stress at the wall, a lot of energy is used to move cells. [ citation needed ]Relationships between hematocrit, viscosity, and shear rate are important factors to put into consideration. Since blood is non-Newtonian, the viscosity of the blood is in relation to the hematocrit, and as a function of shear rate. This is important when it comes to determining shear force, since a lower hematocrit level indicates that there is a need for more force to push the red blood cells through the system. This is because shear rate is defined as the rate to which adjacent layers of fluid move in respect to each other. Plasma is a more viscous material than typically red blood cells, [ citation needed ] since they are able to adjust their size to the radius of a tube; the shear rate is purely dependent on the amount of red blood cells being forced in a vessel. Generally at both sea levels and high altitudes, hematocrit levels rise as children mature. These health-related causes and impacts of elevated hematocrit levels have been reported: Hematocrit levels were also reported to be correlated with social factors that influence subjects. In the 1966–80 Health Examination Survey, there was a small rise in mean hematocrit levels in female and male adolescents that reflected a rise in annual family income. Additionally, a higher education in a parent has been put into account for a rise in mean hematocrit levels of the child. Lowered hematocrit levels also pose health impacts. These causes and impacts have been reported:Generally at both sea levels and high altitudes, hematocrit levels rise as children mature. These health-related causes and impacts of elevated hematocrit levels have been reported: Hematocrit levels were also reported to be correlated with social factors that influence subjects. In the 1966–80 Health Examination Survey, there was a small rise in mean hematocrit levels in female and male adolescents that reflected a rise in annual family income. Additionally, a higher education in a parent has been put into account for a rise in mean hematocrit levels of the child. Lowered hematocrit levels also pose health impacts. These causes and impacts have been reported:

Wiki

Dengue fever

https://api.wikimedia.org/core/v1/wikipedia/en/page/Crimean–Congo_hemorrhagic_fever/html

Crimean–Congo hemorrhagic fever

Crimean–Congo hemorrhagic fever ( CCHF ) is a viral disease . Symptoms of CCHF may include fever , muscle pains , headache , vomiting, diarrhea , and bleeding into the skin . Onset of symptoms is less than two weeks following exposure. Complications may include liver failure . Survivors generally recover around two weeks after onset. The CCHF virus is typically spread by tick bites or close contact with the blood, secretions, organs or other bodily fluids of infected persons or animals. Groups that are at high risk of infection are farmers and those who work in slaughterhouses . The virus can also spread between people via body fluids . Diagnosis can be made by detecting antibodies , the virus's RNA , or viral proteins (antigens). It is a type of viral hemorrhagic fever . There are no FDA - or WHO -approved therapeutics for CCHF, and a vaccine is not commercially available. Prevention involves avoiding tick bites, following safe practices in meat processing plants, and observing universal healthcare precautions. Treatment is typically with supportive care , and the medication ribavirin may also help. CCHF cases are observed in a wide geographic range including Africa , Russia , the Balkans , the Middle East , and Asia . Typically small outbreaks are seen in areas where the virus is endemic. In 2013 Iran , Russia, Turkey , and Uzbekistan documented more than 50 cases. The fatality rate is typically between 10 and 40%, though fatalities as high as 80% have been observed in some outbreaks. The virus was first observed in Crimea in the 1940s and was later identified as the same agent of what had been called Congo Hemorrhagic Fever. In the past 20 years, CCHF outbreaks have been reported in eastern Europe, particularly in the former Soviet Union , throughout the Mediterranean, in northwestern China , central Asia, southern Europe, Africa, the Middle East, and the Indian subcontinent . CCHF is on WHO's priority list for Research and Development and the US National Institute of Allergy and Infectious Diseases (NIH/NIAID) priority A list, as a disease posing the highest level of risk to national security and public health.The clinical illness associated with CCHFV (the CCHF virus) is a severe form of hemorrhagic fever . Following infection by a tick bite, the incubation period is typically two to three days but can last as long as nine days, while the incubation period following contact with infected blood or tissues is usually five to six days with a documented maximum of 13 days. The onset of symptoms ushering in the pre-hemorrhagic phase is sudden, with fever, myalgia (muscle ache), dizziness, neck pain and stiffness, backache, headache, sore eyes and photophobia (sensitivity to light). Typical symptoms include nausea, vomiting (which may progress to severe bleeding and can be fatal if not treated), diarrhea, abdominal pain and sore throat early in the acute infection phase, followed by sharp mood swings, agitations and confusion. After several days, agitation may be replaced by sleepiness, depression and lassitude, and the abdominal pain may localize to the upper right quadrant, with detectable liver enlargement. As the illness progresses into the hemorrhagic phase, large areas of severe bruising, severe nosebleeds, and uncontrolled bleeding at injection sites can be seen, beginning on about the fourth day of illness and lasting for about two weeks. Other clinical signs include tachycardia (fast heart rate), lymphadenopathy (enlarged lymph nodes), and a petechiae (a rash caused by bleeding into the skin) on internal mucosal surfaces, such as in the mouth and throat, and on the skin. The petechiae may give way to larger rashes called ecchymoses, and other haemorrhagic phenomena. There is usually evidence of hepatitis, and severely ill patients may experience rapid kidney deterioration, liver failure or pulmonary failure after the fifth day of illness. In documented outbreaks of CCHF, fatality rates in hospitalized patients have ranged from 9% to as high as 70%, though the WHO notes a typical range of 10–40%, with death often occurring in the second week of illness. In patients who recover, improvement generally begins on the ninth or tenth day after the onset of illness. The long-term effects of CCHF infection have not been studied well enough in survivors to determine whether or not specific complications exist. However, recovery is slow.The Crimean–Congo hemorrhagic fever orthonairovirus (CCHFV) is a member of the genus Orthonairovirus , family Nairoviridae of RNA viruses . The virions are 80–120 nanometers (nm) in diameter and are pleomorphic . There are no host ribosomes within the virion. Each virion contains three distinct RNA sequences, which together make up the viral genome. The envelope is single layered and is formed from a lipid bilayer 5 nm thick. It has no external protrusions. The envelope proteins form small projections ~5–10 nm long. The nucleocapsids are filamentous and circular with a length of 200–3000 nm. Viral entry is thought to be clathrin-mediated with the cell surface protein nucleolin playing a role. The genome is circular, negative-sense RNA in three parts – Small (S), Medium (M) and Large (L). The L segment is 11–14.4 kilobases in length while the M and S segments are 4.4–6.3 and 1.7–2.1 kilobases long respectively. The L segment encodes the RNA polymerase , the M segment encodes the envelope glycoproteins (Gc and Gn), and the S segment encodes the nucleocapsid protein. The mutation rates for the three parts of the genome were estimated to be: 1.09 × 10 −4 , 1.52 × 10 −4 and 0.58 × 10 −4 substitutions/site/year for the S, M, and L segments respectively. CCHFV is the most genetically diverse of the arboviruses : its nucleotide sequences frequently differ between different strains, ranging from a 20% variability for the viral S segment to 31% for the M segment. Viruses with diverse sequences can be found within the same geographic area; closely related viruses have been isolated from widely separated regions, suggesting that viral dispersion has occurred possibly by ticks carried on migratory birds or through international livestock trade. Reassortment among genome segments during coinfection of ticks or vertebrates seems likely to have played a role in generating diversity in this virus. [ citation needed ] Based on the sequence data, seven genotypes of CCHFV have been recognised: Africa 1 ( Senegal ), Africa 2 ( Democratic Republic of the Congo and South Africa), Africa 3 (southern and western Africa), Europe 1 ( Albania , Bulgaria , Kosovo , Russia and Turkey ), Europe 2 ( Greece ), Asia 1 ( the Middle East , Iran and Pakistan ) and Asia 2 ( China , Kazakhstan , Tajikistan and Uzbekistan ). [ citation needed ] Ticks are both "environmental reservoir" and vector for the virus, carrying it from wild animals to domestic animals and humans. Tick species identified as infected with the virus include Argas reflexus , Hyalomma anatolicum , Hyalomma detritum , Hyalomma marginatum marginatum and Rhipicephalus sanguineus . [ citation needed ] At least 31 different species of ticks from the genera Haemaphysalis and Hyalomma in southeastern Iran have been found to carry the virus. Wild animals and small mammals, particularly European hare , Middle-African hedgehogs and multimammate rats are the "amplifying hosts" of the virus. Birds are generally resistant to CCHF, with the exception of ostriches . Domestic animals like sheep, goats and cattle can develop high titers of virus in their blood, but tend not to fall ill. The "sporadic infection" of humans is usually caused by a Hyalomma tick bite. Animals can transmit the virus to humans, but this would usually be as part of a disease cluster . When clusters of illness occur, it is typically after people treat, butcher or eat infected livestock, particularly ruminants and ostriches . Outbreaks have occurred in abattoirs and other places where workers have been exposed to infected human or animal blood and fomites [ citation needed ] Humans can infect humans and outbreaks also occur in clinical facilities through infected blood and unclean medical instruments. The Crimean–Congo hemorrhagic fever orthonairovirus (CCHFV) is a member of the genus Orthonairovirus , family Nairoviridae of RNA viruses . The virions are 80–120 nanometers (nm) in diameter and are pleomorphic . There are no host ribosomes within the virion. Each virion contains three distinct RNA sequences, which together make up the viral genome. The envelope is single layered and is formed from a lipid bilayer 5 nm thick. It has no external protrusions. The envelope proteins form small projections ~5–10 nm long. The nucleocapsids are filamentous and circular with a length of 200–3000 nm. Viral entry is thought to be clathrin-mediated with the cell surface protein nucleolin playing a role. The genome is circular, negative-sense RNA in three parts – Small (S), Medium (M) and Large (L). The L segment is 11–14.4 kilobases in length while the M and S segments are 4.4–6.3 and 1.7–2.1 kilobases long respectively. The L segment encodes the RNA polymerase , the M segment encodes the envelope glycoproteins (Gc and Gn), and the S segment encodes the nucleocapsid protein. The mutation rates for the three parts of the genome were estimated to be: 1.09 × 10 −4 , 1.52 × 10 −4 and 0.58 × 10 −4 substitutions/site/year for the S, M, and L segments respectively. CCHFV is the most genetically diverse of the arboviruses : its nucleotide sequences frequently differ between different strains, ranging from a 20% variability for the viral S segment to 31% for the M segment. Viruses with diverse sequences can be found within the same geographic area; closely related viruses have been isolated from widely separated regions, suggesting that viral dispersion has occurred possibly by ticks carried on migratory birds or through international livestock trade. Reassortment among genome segments during coinfection of ticks or vertebrates seems likely to have played a role in generating diversity in this virus. [ citation needed ] Based on the sequence data, seven genotypes of CCHFV have been recognised: Africa 1 ( Senegal ), Africa 2 ( Democratic Republic of the Congo and South Africa), Africa 3 (southern and western Africa), Europe 1 ( Albania , Bulgaria , Kosovo , Russia and Turkey ), Europe 2 ( Greece ), Asia 1 ( the Middle East , Iran and Pakistan ) and Asia 2 ( China , Kazakhstan , Tajikistan and Uzbekistan ). [ citation needed ]The genome is circular, negative-sense RNA in three parts – Small (S), Medium (M) and Large (L). The L segment is 11–14.4 kilobases in length while the M and S segments are 4.4–6.3 and 1.7–2.1 kilobases long respectively. The L segment encodes the RNA polymerase , the M segment encodes the envelope glycoproteins (Gc and Gn), and the S segment encodes the nucleocapsid protein. The mutation rates for the three parts of the genome were estimated to be: 1.09 × 10 −4 , 1.52 × 10 −4 and 0.58 × 10 −4 substitutions/site/year for the S, M, and L segments respectively. CCHFV is the most genetically diverse of the arboviruses : its nucleotide sequences frequently differ between different strains, ranging from a 20% variability for the viral S segment to 31% for the M segment. Viruses with diverse sequences can be found within the same geographic area; closely related viruses have been isolated from widely separated regions, suggesting that viral dispersion has occurred possibly by ticks carried on migratory birds or through international livestock trade. Reassortment among genome segments during coinfection of ticks or vertebrates seems likely to have played a role in generating diversity in this virus. [ citation needed ] Based on the sequence data, seven genotypes of CCHFV have been recognised: Africa 1 ( Senegal ), Africa 2 ( Democratic Republic of the Congo and South Africa), Africa 3 (southern and western Africa), Europe 1 ( Albania , Bulgaria , Kosovo , Russia and Turkey ), Europe 2 ( Greece ), Asia 1 ( the Middle East , Iran and Pakistan ) and Asia 2 ( China , Kazakhstan , Tajikistan and Uzbekistan ). [ citation needed ]Ticks are both "environmental reservoir" and vector for the virus, carrying it from wild animals to domestic animals and humans. Tick species identified as infected with the virus include Argas reflexus , Hyalomma anatolicum , Hyalomma detritum , Hyalomma marginatum marginatum and Rhipicephalus sanguineus . [ citation needed ] At least 31 different species of ticks from the genera Haemaphysalis and Hyalomma in southeastern Iran have been found to carry the virus. Wild animals and small mammals, particularly European hare , Middle-African hedgehogs and multimammate rats are the "amplifying hosts" of the virus. Birds are generally resistant to CCHF, with the exception of ostriches . Domestic animals like sheep, goats and cattle can develop high titers of virus in their blood, but tend not to fall ill. The "sporadic infection" of humans is usually caused by a Hyalomma tick bite. Animals can transmit the virus to humans, but this would usually be as part of a disease cluster . When clusters of illness occur, it is typically after people treat, butcher or eat infected livestock, particularly ruminants and ostriches . Outbreaks have occurred in abattoirs and other places where workers have been exposed to infected human or animal blood and fomites [ citation needed ] Humans can infect humans and outbreaks also occur in clinical facilities through infected blood and unclean medical instruments. Where mammalian tick infection is common, agricultural regulations require de-ticking farm animals before transportation or delivery for slaughter. Personal tick avoidance measures are recommended, such as use of insect repellents, adequate clothing, and body inspection for adherent ticks. [ citation needed ] When feverish patients with evidence of bleeding require resuscitation or intensive care , body substance isolation precautions should be taken. [ citation needed ] Since the 1970s, several vaccine trials around the world against CCHF have been terminated due to high toxicity. As of March 2011 [ update ] , the only available and probably somewhat efficacious CCHF vaccine has been an inactivated antigen preparation then used in Bulgaria. No publication in the scientific literature related to this vaccine exists, which a Turkish virologist called suspicious both because antiquated technology and mouse brain were used to manufacture it. More vaccines are under development, but the sporadic nature of the disease, even in endemic countries, suggests that large trials of vaccine efficacy will be difficult to perform. Finding volunteers may prove challenging, given growing anti-vaccination sentiment and resistance of populations to vaccination against contagious diseases. The number of people to be vaccinated, and the length of time they would have to be followed to confirm protection would have to be carefully defined. Alternatively, many scientists appear to believe that treatment of CCHF with ribavirin is more practical than prevention, but some recently conducted clinical trials appear to counter assumptions of drug efficacy. In 2011, a Turkish research team led by Erciyes University successfully developed the first non-toxic preventive vaccine, which passed clinical trials. As of 2012, the vaccine was pending approval by the US FDA. Since the Ebola epidemic, the WHO jumpstarted a "Blueprint for Research and Development preparedness" on emerging pathogens with epidemic potential, against which there are no medical treatments. CCHF was the top priority on the initial list from December 2015, and is second as of January 2017. Since the 1970s, several vaccine trials around the world against CCHF have been terminated due to high toxicity. As of March 2011 [ update ] , the only available and probably somewhat efficacious CCHF vaccine has been an inactivated antigen preparation then used in Bulgaria. No publication in the scientific literature related to this vaccine exists, which a Turkish virologist called suspicious both because antiquated technology and mouse brain were used to manufacture it. More vaccines are under development, but the sporadic nature of the disease, even in endemic countries, suggests that large trials of vaccine efficacy will be difficult to perform. Finding volunteers may prove challenging, given growing anti-vaccination sentiment and resistance of populations to vaccination against contagious diseases. The number of people to be vaccinated, and the length of time they would have to be followed to confirm protection would have to be carefully defined. Alternatively, many scientists appear to believe that treatment of CCHF with ribavirin is more practical than prevention, but some recently conducted clinical trials appear to counter assumptions of drug efficacy. In 2011, a Turkish research team led by Erciyes University successfully developed the first non-toxic preventive vaccine, which passed clinical trials. As of 2012, the vaccine was pending approval by the US FDA. Since the Ebola epidemic, the WHO jumpstarted a "Blueprint for Research and Development preparedness" on emerging pathogens with epidemic potential, against which there are no medical treatments. CCHF was the top priority on the initial list from December 2015, and is second as of January 2017. Treatment is mostly supportive . Ribavirin has shown some efficacy in vitro and has been used by mouth during outbreaks, [ citation needed ] but there is uncertain evidence to support its use, and this medication can cause serious side effects including hemolytic anemia and liver damage. As of 2011 [ update ] the use of Immunoglobulin preparations has remained unproven and antibody engineering, which raised hopes for monoclonal antibody therapy, has remained in its infancy. CCHF occurs most frequently among agricultural workers, following the bite of an infected tick, and to a lesser extent among slaughterhouse workers exposed to the blood and tissues of infected livestock, and medical personnel through contact with the body fluids of infected persons. As of 2013 [ update ] the northern limit of CCHF has been 50 degrees northern latitude, north of which the Hyalomma ticks have not been found. Per a WHO map from 2008, Hyalomma ticks occurred south of this latitude across all of the Eurasian continent and Africa, sparing only the islands of Sri Lanka , Indonesia and Japan . Serological or virological evidence of CCHF was widespread in Asia, Eastern Europe, the Middle East (except Israel, Lebanon and Jordan), central Africa, Western Africa, South Africa and Madagascar. In 2008, more than 50 cases/year were reported from only 4 countries: Turkey, Iran, Russia and Uzbekistan. 5-49 cases/year were present in South Africa, Central Asia including Pakistan and Afghanistan (but sparing Turkmenistan), in the Middle East only the UAE and the Balkan countries limited to Romania, Bulgaria, Serbia, Montenegro and Albania. In Russia, the disease is limited to Southern and North Caucasian Federal Districts , but climate change may cause it to spread into more northerly areas. A 2014 map by the CDC shows endemic areas (in red) largely unchanged in Africa and the Middle East, but different for the Balkan, including all countries of the former Yugoslavia, and also Greece, but no longer Romania. India 's Northwestern regions of Rajasthan and Gujarat saw their first cases. From 1995 to 2013, 228 cases of CCHF were reported in the Republic of Kosovo, with a case-fatality rate of 25.5%. Between 2002–2008 the Ministry of Health of Turkey reported 3,128 CCHF cases, with a 5% death rate. [ citation needed ] In July 2005, authorities reported 41 cases of CCHF in central Turkey's Yozgat Province , with one death. [ clarification needed ] As of August 2008, a total of 50 deaths were reported for the year thus far in various cities in Turkey due to CCHF. [ clarification needed ] In 2003, 38 people were infected with CCHF in Mauritania , including 35 residents of Nouakchott. In September 2010, an outbreak was reported in Pakistan's Khyber Pakhtunkhwa province. Poor diagnosis and record keeping caused the extent of the outbreak to be uncertain, though some reports indicated over 100 cases, with a case-fatality rate above 10%. [ citation needed ] In January 2011, the first human cases of CCHF in India was reported in Sanand , Gujarat, India, with 4 reported deaths, which included the index patient , treating physician and nurse. As of May 2012 [ update ] , 71 people were reported to have contracted the disease in Iran, resulting in 8 fatalities. [ citation needed ] In October 2012, a British man died from the disease at the Royal Free Hospital in London. He had earlier been admitted to Gartnavel General Hospital in Glasgow , after returning on a flight from Kabul in Afghanistan . In July 2013, seven people died of CCHF in the Karyana village of Babra , Gujarat, India. In August 2013, a farmer from Agago , Uganda was treated at Kalongo Hospital for a confirmed CCHF infection. The deaths of three other individuals in the northern region were suspected to have been caused by the virus. Another unrelated CCHF patient was admitted to Mulago Hospital on the same day. The Ministry of Health announced on the 19th that the outbreak was under control, but the second patient, a 27-year-old woman from Nansana , died on the 21st. She is believed to have contracted the virus from her husband, who returned to Kampala after being treated for CCHF in Juba , South Sudan. In June 2014, cases were diagnosed in Kazakhstan. Ten people, including an ambulance crew, were admitted on to hospital in southern Kazakhstan with suspected CCHF. [ citation needed ] In July 2014 an 8th person was found to be infected with CCHF at Hayatabad Medical Complex (HMC), Pakistan. The eight patients, including a nurse and 6 Afghan nationals, died between April and July 2014. As of 2015 [ update ] , sporadic confirmed cases have been reported from Bhuj , Amreli , Sanand , Idar and Vadnagar in Gujarat, India. In November 2014, a doctor and a labourer in north Gujarat tested positive for the disease. In the following weeks, three more people died from CCHF. In March 2015, one more person died of CCHF in Gujarat. As of 2015, among livestock, CCHF was recognized as "widespread" in India, only 4 years after the first human case had been diagnosed. In August 2016, the first local case of CCHF in Western Europe occurred in Western Spain. A 62-year-old man, who had been bitten by a tick in Spain died on August 25, having infected a nurse. The tick bite occurred in the province of Ávila , 300 km away from the province of Cáceres , where CCHF viral RNA from ticks was amplified in 2010. As of July 2017 [ update ] it was unclear what specific ecology led to the Spanish cases. In August 2016, a number of Pakistani news sources raised concerns regarding the disease. Between January and October 2016, CCHF outbreaks in Pakistan were reported with highest numbers of cases and deaths during August 2016, just before the festival of Eid-al-Adha (held on September 13–15 in 2016). It was hypothesized that the festival could play an important part as people could come into contact with domestic or imported animals potentially infected with CCHF virus. The Pakistani NIH showed there was no correlation, and that CCHF cases have coincided with the peak tick proliferation during the preceding 8–10 years. In 2017, the General Directorate of Public Health in Turkey published official records of infections and casualties involving CCHF between 2008 and 2017. Cases declined form 1,318 in 2009 to 343 in 2017 alongside a lowered mortality rate. Cases are concentrated in rural areas of the Southern Black Sea Region , Central Anatolia Region , and Eastern Anatolia Region during early summer months. On February 2, 2020, an outbreak was reported in Mali involving fourteen cases and seven deaths, days before the COVID-19 pandemic in Africa . In May 2020, a single case was reported in Mauritania. In 2022, an outbreak occurred in Iraq . Between 1 January and 22 May, 212 cases of CCHF were reported to the WHO. Of the 212 cases, 115 were suspected and 97 laboratory confirmed. Twenty seven deaths were recorded, of which 13 were in laboratory confirmed cases. In July 2023, there was a single confirmed fatality of tick-borne CCHF in North Macedonia . As of 2013 [ update ] the northern limit of CCHF has been 50 degrees northern latitude, north of which the Hyalomma ticks have not been found. Per a WHO map from 2008, Hyalomma ticks occurred south of this latitude across all of the Eurasian continent and Africa, sparing only the islands of Sri Lanka , Indonesia and Japan . Serological or virological evidence of CCHF was widespread in Asia, Eastern Europe, the Middle East (except Israel, Lebanon and Jordan), central Africa, Western Africa, South Africa and Madagascar. In 2008, more than 50 cases/year were reported from only 4 countries: Turkey, Iran, Russia and Uzbekistan. 5-49 cases/year were present in South Africa, Central Asia including Pakistan and Afghanistan (but sparing Turkmenistan), in the Middle East only the UAE and the Balkan countries limited to Romania, Bulgaria, Serbia, Montenegro and Albania. In Russia, the disease is limited to Southern and North Caucasian Federal Districts , but climate change may cause it to spread into more northerly areas. A 2014 map by the CDC shows endemic areas (in red) largely unchanged in Africa and the Middle East, but different for the Balkan, including all countries of the former Yugoslavia, and also Greece, but no longer Romania. India 's Northwestern regions of Rajasthan and Gujarat saw their first cases. From 1995 to 2013, 228 cases of CCHF were reported in the Republic of Kosovo, with a case-fatality rate of 25.5%. Between 2002–2008 the Ministry of Health of Turkey reported 3,128 CCHF cases, with a 5% death rate. [ citation needed ] In July 2005, authorities reported 41 cases of CCHF in central Turkey's Yozgat Province , with one death. [ clarification needed ] As of August 2008, a total of 50 deaths were reported for the year thus far in various cities in Turkey due to CCHF. [ clarification needed ] In 2003, 38 people were infected with CCHF in Mauritania , including 35 residents of Nouakchott. In September 2010, an outbreak was reported in Pakistan's Khyber Pakhtunkhwa province. Poor diagnosis and record keeping caused the extent of the outbreak to be uncertain, though some reports indicated over 100 cases, with a case-fatality rate above 10%. [ citation needed ] In January 2011, the first human cases of CCHF in India was reported in Sanand , Gujarat, India, with 4 reported deaths, which included the index patient , treating physician and nurse. As of May 2012 [ update ] , 71 people were reported to have contracted the disease in Iran, resulting in 8 fatalities. [ citation needed ] In October 2012, a British man died from the disease at the Royal Free Hospital in London. He had earlier been admitted to Gartnavel General Hospital in Glasgow , after returning on a flight from Kabul in Afghanistan . In July 2013, seven people died of CCHF in the Karyana village of Babra , Gujarat, India. In August 2013, a farmer from Agago , Uganda was treated at Kalongo Hospital for a confirmed CCHF infection. The deaths of three other individuals in the northern region were suspected to have been caused by the virus. Another unrelated CCHF patient was admitted to Mulago Hospital on the same day. The Ministry of Health announced on the 19th that the outbreak was under control, but the second patient, a 27-year-old woman from Nansana , died on the 21st. She is believed to have contracted the virus from her husband, who returned to Kampala after being treated for CCHF in Juba , South Sudan. In June 2014, cases were diagnosed in Kazakhstan. Ten people, including an ambulance crew, were admitted on to hospital in southern Kazakhstan with suspected CCHF. [ citation needed ] In July 2014 an 8th person was found to be infected with CCHF at Hayatabad Medical Complex (HMC), Pakistan. The eight patients, including a nurse and 6 Afghan nationals, died between April and July 2014. As of 2015 [ update ] , sporadic confirmed cases have been reported from Bhuj , Amreli , Sanand , Idar and Vadnagar in Gujarat, India. In November 2014, a doctor and a labourer in north Gujarat tested positive for the disease. In the following weeks, three more people died from CCHF. In March 2015, one more person died of CCHF in Gujarat. As of 2015, among livestock, CCHF was recognized as "widespread" in India, only 4 years after the first human case had been diagnosed. In August 2016, the first local case of CCHF in Western Europe occurred in Western Spain. A 62-year-old man, who had been bitten by a tick in Spain died on August 25, having infected a nurse. The tick bite occurred in the province of Ávila , 300 km away from the province of Cáceres , where CCHF viral RNA from ticks was amplified in 2010. As of July 2017 [ update ] it was unclear what specific ecology led to the Spanish cases. In August 2016, a number of Pakistani news sources raised concerns regarding the disease. Between January and October 2016, CCHF outbreaks in Pakistan were reported with highest numbers of cases and deaths during August 2016, just before the festival of Eid-al-Adha (held on September 13–15 in 2016). It was hypothesized that the festival could play an important part as people could come into contact with domestic or imported animals potentially infected with CCHF virus. The Pakistani NIH showed there was no correlation, and that CCHF cases have coincided with the peak tick proliferation during the preceding 8–10 years. In 2017, the General Directorate of Public Health in Turkey published official records of infections and casualties involving CCHF between 2008 and 2017. Cases declined form 1,318 in 2009 to 343 in 2017 alongside a lowered mortality rate. Cases are concentrated in rural areas of the Southern Black Sea Region , Central Anatolia Region , and Eastern Anatolia Region during early summer months. On February 2, 2020, an outbreak was reported in Mali involving fourteen cases and seven deaths, days before the COVID-19 pandemic in Africa . In May 2020, a single case was reported in Mauritania. In 2022, an outbreak occurred in Iraq . Between 1 January and 22 May, 212 cases of CCHF were reported to the WHO. Of the 212 cases, 115 were suspected and 97 laboratory confirmed. Twenty seven deaths were recorded, of which 13 were in laboratory confirmed cases. In July 2023, there was a single confirmed fatality of tick-borne CCHF in North Macedonia . In ancient Celtic settlements in the Upper Danube area in Germany, the CCHF virus was detected in archaeological blood samples, indicating that it was endemic at the time. The virus may have evolved around 1500–1100 BC. It is thought that changing climate and agricultural practices around this time could be behind its evolution. In the 12th century a case of a hemorrhagic disease reported from what is now Tajikistan may have been the first known case of Crimean–Congo hemorrhagic fever. [ citation needed ] In 1944, roughly 200 Soviet military agricultural workers were infected by Crimean hemorrhagic fever (CHF), leading to experiments showing a tick-borne viral etiology. In February 1967, virologists John P. Woodall , David Simpson, Ghislaine Courtois and others published initial reports on a virus they called the Congo virus. In 1956, the Congo virus had first been isolated by physician Ghislaine Courtois, head of the Provincial Medical Laboratory, Stanleyville , in the Belgian Congo . Strain V3010, isolated by Courtois, was sent to the Rockefeller Foundation Virus Laboratory (RFVL) in New York City and found to be identical to another strain from Uganda , but to no other named virus at that time. [ citation needed ] In June 1967, Soviet virologist Mikhail Chumakov registered an isolate from a fatal case that occurred in Samarkand in the Catalogue of Arthropod-borne Viruses. In 1969, the Russian strain, which Chumakov had sent to the RFVL, was found to be antigenically indistinguishable from the Congo virus. In 1973, the International Committee on Taxonomy of Viruses adopted Crimean–Congo hemorrhagic fever virus as the official name. These reports include records of the occurrence of the virus or antibodies to the virus from Greece, Portugal, South Africa, Madagascar (the first isolation from there), the Maghreb , Dubai , Saudi Arabia , Kuwait and Iraq.

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Dengue fever

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Paul Theroux bibliography

List of works by or about Paul Theroux , American novelist, short story writer and travel writer.Waldo . 1967. Fong and the Indians (1968) Girls at Play (1969) Murder in Mount Holly (1969) Jungle Lovers (1971) Saint Jack (1973) The Black House (1974) The Family Arsenal (1976) Picture Palace (1978) A Christmas Card (1978) London Snow (1980) The Mosquito Coast (1981) Doctor Slaughter (1984) – filmed as Half Moon Street (1986) O-Zone . New York: G. P. Putnam's Sons. 1986. My Secret History . New York: G. P. Putnam's Sons. 1989. Chicago Loop (1990) Dr. DeMarr (1990) Millroy the Magician (1993) The Greenest Island (1995) My Other Life (1996) Kowloon Tong (1997) Hotel Honolulu (2001) Nurse Wolf and Dr. Sacks (2001) Blinding Light (2006) A Dead Hand: A Crime in Calcutta (2009) The Lower River (2012) Mother Land (2017) Under the Wave at Waimea (2021) The Bad Angel Brothers (2022) Burma Sahib (2024)

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Dengue fever

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Burkina Faso

Burkinabè Burkinese Burkina Faso [lower-alpha 1] is a landlocked country in West Africa . It covers an area of 274,223 km 2 (105,878 sq mi) , bordered by Mali to the northwest, Niger to the northeast, Benin to the southeast, Togo and Ghana to the south, and Ivory Coast to the southwest. As of 2021, the country had an estimated population of 23,674,480. Previously called Republic of Upper Volta (1958–1984), it was renamed Burkina Faso by President Thomas Sankara . Its citizens are known as Burkinabè , [lower-alpha 2] and its capital and largest city is Ouagadougou . The largest ethnic group in Burkina Faso is the Mossi people , who settled the area in the 11th and 13th centuries. They established powerful kingdoms such as the Ouagadougou, Tenkodogo, and Yatenga. In 1896, it was colonized by the French as part of French West Africa ; in 1958, Upper Volta became a self-governing colony within the French Community . In 1960, it gained full independence with Maurice Yaméogo as president . Since it gained its independence, the country has been subject to instability, droughts , famines and corruption. There have also been various coups , in 1966 , 1980 , 1982 , 1983 , 1987 , and twice in 2022 ( January and September ). There were also unsuccessful coup attempts in 1989 , 2015 , and 2023 . Thomas Sankara came to power following a successful coup in 1983. As president, Sankara embarked on a series of ambitious socioeconomic reforms which included a nationwide literacy campaign, land redistribution to peasants , vaccinations for over 2 million children, railway and road construction, equalized access to education, and the outlawing of female genital mutilation , forced marriages , and polygamy . He served as the country's president until 1987 when he was deposed and assassinated in a coup led by Blaise Compaoré , who became president and ruled the country until his removal on 31 October 2014 . Burkina Faso has been severely affected by the rise of Islamist terrorism in the Sahel since the mid-2010s. Several militias , partly allied with the Islamic State (IS) or al-Qaeda , operate in Burkina Faso and across the border in Mali and Niger . More than one million of the country's 21 million inhabitants are internally displaced persons . Burkina Faso's military seized power in a coup d'état on 23–24 January 2022 , overthrowing President Roch Marc Kaboré . On 31 January, the military junta restored the constitution and appointed Paul-Henri Sandaogo Damiba as interim president, but he was himself overthrown in a second coup on 30 September and replaced by military captain Ibrahim Traoré . Burkina Faso is one of the least developed countries in the world, with a GDP of $16.226 billion. Approximately 63.8 percent of its population practices Islam , while 26.3 percent practice Christianity. The country's official language of government and business was formerly French ; its status was relegated by a constitutional amendment ratified in January 2024, turning French into a "working language" of the country, alongside English . There are 60 indigenous languages officially recognized by the Burkinabè government, with the most common language, Mooré , spoken by over half the population. The country has a strong culture and is geographically biodiverse, with plentiful reserves of gold , manganese , copper and limestone . Burkinabè art has a rich and long history, and is globally renowned for its orthodox style. The country is governed as a semi-presidential republic with executive, legislative and judicial powers. Burkina Faso is a member of the United Nations , La Francophonie and the Organisation of Islamic Cooperation . It is currently suspended from ECOWAS and the African Union .Formerly the Republic of Upper Volta , the country was renamed "Burkina Faso" on 4 August 1984 by then-President Thomas Sankara . The words "Burkina" and "Faso" stem from different languages spoken in the country: "Burkina" comes from Mooré and means "upright", showing how the people are proud of their integrity, while "Faso" comes from the Dioula language (as written in N'Ko : ߝߊ߬ߛߏ߫ faso ) and means "fatherland" (literally, "father's house"). The "-bè" suffix added onto "Burkina" to form the demonym "Burkinabè" comes from the Fula language and means "women or men". The CIA summarizes the etymology as "land of the honest (incorruptible) men". The French colony of Upper Volta was named for its location on the upper courses of the Volta River (the Black , Red and White Volta ). The northwestern part of present-day Burkina Faso was populated by hunter-gatherers from 14,000 BCE to 5000 BCE. Their tools, including scrapers , chisels and arrowheads , were discovered in 1973 through archaeological excavations . Agricultural settlements were established between 3600 and 2600 BCE. The Bura culture was an Iron-Age civilization centred in the southwest portion of modern-day Niger and in the southeast part of contemporary Burkina Faso. Iron industry , in smelting and forging for tools and weapons, had developed in Sub-Saharan Africa by 1200 BCE. To date, the oldest evidence of iron smelting found in Burkina Faso dates from 800 to 700 BCE and forms part of the Ancient Ferrous Metallurgy World Heritage Site. From the 3rd to the 13th centuries CE, the Iron Age Bura culture existed in the territory of present-day southeastern Burkina Faso and southwestern Niger. Various ethnic groups of present-day Burkina Faso, such as the Mossi , Fula and Dioula , arrived in successive waves between the 8th and 15th centuries. From the 11th century, the Mossi people established several separate kingdoms . There is debate about the exact dates when Burkina Faso's many ethnic groups arrived to the area. The Proto-Mossi arrived in the far eastern part of what is today Burkina Faso sometime between the 8th and 11th centuries, they accepted Islam as their religion in the 11th century, the Samo arrived around the 15th century, the Dogon lived in Burkina Faso's north and northwest regions until sometime in the 15th or 16th centuries and many of the other ethnic groups that make up the country's population arrived in the region during this time. During the Middle Ages , the Mossi established several separate kingdoms including those of Tenkodogo, Yatenga, Zandoma, and Ouagadougou. Sometime between 1328 and 1338 Mossi warriors raided Timbuktu but the Mossi were defeated by Sonni Ali of Songhai at the Battle of Kobi in Mali in 1483. During the early 16th century the Songhai conducted many slave raids into what is today Burkina Faso. During the 18th century the Gwiriko Empire was established at Bobo Dioulasso and ethnic groups such as the Dyan, Lobi, and Birifor settled along the Black Volta . Starting in the early 1890s during the European Scramble for Africa , a series of European military officers made attempts to claim parts of what is today Burkina Faso. At times these colonialists and their armies fought the local peoples; at times they forged alliances with them and made treaties. The colonialist officers and their home governments also made treaties among themselves. The territory of Burkina Faso was invaded by France , becoming a French protectorate in 1896. The eastern and western regions, where a standoff against the forces of the powerful ruler Samori Ture complicated the situation, came under French occupation in 1897. By 1898, the majority of the territory corresponding to Burkina Faso was nominally conquered; however, French control of many parts remained uncertain. The Franco-British Convention of 14 June 1898 created the country's modern borders. In the French territory, a war of conquest against local communities and political powers continued for about five years. In 1904, the largely pacified territories of the Volta basin were integrated into the Upper Senegal and Niger colony of French West Africa as part of the reorganization of the French West African colonial empire. The colony had its capital in Bamako . The language of colonial administration and schooling became French. The public education system started from humble origins. Advanced education was provided for many years during the colonial period in Dakar. The indigenous population was highly discriminated against. For example, African children were not allowed to ride bicycles or pick fruit from trees, "privileges" reserved for the children of colonists. Violating these regulations could land parents in jail. Draftees from the territory participated in the European fronts of World War I in the battalions of the Senegalese Rifles . Between 1915 and 1916, the districts in the western part of what is now Burkina Faso and the bordering eastern fringe of Mali became the stage of one of the most important armed oppositions to colonial government: the Volta-Bani War . The French government finally suppressed the movement but only after suffering defeats. It also had to organize its largest expeditionary force of its colonial history to send into the country to suppress the insurrection. Armed opposition wracked the Sahelian north when the Tuareg and allied groups of the Dori region ended their truce with the government. French Upper Volta was established on 1 March 1919. The French feared a recurrence of armed uprising and had related economic considerations. To bolster its administration, the colonial government separated the present territory of Burkina Faso from Upper Senegal and Niger. The new colony was named Haute Volta for its location on the upper courses of the Volta River (the Black , Red and White Volta ), and François Charles Alexis Édouard Hesling became its first governor . Hesling initiated an ambitious road-making program to improve infrastructure and promoted the growth of cotton for export. The cotton policy – based on coercion – failed, and revenue generated by the colony stagnated. The colony was dismantled on 5 September 1932, being split between the French colonies of Ivory Coast , French Sudan and Niger . Ivory Coast received the largest share, which contained most of the population as well as the cities of Ouagadougou and Bobo-Dioulasso. France reversed this change during the period of intense anti-colonial agitation that followed the end of World War II . On 4 September 1947, it revived the colony of Upper Volta, with its previous boundaries, as a part of the French Union . The French designated its colonies as departments of metropolitan France on the European continent. On 11 December 1958 the colony achieved self-government as the Republic of Upper Volta ; it joined the Franco-African Community. A revision in the organization of French Overseas Territories had begun with the passage of the Basic Law (Loi Cadre) of 23 July 1956. This act was followed by reorganization measures approved by the French parliament early in 1957 to ensure a large degree of self-government for individual territories. Upper Volta became an autonomous republic in the French community on 11 December 1958. Full independence from France was received in 1960. The Republic of Upper Volta ( French: République de Haute-Volta ) was established on 11 December 1958 as a self-governing colony within the French Community . The name Upper Volta related to the nation's location along the upper reaches of the Volta River . The river's three tributaries are called the Black , White and Red Volta . These were expressed in the three colors of the former national flag . Before attaining autonomy, it had been French Upper Volta and part of the French Union. On 5 August 1960, it attained full independence from France . The first president, Maurice Yaméogo , was the leader of the Voltaic Democratic Union (UDV). The 1960 constitution provided for election by universal suffrage of a president and a national assembly for five-year terms. Soon after coming to power, Yaméogo banned all political parties other than the UDV. The government lasted until 1966. After much unrest, including mass demonstrations and strikes by students, labor unions, and civil servants, the military intervened. The 1966 military coup deposed Yaméogo, suspended the constitution, dissolved the National Assembly, and placed Lt. Col. Sangoulé Lamizana at the head of a government of senior army officers. The army remained in power for four years. On 14 June 1976, the Voltans ratified a new constitution that established a four-year transition period toward complete civilian rule. Lamizana remained in power throughout the 1970s as president of military or mixed civil-military governments. Lamizana's rule coincided with the beginning of the Sahel drought and famine which had a devastating impact on Upper Volta and neighboring countries. After conflict over the 1976 constitution, a new constitution was written and approved in 1977. Lamizana was re-elected by open elections in 1978. Lamizana's government faced problems with the country's traditionally powerful trade unions, and on 25 November 1980, Col. Saye Zerbo overthrew President Lamizana in a bloodless coup . Colonel Zerbo established the Military Committee of Recovery for National Progress as the supreme governmental authority, thus eradicating the 1977 constitution. Colonel Zerbo also encountered resistance from trade unions and was overthrown two years later by Maj. Dr. Jean-Baptiste Ouédraogo and the Council of Popular Salvation (CSP) in the 1982 Upper Voltan coup d'état . The CSP continued to ban political parties and organizations, yet promised a transition to civilian rule and a new constitution. Infighting developed between the right and left factions of the CSP. The leader of the leftists, Capt. Thomas Sankara , was appointed prime minister in January 1983, but was subsequently arrested. Efforts to free him, directed by Capt. Blaise Compaoré , resulted in a military coup d'état on 4 August 1983. The coup brought Sankara to power and his government began to implement a series of revolutionary programs which included mass-vaccinations, infrastructure improvements, the expansion of women's rights, encouragement of domestic agricultural consumption, and anti-desertification projects. On 2 August 1984, on President Sankara 's initiative, the country's name changed from "Upper Volta" to "Burkina Faso", or land of the honest men ; (the literal translation is land of the upright men .) [ need quotation to verify ] The presidential decree was confirmed by the National Assembly on 4 August. The demonym for people of Burkina Faso, "Burkinabè", includes expatriates or descendants of people of Burkinabè origin. Sankara's government comprised the National Council for the Revolution (CNR – French : Conseil national révolutionnaire ), with Sankara as its president, and established popular Committees for the Defense of the Revolution (CDRs). The Pioneers of the Revolution youth programme was also established. Sankara launched an ambitious socioeconomic programme for change, one of the largest ever undertaken on the African continent. His foreign policies centred on anti-imperialism , with his government rejecting all foreign aid , pushing for odious debt reduction, nationalising all land and mineral wealth and averting the power and influence of the International Monetary Fund (IMF) and World Bank . His domestic policies included a nationwide literacy campaign, land redistribution to peasants, railway and road construction and the outlawing of female genital mutilation , forced marriages and polygamy . Sankara pushed for agrarian self-sufficiency and promoted public health by vaccinating 2,500,000 children against meningitis , yellow fever , and measles . His national agenda also included planting over 10,000,000 trees to halt the growing desertification of the Sahel . Sankara called on every village to build a medical dispensary and had over 350 communities build schools with their own labour. In the 1980s, when ecological awareness was still very low, Thomas Sankara was one of the few African leaders to consider environmental protection a priority. He engaged in three major battles: against bush fires "which will be considered as crimes and will be punished as such"; against cattle roaming "which infringes on the rights of peoples because unattended animals destroy nature"; and against the anarchic cutting of firewood "whose profession will have to be organized and regulated". As part of a development program involving a large part of the population, ten million trees were planted in Burkina Faso in fifteen months during the revolution. To face the advancing desert and recurrent droughts, Thomas Sankara also proposed the planting of wooded strips of about fifty kilometers, crossing the country from east to west. He then thought of extending this vegetation belt to other countries. Cereal production, close to 1.1 billion tons before 1983, was predicted to rise to 1.6 billion tons in 1987. Jean Ziegler, former UN special rapporteur for the right to food, said that the country "had become food self-sufficient." On 15 October 1987, Sankara and twelve other government officials were assassinated in a coup d'état organized by Blaise Compaoré, Sankara's former colleague, who would go on to serve as Burkina Faso's president from October 1987 until October 2014. After the coup and although Sankara was known to be dead, some CDRs mounted an armed resistance to the army for several days. A majority [ quantify ] of Burkinabè citizens hold that France's foreign ministry , the Quai d'Orsay, was behind Compaoré in organizing the coup. There is some evidence for France's support of the coup. Compaoré gave as one of the reasons for the coup the deterioration in relations with neighbouring countries. Compaoré argued that Sankara had jeopardised foreign relations with the former colonial power (France) and with neighbouring Ivory Coast . Following the coup Compaoré immediately reversed the nationalizations, overturned nearly all of Sankara's policies, returned the country back into the IMF fold, and ultimately spurned most of Sankara's legacy. Following an alleged coup-attempt in 1989 , Compaoré introduced limited democratic reforms in 1990. Under the new (1991) constitution , Compaoré was re-elected without opposition in December 1991. In 1998 Compaoré won election in a landslide. In 2004, 13 people were tried for plotting a coup against President Compaoré and the coup's alleged mastermind was sentenced to life imprisonment. As of 2014 [ update ] , Burkina Faso remained one of the least-developed countries in the world. In 2000, the constitution was amended to reduce the presidential term to five years and set term limits to two, preventing successive re-election. The amendment took effect during the 2005 elections. If passed beforehand, it would have prevented Compaoré from being reelected. Other presidential candidates challenged the election results. But in October 2005, the constitutional council ruled that, because Compaoré was the sitting president in 2000, the amendment would not apply to him until the end of his second term in office. This cleared the way for his candidacy in the 2005 election . On 13 November 2005, Compaoré was reelected in a landslide, because of a divided political opposition. In the 2010 presidential election , President Compaoré was re-elected. Only 1.6 million Burkinabè voted, out of a total population 10 times that size. In February 2011, the death of a schoolboy provoked the 2011 Burkinabè protests , a series of popular protests, coupled with a military mutiny and a magistrates' strike, that called for the resignation of Compaoré, democratic reforms, higher wages for troops and public servants and economic freedom. As a result, governors were replaced and wages for public servants were raised. In April 2011, there was an army mutiny ; the president named new chiefs of staff, and a curfew was imposed in Ouagadougou . Compaoré's government played the role of negotiator in several West-African disputes, including the 2010–11 Ivorian crisis , the Inter-Togolese Dialogue (2007), and the 2012 Malian Crisis . Starting on 28 October 2014 protesters began to march and demonstrate in Ouagadougou against President Compaoré, who appeared [ need quotation to verify ] ready to amend the constitution and extend his 27-year rule. On 30 October some protesters set fire to the parliament building and took over the national TV headquarters. Ouagadougou International Airport closed and MPs suspended the vote on changing the constitution (the change would have allowed Compaoré to stand for re-election in 2015). Later in the day, the military dissolved all government institutions and imposed a curfew . On 31 October 2014, President Compaoré, facing mounting pressure, resigned after 27 years in office. Lt. Col. Isaac Zida said that he would lead the country during its transitional period before the planned 2015 presidential election , but there were concerns [ by whom? ] over his close ties to the former president. In November 2014 opposition parties, civil-society groups and religious leaders adopted a plan for a transitional authority to guide Burkina Faso to elections. Under the plan Michel Kafando became the transitional President of Burkina Faso and Lt. Col. Zida became the acting Prime Minister and Defense Minister. On 16 September 2015, the Regiment of Presidential Security (RSP) carried out a coup d'état , seizing the president and prime minister and then declaring the National Council for Democracy the new national government. However, on 22 September 2015, the coup leader, Gilbert Diendéré , apologized and promised to restore civilian government. On 23 September 2015 the prime minister and interim president were restored to power. General elections took place on 29 November 2015. Roch Marc Christian Kaboré won the election in the first round with 53.5% of the vote, defeating businessman Zéphirin Diabré , who took 29.7%. Kaboré was sworn in as president on 29 December 2015. Kaboré was re-elected in the general election of 22 November 2020 , but his party Mouvement du Peuple pour le Progrès (MPP), failed to reach absolute parliamentary majority. It secured 56 seats out of a total of 127. The Congress for Democracy and Progress (CDP), the party of former President Blaise Compaoré, was distant second with 20 seats. A Jihadist insurgency began in August 2015, part of the Islamist insurgency in the Sahel . Between August 2015 and October 2016, seven different posts were attacked across the country. On 15 January 2016, terrorists attacked the capital city of Ouagadougou , killing 30 people. Al-Qaeda in the Islamic Maghreb and Al-Mourabitoune , which until then had mostly operated in neighbouring Mali , claimed responsibility for the attack. In 2016, attacks increased after a new group Ansarul Islam , led by imam Ibrahim Malam Dicko , was founded. Its attacks focused particularly on Soum province and it killed dozens of people in the attack on Nassoumbou on 16 December. Between 27 March – 10 April 2017, the governments of Mali, France, and Burkina Faso launched a joint operation named " Operation Panga ," composed of 1,300 soldiers from the three countries, in Fhero forest, near the Burkina Faso-Mali border , considered a sanctuary for Ansarul Islam. The head of Ansarul Islam, Ibrahim Malam Dicko, was killed in June 2017 and Jafar Dicko became leader. On 2 March 2018, Jama'at Nasr al-Islam wal Muslimin attacked the French embassy in Ouagadougou as well as the general staff of the Burkinabè army. Eight soldiers and eight attackers were killed, and a further 61 soldiers and 24 civilians were injured. The insurgency expanded to the east of the country and, in early October, the Armed Forces of Burkina Faso launched a major military operation in the country's East, supported by French forces. According to Human Rights Watch , between mid-2018 to February 2019, at least 42 people were murdered by jihadists and a minimum of 116 mostly Fulani civilians were killed by military forces without trial. The attacks increased significantly in 2019 . According to the ACLED , armed violence in Burkina Faso jumped by 174% in 2019, with nearly 1,300 civilians dead and 860,000 displaced. Jihadist groups also began to specifically target Christians . On 8 July 2020, the United States raised concerns after a Human Rights Watch report revealed mass graves with at least 180 bodies, which were found in northern Burkina Faso where soldiers were fighting jihadists. On 4 June 2021, the Associated Press reported that according to the government of Burkina Faso, gunmen killed at least 100 people in Solhan village in northern Burkina Faso near the Niger border. A local market and several homes were also burned down. A government spokesman blamed jihadists. Heni Nsaibia, senior researcher at the Armed Conflict Location & Event Data Project said it was the deadliest attack recorded in Burkina Faso since the beginning of the jihadist insurgency. From 4–5 June 2021, unknown militants massacred over 170 people in the villages of Solhan and Tadaryat . Jihadists killed 80 people in Gorgadji on 20 August. On 14 November, the Jama'at Nasr al-Islam wal Muslimin attacked a gendarmerie in Inata , killing 53 soldiers, the heaviest loss of life by the Burkinabe military during the insurgency, and a major morale loss in the country. In December Islamists killed 41 people in an ambush, including the popular vigilante leader Ladji Yoro. Yoro was a central figure in the Volunteers for the Defense of the Homeland (VDP) a pro-government militia that had taken a leading role in the struggle against Islamists. In 2023, shortly after the murder of a Catholic priest at the hands of insurgents, the bishop of Dori, Laurent Dabiré, claimed in an interview with Catholic charity Aid to the Church in Need that around 50% of the country was in the hands of Islamists. In a successful coup on 24 January 2022, mutinying soldiers arrested and deposed President Roch Marc Christian Kaboré following gunfire. The Patriotic Movement for Safeguard and Restoration (MPSR) supported by the military declared itself to be in power, led by Lieutenant Colonel Paul-Henri Sandaogo Damiba . On 31 January, the military junta restored the constitution and appointed Damiba interim president. In the aftermath of the coup, ECOWAS and the African Union suspended Burkina Faso's membership. On 10 February, the Constitutional Council declared Damiba president of Burkina Faso. He was sworn in as president on 16 February. On 1 March 2022, the junta approved a charter allowing a military-led transition of 3 years. The charter provides for the transition process to be followed by the holding of elections. President Kaboré , who had been detained since the military junta took power, was released on 6 April 2022. The insurgency continued following the coup, with about 60% of the country under government control. The Siege of Djibo began in February 2022 and continues as of June 2023. Between 100 and 165 people were killed in Seytenga Department , Séno Province on 12–13 June and around 16,000 people fled their homes. In June, the Government announced the creation of "military zones", which civilians were required to vacate so that the country's Armed and Security Forces could fight insurgents without any "hindrances". On 30 September, Damiba was ousted in a military coup led by Capt. Ibrahim Traoré . This came eight months after Damiba seized power. The rationale given by Traoré for the coup d'état was the purported inability of Paul-Henri Sandaogo Damiba to deal with an Islamist insurgency. Damiba resigned and left the country. On 6 October 2022, Captain Ibrahim Traoré was officially appointed as president of Burkina Faso. Apollinaire Joachim Kyélem de Tambèla was appointed interim Prime Minister on 21 October 2022. On 13 April 2023, authorities in Burkina Faso declared a mobilisation in order to give the nation all means necessary to combat terrorism and create a "legal framework for all the actions to be taken" against the insurgents in recapturing 40 percent of the national territory from Islamist insurgents. On 20 April, the Rapid Intervention Brigade committed the Karma massacre , rounding up and executing civilians en masse . Between 60 and 156 civilians were killed. The northwestern part of present-day Burkina Faso was populated by hunter-gatherers from 14,000 BCE to 5000 BCE. Their tools, including scrapers , chisels and arrowheads , were discovered in 1973 through archaeological excavations . Agricultural settlements were established between 3600 and 2600 BCE. The Bura culture was an Iron-Age civilization centred in the southwest portion of modern-day Niger and in the southeast part of contemporary Burkina Faso. Iron industry , in smelting and forging for tools and weapons, had developed in Sub-Saharan Africa by 1200 BCE. To date, the oldest evidence of iron smelting found in Burkina Faso dates from 800 to 700 BCE and forms part of the Ancient Ferrous Metallurgy World Heritage Site. From the 3rd to the 13th centuries CE, the Iron Age Bura culture existed in the territory of present-day southeastern Burkina Faso and southwestern Niger. Various ethnic groups of present-day Burkina Faso, such as the Mossi , Fula and Dioula , arrived in successive waves between the 8th and 15th centuries. From the 11th century, the Mossi people established several separate kingdoms .There is debate about the exact dates when Burkina Faso's many ethnic groups arrived to the area. The Proto-Mossi arrived in the far eastern part of what is today Burkina Faso sometime between the 8th and 11th centuries, they accepted Islam as their religion in the 11th century, the Samo arrived around the 15th century, the Dogon lived in Burkina Faso's north and northwest regions until sometime in the 15th or 16th centuries and many of the other ethnic groups that make up the country's population arrived in the region during this time. During the Middle Ages , the Mossi established several separate kingdoms including those of Tenkodogo, Yatenga, Zandoma, and Ouagadougou. Sometime between 1328 and 1338 Mossi warriors raided Timbuktu but the Mossi were defeated by Sonni Ali of Songhai at the Battle of Kobi in Mali in 1483. During the early 16th century the Songhai conducted many slave raids into what is today Burkina Faso. During the 18th century the Gwiriko Empire was established at Bobo Dioulasso and ethnic groups such as the Dyan, Lobi, and Birifor settled along the Black Volta . Starting in the early 1890s during the European Scramble for Africa , a series of European military officers made attempts to claim parts of what is today Burkina Faso. At times these colonialists and their armies fought the local peoples; at times they forged alliances with them and made treaties. The colonialist officers and their home governments also made treaties among themselves. The territory of Burkina Faso was invaded by France , becoming a French protectorate in 1896. The eastern and western regions, where a standoff against the forces of the powerful ruler Samori Ture complicated the situation, came under French occupation in 1897. By 1898, the majority of the territory corresponding to Burkina Faso was nominally conquered; however, French control of many parts remained uncertain. The Franco-British Convention of 14 June 1898 created the country's modern borders. In the French territory, a war of conquest against local communities and political powers continued for about five years. In 1904, the largely pacified territories of the Volta basin were integrated into the Upper Senegal and Niger colony of French West Africa as part of the reorganization of the French West African colonial empire. The colony had its capital in Bamako . The language of colonial administration and schooling became French. The public education system started from humble origins. Advanced education was provided for many years during the colonial period in Dakar. The indigenous population was highly discriminated against. For example, African children were not allowed to ride bicycles or pick fruit from trees, "privileges" reserved for the children of colonists. Violating these regulations could land parents in jail. Draftees from the territory participated in the European fronts of World War I in the battalions of the Senegalese Rifles . Between 1915 and 1916, the districts in the western part of what is now Burkina Faso and the bordering eastern fringe of Mali became the stage of one of the most important armed oppositions to colonial government: the Volta-Bani War . The French government finally suppressed the movement but only after suffering defeats. It also had to organize its largest expeditionary force of its colonial history to send into the country to suppress the insurrection. Armed opposition wracked the Sahelian north when the Tuareg and allied groups of the Dori region ended their truce with the government. French Upper Volta was established on 1 March 1919. The French feared a recurrence of armed uprising and had related economic considerations. To bolster its administration, the colonial government separated the present territory of Burkina Faso from Upper Senegal and Niger. The new colony was named Haute Volta for its location on the upper courses of the Volta River (the Black , Red and White Volta ), and François Charles Alexis Édouard Hesling became its first governor . Hesling initiated an ambitious road-making program to improve infrastructure and promoted the growth of cotton for export. The cotton policy – based on coercion – failed, and revenue generated by the colony stagnated. The colony was dismantled on 5 September 1932, being split between the French colonies of Ivory Coast , French Sudan and Niger . Ivory Coast received the largest share, which contained most of the population as well as the cities of Ouagadougou and Bobo-Dioulasso. France reversed this change during the period of intense anti-colonial agitation that followed the end of World War II . On 4 September 1947, it revived the colony of Upper Volta, with its previous boundaries, as a part of the French Union . The French designated its colonies as departments of metropolitan France on the European continent. On 11 December 1958 the colony achieved self-government as the Republic of Upper Volta ; it joined the Franco-African Community. A revision in the organization of French Overseas Territories had begun with the passage of the Basic Law (Loi Cadre) of 23 July 1956. This act was followed by reorganization measures approved by the French parliament early in 1957 to ensure a large degree of self-government for individual territories. Upper Volta became an autonomous republic in the French community on 11 December 1958. Full independence from France was received in 1960. The Republic of Upper Volta ( French: République de Haute-Volta ) was established on 11 December 1958 as a self-governing colony within the French Community . The name Upper Volta related to the nation's location along the upper reaches of the Volta River . The river's three tributaries are called the Black , White and Red Volta . These were expressed in the three colors of the former national flag . Before attaining autonomy, it had been French Upper Volta and part of the French Union. On 5 August 1960, it attained full independence from France . The first president, Maurice Yaméogo , was the leader of the Voltaic Democratic Union (UDV). The 1960 constitution provided for election by universal suffrage of a president and a national assembly for five-year terms. Soon after coming to power, Yaméogo banned all political parties other than the UDV. The government lasted until 1966. After much unrest, including mass demonstrations and strikes by students, labor unions, and civil servants, the military intervened. The 1966 military coup deposed Yaméogo, suspended the constitution, dissolved the National Assembly, and placed Lt. Col. Sangoulé Lamizana at the head of a government of senior army officers. The army remained in power for four years. On 14 June 1976, the Voltans ratified a new constitution that established a four-year transition period toward complete civilian rule. Lamizana remained in power throughout the 1970s as president of military or mixed civil-military governments. Lamizana's rule coincided with the beginning of the Sahel drought and famine which had a devastating impact on Upper Volta and neighboring countries. After conflict over the 1976 constitution, a new constitution was written and approved in 1977. Lamizana was re-elected by open elections in 1978. Lamizana's government faced problems with the country's traditionally powerful trade unions, and on 25 November 1980, Col. Saye Zerbo overthrew President Lamizana in a bloodless coup . Colonel Zerbo established the Military Committee of Recovery for National Progress as the supreme governmental authority, thus eradicating the 1977 constitution. Colonel Zerbo also encountered resistance from trade unions and was overthrown two years later by Maj. Dr. Jean-Baptiste Ouédraogo and the Council of Popular Salvation (CSP) in the 1982 Upper Voltan coup d'état . The CSP continued to ban political parties and organizations, yet promised a transition to civilian rule and a new constitution. Infighting developed between the right and left factions of the CSP. The leader of the leftists, Capt. Thomas Sankara , was appointed prime minister in January 1983, but was subsequently arrested. Efforts to free him, directed by Capt. Blaise Compaoré , resulted in a military coup d'état on 4 August 1983. The coup brought Sankara to power and his government began to implement a series of revolutionary programs which included mass-vaccinations, infrastructure improvements, the expansion of women's rights, encouragement of domestic agricultural consumption, and anti-desertification projects. The 1966 military coup deposed Yaméogo, suspended the constitution, dissolved the National Assembly, and placed Lt. Col. Sangoulé Lamizana at the head of a government of senior army officers. The army remained in power for four years. On 14 June 1976, the Voltans ratified a new constitution that established a four-year transition period toward complete civilian rule. Lamizana remained in power throughout the 1970s as president of military or mixed civil-military governments. Lamizana's rule coincided with the beginning of the Sahel drought and famine which had a devastating impact on Upper Volta and neighboring countries. After conflict over the 1976 constitution, a new constitution was written and approved in 1977. Lamizana was re-elected by open elections in 1978. Lamizana's government faced problems with the country's traditionally powerful trade unions, and on 25 November 1980, Col. Saye Zerbo overthrew President Lamizana in a bloodless coup . Colonel Zerbo established the Military Committee of Recovery for National Progress as the supreme governmental authority, thus eradicating the 1977 constitution. Colonel Zerbo also encountered resistance from trade unions and was overthrown two years later by Maj. Dr. Jean-Baptiste Ouédraogo and the Council of Popular Salvation (CSP) in the 1982 Upper Voltan coup d'état . The CSP continued to ban political parties and organizations, yet promised a transition to civilian rule and a new constitution. Infighting developed between the right and left factions of the CSP. The leader of the leftists, Capt. Thomas Sankara , was appointed prime minister in January 1983, but was subsequently arrested. Efforts to free him, directed by Capt. Blaise Compaoré , resulted in a military coup d'état on 4 August 1983. The coup brought Sankara to power and his government began to implement a series of revolutionary programs which included mass-vaccinations, infrastructure improvements, the expansion of women's rights, encouragement of domestic agricultural consumption, and anti-desertification projects. On 2 August 1984, on President Sankara 's initiative, the country's name changed from "Upper Volta" to "Burkina Faso", or land of the honest men ; (the literal translation is land of the upright men .) [ need quotation to verify ] The presidential decree was confirmed by the National Assembly on 4 August. The demonym for people of Burkina Faso, "Burkinabè", includes expatriates or descendants of people of Burkinabè origin. Sankara's government comprised the National Council for the Revolution (CNR – French : Conseil national révolutionnaire ), with Sankara as its president, and established popular Committees for the Defense of the Revolution (CDRs). The Pioneers of the Revolution youth programme was also established. Sankara launched an ambitious socioeconomic programme for change, one of the largest ever undertaken on the African continent. His foreign policies centred on anti-imperialism , with his government rejecting all foreign aid , pushing for odious debt reduction, nationalising all land and mineral wealth and averting the power and influence of the International Monetary Fund (IMF) and World Bank . His domestic policies included a nationwide literacy campaign, land redistribution to peasants, railway and road construction and the outlawing of female genital mutilation , forced marriages and polygamy . Sankara pushed for agrarian self-sufficiency and promoted public health by vaccinating 2,500,000 children against meningitis , yellow fever , and measles . His national agenda also included planting over 10,000,000 trees to halt the growing desertification of the Sahel . Sankara called on every village to build a medical dispensary and had over 350 communities build schools with their own labour. In the 1980s, when ecological awareness was still very low, Thomas Sankara was one of the few African leaders to consider environmental protection a priority. He engaged in three major battles: against bush fires "which will be considered as crimes and will be punished as such"; against cattle roaming "which infringes on the rights of peoples because unattended animals destroy nature"; and against the anarchic cutting of firewood "whose profession will have to be organized and regulated". As part of a development program involving a large part of the population, ten million trees were planted in Burkina Faso in fifteen months during the revolution. To face the advancing desert and recurrent droughts, Thomas Sankara also proposed the planting of wooded strips of about fifty kilometers, crossing the country from east to west. He then thought of extending this vegetation belt to other countries. Cereal production, close to 1.1 billion tons before 1983, was predicted to rise to 1.6 billion tons in 1987. Jean Ziegler, former UN special rapporteur for the right to food, said that the country "had become food self-sufficient." On 15 October 1987, Sankara and twelve other government officials were assassinated in a coup d'état organized by Blaise Compaoré, Sankara's former colleague, who would go on to serve as Burkina Faso's president from October 1987 until October 2014. After the coup and although Sankara was known to be dead, some CDRs mounted an armed resistance to the army for several days. A majority [ quantify ] of Burkinabè citizens hold that France's foreign ministry , the Quai d'Orsay, was behind Compaoré in organizing the coup. There is some evidence for France's support of the coup. Compaoré gave as one of the reasons for the coup the deterioration in relations with neighbouring countries. Compaoré argued that Sankara had jeopardised foreign relations with the former colonial power (France) and with neighbouring Ivory Coast . Following the coup Compaoré immediately reversed the nationalizations, overturned nearly all of Sankara's policies, returned the country back into the IMF fold, and ultimately spurned most of Sankara's legacy. Following an alleged coup-attempt in 1989 , Compaoré introduced limited democratic reforms in 1990. Under the new (1991) constitution , Compaoré was re-elected without opposition in December 1991. In 1998 Compaoré won election in a landslide. In 2004, 13 people were tried for plotting a coup against President Compaoré and the coup's alleged mastermind was sentenced to life imprisonment. As of 2014 [ update ] , Burkina Faso remained one of the least-developed countries in the world. In 2000, the constitution was amended to reduce the presidential term to five years and set term limits to two, preventing successive re-election. The amendment took effect during the 2005 elections. If passed beforehand, it would have prevented Compaoré from being reelected. Other presidential candidates challenged the election results. But in October 2005, the constitutional council ruled that, because Compaoré was the sitting president in 2000, the amendment would not apply to him until the end of his second term in office. This cleared the way for his candidacy in the 2005 election . On 13 November 2005, Compaoré was reelected in a landslide, because of a divided political opposition. In the 2010 presidential election , President Compaoré was re-elected. Only 1.6 million Burkinabè voted, out of a total population 10 times that size. In February 2011, the death of a schoolboy provoked the 2011 Burkinabè protests , a series of popular protests, coupled with a military mutiny and a magistrates' strike, that called for the resignation of Compaoré, democratic reforms, higher wages for troops and public servants and economic freedom. As a result, governors were replaced and wages for public servants were raised. In April 2011, there was an army mutiny ; the president named new chiefs of staff, and a curfew was imposed in Ouagadougou . Compaoré's government played the role of negotiator in several West-African disputes, including the 2010–11 Ivorian crisis , the Inter-Togolese Dialogue (2007), and the 2012 Malian Crisis . Starting on 28 October 2014 protesters began to march and demonstrate in Ouagadougou against President Compaoré, who appeared [ need quotation to verify ] ready to amend the constitution and extend his 27-year rule. On 30 October some protesters set fire to the parliament building and took over the national TV headquarters. Ouagadougou International Airport closed and MPs suspended the vote on changing the constitution (the change would have allowed Compaoré to stand for re-election in 2015). Later in the day, the military dissolved all government institutions and imposed a curfew . On 31 October 2014, President Compaoré, facing mounting pressure, resigned after 27 years in office. Lt. Col. Isaac Zida said that he would lead the country during its transitional period before the planned 2015 presidential election , but there were concerns [ by whom? ] over his close ties to the former president. In November 2014 opposition parties, civil-society groups and religious leaders adopted a plan for a transitional authority to guide Burkina Faso to elections. Under the plan Michel Kafando became the transitional President of Burkina Faso and Lt. Col. Zida became the acting Prime Minister and Defense Minister. On 16 September 2015, the Regiment of Presidential Security (RSP) carried out a coup d'état , seizing the president and prime minister and then declaring the National Council for Democracy the new national government. However, on 22 September 2015, the coup leader, Gilbert Diendéré , apologized and promised to restore civilian government. On 23 September 2015 the prime minister and interim president were restored to power. General elections took place on 29 November 2015. Roch Marc Christian Kaboré won the election in the first round with 53.5% of the vote, defeating businessman Zéphirin Diabré , who took 29.7%. Kaboré was sworn in as president on 29 December 2015. Kaboré was re-elected in the general election of 22 November 2020 , but his party Mouvement du Peuple pour le Progrès (MPP), failed to reach absolute parliamentary majority. It secured 56 seats out of a total of 127. The Congress for Democracy and Progress (CDP), the party of former President Blaise Compaoré, was distant second with 20 seats. A Jihadist insurgency began in August 2015, part of the Islamist insurgency in the Sahel . Between August 2015 and October 2016, seven different posts were attacked across the country. On 15 January 2016, terrorists attacked the capital city of Ouagadougou , killing 30 people. Al-Qaeda in the Islamic Maghreb and Al-Mourabitoune , which until then had mostly operated in neighbouring Mali , claimed responsibility for the attack. In 2016, attacks increased after a new group Ansarul Islam , led by imam Ibrahim Malam Dicko , was founded. Its attacks focused particularly on Soum province and it killed dozens of people in the attack on Nassoumbou on 16 December. Between 27 March – 10 April 2017, the governments of Mali, France, and Burkina Faso launched a joint operation named " Operation Panga ," composed of 1,300 soldiers from the three countries, in Fhero forest, near the Burkina Faso-Mali border , considered a sanctuary for Ansarul Islam. The head of Ansarul Islam, Ibrahim Malam Dicko, was killed in June 2017 and Jafar Dicko became leader. On 2 March 2018, Jama'at Nasr al-Islam wal Muslimin attacked the French embassy in Ouagadougou as well as the general staff of the Burkinabè army. Eight soldiers and eight attackers were killed, and a further 61 soldiers and 24 civilians were injured. The insurgency expanded to the east of the country and, in early October, the Armed Forces of Burkina Faso launched a major military operation in the country's East, supported by French forces. According to Human Rights Watch , between mid-2018 to February 2019, at least 42 people were murdered by jihadists and a minimum of 116 mostly Fulani civilians were killed by military forces without trial. The attacks increased significantly in 2019 . According to the ACLED , armed violence in Burkina Faso jumped by 174% in 2019, with nearly 1,300 civilians dead and 860,000 displaced. Jihadist groups also began to specifically target Christians . On 8 July 2020, the United States raised concerns after a Human Rights Watch report revealed mass graves with at least 180 bodies, which were found in northern Burkina Faso where soldiers were fighting jihadists. On 4 June 2021, the Associated Press reported that according to the government of Burkina Faso, gunmen killed at least 100 people in Solhan village in northern Burkina Faso near the Niger border. A local market and several homes were also burned down. A government spokesman blamed jihadists. Heni Nsaibia, senior researcher at the Armed Conflict Location & Event Data Project said it was the deadliest attack recorded in Burkina Faso since the beginning of the jihadist insurgency. From 4–5 June 2021, unknown militants massacred over 170 people in the villages of Solhan and Tadaryat . Jihadists killed 80 people in Gorgadji on 20 August. On 14 November, the Jama'at Nasr al-Islam wal Muslimin attacked a gendarmerie in Inata , killing 53 soldiers, the heaviest loss of life by the Burkinabe military during the insurgency, and a major morale loss in the country. In December Islamists killed 41 people in an ambush, including the popular vigilante leader Ladji Yoro. Yoro was a central figure in the Volunteers for the Defense of the Homeland (VDP) a pro-government militia that had taken a leading role in the struggle against Islamists. In 2023, shortly after the murder of a Catholic priest at the hands of insurgents, the bishop of Dori, Laurent Dabiré, claimed in an interview with Catholic charity Aid to the Church in Need that around 50% of the country was in the hands of Islamists. In a successful coup on 24 January 2022, mutinying soldiers arrested and deposed President Roch Marc Christian Kaboré following gunfire. The Patriotic Movement for Safeguard and Restoration (MPSR) supported by the military declared itself to be in power, led by Lieutenant Colonel Paul-Henri Sandaogo Damiba . On 31 January, the military junta restored the constitution and appointed Damiba interim president. In the aftermath of the coup, ECOWAS and the African Union suspended Burkina Faso's membership. On 10 February, the Constitutional Council declared Damiba president of Burkina Faso. He was sworn in as president on 16 February. On 1 March 2022, the junta approved a charter allowing a military-led transition of 3 years. The charter provides for the transition process to be followed by the holding of elections. President Kaboré , who had been detained since the military junta took power, was released on 6 April 2022. The insurgency continued following the coup, with about 60% of the country under government control. The Siege of Djibo began in February 2022 and continues as of June 2023. Between 100 and 165 people were killed in Seytenga Department , Séno Province on 12–13 June and around 16,000 people fled their homes. In June, the Government announced the creation of "military zones", which civilians were required to vacate so that the country's Armed and Security Forces could fight insurgents without any "hindrances". On 30 September, Damiba was ousted in a military coup led by Capt. Ibrahim Traoré . This came eight months after Damiba seized power. The rationale given by Traoré for the coup d'état was the purported inability of Paul-Henri Sandaogo Damiba to deal with an Islamist insurgency. Damiba resigned and left the country. On 6 October 2022, Captain Ibrahim Traoré was officially appointed as president of Burkina Faso. Apollinaire Joachim Kyélem de Tambèla was appointed interim Prime Minister on 21 October 2022. On 13 April 2023, authorities in Burkina Faso declared a mobilisation in order to give the nation all means necessary to combat terrorism and create a "legal framework for all the actions to be taken" against the insurgents in recapturing 40 percent of the national territory from Islamist insurgents. On 20 April, the Rapid Intervention Brigade committed the Karma massacre , rounding up and executing civilians en masse . Between 60 and 156 civilians were killed. On 15 October 1987, Sankara and twelve other government officials were assassinated in a coup d'état organized by Blaise Compaoré, Sankara's former colleague, who would go on to serve as Burkina Faso's president from October 1987 until October 2014. After the coup and although Sankara was known to be dead, some CDRs mounted an armed resistance to the army for several days. A majority [ quantify ] of Burkinabè citizens hold that France's foreign ministry , the Quai d'Orsay, was behind Compaoré in organizing the coup. There is some evidence for France's support of the coup. Compaoré gave as one of the reasons for the coup the deterioration in relations with neighbouring countries. Compaoré argued that Sankara had jeopardised foreign relations with the former colonial power (France) and with neighbouring Ivory Coast . Following the coup Compaoré immediately reversed the nationalizations, overturned nearly all of Sankara's policies, returned the country back into the IMF fold, and ultimately spurned most of Sankara's legacy. Following an alleged coup-attempt in 1989 , Compaoré introduced limited democratic reforms in 1990. Under the new (1991) constitution , Compaoré was re-elected without opposition in December 1991. In 1998 Compaoré won election in a landslide. In 2004, 13 people were tried for plotting a coup against President Compaoré and the coup's alleged mastermind was sentenced to life imprisonment. As of 2014 [ update ] , Burkina Faso remained one of the least-developed countries in the world. In 2000, the constitution was amended to reduce the presidential term to five years and set term limits to two, preventing successive re-election. The amendment took effect during the 2005 elections. If passed beforehand, it would have prevented Compaoré from being reelected. Other presidential candidates challenged the election results. But in October 2005, the constitutional council ruled that, because Compaoré was the sitting president in 2000, the amendment would not apply to him until the end of his second term in office. This cleared the way for his candidacy in the 2005 election . On 13 November 2005, Compaoré was reelected in a landslide, because of a divided political opposition. In the 2010 presidential election , President Compaoré was re-elected. Only 1.6 million Burkinabè voted, out of a total population 10 times that size. In February 2011, the death of a schoolboy provoked the 2011 Burkinabè protests , a series of popular protests, coupled with a military mutiny and a magistrates' strike, that called for the resignation of Compaoré, democratic reforms, higher wages for troops and public servants and economic freedom. As a result, governors were replaced and wages for public servants were raised. In April 2011, there was an army mutiny ; the president named new chiefs of staff, and a curfew was imposed in Ouagadougou . Compaoré's government played the role of negotiator in several West-African disputes, including the 2010–11 Ivorian crisis , the Inter-Togolese Dialogue (2007), and the 2012 Malian Crisis . Starting on 28 October 2014 protesters began to march and demonstrate in Ouagadougou against President Compaoré, who appeared [ need quotation to verify ] ready to amend the constitution and extend his 27-year rule. On 30 October some protesters set fire to the parliament building and took over the national TV headquarters. Ouagadougou International Airport closed and MPs suspended the vote on changing the constitution (the change would have allowed Compaoré to stand for re-election in 2015). Later in the day, the military dissolved all government institutions and imposed a curfew . On 31 October 2014, President Compaoré, facing mounting pressure, resigned after 27 years in office. Lt. Col. Isaac Zida said that he would lead the country during its transitional period before the planned 2015 presidential election , but there were concerns [ by whom? ] over his close ties to the former president. In November 2014 opposition parties, civil-society groups and religious leaders adopted a plan for a transitional authority to guide Burkina Faso to elections. Under the plan Michel Kafando became the transitional President of Burkina Faso and Lt. Col. Zida became the acting Prime Minister and Defense Minister. On 16 September 2015, the Regiment of Presidential Security (RSP) carried out a coup d'état , seizing the president and prime minister and then declaring the National Council for Democracy the new national government. However, on 22 September 2015, the coup leader, Gilbert Diendéré , apologized and promised to restore civilian government. On 23 September 2015 the prime minister and interim president were restored to power. Starting on 28 October 2014 protesters began to march and demonstrate in Ouagadougou against President Compaoré, who appeared [ need quotation to verify ] ready to amend the constitution and extend his 27-year rule. On 30 October some protesters set fire to the parliament building and took over the national TV headquarters. Ouagadougou International Airport closed and MPs suspended the vote on changing the constitution (the change would have allowed Compaoré to stand for re-election in 2015). Later in the day, the military dissolved all government institutions and imposed a curfew . On 31 October 2014, President Compaoré, facing mounting pressure, resigned after 27 years in office. Lt. Col. Isaac Zida said that he would lead the country during its transitional period before the planned 2015 presidential election , but there were concerns [ by whom? ] over his close ties to the former president. In November 2014 opposition parties, civil-society groups and religious leaders adopted a plan for a transitional authority to guide Burkina Faso to elections. Under the plan Michel Kafando became the transitional President of Burkina Faso and Lt. Col. Zida became the acting Prime Minister and Defense Minister. On 16 September 2015, the Regiment of Presidential Security (RSP) carried out a coup d'état , seizing the president and prime minister and then declaring the National Council for Democracy the new national government. However, on 22 September 2015, the coup leader, Gilbert Diendéré , apologized and promised to restore civilian government. On 23 September 2015 the prime minister and interim president were restored to power. General elections took place on 29 November 2015. Roch Marc Christian Kaboré won the election in the first round with 53.5% of the vote, defeating businessman Zéphirin Diabré , who took 29.7%. Kaboré was sworn in as president on 29 December 2015. Kaboré was re-elected in the general election of 22 November 2020 , but his party Mouvement du Peuple pour le Progrès (MPP), failed to reach absolute parliamentary majority. It secured 56 seats out of a total of 127. The Congress for Democracy and Progress (CDP), the party of former President Blaise Compaoré, was distant second with 20 seats. A Jihadist insurgency began in August 2015, part of the Islamist insurgency in the Sahel . Between August 2015 and October 2016, seven different posts were attacked across the country. On 15 January 2016, terrorists attacked the capital city of Ouagadougou , killing 30 people. Al-Qaeda in the Islamic Maghreb and Al-Mourabitoune , which until then had mostly operated in neighbouring Mali , claimed responsibility for the attack. In 2016, attacks increased after a new group Ansarul Islam , led by imam Ibrahim Malam Dicko , was founded. Its attacks focused particularly on Soum province and it killed dozens of people in the attack on Nassoumbou on 16 December. Between 27 March – 10 April 2017, the governments of Mali, France, and Burkina Faso launched a joint operation named " Operation Panga ," composed of 1,300 soldiers from the three countries, in Fhero forest, near the Burkina Faso-Mali border , considered a sanctuary for Ansarul Islam. The head of Ansarul Islam, Ibrahim Malam Dicko, was killed in June 2017 and Jafar Dicko became leader. On 2 March 2018, Jama'at Nasr al-Islam wal Muslimin attacked the French embassy in Ouagadougou as well as the general staff of the Burkinabè army. Eight soldiers and eight attackers were killed, and a further 61 soldiers and 24 civilians were injured. The insurgency expanded to the east of the country and, in early October, the Armed Forces of Burkina Faso launched a major military operation in the country's East, supported by French forces. According to Human Rights Watch , between mid-2018 to February 2019, at least 42 people were murdered by jihadists and a minimum of 116 mostly Fulani civilians were killed by military forces without trial. The attacks increased significantly in 2019 . According to the ACLED , armed violence in Burkina Faso jumped by 174% in 2019, with nearly 1,300 civilians dead and 860,000 displaced. Jihadist groups also began to specifically target Christians . On 8 July 2020, the United States raised concerns after a Human Rights Watch report revealed mass graves with at least 180 bodies, which were found in northern Burkina Faso where soldiers were fighting jihadists. On 4 June 2021, the Associated Press reported that according to the government of Burkina Faso, gunmen killed at least 100 people in Solhan village in northern Burkina Faso near the Niger border. A local market and several homes were also burned down. A government spokesman blamed jihadists. Heni Nsaibia, senior researcher at the Armed Conflict Location & Event Data Project said it was the deadliest attack recorded in Burkina Faso since the beginning of the jihadist insurgency. From 4–5 June 2021, unknown militants massacred over 170 people in the villages of Solhan and Tadaryat . Jihadists killed 80 people in Gorgadji on 20 August. On 14 November, the Jama'at Nasr al-Islam wal Muslimin attacked a gendarmerie in Inata , killing 53 soldiers, the heaviest loss of life by the Burkinabe military during the insurgency, and a major morale loss in the country. In December Islamists killed 41 people in an ambush, including the popular vigilante leader Ladji Yoro. Yoro was a central figure in the Volunteers for the Defense of the Homeland (VDP) a pro-government militia that had taken a leading role in the struggle against Islamists. In 2023, shortly after the murder of a Catholic priest at the hands of insurgents, the bishop of Dori, Laurent Dabiré, claimed in an interview with Catholic charity Aid to the Church in Need that around 50% of the country was in the hands of Islamists. In a successful coup on 24 January 2022, mutinying soldiers arrested and deposed President Roch Marc Christian Kaboré following gunfire. The Patriotic Movement for Safeguard and Restoration (MPSR) supported by the military declared itself to be in power, led by Lieutenant Colonel Paul-Henri Sandaogo Damiba . On 31 January, the military junta restored the constitution and appointed Damiba interim president. In the aftermath of the coup, ECOWAS and the African Union suspended Burkina Faso's membership. On 10 February, the Constitutional Council declared Damiba president of Burkina Faso. He was sworn in as president on 16 February. On 1 March 2022, the junta approved a charter allowing a military-led transition of 3 years. The charter provides for the transition process to be followed by the holding of elections. President Kaboré , who had been detained since the military junta took power, was released on 6 April 2022. The insurgency continued following the coup, with about 60% of the country under government control. The Siege of Djibo began in February 2022 and continues as of June 2023. Between 100 and 165 people were killed in Seytenga Department , Séno Province on 12–13 June and around 16,000 people fled their homes. In June, the Government announced the creation of "military zones", which civilians were required to vacate so that the country's Armed and Security Forces could fight insurgents without any "hindrances". On 30 September, Damiba was ousted in a military coup led by Capt. Ibrahim Traoré . This came eight months after Damiba seized power. The rationale given by Traoré for the coup d'état was the purported inability of Paul-Henri Sandaogo Damiba to deal with an Islamist insurgency. Damiba resigned and left the country. On 6 October 2022, Captain Ibrahim Traoré was officially appointed as president of Burkina Faso. Apollinaire Joachim Kyélem de Tambèla was appointed interim Prime Minister on 21 October 2022. On 13 April 2023, authorities in Burkina Faso declared a mobilisation in order to give the nation all means necessary to combat terrorism and create a "legal framework for all the actions to be taken" against the insurgents in recapturing 40 percent of the national territory from Islamist insurgents. On 20 April, the Rapid Intervention Brigade committed the Karma massacre , rounding up and executing civilians en masse . Between 60 and 156 civilians were killed. The constitution of 2 June 1991 established a semi-presidential government : its parliament could be dissolved by the President of the Republic , who was to be elected for a term of seven years. In 2000, the constitution was amended to reduce the presidential term to five years and set term limits to two, preventing successive re-election. The amendment took effect during the 2005 elections. The parliament consisted of one chamber known as the National Assembly , which had 111 seats with members elected to serve five-year terms. There was also a constitutional chamber, composed of ten members, and an economic and social council whose roles were purely consultative. The 1991 constitution created a bicameral parliament, but the upper house (Chamber of Representatives) was abolished in 2002. The Compaoré administration had worked to decentralize power by devolving some of its powers to regions and municipal authorities. But the widespread distrust of politicians and lack of political involvement by many residents complicated this process. Critics described this as a hybrid decentralisation. Political freedoms are severely restricted in Burkina Faso. Human rights organizations had criticised the Compaoré administration for numerous acts of state-sponsored violence against journalists and other politically active members of society. The prime minister is head of government and is appointed by the president with the approval of the National Assembly. He is responsible for recommending a cabinet for appointment by the president. In 2015, Kaboré promised to revise the 1991 constitution. The revision was completed in 2018. One condition prevents any individual from serving as president for more than ten years either consecutively or intermittently and provides a method for impeaching a president. A referendum on the constitution for the Fifth Republic was scheduled for 24 March 2019. Certain rights are also enshrined in the revised wording: access to drinking water, access to decent housing and a recognition of the right to civil disobedience, for example. The referendum was required because the opposition parties in Parliament refused to sanction the proposed text. Following the January 2022 coup d'état , the military dissolved the parliament, government and constitution. On 31 January, the military junta restored the constitution, but it was suspended again following the September 2022 coup d'état . Burkina Faso is a member of the G5 Sahel , Community of Sahel–Saharan States , La Francophonie , Organisation of Islamic Cooperation , and United Nations. It is currently suspended from ECOWAS and the African Union . The army consists of some 6,000 men in voluntary service, augmented by a part-time national People's Militia composed of civilians between 25 and 35 years of age who are trained in both military and civil duties. According to Jane's Sentinel Country Risk Assessment , Burkina Faso's Army is undermanned for its force structure and poorly equipped, but has wheeled light-armour vehicles, and may have developed useful combat expertise through interventions in Liberia and elsewhere in Africa. In terms of training and equipment, the regular Army is believed to be neglected in relation to the élite Regiment of Presidential Security ( French: Régiment de la Sécurité Présidentielle – RSP). Reports have emerged in recent years of disputes over pay and conditions. There is an air force with some 19 operational aircraft, but no navy, as the country is landlocked. Military expenses constitute approximately 1.2% of the nation's GDP. Burkina Faso employs numerous police and security forces, generally modeled after organizations used by French police . France continues to provide significant support and training to police forces. The Gendarmerie Nationale is organized along military lines, with most police services delivered at the brigade level. The Gendarmerie operates under the authority of the Minister of Defence, and its members are employed chiefly in the rural areas and along borders. There is a municipal police force controlled by the Ministry of Territorial Administration ; a national police force controlled by the Ministry of Security; and an autonomous Regiment of Presidential Security ( Régiment de la Sécurité Présidentielle , or RSP), a 'palace guard' devoted to the protection of the President of the Republic. Both the gendarmerie and the national police are subdivided into both administrative and judicial police functions; the former are detailed to protect public order and provide security, the latter are charged with criminal investigations. All foreigners and citizens are required to carry photo ID passports, or other forms of identification or risk a fine, and police spot identity checks are commonplace for persons traveling by auto, bush-taxi , or bus. The country is divided into 13 administrative regions . These regions encompass 45 provinces and 301 departments . Each region is administered by a governor.In 2015, Kaboré promised to revise the 1991 constitution. The revision was completed in 2018. One condition prevents any individual from serving as president for more than ten years either consecutively or intermittently and provides a method for impeaching a president. A referendum on the constitution for the Fifth Republic was scheduled for 24 March 2019. Certain rights are also enshrined in the revised wording: access to drinking water, access to decent housing and a recognition of the right to civil disobedience, for example. The referendum was required because the opposition parties in Parliament refused to sanction the proposed text. Following the January 2022 coup d'état , the military dissolved the parliament, government and constitution. On 31 January, the military junta restored the constitution, but it was suspended again following the September 2022 coup d'état . Burkina Faso is a member of the G5 Sahel , Community of Sahel–Saharan States , La Francophonie , Organisation of Islamic Cooperation , and United Nations. It is currently suspended from ECOWAS and the African Union .The army consists of some 6,000 men in voluntary service, augmented by a part-time national People's Militia composed of civilians between 25 and 35 years of age who are trained in both military and civil duties. According to Jane's Sentinel Country Risk Assessment , Burkina Faso's Army is undermanned for its force structure and poorly equipped, but has wheeled light-armour vehicles, and may have developed useful combat expertise through interventions in Liberia and elsewhere in Africa. In terms of training and equipment, the regular Army is believed to be neglected in relation to the élite Regiment of Presidential Security ( French: Régiment de la Sécurité Présidentielle – RSP). Reports have emerged in recent years of disputes over pay and conditions. There is an air force with some 19 operational aircraft, but no navy, as the country is landlocked. Military expenses constitute approximately 1.2% of the nation's GDP.Burkina Faso employs numerous police and security forces, generally modeled after organizations used by French police . France continues to provide significant support and training to police forces. The Gendarmerie Nationale is organized along military lines, with most police services delivered at the brigade level. The Gendarmerie operates under the authority of the Minister of Defence, and its members are employed chiefly in the rural areas and along borders. There is a municipal police force controlled by the Ministry of Territorial Administration ; a national police force controlled by the Ministry of Security; and an autonomous Regiment of Presidential Security ( Régiment de la Sécurité Présidentielle , or RSP), a 'palace guard' devoted to the protection of the President of the Republic. Both the gendarmerie and the national police are subdivided into both administrative and judicial police functions; the former are detailed to protect public order and provide security, the latter are charged with criminal investigations. All foreigners and citizens are required to carry photo ID passports, or other forms of identification or risk a fine, and police spot identity checks are commonplace for persons traveling by auto, bush-taxi , or bus. The country is divided into 13 administrative regions . These regions encompass 45 provinces and 301 departments . Each region is administered by a governor.Burkina Faso lies mostly between latitudes 9° and 15° N (a small area is north of 15°), and longitudes 6° W and 3° E . It is made up of two major types of countryside. The larger part of the country is covered by a peneplain , which forms a gently undulating landscape with, in some areas, a few isolated hills, the last vestiges of a Precambrian massif . The southwest of the country, on the other hand, forms a sandstone massif, where the highest peak, Ténakourou , is found at an elevation of 749 meters (2,457 ft) . The massif is bordered by sheer cliffs up to 150 m (492 ft) high. The average altitude of Burkina Faso is 400 m (1,312 ft) and the difference between the highest and lowest terrain is no greater than 600 m (1,969 ft) . Burkina Faso is therefore a relatively flat country. The country owes its former name of Upper Volta to three rivers which cross it: the Black Volta (or Mouhoun ), the White Volta ( Nakambé ) and the Red Volta ( Nazinon ). The Black Volta is one of the country's only two rivers which flow year-round, the other being the Komoé , which flows to the southwest. The basin of the Niger River also drains 27% of the country's surface. The Niger's tributaries – the Béli, Gorouol, Goudébo, and Dargol – are seasonal streams and flow for only four to six months a year. They still can flood and overflow, however. The country also contains numerous lakes – the principal ones are Tingrela, Bam , and Dem. The country contains large ponds, as well, such as Oursi, Béli, Yomboli, and Markoye. Water shortages are often a problem, especially in the north of the country. Burkina Faso lies within two terrestrial ecoregions: Sahelian Acacia savanna and West Sudanian savanna . Burkina Faso has a primarily tropical climate with two very distinct seasons. In the rainy season, the country receives between 600 and 900 mm (24 and 35 in) of rainfall; in the dry season, the harmattan – a hot dry wind from the Sahara – blows. The rainy season lasts around four months, May/June to September, but is shorter in the north of the country. Three climatic zones can be defined: the Sahel , the Sudan-Sahel, and the Sudan-Guinea. The Sahel in the north typically receives less than 600 mm (24 in) of rainfall per year and has high temperatures, 5–47 °C (41–117 °F ) . A relatively dry tropical savanna , the Sahel extends beyond the borders of Burkina Faso, from the Horn of Africa to the Atlantic Ocean, and borders the Sahara to its north and the fertile region of the Sudan to the south. Situated between 11° 3′ and 13° 5′ north latitude , the Sudan-Sahel region is a transitional zone with regard to rainfall and temperature. Further to the south, the Sudan-Guinea zone receives more than 900 mm (35 in) of rain each year and has cooler average temperatures. Geography and environment contribute to Burkina Faso's food insecurity. As the country is situated in the Sahel region, it has some of the most radical climatic variation in the world, ranging from severe flooding to extreme drought. The unpredictable climatic shocks can make it very difficult for Burkina Faso citizens to rely on and prosper from agriculture. Burkina Faso's climate also renders its crops vulnerable to insect attacks, including attacks from locusts and crickets , which destroy crops and further inhibit food production. Not only is most of the population of Burkina Faso dependent on agriculture as a source of income, but they also rely on the agricultural sector for food that will directly feed the household. Due to the vulnerability of agriculture, more and more families are having to look for other sources of non-farm income, and often have to travel outside of their regional zone to find work. Burkina Faso's natural resources include gold, manganese , limestone , marble , phosphates , pumice , and salt . Burkina Faso has a larger number of elephants than many countries in West Africa. Lions, leopards and buffalo can also be found here, including the dwarf or red buffalo, a smaller reddish-brown animal which looks like a fierce kind of short-legged cow. Other large predators live in Burkina Faso, such as the cheetah, the caracal or African lynx, the spotted hyena and the African wild dog, one of the continent's most endangered species. Burkina Faso's fauna and flora are protected in four national parks: and several reserves: see List of national parks in Africa and Nature reserves of Burkina Faso .Burkina Faso has a primarily tropical climate with two very distinct seasons. In the rainy season, the country receives between 600 and 900 mm (24 and 35 in) of rainfall; in the dry season, the harmattan – a hot dry wind from the Sahara – blows. The rainy season lasts around four months, May/June to September, but is shorter in the north of the country. Three climatic zones can be defined: the Sahel , the Sudan-Sahel, and the Sudan-Guinea. The Sahel in the north typically receives less than 600 mm (24 in) of rainfall per year and has high temperatures, 5–47 °C (41–117 °F ) . A relatively dry tropical savanna , the Sahel extends beyond the borders of Burkina Faso, from the Horn of Africa to the Atlantic Ocean, and borders the Sahara to its north and the fertile region of the Sudan to the south. Situated between 11° 3′ and 13° 5′ north latitude , the Sudan-Sahel region is a transitional zone with regard to rainfall and temperature. Further to the south, the Sudan-Guinea zone receives more than 900 mm (35 in) of rain each year and has cooler average temperatures. Geography and environment contribute to Burkina Faso's food insecurity. As the country is situated in the Sahel region, it has some of the most radical climatic variation in the world, ranging from severe flooding to extreme drought. The unpredictable climatic shocks can make it very difficult for Burkina Faso citizens to rely on and prosper from agriculture. Burkina Faso's climate also renders its crops vulnerable to insect attacks, including attacks from locusts and crickets , which destroy crops and further inhibit food production. Not only is most of the population of Burkina Faso dependent on agriculture as a source of income, but they also rely on the agricultural sector for food that will directly feed the household. Due to the vulnerability of agriculture, more and more families are having to look for other sources of non-farm income, and often have to travel outside of their regional zone to find work. Burkina Faso's natural resources include gold, manganese , limestone , marble , phosphates , pumice , and salt .Burkina Faso has a larger number of elephants than many countries in West Africa. Lions, leopards and buffalo can also be found here, including the dwarf or red buffalo, a smaller reddish-brown animal which looks like a fierce kind of short-legged cow. Other large predators live in Burkina Faso, such as the cheetah, the caracal or African lynx, the spotted hyena and the African wild dog, one of the continent's most endangered species. Burkina Faso's fauna and flora are protected in four national parks: and several reserves: see List of national parks in Africa and Nature reserves of Burkina Faso .The value of Burkina Faso's exports fell from $2.77 billion in 2011 to $754 million in 2012. Agriculture represents 32% of its gross domestic product and occupies 80% of the working population. It consists mostly of rearing livestock. Especially in the south and southwest, the people grow crops of sorghum , pearl millet , maize (corn), peanuts, rice and cotton, with surpluses to be sold. A large part of the economic activity of the country is funded by international aid, despite having gold ores in abundance. The top five export commodities in 2017 were, in order of importance: gems and precious metals, US$1.9 billion (78.5% of total exports), cotton, $198.7 million (8.3%), ores, slag, ash, $137.6 million (5.8%), fruits, nuts: $76.6 million (3.2%) and oil seeds: $59.5 million (2.5%). A December 2018 report from the World Bank indicates that in 2017, economic growth increased to 6.4% in 2017 (vs. 5.9% in 2016) primarily due to gold production and increased investment in infrastructure. The increase in consumption linked to growth of the wage bill also supported economic growth. Inflation remained low, 0.4% that year but the public deficit grew to 7.7% of GDP (vs. 3.5% in 2016). The government was continuing to get financial aid and loans to finance the debt. To finance the public deficit, the Government combined concessional aid and borrowing on the regional market. The World Bank said that the economic outlook remained favorable in the short and medium term, although that could be negatively impacted. Risks included high oil prices (imports), lower prices of gold and cotton (exports) as well as terrorist threat and labour strikes. Burkina Faso is part of the West African Monetary and Economic Union (UMEOA) and has adopted the CFA franc . This is issued by the Central Bank of the West African States (BCEAO), situated in Dakar , Senegal. The BCEAO manages the monetary and reserve policy of the member states, and provides regulation and oversight of financial sector and banking activity. A legal framework regarding licensing, bank activities, organizational and capital requirements, inspections and sanctions (all applicable to all countries of the Union) is in place, having been reformed significantly in 1999. Microfinance institutions are governed by a separate law, which regulates microfinance activities in all WAEMU countries. The insurance sector is regulated through the Inter-African Conference on Insurance Markets (CIMA). In 2018, tourism was almost non-existent in large parts of the country. The U.S. government (and others) warn their citizens not to travel into large parts of Burkina Faso: "The northern Sahel border region shared with Mali and Niger due to crime and terrorism. The provinces of Kmoandjari, Tapoa, Kompienga, and Gourma in East Region due to crime and terrorism". The 2018 CIA World Factbook provides this updated summary. "Burkina Faso is a poor, landlocked country that depends on adequate rainfall. Irregular patterns of rainfall, poor soil, and the lack of adequate communications and other infrastructure contribute to the economy's vulnerability to external shocks. About 80% of the population is engaged in subsistence farming and cotton is the main cash crop. The country has few natural resources and a weak industrial base. Cotton and gold are Burkina Faso's key exports ...The country has seen an upswing in gold exploration, production, and exports. While the end of the political crisis has allowed Burkina Faso's economy to resume positive growth, the country's fragile security situation could put these gains at risk. Political insecurity in neighboring Mali, unreliable energy supplies, and poor transportation links pose long-term challenges." The report also highlights the 2018–2020 International Monetary Fund program, including the government's plan to "reduce the budget deficit and preserve critical spending on social services and priority public investments". A 2018 report by the African Development Bank Group discussed a macroeconomic evolution: "higher investment and continued spending on social services and security that will add to the budget deficit". This group's prediction for 2018 indicated that the budget deficit would be reduced to 4.8% of GDP in 2018 and to 2.9% in 2019. Public debt associated with the National Economic and Social Development Plan was estimated at 36.9% of GDP in 2017. Burkina Faso is a member of the Organization for the Harmonization of Business Law in Africa (OHADA). The country also belongs to the United Nations, International Monetary Fund, World Bank, and World Trade Organization. There is mining of copper , iron , manganese , gold , cassiterite (tin ore), and phosphates. These operations provide employment and generate international aid. Gold production increased 32% in 2011 at six gold mine sites, making Burkina Faso the fourth-largest gold producer in Africa, after South Africa, Mali and Ghana. A 2018 report indicated that the country expected record 55 tonnes of gold in that year, a two-thirds increase over 2013. According to Oumarou Idani, there is a more important issue. "We have to diversify production. We mostly only produce gold, but we have huge potential in manganese, zinc, lead, copper, nickel and limestone". There is mining of copper , iron , manganese , gold , cassiterite (tin ore), and phosphates. These operations provide employment and generate international aid. Gold production increased 32% in 2011 at six gold mine sites, making Burkina Faso the fourth-largest gold producer in Africa, after South Africa, Mali and Ghana. A 2018 report indicated that the country expected record 55 tonnes of gold in that year, a two-thirds increase over 2013. According to Oumarou Idani, there is a more important issue. "We have to diversify production. We mostly only produce gold, but we have huge potential in manganese, zinc, lead, copper, nickel and limestone". According to the Global Hunger Index , a multidimensional tool used to measure and track a country's hunger levels, Burkina Faso ranked 65 out of 78 countries in 2013. It is estimated that there are currently over 1.5 million children who are at risk of food insecurity in Burkina Faso, with around 350,000 children who are in need of emergency medical assistance. However, only about a third of these children will actually receive adequate medical attention. Only 11.4 percent of children under the age of two receive the daily recommended number of meals. Stunted growth as a result of food insecurity is a severe problem in Burkina Faso, affecting at least a third of the population from 2008 to 2012. Additionally, stunted children, on average, tend to complete less school than children with normal growth development, further contributing to the low levels of education of the Burkina Faso population. The European Commission expects that approximately 500,000 children under age 5 in Burkina Faso will suffer from acute malnutrition in 2015, including around 149,000 who will suffer from its most life-threatening form. Rates of micronutrient deficiencies are also high. According to the Demographic and Health Survey (DHS 2010), 49 percent of women and 88 percent of children under the age of five suffer from anemia. Forty percent of infant deaths can be attributed to malnutrition , and in turn, these infant mortality rates have decreased Burkina Faso's total work force by 13.6 percent, demonstrating how food security affects more aspects of life beyond health. These high rates of food insecurity and the accompanying effects are even more prevalent in rural populations compared to urban ones, as access to health services in rural areas is much more limited and awareness and education of children's nutritional needs is lower. An October 2018 report by USAid stated that droughts and floods remained problematic, and that "violence and insecurity are disrupting markets, trade and livelihoods activities in some of Burkina Faso's northern and eastern areas". The report estimated that over 954,300 people needed food security support, and that, according to UNICEF , an "estimated 187,200 children under 5 years of age will experience severe acute malnutrition". Agencies providing assistance at the time included USAID's Office of Food for Peace (FFP) working with the UN World Food Programme , the NGO Oxfam Intermón and ACDI/VOCA . The United Nations' World Food Programme has worked on programs that are geared towards increasing food security in Burkina Faso. The Protracted Relief and Recovery Operation 200509 (PRRO) was formed to respond to the high levels of malnutrition in Burkina Faso, following the food and nutrition crisis in 2012. The efforts of this project are mostly geared towards the treatment and prevention of malnutrition and include take home rations for the caretakers of those children who are being treated for malnutrition. Additionally, the activities of this operation contribute to families' abilities to withstand future food crises. Better nutrition among the two most vulnerable groups, young children and pregnant women, prepares them to be able to respond better in times when food security is compromised, such as in droughts. The Country Programme (CP) has two parts: food and nutritional assistance to people with HIV/AIDS, and a school feeding program for all primary schools in the Sahel region. The HIV/AIDS nutrition program aims to better the nutritional recovery of those who are living with HIV/AIDS and to protect at-risk children and orphans from malnutrition and food security. As part of the school feeding component, the Country Programme's goals are to increase enrollment and attendance in schools in the Sahel region, where enrollment rates are below the national average. Furthermore, the program aims at improving gender parity rates in these schools, by providing girls with high attendance in the last two years of primary school with take-home rations of cereals as an incentive to households, encouraging them to send their girls to school. The WFP concluded the formation of a subsequently approved plan in August 2018 "to support the Government's vision of 'a democratic, unified and united nation, transforming the structure of its economy and achieving a strong and inclusive growth through patterns of sustainable consumption and production.' It will take important steps in WFP's new strategic direction for strengthened national and local capacities to enable the Government and communities to own, manage, and implement food and nutrition security programmes by 2030". The World Bank was established in 1944, and comprises five institutions whose shared goals are to end extreme poverty by 2030 and to promote shared prosperity by fostering income growth of the lower forty percent of every country. One of the main projects the World Bank is working on to reduce food insecurity in Burkina Faso is the Agricultural Productivity and Food Security Project. According to the World Bank, the objective of this project is to "improve the capacity of poor producers to increase food production and to ensure improved availability of food products in rural markets." The Agricultural Productivity and Food Security Project has three main parts. Its first component is to work towards the improvement of food production, including financing grants and providing 'voucher for work' programs for households who cannot pay their contribution in cash. The project's next component involves improving the ability of food products, particularly in rural areas. This includes supporting the marketing of food products, and aims to strengthen the capabilities of stakeholders to control the variability of food products and supplies at local and national levels. Lastly, the third component of this project focuses on institutional development and capacity building. Its goal is to reinforce the capacities of service providers and institutions who are specifically involved in project implementation. The project's activities aim to build capacities of service providers, strengthen the capacity of food producer organizations, strengthen agricultural input supply delivery methods, and manage and evaluate project activities. The December 2018 report by the World Bank indicated that the poverty rate fell slightly between 2009 and 2014, from 46% to a still high 40.1%. The report provided this updated summary of the country's development challenges: "Burkina Faso remains vulnerable to climatic shocks related to changes in rainfall patterns and to fluctuations in the prices of its export commodities on world markets. Its economic and social development will, to some extent, be contingent on political stability in the country and the subregion, its openness to international trade, and export diversification". The United Nations' World Food Programme has worked on programs that are geared towards increasing food security in Burkina Faso. The Protracted Relief and Recovery Operation 200509 (PRRO) was formed to respond to the high levels of malnutrition in Burkina Faso, following the food and nutrition crisis in 2012. The efforts of this project are mostly geared towards the treatment and prevention of malnutrition and include take home rations for the caretakers of those children who are being treated for malnutrition. Additionally, the activities of this operation contribute to families' abilities to withstand future food crises. Better nutrition among the two most vulnerable groups, young children and pregnant women, prepares them to be able to respond better in times when food security is compromised, such as in droughts. The Country Programme (CP) has two parts: food and nutritional assistance to people with HIV/AIDS, and a school feeding program for all primary schools in the Sahel region. The HIV/AIDS nutrition program aims to better the nutritional recovery of those who are living with HIV/AIDS and to protect at-risk children and orphans from malnutrition and food security. As part of the school feeding component, the Country Programme's goals are to increase enrollment and attendance in schools in the Sahel region, where enrollment rates are below the national average. Furthermore, the program aims at improving gender parity rates in these schools, by providing girls with high attendance in the last two years of primary school with take-home rations of cereals as an incentive to households, encouraging them to send their girls to school. The WFP concluded the formation of a subsequently approved plan in August 2018 "to support the Government's vision of 'a democratic, unified and united nation, transforming the structure of its economy and achieving a strong and inclusive growth through patterns of sustainable consumption and production.' It will take important steps in WFP's new strategic direction for strengthened national and local capacities to enable the Government and communities to own, manage, and implement food and nutrition security programmes by 2030". The World Bank was established in 1944, and comprises five institutions whose shared goals are to end extreme poverty by 2030 and to promote shared prosperity by fostering income growth of the lower forty percent of every country. One of the main projects the World Bank is working on to reduce food insecurity in Burkina Faso is the Agricultural Productivity and Food Security Project. According to the World Bank, the objective of this project is to "improve the capacity of poor producers to increase food production and to ensure improved availability of food products in rural markets." The Agricultural Productivity and Food Security Project has three main parts. Its first component is to work towards the improvement of food production, including financing grants and providing 'voucher for work' programs for households who cannot pay their contribution in cash. The project's next component involves improving the ability of food products, particularly in rural areas. This includes supporting the marketing of food products, and aims to strengthen the capabilities of stakeholders to control the variability of food products and supplies at local and national levels. Lastly, the third component of this project focuses on institutional development and capacity building. Its goal is to reinforce the capacities of service providers and institutions who are specifically involved in project implementation. The project's activities aim to build capacities of service providers, strengthen the capacity of food producer organizations, strengthen agricultural input supply delivery methods, and manage and evaluate project activities. The December 2018 report by the World Bank indicated that the poverty rate fell slightly between 2009 and 2014, from 46% to a still high 40.1%. The report provided this updated summary of the country's development challenges: "Burkina Faso remains vulnerable to climatic shocks related to changes in rainfall patterns and to fluctuations in the prices of its export commodities on world markets. Its economic and social development will, to some extent, be contingent on political stability in the country and the subregion, its openness to international trade, and export diversification". The United Nations' World Food Programme has worked on programs that are geared towards increasing food security in Burkina Faso. The Protracted Relief and Recovery Operation 200509 (PRRO) was formed to respond to the high levels of malnutrition in Burkina Faso, following the food and nutrition crisis in 2012. The efforts of this project are mostly geared towards the treatment and prevention of malnutrition and include take home rations for the caretakers of those children who are being treated for malnutrition. Additionally, the activities of this operation contribute to families' abilities to withstand future food crises. Better nutrition among the two most vulnerable groups, young children and pregnant women, prepares them to be able to respond better in times when food security is compromised, such as in droughts. The Country Programme (CP) has two parts: food and nutritional assistance to people with HIV/AIDS, and a school feeding program for all primary schools in the Sahel region. The HIV/AIDS nutrition program aims to better the nutritional recovery of those who are living with HIV/AIDS and to protect at-risk children and orphans from malnutrition and food security. As part of the school feeding component, the Country Programme's goals are to increase enrollment and attendance in schools in the Sahel region, where enrollment rates are below the national average. Furthermore, the program aims at improving gender parity rates in these schools, by providing girls with high attendance in the last two years of primary school with take-home rations of cereals as an incentive to households, encouraging them to send their girls to school. The WFP concluded the formation of a subsequently approved plan in August 2018 "to support the Government's vision of 'a democratic, unified and united nation, transforming the structure of its economy and achieving a strong and inclusive growth through patterns of sustainable consumption and production.' It will take important steps in WFP's new strategic direction for strengthened national and local capacities to enable the Government and communities to own, manage, and implement food and nutrition security programmes by 2030". The World Bank was established in 1944, and comprises five institutions whose shared goals are to end extreme poverty by 2030 and to promote shared prosperity by fostering income growth of the lower forty percent of every country. One of the main projects the World Bank is working on to reduce food insecurity in Burkina Faso is the Agricultural Productivity and Food Security Project. According to the World Bank, the objective of this project is to "improve the capacity of poor producers to increase food production and to ensure improved availability of food products in rural markets." The Agricultural Productivity and Food Security Project has three main parts. Its first component is to work towards the improvement of food production, including financing grants and providing 'voucher for work' programs for households who cannot pay their contribution in cash. The project's next component involves improving the ability of food products, particularly in rural areas. This includes supporting the marketing of food products, and aims to strengthen the capabilities of stakeholders to control the variability of food products and supplies at local and national levels. Lastly, the third component of this project focuses on institutional development and capacity building. Its goal is to reinforce the capacities of service providers and institutions who are specifically involved in project implementation. The project's activities aim to build capacities of service providers, strengthen the capacity of food producer organizations, strengthen agricultural input supply delivery methods, and manage and evaluate project activities. The December 2018 report by the World Bank indicated that the poverty rate fell slightly between 2009 and 2014, from 46% to a still high 40.1%. The report provided this updated summary of the country's development challenges: "Burkina Faso remains vulnerable to climatic shocks related to changes in rainfall patterns and to fluctuations in the prices of its export commodities on world markets. Its economic and social development will, to some extent, be contingent on political stability in the country and the subregion, its openness to international trade, and export diversification". While services remain underdeveloped, the National Office for Water and Sanitation (ONEA), a state-owned utility company run along commercial lines, is emerging as one of the best-performing utility companies in Africa. High levels of autonomy and a skilled and dedicated management have driven ONEA's ability to improve production of and access to clean water. Since 2000, nearly 2 million more people have access to water in the four principal urban centres in the country; the company has kept the quality of infrastructure high (less than 18% of the water is lost through leaks – one of the lowest in sub-Saharan Africa ), improved financial reporting, and increased its annual revenue by an average of 12% (well above inflation). Challenges remain, including difficulties among some customers in paying for services, with the need to rely on international aid to expand its infrastructure. The state-owned, commercially run venture has helped the nation reach its Millennium Development Goal (MDG) targets in water-related areas, and has grown as a viable company. However, access to drinking water has improved over the last 28 years. According to UNICEF, access to drinking water has increased from 39 to 76% in rural areas between 1990 and 2015. In this same time span, access to drinking water increased from 75 to 97% in urban areas. A 33-megawatt solar power plant in Zagtouli, near Ouagadougou, came online in late November 2017. At the time of its construction, it was the largest solar power facility in West Africa. The growth rate in Burkina Faso is high although it continues to be plagued by corruption and incursions from terrorist groups from Mali and Niger. Transport in Burkina Faso is limited by relatively underdeveloped infrastructure. As of June 2014 the main international airport, Ouagadougou Airport , had regularly scheduled flights to many destinations in West Africa as well as Paris, Brussels and Istanbul . The other international airport, Bobo Dioulasso Airport , has flights to Ouagadougou and Abidjan . Rail transport in Burkina Faso consists of a single line which runs from Kaya to Abidjan in Ivory Coast via Ouagadougou , Koudougou , Bobo Dioulasso and Banfora . Sitarail operates a passenger train three times a week along the route. There are 15,000 kilometres of roads in Burkina Faso, of which 2,500 kilometres are paved. While services remain underdeveloped, the National Office for Water and Sanitation (ONEA), a state-owned utility company run along commercial lines, is emerging as one of the best-performing utility companies in Africa. High levels of autonomy and a skilled and dedicated management have driven ONEA's ability to improve production of and access to clean water. Since 2000, nearly 2 million more people have access to water in the four principal urban centres in the country; the company has kept the quality of infrastructure high (less than 18% of the water is lost through leaks – one of the lowest in sub-Saharan Africa ), improved financial reporting, and increased its annual revenue by an average of 12% (well above inflation). Challenges remain, including difficulties among some customers in paying for services, with the need to rely on international aid to expand its infrastructure. The state-owned, commercially run venture has helped the nation reach its Millennium Development Goal (MDG) targets in water-related areas, and has grown as a viable company. However, access to drinking water has improved over the last 28 years. According to UNICEF, access to drinking water has increased from 39 to 76% in rural areas between 1990 and 2015. In this same time span, access to drinking water increased from 75 to 97% in urban areas. A 33-megawatt solar power plant in Zagtouli, near Ouagadougou, came online in late November 2017. At the time of its construction, it was the largest solar power facility in West Africa. The growth rate in Burkina Faso is high although it continues to be plagued by corruption and incursions from terrorist groups from Mali and Niger. Transport in Burkina Faso is limited by relatively underdeveloped infrastructure. As of June 2014 the main international airport, Ouagadougou Airport , had regularly scheduled flights to many destinations in West Africa as well as Paris, Brussels and Istanbul . The other international airport, Bobo Dioulasso Airport , has flights to Ouagadougou and Abidjan . Rail transport in Burkina Faso consists of a single line which runs from Kaya to Abidjan in Ivory Coast via Ouagadougou , Koudougou , Bobo Dioulasso and Banfora . Sitarail operates a passenger train three times a week along the route. There are 15,000 kilometres of roads in Burkina Faso, of which 2,500 kilometres are paved. In 2009, Burkina Faso spent 0.20% of GDP on research and development (R&D), one of the lowest ratios in West Africa. There were 48 researchers (in full-time equivalents) per million inhabitants in 2010, which is more than twice the average for sub-Saharan Africa (20 per million population in 2013) and higher than the ratio for Ghana and Nigeria (39). It is, however, much lower than the ratio for Senegal (361 per million inhabitants). In Burkina Faso in 2010, 46% of researchers were working in the health sector, 16% in engineering, 13% in natural sciences, 9% in agricultural sciences, 7% in the humanities and 4% in social sciences. In January 2011, the government created the Ministry of Scientific Research and Innovation. Up until then, management of science, technology and innovation had fallen under the Department of Secondary and Higher Education and Scientific Research. Within this ministry, the Directorate General for Research and Sector Statistics is responsible for planning. A separate body, the Directorate General of Scientific Research, Technology and Innovation, coordinates research. This is a departure from the pattern in many other West African countries where a single body fulfills both functions. The move signals the government's intention to make science and technology a development priority. Burkina Faso was ranked 124th in the Global Innovation Index in 2023. In 2012, Burkina Faso adopted a National Policy for Scientific and Technical Research , the strategic objectives of which are to develop R&D and the application and commercialization of research results. The policy also makes provisions for strengthening the ministry's strategic and operational capacities. One of the key priorities is to improve food security and self-sufficiency by boosting capacity in agricultural and environmental sciences. The creation of a centre of excellence in 2014 at the International Institute of Water and Environmental Engineering in Ouagadougou within the World Bank project provides essential funding for capacity-building in these priority areas. A dual priority is to promote innovative, effective and accessible health systems. The government wishes to develop, in parallel, applied sciences and technology and social and human sciences. To complement the national research policy, the government has prepared a National Strategy to Popularize Technologies, Inventions and Innovations (2012) and a National Innovation Strategy (2014). Other policies also incorporate science and technology, such as that on Secondary and Higher Education and Scientific Research (2010), the National Policy on Food and Nutrition Security (2014) and the National Programme for the Rural Sector (2011). In 2013, Burkina Faso passed the Science, Technology and Innovation Act establishing three mechanisms for financing research and innovation, a clear indication of high-level commitment. These mechanisms are the National Fund for Education and Research, the National Fund for Research and Innovation for Development and the Forum of Scientific Research and Technological Innovation. Burkina Faso is an ethnically integrated, secular state where most people are concentrated in the south and centre, where their density sometimes exceeds 48 inhabitants per square kilometre (120/sq mi) . Hundreds of thousands of Burkinabè migrate regularly to Ivory Coast and Ghana, mainly for seasonal agricultural work. These flows of workers are affected by external events; the September 2002 coup attempt in Ivory Coast and the ensuing fighting meant that hundreds of thousands of Burkinabè returned to Burkina Faso. The regional economy suffered when they were unable to work. In 2015, most of the population belonged to "one of two West African ethnic cultural groups: the Voltaic and the Mandé. Voltaic Mossi make up about 50% of the population and are descended from warriors who moved to the area from Ghana around 1100, establishing an empire that lasted over 800 years". The total fertility rate of Burkina Faso is 5.93 children born per woman (2014 estimates), the sixth highest in the world. In 2009 the U.S. Department of State 's Trafficking in Persons Report reported that slavery in Burkina Faso continued to exist and that Burkinabè children were often the victims. Slavery in the Sahel states in general, is an entrenched institution with a long history that dates back to the trans-Saharan slave trade . In 2018, an estimated 82,000 people in the country were living under "modern slavery" according to the Global Slavery Index. Burkina Faso's 17.3 million people belong to two major West African ethnic cultural groups: the Voltaic and the Mandé (whose common language is Dioula ). The Voltaic Mossi make up about one-half of the population. The Mossi claim descent from warriors who migrated to present-day Burkina Faso from northern Ghana around 1100 AD. They established an empire that lasted more than 800 years. Predominantly farmers, the Mossi kingdom is led by the Mogho Naba , whose court is in Ouagadougou. Burkina Faso is a multilingual country. The working languages are French , which was introduced during the colonial period, and English . Altogether, an estimated 69 languages are spoken in the country, of which about 60 languages are indigenous . The Mooré language is the most spoken language in Burkina Faso, spoken by about half the population, mainly in the central region around the capital, Ouagadougou. According to the 2006 census, the languages spoken natively in Burkina Faso were Mooré by 40.5% of the population, Fula by 9.3%, Gourmanché by 6.1%, Bambara by 4.9%, Bissa by 3.2%, Bwamu by 2.1%, Dagara by 2%, San by 1.9%, Lobiri with 1.8%, Lyélé with 1.7%, Bobo and Sénoufo with 1.4% each, Nuni by 1.2%, Dafing by 1.1%, Tamasheq by 1%, Kassem by 0.7%, Gouin by 0.4%, Dogon , Songhai , and Gourounsi by 0.3% each, Ko, Koussassé , Sembla , and Siamou by 0.1% each, other national languages by 5%, other African languages by 0.2%, French (the official language) by 1.3%, and other non-indigenous languages by 0.1%. In the west, Mandé languages are widely spoken, the most predominant being Dioula (also known as Jula or Dyula), others including Bobo , Samo , and Marka . Fula is widespread, particularly in the north. Gourmanché is spoken in the east, while Bissa is spoken in the south. In 2016, the average life expectancy was estimated at 60 for males and 61 for females. In 2018, the under-five mortality rate and the infant mortality rate was 76 per 1000 live births. In 2014, the median age of its inhabitants was 17 and the estimated population growth rate was 3.05%. In 2011, health expenditures was 6.5% of GDP; the maternal mortality ratio was estimated at 300 deaths per 100000 live births and the physician density at 0.05 per 1000 population in 2010. In 2012, it was estimated that the adult HIV prevalence rate (ages 15–49) was 1.0%. According to the 2011 UNAIDS Report, HIV prevalence is declining among pregnant women who attend antenatal clinics. According to a 2005 World Health Organization report, an estimated 72.5% of Burkina Faso's girls and women have had female genital mutilation , administered according to traditional rituals. Central government spending on health was 3% in 2001. As of 2009 [ update ] , studies estimated there were as few as 10 physicians per 100,000 people. In addition, there were 41 nurses and 13 midwives per 100,000 people. Demographic and Health Surveys has completed three surveys in Burkina Faso since 1993, and had another in 2009. A Dengue fever outbreak in 2016 killed 20 patients. Cases of the disease were reported from all 12 districts of Ouagadougou. The government of Burkina Faso 's 2019 census reported that 63.8% of the population practice Islam, and that the majority of this group belong to the Sunni branch, while a small minority adheres to Shia Islam . A significant number of Sunni Muslims identify with the Tijaniyah Sufi order. The 2019 census also found that 26.3% of the population are Christians (20.1% being Roman Catholics and 6.2% members of Protestant denominations) and 9.0% follow traditional indigenous beliefs such as the Dogon religion , 0.2% have other religions, and 0.7% have none. Animists are the largest religious group in the country's Sud-Ouest region, forming 48.1% of its total population. Education in Burkina Faso is divided into primary, secondary and higher education. High school costs approximately CFA 25,000 (US$50) per year, which is far above the means of most Burkinabè families. Boys receive preference in schooling; as such, girls' education and literacy rates are far lower than their male counterparts. An increase in girls' schooling has been observed because of the government's policy of making school cheaper for girls and granting them more scholarships. To proceed from primary to middle school, middle to high school or high school to college, national exams must be passed. Institutions of higher education include the University of Ouagadougou , The Polytechnic University of Bobo-Dioulasso , and the University of Koudougou , which is also a teacher training institution. There are some small private colleges in the capital city of Ouagadougou but these are affordable to only a small portion of the population. There is also the International School of Ouagadougou (ISO), an American-based private school located in Ouagadougou. The 2008 UN Development Program Report ranked Burkina Faso as the country with the lowest level of literacy in the world, despite a concerted effort to double its literacy rate from 12.8% in 1990 to 25.3% in 2008. Burkina Faso's 17.3 million people belong to two major West African ethnic cultural groups: the Voltaic and the Mandé (whose common language is Dioula ). The Voltaic Mossi make up about one-half of the population. The Mossi claim descent from warriors who migrated to present-day Burkina Faso from northern Ghana around 1100 AD. They established an empire that lasted more than 800 years. Predominantly farmers, the Mossi kingdom is led by the Mogho Naba , whose court is in Ouagadougou. Burkina Faso is a multilingual country. The working languages are French , which was introduced during the colonial period, and English . Altogether, an estimated 69 languages are spoken in the country, of which about 60 languages are indigenous . The Mooré language is the most spoken language in Burkina Faso, spoken by about half the population, mainly in the central region around the capital, Ouagadougou. According to the 2006 census, the languages spoken natively in Burkina Faso were Mooré by 40.5% of the population, Fula by 9.3%, Gourmanché by 6.1%, Bambara by 4.9%, Bissa by 3.2%, Bwamu by 2.1%, Dagara by 2%, San by 1.9%, Lobiri with 1.8%, Lyélé with 1.7%, Bobo and Sénoufo with 1.4% each, Nuni by 1.2%, Dafing by 1.1%, Tamasheq by 1%, Kassem by 0.7%, Gouin by 0.4%, Dogon , Songhai , and Gourounsi by 0.3% each, Ko, Koussassé , Sembla , and Siamou by 0.1% each, other national languages by 5%, other African languages by 0.2%, French (the official language) by 1.3%, and other non-indigenous languages by 0.1%. In the west, Mandé languages are widely spoken, the most predominant being Dioula (also known as Jula or Dyula), others including Bobo , Samo , and Marka . Fula is widespread, particularly in the north. Gourmanché is spoken in the east, while Bissa is spoken in the south.In 2016, the average life expectancy was estimated at 60 for males and 61 for females. In 2018, the under-five mortality rate and the infant mortality rate was 76 per 1000 live births. In 2014, the median age of its inhabitants was 17 and the estimated population growth rate was 3.05%. In 2011, health expenditures was 6.5% of GDP; the maternal mortality ratio was estimated at 300 deaths per 100000 live births and the physician density at 0.05 per 1000 population in 2010. In 2012, it was estimated that the adult HIV prevalence rate (ages 15–49) was 1.0%. According to the 2011 UNAIDS Report, HIV prevalence is declining among pregnant women who attend antenatal clinics. According to a 2005 World Health Organization report, an estimated 72.5% of Burkina Faso's girls and women have had female genital mutilation , administered according to traditional rituals. Central government spending on health was 3% in 2001. As of 2009 [ update ] , studies estimated there were as few as 10 physicians per 100,000 people. In addition, there were 41 nurses and 13 midwives per 100,000 people. Demographic and Health Surveys has completed three surveys in Burkina Faso since 1993, and had another in 2009. A Dengue fever outbreak in 2016 killed 20 patients. Cases of the disease were reported from all 12 districts of Ouagadougou. The government of Burkina Faso 's 2019 census reported that 63.8% of the population practice Islam, and that the majority of this group belong to the Sunni branch, while a small minority adheres to Shia Islam . A significant number of Sunni Muslims identify with the Tijaniyah Sufi order. The 2019 census also found that 26.3% of the population are Christians (20.1% being Roman Catholics and 6.2% members of Protestant denominations) and 9.0% follow traditional indigenous beliefs such as the Dogon religion , 0.2% have other religions, and 0.7% have none. Animists are the largest religious group in the country's Sud-Ouest region, forming 48.1% of its total population. Education in Burkina Faso is divided into primary, secondary and higher education. High school costs approximately CFA 25,000 (US$50) per year, which is far above the means of most Burkinabè families. Boys receive preference in schooling; as such, girls' education and literacy rates are far lower than their male counterparts. An increase in girls' schooling has been observed because of the government's policy of making school cheaper for girls and granting them more scholarships. To proceed from primary to middle school, middle to high school or high school to college, national exams must be passed. Institutions of higher education include the University of Ouagadougou , The Polytechnic University of Bobo-Dioulasso , and the University of Koudougou , which is also a teacher training institution. There are some small private colleges in the capital city of Ouagadougou but these are affordable to only a small portion of the population. There is also the International School of Ouagadougou (ISO), an American-based private school located in Ouagadougou. The 2008 UN Development Program Report ranked Burkina Faso as the country with the lowest level of literacy in the world, despite a concerted effort to double its literacy rate from 12.8% in 1990 to 25.3% in 2008. Literature in Burkina Faso is based on the oral tradition , which remains important. In 1934, during French occupation, Dim-Dolobsom Ouedraogo published his Maximes, pensées et devinettes mossi ( Maxims, Thoughts and Riddles of the Mossi ), a record of the oral history of the Mossi people . The oral tradition continued to have an influence on Burkinabè writers in the post-independence Burkina Faso of the 1960s, such as Nazi Boni and Roger Nikiema. The 1960s saw a growth in the number of playwrights being published. Since the 1970s, literature has developed in Burkina Faso with many more writers being published. The theatre of Burkina Faso combines traditional Burkinabè performance with the colonial influences and post-colonial efforts to educate rural people to produce a distinctive national theatre. Traditional ritual ceremonies of the many ethnic groups in Burkina Faso have long involved dancing with masks . Western-style theatre became common during colonial times, heavily influenced by French theatre . With independence came a new style of theatre inspired by forum theatre aimed at educating and entertaining Burkina Faso's rural people. [ citation needed ] Slam poetry is increasing in popularity in the country, in part due to the efforts of slam poet Malika Outtara . She uses her skills to raise awareness around issues such as blood donation, albinism and the impact of COVID-19. In addition to several rich traditional artistic heritages among the peoples, there is a large artist community in Burkina Faso, especially in Ouagadougou . Much of the crafts produced are for the country's growing tourist industry. Burkina Faso also hosts the International Art and Craft Fair, Ouagadougou. It is better known by its French name as SIAO , Le Salon International de l' Artisanat de Ouagadougou , and is one of the most important African handicraft fairs. Typical of West African cuisine, Burkina Faso's cuisine is based on staple foods of sorghum , millet , rice, maize, peanuts, potatoes, beans , yams and okra . The most common sources of animal protein are chicken, chicken eggs and freshwater fish. A typical Burkinabè beverage is Banji or Palm Wine, which is fermented palm sap ; and Zoom-kom, or "grain water" purportedly the national drink of Burkina Faso. Zoom-kom is milky-looking and whitish, having a water and cereal base, best drunk with ice cubes. In the more rural regions, in the outskirts of Burkina, you would find Dolo, which is drink made from fermented millet. In times of crisis, one legume native to Burkina, Zamnè, can be served as a main dish or in a sauce. The cinema of Burkina Faso is an important part of the West African film industry and African film as a whole. Burkina's contribution to African cinema started with the establishment of the film festival FESPACO (Festival Panafricain du Cinéma et de la Télévision de Ouagadougou), which was launched as a film week in 1969. Many of the nation's filmmakers are known internationally and have won international prizes. For many years the headquarters of the Federation of Panafrican Filmmakers (FEPACI) was in Ouagadougou, rescued in 1983 from a period of moribund inactivity by the enthusiastic support and funding of President Sankara . (In 2006 the Secretariat of FEPACI moved to South Africa, but the headquarters of the organization is still in Ouagadougou.) Among the best known directors from Burkina Faso are Gaston Kaboré , Idrissa Ouedraogo and Dani Kouyate . Burkina produces popular television series such as Les Bobodiouf . Internationally known filmmakers such as Ouedraogo, Kabore, Yameogo, and Kouyate make popular television series. Sport in Burkina Faso is widespread and includes football, basketball, cycling, rugby union, handball, tennis, boxing and martial arts. Football is the most popular sport in Burkina Faso, played both professionally, and informally in towns and villages across the country. The national team is nicknamed "Les Etalons" ("the Stallions") in reference to the legendary horse of Princess Yennenga . In 1998, Burkina Faso hosted the Africa Cup of Nations for which the Omnisport Stadium in Bobo-Dioulasso was built. Burkina Faso qualified for the 2013 African Cup of Nations in South Africa and reached the final, but then lost to Nigeria 0–1. The country has never qualified for a FIFA World Cup . Basketball is another sport which enjoys much popularity for both men and women. The country's men's national team had its most successful year in 2013 when it qualified for the AfroBasket , the continent's prime basketball event. At the 2020 Summer Olympics , the athlete Hugues Fabrice Zango won Burkina Faso's first Olympic medal, winning bronze in the men's triple jump . Cricket is also picking up in Burkina Faso with Cricket Burkina Faso running a 10 club league. The music of Burkina Faso includes the folk music of 60 different ethnic groups . The Mossi people , centrally located around the capital, Ouagadougou , account for 40% of the population while, to the south, Gurunsi , Gurma , Dagaaba and Lobi populations, speaking Gur languages closely related to the Mossi language , extend into the coastal states. In the north and east the Fulani of the Sahel preponderate, while in the south and west the Mande languages are common; Samo , Bissa , Bobo , Senufo and Marka . Burkinabé traditional music has continued to thrive and musical output remains quite diverse. Popular music is mostly in French: Burkina Faso has yet to produce a major pan-African success. The nation's principal media outlet is its state-sponsored combined television and radio service, Radio Télévision du Burkina (RTB). RTB broadcasts on two medium-wave ( AM ) and several FM frequencies. Besides RTB, there are privately owned sports, cultural, music, and religious FM radio stations. RTB maintains a worldwide short-wave news broadcast ( Radio Nationale Burkina ) in the French language from the capital at Ouagadougou using a 100 kW transmitter on 4.815 and 5.030 MHz. Attempts to develop an independent press and media in Burkina Faso have been intermittent. In 1998, investigative journalist Norbert Zongo , his brother Ernest, his driver, and another man were assassinated by unknown assailants, and the bodies burned. The crime was never solved. However, an independent Commission of Inquiry later concluded that Norbert Zongo was killed for political reasons because of his investigative work into the death of David Ouedraogo, a chauffeur who worked for François Compaoré, President Blaise Compaoré's brother. In January 1999, François Compaoré was charged with the murder of David Ouedraogo, who had died as a result of torture in January 1998. The charges were later dropped by a military tribunal after an appeal. In August 2000, five members of the President's personal security guard detail ( Régiment de la Sécurité Présidentielle , or RSP) were charged with the murder of Ouedraogo. RSP members Marcel Kafando, Edmond Koama, and Ousseini Yaro, investigated as suspects in the Norbert Zongo assassination, were convicted in the Ouedraogo case and sentenced to lengthy prison terms. Since the death of Norbert Zongo, several protests regarding the Zongo investigation and treatment of journalists have been prevented or dispersed by government police and security forces. In April 2007, popular radio reggae host Karim Sama , whose programs feature reggae songs interspersed with critical commentary on alleged government injustice and corruption, received several death threats. Sama's personal car was later burned outside the private radio station Ouaga FM by unknown vandals. In response, the Committee to Protect Journalists (CPJ) wrote to President Compaoré to request his government investigate the sending of e-mailed death threats to journalists and radio commentators in Burkina Faso who were critical of the government. In December 2008, police in Ouagadougou questioned leaders of a protest march that called for a renewed investigation into the unsolved Zongo assassination. Among the marchers was Jean-Claude Meda, the president of the Association of Journalists of Burkina Faso. Every two years, Ouagadougou hosts the Panafrican Film and Television Festival of Ouagadougou (FESPACO), the largest African cinema festival on the continent (February, odd years). Held every two years since 1988, the International Art and Craft Fair, Ouagadougou (SIAO), is one of Africa's most important trade shows for art and handicrafts (late October-early November, even years). Also every two years, the Symposium de sculpture sur granit de Laongo takes place on a site located about 35 kilometres (22 miles) from Ouagadougou , in the province of Oubritenga . The National Culture Week of Burkina Faso , better known by its French name La Semaine Nationale de la culture (SNC), is one of the most important cultural activities of Burkina Faso. It is a biennial event which takes place every two years in Bobo Dioulasso, the second-largest city in the country. The Festival International des Masques et des Arts (FESTIMA), celebrating traditional masks , is held every two years in Dédougou .In addition to several rich traditional artistic heritages among the peoples, there is a large artist community in Burkina Faso, especially in Ouagadougou . Much of the crafts produced are for the country's growing tourist industry. Burkina Faso also hosts the International Art and Craft Fair, Ouagadougou. It is better known by its French name as SIAO , Le Salon International de l' Artisanat de Ouagadougou , and is one of the most important African handicraft fairs.Typical of West African cuisine, Burkina Faso's cuisine is based on staple foods of sorghum , millet , rice, maize, peanuts, potatoes, beans , yams and okra . The most common sources of animal protein are chicken, chicken eggs and freshwater fish. A typical Burkinabè beverage is Banji or Palm Wine, which is fermented palm sap ; and Zoom-kom, or "grain water" purportedly the national drink of Burkina Faso. Zoom-kom is milky-looking and whitish, having a water and cereal base, best drunk with ice cubes. In the more rural regions, in the outskirts of Burkina, you would find Dolo, which is drink made from fermented millet. In times of crisis, one legume native to Burkina, Zamnè, can be served as a main dish or in a sauce. The cinema of Burkina Faso is an important part of the West African film industry and African film as a whole. Burkina's contribution to African cinema started with the establishment of the film festival FESPACO (Festival Panafricain du Cinéma et de la Télévision de Ouagadougou), which was launched as a film week in 1969. Many of the nation's filmmakers are known internationally and have won international prizes. For many years the headquarters of the Federation of Panafrican Filmmakers (FEPACI) was in Ouagadougou, rescued in 1983 from a period of moribund inactivity by the enthusiastic support and funding of President Sankara . (In 2006 the Secretariat of FEPACI moved to South Africa, but the headquarters of the organization is still in Ouagadougou.) Among the best known directors from Burkina Faso are Gaston Kaboré , Idrissa Ouedraogo and Dani Kouyate . Burkina produces popular television series such as Les Bobodiouf . Internationally known filmmakers such as Ouedraogo, Kabore, Yameogo, and Kouyate make popular television series.Sport in Burkina Faso is widespread and includes football, basketball, cycling, rugby union, handball, tennis, boxing and martial arts. Football is the most popular sport in Burkina Faso, played both professionally, and informally in towns and villages across the country. The national team is nicknamed "Les Etalons" ("the Stallions") in reference to the legendary horse of Princess Yennenga . In 1998, Burkina Faso hosted the Africa Cup of Nations for which the Omnisport Stadium in Bobo-Dioulasso was built. Burkina Faso qualified for the 2013 African Cup of Nations in South Africa and reached the final, but then lost to Nigeria 0–1. The country has never qualified for a FIFA World Cup . Basketball is another sport which enjoys much popularity for both men and women. The country's men's national team had its most successful year in 2013 when it qualified for the AfroBasket , the continent's prime basketball event. At the 2020 Summer Olympics , the athlete Hugues Fabrice Zango won Burkina Faso's first Olympic medal, winning bronze in the men's triple jump . Cricket is also picking up in Burkina Faso with Cricket Burkina Faso running a 10 club league. The music of Burkina Faso includes the folk music of 60 different ethnic groups . The Mossi people , centrally located around the capital, Ouagadougou , account for 40% of the population while, to the south, Gurunsi , Gurma , Dagaaba and Lobi populations, speaking Gur languages closely related to the Mossi language , extend into the coastal states. In the north and east the Fulani of the Sahel preponderate, while in the south and west the Mande languages are common; Samo , Bissa , Bobo , Senufo and Marka . Burkinabé traditional music has continued to thrive and musical output remains quite diverse. Popular music is mostly in French: Burkina Faso has yet to produce a major pan-African success.The nation's principal media outlet is its state-sponsored combined television and radio service, Radio Télévision du Burkina (RTB). RTB broadcasts on two medium-wave ( AM ) and several FM frequencies. Besides RTB, there are privately owned sports, cultural, music, and religious FM radio stations. RTB maintains a worldwide short-wave news broadcast ( Radio Nationale Burkina ) in the French language from the capital at Ouagadougou using a 100 kW transmitter on 4.815 and 5.030 MHz. Attempts to develop an independent press and media in Burkina Faso have been intermittent. In 1998, investigative journalist Norbert Zongo , his brother Ernest, his driver, and another man were assassinated by unknown assailants, and the bodies burned. The crime was never solved. However, an independent Commission of Inquiry later concluded that Norbert Zongo was killed for political reasons because of his investigative work into the death of David Ouedraogo, a chauffeur who worked for François Compaoré, President Blaise Compaoré's brother. In January 1999, François Compaoré was charged with the murder of David Ouedraogo, who had died as a result of torture in January 1998. The charges were later dropped by a military tribunal after an appeal. In August 2000, five members of the President's personal security guard detail ( Régiment de la Sécurité Présidentielle , or RSP) were charged with the murder of Ouedraogo. RSP members Marcel Kafando, Edmond Koama, and Ousseini Yaro, investigated as suspects in the Norbert Zongo assassination, were convicted in the Ouedraogo case and sentenced to lengthy prison terms. Since the death of Norbert Zongo, several protests regarding the Zongo investigation and treatment of journalists have been prevented or dispersed by government police and security forces. In April 2007, popular radio reggae host Karim Sama , whose programs feature reggae songs interspersed with critical commentary on alleged government injustice and corruption, received several death threats. Sama's personal car was later burned outside the private radio station Ouaga FM by unknown vandals. In response, the Committee to Protect Journalists (CPJ) wrote to President Compaoré to request his government investigate the sending of e-mailed death threats to journalists and radio commentators in Burkina Faso who were critical of the government. In December 2008, police in Ouagadougou questioned leaders of a protest march that called for a renewed investigation into the unsolved Zongo assassination. Among the marchers was Jean-Claude Meda, the president of the Association of Journalists of Burkina Faso. Every two years, Ouagadougou hosts the Panafrican Film and Television Festival of Ouagadougou (FESPACO), the largest African cinema festival on the continent (February, odd years). Held every two years since 1988, the International Art and Craft Fair, Ouagadougou (SIAO), is one of Africa's most important trade shows for art and handicrafts (late October-early November, even years). Also every two years, the Symposium de sculpture sur granit de Laongo takes place on a site located about 35 kilometres (22 miles) from Ouagadougou , in the province of Oubritenga . The National Culture Week of Burkina Faso , better known by its French name La Semaine Nationale de la culture (SNC), is one of the most important cultural activities of Burkina Faso. It is a biennial event which takes place every two years in Bobo Dioulasso, the second-largest city in the country. The Festival International des Masques et des Arts (FESTIMA), celebrating traditional masks , is held every two years in Dédougou .

Wiki

Dengue fever

https://api.wikimedia.org/core/v1/wikipedia/en/page/Marburg_virus_disease/html

Marburg virus disease

Marburg virus disease ( MVD ; formerly Marburg hemorrhagic fever ) is a viral hemorrhagic fever in human and non-human primates caused by either of the two Marburgviruses : Marburg virus (MARV) and Ravn virus (RAVV). Its clinical symptoms are very similar to those of Ebola virus disease (EVD). Egyptian fruit bats are believed to be the normal carrier in nature and Marburg virus RNA has been isolated from them. The most detailed study on the frequency, onset, and duration of MVD clinical signs and symptoms was performed during the 1998–2000 mixed MARV/RAVV disease outbreak. A skin rash , red or purple spots (e.g. petechiae or purpura ), bruises , and hematomas (especially around needle injection sites) are typical hemorrhagic manifestations. However, contrary to popular belief, hemorrhage does not lead to hypovolemia and is not the cause of death (total blood loss is minimal except during labor ). Instead, death occurs due to multiple organ dysfunction syndrome (MODS) due to fluid redistribution, hypotension , disseminated intravascular coagulation , and focal tissue necroses . Clinical phases of Marburg hemorrhagic fever's presentation are described below. Note that phases overlap due to variability between cases.MVD is caused by two viruses; Marburg virus (MARV) and Ravn virus (RAVV) , family Filoviridae. : 458 Marburgviruses are endemic in arid woodlands of equatorial Africa . Most marburgvirus infections were repeatedly associated with people visiting natural caves or working in mines . In 2009, the successful isolation of infectious MARV and RAVV was reported from healthy Egyptian fruit bat caught in caves. This isolation strongly suggests that Old World fruit bats are involved in the natural maintenance of marburgviruses and that visiting bat-infested caves is a risk factor for acquiring marburgvirus infections. Further studies are necessary to establish whether Egyptian rousettes are the actual hosts of MARV and RAVV or whether they get infected via contact with another animal and therefore serve only as intermediate hosts. Another risk factor is contact with nonhuman primates, although only one outbreak of MVD (in 1967) was due to contact with infected monkeys. Contrary to Ebola virus disease (EVD) , which has been associated with heavy rains after long periods of dry weather, triggering factors for spillover of marburgviruses into the human population have not yet been described.MVD is clinically indistinguishable from Ebola virus disease (EVD) , and it can also easily be confused with many other diseases prevalent in Equatorial Africa , such as other viral hemorrhagic fevers , falciparum malaria , typhoid fever , shigellosis , rickettsial diseases such as typhus , cholera , gram-negative sepsis , borreliosis such as relapsing fever or EHEC enteritis . Other infectious diseases that ought to be included in the differential diagnosis include leptospirosis , scrub typhus , plague , Q fever , candidiasis , histoplasmosis , trypanosomiasis , visceral leishmaniasis , hemorrhagic smallpox , measles , and fulminant viral hepatitis . Non-infectious diseases that can be confused with MVD are acute promyelocytic leukemia , hemolytic uremic syndrome , snake envenomation , clotting factor deficiencies/platelet disorders, thrombotic thrombocytopenic purpura , hereditary hemorrhagic telangiectasia , Kawasaki disease , and even warfarin intoxication. The most important indicator that may lead to the suspicion of MVD at clinical examination is the medical history of the patient, in particular the travel and occupational history (which countries and caves were visited?) and the patient's exposure to wildlife (exposure to bats or bat excrements?). MVD can be confirmed by isolation of marburgviruses from or by detection of marburgvirus antigen or genomic or subgenomic RNAs in patient blood or serum samples during the acute phase of MVD. Marburgvirus isolation is usually performed by inoculation of grivet kidney epithelial Vero E6 or MA-104 cell cultures or by inoculation of human adrenal carcinoma SW-13 cells, all of which react to infection with characteristic cytopathic effects . Filovirions can easily be visualized and identified in cell culture by electron microscopy due to their unique filamentous shapes, but electron microscopy cannot differentiate the various filoviruses alone despite some overall length differences. Immunofluorescence assays are used to confirm marburgvirus presence in cell cultures. During an outbreak, virus isolation and electron microscopy are most often not feasible options. The most common diagnostic methods are therefore RT-PCR in conjunction with antigen-capture ELISA , which can be performed in field or mobile hospitals and laboratories. Indirect immunofluorescence assays (IFAs) are not used for diagnosis of MVD in the field anymore. [ citation needed ] Marburg virus disease (MVD) is the official name listed in the World Health Organization 's International Statistical Classification of Diseases and Related Health Problems 10 (ICD-10) for the human disease caused by any of the two marburgviruses Marburg virus (MARV) and Ravn virus (RAVV). In the scientific literature, Marburg hemorrhagic fever (MHF) is often used as an unofficial alternative name for the same disease. Both disease names are derived from the German city Marburg , where MARV was first discovered. Marburg virus disease (MVD) is the official name listed in the World Health Organization 's International Statistical Classification of Diseases and Related Health Problems 10 (ICD-10) for the human disease caused by any of the two marburgviruses Marburg virus (MARV) and Ravn virus (RAVV). In the scientific literature, Marburg hemorrhagic fever (MHF) is often used as an unofficial alternative name for the same disease. Both disease names are derived from the German city Marburg , where MARV was first discovered. The details of the initial transmission of MVD to humans remain incompletely understood. Transmission most likely occurs from Egyptian fruit bats or another natural host, such as non-human primates or through the consumption of bushmeat , but the specific routes and body fluids involved are unknown. Human-to-human transmission of MVD occurs through direct contact with infected bodily fluids such as blood. Transmission events are relatively rare – there have been only 11 recorded outbreaks of MARV between 1975 and 2011, with one event involving both MARV and RAVV. There are currently no Food and Drug Administration -approved vaccines for the prevention of MVD. Many candidate vaccines have been developed and tested in various animal models. Of those, the most promising ones are DNA vaccines or based on Venezuelan equine encephalitis virus replicons , vesicular stomatitis Indiana virus (VSIV) or filovirus-like particles (VLPs) as all of these candidates could protect nonhuman primates from marburgvirus-induced disease. DNA vaccines have entered clinical trials. Marburgviruses are highly infectious , but not very contagious . They do not get transmitted by aerosol during natural MVD outbreaks. Due to the absence of an approved vaccine, prevention of MVD therefore relies predominantly on quarantine of confirmed or high probability cases, proper personal protective equipment , and sterilization and disinfection . [ citation needed ] The natural maintenance hosts of marburgviruses remain to be identified unequivocally. However, the isolation of both MARV and RAVV from bats and the association of several MVD outbreaks with bat-infested mines or caves strongly suggests that bats are involved in Marburg virus transmission to humans. Avoidance of contact with bats and abstaining from visits to caves is highly recommended, but may not be possible for those working in mines or people dependent on bats as a food source. [ citation needed ] Since marburgviruses are not spread via aerosol, the most straightforward prevention method during MVD outbreaks is to avoid direct (skin-to-skin) contact with patients, their excretions and body fluids , and any possibly contaminated materials and utensils. Patients should be isolated, but still are safe to be visited by family members. Medical staff should be trained in and apply strict barrier nursing techniques (disposable face mask, gloves, goggles, and a gown at all times). Traditional burial rituals, especially those requiring embalming of bodies, should be discouraged or modified, ideally with the help of local traditional healers . Marburgviruses are World Health Organization Risk Group 4 Pathogens, requiring Biosafety Level 4-equivalent containment , laboratory researchers have to be properly trained in BSL-4 practices and wear proper personal protective equipment.The natural maintenance hosts of marburgviruses remain to be identified unequivocally. However, the isolation of both MARV and RAVV from bats and the association of several MVD outbreaks with bat-infested mines or caves strongly suggests that bats are involved in Marburg virus transmission to humans. Avoidance of contact with bats and abstaining from visits to caves is highly recommended, but may not be possible for those working in mines or people dependent on bats as a food source. [ citation needed ]Since marburgviruses are not spread via aerosol, the most straightforward prevention method during MVD outbreaks is to avoid direct (skin-to-skin) contact with patients, their excretions and body fluids , and any possibly contaminated materials and utensils. Patients should be isolated, but still are safe to be visited by family members. Medical staff should be trained in and apply strict barrier nursing techniques (disposable face mask, gloves, goggles, and a gown at all times). Traditional burial rituals, especially those requiring embalming of bodies, should be discouraged or modified, ideally with the help of local traditional healers . Marburgviruses are World Health Organization Risk Group 4 Pathogens, requiring Biosafety Level 4-equivalent containment , laboratory researchers have to be properly trained in BSL-4 practices and wear proper personal protective equipment.There is currently no effective marburgvirus-specific therapy for MVD. Treatment is primarily supportive in nature and includes minimizing invasive procedures, balancing fluids and electrolytes to counter dehydration , administration of anticoagulants early in infection to prevent or control disseminated intravascular coagulation , administration of procoagulants late in infection to control hemorrhaging , maintaining oxygen levels, pain management , and administration of antibiotics or antifungals to treat secondary infections. Although supportive care can improve survival chances, marburg virus disease is fatal in the majority of cases. As of 2023 [ update ] the case fatality rate was assessed to be 61.9%. The WHO identifies marburg virus disease as having pandemic potential. Below is a table of outbreaks concerning MVD from 1967 to 2023: MVD was first documented in 1967, when 31 people became ill in the German towns of Marburg and Frankfurt am Main , and in Belgrade , Yugoslavia . The outbreak involved 25 primary MARV infections and seven deaths, and six nonlethal secondary cases. The outbreak was traced to infected grivets (species Chlorocebus aethiops ) imported from an undisclosed location in Uganda and used in developing poliomyelitis vaccines . The monkeys were received by Behringwerke, a Marburg company founded by the first winner of the Nobel Prize in Medicine , Emil von Behring . The company, which at the time was owned by Hoechst , was originally set up to develop sera against tetanus and diphtheria . Primary infections occurred in Behringwerke laboratory staff while working with grivet tissues or tissue cultures without adequate personal protective equipment . Secondary cases involved two physicians , a nurse , a post-mortem attendant, and the wife of a veterinarian . All secondary cases had direct contact, usually involving blood, with a primary case. Both physicians became infected through accidental skin pricks when drawing blood from patients. In 1975, an Australian tourist became infected with MARV in Rhodesia (today Zimbabwe ). He died in a hospital in Johannesburg , South Africa . His girlfriend and an attending nurse were subsequently infected with MVD, but survived. A case of MARV infection occurred in 1980 in Kenya . A French man, who worked as an electrical engineer in a sugar factory in Nzoia (close to Bungoma ) at the base of Mount Elgon (which contains Kitum Cave ), became infected by unknown means and died on 15 January shortly after admission to Nairobi Hospital. The attending physician contracted MVD, but survived. A popular science account of these cases can be found in Richard Preston 's book The Hot Zone (the French man is referred to under the pseudonym "Charles Monet", whereas the physician is identified under his real name, Shem Musoke). In 1987, a single lethal case of RAVV infection occurred in a 15-year-old Danish boy, who spent his vacation in Kisumu , Kenya . He had visited Kitum Cave on Mount Elgon prior to travelling to Mombasa , where he developed clinical signs of infection. The boy died after transfer to Nairobi Hospital. A popular science account of this case can be found in Richard Preston 's book The Hot Zone (the boy is referred to under the pseudonym "Peter Cardinal"). In 1988, researcher Nikolai Ustinov infected himself lethally with MARV after accidentally pricking himself with a syringe used for inoculation of guinea pigs . The accident occurred at the Scientific-Production Association "Vektor" (today the State Research Center of Virology and Biotechnology "Vektor" ) in Koltsovo , USSR (today Russia ). Very little information is publicly available about this MVD case because Ustinov's experiments were classified. A popular science account of this case can be found in Ken Alibek 's book Biohazard . Another laboratory accident occurred at the Scientific-Production Association "Vektor" (today the State Research Center of Virology and Biotechnology "Vektor" ) in Koltsovo , USSR , when a scientist contracted MARV by unknown means. A major MVD outbreak occurred among illegal gold miners around Goroumbwa mine in Durba and Watsa , Democratic Republic of Congo from 1998 to 2000, when co-circulating MARV and RAVV caused 154 cases of MVD and 128 deaths. The outbreak ended with the flooding of the mine. In early 2005, the World Health Organization (WHO) began investigating an outbreak of viral hemorrhagic fever in Angola , which was centered in the northeastern Uíge Province but also affected many other provinces. The Angolan government had to ask for international assistance, pointing out that there were only approximately 1,200 doctors in the entire country, with some provinces having as few as two. Health care workers also complained about a shortage of personal protective equipment such as gloves, gowns, and masks. Médecins Sans Frontières (MSF) reported that when their team arrived at the provincial hospital at the center of the outbreak, they found it operating without water and electricity . Contact tracing was complicated by the fact that the country's roads and other infrastructure were devastated after nearly three decades of civil war and the countryside remained littered with land mines . Americo Boa Vida Hospital in the Angolan capital Luanda set up a special isolation ward to treat infected people from the countryside. Unfortunately, because MVD often results in death, some people came to view hospitals and medical workers with suspicion and treated helpers with hostility. For instance, a specially-equipped isolation ward at the provincial hospital in Uíge was reported to be empty during much of the epidemic, even though the facility was at the center of the outbreak. WHO was forced to implement what it described as a "harm reduction strategy", which entailed distributing disinfectants to affected families who refused hospital care. Of the 252 people who contracted MVD during outbreak, 227 died. In 2007, four miners became infected with marburgviruses in Kamwenge District , Uganda . The first case, a 29-year-old man, became symptomatic on July 4, 2007, was admitted to a hospital on July 7, and died on July 13. Contact tracing revealed that the man had had prolonged close contact with two colleagues (a 22-year-old man and a 23-year-old man), who experienced clinical signs of infection before his disease onset. Both men had been admitted to hospitals in June and survived their infections, which were proven to be due to MARV. A fourth, 25-year-old man, developed MVD clinical signs in September and was shown to be infected with RAVV. He also survived the infection. On July 10, 2008, the Netherlands National Institute for Public Health and the Environment reported that a 41-year-old Dutch woman, who had visited Python Cave in Maramagambo Forest during her holiday in Uganda , had MVD due to MARV infection, and had been admitted to a hospital in the Netherlands . The woman died under treatment in the Leiden University Medical Centre in Leiden on July 11. The Ugandan Ministry of Health closed the cave after this case. On January 9 of that year an infectious diseases physician notified the Colorado Department of Public Health and the Environment that a 44-year-old American woman who had returned from Uganda had been hospitalized with a fever of unknown origin . At the time, serologic testing was negative for viral hemorrhagic fever . She was discharged on January 19, 2008. After the death of the Dutch patient and the discovery that the American woman had visited Python Cave, further testing confirmed the patient demonstrated MARV antibodies and RNA . In October 2017 an outbreak of Marburg virus disease was detected in Kween District , Eastern Uganda. All three initial cases (belonging to one family – two brothers and one sister) had died by 3 November. The fourth case – a health care worker – developed symptoms on 4 November and was admitted to a hospital. The first confirmed case traveled to Kenya before the death. A close contact of the second confirmed case traveled to Kampala . It is reported that several hundred people may have been exposed to infection. In August 2021, two months after the re-emergent Ebola epidemic in the Guéckédou prefecture was declared over, a case of the Marburg disease was confirmed by health authorities through laboratory analysis. Other potential case of the disease in a contact awaits official results. This was the first case of the Marburg hemorrhagic fever confirmed to happen in West Africa. The case of Marburg also has been identified in Guéckédou . During the outbreak, a total of one confirmed case, who died ( CFR =100%), and 173 contacts were identified, including 14 high-risk contacts based on exposure. Among them, 172 were followed for a period of 21 days, of which none developed symptoms. One high-risk contact was lost to follow up. Sequencing of an isolate from the Guinean patient showed that this outbreak was caused by the Angola-like Marburg virus. A colony of Egyptian rousettus bats ( reservoir host of Marburg virus ) was found in close proximity (4.5 km) to the village, where the Marburg virus disease outbreak emerged in 2021. Two sampled fruit bats from this colony were PCR-positive on the Marburg virus. In July 2022, preliminary analysis of samples taken from two patients – both deceased – in Ghana indicated the cases were positive for Marburg. However, per standard procedure, the samples were sent to the Pasteur Institute of Dakar for confirmation. On 17 July 2022 the two cases were confirmed by Ghana, which caused the country to declare a Marburg virus disease outbreak. An additional case was identified, bringing the total to three. A disease outbreak was first reported in Equatorial Guinea on 7 February 2023, and on 13 February 2023, it was identified as being Marburg virus disease. It was the first time the disease was detected in the country. Neighbouring Cameroon detected two suspected cases of Marburg virus disease on 13 February 2023, but they were later ruled out. On 25 February, a suspected case of Marburg was reported in the Spanish city of Valencia , however this case was subsequently discounted. As of 4 April 2023, there were 14 confirmed cases and 28 suspected cases, including ten confirmed deaths from the disease in Equatorial Guinea. On 8 June 2023, the World Health Organization declared the outbreak over. In total, 17 laboratory-confirmed cases and 12 deaths were recorded. All the 23 probable cases reportedly died. Four patients recovered from the virus and have been enrolled in a survivors programme to receive psychosocial and other post-recovery support. A Marburg virus disease outbreak in Tanzania was first reported on 21 March 2023 by the Ministry of Health of Tanzania. This was the first time that Tanzania had reported an outbreak of the disease. On 2 June 2023, Tanzania declared the outbreak over. There were 9 total infections, resulting in 6 total deaths. The WHO identifies marburg virus disease as having pandemic potential. Below is a table of outbreaks concerning MVD from 1967 to 2023:MVD was first documented in 1967, when 31 people became ill in the German towns of Marburg and Frankfurt am Main , and in Belgrade , Yugoslavia . The outbreak involved 25 primary MARV infections and seven deaths, and six nonlethal secondary cases. The outbreak was traced to infected grivets (species Chlorocebus aethiops ) imported from an undisclosed location in Uganda and used in developing poliomyelitis vaccines . The monkeys were received by Behringwerke, a Marburg company founded by the first winner of the Nobel Prize in Medicine , Emil von Behring . The company, which at the time was owned by Hoechst , was originally set up to develop sera against tetanus and diphtheria . Primary infections occurred in Behringwerke laboratory staff while working with grivet tissues or tissue cultures without adequate personal protective equipment . Secondary cases involved two physicians , a nurse , a post-mortem attendant, and the wife of a veterinarian . All secondary cases had direct contact, usually involving blood, with a primary case. Both physicians became infected through accidental skin pricks when drawing blood from patients. In 1975, an Australian tourist became infected with MARV in Rhodesia (today Zimbabwe ). He died in a hospital in Johannesburg , South Africa . His girlfriend and an attending nurse were subsequently infected with MVD, but survived. A case of MARV infection occurred in 1980 in Kenya . A French man, who worked as an electrical engineer in a sugar factory in Nzoia (close to Bungoma ) at the base of Mount Elgon (which contains Kitum Cave ), became infected by unknown means and died on 15 January shortly after admission to Nairobi Hospital. The attending physician contracted MVD, but survived. A popular science account of these cases can be found in Richard Preston 's book The Hot Zone (the French man is referred to under the pseudonym "Charles Monet", whereas the physician is identified under his real name, Shem Musoke). In 1987, a single lethal case of RAVV infection occurred in a 15-year-old Danish boy, who spent his vacation in Kisumu , Kenya . He had visited Kitum Cave on Mount Elgon prior to travelling to Mombasa , where he developed clinical signs of infection. The boy died after transfer to Nairobi Hospital. A popular science account of this case can be found in Richard Preston 's book The Hot Zone (the boy is referred to under the pseudonym "Peter Cardinal"). In 1988, researcher Nikolai Ustinov infected himself lethally with MARV after accidentally pricking himself with a syringe used for inoculation of guinea pigs . The accident occurred at the Scientific-Production Association "Vektor" (today the State Research Center of Virology and Biotechnology "Vektor" ) in Koltsovo , USSR (today Russia ). Very little information is publicly available about this MVD case because Ustinov's experiments were classified. A popular science account of this case can be found in Ken Alibek 's book Biohazard . Another laboratory accident occurred at the Scientific-Production Association "Vektor" (today the State Research Center of Virology and Biotechnology "Vektor" ) in Koltsovo , USSR , when a scientist contracted MARV by unknown means. A major MVD outbreak occurred among illegal gold miners around Goroumbwa mine in Durba and Watsa , Democratic Republic of Congo from 1998 to 2000, when co-circulating MARV and RAVV caused 154 cases of MVD and 128 deaths. The outbreak ended with the flooding of the mine. In early 2005, the World Health Organization (WHO) began investigating an outbreak of viral hemorrhagic fever in Angola , which was centered in the northeastern Uíge Province but also affected many other provinces. The Angolan government had to ask for international assistance, pointing out that there were only approximately 1,200 doctors in the entire country, with some provinces having as few as two. Health care workers also complained about a shortage of personal protective equipment such as gloves, gowns, and masks. Médecins Sans Frontières (MSF) reported that when their team arrived at the provincial hospital at the center of the outbreak, they found it operating without water and electricity . Contact tracing was complicated by the fact that the country's roads and other infrastructure were devastated after nearly three decades of civil war and the countryside remained littered with land mines . Americo Boa Vida Hospital in the Angolan capital Luanda set up a special isolation ward to treat infected people from the countryside. Unfortunately, because MVD often results in death, some people came to view hospitals and medical workers with suspicion and treated helpers with hostility. For instance, a specially-equipped isolation ward at the provincial hospital in Uíge was reported to be empty during much of the epidemic, even though the facility was at the center of the outbreak. WHO was forced to implement what it described as a "harm reduction strategy", which entailed distributing disinfectants to affected families who refused hospital care. Of the 252 people who contracted MVD during outbreak, 227 died. In 2007, four miners became infected with marburgviruses in Kamwenge District , Uganda . The first case, a 29-year-old man, became symptomatic on July 4, 2007, was admitted to a hospital on July 7, and died on July 13. Contact tracing revealed that the man had had prolonged close contact with two colleagues (a 22-year-old man and a 23-year-old man), who experienced clinical signs of infection before his disease onset. Both men had been admitted to hospitals in June and survived their infections, which were proven to be due to MARV. A fourth, 25-year-old man, developed MVD clinical signs in September and was shown to be infected with RAVV. He also survived the infection. On July 10, 2008, the Netherlands National Institute for Public Health and the Environment reported that a 41-year-old Dutch woman, who had visited Python Cave in Maramagambo Forest during her holiday in Uganda , had MVD due to MARV infection, and had been admitted to a hospital in the Netherlands . The woman died under treatment in the Leiden University Medical Centre in Leiden on July 11. The Ugandan Ministry of Health closed the cave after this case. On January 9 of that year an infectious diseases physician notified the Colorado Department of Public Health and the Environment that a 44-year-old American woman who had returned from Uganda had been hospitalized with a fever of unknown origin . At the time, serologic testing was negative for viral hemorrhagic fever . She was discharged on January 19, 2008. After the death of the Dutch patient and the discovery that the American woman had visited Python Cave, further testing confirmed the patient demonstrated MARV antibodies and RNA . In October 2017 an outbreak of Marburg virus disease was detected in Kween District , Eastern Uganda. All three initial cases (belonging to one family – two brothers and one sister) had died by 3 November. The fourth case – a health care worker – developed symptoms on 4 November and was admitted to a hospital. The first confirmed case traveled to Kenya before the death. A close contact of the second confirmed case traveled to Kampala . It is reported that several hundred people may have been exposed to infection. In August 2021, two months after the re-emergent Ebola epidemic in the Guéckédou prefecture was declared over, a case of the Marburg disease was confirmed by health authorities through laboratory analysis. Other potential case of the disease in a contact awaits official results. This was the first case of the Marburg hemorrhagic fever confirmed to happen in West Africa. The case of Marburg also has been identified in Guéckédou . During the outbreak, a total of one confirmed case, who died ( CFR =100%), and 173 contacts were identified, including 14 high-risk contacts based on exposure. Among them, 172 were followed for a period of 21 days, of which none developed symptoms. One high-risk contact was lost to follow up. Sequencing of an isolate from the Guinean patient showed that this outbreak was caused by the Angola-like Marburg virus. A colony of Egyptian rousettus bats ( reservoir host of Marburg virus ) was found in close proximity (4.5 km) to the village, where the Marburg virus disease outbreak emerged in 2021. Two sampled fruit bats from this colony were PCR-positive on the Marburg virus. In July 2022, preliminary analysis of samples taken from two patients – both deceased – in Ghana indicated the cases were positive for Marburg. However, per standard procedure, the samples were sent to the Pasteur Institute of Dakar for confirmation. On 17 July 2022 the two cases were confirmed by Ghana, which caused the country to declare a Marburg virus disease outbreak. An additional case was identified, bringing the total to three. A disease outbreak was first reported in Equatorial Guinea on 7 February 2023, and on 13 February 2023, it was identified as being Marburg virus disease. It was the first time the disease was detected in the country. Neighbouring Cameroon detected two suspected cases of Marburg virus disease on 13 February 2023, but they were later ruled out. On 25 February, a suspected case of Marburg was reported in the Spanish city of Valencia , however this case was subsequently discounted. As of 4 April 2023, there were 14 confirmed cases and 28 suspected cases, including ten confirmed deaths from the disease in Equatorial Guinea. On 8 June 2023, the World Health Organization declared the outbreak over. In total, 17 laboratory-confirmed cases and 12 deaths were recorded. All the 23 probable cases reportedly died. Four patients recovered from the virus and have been enrolled in a survivors programme to receive psychosocial and other post-recovery support. A Marburg virus disease outbreak in Tanzania was first reported on 21 March 2023 by the Ministry of Health of Tanzania. This was the first time that Tanzania had reported an outbreak of the disease. On 2 June 2023, Tanzania declared the outbreak over. There were 9 total infections, resulting in 6 total deaths. Experimentally, recombinant vesicular stomatitis Indiana virus (VSIV) expressing the glycoprotein of MARV has been used successfully in nonhuman primate models as post-exposure prophylaxis. A vaccine candidate has been effective in nonhuman primates. Experimental therapeutic regimens relying on antisense technology have shown promise, with phosphorodiamidate morpholino oligomers (PMOs) targeting the MARV genome New therapies from Sarepta and Tekmira have also been successfully used in humans as well as primates.

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Dengue fever

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All Born Screaming

Total Pleasure VMG "Broken Man" Released: February 29, 2024 "Flea" Released: March 28, 2024 "Big Time Nothing" Released: April 23, 2024 All Born Screaming is the upcoming seventh studio album by American musician St. Vincent , scheduled for release on April 26, 2024, through Total Pleasure Records and the Virgin Music Group .On February 16, 2024, the musician first spoke about the record, saying how she "needed to go deeper in finding [her] own sonic vocabulary" and likes to refer to the album as "post-plague pop". All Born Screaming marks the first studio album entirely produced by Clark herself, alongside additional mixing by Cian Riordan. The record features contributions from several artists, including Dave Grohl , Cate Le Bon , Justin Meldal-Johnsen , Josh Freese , Stella Mozgawa , Rachel Eckroth , Mark Guiliana , and David Ralicke of Dengue Fever . Trying to explain the sound of the album, Clark compared it to "taking the long walk into the woods alone" in order to find the messages of your heart. As a result, she opined that it "sounds real because it is real". Clark shared the lead single "Broken Man", an " industrial menacing rock " piece, on February 29, 2024, along with a music video directed by Alex Da Corte . During the video, she bursts into flames, an image that is also depicted as the album artwork. A second single, "Flea", was released on March 28, the same day the All Born Screaming Tour was officially announced. The song "Sweetest Fruit" includes an ode to Sophie , a music producer whom Clark admired and who died in 2021, and is about "people trying for transcendence, and at least they were taking a big swing or trying for something beautiful".

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Dengue fever

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Toxorhynchites

See text. Toxorhynchites , also called elephant mosquito or mosquito eater , is a genus of diurnal and often relatively colorful mosquitoes , found worldwide between about 35° north and 35° south . Most species occur in forests . It includes the largest known species of mosquito, at up to 18 mm (0.71 in) in length and 24 mm (0.94 in) in wingspan. It is among the many kinds of mosquito that do not consume blood . The adults subsist on carbohydrate -rich materials, such as honeydew , or saps and juices from damaged plants, refuse , fruit, and nectar . Mating in mid-air, males and females synchronize their wing beats to the same frequency. Eggs are deposited by flinging them onto water surfaces while hovering. They are either white or yellow in color, with an incubation period of 40–60 hours depending on the temperature. The older the female mosquito, the less likely the eggs will be healthy. In contrast to blood-sucking species of mosquitoes, their larvae prey on the larvae of other mosquitoes and similar nektonic prey, making Toxorhynchites beneficial to humans. Living on this protein and fat rich diet, females have no need to risk their lives sucking blood in adulthood, having already accumulated the necessary materials for oogenesis and vitellogenesis . The larvae of one jungle variety, Toxorhynchites splendens , consume larvae of other mosquito species occurring in tree crevices, particularly Aedes aegypti . Environmental scientists have suggested that Toxorhynchites mosquitoes be introduced to areas outside their natural range in order to fight dengue fever . This has been practiced historically, but errors have been made. For example, when intending to introduce T. splendens to new areas, scientists actually introduced T. amboinensis . An extinct species T. mexicanus is known from Miocene aged Mexican Amber . The genus Toxorhynchites is divided into 4 subgenera and contains 90 species also included 1 extinct species:

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Dengue fever

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Rift Valley fever

Rift Valley fever ( RVF ) is a viral disease of humans and livestock that can cause mild to severe symptoms. The mild symptoms may include: fever , muscle pains , and headaches which often last for up to a week. The severe symptoms may include: loss of sight beginning three weeks after the infection, infections of the brain causing severe headaches and confusion , and bleeding together with liver problems which may occur within the first few days. Those who have bleeding have a chance of death as high as 50%. The disease is caused by the RVF virus . It is spread by either touching infected animal blood, breathing in the air around an infected animal being butchered , drinking raw milk from an infected animal, or the bite of infected mosquitoes . Animals such as cows, sheep, goats, and camels may be affected. In these animals it is spread mostly by mosquitoes. It does not appear that one person can infect another person. The disease is diagnosed by finding antibodies against the virus or the virus itself in the blood. Prevention of the disease in humans is accomplished by vaccinating animals against the disease. This must be done before an outbreak occurs because if it is done during an outbreak it may worsen the situation. Stopping the movement of animals during an outbreak may also be useful, as may decreasing mosquito numbers and avoiding their bites. There is a human vaccine ; however, as of 2010 it is not widely available. There is no specific treatment and medical efforts are supportive. Outbreaks of the disease have only occurred in Africa and Arabia . Outbreaks usually occur during periods of increased rain which increase the number of mosquitoes. The disease was first reported among livestock in Rift Valley of Kenya in the early 1900s, and the virus was first isolated in 1931. In humans, the virus can cause several syndromes. Usually, they have either no symptoms or only a mild illness with fever, headache , muscle pains , and liver abnormalities. In a small percentage of cases (< 2%), the illness can progress to hemorrhagic fever syndrome, meningoencephalitis (inflammation of the brain and tissues lining the brain ), or affect the eye. Patients who become ill usually experience fever, generalised weakness, back pain, dizziness, and weight loss at the onset of the illness. Typically, people recover within two to seven days after onset. About 1% of people with the disease die of it. In livestock, the fatality level is significantly higher. Pregnant livestock infected with RVF abort virtually 100% of foetuses. An epizootic (animal disease epidemic) of RVF is usually first indicated by a wave of unexplained abortions. [ citation needed ] Other signs in livestock include vomiting and diarrhea, respiratory disease, fever, lethargy, anorexia and sudden death in young animals. The virus belongs to the Bunyavirales order. This is an order of enveloped negative single stranded RNA viruses. All Bunyaviruses have an outer lipid envelope with two glycoproteins —G(N) and G(C)—required for cell entry. They deliver their genome into the host-cell cytoplasm by fusing their envelope with an endosomal membrane . [ citation needed ] The virus' G(C) protein has a class II membrane fusion protein architecture similar to that found in flaviviruses and alphaviruses . This structural similarity suggests that there may be a common origin for these viral families. [ citation needed ] The virus' 11.5 kb tripartite genome is composed of single-stranded RNA . As a Phlebovirus , it has an ambisense genome. Its L and M segments are negative-sense, but its S segment is ambisense. These three genome segments code for six major proteins: L protein ( viral polymerase ), the two glycoproteins G(N) and G(C), the nucleocapsid N protein, and the nonstructural NSs and NSm proteins. The virus is transmitted through mosquito vectors , as well as through contact with the tissue of infected animals. Two species— Culex tritaeniorhynchus and Aedes vexans —are known to transmit the virus. Other potential vectors include Aedes caspius , Aedes mcintosh , Aedes ochraceus , Culex pipiens , Culex antennatus , Culex perexiguus , Culex zombaensis and Culex quinquefasciatus . Contact with infected tissue is considered to be the main source of human infections. The virus has been isolated from two bat species: the Peter's epauletted fruit bat ( Micropteropus pusillus ) and the aba roundleaf bat ( Hipposideros abae ), which are believed to be reservoirs for the virus. The virus belongs to the Bunyavirales order. This is an order of enveloped negative single stranded RNA viruses. All Bunyaviruses have an outer lipid envelope with two glycoproteins —G(N) and G(C)—required for cell entry. They deliver their genome into the host-cell cytoplasm by fusing their envelope with an endosomal membrane . [ citation needed ] The virus' G(C) protein has a class II membrane fusion protein architecture similar to that found in flaviviruses and alphaviruses . This structural similarity suggests that there may be a common origin for these viral families. [ citation needed ] The virus' 11.5 kb tripartite genome is composed of single-stranded RNA . As a Phlebovirus , it has an ambisense genome. Its L and M segments are negative-sense, but its S segment is ambisense. These three genome segments code for six major proteins: L protein ( viral polymerase ), the two glycoproteins G(N) and G(C), the nucleocapsid N protein, and the nonstructural NSs and NSm proteins. The virus is transmitted through mosquito vectors , as well as through contact with the tissue of infected animals. Two species— Culex tritaeniorhynchus and Aedes vexans —are known to transmit the virus. Other potential vectors include Aedes caspius , Aedes mcintosh , Aedes ochraceus , Culex pipiens , Culex antennatus , Culex perexiguus , Culex zombaensis and Culex quinquefasciatus . Contact with infected tissue is considered to be the main source of human infections. The virus has been isolated from two bat species: the Peter's epauletted fruit bat ( Micropteropus pusillus ) and the aba roundleaf bat ( Hipposideros abae ), which are believed to be reservoirs for the virus. Although many components of the RVFV's RNA play an important role in the virus' pathology, the nonstructural protein encoded on the S segment (NSs) is the only component that has been found to directly affect the host. NSs is hostile and combative against the host interferon (IFNs) antiviral response. IFNs are essential in order for the immune system to fight off viral infections in a host. This inhibitory mechanism is believed to be due to a number of reasons, the first being, competitive inhibition of the formation of the transcription factor. On this transcription factor, NSs interacts with and binds to a subunit that is needed for RNA polymerase I and II. This interaction cause competitive inhibition with another transcription factor component and prevents the assembly process of the transcription factor complex, which results in the suppression of the host antiviral response. Transcription suppression is believed to be another mechanism of this inhibitory process. This occurs when an area of NSs interacts with and binds to the host's protein, SAP30 and forms a complex. This complex causes histone acetylation to regress, which is needed for transcriptional activation of the IFN promoter. This causes IFN expression to be obstructed. Lastly, NSs has also been known to affect regular activity of double-stranded RNA-dependent protein kinase R. This protein is involved in cellular antiviral responses in the host. When RVFV is able to enter the host's DNA, NSs forms a filamentous structure in the nucleus. This allows the virus to interact with specific areas of the host's DNA that relates to segregation defects and induction of chromosome continuity. This increases host infectivity and decreases the host's antiviral response. Diagnosis relies on viral isolation from tissues, or serological testing with an ELISA . Other methods of diagnosis include Nucleic Acid Testing (NAT), cell culture , and IgM antibody assays. As of September 2016, the Kenya Medical Research Institute (KEMRI) has developed a product called Immunoline, designed to diagnose the disease in humans much faster than in previous methods. A person's chances of becoming infected can be reduced by taking measures to decrease contact with blood, body fluids, or tissues of infected animals and protection against mosquitoes and other bloodsucking insects. Use of mosquito repellents and bed nets are two effective methods. For persons working with animals in RVF-endemic areas, wearing protective equipment to avoid any exposure to blood or tissues of animals that may potentially be infected is an important protective measure. Potentially, establishing environmental monitoring and case surveillance systems may aid in the prediction and control of future RVF outbreaks. No vaccines are currently available for humans. While a vaccines have been developed for humans, it has only been used experimentally for scientific personnel in high-risk environments. Trials of a number of vaccines, such as NDBR-103 and TSI-GSD 200, are ongoing. Different types of vaccines for veterinary use are available. The killed vaccines are not practical in routine animal field vaccination because of the need of multiple injections. Live vaccines require a single injection but are known to cause birth defects and abortions in sheep and induce only low-level protection in cattle. The live-attenuated vaccine, MP-12, has demonstrated promising results in laboratory trials in domesticated animals, but more research is needed before the vaccine can be used in the field. The live-attenuated clone 13 vaccine was recently registered and used in South Africa. Alternative vaccines using molecular recombinant constructs are in development and show promising results. A vaccine has been conditionally approved for use in animals in the US. It has been shown that knockout of the NSs and NSm nonstructural proteins of this virus produces an effective vaccine in sheep as well. RVF outbreaks occur across sub-Saharan Africa , with outbreaks occurring elsewhere infrequently. Outbreaks of this disease usually correspond with the warm phases of the EI Niño/Southern Oscillation. During this time there is an increase in rainfall, flooding and greenness of vegetation index , which leads to an increase in mosquito vectors. RVFV can be transmitted vertically in mosquitos, meaning that the virus can be passed from the mother to her offspring. During dry conditions, the virus can remain viable for a number of years in the egg. Mosquitos lay their eggs in water, where they eventually hatch. As water is essential for mosquito eggs to hatch, rainfall and flooding cause an increase in the mosquito population and an increased potential for the virus. The first documented outbreak was identified in Kenya in 1931, in sheep, cattle and humans; another severe outbreak in the country in 1950–1951 involved 100,000 deaths in livestock and an unrecorded number of humans with fever. An outbreak occurred in South Africa in 1974–1976, with more than 500,000 infected animals and the first deaths in humans. In Egypt in 1977–78, an estimated 200,000 people were infected and there were at least 594 deaths. In Kenya in 1998, the virus killed more than 400 people. [ citation needed ] Since then, there have been outbreaks in Saudi Arabia and Yemen (2000), [ citation needed ] East Africa (2006–2007) , Sudan (2007), South Africa (2010), Uganda (2016), Kenya (2018), and Mayotte (2018–2019). 2020–2021 in Kenya, in 2022 an outbreak is ongoing in Burundi.Rift Valley fever was one of more than a dozen agents that the United States researched as potential biological weapons before the nation suspended its biological weapons program in 1969. The disease is one of several identified by WHO as a likely cause of a future epidemic in a new plan developed after the Ebola epidemic for urgent research and development toward new diagnostic tests, vaccines and medicines.

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Pushpa: The Rise

Sukumar Mythri Movie Makers Muttamsetty Media 17 December 2021 ( 2021-12-17 ) Pushpa: The Rise is a 2021 Indian Telugu -language action drama film written and directed by Sukumar . It stars Allu Arjun as the title character alongside Fahadh Faasil (his Telugu debut), and Rashmika Mandanna while Jagadeesh Prathap Bandari , Sunil , Raj Tirandasu, Rao Ramesh , Dhananjaya , Anasuya Bharadwaj , Ajay and Ajay Ghosh play supporting roles. It is produced by Mythri Movie Makers in association with Muttamsetty Media. The first installment in the Pushpa film series , the film depicts the rise of a coolie Pushpa Raj in the smuggling syndicate of red sandalwood , a rare wood that grows only in the Seshachalam Hills of Tirupati in Andhra Pradesh state. Devi Sri Prasad composed the film's score and soundtrack while the cinematography and editing are performed by Miroslaw Kuba Brozek and Karthika Srinivas – Ruben respectively. The film began its production in December 2019 but was halted in March 2020 by the COVID-19 pandemic . Filming resumed in November 2020 and ended in November 2021, predominantly taking place at the Ramoji Film City in Hyderabad and Maredumilli forest in Andhra Pradesh. Pushpa: The Rise was released on 17 December 2021. The film received generally mixed reviews from critics, who praised the performances (particularly of Allu Arjun , Sunil and Fahadh Faasil ), action choreography, cinematography, direction, dialogues, and soundtrack but criticised the runtime, screenplay and editing. The film was commercially successful, grossing ₹ 360 crore (US$45 million) - ₹ 373 crore (US$47 million) at the box office . It became the highest-grossing Indian film of 2021 , and ranks among the highest-grossing Telugu films of all time. The Rise was featured retrospectively at the 74th Berlinale . At the 69th National Film Awards , Pushpa: The Rise won 2 awards – Best Actor (Arjun) and Best Music Direction (Prasad). At the 67th Filmfare Awards South , the film received 8 nominations, including Best Actress – Telugu (Mandanna), and won 7 awards, including Best Film – Telugu , Best Director – Telugu (Sukumar) and Best Actor – Telugu (Arjun). A sequel titled Pushpa 2: The Rule is under production and is scheduled to release on 15 August 2024. Set in the late 90s, labourer Pushpa Raj decides to smuggle red sandalwood with his friend Kesava. He moves up the ranks in smuggler Konda Reddy's group while evading DSP Govindappa. Konda's brother Jaali hates Pushpa for getting more attention from his elder brother. Konda's boss, Srinu, entrusts Konda to keep his contraband of tonnes of sandalwood safe from the Police Department, and Pushpa is assigned to the task by the Reddy brothers, so that if anything happens to it, they can blame him in front of Srinu. Jaali intentionally sabotages Pushpa so he'll get caught by the police, but Pushpa and Kesava use their quick thinking to avoid getting caught. Pushpa finds out Srinu is scamming his workers and tells Konda, but he refuses to go up against the powerful Srinu. Pushpa falls in love with Srivalli, a milk seller, and an engagement is arranged. During the ceremony, Pushpa's elder half-brother Mohan makes a scene, revealing Pushpa is illegitimate. In the ensuing scuffle, Pushpa's mother gets hurt, which motivates him to make his way up. He bypasses Srinu, and is able to get a higher profit for the wood that he agrees to split with Konda. Jaali discovers Srivalli's father is a mole for Govindappa; lusting after Srivalli, Jaali blackmails her to sleep with him to save her father. Srivalli tells Pushpa, who beats Jaali and leaves him paralysed. Jaali doesn't tell Konda who beat him, wanting to kill Pushpa himself, but Konda discovers the truth on his own. Konda attempts to kill Pushpa, but they're attacked by Srinu's men and brother-in-law, Mogileesu, who kills Konda Reddy. Pushpa rescues Konda's younger brother Jakka, rekindling their partnership, and murders Mogileesu. MP Naidu arranges a truce between Pushpa and Srinu, but after discovering about the latter's scams, he appoints Pushpa to replace Srinu. As time goes by, Pushpa takes control of the entire syndicate. Govindappa resigns, and Bhanwar Singh Shekawat takes charge. Pushpa offers a bribe to Shekawat, but Shekawat ridicules Pushpa due to arrogance. After this incident, Pushpa ostensibly turns meek and submissive towards Shekawat, but on the day of his wedding, Pushpa gets his revenge on Shekawat, revealing that he promised his mother he would stay safe and not get into trouble before his wedding day . Pushpa forces Shekawat to strip down to his underwear while he also does the same, boasting that he derives his prestige and power from his own self, while Shekawat is nothing without his uniform and that without it, even his dog won't recognize him. Pushpa leaves to marry Srivalli, while a humiliated Shekawat walks home, where his dog fails to identify him, just like how Pushpa predicted. Enraged, Shekawat shoots and kills his dog, whilst also burning Pushpa's bribe money, swearing revenge. Pushpa, after tying the knot to Srivalli, tells her that his rule has just begun.Post the success of Rangasthalam (2018), Sukumar narrated a script to Mahesh Babu , with whom he previously worked in 1: Nenokkadine (2014). Babu, who liked the story, gave a nod to the project, and was reported to start the shoot after completing Vamshi Paidipally 's project Maharshi (2019). In mid-April 2019, Mythri Movie Makers , which collaborated with Sukumar in their previous film Rangasthalam , officially announced the project which was tentatively titled as #SSMB26 , thus marking their second collaboration with Babu and Sukumar. [lower-alpha 3] The film was expected to begin in January 2019, but, in that March, Babu walked out of Sukumar's project citing creative differences, and he confirmed this through Twitter . The actor instead signed his next project with Anil Ravipudi titled as Sarileru Neekevvaru , whereas Sukumar approached Allu Arjun for his next marking his reunion with the director after a decade since Arya 2 (2009); Mythri Movie Makers which earlier associated with Babu and Sukumar's project also agreed to produce the venture. Sukamar narrated Babu a story based on red sanders . However, once the project was shelved, he came up with a different storyline on red sanders for Allu Arjun. Speaking with Press Trust of India , Sukumar said: "with Mahesh Babu, I couldn't make him cool. He is very fair. So, the backdrop was the same but the story is different." Sukumar described the storyline as follows: "the red sanders heist in the hills of Andhra is a convoluted nexus that unfurls in the course of the narrative through a coolie-turned-smuggler." Sukumar explored the subject of red sandalwood smuggling when he read about such incidents in Andhra Pradesh years ago. Sukumar did his research and thought of developing the project as a web series. However, he later decided to make it as a feature film. He personally went for location scouting across Nallamala Forest as the film is set in Rayalaseema and Nellore and the plot revolves around red sanders smuggling . Since most of the film takes place in a rural backdrop, Allu Arjun was reported to master Chittoor accent for the film, and the makers hired a team from Bollywood to work on his look. The story was set against the backdrop of Seshachalam forest, located in the hilly region of Tirumala . Polish cinematographer Miroslaw Kuba Brozek , who worked for Nani's Gangleader (2019) was signed for the film. Karthika Srinivas is performing the film's editing , whereas Mounika and Ramakrishna, the art directors of Sukumar's previous film Rangasthalam (2018) were chosen for production design . Resul Pookutty is signed for the film's sound design , along with Vijay Kumar. The film's title Pushpa was officially announced on 8 April 2020, on the occasion of Allu Arjun's birthday and a poster was also released. Allu Arjun played the titular character Pushpa Raj, a red-sanders smuggler, and sported a bearded look for his role in the film. Rashmika Mandanna was cast as the film's lead actress, with an official announcement made on Allu Arjun 's birthday (8 April 2019). Mandanna in an online interaction confirmed that she will be learning a new dialect for the film, which is slightly based on the dialect of Chittoor. Jisshu Sengupta was originally offered to play the antagonist but he refused due to pandemic and time constraint. Vijay Sethupathi entered in talks to play the antagonist in October 2019, after working with Sukumar in the director's production venture Uppena (2021), and was confirmed to be part of the film in January 2020. However, in July 2020, Sethupathi left the film citing scheduling conflicts. Post Sethupathi's exit, Vikram , Bobby Simha , Madhavan and Arya were reported to play negative roles in the film, but Malayalam actor Fahadh Faasil was announced as the film's antagonist in March 2021, thus marking his debut in Telugu cinema. For his role in the film, Fahadh sported a bald look and a rough moustache. Kannada actor Dhananjaya was reported to play a pivotal role in April 2020. In November 2020, Sunil was cast in a supporting role and was present in the film's second schedule. Sunil's character was reported to have grey shades in the film. Though it was reported that Anasuya Bharadwaj was playing a crucial role, she later clarified that she wasn't approached for the film. However, Bharadwaj joined the film shooting in April 2021. In July 2021, Sritej confirmed that he was cast in the role of Pushpa Raj's brother. The film had three antagonists, with Sunil and Anasuya, being the antagonists in the first part, while Fahadh's character, Bhanwar Singh Shekhawat, the main antagonist, will appear only at the end of the first part and will continue throughout its sequel. Jagadeesh was cast by Sukumar after watching his performances in the films Mallesham (2019) and George Reddy (2019). In an interview, Jagadeesh Prathap Bandari revealed that he has left 15 smaller projects for working in the film. Samantha joined the production in late-November 2021. She has shot for the item song "Oo Antava Oo Oo Antava" alongside Allu Arjun and others. On working in the song, she said that "being sexy is next level hard work". In July 2019, the makers planned to start the filming during the occasion of Dusshera (7 October 2019). However, the launch event of the film took place on 30 October 2019, with a formal puja ceremony held in Hyderabad at the office of Mythri Movie Makers, with the film's cast and crew being present at the event. In December 2019, Sukumar performed a test shoot in Kerala 's Athirappilly Falls . After Allu Arjun's involvement in the promotions of Ala Vaikunthapurramuloo (2020), the makers planned to shoot the first schedule of the film in Kerala in March 2020, with Arjun joining the schedule, however, the filming was halted due to COVID-19 pandemic in India . For a 6-minute action sequence in the film, the team planned to hire action choreographers from South India , instead of opting for foreign technicians. Thus, the film became a "Make In India" project, an initiative to provide employment to the workers from the Indian Film Industry , after some technicians faced employment crisis due to the pandemic. [ citation needed ] This sequence is reported to be made a cost of ₹ 6 crore (US$750,000) and Allu Arjun has been trained intensively for this sequence. The makers later planned to shift the location from Kerala to Andhra Pradesh, due to restrictions on travel, in order to curb the COVID-19 pandemic. In June 2020, the makers planned to resume the shoot in Ramoji Film City in Hyderabad , and later planned to shoot the film at Nalgonda . Post government permitted film shootings with minimal crew, the makers resumed filming on 10 November 2020 in Maredumilli forest in Andhra Pradesh, and completed within 14 days. The team moved to Rajahmundry in December 2020 to shoot key sequences, but was indefinitely postponed to January 2021, as twelve crew members working in the film were diagnosed with COVID-19. The shooting later resumed in January 2021 and the production house tweeted that two schedules at Rampachodavaram and Maredumilli was completed within February 2021. The team also finished a schedule at Kerala in March 2021. The shooting of the film was put on hold due to restrictions following second wave of COVID-19 pandemic in India , and Allu Arjun was also diagnosed with COVID-19 in late April. The team resumed the final leg shooting on 6 July 2021, with a major schedule was filmed in Secunderabad , but came to a halt on 24 July 2021 when Sukumar was diagnosed with dengue fever . The filming resumed after Sukumar recovered from the disease. On 22 August 2021, Fahadh Faasil joined the shooting schedule of the film. After wrapping her portions in the Hindi film Goodbye , Rashmika joined the shoot for filming her portions. In September 2021, she rejoined the shoot after a brief break. On 8 September, Allu Arjun headed to Maredumilli to film the final schedule. After a month-long production, on 4 October, the team started shooting face off scenes between Allu Arjun and Fahadh Faasil. Finally, a special song featuring Samantha was filmed in November 2021 at a specially constructed set at the Ramoji Film City and "Ey Bidda Idi Na Adda " ( transl. This is my area ) song was filmed at Mallikarjun Swami Temple of Beeramguda . After this, the film entered into the full-fledged post-production phase. Speaking to the media at a promotional event of Tamil version in Chennai , Allu Arjun said that "We had about 400-500 cars in the forest that would take us from point A to B. In some places, there were no roads and we had to create a pathway with whatever was available. The filming itself took us almost two years, that is why I say this: the effort we had put in for Pushpa is equal to four films." The dubbing works of the film have begun in April 2021. Ten days before the release of the film, Shreyas Talpade confirmed that he has dubbed for Allu Arjun of the film's Hindi version. Jis Joy who has dubbed for Arjun's previous films in Malayalam, has been signed to voice dub for Allu Arjun of the film's Malayalam version. By the early-December 2021 he has completed his portions of dubbing. K. P. Sekar lent Allu Arjun's voice for the film's Tamil version. Fahadh Faasil has dubbed for his role in all the languages, except Hindi which was dubbed by Rajesh Khattar .Post the success of Rangasthalam (2018), Sukumar narrated a script to Mahesh Babu , with whom he previously worked in 1: Nenokkadine (2014). Babu, who liked the story, gave a nod to the project, and was reported to start the shoot after completing Vamshi Paidipally 's project Maharshi (2019). In mid-April 2019, Mythri Movie Makers , which collaborated with Sukumar in their previous film Rangasthalam , officially announced the project which was tentatively titled as #SSMB26 , thus marking their second collaboration with Babu and Sukumar. [lower-alpha 3] The film was expected to begin in January 2019, but, in that March, Babu walked out of Sukumar's project citing creative differences, and he confirmed this through Twitter . The actor instead signed his next project with Anil Ravipudi titled as Sarileru Neekevvaru , whereas Sukumar approached Allu Arjun for his next marking his reunion with the director after a decade since Arya 2 (2009); Mythri Movie Makers which earlier associated with Babu and Sukumar's project also agreed to produce the venture. Sukamar narrated Babu a story based on red sanders . However, once the project was shelved, he came up with a different storyline on red sanders for Allu Arjun. Speaking with Press Trust of India , Sukumar said: "with Mahesh Babu, I couldn't make him cool. He is very fair. So, the backdrop was the same but the story is different." Sukumar described the storyline as follows: "the red sanders heist in the hills of Andhra is a convoluted nexus that unfurls in the course of the narrative through a coolie-turned-smuggler." Sukumar explored the subject of red sandalwood smuggling when he read about such incidents in Andhra Pradesh years ago. Sukumar did his research and thought of developing the project as a web series. However, he later decided to make it as a feature film. He personally went for location scouting across Nallamala Forest as the film is set in Rayalaseema and Nellore and the plot revolves around red sanders smuggling . Since most of the film takes place in a rural backdrop, Allu Arjun was reported to master Chittoor accent for the film, and the makers hired a team from Bollywood to work on his look. The story was set against the backdrop of Seshachalam forest, located in the hilly region of Tirumala . Polish cinematographer Miroslaw Kuba Brozek , who worked for Nani's Gangleader (2019) was signed for the film. Karthika Srinivas is performing the film's editing , whereas Mounika and Ramakrishna, the art directors of Sukumar's previous film Rangasthalam (2018) were chosen for production design . Resul Pookutty is signed for the film's sound design , along with Vijay Kumar. The film's title Pushpa was officially announced on 8 April 2020, on the occasion of Allu Arjun's birthday and a poster was also released. Allu Arjun played the titular character Pushpa Raj, a red-sanders smuggler, and sported a bearded look for his role in the film. Rashmika Mandanna was cast as the film's lead actress, with an official announcement made on Allu Arjun 's birthday (8 April 2019). Mandanna in an online interaction confirmed that she will be learning a new dialect for the film, which is slightly based on the dialect of Chittoor. Jisshu Sengupta was originally offered to play the antagonist but he refused due to pandemic and time constraint. Vijay Sethupathi entered in talks to play the antagonist in October 2019, after working with Sukumar in the director's production venture Uppena (2021), and was confirmed to be part of the film in January 2020. However, in July 2020, Sethupathi left the film citing scheduling conflicts. Post Sethupathi's exit, Vikram , Bobby Simha , Madhavan and Arya were reported to play negative roles in the film, but Malayalam actor Fahadh Faasil was announced as the film's antagonist in March 2021, thus marking his debut in Telugu cinema. For his role in the film, Fahadh sported a bald look and a rough moustache. Kannada actor Dhananjaya was reported to play a pivotal role in April 2020. In November 2020, Sunil was cast in a supporting role and was present in the film's second schedule. Sunil's character was reported to have grey shades in the film. Though it was reported that Anasuya Bharadwaj was playing a crucial role, she later clarified that she wasn't approached for the film. However, Bharadwaj joined the film shooting in April 2021. In July 2021, Sritej confirmed that he was cast in the role of Pushpa Raj's brother. The film had three antagonists, with Sunil and Anasuya, being the antagonists in the first part, while Fahadh's character, Bhanwar Singh Shekhawat, the main antagonist, will appear only at the end of the first part and will continue throughout its sequel. Jagadeesh was cast by Sukumar after watching his performances in the films Mallesham (2019) and George Reddy (2019). In an interview, Jagadeesh Prathap Bandari revealed that he has left 15 smaller projects for working in the film. Samantha joined the production in late-November 2021. She has shot for the item song "Oo Antava Oo Oo Antava" alongside Allu Arjun and others. On working in the song, she said that "being sexy is next level hard work". In July 2019, the makers planned to start the filming during the occasion of Dusshera (7 October 2019). However, the launch event of the film took place on 30 October 2019, with a formal puja ceremony held in Hyderabad at the office of Mythri Movie Makers, with the film's cast and crew being present at the event. In December 2019, Sukumar performed a test shoot in Kerala 's Athirappilly Falls . After Allu Arjun's involvement in the promotions of Ala Vaikunthapurramuloo (2020), the makers planned to shoot the first schedule of the film in Kerala in March 2020, with Arjun joining the schedule, however, the filming was halted due to COVID-19 pandemic in India . For a 6-minute action sequence in the film, the team planned to hire action choreographers from South India , instead of opting for foreign technicians. Thus, the film became a "Make In India" project, an initiative to provide employment to the workers from the Indian Film Industry , after some technicians faced employment crisis due to the pandemic. [ citation needed ] This sequence is reported to be made a cost of ₹ 6 crore (US$750,000) and Allu Arjun has been trained intensively for this sequence. The makers later planned to shift the location from Kerala to Andhra Pradesh, due to restrictions on travel, in order to curb the COVID-19 pandemic. In June 2020, the makers planned to resume the shoot in Ramoji Film City in Hyderabad , and later planned to shoot the film at Nalgonda . Post government permitted film shootings with minimal crew, the makers resumed filming on 10 November 2020 in Maredumilli forest in Andhra Pradesh, and completed within 14 days. The team moved to Rajahmundry in December 2020 to shoot key sequences, but was indefinitely postponed to January 2021, as twelve crew members working in the film were diagnosed with COVID-19. The shooting later resumed in January 2021 and the production house tweeted that two schedules at Rampachodavaram and Maredumilli was completed within February 2021. The team also finished a schedule at Kerala in March 2021. The shooting of the film was put on hold due to restrictions following second wave of COVID-19 pandemic in India , and Allu Arjun was also diagnosed with COVID-19 in late April. The team resumed the final leg shooting on 6 July 2021, with a major schedule was filmed in Secunderabad , but came to a halt on 24 July 2021 when Sukumar was diagnosed with dengue fever . The filming resumed after Sukumar recovered from the disease. On 22 August 2021, Fahadh Faasil joined the shooting schedule of the film. After wrapping her portions in the Hindi film Goodbye , Rashmika joined the shoot for filming her portions. In September 2021, she rejoined the shoot after a brief break. On 8 September, Allu Arjun headed to Maredumilli to film the final schedule. After a month-long production, on 4 October, the team started shooting face off scenes between Allu Arjun and Fahadh Faasil. Finally, a special song featuring Samantha was filmed in November 2021 at a specially constructed set at the Ramoji Film City and "Ey Bidda Idi Na Adda " ( transl. This is my area ) song was filmed at Mallikarjun Swami Temple of Beeramguda . After this, the film entered into the full-fledged post-production phase. Speaking to the media at a promotional event of Tamil version in Chennai , Allu Arjun said that "We had about 400-500 cars in the forest that would take us from point A to B. In some places, there were no roads and we had to create a pathway with whatever was available. The filming itself took us almost two years, that is why I say this: the effort we had put in for Pushpa is equal to four films." The dubbing works of the film have begun in April 2021. Ten days before the release of the film, Shreyas Talpade confirmed that he has dubbed for Allu Arjun of the film's Hindi version. Jis Joy who has dubbed for Arjun's previous films in Malayalam, has been signed to voice dub for Allu Arjun of the film's Malayalam version. By the early-December 2021 he has completed his portions of dubbing. K. P. Sekar lent Allu Arjun's voice for the film's Tamil version. Fahadh Faasil has dubbed for his role in all the languages, except Hindi which was dubbed by Rajesh Khattar .Sukumar's regular collaborator Devi Sri Prasad composed score and soundtrack of this film. [lower-alpha 4] The soundtrack features five songs written by Chandrabose , including "Daakko Daakko Meka", "Srivalli", "Oo Antava Oo Oo Antava", "Saami Saami", and "Eyy Bidda Idhi Naa Adda". Pushpa: The Rise was released on 17 December 2021. Previously, the film was announced to release on 13 August 2021, coinciding with the Independence Day weekend. In May 2021, the makers announced that the film would be releasing in two parts, with the first part coming on the originally intended release date while the second installment will be arriving in 2023. The producers released a statement saying: "The storyline and the characters took on lives of their own and grew to a span that required the movie to be released in two parts", with the title of the film's first part was unveiled as Pushpa: The Rise – Part 1 in August 2021. Due to surge in the COVID-19 pandemic , the film's release was rescheduled to Christmas 2021. In October 2021, the makers announced the release date as 17 December 2021. It simultaneously released in Telugu and dubbed versions in Tamil , Kannada , Malayalam and Hindi languages. Following the release, the makers deleted a controversial scene on fans' demand. In the scene, Pushpa (played by Arjun) touches Srivalli's (played by Mandanna) chest and have a conversation about it, and they felt it may not go well with the family audience. It is also reported that a few more scenes were cut to reduce its runtime. In later half of 2022, it got officially dubbed in Russian , the production company released Russian -language trailer on YouTube on 29 November 2022 and the film was released in theatres of Russia. The film was screened at the Moscow International Film Festival in 2022. It was screened in the category "Blockbuster hits from around the world". On 25 June 2021, Eenadu reported that the Hindi dubbing rights were sold for ₹ 17.3 crore (equivalent to ₹ 19 crore or US$2.4 million in 2023) . Initially Karan Johar 's Dharma Productions were reported to acquire the distribution rights, and may present and promote the Hindi version of the film in North Indian theatres. This was reported to be third South Indian film to be presented by the company after the Baahubali franchise and 2.0 (2018). However, it was reported that the film's Hindi version will not have a be simultaneous theatre release, instead the Hindi dubbed version will release directly on YouTube . It has been reported that, the Hindi version faced troubles due to the legal disputes between the producers and Goldmines Telefilms, which regularly distributed the Hindi versions of the actor's previous films. However, in November 2021, a Hindi-version poster was later released, thus clarifying that the film will have theatrical release in Hindi. In the same month it was also reported that the Goldmines Telefilms will distribute the film in the Hindi-version by collaborating with another production company. On 20 November 2021, it was confirmed through social media that the Hindi distribution would be done by AA Films . The film is distributed in Tamil Nadu by Lyca Productions and Sri Lakshmi Movies, Swagath Enterprises in Karnataka and by E4 Entertainments in Kerala . Star India Network acquired the satellite rights of the film (except the Hindi version, which was acquired by Goldmines TV), while Amazon Prime Video acquired the digital rights. The film began streaming 21 days later through Amazon Prime Video on 7 January 2022, while the Hindi version began streaming from 14 January 2022. Pushpa: The Rise was released on 17 December 2021. Previously, the film was announced to release on 13 August 2021, coinciding with the Independence Day weekend. In May 2021, the makers announced that the film would be releasing in two parts, with the first part coming on the originally intended release date while the second installment will be arriving in 2023. The producers released a statement saying: "The storyline and the characters took on lives of their own and grew to a span that required the movie to be released in two parts", with the title of the film's first part was unveiled as Pushpa: The Rise – Part 1 in August 2021. Due to surge in the COVID-19 pandemic , the film's release was rescheduled to Christmas 2021. In October 2021, the makers announced the release date as 17 December 2021. It simultaneously released in Telugu and dubbed versions in Tamil , Kannada , Malayalam and Hindi languages. Following the release, the makers deleted a controversial scene on fans' demand. In the scene, Pushpa (played by Arjun) touches Srivalli's (played by Mandanna) chest and have a conversation about it, and they felt it may not go well with the family audience. It is also reported that a few more scenes were cut to reduce its runtime. In later half of 2022, it got officially dubbed in Russian , the production company released Russian -language trailer on YouTube on 29 November 2022 and the film was released in theatres of Russia. The film was screened at the Moscow International Film Festival in 2022. It was screened in the category "Blockbuster hits from around the world". On 25 June 2021, Eenadu reported that the Hindi dubbing rights were sold for ₹ 17.3 crore (equivalent to ₹ 19 crore or US$2.4 million in 2023) . Initially Karan Johar 's Dharma Productions were reported to acquire the distribution rights, and may present and promote the Hindi version of the film in North Indian theatres. This was reported to be third South Indian film to be presented by the company after the Baahubali franchise and 2.0 (2018). However, it was reported that the film's Hindi version will not have a be simultaneous theatre release, instead the Hindi dubbed version will release directly on YouTube . It has been reported that, the Hindi version faced troubles due to the legal disputes between the producers and Goldmines Telefilms, which regularly distributed the Hindi versions of the actor's previous films. However, in November 2021, a Hindi-version poster was later released, thus clarifying that the film will have theatrical release in Hindi. In the same month it was also reported that the Goldmines Telefilms will distribute the film in the Hindi-version by collaborating with another production company. On 20 November 2021, it was confirmed through social media that the Hindi distribution would be done by AA Films . The film is distributed in Tamil Nadu by Lyca Productions and Sri Lakshmi Movies, Swagath Enterprises in Karnataka and by E4 Entertainments in Kerala . Star India Network acquired the satellite rights of the film (except the Hindi version, which was acquired by Goldmines TV), while Amazon Prime Video acquired the digital rights. The film began streaming 21 days later through Amazon Prime Video on 7 January 2022, while the Hindi version began streaming from 14 January 2022. On its opening day, Pushpa: The Rise netted ₹44 crore in India with a gross of around ₹53 crore , and set a post-pandemic record for day one. Including the premieres, the film grossed $850,000 in the United States and obtained a worldwide gross of ₹ 74 crore on its first day. Pushpa grossed over ₹161 crore worldwide in its opening weekend. It netted over ₹ 107.5 crore in three days, making it the first ₹ 100 crore weekend in India post- COVID-19 pandemic . Overall, it is the 13th film and fourth South India film to achieve this feat. Box Office India reported that the opening would have been higher, if not for the ticket pricing issue in Andhra Pradesh state. An article from The Indian Express analysed the losses incurred by The Rise due to low ticket prices in Andhra. " Pushpa collected a [distributor's] share of a little more than ₹ 13 crore from the state's 1100 screens. To put this in perspective, in Telangana , the first-day share of Pushpa was pegged at over ₹ 11 crore from around 600-odd screens," the article stated. The film's Hindi dubbed version is commercially successful. The Rise ' s Hindi version netted ₹ 26.50 crore in its first week, and over ₹ 62 crore by the end of third weekend. The Rise netted over ₹200 crore in India in two weeks, and became the seventh South India film and the second Allu Arjun film after Ala Vaikunthapurramuloo (2020) to do so. The film grossed ₹300 crore worldwide from all versions by the end of the third weekend, and emerged as the highest grossing Indian film in 2021 . The scale of the dub's commercial gains have been considered unusual, especially as the film was also available on streaming platforms during its Hindi theatrical run. Its success, as well as the popularity of other Telugu films dubbed into Hindi, has been mainly attributed to the film's mass appeal as a masala film during a time when Hindi cinema has focused more on realism and has become more "toned down". Bollywood Hungama gave it 3.5/5 rating, noting it as a "Paisa Vasool" ( transl. Value for money ) film and called Sukumar's screenplay "top notch". The Indian Express gave it 3 out of 5 stars and wrote "Allu Arjun walks away with the film with his strong performance. He embraces his deglamorized look and delivers a memorable performance". Deccan Chronicle gave the film 3 out of 5 stars, and called it a "one-man show" referring to lead actor Allu Arjun. The reviewer added that the latter half was predictable and Sami Sami song appears without context with the climax lacking punch. A reviewer from Pinkvilla gave the film 3 out of 5 stars praising Allu's performance and soundtrack writing, "' Pushpa: The Rise ' needed smarter writing for sure. But it's still one of the most engaging mass masala films in recent times. Devi Sri Prasad's superb songs hit the ball out of the park". The Times of India critic Neeshita Nyayapati rated the film 3 out of 5 stars and praised Allu's performance, action sequences, direction, cinematography and score but criticised the technical aspects while stating: " Pushpa: The Rise is Allu Arjun's show all the way. He shines in playing this rustic character that is hard on the surface but vulnerable in ways that others don't see." Rating the film 3/5, India Today critic Janani K. praised Allu and Sunil's performances but felt that Mandanna was in the film "only for the male gaze". On technical aspects, she appreciated cinematography and editing but criticised Sukumar's screenplay, calling it "one of the weakest screenplay of his career." Haricharan Pudipeddi of Hindustan Times called it "Ahaa Oho", writing, "At three-hour-long, Pushpa manages to stay engaging for the most part and never makes sitting through the film tiring. It's a character-driven story and Sukumar needs to be lauded for effectively establishing the character of Pushpa, whose growth couldn't have been handled more satisfyingly." News18 praised the performances, action sequences and soundtrack writing "Overall, the film is a massy entertainer with a decent storyline and is custom-made for Allu Arjun's fans." Reviewing the Hindi dubbed version, Komal Nahata praised Arjun's acting and Shreyas Talpade 's Hindi dubbing of Pushpa character. Praising the work of cast and crew, a reviewer from Eenadu opined that Sukumar should have re-thought about the runtime and spent more time in the post-production. In ABP News ' s review, Ravi Bule felt that the story was not fresh but by the style it was expressed its new. Writing for The News Minute , Sowmya Rajendran said: "Allu Arjun is immensely likable on screen and that keeps Pushpa going despite its lengthy runtime of three hours." Also opining that the film was a bit long, Firstpost ' s Sankeertana Varma said: "Sukumar has a vision for who Pushpa is, both the character and the film." Calling it a "mixed bag", Sangeetha Devi Dundoo of The Hindu , wrote, " Pushpa – The Rise is riveting in some segments and bland in others. Allu Arjun shoulders the film, but his coming together with Sukumar should have been for a more absorbing narrative." The Hans India rated the film 2.75 out of 5 stars and wrote "The first half is quite engaging but the second half moves at a snail pace and bores us to the core. Barring Allu Arjun's exceptional performance, there is nothing else to watch out for in Pushpa". Karthik Keramalu of The Quint rated the film 2.5 out of 5 stars and wrote "The meat of the story doesn't have enough protein to sustain a sequel. Sukumar could have easily wrapped up everything in this movie itself. And now we'll have to sit through three more hours of Shekhawat versus Pushpa". Anji Shetty of Sakshi appreciated the red sandalwood backdrop and Allu's characterisation but felt that the story was predictable and the climax with Fahadh was a disappointment. In her review for BBC Telugu , Sahiti stated Sukumar deviated from his usual style of filmmaking and opted for flat narrative in Pushpa which was one of the film's downsides. A News 18 Hindi reviewer also felt the same. She added Mandanna's role was very dull and director doesn't dwell onto how ordinary kid like Pushpa grows up to a goon of his village. On its opening day, Pushpa: The Rise netted ₹44 crore in India with a gross of around ₹53 crore , and set a post-pandemic record for day one. Including the premieres, the film grossed $850,000 in the United States and obtained a worldwide gross of ₹ 74 crore on its first day. Pushpa grossed over ₹161 crore worldwide in its opening weekend. It netted over ₹ 107.5 crore in three days, making it the first ₹ 100 crore weekend in India post- COVID-19 pandemic . Overall, it is the 13th film and fourth South India film to achieve this feat. Box Office India reported that the opening would have been higher, if not for the ticket pricing issue in Andhra Pradesh state. An article from The Indian Express analysed the losses incurred by The Rise due to low ticket prices in Andhra. " Pushpa collected a [distributor's] share of a little more than ₹ 13 crore from the state's 1100 screens. To put this in perspective, in Telangana , the first-day share of Pushpa was pegged at over ₹ 11 crore from around 600-odd screens," the article stated. The film's Hindi dubbed version is commercially successful. The Rise ' s Hindi version netted ₹ 26.50 crore in its first week, and over ₹ 62 crore by the end of third weekend. The Rise netted over ₹200 crore in India in two weeks, and became the seventh South India film and the second Allu Arjun film after Ala Vaikunthapurramuloo (2020) to do so. The film grossed ₹300 crore worldwide from all versions by the end of the third weekend, and emerged as the highest grossing Indian film in 2021 . The scale of the dub's commercial gains have been considered unusual, especially as the film was also available on streaming platforms during its Hindi theatrical run. Its success, as well as the popularity of other Telugu films dubbed into Hindi, has been mainly attributed to the film's mass appeal as a masala film during a time when Hindi cinema has focused more on realism and has become more "toned down". Bollywood Hungama gave it 3.5/5 rating, noting it as a "Paisa Vasool" ( transl. Value for money ) film and called Sukumar's screenplay "top notch". The Indian Express gave it 3 out of 5 stars and wrote "Allu Arjun walks away with the film with his strong performance. He embraces his deglamorized look and delivers a memorable performance". Deccan Chronicle gave the film 3 out of 5 stars, and called it a "one-man show" referring to lead actor Allu Arjun. The reviewer added that the latter half was predictable and Sami Sami song appears without context with the climax lacking punch. A reviewer from Pinkvilla gave the film 3 out of 5 stars praising Allu's performance and soundtrack writing, "' Pushpa: The Rise ' needed smarter writing for sure. But it's still one of the most engaging mass masala films in recent times. Devi Sri Prasad's superb songs hit the ball out of the park". The Times of India critic Neeshita Nyayapati rated the film 3 out of 5 stars and praised Allu's performance, action sequences, direction, cinematography and score but criticised the technical aspects while stating: " Pushpa: The Rise is Allu Arjun's show all the way. He shines in playing this rustic character that is hard on the surface but vulnerable in ways that others don't see." Rating the film 3/5, India Today critic Janani K. praised Allu and Sunil's performances but felt that Mandanna was in the film "only for the male gaze". On technical aspects, she appreciated cinematography and editing but criticised Sukumar's screenplay, calling it "one of the weakest screenplay of his career." Haricharan Pudipeddi of Hindustan Times called it "Ahaa Oho", writing, "At three-hour-long, Pushpa manages to stay engaging for the most part and never makes sitting through the film tiring. It's a character-driven story and Sukumar needs to be lauded for effectively establishing the character of Pushpa, whose growth couldn't have been handled more satisfyingly." News18 praised the performances, action sequences and soundtrack writing "Overall, the film is a massy entertainer with a decent storyline and is custom-made for Allu Arjun's fans." Reviewing the Hindi dubbed version, Komal Nahata praised Arjun's acting and Shreyas Talpade 's Hindi dubbing of Pushpa character. Praising the work of cast and crew, a reviewer from Eenadu opined that Sukumar should have re-thought about the runtime and spent more time in the post-production. In ABP News ' s review, Ravi Bule felt that the story was not fresh but by the style it was expressed its new. Writing for The News Minute , Sowmya Rajendran said: "Allu Arjun is immensely likable on screen and that keeps Pushpa going despite its lengthy runtime of three hours." Also opining that the film was a bit long, Firstpost ' s Sankeertana Varma said: "Sukumar has a vision for who Pushpa is, both the character and the film." Calling it a "mixed bag", Sangeetha Devi Dundoo of The Hindu , wrote, " Pushpa – The Rise is riveting in some segments and bland in others. Allu Arjun shoulders the film, but his coming together with Sukumar should have been for a more absorbing narrative." The Hans India rated the film 2.75 out of 5 stars and wrote "The first half is quite engaging but the second half moves at a snail pace and bores us to the core. Barring Allu Arjun's exceptional performance, there is nothing else to watch out for in Pushpa". Karthik Keramalu of The Quint rated the film 2.5 out of 5 stars and wrote "The meat of the story doesn't have enough protein to sustain a sequel. Sukumar could have easily wrapped up everything in this movie itself. And now we'll have to sit through three more hours of Shekhawat versus Pushpa". Anji Shetty of Sakshi appreciated the red sandalwood backdrop and Allu's characterisation but felt that the story was predictable and the climax with Fahadh was a disappointment. In her review for BBC Telugu , Sahiti stated Sukumar deviated from his usual style of filmmaking and opted for flat narrative in Pushpa which was one of the film's downsides. A News 18 Hindi reviewer also felt the same. She added Mandanna's role was very dull and director doesn't dwell onto how ordinary kid like Pushpa grows up to a goon of his village. Sukumar and the makers were accused of copyright infringement by the writer Vempalli Gangadhar . In a Facebook post dated 27 August 2020, Gangadhar stated that the storyline which is based on red sandalwood smuggling, was plagiarised from his short story titled Coolie written for Sakshi newspaper which was published two years earlier. [ further explanation needed ] In December 2021, a lawsuit was filed at a court in Andhra Pradesh against a song in the film titled " Oo Antava Oo Oo Antava " ( transl. Will you say yes or will you say no? ) by a certain [ which? ] men's association [ who? ] . According to them, the song portrayed men as casanovas and eve teasers as its lyrics seemingly mock the male gaze. They also asked for a ban on the song. Sukumar and the makers were accused of copyright infringement by the writer Vempalli Gangadhar . In a Facebook post dated 27 August 2020, Gangadhar stated that the storyline which is based on red sandalwood smuggling, was plagiarised from his short story titled Coolie written for Sakshi newspaper which was published two years earlier. [ further explanation needed ]In December 2021, a lawsuit was filed at a court in Andhra Pradesh against a song in the film titled " Oo Antava Oo Oo Antava " ( transl. Will you say yes or will you say no? ) by a certain [ which? ] men's association [ who? ] . According to them, the song portrayed men as casanovas and eve teasers as its lyrics seemingly mock the male gaze. They also asked for a ban on the song. Initially planned as a single film, it was later decided to make the film a two-part release. The second part, titled Pushpa 2: The Rule , is scheduled to release on 15 August 2024.

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KL Rahul

Kannanur Lokesh Rahul ( / k ə n uː r l oʊ k eɪ ʃ ˌ r ɑː h ʊ l / ; born 18 April 1992) is an Indian international cricketer . A right-handed wicket-keeping batsman, Rahul plays for Karnataka at the domestic level and captains the Lucknow Super Giants in the Indian Premier League . He is a occasional captain of India national cricket team . He was a part of the Indian squads which won the 2018 Asia Cup and 2023 Asia Cup . He made his international debut in 2014 against Australia in the Boxing Day Test-match in Melbourne . Two years after his Test debut, Rahul made his One-Day International Debut in 2016 against Zimbabwe , where he scored his first century by hitting a six on the last ball to reach 100*(115) from 94(114), which was also the only six of the entire match. On the same tour, he made his T20I debut. Rahul is the first and only Indian cricketer to score an ODI century on his debut. He is the fastest batsman in the world to score an International century across all three formats, taking only 20 innings to achieve this feat. Rahul was born on 18 April 1992 to K. N. Lokesh and Rajeshwari in Bangalore , Karnataka . His father Lokesh, who hails from Kannanur in Mangalore , is a professor and former director at the National Institute of Technology Karnataka (NITK) in Mangalore . His mother, Rajeshwari, is a professor at Mangalore University . His father, Lokesh who was a fan of cricketer Sunil Gavaskar , wanted to name his son after Gavaskar's son, but mistook Rohan Gavaskar 's name for Rahul. His mother tongue is Kannada . Rahul grew up in Mangalore , completing his high school at NITK English Medium School and pre-university at St. Aloysius College . He started cricket training at the age of 10, and, two years later, started playing matches for both Bangalore United Cricket Club and his club in Mangalore. At age 18, he moved to Bangalore to study at Jain University and pursue his cricket career. On 23 January 2023, Rahul married his long-time partner, Indian actress Athiya Shetty , daughter of actor Suniel Shetty , after dating for more than three years. Rahul made his first-class cricket debut for Karnataka in the 2010–11 season. In the same season, he represented his country at the 2010 ICC Under-19 Cricket World Cup , scoring 143 runs in the competition. He made his debut in the Indian Premier League in 2013, for Royal Challengers Bangalore . During the 2013–14 domestic season he scored 1,033 first-class runs, the second highest scorer that season. Playing for South Zone in the final of the 2014–15 Duleep Trophy against Central Zone, Rahul scored 185 off 233 balls in the first innings and 130 off 152 in the second. He was named the player of the match and selected to the Indian Test squad for the Australian tour followed. Returning home after the Test series, Rahul became Karnataka's first triple-centurion, scoring 337 against Uttar Pradesh . He went on to score 188 in the 2014–15 Ranji Trophy final against Tamil Nadu and finished the season with an average of 93.11 in the nine matches he played.Rahul made his Test debut in the 2014 Boxing Day Test at the Melbourne Cricket Ground . He replaced Rohit Sharma and was presented with his Test cap by MS Dhoni . He managed to score only 3 and 1 on his debut. In the next test at Sydney where he opened the innings for the first time, and made his maiden international century, scoring 110 runs. He was named in the 15-man squad for the Indian tour of Bangladesh in June 2015 but withdrew due to Dengue fever . He returned to the side for the first Test of the Sri Lankan tour after Murali Vijay was ruled out due to injury, scoring his second Test century and winning the Man of the Match award. During the match, he kept wicket after Wriddhiman Saha was injured. In July 2016, Rahul was named in the squad for India tour of West Indies . In the second series test, Rahul scored 158 runs, his then-highest score in test cricket. In September 2016, he was named in the squad for the home series against New Zealand . After the first test, he was replaced by Gautam Gambhir due to an injury. Rahul was selected in the squad against England in the 2016-17 Test series but was injured while training in the nets. He was ruled out of the third test, but he made his comeback to the team in the fourth test but failed to make an impact. In the fifth and final test of the series, Rahul went on to make his fourth test ton, scoring his career-best 199 runs. Rahul was named in the squad to tour Zimbabwe in 2016 . He made his One Day International (ODI) debut against Zimbabwe at Harare Sports Club . Rahul scored an unbeaten 100*(115) on debut, thus becoming the first Indian cricketer to score a century on an ODI debut. He was named the man of the series. He made his Twenty20 International (T20I) debut later in the same tour. Rahul got out on a golden duck on his T20I debut as India lost the first T20I against Zimbabwe. Rahul was named in T20I squad for the tour of West Indies in 2016 , where he made his first T20I century of just 46 balls and ended up scoring an unbeaten 110 off just 51 balls. He became the first player to score a T20I century while batting at number four whilst in pursuit of the highest T20I run chase at that time of 246. However, India lost the match by just one run. In his 20th international innings, Rahul became the fastest batsman to have scored centuries in all three formats, surpassing the record of Ahmed Shehzad , who took 76 innings. On 3 July 2018, Rahul scored his second T20 International ton against England. He is also the first Indian batsman to be dismissed hit-wicket in T20Is. On 11 January 2019, Hardik Pandya and K. L. Rahul were suspended by the Board of Control for Cricket in India (BCCI) following controversial comments they made on the Indian talk show Koffee with Karan earlier in the month. They were both sent home ahead of the ODI series against Australia and the fixtures of India's tour to New Zealand . On 24 January 2019, after lifting the suspension on Pandya and Rahul, the BCCI announced that Rahul would re-join the squad for India A matches. In April 2019, he was named in India's squad for the 2019 Cricket World Cup . He played at number 4 in the first two games but got back to opening the innings alongside Rohit Sharma as Shikhar Dhawan was ruled out of the rest of the tournament due to injury. Overall, Rahul scored 361 runs with two fifties and one hundred in the tournament and finished as India's third-highest run scorer in the tournament after Rohit Sharma and Virat Kohli . Due to lack of form in the Test format, Rahul was dropped from the Test squad for the Home tests against South Africa. However, he remained in the limited over sides. In December 2019, in the first T20I match against the West Indies , Rahul scored his 1,000th run in T20I cricket. He scored 62 (40) in the first T20I against West Indies. He scored 91 (56) in the third T20I, for which he was convicted the Man of the Match. He scored his 3rd ODI century in the 2nd ODI against West Indies. In the 2-match T20I series against Sri Lanka, Rahul scored 45 in the first match and 54 in the second T20I. In January 2020, Rahul made 80 (52) batting at number five in the second ODI against Australia and was rewarded as the man of the match. In India's tour of New Zealand in 2019–20 , Rahul was declared man of the series in the five-match T20I series for scoring 224 runs at an average of 56. He was also the stand-in captain in the 5th T20I after Rohit Sharma suffered a hamstring injury during the 1st innings. In the ODI series against New Zealand, he scored 88* (64) in the first ODI and scored his fourth ton in ODIs, 112 (113) in the third ODI. In October 2020, Rahul was named as India 's vice captain for the ODI and T20I series against Australia . Rahul had a moderate ODI and T20I series against Australia. He made 77 against Australia in the second ODI and 51 in the first T20I. India lost the ODI series 2–1 but won the T20I series by the same margin. Rahul was included in the test squad for the Border-Gavaskar Trophy but was not picked in the playing XI for the first two Tests. He injured himself during practice and was ruled out of the remaining part of the tour. As a result, he also missed the home Test series against England in February 2021. He returned to the national side for the T20I and ODI series against England. There was a dip in his form in the T20I series. He returned to form in the ODI series scoring a match-winning 62* and was involved in a 100-run partnership with debutant Krunal Pandya who scored a fifty. He continued his form by scoring 108 runs in the second ODI and was involved in another 100-run partnership with Rishabh Pant. Rahul was named to India's test squad for their tour of England in 2021. As Shubman Gill and Mayank Agarwal were injured, Rahul opened alongside teammate Rohit Sharma .In the first test at Trent Bridge, Rahul scored 84 and 26. He scored 129 (250) at Lords and was awarded the man of the match in the second test. Rahul displayed excellent technical skills for batting in England, including playing the ball late and leaving the ball well. Rahul scored 315 runs in eight innings of four matches played and was the second-highest run scorer for India in the tour behind Rohit Sharma. In September 2021, Rahul was named to India's squad for the 2021 ICC Men's T20 World Cup . He was the highest run scorer for India in the tournament, scoring 194 runs including three consecutive fifties. He also scored the tournament's joint fastest fifty in just 18 balls against Scotland . After Virat Kohli stepped down as Indian T20i captain, Rahul was appointed the Vice-captain of Indian Cricket Team in T20i as former Vice-captain Rohit Sharma was appointed the new Captain of T20i format. Later, Rahul was appointed ODI vice-captain as well due to the change of captaincy in the white ball format of the Indian team. In December 2021, Rahul was named as India's test vice-captain for the away series against South Africa after India's regular vice-captain Rohit Sharma was ruled out of the series. Rahul was also named as the ODI captain for the One Day series of the same tour as India's regular ODI captain Rohit Sharma was ruled out of the series due to a hamstring injury. In the first test match against South Africa in December 2021, he scored 123 in India's first innings and 23 in India's second innings. For this performance, he was awarded the Man of the Match award. In the second test against South Africa in January 2022, Rahul captained India for the first time in test cricket and became the 34th Test captain of India. He scored a half-century on his captaincy debut. Despite his best efforts, Rahul couldn't lead the team to victory, and India lost the second Test by seven wickets. In the first ODI against South Africa, he made his debut in ODI Captaincy and became the 26th ODI captain of India. However, India lost the series 3–0 to South Africa. In February 2022, during the second ODI of India against the West Indies, Rahul scored 49 (48) and completed 6000 runs in International cricket across all formats. In the same ODI, Rahul sustained an upper left hamstring strain and was ruled out of the next ODI as well as the upcoming T20Is series against the West Indies. Rahul was named captain for the South African tour of India in June , but was later ruled out of the series due to a groin injury. After a successful sports hernia surgery, Rahul came back to the team and was named captain for the India Tour of Zimbabwe in August . Rahul was the stand-in captain for the team during the last match played by team India in the 2022 Asia Cup against Afghanistan . Due to poor form, in February 2023 he was removed from the Test vice-captaincy, with his spot in the team questioned. Rahul made his return to cricket in Asia Cup 2023 against Pakistan . Rahul scored an unbeaten century on his return, scoring 111 off 106 balls. Following a successful Asia Cup, Rahul was named in the squad for 2023 Cricket World Cup . Ahead of the World Cup, Rahul was named as the captain for first two ODIs for the series against Australia . Rahul started his World Cup 2023 campaign scoring an unbeaten 97 against Australia in a tricky chase after India lost 3 wickets at the score of 2. In the final match of the group stage of the World Cup, against the Netherlands at the M. Chinnaswamy Stadium , Rahul recorded the fastest century by an Indian batter in a World Cup, when he reached the milestone in 62 deliveries. He coincidentally broke the record held by Rohit Sharma who hit a century earlier of 63 deliveries in the tournament during India's match against Afghanistan. In the World Cup Final against Australia, Rahul top scored India's first innings with 66 runs to help post team India a fighting score of 240 on a challenging afternoon wicket at the Narendra Modi Stadium . On 30 November, Rahul was announced as the captain for the 3 match ODI series against South Africa after the regular ODI captain Rohit Sharma had taken a break following an intense 2023 Cricket World Cup schedule. Rahul subsequently, won the series 2-1 making him the second captain in Indian Cricket after Virat Kohli to win an ODI series in South Africa. In December 2023, during the first test match of the series between India and South Africa , Rahul scored his 8th test match century helping India to post a challenging first innings score of 245 during challenging batting conditions. He top scored that innings with 101 runs with the second highest score only being 38 runs. Despite his efforts, India ended up losing the match by an innings and 32 runs. Rahul made his Test debut in the 2014 Boxing Day Test at the Melbourne Cricket Ground . He replaced Rohit Sharma and was presented with his Test cap by MS Dhoni . He managed to score only 3 and 1 on his debut. In the next test at Sydney where he opened the innings for the first time, and made his maiden international century, scoring 110 runs. He was named in the 15-man squad for the Indian tour of Bangladesh in June 2015 but withdrew due to Dengue fever . He returned to the side for the first Test of the Sri Lankan tour after Murali Vijay was ruled out due to injury, scoring his second Test century and winning the Man of the Match award. During the match, he kept wicket after Wriddhiman Saha was injured. In July 2016, Rahul was named in the squad for India tour of West Indies . In the second series test, Rahul scored 158 runs, his then-highest score in test cricket. In September 2016, he was named in the squad for the home series against New Zealand . After the first test, he was replaced by Gautam Gambhir due to an injury. Rahul was selected in the squad against England in the 2016-17 Test series but was injured while training in the nets. He was ruled out of the third test, but he made his comeback to the team in the fourth test but failed to make an impact. In the fifth and final test of the series, Rahul went on to make his fourth test ton, scoring his career-best 199 runs. Rahul was named in the squad to tour Zimbabwe in 2016 . He made his One Day International (ODI) debut against Zimbabwe at Harare Sports Club . Rahul scored an unbeaten 100*(115) on debut, thus becoming the first Indian cricketer to score a century on an ODI debut. He was named the man of the series. He made his Twenty20 International (T20I) debut later in the same tour. Rahul got out on a golden duck on his T20I debut as India lost the first T20I against Zimbabwe. Rahul was named in T20I squad for the tour of West Indies in 2016 , where he made his first T20I century of just 46 balls and ended up scoring an unbeaten 110 off just 51 balls. He became the first player to score a T20I century while batting at number four whilst in pursuit of the highest T20I run chase at that time of 246. However, India lost the match by just one run. In his 20th international innings, Rahul became the fastest batsman to have scored centuries in all three formats, surpassing the record of Ahmed Shehzad , who took 76 innings. On 3 July 2018, Rahul scored his second T20 International ton against England. He is also the first Indian batsman to be dismissed hit-wicket in T20Is. On 11 January 2019, Hardik Pandya and K. L. Rahul were suspended by the Board of Control for Cricket in India (BCCI) following controversial comments they made on the Indian talk show Koffee with Karan earlier in the month. They were both sent home ahead of the ODI series against Australia and the fixtures of India's tour to New Zealand . On 24 January 2019, after lifting the suspension on Pandya and Rahul, the BCCI announced that Rahul would re-join the squad for India A matches. In April 2019, he was named in India's squad for the 2019 Cricket World Cup . He played at number 4 in the first two games but got back to opening the innings alongside Rohit Sharma as Shikhar Dhawan was ruled out of the rest of the tournament due to injury. Overall, Rahul scored 361 runs with two fifties and one hundred in the tournament and finished as India's third-highest run scorer in the tournament after Rohit Sharma and Virat Kohli . Due to lack of form in the Test format, Rahul was dropped from the Test squad for the Home tests against South Africa. However, he remained in the limited over sides. In December 2019, in the first T20I match against the West Indies , Rahul scored his 1,000th run in T20I cricket. He scored 62 (40) in the first T20I against West Indies. He scored 91 (56) in the third T20I, for which he was convicted the Man of the Match. He scored his 3rd ODI century in the 2nd ODI against West Indies. In the 2-match T20I series against Sri Lanka, Rahul scored 45 in the first match and 54 in the second T20I. In January 2020, Rahul made 80 (52) batting at number five in the second ODI against Australia and was rewarded as the man of the match. In India's tour of New Zealand in 2019–20 , Rahul was declared man of the series in the five-match T20I series for scoring 224 runs at an average of 56. He was also the stand-in captain in the 5th T20I after Rohit Sharma suffered a hamstring injury during the 1st innings. In the ODI series against New Zealand, he scored 88* (64) in the first ODI and scored his fourth ton in ODIs, 112 (113) in the third ODI. In October 2020, Rahul was named as India 's vice captain for the ODI and T20I series against Australia . Rahul had a moderate ODI and T20I series against Australia. He made 77 against Australia in the second ODI and 51 in the first T20I. India lost the ODI series 2–1 but won the T20I series by the same margin. Rahul was included in the test squad for the Border-Gavaskar Trophy but was not picked in the playing XI for the first two Tests. He injured himself during practice and was ruled out of the remaining part of the tour. As a result, he also missed the home Test series against England in February 2021. He returned to the national side for the T20I and ODI series against England. There was a dip in his form in the T20I series. He returned to form in the ODI series scoring a match-winning 62* and was involved in a 100-run partnership with debutant Krunal Pandya who scored a fifty. He continued his form by scoring 108 runs in the second ODI and was involved in another 100-run partnership with Rishabh Pant. Rahul was named to India's test squad for their tour of England in 2021. As Shubman Gill and Mayank Agarwal were injured, Rahul opened alongside teammate Rohit Sharma .In the first test at Trent Bridge, Rahul scored 84 and 26. He scored 129 (250) at Lords and was awarded the man of the match in the second test. Rahul displayed excellent technical skills for batting in England, including playing the ball late and leaving the ball well. Rahul scored 315 runs in eight innings of four matches played and was the second-highest run scorer for India in the tour behind Rohit Sharma. In September 2021, Rahul was named to India's squad for the 2021 ICC Men's T20 World Cup . He was the highest run scorer for India in the tournament, scoring 194 runs including three consecutive fifties. He also scored the tournament's joint fastest fifty in just 18 balls against Scotland . After Virat Kohli stepped down as Indian T20i captain, Rahul was appointed the Vice-captain of Indian Cricket Team in T20i as former Vice-captain Rohit Sharma was appointed the new Captain of T20i format. Later, Rahul was appointed ODI vice-captain as well due to the change of captaincy in the white ball format of the Indian team. In December 2021, Rahul was named as India's test vice-captain for the away series against South Africa after India's regular vice-captain Rohit Sharma was ruled out of the series. Rahul was also named as the ODI captain for the One Day series of the same tour as India's regular ODI captain Rohit Sharma was ruled out of the series due to a hamstring injury. In the first test match against South Africa in December 2021, he scored 123 in India's first innings and 23 in India's second innings. For this performance, he was awarded the Man of the Match award. In the second test against South Africa in January 2022, Rahul captained India for the first time in test cricket and became the 34th Test captain of India. He scored a half-century on his captaincy debut. Despite his best efforts, Rahul couldn't lead the team to victory, and India lost the second Test by seven wickets. In the first ODI against South Africa, he made his debut in ODI Captaincy and became the 26th ODI captain of India. However, India lost the series 3–0 to South Africa. In February 2022, during the second ODI of India against the West Indies, Rahul scored 49 (48) and completed 6000 runs in International cricket across all formats. In the same ODI, Rahul sustained an upper left hamstring strain and was ruled out of the next ODI as well as the upcoming T20Is series against the West Indies. Rahul was named captain for the South African tour of India in June , but was later ruled out of the series due to a groin injury. After a successful sports hernia surgery, Rahul came back to the team and was named captain for the India Tour of Zimbabwe in August . Rahul was the stand-in captain for the team during the last match played by team India in the 2022 Asia Cup against Afghanistan . Due to poor form, in February 2023 he was removed from the Test vice-captaincy, with his spot in the team questioned. Rahul made his return to cricket in Asia Cup 2023 against Pakistan . Rahul scored an unbeaten century on his return, scoring 111 off 106 balls. Following a successful Asia Cup, Rahul was named in the squad for 2023 Cricket World Cup . Ahead of the World Cup, Rahul was named as the captain for first two ODIs for the series against Australia . Rahul started his World Cup 2023 campaign scoring an unbeaten 97 against Australia in a tricky chase after India lost 3 wickets at the score of 2. In the final match of the group stage of the World Cup, against the Netherlands at the M. Chinnaswamy Stadium , Rahul recorded the fastest century by an Indian batter in a World Cup, when he reached the milestone in 62 deliveries. He coincidentally broke the record held by Rohit Sharma who hit a century earlier of 63 deliveries in the tournament during India's match against Afghanistan. In the World Cup Final against Australia, Rahul top scored India's first innings with 66 runs to help post team India a fighting score of 240 on a challenging afternoon wicket at the Narendra Modi Stadium . On 30 November, Rahul was announced as the captain for the 3 match ODI series against South Africa after the regular ODI captain Rohit Sharma had taken a break following an intense 2023 Cricket World Cup schedule. Rahul subsequently, won the series 2-1 making him the second captain in Indian Cricket after Virat Kohli to win an ODI series in South Africa. In December 2023, during the first test match of the series between India and South Africa , Rahul scored his 8th test match century helping India to post a challenging first innings score of 245 during challenging batting conditions. He top scored that innings with 101 runs with the second highest score only being 38 runs. Despite his efforts, India ended up losing the match by an innings and 32 runs. Rahul made his Indian Premier League (IPL) debut for Royal Challengers Bangalore (RCB) as a wicket-keeper batsman during the 2013 competition . Ahead of the 2014 IPL , he was bought by the Sunrisers Hyderabad for INR 1 crore. Rahul returned to RCB ahead of the 2016 IPL season. In the 2016 IPL season with Royal Challengers Bangalore , Rahul finished the season as the 11th-highest run-scorer and RCB's third, with 397 runs from 14 matches. For his performances in the 2016 IPL season, he was named as wicketkeeper in the ESPNcricinfo and Cricbuzz IPL XI. Rahul missed the 2017 season due to a shoulder injury. In the 2018 IPL Auction, he was bought by Kings XI Punjab (now Punjab Kings ) for INR 11 crore, the joint-third highest price. In the team's first match of the season , he scored the fastest 50 in IPL history, taking 14 balls to reach the milestone and breaking the record of Sunil Narine . KL in total scored 659 runs in the season at a strike rate of 158.41 and an average of 54.91. He finished the season as third highest run scorer, and he was named in the Cricinfo and Cricbuzz IPL XI. Kings XI Punjab retained Rahul for the 2019 season. Rahul was named as vice-captain for the season. He scored his maiden IPL century, scoring 100 not out off 64 balls against Mumbai Indians . In total KL scored 593 runs in the season with average of 53.90 and strike rate of 135.38. On 19 December 2019, Rahul was announced as captain of the Punjab for the 2020 season , after former captain Ravichandran Ashwin was traded to Delhi Capitals . In the match against RCB on 24 September 2020, he scored an unbeaten 132*, then the most runs scored by an Indian batsman in an IPL match. Rahul won the Orange Cap in IPL 2020 for scoring most runs in IPL 2020 (670 runs). He was also awarded as the Dream 11 Game changer of the season. KL Rahul was retained as the captain by the Punjab Kings ahead of the 2021 IPL season. He scored 626 runs in IPL 2021 , finishing as the team's highest scorer in the season. Prior to the 2022 , Rahul parted ways with the Punjab Kings and was drafted by Lucknow Super Giants (LSG) as their captain for INR 17 crore, making him the joint highest paid cricketer in the IPL alongside Virat Kohli . On 16 April 2022, Rahul scored his first century for Lucknow (103* off 60) against Mumbai. He followed this up with another unbeaten century(103* off 62) against the same opposition eight days later. Rahul led his team to play-offs in the debut season for LSG but ended up losing to Royal Challengers Bangalore (RCB) in the Eliminator. Rahul was the highest scorer for his team, scoring 616 runs with an average of 51.33 scoring 2 centuries in the season. Rahul was retained as the captain for Lucknow Super Giants for 2023 season . Rahul was ruled out of the tournament mid way after sustaining an injury while fielding in a match against Royal Challengers Bangalore. Rahul made his Indian Premier League (IPL) debut for Royal Challengers Bangalore (RCB) as a wicket-keeper batsman during the 2013 competition . Ahead of the 2014 IPL , he was bought by the Sunrisers Hyderabad for INR 1 crore. Rahul returned to RCB ahead of the 2016 IPL season. In the 2016 IPL season with Royal Challengers Bangalore , Rahul finished the season as the 11th-highest run-scorer and RCB's third, with 397 runs from 14 matches. For his performances in the 2016 IPL season, he was named as wicketkeeper in the ESPNcricinfo and Cricbuzz IPL XI. Rahul missed the 2017 season due to a shoulder injury. In the 2018 IPL Auction, he was bought by Kings XI Punjab (now Punjab Kings ) for INR 11 crore, the joint-third highest price. In the team's first match of the season , he scored the fastest 50 in IPL history, taking 14 balls to reach the milestone and breaking the record of Sunil Narine . KL in total scored 659 runs in the season at a strike rate of 158.41 and an average of 54.91. He finished the season as third highest run scorer, and he was named in the Cricinfo and Cricbuzz IPL XI. Kings XI Punjab retained Rahul for the 2019 season. Rahul was named as vice-captain for the season. He scored his maiden IPL century, scoring 100 not out off 64 balls against Mumbai Indians . In total KL scored 593 runs in the season with average of 53.90 and strike rate of 135.38. On 19 December 2019, Rahul was announced as captain of the Punjab for the 2020 season , after former captain Ravichandran Ashwin was traded to Delhi Capitals . In the match against RCB on 24 September 2020, he scored an unbeaten 132*, then the most runs scored by an Indian batsman in an IPL match. Rahul won the Orange Cap in IPL 2020 for scoring most runs in IPL 2020 (670 runs). He was also awarded as the Dream 11 Game changer of the season. KL Rahul was retained as the captain by the Punjab Kings ahead of the 2021 IPL season. He scored 626 runs in IPL 2021 , finishing as the team's highest scorer in the season. Prior to the 2022 , Rahul parted ways with the Punjab Kings and was drafted by Lucknow Super Giants (LSG) as their captain for INR 17 crore, making him the joint highest paid cricketer in the IPL alongside Virat Kohli . On 16 April 2022, Rahul scored his first century for Lucknow (103* off 60) against Mumbai. He followed this up with another unbeaten century(103* off 62) against the same opposition eight days later. Rahul led his team to play-offs in the debut season for LSG but ended up losing to Royal Challengers Bangalore (RCB) in the Eliminator. Rahul was the highest scorer for his team, scoring 616 runs with an average of 51.33 scoring 2 centuries in the season. Rahul was retained as the captain for Lucknow Super Giants for 2023 season . Rahul was ruled out of the tournament mid way after sustaining an injury while fielding in a match against Royal Challengers Bangalore. As of January 2024 Rahul has made 17 international centuries - 8 in Test cricket , 7 in One-Day Internationals and 2 in T20Is . Rahul is the only Indian player to score a century on his ODI debut. He is also the first batter to score a century in T20Is while playing at 4th or lower batting position.

Wiki

Dengue fever

https://api.wikimedia.org/core/v1/wikipedia/en/page/Cells_at_Work!/html

Cells at Work!

Kenichi Suzuki ( S1 ) Hirofumi Ogura ( S2 ) YÅ«ko Kakihara Kenichi Suzuki Kenichiro Suehiro Mayuko Nakayoshi Palcy Cells at Work! ( Japanese : はたらく細胞 , Hepburn : Hataraku Saibō ) is a Japanese manga series written and illustrated by Akane Shimizu. It features the anthropomorphized cells of a human body, with the two main protagonists being a red blood cell and a white blood cell she frequently encounters. It was serialized in Kodansha 's shōnen manga magazine Monthly Shōnen Sirius from January 2015 to January 2021. It is licensed in North America by Kodansha USA . A spin-off manga series, Cells at Work! Code Black , was published from 2018 to 2021. The series has been adapted into an anime television series by David Production , with two seasons broadcast from July 2018 to February 2021, totaling 21 episodes. A theatrical anime titled "Hataraku Saibō!!" Saikyō no Teki, Futatabi. Karada no Naka wa "Chō" Ōsawagi! premiered in September 2020.The story takes place inside the human body, where trillions of anthropomorphic cells each do their job to keep the body healthy. The series largely focuses on two such cells; a rookie red blood cell, AE3803, who often gets lost during deliveries, and a relentless white blood cell, U-1146, who fights against any germs that invade the body.Written and illustrated by Akane Shimizu, Cells at Work! was serialized in Kodansha 's shōnen manga magazine Monthly Shōnen Sirius from January 26, 2015, to January 26, 2021. Kodansha has collected the manga into six tankōbon volumes as of February 2021 [ update ] . Kodansha USA announced that it had licensed Cells at Work! in North America on March 21, 2016. The manga is also licensed in Taiwan by Tong Li Publishing . Kodansha USA also announced that it has licensed Cells at Work! Code Black . Kodansha USA has also licensed five other spin-offs Cells at Work!: Bacteria! , Cells at Work!: Platelets! and Cells at Work!: Baby! , Cells at Work! Neo Bacteria , and Cells at Work! White Brigade. The manga received a spin-off in the May 2017 issue of Nakayoshi called Cells at Work!: Bacteria! ( はたらく細菌 ; "Bacteria at Work") by Haruyuki Yoshida, which follows the lives of good and bad bacteria in the intestines. On June 3, 2020, it was announced that Cells at Work!: Bacteria! would end on July 3, 2020. A sequel series, titled Cells at Work! Neo Bacteria , was serialized on Nakayoshi and the Palcy manga app from December 28, 2020, to February 22, 2021, with a single volume released on the latter date. Another spin-off, titled Cells NOT at Work! ( はたらかない細胞 ; "Cells That Don't Work") by Moe Sugimoto, about immature red blood cells ( erythroblasts ) that do not want to work, was launched in the September 2017 issue of Monthly Shōnen Sirius . It published its final chapter on November 26, 2021. The manga received another spin-off titled Cells at Work! Code Black ( はたらく細胞BLACK ) , set in a " black " environment of a human body suffering an unhealthy lifestyle, that runs in Weekly Morning since June 7, 2018. It is written by Shigemitsu Harada, with illustrations by Issei Hatsuyoshi and supervision by Shimizu. The manga received another spin-off titled Cells at Work and Friends! ( はたらく細胞フレンド ; "Cells at Work! Friend"), which centers around a Killer T Cell who is normally strict with himself and others, but wants to have fun during his free time. He also wants to make friends but does not want to ruin his reputation. The series began running in Bessatsu Friend on January 12, 2019. It is written by Kanna Kurono, and illustrated by Mio Izumi. It concluded on April 13, 2021. Another spin-off series focusing on the platelet characters, titled Cells at Work!: Platelets! ( はたらく血小板ちゃん , Platelets at Work ) written by Kanna Kurono and illustrated by Mio Izumi, began serialization in the June issue of Monthly Shōnen Sirius that was released on May 25, 2019. It concluded on April 26, 2021. Another spin-off series focusing cells inside the body of a baby 40 weeks since conception and nearing delivery, with the cells knowing nothing, titled Cells at Work!: Baby! ( はたらく細胞BABY ) illustrated by Yasuhiro Fukuda, was launched in the 45th issue of Weekly Morning on October 17, 2019. It concluded on October 7, 2021. Another spin-off series focusing on cells in the body of an adult woman, titled Cells at Work!: Lady! ( はたらく細胞LADY ) written by Harada and illustrated by Akari Otokawa, was launched in Morning Two [ ja ] on January 22, 2020. The magazine ceased print publication and moved to a digital release starting on August 4, 2022. The series concluded on September 26, 2022. Another spin-off series focusing on white blood cells, titled Cells at Work!: White Brigade ( はたらく細胞WHITE ) illustrated by Tetsuji Kanie, was launched in the December issue of Monthly Shōnen Sirius , which was released in October 2020. The series ended serialization on July 26, 2022. Another spin-off series focusing on the cells of a person taking illegal substances , titled Cells at Work!: Illegal ( はたらく細胞イリーガル ) written and illustrated by Kae Hashimoto, began serialization in Kodansha 's YanMaga Web digital manga platform on February 1, 2022. The series ended with the serialization on July 18, 2023. Another spin-off series focusing on muscles in the human body, titled Cells at Work! Muscle ( はたらく細胞マッスル ) written and illustrated by YÅ« Maeda began serialization on the Morning Two manga website on February 16, 2023. Two spin-off series began serialization in the Monthly Shōnen Sirius magazine on May 25, 2023. The first spin-off is centered around cells in the body of a cat, titled Cells at Work!: Cat ( はたらく細胞 猫 ) , and is written by Choco Aozora and illustrated by Meku Kaire. The second spin-off is centered around medicine, titled Cells at Work!: Medicine ( はたらく細胞 おくすり ) , and is written by Koma Warita and illustrated by Ryō Kuji. 1. "Pneumococcus" ( 肺炎球菌 , HaienkyÅ«kin ) 2. "Cedar Pollen Allergy" ( スギ花粉アレルギー , Sugi Kafun ArerugÄ« ) 3. "Influenza" ( インフルエンザ , Infuruenza ) 4. "Scrape Wound" ( すり傷 , Surikizu ) 5. "Food Poisoning" ( 食中毒 , ShokuchÅ«doku ) 6. "Heat Stress" ( 熱中症 , NetchÅ«shō ) 7. "Erythroblasts and Myelocytes" ( 赤芽球と骨髄球 , SekigakyÅ« to KotsuzuikyÅ« ) 8. "Cancer Cells (Part I)" ( がん細胞(前編) , Gan Saibō (Zenpen) ) 9. "Cancer Cells (Part II)" ( がん細胞(後編) , Gan Saibō (Kōhen) ) 10. "The Circulatory System" ( 血液循環 , Ketsueki Junkan ) 11. "The Common Cold" ( 風邪症候群 , Kaze Shōkōgun ) 12. "Thymocytes" ( èƒ¸è ºç´°èƒž , Kyōsen Saibō ) 13. "Acquired Immunity" ( ç²å¾—å ç–« , Kakutoku Men'eki ) 14. "Acne" ( ニキビ , Nikibi ) 15. "Staphylococcus aureus" ( 黄色ブドウ球菌 , Ōshoku Budō KyÅ«kin ) 16. "Dengue Fever" ( デング熱 , Dengu Netsu ) 17. "Hypovolemic Shock (Part I)" ( 出血性ショック(前編) , Shukketsusei Shokku (Zenpen) ) 18. "Hypovolemic Shock (Part II)" ( 出血性ショック(後編) , Shukketsusei Shokku (Kōhen) ) 19. "Peyer's Patch" ( パイエル板 , Paieru-ban ) 20. "H. Pylori" ( ピロリ菌 , Pirorikin ) 21. "Antigenic Shift" ( 抗原変異 , Kōgen Hen'i ) 22. "Cytokines" ( サイトカイン , Saitokain ) 23. "Harmful Bacteria" ( 悪玉菌 , Akudamakin ) 24. "Cancer Cell II (Part I)" ( がん細胞2(前編) , Gan Saibō TsÅ« (Zenpen) ) 25. "Cancer Cell II (Part II)" ( がん細胞2(後編) , Gan Saibō TsÅ« (Kōhen) ) 26. "A Bump on the Head" ( たんこぶ , Tankobu ) 27. "Left Shift" ( 左方移動 , Hidari ni Idō ) 28. "IPS Cells" ( ips細胞 , Ips Saibō ) Special- "Psoriasis" ( 乾癬 , Kansen ) 29. "Novel Coronavirus" ( 新型コロナウイルス , Shingata Koronauirusu ) "Come Forth, Stinky Farts! Antibacterial Turf War" "Edible Fiber Incoming! The Good Bacteria Strike Back!" "Between Encampments - a Micro Meeting!" "Constipation Consternation! The Bifidum Blues" "The Most Numerous Bacterium in the Intestines is Me, Bacteroides!" "Names aren't Everything! Cry of the E. Coli" "I'll Put Some Pep in your Step! Lactobacillus" "Skin Condition Crisis! Staphylococcus Epidermis vs. Staphylococcus Aureus" "I'll Live on your Skin☠Malassezia Fungus" "Dropping in☠along with Your Food! Natto Bacteria" "Intestinal Ruin?! Salmonella (First Half)" "Intestinal Ruin?! Salmonella (Second Half)" "Let's Make Magnificent Cavities! Team Cavity Bacteria" "What're You Doing In the Intestines? Yogurt Bacteria" "The Pimple's Source: Acne! (Propionibacterium Acnes)" "Alone With meat... Hehehe ❤ Aspergillus Oryzae (Koji Mold)" "Th-That Stinks! What On Earth Is That Fluffy Bacterium?!" "It's In Your Mouth No Matter What?! Periodontal Disease Bacteria" "Th-Th-That Itches! Athlete's Foot Fungus" "Bow Down Before Me. 0157" "Into the Intestines Together With Vegetables! Butyric-Acid Bacteria" "It Absorbs Fat?! Sake Lees!" "Why Do Bad Bacteria Exist...? The Agony of Staphylococcus Aureus" "I Have Bad Skin Even Though I'm On Top of Skin Care... The Cause Is the Gut?!" "Stop Holding Back On Going To the Bathroom!" "What Happens If You Don't Eat Meat...? Nutrients and the Gut" "Even Around the Eyes! Fierce Battle and the Sty" "Ice Cream! Ice! Sherbet! What Would Your Intestines Be Like Then?!" "Manicure Time♪ But Under Those Nails...? Pseudomonas Aeruginosa" "We're the Strongest❤ Team Miso!" "I've Gotta Do Something About This! Chapped Lips" "Together With You Ever Since You Were A Baby" "Your Mouth Stinks! What's the Cause?" "Green Tea's Secret Power Is What?!" "Extra: You'll Understand In Thirteen Pages! "Cells at Work: Bacteria!"" "The Angel's A Devil?! A Day In the Life of Bacteroides Bacteria" "A Must-See! The Correct Way of Washing Your Hands" "Popping Up On the Finger! Warts!" "If You Don't Drink Enough Water... Watch Out! The Intestines and Dehydration" "I Want To Improve! Mouth Discomfort When You Wake Up!" "Armpit Care Is Important! Armpit Odor Causing Bacteria" "Red Pimples! What Causes Them?" "Our Leader Is..." "Little Longum and Mini Longum's Efforts!" "What Happens When the Skin Gets Sunburns?!" "The Dreadful Norovirus!" "Familiar Problems! The Fascinating Nail Troubles!" "This Place Is A Music Venue?! The Bad Bacteria's Rampage!" "The Dimwitted Bug!" "Keep Your Legs Beautiful! Your Skin-Care Routine Shouldn't Be All About the Face☠" "The Lactobacilli Who Cheer On the Host" "More "Cells At Work: Bacteria!"" "Good Bacteria On the Double!" "It's Not Just Bacteria! The World of Viruses You Never Knew About" "The Intestinal Environment Says Everything About the Host's Life" "The Host's Tiny Slip-Up Stirs Up A Storm and Bacterial Proliferation!" "The Staphylocococcus Aureus bacteria Aim For A New World Record!" "The Melancholy of An Elite Streptococcus Pyogenes Bacteria!" "A Secret Paradise In the Body" "Bacteria At Work (Part One)" "Bacteria At Work (Part Two)" 1. "Erythroblasts in Moratorium" 2. "Cells Unable to Work?" 3. "Macrophage's Grand Scheme For Enucleation! ☆" 4. "Artists" 5. "871's Policy" 6. "328's Idol" 7. "What Even Is a Nucleus?" 8. "Speedy Erythroblasts" 9. "An Unacceptable Mascot" 10. "The Immoral Macrophage (Part One)" 11. "The Immortal Macrophage (Part Two)" 12. "Macrophage Chronicles" 13. "Cells with Insomnia" 14. "Ghost in the Cell" 15. "A Macro Oath" 16. "The Fable of King 3104" 17. "725" 18. "Enucleation Ceremony" 19. "A Red Boy with a Green Pet" 20. "Deep Crimson Takes the Stage" 21. "Reunion" 22. "Regarding My Little Sister Being Acquainted with the NEET I Excessively Fret About" 23. "036's Big Brother" 24. "Cells Still Not at Work" 25. "In a Certain Collection Pool" 26. "An Average Day in the Bone Marrow" 27. "The Defendant, 871" 28. "A Shut Door" 29. "An Afternoon in the Infirmary" 30. "Meg the Mega-karyocyte" 31. "Hide & Seek & Molecules" 32. "A Game of Shi-ritori" 33. "Cell-tural Exchange" 34. "Friends" 35. "Iron's Journey" 36. "The Duel (Part 1)" 37. "The Duel (Part 2)" 38. "All or Nothing!" 39. "Hero in White" 40. 1516's Strawberry Diary" 41. "Monster Teacher" 41.5. "Meanwhile in the Kidneys" 42. "Enucleation" 43. "Head Over Heels Dream Come True" 44. "What is a Nucleus? Part 2" 44.5. "Reminiscence" 45. "Red Blood Cell Nostalgia" Extra- "Phagocytosis Gourmet" "The Lone Wolf" "Hot Pot Party" "Ransomware" "Flower Viewing" "Rental Video" "Tree Climbing" "Mini Class Reunion" "Photgenic" "Sleep Paralysis" "Ocean" "Summer Festival" "Motivation" "Tidying Up" "Recreation" "Zero Calories" "Relationship Rumors" "After 7" "Autumn Doldrums" "Mountains" "Anger Management" "Year End Party" "Preparation" "New Year Sales" "Share Boss" "Measles" "Chilly" "Mite" "Habit" "One Team" "Slump" "Boot Camp" "Girls-Only Party" "Jogging" "Bonesetting" "Training Camp" "Cashless" "Clonal Selection" "Freestyle" "Latent Infection" "Loss of Appetite" "A Present" "A Tour Around the Body" "Countdown" "Valentine" "Job Rotation" "P.R. Movie" "Staff Reassignment" "Killer T Cell" 1. "The Little Work Group!" 2. "I Want To Be A Full-Fledged Platelet Soon!" 3. "Mini-Rangers, Move Out!" 4. "Tale of the Tumbling Coagulant Canister" 5. "Don't Call Me A Baby!" 6. "We've Been Invited!" 7. "Traveling 3,000 Leagues To Deliver A Letter" 8. "Being Myself" 9. "Break Time Under the Tree" 10. "The Platelets' Exciting 24 Hours!" 11. "For the Sake of What We Must Protect" 12. "A Thrilling Tour of the Small Intestine" 13. "Leader and Vice Leader At Odds" 14. "Tough Mud Balls" 15. "A Moment of Emptiness" 16. "The Way of the Adults" 17. "Anywhere But Here" 18. "Pool Duty" 19. "What I Want To Be" 20. "A Warm Place" 21. "Exciting Chekups" 22. "The Master Trainer's Secret" 23. "Will That Rare Card Come?" 24. "JJ Channel" Final- "Platelets at Work" 1. "Birth (Part One)" 2. "Birth (Part Two)" 3. "Pulmonary Circulation" 4. "Mother's Milk" 5. "Norovirus" 6. "Heat Rash" 7. "Immunity" 5. "Bump" 6. "Vaccination" 7. "F-Niichan" 8. "RS Virus (Part 1)" 9. "RS Virus (Part 2)" 10. "RS Virus (Part 3)" 11. "Feces" 12. "Choking" 16. "Pee" 17. "Diaper Rash" 18. "Growing" 19. "IgG" 20. "Teamwork" Bonus 1. "The Promise" Bonus 2. ""Niichan"" Bonus- "First Encounter" 21. "Food Allergies (Part 1)" 22. "Food Allergies (Part 2)" 23. "Selfish" 24. "Nowhere In This Body" 25. "I Hate Him" Final- "Senpai" 1. "An Admired Superior" 2. "First Training" 3. "Rival" 4. "Let's Phagocytize!" 5. "Lost Myelocyte" 6. "A Scratch" Special Bonus 7. "Teatime With Everyone" 8. "Enhance Your Image!" 9. "Field Trip in the Intestines" 10. "Physical Fitness Test With Everyone" 11. "A Bit of Rest and Relaxation" Special Bonus 12. "Portrait Battle" 13. "Heatstroke" 14. "Super-Secret (?) Training!" 15. "Pseudomonas Aeruginosa's Counterattack" 16. "White Blood Cell Observation Journal" 17. "Intern" Special Bonus Chapter 18. "The Backs of My Seniors" 19. "Two Band Cells" 20. "Training Camp Starts!: 21. "Test of Courage Rally" 22. "Sudden Debut?!" 23. "An Ordeal" Final- "Band Cell at Work" Special Bonus Chapter 1. "The Gut Bacteria and the Host In Love" 2. "Staphylococcus Epidermidis Is the Ally of the Skin" 3. "Standing In Solidarity To Finish Off Viruses" An anime television series adaptation was announced in January 2018. It is directed by Kenichi Suzuki and animated by David Production , with scripts written by Suzuki and YÅ«ko Kakihara, and character designs by Takahiko Yoshida. The series' music is composed by Kenichiro Suehiro and Mayuko . The anime series premiered on July 8, 2018, on Tokyo MX and other channels. The series ran for 13 episodes. Aniplex of America licensed the series in North America and simulcast it on Crunchyroll . Madman Entertainment simulcasted Australia and New Zealand on AnimeLab, while Muse Communication licensed the series in Southeast Asia and South Asia, and simulcasted it on Animax Asia . MVM Entertainment acquired the series for distribution in the United Kingdom and Ireland. The opening theme is "Mission! Health Comes First" ( ミッション! 健・康・第・イチ , Mission! Ken - Kō - Dai - Ichi ) by Red Blood Cell ( Kana Hanazawa / Cherami Leigh ), White Blood Cell ( Tomoaki Maeno / Billy Kametz ), Killer T Cell ( Daisuke Ono / Robbie Daymond ), and Macrophage ( Kikuko Inoue / Laura Post ), while the ending theme is "CheerS" by ClariS . A special episode premiered on December 27, 2018. Aniplex of America released the English dub on August 27, 2019. On March 23, 2019, the official Twitter account announced that the series will receive a second season. The second season aired from January 9 to February 27, 2021. The main staff at David Production is returning for producing the second season, with the exception of director Kenichi Suzuki being replaced by director Hirofumi Ogura. The opening theme is "Go! Go! Saibō Festa!" by the main cast members, while the ending theme is "Fight!!" by ClariS. A theatrical anime titled "Hataraku Saibō!!" Saikyō no Teki, Futatabi. Karada no Naka wa "Chō" Ōsawagi! was announced on July 4, 2020, as an advanced screening of episodes 4–8 later aired in the second season. Also shown with a short animation "Kesshouban: Eigakan e Iku". The main staff at David Production returned for producing the film, with the exception of director Kenichi Suzuki being replaced by director Hirofumi Ogura. It premiered on September 5, 2020. AE3803 gets lost again and finds herself in her birthplace, the Red Bone Marrow. She reminisces on being a young Erythroblast being trained by a Macrophage on how to be a Red Blood Cell. One day, while practicing to evacuate from bacteria, she got lost and was separated from the others. She got captured by a Pseudomonas bacterium who intended to torture and kill her before moving on to other blood cells. A young Myelocyte came to her rescue, and although no match for the bacterium, bought enough time for Macrophage and a Neutrophil to arrive and kill the bacterium. She thanked the Myelocyte for helping her and they went their separate ways hoping to someday see each other again. In the present, she runs into U-1146. As he offers to guide her to her destination, she suspects the Myelocyte who saved her grew up to be U-1146. Part 1: AE3803 is assigned to be a mentor to a new red blood cell named NT4201, but finds herself out of her depth. AE3803 is embarrassed when she gets them lost several times and finds that NT4201 seems to already know about the body, and that she prefers to do her job as efficiently as possible and not associate with non red blood cells. The body suffers a head injury which results in massive blood loss. NT4201 starts to panic due to the change in her perfect schedule, but AE3803 manages to get her back on track. As the body temperature begins to drop, U-1146 defeats germs that entered through the injury, then is horrified to realize the number of red blood cells have depleted. "Acquired Immunity": Memory Cell receives visions of destruction and believes he has gained the power to see the future. The Parotid gland gets invaded by the Mumps virus. As the immune cells fight them, B Cell cannot create antibodies without Memory Cell's information, but Memory Cell is obsessed with trying to see the future again and is useless. When B Cell strikes him in frustration, he realizes he was actually seeing his memories of the past when the body received a Mumps vaccine. B Cell creates antibodies from the information and wipes out the virus. Afterwards, B Cell explains why it took him so long, resulting in the cells beating Memory Cell up. "Dengue Fever": The cells complain to Mast Cell when she releases excess histamines for a minor problem and causes inflammation, making her angry and vow not to do her job. The body gets bitten by a mosquito that sucks out several blood cells, then infects the body with the Dengue virus . The virus takes over Langerhans cells and they attack the body. Despite seeing the damage, Mast Cell refuses to release histamines until Basophil tells her to do what she thinks is right. The histamines distract the infected cells and alert the immune cells so they can wipe out the virus. The cells apologize to Mast Cell, but she gloats that she was right all along and did not do anything wrong with her previous histamine releases. "H. Pylori": Normal Cell, who dreams of saving someone like the immune cells do, finds four cute and tiny bacteria and keeps them as pets. AE3083 delivers oxygen to him while U-1146 detects the bacteria and confiscates them for future disposal just as he is called to the stomach. Normal Cell follows him, worried about the bacteria. The stomach is being attacked by H. Pylori . When Normal Cell saves the bacteria from falling debris, one of them beats up the H. Pylori, allowing U-1146 to kill it. U-1146 realizes that they are Lactic acid bacteria , benevolent to the body. The one that fought stays in the stomach while the others stay with Normal Cell. U-1146 thanks Normal Cell and invites him to join him on patrol. Part 1: Normal Cell, AE3083, and the platelets continue to evacuate. Memory T Cell remembers Cancer Cell's techniques, giving his team the advantage, but they are shocked when Regulatory T Cell defends Cancer Cell, believing he is a Normal Cell that needs to be protected. U-1146 is injured and Cancer Cell traps him in a pod, saying he's fascinated with him for the contradiction of being a defender when his function is to kill. Cancer Cell strengthens himself by absorbing the carcinogens in the toxic gas and plans to kill the body so that everyone will be equal in death. Despite hearing this, Regulatory T Cell continues to defend him and effortlessly beats up NK Cell and Memory T Cell. Normal Cell is cornered by harmful bacteria. The lactic acid bacterium tries to defend him, but is swatted aside. Normal Cell orders it to run and it does. The bacteria start torturing him. A light novel adaptation of the manga titled as Shōsetsu Hataraku Saibō ( 小説 はたらく細胞 ) was published on July 12, 2018, by Kodansha. It is written by Yui Tokiumi and illustrated by Akane Shimizu and has three volumes. A stage play adaptation titled Tainai Katsugeki Hataraku Saibō ( ä½“å† æ´»åŠ‡ã€Œã¯ãŸã‚‰ãç´°èƒžã€ ) was announced in the August issue of Kodansha's Monthly Shōnen Sirius magazine. The play was held at Tokyo's Theatre 1010 from November 16 to 25, 2018. The play which was directed by Tsuyoshi Kida, starred Masanari Wada as U-1146 and Kanon Nanaki as AE3803, while Keita Kawajiri wrote the script for the play. The last performance, which was held on the 25th, was also distributed live. A tower-defense game for iOS and Android mobile devices titled Always Cells at Work ( いつでも はたらく細胞 , Itsudemo Hataraku Saibō ) was announced in November 2018. The game service shut down on January 31, 2020. A live-action film adaptation was announced by Kodansha and Flag Pictures on March 20, 2023. It will be directed by Hideki Takeuchi and the script of which will be written by Yuichi Tokunaga. Written and illustrated by Akane Shimizu, Cells at Work! was serialized in Kodansha 's shōnen manga magazine Monthly Shōnen Sirius from January 26, 2015, to January 26, 2021. Kodansha has collected the manga into six tankōbon volumes as of February 2021 [ update ] . Kodansha USA announced that it had licensed Cells at Work! in North America on March 21, 2016. The manga is also licensed in Taiwan by Tong Li Publishing . Kodansha USA also announced that it has licensed Cells at Work! Code Black . Kodansha USA has also licensed five other spin-offs Cells at Work!: Bacteria! , Cells at Work!: Platelets! and Cells at Work!: Baby! , Cells at Work! Neo Bacteria , and Cells at Work! White Brigade. The manga received a spin-off in the May 2017 issue of Nakayoshi called Cells at Work!: Bacteria! ( はたらく細菌 ; "Bacteria at Work") by Haruyuki Yoshida, which follows the lives of good and bad bacteria in the intestines. On June 3, 2020, it was announced that Cells at Work!: Bacteria! would end on July 3, 2020. A sequel series, titled Cells at Work! Neo Bacteria , was serialized on Nakayoshi and the Palcy manga app from December 28, 2020, to February 22, 2021, with a single volume released on the latter date. Another spin-off, titled Cells NOT at Work! ( はたらかない細胞 ; "Cells That Don't Work") by Moe Sugimoto, about immature red blood cells ( erythroblasts ) that do not want to work, was launched in the September 2017 issue of Monthly Shōnen Sirius . It published its final chapter on November 26, 2021. The manga received another spin-off titled Cells at Work! Code Black ( はたらく細胞BLACK ) , set in a " black " environment of a human body suffering an unhealthy lifestyle, that runs in Weekly Morning since June 7, 2018. It is written by Shigemitsu Harada, with illustrations by Issei Hatsuyoshi and supervision by Shimizu. The manga received another spin-off titled Cells at Work and Friends! ( はたらく細胞フレンド ; "Cells at Work! Friend"), which centers around a Killer T Cell who is normally strict with himself and others, but wants to have fun during his free time. He also wants to make friends but does not want to ruin his reputation. The series began running in Bessatsu Friend on January 12, 2019. It is written by Kanna Kurono, and illustrated by Mio Izumi. It concluded on April 13, 2021. Another spin-off series focusing on the platelet characters, titled Cells at Work!: Platelets! ( はたらく血小板ちゃん , Platelets at Work ) written by Kanna Kurono and illustrated by Mio Izumi, began serialization in the June issue of Monthly Shōnen Sirius that was released on May 25, 2019. It concluded on April 26, 2021. Another spin-off series focusing cells inside the body of a baby 40 weeks since conception and nearing delivery, with the cells knowing nothing, titled Cells at Work!: Baby! ( はたらく細胞BABY ) illustrated by Yasuhiro Fukuda, was launched in the 45th issue of Weekly Morning on October 17, 2019. It concluded on October 7, 2021. Another spin-off series focusing on cells in the body of an adult woman, titled Cells at Work!: Lady! ( はたらく細胞LADY ) written by Harada and illustrated by Akari Otokawa, was launched in Morning Two [ ja ] on January 22, 2020. The magazine ceased print publication and moved to a digital release starting on August 4, 2022. The series concluded on September 26, 2022. Another spin-off series focusing on white blood cells, titled Cells at Work!: White Brigade ( はたらく細胞WHITE ) illustrated by Tetsuji Kanie, was launched in the December issue of Monthly Shōnen Sirius , which was released in October 2020. The series ended serialization on July 26, 2022. Another spin-off series focusing on the cells of a person taking illegal substances , titled Cells at Work!: Illegal ( はたらく細胞イリーガル ) written and illustrated by Kae Hashimoto, began serialization in Kodansha 's YanMaga Web digital manga platform on February 1, 2022. The series ended with the serialization on July 18, 2023. Another spin-off series focusing on muscles in the human body, titled Cells at Work! Muscle ( はたらく細胞マッスル ) written and illustrated by YÅ« Maeda began serialization on the Morning Two manga website on February 16, 2023. Two spin-off series began serialization in the Monthly Shōnen Sirius magazine on May 25, 2023. The first spin-off is centered around cells in the body of a cat, titled Cells at Work!: Cat ( はたらく細胞 猫 ) , and is written by Choco Aozora and illustrated by Meku Kaire. The second spin-off is centered around medicine, titled Cells at Work!: Medicine ( はたらく細胞 おくすり ) , and is written by Koma Warita and illustrated by Ryō Kuji. 1. "Pneumococcus" ( 肺炎球菌 , HaienkyÅ«kin ) 2. "Cedar Pollen Allergy" ( スギ花粉アレルギー , Sugi Kafun ArerugÄ« ) 3. "Influenza" ( インフルエンザ , Infuruenza ) 4. "Scrape Wound" ( すり傷 , Surikizu ) 5. "Food Poisoning" ( 食中毒 , ShokuchÅ«doku ) 6. "Heat Stress" ( 熱中症 , NetchÅ«shō ) 7. "Erythroblasts and Myelocytes" ( 赤芽球と骨髄球 , SekigakyÅ« to KotsuzuikyÅ« ) 8. "Cancer Cells (Part I)" ( がん細胞(前編) , Gan Saibō (Zenpen) ) 9. "Cancer Cells (Part II)" ( がん細胞(後編) , Gan Saibō (Kōhen) ) 10. "The Circulatory System" ( 血液循環 , Ketsueki Junkan ) 11. "The Common Cold" ( 風邪症候群 , Kaze Shōkōgun ) 12. "Thymocytes" ( èƒ¸è ºç´°èƒž , Kyōsen Saibō ) 13. "Acquired Immunity" ( ç²å¾—å ç–« , Kakutoku Men'eki ) 14. "Acne" ( ニキビ , Nikibi ) 15. "Staphylococcus aureus" ( 黄色ブドウ球菌 , Ōshoku Budō KyÅ«kin ) 16. "Dengue Fever" ( デング熱 , Dengu Netsu ) 17. "Hypovolemic Shock (Part I)" ( 出血性ショック(前編) , Shukketsusei Shokku (Zenpen) ) 18. "Hypovolemic Shock (Part II)" ( 出血性ショック(後編) , Shukketsusei Shokku (Kōhen) ) 19. "Peyer's Patch" ( パイエル板 , Paieru-ban ) 20. "H. Pylori" ( ピロリ菌 , Pirorikin ) 21. "Antigenic Shift" ( 抗原変異 , Kōgen Hen'i ) 22. "Cytokines" ( サイトカイン , Saitokain ) 23. "Harmful Bacteria" ( 悪玉菌 , Akudamakin ) 24. "Cancer Cell II (Part I)" ( がん細胞2(前編) , Gan Saibō TsÅ« (Zenpen) ) 25. "Cancer Cell II (Part II)" ( がん細胞2(後編) , Gan Saibō TsÅ« (Kōhen) ) 26. "A Bump on the Head" ( たんこぶ , Tankobu ) 27. "Left Shift" ( 左方移動 , Hidari ni Idō ) 28. "IPS Cells" ( ips細胞 , Ips Saibō ) Special- "Psoriasis" ( 乾癬 , Kansen ) 29. "Novel Coronavirus" ( 新型コロナウイルス , Shingata Koronauirusu ) "Come Forth, Stinky Farts! Antibacterial Turf War" "Edible Fiber Incoming! The Good Bacteria Strike Back!" "Between Encampments - a Micro Meeting!" "Constipation Consternation! The Bifidum Blues" "The Most Numerous Bacterium in the Intestines is Me, Bacteroides!" "Names aren't Everything! Cry of the E. Coli" "I'll Put Some Pep in your Step! Lactobacillus" "Skin Condition Crisis! Staphylococcus Epidermis vs. Staphylococcus Aureus" "I'll Live on your Skin☠Malassezia Fungus" "Dropping in☠along with Your Food! Natto Bacteria" "Intestinal Ruin?! Salmonella (First Half)" "Intestinal Ruin?! Salmonella (Second Half)" "Let's Make Magnificent Cavities! Team Cavity Bacteria" "What're You Doing In the Intestines? Yogurt Bacteria" "The Pimple's Source: Acne! (Propionibacterium Acnes)" "Alone With meat... Hehehe ❤ Aspergillus Oryzae (Koji Mold)" "Th-That Stinks! What On Earth Is That Fluffy Bacterium?!" "It's In Your Mouth No Matter What?! Periodontal Disease Bacteria" "Th-Th-That Itches! Athlete's Foot Fungus" "Bow Down Before Me. 0157" "Into the Intestines Together With Vegetables! Butyric-Acid Bacteria" "It Absorbs Fat?! Sake Lees!" "Why Do Bad Bacteria Exist...? The Agony of Staphylococcus Aureus" "I Have Bad Skin Even Though I'm On Top of Skin Care... The Cause Is the Gut?!" "Stop Holding Back On Going To the Bathroom!" "What Happens If You Don't Eat Meat...? Nutrients and the Gut" "Even Around the Eyes! Fierce Battle and the Sty" "Ice Cream! Ice! Sherbet! What Would Your Intestines Be Like Then?!" "Manicure Time♪ But Under Those Nails...? Pseudomonas Aeruginosa" "We're the Strongest❤ Team Miso!" "I've Gotta Do Something About This! Chapped Lips" "Together With You Ever Since You Were A Baby" "Your Mouth Stinks! What's the Cause?" "Green Tea's Secret Power Is What?!" "Extra: You'll Understand In Thirteen Pages! "Cells at Work: Bacteria!"" "The Angel's A Devil?! A Day In the Life of Bacteroides Bacteria" "A Must-See! The Correct Way of Washing Your Hands" "Popping Up On the Finger! Warts!" "If You Don't Drink Enough Water... Watch Out! The Intestines and Dehydration" "I Want To Improve! Mouth Discomfort When You Wake Up!" "Armpit Care Is Important! Armpit Odor Causing Bacteria" "Red Pimples! What Causes Them?" "Our Leader Is..." "Little Longum and Mini Longum's Efforts!" "What Happens When the Skin Gets Sunburns?!" "The Dreadful Norovirus!" "Familiar Problems! The Fascinating Nail Troubles!" "This Place Is A Music Venue?! The Bad Bacteria's Rampage!" "The Dimwitted Bug!" "Keep Your Legs Beautiful! Your Skin-Care Routine Shouldn't Be All About the Face☠" "The Lactobacilli Who Cheer On the Host" "More "Cells At Work: Bacteria!"" "Good Bacteria On the Double!" "It's Not Just Bacteria! The World of Viruses You Never Knew About" "The Intestinal Environment Says Everything About the Host's Life" "The Host's Tiny Slip-Up Stirs Up A Storm and Bacterial Proliferation!" "The Staphylocococcus Aureus bacteria Aim For A New World Record!" "The Melancholy of An Elite Streptococcus Pyogenes Bacteria!" "A Secret Paradise In the Body" "Bacteria At Work (Part One)" "Bacteria At Work (Part Two)" 1. "Erythroblasts in Moratorium" 2. "Cells Unable to Work?" 3. "Macrophage's Grand Scheme For Enucleation! ☆" 4. "Artists" 5. "871's Policy" 6. "328's Idol" 7. "What Even Is a Nucleus?" 8. "Speedy Erythroblasts" 9. "An Unacceptable Mascot" 10. "The Immoral Macrophage (Part One)" 11. "The Immortal Macrophage (Part Two)" 12. "Macrophage Chronicles" 13. "Cells with Insomnia" 14. "Ghost in the Cell" 15. "A Macro Oath" 16. "The Fable of King 3104" 17. "725" 18. "Enucleation Ceremony" 19. "A Red Boy with a Green Pet" 20. "Deep Crimson Takes the Stage" 21. "Reunion" 22. "Regarding My Little Sister Being Acquainted with the NEET I Excessively Fret About" 23. "036's Big Brother" 24. "Cells Still Not at Work" 25. "In a Certain Collection Pool" 26. "An Average Day in the Bone Marrow" 27. "The Defendant, 871" 28. "A Shut Door" 29. "An Afternoon in the Infirmary" 30. "Meg the Mega-karyocyte" 31. "Hide & Seek & Molecules" 32. "A Game of Shi-ritori" 33. "Cell-tural Exchange" 34. "Friends" 35. "Iron's Journey" 36. "The Duel (Part 1)" 37. "The Duel (Part 2)" 38. "All or Nothing!" 39. "Hero in White" 40. 1516's Strawberry Diary" 41. "Monster Teacher" 41.5. "Meanwhile in the Kidneys" 42. "Enucleation" 43. "Head Over Heels Dream Come True" 44. "What is a Nucleus? Part 2" 44.5. "Reminiscence" 45. "Red Blood Cell Nostalgia" Extra- "Phagocytosis Gourmet" "The Lone Wolf" "Hot Pot Party" "Ransomware" "Flower Viewing" "Rental Video" "Tree Climbing" "Mini Class Reunion" "Photgenic" "Sleep Paralysis" "Ocean" "Summer Festival" "Motivation" "Tidying Up" "Recreation" "Zero Calories" "Relationship Rumors" "After 7" "Autumn Doldrums" "Mountains" "Anger Management" "Year End Party" "Preparation" "New Year Sales" "Share Boss" "Measles" "Chilly" "Mite" "Habit" "One Team" "Slump" "Boot Camp" "Girls-Only Party" "Jogging" "Bonesetting" "Training Camp" "Cashless" "Clonal Selection" "Freestyle" "Latent Infection" "Loss of Appetite" "A Present" "A Tour Around the Body" "Countdown" "Valentine" "Job Rotation" "P.R. Movie" "Staff Reassignment" "Killer T Cell" 1. "The Little Work Group!" 2. "I Want To Be A Full-Fledged Platelet Soon!" 3. "Mini-Rangers, Move Out!" 4. "Tale of the Tumbling Coagulant Canister" 5. "Don't Call Me A Baby!" 6. "We've Been Invited!" 7. "Traveling 3,000 Leagues To Deliver A Letter" 8. "Being Myself" 9. "Break Time Under the Tree" 10. "The Platelets' Exciting 24 Hours!" 11. "For the Sake of What We Must Protect" 12. "A Thrilling Tour of the Small Intestine" 13. "Leader and Vice Leader At Odds" 14. "Tough Mud Balls" 15. "A Moment of Emptiness" 16. "The Way of the Adults" 17. "Anywhere But Here" 18. "Pool Duty" 19. "What I Want To Be" 20. "A Warm Place" 21. "Exciting Chekups" 22. "The Master Trainer's Secret" 23. "Will That Rare Card Come?" 24. "JJ Channel" Final- "Platelets at Work" 1. "Birth (Part One)" 2. "Birth (Part Two)" 3. "Pulmonary Circulation" 4. "Mother's Milk" 5. "Norovirus" 6. "Heat Rash" 7. "Immunity" 5. "Bump" 6. "Vaccination" 7. "F-Niichan" 8. "RS Virus (Part 1)" 9. "RS Virus (Part 2)" 10. "RS Virus (Part 3)" 11. "Feces" 12. "Choking" 16. "Pee" 17. "Diaper Rash" 18. "Growing" 19. "IgG" 20. "Teamwork" Bonus 1. "The Promise" Bonus 2. ""Niichan"" Bonus- "First Encounter" 21. "Food Allergies (Part 1)" 22. "Food Allergies (Part 2)" 23. "Selfish" 24. "Nowhere In This Body" 25. "I Hate Him" Final- "Senpai" 1. "An Admired Superior" 2. "First Training" 3. "Rival" 4. "Let's Phagocytize!" 5. "Lost Myelocyte" 6. "A Scratch" Special Bonus 7. "Teatime With Everyone" 8. "Enhance Your Image!" 9. "Field Trip in the Intestines" 10. "Physical Fitness Test With Everyone" 11. "A Bit of Rest and Relaxation" Special Bonus 12. "Portrait Battle" 13. "Heatstroke" 14. "Super-Secret (?) Training!" 15. "Pseudomonas Aeruginosa's Counterattack" 16. "White Blood Cell Observation Journal" 17. "Intern" Special Bonus Chapter 18. "The Backs of My Seniors" 19. "Two Band Cells" 20. "Training Camp Starts!: 21. "Test of Courage Rally" 22. "Sudden Debut?!" 23. "An Ordeal" Final- "Band Cell at Work" Special Bonus Chapter 1. "The Gut Bacteria and the Host In Love" 2. "Staphylococcus Epidermidis Is the Ally of the Skin" 3. "Standing In Solidarity To Finish Off Viruses"The manga received a spin-off in the May 2017 issue of Nakayoshi called Cells at Work!: Bacteria! ( はたらく細菌 ; "Bacteria at Work") by Haruyuki Yoshida, which follows the lives of good and bad bacteria in the intestines. On June 3, 2020, it was announced that Cells at Work!: Bacteria! would end on July 3, 2020. A sequel series, titled Cells at Work! Neo Bacteria , was serialized on Nakayoshi and the Palcy manga app from December 28, 2020, to February 22, 2021, with a single volume released on the latter date. Another spin-off, titled Cells NOT at Work! ( はたらかない細胞 ; "Cells That Don't Work") by Moe Sugimoto, about immature red blood cells ( erythroblasts ) that do not want to work, was launched in the September 2017 issue of Monthly Shōnen Sirius . It published its final chapter on November 26, 2021. The manga received another spin-off titled Cells at Work! Code Black ( はたらく細胞BLACK ) , set in a " black " environment of a human body suffering an unhealthy lifestyle, that runs in Weekly Morning since June 7, 2018. It is written by Shigemitsu Harada, with illustrations by Issei Hatsuyoshi and supervision by Shimizu. The manga received another spin-off titled Cells at Work and Friends! ( はたらく細胞フレンド ; "Cells at Work! Friend"), which centers around a Killer T Cell who is normally strict with himself and others, but wants to have fun during his free time. He also wants to make friends but does not want to ruin his reputation. The series began running in Bessatsu Friend on January 12, 2019. It is written by Kanna Kurono, and illustrated by Mio Izumi. It concluded on April 13, 2021. Another spin-off series focusing on the platelet characters, titled Cells at Work!: Platelets! ( はたらく血小板ちゃん , Platelets at Work ) written by Kanna Kurono and illustrated by Mio Izumi, began serialization in the June issue of Monthly Shōnen Sirius that was released on May 25, 2019. It concluded on April 26, 2021. Another spin-off series focusing cells inside the body of a baby 40 weeks since conception and nearing delivery, with the cells knowing nothing, titled Cells at Work!: Baby! ( はたらく細胞BABY ) illustrated by Yasuhiro Fukuda, was launched in the 45th issue of Weekly Morning on October 17, 2019. It concluded on October 7, 2021. Another spin-off series focusing on cells in the body of an adult woman, titled Cells at Work!: Lady! ( はたらく細胞LADY ) written by Harada and illustrated by Akari Otokawa, was launched in Morning Two [ ja ] on January 22, 2020. The magazine ceased print publication and moved to a digital release starting on August 4, 2022. The series concluded on September 26, 2022. Another spin-off series focusing on white blood cells, titled Cells at Work!: White Brigade ( はたらく細胞WHITE ) illustrated by Tetsuji Kanie, was launched in the December issue of Monthly Shōnen Sirius , which was released in October 2020. The series ended serialization on July 26, 2022. Another spin-off series focusing on the cells of a person taking illegal substances , titled Cells at Work!: Illegal ( はたらく細胞イリーガル ) written and illustrated by Kae Hashimoto, began serialization in Kodansha 's YanMaga Web digital manga platform on February 1, 2022. The series ended with the serialization on July 18, 2023. Another spin-off series focusing on muscles in the human body, titled Cells at Work! Muscle ( はたらく細胞マッスル ) written and illustrated by YÅ« Maeda began serialization on the Morning Two manga website on February 16, 2023. Two spin-off series began serialization in the Monthly Shōnen Sirius magazine on May 25, 2023. The first spin-off is centered around cells in the body of a cat, titled Cells at Work!: Cat ( はたらく細胞 猫 ) , and is written by Choco Aozora and illustrated by Meku Kaire. The second spin-off is centered around medicine, titled Cells at Work!: Medicine ( はたらく細胞 おくすり ) , and is written by Koma Warita and illustrated by Ryō Kuji. 1. "Pneumococcus" ( 肺炎球菌 , HaienkyÅ«kin ) 2. "Cedar Pollen Allergy" ( スギ花粉アレルギー , Sugi Kafun ArerugÄ« ) 3. "Influenza" ( インフルエンザ , Infuruenza ) 4. "Scrape Wound" ( すり傷 , Surikizu ) 5. "Food Poisoning" ( 食中毒 , ShokuchÅ«doku ) 6. "Heat Stress" ( 熱中症 , NetchÅ«shō ) 7. "Erythroblasts and Myelocytes" ( 赤芽球と骨髄球 , SekigakyÅ« to KotsuzuikyÅ« ) 8. "Cancer Cells (Part I)" ( がん細胞(前編) , Gan Saibō (Zenpen) ) 9. "Cancer Cells (Part II)" ( がん細胞(後編) , Gan Saibō (Kōhen) ) 10. "The Circulatory System" ( 血液循環 , Ketsueki Junkan ) 11. "The Common Cold" ( 風邪症候群 , Kaze Shōkōgun ) 12. "Thymocytes" ( èƒ¸è ºç´°èƒž , Kyōsen Saibō ) 13. "Acquired Immunity" ( ç²å¾—å ç–« , Kakutoku Men'eki ) 14. "Acne" ( ニキビ , Nikibi ) 15. "Staphylococcus aureus" ( 黄色ブドウ球菌 , Ōshoku Budō KyÅ«kin ) 16. "Dengue Fever" ( デング熱 , Dengu Netsu ) 17. "Hypovolemic Shock (Part I)" ( 出血性ショック(前編) , Shukketsusei Shokku (Zenpen) ) 18. "Hypovolemic Shock (Part II)" ( 出血性ショック(後編) , Shukketsusei Shokku (Kōhen) ) 19. "Peyer's Patch" ( パイエル板 , Paieru-ban ) 20. "H. Pylori" ( ピロリ菌 , Pirorikin ) 21. "Antigenic Shift" ( 抗原変異 , Kōgen Hen'i ) 22. "Cytokines" ( サイトカイン , Saitokain ) 23. "Harmful Bacteria" ( 悪玉菌 , Akudamakin ) 24. "Cancer Cell II (Part I)" ( がん細胞2(前編) , Gan Saibō TsÅ« (Zenpen) ) 25. "Cancer Cell II (Part II)" ( がん細胞2(後編) , Gan Saibō TsÅ« (Kōhen) ) 26. "A Bump on the Head" ( たんこぶ , Tankobu ) 27. "Left Shift" ( 左方移動 , Hidari ni Idō ) 28. "IPS Cells" ( ips細胞 , Ips Saibō ) Special- "Psoriasis" ( 乾癬 , Kansen ) 29. "Novel Coronavirus" ( 新型コロナウイルス , Shingata Koronauirusu ) "Come Forth, Stinky Farts! Antibacterial Turf War" "Edible Fiber Incoming! The Good Bacteria Strike Back!" "Between Encampments - a Micro Meeting!" "Constipation Consternation! The Bifidum Blues" "The Most Numerous Bacterium in the Intestines is Me, Bacteroides!" "Names aren't Everything! Cry of the E. Coli" "I'll Put Some Pep in your Step! Lactobacillus" "Skin Condition Crisis! Staphylococcus Epidermis vs. Staphylococcus Aureus" "I'll Live on your Skin☠Malassezia Fungus" "Dropping in☠along with Your Food! Natto Bacteria" "Intestinal Ruin?! Salmonella (First Half)" "Intestinal Ruin?! Salmonella (Second Half)" "Let's Make Magnificent Cavities! Team Cavity Bacteria" "What're You Doing In the Intestines? Yogurt Bacteria" "The Pimple's Source: Acne! (Propionibacterium Acnes)" "Alone With meat... Hehehe ❤ Aspergillus Oryzae (Koji Mold)" "Th-That Stinks! What On Earth Is That Fluffy Bacterium?!" "It's In Your Mouth No Matter What?! Periodontal Disease Bacteria" "Th-Th-That Itches! Athlete's Foot Fungus" "Bow Down Before Me. 0157" "Into the Intestines Together With Vegetables! Butyric-Acid Bacteria" "It Absorbs Fat?! Sake Lees!" "Why Do Bad Bacteria Exist...? The Agony of Staphylococcus Aureus" "I Have Bad Skin Even Though I'm On Top of Skin Care... The Cause Is the Gut?!" "Stop Holding Back On Going To the Bathroom!" "What Happens If You Don't Eat Meat...? Nutrients and the Gut" "Even Around the Eyes! Fierce Battle and the Sty" "Ice Cream! Ice! Sherbet! What Would Your Intestines Be Like Then?!" "Manicure Time♪ But Under Those Nails...? Pseudomonas Aeruginosa" "We're the Strongest❤ Team Miso!" "I've Gotta Do Something About This! Chapped Lips" "Together With You Ever Since You Were A Baby" "Your Mouth Stinks! What's the Cause?" "Green Tea's Secret Power Is What?!" "Extra: You'll Understand In Thirteen Pages! "Cells at Work: Bacteria!"" "The Angel's A Devil?! A Day In the Life of Bacteroides Bacteria" "A Must-See! The Correct Way of Washing Your Hands" "Popping Up On the Finger! Warts!" "If You Don't Drink Enough Water... Watch Out! The Intestines and Dehydration" "I Want To Improve! Mouth Discomfort When You Wake Up!" "Armpit Care Is Important! Armpit Odor Causing Bacteria" "Red Pimples! What Causes Them?" "Our Leader Is..." "Little Longum and Mini Longum's Efforts!" "What Happens When the Skin Gets Sunburns?!" "The Dreadful Norovirus!" "Familiar Problems! The Fascinating Nail Troubles!" "This Place Is A Music Venue?! The Bad Bacteria's Rampage!" "The Dimwitted Bug!" "Keep Your Legs Beautiful! Your Skin-Care Routine Shouldn't Be All About the Face☠" "The Lactobacilli Who Cheer On the Host" "More "Cells At Work: Bacteria!"" "Good Bacteria On the Double!" "It's Not Just Bacteria! The World of Viruses You Never Knew About" "The Intestinal Environment Says Everything About the Host's Life" "The Host's Tiny Slip-Up Stirs Up A Storm and Bacterial Proliferation!" "The Staphylocococcus Aureus bacteria Aim For A New World Record!" "The Melancholy of An Elite Streptococcus Pyogenes Bacteria!" "A Secret Paradise In the Body" "Bacteria At Work (Part One)" "Bacteria At Work (Part Two)" 1. "Erythroblasts in Moratorium" 2. "Cells Unable to Work?" 3. "Macrophage's Grand Scheme For Enucleation! ☆" 4. "Artists" 5. "871's Policy" 6. "328's Idol" 7. "What Even Is a Nucleus?" 8. "Speedy Erythroblasts" 9. "An Unacceptable Mascot" 10. "The Immoral Macrophage (Part One)" 11. "The Immortal Macrophage (Part Two)" 12. "Macrophage Chronicles" 13. "Cells with Insomnia" 14. "Ghost in the Cell" 15. "A Macro Oath" 16. "The Fable of King 3104" 17. "725" 18. "Enucleation Ceremony" 19. "A Red Boy with a Green Pet" 20. "Deep Crimson Takes the Stage" 21. "Reunion" 22. "Regarding My Little Sister Being Acquainted with the NEET I Excessively Fret About" 23. "036's Big Brother" 24. "Cells Still Not at Work" 25. "In a Certain Collection Pool" 26. "An Average Day in the Bone Marrow" 27. "The Defendant, 871" 28. "A Shut Door" 29. "An Afternoon in the Infirmary" 30. "Meg the Mega-karyocyte" 31. "Hide & Seek & Molecules" 32. "A Game of Shi-ritori" 33. "Cell-tural Exchange" 34. "Friends" 35. "Iron's Journey" 36. "The Duel (Part 1)" 37. "The Duel (Part 2)" 38. "All or Nothing!" 39. "Hero in White" 40. 1516's Strawberry Diary" 41. "Monster Teacher" 41.5. "Meanwhile in the Kidneys" 42. "Enucleation" 43. "Head Over Heels Dream Come True" 44. "What is a Nucleus? Part 2" 44.5. "Reminiscence" 45. "Red Blood Cell Nostalgia" Extra- "Phagocytosis Gourmet" "The Lone Wolf" "Hot Pot Party" "Ransomware" "Flower Viewing" "Rental Video" "Tree Climbing" "Mini Class Reunion" "Photgenic" "Sleep Paralysis" "Ocean" "Summer Festival" "Motivation" "Tidying Up" "Recreation" "Zero Calories" "Relationship Rumors" "After 7" "Autumn Doldrums" "Mountains" "Anger Management" "Year End Party" "Preparation" "New Year Sales" "Share Boss" "Measles" "Chilly" "Mite" "Habit" "One Team" "Slump" "Boot Camp" "Girls-Only Party" "Jogging" "Bonesetting" "Training Camp" "Cashless" "Clonal Selection" "Freestyle" "Latent Infection" "Loss of Appetite" "A Present" "A Tour Around the Body" "Countdown" "Valentine" "Job Rotation" "P.R. Movie" "Staff Reassignment" "Killer T Cell" 1. "The Little Work Group!" 2. "I Want To Be A Full-Fledged Platelet Soon!" 3. "Mini-Rangers, Move Out!" 4. "Tale of the Tumbling Coagulant Canister" 5. "Don't Call Me A Baby!" 6. "We've Been Invited!" 7. "Traveling 3,000 Leagues To Deliver A Letter" 8. "Being Myself" 9. "Break Time Under the Tree" 10. "The Platelets' Exciting 24 Hours!" 11. "For the Sake of What We Must Protect" 12. "A Thrilling Tour of the Small Intestine" 13. "Leader and Vice Leader At Odds" 14. "Tough Mud Balls" 15. "A Moment of Emptiness" 16. "The Way of the Adults" 17. "Anywhere But Here" 18. "Pool Duty" 19. "What I Want To Be" 20. "A Warm Place" 21. "Exciting Chekups" 22. "The Master Trainer's Secret" 23. "Will That Rare Card Come?" 24. "JJ Channel" Final- "Platelets at Work" 1. "Birth (Part One)" 2. "Birth (Part Two)" 3. "Pulmonary Circulation" 4. "Mother's Milk" 5. "Norovirus" 6. "Heat Rash" 7. "Immunity" 5. "Bump" 6. "Vaccination" 7. "F-Niichan" 8. "RS Virus (Part 1)" 9. "RS Virus (Part 2)" 10. "RS Virus (Part 3)" 11. "Feces" 12. "Choking" 16. "Pee" 17. "Diaper Rash" 18. "Growing" 19. "IgG" 20. "Teamwork" Bonus 1. "The Promise" Bonus 2. ""Niichan"" Bonus- "First Encounter" 21. "Food Allergies (Part 1)" 22. "Food Allergies (Part 2)" 23. "Selfish" 24. "Nowhere In This Body" 25. "I Hate Him" Final- "Senpai" 1. "An Admired Superior" 2. "First Training" 3. "Rival" 4. "Let's Phagocytize!" 5. "Lost Myelocyte" 6. "A Scratch" Special Bonus 7. "Teatime With Everyone" 8. "Enhance Your Image!" 9. "Field Trip in the Intestines" 10. "Physical Fitness Test With Everyone" 11. "A Bit of Rest and Relaxation" Special Bonus 12. "Portrait Battle" 13. "Heatstroke" 14. "Super-Secret (?) Training!" 15. "Pseudomonas Aeruginosa's Counterattack" 16. "White Blood Cell Observation Journal" 17. "Intern" Special Bonus Chapter 18. "The Backs of My Seniors" 19. "Two Band Cells" 20. "Training Camp Starts!: 21. "Test of Courage Rally" 22. "Sudden Debut?!" 23. "An Ordeal" Final- "Band Cell at Work" Special Bonus Chapter 1. "The Gut Bacteria and the Host In Love" 2. "Staphylococcus Epidermidis Is the Ally of the Skin" 3. "Standing In Solidarity To Finish Off Viruses"1. "Pneumococcus" ( 肺炎球菌 , HaienkyÅ«kin ) 2. "Cedar Pollen Allergy" ( スギ花粉アレルギー , Sugi Kafun ArerugÄ« ) 3. "Influenza" ( インフルエンザ , Infuruenza ) 4. "Scrape Wound" ( すり傷 , Surikizu ) 5. "Food Poisoning" ( 食中毒 , ShokuchÅ«doku ) 6. "Heat Stress" ( 熱中症 , NetchÅ«shō ) 7. "Erythroblasts and Myelocytes" ( 赤芽球と骨髄球 , SekigakyÅ« to KotsuzuikyÅ« ) 8. "Cancer Cells (Part I)" ( がん細胞(前編) , Gan Saibō (Zenpen) ) 9. "Cancer Cells (Part II)" ( がん細胞(後編) , Gan Saibō (Kōhen) ) 10. "The Circulatory System" ( 血液循環 , Ketsueki Junkan ) 11. "The Common Cold" ( 風邪症候群 , Kaze Shōkōgun ) 12. "Thymocytes" ( èƒ¸è ºç´°èƒž , Kyōsen Saibō ) 13. "Acquired Immunity" ( ç²å¾—å ç–« , Kakutoku Men'eki ) 14. "Acne" ( ニキビ , Nikibi ) 15. "Staphylococcus aureus" ( 黄色ブドウ球菌 , Ōshoku Budō KyÅ«kin ) 16. "Dengue Fever" ( デング熱 , Dengu Netsu ) 17. "Hypovolemic Shock (Part I)" ( 出血性ショック(前編) , Shukketsusei Shokku (Zenpen) ) 18. "Hypovolemic Shock (Part II)" ( 出血性ショック(後編) , Shukketsusei Shokku (Kōhen) ) 19. "Peyer's Patch" ( パイエル板 , Paieru-ban ) 20. "H. Pylori" ( ピロリ菌 , Pirorikin ) 21. "Antigenic Shift" ( 抗原変異 , Kōgen Hen'i ) 22. "Cytokines" ( サイトカイン , Saitokain ) 23. "Harmful Bacteria" ( 悪玉菌 , Akudamakin ) 24. "Cancer Cell II (Part I)" ( がん細胞2(前編) , Gan Saibō TsÅ« (Zenpen) ) 25. "Cancer Cell II (Part II)" ( がん細胞2(後編) , Gan Saibō TsÅ« (Kōhen) ) 26. "A Bump on the Head" ( たんこぶ , Tankobu ) 27. "Left Shift" ( 左方移動 , Hidari ni Idō ) 28. "IPS Cells" ( ips細胞 , Ips Saibō ) Special- "Psoriasis" ( 乾癬 , Kansen ) 29. "Novel Coronavirus" ( 新型コロナウイルス , Shingata Koronauirusu )"Come Forth, Stinky Farts! Antibacterial Turf War" "Edible Fiber Incoming! The Good Bacteria Strike Back!" "Between Encampments - a Micro Meeting!" "Constipation Consternation! The Bifidum Blues" "The Most Numerous Bacterium in the Intestines is Me, Bacteroides!" "Names aren't Everything! Cry of the E. Coli" "I'll Put Some Pep in your Step! Lactobacillus" "Skin Condition Crisis! Staphylococcus Epidermis vs. Staphylococcus Aureus" "I'll Live on your Skin☠Malassezia Fungus" "Dropping in☠along with Your Food! Natto Bacteria" "Intestinal Ruin?! Salmonella (First Half)" "Intestinal Ruin?! Salmonella (Second Half)" "Let's Make Magnificent Cavities! Team Cavity Bacteria" "What're You Doing In the Intestines? Yogurt Bacteria" "The Pimple's Source: Acne! (Propionibacterium Acnes)" "Alone With meat... Hehehe ❤ Aspergillus Oryzae (Koji Mold)" "Th-That Stinks! What On Earth Is That Fluffy Bacterium?!" "It's In Your Mouth No Matter What?! Periodontal Disease Bacteria" "Th-Th-That Itches! Athlete's Foot Fungus" "Bow Down Before Me. 0157" "Into the Intestines Together With Vegetables! Butyric-Acid Bacteria" "It Absorbs Fat?! Sake Lees!" "Why Do Bad Bacteria Exist...? The Agony of Staphylococcus Aureus" "I Have Bad Skin Even Though I'm On Top of Skin Care... The Cause Is the Gut?!" "Stop Holding Back On Going To the Bathroom!" "What Happens If You Don't Eat Meat...? Nutrients and the Gut" "Even Around the Eyes! Fierce Battle and the Sty" "Ice Cream! Ice! Sherbet! What Would Your Intestines Be Like Then?!" "Manicure Time♪ But Under Those Nails...? Pseudomonas Aeruginosa" "We're the Strongest❤ Team Miso!" "I've Gotta Do Something About This! Chapped Lips" "Together With You Ever Since You Were A Baby" "Your Mouth Stinks! What's the Cause?" "Green Tea's Secret Power Is What?!" "Extra: You'll Understand In Thirteen Pages! "Cells at Work: Bacteria!"" "The Angel's A Devil?! A Day In the Life of Bacteroides Bacteria" "A Must-See! The Correct Way of Washing Your Hands" "Popping Up On the Finger! Warts!" "If You Don't Drink Enough Water... Watch Out! The Intestines and Dehydration" "I Want To Improve! Mouth Discomfort When You Wake Up!" "Armpit Care Is Important! Armpit Odor Causing Bacteria" "Red Pimples! What Causes Them?" "Our Leader Is..." "Little Longum and Mini Longum's Efforts!" "What Happens When the Skin Gets Sunburns?!" "The Dreadful Norovirus!" "Familiar Problems! The Fascinating Nail Troubles!" "This Place Is A Music Venue?! The Bad Bacteria's Rampage!" "The Dimwitted Bug!" "Keep Your Legs Beautiful! Your Skin-Care Routine Shouldn't Be All About the Face☠" "The Lactobacilli Who Cheer On the Host" "More "Cells At Work: Bacteria!"" "Good Bacteria On the Double!" "It's Not Just Bacteria! The World of Viruses You Never Knew About" "The Intestinal Environment Says Everything About the Host's Life" "The Host's Tiny Slip-Up Stirs Up A Storm and Bacterial Proliferation!" "The Staphylocococcus Aureus bacteria Aim For A New World Record!" "The Melancholy of An Elite Streptococcus Pyogenes Bacteria!" "A Secret Paradise In the Body" "Bacteria At Work (Part One)" "Bacteria At Work (Part Two)"1. "Erythroblasts in Moratorium" 2. "Cells Unable to Work?" 3. "Macrophage's Grand Scheme For Enucleation! ☆" 4. "Artists" 5. "871's Policy" 6. "328's Idol" 7. "What Even Is a Nucleus?" 8. "Speedy Erythroblasts" 9. "An Unacceptable Mascot" 10. "The Immoral Macrophage (Part One)" 11. "The Immortal Macrophage (Part Two)" 12. "Macrophage Chronicles" 13. "Cells with Insomnia" 14. "Ghost in the Cell" 15. "A Macro Oath" 16. "The Fable of King 3104" 17. "725" 18. "Enucleation Ceremony" 19. "A Red Boy with a Green Pet" 20. "Deep Crimson Takes the Stage" 21. "Reunion" 22. "Regarding My Little Sister Being Acquainted with the NEET I Excessively Fret About" 23. "036's Big Brother" 24. "Cells Still Not at Work" 25. "In a Certain Collection Pool" 26. "An Average Day in the Bone Marrow" 27. "The Defendant, 871" 28. "A Shut Door" 29. "An Afternoon in the Infirmary" 30. "Meg the Mega-karyocyte" 31. "Hide & Seek & Molecules" 32. "A Game of Shi-ritori" 33. "Cell-tural Exchange" 34. "Friends" 35. "Iron's Journey" 36. "The Duel (Part 1)" 37. "The Duel (Part 2)" 38. "All or Nothing!" 39. "Hero in White" 40. 1516's Strawberry Diary" 41. "Monster Teacher" 41.5. "Meanwhile in the Kidneys" 42. "Enucleation" 43. "Head Over Heels Dream Come True" 44. "What is a Nucleus? Part 2" 44.5. "Reminiscence" 45. "Red Blood Cell Nostalgia" Extra- "Phagocytosis Gourmet""The Lone Wolf" "Hot Pot Party" "Ransomware" "Flower Viewing" "Rental Video" "Tree Climbing" "Mini Class Reunion" "Photgenic" "Sleep Paralysis" "Ocean" "Summer Festival" "Motivation" "Tidying Up" "Recreation" "Zero Calories" "Relationship Rumors" "After 7" "Autumn Doldrums" "Mountains" "Anger Management" "Year End Party" "Preparation" "New Year Sales" "Share Boss" "Measles" "Chilly" "Mite" "Habit" "One Team" "Slump" "Boot Camp" "Girls-Only Party" "Jogging" "Bonesetting" "Training Camp" "Cashless" "Clonal Selection" "Freestyle" "Latent Infection" "Loss of Appetite" "A Present" "A Tour Around the Body" "Countdown" "Valentine" "Job Rotation" "P.R. Movie" "Staff Reassignment" "Killer T Cell"1. "The Little Work Group!" 2. "I Want To Be A Full-Fledged Platelet Soon!" 3. "Mini-Rangers, Move Out!" 4. "Tale of the Tumbling Coagulant Canister" 5. "Don't Call Me A Baby!" 6. "We've Been Invited!" 7. "Traveling 3,000 Leagues To Deliver A Letter" 8. "Being Myself" 9. "Break Time Under the Tree" 10. "The Platelets' Exciting 24 Hours!" 11. "For the Sake of What We Must Protect" 12. "A Thrilling Tour of the Small Intestine" 13. "Leader and Vice Leader At Odds" 14. "Tough Mud Balls" 15. "A Moment of Emptiness" 16. "The Way of the Adults" 17. "Anywhere But Here" 18. "Pool Duty" 19. "What I Want To Be" 20. "A Warm Place" 21. "Exciting Chekups" 22. "The Master Trainer's Secret" 23. "Will That Rare Card Come?" 24. "JJ Channel" Final- "Platelets at Work"1. "Birth (Part One)" 2. "Birth (Part Two)" 3. "Pulmonary Circulation" 4. "Mother's Milk" 5. "Norovirus" 6. "Heat Rash" 7. "Immunity" 5. "Bump" 6. "Vaccination" 7. "F-Niichan" 8. "RS Virus (Part 1)" 9. "RS Virus (Part 2)" 10. "RS Virus (Part 3)" 11. "Feces" 12. "Choking" 16. "Pee" 17. "Diaper Rash" 18. "Growing" 19. "IgG" 20. "Teamwork" Bonus 1. "The Promise" Bonus 2. ""Niichan"" Bonus- "First Encounter" 21. "Food Allergies (Part 1)" 22. "Food Allergies (Part 2)" 23. "Selfish" 24. "Nowhere In This Body" 25. "I Hate Him" Final- "Senpai"1. "An Admired Superior" 2. "First Training" 3. "Rival" 4. "Let's Phagocytize!" 5. "Lost Myelocyte" 6. "A Scratch" Special Bonus 7. "Teatime With Everyone" 8. "Enhance Your Image!" 9. "Field Trip in the Intestines" 10. "Physical Fitness Test With Everyone" 11. "A Bit of Rest and Relaxation" Special Bonus 12. "Portrait Battle" 13. "Heatstroke" 14. "Super-Secret (?) Training!" 15. "Pseudomonas Aeruginosa's Counterattack" 16. "White Blood Cell Observation Journal" 17. "Intern" Special Bonus Chapter 18. "The Backs of My Seniors" 19. "Two Band Cells" 20. "Training Camp Starts!: 21. "Test of Courage Rally" 22. "Sudden Debut?!" 23. "An Ordeal" Final- "Band Cell at Work" Special Bonus Chapter1. "The Gut Bacteria and the Host In Love" 2. "Staphylococcus Epidermidis Is the Ally of the Skin" 3. "Standing In Solidarity To Finish Off Viruses"An anime television series adaptation was announced in January 2018. It is directed by Kenichi Suzuki and animated by David Production , with scripts written by Suzuki and YÅ«ko Kakihara, and character designs by Takahiko Yoshida. The series' music is composed by Kenichiro Suehiro and Mayuko . The anime series premiered on July 8, 2018, on Tokyo MX and other channels. The series ran for 13 episodes. Aniplex of America licensed the series in North America and simulcast it on Crunchyroll . Madman Entertainment simulcasted Australia and New Zealand on AnimeLab, while Muse Communication licensed the series in Southeast Asia and South Asia, and simulcasted it on Animax Asia . MVM Entertainment acquired the series for distribution in the United Kingdom and Ireland. The opening theme is "Mission! Health Comes First" ( ミッション! 健・康・第・イチ , Mission! Ken - Kō - Dai - Ichi ) by Red Blood Cell ( Kana Hanazawa / Cherami Leigh ), White Blood Cell ( Tomoaki Maeno / Billy Kametz ), Killer T Cell ( Daisuke Ono / Robbie Daymond ), and Macrophage ( Kikuko Inoue / Laura Post ), while the ending theme is "CheerS" by ClariS . A special episode premiered on December 27, 2018. Aniplex of America released the English dub on August 27, 2019. On March 23, 2019, the official Twitter account announced that the series will receive a second season. The second season aired from January 9 to February 27, 2021. The main staff at David Production is returning for producing the second season, with the exception of director Kenichi Suzuki being replaced by director Hirofumi Ogura. The opening theme is "Go! Go! Saibō Festa!" by the main cast members, while the ending theme is "Fight!!" by ClariS. A theatrical anime titled "Hataraku Saibō!!" Saikyō no Teki, Futatabi. Karada no Naka wa "Chō" Ōsawagi! was announced on July 4, 2020, as an advanced screening of episodes 4–8 later aired in the second season. Also shown with a short animation "Kesshouban: Eigakan e Iku". The main staff at David Production returned for producing the film, with the exception of director Kenichi Suzuki being replaced by director Hirofumi Ogura. It premiered on September 5, 2020. AE3803 gets lost again and finds herself in her birthplace, the Red Bone Marrow. She reminisces on being a young Erythroblast being trained by a Macrophage on how to be a Red Blood Cell. One day, while practicing to evacuate from bacteria, she got lost and was separated from the others. She got captured by a Pseudomonas bacterium who intended to torture and kill her before moving on to other blood cells. A young Myelocyte came to her rescue, and although no match for the bacterium, bought enough time for Macrophage and a Neutrophil to arrive and kill the bacterium. She thanked the Myelocyte for helping her and they went their separate ways hoping to someday see each other again. In the present, she runs into U-1146. As he offers to guide her to her destination, she suspects the Myelocyte who saved her grew up to be U-1146. Part 1: AE3803 is assigned to be a mentor to a new red blood cell named NT4201, but finds herself out of her depth. AE3803 is embarrassed when she gets them lost several times and finds that NT4201 seems to already know about the body, and that she prefers to do her job as efficiently as possible and not associate with non red blood cells. The body suffers a head injury which results in massive blood loss. NT4201 starts to panic due to the change in her perfect schedule, but AE3803 manages to get her back on track. As the body temperature begins to drop, U-1146 defeats germs that entered through the injury, then is horrified to realize the number of red blood cells have depleted. "Acquired Immunity": Memory Cell receives visions of destruction and believes he has gained the power to see the future. The Parotid gland gets invaded by the Mumps virus. As the immune cells fight them, B Cell cannot create antibodies without Memory Cell's information, but Memory Cell is obsessed with trying to see the future again and is useless. When B Cell strikes him in frustration, he realizes he was actually seeing his memories of the past when the body received a Mumps vaccine. B Cell creates antibodies from the information and wipes out the virus. Afterwards, B Cell explains why it took him so long, resulting in the cells beating Memory Cell up. "Dengue Fever": The cells complain to Mast Cell when she releases excess histamines for a minor problem and causes inflammation, making her angry and vow not to do her job. The body gets bitten by a mosquito that sucks out several blood cells, then infects the body with the Dengue virus . The virus takes over Langerhans cells and they attack the body. Despite seeing the damage, Mast Cell refuses to release histamines until Basophil tells her to do what she thinks is right. The histamines distract the infected cells and alert the immune cells so they can wipe out the virus. The cells apologize to Mast Cell, but she gloats that she was right all along and did not do anything wrong with her previous histamine releases. "H. Pylori": Normal Cell, who dreams of saving someone like the immune cells do, finds four cute and tiny bacteria and keeps them as pets. AE3083 delivers oxygen to him while U-1146 detects the bacteria and confiscates them for future disposal just as he is called to the stomach. Normal Cell follows him, worried about the bacteria. The stomach is being attacked by H. Pylori . When Normal Cell saves the bacteria from falling debris, one of them beats up the H. Pylori, allowing U-1146 to kill it. U-1146 realizes that they are Lactic acid bacteria , benevolent to the body. The one that fought stays in the stomach while the others stay with Normal Cell. U-1146 thanks Normal Cell and invites him to join him on patrol. Part 1: Normal Cell, AE3083, and the platelets continue to evacuate. Memory T Cell remembers Cancer Cell's techniques, giving his team the advantage, but they are shocked when Regulatory T Cell defends Cancer Cell, believing he is a Normal Cell that needs to be protected. U-1146 is injured and Cancer Cell traps him in a pod, saying he's fascinated with him for the contradiction of being a defender when his function is to kill. Cancer Cell strengthens himself by absorbing the carcinogens in the toxic gas and plans to kill the body so that everyone will be equal in death. Despite hearing this, Regulatory T Cell continues to defend him and effortlessly beats up NK Cell and Memory T Cell. Normal Cell is cornered by harmful bacteria. The lactic acid bacterium tries to defend him, but is swatted aside. Normal Cell orders it to run and it does. The bacteria start torturing him.AE3803 gets lost again and finds herself in her birthplace, the Red Bone Marrow. She reminisces on being a young Erythroblast being trained by a Macrophage on how to be a Red Blood Cell. One day, while practicing to evacuate from bacteria, she got lost and was separated from the others. She got captured by a Pseudomonas bacterium who intended to torture and kill her before moving on to other blood cells. A young Myelocyte came to her rescue, and although no match for the bacterium, bought enough time for Macrophage and a Neutrophil to arrive and kill the bacterium. She thanked the Myelocyte for helping her and they went their separate ways hoping to someday see each other again. In the present, she runs into U-1146. As he offers to guide her to her destination, she suspects the Myelocyte who saved her grew up to be U-1146. Part 1: AE3803 is assigned to be a mentor to a new red blood cell named NT4201, but finds herself out of her depth. AE3803 is embarrassed when she gets them lost several times and finds that NT4201 seems to already know about the body, and that she prefers to do her job as efficiently as possible and not associate with non red blood cells. The body suffers a head injury which results in massive blood loss. NT4201 starts to panic due to the change in her perfect schedule, but AE3803 manages to get her back on track. As the body temperature begins to drop, U-1146 defeats germs that entered through the injury, then is horrified to realize the number of red blood cells have depleted."Acquired Immunity": Memory Cell receives visions of destruction and believes he has gained the power to see the future. The Parotid gland gets invaded by the Mumps virus. As the immune cells fight them, B Cell cannot create antibodies without Memory Cell's information, but Memory Cell is obsessed with trying to see the future again and is useless. When B Cell strikes him in frustration, he realizes he was actually seeing his memories of the past when the body received a Mumps vaccine. B Cell creates antibodies from the information and wipes out the virus. Afterwards, B Cell explains why it took him so long, resulting in the cells beating Memory Cell up. "Dengue Fever": The cells complain to Mast Cell when she releases excess histamines for a minor problem and causes inflammation, making her angry and vow not to do her job. The body gets bitten by a mosquito that sucks out several blood cells, then infects the body with the Dengue virus . The virus takes over Langerhans cells and they attack the body. Despite seeing the damage, Mast Cell refuses to release histamines until Basophil tells her to do what she thinks is right. The histamines distract the infected cells and alert the immune cells so they can wipe out the virus. The cells apologize to Mast Cell, but she gloats that she was right all along and did not do anything wrong with her previous histamine releases. "H. Pylori": Normal Cell, who dreams of saving someone like the immune cells do, finds four cute and tiny bacteria and keeps them as pets. AE3083 delivers oxygen to him while U-1146 detects the bacteria and confiscates them for future disposal just as he is called to the stomach. Normal Cell follows him, worried about the bacteria. The stomach is being attacked by H. Pylori . When Normal Cell saves the bacteria from falling debris, one of them beats up the H. Pylori, allowing U-1146 to kill it. U-1146 realizes that they are Lactic acid bacteria , benevolent to the body. The one that fought stays in the stomach while the others stay with Normal Cell. U-1146 thanks Normal Cell and invites him to join him on patrol. Part 1: Normal Cell, AE3083, and the platelets continue to evacuate. Memory T Cell remembers Cancer Cell's techniques, giving his team the advantage, but they are shocked when Regulatory T Cell defends Cancer Cell, believing he is a Normal Cell that needs to be protected. U-1146 is injured and Cancer Cell traps him in a pod, saying he's fascinated with him for the contradiction of being a defender when his function is to kill. Cancer Cell strengthens himself by absorbing the carcinogens in the toxic gas and plans to kill the body so that everyone will be equal in death. Despite hearing this, Regulatory T Cell continues to defend him and effortlessly beats up NK Cell and Memory T Cell. Normal Cell is cornered by harmful bacteria. The lactic acid bacterium tries to defend him, but is swatted aside. Normal Cell orders it to run and it does. The bacteria start torturing him.A light novel adaptation of the manga titled as Shōsetsu Hataraku Saibō ( 小説 はたらく細胞 ) was published on July 12, 2018, by Kodansha. It is written by Yui Tokiumi and illustrated by Akane Shimizu and has three volumes. A stage play adaptation titled Tainai Katsugeki Hataraku Saibō ( ä½“å† æ´»åŠ‡ã€Œã¯ãŸã‚‰ãç´°èƒžã€ ) was announced in the August issue of Kodansha's Monthly Shōnen Sirius magazine. The play was held at Tokyo's Theatre 1010 from November 16 to 25, 2018. The play which was directed by Tsuyoshi Kida, starred Masanari Wada as U-1146 and Kanon Nanaki as AE3803, while Keita Kawajiri wrote the script for the play. The last performance, which was held on the 25th, was also distributed live. A tower-defense game for iOS and Android mobile devices titled Always Cells at Work ( いつでも はたらく細胞 , Itsudemo Hataraku Saibō ) was announced in November 2018. The game service shut down on January 31, 2020. A live-action film adaptation was announced by Kodansha and Flag Pictures on March 20, 2023. It will be directed by Hideki Takeuchi and the script of which will be written by Yuichi Tokunaga. Rebecca Silverman of Anime News Network highlighted the educational aspect of the manga despite flaws in presentation of information, and ultimately found the manga entertaining with likable characters. Sean Gaffney of A Case Suitable for Treatment called it a "very fun shonen action manga", complimenting the manga's ridiculousness and humor. Ian Wolf of Anime UK News gave the British Blu-ray release of the anime a score of 9 out of 10, and described the show as the most bloody on television, because so many of the characters are blood cells and thus means it contains more blood than shows depicting much violence. The 2016 Kono Manga ga Sugoi! guidebook listed the manga as the seventh top manga for male readers. Paul Gravett included the manga in his list of "Top 22 Comics, Graphic Novels & Manga" for October 2016. By July 2017, the manga had over 1.3 million copies in print; it had over 1.5 million copies in print by January 2018. Dr. Satoru Otsuka, postdoctoral fellow in the molecular neuro-oncology department of Emory University School of Medicine in Atlanta, Georgia , praised the series' depiction of cancer cells during the series' seventh episode. Biology teachers at a high school affiliated with China's Southwest University were so impressed with the accuracy of the series that they assigned it as homework for their students.

Wiki

Dengue fever

https://api.wikimedia.org/core/v1/wikipedia/en/page/Insect_repellent/html

Insect repellent

An insect repellent (also commonly called " bug spray ") is a substance applied to the skin, clothing, or other surfaces to discourage insects (and arthropods in general) from landing or climbing on that surface. Insect repellents help prevent and control the outbreak of insect-borne (and other arthropod -bourne) diseases such as malaria , Lyme disease , dengue fever , bubonic plague , river blindness , and West Nile fever . Pest animals commonly serving as vectors for disease include insects such as flea , fly , and mosquito ; and ticks (arachnids). [ citation needed ] Some insect repellents are insecticides (bug killers), but most simply discourage insects and send them flying or crawling away. Nearly any would be fatal upon reaching the median lethal dose , but classification as an insecticide implies death even at lower doses.Synthetic repellents tend to be more effective and/or longer lasting than "natural" repellents. For protection against mosquito bites, the U.S. Centers for Disease Control (CDC) recommends DEET , icaridin (picaridin, KBR 3023), oil of lemon eucalyptus ( para-menthane-diol or PMD), IR3535 and 2-undecanone with the caveat that higher percentages of the active ingredient provide longer protection. In 2015, Researchers at New Mexico State University tested 10 commercially available products for their effectiveness at repelling mosquitoes. On the mosquito Aedes aegypti , the vector of Zika virus, only one repellent that did not contain DEET had a strong effect for the duration of the 240 minutes test: a lemon eucalyptus oil repellent. All DEET-containing mosquito repellents were active. In one comparative study from 2004, IR3535 was as effective or better than DEET in protection against Aedes aegypti and Culex quinquefasciatus mosquitoes. Other sources (official publications of the associations of German physicians as well as of German druggists ) suggest the contrary and state DEET is still the most efficient substance available and the substance of choice for stays in malaria regions, while IR3535 has little effect. However, some plant-based repellents may provide effective relief as well. Essential oil repellents can be short-lived in their effectiveness. A test of various insect repellents by an independent consumer organization found that repellents containing DEET or icaridin are more effective than repellents with "natural" active ingredients. All the synthetics gave almost 100% repellency for the first 2 hours, where the natural repellent products were most effective for the first 30 to 60 minutes, and required reapplication to be effective over several hours. Although highly toxic to cats, permethrin is recommended as protection against mosquitoes for clothing, gear, or bed nets. In an earlier report, the CDC found oil of lemon eucalyptus to be more effective than other plant-based treatments, with a similar effectiveness to low concentrations of DEET. However, a 2006 published study found in both cage and field studies that a product containing 40% oil of lemon eucalyptus was just as effective as products containing high concentrations of DEET. Research has also found that neem oil is mosquito repellent for up to 12 hours. Citronella oil 's mosquito repellency has also been verified by research, including effectiveness in repelling Aedes aegypti , but requires reapplication after 30 to 60 minutes. There are also products available based on sound production, particularly ultrasound (inaudibly high-frequency sounds) which purport to be insect repellents. However, these electronic devices have been shown to be ineffective based on studies done by the United States Environmental Protection Agency and many universities. Children may be at greater risk for adverse reactions to repellents, in part, because their exposure may be greater. Children can be at greater risk of accidental eye contact or ingestion. As with chemical exposures in general, pregnant women should take care to avoid exposures to repellents when practical, as the fetus may be vulnerable. Some experts also recommend against applying chemicals such as DEET and sunscreen simultaneously since that would increase DEET penetration. Canadian researcher, Xiaochen Gu, a professor at the University of Manitoba's faculty of Pharmacy who led a study about mosquitos, advises that DEET should be applied 30 or more minutes later. Gu also recommends insect repellent sprays instead of lotions which are rubbed into the skin "forcing molecules into the skin". Regardless of which repellent product used, it is recommended to read the label before use and carefully follow directions. Usage instructions for repellents vary from country to country. Some insect repellents are not recommended for use on younger children. In the DEET Reregistration Eligibility Decision (RED) the United States Environmental Protection Agency (EPA) reported 14 to 46 cases of potential DEET associated seizures , including 4 deaths. The EPA states: "... it does appear that some cases are likely related to DEET toxicity ," but observed that with 30% of the US population using DEET, the likely seizure rate is only about one per 100 million users. The Pesticide Information Project of Cooperative Extension Offices of Cornell University states that, " Everglades National Park employees having extensive DEET exposure were more likely to have insomnia, mood disturbances and impaired cognitive function than were lesser exposed co-workers". The EPA states that citronella oil shows little or no toxicity and has been used as a topical insect repellent for 60 years. However, the EPA also states that citronella may irritate skin and cause dermatitis in certain individuals. Canadian regulatory authorities concern with citronella based repellents is primarily based on data-gaps in toxicology , not on incidents. Within countries of the European Union, implementation of Regulation 98/8/EC, commonly referred to as the Biocidal Products Directive, has severely limited the number and type of insect repellents available to European consumers. Only a small number of active ingredients have been supported by manufacturers in submitting dossiers to the EU Authorities. In general, only formulations containing DEET, icaridin (sold under the trade name Saltidin and formerly known as Bayrepel or KBR3023), IR3535 and citriodiol ( p-menthane-3,8-diol ) are available. Most "natural" insect repellents such as citronella, neem oil, and herbal extracts are no longer permitted for sale as insect repellents in the EU due to their lack of effectiveness; this does not preclude them from being sold for other purposes, as long as the label does not indicate they are a biocide (insect repellent). [ citation needed ] A 2018 study found that Icaridin , is highly toxic to salamander larvae , in what the authors described as conservative exposure doses. The LC50 standard was additionally found to be completely inadequate in the context of finding this result. Permethrin is highly toxic to cats but not to dogs or humans. Children may be at greater risk for adverse reactions to repellents, in part, because their exposure may be greater. Children can be at greater risk of accidental eye contact or ingestion. As with chemical exposures in general, pregnant women should take care to avoid exposures to repellents when practical, as the fetus may be vulnerable. Some experts also recommend against applying chemicals such as DEET and sunscreen simultaneously since that would increase DEET penetration. Canadian researcher, Xiaochen Gu, a professor at the University of Manitoba's faculty of Pharmacy who led a study about mosquitos, advises that DEET should be applied 30 or more minutes later. Gu also recommends insect repellent sprays instead of lotions which are rubbed into the skin "forcing molecules into the skin". Regardless of which repellent product used, it is recommended to read the label before use and carefully follow directions. Usage instructions for repellents vary from country to country. Some insect repellents are not recommended for use on younger children. In the DEET Reregistration Eligibility Decision (RED) the United States Environmental Protection Agency (EPA) reported 14 to 46 cases of potential DEET associated seizures , including 4 deaths. The EPA states: "... it does appear that some cases are likely related to DEET toxicity ," but observed that with 30% of the US population using DEET, the likely seizure rate is only about one per 100 million users. The Pesticide Information Project of Cooperative Extension Offices of Cornell University states that, " Everglades National Park employees having extensive DEET exposure were more likely to have insomnia, mood disturbances and impaired cognitive function than were lesser exposed co-workers". The EPA states that citronella oil shows little or no toxicity and has been used as a topical insect repellent for 60 years. However, the EPA also states that citronella may irritate skin and cause dermatitis in certain individuals. Canadian regulatory authorities concern with citronella based repellents is primarily based on data-gaps in toxicology , not on incidents. Within countries of the European Union, implementation of Regulation 98/8/EC, commonly referred to as the Biocidal Products Directive, has severely limited the number and type of insect repellents available to European consumers. Only a small number of active ingredients have been supported by manufacturers in submitting dossiers to the EU Authorities. In general, only formulations containing DEET, icaridin (sold under the trade name Saltidin and formerly known as Bayrepel or KBR3023), IR3535 and citriodiol ( p-menthane-3,8-diol ) are available. Most "natural" insect repellents such as citronella, neem oil, and herbal extracts are no longer permitted for sale as insect repellents in the EU due to their lack of effectiveness; this does not preclude them from being sold for other purposes, as long as the label does not indicate they are a biocide (insect repellent). [ citation needed ]A 2018 study found that Icaridin , is highly toxic to salamander larvae , in what the authors described as conservative exposure doses. The LC50 standard was additionally found to be completely inadequate in the context of finding this result. Permethrin is highly toxic to cats but not to dogs or humans. Several natural ingredients are certified by the United States Environmental Protection Agency as insect repellents, namely catnip oil, oil of lemon eucalyptus (OLE) (and its active ingredient p-Menthane-3,8-diol ), oil of citronella , and 2-Undecanone , which is usually produced synthetically but has also been isolated from many plant sources. Many other studies have also investigated the potential of natural compounds from plants as insect repellents. Moreover, there are many preparations from naturally occurring sources that have been used as a repellent to certain insects. Some of these act as insecticides while others are only repellent. Below is a list of some natural products with repellent activity: Some old studies suggested that the ingestion of large doses of thiamine (vitamin B 1 ) could be effective as an oral insect repellent against mosquito bites. However, there is now conclusive evidence that thiamin has no efficacy against mosquito bites. Some claim that plants such as wormwood or sagewort, lemon balm , lemon grass , lemon thyme , and the mosquito plant (Pelargonium) will act against mosquitoes. However, scientists have determined that these plants are "effective" for a limited time only when the leaves are crushed and applied directly to the skin. There are several, widespread, unproven theories about mosquito control , such as the assertion that vitamin B , in particular B 1 (thiamine), garlic , ultrasonic devices or incense can be used to repel or control mosquitoes. Moreover, manufacturers of "mosquito repelling" ultrasonic devices have been found to be fraudulent, and their devices were deemed "useless" according to a review of scientific studies. Several natural ingredients are certified by the United States Environmental Protection Agency as insect repellents, namely catnip oil, oil of lemon eucalyptus (OLE) (and its active ingredient p-Menthane-3,8-diol ), oil of citronella , and 2-Undecanone , which is usually produced synthetically but has also been isolated from many plant sources. Many other studies have also investigated the potential of natural compounds from plants as insect repellents. Moreover, there are many preparations from naturally occurring sources that have been used as a repellent to certain insects. Some of these act as insecticides while others are only repellent. Below is a list of some natural products with repellent activity:Some old studies suggested that the ingestion of large doses of thiamine (vitamin B 1 ) could be effective as an oral insect repellent against mosquito bites. However, there is now conclusive evidence that thiamin has no efficacy against mosquito bites. Some claim that plants such as wormwood or sagewort, lemon balm , lemon grass , lemon thyme , and the mosquito plant (Pelargonium) will act against mosquitoes. However, scientists have determined that these plants are "effective" for a limited time only when the leaves are crushed and applied directly to the skin. There are several, widespread, unproven theories about mosquito control , such as the assertion that vitamin B , in particular B 1 (thiamine), garlic , ultrasonic devices or incense can be used to repel or control mosquitoes. Moreover, manufacturers of "mosquito repelling" ultrasonic devices have been found to be fraudulent, and their devices were deemed "useless" according to a review of scientific studies. People can reduce the number of mosquito bites they receive (to a greater or lesser degree) by:Testing and scientific certainty were desired at the end of the 1940s. To that end products meant to be used by humans were tested with model animals to speed trials. Eddy & McGregor 1949 and Wiesmann & Lotmar 1949 used mice , Wasicky et al. 1949 canaries and guinea pigs , Kasman et al. 1953 also guinea pigs, Starnes & Granett 1953 rabbits , and many used cattle .

Wiki

Ebola

https://api.wikimedia.org/core/v1/wikipedia/en/page/Ebola/html

Ebola

Ebola , also known as Ebola virus disease ( EVD ) and Ebola hemorrhagic fever ( EHF ), is a viral hemorrhagic fever in humans and other primates , caused by ebolaviruses . Symptoms typically start anywhere between two days and three weeks after infection. The first symptoms are usually fever , sore throat , muscle pain , and headaches . These are usually followed by vomiting , diarrhoea , rash and decreased liver and kidney function, at which point some people begin to bleed both internally and externally. It kills between 25% and 90% of those infected – about 50% on average. Death is often due to shock from fluid loss , and typically occurs between six and 16 days after the first symptoms appear. Early treatment of symptoms increases the survival rate considerably compared to late start. An Ebola vaccine was approved by the US FDA in December 2019. The virus spreads through direct contact with body fluids , such as blood from infected humans or other animals, or from contact with items that have recently been contaminated with infected body fluids. There have been no documented cases, either in nature or under laboratory conditions, of spread through the air between humans or other primates . After recovering from Ebola, semen or breast milk may continue to carry the virus for anywhere between several weeks to several months. Fruit bats are believed to be the normal carrier in nature ; they are able to spread the virus without being affected by it. The symptoms of Ebola may resemble those of several other diseases, including malaria , cholera , typhoid fever , meningitis and other viral hemorrhagic fevers. Diagnosis is confirmed by testing blood samples for the presence of viral RNA , viral antibodies or the virus itself. Control of outbreaks requires coordinated medical services and community engagement, including rapid detection, contact tracing of those exposed, quick access to laboratory services, care for those infected, and proper disposal of the dead through cremation or burial. Prevention measures involve wearing proper protective clothing and washing hands when in close proximity to patients and while handling potentially infected bushmeat , as well as thoroughly cooking bushmeat. An Ebola vaccine was approved by the US FDA in December 2019. While there is no approved treatment for Ebola as of 2019 [ update ] , two treatments ( atoltivimab/maftivimab/odesivimab and ansuvimab ) are associated with improved outcomes. Supportive efforts also improve outcomes. These include oral rehydration therapy (drinking slightly sweetened and salty water) or giving intravenous fluids , and treating symptoms. In October 2020, atoltivimab/maftivimab/odesivimab (Inmazeb) was approved for medical use in the United States to treat the disease caused by Zaire ebolavirus . Ebola was first identified in 1976, in two simultaneous outbreaks, one in Nzara (a town in South Sudan ) and the other in Yambuku ( the Democratic Republic of the Congo ), a village near the Ebola River , for which the disease was named. Ebola outbreaks occur intermittently in tropical regions of sub-Saharan Africa . Between 1976 and 2012, according to the World Health Organization , there were 24 outbreaks of Ebola resulting in a total of 2,387 cases, and 1,590 deaths . The largest Ebola outbreak to date was an epidemic in West Africa from December 2013 to January 2016, with 28,646 cases and 11,323 deaths. On 29 March 2016, it was declared to no longer be an emergency. Other outbreaks in Africa began in the Democratic Republic of the Congo in May 2017, and 2018. In July 2019, the World Health Organization declared the Congo Ebola outbreak a world health emergency . The length of time between exposure to the virus and the development of symptoms ( incubation period ) is between 2 and 21 days, and usually between 4 and 10 days. However, recent estimates based on mathematical models predict that around 5% of cases may take longer than 21 days to develop. Symptoms usually begin with a sudden influenza -like stage characterised by fatigue , fever , weakness , decreased appetite , muscular pain , joint pain , headache, and sore throat. The fever is usually higher than 38.3 °C (101 °F) . This is often followed by nausea, vomiting, diarrhoea , abdominal pain, and sometimes hiccups . The combination of severe vomiting and diarrhoea often leads to severe dehydration . Next, shortness of breath and chest pain may occur, along with swelling , headaches , and confusion . In about half of the cases, the skin may develop a maculopapular rash , a flat red area covered with small bumps, five to seven days after symptoms begin. In some cases, internal and external bleeding may occur. This typically begins five to seven days after the first symptoms. All infected people show some decreased blood clotting . Bleeding from mucous membranes or from sites of needle punctures has been reported in 40–50% of cases. This may cause vomiting blood , coughing up of blood , or blood in stool . Bleeding into the skin may create petechiae , purpura , ecchymoses or haematomas (especially around needle injection sites). Bleeding into the whites of the eyes may also occur. Heavy bleeding is uncommon; if it occurs, it is usually in the gastrointestinal tract . The incidence of bleeding into the gastrointestinal tract was reported to be ~58% in the 2001 outbreak in Gabon, but in the 2014–15 outbreak in the US it was ~18%, possibly due to improved prevention of disseminated intravascular coagulation . Recovery may begin between seven and 14 days after first symptoms. Death, if it occurs, follows typically six to sixteen days from first symptoms and is often due to shock from fluid loss . In general, bleeding often indicates a worse outcome, and blood loss may result in death. People are often in a coma near the end of life. Those who survive often have ongoing muscular and joint pain, liver inflammation , and decreased hearing, and may have continued tiredness, continued weakness, decreased appetite, and difficulty returning to pre-illness weight. Problems with vision may develop. It is recommended that survivors of EVD wear condoms for at least twelve months after initial infection or until the semen of a male survivor tests negative for Ebola virus on two separate occasions. Survivors develop antibodies against Ebola that last at least 10 years, but it is unclear whether they are immune to additional infections. The length of time between exposure to the virus and the development of symptoms ( incubation period ) is between 2 and 21 days, and usually between 4 and 10 days. However, recent estimates based on mathematical models predict that around 5% of cases may take longer than 21 days to develop. Symptoms usually begin with a sudden influenza -like stage characterised by fatigue , fever , weakness , decreased appetite , muscular pain , joint pain , headache, and sore throat. The fever is usually higher than 38.3 °C (101 °F) . This is often followed by nausea, vomiting, diarrhoea , abdominal pain, and sometimes hiccups . The combination of severe vomiting and diarrhoea often leads to severe dehydration . Next, shortness of breath and chest pain may occur, along with swelling , headaches , and confusion . In about half of the cases, the skin may develop a maculopapular rash , a flat red area covered with small bumps, five to seven days after symptoms begin. In some cases, internal and external bleeding may occur. This typically begins five to seven days after the first symptoms. All infected people show some decreased blood clotting . Bleeding from mucous membranes or from sites of needle punctures has been reported in 40–50% of cases. This may cause vomiting blood , coughing up of blood , or blood in stool . Bleeding into the skin may create petechiae , purpura , ecchymoses or haematomas (especially around needle injection sites). Bleeding into the whites of the eyes may also occur. Heavy bleeding is uncommon; if it occurs, it is usually in the gastrointestinal tract . The incidence of bleeding into the gastrointestinal tract was reported to be ~58% in the 2001 outbreak in Gabon, but in the 2014–15 outbreak in the US it was ~18%, possibly due to improved prevention of disseminated intravascular coagulation . Recovery may begin between seven and 14 days after first symptoms. Death, if it occurs, follows typically six to sixteen days from first symptoms and is often due to shock from fluid loss . In general, bleeding often indicates a worse outcome, and blood loss may result in death. People are often in a coma near the end of life. Those who survive often have ongoing muscular and joint pain, liver inflammation , and decreased hearing, and may have continued tiredness, continued weakness, decreased appetite, and difficulty returning to pre-illness weight. Problems with vision may develop. It is recommended that survivors of EVD wear condoms for at least twelve months after initial infection or until the semen of a male survivor tests negative for Ebola virus on two separate occasions. Survivors develop antibodies against Ebola that last at least 10 years, but it is unclear whether they are immune to additional infections. EVD in humans is caused by four of six viruses of the genus Ebolavirus . The four are Bundibugyo virus (BDBV), Sudan virus (SUDV), Taï Forest virus (TAFV) and one simply called Ebola virus (EBOV, formerly Zaire Ebola virus). EBOV, species Zaire ebolavirus , is the most dangerous of the known EVD-causing viruses, and is responsible for the largest number of outbreaks. The fifth and sixth viruses, Reston virus (RESTV) and Bombali virus (BOMV), are not thought to cause disease in humans, but have caused disease in other primates. All five viruses are closely related to marburgviruses . Ebolaviruses contain single-stranded, non-infectious RNA genomes . Ebolavirus genomes contain seven genes including 3'-UTR - NP - VP35 - VP40 - GP - VP30 - VP24 - L - 5'-UTR . The genomes of the five different ebolaviruses (BDBV, EBOV, RESTV, SUDV and TAFV) differ in sequence and the number and location of gene overlaps. As with all filoviruses , ebolavirus virions are filamentous particles that may appear in the shape of a shepherd's crook, of a "U" or of a "6," and they may be coiled, toroid or branched. In general, ebolavirions are 80 nanometers (nm) in width and may be as long as 14,000 nm. Their life cycle is thought to begin with a virion attaching to specific cell-surface receptors such as C-type lectins , DC-SIGN , or integrins , which is followed by fusion of the viral envelope with cellular membranes . The virions taken up by the cell then travel to acidic endosomes and lysosomes where the viral envelope glycoprotein GP is cleaved. This processing appears to allow the virus to bind to cellular proteins enabling it to fuse with internal cellular membranes and release the viral nucleocapsid . The Ebolavirus structural glycoprotein (known as GP1,2) is responsible for the virus' ability to bind to and infect targeted cells. The viral RNA polymerase , encoded by the L gene, partially uncoats the nucleocapsid and transcribes the genes into positive-strand mRNAs , which are then translated into structural and nonstructural proteins. The most abundant protein produced is the nucleoprotein, whose concentration in the host cell determines when L switches from gene transcription to genome replication. Replication of the viral genome results in full-length, positive-strand antigenomes that are, in turn, transcribed into genome copies of negative-strand virus progeny. Newly synthesised structural proteins and genomes self-assemble and accumulate near the inside of the cell membrane . Virions bud off from the cell, gaining their envelopes from the cellular membrane from which they bud. The mature progeny particles then infect other cells to repeat the cycle. The genetics of the Ebola virus are difficult to study because of EBOV's virulent characteristics. It is believed that between people, Ebola disease spreads only by direct contact with the blood or other body fluids of a person who has developed symptoms of the disease. Body fluids that may contain Ebola viruses include saliva, mucus, vomit, feces, sweat, tears, breast milk, urine and semen . The WHO states that only people who are very sick are able to spread Ebola disease in saliva , and the virus has not been reported to be transmitted through sweat. Most people spread the virus through blood, feces and vomit. Entry points for the virus include the nose, mouth, eyes, open wounds, cuts and abrasions. Ebola may be spread through large droplets ; however, this is believed to occur only when a person is very sick. This contamination can happen if a person is splashed with droplets. Contact with surfaces or objects contaminated by the virus, particularly needles and syringes, may also transmit the infection. The virus is able to survive on objects for a few hours in a dried state, and can survive for a few days within body fluids outside of a person. The Ebola virus may be able to persist for more than three months in the semen after recovery, which could lead to infections via sexual intercourse . Virus persistence in semen for over a year has been recorded in a national screening programme. Ebola may also occur in the breast milk of women after recovery, and it is not known when it is safe to breastfeed again. The virus was also found in the eye of one patient in 2014, two months after it was cleared from his blood. Otherwise, people who have recovered are not infectious. The potential for widespread infections in countries with medical systems capable of observing correct medical isolation procedures is considered low. Usually when someone has symptoms of the disease, they are unable to travel without assistance. Dead bodies remain infectious; thus, people handling human remains in practices such as traditional burial rituals or more modern processes such as embalming are at risk. Of the cases of Ebola infections in Guinea during the 2014 outbreak, 69% are believed to have been contracted via unprotected (or unsuitably protected) contact with infected corpses during certain Guinean burial rituals. Health-care workers treating people with Ebola are at greatest risk of infection. The risk increases when they do not have appropriate protective clothing such as masks, gowns, gloves and eye protection; do not wear it properly; or handle contaminated clothing incorrectly. This risk is particularly common in parts of Africa where the disease mostly occurs and health systems function poorly. There has been transmission in hospitals in some African countries that reuse hypodermic needles. Some health-care centres caring for people with the disease do not have running water. In the United States the spread to two medical workers treating infected patients prompted criticism of inadequate training and procedures. Human-to-human transmission of EBOV through the air has not been reported to occur during EVD outbreaks, and airborne transmission has only been demonstrated in very strict laboratory conditions, and then only from pigs to primates , but not from primates to primates. Spread of EBOV by water, or food other than bushmeat, has not been observed. No spread by mosquitos or other insects has been reported. Other possible methods of transmission are being studied. Airborne transmission among humans is theoretically possible due to the presence of Ebola virus particles in saliva, which can be discharged into the air with a cough or sneeze, but observational data from previous epidemics suggests the actual risk of airborne transmission is low. A number of studies examining airborne transmission broadly concluded that transmission from pigs to primates could happen without direct contact because, unlike humans and primates, pigs with EVD get very high ebolavirus concentrations in their lungs, and not their bloodstream. Therefore, pigs with EVD can spread the disease through droplets in the air or on the ground when they sneeze or cough. By contrast, humans and other primates accumulate the virus throughout their body and specifically in their blood, but not very much in their lungs. It is believed that this is the reason researchers have observed pig to primate transmission without physical contact, but no evidence has been found of primates being infected without actual contact, even in experiments where infected and uninfected primates shared the same air. Although it is not entirely clear how Ebola initially spreads from animals to humans, the spread is believed to involve direct contact with an infected wild animal or fruit bat. Besides bats, other wild animals that are sometimes infected with EBOV include several species of monkeys such as baboons , great apes ( chimpanzees and gorillas ), and duikers (a species of antelope ). Animals may become infected when they eat fruit partially eaten by bats carrying the virus. Fruit production, animal behavior and other factors may trigger outbreaks among animal populations. Evidence indicates that both domestic dogs and pigs can also be infected with EBOV. Dogs do not appear to develop symptoms when they carry the virus, and pigs appear to be able to transmit the virus to at least some primates. Although some dogs in an area in which a human outbreak occurred had antibodies to EBOV, it is unclear whether they played a role in spreading the disease to people. The natural reservoir for Ebola has yet to be confirmed; however, bats are considered to be the most likely candidate. Three types of fruit bats ( Hypsignathus monstrosus , Epomops franqueti and Myonycteris torquata ) were found to possibly carry the virus without getting sick. As of 2013 [ update ] , whether other animals are involved in its spread is not known. Plants, arthropods , rodents , and birds have also been considered possible viral reservoirs. Bats were known to roost in the cotton factory in which the first cases of the 1976 and 1979 outbreaks were observed, and they have also been implicated in Marburg virus infections in 1975 and 1980. Of 24 plant and 19 vertebrate species experimentally inoculated with EBOV, only bats became infected. The bats displayed no clinical signs of disease, which is considered evidence that these bats are a reservoir species of EBOV. In a 2002–2003 survey of 1,030 animals including 679 bats from Gabon and the Republic of the Congo , immunoglobulin G (IgG) immune defense molecules indicative of Ebola infection were found in three bat species; at various periods of study, between 2.2 and 22.6% of bats were found to contain both RNA sequences and IgG molecules indicating Ebola infection. Antibodies against Zaire and Reston viruses have been found in fruit bats in Bangladesh , suggesting that these bats are also potential hosts of the virus and that the filoviruses are present in Asia. Between 1976 and 1998, in 30,000 mammals, birds, reptiles, amphibians and arthropods sampled from regions of EBOV outbreaks, no Ebola virus was detected apart from some genetic traces found in six rodents (belonging to the species Mus setulosus and Praomys ) and one shrew ( Sylvisorex ollula ) collected from the Central African Republic . However, further research efforts have not confirmed rodents as a reservoir. Traces of EBOV were detected in the carcasses of gorillas and chimpanzees during outbreaks in 2001 and 2003, which later became the source of human infections. However, the high rates of death in these species resulting from EBOV infection make it unlikely that these species represent a natural reservoir for the virus. Deforestation has been mentioned as a possible contributor to recent outbreaks, including the West African Ebola virus epidemic . Index cases of EVD have often been close to recently deforested lands. Ebolaviruses contain single-stranded, non-infectious RNA genomes . Ebolavirus genomes contain seven genes including 3'-UTR - NP - VP35 - VP40 - GP - VP30 - VP24 - L - 5'-UTR . The genomes of the five different ebolaviruses (BDBV, EBOV, RESTV, SUDV and TAFV) differ in sequence and the number and location of gene overlaps. As with all filoviruses , ebolavirus virions are filamentous particles that may appear in the shape of a shepherd's crook, of a "U" or of a "6," and they may be coiled, toroid or branched. In general, ebolavirions are 80 nanometers (nm) in width and may be as long as 14,000 nm. Their life cycle is thought to begin with a virion attaching to specific cell-surface receptors such as C-type lectins , DC-SIGN , or integrins , which is followed by fusion of the viral envelope with cellular membranes . The virions taken up by the cell then travel to acidic endosomes and lysosomes where the viral envelope glycoprotein GP is cleaved. This processing appears to allow the virus to bind to cellular proteins enabling it to fuse with internal cellular membranes and release the viral nucleocapsid . The Ebolavirus structural glycoprotein (known as GP1,2) is responsible for the virus' ability to bind to and infect targeted cells. The viral RNA polymerase , encoded by the L gene, partially uncoats the nucleocapsid and transcribes the genes into positive-strand mRNAs , which are then translated into structural and nonstructural proteins. The most abundant protein produced is the nucleoprotein, whose concentration in the host cell determines when L switches from gene transcription to genome replication. Replication of the viral genome results in full-length, positive-strand antigenomes that are, in turn, transcribed into genome copies of negative-strand virus progeny. Newly synthesised structural proteins and genomes self-assemble and accumulate near the inside of the cell membrane . Virions bud off from the cell, gaining their envelopes from the cellular membrane from which they bud. The mature progeny particles then infect other cells to repeat the cycle. The genetics of the Ebola virus are difficult to study because of EBOV's virulent characteristics. It is believed that between people, Ebola disease spreads only by direct contact with the blood or other body fluids of a person who has developed symptoms of the disease. Body fluids that may contain Ebola viruses include saliva, mucus, vomit, feces, sweat, tears, breast milk, urine and semen . The WHO states that only people who are very sick are able to spread Ebola disease in saliva , and the virus has not been reported to be transmitted through sweat. Most people spread the virus through blood, feces and vomit. Entry points for the virus include the nose, mouth, eyes, open wounds, cuts and abrasions. Ebola may be spread through large droplets ; however, this is believed to occur only when a person is very sick. This contamination can happen if a person is splashed with droplets. Contact with surfaces or objects contaminated by the virus, particularly needles and syringes, may also transmit the infection. The virus is able to survive on objects for a few hours in a dried state, and can survive for a few days within body fluids outside of a person. The Ebola virus may be able to persist for more than three months in the semen after recovery, which could lead to infections via sexual intercourse . Virus persistence in semen for over a year has been recorded in a national screening programme. Ebola may also occur in the breast milk of women after recovery, and it is not known when it is safe to breastfeed again. The virus was also found in the eye of one patient in 2014, two months after it was cleared from his blood. Otherwise, people who have recovered are not infectious. The potential for widespread infections in countries with medical systems capable of observing correct medical isolation procedures is considered low. Usually when someone has symptoms of the disease, they are unable to travel without assistance. Dead bodies remain infectious; thus, people handling human remains in practices such as traditional burial rituals or more modern processes such as embalming are at risk. Of the cases of Ebola infections in Guinea during the 2014 outbreak, 69% are believed to have been contracted via unprotected (or unsuitably protected) contact with infected corpses during certain Guinean burial rituals. Health-care workers treating people with Ebola are at greatest risk of infection. The risk increases when they do not have appropriate protective clothing such as masks, gowns, gloves and eye protection; do not wear it properly; or handle contaminated clothing incorrectly. This risk is particularly common in parts of Africa where the disease mostly occurs and health systems function poorly. There has been transmission in hospitals in some African countries that reuse hypodermic needles. Some health-care centres caring for people with the disease do not have running water. In the United States the spread to two medical workers treating infected patients prompted criticism of inadequate training and procedures. Human-to-human transmission of EBOV through the air has not been reported to occur during EVD outbreaks, and airborne transmission has only been demonstrated in very strict laboratory conditions, and then only from pigs to primates , but not from primates to primates. Spread of EBOV by water, or food other than bushmeat, has not been observed. No spread by mosquitos or other insects has been reported. Other possible methods of transmission are being studied. Airborne transmission among humans is theoretically possible due to the presence of Ebola virus particles in saliva, which can be discharged into the air with a cough or sneeze, but observational data from previous epidemics suggests the actual risk of airborne transmission is low. A number of studies examining airborne transmission broadly concluded that transmission from pigs to primates could happen without direct contact because, unlike humans and primates, pigs with EVD get very high ebolavirus concentrations in their lungs, and not their bloodstream. Therefore, pigs with EVD can spread the disease through droplets in the air or on the ground when they sneeze or cough. By contrast, humans and other primates accumulate the virus throughout their body and specifically in their blood, but not very much in their lungs. It is believed that this is the reason researchers have observed pig to primate transmission without physical contact, but no evidence has been found of primates being infected without actual contact, even in experiments where infected and uninfected primates shared the same air. Although it is not entirely clear how Ebola initially spreads from animals to humans, the spread is believed to involve direct contact with an infected wild animal or fruit bat. Besides bats, other wild animals that are sometimes infected with EBOV include several species of monkeys such as baboons , great apes ( chimpanzees and gorillas ), and duikers (a species of antelope ). Animals may become infected when they eat fruit partially eaten by bats carrying the virus. Fruit production, animal behavior and other factors may trigger outbreaks among animal populations. Evidence indicates that both domestic dogs and pigs can also be infected with EBOV. Dogs do not appear to develop symptoms when they carry the virus, and pigs appear to be able to transmit the virus to at least some primates. Although some dogs in an area in which a human outbreak occurred had antibodies to EBOV, it is unclear whether they played a role in spreading the disease to people. The natural reservoir for Ebola has yet to be confirmed; however, bats are considered to be the most likely candidate. Three types of fruit bats ( Hypsignathus monstrosus , Epomops franqueti and Myonycteris torquata ) were found to possibly carry the virus without getting sick. As of 2013 [ update ] , whether other animals are involved in its spread is not known. Plants, arthropods , rodents , and birds have also been considered possible viral reservoirs. Bats were known to roost in the cotton factory in which the first cases of the 1976 and 1979 outbreaks were observed, and they have also been implicated in Marburg virus infections in 1975 and 1980. Of 24 plant and 19 vertebrate species experimentally inoculated with EBOV, only bats became infected. The bats displayed no clinical signs of disease, which is considered evidence that these bats are a reservoir species of EBOV. In a 2002–2003 survey of 1,030 animals including 679 bats from Gabon and the Republic of the Congo , immunoglobulin G (IgG) immune defense molecules indicative of Ebola infection were found in three bat species; at various periods of study, between 2.2 and 22.6% of bats were found to contain both RNA sequences and IgG molecules indicating Ebola infection. Antibodies against Zaire and Reston viruses have been found in fruit bats in Bangladesh , suggesting that these bats are also potential hosts of the virus and that the filoviruses are present in Asia. Between 1976 and 1998, in 30,000 mammals, birds, reptiles, amphibians and arthropods sampled from regions of EBOV outbreaks, no Ebola virus was detected apart from some genetic traces found in six rodents (belonging to the species Mus setulosus and Praomys ) and one shrew ( Sylvisorex ollula ) collected from the Central African Republic . However, further research efforts have not confirmed rodents as a reservoir. Traces of EBOV were detected in the carcasses of gorillas and chimpanzees during outbreaks in 2001 and 2003, which later became the source of human infections. However, the high rates of death in these species resulting from EBOV infection make it unlikely that these species represent a natural reservoir for the virus. Deforestation has been mentioned as a possible contributor to recent outbreaks, including the West African Ebola virus epidemic . Index cases of EVD have often been close to recently deforested lands. Like other filoviruses , EBOV replicates very efficiently in many cells , producing large amounts of virus in monocytes , macrophages , dendritic cells and other cells including liver cells , fibroblasts , and adrenal gland cells . Viral replication triggers high levels of inflammatory chemical signals and leads to a septic state . EBOV is thought to infect humans through contact with mucous membranes or skin breaks. After infection, endothelial cells (cells lining the inside of blood vessels), liver cells, and several types of immune cells such as macrophages, monocytes , and dendritic cells are the main targets of attack. Following infection, immune cells carry the virus to nearby lymph nodes where further reproduction of the virus takes place. From there the virus can enter the bloodstream and lymphatic system and spread throughout the body. Macrophages are the first cells infected with the virus, and this infection results in programmed cell death . Other types of white blood cells , such as lymphocytes , also undergo programmed cell death leading to an abnormally low concentration of lymphocytes in the blood. This contributes to the weakened immune response seen in those infected with EBOV. Endothelial cells may be infected within three days after exposure to the virus. The breakdown of endothelial cells leading to blood vessel injury can be attributed to EBOV glycoproteins . This damage occurs due to the synthesis of Ebola virus glycoprotein (GP), which reduces the availability of specific integrins responsible for cell adhesion to the intercellular structure and causes liver damage, leading to improper clotting . The widespread bleeding that occurs in affected people causes swelling and shock due to loss of blood volume . The dysfunctional bleeding and clotting commonly seen in EVD has been attributed to increased activation of the extrinsic pathway of the coagulation cascade due to excessive tissue factor production by macrophages and monocytes. After infection, a secreted glycoprotein , small soluble glycoprotein (sGP or GP) is synthesised. EBOV replication overwhelms protein synthesis of infected cells and the host immune defences. The GP forms a trimeric complex , which tethers the virus to the endothelial cells. The sGP forms a dimeric protein that interferes with the signalling of neutrophils , another type of white blood cell. This enables the virus to evade the immune system by inhibiting early steps of neutrophil activation. [ medical citation needed ] Furthermore, the virus is capable of hijacking cellular metabolism. Studies have shown that Ebola virus-like particles can reprogram metabolism in both vascular and immune cells. Filoviral infection also interferes with proper functioning of the innate immune system . EBOV proteins blunt the human immune system's response to viral infections by interfering with the cells' ability to produce and respond to interferon proteins such as interferon-alpha , interferon-beta , and interferon gamma . The VP24 and VP35 structural proteins of EBOV play a key role in this interference. When a cell is infected with EBOV, receptors located in the cell's cytosol (such as RIG-I and MDA5 ) or outside of the cytosol (such as Toll-like receptor 3 (TLR3) , TLR7 , TLR8 and TLR9 ) recognise infectious molecules associated with the virus. On TLR activation, proteins including interferon regulatory factor 3 and interferon regulatory factor 7 trigger a signalling cascade that leads to the expression of type 1 interferons . The type 1 interferons are then released and bind to the IFNAR1 and IFNAR2 receptors expressed on the surface of a neighbouring cell. Once interferon has bound to its receptors on the neighbouring cell, the signalling proteins STAT1 and STAT2 are activated and move to the cell's nucleus . This triggers the expression of interferon-stimulated genes , which code for proteins with antiviral properties. EBOV's V24 protein blocks the production of these antiviral proteins by preventing the STAT1 signalling protein in the neighbouring cell from entering the nucleus. The VP35 protein directly inhibits the production of interferon-beta. By inhibiting these immune responses, EBOV may quickly spread throughout the body. Filoviral infection also interferes with proper functioning of the innate immune system . EBOV proteins blunt the human immune system's response to viral infections by interfering with the cells' ability to produce and respond to interferon proteins such as interferon-alpha , interferon-beta , and interferon gamma . The VP24 and VP35 structural proteins of EBOV play a key role in this interference. When a cell is infected with EBOV, receptors located in the cell's cytosol (such as RIG-I and MDA5 ) or outside of the cytosol (such as Toll-like receptor 3 (TLR3) , TLR7 , TLR8 and TLR9 ) recognise infectious molecules associated with the virus. On TLR activation, proteins including interferon regulatory factor 3 and interferon regulatory factor 7 trigger a signalling cascade that leads to the expression of type 1 interferons . The type 1 interferons are then released and bind to the IFNAR1 and IFNAR2 receptors expressed on the surface of a neighbouring cell. Once interferon has bound to its receptors on the neighbouring cell, the signalling proteins STAT1 and STAT2 are activated and move to the cell's nucleus . This triggers the expression of interferon-stimulated genes , which code for proteins with antiviral properties. EBOV's V24 protein blocks the production of these antiviral proteins by preventing the STAT1 signalling protein in the neighbouring cell from entering the nucleus. The VP35 protein directly inhibits the production of interferon-beta. By inhibiting these immune responses, EBOV may quickly spread throughout the body. When EVD is suspected, travel, work history, and exposure to wildlife are important factors with respect to further diagnostic efforts. Possible non-specific laboratory indicators of EVD include a low platelet count ; an initially decreased white blood cell count followed by an increased white blood cell count ; elevated levels of the liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST); and abnormalities in blood clotting often consistent with disseminated intravascular coagulation (DIC) such as a prolonged prothrombin time , partial thromboplastin time , and bleeding time . Filovirions such as EBOV may be identified by their unique filamentous shapes in cell cultures examined with electron microscopy . The specific diagnosis of EVD is confirmed by isolating the virus, detecting its RNA or proteins, or detecting antibodies against the virus in a person's blood. Isolating the virus by cell culture , detecting the viral RNA by polymerase chain reaction (PCR) and detecting proteins by enzyme-linked immunosorbent assay (ELISA) are methods best used in the early stages of the disease and also for detecting the virus in human remains. Detecting antibodies against the virus is most reliable in the later stages of the disease and in those who recover. IgM antibodies are detectable two days after symptom onset and IgG antibodies can be detected six to 18 days after symptom onset. During an outbreak, isolation of the virus with cell culture methods is often not feasible. In field or mobile hospitals, the most common and sensitive diagnostic methods are real-time PCR and ELISA. In 2014, with new mobile testing facilities deployed in parts of Liberia, test results were obtained 3–5 hours after sample submission. In 2015, a rapid antigen test which gives results in 15 minutes was approved for use by WHO. It is able to confirm Ebola in 92% of those affected and rule it out in 85% of those not affected. Early symptoms of EVD may be similar to those of other diseases common in Africa, including malaria and dengue fever . The symptoms are also similar to those of other viral haemorrhagic fevers such as Marburg virus disease , Crimean–Congo haemorrhagic fever , and Lassa fever . The complete differential diagnosis is extensive and requires consideration of many other infectious diseases such as typhoid fever , shigellosis , rickettsial diseases , cholera , sepsis , borreliosis , EHEC enteritis , leptospirosis , scrub typhus , plague , Q fever , candidiasis , histoplasmosis , trypanosomiasis , visceral leishmaniasis , measles , and viral hepatitis among others. Non-infectious diseases that may result in symptoms similar to those of EVD include acute promyelocytic leukaemia , haemolytic uraemic syndrome , snake envenomation , clotting factor deficiencies/platelet disorders, thrombotic thrombocytopenic purpura , hereditary haemorrhagic telangiectasia , Kawasaki disease , and warfarin poisoning. Possible non-specific laboratory indicators of EVD include a low platelet count ; an initially decreased white blood cell count followed by an increased white blood cell count ; elevated levels of the liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST); and abnormalities in blood clotting often consistent with disseminated intravascular coagulation (DIC) such as a prolonged prothrombin time , partial thromboplastin time , and bleeding time . Filovirions such as EBOV may be identified by their unique filamentous shapes in cell cultures examined with electron microscopy . The specific diagnosis of EVD is confirmed by isolating the virus, detecting its RNA or proteins, or detecting antibodies against the virus in a person's blood. Isolating the virus by cell culture , detecting the viral RNA by polymerase chain reaction (PCR) and detecting proteins by enzyme-linked immunosorbent assay (ELISA) are methods best used in the early stages of the disease and also for detecting the virus in human remains. Detecting antibodies against the virus is most reliable in the later stages of the disease and in those who recover. IgM antibodies are detectable two days after symptom onset and IgG antibodies can be detected six to 18 days after symptom onset. During an outbreak, isolation of the virus with cell culture methods is often not feasible. In field or mobile hospitals, the most common and sensitive diagnostic methods are real-time PCR and ELISA. In 2014, with new mobile testing facilities deployed in parts of Liberia, test results were obtained 3–5 hours after sample submission. In 2015, a rapid antigen test which gives results in 15 minutes was approved for use by WHO. It is able to confirm Ebola in 92% of those affected and rule it out in 85% of those not affected. Early symptoms of EVD may be similar to those of other diseases common in Africa, including malaria and dengue fever . The symptoms are also similar to those of other viral haemorrhagic fevers such as Marburg virus disease , Crimean–Congo haemorrhagic fever , and Lassa fever . The complete differential diagnosis is extensive and requires consideration of many other infectious diseases such as typhoid fever , shigellosis , rickettsial diseases , cholera , sepsis , borreliosis , EHEC enteritis , leptospirosis , scrub typhus , plague , Q fever , candidiasis , histoplasmosis , trypanosomiasis , visceral leishmaniasis , measles , and viral hepatitis among others. Non-infectious diseases that may result in symptoms similar to those of EVD include acute promyelocytic leukaemia , haemolytic uraemic syndrome , snake envenomation , clotting factor deficiencies/platelet disorders, thrombotic thrombocytopenic purpura , hereditary haemorrhagic telangiectasia , Kawasaki disease , and warfarin poisoning. An Ebola vaccine , rVSV-ZEBOV , was approved in the United States in December 2019. It appears to be fully effective ten days after being given. It was studied in Guinea between 2014 and 2016. More than 100,000 people have been vaccinated against Ebola as of 2019 [ update ] . The WHO reported that approximately 345,000 people were given the vaccine during the Kivu Ebola epidemic from 2018 to 2020. Community awareness of the benefits on survival chances of admitting cases early is important for the infected and infection control People who care for those infected with Ebola should wear protective clothing including masks, gloves, gowns and goggles. The U.S. Centers for Disease Control (CDC) recommend that the protective gear leaves no skin exposed. These measures are also recommended for those who may handle objects contaminated by an infected person's body fluids. In 2014, the CDC began recommending that medical personnel receive training on the proper suit-up and removal of personal protective equipment (PPE); in addition, a designated person, appropriately trained in biosafety, should be watching each step of these procedures to ensure they are done correctly. In Sierra Leone, the typical training period for the use of such safety equipment lasts approximately 12 days. In 2022 in Uganda, lighter personal protection equipment has become available as well as possibilities to monitor and communicate with patients from windows in the treatment tents until it is necessary to enter if e.g. a patient's oxygen levels drop. The infected person should be in barrier-isolation from other people. All equipment, medical waste, patient waste and surfaces that may have come into contact with body fluids need to be disinfected . During the 2014 outbreak, kits were put together to help families treat Ebola disease in their homes, which included protective clothing as well as chlorine powder and other cleaning supplies. Education of caregivers in these techniques, and providing such barrier-separation supplies has been a priority of Doctors Without Borders . Ebolaviruses can be eliminated with heat (heating for 30 to 60 minutes at 60 °C or boiling for five minutes). To disinfect surfaces, some lipid solvents such as some alcohol-based products, detergents, sodium hypochlorite (bleach) or calcium hypochlorite (bleaching powder), and other suitable disinfectants may be used at appropriate concentrations. Education of the general public about the risk factors for Ebola infection and of the protective measures individuals may take to prevent infection is recommended by the World Health Organization . These measures include avoiding direct contact with infected people and regular hand washing using soap and water. Bushmeat , an important source of protein in the diet of some Africans, should be handled and prepared with appropriate protective clothing and thoroughly cooked before consumption. Some research suggests that an outbreak of Ebola disease in the wild animals used for consumption may result in a corresponding human outbreak. Since 2003, such animal outbreaks have been monitored to predict and prevent Ebola outbreaks in humans. If a person with Ebola disease dies, direct contact with the body should be avoided. Certain burial rituals , which may have included making various direct contacts with a dead body, require reformulation so that they consistently maintain a proper protective barrier between the dead body and the living. Social anthropologists may help find alternatives to traditional rules for burials. Transportation crews are instructed to follow a certain isolation procedure, should anyone exhibit symptoms resembling EVD. As of August 2014 [ update ] , the WHO does not consider travel bans to be useful in decreasing spread of the disease. In October 2014, the CDC defined four risk levels used to determine the level of 21-day monitoring for symptoms and restrictions on public activities. In the United States, the CDC recommends that restrictions on public activity, including travel restrictions, are not required for the following defined risk levels: having been in a country with widespread Ebola disease transmission and having no known exposure (low risk); or having been in that country more than 21 days ago (no risk) encounter with a person showing symptoms; but not within three feet of the person with Ebola without wearing PPE; and no direct contact with body fluids having had brief skin contact with a person showing symptoms of Ebola disease when the person was believed to be not very contagious (low risk) in countries without widespread Ebola disease transmission: direct contact with a person showing symptoms of the disease while wearing PPE (low risk) contact with a person with Ebola disease before the person was showing symptoms (no risk). The CDC recommends monitoring for the symptoms of Ebola disease for those both at "low risk" and at higher risk. In laboratories where diagnostic testing is carried out, biosafety level 4-equivalent containment is required. Laboratory researchers must be properly trained in BSL-4 practices and wear proper PPE. Isolation refers to separating those who are sick from those who are not. Quarantine refers to separating those who may have been exposed to a disease until they either show signs of the disease or are no longer at risk. Quarantine, also known as enforced isolation, is usually effective in decreasing spread. Governments often quarantine areas where the disease is occurring or individuals who may transmit the disease outside of an initial area. In the United States, the law allows quarantine of those infected with ebolaviruses. Contact tracing is considered important to contain an outbreak. It involves finding everyone who had close contact with infected individuals and monitoring them for signs of illness for 21 days. If any of these contacts comes down with the disease, they should be isolated, tested and treated. Then the process is repeated, tracing the contacts' contacts. An Ebola vaccine , rVSV-ZEBOV , was approved in the United States in December 2019. It appears to be fully effective ten days after being given. It was studied in Guinea between 2014 and 2016. More than 100,000 people have been vaccinated against Ebola as of 2019 [ update ] . The WHO reported that approximately 345,000 people were given the vaccine during the Kivu Ebola epidemic from 2018 to 2020. Community awareness of the benefits on survival chances of admitting cases early is important for the infected and infection control People who care for those infected with Ebola should wear protective clothing including masks, gloves, gowns and goggles. The U.S. Centers for Disease Control (CDC) recommend that the protective gear leaves no skin exposed. These measures are also recommended for those who may handle objects contaminated by an infected person's body fluids. In 2014, the CDC began recommending that medical personnel receive training on the proper suit-up and removal of personal protective equipment (PPE); in addition, a designated person, appropriately trained in biosafety, should be watching each step of these procedures to ensure they are done correctly. In Sierra Leone, the typical training period for the use of such safety equipment lasts approximately 12 days. In 2022 in Uganda, lighter personal protection equipment has become available as well as possibilities to monitor and communicate with patients from windows in the treatment tents until it is necessary to enter if e.g. a patient's oxygen levels drop. The infected person should be in barrier-isolation from other people. All equipment, medical waste, patient waste and surfaces that may have come into contact with body fluids need to be disinfected . During the 2014 outbreak, kits were put together to help families treat Ebola disease in their homes, which included protective clothing as well as chlorine powder and other cleaning supplies. Education of caregivers in these techniques, and providing such barrier-separation supplies has been a priority of Doctors Without Borders . Ebolaviruses can be eliminated with heat (heating for 30 to 60 minutes at 60 °C or boiling for five minutes). To disinfect surfaces, some lipid solvents such as some alcohol-based products, detergents, sodium hypochlorite (bleach) or calcium hypochlorite (bleaching powder), and other suitable disinfectants may be used at appropriate concentrations. Education of the general public about the risk factors for Ebola infection and of the protective measures individuals may take to prevent infection is recommended by the World Health Organization . These measures include avoiding direct contact with infected people and regular hand washing using soap and water. Bushmeat , an important source of protein in the diet of some Africans, should be handled and prepared with appropriate protective clothing and thoroughly cooked before consumption. Some research suggests that an outbreak of Ebola disease in the wild animals used for consumption may result in a corresponding human outbreak. Since 2003, such animal outbreaks have been monitored to predict and prevent Ebola outbreaks in humans. If a person with Ebola disease dies, direct contact with the body should be avoided. Certain burial rituals , which may have included making various direct contacts with a dead body, require reformulation so that they consistently maintain a proper protective barrier between the dead body and the living. Social anthropologists may help find alternatives to traditional rules for burials. Transportation crews are instructed to follow a certain isolation procedure, should anyone exhibit symptoms resembling EVD. As of August 2014 [ update ] , the WHO does not consider travel bans to be useful in decreasing spread of the disease. In October 2014, the CDC defined four risk levels used to determine the level of 21-day monitoring for symptoms and restrictions on public activities. In the United States, the CDC recommends that restrictions on public activity, including travel restrictions, are not required for the following defined risk levels: having been in a country with widespread Ebola disease transmission and having no known exposure (low risk); or having been in that country more than 21 days ago (no risk) encounter with a person showing symptoms; but not within three feet of the person with Ebola without wearing PPE; and no direct contact with body fluids having had brief skin contact with a person showing symptoms of Ebola disease when the person was believed to be not very contagious (low risk) in countries without widespread Ebola disease transmission: direct contact with a person showing symptoms of the disease while wearing PPE (low risk) contact with a person with Ebola disease before the person was showing symptoms (no risk). The CDC recommends monitoring for the symptoms of Ebola disease for those both at "low risk" and at higher risk. In laboratories where diagnostic testing is carried out, biosafety level 4-equivalent containment is required. Laboratory researchers must be properly trained in BSL-4 practices and wear proper PPE. People who care for those infected with Ebola should wear protective clothing including masks, gloves, gowns and goggles. The U.S. Centers for Disease Control (CDC) recommend that the protective gear leaves no skin exposed. These measures are also recommended for those who may handle objects contaminated by an infected person's body fluids. In 2014, the CDC began recommending that medical personnel receive training on the proper suit-up and removal of personal protective equipment (PPE); in addition, a designated person, appropriately trained in biosafety, should be watching each step of these procedures to ensure they are done correctly. In Sierra Leone, the typical training period for the use of such safety equipment lasts approximately 12 days. In 2022 in Uganda, lighter personal protection equipment has become available as well as possibilities to monitor and communicate with patients from windows in the treatment tents until it is necessary to enter if e.g. a patient's oxygen levels drop. The infected person should be in barrier-isolation from other people. All equipment, medical waste, patient waste and surfaces that may have come into contact with body fluids need to be disinfected . During the 2014 outbreak, kits were put together to help families treat Ebola disease in their homes, which included protective clothing as well as chlorine powder and other cleaning supplies. Education of caregivers in these techniques, and providing such barrier-separation supplies has been a priority of Doctors Without Borders . Ebolaviruses can be eliminated with heat (heating for 30 to 60 minutes at 60 °C or boiling for five minutes). To disinfect surfaces, some lipid solvents such as some alcohol-based products, detergents, sodium hypochlorite (bleach) or calcium hypochlorite (bleaching powder), and other suitable disinfectants may be used at appropriate concentrations. Education of the general public about the risk factors for Ebola infection and of the protective measures individuals may take to prevent infection is recommended by the World Health Organization . These measures include avoiding direct contact with infected people and regular hand washing using soap and water. Bushmeat , an important source of protein in the diet of some Africans, should be handled and prepared with appropriate protective clothing and thoroughly cooked before consumption. Some research suggests that an outbreak of Ebola disease in the wild animals used for consumption may result in a corresponding human outbreak. Since 2003, such animal outbreaks have been monitored to predict and prevent Ebola outbreaks in humans. If a person with Ebola disease dies, direct contact with the body should be avoided. Certain burial rituals , which may have included making various direct contacts with a dead body, require reformulation so that they consistently maintain a proper protective barrier between the dead body and the living. Social anthropologists may help find alternatives to traditional rules for burials. Transportation crews are instructed to follow a certain isolation procedure, should anyone exhibit symptoms resembling EVD. As of August 2014 [ update ] , the WHO does not consider travel bans to be useful in decreasing spread of the disease. In October 2014, the CDC defined four risk levels used to determine the level of 21-day monitoring for symptoms and restrictions on public activities. In the United States, the CDC recommends that restrictions on public activity, including travel restrictions, are not required for the following defined risk levels: having been in a country with widespread Ebola disease transmission and having no known exposure (low risk); or having been in that country more than 21 days ago (no risk) encounter with a person showing symptoms; but not within three feet of the person with Ebola without wearing PPE; and no direct contact with body fluids having had brief skin contact with a person showing symptoms of Ebola disease when the person was believed to be not very contagious (low risk) in countries without widespread Ebola disease transmission: direct contact with a person showing symptoms of the disease while wearing PPE (low risk) contact with a person with Ebola disease before the person was showing symptoms (no risk). The CDC recommends monitoring for the symptoms of Ebola disease for those both at "low risk" and at higher risk. In laboratories where diagnostic testing is carried out, biosafety level 4-equivalent containment is required. Laboratory researchers must be properly trained in BSL-4 practices and wear proper PPE. Isolation refers to separating those who are sick from those who are not. Quarantine refers to separating those who may have been exposed to a disease until they either show signs of the disease or are no longer at risk. Quarantine, also known as enforced isolation, is usually effective in decreasing spread. Governments often quarantine areas where the disease is occurring or individuals who may transmit the disease outside of an initial area. In the United States, the law allows quarantine of those infected with ebolaviruses. Contact tracing is considered important to contain an outbreak. It involves finding everyone who had close contact with infected individuals and monitoring them for signs of illness for 21 days. If any of these contacts comes down with the disease, they should be isolated, tested and treated. Then the process is repeated, tracing the contacts' contacts. As of 2019 [ update ] two treatments ( atoltivimab/maftivimab/odesivimab and ansuvimab ) are associated with improved outcomes. The U.S. Food and Drug Administration (FDA) advises people to be careful of advertisements making unverified or fraudulent claims of benefits supposedly gained from various anti-Ebola products. In October 2020, the U.S. Food and Drug Administration (FDA) approved atoltivimab/maftivimab/odesivimab with an indication for the treatment of infection caused by Zaire ebolavirus . Treatment is primarily supportive in nature. Early supportive care with rehydration and symptomatic treatment improves survival. Rehydration may be via the oral or intravenous route. These measures may include pain management , and treatment for nausea , fever , and anxiety . The World Health Organization (WHO) recommends avoiding aspirin or ibuprofen for pain management, due to the risk of bleeding associated with these medications. Blood products such as packed red blood cells , platelets , or fresh frozen plasma may also be used. Other regulators of coagulation have also been tried including heparin in an effort to prevent disseminated intravascular coagulation and clotting factors to decrease bleeding. Antimalarial medications and antibiotics are often used before the diagnosis is confirmed, though there is no evidence to suggest such treatment helps. Several experimental treatments are being studied . Where hospital care is not possible, the WHO's guidelines for home care have been relatively successful. Recommendations include using towels soaked in a bleach solution when moving infected people or bodies and also applying bleach on stains. It is also recommended that the caregivers wash hands with bleach solutions and cover their mouth and nose with a cloth. Intensive care is often used in the developed world. This may include maintaining blood volume and electrolytes (salts) balance as well as treating any bacterial infections that may develop. Dialysis may be needed for kidney failure , and extracorporeal membrane oxygenation may be used for lung dysfunction. Treatment is primarily supportive in nature. Early supportive care with rehydration and symptomatic treatment improves survival. Rehydration may be via the oral or intravenous route. These measures may include pain management , and treatment for nausea , fever , and anxiety . The World Health Organization (WHO) recommends avoiding aspirin or ibuprofen for pain management, due to the risk of bleeding associated with these medications. Blood products such as packed red blood cells , platelets , or fresh frozen plasma may also be used. Other regulators of coagulation have also been tried including heparin in an effort to prevent disseminated intravascular coagulation and clotting factors to decrease bleeding. Antimalarial medications and antibiotics are often used before the diagnosis is confirmed, though there is no evidence to suggest such treatment helps. Several experimental treatments are being studied . Where hospital care is not possible, the WHO's guidelines for home care have been relatively successful. Recommendations include using towels soaked in a bleach solution when moving infected people or bodies and also applying bleach on stains. It is also recommended that the caregivers wash hands with bleach solutions and cover their mouth and nose with a cloth. Intensive care is often used in the developed world. This may include maintaining blood volume and electrolytes (salts) balance as well as treating any bacterial infections that may develop. Dialysis may be needed for kidney failure , and extracorporeal membrane oxygenation may be used for lung dysfunction. EVD has a risk of death in those infected of between 25% and 90%. As of September 2014 [ update ] , the average risk of death among those infected is 50%. The highest risk of death was 90% in the 2002–2003 Republic of the Congo outbreak. Early admission significantly increases survival rates Death, if it occurs, follows typically six to sixteen days after symptoms appear and is often due to low blood pressure from fluid loss . Early supportive care to prevent dehydration may reduce the risk of death. If an infected person survives, recovery may be quick and complete. However, a large portion of survivors develop post-Ebola virus syndrome after the acute phase of the infection. Prolonged cases are often complicated by the occurrence of long-term problems, such as inflammation of the testicles , joint pains , fatigue, hearing loss, mood and sleep disturbances, muscular pain , abdominal pain, menstrual abnormalities , miscarriages , skin peeling , or hair loss . Inflammation and swelling of the uveal layer of the eye is the most common eye complication in survivors of Ebola virus disease. Eye symptoms, such as light sensitivity , excess tearing , and vision loss have been described. Ebola can stay in some body parts like the eyes, breasts, and testicles after infection. Sexual transmission after recovery has been suspected. If sexual transmission occurs following recovery it is believed to be a rare event. One case of a condition similar to meningitis has been reported many months after recovery, as of October 2015 [ update ] . If an infected person survives, recovery may be quick and complete. However, a large portion of survivors develop post-Ebola virus syndrome after the acute phase of the infection. Prolonged cases are often complicated by the occurrence of long-term problems, such as inflammation of the testicles , joint pains , fatigue, hearing loss, mood and sleep disturbances, muscular pain , abdominal pain, menstrual abnormalities , miscarriages , skin peeling , or hair loss . Inflammation and swelling of the uveal layer of the eye is the most common eye complication in survivors of Ebola virus disease. Eye symptoms, such as light sensitivity , excess tearing , and vision loss have been described. Ebola can stay in some body parts like the eyes, breasts, and testicles after infection. Sexual transmission after recovery has been suspected. If sexual transmission occurs following recovery it is believed to be a rare event. One case of a condition similar to meningitis has been reported many months after recovery, as of October 2015 [ update ] . The disease typically occurs in outbreaks in tropical regions of Sub-Saharan Africa . From 1976 (when it was first identified) through 2013, the WHO reported 2,387 confirmed cases with 1,590 overall fatalities. The largest outbreak to date was the Ebola virus epidemic in West Africa , which caused a large number of deaths in Guinea , Sierra Leone , and Liberia . The first known outbreak of EVD was identified only after the fact. It occurred between June and November 1976, in Nzara, South Sudan (then part of Sudan ), and was caused by Sudan virus (SUDV). The Sudan outbreak infected 284 people and killed 151. The first identifiable case in Sudan occurred on 27 June in a storekeeper in a cotton factory in Nzara , who was hospitalised on 30 June and died on 6 July. Although the WHO medical staff involved in the Sudan outbreak knew that they were dealing with a heretofore unknown disease, the actual "positive identification" process and the naming of the virus did not occur until some months later in Zaire . On 26 August 1976, the second outbreak of EVD began in Yambuku , a small rural village in Mongala District in northern Zaire (now known as the Democratic Republic of the Congo ). This outbreak was caused by EBOV, formerly designated Zaire ebolavirus , a different member of the genus Ebolavirus than in the first Sudan outbreak. The first person infected with the disease was the village school's headmaster Mabalo Lokela , who began displaying symptoms on 26 August 1976. Lokela had returned from a trip to Northern Zaire near the border of the Central African Republic , after visiting the Ebola River between 12 and 22 August. He was originally believed to have malaria and was given quinine . However, his symptoms continued to worsen, and he was admitted to Yambuku Mission Hospital on 5 September. Lokela died on 8 September 14 days after he began displaying symptoms. Soon after Lokela's death, others who had been in contact with him also died, and people in Yambuku began to panic. The country's Minister of Health and Zaire President Mobutu Sese Seko declared the entire region, including Yambuku and the country's capital, Kinshasa , a quarantine zone. No-one was permitted to enter or leave the area, and roads, waterways, and airfields were placed under martial law . Schools, businesses and social organisations were closed. The initial response was led by Congolese doctors, including Jean-Jacques Muyembe-Tamfum , one of the discoverers of Ebola. Muyembe took a blood sample from a Belgian nun; this sample would eventually be used by Peter Piot to identify the previously unknown Ebola virus. Muyembe was also the first scientist to come into direct contact with the disease and survive. Researchers from the Centers for Disease Control and Prevention (CDC), including Piot, co-discoverer of Ebola, later arrived to assess the effects of the outbreak, observing that "the whole region was in panic." Piot concluded that Belgian nuns had inadvertently started the epidemic by giving unnecessary vitamin injections to pregnant women without sterilizing the syringes and needles. The outbreak lasted 26 days and the quarantine lasted two weeks. Researchers speculated that the disease disappeared due to the precautions taken by locals, the quarantine of the area, and discontinuing of the injections. During this outbreak, Ngoy Mushola recorded the first clinical description of EVD in Yambuku , where he wrote the following in his daily log: "The illness is characterised with a high temperature of about 39 °C (102 °F) , haematemesis , diarrhoea with blood, retrosternal abdominal pain, prostration with 'heavy' articulations, and rapid evolution death after a mean of three days." The virus responsible for the initial outbreak, first thought to be the Marburg virus , was later identified as a new type of virus related to the genus Marburgvirus . Virus strain samples isolated from both outbreaks were named "Ebola virus" after the Ebola River , near the first-identified viral outbreak site in Zaire. Reports conflict about who initially coined the name: either Karl Johnson of the American CDC team or Belgian researchers. Subsequently, a number of other cases were reported, almost all centred on the Yambuku mission hospital or close contacts of another case. In all, 318 cases and 280 deaths (an 88% fatality rate) occurred in Zaire. Although the two outbreaks were at first believed connected, scientists later realised that they were caused by two distinct ebolaviruses, SUDV and EBOV. The second major outbreak occurred in Zaire (now the Democratic Republic of the Congo , DRC), in 1995, affecting 315 and killing 254. In 2000, Uganda had an outbreak infecting 425 and killing 224; in this case, the Sudan virus was found to be the Ebola species responsible for the outbreak. In 2003, an outbreak in the DRC infected 143 and killed 128, a 90% death rate, the highest of a genus Ebolavirus outbreak to date. In 2004, a Russian scientist died from Ebola after sticking herself with an infected needle. Between April and August 2007, a fever epidemic in a four-village region of the DRC was confirmed in September to have been cases of Ebola. Many people who attended the recent funeral of a local village chief died. The 2007 outbreak eventually infected 264 individuals and killed 187. On 30 November 2007, the Uganda Ministry of Health confirmed an outbreak of Ebola in the Bundibugyo District in Western Uganda. After confirming samples tested by the United States National Reference Laboratories and the Centers for Disease Control, the World Health Organization (WHO) confirmed the presence of a new species of genus Ebolavirus , which was tentatively named Bundibugyo. The WHO reported 149 cases of this new strain and 37 of those led to deaths. The WHO confirmed two small outbreaks in Uganda in 2012, both caused by the Sudan variant. The first outbreak affected seven people, killing four, and the second affected 24, killing 17. On 17 August 2012, the Ministry of Health of the DRC reported an outbreak of the Ebola-Bundibugyo variant in the eastern region. Other than its discovery in 2007, this was the only time that this variant has been identified as responsible for an outbreak. The WHO revealed that the virus had sickened 57 people and killed 29. The probable cause of the outbreak was tainted bush meat hunted by local villagers around the towns of Isiro and Viadana. In 2014, an outbreak occurred in the DRC. Genome-sequencing showed that this outbreak was not related to the 2014–15 West Africa Ebola virus outbreak , but was the same EBOV species, the Zaire species. It began in August 2014, and was declared over in November with 66 cases and 49 deaths. This was the 7th outbreak in the DRC, three of which occurred during the period when the country was known as Zaire . In March 2014, the World Health Organization (WHO) reported a major Ebola outbreak in Guinea , a West African nation. Researchers traced the outbreak to a one-year-old child who died in December 2013. The disease rapidly spread to the neighbouring countries of Liberia and Sierra Leone . It was the largest Ebola outbreak ever documented, and the first recorded in the region. On 8 August 2014, the WHO declared the epidemic an international public health emergency. Urging the world to offer aid to the affected regions, its Director-General said, "Countries affected to date simply do not have the capacity to manage an outbreak of this size and complexity on their own. I urge the international community to provide this support on the most urgent basis possible." By mid-August 2014, Doctors Without Borders reported the situation in Liberia's capital, Monrovia , was "catastrophic" and "deteriorating daily". They reported that fears of Ebola among staff members and patients had shut down much of the city's health system, leaving many people without medical treatment for other conditions. In a 26 September statement, WHO said, "The Ebola epidemic ravaging parts of West Africa is the most severe acute public health emergency seen in modern times. Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over such a broad geographical area, for so long." Intense contact tracing and strict isolation largely prevented further spread of the disease in the countries that had imported cases. It caused significant mortality, with a considerable case fatality rate . [note 1] By the end of the epidemic, 28,616 people had been infected; of these, 11,310 had died, for a case-fatality rate of 40%. As of 8 May 2016 [ update ] , 28,646 suspected cases and 11,323 deaths were reported; however, the WHO said that these numbers may be underestimated. Because they work closely with the body fluids of infected patients, healthcare workers were especially vulnerable to infection; in August 2014, the WHO reported that 10% of the dead were healthcare workers. In September 2014, it was estimated that the countries' capacity for treating Ebola patients was insufficient by the equivalent of 2,122 beds; by December there were a sufficient number of beds to treat and isolate all reported Ebola cases, although the uneven distribution of cases was causing serious shortfalls in some areas. On 28 January 2015, the WHO reported that for the first time since the week ending 29 June 2014, there had been fewer than 100 new confirmed cases reported in a week in the three most-affected countries. The response to the epidemic then moved to a second phase, as the focus shifted from slowing transmission to ending the epidemic. On 8 April 2015, the WHO reported only 30 confirmed cases, the lowest weekly total since the third week of May 2014. On 29 December 2015, 42 days after the last person tested negative for a second time, Guinea was declared free of Ebola transmission. At that time, a 90-day period of heightened surveillance was announced by that agency. "This is the first time that all three countries – Guinea, Liberia and Sierra Leone – have stopped the original chains of transmission ...", the organisation stated in a news release. A new case was detected in Sierra Leone on 14 January 2016. However, the outbreak was declared no longer an emergency on 29 March 2016. On 19 September, Eric Duncan flew from his native Liberia to Texas; five days later he began showing symptoms and visited a hospital but was sent home. His condition worsened and he returned to the hospital on 28 September, where he died on 8 October. Health officials confirmed a diagnosis of Ebola on 30 September – the first case in the United States. In early October, Teresa Romero, a 44-year-old Spanish nurse, contracted Ebola after caring for a priest who had been repatriated from West Africa. This was the first transmission of the virus to occur outside Africa. Romero tested negative for the disease on 20 October, suggesting that she may have recovered from Ebola infection. On 12 October, the Centers for Disease Control and Prevention (CDC) confirmed that a nurse in Texas, Nina Pham , who had treated Duncan tested positive for the Ebola virus, the first known case of transmission in the United States. On 15 October, a second Texas health-care worker who had treated Duncan was confirmed to have the virus. Both of these people recovered. An unrelated case involved a doctor in New York City, who returned to the United States from Guinea after working with Médecins Sans Frontières and tested positive for Ebola on 23 October. The person recovered and was discharged from Bellevue Hospital on 11 November. On 24 December 2014, a laboratory in Atlanta , Georgia reported that a technician had been exposed to Ebola. On 29 December 2014, Pauline Cafferkey , a British nurse who had just returned to Glasgow from Sierra Leone, was diagnosed with Ebola at Glasgow's Gartnavel General Hospital . After initial treatment in Glasgow, she was transferred by air to RAF Northolt , then to the specialist high-level isolation unit at the Royal Free Hospital in London for longer-term treatment. On 11 May 2017, the DRC Ministry of Public Health notified the WHO about an outbreak of Ebola. Four people died, and four people survived; five of these eight cases were laboratory-confirmed. A total of 583 contacts were monitored. On 2 July 2017, the WHO declared the end of the outbreak. On 14 May 2018, the World Health Organization reported that "the Democratic Republic of Congo reported 39 suspected, probable or confirmed cases of Ebola between 4 April and 13 May, including 19 deaths." Some 393 people identified as contacts of Ebola patients were being followed up. The outbreak centred on the Bikoro , Iboko, and Wangata areas in Equateur province, including in the large city of Mbandaka . The DRC Ministry of Public Health approved the use of an experimental vaccine. On 13 May 2018, WHO Director-General Tedros Adhanom Ghebreyesus visited Bikoro. Reports emerged that maps of the area were inaccurate, not so much hampering medical providers as epidemiologists and officials trying to assess the outbreak and containment efforts. The 2018 outbreak in the DRC was declared over on 24 July 2018. On 1 August 2018, the world's 10th Ebola outbreak was declared in North Kivu province of the Democratic Republic of the Congo. It was the first Ebola outbreak in a military conflict zone, with thousands of refugees in the area. By November 2018, nearly 200 Congolese had died of Ebola, about half of them from the city of Beni , where armed groups are fighting over the region's mineral wealth, impeding medical relief efforts. By March 2019, this became the second largest Ebola outbreak ever recorded, with more than 1,000 cases and insecurity continuing to be the major resistance to providing an adequate response. As of 4 June 2019 [ update ] , the WHO reported 2025 confirmed and probable cases with 1357 deaths. In June 2019, two people died of Ebola in neighbouring Uganda . In July 2019, an infected man travelled to Goma , home to more than two million people. One week later, on 17 July 2019, the WHO declared the Ebola outbreak a global health emergency , the fifth time such a declaration has been made by the organisation. A government spokesman said that half of the Ebola cases are unidentified, and he added that the current outbreak could last up to three years. On 25 June 2020, the second biggest EVD outbreak ever was declared over. On 1 June 2020, the Congolese health ministry announced a new DRC outbreak of Ebola in Mbandaka , Équateur Province , a region along the Congo River. Genome sequencing suggests that this outbreak, the 11th outbreak since the virus was first discovered in the country in 1976, is unrelated to the one in North Kivu Province or the previous outbreak in the same area in 2018. It was reported that six cases had been identified; four of the people had died. It is expected that more people will be identified as surveillance activities increase. By 15 June the case count had increased to 17 with 11 deaths, with more than 2,500 people having been vaccinated. The 11th EVD outbreak was officially declared over on 19 November 2020. By the time the Équateur outbreak ended, it had 130 confirmed cases with 75 recoveries and 55 deaths. On 7 February 2021, the Congolese health ministry announced a new case of Ebola near Butembo, North Kivu detected a day before. The case was a 42-year-old woman who had symptoms of Ebola in Biena on 1 February 2021. A few days after, she died in a hospital in Butembo. The WHO said that more than 70 people with contact with the woman had been tracked. On 11 February 2021, another woman who had contact with the previous woman died in the same town, and the number of traced contacts increased to 100. A day after, a third case was detected in Butembo. On 3 May 2021, the 12th EVD outbreak was declared over, resulting in 12 cases and six deaths. Heightened surveillance will continue for 90 days after the declaration, in case of resurgence. In February 2021, Sakoba Keita, head of Guinea's national health agency confirmed that three people had died of Ebola in the south-eastern region near the city of Nzérékoré. A further five people also tested positive. Keita also confirmed more testing was underway, and attempts to trace and isolate further cases had begun. On 14 February, the Guinean government declared an Ebola epidemic. The outbreak may have started following reactivation of a latent case in a survivor of an earlier outbreak. As of 4 May 2021, 23 cases were reported, with no new cases or deaths since 3 April 2021. A 42-day countdown period was started on 8 May 2021, and on 19 June, the outbreak was declared over. On 14 August 2021, The Ministry of Health of Cote d'Ivoire confirmed the country's first case of Ebola since 1994. This came after the Institut Pasteur in Cote d'Ivoire confirmed the Ebola Virus Disease in samples collected from a patient, who was hospitalized in the commercial capital of Abidjan , after arriving from Guinea. However, on 31 August 2021, the WHO found that, after further tests in a laboratory in Lyon , the patient did not have Ebola. The cause of her disease is still being analyzed. On 23 April 2022, a case of Ebola was confirmed in the DRC in the Equateur province. The case was a 31-year-old man whose symptoms began on 5 April, but did not seek treatment for over a week. On 21 April, he was admitted to an Ebola treatment centre and died later that day. By 24 May 2022, there were 5 recorded deaths in the DRC. On 15 August, the fifth case was buried, and the outbreak was declared over, 42 days after, on 4 July 2022. In September 2022, Uganda reported 7 cases infected with the Ebola Sudan strain , but by mid-October the count had increased to 63. In November 2022, the outbreak in Uganda continued - still without a vaccine. On 10 January 2023, the outbreak was considered over after no new cases had been reported for 42 days; the outbreak killed nearly 80 people. The first known outbreak of EVD was identified only after the fact. It occurred between June and November 1976, in Nzara, South Sudan (then part of Sudan ), and was caused by Sudan virus (SUDV). The Sudan outbreak infected 284 people and killed 151. The first identifiable case in Sudan occurred on 27 June in a storekeeper in a cotton factory in Nzara , who was hospitalised on 30 June and died on 6 July. Although the WHO medical staff involved in the Sudan outbreak knew that they were dealing with a heretofore unknown disease, the actual "positive identification" process and the naming of the virus did not occur until some months later in Zaire . On 26 August 1976, the second outbreak of EVD began in Yambuku , a small rural village in Mongala District in northern Zaire (now known as the Democratic Republic of the Congo ). This outbreak was caused by EBOV, formerly designated Zaire ebolavirus , a different member of the genus Ebolavirus than in the first Sudan outbreak. The first person infected with the disease was the village school's headmaster Mabalo Lokela , who began displaying symptoms on 26 August 1976. Lokela had returned from a trip to Northern Zaire near the border of the Central African Republic , after visiting the Ebola River between 12 and 22 August. He was originally believed to have malaria and was given quinine . However, his symptoms continued to worsen, and he was admitted to Yambuku Mission Hospital on 5 September. Lokela died on 8 September 14 days after he began displaying symptoms. Soon after Lokela's death, others who had been in contact with him also died, and people in Yambuku began to panic. The country's Minister of Health and Zaire President Mobutu Sese Seko declared the entire region, including Yambuku and the country's capital, Kinshasa , a quarantine zone. No-one was permitted to enter or leave the area, and roads, waterways, and airfields were placed under martial law . Schools, businesses and social organisations were closed. The initial response was led by Congolese doctors, including Jean-Jacques Muyembe-Tamfum , one of the discoverers of Ebola. Muyembe took a blood sample from a Belgian nun; this sample would eventually be used by Peter Piot to identify the previously unknown Ebola virus. Muyembe was also the first scientist to come into direct contact with the disease and survive. Researchers from the Centers for Disease Control and Prevention (CDC), including Piot, co-discoverer of Ebola, later arrived to assess the effects of the outbreak, observing that "the whole region was in panic." Piot concluded that Belgian nuns had inadvertently started the epidemic by giving unnecessary vitamin injections to pregnant women without sterilizing the syringes and needles. The outbreak lasted 26 days and the quarantine lasted two weeks. Researchers speculated that the disease disappeared due to the precautions taken by locals, the quarantine of the area, and discontinuing of the injections. During this outbreak, Ngoy Mushola recorded the first clinical description of EVD in Yambuku , where he wrote the following in his daily log: "The illness is characterised with a high temperature of about 39 °C (102 °F) , haematemesis , diarrhoea with blood, retrosternal abdominal pain, prostration with 'heavy' articulations, and rapid evolution death after a mean of three days." The virus responsible for the initial outbreak, first thought to be the Marburg virus , was later identified as a new type of virus related to the genus Marburgvirus . Virus strain samples isolated from both outbreaks were named "Ebola virus" after the Ebola River , near the first-identified viral outbreak site in Zaire. Reports conflict about who initially coined the name: either Karl Johnson of the American CDC team or Belgian researchers. Subsequently, a number of other cases were reported, almost all centred on the Yambuku mission hospital or close contacts of another case. In all, 318 cases and 280 deaths (an 88% fatality rate) occurred in Zaire. Although the two outbreaks were at first believed connected, scientists later realised that they were caused by two distinct ebolaviruses, SUDV and EBOV. The first known outbreak of EVD was identified only after the fact. It occurred between June and November 1976, in Nzara, South Sudan (then part of Sudan ), and was caused by Sudan virus (SUDV). The Sudan outbreak infected 284 people and killed 151. The first identifiable case in Sudan occurred on 27 June in a storekeeper in a cotton factory in Nzara , who was hospitalised on 30 June and died on 6 July. Although the WHO medical staff involved in the Sudan outbreak knew that they were dealing with a heretofore unknown disease, the actual "positive identification" process and the naming of the virus did not occur until some months later in Zaire . On 26 August 1976, the second outbreak of EVD began in Yambuku , a small rural village in Mongala District in northern Zaire (now known as the Democratic Republic of the Congo ). This outbreak was caused by EBOV, formerly designated Zaire ebolavirus , a different member of the genus Ebolavirus than in the first Sudan outbreak. The first person infected with the disease was the village school's headmaster Mabalo Lokela , who began displaying symptoms on 26 August 1976. Lokela had returned from a trip to Northern Zaire near the border of the Central African Republic , after visiting the Ebola River between 12 and 22 August. He was originally believed to have malaria and was given quinine . However, his symptoms continued to worsen, and he was admitted to Yambuku Mission Hospital on 5 September. Lokela died on 8 September 14 days after he began displaying symptoms. Soon after Lokela's death, others who had been in contact with him also died, and people in Yambuku began to panic. The country's Minister of Health and Zaire President Mobutu Sese Seko declared the entire region, including Yambuku and the country's capital, Kinshasa , a quarantine zone. No-one was permitted to enter or leave the area, and roads, waterways, and airfields were placed under martial law . Schools, businesses and social organisations were closed. The initial response was led by Congolese doctors, including Jean-Jacques Muyembe-Tamfum , one of the discoverers of Ebola. Muyembe took a blood sample from a Belgian nun; this sample would eventually be used by Peter Piot to identify the previously unknown Ebola virus. Muyembe was also the first scientist to come into direct contact with the disease and survive. Researchers from the Centers for Disease Control and Prevention (CDC), including Piot, co-discoverer of Ebola, later arrived to assess the effects of the outbreak, observing that "the whole region was in panic." Piot concluded that Belgian nuns had inadvertently started the epidemic by giving unnecessary vitamin injections to pregnant women without sterilizing the syringes and needles. The outbreak lasted 26 days and the quarantine lasted two weeks. Researchers speculated that the disease disappeared due to the precautions taken by locals, the quarantine of the area, and discontinuing of the injections. During this outbreak, Ngoy Mushola recorded the first clinical description of EVD in Yambuku , where he wrote the following in his daily log: "The illness is characterised with a high temperature of about 39 °C (102 °F) , haematemesis , diarrhoea with blood, retrosternal abdominal pain, prostration with 'heavy' articulations, and rapid evolution death after a mean of three days." The virus responsible for the initial outbreak, first thought to be the Marburg virus , was later identified as a new type of virus related to the genus Marburgvirus . Virus strain samples isolated from both outbreaks were named "Ebola virus" after the Ebola River , near the first-identified viral outbreak site in Zaire. Reports conflict about who initially coined the name: either Karl Johnson of the American CDC team or Belgian researchers. Subsequently, a number of other cases were reported, almost all centred on the Yambuku mission hospital or close contacts of another case. In all, 318 cases and 280 deaths (an 88% fatality rate) occurred in Zaire. Although the two outbreaks were at first believed connected, scientists later realised that they were caused by two distinct ebolaviruses, SUDV and EBOV. The second major outbreak occurred in Zaire (now the Democratic Republic of the Congo , DRC), in 1995, affecting 315 and killing 254. In 2000, Uganda had an outbreak infecting 425 and killing 224; in this case, the Sudan virus was found to be the Ebola species responsible for the outbreak. In 2003, an outbreak in the DRC infected 143 and killed 128, a 90% death rate, the highest of a genus Ebolavirus outbreak to date. In 2004, a Russian scientist died from Ebola after sticking herself with an infected needle. Between April and August 2007, a fever epidemic in a four-village region of the DRC was confirmed in September to have been cases of Ebola. Many people who attended the recent funeral of a local village chief died. The 2007 outbreak eventually infected 264 individuals and killed 187. On 30 November 2007, the Uganda Ministry of Health confirmed an outbreak of Ebola in the Bundibugyo District in Western Uganda. After confirming samples tested by the United States National Reference Laboratories and the Centers for Disease Control, the World Health Organization (WHO) confirmed the presence of a new species of genus Ebolavirus , which was tentatively named Bundibugyo. The WHO reported 149 cases of this new strain and 37 of those led to deaths. The WHO confirmed two small outbreaks in Uganda in 2012, both caused by the Sudan variant. The first outbreak affected seven people, killing four, and the second affected 24, killing 17. On 17 August 2012, the Ministry of Health of the DRC reported an outbreak of the Ebola-Bundibugyo variant in the eastern region. Other than its discovery in 2007, this was the only time that this variant has been identified as responsible for an outbreak. The WHO revealed that the virus had sickened 57 people and killed 29. The probable cause of the outbreak was tainted bush meat hunted by local villagers around the towns of Isiro and Viadana. In 2014, an outbreak occurred in the DRC. Genome-sequencing showed that this outbreak was not related to the 2014–15 West Africa Ebola virus outbreak , but was the same EBOV species, the Zaire species. It began in August 2014, and was declared over in November with 66 cases and 49 deaths. This was the 7th outbreak in the DRC, three of which occurred during the period when the country was known as Zaire . In March 2014, the World Health Organization (WHO) reported a major Ebola outbreak in Guinea , a West African nation. Researchers traced the outbreak to a one-year-old child who died in December 2013. The disease rapidly spread to the neighbouring countries of Liberia and Sierra Leone . It was the largest Ebola outbreak ever documented, and the first recorded in the region. On 8 August 2014, the WHO declared the epidemic an international public health emergency. Urging the world to offer aid to the affected regions, its Director-General said, "Countries affected to date simply do not have the capacity to manage an outbreak of this size and complexity on their own. I urge the international community to provide this support on the most urgent basis possible." By mid-August 2014, Doctors Without Borders reported the situation in Liberia's capital, Monrovia , was "catastrophic" and "deteriorating daily". They reported that fears of Ebola among staff members and patients had shut down much of the city's health system, leaving many people without medical treatment for other conditions. In a 26 September statement, WHO said, "The Ebola epidemic ravaging parts of West Africa is the most severe acute public health emergency seen in modern times. Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over such a broad geographical area, for so long." Intense contact tracing and strict isolation largely prevented further spread of the disease in the countries that had imported cases. It caused significant mortality, with a considerable case fatality rate . [note 1] By the end of the epidemic, 28,616 people had been infected; of these, 11,310 had died, for a case-fatality rate of 40%. As of 8 May 2016 [ update ] , 28,646 suspected cases and 11,323 deaths were reported; however, the WHO said that these numbers may be underestimated. Because they work closely with the body fluids of infected patients, healthcare workers were especially vulnerable to infection; in August 2014, the WHO reported that 10% of the dead were healthcare workers. In September 2014, it was estimated that the countries' capacity for treating Ebola patients was insufficient by the equivalent of 2,122 beds; by December there were a sufficient number of beds to treat and isolate all reported Ebola cases, although the uneven distribution of cases was causing serious shortfalls in some areas. On 28 January 2015, the WHO reported that for the first time since the week ending 29 June 2014, there had been fewer than 100 new confirmed cases reported in a week in the three most-affected countries. The response to the epidemic then moved to a second phase, as the focus shifted from slowing transmission to ending the epidemic. On 8 April 2015, the WHO reported only 30 confirmed cases, the lowest weekly total since the third week of May 2014. On 29 December 2015, 42 days after the last person tested negative for a second time, Guinea was declared free of Ebola transmission. At that time, a 90-day period of heightened surveillance was announced by that agency. "This is the first time that all three countries – Guinea, Liberia and Sierra Leone – have stopped the original chains of transmission ...", the organisation stated in a news release. A new case was detected in Sierra Leone on 14 January 2016. However, the outbreak was declared no longer an emergency on 29 March 2016. On 19 September, Eric Duncan flew from his native Liberia to Texas; five days later he began showing symptoms and visited a hospital but was sent home. His condition worsened and he returned to the hospital on 28 September, where he died on 8 October. Health officials confirmed a diagnosis of Ebola on 30 September – the first case in the United States. In early October, Teresa Romero, a 44-year-old Spanish nurse, contracted Ebola after caring for a priest who had been repatriated from West Africa. This was the first transmission of the virus to occur outside Africa. Romero tested negative for the disease on 20 October, suggesting that she may have recovered from Ebola infection. On 12 October, the Centers for Disease Control and Prevention (CDC) confirmed that a nurse in Texas, Nina Pham , who had treated Duncan tested positive for the Ebola virus, the first known case of transmission in the United States. On 15 October, a second Texas health-care worker who had treated Duncan was confirmed to have the virus. Both of these people recovered. An unrelated case involved a doctor in New York City, who returned to the United States from Guinea after working with Médecins Sans Frontières and tested positive for Ebola on 23 October. The person recovered and was discharged from Bellevue Hospital on 11 November. On 24 December 2014, a laboratory in Atlanta , Georgia reported that a technician had been exposed to Ebola. On 29 December 2014, Pauline Cafferkey , a British nurse who had just returned to Glasgow from Sierra Leone, was diagnosed with Ebola at Glasgow's Gartnavel General Hospital . After initial treatment in Glasgow, she was transferred by air to RAF Northolt , then to the specialist high-level isolation unit at the Royal Free Hospital in London for longer-term treatment. On 19 September, Eric Duncan flew from his native Liberia to Texas; five days later he began showing symptoms and visited a hospital but was sent home. His condition worsened and he returned to the hospital on 28 September, where he died on 8 October. Health officials confirmed a diagnosis of Ebola on 30 September – the first case in the United States. In early October, Teresa Romero, a 44-year-old Spanish nurse, contracted Ebola after caring for a priest who had been repatriated from West Africa. This was the first transmission of the virus to occur outside Africa. Romero tested negative for the disease on 20 October, suggesting that she may have recovered from Ebola infection. On 12 October, the Centers for Disease Control and Prevention (CDC) confirmed that a nurse in Texas, Nina Pham , who had treated Duncan tested positive for the Ebola virus, the first known case of transmission in the United States. On 15 October, a second Texas health-care worker who had treated Duncan was confirmed to have the virus. Both of these people recovered. An unrelated case involved a doctor in New York City, who returned to the United States from Guinea after working with Médecins Sans Frontières and tested positive for Ebola on 23 October. The person recovered and was discharged from Bellevue Hospital on 11 November. On 24 December 2014, a laboratory in Atlanta , Georgia reported that a technician had been exposed to Ebola. On 29 December 2014, Pauline Cafferkey , a British nurse who had just returned to Glasgow from Sierra Leone, was diagnosed with Ebola at Glasgow's Gartnavel General Hospital . After initial treatment in Glasgow, she was transferred by air to RAF Northolt , then to the specialist high-level isolation unit at the Royal Free Hospital in London for longer-term treatment. On 11 May 2017, the DRC Ministry of Public Health notified the WHO about an outbreak of Ebola. Four people died, and four people survived; five of these eight cases were laboratory-confirmed. A total of 583 contacts were monitored. On 2 July 2017, the WHO declared the end of the outbreak. On 14 May 2018, the World Health Organization reported that "the Democratic Republic of Congo reported 39 suspected, probable or confirmed cases of Ebola between 4 April and 13 May, including 19 deaths." Some 393 people identified as contacts of Ebola patients were being followed up. The outbreak centred on the Bikoro , Iboko, and Wangata areas in Equateur province, including in the large city of Mbandaka . The DRC Ministry of Public Health approved the use of an experimental vaccine. On 13 May 2018, WHO Director-General Tedros Adhanom Ghebreyesus visited Bikoro. Reports emerged that maps of the area were inaccurate, not so much hampering medical providers as epidemiologists and officials trying to assess the outbreak and containment efforts. The 2018 outbreak in the DRC was declared over on 24 July 2018. On 1 August 2018, the world's 10th Ebola outbreak was declared in North Kivu province of the Democratic Republic of the Congo. It was the first Ebola outbreak in a military conflict zone, with thousands of refugees in the area. By November 2018, nearly 200 Congolese had died of Ebola, about half of them from the city of Beni , where armed groups are fighting over the region's mineral wealth, impeding medical relief efforts. By March 2019, this became the second largest Ebola outbreak ever recorded, with more than 1,000 cases and insecurity continuing to be the major resistance to providing an adequate response. As of 4 June 2019 [ update ] , the WHO reported 2025 confirmed and probable cases with 1357 deaths. In June 2019, two people died of Ebola in neighbouring Uganda . In July 2019, an infected man travelled to Goma , home to more than two million people. One week later, on 17 July 2019, the WHO declared the Ebola outbreak a global health emergency , the fifth time such a declaration has been made by the organisation. A government spokesman said that half of the Ebola cases are unidentified, and he added that the current outbreak could last up to three years. On 25 June 2020, the second biggest EVD outbreak ever was declared over. On 1 June 2020, the Congolese health ministry announced a new DRC outbreak of Ebola in Mbandaka , Équateur Province , a region along the Congo River. Genome sequencing suggests that this outbreak, the 11th outbreak since the virus was first discovered in the country in 1976, is unrelated to the one in North Kivu Province or the previous outbreak in the same area in 2018. It was reported that six cases had been identified; four of the people had died. It is expected that more people will be identified as surveillance activities increase. By 15 June the case count had increased to 17 with 11 deaths, with more than 2,500 people having been vaccinated. The 11th EVD outbreak was officially declared over on 19 November 2020. By the time the Équateur outbreak ended, it had 130 confirmed cases with 75 recoveries and 55 deaths.On 7 February 2021, the Congolese health ministry announced a new case of Ebola near Butembo, North Kivu detected a day before. The case was a 42-year-old woman who had symptoms of Ebola in Biena on 1 February 2021. A few days after, she died in a hospital in Butembo. The WHO said that more than 70 people with contact with the woman had been tracked. On 11 February 2021, another woman who had contact with the previous woman died in the same town, and the number of traced contacts increased to 100. A day after, a third case was detected in Butembo. On 3 May 2021, the 12th EVD outbreak was declared over, resulting in 12 cases and six deaths. Heightened surveillance will continue for 90 days after the declaration, in case of resurgence. In February 2021, Sakoba Keita, head of Guinea's national health agency confirmed that three people had died of Ebola in the south-eastern region near the city of Nzérékoré. A further five people also tested positive. Keita also confirmed more testing was underway, and attempts to trace and isolate further cases had begun. On 14 February, the Guinean government declared an Ebola epidemic. The outbreak may have started following reactivation of a latent case in a survivor of an earlier outbreak. As of 4 May 2021, 23 cases were reported, with no new cases or deaths since 3 April 2021. A 42-day countdown period was started on 8 May 2021, and on 19 June, the outbreak was declared over. On 14 August 2021, The Ministry of Health of Cote d'Ivoire confirmed the country's first case of Ebola since 1994. This came after the Institut Pasteur in Cote d'Ivoire confirmed the Ebola Virus Disease in samples collected from a patient, who was hospitalized in the commercial capital of Abidjan , after arriving from Guinea. However, on 31 August 2021, the WHO found that, after further tests in a laboratory in Lyon , the patient did not have Ebola. The cause of her disease is still being analyzed. On 7 February 2021, the Congolese health ministry announced a new case of Ebola near Butembo, North Kivu detected a day before. The case was a 42-year-old woman who had symptoms of Ebola in Biena on 1 February 2021. A few days after, she died in a hospital in Butembo. The WHO said that more than 70 people with contact with the woman had been tracked. On 11 February 2021, another woman who had contact with the previous woman died in the same town, and the number of traced contacts increased to 100. A day after, a third case was detected in Butembo. On 3 May 2021, the 12th EVD outbreak was declared over, resulting in 12 cases and six deaths. Heightened surveillance will continue for 90 days after the declaration, in case of resurgence. In February 2021, Sakoba Keita, head of Guinea's national health agency confirmed that three people had died of Ebola in the south-eastern region near the city of Nzérékoré. A further five people also tested positive. Keita also confirmed more testing was underway, and attempts to trace and isolate further cases had begun. On 14 February, the Guinean government declared an Ebola epidemic. The outbreak may have started following reactivation of a latent case in a survivor of an earlier outbreak. As of 4 May 2021, 23 cases were reported, with no new cases or deaths since 3 April 2021. A 42-day countdown period was started on 8 May 2021, and on 19 June, the outbreak was declared over. On 14 August 2021, The Ministry of Health of Cote d'Ivoire confirmed the country's first case of Ebola since 1994. This came after the Institut Pasteur in Cote d'Ivoire confirmed the Ebola Virus Disease in samples collected from a patient, who was hospitalized in the commercial capital of Abidjan , after arriving from Guinea. However, on 31 August 2021, the WHO found that, after further tests in a laboratory in Lyon , the patient did not have Ebola. The cause of her disease is still being analyzed. On 23 April 2022, a case of Ebola was confirmed in the DRC in the Equateur province. The case was a 31-year-old man whose symptoms began on 5 April, but did not seek treatment for over a week. On 21 April, he was admitted to an Ebola treatment centre and died later that day. By 24 May 2022, there were 5 recorded deaths in the DRC. On 15 August, the fifth case was buried, and the outbreak was declared over, 42 days after, on 4 July 2022. In September 2022, Uganda reported 7 cases infected with the Ebola Sudan strain , but by mid-October the count had increased to 63. In November 2022, the outbreak in Uganda continued - still without a vaccine. On 10 January 2023, the outbreak was considered over after no new cases had been reported for 42 days; the outbreak killed nearly 80 people. Ebolavirus is classified as a biosafety level 4 agent, as well as a Category A bioterrorism agent by the Centers for Disease Control and Prevention. It has the potential to be weaponised for use in biological warfare , and was investigated by Biopreparat for such use, but might be difficult to prepare as a weapon of mass destruction because the virus becomes ineffective quickly in open air. Fake emails pretending to be Ebola information from the WHO or the Mexican government have, in 2014, been misused to spread computer malware. The BBC reported in 2015 that "North Korean state media has suggested the disease was created by the U.S. military as a biological weapon." Richard Preston 's 1995 best-selling book, The Hot Zone , dramatised the Ebola outbreak in Reston, Virginia. William Close 's 1995 Ebola: A Documentary Novel of Its First Explosion and 2002 Ebola: Through the Eyes of the People focused on individuals' reactions to the 1976 Ebola outbreak in Zaire. Tom Clancy 's 1996 novel, Executive Orders , involves a Middle Eastern terrorist attack on the United States using an airborne form of a deadly Ebola virus strain named "Ebola Mayinga" (see Mayinga N'Seka ). As the Ebola virus epidemic in West Africa developed in 2014, a number of popular self-published and well-reviewed books containing sensational and misleading information about the disease appeared in electronic and printed formats. The authors of some such books admitted that they lacked medical credentials and were not technically qualified to give medical advice. The World Health Organization and the United Nations stated that such misinformation had contributed to the spread of the disease. Ebolavirus is classified as a biosafety level 4 agent, as well as a Category A bioterrorism agent by the Centers for Disease Control and Prevention. It has the potential to be weaponised for use in biological warfare , and was investigated by Biopreparat for such use, but might be difficult to prepare as a weapon of mass destruction because the virus becomes ineffective quickly in open air. Fake emails pretending to be Ebola information from the WHO or the Mexican government have, in 2014, been misused to spread computer malware. The BBC reported in 2015 that "North Korean state media has suggested the disease was created by the U.S. military as a biological weapon." Richard Preston 's 1995 best-selling book, The Hot Zone , dramatised the Ebola outbreak in Reston, Virginia. William Close 's 1995 Ebola: A Documentary Novel of Its First Explosion and 2002 Ebola: Through the Eyes of the People focused on individuals' reactions to the 1976 Ebola outbreak in Zaire. Tom Clancy 's 1996 novel, Executive Orders , involves a Middle Eastern terrorist attack on the United States using an airborne form of a deadly Ebola virus strain named "Ebola Mayinga" (see Mayinga N'Seka ). As the Ebola virus epidemic in West Africa developed in 2014, a number of popular self-published and well-reviewed books containing sensational and misleading information about the disease appeared in electronic and printed formats. The authors of some such books admitted that they lacked medical credentials and were not technically qualified to give medical advice. The World Health Organization and the United Nations stated that such misinformation had contributed to the spread of the disease. Ebola has a high mortality rate among primates. Frequent outbreaks of Ebola may have resulted in the deaths of 5,000 gorillas. Outbreaks of Ebola may have been responsible for an 88% decline in tracking indices of observed chimpanzee populations in the 420 km 2 Lossi Sanctuary between 2002 and 2003. Transmission among chimpanzees through meat consumption constitutes a significant risk factor, whereas contact between the animals, such as touching dead bodies and grooming, is not. Recovered gorilla carcasses have contained multiple Ebola virus strains, suggesting multiple introductions of the virus. Bodies decompose quickly and carcasses are not infectious after three to four days. Contact between gorilla groups is rare, suggesting that transmission among gorilla groups is unlikely, and that outbreaks result from transmission between viral reservoirs and animal populations. In 2012, it was demonstrated that the virus can travel without contact from pigs to nonhuman primates, although the same study failed to achieve transmission in that manner between primates. Dogs may become infected with EBOV but not develop symptoms. Dogs in some parts of Africa scavenge for food, and they sometimes eat EBOV-infected animals and also the corpses of humans. A 2005 survey of dogs during an EBOV outbreak found that although they remain asymptomatic, about 32 percent of dogs closest to an outbreak showed a seroprevalence for EBOV versus nine percent of those farther away. The authors concluded that there were "potential implications for preventing and controlling human outbreaks." In late 1989, Hazelton Research Products' Reston Quarantine Unit in Reston, Virginia , had an outbreak of fatal illness amongst certain lab monkeys. This lab outbreak was initially diagnosed as simian haemorrhagic fever virus (SHFV) and occurred amongst a shipment of crab-eating macaque monkeys imported from the Philippines. Hazelton's veterinary pathologist in Reston sent tissue samples from dead animals to the United States Army Medical Research Institute of Infectious Diseases (USAMRIID) at Fort Detrick, Maryland , where an ELISA test indicated the antibodies present in the tissue were a response to Ebola virus and not SHFV. An electron microscopist from USAMRIID discovered filoviruses similar in appearance, in crystalloid aggregates and as single filaments with a shepherd's hook, to Ebola in the tissue samples sent from Hazelton Research Products' Reston Quarantine Unit. A US Army team headquartered at USAMRIID euthanised the surviving monkeys, and brought all the dead monkeys to Fort Detrick for study by the Army's veterinary pathologists and virologists, and eventual disposal under safe conditions. Blood samples were taken from 178 animal handlers during the incident. Of those, six animal handlers eventually seroconverted , including one who had cut himself with a bloody scalpel. Despite its status as a Level‑4 organism and its apparent pathogenicity in monkeys, when the handlers did not become ill, the CDC concluded that the virus had a very low pathogenicity to humans. The Philippines and the United States had no previous cases of Ebola infection, and upon further isolation, researchers concluded it was another strain of Ebola, or a new filovirus of Asian origin, which they named Reston ebolavirus (RESTV) after the location of the incident. Reston virus (RESTV) can be transmitted to pigs. Since the initial outbreak it has since been found in nonhuman primates in Pennsylvania, Texas, and Italy, where the virus had infected pigs. According to the WHO, routine cleaning and disinfection of pig (or monkey) farms with sodium hypochlorite or detergents should be effective in inactivating the Reston ebolavirus . Pigs that have been infected with RESTV tend to show symptoms of the disease. Ebola has a high mortality rate among primates. Frequent outbreaks of Ebola may have resulted in the deaths of 5,000 gorillas. Outbreaks of Ebola may have been responsible for an 88% decline in tracking indices of observed chimpanzee populations in the 420 km 2 Lossi Sanctuary between 2002 and 2003. Transmission among chimpanzees through meat consumption constitutes a significant risk factor, whereas contact between the animals, such as touching dead bodies and grooming, is not. Recovered gorilla carcasses have contained multiple Ebola virus strains, suggesting multiple introductions of the virus. Bodies decompose quickly and carcasses are not infectious after three to four days. Contact between gorilla groups is rare, suggesting that transmission among gorilla groups is unlikely, and that outbreaks result from transmission between viral reservoirs and animal populations. In 2012, it was demonstrated that the virus can travel without contact from pigs to nonhuman primates, although the same study failed to achieve transmission in that manner between primates. Dogs may become infected with EBOV but not develop symptoms. Dogs in some parts of Africa scavenge for food, and they sometimes eat EBOV-infected animals and also the corpses of humans. A 2005 survey of dogs during an EBOV outbreak found that although they remain asymptomatic, about 32 percent of dogs closest to an outbreak showed a seroprevalence for EBOV versus nine percent of those farther away. The authors concluded that there were "potential implications for preventing and controlling human outbreaks."In late 1989, Hazelton Research Products' Reston Quarantine Unit in Reston, Virginia , had an outbreak of fatal illness amongst certain lab monkeys. This lab outbreak was initially diagnosed as simian haemorrhagic fever virus (SHFV) and occurred amongst a shipment of crab-eating macaque monkeys imported from the Philippines. Hazelton's veterinary pathologist in Reston sent tissue samples from dead animals to the United States Army Medical Research Institute of Infectious Diseases (USAMRIID) at Fort Detrick, Maryland , where an ELISA test indicated the antibodies present in the tissue were a response to Ebola virus and not SHFV. An electron microscopist from USAMRIID discovered filoviruses similar in appearance, in crystalloid aggregates and as single filaments with a shepherd's hook, to Ebola in the tissue samples sent from Hazelton Research Products' Reston Quarantine Unit. A US Army team headquartered at USAMRIID euthanised the surviving monkeys, and brought all the dead monkeys to Fort Detrick for study by the Army's veterinary pathologists and virologists, and eventual disposal under safe conditions. Blood samples were taken from 178 animal handlers during the incident. Of those, six animal handlers eventually seroconverted , including one who had cut himself with a bloody scalpel. Despite its status as a Level‑4 organism and its apparent pathogenicity in monkeys, when the handlers did not become ill, the CDC concluded that the virus had a very low pathogenicity to humans. The Philippines and the United States had no previous cases of Ebola infection, and upon further isolation, researchers concluded it was another strain of Ebola, or a new filovirus of Asian origin, which they named Reston ebolavirus (RESTV) after the location of the incident. Reston virus (RESTV) can be transmitted to pigs. Since the initial outbreak it has since been found in nonhuman primates in Pennsylvania, Texas, and Italy, where the virus had infected pigs. According to the WHO, routine cleaning and disinfection of pig (or monkey) farms with sodium hypochlorite or detergents should be effective in inactivating the Reston ebolavirus . Pigs that have been infected with RESTV tend to show symptoms of the disease. As of July 2015 [ update ] , no medication has been proven safe and effective for treating Ebola. By the time the Ebola virus epidemic in West Africa began in 2013, there were at least nine different candidate treatments. Several trials were conducted in late 2014, and early 2015, but some were abandoned due to lack of efficacy or lack of people to study. As of August 2019 [ update ] , two experimental treatments known as atoltivimab/maftivimab/odesivimab and ansuvimab were found to be 90% effective. The diagnostic tests currently available require specialised equipment and highly trained personnel. Since there are few suitable testing centres in West Africa, this leads to delay in diagnosis. On 29 November 2014, a new 15-minute Ebola test was reported that if successful, "not only gives patients a better chance of survival, but it prevents transmission of the virus to other people." The new equipment, about the size of a laptop and solar-powered, allows testing to be done in remote areas. On 29 December 2014, the U.S. Food and Drug Administration (FDA) approved the LightMix Ebola Zaire rRT-PCR test for patients with symptoms of Ebola. Animal models and in particular non-human primates are being used to study different aspects of Ebola virus disease. Developments in organ-on-a-chip technology have led to a chip-based model for Ebola haemorrhagic syndrome. As of July 2015 [ update ] , no medication has been proven safe and effective for treating Ebola. By the time the Ebola virus epidemic in West Africa began in 2013, there were at least nine different candidate treatments. Several trials were conducted in late 2014, and early 2015, but some were abandoned due to lack of efficacy or lack of people to study. As of August 2019 [ update ] , two experimental treatments known as atoltivimab/maftivimab/odesivimab and ansuvimab were found to be 90% effective. The diagnostic tests currently available require specialised equipment and highly trained personnel. Since there are few suitable testing centres in West Africa, this leads to delay in diagnosis. On 29 November 2014, a new 15-minute Ebola test was reported that if successful, "not only gives patients a better chance of survival, but it prevents transmission of the virus to other people." The new equipment, about the size of a laptop and solar-powered, allows testing to be done in remote areas. On 29 December 2014, the U.S. Food and Drug Administration (FDA) approved the LightMix Ebola Zaire rRT-PCR test for patients with symptoms of Ebola. Animal models and in particular non-human primates are being used to study different aspects of Ebola virus disease. Developments in organ-on-a-chip technology have led to a chip-based model for Ebola haemorrhagic syndrome.

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Western African Ebola virus epidemic

The 2013–2016 epidemic of Ebola virus disease , centered in Western Africa , was the most widespread outbreak of the disease in history . It caused major loss of life and socioeconomic disruption in the region, mainly in Guinea , Liberia and Sierra Leone . The first cases were recorded in Guinea in December 2013; later, the disease spread to neighbouring Liberia and Sierra Leone, with minor outbreaks occurring in Nigeria and Mali . Secondary infections of medical workers occurred in the United States and Spain . In addition, isolated cases were recorded in Senegal , the United Kingdom and Italy . The number of cases peaked in October 2014 and then began to decline gradually, following the commitment of substantial international resources. It caused significant mortality, with a considerable case fatality rate . [note 1] By the end of the epidemic, 28,616 people had been infected; of these, 11,310 had died, for a case-fatality rate of 40%. As of 8 May 2016 [ update ] , the World Health Organization (WHO) and respective governments reported a total of 28,646 suspected cases and 11,323 deaths (39.5%), though the WHO believes that this substantially understates the magnitude of the outbreak. On 8 August 2014, a Public Health Emergency of International Concern was declared and on 29 March 2016, the WHO terminated the Public Health Emergency of International Concern status of the outbreak. Subsequent flare-ups occurred; the epidemic was finally declared over on 9 June 2016, 42 days after the last case tested negative on 28 April 2016 in Monrovia . The outbreak left about 17,000 survivors of the disease, many of whom report post-recovery symptoms termed post-Ebola syndrome , often severe enough to require medical care for months or even years. An additional cause for concern is the apparent ability of the virus to "hide" in a recovered survivor's body for an extended period of time and then become active months or years later, either in the same individual or in a sexual partner. In December 2016, the WHO announced that a two-year trial of the rVSV-ZEBOV vaccine appeared to offer protection from the variant of EBOV responsible for the Western Africa outbreak. The vaccine is considered to be effective and is the only prophylactic which offers protection; hence, 300,000 doses have been stockpiled. rVSV-ZEBOV received regulatory approval in 2019. Ebola virus disease (commonly known as "Ebola") was first described in 1976 in two simultaneous outbreaks in the Democratic Republic of the Congo and what is now South Sudan . The 2013–2016 outbreak, caused by Ebola virus (EBOV), was the first anywhere in the world to reach epidemic proportions. Previous outbreaks had been brought under control in a much shorter period of time. Extreme poverty , dysfunctional healthcare systems, distrust of government after years of armed conflict, and the delay in responding for several months, all contributed to the failure to control the epidemic. Other factors, per media reports, included local burial customs of washing the body and the unprecedented spread of Ebola to densely populated cities. As the outbreak progressed, the media reports, many hospitals, short on both staff and supplies, were overwhelmed and closed down, leading some health experts to state that the inability to treat other medical needs may have been causing "an additional death toll [that is] likely to exceed that of the outbreak itself". Hospital workers, who worked closely with the highly contagious body fluids of the victims, were especially vulnerable to contracting the virus; in August 2014, the WHO reported that ten per cent of the dead had been healthcare workers. In September 2014, it was estimated that the affected countries' capacity for treating Ebola patients was insufficient by the equivalent of 2,122 beds; however, by December 2014 there were enough beds to treat and isolate all reported cases, although the uneven distribution of cases was resulting in serious shortfalls in some areas. The WHO has been widely criticised for its delay in taking action to address the epidemic. On 8 August 2014, it declared the outbreak a public health emergency of international concern . By September 2014, Médecins Sans Frontières/Doctors Without Borders (MSF), the non-governmental organisation with the largest working presence in the affected countries, had grown increasingly critical of the international response. Speaking on 3 September, the International President of MSF spoke out concerning the lack of assistance from United Nations (UN) member countries: "Six months into the worst Ebola epidemic in history, the world is losing the battle to contain it." In a 26 September statement, the WHO stated that "[t]he Ebola epidemic ravaging parts of Western Africa is the most severe acute public health emergency seen in modern times" and its Director-General called the outbreak "the largest, most complex and most severe we've ever seen". In March 2015, the United Nations Development Group reported that due to a decrease in trade, closing of borders, flight cancellations, and drop in foreign investment and tourism activity fuelled by stigma, the epidemic had resulted in vast economic consequences in both the affected areas in Western Africa and even in other African nations with no cases of Ebola. On 28 January 2015, the WHO reported that for the first time since the week ending 29 June 2014, there had been fewer than 100 new confirmed cases reported in a week in the three most-affected countries. The response to the epidemic then moved to a second phase, as the focus shifted from slowing transmission to ending the epidemic. On 8 April 2015, the WHO reported a total of only 30 confirmed cases, and the weekly update for 29 July reported only seven new cases. Cases continued to gradually dwindle and on 7 October 2015, all three of the most seriously affected countries, per media reports, recorded their first joint week without any new cases. However, as of late 2015, while the large-scale epidemic had ended, according to media reports, sporadic new cases were still being recorded, frustrating hopes that the epidemic could be declared over. On 31 July 2015, the WHO announced "an extremely promising development" in the search for an effective vaccine for Ebola virus disease. While the vaccine had shown high efficacy in individuals, more conclusive evidence was needed regarding its capacity to protect populations through herd immunity . In August 2015, after substantial progress in reducing the scale of the epidemic, the WHO held a meeting to work out a "Comprehensive care plan for Ebola survivors" and identify research needed to optimise clinical care and social well-being. Stating that "the Ebola outbreak has decimated families, health systems, economies, and social structures", the WHO called the aftermath of the epidemic "an emergency within an emergency." Of special concern is recent research that shows some Ebola survivors experience a so-called "post-Ebola Syndrome", with symptoms so severe that survivors may require medical care for months and even years. As the main epidemic was coming to an end in December 2015, the UN announced that 22,000 children had lost one or both parents to Ebola. On 29 March 2016, the Director-General of WHO terminated the Public Health Emergency of International Concern status of the Western African Ebola virus epidemic. It is generally believed that a one or two-year-old boy, later identified as Emile Ouamouno , who died in December 2013 in the village of Méliandou , Guéckédou Prefecture , Guinea , was the index case of the Western African epidemic. Scientists have deduced that bats are involved in the spread of the virus, and, incidentally, the boy's home was in the vicinity of a large colony of Angolan free-tailed bats , according to media reports. His mother, sister, and grandmother, per media reports later became ill with similar symptoms and also died; people infected by these initial cases spread the disease to other villages. There was knowledge of Tai Forest virus in Côte d'Ivoire, which had resulted in one human transmission in 1994. Thus, these early cases were diagnosed as other conditions more common to the area and the disease had several months to spread before it became recognised as Ebola. On 25 March 2014, the WHO indicated that Guinea's Ministry of Health had reported an outbreak of Ebola virus disease in four southeastern districts, and that suspected cases in the neighbouring countries of Liberia and Sierra Leone were being investigated. In Guinea, a total of 86 suspected cases, including 59 deaths, had been reported as of 24 March. By late May, the outbreak had spread to Conakry , Guinea's capital—a city of about two million people. On 28 May, the total number of reported cases had reached 281, with 186 deaths. In Liberia, the disease was reported in four counties by mid-April 2014 and cases in Liberia's capital Monrovia were reported in mid-June. The outbreak then spread to Sierra Leone and progressed rapidly. By 17 July, the total number of suspected cases in the country stood at 442, surpassing those in Guinea and Liberia. By 20 July, additional cases of the disease had been reported by the media in the Bo District , while the first case in Freetown , Sierra Leone's capital, was reported in late July. As the epidemic progressed, a small outbreak occurred in Nigeria that resulted in 20 cases and another in Mali with 7 cases. Four other countries (Senegal, Spain, the United Kingdom and the United States of America) also reported cases imported from Western Africa, with widespread and intense transmission. On 31 March 2015, one year after the first report of the outbreak, the total number of cases was in excess of 25,000—with over 10,000 deaths. As the epidemic waned, following international control efforts, the edition of 8 April 2015 of the WHO's Ebola Situation Reports stated that a total of 30 cases were reported and on 29 July 2015, the WHO weekly update reported only 7 cases—the lowest in more than a year. In October 2015, the WHO recorded its first week without any new cases, and while the large-scale epidemic appeared to have ended by late 2015, sporadic new cases continued to be reported. On 14 January 2016, after all the previously infected countries had been declared Ebola-free, the WHO reported that "all known chains of transmission have been stopped in Western Africa", but cautioned that further small outbreaks of the disease could occur in the future. The following day, Sierra Leone confirmed its first new case since September 2015. On 25 March 2014, the WHO reported an outbreak of Ebola virus disease in four southeastern districts of Guinea with a total of 86 suspected cases, including 59 deaths, and MSF assisted the Ministry of Health by establishing Ebola treatment centres in the epicentre of the outbreak. On 31 March, the U.S. Centers for Disease Control and Prevention (CDC) sent a five-person team to assist in the response to the outbreak. Thinking that spread of the virus had been contained, MSF closed its treatment centres in May, leaving only a skeleton staff to handle the Macenta region. However, in late August, according to media reports, large numbers of new cases reappeared in the region. In February 2015, Guinea recorded a rise in cases; health authorities stated that this was related to the fact that they "were only now gaining access to faraway villages", where violence had previously prevented them from entering. On 14 February, violence erupted and an Ebola treatment centre near the centre of the country was destroyed. Guinean Red Cross teams said they had suffered an average of 10 attacks a month over the previous year; MSF reported that acceptance of Ebola education remained low and that further violence against their workers might force them to leave. Resistance to interventions by health officials among the Guinean population remained greater than in Sierra Leone and Liberia, per media reports, raising concerns over its impact on ongoing efforts to halt the epidemic; in mid-March, there were 95 new cases and on 28 March, and a 45-day "health emergency" was declared in 5 regions of the country. On 22 May, the WHO reported another rise in cases, per media reports. On 25 May, six persons were placed in prison isolation after they were found travelling with the corpse of an individual who had died of the disease, on 1 June, it was reported that violent protests in a north Guinean town at the border with Guinea-Bissau had caused the Red Cross to withdraw its workers. In late June 2015, the WHO reported that "weekly case incidence has stalled at between 20 and 27 cases since the end of May, whilst cases continue to arise from unknown sources of infection, and to be detected only after post-mortem testing of community deaths". On 29 July, a sharp decline in cases was reported, with only a single case, per media reports left by the end of the week, the number of cases eventually plateaued at 1 or 2 cases per week after the beginning of August. On 28 October, an additional 3 cases were reported in the Forécariah Prefecture by the WHO. On 6 November, a media report indicated Tana village to be the last known place with Ebola in the country, and on 11 November, WHO indicated that no Ebola cases were reported in Guinea; this was the first time since the epidemic began, that no cases had been reported in any country. On 15 November, the last quarantined individuals were released, per media reports and on 17 November, the last Ebola patient in Guinea—a 3-week-old baby—had recovered; the 42-day countdown toward the country being declared Ebola-free started on 17 November, the day after the patient yielded a second consecutive negative blood test. The patient was discharged from the hospital on 28 November, per media reports on 29 December 2015, upon expiration of the 42-day waiting period, the WHO declared Guinea Ebola-free. On 17 March 2016, the government of Guinea reported, per the media, that 2 people had again tested positive for Ebola virus in Korokpara , it was also reported that they were from the village where members of one family had recently died from vomiting (and diarrhea). On 19 March, it was also reported by the media that another individual had died due to the virus at the treatment centre in Nzerekore , consequently, the country's government quarantined an area around the home where the cases took place. On 22 March, the media reported that medical authorities in Guinea had quarantined 816 suspected contacts of the prior cases (more than 100 individuals were considered high-risk); the same day, Liberia ordered its border with Guinea closed. Macenta Prefecture , 200 kilometres (120 mi) from Korokpara, registered Guinea's fifth fatality due to Ebola virus disease within the same period. On 29 March, it was reported that about 1,000 contacts had been identified (142 of them high-risk), and on 30 March 3 more confirmed cases were reported from the sub-prefecture of Koropara. On 1 April, it was reported by the media, that possible contacts, which numbered in the hundreds, had been vaccinated with an experimental vaccine using a ring vaccination approach. On 5 April 2016, it was reported via the media, that there had been 9 new cases of Ebola since the virus resurfaced, out of which 8 were fatal; on 1 June, after the stipulated waiting period, the WHO again declared Guinea Ebola-free, after which the country entered a 90-day period of heightened surveillance that was concluded on 30 August 2016. In September 2016, findings were published suggesting that the resurgence in Guinea was caused by an Ebola survivor who, after eight months of abstinence, had sexual relations with several partners, including the first victim in the new outbreak. The disease was also spread to Liberia by a woman who went there after her husband had died of Ebola. The first person reported infected in Sierra Leone, according to media reports, was a tribal healer who had been treating Ebola patients from across the nearby border with Guinea and who died on 26 May 2014; according to tribal tradition, her body was washed for burial, and this appears to have led to infections in women from neighbouring towns. On 11 June Sierra Leone shut its borders for trade with Guinea and Liberia and closed some schools in an attempt to slow the spread of the virus; on 30 July the government began to deploy troops to enforce quarantines. During the first week of November reports told of a worsening situation due to intense transmission in Freetown. According to the Disaster Emergency Committee, food shortages resulting from aggressive quarantines were making the situation worse, and on 4 November media reported that thousands had violated quarantine in search of food in the town of Kenema . With the number of cases continuing to increase, an MSF coordinator described the situation in Sierra Leone as "catastrophic", saying, "there are several villages and communities that have been basically wiped out ... Whole communities have disappeared but many of them are not in the statistics." In mid-November the WHO reported that, while there was some evidence that the number of cases were no longer rising in Guinea and Liberia, steep increases persisted in Sierra Leone. On 9 December 2014 news reports described the discovery of "a grim scene"—piles of bodies, overwhelmed medical personnel and exhausted burial teams—in the remote eastern Kono District . On 15 December the CDC indicated that their main concern was Sierra Leone, where the epidemic had shown no signs of abating as cases continued to rise exponentially; by the second week of December, Sierra Leone had reported nearly 400 cases—more than three times the number reported by Guinea and Liberia combined. According to the CDC, "the risk we face now [is] that Ebola will simmer along, become native and be a problem for Africa and the world, for years to come". On 17 December President Koroma of Sierra Leone launched "Operation Western Area Surge" and workers went door-to-door in the capital city looking for possible cases. The operation led to a surge in reports of cases, with 403 new ones reported between 14 and 17 December. According to the 21 January 2015 WHO Situation Report, the case incidence was rapidly decreasing in Sierra Leone. However, in February and March reports indicated a rise again in the number of cases. The following month, the 5 April WHO report again disclosed a downward trend and the WHO weekly update for 29 July reported a total of only 3 new cases, the lowest in more than a year. On 17 August the country marked its first week with no new cases, and one week later the last patients were released. However, a new case emerged on 1 September, when a patient from Sella Kafta village in Kambia District tested positive for the disease after her death; her case eventually resulted in 3 other infections among her contacts. On 14 September 2015 Sierra Leone's National Ebola Response Centre confirmed the death of a 16-year-old in a village in the Bombali District . It is suspected that she contracted the disease from the semen of an Ebola survivor who had been discharged in March 2015. On 27 September a new 42-day countdown began to declare the country Ebola-free, which eventually occurred on 7 November 2015; thereafter, the country increased its vigilance on the Guinean border. Sierra Leone had entered a 90-day period of enhanced surveillance that was scheduled to end on 5 February 2016, when, on 14 January, a new Ebola death was reported in the Tonkolili District . Prior to this case, the WHO had advised that "we still anticipate more flare-ups and must be prepared for them. A massive effort is underway to ensure robust prevention, surveillance and response capacity across all three countries by the end of March." On 16 January aid workers reported that a woman had died of the virus and that she may have exposed several individuals; the government later announced that 100 people had been quarantined. Investigations indicated that the deceased was a female student from Lunsar , in Port Loko District , who had gone to Kambia District on 28 December 2015 before returning symptomatic. She had also visited Bombali District to consult a herbalist, and had later gone to a government hospital in Magburaka . The WHO indicated that there were 109 contacts (28 of them high-risk), that there were another 3 missing contacts, and that the source or route of transmission that caused the fatality was unknown. A second new case—confirmed by WHO spokesman Tarik Jasarevic to involve a 38-year-old relative and caregiver of the aforementioned Ebola victim—had become symptomatic on 20 Jan while under observation at a quarantine centre. On 22 January it was reported that this patient was responding to treatment. On 26 January WHO Director-General, Dr Margaret Chan officially confirmed that the outbreak was not yet over; that same day, it was also reported that Ebola restrictions had halted market activity in Kambia District amid protests. On 7 February 70 individuals were released from quarantine, and on 8 February the last Ebola patient was also released. On 17 February the WHO indicated that 2,600 Ebola survivors had accessed health assessments and eye examinations. On 4 February 2016 the last known case tested negative for a second consecutive time and Sierra Leone commenced another 42-day countdown towards being declared Ebola-free. On 17 March 2016 the WHO announced that the Sierra Leone flare-up was over, and that no other chains of transmission were known to be active at that time. The media reported that Sierra Leone then entered a 90-day period of heightened surveillance, which concluded on 15 June 2016, and it was reported that by 15 July the country had discontinued testing corpses for the virus. In Liberia, the disease was reported in both Lofa and Nimba counties in late March 2014. On 27 July, President Ellen Johnson Sirleaf announced that Liberia would close its borders, with the exception of a few crossing points such as Roberts International Airport , where screening centres would be established. Schools and universities were closed, and the worst-affected areas in the country were placed under quarantine. With only 50 physicians in the entire country—one for every 70,000 citizens—Liberia was already in a healthcare crisis. In September, the CDC reported that some hospitals had been abandoned, while those still functioning lacked basic facilities and supplies. In October, the Liberian ambassador in Washington was reported as saying that he feared that his country may be "close to collapse"; by 24 October, all 15 counties had reported Ebola cases. By November 2014, the rate of new infections in Liberia appeared to be declining and the state of emergency was lifted. The drop in cases was believed to be related to an integrated strategy combining isolation and treatment with community behaviour change, including safe burial practices, case finding and contact tracing . Roselyn Nugba-Ballah , leader of the Safe & Diginified Burial Practices Team during the crisis, was awarded the Florence Nightingale Medal in 2017 for her work during the crisis. In January 2015, the MSF field coordinator reported that Liberia was down to only 5 confirmed cases. In March, after two weeks of not reporting any new cases, 3 new cases were confirmed. On 8 April, a new health minister was named in an effort to end Ebola in the country and on 26 April, MSF handed the Ebola treatment facility, ELWA-3, over to the government. On 30 April, the US shut down a special Ebola treatment unit in Liberia. The last known case of Ebola died on 27 March, and the country was officially declared Ebola-free on 9 May 2015, after 42 days without any further cases being recorded. The WHO congratulated Liberia saying, "reaching this milestone is a testament to the strong leadership and coordination of Liberian President Ellen Johnson Sirleaf and the Liberian Government, the determination and vigilance of Liberian communities, the extensive support of global partners, and the tireless and heroic work of local and international health teams." As at May 2015, the country remained on high alert against recurrence of the disease. After three months with no new reports of cases, on 29 June Liberia reported that the body of a 17-year-old boy, who had been treated for malaria, tested positive for Ebola. The WHO said the boy had been in close contact with at least 200 people, who they were following up, and that "the case reportedly had no recent history of travel, contact with visitors from affected areas, or funeral attendance." A second case was confirmed on 1 July. After a third new case was confirmed on 2 July, and it was discovered that all 3 new cases had shared a meal of dog meat , researchers looked at the possibility that the meat may have been involved in the transfer of the virus. Testing of the dog's remains, however, was negative for the Ebola virus. By 9 July 3 more cases were discovered, bringing the total number of new cases to 5, all from the same area. On 14 July, a woman died of the disease in the county of Montserrado , bringing the total to 6. On 20 July, the last patients were discharged, and on 3 September 2015, Liberia was declared Ebola-free again. After two months of being Ebola-free, a new case was confirmed on 20 November 2015, when a 15-year-old boy was diagnosed with the virus and two family members subsequently tested positive as well. Health officials were concerned because the child had not recently travelled or been exposed to someone with Ebola and the WHO stated that "we believe that this is probably again, somehow, someone who has come in contact with a virus that had been persisting in an individual, who had suffered the disease months ago." Two staff of the CDC were sent to the country to help ascertain the cause of the new cases. The infected boy died on 24 November, and on 3 December 2 remaining cases were released after recovering from the disease. The 42-day countdown toward Liberia being declared Ebola-free, for the third time, started on 4 December 2015. On 16 December, the WHO reaffirmed that the cases in Liberia were the result of re-emergence of the virus in a previously infected person, and there was speculation that the boy may have been infected by an individual who became infectious once more due to pregnancy, which may have weakened her immune system. On 18 December, the WHO indicated that it still considered Ebola in Western Africa a public health emergency, though progress had been made. After having completed the 42-day time period, Liberia was declared free from the virus on 14 January 2016, effectively ending the outbreak that had started in neighbouring Guinea 2 years earlier. Liberia began a 90-day period of heightened surveillance, scheduled to conclude on 13 April 2016, but on 1 April, it was reported that a new Ebola fatality had occurred, and on 3 April, a second case was reported in Monrovia . On 4 April, it was reported that 84 individuals were under observation due to contact with the 2 confirmed Ebola cases. By 7 April, Liberia had confirmed 3 new cases since the virus resurfaced and a total of 97 contacts, including 15 healthcare workers, were being monitored. The index case of the new flareup was reported to be the wife of a patient who died from Ebola in Guinea; she had travelled to Monrovia after the funeral but died from the disease. The outbreak in Guinea, in turn, had begun when a man, who had survived Ebola, had sexual intercourse with a woman and passed the virus to her, even though he had recovered more than a year earlier. On 29 April, WHO reported that Liberia had discharged the last patient and had begun the 42-day countdown to be declared Ebola-free once more. According to the WHO, tests indicated that the flare-up was likely due to contact with a prior Ebola survivor's infected body fluids. On 9 June, the flare-up was declared over, and the country Ebola-free, due to the passage of the 42-day period; Liberia then entered a 90-day period of heightened surveillance, which ended on 7 September 2016. In early July 2016, a trial for males with detectable Ebola RNA in semen, started. In March 2014, the Senegal Ministry of Interior closed its southern border with Guinea, but on 29 August, the health minister announced the country's first case – a university student from Guinea who was being treated in a Dakar hospital. The patient was a native of Guinea who had travelled to Dakar, arriving on 20 August. On 23 August, he sought medical care for symptoms including diarrhoea, and vomiting plus signs of fever. He received treatment for malaria but did not improve and left the facility. Still experiencing the same symptoms, on 26 August he was referred to a specialised facility for infectious diseases, and subsequently hospitalised. On 28 August 2014, authorities in Guinea issued an alert informing their medical services and neighbouring countries that a person who had been in close contact with an Ebola-infected patient had escaped their surveillance system. The alert prompted testing for Ebola at the Dakar laboratory, and the positive result launched an investigation, triggering urgent contact tracing. On 10 September, it was reported that the student had recovered but health officials continued to monitor his contacts for 21 days. No further cases were reported, and on 17 October 2014, the WHO officially declared that the outbreak in Senegal had ended. The WHO officially commended the Senegalese government, and in particular the President Macky Sall and the Minister of Health, Dr Awa Coll-Seck , for their response in quickly isolating the patient and tracing and following up 74 contacts, as well as for their public awareness campaign. This acknowledgement was also extended to MSF and the CDC for their assistance. The first case in Nigeria was a Liberian-American, who flew from Liberia to Nigeria's most populated city of Lagos on 20 July 2014. On 6 August 2014, the Nigerian health minister told reporters that one of the nurses that attended to the Liberian had died from the disease. 5 newly confirmed cases were being treated at an isolation ward. On 22 September 2014, the Nigerian health ministry announced, "As of today, there is no case of Ebola in Nigeria." According to the WHO, 20 cases and 8 deaths were confirmed, including the imported case, who also died. 4 of the dead were health workers who had cared for the index case. The WHO's representative in Nigeria officially declared the country Ebola-free on 20 October 2014, after no new active cases were reported in the follow-up contacts, stating it was a "spectacular success story". Nigeria was the first African country to be declared Ebola free. This was largely due to the early quarantine efforts of Dr. Ameyo Stella Adadevoh at First Consultants Medical Centre in Lagos. On 23 October 2014, the first case of Ebola virus disease in Mali was confirmed in the city of Kayes —a two-year-old girl who had arrived with a family group from Guinea, and died the next day. Her father had worked for the Red Cross in Guinea and also in a private health clinic; he had died earlier in the month, likely from an Ebola infection contracted in the private clinic. It was later established that a number of family members had also died of Ebola. The family had returned to Mali after the father's funeral via public bus and taxi—a journey of more than 1,200 kilometres (750 mi) . All contacts were followed for 21 days, with no further spread of the disease reported. On 12 November 2014, Mali reported deaths from Ebola in an outbreak unconnected with the first case in Kayes. The first probable case was an imam who had fallen ill on 17 October in Guinea and was transferred to the Pasteur Clinic in Mali's capital city, Bamako , for treatment. He was treated for kidney failure but was not tested for Ebola; he died on 27 October and his body returned to Guinea for burial. A nurse and a doctor who had treated the imam subsequently fell ill with Ebola and died. The next 3 cases were related to the imam as well: a man who had visited the imam while he was in hospital, his wife and his son. On 22 November, the final case related to the imam was reported—a friend of the Pasteur Clinic nurse who had died from the Ebola virus. On 12 December, the last case in treatment recovered and was discharged, "so there are no more people sick with Ebola in Mali", according to a Ministry of Health source. On 16 December, Mali released the final 13 individuals who were being quarantined and 24 days later (18 January 2015) without new cases, the country was declared Ebola-free. On 29 December 2014, Pauline Cafferkey , a British aid worker who had just returned to Glasgow from Sierra Leone, was diagnosed with Ebola. She was treated and declared to be free of infection and released from hospital on 24 January 2015. On 8 October, she was readmitted for complications caused by the virus and was in "serious" condition, according to a hospital report. On 14 October, her condition was listed as "critical" and 58 individuals were being monitored and 25 received an experimental vaccination, being close contacts. On 21 October, it was reported that she had been diagnosed with meningitis caused by the virus persisting in her brain. On 12 November, she was released from hospital after making a full recovery. However, on 23 February, Ms. Cafferkey was admitted for a third time, "under routine monitoring by the Infectious Diseases Unit ... for further investigations", according to a spokesperson. On 12 May 2015, it was reported that a nurse, who had been working in Sierra Leone, had been diagnosed with Ebola after returning home to the Italian island of Sardinia . He was treated at Spallanzani Hospital , the national reference centre for Ebola patients. On 10 June, it was reported that he had recovered and was disease-free and he was released from hospital. On 5 August 2014, the Brothers Hospitallers of Saint John of God confirmed that Brother Miguel Pajares, who had been volunteering in Liberia, had become infected. He was evacuated to Spain and died on 12 August. On 21 September it was announced that Brother Manuel García Viejo, another Spanish citizen who was medical director at the St John of God Hospital Sierra Leone in Lunsar , had been evacuated to Spain from Sierra Leone after being infected with the virus. His death was announced on 25 September. In October 2014, a nursing assistant, Teresa Romero, who had cared for these patients became unwell and on 6 October tested positive for Ebola, making this the first confirmed case of Ebola transmission outside of Africa. On 19 October, it was reported that Romero had recovered, and on 2 December the WHO declared Spain Ebola-free following the passage of 42 days since Teresa Romero was found to be cured. On 30 September 2014, the CDC declared its first case of Ebola virus disease. It disclosed that Thomas Eric Duncan became infected in Liberia and travelled to Dallas , Texas on 20 September. On 26 September, he fell ill and sought medical treatment, but was sent home with antibiotics. He returned to the hospital by ambulance on 28 September and was placed in isolation and tested for Ebola. He died on 8 October. Two cases stemmed from Duncan, when two nurses that had treated him tested positive for the virus; they were declared Ebola-free on 24 and 22 October, respectively. A fourth case was identified on 23 October 2014, when Craig Spencer , an American physician who had returned to the United States after treating Ebola patients in Western Africa, tested positive for the virus. This case, however, had no relation to those originating from Duncan. Spencer recovered and was released from hospital on 11 November. A number of people who had become infected with Ebola were medically evacuated for treatment in isolation wards in Europe or the US. They were mostly health workers with one of the NGOs in Western Africa. With the exception of a single isolated case in Spain , no secondary infections occurred as a result of the medical evacuations. The US accepted four evacuees and three were flown to Germany. France, Italy, the Netherlands, Norway, Switzerland, and the United Kingdom received two patients (and five who were exposed). In August 2014, the WHO reported an outbreak of Ebola virus in the Boende District, part of the northern Équateur province of the Democratic Republic of the Congo (DRC), where 13 people were reported to have died of Ebola-like symptoms. Genetic sequencing revealed that this outbreak was caused by the Zaire Ebola species, which is native to the DRC; there have been seven previous Ebola outbreaks in the country since 1976. The virology results and epidemiological findings indicated no connection to the epidemic in Western Africa. The index case was initially reported to have been a woman from Ikanamongo Village, who became ill with symptoms of Ebola after she had butchered a bush animal. However, later findings suggested that there may have been several previous cases, and it was reported that pigs in the village may have been infected with Ebola some time before the first human case occurred. The WHO declared the outbreak over on 21 November 2014, after a total of 66 cases and 49 deaths. It is generally believed that a one or two-year-old boy, later identified as Emile Ouamouno , who died in December 2013 in the village of Méliandou , Guéckédou Prefecture , Guinea , was the index case of the Western African epidemic. Scientists have deduced that bats are involved in the spread of the virus, and, incidentally, the boy's home was in the vicinity of a large colony of Angolan free-tailed bats , according to media reports. His mother, sister, and grandmother, per media reports later became ill with similar symptoms and also died; people infected by these initial cases spread the disease to other villages. There was knowledge of Tai Forest virus in Côte d'Ivoire, which had resulted in one human transmission in 1994. Thus, these early cases were diagnosed as other conditions more common to the area and the disease had several months to spread before it became recognised as Ebola. On 25 March 2014, the WHO indicated that Guinea's Ministry of Health had reported an outbreak of Ebola virus disease in four southeastern districts, and that suspected cases in the neighbouring countries of Liberia and Sierra Leone were being investigated. In Guinea, a total of 86 suspected cases, including 59 deaths, had been reported as of 24 March. By late May, the outbreak had spread to Conakry , Guinea's capital—a city of about two million people. On 28 May, the total number of reported cases had reached 281, with 186 deaths. In Liberia, the disease was reported in four counties by mid-April 2014 and cases in Liberia's capital Monrovia were reported in mid-June. The outbreak then spread to Sierra Leone and progressed rapidly. By 17 July, the total number of suspected cases in the country stood at 442, surpassing those in Guinea and Liberia. By 20 July, additional cases of the disease had been reported by the media in the Bo District , while the first case in Freetown , Sierra Leone's capital, was reported in late July. As the epidemic progressed, a small outbreak occurred in Nigeria that resulted in 20 cases and another in Mali with 7 cases. Four other countries (Senegal, Spain, the United Kingdom and the United States of America) also reported cases imported from Western Africa, with widespread and intense transmission. On 31 March 2015, one year after the first report of the outbreak, the total number of cases was in excess of 25,000—with over 10,000 deaths. As the epidemic waned, following international control efforts, the edition of 8 April 2015 of the WHO's Ebola Situation Reports stated that a total of 30 cases were reported and on 29 July 2015, the WHO weekly update reported only 7 cases—the lowest in more than a year. In October 2015, the WHO recorded its first week without any new cases, and while the large-scale epidemic appeared to have ended by late 2015, sporadic new cases continued to be reported. On 14 January 2016, after all the previously infected countries had been declared Ebola-free, the WHO reported that "all known chains of transmission have been stopped in Western Africa", but cautioned that further small outbreaks of the disease could occur in the future. The following day, Sierra Leone confirmed its first new case since September 2015. On 25 March 2014, the WHO reported an outbreak of Ebola virus disease in four southeastern districts of Guinea with a total of 86 suspected cases, including 59 deaths, and MSF assisted the Ministry of Health by establishing Ebola treatment centres in the epicentre of the outbreak. On 31 March, the U.S. Centers for Disease Control and Prevention (CDC) sent a five-person team to assist in the response to the outbreak. Thinking that spread of the virus had been contained, MSF closed its treatment centres in May, leaving only a skeleton staff to handle the Macenta region. However, in late August, according to media reports, large numbers of new cases reappeared in the region. In February 2015, Guinea recorded a rise in cases; health authorities stated that this was related to the fact that they "were only now gaining access to faraway villages", where violence had previously prevented them from entering. On 14 February, violence erupted and an Ebola treatment centre near the centre of the country was destroyed. Guinean Red Cross teams said they had suffered an average of 10 attacks a month over the previous year; MSF reported that acceptance of Ebola education remained low and that further violence against their workers might force them to leave. Resistance to interventions by health officials among the Guinean population remained greater than in Sierra Leone and Liberia, per media reports, raising concerns over its impact on ongoing efforts to halt the epidemic; in mid-March, there were 95 new cases and on 28 March, and a 45-day "health emergency" was declared in 5 regions of the country. On 22 May, the WHO reported another rise in cases, per media reports. On 25 May, six persons were placed in prison isolation after they were found travelling with the corpse of an individual who had died of the disease, on 1 June, it was reported that violent protests in a north Guinean town at the border with Guinea-Bissau had caused the Red Cross to withdraw its workers. In late June 2015, the WHO reported that "weekly case incidence has stalled at between 20 and 27 cases since the end of May, whilst cases continue to arise from unknown sources of infection, and to be detected only after post-mortem testing of community deaths". On 29 July, a sharp decline in cases was reported, with only a single case, per media reports left by the end of the week, the number of cases eventually plateaued at 1 or 2 cases per week after the beginning of August. On 28 October, an additional 3 cases were reported in the Forécariah Prefecture by the WHO. On 6 November, a media report indicated Tana village to be the last known place with Ebola in the country, and on 11 November, WHO indicated that no Ebola cases were reported in Guinea; this was the first time since the epidemic began, that no cases had been reported in any country. On 15 November, the last quarantined individuals were released, per media reports and on 17 November, the last Ebola patient in Guinea—a 3-week-old baby—had recovered; the 42-day countdown toward the country being declared Ebola-free started on 17 November, the day after the patient yielded a second consecutive negative blood test. The patient was discharged from the hospital on 28 November, per media reports on 29 December 2015, upon expiration of the 42-day waiting period, the WHO declared Guinea Ebola-free. On 17 March 2016, the government of Guinea reported, per the media, that 2 people had again tested positive for Ebola virus in Korokpara , it was also reported that they were from the village where members of one family had recently died from vomiting (and diarrhea). On 19 March, it was also reported by the media that another individual had died due to the virus at the treatment centre in Nzerekore , consequently, the country's government quarantined an area around the home where the cases took place. On 22 March, the media reported that medical authorities in Guinea had quarantined 816 suspected contacts of the prior cases (more than 100 individuals were considered high-risk); the same day, Liberia ordered its border with Guinea closed. Macenta Prefecture , 200 kilometres (120 mi) from Korokpara, registered Guinea's fifth fatality due to Ebola virus disease within the same period. On 29 March, it was reported that about 1,000 contacts had been identified (142 of them high-risk), and on 30 March 3 more confirmed cases were reported from the sub-prefecture of Koropara. On 1 April, it was reported by the media, that possible contacts, which numbered in the hundreds, had been vaccinated with an experimental vaccine using a ring vaccination approach. On 5 April 2016, it was reported via the media, that there had been 9 new cases of Ebola since the virus resurfaced, out of which 8 were fatal; on 1 June, after the stipulated waiting period, the WHO again declared Guinea Ebola-free, after which the country entered a 90-day period of heightened surveillance that was concluded on 30 August 2016. In September 2016, findings were published suggesting that the resurgence in Guinea was caused by an Ebola survivor who, after eight months of abstinence, had sexual relations with several partners, including the first victim in the new outbreak. The disease was also spread to Liberia by a woman who went there after her husband had died of Ebola. The first person reported infected in Sierra Leone, according to media reports, was a tribal healer who had been treating Ebola patients from across the nearby border with Guinea and who died on 26 May 2014; according to tribal tradition, her body was washed for burial, and this appears to have led to infections in women from neighbouring towns. On 11 June Sierra Leone shut its borders for trade with Guinea and Liberia and closed some schools in an attempt to slow the spread of the virus; on 30 July the government began to deploy troops to enforce quarantines. During the first week of November reports told of a worsening situation due to intense transmission in Freetown. According to the Disaster Emergency Committee, food shortages resulting from aggressive quarantines were making the situation worse, and on 4 November media reported that thousands had violated quarantine in search of food in the town of Kenema . With the number of cases continuing to increase, an MSF coordinator described the situation in Sierra Leone as "catastrophic", saying, "there are several villages and communities that have been basically wiped out ... Whole communities have disappeared but many of them are not in the statistics." In mid-November the WHO reported that, while there was some evidence that the number of cases were no longer rising in Guinea and Liberia, steep increases persisted in Sierra Leone. On 9 December 2014 news reports described the discovery of "a grim scene"—piles of bodies, overwhelmed medical personnel and exhausted burial teams—in the remote eastern Kono District . On 15 December the CDC indicated that their main concern was Sierra Leone, where the epidemic had shown no signs of abating as cases continued to rise exponentially; by the second week of December, Sierra Leone had reported nearly 400 cases—more than three times the number reported by Guinea and Liberia combined. According to the CDC, "the risk we face now [is] that Ebola will simmer along, become native and be a problem for Africa and the world, for years to come". On 17 December President Koroma of Sierra Leone launched "Operation Western Area Surge" and workers went door-to-door in the capital city looking for possible cases. The operation led to a surge in reports of cases, with 403 new ones reported between 14 and 17 December. According to the 21 January 2015 WHO Situation Report, the case incidence was rapidly decreasing in Sierra Leone. However, in February and March reports indicated a rise again in the number of cases. The following month, the 5 April WHO report again disclosed a downward trend and the WHO weekly update for 29 July reported a total of only 3 new cases, the lowest in more than a year. On 17 August the country marked its first week with no new cases, and one week later the last patients were released. However, a new case emerged on 1 September, when a patient from Sella Kafta village in Kambia District tested positive for the disease after her death; her case eventually resulted in 3 other infections among her contacts. On 14 September 2015 Sierra Leone's National Ebola Response Centre confirmed the death of a 16-year-old in a village in the Bombali District . It is suspected that she contracted the disease from the semen of an Ebola survivor who had been discharged in March 2015. On 27 September a new 42-day countdown began to declare the country Ebola-free, which eventually occurred on 7 November 2015; thereafter, the country increased its vigilance on the Guinean border. Sierra Leone had entered a 90-day period of enhanced surveillance that was scheduled to end on 5 February 2016, when, on 14 January, a new Ebola death was reported in the Tonkolili District . Prior to this case, the WHO had advised that "we still anticipate more flare-ups and must be prepared for them. A massive effort is underway to ensure robust prevention, surveillance and response capacity across all three countries by the end of March." On 16 January aid workers reported that a woman had died of the virus and that she may have exposed several individuals; the government later announced that 100 people had been quarantined. Investigations indicated that the deceased was a female student from Lunsar , in Port Loko District , who had gone to Kambia District on 28 December 2015 before returning symptomatic. She had also visited Bombali District to consult a herbalist, and had later gone to a government hospital in Magburaka . The WHO indicated that there were 109 contacts (28 of them high-risk), that there were another 3 missing contacts, and that the source or route of transmission that caused the fatality was unknown. A second new case—confirmed by WHO spokesman Tarik Jasarevic to involve a 38-year-old relative and caregiver of the aforementioned Ebola victim—had become symptomatic on 20 Jan while under observation at a quarantine centre. On 22 January it was reported that this patient was responding to treatment. On 26 January WHO Director-General, Dr Margaret Chan officially confirmed that the outbreak was not yet over; that same day, it was also reported that Ebola restrictions had halted market activity in Kambia District amid protests. On 7 February 70 individuals were released from quarantine, and on 8 February the last Ebola patient was also released. On 17 February the WHO indicated that 2,600 Ebola survivors had accessed health assessments and eye examinations. On 4 February 2016 the last known case tested negative for a second consecutive time and Sierra Leone commenced another 42-day countdown towards being declared Ebola-free. On 17 March 2016 the WHO announced that the Sierra Leone flare-up was over, and that no other chains of transmission were known to be active at that time. The media reported that Sierra Leone then entered a 90-day period of heightened surveillance, which concluded on 15 June 2016, and it was reported that by 15 July the country had discontinued testing corpses for the virus. In Liberia, the disease was reported in both Lofa and Nimba counties in late March 2014. On 27 July, President Ellen Johnson Sirleaf announced that Liberia would close its borders, with the exception of a few crossing points such as Roberts International Airport , where screening centres would be established. Schools and universities were closed, and the worst-affected areas in the country were placed under quarantine. With only 50 physicians in the entire country—one for every 70,000 citizens—Liberia was already in a healthcare crisis. In September, the CDC reported that some hospitals had been abandoned, while those still functioning lacked basic facilities and supplies. In October, the Liberian ambassador in Washington was reported as saying that he feared that his country may be "close to collapse"; by 24 October, all 15 counties had reported Ebola cases. By November 2014, the rate of new infections in Liberia appeared to be declining and the state of emergency was lifted. The drop in cases was believed to be related to an integrated strategy combining isolation and treatment with community behaviour change, including safe burial practices, case finding and contact tracing . Roselyn Nugba-Ballah , leader of the Safe & Diginified Burial Practices Team during the crisis, was awarded the Florence Nightingale Medal in 2017 for her work during the crisis. In January 2015, the MSF field coordinator reported that Liberia was down to only 5 confirmed cases. In March, after two weeks of not reporting any new cases, 3 new cases were confirmed. On 8 April, a new health minister was named in an effort to end Ebola in the country and on 26 April, MSF handed the Ebola treatment facility, ELWA-3, over to the government. On 30 April, the US shut down a special Ebola treatment unit in Liberia. The last known case of Ebola died on 27 March, and the country was officially declared Ebola-free on 9 May 2015, after 42 days without any further cases being recorded. The WHO congratulated Liberia saying, "reaching this milestone is a testament to the strong leadership and coordination of Liberian President Ellen Johnson Sirleaf and the Liberian Government, the determination and vigilance of Liberian communities, the extensive support of global partners, and the tireless and heroic work of local and international health teams." As at May 2015, the country remained on high alert against recurrence of the disease. After three months with no new reports of cases, on 29 June Liberia reported that the body of a 17-year-old boy, who had been treated for malaria, tested positive for Ebola. The WHO said the boy had been in close contact with at least 200 people, who they were following up, and that "the case reportedly had no recent history of travel, contact with visitors from affected areas, or funeral attendance." A second case was confirmed on 1 July. After a third new case was confirmed on 2 July, and it was discovered that all 3 new cases had shared a meal of dog meat , researchers looked at the possibility that the meat may have been involved in the transfer of the virus. Testing of the dog's remains, however, was negative for the Ebola virus. By 9 July 3 more cases were discovered, bringing the total number of new cases to 5, all from the same area. On 14 July, a woman died of the disease in the county of Montserrado , bringing the total to 6. On 20 July, the last patients were discharged, and on 3 September 2015, Liberia was declared Ebola-free again. After two months of being Ebola-free, a new case was confirmed on 20 November 2015, when a 15-year-old boy was diagnosed with the virus and two family members subsequently tested positive as well. Health officials were concerned because the child had not recently travelled or been exposed to someone with Ebola and the WHO stated that "we believe that this is probably again, somehow, someone who has come in contact with a virus that had been persisting in an individual, who had suffered the disease months ago." Two staff of the CDC were sent to the country to help ascertain the cause of the new cases. The infected boy died on 24 November, and on 3 December 2 remaining cases were released after recovering from the disease. The 42-day countdown toward Liberia being declared Ebola-free, for the third time, started on 4 December 2015. On 16 December, the WHO reaffirmed that the cases in Liberia were the result of re-emergence of the virus in a previously infected person, and there was speculation that the boy may have been infected by an individual who became infectious once more due to pregnancy, which may have weakened her immune system. On 18 December, the WHO indicated that it still considered Ebola in Western Africa a public health emergency, though progress had been made. After having completed the 42-day time period, Liberia was declared free from the virus on 14 January 2016, effectively ending the outbreak that had started in neighbouring Guinea 2 years earlier. Liberia began a 90-day period of heightened surveillance, scheduled to conclude on 13 April 2016, but on 1 April, it was reported that a new Ebola fatality had occurred, and on 3 April, a second case was reported in Monrovia . On 4 April, it was reported that 84 individuals were under observation due to contact with the 2 confirmed Ebola cases. By 7 April, Liberia had confirmed 3 new cases since the virus resurfaced and a total of 97 contacts, including 15 healthcare workers, were being monitored. The index case of the new flareup was reported to be the wife of a patient who died from Ebola in Guinea; she had travelled to Monrovia after the funeral but died from the disease. The outbreak in Guinea, in turn, had begun when a man, who had survived Ebola, had sexual intercourse with a woman and passed the virus to her, even though he had recovered more than a year earlier. On 29 April, WHO reported that Liberia had discharged the last patient and had begun the 42-day countdown to be declared Ebola-free once more. According to the WHO, tests indicated that the flare-up was likely due to contact with a prior Ebola survivor's infected body fluids. On 9 June, the flare-up was declared over, and the country Ebola-free, due to the passage of the 42-day period; Liberia then entered a 90-day period of heightened surveillance, which ended on 7 September 2016. In early July 2016, a trial for males with detectable Ebola RNA in semen, started. On 25 March 2014, the WHO reported an outbreak of Ebola virus disease in four southeastern districts of Guinea with a total of 86 suspected cases, including 59 deaths, and MSF assisted the Ministry of Health by establishing Ebola treatment centres in the epicentre of the outbreak. On 31 March, the U.S. Centers for Disease Control and Prevention (CDC) sent a five-person team to assist in the response to the outbreak. Thinking that spread of the virus had been contained, MSF closed its treatment centres in May, leaving only a skeleton staff to handle the Macenta region. However, in late August, according to media reports, large numbers of new cases reappeared in the region. In February 2015, Guinea recorded a rise in cases; health authorities stated that this was related to the fact that they "were only now gaining access to faraway villages", where violence had previously prevented them from entering. On 14 February, violence erupted and an Ebola treatment centre near the centre of the country was destroyed. Guinean Red Cross teams said they had suffered an average of 10 attacks a month over the previous year; MSF reported that acceptance of Ebola education remained low and that further violence against their workers might force them to leave. Resistance to interventions by health officials among the Guinean population remained greater than in Sierra Leone and Liberia, per media reports, raising concerns over its impact on ongoing efforts to halt the epidemic; in mid-March, there were 95 new cases and on 28 March, and a 45-day "health emergency" was declared in 5 regions of the country. On 22 May, the WHO reported another rise in cases, per media reports. On 25 May, six persons were placed in prison isolation after they were found travelling with the corpse of an individual who had died of the disease, on 1 June, it was reported that violent protests in a north Guinean town at the border with Guinea-Bissau had caused the Red Cross to withdraw its workers. In late June 2015, the WHO reported that "weekly case incidence has stalled at between 20 and 27 cases since the end of May, whilst cases continue to arise from unknown sources of infection, and to be detected only after post-mortem testing of community deaths". On 29 July, a sharp decline in cases was reported, with only a single case, per media reports left by the end of the week, the number of cases eventually plateaued at 1 or 2 cases per week after the beginning of August. On 28 October, an additional 3 cases were reported in the Forécariah Prefecture by the WHO. On 6 November, a media report indicated Tana village to be the last known place with Ebola in the country, and on 11 November, WHO indicated that no Ebola cases were reported in Guinea; this was the first time since the epidemic began, that no cases had been reported in any country. On 15 November, the last quarantined individuals were released, per media reports and on 17 November, the last Ebola patient in Guinea—a 3-week-old baby—had recovered; the 42-day countdown toward the country being declared Ebola-free started on 17 November, the day after the patient yielded a second consecutive negative blood test. The patient was discharged from the hospital on 28 November, per media reports on 29 December 2015, upon expiration of the 42-day waiting period, the WHO declared Guinea Ebola-free. On 17 March 2016, the government of Guinea reported, per the media, that 2 people had again tested positive for Ebola virus in Korokpara , it was also reported that they were from the village where members of one family had recently died from vomiting (and diarrhea). On 19 March, it was also reported by the media that another individual had died due to the virus at the treatment centre in Nzerekore , consequently, the country's government quarantined an area around the home where the cases took place. On 22 March, the media reported that medical authorities in Guinea had quarantined 816 suspected contacts of the prior cases (more than 100 individuals were considered high-risk); the same day, Liberia ordered its border with Guinea closed. Macenta Prefecture , 200 kilometres (120 mi) from Korokpara, registered Guinea's fifth fatality due to Ebola virus disease within the same period. On 29 March, it was reported that about 1,000 contacts had been identified (142 of them high-risk), and on 30 March 3 more confirmed cases were reported from the sub-prefecture of Koropara. On 1 April, it was reported by the media, that possible contacts, which numbered in the hundreds, had been vaccinated with an experimental vaccine using a ring vaccination approach. On 5 April 2016, it was reported via the media, that there had been 9 new cases of Ebola since the virus resurfaced, out of which 8 were fatal; on 1 June, after the stipulated waiting period, the WHO again declared Guinea Ebola-free, after which the country entered a 90-day period of heightened surveillance that was concluded on 30 August 2016. In September 2016, findings were published suggesting that the resurgence in Guinea was caused by an Ebola survivor who, after eight months of abstinence, had sexual relations with several partners, including the first victim in the new outbreak. The disease was also spread to Liberia by a woman who went there after her husband had died of Ebola. The first person reported infected in Sierra Leone, according to media reports, was a tribal healer who had been treating Ebola patients from across the nearby border with Guinea and who died on 26 May 2014; according to tribal tradition, her body was washed for burial, and this appears to have led to infections in women from neighbouring towns. On 11 June Sierra Leone shut its borders for trade with Guinea and Liberia and closed some schools in an attempt to slow the spread of the virus; on 30 July the government began to deploy troops to enforce quarantines. During the first week of November reports told of a worsening situation due to intense transmission in Freetown. According to the Disaster Emergency Committee, food shortages resulting from aggressive quarantines were making the situation worse, and on 4 November media reported that thousands had violated quarantine in search of food in the town of Kenema . With the number of cases continuing to increase, an MSF coordinator described the situation in Sierra Leone as "catastrophic", saying, "there are several villages and communities that have been basically wiped out ... Whole communities have disappeared but many of them are not in the statistics." In mid-November the WHO reported that, while there was some evidence that the number of cases were no longer rising in Guinea and Liberia, steep increases persisted in Sierra Leone. On 9 December 2014 news reports described the discovery of "a grim scene"—piles of bodies, overwhelmed medical personnel and exhausted burial teams—in the remote eastern Kono District . On 15 December the CDC indicated that their main concern was Sierra Leone, where the epidemic had shown no signs of abating as cases continued to rise exponentially; by the second week of December, Sierra Leone had reported nearly 400 cases—more than three times the number reported by Guinea and Liberia combined. According to the CDC, "the risk we face now [is] that Ebola will simmer along, become native and be a problem for Africa and the world, for years to come". On 17 December President Koroma of Sierra Leone launched "Operation Western Area Surge" and workers went door-to-door in the capital city looking for possible cases. The operation led to a surge in reports of cases, with 403 new ones reported between 14 and 17 December. According to the 21 January 2015 WHO Situation Report, the case incidence was rapidly decreasing in Sierra Leone. However, in February and March reports indicated a rise again in the number of cases. The following month, the 5 April WHO report again disclosed a downward trend and the WHO weekly update for 29 July reported a total of only 3 new cases, the lowest in more than a year. On 17 August the country marked its first week with no new cases, and one week later the last patients were released. However, a new case emerged on 1 September, when a patient from Sella Kafta village in Kambia District tested positive for the disease after her death; her case eventually resulted in 3 other infections among her contacts. On 14 September 2015 Sierra Leone's National Ebola Response Centre confirmed the death of a 16-year-old in a village in the Bombali District . It is suspected that she contracted the disease from the semen of an Ebola survivor who had been discharged in March 2015. On 27 September a new 42-day countdown began to declare the country Ebola-free, which eventually occurred on 7 November 2015; thereafter, the country increased its vigilance on the Guinean border. Sierra Leone had entered a 90-day period of enhanced surveillance that was scheduled to end on 5 February 2016, when, on 14 January, a new Ebola death was reported in the Tonkolili District . Prior to this case, the WHO had advised that "we still anticipate more flare-ups and must be prepared for them. A massive effort is underway to ensure robust prevention, surveillance and response capacity across all three countries by the end of March." On 16 January aid workers reported that a woman had died of the virus and that she may have exposed several individuals; the government later announced that 100 people had been quarantined. Investigations indicated that the deceased was a female student from Lunsar , in Port Loko District , who had gone to Kambia District on 28 December 2015 before returning symptomatic. She had also visited Bombali District to consult a herbalist, and had later gone to a government hospital in Magburaka . The WHO indicated that there were 109 contacts (28 of them high-risk), that there were another 3 missing contacts, and that the source or route of transmission that caused the fatality was unknown. A second new case—confirmed by WHO spokesman Tarik Jasarevic to involve a 38-year-old relative and caregiver of the aforementioned Ebola victim—had become symptomatic on 20 Jan while under observation at a quarantine centre. On 22 January it was reported that this patient was responding to treatment. On 26 January WHO Director-General, Dr Margaret Chan officially confirmed that the outbreak was not yet over; that same day, it was also reported that Ebola restrictions had halted market activity in Kambia District amid protests. On 7 February 70 individuals were released from quarantine, and on 8 February the last Ebola patient was also released. On 17 February the WHO indicated that 2,600 Ebola survivors had accessed health assessments and eye examinations. On 4 February 2016 the last known case tested negative for a second consecutive time and Sierra Leone commenced another 42-day countdown towards being declared Ebola-free. On 17 March 2016 the WHO announced that the Sierra Leone flare-up was over, and that no other chains of transmission were known to be active at that time. The media reported that Sierra Leone then entered a 90-day period of heightened surveillance, which concluded on 15 June 2016, and it was reported that by 15 July the country had discontinued testing corpses for the virus. In Liberia, the disease was reported in both Lofa and Nimba counties in late March 2014. On 27 July, President Ellen Johnson Sirleaf announced that Liberia would close its borders, with the exception of a few crossing points such as Roberts International Airport , where screening centres would be established. Schools and universities were closed, and the worst-affected areas in the country were placed under quarantine. With only 50 physicians in the entire country—one for every 70,000 citizens—Liberia was already in a healthcare crisis. In September, the CDC reported that some hospitals had been abandoned, while those still functioning lacked basic facilities and supplies. In October, the Liberian ambassador in Washington was reported as saying that he feared that his country may be "close to collapse"; by 24 October, all 15 counties had reported Ebola cases. By November 2014, the rate of new infections in Liberia appeared to be declining and the state of emergency was lifted. The drop in cases was believed to be related to an integrated strategy combining isolation and treatment with community behaviour change, including safe burial practices, case finding and contact tracing . Roselyn Nugba-Ballah , leader of the Safe & Diginified Burial Practices Team during the crisis, was awarded the Florence Nightingale Medal in 2017 for her work during the crisis. In January 2015, the MSF field coordinator reported that Liberia was down to only 5 confirmed cases. In March, after two weeks of not reporting any new cases, 3 new cases were confirmed. On 8 April, a new health minister was named in an effort to end Ebola in the country and on 26 April, MSF handed the Ebola treatment facility, ELWA-3, over to the government. On 30 April, the US shut down a special Ebola treatment unit in Liberia. The last known case of Ebola died on 27 March, and the country was officially declared Ebola-free on 9 May 2015, after 42 days without any further cases being recorded. The WHO congratulated Liberia saying, "reaching this milestone is a testament to the strong leadership and coordination of Liberian President Ellen Johnson Sirleaf and the Liberian Government, the determination and vigilance of Liberian communities, the extensive support of global partners, and the tireless and heroic work of local and international health teams." As at May 2015, the country remained on high alert against recurrence of the disease. After three months with no new reports of cases, on 29 June Liberia reported that the body of a 17-year-old boy, who had been treated for malaria, tested positive for Ebola. The WHO said the boy had been in close contact with at least 200 people, who they were following up, and that "the case reportedly had no recent history of travel, contact with visitors from affected areas, or funeral attendance." A second case was confirmed on 1 July. After a third new case was confirmed on 2 July, and it was discovered that all 3 new cases had shared a meal of dog meat , researchers looked at the possibility that the meat may have been involved in the transfer of the virus. Testing of the dog's remains, however, was negative for the Ebola virus. By 9 July 3 more cases were discovered, bringing the total number of new cases to 5, all from the same area. On 14 July, a woman died of the disease in the county of Montserrado , bringing the total to 6. On 20 July, the last patients were discharged, and on 3 September 2015, Liberia was declared Ebola-free again. After two months of being Ebola-free, a new case was confirmed on 20 November 2015, when a 15-year-old boy was diagnosed with the virus and two family members subsequently tested positive as well. Health officials were concerned because the child had not recently travelled or been exposed to someone with Ebola and the WHO stated that "we believe that this is probably again, somehow, someone who has come in contact with a virus that had been persisting in an individual, who had suffered the disease months ago." Two staff of the CDC were sent to the country to help ascertain the cause of the new cases. The infected boy died on 24 November, and on 3 December 2 remaining cases were released after recovering from the disease. The 42-day countdown toward Liberia being declared Ebola-free, for the third time, started on 4 December 2015. On 16 December, the WHO reaffirmed that the cases in Liberia were the result of re-emergence of the virus in a previously infected person, and there was speculation that the boy may have been infected by an individual who became infectious once more due to pregnancy, which may have weakened her immune system. On 18 December, the WHO indicated that it still considered Ebola in Western Africa a public health emergency, though progress had been made. After having completed the 42-day time period, Liberia was declared free from the virus on 14 January 2016, effectively ending the outbreak that had started in neighbouring Guinea 2 years earlier. Liberia began a 90-day period of heightened surveillance, scheduled to conclude on 13 April 2016, but on 1 April, it was reported that a new Ebola fatality had occurred, and on 3 April, a second case was reported in Monrovia . On 4 April, it was reported that 84 individuals were under observation due to contact with the 2 confirmed Ebola cases. By 7 April, Liberia had confirmed 3 new cases since the virus resurfaced and a total of 97 contacts, including 15 healthcare workers, were being monitored. The index case of the new flareup was reported to be the wife of a patient who died from Ebola in Guinea; she had travelled to Monrovia after the funeral but died from the disease. The outbreak in Guinea, in turn, had begun when a man, who had survived Ebola, had sexual intercourse with a woman and passed the virus to her, even though he had recovered more than a year earlier. On 29 April, WHO reported that Liberia had discharged the last patient and had begun the 42-day countdown to be declared Ebola-free once more. According to the WHO, tests indicated that the flare-up was likely due to contact with a prior Ebola survivor's infected body fluids. On 9 June, the flare-up was declared over, and the country Ebola-free, due to the passage of the 42-day period; Liberia then entered a 90-day period of heightened surveillance, which ended on 7 September 2016. In early July 2016, a trial for males with detectable Ebola RNA in semen, started. In March 2014, the Senegal Ministry of Interior closed its southern border with Guinea, but on 29 August, the health minister announced the country's first case – a university student from Guinea who was being treated in a Dakar hospital. The patient was a native of Guinea who had travelled to Dakar, arriving on 20 August. On 23 August, he sought medical care for symptoms including diarrhoea, and vomiting plus signs of fever. He received treatment for malaria but did not improve and left the facility. Still experiencing the same symptoms, on 26 August he was referred to a specialised facility for infectious diseases, and subsequently hospitalised. On 28 August 2014, authorities in Guinea issued an alert informing their medical services and neighbouring countries that a person who had been in close contact with an Ebola-infected patient had escaped their surveillance system. The alert prompted testing for Ebola at the Dakar laboratory, and the positive result launched an investigation, triggering urgent contact tracing. On 10 September, it was reported that the student had recovered but health officials continued to monitor his contacts for 21 days. No further cases were reported, and on 17 October 2014, the WHO officially declared that the outbreak in Senegal had ended. The WHO officially commended the Senegalese government, and in particular the President Macky Sall and the Minister of Health, Dr Awa Coll-Seck , for their response in quickly isolating the patient and tracing and following up 74 contacts, as well as for their public awareness campaign. This acknowledgement was also extended to MSF and the CDC for their assistance. The first case in Nigeria was a Liberian-American, who flew from Liberia to Nigeria's most populated city of Lagos on 20 July 2014. On 6 August 2014, the Nigerian health minister told reporters that one of the nurses that attended to the Liberian had died from the disease. 5 newly confirmed cases were being treated at an isolation ward. On 22 September 2014, the Nigerian health ministry announced, "As of today, there is no case of Ebola in Nigeria." According to the WHO, 20 cases and 8 deaths were confirmed, including the imported case, who also died. 4 of the dead were health workers who had cared for the index case. The WHO's representative in Nigeria officially declared the country Ebola-free on 20 October 2014, after no new active cases were reported in the follow-up contacts, stating it was a "spectacular success story". Nigeria was the first African country to be declared Ebola free. This was largely due to the early quarantine efforts of Dr. Ameyo Stella Adadevoh at First Consultants Medical Centre in Lagos. On 23 October 2014, the first case of Ebola virus disease in Mali was confirmed in the city of Kayes —a two-year-old girl who had arrived with a family group from Guinea, and died the next day. Her father had worked for the Red Cross in Guinea and also in a private health clinic; he had died earlier in the month, likely from an Ebola infection contracted in the private clinic. It was later established that a number of family members had also died of Ebola. The family had returned to Mali after the father's funeral via public bus and taxi—a journey of more than 1,200 kilometres (750 mi) . All contacts were followed for 21 days, with no further spread of the disease reported. On 12 November 2014, Mali reported deaths from Ebola in an outbreak unconnected with the first case in Kayes. The first probable case was an imam who had fallen ill on 17 October in Guinea and was transferred to the Pasteur Clinic in Mali's capital city, Bamako , for treatment. He was treated for kidney failure but was not tested for Ebola; he died on 27 October and his body returned to Guinea for burial. A nurse and a doctor who had treated the imam subsequently fell ill with Ebola and died. The next 3 cases were related to the imam as well: a man who had visited the imam while he was in hospital, his wife and his son. On 22 November, the final case related to the imam was reported—a friend of the Pasteur Clinic nurse who had died from the Ebola virus. On 12 December, the last case in treatment recovered and was discharged, "so there are no more people sick with Ebola in Mali", according to a Ministry of Health source. On 16 December, Mali released the final 13 individuals who were being quarantined and 24 days later (18 January 2015) without new cases, the country was declared Ebola-free. In March 2014, the Senegal Ministry of Interior closed its southern border with Guinea, but on 29 August, the health minister announced the country's first case – a university student from Guinea who was being treated in a Dakar hospital. The patient was a native of Guinea who had travelled to Dakar, arriving on 20 August. On 23 August, he sought medical care for symptoms including diarrhoea, and vomiting plus signs of fever. He received treatment for malaria but did not improve and left the facility. Still experiencing the same symptoms, on 26 August he was referred to a specialised facility for infectious diseases, and subsequently hospitalised. On 28 August 2014, authorities in Guinea issued an alert informing their medical services and neighbouring countries that a person who had been in close contact with an Ebola-infected patient had escaped their surveillance system. The alert prompted testing for Ebola at the Dakar laboratory, and the positive result launched an investigation, triggering urgent contact tracing. On 10 September, it was reported that the student had recovered but health officials continued to monitor his contacts for 21 days. No further cases were reported, and on 17 October 2014, the WHO officially declared that the outbreak in Senegal had ended. The WHO officially commended the Senegalese government, and in particular the President Macky Sall and the Minister of Health, Dr Awa Coll-Seck , for their response in quickly isolating the patient and tracing and following up 74 contacts, as well as for their public awareness campaign. This acknowledgement was also extended to MSF and the CDC for their assistance. The first case in Nigeria was a Liberian-American, who flew from Liberia to Nigeria's most populated city of Lagos on 20 July 2014. On 6 August 2014, the Nigerian health minister told reporters that one of the nurses that attended to the Liberian had died from the disease. 5 newly confirmed cases were being treated at an isolation ward. On 22 September 2014, the Nigerian health ministry announced, "As of today, there is no case of Ebola in Nigeria." According to the WHO, 20 cases and 8 deaths were confirmed, including the imported case, who also died. 4 of the dead were health workers who had cared for the index case. The WHO's representative in Nigeria officially declared the country Ebola-free on 20 October 2014, after no new active cases were reported in the follow-up contacts, stating it was a "spectacular success story". Nigeria was the first African country to be declared Ebola free. This was largely due to the early quarantine efforts of Dr. Ameyo Stella Adadevoh at First Consultants Medical Centre in Lagos. On 23 October 2014, the first case of Ebola virus disease in Mali was confirmed in the city of Kayes —a two-year-old girl who had arrived with a family group from Guinea, and died the next day. Her father had worked for the Red Cross in Guinea and also in a private health clinic; he had died earlier in the month, likely from an Ebola infection contracted in the private clinic. It was later established that a number of family members had also died of Ebola. The family had returned to Mali after the father's funeral via public bus and taxi—a journey of more than 1,200 kilometres (750 mi) . All contacts were followed for 21 days, with no further spread of the disease reported. On 12 November 2014, Mali reported deaths from Ebola in an outbreak unconnected with the first case in Kayes. The first probable case was an imam who had fallen ill on 17 October in Guinea and was transferred to the Pasteur Clinic in Mali's capital city, Bamako , for treatment. He was treated for kidney failure but was not tested for Ebola; he died on 27 October and his body returned to Guinea for burial. A nurse and a doctor who had treated the imam subsequently fell ill with Ebola and died. The next 3 cases were related to the imam as well: a man who had visited the imam while he was in hospital, his wife and his son. On 22 November, the final case related to the imam was reported—a friend of the Pasteur Clinic nurse who had died from the Ebola virus. On 12 December, the last case in treatment recovered and was discharged, "so there are no more people sick with Ebola in Mali", according to a Ministry of Health source. On 16 December, Mali released the final 13 individuals who were being quarantined and 24 days later (18 January 2015) without new cases, the country was declared Ebola-free. On 29 December 2014, Pauline Cafferkey , a British aid worker who had just returned to Glasgow from Sierra Leone, was diagnosed with Ebola. She was treated and declared to be free of infection and released from hospital on 24 January 2015. On 8 October, she was readmitted for complications caused by the virus and was in "serious" condition, according to a hospital report. On 14 October, her condition was listed as "critical" and 58 individuals were being monitored and 25 received an experimental vaccination, being close contacts. On 21 October, it was reported that she had been diagnosed with meningitis caused by the virus persisting in her brain. On 12 November, she was released from hospital after making a full recovery. However, on 23 February, Ms. Cafferkey was admitted for a third time, "under routine monitoring by the Infectious Diseases Unit ... for further investigations", according to a spokesperson. On 12 May 2015, it was reported that a nurse, who had been working in Sierra Leone, had been diagnosed with Ebola after returning home to the Italian island of Sardinia . He was treated at Spallanzani Hospital , the national reference centre for Ebola patients. On 10 June, it was reported that he had recovered and was disease-free and he was released from hospital. On 5 August 2014, the Brothers Hospitallers of Saint John of God confirmed that Brother Miguel Pajares, who had been volunteering in Liberia, had become infected. He was evacuated to Spain and died on 12 August. On 21 September it was announced that Brother Manuel García Viejo, another Spanish citizen who was medical director at the St John of God Hospital Sierra Leone in Lunsar , had been evacuated to Spain from Sierra Leone after being infected with the virus. His death was announced on 25 September. In October 2014, a nursing assistant, Teresa Romero, who had cared for these patients became unwell and on 6 October tested positive for Ebola, making this the first confirmed case of Ebola transmission outside of Africa. On 19 October, it was reported that Romero had recovered, and on 2 December the WHO declared Spain Ebola-free following the passage of 42 days since Teresa Romero was found to be cured. On 30 September 2014, the CDC declared its first case of Ebola virus disease. It disclosed that Thomas Eric Duncan became infected in Liberia and travelled to Dallas , Texas on 20 September. On 26 September, he fell ill and sought medical treatment, but was sent home with antibiotics. He returned to the hospital by ambulance on 28 September and was placed in isolation and tested for Ebola. He died on 8 October. Two cases stemmed from Duncan, when two nurses that had treated him tested positive for the virus; they were declared Ebola-free on 24 and 22 October, respectively. A fourth case was identified on 23 October 2014, when Craig Spencer , an American physician who had returned to the United States after treating Ebola patients in Western Africa, tested positive for the virus. This case, however, had no relation to those originating from Duncan. Spencer recovered and was released from hospital on 11 November. On 29 December 2014, Pauline Cafferkey , a British aid worker who had just returned to Glasgow from Sierra Leone, was diagnosed with Ebola. She was treated and declared to be free of infection and released from hospital on 24 January 2015. On 8 October, she was readmitted for complications caused by the virus and was in "serious" condition, according to a hospital report. On 14 October, her condition was listed as "critical" and 58 individuals were being monitored and 25 received an experimental vaccination, being close contacts. On 21 October, it was reported that she had been diagnosed with meningitis caused by the virus persisting in her brain. On 12 November, she was released from hospital after making a full recovery. However, on 23 February, Ms. Cafferkey was admitted for a third time, "under routine monitoring by the Infectious Diseases Unit ... for further investigations", according to a spokesperson. On 12 May 2015, it was reported that a nurse, who had been working in Sierra Leone, had been diagnosed with Ebola after returning home to the Italian island of Sardinia . He was treated at Spallanzani Hospital , the national reference centre for Ebola patients. On 10 June, it was reported that he had recovered and was disease-free and he was released from hospital. On 5 August 2014, the Brothers Hospitallers of Saint John of God confirmed that Brother Miguel Pajares, who had been volunteering in Liberia, had become infected. He was evacuated to Spain and died on 12 August. On 21 September it was announced that Brother Manuel García Viejo, another Spanish citizen who was medical director at the St John of God Hospital Sierra Leone in Lunsar , had been evacuated to Spain from Sierra Leone after being infected with the virus. His death was announced on 25 September. In October 2014, a nursing assistant, Teresa Romero, who had cared for these patients became unwell and on 6 October tested positive for Ebola, making this the first confirmed case of Ebola transmission outside of Africa. On 19 October, it was reported that Romero had recovered, and on 2 December the WHO declared Spain Ebola-free following the passage of 42 days since Teresa Romero was found to be cured. On 30 September 2014, the CDC declared its first case of Ebola virus disease. It disclosed that Thomas Eric Duncan became infected in Liberia and travelled to Dallas , Texas on 20 September. On 26 September, he fell ill and sought medical treatment, but was sent home with antibiotics. He returned to the hospital by ambulance on 28 September and was placed in isolation and tested for Ebola. He died on 8 October. Two cases stemmed from Duncan, when two nurses that had treated him tested positive for the virus; they were declared Ebola-free on 24 and 22 October, respectively. A fourth case was identified on 23 October 2014, when Craig Spencer , an American physician who had returned to the United States after treating Ebola patients in Western Africa, tested positive for the virus. This case, however, had no relation to those originating from Duncan. Spencer recovered and was released from hospital on 11 November. A number of people who had become infected with Ebola were medically evacuated for treatment in isolation wards in Europe or the US. They were mostly health workers with one of the NGOs in Western Africa. With the exception of a single isolated case in Spain , no secondary infections occurred as a result of the medical evacuations. The US accepted four evacuees and three were flown to Germany. France, Italy, the Netherlands, Norway, Switzerland, and the United Kingdom received two patients (and five who were exposed). In August 2014, the WHO reported an outbreak of Ebola virus in the Boende District, part of the northern Équateur province of the Democratic Republic of the Congo (DRC), where 13 people were reported to have died of Ebola-like symptoms. Genetic sequencing revealed that this outbreak was caused by the Zaire Ebola species, which is native to the DRC; there have been seven previous Ebola outbreaks in the country since 1976. The virology results and epidemiological findings indicated no connection to the epidemic in Western Africa. The index case was initially reported to have been a woman from Ikanamongo Village, who became ill with symptoms of Ebola after she had butchered a bush animal. However, later findings suggested that there may have been several previous cases, and it was reported that pigs in the village may have been infected with Ebola some time before the first human case occurred. The WHO declared the outbreak over on 21 November 2014, after a total of 66 cases and 49 deaths. Ebola virus disease is caused by four of six viruses classified in the genus Ebolavirus . Of the four disease-causing viruses, Ebola virus (formerly and often still called the Zaire Ebola virus) is dangerous and is the virus responsible for the epidemic in Western Africa. Since the discovery of the viruses in 1976, when outbreaks occurred in South Sudan (then Sudan) and Democratic Republic of the Congo (then Zaire), Ebola virus disease had been confined to areas in Middle Africa, where it is native. With the current outbreak, it was initially thought that a new species native to Guinea might be the cause, rather than being imported from Middle to Western Africa. However, further studies have shown that the outbreak was likely caused by an Ebola virus lineage that spread from Middle Africa via an animal host within the last decade, with the first viral transfer to humans in Guinea. In a study done by Tulane University , the Broad Institute and Harvard University , in partnership with the Sierra Leone Ministry of Health and Sanitation , researchers provided information about the origin and transmission of the Ebola virus that set the Western African outbreak apart from previous ones, including 341 genetic changes in the virion . Five members of the research team became ill and died from Ebola before the study was published in August 2014. In a report released in August 2014, researchers tracked the spread of Ebola in Sierra Leone from the group first infected—13 women who had attended the funeral of the traditional healer, where they contracted the disease—giving them a unique opportunity to track how the virus had changed. This provided "the first time that the real evolution of the Ebola virus [could] be observed in humans." The research showed that the outbreak in Sierra Leone was sparked by at least two distinct lineages introduced from Guinea at about the same time. It is not clear whether the traditional healer was infected with both variants, or if perhaps one of the women attending the funeral was independently infected. As the Sierra Leone epidemic progressed, one virus lineage disappeared from patient samples, while a third one appeared. In January 2015, the media stated researchers in Guinea had reported mutations in the virus samples that they were looking at. According to them, "we've now seen several cases that don't have any symptoms at all, asymptomatic cases. These people may be the people who can spread the virus better, but we still don't know that yet. A virus can change itself to [become] less deadly, but more contagious and that's something we are afraid of." A 2015 study suggested that accelerating the rate of mutation of the Ebola virus could make the virus less capable of infecting humans. In this animal study, the virus became practically non-viable, consequently increasing survival. The initial infection is believed to occur after an Ebola virus is transmitted to a human by contact with an infected animal's body fluids. Evidence strongly implicates bats as the reservoir hosts for ebolaviruses (however, despite considerable research, infectious ebolaviruses have never been recovered from bats). Bats drop partially eaten fruit and pulp, then land mammals such as gorillas and duikers feed on this fallen fruit. This chain of events forms a possible indirect means of transmission from the natural host to animal populations. As primates in the area were not found to be infected and fruit bats do not live near the location of the initial zoonotic transmission event in Meliandou, Guinea, it is suspected that the index case occurred after a child had contact with an insectivorous bat from a colony of Angolan free-tailed bats near the village. On 12 January, the journal Nature reported that the virus emergence could be found by studying how bush-meat hunters interacted with the ecosystem. The continent of Africa has experienced deforestation in several areas or regions; this may contribute to recent outbreaks, including this epidemic, as initial cases have been in the proximity of deforested lands where fruit-eating bats natural habitat may be affected, though 100% evidence does not as yet exist. Prior to this outbreak, it was believed that human-to-human transmission occurred only via direct contact with blood or bodily fluids from an infected person who is showing symptoms of infection, by contact with the body of a person who had died of Ebola, or by contact with objects recently contaminated with the body fluids of an actively ill infected person. It is now known that the Ebola virus can be transmitted sexually. Over time, studies have suggested that the virus can persist in seminal fluid , with a study released in September 2016 suggesting that the virus may survive more than 530 days after infection. EBOV RNA in semen is not the same situation as perseverance of EBOV in semen, however the "clinical significance of low levels of virus RNA in convalescent" individuals who are healthy is unknown. In September 2014, the WHO had reported: "No formal evidence exists of sexual transmission, but sexual transmission from convalescent patients cannot be ruled out. There is evidence that live Ebola virus can be isolated in seminal fluids of convalescent men for 82 days after onset of symptoms. Evidence is not available yet beyond 82 days." In April 2015, following a report that the RNA virus had been detected in a semen sample six months after a man's recovery, the WHO issued a statement: "For greater security and prevention of other sexually transmitted infections, Ebola survivors should consider correct and consistent use of condoms for all sexual acts beyond three months until more information is available." The WHO based their new recommendations on a March 2015 case, in which a Liberian woman who had no contact with the disease other than having had unprotected sex with a man who had had the disease in October 2014, was diagnosed with Ebola. While no evidence of the virus was found in his blood, his semen revealed Ebola virus RNA closely matching the variant that infected the woman. However, "doctors don't know if there was any fully formed (and therefore infectious) virus in the guy's semen." It is known that testes are protected from the body's immune system to protect the developing sperm , and it is thought that this same protection may allow the virus to survive in the testes for an unknown time. On 14 September 2015, the body of a girl who had died in Sierra Leone tested positive for Ebola and it was suspected that she may have contracted the disease from the semen of an Ebola survivor who was discharged in March 2015. According to some news reports, a new study to be published in the New England Journal of Medicine indicated that the RNA virus could remain in the semen of survivors for up to six months, and according to other researchers, the RNA virus could continue in semen for 82 days and maybe longer. Furthermore, Ebola RNA had been found up to 284 days post-onset of viral symptoms. One of the primary reasons for the spread of the disease is the low-quality, functioning health systems in the parts of Africa where the disease occurs. The risk of transmission is increased among those caring for people infected. Recommended measures when caring for those who are infected include medical isolation via the proper use of boots, gowns, gloves, masks and goggles, and sterilizing all equipment and surfaces . One of the biggest dangers of infection faced by medical staff requires their learning how to properly suit up and remove personal protective equipment. Full training for wearing protective body clothing can take 10 to 14 days. Even with proper isolation equipment available, working conditions such as lack of running water, climate control, and flooring have made direct care difficult. Two American health workers who contracted the disease and later recovered said that to the best of their knowledge, their team of workers had been following "to the letter all of the protocols for safety that were developed by the [CDC] and WHO", including a full body coverall, several layers of gloves, and face protection including goggles. One of the two, a physician, had worked with patients, but the other was assisting workers to get in and out of their protective gear while wearing protective gear herself. Difficulties in attempting to halt transmission have also included the multiple disease outbreaks across country borders. Dr Peter Piot , the scientist who co-discovered the Ebola virus, stated that the outbreak was not following its usual linear patterns as mapped out in earlier outbreaks—this time the virus was "hopping" all over the Western African epidemic region. Furthermore, most past epidemics had occurred in remote regions, but this outbreak spread to large urban areas, which had increased the number of contacts an infected person might have and made transmission harder to track and break. On 9 December, a study indicated that a single individual introduced the virus into Liberia, causing the most cases of the disease in that country. The initial infection is believed to occur after an Ebola virus is transmitted to a human by contact with an infected animal's body fluids. Evidence strongly implicates bats as the reservoir hosts for ebolaviruses (however, despite considerable research, infectious ebolaviruses have never been recovered from bats). Bats drop partially eaten fruit and pulp, then land mammals such as gorillas and duikers feed on this fallen fruit. This chain of events forms a possible indirect means of transmission from the natural host to animal populations. As primates in the area were not found to be infected and fruit bats do not live near the location of the initial zoonotic transmission event in Meliandou, Guinea, it is suspected that the index case occurred after a child had contact with an insectivorous bat from a colony of Angolan free-tailed bats near the village. On 12 January, the journal Nature reported that the virus emergence could be found by studying how bush-meat hunters interacted with the ecosystem. The continent of Africa has experienced deforestation in several areas or regions; this may contribute to recent outbreaks, including this epidemic, as initial cases have been in the proximity of deforested lands where fruit-eating bats natural habitat may be affected, though 100% evidence does not as yet exist. Prior to this outbreak, it was believed that human-to-human transmission occurred only via direct contact with blood or bodily fluids from an infected person who is showing symptoms of infection, by contact with the body of a person who had died of Ebola, or by contact with objects recently contaminated with the body fluids of an actively ill infected person. It is now known that the Ebola virus can be transmitted sexually. Over time, studies have suggested that the virus can persist in seminal fluid , with a study released in September 2016 suggesting that the virus may survive more than 530 days after infection. EBOV RNA in semen is not the same situation as perseverance of EBOV in semen, however the "clinical significance of low levels of virus RNA in convalescent" individuals who are healthy is unknown. In September 2014, the WHO had reported: "No formal evidence exists of sexual transmission, but sexual transmission from convalescent patients cannot be ruled out. There is evidence that live Ebola virus can be isolated in seminal fluids of convalescent men for 82 days after onset of symptoms. Evidence is not available yet beyond 82 days." In April 2015, following a report that the RNA virus had been detected in a semen sample six months after a man's recovery, the WHO issued a statement: "For greater security and prevention of other sexually transmitted infections, Ebola survivors should consider correct and consistent use of condoms for all sexual acts beyond three months until more information is available." The WHO based their new recommendations on a March 2015 case, in which a Liberian woman who had no contact with the disease other than having had unprotected sex with a man who had had the disease in October 2014, was diagnosed with Ebola. While no evidence of the virus was found in his blood, his semen revealed Ebola virus RNA closely matching the variant that infected the woman. However, "doctors don't know if there was any fully formed (and therefore infectious) virus in the guy's semen." It is known that testes are protected from the body's immune system to protect the developing sperm , and it is thought that this same protection may allow the virus to survive in the testes for an unknown time. On 14 September 2015, the body of a girl who had died in Sierra Leone tested positive for Ebola and it was suspected that she may have contracted the disease from the semen of an Ebola survivor who was discharged in March 2015. According to some news reports, a new study to be published in the New England Journal of Medicine indicated that the RNA virus could remain in the semen of survivors for up to six months, and according to other researchers, the RNA virus could continue in semen for 82 days and maybe longer. Furthermore, Ebola RNA had been found up to 284 days post-onset of viral symptoms. One of the primary reasons for the spread of the disease is the low-quality, functioning health systems in the parts of Africa where the disease occurs. The risk of transmission is increased among those caring for people infected. Recommended measures when caring for those who are infected include medical isolation via the proper use of boots, gowns, gloves, masks and goggles, and sterilizing all equipment and surfaces . One of the biggest dangers of infection faced by medical staff requires their learning how to properly suit up and remove personal protective equipment. Full training for wearing protective body clothing can take 10 to 14 days. Even with proper isolation equipment available, working conditions such as lack of running water, climate control, and flooring have made direct care difficult. Two American health workers who contracted the disease and later recovered said that to the best of their knowledge, their team of workers had been following "to the letter all of the protocols for safety that were developed by the [CDC] and WHO", including a full body coverall, several layers of gloves, and face protection including goggles. One of the two, a physician, had worked with patients, but the other was assisting workers to get in and out of their protective gear while wearing protective gear herself. Difficulties in attempting to halt transmission have also included the multiple disease outbreaks across country borders. Dr Peter Piot , the scientist who co-discovered the Ebola virus, stated that the outbreak was not following its usual linear patterns as mapped out in earlier outbreaks—this time the virus was "hopping" all over the Western African epidemic region. Furthermore, most past epidemics had occurred in remote regions, but this outbreak spread to large urban areas, which had increased the number of contacts an infected person might have and made transmission harder to track and break. On 9 December, a study indicated that a single individual introduced the virus into Liberia, causing the most cases of the disease in that country. In August 2014, the WHO published a road map of the steps required to bring the epidemic under control and to prevent further transmission of the disease within Western Africa; the coordinated international response worked towards realising this plan. Contact tracing is an essential method of preventing the spread of the disease, this requires effective community surveillance so that a possible case of Ebola can be registered and accurately diagnosed as soon as possible, and subsequently finding everyone who has had close contact with the case and tracking them for 21 days. However, this requires careful record-keeping by properly trained and equipped staff. WHO Assistant Director-General for Global Health Security, Keiji Fukuda, said on 3 September 2014, "We don't have enough health workers, doctors, nurses, drivers, and contact tracers to handle the increasing number of cases." There was a massive effort to train volunteers and health workers, sponsored by United States Agency for International Development (USAID). According to WHO reports, 25,926 contacts from Guinea, 35,183 from Liberia and 104,454 from Sierra Leone were listed and traced as of 23 November 2014. According to one study, it is important to have a public awareness campaign to inform the affected community about the importance of contact tracing, so that true information can be obtained from the community. To reduce the spread, the WHO recommended raising community awareness of the risk factors for Ebola infection and the protective measures individuals can take. These include avoiding contact with infected people and regular hand washing using soap and water. A condition of extreme poverty exists in many of the areas that experienced a high incidence of infections. According to the director of the NGO Plan International in Guinea, "The poor living conditions and lack of water and sanitation in most districts of Conakry pose a serious risk that the epidemic escalates into a crisis. People do not think to wash their hands when they do not have enough water to drink ." One study showed that once people had heard of the Ebola virus disease, hand washing with soap and water improved, though socio-demographic factors influenced hygiene. A number of organisations enrolled local people to conduct public awareness campaigns among the communities in Western Africa. "... what we mean by social mobilization is to try to convey the right messages, in terms of prevention measures, adapted to the local context—adapted to the cultural practices in a specific area," said Vincent Martin, FAO 's representative in Senegal. Denial in some affected countries also made containment efforts difficult. Language barriers and the appearance of medical teams in protective suits sometimes increased fears of the virus. In Liberia, a mob attacked an Ebola isolation centre, stealing equipment and "freeing" patients while shouting "There's no Ebola." Red Cross staff were forced to suspend operations in southeast Guinea after they were threatened by a group of men armed with knives. In September, in the town of Womey in Guinea, suspicious inhabitants wielding machetes murdered at least eight aid workers and dumped their bodies in a latrine . An August 2014 study found that nearly two-thirds of Ebola cases in Guinea were believed to be due to burial practices including washing of the body of one who had died . In November, WHO released a protocol for the safe and dignified burial of people who die from Ebola virus disease. It encouraged the inclusion of family and clergy, and gave specific instructions for Muslim and Christian burials. In the 21 January 2015 WHO road map update, it was reported that 100% of districts in Sierra Leone and 71% of districts in Guinea had a list of key religious leaders who promoted safe and dignified burials. Speaking on 27 January 2015, Guinea's Grand Imam, the country's highest cleric, gave a very strong message saying, "There is nothing in the Koran that says you must wash, kiss or hold your dead loved ones," and he called on citizens to do more to stop the virus by practising safer burying rituals that do not compromise tradition. During the height of the epidemic, most schools in the three most affected countries were shut down and remained closed for several months. During the period of closure UNICEF and its partners established strict hygiene protocols to be used when the schools were reopened in January 2015. They met with thousands of teachers and administrators to work out hygiene guidelines. Their efforts included installing hand-washing stations and distributing millions of bars of soap and chlorine and plans for taking the temperature of children and staff at the school gate. Their efforts were complicated by the fact that less than 50% of the schools in these three countries had access to running water. In August 2015, UNICEF released a report that stated, "Across the three countries, there have been no reported cases of a student or teacher being infected at a school since strict hygiene protocols were introduced when classes resumed at the beginning of the year after a months-long delay caused by the virus." Researchers presented evidence indicating that infected people that lived in low socioeconomic areas were more likely to transmit the virus to other socioeconomic status (SES) communities, in contrast to individuals in higher SES areas who were infected as well. Another study showed that, in Guinea, a satisfactory knowledge had not altered the level of comprehensive knowledge about the virus. As a consequence, the high level of misinterpretation was responsible for a low comprehensive knowledge about the virus; 82% of individuals believed that Ebola was the result of a virus (36.2% thought that a higher power had caused it). A study on Nigeria's success story stated that, in this case, a prompt response by the government and proactive public health measures had resulted in the quick control of the outbreak. During the height of the crisis, Wikipedia's Ebola page received 2.5 million page views per day, making Wikipedia one of the world's most highly used sources of trusted medical information regarding the disease. There was serious concern that the disease would spread further within Western Africa or elsewhere in the world, such as:Contact tracing is an essential method of preventing the spread of the disease, this requires effective community surveillance so that a possible case of Ebola can be registered and accurately diagnosed as soon as possible, and subsequently finding everyone who has had close contact with the case and tracking them for 21 days. However, this requires careful record-keeping by properly trained and equipped staff. WHO Assistant Director-General for Global Health Security, Keiji Fukuda, said on 3 September 2014, "We don't have enough health workers, doctors, nurses, drivers, and contact tracers to handle the increasing number of cases." There was a massive effort to train volunteers and health workers, sponsored by United States Agency for International Development (USAID). According to WHO reports, 25,926 contacts from Guinea, 35,183 from Liberia and 104,454 from Sierra Leone were listed and traced as of 23 November 2014. According to one study, it is important to have a public awareness campaign to inform the affected community about the importance of contact tracing, so that true information can be obtained from the community. To reduce the spread, the WHO recommended raising community awareness of the risk factors for Ebola infection and the protective measures individuals can take. These include avoiding contact with infected people and regular hand washing using soap and water. A condition of extreme poverty exists in many of the areas that experienced a high incidence of infections. According to the director of the NGO Plan International in Guinea, "The poor living conditions and lack of water and sanitation in most districts of Conakry pose a serious risk that the epidemic escalates into a crisis. People do not think to wash their hands when they do not have enough water to drink ." One study showed that once people had heard of the Ebola virus disease, hand washing with soap and water improved, though socio-demographic factors influenced hygiene. A number of organisations enrolled local people to conduct public awareness campaigns among the communities in Western Africa. "... what we mean by social mobilization is to try to convey the right messages, in terms of prevention measures, adapted to the local context—adapted to the cultural practices in a specific area," said Vincent Martin, FAO 's representative in Senegal. Denial in some affected countries also made containment efforts difficult. Language barriers and the appearance of medical teams in protective suits sometimes increased fears of the virus. In Liberia, a mob attacked an Ebola isolation centre, stealing equipment and "freeing" patients while shouting "There's no Ebola." Red Cross staff were forced to suspend operations in southeast Guinea after they were threatened by a group of men armed with knives. In September, in the town of Womey in Guinea, suspicious inhabitants wielding machetes murdered at least eight aid workers and dumped their bodies in a latrine . An August 2014 study found that nearly two-thirds of Ebola cases in Guinea were believed to be due to burial practices including washing of the body of one who had died . In November, WHO released a protocol for the safe and dignified burial of people who die from Ebola virus disease. It encouraged the inclusion of family and clergy, and gave specific instructions for Muslim and Christian burials. In the 21 January 2015 WHO road map update, it was reported that 100% of districts in Sierra Leone and 71% of districts in Guinea had a list of key religious leaders who promoted safe and dignified burials. Speaking on 27 January 2015, Guinea's Grand Imam, the country's highest cleric, gave a very strong message saying, "There is nothing in the Koran that says you must wash, kiss or hold your dead loved ones," and he called on citizens to do more to stop the virus by practising safer burying rituals that do not compromise tradition. During the height of the epidemic, most schools in the three most affected countries were shut down and remained closed for several months. During the period of closure UNICEF and its partners established strict hygiene protocols to be used when the schools were reopened in January 2015. They met with thousands of teachers and administrators to work out hygiene guidelines. Their efforts included installing hand-washing stations and distributing millions of bars of soap and chlorine and plans for taking the temperature of children and staff at the school gate. Their efforts were complicated by the fact that less than 50% of the schools in these three countries had access to running water. In August 2015, UNICEF released a report that stated, "Across the three countries, there have been no reported cases of a student or teacher being infected at a school since strict hygiene protocols were introduced when classes resumed at the beginning of the year after a months-long delay caused by the virus." Researchers presented evidence indicating that infected people that lived in low socioeconomic areas were more likely to transmit the virus to other socioeconomic status (SES) communities, in contrast to individuals in higher SES areas who were infected as well. Another study showed that, in Guinea, a satisfactory knowledge had not altered the level of comprehensive knowledge about the virus. As a consequence, the high level of misinterpretation was responsible for a low comprehensive knowledge about the virus; 82% of individuals believed that Ebola was the result of a virus (36.2% thought that a higher power had caused it). A study on Nigeria's success story stated that, in this case, a prompt response by the government and proactive public health measures had resulted in the quick control of the outbreak. During the height of the crisis, Wikipedia's Ebola page received 2.5 million page views per day, making Wikipedia one of the world's most highly used sources of trusted medical information regarding the disease. There was serious concern that the disease would spread further within Western Africa or elsewhere in the world, such as:No proven Ebola virus-specific treatment presently exists; however, measures can be taken to improve a patient's chances of survival. Ebola symptoms may begin as early as two days or as long as 21 days after one is exposed to the virus. Symptoms usually begin with a sudden influenza -like illness characterised by feeling tired , and pain in the muscles and joints . Later symptoms may include headache, nausea , and abdominal pain; this is often followed by severe vomiting and diarrhoea . In past outbreaks, it has been noted that some patients bleed internally and/or externally; however data published in October 2014 showed that this had been a rare symptom in the Western African outbreak. Another study published in October 2014 suggested that a person's genetic makeup may play a major role in determining how an infected person's body reacts to the disease, with some infected people experiencing mild or no symptoms while others progress to a very severe stage that includes bleeding. Without fluid replacement, such an extreme loss of fluids leads to dehydration , which in turn may lead to hypovolaemic shock —a condition in which there is not enough blood for the heart to pump through the body. If a patient is alert and is not vomiting, oral rehydration therapy may be instituted, but patients who are vomiting or are delirious must be hydrated with intravenous (IV) therapy . However, administration of IV fluids is difficult in the African environment. Inserting an IV needle while wearing three pairs of gloves and goggles that may be fogged is difficult, and once in place, the IV site and line must be constantly monitored. Without sufficient staff to care for patients, needles may become dislodged or pulled out by a delirious patient. A patient's electrolytes must be closely monitored to determine correct fluid administration, for which many areas did not have access to the required laboratory services. Treatment centres were overflowing with patients while others waited to be admitted; dead patients were so numerous that it was difficult to arrange for safe burials. Based on many years of experience in Africa—and several months working in the present epidemic—MSF took a conservative approach. While using IV treatment for as many patients as they could manage, they argued that improperly managed IV treatment was not helpful and may even kill a patient when not properly managed. They also said that they were concerned about further risk to already overworked staff. In 2015 experts studied the mortality rates of different treatment settings, and given the wide differences in variables that affected outcomes, adequate information had not yet been gathered to make a definitive statement about what constituted optimal care in the Western African setting. Paul Farmer of Partners in Health , an NGO that only as of January 2015 had begun to treat Ebola patients, strongly supported IV therapy for all Ebola patients stating: "What if the fatality rate isn't the virulence of disease but the mediocrity of the medical delivery?" Farmer suggested that every treatment facility should have a team that specializes in inserting IVs, or better yet, peripherally inserted central catheter lines. In 2020, viewing the information gathered from the pandemic Farmer noted that there were almost no deaths in the U.S. and European patients because they had received optimal care. Ebola virus disease has a high case fatality rate (CFR), which in past outbreaks varied between 25% and 90%, with an average of about 50%. The epidemic caused significant mortality, with reported CFRs of up to 70%. Care settings that have access to medical expertise may increase survival by providing good maintenance of hydration, circulatory volume, and blood pressure. The disease affects males and females equally and the majority of those that contract Ebola disease are between 15 and 45 years of age. For those over 45 years, a fatal outcome was more likely in the Western African epidemic, as was also noted in preceding outbreaks. Only rarely do pregnant women survive—a midwife who worked with MSF in a Sierra Leone treatment centre stated that she knew of "no reported cases of pregnant mothers and unborn babies surviving Ebola in Sierra Leone." In September 2015, the WHO issued pregnancy guidance information entitled, "Interim Guidance on Ebola Virus Disease in Pregnancy." It has been suggested that the loss of human life was not limited to Ebola victims alone. Many hospitals had to shut down, leaving people with other medical needs without care. A spokesperson for the UK-based health foundation, the Wellcome Trust , said in October 2014 that "the additional death toll from malaria and other diseases [is] likely to exceed that of the outbreak itself". Dr Paul Farmer stated: "Most of Ebola's victims may well be dying from other causes: women in childbirth, children from diarrhoea, people in road accidents or from trauma of other sorts." As the epidemic drew to a close in 2015, a report from Sierra Leone showed that the fear and mistrust of hospitals generated by the epidemic had resulted in an 11% decline in facility-based births, and that those receiving care before or after birth fell by about a fifth. Consequently, between May 2014 and April 2015, the deaths of women during or just after childbirth rose by almost a third and those of newborns by a quarter, compared to the previous year. Research suggests that many Ebola infections are asymptomatic, meaning that some infected people show no symptoms of the disease. For example, two studies done on previous outbreaks showed that 71% of seropositive individuals did not have the clinical disease in one outbreak and another study reported that 46% of asymptomatic close contacts of patients with Ebola were seropositive. On 22 January, the WHO issued Clinical Care for survivors of Ebola Virus Disease: interim guidance . The guidance covers specific issues like musculoskeletal pain, which is reported in up to 75% of survivors. The pain is symmetrical and more pronounced in the morning, with the larger joints most affected. There is also possible periarticular tenosynovitis affecting the shoulders. The WHO guidelines advise to distinguish non-inflammatory arthralgia from inflammatory arthritis . With regard to ocular problems, sensitivity to light and blurry vision have been indicated among survivors. Among the aftereffects of Ebola virus disease, uveitis and optic nerve disease could appear after an individual is discharged. Ocular problems could threaten sight in survivors, thus the need for prompt treatment. In treating such individuals, the WHO recommends urgent intervention if uveitis is suspected; this consists mainly of prednisone (a corticosteroid ). Hearing loss has been reported in Ebola survivors 25% of the time. Treatment, in the case of acute labyrinthitis (inner ear disorder), should be given within 10 days of the onset of symptoms and prochlorperazine, a vestibular sedative, may be administered for vertigo . There are at least 17,000 people who have survived infection from the Ebola virus in Western Africa; some of them have reported lingering health effects. In early November, a WHO consultant reported: "Many of the survivors are discharged with the so-called Post-Ebola Syndrome. We want to ascertain whether these medical conditions are due to the disease itself, the treatment given or chlorine used during disinfection of the patients. This is a new area for research; little is known about the post-Ebola symptoms." In February 2015, a Sierra Leone physician said about half of the recovered patients she saw reported declining health and that she had seen survivors go blind. In May 2015, a senior consultant to the WHO said that the reports of eye problems were especially worrying because "there are hardly any ophthalmologists in Western Africa, and only they have the skills and equipment to diagnose conditions like uveitis that affect the inner chambers of the eye." The medical director of a hospital in Liberia reported that he was seeing health problems in patients who had been in recovery for as long as nine months. Problems he was seeing included chronic pain, sometimes so severe that walking was difficult; eye problems, including uveitis; and headaches as the most common physical symptoms. "They're still very severe and impacting their life every day. These patients will need medical care for months and maybe years." A physician from the Kenema hospital in Sierra Leone reported similar health difficulties. In December 2014, a British aid worker who had just returned from Sierra Leone was diagnosed with Ebola. She was treated with survivors' blood plasma and experimental drugs and declared free of disease in January 2015. However, in October 2015, she again became critically ill and was diagnosed with meningitis. In this unprecedented case it is thought that the virus remained in her brain replicating at a very low level until it had replicated to a degree capable of causing clinical meningitis. The woman was treated and in November 2015 it was reported that she had recovered. In terms of medical literature that are reviews, few articles have been published, such as Shantha, et al. which discusses management of panuveitis and iris heterochromia. An observational study, done roughly 29 months after the 2007 Bundibugyo outbreak in Uganda , found that long-term sequelae (i.e. consequences) persisted among survivors. Symptoms included eye pain, blurred vision, hearing loss, difficulty swallowing, difficulty sleeping, arthralgias, memory loss or confusion, and "various constitutional symptoms controlling for age and sex". From August through December 2014, a total of 10 patients with Ebola were treated in US hospitals; of these patients, 8 survived. In March 2015, the CDC interviewed the survivors; they all reported having had at least one adverse symptom during their recovery period. The symptoms ranged from mild (e.g. hair loss) to more severe complications requiring re-hospitalisation or treatment. The most frequently reported symptoms were lethargy or fatigue, joint pain, and hair loss. Sixty-three per cent reported having eye problems including two who were diagnosed with uveitis, 75% reported psychological or cognitive symptoms, and 38% reported neural difficulties. Although most symptoms resolved or improved over time, only one survivor reported complete resolution of all symptoms. A study published in May 2015 discussed the case of Ian Crozier, a Zimbabwe-born physician and American citizen who became infected with Ebola while he was working at an Ebola treatment centre in Sierra Leone. He was transported to the US and successfully treated at Emory University Hospital. However, after discharge Crozier began to experience symptoms including low back pain, bilateral enthesitis of the Achilles tendon , paresthesias involving his lower legs, and eye pain, which was diagnosed as uveitis. His eye condition worsened and a specimen of aqueous humor obtained from his eye tested positive for Ebola. The authors of the study concluded that "further studies to investigate the mechanisms responsible for the ocular persistence of Ebola and the possible presence of the virus in other immune-privileged sites (e.g., in the central nervous system , gonads , and articular cartilage ) are warranted." The authors also noted that 40% of participants in a survey of 85 Ebola survivors in Sierra Leone reported having "eye problems", though the incidence of actual uveitis was unknown. Another study, which was released in August 2015 looked at the health difficulties reported by survivors. Calling the set of symptoms " post-Ebolavirus disease syndrome ", the research found symptoms that included "chronic joint and muscle pain, fatigue, anorexia, hearing loss, blurred vision, headache, sleep disturbances, low mood and short-term memory problems", and suggested the "implementation of specialised health services to treat and follow-up survivors". In 2018, over two years after the resolution of the Ebola outbreak in Eastern Sierra Leone, a study was conducted of Ebola survivors, with their families used as a control group. The study was published in 2021. Looking at the results, the researchers were able to find an underlying process leading to persistent symptoms in some but not all Ebola survivors. One hypothesis suggests "ongoing inflammation due to persistent infection vs autoimmune phenomena." The authors suggest that more study is needed to come to conclusions about why some survivors continue to experience post-syndrome ailments. In June 2014, it was reported that local authorities did not have the resources to contain the disease, with health centres closing and hospitals becoming overwhelmed. There were also reports that adequate personal protection equipment was not being provided for medical personnel. The Director-General of MSF said: "Countries affected to date simply do not have the capacity to manage an outbreak of this size and complexity on their own. I urge the international community to provide this support on the most urgent basis possible." In late August, MSF called the situation "chaotic" and the medical response "inadequate." They reported that they had expanded their operations, but couldn't keep up with the rapidly increasing need for assistance, which had forced them to reduce the level of care: "It is not currently possible, for example, to administer intravenous treatments." Calling the situation "an emergency within the emergency", MSF reported that many hospitals had shut down due to lack of staff or fears of the virus among patients and staff, which had left people with other health problems without any care at all. Speaking from a remote region, an MSF worker said that a shortage of protective equipment was making the medical management of the disease difficult and that they had limited capacity to safely bury bodies. By September, treatment for Ebola patients had become unavailable in some areas. Speaking on 12 September, WHO Director-General, Margaret Chan, said: "In the three hardest hit countries, Guinea, Liberia and Sierra Leone, the number of new cases is moving far faster than the capacity to manage them in the Ebola-specific treatment centres. Today, there is not one single bed available for the treatment of an Ebola patient in the entire country of Liberia." According to a WHO report released on 19 September, Sierra Leone was meeting only 35% of its need for patient beds, while for Liberia it was just 20%. In early December, the WHO reported that at a national level there were enough beds in treatment facilities to treat and isolate all reported Ebola cases, although their uneven distribution was resulting in serious shortfalls in some areas. Similarly, all affected countries had sufficient and widespread capacity to bury reported deaths; however, because not all deaths were reported, it was possible that the reverse could have been the case in some areas. WHO also reported that every district had access to a laboratory to confirm cases of Ebola within 24 hours of sample collection, and that all three countries had reported that more than 80% of registered contacts associated with known cases of Ebola virus disease were being traced, although contact tracing was still a challenge in areas of intense transmission and those with community resistance. A number of Ebola Treatment Centres were set up in the area, supported by international aid organisations and staffed by a combination of local and international staff. Each treatment centre is divided into a number of distinct and rigorously separate areas. For patients, there is a triage area, and low- and high-risk care wards. For staff, there are areas for preparation and decontamination. An important part of each centre is an arrangement for safe burial or cremation of bodies, required to prevent further infection. In January 2015, a new treatment and research centre was built by Rusal and Russia in the city of Kindia in Guinea. It is one of the most modern medical centres in Guinea. Also in January, MSF admitted its first patients to a new treatment centre in Kissy , an Ebola hotspot on the outskirts of Freetown, Sierra Leone. The centre has a maternity unit for pregnant women with the virus. Although the WHO does not advise caring for Ebola patients at home, in some cases it became a necessity when no hospital treatment beds were available. For those being treated at home, the WHO advised informing the local public health authority and acquiring appropriate training and equipment. UNICEF, USAID and Samaritan's Purse began to take measures to provide support for families that were forced to care for patients at home by supplying caregiver kits intended for interim home-based interventions. The kits included protective clothing, hydration items, medicines, and disinfectant, among other items. Even where hospital beds were available, it was debated whether conventional hospitals are the best place to care for Ebola patients, as the risk of spreading the infection is high. In October, the WHO and non-profit partners launched a program in Liberia to move infected people out of their homes into ad hoc centres that could provide rudimentary care. Health facilities with low-quality systems for preventing infection were involved as sites of amplification during viral outbreaks. The Ebola epidemic caused an increasing demand for protective clothing. A full set of protective clothing includes a suit, goggles, a mask, socks and boots, and an apron. Boots and aprons can be disinfected and reused, but everything else must be destroyed after use. Health workers change garments frequently, discarding gear that has barely been used. This not only takes a great deal of time but also exposes them to the virus because, for those wearing protective clothing, one of the most dangerous moments for contracting Ebola is while suits are being removed. The protective clothing sets that MSF uses cost about $75 apiece. Staff who have returned from deployments to Western Africa say the clothing is so heavy that it can be worn for only about 40 minutes at a stretch. A physician working in Sierra Leone has said: "After about 30 or 40 minutes, your goggles have fogged up; your socks are completely drenched in sweat. You're just walking in water in your boots. And at that point, you have to exit for your own safety ... Here it takes 20–25 minutes to take off a protective suit and must be done with two trained supervisors who watch every step in a military manner to ensure no mistakes are made, because a slip up can easily occur and of course can be fatal." By October, there were reports that protective outfits were beginning to be in short supply and manufacturers began to increase their production. USAID published an open competitive bidding for proposals that address the challenge of developing "new practical and cost-effective solutions to improve infection treatment and control that can be rapidly deployed; 1) to help health care workers provide better care and 2) transform our ability to combat Ebola". On 12 December 2014, USAID announced the result of the first selection in a press release. On 17 December 2014, a team at Johns Hopkins University developed a prototype breakaway hazmat suit, and was awarded a grant from the USAID to develop it. The prototype has a small, battery-powered cooling pack on the worker's belt. "You'll have air blowing out that is room temperature but it's 0% humidity ... the Ebola worker is going to feel cold and will be able to function inside the suit without having to change the suit so frequently", said one source. In March, Google developed a tablet that could be cleaned with chlorine; it is charged wirelessly and can transmit information to servers outside the working area. The WHO recommends the use of 2 pairs of gloves, with the outer pair worn over the gown. Using 2 pairs may reduce the risk of sharp injuries; however, there is no evidence that using more than the recommended will give additional protection. WHO also recommends the use of a coverall, which is generally appraised in terms of its resistance to non-enveloped DNA virus. When a gown (or coverall) is worn, it should continue beyond the shoe covers. According to guidelines released by the CDC in August 2015, updates were put in place to improve the PAPR doffing method to make the steps easier, and affirm the importance of cleaning the floor where doffing has been done. Additionally, a designated doffing assistant was recommended to help in this process. The order in which boot covers are removed, by these guidelines, indicates their removal after the coverall or gown. Finally, a trained observer is to read to the healthcare worker each step in donning and doffing, but must not physically assist therein. In the hardest hit areas there have historically been only one or two doctors available to treat 100,000 people, and these doctors are heavily concentrated in urban areas. Ebola patients' healthcare providers, as well as family and friends, are at highest risk of getting infected because they are more likely to come in direct contact with their blood or body fluids. In some places affected by the outbreak, care may have been provided in clinics with limited resources, and workers could be in these areas for several hours with a number of Ebola infected patients. According to the WHO, the high proportion of infected medical staff could be explained by a lack of adequate manpower to manage such a large outbreak, shortages of protective equipment or improper use of what was available, and "the compassion that causes medical staff to work in isolation wards far beyond the number of hours recommended as safe". In August 2014, healthcare workers represented nearly 10 per cent of cases and fatalities—significantly impairing the capacity to respond to an outbreak in an area already facing severe shortages. By 1 July 2015, the WHO reported that a total of 874 health workers had been infected, of which 509 had died. Among the fatalities was Samuel Brisbane, a former adviser to the Liberian Ministry of Health and Social Welfare, described as "one of Liberia's most high-profile doctors". In July 2014, leading Ebola doctor Sheik Umar Khan from Sierra Leone also died in the outbreak. In August, a well-known Nigerian physician, Ameyo Adadevoh , died. Mbalu Fonnie, a licensed nurse-midwife and nursing supervisor at the Kenema hospital in Sierra Leone, with over 30 years of experience, died after contracting Ebola while caring for a fellow nurse who was pregnant and had the disease. Fonnie was also a co-author of a study that analysed the genetics of the Ebola virus; five others contracted Ebola and died while working on the same study. Basing their choice on "the person or persons who most affected the news and our lives, for good or ill, and embodied what was important about the year", the editors of Time magazine in December 2014 named the Ebola health workers as Person of the Year . Editor Nancy Gibbs said: "The rest of the world can sleep at night because a group of men and women are willing to stand and fight. For tireless acts of courage and mercy, for buying the world time to boost its defences, for risking, for persisting, for sacrificing and saving, the Ebola fighters are Time's 2014 Person of the Year." According to an October 2015 report by the CDC, Guinean healthcare workers had 42.2 times higher Ebola infection rates than non-healthcare workers, and male healthcare workers were more affected than their female counterparts. The report indicated that 27% of Ebola infections among healthcare workers in Guinea occurred among doctors. The CDC report also stated that the Guinea Ministry of Health recorded males as representing 46% of the health workforce, and that 67% of Ebola infections among non-doctor healthcare workers occurred among males. The CDC further indicated that healthcare workers in Guinea were less likely to report contact with an infected individual than non-healthcare workers. Ebola virus disease has a high case fatality rate (CFR), which in past outbreaks varied between 25% and 90%, with an average of about 50%. The epidemic caused significant mortality, with reported CFRs of up to 70%. Care settings that have access to medical expertise may increase survival by providing good maintenance of hydration, circulatory volume, and blood pressure. The disease affects males and females equally and the majority of those that contract Ebola disease are between 15 and 45 years of age. For those over 45 years, a fatal outcome was more likely in the Western African epidemic, as was also noted in preceding outbreaks. Only rarely do pregnant women survive—a midwife who worked with MSF in a Sierra Leone treatment centre stated that she knew of "no reported cases of pregnant mothers and unborn babies surviving Ebola in Sierra Leone." In September 2015, the WHO issued pregnancy guidance information entitled, "Interim Guidance on Ebola Virus Disease in Pregnancy." It has been suggested that the loss of human life was not limited to Ebola victims alone. Many hospitals had to shut down, leaving people with other medical needs without care. A spokesperson for the UK-based health foundation, the Wellcome Trust , said in October 2014 that "the additional death toll from malaria and other diseases [is] likely to exceed that of the outbreak itself". Dr Paul Farmer stated: "Most of Ebola's victims may well be dying from other causes: women in childbirth, children from diarrhoea, people in road accidents or from trauma of other sorts." As the epidemic drew to a close in 2015, a report from Sierra Leone showed that the fear and mistrust of hospitals generated by the epidemic had resulted in an 11% decline in facility-based births, and that those receiving care before or after birth fell by about a fifth. Consequently, between May 2014 and April 2015, the deaths of women during or just after childbirth rose by almost a third and those of newborns by a quarter, compared to the previous year. Research suggests that many Ebola infections are asymptomatic, meaning that some infected people show no symptoms of the disease. For example, two studies done on previous outbreaks showed that 71% of seropositive individuals did not have the clinical disease in one outbreak and another study reported that 46% of asymptomatic close contacts of patients with Ebola were seropositive. On 22 January, the WHO issued Clinical Care for survivors of Ebola Virus Disease: interim guidance . The guidance covers specific issues like musculoskeletal pain, which is reported in up to 75% of survivors. The pain is symmetrical and more pronounced in the morning, with the larger joints most affected. There is also possible periarticular tenosynovitis affecting the shoulders. The WHO guidelines advise to distinguish non-inflammatory arthralgia from inflammatory arthritis . With regard to ocular problems, sensitivity to light and blurry vision have been indicated among survivors. Among the aftereffects of Ebola virus disease, uveitis and optic nerve disease could appear after an individual is discharged. Ocular problems could threaten sight in survivors, thus the need for prompt treatment. In treating such individuals, the WHO recommends urgent intervention if uveitis is suspected; this consists mainly of prednisone (a corticosteroid ). Hearing loss has been reported in Ebola survivors 25% of the time. Treatment, in the case of acute labyrinthitis (inner ear disorder), should be given within 10 days of the onset of symptoms and prochlorperazine, a vestibular sedative, may be administered for vertigo . There are at least 17,000 people who have survived infection from the Ebola virus in Western Africa; some of them have reported lingering health effects. In early November, a WHO consultant reported: "Many of the survivors are discharged with the so-called Post-Ebola Syndrome. We want to ascertain whether these medical conditions are due to the disease itself, the treatment given or chlorine used during disinfection of the patients. This is a new area for research; little is known about the post-Ebola symptoms." In February 2015, a Sierra Leone physician said about half of the recovered patients she saw reported declining health and that she had seen survivors go blind. In May 2015, a senior consultant to the WHO said that the reports of eye problems were especially worrying because "there are hardly any ophthalmologists in Western Africa, and only they have the skills and equipment to diagnose conditions like uveitis that affect the inner chambers of the eye." The medical director of a hospital in Liberia reported that he was seeing health problems in patients who had been in recovery for as long as nine months. Problems he was seeing included chronic pain, sometimes so severe that walking was difficult; eye problems, including uveitis; and headaches as the most common physical symptoms. "They're still very severe and impacting their life every day. These patients will need medical care for months and maybe years." A physician from the Kenema hospital in Sierra Leone reported similar health difficulties. In December 2014, a British aid worker who had just returned from Sierra Leone was diagnosed with Ebola. She was treated with survivors' blood plasma and experimental drugs and declared free of disease in January 2015. However, in October 2015, she again became critically ill and was diagnosed with meningitis. In this unprecedented case it is thought that the virus remained in her brain replicating at a very low level until it had replicated to a degree capable of causing clinical meningitis. The woman was treated and in November 2015 it was reported that she had recovered. In terms of medical literature that are reviews, few articles have been published, such as Shantha, et al. which discusses management of panuveitis and iris heterochromia. An observational study, done roughly 29 months after the 2007 Bundibugyo outbreak in Uganda , found that long-term sequelae (i.e. consequences) persisted among survivors. Symptoms included eye pain, blurred vision, hearing loss, difficulty swallowing, difficulty sleeping, arthralgias, memory loss or confusion, and "various constitutional symptoms controlling for age and sex". From August through December 2014, a total of 10 patients with Ebola were treated in US hospitals; of these patients, 8 survived. In March 2015, the CDC interviewed the survivors; they all reported having had at least one adverse symptom during their recovery period. The symptoms ranged from mild (e.g. hair loss) to more severe complications requiring re-hospitalisation or treatment. The most frequently reported symptoms were lethargy or fatigue, joint pain, and hair loss. Sixty-three per cent reported having eye problems including two who were diagnosed with uveitis, 75% reported psychological or cognitive symptoms, and 38% reported neural difficulties. Although most symptoms resolved or improved over time, only one survivor reported complete resolution of all symptoms. A study published in May 2015 discussed the case of Ian Crozier, a Zimbabwe-born physician and American citizen who became infected with Ebola while he was working at an Ebola treatment centre in Sierra Leone. He was transported to the US and successfully treated at Emory University Hospital. However, after discharge Crozier began to experience symptoms including low back pain, bilateral enthesitis of the Achilles tendon , paresthesias involving his lower legs, and eye pain, which was diagnosed as uveitis. His eye condition worsened and a specimen of aqueous humor obtained from his eye tested positive for Ebola. The authors of the study concluded that "further studies to investigate the mechanisms responsible for the ocular persistence of Ebola and the possible presence of the virus in other immune-privileged sites (e.g., in the central nervous system , gonads , and articular cartilage ) are warranted." The authors also noted that 40% of participants in a survey of 85 Ebola survivors in Sierra Leone reported having "eye problems", though the incidence of actual uveitis was unknown. Another study, which was released in August 2015 looked at the health difficulties reported by survivors. Calling the set of symptoms " post-Ebolavirus disease syndrome ", the research found symptoms that included "chronic joint and muscle pain, fatigue, anorexia, hearing loss, blurred vision, headache, sleep disturbances, low mood and short-term memory problems", and suggested the "implementation of specialised health services to treat and follow-up survivors". In 2018, over two years after the resolution of the Ebola outbreak in Eastern Sierra Leone, a study was conducted of Ebola survivors, with their families used as a control group. The study was published in 2021. Looking at the results, the researchers were able to find an underlying process leading to persistent symptoms in some but not all Ebola survivors. One hypothesis suggests "ongoing inflammation due to persistent infection vs autoimmune phenomena." The authors suggest that more study is needed to come to conclusions about why some survivors continue to experience post-syndrome ailments. An observational study, done roughly 29 months after the 2007 Bundibugyo outbreak in Uganda , found that long-term sequelae (i.e. consequences) persisted among survivors. Symptoms included eye pain, blurred vision, hearing loss, difficulty swallowing, difficulty sleeping, arthralgias, memory loss or confusion, and "various constitutional symptoms controlling for age and sex". From August through December 2014, a total of 10 patients with Ebola were treated in US hospitals; of these patients, 8 survived. In March 2015, the CDC interviewed the survivors; they all reported having had at least one adverse symptom during their recovery period. The symptoms ranged from mild (e.g. hair loss) to more severe complications requiring re-hospitalisation or treatment. The most frequently reported symptoms were lethargy or fatigue, joint pain, and hair loss. Sixty-three per cent reported having eye problems including two who were diagnosed with uveitis, 75% reported psychological or cognitive symptoms, and 38% reported neural difficulties. Although most symptoms resolved or improved over time, only one survivor reported complete resolution of all symptoms. A study published in May 2015 discussed the case of Ian Crozier, a Zimbabwe-born physician and American citizen who became infected with Ebola while he was working at an Ebola treatment centre in Sierra Leone. He was transported to the US and successfully treated at Emory University Hospital. However, after discharge Crozier began to experience symptoms including low back pain, bilateral enthesitis of the Achilles tendon , paresthesias involving his lower legs, and eye pain, which was diagnosed as uveitis. His eye condition worsened and a specimen of aqueous humor obtained from his eye tested positive for Ebola. The authors of the study concluded that "further studies to investigate the mechanisms responsible for the ocular persistence of Ebola and the possible presence of the virus in other immune-privileged sites (e.g., in the central nervous system , gonads , and articular cartilage ) are warranted." The authors also noted that 40% of participants in a survey of 85 Ebola survivors in Sierra Leone reported having "eye problems", though the incidence of actual uveitis was unknown. Another study, which was released in August 2015 looked at the health difficulties reported by survivors. Calling the set of symptoms " post-Ebolavirus disease syndrome ", the research found symptoms that included "chronic joint and muscle pain, fatigue, anorexia, hearing loss, blurred vision, headache, sleep disturbances, low mood and short-term memory problems", and suggested the "implementation of specialised health services to treat and follow-up survivors". In 2018, over two years after the resolution of the Ebola outbreak in Eastern Sierra Leone, a study was conducted of Ebola survivors, with their families used as a control group. The study was published in 2021. Looking at the results, the researchers were able to find an underlying process leading to persistent symptoms in some but not all Ebola survivors. One hypothesis suggests "ongoing inflammation due to persistent infection vs autoimmune phenomena." The authors suggest that more study is needed to come to conclusions about why some survivors continue to experience post-syndrome ailments. In June 2014, it was reported that local authorities did not have the resources to contain the disease, with health centres closing and hospitals becoming overwhelmed. There were also reports that adequate personal protection equipment was not being provided for medical personnel. The Director-General of MSF said: "Countries affected to date simply do not have the capacity to manage an outbreak of this size and complexity on their own. I urge the international community to provide this support on the most urgent basis possible." In late August, MSF called the situation "chaotic" and the medical response "inadequate." They reported that they had expanded their operations, but couldn't keep up with the rapidly increasing need for assistance, which had forced them to reduce the level of care: "It is not currently possible, for example, to administer intravenous treatments." Calling the situation "an emergency within the emergency", MSF reported that many hospitals had shut down due to lack of staff or fears of the virus among patients and staff, which had left people with other health problems without any care at all. Speaking from a remote region, an MSF worker said that a shortage of protective equipment was making the medical management of the disease difficult and that they had limited capacity to safely bury bodies. By September, treatment for Ebola patients had become unavailable in some areas. Speaking on 12 September, WHO Director-General, Margaret Chan, said: "In the three hardest hit countries, Guinea, Liberia and Sierra Leone, the number of new cases is moving far faster than the capacity to manage them in the Ebola-specific treatment centres. Today, there is not one single bed available for the treatment of an Ebola patient in the entire country of Liberia." According to a WHO report released on 19 September, Sierra Leone was meeting only 35% of its need for patient beds, while for Liberia it was just 20%. In early December, the WHO reported that at a national level there were enough beds in treatment facilities to treat and isolate all reported Ebola cases, although their uneven distribution was resulting in serious shortfalls in some areas. Similarly, all affected countries had sufficient and widespread capacity to bury reported deaths; however, because not all deaths were reported, it was possible that the reverse could have been the case in some areas. WHO also reported that every district had access to a laboratory to confirm cases of Ebola within 24 hours of sample collection, and that all three countries had reported that more than 80% of registered contacts associated with known cases of Ebola virus disease were being traced, although contact tracing was still a challenge in areas of intense transmission and those with community resistance. A number of Ebola Treatment Centres were set up in the area, supported by international aid organisations and staffed by a combination of local and international staff. Each treatment centre is divided into a number of distinct and rigorously separate areas. For patients, there is a triage area, and low- and high-risk care wards. For staff, there are areas for preparation and decontamination. An important part of each centre is an arrangement for safe burial or cremation of bodies, required to prevent further infection. In January 2015, a new treatment and research centre was built by Rusal and Russia in the city of Kindia in Guinea. It is one of the most modern medical centres in Guinea. Also in January, MSF admitted its first patients to a new treatment centre in Kissy , an Ebola hotspot on the outskirts of Freetown, Sierra Leone. The centre has a maternity unit for pregnant women with the virus. Although the WHO does not advise caring for Ebola patients at home, in some cases it became a necessity when no hospital treatment beds were available. For those being treated at home, the WHO advised informing the local public health authority and acquiring appropriate training and equipment. UNICEF, USAID and Samaritan's Purse began to take measures to provide support for families that were forced to care for patients at home by supplying caregiver kits intended for interim home-based interventions. The kits included protective clothing, hydration items, medicines, and disinfectant, among other items. Even where hospital beds were available, it was debated whether conventional hospitals are the best place to care for Ebola patients, as the risk of spreading the infection is high. In October, the WHO and non-profit partners launched a program in Liberia to move infected people out of their homes into ad hoc centres that could provide rudimentary care. Health facilities with low-quality systems for preventing infection were involved as sites of amplification during viral outbreaks. The Ebola epidemic caused an increasing demand for protective clothing. A full set of protective clothing includes a suit, goggles, a mask, socks and boots, and an apron. Boots and aprons can be disinfected and reused, but everything else must be destroyed after use. Health workers change garments frequently, discarding gear that has barely been used. This not only takes a great deal of time but also exposes them to the virus because, for those wearing protective clothing, one of the most dangerous moments for contracting Ebola is while suits are being removed. The protective clothing sets that MSF uses cost about $75 apiece. Staff who have returned from deployments to Western Africa say the clothing is so heavy that it can be worn for only about 40 minutes at a stretch. A physician working in Sierra Leone has said: "After about 30 or 40 minutes, your goggles have fogged up; your socks are completely drenched in sweat. You're just walking in water in your boots. And at that point, you have to exit for your own safety ... Here it takes 20–25 minutes to take off a protective suit and must be done with two trained supervisors who watch every step in a military manner to ensure no mistakes are made, because a slip up can easily occur and of course can be fatal." By October, there were reports that protective outfits were beginning to be in short supply and manufacturers began to increase their production. USAID published an open competitive bidding for proposals that address the challenge of developing "new practical and cost-effective solutions to improve infection treatment and control that can be rapidly deployed; 1) to help health care workers provide better care and 2) transform our ability to combat Ebola". On 12 December 2014, USAID announced the result of the first selection in a press release. On 17 December 2014, a team at Johns Hopkins University developed a prototype breakaway hazmat suit, and was awarded a grant from the USAID to develop it. The prototype has a small, battery-powered cooling pack on the worker's belt. "You'll have air blowing out that is room temperature but it's 0% humidity ... the Ebola worker is going to feel cold and will be able to function inside the suit without having to change the suit so frequently", said one source. In March, Google developed a tablet that could be cleaned with chlorine; it is charged wirelessly and can transmit information to servers outside the working area. The WHO recommends the use of 2 pairs of gloves, with the outer pair worn over the gown. Using 2 pairs may reduce the risk of sharp injuries; however, there is no evidence that using more than the recommended will give additional protection. WHO also recommends the use of a coverall, which is generally appraised in terms of its resistance to non-enveloped DNA virus. When a gown (or coverall) is worn, it should continue beyond the shoe covers. According to guidelines released by the CDC in August 2015, updates were put in place to improve the PAPR doffing method to make the steps easier, and affirm the importance of cleaning the floor where doffing has been done. Additionally, a designated doffing assistant was recommended to help in this process. The order in which boot covers are removed, by these guidelines, indicates their removal after the coverall or gown. Finally, a trained observer is to read to the healthcare worker each step in donning and doffing, but must not physically assist therein. In the hardest hit areas there have historically been only one or two doctors available to treat 100,000 people, and these doctors are heavily concentrated in urban areas. Ebola patients' healthcare providers, as well as family and friends, are at highest risk of getting infected because they are more likely to come in direct contact with their blood or body fluids. In some places affected by the outbreak, care may have been provided in clinics with limited resources, and workers could be in these areas for several hours with a number of Ebola infected patients. According to the WHO, the high proportion of infected medical staff could be explained by a lack of adequate manpower to manage such a large outbreak, shortages of protective equipment or improper use of what was available, and "the compassion that causes medical staff to work in isolation wards far beyond the number of hours recommended as safe". In August 2014, healthcare workers represented nearly 10 per cent of cases and fatalities—significantly impairing the capacity to respond to an outbreak in an area already facing severe shortages. By 1 July 2015, the WHO reported that a total of 874 health workers had been infected, of which 509 had died. Among the fatalities was Samuel Brisbane, a former adviser to the Liberian Ministry of Health and Social Welfare, described as "one of Liberia's most high-profile doctors". In July 2014, leading Ebola doctor Sheik Umar Khan from Sierra Leone also died in the outbreak. In August, a well-known Nigerian physician, Ameyo Adadevoh , died. Mbalu Fonnie, a licensed nurse-midwife and nursing supervisor at the Kenema hospital in Sierra Leone, with over 30 years of experience, died after contracting Ebola while caring for a fellow nurse who was pregnant and had the disease. Fonnie was also a co-author of a study that analysed the genetics of the Ebola virus; five others contracted Ebola and died while working on the same study. Basing their choice on "the person or persons who most affected the news and our lives, for good or ill, and embodied what was important about the year", the editors of Time magazine in December 2014 named the Ebola health workers as Person of the Year . Editor Nancy Gibbs said: "The rest of the world can sleep at night because a group of men and women are willing to stand and fight. For tireless acts of courage and mercy, for buying the world time to boost its defences, for risking, for persisting, for sacrificing and saving, the Ebola fighters are Time's 2014 Person of the Year." According to an October 2015 report by the CDC, Guinean healthcare workers had 42.2 times higher Ebola infection rates than non-healthcare workers, and male healthcare workers were more affected than their female counterparts. The report indicated that 27% of Ebola infections among healthcare workers in Guinea occurred among doctors. The CDC report also stated that the Guinea Ministry of Health recorded males as representing 46% of the health workforce, and that 67% of Ebola infections among non-doctor healthcare workers occurred among males. The CDC further indicated that healthcare workers in Guinea were less likely to report contact with an infected individual than non-healthcare workers. The Ebola epidemic caused an increasing demand for protective clothing. A full set of protective clothing includes a suit, goggles, a mask, socks and boots, and an apron. Boots and aprons can be disinfected and reused, but everything else must be destroyed after use. Health workers change garments frequently, discarding gear that has barely been used. This not only takes a great deal of time but also exposes them to the virus because, for those wearing protective clothing, one of the most dangerous moments for contracting Ebola is while suits are being removed. The protective clothing sets that MSF uses cost about $75 apiece. Staff who have returned from deployments to Western Africa say the clothing is so heavy that it can be worn for only about 40 minutes at a stretch. A physician working in Sierra Leone has said: "After about 30 or 40 minutes, your goggles have fogged up; your socks are completely drenched in sweat. You're just walking in water in your boots. And at that point, you have to exit for your own safety ... Here it takes 20–25 minutes to take off a protective suit and must be done with two trained supervisors who watch every step in a military manner to ensure no mistakes are made, because a slip up can easily occur and of course can be fatal." By October, there were reports that protective outfits were beginning to be in short supply and manufacturers began to increase their production. USAID published an open competitive bidding for proposals that address the challenge of developing "new practical and cost-effective solutions to improve infection treatment and control that can be rapidly deployed; 1) to help health care workers provide better care and 2) transform our ability to combat Ebola". On 12 December 2014, USAID announced the result of the first selection in a press release. On 17 December 2014, a team at Johns Hopkins University developed a prototype breakaway hazmat suit, and was awarded a grant from the USAID to develop it. The prototype has a small, battery-powered cooling pack on the worker's belt. "You'll have air blowing out that is room temperature but it's 0% humidity ... the Ebola worker is going to feel cold and will be able to function inside the suit without having to change the suit so frequently", said one source. In March, Google developed a tablet that could be cleaned with chlorine; it is charged wirelessly and can transmit information to servers outside the working area. The WHO recommends the use of 2 pairs of gloves, with the outer pair worn over the gown. Using 2 pairs may reduce the risk of sharp injuries; however, there is no evidence that using more than the recommended will give additional protection. WHO also recommends the use of a coverall, which is generally appraised in terms of its resistance to non-enveloped DNA virus. When a gown (or coverall) is worn, it should continue beyond the shoe covers. According to guidelines released by the CDC in August 2015, updates were put in place to improve the PAPR doffing method to make the steps easier, and affirm the importance of cleaning the floor where doffing has been done. Additionally, a designated doffing assistant was recommended to help in this process. The order in which boot covers are removed, by these guidelines, indicates their removal after the coverall or gown. Finally, a trained observer is to read to the healthcare worker each step in donning and doffing, but must not physically assist therein. In the hardest hit areas there have historically been only one or two doctors available to treat 100,000 people, and these doctors are heavily concentrated in urban areas. Ebola patients' healthcare providers, as well as family and friends, are at highest risk of getting infected because they are more likely to come in direct contact with their blood or body fluids. In some places affected by the outbreak, care may have been provided in clinics with limited resources, and workers could be in these areas for several hours with a number of Ebola infected patients. According to the WHO, the high proportion of infected medical staff could be explained by a lack of adequate manpower to manage such a large outbreak, shortages of protective equipment or improper use of what was available, and "the compassion that causes medical staff to work in isolation wards far beyond the number of hours recommended as safe". In August 2014, healthcare workers represented nearly 10 per cent of cases and fatalities—significantly impairing the capacity to respond to an outbreak in an area already facing severe shortages. By 1 July 2015, the WHO reported that a total of 874 health workers had been infected, of which 509 had died. Among the fatalities was Samuel Brisbane, a former adviser to the Liberian Ministry of Health and Social Welfare, described as "one of Liberia's most high-profile doctors". In July 2014, leading Ebola doctor Sheik Umar Khan from Sierra Leone also died in the outbreak. In August, a well-known Nigerian physician, Ameyo Adadevoh , died. Mbalu Fonnie, a licensed nurse-midwife and nursing supervisor at the Kenema hospital in Sierra Leone, with over 30 years of experience, died after contracting Ebola while caring for a fellow nurse who was pregnant and had the disease. Fonnie was also a co-author of a study that analysed the genetics of the Ebola virus; five others contracted Ebola and died while working on the same study. Basing their choice on "the person or persons who most affected the news and our lives, for good or ill, and embodied what was important about the year", the editors of Time magazine in December 2014 named the Ebola health workers as Person of the Year . Editor Nancy Gibbs said: "The rest of the world can sleep at night because a group of men and women are willing to stand and fight. For tireless acts of courage and mercy, for buying the world time to boost its defences, for risking, for persisting, for sacrificing and saving, the Ebola fighters are Time's 2014 Person of the Year." According to an October 2015 report by the CDC, Guinean healthcare workers had 42.2 times higher Ebola infection rates than non-healthcare workers, and male healthcare workers were more affected than their female counterparts. The report indicated that 27% of Ebola infections among healthcare workers in Guinea occurred among doctors. The CDC report also stated that the Guinea Ministry of Health recorded males as representing 46% of the health workforce, and that 67% of Ebola infections among non-doctor healthcare workers occurred among males. The CDC further indicated that healthcare workers in Guinea were less likely to report contact with an infected individual than non-healthcare workers. There is as yet no known confirmed medication or treatment for Ebola virus disease. The director of the US National Institute of Allergy and Infectious Diseases has stated that the scientific community is still in the early stages of understanding how infection with the Ebola virus can be treated and prevented. A number of experimental treatments are undergoing clinical trials . During the epidemic some patients received experimental blood transfusions from Ebola survivors, but a later study found that the treatment did not provide significant benefit. The effectiveness of potential treatments for any disease is usually assessed in a randomised controlled trial , which compares the outcome of those who received treatment to those who received a placebo (i.e. dummy treatment). However, randomised controlled trials are considered unethical when a disease is frequently fatal, as is the case with Ebola. In December 2015, a study was released that found that the viral load found in a patient's blood in the week after the onset of symptoms is a strong indication of the patient's likelihood to die or survive the disease. The researchers suggested that this information could help to assess the efficacy of proposed treatments more accurately in non-randomised clinical trials. Ebola control is hindered by the fact that current diagnostic tests require specialised equipment and highly trained personnel. Since there are few suitable testing centres in Western Africa, this delays diagnosis. As of February 2015 [ update ] a number of rapid diagnostic tests were under trial. In September 2015, a new chip-based testing method that can detect Ebola accurately was reported. This new device allows for the use of portable instruments that can provide immediate diagnosis. Several Ebola vaccine candidates had been developed in the decade prior to 2014 and had been shown to protect nonhuman primates against infection, but none had yet been approved for clinical use in humans. According to a 2015 review article, about 15 different vaccines were in preclinical stages of development, including DNA vaccines, virus-like particles and viral vectors and another seven as yet unheard-of vaccines were being developed. Additionally, there were two phase III studies being conducted with two different vaccines. In July 2015, researchers announced that a vaccine trial in Guinea had been completed that appeared to give protection from the virus. The vaccine, rVSV-ZEBOV , had shown high efficacy in individuals, but more conclusive evidence was needed regarding its capacity to protect populations through "herd immunity" . The vaccine trial employed "ring vaccination", a technique that was also used in the 1970s to eradicate smallpox , in which health workers control an outbreak by vaccinating all suspected infected individuals within the surrounding area. In December 2016, the results of the two-year Guinea trial were published announcing that rVSV-ZEBOV had been found to protect people who had been exposed to cases of Ebola. Of the nearly 6,000 people vaccinated, none had contracted Ebola after a ten-day period while in the group not vaccinated 23 cases developed. In addition to showing high efficacy among those vaccinated, the trial also showed that unvaccinated people were indirectly protected from Ebola virus through the ring vaccination approach, termed "herd immunity". The vaccine has not yet had regulatory approval, but it is considered to be so effective that 300,000 doses have already been stockpiled. Researchers have found the results "quite encouraging [but] there is still a lot more work to be done on vaccines for Ebola." Not yet known is the length of time that a vaccination will be effective and whether it will prove effective for the Sudan virus rather than only EBOV, which is responsible for the Western Africa outbreak. In April 2018 rVSV-ZEBOV Ebola vaccine was used to stop an outbreak for the first time, the 2018 Équateur province Democratic Republic of the Congo Ebola virus outbreak, with 3,481 people vaccinated. rVSV-ZEBOV received regulatory approval in 2019. From the beginning of the outbreak, there existed considerable difficulty in getting reliable estimates—both of the number of people affected and of its geographical extent. The three most affected countries—Guinea, Liberia and Sierra Leone—are among the poorest in the world, with extremely low levels of literacy, few hospitals or doctors, low-quality physical infrastructure, and weakly functioning government institutions. One study yielded results of the spatio-temporal evolution of the viral outbreak. With the use of heat maps , it was determined that the outbreak did not uniformly unfold over the affected community areas. Growth in the regions of Guinea, Liberia and Sierra Leone was very different over time, indicating that monitoring the outbreak at district level was important. Visual inspection of incidence curves alone could not render the needed results or data; growth rates with a two-dimensional heat map were used. Finally, the study showed that accurate predictions of growth were improbable, coupled with knowledge about the disease that was not fully adequate at the time (as there were now cases of sexual transmission). Calculating the case fatality rate (CFR) accurately is difficult in an ongoing epidemic due to differences in testing policies, the inclusion of probable and suspected cases, and the inclusion of new cases that have not run their course. In August 2014, the WHO made an initial CFR estimate of 53%, though this included suspected cases. In September and December 2014, the WHO released revised and more accurate CFR figures of 70.8% and 71% respectively, using data from patients with definitive clinical outcomes. The CFR among hospitalised patients, based on the three intense-transmission countries, was between 57% and 59% in January 2015. Mortality is measured by number of deaths in a population per the proportion of the population per unit of time. The basic reproduction number , R 0 , is a statistical measure of the average number of people infected by a single infectious individual in a population with no prior immunity. If the basic reproduction number is less than 1, the epidemic will die out; if it is greater than 1, the epidemic will continues to spread—with exponential growth in the number of cases. In September 2014, the estimated values of R 0 were 1.71 (95% CI , 1.44 to 2.01) for Guinea, 1.83 (95% CI, 1.72 to 1.94) for Liberia, and 2.02 (95% CI, 1.79 to 2.26) for Sierra Leone. In October 2014, the WHO noted that exponential increase of cases continued in the three countries with the most intense transmission. On 28 August 2014, the WHO released its first estimate of the possible total cases from the outbreak as part of its road map for stopping the transmission of the virus. It stated that "this Roadmap assumes that in many areas of intense transmission the actual number of cases may be two- to fourfold higher than that currently reported. It acknowledges that the aggregate case load of Ebola could exceed 20,000 over the course of this emergency. The Roadmap assumes that a rapid escalation of the complementary strategies in intense transmission, resource-constrained areas will allow the comprehensive application of more standard containment strategies within three months." The report included an assumption that some country or countries would pay the required cost of their plan, estimated at half a billion US dollars. When the WHO released these estimates, a number of epidemiologists presented data to show that the WHO projection of a total of 20,000 cases was likely an underestimate. On 9 September, Jonas Schmidt-Chanasit of the Bernhard Nocht Institute for Tropical Medicine in Germany, controversially announced that the containment fight in Sierra Leone and Liberia had already been "lost" and that the disease would "burn itself out". On 23 September 2014, the WHO revised their previous projection, stating that they expected the number of Ebola cases in Western Africa to be in excess of 20,000 by 2 November 2014. They further stated, that if the disease was not adequately contained it could become native in Guinea, Sierra Leone and Liberia, "spreading as routinely as malaria or the flu", and according to an editorial in the New England Journal of Medicine , eventually to other parts of Africa and beyond. In a report released on 23 September 2014, the CDC analysed the impact of under-reporting, which required correction of case numbers by a factor of up to 2.5. With this correction factor, approximately 21,000 total cases were estimated for the end of September 2014 in Liberia and Sierra Leone alone. The same report predicted that total cases, including unreported cases, could reach 1.4 million in Liberia and Sierra Leone by the end of January 2015 if no improvement in intervention or community behaviour occurred. However, at a congressional hearing on 19 November, the Director of the CDC said that the number of Ebola cases was no longer expected to exceed 1 million, moving away from the worst-case scenario that had been previously predicted. A study published in December 2014 found that transmission of the Ebola virus occurs principally within families, in hospitals and at funerals. The data, gathered during three weeks of contact tracing in August, showed that the third person in any transmission chain often knew both the first and second person. The authors estimated that between 17% and 70% of cases in Western Africa were unreported—far fewer than had been estimated in prior projections. The study concluded that the epidemic would not be as difficult to control as feared, if rapid, vigorous contact tracing and quarantines were employed. Projections of future cases should also reflect the possibility that deforestation might have a hand in terms of the more recent Ebola outbreaks. It has been suggested that due to the clearing of forest for commercial use, various types of bats namely fruit bats may be taken out of their natural habitat and therefore into closer and potential contact with civilisation. Calculating the case fatality rate (CFR) accurately is difficult in an ongoing epidemic due to differences in testing policies, the inclusion of probable and suspected cases, and the inclusion of new cases that have not run their course. In August 2014, the WHO made an initial CFR estimate of 53%, though this included suspected cases. In September and December 2014, the WHO released revised and more accurate CFR figures of 70.8% and 71% respectively, using data from patients with definitive clinical outcomes. The CFR among hospitalised patients, based on the three intense-transmission countries, was between 57% and 59% in January 2015. Mortality is measured by number of deaths in a population per the proportion of the population per unit of time. The basic reproduction number , R 0 , is a statistical measure of the average number of people infected by a single infectious individual in a population with no prior immunity. If the basic reproduction number is less than 1, the epidemic will die out; if it is greater than 1, the epidemic will continues to spread—with exponential growth in the number of cases. In September 2014, the estimated values of R 0 were 1.71 (95% CI , 1.44 to 2.01) for Guinea, 1.83 (95% CI, 1.72 to 1.94) for Liberia, and 2.02 (95% CI, 1.79 to 2.26) for Sierra Leone. In October 2014, the WHO noted that exponential increase of cases continued in the three countries with the most intense transmission. On 28 August 2014, the WHO released its first estimate of the possible total cases from the outbreak as part of its road map for stopping the transmission of the virus. It stated that "this Roadmap assumes that in many areas of intense transmission the actual number of cases may be two- to fourfold higher than that currently reported. It acknowledges that the aggregate case load of Ebola could exceed 20,000 over the course of this emergency. The Roadmap assumes that a rapid escalation of the complementary strategies in intense transmission, resource-constrained areas will allow the comprehensive application of more standard containment strategies within three months." The report included an assumption that some country or countries would pay the required cost of their plan, estimated at half a billion US dollars. When the WHO released these estimates, a number of epidemiologists presented data to show that the WHO projection of a total of 20,000 cases was likely an underestimate. On 9 September, Jonas Schmidt-Chanasit of the Bernhard Nocht Institute for Tropical Medicine in Germany, controversially announced that the containment fight in Sierra Leone and Liberia had already been "lost" and that the disease would "burn itself out". On 23 September 2014, the WHO revised their previous projection, stating that they expected the number of Ebola cases in Western Africa to be in excess of 20,000 by 2 November 2014. They further stated, that if the disease was not adequately contained it could become native in Guinea, Sierra Leone and Liberia, "spreading as routinely as malaria or the flu", and according to an editorial in the New England Journal of Medicine , eventually to other parts of Africa and beyond. In a report released on 23 September 2014, the CDC analysed the impact of under-reporting, which required correction of case numbers by a factor of up to 2.5. With this correction factor, approximately 21,000 total cases were estimated for the end of September 2014 in Liberia and Sierra Leone alone. The same report predicted that total cases, including unreported cases, could reach 1.4 million in Liberia and Sierra Leone by the end of January 2015 if no improvement in intervention or community behaviour occurred. However, at a congressional hearing on 19 November, the Director of the CDC said that the number of Ebola cases was no longer expected to exceed 1 million, moving away from the worst-case scenario that had been previously predicted. A study published in December 2014 found that transmission of the Ebola virus occurs principally within families, in hospitals and at funerals. The data, gathered during three weeks of contact tracing in August, showed that the third person in any transmission chain often knew both the first and second person. The authors estimated that between 17% and 70% of cases in Western Africa were unreported—far fewer than had been estimated in prior projections. The study concluded that the epidemic would not be as difficult to control as feared, if rapid, vigorous contact tracing and quarantines were employed. Projections of future cases should also reflect the possibility that deforestation might have a hand in terms of the more recent Ebola outbreaks. It has been suggested that due to the clearing of forest for commercial use, various types of bats namely fruit bats may be taken out of their natural habitat and therefore into closer and potential contact with civilisation. In addition to the loss of life, the outbreak had a number of significant economic impacts. In March 2015, the United Nations Development Group reported that due to a decrease in trade, closing of borders, flight cancellations, and drop in foreign investment and tourism activity fuelled by stigma, the epidemic resulted in vast economic consequences both in the affected areas and throughout Africa. A September 2014 report in the Financial Times suggested that the economic impact of the Ebola outbreak could kill more people than the disease itself. With regard to Ebola and economic activity in the country of Liberia, a study found that 8% of automotive firms, 8% of construction firms, 15% of food businesses and 30% of restaurants had closed due to the Ebola outbreak. Montserrado county experienced up to 20% firm closure. This indicated a decline in the Liberian national economy during the outbreak, as well as an indication that the county of Montserrado was hardest hit economically. The capital city Monrovia suffered construction and restaurant unemployment the most, while outside the capital, the food and beverage sectors suffered economically. A recuperation in the economy, at the end of the outbreak, was expected to be more rapid in some sectors than in others. Also, if the massive decline in economic activity persisted, the authors suggested a focus on economic recovery in addition to support for the healthcare system. The World Bank had projected an estimated loss of $1.6 billion in productivity for all three affected Western African countries combined for 2015. In Liberian counties that were less affected by the outbreak, the number of individuals employed fell by 24%. Montserrado saw a 47% decline in employment per firm in contrast to what was obtained prior to the Ebola outbreak. Another study showed that the economic effect of the Ebola outbreak would be felt for years due to preexisting social vulnerability . The economic effects were being felt nationwide in Liberia, such as the termination of expansions in the mining business. Initial scenarios had placed expected economic losses at $25 billion; however subsequent World Bank estimates were much lower, at about 12% of the combined GDP of the 3 worst hit countries. The authors went on to state that social vulnerability has multiple factors and proposed a classification based on multiple variables instead of single indicators such as food insecurity or lack of hospitals, which were problems faced by rural Liberians. In spite of the end of civil violence since 2003 and inflows from international donors, the reconstruction of Liberia had been very slow and non-productive—water delivery systems, sanitation facilities and centralised electricity were practically non-existent, even in Monrovia. Even before the outbreak, medical facilities did not have potable water, lighting or refrigeration. The authors indicated that lack of food and other economic effects would probably continue in the rural population long after the Ebola outbreak had ended. Other economic impacts were as follows: In January 2015, Oxfam , a UK-based disaster relief organisation, indicated that a " Marshall Plan " (a reference to the massive plan to rebuild Europe after World War II ) was needed so that countries could begin to financially assist those that had been worst hit by the virus. The call was repeated in April 2015 when the most-affected Western African countries asked for an $8 billion "Marshall Plan" to rebuild their economies. Speaking at the World Bank and the International Monetary Fund (IMF), Liberian president Ellen Johnson Sirleaf said the amount was needed because "[o]ur health systems collapsed, investors left our countries, revenues declined and spending increased." The IMF has been criticised for its lack of assistance in the efforts to combat the epidemic. In December 2014, a Cambridge University study linked IMF policies with the financial difficulties that prevented a strong Ebola response in the three most heavily affected countries, and they were urged by both the UN and NGOs who had worked in the affected countries to grant debt relief rather than low-interest loans. According to one advocacy group, "... yet the IMF, which has made a $9 billion surplus from its lending over the last three years, is considering offering loans, not debt relief and grants, in response". On 30 January 2015, the IMF reported it was close to reaching a deal on debt forgiveness. On 22 December, it was reported that the IMF had given Liberia an additional $10 million due to the economic impact of the Ebola virus outbreak. In October 2014, a World Bank report estimated overall economic impacts of between $3.8 billion and $32.6 billion, depending on the extent of the outbreak and speed of containment. It expected the most severe losses in the three affected countries, with a wider impact across the broader Western African region. On 13 April 2015, the World Bank said that they would soon announce a major new effort to rebuild the economies of the three hardest-hit countries. On 23 July, a World Bank poll warned that "we are not ready for another Ebola outbreak". On 15 December, the World Bank indicated that by 1 December 2015, it had marshalled $1.62 billion in financing for the Ebola outbreak response. On 6 July 2015, UN Secretary-General Ban Ki-moon announced that he would host an Ebola recovery conference to raise funds for reconstruction, stating that the three countries hardest hit by Ebola needed about $700 million to rebuild their health services over a two-year period. On 10 July, it was announced that the countries most affected by the Ebola epidemic would receive $3.4 billion to rebuild their economies. On 29 September, the leaders of both Sierra Leone and Liberia indicated at the UN General Assembly the launch of a "Post-Ebola Economic Stabilization and Recovery Plan". On 24 November, it was reported that due to the decrease in commodity prices and the Western African Ebola epidemic, China's investment in the continent had declined 43% in the first 6 months of 2015. On 25 January, the IMF projected a GDP growth of 0.3% for Liberia, that country indicating it would cut spending by 11 per cent due to a stagnation in the mining sector, which would cause a domestic revenues drop of $57 million. In July 2014, the WHO convened an emergency meeting of health ministers from eleven countries and announced collaboration on a strategy to co-ordinate technical support to combat the epidemic. In August they published a road map to guide and coordinate the international response to the outbreak, aiming to stop ongoing Ebola transmission worldwide within 6–9 months, and formally designated the outbreak as a Public Health Emergency of International Concern . This is a legal designation used only twice before (for the 2009 H1N1 (swine flu) pandemic and the 2014 resurgence of poliomyelitis) that invokes legal measures on disease prevention, surveillance, control, and response, by 194 signatory countries. In September 2014, the United Nations Security Council declared the Ebola virus outbreak in Western Africa "a threat to international peace and security" and unanimously adopted a resolution urging UN member states to provide more resources to fight the outbreak. In October, WHO and the UN Mission for Ebola Emergency Response announced a comprehensive 90-day plan to control and reverse the Ebola epidemic. The ultimate goal was to have capacity in place for the isolation of 100% of Ebola cases and the safe burial of 100% of casualties by 1 January 2015 (the 90-day target). Many nations and charitable organisations cooperated to realise the plan, and a WHO situation report published mid-December indicated that the international community was on track to meet the 90-day target. On 5 November 2014, Australian Prime Minister Tony Abbott announced that Australian health services company Aspen Medical would be staffing a 100-bed hospital in Sierra Leone after an agreement was reached with the United Kingdom to treat any infected Australian workers. From 2014 to 2015, China's People's Liberation Army deployed 524 medical staff on a rotational basis to combat the outbreak in Liberia, Sierra Leone, Guinea, and Guinea-Bissau. : 245 In May 2015, Dr Margaret Chan indicated, "demands on WHO were more than ten times greater than ever experienced in the almost 70-year history of this Organization" and on 23 March, she stated that "the world remains woefully ill-prepared to respond to outbreaks that are both severe and sustained." There was significant criticism of the WHO from some aid agencies because its response was perceived as slow and insufficient, especially during the early stages of the outbreak. In October 2014, the Associated Press reported in an internal draft document that the WHO admitted "nearly everyone" involved in the Ebola response failed to notice factors that turned the outbreak into the largest on record, and that they had missed chances to stop the spread of Ebola due to "incompetent staff, bureaucracy and a lack of reliable information". Peter Piot, co-discoverer of the Ebola virus, called the WHO regional office in Africa "really not competent." In April 2015, the WHO admitted very serious failings in handling the crisis and indicated reforms for any future crises; "we did not work effectively in coordination with other partners, there were shortcomings in risk communications and there was confusion of roles and responsibilities". The Ebola crisis was discussed at the June 2015 G7 meeting . The leaders pledged to assist in carrying out WHO regulations. Critics criticised the G7 leaders, saying they were not committed enough in the fight against the possibility of future pandemics. In 2015 a panel of experts looked at the ways of preventing small outbreaks from becoming large epidemics. Their recommendations were published in the November issue of The Lancet . According to the panel, the epidemic had exposed problems in the national (and international) institutions responsible for protecting the public from the human consequences of infectious disease outbreaks such as the Ebola epidemic. The panel was highly critical of the WHO's management of the Ebola crisis noting that it took them months to respond and when they did they were slow to act, poorly co-ordinated and inadequately informed. The report pointed out that the committee responsible for checking the WHO's actions during the outbreak (i.e. the WHO Ebola Interim Assessment Panel) had delayed responses due to worries about political resistance from the Western African leaders, economic consequences, and a system within the WHO that discouraged open debate about issues such as emergency declarations. The WHO may also have hesitated because it was criticised for creating panic by declaring a public health emergency during the relatively mild 2009 H1N1 pandemic . This, the report states, showed the risks in having such consequential decision-making power in one individual—a risk made worse when there was no mechanism of responsibility for such leadership failure. The panel outlined 10 recommendations for the prevention and handling of future infectious disease outbreaks. Included in the recommendations of the changes needed to fight future outbreaks is the creation of a U.N. Security Council health committee to expedite political attention to health issues and the establishment of a global fund to finance and accelerate the development of outbreak-relevant drugs and treatment. The report also noted that competent governance of the global system demanded political leadership and a WHO that is more focused and appropriately financed and whose integrity is restored through the application of adequate reforms and leadership. The WHO also came under fire for refusing to send Dr. Olivet Buck to Germany for experimental treatment after she contracted Ebola per the government of Sierra Leone's request. WHO claimed they could only evacuate medical professionals they had deployed to the region, not locals. Dr. Olivet Buck was the Medical Superintendent at Lumley Government Hospital in Freetown, Sierra Leone. It's believed that she contracted the virus while continuing to treat patients even during a shortage of personal protective equipment. Her loyalty and dedication to her community never wavered. There was significant criticism of the WHO from some aid agencies because its response was perceived as slow and insufficient, especially during the early stages of the outbreak. In October 2014, the Associated Press reported in an internal draft document that the WHO admitted "nearly everyone" involved in the Ebola response failed to notice factors that turned the outbreak into the largest on record, and that they had missed chances to stop the spread of Ebola due to "incompetent staff, bureaucracy and a lack of reliable information". Peter Piot, co-discoverer of the Ebola virus, called the WHO regional office in Africa "really not competent." In April 2015, the WHO admitted very serious failings in handling the crisis and indicated reforms for any future crises; "we did not work effectively in coordination with other partners, there were shortcomings in risk communications and there was confusion of roles and responsibilities". The Ebola crisis was discussed at the June 2015 G7 meeting . The leaders pledged to assist in carrying out WHO regulations. Critics criticised the G7 leaders, saying they were not committed enough in the fight against the possibility of future pandemics. In 2015 a panel of experts looked at the ways of preventing small outbreaks from becoming large epidemics. Their recommendations were published in the November issue of The Lancet . According to the panel, the epidemic had exposed problems in the national (and international) institutions responsible for protecting the public from the human consequences of infectious disease outbreaks such as the Ebola epidemic. The panel was highly critical of the WHO's management of the Ebola crisis noting that it took them months to respond and when they did they were slow to act, poorly co-ordinated and inadequately informed. The report pointed out that the committee responsible for checking the WHO's actions during the outbreak (i.e. the WHO Ebola Interim Assessment Panel) had delayed responses due to worries about political resistance from the Western African leaders, economic consequences, and a system within the WHO that discouraged open debate about issues such as emergency declarations. The WHO may also have hesitated because it was criticised for creating panic by declaring a public health emergency during the relatively mild 2009 H1N1 pandemic . This, the report states, showed the risks in having such consequential decision-making power in one individual—a risk made worse when there was no mechanism of responsibility for such leadership failure. The panel outlined 10 recommendations for the prevention and handling of future infectious disease outbreaks. Included in the recommendations of the changes needed to fight future outbreaks is the creation of a U.N. Security Council health committee to expedite political attention to health issues and the establishment of a global fund to finance and accelerate the development of outbreak-relevant drugs and treatment. The report also noted that competent governance of the global system demanded political leadership and a WHO that is more focused and appropriately financed and whose integrity is restored through the application of adequate reforms and leadership. The WHO also came under fire for refusing to send Dr. Olivet Buck to Germany for experimental treatment after she contracted Ebola per the government of Sierra Leone's request. WHO claimed they could only evacuate medical professionals they had deployed to the region, not locals. Dr. Olivet Buck was the Medical Superintendent at Lumley Government Hospital in Freetown, Sierra Leone. It's believed that she contracted the virus while continuing to treat patients even during a shortage of personal protective equipment. Her loyalty and dedication to her community never wavered. Note 2: Data are from reports by the WHO Global Alert and Response Unit [Resource 1] and the WHO's Regional Office for Africa. [Resource 2] All numbers are correlated with UN Office for the Coordination of Humanitarian Affairs (OCHA), if available. [Resource 3] The reports were sourced from official information from the affected countries' health ministries. The WHO has stated that the reported numbers "vastly underestimate the magnitude of the outbreak", estimating there may be three times as many cases as officially reported. Note 3: Date is the "as of" date from the reference. A single source may report statistics for multiple "as of" dates.

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Ebola

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Kivu Ebola epidemic

The Kivu Ebola epidemic [note 2] was an outbreak of Ebola virus disease (EVD) mainly in eastern Democratic Republic of the Congo (DRC), and in other parts of Central Africa , from 2018 to 2020. Between 1 August 2018 and 25 June 2020 it resulted in 3,470 reported cases. The Kivu outbreak also affected Ituri Province , whose first case was confirmed on 13 August 2018. In November 2018, the outbreak became the biggest Ebola outbreak in the DRC's history, and had become the second-largest Ebola outbreak in recorded history worldwide, behind only the 2013–2016 Western Africa epidemic . In June 2019, the virus reached Uganda , having infected a 5-year-old Congolese boy who entered Uganda with his family, but was contained. A military conflict in the region that had begun in January 2015 hindered treatment and prevention efforts. The World Health Organization (WHO) described the combination of military conflict and civilian distress as a potential "perfect storm" that could lead to a rapid worsening of the outbreak. In May 2019, the WHO reported that since January, 85 health workers had been wounded or killed in 42 attacks on health facilities. In some areas, aid organizations had to stop their work due to violence. Health workers also had to deal with misinformation spread by opposing politicians. Due to the deteriorating security situation in North Kivu and surrounding areas, the WHO raised the risk assessment at the national and regional level from "high" to "very high" in September 2018. In October, the United Nations Security Council stressed that all armed hostility in the DRC should come to a stop to better fight the ongoing EVD outbreak. A confirmed case in Goma triggered the decision by the WHO to convene an emergency committee for the fourth time, and on 17 July 2019, the WHO announced a Public Health Emergency of International Concern (PHEIC), the highest level of alarm the WHO can sound. On 15 September 2019, some slowdown of EVD cases was noted by the WHO in DRC. However, contact tracing continued to be less than 100%; at the time, it was at 89%. As of mid-October the transmission of the virus had significantly reduced; by then it was confined to the Mandima region near where the outbreak began, and was only affecting 27 health zones in the DRC (down from a peak of 207). New cases dwindled to zero by 17 February 2020, but after 52 days without a case, surveillance and response teams on the ground confirmed three new cases of Ebola in Beni health zone in mid-April. On 25 June 2020, the outbreak was declared ended. As a new and separate outbreak, the Congolese health ministry reported on 1 June 2020 that there were cases of Ebola in Équateur Province in north-western DRC, described as the eleventh Ebola outbreak since records began. This separate outbreak was declared over as of 18 November following no reported cases for 42 days, and caused 130 cases and 55 deaths. As indicated below and per numbers offered by the United Nations the final death toll was 2,280 with a total of 3,470 cases in DRC in almost a two-year period. This was made very difficult due to the ongoing military attacks in the region which created a perfect storm for the virus, despite there being a vaccine. rVSV-ZEBOV or Ebola Zaire vaccine live, is a vaccine that prevents Ebola caused by the Zaire ebolavirus . The graph of reported cases reflects cases that were not able to have a laboratory test sample before burial as probable cases . On 1 August 2018, the North Kivu health division notified Congo's health ministry of 26 cases of hemorrhagic fever , including 20 deaths. Four of the six samples that were sent for analysis to the National Institute of Biological Research in Kinshasa came back positive for Ebola and an outbreak was declared on that date. The index case is believed to have been the death and unsafe burial of a 65-year-old woman on 25 July in Mangina, quickly followed by the deaths of seven close family members. This outbreak started just days after the end of the outbreak in Équateur province . On 1 August, just after the Ebola epidemic had been declared, Doctors Without Borders/Médecins Sans Frontières (MSF) arrived in Mangina, the point of origin of the outbreak, to mount a response. On 2 August, Oxfam indicated it would be taking part in the response to this latest outbreak in the DRC. On 4 August, the WHO indicated that the current situation in the DRC, due to several factors, warranted a "high risk assessment" at the national and regional level for public health. By 3 August, the virus had developed in multiple locations; cases were reported in five health zones – Beni , Butembo , Oicha , Musienene and Mabalako – in North Kivu province as well as Mandima and Mambasa in Ituri Province . However, one month later there had been confirmed cases only in the Mabalako, Mandima, Beni and Oicha health zones. The five suspected cases in the Mambasa Health Zone proved not to be EVD; it was not possible to confirm the one probable case in the Musienene Health Zone and the two probable cases in the Butembo Health Zone. No new cases had been recorded in any of those health zones. WHO chief Tedros Adhanom Ghebreyesu indicated on 15 August that the outbreak then in the DRC might be worse than the West African outbreak of 2013–2016, with the IRC connecting this to the ongoing Kivu conflict . The Kivu outbreak was the biggest of the ten recorded outbreaks recorded in the DRC. The first confirmed case in Butembo was announced on 4 September, the same day that it was announced that one of the cases registered at Beni had actually come from the Kalunguta Health Zone. In November, it was reported that the EVD outbreak ran across two provinces and 14 health zones. By 23 December, the EVD outbreak had spread to more health zones, and at that time 18 such areas had been affected. On 7 August 2018, the DRC Ministry of Public Health indicated that the total count had climbed to almost 90 cases, and the Uganda Ministry of Health issued an alert for extra surveillance as the outbreak was just 100 kilometres (62 mi) away from its border. Two days later the total count was nearly 100 cases. On 16 August, the United Kingdom indicated it would help with EVD diagnosis and monitoring in the DRC. On 17 August 2018, the WHO reported that there were around 1,500 " contacts ", while noting that certain conflict zones in the DRC that could not be reached might have contained more contacts. Some 954 contacts were successfully followed up on 18 August; however, Mandima Health Zone indicated resistance, so contacts were not followed up there. On 4 September, Butembo , a city with almost one million people and an international airport, recorded its first fatality in the Ebola outbreak. The city of Butembo, in the DRC, has trade links to nearby Uganda. On 24 September, it was reported that all contact tracing and vaccinations would stop for the foreseeable future in Beni due to a deadly attack by rebel groups the day before. On 25 September, Peter Salama of the WHO indicated that insecurity was obstructing efforts to stop the virus and believed a combination of factors could establish conditions for an epidemic. On 18 October, the U.S. Centers for Disease Control and Prevention (CDC) raised its travelers' alert to the DRC from a level 1 to level 2 for all U.S. travelers. On 26 October, the WHO indicated that half of confirmed cases were not showing any fever symptoms, thus making diagnosis more difficult. According to a September 2018 Lancet survey, 25% of respondents in Beni and Butembo believed the Ebola outbreak to be a hoax. These beliefs correlated with decreased likelihood of seeking healthcare or accepting vaccination. On 6 November 2018, the CDC indicated that the current outbreak in the east region of the DRC was potentially non-containable. This would be the first time since 1976 that an outbreak was not able to be curbed. On 13 November, the WHO indicated that the viral outbreak would last at least six months. On 29 December 2018, the DRC Ministry of Public Health announced that there had been "0 new confirmed cases detected because of the paralysis of the activities of the response in Beni, Butembo, Komanda and Mabalako" and no vaccination had occurred for three consecutive days. On 22 January, the total case count approached 1,000 cases, (951 suspected) in the DRC Ministry of Public Health situation report. The graphs below demonstrate the EVD intensity in different locations in the DRC, as well as in the West African epidemic of 2014–15 as a comparison: On 16 March 2019, the director of the CDC indicated that the outbreak in the DRC could last another year, additionally suggesting that vaccine supplies could run out. According to the WHO, resistance to vaccination in the Kaniyi Health Zone was ongoing as of March 2019. There was still a belief by some in surrounding areas that the epidemic was a hoax. Until the outbreak in North Kivu in 2018, no outbreak had surpassed 320 total cases in the Democratic Republic of the Congo. By 24 February 2019, the epidemic had surpassed 1,000 total cases (1,048). On 10 May 2019, the U.S. Centers for Disease Control and Prevention indicated that the outbreak could eventually surpass the West African epidemic. The 12 May 2019 issue of WHO Weekly Bulletin on Outbreaks and Other Emergencies, indicates that " continued increase in the number of new EVD cases in the Democratic Republic of the Congo is worrying...no end in sight to the difficult security situation ". On 25 November 2019, it was reported that violence had broken out in Beni again, to such a degree that some aid agencies had evacuated. According to the same report, around 300 individuals might have been exposed to EVD via an infected individual. On 14 July 2019, the first case of EVD was confirmed in the capital of North Kivu, Goma , a city with an international airport and a highly mobile population of 2 million people located near the DRC's eastern border with Rwanda . This case was a man who had passed through three health checkpoints, with different names on traveller lists. The WHO stated that he died in a treatment centre, whereas according to Reuters he died en route to a treatment centre. This case triggered the decision by the WHO to again reconvene an emergency committee, where the situation was officially declared a Public Health Emergency of International Concern . On 30 July, a second case of EVD was confirmed in the city of Goma, apparently not linked to the first case. Across the border from Goma in the country of Rwanda, Ebola simulation drills were being conducted at health facilities. A third case of EVD was confirmed in Goma on 1 August. On 22 August 2019, Nyiragongo Health Zone, the affected area on the outskirts of Goma, reached 21 days without further cases being confirmed. On 16 August 2019, it was reported that the Ebola virus disease had spread to a third province – South Kivu – via two new cases who had travelled from Beni, North Kivu. By 22 August the number of cases in Mwenga had risen to four, including one person at a health facility visited by the first case. In August 2018 a UN agency indicated that active screening was deployed to ensure that those leaving the DRC into Uganda were not infected with Ebola. The government of Uganda opened two Ebola treatment centers at the border with the DRC, though there had not yet been any confirmed cases in the country of Uganda. By 13 June 2019, nine treatment units were in place near the affected border. According to the International Red Cross , a "most likely scenario" entailed an asymptomatic case entering the country of Uganda undetected among the numerous refugees then coming from the DRC. On 20 September, Uganda indicated it was ready for immediate vaccination, should the Ebola virus be detected in any individual. On 21 September, officials of the DRC indicated a confirmed case of EVD at Lake Albert , an entry point into Uganda, though no cases were then confirmed within Ugandan territory. On 2 November, it was reported that the Ugandan government would start vaccinating health workers along the border with the DRC as a proactive measure against the virus. Vaccinations started on 7 November, and by 13 June 2019, 4,699 health workers at 165 sites had been vaccinated. Proactive vaccination was also carried out in South Sudan , with 1,471 health workers vaccinated by 7 May 2019. On 2 January 2019, it was reported that refugee movement from the DRC to Uganda had increased after the presidential elections. On 12 February, it was reported that 13 individuals had been isolated due to their contact with a suspected Ebola case in Uganda; lab results came back negative several hours later. On 11 June 2019, the WHO reported that the virus had spread to Uganda. A 5-year-old Congolese boy entered Uganda on the previous Sunday with his family to seek medical care. On 12 June, the WHO reported that the 5-year-old patient had died, while 2 more cases of Ebola infection within the same family were also confirmed. On 14 June it was reported that there were 112 contacts since EVD was first detected in Uganda. Ring vaccination of Ugandan contacts was scheduled to start on 15 June. As of 18 June 2019, 275 contacts had been vaccinated per the Uganda Ministry of Health. On 14 July, an individual entered the country of Uganda from DRC while symptomatic for EVD; a search for contacts in Mpondwe followed. On 24 July, Uganda marked the needed 42 day period without any EVD cases to be declared Ebola-free. On 29 August, a 9-year-old Congolese girl became the fourth individual in Uganda to test positive for EVD when she crossed from the DRC into the district of Kasese . In regards to possible EVD cases in Tanzania, the WHO stated on 21 September 2019 that "to date, the clinical details and the results of the investigation, including laboratory tests performed for differential diagnosis of these patients, have not been shared with WHO. The insufficient information received by WHO does not allow for a formulation of a hypotheses regarding the possible cause of the illness". On 27 September, the CDC and U.S. State Department alerted potential travellers to the possibility of unreported EVD cases within Tanzania. The Tanzanian Health Minister Ummy Mwalimu stated on 3 October 2019 that there was no Ebola outbreak in Tanzania. The WHO were provided with a preparedness update on 18 October which outlined a range of actions, and included commentary that since the outbreak commenced, there had been "29 alerts of Ebola suspect cases reported, 17 samples tested and were negative for Ebola (including 2 in September 2019)". On 29 December, an American physician who was exposed to the Ebola virus (and who was non-symptomatic) was evacuated, and taken to the University of Nebraska Medical Center . On 12 January, the individual was released after 21 days without symptoms. The table which follows indicates confirmed , probable and suspected cases, as well as deaths ; the table also indicates the multiple countries where these cases took place, during this outbreak. # These figures may increase when new cases are discovered, and fall consequently, when tests show cases were not Ebola-related. †DRC Ministry of Public Health ‡ indicates suspected cases were not counted towards CFR x indicates 42 days have passed since the last case and outbreak is declared over At the time of the epidemic, there were about 70 armed military groups, among them the Alliance of Patriots for a Free and Sovereign Congo and the Mai-Mayi Nduma défense du Congo-Rénové , in North Kivu. The fighting displaced thousands of individuals and seriously affected the response to the outbreak. According to the WHO, health care workers were to be accompanied by military personnel for protection and ring vaccination may not be possible. On 11 August 2018, it was reported that seven individuals were killed in Mayi-Moya due to a militant group, about 24 miles from the city of Beni where there were several EVD cases. On 24 August 2018, it was reported that an Ebola-stricken physician had been in contact with 97 individuals in an inaccessible military area, who hence could not be diagnosed. In September, it was reported that 2 peacekeepers were attacked and wounded by rebel groups in Beni, and 14 individuals were killed in a military attack. In September 2018, the WHO's Deputy Director-General for Emergency Preparedness and Response described the combination of military conflict and civilian distress as a potential "perfect storm" that could lead to a rapid worsening of the outbreak. On 20 October 2018, an armed rebel group in the DRC killed 13 civilians and took 12 children as hostages in Beni, which was then experiencing one of the worst outbreaks. On 11 November, six people were killed in an attack by an armed rebel group in Beni; as a consequence vaccinations were suspended there. Yet another attack reported on 17 November, in Beni by an armed rebel group forced the cessation of EVD containment efforts and WHO staff to evacuate to another DRC city for the time being. Beni continued to be the site of attacks by militant groups as 18 civilians were killed on 6 December. On 22 December, it was reported that elections for the President of the DRC would go forward despite the EVD outbreak, including in the Ebola-stricken area of Beni. Four days later, on 26 December, the DRC government reversed itself to indicate those Ebola-stricken areas, such as Beni, would not vote for several months; as a consequence election protesters ransacked an Ebola assessment center in Beni. Post election tensions continued when it was reported that the DRC government had cut off internet connectivity for the population, as the vote results were yet to be released. On 29 December 2018, Oxfam said it would suspend its work due to the ongoing violence in the DRC; on the same day, the International Rescue Committee suspended their Ebola support efforts as well. On 18 January, the African Union indicated that presidential election results announcements should be suspended in the DRC. On 1 August 2018, the North Kivu health division notified Congo's health ministry of 26 cases of hemorrhagic fever , including 20 deaths. Four of the six samples that were sent for analysis to the National Institute of Biological Research in Kinshasa came back positive for Ebola and an outbreak was declared on that date. The index case is believed to have been the death and unsafe burial of a 65-year-old woman on 25 July in Mangina, quickly followed by the deaths of seven close family members. This outbreak started just days after the end of the outbreak in Équateur province . On 1 August, just after the Ebola epidemic had been declared, Doctors Without Borders/Médecins Sans Frontières (MSF) arrived in Mangina, the point of origin of the outbreak, to mount a response. On 2 August, Oxfam indicated it would be taking part in the response to this latest outbreak in the DRC. On 4 August, the WHO indicated that the current situation in the DRC, due to several factors, warranted a "high risk assessment" at the national and regional level for public health. By 3 August, the virus had developed in multiple locations; cases were reported in five health zones – Beni , Butembo , Oicha , Musienene and Mabalako – in North Kivu province as well as Mandima and Mambasa in Ituri Province . However, one month later there had been confirmed cases only in the Mabalako, Mandima, Beni and Oicha health zones. The five suspected cases in the Mambasa Health Zone proved not to be EVD; it was not possible to confirm the one probable case in the Musienene Health Zone and the two probable cases in the Butembo Health Zone. No new cases had been recorded in any of those health zones. WHO chief Tedros Adhanom Ghebreyesu indicated on 15 August that the outbreak then in the DRC might be worse than the West African outbreak of 2013–2016, with the IRC connecting this to the ongoing Kivu conflict . The Kivu outbreak was the biggest of the ten recorded outbreaks recorded in the DRC. The first confirmed case in Butembo was announced on 4 September, the same day that it was announced that one of the cases registered at Beni had actually come from the Kalunguta Health Zone. In November, it was reported that the EVD outbreak ran across two provinces and 14 health zones. By 23 December, the EVD outbreak had spread to more health zones, and at that time 18 such areas had been affected. On 7 August 2018, the DRC Ministry of Public Health indicated that the total count had climbed to almost 90 cases, and the Uganda Ministry of Health issued an alert for extra surveillance as the outbreak was just 100 kilometres (62 mi) away from its border. Two days later the total count was nearly 100 cases. On 16 August, the United Kingdom indicated it would help with EVD diagnosis and monitoring in the DRC. On 17 August 2018, the WHO reported that there were around 1,500 " contacts ", while noting that certain conflict zones in the DRC that could not be reached might have contained more contacts. Some 954 contacts were successfully followed up on 18 August; however, Mandima Health Zone indicated resistance, so contacts were not followed up there. On 4 September, Butembo , a city with almost one million people and an international airport, recorded its first fatality in the Ebola outbreak. The city of Butembo, in the DRC, has trade links to nearby Uganda. On 24 September, it was reported that all contact tracing and vaccinations would stop for the foreseeable future in Beni due to a deadly attack by rebel groups the day before. On 25 September, Peter Salama of the WHO indicated that insecurity was obstructing efforts to stop the virus and believed a combination of factors could establish conditions for an epidemic. On 18 October, the U.S. Centers for Disease Control and Prevention (CDC) raised its travelers' alert to the DRC from a level 1 to level 2 for all U.S. travelers. On 26 October, the WHO indicated that half of confirmed cases were not showing any fever symptoms, thus making diagnosis more difficult. According to a September 2018 Lancet survey, 25% of respondents in Beni and Butembo believed the Ebola outbreak to be a hoax. These beliefs correlated with decreased likelihood of seeking healthcare or accepting vaccination. On 6 November 2018, the CDC indicated that the current outbreak in the east region of the DRC was potentially non-containable. This would be the first time since 1976 that an outbreak was not able to be curbed. On 13 November, the WHO indicated that the viral outbreak would last at least six months. On 29 December 2018, the DRC Ministry of Public Health announced that there had been "0 new confirmed cases detected because of the paralysis of the activities of the response in Beni, Butembo, Komanda and Mabalako" and no vaccination had occurred for three consecutive days. On 22 January, the total case count approached 1,000 cases, (951 suspected) in the DRC Ministry of Public Health situation report. The graphs below demonstrate the EVD intensity in different locations in the DRC, as well as in the West African epidemic of 2014–15 as a comparison: On 16 March 2019, the director of the CDC indicated that the outbreak in the DRC could last another year, additionally suggesting that vaccine supplies could run out. According to the WHO, resistance to vaccination in the Kaniyi Health Zone was ongoing as of March 2019. There was still a belief by some in surrounding areas that the epidemic was a hoax. Until the outbreak in North Kivu in 2018, no outbreak had surpassed 320 total cases in the Democratic Republic of the Congo. By 24 February 2019, the epidemic had surpassed 1,000 total cases (1,048). On 10 May 2019, the U.S. Centers for Disease Control and Prevention indicated that the outbreak could eventually surpass the West African epidemic. The 12 May 2019 issue of WHO Weekly Bulletin on Outbreaks and Other Emergencies, indicates that " continued increase in the number of new EVD cases in the Democratic Republic of the Congo is worrying...no end in sight to the difficult security situation ". On 25 November 2019, it was reported that violence had broken out in Beni again, to such a degree that some aid agencies had evacuated. According to the same report, around 300 individuals might have been exposed to EVD via an infected individual. On 14 July 2019, the first case of EVD was confirmed in the capital of North Kivu, Goma , a city with an international airport and a highly mobile population of 2 million people located near the DRC's eastern border with Rwanda . This case was a man who had passed through three health checkpoints, with different names on traveller lists. The WHO stated that he died in a treatment centre, whereas according to Reuters he died en route to a treatment centre. This case triggered the decision by the WHO to again reconvene an emergency committee, where the situation was officially declared a Public Health Emergency of International Concern . On 30 July, a second case of EVD was confirmed in the city of Goma, apparently not linked to the first case. Across the border from Goma in the country of Rwanda, Ebola simulation drills were being conducted at health facilities. A third case of EVD was confirmed in Goma on 1 August. On 22 August 2019, Nyiragongo Health Zone, the affected area on the outskirts of Goma, reached 21 days without further cases being confirmed. On 16 August 2019, it was reported that the Ebola virus disease had spread to a third province – South Kivu – via two new cases who had travelled from Beni, North Kivu. By 22 August the number of cases in Mwenga had risen to four, including one person at a health facility visited by the first case. On 7 August 2018, the DRC Ministry of Public Health indicated that the total count had climbed to almost 90 cases, and the Uganda Ministry of Health issued an alert for extra surveillance as the outbreak was just 100 kilometres (62 mi) away from its border. Two days later the total count was nearly 100 cases. On 16 August, the United Kingdom indicated it would help with EVD diagnosis and monitoring in the DRC. On 17 August 2018, the WHO reported that there were around 1,500 " contacts ", while noting that certain conflict zones in the DRC that could not be reached might have contained more contacts. Some 954 contacts were successfully followed up on 18 August; however, Mandima Health Zone indicated resistance, so contacts were not followed up there. On 4 September, Butembo , a city with almost one million people and an international airport, recorded its first fatality in the Ebola outbreak. The city of Butembo, in the DRC, has trade links to nearby Uganda. On 24 September, it was reported that all contact tracing and vaccinations would stop for the foreseeable future in Beni due to a deadly attack by rebel groups the day before. On 25 September, Peter Salama of the WHO indicated that insecurity was obstructing efforts to stop the virus and believed a combination of factors could establish conditions for an epidemic. On 18 October, the U.S. Centers for Disease Control and Prevention (CDC) raised its travelers' alert to the DRC from a level 1 to level 2 for all U.S. travelers. On 26 October, the WHO indicated that half of confirmed cases were not showing any fever symptoms, thus making diagnosis more difficult. According to a September 2018 Lancet survey, 25% of respondents in Beni and Butembo believed the Ebola outbreak to be a hoax. These beliefs correlated with decreased likelihood of seeking healthcare or accepting vaccination. On 6 November 2018, the CDC indicated that the current outbreak in the east region of the DRC was potentially non-containable. This would be the first time since 1976 that an outbreak was not able to be curbed. On 13 November, the WHO indicated that the viral outbreak would last at least six months. On 29 December 2018, the DRC Ministry of Public Health announced that there had been "0 new confirmed cases detected because of the paralysis of the activities of the response in Beni, Butembo, Komanda and Mabalako" and no vaccination had occurred for three consecutive days. On 22 January, the total case count approached 1,000 cases, (951 suspected) in the DRC Ministry of Public Health situation report. The graphs below demonstrate the EVD intensity in different locations in the DRC, as well as in the West African epidemic of 2014–15 as a comparison: On 16 March 2019, the director of the CDC indicated that the outbreak in the DRC could last another year, additionally suggesting that vaccine supplies could run out. According to the WHO, resistance to vaccination in the Kaniyi Health Zone was ongoing as of March 2019. There was still a belief by some in surrounding areas that the epidemic was a hoax. Until the outbreak in North Kivu in 2018, no outbreak had surpassed 320 total cases in the Democratic Republic of the Congo. By 24 February 2019, the epidemic had surpassed 1,000 total cases (1,048). On 10 May 2019, the U.S. Centers for Disease Control and Prevention indicated that the outbreak could eventually surpass the West African epidemic. The 12 May 2019 issue of WHO Weekly Bulletin on Outbreaks and Other Emergencies, indicates that " continued increase in the number of new EVD cases in the Democratic Republic of the Congo is worrying...no end in sight to the difficult security situation ". On 25 November 2019, it was reported that violence had broken out in Beni again, to such a degree that some aid agencies had evacuated. According to the same report, around 300 individuals might have been exposed to EVD via an infected individual. On 14 July 2019, the first case of EVD was confirmed in the capital of North Kivu, Goma , a city with an international airport and a highly mobile population of 2 million people located near the DRC's eastern border with Rwanda . This case was a man who had passed through three health checkpoints, with different names on traveller lists. The WHO stated that he died in a treatment centre, whereas according to Reuters he died en route to a treatment centre. This case triggered the decision by the WHO to again reconvene an emergency committee, where the situation was officially declared a Public Health Emergency of International Concern . On 30 July, a second case of EVD was confirmed in the city of Goma, apparently not linked to the first case. Across the border from Goma in the country of Rwanda, Ebola simulation drills were being conducted at health facilities. A third case of EVD was confirmed in Goma on 1 August. On 22 August 2019, Nyiragongo Health Zone, the affected area on the outskirts of Goma, reached 21 days without further cases being confirmed. On 16 August 2019, it was reported that the Ebola virus disease had spread to a third province – South Kivu – via two new cases who had travelled from Beni, North Kivu. By 22 August the number of cases in Mwenga had risen to four, including one person at a health facility visited by the first case. In August 2018 a UN agency indicated that active screening was deployed to ensure that those leaving the DRC into Uganda were not infected with Ebola. The government of Uganda opened two Ebola treatment centers at the border with the DRC, though there had not yet been any confirmed cases in the country of Uganda. By 13 June 2019, nine treatment units were in place near the affected border. According to the International Red Cross , a "most likely scenario" entailed an asymptomatic case entering the country of Uganda undetected among the numerous refugees then coming from the DRC. On 20 September, Uganda indicated it was ready for immediate vaccination, should the Ebola virus be detected in any individual. On 21 September, officials of the DRC indicated a confirmed case of EVD at Lake Albert , an entry point into Uganda, though no cases were then confirmed within Ugandan territory. On 2 November, it was reported that the Ugandan government would start vaccinating health workers along the border with the DRC as a proactive measure against the virus. Vaccinations started on 7 November, and by 13 June 2019, 4,699 health workers at 165 sites had been vaccinated. Proactive vaccination was also carried out in South Sudan , with 1,471 health workers vaccinated by 7 May 2019. On 2 January 2019, it was reported that refugee movement from the DRC to Uganda had increased after the presidential elections. On 12 February, it was reported that 13 individuals had been isolated due to their contact with a suspected Ebola case in Uganda; lab results came back negative several hours later. On 11 June 2019, the WHO reported that the virus had spread to Uganda. A 5-year-old Congolese boy entered Uganda on the previous Sunday with his family to seek medical care. On 12 June, the WHO reported that the 5-year-old patient had died, while 2 more cases of Ebola infection within the same family were also confirmed. On 14 June it was reported that there were 112 contacts since EVD was first detected in Uganda. Ring vaccination of Ugandan contacts was scheduled to start on 15 June. As of 18 June 2019, 275 contacts had been vaccinated per the Uganda Ministry of Health. On 14 July, an individual entered the country of Uganda from DRC while symptomatic for EVD; a search for contacts in Mpondwe followed. On 24 July, Uganda marked the needed 42 day period without any EVD cases to be declared Ebola-free. On 29 August, a 9-year-old Congolese girl became the fourth individual in Uganda to test positive for EVD when she crossed from the DRC into the district of Kasese . In regards to possible EVD cases in Tanzania, the WHO stated on 21 September 2019 that "to date, the clinical details and the results of the investigation, including laboratory tests performed for differential diagnosis of these patients, have not been shared with WHO. The insufficient information received by WHO does not allow for a formulation of a hypotheses regarding the possible cause of the illness". On 27 September, the CDC and U.S. State Department alerted potential travellers to the possibility of unreported EVD cases within Tanzania. The Tanzanian Health Minister Ummy Mwalimu stated on 3 October 2019 that there was no Ebola outbreak in Tanzania. The WHO were provided with a preparedness update on 18 October which outlined a range of actions, and included commentary that since the outbreak commenced, there had been "29 alerts of Ebola suspect cases reported, 17 samples tested and were negative for Ebola (including 2 in September 2019)". On 29 December, an American physician who was exposed to the Ebola virus (and who was non-symptomatic) was evacuated, and taken to the University of Nebraska Medical Center . On 12 January, the individual was released after 21 days without symptoms. The table which follows indicates confirmed , probable and suspected cases, as well as deaths ; the table also indicates the multiple countries where these cases took place, during this outbreak. # These figures may increase when new cases are discovered, and fall consequently, when tests show cases were not Ebola-related. †DRC Ministry of Public Health ‡ indicates suspected cases were not counted towards CFR x indicates 42 days have passed since the last case and outbreak is declared overAt the time of the epidemic, there were about 70 armed military groups, among them the Alliance of Patriots for a Free and Sovereign Congo and the Mai-Mayi Nduma défense du Congo-Rénové , in North Kivu. The fighting displaced thousands of individuals and seriously affected the response to the outbreak. According to the WHO, health care workers were to be accompanied by military personnel for protection and ring vaccination may not be possible. On 11 August 2018, it was reported that seven individuals were killed in Mayi-Moya due to a militant group, about 24 miles from the city of Beni where there were several EVD cases. On 24 August 2018, it was reported that an Ebola-stricken physician had been in contact with 97 individuals in an inaccessible military area, who hence could not be diagnosed. In September, it was reported that 2 peacekeepers were attacked and wounded by rebel groups in Beni, and 14 individuals were killed in a military attack. In September 2018, the WHO's Deputy Director-General for Emergency Preparedness and Response described the combination of military conflict and civilian distress as a potential "perfect storm" that could lead to a rapid worsening of the outbreak. On 20 October 2018, an armed rebel group in the DRC killed 13 civilians and took 12 children as hostages in Beni, which was then experiencing one of the worst outbreaks. On 11 November, six people were killed in an attack by an armed rebel group in Beni; as a consequence vaccinations were suspended there. Yet another attack reported on 17 November, in Beni by an armed rebel group forced the cessation of EVD containment efforts and WHO staff to evacuate to another DRC city for the time being. Beni continued to be the site of attacks by militant groups as 18 civilians were killed on 6 December. On 22 December, it was reported that elections for the President of the DRC would go forward despite the EVD outbreak, including in the Ebola-stricken area of Beni. Four days later, on 26 December, the DRC government reversed itself to indicate those Ebola-stricken areas, such as Beni, would not vote for several months; as a consequence election protesters ransacked an Ebola assessment center in Beni. Post election tensions continued when it was reported that the DRC government had cut off internet connectivity for the population, as the vote results were yet to be released. On 29 December 2018, Oxfam said it would suspend its work due to the ongoing violence in the DRC; on the same day, the International Rescue Committee suspended their Ebola support efforts as well. On 18 January, the African Union indicated that presidential election results announcements should be suspended in the DRC. The DRC Ministry of Public Health confirmed that the new Ebola outbreak was caused by the Zaire ebolavirus species – the same strain involved in the early 2018 outbreak in western DRC , but different genetic coding. The most lethal of the six known strains (including the newly discovered Bombali strain), Zaire ebolavirus strain is fatal in up to 90% of cases. Both Ebola and Marburg virus are part of the Filoviridae family, which is a virus family that causes severe hemorrhagic fever. The natural reservoir of the virus is thought to be the African fruit bat , which is used in many parts of Africa as bushmeat . A significant part of the actual EVD infection is based on immune suppression along with systemic inflammation, leading to multiple organ failure and shock . Systemic inflammation and fever may damage many types of tissues in the body but the consequences are especially profound in the liver where Ebola wipes out cells required to produce coagulation . In the gastrointestinal tract damaged cells lead to diarrhea putting patients at risk of dehydration. And in the adrenal gland the virus cripples the cells that make steroids which regulate blood pressure, resulting in circulatory collapse . Genetic epidemiology is a medical field that studies how genetic factors and the environment interact, in this case the outbreak affecting the populations of the Democratic Republic of the Congo and the neighboring country of Uganda. Genetic sequencing had already identified another unrelated strain of Zaire ebolavirus that was implicated in the 2018 outbreak in Équateur province which had ended only a week previously. This was the first time two epidemiologically and genetically distinct outbreaks of Ebola had emerged within weeks of each other. In 2020 a third outbreak of Zaire ebolavirus occurred in the DRC. Genome sequencing suggests that this outbreak – the 11th outbreak since the virus was first discovered in the country in 1976 – is related to neither the one in North Kivu Province nor the previous outbreak in the same area in 2018. A significant part of the actual EVD infection is based on immune suppression along with systemic inflammation, leading to multiple organ failure and shock . Systemic inflammation and fever may damage many types of tissues in the body but the consequences are especially profound in the liver where Ebola wipes out cells required to produce coagulation . In the gastrointestinal tract damaged cells lead to diarrhea putting patients at risk of dehydration. And in the adrenal gland the virus cripples the cells that make steroids which regulate blood pressure, resulting in circulatory collapse . Genetic epidemiology is a medical field that studies how genetic factors and the environment interact, in this case the outbreak affecting the populations of the Democratic Republic of the Congo and the neighboring country of Uganda. Genetic sequencing had already identified another unrelated strain of Zaire ebolavirus that was implicated in the 2018 outbreak in Équateur province which had ended only a week previously. This was the first time two epidemiologically and genetically distinct outbreaks of Ebola had emerged within weeks of each other. In 2020 a third outbreak of Zaire ebolavirus occurred in the DRC. Genome sequencing suggests that this outbreak – the 11th outbreak since the virus was first discovered in the country in 1976 – is related to neither the one in North Kivu Province nor the previous outbreak in the same area in 2018. Ebola virus is found in a variety of bodily fluids, such as breast milk, saliva, stool, blood, and semen, rendering it highly contagious due to ease of contact. Although a few transmission methods are known, there is a possibility that many other methods are unknown and must be further researched. Here are some potential routes of transmission: Droplets: Droplet transmission occurs when contact is made with virus-containing droplets. Fomites : Occurs when an individual comes in contact with a pathogen-containing surface. Bodily fluids: The most common way of transmitting the Ebola virus in humans is through contact with infected bodily fluids. Those infected by EVD generally gain immunity, although it is considered possible that such immunity is only temporary. On 31 October 2019, it was reported that an EVD survivor who had been assisting at a treatment center in Beni had been reinfected with EVD and died; such an incident was unprecedented. Even with the advances made in vaccine technology and treatment options during previous Ebola outbreaks, effective control of the North Kivu Epidemic continued to rely on traditional public health efforts including the timely identification and isolation of cases, control measures in hospital settings, identification and follow-up of contacts, community engagement, and safe burials. Data from the West African Ebola Outbreak showed that response strategies that achieved 60% efficacy for sanitary burial, case isolation, and contact-tracing combined, could have greatly reduced the daily number of Ebola cases and ended the outbreak after only 6 months. Contact tracing is defined as the identification and follow-up of persons who may have been in contact with a person infected with Ebola. Ideally, close contacts are observed for 21 days after their last known exposure to a case and isolated if they become symptomatic. The volume of contacts and the duration of monitoring presented challenges in Ebola surveillance as it required careful record-keeping by properly trained and equipped staff. To strengthen surveillance activities, the DRC Ministry of Health began disseminating standardized Ebola case definitions, developed reporting tools, and communication strategies, and began distribution of daily situation reports. Rapid response teams were deployed to affected health zones to strengthen Ebola case management and infection prevention and control in health care facilities and treatment centers. Similar to the West African Ebola Outbreak, relatively few (less than 10%) Ebola cases presented with hemorrhagic symptoms. In North Kivu and Ituri, outbreaks of sporadic violence and suspicion of the response in parts of some affected communities impacted heavily on disease surveillance. Poor record keeping by local health facilities also made it difficult or impossible to identify and trace contacts that might have been exposed to the disease while they were undergoing treatment for other illness at health centers. Additionally, the high degree of mobility of affected populations, combined with occasional mistrust of the response has meant that contacts that had been identified have sometimes been lost to follow-up for extended periods. Initially, it was estimated that 30-50% of contacts may not have originally been registered by contact tracing teams. Surveys among the affected population in North Kivu and Ituri showed both general mistrust with the Ebola response, partly related to years of mistrust of any governmental or external action, and specific opposition to the response because of conflicts with local cultural practices. Some of the cultural practices which complicated the Ebola response included eating bush meat, regular gatherings at family or village events, and traditional funeral practices, which were events that were particularly high risk for Ebola transmission. Additionally, people from the affected region reported that their perception of security and trust in the government, as well as humanitarian workers, declined over the course of the outbreak, complicating an already complex response. Combatting misinformation was a key element in overcoming Ebola in North Kivu. One study using surveys found that low institutional trust coupled with a belief in misinformation about Ebola were inversely associated with preventive behaviors in individuals, including Ebola vaccine acceptance. Belief in misinformation regarding Ebola was widespread, with 25% of respondents reporting that they did not believe the Ebola outbreak was real. Some of the rumors that were being circulated included statements that the outbreak did not exist, it was fabricated by the authorities for financial gains , or was fabricated to destabilize the region. Approximately 68% of respondents reported that they did not trust the local authorities to represent their interest, and community trust in the Ebola response was often further undermined by misinformation spread by local politicians. Early in the epidemic there were delays in patients seeking care for Ebola because the initial cases were misdiagnosed. Ebola symptoms were similar to symptoms of more common infectious diseases such as malaria, flu, and typhoid fever so patients would wait until their clinical situation deteriorated dangerously, usually after failure to respond to anti-malarial and/or antibiotic regimens, before reporting to the hospitals. The IFRC has called funerals "super-spreading events" as burial traditions include kissing and generally touching bodies. Safe burial teams formed by health workers are subject to suspicion. On 26 July 2019, it was reported that the country of Saudi Arabia would not allow visas from the DRC after the WHO declared it an international emergency due to EVD. On 1 August 2019, the country of Rwanda closed its border with the DRC after multiple cases in the city of Goma, which borders the country in the upper Northwestern region. To minimize the risk of the spread to neighboring countries, screening points which consisted of temperature and symptom monitoring were established at many border crossings. Over 2 million screenings were undertaken during the outbreak which no doubt contributed to the containment of the epidemic within DRC. Contact tracing is defined as the identification and follow-up of persons who may have been in contact with a person infected with Ebola. Ideally, close contacts are observed for 21 days after their last known exposure to a case and isolated if they become symptomatic. The volume of contacts and the duration of monitoring presented challenges in Ebola surveillance as it required careful record-keeping by properly trained and equipped staff. To strengthen surveillance activities, the DRC Ministry of Health began disseminating standardized Ebola case definitions, developed reporting tools, and communication strategies, and began distribution of daily situation reports. Rapid response teams were deployed to affected health zones to strengthen Ebola case management and infection prevention and control in health care facilities and treatment centers. Similar to the West African Ebola Outbreak, relatively few (less than 10%) Ebola cases presented with hemorrhagic symptoms. In North Kivu and Ituri, outbreaks of sporadic violence and suspicion of the response in parts of some affected communities impacted heavily on disease surveillance. Poor record keeping by local health facilities also made it difficult or impossible to identify and trace contacts that might have been exposed to the disease while they were undergoing treatment for other illness at health centers. Additionally, the high degree of mobility of affected populations, combined with occasional mistrust of the response has meant that contacts that had been identified have sometimes been lost to follow-up for extended periods. Initially, it was estimated that 30-50% of contacts may not have originally been registered by contact tracing teams. Surveys among the affected population in North Kivu and Ituri showed both general mistrust with the Ebola response, partly related to years of mistrust of any governmental or external action, and specific opposition to the response because of conflicts with local cultural practices. Some of the cultural practices which complicated the Ebola response included eating bush meat, regular gatherings at family or village events, and traditional funeral practices, which were events that were particularly high risk for Ebola transmission. Additionally, people from the affected region reported that their perception of security and trust in the government, as well as humanitarian workers, declined over the course of the outbreak, complicating an already complex response. Combatting misinformation was a key element in overcoming Ebola in North Kivu. One study using surveys found that low institutional trust coupled with a belief in misinformation about Ebola were inversely associated with preventive behaviors in individuals, including Ebola vaccine acceptance. Belief in misinformation regarding Ebola was widespread, with 25% of respondents reporting that they did not believe the Ebola outbreak was real. Some of the rumors that were being circulated included statements that the outbreak did not exist, it was fabricated by the authorities for financial gains , or was fabricated to destabilize the region. Approximately 68% of respondents reported that they did not trust the local authorities to represent their interest, and community trust in the Ebola response was often further undermined by misinformation spread by local politicians. Early in the epidemic there were delays in patients seeking care for Ebola because the initial cases were misdiagnosed. Ebola symptoms were similar to symptoms of more common infectious diseases such as malaria, flu, and typhoid fever so patients would wait until their clinical situation deteriorated dangerously, usually after failure to respond to anti-malarial and/or antibiotic regimens, before reporting to the hospitals. Combatting misinformation was a key element in overcoming Ebola in North Kivu. One study using surveys found that low institutional trust coupled with a belief in misinformation about Ebola were inversely associated with preventive behaviors in individuals, including Ebola vaccine acceptance. Belief in misinformation regarding Ebola was widespread, with 25% of respondents reporting that they did not believe the Ebola outbreak was real. Some of the rumors that were being circulated included statements that the outbreak did not exist, it was fabricated by the authorities for financial gains , or was fabricated to destabilize the region. Approximately 68% of respondents reported that they did not trust the local authorities to represent their interest, and community trust in the Ebola response was often further undermined by misinformation spread by local politicians. Early in the epidemic there were delays in patients seeking care for Ebola because the initial cases were misdiagnosed. Ebola symptoms were similar to symptoms of more common infectious diseases such as malaria, flu, and typhoid fever so patients would wait until their clinical situation deteriorated dangerously, usually after failure to respond to anti-malarial and/or antibiotic regimens, before reporting to the hospitals. The IFRC has called funerals "super-spreading events" as burial traditions include kissing and generally touching bodies. Safe burial teams formed by health workers are subject to suspicion. On 26 July 2019, it was reported that the country of Saudi Arabia would not allow visas from the DRC after the WHO declared it an international emergency due to EVD. On 1 August 2019, the country of Rwanda closed its border with the DRC after multiple cases in the city of Goma, which borders the country in the upper Northwestern region. To minimize the risk of the spread to neighboring countries, screening points which consisted of temperature and symptom monitoring were established at many border crossings. Over 2 million screenings were undertaken during the outbreak which no doubt contributed to the containment of the epidemic within DRC. In August 2018, the WHO evaluated several drugs used to treat EVD, including Remdesivir , ZMapp , atoltivimab/maftivimab/odesivimab , ansuvimab and favipiravir . The drug ansuvimab (which is a monoclonal antibody ) was deployed for the first time to treat infected individuals during this EVD outbreak. In November 2018, the DRC gave approval to start randomized clinical trials for EVD treatment. On 12 August 2019, it was announced that two clinical trial medications were found to improve the rate of survival in those infected by EVD: atoltivimab/maftivimab/odesivimab, a cocktail of three monoclonal Ebola antibodies, and ansuvimab. These two will be further used in therapy; when used shortly after infection they were found to have a 90% survival rate. ZMapp and Remdesivir were subsequently discontinued. In October 2020, the U.S. Food and Drug Administration (FDA) approved atoltivimab/maftivimab/odesivimab with an indication for the treatment of infection caused by Zaire ebolavirus . On 8 August 2018, the process of vaccination began with rVSV-ZEBOV Ebola vaccine . While several studies have shown the vaccine to be safe and protective against the virus, additional research is needed before it can be licensed. Consequently, the WHO reported that it was being used under a ring vaccination strategy with what is known as " compassionate use " to protect persons at highest risk of the Ebola outbreak, i.e. contacts of those infected, contacts of those contacts, and front-line medical personnel. As of 15 September, according to the WHO, almost a quarter of a million individuals had been vaccinated in the outbreak. On 20 September 2019 it was reported that a second vaccine by Johnson & Johnson would be introduced in the current EVD epidemic in the DRC. In November 2019, the World Health Organization prequalified an Ebola vaccine, rVSV-ZEBOV, for the first time. As of 22 February 2020, a total of 297,275 people had been vaccinated since the start of the outbreak. By 21 June 2020, 303,905 people had been vaccinated with rVSV-ZEBOV and 20,339 were given the initial dose of Ad26-ZEBOV/MVA-BN-FILO. Vaccination has helped to contain the epidemic, though military attacks and community resistance have complicated distribution of the vaccines. Based on a lack of evidence about the safety of the vaccine during pregnancy, the DRC ministry of health and the WHO decided to cease vaccinating women who were pregnant or lactating. Some authorities criticized this decision as ethically "utterly indefensible". They noted that as caregivers of the sick, pregnant and lactating women are more likely to contract Ebola. They also noted that since it is known that almost 100% of pregnant women who contract Ebola will die, a safety concern should not be a deciding factor. As of June 2019, pregnant and lactating women were also being vaccinated. The DRC Ministry of Public Health reported on 16 August 2018 that 316 individuals had been vaccinated. On 24 August, the DRC indicated it had vaccinated 2,957 individuals, including 1,422 in Mabalako against the Ebola virus. By late October, more than 20,000 individuals had been vaccinated. In December, Dr. Peter Salama, who is Deputy Director-General of Emergency Preparedness and Response for WHO, reported that the current 300,000 vaccine stockpile might not be enough to contain the EVD outbreak, especially since it takes several months to make more of the Zaire EVD vaccine (rVSV-ZEBOV). On 11 December, it was reported that Beni only had 4,290 doses of vaccine in stock. As of August 2019, Merck & Co , the producers of the vaccine in use, reported a stockpile sufficient for 500,000 individuals, with more in production. In April 2019, the WHO published the preliminary results of its research, in association with the DRC's Institut National pour la Recherche Biomedicale , into the effectiveness of the ring vaccination program, including data from 93,965 at-risk people who had been vaccinated. WHO stated that the rVSV-ZEBOV-GP vaccine had been 97.5% effective at stopping Ebola transmission. The vaccine had also reduced mortality among those who were infected after vaccination. The ring vaccination strategy was effective at reducing EVD in contacts of contacts (tertiary cases), with only two such cases being reported. In August 2018, the Mangina Ebola Treatment Center was reported to be operational. A fourth Ebola Treatment Center (after those in Mangina, Beni and Butembo ) was inaugurated in September in Makeke in the Mandima Health Zone of Ituri Province . Makeke is less than five kilometers from Mangina along a well-traveled local road; the site had been proposed in August when it appeared that a second Ebola Treatment Center would be needed in the area, and space was insufficient in Mangina itself to accommodate one. By mid-September, however, there had been only two additional cases in the Mandima Health Zone, and only sporadic cases were being reported in the Mabalako Health Zone. In February 2019, it was reported that attacks at treatment centers had been carried out in Butembo and Katwa. The motives behind the attacks were unclear. Due to the violence, international aid organizations had to stop their work in the two communities. In April, an epidemiologist from WHO was killed and two health workers injured in a militia attack on Butembo University Hospital in Katwa. In May, WHO's health emergencies chief said insecurity had become a "major impediment" to controlling the outbreak. He reported that since January there had been 42 attacks on health facilities and 85 health workers had been wounded or killed. "Every time we have managed to regain control over the virus and contain its spread, we have suffered major, major security events. We are anticipating a scenario of continued intense transmission". Health workers must wear personal protection equipment during treatment of those affected by the virus. On 3 September 2018, WHO stated that 16 health workers had contracted the virus. On 10 December, the WHO reported that the current DRC outbreak had led to 49 healthcare workers contracting the Ebola virus, and 15 had died. As of 30 April 2019, there have been 92 health care workers in the DRC infected with EVD, of which 33 had died. With false rumors being spread by word-of-mouth and social media, residents remain mistrustful and fearful of health care workers. In January 2020, it was reported that there had been nearly 400 attacks on medical workers since the outbreak began in 2018. On 8 August 2018, the process of vaccination began with rVSV-ZEBOV Ebola vaccine . While several studies have shown the vaccine to be safe and protective against the virus, additional research is needed before it can be licensed. Consequently, the WHO reported that it was being used under a ring vaccination strategy with what is known as " compassionate use " to protect persons at highest risk of the Ebola outbreak, i.e. contacts of those infected, contacts of those contacts, and front-line medical personnel. As of 15 September, according to the WHO, almost a quarter of a million individuals had been vaccinated in the outbreak. On 20 September 2019 it was reported that a second vaccine by Johnson & Johnson would be introduced in the current EVD epidemic in the DRC. In November 2019, the World Health Organization prequalified an Ebola vaccine, rVSV-ZEBOV, for the first time. As of 22 February 2020, a total of 297,275 people had been vaccinated since the start of the outbreak. By 21 June 2020, 303,905 people had been vaccinated with rVSV-ZEBOV and 20,339 were given the initial dose of Ad26-ZEBOV/MVA-BN-FILO. Vaccination has helped to contain the epidemic, though military attacks and community resistance have complicated distribution of the vaccines. Based on a lack of evidence about the safety of the vaccine during pregnancy, the DRC ministry of health and the WHO decided to cease vaccinating women who were pregnant or lactating. Some authorities criticized this decision as ethically "utterly indefensible". They noted that as caregivers of the sick, pregnant and lactating women are more likely to contract Ebola. They also noted that since it is known that almost 100% of pregnant women who contract Ebola will die, a safety concern should not be a deciding factor. As of June 2019, pregnant and lactating women were also being vaccinated. The DRC Ministry of Public Health reported on 16 August 2018 that 316 individuals had been vaccinated. On 24 August, the DRC indicated it had vaccinated 2,957 individuals, including 1,422 in Mabalako against the Ebola virus. By late October, more than 20,000 individuals had been vaccinated. In December, Dr. Peter Salama, who is Deputy Director-General of Emergency Preparedness and Response for WHO, reported that the current 300,000 vaccine stockpile might not be enough to contain the EVD outbreak, especially since it takes several months to make more of the Zaire EVD vaccine (rVSV-ZEBOV). On 11 December, it was reported that Beni only had 4,290 doses of vaccine in stock. As of August 2019, Merck & Co , the producers of the vaccine in use, reported a stockpile sufficient for 500,000 individuals, with more in production. In April 2019, the WHO published the preliminary results of its research, in association with the DRC's Institut National pour la Recherche Biomedicale , into the effectiveness of the ring vaccination program, including data from 93,965 at-risk people who had been vaccinated. WHO stated that the rVSV-ZEBOV-GP vaccine had been 97.5% effective at stopping Ebola transmission. The vaccine had also reduced mortality among those who were infected after vaccination. The ring vaccination strategy was effective at reducing EVD in contacts of contacts (tertiary cases), with only two such cases being reported. Based on a lack of evidence about the safety of the vaccine during pregnancy, the DRC ministry of health and the WHO decided to cease vaccinating women who were pregnant or lactating. Some authorities criticized this decision as ethically "utterly indefensible". They noted that as caregivers of the sick, pregnant and lactating women are more likely to contract Ebola. They also noted that since it is known that almost 100% of pregnant women who contract Ebola will die, a safety concern should not be a deciding factor. As of June 2019, pregnant and lactating women were also being vaccinated. The DRC Ministry of Public Health reported on 16 August 2018 that 316 individuals had been vaccinated. On 24 August, the DRC indicated it had vaccinated 2,957 individuals, including 1,422 in Mabalako against the Ebola virus. By late October, more than 20,000 individuals had been vaccinated. In December, Dr. Peter Salama, who is Deputy Director-General of Emergency Preparedness and Response for WHO, reported that the current 300,000 vaccine stockpile might not be enough to contain the EVD outbreak, especially since it takes several months to make more of the Zaire EVD vaccine (rVSV-ZEBOV). On 11 December, it was reported that Beni only had 4,290 doses of vaccine in stock. As of August 2019, Merck & Co , the producers of the vaccine in use, reported a stockpile sufficient for 500,000 individuals, with more in production. In April 2019, the WHO published the preliminary results of its research, in association with the DRC's Institut National pour la Recherche Biomedicale , into the effectiveness of the ring vaccination program, including data from 93,965 at-risk people who had been vaccinated. WHO stated that the rVSV-ZEBOV-GP vaccine had been 97.5% effective at stopping Ebola transmission. The vaccine had also reduced mortality among those who were infected after vaccination. The ring vaccination strategy was effective at reducing EVD in contacts of contacts (tertiary cases), with only two such cases being reported. In August 2018, the Mangina Ebola Treatment Center was reported to be operational. A fourth Ebola Treatment Center (after those in Mangina, Beni and Butembo ) was inaugurated in September in Makeke in the Mandima Health Zone of Ituri Province . Makeke is less than five kilometers from Mangina along a well-traveled local road; the site had been proposed in August when it appeared that a second Ebola Treatment Center would be needed in the area, and space was insufficient in Mangina itself to accommodate one. By mid-September, however, there had been only two additional cases in the Mandima Health Zone, and only sporadic cases were being reported in the Mabalako Health Zone. In February 2019, it was reported that attacks at treatment centers had been carried out in Butembo and Katwa. The motives behind the attacks were unclear. Due to the violence, international aid organizations had to stop their work in the two communities. In April, an epidemiologist from WHO was killed and two health workers injured in a militia attack on Butembo University Hospital in Katwa. In May, WHO's health emergencies chief said insecurity had become a "major impediment" to controlling the outbreak. He reported that since January there had been 42 attacks on health facilities and 85 health workers had been wounded or killed. "Every time we have managed to regain control over the virus and contain its spread, we have suffered major, major security events. We are anticipating a scenario of continued intense transmission". Health workers must wear personal protection equipment during treatment of those affected by the virus. On 3 September 2018, WHO stated that 16 health workers had contracted the virus. On 10 December, the WHO reported that the current DRC outbreak had led to 49 healthcare workers contracting the Ebola virus, and 15 had died. As of 30 April 2019, there have been 92 health care workers in the DRC infected with EVD, of which 33 had died. With false rumors being spread by word-of-mouth and social media, residents remain mistrustful and fearful of health care workers. In January 2020, it was reported that there had been nearly 400 attacks on medical workers since the outbreak began in 2018. Health workers must wear personal protection equipment during treatment of those affected by the virus. On 3 September 2018, WHO stated that 16 health workers had contracted the virus. On 10 December, the WHO reported that the current DRC outbreak had led to 49 healthcare workers contracting the Ebola virus, and 15 had died. As of 30 April 2019, there have been 92 health care workers in the DRC infected with EVD, of which 33 had died. With false rumors being spread by word-of-mouth and social media, residents remain mistrustful and fearful of health care workers. In January 2020, it was reported that there had been nearly 400 attacks on medical workers since the outbreak began in 2018. In terms of prognosis, aside from the possible effects of post-Ebola syndrome , there is also the reality of survivors returning to communities where they might be shunned due to the fear many have towards the Ebola virus, hence psychosocial assistance is needed. Many survivors of EVD face serious side effects, including but not limited to the following: The Ebola virus disease outbreak in Zaire (Yambuku) started in late 1976, and was the second outbreak ever after the earlier one in Sudan the same year. On 1 August 2018, the tenth Ebola outbreak was declared in the DRC, only a few days after a prior outbreak in the same country had been declared over on 24 July. Learning from other responses, such as in the 2000 outbreak in Uganda , the WHO established its Global Outbreak Alert and Response Network , and other public health measures were instituted in areas at high risk. Field laboratories were established to confirm cases, instead of shipping samples to South Africa . Additionally, the outbreak was closely monitored by the CDC Special Pathogens Branch. One way to measure the outbreak is via the basic reproduction number , R 0 , a statistical measure of the average number of people expected to be infected by one person with a disease. If the basic reproduction number is less than 1, the infection dies out; if it is greater than 1, the infection continues to spread—with exponential growth in the number of cases. A March 2019 paper by Tariq et al. suggested that R 0 was oscillating around 0.9. During the Ebola outbreak in Democratic Republic of the Congo, a number of organizations helped in different capacities: CARITAS DRC, CARE International , Cooperazione Internationale (COOPE), Catholic Organization for Relief and Development Aid (CORDAID/PAP-DRC), International Rescue Committee (IRC), Médecins Sans Frontières (MSF), Oxfam , International Federation of Red Cross and Red Crescent Societies (IFRC), International Committee of the Red Cross (ICRC), and Samaritan's Purse . On 12 April 2019, the WHO Emergency Committee was reconvened by the WHO Director-General after an increase in the rate of new cases, and determined that the outbreak still failed to meet the criteria for a Public Health Emergency of International Concern (PHEIC). Following the confirmation of Ebola crossing into Uganda, a third review by the WHO on 14 June 2019 concluded that while the outbreak was a health emergency in the DRC and the region, it did not meet all three criteria required for a PHEIC. Following a case in Goma, the reconvening of a fourth review was announced on 15 July 2019. The WHO officially declared the situation a PHEIC on 17 July 2019, and as of 12 February 2020, it continues to be a PHEIC. In September 2021, a commission found that between 2018 and 2020, WHO staff had engaged in sex abuse and rape. The report prompted WHO's chief Tedros Adhanom to issue a formal apology to those women and girls affected. The World Bank was criticised when its Pandemic Emergency Financing Facility , intended to support countries affected by pandemic diseases, had only paid out $31 million of a potential total of $425 million by August 2019 while generating substantial returns for investors. The conditions used to decide when the fund should pay out to disease-affected countries were criticised as too stringent. Financial support has been contributed by the governments of the US and the UK, among others. The UK DfID minister, Rory Stewart , visited the area in July 2019, and called for other western countries, including Canada , France and Germany , to donate more financial aid. He identified a funding deficit of $100–300 million to continue responding to the outbreak until December. He urged WHO to classify the situation as a PHEIC, to facilitate the release of international aid. On 12 April 2019, the WHO Emergency Committee was reconvened by the WHO Director-General after an increase in the rate of new cases, and determined that the outbreak still failed to meet the criteria for a Public Health Emergency of International Concern (PHEIC). Following the confirmation of Ebola crossing into Uganda, a third review by the WHO on 14 June 2019 concluded that while the outbreak was a health emergency in the DRC and the region, it did not meet all three criteria required for a PHEIC. Following a case in Goma, the reconvening of a fourth review was announced on 15 July 2019. The WHO officially declared the situation a PHEIC on 17 July 2019, and as of 12 February 2020, it continues to be a PHEIC. In September 2021, a commission found that between 2018 and 2020, WHO staff had engaged in sex abuse and rape. The report prompted WHO's chief Tedros Adhanom to issue a formal apology to those women and girls affected. In September 2021, a commission found that between 2018 and 2020, WHO staff had engaged in sex abuse and rape. The report prompted WHO's chief Tedros Adhanom to issue a formal apology to those women and girls affected. The World Bank was criticised when its Pandemic Emergency Financing Facility , intended to support countries affected by pandemic diseases, had only paid out $31 million of a potential total of $425 million by August 2019 while generating substantial returns for investors. The conditions used to decide when the fund should pay out to disease-affected countries were criticised as too stringent. Financial support has been contributed by the governments of the US and the UK, among others. The UK DfID minister, Rory Stewart , visited the area in July 2019, and called for other western countries, including Canada , France and Germany , to donate more financial aid. He identified a funding deficit of $100–300 million to continue responding to the outbreak until December. He urged WHO to classify the situation as a PHEIC, to facilitate the release of international aid. On 1 June 2020, the Congolese health ministry announced a new DRC outbreak of Ebola in Mbandaka , Équateur Province , a region along the Congo River. This area was the site of the 2018 Équateur province Ebola outbreak , which infected 53 people and resulted in 29 deaths. That outbreak was quickly brought under control with the use of the Ebola vaccine. Genome sequencing suggested that this 2020 outbreak, the 11th outbreak since the virus was first discovered in the country in 1976, was unrelated to the one in North Kivu Province or the previous outbreak in the same area in 2018. It was reported that six cases had been identified with four fatalities. It was expected that more people would be identified as surveillance activities increased. The WHO assisted with the response to this outbreak in part using the structures put in place for the 2018 outbreak. Testing and contact tracing was used and additional medical staff had been sent in. Médecins Sans Frontières was also on hand to give assistance if needed. The outbreak added to an already difficult time for the Congo due to both COVID-19 cases and a large measles outbreak that has caused more than 7,000 deaths as of August 2020. By 8 June, a total of 12 cases had been identified in and around Mbandaka and 6 deaths due to the virus. The WHO said 300 people in Mbandaka and the surrounding Équateur province had been vaccinated. By 15 June the case count had increased to 17 with 11 deaths, with more than 2,500 people having been vaccinated. On 17 October, it had increased to 128 cases and 53 deaths, despite an effective vaccine being available. As of 18 November, the World Health Organization has had no reported cases of Ebola in Équateur province for 42 days; therefore the outbreak is over. In the end there were 130 cases and 55 dead due to the virus. On 1 June 2020, the Congolese health ministry announced a new DRC outbreak of Ebola in Mbandaka , Équateur Province , a region along the Congo River. This area was the site of the 2018 Équateur province Ebola outbreak , which infected 53 people and resulted in 29 deaths. That outbreak was quickly brought under control with the use of the Ebola vaccine. Genome sequencing suggested that this 2020 outbreak, the 11th outbreak since the virus was first discovered in the country in 1976, was unrelated to the one in North Kivu Province or the previous outbreak in the same area in 2018. It was reported that six cases had been identified with four fatalities. It was expected that more people would be identified as surveillance activities increased. The WHO assisted with the response to this outbreak in part using the structures put in place for the 2018 outbreak. Testing and contact tracing was used and additional medical staff had been sent in. Médecins Sans Frontières was also on hand to give assistance if needed. The outbreak added to an already difficult time for the Congo due to both COVID-19 cases and a large measles outbreak that has caused more than 7,000 deaths as of August 2020. By 8 June, a total of 12 cases had been identified in and around Mbandaka and 6 deaths due to the virus. The WHO said 300 people in Mbandaka and the surrounding Équateur province had been vaccinated. By 15 June the case count had increased to 17 with 11 deaths, with more than 2,500 people having been vaccinated. On 17 October, it had increased to 128 cases and 53 deaths, despite an effective vaccine being available. As of 18 November, the World Health Organization has had no reported cases of Ebola in Équateur province for 42 days; therefore the outbreak is over. In the end there were 130 cases and 55 dead due to the virus.

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Ebola

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Ebola (disambiguation)

Ebola is the Ebola virus disease of humans and other primates caused by ebolaviruses. Ebola may also refer to:

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Ebola

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Ebola virus cases in the United States

Four laboratory-confirmed cases of Ebola virus disease (commonly known as "Ebola") occurred in the United States in 2014. Eleven cases were reported, including these four cases and seven cases medically evacuated from other countries. The first was reported in September 2014. Nine of the people contracted the disease outside the US and traveled into the country, either as regular airline passengers or as medical evacuees ; of those nine, two died. Two people contracted Ebola in the United States. Both were nurses who treated an Ebola patient; both recovered. On September 30, 2014, the Centers for Disease Control and Prevention (CDC) announced that Thomas Eric Duncan , a 45-year-old Liberian national visiting the United States from Liberia , had been diagnosed with Ebola in Dallas, Texas . Duncan, who had been visiting family in Dallas, was treated at Texas Health Presbyterian Hospital Dallas . By October 4, his condition had deteriorated from "serious but stable" to "critical". On October 8, he died of Ebola. The other three cases diagnosed in the United States as of October 2014 [ update ] were: Hundreds of people were tested or monitored for potential Ebola virus infection, but the two nurses were the only confirmed cases of locally transmitted Ebola. Public health experts and the Obama administration opposed instituting a travel ban on Ebola endemic areas, stating that it would be ineffective and would paradoxically worsen the situation. No one who contracted Ebola while in the United States died from it. No new cases were diagnosed in the United States after Spencer was released from Bellevue Hospital on November 11, 2014. Thomas Eric Duncan was from Monrovia, Liberia , to date the country hit hardest by the Ebola virus epidemic . He worked as a personal driver for the general manager of Safeway Cargo, a FedEx contractor in Liberia. According to manager Henry Brunson, Duncan had abruptly quit his job on September 4, 2014, giving no reason. On September 15, 2014, the family of Marthalene Williams, who later died of Ebola virus disease , could not call an ambulance to transfer the pregnant Williams to a hospital. Duncan, their tenant, helped to transfer Williams by taxi to an Ebola treatment ward in Monrovia. Duncan rode in the taxi to the treatment ward with Williams, her father and her brother. On September 19, Duncan went to Monrovia Airport , where, according to Liberian officials, he lied about his history of contact with the disease on an airport questionnaire before boarding a Brussels Airlines flight to Brussels . In Brussels, he boarded United Airlines Flight 951 to Washington Dulles Airport . From Dulles, he boarded United Airlines Flight 822 to Dallas/Fort Worth. He arrived in Dallas at 7:01 p.m. CDT on September 20, 2014, and stayed with his partner and her five children, who lived in the Fair Oaks apartment complex in the Vickery Meadow neighborhood of Dallas. Vickery Meadow , the neighborhood in Dallas where Duncan lived, has a large African immigrant population and is Dallas's densest neighborhood. Duncan began experiencing symptoms on September 24, 2014, and arrived at the Texas Health Presbyterian Hospital emergency room at 10:37 p.m. on September 25. At 11:36 p.m. , a triage nurse asked him about his symptoms, and he reported feeling "abdominal pain, dizziness, nausea and headache (new onset)". The nurse recorded a fever of 100.1 °F (37.8 °C) , but did not inquire as to his travel history as this was not triage protocol at the time. At 12:05 a.m. , Duncan was admitted into a treatment area room where the on-duty physician accessed the electronic health record (EHR). The physician noted nasal congestion, a runny nose, and abdominal tenderness. Duncan was given paracetamol (acetaminophen) at 1:24 a.m. CT scan results came back noting "no acute disease" for the abdominal and pelvic areas and "unremarkable" for the head. Lab results returned showing slightly low white blood cells , low platelets , increased creatinine , and elevated levels of the liver enzyme AST . His temperature was noted at 103.0 °F (39.4 °C) at 3:02 a.m. and 101.2 °F (38.4 °C) at 3:32 a.m. Duncan was diagnosed with sinusitis and abdominal pain and sent home at 3:37 a.m. with a prescription for antibiotics , which are not effective for treating viral diseases . What we're seeing now is not an "outbreak" or an "epidemic" of Ebola in America. This is a serious disease, but we can't give in to hysteria or fear. – President Barack Obama on the Ebola outbreak Duncan's condition worsened, and he was transported on September 28 to the same Texas Health Presbyterian Hospital emergency room by ambulance. He arrived in the emergency room at 10:07 a.m. , experiencing diarrhea, abdominal pain, and fever. Within fifteen minutes, a doctor noted that Duncan had recently come from Liberia and needed to be tested for Ebola. The doctor described following "strict [CDC] protocol" including wearing a mask, gown, and gloves. At 12:58 p.m. , the doctor called the CDC directly. By 9:40 p.m. , Duncan was experiencing explosive diarrhea and projectile vomiting. At 8:28 a.m. the next morning, the doctor noted that he "appeared to be deteriorating". By 11:32 a.m. , he was severely fatigued, enough to prevent him from using the bedside toilet. Later that day, he was transferred to an intensive care unit (ICU) after all other patients had been evacuated. The next day, September 30, he was diagnosed with Ebola virus disease after a positive test result. Duncan's diagnosis was publicly confirmed during a CDC news conference the same day. That evening, Duncan reported feeling better and requested to watch a movie. The following morning, he was breathing rapidly and complaining of "pain all over". By the afternoon, however, he was able to eat, and the doctor noted that he was feeling better. The next day, October 3, he again reported feeling abdominal pain. That evening, the hospital contacted Chimerix , a biotechnology company developing Brincidofovir to combat the disease. The next day, Duncan's organs were failing , and he was intubated to help him breathe. In the afternoon, the hospital began administering Brincidofovir. Nurses Nina Pham and Amber Joy Vinson continued to care for Duncan around the clock. On October 7, the hospital reported that Duncan's condition was improving. However, he died at 7:51 a.m. on October 8, becoming the first person to die in the United States of Ebola virus disease and the index patient for the later infections of nurses Pham and Vinson. On October 5, the CDC announced it had lost track of a homeless man who had been in the same ambulance as Duncan. They announced efforts were underway to find the man and place him in a comfortable and compassionate monitoring environment. Later that day, the CDC announced that the man had been found and was being monitored. Up to 100 people may have had contact with those who had direct contact with Duncan after he showed symptoms. Health officials later monitored 50 low- and 10 high-risk contacts, the high-risk contacts being Duncan's close family members and three ambulance workers who took him to the hospital. Everyone who came into contact with Duncan was being monitored daily to watch for symptoms of the virus, until October 20, when health officials removed 43 out of the 48 initial contacts of Thomas Duncan from isolation. On November 7, 2014, Dallas was officially declared "Ebola free" after 177 monitored people cleared the 21 day threshold without becoming ill. On October 2, Liberian authorities said they could prosecute Duncan if he returned because before flying he had filled out a form in which he had falsely stated he had not come into contact with an Ebola case. Liberian President Ellen Johnson Sirleaf told the Canadian Broadcasting Corporation she was angry with Duncan for what he had done, especially given how much the United States was doing to help tackle the crisis: "One of our compatriots didn't take due care, and so, he's gone there and in a way put some Americans in a state of fear, and put them at some risk, and so I feel very saddened by that and very angry with him. ... The fact that he knew (he might be a carrier) and he left the country is unpardonable, quite frankly." Before his death, Duncan brazenly claimed that he did not know at the time of boarding the flight that he had been exposed to Ebola; he said he believed the woman he helped was having a miscarriage, which contradicts corroborated accounts from family members who also helped transport the woman to an Ebola ward. Duncan's family said the care Duncan received was at best "incompetent" and at worst "racially motivated". Family members threatened legal action against the hospital where Duncan received treatment. In response, Texas Health Presbyterian Hospital issued a statement, "Our care team provided Mr. Duncan with the same high level of attention and care that would be given any patient, regardless of nationality or ability to pay for care. We have a long history of treating a multicultural community in this area." The hospital spent an estimated $500,000 to treat the uninsured Duncan. Officials at Texas Presbyterian Hospital reported that patients' cancellation of elective surgeries and potential emergency patients' preference for other hospitals' emergency rooms had left their hospital looking like a "ghost town". The reaction to the care and treatment of Thomas Duncan, and the subsequent transmission to two of the nurses on his care team, caused several hospitals to question the extent to which they are obligated to treat Ebola patients. Their concern surrounds the reality that understaffed and poorly equipped hospitals performing invasive procedures, like renal dialysis and intubation, both of which Duncan received at Texas Presbyterian, could put staff at too much risk for contracting the virus. Emory University Hospital in Atlanta also used renal dialysis in treating patients at their biocontainment unit, but no health care workers became infected. In October 2014 Vickery Meadow residents stated that people were discriminating against them because of the incident. On the night of October 10, Nina Pham, a 26-year-old nurse who had treated Duncan at Texas Health Presbyterian Hospital, reported a low-grade fever and was placed in isolation. On October 11, she tested positive for Ebola virus, becoming the first person to contract the virus in the U.S. On October 12, the CDC confirmed the positive test results. Hospital officials said Pham had worn the recommended protective gear when treating Duncan on his second visit to the hospital and had "extensive contact" with him on "multiple occasions". Pham was in stable condition as of October 12. On October 16, Pham was transferred to the National Institutes of Health Clinical Center in Bethesda, Maryland . On October 24, the NIH declared Pham free of the Ebola virus. That day Pham traveled to the White House where she met with President Obama. Tom Frieden , director of the Centers for Disease Control and Prevention , initially blamed a breach in protocol for the infection. The hospital's chief clinical officer, Dr. Dan Varga, said all staff had followed CDC recommendations. Bonnie Costello of National Nurses United said, "You don't scapegoat and blame when you have a disease outbreak. We have a system failure. That is what we have to correct." Frieden later spoke to "clarify" that he had not found "fault with the hospital or the healthcare worker". National Nurses United criticized the hospital for its lack of Ebola protocols and for guidelines that were "constantly changing". Briana Aguirre, a nurse who had cared for Nina Pham, criticized the hospital in an appearance on NBC's Today Show . Aguirre said that she and others had not received proper training or personal protective equipment , and that the hospital had not provided consistent protocols for handling potential Ebola patients into the second week of the crisis. A report indicated that healthcare workers did not wear hazmat suits until Duncan's test results confirmed his infection due to Ebola, two days after his admission to the hospital. Frieden later said that the CDC could have been more aggressive in the management and control of the virus at the hospital. On March 2, 2015 The New York Times reported that Pham filed a suit against Texas Health Resources , her hospital's parent company, accusing it of "negligence, fraud and invasion of privacy". Pham was described as still experiencing numerous physical and psychological problems, listing lack of proper training as the reason for her illness. On October 14, a second nurse at the same hospital, identified as 29-year-old Amber Vinson, reported a fever . Amber Joy Vinson was among the nurses who had provided treatment for Duncan. Vinson was isolated within 90 minutes of reporting the fever. By the next day, Vinson had tested positive for Ebola virus. On October 13, Vinson had flown Frontier Airlines Flight 1143 from Cleveland to Dallas, after spending the weekend in Tallmadge and Akron, Ohio . Vinson had an elevated temperature of 99.5 °F (37.5 °C) before boarding the 138-passenger jet, according to public health officials. Vinson had flown to Cleveland from Dallas on Frontier Airlines Flight 1142 on October 10. Flight crew members from Flight 1142 were put on paid leave for 21 days. During a press conference, CDC Director Tom Frieden stated she should not have traveled since she was one of the health care workers known to have had exposure to Duncan. Passengers of both flights were asked to contact the CDC as a precautionary measure. It was later discovered that the CDC had, in fact, given Vinson permission to board a commercial flight to Cleveland. Before her trip back to Dallas, she spoke to Dallas County Health Department and called the CDC several times to report her 99.5 °F (37.5 °C) temperature before boarding her flight. A CDC employee who took her call checked a CDC chart, noted that Vinson's temperature was not a true fever – a temperature of 100.4 °F (38.0 °C) or higher – which the CDC deemed as "high risk", and let her board the commercial flight. On October 19, Vinson's family released a statement detailing her government-approved travel clearances and announcing that they had hired a Washington, DC, attorney, Billy Martin . As a precaution, sixteen people in Ohio who had had contact with Vinson were voluntarily quarantined. On October 15, Vinson was transferred to the Emory University Hospital in Atlanta. Seven days later, Vinson was declared Ebola free by Emory University Hospital. As of October 15, 2014 [ update ] , there were 76 Texas Presbyterian Hospital health care workers being monitored because they had had some level of contact with Thomas Duncan. On October 16, after learning that Vinson had traveled on a plane before her Ebola diagnosis, the Texas Department of State Health Services advised all health care workers exposed to Duncan to avoid travel and public places until 21 days after their last known exposure. On October 23, Craig Spencer, a physician who treated Ebola patients in West Africa, tested positive for Ebola at Bellevue Hospital Center after having a 100.3 °F (37.9 °C) fever . Officials said he was hospitalized with fever, nausea, pain, and fatigue. He had flown to New York City from Guinea within the previous ten days, and contacted the city's Department of Health and Doctors without Borders after showing symptoms. Dr. Spencer traveled to Guinea to treat Ebola victims on September 16 and returned on October 16. He had been self-monitoring for symptoms of the disease, and began to feel sluggish on October 21, but did not show any symptoms for two days. His case was the first to be diagnosed in New York. The city was trying to find people who may have been in contact with Dr. Spencer between October 21 and 23. On October 22, the day before he had symptoms, Dr. Spencer rode the New York City Subway , walked on the High Line park, went to a bowling alley and a restaurant in Brooklyn , took an Uber to his home in Manhattan , and took a 3-mile (4.8 km) jog in Harlem near where he lived. Three other people who were with Dr. Spencer in the previous few days were quarantined as well. Dr. Spencer's apartment and the bowling alley he went to were cleaned by hazmat company Bio Recovery Corporation . Health officials stated it was unlikely that Dr. Spencer could have transmitted the disease through subway poles, hand railings, or via bowling balls. New York hospitals, health-workers, and officials had conducted weeks of drills and training in preparation for patients like Dr. Spencer. Upon arrival at the hospital, he was put in a specially designed isolation center for treatment. Not many details about the treatment were given, except that he participated in decisions relating to his medical care. On October 25, the New York Post reported that an anonymous source had said that nurses at Bellevue had been calling in sick to avoid having to care for Spencer. A hospital spokesperson denied there was a sick out. On November 1, his condition was upgraded to "stable", and on November 7 the hospital announced he was free of Ebola. Spencer was released from the hospital on November 11. He was cheered and applauded by medical staff members, and hugged by the Mayor of New York, Bill de Blasio as he walked out of the hospital. The Mayor also declared: "New York City is Ebola free". As a result of Dr. Spencer's Ebola case, U.S. Senator Charles Schumer (D-NY), proposed an Ebola fund in an omnibus bill to be considered in fiscal year 2015. Schumer said the funds were needed to compensate New York City, as well as other cities treating Ebola patients, in the same way the federal government covers communities that suffer after a natural disaster. Schumer said Dr. Spencer's care at Bellevue Hospital involved around 100 health care workers. In addition, the city's health department established a 24-hour-a-day operation involving 500 staffers to keep track of the approximately 300 persons from West Africa hot spots who arrive in New York every day. Thomas Eric Duncan was from Monrovia, Liberia , to date the country hit hardest by the Ebola virus epidemic . He worked as a personal driver for the general manager of Safeway Cargo, a FedEx contractor in Liberia. According to manager Henry Brunson, Duncan had abruptly quit his job on September 4, 2014, giving no reason. On September 15, 2014, the family of Marthalene Williams, who later died of Ebola virus disease , could not call an ambulance to transfer the pregnant Williams to a hospital. Duncan, their tenant, helped to transfer Williams by taxi to an Ebola treatment ward in Monrovia. Duncan rode in the taxi to the treatment ward with Williams, her father and her brother. On September 19, Duncan went to Monrovia Airport , where, according to Liberian officials, he lied about his history of contact with the disease on an airport questionnaire before boarding a Brussels Airlines flight to Brussels . In Brussels, he boarded United Airlines Flight 951 to Washington Dulles Airport . From Dulles, he boarded United Airlines Flight 822 to Dallas/Fort Worth. He arrived in Dallas at 7:01 p.m. CDT on September 20, 2014, and stayed with his partner and her five children, who lived in the Fair Oaks apartment complex in the Vickery Meadow neighborhood of Dallas. Vickery Meadow , the neighborhood in Dallas where Duncan lived, has a large African immigrant population and is Dallas's densest neighborhood. Duncan began experiencing symptoms on September 24, 2014, and arrived at the Texas Health Presbyterian Hospital emergency room at 10:37 p.m. on September 25. At 11:36 p.m. , a triage nurse asked him about his symptoms, and he reported feeling "abdominal pain, dizziness, nausea and headache (new onset)". The nurse recorded a fever of 100.1 °F (37.8 °C) , but did not inquire as to his travel history as this was not triage protocol at the time. At 12:05 a.m. , Duncan was admitted into a treatment area room where the on-duty physician accessed the electronic health record (EHR). The physician noted nasal congestion, a runny nose, and abdominal tenderness. Duncan was given paracetamol (acetaminophen) at 1:24 a.m. CT scan results came back noting "no acute disease" for the abdominal and pelvic areas and "unremarkable" for the head. Lab results returned showing slightly low white blood cells , low platelets , increased creatinine , and elevated levels of the liver enzyme AST . His temperature was noted at 103.0 °F (39.4 °C) at 3:02 a.m. and 101.2 °F (38.4 °C) at 3:32 a.m. Duncan was diagnosed with sinusitis and abdominal pain and sent home at 3:37 a.m. with a prescription for antibiotics , which are not effective for treating viral diseases . What we're seeing now is not an "outbreak" or an "epidemic" of Ebola in America. This is a serious disease, but we can't give in to hysteria or fear. – President Barack Obama on the Ebola outbreak Duncan's condition worsened, and he was transported on September 28 to the same Texas Health Presbyterian Hospital emergency room by ambulance. He arrived in the emergency room at 10:07 a.m. , experiencing diarrhea, abdominal pain, and fever. Within fifteen minutes, a doctor noted that Duncan had recently come from Liberia and needed to be tested for Ebola. The doctor described following "strict [CDC] protocol" including wearing a mask, gown, and gloves. At 12:58 p.m. , the doctor called the CDC directly. By 9:40 p.m. , Duncan was experiencing explosive diarrhea and projectile vomiting. At 8:28 a.m. the next morning, the doctor noted that he "appeared to be deteriorating". By 11:32 a.m. , he was severely fatigued, enough to prevent him from using the bedside toilet. Later that day, he was transferred to an intensive care unit (ICU) after all other patients had been evacuated. The next day, September 30, he was diagnosed with Ebola virus disease after a positive test result. Duncan's diagnosis was publicly confirmed during a CDC news conference the same day. That evening, Duncan reported feeling better and requested to watch a movie. The following morning, he was breathing rapidly and complaining of "pain all over". By the afternoon, however, he was able to eat, and the doctor noted that he was feeling better. The next day, October 3, he again reported feeling abdominal pain. That evening, the hospital contacted Chimerix , a biotechnology company developing Brincidofovir to combat the disease. The next day, Duncan's organs were failing , and he was intubated to help him breathe. In the afternoon, the hospital began administering Brincidofovir. Nurses Nina Pham and Amber Joy Vinson continued to care for Duncan around the clock. On October 7, the hospital reported that Duncan's condition was improving. However, he died at 7:51 a.m. on October 8, becoming the first person to die in the United States of Ebola virus disease and the index patient for the later infections of nurses Pham and Vinson. On October 5, the CDC announced it had lost track of a homeless man who had been in the same ambulance as Duncan. They announced efforts were underway to find the man and place him in a comfortable and compassionate monitoring environment. Later that day, the CDC announced that the man had been found and was being monitored. Up to 100 people may have had contact with those who had direct contact with Duncan after he showed symptoms. Health officials later monitored 50 low- and 10 high-risk contacts, the high-risk contacts being Duncan's close family members and three ambulance workers who took him to the hospital. Everyone who came into contact with Duncan was being monitored daily to watch for symptoms of the virus, until October 20, when health officials removed 43 out of the 48 initial contacts of Thomas Duncan from isolation. On November 7, 2014, Dallas was officially declared "Ebola free" after 177 monitored people cleared the 21 day threshold without becoming ill. On October 2, Liberian authorities said they could prosecute Duncan if he returned because before flying he had filled out a form in which he had falsely stated he had not come into contact with an Ebola case. Liberian President Ellen Johnson Sirleaf told the Canadian Broadcasting Corporation she was angry with Duncan for what he had done, especially given how much the United States was doing to help tackle the crisis: "One of our compatriots didn't take due care, and so, he's gone there and in a way put some Americans in a state of fear, and put them at some risk, and so I feel very saddened by that and very angry with him. ... The fact that he knew (he might be a carrier) and he left the country is unpardonable, quite frankly." Before his death, Duncan brazenly claimed that he did not know at the time of boarding the flight that he had been exposed to Ebola; he said he believed the woman he helped was having a miscarriage, which contradicts corroborated accounts from family members who also helped transport the woman to an Ebola ward. Duncan's family said the care Duncan received was at best "incompetent" and at worst "racially motivated". Family members threatened legal action against the hospital where Duncan received treatment. In response, Texas Health Presbyterian Hospital issued a statement, "Our care team provided Mr. Duncan with the same high level of attention and care that would be given any patient, regardless of nationality or ability to pay for care. We have a long history of treating a multicultural community in this area." The hospital spent an estimated $500,000 to treat the uninsured Duncan. Officials at Texas Presbyterian Hospital reported that patients' cancellation of elective surgeries and potential emergency patients' preference for other hospitals' emergency rooms had left their hospital looking like a "ghost town". The reaction to the care and treatment of Thomas Duncan, and the subsequent transmission to two of the nurses on his care team, caused several hospitals to question the extent to which they are obligated to treat Ebola patients. Their concern surrounds the reality that understaffed and poorly equipped hospitals performing invasive procedures, like renal dialysis and intubation, both of which Duncan received at Texas Presbyterian, could put staff at too much risk for contracting the virus. Emory University Hospital in Atlanta also used renal dialysis in treating patients at their biocontainment unit, but no health care workers became infected. In October 2014 Vickery Meadow residents stated that people were discriminating against them because of the incident. Thomas Eric Duncan was from Monrovia, Liberia , to date the country hit hardest by the Ebola virus epidemic . He worked as a personal driver for the general manager of Safeway Cargo, a FedEx contractor in Liberia. According to manager Henry Brunson, Duncan had abruptly quit his job on September 4, 2014, giving no reason. On September 15, 2014, the family of Marthalene Williams, who later died of Ebola virus disease , could not call an ambulance to transfer the pregnant Williams to a hospital. Duncan, their tenant, helped to transfer Williams by taxi to an Ebola treatment ward in Monrovia. Duncan rode in the taxi to the treatment ward with Williams, her father and her brother. On September 19, Duncan went to Monrovia Airport , where, according to Liberian officials, he lied about his history of contact with the disease on an airport questionnaire before boarding a Brussels Airlines flight to Brussels . In Brussels, he boarded United Airlines Flight 951 to Washington Dulles Airport . From Dulles, he boarded United Airlines Flight 822 to Dallas/Fort Worth. He arrived in Dallas at 7:01 p.m. CDT on September 20, 2014, and stayed with his partner and her five children, who lived in the Fair Oaks apartment complex in the Vickery Meadow neighborhood of Dallas. Vickery Meadow , the neighborhood in Dallas where Duncan lived, has a large African immigrant population and is Dallas's densest neighborhood. Duncan began experiencing symptoms on September 24, 2014, and arrived at the Texas Health Presbyterian Hospital emergency room at 10:37 p.m. on September 25. At 11:36 p.m. , a triage nurse asked him about his symptoms, and he reported feeling "abdominal pain, dizziness, nausea and headache (new onset)". The nurse recorded a fever of 100.1 °F (37.8 °C) , but did not inquire as to his travel history as this was not triage protocol at the time. At 12:05 a.m. , Duncan was admitted into a treatment area room where the on-duty physician accessed the electronic health record (EHR). The physician noted nasal congestion, a runny nose, and abdominal tenderness. Duncan was given paracetamol (acetaminophen) at 1:24 a.m. CT scan results came back noting "no acute disease" for the abdominal and pelvic areas and "unremarkable" for the head. Lab results returned showing slightly low white blood cells , low platelets , increased creatinine , and elevated levels of the liver enzyme AST . His temperature was noted at 103.0 °F (39.4 °C) at 3:02 a.m. and 101.2 °F (38.4 °C) at 3:32 a.m. Duncan was diagnosed with sinusitis and abdominal pain and sent home at 3:37 a.m. with a prescription for antibiotics , which are not effective for treating viral diseases . What we're seeing now is not an "outbreak" or an "epidemic" of Ebola in America. This is a serious disease, but we can't give in to hysteria or fear. – President Barack Obama on the Ebola outbreak Duncan's condition worsened, and he was transported on September 28 to the same Texas Health Presbyterian Hospital emergency room by ambulance. He arrived in the emergency room at 10:07 a.m. , experiencing diarrhea, abdominal pain, and fever. Within fifteen minutes, a doctor noted that Duncan had recently come from Liberia and needed to be tested for Ebola. The doctor described following "strict [CDC] protocol" including wearing a mask, gown, and gloves. At 12:58 p.m. , the doctor called the CDC directly. By 9:40 p.m. , Duncan was experiencing explosive diarrhea and projectile vomiting. At 8:28 a.m. the next morning, the doctor noted that he "appeared to be deteriorating". By 11:32 a.m. , he was severely fatigued, enough to prevent him from using the bedside toilet. Later that day, he was transferred to an intensive care unit (ICU) after all other patients had been evacuated. The next day, September 30, he was diagnosed with Ebola virus disease after a positive test result. Duncan's diagnosis was publicly confirmed during a CDC news conference the same day. That evening, Duncan reported feeling better and requested to watch a movie. The following morning, he was breathing rapidly and complaining of "pain all over". By the afternoon, however, he was able to eat, and the doctor noted that he was feeling better. The next day, October 3, he again reported feeling abdominal pain. That evening, the hospital contacted Chimerix , a biotechnology company developing Brincidofovir to combat the disease. The next day, Duncan's organs were failing , and he was intubated to help him breathe. In the afternoon, the hospital began administering Brincidofovir. Nurses Nina Pham and Amber Joy Vinson continued to care for Duncan around the clock. On October 7, the hospital reported that Duncan's condition was improving. However, he died at 7:51 a.m. on October 8, becoming the first person to die in the United States of Ebola virus disease and the index patient for the later infections of nurses Pham and Vinson. On October 5, the CDC announced it had lost track of a homeless man who had been in the same ambulance as Duncan. They announced efforts were underway to find the man and place him in a comfortable and compassionate monitoring environment. Later that day, the CDC announced that the man had been found and was being monitored. Up to 100 people may have had contact with those who had direct contact with Duncan after he showed symptoms. Health officials later monitored 50 low- and 10 high-risk contacts, the high-risk contacts being Duncan's close family members and three ambulance workers who took him to the hospital. Everyone who came into contact with Duncan was being monitored daily to watch for symptoms of the virus, until October 20, when health officials removed 43 out of the 48 initial contacts of Thomas Duncan from isolation. On November 7, 2014, Dallas was officially declared "Ebola free" after 177 monitored people cleared the 21 day threshold without becoming ill. On October 2, Liberian authorities said they could prosecute Duncan if he returned because before flying he had filled out a form in which he had falsely stated he had not come into contact with an Ebola case. Liberian President Ellen Johnson Sirleaf told the Canadian Broadcasting Corporation she was angry with Duncan for what he had done, especially given how much the United States was doing to help tackle the crisis: "One of our compatriots didn't take due care, and so, he's gone there and in a way put some Americans in a state of fear, and put them at some risk, and so I feel very saddened by that and very angry with him. ... The fact that he knew (he might be a carrier) and he left the country is unpardonable, quite frankly." Before his death, Duncan brazenly claimed that he did not know at the time of boarding the flight that he had been exposed to Ebola; he said he believed the woman he helped was having a miscarriage, which contradicts corroborated accounts from family members who also helped transport the woman to an Ebola ward. Duncan's family said the care Duncan received was at best "incompetent" and at worst "racially motivated". Family members threatened legal action against the hospital where Duncan received treatment. In response, Texas Health Presbyterian Hospital issued a statement, "Our care team provided Mr. Duncan with the same high level of attention and care that would be given any patient, regardless of nationality or ability to pay for care. We have a long history of treating a multicultural community in this area." The hospital spent an estimated $500,000 to treat the uninsured Duncan. Officials at Texas Presbyterian Hospital reported that patients' cancellation of elective surgeries and potential emergency patients' preference for other hospitals' emergency rooms had left their hospital looking like a "ghost town". The reaction to the care and treatment of Thomas Duncan, and the subsequent transmission to two of the nurses on his care team, caused several hospitals to question the extent to which they are obligated to treat Ebola patients. Their concern surrounds the reality that understaffed and poorly equipped hospitals performing invasive procedures, like renal dialysis and intubation, both of which Duncan received at Texas Presbyterian, could put staff at too much risk for contracting the virus. Emory University Hospital in Atlanta also used renal dialysis in treating patients at their biocontainment unit, but no health care workers became infected. In October 2014 Vickery Meadow residents stated that people were discriminating against them because of the incident. On the night of October 10, Nina Pham, a 26-year-old nurse who had treated Duncan at Texas Health Presbyterian Hospital, reported a low-grade fever and was placed in isolation. On October 11, she tested positive for Ebola virus, becoming the first person to contract the virus in the U.S. On October 12, the CDC confirmed the positive test results. Hospital officials said Pham had worn the recommended protective gear when treating Duncan on his second visit to the hospital and had "extensive contact" with him on "multiple occasions". Pham was in stable condition as of October 12. On October 16, Pham was transferred to the National Institutes of Health Clinical Center in Bethesda, Maryland . On October 24, the NIH declared Pham free of the Ebola virus. That day Pham traveled to the White House where she met with President Obama. Tom Frieden , director of the Centers for Disease Control and Prevention , initially blamed a breach in protocol for the infection. The hospital's chief clinical officer, Dr. Dan Varga, said all staff had followed CDC recommendations. Bonnie Costello of National Nurses United said, "You don't scapegoat and blame when you have a disease outbreak. We have a system failure. That is what we have to correct." Frieden later spoke to "clarify" that he had not found "fault with the hospital or the healthcare worker". National Nurses United criticized the hospital for its lack of Ebola protocols and for guidelines that were "constantly changing". Briana Aguirre, a nurse who had cared for Nina Pham, criticized the hospital in an appearance on NBC's Today Show . Aguirre said that she and others had not received proper training or personal protective equipment , and that the hospital had not provided consistent protocols for handling potential Ebola patients into the second week of the crisis. A report indicated that healthcare workers did not wear hazmat suits until Duncan's test results confirmed his infection due to Ebola, two days after his admission to the hospital. Frieden later said that the CDC could have been more aggressive in the management and control of the virus at the hospital. On March 2, 2015 The New York Times reported that Pham filed a suit against Texas Health Resources , her hospital's parent company, accusing it of "negligence, fraud and invasion of privacy". Pham was described as still experiencing numerous physical and psychological problems, listing lack of proper training as the reason for her illness. Tom Frieden , director of the Centers for Disease Control and Prevention , initially blamed a breach in protocol for the infection. The hospital's chief clinical officer, Dr. Dan Varga, said all staff had followed CDC recommendations. Bonnie Costello of National Nurses United said, "You don't scapegoat and blame when you have a disease outbreak. We have a system failure. That is what we have to correct." Frieden later spoke to "clarify" that he had not found "fault with the hospital or the healthcare worker". National Nurses United criticized the hospital for its lack of Ebola protocols and for guidelines that were "constantly changing". Briana Aguirre, a nurse who had cared for Nina Pham, criticized the hospital in an appearance on NBC's Today Show . Aguirre said that she and others had not received proper training or personal protective equipment , and that the hospital had not provided consistent protocols for handling potential Ebola patients into the second week of the crisis. A report indicated that healthcare workers did not wear hazmat suits until Duncan's test results confirmed his infection due to Ebola, two days after his admission to the hospital. Frieden later said that the CDC could have been more aggressive in the management and control of the virus at the hospital. On March 2, 2015 The New York Times reported that Pham filed a suit against Texas Health Resources , her hospital's parent company, accusing it of "negligence, fraud and invasion of privacy". Pham was described as still experiencing numerous physical and psychological problems, listing lack of proper training as the reason for her illness. On October 14, a second nurse at the same hospital, identified as 29-year-old Amber Vinson, reported a fever . Amber Joy Vinson was among the nurses who had provided treatment for Duncan. Vinson was isolated within 90 minutes of reporting the fever. By the next day, Vinson had tested positive for Ebola virus. On October 13, Vinson had flown Frontier Airlines Flight 1143 from Cleveland to Dallas, after spending the weekend in Tallmadge and Akron, Ohio . Vinson had an elevated temperature of 99.5 °F (37.5 °C) before boarding the 138-passenger jet, according to public health officials. Vinson had flown to Cleveland from Dallas on Frontier Airlines Flight 1142 on October 10. Flight crew members from Flight 1142 were put on paid leave for 21 days. During a press conference, CDC Director Tom Frieden stated she should not have traveled since she was one of the health care workers known to have had exposure to Duncan. Passengers of both flights were asked to contact the CDC as a precautionary measure. It was later discovered that the CDC had, in fact, given Vinson permission to board a commercial flight to Cleveland. Before her trip back to Dallas, she spoke to Dallas County Health Department and called the CDC several times to report her 99.5 °F (37.5 °C) temperature before boarding her flight. A CDC employee who took her call checked a CDC chart, noted that Vinson's temperature was not a true fever – a temperature of 100.4 °F (38.0 °C) or higher – which the CDC deemed as "high risk", and let her board the commercial flight. On October 19, Vinson's family released a statement detailing her government-approved travel clearances and announcing that they had hired a Washington, DC, attorney, Billy Martin . As a precaution, sixteen people in Ohio who had had contact with Vinson were voluntarily quarantined. On October 15, Vinson was transferred to the Emory University Hospital in Atlanta. Seven days later, Vinson was declared Ebola free by Emory University Hospital. As of October 15, 2014 [ update ] , there were 76 Texas Presbyterian Hospital health care workers being monitored because they had had some level of contact with Thomas Duncan. On October 16, after learning that Vinson had traveled on a plane before her Ebola diagnosis, the Texas Department of State Health Services advised all health care workers exposed to Duncan to avoid travel and public places until 21 days after their last known exposure. As of October 15, 2014 [ update ] , there were 76 Texas Presbyterian Hospital health care workers being monitored because they had had some level of contact with Thomas Duncan. On October 16, after learning that Vinson had traveled on a plane before her Ebola diagnosis, the Texas Department of State Health Services advised all health care workers exposed to Duncan to avoid travel and public places until 21 days after their last known exposure. On October 23, Craig Spencer, a physician who treated Ebola patients in West Africa, tested positive for Ebola at Bellevue Hospital Center after having a 100.3 °F (37.9 °C) fever . Officials said he was hospitalized with fever, nausea, pain, and fatigue. He had flown to New York City from Guinea within the previous ten days, and contacted the city's Department of Health and Doctors without Borders after showing symptoms. Dr. Spencer traveled to Guinea to treat Ebola victims on September 16 and returned on October 16. He had been self-monitoring for symptoms of the disease, and began to feel sluggish on October 21, but did not show any symptoms for two days. His case was the first to be diagnosed in New York. The city was trying to find people who may have been in contact with Dr. Spencer between October 21 and 23. On October 22, the day before he had symptoms, Dr. Spencer rode the New York City Subway , walked on the High Line park, went to a bowling alley and a restaurant in Brooklyn , took an Uber to his home in Manhattan , and took a 3-mile (4.8 km) jog in Harlem near where he lived. Three other people who were with Dr. Spencer in the previous few days were quarantined as well. Dr. Spencer's apartment and the bowling alley he went to were cleaned by hazmat company Bio Recovery Corporation . Health officials stated it was unlikely that Dr. Spencer could have transmitted the disease through subway poles, hand railings, or via bowling balls. New York hospitals, health-workers, and officials had conducted weeks of drills and training in preparation for patients like Dr. Spencer. Upon arrival at the hospital, he was put in a specially designed isolation center for treatment. Not many details about the treatment were given, except that he participated in decisions relating to his medical care. On October 25, the New York Post reported that an anonymous source had said that nurses at Bellevue had been calling in sick to avoid having to care for Spencer. A hospital spokesperson denied there was a sick out. On November 1, his condition was upgraded to "stable", and on November 7 the hospital announced he was free of Ebola. Spencer was released from the hospital on November 11. He was cheered and applauded by medical staff members, and hugged by the Mayor of New York, Bill de Blasio as he walked out of the hospital. The Mayor also declared: "New York City is Ebola free". As a result of Dr. Spencer's Ebola case, U.S. Senator Charles Schumer (D-NY), proposed an Ebola fund in an omnibus bill to be considered in fiscal year 2015. Schumer said the funds were needed to compensate New York City, as well as other cities treating Ebola patients, in the same way the federal government covers communities that suffer after a natural disaster. Schumer said Dr. Spencer's care at Bellevue Hospital involved around 100 health care workers. In addition, the city's health department established a 24-hour-a-day operation involving 500 staffers to keep track of the approximately 300 persons from West Africa hot spots who arrive in New York every day. By the time the Ebola virus epidemic in West Africa was over in June 2016, seven Americans had been evacuated to the U.S. for treatment after contracting Ebola virus while working with medical teams trying to stop the epidemic. Kent Brantly , a physician and medical director in Liberia for the aid group Samaritan's Purse , and co-worker Nancy Writebol were infected in July 2014, while working in Monrovia . Both were flown to the United States at the beginning of August via the CDC's Aeromedical Biological Containment System for further treatment in Atlanta 's Emory University Hospital . On August 21, Brantly and Writebol recovered and were discharged. Brantly has since donated blood to three others with Ebola (Sacra, Mukpo and Pham). [ citation needed ] On September 4, a Massachusetts physician, Rick Sacra, was airlifted from Liberia to be treated in Omaha, Nebraska at the Nebraska Medical Center . Working for Serving In Mission (SIM), he was the third U.S. missionary to contract Ebola. He thought that he probably contracted Ebola while performing a Caesarean section on a patient who had not been diagnosed with the disease. While in hospital, Sacra received a blood transfusion from Brantly, who had recently recovered from the disease. On September 25, Sacra was declared Ebola-free and released from the hospital. On September 9, the fourth U.S. citizen who contracted the Ebola virus arrived at Emory University Hospital in Atlanta for treatment. On October 16, he released a statement saying he had improved and expected to be discharged in the near future. The doctor was identified as Ian Crozier , and according to the hospital, the sickest patient treated. He was scheduled to receive a blood or serum transfusion from a British man who had recently recovered from the disease. In addition, on September 21, a CDC employee, who showed no symptoms of the disease, was flown back to the United States as a preventive measure after low-risk exposure with a healthcare worker; he posed no risks to his family or the United States, and he is not known to have died. On September 28, a fourth American doctor was admitted to National Institutes of Health hospital. On October 2, NBC News photojournalist Ashoka Mukpo, covering the outbreak in Liberia, tested positive for Ebola after showing symptoms. Four other members of the NBC team, including physician Nancy Snyderman , were being closely monitored for symptoms. Mukpo was evacuated on October 6 to the University of Nebraska Medical Center for treatment in their isolation unit. On October 21, Mukpo was declared Ebola-free and allowed to return to his home in Rhode Island. A government official in Sierra Leone announced on November 13, that a doctor from Sierra Leone, a permanent resident of the United States married to a U.S. citizen, would be transported to the Nebraska Medical Center for treatment for Ebola. The doctor, identified later as Martin Salia, became symptomatic while in Sierra Leone. His initial Ebola test came back negative, but his symptoms persisted. He attempted to treat his symptoms, which included vomiting and diarrhea, believing he had malaria. A second test for Ebola came back positive. His family expressed concern that the delay in diagnosis might have impacted his recovery. Salia arrived at Eppley Airfield in Omaha on November 15, and was transported to the Nebraska Medical Center. According to the team that assisted in the transport, he was critically ill and considered to be the sickest patient to be evacuated, but stable enough to fly. On November 17, Salia died from the disease. Dr. Philip Smith, medical director of the biocontainment unit at Nebraska Medical Center, said Salia's disease was already "extremely advanced" by the time he arrived in Omaha. By then, Salia's kidneys had failed and he was in acute respiratory distress. Salia's treatment included a blood plasma transfusion from an Ebola survivor, as well as the experimental drug ZMapp . Salia had been working as a general surgeon in Freetown , Sierra Leone when he fell ill. It was not clear when or where he had had contact with Ebola patients. A U.S. clinician contracted Ebola while working in Port Loko, Sierra Leone. He collapsed in the hospital and colleagues who assisted him were monitored for exposure. He was diagnosed with Ebola on March 10, 2015, and medically evacuated to the National Institutes of Health in Bethesda, Maryland on March 13. His condition was downgraded from serious to critical on March 16. The ten exposed colleagues were flown back to the U.S., going into isolation near the Ebola-rated hospitals at Nebraska, Georgia, and Maryland. On March 26, 2015, the NIH upgraded the medically evacuated health worker being treated in Bethesda from critical to serious. A further 16 volunteers were monitored for possible exposure. On April 9, 2015, the clinician was upgraded to good condition and discharged. He was treated by Dr. Anthony Fauci, who later said he was "the sickest person he had ever treated, who recovered." This patient wished to remain anonymous until late 2019, when he revealed his identity: Preston Gorman, a physician assistant. The U.S. military released plans to send up to 4,000 troops to West Africa to establish treatment centers starting September 29. The troops are tasked with building modular hospitals known as Expeditionary Medical Support Systems (EMEDS). Plans included building a 25-bed hospital for health care workers and 17 treatment centers with 100 beds each in Liberia. By the end of September 2014 150 military personnel were helping USAID in the capital, Monrovia. U.S. Army chief of staff Ray Odierno ordered on October 27 a 21-day quarantine of all soldiers returning from Operation United Assistance. Up to 12 soldiers were quarantined in a U.S. base in Italy. Since 2007, US hospitals have relied on CDC infection control protocols to contain Ebola virus disease. Until October 20, 2014, the CDC guidelines allowed hospitals wide latitude to select gear based on interaction between healthcare workers and patients and on the mode of transmission of the disease being handled. The guidelines suggested gowns with "full coverage of the arms and body front, from neck to the mid-thigh or below, will ensure that clothing and exposed upper body areas are protected", and additionally recommend masks and goggles. Some infection control experts [ who? ] said that many American hospitals improperly trained their personnel to handle Ebola cases because they were following federal guidelines that were too lax. US officials abruptly changed their guidelines on October 14. The New York Times stated that this was an effective acknowledgment that there were problems with the procedures for protecting health care workers. Sean Kaufman, who oversaw infection control at Emory University Hospital while it treated Ebola patients, has said the previous CDC guidelines were "absolutely irresponsible and dead wrong". Kaufman called to warn the agency about its lax guidelines but, according to Kaufman, "They kind of blew me off." A Doctors Without Borders representative, whose organization has been treating Ebola patients in Africa, criticized a CDC poster for lax guidelines on containing Ebola, saying, "It doesn't say anywhere that it's for Ebola. I was surprised that it was only one set of gloves, and the rest bare hands. It seems to be for general cases of infectious disease." The national nursing union National Nurses United criticized the CDC for making the guidelines voluntary. There were complaints at the Texas hospital that healthcare professionals had to use tape to cover their exposed necks. According to Frieden, the CDC is appointing a hospital site manager to oversee Ebola containment efforts and are making "intensive efforts" to retrain and supervise staff. On October 14, the WHO reported that 125 contacts in the United States were being traced and monitored. On October 20, the CDC updated its guidance on personal protective equipment with new detailed instructions that include specifying that no skin should be exposed and adding extensive instructions for donning and doffing the equipment. On October 20 CDC updated its guidance to add clarification that Ebola may spread through wet droplets such as sneezes. In mid-October 2014, President Barack Obama appointed Ron Klain as the "Ebola response coordinator" of the United States. Klain is a lawyer who previously served as chief of staff to vice presidents Al Gore and Joe Biden . Klain had no medical or health care experience. After criticism, Obama said, "It may make sense for us to have one person ... so that after this initial surge of activity, we can have a more regular process just to make sure that we're crossing all the T's and dotting all the I's going forward". Klain reported to Homeland Security Adviser Lisa Monaco and National Security Advisor Susan Rice . Klain did not coordinate with hospitals and the United States Public Health Service , as this was the responsibility of Nicole Lurie , Assistant Secretary for Preparedness and Response. President Barack Obama attempted to calm public fears by hugging nurse Nina Pham who had been cured of Ebola. President Obama announced the formation of rapid response teams to travel to hospitals with newly diagnosed patients. A second set of teams will prep hospitals in cities deemed most likely to see an Ebola virus case. Three of those teams are already operating. In announcing the formation of the teams, President Obama explained, "We want a rapid response team, a SWAT team essentially, from the CDC to be on the ground as quickly as possible, hopefully within 24 hours, so that they are taking the local hospital step by step through what needs to be done." The CDC has developed two sets of teams, identified by the acronyms CERT (CDC Ebola Response Team) and FAST (Facility Assessment and Support Teams). The CERTs have 10 to 20 people each, who can be sent to a hospital with a suspected and/or laboratory confirmed Ebola virus case. The teams are drawn from 100 CDC workers and others. The FAST teams assist hospitals that have indicated they are willing to take on Ebola cases. Starting in October 2014, U.S. government officials began questioning airplane passengers and screening them for fever at five U.S. airports: John F. Kennedy International Airport in New York, Newark Liberty International Airport in New Jersey, O'Hare International Airport in Illinois, Washington Dulles International Airport in Virginia, and Hartsfield–Jackson Atlanta International Airport in Georgia. Combined, these airports receive more than 94% of passengers from Guinea, Liberia, and Sierra Leone, the three countries most affected by Ebola. Although no plans have been announced for other airports, screening in the U.S. represents a second layer of protection since passengers are already being screened upon exiting these three countries. However, the risk can never be eliminated. On October 21, the Department of Homeland Security announced that all passengers from Liberia, Sierra Leone, and Guinea will be required to fly into one of these five airports. On October 23, the CDC announced that all passengers from these countries would receive 21-day monitoring. A physician with the WHO , Aileen Marty , who had spent 31 days in Nigeria , criticized the complete lack of screening for Ebola on her recent return to the United States through Miami International Airport on October 12. [ citation needed ] There have also been calls by congressional leaders, including U.S. representative Ed Royce , Chairman of the House Foreign Relations Committee, and U.S. representative Michael McCaul of Texas, Chair of the Homeland Security Committee, to suspend issuing visas to travelers from the affected West African countries, including Liberia, Sierra Leone, and Guinea. On October 7, 2014, Connecticut governor Dannel Malloy signed an order authorizing the mandatory quarantine for 21 days of anyone, even if asymptomatic, who had direct contact with Ebola patients. Nine people were quarantined on October 22, in accordance with the Connecticut order. At a joint news conference on October 24, New York governor Andrew Cuomo and New Jersey governor Chris Christie announced that they were imposing a mandatory 21-day quarantine on all air travelers returning to New York and New Jersey from West Africa who have had contact with Ebola patients. In explaining the move from the CDC's voluntary quarantine to a state ordered mandatory one, Cuomo cited the case of Dr. Spencer. "In a region like this, you go out three times, you ride the subway, you ride the bus, you could affect hundreds of people." Cuomo praised Dr. Spencer's work but stated, "He's a doctor and even he didn't follow the voluntary quarantine. Let's be honest." Governors Cuomo and Christie stated that their two states needed to go beyond the federal CDC guidelines. Cuomo said Dr. Spencer's activity in the days before his diagnosis showed the guidelines, which includes urging health care workers and others who have had contact with Ebola patients to voluntarily quarantine themselves, were not enough. Late on October 26, Cuomo modified the state's quarantine procedure, stating that people entering New York who have had contact with Ebola patients in West Africa will be quarantined in their homes for the 21 days, with twice daily checks to ensure their health has not changed and that they are complying with the order, and would receive some compensation for lost wages, if any. President Obama and his staff had been attempting to persuade Cuomo, Christie, and the government of Illinois to reverse their mandatory quarantines. Illinois governor Pat Quinn issued a similar quarantine authorization the same day as New York and New Jersey initially did, with Florida governor Rick Scott on October 25, authorizing mandatory twice daily monitoring for 21 days of people identified as coming from countries affected by Ebola. Illinois health officials later said that only people at high risk of Ebola exposure, such as not wearing protective gear near Ebola patients, will be quarantined. Pennsylvania , Maryland , and Georgia have all authorized mandatory twice daily health monitoring and/or temperature reporting for 21 days for people exposed to people with Ebola. Virginia has also implemented mandatory twice daily temperature reporting and daily monitoring from health authorities, but has also authorized mandatory quarantine for higher risk patients. California mandated a 21-day quarantine for all health workers who have had contact with Ebola patients. Kaci Hickox, an American nurse who treated Ebola patients in Sierra Leone became the first person placed under the new mandatory quarantine rules on her arrival at Newark Liberty International Airport , in New Jersey. A low-accuracy (forehead) thermometer indicated Hickox developed a fever on Friday night and was taken to University Hospital in Newark. She later tested negative for the Ebola virus but remained quarantined in a medical tent. Hickox and Doctors Without Borders criticized the condition of the quarantine in a tent with a bed and a portable toilet , but without shower facility. Hickox expressed that it was inhumane. The hospital responded that they tried their best to accommodate Hickox by allowing her to have computer access, cell phone, reading materials, and providing take-out food and drink. On October 27, after being symptom free for an additional 24-hour period, testing negative for Ebola, and after the state's quarantine policy was relaxed the night before, Hickox was released from quarantine in New Jersey. She has filed suit. Hickox was escorted out of New Jersey and into Maine the following day by a private convoy of SUVs. Maine governor Paul LePage announced he was joining with his state's health department in seeking legal authority to enforce the quarantine after Hickox announced she would not comply with the isolation protocols in Maine. She left her house on October 29 and 30. The governor said: "She's violated every promise she's made so far, so I can't trust her. I don't trust her." A Maine judge ruled against a mandatory quarantine on October 31, but required Hickox to comply with "direct active monitoring", to coordinate her travel with Maine health officials, and to notify health officials if she develops symptoms of Ebola. On October 29, Texas governor Rick Perry announced that a Texas nurse returning from Sierra Leone where she treated Ebola patients, had agreed to self-quarantine at her Austin home for 21 days following her return to Texas, and undergo frequent monitoring from state health officials. although she did not have any symptoms of Ebola virus. The nurse was not named to protect her privacy. Perry spoke with the nurse over the phone to thank her for work to fight Ebola. U.S. Army Chief of Staff Ray Odierno also ordered on October 27 a 21-day quarantine of all soldiers returning from Operation United Assistance in Liberia. Up to 12 soldiers have been quarantined so far in a U.S. base in Italy. On November 13, 2014, President Obama issued a presidential memorandum , invoking a federal law to immunize contractors hired by the U.S. Agency for International Development (USAID) from liability "with respect to claims, losses, or damage arising out of or resulting from exposure, in the course of performance of the contracts, to Ebola" during the emergency period. There were numerous overreactions to the perceived threat of an Ebola outbreak, particularly on the part of school officials. On October 16, a building housing two schools in the Solon City School District near Cleveland , Ohio, was closed for a single day of disinfection procedures after finding that a staff member may have been on the aircraft that Amber Vinson used on a previous flight. Another school in the Cleveland Metropolitan School District was disinfected overnight due to similar concerns but remained open. In both cases, affected staff were sent home until cleared by health officials. School officials said that they had been assured by city health officials that there was no risk and that the disinfection was "strictly precautionary". Three schools in the Belton Independent School District in Belton, Texas, were also closed. Infectious disease experts considered these closures to be an overreaction and were concerned that it would frighten the public into believing that Ebola is a greater danger than it actually is. In Hazlehurst, Mississippi, in response to numerous parents keeping their children from attending school, a principal at Hazlehurst Middle School, agreed to take personal vacation time after he had traveled to Zambia, a country with no current Ebola cases and 3,000 miles (4,800 kilometres) away from West Africa. The U.S. military released plans to send up to 4,000 troops to West Africa to establish treatment centers starting September 29. The troops are tasked with building modular hospitals known as Expeditionary Medical Support Systems (EMEDS). Plans included building a 25-bed hospital for health care workers and 17 treatment centers with 100 beds each in Liberia. By the end of September 2014 150 military personnel were helping USAID in the capital, Monrovia. U.S. Army chief of staff Ray Odierno ordered on October 27 a 21-day quarantine of all soldiers returning from Operation United Assistance. Up to 12 soldiers were quarantined in a U.S. base in Italy. Since 2007, US hospitals have relied on CDC infection control protocols to contain Ebola virus disease. Until October 20, 2014, the CDC guidelines allowed hospitals wide latitude to select gear based on interaction between healthcare workers and patients and on the mode of transmission of the disease being handled. The guidelines suggested gowns with "full coverage of the arms and body front, from neck to the mid-thigh or below, will ensure that clothing and exposed upper body areas are protected", and additionally recommend masks and goggles. Some infection control experts [ who? ] said that many American hospitals improperly trained their personnel to handle Ebola cases because they were following federal guidelines that were too lax. US officials abruptly changed their guidelines on October 14. The New York Times stated that this was an effective acknowledgment that there were problems with the procedures for protecting health care workers. Sean Kaufman, who oversaw infection control at Emory University Hospital while it treated Ebola patients, has said the previous CDC guidelines were "absolutely irresponsible and dead wrong". Kaufman called to warn the agency about its lax guidelines but, according to Kaufman, "They kind of blew me off." A Doctors Without Borders representative, whose organization has been treating Ebola patients in Africa, criticized a CDC poster for lax guidelines on containing Ebola, saying, "It doesn't say anywhere that it's for Ebola. I was surprised that it was only one set of gloves, and the rest bare hands. It seems to be for general cases of infectious disease." The national nursing union National Nurses United criticized the CDC for making the guidelines voluntary. There were complaints at the Texas hospital that healthcare professionals had to use tape to cover their exposed necks. According to Frieden, the CDC is appointing a hospital site manager to oversee Ebola containment efforts and are making "intensive efforts" to retrain and supervise staff. On October 14, the WHO reported that 125 contacts in the United States were being traced and monitored. On October 20, the CDC updated its guidance on personal protective equipment with new detailed instructions that include specifying that no skin should be exposed and adding extensive instructions for donning and doffing the equipment. On October 20 CDC updated its guidance to add clarification that Ebola may spread through wet droplets such as sneezes. In mid-October 2014, President Barack Obama appointed Ron Klain as the "Ebola response coordinator" of the United States. Klain is a lawyer who previously served as chief of staff to vice presidents Al Gore and Joe Biden . Klain had no medical or health care experience. After criticism, Obama said, "It may make sense for us to have one person ... so that after this initial surge of activity, we can have a more regular process just to make sure that we're crossing all the T's and dotting all the I's going forward". Klain reported to Homeland Security Adviser Lisa Monaco and National Security Advisor Susan Rice . Klain did not coordinate with hospitals and the United States Public Health Service , as this was the responsibility of Nicole Lurie , Assistant Secretary for Preparedness and Response. President Barack Obama attempted to calm public fears by hugging nurse Nina Pham who had been cured of Ebola. President Obama announced the formation of rapid response teams to travel to hospitals with newly diagnosed patients. A second set of teams will prep hospitals in cities deemed most likely to see an Ebola virus case. Three of those teams are already operating. In announcing the formation of the teams, President Obama explained, "We want a rapid response team, a SWAT team essentially, from the CDC to be on the ground as quickly as possible, hopefully within 24 hours, so that they are taking the local hospital step by step through what needs to be done." The CDC has developed two sets of teams, identified by the acronyms CERT (CDC Ebola Response Team) and FAST (Facility Assessment and Support Teams). The CERTs have 10 to 20 people each, who can be sent to a hospital with a suspected and/or laboratory confirmed Ebola virus case. The teams are drawn from 100 CDC workers and others. The FAST teams assist hospitals that have indicated they are willing to take on Ebola cases. Starting in October 2014, U.S. government officials began questioning airplane passengers and screening them for fever at five U.S. airports: John F. Kennedy International Airport in New York, Newark Liberty International Airport in New Jersey, O'Hare International Airport in Illinois, Washington Dulles International Airport in Virginia, and Hartsfield–Jackson Atlanta International Airport in Georgia. Combined, these airports receive more than 94% of passengers from Guinea, Liberia, and Sierra Leone, the three countries most affected by Ebola. Although no plans have been announced for other airports, screening in the U.S. represents a second layer of protection since passengers are already being screened upon exiting these three countries. However, the risk can never be eliminated. On October 21, the Department of Homeland Security announced that all passengers from Liberia, Sierra Leone, and Guinea will be required to fly into one of these five airports. On October 23, the CDC announced that all passengers from these countries would receive 21-day monitoring. A physician with the WHO , Aileen Marty , who had spent 31 days in Nigeria , criticized the complete lack of screening for Ebola on her recent return to the United States through Miami International Airport on October 12. [ citation needed ] There have also been calls by congressional leaders, including U.S. representative Ed Royce , Chairman of the House Foreign Relations Committee, and U.S. representative Michael McCaul of Texas, Chair of the Homeland Security Committee, to suspend issuing visas to travelers from the affected West African countries, including Liberia, Sierra Leone, and Guinea. On October 7, 2014, Connecticut governor Dannel Malloy signed an order authorizing the mandatory quarantine for 21 days of anyone, even if asymptomatic, who had direct contact with Ebola patients. Nine people were quarantined on October 22, in accordance with the Connecticut order. At a joint news conference on October 24, New York governor Andrew Cuomo and New Jersey governor Chris Christie announced that they were imposing a mandatory 21-day quarantine on all air travelers returning to New York and New Jersey from West Africa who have had contact with Ebola patients. In explaining the move from the CDC's voluntary quarantine to a state ordered mandatory one, Cuomo cited the case of Dr. Spencer. "In a region like this, you go out three times, you ride the subway, you ride the bus, you could affect hundreds of people." Cuomo praised Dr. Spencer's work but stated, "He's a doctor and even he didn't follow the voluntary quarantine. Let's be honest." Governors Cuomo and Christie stated that their two states needed to go beyond the federal CDC guidelines. Cuomo said Dr. Spencer's activity in the days before his diagnosis showed the guidelines, which includes urging health care workers and others who have had contact with Ebola patients to voluntarily quarantine themselves, were not enough. Late on October 26, Cuomo modified the state's quarantine procedure, stating that people entering New York who have had contact with Ebola patients in West Africa will be quarantined in their homes for the 21 days, with twice daily checks to ensure their health has not changed and that they are complying with the order, and would receive some compensation for lost wages, if any. President Obama and his staff had been attempting to persuade Cuomo, Christie, and the government of Illinois to reverse their mandatory quarantines. Illinois governor Pat Quinn issued a similar quarantine authorization the same day as New York and New Jersey initially did, with Florida governor Rick Scott on October 25, authorizing mandatory twice daily monitoring for 21 days of people identified as coming from countries affected by Ebola. Illinois health officials later said that only people at high risk of Ebola exposure, such as not wearing protective gear near Ebola patients, will be quarantined. Pennsylvania , Maryland , and Georgia have all authorized mandatory twice daily health monitoring and/or temperature reporting for 21 days for people exposed to people with Ebola. Virginia has also implemented mandatory twice daily temperature reporting and daily monitoring from health authorities, but has also authorized mandatory quarantine for higher risk patients. California mandated a 21-day quarantine for all health workers who have had contact with Ebola patients. Kaci Hickox, an American nurse who treated Ebola patients in Sierra Leone became the first person placed under the new mandatory quarantine rules on her arrival at Newark Liberty International Airport , in New Jersey. A low-accuracy (forehead) thermometer indicated Hickox developed a fever on Friday night and was taken to University Hospital in Newark. She later tested negative for the Ebola virus but remained quarantined in a medical tent. Hickox and Doctors Without Borders criticized the condition of the quarantine in a tent with a bed and a portable toilet , but without shower facility. Hickox expressed that it was inhumane. The hospital responded that they tried their best to accommodate Hickox by allowing her to have computer access, cell phone, reading materials, and providing take-out food and drink. On October 27, after being symptom free for an additional 24-hour period, testing negative for Ebola, and after the state's quarantine policy was relaxed the night before, Hickox was released from quarantine in New Jersey. She has filed suit. Hickox was escorted out of New Jersey and into Maine the following day by a private convoy of SUVs. Maine governor Paul LePage announced he was joining with his state's health department in seeking legal authority to enforce the quarantine after Hickox announced she would not comply with the isolation protocols in Maine. She left her house on October 29 and 30. The governor said: "She's violated every promise she's made so far, so I can't trust her. I don't trust her." A Maine judge ruled against a mandatory quarantine on October 31, but required Hickox to comply with "direct active monitoring", to coordinate her travel with Maine health officials, and to notify health officials if she develops symptoms of Ebola. On October 29, Texas governor Rick Perry announced that a Texas nurse returning from Sierra Leone where she treated Ebola patients, had agreed to self-quarantine at her Austin home for 21 days following her return to Texas, and undergo frequent monitoring from state health officials. although she did not have any symptoms of Ebola virus. The nurse was not named to protect her privacy. Perry spoke with the nurse over the phone to thank her for work to fight Ebola. U.S. Army Chief of Staff Ray Odierno also ordered on October 27 a 21-day quarantine of all soldiers returning from Operation United Assistance in Liberia. Up to 12 soldiers have been quarantined so far in a U.S. base in Italy. On November 13, 2014, President Obama issued a presidential memorandum , invoking a federal law to immunize contractors hired by the U.S. Agency for International Development (USAID) from liability "with respect to claims, losses, or damage arising out of or resulting from exposure, in the course of performance of the contracts, to Ebola" during the emergency period. There were numerous overreactions to the perceived threat of an Ebola outbreak, particularly on the part of school officials. On October 16, a building housing two schools in the Solon City School District near Cleveland , Ohio, was closed for a single day of disinfection procedures after finding that a staff member may have been on the aircraft that Amber Vinson used on a previous flight. Another school in the Cleveland Metropolitan School District was disinfected overnight due to similar concerns but remained open. In both cases, affected staff were sent home until cleared by health officials. School officials said that they had been assured by city health officials that there was no risk and that the disinfection was "strictly precautionary". Three schools in the Belton Independent School District in Belton, Texas, were also closed. Infectious disease experts considered these closures to be an overreaction and were concerned that it would frighten the public into believing that Ebola is a greater danger than it actually is. In Hazlehurst, Mississippi, in response to numerous parents keeping their children from attending school, a principal at Hazlehurst Middle School, agreed to take personal vacation time after he had traveled to Zambia, a country with no current Ebola cases and 3,000 miles (4,800 kilometres) away from West Africa. The United States has the capacity to isolate and manage 11 patients in four specialized biocontainment units. These include the University of Nebraska Medical Center in Omaha, Nebraska, the National Institutes of Health in Bethesda, Maryland, St. Patrick Hospital and Health Sciences Center in Missoula, Montana and Emory University Hospital in Atlanta, Georgia. There is as yet no medication for Ebola approved by the U.S. Food and Drug Administration (FDA). The director of the US National Institute of Allergy and Infectious Diseases , Dr. Anthony Fauci , has stated that the scientific community is still in the early stages of understanding how infection with the Ebola virus can be treated and prevented. There is no cure or specific treatment that is currently approved. However, survival is improved by early supportive care with rehydration and symptomatic treatment. Treatment is primarily supportive in nature. A number of experimental treatments are being considered for use in the context of this outbreak, and are currently or will soon undergo clinical trials . In late August 2014, both Kent Brantly and Nancy Writebol became the first people to be given the experimental drug ZMapp . They both recovered, but there was no confirmation or proof that the drug was a factor. A Spanish priest with Ebola had taken ZMapp but died afterward. Up until that time, ZMapp had only been tested on primates and looked promising, causing no serious side effects and protecting the animals from infection. The Bill & Melinda Gates Foundation has donated $150,000 to help Amgen increase its production, and the U.S. Department of Health and Human Services has asked a number of centers to also increase production. There have been at least two promising treatments for those already infected. The first is brincidofovir , an experimental antiviral drug, which was given to Duncan, Mukpo, and Spencer. Treatment using a transfusion of plasma from Ebola survivors, a form of "passive immunotherapy", since it contains antibodies able to fight the virus, has been used with apparent success on a number of patients. Survivor Kent Brantly donated his blood to Rick Sacra, Ashoka Mukpo and nurse Nina Pham. The World Health Organization (WHO) has made it a priority to try the treatment, and has been telling affected countries how to do it. Many Ebola vaccine candidates had been developed in the decade before 2014, but none has yet been approved for clinical use in humans. Several promising vaccine candidates have been shown to protect nonhuman primates (usually macaques) against lethal infection, and some are now going through the clinical trial process. In late October 2014, Canada planned to ship 800 vials of an experimental vaccine to the WHO in Geneva, the drug having been licensed by NewLink Genetics Corporation, of Iowa. British drugmaker GlaxoSmithKline also announced it had expedited research and development of a vaccine, which, if successful, could be available in 2015. Although it's still unknown which ones will be approved, WHO hopes to have millions of vaccine doses ready sometime in 2015, and expects that five more experimental vaccines will start being tested in March 2015. In December 2019, the first Ebola vaccine was approved. rVSV-ZEBOV , otherwise known as Ervebo, is a vaccine for adults that prevents the Zaire ebolavirus . The United States has the capacity to isolate and manage 11 patients in four specialized biocontainment units. These include the University of Nebraska Medical Center in Omaha, Nebraska, the National Institutes of Health in Bethesda, Maryland, St. Patrick Hospital and Health Sciences Center in Missoula, Montana and Emory University Hospital in Atlanta, Georgia. There is as yet no medication for Ebola approved by the U.S. Food and Drug Administration (FDA). The director of the US National Institute of Allergy and Infectious Diseases , Dr. Anthony Fauci , has stated that the scientific community is still in the early stages of understanding how infection with the Ebola virus can be treated and prevented. There is no cure or specific treatment that is currently approved. However, survival is improved by early supportive care with rehydration and symptomatic treatment. Treatment is primarily supportive in nature. A number of experimental treatments are being considered for use in the context of this outbreak, and are currently or will soon undergo clinical trials . In late August 2014, both Kent Brantly and Nancy Writebol became the first people to be given the experimental drug ZMapp . They both recovered, but there was no confirmation or proof that the drug was a factor. A Spanish priest with Ebola had taken ZMapp but died afterward. Up until that time, ZMapp had only been tested on primates and looked promising, causing no serious side effects and protecting the animals from infection. The Bill & Melinda Gates Foundation has donated $150,000 to help Amgen increase its production, and the U.S. Department of Health and Human Services has asked a number of centers to also increase production. There have been at least two promising treatments for those already infected. The first is brincidofovir , an experimental antiviral drug, which was given to Duncan, Mukpo, and Spencer. Treatment using a transfusion of plasma from Ebola survivors, a form of "passive immunotherapy", since it contains antibodies able to fight the virus, has been used with apparent success on a number of patients. Survivor Kent Brantly donated his blood to Rick Sacra, Ashoka Mukpo and nurse Nina Pham. The World Health Organization (WHO) has made it a priority to try the treatment, and has been telling affected countries how to do it. Many Ebola vaccine candidates had been developed in the decade before 2014, but none has yet been approved for clinical use in humans. Several promising vaccine candidates have been shown to protect nonhuman primates (usually macaques) against lethal infection, and some are now going through the clinical trial process. In late October 2014, Canada planned to ship 800 vials of an experimental vaccine to the WHO in Geneva, the drug having been licensed by NewLink Genetics Corporation, of Iowa. British drugmaker GlaxoSmithKline also announced it had expedited research and development of a vaccine, which, if successful, could be available in 2015. Although it's still unknown which ones will be approved, WHO hopes to have millions of vaccine doses ready sometime in 2015, and expects that five more experimental vaccines will start being tested in March 2015. In December 2019, the first Ebola vaccine was approved. rVSV-ZEBOV , otherwise known as Ervebo, is a vaccine for adults that prevents the Zaire ebolavirus . In October 2014, Navarro College , a two-year public school located in Texas, received media attention for admission rejection letters sent to two prospective students from Nigeria. The letters informed the applicants that the college was "not accepting international students from countries with confirmed Ebola cases". On October 16, Navarro's Vice-President Dewayne Gragg issued a statement confirming that there had indeed been a decision to "postpone our recruitment in those nations that the Center for Disease Control and the U.S. State Department have identified as at risk". Nigeria's outbreak was among the least severe in West Africa and was considered over by the WHO on October 20; the Nigerian health ministry had previously announced on September 22 that there were no confirmed cases of Ebola within the country. [ citation needed ] In October 2014, the S. I. Newhouse School of Public Communications at Syracuse University withdrew an invitation it had extended to Pulitzer Prize winning photojournalist Michel du Cille because he'd returned three weeks earlier from covering the Ebola outbreak in Liberia . In October 2014, Case Western Reserve University withdrew their speaking invitation to Dr. Richard E. Besser , chief health editor at ABC News and former director of the CDC. Besser had recently returned from a trip to Liberia . On October 17, Harvard University imposed limits on travel to Ebola-affected countries (Sierra Leone, Guinea and Liberia) for its students, staff, and faculty. All travel to these countries is "strongly discourage[d]", and such travel as part of a Harvard program requires approval from the provost . On October 25, CDC allowed state and local officials to set tighter control policies and Barbara Reynolds, a CDC spokeswoman released a statement saying "we will consider any measures that we believe have the potential to make the American people safer". On November 1, Ohio tightened restrictions on people travelling to Western African countries impacted by Ebola. Time magazine's 2014 Person of the Year issue honored health professionals dedicated to fighting Ebola, including Kent Brantly. On October 28, future president Donald Trump tweeted that governors backing off from the Ebola quarantine would lead to more mayhem. In 2020, during the COVID-19 pandemic in the United States , these tweets were contrasted with Trump's then-opposition to mandatory quarantines.

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Ebola

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Peter Piot

Sir Peter Karel, Baron Piot , KCMG , FRCP , FFPH , FMedSci (born 17 February 1949) is a Belgian-British microbiologist known for his research into Ebola and AIDS . After helping discover the Ebola virus in 1976 and leading efforts to contain the first-ever recorded Ebola epidemic that same year, Piot became a pioneering researcher into AIDS. He has held key positions in the United Nations and World Health Organization involving AIDS research and management. He has also served as a professor at several universities worldwide. He is the author of 16 books and over 600 scientific articles.Piot was born in Leuven , Belgium. His father was a civil servant who worked with agricultural exports and his mother ran a construction company. Piot is the oldest of two brothers and a sister. After beginning in the school of engineering and physics at Ghent University studying physics, Piot changed to medicine. During medical school, Piot received a Diploma in Tropical Medicine (DTM) from the Institute of Tropical Medicine Antwerp in Antwerp. In 1974, he received an MD degree from Ghent University. In 1980, Piot received a PhD degree in clinical microbiology from the University of Antwerp . In 1976, while working at the Institute of Tropical Medicine, Piot was part of a team that observed a Marburg-like virus in a sample of blood taken from a sick nun working in Zaire . Piot and his colleagues subsequently traveled to Zaire as part of an International Commission set up by the Government of Zaire to help quell the outbreak. The International Commission made key discoveries into how the virus spread, and traveled from village to village, spreading information and putting the ill and those who had come into contact with them into quarantine. The epidemic was already waning when the International Commission arrived, thanks to measures taken by local and national authorities, and it finally stopped in three months, after it had killed almost 300 people. The events were dramatised by Mike Walker on BBC Radio 4 in December 2014 in a production by David Morley . Piot narrated the programme. Piot has received the majority of the credit for discovering Ebola, since in 1976, it was claimed he was the one to receive blood samples while working in a lab at the Institute for Tropical Medicine in Antwerp, Belgium. The samples were once claimed to be originally sent by Dr. Jean-Jacques Muyembe-Tamfum , a Congolese doctor who obtained the blood samples from those sickened with a mysterious disease in then-Zaire, later discovered to be Ebola. In 2012, Piot published a memoir entitled No Time to Lose which chronicles his professional work, including the discovery of the Ebolavirus; he mentions Muyembe in passing rather than as a co-discoverer. In a 2016 Journal of Infectious Disease article, co-signed by most of the actors from that first outbreak, including Peter Piot and Jean-Jacques Muyembe, the claims by both Piot and Muyembe to have played a significant role in the early discovery of Ebola have been refuted. Piot stated in 2019 that "my book was not an attempt to write the history of Ebola, but more my personal experience". In the 1980s, Piot participated in a series of collaborative projects in Burundi, Côte d'Ivoire, Kenya, Tanzania, and Zaire. Project SIDA in Kinshasa, Zaire was the first international project on AIDS in Africa and is widely acknowledged as having provided the foundations of science's understanding of HIV infection in Africa. He was a professor of microbiology , and of public health at the Prince Leopold Institute of Tropical Medicine , in Antwerp , and at the University of Nairobi , Vrije Universiteit Brussel , the Lausanne , and a visiting professor at the London School of Economics . He was also a senior fellow at the University of Washington in Seattle, a scholar in residence at the Ford Foundation , and a senior fellow at the Bill & Melinda Gates Foundation . From 1991 to 1994, Piot was president of the International AIDS Society . In 1992, he became assistant director of the World Health Organization 's Global Programme on HIV/AIDS. On 12 December 1994, he was appointed executive director of the Joint United Nations Programme on HIV/AIDS (UNAIDS) and Assistant-Secretary-General of the United Nations. From 2009 to 2010, Piot served as director of the Institute for Global Health at Imperial College London . In October 2010, Piot became the director of the London School of Hygiene & Tropical Medicine . In addition to his work at LSHTM, Piot is a member of the Institute of Medicine of the National Academy of Sciences of the United States and the Royal Academy of Medicine of Belgium, a Fellow of the Royal College of Physicians of London , UK and a Fellow of the Academy of Medical Sciences . In 2011, Amy Gutmann appointed him to serve on the International Research Panel at the Presidential Commission for the Study of Bioethical Issues . In 2014, in the face of an unprecedented Ebola epidemic in western Africa , Piot and other scientists called for the emergency release of the experimental ZMapp vaccine for use on humans before it had undergone clinical testing on humans. That year, he was appointed by Director General Margaret Chan to the World Health Organization 's Advisory Group on the Ebola Virus Disease Response, co-chaired by Sam Zaramba and David L. Heymann . He also chaired an independent panel convened by Harvard Global Health Institute and the London School of Hygiene & Tropical Medicine into the national and international response to the epidemic, which sharply criticised the response of the WHO and put forward ten recommendations for the body's reorganisation. In February 2020, he criticised the delay in declaring the 2019–20 novel coronavirus outbreak focused on Hubei , China, a Public Health Emergency of International Concern , and advocated a five-point scale for outbreaks, rather the current binary (emergency/no emergency) system. In 2020, Piot was appointed to the European Commission 's advisory panel on COVID-19 , co-chaired by Ursula von der Leyen and Stella Kyriakides . In the preparations for the Global Health Summit hosted by the European Commission and the G20 in May 2021, Piot co-chaired the event's High Level Scientific Panel. In October 2010, Piot became the director of the London School of Hygiene & Tropical Medicine . In addition to his work at LSHTM, Piot is a member of the Institute of Medicine of the National Academy of Sciences of the United States and the Royal Academy of Medicine of Belgium, a Fellow of the Royal College of Physicians of London , UK and a Fellow of the Academy of Medical Sciences . In 2011, Amy Gutmann appointed him to serve on the International Research Panel at the Presidential Commission for the Study of Bioethical Issues . In 2014, in the face of an unprecedented Ebola epidemic in western Africa , Piot and other scientists called for the emergency release of the experimental ZMapp vaccine for use on humans before it had undergone clinical testing on humans. That year, he was appointed by Director General Margaret Chan to the World Health Organization 's Advisory Group on the Ebola Virus Disease Response, co-chaired by Sam Zaramba and David L. Heymann . He also chaired an independent panel convened by Harvard Global Health Institute and the London School of Hygiene & Tropical Medicine into the national and international response to the epidemic, which sharply criticised the response of the WHO and put forward ten recommendations for the body's reorganisation. In February 2020, he criticised the delay in declaring the 2019–20 novel coronavirus outbreak focused on Hubei , China, a Public Health Emergency of International Concern , and advocated a five-point scale for outbreaks, rather the current binary (emergency/no emergency) system. In 2020, Piot was appointed to the European Commission 's advisory panel on COVID-19 , co-chaired by Ursula von der Leyen and Stella Kyriakides . In the preparations for the Global Health Summit hosted by the European Commission and the G20 in May 2021, Piot co-chaired the event's High Level Scientific Panel. In May 2020, Piot disclosed that he had had COVID-19 . Piot is fluent in English, French, and Dutch. He is married to the American anthropologist Heidi Larson . 2002: Jonathan Dimbleby (TV series) – episode: "The AIDS Crisis in Africa" 2006: Frontline (TV series documentary) – episode: "The Age of AIDS" 2006: 60 Minutes (TV series documentary) – episode: "The New Space Race/Fighting AIDS/Immortality" 2009: House of Numbers: Anatomy of an Epidemic (Documentary) 2014: Horizon: Ebola: The Search for a Cure (TV series documentary) 2017: Heart of the Matter (documentary short) 2017: Unseen Enemy (documentary)

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Ebola

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Zaire ebolavirus

Zaire ebolavirus , more commonly known as Ebola virus ( / i ˈ b oʊ l ə , ɪ -/ ; EBOV ), is one of six known species within the genus Ebolavirus . Four of the six known ebolaviruses, including EBOV, cause a severe and often fatal hemorrhagic fever in humans and other mammals , known as Ebola virus disease (EVD). Ebola virus has caused the majority of human deaths from EVD, and was the cause of the 2013–2016 epidemic in western Africa , which resulted in at least 28,646 suspected cases and 11,323 confirmed deaths. Ebola virus and its genus were both originally named for Zaire (now the Democratic Republic of the Congo ), the country where it was first described , and was at first suspected to be a new "strain" of the closely related Marburg virus . The virus was renamed "Ebola virus" in 2010 to avoid confusion. Ebola virus is the single member of the species Zaire ebolavirus , which is assigned to the genus Ebolavirus , family Filoviridae , order Mononegavirales . The members of the species are called Zaire ebolaviruses. The natural reservoir of Ebola virus is believed to be bats , particularly fruit bats , and it is primarily transmitted between humans and from animals to humans through body fluids . The EBOV genome is a single-stranded RNA, approximately 19,000 nucleotides long. It encodes seven structural proteins : nucleoprotein (NP), polymerase cofactor (VP35), (VP40), GP, transcription activator (VP30), VP24 , and RNA-dependent RNA polymerase (L). Because of its high fatality rate (up to 83 to 90 percent), EBOV is also listed as a select agent , World Health Organization Risk Group 4 Pathogen (requiring Biosafety Level 4-equivalent containment ), a US National Institutes of Health / National Institute of Allergy and Infectious Diseases Category A Priority Pathogen, US CDC Centers for Disease Control and Prevention Category A Bioterrorism Agent , and a Biological Agent for Export Control by the Australia Group . [ citation needed ]EBOV carries a negative-sense RNA genome in virions that are cylindrical/tubular, and contain viral envelope , matrix, and nucleocapsid components. The overall cylinders are generally approximately 80 nm in diameter, and have a virally encoded glycoprotein (GP) projecting as 7–10 nm long spikes from its lipid bilayer surface. The cylinders are of variable length, typically 800 nm, but sometimes up to 1000 nm long. The outer viral envelope of the virion is derived by budding from domains of host cell membrane into which the GP spikes have been inserted during their biosynthesis. Individual GP molecules appear with spacings of about 10 nm. Viral proteins VP40 and VP24 are located between the envelope and the nucleocapsid (see following), in the matrix space . At the center of the virion structure is the nucleocapsid , which is composed of a series of viral proteins attached to an 18–19 kb linear, negative-sense RNA without 3′- polyadenylation or 5′-capping (see following); the RNA is helically wound and complexed with the NP, VP35, VP30, and L proteins; this helix has a diameter of 80 nm. The overall shape of the virions after purification and visualization (e.g., by ultracentrifugation and electron microscopy , respectively) varies considerably; simple cylinders are far less prevalent than structures showing reversed direction, branches, and loops (e.g., U-, shepherd's crook -, 9-, or eye bolt -shapes, or other or circular/coiled appearances), the origin of which may be in the laboratory techniques applied. The characteristic "threadlike" structure is, however, a more general morphologic characteristic of filoviruses (alongside their GP-decorated viral envelope, RNA nucleocapsid, etc.). Each virion contains one molecule of linear, single-stranded, negative-sense RNA, 18,959 to 18,961 nucleotides in length. The 3′ terminus is not polyadenylated and the 5′ end is not capped. This viral genome codes for seven structural proteins and one non-structural protein. The gene order is 3′ – leader – NP – VP35 – VP40 – GP/sGP – VP30 – VP24 – L – trailer – 5′; with the leader and trailer being non-transcribed regions, which carry important signals to control transcription, replication, and packaging of the viral genomes into new virions. Sections of the NP, VP35 and the L genes from filoviruses have been identified as endogenous in the genomes of several groups of small mammals. It was found that 472 nucleotides from the 3' end and 731 nucleotides from the 5' end are sufficient for replication of a viral "minigenome", though not sufficient for infection. Virus sequencing from 78 patients with confirmed Ebola virus disease, representing more than 70% of cases diagnosed in Sierra Leone from late May to mid-June 2014, provided evidence that the 2014 outbreak was no longer being fed by new contacts with its natural reservoir. Using third-generation sequencing technology, investigators were able to sequence samples as quickly as 48 hours. Like other RNA viruses, Ebola virus mutates rapidly, both within a person during the progression of disease and in the reservoir among the local human population. The observed mutation rate of 2.0 x 10 −3 substitutions per site per year is as fast as that of seasonal influenza . There are two candidates for host cell entry proteins. The first is a cholesterol transporter protein, the host-encoded Niemann–Pick C1 ( NPC1 ), which appears to be essential for entry of Ebola virions into the host cell and for its ultimate replication. In one study, mice with one copy of the NPC1 gene removed showed an 80 percent survival rate fifteen days after exposure to mouse-adapted Ebola virus, while only 10 percent of unmodified mice survived this long. In another study, small molecules were shown to inhibit Ebola virus infection by preventing viral envelope glycoprotein (GP) from binding to NPC1. Hence, NPC1 was shown to be critical to entry of this filovirus , because it mediates infection by binding directly to viral GP. When cells from Niemann–Pick Type C individuals lacking this transporter were exposed to Ebola virus in the laboratory, the cells survived and appeared impervious to the virus, further indicating that Ebola relies on NPC1 to enter cells; mutations in the NPC1 gene in humans were conjectured as a possible mode to make some individuals resistant to this deadly viral disease. The same studies described similar results regarding NPC1's role in virus entry for Marburg virus , a related filovirus . A further study has also presented evidence that NPC1 is the critical receptor mediating Ebola infection via its direct binding to the viral GP, and that it is the second "lysosomal" domain of NPC1 that mediates this binding. The second candidate is TIM-1 (a.k.a. HAVCR1 ). TIM-1 was shown to bind to the receptor binding domain of the EBOV glycoprotein, to increase the receptivity of Vero cells . Silencing its effect with siRNA prevented infection of Vero cells . TIM1 is expressed in tissues known to be seriously impacted by EBOV lysis (trachea, cornea, and conjunctiva). A monoclonal antibody against the IgV domain of TIM-1, ARD5, blocked EBOV binding and infection. Together, these studies suggest NPC1 and TIM-1 may be potential therapeutic targets for an Ebola anti-viral drug and as a basis for a rapid field diagnostic assay. [ citation needed ]Being acellular, viruses such as Ebola do not replicate through any type of cell division; rather, they use a combination of host- and virally encoded enzymes, alongside host cell structures, to produce multiple copies of themselves. These then self-assemble into viral macromolecular structures in the host cell. The virus completes a set of steps when infecting each individual cell. The virus begins its attack by attaching to host receptors through the glycoprotein (GP) surface peplomer and is endocytosed into macropinosomes in the host cell. To penetrate the cell, the viral membrane fuses with vesicle membrane, and the nucleocapsid is released into the cytoplasm . Encapsidated, negative-sense genomic ssRNA is used as a template for the synthesis (3'–5') of polyadenylated, monocistronic mRNAs and, using the host cell's ribosomes, tRNA molecules, etc., the mRNA is translated into individual viral proteins. These viral proteins are processed: a glycoprotein precursor (GP0) is cleaved to GP1 and GP2, which are then heavily glycosylated using cellular enzymes and substrates. These two molecules assemble, first into heterodimers, and then into trimers to give the surface peplomers. Secreted glycoprotein (sGP) precursor is cleaved to sGP and delta peptide, both of which are released from the cell. As viral protein levels rise, a switch occurs from translation to replication. Using the negative-sense genomic RNA as a template, a complementary +ssRNA is synthesized; this is then used as a template for the synthesis of new genomic (-)ssRNA, which is rapidly encapsidated. The newly formed nucleocapsids and envelope proteins associate at the host cell's plasma membrane; budding occurs, destroying the cell. [ citation needed ]Ebola virus is a zoonotic pathogen. Intermediary hosts have been reported to be "various species of fruit bats ... throughout central and sub-Saharan Africa". Evidence of infection in bats has been detected through molecular and serologic means. However, ebolaviruses have not been isolated in bats. End hosts are humans and great apes, infected through bat contact or through other end hosts. Pigs in the Philippines have been reported to be infected with Reston virus , so other interim or amplifying hosts may exist. Ebola virus outbreaks tend to occur when temperatures are lower and humidity is higher than usual for Africa. Even after a person recovers from the acute phase of the disease, Ebola virus survives for months in certain organs such as the eyes and testes. Zaire ebolavirus is one of the four ebolaviruses known to cause disease in humans. It has the highest case-fatality rate of these ebolaviruses, averaging 83 percent since the first outbreaks in 1976, although a fatality rate of up to 90 percent was recorded in one outbreak in the Republic of the Congo between December 2002 and April 2003. There have also been more outbreaks of Zaire ebolavirus than of any other ebolavirus. The first outbreak occurred on 26 August 1976 in Yambuku . The first recorded case was Mabalo Lokela, a 44‑year-old schoolteacher. The symptoms resembled malaria , and subsequent patients received quinine . Transmission has been attributed to reuse of unsterilized needles and close personal contact, body fluids and places where the person has touched. During the 1976 Ebola outbreak in Zaire , Ngoy Mushola travelled from Bumba to Yambuku , where he recorded the first clinical description of the disease in his daily log: The illness is characterized with a high temperature of about 39°C, hematemesis , diarrhea with blood, retrosternal abdominal pain, prostration with "heavy" articulations, and rapid evolution death after a mean of three days. Since the first recorded clinical description of the disease during 1976 in Zaire, the recent Ebola outbreak that started in March 2014, in addition, reached epidemic proportions and has killed more than 8000 people as of January 2015. This outbreak was centered in West Africa, an area that had not previously been affected by the disease. The toll was particularly grave in three countries: Guinea, Liberia, and Sierra Leone. A few cases were also reported in countries outside of West Africa, all related to international travelers who were exposed in the most affected regions and later showed symptoms of Ebola fever after reaching their destinations. The severity of the disease in humans varies widely, from rapid fatality to mild illness or even asymptomatic response. Studies of outbreaks in the late twentieth century failed to find a correlation between the disease severity and the genetic nature of the virus. Hence the variability in the severity of illness was suspected to correlate with genetic differences in the victims. This has been difficult to study in animal models that respond to the virus with hemorrhagic fever in a similar manner as humans, because typical mouse models do not so respond, and the required large numbers of appropriate test subjects are not easily available. In late October 2014, a publication reported a study of the response to a mouse-adapted strain of Zaire ebolavirus presented by a genetically diverse population of mice that was bred to have a range of responses to the virus that includes fatality from hemorrhagic fever. In December 2016, a study found the VSV-EBOV vaccine to be 70–100% effective against the Zaire ebola virus (not the Sudan ebolavirus ), making it the first vaccine against the disease. VSV-EBOV was approved by the U.S. Food and Drug Administration in December 2019. In December 2016, a study found the VSV-EBOV vaccine to be 70–100% effective against the Zaire ebola virus (not the Sudan ebolavirus ), making it the first vaccine against the disease. VSV-EBOV was approved by the U.S. Food and Drug Administration in December 2019. Ebola virus was first identified as a possible new "strain" of Marburg virus in 1976. The International Committee on Taxonomy of Viruses (ICTV) identifies Ebola virus as species Zaire ebolavirus , which is part of the genus Ebolavirus , family Filoviridae , order Mononegavirales . The name "Ebola virus" is derived from the Ebola River —a river that was at first thought to be in close proximity to the area in Democratic Republic of Congo , previously called Zaire , where the 1976 Zaire Ebola virus outbreak occurred—and the taxonomic suffix virus . In 1998, the virus name was changed to "Zaire Ebola virus" and in 2002 to species Zaire ebolavirus . However, most scientific articles continued to refer to "Ebola virus" or used the terms "Ebola virus" and " Zaire ebolavirus " in parallel. Consequently, in 2010, a group of researchers recommended that the name "Ebola virus" be adopted for a subclassification within the species Zaire ebolavirus , with the corresponding abbreviation EBOV. Previous abbreviations for the virus were EBOV-Z (for "Ebola virus Zaire") and ZEBOV (for "Zaire Ebola virus" or " Zaire ebolavirus "). In 2011, the ICTV explicitly rejected a proposal (2010.010bV) to recognize this name, as ICTV does not designate names for subtypes, variants, strains, or other subspecies level groupings. At present, ICTV does not officially recognize "Ebola virus" as a taxonomic rank, but rather continues to use and recommend only the species designation Zaire ebolavirus . The prototype Ebola virus, variant Mayinga (EBOV/May), was named for Mayinga N'Seka, a nurse who died during the 1976 Zaire outbreak. The name Zaire ebolavirus is derived from Zaire and the taxonomic suffix ebolavirus (which denotes an ebolavirus species and refers to the Ebola River ). According to the rules for taxon naming established by the International Committee on Taxonomy of Viruses (ICTV), the name Zaire ebolavirus is always to be capitalized , italicized , and to be preceded by the word "species". The names of its members (Zaire ebolaviruses) are to be capitalized, are not italicized, and used without articles . A virus of the genus Ebolavirus is a member of the species Zaire ebolavirus if: Zaire ebolavirus diverged from its ancestors between 1960 and 1976. The genetic diversity of Ebolavirus remained constant before 1900. Then, around the 1960s, most likely due to climate change or human activities, the genetic diversity of the virus dropped rapidly and most lineages became extinct. As the number of susceptible hosts declines, so does the effective population size and its genetic diversity. This genetic bottleneck effect has implications for the species' ability to cause Ebola virus disease in human hosts. [ citation needed ] A recombination event between Zaire ebolavirus lineages likely took place between 1996 and 2001 in wild apes giving rise to recombinant progeny viruses. These recombinant viruses appear to have been responsible for a series of outbreaks among humans in Central Africa in 2001–2003. Zaire ebolavirus – Makona variant caused the 2014 West Africa outbreak. The outbreak was characterized by the longest instance of human-to-human transmission of the viral species. Pressures to adapt to the human host were seen at this time, however, no phenotypic changes in the virus (such as increased transmission, increased immune evasion by the virus) were seen. [ citation needed ]

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Ebola

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Ebola vaccine

Ebola vaccines are vaccines either approved or in development to prevent Ebola . As of 2022, there are only vaccines against the Zaire ebolavirus . The first vaccine to be approved in the United States was rVSV-ZEBOV in December 2019. It had been used extensively in the Kivu Ebola epidemic under a compassionate use protocol. During the early 21st century, several vaccine candidates displayed efficacy to protect nonhuman primates (usually macaques ) against lethal infection. Vaccines include replication -deficient adenovirus vectors , replication-competent vesicular stomatitis (VSV) and human parainfluenza (HPIV-3) vectors, and virus-like nanoparticle preparations. Conventional trials to study efficacy by exposure of humans to the pathogen after immunization are not ethical in this case. For such situations, the US Food and Drug Administration (FDA) has established the " animal efficacy rule " allowing licensure to be approved on the basis of animal model studies that replicate human disease, combined with evidence of safety and a potentially potent immune response (antibodies in the blood) from humans given the vaccine. Clinical trials involve the administration of the vaccine to healthy human subjects to evaluate the immune response, identify any side effects and determine the appropriate dosage. VSV-EBOV or rVSV-ZEBOV , sold under the brand name Ervebo, is a vaccine based on the vesicular stomatitis virus which was genetically modified to express a surface glycoprotein of Zaire Ebola virus . In November 2019, the European Commission granted a conditional marketing authorization. The WHO prequalification came fewer than 48 hours later, making it the fastest vaccine prequalification process ever conducted by WHO. It was approved for medical use in the European Union in November 2019. It was approved for medical use in the United States in December 2019. The most common side effects include pain, swelling and redness at the injection site, headache, fever, muscle pain, tiredness and joint pain. In general, these reactions occur within seven days after vaccination, are mild to moderate in intensity and resolved in less than a week. It was developed by the Public Health Agency of Canada , with development subsequently taken over by Merck Inc . In October 2014, the Wellcome Trust , who was also one of the biggest UK founders, announced the start of multiple trials in healthy volunteers in Europe, Gabon, Kenya, and the US. The vaccine was proven safe at multiple sites in North America, Europe, and Africa, but several volunteers at one trial site in Geneva, Switzerland, developed vaccine-related arthritis after about two weeks, and about 20–30% of volunteers at reporting sites developed low-grade post-vaccine fever, which resolved within a day or two. Other common side-effects were pain at the site of injection, myalgia, and fatigue. The trial was temporarily halted in December 2014 due to possible adverse effects, but subsequently resumed. As of April 2015 [ update ] , a Phase III trial with a single dose of VSV-EBOV began in Liberia after a successful Phase II study in the West African country. On 31 July 2015, preliminary results of a Phase III trial in Guinea indicated that the vaccine appeared to be "highly efficacious and safe." The trial used a ring vaccination protocol that first vaccinated all the closest contacts of new cases of Ebola infection either immediately or after 21 days. Because of the demonstrated efficacy of immediate vaccination, all recipients will now be immunized immediately. Ring vaccination is the method used in the program to eradicate smallpox in the 1970s. The trial will continue to assess whether the vaccine is effective in creating herd immunity to Ebola virus infection. In December 2016, a study found the VSV-EBOV vaccine to be 95–100% effective against the Ebola virus, making it the first proven vaccine against the disease. The approval was supported by a study conducted in Guinea during the 2014–2016 outbreak in individuals 18 years of age and older. The study was a randomized cluster (ring) vaccination study in which 3,537 contacts, and contacts of contacts, of individuals with laboratory-confirmed Ebola virus disease (EVD) received either "immediate" or 21-day "delayed" vaccination. This design was intended to capture a social network of individuals and locations that might include dwellings or workplaces where a patient spent time while symptomatic, or the households of individuals who had contact with the patient during that person's illness or death. In a comparison of cases of EVD among 2,108 individuals in the "immediate" vaccination arm and 1,429 individuals in the "delayed" vaccination arm, Ervebo was determined to be 100% effective in preventing Ebola cases with symptom onset greater than ten days after vaccination. No cases of EVD with symptom onset greater than ten days after vaccination were observed in the "immediate" cluster group, compared with ten cases of EVD in the 21-day "delayed" cluster group. In additional studies, antibody responses were assessed in 477 individuals in Liberia, some 500 individuals in Sierra Leone, and about 900 individuals in Canada, Spain, and the US. The antibody responses among those in the study conducted in Canada, Spain and the US were similar to those among individuals in the studies conducted in Liberia and Sierra Leone. The safety was assessed in approximately 15,000 individuals in Africa, Europe, and North America. The most commonly reported side effects were pain, swelling and redness at the injection site, as well as headache, fever, joint and muscle aches and fatigue. In December 2016, a study found the VSV-EBOV vaccine to be 70–100% effective against the Ebola virus, making it the first proven vaccine against the disease. However, the design of this study and the high efficacy of the vaccine were questioned. In November 2019, the European Commission granted a conditional marketing authorization to Ervebo (rVSV∆G-ZEBOV-GP, live) and the WHO prequalified an Ebola vaccine for the first time. In July 2023, the FDA expanded the indication for Ervebo to cover people aged 12 years of age and older. The two-dose regimen of Ad26.ZEBOV and MVA-BN-Filo, sold under the brand names Zabdeno and Mvabea, was developed by Johnson & Johnson at its Janssen Pharmaceutical company. It was approved for medical use in the European Union in July 2020. The regimen consists of two vaccine components (first vaccine as prime, followed by a second vaccine as boost ) – the first based on AdVac technology from Crucell Holland B.V. (which is part of Janssen), the second based on the MVA-BN technology from Bavarian Nordic . The Ad26.ZEBOV is derived from human adenovirus serotype 26 (Ad26) expressing the Ebola virus Mayinga variant glycoprotein, while the second component MVA-BN is the Modified Vaccinia Virus Ankara – Bavarian Nordic (MVA-BN) Filo-vector. This product commenced Phase I clinical trial at the Jenner Institute in Oxford during January 2015. The preliminary data indicated the prime-boost vaccine regimen elicited temporary immunologic response in the volunteers as expected from vaccination. The Phase II trial enrolled 612 adult volunteers and commenced in July 2015, in the United Kingdom and France. A second Phase II trial, involving 1,200 volunteers, was initiated in Africa with the first trial commenced in Sierra Leone in October 2015. In September 2019, the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA) granted an accelerated assessment to Janssen for Ad26.ZEBOV and MVA-BN-Filo, and in November 2019, Janssen submitted a Marketing Authorization Application (MAA) to the EMA for approval of Ad26.ZEBOV and MVA-BN-Filo. In May 2020, the EMA CHMP recommended granting a marketing authorization for the combination of Ad26.ZEBOV (Zabdeno) and MVA-BN-Filo (Mvabea) vaccines. Zabdeno is given first and Mvabea is administered approximately eight weeks later as a booster. This prophylactic two-dose regimen is therefore not suitable for an outbreak response where immediate protection is necessary. As a precautionary measure for individuals at imminent risk of exposure to Ebola virus (for example healthcare professionals and those living in or visiting areas with an ongoing Ebola virus disease outbreak), an extra Zabdeno booster vaccination should be considered for individuals who completed the Zabdeno-Mvabea two-dose vaccination regimen more than four months ago. Efficacy for humans is not yet known as the efficacy has been extrapolated from animal studies. In late 2014 and early 2015, a double-blind, randomized Phase I trial was conducted in the Jiangsu Province of China; the trial examined a vaccine that contains glycoproteins of the 2014 strain, rather than those of the 1976 strain. The trial found signals of efficacy and raised no significant safety concerns. In 2017, the China Food and Drug Administration (CFDA) announced approval of an Ebola vaccine, co-developed by the Institute of Biotechnology of the Academy of Military Medical Sciences and the private vaccine-maker CanSino Biologics . It contains a human adenovirus serotype 5 vector (Ad5) with the glycoprotein gene from ZEBOV. Their findings were consistent with previous tests on rVSV-ZEBOV in Africa and Europe. VSV-EBOV or rVSV-ZEBOV , sold under the brand name Ervebo, is a vaccine based on the vesicular stomatitis virus which was genetically modified to express a surface glycoprotein of Zaire Ebola virus . In November 2019, the European Commission granted a conditional marketing authorization. The WHO prequalification came fewer than 48 hours later, making it the fastest vaccine prequalification process ever conducted by WHO. It was approved for medical use in the European Union in November 2019. It was approved for medical use in the United States in December 2019. The most common side effects include pain, swelling and redness at the injection site, headache, fever, muscle pain, tiredness and joint pain. In general, these reactions occur within seven days after vaccination, are mild to moderate in intensity and resolved in less than a week. It was developed by the Public Health Agency of Canada , with development subsequently taken over by Merck Inc . In October 2014, the Wellcome Trust , who was also one of the biggest UK founders, announced the start of multiple trials in healthy volunteers in Europe, Gabon, Kenya, and the US. The vaccine was proven safe at multiple sites in North America, Europe, and Africa, but several volunteers at one trial site in Geneva, Switzerland, developed vaccine-related arthritis after about two weeks, and about 20–30% of volunteers at reporting sites developed low-grade post-vaccine fever, which resolved within a day or two. Other common side-effects were pain at the site of injection, myalgia, and fatigue. The trial was temporarily halted in December 2014 due to possible adverse effects, but subsequently resumed. As of April 2015 [ update ] , a Phase III trial with a single dose of VSV-EBOV began in Liberia after a successful Phase II study in the West African country. On 31 July 2015, preliminary results of a Phase III trial in Guinea indicated that the vaccine appeared to be "highly efficacious and safe." The trial used a ring vaccination protocol that first vaccinated all the closest contacts of new cases of Ebola infection either immediately or after 21 days. Because of the demonstrated efficacy of immediate vaccination, all recipients will now be immunized immediately. Ring vaccination is the method used in the program to eradicate smallpox in the 1970s. The trial will continue to assess whether the vaccine is effective in creating herd immunity to Ebola virus infection. In December 2016, a study found the VSV-EBOV vaccine to be 95–100% effective against the Ebola virus, making it the first proven vaccine against the disease. The approval was supported by a study conducted in Guinea during the 2014–2016 outbreak in individuals 18 years of age and older. The study was a randomized cluster (ring) vaccination study in which 3,537 contacts, and contacts of contacts, of individuals with laboratory-confirmed Ebola virus disease (EVD) received either "immediate" or 21-day "delayed" vaccination. This design was intended to capture a social network of individuals and locations that might include dwellings or workplaces where a patient spent time while symptomatic, or the households of individuals who had contact with the patient during that person's illness or death. In a comparison of cases of EVD among 2,108 individuals in the "immediate" vaccination arm and 1,429 individuals in the "delayed" vaccination arm, Ervebo was determined to be 100% effective in preventing Ebola cases with symptom onset greater than ten days after vaccination. No cases of EVD with symptom onset greater than ten days after vaccination were observed in the "immediate" cluster group, compared with ten cases of EVD in the 21-day "delayed" cluster group. In additional studies, antibody responses were assessed in 477 individuals in Liberia, some 500 individuals in Sierra Leone, and about 900 individuals in Canada, Spain, and the US. The antibody responses among those in the study conducted in Canada, Spain and the US were similar to those among individuals in the studies conducted in Liberia and Sierra Leone. The safety was assessed in approximately 15,000 individuals in Africa, Europe, and North America. The most commonly reported side effects were pain, swelling and redness at the injection site, as well as headache, fever, joint and muscle aches and fatigue. In December 2016, a study found the VSV-EBOV vaccine to be 70–100% effective against the Ebola virus, making it the first proven vaccine against the disease. However, the design of this study and the high efficacy of the vaccine were questioned. In November 2019, the European Commission granted a conditional marketing authorization to Ervebo (rVSV∆G-ZEBOV-GP, live) and the WHO prequalified an Ebola vaccine for the first time. In July 2023, the FDA expanded the indication for Ervebo to cover people aged 12 years of age and older. The two-dose regimen of Ad26.ZEBOV and MVA-BN-Filo, sold under the brand names Zabdeno and Mvabea, was developed by Johnson & Johnson at its Janssen Pharmaceutical company. It was approved for medical use in the European Union in July 2020. The regimen consists of two vaccine components (first vaccine as prime, followed by a second vaccine as boost ) – the first based on AdVac technology from Crucell Holland B.V. (which is part of Janssen), the second based on the MVA-BN technology from Bavarian Nordic . The Ad26.ZEBOV is derived from human adenovirus serotype 26 (Ad26) expressing the Ebola virus Mayinga variant glycoprotein, while the second component MVA-BN is the Modified Vaccinia Virus Ankara – Bavarian Nordic (MVA-BN) Filo-vector. This product commenced Phase I clinical trial at the Jenner Institute in Oxford during January 2015. The preliminary data indicated the prime-boost vaccine regimen elicited temporary immunologic response in the volunteers as expected from vaccination. The Phase II trial enrolled 612 adult volunteers and commenced in July 2015, in the United Kingdom and France. A second Phase II trial, involving 1,200 volunteers, was initiated in Africa with the first trial commenced in Sierra Leone in October 2015. In September 2019, the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA) granted an accelerated assessment to Janssen for Ad26.ZEBOV and MVA-BN-Filo, and in November 2019, Janssen submitted a Marketing Authorization Application (MAA) to the EMA for approval of Ad26.ZEBOV and MVA-BN-Filo. In May 2020, the EMA CHMP recommended granting a marketing authorization for the combination of Ad26.ZEBOV (Zabdeno) and MVA-BN-Filo (Mvabea) vaccines. Zabdeno is given first and Mvabea is administered approximately eight weeks later as a booster. This prophylactic two-dose regimen is therefore not suitable for an outbreak response where immediate protection is necessary. As a precautionary measure for individuals at imminent risk of exposure to Ebola virus (for example healthcare professionals and those living in or visiting areas with an ongoing Ebola virus disease outbreak), an extra Zabdeno booster vaccination should be considered for individuals who completed the Zabdeno-Mvabea two-dose vaccination regimen more than four months ago. Efficacy for humans is not yet known as the efficacy has been extrapolated from animal studies. In late 2014 and early 2015, a double-blind, randomized Phase I trial was conducted in the Jiangsu Province of China; the trial examined a vaccine that contains glycoproteins of the 2014 strain, rather than those of the 1976 strain. The trial found signals of efficacy and raised no significant safety concerns. In 2017, the China Food and Drug Administration (CFDA) announced approval of an Ebola vaccine, co-developed by the Institute of Biotechnology of the Academy of Military Medical Sciences and the private vaccine-maker CanSino Biologics . It contains a human adenovirus serotype 5 vector (Ad5) with the glycoprotein gene from ZEBOV. Their findings were consistent with previous tests on rVSV-ZEBOV in Africa and Europe. In September 2014, two Phase I clinical trials began for the vaccine cAd3-EBO Z , which is based on an attenuated version of a chimpanzee adenovirus (cAd3) that has been genetically altered so that it is unable to replicate in humans. The cAd3 vector has a DNA fragment insert that encodes the Ebola virus glycoprotein, which is expressed on the virion surface and is critical for attachment to host cells and catalysis of membrane fusion. It was developed by NIAID in collaboration with Okairos, now a division of GlaxoSmithKline . For the trial designated VRC 20, 20 volunteers were recruited by the NIAID in Bethesda, Maryland, while three dose-specific groups of 20 volunteers each were recruited for trial EBL01 by University of Oxford, UK. Initial results were released in November 2014; all 20 volunteers developed antibodies against Ebola and there were no significant concerns raised about safety. In December 2014, University of Oxford expanded the trial to include a booster vaccine based on MVA-BN, a strain of Modified vaccinia Ankara , developed by Bavarian Nordic , to investigate whether it can help increase immune responses further. The trial which has enrolled a total of 60 volunteers will see 30 volunteers vaccinated with the booster vaccine. As of April 2015 [ update ] , Phase III trial with a single dose of cAd3-EBO Z begins in Sierra Leone after a successful Phase 2 study in West Africa countries. At the 8th Vaccine and ISV Conference in Philadelphia on 27−28 October 2014, Novavax Inc. reported the development in a "few weeks" of a glycoprotein (GP) nanoparticle Ebola virus (EBOV GP) vaccine using their proprietary recombinant technology. A recombinant protein is a protein whose code is carried by recombinant DNA . The vaccine is based on the newly published genetic sequence of the 2014 Guinea Ebola (Makona) strain that is responsible for the 2014 Ebola disease epidemic in West Africa. In animal studies, a useful immune response was induced and was found to be enhanced ten to a hundred-fold by the company's "Matrix-M" immunologic adjuvant . A study of the response of non-human primate to the vaccine had been initiated. As of February 2015 [ update ] , Novavax had completed two primate studies on baboons and macaques and had initiated a Phase I clinical trial in Australia. The Lipid nanoparticle (LNP)-encapsulated siRNAs rapidly adapted to target the Makona outbreak strain of EBOV and are able to protect 100% of rhesus monkeys against lethal challenge when treatment was initiated at three days post-exposure while animals were viremic and clinically ill. The top line Phase I human trial results showed that the adjuvanted Ebola GP Vaccine was highly immunogenic at all dose levels. [ medical citation needed ] On 5 November 2014, the Houston Chronicle reported that a research team at the University of Texas-Austin was developing a nasal spray Ebola vaccine, which the team had been working on for seven years. The team reported in 2014, that in the nonhuman primate studies it conducted, the vaccine had more efficacy when delivered via nasal spray than by injection. As of November 2014 [ update ] , further development by the team appeared unlikely due to lack of funding. Vaxart Inc. is developing a vaccine technology in the form of a temperature-stable tablet which may offer advantages such as reduced cold chain requirement, and rapid and scalable manufacturing. In January 2015, Vaxart announced that it had secured funding to develop its Ebola vaccine to Phase I trial. A study published in Science during March 2015, demonstrated that vaccination with a weakened form of the Ebola virus provides some measure of protection to non-human primates. This study was conducted in accordance with a protocol approved by an Institutional Animal Care and Use Committee of the National Institutes of Health. The new vaccine relies on a strain of Ebola called EBOVΔVP30, which is unable to replicate. A study published in Human Vaccines & Immunotherapeutics in March 2017, analyzing data from a clinical trial of the GamEvac-Combi vaccine in Russia, concluded said vaccine to be safe and effective and recommended proceeding to Phase III trials. In September 2019, a study published in Cell Reports demonstrated the role of the Ebola virus VP35 protein in its immune evasion. A recombinant form of Ebola virus with a mutant VP35 protein (VP35m) was developed, and showed positive results in the activation of the RIG-I-like receptor signaling. Non-human primates were challenged with different doses of VP35. This challenge resulted in the activation of the innate immune system and the production of anti-EBOV antibodies. The primates were then back-challenged with the wild type Ebola virus and survived. This potentially creates a prospect for a future vaccine development. In September 2014, two Phase I clinical trials began for the vaccine cAd3-EBO Z , which is based on an attenuated version of a chimpanzee adenovirus (cAd3) that has been genetically altered so that it is unable to replicate in humans. The cAd3 vector has a DNA fragment insert that encodes the Ebola virus glycoprotein, which is expressed on the virion surface and is critical for attachment to host cells and catalysis of membrane fusion. It was developed by NIAID in collaboration with Okairos, now a division of GlaxoSmithKline . For the trial designated VRC 20, 20 volunteers were recruited by the NIAID in Bethesda, Maryland, while three dose-specific groups of 20 volunteers each were recruited for trial EBL01 by University of Oxford, UK. Initial results were released in November 2014; all 20 volunteers developed antibodies against Ebola and there were no significant concerns raised about safety. In December 2014, University of Oxford expanded the trial to include a booster vaccine based on MVA-BN, a strain of Modified vaccinia Ankara , developed by Bavarian Nordic , to investigate whether it can help increase immune responses further. The trial which has enrolled a total of 60 volunteers will see 30 volunteers vaccinated with the booster vaccine. As of April 2015 [ update ] , Phase III trial with a single dose of cAd3-EBO Z begins in Sierra Leone after a successful Phase 2 study in West Africa countries. At the 8th Vaccine and ISV Conference in Philadelphia on 27−28 October 2014, Novavax Inc. reported the development in a "few weeks" of a glycoprotein (GP) nanoparticle Ebola virus (EBOV GP) vaccine using their proprietary recombinant technology. A recombinant protein is a protein whose code is carried by recombinant DNA . The vaccine is based on the newly published genetic sequence of the 2014 Guinea Ebola (Makona) strain that is responsible for the 2014 Ebola disease epidemic in West Africa. In animal studies, a useful immune response was induced and was found to be enhanced ten to a hundred-fold by the company's "Matrix-M" immunologic adjuvant . A study of the response of non-human primate to the vaccine had been initiated. As of February 2015 [ update ] , Novavax had completed two primate studies on baboons and macaques and had initiated a Phase I clinical trial in Australia. The Lipid nanoparticle (LNP)-encapsulated siRNAs rapidly adapted to target the Makona outbreak strain of EBOV and are able to protect 100% of rhesus monkeys against lethal challenge when treatment was initiated at three days post-exposure while animals were viremic and clinically ill. The top line Phase I human trial results showed that the adjuvanted Ebola GP Vaccine was highly immunogenic at all dose levels. [ medical citation needed ]On 5 November 2014, the Houston Chronicle reported that a research team at the University of Texas-Austin was developing a nasal spray Ebola vaccine, which the team had been working on for seven years. The team reported in 2014, that in the nonhuman primate studies it conducted, the vaccine had more efficacy when delivered via nasal spray than by injection. As of November 2014 [ update ] , further development by the team appeared unlikely due to lack of funding. Vaxart Inc. is developing a vaccine technology in the form of a temperature-stable tablet which may offer advantages such as reduced cold chain requirement, and rapid and scalable manufacturing. In January 2015, Vaxart announced that it had secured funding to develop its Ebola vaccine to Phase I trial. A study published in Science during March 2015, demonstrated that vaccination with a weakened form of the Ebola virus provides some measure of protection to non-human primates. This study was conducted in accordance with a protocol approved by an Institutional Animal Care and Use Committee of the National Institutes of Health. The new vaccine relies on a strain of Ebola called EBOVΔVP30, which is unable to replicate. A study published in Human Vaccines & Immunotherapeutics in March 2017, analyzing data from a clinical trial of the GamEvac-Combi vaccine in Russia, concluded said vaccine to be safe and effective and recommended proceeding to Phase III trials. In September 2019, a study published in Cell Reports demonstrated the role of the Ebola virus VP35 protein in its immune evasion. A recombinant form of Ebola virus with a mutant VP35 protein (VP35m) was developed, and showed positive results in the activation of the RIG-I-like receptor signaling. Non-human primates were challenged with different doses of VP35. This challenge resulted in the activation of the innate immune system and the production of anti-EBOV antibodies. The primates were then back-challenged with the wild type Ebola virus and survived. This potentially creates a prospect for a future vaccine development. In January 2015, Marie-Paule Kieny, the World Health Organization 's (WHO) assistant director-general of health systems and innovation, announced that the vaccines cAd3-EBO Z and VSV-EBOV had demonstrated acceptable safety profiles during early testing and would soon progress to large-scale trials in Liberia, Sierra Leone, and Guinea. The trials would involve up to 27,000 people and comprise three groups – members of the first two groups would receive the two candidate vaccines, while the third group will receive a placebo . Both vaccines have since successfully completed the Phase 2 studies. The large scale Phase 3 studies have begun as of April 2015 [ update ] , in Liberia and Sierra Leone, and in Guinea in March 2016. In addition, a medical anthropologist at Université de Montréal , had been working in Guinea and raised further questions about safety in the ring trial after spending time in April at one of the Ebola treatment units where trial participants are taken if they become ill, the centre in Coyah, about 50 km from the capital of Conakry. The Russian Foreign Ministry announced in 2016, the intention to conduct field trials of two Russian vaccines involving 2000 people. According to local media reports, the Guinean government authorized the commencement of the trials on 9 August 2017, at the Rusal -built Research and Diagnostic Center of Epidemiology and Microbiology in Kindia . The trials were slated to continue until 2018. As of October 2019, Russia licensed the vaccine by local regulatory authorities and was reportedly ready to ship vaccine to Africa. In 2014, Credit Suisse estimated that the U.S. government will provide over $1 billion in contracts to companies to develop medicine and vaccines for Ebola virus disease. Congress passed a law in 2004 that funds a national stockpile of vaccines and medicine for possible outbreaks of disease. A number of companies were expected to develop Ebola vaccines: GlaxoSmithKline , NewLink Genetics , Johnson & Johnson , and Bavarian Nordic . Another company, Emergent BioSolutions , was a contestant for manufacturing new doses of ZMapp , [ citation needed ] a drug for Ebola virus disease treatment originally developed by Mapp Biopharmaceutical . Supplies of ZMapp ran out in August 2014. In September 2014, the Biomedical Advanced Research and Development Authority (BARDA) entered into a multimillion-dollar contract with Mapp Biopharmaceutical to accelerate the development of ZMapp. Additional contracts were signed in 2017.

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Ebola

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Ebola Syndrome

15 June 1996 ( 1996-06-15 ) (Hong Kong) Ebola Syndrome (ä¼Šæ³¢æ‹‰ç— æ¯’) is a 1996 Hong Kong Category III exploitation film directed by Herman Yau and starring Anthony Wong . Living in Hong Kong in 1986, Kai San works for Kwan. Kai has sex with Kwan's wife. Kwan catches them, and the wife accuses Kai of assaulting her. In the ensuing fight, Kai kills Kwan, Kwan's wife, and Kwan's thug. He is about to kill Kwan's daughter Lily but is interrupted. Now a wanted convict, he flees to South Africa . Ten years later, Kai works as a chef in a Chinese restaurant. His boss, Kei, and Kei's wife bully Kai frequently. Meanwhile, Lily is now a young woman working as a flight attendant. She goes to Kai's restaurant and gets sick when she is near him. Trying to get some cheap pig meat, Kei goes to see the Zulu tribe, and he brings Kai with him. The tribe performs a ceremony around several members who are sick. Kei buys the pigs. On the way home, Kai crashes the car into a tree. As Kei fixes the car, Kai wanders off and sees a dying infected member of the tribe. He rapes and kills her. Shortly afterward, he gets a fever. The doctor says he has the Ebola virus. Kai is one of the rare people immune to Ebola and becomes a living carrier who can spread the disease to others through bodily fluids. While Kei is out, his wife talks about killing Kai. Kai overhears and attacks her. Then, Kei returns to the restaurant. He tries to defend his wife, but Kai kills him. He rapes and kills Kei's wife. The wife's cousin stops by, and Kai kills him, as well. He cuts up all of the corpses and serves them to the restaurant's customers as hamburgers. Lily and her boyfriend go back to the restaurant, and she realizes who Kai is. They go to the police, who cannot do anything without evidence. Many people in the area start getting sick. Using Kei's money, Kai returns to Hong Kong. He has sex with two prostitutes, and both of them get sick. Working together, the South African police, the Hong Kong police, and Lily figure out that Kai is the person spreading the virus. Kai meets up with his ex-girlfriend Har, who now has a husband and daughter. Kai buys Har from her husband and spreads the virus to many people, including Lily. He has sex with Har. Afterward, Har learns about Kai's disease and attempts to leave him. Kai grabs a knife and takes the daughter hostage to keep the police from taking him into custody. He spits in random people's faces. While trying to get away, he accidentally chokes Har's daughter to death. The police then light Kai on fire and shoot him repeatedly, killing him.Anthony Wong as Kai San Lo Mang as Boss Kei Lu Cheung as Kei's wife Wan Yeung-ming as Sergeant Yeung Mariane Chan as Har Angel Wong as Lily Chow Ng Shui Ting as Lily's boyfriend Shing Fui-On as Boss Kwan Tsang Yin as Kwan's wife Yip Sin-yi as prostitute Lori Shannon as prostitute Peter Ngor as Ma Bobby Yip as Short Ugly TriadEbola Syndrome was released in Hong Kong on 15 June 1996. On Rotten Tomatoes , the film has a 20% rating with five reviews.

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Ebola

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List of Ebola outbreaks

This list of Ebola outbreaks records the known occurrences of Ebola virus disease , a highly infectious and acutely lethal viral disease that has afflicted humans and animals primarily in equatorial Africa . The pathogens responsible for the disease are the five ebolaviruses recognized by the International Committee on Taxonomy of Viruses : Ebola virus (EBOV), Sudan virus (SUDV), Reston virus (RESTV), Taï Forest virus (TAFV), and Bundibugyo virus (BDBV). Four of the five variants have caused the disease in humans as well as other animals; RESTV has caused clinical symptoms only in non-human primates . RESTV has caused subclinical infections in humans, producing an antibody response but no visual symptoms or disease state manifestations. Transmission of the ebolaviruses between natural reservoirs and humans is rare, and outbreaks of Ebola virus disease are often traceable to a single case where an individual has handled the carcass of a gorilla , chimpanzee , bats , or duiker . The virus then spreads person-to-person, especially within families, in hospitals, and during some mortuary rituals where contact among individuals becomes more likely. Learning from failed responses, such as during the 2000 outbreak in Uganda , the World Health Organization (WHO) established its Global Outbreak Alert and Response Network , and other public health measures were instituted in areas at high risk. Field laboratories were established to confirm cases, instead of shipping samples to South Africa . Outbreaks are also closely monitored by the United States Centers for Disease Control and Prevention (CDC) Special Pathogens Branch. Nigeria was the first country in western Africa to successfully curtail the virus, and its procedures have served as a model for other countries to follow. The information in the following tables comes from the World Health Organization (WHO). This data excludes all laboratory personnel cases, Reston virus cases (since they are all asymptomatic ), and suspected cases. For a complete overview, those cases are included below with footnotes and supporting sources. The last strain Occurred in the Booué area with transport of patients to Libreville . The index case-patient was a hunter who lived in a forest timber camp . The disease was spread by close contact with infected persons. A dead chimpanzee found in the forest at the time was determined to be infected. The second strain Occurred in the districts of Mbomo and Kelle in the Cuvette-Ouest Department . The third strain Occurred in Mbomo and Mbandza villages, located in Mbomo District in the Cuvette-Ouest Department. On 8 May 2018, the government of the Democratic Republic of the Congo reported two confirmed cases of Ebola infection in the northwestern town of Bikoro . On 17 May, a case was confirmed in the city of Mbandaka . Health authorities were planning to ring vaccinate with rVSV-ZEBOV , a recently developed experimental Ebola vaccine , to contain the outbreak. The outbreak was ongoing as of 24 June 2018, in 2014 a different area of Equateur province was affected On 24 July 2018 the outbreak was declared over. On 1 August 2018, the Democratic Republic of the Congo Ministry of Health declared an outbreak when 4 individuals tested positive for the Ebola virus. On 11 June 2019, the WHO confirmed that a five-year-old boy in Uganda died after being diagnosed with Ebola. On 25 June 2020, the second biggest EVD outbreak ever was declared over. By 18 November 2020, the World Health Organization and the Congolese government had not received reports of any cases of Ebola in Équateur province or all of the DRC for 42 days. When the outbreak was declared over, there were 130 reported cases and 55 reported fatalities due to the virus. On 11 May 2017, the Ministry of Public Health for the Democratic Republic of the Congo notified the WHO of an Ebola outbreak in the Likati health zone (LHZ) in Bas-Uele province, in the northern part of the country. Suspected infections were reported from Nambwa, Mouma, and Ngay. The LHZ borders the Central African Republic , which made this outbreak a moderate risk to the region. First time Marburg virus disease was detected in the country.The last strain Occurred in the Booué area with transport of patients to Libreville . The index case-patient was a hunter who lived in a forest timber camp . The disease was spread by close contact with infected persons. A dead chimpanzee found in the forest at the time was determined to be infected. The second strain Occurred in the districts of Mbomo and Kelle in the Cuvette-Ouest Department . The third strain Occurred in Mbomo and Mbandza villages, located in Mbomo District in the Cuvette-Ouest Department. On 8 May 2018, the government of the Democratic Republic of the Congo reported two confirmed cases of Ebola infection in the northwestern town of Bikoro . On 17 May, a case was confirmed in the city of Mbandaka . Health authorities were planning to ring vaccinate with rVSV-ZEBOV , a recently developed experimental Ebola vaccine , to contain the outbreak. The outbreak was ongoing as of 24 June 2018, in 2014 a different area of Equateur province was affected On 24 July 2018 the outbreak was declared over. On 1 August 2018, the Democratic Republic of the Congo Ministry of Health declared an outbreak when 4 individuals tested positive for the Ebola virus. On 11 June 2019, the WHO confirmed that a five-year-old boy in Uganda died after being diagnosed with Ebola. On 25 June 2020, the second biggest EVD outbreak ever was declared over. By 18 November 2020, the World Health Organization and the Congolese government had not received reports of any cases of Ebola in Équateur province or all of the DRC for 42 days. When the outbreak was declared over, there were 130 reported cases and 55 reported fatalities due to the virus. On 11 May 2017, the Ministry of Public Health for the Democratic Republic of the Congo notified the WHO of an Ebola outbreak in the Likati health zone (LHZ) in Bas-Uele province, in the northern part of the country. Suspected infections were reported from Nambwa, Mouma, and Ngay. The LHZ borders the Central African Republic , which made this outbreak a moderate risk to the region. First time Marburg virus disease was detected in the country.

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Guinea

Guinea ( / ˈ ɡ ɪ n i / ⓘ GHIN -ee ), [lower-alpha 1] officially the Republic of Guinea ( French : République de Guinée ), is a coastal country in West Africa . It borders the Atlantic Ocean to the west, Guinea-Bissau to the northwest, Senegal to the north, Mali to the northeast, Cote d'Ivoire to the southeast, and Sierra Leone and Liberia to the south. It is sometimes referred to as Guinea-Conakry after its capital Conakry , to distinguish it from other territories in the eponymous region such as Guinea-Bissau and Equatorial Guinea . Guinea has a population of 14 million and an area of 245,857 square kilometres (94,926 sq mi) . Formerly French Guinea , it achieved independence in 1958. Guinea has a history of military coups d'état . After decades of authoritarian rule, in 2010 it held its first democratic election . As it continued to hold multi-party elections, the country continued to face ethnic conflicts, corruption, and abuses by military and police. In 2011, the United States government claimed that torture by security forces and abuse of women and children (including female genital mutilation ) were ongoing human rights issues. In 2021, a military faction overthrew president Alpha Condé and suspended the constitution. Muslims represent 90% of the population. The country is divided into four geographic regions: Maritime Guinea on the Atlantic coast, the Fouta Djallon or Middle Guinea highlands, the Upper Guinea savanna region in the northeast, and the Guinée forestière region of tropical forests. French, the official language of Guinea, is a language of communication in schools, in government administration, and the media. More than 24 indigenous languages are spoken and the largest are Susu , Pular , and Maninka , which dominate respectively in Maritime Guinea, Fouta Djallon, and Upper Guinea, while Guinée forestière is ethnolinguistically diverse. Guinea's economy is mostly dependent on agriculture and mineral production. It is the world's second largest producer of bauxite , and has deposits of diamonds and gold. The country was at the core of the 2014 Ebola outbreak .Guinea is named after the Guinea region which lies along the Gulf of Guinea . It stretches north through the forested tropical regions and ends at the Sahel . The English term Guinea comes directly from the Portuguese word Guiné which emerged in the mid-15th century to refer to the lands inhabited by the Guineus , a generic term for the black African peoples south of the Senegal River , in contrast to the "tawny" Zenaga Berbers above it, whom they called Azengues or Moors . In 1978, the official name became the People's Revolutionary Republic of Guinea. In 1984, the country was renamed the Republic of Guinea after the death of the first president Ahmed Sékou Touré.The land that is now Guinea either bordered or was situated within a series of historic African empires before the French arrived in the 1890s and claimed the terrain as part of colonial French West Africa . Guinea declared independence from France on 2 October 1958. From independence until the presidential election of 2010, Guinea was governed by multiple autocratic rulers. What is now Guinea sat on the fringes of various West African empires. The earliest, the Ghana Empire , grew on trade and ultimately fell after repeated incursions of the Almoravids . It was in this period that Islam first arrived in the region by way of North African traders. The Sosso Empire (12th to 13th centuries) flourished in the resulting void, and the Mali Empire came to prominence when Soundiata Kéïta defeated the Sosso ruler Soumangourou Kanté at the Battle of Kirina , in c. 1235 . The Mali Empire was ruled by Mansa (Emperors), including Kankou Moussa who made a hajj to Mecca in 1324. After his reign, the Mali Empire began to decline and was ultimately supplanted by its vassal states in the 15th century. The Songhai Empire expanded its power from about 1460 and eventually surpassed the Mali Empire in both territory and wealth. It continued to prosper until a civil war, over succession, followed the death of Askia Daoud in 1582. The empire fell to invaders from Morocco at the Battle of Tondibi 3 years later. The Moroccans proved unable to rule the kingdom effectively and it split into smaller kingdoms. After the fall of some of the West African empires, various kingdoms existed in what is now Guinea. Fulani Muslims migrated to Futa Jallon in Central Guinea, and established an Islamic state from 1727 to 1896, with a written constitution and alternate rulers. The Wassoulou or Wassulu Empire (1878–1898) was led by Samori Toure in the predominantly Malinké area of what is now upper Guinea and southwestern Mali (Wassoulou). It moved to Ivory Coast before being conquered by the French. European traders competed for the cape trade from the 17th century onward and made inroads earlier. Slaves were exported to work elsewhere. The traders used the regional slave practices. Guinea's colonial period began with French military penetration into the area in the mid-19th century. French domination was assured by the defeat in 1898 of the armies of Samori Touré , Mansa (or Emperor) of the Ouassoulou state and leader of Malinké descent, which gave France control of what today is Guinea and adjacent areas. France negotiated Guinea's present boundaries in the late 19th and early 20th centuries with the British for Sierra Leone , the Portuguese for their Guinea colony (now Guinea-Bissau ), and Liberia . Under the French, the country formed the Territory of Guinea within French West Africa , administered by a governor general resident in Dakar . Lieutenant governors administered the individual colonies, including Guinea. In 1958, the French Fourth Republic collapsed due to political instability and its failures in dealing with its colonies, especially Indochina and Algeria . The French Fifth Republic gave the colonies the choice of autonomy in a new French Community or immediate independence, in the referendum of 28 September 1958. Unlike most other colonies, Guinea voted overwhelmingly for independence. It was led by Ahmed Sékou Touré whose Democratic Party of Guinea-African Democratic Rally (PDG) had won 56 of 60 seats in 1957 territorial elections. The French withdrew, and on 2 October 1958, Guinea proclaimed itself a sovereign and independent republic, with Sékou Touré as president. The Washington Post observed the "brutal" French tearing down all that they considered their contributions to Guinea: "In reaction, and as a warning to other French-speaking territories, the French pulled out of Guinea over a two-month period, taking everything they could with them. They unscrewed lightbulbs, removed plans for sewage pipelines in Conakry, the capital, and even burned medicines rather than leave them for the Guineans." Subsequently, Guinea aligned itself with the Soviet Union and adopted socialist policies. It then moved towards a Chinese model of socialism. It continued to receive investment from capitalist countries, such as the United States. By 1960, Touré had declared PDG the country's only legal political party, and for the next 24 years, the government and PDG were one. Touré was re-elected unopposed to 4 7-year terms as president, and every 5 years voters were presented with a single list of PDG candidates for the National Assembly. Advocating a hybrid African Socialism domestically and Pan-Africanism abroad, Touré became a polarising leader, with his government becoming intolerant of dissent, imprisoning thousands, and stifling the press. Throughout the 1960s, the Guinean government nationalised land, removed French-appointed and traditional chiefs from power, and had strained ties with the French government and French companies. Touré's government relied on the Soviet Union and China for infrastructure aid and development, and much of this was used for political and not economic purposes, such as the building of stadiums to hold political rallies. On 22 November 1970, Portuguese forces from neighbouring Portuguese Guinea staged Operation Green Sea , a raid on Conakry by several hundred exiled Guinean opposition forces. Among their goals, the Portuguese military wanted to kill or capture Sekou Touré due to his support of PAIGC , an independence movement and rebel group that had carried out attacks inside Portuguese Guinea from their bases in Guinea. After some fighting, the Portuguese-backed forces retreated, having freed several dozen Portuguese prisoners of war that were being held by PAIGC in Conakry, and without having ousted Touré. In the years after the raid, purges were carried out by the Touré government, and at least 50 thousand people were killed. Others were imprisoned and faced torture. Some foreigners were forced to leave the country, after having had their Guinean spouse arrested and their children placed into state custody. Guinea was elected as a non-permanent member of the UN Security Council 1972–73. In 1977, a declining economy, mass killings, a stifling political atmosphere, and a ban on all private economic transactions led to the Market Women's Revolt , a series of anti-government riots started by women working in Conakry's Madina Market . This prompted Touré to make major reforms. Touré vacillated from supporting the Soviet Union to supporting the United States. The late 1970s and early 1980s saw some economic reforms, while Touré's centralized control of the state remained. Regarding its relationship with France, after the election of Valéry Giscard d'Estaing as French president, trade increased and the two countries exchanged diplomatic visits. Sékou Touré died on 26 March 1984, after a heart operation in the United States, and was replaced by Prime Minister Louis Lansana Beavogui , who was to serve as interim president, pending new elections. PDG was due to elect a new leader on 3 April 1984. Under the constitution, that person would have been the only candidate for president. Hours before that meeting, Colonels Lansana Conté and Diarra Traoré seized power in a bloodless coup. Conté assumed the role of president, with Traoré serving as prime minister, until December. Conté denounced the previous regime's record on human rights, releasing 250 political prisoners and encouraging approximately 200 thousand more to return from exile. He made explicit the turn away from socialism. In 1992, Conté announced a return to civilian rule, with a presidential poll in 1993, followed by elections to parliament in 1995 (in which his party—the Party of Unity and Progress —won 71 of 114 seats.) In September 2001, the opposition leader Alpha Condé was imprisoned for endangering state security and pardoned 8 months later. Subsequently, he spent time in exile in France. In 2001, Conté organized and won a referendum to lengthen the presidential term, and in 2003, began his third term after elections were boycotted by the opposition. In January 2005, Conté survived a suspected assassination attempt while making a public appearance in the capital of Conakry . His opponents claimed that he was a "tired dictator", whose departure was inevitable, whereas his supporters believed that he was winning a battle with dissidents. According to Foreign Policy , Guinea was in danger of becoming a failed state . In 2000, Guinea suffered from the instability which had blighted the rest of West Africa, as rebels crossed the borders from Liberia and Sierra Leone . It seemed that the country was headed for civil war. Conté blamed neighbouring leaders for coveting Guinea's natural resources, and these claims were denied. In 2003, Guinea agreed to plans with her neighbours to tackle the insurgents. The 2007 Guinean general strike resulted in the appointment of a new prime minister. Conté remained in power until his death on 23 December 2008. Several hours after his death, Moussa Dadis Camara seized control in a coup , declaring himself head of a military junta . Protests against the coup became violent, and 157 people were killed when, on 28 September 2009, the junta ordered its soldiers to attack people gathered to protest Camara's attempt to become president. The soldiers went on a rampage of rape, mutilation, and murder, which caused some foreign governments to withdraw their support for the new regime. On 3 December 2009, an aide shot Camara during a dispute over the rampage in September. Camara went to Morocco for medical care. Vice-president (and defense minister) Sékouba Konaté flew from Lebanon to run the country. After meeting in Ouagadougou on 13 and 14 January 2010, Camara, Konaté and Blaise Compaoré , President of Burkina Faso , produced a formal statement of 12 principles promising a return of Guinea to civilian rule within 6 months. The presidential election of 27 June brought allegations of fraud, and a second election was held on 7 November. Voter turnout was "high", and the elections went "relatively smoothly". Alpha Condé , leader of the opposition party Rally of the Guinean People (RGP), won the election, promising to reform the security sector and review mining contracts. In February 2013, political violence erupted after street protests over transparency of upcoming May elections. The protests were fueled by the opposition coalition's decision to step down from the elections, in protest of the lack of transparency in the preparations for elections. 9 people were killed during the protests, and around 220 were injured. Some deaths and injuries were caused by security forces using live ammunition on protesters. The violence led to ethnic clashes between the Malinke and Fula , who supported and opposed President Condé, respectively. On 26 March 2013, the opposition party backed out of negotiations with the government over the election, saying that the government had not respected them, and had broken all agreements. On 25 March 2014, the World Health Organization stated that Guinea's Ministry of Health had reported an outbreak of Ebola virus disease in Guinea. This initial outbreak had 86 cases, including 59 deaths. By 28 May, there were 281 cases, with 186 deaths. It is believed that the first case was Emile Ouamouno, a 2-year-old boy in the village of Meliandou . He fell ill on 2 December 2013 and died on 6 December. On 18 September 2014, 8 members of an Ebola education health care team were murdered by villagers in the town of Womey . As of 1 November 2015, there had been 3,810 cases and 2,536 deaths in Guinea. Mass civil unrest and violent protests broke out against the rule of Alpha Conde on October 14, 2019, against constitutional changes. More than 800 were killed in clashes. After the 2020 Guinean presidential election , Alpha Condé's election to a third term was challenged by the opposition, who accused him of fraud. Condé claimed a constitutional referendum from March 2020 allowed him to run despite the 2-term limit. On 5 September 2021, after hours of gunfire near the presidential palace, Lieutenant Colonel Mamady Doumbouya seized control of state television and declared that President Alpha Conde 's government had been dissolved and the nation's borders closed. By the evening, the putschists declared control of all Conakry and the country's armed forces. According to Guinée Matin, by 6 September the military fully controlled the state administration and started to replace the civil administration with its military counterpart. The United Nations , European Union , African Union , ECOWAS (which suspended Guinea's membership) and La Francophonie denounced the coup, and called for President Condé's unconditional release. Similar responses came from some neighboring and Western countries (including the United States ), and from China (which relies on Guinea for half of its aluminum ore, facilitated by its connections to President Condé). Despite these, On 1 October 2021, Mamady Doumbouya was sworn in as interim President. On 11 May 2023, at least 7 people were shot dead in anti-government demonstrations in cities across Guinea. The anti-government movement became involved in peaceful protests and called on rulers to end military rule in Guinea and transition the country to democracy. On 18 December 2023, an explosion occurred at the country's main oil depot in Conakry , killing 24 people and causing extensive fuel shortages in the country in the following weeks. Existing civil and economic unrest in the country temporarily worsened as a result, with several confrontations between protestors and police in Conakry, increased fuel and travel costs, and general price inflation throughout the country.What is now Guinea sat on the fringes of various West African empires. The earliest, the Ghana Empire , grew on trade and ultimately fell after repeated incursions of the Almoravids . It was in this period that Islam first arrived in the region by way of North African traders. The Sosso Empire (12th to 13th centuries) flourished in the resulting void, and the Mali Empire came to prominence when Soundiata Kéïta defeated the Sosso ruler Soumangourou Kanté at the Battle of Kirina , in c. 1235 . The Mali Empire was ruled by Mansa (Emperors), including Kankou Moussa who made a hajj to Mecca in 1324. After his reign, the Mali Empire began to decline and was ultimately supplanted by its vassal states in the 15th century. The Songhai Empire expanded its power from about 1460 and eventually surpassed the Mali Empire in both territory and wealth. It continued to prosper until a civil war, over succession, followed the death of Askia Daoud in 1582. The empire fell to invaders from Morocco at the Battle of Tondibi 3 years later. The Moroccans proved unable to rule the kingdom effectively and it split into smaller kingdoms. After the fall of some of the West African empires, various kingdoms existed in what is now Guinea. Fulani Muslims migrated to Futa Jallon in Central Guinea, and established an Islamic state from 1727 to 1896, with a written constitution and alternate rulers. The Wassoulou or Wassulu Empire (1878–1898) was led by Samori Toure in the predominantly Malinké area of what is now upper Guinea and southwestern Mali (Wassoulou). It moved to Ivory Coast before being conquered by the French.European traders competed for the cape trade from the 17th century onward and made inroads earlier. Slaves were exported to work elsewhere. The traders used the regional slave practices. Guinea's colonial period began with French military penetration into the area in the mid-19th century. French domination was assured by the defeat in 1898 of the armies of Samori Touré , Mansa (or Emperor) of the Ouassoulou state and leader of Malinké descent, which gave France control of what today is Guinea and adjacent areas. France negotiated Guinea's present boundaries in the late 19th and early 20th centuries with the British for Sierra Leone , the Portuguese for their Guinea colony (now Guinea-Bissau ), and Liberia . Under the French, the country formed the Territory of Guinea within French West Africa , administered by a governor general resident in Dakar . Lieutenant governors administered the individual colonies, including Guinea. In 1958, the French Fourth Republic collapsed due to political instability and its failures in dealing with its colonies, especially Indochina and Algeria . The French Fifth Republic gave the colonies the choice of autonomy in a new French Community or immediate independence, in the referendum of 28 September 1958. Unlike most other colonies, Guinea voted overwhelmingly for independence. It was led by Ahmed Sékou Touré whose Democratic Party of Guinea-African Democratic Rally (PDG) had won 56 of 60 seats in 1957 territorial elections. The French withdrew, and on 2 October 1958, Guinea proclaimed itself a sovereign and independent republic, with Sékou Touré as president. The Washington Post observed the "brutal" French tearing down all that they considered their contributions to Guinea: "In reaction, and as a warning to other French-speaking territories, the French pulled out of Guinea over a two-month period, taking everything they could with them. They unscrewed lightbulbs, removed plans for sewage pipelines in Conakry, the capital, and even burned medicines rather than leave them for the Guineans." Subsequently, Guinea aligned itself with the Soviet Union and adopted socialist policies. It then moved towards a Chinese model of socialism. It continued to receive investment from capitalist countries, such as the United States. By 1960, Touré had declared PDG the country's only legal political party, and for the next 24 years, the government and PDG were one. Touré was re-elected unopposed to 4 7-year terms as president, and every 5 years voters were presented with a single list of PDG candidates for the National Assembly. Advocating a hybrid African Socialism domestically and Pan-Africanism abroad, Touré became a polarising leader, with his government becoming intolerant of dissent, imprisoning thousands, and stifling the press. Throughout the 1960s, the Guinean government nationalised land, removed French-appointed and traditional chiefs from power, and had strained ties with the French government and French companies. Touré's government relied on the Soviet Union and China for infrastructure aid and development, and much of this was used for political and not economic purposes, such as the building of stadiums to hold political rallies. On 22 November 1970, Portuguese forces from neighbouring Portuguese Guinea staged Operation Green Sea , a raid on Conakry by several hundred exiled Guinean opposition forces. Among their goals, the Portuguese military wanted to kill or capture Sekou Touré due to his support of PAIGC , an independence movement and rebel group that had carried out attacks inside Portuguese Guinea from their bases in Guinea. After some fighting, the Portuguese-backed forces retreated, having freed several dozen Portuguese prisoners of war that were being held by PAIGC in Conakry, and without having ousted Touré. In the years after the raid, purges were carried out by the Touré government, and at least 50 thousand people were killed. Others were imprisoned and faced torture. Some foreigners were forced to leave the country, after having had their Guinean spouse arrested and their children placed into state custody. Guinea was elected as a non-permanent member of the UN Security Council 1972–73. In 1977, a declining economy, mass killings, a stifling political atmosphere, and a ban on all private economic transactions led to the Market Women's Revolt , a series of anti-government riots started by women working in Conakry's Madina Market . This prompted Touré to make major reforms. Touré vacillated from supporting the Soviet Union to supporting the United States. The late 1970s and early 1980s saw some economic reforms, while Touré's centralized control of the state remained. Regarding its relationship with France, after the election of Valéry Giscard d'Estaing as French president, trade increased and the two countries exchanged diplomatic visits. Sékou Touré died on 26 March 1984, after a heart operation in the United States, and was replaced by Prime Minister Louis Lansana Beavogui , who was to serve as interim president, pending new elections. PDG was due to elect a new leader on 3 April 1984. Under the constitution, that person would have been the only candidate for president. Hours before that meeting, Colonels Lansana Conté and Diarra Traoré seized power in a bloodless coup. Conté assumed the role of president, with Traoré serving as prime minister, until December. Conté denounced the previous regime's record on human rights, releasing 250 political prisoners and encouraging approximately 200 thousand more to return from exile. He made explicit the turn away from socialism. In 1992, Conté announced a return to civilian rule, with a presidential poll in 1993, followed by elections to parliament in 1995 (in which his party—the Party of Unity and Progress —won 71 of 114 seats.) In September 2001, the opposition leader Alpha Condé was imprisoned for endangering state security and pardoned 8 months later. Subsequently, he spent time in exile in France. In 2001, Conté organized and won a referendum to lengthen the presidential term, and in 2003, began his third term after elections were boycotted by the opposition. In January 2005, Conté survived a suspected assassination attempt while making a public appearance in the capital of Conakry . His opponents claimed that he was a "tired dictator", whose departure was inevitable, whereas his supporters believed that he was winning a battle with dissidents. According to Foreign Policy , Guinea was in danger of becoming a failed state . In 2000, Guinea suffered from the instability which had blighted the rest of West Africa, as rebels crossed the borders from Liberia and Sierra Leone . It seemed that the country was headed for civil war. Conté blamed neighbouring leaders for coveting Guinea's natural resources, and these claims were denied. In 2003, Guinea agreed to plans with her neighbours to tackle the insurgents. The 2007 Guinean general strike resulted in the appointment of a new prime minister. Conté remained in power until his death on 23 December 2008. Several hours after his death, Moussa Dadis Camara seized control in a coup , declaring himself head of a military junta . Protests against the coup became violent, and 157 people were killed when, on 28 September 2009, the junta ordered its soldiers to attack people gathered to protest Camara's attempt to become president. The soldiers went on a rampage of rape, mutilation, and murder, which caused some foreign governments to withdraw their support for the new regime. On 3 December 2009, an aide shot Camara during a dispute over the rampage in September. Camara went to Morocco for medical care. Vice-president (and defense minister) Sékouba Konaté flew from Lebanon to run the country. After meeting in Ouagadougou on 13 and 14 January 2010, Camara, Konaté and Blaise Compaoré , President of Burkina Faso , produced a formal statement of 12 principles promising a return of Guinea to civilian rule within 6 months. The presidential election of 27 June brought allegations of fraud, and a second election was held on 7 November. Voter turnout was "high", and the elections went "relatively smoothly". Alpha Condé , leader of the opposition party Rally of the Guinean People (RGP), won the election, promising to reform the security sector and review mining contracts. In February 2013, political violence erupted after street protests over transparency of upcoming May elections. The protests were fueled by the opposition coalition's decision to step down from the elections, in protest of the lack of transparency in the preparations for elections. 9 people were killed during the protests, and around 220 were injured. Some deaths and injuries were caused by security forces using live ammunition on protesters. The violence led to ethnic clashes between the Malinke and Fula , who supported and opposed President Condé, respectively. On 26 March 2013, the opposition party backed out of negotiations with the government over the election, saying that the government had not respected them, and had broken all agreements. On 25 March 2014, the World Health Organization stated that Guinea's Ministry of Health had reported an outbreak of Ebola virus disease in Guinea. This initial outbreak had 86 cases, including 59 deaths. By 28 May, there were 281 cases, with 186 deaths. It is believed that the first case was Emile Ouamouno, a 2-year-old boy in the village of Meliandou . He fell ill on 2 December 2013 and died on 6 December. On 18 September 2014, 8 members of an Ebola education health care team were murdered by villagers in the town of Womey . As of 1 November 2015, there had been 3,810 cases and 2,536 deaths in Guinea. Mass civil unrest and violent protests broke out against the rule of Alpha Conde on October 14, 2019, against constitutional changes. More than 800 were killed in clashes. After the 2020 Guinean presidential election , Alpha Condé's election to a third term was challenged by the opposition, who accused him of fraud. Condé claimed a constitutional referendum from March 2020 allowed him to run despite the 2-term limit. On 5 September 2021, after hours of gunfire near the presidential palace, Lieutenant Colonel Mamady Doumbouya seized control of state television and declared that President Alpha Conde 's government had been dissolved and the nation's borders closed. By the evening, the putschists declared control of all Conakry and the country's armed forces. According to Guinée Matin, by 6 September the military fully controlled the state administration and started to replace the civil administration with its military counterpart. The United Nations , European Union , African Union , ECOWAS (which suspended Guinea's membership) and La Francophonie denounced the coup, and called for President Condé's unconditional release. Similar responses came from some neighboring and Western countries (including the United States ), and from China (which relies on Guinea for half of its aluminum ore, facilitated by its connections to President Condé). Despite these, On 1 October 2021, Mamady Doumbouya was sworn in as interim President. On 11 May 2023, at least 7 people were shot dead in anti-government demonstrations in cities across Guinea. The anti-government movement became involved in peaceful protests and called on rulers to end military rule in Guinea and transition the country to democracy. On 18 December 2023, an explosion occurred at the country's main oil depot in Conakry , killing 24 people and causing extensive fuel shortages in the country in the following weeks. Existing civil and economic unrest in the country temporarily worsened as a result, with several confrontations between protestors and police in Conakry, increased fuel and travel costs, and general price inflation throughout the country.Guinea shares a border with Guinea-Bissau to the northwest , Senegal to the north , Mali to the northeast , Ivory Coast to the east , Sierra Leone to the southwest and Liberia to the south . The nation forms a crescent as it curves from its southeast region to the north and west, to its northwest border with Guinea-Bissau and southwestern coast on the Atlantic Ocean. The sources of the Niger River , the Gambia River , and the Senegal River are all found in the Guinea Highlands . At 245,857 km 2 (94,926 sq mi) , Guinea is roughly the size of the United Kingdom. There are 320 km (200 mi) of coastline and a total land border of 3,400 km (2,100 mi) . It lies mostly between latitudes 7° and 13°N , and longitudes 7° and 15°W , with a smaller area that is west of 15°. Guinea is divided into 4 regions: Maritime Guinea , also known as Lower Guinea or the Basse-Coté lowlands, populated mainly by the Susu ethnic group; the cooler, more mountainous Fouta Djallon that run roughly north–south through the middle of the country, populated by Fulas; the Sahelian Haute-Guinea to the northeast, populated by Malinké ; and the forested jungle regions in the southeast, with several ethnic groups. Guinea's mountains are the source for the Niger, the Gambia, and Senegal Rivers, and rivers flowing to the sea on the west side of the range in Sierra Leone and Ivory Coast. The highest point in Guinea is Mount Nimba at 1,752 m (5,748 ft) . While the Guinean and Ivorian sides of the Nimba Massif are a UNESCO Strict Nature Reserve , the portion of the so-called Guinean Backbone continues into Liberia , where it has been mined for decades; the damage is evident in the Nzérékoré Region at 7°32′17″N 8°29′50″W / 7.53806°N 8.49722°W / 7.53806; -8.49722 . Guinea is home to 5 ecoregions: Guinean montane forests , Western Guinean lowland forests , Guinean forest-savanna mosaic , West Sudanian savanna , and Guinean mangroves . It had a 2019 Forest Landscape Integrity Index mean score of 4.9/10, ranking it 114th globally out of 172 countries. The southern part of Guinea lies within the Guinean Forests of West Africa Biodiversity hotspot , while the north-east is characterized by dry savanna woodlands. Declining populations of some animals are restricted to uninhabited distant parts of parks and reserves. Species found in Guinea include the following: The Republic of Guinea covers 245,857 square kilometres (94,926 sq mi) of West Africa, about 10 degrees north of the equator. It is divided into 4 natural regions with distinct human, geographic, and climatic characteristics: Guinea is divided into 8 administrative regions which are subdivided into 33 prefectures . The capital Conakry with a population of 1,675,069 ranks as a special zone.The southern part of Guinea lies within the Guinean Forests of West Africa Biodiversity hotspot , while the north-east is characterized by dry savanna woodlands. Declining populations of some animals are restricted to uninhabited distant parts of parks and reserves. Species found in Guinea include the following:The Republic of Guinea covers 245,857 square kilometres (94,926 sq mi) of West Africa, about 10 degrees north of the equator. It is divided into 4 natural regions with distinct human, geographic, and climatic characteristics: Guinea is divided into 8 administrative regions which are subdivided into 33 prefectures . The capital Conakry with a population of 1,675,069 ranks as a special zone.Guinea is a republic. The president is directly elected by the people and is the head of state and the head of government . The unicameral National Assembly is the legislative body of the country, and its members are directly elected by the people. The judicial branch is headed by the Supreme Court of Guinea , the highest and final court of appeal in the country. The National Assembly of Guinea , the country's legislative body, did not meet from 2008 to 2013, when it was dissolved after the military coup in December. Elections have been postponed multiple times since 2007. In April 2012, President Condé postponed the elections indefinitely, citing the need to ensure that they were "transparent and democratic". The 2013 Guinean legislative election was held on 24 September. President Alpha Condé 's party, the Rally of the Guinean People (RPG), won a plurality of seats in the National Assembly of Guinea , with 53 out of 114 seats. The opposition parties won a total of 53 seats, and opposition leaders denounced the official results as fraudulent. The president of Guinea is normally elected by popular vote for a 5-year term; the winning candidate must receive a majority of the votes cast to be elected president. The president governs Guinea, assisted by a council of 25 civilian ministers , appointed by him. The government administers the country through 8 regions, 33 prefectures , over 100 subprefectures , and districts (known as communes in Conakry and other cities and villages, or quartiers in the interior). District-level leaders are elected; the president appoints officials to all other levels of the centralized administration. Former President Alpha Condé derived support from Guinea's second-largest ethnic group, the Malinke . Guinea's opposition was backed by the Fula ethnic group, who account for around 33.4% of the population. Guinea is a member of the African Union , Agency for the French-Speaking Community , African Development Bank , Economic Community of West African States , World Bank , Islamic Development Bank , IMF , and the United Nations . According to a February 2009 U.S. Department of State statement, Guinea's foreign relations, including those with its West African neighbours, had improved steadily since 1985. The Department's October 2018 statement indicated that—although "the U.S. condemned" Guinea's "2008 military coup d'etat,"—the U.S. had "close relations" with Guinea before the coup, and after "Guinea's presidential elections in 2010, the United States re-established strong diplomatic relations with the government." The statement indicated support for the "legislative elections in 2013 and a second presidential election in 2015," as signs of "democratic reform." A March 2021 report by the U.S. State Department blasted extensive human rights violations by the government, security forces and businesses in Guinea. The report cited extensive international criticism of the recent national elections, which yielded "President Alpha Conde's re-election (despite disputed results)... following a controversial March referendum amending the constitution and allowing him to run for a third term." The Department condemned the 2021 coup, warning that "violence and any extra-constitutional measures will only erode Guinea's prospects for peace, stability, and prosperity, [and] could limit the ability of the United States and Guinea's other international partners to support the country...," While not explicitly calling for President Condé's return to power, the U.S. called for "national dialogue to address concerns sustainably and transparently to enable a peaceful and democratic way forward for Guinea..." The United Nations promptly denounced the 2021 coup, and some of Guinea's allies condemned the coup. The African Union and West Africa's regional bloc ( ECOWAS ), both threatened sanctions—while some analysts expect the threats to be of limited effect because Guinea is not a member of the West African currency union, and is not a landlocked country. ECOWAS promptly suspended Guinea's membership, and demanded the unconditional release of President Condé, while sending envoys to Conakry to attempt a "constitutional" resolution of the situation. Uncharacteristically responding to another nation's internal affairs, China (which relies on Guinea for half of its aluminium ore, facilitated by connections to ousted President Condé) openly opposed the coup. Guinea's armed forces are divided into 5 branches—army, navy, air force, the paramilitary National Gendarmerie and the Republican Guard—whose chiefs report to the Chairman of the Joint Chiefs of Staff who is subordinate to the Minister of Defence. In addition, regime security forces include the National Police Force (Sûreté Nationale). The Gendarmerie, responsible for internal security, has a strength of several thousand. The army, with about 15,000 personnel, is by far the largest branch of the armed forces and is mainly responsible for protecting the state borders, the security of administered territories, and defending Guinea's national interests. Air force personnel total about 700. Its equipment includes several Russian-supplied fighter planes and transports. The navy has about 900 personnel and operates several small patrol craft and barges. Homosexuality is illegal in Guinea. The prime minister declared in 2010 that he does not consider sexual orientation a legitimate human right. Guinea has one of the world's highest rates of female genital mutilation (FGM, sometimes referred to as 'female circumcision') according to Anastasia Gage, an associate professor at Tulane University , and Ronan van Rossem, an associate professor at Ghent University . Female genital mutilation in Guinea had been performed on more than 98% of women as of 2009 [ update ] . In Guinea "almost all cultures, religions, and ethnicities" practice female genital mutilation. The 2005 Demographic and Health Survey reported that 96% of women have gone through the operation. Guinea is a member of the African Union , Agency for the French-Speaking Community , African Development Bank , Economic Community of West African States , World Bank , Islamic Development Bank , IMF , and the United Nations . According to a February 2009 U.S. Department of State statement, Guinea's foreign relations, including those with its West African neighbours, had improved steadily since 1985. The Department's October 2018 statement indicated that—although "the U.S. condemned" Guinea's "2008 military coup d'etat,"—the U.S. had "close relations" with Guinea before the coup, and after "Guinea's presidential elections in 2010, the United States re-established strong diplomatic relations with the government." The statement indicated support for the "legislative elections in 2013 and a second presidential election in 2015," as signs of "democratic reform." A March 2021 report by the U.S. State Department blasted extensive human rights violations by the government, security forces and businesses in Guinea. The report cited extensive international criticism of the recent national elections, which yielded "President Alpha Conde's re-election (despite disputed results)... following a controversial March referendum amending the constitution and allowing him to run for a third term." The Department condemned the 2021 coup, warning that "violence and any extra-constitutional measures will only erode Guinea's prospects for peace, stability, and prosperity, [and] could limit the ability of the United States and Guinea's other international partners to support the country...," While not explicitly calling for President Condé's return to power, the U.S. called for "national dialogue to address concerns sustainably and transparently to enable a peaceful and democratic way forward for Guinea..." The United Nations promptly denounced the 2021 coup, and some of Guinea's allies condemned the coup. The African Union and West Africa's regional bloc ( ECOWAS ), both threatened sanctions—while some analysts expect the threats to be of limited effect because Guinea is not a member of the West African currency union, and is not a landlocked country. ECOWAS promptly suspended Guinea's membership, and demanded the unconditional release of President Condé, while sending envoys to Conakry to attempt a "constitutional" resolution of the situation. Uncharacteristically responding to another nation's internal affairs, China (which relies on Guinea for half of its aluminium ore, facilitated by connections to ousted President Condé) openly opposed the coup. Guinea's armed forces are divided into 5 branches—army, navy, air force, the paramilitary National Gendarmerie and the Republican Guard—whose chiefs report to the Chairman of the Joint Chiefs of Staff who is subordinate to the Minister of Defence. In addition, regime security forces include the National Police Force (Sûreté Nationale). The Gendarmerie, responsible for internal security, has a strength of several thousand. The army, with about 15,000 personnel, is by far the largest branch of the armed forces and is mainly responsible for protecting the state borders, the security of administered territories, and defending Guinea's national interests. Air force personnel total about 700. Its equipment includes several Russian-supplied fighter planes and transports. The navy has about 900 personnel and operates several small patrol craft and barges.Homosexuality is illegal in Guinea. The prime minister declared in 2010 that he does not consider sexual orientation a legitimate human right. Guinea has one of the world's highest rates of female genital mutilation (FGM, sometimes referred to as 'female circumcision') according to Anastasia Gage, an associate professor at Tulane University , and Ronan van Rossem, an associate professor at Ghent University . Female genital mutilation in Guinea had been performed on more than 98% of women as of 2009 [ update ] . In Guinea "almost all cultures, religions, and ethnicities" practice female genital mutilation. The 2005 Demographic and Health Survey reported that 96% of women have gone through the operation. The agriculture sector at some point employed approximately 75% of the country. The rice is cultivated in the flooded zones between streams and rivers. The local production of rice is not sufficient to feed the country, so rice is imported from Asia. The sector cultivates coffee beans, pineapples, peaches, nectarines, mangoes , oranges, bananas, potatoes, tomatoes, cucumbers, pepper, and other types of produce. Guinea is one of the emerging regional producers of apples and pears. There are plantations of grapes, pomegranates, and more recent years have seen the development of strawberry plantations, based on the vertical hydroponic system. Soil, water, and climatic conditions provide opportunities for irrigated farming and agro industry. Other industries include processing plants for beer, juices, soft drinks and tobacco. Guinea has 25% or more of the world's known bauxite reserves. It has diamonds, gold, and other metals. Bauxite and alumina are the most major exports. Guinea possesses over 25 billion tonnes (metric tons) of bauxite – and perhaps up to one half of the world's reserves. Its mineral wealth includes more than 4-billion tonnes of high-grade iron ore, and diamond and gold deposits, and uranium . Possibilities for investment and commercial activities exist in all these areas, and Guinea's "poorly developed infrastructure and rampant corruption continue to present obstacles to large-scale investment projects". Joint venture bauxite mining and alumina operations in north-west Guinea historically provide about 80% of Guinea's Foreign exchange reserves . Bauxite is refined into alumina , which is later smelted into aluminium. The Compagnie des Bauxites de Guinée (CBG) exports about 14 million tonnes of high-grade bauxite annually. CBG is a joint venture, 49% owned by the Guinean government and 51% by an international consortium known as Halco Mining Inc., itself a joint venture controlled by aluminium producer Alcoa (AA), global miner Rio Tinto Group and Dadco Investments. CBG has exclusive rights to bauxite reserves and resources in north-western Guinea, through 2038. In 2008, protesters upset about poor electrical services blocked the tracks CBG uses. Guinea includes a proviso in its agreements with international oil companies, requiring its partners to generate power for nearby communities. The Compagnie des Bauxites de Kindia (CBK), a joint venture between the government of Guinea and RUSAL , produces some 2.5 million tonnes annually, nearly all of which is exported to Russia and Eastern Europe. Dian Dian , a Guinean/ Ukrainian joint bauxite venture, has a projected production rate of 1,000,000 t (1,102,311 short tons ; 984,207 long tons ) per year, and is not expected to begin operation for several years. The Alumina Compagnie de Guinée (ACG) which took over the former Friguia Consortium produced about 2.4 million tonnes in 2004, as raw material for its alumina refinery. The refinery exports about 750,000 tonnes of alumina. Both Global Alumina and Alcoa-Alcan have signed conventions with the government of Guinea to build large alumina refineries, with a combined capacity of about 4 million tonnes per year. The Simandou mine is an iron ore reserve. In March 2010, Anglo-Australian corporation Rio Tinto Group and its biggest shareholder, Aluminum Corporation of China Limited (Chinalco), signed a preliminary agreement to develop Rio Tinto's iron ore project. In 2017, the Serious Fraud Office (SFO), Britain's anti-fraud regulator, launched an official investigation into Rio Tinto's business and mining practices in Guinea. Tigui Camara , a former model, is the first woman in Guinea to own a mining company which is partially run as a social enterprise. In 2006, Guinea signed a production sharing agreement with Hyperdynamics Corporation of Houston to explore an offshore tract, and was then in partnership with Dana Petroleum PLC ( Aberdeen , United Kingdom). The initial well, the Sabu-1, was scheduled to begin drilling in October 2011, at a site in approximately 700 metres of water. The Sabu-1 targeted a 4-way anticline prospect with upper Cretaceous sands, and was anticipated to be drilled to a total depth of 3,600 meters. Following the completion of exploratory drilling in 2012, the Sabu-1 well was not deemed commercially viable. In November 2012, Hyperdynamics subsidiary SCS reached an agreement for a sale of 40% of the concession to Tullow Oil , bringing ownership shares in the Guinea offshore tract to 37% Hyperdynamics, 40% Tullow Oil, and 23% Dana Petroleum. Hyperdynamics will have until September 2016, under the current agreement, to begin drilling its next selected site, the Fatala Cenomanian turbidite fan prospect. Among the attractions in Guinea are the waterfalls found mostly in the Basse Guinee (Lower Guinea) and Moyenne Guinee (Middle Guinea) regions. The Soumba cascade at the foot of Mount Kakoulima in Kindia, Voile de la Mariée (Bride's Veil) in Dubreka, the Kinkon cascades that are about 80 m (260 ft) high on the Kokoula River in the prefecture of Pita, the Kambadaga falls that can reach 100 m (330 ft) during the rainy season on the same river, the Ditinn & Mitty waterfalls in Dalaba, and the Fetoré waterfalls and the stone bridge in the region of Labe are among water-related tourist sites.The agriculture sector at some point employed approximately 75% of the country. The rice is cultivated in the flooded zones between streams and rivers. The local production of rice is not sufficient to feed the country, so rice is imported from Asia. The sector cultivates coffee beans, pineapples, peaches, nectarines, mangoes , oranges, bananas, potatoes, tomatoes, cucumbers, pepper, and other types of produce. Guinea is one of the emerging regional producers of apples and pears. There are plantations of grapes, pomegranates, and more recent years have seen the development of strawberry plantations, based on the vertical hydroponic system. Soil, water, and climatic conditions provide opportunities for irrigated farming and agro industry. Other industries include processing plants for beer, juices, soft drinks and tobacco.Guinea has 25% or more of the world's known bauxite reserves. It has diamonds, gold, and other metals. Bauxite and alumina are the most major exports.Guinea possesses over 25 billion tonnes (metric tons) of bauxite – and perhaps up to one half of the world's reserves. Its mineral wealth includes more than 4-billion tonnes of high-grade iron ore, and diamond and gold deposits, and uranium . Possibilities for investment and commercial activities exist in all these areas, and Guinea's "poorly developed infrastructure and rampant corruption continue to present obstacles to large-scale investment projects". Joint venture bauxite mining and alumina operations in north-west Guinea historically provide about 80% of Guinea's Foreign exchange reserves . Bauxite is refined into alumina , which is later smelted into aluminium. The Compagnie des Bauxites de Guinée (CBG) exports about 14 million tonnes of high-grade bauxite annually. CBG is a joint venture, 49% owned by the Guinean government and 51% by an international consortium known as Halco Mining Inc., itself a joint venture controlled by aluminium producer Alcoa (AA), global miner Rio Tinto Group and Dadco Investments. CBG has exclusive rights to bauxite reserves and resources in north-western Guinea, through 2038. In 2008, protesters upset about poor electrical services blocked the tracks CBG uses. Guinea includes a proviso in its agreements with international oil companies, requiring its partners to generate power for nearby communities. The Compagnie des Bauxites de Kindia (CBK), a joint venture between the government of Guinea and RUSAL , produces some 2.5 million tonnes annually, nearly all of which is exported to Russia and Eastern Europe. Dian Dian , a Guinean/ Ukrainian joint bauxite venture, has a projected production rate of 1,000,000 t (1,102,311 short tons ; 984,207 long tons ) per year, and is not expected to begin operation for several years. The Alumina Compagnie de Guinée (ACG) which took over the former Friguia Consortium produced about 2.4 million tonnes in 2004, as raw material for its alumina refinery. The refinery exports about 750,000 tonnes of alumina. Both Global Alumina and Alcoa-Alcan have signed conventions with the government of Guinea to build large alumina refineries, with a combined capacity of about 4 million tonnes per year. The Simandou mine is an iron ore reserve. In March 2010, Anglo-Australian corporation Rio Tinto Group and its biggest shareholder, Aluminum Corporation of China Limited (Chinalco), signed a preliminary agreement to develop Rio Tinto's iron ore project. In 2017, the Serious Fraud Office (SFO), Britain's anti-fraud regulator, launched an official investigation into Rio Tinto's business and mining practices in Guinea. Tigui Camara , a former model, is the first woman in Guinea to own a mining company which is partially run as a social enterprise. In 2006, Guinea signed a production sharing agreement with Hyperdynamics Corporation of Houston to explore an offshore tract, and was then in partnership with Dana Petroleum PLC ( Aberdeen , United Kingdom). The initial well, the Sabu-1, was scheduled to begin drilling in October 2011, at a site in approximately 700 metres of water. The Sabu-1 targeted a 4-way anticline prospect with upper Cretaceous sands, and was anticipated to be drilled to a total depth of 3,600 meters. Following the completion of exploratory drilling in 2012, the Sabu-1 well was not deemed commercially viable. In November 2012, Hyperdynamics subsidiary SCS reached an agreement for a sale of 40% of the concession to Tullow Oil , bringing ownership shares in the Guinea offshore tract to 37% Hyperdynamics, 40% Tullow Oil, and 23% Dana Petroleum. Hyperdynamics will have until September 2016, under the current agreement, to begin drilling its next selected site, the Fatala Cenomanian turbidite fan prospect. Among the attractions in Guinea are the waterfalls found mostly in the Basse Guinee (Lower Guinea) and Moyenne Guinee (Middle Guinea) regions. The Soumba cascade at the foot of Mount Kakoulima in Kindia, Voile de la Mariée (Bride's Veil) in Dubreka, the Kinkon cascades that are about 80 m (260 ft) high on the Kokoula River in the prefecture of Pita, the Kambadaga falls that can reach 100 m (330 ft) during the rainy season on the same river, the Ditinn & Mitty waterfalls in Dalaba, and the Fetoré waterfalls and the stone bridge in the region of Labe are among water-related tourist sites.Guinea was ranked 128th out of 132 in the Global Innovation Index in 2023. Ahmed Sékou Touré International Airport is the largest airport in the country, with flights to other cities in Africa and to Europe. Built between 1904 and 1910, a railway once linked Conakry to Kankan via Kouroussa ceased operating in 1995 and had been dismantled altogether by 2007 with rails mostly stolen and/or sold for scrap. Plans had at one time been mooted for the passenger line to be rehabilitated as part of an iron-ore development master plan and while the start of work was announced in 2010, corruption charges led the whole master plan to be paused and the line was rebuilt as a 105 km mineral railway, paralleling the older route as far as the mines of Kalia . There is a state run mineral railway linking the bauxite mines of Sangarédi to the port of Kamsar (137 km) and a 1960s narrow-gauge line operated by Russian aluminium producer RusAl to the mines at Fria (143 km). As part of the plans to restart iron ore mining at Simandou blocks 1 and 2, the new development consortium pledged in 2019 to fund the construction of a new heavy-duty standard gauge railway to Matakong on the Atlantic coast where they would invest some US$20 billion in developing a deepwater port. The 650 km route is longer than an alternative heading south to the port of Buchanan, Liberia , which was considered as an alternative in an October 2019 feasibility study. However, the Matakong route would be entirely within Guinea and tied to an agricultural development corridor for citizens along the route. Some vehicles in Guinea are more than 20 years old, and cabs are any 4-door vehicle which the owner has designated as being for hire. Locals, nearly entirely without vehicles of their own, rely upon these taxis (which charge per seat) and small buses to take them around town and across the country. They also rely on motorcycles, of which some operate as a taxi service. Horses and donkeys pull carts, primarily to transport construction materials.In 2021, the population of Guinea was estimated to be 13.5 million. Conakry , the capital and most populous city, is a hub of economy, commerce, education, and culture. In 2014, the total fertility rate (TFR) of Guinea was estimated at 4.93 children born per woman. Many languages are spoken in Guinea . The official language is French . Pular was the native language of 33.9% of the population in 2018, followed by Mandingo with 29.4%. The third most spoken native language is the Susu , spoken by 21.2% of the population in 2018 as their first language. The remainder of the population has other native languages, including Kissi and Kpelle . The population of Guinea comprises about 24 ethnic groups. The Mandinka , also known as Mandingo or Malinké, comprise 29.4% of the population and are mostly found in eastern Guinea concentrated around the Kankan and Kissidougou prefectures. The Fulas or Fulani , comprise 33.4% of the population and are mostly found in the Futa Djallon region. The Soussou , comprising 21.2% of the population, are predominantly in western areas around the capital Conakry , Forécariah , and Kindia . Smaller ethnic groups make up the remaining 16% of the population, including Kpelle , Kissi , Zialo , Toma and others. In 2017 approximately 10,000 non-Africans lived in Guinea, predominantly Lebanese, French, and other Europeans. In 2023, the Association of Religion Date Archives (ARDA) noted that the population was made up of Muslims at 86.8%, Christian 3.52%, and Animist 9.42%. In the past Muslims and Christians have incorporated indigenous African beliefs into their outlook. The majority of Guinean Muslims are adherent to Sunni Islam , of the Maliki school of jurisprudence, influenced by Sufism . Christian groups include Roman Catholics , Anglicans , Baptists , Seventh-day Adventists , and Evangelical groups. Jehovah's Witnesses are active in the country and recognized by the Government. There is a Bahá'í Faith community. There are numbers of Hindus , Buddhists , and traditional Chinese religious groups among the expatriate community. There were three days of ethno-religious fighting in the city of Nzerekore in July 2013. Fighting between ethnic Kpelle who are Christian or animist, and ethnic Konianke who are Muslims and close to the larger Malinke ethnic group, left at least 54 dead. The dead included people who were killed with machetes and burned alive. The violence ended after the Guinean military imposed a curfew, and President Conde made a televised appeal for calm. In 2021, violence was limited to Kendoumaya, Lower Guinea, and mainly concerned a land rights dispute between locals and a monastery. In 2010 it was estimated that 41% of adults were literate (52% of males and 30% of females). Primary education is compulsory for 6 years. In 1999, primary school attendance was 40% and children, particularly girls, were kept out of school to assist their parents with domestic work or agriculture, or to be married. In 2015 Guinea had "one of the highest rates" of child marriage in the world, although in 2023 they are no longer in the top 5. In 2014, an outbreak of the Ebola virus occurred in Guinea . In response, the health ministry banned the sale and consumption of bats , thought to be carriers of the disease. The virus eventually spread from rural areas to Conakry, and by June 2014 had spread to neighbouring countries - Sierra Leone and Liberia. In August 2014 Guinea closed its borders to Sierra Leone and Liberia to help contain the spread of the virus, as more new cases of the disease were being reported in those countries than in Guinea. The outbreak began in December in a village called Meliandou, southeastern Guinea, near the borders with Liberia and Sierra Leone. The first known case involved a 2-year-old child who died, after fever and vomiting and passing black stool, on 6 December. The child's mother died a week later, then a sister and a grandmother, all with symptoms that included fever, vomiting, and diarrhoea. Then, by way of care-giving visits or attendance at funerals, the outbreak spread to other villages. "Unsafe burials" is a source of the transmission of the disease. The World Health Organization (WHO) reported that the inability to engage with local communities hindered the ability of health workers to trace the origins and strains of the virus. While WHO terminated the Public Health Emergency of International Concern (PHEIC) on 29 March 2016, the Ebola Situation Report released on 30 March confirmed 5 more cases in the preceding 2 weeks, with viral sequencing relating 1 of the cases to the November 2014 outbreak. The Ebola epidemic affected the treatment of other diseases in Guinea. Healthcare visits by the population declined due to fear of infection and to mistrust in the health-care system, and the system's ability to provide routine health-care and HIV/AIDS treatments decreased due to the Ebola outbreak. Ebola re-emerged in Guinea in January–February 2021. The 2021 maternal mortality rate per 100,000 births for Guinea is 576. This is compared with 680 in 2010, 859.9 in 2008 and 964.7 in 1990. The under 5 mortality rate, per 1,000 births is 146 and the neonatal mortality as a percentage of under 5's mortality is 29. In Guinea the number of midwives per 1,000 live births is 1 and the lifetime risk of death for pregnant women is 1 in 26. Guinea has the second highest prevalence of female genital mutilation in the world. An estimated 170,000 adults and children were infected at the end of 2004. Surveillance surveys conducted in 2001 and 2002 show higher rates of HIV in urban areas than in rural areas. Prevalence was highest in Conakry (5%) and in the cities of the Forest Guinea region (7%) bordering Côte d'Ivoire , Liberia , and Sierra Leone . HIV is spread primarily through multiple-partner intercourse. Men and women are at nearly equal risk for HIV, with people aged 15 to 24 most vulnerable. Surveillance figures from 2001 to 2002 show the rates among commercial sex workers (42%), active military personnel (6.6%), truck drivers and bush taxi drivers (7.3%), miners (4.7%), and adults with tuberculosis (8.6%). Several factors were attributed to what fuel the HIV/AIDS epidemic in Guinea. They include unprotected sex, multiple sexual partners, illiteracy, endemic poverty, unstable borders, refugee migration, lack of civic responsibility, and scarce medical care and public services. A 2012 study reported malnutrition rates with levels ranging from 34% to 40% by region, and acute malnutrition rates above 10% in Upper Guinea's mining zones. The survey showed that 139,200 children underwent acute malnutrition, 609,696 underwent chronic malnutrition and further 1,592,892 have anemia. Degradation of care practices, limited access to medical services, inadequate hygiene practices and a lack of food diversity were said to explain these levels. Malaria is transmitted year-round, with peak transmission from July through October. It is a cause of disability in Guinea. The first case of COVID-19 was reported in Guinea on 13 March 2020 . By the end of 2020 the total number of confirmed cases was 13,722. Of these, 13,141 had recovered, 500 were active, and 81 people had died. In 2023, the Association of Religion Date Archives (ARDA) noted that the population was made up of Muslims at 86.8%, Christian 3.52%, and Animist 9.42%. In the past Muslims and Christians have incorporated indigenous African beliefs into their outlook. The majority of Guinean Muslims are adherent to Sunni Islam , of the Maliki school of jurisprudence, influenced by Sufism . Christian groups include Roman Catholics , Anglicans , Baptists , Seventh-day Adventists , and Evangelical groups. Jehovah's Witnesses are active in the country and recognized by the Government. There is a Bahá'í Faith community. There are numbers of Hindus , Buddhists , and traditional Chinese religious groups among the expatriate community. There were three days of ethno-religious fighting in the city of Nzerekore in July 2013. Fighting between ethnic Kpelle who are Christian or animist, and ethnic Konianke who are Muslims and close to the larger Malinke ethnic group, left at least 54 dead. The dead included people who were killed with machetes and burned alive. The violence ended after the Guinean military imposed a curfew, and President Conde made a televised appeal for calm. In 2021, violence was limited to Kendoumaya, Lower Guinea, and mainly concerned a land rights dispute between locals and a monastery. In 2010 it was estimated that 41% of adults were literate (52% of males and 30% of females). Primary education is compulsory for 6 years. In 1999, primary school attendance was 40% and children, particularly girls, were kept out of school to assist their parents with domestic work or agriculture, or to be married. In 2015 Guinea had "one of the highest rates" of child marriage in the world, although in 2023 they are no longer in the top 5. In 2014, an outbreak of the Ebola virus occurred in Guinea . In response, the health ministry banned the sale and consumption of bats , thought to be carriers of the disease. The virus eventually spread from rural areas to Conakry, and by June 2014 had spread to neighbouring countries - Sierra Leone and Liberia. In August 2014 Guinea closed its borders to Sierra Leone and Liberia to help contain the spread of the virus, as more new cases of the disease were being reported in those countries than in Guinea. The outbreak began in December in a village called Meliandou, southeastern Guinea, near the borders with Liberia and Sierra Leone. The first known case involved a 2-year-old child who died, after fever and vomiting and passing black stool, on 6 December. The child's mother died a week later, then a sister and a grandmother, all with symptoms that included fever, vomiting, and diarrhoea. Then, by way of care-giving visits or attendance at funerals, the outbreak spread to other villages. "Unsafe burials" is a source of the transmission of the disease. The World Health Organization (WHO) reported that the inability to engage with local communities hindered the ability of health workers to trace the origins and strains of the virus. While WHO terminated the Public Health Emergency of International Concern (PHEIC) on 29 March 2016, the Ebola Situation Report released on 30 March confirmed 5 more cases in the preceding 2 weeks, with viral sequencing relating 1 of the cases to the November 2014 outbreak. The Ebola epidemic affected the treatment of other diseases in Guinea. Healthcare visits by the population declined due to fear of infection and to mistrust in the health-care system, and the system's ability to provide routine health-care and HIV/AIDS treatments decreased due to the Ebola outbreak. Ebola re-emerged in Guinea in January–February 2021. The 2021 maternal mortality rate per 100,000 births for Guinea is 576. This is compared with 680 in 2010, 859.9 in 2008 and 964.7 in 1990. The under 5 mortality rate, per 1,000 births is 146 and the neonatal mortality as a percentage of under 5's mortality is 29. In Guinea the number of midwives per 1,000 live births is 1 and the lifetime risk of death for pregnant women is 1 in 26. Guinea has the second highest prevalence of female genital mutilation in the world. An estimated 170,000 adults and children were infected at the end of 2004. Surveillance surveys conducted in 2001 and 2002 show higher rates of HIV in urban areas than in rural areas. Prevalence was highest in Conakry (5%) and in the cities of the Forest Guinea region (7%) bordering Côte d'Ivoire , Liberia , and Sierra Leone . HIV is spread primarily through multiple-partner intercourse. Men and women are at nearly equal risk for HIV, with people aged 15 to 24 most vulnerable. Surveillance figures from 2001 to 2002 show the rates among commercial sex workers (42%), active military personnel (6.6%), truck drivers and bush taxi drivers (7.3%), miners (4.7%), and adults with tuberculosis (8.6%). Several factors were attributed to what fuel the HIV/AIDS epidemic in Guinea. They include unprotected sex, multiple sexual partners, illiteracy, endemic poverty, unstable borders, refugee migration, lack of civic responsibility, and scarce medical care and public services. A 2012 study reported malnutrition rates with levels ranging from 34% to 40% by region, and acute malnutrition rates above 10% in Upper Guinea's mining zones. The survey showed that 139,200 children underwent acute malnutrition, 609,696 underwent chronic malnutrition and further 1,592,892 have anemia. Degradation of care practices, limited access to medical services, inadequate hygiene practices and a lack of food diversity were said to explain these levels. Malaria is transmitted year-round, with peak transmission from July through October. It is a cause of disability in Guinea. The first case of COVID-19 was reported in Guinea on 13 March 2020 . By the end of 2020 the total number of confirmed cases was 13,722. Of these, 13,141 had recovered, 500 were active, and 81 people had died. In 2014, an outbreak of the Ebola virus occurred in Guinea . In response, the health ministry banned the sale and consumption of bats , thought to be carriers of the disease. The virus eventually spread from rural areas to Conakry, and by June 2014 had spread to neighbouring countries - Sierra Leone and Liberia. In August 2014 Guinea closed its borders to Sierra Leone and Liberia to help contain the spread of the virus, as more new cases of the disease were being reported in those countries than in Guinea. The outbreak began in December in a village called Meliandou, southeastern Guinea, near the borders with Liberia and Sierra Leone. The first known case involved a 2-year-old child who died, after fever and vomiting and passing black stool, on 6 December. The child's mother died a week later, then a sister and a grandmother, all with symptoms that included fever, vomiting, and diarrhoea. Then, by way of care-giving visits or attendance at funerals, the outbreak spread to other villages. "Unsafe burials" is a source of the transmission of the disease. The World Health Organization (WHO) reported that the inability to engage with local communities hindered the ability of health workers to trace the origins and strains of the virus. While WHO terminated the Public Health Emergency of International Concern (PHEIC) on 29 March 2016, the Ebola Situation Report released on 30 March confirmed 5 more cases in the preceding 2 weeks, with viral sequencing relating 1 of the cases to the November 2014 outbreak. The Ebola epidemic affected the treatment of other diseases in Guinea. Healthcare visits by the population declined due to fear of infection and to mistrust in the health-care system, and the system's ability to provide routine health-care and HIV/AIDS treatments decreased due to the Ebola outbreak. Ebola re-emerged in Guinea in January–February 2021. The 2021 maternal mortality rate per 100,000 births for Guinea is 576. This is compared with 680 in 2010, 859.9 in 2008 and 964.7 in 1990. The under 5 mortality rate, per 1,000 births is 146 and the neonatal mortality as a percentage of under 5's mortality is 29. In Guinea the number of midwives per 1,000 live births is 1 and the lifetime risk of death for pregnant women is 1 in 26. Guinea has the second highest prevalence of female genital mutilation in the world. An estimated 170,000 adults and children were infected at the end of 2004. Surveillance surveys conducted in 2001 and 2002 show higher rates of HIV in urban areas than in rural areas. Prevalence was highest in Conakry (5%) and in the cities of the Forest Guinea region (7%) bordering Côte d'Ivoire , Liberia , and Sierra Leone . HIV is spread primarily through multiple-partner intercourse. Men and women are at nearly equal risk for HIV, with people aged 15 to 24 most vulnerable. Surveillance figures from 2001 to 2002 show the rates among commercial sex workers (42%), active military personnel (6.6%), truck drivers and bush taxi drivers (7.3%), miners (4.7%), and adults with tuberculosis (8.6%). Several factors were attributed to what fuel the HIV/AIDS epidemic in Guinea. They include unprotected sex, multiple sexual partners, illiteracy, endemic poverty, unstable borders, refugee migration, lack of civic responsibility, and scarce medical care and public services. A 2012 study reported malnutrition rates with levels ranging from 34% to 40% by region, and acute malnutrition rates above 10% in Upper Guinea's mining zones. The survey showed that 139,200 children underwent acute malnutrition, 609,696 underwent chronic malnutrition and further 1,592,892 have anemia. Degradation of care practices, limited access to medical services, inadequate hygiene practices and a lack of food diversity were said to explain these levels. Malaria is transmitted year-round, with peak transmission from July through October. It is a cause of disability in Guinea. The first case of COVID-19 was reported in Guinea on 13 March 2020 . By the end of 2020 the total number of confirmed cases was 13,722. Of these, 13,141 had recovered, 500 were active, and 81 people had died. Football is the "most popular sport" in the country of Guinea, alongside basketball . Football operations are run by the Guinean Football Federation . The association administers the national football team , and the national league. It was founded in 1960 and affiliated with FIFA since 1962 and with the Confederation of African Football since 1963. The Guinea national football team , nicknamed Syli nationale (National Elephants), have played international football since 1962. Their first opponent was East Germany. They have yet to reach World Cup finals, and were runners-up to Morocco in the Africa Cup of Nations in 1976. Guinée Championnat National is the top division of Guinean football. Since it was established in 1965, 3 teams have dominated in winning the Guinée Coupe Nationale . Horoya AC has at least 16 titles and is the 2017–2018 champion. Hafia FC (known as Conakry II in 1960s) has at least 15 titles, having dominated in 1960s and 70s. AS Kaloum Star (known as Conakry I in the 1960s) has at least 13 titles. All 3 teams are based in the capital, Conakry . Hafia FC won the African Cup of Champions Clubs 3 times, in 1972 , 1975 and 1977 , while Horoya AC won the 1978 African Cup Winners' Cup . Polygamy is generally prohibited by law in Guinea, but there are exceptions. In 2020, it was estimated that about 26% of marriages were polygamous (29% Muslim and 10% Christian). Guinean cuisine varies by region with rice as a staple. Cassava is consumed. Part of West African cuisine , the foods of Guinea include yétissé , peanut sauce , okra sauce and tapalapa bread . In rural areas, food is eaten from a "large serving dish" and eaten by hand outside of homes. Football is the "most popular sport" in the country of Guinea, alongside basketball . Football operations are run by the Guinean Football Federation . The association administers the national football team , and the national league. It was founded in 1960 and affiliated with FIFA since 1962 and with the Confederation of African Football since 1963. The Guinea national football team , nicknamed Syli nationale (National Elephants), have played international football since 1962. Their first opponent was East Germany. They have yet to reach World Cup finals, and were runners-up to Morocco in the Africa Cup of Nations in 1976. Guinée Championnat National is the top division of Guinean football. Since it was established in 1965, 3 teams have dominated in winning the Guinée Coupe Nationale . Horoya AC has at least 16 titles and is the 2017–2018 champion. Hafia FC (known as Conakry II in 1960s) has at least 15 titles, having dominated in 1960s and 70s. AS Kaloum Star (known as Conakry I in the 1960s) has at least 13 titles. All 3 teams are based in the capital, Conakry . Hafia FC won the African Cup of Champions Clubs 3 times, in 1972 , 1975 and 1977 , while Horoya AC won the 1978 African Cup Winners' Cup . Polygamy is generally prohibited by law in Guinea, but there are exceptions. In 2020, it was estimated that about 26% of marriages were polygamous (29% Muslim and 10% Christian). Guinean cuisine varies by region with rice as a staple. Cassava is consumed. Part of West African cuisine , the foods of Guinea include yétissé , peanut sauce , okra sauce and tapalapa bread . In rural areas, food is eaten from a "large serving dish" and eaten by hand outside of homes.

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Ebola

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Ebola River

The Ebola River ( / i ˌ b oʊ l ə / or / ə ˈ b oʊ l ə / ), also commonly known by its Ngbandi name Legbala , is the headstream of the Mongala River , a tributary of the Congo River , in northern Democratic Republic of the Congo . It is roughly 250 kilometers (160 mi) in length. [ citation needed ] The name Ebola is a French corruption of Legbala , its name in Ngbandi which means 'white water'. During the Belgian administration these names were interchangeable along with the French names Eau Blanche and rarely L'Ébola . In 1976, Ebola virus was first identified in Yambuku , 111 kilometers (69 mi) from the Ebola River, but the virologist Karl Johnson decided to name it after the river so that the town would not be associated with the disease's stigma. Thus, the river is eponymous to the terms Ebola virus , Ebolavirus , and Ebola virus disease (usually referred to as simply "Ebola").

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Ebola

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The Hot Zone

The Hot Zone: A Terrifying True Story is a best-selling 1994 nonfiction thriller by Richard Preston about the origins and incidents involving viral hemorrhagic fevers , particularly ebolaviruses and marburgviruses . The basis of the book was Preston's 1992 New Yorker article "Crisis in the Hot Zone". The filoviruses —including Ebola virus , Sudan virus , Marburg virus , and Ravn virus —are Biosafety Level 4 agents, extremely dangerous to humans because they are very infectious, have a high fatality rate, and most have no known prophylactic measures , treatments, or cures. Along with describing the history of the devastation caused by two of these Central African diseases, Ebola virus disease and Marburg virus disease , Preston described a 1989 incident in which a relative of Ebola virus, Reston virus , was discovered at a primate quarantine facility in Reston, Virginia , less than 15 miles (24 km) away from Washington, D.C.The book is in four sections: The book starts with "Charles Monet" visiting Kitum Cave during a camping trip to Mount Elgon in Central Africa. Not long after, he begins to suffer from a number of symptoms, including vomiting, diarrhea and red eye. He is taken to Nairobi Hospital for treatment, but his condition deteriorates further, and he goes into a coma while in the waiting room. This particular filovirus is called Marburg virus. Dr. Nancy Jaax had been promoted to work in the Level 4 Biosafety containment area at the United States Army Medical Research Institute of Infectious Diseases, and is assigned to research Ebola virus. While preparing food for her family at home, she cuts her right hand. Later, while working on a dead monkey infected with Ebola virus, one of the gloves on the hand with the open wound tears, and she is almost exposed to contaminated blood, but does not get infected. Nurse Mayinga is also infected by a nun and goes to Ngaleima Hospital in Kinshasa for treatment, where she succumbs to the disease. In Reston, Virginia, less than fifteen miles (24 km) away from Washington, D.C., a company called Hazelton Research once operated a quarantine center for monkeys that were destined for laboratories. In October 1989, when an unusually high number of their monkeys began to die, their veterinarian decided to send some samples to Fort Detrick (USAMRIID) for study. Early during the testing process in biosafety level 3 , when one of the flasks appeared to be contaminated with harmless pseudomonas bacterium , two USAMRIID scientists exposed themselves to the virus by wafting the flask. The virus found at the facility was a mutated form of the original Ebola virus and was initially mistaken for simian hemorrhagic fever virus . They later determine that, while the virus is lethal to monkeys, humans can be infected with it without any health effects at all. This virus is now known as Reston virus. Finally, the author goes to Africa to explore Kitum Cave. On the way, he discusses the role of AIDS in the present, as the Kinshasa Highway that he travels on was sometimes called the "AIDS Highway" after its early appearance in the region. Equipped with a hazmat suit , he enters the cave and finds a large number of animals, one of which might be the virus carrier. At the conclusion of the book, he travels to the quarantine facility in Reston. He finds the building abandoned and deteriorating. He concludes the book by claiming that Ebola will be back.The discovery of the Reston virus was made in November 1989 by Thomas W. Geisbert, an intern at United States Army Medical Research Institute of Infectious Diseases. Dr. Peter B. Jahrling isolated the filovirus further. The Center for Disease Control and Prevention conducted blood tests of the 178 animal handlers. While six tested positive, they did not exhibit any symptoms. The Reston virus was found to have low pathogenicity in humans. This was further supported later when a handler infected himself during a necropsy of an infected monkey, as the handler did not show symptoms of the virus after the incubation period. The Hot Zone was listed as one of around 100 books that shaped a century of science by American Scientist . Many reviews of The Hot Zone exemplify the impact the book had on the public's view of emerging viruses. A review in the British Medical Journal captures the paranoia and public panic described in this book. The reviewer was left "wondering when and where this enigmatic agent will appear next and what other disasters may await human primates". This can also be seen in a review in the Public Health Reports which highlights the "seriousness of our current situation" and "our ability to respond to a major health threat". The Hot Zone is described as a "romantic account of environmental transgression". Reactions to this book could be seen not only in the public's view of emerging viruses, but in the changes in the Centers for Disease Control and Prevention . In addition to the funding of public health infrastructure during the early 1970s, there were many public discussions of biodefense. This book continued to fuel the emerging diseases campaign. By connecting international health to national security , this campaign used The Hot Zone as a method of justifying increased intervention in the global phenomena of disease. The Hot Zone elicited a major response by the World Health Organization (WHO) by shedding light on the Ebola Zaire outbreak . [ clarification needed ] Teams of experts were immediately released. [ clarification needed ] Many countries tightened their borders, issued warnings to custom officials, quarantined travelers, and issued travel advisories. In his blurb , horror writer Stephen King called the first chapter "one of the most horrifying things I've read in my whole life". When asked whether any book "scared the pants off you" writer Suzanne Collins answered " The Hot Zone , by Richard Preston. I just read it a few weeks ago. Still recovering." The Hot Zone has received criticism for sensationalizing the effects of Ebola virus. In their memoir Level 4: Virus Hunters of the CDC (1996), former CDC scientists Joseph B. McCormick and Susan Fisher-Hoch lambasted Preston for claiming that Ebola dissolves organs, stating that although it causes great blood loss in tissues the organs remain structurally intact. McCormick and Fisher-Hoch also dispute Preston's version of the CDC's actions in the Reston virus incident. [ citation needed ] In an interview about his book Ebola: The Natural and Human History of a Deadly Virus (2014), David Quammen claimed that The Hot Zone had "vivid, gruesome details" that gave an "exaggerated idea of Ebola over the years" causing "people to view this disease as though it was some sort of preternatural phenomenon". In January 1993, 20th Century Fox producer Lynda Obst won a bidding war for the film rights to Preston's 1992 New Yorker article, which was still being transitioned into book form. In response to being outbid, Warner Bros. producer Arnold Kopelson immediately began working on a similarly themed production. This competing film, Outbreak , would ultimately be a factor in the collapse of Fox's planned production, Crisis in The Hot Zone . Directors considered for Crisis in The Hot Zone included Wolfgang Petersen (who would later direct Outbreak ), Michael Mann , and Ridley Scott . Scott eventually signed on to direct the film in February 1994. Screenwriter James V. Hart was also signed to adapt the book. In late April 1994, Fox announced they had signed Robert Redford and Jodie Foster to star in the film. Crisis in The Hot Zone , however, was never made. Foster dropped out of the film just before filming was to begin and production was delayed, with Meryl Streep , Sharon Stone , and Robin Wright touted as possible replacements. In August 1994, Redford also dropped out of the film; a few days after Redford left it was announced that pre-production had been shut down. On October 16, 2014, The Hollywood Reporter announced that Ridley Scott again planned to adapt the book, this time as a television miniseries for NatGeo . Kelly Souders, Brian Peterson , and Jeff Vintar wrote the pilot. Julianna Margulies starred as Nancy Jaax. Filming began in September 2018. Lynda Obst again produced the series. The series first aired from May 27 to May 29, 2019, and was later renewed for a second season.In January 1993, 20th Century Fox producer Lynda Obst won a bidding war for the film rights to Preston's 1992 New Yorker article, which was still being transitioned into book form. In response to being outbid, Warner Bros. producer Arnold Kopelson immediately began working on a similarly themed production. This competing film, Outbreak , would ultimately be a factor in the collapse of Fox's planned production, Crisis in The Hot Zone . Directors considered for Crisis in The Hot Zone included Wolfgang Petersen (who would later direct Outbreak ), Michael Mann , and Ridley Scott . Scott eventually signed on to direct the film in February 1994. Screenwriter James V. Hart was also signed to adapt the book. In late April 1994, Fox announced they had signed Robert Redford and Jodie Foster to star in the film. Crisis in The Hot Zone , however, was never made. Foster dropped out of the film just before filming was to begin and production was delayed, with Meryl Streep , Sharon Stone , and Robin Wright touted as possible replacements. In August 1994, Redford also dropped out of the film; a few days after Redford left it was announced that pre-production had been shut down. On October 16, 2014, The Hollywood Reporter announced that Ridley Scott again planned to adapt the book, this time as a television miniseries for NatGeo . Kelly Souders, Brian Peterson , and Jeff Vintar wrote the pilot. Julianna Margulies starred as Nancy Jaax. Filming began in September 2018. Lynda Obst again produced the series. The series first aired from May 27 to May 29, 2019, and was later renewed for a second season.

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Ebola

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Marburg virus

Marburg virus (MARV) is a hemorrhagic fever virus of the Filoviridae family of viruses and a member of the species Marburg marburgvirus , genus Marburgvirus . It causes Marburg virus disease in primates, a form of viral hemorrhagic fever . The virus is considered to be extremely dangerous. The World Health Organization (WHO) rates it as a Risk Group 4 Pathogen (requiring biosafety level 4-equivalent containment ). In the United States, the National Institute of Allergy and Infectious Diseases ranks it as a Category A Priority Pathogen and the Centers for Disease Control and Prevention lists it as a Category A Bioterrorism Agent . It is also listed as a biological agent for export control by the Australia Group . The virus can be transmitted by exposure to one species of fruit bats or it can be transmitted between people via body fluids through unprotected sex and broken skin. The disease can cause haemorrhage , fever, and other symptoms similar to Ebola , which belongs to the same family of viruses. According to the WHO, there are no approved vaccines or antiviral treatment for Marburg, but early, professional treatment of symptoms like dehydration considerably increases survival chances. In 2009, expanded clinical trials of an Ebola and Marburg vaccine began in Kampala , Uganda. Marburg virus was first described in 1967. It was discovered that year during a set of outbreaks of Marburg virus disease in the German cities of Marburg and Frankfurt and the Yugoslav capital Belgrade . Laboratory workers were exposed to tissues of infected grivet monkeys (the African green monkey, Chlorocebus aethiops ) at the Behringwerke , a major industrial plant in Marburg which was then part of Hoechst , and later part of CSL Behring . During the outbreaks, thirty-one people became infected and seven of them died. The virus is one of two members of the species Marburg marburgvirus , which is included in the genus Marburgvirus , family Filoviridae , and order Mononegavirales . The name Marburg virus is derived from Marburg (the city in Hesse , Germany, where the virus was first discovered) and the taxonomic suffix virus . Marburg virus was first introduced under this name in 1967. The virus name was changed to Lake Victoria marburgvirus in 2005, confusingly making the only difference in distinguishing between a Marburg virus organism and its species as a whole italicization, as in Lake Victoria marburgvirus . Still, most scientific articles continued to use the name Marburg virus. Consequently, in 2010, the name Marburg virus was reinstated and the species name changed. Marburg virus was first described in 1967. It was discovered that year during a set of outbreaks of Marburg virus disease in the German cities of Marburg and Frankfurt and the Yugoslav capital Belgrade . Laboratory workers were exposed to tissues of infected grivet monkeys (the African green monkey, Chlorocebus aethiops ) at the Behringwerke , a major industrial plant in Marburg which was then part of Hoechst , and later part of CSL Behring . During the outbreaks, thirty-one people became infected and seven of them died. The virus is one of two members of the species Marburg marburgvirus , which is included in the genus Marburgvirus , family Filoviridae , and order Mononegavirales . The name Marburg virus is derived from Marburg (the city in Hesse , Germany, where the virus was first discovered) and the taxonomic suffix virus . Marburg virus was first introduced under this name in 1967. The virus name was changed to Lake Victoria marburgvirus in 2005, confusingly making the only difference in distinguishing between a Marburg virus organism and its species as a whole italicization, as in Lake Victoria marburgvirus . Still, most scientific articles continued to use the name Marburg virus. Consequently, in 2010, the name Marburg virus was reinstated and the species name changed. Like all mononegaviruses , marburg virions contain non-infectious, linear nonsegmented, single-stranded RNA genomes of negative polarity that possess inverse-complementary 3' and 5' termini, do not possess a 5' cap , are not polyadenylated , and are not covalently linked to a protein . Marburgvirus genomes are approximately 19 kbp long and contain seven genes in the order 3'-UTR - NP - VP35 - VP40 - GP - VP30 - VP24 - L - 5'-UTR . Like all filoviruses , marburgvirions are filamentous particles that may appear in the shape of a shepherd's crook or in the shape of a "U" or a "6", and they may be coiled, toroid, or branched. Marburgvirions are generally 80 nm in width , but vary somewhat in length. In general, the median particle length of marburgviruses ranges from 795 to 828 nm (in contrast to ebolavirions , whose median particle length was measured to be 974–1,086 nm), but particles as long as 14,000 nm have been detected in tissue culture. Marburgvirions consist of seven structural proteins. At the center is the helical ribonucleocapsid , which consists of the genomic RNA wrapped around a polymer of nucleoproteins (NP). Associated with the ribonucleoprotein is the RNA-dependent RNA polymerase (L) with the polymerase cofactor (VP35) and a transcription activator (VP30). The ribonucleoprotein is embedded in a matrix, formed by the major (VP40) and minor (VP24) matrix proteins. These particles are surrounded by a lipid membrane derived from the host cell membrane. The membrane anchors a glycoprotein (GP 1,2 ) that projects 7 to 10 nm spikes away from its surface. While nearly identical to ebolavirions in structure, marburgvirions are antigenically distinct. Niemann–Pick C1 (NPC1) cholesterol transporter protein appears to be essential for infection with both Ebola and Marburg virus. Two independent studies reported in the same issue of Nature showed that Ebola virus cell entry and replication requires NPC1. When cells from patients lacking NPC1 were exposed to Ebola virus in the laboratory, the cells survived and appeared immune to the virus , further indicating that Ebola relies on NPC1 to enter cells. This might imply that genetic mutations in the NPC1 gene in humans could make some people resistant to one of the deadliest known viruses affecting humans. The same studies described similar results with Marburg virus, showing that it also needs NPC1 to enter cells. Furthermore, NPC1 was shown to be critical to filovirus entry because it mediates infection by binding directly to the viral envelope glycoprotein and that the second lysosomal domain of NPC1 mediates this binding. In one of the original studies, a small molecule was shown to inhibit Ebola virus infection by preventing the virus glycoprotein from binding to NPC1. In the other study, mice that were heterozygous for NPC1 were shown to be protected from lethal challenge with mouse-adapted Ebola virus. The Marburg virus life cycle begins with virion attachment to specific cell-surface receptors , followed by fusion of the virion envelope with cellular membranes and the concomitant release of the virus nucleocapsid into the cytosol . [ citation needed ] The virus RdRp partially uncoats the nucleocapsid and transcribes the genes into positive-stranded mRNAs , which are then translated into structural and nonstructural proteins . Marburgvirus L binds to a single promoter located at the 3' end of the genome. Transcription either terminates after a gene or continues to the next gene downstream. This means that genes close to the 3' end of the genome are transcribed in the greatest abundance, whereas those toward the 5' end are least likely to be transcribed. The gene order is therefore a simple but effective form of transcriptional regulation. The most abundant protein produced is the nucleoprotein , whose concentration in the cell determines when L switches from gene transcription to genome replication. Replication results in full-length, positive-stranded antigenomes that are in turn transcribed into negative-stranded virus progeny genome copies. Newly synthesized structural proteins and genomes self-assemble and accumulate near the inside of the cell membrane . Virions bud off from the cell, gaining their envelopes from the cellular membrane they bud from. The mature progeny particles then infect other cells to repeat the cycle. Like all mononegaviruses , marburg virions contain non-infectious, linear nonsegmented, single-stranded RNA genomes of negative polarity that possess inverse-complementary 3' and 5' termini, do not possess a 5' cap , are not polyadenylated , and are not covalently linked to a protein . Marburgvirus genomes are approximately 19 kbp long and contain seven genes in the order 3'-UTR - NP - VP35 - VP40 - GP - VP30 - VP24 - L - 5'-UTR . Like all filoviruses , marburgvirions are filamentous particles that may appear in the shape of a shepherd's crook or in the shape of a "U" or a "6", and they may be coiled, toroid, or branched. Marburgvirions are generally 80 nm in width , but vary somewhat in length. In general, the median particle length of marburgviruses ranges from 795 to 828 nm (in contrast to ebolavirions , whose median particle length was measured to be 974–1,086 nm), but particles as long as 14,000 nm have been detected in tissue culture. Marburgvirions consist of seven structural proteins. At the center is the helical ribonucleocapsid , which consists of the genomic RNA wrapped around a polymer of nucleoproteins (NP). Associated with the ribonucleoprotein is the RNA-dependent RNA polymerase (L) with the polymerase cofactor (VP35) and a transcription activator (VP30). The ribonucleoprotein is embedded in a matrix, formed by the major (VP40) and minor (VP24) matrix proteins. These particles are surrounded by a lipid membrane derived from the host cell membrane. The membrane anchors a glycoprotein (GP 1,2 ) that projects 7 to 10 nm spikes away from its surface. While nearly identical to ebolavirions in structure, marburgvirions are antigenically distinct. Niemann–Pick C1 (NPC1) cholesterol transporter protein appears to be essential for infection with both Ebola and Marburg virus. Two independent studies reported in the same issue of Nature showed that Ebola virus cell entry and replication requires NPC1. When cells from patients lacking NPC1 were exposed to Ebola virus in the laboratory, the cells survived and appeared immune to the virus , further indicating that Ebola relies on NPC1 to enter cells. This might imply that genetic mutations in the NPC1 gene in humans could make some people resistant to one of the deadliest known viruses affecting humans. The same studies described similar results with Marburg virus, showing that it also needs NPC1 to enter cells. Furthermore, NPC1 was shown to be critical to filovirus entry because it mediates infection by binding directly to the viral envelope glycoprotein and that the second lysosomal domain of NPC1 mediates this binding. In one of the original studies, a small molecule was shown to inhibit Ebola virus infection by preventing the virus glycoprotein from binding to NPC1. In the other study, mice that were heterozygous for NPC1 were shown to be protected from lethal challenge with mouse-adapted Ebola virus. The Marburg virus life cycle begins with virion attachment to specific cell-surface receptors , followed by fusion of the virion envelope with cellular membranes and the concomitant release of the virus nucleocapsid into the cytosol . [ citation needed ] The virus RdRp partially uncoats the nucleocapsid and transcribes the genes into positive-stranded mRNAs , which are then translated into structural and nonstructural proteins . Marburgvirus L binds to a single promoter located at the 3' end of the genome. Transcription either terminates after a gene or continues to the next gene downstream. This means that genes close to the 3' end of the genome are transcribed in the greatest abundance, whereas those toward the 5' end are least likely to be transcribed. The gene order is therefore a simple but effective form of transcriptional regulation. The most abundant protein produced is the nucleoprotein , whose concentration in the cell determines when L switches from gene transcription to genome replication. Replication results in full-length, positive-stranded antigenomes that are in turn transcribed into negative-stranded virus progeny genome copies. Newly synthesized structural proteins and genomes self-assemble and accumulate near the inside of the cell membrane . Virions bud off from the cell, gaining their envelopes from the cellular membrane they bud from. The mature progeny particles then infect other cells to repeat the cycle. In 2009, the successful isolation of infectious MARV was reported from caught healthy Egyptian fruit bats ( Rousettus aegyptiacus ) . This isolation, together with the isolation of infectious RAVV , strongly suggests that Old World fruit bats are involved in the natural maintenance of marburgviruses. Further studies are necessary to establish whether Egyptian rousettes are the actual hosts of MARV and RAVV or whether they get infected via contact with another animal and therefore serve only as intermediate hosts. In 2012 the first experimental infection study of Rousettus aegyptiacus with MARV provided further insight into the possible involvement of these bats in MARV ecology. Experimentally infected bats developed relatively low viremia lasting at least five days, but remained healthy and did not develop any notable gross pathology. The virus also replicated to high titers in major organs (liver and spleen), and organs that might possibly be involved in virus transmission (lung, intestine, reproductive organs, salivary gland, kidney, bladder, and mammary gland). The relatively long period of viremia noted in this experiment could possibly also facilitate mechanical transmission by blood sucking arthropods in addition to infection of susceptible vertebrate hosts by direct contact with infected blood. The viral strains fall into two clades: Ravn virus and Marburg virus. The Marburg strains can be divided into two: A and B. The A strains were isolated from Uganda (five from 1967), Kenya (1980) and Angola (2004–2005) while the B strains were from the Democratic Republic of the Congo epidemic (1999–2000) and a group of Ugandan isolates isolated in 2007–2009. The mean evolutionary rate of the whole genome was 3.3 × 10 −4 substitutions/site/year (credibility interval 2.0–4.8). The Marburg strains had a mean root time of the most recent common ancestor of 177.9 years ago (95% highest posterior density 87–284) suggesting an origin in the mid 19th century. In contrast, the Ravn strains origin dated back to a mean 33.8 years ago (the early 1980s). The most probable location of the Marburg virus ancestor was Uganda whereas that of the RAVV ancestor was Kenya. [ citation needed ]MARV is one of two Marburg viruses that causes Marburg virus disease (MVD) in humans (in the literature also often referred to as Marburg hemorrhagic fever, MHF). The other one is Ravn virus (RAVV). Both viruses fulfill the criteria for being a member of the species Marburg marburgvirus because their genomes diverge from the prototype Marburg marburgvirus or the Marburg virus variant Musoke (MARV/Mus) by <10% at the nucleotide level. See Ghana Marburg virus outbreak 2022 . See Ghana Marburg virus outbreak 2022 . The first clinical study testing the efficacy of a Marburg virus vaccine was conducted in 2014. The study tested a DNA vaccine and concluded that individuals inoculated with the vaccine exhibited some level of antibodies. However, these vaccines were not expected to provide definitive immunity. Several animal models have shown to be effective in the research of Marburg virus, such as hamsters, mice, and non-human primates (NHPs). Mice are useful in the initial phases of vaccine development as they are ample models for mammalian disease, but their immune systems are still different enough from humans to warrant trials with other mammals. Of these models, the infection in macaques seems to be the most similar to the effects in humans. A variety of other vaccines have been considered. Virus replicon particles (VRPs) were shown to be effective in guinea pigs, but lost efficacy once tested on NHPs. Additionally, an inactivated virus vaccine proved ineffective. DNA vaccines showed some efficacy in NHPs, but all inoculated individuals showed signs of infection. Because Marburg virus and Ebola virus belong to the same family, Filoviridae, some scientists have attempted to create a single-injection vaccine for both viruses. This would both make the vaccine more practical and lower the cost for developing countries. Using a single-injection vaccine has shown to not cause any adverse reactogenicity, which the possible immune response to vaccination, in comparison to two separate vaccinations. As of June 23, 2022, researchers working with the Public Health Agency of Canada conducted a study which showed promising results of a recombinant vesicular stomatitis virus (rVSV) vaccine in guinea pigs, entitled PHV01. According to the study, inoculation with the vaccine approximately one month prior to infection with the virus provided a high level of protection. Even though there is much experimental research on Marburg virus, there is still no prominent vaccine. Human vaccination trials are either ultimately unsuccessful or are missing data specifically regarding Marburg virus. Due to the cost needed to handle Marburg virus at qualified facilities, the relatively few number of fatalities, and lack of commercial interest, the possibility of a vaccine has simply not come to fruition. The Soviet Union had an extensive offensive and defensive biological weapons program that included MARV. At least three Soviet research institutes had MARV research programs during the Cold War : The Virology Center of the Scientific-Research Institute for Microbiology in Zagorsk (today Sergiev Posad ), the Scientific-Production Association "Vektor" (today the State Research Center of Virology and Biotechnology "Vektor" ) in Koltsovo , and the Irkutsk Scientific-Research Anti-Plague Institute of Siberia and the Far East in Irkutsk . As most performed research was highly classified , it remains unclear how successful the MARV program was. However, Soviet defector Ken Alibek claimed that a weapon filled with MARV was tested at the Stepnogorsk Scientific Experimental and Production Base in Stepnogorsk , Kazakh Soviet Socialist Republic (today Kazakhstan ), suggesting that the development of a MARV biological weapon had reached advanced stages. Independent confirmation for this claim is lacking. At least one laboratory accident with MARV, resulting in the death of Koltsovo researcher Nikolai Ustinov, occurred during the Cold War in the Soviet Union and was first described in detail by Alibek. MARV is a select agent under US law.

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Nairaland

Nairaland is a Nigerian English-language internet forum . Founded by Nigerian entrepreneur Seun Osewa on March 8, 2005, it is targeted primarily at Nigerian domestic residents and is the 6th most visited website in Nigeria. It currently has over 3.0 million registered users with over 7.4 million topics created to date, and it is estimated that approximately 3% of Nigerian Internet users are registered on Nairaland, compared to Facebook 's 11 million Nigerian users, which corresponds to approximately 20% of the local Internet population. Registration is only necessary for posting, commenting or liking posts.During the Ebola virus epidemic , trolls from 4chan registered on Nairaland in 2014 to propagate false claims that Americans and Europeans were spreading the Ebola virus in magical rituals through worship of 4chan's " Ebola-chan " meme (an anime personification of the Ebola virus). On June 22, 2014, following a successful hacking attempt, Nairaland went offline briefly. The hackers were able to gain access to, and wipe the contents of, the website's host server and backup. Three days later, it was back online after some data had been recovered from a remote backup. However, user posts and registration between January 10, 2014, and June 22, 2014, was lost. Users with lost accounts were required to re-register. In August 2020, The Daily Beast reported that some users on Nairaland were promoting the QAnon conspiracy theory. Nairaland has faced criticism for hosting content and fostering communities promoting ethnic bigotry. Although the platform has implemented policies against hate speech and discrimination, concerns remain about the prevalence of ethnic slurs, stereotypes, and inflammatory rhetoric targeting various Nigerian ethnic groups. This has led to the erosion of members from Nairaland to other social networks like Facebook, Nelogram and Twitter that have strict rules against abuse and hate speech. Unannounced to the public, Nairaland site was shutdown on the 18th of December, 2023 by the site host. The founder of the micro-blogging site, Nairaland.com, Seun Osewa, said the site is experiencing a downtime after it was "taken down" by the host of its server. Users of the site on Monday night, had raised the alarm of being shut out, raising concerns of possible hacking. A check on the platform showed several error messages indicating a problem with the server, a situation Osewa acknowledged was punishment for overlooking an earlier sent abuse report. In a series of tweets on Tuesday morning, the founder explained that though the said offensive content had been removed, the server user interface was still experiencing a delay. Osewa posted, "Nairaland's server was taken down because I overlooked an abuse report that was originally sent on the 14th. After the takedown, I removed the offensive content. During the Ebola virus epidemic , trolls from 4chan registered on Nairaland in 2014 to propagate false claims that Americans and Europeans were spreading the Ebola virus in magical rituals through worship of 4chan's " Ebola-chan " meme (an anime personification of the Ebola virus). On June 22, 2014, following a successful hacking attempt, Nairaland went offline briefly. The hackers were able to gain access to, and wipe the contents of, the website's host server and backup. Three days later, it was back online after some data had been recovered from a remote backup. However, user posts and registration between January 10, 2014, and June 22, 2014, was lost. Users with lost accounts were required to re-register. In August 2020, The Daily Beast reported that some users on Nairaland were promoting the QAnon conspiracy theory. Nairaland has faced criticism for hosting content and fostering communities promoting ethnic bigotry. Although the platform has implemented policies against hate speech and discrimination, concerns remain about the prevalence of ethnic slurs, stereotypes, and inflammatory rhetoric targeting various Nigerian ethnic groups. This has led to the erosion of members from Nairaland to other social networks like Facebook, Nelogram and Twitter that have strict rules against abuse and hate speech. Unannounced to the public, Nairaland site was shutdown on the 18th of December, 2023 by the site host. The founder of the micro-blogging site, Nairaland.com, Seun Osewa, said the site is experiencing a downtime after it was "taken down" by the host of its server. Users of the site on Monday night, had raised the alarm of being shut out, raising concerns of possible hacking. A check on the platform showed several error messages indicating a problem with the server, a situation Osewa acknowledged was punishment for overlooking an earlier sent abuse report. In a series of tweets on Tuesday morning, the founder explained that though the said offensive content had been removed, the server user interface was still experiencing a delay. Osewa posted, "Nairaland's server was taken down because I overlooked an abuse report that was originally sent on the 14th. After the takedown, I removed the offensive content.

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Ebola

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Ebola Rex

Mel Novak Shawn C. Phillips September 1, 2020 ( 2020-09-01 ) Ebola Rex is a 2020 American horror film written and directed by Dustin Ferguson , starring Mel Novak , Mike Ferguson, and Shawn C. Phillips. The film is available on VOD and DVD on SCS Entertainment. A dangerous, captive Tyrannosaurus Rex is injected with the Ebola Virus and escapes a secret government lab to wreak bloody havoc in Southern California. A brave General, Davis, and Dick Steel, an obsessed, renegade soldier, try to stop it. Mel Novak as General Davis Ken May as Dick Steel Mike Ferguson as Mike Shawn C. Phillips as Protester #1 Erik Anthony Russo as Erik Jennifer Nangle as Malvolia, the Queen of ScreamsEbola Rex premiered on September 1, 2020 and was made available on VOD and DVD on SCS Entertainment. The film was later re-released on June 8, 2021. Horror Society was critical of the film while also stating that "Ferguson and company took a time where people are panicking and turned it into a way to express himself. I would have chose a different approach but at least he spent his time making movies and not bitching about politics on the internet." Another review, at Reel Reviews, was more appreciative of the funny aspects of the film, as did other reviews including one at CBR, calling it a mockbuster . In 2021 Ferguson released a sequel, Ebola Rex Versus Murder Hornets . The film had a premiere on YouTube on March 1, 2021 and was released as a limited edition DVD the following day. Mel Novak returned for the sequel. In 2021 SoCal Cinema (SCS) Studios released video game adaptations of Ebola Rex and Ebola Rex Versus Murder Hornets . In 2021 Ferguson released a sequel, Ebola Rex Versus Murder Hornets . The film had a premiere on YouTube on March 1, 2021 and was released as a limited edition DVD the following day. Mel Novak returned for the sequel. In 2021 SoCal Cinema (SCS) Studios released video game adaptations of Ebola Rex and Ebola Rex Versus Murder Hornets .

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Bushmeat

Bushmeat is meat from wildlife species that are hunted for human consumption. Bushmeat represents a primary source of animal protein and a cash-earning commodity in poor and rural communities of humid tropical forest regions of the world. The numbers of animals killed and traded as bushmeat in the 1990s in West and Central Africa were thought to be unsustainable. By 2005, commercial harvesting and trading of bushmeat was considered a threat to biodiversity . As of 2016, 301 terrestrial mammals were threatened with extinction due to hunting for bushmeat including primates , even-toed ungulates , bats , diprotodont marsupials , rodents and carnivores occurring in developing countries . Bushmeat provides increased opportunity for transmission of several zoonotic viruses from animal hosts to humans, such as Ebolavirus and HIV . The term 'bushmeat' is originally an African term for wildlife species that are hunted for human consumption, and usually refers specifically to the meat of African wildlife. In October 2000, the IUCN World Conservation Congress passed a resolution on the unsustainable commercial trade in wild meat . Affected countries were urged to recognize the increasing ramifications of the bushmeat trade, to strengthen and enforce legislation, and to develop action programmes to mitigate the consequences of the trade. Donor organisations were requested to provide funding for the implementation of such programmes. Wildlife hunting for food is important for the livelihood security of and supply of dietary protein for poor people. It can be sustainable when carried out by traditional hunter-gatherers in large landscapes for their own consumption. Due to the extent of bushmeat hunting for trade in markets, the survival of those species that are large-bodied and reproduce slowly is threatened. The term bushmeat crisis was coined in 2007 and refers to this dual threat of depleting food resources and wildlife extinctions , both entailed by the bushmeat trade. Globally, more than 1,000 animal species are estimated to be affected by hunting for bushmeat. Bushmeat hunters use mostly leg-hold snare traps to catch any wildlife, but prefer to kill large species, as these provide a greater amount of meat than small species. The volume of the bushmeat trade in West and Central Africa was estimated at 1–5 million tonnes (980,000–4,920,000 long tons; 1,100,000–5,500,000 short tons) per year at the turn of the 21st century. In 2002, it was estimated that species weighing more than 10 kg (22 lb) contribute 177.7 ± 358.4 kg/km 2 (1,015 ± 2,046 lb/sq mi) of meat per year to the bushmeat extracted in the Congo Basin , based on 24 individuals. Species weighing less than 10 kg (22 lb) were estimated to contribute 35.4 ± 72.2 kg/km 2 (202 ± 412 lb/sq mi) , also based on 24 individuals. Bushmeat extraction in the Amazon rainforest was estimated to be much lower, at 3.69 ± 3.9 kg/km 2 (21.1 ± 22.3 lb/sq mi) in the case of species weighing more than 10 kg and 0.6 ± 0.9 kg/km 2 (3.4 ± 5.1 lb/sq mi) in the case of species weighing less than 10 kg, based on 3 individuals. [ better source needed ] Based on these estimates, a total of 2,200,000 t (2,200,000 long tons; 2,400,000 short tons) bushmeat is extracted in the Congo Basin per year, ranging from 12,938 t (12,734 long tons; 14,262 short tons) in Equatorial Guinea to 1,665,972 t (1,639,661 long tons; 1,836,420 short tons) in the Democratic Republic of the Congo . The 301 mammal species threatened by hunting for bushmeat comprise 126 primates, 65 even-toed ungulates, 27 bats, 26 diprotodont marsupials, 21 rodents, 12 carnivores and all pangolin species. Primate species offered fresh and smoked in 2009 at a wildlife market by Liberia's Cavally River included chimpanzee ( Pan troglodytes ), Diana monkey ( Cercopithecus diana ), putty-nosed monkey ( C. nictitans ), lesser spot-nosed monkey ( C. petaurista ), Campbell's mona monkey ( C. campbelli ), sooty mangabey ( Cercocebus atys ), king colobus ( Colobus polykomos ), olive colobus ( Procolobus verus ), western red colobus ( P. badius ). Duiker species constituted more than half of the total 723 animals offered. In 2012, the bushmeat trade was surveyed in three villages in the Sassandra Department , Ivory Coast . During six months, nine restaurants received 376 mammals and eight reptiles, including dwarf crocodile ( Osteolaemus tetraspis ), harnessed bushbuck ( Tragelaphus scriptus ), Maxwell's duiker ( Philantomba maxwellii ), bay duiker ( Cephalophus dorsalis ), Campbell's mona monkey, lesser spot-nosed monkey, potto ( Perodicticus potto ), tree pangolin ( Phataginus tricuspis ), long-tailed pangolin ( P. tetradactyla ), African brush-tailed porcupine ( Atherurus africanus ), giant pouched rat ( Cricetomys gambianus ), greater cane rat ( Thryonomys swinderianus ), striped ground squirrel ( Xerus erythropus ) and western tree hyrax ( Dendrohyrax dorsalis ). About 128,400 straw-coloured fruit bats ( Eidolon helvum ) were estimated in 2011 to be traded as bushmeat every year in four cities in southern Ghana. In 2006, it was estimated that about 1,437,458 animals are killed every year in the Nigerian and Cameroon parts of the Cross-Sanaga-Bioko coastal forests , including about 43,880 Emin's pouched rats ( Cricetomys emini ), 41,800 tree pangolins, 39,700 putty-nosed monkeys, 22,500 Mona monkeys ( Cercopithecus mona ), 3,500 red-eared guenons ( C. erythrotis ), 20,300 drills ( Mandrillus leucophaeus ), 15,300 African civets ( Civettictis civetta ), 11,900 common kusimanses ( Crossarchus obscurus ), more than 7,600 African palm civets ( Nandinia binotata ), 26,760 Nile monitors ( Varanus niloticus ) and 410 African forest elephants ( Loxodonta cyclotis ). Between 1983 and 2002, the Gabon populations of western gorilla ( Gorilla gorilla ) and common chimpanzee ( Pan troglodytes ) were estimated to have declined by 56%. This decline was primarily caused by the commercial hunting, which was facilitated by the extended infrastructure for logging purposes. Marsh mongoose ( Atilax paludinosus ) and long-nosed mongoose ( Herpestes naso ) are the most numerous small carnivores offered in rural bushmeat markets in the country. In the late 1990s, fresh and smoked bonobo ( Pan paniscus ) carcasses were observed in Basankusu in the Province of Équateur in the Congo Basin. The main species killed by bushmeat hunters in Tanzania's Katavi - Rukwa Region include impala ( Aepyceros melampus ), common duiker ( Sylvicapra grimmia ), warthog ( Phacocherus africanus ), Cape buffalo ( Syncerus caffer ), harnessed bushbuck, red river hog ( Potamochoerus porcus ) and plains zebra ( Equus quagga ). A survey in a rural area in southwestern Madagascar revealed that bushmeat hunters target bushpig ( Potamochoerus larvatus ), ring-tailed lemur ( Lemur catta ), Verreaux's sifaka ( Propithecus verreauxi ), Hubbard's sportive lemur ( Lepilemur hubbardorum ), fat-tailed dwarf lemur ( Cheirogaleus medius ), common tenrec ( Tenrec ecaudatus ), grey mouse lemur ( Microcebus murinus ), reddish-gray mouse lemur ( M. griseorufus ), Madagascan fruit bat ( Eidolon dupreanum ) and Madagascan flying fox ( Pteropus rufus ). Logging concessions operated by companies in African forests have been closely linked to the bushmeat trade. Because they provide roads, trucks and other access to remote forests, they are the primary means for the transportation of hunters and meat between forests and urban centres. Some, including the Congolaise Industrielle du Bois (CIB) in the Republic of Congo , partnered with governments and international conservation organizations to regulate the bushmeat trade within the concessions where they operate. Numerous solutions are needed; because each country has different circumstances, traditions and laws, no one solution will work in every location. Bushmeat can be an important source of micronutrients and macronutrients . A study of South Americans in the Tres Fronteras region found that those who consumed bushmeat were at a lower risk of anemia and chronic health conditions, as their diets included more iron , zinc , and vitamin C than those who did not eat bushmeat. In Ghana , international illegal over-exploitation of African fishing grounds has increased demand for bushmeat. Both European Union -subsidized fleets and local commercial fleets have depleted fish stocks, leaving local people to supplement their diets with animals hunted from nature reserves. Over 30 years of data link sharp declines in both mammal populations and the biomass of 41 wildlife species with a decreased supply of fish. Consumption of fish and of bushmeat is correlated: the decline of one resource drives up the demand and price for the other. Transhumant pastoralists from the border area between Sudan and the Central African Republic are accompanied by armed merchants who also engage in poaching large herbivores . The decline of giant eland , Cape buffalo, hartebeest and waterbuck in the Chinko area between 2012 and 2017 is attributed to their poaching activities. They use livestock to transport bushmeat to markets. Logging concessions operated by companies in African forests have been closely linked to the bushmeat trade. Because they provide roads, trucks and other access to remote forests, they are the primary means for the transportation of hunters and meat between forests and urban centres. Some, including the Congolaise Industrielle du Bois (CIB) in the Republic of Congo , partnered with governments and international conservation organizations to regulate the bushmeat trade within the concessions where they operate. Numerous solutions are needed; because each country has different circumstances, traditions and laws, no one solution will work in every location. Bushmeat can be an important source of micronutrients and macronutrients . A study of South Americans in the Tres Fronteras region found that those who consumed bushmeat were at a lower risk of anemia and chronic health conditions, as their diets included more iron , zinc , and vitamin C than those who did not eat bushmeat. In Ghana , international illegal over-exploitation of African fishing grounds has increased demand for bushmeat. Both European Union -subsidized fleets and local commercial fleets have depleted fish stocks, leaving local people to supplement their diets with animals hunted from nature reserves. Over 30 years of data link sharp declines in both mammal populations and the biomass of 41 wildlife species with a decreased supply of fish. Consumption of fish and of bushmeat is correlated: the decline of one resource drives up the demand and price for the other. Transhumant pastoralists from the border area between Sudan and the Central African Republic are accompanied by armed merchants who also engage in poaching large herbivores . The decline of giant eland , Cape buffalo, hartebeest and waterbuck in the Chinko area between 2012 and 2017 is attributed to their poaching activities. They use livestock to transport bushmeat to markets. Animal sources may have been the cause for infectious diseases such as tuberculosis , leprosy , cholera , smallpox , measles , influenza , and syphilis acquired by early agrarians. The emergence of HIV-1 , AIDS , Ebola virus disease , and Creutzfeldt-Jakob disease are attributed to animal sources today. Thomas's rope squirrel ( Funisciurus anerythrus ) and red-legged sun squirrel ( Heliosciurus rufobrachium ) were identified as reservoirs of the mpox virus in the Democratic Republic of the Congo in the 1980s. Outbreaks of the Ebola virus in the Congo Basin and in Gabon in the 1990s have been associated with the butchering and consumption of chimpanzees and bonobos . Bushmeat hunters in Central Africa infected with the human T-lymphotropic virus were closely exposed to wild primates. Anthrax can be transmitted when butchering and eating ungulates. The risk of bloodborne diseases to be transmitted is higher when butchering a carcass than when transporting, cooking and eating it. Many hunters and traders are not aware of zoonosis and the risks of disease transmissions. An interview survey in rural communities in Nigeria revealed that 55% of the respondents knew of zoonoses , but their education and cultural traditions are important drivers for hunting and eating bushmeat despite the risks involved. Results of research on wild chimpanzees in Cameroon indicate that they are naturally infected with the simian foamy virus and constitute a reservoir of HIV-1, a precursor of the acquired immunodeficiency syndrome (AIDS) in humans . There are several distinct strains of HIV, indicating that this cross-species transfer has occurred several times. Simian immunodeficiency virus present in chimpanzees is reportedly derived from older strains of the virus present in the collared mangabey ( Cercocebus torquatus ) and the putty-nosed monkey. It is likely that HIV was initially transferred to humans after having come into contact with infected bushmeat. The natural reservoirs of ebolaviruses are unknown. Possible reservoirs include non-human primates , megabats , rodents, shrews, carnivores, and ungulates. Between October 2001 and December 2003, five Ebola virus outbreaks occurred in the border area between Gabon and Republic of Congo. Autopsies of wildlife carcasses showed that chimpanzees, gorillas and bay duikers were infected with the virus. The Ebola virus has been linked to bushmeat, with some researchers hypothesizing that megabats are a primary host of at least some variants of Ebola virus. Between the first recorded outbreak in 1976 and the largest in 2014, the virus has transferred from animals to humans only 30 times, despite large numbers of bats being killed and sold each year. Bats drop partially eaten fruits and pulp, then terrestrial mammals such as gorillas and duikers feed on these fruits. This chain of events forms a possible indirect means of transmission from the natural host to animal populations. The suspected index case for the Ebola virus epidemic in West Africa in 2014 was a two-year-old boy in Meliandou in south-eastern Guinea, who played in a hollow tree harbouring a colony of Angolan free-tailed bats ( Mops condylurus ). Results of a study conducted during the Ebola crisis in Liberia showed that socio-economic conditions affected bushmeat consumption. During the crisis, there was a decrease in bushmeat consumption and daily meal frequency. In addition, preferences for bushmeat species stayed the same. In Cameroon, 15 primate species were examined for gastrointestinal parasites . Bushmeat primates were infected with Trichuris , Entamoeba , Ascaris , Capillaria , pinworms , Bertiella and Endolimax nana . A large proportion of Bitis vipers sold at rural bushmeat markets in the Democratic Republic of the Congo are infected by Armillifer grandis , which represent a threat to public health. Results of research on wild chimpanzees in Cameroon indicate that they are naturally infected with the simian foamy virus and constitute a reservoir of HIV-1, a precursor of the acquired immunodeficiency syndrome (AIDS) in humans . There are several distinct strains of HIV, indicating that this cross-species transfer has occurred several times. Simian immunodeficiency virus present in chimpanzees is reportedly derived from older strains of the virus present in the collared mangabey ( Cercocebus torquatus ) and the putty-nosed monkey. It is likely that HIV was initially transferred to humans after having come into contact with infected bushmeat. The natural reservoirs of ebolaviruses are unknown. Possible reservoirs include non-human primates , megabats , rodents, shrews, carnivores, and ungulates. Between October 2001 and December 2003, five Ebola virus outbreaks occurred in the border area between Gabon and Republic of Congo. Autopsies of wildlife carcasses showed that chimpanzees, gorillas and bay duikers were infected with the virus. The Ebola virus has been linked to bushmeat, with some researchers hypothesizing that megabats are a primary host of at least some variants of Ebola virus. Between the first recorded outbreak in 1976 and the largest in 2014, the virus has transferred from animals to humans only 30 times, despite large numbers of bats being killed and sold each year. Bats drop partially eaten fruits and pulp, then terrestrial mammals such as gorillas and duikers feed on these fruits. This chain of events forms a possible indirect means of transmission from the natural host to animal populations. The suspected index case for the Ebola virus epidemic in West Africa in 2014 was a two-year-old boy in Meliandou in south-eastern Guinea, who played in a hollow tree harbouring a colony of Angolan free-tailed bats ( Mops condylurus ). Results of a study conducted during the Ebola crisis in Liberia showed that socio-economic conditions affected bushmeat consumption. During the crisis, there was a decrease in bushmeat consumption and daily meal frequency. In addition, preferences for bushmeat species stayed the same. In Cameroon, 15 primate species were examined for gastrointestinal parasites . Bushmeat primates were infected with Trichuris , Entamoeba , Ascaris , Capillaria , pinworms , Bertiella and Endolimax nana . A large proportion of Bitis vipers sold at rural bushmeat markets in the Democratic Republic of the Congo are infected by Armillifer grandis , which represent a threat to public health. Suggestions for reducing or halting bushmeat harvest and trade include: As an alternative to bushmeat, captive breeding of species traditionally harvested from the wild is sometimes feasible. Captive breeding efforts must be closely monitored, as there is risk they can be used to launder and legitimize individuals captured from the wild, similar to the laundering of wild green tree pythons in Indonesia for the pet trade.

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Ebola

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Reston virus

Reston virus (RESTV) Reston virus (RESTV) is one of six known viruses within the genus Ebolavirus . Reston virus causes Ebola virus disease in non-human primates; unlike the other five ebolaviruses, it is not known to cause disease in humans, but has caused asymptomatic infections. Reston virus was first described in 1990 as a new "strain" of Ebola virus (EBOV). It is the single member of the species Reston ebolavirus , which is included into the genus Ebolavirus , family Filoviridae , order Mononegavirales . Reston virus is named after Reston, Virginia , US, where the virus was first discovered. RESTV was discovered in crab-eating macaques from Hazleton Laboratories (now Labcorp Drug Development) in 1989. This attracted significant media attention due to Reston's location in the Washington metropolitan area and the lethality of a closely related Ebola virus. Despite its status as a level-4 organism, Reston virus is non- pathogenic to humans, though hazardous to monkeys; the perception of its lethality was compounded by the monkey's coinfection with Simian hemorrhagic fever virus (SHFV). Despite ongoing research, the determinants for lack of human pathogenicity are yet to be discovered. Reston virus was first introduced as a new "strain" of Ebola virus in 1990. In 2000, it received the designation Reston Ebola virus and in 2002, the name was changed to Reston ebolavirus. Previous abbreviations for the virus were EBOV-R (for Ebola virus Reston) and most recently REBOV (for Reston Ebola virus or Reston ebolavirus). The virus received its current designation in 2010, when it was renamed Reston virus (RESTV). A virus of the species Reston ebolavirus is a Reston virus (RESTV) if it has the properties of Reston ebolaviruses and if its genome diverges from that of the prototype Reston virus. For example, there exists Reston virus variant Pennsylvania (RESTV/Pen), differing by less than 10% at the nucleotide level. While investigating an outbreak of Simian hemorrhagic fever (SHFV) in November 1989, an electron microscopist from USAMRIID named Thomas W. Geisbert discovered filoviruses similar in appearance to Ebola virus in tissue samples taken from a crab-eating macaque imported from the Philippines to Hazleton Laboratories in Reston, Virginia. The filovirus was further isolated by Dr. Peter Jahrling , and over the period of three months over a third of the monkeys died—at a rate of two or three a day. Blood samples were taken from 178 animal handlers during the incident. Of them, six eventually seroconverted , testing positive using ELISA . They remained, however, asymptomatic. In January 1990, an animal handler at Hazelton cut himself while performing a necropsy on the liver of an infected Cynomolgus . Under the direction of the Centers for Disease Control and Prevention (CDC), the animal handler was placed under surveillance for the duration of the incubation period . When the animal handler failed to become ill, it was concluded that the virus had a low pathogenicity in humans. Following the discovery of a filovirus in crab-eating macaques, an investigation tracing the infection was conducted by the CDC . The monkeys were imported from the Philippines , which had no previous record of SHFV or ebolavirus infections. It was suspected that the monkeys contracted both diseases while in transit aboard KLM Airlines before reaching Reston. Shipments were tracked to New York City , Texas , and Mexico City , none of which produced cases of infection. By January 1990, Hazelton Laboratories recovered from its previous losses and began importing monkeys again from the same establishment in Manila that had provided the original animals. The imported monkeys became infected and were euthanized. In early February the CDC received reports of the disease in Alice, Texas. In March the Division of Quarantine at the CDC secured a temporary ban on the importation of monkeys into the United States from anywhere in the world. Following the announcement of the filovirus disease outbreak in Reston, Virginia, a serosurvey was conducted to assess the prevalence of the infection. Of the several hundred serums received by the CDC, approximately ten percent showed some reaction to ebolavirus antigen—though usually at low levels. Counterintuitively, the majority of the monkeys found positive were from Indonesia . In May 1990, an investigation led by Susan Fisher-Hoch, Steve Ostroff, and Jerry Jennings was sent to Indonesia. During the investigation, it was hypothesized that there could be a cross infection since monkeys suspected of illness were typically placed in gang cages containing up to twenty to thirty other monkeys suspected of illness. Upon arrival they were told that most of the monkeys were imported from the island of Sumatra . The investigation team found no trace of the virus in either case. Following the investigation in Indonesia, an experiment was conducted in the level-4 lab at the CDC campus in DeKalb County , Georgia with thirty-two monkeys: sixteen green monkeys ( Cercopithecus aethiops ) and sixteen crab-eating macaques. Half of the sixteen green monkeys and crab-eating macaques were infected with Reston virus and the other half with Ebola virus. Ebola virus infection was lethal to nearly all monkeys. However, most of the monkeys infected with Reston virus recovered in a month. The surviving monkeys were kept for two years to detect any trace of the virus - none was found. However, the monkeys continued to possess a high level of antibody . Following the test at the CDC campus in DeKalb County, two of the monkeys who had survived Reston virus infection were infected with a very large dose of the Ebola virus in an effort to produce an Ebola vaccine . One of the two monkeys remained resistant; the second died. The physical building in which the outbreak occurred was demolished on 30 May 1995 and a daycare center was constructed in its place. Modern spatial computer simulation indicates that the pathogen could have reached both major airports ( Dulles International Airport and Ronald Reagan Washington National Airport ) in less than 45 minutes assuming direct transmission paths. While investigating an outbreak of Simian hemorrhagic fever (SHFV) in November 1989, an electron microscopist from USAMRIID named Thomas W. Geisbert discovered filoviruses similar in appearance to Ebola virus in tissue samples taken from a crab-eating macaque imported from the Philippines to Hazleton Laboratories in Reston, Virginia. The filovirus was further isolated by Dr. Peter Jahrling , and over the period of three months over a third of the monkeys died—at a rate of two or three a day. Blood samples were taken from 178 animal handlers during the incident. Of them, six eventually seroconverted , testing positive using ELISA . They remained, however, asymptomatic. In January 1990, an animal handler at Hazelton cut himself while performing a necropsy on the liver of an infected Cynomolgus . Under the direction of the Centers for Disease Control and Prevention (CDC), the animal handler was placed under surveillance for the duration of the incubation period . When the animal handler failed to become ill, it was concluded that the virus had a low pathogenicity in humans. Following the discovery of a filovirus in crab-eating macaques, an investigation tracing the infection was conducted by the CDC . The monkeys were imported from the Philippines , which had no previous record of SHFV or ebolavirus infections. It was suspected that the monkeys contracted both diseases while in transit aboard KLM Airlines before reaching Reston. Shipments were tracked to New York City , Texas , and Mexico City , none of which produced cases of infection. By January 1990, Hazelton Laboratories recovered from its previous losses and began importing monkeys again from the same establishment in Manila that had provided the original animals. The imported monkeys became infected and were euthanized. In early February the CDC received reports of the disease in Alice, Texas. In March the Division of Quarantine at the CDC secured a temporary ban on the importation of monkeys into the United States from anywhere in the world. Following the announcement of the filovirus disease outbreak in Reston, Virginia, a serosurvey was conducted to assess the prevalence of the infection. Of the several hundred serums received by the CDC, approximately ten percent showed some reaction to ebolavirus antigen—though usually at low levels. Counterintuitively, the majority of the monkeys found positive were from Indonesia . In May 1990, an investigation led by Susan Fisher-Hoch, Steve Ostroff, and Jerry Jennings was sent to Indonesia. During the investigation, it was hypothesized that there could be a cross infection since monkeys suspected of illness were typically placed in gang cages containing up to twenty to thirty other monkeys suspected of illness. Upon arrival they were told that most of the monkeys were imported from the island of Sumatra . The investigation team found no trace of the virus in either case. Following the investigation in Indonesia, an experiment was conducted in the level-4 lab at the CDC campus in DeKalb County , Georgia with thirty-two monkeys: sixteen green monkeys ( Cercopithecus aethiops ) and sixteen crab-eating macaques. Half of the sixteen green monkeys and crab-eating macaques were infected with Reston virus and the other half with Ebola virus. Ebola virus infection was lethal to nearly all monkeys. However, most of the monkeys infected with Reston virus recovered in a month. The surviving monkeys were kept for two years to detect any trace of the virus - none was found. However, the monkeys continued to possess a high level of antibody . Following the test at the CDC campus in DeKalb County, two of the monkeys who had survived Reston virus infection were infected with a very large dose of the Ebola virus in an effort to produce an Ebola vaccine . One of the two monkeys remained resistant; the second died. The physical building in which the outbreak occurred was demolished on 30 May 1995 and a daycare center was constructed in its place. Modern spatial computer simulation indicates that the pathogen could have reached both major airports ( Dulles International Airport and Ronald Reagan Washington National Airport ) in less than 45 minutes assuming direct transmission paths.

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Ebola

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RVSV-ZEBOV vaccine

none Recombinant vesicular stomatitis virus–Zaire Ebola virus ( rVSV-ZEBOV ), also known as Ebola Zaire vaccine live and sold under the brand name Ervebo , is an Ebola vaccine for adults that prevents Ebola caused by the Zaire ebolavirus . When used in ring vaccination , rVSV-ZEBOV has shown a high level of protection. Around half the people given the vaccine have mild to moderate adverse effects that include headache, fatigue, and muscle pain. rVSV-ZEBOV is a recombinant , replication-competent viral vector vaccine . It consists of rice-derived recombinant human serum albumin and live attenuated recombinant vesicular stomatitis virus (VSV), which has been genetically engineered to express the main glycoprotein from the Zaire ebolavirus so as to provoke a neutralizing immune response to the Ebola virus. The vaccine was approved for medical use in the European Union and the United States in 2019. It was created by scientists at the National Microbiology Laboratory in Winnipeg, Manitoba , Canada, which is part of the Public Health Agency of Canada (PHAC). PHAC licensed it to a small company, Newlink Genetics, which started developing the vaccine; Newlink in turn licensed it to Merck in 2014. It was used in the DR Congo in a 2018 outbreak in Équateur province , and has since been used extensively in the 2018–20 Kivu Ebola outbreak , with over 90,000 people vaccinated. Nearly 800 people were ring vaccinated on an emergency basis with VSV-EBOV when another Ebola outbreak occurred in Guinea in March 2016. In 2017, in the face of a new outbreak of Ebola in the Democratic Republic of the Congo , the Ministry of Health approved the vaccine's emergency use, but it was not immediately deployed. In April 2019, following a large-scale ring-vaccination scheme in the DRC outbreak, the WHO published the preliminary results of its research, in association with the DRC's Institut National pour la Recherche Biomedicale , into the effectiveness of the ring vaccination program, stating that the rVSV-ZEBOV-GP vaccine had been 97.5% effective at stopping Ebola transmission, relative to no vaccination. In April 2019, following a large-scale ring-vaccination scheme in the DRC outbreak, the WHO published the preliminary results of its research, in association with the DRC's Institut National pour la Recherche Biomedicale , into the effectiveness of the ring vaccination program, stating that the rVSV-ZEBOV-GP vaccine had been 97.5% effective at stopping Ebola transmission, relative to no vaccination. Systemic side effects include headache, feverishness, fatigue, joint and muscle pain, nausea, arthritis, rash, and abnormal sweating. Injection-site side events include injection-site pain, swelling, and redness. rVSV-ZEBOV is a live, attenuated recombinant vesicular stomatitis virus (VSV) in which the gene for the native envelope glycoprotein ( P03522 ) is replaced with that from the Ebola virus ( P87666 ), Kikwit 1995 Zaire strain. Manufacturing of the vaccine for the Phase I trial was done by IDT Biologika. Manufacturing of vaccine for the Phase III trial was done by Merck , using the Vero cell line , which Merck already used to make its RotaTeq vaccine against rotavirus . Scientists working for the Public Health Agency of Canada (PHAC) created the vaccine, and PHAC applied for a patent in 2003. From 2005, to 2009, three animal trials on the virus were published, all of them funded by the Canadian and U.S. governments. In 2005, a single intramuscular injection of the EBOV or MARV vaccine was found to induce completely protective immune responses in nonhuman primates ( crab-eating macaques ) against corresponding infections with the otherwise typically lethal EBOV or MARV. In 2010, PHAC licensed the intellectual property on the vaccine to a small U.S. company called Bioprotection Systems, which was a subsidiary of Newlink Genetics, for US $205,000 and "low single-digit percentage" royalties. Newlink had funding from the U.S. Defense Threat Reduction Agency to develop vaccines. In December 2013, the largest-ever Ebola epidemic started in West Africa, specifically, in Guinea. On August 12, the WHO ruled that offering people infected with Ebola the RVSV-ZEBOV vaccine (which at the time was untested on humans) was ethical, and the Canadian government donated 500 doses of the vaccine to the WHO. In October 2014, Newlink had no vaccine in production and no human trials underway, and there were calls for the Canadian government to cancel the contract. In September or October 2014, Newlink formed a steering committee among the interested parties, including PHAC, the NIH, and the WHO, to plan the clinical development of the vaccine. In October 2014, Newlink Genetics began a Phase I clinical trial of rVSV-ZEBOV on healthy human subjects to evaluate the immune response, identify any side effects and determine the appropriate dosage. Phase I trials took place in Gabon, Kenya, Germany, Switzerland, the US, and Canada. In November 2014, Newlink exclusively licensed rights to the vaccine to Merck for US $50 million plus royalties. The Phase I study started with a high dose which caused arthritis and skin reactions in some people, and the vaccine was found replicating in the synovial fluid of the joints of the affected people; the clinical trial was halted because of that, then recommenced with a lower dose. In March 2015, a Phase II clinical trial and a Phase III started in Guinea at the same time; the Phase II trial focused on frontline health workers, while the Phase III trial was a ring vaccination in which close contacts of people who had contracted Ebola virus were vaccinated with VSV-EBOV. In January 2016, the GAVI Alliance signed an agreement with Merck under which Merck agreed to provide VSV-EBOV vaccine for future outbreaks of Ebola and GAVI paid Merck US$5 million ; Merck will use the funds to complete clinical trials and obtain regulatory approval. As of that date, Merck had submitted an application to the World Health Organization (WHO) through their Emergency Use Assessment and Listing (EUAL) program to allow for use of the vaccine in the case of another epidemic. It was used on an emergency basis in Guinea in March 2016. Results of the Phase III Guinea trial were published in December 2016. It was widely reported in the media that vaccine was safe and appeared to be nearly 100% effective, but the vaccine remained unavailable for commercial use as of December 2016. In April 2017, scientists from the U.S. National Academy of Medicine (NAM) published a review of the response to the Ebola outbreak that included a discussion of how clinical trial candidates were selected, how trials were designed and conducted, and reviewed the data resulting from the trials. The committee found that data from the Phase III Guinea trial were difficult to interpret for several reasons. The trial had no placebo arm; it was omitted for ethical reasons and everyone involved, including the committee, agreed with the decision. This left only a delayed treatment group to serve as a control, but this group was eliminated after an interim analysis showed high levels of protection, which left the trial even more underpowered . The committee found that under an intention-to-treat analysis , the rVSV-ZEBOV vaccine might have had no efficacy, agreed with the authors of the December 2016 report that it probably had some efficacy, but found statements that it had substantial or 100% efficacy to be unsupportable. In April 2019, following a large-scale ring-vaccination scheme in the DRC outbreak, preliminary results showed that the vaccine had been 97.5% effective at stopping Ebola transmission, relative to no vaccination. In September 2019, the US Food and Drug Administration (FDA) accepted Merck's Biologics License Application and granted priority review for the vaccine. In October 2019, the European Medicines Agency (EMA) recommended granting conditional marketing authorization for the rVSV-ZEBOV-GP vaccine. In November 2019, the European Commission granted a conditional marketing authorization to Ervebo and the World Health Organization (WHO) prequalified an Ebola vaccine for the first time, indicating that the vaccine met WHO standards for quality, safety and efficacy, and allowing UN agencies and GAVI to procure vaccine for distributions. In December 2019, Ervebo was approved for use in the United States. The approval of Ervebo was supported by a study conducted in Guinea during the 2014-2016 outbreak in individuals 18 years of age and older. The study was a randomized cluster (ring) vaccination study in which 3,537 contacts, and contacts of contacts, of individuals with laboratory-confirmed Ebola virus disease (EVD) received either "immediate" or 21-day "delayed" vaccination with Ervebo. This noteworthy design was intended to capture a social network of individuals and locations that might include dwellings or workplaces where a patient spent time while symptomatic, or the households of individuals who had contact with the patient during that person's illness or death. In a comparison of cases of EVD among 2,108 individuals in the "immediate" vaccination arm and 1,429 individuals in the "delayed" vaccination arm, Ervebo was determined to be 100% effective in preventing Ebola cases with symptom onset greater than ten days after vaccination. No cases of EVD with symptom onset greater than ten days after vaccination were observed in the "immediate" cluster group, compared with ten cases of EVD in the 21-day "delayed" cluster group. In additional studies, antibody responses to Ervebo were assessed in 477 individuals in Liberia, approximately 500 individuals in Sierra Leone and approximately 900 individuals in Canada, Spain, and the US. The antibody responses among those in the study conducted in Canada, Spain and the US were similar to those among individuals in the studies conducted in Liberia and Sierra Leone. The safety of Ervebo was assessed in approximately 15,000 individuals in Africa, Europe and North America. The most commonly reported side effects were pain, swelling and redness at the injection site, as well as headache, fever, joint and muscle aches and fatigue. The application for Ervebo in the United States was granted priority review , a tropical disease priority review voucher, and breakthrough therapy designation. The US Food and Drug Administration (FDA) granted approval for Ervebo to Merck & Co., Inc. Merck discontinued development of the related rVSV vaccines for Marburg virus ( rVSV-MARV ) and Sudan ebolavirus ( rVSV-SUDV ). Merck returned the rights on these vaccines back to Public Health Agency of Canada. The knowledge on developing rVSV vaccines which Merck gained with GAVI funding remains Merck's, and cannot be used by anyone else wishing to develop a rVSV vaccine. In July 2023, the FDA expanded the approval of Ervebo for use in people aged 12 months through 17 years of age. Ervebo was approved for use in people aged 18 years of age and older in December 2019. During an outbreak in the Democratic Republic of the Congo in 2018 , the ZEBOV vaccine was used, and what was once contact tracing which numbered 1,706 individuals (ring vaccination which totaled 3,330) was reduced to zero on June 28, 2018. The outbreak completed the required 42-day cycle on July 24. On August 1, 2018, an EVD outbreak was declared in North Kivu DRC. After six months the current totals stand at 735 total cases and 371 deaths; violence in the region has helped the spread of the virus. Preliminary results show ring vaccination with the vaccine has been highly effective at reducing Ebola transmission. During an outbreak in the Democratic Republic of the Congo in 2018 , the ZEBOV vaccine was used, and what was once contact tracing which numbered 1,706 individuals (ring vaccination which totaled 3,330) was reduced to zero on June 28, 2018. The outbreak completed the required 42-day cycle on July 24. On August 1, 2018, an EVD outbreak was declared in North Kivu DRC. After six months the current totals stand at 735 total cases and 371 deaths; violence in the region has helped the spread of the virus. Preliminary results show ring vaccination with the vaccine has been highly effective at reducing Ebola transmission.

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Ebola

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Ron Klain

Ronald Alan Klain ( / ˈ k l eɪ n / KLAYN ; born August 8, 1961) is an American attorney, political consultant, and former lobbyist who served as White House chief of staff under President Joe Biden from 2021 to 2023. A Democrat , Klain previously served as chief of staff to two vice presidents: Al Gore from 1995 to 1999 and Biden from 2009 to 2011. He was also appointed by President Barack Obama as White House Ebola Response Coordinator after the appearance of Ebola virus cases in the United States , serving from 2014 to 2015. Throughout 2020 he worked as a senior advisor to Biden's presidential campaign . Following his victory, Biden announced on November 12 that Klain would serve as White House chief of staff. During his tenure as chief of staff, Klain was often characterized as a key ally of the progressive wing of the Democratic Party within the White House. In January 2023, Klain announced his plans to step down as chief of staff in the weeks after Biden's State of the Union address in February. He was succeeded in the role by Jeff Zients on February 7. Ronald Alan Klain was born in Indianapolis , Indiana, to Stanley Klain, a building contractor, and Sarann Warner ( née Horwitz), a travel agent. Klain is Jewish. He graduated from North Central High School in 1979 and was on the school's Brain Game team which finished as season runner-up. A first-generation college graduate, he received his Bachelor of Arts degree, summa cum laude , from Georgetown University in 1983. In 1987, he received his Juris Doctor degree, magna cum laude , from Harvard Law School , where he was an editor of the Harvard Law Review . From 1983 to 1984, Klain served as legislative director for U.S. representative Ed Markey (D–MA). Klain was a law clerk for Supreme Court justice Byron White during the 1987 and 1988 terms. From 1989 to 1992, he served as chief counsel to the U.S. Senate Committee on the Judiciary , overseeing the legal staff's work on matters of constitutional law, criminal law, antitrust law, and Supreme Court nominations, including the 1991 Clarence Thomas Supreme Court nomination . In 1995, Senator Tom Daschle appointed him the staff director of the Senate Democratic Leadership Committee. Klain joined the Clinton-Gore campaign in 1992 and was involved in both of Bill Clinton 's presidential campaigns. He oversaw Clinton's judicial nominations. In the White House, Klain was Associate Counsel to the President, directing judicial selection efforts and leading the team that won confirmation of Supreme Court Justice Ruth Bader Ginsburg . In 1994, he became chief of staff and counselor to Attorney General Janet Reno and in 1995, chief of staff to Al Gore . Klain continued to serve as Gore's chief of staff following the official launch of Gore's presidential campaign on June 16, 1999. On August 2, 1999, Klain resigned from the role to join the Washington, D.C., office of O'Melveny & Myers , a law firm. As general counsel of Gore's Recount Committee, Klain oversaw the November–December 2000 recount of votes in Florida , which ended when the Supreme Court put an end to the counting and George W. Bush was named the winner. During the early primaries of the 2004 presidential campaign, Klain worked as an adviser to Wesley Clark during Clark's run for president. After John Kerry won the Democratic nomination, Klain became heavily involved behind the scenes in his campaign. Klain served as an informal adviser to Evan Bayh who is from Klain's home state of Indiana. In 2005, Klain left his partnership at O'Melveny & Myers to become executive vice president and general counsel of Revolution LLC , a technology venture capital firm launched by AOL co-founder Steve Case . At the time of his October 2014 appointment as Ebola response coordinator, he was general counsel at Revolution LLC and President of Case Holdings. Klain was one of the people who assisted Barack Obama in his preparation for the 2008 United States presidential debates . On November 12, 2008, Roll Call announced that Klain had been chosen to serve as chief of staff to Vice President Joe Biden , the same role he served for Gore. Klain had worked with Biden, having served as counsel to the United States Senate Committee on the Judiciary while Biden chaired the committee and assisted Biden's speechwriting team during the 1988 presidential campaign . In May 2010, amid concerns about whether the now-defunct solar-panel company Solyndra was viable, Klain gave the go-ahead for an Obama visit to the factory, and stated in an email to White House advisor Valerie Jarrett that "the reality is that if POTUS visited 10 such places over the next 10 months, probably a few will be belly-up by election day 2012." Klain was mentioned as a possible replacement for White House chief of staff Rahm Emanuel , but opted to leave the White House in January 2011 and return to Case Holdings, where he oversaw Revolution LLC and assisted Steve Case and his wife, Jean Case , in administering the Case Foundation . On October 17, 2014, Klain was appointed the " Ebola response coordinator " sometimes referred to as Ebola "czar." Although Klain, according to Julie Hirschfeld Davis writing in The New York Times , had "no record or expertise in Ebola specifically or public health in general," the choice was praised by Ezra Klein for his bureaucratic experience with coordinating agencies. His term as Ebola response coordinator ended in February 2015. After his term as Ebola czar, Klain worked as an external advisor to the Skoll Foundation Global Threats Fund. He also served as chairman, public advocate and private advisor for Higher Grounds Labs, which describes itself as supporting "start-ups building products that help progressives win." In 2015, Klain joined Hillary Clinton 's ultimately-unsuccessful presidential campaign . He helped Clinton prepare for the Democratic primary debates , as well as the presidential debates against Republican nominee Donald Trump . After Trump's election, he continued to work at Revolution LLC, and repeatedly criticized the administration in op-eds and television appearances. During the 2020 Biden campaign, Klain served as an advisor on the COVID-19 pandemic . In April 2020 he told Wired : "If we're going to make Covid-19 go away, we're going to need a very high vaccination rate. The number one public health challenge of 2021 is going to be getting people to take the vaccine." He helped Biden prepare for the presidential debates against Trump. On November 11, 2020, it was announced that President-elect Joe Biden had selected Klain to be White House Chief of Staff . Klain has received praise for his organizational abilities and for his responsiveness while serving as President Biden's chief of staff, while drawing criticism for being overly concerned with élite opinion, as reflected by his active Twitter presence, and for being too aligned with his party's left bloc. During his first year in his position, Klain used Twitter, saying "I find being on Twitter useful as an early-warning system of things that, to be honest, reporters are talking about." He also uses the platform to take aim at critics and to push pro-Biden messages. In October 2022, the Office of Special Counsel found that Klain had violated the Hatch Act and was warned not to do so again. Klain was seen as a highly impactful chief of staff who achieved major legislative victories such as passing the American Rescue Plan Act and the Infrastructure Investment and Jobs Act . Klain resigned on a high note for the Biden Administration following an unexpectedly strong showing in the 2022 midterm elections and signs of easing inflation. On January 21, 2023, it was reported that Klain would resign as chief of staff in the period following the 2023 State of the Union Address on February 7. On February 1, 2023, the White House held a goodbye transition event for Klain. Klain returned to legal services firm, O'Melveny & Myers LLP as a partner, on April 18, 2023, to lead its Strategic Counseling and Crisis Management Practice. On November 20, 2023, Airbnb announced that Klain would join the company as chief legal officer. During the run-up to the 2024 presidential election , Klain publicly warned the Biden reelection campaign to refocus on immediate economic problems affecting American voters such as inflation rather than long-term projects such as infrastructure investments. From 1983 to 1984, Klain served as legislative director for U.S. representative Ed Markey (D–MA). Klain was a law clerk for Supreme Court justice Byron White during the 1987 and 1988 terms. From 1989 to 1992, he served as chief counsel to the U.S. Senate Committee on the Judiciary , overseeing the legal staff's work on matters of constitutional law, criminal law, antitrust law, and Supreme Court nominations, including the 1991 Clarence Thomas Supreme Court nomination . In 1995, Senator Tom Daschle appointed him the staff director of the Senate Democratic Leadership Committee. Klain joined the Clinton-Gore campaign in 1992 and was involved in both of Bill Clinton 's presidential campaigns. He oversaw Clinton's judicial nominations. In the White House, Klain was Associate Counsel to the President, directing judicial selection efforts and leading the team that won confirmation of Supreme Court Justice Ruth Bader Ginsburg . In 1994, he became chief of staff and counselor to Attorney General Janet Reno and in 1995, chief of staff to Al Gore . Klain continued to serve as Gore's chief of staff following the official launch of Gore's presidential campaign on June 16, 1999. On August 2, 1999, Klain resigned from the role to join the Washington, D.C., office of O'Melveny & Myers , a law firm. As general counsel of Gore's Recount Committee, Klain oversaw the November–December 2000 recount of votes in Florida , which ended when the Supreme Court put an end to the counting and George W. Bush was named the winner. During the early primaries of the 2004 presidential campaign, Klain worked as an adviser to Wesley Clark during Clark's run for president. After John Kerry won the Democratic nomination, Klain became heavily involved behind the scenes in his campaign. Klain served as an informal adviser to Evan Bayh who is from Klain's home state of Indiana. In 2005, Klain left his partnership at O'Melveny & Myers to become executive vice president and general counsel of Revolution LLC , a technology venture capital firm launched by AOL co-founder Steve Case . At the time of his October 2014 appointment as Ebola response coordinator, he was general counsel at Revolution LLC and President of Case Holdings. Klain was one of the people who assisted Barack Obama in his preparation for the 2008 United States presidential debates . On November 12, 2008, Roll Call announced that Klain had been chosen to serve as chief of staff to Vice President Joe Biden , the same role he served for Gore. Klain had worked with Biden, having served as counsel to the United States Senate Committee on the Judiciary while Biden chaired the committee and assisted Biden's speechwriting team during the 1988 presidential campaign . In May 2010, amid concerns about whether the now-defunct solar-panel company Solyndra was viable, Klain gave the go-ahead for an Obama visit to the factory, and stated in an email to White House advisor Valerie Jarrett that "the reality is that if POTUS visited 10 such places over the next 10 months, probably a few will be belly-up by election day 2012." Klain was mentioned as a possible replacement for White House chief of staff Rahm Emanuel , but opted to leave the White House in January 2011 and return to Case Holdings, where he oversaw Revolution LLC and assisted Steve Case and his wife, Jean Case , in administering the Case Foundation . On October 17, 2014, Klain was appointed the " Ebola response coordinator " sometimes referred to as Ebola "czar." Although Klain, according to Julie Hirschfeld Davis writing in The New York Times , had "no record or expertise in Ebola specifically or public health in general," the choice was praised by Ezra Klein for his bureaucratic experience with coordinating agencies. His term as Ebola response coordinator ended in February 2015. After his term as Ebola czar, Klain worked as an external advisor to the Skoll Foundation Global Threats Fund. He also served as chairman, public advocate and private advisor for Higher Grounds Labs, which describes itself as supporting "start-ups building products that help progressives win." In 2015, Klain joined Hillary Clinton 's ultimately-unsuccessful presidential campaign . He helped Clinton prepare for the Democratic primary debates , as well as the presidential debates against Republican nominee Donald Trump . After Trump's election, he continued to work at Revolution LLC, and repeatedly criticized the administration in op-eds and television appearances. During the 2020 Biden campaign, Klain served as an advisor on the COVID-19 pandemic . In April 2020 he told Wired : "If we're going to make Covid-19 go away, we're going to need a very high vaccination rate. The number one public health challenge of 2021 is going to be getting people to take the vaccine." He helped Biden prepare for the presidential debates against Trump. On November 11, 2020, it was announced that President-elect Joe Biden had selected Klain to be White House Chief of Staff . Klain has received praise for his organizational abilities and for his responsiveness while serving as President Biden's chief of staff, while drawing criticism for being overly concerned with élite opinion, as reflected by his active Twitter presence, and for being too aligned with his party's left bloc. During his first year in his position, Klain used Twitter, saying "I find being on Twitter useful as an early-warning system of things that, to be honest, reporters are talking about." He also uses the platform to take aim at critics and to push pro-Biden messages. In October 2022, the Office of Special Counsel found that Klain had violated the Hatch Act and was warned not to do so again. Klain was seen as a highly impactful chief of staff who achieved major legislative victories such as passing the American Rescue Plan Act and the Infrastructure Investment and Jobs Act . Klain resigned on a high note for the Biden Administration following an unexpectedly strong showing in the 2022 midterm elections and signs of easing inflation. On January 21, 2023, it was reported that Klain would resign as chief of staff in the period following the 2023 State of the Union Address on February 7. On February 1, 2023, the White House held a goodbye transition event for Klain. Klain returned to legal services firm, O'Melveny & Myers LLP as a partner, on April 18, 2023, to lead its Strategic Counseling and Crisis Management Practice. On November 20, 2023, Airbnb announced that Klain would join the company as chief legal officer. During the run-up to the 2024 presidential election , Klain publicly warned the Biden reelection campaign to refocus on immediate economic problems affecting American voters such as inflation rather than long-term projects such as infrastructure investments. Klain is married to Monica Medina , an attorney, consultant, and co-founder of Our Daily Planet, an environmental news platform. They were college sweethearts at Georgetown and in February 2019 he tweeted that they were celebrating their 40th Valentine's Day together. They have three adult children, Hannah, Michael and Daniel. In financial disclosures, Klain reported owning assets worth between $4.4–12.2 million in 2021 compared to between $1.4–3.5 million in 2009. He received a salary of almost $2 million in 2020 from the venture capital firm Revolution LLC , where he served as general counsel and executive vice president. In 2009, he reported earning a salary of $1 million. Klain lives in what The New York Times calls the "verdant power enclave" of Chevy Chase, Maryland , with neighbors that include Chief Justice John Roberts and Justice Brett Kavanaugh . He has referred to his large home as "the House That O'Melveny Built," after his lucrative time at the international law firm O'Melveny & Myers. Klain was portrayed by Kevin Spacey in the HBO film Recount , which depicted the tumult of the 2000 presidential election . In 2021, he was included in the Time 100 , Time ' s annual list of the 100 most influential people in the world. In 2023, Klain was portrayed by Jon Levine in season four of For All Mankind , which takes place in an alternate timeline in which Al Gore wins the 2000 election and Klain becomes the White House liaison to NASA .

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Ebola

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Ebola-chan

Ebola-chan is an Internet meme depicting a moe anthropomorphization of the Ebola virus and was popularized on 4chan . The first known image of Ebola-chan began on the Japanese social media site, Pixiv , in 2014. A few days after, it was posted 4chan's /pol/ (politically incorrect) thread , who began posting messages praising Ebola-chan. Soon after, 4chan users began spreading the meme to Nairaland , the largest online message board in Nigeria, accompanying images of Ebola-chan with racist messages and associated conspiracy theories . This included claims that Ebola was CIA -made and that white people were performing rituals for Ebola to spread. The meme's spread has been considered racist and has been attributed to increased mistrust between West Africans and medical professionals.In 2014, ebola virus epidemic broke out in West Africa. The first cases of the outbreak were recorded in Guinea in December 2013. Subsequently, the outbreak spread to the neighbouring countries of Liberia and Sierra Leone , with addition outbreaks in Nigeria and Mali . The epidemic would go on to receive widespread, world-wide media coverage, with increased public awareness and concern over the virus and its transmission. The first known image of the "Ebola-chan" meme was originally published on Pixiv on August 4, 2014. On August 7, 2014, Ebola-chan was posted to the /pol/ thread on 4chan. The image was accompanied with a tongue-in-cheek message that would threaten users with death and pain if they did not reply with the phrase "I Love You Ebola-chan." The image began appearing on Reddit , Facebook , and DeviantArt , with users often making comments such as "GOOD LUCK EBOLA-CHAN!" and "HAIL BLOOD-GODDESS! HAIL EBOLA-CHAN!", accompanied with racist messages. Users on 4chan began uploading the meme to Nairaland, in an effort to "increase tensions between blacks and whites in Africa" by convincing people in West Africa that Ebola was created by the white race , taking advantage of African beliefs in voodoo . These images would include makeshift shrines and allusions to death cults, blood sacrifices , and demon worship . While the initial post was mostly seen as an attempt at ' trolling' , many Nigerian users of the site were later convinced that American and European users were performing "magical rituals in order to spread the disease and kill people" and regarded Ebola-chan as a plague goddess. Other threads would promote the conspiracy theory that Ebola was CIA-made and being intentionally spread by the United States. This would expand into users claiming that Ebola doctors were part of the cult and intentionally spreading the illness. In September 2014, 4chan administrators began removing posts of Ebola-chan from the site. On October 9, 2014, a man walking his dog in East Longmeadow, Massachusetts found an altar containing an image of Ebola-chan. Accompanying this was a carved wooden mask, an unlit candle, Christmas decorations, sheets of paper with incomprehensible writing and symbols, and a bowl of rice mixed with twigs and fake blood. The police investigating the shrine believe it was connected to a recent total lunar eclipse , or a blood moon. Ebola-chan is an anime anthropomorphization of the Ebola virus. The character has a long pink hair that curls in the characteristic shape of Ebola. Ebola-chan has been described as being caucasian-stylized . Ebola-chan was often depicted wearing a nurse outfit and holding a bloodied-skull. Some depictions of the character include small purple demon wings and a happy disposition. Oftentime, the character would be depicted in a sexualized manner, alongside a lesbian partner. Ebola-chan has been criticized as racially motivated and a concerted effort to increase black-white tensions. During the height of the outbreak, aid workers reported they faced mistrust and misinformation in affected communities, with many West Africans believing that the disease was the work of 'sorcerers'. The International Business Times and Washington Post would describe Ebola-chan as an exacerbating factor. Ebola-chan has been compared to the gijinka ISIS-chan , as they were both used to personify controversial topics. In 2020, during the COVID-19 pandemic , 4chan would create Corona-chan , a personification of coronavirus which would also be compared to Ebola-chan.

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Ebola drug

Potential Ebola drugs include:

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Ebola

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Eddie Watson

Eddie Samuel Obong Watson Jr. (born May 22, 1980) is a Liberian -born Ghanaian actor and producer. He received his first Ghanaian Movie Award in 2014 for his film Ebola which he wrote, directed and produced. Watson's professional acting career started in 2010 with Labour of Love. He later went on the same year to star in the African war movie, Somewhere in Africa , where he had a supporting role. Costar Majid Michel suggested Watson to the director, Frank Rajah , for the role of a new character being introduced in the sequel 4Play Reloaded of the already popular 4Play by Venus Films. His supporting role in Frank Rajah 's Somewhere in Africa earned him a nomination at the Nollywood & African Films Critics Awards ( NAFCA ). The following year, Watson had roles in movies like A Reason to Kill and Single Six and by 2011 the actor has made his first move into Nollywood when he starred alongside Queen Nwokoye in Desperate Heart. With movies like Single and Married in 2012, House of Gold , Letters to My Mother and Purple Rose in 2013 the actor soon became a house-hold name in African entertainment. The year 2014, was a bitter sweet year for Watson. West Africa and Watson's home country, Liberia , which was one of the worst affected by the Ebola virus . Watson wrote, produced and directed the short film, Ebola. The year also brought many nominations for the actor for different roles in films such as Bachelors, Sister at War and Purple Rose. And for the first time he was nominated in two different categories for the Ghana Movie Award (Best Actor in Lead Role for Bachelors and Best Short Film for Ebola, which he won) . The actor has now produced two major movies; Jack & Jill and She Prayed. On Saturday, December 5, 2015, Eddie Watson premiered She Prayed in Sierra Leone with support from some of the cast and other African movie stars including Majid Michel , Beverly Osu and Melvin Oduah . The screening of She Prayed is said to be the biggest show in all the premieres and all international shows in 2015 in Sierra Leone . The movie banked an impressive 98% hold of its premiere rating. Eddie Watson married his partner of two years, actress Naomi Baaba Watson, in a private ceremony. The couple welcomed their first child, Emirror (Emi) Cassia Watson on February 2, 2015. Watson took to his Instagram page to share the passing of his mother Leonora Caulker on May 27, 2021.Eddie Watson's documentary film "Ebola" was one of his humanitarian efforts after the outbreak hit West Africa in 2014. The film was meant to educate people in areas affected by the disease. The film was totally financed by Eddie Watson himself and was distributed to most media houses in countries affected plus others in the region of publication and also throughout the internet without a single charge from the actor. He launched the "We Need Help-Ebola Campaign" the same year the film was shot with the Twitter hashtag #WeNeedHelpEbola. The Ebola documentary film starred some popular faces in Ghana 's movie and music industries including Yvonne Nelson and Sarkodie and more. Later that year, the film went on to win Best Short Film Movie at the Ghana Movie Awards ( GMA ). List of Selected Movies Television

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Ebola

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Ebolavirus

The genus Ebolavirus ( / i ˈ b oʊ l ə / - or / ə ˈ b oʊ l ə ˌ v aɪ r ə s / ; ee- BOH -lə - or ə- BOH -lə- VY -rəs ) is a virological taxon included in the family Filoviridae (filament-shaped viruses), order Mononegavirales . The members of this genus are called ebolaviruses, and encode their genome in the form of single-stranded negative-sense RNA . The six known virus species are named for the region where each was originally identified: Bundibugyo ebolavirus , Reston ebolavirus , Sudan ebolavirus , Taï Forest ebolavirus (originally Côte d'Ivoire ebolavirus ), Zaire ebolavirus , and Bombali ebolavirus . The last is the most recent species to be named and was isolated from Angolan free-tailed bats in Sierra Leone . Each species of the genus Ebolavirus has one member virus, and four of these cause Ebola virus disease (EVD) in humans, a type of hemorrhagic fever having a very high case fatality rate . The Reston virus has caused EVD in other primates. Zaire ebolavirus has the highest mortality rate of the ebolaviruses and is responsible for the largest number of outbreaks of the six known species of the genus, including the 1976 Zaire outbreak and the outbreak with the most deaths (2014). Ebolaviruses were first described after outbreaks of EVD in southern Sudan in June 1976 and in Zaire in August 1976. The name Ebolavirus is derived from the Ebola River in Zaire (now the Democratic Republic of the Congo ), near the location of the 1976 outbreak, and the taxonomic suffix -virus (denoting a viral genus). This genus was introduced in 1998 as the "Ebola-like viruses". In 2002, the name was changed to Ebolavirus and in 2010, the genus was emended. Ebolaviruses are closely related to marburgviruses .Ebolavirus is a filamentous, enveloped virus within the order Mononegavirales which also contains rabies and measles viruses. This order is characterized by non-segmented, single-stranded negative-sense RNA (-ssRNA) genomes that are surrounded by a helical nucleocapsid. Filoviruses encode seven different proteins that include: NP (nucleoprotein), VP35 (part of the polymerase complex), VP40 (matrix protein), GP (glycoprotein spike), VP30 (transcription activator), VP42 (second matrix protein), and L (RdRp). Of these proteins, GP and NP proteins are crucial for viral entry and replication. GP is the protein responsible for pathogenic differences among ebolaviruses. GP encodes two glycoproteins, one of which is sGP (soluble glycoprotein) which has a role in Ebola pathogenesis. Research has suggested that sGP is able to subvert the host immune response increasing the EBOV pathogenesis. NP contains both the filoviral genome and the antigenome. NP oligomerization is responsible for the NC (helical nucleocapsid) formation which allows the -ssRNA genome to be protected against host cell degradation by endonucleases and host immune response. NP is also shown to recruit host cell proteins to facilitate virus transcription and replication within the cytoplasm. Researchers have found evidence of Ebola infection in three species of fruit bat. The bats show no symptoms of the disease, indicating that they may be the main natural reservoirs of the Ebolavirus. It is possible that there are other reservoirs and vectors. Understanding where the virus incubates between outbreaks and how it is transmitted between species will help protect humans and other primates from the virus. The researchers found that bats of three species – Franquet's epauletted fruit bat ( Epomops franqueti ), the hammer-headed bat ( Hypsignathus monstrosus ) and the little collared fruit bat ( Myonycteris torquata ) – had either genetic material from the Ebola virus, known as RNA sequences, or evidence of an immune response to the disease. The bats showed no symptoms themselves. The Bombali ebolavirus (BOMV) was isolated from the little free-tailed bat ( Chaerephon pumilus ) and the Angolan free-tailed bat ( Mops condylurus ) in Sierra Leone . The entry pathway that the virus uses is a key step in its cycle. Several pathways have been suggested for Ebolavirus such as phagocytosis and clathrin and caveolin mediated endocytosis. However, Nanbo et al. (2010) and Saeed et al. (2010) independently proved that neither of these pathways is actually used. They discovered that Ebolavirus uses macropinocytosis to enter the host cells. Induction of macropinocytosis leads to the formation of macropinocytosis-specific endosomes (macropinosomes), which are large enough to accommodate Ebola virions. This discovery was proven by the fact that Ebolavirus co-localizes with sorting nexin 5 (SNX5), which consists of a large family of peripheral membrane proteins that associate with newly formed macropinosomes. Also, blocking the macropinocytosis pathway has been proven to stop Ebolavirus from entering the cells. Four different macropinocytosis specific inhibitors were tested: cytochalasin D (depolymerizing agent), wortmannin (Wort), LY-294002 (both are inhibitors of PI3K) and EIPA (5-(N-ethyl-N-isopropyl) amiloride), an inhibitor of the Na+/H+ exchanger specific for pinocytosis. Then, internalized EBOV particles are transported to late endosomes and, there, co-localization with GTPase Rab7 (marker of late endosomes) is observed. Mutation of both Rab5 and Rab7 GTPases additionally inhibits viral entry. After trafficking to late endosomes, Ebola virus binds the intracellular receptor Neimann-Pick C1 (NPC1) and the viral membrane fuses with the endosomal membrane, allowing the virus to release its genome into the cytoplasm. The main reason that there are not many available treatments is that Ebola is such a severe virus, with a 90% fatality rate. It can only be explored in a BSL-4 laboratory which is very selective. In order for it to be studied more widely, BSL-2 laboratories have been able to use systems that are substitutes for the actual infectious virus. Scientists have used pseudo types that have the same glycoprotein on the surface that is used for entry into the host cell. They also use noninfectious Ebola-like particles as a replacement system to study. The search for a vaccine for Ebola began immediately after it was first discovered in 1976. There are currently only two FDA approved drugs. In October 2020 Immazab was officially approved and in December 2020, Ebanga was also officially approved. The difference between the two treatments is that Immazeb uses three monoclonal antibodies whereas Ebanga only has one monoclonal antibody. Both of these treatments are designed to attack the glycoprotein in order to prevent the virus from entering a new host cell and replicating. Besides these two drugs, there is more general treatment care such as managing symptoms that are caused by Ebola such as vomiting, fever, diarrhea, and any pain. According to the rules for taxon naming established by the International Committee on Taxonomy of Viruses (ICTV), the name of the genus Ebolavirus is always to be capitalized , italicized , never abbreviated, and to be preceded by the word "genus". The names of its members (ebolaviruses) are to be written in lower case, are not italicized, and used without articles . A virus of the family Filoviridae is a member of the genus Ebolavirus if The genera Ebolavirus and Marburgvirus were originally classified as the species of the now-obsolete genus Filovirus . In March 1998, the Vertebrate Virus Subcommittee proposed in the International Committee on Taxonomy of Viruses (ICTV) to change the genus Filovirus to the family Filoviridae with two specific genera: Ebola-like viruses and Marburg-like viruses . This proposal was implemented in Washington, D.C., as of April 2001 and in Paris as of July 2002. In 2000, another proposal was made in Washington, D.C., to change the "-like viruses" to "-virus" resulting in today's Ebolavirus and Marburgvirus . Five characterised species of the genus Ebolavirus are:Rates of genetic change are 8*10 −4 per site per year and are thus one fourth as fast as influenza A in humans. Extrapolating backwards , Ebolavirus and Marburgvirus probably diverged several thousand years ago. A study done in 1995 and 1996 found that the genes of Ebolavirus and Marburgvirus differed by about 55% at the nucleotide level, and at least 67% at the amino acid level. The same study found that the strains of Ebolavirus differed by about 37–41% across the nucleotide level and 34–43% across the amino acid level. The EBOV strain was found to have an almost 2% change in the nucleotide level from the original 1976 strain from the Yambuki outbreak and the strain from the 1995 Kikwit outbreak. However, paleoviruses of filoviruses found in mammals indicate that the family itself is at least tens of millions of years old. The genus Ebolavirus has been organized into six species; however, the nomenclature has proven somewhat controversial, with many authors continuing to use common names rather than species names when referring to these viruses. In particular, the generic term "Ebola virus" is widely used to refer specifically to members of the species Zaire ebolavirus . Consequently, in 2010, a group of researchers recommended that the name "Ebola virus" be adopted for a subclassification [note 1] within the species Zaire ebolavirus and that similar common names be formally adopted for other Ebolavirus species. In 2011, the International Committee on Taxonomy of Viruses (ICTV) rejected a proposal (2010.010bV) to formally recognize these names, as they do not designate names for subtypes, variants, strains, or other subspecies level groupings. As such, the widely used common names are not formally recognized as part of the taxonomic nomenclature. In particular, "Ebola virus" does not have an official meaning recognized by ICTV, and rather they continue to use and recommend only the species designation Zaire ebolavirus . The threshold for putting isolates into different species is usually a difference of more than 30% at the nucleotide level, compared to the type strain . If a virus is in a given species but differs from the type strain by more than 10% at the nucleotide level, it is proposed that it be named as a new virus. As of 2019 [ update ] , none of the Ebolavirus species contain members divergent enough to receive more than one "virus" designation. A 2013 study isolated antibodies from fruit bats in Bangladesh, against Ebola Zaire and Reston viruses , thus identifying potential virus hosts and signs of the filoviruses in Asia. A recent alignment-free analysis of Ebola virus genomes from the current outbreak reveals the presence of three short DNA sequences that appear nowhere in the human genome, suggesting that the identification of specific species sequences may prove to be useful for the development of both diagnosis and therapeutics.

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Gluten Free Ebola

" Gluten Free Ebola " is the second episode in the eighteenth season of the American animated television series South Park . The 249th overall episode, it was written and directed by series co-creator Trey Parker . The episode premiered on Comedy Central in the United States on October 1, 2014. The episode lampoons the trend of the gluten-free diet lifestyle and the constant changes recommended to the Western pattern diet and the current food guide .Following the events of " Go Fund Yourself ", Stan , Cartman , Kyle , and Kenny return to school, only to find themselves ostracized and ridiculed for their recent actions. Meanwhile, at a meeting, Mr. Mackey gloats about his newfound gluten-free diet , greatly annoying other staff. In order to gain back their popularity, Cartman decides to throw a party for a "cause", choosing Scott Malkinson 's diabetes . They announce the party over the local radio station WSPIC, with Principal Victoria , who had earlier been converted into gluten-free by Mr. Mackey, asking whether it has gluten-free foods, for which the boys have no response. Later at the community center, a scientist from the United States Department of Agriculture tries to explain that the rumors about gluten being bad are false by extracting gluten from a piece of dough made of wheat. Mr. Mackey pressures him to drink the gluten sample in order to back the scientist's claims; he complies, and abruptly starts to violently die, sending the entire town into anarchy. Cartman, who's in a panicked state, calls Kyle and tells him that the whole town has taken all the food with gluten and the party cannot happen. The USDA tries to find a way to end the crisis. At the Marsh residence, two USDA agents enter and find a can of beer in the garbage, which Randy sees no problem with. Unknown to him, beer contains wheat, which ends up getting him quarantined at a Papa John's restaurant with Mr. Garrison and an unnamed civilian. Cartman then has a dream of Aunt Jemima (a parody reference to Mother Abigail ), who tells him the food pyramids are upside-down, but Cartman has no idea what she is talking about. As the gluten-free toppings at the Papa John's run out, the unnamed resident eats the pizza dough containing gluten, thinking it's all a setup, but he dies shortly afterwards. At the radio station, Stan, Kyle, and Kenny announced that they have canceled the party to focus their efforts on addressing the public about the dangers of gluten. Cartman, claiming that he knows how to solve the crisis, calls the USDA and tells them that the food pyramid is upside down. Much to their surprise, the new dietary system works. The boys then throw a successful party with Stan reconciling with Wendy , leading her to ask him to dance with her as the credits appended "GF" (gluten-free) to a handful of the cast and crew.The idea for the episode came from Trey Parker and Matt Stone noticing how people they work with, and society in general, were going on gluten-free diets. It became so common that they went on diets themselves and thought it would be fun to do an episode mocking themselves. The episode received a C from The A.V. Club ' s Josh Mordell. Mordell found the gluten-free panic "reasonably funny", but felt the episode lacked a B-story. Similarly, IGN 's contributor Max Nicholson gave the episode a 7 out of 10, praising the panic caused by gluten products, but was also disappointed with the storyline following the boys' party, noting that "the radio show segments were among the least funny South Park moments in recent memory". Spin magazine 's Brennan Carley criticized the Lorde parody, asking: "has Lorde ever really done anything all that worthy of drawing the cartoon creators' ire?" South Park responded by a subplot in the following week's episode " The Cissy ", featuring a Spin reporter named "Brandon Carlile" investigating the concert and stating: "It would be a shame if someone was…having fun at her expense."

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Olivia Hallisey

Olivia Hallisey is an American scientist at Stanford University . Previously, she attended Greenwich High School in Greenwich, Connecticut . While a junior in high school, she won first prize in the 2015 Google Science Fair for inventing a low-cost, rapid test for Ebola . The prize also came with $50,000. According to Hallisey, her test can be completed in as little as 30 minutes at a cost of $25, and, unlike existing ebola detection methods, does not require refrigeration. She became interested in fighting Ebola while watching the 2014 West Africa Ebola outbreak in which thousands of people died. In 2016, she was presented as a debutante at Le Bal des débutantes in Paris.

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2018 Democratic Republic of the Congo Ebola virus disease outbreak

2018 DRC Ebola virus outbreak could mean:

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Ebola

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Ebola (band)

Ebola (อีโบล่า) is a Thai rock band from Bangkok , currently signed to ME Records . The band is most known for their songs "Saeng Sawang" (แสงสว่าง - Enlighten), "Klab Su Jud Reum Ton" (กลับสู่จุดเริ่มต้น - Back to Beginning), and "Sing Tee Chan Pen" (สิ่งที่ฉันเป็น - As I Am).Ebola was formed in 1996 while the members were studying at Dhonburi Rajabhat University. They spent years performing under the name Ebola, mainly as an underground band, and gained popularity with their energetic live performances. Ebola released three records (one EP and two studio albums) under independent labels, namely E.P 97 (Demo – 1997), In My Hate (1999) and Satisfy (2001). The band released their first live album, Ebola Live , under the distribution of Warner Music Thailand in 2002. Later that year, they also released their Live to Play VCD. Ebola gained wider attention when they released Pole , their third studio album, in 2004. Ebola had the opportunity to perform as the opening act for Linkin Park and Slipknot during their 2004 tours in Thailand. Enlighten was released in August 2005. The album contained chart-topping hits including "Saeng Sawang" (แสงสว่าง - Enlighten), "Klab Su Jud Reum Ton" (กลับสู่จุดเริ่มต้น - Back to Beginning), and "Sing Tee Chan Pen" (สิ่งที่ฉันเป็น - As I Am). The band's long-time producer, Warut Rintranuku, won Best Producer at the 2005 Seed Awards , and they won the Best Rock Album award from Hamburger magazine. [ citation needed ] On 25 March 2006 the celebrate their 10th anniversary, the band held Survivor Concert . The concert took place at Thunder Dome, Muang Thong Thani. In April 2007, the single "Sing Tee Chan Pen" (สิ่งที่ฉันเป็น - As I Am) was selected to be a theme song of the movie Me ... Myself . The film, produced and directed by Pongpat Wachirabunjong , starred Ananda Everingham and Chayanan Manomaisantibhap. The Way was their fifth album: its lead single was "Wi Tee Thang" (วิถีทาง - The Way) in August 2007. Ebola was nominated for Producer of the Year, Rock Album of the Year, and Rock Artist of the Year at the 2007 Seed Awards but didn't win. In 2009, it was revealed that Ebola had signed a new contract with GMM Grammy. Collaborating internationally, the band worked with the Philippine rock band Rivermaya on the song "Thang Leuk" (ทางเลือก - The Choice). The Way was mastered by Dave Collins. In 2010, Ebola released their sixth studio album, titled 5:59 . The album contained singles such as "Aow Hai Tai" (เอาให้ตาย - To The Death) and "Wan Tee Mai Mee Jing" (วันที่ไม่มีจริง - The Day That Doesn't Exist). In 2011, Ebola opened for Linkin Park 's Live in Bangkok A Thousand Suns World Tour 2011. Ebola released their seventh studio album via Warner Music in 2013, entitled Still Alive (EP: 2013) . Kittisak "Aey" Buaphan – Lead vocals Wannit "Golf" Puntarikapa – Lead guitar Surapong "Ao" Buaphan – Rhythm guitar Chaowalit "A" Prasongsin – Bass guitar Pongpan "Pan" Peonimit – DrumsE.P.97 (Demo) (1997) In My Hate (1998) Satisfy (2000) Pole (2004) Enlighten (2005) The Way (2007) 5:59 (2010) Still Alive (EP: 2013) (2013)EBOLA LIVE (2002) SURVIVOR CONCERT (2006)DEMONIC CONCERT (1997) EBOLA LIVE (2002) CAMPUS TOUR (2002) PATTAYA MUSIC FESTIVAL (2003) EBOLA POLE LIVE (2004) TERRITORY (2004) DEMONIC CONCERT (2004) LINKIN PARK: LIVE IN BANGKOK (2004) SLIPKNOT: LIVE IN BANGKOK (2004) EBOLA ENLIGHTEN SEED CONCERT (2005) 100 ROCK CONCERT (2005) EBOLA SURVIVOR CONCERT (2006) LINKIN PARK: A THOUSAND SUNS TOUR LIVE IN BANGKOK (2011) G16* (genie fest 16)(*only Aey Ebola as special guest for sweet mullet's cover of เอาให้ตาย) (2014) BLACK VALETINES (2020)

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Ebola

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Marburg virus disease

Marburg virus disease ( MVD ; formerly Marburg hemorrhagic fever ) is a viral hemorrhagic fever in human and non-human primates caused by either of the two Marburgviruses : Marburg virus (MARV) and Ravn virus (RAVV). Its clinical symptoms are very similar to those of Ebola virus disease (EVD). Egyptian fruit bats are believed to be the normal carrier in nature and Marburg virus RNA has been isolated from them. The most detailed study on the frequency, onset, and duration of MVD clinical signs and symptoms was performed during the 1998–2000 mixed MARV/RAVV disease outbreak. A skin rash , red or purple spots (e.g. petechiae or purpura ), bruises , and hematomas (especially around needle injection sites) are typical hemorrhagic manifestations. However, contrary to popular belief, hemorrhage does not lead to hypovolemia and is not the cause of death (total blood loss is minimal except during labor ). Instead, death occurs due to multiple organ dysfunction syndrome (MODS) due to fluid redistribution, hypotension , disseminated intravascular coagulation , and focal tissue necroses . Clinical phases of Marburg hemorrhagic fever's presentation are described below. Note that phases overlap due to variability between cases.MVD is caused by two viruses; Marburg virus (MARV) and Ravn virus (RAVV) , family Filoviridae. : 458 Marburgviruses are endemic in arid woodlands of equatorial Africa . Most marburgvirus infections were repeatedly associated with people visiting natural caves or working in mines . In 2009, the successful isolation of infectious MARV and RAVV was reported from healthy Egyptian fruit bat caught in caves. This isolation strongly suggests that Old World fruit bats are involved in the natural maintenance of marburgviruses and that visiting bat-infested caves is a risk factor for acquiring marburgvirus infections. Further studies are necessary to establish whether Egyptian rousettes are the actual hosts of MARV and RAVV or whether they get infected via contact with another animal and therefore serve only as intermediate hosts. Another risk factor is contact with nonhuman primates, although only one outbreak of MVD (in 1967) was due to contact with infected monkeys. Contrary to Ebola virus disease (EVD) , which has been associated with heavy rains after long periods of dry weather, triggering factors for spillover of marburgviruses into the human population have not yet been described.MVD is clinically indistinguishable from Ebola virus disease (EVD) , and it can also easily be confused with many other diseases prevalent in Equatorial Africa , such as other viral hemorrhagic fevers , falciparum malaria , typhoid fever , shigellosis , rickettsial diseases such as typhus , cholera , gram-negative sepsis , borreliosis such as relapsing fever or EHEC enteritis . Other infectious diseases that ought to be included in the differential diagnosis include leptospirosis , scrub typhus , plague , Q fever , candidiasis , histoplasmosis , trypanosomiasis , visceral leishmaniasis , hemorrhagic smallpox , measles , and fulminant viral hepatitis . Non-infectious diseases that can be confused with MVD are acute promyelocytic leukemia , hemolytic uremic syndrome , snake envenomation , clotting factor deficiencies/platelet disorders, thrombotic thrombocytopenic purpura , hereditary hemorrhagic telangiectasia , Kawasaki disease , and even warfarin intoxication. The most important indicator that may lead to the suspicion of MVD at clinical examination is the medical history of the patient, in particular the travel and occupational history (which countries and caves were visited?) and the patient's exposure to wildlife (exposure to bats or bat excrements?). MVD can be confirmed by isolation of marburgviruses from or by detection of marburgvirus antigen or genomic or subgenomic RNAs in patient blood or serum samples during the acute phase of MVD. Marburgvirus isolation is usually performed by inoculation of grivet kidney epithelial Vero E6 or MA-104 cell cultures or by inoculation of human adrenal carcinoma SW-13 cells, all of which react to infection with characteristic cytopathic effects . Filovirions can easily be visualized and identified in cell culture by electron microscopy due to their unique filamentous shapes, but electron microscopy cannot differentiate the various filoviruses alone despite some overall length differences. Immunofluorescence assays are used to confirm marburgvirus presence in cell cultures. During an outbreak, virus isolation and electron microscopy are most often not feasible options. The most common diagnostic methods are therefore RT-PCR in conjunction with antigen-capture ELISA , which can be performed in field or mobile hospitals and laboratories. Indirect immunofluorescence assays (IFAs) are not used for diagnosis of MVD in the field anymore. [ citation needed ] Marburg virus disease (MVD) is the official name listed in the World Health Organization 's International Statistical Classification of Diseases and Related Health Problems 10 (ICD-10) for the human disease caused by any of the two marburgviruses Marburg virus (MARV) and Ravn virus (RAVV). In the scientific literature, Marburg hemorrhagic fever (MHF) is often used as an unofficial alternative name for the same disease. Both disease names are derived from the German city Marburg , where MARV was first discovered. Marburg virus disease (MVD) is the official name listed in the World Health Organization 's International Statistical Classification of Diseases and Related Health Problems 10 (ICD-10) for the human disease caused by any of the two marburgviruses Marburg virus (MARV) and Ravn virus (RAVV). In the scientific literature, Marburg hemorrhagic fever (MHF) is often used as an unofficial alternative name for the same disease. Both disease names are derived from the German city Marburg , where MARV was first discovered. The details of the initial transmission of MVD to humans remain incompletely understood. Transmission most likely occurs from Egyptian fruit bats or another natural host, such as non-human primates or through the consumption of bushmeat , but the specific routes and body fluids involved are unknown. Human-to-human transmission of MVD occurs through direct contact with infected bodily fluids such as blood. Transmission events are relatively rare – there have been only 11 recorded outbreaks of MARV between 1975 and 2011, with one event involving both MARV and RAVV. There are currently no Food and Drug Administration -approved vaccines for the prevention of MVD. Many candidate vaccines have been developed and tested in various animal models. Of those, the most promising ones are DNA vaccines or based on Venezuelan equine encephalitis virus replicons , vesicular stomatitis Indiana virus (VSIV) or filovirus-like particles (VLPs) as all of these candidates could protect nonhuman primates from marburgvirus-induced disease. DNA vaccines have entered clinical trials. Marburgviruses are highly infectious , but not very contagious . They do not get transmitted by aerosol during natural MVD outbreaks. Due to the absence of an approved vaccine, prevention of MVD therefore relies predominantly on quarantine of confirmed or high probability cases, proper personal protective equipment , and sterilization and disinfection . [ citation needed ] The natural maintenance hosts of marburgviruses remain to be identified unequivocally. However, the isolation of both MARV and RAVV from bats and the association of several MVD outbreaks with bat-infested mines or caves strongly suggests that bats are involved in Marburg virus transmission to humans. Avoidance of contact with bats and abstaining from visits to caves is highly recommended, but may not be possible for those working in mines or people dependent on bats as a food source. [ citation needed ] Since marburgviruses are not spread via aerosol, the most straightforward prevention method during MVD outbreaks is to avoid direct (skin-to-skin) contact with patients, their excretions and body fluids , and any possibly contaminated materials and utensils. Patients should be isolated, but still are safe to be visited by family members. Medical staff should be trained in and apply strict barrier nursing techniques (disposable face mask, gloves, goggles, and a gown at all times). Traditional burial rituals, especially those requiring embalming of bodies, should be discouraged or modified, ideally with the help of local traditional healers . Marburgviruses are World Health Organization Risk Group 4 Pathogens, requiring Biosafety Level 4-equivalent containment , laboratory researchers have to be properly trained in BSL-4 practices and wear proper personal protective equipment.The natural maintenance hosts of marburgviruses remain to be identified unequivocally. However, the isolation of both MARV and RAVV from bats and the association of several MVD outbreaks with bat-infested mines or caves strongly suggests that bats are involved in Marburg virus transmission to humans. Avoidance of contact with bats and abstaining from visits to caves is highly recommended, but may not be possible for those working in mines or people dependent on bats as a food source. [ citation needed ]Since marburgviruses are not spread via aerosol, the most straightforward prevention method during MVD outbreaks is to avoid direct (skin-to-skin) contact with patients, their excretions and body fluids , and any possibly contaminated materials and utensils. Patients should be isolated, but still are safe to be visited by family members. Medical staff should be trained in and apply strict barrier nursing techniques (disposable face mask, gloves, goggles, and a gown at all times). Traditional burial rituals, especially those requiring embalming of bodies, should be discouraged or modified, ideally with the help of local traditional healers . Marburgviruses are World Health Organization Risk Group 4 Pathogens, requiring Biosafety Level 4-equivalent containment , laboratory researchers have to be properly trained in BSL-4 practices and wear proper personal protective equipment.There is currently no effective marburgvirus-specific therapy for MVD. Treatment is primarily supportive in nature and includes minimizing invasive procedures, balancing fluids and electrolytes to counter dehydration , administration of anticoagulants early in infection to prevent or control disseminated intravascular coagulation , administration of procoagulants late in infection to control hemorrhaging , maintaining oxygen levels, pain management , and administration of antibiotics or antifungals to treat secondary infections. Although supportive care can improve survival chances, marburg virus disease is fatal in the majority of cases. As of 2023 [ update ] the case fatality rate was assessed to be 61.9%. The WHO identifies marburg virus disease as having pandemic potential. Below is a table of outbreaks concerning MVD from 1967 to 2023: MVD was first documented in 1967, when 31 people became ill in the German towns of Marburg and Frankfurt am Main , and in Belgrade , Yugoslavia . The outbreak involved 25 primary MARV infections and seven deaths, and six nonlethal secondary cases. The outbreak was traced to infected grivets (species Chlorocebus aethiops ) imported from an undisclosed location in Uganda and used in developing poliomyelitis vaccines . The monkeys were received by Behringwerke, a Marburg company founded by the first winner of the Nobel Prize in Medicine , Emil von Behring . The company, which at the time was owned by Hoechst , was originally set up to develop sera against tetanus and diphtheria . Primary infections occurred in Behringwerke laboratory staff while working with grivet tissues or tissue cultures without adequate personal protective equipment . Secondary cases involved two physicians , a nurse , a post-mortem attendant, and the wife of a veterinarian . All secondary cases had direct contact, usually involving blood, with a primary case. Both physicians became infected through accidental skin pricks when drawing blood from patients. In 1975, an Australian tourist became infected with MARV in Rhodesia (today Zimbabwe ). He died in a hospital in Johannesburg , South Africa . His girlfriend and an attending nurse were subsequently infected with MVD, but survived. A case of MARV infection occurred in 1980 in Kenya . A French man, who worked as an electrical engineer in a sugar factory in Nzoia (close to Bungoma ) at the base of Mount Elgon (which contains Kitum Cave ), became infected by unknown means and died on 15 January shortly after admission to Nairobi Hospital. The attending physician contracted MVD, but survived. A popular science account of these cases can be found in Richard Preston 's book The Hot Zone (the French man is referred to under the pseudonym "Charles Monet", whereas the physician is identified under his real name, Shem Musoke). In 1987, a single lethal case of RAVV infection occurred in a 15-year-old Danish boy, who spent his vacation in Kisumu , Kenya . He had visited Kitum Cave on Mount Elgon prior to travelling to Mombasa , where he developed clinical signs of infection. The boy died after transfer to Nairobi Hospital. A popular science account of this case can be found in Richard Preston 's book The Hot Zone (the boy is referred to under the pseudonym "Peter Cardinal"). In 1988, researcher Nikolai Ustinov infected himself lethally with MARV after accidentally pricking himself with a syringe used for inoculation of guinea pigs . The accident occurred at the Scientific-Production Association "Vektor" (today the State Research Center of Virology and Biotechnology "Vektor" ) in Koltsovo , USSR (today Russia ). Very little information is publicly available about this MVD case because Ustinov's experiments were classified. A popular science account of this case can be found in Ken Alibek 's book Biohazard . Another laboratory accident occurred at the Scientific-Production Association "Vektor" (today the State Research Center of Virology and Biotechnology "Vektor" ) in Koltsovo , USSR , when a scientist contracted MARV by unknown means. A major MVD outbreak occurred among illegal gold miners around Goroumbwa mine in Durba and Watsa , Democratic Republic of Congo from 1998 to 2000, when co-circulating MARV and RAVV caused 154 cases of MVD and 128 deaths. The outbreak ended with the flooding of the mine. In early 2005, the World Health Organization (WHO) began investigating an outbreak of viral hemorrhagic fever in Angola , which was centered in the northeastern Uíge Province but also affected many other provinces. The Angolan government had to ask for international assistance, pointing out that there were only approximately 1,200 doctors in the entire country, with some provinces having as few as two. Health care workers also complained about a shortage of personal protective equipment such as gloves, gowns, and masks. Médecins Sans Frontières (MSF) reported that when their team arrived at the provincial hospital at the center of the outbreak, they found it operating without water and electricity . Contact tracing was complicated by the fact that the country's roads and other infrastructure were devastated after nearly three decades of civil war and the countryside remained littered with land mines . Americo Boa Vida Hospital in the Angolan capital Luanda set up a special isolation ward to treat infected people from the countryside. Unfortunately, because MVD often results in death, some people came to view hospitals and medical workers with suspicion and treated helpers with hostility. For instance, a specially-equipped isolation ward at the provincial hospital in Uíge was reported to be empty during much of the epidemic, even though the facility was at the center of the outbreak. WHO was forced to implement what it described as a "harm reduction strategy", which entailed distributing disinfectants to affected families who refused hospital care. Of the 252 people who contracted MVD during outbreak, 227 died. In 2007, four miners became infected with marburgviruses in Kamwenge District , Uganda . The first case, a 29-year-old man, became symptomatic on July 4, 2007, was admitted to a hospital on July 7, and died on July 13. Contact tracing revealed that the man had had prolonged close contact with two colleagues (a 22-year-old man and a 23-year-old man), who experienced clinical signs of infection before his disease onset. Both men had been admitted to hospitals in June and survived their infections, which were proven to be due to MARV. A fourth, 25-year-old man, developed MVD clinical signs in September and was shown to be infected with RAVV. He also survived the infection. On July 10, 2008, the Netherlands National Institute for Public Health and the Environment reported that a 41-year-old Dutch woman, who had visited Python Cave in Maramagambo Forest during her holiday in Uganda , had MVD due to MARV infection, and had been admitted to a hospital in the Netherlands . The woman died under treatment in the Leiden University Medical Centre in Leiden on July 11. The Ugandan Ministry of Health closed the cave after this case. On January 9 of that year an infectious diseases physician notified the Colorado Department of Public Health and the Environment that a 44-year-old American woman who had returned from Uganda had been hospitalized with a fever of unknown origin . At the time, serologic testing was negative for viral hemorrhagic fever . She was discharged on January 19, 2008. After the death of the Dutch patient and the discovery that the American woman had visited Python Cave, further testing confirmed the patient demonstrated MARV antibodies and RNA . In October 2017 an outbreak of Marburg virus disease was detected in Kween District , Eastern Uganda. All three initial cases (belonging to one family – two brothers and one sister) had died by 3 November. The fourth case – a health care worker – developed symptoms on 4 November and was admitted to a hospital. The first confirmed case traveled to Kenya before the death. A close contact of the second confirmed case traveled to Kampala . It is reported that several hundred people may have been exposed to infection. In August 2021, two months after the re-emergent Ebola epidemic in the Guéckédou prefecture was declared over, a case of the Marburg disease was confirmed by health authorities through laboratory analysis. Other potential case of the disease in a contact awaits official results. This was the first case of the Marburg hemorrhagic fever confirmed to happen in West Africa. The case of Marburg also has been identified in Guéckédou . During the outbreak, a total of one confirmed case, who died ( CFR =100%), and 173 contacts were identified, including 14 high-risk contacts based on exposure. Among them, 172 were followed for a period of 21 days, of which none developed symptoms. One high-risk contact was lost to follow up. Sequencing of an isolate from the Guinean patient showed that this outbreak was caused by the Angola-like Marburg virus. A colony of Egyptian rousettus bats ( reservoir host of Marburg virus ) was found in close proximity (4.5 km) to the village, where the Marburg virus disease outbreak emerged in 2021. Two sampled fruit bats from this colony were PCR-positive on the Marburg virus. In July 2022, preliminary analysis of samples taken from two patients – both deceased – in Ghana indicated the cases were positive for Marburg. However, per standard procedure, the samples were sent to the Pasteur Institute of Dakar for confirmation. On 17 July 2022 the two cases were confirmed by Ghana, which caused the country to declare a Marburg virus disease outbreak. An additional case was identified, bringing the total to three. A disease outbreak was first reported in Equatorial Guinea on 7 February 2023, and on 13 February 2023, it was identified as being Marburg virus disease. It was the first time the disease was detected in the country. Neighbouring Cameroon detected two suspected cases of Marburg virus disease on 13 February 2023, but they were later ruled out. On 25 February, a suspected case of Marburg was reported in the Spanish city of Valencia , however this case was subsequently discounted. As of 4 April 2023, there were 14 confirmed cases and 28 suspected cases, including ten confirmed deaths from the disease in Equatorial Guinea. On 8 June 2023, the World Health Organization declared the outbreak over. In total, 17 laboratory-confirmed cases and 12 deaths were recorded. All the 23 probable cases reportedly died. Four patients recovered from the virus and have been enrolled in a survivors programme to receive psychosocial and other post-recovery support. A Marburg virus disease outbreak in Tanzania was first reported on 21 March 2023 by the Ministry of Health of Tanzania. This was the first time that Tanzania had reported an outbreak of the disease. On 2 June 2023, Tanzania declared the outbreak over. There were 9 total infections, resulting in 6 total deaths. The WHO identifies marburg virus disease as having pandemic potential. Below is a table of outbreaks concerning MVD from 1967 to 2023:MVD was first documented in 1967, when 31 people became ill in the German towns of Marburg and Frankfurt am Main , and in Belgrade , Yugoslavia . The outbreak involved 25 primary MARV infections and seven deaths, and six nonlethal secondary cases. The outbreak was traced to infected grivets (species Chlorocebus aethiops ) imported from an undisclosed location in Uganda and used in developing poliomyelitis vaccines . The monkeys were received by Behringwerke, a Marburg company founded by the first winner of the Nobel Prize in Medicine , Emil von Behring . The company, which at the time was owned by Hoechst , was originally set up to develop sera against tetanus and diphtheria . Primary infections occurred in Behringwerke laboratory staff while working with grivet tissues or tissue cultures without adequate personal protective equipment . Secondary cases involved two physicians , a nurse , a post-mortem attendant, and the wife of a veterinarian . All secondary cases had direct contact, usually involving blood, with a primary case. Both physicians became infected through accidental skin pricks when drawing blood from patients. In 1975, an Australian tourist became infected with MARV in Rhodesia (today Zimbabwe ). He died in a hospital in Johannesburg , South Africa . His girlfriend and an attending nurse were subsequently infected with MVD, but survived. A case of MARV infection occurred in 1980 in Kenya . A French man, who worked as an electrical engineer in a sugar factory in Nzoia (close to Bungoma ) at the base of Mount Elgon (which contains Kitum Cave ), became infected by unknown means and died on 15 January shortly after admission to Nairobi Hospital. The attending physician contracted MVD, but survived. A popular science account of these cases can be found in Richard Preston 's book The Hot Zone (the French man is referred to under the pseudonym "Charles Monet", whereas the physician is identified under his real name, Shem Musoke). In 1987, a single lethal case of RAVV infection occurred in a 15-year-old Danish boy, who spent his vacation in Kisumu , Kenya . He had visited Kitum Cave on Mount Elgon prior to travelling to Mombasa , where he developed clinical signs of infection. The boy died after transfer to Nairobi Hospital. A popular science account of this case can be found in Richard Preston 's book The Hot Zone (the boy is referred to under the pseudonym "Peter Cardinal"). In 1988, researcher Nikolai Ustinov infected himself lethally with MARV after accidentally pricking himself with a syringe used for inoculation of guinea pigs . The accident occurred at the Scientific-Production Association "Vektor" (today the State Research Center of Virology and Biotechnology "Vektor" ) in Koltsovo , USSR (today Russia ). Very little information is publicly available about this MVD case because Ustinov's experiments were classified. A popular science account of this case can be found in Ken Alibek 's book Biohazard . Another laboratory accident occurred at the Scientific-Production Association "Vektor" (today the State Research Center of Virology and Biotechnology "Vektor" ) in Koltsovo , USSR , when a scientist contracted MARV by unknown means. A major MVD outbreak occurred among illegal gold miners around Goroumbwa mine in Durba and Watsa , Democratic Republic of Congo from 1998 to 2000, when co-circulating MARV and RAVV caused 154 cases of MVD and 128 deaths. The outbreak ended with the flooding of the mine. In early 2005, the World Health Organization (WHO) began investigating an outbreak of viral hemorrhagic fever in Angola , which was centered in the northeastern Uíge Province but also affected many other provinces. The Angolan government had to ask for international assistance, pointing out that there were only approximately 1,200 doctors in the entire country, with some provinces having as few as two. Health care workers also complained about a shortage of personal protective equipment such as gloves, gowns, and masks. Médecins Sans Frontières (MSF) reported that when their team arrived at the provincial hospital at the center of the outbreak, they found it operating without water and electricity . Contact tracing was complicated by the fact that the country's roads and other infrastructure were devastated after nearly three decades of civil war and the countryside remained littered with land mines . Americo Boa Vida Hospital in the Angolan capital Luanda set up a special isolation ward to treat infected people from the countryside. Unfortunately, because MVD often results in death, some people came to view hospitals and medical workers with suspicion and treated helpers with hostility. For instance, a specially-equipped isolation ward at the provincial hospital in Uíge was reported to be empty during much of the epidemic, even though the facility was at the center of the outbreak. WHO was forced to implement what it described as a "harm reduction strategy", which entailed distributing disinfectants to affected families who refused hospital care. Of the 252 people who contracted MVD during outbreak, 227 died. In 2007, four miners became infected with marburgviruses in Kamwenge District , Uganda . The first case, a 29-year-old man, became symptomatic on July 4, 2007, was admitted to a hospital on July 7, and died on July 13. Contact tracing revealed that the man had had prolonged close contact with two colleagues (a 22-year-old man and a 23-year-old man), who experienced clinical signs of infection before his disease onset. Both men had been admitted to hospitals in June and survived their infections, which were proven to be due to MARV. A fourth, 25-year-old man, developed MVD clinical signs in September and was shown to be infected with RAVV. He also survived the infection. On July 10, 2008, the Netherlands National Institute for Public Health and the Environment reported that a 41-year-old Dutch woman, who had visited Python Cave in Maramagambo Forest during her holiday in Uganda , had MVD due to MARV infection, and had been admitted to a hospital in the Netherlands . The woman died under treatment in the Leiden University Medical Centre in Leiden on July 11. The Ugandan Ministry of Health closed the cave after this case. On January 9 of that year an infectious diseases physician notified the Colorado Department of Public Health and the Environment that a 44-year-old American woman who had returned from Uganda had been hospitalized with a fever of unknown origin . At the time, serologic testing was negative for viral hemorrhagic fever . She was discharged on January 19, 2008. After the death of the Dutch patient and the discovery that the American woman had visited Python Cave, further testing confirmed the patient demonstrated MARV antibodies and RNA . In October 2017 an outbreak of Marburg virus disease was detected in Kween District , Eastern Uganda. All three initial cases (belonging to one family – two brothers and one sister) had died by 3 November. The fourth case – a health care worker – developed symptoms on 4 November and was admitted to a hospital. The first confirmed case traveled to Kenya before the death. A close contact of the second confirmed case traveled to Kampala . It is reported that several hundred people may have been exposed to infection. In August 2021, two months after the re-emergent Ebola epidemic in the Guéckédou prefecture was declared over, a case of the Marburg disease was confirmed by health authorities through laboratory analysis. Other potential case of the disease in a contact awaits official results. This was the first case of the Marburg hemorrhagic fever confirmed to happen in West Africa. The case of Marburg also has been identified in Guéckédou . During the outbreak, a total of one confirmed case, who died ( CFR =100%), and 173 contacts were identified, including 14 high-risk contacts based on exposure. Among them, 172 were followed for a period of 21 days, of which none developed symptoms. One high-risk contact was lost to follow up. Sequencing of an isolate from the Guinean patient showed that this outbreak was caused by the Angola-like Marburg virus. A colony of Egyptian rousettus bats ( reservoir host of Marburg virus ) was found in close proximity (4.5 km) to the village, where the Marburg virus disease outbreak emerged in 2021. Two sampled fruit bats from this colony were PCR-positive on the Marburg virus. In July 2022, preliminary analysis of samples taken from two patients – both deceased – in Ghana indicated the cases were positive for Marburg. However, per standard procedure, the samples were sent to the Pasteur Institute of Dakar for confirmation. On 17 July 2022 the two cases were confirmed by Ghana, which caused the country to declare a Marburg virus disease outbreak. An additional case was identified, bringing the total to three. A disease outbreak was first reported in Equatorial Guinea on 7 February 2023, and on 13 February 2023, it was identified as being Marburg virus disease. It was the first time the disease was detected in the country. Neighbouring Cameroon detected two suspected cases of Marburg virus disease on 13 February 2023, but they were later ruled out. On 25 February, a suspected case of Marburg was reported in the Spanish city of Valencia , however this case was subsequently discounted. As of 4 April 2023, there were 14 confirmed cases and 28 suspected cases, including ten confirmed deaths from the disease in Equatorial Guinea. On 8 June 2023, the World Health Organization declared the outbreak over. In total, 17 laboratory-confirmed cases and 12 deaths were recorded. All the 23 probable cases reportedly died. Four patients recovered from the virus and have been enrolled in a survivors programme to receive psychosocial and other post-recovery support. A Marburg virus disease outbreak in Tanzania was first reported on 21 March 2023 by the Ministry of Health of Tanzania. This was the first time that Tanzania had reported an outbreak of the disease. On 2 June 2023, Tanzania declared the outbreak over. There were 9 total infections, resulting in 6 total deaths. Experimentally, recombinant vesicular stomatitis Indiana virus (VSIV) expressing the glycoprotein of MARV has been used successfully in nonhuman primate models as post-exposure prophylaxis. A vaccine candidate has been effective in nonhuman primates. Experimental therapeutic regimens relying on antisense technology have shown promise, with phosphorodiamidate morpholino oligomers (PMOs) targeting the MARV genome New therapies from Sarepta and Tekmira have also been successfully used in humans as well as primates.

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Ebola

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Bibliography of Ebola

This is a bibliography of the Ebola virus disease , also known as Ebola hemorrhagic fever , a viral hemorrhagic fever of humans and other primates caused by ebolaviruses . It includes non-fiction works relating to the background and history of the disease, general works, memoirs of those involved in outbreaks such as health workers, works about the effects on particular groups of individuals, and a link to the World Health Organization list of publications about Ebola.Full list here .

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Ebola

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Ebola virus epidemic in Sierra Leone

An Ebola virus epidemic in Sierra Leone occurred in 2014, along with the neighbouring countries of Guinea and Liberia . At the time it was discovered, it was thought that Ebola virus was not endemic to Sierra Leone or to the West African region and that the epidemic represented the first time the virus was discovered there. However, US researchers pointed to lab samples used for Lassa fever testing to suggest that Ebola had been in Sierra Leone as early as 2006. In 2014, it was discovered that samples of suspected Lassa fever showed evidence of the Zaire strain of Ebola virus in Sierra Leone as early as 2006. Prior to the current Zaire strain outbreak in 2014, Ebola had not really been seen in Sierra Leone, or even in West Africa among humans. It is suspected that fruit bats are natural carriers of disease, native to this region of Africa including Sierra Leone and also a popular food source for both humans and wildlife. The Gola forests in south-east Sierra Leone are a noted source of bushmeat. Bats are known to be carriers of at least 90 different viruses that can make transition to a human host. However, the virus has different symptoms in humans. It takes one to ten viruses to infect a human but there can be millions in a drop of blood from someone very sick from the disease. Transmission is believed to be by contact with the blood and body fluids of those infected with the virus, as well as by handling raw bushmeat such as bats and monkeys, which are important sources of protein in West Africa. Infectious body fluids include blood, sweat, semen, breast milk, saliva, tears, feces, urine, vaginal secretions, vomit, and diarrhea. Even after a successful recovery from an Ebola infection, semen may contain the virus for at least two months. Breast milk may contain the virus for two weeks after recovery, and transmission of the disease to a consumer of the breast milk may be possible. By October 2014, it was suspected that handling a piece of contaminated paper may be enough to contract the disease. Contamination on paper makes it harder to keep records in Ebola clinics, as data about patients written on paper that gets written down in a "hot" zone is hard to pass to a "safe" zone, because if there is any contamination it may bring Ebola into that area. One aspect of Sierra Leone that is alleged to have aided the disease, is the strong desire of many to have very involved funeral practices. For example, for the Kissi people who inhabit part of Sierra Leone, it is important to bury the bodies of the dead near them. Funeral practices include rubbing the corpses down with oil, dressing them in fine clothes, then having those at the funeral hug and kiss the dead body. This may aid the transmission of Ebola, because those that die from Ebola disease are thought to have high concentrations of the virus in their body, even after they have died. For the 2001 outbreak of Sudan virus in Uganda, attending a funeral of an Ebola victim was rated by the Centers for Disease Control and Prevention (CDC) as one of the top three risk factors for contracting Ebola, along with contact with a family member with Ebola or providing medical care to someone with a case of Ebola virus disease. The main start of the outbreak in Sierra Leone was linked to a single funeral in which the World Health Organization (WHO) estimates as many as 365 died from Ebola disease after getting the disease at the funeral. Bushmeat has also been implicated in spreading Ebola disease, either by handling the raw meat or through droppings from the animals. It is the raw blood and meat that is thought to be more dangerous, so it is those that hunt and butcher the raw meat that are more at risk as opposed to cooked meat sold at market. Health care workers in Sierra Leone have been warned not to go to markets. In late March 2014, there were suspected but not confirmed cases in Sierra Leone. The government announced on 31 March 2014, that there were no cases in Sierra Leone. Cases initially started appearing soon after the arrival of US researchers into the area. "After Ebola was first confirmed by laboratory tests in mid-March 2014, persistent rumours in the region linked the outbreak to a US-run research laboratory in Kenema, Sierra Leone (Wilkinson, 2017) ." Two U.S. doctors who "followed all CDC and WHO protocols to the letter" contracted Ebola, and it is not clear how they got infected. By 27 May 2014, it was reported 5 people died from the Ebola virus and there were 16 new cases of the disease. Between 27 May 2014, and 30 May the number of confirmed, probable, or suspected cases of Ebola went from 16 to 50. By 9 June, the number of cases had risen to 42 known and 113 being tested, with a total of 16 known to have died from the disease by that time. The disease spread rapidly in Kenema, and the local government hospital was overwhelmed. At that hospital, 12 nurses died despite having the world's only Lassa fever isolation ward, according to the U.N. Many health are workers were infected at the state hospital, including beloved physician and hemorrhagic fever expert, Dr. Sheik Humarr Khan, and chief nurse Mbalu Fonnie. Khan and his colleagues had bravely provided care to patients with this devastating illness. On 12 June, the country declared a state of emergency in the Kailahun District , where it announced the closure of schools, cinemas, and nightlife places; the district borders both Guinea and Liberia, and all vehicles would be subject to screening at checkpoints. The government declared on 11 June, that its country's borders would be closed to Guinea and Liberia; but many local people cross the borders on unofficial routes which were difficult for authorities to control. Seasonal rains that fall between June and August interfered with the fight against Ebola, and in some cases caused flooding in Sierra Leone. By 11 July 2014, the first case was reported in the capital of Sierra Leone, Freetown, however the person had traveled to the capital from another area of the country. By this time there were over 300 confirmed cases and 99 were confirmed to have died from Ebola. There was another case before the end of the month. On 29 July, well-known physician Sheik Umar Khan , Sierra Leone's only expert on hemorrhagic fever, died after contracting Ebola at his clinic in Kenema . Khan had long worked with Lassa fever , a disease that kills over 5,000 a year in Africa. He had expanded his clinic to accept Ebola patients. Sierra Leone's president, Ernest Bai Koroma, celebrated Khan as a "national hero". On 30 July, Sierra Leone declared a state of emergency and deployed troops to quarantine hot spots. In August, awareness campaigns in Freetown , Sierra Leone's capital, were delivered over the radio and through loudspeakers. Also in August, Sierra Leone passed a law that subjected anyone hiding someone believed to be infected to two years in jail. At the time the law was enacted, a top parliamentarian was critical of failures by neighboring countries to stop the outbreak. Also in early August Sierra Leone cancelled league football (soccer) matches. Within 2 days of 12 September 2014, there were 20 lab-confirmed cases discovered in Freetown, Sierra Leone. One issue was that residents were leaving dead bodies in the street. By 6 September 2014, there were 60 cases of Ebola in Freetown, out of about 1100 nationwide at this time. However, not everyone was bringing cases to doctors, and they were not always being treated. One doctor said the Freetown health system was not functioning, and during this time, respected Freetown Doctor Olivette Buck fell ill and died from Ebola by 14 September 2014. The population of Freetown in 2011 was 941,000. By 18 September 2014, teams of people that buried the dead were struggling to keep up, as 20–30 bodies needed to be buried each day. The teams drove on motor-bikes to collect samples from corpses to see if they died from Ebola. Freetown, Sierra Leone had one laboratory that could do Ebola testing. WHO estimated on 21 September, that Sierra Leone's capacity to treat Ebola cases fell short by the equivalent of 532 beds. Experts pushed for a greater response at this time noting that it could destroy Sierra Leone and Liberia. At that time it was estimated that if it spread through both Liberia and Sierra Leone up to 5 million could be killed; the population of Liberia is about 4.3 million and Sierra Leone is about 6.1 million. In an attempt to control the disease, Sierra Leone imposed a three-day lockdown on its population from 19 to 21 September. During this period 28,500 trained community workers and volunteers went door-to-door providing information on how to prevent infection, as well as setting up community Ebola surveillance teams. The campaign was called the Ouse to Ouse Tock in Krio language . There was concern the 72-hour lock-down could backfire. On 22 September, Stephen Gaojia said that the three-day lock down had obtained its objective and would not be extended. Eighty percent of targeted households were reached in the operation. A total of around 150 new cases were uncovered, but the exact figures would only be known on the following Thursday as the health ministry was still awaiting reports from remote locations. One incident during the lock-down was when a burial team was attacked. On 24 September, President Ernest Bai Koroma added three more districts under "isolation", in an effort to contain the spread. The districts included Port Loko , Bombali , and Moyamba . In the capital, Freetown, all homes with identified cases would be quarantined. This brought the total areas under isolation to 5, including the outbreak "hot spots" Kenema and Kailahun which were already in isolation. Only deliveries and essential services would be allowed in and out. A sharp rise in cases in these areas was also noted by WHO. As of late September, about 2 million people were in areas of restricted travel, which included Kailahun, Kenema, Bombali, Tonkolili, and Port Loko Districts. The number of cases seemed to be doubling every 20 days, which led to the estimate that by January 2015 the number of cases in Liberia and Sierra Leone could grow to 1.4 million. On 25 September, there were 1940 cases and 587 deaths officially, however, many acknowledged under-reporting and there was an increasing number of cases in Freetown (the capital of Sierra Leone). WHO estimated on 21 September, that Sierra Leone's capacity to treat Ebola cases fell short by the equivalent of 532 beds. There were reports that political interference and administrative incompetence had hindered the flow of medical supplies into the country. By 2 October 2014, an estimated 5 people per hour were being infected with the Ebola virus in Sierra Leone. By this time it was estimated the number of infected had been doubling every 20 days. On 4 October, Sierra Leone recorded 121 fatalities, the largest number in a single day. On 8 October, Sierra Leone burial crews went on strike. On 12 October, it was reported that the UK would begin providing military support to Sierra Leone in addition to a major UK civilian operation in support of the Government of Sierra Leone. In October, it was noted hospitals were running out of supplies in Sierra Leone. There were reports that political interference and administrative incompetence hindered the flow of medical supplies into the country. In the week prior to 2 October there were 765 new cases, and Ebola was spreading rapidly. At the start of October, there were nearly 2200 laboratory confirmed cases of Ebola and over 600 had died from it. The epidemic also had claimed the life of 4 doctors and at least 60 nurses by the end of September 2014. Sierra Leone limited its reported deaths to laboratory confirmed cases in facilities, so the actual number of losses was known to be higher. Sierra Leone was considering making reduced care clinics, to stop those sick with Ebola from getting their families sick with the disease and to provide something in between home-care and the full-care clinics. These "isolation centers" would provide an alternative to the overwhelmed clinics. The problem the country was facing was 726 new Ebola cases but less than 330 beds available. More than 160 additional medical personnel from Cuba arrived in early October, building on about 60 that had been there since September. At that time there were about 327 beds for patients in Sierra Leone. Canada announced it was sending a 2nd mobile lab and more staff to Sierra Leone on 4 October 2014. There were reports of drunken grave-diggers making graves for Ebola patients too shallow, and as a result wildlife came and dug up and ate at the corpses. In addition, in some cases bodies were not buried for days, because no one came to collect them. One problem was that it was hard to care for local health care workers, and there was not enough money to evacuate them. Meanwhile, other diseases like malaria, pneumonia, and diarrhea were not being treated properly because the health system was trying to deal with Ebola patients. On 7 October 2014, Canada sent a C-130 loaded with 128,000 face shields to Freetown. In early October 2014, a burial team leader said there were piles of corpses south of Freetown. On 9 October, the International Charter on Space and Major Disasters was activated on Sierra Leone's behalf, the first time that its charitably repurposed satellite imaging assets had been deployed in an epidemiological role. On 14 October 2014, 800 Sierra Leone peacekeepers due to relieve a contingent deployed in Somalia , were placed under quarantine when one of the soldiers tested positive for Ebola. The last district in Sierra Leone untouched by the Ebola virus declared Ebola cases. According to Abdul Sesay, a local health official, 15 suspected deaths with 2 confirmed cases of the deadly disease were reported on 16 October, in the village of Fakonya. The village is 60 miles from the town of Kabala in the center of the mountainous region of the Koinadugu district. This was the last district free from the virus in Sierra Leone. All of the districts in this country had then confirmed cases of Ebola. In late October 2014, the United Kingdom sent one of their hospital ships, the Royal Navy's Argus , to help Sierra Leone. By late October Sierra Leone was experiencing more than twenty deaths a day from Ebola. In October 2014, officials reported that very few pregnant women were surviving Ebola disease. In previous outbreaks pregnant women were noted to have a higher rate of death with Ebola. Officials struggled to maintain order in one town after a medical team trying to take a blood sample from a corpse were blocked by an angry machete-wielding mob. They allegedly believed the person had died from high-blood pressure and did not want the body being tested for Ebola. When security forces tried to defend the medical team, a riot ensued leaving two dead. The town was placed on a 24-hour curfew and authorities tried to calm the situation down. Despite this several buildings were attacked. On 30 October, the ship Argus arrived in Sierra Leone. It carried 32 off-road vehicles to support Ebola treatment units. The ship also carried three transport helicopters to support operations against the epidemic. By the end of October 2014 there were over 5200 laboratory confirmed cases of Ebola virus disease in Sierra Leone. [ citation needed ] On 31 October 2014, an ambulance driver in Bo District died of Ebola. His ambulance picked up Ebola patients (or suspected Ebola cases) and took them to treatment centers. On 1 November, the United Kingdom announced plans to build three more Ebola laboratories in Sierra Leone. The labs helped to determine if a patient had been infected by the Ebola virus. At that time, it took as much as five days to test a sample because of the volume of samples that needed to be tested. On 2 November, a person with Ebola employed by the United Nations was evacuated from Sierra Leone to France for treatment. On 4 November, it was reported that thousands violated quarantine in search for food, in the town of Kenema. On 6 November, it was reported that the situation was "getting worse" due to "intense transmission" in Freetown as a contributing factor; the capital city reported 115 cases in the previous week alone. Food shortages and aggressive quarantines were reported to be making the situation worse, according to the Disaster Emergency Committee. Sierra Leone established call centers in Port Loko and Kambia, according to MSSL Communications as reported on 21 November; this was in addition to the June hotline originally established. On 12 November, more than 400 health workers went on strike over salary issues at one of the few Ebola treatment centers in the country. On 18 November, the supply ship Karel Doorman of the Royal Netherlands Navy ( Koninklijke Marine ) arrived in Freetown, with supplies. Its Captain-Commander, Peter van den Berg, took steps to reduce the chance of the crew contracting Ebola virus disease. The Neini Chiefdom in Koinadugu District was subject to isolation after Ebola cases. On 19 November, it was reported that the Ebola virus was spreading intensely; "much of this was driven by intense transmission in the country's west and north", the WHO said. A British-built Ebola Treatment Centre which started in Kerry Town during November, generated some controversy because of its initially limited capacity. However, this was because they were following guidelines of how to safely open an Ebola treatment unit. This was the first of six planned treatment centres which, when completed, would be staffed by a number of NGOs . In mid-November the WHO reported that while all cases and deaths continued to be under-reported, "there is some evidence that case incidence is no longer increasing nationally in Guinea and Liberia, but steep increases persist in Sierra Leone". On 19 November, it was reported that the Ebola virus was spreading intensely; "much of this was driven by intense transmission in the country's west and north", the WHO said. The first Cuban doctor to be infected with the virus was flown to Geneva. On 26 November, it was reported that due to Sierra Leone's increased Ebola transmission, the country would surpass Liberia in the total cases count. On 27 November, Canada announced it would deploy military health staff to the infected region. On 29 November, the President of Sierra Leone canceled a planned three-day shutdown in Freetown to curb the virus. On 2 December, it was reported that the Tonkolili district had begun a two-week lockdown, "which was agreed in a key stakeholders meeting of cabinet ministers, parliamentarians and paramount chiefs of the district as part of efforts to stem the spread of the disease", according to a ministry spokesman. The move meant that a total of six districts, containing more than half of the population, were locked down. Sierra Leone indicated, in a report on 5 December, that about 100 cases of the virus were now being reported daily. On the same day, it was further reported that families caught taking part in burial washing rituals, which can spread the virus, would be taken to jail. On 6 December, a report indicated that the Canadian Armed Forces would send a medical team to the country of Sierra Leone to help combat the Ebola virus epidemic. On 8 December, the doctors in Sierra Leone went on strike, demanding better treatment for health care workers, according to Health Ministry spokesman Jonathan Abass Kamara. On 9 December, Sierra Leone authorities placed the Eastern Kono District in a two-week lock-down following the alarming rate of infection and deaths there. The lock down lasted until 23 December. This followed the grim discovery of bodies piling up in the district. The WHO reported fear of a major breakout in the area. The district with 350,000 inhabitants buried 87 bodies in 11 days, with 25 patients dying in 5 days before the WHO arrived. On 12 December, Sierra Leone banned all public festivities for Christmas or New Year, because of the outbreak. On 13 December, it was reported that the first Australian facility had been opened; "operations will be gradually scaled up to full capacity at 100 beds under strict guidelines to ensure infection control procedures are working effectively and trained staff ... are in place", one source indicated. Médecins Sans Frontières /Doctors Without Borders, in partnership with the Ministry of Health, carried out during December the largest-ever distribution of antimalarials in Sierra Leone. Teams distributed 1.5 million antimalarial treatments in Freetown and surrounding districts with the aim of protecting people from malaria during the disease's peak season. A spokesman said "In the context of Ebola, malaria is a major concern, because people who are sick with malaria have the same symptoms as people sick with Ebola. As a result, most people turn up at Ebola treatment centres thinking that they have Ebola, when actually they have malaria. It's a huge load on the system, as well as being a huge stress on patients and their families." Between 14 and 17 December Sierra Leone reported 403 new cases with a total of 8,759 cases on the latter date. On 25 December, Sierra Leone put the north area of the country on lockdown. By the end of December Sierra Leone again reported a surge in numbers, with 9,446 cases reported. On 29 December 2014, Pauline Cafferkey , a British aid worker who had just returned to Glasgow from working at the treatment centre in Kerry Town, was diagnosed with Ebola at Glasgow's Gartnavel General Hospital . Two U.S. doctors who "followed all CDC and WHO protocols to the letter" contracted Ebola, and it is not clear how they got infected. By 27 May 2014, it was reported 5 people died from the Ebola virus and there were 16 new cases of the disease. Between 27 May 2014, and 30 May the number of confirmed, probable, or suspected cases of Ebola went from 16 to 50. By 9 June, the number of cases had risen to 42 known and 113 being tested, with a total of 16 known to have died from the disease by that time. The disease spread rapidly in Kenema, and the local government hospital was overwhelmed. At that hospital, 12 nurses died despite having the world's only Lassa fever isolation ward, according to the U.N. Many health are workers were infected at the state hospital, including beloved physician and hemorrhagic fever expert, Dr. Sheik Humarr Khan, and chief nurse Mbalu Fonnie. Khan and his colleagues had bravely provided care to patients with this devastating illness. On 12 June, the country declared a state of emergency in the Kailahun District , where it announced the closure of schools, cinemas, and nightlife places; the district borders both Guinea and Liberia, and all vehicles would be subject to screening at checkpoints. The government declared on 11 June, that its country's borders would be closed to Guinea and Liberia; but many local people cross the borders on unofficial routes which were difficult for authorities to control. Seasonal rains that fall between June and August interfered with the fight against Ebola, and in some cases caused flooding in Sierra Leone. By 11 July 2014, the first case was reported in the capital of Sierra Leone, Freetown, however the person had traveled to the capital from another area of the country. By this time there were over 300 confirmed cases and 99 were confirmed to have died from Ebola. There was another case before the end of the month. On 29 July, well-known physician Sheik Umar Khan , Sierra Leone's only expert on hemorrhagic fever, died after contracting Ebola at his clinic in Kenema . Khan had long worked with Lassa fever , a disease that kills over 5,000 a year in Africa. He had expanded his clinic to accept Ebola patients. Sierra Leone's president, Ernest Bai Koroma, celebrated Khan as a "national hero". On 30 July, Sierra Leone declared a state of emergency and deployed troops to quarantine hot spots. In August, awareness campaigns in Freetown , Sierra Leone's capital, were delivered over the radio and through loudspeakers. Also in August, Sierra Leone passed a law that subjected anyone hiding someone believed to be infected to two years in jail. At the time the law was enacted, a top parliamentarian was critical of failures by neighboring countries to stop the outbreak. Also in early August Sierra Leone cancelled league football (soccer) matches. Within 2 days of 12 September 2014, there were 20 lab-confirmed cases discovered in Freetown, Sierra Leone. One issue was that residents were leaving dead bodies in the street. By 6 September 2014, there were 60 cases of Ebola in Freetown, out of about 1100 nationwide at this time. However, not everyone was bringing cases to doctors, and they were not always being treated. One doctor said the Freetown health system was not functioning, and during this time, respected Freetown Doctor Olivette Buck fell ill and died from Ebola by 14 September 2014. The population of Freetown in 2011 was 941,000. By 18 September 2014, teams of people that buried the dead were struggling to keep up, as 20–30 bodies needed to be buried each day. The teams drove on motor-bikes to collect samples from corpses to see if they died from Ebola. Freetown, Sierra Leone had one laboratory that could do Ebola testing. WHO estimated on 21 September, that Sierra Leone's capacity to treat Ebola cases fell short by the equivalent of 532 beds. Experts pushed for a greater response at this time noting that it could destroy Sierra Leone and Liberia. At that time it was estimated that if it spread through both Liberia and Sierra Leone up to 5 million could be killed; the population of Liberia is about 4.3 million and Sierra Leone is about 6.1 million. In an attempt to control the disease, Sierra Leone imposed a three-day lockdown on its population from 19 to 21 September. During this period 28,500 trained community workers and volunteers went door-to-door providing information on how to prevent infection, as well as setting up community Ebola surveillance teams. The campaign was called the Ouse to Ouse Tock in Krio language . There was concern the 72-hour lock-down could backfire. On 22 September, Stephen Gaojia said that the three-day lock down had obtained its objective and would not be extended. Eighty percent of targeted households were reached in the operation. A total of around 150 new cases were uncovered, but the exact figures would only be known on the following Thursday as the health ministry was still awaiting reports from remote locations. One incident during the lock-down was when a burial team was attacked. On 24 September, President Ernest Bai Koroma added three more districts under "isolation", in an effort to contain the spread. The districts included Port Loko , Bombali , and Moyamba . In the capital, Freetown, all homes with identified cases would be quarantined. This brought the total areas under isolation to 5, including the outbreak "hot spots" Kenema and Kailahun which were already in isolation. Only deliveries and essential services would be allowed in and out. A sharp rise in cases in these areas was also noted by WHO. As of late September, about 2 million people were in areas of restricted travel, which included Kailahun, Kenema, Bombali, Tonkolili, and Port Loko Districts. The number of cases seemed to be doubling every 20 days, which led to the estimate that by January 2015 the number of cases in Liberia and Sierra Leone could grow to 1.4 million. On 25 September, there were 1940 cases and 587 deaths officially, however, many acknowledged under-reporting and there was an increasing number of cases in Freetown (the capital of Sierra Leone). WHO estimated on 21 September, that Sierra Leone's capacity to treat Ebola cases fell short by the equivalent of 532 beds. There were reports that political interference and administrative incompetence had hindered the flow of medical supplies into the country. By 2 October 2014, an estimated 5 people per hour were being infected with the Ebola virus in Sierra Leone. By this time it was estimated the number of infected had been doubling every 20 days. On 4 October, Sierra Leone recorded 121 fatalities, the largest number in a single day. On 8 October, Sierra Leone burial crews went on strike. On 12 October, it was reported that the UK would begin providing military support to Sierra Leone in addition to a major UK civilian operation in support of the Government of Sierra Leone. In October, it was noted hospitals were running out of supplies in Sierra Leone. There were reports that political interference and administrative incompetence hindered the flow of medical supplies into the country. In the week prior to 2 October there were 765 new cases, and Ebola was spreading rapidly. At the start of October, there were nearly 2200 laboratory confirmed cases of Ebola and over 600 had died from it. The epidemic also had claimed the life of 4 doctors and at least 60 nurses by the end of September 2014. Sierra Leone limited its reported deaths to laboratory confirmed cases in facilities, so the actual number of losses was known to be higher. Sierra Leone was considering making reduced care clinics, to stop those sick with Ebola from getting their families sick with the disease and to provide something in between home-care and the full-care clinics. These "isolation centers" would provide an alternative to the overwhelmed clinics. The problem the country was facing was 726 new Ebola cases but less than 330 beds available. More than 160 additional medical personnel from Cuba arrived in early October, building on about 60 that had been there since September. At that time there were about 327 beds for patients in Sierra Leone. Canada announced it was sending a 2nd mobile lab and more staff to Sierra Leone on 4 October 2014. There were reports of drunken grave-diggers making graves for Ebola patients too shallow, and as a result wildlife came and dug up and ate at the corpses. In addition, in some cases bodies were not buried for days, because no one came to collect them. One problem was that it was hard to care for local health care workers, and there was not enough money to evacuate them. Meanwhile, other diseases like malaria, pneumonia, and diarrhea were not being treated properly because the health system was trying to deal with Ebola patients. On 7 October 2014, Canada sent a C-130 loaded with 128,000 face shields to Freetown. In early October 2014, a burial team leader said there were piles of corpses south of Freetown. On 9 October, the International Charter on Space and Major Disasters was activated on Sierra Leone's behalf, the first time that its charitably repurposed satellite imaging assets had been deployed in an epidemiological role. On 14 October 2014, 800 Sierra Leone peacekeepers due to relieve a contingent deployed in Somalia , were placed under quarantine when one of the soldiers tested positive for Ebola. The last district in Sierra Leone untouched by the Ebola virus declared Ebola cases. According to Abdul Sesay, a local health official, 15 suspected deaths with 2 confirmed cases of the deadly disease were reported on 16 October, in the village of Fakonya. The village is 60 miles from the town of Kabala in the center of the mountainous region of the Koinadugu district. This was the last district free from the virus in Sierra Leone. All of the districts in this country had then confirmed cases of Ebola. In late October 2014, the United Kingdom sent one of their hospital ships, the Royal Navy's Argus , to help Sierra Leone. By late October Sierra Leone was experiencing more than twenty deaths a day from Ebola. In October 2014, officials reported that very few pregnant women were surviving Ebola disease. In previous outbreaks pregnant women were noted to have a higher rate of death with Ebola. Officials struggled to maintain order in one town after a medical team trying to take a blood sample from a corpse were blocked by an angry machete-wielding mob. They allegedly believed the person had died from high-blood pressure and did not want the body being tested for Ebola. When security forces tried to defend the medical team, a riot ensued leaving two dead. The town was placed on a 24-hour curfew and authorities tried to calm the situation down. Despite this several buildings were attacked. On 30 October, the ship Argus arrived in Sierra Leone. It carried 32 off-road vehicles to support Ebola treatment units. The ship also carried three transport helicopters to support operations against the epidemic. By the end of October 2014 there were over 5200 laboratory confirmed cases of Ebola virus disease in Sierra Leone. [ citation needed ] On 31 October 2014, an ambulance driver in Bo District died of Ebola. His ambulance picked up Ebola patients (or suspected Ebola cases) and took them to treatment centers. On 1 November, the United Kingdom announced plans to build three more Ebola laboratories in Sierra Leone. The labs helped to determine if a patient had been infected by the Ebola virus. At that time, it took as much as five days to test a sample because of the volume of samples that needed to be tested. On 2 November, a person with Ebola employed by the United Nations was evacuated from Sierra Leone to France for treatment. On 4 November, it was reported that thousands violated quarantine in search for food, in the town of Kenema. On 6 November, it was reported that the situation was "getting worse" due to "intense transmission" in Freetown as a contributing factor; the capital city reported 115 cases in the previous week alone. Food shortages and aggressive quarantines were reported to be making the situation worse, according to the Disaster Emergency Committee. Sierra Leone established call centers in Port Loko and Kambia, according to MSSL Communications as reported on 21 November; this was in addition to the June hotline originally established. On 12 November, more than 400 health workers went on strike over salary issues at one of the few Ebola treatment centers in the country. On 18 November, the supply ship Karel Doorman of the Royal Netherlands Navy ( Koninklijke Marine ) arrived in Freetown, with supplies. Its Captain-Commander, Peter van den Berg, took steps to reduce the chance of the crew contracting Ebola virus disease. The Neini Chiefdom in Koinadugu District was subject to isolation after Ebola cases. On 19 November, it was reported that the Ebola virus was spreading intensely; "much of this was driven by intense transmission in the country's west and north", the WHO said. A British-built Ebola Treatment Centre which started in Kerry Town during November, generated some controversy because of its initially limited capacity. However, this was because they were following guidelines of how to safely open an Ebola treatment unit. This was the first of six planned treatment centres which, when completed, would be staffed by a number of NGOs . In mid-November the WHO reported that while all cases and deaths continued to be under-reported, "there is some evidence that case incidence is no longer increasing nationally in Guinea and Liberia, but steep increases persist in Sierra Leone". On 19 November, it was reported that the Ebola virus was spreading intensely; "much of this was driven by intense transmission in the country's west and north", the WHO said. The first Cuban doctor to be infected with the virus was flown to Geneva. On 26 November, it was reported that due to Sierra Leone's increased Ebola transmission, the country would surpass Liberia in the total cases count. On 27 November, Canada announced it would deploy military health staff to the infected region. On 29 November, the President of Sierra Leone canceled a planned three-day shutdown in Freetown to curb the virus. On 2 December, it was reported that the Tonkolili district had begun a two-week lockdown, "which was agreed in a key stakeholders meeting of cabinet ministers, parliamentarians and paramount chiefs of the district as part of efforts to stem the spread of the disease", according to a ministry spokesman. The move meant that a total of six districts, containing more than half of the population, were locked down. Sierra Leone indicated, in a report on 5 December, that about 100 cases of the virus were now being reported daily. On the same day, it was further reported that families caught taking part in burial washing rituals, which can spread the virus, would be taken to jail. On 6 December, a report indicated that the Canadian Armed Forces would send a medical team to the country of Sierra Leone to help combat the Ebola virus epidemic. On 8 December, the doctors in Sierra Leone went on strike, demanding better treatment for health care workers, according to Health Ministry spokesman Jonathan Abass Kamara. On 9 December, Sierra Leone authorities placed the Eastern Kono District in a two-week lock-down following the alarming rate of infection and deaths there. The lock down lasted until 23 December. This followed the grim discovery of bodies piling up in the district. The WHO reported fear of a major breakout in the area. The district with 350,000 inhabitants buried 87 bodies in 11 days, with 25 patients dying in 5 days before the WHO arrived. On 12 December, Sierra Leone banned all public festivities for Christmas or New Year, because of the outbreak. On 13 December, it was reported that the first Australian facility had been opened; "operations will be gradually scaled up to full capacity at 100 beds under strict guidelines to ensure infection control procedures are working effectively and trained staff ... are in place", one source indicated. Médecins Sans Frontières /Doctors Without Borders, in partnership with the Ministry of Health, carried out during December the largest-ever distribution of antimalarials in Sierra Leone. Teams distributed 1.5 million antimalarial treatments in Freetown and surrounding districts with the aim of protecting people from malaria during the disease's peak season. A spokesman said "In the context of Ebola, malaria is a major concern, because people who are sick with malaria have the same symptoms as people sick with Ebola. As a result, most people turn up at Ebola treatment centres thinking that they have Ebola, when actually they have malaria. It's a huge load on the system, as well as being a huge stress on patients and their families." Between 14 and 17 December Sierra Leone reported 403 new cases with a total of 8,759 cases on the latter date. On 25 December, Sierra Leone put the north area of the country on lockdown. By the end of December Sierra Leone again reported a surge in numbers, with 9,446 cases reported. On 29 December 2014, Pauline Cafferkey , a British aid worker who had just returned to Glasgow from working at the treatment centre in Kerry Town, was diagnosed with Ebola at Glasgow's Gartnavel General Hospital . On 4 January, the lockdown was extended for two weeks. On this day the country reported 9780 cases with 2943 deaths. Among healthcare workers there were 296 cases with 221 fatalities reported. On 8 January, MSF admitted its first patients to a Treatment Centre (ETC) in Kissy , an Ebola hotspot on the outskirts of Freetown. Once the ETC is fully operational it will include specialist facilities for pregnant women. By 9 January, the case load in the country exceeded 10,000, with 10,074 cases and 3,029 deaths reported. On 9 January, it was reported that South Korea would send a medical team to Goderich . On 10 January, Sierra Leone declared its first Ebola-free district. The Pujehun district in the south east of the country reported no new cases for 42 days. A worker at Kerry Town clinic was evacuated to the United Kingdom on 2 February 2015, after a needlestick injury . On 5 February, it was reported that there was a rise in weekly cases for the first time this year. The U.N. indicated that the sharp drop in cases had "flattened out" raising concern about the virus. On 5 March, a report indicated cases in Sierra Leone continued to rise. The government of Sierra Leone declared a three-day country-wide lock-down including 2.5 million people on 18 March. The U.N. indicates the outbreak will be over by August of this year. The 3-day lock-down of over 6 million inhabitants revealed a 191% increase in possible Ebola cases. In Freetown alone 173 patients meeting the criteria for Ebola were discovered according to Obi Sesay from the National Ebola Response Center. As of 12 May, Sierra Leone had gone 8 days without an Ebola case, and was down to two confirmed cases of Ebola. The WHO weekly update for 29 July reported a total of only three new cases, the lowest total in more than a year. On 17 August, the country had its first week with no new cases, and one week later the last patients were released. A new death was reported on 1 September after a patient from Sella Kafta village in Kambia District was tested positive for the disease after her death. On 5 September, another case of Ebola was identified in the village among the approximately 1000 people currently under quarantine. A woman tested positive for the virus. The " Guinea ring vaccine " has been administered by a WHO team in the village since Friday 5 September. On 8 September the head of the National Ebola Response Center confirmed new cases of Ebola. This brought the total from the village to four cases, with all of them being under the "high risk" contact cases with the death of the new index case in the village. In total four cases were then confirmed including the dead woman. On 14 September, the National Ebola Response Center confirmed the death of a 16-year-old in a village in the Bombali district. Swabs taken from the body tested positive for the disease. The village was placed under quarantine. She had no history of traveling outside the village, and it is suspected that she contracted the disease from the semen of an Ebola survivor who was discharged in March 2015. Seven of her immediate contacts were taken to an Ebola treatment center, with a further three patients she had contact with at a health clinic. A new study to be published in the New England Journal of Medicine indicates the possibility that the virus may lurk in the semen of survivors for up to six months. Nearly half of 200 patients tested had traces of the virus in their semen six months after surviving the disease. On 7 November, the World Health Organization declared Sierra Leone Ebola-free. Sierra Leone entered a 90-day period of enhanced surveillance which was scheduled to conclude on 5 February 2016, but due to a new case in mid-January it did not. On 14 January, it was reported there had been a fatality linked to the Ebola virus. The case occurred in the Tonkolili district. Prior to this case WHO had advised, "we anticipate more flare-ups and must be prepared for them ... massive effort is underway to ensure robust prevention, surveillance and response capacity across all three countries by the end of March." On 16 January, it was reported that the woman who died of the virus may have exposed several individuals; the government announced that 100 people had been quarantined. On the same day, WHO released a statement, indicating that originally the 90-day enhanced surveillance period was to end on 5 February. Investigations indicate the female case was a student at Lunsar in Port Loko district, who had gone to Kambia district on December the 28th until returning symptomatic. Bombali district was visited by the individual, for consultation with an herbalist, later going to a government hospital in Magburaka. WHO indicates there are 109 contacts, 28 of which are high risk, furthermore, there are three missing contacts.The source or route of transmission which caused the fatality is still unknown. A second new case was confirmed on 20 January; the patient had contact with the previous fatality. On 17 March, the WHO declared the country Ebola-free. On 4 January, the lockdown was extended for two weeks. On this day the country reported 9780 cases with 2943 deaths. Among healthcare workers there were 296 cases with 221 fatalities reported. On 8 January, MSF admitted its first patients to a Treatment Centre (ETC) in Kissy , an Ebola hotspot on the outskirts of Freetown. Once the ETC is fully operational it will include specialist facilities for pregnant women. By 9 January, the case load in the country exceeded 10,000, with 10,074 cases and 3,029 deaths reported. On 9 January, it was reported that South Korea would send a medical team to Goderich . On 10 January, Sierra Leone declared its first Ebola-free district. The Pujehun district in the south east of the country reported no new cases for 42 days. A worker at Kerry Town clinic was evacuated to the United Kingdom on 2 February 2015, after a needlestick injury . On 5 February, it was reported that there was a rise in weekly cases for the first time this year. The U.N. indicated that the sharp drop in cases had "flattened out" raising concern about the virus. On 5 March, a report indicated cases in Sierra Leone continued to rise. The government of Sierra Leone declared a three-day country-wide lock-down including 2.5 million people on 18 March. The U.N. indicates the outbreak will be over by August of this year. The 3-day lock-down of over 6 million inhabitants revealed a 191% increase in possible Ebola cases. In Freetown alone 173 patients meeting the criteria for Ebola were discovered according to Obi Sesay from the National Ebola Response Center. As of 12 May, Sierra Leone had gone 8 days without an Ebola case, and was down to two confirmed cases of Ebola. The WHO weekly update for 29 July reported a total of only three new cases, the lowest total in more than a year. On 17 August, the country had its first week with no new cases, and one week later the last patients were released. A new death was reported on 1 September after a patient from Sella Kafta village in Kambia District was tested positive for the disease after her death. On 5 September, another case of Ebola was identified in the village among the approximately 1000 people currently under quarantine. A woman tested positive for the virus. The " Guinea ring vaccine " has been administered by a WHO team in the village since Friday 5 September. On 8 September the head of the National Ebola Response Center confirmed new cases of Ebola. This brought the total from the village to four cases, with all of them being under the "high risk" contact cases with the death of the new index case in the village. In total four cases were then confirmed including the dead woman. On 14 September, the National Ebola Response Center confirmed the death of a 16-year-old in a village in the Bombali district. Swabs taken from the body tested positive for the disease. The village was placed under quarantine. She had no history of traveling outside the village, and it is suspected that she contracted the disease from the semen of an Ebola survivor who was discharged in March 2015. Seven of her immediate contacts were taken to an Ebola treatment center, with a further three patients she had contact with at a health clinic. A new study to be published in the New England Journal of Medicine indicates the possibility that the virus may lurk in the semen of survivors for up to six months. Nearly half of 200 patients tested had traces of the virus in their semen six months after surviving the disease. On 7 November, the World Health Organization declared Sierra Leone Ebola-free. Sierra Leone entered a 90-day period of enhanced surveillance which was scheduled to conclude on 5 February 2016, but due to a new case in mid-January it did not. On 14 January, it was reported there had been a fatality linked to the Ebola virus. The case occurred in the Tonkolili district. Prior to this case WHO had advised, "we anticipate more flare-ups and must be prepared for them ... massive effort is underway to ensure robust prevention, surveillance and response capacity across all three countries by the end of March." On 16 January, it was reported that the woman who died of the virus may have exposed several individuals; the government announced that 100 people had been quarantined. On the same day, WHO released a statement, indicating that originally the 90-day enhanced surveillance period was to end on 5 February. Investigations indicate the female case was a student at Lunsar in Port Loko district, who had gone to Kambia district on December the 28th until returning symptomatic. Bombali district was visited by the individual, for consultation with an herbalist, later going to a government hospital in Magburaka. WHO indicates there are 109 contacts, 28 of which are high risk, furthermore, there are three missing contacts.The source or route of transmission which caused the fatality is still unknown. A second new case was confirmed on 20 January; the patient had contact with the previous fatality. On 17 March, the WHO declared the country Ebola-free. Long-term political factors contributed to the Ebola crisis including the acute dependency on external health assistance, patron-client politics, corruption and a weak state capacity . Prior to the Ebola epidemic Sierra Leone had about 136 doctors and 1,017 nurses/midwives for a population of about 6 million people. On 26 August, the WHO (World Health Organisation) shut down one of two laboratories after a health worker became infected. The laboratory was situated in the Kailahun district, one of the worst-affected areas. It was thought by some that this move would disrupt efforts to increase the global response to the outbreak of the disease in the district. "It's a temporary measure to take care of the welfare of our remaining workers", WHO spokesperson Christy Feig announced. He did not specify how long the closure would last, but said they would return after an assessment of the situation by the WHO. The medical worker, one of the first WHO staff infected by the Ebola Virus, was treated at a hospital in Kenema and then evacuated to Germany . By 4 October 2014, it was announced he has recovered and left Germany. As the Ebola epidemic grew it damaged the health care infrastructure, leading to increased deaths from other health issues including malaria, diarrhoea, and pneumonia because they were not being treated. The WHO estimated on 21 September that Sierra Leone's capacity to treat Ebola cases fell short by the equivalent of 532 beds. On 27 August 2014, Dr. Sahr Rogers died from Ebola after contracting it working in Kenema. Sierra Leone lost three of its top doctors by the end of August to Ebola. A fourth doctor, Dr. Olivette Buck, became ill with Ebola in September and died later that month. Dr. Olivette Buck was a Sierra Leone doctor who worked in Freetown, who tested positive for Ebola on 9 September 2014, and died on 14 September 2014. Her staff believes she was exposed in August. She eventually went to Lumley Hospital on 1 September 2014, with a fever, thinking it was malaria. After a few more days of illness she was admitted to Connaught Hospital . By 23 September 2014, out of 91 health workers known to have been infected with Ebola in Sierra Leone, approximately 61 had died. On 19 October, the WHO reported 129 cases with 95 deaths of healthcare workers (125 / 91 confirmed). On 2 November 2014, a fifth doctor, Dr. Godfrey George, a medical superintendent of Kambia Government Hospital died as a result of Ebola infection. On 17 November 2014, a sixth doctor, Dr Martin Salia, died as a result of Ebola infection, after being transported by medevac to Nebraska Medical Center in the United States. On 18 November 2014, a seventh doctor, Dr Michael Kargbo, died in Sierra Leone. He worked at the Magburaka Government Hospital . Dr. Aiah Solomon Konoyeima was reported to have Ebola in late November 2014, which would make him the eighth physician to contract Ebola. He was reported to have died from the disease on 7 December 2014, becoming what was reported as the tenth doctor to die from Ebola. On 26 November 2014, a ninth doctor, Dr. Songo Mbriwa, was reported to be sick with Ebola disease. He was working at an Ebola treatment centre in Freetown. He was one of the doctors that cared for the late Dr Martin Salia, who experienced a false-negative Ebola test, but did indeed have it and may have exposed others. On Friday 5 December, a senior health official announced the death of two of the country's doctors in one day. This brings the total number of doctors who have died from the disease in Sierra Leone to ten. Dr Dauda Koroma and Dr Thomas Rogers are the latest deaths among healthcare workers. The two doctors were not in the front line of the Ebola battle and did not work in an Ebola treatment hospital. On 18 December, Dr. Victor Willoughby died from the disease after being tested positive for the disease on Saturday 6 December. The doctor died hours before he was to receive ZMAb, an experimental treatment from Canada, according to Dr. Brima Kargbo the country's chief medical officer. Dr. Victor Willoughby is the 11th doctor, and a top physician, to succumb to the disease. On 27 August 2014, Dr. Sahr Rogers died from Ebola after contracting it working in Kenema. Sierra Leone lost three of its top doctors by the end of August to Ebola. A fourth doctor, Dr. Olivette Buck, became ill with Ebola in September and died later that month. Dr. Olivette Buck was a Sierra Leone doctor who worked in Freetown, who tested positive for Ebola on 9 September 2014, and died on 14 September 2014. Her staff believes she was exposed in August. She eventually went to Lumley Hospital on 1 September 2014, with a fever, thinking it was malaria. After a few more days of illness she was admitted to Connaught Hospital . By 23 September 2014, out of 91 health workers known to have been infected with Ebola in Sierra Leone, approximately 61 had died. On 19 October, the WHO reported 129 cases with 95 deaths of healthcare workers (125 / 91 confirmed). On 2 November 2014, a fifth doctor, Dr. Godfrey George, a medical superintendent of Kambia Government Hospital died as a result of Ebola infection. On 17 November 2014, a sixth doctor, Dr Martin Salia, died as a result of Ebola infection, after being transported by medevac to Nebraska Medical Center in the United States. On 18 November 2014, a seventh doctor, Dr Michael Kargbo, died in Sierra Leone. He worked at the Magburaka Government Hospital . Dr. Aiah Solomon Konoyeima was reported to have Ebola in late November 2014, which would make him the eighth physician to contract Ebola. He was reported to have died from the disease on 7 December 2014, becoming what was reported as the tenth doctor to die from Ebola. On 26 November 2014, a ninth doctor, Dr. Songo Mbriwa, was reported to be sick with Ebola disease. He was working at an Ebola treatment centre in Freetown. He was one of the doctors that cared for the late Dr Martin Salia, who experienced a false-negative Ebola test, but did indeed have it and may have exposed others. On Friday 5 December, a senior health official announced the death of two of the country's doctors in one day. This brings the total number of doctors who have died from the disease in Sierra Leone to ten. Dr Dauda Koroma and Dr Thomas Rogers are the latest deaths among healthcare workers. The two doctors were not in the front line of the Ebola battle and did not work in an Ebola treatment hospital. On 18 December, Dr. Victor Willoughby died from the disease after being tested positive for the disease on Saturday 6 December. The doctor died hours before he was to receive ZMAb, an experimental treatment from Canada, according to Dr. Brima Kargbo the country's chief medical officer. Dr. Victor Willoughby is the 11th doctor, and a top physician, to succumb to the disease. Since the beginning of the outbreak in Sierra Leone in late May 2014, several people have been evacuated. An increasing lack of hospital beds , medical equipment, and health care personnel made treatment difficult. [ citation needed ] On 24 August William Pooley , a British nurse, was evacuated from Sierra Leone. He was released on 3 September 2014. In October 2014, he announced he would return to Sierra Leone. On 21 September 2014, Spain evacuated a Catholic priest who had contracted Ebola while working in Sierra Leone with Hospital Order of San Juan de Dios. He died on 25 September in Madrid. On 6 October 2014, a nurse who treated the priest tested positive for Ebola. By 20 October 2014, the nurse seemed to have recovered after many days battling the disease in the hospital, with tests coming back negative. A doctor from Senegal contracted Ebola while working in Sierra Leone for the WHO, and was evacuated to Germany at the end of August 2014. By 4 October 2014, it was announced he has recovered and returned to Senegal. In late September, a doctor working for an International Aid organization in Sierra Leone, was evacuated to Switzerland after potentially being exposed. He later tested negative for the disease. In late September 2014, an American doctor working in Sierra Leone was evacuated to Maryland, USA, after being exposed to Ebola. "Just because someone is exposed to the deadly virus, it doesn't necessarily mean they are infected", said Anthony S. Fauci , director of the National Institute of Allergy and Infectious Diseases at the NIH . He was evacuated after a needle sticking accident and even developed a fever, but he was determined not to have Ebola and was released the first week in October 2014. After being discharged he remained at home under medical observation, checking his temperature twice a day for 21 days. In early October, a Ugandan doctor who contracted Ebola while working in Sierra Leone was evacuated for treatment to Frankfurt, Germany. The doctor was working at Lakaa Hospital and flown out from Lungi Airport . On 6 October 2014, a female Norwegian MSF worker tested positive for Ebola virus and was subsequently evacuated to Norway. Norwegian authorities reported that they had been granted a dose of the experimental biopharmaceutical drug ZMAb , a variant of ZMapp . ZMapp has previously been used on 3 Liberian health workers, of which 2 survived. It was also used on 4 evacuated westerners, of which 3 survived. A U.N. employee was evacuated to France in early November 2014 after contracting Ebola. On 12 November 2014, Dr Martin Salia, a permanent resident of the United States, tested positive for Ebola while working as a specialist surgeon at the Connaught Hospital in Freetown . He is the sixth Sierra Leone doctor to have contracted Ebola virus disease. Initially he preferred to be treated at the Hastings Holding Centre by Sierra Leonean medical personnel, however on 15 November 2014, he was evacuated to the Nebraska Medical Center where his condition was reported as "still extremely critical" on 16 November. On 16 November the hospital released a statement that he "passed away as a result of the advanced symptoms of the disease". On 18 November a Cuban doctor, Felix Baez, tested positive for Ebola and was due to be sent to Geneva for treatment. He later recovered. Baez was one of 165 Cuban doctors and nurses in Sierra Leone helping treat Ebola patients. There were a further 53 Cubans in Liberia and 38 in Guinea, making this the largest single country medical team mobilized during the outbreak. On 5 October, The New York Times reported that a shipping container full of protective gowns, gloves, stretchers, mattresses and other medical supplies had been allowed to sit unopened on the docks in Freetown, Sierra Leone, since 9 August. The $140,000 worth of equipment included 100 bags and boxes of hospital linens, 100 cases of protective suits, 80 cases of face masks and other items, and were donated by individuals and institutions in the United States. The shipment was organised by Mr Chernoh Alpha Bah, a Sierra Leonean opposition politician, who comes from Sierra Leonean President Ernest Bai Koroma 's hometown, Makeni . The New York Times reported that political tensions may have contributed to the government delay in clearing the shipping container, to prevent the political opposition from trumpeting the donations. Government officials stated that the shipping container could not be cleared through customs, as proper procedures had not been followed. The Sierra Leonean government refused to pay the shipping fee of $6,500. The New York Times noted that the government had already received well over $40 million in cash from international donors to fight Ebola. The New York Times noted that in the 2 months that the shipping container remained on the docks in Freetown, health workers in Sierra Leone endured severe shortages of protective supplies, with some nurses having to wear street clothes. David Tam-Baryoh, a radio journalist , was held for 11 days when he and a talk show guest, an opposition party spokesperson, criticised how President Ernest Bai Koroma handled the Ebola outbreak in a live broadcast on 1 November 2014. The weekly show Monologue was taken off-air mid-show from the independently run Citizen FM. He was arrested on 3 November and sent to the Pademba Road jail, after an executive order was signed by the president. On 14 November Sierra Leone's Deputy Information Minister Theo Nicol gave a statement that Baryoh had "been put on a ten thousand dollar bail by the Criminal Investigation Department after a statement has been taken from him". Amid concerns for his health, Tam-Baryoh apparently signed a confession to ensure his release from the prison, engineered by a committee made up of his lawyer, 2 journalists and a peace studies lecturer of the University of Sierra Leone . Rightsway International, an independent human rights group, has condemned President Koroma for allegedly dictating to the committee about obtaining the confession. A statement later released by the group read: Rightsway is disappointed that Tam Baryoh's forced confession has been published widely by pro-government media outlets and social networks. The publication of forced confessions is often used to discredit dissident news and information providers. This is a media propaganda tool used by dictatorial regimes, to avoid being exposed, investigated and punished for the grave violations of human rights. On 21 October, there was Ebola related violence and rioting in the eastern town of Koidu , with police imposing a curfew. Local youth fired at police with shotguns after a former youth leader refused health authorities permission to take her relative for an Ebola test. Several buildings were attacked and youth gangs roamed the streets shouting "No more Ebola!" A local leader reported seeing two bodies with gunshot wounds in the aftermath. Police denied that anyone had been killed. Doctors reported two dead. The local district medical officer said he had been forced to abandon the local hospital because of the rioting. On 5 October, The New York Times reported that a shipping container full of protective gowns, gloves, stretchers, mattresses and other medical supplies had been allowed to sit unopened on the docks in Freetown, Sierra Leone, since 9 August. The $140,000 worth of equipment included 100 bags and boxes of hospital linens, 100 cases of protective suits, 80 cases of face masks and other items, and were donated by individuals and institutions in the United States. The shipment was organised by Mr Chernoh Alpha Bah, a Sierra Leonean opposition politician, who comes from Sierra Leonean President Ernest Bai Koroma 's hometown, Makeni . The New York Times reported that political tensions may have contributed to the government delay in clearing the shipping container, to prevent the political opposition from trumpeting the donations. Government officials stated that the shipping container could not be cleared through customs, as proper procedures had not been followed. The Sierra Leonean government refused to pay the shipping fee of $6,500. The New York Times noted that the government had already received well over $40 million in cash from international donors to fight Ebola. The New York Times noted that in the 2 months that the shipping container remained on the docks in Freetown, health workers in Sierra Leone endured severe shortages of protective supplies, with some nurses having to wear street clothes. David Tam-Baryoh, a radio journalist , was held for 11 days when he and a talk show guest, an opposition party spokesperson, criticised how President Ernest Bai Koroma handled the Ebola outbreak in a live broadcast on 1 November 2014. The weekly show Monologue was taken off-air mid-show from the independently run Citizen FM. He was arrested on 3 November and sent to the Pademba Road jail, after an executive order was signed by the president. On 14 November Sierra Leone's Deputy Information Minister Theo Nicol gave a statement that Baryoh had "been put on a ten thousand dollar bail by the Criminal Investigation Department after a statement has been taken from him". Amid concerns for his health, Tam-Baryoh apparently signed a confession to ensure his release from the prison, engineered by a committee made up of his lawyer, 2 journalists and a peace studies lecturer of the University of Sierra Leone . Rightsway International, an independent human rights group, has condemned President Koroma for allegedly dictating to the committee about obtaining the confession. A statement later released by the group read: Rightsway is disappointed that Tam Baryoh's forced confession has been published widely by pro-government media outlets and social networks. The publication of forced confessions is often used to discredit dissident news and information providers. This is a media propaganda tool used by dictatorial regimes, to avoid being exposed, investigated and punished for the grave violations of human rights.On 21 October, there was Ebola related violence and rioting in the eastern town of Koidu , with police imposing a curfew. Local youth fired at police with shotguns after a former youth leader refused health authorities permission to take her relative for an Ebola test. Several buildings were attacked and youth gangs roamed the streets shouting "No more Ebola!" A local leader reported seeing two bodies with gunshot wounds in the aftermath. Police denied that anyone had been killed. Doctors reported two dead. The local district medical officer said he had been forced to abandon the local hospital because of the rioting. There are various restrictions and quarantines within Sierra Leone, and a state of emergency was declared on 31 July 2014. Countries at higher risk for Ebola in Africa include Benin, Burkina Faso, Côte d'Ivoire, Guinea-Bissau, Mali, and Senegal. [ citation needed ] The outbreak was noted for increasing hand washing stations, and reducing the prevalence of physical greetings such as hand-shakes between members of society. In June 2014 all schools were closed because of the spread of Ebola. In August 2014 the S.L. Health Minister was removed from that office. (see Cabinet of Sierra Leone ) In October 2014 the Defense Minister was placed in charge of the anti-Ebola efforts. The president at this time was Ernest Bai Koroma . On 13 October, the UN's International Fund for Agricultural Development stated up to 40% of farms had been abandoned in the worst Ebola-hit areas of Sierra Leone. In October 2014 Sierra Leone launched a school by radio program, that will be transmitted on 41 of the local radio stations as well as on the only local TV station. (See Cultural effects of the Ebola crisis ) September through October is the malaria season, which may complicate efforts to treat Ebola. For example, one Freetown doctor did not immediately quarantine herself because she thought she had malaria not Ebola. The doctor was eventually diagnosed with Ebola and died in September 2014. There are various restrictions and quarantines within Sierra Leone, and a state of emergency was declared on 31 July 2014. Countries at higher risk for Ebola in Africa include Benin, Burkina Faso, Côte d'Ivoire, Guinea-Bissau, Mali, and Senegal. [ citation needed ]The outbreak was noted for increasing hand washing stations, and reducing the prevalence of physical greetings such as hand-shakes between members of society. In June 2014 all schools were closed because of the spread of Ebola. In August 2014 the S.L. Health Minister was removed from that office. (see Cabinet of Sierra Leone ) In October 2014 the Defense Minister was placed in charge of the anti-Ebola efforts. The president at this time was Ernest Bai Koroma . On 13 October, the UN's International Fund for Agricultural Development stated up to 40% of farms had been abandoned in the worst Ebola-hit areas of Sierra Leone. In October 2014 Sierra Leone launched a school by radio program, that will be transmitted on 41 of the local radio stations as well as on the only local TV station. (See Cultural effects of the Ebola crisis ) September through October is the malaria season, which may complicate efforts to treat Ebola. For example, one Freetown doctor did not immediately quarantine herself because she thought she had malaria not Ebola. The doctor was eventually diagnosed with Ebola and died in September 2014.

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Band Aid 30

Band Aid 30 is the 2014 incarnation of the charity supergroup Band Aid . The group was announced on 10 November 2014 by Bob Geldof and Midge Ure , with Geldof stating that he took the step after the United Nations had contacted him, saying help was urgently needed to prevent the 2014 Ebola crisis in Western Africa spreading throughout the world. As in previous incarnations, the group covered the track " Do They Know It's Christmas? ", written in 1984 by Geldof and Ure, this time to raise money towards the Ebola crisis in Western Africa. The track re-tweaked lyrics to reflect the Ebola virus epidemic in West Africa , and all proceeds went towards battling what Geldof described as a "particularly pernicious illness because it renders humans untouchable and that is sickening". The song was recorded by some of the biggest-selling current British and Irish pop acts, including One Direction , Sam Smith , Ed Sheeran , Emeli Sandé , Ellie Goulding and Rita Ora . Bastille and Guy Garvey of Mercury prize -winning band Elbow were also on board, along with Chris Martin ( Coldplay ) and Bono ( U2 )—the third time he has contributed to a Band Aid recording. For the first time, different language versions were recorded, a French one titled " Noël est là " and a German one titled "Do They Know It's Christmas? (2014) [ Deutsche Version ]" with respective artists.The song was recorded on 15 November 2014, with all contributions going towards battling the Ebola virus epidemic in West Africa . Due to her filming commitments on The Voice UK , Rita Ora recorded her lines first thing in the morning, and was not present for the whole group chorus (although the video cuts to her singing alone along with them). [ citation needed ] The song was recorded in Sarm West Studios in Notting Hill , London, the same studio used for the original track. Organiser Bob Geldof said he addressed the participants "like the headmaster" before they sang the chorus: "I explained the situation in West Africa, I explained what the UN were saying, explained what we could do, and just geed them up." Footage of the recording of the session was streamed live on an official app, with the footage forming the basis for the music video. The record was produced by Paul Epworth , who has worked with the likes of Adele and One Direction . The official music video for Band Aid 30 was first shown on the results show of The X Factor on 16 November 2014, with Geldof suggesting that the song and video shown on The X Factor may not be the finished versions. "We'll have a rough edit on The X Factor and we'll have a rough edit of the film," he said. The video was introduced by Geldof, who described the new recording as a "bit of pop history". He said the video—which began with shots of victims of Ebola—was "harrowing and not meant for an entertainment show" but was something The X Factor audience should see. Following this, the song was available for digital download on 17 November 2014, just 11 days short of the 30th anniversary of the release of the original version of the track. The physical version of the song will be released three weeks later on 8 December, and will feature cover artwork designed by artist Tracey Emin . The download costs 99p, while the CD single will retail for £4. The song will not be made available on Spotify and other music streaming services until January 2015. On 15 November 2014, it was confirmed by Geldof that the Chancellor George Osborne would waive VAT on the record, with all the money raised by the track going towards the cause. He also confirmed in interviews that iTunes is not taking a cut of the 99p download cost. On 18 November 2014, the BBC reported that the song was the fastest selling single of the year so far, with 206,000 copies sold since its release the day before. Martin Talbot, Chief executive of the Official Charts Company , said: "Everyone expected a strong start from Bob Geldof and his team, but they have outperformed expectations with a truly exceptional first day's sales." This makes it the fastest selling single since the Military Wives track " Wherever You Are " in December 2011.The line up for Band Aid 30: Unlike Band Aid II and Band Aid 20 , where lyrics were almost identical to the original, the lyrics to " Do They Know It's Christmas? " for Band Aid 30 have been altered to address the current situation in Western Africa, with the ongoing Ebola epidemic . The changes include: "Where the only water flowing is the bitter sting of tears" replaced with "Where a kiss of love can kill you and there's death in every tear" "Well tonight thank God it's them instead of you" replaced with "Well tonight we're reaching out and touching you"British artist Tracey Emin designed the cover sleeve for the physical release of the single. After release for download, the single went straight to number one in the UK Official Singles Chart for week ending 29 November 2014 having sold 312,000 copies. It dropped the following week. On its physical release on 8 December, it reached number three. The UK version of the song reached number 25 in France, number 2 in Germany and number 1 in Spain and Ireland. Initial response to the single was mixed. The Daily Telegraph noted how "technically impressive the current generation of British pop singers are.... [with the artists putting in] a hell of a lot into every over-stretched syllable", although noted that the "jump cut from distressing Third World scenes to smiling first world celebrities will always strike an awkward note". The Guardian noted that in contrast to previous versions of the track, it was "more sombre and downbeat: it features plenty of representatives from the vogueish world of pop-house but their actual sound doesn't impact on the track at all". Finally, Digital Spy were heavily critical of the single stating that they wouldn't "be bullied into buying a mediocre record when there are plenty of other ways to donate and do your bit to help". The Independent criticised the song for retaining what was described as perpetuating the patronising and condescending perspective of the original, with rapper Fuse ODG citing this as the reason he dropped out of the project. On 18 November, Liberian Robtel Neajai Pailey, a researcher at the School of Oriental and African Studies , argued on BBC Radio 4 's Today that the question "Do They Know It's Christmas?" was meaningless, as most of the victims were Muslim . She described the song as "unoriginal and redundant" and said that it was "reinforcing stereotypes", painting the continent "as unchanging and frozen in time" and was "incredibly patronising and problematic." Arguing against Pailey, producer Harvey Goldsmith said her concerns were "ridiculous", adding "I think it's disingenuous for people to turn round and say we shouldn't do anything or sit back and watch it all happen or wait for all those countries that pledged aid and refused to give it so far." For Al Jazeera Paley wrote "It reeks of the "white saviour complex" because it negates local efforts that have come before it." On 23 November, singer Lily Allen revealed that she had refused to appear on the record because she considered it "smug" and preferred to donate "actual money". In December 2014, Ebola survivor, William Pooley , described the song as "cultural ignorance" and "cringeworthy". Bob Geldof responded by saying "Please. It's a pop song. Relax." He also said that those critical of the lyrics could "fuck off". The release history for the tracks is as follows: Bob Geldof confirmed that there would be French and German versions of the track, with Carla Bruni leading the French and Die Toten Hosen lead vocalist Campino leading the German version. The German version "Do They Know It's Christmas? (2014) [Deutsche Version]" performed well in the charts, reaching the best-seller position in the beginning of December 2014. Involved artists and bands sorted by their appearance in the German Band Aid 30 song "Do They Know It's Christmas": Campino of Die Toten Hosen , Philipp Poisel , Clueso , Seeed , Andreas Bourani , Ina Müller , Jan Delay , Marteria , Michi Beck of Die Fantastischen Vier , Max Herre , Cro , Sportfreunde Stiller , Silbermond , Milky Chance , Max Raabe , Wolfgang Niedecken , Udo Lindenberg , Sammy Amara of Broilers , Anna Loos , Peter Maffay , Thees Uhlmann , Joy Denalane , Gentleman , Patrice , Jan Josef Liefers , Adel Tawil , 2raumwohnung , Donots , Jennifer Rostock The French version of the song, titled " Noël est là " ("Christmas is here"), features words by Carla Bruni and was released on 1 December 2014. Artists featured in the recording include Renaud , Nicola Sirkis , Benjamin Biolay , Vanessa Paradis , Joey Starr , Yannick Noah , Thomas Dutronc , Amandine Bourgeois , Louis Bertignac , Tété and Christophe Willem . It entered the French singles chart at number 58. It also charted in Belgium Wallonia Francophone market.The German version "Do They Know It's Christmas? (2014) [Deutsche Version]" performed well in the charts, reaching the best-seller position in the beginning of December 2014. Involved artists and bands sorted by their appearance in the German Band Aid 30 song "Do They Know It's Christmas": Campino of Die Toten Hosen , Philipp Poisel , Clueso , Seeed , Andreas Bourani , Ina Müller , Jan Delay , Marteria , Michi Beck of Die Fantastischen Vier , Max Herre , Cro , Sportfreunde Stiller , Silbermond , Milky Chance , Max Raabe , Wolfgang Niedecken , Udo Lindenberg , Sammy Amara of Broilers , Anna Loos , Peter Maffay , Thees Uhlmann , Joy Denalane , Gentleman , Patrice , Jan Josef Liefers , Adel Tawil , 2raumwohnung , Donots , Jennifer RostockThe French version of the song, titled " Noël est là " ("Christmas is here"), features words by Carla Bruni and was released on 1 December 2014. Artists featured in the recording include Renaud , Nicola Sirkis , Benjamin Biolay , Vanessa Paradis , Joey Starr , Yannick Noah , Thomas Dutronc , Amandine Bourgeois , Louis Bertignac , Tété and Christophe Willem . It entered the French singles chart at number 58. It also charted in Belgium Wallonia Francophone market.

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Ebola

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Public Health Service Ebola Campaign Medal

The Public Health Service Ebola Campaign Medal is a decoration of the United States Public Health Service presented to members of the United States Public Health Service Commissioned Corps . It recognizes service in responding to an outbreak of the Ebola virus .The PHS Ebola Campaign Medal is awarded to officers who served on or after 31 March 2014 for a period of not less than 30 consecutive days or 60 non-consecutive days in support of an international Ebola activation of the USPHS Commissioned Corps by the President of the United States or the United States Secretary of Health and Human Services . The Surgeon General of the United States determines which assignments qualify for the medal. An officer may receive only one award of the medal for participation in the same Ebola initiative or mission. The Surgeon General may authorize other response service awards in conjunction with the Ebola Campaign Medal. Officers must meet the established criteria for awarding the Public Health Service Foreign Duty Award and the Public Health Service Hazardous Duty Award during an Ebola mission. Officers are not authorized to receive any other service awards in conjunction with the Ebola Campaign Medal.

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Ebola

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Ebola in Nigeria

Cases of the Ebola virus disease in Nigeria were reported in 2014 as a small part of the epidemic of Ebola virus disease (commonly known as "Ebola") which originated in Guinea that represented the first outbreak of the disease in a West African country. Previous outbreaks had been confined to countries in Central Africa . On 25 March 2014, the World Health Organization (WHO) reported that Guinea's Ministry of Health had reported an outbreak of Ebola virus disease in four southeastern districts, with suspected cases in the neighbouring countries of Liberia and Sierra Leone being investigated. In Guinea, a total of 86 suspected cases, including 59 deaths had been reported as of 24 March. Researchers generally believe that a one-year-old boy, later identified as Emile Ouamouno , who died in December 2013 in the village of Meliandou , Guéckédou Prefecture , Guinea , was the index case of the Ebola virus disease epidemic. His mother, sister, and grandmother then became ill with similar symptoms and also died. People infected by those initial cases spread the disease to other villages. Although Ebola represents a major public health issue in sub-Saharan Africa, no cases had ever been reported in West Africa and the early cases were diagnosed as other diseases more common to the area. Thus, the disease had several months to spread before it was recognized as Ebola. The index case in Nigeria was a Liberian-American, Patrick Sawyer , who flew from Liberia to Nigeria's most populous city of Lagos on 20 July 2014. Sawyer became violently ill upon arriving at the airport and died five days later. In response, the Nigerian government observed all of Sawyer's contacts for signs of infection and increased surveillance at all entry points to the country. Sawyer was believed to have suspected he was infected with Ebola because he cared for his sister who died of the disease on July 8, he was hospitalised in Monrovia for fever and Ebola symptoms on July 17 before discharging himself (against professional medical advice) to fly to Lagos, where he lied to the staff of First Consultants Medical Centre that he had not had any exposure to anyone that had contracted Ebola. On 6 August 2014, the Nigerian health minister told reporters, "Yesterday the first known Nigerian to die of Ebola was recorded. This was one of the nurses that attended to the Liberian. The other five newly confirmed cases are being treated at an isolation ward." The nurse was Obi Justina Ejelonu. The doctor who treated Sawyer, Ameyo Adadevoh , subsequently also died of Ebola. Others that died included Mrs Ukoh (a Ward Maid at First Consultants Medical Center), Jato Asihu Abdulqudir (an acquaintance of Sawyer, who was on the plane with him and carried his bag when he was ill), a private hospital doctor in Port Harcourt who was treating Jato and an elderly patient at the hospital that treated the private hospital doctor for Ebola. On 22 September 2014, the Nigeria health ministry announced, "As of today, there is no case of Ebola in Nigeria. All listed contacts who were under surveillance have been followed up for 21 days." According to the WHO, 20 cases and 8 deaths had been confirmed, including the imported case, who also died. Four of the dead were health care workers who had cared for Sawyer. In all, 529 contacts had been followed and of that date they had all completed a 21-day mandatory period of surveillance. On 9 October 2014, the European Centre for Disease Prevention and Control (ECDC) acknowledged Nigeria's positive role in controlling the effort to contain the Ebola outbreak. "We wish to thank the Federal Ministry of Health, Abuja, Nigeria, and the staff of the Ebola Emergency Centre who coordinated the management of cases, containment of outbreaks and treatment protocols in Nigeria." Nigeria's quick responses, including intense and rapid contact tracing, surveillance of potential contacts, and isolation of all contacts were of particular importance in controlling and limiting the outbreak, according to the ECDC. Complimenting Nigeria's successful efforts to control the outbreak, "the usually measured WHO declared the feat 'a piece of world-class epidemiological detective work'." The WHO's representative in Nigeria officially declared Nigeria to be Ebola free on 20 October after no new active cases were reported in the follow-up contacts, stating it was a "spectacular success story ". On 14 August 2014 the Nigerian government said Aliko Dangote have donated $1 million to halt the spread of the Ebola virus outbreak. On 5 November 2014 volunteer medical workers arrived in Liberia and Sierra Leone from Nigeria . The first arrivals included 100 volunteers in Freetown, Sierra Leone and a further 76 in Liberia. Nigeria announced it would send 600 volunteers to help stem the spread of the disease. On 25 March 2014, the World Health Organization (WHO) reported that Guinea's Ministry of Health had reported an outbreak of Ebola virus disease in four southeastern districts, with suspected cases in the neighbouring countries of Liberia and Sierra Leone being investigated. In Guinea, a total of 86 suspected cases, including 59 deaths had been reported as of 24 March. Researchers generally believe that a one-year-old boy, later identified as Emile Ouamouno , who died in December 2013 in the village of Meliandou , Guéckédou Prefecture , Guinea , was the index case of the Ebola virus disease epidemic. His mother, sister, and grandmother then became ill with similar symptoms and also died. People infected by those initial cases spread the disease to other villages. Although Ebola represents a major public health issue in sub-Saharan Africa, no cases had ever been reported in West Africa and the early cases were diagnosed as other diseases more common to the area. Thus, the disease had several months to spread before it was recognized as Ebola. The index case in Nigeria was a Liberian-American, Patrick Sawyer , who flew from Liberia to Nigeria's most populous city of Lagos on 20 July 2014. Sawyer became violently ill upon arriving at the airport and died five days later. In response, the Nigerian government observed all of Sawyer's contacts for signs of infection and increased surveillance at all entry points to the country. Sawyer was believed to have suspected he was infected with Ebola because he cared for his sister who died of the disease on July 8, he was hospitalised in Monrovia for fever and Ebola symptoms on July 17 before discharging himself (against professional medical advice) to fly to Lagos, where he lied to the staff of First Consultants Medical Centre that he had not had any exposure to anyone that had contracted Ebola. On 6 August 2014, the Nigerian health minister told reporters, "Yesterday the first known Nigerian to die of Ebola was recorded. This was one of the nurses that attended to the Liberian. The other five newly confirmed cases are being treated at an isolation ward." The nurse was Obi Justina Ejelonu. The doctor who treated Sawyer, Ameyo Adadevoh , subsequently also died of Ebola. Others that died included Mrs Ukoh (a Ward Maid at First Consultants Medical Center), Jato Asihu Abdulqudir (an acquaintance of Sawyer, who was on the plane with him and carried his bag when he was ill), a private hospital doctor in Port Harcourt who was treating Jato and an elderly patient at the hospital that treated the private hospital doctor for Ebola. On 22 September 2014, the Nigeria health ministry announced, "As of today, there is no case of Ebola in Nigeria. All listed contacts who were under surveillance have been followed up for 21 days." According to the WHO, 20 cases and 8 deaths had been confirmed, including the imported case, who also died. Four of the dead were health care workers who had cared for Sawyer. In all, 529 contacts had been followed and of that date they had all completed a 21-day mandatory period of surveillance. On 9 October 2014, the European Centre for Disease Prevention and Control (ECDC) acknowledged Nigeria's positive role in controlling the effort to contain the Ebola outbreak. "We wish to thank the Federal Ministry of Health, Abuja, Nigeria, and the staff of the Ebola Emergency Centre who coordinated the management of cases, containment of outbreaks and treatment protocols in Nigeria." Nigeria's quick responses, including intense and rapid contact tracing, surveillance of potential contacts, and isolation of all contacts were of particular importance in controlling and limiting the outbreak, according to the ECDC. Complimenting Nigeria's successful efforts to control the outbreak, "the usually measured WHO declared the feat 'a piece of world-class epidemiological detective work'." The WHO's representative in Nigeria officially declared Nigeria to be Ebola free on 20 October after no new active cases were reported in the follow-up contacts, stating it was a "spectacular success story ". On 14 August 2014 the Nigerian government said Aliko Dangote have donated $1 million to halt the spread of the Ebola virus outbreak. On 5 November 2014 volunteer medical workers arrived in Liberia and Sierra Leone from Nigeria . The first arrivals included 100 volunteers in Freetown, Sierra Leone and a further 76 in Liberia. Nigeria announced it would send 600 volunteers to help stem the spread of the disease. Health care delivery in Nigeria is a concurrent responsibility of the three tiers of government in the country, and the private sector. Nigeria has been reorganizing its health system since the Bamako Initiative of 1987, which formally promoted community-based methods of increasing accessibility of drugs and health care services to the population, in part by implementing user fees. The new strategy dramatically increased accessibility through community-based healthcare reform, resulting in more efficient and equitable provision of services. A comprehensive approach strategy was extended to all areas of health care, with subsequent improvement in the health care indicators and improvement in health care efficiency and cost. The Nigerian health care system is continuously faced with a shortage of doctors and nurses known as ' brain drain ', because of emigration by skilled Nigerian doctors and nurses to North America and Europe. In 1995, it was estimated that 21,000 Nigerian doctors were practising in the United States alone, which was about the same as the number of doctors working in the Nigerian public service. Retaining these expensively trained professionals has been identified as one of the goals of the government. Despite this, in the 2014 Ebola outbreak, Nigeria was the first country to effectively contain and eliminate the Ebola threat that was ravaging three other countries in the West African region. The Nigerian unique method of contact tracing became an effective method later used by other countries, such as the United States, when Ebola threats were discovered. The 2016 Nigerian drama thriller film 93 Days tells the story of the treatment of Patrick Sawyer by Adadevoh and other medical staff, and the successful containment of the outbreak.

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Ebola

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Centers for Disease Control and Prevention

Office of National Defense Malaria Control Activities (1942) Office of Malaria Control in War Areas (1942–46) Communicable Disease Center (1946–67) National Communicable Disease Center (1967–70) Center for Disease Control (1970–80) Centers for Disease Control (1980–92) The Centers for Disease Control and Prevention ( CDC ) is the national public health agency of the United States. It is a United States federal agency under the Department of Health and Human Services , and is headquartered in Atlanta , Georgia . The agency's main goal is the protection of public health and safety through the control and prevention of disease, injury, and disability in the US and worldwide. The CDC focuses national attention on developing and applying disease control and prevention. It especially focuses its attention on infectious disease , food borne pathogens , environmental health , occupational safety and health , health promotion , injury prevention , and educational activities designed to improve the health of United States citizens . The CDC also conducts research and provides information on non-infectious diseases , such as obesity and diabetes , and is a founding member of the International Association of National Public Health Institutes . The CDC's current Director is Mandy Cohen who assumed office on July 10, 2023. The Communicable Disease Center was founded July 1, 1946, as the successor to the World War II Malaria Control in War Areas program of the Office of National Defense Malaria Control Activities. Preceding its founding, organizations with global influence in malaria control were the Malaria Commission of the League of Nations and the Rockefeller Foundation . The Rockefeller Foundation greatly supported malaria control, sought to have the governments take over some of its efforts, and collaborated with the agency. The new agency was a branch of the U.S. Public Health Service and Atlanta was chosen as the location because malaria was endemic in the Southern United States. The agency changed names (see infobox on top) before adopting the name Communicable Disease Center in 1946. Offices were located on the sixth floor of the Volunteer Building on Peachtree Street. With a budget at the time of about $1 million, 59 percent of its personnel were engaged in mosquito abatement and habitat control with the objective of control and eradication of malaria in the United States (see National Malaria Eradication Program ). Among its 369 employees, the main jobs at CDC were originally entomology and engineering. In CDC's initial years, more than six and a half million homes were sprayed, mostly with DDT . In 1946, there were only seven medical officers on duty and an early organization chart was drawn. Under Joseph Walter Mountin , the CDC continued to be an advocate for public health issues and pushed to extend its responsibilities to many other communicable diseases . In 1947, the CDC made a token payment of $10 to Emory University for 15 acres (61,000 m 2 ) of land on Clifton Road in DeKalb County, still the home of CDC headquarters as of 2019. CDC employees collected the money to make the purchase. The benefactor behind the "gift" was Robert W. Woodruff , chairman of the board of The Coca-Cola Company . Woodruff had a long-time interest in malaria control, which had been a problem in areas where he went hunting. The same year, the PHS transferred its San Francisco based plague laboratory into the CDC as the Epidemiology Division, and a new Veterinary Diseases Division was established. In 1951, Chief Epidemiologist Alexander Langmuir's warnings of potential biological warfare during the Korean War spurred the creation of the Epidemic Intelligence Service (EIS) as a two-year postgraduate training program in epidemiology. The success of the EIS program led to the launch of Field Epidemiology Training Programs (FETP) in 1980, training more than 18,000 disease detectives in over 80 countries. In 2020, FETP celebrated the 40th anniversary of the CDC's support for Thailand's Field Epidemiology Training Program. Thailand was the first FETP site created outside of North America and is found in numerous countries, reflecting CDC's influence in promoting this model internationally. The Training Programs in Epidemiology and Public Health Interventions Network ( TEPHINET ) has graduated 950 students. The mission of the CDC expanded beyond its original focus on malaria to include sexually transmitted diseases when the Venereal Disease Division of the U.S. Public Health Service (PHS) was transferred to the CDC in 1957. Shortly thereafter, Tuberculosis Control was transferred (in 1960) to the CDC from PHS, and then in 1963 the Immunization program was established. It became the National Communicable Disease Center effective July 1, 1967, and the Center for Disease Control on June 24, 1970. At the end of the Public Health Service reorganizations of 1966–1973 , it was promoted to being a principal operating agency of PHS. It was renamed to the plural Centers for Disease Control effective October 14, 1980, as the modern organization of having multiple constituent centers was established. By 1990, it had four centers formed in the 1980s: the Center for Infectious Diseases, Center for Chronic Disease Prevention and Health Promotion, the Center for Environmental Health and Injury Control, and the Center for Prevention Services; as well as two centers that had been absorbed by CDC from outside: the National Institute for Occupational Safety and Health in 1973, and the National Center for Health Statistics in 1987. An act of the United States Congress appended the words "and Prevention" to the name effective October 27, 1992. However, Congress directed that the initialism CDC be retained because of its name recognition. Since the 1990s, the CDC focus has broadened to include chronic diseases , disabilities , injury control, workplace hazards , environmental health threats, and terrorism preparedness. CDC combats emerging diseases and other health risks, including birth defects , West Nile virus , obesity , avian , swine , and pandemic flu , E. coli , and bioterrorism , to name a few. The organization would also prove to be an important factor in preventing the abuse of penicillin . In May 1994 the CDC admitted having sent samples of communicable diseases to the Iraqi government from 1984 through 1989 which were subsequently repurposed for biological warfare, including Botulinum toxin , West Nile virus , Yersinia pestis and Dengue fever virus. On April 21, 2005, then–CDC Director Julie Gerberding formally announced the reorganization of CDC to "confront the challenges of 21st-century health threats". She established four Coordinating Centers. In 2009 the Obama Administration re-evaluated this change and ordered them cut as an unnecessary management layer. As of 2013, the CDC's Biosafety Level 4 laboratories were among the few that exist in the world. They included one of only two official repositories of smallpox in the world, with the other one located at the State Research Center of Virology and Biotechnology VECTOR in the Russian Federation. In 2014, the CDC revealed they had discovered several misplaced smallpox samples while their lab workers were "potentially infected" with anthrax . The city of Atlanta annexed the property of the CDC headquarters effective January 1, 2018, as a part of the city's largest annexation within a period of 65 years; the Atlanta City Council had voted to do so the prior December. The CDC and Emory University had requested that the Atlanta city government annex the area, paving the way for a MARTA expansion through the Emory campus, funded by city tax dollars. The headquarters were located in an unincorporated area , statistically in the Druid Hills census-designated place . On August 17, 2022, Dr. Walensky said the CDC would make drastic changes in the wake of mistakes during the COVID-19 pandemic. She outlined an overhaul of how the CDC would analyze and share data and how they would communicate information to the general public. In her statement to all CDC employees, she said: "For 75 years, CDC and public health have been preparing for COVID-19, and in our big moment, our performance did not reliably meet expectations." Based on the findings of an internal report, Walensky concluded that "The CDC must refocus itself on public health needs, respond much faster to emergencies and outbreaks of disease, and provide information in a way that ordinary people and state and local health authorities can understand and put to use" (as summarized by the New York Times). The Communicable Disease Center was founded July 1, 1946, as the successor to the World War II Malaria Control in War Areas program of the Office of National Defense Malaria Control Activities. Preceding its founding, organizations with global influence in malaria control were the Malaria Commission of the League of Nations and the Rockefeller Foundation . The Rockefeller Foundation greatly supported malaria control, sought to have the governments take over some of its efforts, and collaborated with the agency. The new agency was a branch of the U.S. Public Health Service and Atlanta was chosen as the location because malaria was endemic in the Southern United States. The agency changed names (see infobox on top) before adopting the name Communicable Disease Center in 1946. Offices were located on the sixth floor of the Volunteer Building on Peachtree Street. With a budget at the time of about $1 million, 59 percent of its personnel were engaged in mosquito abatement and habitat control with the objective of control and eradication of malaria in the United States (see National Malaria Eradication Program ). Among its 369 employees, the main jobs at CDC were originally entomology and engineering. In CDC's initial years, more than six and a half million homes were sprayed, mostly with DDT . In 1946, there were only seven medical officers on duty and an early organization chart was drawn. Under Joseph Walter Mountin , the CDC continued to be an advocate for public health issues and pushed to extend its responsibilities to many other communicable diseases . In 1947, the CDC made a token payment of $10 to Emory University for 15 acres (61,000 m 2 ) of land on Clifton Road in DeKalb County, still the home of CDC headquarters as of 2019. CDC employees collected the money to make the purchase. The benefactor behind the "gift" was Robert W. Woodruff , chairman of the board of The Coca-Cola Company . Woodruff had a long-time interest in malaria control, which had been a problem in areas where he went hunting. The same year, the PHS transferred its San Francisco based plague laboratory into the CDC as the Epidemiology Division, and a new Veterinary Diseases Division was established. In 1951, Chief Epidemiologist Alexander Langmuir's warnings of potential biological warfare during the Korean War spurred the creation of the Epidemic Intelligence Service (EIS) as a two-year postgraduate training program in epidemiology. The success of the EIS program led to the launch of Field Epidemiology Training Programs (FETP) in 1980, training more than 18,000 disease detectives in over 80 countries. In 2020, FETP celebrated the 40th anniversary of the CDC's support for Thailand's Field Epidemiology Training Program. Thailand was the first FETP site created outside of North America and is found in numerous countries, reflecting CDC's influence in promoting this model internationally. The Training Programs in Epidemiology and Public Health Interventions Network ( TEPHINET ) has graduated 950 students. The mission of the CDC expanded beyond its original focus on malaria to include sexually transmitted diseases when the Venereal Disease Division of the U.S. Public Health Service (PHS) was transferred to the CDC in 1957. Shortly thereafter, Tuberculosis Control was transferred (in 1960) to the CDC from PHS, and then in 1963 the Immunization program was established. It became the National Communicable Disease Center effective July 1, 1967, and the Center for Disease Control on June 24, 1970. At the end of the Public Health Service reorganizations of 1966–1973 , it was promoted to being a principal operating agency of PHS. It was renamed to the plural Centers for Disease Control effective October 14, 1980, as the modern organization of having multiple constituent centers was established. By 1990, it had four centers formed in the 1980s: the Center for Infectious Diseases, Center for Chronic Disease Prevention and Health Promotion, the Center for Environmental Health and Injury Control, and the Center for Prevention Services; as well as two centers that had been absorbed by CDC from outside: the National Institute for Occupational Safety and Health in 1973, and the National Center for Health Statistics in 1987. An act of the United States Congress appended the words "and Prevention" to the name effective October 27, 1992. However, Congress directed that the initialism CDC be retained because of its name recognition. Since the 1990s, the CDC focus has broadened to include chronic diseases , disabilities , injury control, workplace hazards , environmental health threats, and terrorism preparedness. CDC combats emerging diseases and other health risks, including birth defects , West Nile virus , obesity , avian , swine , and pandemic flu , E. coli , and bioterrorism , to name a few. The organization would also prove to be an important factor in preventing the abuse of penicillin . In May 1994 the CDC admitted having sent samples of communicable diseases to the Iraqi government from 1984 through 1989 which were subsequently repurposed for biological warfare, including Botulinum toxin , West Nile virus , Yersinia pestis and Dengue fever virus. On April 21, 2005, then–CDC Director Julie Gerberding formally announced the reorganization of CDC to "confront the challenges of 21st-century health threats". She established four Coordinating Centers. In 2009 the Obama Administration re-evaluated this change and ordered them cut as an unnecessary management layer. As of 2013, the CDC's Biosafety Level 4 laboratories were among the few that exist in the world. They included one of only two official repositories of smallpox in the world, with the other one located at the State Research Center of Virology and Biotechnology VECTOR in the Russian Federation. In 2014, the CDC revealed they had discovered several misplaced smallpox samples while their lab workers were "potentially infected" with anthrax . The city of Atlanta annexed the property of the CDC headquarters effective January 1, 2018, as a part of the city's largest annexation within a period of 65 years; the Atlanta City Council had voted to do so the prior December. The CDC and Emory University had requested that the Atlanta city government annex the area, paving the way for a MARTA expansion through the Emory campus, funded by city tax dollars. The headquarters were located in an unincorporated area , statistically in the Druid Hills census-designated place . On August 17, 2022, Dr. Walensky said the CDC would make drastic changes in the wake of mistakes during the COVID-19 pandemic. She outlined an overhaul of how the CDC would analyze and share data and how they would communicate information to the general public. In her statement to all CDC employees, she said: "For 75 years, CDC and public health have been preparing for COVID-19, and in our big moment, our performance did not reliably meet expectations." Based on the findings of an internal report, Walensky concluded that "The CDC must refocus itself on public health needs, respond much faster to emergencies and outbreaks of disease, and provide information in a way that ordinary people and state and local health authorities can understand and put to use" (as summarized by the New York Times). The CDC is organized into "Centers, Institutes, and Offices" (CIOs), with each organizational unit implementing the agency's activities in a particular area of expertise while also providing intra-agency support and resource-sharing for cross-cutting issues and specific health threats. As of the most recent reorganization in February 2023, the CIOs are: Director National Center for Immunization and Respiratory Diseases National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration Health National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention National Center on Birth Defects and Developmental Disabilities National Center for Chronic Disease Prevention and Health Promotion National Center for Environmental Health / Agency for Toxic Substances and Disease Registry National Center for Injury Prevention and Control National Institute for Occupational Safety and Health Public Health Infrastructure Center Global Health Center Immediate Office of the Director Chief of Staff Office of the Chief Operating Officer Office of Policy, Performance, and Evaluation Office of Equal Employment Opportunity and Workplace Equity Office of Communications Office of Health Equity Office of Science CDC Washington Office Office of Laboratory Science and Safety Office of Readiness and Response Center for Forecasting and Outbreak Analytics Office of Public Health Data, Surveillance, and Technology National Center for Health Statistics National Center for Immunization and Respiratory Diseases National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration Health National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention National Center on Birth Defects and Developmental Disabilities National Center for Chronic Disease Prevention and Health Promotion National Center for Environmental Health / Agency for Toxic Substances and Disease Registry National Center for Injury Prevention and Control National Institute for Occupational Safety and Health Public Health Infrastructure Center Global Health Center Immediate Office of the Director Chief of Staff Office of the Chief Operating Officer Office of Policy, Performance, and Evaluation Office of Equal Employment Opportunity and Workplace Equity Office of Communications Office of Health Equity Office of Science CDC Washington Office Office of Laboratory Science and Safety Office of Readiness and Response Center for Forecasting and Outbreak Analytics Office of Public Health Data, Surveillance, and Technology National Center for Health Statistics Chief of Staff Office of the Chief Operating Officer Office of Policy, Performance, and Evaluation Office of Equal Employment Opportunity and Workplace Equity Office of Communications Office of Health Equity Office of Science CDC Washington Office Office of Laboratory Science and Safety Office of Readiness and Response Center for Forecasting and Outbreak Analytics Office of Public Health Data, Surveillance, and Technology National Center for Health Statistics Center for Forecasting and Outbreak Analytics The Office of Public Health Preparedness was created during the 2001 anthrax attacks shortly after the terrorist attacks of September 11, 2001. Its purpose was to coordinate among the government the response to a range of biological terrorism threats. Most CDC centers are located in Atlanta . Building 18, which opened in 2005 at the CDC's main Roybal campus (named in honor of the late Representative Edward R. Roybal ), contains the premier BSL4 laboratory in the United States. A few of the centers are based in or operate other domestic locations: In addition, CDC operates quarantine facilities in 20 cities in the U.S. Most CDC centers are located in Atlanta . Building 18, which opened in 2005 at the CDC's main Roybal campus (named in honor of the late Representative Edward R. Roybal ), contains the premier BSL4 laboratory in the United States. A few of the centers are based in or operate other domestic locations: In addition, CDC operates quarantine facilities in 20 cities in the U.S. CDC's budget for fiscal year 2018 was $11.9 billion; this decreased to $11.09 billion for fiscal year 2019. The CDC offers grants to help organizations advance health, safety and awareness at the community level in the United States. The CDC awards [ when? ] over 85 percent of its annual budget through these grants. As of 2021 , [ update ] CDC staff numbered approximately 15,000 personnel (including 6,000 contractors and 840 United States Public Health Service Commissioned Corps officers) in 170 occupations. Eighty percent held bachelor's degrees or higher; almost half had advanced degrees (a master's degree or a doctorate such as a PhD, D.O. , or M.D. ). Common CDC job titles include engineer, entomologist , epidemiologist , biologist, physician, veterinarian , behavioral scientist , nurse , medical technologist , economist, public health advisor, health communicator, toxicologist , chemist, computer scientist , and statistician. The CDC also operates a number of notable training and fellowship programs, including those indicated below. The Epidemic Intelligence Service (EIS) is composed of "boots-on-the-ground disease detectives" who investigate public health problems domestically and globally. When called upon by a governmental body, EIS officers may embark on short-term epidemiological assistance assignments, or "Epi-Aids", to provide technical expertise in containing and investigating disease outbreaks. The EIS program is a model for the international Field Epidemiology Training Program . The CDC also operates the Public Health Associate Program (PHAP), a two-year paid fellowship for recent college graduates to work in public health agencies all over the United States. PHAP was founded in 2007 and currently [ when? ] has 159 associates in 34 states. The Epidemic Intelligence Service (EIS) is composed of "boots-on-the-ground disease detectives" who investigate public health problems domestically and globally. When called upon by a governmental body, EIS officers may embark on short-term epidemiological assistance assignments, or "Epi-Aids", to provide technical expertise in containing and investigating disease outbreaks. The EIS program is a model for the international Field Epidemiology Training Program .The CDC also operates the Public Health Associate Program (PHAP), a two-year paid fellowship for recent college graduates to work in public health agencies all over the United States. PHAP was founded in 2007 and currently [ when? ] has 159 associates in 34 states. The Director of CDC is a Senior Executive Service position that may be filled either by a career employee, or as a political appointment that does not require Senate confirmation , with the latter method typically being used. The director serves at the pleasure of the President and may be fired at any time. On January 20, 2025, the CDC Director position will change to require Senate confirmation, due to a provision in the Consolidated Appropriations Act, 2023 . The CDC Director concurrently serves as the Administrator of the Agency for Toxic Substances and Disease Registry . Twenty directors have [ when? ] served the CDC or its predecessor agencies, including three who have served during the Trump administration (including Anne Schuchat who twice served as acting director) and three who have served during the Carter administration (including one acting director not shown here). Two served under Bill Clinton, but only one under the Nixon to Ford terms.The CDC's programs address more than 400 diseases, health threats, and conditions that are major causes of death, disease, and disability. The CDC's website has information on various infectious (and noninfectious) diseases, including smallpox , measles , and others. The CDC targets the transmission of influenza , including the H1N1 swine flu, and launched websites to educate people about hygiene. Within the division are two programs: the Federal Select Agent Program (FSAP) and the Import Permit Program. The FSAP is run jointly with an office within the U.S. Department of Agriculture, regulating agents that can cause disease in humans, animals, and plants. The Import Permit Program regulates the importation of "infectious biological materials." The CDC runs a program that protects the public from rare and dangerous substances such as anthrax and the Ebola virus . The program, called the Federal Select Agent Program, calls for inspections of labs in the U.S. that work with dangerous pathogens. During the 2014 Ebola outbreak in West Africa , the CDC helped coordinate the return of two infected American aid workers for treatment at Emory University Hospital , the home of a special unit to handle highly infectious diseases. As a response to the 2014 Ebola outbreak, Congress passed a Continuing Appropriations Resolution allocating $30,000,000 towards CDC's efforts to fight the virus. The CDC also works on non-communicable diseases, including chronic diseases caused by obesity , physical inactivity and tobacco-use. The work of the Division for Cancer Prevention and Control, led from 2010 by Lisa C. Richardson , is also within this remit. The CDC implemented their National Action Plan for Combating Antibiotic Resistant Bacteria as a measure against the spread of antibiotic resistance in the United States. This initiative has a budget of $161 million and includes the development of the Antibiotic Resistance Lab Network . Globally, the CDC works with other organizations to address global health challenges and contain disease threats at their source. They work with many international organizations such as the World Health Organization (WHO) as well as ministries of health and other groups on the front lines of outbreaks. The agency maintains staff in more than 60 countries, including some from the U.S. but more from the countries in which they operate. The agency's global divisions include the Division of Global HIV and TB (DGHT), the Division of Parasitic Diseases and Malaria (DPDM), the Division of Global Health Protection (DGHP), and the Global Immunization Division (GID). The CDC has been working with the WHO to implement the International Health Regulations (IHR) , an agreement between 196 countries to prevent, control, and report on the international spread of disease, through initiatives including the Global Disease Detection Program (GDD). The CDC has also been involved in implementing the U.S. global health initiatives President's Emergency Plan for AIDS Relief (PEPFAR) and President's Malaria Initiative . The CDC collects and publishes health information for travelers in a comprehensive book, CDC Health Information for International Travel , which is commonly known as the "yellow book." The book is available online and in print as a new edition every other year and includes current travel health guidelines, vaccine recommendations, and information on specific travel destinations . The CDC also issues travel health notices on its website, consisting of three levels: "Watch": Level 1 (practice usual precautions) "Alert": Level 2 (practice enhanced precautions) "Warning": Level 3 (avoid nonessential travel) The CDC uses a number of tools to monitor the safety of vaccines. The Vaccine Adverse Event Reporting System (VAERS), a national vaccine safety surveillance program run by CDC and the FDA. "VAERS detects possible safety issues with U.S. vaccines by collecting information about adverse events (possible side effects or health problems) after vaccination." The CDC's Safety Information by Vaccine page provides a list of the latest safety information, side effects, and answers to common questions about CDC recommended vaccines. The Vaccine Safety Datalink (VSD) works with a network of healthcare organizations to share data on vaccine safety and adverse events. The Clinical Immunization Safety Assessment (CISA) project is a network of vaccine experts and health centers that research and assist the CDC in the area of vaccine safety. CDC also runs a program called V-safe, a smartphone web application that allows COVID-19 vaccine recipients to be surveyed in detail about their health in response to getting the shot. The CDC's programs address more than 400 diseases, health threats, and conditions that are major causes of death, disease, and disability. The CDC's website has information on various infectious (and noninfectious) diseases, including smallpox , measles , and others. The CDC targets the transmission of influenza , including the H1N1 swine flu, and launched websites to educate people about hygiene. Within the division are two programs: the Federal Select Agent Program (FSAP) and the Import Permit Program. The FSAP is run jointly with an office within the U.S. Department of Agriculture, regulating agents that can cause disease in humans, animals, and plants. The Import Permit Program regulates the importation of "infectious biological materials." The CDC runs a program that protects the public from rare and dangerous substances such as anthrax and the Ebola virus . The program, called the Federal Select Agent Program, calls for inspections of labs in the U.S. that work with dangerous pathogens. During the 2014 Ebola outbreak in West Africa , the CDC helped coordinate the return of two infected American aid workers for treatment at Emory University Hospital , the home of a special unit to handle highly infectious diseases. As a response to the 2014 Ebola outbreak, Congress passed a Continuing Appropriations Resolution allocating $30,000,000 towards CDC's efforts to fight the virus. The CDC targets the transmission of influenza , including the H1N1 swine flu, and launched websites to educate people about hygiene. Within the division are two programs: the Federal Select Agent Program (FSAP) and the Import Permit Program. The FSAP is run jointly with an office within the U.S. Department of Agriculture, regulating agents that can cause disease in humans, animals, and plants. The Import Permit Program regulates the importation of "infectious biological materials." The CDC runs a program that protects the public from rare and dangerous substances such as anthrax and the Ebola virus . The program, called the Federal Select Agent Program, calls for inspections of labs in the U.S. that work with dangerous pathogens. During the 2014 Ebola outbreak in West Africa , the CDC helped coordinate the return of two infected American aid workers for treatment at Emory University Hospital , the home of a special unit to handle highly infectious diseases. As a response to the 2014 Ebola outbreak, Congress passed a Continuing Appropriations Resolution allocating $30,000,000 towards CDC's efforts to fight the virus. The CDC also works on non-communicable diseases, including chronic diseases caused by obesity , physical inactivity and tobacco-use. The work of the Division for Cancer Prevention and Control, led from 2010 by Lisa C. Richardson , is also within this remit. The CDC implemented their National Action Plan for Combating Antibiotic Resistant Bacteria as a measure against the spread of antibiotic resistance in the United States. This initiative has a budget of $161 million and includes the development of the Antibiotic Resistance Lab Network . Globally, the CDC works with other organizations to address global health challenges and contain disease threats at their source. They work with many international organizations such as the World Health Organization (WHO) as well as ministries of health and other groups on the front lines of outbreaks. The agency maintains staff in more than 60 countries, including some from the U.S. but more from the countries in which they operate. The agency's global divisions include the Division of Global HIV and TB (DGHT), the Division of Parasitic Diseases and Malaria (DPDM), the Division of Global Health Protection (DGHP), and the Global Immunization Division (GID). The CDC has been working with the WHO to implement the International Health Regulations (IHR) , an agreement between 196 countries to prevent, control, and report on the international spread of disease, through initiatives including the Global Disease Detection Program (GDD). The CDC has also been involved in implementing the U.S. global health initiatives President's Emergency Plan for AIDS Relief (PEPFAR) and President's Malaria Initiative . The CDC collects and publishes health information for travelers in a comprehensive book, CDC Health Information for International Travel , which is commonly known as the "yellow book." The book is available online and in print as a new edition every other year and includes current travel health guidelines, vaccine recommendations, and information on specific travel destinations . The CDC also issues travel health notices on its website, consisting of three levels: "Watch": Level 1 (practice usual precautions) "Alert": Level 2 (practice enhanced precautions) "Warning": Level 3 (avoid nonessential travel) The CDC uses a number of tools to monitor the safety of vaccines. The Vaccine Adverse Event Reporting System (VAERS), a national vaccine safety surveillance program run by CDC and the FDA. "VAERS detects possible safety issues with U.S. vaccines by collecting information about adverse events (possible side effects or health problems) after vaccination." The CDC's Safety Information by Vaccine page provides a list of the latest safety information, side effects, and answers to common questions about CDC recommended vaccines. The Vaccine Safety Datalink (VSD) works with a network of healthcare organizations to share data on vaccine safety and adverse events. The Clinical Immunization Safety Assessment (CISA) project is a network of vaccine experts and health centers that research and assist the CDC in the area of vaccine safety. CDC also runs a program called V-safe, a smartphone web application that allows COVID-19 vaccine recipients to be surveyed in detail about their health in response to getting the shot. The CDC Foundation operates independently from CDC as a private, nonprofit 501(c)(3) organization incorporated in the State of Georgia . The creation of the Foundation was authorized by section 399F of the Public Health Service Act to support the mission of CDC in partnership with the private sector, including organizations, foundations, businesses, educational groups, and individuals. From 1995 to 2022, the Foundation raised over $1.6 billion and launched more than 1,200 health programs. Bill Cosby formerly served as a member of the Foundation's Board of Directors, continuing as an honorary member after completing his term. The Foundation engages in research projects and health programs in more than 160 countries every year, including in focus areas such as cardiovascular disease , cancer , emergency response , and infectious diseases , particularly HIV/AIDS , Ebola , rotavirus , and COVID-19 . In 2015, BMJ associate editor Jeanne Lenzer raised concerns that the CDC's recommendations and publications may be influenced by donations received through the Foundation, which includes pharmaceutical companies. The Foundation engages in research projects and health programs in more than 160 countries every year, including in focus areas such as cardiovascular disease , cancer , emergency response , and infectious diseases , particularly HIV/AIDS , Ebola , rotavirus , and COVID-19 . In 2015, BMJ associate editor Jeanne Lenzer raised concerns that the CDC's recommendations and publications may be influenced by donations received through the Foundation, which includes pharmaceutical companies. For 15 years, the CDC had direct oversight over the Tuskegee syphilis experiment . In the study, which lasted from 1932 to 1972, a group of Black men (nearly 400 of whom had syphilis) were studied to learn more about the disease. The disease was left untreated in the men, who had not given their informed consent to serve as research subjects. The Tuskegee Study was initiated in 1932 by the Public Health Service, with the CDC taking over the Tuskegee Health Benefit Program in 1995. An area of partisan dispute related to CDC funding is studying firearms effectiveness. Although the CDC was one of the first government agencies to study gun related data, in 1996 the Dickey Amendment , passed with the support of the National Rifle Association of America , states "none of the funds available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control". Advocates for gun control oppose the amendment and have tried to overturn it. Looking at the history of the passage of the Dickey Amendment, in 1992, Mark L. Rosenberg and five CDC colleagues founded the CDC's National Center for Injury Prevention and Control, with an annual budget of approximately $260,000. They focused on "identifying causes of firearm deaths, and methods to prevent them". Their first report, published in the New England Journal of Medicine in 1993 entitled "Guns are a Risk Factor for Homicide in the Home", reported "mere presence of a gun in a home increased the risk of a firearm-related death by 2.7 percent, and suicide fivefold—a "huge" increase." In response, the NRA launched a "campaign to shut down the Injury Center." Two conservative pro-gun groups, Doctors for Responsible Gun Ownership and Doctors for Integrity and Policy Research joined the pro-gun effort, and, by 1995, politicians also supported the pro-gun initiative. In 1996, Jay Dickey (R) Arkansas introduced the Dickey Amendment statement stating "none of the funds available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control" as a rider. in the 1996 appropriations bill ." In 1997, "Congress re-directed all of the money for gun research to the study of traumatic brain injury." David Satcher , CDC head 1993-98 advocated for firearms research. In 2016 over a dozen "public health insiders, including current and former CDC senior leaders" told The Trace interviewers that CDC senior leaders took a cautious stance in their interpretation of the Dickey Amendment and that they could do more but were afraid of political and personal retribution. In 2013, the American Medical Association , the American Psychological Association , and the American Academy of Pediatrics sent a letter to the leaders of the Senate Appropriations Committee asking them "to support at least $10 million within the Centers for Disease Control and Prevention (CDC) in FY 2014 along with sufficient new taxes at the National Institutes of Health to support research into the causes and prevention of violence. Furthermore, we urge Members to oppose any efforts to reduce, eliminate, or condition CDC funding related to violence prevention research." Congress maintained the ban in subsequent budgets. In October 2014, the CDC gave a nurse with a fever who was later diagnosed with Ebola permission to board a commercial flight to Cleveland . The CDC has been widely criticized for its handling of the COVID-19 pandemic. In 2022, CDC director Rochelle Walensky acknowledged "some pretty dramatic, pretty public mistakes, from testing to data to communications", based on the findings of an internal examination. The first confirmed case of COVID-19 was discovered in the U.S. on January 20, 2020. However, widespread COVID-19 testing in the United States was effectively stalled until February 28, when federal officials revised a faulty CDC test, and days afterward, when the Food and Drug Administration began loosening rules that had restricted other labs from developing tests. In February 2020, as the CDC's early coronavirus test malfunctioned nationwide, CDC Director Robert R. Redfield reassured fellow officials on the White House Coronavirus Task Force that the problem would be quickly solved, according to White House officials. It took about three weeks to sort out the failed test kits, which may have been contaminated during their processing in a CDC lab. Later investigations by the FDA and the Department of Health and Human Services found that the CDC had violated its own protocols in developing its tests. In November 2020, NPR reported that an internal review document they obtained revealed that the CDC was aware that the first batch of tests which were issued in early January had a chance of being wrong 33 percent of the time, but they released them anyway. In May 2020, The Atlantic reported that the CDC was conflating the results of two different types of coronavirus tests — tests that diagnose current coronavirus infections, and tests that measure whether someone has ever had the virus. The magazine said this distorted several important metrics, provided the country with an inaccurate picture of the state of the pandemic, and overstated the country's testing ability. In July 2020, the Trump administration ordered hospitals to bypass the CDC and instead send all COVID-19 patient information to a database at the Department of Health and Human Services . Some health experts opposed the order and warned that the data might become politicized or withheld from the public. On July 15, the CDC alarmed health care groups by temporarily removing COVID-19 dashboards from its website. It restored the data a day later. In August 2020, the CDC recommended that people showing no COVID-19 symptoms do not need testing. The new guidelines alarmed many public health experts. The guidelines were crafted by the White House Coronavirus Task Force without the sign-off of Anthony Fauci of the NIH. Objections by other experts at the CDC went unheard. Officials said that a CDC document in July arguing for "the importance of reopening schools" was also crafted outside the CDC. On August 16, the chief of staff, Kyle McGowan, and his deputy, Amanda Campbell, resigned from the agency. The testing guidelines were reversed on September 18, 2020, after public controversy. In September 2020, the CDC drafted an order requiring masks on all public transportation in the United States, but the White House Coronavirus Task Force blocked the order, refusing to discuss it, according to two federal health officials. In October 2020, it was disclosed that White House advisers had repeatedly altered the writings of CDC scientists about COVID-19, including recommendations on church choirs, social distancing in bars and restaurants, and summaries of public-health reports. In the lead up to 2020 Thanksgiving , the CDC advised Americans not to travel for the holiday saying, "It's not a requirement. It's a recommendation for the American public to consider." The White House coronavirus task force had its first public briefing in months on that date but travel was not mentioned. The New York Times later concluded that the CDC's decisions to "ben[d] to political pressure from the Trump White House to alter key public health guidance or withhold it from the public [...] cost it a measure of public trust that experts say it still has not recaptured" as of 2022. In May 2021, following criticism by scientists, the CDC updated its COVID-19 guidance to acknowledge airborne transmission of COVID-19, after having previously claimed that the majority of infections occurred via "close contact, not airborne transmission". In December 2021, following a request from the CEO of Delta Air Lines , CDC shortened its recommended isolation period for asymptomatic individuals infected with Covid-19 from 10 days to five. Until 2022, the CDC withheld critical data about COVID-19 vaccine boosters, hospitalizations and wastewater data. On June 10, 2022, the Biden Administration ordered the CDC to remove the COVID-19 testing requirement for air travelers entering the United States. In January 2022, it was revealed that the CDC had communicated with moderators at Facebook and Instagram over COVID-19 information and discussion on the platforms, including information that the CDC considered false or misleading and that might influence people not to get the COVID-19 vaccines. During the pandemic, the CDC Morbidity and Mortality Weekly Report (MMWR) came under pressure from political appointees at the Department of Health and Human Services (HHS) to modify its reporting so as not to conflict with what Trump was saying about the pandemic. Starting in June 2020, Michael Caputo , the HHS assistant secretary for public affairs, and his chief advisor Paul Alexander tried to delay, suppress, change, and retroactively edit MMR releases about the effectiveness of potential treatments for COVID-19, the transmissibility of the virus, and other issues where the president had taken a public stance. Alexander tried unsuccessfully to get personal approval of all issues of MMWR before they went out. Caputo claimed this oversight was necessary because MMWR reports were being tainted by "political content"; he demanded to know the political leanings of the scientists who reported that hydroxychloroquine had little benefit as a treatment while Trump was saying the opposite. In emails Alexander accused CDC scientists of attempting to "hurt the president" and writing "hit pieces on the administration". In October 2020, emails obtained by Politico showed that Alexander requested multiple alterations in a report. The published alterations included a title being changed from "Children, Adolescents, and Young Adults" to "Persons." One current and two former CDC officials who reviewed the email exchanges said they were troubled by the "intervention to alter scientific reports viewed as untouchable prior to the Trump administration" that "appeared to minimize the risks of the coronavirus to children by making the report's focus on children less clear." A poll conducted in September 2020 found that nearly 8 in 10 Americans trusted the CDC, a decrease from 87 percent in April 2020. Another poll showed an even larger drop in trust with the results dropping 16 percentage points. By January 2022, according to an NBC News poll, only 44% of Americans trusted the CDC compared to 69% at the beginning of the pandemic. As the trustworthiness eroded, so too did the information it disseminates. The diminishing level of trust in the CDC and the information releases also incited " vaccine hesitancy " with the result that "just 53 percent of Americans said they would be somewhat or extremely likely to get a vaccine." In September 2020, amid the accusations and the faltering image of the CDC, the agency's leadership was called into question. Former acting director at the CDC, Richard Besser , said of Redfield that "I find it concerning that the CDC director has not been outspoken when there have been instances of clear political interference in the interpretation of science." In addition, Mark Rosenberg , the first director of CDC's National Center for Injury Prevention and Control , also questioned Redfield's leadership and his lack of defense of the science. Historically, the CDC has not been a political agency; however, the COVID-19 pandemic , and specifically the Trump Administration's handling of the pandemic, resulted in a "dangerous shift" according to a previous CDC director and others. Four previous directors claim that the agency's voice was "muted for political reasons." Politicization of the agency has continued into the Biden administration as COVID-19 guidance is contradicted by State guidance and the agency is criticized as "CDC's credibility is eroding". In 2021, the CDC, then under the leadership of the Biden Administration, received criticism for its mixed messaging surrounding COVID-19 vaccines, mask-wearing guidance , and the state of the pandemic. In 2024, evolutionary biologist Richard Dawkins and physicist Alan Sokal co-authored an op-ed in The Boston Globe criticizing the use of the terminology " sex assigned at birth " instead of " sex " by the CDC, the American Medical Association , the American Psychological Association , and the American Academy of Pediatrics . Dawkins and Sokal wrote that sex is an "objective biological reality" that "is determined at conception and is then observed at birth," rather than assigned by a medical professional. Calling this " social constructionism gone amok," Dawkins and Sokal argued that "distort[ing] the scientific facts in the service of a social cause" risks undermining trust in medical institutions. For 15 years, the CDC had direct oversight over the Tuskegee syphilis experiment . In the study, which lasted from 1932 to 1972, a group of Black men (nearly 400 of whom had syphilis) were studied to learn more about the disease. The disease was left untreated in the men, who had not given their informed consent to serve as research subjects. The Tuskegee Study was initiated in 1932 by the Public Health Service, with the CDC taking over the Tuskegee Health Benefit Program in 1995. An area of partisan dispute related to CDC funding is studying firearms effectiveness. Although the CDC was one of the first government agencies to study gun related data, in 1996 the Dickey Amendment , passed with the support of the National Rifle Association of America , states "none of the funds available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control". Advocates for gun control oppose the amendment and have tried to overturn it. Looking at the history of the passage of the Dickey Amendment, in 1992, Mark L. Rosenberg and five CDC colleagues founded the CDC's National Center for Injury Prevention and Control, with an annual budget of approximately $260,000. They focused on "identifying causes of firearm deaths, and methods to prevent them". Their first report, published in the New England Journal of Medicine in 1993 entitled "Guns are a Risk Factor for Homicide in the Home", reported "mere presence of a gun in a home increased the risk of a firearm-related death by 2.7 percent, and suicide fivefold—a "huge" increase." In response, the NRA launched a "campaign to shut down the Injury Center." Two conservative pro-gun groups, Doctors for Responsible Gun Ownership and Doctors for Integrity and Policy Research joined the pro-gun effort, and, by 1995, politicians also supported the pro-gun initiative. In 1996, Jay Dickey (R) Arkansas introduced the Dickey Amendment statement stating "none of the funds available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control" as a rider. in the 1996 appropriations bill ." In 1997, "Congress re-directed all of the money for gun research to the study of traumatic brain injury." David Satcher , CDC head 1993-98 advocated for firearms research. In 2016 over a dozen "public health insiders, including current and former CDC senior leaders" told The Trace interviewers that CDC senior leaders took a cautious stance in their interpretation of the Dickey Amendment and that they could do more but were afraid of political and personal retribution. In 2013, the American Medical Association , the American Psychological Association , and the American Academy of Pediatrics sent a letter to the leaders of the Senate Appropriations Committee asking them "to support at least $10 million within the Centers for Disease Control and Prevention (CDC) in FY 2014 along with sufficient new taxes at the National Institutes of Health to support research into the causes and prevention of violence. Furthermore, we urge Members to oppose any efforts to reduce, eliminate, or condition CDC funding related to violence prevention research." Congress maintained the ban in subsequent budgets. In October 2014, the CDC gave a nurse with a fever who was later diagnosed with Ebola permission to board a commercial flight to Cleveland . The CDC has been widely criticized for its handling of the COVID-19 pandemic. In 2022, CDC director Rochelle Walensky acknowledged "some pretty dramatic, pretty public mistakes, from testing to data to communications", based on the findings of an internal examination. The first confirmed case of COVID-19 was discovered in the U.S. on January 20, 2020. However, widespread COVID-19 testing in the United States was effectively stalled until February 28, when federal officials revised a faulty CDC test, and days afterward, when the Food and Drug Administration began loosening rules that had restricted other labs from developing tests. In February 2020, as the CDC's early coronavirus test malfunctioned nationwide, CDC Director Robert R. Redfield reassured fellow officials on the White House Coronavirus Task Force that the problem would be quickly solved, according to White House officials. It took about three weeks to sort out the failed test kits, which may have been contaminated during their processing in a CDC lab. Later investigations by the FDA and the Department of Health and Human Services found that the CDC had violated its own protocols in developing its tests. In November 2020, NPR reported that an internal review document they obtained revealed that the CDC was aware that the first batch of tests which were issued in early January had a chance of being wrong 33 percent of the time, but they released them anyway. In May 2020, The Atlantic reported that the CDC was conflating the results of two different types of coronavirus tests — tests that diagnose current coronavirus infections, and tests that measure whether someone has ever had the virus. The magazine said this distorted several important metrics, provided the country with an inaccurate picture of the state of the pandemic, and overstated the country's testing ability. In July 2020, the Trump administration ordered hospitals to bypass the CDC and instead send all COVID-19 patient information to a database at the Department of Health and Human Services . Some health experts opposed the order and warned that the data might become politicized or withheld from the public. On July 15, the CDC alarmed health care groups by temporarily removing COVID-19 dashboards from its website. It restored the data a day later. In August 2020, the CDC recommended that people showing no COVID-19 symptoms do not need testing. The new guidelines alarmed many public health experts. The guidelines were crafted by the White House Coronavirus Task Force without the sign-off of Anthony Fauci of the NIH. Objections by other experts at the CDC went unheard. Officials said that a CDC document in July arguing for "the importance of reopening schools" was also crafted outside the CDC. On August 16, the chief of staff, Kyle McGowan, and his deputy, Amanda Campbell, resigned from the agency. The testing guidelines were reversed on September 18, 2020, after public controversy. In September 2020, the CDC drafted an order requiring masks on all public transportation in the United States, but the White House Coronavirus Task Force blocked the order, refusing to discuss it, according to two federal health officials. In October 2020, it was disclosed that White House advisers had repeatedly altered the writings of CDC scientists about COVID-19, including recommendations on church choirs, social distancing in bars and restaurants, and summaries of public-health reports. In the lead up to 2020 Thanksgiving , the CDC advised Americans not to travel for the holiday saying, "It's not a requirement. It's a recommendation for the American public to consider." The White House coronavirus task force had its first public briefing in months on that date but travel was not mentioned. The New York Times later concluded that the CDC's decisions to "ben[d] to political pressure from the Trump White House to alter key public health guidance or withhold it from the public [...] cost it a measure of public trust that experts say it still has not recaptured" as of 2022. In May 2021, following criticism by scientists, the CDC updated its COVID-19 guidance to acknowledge airborne transmission of COVID-19, after having previously claimed that the majority of infections occurred via "close contact, not airborne transmission". In December 2021, following a request from the CEO of Delta Air Lines , CDC shortened its recommended isolation period for asymptomatic individuals infected with Covid-19 from 10 days to five. Until 2022, the CDC withheld critical data about COVID-19 vaccine boosters, hospitalizations and wastewater data. On June 10, 2022, the Biden Administration ordered the CDC to remove the COVID-19 testing requirement for air travelers entering the United States. In January 2022, it was revealed that the CDC had communicated with moderators at Facebook and Instagram over COVID-19 information and discussion on the platforms, including information that the CDC considered false or misleading and that might influence people not to get the COVID-19 vaccines. During the pandemic, the CDC Morbidity and Mortality Weekly Report (MMWR) came under pressure from political appointees at the Department of Health and Human Services (HHS) to modify its reporting so as not to conflict with what Trump was saying about the pandemic. Starting in June 2020, Michael Caputo , the HHS assistant secretary for public affairs, and his chief advisor Paul Alexander tried to delay, suppress, change, and retroactively edit MMR releases about the effectiveness of potential treatments for COVID-19, the transmissibility of the virus, and other issues where the president had taken a public stance. Alexander tried unsuccessfully to get personal approval of all issues of MMWR before they went out. Caputo claimed this oversight was necessary because MMWR reports were being tainted by "political content"; he demanded to know the political leanings of the scientists who reported that hydroxychloroquine had little benefit as a treatment while Trump was saying the opposite. In emails Alexander accused CDC scientists of attempting to "hurt the president" and writing "hit pieces on the administration". In October 2020, emails obtained by Politico showed that Alexander requested multiple alterations in a report. The published alterations included a title being changed from "Children, Adolescents, and Young Adults" to "Persons." One current and two former CDC officials who reviewed the email exchanges said they were troubled by the "intervention to alter scientific reports viewed as untouchable prior to the Trump administration" that "appeared to minimize the risks of the coronavirus to children by making the report's focus on children less clear." A poll conducted in September 2020 found that nearly 8 in 10 Americans trusted the CDC, a decrease from 87 percent in April 2020. Another poll showed an even larger drop in trust with the results dropping 16 percentage points. By January 2022, according to an NBC News poll, only 44% of Americans trusted the CDC compared to 69% at the beginning of the pandemic. As the trustworthiness eroded, so too did the information it disseminates. The diminishing level of trust in the CDC and the information releases also incited " vaccine hesitancy " with the result that "just 53 percent of Americans said they would be somewhat or extremely likely to get a vaccine." In September 2020, amid the accusations and the faltering image of the CDC, the agency's leadership was called into question. Former acting director at the CDC, Richard Besser , said of Redfield that "I find it concerning that the CDC director has not been outspoken when there have been instances of clear political interference in the interpretation of science." In addition, Mark Rosenberg , the first director of CDC's National Center for Injury Prevention and Control , also questioned Redfield's leadership and his lack of defense of the science. Historically, the CDC has not been a political agency; however, the COVID-19 pandemic , and specifically the Trump Administration's handling of the pandemic, resulted in a "dangerous shift" according to a previous CDC director and others. Four previous directors claim that the agency's voice was "muted for political reasons." Politicization of the agency has continued into the Biden administration as COVID-19 guidance is contradicted by State guidance and the agency is criticized as "CDC's credibility is eroding". In 2021, the CDC, then under the leadership of the Biden Administration, received criticism for its mixed messaging surrounding COVID-19 vaccines, mask-wearing guidance , and the state of the pandemic. During the pandemic, the CDC Morbidity and Mortality Weekly Report (MMWR) came under pressure from political appointees at the Department of Health and Human Services (HHS) to modify its reporting so as not to conflict with what Trump was saying about the pandemic. Starting in June 2020, Michael Caputo , the HHS assistant secretary for public affairs, and his chief advisor Paul Alexander tried to delay, suppress, change, and retroactively edit MMR releases about the effectiveness of potential treatments for COVID-19, the transmissibility of the virus, and other issues where the president had taken a public stance. Alexander tried unsuccessfully to get personal approval of all issues of MMWR before they went out. Caputo claimed this oversight was necessary because MMWR reports were being tainted by "political content"; he demanded to know the political leanings of the scientists who reported that hydroxychloroquine had little benefit as a treatment while Trump was saying the opposite. In emails Alexander accused CDC scientists of attempting to "hurt the president" and writing "hit pieces on the administration". In October 2020, emails obtained by Politico showed that Alexander requested multiple alterations in a report. The published alterations included a title being changed from "Children, Adolescents, and Young Adults" to "Persons." One current and two former CDC officials who reviewed the email exchanges said they were troubled by the "intervention to alter scientific reports viewed as untouchable prior to the Trump administration" that "appeared to minimize the risks of the coronavirus to children by making the report's focus on children less clear." A poll conducted in September 2020 found that nearly 8 in 10 Americans trusted the CDC, a decrease from 87 percent in April 2020. Another poll showed an even larger drop in trust with the results dropping 16 percentage points. By January 2022, according to an NBC News poll, only 44% of Americans trusted the CDC compared to 69% at the beginning of the pandemic. As the trustworthiness eroded, so too did the information it disseminates. The diminishing level of trust in the CDC and the information releases also incited " vaccine hesitancy " with the result that "just 53 percent of Americans said they would be somewhat or extremely likely to get a vaccine." In September 2020, amid the accusations and the faltering image of the CDC, the agency's leadership was called into question. Former acting director at the CDC, Richard Besser , said of Redfield that "I find it concerning that the CDC director has not been outspoken when there have been instances of clear political interference in the interpretation of science." In addition, Mark Rosenberg , the first director of CDC's National Center for Injury Prevention and Control , also questioned Redfield's leadership and his lack of defense of the science. Historically, the CDC has not been a political agency; however, the COVID-19 pandemic , and specifically the Trump Administration's handling of the pandemic, resulted in a "dangerous shift" according to a previous CDC director and others. Four previous directors claim that the agency's voice was "muted for political reasons." Politicization of the agency has continued into the Biden administration as COVID-19 guidance is contradicted by State guidance and the agency is criticized as "CDC's credibility is eroding". In 2021, the CDC, then under the leadership of the Biden Administration, received criticism for its mixed messaging surrounding COVID-19 vaccines, mask-wearing guidance , and the state of the pandemic. In 2024, evolutionary biologist Richard Dawkins and physicist Alan Sokal co-authored an op-ed in The Boston Globe criticizing the use of the terminology " sex assigned at birth " instead of " sex " by the CDC, the American Medical Association , the American Psychological Association , and the American Academy of Pediatrics . Dawkins and Sokal wrote that sex is an "objective biological reality" that "is determined at conception and is then observed at birth," rather than assigned by a medical professional. Calling this " social constructionism gone amok," Dawkins and Sokal argued that "distort[ing] the scientific facts in the service of a social cause" risks undermining trust in medical institutions. On May 16, 2011, the Centers for Disease Control and Prevention's blog published an article instructing the public on what to do to prepare for a zombie invasion. While the article did not claim that such a scenario was possible, it did use the popular culture appeal as a means of urging citizens to prepare for all potential hazards, such as earthquakes, tornadoes, and floods. According to David Daigle, the associate director for Communications, Public Health Preparedness and Response, the idea arose when his team was discussing their upcoming hurricane-information campaign and Daigle mused that "we say pretty much the same things every year, in the same way, and I just wonder how many people are paying attention." A social-media employee mentioned that the subject of zombies had come up a lot on Twitter when she had been tweeting about the Fukushima Daiichi nuclear disaster and radiation . The team realized that a campaign like this would most likely reach a different audience from the one that normally pays attention to hurricane-preparedness warnings and went to work on the zombie campaign, launching it right before hurricane season began. "The whole idea was, if you're prepared for a zombie apocalypse, you're prepared for pretty much anything," said Daigle. Once the blog article was posted, the CDC announced an open contest for YouTube submissions of the most creative and effective videos covering preparedness for a zombie apocalypse (or apocalypse of any kind), to be judged by the "CDC Zombie Task Force". Submissions were open until October 11, 2011. They also released a zombie-themed graphic novella available on their website. Zombie-themed educational materials for teachers are available on the site. On May 16, 2011, the Centers for Disease Control and Prevention's blog published an article instructing the public on what to do to prepare for a zombie invasion. While the article did not claim that such a scenario was possible, it did use the popular culture appeal as a means of urging citizens to prepare for all potential hazards, such as earthquakes, tornadoes, and floods. According to David Daigle, the associate director for Communications, Public Health Preparedness and Response, the idea arose when his team was discussing their upcoming hurricane-information campaign and Daigle mused that "we say pretty much the same things every year, in the same way, and I just wonder how many people are paying attention." A social-media employee mentioned that the subject of zombies had come up a lot on Twitter when she had been tweeting about the Fukushima Daiichi nuclear disaster and radiation . The team realized that a campaign like this would most likely reach a different audience from the one that normally pays attention to hurricane-preparedness warnings and went to work on the zombie campaign, launching it right before hurricane season began. "The whole idea was, if you're prepared for a zombie apocalypse, you're prepared for pretty much anything," said Daigle. Once the blog article was posted, the CDC announced an open contest for YouTube submissions of the most creative and effective videos covering preparedness for a zombie apocalypse (or apocalypse of any kind), to be judged by the "CDC Zombie Task Force". Submissions were open until October 11, 2011. They also released a zombie-themed graphic novella available on their website. Zombie-themed educational materials for teachers are available on the site.

Wiki

Ebola

https://api.wikimedia.org/core/v1/wikipedia/en/page/Ebola_virus_epidemic_in_Liberia/html

Ebola virus epidemic in Liberia

An epidemic of Ebola virus disease occurred in Liberia from 2014 to 2015, along with the neighbouring countries of Guinea and Sierra Leone . The first cases of virus were reported by late March 2014. The Ebola virus , a biosafety level four pathogen , is an RNA virus discovered in 1976. Before the outbreak of the Ebola epidemic the country had 50 doctors for its population of 4.3 million. The country's health system was seriously weakened by a civil war that ended in 2003. Researchers generally believe that a two-year-old boy, later identified as Emile Ouamouno , who died in December 2013 in the village of Meliandou , Guéckédou Prefecture , Guinea , was the index case of the current Ebola virus disease epidemic. His mother, sister, and grandmother then became ill with similar symptoms and also died. People infected by those initial cases spread the disease to other villages. Although Ebola represents a major public health issue in sub-Saharan Africa, no cases had ever been reported in West Africa and the early cases were diagnosed as other diseases more common to the area. Thus, the disease had several months to spread before it was recognized as Ebola. Researchers generally believe that a two-year-old boy, later identified as Emile Ouamouno , who died in December 2013 in the village of Meliandou , Guéckédou Prefecture , Guinea , was the index case of the current Ebola virus disease epidemic. His mother, sister, and grandmother then became ill with similar symptoms and also died. People infected by those initial cases spread the disease to other villages. Although Ebola represents a major public health issue in sub-Saharan Africa, no cases had ever been reported in West Africa and the early cases were diagnosed as other diseases more common to the area. Thus, the disease had several months to spread before it was recognized as Ebola. On 30 March 2014, Liberia confirmed its first two cases of Ebola virus disease in Foya , Lofa County. By 23 April, thirty-four cases and six deaths from Ebola in Liberia were recorded. By 17 June, sixteen people had died from the disease in the country. The initial cases were thought to be malaria , an extremely common disease in Liberia, and thus leading to doctors being infected with the Ebola virus. By 17 June, the first deaths occurred in Monrovia from Ebola when seven patients died from the disease. Among them was a nurse, along with other members of her household. At the time, there were about 16 cases reported in Liberia in total. The nurse was treated at Redemption Hospital, a free state-run health care facility in New Kru Town , west of Monrovia. On 2 July, the head surgeon of Redemption Hospital died from the disease. He was treated at the JFK Medical Center in Monrovia. Following his death Redemption Hospital was shut down, and patients were either transferred or referred to other facilities in the area. By 21 July, four nurses at Phebe Hospital in Bong County contracted the disease. On 27 July, Samuel Brisbane, one of Liberia's top doctors, died from Ebola. A doctor from Uganda also died from the disease. Two U.S. health care workers, one a doctor ( Kent Brantly ) and the other a nurse were also infected with the disease. Both of them missionaries, they were medically evacuated from Liberia to the US for treatment where they made a full recovery. By 28 July, most border crossings had been closed, with medical checkpoints set up at the remaining ports and quarantines in some areas. Arik Air suspended all flights between Nigeria and Liberia. On 30 July, Liberia shut down its schools in an attempt to prevent the outbreak from spreading. On the first weekend of August, locals quarreled with a burial team trying to bury 22 bodies. The police were summoned and order was restored. On 4 August, the Liberian government ordered all corpses of those who died to be cremated. The body of a patient who died from Ebola is highly contagious in the days following the death. At the time, there were 156 recorded deaths from the disease in Liberia. On 11 August, the Ivorian government announced the suspension of all flights to and from countries affected by Ebola. Ten days later, it decided to close its borders as well with Guinea and Liberia, the two countries most affected by Ebola. On 27 August, wild dogs were seen eating the corpses that had not been collected for burial. A pack of dogs were observed digging up bodies and eating them in Liberia. One study indicated that dogs may eat at Ebola-infected carcasses and may become carriers of the disease. On 18 August, a mob of residents from West Point , an impoverished area of Monrovia, descended upon a local Ebola clinic to protest its presence. The protesters turned violent, threatening the caretakers, removing the infected patients, and looting the clinic of its supplies, including blood-stained bed sheets and mattresses. Police and aid workers expressed fear that this would lead to mass infections of Ebola in West Point. On 19 August, the Liberian government quarantined the entirety of West Point and issued a curfew statewide. Violence again broke out on 22 August, after the military fired on protesting crowds. An inquiry into the incident found the security forces at fault, stating they "fired with complete disregard for human life". The quarantine blockade of the West Point area was lifted on 30 August. The Information Minister, Lewis Brown, said that this step was taken to ease efforts to screen, test, and treat residents. By 1 September, Ivory Coast announced the opening of humanitarian corridors with its two affected neighboring countries. On 20 September, Liberia opened a new 150-bed treatment unit clinic in Monrovia. At the opening ceremony of the Old Island Clinic on Bushrod Island six ambulances were already waiting with suspected Ebola patients. More patients were waiting by the clinic after making their way on foot with the help of relatives. Two days later 112 beds were already filled with 46 patients testing positive for Ebola, while the rest were admitted for observation. This expanded the number of beds in the city beyond 240. Its capacity was exceeded within 24 hours with a shortage of staff and logistics to take care of a patient with correct precautions in place. One source says it opened on 21 September 2014, with a 100-bed capacity. As of 23 September, there had been 3,458 total cases, 1,830 deaths, and 914 lab confirmed cases according to the World Health Organization . By late September, there were three clinics in Monrovia. Despite this patients waiting to be treated died outside as the clinics had run out of space to treat the increasing number of patients. If patients could not get a bed in the clinic they sometimes waited in holding centers until a bed opened up. There were additional cases in Monrovia where the bodies were dumped into the river. One woman used trash bags to protect herself as she cared for four other family members ill with Ebola. Her father became ill in late July, but they could not find a place of treatment for him and ended up doing home-care. On 25 September, Liberia's chief medical official went on a self-enforced quarantine after her assistant died from the disease, fearing she might have been accidentally exposed to the virus. By 29 September it was announced she tested negative for Ebola and government officials praised her for following the self quarantine protocol. A few days later, on 28 September Ivory Coast resumed flights to Liberia which had been suspended since 11 August 2014, after WHO's critique for tending to economically strangle the affected nations. From the beginning of the crisis, WHO has discouraged closing the borders with affected countries. On 30 September, a cameraman was tested positive for Ebola in a Texas hospital after contracting the disease before traveling back to the United States from Liberia. He covered the Ebola outbreak for NBC News (see 2014 Ebola virus cases in the United States ). Following this the Liberian government enacted strict restrictions on journalistic coverage aimed at protecting patients' privacy. In early October, Ellen Johnson Sirleaf , the President of Liberia , continued requesting more aid to fight the disease. On 2 October, a new 60-bed clinic was opened in Kenema. By then, the outbreak was described as being out of control and an exponential growth in cases was seen. The focus shifted to slowing the outbreak down. A key element was the fact that the health care establishments were overwhelmed thus leading to those infected being turned away from treatment centers. This eventually led to the infection of others taking care of sick or dying patients at home. By 3 October, at least eight Liberian soldiers died after contracting the disease from a female visitor. On 3 October more medical supplies arrived from Germany. On that same day Gerlib opened up an Ebola isolation ward at its 48-bed facility in Paynesville (Monrovia). On 10 October all journalists were banned from entering Ebola clinics. On 14 October, a hundred U.S. troops arrived in Liberia, bringing the total to 565 to aid in the fight against the deadly disease. On 16 October, U.S. President Obama authorized, via executive order, the use of National Guard and reservists in Liberia. A report on 15 October indicates that Liberia may need 80,000 more body bags and about 1 million protective suits for the next six months. In October, WHO pushed for its 70-70-60 plan to control the outbreak. By 19 October, it was reported that 223 health care workers had been infected with Ebola, and 103 of them had died in Liberia. On 19 October, the President of Liberia apologized to the Mayor of Dallas, for the Liberian national that brought the disease to the United States. By 19 October, only one area in Liberia, Grand Gedeh County , had yet to report an Ebola case. 14 out of the 15 districts have reported cases. The disease had been noted to be spreading in Monrovia , the nation's capital with over one million inhabitants. Monrovia was particularly affected with 305 new cases reported in the week ending 19 October. By 5 November, Liberia had 6,525 cases (including 1,627 probable, 2,447 suspected cases) and 2,697 deaths. The 5 November WHO situation report noted that, "There appears to be some evidence of a decline at the national level in Liberia, although new case numbers remain high in parts of the country." A report by CDC released on 14 November, based on data collected from Lofa county, indicates that there has been a genuine reduction in new infections. This is credited to an integrated strategy combining isolation and treatment with community behaviour change including safe burial practices, case finding and contract tracing – this strategy might serve as a model to implement in other affected areas to accelerate control of Ebola. Roselyn Nugba-Ballah led the Safe & Dignified Burial Practices Team for the Liberian Red Cross and was awarded the Florence Nightingale Medal for her work during the crisis in 2017. On 13 November, the Liberian President announced the lifting of the state of emergency in the country following the decrease in the number of new cases in the country. The decline in Liberia cases was contradicted in reports from WHO with 439 new cases reported between 23 and 28 November. On 4 December, it was reported that President Sirleaf banned all rallies and gatherings in Monrovia before the senatorial election, fearing that the risk of the Ebola virus spreading may be increased. By 23 April, thirty-four cases and six deaths from Ebola in Liberia were recorded. By 17 June, sixteen people had died from the disease in the country. The initial cases were thought to be malaria , an extremely common disease in Liberia, and thus leading to doctors being infected with the Ebola virus. By 17 June, the first deaths occurred in Monrovia from Ebola when seven patients died from the disease. Among them was a nurse, along with other members of her household. At the time, there were about 16 cases reported in Liberia in total. The nurse was treated at Redemption Hospital, a free state-run health care facility in New Kru Town , west of Monrovia. On 2 July, the head surgeon of Redemption Hospital died from the disease. He was treated at the JFK Medical Center in Monrovia. Following his death Redemption Hospital was shut down, and patients were either transferred or referred to other facilities in the area. By 21 July, four nurses at Phebe Hospital in Bong County contracted the disease. On 27 July, Samuel Brisbane, one of Liberia's top doctors, died from Ebola. A doctor from Uganda also died from the disease. Two U.S. health care workers, one a doctor ( Kent Brantly ) and the other a nurse were also infected with the disease. Both of them missionaries, they were medically evacuated from Liberia to the US for treatment where they made a full recovery. By 28 July, most border crossings had been closed, with medical checkpoints set up at the remaining ports and quarantines in some areas. Arik Air suspended all flights between Nigeria and Liberia. On 30 July, Liberia shut down its schools in an attempt to prevent the outbreak from spreading. On the first weekend of August, locals quarreled with a burial team trying to bury 22 bodies. The police were summoned and order was restored. On 4 August, the Liberian government ordered all corpses of those who died to be cremated. The body of a patient who died from Ebola is highly contagious in the days following the death. At the time, there were 156 recorded deaths from the disease in Liberia. On 11 August, the Ivorian government announced the suspension of all flights to and from countries affected by Ebola. Ten days later, it decided to close its borders as well with Guinea and Liberia, the two countries most affected by Ebola. On 27 August, wild dogs were seen eating the corpses that had not been collected for burial. A pack of dogs were observed digging up bodies and eating them in Liberia. One study indicated that dogs may eat at Ebola-infected carcasses and may become carriers of the disease. On 18 August, a mob of residents from West Point , an impoverished area of Monrovia, descended upon a local Ebola clinic to protest its presence. The protesters turned violent, threatening the caretakers, removing the infected patients, and looting the clinic of its supplies, including blood-stained bed sheets and mattresses. Police and aid workers expressed fear that this would lead to mass infections of Ebola in West Point. On 19 August, the Liberian government quarantined the entirety of West Point and issued a curfew statewide. Violence again broke out on 22 August, after the military fired on protesting crowds. An inquiry into the incident found the security forces at fault, stating they "fired with complete disregard for human life". The quarantine blockade of the West Point area was lifted on 30 August. The Information Minister, Lewis Brown, said that this step was taken to ease efforts to screen, test, and treat residents. On 18 August, a mob of residents from West Point , an impoverished area of Monrovia, descended upon a local Ebola clinic to protest its presence. The protesters turned violent, threatening the caretakers, removing the infected patients, and looting the clinic of its supplies, including blood-stained bed sheets and mattresses. Police and aid workers expressed fear that this would lead to mass infections of Ebola in West Point. On 19 August, the Liberian government quarantined the entirety of West Point and issued a curfew statewide. Violence again broke out on 22 August, after the military fired on protesting crowds. An inquiry into the incident found the security forces at fault, stating they "fired with complete disregard for human life". The quarantine blockade of the West Point area was lifted on 30 August. The Information Minister, Lewis Brown, said that this step was taken to ease efforts to screen, test, and treat residents. By 1 September, Ivory Coast announced the opening of humanitarian corridors with its two affected neighboring countries. On 20 September, Liberia opened a new 150-bed treatment unit clinic in Monrovia. At the opening ceremony of the Old Island Clinic on Bushrod Island six ambulances were already waiting with suspected Ebola patients. More patients were waiting by the clinic after making their way on foot with the help of relatives. Two days later 112 beds were already filled with 46 patients testing positive for Ebola, while the rest were admitted for observation. This expanded the number of beds in the city beyond 240. Its capacity was exceeded within 24 hours with a shortage of staff and logistics to take care of a patient with correct precautions in place. One source says it opened on 21 September 2014, with a 100-bed capacity. As of 23 September, there had been 3,458 total cases, 1,830 deaths, and 914 lab confirmed cases according to the World Health Organization . By late September, there were three clinics in Monrovia. Despite this patients waiting to be treated died outside as the clinics had run out of space to treat the increasing number of patients. If patients could not get a bed in the clinic they sometimes waited in holding centers until a bed opened up. There were additional cases in Monrovia where the bodies were dumped into the river. One woman used trash bags to protect herself as she cared for four other family members ill with Ebola. Her father became ill in late July, but they could not find a place of treatment for him and ended up doing home-care. On 25 September, Liberia's chief medical official went on a self-enforced quarantine after her assistant died from the disease, fearing she might have been accidentally exposed to the virus. By 29 September it was announced she tested negative for Ebola and government officials praised her for following the self quarantine protocol. A few days later, on 28 September Ivory Coast resumed flights to Liberia which had been suspended since 11 August 2014, after WHO's critique for tending to economically strangle the affected nations. From the beginning of the crisis, WHO has discouraged closing the borders with affected countries. On 30 September, a cameraman was tested positive for Ebola in a Texas hospital after contracting the disease before traveling back to the United States from Liberia. He covered the Ebola outbreak for NBC News (see 2014 Ebola virus cases in the United States ). Following this the Liberian government enacted strict restrictions on journalistic coverage aimed at protecting patients' privacy. In early October, Ellen Johnson Sirleaf , the President of Liberia , continued requesting more aid to fight the disease. On 2 October, a new 60-bed clinic was opened in Kenema. By then, the outbreak was described as being out of control and an exponential growth in cases was seen. The focus shifted to slowing the outbreak down. A key element was the fact that the health care establishments were overwhelmed thus leading to those infected being turned away from treatment centers. This eventually led to the infection of others taking care of sick or dying patients at home. By 3 October, at least eight Liberian soldiers died after contracting the disease from a female visitor. On 3 October more medical supplies arrived from Germany. On that same day Gerlib opened up an Ebola isolation ward at its 48-bed facility in Paynesville (Monrovia). On 10 October all journalists were banned from entering Ebola clinics. On 14 October, a hundred U.S. troops arrived in Liberia, bringing the total to 565 to aid in the fight against the deadly disease. On 16 October, U.S. President Obama authorized, via executive order, the use of National Guard and reservists in Liberia. A report on 15 October indicates that Liberia may need 80,000 more body bags and about 1 million protective suits for the next six months. In October, WHO pushed for its 70-70-60 plan to control the outbreak. By 19 October, it was reported that 223 health care workers had been infected with Ebola, and 103 of them had died in Liberia. On 19 October, the President of Liberia apologized to the Mayor of Dallas, for the Liberian national that brought the disease to the United States. By 19 October, only one area in Liberia, Grand Gedeh County , had yet to report an Ebola case. 14 out of the 15 districts have reported cases. The disease had been noted to be spreading in Monrovia , the nation's capital with over one million inhabitants. Monrovia was particularly affected with 305 new cases reported in the week ending 19 October. By 5 November, Liberia had 6,525 cases (including 1,627 probable, 2,447 suspected cases) and 2,697 deaths. The 5 November WHO situation report noted that, "There appears to be some evidence of a decline at the national level in Liberia, although new case numbers remain high in parts of the country." A report by CDC released on 14 November, based on data collected from Lofa county, indicates that there has been a genuine reduction in new infections. This is credited to an integrated strategy combining isolation and treatment with community behaviour change including safe burial practices, case finding and contract tracing – this strategy might serve as a model to implement in other affected areas to accelerate control of Ebola. Roselyn Nugba-Ballah led the Safe & Dignified Burial Practices Team for the Liberian Red Cross and was awarded the Florence Nightingale Medal for her work during the crisis in 2017. On 13 November, the Liberian President announced the lifting of the state of emergency in the country following the decrease in the number of new cases in the country. The decline in Liberia cases was contradicted in reports from WHO with 439 new cases reported between 23 and 28 November. On 4 December, it was reported that President Sirleaf banned all rallies and gatherings in Monrovia before the senatorial election, fearing that the risk of the Ebola virus spreading may be increased. On 13 January 2015, the Liberian government announced that new cases of Ebola in Liberia were now restricted to only two of its counties: Grand Cape Mount County and Montserrado County . On 28 January, the ELWA-3 Ebola treatment centre in Monrovia was partially dismantled. When the centre opened in August it had been swamped with patients, even needing to turn some away, but according to staff it was now down to only two patients. The MSF field coordinator said that as of that date Liberia was down to only five confirmed cases in all of Liberia. On 30 January, Liberia extended school reopenings by two weeks. On 10 February, the U.S. military indicated it would end its relief mission. On 20 February, Liberia opened its land borders. In the first week of March, the World Health Organization announced that Liberia had released its last Ebola patient after going a week without any new cases of the virus being reported. If the country had reported no new cases for 42 days, it would be declared Ebola-free according to the WHO. On 5 March Tolbert Nyeswah, the assistant health minister of Liberia, reported that the country have released their last confirmed case of Ebola from a Chinese-staffed treatment centre. Beatrice Yardoldo was the last confirmed case and has been treated since 18 February. No new cases were reported for two weeks. On 20 March Moses Massaquoi, leader of the Clinton Health Access Initiative in Liberia, reported a new confirmed case in the country. The patient developed symptoms on 15 March, and was tested positive on 20 March. Subsequently, the patient died on 27 March. The countdown restarted on 28 March, following the burial of the last casualty. The country was officially declared Ebola-free on 9 May, after 42 days passed with no new cases of Ebola being reported. As of May 2015, the country remained on high alert against recurrence of the disease. Three months passed with no new reports of cases. However, on 29 June, Liberia reported that the body of a 17-year-old youth, who had been treated for malaria, tested positive for Ebola. The patient was from Nedowein , a village in Margibi County near the capital Monrovia 's international airport. The WHO announced the male youth had been in close contact with at least 102 people with no recent history of traveling. Contact tracing followed with visitors from affected areas and those attending his funeral. On 1 July a second case was confirmed. By 2 July a third new case was confirmed leading to the possibility that they might have been infected with the Ebola virus lurking in animal meat according to researchers. All three cases may be linked to a dog meat meal they shared. "Today, 3 September 2015, WHO declares Liberia free of Ebola virus transmission in the human population. Forty-two days have passed since the second negative test on 22 July 2015 of the last laboratory-confirmed case. Liberia now enters a 90-day period of heightened surveillance...". "WHO commends the Government of Liberia and its people on the successful response to this recent re-emergence. It is in full accord with government calls for sustained vigilance...". After two months of going Ebola-free, on 20 November, a new case was confirmed when a 15-year-old boy was diagnosed with Ebola and two family members subsequently tested positive as well. Health officials were concerned because the child had not recently travelled or been exposed to someone with Ebola and the WHO stated, "we believe that this is probably again, somehow, someone who has come in contact with a virus that had been persisting in an individual, who had suffered the disease months ago." Two members of the US CDC were sent to the country to help to ascertain the cause of the new cases. The infected boy died on 24 November, and on 3 December the two remaining cases were released after recovering from the virus. The 42-day countdown toward Liberia being declared Ebola-free, for the third time, started on 4 December 2015 and ended on 14 January 2016 when Liberia was declared Ebola-free. On 16 December, WHO reaffirmed that the cases in Liberia were the result of re-emergence of the virus in a previously infected person, and there was speculation that the boy may have been infected by an individual who became infectious once more due to pregnancy which may have weakened her immune system. On 18 December, the WHO indicated that it still considers Ebola in West Africa a public health emergency, though progress has been made. Three months passed with no new reports of cases. However, on 29 June, Liberia reported that the body of a 17-year-old youth, who had been treated for malaria, tested positive for Ebola. The patient was from Nedowein , a village in Margibi County near the capital Monrovia 's international airport. The WHO announced the male youth had been in close contact with at least 102 people with no recent history of traveling. Contact tracing followed with visitors from affected areas and those attending his funeral. On 1 July a second case was confirmed. By 2 July a third new case was confirmed leading to the possibility that they might have been infected with the Ebola virus lurking in animal meat according to researchers. All three cases may be linked to a dog meat meal they shared. "Today, 3 September 2015, WHO declares Liberia free of Ebola virus transmission in the human population. Forty-two days have passed since the second negative test on 22 July 2015 of the last laboratory-confirmed case. Liberia now enters a 90-day period of heightened surveillance...". "WHO commends the Government of Liberia and its people on the successful response to this recent re-emergence. It is in full accord with government calls for sustained vigilance...". After two months of going Ebola-free, on 20 November, a new case was confirmed when a 15-year-old boy was diagnosed with Ebola and two family members subsequently tested positive as well. Health officials were concerned because the child had not recently travelled or been exposed to someone with Ebola and the WHO stated, "we believe that this is probably again, somehow, someone who has come in contact with a virus that had been persisting in an individual, who had suffered the disease months ago." Two members of the US CDC were sent to the country to help to ascertain the cause of the new cases. The infected boy died on 24 November, and on 3 December the two remaining cases were released after recovering from the virus. The 42-day countdown toward Liberia being declared Ebola-free, for the third time, started on 4 December 2015 and ended on 14 January 2016 when Liberia was declared Ebola-free. On 16 December, WHO reaffirmed that the cases in Liberia were the result of re-emergence of the virus in a previously infected person, and there was speculation that the boy may have been infected by an individual who became infectious once more due to pregnancy which may have weakened her immune system. On 18 December, the WHO indicated that it still considers Ebola in West Africa a public health emergency, though progress has been made. After having completed the 42 day time period, Liberia was declared free from the virus on 14 January 2016, effectively ending the outbreak started in neighbouring Guinea 2 years earlier. Liberia however had a 90-day period of heightened surveillance which was scheduled to conclude on 13 April 2016. On 1 April, it was reported that a new Ebola fatality had occurred in Liberia, and on 3 April, a second case was reported in Monrovia. On 4 April, it was reported that 84 individuals were under observation due to contact with the 2 confirmed cases of the virus. On 7 April, Liberia confirmed three new cases since the virus resurfaced. A total of 97 contacts, including 15 healthcare workers were being monitored. The index case of the new flare up was reported to be the wife of a patient who died from the virus in Guinea. She traveled to Monrovia after the funeral of her husband but died from the disease. The national Incident Management System (IMS) was immediately reactivated to coordinate the response to this flare-up and the counties enhanced the surveillance and prevention for a quick detention and interruption of transmission in case of eventual importation of cases from Monrovia. On 9 June, after 42 days, the country was declared Ebola-free. On 1 April, it was reported that a new Ebola fatality had occurred in Liberia, and on 3 April, a second case was reported in Monrovia. On 4 April, it was reported that 84 individuals were under observation due to contact with the 2 confirmed cases of the virus. On 7 April, Liberia confirmed three new cases since the virus resurfaced. A total of 97 contacts, including 15 healthcare workers were being monitored. The index case of the new flare up was reported to be the wife of a patient who died from the virus in Guinea. She traveled to Monrovia after the funeral of her husband but died from the disease. The national Incident Management System (IMS) was immediately reactivated to coordinate the response to this flare-up and the counties enhanced the surveillance and prevention for a quick detention and interruption of transmission in case of eventual importation of cases from Monrovia. On 9 June, after 42 days, the country was declared Ebola-free. On 20 September 2014, Liberia opened the 150-bed Old Island Clinic on Bushrod Island in Monrovia. Another clinic in Monrovia is a 160-bed facility staffed and run by Médecins Sans Frontières . On 25 November China opened a "state of the art clinic" outside Monrovia. The 100-bed clinic was mostly staffed by Chinese medical and other personnel. JFK ( John F. Kennedy Medical Center ) is another treatment center, and could hold 35 beds but expanded to 75 because of the increasing demand for beds. On 10 November, the U.S. opened the first of 17 Ebola treatment facilities it was building for Liberia, in Tubmanburg . On 20 September 2014, Liberia opened the 150-bed Old Island Clinic on Bushrod Island in Monrovia. Another clinic in Monrovia is a 160-bed facility staffed and run by Médecins Sans Frontières . On 25 November China opened a "state of the art clinic" outside Monrovia. The 100-bed clinic was mostly staffed by Chinese medical and other personnel. JFK ( John F. Kennedy Medical Center ) is another treatment center, and could hold 35 beds but expanded to 75 because of the increasing demand for beds. On 10 November, the U.S. opened the first of 17 Ebola treatment facilities it was building for Liberia, in Tubmanburg . Sanitation is a major struggle in most parts of Monrovia. There are four public toilets in the West Point area in Monrovia, an area with 70,000 inhabitants. The beach and river surrounding West Point area are often used as a lavatory. The Mesurado River is a source of drinking water, and the fish from the water are a primary source of food for many. It has been reported that body-collection teams, dispatched to collect the body of a suspected Ebola death, accepted bribes to issue falsified death certificates to family members. Due to the stigma of Ebola some families did not want to admit that their relative died from Ebola. The body of the deceased would then be left with relatives for a traditional funeral. During the 10-day Liberian government quarantine of the West Point slum in Monrovia , residents were able to leave the quarantine area by bribing soldiers and police officers. A journalist inside West Point told a local radio station that Liberian soldiers and police were seen "daily soliciting monies from those being quarantined in the area to escape". The journalist reported that "many of those even suspected of having the disease were given free passage to leave West Point for Monrovia city center." An American non-governmental organization journalist reported that Liberian police threatened arrest and demanded bribes in order for him to leave the MSF compound. In October, it was noted that many of the Ebola deaths and those dying were not being reported to health authorities. While the epidemic had been accelerating, the number of bodies being collected was falling. "Very, very few of those dying in the community are being brought forward," said Cokie van der Velde, who organized the collections of bodies with Médecins Sans Frontières . Van der Velde announced that the main crematorium in Monrovia was running at full capacity in Monrovia. It was cremating 80 bodies at its mass pyre per day. In early October, the number of cremations drastically decreased to 30 or 40 per day. Van der Velde said, "That means they're being kept hidden and buried in secret". Traditional funeral rituals are a risk factor in the spread of Ebola, as the body is at its most contagious stage post-mortem. By late October, it was reported that many beds in Liberian Ebola treatment centers were empty due to people no longer reporting suspected Ebola cases to health authorities. The assistant Liberian health minister announced at the time that an assessment of Ebola treatment units discovered that out of the 742 beds only 351 were occupied by patients. The non-reporting is believed to be due to a policy decision in August to cremate all bodies of suspected Ebola cases in Monrovia. Cremation was against local culture of a traditional burial. The cremation order came after people in Monrovia's neighborhoods resisted the burial of hundreds of Ebola victims near their homes. On 6 August 2014, President Sirleaf, in an emergency announcement, informed absent government ministers and civil service leaders to return to their duties in Liberia. In late August Sirleaf dismissed 10 government officials, including deputy ministers in the central government who refused to return to work. The benefits and pay for nearly twenty other high-ranking officials who refused to return were halted. In mid-November, President Sirleaf reshuffled the country's cabinet in response to widespread criticism of the government's heavy-handed yet ineffective response to the Ebola crisis. George Warner, previously the head of civil service , would replace Walter Gwenigale as health minister . Sirleaf commented Gwenigale had her "full confidence" and would continue as an adviser. A black market for the blood of Ebola survivors was reported in Liberia. Buyers of the blood hoped to gain immunity or recovery via a blood transfusion. These transfusions have been noted as posing a risk for the transmission of HIV/AIDS , malaria and other blood-borne diseases. "This has the potential to divert time and resources originally allocated to control Ebola", according to a US military report. Sanitation is a major struggle in most parts of Monrovia. There are four public toilets in the West Point area in Monrovia, an area with 70,000 inhabitants. The beach and river surrounding West Point area are often used as a lavatory. The Mesurado River is a source of drinking water, and the fish from the water are a primary source of food for many. It has been reported that body-collection teams, dispatched to collect the body of a suspected Ebola death, accepted bribes to issue falsified death certificates to family members. Due to the stigma of Ebola some families did not want to admit that their relative died from Ebola. The body of the deceased would then be left with relatives for a traditional funeral. During the 10-day Liberian government quarantine of the West Point slum in Monrovia , residents were able to leave the quarantine area by bribing soldiers and police officers. A journalist inside West Point told a local radio station that Liberian soldiers and police were seen "daily soliciting monies from those being quarantined in the area to escape". The journalist reported that "many of those even suspected of having the disease were given free passage to leave West Point for Monrovia city center." An American non-governmental organization journalist reported that Liberian police threatened arrest and demanded bribes in order for him to leave the MSF compound. In October, it was noted that many of the Ebola deaths and those dying were not being reported to health authorities. While the epidemic had been accelerating, the number of bodies being collected was falling. "Very, very few of those dying in the community are being brought forward," said Cokie van der Velde, who organized the collections of bodies with Médecins Sans Frontières . Van der Velde announced that the main crematorium in Monrovia was running at full capacity in Monrovia. It was cremating 80 bodies at its mass pyre per day. In early October, the number of cremations drastically decreased to 30 or 40 per day. Van der Velde said, "That means they're being kept hidden and buried in secret". Traditional funeral rituals are a risk factor in the spread of Ebola, as the body is at its most contagious stage post-mortem. By late October, it was reported that many beds in Liberian Ebola treatment centers were empty due to people no longer reporting suspected Ebola cases to health authorities. The assistant Liberian health minister announced at the time that an assessment of Ebola treatment units discovered that out of the 742 beds only 351 were occupied by patients. The non-reporting is believed to be due to a policy decision in August to cremate all bodies of suspected Ebola cases in Monrovia. Cremation was against local culture of a traditional burial. The cremation order came after people in Monrovia's neighborhoods resisted the burial of hundreds of Ebola victims near their homes. On 6 August 2014, President Sirleaf, in an emergency announcement, informed absent government ministers and civil service leaders to return to their duties in Liberia. In late August Sirleaf dismissed 10 government officials, including deputy ministers in the central government who refused to return to work. The benefits and pay for nearly twenty other high-ranking officials who refused to return were halted. In mid-November, President Sirleaf reshuffled the country's cabinet in response to widespread criticism of the government's heavy-handed yet ineffective response to the Ebola crisis. George Warner, previously the head of civil service , would replace Walter Gwenigale as health minister . Sirleaf commented Gwenigale had her "full confidence" and would continue as an adviser. A black market for the blood of Ebola survivors was reported in Liberia. Buyers of the blood hoped to gain immunity or recovery via a blood transfusion. These transfusions have been noted as posing a risk for the transmission of HIV/AIDS , malaria and other blood-borne diseases. "This has the potential to divert time and resources originally allocated to control Ebola", according to a US military report. On 5 August 2014, the Brothers Hospitallers of St. John of God confirmed that Brother Miguel Pajares had been infected after volunteering in Liberia. The Spanish military assisted with his transfer on 6 August. Authorities stated he would be treated in the 'Carlos III' hospital in Madrid. This attracted controversy, amid questions as to the authorities' ability to guarantee no risk of transmission. Brother Pajares died from the virus on 12 August. Kent Brantly , a physician and medical director in Liberia for the aid group Samaritan's Purse , and co-worker Nancy Writebol were infected while working in Monrovia . Both were flown to the United States at the beginning of August for further treatment. On 21 August, Brantly and Writebol recovered and were discharged. A French volunteer health worker working for MSF in Liberia contracted Ebola there and was flown to France on 18 September 2014. French Health Minister Marisol Touraine stated the nurse would receive the experimental drug favipiravir . By 4 October she had recovered and was released from hospital. After a news-network's cameraman came down with Ebola, he was evacuated to the U.S. and the rest of the crew also returned and went into quarantine. On 24 May 2016, Liberian Child's right and Environmental Activist, Chair-Person of the National Children and Youth Advisory Board Wantoe Teah Wantoe, acknowledged The United Nations body, Government body, and civil society actors at the World Humanitarian Summit through his Preliminary address on the need to contribute to Liberia's resilience and recovery after the casualties of the Ebola virus disease . He spoke of the vulnerabilities of Liberian children whose status had been changed to orphans and semi-orphans due to the deaths caused by the Ebola virus. On 5 August 2014, the Brothers Hospitallers of St. John of God confirmed that Brother Miguel Pajares had been infected after volunteering in Liberia. The Spanish military assisted with his transfer on 6 August. Authorities stated he would be treated in the 'Carlos III' hospital in Madrid. This attracted controversy, amid questions as to the authorities' ability to guarantee no risk of transmission. Brother Pajares died from the virus on 12 August. Kent Brantly , a physician and medical director in Liberia for the aid group Samaritan's Purse , and co-worker Nancy Writebol were infected while working in Monrovia . Both were flown to the United States at the beginning of August for further treatment. On 21 August, Brantly and Writebol recovered and were discharged. A French volunteer health worker working for MSF in Liberia contracted Ebola there and was flown to France on 18 September 2014. French Health Minister Marisol Touraine stated the nurse would receive the experimental drug favipiravir . By 4 October she had recovered and was released from hospital. After a news-network's cameraman came down with Ebola, he was evacuated to the U.S. and the rest of the crew also returned and went into quarantine. On 24 May 2016, Liberian Child's right and Environmental Activist, Chair-Person of the National Children and Youth Advisory Board Wantoe Teah Wantoe, acknowledged The United Nations body, Government body, and civil society actors at the World Humanitarian Summit through his Preliminary address on the need to contribute to Liberia's resilience and recovery after the casualties of the Ebola virus disease . He spoke of the vulnerabilities of Liberian children whose status had been changed to orphans and semi-orphans due to the deaths caused by the Ebola virus.

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2018 DRC Ebola virus outbreak

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Public health emergency of international concern

A public health emergency of international concern ( PHEIC / f eɪ k / FAYK ) is a formal declaration by the World Health Organization (WHO) of "an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response", formulated when a situation arises that is "serious, sudden, unusual, or unexpected", which "carries implications for public health beyond the affected state's national border" and "may require immediate international action". Under the 2005 International Health Regulations (IHR), states have a legal duty to respond promptly to a PHEIC. The declaration is publicized by an IHR Emergency Committee (EC) of international experts, which was developed following the 2002–2004 SARS outbreak . From 2005 to the present, there have been seven PHEIC declarations: the 2009–2010 H1N1 (or swine flu) pandemic , the ongoing 2014 polio declaration , the 2013–2016 outbreak of Ebola in Western Africa , the 2015–2016 Zika virus epidemic , the 2018–2020 Kivu Ebola epidemic , the 2020–2023 declaration for the COVID-19 pandemic , and the 2022–2023 mpox outbreak . The recommendations are temporary and require reviews every three months. Automatically, SARS , smallpox , wild type poliomyelitis , and any new subtype of human influenza are considered as PHEICs and thus do not require an IHR decision to declare them as such. A PHEIC is not only confined to infectious diseases, and may cover an emergency caused by exposure to a chemical agent or radioactive material. It can be seen as an "alarm system", a "call to action", and "last resort" measure. Multiple surveillance and response systems exist worldwide for the early detection and effective response to contain the spread of disease. Time delays occur for two main reasons. The first is the delay between the first case and the confirmation of the outbreak by the healthcare system, allayed by good surveillance via data collection, evaluation, and organisation. The second is when there is a delay between the detection of the outbreak and widespread recognition and declaration of it as an international concern. The declaration is promulgated by an emergency committee (EC) made up of international experts operating under the IHR (2005), which was developed following the SARS outbreak of 2002–2003. Between 2009 and 2016, there were four PHEIC declarations. The fifth was the 2018–2020 Kivu Ebola epidemic , declared in July 2019 and ended in June 2020. The sixth was the COVID-19 pandemic , declared in January 2020 and ended in May 2023. The seventh was the 2022–2023 mpox outbreak , declared in July 2022 and ended in May 2023. Under the 2005 International Health Regulations (IHR), states have a legal duty to respond promptly to a PHEIC. PHEIC is defined as: an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response. This definition designates a public health crisis of potentially global reach and implies a situation that is "serious, sudden, unusual, or unexpected", which may necessitate immediate international action. It can be seen as an "alarm system", a "call to action" and "last resort" measure. WHO Member States have 24 hours within which to report potential PHEIC events to the WHO. It does not have to be a member state that reports a potential outbreak, hence reports to the WHO may also be received informally, by non-governmental sources. Under the IHR (2005), ways to detect, evaluate, notify, and report events were ascertained by all countries in order to avoid PHEICs. The response to public health risks also was decided. The IHR decision algorithm assists WHO Member States in deciding whether a potential PHEIC exists and whether the WHO should be notified. The WHO should be notified if any two of the four following questions are affirmed: Is the public health impact of the event serious? Is the event unusual or unexpected? Is there a significant risk for international spread? Is there a significant risk for international travel or trade restrictions? The PHEIC criteria include a list of diseases that are always notifiable . SARS , smallpox , wild type poliomyelitis , and any new subtype of human influenza are always a PHEIC and do not require an IHR decision to declare them as such. Large scale health emergencies that attract public attention do not necessarily fulfill the criteria to be a PHEIC. ECs were not convened for the cholera outbreak in Haiti , chemical weapons use in Syria , or the Fukushima nuclear disaster in Japan , for example. Further assessment is required for diseases that are prone to becoming pandemics , including, but not limited to cholera , pneumonic plague , yellow fever , and viral hemorrhagic fevers. A declaration of a PHEIC may appear as an economic burden to the state facing the epidemic. Incentives to declare an epidemic are lacking and the PHEIC may be seen as placing limitations on trade in countries that already are struggling. In order to declare a PHEIC, the WHO Director-General is required to take into account factors that include the risk to human health and international spread as well as advice from an international committee of experts, the IHR Emergency Committee (EC), one of whom should be an expert nominated by the State within whose region the event arises. Rather than being a standing committee, the EC is created on an ad hoc basis. Until 2011, the names of IHR EC members were not publicly disclosed; in the wake of reforms, now they are. These members are selected according to the disease in question and the nature of the event. Names are taken from the IHR Experts Roster . The director-general takes the advice of the EC, following their technical assessment of the crisis using legal criteria and a predetermined algorithm after a review of all available data on the event. Upon declaration, the EC then makes recommendations on what actions the director-general and member states should take to address the crisis. The recommendations are temporary and require review every three months while in place. Summary of PHEIC declarations In the spring of 2009, a novel influenza A (H1N1) virus emerged. It was detected first in Mexico , North America . It spread quickly across the United States and the world . On 26 April 2009, more than one month after its first emergence, the initial PHEIC was declared when the H1N1 (or swine flu) pandemic was still in phase three . Within three hours on the same day, the WHO web site received almost two million visits, necessitating a dedicated web site for the swine influenza pandemic. At the time that H1N1 had been declared a PHEIC, it had occurred in only three countries. Therefore, it was argued that the declaration of the H1N1 outbreak as a PHEIC, was fueling public fear. A 2013 study sponsored by the WHO estimated that, although similar in magnitude to seasonal influenza, it cost more life-years than seasonal flu, due to a shift toward mortality among persons less than 65 years of age. The second PHEIC was the 2014 polio declaration , issued on 5 May 2014 with a rise in cases of wild polio and circulating vaccine-derived poliovirus. The status achieved, as global eradication, was deemed to be at risk by air travel and border crossing overland, with small numbers of cases in Afghanistan, Pakistan, and Nigeria. In October 2019, continuing cases of wild polio in Pakistan and Afghanistan, in addition to new vaccine-derived cases in Africa and Asia, was reviewed and polio continued to be a PHEIC. As of November 2021, taking into account recent events in Afghanistan, a large number of unvaccinated children, increasing mobile people in Pakistan and the risks associated with the COVID-19 pandemic among others, polio remains a PHEIC. Confirmed cases of Ebola were being reported in Guinea and Liberia in March 2014 and Sierra Leone by May 2014. On Friday, 8 August 2014, following the occurrence of Ebola in the United States and Europe and with the already intense transmission ongoing in three other countries for months, the WHO declared its third PHEIC in response to the outbreak of Ebola in Western Africa . Later, one review showed that a direct impact of this epidemic on America escalated a PHEIC declaration. It was the first PHEIC in a resource-poor setting. On 1 February 2016, the WHO declared its fourth PHEIC in response to clusters of microcephaly and Guillain–Barré syndrome in the Americas , which at the time were suspected to be associated with the ongoing 2015–2016 Zika virus epidemic . Later research and evidence bore out these concerns; in April, the WHO stated that "there is scientific consensus that Zika virus is a cause of microcephaly and Guillain–Barré syndrome." This was the first time a PHEIC was declared for a mosquito‐borne disease . This declaration was lifted on 18 November 2016. In October 2018 and then later in April 2019, the WHO did not consider the 2018–2020 Kivu Ebola epidemic to be a PHEIC. The decision was controversial, with Michael Osterholm , director of the Center for Infectious Disease Research and Policy (CIDRAP) responding with disappointment and describing the situation as "an Ebola gas can sitting in DRC that's just waiting for a match to hit it", while the WHO panel were unanimous in their decision that declaring it a PHEIC would not give any added benefit. The advice against declaring a PHEIC in October 2018 and April 2019, despite the criteria for doing so appearing to be met on both occasions, has led to the transparency of the IHR EC coming into question. The language used in the statements for the Kivu Ebola epidemic has been noted to be different. In October 2018, the EC stated "a PHEIC should not be declared at this time". In the 13 previously declined proposals for declaring a PHEIC, the resultant statements quoted "the conditions for a PHEIC are not currently met" and "does not constitute a PHEIC". In April 2019, they stated that "there is no added benefit to declaring a PHEIC at this stage", a notion that is not part of the PHEIC criteria laid down in the IHR. After confirmed cases of Ebola in neighbouring Uganda in June 2019, Tedros Adhanom , the director-general of the WHO, announced that the third meeting of a group of experts would be held on 14 June 2019 to assess whether the Ebola spread had become a PHEIC. The conclusion was that while the outbreak was a health emergency in the Democratic Republic of the Congo (DRC) and the region, it did not meet all the three criteria for a PHEIC. Despite the number of deaths reaching 1,405 by 11 June 2019 and 1,440 by 17 June 2019, the reason for not declaring a PHEIC was that the overall risk of international spread was deemed to be low, and the risk of damaging the economy of the DRC high. Adhanom also stated that declaring a PHEIC would be an inappropriate way to raise money for the epidemic. Following a visit to the DRC in July 2019, Rory Stewart , the UK's DfID minister, called for the WHO to declare it an emergency. Acknowledging a high risk of spread to the capital of North Kivu, Goma , a call for a PHEIC declaration was published on 10 July 2019 in The Washington Post by Daniel Lucey and Ron Klain (the former United States Ebola response coordinator ). Their declaration stated that "in the absence of a trajectory toward extinguishing the outbreak, the opposite path—severe escalation—remains possible. The risk of the disease moving into nearby Goma, Congo—a city of 1 million residents with an international airport—or crossing into the massive refugee camps in South Sudan is mounting. With a limited number of vaccine doses remaining, either would be a catastrophe". Four days later, on 14 July 2019, a case of Ebola was confirmed in Goma, which has an international airport and a highly mobile population. Subsequently, the WHO announced a reconvening of a fourth EC meeting on 17 July 2019, when they officially announced it "a regional emergency, and by no means a global threat" and declared it as a PHEIC, without restrictions on trade or travel. In response to the declaration, the president of the DRC, together with an expert committee led by a virologist, took responsibility for directly supervising action, while in protest of the declaration, health minister, Oly Ilunga Kalenga resigned. A review of the PHEIC had been planned at a fifth meeting of the EC on 10 October 2019 and on 18 October 2019 it remained a PHEIC until 26 June 2020 when it was decided that the situation no longer constituted a PHEIC, as the outbreak was considered over. On 30 January 2020, the WHO declared the outbreak of COVID-19 , centered on Wuhan in central China , a PHEIC. On 5 May 2023, the WHO ended the PHEIC declaration for COVID-19. On the date of the declaration, there were 7,818 cases confirmed globally, affecting 19 countries in five of the six WHO regions. Previously, the WHO had held EC meetings on 22 and 23 January 2020 regarding the outbreak, but it was determined at that time that it was too early to declare a PHEIC, given the lack of necessary data and the then-scale of global impact. The WHO recognized the spread of COVID-19 as a pandemic on 11 March 2020. The emergency committee convened its third meeting on 30 April 2020, fourth on 31 July, fifth on 29 October, sixth on 14 January 2021, seventh on 15 April 2021, ninth in October 2021, tenth in January 2022, eleventh in April 2022, twelfth in July 2022, thirteenth in October 2022, fourteenth in January 2023, and fifteenth in May 2023. In September 2022, the Lancet commission on COVID-19 published a report, calling the response to the pandemic "a massive global failure on multiple levels". The WHO responded by noting "several key omissions and misinterpretations in the report, not least regarding the public health emergency of international concern (PHEIC) and the speed and scope of WHO's actions." They stated that the report "offers the best opportunity to insist that the failures and lessons from the past 3 years are not wasted but are constructively used to build more resilient health systems and stronger political systems that support the health and wellbeing of people and planet during the 21st century." The formal end of the COVID-19 PHEIC is a matter of much nuance which carries its own risks, and as of March 2023, "WHO member states are negotiating amendments to the International Health Regulations as well as a new legally binding agreement (most likely a treaty) on pandemic prevention, preparedness, and response. Proposals include the possibility of issuing intermediate public health alerts (short of PHEICs) and determining public health emergencies of regional concern. Notably, although COVID-19 is routinely referred to as a pandemic, this word is not used in the International Health Regulations." With the emergency phase of the pandemic being regarded as having ended, more subtle and robust institutional responses and protocols are in the works for further iterations of this pandemic as well as global pandemics of whatever etiology . At the second IHR meeting for the 2022–2023 mpox outbreak on 21 July 2022, members of the emergency committee were divided about issuing a PHEIC, with six in favor and nine against. On 23 July 2022, the WHO director-general declared the outbreak a PHEIC. On 11 May 2023, the WHO ended the PHEIC declaration for Mpox, six days after doing so for COVID-19. On the date of the declaration, there were 17,186 cases reported globally, affecting 75 countries in all six WHO regions, with five deaths reported outside Africa and 72 deaths in African countries. The WHO had previously held an EC meeting on 23 June 2022 regarding the outbreak, which had more than 2,100 cases in over 42 countries at that point; it did not reach the criteria for a PHEIC alert at the time. In the spring of 2009, a novel influenza A (H1N1) virus emerged. It was detected first in Mexico , North America . It spread quickly across the United States and the world . On 26 April 2009, more than one month after its first emergence, the initial PHEIC was declared when the H1N1 (or swine flu) pandemic was still in phase three . Within three hours on the same day, the WHO web site received almost two million visits, necessitating a dedicated web site for the swine influenza pandemic. At the time that H1N1 had been declared a PHEIC, it had occurred in only three countries. Therefore, it was argued that the declaration of the H1N1 outbreak as a PHEIC, was fueling public fear. A 2013 study sponsored by the WHO estimated that, although similar in magnitude to seasonal influenza, it cost more life-years than seasonal flu, due to a shift toward mortality among persons less than 65 years of age. The second PHEIC was the 2014 polio declaration , issued on 5 May 2014 with a rise in cases of wild polio and circulating vaccine-derived poliovirus. The status achieved, as global eradication, was deemed to be at risk by air travel and border crossing overland, with small numbers of cases in Afghanistan, Pakistan, and Nigeria. In October 2019, continuing cases of wild polio in Pakistan and Afghanistan, in addition to new vaccine-derived cases in Africa and Asia, was reviewed and polio continued to be a PHEIC. As of November 2021, taking into account recent events in Afghanistan, a large number of unvaccinated children, increasing mobile people in Pakistan and the risks associated with the COVID-19 pandemic among others, polio remains a PHEIC. Confirmed cases of Ebola were being reported in Guinea and Liberia in March 2014 and Sierra Leone by May 2014. On Friday, 8 August 2014, following the occurrence of Ebola in the United States and Europe and with the already intense transmission ongoing in three other countries for months, the WHO declared its third PHEIC in response to the outbreak of Ebola in Western Africa . Later, one review showed that a direct impact of this epidemic on America escalated a PHEIC declaration. It was the first PHEIC in a resource-poor setting. On 1 February 2016, the WHO declared its fourth PHEIC in response to clusters of microcephaly and Guillain–Barré syndrome in the Americas , which at the time were suspected to be associated with the ongoing 2015–2016 Zika virus epidemic . Later research and evidence bore out these concerns; in April, the WHO stated that "there is scientific consensus that Zika virus is a cause of microcephaly and Guillain–Barré syndrome." This was the first time a PHEIC was declared for a mosquito‐borne disease . This declaration was lifted on 18 November 2016. In October 2018 and then later in April 2019, the WHO did not consider the 2018–2020 Kivu Ebola epidemic to be a PHEIC. The decision was controversial, with Michael Osterholm , director of the Center for Infectious Disease Research and Policy (CIDRAP) responding with disappointment and describing the situation as "an Ebola gas can sitting in DRC that's just waiting for a match to hit it", while the WHO panel were unanimous in their decision that declaring it a PHEIC would not give any added benefit. The advice against declaring a PHEIC in October 2018 and April 2019, despite the criteria for doing so appearing to be met on both occasions, has led to the transparency of the IHR EC coming into question. The language used in the statements for the Kivu Ebola epidemic has been noted to be different. In October 2018, the EC stated "a PHEIC should not be declared at this time". In the 13 previously declined proposals for declaring a PHEIC, the resultant statements quoted "the conditions for a PHEIC are not currently met" and "does not constitute a PHEIC". In April 2019, they stated that "there is no added benefit to declaring a PHEIC at this stage", a notion that is not part of the PHEIC criteria laid down in the IHR. After confirmed cases of Ebola in neighbouring Uganda in June 2019, Tedros Adhanom , the director-general of the WHO, announced that the third meeting of a group of experts would be held on 14 June 2019 to assess whether the Ebola spread had become a PHEIC. The conclusion was that while the outbreak was a health emergency in the Democratic Republic of the Congo (DRC) and the region, it did not meet all the three criteria for a PHEIC. Despite the number of deaths reaching 1,405 by 11 June 2019 and 1,440 by 17 June 2019, the reason for not declaring a PHEIC was that the overall risk of international spread was deemed to be low, and the risk of damaging the economy of the DRC high. Adhanom also stated that declaring a PHEIC would be an inappropriate way to raise money for the epidemic. Following a visit to the DRC in July 2019, Rory Stewart , the UK's DfID minister, called for the WHO to declare it an emergency. Acknowledging a high risk of spread to the capital of North Kivu, Goma , a call for a PHEIC declaration was published on 10 July 2019 in The Washington Post by Daniel Lucey and Ron Klain (the former United States Ebola response coordinator ). Their declaration stated that "in the absence of a trajectory toward extinguishing the outbreak, the opposite path—severe escalation—remains possible. The risk of the disease moving into nearby Goma, Congo—a city of 1 million residents with an international airport—or crossing into the massive refugee camps in South Sudan is mounting. With a limited number of vaccine doses remaining, either would be a catastrophe". Four days later, on 14 July 2019, a case of Ebola was confirmed in Goma, which has an international airport and a highly mobile population. Subsequently, the WHO announced a reconvening of a fourth EC meeting on 17 July 2019, when they officially announced it "a regional emergency, and by no means a global threat" and declared it as a PHEIC, without restrictions on trade or travel. In response to the declaration, the president of the DRC, together with an expert committee led by a virologist, took responsibility for directly supervising action, while in protest of the declaration, health minister, Oly Ilunga Kalenga resigned. A review of the PHEIC had been planned at a fifth meeting of the EC on 10 October 2019 and on 18 October 2019 it remained a PHEIC until 26 June 2020 when it was decided that the situation no longer constituted a PHEIC, as the outbreak was considered over. On 30 January 2020, the WHO declared the outbreak of COVID-19 , centered on Wuhan in central China , a PHEIC. On 5 May 2023, the WHO ended the PHEIC declaration for COVID-19. On the date of the declaration, there were 7,818 cases confirmed globally, affecting 19 countries in five of the six WHO regions. Previously, the WHO had held EC meetings on 22 and 23 January 2020 regarding the outbreak, but it was determined at that time that it was too early to declare a PHEIC, given the lack of necessary data and the then-scale of global impact. The WHO recognized the spread of COVID-19 as a pandemic on 11 March 2020. The emergency committee convened its third meeting on 30 April 2020, fourth on 31 July, fifth on 29 October, sixth on 14 January 2021, seventh on 15 April 2021, ninth in October 2021, tenth in January 2022, eleventh in April 2022, twelfth in July 2022, thirteenth in October 2022, fourteenth in January 2023, and fifteenth in May 2023. In September 2022, the Lancet commission on COVID-19 published a report, calling the response to the pandemic "a massive global failure on multiple levels". The WHO responded by noting "several key omissions and misinterpretations in the report, not least regarding the public health emergency of international concern (PHEIC) and the speed and scope of WHO's actions." They stated that the report "offers the best opportunity to insist that the failures and lessons from the past 3 years are not wasted but are constructively used to build more resilient health systems and stronger political systems that support the health and wellbeing of people and planet during the 21st century." The formal end of the COVID-19 PHEIC is a matter of much nuance which carries its own risks, and as of March 2023, "WHO member states are negotiating amendments to the International Health Regulations as well as a new legally binding agreement (most likely a treaty) on pandemic prevention, preparedness, and response. Proposals include the possibility of issuing intermediate public health alerts (short of PHEICs) and determining public health emergencies of regional concern. Notably, although COVID-19 is routinely referred to as a pandemic, this word is not used in the International Health Regulations." With the emergency phase of the pandemic being regarded as having ended, more subtle and robust institutional responses and protocols are in the works for further iterations of this pandemic as well as global pandemics of whatever etiology . At the second IHR meeting for the 2022–2023 mpox outbreak on 21 July 2022, members of the emergency committee were divided about issuing a PHEIC, with six in favor and nine against. On 23 July 2022, the WHO director-general declared the outbreak a PHEIC. On 11 May 2023, the WHO ended the PHEIC declaration for Mpox, six days after doing so for COVID-19. On the date of the declaration, there were 17,186 cases reported globally, affecting 75 countries in all six WHO regions, with five deaths reported outside Africa and 72 deaths in African countries. The WHO had previously held an EC meeting on 23 June 2022 regarding the outbreak, which had more than 2,100 cases in over 42 countries at that point; it did not reach the criteria for a PHEIC alert at the time. In 2018, an examination of the first four declarations (2009–2016) showed that the WHO was noted to be more effective in responding to international health emergencies, and that the international system in dealing with these emergencies was "robust". Another review of the first four declarations, with the exception of wild polio, demonstrated that responses were varied. Severe outbreaks, or those that threatened larger numbers of people, did not receive a swift PHEIC declaration, and the study hypothesized that responses were quicker when American citizens were infected and when the emergencies did not coincide with holidays. PHEIC was not invoked with the Middle Eastern Respiratory Syndrome (MERS) outbreak in 2013. Originating in Saudi Arabia, MERS reached more than 24 countries and resulted in more than 580 deaths by 2015, although most cases were in hospital settings rather than sustained community spread. As a result, what constitutes a PHEIC has been unclear. As of May 2020, there had been 876 deaths. PHEIC was not invoked with the Middle Eastern Respiratory Syndrome (MERS) outbreak in 2013. Originating in Saudi Arabia, MERS reached more than 24 countries and resulted in more than 580 deaths by 2015, although most cases were in hospital settings rather than sustained community spread. As a result, what constitutes a PHEIC has been unclear. As of May 2020, there had been 876 deaths. PHEIC are not confined to only infectious diseases or biological ones. It may cover events caused by chemical agents or radioactive materials. Debate exists regarding whether the emergence and spread of antimicrobial resistance may constitute a PHEIC.

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World Health Organization

The World Health Organization ( WHO ) is a specialized agency of the United Nations responsible for international public health . It is headquartered in Geneva , Switzerland, and has six regional offices and 150 field offices worldwide. The WHO was established on April 7, 1948, and convened its first meeting on July 24 of that year. It incorporated the assets, personnel, and duties of the League of Nations ' Health Organization and the Paris-based Office International d'Hygiène Publique , including the International Classification of Diseases (ICD). The agency's work began in earnest in 1951 after a significant infusion of financial and technical resources. The WHO's official mandate is to promote health and safety while helping the vulnerable worldwide. It provides technical assistance to countries, sets international health standards, collects data on global health issues, and serves as a forum for scientific or policy discussions related to health. Its official publication, the World Health Report , provides assessments of worldwide health topics. The WHO has played a leading role in several public health achievements, most notably the eradication of smallpox , the near- eradication of polio , and the development of an Ebola vaccine . Its current priorities include communicable diseases , such as HIV/AIDS , Ebola , malaria and tuberculosis ; non-communicable diseases such as heart disease and cancer ; healthy diet , nutrition, and food security ; occupational health ; and substance abuse . The agency advocates for universal health care coverage, engagement with the monitoring of public health risks, coordinating responses to health emergencies, and promoting health and well-being generally. The WHO is governed by the World Health Assembly (WHA), which is composed of its 194 member states. The WHA elects and advises an executive board made up of 34 health specialists; selects the WHO's chief administrator, the director-general (currently Tedros Adhanom Ghebreyesus of Ethiopia); sets goals and priorities; and approves the budget and activities. The WHO is funded primarily by contributions from member states (both assessed a Then and voluntary), followed by private donors. Its total approved budget for 2020–2021 is over $7.2 billion., while the approved budget for 2022–2023 is over $6.2 billion. The budget is $6.83 billion for 2024 - 2025The International Sanitary Conferences (ISC), the first of which was held on 23 June 1851, were a series of conferences that took place until 1938, about 87 years. The first conference, in Paris, was almost solely concerned with cholera , which would remain the disease of major concern for the ISC for most of the 19th century. With the cause , origin, and communicability of many epidemic diseases still uncertain and a matter of scientific argument, international agreement on appropriate measures was difficult to reach. Seven of these international conferences, spanning 41 years, were convened before any resulted in a multi-state international agreement. The seventh conference, in Venice in 1892, finally resulted in a convention. It was concerned only with the sanitary control of shipping traversing the Suez Canal , and was an effort to guard against importation of cholera. : 65 Five years later, in 1897, a convention concerning the bubonic plague was signed by sixteen of the 19 states attending the Venice conference. While Denmark , Sweden-Norway , and the US did not sign this convention, it was unanimously agreed that the work of the prior conferences should be codified for implementation. Subsequent conferences, from 1902 until the final one in 1938, widened the diseases of concern for the ISC, and included discussions of responses to yellow fever , brucellosis , leprosy , tuberculosis , and typhoid . In part as a result of the successes of the Conferences, the Pan-American Sanitary Bureau (1902), and the Office International d'Hygiène Publique (1907) were soon founded. When the League of Nations was formed in 1920, it established the Health Organization of the League of Nations. After World War II , the United Nations absorbed all the other health organizations, to form the WHO. During the 1945 United Nations Conference on International Organization, Szeming Sze , a delegate from China , conferred with Norwegian and Brazilian delegates on creating an international health organization under the auspices of the new United Nations. After failing to get a resolution passed on the subject, Alger Hiss , the secretary general of the conference, recommended using a declaration to establish such an organization. Sze and other delegates lobbied and a declaration passed calling for an international conference on health. The use of the word "world", rather than "international", emphasized the truly global nature of what the organization was seeking to achieve. The constitution of the World Health Organization was signed by all 51 countries of the United Nations, and by 10 other countries, on 22 July 1946. It thus became the first specialized agency of the United Nations to which every member subscribed. Its constitution formally came into force on the first World Health Day on 7 April 1948, when it was ratified by the 26th member state. The first meeting of the World Health Assembly finished on 24 July 1948, having secured a budget of US$5 million (then £1,250,000 ) for the 1949 year. G. Brock Chisholm was appointed director-general of the WHO, having served as executive secretary and a founding member during the planning stages, while Andrija Štampar was the assembly's first president. Its first priorities were to control the spread of malaria , tuberculosis and sexually transmitted infections , and to improve maternal and child health , nutrition and environmental hygiene. Its first legislative act was concerning the compilation of accurate statistics on the spread and morbidity of disease. The logo of the World Health Organization features the Rod of Asclepius as a symbol for healing. In 1959, the WHO signed Agreement WHA 12–40 with the International Atomic Energy Agency (IAEA), which says: whenever either organization proposes to initiate a programme or activity on a subject in which the other organization has or may have a substantial interest, the first party shall consult the other with a view to adjusting the matter by mutual agreement . The nature of this statement has led some groups and activists including Women in Europe for a Common Future to claim that the WHO is restricted in its ability to investigate the effects on human health of radiation caused by the use of nuclear power and the continuing effects of nuclear disasters in Chernobyl and Fukushima . They believe WHO must regain what they see as independence. Independent WHO held a weekly vigil from 2007 to 2017 in front of WHO headquarters. However, as pointed out by Foreman in clause 2 it states: In particular, and in accordance with the Constitution of the World Health Organization and the Statute of the International Atomic Energy Agency and its agreement with the United Nations together with the exchange of letters related thereto, and taking into account the respective co-ordinating responsibilities of both organizations, it is recognized by the World Health Organization that the International Atomic Energy Agency has the primary responsibility for encouraging, assisting and co-ordinating research and development and practical application of atomic energy for peaceful uses throughout the world without prejudice to the right of the World Health Organization to concern itself with promoting, developing, assisting and co-ordinating international health work, including research, in all its aspects . The key text is highlighted in bold, the agreement in clause 2 states that the WHO is free to perform any health-related work. 1947 : The WHO established an epidemiological information service via telex . : 5 1949 : The Soviet Union and its constituent republics quit the WHO over the organization's unwillingness to share the penicillin recipe. They would not return until 1956. 1950 : A mass tuberculosis inoculation drive using the BCG vaccine gets under way. : 8 1955 : The malaria eradication programme was launched, although objectives were later modified. (In most areas, the programme goals became control instead of eradication.) : 9 1958 : Viktor Zhdanov , Deputy Minister of Health for the USSR , called on the World Health Assembly to undertake a global initiative to eradicate smallpox, resulting in Resolution WHA11.54. : 366–371, 393, 399, 419 1965 : The first report on diabetes mellitus and the creation of the International Agency for Research on Cancer . : 10–11 1966 : The WHO moved its headquarters from the Ariana wing at the Palace of Nations to a newly constructed headquarters elsewhere in Geneva. : 12 1967 : The WHO intensified the global smallpox eradication campaign by contributing $2.4 million annually to the effort and adopted a new disease surveillance method, at a time when 2 million people were dying from smallpox per year. The initial problem the WHO team faced was inadequate reporting of smallpox cases. WHO established a network of consultants who assisted countries in setting up surveillance and containment activities. The WHO also helped contain the last European outbreak in Yugoslavia in 1972 . After over two decades of fighting smallpox, a Global Commission declared in 1979 that the disease had been eradicated – the first disease in history to be eliminated by human effort. 1974 : The Expanded Programme on Immunization : 13 and the control programme of onchocerciasis was started, an important partnership between the Food and Agriculture Organization (FAO), the United Nations Development Programme (UNDP), and the World Bank . : 14 1975 : The WHO launched the Special Programme for Research and Training in Tropical diseases (the TDR). : 15 Co-sponsored by UNICEF, UNDP, and the World Bank, it was established in response to a 1974 request from the WHA for an intensive effort to develop improved control of tropical diseases. The TDR's goals are, firstly, to support and coordinate international research into diagnosis, treatment and control of tropical diseases; and, secondly, to strengthen research capabilities within endemic countries. 1976 : The WHA enacted a resolution on disability prevention and rehabilitation , with a focus on community-driven care : 16 1977 and 1978 : The first list of essential medicines was drawn up, : 17 and a year later the ambitious goal of " Health For All " was declared. : 18 1986 : The WHO began its global programme on HIV/AIDS . : 20 Two years later preventing discrimination against patients was attended to : 21 and in 1996 the Joint United Nations Programme on HIV/AIDS (UNAIDS) was formed. : 23 1988 : The Global Polio Eradication Initiative was established. : 22 1995 : The WHO established an independent International Commission for the Certification of Dracunculiasis Eradication (Guinea worm disease eradication; ICCDE). : 23 The ICCDE recommends to the WHO which countries fulfil requirements for certification. It also has role in advising on progress made towards elimination of transmission and processes for verification. 1998 : The WHO's director-general highlighted gains in child survival, reduced infant mortality , increased life expectancy and reduced rates of "scourges" such as smallpox and polio on the fiftieth anniversary of WHO's founding. He, did, however, accept that more had to be done to assist maternal health and that progress in this area had been slow. 2000 : The Stop TB Partnership was created along with the UN's formulation of the Millennium Development Goals . : 24 2001 : The measles initiative was formed, and credited with reducing global deaths from the disease by 68% by 2007. : 26 2002 : The Global Fund to Fight AIDS, Tuberculosis and Malaria was drawn up to improve the resources available. : 27 2005 : The WHO revises International Health Regulations (IHR) in light of emerging health threats and the experience of the 2002/3 SARS epidemic, authorizing WHO, among other things, to declare a health threat a Public Health Emergency of International Concern . 2006 : The WHO endorsed the world's first official HIV/AIDS Toolkit for Zimbabwe, which formed the basis for global prevention, treatment, and support the plan to fight the AIDS pandemic . [ better source needed ] 2016 : Following the perceived failure of the response to the West Africa Ebola outbreak , the World Health Emergencies programme was formed, changing the WHO from just being a "normative" agency to one that responds operationally to health emergencies. 2022 : The WHO suggests formation of a Global Health Emergency Council, with new global health emergency workforce, and recommends revision of the International Health Regulations. The International Sanitary Conferences (ISC), the first of which was held on 23 June 1851, were a series of conferences that took place until 1938, about 87 years. The first conference, in Paris, was almost solely concerned with cholera , which would remain the disease of major concern for the ISC for most of the 19th century. With the cause , origin, and communicability of many epidemic diseases still uncertain and a matter of scientific argument, international agreement on appropriate measures was difficult to reach. Seven of these international conferences, spanning 41 years, were convened before any resulted in a multi-state international agreement. The seventh conference, in Venice in 1892, finally resulted in a convention. It was concerned only with the sanitary control of shipping traversing the Suez Canal , and was an effort to guard against importation of cholera. : 65 Five years later, in 1897, a convention concerning the bubonic plague was signed by sixteen of the 19 states attending the Venice conference. While Denmark , Sweden-Norway , and the US did not sign this convention, it was unanimously agreed that the work of the prior conferences should be codified for implementation. Subsequent conferences, from 1902 until the final one in 1938, widened the diseases of concern for the ISC, and included discussions of responses to yellow fever , brucellosis , leprosy , tuberculosis , and typhoid . In part as a result of the successes of the Conferences, the Pan-American Sanitary Bureau (1902), and the Office International d'Hygiène Publique (1907) were soon founded. When the League of Nations was formed in 1920, it established the Health Organization of the League of Nations. After World War II , the United Nations absorbed all the other health organizations, to form the WHO. During the 1945 United Nations Conference on International Organization, Szeming Sze , a delegate from China , conferred with Norwegian and Brazilian delegates on creating an international health organization under the auspices of the new United Nations. After failing to get a resolution passed on the subject, Alger Hiss , the secretary general of the conference, recommended using a declaration to establish such an organization. Sze and other delegates lobbied and a declaration passed calling for an international conference on health. The use of the word "world", rather than "international", emphasized the truly global nature of what the organization was seeking to achieve. The constitution of the World Health Organization was signed by all 51 countries of the United Nations, and by 10 other countries, on 22 July 1946. It thus became the first specialized agency of the United Nations to which every member subscribed. Its constitution formally came into force on the first World Health Day on 7 April 1948, when it was ratified by the 26th member state. The first meeting of the World Health Assembly finished on 24 July 1948, having secured a budget of US$5 million (then £1,250,000 ) for the 1949 year. G. Brock Chisholm was appointed director-general of the WHO, having served as executive secretary and a founding member during the planning stages, while Andrija Štampar was the assembly's first president. Its first priorities were to control the spread of malaria , tuberculosis and sexually transmitted infections , and to improve maternal and child health , nutrition and environmental hygiene. Its first legislative act was concerning the compilation of accurate statistics on the spread and morbidity of disease. The logo of the World Health Organization features the Rod of Asclepius as a symbol for healing. In 1959, the WHO signed Agreement WHA 12–40 with the International Atomic Energy Agency (IAEA), which says: whenever either organization proposes to initiate a programme or activity on a subject in which the other organization has or may have a substantial interest, the first party shall consult the other with a view to adjusting the matter by mutual agreement . The nature of this statement has led some groups and activists including Women in Europe for a Common Future to claim that the WHO is restricted in its ability to investigate the effects on human health of radiation caused by the use of nuclear power and the continuing effects of nuclear disasters in Chernobyl and Fukushima . They believe WHO must regain what they see as independence. Independent WHO held a weekly vigil from 2007 to 2017 in front of WHO headquarters. However, as pointed out by Foreman in clause 2 it states: In particular, and in accordance with the Constitution of the World Health Organization and the Statute of the International Atomic Energy Agency and its agreement with the United Nations together with the exchange of letters related thereto, and taking into account the respective co-ordinating responsibilities of both organizations, it is recognized by the World Health Organization that the International Atomic Energy Agency has the primary responsibility for encouraging, assisting and co-ordinating research and development and practical application of atomic energy for peaceful uses throughout the world without prejudice to the right of the World Health Organization to concern itself with promoting, developing, assisting and co-ordinating international health work, including research, in all its aspects . The key text is highlighted in bold, the agreement in clause 2 states that the WHO is free to perform any health-related work.1947 : The WHO established an epidemiological information service via telex . : 5 1949 : The Soviet Union and its constituent republics quit the WHO over the organization's unwillingness to share the penicillin recipe. They would not return until 1956. 1950 : A mass tuberculosis inoculation drive using the BCG vaccine gets under way. : 8 1955 : The malaria eradication programme was launched, although objectives were later modified. (In most areas, the programme goals became control instead of eradication.) : 9 1958 : Viktor Zhdanov , Deputy Minister of Health for the USSR , called on the World Health Assembly to undertake a global initiative to eradicate smallpox, resulting in Resolution WHA11.54. : 366–371, 393, 399, 419 1965 : The first report on diabetes mellitus and the creation of the International Agency for Research on Cancer . : 10–11 1966 : The WHO moved its headquarters from the Ariana wing at the Palace of Nations to a newly constructed headquarters elsewhere in Geneva. : 12 1967 : The WHO intensified the global smallpox eradication campaign by contributing $2.4 million annually to the effort and adopted a new disease surveillance method, at a time when 2 million people were dying from smallpox per year. The initial problem the WHO team faced was inadequate reporting of smallpox cases. WHO established a network of consultants who assisted countries in setting up surveillance and containment activities. The WHO also helped contain the last European outbreak in Yugoslavia in 1972 . After over two decades of fighting smallpox, a Global Commission declared in 1979 that the disease had been eradicated – the first disease in history to be eliminated by human effort. 1974 : The Expanded Programme on Immunization : 13 and the control programme of onchocerciasis was started, an important partnership between the Food and Agriculture Organization (FAO), the United Nations Development Programme (UNDP), and the World Bank . : 14 1975 : The WHO launched the Special Programme for Research and Training in Tropical diseases (the TDR). : 15 Co-sponsored by UNICEF, UNDP, and the World Bank, it was established in response to a 1974 request from the WHA for an intensive effort to develop improved control of tropical diseases. The TDR's goals are, firstly, to support and coordinate international research into diagnosis, treatment and control of tropical diseases; and, secondly, to strengthen research capabilities within endemic countries. 1976 : The WHA enacted a resolution on disability prevention and rehabilitation , with a focus on community-driven care : 16 1977 and 1978 : The first list of essential medicines was drawn up, : 17 and a year later the ambitious goal of " Health For All " was declared. : 18 1986 : The WHO began its global programme on HIV/AIDS . : 20 Two years later preventing discrimination against patients was attended to : 21 and in 1996 the Joint United Nations Programme on HIV/AIDS (UNAIDS) was formed. : 23 1988 : The Global Polio Eradication Initiative was established. : 22 1995 : The WHO established an independent International Commission for the Certification of Dracunculiasis Eradication (Guinea worm disease eradication; ICCDE). : 23 The ICCDE recommends to the WHO which countries fulfil requirements for certification. It also has role in advising on progress made towards elimination of transmission and processes for verification. 1998 : The WHO's director-general highlighted gains in child survival, reduced infant mortality , increased life expectancy and reduced rates of "scourges" such as smallpox and polio on the fiftieth anniversary of WHO's founding. He, did, however, accept that more had to be done to assist maternal health and that progress in this area had been slow. 2000 : The Stop TB Partnership was created along with the UN's formulation of the Millennium Development Goals . : 24 2001 : The measles initiative was formed, and credited with reducing global deaths from the disease by 68% by 2007. : 26 2002 : The Global Fund to Fight AIDS, Tuberculosis and Malaria was drawn up to improve the resources available. : 27 2005 : The WHO revises International Health Regulations (IHR) in light of emerging health threats and the experience of the 2002/3 SARS epidemic, authorizing WHO, among other things, to declare a health threat a Public Health Emergency of International Concern . 2006 : The WHO endorsed the world's first official HIV/AIDS Toolkit for Zimbabwe, which formed the basis for global prevention, treatment, and support the plan to fight the AIDS pandemic . [ better source needed ] 2016 : Following the perceived failure of the response to the West Africa Ebola outbreak , the World Health Emergencies programme was formed, changing the WHO from just being a "normative" agency to one that responds operationally to health emergencies. 2022 : The WHO suggests formation of a Global Health Emergency Council, with new global health emergency workforce, and recommends revision of the International Health Regulations. The WHO's Constitution states that its objective "is the attainment by all people of the highest possible level of health". The WHO fulfils this objective through its functions as defined in its Constitution: (a) To act as the directing and coordinating authority on international health work; (b) To establish and maintain effective collaboration with the United Nations, specialized agencies, governmental health administrations, professional groups and such other organizations as may be deemed appropriate; (c) To assist Governments, upon request, in strengthening health services; (d) To furnish appropriate technical assistance and, in emergencies, necessary aid upon the request or acceptance of Governments; (e) To provide or assist in providing, upon the request of the United Nations, health services and facilities to special groups, such as the peoples of trust territories; (f) To establish and maintain such administrative and technical services as may be required, including epidemiological and statistical services; (g) To stimulate and advance work to eradicate epidemic, endemic and other diseases; (h) To promote, in co-operation with other specialized agencies where necessary, the prevention of accidental injuries; (i) To promote, in co-operation with other specialized agencies where necessary, the improvement of nutrition, housing, sanitation, recreation, economic or working conditions and other aspects of environmental hygiene; (j) To promote co-operation among scientific and professional groups which contribute to the advancement of health; (k) To propose conventions, agreements and regulations, and make recommendations with respect to international health matters and to perform (Article 2 of the Constitution). As of 2012 [ update ] , the WHO has defined its role in public health as follows: providing leadership on matters critical to health and engaging in partnerships where joint action is needed; shaping the research agenda and stimulating the generation, translation, and dissemination of valuable knowledge; setting norms and standards and promoting and monitoring their implementation; articulating ethical and evidence-based policy options; providing technical support, catalysing change, and building sustainable institutional capacity; and monitoring the health situation and assessing health trends. CRVS ( civil registration and vital statistics ) to provide monitoring of vital events (birth, death, wedding, divorce). Since the late 20th century, the rise of new actors engaged in global health—such as the World Bank , the Bill & Melinda Gates Foundation, the U.S. President's Emergency Plan for AIDS Relief ( PEPFAR ) and dozens of public-private partnerships for global health—have weakened the WHO's role as a coordinator and policy leader in the field; subsequently, there are various proposals to reform or reorient the WHO's role and priorities in public health, ranging from narrowing its mandate to strengthening its independence and authority. During the 1970s, WHO had dropped its commitment to a global malaria eradication campaign as too ambitious, it retained a strong commitment to malaria control. WHO's Global Malaria Programme works to keep track of malaria cases, and future problems in malaria control schemes. As of 2012, the WHO was to report as to whether RTS,S /AS01, were a viable malaria vaccine . For the time being, insecticide -treated mosquito nets and insecticide sprays are used to prevent the spread of malaria, as are antimalarial drugs – particularly to vulnerable people such as pregnant women and young children. In 1988, WHO launched the Global Polio Eradication Initiative to eradicate polio . It has also been successful in helping to reduce cases by 99% since WHO partnered with Rotary International , the US Centers for Disease Control and Prevention (CDC), the United Nations Children's Fund (UNICEF), and smaller organizations. As of 2011 [ update ] , it has been working to immunize young children and prevent the re-emergence of cases in countries declared "polio-free". In 2017, a study was conducted as to why Polio Vaccines may not be enough to eradicate the Virus & conduct new technology. Polio is now on the verge of extinction, thanks to a Global Vaccination Drive. The World Health Organization (WHO) stated the eradication programme has saved millions from deadly disease. Between 1990 and 2010, WHO's help has contributed to a 40% decline in the number of deaths from tuberculosis, and since 2005, over 46 million people have been treated and an estimated 7 million lives saved through practices advocated by WHO. These include engaging national governments and their financing, early diagnosis, standardising treatment, monitoring of the spread and effect of tuberculosis, and stabilising the drug supply. It has also recognized the vulnerability of victims of HIV/AIDS to tuberculosis. In 2003, the WHO denounced the Roman Curia 's health department's opposition to the use of condoms , saying: "These incorrect statements about condoms and HIV are dangerous when we are facing a global pandemic which has already killed more than 20 million people, and currently affects at least 42 million." As of 2009 [ update ] , the Catholic Church remains opposed to increasing the use of contraception to combat HIV/AIDS . At the time, the World Health Assembly president, Guyana's Health Minister Leslie Ramsammy , condemned Pope Benedict's opposition to contraception, saying he was trying to "create confusion" and "impede" proven strategies in the battle against the disease. In 2007, the WHO organized work on pandemic influenza vaccine development through clinical trials in collaboration with many experts and health officials. A pandemic involving the H1N1 influenza virus was declared by the then director-general Margaret Chan in April 2009. Margret Chan declared in 2010 that the H1N1 has moved into the post-pandemic period. By the post-pandemic period, critics claimed the WHO had exaggerated the danger, spreading "fear and confusion" rather than "immediate information". Industry experts countered that the 2009 pandemic had led to "unprecedented collaboration between global health authorities, scientists and manufacturers, resulting in the most comprehensive pandemic response ever undertaken, with a number of vaccines approved for use three months after the pandemic declaration. This response was only possible because of the extensive preparations undertaken during the last decade". The 2012–2013 WHO budget identified five areas among which funding was distributed. : 5, 20 Two of those five areas related to communicable diseases : the first, to reduce the "health, social and economic burden" of communicable diseases in general; the second to combat HIV/AIDS , malaria and tuberculosis in particular. : 5, 26 As of 2015 [ update ] , the World Health Organization has worked within the UNAIDS network and strives to involve sections of society other than health to help deal with the economic and social effects of HIV/AIDS . In line with UNAIDS, WHO has set itself the interim task between 2009 and 2015 of reducing the number of those aged 15–24 years who are infected by 50%; reducing new HIV infections in children by 90%; and reducing HIV-related deaths by 25%. The World Health Organization's definition of neglected tropical disease has been criticised to be restrictive (focusing only on communicable diseases) and described as a form of epistemic injustice, where conditions like snakebite are forced to be framed as a medical problem. One of the thirteen WHO priority areas is aimed at the prevention and reduction of "disease, disability and premature deaths from chronic noncommunicable diseases , mental disorders , violence and injuries , and visual impairment which are collectively responsible for almost 71% of all deaths worldwide". The Division of Noncommunicable Diseases for Promoting Health through the Reproductive Health has published the magazine, Entre Nous , across Europe since 1983. WHO is mandated under two of the international drug control conventions ( Single Convention on Narcotic Drugs, 1961 and Convention on Psychotropic Substances , 1971) to carry out scientific assessments of substances for international drug control . Through the WHO Expert Committee on Drug Dependence (ECDD) , it can recommend changes to scheduling of substances to the United Nations Commission on Narcotic Drugs . The ECDD is in charge of evaluating "the impact of psychoactive substances on public health" and "their dependence producing properties and potential harm to health, as well as considering their potential medical benefits and therapeutic applications." The WHO estimates that 12.6 million people died as a result of living or working in an unhealthy environment in 2012 – this accounts for nearly 1 in 4 of total global deaths. Environmental risk factors, such as air, water, and soil pollution , chemical exposures, climate change, and ultraviolet radiation, contribute to more than 100 diseases and injuries. This can result in a number of pollution-related diseases . WHO works to "reduce morbidity and mortality and improve health during key stages of life, including pregnancy, childbirth, the neonatal period , childhood and adolescence, and improve sexual and reproductive health and promote active and healthy aging for all individuals", for instance with the Special Programme on Human Reproduction . : 39–45 It also tries to prevent or reduce risk factors for "health conditions associated with use of tobacco, alcohol, drugs and other psychoactive substances, unhealthy diets and physical inactivity and unsafe sex ". : 50–55 The WHO works to improve nutrition, food safety and food security and to ensure this has a positive effect on public health and sustainable development . : 66–71 In April 2019, the WHO released new recommendations stating that children between the ages of two and five should spend no more than one hour per day engaging in sedentary behaviour in front of a screen and that children under two should not be permitted any sedentary screen time. The World Health Organization promotes road safety as a means to reduce traffic-related injuries. It has also worked on global initiatives in surgery, including emergency and essential surgical care, trauma care, and safe surgery. The WHO Surgical Safety Checklist is in current use worldwide in the effort to improve patient safety. The World Health Organization's primary objective in natural and man-made emergencies is to coordinate with member states and other stakeholders to "reduce avoidable loss of life and the burden of disease and disability." : 46–49 On 5 May 2014, WHO announced that the spread of polio was a world health emergency – outbreaks of the disease in Asia, Africa, and the Middle East were considered "extraordinary". On 8 August 2014, WHO declared that the spread of Ebola was a public health emergency; an outbreak which was believed to have started in Guinea had spread to other nearby countries such as Liberia and Sierra Leone. The situation in West Africa was considered very serious. Following the 2014 Ebola outbreak in West Africa, the organization was heavily criticized for its bureaucracy, insufficient financing, regional structure, and staffing profile. An internal WHO report on the Ebola response pointed to underfunding and the lack of "core capacity" in health systems in developing countries as the primary weaknesses of the existing system. At the annual World Health Assembly in 2015, Director-General Margaret Chan announced a $100 million Contingency Fund for rapid response to future emergencies, of which it had received $26.9 million by April 2016 (for 2017 disbursement). WHO has budgeted an additional $494 million for its Health Emergencies Programme in 2016–17, for which it had received $140 million by April 2016. The program was aimed at rebuilding WHO capacity for direct action, which critics said had been lost due to budget cuts in the previous decade that had left the organization in an advisory role dependent on member states for on-the-ground activities. In comparison, billions of dollars have been spent by developed countries on the 2013–2016 Ebola epidemic and 2015–16 Zika epidemic. The WHO created an Incident Management Support Team on 1 January 2020, one day after Chinese health authorities notified the organization of a cluster of pneumonia cases of unknown aetiology. On 5 January the WHO notified all member states of the outbreak, and in subsequent days provided guidance to all countries on how to respond, and confirmed the first infection outside China. On 14 January 2020, the WHO announced that preliminary investigations conducted by Chinese authorities had found no clear evidence of human-to-human transmission of the novel coronavirus (2019-nCoV) identified in Wuhan. The same day, the organization warned of limited human-to-human transmission, and confirmed human-to-human transmission one week later. On 30 January the WHO declared a Public Health Emergency of International Concern (PHEIC), considered a "call to action" and "last resort" measure for the international community and a pandemic on 11 March. While organizing the global response to the COVID-19 pandemic and overseeing "more than 35 emergency operations" for cholera, measles and other epidemics internationally, the WHO has been criticized for praising China's public health response to the crisis while seeking to maintain a "diplomatic balancing act" between the United States and China. David L. Heymann , professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine , said that "China has been very transparent and open in sharing its data... and they opened up all of their files with the WHO present." The WHO faced criticism from the United States' Trump administration while "guid[ing] the world in how to tackle the deadly" COVID-19 pandemic . On 14 April 2020, United States president Donald Trump said that he would halt United States funding to the WHO while reviewing its role in "severely mismanaging and covering up the spread of the coronavirus." World leaders and health experts largely condemned President Trump's announcement, which came amid criticism of his response to the outbreak in the United States. WHO called the announcement "regrettable" and defended its actions in alerting the world to the emergence of COVID-19. On 8 May 2020, the United States blocked a vote on a U.N. Security Council resolution aimed at promoting nonviolent international cooperation during the pandemic, and mentioning the WHO. On 7 July 2020, President Trump formally notified the UN of his intent to withdraw the United States from the WHO. However, Trump's successor, President Joe Biden , cancelled the planned withdrawal and announced in January 2021 that the U.S. would resume funding the organization. In May 2023, the WHO announced that COVID-19 was no longer a world-wide health emergency. WHO addresses government health policy with two aims: firstly, "to address the underlying social and economic determinants of health through policies and programmes that enhance health equity and integrate pro-poor, gender-responsive, and human rights-based approaches" and secondly "to promote a healthier environment, intensify primary prevention and influence public policies in all sectors so as to address the root causes of environmental threats to health". : 61–65 The organization develops and promotes the use of evidence-based tools, norms and standards to support member states to inform health policy options. It oversees the implementation of the International Health Regulations , and publishes a series of medical classifications ; of these, three are over-reaching "reference classifications": the International Statistical Classification of Diseases (ICD), the International Classification of Functioning, Disability and Health (ICF) and the International Classification of Health Interventions (ICHI). Other international policy frameworks produced by WHO include the International Code of Marketing of Breast-milk Substitutes (adopted in 1981), Framework Convention on Tobacco Control (adopted in 2003) the Global Code of Practice on the International Recruitment of Health Personnel (adopted in 2010) as well as the WHO Model List of Essential Medicines and its pediatric counterpart . An international convention on pandemic prevention and preparedness is being actively considered. In terms of health services, WHO looks to improve "governance, financing, staffing and management" and the availability and quality of evidence and research to guide policy. It also strives to "ensure improved access, quality and use of medical products and technologies". : 72–83 WHO – working with donor agencies and national governments – can improve their reporting about use of research evidence. On Digital Health topics, WHO has existing Inter-Agency collaboration with the International Telecommunication Union (the UN Specialized Agency for ICT ), including the Be Health, Be Mobile initiate and the ITU-WHO Focus Group on Artificial Intelligence for Health. The WHO has developed several technical policy packages to support countries to improve health: ACTIVE (physical activity) HEARTS (cardiovascular diseases) MPOWER (tobacco control) REPLACE (trans fat) SAFER (alcohol) SHAKE (salt reduction) The remaining two of WHO's thirteen identified policy areas relate to the role of WHO itself: : 84–91 "to provide leadership, strengthen governance and foster partnership and collaboration with countries, the United Nations system, and other stakeholders in order to fulfil the mandate of WHO in advancing the global health agenda"; and "to develop and sustain WHO as a flexible, learning organization, enabling it to carry out its mandate more efficiently and effectively". The WHO along with the World Bank constitute the core team responsible for administering the International Health Partnership (IHP+). The IHP+ is a group of partner governments, development agencies, civil society, and others committed to improving the health of citizens in developing countries . Partners work together to put international principles for aid effectiveness and development co-operation into practice in the health sector. The organization relies on contributions from renowned scientists and professionals to inform its work, such as the WHO Expert Committee on Biological Standardization , the WHO Expert Committee on Leprosy , and the WHO Study Group on Interprofessional Education & Collaborative Practice . WHO runs the Alliance for Health Policy and Systems Research , targeted at improving health policy and systems . WHO also aims to improve access to health research and literature in developing countries such as through the HINARI network. WHO collaborates with The Global Fund to Fight AIDS, Tuberculosis and Malaria , UNITAID, and the United States President's Emergency Plan for AIDS Relief to spearhead and fund the development of HIV programs. WHO created the Civil Society Reference Group on HIV, which brings together other networks that are involved in policymaking and the dissemination of guidelines. WHO, a sector of the United Nations, partners with UNAIDS to contribute to the development of HIV responses in different areas of the world. WHO facilitates technical partnerships through the Technical Advisory Committee on HIV, which they created to develop WHO guidelines and policies. In 2014, WHO released the Global Atlas of Palliative Care at the End of Life in a joint publication with the Worldwide Hospice Palliative Care Alliance , an affiliated NGO working collaboratively with the WHO to promote palliative care in national and international health policy . The practice of empowering individuals to exert more control over and make improvements to their health is known as health education, as described by the WHO. It shifts away from an emphasis on personal behaviour and toward a variety of societal and environmental solutions. Each year, the organization marks World Health Day and other observances focusing on a specific health promotion topic. World Health Day falls on 7 April each year, timed to match the anniversary of WHO's founding. Recent themes have been vector-borne diseases (2014), healthy ageing (2012) and drug resistance (2011). The other official global public health campaigns marked by WHO are World Tuberculosis Day , World Immunization Week , World Malaria Day , World No Tobacco Day , World Blood Donor Day , World Hepatitis Day , and World AIDS Day . As part of the United Nations, the World Health Organization supports work towards the Millennium Development Goals . Of the eight Millennium Development Goals, three – reducing child mortality by two-thirds, to reduce maternal deaths by three-quarters, and to halt and begin to reduce the spread of HIV/AIDS – relate directly to the WHO's scope; the other five inter-relate and affect world health. The World Health Organization works to provide the needed health and well-being evidence through a variety of data collection platforms, including the World Health Survey covering almost 400,000 respondents from 70 countries, and the Study on Global Aging and Adult Health (SAGE) covering over 50,000 persons over 50 years old in 23 countries. The Country Health Intelligence Portal (CHIP), has also been developed to provide an access point to information about the health services that are available in different countries. The information gathered in this portal is used by the countries to set priorities for future strategies or plans, implement, monitor, and evaluate it. The WHO has published various tools for measuring and monitoring the capacity of national health systems and health workforces . The Global Health Observatory (GHO) has been the WHO's main portal which provides access to data and analyses for key health themes by monitoring health situations around the globe. The WHO Assessment Instrument for Mental Health Systems (WHO-AIMS), the WHO Quality of Life Instrument (WHOQOL), and the Service Availability and Readiness Assessment (SARA) provide guidance for data collection. Collaborative efforts between WHO and other agencies, such as through the Health Metrics Network , also aim to provide sufficient high-quality information to assist governmental decision making. WHO promotes the development of capacities in member states to use and produce research that addresses their national needs, including through the Evidence-Informed Policy Network (EVIPNet). The Pan American Health Organization (PAHO/AMRO) became the first region to develop and pass a policy on research for health approved in September 2009. On 10 December 2013, a new WHO database, known as MiNDbank, went online. The database was launched on Human Rights Day , and is part of WHO's QualityRights initiative, which aims to end human rights violations against people with mental health conditions. The new database presents a great deal of information about mental health, substance abuse, disability, human rights, and the different policies, strategies, laws, and service standards being implemented in different countries. It also contains important international documents and information. The database allows visitors to access the health information of WHO member states and other partners. Users can review policies, laws, and strategies and search for the best practices and success stories in the field of mental health. The WHO regularly publishes a World Health Report , its leading publication, including an expert assessment of a specific global health topic. Other publications of WHO include the Bulletin of the World Health Organization , the Eastern Mediterranean Health Journal (overseen by EMRO), the Human Resources for Health (published in collaboration with BioMed Central ), and the Pan American Journal of Public Health (overseen by PAHO/AMRO). In 2016, the World Health Organization drafted a global health sector strategy on HIV. In the draft, the World Health Organization outlines its commitment to ending the AIDS epidemic by 2030 with interim targets for the year 2020. To make achievements towards these targets, the draft lists actions that countries and the WHO can take, such as a commitment to universal health coverage, medical accessibility, prevention and eradication of disease, and efforts to educate the public. Some notable points made in the draft include tailoring resources to mobilized regions where the health system may be compromised due to natural disasters, etc. Among the points made, it seems clear that although the prevalence of HIV transmission is declining, there is still a need for resources, health education, and global efforts to end this epidemic. The WHO has a Framework Convention on Tobacco implementation database which is one of the few mechanisms to help enforce compliance with the FCTC. However, there have been reports of numerous discrepancies between it and national implementation reports on which it was built. As researchers Hoffman and Rizvi report "As of July 4, 2012, 361 (32·7%) of 1104 countries' responses were misreported: 33 (3·0%) were clear errors (e.g., database indicated 'yes' when report indicated 'no'), 270 (24·5%) were missing despite countries having submitted responses, and 58 (5·3%) were, in our opinion, misinterpreted by WHO staff". WHO has been moving toward acceptance and integration of traditional medicine and traditional Chinese medicine (TCM). In 2022, the new International Statistical Classification of Diseases and Related Health Problems , ICD-11, will attempt to enable classifications from traditional medicine to be integrated with classifications from evidence-based medicine . Though Chinese authorities have pushed for the change, this and other support of the WHO for traditional medicine has been criticized by the medical and scientific community, due to lack of evidence and the risk of endangering wildlife hunted for traditional remedies. A WHO spokesman said that the inclusion was "not an endorsement of the scientific validity of any Traditional Medicine practice or the efficacy of any Traditional Medicine intervention." The WHO sub-department, the International Agency for Research on Cancer (IARC), conducts and coordinates research into the causes of cancer . It also collects and publishes surveillance data regarding the occurrence of cancer worldwide. Its Monographs Programme identifies carcinogenic hazards and evaluates environmental causes of cancer in humans. The WHO's Constitution states that its objective "is the attainment by all people of the highest possible level of health". The WHO fulfils this objective through its functions as defined in its Constitution: (a) To act as the directing and coordinating authority on international health work; (b) To establish and maintain effective collaboration with the United Nations, specialized agencies, governmental health administrations, professional groups and such other organizations as may be deemed appropriate; (c) To assist Governments, upon request, in strengthening health services; (d) To furnish appropriate technical assistance and, in emergencies, necessary aid upon the request or acceptance of Governments; (e) To provide or assist in providing, upon the request of the United Nations, health services and facilities to special groups, such as the peoples of trust territories; (f) To establish and maintain such administrative and technical services as may be required, including epidemiological and statistical services; (g) To stimulate and advance work to eradicate epidemic, endemic and other diseases; (h) To promote, in co-operation with other specialized agencies where necessary, the prevention of accidental injuries; (i) To promote, in co-operation with other specialized agencies where necessary, the improvement of nutrition, housing, sanitation, recreation, economic or working conditions and other aspects of environmental hygiene; (j) To promote co-operation among scientific and professional groups which contribute to the advancement of health; (k) To propose conventions, agreements and regulations, and make recommendations with respect to international health matters and to perform (Article 2 of the Constitution). As of 2012 [ update ] , the WHO has defined its role in public health as follows: providing leadership on matters critical to health and engaging in partnerships where joint action is needed; shaping the research agenda and stimulating the generation, translation, and dissemination of valuable knowledge; setting norms and standards and promoting and monitoring their implementation; articulating ethical and evidence-based policy options; providing technical support, catalysing change, and building sustainable institutional capacity; and monitoring the health situation and assessing health trends. CRVS ( civil registration and vital statistics ) to provide monitoring of vital events (birth, death, wedding, divorce). Since the late 20th century, the rise of new actors engaged in global health—such as the World Bank , the Bill & Melinda Gates Foundation, the U.S. President's Emergency Plan for AIDS Relief ( PEPFAR ) and dozens of public-private partnerships for global health—have weakened the WHO's role as a coordinator and policy leader in the field; subsequently, there are various proposals to reform or reorient the WHO's role and priorities in public health, ranging from narrowing its mandate to strengthening its independence and authority. During the 1970s, WHO had dropped its commitment to a global malaria eradication campaign as too ambitious, it retained a strong commitment to malaria control. WHO's Global Malaria Programme works to keep track of malaria cases, and future problems in malaria control schemes. As of 2012, the WHO was to report as to whether RTS,S /AS01, were a viable malaria vaccine . For the time being, insecticide -treated mosquito nets and insecticide sprays are used to prevent the spread of malaria, as are antimalarial drugs – particularly to vulnerable people such as pregnant women and young children. In 1988, WHO launched the Global Polio Eradication Initiative to eradicate polio . It has also been successful in helping to reduce cases by 99% since WHO partnered with Rotary International , the US Centers for Disease Control and Prevention (CDC), the United Nations Children's Fund (UNICEF), and smaller organizations. As of 2011 [ update ] , it has been working to immunize young children and prevent the re-emergence of cases in countries declared "polio-free". In 2017, a study was conducted as to why Polio Vaccines may not be enough to eradicate the Virus & conduct new technology. Polio is now on the verge of extinction, thanks to a Global Vaccination Drive. The World Health Organization (WHO) stated the eradication programme has saved millions from deadly disease. Between 1990 and 2010, WHO's help has contributed to a 40% decline in the number of deaths from tuberculosis, and since 2005, over 46 million people have been treated and an estimated 7 million lives saved through practices advocated by WHO. These include engaging national governments and their financing, early diagnosis, standardising treatment, monitoring of the spread and effect of tuberculosis, and stabilising the drug supply. It has also recognized the vulnerability of victims of HIV/AIDS to tuberculosis. In 2003, the WHO denounced the Roman Curia 's health department's opposition to the use of condoms , saying: "These incorrect statements about condoms and HIV are dangerous when we are facing a global pandemic which has already killed more than 20 million people, and currently affects at least 42 million." As of 2009 [ update ] , the Catholic Church remains opposed to increasing the use of contraception to combat HIV/AIDS . At the time, the World Health Assembly president, Guyana's Health Minister Leslie Ramsammy , condemned Pope Benedict's opposition to contraception, saying he was trying to "create confusion" and "impede" proven strategies in the battle against the disease. In 2007, the WHO organized work on pandemic influenza vaccine development through clinical trials in collaboration with many experts and health officials. A pandemic involving the H1N1 influenza virus was declared by the then director-general Margaret Chan in April 2009. Margret Chan declared in 2010 that the H1N1 has moved into the post-pandemic period. By the post-pandemic period, critics claimed the WHO had exaggerated the danger, spreading "fear and confusion" rather than "immediate information". Industry experts countered that the 2009 pandemic had led to "unprecedented collaboration between global health authorities, scientists and manufacturers, resulting in the most comprehensive pandemic response ever undertaken, with a number of vaccines approved for use three months after the pandemic declaration. This response was only possible because of the extensive preparations undertaken during the last decade". The 2012–2013 WHO budget identified five areas among which funding was distributed. : 5, 20 Two of those five areas related to communicable diseases : the first, to reduce the "health, social and economic burden" of communicable diseases in general; the second to combat HIV/AIDS , malaria and tuberculosis in particular. : 5, 26 As of 2015 [ update ] , the World Health Organization has worked within the UNAIDS network and strives to involve sections of society other than health to help deal with the economic and social effects of HIV/AIDS . In line with UNAIDS, WHO has set itself the interim task between 2009 and 2015 of reducing the number of those aged 15–24 years who are infected by 50%; reducing new HIV infections in children by 90%; and reducing HIV-related deaths by 25%. The World Health Organization's definition of neglected tropical disease has been criticised to be restrictive (focusing only on communicable diseases) and described as a form of epistemic injustice, where conditions like snakebite are forced to be framed as a medical problem. One of the thirteen WHO priority areas is aimed at the prevention and reduction of "disease, disability and premature deaths from chronic noncommunicable diseases , mental disorders , violence and injuries , and visual impairment which are collectively responsible for almost 71% of all deaths worldwide". The Division of Noncommunicable Diseases for Promoting Health through the Reproductive Health has published the magazine, Entre Nous , across Europe since 1983. WHO is mandated under two of the international drug control conventions ( Single Convention on Narcotic Drugs, 1961 and Convention on Psychotropic Substances , 1971) to carry out scientific assessments of substances for international drug control . Through the WHO Expert Committee on Drug Dependence (ECDD) , it can recommend changes to scheduling of substances to the United Nations Commission on Narcotic Drugs . The ECDD is in charge of evaluating "the impact of psychoactive substances on public health" and "their dependence producing properties and potential harm to health, as well as considering their potential medical benefits and therapeutic applications." The WHO estimates that 12.6 million people died as a result of living or working in an unhealthy environment in 2012 – this accounts for nearly 1 in 4 of total global deaths. Environmental risk factors, such as air, water, and soil pollution , chemical exposures, climate change, and ultraviolet radiation, contribute to more than 100 diseases and injuries. This can result in a number of pollution-related diseases . WHO works to "reduce morbidity and mortality and improve health during key stages of life, including pregnancy, childbirth, the neonatal period , childhood and adolescence, and improve sexual and reproductive health and promote active and healthy aging for all individuals", for instance with the Special Programme on Human Reproduction . : 39–45 It also tries to prevent or reduce risk factors for "health conditions associated with use of tobacco, alcohol, drugs and other psychoactive substances, unhealthy diets and physical inactivity and unsafe sex ". : 50–55 The WHO works to improve nutrition, food safety and food security and to ensure this has a positive effect on public health and sustainable development . : 66–71 In April 2019, the WHO released new recommendations stating that children between the ages of two and five should spend no more than one hour per day engaging in sedentary behaviour in front of a screen and that children under two should not be permitted any sedentary screen time. The World Health Organization promotes road safety as a means to reduce traffic-related injuries. It has also worked on global initiatives in surgery, including emergency and essential surgical care, trauma care, and safe surgery. The WHO Surgical Safety Checklist is in current use worldwide in the effort to improve patient safety. The World Health Organization's primary objective in natural and man-made emergencies is to coordinate with member states and other stakeholders to "reduce avoidable loss of life and the burden of disease and disability." : 46–49 On 5 May 2014, WHO announced that the spread of polio was a world health emergency – outbreaks of the disease in Asia, Africa, and the Middle East were considered "extraordinary". On 8 August 2014, WHO declared that the spread of Ebola was a public health emergency; an outbreak which was believed to have started in Guinea had spread to other nearby countries such as Liberia and Sierra Leone. The situation in West Africa was considered very serious. Following the 2014 Ebola outbreak in West Africa, the organization was heavily criticized for its bureaucracy, insufficient financing, regional structure, and staffing profile. An internal WHO report on the Ebola response pointed to underfunding and the lack of "core capacity" in health systems in developing countries as the primary weaknesses of the existing system. At the annual World Health Assembly in 2015, Director-General Margaret Chan announced a $100 million Contingency Fund for rapid response to future emergencies, of which it had received $26.9 million by April 2016 (for 2017 disbursement). WHO has budgeted an additional $494 million for its Health Emergencies Programme in 2016–17, for which it had received $140 million by April 2016. The program was aimed at rebuilding WHO capacity for direct action, which critics said had been lost due to budget cuts in the previous decade that had left the organization in an advisory role dependent on member states for on-the-ground activities. In comparison, billions of dollars have been spent by developed countries on the 2013–2016 Ebola epidemic and 2015–16 Zika epidemic. The WHO created an Incident Management Support Team on 1 January 2020, one day after Chinese health authorities notified the organization of a cluster of pneumonia cases of unknown aetiology. On 5 January the WHO notified all member states of the outbreak, and in subsequent days provided guidance to all countries on how to respond, and confirmed the first infection outside China. On 14 January 2020, the WHO announced that preliminary investigations conducted by Chinese authorities had found no clear evidence of human-to-human transmission of the novel coronavirus (2019-nCoV) identified in Wuhan. The same day, the organization warned of limited human-to-human transmission, and confirmed human-to-human transmission one week later. On 30 January the WHO declared a Public Health Emergency of International Concern (PHEIC), considered a "call to action" and "last resort" measure for the international community and a pandemic on 11 March. While organizing the global response to the COVID-19 pandemic and overseeing "more than 35 emergency operations" for cholera, measles and other epidemics internationally, the WHO has been criticized for praising China's public health response to the crisis while seeking to maintain a "diplomatic balancing act" between the United States and China. David L. Heymann , professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine , said that "China has been very transparent and open in sharing its data... and they opened up all of their files with the WHO present." The WHO faced criticism from the United States' Trump administration while "guid[ing] the world in how to tackle the deadly" COVID-19 pandemic . On 14 April 2020, United States president Donald Trump said that he would halt United States funding to the WHO while reviewing its role in "severely mismanaging and covering up the spread of the coronavirus." World leaders and health experts largely condemned President Trump's announcement, which came amid criticism of his response to the outbreak in the United States. WHO called the announcement "regrettable" and defended its actions in alerting the world to the emergence of COVID-19. On 8 May 2020, the United States blocked a vote on a U.N. Security Council resolution aimed at promoting nonviolent international cooperation during the pandemic, and mentioning the WHO. On 7 July 2020, President Trump formally notified the UN of his intent to withdraw the United States from the WHO. However, Trump's successor, President Joe Biden , cancelled the planned withdrawal and announced in January 2021 that the U.S. would resume funding the organization. In May 2023, the WHO announced that COVID-19 was no longer a world-wide health emergency. WHO addresses government health policy with two aims: firstly, "to address the underlying social and economic determinants of health through policies and programmes that enhance health equity and integrate pro-poor, gender-responsive, and human rights-based approaches" and secondly "to promote a healthier environment, intensify primary prevention and influence public policies in all sectors so as to address the root causes of environmental threats to health". : 61–65 The organization develops and promotes the use of evidence-based tools, norms and standards to support member states to inform health policy options. It oversees the implementation of the International Health Regulations , and publishes a series of medical classifications ; of these, three are over-reaching "reference classifications": the International Statistical Classification of Diseases (ICD), the International Classification of Functioning, Disability and Health (ICF) and the International Classification of Health Interventions (ICHI). Other international policy frameworks produced by WHO include the International Code of Marketing of Breast-milk Substitutes (adopted in 1981), Framework Convention on Tobacco Control (adopted in 2003) the Global Code of Practice on the International Recruitment of Health Personnel (adopted in 2010) as well as the WHO Model List of Essential Medicines and its pediatric counterpart . An international convention on pandemic prevention and preparedness is being actively considered. In terms of health services, WHO looks to improve "governance, financing, staffing and management" and the availability and quality of evidence and research to guide policy. It also strives to "ensure improved access, quality and use of medical products and technologies". : 72–83 WHO – working with donor agencies and national governments – can improve their reporting about use of research evidence. On Digital Health topics, WHO has existing Inter-Agency collaboration with the International Telecommunication Union (the UN Specialized Agency for ICT ), including the Be Health, Be Mobile initiate and the ITU-WHO Focus Group on Artificial Intelligence for Health.During the 1970s, WHO had dropped its commitment to a global malaria eradication campaign as too ambitious, it retained a strong commitment to malaria control. WHO's Global Malaria Programme works to keep track of malaria cases, and future problems in malaria control schemes. As of 2012, the WHO was to report as to whether RTS,S /AS01, were a viable malaria vaccine . For the time being, insecticide -treated mosquito nets and insecticide sprays are used to prevent the spread of malaria, as are antimalarial drugs – particularly to vulnerable people such as pregnant women and young children. In 1988, WHO launched the Global Polio Eradication Initiative to eradicate polio . It has also been successful in helping to reduce cases by 99% since WHO partnered with Rotary International , the US Centers for Disease Control and Prevention (CDC), the United Nations Children's Fund (UNICEF), and smaller organizations. As of 2011 [ update ] , it has been working to immunize young children and prevent the re-emergence of cases in countries declared "polio-free". In 2017, a study was conducted as to why Polio Vaccines may not be enough to eradicate the Virus & conduct new technology. Polio is now on the verge of extinction, thanks to a Global Vaccination Drive. The World Health Organization (WHO) stated the eradication programme has saved millions from deadly disease. Between 1990 and 2010, WHO's help has contributed to a 40% decline in the number of deaths from tuberculosis, and since 2005, over 46 million people have been treated and an estimated 7 million lives saved through practices advocated by WHO. These include engaging national governments and their financing, early diagnosis, standardising treatment, monitoring of the spread and effect of tuberculosis, and stabilising the drug supply. It has also recognized the vulnerability of victims of HIV/AIDS to tuberculosis. In 2003, the WHO denounced the Roman Curia 's health department's opposition to the use of condoms , saying: "These incorrect statements about condoms and HIV are dangerous when we are facing a global pandemic which has already killed more than 20 million people, and currently affects at least 42 million." As of 2009 [ update ] , the Catholic Church remains opposed to increasing the use of contraception to combat HIV/AIDS . At the time, the World Health Assembly president, Guyana's Health Minister Leslie Ramsammy , condemned Pope Benedict's opposition to contraception, saying he was trying to "create confusion" and "impede" proven strategies in the battle against the disease. In 2007, the WHO organized work on pandemic influenza vaccine development through clinical trials in collaboration with many experts and health officials. A pandemic involving the H1N1 influenza virus was declared by the then director-general Margaret Chan in April 2009. Margret Chan declared in 2010 that the H1N1 has moved into the post-pandemic period. By the post-pandemic period, critics claimed the WHO had exaggerated the danger, spreading "fear and confusion" rather than "immediate information". Industry experts countered that the 2009 pandemic had led to "unprecedented collaboration between global health authorities, scientists and manufacturers, resulting in the most comprehensive pandemic response ever undertaken, with a number of vaccines approved for use three months after the pandemic declaration. This response was only possible because of the extensive preparations undertaken during the last decade". The 2012–2013 WHO budget identified five areas among which funding was distributed. : 5, 20 Two of those five areas related to communicable diseases : the first, to reduce the "health, social and economic burden" of communicable diseases in general; the second to combat HIV/AIDS , malaria and tuberculosis in particular. : 5, 26 As of 2015 [ update ] , the World Health Organization has worked within the UNAIDS network and strives to involve sections of society other than health to help deal with the economic and social effects of HIV/AIDS . In line with UNAIDS, WHO has set itself the interim task between 2009 and 2015 of reducing the number of those aged 15–24 years who are infected by 50%; reducing new HIV infections in children by 90%; and reducing HIV-related deaths by 25%. The World Health Organization's definition of neglected tropical disease has been criticised to be restrictive (focusing only on communicable diseases) and described as a form of epistemic injustice, where conditions like snakebite are forced to be framed as a medical problem. One of the thirteen WHO priority areas is aimed at the prevention and reduction of "disease, disability and premature deaths from chronic noncommunicable diseases , mental disorders , violence and injuries , and visual impairment which are collectively responsible for almost 71% of all deaths worldwide". The Division of Noncommunicable Diseases for Promoting Health through the Reproductive Health has published the magazine, Entre Nous , across Europe since 1983. WHO is mandated under two of the international drug control conventions ( Single Convention on Narcotic Drugs, 1961 and Convention on Psychotropic Substances , 1971) to carry out scientific assessments of substances for international drug control . Through the WHO Expert Committee on Drug Dependence (ECDD) , it can recommend changes to scheduling of substances to the United Nations Commission on Narcotic Drugs . The ECDD is in charge of evaluating "the impact of psychoactive substances on public health" and "their dependence producing properties and potential harm to health, as well as considering their potential medical benefits and therapeutic applications." The WHO estimates that 12.6 million people died as a result of living or working in an unhealthy environment in 2012 – this accounts for nearly 1 in 4 of total global deaths. Environmental risk factors, such as air, water, and soil pollution , chemical exposures, climate change, and ultraviolet radiation, contribute to more than 100 diseases and injuries. This can result in a number of pollution-related diseases .WHO works to "reduce morbidity and mortality and improve health during key stages of life, including pregnancy, childbirth, the neonatal period , childhood and adolescence, and improve sexual and reproductive health and promote active and healthy aging for all individuals", for instance with the Special Programme on Human Reproduction . : 39–45 It also tries to prevent or reduce risk factors for "health conditions associated with use of tobacco, alcohol, drugs and other psychoactive substances, unhealthy diets and physical inactivity and unsafe sex ". : 50–55 The WHO works to improve nutrition, food safety and food security and to ensure this has a positive effect on public health and sustainable development . : 66–71 In April 2019, the WHO released new recommendations stating that children between the ages of two and five should spend no more than one hour per day engaging in sedentary behaviour in front of a screen and that children under two should not be permitted any sedentary screen time. The World Health Organization promotes road safety as a means to reduce traffic-related injuries. It has also worked on global initiatives in surgery, including emergency and essential surgical care, trauma care, and safe surgery. The WHO Surgical Safety Checklist is in current use worldwide in the effort to improve patient safety. The World Health Organization's primary objective in natural and man-made emergencies is to coordinate with member states and other stakeholders to "reduce avoidable loss of life and the burden of disease and disability." : 46–49 On 5 May 2014, WHO announced that the spread of polio was a world health emergency – outbreaks of the disease in Asia, Africa, and the Middle East were considered "extraordinary". On 8 August 2014, WHO declared that the spread of Ebola was a public health emergency; an outbreak which was believed to have started in Guinea had spread to other nearby countries such as Liberia and Sierra Leone. The situation in West Africa was considered very serious. Following the 2014 Ebola outbreak in West Africa, the organization was heavily criticized for its bureaucracy, insufficient financing, regional structure, and staffing profile. An internal WHO report on the Ebola response pointed to underfunding and the lack of "core capacity" in health systems in developing countries as the primary weaknesses of the existing system. At the annual World Health Assembly in 2015, Director-General Margaret Chan announced a $100 million Contingency Fund for rapid response to future emergencies, of which it had received $26.9 million by April 2016 (for 2017 disbursement). WHO has budgeted an additional $494 million for its Health Emergencies Programme in 2016–17, for which it had received $140 million by April 2016. The program was aimed at rebuilding WHO capacity for direct action, which critics said had been lost due to budget cuts in the previous decade that had left the organization in an advisory role dependent on member states for on-the-ground activities. In comparison, billions of dollars have been spent by developed countries on the 2013–2016 Ebola epidemic and 2015–16 Zika epidemic. The WHO created an Incident Management Support Team on 1 January 2020, one day after Chinese health authorities notified the organization of a cluster of pneumonia cases of unknown aetiology. On 5 January the WHO notified all member states of the outbreak, and in subsequent days provided guidance to all countries on how to respond, and confirmed the first infection outside China. On 14 January 2020, the WHO announced that preliminary investigations conducted by Chinese authorities had found no clear evidence of human-to-human transmission of the novel coronavirus (2019-nCoV) identified in Wuhan. The same day, the organization warned of limited human-to-human transmission, and confirmed human-to-human transmission one week later. On 30 January the WHO declared a Public Health Emergency of International Concern (PHEIC), considered a "call to action" and "last resort" measure for the international community and a pandemic on 11 March. While organizing the global response to the COVID-19 pandemic and overseeing "more than 35 emergency operations" for cholera, measles and other epidemics internationally, the WHO has been criticized for praising China's public health response to the crisis while seeking to maintain a "diplomatic balancing act" between the United States and China. David L. Heymann , professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine , said that "China has been very transparent and open in sharing its data... and they opened up all of their files with the WHO present." The WHO faced criticism from the United States' Trump administration while "guid[ing] the world in how to tackle the deadly" COVID-19 pandemic . On 14 April 2020, United States president Donald Trump said that he would halt United States funding to the WHO while reviewing its role in "severely mismanaging and covering up the spread of the coronavirus." World leaders and health experts largely condemned President Trump's announcement, which came amid criticism of his response to the outbreak in the United States. WHO called the announcement "regrettable" and defended its actions in alerting the world to the emergence of COVID-19. On 8 May 2020, the United States blocked a vote on a U.N. Security Council resolution aimed at promoting nonviolent international cooperation during the pandemic, and mentioning the WHO. On 7 July 2020, President Trump formally notified the UN of his intent to withdraw the United States from the WHO. However, Trump's successor, President Joe Biden , cancelled the planned withdrawal and announced in January 2021 that the U.S. would resume funding the organization. In May 2023, the WHO announced that COVID-19 was no longer a world-wide health emergency. Following the 2014 Ebola outbreak in West Africa, the organization was heavily criticized for its bureaucracy, insufficient financing, regional structure, and staffing profile. An internal WHO report on the Ebola response pointed to underfunding and the lack of "core capacity" in health systems in developing countries as the primary weaknesses of the existing system. At the annual World Health Assembly in 2015, Director-General Margaret Chan announced a $100 million Contingency Fund for rapid response to future emergencies, of which it had received $26.9 million by April 2016 (for 2017 disbursement). WHO has budgeted an additional $494 million for its Health Emergencies Programme in 2016–17, for which it had received $140 million by April 2016. The program was aimed at rebuilding WHO capacity for direct action, which critics said had been lost due to budget cuts in the previous decade that had left the organization in an advisory role dependent on member states for on-the-ground activities. In comparison, billions of dollars have been spent by developed countries on the 2013–2016 Ebola epidemic and 2015–16 Zika epidemic. The WHO created an Incident Management Support Team on 1 January 2020, one day after Chinese health authorities notified the organization of a cluster of pneumonia cases of unknown aetiology. On 5 January the WHO notified all member states of the outbreak, and in subsequent days provided guidance to all countries on how to respond, and confirmed the first infection outside China. On 14 January 2020, the WHO announced that preliminary investigations conducted by Chinese authorities had found no clear evidence of human-to-human transmission of the novel coronavirus (2019-nCoV) identified in Wuhan. The same day, the organization warned of limited human-to-human transmission, and confirmed human-to-human transmission one week later. On 30 January the WHO declared a Public Health Emergency of International Concern (PHEIC), considered a "call to action" and "last resort" measure for the international community and a pandemic on 11 March. While organizing the global response to the COVID-19 pandemic and overseeing "more than 35 emergency operations" for cholera, measles and other epidemics internationally, the WHO has been criticized for praising China's public health response to the crisis while seeking to maintain a "diplomatic balancing act" between the United States and China. David L. Heymann , professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine , said that "China has been very transparent and open in sharing its data... and they opened up all of their files with the WHO present." The WHO faced criticism from the United States' Trump administration while "guid[ing] the world in how to tackle the deadly" COVID-19 pandemic . On 14 April 2020, United States president Donald Trump said that he would halt United States funding to the WHO while reviewing its role in "severely mismanaging and covering up the spread of the coronavirus." World leaders and health experts largely condemned President Trump's announcement, which came amid criticism of his response to the outbreak in the United States. WHO called the announcement "regrettable" and defended its actions in alerting the world to the emergence of COVID-19. On 8 May 2020, the United States blocked a vote on a U.N. Security Council resolution aimed at promoting nonviolent international cooperation during the pandemic, and mentioning the WHO. On 7 July 2020, President Trump formally notified the UN of his intent to withdraw the United States from the WHO. However, Trump's successor, President Joe Biden , cancelled the planned withdrawal and announced in January 2021 that the U.S. would resume funding the organization. In May 2023, the WHO announced that COVID-19 was no longer a world-wide health emergency. WHO addresses government health policy with two aims: firstly, "to address the underlying social and economic determinants of health through policies and programmes that enhance health equity and integrate pro-poor, gender-responsive, and human rights-based approaches" and secondly "to promote a healthier environment, intensify primary prevention and influence public policies in all sectors so as to address the root causes of environmental threats to health". : 61–65 The organization develops and promotes the use of evidence-based tools, norms and standards to support member states to inform health policy options. It oversees the implementation of the International Health Regulations , and publishes a series of medical classifications ; of these, three are over-reaching "reference classifications": the International Statistical Classification of Diseases (ICD), the International Classification of Functioning, Disability and Health (ICF) and the International Classification of Health Interventions (ICHI). Other international policy frameworks produced by WHO include the International Code of Marketing of Breast-milk Substitutes (adopted in 1981), Framework Convention on Tobacco Control (adopted in 2003) the Global Code of Practice on the International Recruitment of Health Personnel (adopted in 2010) as well as the WHO Model List of Essential Medicines and its pediatric counterpart . An international convention on pandemic prevention and preparedness is being actively considered. In terms of health services, WHO looks to improve "governance, financing, staffing and management" and the availability and quality of evidence and research to guide policy. It also strives to "ensure improved access, quality and use of medical products and technologies". : 72–83 WHO – working with donor agencies and national governments – can improve their reporting about use of research evidence. On Digital Health topics, WHO has existing Inter-Agency collaboration with the International Telecommunication Union (the UN Specialized Agency for ICT ), including the Be Health, Be Mobile initiate and the ITU-WHO Focus Group on Artificial Intelligence for Health.The WHO has developed several technical policy packages to support countries to improve health: ACTIVE (physical activity) HEARTS (cardiovascular diseases) MPOWER (tobacco control) REPLACE (trans fat) SAFER (alcohol) SHAKE (salt reduction)The remaining two of WHO's thirteen identified policy areas relate to the role of WHO itself: : 84–91 "to provide leadership, strengthen governance and foster partnership and collaboration with countries, the United Nations system, and other stakeholders in order to fulfil the mandate of WHO in advancing the global health agenda"; and "to develop and sustain WHO as a flexible, learning organization, enabling it to carry out its mandate more efficiently and effectively". The WHO along with the World Bank constitute the core team responsible for administering the International Health Partnership (IHP+). The IHP+ is a group of partner governments, development agencies, civil society, and others committed to improving the health of citizens in developing countries . Partners work together to put international principles for aid effectiveness and development co-operation into practice in the health sector. The organization relies on contributions from renowned scientists and professionals to inform its work, such as the WHO Expert Committee on Biological Standardization , the WHO Expert Committee on Leprosy , and the WHO Study Group on Interprofessional Education & Collaborative Practice . WHO runs the Alliance for Health Policy and Systems Research , targeted at improving health policy and systems . WHO also aims to improve access to health research and literature in developing countries such as through the HINARI network. WHO collaborates with The Global Fund to Fight AIDS, Tuberculosis and Malaria , UNITAID, and the United States President's Emergency Plan for AIDS Relief to spearhead and fund the development of HIV programs. WHO created the Civil Society Reference Group on HIV, which brings together other networks that are involved in policymaking and the dissemination of guidelines. WHO, a sector of the United Nations, partners with UNAIDS to contribute to the development of HIV responses in different areas of the world. WHO facilitates technical partnerships through the Technical Advisory Committee on HIV, which they created to develop WHO guidelines and policies. In 2014, WHO released the Global Atlas of Palliative Care at the End of Life in a joint publication with the Worldwide Hospice Palliative Care Alliance , an affiliated NGO working collaboratively with the WHO to promote palliative care in national and international health policy . The practice of empowering individuals to exert more control over and make improvements to their health is known as health education, as described by the WHO. It shifts away from an emphasis on personal behaviour and toward a variety of societal and environmental solutions. Each year, the organization marks World Health Day and other observances focusing on a specific health promotion topic. World Health Day falls on 7 April each year, timed to match the anniversary of WHO's founding. Recent themes have been vector-borne diseases (2014), healthy ageing (2012) and drug resistance (2011). The other official global public health campaigns marked by WHO are World Tuberculosis Day , World Immunization Week , World Malaria Day , World No Tobacco Day , World Blood Donor Day , World Hepatitis Day , and World AIDS Day . As part of the United Nations, the World Health Organization supports work towards the Millennium Development Goals . Of the eight Millennium Development Goals, three – reducing child mortality by two-thirds, to reduce maternal deaths by three-quarters, and to halt and begin to reduce the spread of HIV/AIDS – relate directly to the WHO's scope; the other five inter-relate and affect world health. The WHO along with the World Bank constitute the core team responsible for administering the International Health Partnership (IHP+). The IHP+ is a group of partner governments, development agencies, civil society, and others committed to improving the health of citizens in developing countries . Partners work together to put international principles for aid effectiveness and development co-operation into practice in the health sector. The organization relies on contributions from renowned scientists and professionals to inform its work, such as the WHO Expert Committee on Biological Standardization , the WHO Expert Committee on Leprosy , and the WHO Study Group on Interprofessional Education & Collaborative Practice . WHO runs the Alliance for Health Policy and Systems Research , targeted at improving health policy and systems . WHO also aims to improve access to health research and literature in developing countries such as through the HINARI network. WHO collaborates with The Global Fund to Fight AIDS, Tuberculosis and Malaria , UNITAID, and the United States President's Emergency Plan for AIDS Relief to spearhead and fund the development of HIV programs. WHO created the Civil Society Reference Group on HIV, which brings together other networks that are involved in policymaking and the dissemination of guidelines. WHO, a sector of the United Nations, partners with UNAIDS to contribute to the development of HIV responses in different areas of the world. WHO facilitates technical partnerships through the Technical Advisory Committee on HIV, which they created to develop WHO guidelines and policies. In 2014, WHO released the Global Atlas of Palliative Care at the End of Life in a joint publication with the Worldwide Hospice Palliative Care Alliance , an affiliated NGO working collaboratively with the WHO to promote palliative care in national and international health policy . The practice of empowering individuals to exert more control over and make improvements to their health is known as health education, as described by the WHO. It shifts away from an emphasis on personal behaviour and toward a variety of societal and environmental solutions. Each year, the organization marks World Health Day and other observances focusing on a specific health promotion topic. World Health Day falls on 7 April each year, timed to match the anniversary of WHO's founding. Recent themes have been vector-borne diseases (2014), healthy ageing (2012) and drug resistance (2011). The other official global public health campaigns marked by WHO are World Tuberculosis Day , World Immunization Week , World Malaria Day , World No Tobacco Day , World Blood Donor Day , World Hepatitis Day , and World AIDS Day . As part of the United Nations, the World Health Organization supports work towards the Millennium Development Goals . Of the eight Millennium Development Goals, three – reducing child mortality by two-thirds, to reduce maternal deaths by three-quarters, and to halt and begin to reduce the spread of HIV/AIDS – relate directly to the WHO's scope; the other five inter-relate and affect world health. The World Health Organization works to provide the needed health and well-being evidence through a variety of data collection platforms, including the World Health Survey covering almost 400,000 respondents from 70 countries, and the Study on Global Aging and Adult Health (SAGE) covering over 50,000 persons over 50 years old in 23 countries. The Country Health Intelligence Portal (CHIP), has also been developed to provide an access point to information about the health services that are available in different countries. The information gathered in this portal is used by the countries to set priorities for future strategies or plans, implement, monitor, and evaluate it. The WHO has published various tools for measuring and monitoring the capacity of national health systems and health workforces . The Global Health Observatory (GHO) has been the WHO's main portal which provides access to data and analyses for key health themes by monitoring health situations around the globe. The WHO Assessment Instrument for Mental Health Systems (WHO-AIMS), the WHO Quality of Life Instrument (WHOQOL), and the Service Availability and Readiness Assessment (SARA) provide guidance for data collection. Collaborative efforts between WHO and other agencies, such as through the Health Metrics Network , also aim to provide sufficient high-quality information to assist governmental decision making. WHO promotes the development of capacities in member states to use and produce research that addresses their national needs, including through the Evidence-Informed Policy Network (EVIPNet). The Pan American Health Organization (PAHO/AMRO) became the first region to develop and pass a policy on research for health approved in September 2009. On 10 December 2013, a new WHO database, known as MiNDbank, went online. The database was launched on Human Rights Day , and is part of WHO's QualityRights initiative, which aims to end human rights violations against people with mental health conditions. The new database presents a great deal of information about mental health, substance abuse, disability, human rights, and the different policies, strategies, laws, and service standards being implemented in different countries. It also contains important international documents and information. The database allows visitors to access the health information of WHO member states and other partners. Users can review policies, laws, and strategies and search for the best practices and success stories in the field of mental health. The WHO regularly publishes a World Health Report , its leading publication, including an expert assessment of a specific global health topic. Other publications of WHO include the Bulletin of the World Health Organization , the Eastern Mediterranean Health Journal (overseen by EMRO), the Human Resources for Health (published in collaboration with BioMed Central ), and the Pan American Journal of Public Health (overseen by PAHO/AMRO). In 2016, the World Health Organization drafted a global health sector strategy on HIV. In the draft, the World Health Organization outlines its commitment to ending the AIDS epidemic by 2030 with interim targets for the year 2020. To make achievements towards these targets, the draft lists actions that countries and the WHO can take, such as a commitment to universal health coverage, medical accessibility, prevention and eradication of disease, and efforts to educate the public. Some notable points made in the draft include tailoring resources to mobilized regions where the health system may be compromised due to natural disasters, etc. Among the points made, it seems clear that although the prevalence of HIV transmission is declining, there is still a need for resources, health education, and global efforts to end this epidemic. The WHO has a Framework Convention on Tobacco implementation database which is one of the few mechanisms to help enforce compliance with the FCTC. However, there have been reports of numerous discrepancies between it and national implementation reports on which it was built. As researchers Hoffman and Rizvi report "As of July 4, 2012, 361 (32·7%) of 1104 countries' responses were misreported: 33 (3·0%) were clear errors (e.g., database indicated 'yes' when report indicated 'no'), 270 (24·5%) were missing despite countries having submitted responses, and 58 (5·3%) were, in our opinion, misinterpreted by WHO staff". WHO has been moving toward acceptance and integration of traditional medicine and traditional Chinese medicine (TCM). In 2022, the new International Statistical Classification of Diseases and Related Health Problems , ICD-11, will attempt to enable classifications from traditional medicine to be integrated with classifications from evidence-based medicine . Though Chinese authorities have pushed for the change, this and other support of the WHO for traditional medicine has been criticized by the medical and scientific community, due to lack of evidence and the risk of endangering wildlife hunted for traditional remedies. A WHO spokesman said that the inclusion was "not an endorsement of the scientific validity of any Traditional Medicine practice or the efficacy of any Traditional Medicine intervention." The WHO sub-department, the International Agency for Research on Cancer (IARC), conducts and coordinates research into the causes of cancer . It also collects and publishes surveillance data regarding the occurrence of cancer worldwide. Its Monographs Programme identifies carcinogenic hazards and evaluates environmental causes of cancer in humans. The WHO sub-department, the International Agency for Research on Cancer (IARC), conducts and coordinates research into the causes of cancer . It also collects and publishes surveillance data regarding the occurrence of cancer worldwide. Its Monographs Programme identifies carcinogenic hazards and evaluates environmental causes of cancer in humans. The World Health Organization is a member of the United Nations Development Group . As of January 2021 [ update ] , the WHO has 194 member states: all member states of the United Nations except for Liechtenstein (192 countries), plus the Cook Islands and Niue . A state becomes a full member of WHO by ratifying the treaty known as the Constitution of the World Health Organization. As of January 2021, it also had two associate members, Puerto Rico and Tokelau . The WHO two-year budget for 2022–2023 is paid by its 194 members and 2 associate members. Several other countries have been granted observer status . Palestine is an observer as a "national liberation movement" recognized by the League of Arab States under United Nations Resolution 3118. The Sovereign Military Order of Malta (or Order of Malta ) also attends on an observer basis. The Holy See attends as an observer, and its participation as "non-Member State Observer" was formalized by an Assembly resolution in 2021. The government of Taiwan was allowed to participate under the designation " Chinese Taipei " as an observer from 2009 to 2016, but has not been invited again since. WHO member states appoint delegations to the World Health Assembly , the WHO's supreme decision-making body. All UN member states are eligible for WHO membership, and, according to the WHO website, "other countries may be admitted as members when their application has been approved by a simple majority vote of the World Health Assembly". The World Health Assembly is attended by delegations from all member states, and determines the policies of the organization. The executive board is composed of members technically qualified in health and gives effect to the decisions and policies of the World Health Assembly. In addition, the UN observer organizations International Committee of the Red Cross and International Federation of Red Cross and Red Crescent Societies have entered into "official relations" with WHO and are invited as observers. In the World Health Assembly , they are seated alongside the other NGOs. The Republic of China (ROC), which controlled mainland China from 1912 to 1949 and currently governs Taiwan since 1945 following World War II, was the founding member of WHO since its inception had represented "China" in the organization, but the representation was changed to the People's Republic of China (PRC), established in 1949 by the Chinese Communist Party (CCP), in 1971 that expelled the ROC from both WHO and the UN organs. Since that time, per the One-China policy , both the ROC and PRC lay claims of sovereignty to each other's territory. In May 2009, the Department of Health of the Republic of China was invited by the WHO to attend the 62nd World Health Assembly as an observer under the name " Chinese Taipei ". This was the ROC's first participation at WHO meetings since 1971, as a result of the improved cross-strait relations since Ma Ying-jeou became the president of the Republic of China a year before. Its participation with WHO ended due to diplomatic pressure from the PRC following the election in 2016 that brought the independence-minded Democratic Progressive Party back into power. Political pressure from the PRC has led to the ROC being barred from membership of the WHO and other UN-affiliated organizations, and in 2017 to 2020 the WHO refused to allow Taiwanese delegates to attend the WHO annual assembly . According to Taiwanese publication The News Lens , on multiple occasions Taiwanese journalists have been denied access to report on the assembly. In May 2018, the WHO denied access to its annual assembly by Taiwanese media, reportedly due to demands from the PRC. Later in May 172 members of the United States House of Representatives wrote to the director-general of the World Health Organization to argue for Taiwan's inclusion as an observer at the WHA. The United States, Japan, Germany, and Australia all support Taiwan's inclusion in WHO. Pressure to allow the ROC to participate in WHO increased as a result of the COVID-19 pandemic with Taiwan's exclusion from emergency meetings concerning the outbreak bringing a rare united front from Taiwan's diverse political parties. Taiwan's main opposition party, the Kuomintang (KMT, Chinese Nationalist Party), expressed their anger at being excluded arguing that disease respects neither politics nor geography. China once again dismissed concerns over Taiwanese inclusion with the foreign minister claiming that no-one cares more about the health and wellbeing of the Taiwanese people than central government of the PRC. During the outbreak Canadian Prime Minister Justin Trudeau voiced his support for Taiwan's participation in WHO, as did Japanese Prime Minister Shinzo Abe . In January 2020 the European Union , a WHO observer, backed Taiwan's participation in WHO meetings related to the coronavirus pandemic as well as their general participation. In a 2020 interview, Assistant Director-General Bruce Aylward appeared to dodge a question from RTHK reporter Yvonne Tong about Taiwan's response to the pandemic and inclusion in the WHO, blaming internet connection issues. When the video chat was restarted, he was asked another question about Taiwan. He responded by indicating that they had already discussed China and formally ended the interview. This incident led to accusations about the PRC's political influence over the international organization. Taiwan's effective response to the 2019–20 COVID-19 pandemic has bolstered its case for WHO membership. Taiwan's response to the outbreak has been praised by a number of experts. In early May 2020, New Zealand Foreign Minister Winston Peters expressed support for the ROC's bid to rejoin the WHO during a media conference. The New Zealand Government subsequently supporting Taiwan's bid to join the WHO, putting NZ alongside Australia and the United States who have taken similar positions. On 9 May, Congressmen Eliot Engel , the Democratic chairman of the United States House Committee on Foreign Affairs , Michael McCaul , the House Committee's ranking Republican member, Senator Jim Risch , the Republican chairman of the United States Senate Committee on Foreign Relations , and Senator Bob Menendez , the Senate Committee's ranking Democratic member, submitted a joint letter to nearly 60 "like-minded" countries including Canada, Thailand, Japan, Germany, the United Kingdom, Saudi Arabia, and Australia, urging them to support ROC's participation in the World Health Organization. In November 2020, the word "Taiwan" was blocked in comments on a livestream on the WHO's Facebook page. The World Health Assembly (WHA) is the legislative and supreme body of the WHO. Based in Geneva, it typically meets yearly in May. It appoints the director-general every five years and votes on matters of policy and finance of WHO, including the proposed budget. It also reviews reports of the executive board and decides whether there are areas of work requiring further examination. The Assembly elects 34 members, technically qualified in the field of health, to the executive board for three-year terms. The main functions of the board are to carry out the decisions and policies of the Assembly, to advise it, and to facilitate its work. As of June 2023, the chair of the executive board is Dr. Hanan Mohamed Al Kuwari of Qatar. The head of the organization is the director-general, elected by the World Health Assembly . The term lasts for five years, and directors-general are typically appointed in May, when the Assembly meets. The current director-general is Dr. Tedros Adhanom Ghebreyesus , who was appointed on 1 July 2017. Apart from regional, country, and liaison offices, the World Health Assembly has also established other institutions for promoting and carrying on research. The WHO employs 7,000 people in 149 countries and regions to carry out its principles. In support of the principle of a tobacco-free work environment, the WHO does not recruit cigarette smokers. The organization has previously instigated the Framework Convention on Tobacco Control in 2003. The WHO operates " Goodwill Ambassadors "; members of the arts, sports, or other fields of public life aimed at drawing attention to the WHO's initiatives and projects. There are currently five Goodwill Ambassadors ( Jet Li , Nancy Brinker , Peng Liyuan , Yohei Sasakawa and the Vienna Philharmonic Orchestra ) and a further ambassador associated with a partnership project ( Craig David ). On 21 October 2017, the director-general Tedros Adhanom Ghebreyesus appointed the then Zimbabwean president Robert Mugabe as a WHO Goodwill Ambassador to help promote the fight against non-communicable diseases. The appointment address praised Mugabe for his commitment to public health in Zimbabwe. The appointment attracted widespread condemnation and criticism in WHO member states and international organizations due to Robert Mugabe's poor record on human rights and presiding over a decline in Zimbabwe's public health. Due to the outcry, the following day the appointment was revoked. Since the beginning, the WHO has had the Medical Society of the World Health Organization . It has conducted lectures by noted researchers and published findings, recommendations. [ excessive citations ] The founder, Dr. S. William A. Gunn has been its president. In 1983, Murray Eden was awarded the WHO Medical Society medal, for his work as consultant on research and development for WHO's director-general. The WHO is financed by contributions from member states and outside donors. In 2020–21, the largest contributors were the Germany , Bill & Melinda Gates Foundation , United States , United Kingdom and European Commission . The WHO Executive Board formed a Working Group on Sustainable Financing in 2021, charged to rethink WHO's funding strategy and present recommendations. Its recommendations were adopted by the 2022 World Health Assembly, the key one being to raise compulsory member dues to a level equal to 50% of WHO's 2022-2023 base budget by the end of the 2020s. Assessed contributions are the dues the Member States pay depending on the states' wealth and population Voluntary contributions specified are funds for specific programme areas provided by the Member States or other partners Core voluntary contributions are funds for flexible uses provided by the Member States or other partners At the beginning of the 21st century, the WHO's work involved increasing collaboration with external bodies. As of 2002 [ update ] , a total of 473 nongovernmental organizations (NGO) had some form of partnership with WHO. There were 189 partnerships with international NGOs in formal "official relations" – the rest being considered informal in character. Partners include the Bill and Melinda Gates Foundation and the Rockefeller Foundation . As of 2012 [ update ] , the largest annual assessed contributions from member states came from the United States ($110 million), Japan ($58 million), Germany ($37 million), United Kingdom ($31 million) and France ($31 million). The combined 2012–2013 budget proposed a total expenditure of $3,959 million, of which $944 million (24%) will come from assessed contributions. This represented a significant fall in outlay compared to the previous 2009–2010 budget, adjusting to take account of previous underspends. Assessed contributions were kept the same. Voluntary contributions will account for $3,015 million (76%), of which $800 million is regarded as highly or moderately flexible funding, with the remainder tied to particular programmes or objectives. According to The Associated Press , the WHO routinely spends about $200 million a year on travel expenses, more than it spends to tackle mental health problems, HIV/AIDS , tuberculosis and malaria combined. In 2016, Margaret Chan , director-general of WHO from January 2007 to June 2017, stayed in a $1000-per-night hotel room while visiting West Africa. The biggest contributor used to be the United States, which gives over $400 million annually. U.S. contributions to the WHO are funded through the U.S. State Department's account for Contributions to International Organizations (CIO). In April 2020, U.S. President Donald Trump , with backing by members of his party, announced that his administration would halt funding to the WHO. Funds previously earmarked for the WHO were to be held for 60–90 days pending an investigation into the WHO's handling of the COVID-19 pandemic , particularly in respect to the organization's purported relationship with China. The announcement was immediately criticized by world leaders including António Guterres , the secretary general of the United Nations; Heiko Maas , the German foreign minister; and Moussa Faki Mahamat , African Union chairman. During the first two years of the pandemic, American funding of the WHO declined by a quarter, although it is expected to increase during 2022 and 2023. On 16 May 2020, the Trump Administration agreed to pay up to what China pays in assessed contributions, which is less than about one-tenth of its previous funding. Biennium 2018–2019 China paid in assessed contributions US$75,796K, in specified voluntary contributions US$10,184K, for a total US$85,980K. World Health Organization Prizes and Awards are given to recognize major achievements in public health. The candidates are nominated and recommended by each prize and award selection panel. The WHO Executive Board selects the winners, which are presented during the World Health Assembly. As of January 2021 [ update ] , the WHO has 194 member states: all member states of the United Nations except for Liechtenstein (192 countries), plus the Cook Islands and Niue . A state becomes a full member of WHO by ratifying the treaty known as the Constitution of the World Health Organization. As of January 2021, it also had two associate members, Puerto Rico and Tokelau . The WHO two-year budget for 2022–2023 is paid by its 194 members and 2 associate members. Several other countries have been granted observer status . Palestine is an observer as a "national liberation movement" recognized by the League of Arab States under United Nations Resolution 3118. The Sovereign Military Order of Malta (or Order of Malta ) also attends on an observer basis. The Holy See attends as an observer, and its participation as "non-Member State Observer" was formalized by an Assembly resolution in 2021. The government of Taiwan was allowed to participate under the designation " Chinese Taipei " as an observer from 2009 to 2016, but has not been invited again since. WHO member states appoint delegations to the World Health Assembly , the WHO's supreme decision-making body. All UN member states are eligible for WHO membership, and, according to the WHO website, "other countries may be admitted as members when their application has been approved by a simple majority vote of the World Health Assembly". The World Health Assembly is attended by delegations from all member states, and determines the policies of the organization. The executive board is composed of members technically qualified in health and gives effect to the decisions and policies of the World Health Assembly. In addition, the UN observer organizations International Committee of the Red Cross and International Federation of Red Cross and Red Crescent Societies have entered into "official relations" with WHO and are invited as observers. In the World Health Assembly , they are seated alongside the other NGOs. The Republic of China (ROC), which controlled mainland China from 1912 to 1949 and currently governs Taiwan since 1945 following World War II, was the founding member of WHO since its inception had represented "China" in the organization, but the representation was changed to the People's Republic of China (PRC), established in 1949 by the Chinese Communist Party (CCP), in 1971 that expelled the ROC from both WHO and the UN organs. Since that time, per the One-China policy , both the ROC and PRC lay claims of sovereignty to each other's territory. In May 2009, the Department of Health of the Republic of China was invited by the WHO to attend the 62nd World Health Assembly as an observer under the name " Chinese Taipei ". This was the ROC's first participation at WHO meetings since 1971, as a result of the improved cross-strait relations since Ma Ying-jeou became the president of the Republic of China a year before. Its participation with WHO ended due to diplomatic pressure from the PRC following the election in 2016 that brought the independence-minded Democratic Progressive Party back into power. Political pressure from the PRC has led to the ROC being barred from membership of the WHO and other UN-affiliated organizations, and in 2017 to 2020 the WHO refused to allow Taiwanese delegates to attend the WHO annual assembly . According to Taiwanese publication The News Lens , on multiple occasions Taiwanese journalists have been denied access to report on the assembly. In May 2018, the WHO denied access to its annual assembly by Taiwanese media, reportedly due to demands from the PRC. Later in May 172 members of the United States House of Representatives wrote to the director-general of the World Health Organization to argue for Taiwan's inclusion as an observer at the WHA. The United States, Japan, Germany, and Australia all support Taiwan's inclusion in WHO. Pressure to allow the ROC to participate in WHO increased as a result of the COVID-19 pandemic with Taiwan's exclusion from emergency meetings concerning the outbreak bringing a rare united front from Taiwan's diverse political parties. Taiwan's main opposition party, the Kuomintang (KMT, Chinese Nationalist Party), expressed their anger at being excluded arguing that disease respects neither politics nor geography. China once again dismissed concerns over Taiwanese inclusion with the foreign minister claiming that no-one cares more about the health and wellbeing of the Taiwanese people than central government of the PRC. During the outbreak Canadian Prime Minister Justin Trudeau voiced his support for Taiwan's participation in WHO, as did Japanese Prime Minister Shinzo Abe . In January 2020 the European Union , a WHO observer, backed Taiwan's participation in WHO meetings related to the coronavirus pandemic as well as their general participation. In a 2020 interview, Assistant Director-General Bruce Aylward appeared to dodge a question from RTHK reporter Yvonne Tong about Taiwan's response to the pandemic and inclusion in the WHO, blaming internet connection issues. When the video chat was restarted, he was asked another question about Taiwan. He responded by indicating that they had already discussed China and formally ended the interview. This incident led to accusations about the PRC's political influence over the international organization. Taiwan's effective response to the 2019–20 COVID-19 pandemic has bolstered its case for WHO membership. Taiwan's response to the outbreak has been praised by a number of experts. In early May 2020, New Zealand Foreign Minister Winston Peters expressed support for the ROC's bid to rejoin the WHO during a media conference. The New Zealand Government subsequently supporting Taiwan's bid to join the WHO, putting NZ alongside Australia and the United States who have taken similar positions. On 9 May, Congressmen Eliot Engel , the Democratic chairman of the United States House Committee on Foreign Affairs , Michael McCaul , the House Committee's ranking Republican member, Senator Jim Risch , the Republican chairman of the United States Senate Committee on Foreign Relations , and Senator Bob Menendez , the Senate Committee's ranking Democratic member, submitted a joint letter to nearly 60 "like-minded" countries including Canada, Thailand, Japan, Germany, the United Kingdom, Saudi Arabia, and Australia, urging them to support ROC's participation in the World Health Organization. In November 2020, the word "Taiwan" was blocked in comments on a livestream on the WHO's Facebook page. The Republic of China (ROC), which controlled mainland China from 1912 to 1949 and currently governs Taiwan since 1945 following World War II, was the founding member of WHO since its inception had represented "China" in the organization, but the representation was changed to the People's Republic of China (PRC), established in 1949 by the Chinese Communist Party (CCP), in 1971 that expelled the ROC from both WHO and the UN organs. Since that time, per the One-China policy , both the ROC and PRC lay claims of sovereignty to each other's territory. In May 2009, the Department of Health of the Republic of China was invited by the WHO to attend the 62nd World Health Assembly as an observer under the name " Chinese Taipei ". This was the ROC's first participation at WHO meetings since 1971, as a result of the improved cross-strait relations since Ma Ying-jeou became the president of the Republic of China a year before. Its participation with WHO ended due to diplomatic pressure from the PRC following the election in 2016 that brought the independence-minded Democratic Progressive Party back into power. Political pressure from the PRC has led to the ROC being barred from membership of the WHO and other UN-affiliated organizations, and in 2017 to 2020 the WHO refused to allow Taiwanese delegates to attend the WHO annual assembly . According to Taiwanese publication The News Lens , on multiple occasions Taiwanese journalists have been denied access to report on the assembly. In May 2018, the WHO denied access to its annual assembly by Taiwanese media, reportedly due to demands from the PRC. Later in May 172 members of the United States House of Representatives wrote to the director-general of the World Health Organization to argue for Taiwan's inclusion as an observer at the WHA. The United States, Japan, Germany, and Australia all support Taiwan's inclusion in WHO. Pressure to allow the ROC to participate in WHO increased as a result of the COVID-19 pandemic with Taiwan's exclusion from emergency meetings concerning the outbreak bringing a rare united front from Taiwan's diverse political parties. Taiwan's main opposition party, the Kuomintang (KMT, Chinese Nationalist Party), expressed their anger at being excluded arguing that disease respects neither politics nor geography. China once again dismissed concerns over Taiwanese inclusion with the foreign minister claiming that no-one cares more about the health and wellbeing of the Taiwanese people than central government of the PRC. During the outbreak Canadian Prime Minister Justin Trudeau voiced his support for Taiwan's participation in WHO, as did Japanese Prime Minister Shinzo Abe . In January 2020 the European Union , a WHO observer, backed Taiwan's participation in WHO meetings related to the coronavirus pandemic as well as their general participation. In a 2020 interview, Assistant Director-General Bruce Aylward appeared to dodge a question from RTHK reporter Yvonne Tong about Taiwan's response to the pandemic and inclusion in the WHO, blaming internet connection issues. When the video chat was restarted, he was asked another question about Taiwan. He responded by indicating that they had already discussed China and formally ended the interview. This incident led to accusations about the PRC's political influence over the international organization. Taiwan's effective response to the 2019–20 COVID-19 pandemic has bolstered its case for WHO membership. Taiwan's response to the outbreak has been praised by a number of experts. In early May 2020, New Zealand Foreign Minister Winston Peters expressed support for the ROC's bid to rejoin the WHO during a media conference. The New Zealand Government subsequently supporting Taiwan's bid to join the WHO, putting NZ alongside Australia and the United States who have taken similar positions. On 9 May, Congressmen Eliot Engel , the Democratic chairman of the United States House Committee on Foreign Affairs , Michael McCaul , the House Committee's ranking Republican member, Senator Jim Risch , the Republican chairman of the United States Senate Committee on Foreign Relations , and Senator Bob Menendez , the Senate Committee's ranking Democratic member, submitted a joint letter to nearly 60 "like-minded" countries including Canada, Thailand, Japan, Germany, the United Kingdom, Saudi Arabia, and Australia, urging them to support ROC's participation in the World Health Organization. In November 2020, the word "Taiwan" was blocked in comments on a livestream on the WHO's Facebook page. The World Health Assembly (WHA) is the legislative and supreme body of the WHO. Based in Geneva, it typically meets yearly in May. It appoints the director-general every five years and votes on matters of policy and finance of WHO, including the proposed budget. It also reviews reports of the executive board and decides whether there are areas of work requiring further examination. The Assembly elects 34 members, technically qualified in the field of health, to the executive board for three-year terms. The main functions of the board are to carry out the decisions and policies of the Assembly, to advise it, and to facilitate its work. As of June 2023, the chair of the executive board is Dr. Hanan Mohamed Al Kuwari of Qatar. The head of the organization is the director-general, elected by the World Health Assembly . The term lasts for five years, and directors-general are typically appointed in May, when the Assembly meets. The current director-general is Dr. Tedros Adhanom Ghebreyesus , who was appointed on 1 July 2017. Apart from regional, country, and liaison offices, the World Health Assembly has also established other institutions for promoting and carrying on research. The WHO employs 7,000 people in 149 countries and regions to carry out its principles. In support of the principle of a tobacco-free work environment, the WHO does not recruit cigarette smokers. The organization has previously instigated the Framework Convention on Tobacco Control in 2003. The WHO operates " Goodwill Ambassadors "; members of the arts, sports, or other fields of public life aimed at drawing attention to the WHO's initiatives and projects. There are currently five Goodwill Ambassadors ( Jet Li , Nancy Brinker , Peng Liyuan , Yohei Sasakawa and the Vienna Philharmonic Orchestra ) and a further ambassador associated with a partnership project ( Craig David ). On 21 October 2017, the director-general Tedros Adhanom Ghebreyesus appointed the then Zimbabwean president Robert Mugabe as a WHO Goodwill Ambassador to help promote the fight against non-communicable diseases. The appointment address praised Mugabe for his commitment to public health in Zimbabwe. The appointment attracted widespread condemnation and criticism in WHO member states and international organizations due to Robert Mugabe's poor record on human rights and presiding over a decline in Zimbabwe's public health. Due to the outcry, the following day the appointment was revoked. Since the beginning, the WHO has had the Medical Society of the World Health Organization . It has conducted lectures by noted researchers and published findings, recommendations. [ excessive citations ] The founder, Dr. S. William A. Gunn has been its president. In 1983, Murray Eden was awarded the WHO Medical Society medal, for his work as consultant on research and development for WHO's director-general. The WHO is financed by contributions from member states and outside donors. In 2020–21, the largest contributors were the Germany , Bill & Melinda Gates Foundation , United States , United Kingdom and European Commission . The WHO Executive Board formed a Working Group on Sustainable Financing in 2021, charged to rethink WHO's funding strategy and present recommendations. Its recommendations were adopted by the 2022 World Health Assembly, the key one being to raise compulsory member dues to a level equal to 50% of WHO's 2022-2023 base budget by the end of the 2020s. Assessed contributions are the dues the Member States pay depending on the states' wealth and population Voluntary contributions specified are funds for specific programme areas provided by the Member States or other partners Core voluntary contributions are funds for flexible uses provided by the Member States or other partners At the beginning of the 21st century, the WHO's work involved increasing collaboration with external bodies. As of 2002 [ update ] , a total of 473 nongovernmental organizations (NGO) had some form of partnership with WHO. There were 189 partnerships with international NGOs in formal "official relations" – the rest being considered informal in character. Partners include the Bill and Melinda Gates Foundation and the Rockefeller Foundation . As of 2012 [ update ] , the largest annual assessed contributions from member states came from the United States ($110 million), Japan ($58 million), Germany ($37 million), United Kingdom ($31 million) and France ($31 million). The combined 2012–2013 budget proposed a total expenditure of $3,959 million, of which $944 million (24%) will come from assessed contributions. This represented a significant fall in outlay compared to the previous 2009–2010 budget, adjusting to take account of previous underspends. Assessed contributions were kept the same. Voluntary contributions will account for $3,015 million (76%), of which $800 million is regarded as highly or moderately flexible funding, with the remainder tied to particular programmes or objectives. According to The Associated Press , the WHO routinely spends about $200 million a year on travel expenses, more than it spends to tackle mental health problems, HIV/AIDS , tuberculosis and malaria combined. In 2016, Margaret Chan , director-general of WHO from January 2007 to June 2017, stayed in a $1000-per-night hotel room while visiting West Africa. The biggest contributor used to be the United States, which gives over $400 million annually. U.S. contributions to the WHO are funded through the U.S. State Department's account for Contributions to International Organizations (CIO). In April 2020, U.S. President Donald Trump , with backing by members of his party, announced that his administration would halt funding to the WHO. Funds previously earmarked for the WHO were to be held for 60–90 days pending an investigation into the WHO's handling of the COVID-19 pandemic , particularly in respect to the organization's purported relationship with China. The announcement was immediately criticized by world leaders including António Guterres , the secretary general of the United Nations; Heiko Maas , the German foreign minister; and Moussa Faki Mahamat , African Union chairman. During the first two years of the pandemic, American funding of the WHO declined by a quarter, although it is expected to increase during 2022 and 2023. On 16 May 2020, the Trump Administration agreed to pay up to what China pays in assessed contributions, which is less than about one-tenth of its previous funding. Biennium 2018–2019 China paid in assessed contributions US$75,796K, in specified voluntary contributions US$10,184K, for a total US$85,980K. At the beginning of the 21st century, the WHO's work involved increasing collaboration with external bodies. As of 2002 [ update ] , a total of 473 nongovernmental organizations (NGO) had some form of partnership with WHO. There were 189 partnerships with international NGOs in formal "official relations" – the rest being considered informal in character. Partners include the Bill and Melinda Gates Foundation and the Rockefeller Foundation . As of 2012 [ update ] , the largest annual assessed contributions from member states came from the United States ($110 million), Japan ($58 million), Germany ($37 million), United Kingdom ($31 million) and France ($31 million). The combined 2012–2013 budget proposed a total expenditure of $3,959 million, of which $944 million (24%) will come from assessed contributions. This represented a significant fall in outlay compared to the previous 2009–2010 budget, adjusting to take account of previous underspends. Assessed contributions were kept the same. Voluntary contributions will account for $3,015 million (76%), of which $800 million is regarded as highly or moderately flexible funding, with the remainder tied to particular programmes or objectives. According to The Associated Press , the WHO routinely spends about $200 million a year on travel expenses, more than it spends to tackle mental health problems, HIV/AIDS , tuberculosis and malaria combined. In 2016, Margaret Chan , director-general of WHO from January 2007 to June 2017, stayed in a $1000-per-night hotel room while visiting West Africa. The biggest contributor used to be the United States, which gives over $400 million annually. U.S. contributions to the WHO are funded through the U.S. State Department's account for Contributions to International Organizations (CIO). In April 2020, U.S. President Donald Trump , with backing by members of his party, announced that his administration would halt funding to the WHO. Funds previously earmarked for the WHO were to be held for 60–90 days pending an investigation into the WHO's handling of the COVID-19 pandemic , particularly in respect to the organization's purported relationship with China. The announcement was immediately criticized by world leaders including António Guterres , the secretary general of the United Nations; Heiko Maas , the German foreign minister; and Moussa Faki Mahamat , African Union chairman. During the first two years of the pandemic, American funding of the WHO declined by a quarter, although it is expected to increase during 2022 and 2023. On 16 May 2020, the Trump Administration agreed to pay up to what China pays in assessed contributions, which is less than about one-tenth of its previous funding. Biennium 2018–2019 China paid in assessed contributions US$75,796K, in specified voluntary contributions US$10,184K, for a total US$85,980K. World Health Organization Prizes and Awards are given to recognize major achievements in public health. The candidates are nominated and recommended by each prize and award selection panel. The WHO Executive Board selects the winners, which are presented during the World Health Assembly. The seat of the organization is in Geneva , Switzerland. It was designed by Swiss architect Jean Tschumi and inaugurated in 1966. In 2017, the organization launched an international competition to redesign and extend its headquarters. The World Health Organization operates 150 country offices in six different regions. It also operates several liaison offices, including those with the European Union , United Nations and a single office covering the World Bank and International Monetary Fund . It also operates the International Agency for Research on Cancer in Lyon , France, and the WHO Centre for Health Development in Kobe , Japan. Additional offices include those in Pristina ; the West Bank and Gaza ; the US-Mexico Border Field Office in El Paso ; the Office of the Caribbean Program Coordination in Barbados; and the Northern Micronesia office. There will generally be one WHO country office in the capital, occasionally accompanied by satellite-offices in the provinces or sub-regions of the country in question. The country office is headed by a WHO Representative (WR). As of 2010 [ update ] , the only WHO Representative outside Europe to be a national of that country was for the Libyan Arab Jamahiriya ("Libya"); all other staff was international. WHO Representatives in the Region termed the Americas are referred to as PAHO/WHO Representatives. In Europe, WHO Representatives also serve as head of the country office, and are nationals except for Serbia; there are also heads of the country office in Albania, the Russian Federation, Tajikistan, Turkey, and Uzbekistan. The WR is a member of the UN system country team which is coordinated by the UN System Resident Coordinator . The country office consists of the WR, and several health and other experts, both foreign and local, as well as the necessary support staff. The main functions of WHO country offices include being the primary adviser of that country's government in matters of health and pharmaceutical policies. The regional divisions of WHO were created between 1949 and 1952, following the model of the pre-existing Pan American Health Organization , and are based on article 44 of the WHO's constitution, which allowed the WHO to "establish a [single] regional organization to meet the special needs of [each defined] area". Many decisions are made at the regional level, including important discussions over WHO's budget, and in deciding the members of the next assembly, which are designated by the regions. Each region has a regional committee, which generally meets once a year, normally in the autumn. Representatives attend from each member or associative member in each region, including those states that are not full members. For example, Palestine attends meetings of the Eastern Mediterranean Regional Office . Each region also has a regional office. Each regional office is headed by a director, who is elected by the Regional Committee. The board must approve such appointments, although as of 2004, it had never over-ruled the preference of a regional committee. The exact role of the board in the process has been a subject of debate, but the practical effect has always been small. Since 1999, regional directors serve for a once-renewable five-year term, and typically take their position on 1 February. Each regional committee of the WHO consists of all the Health Department heads, in all the governments of the countries that constitute the Region. Aside from electing the regional director, the regional committee is also in charge of setting the guidelines for the implementation, within the region, of the health and other policies adopted by the World Health Assembly . The regional committee also serves as a progress review board for the actions of WHO within the Region. [ citation needed ] The regional director is effectively the head of WHO for his or her region. The RD manages and/or supervises a staff of health and other experts at the regional offices and in specialized centres. The RD is also the direct supervising authority – concomitantly with the WHO Director-General – of all the heads of WHO country offices, known as WHO Representatives, within the region. [ citation needed ] The strong position of the regional offices has been criticized in WHO history for undermining its effectiveness and led to unsuccessful attempts to integrate them more strongly within 'One WHO'. Disease specific programmes such as the smallpox eradication programme or the 1980s Global Programme on AIDS were set up with more direct, vertical structures that bypassed the regional offices.The World Health Organization operates 150 country offices in six different regions. It also operates several liaison offices, including those with the European Union , United Nations and a single office covering the World Bank and International Monetary Fund . It also operates the International Agency for Research on Cancer in Lyon , France, and the WHO Centre for Health Development in Kobe , Japan. Additional offices include those in Pristina ; the West Bank and Gaza ; the US-Mexico Border Field Office in El Paso ; the Office of the Caribbean Program Coordination in Barbados; and the Northern Micronesia office. There will generally be one WHO country office in the capital, occasionally accompanied by satellite-offices in the provinces or sub-regions of the country in question. The country office is headed by a WHO Representative (WR). As of 2010 [ update ] , the only WHO Representative outside Europe to be a national of that country was for the Libyan Arab Jamahiriya ("Libya"); all other staff was international. WHO Representatives in the Region termed the Americas are referred to as PAHO/WHO Representatives. In Europe, WHO Representatives also serve as head of the country office, and are nationals except for Serbia; there are also heads of the country office in Albania, the Russian Federation, Tajikistan, Turkey, and Uzbekistan. The WR is a member of the UN system country team which is coordinated by the UN System Resident Coordinator . The country office consists of the WR, and several health and other experts, both foreign and local, as well as the necessary support staff. The main functions of WHO country offices include being the primary adviser of that country's government in matters of health and pharmaceutical policies. The regional divisions of WHO were created between 1949 and 1952, following the model of the pre-existing Pan American Health Organization , and are based on article 44 of the WHO's constitution, which allowed the WHO to "establish a [single] regional organization to meet the special needs of [each defined] area". Many decisions are made at the regional level, including important discussions over WHO's budget, and in deciding the members of the next assembly, which are designated by the regions. Each region has a regional committee, which generally meets once a year, normally in the autumn. Representatives attend from each member or associative member in each region, including those states that are not full members. For example, Palestine attends meetings of the Eastern Mediterranean Regional Office . Each region also has a regional office. Each regional office is headed by a director, who is elected by the Regional Committee. The board must approve such appointments, although as of 2004, it had never over-ruled the preference of a regional committee. The exact role of the board in the process has been a subject of debate, but the practical effect has always been small. Since 1999, regional directors serve for a once-renewable five-year term, and typically take their position on 1 February. Each regional committee of the WHO consists of all the Health Department heads, in all the governments of the countries that constitute the Region. Aside from electing the regional director, the regional committee is also in charge of setting the guidelines for the implementation, within the region, of the health and other policies adopted by the World Health Assembly . The regional committee also serves as a progress review board for the actions of WHO within the Region. [ citation needed ] The regional director is effectively the head of WHO for his or her region. The RD manages and/or supervises a staff of health and other experts at the regional offices and in specialized centres. The RD is also the direct supervising authority – concomitantly with the WHO Director-General – of all the heads of WHO country offices, known as WHO Representatives, within the region. [ citation needed ] The strong position of the regional offices has been criticized in WHO history for undermining its effectiveness and led to unsuccessful attempts to integrate them more strongly within 'One WHO'. Disease specific programmes such as the smallpox eradication programme or the 1980s Global Programme on AIDS were set up with more direct, vertical structures that bypassed the regional offices.

Wiki

Ebola

https://api.wikimedia.org/core/v1/wikipedia/en/page/Ebola_virus_epidemic_in_Guinea/html

Ebola virus epidemic in Guinea

An epidemic of Ebola virus disease in Guinea from 2013 to 2016 represents the first ever outbreak of Ebola in a West African country . Previous outbreaks have been confined to several countries in Sub-Saharan Africa . The epidemic, which began with the death of a two-year-old boy, was part of a larger Ebola virus epidemic in West Africa which spread through Guinea and the neighboring countries of Liberia and Sierra Leone , with minor outbreaks occurring in Senegal , Nigeria , and Mali . In December 2015, Guinea was declared free of Ebola transmission by the U.N. World Health Organization, however further cases continued to be reported from March 2016. The country was again declared as Ebola-free in June 2016. Researchers from the Robert Koch Institute believe that the index case was a one or two-year-old boy who lived in the remote village of Meliandou , Guéckédou located in the Nzérékoré Region of Guinea . Researchers believe that the boy was said to have contracted the virus while he was playing near a tree that was a roosting place for Angolan free-tailed bats infected with the virus. Dr. Fabian Leendertz, an epidemiologist who was part of the investigative team, said Ebola virus is transmitted to humans either through contact with larger wildlife or by direct contact with bats. The boy, later identified as Emile Ouamouno, fell ill on 2 December 2013 and died four days later. The boy's sister fell ill next, followed by his mother and grandmother. It is believed the Ebola virus later spread to the villages of Dandou Pombo and Dawa , both in Guéckédou, by the midwife who attended the boy. From Dawa village the virus spread to Guéckédou Baladou District and Guéckédou Farako District , and on to Macenta and Kissidougou . Although Ebola represents a major public health issue in sub-Saharan Africa , no cases had ever been reported in West Africa and the early cases were diagnosed as other diseases more common to the area such as Lassa fever , another hemorrhagic fever similar to Ebola. Thus, it was not until March 2014 that the outbreak was recognized as Ebola . The Ministry of Health of Guinea notified the World Health Organization (WHO), and on 23 March the WHO announced an outbreak of Ebola virus disease in Guinea with a total of 49 cases as of that date. By late May, the outbreak had spread to Conakry , Guinea's capital, a city of about two million inhabitants. In August, Guinea's President Alpha Conde declared a national health emergency due to the outbreak. He stated efforts to control the spread of the Ebola virus would include forbidding Ebola patients from leaving their homes, border control, travel restrictions, and hospitalization for individuals suspected to be infected until cleared by laboratory results. He also banned the transporting of the dead between towns. Good disease tracing was important to prevent the outbreak from spreading. Previous Ebola outbreaks had occurred in remote areas making containment easier; the West African outbreak struck in an area that lies at the centre of both a highly-mobile and densely populated region which made tracking more difficult: "This time, the virus is traveling effortlessly across borders by plane, car and foot, shifting from forests to cities and springing up in clusters far from any previously known infections. Border closures, flight bans and mass quarantines have been ineffective." Peter Piot , who co-discovered Ebola, said Ebola "isn't striking in a 'linear fashion' this time. It's hopping around, especially in Liberia, Guinea and Sierra Leone". Containment was also difficult due to fear of healthcare workers. Infected people and those that they were in contact with evaded surveillance, moving at will and hiding their illnesses while they infected others in turn. Entire villages, stricken by fear, closed themselves off, giving the disease an opportunity to strike in another area. It was reported that in some areas it was believed that health workers were purposely spreading the disease to the people, while others believed that the disease did not exist. Riots broke out in the regional capital, Nzérékoré, when rumors were spread that people were being contaminated when health workers were spraying a market area to decontaminate it. In May, the number of Ebola cases appeared to be decreasing and Médecins Sans Frontières (MSF) closed a treatment facility in the Macenta region because the outbreak of Ebola there appeared to have been resolved. At the time it was thought that the new cases were caused by people returning from Liberia or from Sierra Leone; however it was later suggested that villagers had become fearful and were hiding cases rather than reporting them. Seeing workers wearing the required protection outfits worn by health workers and taking those suspected of having Ebola or of being contacts to the treatment center (perhaps never to be seen again), refusing the usual burial rituals when a patient died, and other actions taken by the unfamiliar individuals that had come to their remote areas, had led to rumors of organ harvesting and government and tribal plots. According to a September news report, "Many Guineans say local and foreign healthcare workers are part of a conspiracy which either deliberately introduced the outbreak, or invented it as a means of luring Africans to clinics to harvest their blood and organs." As described in another news article, "The health workers don't look like any people you've ever seen. They perform stiffly and slowly, and then they disappear into the tent where your mother or brother may be, and everything that happens inside is left to your imagination. Villagers began to whisper to one another— They're harvesting our organs; they're taking our limbs ". Moreover, due to fear, many people were avoiding hospital treatment for any ailment and were self-treating with over the counter drugs from a pharmacy. On 18 September, eight members of a health care team were murdered by local villagers in the town of Womey near Nzérékoré . The team consisted of Guinean health and government officials accompanied by journalists, who had been distributing Ebola information and doing disinfection work. They were attacked with machetes and clubs, and their bodies were found in a septic tank. The dead included three journalists and four volunteers. In August, Guinea's President Alpha Conde declared a national health emergency due to the outbreak. He stated efforts to control the spread of the Ebola virus would include forbidding Ebola patients from leaving their homes, border control, travel restrictions, and hospitalization for individuals suspected to be infected until cleared by laboratory results. He also banned the transporting of the dead between towns. Good disease tracing was important to prevent the outbreak from spreading. Previous Ebola outbreaks had occurred in remote areas making containment easier; the West African outbreak struck in an area that lies at the centre of both a highly-mobile and densely populated region which made tracking more difficult: "This time, the virus is traveling effortlessly across borders by plane, car and foot, shifting from forests to cities and springing up in clusters far from any previously known infections. Border closures, flight bans and mass quarantines have been ineffective." Peter Piot , who co-discovered Ebola, said Ebola "isn't striking in a 'linear fashion' this time. It's hopping around, especially in Liberia, Guinea and Sierra Leone". Containment was also difficult due to fear of healthcare workers. Infected people and those that they were in contact with evaded surveillance, moving at will and hiding their illnesses while they infected others in turn. Entire villages, stricken by fear, closed themselves off, giving the disease an opportunity to strike in another area. It was reported that in some areas it was believed that health workers were purposely spreading the disease to the people, while others believed that the disease did not exist. Riots broke out in the regional capital, Nzérékoré, when rumors were spread that people were being contaminated when health workers were spraying a market area to decontaminate it. In May, the number of Ebola cases appeared to be decreasing and Médecins Sans Frontières (MSF) closed a treatment facility in the Macenta region because the outbreak of Ebola there appeared to have been resolved. At the time it was thought that the new cases were caused by people returning from Liberia or from Sierra Leone; however it was later suggested that villagers had become fearful and were hiding cases rather than reporting them. Seeing workers wearing the required protection outfits worn by health workers and taking those suspected of having Ebola or of being contacts to the treatment center (perhaps never to be seen again), refusing the usual burial rituals when a patient died, and other actions taken by the unfamiliar individuals that had come to their remote areas, had led to rumors of organ harvesting and government and tribal plots. According to a September news report, "Many Guineans say local and foreign healthcare workers are part of a conspiracy which either deliberately introduced the outbreak, or invented it as a means of luring Africans to clinics to harvest their blood and organs." As described in another news article, "The health workers don't look like any people you've ever seen. They perform stiffly and slowly, and then they disappear into the tent where your mother or brother may be, and everything that happens inside is left to your imagination. Villagers began to whisper to one another— They're harvesting our organs; they're taking our limbs ". Moreover, due to fear, many people were avoiding hospital treatment for any ailment and were self-treating with over the counter drugs from a pharmacy. On 18 September, eight members of a health care team were murdered by local villagers in the town of Womey near Nzérékoré . The team consisted of Guinean health and government officials accompanied by journalists, who had been distributing Ebola information and doing disinfection work. They were attacked with machetes and clubs, and their bodies were found in a septic tank. The dead included three journalists and four volunteers. The governor of Conakry , Soriba Sorel Camara, prohibited all cultural events for the holiday of Tabaski in a decree of 2 October 2014. In the WHO Situation Report of 8 October, it was reported, that the transmission of Ebola was persistently high with approximately 100 new confirmed cases in the first week of October. The first cases were reported in the district of Lola. Médecins Sans Frontières reported a massive spike in the number of new cases in the capital city of Conakry. One facility admitted 22 patients in a single day (6 October), 18 of them coming from Coyah region , 50 kilometres (31 miles) east of Conakry. On 19 October, Guinea reported two new districts with Ebola cases. The Kankan district, on the border with the Côte d'Ivoire and a major trade route to Mali , confirmed one case. Kankan also borders the district of Kerouane in this country, one of the areas with the most intense virus transmissions. The Faranah district to the north of the border area of Koinadugu in Sierra Leone also reported a confirmed case. Koinadugu was one of the last Ebola-free regions in that country. According to a WHO report, this new development highlights the need for increased surveillance of cross border traffic in an effort to contain the disease to the three most affected countries. On 23 October, Saccoba Keita, the head of Guinea's Ebola mission, announced the government has started compensating the families of health care workers who died after contracting the virus. At that time, 42 health care workers had died, including doctors, nurses, drivers, and porters. The compensation totals $10,000 (£6,200) and is to be paid as a lump sum. In mid-November, the WHO reported that while intense transmission persists and cases and deaths continue to be under-reported, there is some evidence that case incidence is no longer increasing nationally in Guinea. They report that case numbers in some districts have been fluctuating, but they remain consistently high. New case numbers have been declining in the outbreak's point of origin, Gueckedou, but transmission continues to be high in Macenta. Of a total of 34 districts in Guinea, 10 remain unaffected by Ebola, contrasting with Liberia and Sierra Leone, where every district has been affected. On 20 November, the local Red Cross in Kankan Prefecture sent blood samples via a courier when the taxi he was traveling in was stopped by robbers. The bandits made off with the cooler bag containing the blood samples. The Guinea authorities made a public appeal for the return of the blood samples. The robbery occurred near the town of Kissidougou. On 14 December the WHO stated that 17 districts reported new confirmed or suspected cases in this week. Guinea reported 2,416 cases with 1,525 deaths on this date. Only 10 out of the 34 districts have not reported cases. Conakry reported 18 new cases in this week. The northern district of Siguiri is of particular concern, as it borders Mali and reported 4 new probable cases. The country was declared free of Ebola transmission on 29 December 2015, 42 days after the last Ebola patient tested negative for a second time. Guinea was subsequently in a 90-day period of heightened surveillance according to the U.N. World Health Organization which also offered assistance - with funding from the agency's donors.The governor of Conakry , Soriba Sorel Camara, prohibited all cultural events for the holiday of Tabaski in a decree of 2 October 2014. In the WHO Situation Report of 8 October, it was reported, that the transmission of Ebola was persistently high with approximately 100 new confirmed cases in the first week of October. The first cases were reported in the district of Lola. Médecins Sans Frontières reported a massive spike in the number of new cases in the capital city of Conakry. One facility admitted 22 patients in a single day (6 October), 18 of them coming from Coyah region , 50 kilometres (31 miles) east of Conakry. On 19 October, Guinea reported two new districts with Ebola cases. The Kankan district, on the border with the Côte d'Ivoire and a major trade route to Mali , confirmed one case. Kankan also borders the district of Kerouane in this country, one of the areas with the most intense virus transmissions. The Faranah district to the north of the border area of Koinadugu in Sierra Leone also reported a confirmed case. Koinadugu was one of the last Ebola-free regions in that country. According to a WHO report, this new development highlights the need for increased surveillance of cross border traffic in an effort to contain the disease to the three most affected countries. On 23 October, Saccoba Keita, the head of Guinea's Ebola mission, announced the government has started compensating the families of health care workers who died after contracting the virus. At that time, 42 health care workers had died, including doctors, nurses, drivers, and porters. The compensation totals $10,000 (£6,200) and is to be paid as a lump sum. In mid-November, the WHO reported that while intense transmission persists and cases and deaths continue to be under-reported, there is some evidence that case incidence is no longer increasing nationally in Guinea. They report that case numbers in some districts have been fluctuating, but they remain consistently high. New case numbers have been declining in the outbreak's point of origin, Gueckedou, but transmission continues to be high in Macenta. Of a total of 34 districts in Guinea, 10 remain unaffected by Ebola, contrasting with Liberia and Sierra Leone, where every district has been affected. On 20 November, the local Red Cross in Kankan Prefecture sent blood samples via a courier when the taxi he was traveling in was stopped by robbers. The bandits made off with the cooler bag containing the blood samples. The Guinea authorities made a public appeal for the return of the blood samples. The robbery occurred near the town of Kissidougou. On 14 December the WHO stated that 17 districts reported new confirmed or suspected cases in this week. Guinea reported 2,416 cases with 1,525 deaths on this date. Only 10 out of the 34 districts have not reported cases. Conakry reported 18 new cases in this week. The northern district of Siguiri is of particular concern, as it borders Mali and reported 4 new probable cases. The country was declared free of Ebola transmission on 29 December 2015, 42 days after the last Ebola patient tested negative for a second time. Guinea was subsequently in a 90-day period of heightened surveillance according to the U.N. World Health Organization which also offered assistance - with funding from the agency's donors.On 17 March 2016, the government of Guinea reported 2 people had tested positive for Ebola virus in Korokpara . It was also reported that they were from a village where members of one family had died recently from vomiting (and diarrhoea). On 19 March, it was reported that another individual died due to the virus, at the treatment centre in Nzerekore. The country's government quarantined an area around the home where the cases took place. This region of Guinea is where the first case was registered in December 2013, at the beginning of the Ebola outbreak. On 22 March, it was reported that medical authorities in Guinea have quarantined 816 people as possibly having had contact with the prior cases (more than one hundred individuals were considered high risk ); on the same day Liberia ordered its border with Guinea closed. Macenta prefecture, 200 kilometers from Korokpara, registered the fifth fatality due to the Ebola virus disease in Guinea. On 29 March it was reported that about 1000 contacts had been identified (142 as high risk), and on 30 March 3 more confirmed cases were reported from the sub-prefecture of Koropara in Guinea. On 1 April it was reported that possible contacts, which number in the hundreds, had been vaccinated with an experimental vaccine, in a " ring vaccination " approach. On 5 April it was reported that there were nine new cases of Ebola since the virus resurfaced. Of these nine cases eight have died. After a 42-day waiting period, the WHO declared the country free of Ebola on 1 June. After a trial run of an experimental Ebola vaccine involving 11,000 people in Guinea, Merck, the vaccine's manufacturer, announced it was found to be "highly protective" against the virus. This confirmed the results of a study published in 2015 that awarded the vaccine 100 percent effectiveness after tests on 4000 people in Guinea who had been in close contact with Ebola patients. However, a study sponsored by the National Institutes of Health, the Food and Drug Administration and the U.S. Department of Health and Human Services, and conducted by researchers from the U.S. National Academy of Medicine, called the vaccine's effectiveness in preventing Ebola infections into question. In particular, the authors criticized the methodology of the patient trail, and argued that the protection provided by the vaccine may be lower than officially announced. The WHO approved the vaccine for use in the ongoing Ebola outbreak on 29 May 2017. It was announced in May 2017 that the Gamaleya Research Institute of Epidemiology and Microbiology in Russia would deliver 1000 doses of an independently produced vaccine to Guinea for testing. According to a Xinhua report, it is the only officially authorized and approved Ebola vaccine for clinical use to date.

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Ebola

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Sudan ebolavirus

Sudan virus (SUDV) The species Sudan ebolavirus is a virological taxon included in the genus Ebolavirus , family Filoviridae , order Mononegavirales . The species has a single virus member, Sudan virus (SUDV). The members of the species are called Sudan ebolaviruses. It was discovered in 1977 and causes Ebola clinically indistinguishable from the ebola Zaire strain, but is less transmissible than it. Unlike with ebola Zaire there is no vaccine available.The name Sudan ebolavirus is derived from Sudan (the country in which Sudan virus was first discovered) and the taxonomic suffix ebolavirus (which denotes an ebolavirus species). The species was introduced in 1998 as Sudan Ebola virus . In 2002, the name was changed to Sudan ebolavirus . A virus of the genus Ebolavirus is a member of the species Sudan ebolavirus if: Sudan virus (SUDV) is one of six known viruses within the genus Ebolavirus and one of the four that causes Ebola virus disease (EVD) in humans and other primates ; it is the sole member of the species Sudan ebolavirus . SUDV is a Select agent , World Health Organization Risk Group 4 Pathogen (requiring Biosafety Level 4-equivalent containment ), National Institutes of Health / National Institute of Allergy and Infectious Diseases Category A Priority Pathogen, Centers for Disease Control and Prevention Category A Bioterrorism Agent , and listed as a Biological Agent for Export Control by the Australia Group . [ citation needed ] The first known outbreak of EVD occurred due to Sudan virus in South Sudan between June and November 1976, infecting 284 people and killing 151, with the first identifiable case on 27 June 1976. Sudan virus (abbreviated SUDV) was first described in 1977. It is the single member of the species Sudan ebolavirus , which is included into the genus Ebolavirus , family Filoviridae , order Mononegavirales . The name Sudan virus is derived from South Sudan (where it was first discovered before South Sudan seceded from Sudan ) and the taxonomic suffix virus . [ citation needed ]Sudan virus was first introduced as a new "strain" of Ebola virus in 1977. Sudan virus was described as "Ebola haemorrhagic fever" in a 1978 WHO report describing the 1976 Sudan outbreak. In 2000, it received the designation Sudan Ebola virus and in 2002 the name was changed to Sudan ebolavirus. Previous abbreviations for the virus were EBOV-S (for Ebola virus Sudan) and most recently SEBOV (for Sudan Ebola virus or Sudan ebolavirus). The virus received its final designation in 2010, when it was renamed Sudan virus (SUDV). A virus of the species Sudan ebolavirus is a Sudan virus (SUDV) if it has the properties of Sudan ebolaviruses and if its genome diverges from that of the prototype Sudan virus, Sudan virus variant Boniface (SUDV/Bon), by ≤10% at the nucleotide level. SUDV is one of four ebolaviruses that causes Ebola virus disease (EVD) in humans (in the literature also often referred to as Ebola hemorrhagic fever, EHF). EVD due to SUDV infection cannot be differentiated from EVD caused by other ebolaviruses by clinical observation alone, which is why the clinical presentation and pathology of infections by all ebolaviruses is presented together on a separate page. The strain is less transmissible than Zaire ebolavirus . In the past, SUDV has caused the following EVD outbreaks: [ additional citation(s) needed ]As of 2022, there are six experimental vaccines but only three have advanced to the stage where human clinical trials have begun. As the Public Health Agency of Canada developed a candidate RVSV vaccine for Sudan ebolavirus. Merck was developing it, but as of 18 October 2022 [ update ] had discontinued development; Merck's monopolies on rVSV techniques, acquired with funding from GAVI , are not available to others developing rVSV vaccines. As of 2021 GeoVax was developing MVA-SUDV-VLP, which is a modified vaccinia Ankara virus producing Sudan virus-like particles; early data from their research showed the GeoVax vaccine candidate to be 100% effective at preventing death from the Sudan ebolavirus in animals. An adenovirus based vaccine previously licensed by GSK was donated to and further developed by the Sabin Vaccine Institute in partnership with the Vaccine Research Center at the US National Institute of Allergy and Infectious Diseases; as of October 2022, it will be offered to contacts of known SDV cases in the 2022 Uganda Ebola outbreak as part of a clinical trial . The ecology of SUDV is currently unclear and no reservoir host has yet been identified. Therefore, it remains unclear how SUDV was repeatedly introduced into human populations. As of 2009, bats have been suspected to harbor the virus because infectious Marburg virus (MARV), a distantly related filovirus, has been isolated from bats, and because traces (but no infectious particles) of the more closely related Ebola virus (EBOV) were found in bats as well. SUDV is basically uncharacterized on a molecular level. However, its genomic sequence, and with it the genomic organization and the conservation of individual open reading frames , is similar to that of the other four known ebolaviruses. It is therefore currently assumed that the knowledge obtained for EBOV can be extrapolated to SUDV and that all SUDV proteins behave analogous to those of EBOV. [ citation needed ]

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Ebola

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Sierra Leone

Rank based on 2007 figure Sierra Leone , [lower-alpha 1] officially the Republic of Sierra Leone , is a country on the southwest coast of West Africa . It shares its southeastern border with Liberia and is bordered by Guinea to the north. With a land area of 71,740 km 2 (27,699 sq mi) , Sierra Leone has a tropical climate and with a variety of environments ranging from savannas to rainforests . According to the 2015 census, Sierra Leone has a population of 7,092,113, with Freetown serving as both the capital and largest city. The country is divided into five administrative regions, which are further subdivided into 16 districts . Sierra Leone is governed as a presidential republic , with a unicameral parliament and a directly elected president . Sierra Leone is a secular state with the constitution providing for the separation of state and religion and freedom of conscience , encompassing freedom of thought and religion . Muslims constitute three-quarters of the population with a significant Christian minority. Notably, religious tolerance is very high, reflecting a social norm and part of the nation's cultural identity. Sierra Leone's current territorial configuration was established by the British Empire through two historical phases: initially, the coastal Sierra Leone Colony was founded in 1808 to resettle returning Africans following the abolition of the slave trade ; subsequently, the inland Protectorate was created in 1896 in the wake of the Berlin Conference of 1884–1885 . This led to the formal recognition of the territory as the Sierra Leone Colony and Protectorate , or British Sierra Leone. Independence from the United Kingdom was attained in 1961, with Sierra Leone transitioning into a Commonwealth realm as the Dominion of Sierra Leone under the leadership of Prime Minister Sir Milton Margai of the Sierra Leone People's Party (SLPP). Under prime minister Siaka Stevens of the All People's Congress (APC), the country adopted a new constitution in 1971, transforming Sierra Leone into a presidential republic with Stevens as the inaugural president. After declaring the APC the sole legal party in 1978, Stevens was succeeded by Joseph Saidu Momoh in 1985. Momoh's enactment of a new constitution in 1991 reintroduced a multi-party system . That year, a protracted civil war initiated, featuring the government and the Revolutionary United Front (RUF) rebel group, leading to significant turmoil. The conflict, characterized by multiple coups d'état , persisted for 11 years. Intervention by ECOMOG forces and later the United Kingdom resulted in the defeat of the RUF in 2002, ushering in a period of relative stability and recovery efforts. The remaining two main political parties are the APC and the SLPP. Sierra Leone is a culturally diverse nation, home to approximately 18 ethnic groups , with the Temne and Mende peoples being predominant. The Creole people , descendants of freed African-American, Afro-Caribbean slaves and liberated Africans, constitute about 1.2% of the population. English is the official language, while Krio is the lingua franca , spoken by 97% of the population. The country is rich with natural resources, notably diamonds, gold, bauxite and aluminium. Sierra Leone maintains membership in several international organizations, including the United Nations, African Union, Economic Community of West African States (ECOWAS), and the Commonwealth of Nations, among others.Sierra Leone derives its name from the Lion Mountains near Freetown. Originally named Serra Leoa ( Portuguese for 'lioness mountains') by Portuguese explorer Pedro de Sintra in 1462, the modern name is derived from the Venetian spelling, which was introduced by Venetian explorer Alvise Cadamosto and subsequently adopted by other European mapmakers . Sierra Leone's history is marked by continuous human habitation for at least 2,500 years, influenced by migrations from across Africa. The adoption of iron technology by the ninth century and the establishment of agriculture by 1000 AD along the coast. Climate shifts over centuries altered the ecological zones, influencing migration and conquest dynamics. The region's dense tropical rainforest and swamps, coupled with the presence of the tsetse fly which carried a disease fatal to horses and the zebu cattle used by the Mandé people , provided natural defenses against invasions by the Mandinka Empire and other African empires, and limited influence by the Mali Empire , preserving its indigenous cultures from external dominions. The introduction of Islam by Susu traders, merchants and migrants in the 18th century further enriched the cultural tapestry, eventually establishing a strong foothold in the north. The later conquest by Samory Touré in the northeast solidified Islam among the Yalunka , Kuranko and Limba people. The 15th century marked the beginning of European interaction with Sierra Leone, highlighted by Portuguese explorer Pedro de Sintra mapping the region in 1462 and naming it after the lioness mountains. This naming has been subject to historical reinterpretation, suggesting earlier European knowledge of the region. Following Sintra, European traders established fortified posts, engaging primarily in the slave trade , which shaped the socio-economic landscape significantly. Traders from European nations, such as the Dutch Republic , England and France also started to arrive in Sierra Leone and establish trading stations. These stations quickly began to primarily deal in slaves, who were brought to the coast by indigenous traders from interior areas undergoing wars and conflicts over territory. The Europeans made payments, called Cole , for rent, tribute, and trading rights, to the king of an area. Local Afro-European merchants often acted as middlemen, the Europeans advancing them goods to trade to indigenous merchants, most often for slaves and ivory. Portuguese traders were particularly drawn to the local craftsmanship in ivory , leading to a notable trade in ivory artifacts such as horns, saltcellars , and spoons. This exchange underscored the region's artistic talents during the period. The 1600s witnessed several waves of Mane people migrating into Sierra Leone, adding to the region's cultural diversity. [ citation needed ] In the late 18th century, African Americans who had fought for the British Crown during the American Revolutionary War were resettled in Sierra Leone, forming a unique community named Black Loyalists . This resettlement scheme was partly motivated by social issues in London, with the Sierra Leone Resettlement Scheme offering a new beginning for the Black Poor , though it was fraught with challenges. In the late 18th century, many African Americans claimed the protection of the British Crown. There were thousands of these Black Loyalists, people of African ancestry who joined the British military forces during the American Revolutionary War. Many of these Loyalists had been slaves who had escaped to join the British, lured by promises of freedom ( emancipation ). The official documentation known as the Book of Negroes lists thousands of freed slaves whom the British evacuated from the nascent United States and resettled in colonies elsewhere in British North America (north to Canada, or south to the West Indies). Pro-slavery advocates accused the Black Poor of being responsible for a large proportion of crime in 18th century London. While the broader community included some women, the Black Poor seems to have exclusively consisted of men, some of whom developed relationships with local women and often married them. Slave owner Edward Long criticized marriage between black men and white women. However, on the voyage between Plymouth, England and Sierra Leone, seventy European girlfriends and wives accompanied the Black Poor settlers . Many in London thought that moving them to Sierra Leone would lift them out of poverty. The Sierra Leone Resettlement Scheme was proposed by entomologist Henry Smeathman and drew interest from humanitarians like Granville Sharp , who saw it as a means of showing the pro-slavery lobby that black people could contribute towards the running of the new colony of Sierra Leone. Government officials soon became involved in the scheme as well, although their interest was spurred by the possibility of resettling a large group of poor citizens elsewhere. William Pitt the Younger , prime minister and leader of the Tory party, had an active interest in the Scheme because he saw it as a means to repatriate the Black Poor to Africa, since "it was necessary they should be sent somewhere, and be no longer suffered to infest the streets of London". In January 1787, the Atlantic and the Belisarius set sail for Sierra Leone, but bad weather forced them to divert to Plymouth, during which time about 50 passengers died. Another 24 were discharged, and another 23 ran away. Eventually, with some more recruitment, 411 passengers sailed to Sierra Leone in April 1787. On the voyage between Plymouth and Sierra Leone, 96 passengers died. In 1787 the British Crown founded a settlement in Sierra Leone in what was called the " Province of Freedom ". About 400 black and 60 white colonists reached Sierra Leone on 15 May 1787. After they established Granville Town , most of the first group of colonists died, owing to disease and warfare with the indigenous African peoples ( Temne ), who resisted their encroachment. When the ships left them in September, their numbers had been reduced to "276 persons, namely 212 black men, 30 black women, 5 white men and 29 white women". The settlers that remained forcibly captured land from a local African chieftain, but he retaliated, attacking the settlement, which was reduced to a mere 64 settlers comprising 39 black men, 19 black women, and six white women. Black settlers were captured by unscrupulous traders and sold as slaves, and the remaining colonists were forced to arm themselves for their own protection. The 64 remaining colonists established a second Granville Town. Following the American Revolution, Black Loyalists from Nova Scotia , Canada, were relocated to Sierra Leone, founding Freetown and contributing significantly to the Krio people and Krio language that would come to define the region. Following the American Revolution , more than 3,000 Black Loyalists had also been settled in Nova Scotia , where they were finally granted land. They founded Birchtown , but faced harsh northern winters and racial discrimination from nearby Shelburne . Thomas Peters pressed British authorities for relief and more aid; together with British abolitionist John Clarkson , the Sierra Leone Company was established to relocate Black Loyalists who wanted to take their chances in West Africa. In 1792 nearly 1,200 persons from Nova Scotia crossed the Atlantic to build the second (and only permanent) Colony of Sierra Leone and the settlement of Freetown on 11 March 1792. In Sierra Leone they were called the Nova Scotian Settlers , the Nova Scotians , or the Settlers . Clarkson initially banned the survivors of Granville Town from joining the new settlement, blaming them for the demise of Granville Town. The Settlers built Freetown in the styles they knew from their lives in the American South ; they also continued American fashion and American manners. In addition, many continued to practise Methodism in Freetown. In the 1790s, the Settlers, including adult women, voted for the first time in elections. In 1792, in a move that foreshadowed the women's suffrage movements in Britain, the heads of all households, of which a third were women, were given the right to vote. Black settlers in Sierra Leone enjoyed much more autonomy than their white equivalent in European countries. Black migrants elected different levels of political representatives, 'tithingmen', who represented each dozen settlers and 'hundreders' who represented larger amounts. This sort of representation was not available in Nova Scotia. The initial process of society-building in Freetown was a harsh struggle. The Crown did not supply enough basic supplies and provisions and the Settlers were continually threatened by illegal slave trading and the risk of re-enslavement. The Sierra Leone Company, controlled by London investors, refused to allow the settlers to take freehold of the land. In 1799 some of the settlers revolted. The Crown subdued the revolt by bringing in forces of more than 500 Jamaican Maroons , whom they transported from Cudjoe's Town (Trelawny Town) via Nova Scotia in 1800. Led by Colonel Montague James , the Maroons helped the colonial forces to put down the revolt, and in the process the Jamaican Maroons in Sierra Leone secured the best houses and farms. On 1 January 1808, Thomas Ludlam , the Governor of the Sierra Leone Company and a leading abolitionist, surrendered the company's charter. This ended its 16 years of running the Colony. The British Crown reorganised the Sierra Leone Company as the African Institution ; it was directed to improve the local economy. Its members represented both British who hoped to inspire local entrepreneurs and those with interest in the Macauley & Babington Company, which held the (British) monopoly on Sierra Leone trade. At about the same time (following the Slave Trade Act 1807 which abolished the slave trade), Royal Navy crews delivered thousands of formerly enslaved Africans to Freetown, after liberating them from illegal slave ships. These Liberated Africans or recaptives were sold for $20 a head as apprentices to the white settlers, Nova Scotian Settlers, and the Jamaican Maroons. Many Liberated Africans were treated poorly and even abused because some of the original settlers considered them their property. Cut off from their various homelands and traditions, the Liberated Africans were forced to assimilate to the Western styles of Settlers and Maroons. For example, some of the Liberated Africans were forced to change their name to a more Western sounding one. Though some people happily embraced these changes because they considered it as being part of the community, some were not happy with these changes and wanted to keep their own identity. Many Liberated Africans were so unhappy that they risked the possibility of being sold back into slavery by leaving Sierra Leone and going back to their original villages. The Liberated Africans eventually modified their customs to adopt those of the Nova Scotians, Maroons and Europeans, yet kept some of their ethnic traditions. As the Liberated Africans became successful traders and spread Christianity throughout West Africa, they intermarried with the Nova Scotians and Maroons, and the two groups eventually became a fusion of African and Western societies. : 3–4, 223–255 These Liberated Africans were from many areas of Africa, but principally the west coast. Between the 18th and 19th century, freed African Americans, some Americo Liberian "refugees", and particularly Afro-Caribbeans , mainly Jamaican Maroons, also immigrated and settled in Freetown. Together these peoples formed the Creole/Krio ethnicity and an English-based creole language ( Krio ), which is the lingua franca and de facto national language used among many of the ethnicities in the country. The colonial era saw Sierra Leone evolving under British rule, with a unique settlement pattern composed of displaced Africans following the abolition of the slave trade . Sierra Leone developed as an educational center in West Africa, with the establishment of Fourah Bay College in 1827, attracting English-speaking Africans from across the region. The settlement of Sierra Leone in the 1800s was unique in that the population was composed of displaced Africans who were brought to the colony after the British abolition of the slave trade in 1807. Upon arrival in Sierra Leone, each recaptive was given a registration number, and information on their physical qualities would be entered into the Register of Liberated Africans. Oftentimes the documentation would be overwhelmingly subjective and would result in inaccurate entries, making them difficult to track. In addition, differences between the Register of Liberated Africans of 1808 and the List of Captured Negroes of 1812 (which emulated the 1808 document) revealed some disparities in the entries of the recaptives, specifically in the names; many recaptives decided to change their given names to more anglicised versions which contributed to the difficulty in tracking them after they arrived in Sierra Leone. In the early 19th century, Freetown served as the residence of the British colonial governor of the region, who also administered the Gold Coast (now Ghana ) and the Gambia settlements. Sierra Leone developed as the educational centre of British West Africa . The British established Fourah Bay College in 1827, which rapidly became a magnet for English-speaking Africans on the West Coast. For more than a century, it was the only European-style university in western Sub-Saharan Africa . Samuel Ajayi Crowther was the first student to be enrolled at Fourah Bay. Fourah Bay College soon became a magnet for Creoles/Krio people and other Africans seeking higher education in British West Africa. These included Nigerians, Ghanaians, Ivorians and many more, especially in the fields of theology and education. Freetown was known as the " Athens of Africa" due to the large number of excellent schools in Freetown and surrounding areas. The British interacted mostly with the Krio people in Freetown, who did most of the trading with the indigenous peoples of the interior. Educated Krio people held numerous positions in the colonial government, giving them status and well-paying positions. Following the Berlin Conference of 1884–1885, the British decided that they needed to establish more dominion over the inland areas, to satisfy what was described by the European powers as "effective occupation" of territories. In 1896 it annexed these areas, declaring them the Sierra Leone Protectorate. With this change, the British began to expand their administration in the region, recruiting British citizens to posts and pushing Krio people out of positions in government and even the desirable residential areas in Freetown. During the British annexation in Sierra Leone, several chiefs in the northern and southern parts of the country were resisting the "hut tax" imposed by the colonial administrators but they used diplomacy to achieve their goal. In the north, from 1820 to 1906, there was a Limba chief named Almamy Suluku who ruled his territory for many years, fighting to protect his territory, while at the same time using diplomacy to trick the protectorate administrators while sending fighters to assist Bai Bureh , a prominent Temne chief in Kasseh who was fighting against the imposition of the "hut tax" by the colonial administrators. The war was later known as the Hut Tax War . Another prominent figure in Sierra Leone history is Bai Sherbro ( c. 1830–1912 ). Bai Sherbro was a chief and warrior on Bonthe Island, in the southwestern part of the country. He, like Bai Bureh, resisted the British. Sherbro also sent fighters to assist Bai Bureh in the fight against the British. Sherbro was influential and powerful and the British greatly feared him. Bai Sherbro was captured and with Bai Bureh, exiled to the Gold Coast (modern Ghana). Nyagua ( c. 1842 –1906), also known as the "Tracking King", was a fierce king who captured many districts and many people came to join him for protection. Nyagua also resisted the British. Realizing that he lacked sufficient strength, he resorted to diplomacy. At the same time, he sent warriors to assist Bai Bureh in fighting against the British. The British later captured Nyagua, and he was also exiled to the Gold Coast. Madam Yoko ( c. 1849 –1906) was a brilliant woman of culture and ambition. She employed her capacity for friendly communications to persuade the British to give her control of the Kpaa Mende chiefdom. She used diplomacy to communicate with many local chiefs who did not trust her friendship with the British. Because Madam Yoko supported the British, some sub-chiefs rebelled, causing Yoko to take refuge in the police barracks. For her loyalty, she was awarded a silver medal by Queen Victoria . Until 1906, Madam Yoko ruled as a paramount chief in the new British Protectorate. It appears that she committed suicide at the age of fifty-five, perhaps due to the loss of support from her own people. The British annexation of the Protectorate interfered with the sovereignty of indigenous chiefs. They designated chiefs as units of local government, rather than dealing with them individually as had been the previous practice. They did not maintain relationships even with longstanding allies, such as Bai Bureh, who was later unfairly portrayed as a prime instigator of the Hut Tax War. Colonel Frederic Cardew , military governor of the Protectorate, in 1898 established a new tax on dwellings and demanded that the chiefs use their people to maintain roads. The taxes were often higher than the value of the dwellings, and 24 chiefs signed a petition to Cardew, stating how destructive this was; their people could not afford to take time off from their subsistence agriculture. They resisted payment of taxes, tensions over the new colonial requirements and the administration's suspicions towards the chiefs, led to the Hut Tax war of 1898, also called the Temne-Mende War. The British fired first; the northern front of mainly Temne people was led by Bai Bureh. The southern front, consisting mostly of Mende people , entered the conflict somewhat later, for other reasons. For several months, Bureh's fighters had the advantage over the vastly more powerful British forces but both sides suffered hundreds of fatalities. Bureh surrendered on 11 November 1898 to end the destruction of his people's territory and dwellings. Although the British government recommended leniency, Cardew insisted on sending the chief and two allies into exile in the Gold Coast; his government hanged 96 of the chief's warriors. Bureh was allowed to return in 1905, when he resumed his chieftaincy of Kasseh. The defeat of the Temne and Mende in the Hut Tax war ended mass resistance to the Protectorate and colonial government, but intermittent rioting and labour unrest continued throughout the colonial period. Riots in 1955 and 1956 involved "tens of thousands" of Sierra Leoneans in the Protectorate. Domestic slavery , which continued to be practised by local African elites, was abolished in 1928. A notable event in 1935 was the granting of a monopoly on mineral mining to the Sierra Leone Selection Trust , run by De Beers . The monopoly was scheduled to last 98 years. Mining of diamonds in the east and other minerals expanded, drawing labourers there from other parts of the country. In 1924, the UK government divided the administration of Sierra Leone into Colony and Protectorate, with different political systems constitutionally defined for each. The Colony was Freetown and its coastal area; the Protectorate was defined as the hinterland areas dominated by local chiefs. Antagonism between the two entities escalated to a heated debate in 1947, when proposals were introduced to provide for a single political system for both the Colony and the Protectorate. Most of the proposals came from leaders of the Protectorate, whose population far outnumbered that in the colony. The Krios, led by Isaac Wallace-Johnson , opposed the proposals, as they would have resulted in reducing the political power of the Krios in the Colony. In 1951, Lamina Sankoh ( born : Etheldred Jones) collaborated with educated protectorate leaders from different groups, including Sir Milton Margai , Siaka Stevens , Mohamed Sanusi Mustapha, John Karefa-Smart , Kande Bureh, Sir Albert Margai , Amadu Wurie and Sir Banja Tejan-Sie joined together with the powerful paramount chiefs in the protectorate to form the Sierra Leone People's Party or SLPP as the party of the Protectorate. The SLPP leadership, led by Sir Milton Margai, negotiated with the British and the educated Krio-dominated colony based in Freetown to achieve independence. Owing to the astute politics of Milton Margai, the educated Protectorate elites were able to join forces with the paramount chiefs in the face of Krio intransigence. Later, Margai used the same skills to win over opposition leaders and moderate Krio elements to achieve independence from the UK. In November 1951, Margai oversaw the drafting of a new constitution, which united the separate Colonial and Protectorate legislatures and provided a framework for decolonisation . In 1953, Sierra Leone was granted local ministerial powers and Margai was elected Chief Minister of Sierra Leone. The new constitution ensured Sierra Leone had a parliamentary system within the Commonwealth of Nations . In May 1957, Sierra Leone held its first parliamentary election. The SLPP, which was then the most popular political party in the colony of Sierra Leone as well as being supported by the powerful paramount chiefs in the provinces, won the most seats in Parliament and Margai was re-elected as Chief Minister by a landslide. Sierra Leone gained independence from the United Kingdom in 1961, transitioning to a nation with its own governance structures, though it faced significant political instability post-independence, including the establishment of a one-party state and periods of civil unrest. On 20 April 1960, Milton Margai led a 24-member Sierra Leonean delegation at constitutional conferences that were held with the Government of Queen Elizabeth II and British Colonial Secretary Iain Macleod in negotiations for independence held in London. On the conclusion of talks in London on 4 May 1960, the United Kingdom agreed to grant Sierra Leone independence on 27 April 1961. On 27 April 1961, Sir Milton Margai led Sierra Leone to independence from Great Britain and became the country's first Prime Minister. Sierra Leone had its own parliament and its own prime minister, and had the ability to make 100% of its own laws, however, as with countries such as Canada and Australia, Sierra Leone remained a "Dominion" and Queen Elizabeth was Queen of the independent Dominion of Sierra Leone . Thousands of Sierra Leoneans took to the streets in celebration. The Dominion of Sierra Leone retained a parliamentary system of government and was a member of the Commonwealth of Nations. The leader of the main opposition All People's Congress (APC), Siaka Stevens, along with Isaac Wallace-Johnson, another outspoken critic of the SLPP government, were arrested and placed under house arrest in Freetown, along with sixteen others charged with disrupting the independence celebration. In May 1962, Sierra Leone held its first general election as an independent nation. The Sierra Leone People's Party (SLPP) won a plurality of seats in parliament, and Milton Margai was re-elected as prime minister. Margai was popular among Sierra Leoneans during his time in power, mostly known for his self-effacement. He was neither corrupt nor did he make a lavish display of his power or status. He based the government on the rule of law and the separation of powers, with multiparty political institutions and fairly viable representative structures. Margai used his conservative ideology to lead Sierra Leone without much strife. He appointed government officials to represent various ethnic groups. Margai employed a brokerage style of politics, by sharing political power among political parties and interest groups; especially the involvement of powerful paramount chiefs in the provinces, most of whom were key allies of his government. [ citation needed ] Upon Milton Margai's unexpected death in 1964, his younger half-brother , Sir Albert Margai, was appointed as Prime Minister by parliament. Sir Albert's leadership was briefly challenged by Foreign Minister John Karefa-Smart, who questioned Sir Albert's succession to the SLPP leadership position. Karefa-Smart led a prominent small minority faction within the SLPP party in opposition of Albert Margai as Prime Minister. However, Karefa-Smart failed to receive broad support within the SLPP in his attempt to oust Albert Margai as both the leader of the SLPP and Prime Minister. The large majority of SLPP members backed Albert Margai over Karefa-Smart. Soon after Albert Margai was sworn in as Prime Minister, he fired several senior government officials who had served in his elder brother Sir Milton's government, viewing them as a threat to his administration, including Karefa-Smart. Sir Albert resorted to increasingly authoritarian actions in response to protests and enacted several laws against the opposition All People's Congress, whilst attempting to establish a one-party state . Sir Albert was opposed to the colonial legacy of allowing executive powers to the Paramount Chiefs, many of whom had been key allies of his late brother Sir Milton. Accordingly, they began to consider Sir Albert a threat to the ruling houses across the country. Margai appointed many non-Creoles to the country's civil service in Freetown, in an overall diversification of the civil service in the capital, which had been dominated by members of the Creole ethnic group. As a result, Albert Margai became unpopular in the Creole community, many of whom had supported Sir Milton. Margai sought to make the army homogeneously Mende , his own ethnic group, and was accused of favouring members of the Mende for prominent positions. In 1967, riots broke out in Freetown against Margai's policies; in response, he declared a state of emergency across the country. Sir Albert was accused of corruption and of a policy of affirmative action in favour of the Mende ethnic group. He also endeavoured to change Sierra Leone from a democracy to a one-party state . Although possessing the full backing of the country's security forces, he called for free and fair elections. [ citation needed ] The APC, with its leader Siaka Stevens , narrowly won a small majority of seats in Parliament over the SLPP in a closely contested 1967 general election . Stevens was sworn in as Prime Minister on 21 March 1967. Within hours after taking office, Stevens was ousted in a bloodless military coup led by Brigadier General David Lansana , the commander of the Sierra Leone Armed Forces . He was a close ally of Albert Margai, who had appointed him to the position in 1964. Lansana placed Stevens under house arrest in Freetown and insisted that the determination of the Prime Minister should await the election of the tribal representatives to the House. Steven was later freed and fled the country, going into exile in neighbouring Guinea. However, on 23 March 1967, a group of military officers in the Sierra Leone Army led by Brigadier General Andrew Juxon-Smith , staged a counter-coup against Commander Lansana. They seized control of the government, arrested Lansana, and suspended the constitution. The group set up the National Reformation Council (NRC), with Andrew Juxon-Smith as its chairman and Head of State of the country. On 18 April 1968 a group of low-ranking soldiers in the Sierra Leone Army who called themselves the Anti-Corruption Revolutionary Movement (ACRM), led by Brigadier General John Amadu Bangura , overthrew the NRC junta . The ACRM junta arrested many senior NRC members. They reinstated the constitution and returned power to Stevens, who at last assumed the office of Prime Minister. Stevens had Bangura arrested in 1970 and charged with conspiracy and treason. He was found guilty and sentenced to death, despite the fact that it was Bangura whose actions led to Stevens' return to power. Brigadier Lansana and Hinga Norman , the main army officers involved in the first coup (1967), were unceremoniously dismissed from the armed forces and made to serve time in prison. Norman was a guard to Governor-general Sir Henry Lightfoot-Boston . Lansana was later tried and found guilty of treason and sentenced to death in 1975. Stevens assumed power as Prime Minister again in 1968, following a series of coups, with a great deal of hope and ambition. Much trust was placed upon him as he championed multi-party politics. Stevens had campaigned on a platform of bringing the tribes together under socialist principles. During his first decade or so in power, Stevens renegotiated some of what he called "useless prefinanced schemes" contracted by his predecessors, both Albert Margai of the SLPP and Juxon-Smith of the NRC. Some of these policies by the SLPP and the NRC were said to have left the country in an economically deprived state. Stevens reorganised the country's oil refinery, the government-owned Cape Sierra Hotel, and a cement factory. He cancelled Juxon-Smith's construction of a church and mosque on the grounds of Victoria Park (now known as Freetown Amusement Park – since 2017). Stevens began efforts that would later improve transportation and movements between the provinces and the city of Freetown. Roads and hospitals were constructed in the provinces, and Paramount Chiefs and provincial peoples became a prominent force in Freetown. Under the pressure of several coup attempts, real or perceived, Stevens' rule grew more and more authoritarian , and his relationship with some of his ardent supporters deteriorated. He removed the SLPP party from competitive politics in general elections, some believed, through the use of violence and intimidation. To maintain the support of the military, Stevens retained the popular John Amadu Bangura as head of the Sierra Leone Armed Forces. After the return to civilian rule, by-elections were held (beginning in autumn 1968) and an all-APC cabinet was appointed. Calm was not completely restored. In November 1968, unrest in the provinces led Stevens to declare a state of emergency across the country. Many senior officers in the Sierra Leone Army were greatly disappointed with Stevens' policies and his handling of the Sierra Leone Military, but none could confront Stevens. Brigadier General Bangura, who had reinstated Stevens as Prime Minister, was widely considered the only person who could control Stevens. The army was devoted to Bangura, and this made him potentially dangerous to Stevens. In January 1970, Bangura was arrested and charged with conspiracy and plotting to commit a coup against the Stevens government. After a trial that lasted a few months, Bangura was convicted and sentenced to death . On 29 March 1970, Brigadier Bangura was executed by hanging in Freetown. After the execution of Bangura, a group of soldiers loyal to the executed general held a mutiny in Freetown and other parts of the country in opposition to Stevens' government. Dozens of soldiers were arrested and convicted by a court martial in Freetown for their participation in the mutiny against the president. Among the soldiers arrested was a little-known army corporal , Foday Sankoh , a strong Bangura supporter, who would later form the Revolutionary United Front (RUF) . Corporal Sankoh was convicted and jailed for seven years at the Pademba Road Prison in Freetown. In April 1971, a new republican constitution was adopted under which Stevens became president. In the 1972 by-elections, the opposition SLPP complained of intimidation and procedural obstruction by the APC and militia. These problems became so severe that the SLPP boycotted the 1973 general election ; as a result, the APC won 84 of the 85 elected seats. An alleged plot to overthrow President Stevens failed in 1974 and its leaders were executed. In mid-1974, Guinean soldiers, as requested by Stevens, were stationed in the country to help maintain his hold on power, as Stevens was a close ally of then-Guinean president Ahmed Sékou Touré . In March 1976, Stevens was elected without opposition for a second five-year term as president. On 19 July 1975, 14 senior army and government officials, including David Lansana, former cabinet minister Mohamed Sorie Forna (father of writer Aminatta Forna ), Brigadier General Ibrahim Bash Taqi and Lieutenant Habib Lansana Kamara were executed after being convicted of attempting a coup to topple president Stevens' government. In 1977, a nationwide student demonstration against the government disrupted Sierra Leone's politics. The demonstration was quickly put down by the army and Stevens' own personal Special Security Division (SSD), a heavily armed paramilitary force he had created to protect him and maintain his hold on power. SSD officers were loyal to Stevens and were deployed across the country to clamp down on any rebellion or protest against Stevens' government. A general election was called later that year in which corruption was again endemic; the APC won 74 seats and the SLPP 15. In 1978, the APC-dominant parliament approved a new constitution making the country a one-party state. The 1978 constitution made the APC the only legal political party in Sierra Leone. This move led to another major demonstration against the government in many parts of the country, but it was also put down by the army and Stevens' SSD force. Stevens is generally criticised for dictatorial methods and government corruption, but on a positive note, he kept the country stable and from collapsing into civil war. He created several government institutions that are still in use today. [ citation needed ] Stevens also reduced ethnic polarisation in government by incorporating members of various ethnic groups into his all-dominant APC government. Siaka Stevens retired from politics in November 1985 after being in power for eighteen years. The APC named a new presidential candidate to succeed Stevens at the party's last delegate conference, held in Freetown in November 1985. The candidate was Major General Joseph Saidu Momoh , head of the Sierra Leone Armed Forces and Stevens' own choice to succeed him. As head of the armed forces, General Momoh had been loyal to Stevens, who had appointed him to the position. Like Stevens, Momoh was also a member of the minority Limba ethnic group. As the sole candidate, Momoh was elected president without opposition and sworn in as Sierra Leone's second president on 28 November 1985 in Freetown. A one-party parliamentary election between APC members was held in May 1986. President Momoh appointed his former military colleague and key ally, Major General Mohamed Tarawalie to succeed him as the head of the Sierra Leone Military. General Tarawalie was also a strong loyalist and key Momoh supporter. President Momoh named James Bambay Kamara as the head of the Sierra Leone Police . Bambay Kamara was also a strong Momoh loyalist and supporter. Momoh broke from former President Siaka Stevens by integrating the powerful SSD into the Sierra Leone Police as a special paramilitary force . Under President Stevens, the SSD had been a powerful personal force used to maintain his hold on power, independent from the Sierra Leone Military and Sierra Leone Police Force. The Sierra Leone Police under Bambay Kamara's leadership was accused of physical violence, arrest, and intimidation against critics of President Momoh's government. President Momoh's strong links with the army and his verbal attacks on corruption earned him much-needed initial support among Sierra Leoneans. With the lack of new faces in the new APC cabinet under President Momoh and the return of many of the old faces from Stevens' government, criticisms soon arose that Momoh was simply perpetuating the rule of Stevens. The next few years under the Momoh administration were characterised by corruption, which Momoh defused by sacking several senior cabinet ministers. To formalise his war against corruption, President Momoh announced a " Code of Conduct for Political Leaders and Public Servants". After an alleged attempt to overthrow President Momoh in March 1987, more than 60 senior government officials were arrested, including Vice-President Francis Minah , who was removed from office, convicted of plotting the coup, and executed by hanging in 1989, along with five others. The brutal civil war significantly impacted Sierra Leone, with internal and external factors contributing to widespread violence. International interventions, notably by the United Kingdom and the United Nations, were crucial in restoring peace. In October 1990, owing to mounting pressure from both within and outside the country for political and economic reforms, president Momoh set up a constitutional review commission to assess the 1978 one-party constitution. Based on the commission's recommendations, a constitution re-establishing a multi-party system was approved by the exclusive APC Parliament by a 60% majority vote, becoming effective on 1 October 1991. There was great suspicion that President Momoh was not serious about his promise of political reform, as APC rule continued to be increasingly marked by abuses of power. The brutal civil war that was going on in neighbouring Liberia played a significant role in the outbreak of fighting in Sierra Leone. Charles Taylor – then leader of the National Patriotic Front of Liberia – reportedly helped form the Revolutionary United Front (RUF) under the command of former Sierra Leonean army corporal Foday Saybana Sankoh , an ethnic Temne from Tonkolili District in Northern Sierra Leone. Sankoh was a British trained former army corporal who had also undergone guerrilla training in Libya. Taylor's aim was for the RUF to attack the bases of Nigerian dominated peacekeeping troops in Sierra Leone who were opposed to his rebel movement in Liberia. On 29 April 1992, a group of young soldiers in the Sierra Leone Army, led by seven army officers—Lieutenant Sahr Sandy, Captain Valentine Strasser, Lieutenant Solomon "SAJ" Musa , Captain Komba Mondeh , Lieutenant Tom Nyuma , Captain Julius Maada Bio and Captain Komba Kambo —staged a military coup that sent president Momoh into exile in Guinea, and the young soldiers established the National Provisional Ruling Council (NPRC), with 25-year-old Captain Valentine Strasser as its chairman and Head of State of the country. The NPRC junta immediately suspended the constitution, banned all political parties, limited freedom of speech and freedom of the press and enacted a rule-by-decree policy, in which soldiers were granted unlimited powers of administrative detention without charge or trial, and challenges against such detentions in court were precluded. SAJ Musa, a childhood friend of Strasser, became the deputy chairman and deputy leader of the NPRC government. Strasser became the world's youngest Head of State when he seized power just three days after his 25th birthday. The NPRC junta established the National Supreme Council of State as the military highest command and final authority in all matters and was exclusively made up of the highest-ranking NPRC soldiers, including Strasser himself and the original soldiers who toppled President Momoh. One of the top-ranking soldiers in the NPRC junta, Lieutenant Sahr Sandy, a trusted ally of Strasser, was assassinated, allegedly by Major S.I.M. Turay, a key loyalist of ousted president Momoh. A heavily armed military manhunt was carried out across the country to find Lieutenant Sandy's killer. However, the main suspect, Major S.I.M. Turay, went into hiding and fled the country to Guinea, fearing for his life. Dozens of soldiers loyal to the ousted president Momoh were arrested, including Colonel Kahota M. Dumbuya and Major Yayah Turay. Lieutenant Sandy was given a state funeral and his funeral prayers service at the cathedral church in Freetown was attended by many high-ranking soldiers of the NPRC junta, including Strasser himself and NPRC deputy leader Sergeant Solomon Musa. The NPRC junta maintained relations with ECOWAS and strengthened support for Sierra Leone-based ECOMOG troops fighting in the Liberian war. On 28 December 1992, an alleged coup attempt against the NPRC government of Strasser, aimed at freeing the detained Colonel Yahya Kanu, Colonel Kahota M.S. Dumbuya and former inspector general of police Bambay Kamara, was foiled. Several Junior army officers led by Sergeant Mohamed Lamin Bangura were identified as being behind the coup plot. The coup plot led to the execution of seventeen soldiers by firing squad . Some of those executed include Colonel Kahota Dumbuya, Major Yayah Kanu and Sergeant Mohamed Lamin Bangura. Several prominent members of the Momoh government who had been in detention at the Pa Demba Road prison, including former inspector general of police Bambay Kamara, were also executed. On 5 July 1994 SAJ Musa, who was popular among the general population, particularly in Freetown, was arrested and sent into exile after he was accused of planning a coup to topple Strasser, an accusation SAJ Musa denied. Strasser replaced Musa as deputy NPRC chairman with Captain Bio, who was instantly promoted by Strasser to brigadier . The NPRC's efforts proved to be nearly as ineffective as the ousted Momoh administration in repelling the RUF rebels. More and more of the country fell into the hands of RUF fighters, and by 1994 they had gained control of much of the diamond-rich Eastern Province and were getting close to the capital Freetown. In response, the NPRC hired the services of South African -based private military contractor Executive Outcomes for several hundred mercenary fighters in order to strengthen the response to the advances of the RUF rebels. Within a month they had driven RUF fighters back to enclaves along Sierra Leone's borders and cleared the RUF from the Kono diamond-producing areas of Sierra Leone. With Strasser's two most senior NPRC allies and commanders Lieutenant Sahr Sandy and Lieutenant Solomon Musa no longer around to defend him, Strasser's leadership within the NPRC's Supreme Council of State became fragile. On 16 January 1996, after about four years in power, Strasser was arrested in a palace coup staged by his fellow NPRC soldiers led by Brigadier Bio at the Defence Headquarters in Freetown. Strasser was immediately flown into exile in a military helicopter to Conakry , Guinea . In his first public broadcast to the nation following the 1996 coup, Brigadier Bio stated that his support for returning Sierra Leone to a democratically elected civilian government and his commitment to ending the civil war were his motivations for the coup. Promises of a return to civilian rule were fulfilled by Bio. Prior to conducting the election, Sierra Leoneans and international stakeholders were involved in a major debate on whether the nation should focus on trying to end the long running civil war, or to conduct elections and hence returning governance back to a civilian-led administration with a multi-party system of parliament that would provide the foundation for long-lasting peace and national prosperity. Following the 1995 National Consultative Conference at the Bintumani Hotel in Freetown, dubbed "Bintumani I", which was a Strasser-led initiative, another National Consultative Conference at the same Bintumani Hotel in Freetown, dubbed "Bintumani II", was initiated by the Bio administration that involved both national and international stakeholders, in an effort to find a viable solution to the issues plaguing the country. " Peace before Elections vs Elections before Peace " became a key debate topic and this quickly became a point of national discussion. The discussions eventually concluded with key stakeholders, including Bio's administration and the UN, agreeing that while efforts in finding a peaceful solution to ending the war should continue, a general election should be held as soon as possible. Bio handed power over to Ahmad Tejan Kabbah of the SLPP, after the conclusion of elections in early 1996 which Kabbah won. President Kabbah took power with a great promise of ending the civil war. After taking over, President Kabbah immediately opened dialogue with the RUF and invited their leader Foday Sankoh for peace negotiations. On 25 May 1997, 17 soldiers in the Sierra Leone army led by Corporal Tamba Gborie, loyal to the detained Major Johnny Paul Koroma , launched a military coup which sent President Kabbah into exile in Guinea and they established the Armed Forces Revolutionary Council (AFRC). Corporal Gborie quickly went to the Sierra Leone Broadcasting Services headquarters in New England, Freetown to announce the coup to a shocked nation and to alert all soldiers across the country to report for guard duty. The soldiers immediately released Koroma from prison and installed him as their chairman and Head of State. Koroma suspended the constitution, banned demonstrations, shut down all private radio stations in the country and invited the RUF to join the new junta government, with its leader Foday Sankoh as the Vice-Chairman of the new AFRC-RUF coalition junta government. Within days, Freetown was overwhelmed by the presence of the RUF combatants who came to the city in thousands. The Kamajors, a group of traditional fighters mostly from the Mende ethnic group under the command of deputy Defence Minister Samuel Hinga Norman , remained loyal to President Kabbah and defended the Southern part of Sierra Leone from the soldiers. After nine months in office, the junta was overthrown by the Nigerian-led ECOMOG forces, and the democratically elected government of president Kabbah was reinstated in February 1998. On 19 October 1998, 24 soldiers in the Sierra Leone army—including Gborie, Brigadier Hassan Karim Conteh, Colonel Samuel Francis Koroma, Major Kula Samba and Colonel Abdul Karim Sesay—were executed by firing squad after they were convicted in a court martial in Freetown, some for orchestrating the 1997 coup that overthrew President Kabbah and others for failure to reverse the mutiny. In October 1999, the United Nations agreed to send peacekeepers to help restore order and disarm the rebels. The first of the 6,000-member force began arriving in December, and the UN Security Council voted in February 2000 to increase the force to 11,000, and later to 13,000. But in May, when nearly all Nigerian forces had left and UN forces were trying to disarm the RUF in eastern Sierra Leone, Sankoh 's forces clashed with the UN troops, and some 500 peacekeepers were taken hostage as the peace accord effectively collapsed. The hostage crisis resulted in more fighting between the RUF and the government as UN troops launched Operation Khukri to end the siege. The Operation was successful with Indian and British Special Forces being the main contingents. The situation in the country deteriorated to such an extent that British troops were deployed in Operation Palliser , originally simply to evacuate foreign nationals. However, the British exceeded their original mandate and took full military action to finally defeat the rebels and restore order. The British were the catalyst for the ceasefire that ended the civil war. Elements of the British Army , together with administrators and politicians, remained after withdrawal to help train the armed forces, improve the infrastructure of the country and administer financial and material aid. Tony Blair , the Prime Minister of Britain at the time of the British intervention, is regarded as a hero by the people of Sierra Leone, many of whom are keen for more British involvement. Between 1991 and 2001, about 50,000 people were killed in Sierra Leone's civil war. Hundreds of thousands of people were forced from their homes and many became refugees in Guinea and Liberia . In 2001, UN forces moved into rebel-held areas and began to disarm rebel soldiers. By January 2002, the war was declared over. In May 2002, Kabbah was re-elected president by a landslide. By 2004, the disarmament process was complete. Also in 2004, a UN-backed war crimes court began holding trials of senior leaders from both sides of the war. In December 2005, UN peacekeeping forces pulled out of Sierra Leone. The elections in 2007 and 2012 marked a return to multi-party democracy , with Ernest Bai Koroma 's election signaling a period of stability and recovery from the civil war. The Ebola epidemic in 2014 posed a significant health crisis, leading to a national state of emergency and highlighting the ongoing challenges faced by Sierra Leone in public health and governance. Sierra Leone's history is marked by continuous human habitation for at least 2,500 years, influenced by migrations from across Africa. The adoption of iron technology by the ninth century and the establishment of agriculture by 1000 AD along the coast. Climate shifts over centuries altered the ecological zones, influencing migration and conquest dynamics. The region's dense tropical rainforest and swamps, coupled with the presence of the tsetse fly which carried a disease fatal to horses and the zebu cattle used by the Mandé people , provided natural defenses against invasions by the Mandinka Empire and other African empires, and limited influence by the Mali Empire , preserving its indigenous cultures from external dominions. The introduction of Islam by Susu traders, merchants and migrants in the 18th century further enriched the cultural tapestry, eventually establishing a strong foothold in the north. The later conquest by Samory Touré in the northeast solidified Islam among the Yalunka , Kuranko and Limba people. The 15th century marked the beginning of European interaction with Sierra Leone, highlighted by Portuguese explorer Pedro de Sintra mapping the region in 1462 and naming it after the lioness mountains. This naming has been subject to historical reinterpretation, suggesting earlier European knowledge of the region. Following Sintra, European traders established fortified posts, engaging primarily in the slave trade , which shaped the socio-economic landscape significantly. Traders from European nations, such as the Dutch Republic , England and France also started to arrive in Sierra Leone and establish trading stations. These stations quickly began to primarily deal in slaves, who were brought to the coast by indigenous traders from interior areas undergoing wars and conflicts over territory. The Europeans made payments, called Cole , for rent, tribute, and trading rights, to the king of an area. Local Afro-European merchants often acted as middlemen, the Europeans advancing them goods to trade to indigenous merchants, most often for slaves and ivory. Portuguese traders were particularly drawn to the local craftsmanship in ivory , leading to a notable trade in ivory artifacts such as horns, saltcellars , and spoons. This exchange underscored the region's artistic talents during the period.The 1600s witnessed several waves of Mane people migrating into Sierra Leone, adding to the region's cultural diversity. [ citation needed ]In the late 18th century, African Americans who had fought for the British Crown during the American Revolutionary War were resettled in Sierra Leone, forming a unique community named Black Loyalists . This resettlement scheme was partly motivated by social issues in London, with the Sierra Leone Resettlement Scheme offering a new beginning for the Black Poor , though it was fraught with challenges. In the late 18th century, many African Americans claimed the protection of the British Crown. There were thousands of these Black Loyalists, people of African ancestry who joined the British military forces during the American Revolutionary War. Many of these Loyalists had been slaves who had escaped to join the British, lured by promises of freedom ( emancipation ). The official documentation known as the Book of Negroes lists thousands of freed slaves whom the British evacuated from the nascent United States and resettled in colonies elsewhere in British North America (north to Canada, or south to the West Indies). Pro-slavery advocates accused the Black Poor of being responsible for a large proportion of crime in 18th century London. While the broader community included some women, the Black Poor seems to have exclusively consisted of men, some of whom developed relationships with local women and often married them. Slave owner Edward Long criticized marriage between black men and white women. However, on the voyage between Plymouth, England and Sierra Leone, seventy European girlfriends and wives accompanied the Black Poor settlers . Many in London thought that moving them to Sierra Leone would lift them out of poverty. The Sierra Leone Resettlement Scheme was proposed by entomologist Henry Smeathman and drew interest from humanitarians like Granville Sharp , who saw it as a means of showing the pro-slavery lobby that black people could contribute towards the running of the new colony of Sierra Leone. Government officials soon became involved in the scheme as well, although their interest was spurred by the possibility of resettling a large group of poor citizens elsewhere. William Pitt the Younger , prime minister and leader of the Tory party, had an active interest in the Scheme because he saw it as a means to repatriate the Black Poor to Africa, since "it was necessary they should be sent somewhere, and be no longer suffered to infest the streets of London". In January 1787, the Atlantic and the Belisarius set sail for Sierra Leone, but bad weather forced them to divert to Plymouth, during which time about 50 passengers died. Another 24 were discharged, and another 23 ran away. Eventually, with some more recruitment, 411 passengers sailed to Sierra Leone in April 1787. On the voyage between Plymouth and Sierra Leone, 96 passengers died. In 1787 the British Crown founded a settlement in Sierra Leone in what was called the " Province of Freedom ". About 400 black and 60 white colonists reached Sierra Leone on 15 May 1787. After they established Granville Town , most of the first group of colonists died, owing to disease and warfare with the indigenous African peoples ( Temne ), who resisted their encroachment. When the ships left them in September, their numbers had been reduced to "276 persons, namely 212 black men, 30 black women, 5 white men and 29 white women". The settlers that remained forcibly captured land from a local African chieftain, but he retaliated, attacking the settlement, which was reduced to a mere 64 settlers comprising 39 black men, 19 black women, and six white women. Black settlers were captured by unscrupulous traders and sold as slaves, and the remaining colonists were forced to arm themselves for their own protection. The 64 remaining colonists established a second Granville Town. In the late 18th century, many African Americans claimed the protection of the British Crown. There were thousands of these Black Loyalists, people of African ancestry who joined the British military forces during the American Revolutionary War. Many of these Loyalists had been slaves who had escaped to join the British, lured by promises of freedom ( emancipation ). The official documentation known as the Book of Negroes lists thousands of freed slaves whom the British evacuated from the nascent United States and resettled in colonies elsewhere in British North America (north to Canada, or south to the West Indies). Pro-slavery advocates accused the Black Poor of being responsible for a large proportion of crime in 18th century London. While the broader community included some women, the Black Poor seems to have exclusively consisted of men, some of whom developed relationships with local women and often married them. Slave owner Edward Long criticized marriage between black men and white women. However, on the voyage between Plymouth, England and Sierra Leone, seventy European girlfriends and wives accompanied the Black Poor settlers . Many in London thought that moving them to Sierra Leone would lift them out of poverty. The Sierra Leone Resettlement Scheme was proposed by entomologist Henry Smeathman and drew interest from humanitarians like Granville Sharp , who saw it as a means of showing the pro-slavery lobby that black people could contribute towards the running of the new colony of Sierra Leone. Government officials soon became involved in the scheme as well, although their interest was spurred by the possibility of resettling a large group of poor citizens elsewhere. William Pitt the Younger , prime minister and leader of the Tory party, had an active interest in the Scheme because he saw it as a means to repatriate the Black Poor to Africa, since "it was necessary they should be sent somewhere, and be no longer suffered to infest the streets of London". In January 1787, the Atlantic and the Belisarius set sail for Sierra Leone, but bad weather forced them to divert to Plymouth, during which time about 50 passengers died. Another 24 were discharged, and another 23 ran away. Eventually, with some more recruitment, 411 passengers sailed to Sierra Leone in April 1787. On the voyage between Plymouth and Sierra Leone, 96 passengers died. In 1787 the British Crown founded a settlement in Sierra Leone in what was called the " Province of Freedom ". About 400 black and 60 white colonists reached Sierra Leone on 15 May 1787. After they established Granville Town , most of the first group of colonists died, owing to disease and warfare with the indigenous African peoples ( Temne ), who resisted their encroachment. When the ships left them in September, their numbers had been reduced to "276 persons, namely 212 black men, 30 black women, 5 white men and 29 white women". The settlers that remained forcibly captured land from a local African chieftain, but he retaliated, attacking the settlement, which was reduced to a mere 64 settlers comprising 39 black men, 19 black women, and six white women. Black settlers were captured by unscrupulous traders and sold as slaves, and the remaining colonists were forced to arm themselves for their own protection. The 64 remaining colonists established a second Granville Town. Following the American Revolution, Black Loyalists from Nova Scotia , Canada, were relocated to Sierra Leone, founding Freetown and contributing significantly to the Krio people and Krio language that would come to define the region. Following the American Revolution , more than 3,000 Black Loyalists had also been settled in Nova Scotia , where they were finally granted land. They founded Birchtown , but faced harsh northern winters and racial discrimination from nearby Shelburne . Thomas Peters pressed British authorities for relief and more aid; together with British abolitionist John Clarkson , the Sierra Leone Company was established to relocate Black Loyalists who wanted to take their chances in West Africa. In 1792 nearly 1,200 persons from Nova Scotia crossed the Atlantic to build the second (and only permanent) Colony of Sierra Leone and the settlement of Freetown on 11 March 1792. In Sierra Leone they were called the Nova Scotian Settlers , the Nova Scotians , or the Settlers . Clarkson initially banned the survivors of Granville Town from joining the new settlement, blaming them for the demise of Granville Town. The Settlers built Freetown in the styles they knew from their lives in the American South ; they also continued American fashion and American manners. In addition, many continued to practise Methodism in Freetown. In the 1790s, the Settlers, including adult women, voted for the first time in elections. In 1792, in a move that foreshadowed the women's suffrage movements in Britain, the heads of all households, of which a third were women, were given the right to vote. Black settlers in Sierra Leone enjoyed much more autonomy than their white equivalent in European countries. Black migrants elected different levels of political representatives, 'tithingmen', who represented each dozen settlers and 'hundreders' who represented larger amounts. This sort of representation was not available in Nova Scotia. The initial process of society-building in Freetown was a harsh struggle. The Crown did not supply enough basic supplies and provisions and the Settlers were continually threatened by illegal slave trading and the risk of re-enslavement. The Sierra Leone Company, controlled by London investors, refused to allow the settlers to take freehold of the land. In 1799 some of the settlers revolted. The Crown subdued the revolt by bringing in forces of more than 500 Jamaican Maroons , whom they transported from Cudjoe's Town (Trelawny Town) via Nova Scotia in 1800. Led by Colonel Montague James , the Maroons helped the colonial forces to put down the revolt, and in the process the Jamaican Maroons in Sierra Leone secured the best houses and farms. On 1 January 1808, Thomas Ludlam , the Governor of the Sierra Leone Company and a leading abolitionist, surrendered the company's charter. This ended its 16 years of running the Colony. The British Crown reorganised the Sierra Leone Company as the African Institution ; it was directed to improve the local economy. Its members represented both British who hoped to inspire local entrepreneurs and those with interest in the Macauley & Babington Company, which held the (British) monopoly on Sierra Leone trade. At about the same time (following the Slave Trade Act 1807 which abolished the slave trade), Royal Navy crews delivered thousands of formerly enslaved Africans to Freetown, after liberating them from illegal slave ships. These Liberated Africans or recaptives were sold for $20 a head as apprentices to the white settlers, Nova Scotian Settlers, and the Jamaican Maroons. Many Liberated Africans were treated poorly and even abused because some of the original settlers considered them their property. Cut off from their various homelands and traditions, the Liberated Africans were forced to assimilate to the Western styles of Settlers and Maroons. For example, some of the Liberated Africans were forced to change their name to a more Western sounding one. Though some people happily embraced these changes because they considered it as being part of the community, some were not happy with these changes and wanted to keep their own identity. Many Liberated Africans were so unhappy that they risked the possibility of being sold back into slavery by leaving Sierra Leone and going back to their original villages. The Liberated Africans eventually modified their customs to adopt those of the Nova Scotians, Maroons and Europeans, yet kept some of their ethnic traditions. As the Liberated Africans became successful traders and spread Christianity throughout West Africa, they intermarried with the Nova Scotians and Maroons, and the two groups eventually became a fusion of African and Western societies. : 3–4, 223–255 These Liberated Africans were from many areas of Africa, but principally the west coast. Between the 18th and 19th century, freed African Americans, some Americo Liberian "refugees", and particularly Afro-Caribbeans , mainly Jamaican Maroons, also immigrated and settled in Freetown. Together these peoples formed the Creole/Krio ethnicity and an English-based creole language ( Krio ), which is the lingua franca and de facto national language used among many of the ethnicities in the country. The colonial era saw Sierra Leone evolving under British rule, with a unique settlement pattern composed of displaced Africans following the abolition of the slave trade . Sierra Leone developed as an educational center in West Africa, with the establishment of Fourah Bay College in 1827, attracting English-speaking Africans from across the region. The settlement of Sierra Leone in the 1800s was unique in that the population was composed of displaced Africans who were brought to the colony after the British abolition of the slave trade in 1807. Upon arrival in Sierra Leone, each recaptive was given a registration number, and information on their physical qualities would be entered into the Register of Liberated Africans. Oftentimes the documentation would be overwhelmingly subjective and would result in inaccurate entries, making them difficult to track. In addition, differences between the Register of Liberated Africans of 1808 and the List of Captured Negroes of 1812 (which emulated the 1808 document) revealed some disparities in the entries of the recaptives, specifically in the names; many recaptives decided to change their given names to more anglicised versions which contributed to the difficulty in tracking them after they arrived in Sierra Leone. In the early 19th century, Freetown served as the residence of the British colonial governor of the region, who also administered the Gold Coast (now Ghana ) and the Gambia settlements. Sierra Leone developed as the educational centre of British West Africa . The British established Fourah Bay College in 1827, which rapidly became a magnet for English-speaking Africans on the West Coast. For more than a century, it was the only European-style university in western Sub-Saharan Africa . Samuel Ajayi Crowther was the first student to be enrolled at Fourah Bay. Fourah Bay College soon became a magnet for Creoles/Krio people and other Africans seeking higher education in British West Africa. These included Nigerians, Ghanaians, Ivorians and many more, especially in the fields of theology and education. Freetown was known as the " Athens of Africa" due to the large number of excellent schools in Freetown and surrounding areas. The British interacted mostly with the Krio people in Freetown, who did most of the trading with the indigenous peoples of the interior. Educated Krio people held numerous positions in the colonial government, giving them status and well-paying positions. Following the Berlin Conference of 1884–1885, the British decided that they needed to establish more dominion over the inland areas, to satisfy what was described by the European powers as "effective occupation" of territories. In 1896 it annexed these areas, declaring them the Sierra Leone Protectorate. With this change, the British began to expand their administration in the region, recruiting British citizens to posts and pushing Krio people out of positions in government and even the desirable residential areas in Freetown. During the British annexation in Sierra Leone, several chiefs in the northern and southern parts of the country were resisting the "hut tax" imposed by the colonial administrators but they used diplomacy to achieve their goal. In the north, from 1820 to 1906, there was a Limba chief named Almamy Suluku who ruled his territory for many years, fighting to protect his territory, while at the same time using diplomacy to trick the protectorate administrators while sending fighters to assist Bai Bureh , a prominent Temne chief in Kasseh who was fighting against the imposition of the "hut tax" by the colonial administrators. The war was later known as the Hut Tax War . Another prominent figure in Sierra Leone history is Bai Sherbro ( c. 1830–1912 ). Bai Sherbro was a chief and warrior on Bonthe Island, in the southwestern part of the country. He, like Bai Bureh, resisted the British. Sherbro also sent fighters to assist Bai Bureh in the fight against the British. Sherbro was influential and powerful and the British greatly feared him. Bai Sherbro was captured and with Bai Bureh, exiled to the Gold Coast (modern Ghana). Nyagua ( c. 1842 –1906), also known as the "Tracking King", was a fierce king who captured many districts and many people came to join him for protection. Nyagua also resisted the British. Realizing that he lacked sufficient strength, he resorted to diplomacy. At the same time, he sent warriors to assist Bai Bureh in fighting against the British. The British later captured Nyagua, and he was also exiled to the Gold Coast. Madam Yoko ( c. 1849 –1906) was a brilliant woman of culture and ambition. She employed her capacity for friendly communications to persuade the British to give her control of the Kpaa Mende chiefdom. She used diplomacy to communicate with many local chiefs who did not trust her friendship with the British. Because Madam Yoko supported the British, some sub-chiefs rebelled, causing Yoko to take refuge in the police barracks. For her loyalty, she was awarded a silver medal by Queen Victoria . Until 1906, Madam Yoko ruled as a paramount chief in the new British Protectorate. It appears that she committed suicide at the age of fifty-five, perhaps due to the loss of support from her own people. The British annexation of the Protectorate interfered with the sovereignty of indigenous chiefs. They designated chiefs as units of local government, rather than dealing with them individually as had been the previous practice. They did not maintain relationships even with longstanding allies, such as Bai Bureh, who was later unfairly portrayed as a prime instigator of the Hut Tax War. Colonel Frederic Cardew , military governor of the Protectorate, in 1898 established a new tax on dwellings and demanded that the chiefs use their people to maintain roads. The taxes were often higher than the value of the dwellings, and 24 chiefs signed a petition to Cardew, stating how destructive this was; their people could not afford to take time off from their subsistence agriculture. They resisted payment of taxes, tensions over the new colonial requirements and the administration's suspicions towards the chiefs, led to the Hut Tax war of 1898, also called the Temne-Mende War. The British fired first; the northern front of mainly Temne people was led by Bai Bureh. The southern front, consisting mostly of Mende people , entered the conflict somewhat later, for other reasons. For several months, Bureh's fighters had the advantage over the vastly more powerful British forces but both sides suffered hundreds of fatalities. Bureh surrendered on 11 November 1898 to end the destruction of his people's territory and dwellings. Although the British government recommended leniency, Cardew insisted on sending the chief and two allies into exile in the Gold Coast; his government hanged 96 of the chief's warriors. Bureh was allowed to return in 1905, when he resumed his chieftaincy of Kasseh. The defeat of the Temne and Mende in the Hut Tax war ended mass resistance to the Protectorate and colonial government, but intermittent rioting and labour unrest continued throughout the colonial period. Riots in 1955 and 1956 involved "tens of thousands" of Sierra Leoneans in the Protectorate. Domestic slavery , which continued to be practised by local African elites, was abolished in 1928. A notable event in 1935 was the granting of a monopoly on mineral mining to the Sierra Leone Selection Trust , run by De Beers . The monopoly was scheduled to last 98 years. Mining of diamonds in the east and other minerals expanded, drawing labourers there from other parts of the country. In 1924, the UK government divided the administration of Sierra Leone into Colony and Protectorate, with different political systems constitutionally defined for each. The Colony was Freetown and its coastal area; the Protectorate was defined as the hinterland areas dominated by local chiefs. Antagonism between the two entities escalated to a heated debate in 1947, when proposals were introduced to provide for a single political system for both the Colony and the Protectorate. Most of the proposals came from leaders of the Protectorate, whose population far outnumbered that in the colony. The Krios, led by Isaac Wallace-Johnson , opposed the proposals, as they would have resulted in reducing the political power of the Krios in the Colony. In 1951, Lamina Sankoh ( born : Etheldred Jones) collaborated with educated protectorate leaders from different groups, including Sir Milton Margai , Siaka Stevens , Mohamed Sanusi Mustapha, John Karefa-Smart , Kande Bureh, Sir Albert Margai , Amadu Wurie and Sir Banja Tejan-Sie joined together with the powerful paramount chiefs in the protectorate to form the Sierra Leone People's Party or SLPP as the party of the Protectorate. The SLPP leadership, led by Sir Milton Margai, negotiated with the British and the educated Krio-dominated colony based in Freetown to achieve independence. Owing to the astute politics of Milton Margai, the educated Protectorate elites were able to join forces with the paramount chiefs in the face of Krio intransigence. Later, Margai used the same skills to win over opposition leaders and moderate Krio elements to achieve independence from the UK. In November 1951, Margai oversaw the drafting of a new constitution, which united the separate Colonial and Protectorate legislatures and provided a framework for decolonisation . In 1953, Sierra Leone was granted local ministerial powers and Margai was elected Chief Minister of Sierra Leone. The new constitution ensured Sierra Leone had a parliamentary system within the Commonwealth of Nations . In May 1957, Sierra Leone held its first parliamentary election. The SLPP, which was then the most popular political party in the colony of Sierra Leone as well as being supported by the powerful paramount chiefs in the provinces, won the most seats in Parliament and Margai was re-elected as Chief Minister by a landslide.Sierra Leone gained independence from the United Kingdom in 1961, transitioning to a nation with its own governance structures, though it faced significant political instability post-independence, including the establishment of a one-party state and periods of civil unrest. On 20 April 1960, Milton Margai led a 24-member Sierra Leonean delegation at constitutional conferences that were held with the Government of Queen Elizabeth II and British Colonial Secretary Iain Macleod in negotiations for independence held in London. On the conclusion of talks in London on 4 May 1960, the United Kingdom agreed to grant Sierra Leone independence on 27 April 1961. On 27 April 1961, Sir Milton Margai led Sierra Leone to independence from Great Britain and became the country's first Prime Minister. Sierra Leone had its own parliament and its own prime minister, and had the ability to make 100% of its own laws, however, as with countries such as Canada and Australia, Sierra Leone remained a "Dominion" and Queen Elizabeth was Queen of the independent Dominion of Sierra Leone . Thousands of Sierra Leoneans took to the streets in celebration. The Dominion of Sierra Leone retained a parliamentary system of government and was a member of the Commonwealth of Nations. The leader of the main opposition All People's Congress (APC), Siaka Stevens, along with Isaac Wallace-Johnson, another outspoken critic of the SLPP government, were arrested and placed under house arrest in Freetown, along with sixteen others charged with disrupting the independence celebration. In May 1962, Sierra Leone held its first general election as an independent nation. The Sierra Leone People's Party (SLPP) won a plurality of seats in parliament, and Milton Margai was re-elected as prime minister. Margai was popular among Sierra Leoneans during his time in power, mostly known for his self-effacement. He was neither corrupt nor did he make a lavish display of his power or status. He based the government on the rule of law and the separation of powers, with multiparty political institutions and fairly viable representative structures. Margai used his conservative ideology to lead Sierra Leone without much strife. He appointed government officials to represent various ethnic groups. Margai employed a brokerage style of politics, by sharing political power among political parties and interest groups; especially the involvement of powerful paramount chiefs in the provinces, most of whom were key allies of his government. [ citation needed ] Upon Milton Margai's unexpected death in 1964, his younger half-brother , Sir Albert Margai, was appointed as Prime Minister by parliament. Sir Albert's leadership was briefly challenged by Foreign Minister John Karefa-Smart, who questioned Sir Albert's succession to the SLPP leadership position. Karefa-Smart led a prominent small minority faction within the SLPP party in opposition of Albert Margai as Prime Minister. However, Karefa-Smart failed to receive broad support within the SLPP in his attempt to oust Albert Margai as both the leader of the SLPP and Prime Minister. The large majority of SLPP members backed Albert Margai over Karefa-Smart. Soon after Albert Margai was sworn in as Prime Minister, he fired several senior government officials who had served in his elder brother Sir Milton's government, viewing them as a threat to his administration, including Karefa-Smart. Sir Albert resorted to increasingly authoritarian actions in response to protests and enacted several laws against the opposition All People's Congress, whilst attempting to establish a one-party state . Sir Albert was opposed to the colonial legacy of allowing executive powers to the Paramount Chiefs, many of whom had been key allies of his late brother Sir Milton. Accordingly, they began to consider Sir Albert a threat to the ruling houses across the country. Margai appointed many non-Creoles to the country's civil service in Freetown, in an overall diversification of the civil service in the capital, which had been dominated by members of the Creole ethnic group. As a result, Albert Margai became unpopular in the Creole community, many of whom had supported Sir Milton. Margai sought to make the army homogeneously Mende , his own ethnic group, and was accused of favouring members of the Mende for prominent positions. In 1967, riots broke out in Freetown against Margai's policies; in response, he declared a state of emergency across the country. Sir Albert was accused of corruption and of a policy of affirmative action in favour of the Mende ethnic group. He also endeavoured to change Sierra Leone from a democracy to a one-party state . Although possessing the full backing of the country's security forces, he called for free and fair elections. [ citation needed ] The APC, with its leader Siaka Stevens , narrowly won a small majority of seats in Parliament over the SLPP in a closely contested 1967 general election . Stevens was sworn in as Prime Minister on 21 March 1967. Within hours after taking office, Stevens was ousted in a bloodless military coup led by Brigadier General David Lansana , the commander of the Sierra Leone Armed Forces . He was a close ally of Albert Margai, who had appointed him to the position in 1964. Lansana placed Stevens under house arrest in Freetown and insisted that the determination of the Prime Minister should await the election of the tribal representatives to the House. Steven was later freed and fled the country, going into exile in neighbouring Guinea. However, on 23 March 1967, a group of military officers in the Sierra Leone Army led by Brigadier General Andrew Juxon-Smith , staged a counter-coup against Commander Lansana. They seized control of the government, arrested Lansana, and suspended the constitution. The group set up the National Reformation Council (NRC), with Andrew Juxon-Smith as its chairman and Head of State of the country. On 18 April 1968 a group of low-ranking soldiers in the Sierra Leone Army who called themselves the Anti-Corruption Revolutionary Movement (ACRM), led by Brigadier General John Amadu Bangura , overthrew the NRC junta . The ACRM junta arrested many senior NRC members. They reinstated the constitution and returned power to Stevens, who at last assumed the office of Prime Minister. Stevens had Bangura arrested in 1970 and charged with conspiracy and treason. He was found guilty and sentenced to death, despite the fact that it was Bangura whose actions led to Stevens' return to power. Brigadier Lansana and Hinga Norman , the main army officers involved in the first coup (1967), were unceremoniously dismissed from the armed forces and made to serve time in prison. Norman was a guard to Governor-general Sir Henry Lightfoot-Boston . Lansana was later tried and found guilty of treason and sentenced to death in 1975. Stevens assumed power as Prime Minister again in 1968, following a series of coups, with a great deal of hope and ambition. Much trust was placed upon him as he championed multi-party politics. Stevens had campaigned on a platform of bringing the tribes together under socialist principles. During his first decade or so in power, Stevens renegotiated some of what he called "useless prefinanced schemes" contracted by his predecessors, both Albert Margai of the SLPP and Juxon-Smith of the NRC. Some of these policies by the SLPP and the NRC were said to have left the country in an economically deprived state. Stevens reorganised the country's oil refinery, the government-owned Cape Sierra Hotel, and a cement factory. He cancelled Juxon-Smith's construction of a church and mosque on the grounds of Victoria Park (now known as Freetown Amusement Park – since 2017). Stevens began efforts that would later improve transportation and movements between the provinces and the city of Freetown. Roads and hospitals were constructed in the provinces, and Paramount Chiefs and provincial peoples became a prominent force in Freetown. Under the pressure of several coup attempts, real or perceived, Stevens' rule grew more and more authoritarian , and his relationship with some of his ardent supporters deteriorated. He removed the SLPP party from competitive politics in general elections, some believed, through the use of violence and intimidation. To maintain the support of the military, Stevens retained the popular John Amadu Bangura as head of the Sierra Leone Armed Forces. After the return to civilian rule, by-elections were held (beginning in autumn 1968) and an all-APC cabinet was appointed. Calm was not completely restored. In November 1968, unrest in the provinces led Stevens to declare a state of emergency across the country. Many senior officers in the Sierra Leone Army were greatly disappointed with Stevens' policies and his handling of the Sierra Leone Military, but none could confront Stevens. Brigadier General Bangura, who had reinstated Stevens as Prime Minister, was widely considered the only person who could control Stevens. The army was devoted to Bangura, and this made him potentially dangerous to Stevens. In January 1970, Bangura was arrested and charged with conspiracy and plotting to commit a coup against the Stevens government. After a trial that lasted a few months, Bangura was convicted and sentenced to death . On 29 March 1970, Brigadier Bangura was executed by hanging in Freetown. After the execution of Bangura, a group of soldiers loyal to the executed general held a mutiny in Freetown and other parts of the country in opposition to Stevens' government. Dozens of soldiers were arrested and convicted by a court martial in Freetown for their participation in the mutiny against the president. Among the soldiers arrested was a little-known army corporal , Foday Sankoh , a strong Bangura supporter, who would later form the Revolutionary United Front (RUF) . Corporal Sankoh was convicted and jailed for seven years at the Pademba Road Prison in Freetown. In April 1971, a new republican constitution was adopted under which Stevens became president. In the 1972 by-elections, the opposition SLPP complained of intimidation and procedural obstruction by the APC and militia. These problems became so severe that the SLPP boycotted the 1973 general election ; as a result, the APC won 84 of the 85 elected seats. An alleged plot to overthrow President Stevens failed in 1974 and its leaders were executed. In mid-1974, Guinean soldiers, as requested by Stevens, were stationed in the country to help maintain his hold on power, as Stevens was a close ally of then-Guinean president Ahmed Sékou Touré . In March 1976, Stevens was elected without opposition for a second five-year term as president. On 19 July 1975, 14 senior army and government officials, including David Lansana, former cabinet minister Mohamed Sorie Forna (father of writer Aminatta Forna ), Brigadier General Ibrahim Bash Taqi and Lieutenant Habib Lansana Kamara were executed after being convicted of attempting a coup to topple president Stevens' government. In 1977, a nationwide student demonstration against the government disrupted Sierra Leone's politics. The demonstration was quickly put down by the army and Stevens' own personal Special Security Division (SSD), a heavily armed paramilitary force he had created to protect him and maintain his hold on power. SSD officers were loyal to Stevens and were deployed across the country to clamp down on any rebellion or protest against Stevens' government. A general election was called later that year in which corruption was again endemic; the APC won 74 seats and the SLPP 15. In 1978, the APC-dominant parliament approved a new constitution making the country a one-party state. The 1978 constitution made the APC the only legal political party in Sierra Leone. This move led to another major demonstration against the government in many parts of the country, but it was also put down by the army and Stevens' SSD force. Stevens is generally criticised for dictatorial methods and government corruption, but on a positive note, he kept the country stable and from collapsing into civil war. He created several government institutions that are still in use today. [ citation needed ] Stevens also reduced ethnic polarisation in government by incorporating members of various ethnic groups into his all-dominant APC government. Siaka Stevens retired from politics in November 1985 after being in power for eighteen years. The APC named a new presidential candidate to succeed Stevens at the party's last delegate conference, held in Freetown in November 1985. The candidate was Major General Joseph Saidu Momoh , head of the Sierra Leone Armed Forces and Stevens' own choice to succeed him. As head of the armed forces, General Momoh had been loyal to Stevens, who had appointed him to the position. Like Stevens, Momoh was also a member of the minority Limba ethnic group. As the sole candidate, Momoh was elected president without opposition and sworn in as Sierra Leone's second president on 28 November 1985 in Freetown. A one-party parliamentary election between APC members was held in May 1986. President Momoh appointed his former military colleague and key ally, Major General Mohamed Tarawalie to succeed him as the head of the Sierra Leone Military. General Tarawalie was also a strong loyalist and key Momoh supporter. President Momoh named James Bambay Kamara as the head of the Sierra Leone Police . Bambay Kamara was also a strong Momoh loyalist and supporter. Momoh broke from former President Siaka Stevens by integrating the powerful SSD into the Sierra Leone Police as a special paramilitary force . Under President Stevens, the SSD had been a powerful personal force used to maintain his hold on power, independent from the Sierra Leone Military and Sierra Leone Police Force. The Sierra Leone Police under Bambay Kamara's leadership was accused of physical violence, arrest, and intimidation against critics of President Momoh's government. President Momoh's strong links with the army and his verbal attacks on corruption earned him much-needed initial support among Sierra Leoneans. With the lack of new faces in the new APC cabinet under President Momoh and the return of many of the old faces from Stevens' government, criticisms soon arose that Momoh was simply perpetuating the rule of Stevens. The next few years under the Momoh administration were characterised by corruption, which Momoh defused by sacking several senior cabinet ministers. To formalise his war against corruption, President Momoh announced a " Code of Conduct for Political Leaders and Public Servants". After an alleged attempt to overthrow President Momoh in March 1987, more than 60 senior government officials were arrested, including Vice-President Francis Minah , who was removed from office, convicted of plotting the coup, and executed by hanging in 1989, along with five others.On 20 April 1960, Milton Margai led a 24-member Sierra Leonean delegation at constitutional conferences that were held with the Government of Queen Elizabeth II and British Colonial Secretary Iain Macleod in negotiations for independence held in London. On the conclusion of talks in London on 4 May 1960, the United Kingdom agreed to grant Sierra Leone independence on 27 April 1961. On 27 April 1961, Sir Milton Margai led Sierra Leone to independence from Great Britain and became the country's first Prime Minister. Sierra Leone had its own parliament and its own prime minister, and had the ability to make 100% of its own laws, however, as with countries such as Canada and Australia, Sierra Leone remained a "Dominion" and Queen Elizabeth was Queen of the independent Dominion of Sierra Leone . Thousands of Sierra Leoneans took to the streets in celebration. The Dominion of Sierra Leone retained a parliamentary system of government and was a member of the Commonwealth of Nations. The leader of the main opposition All People's Congress (APC), Siaka Stevens, along with Isaac Wallace-Johnson, another outspoken critic of the SLPP government, were arrested and placed under house arrest in Freetown, along with sixteen others charged with disrupting the independence celebration. In May 1962, Sierra Leone held its first general election as an independent nation. The Sierra Leone People's Party (SLPP) won a plurality of seats in parliament, and Milton Margai was re-elected as prime minister. Margai was popular among Sierra Leoneans during his time in power, mostly known for his self-effacement. He was neither corrupt nor did he make a lavish display of his power or status. He based the government on the rule of law and the separation of powers, with multiparty political institutions and fairly viable representative structures. Margai used his conservative ideology to lead Sierra Leone without much strife. He appointed government officials to represent various ethnic groups. Margai employed a brokerage style of politics, by sharing political power among political parties and interest groups; especially the involvement of powerful paramount chiefs in the provinces, most of whom were key allies of his government. [ citation needed ]Upon Milton Margai's unexpected death in 1964, his younger half-brother , Sir Albert Margai, was appointed as Prime Minister by parliament. Sir Albert's leadership was briefly challenged by Foreign Minister John Karefa-Smart, who questioned Sir Albert's succession to the SLPP leadership position. Karefa-Smart led a prominent small minority faction within the SLPP party in opposition of Albert Margai as Prime Minister. However, Karefa-Smart failed to receive broad support within the SLPP in his attempt to oust Albert Margai as both the leader of the SLPP and Prime Minister. The large majority of SLPP members backed Albert Margai over Karefa-Smart. Soon after Albert Margai was sworn in as Prime Minister, he fired several senior government officials who had served in his elder brother Sir Milton's government, viewing them as a threat to his administration, including Karefa-Smart. Sir Albert resorted to increasingly authoritarian actions in response to protests and enacted several laws against the opposition All People's Congress, whilst attempting to establish a one-party state . Sir Albert was opposed to the colonial legacy of allowing executive powers to the Paramount Chiefs, many of whom had been key allies of his late brother Sir Milton. Accordingly, they began to consider Sir Albert a threat to the ruling houses across the country. Margai appointed many non-Creoles to the country's civil service in Freetown, in an overall diversification of the civil service in the capital, which had been dominated by members of the Creole ethnic group. As a result, Albert Margai became unpopular in the Creole community, many of whom had supported Sir Milton. Margai sought to make the army homogeneously Mende , his own ethnic group, and was accused of favouring members of the Mende for prominent positions. In 1967, riots broke out in Freetown against Margai's policies; in response, he declared a state of emergency across the country. Sir Albert was accused of corruption and of a policy of affirmative action in favour of the Mende ethnic group. He also endeavoured to change Sierra Leone from a democracy to a one-party state . Although possessing the full backing of the country's security forces, he called for free and fair elections. [ citation needed ]The APC, with its leader Siaka Stevens , narrowly won a small majority of seats in Parliament over the SLPP in a closely contested 1967 general election . Stevens was sworn in as Prime Minister on 21 March 1967. Within hours after taking office, Stevens was ousted in a bloodless military coup led by Brigadier General David Lansana , the commander of the Sierra Leone Armed Forces . He was a close ally of Albert Margai, who had appointed him to the position in 1964. Lansana placed Stevens under house arrest in Freetown and insisted that the determination of the Prime Minister should await the election of the tribal representatives to the House. Steven was later freed and fled the country, going into exile in neighbouring Guinea. However, on 23 March 1967, a group of military officers in the Sierra Leone Army led by Brigadier General Andrew Juxon-Smith , staged a counter-coup against Commander Lansana. They seized control of the government, arrested Lansana, and suspended the constitution. The group set up the National Reformation Council (NRC), with Andrew Juxon-Smith as its chairman and Head of State of the country. On 18 April 1968 a group of low-ranking soldiers in the Sierra Leone Army who called themselves the Anti-Corruption Revolutionary Movement (ACRM), led by Brigadier General John Amadu Bangura , overthrew the NRC junta . The ACRM junta arrested many senior NRC members. They reinstated the constitution and returned power to Stevens, who at last assumed the office of Prime Minister. Stevens had Bangura arrested in 1970 and charged with conspiracy and treason. He was found guilty and sentenced to death, despite the fact that it was Bangura whose actions led to Stevens' return to power. Brigadier Lansana and Hinga Norman , the main army officers involved in the first coup (1967), were unceremoniously dismissed from the armed forces and made to serve time in prison. Norman was a guard to Governor-general Sir Henry Lightfoot-Boston . Lansana was later tried and found guilty of treason and sentenced to death in 1975. Stevens assumed power as Prime Minister again in 1968, following a series of coups, with a great deal of hope and ambition. Much trust was placed upon him as he championed multi-party politics. Stevens had campaigned on a platform of bringing the tribes together under socialist principles. During his first decade or so in power, Stevens renegotiated some of what he called "useless prefinanced schemes" contracted by his predecessors, both Albert Margai of the SLPP and Juxon-Smith of the NRC. Some of these policies by the SLPP and the NRC were said to have left the country in an economically deprived state. Stevens reorganised the country's oil refinery, the government-owned Cape Sierra Hotel, and a cement factory. He cancelled Juxon-Smith's construction of a church and mosque on the grounds of Victoria Park (now known as Freetown Amusement Park – since 2017). Stevens began efforts that would later improve transportation and movements between the provinces and the city of Freetown. Roads and hospitals were constructed in the provinces, and Paramount Chiefs and provincial peoples became a prominent force in Freetown. Under the pressure of several coup attempts, real or perceived, Stevens' rule grew more and more authoritarian , and his relationship with some of his ardent supporters deteriorated. He removed the SLPP party from competitive politics in general elections, some believed, through the use of violence and intimidation. To maintain the support of the military, Stevens retained the popular John Amadu Bangura as head of the Sierra Leone Armed Forces. After the return to civilian rule, by-elections were held (beginning in autumn 1968) and an all-APC cabinet was appointed. Calm was not completely restored. In November 1968, unrest in the provinces led Stevens to declare a state of emergency across the country. Many senior officers in the Sierra Leone Army were greatly disappointed with Stevens' policies and his handling of the Sierra Leone Military, but none could confront Stevens. Brigadier General Bangura, who had reinstated Stevens as Prime Minister, was widely considered the only person who could control Stevens. The army was devoted to Bangura, and this made him potentially dangerous to Stevens. In January 1970, Bangura was arrested and charged with conspiracy and plotting to commit a coup against the Stevens government. After a trial that lasted a few months, Bangura was convicted and sentenced to death . On 29 March 1970, Brigadier Bangura was executed by hanging in Freetown. After the execution of Bangura, a group of soldiers loyal to the executed general held a mutiny in Freetown and other parts of the country in opposition to Stevens' government. Dozens of soldiers were arrested and convicted by a court martial in Freetown for their participation in the mutiny against the president. Among the soldiers arrested was a little-known army corporal , Foday Sankoh , a strong Bangura supporter, who would later form the Revolutionary United Front (RUF) . Corporal Sankoh was convicted and jailed for seven years at the Pademba Road Prison in Freetown. In April 1971, a new republican constitution was adopted under which Stevens became president. In the 1972 by-elections, the opposition SLPP complained of intimidation and procedural obstruction by the APC and militia. These problems became so severe that the SLPP boycotted the 1973 general election ; as a result, the APC won 84 of the 85 elected seats. An alleged plot to overthrow President Stevens failed in 1974 and its leaders were executed. In mid-1974, Guinean soldiers, as requested by Stevens, were stationed in the country to help maintain his hold on power, as Stevens was a close ally of then-Guinean president Ahmed Sékou Touré . In March 1976, Stevens was elected without opposition for a second five-year term as president. On 19 July 1975, 14 senior army and government officials, including David Lansana, former cabinet minister Mohamed Sorie Forna (father of writer Aminatta Forna ), Brigadier General Ibrahim Bash Taqi and Lieutenant Habib Lansana Kamara were executed after being convicted of attempting a coup to topple president Stevens' government. In 1977, a nationwide student demonstration against the government disrupted Sierra Leone's politics. The demonstration was quickly put down by the army and Stevens' own personal Special Security Division (SSD), a heavily armed paramilitary force he had created to protect him and maintain his hold on power. SSD officers were loyal to Stevens and were deployed across the country to clamp down on any rebellion or protest against Stevens' government. A general election was called later that year in which corruption was again endemic; the APC won 74 seats and the SLPP 15. In 1978, the APC-dominant parliament approved a new constitution making the country a one-party state. The 1978 constitution made the APC the only legal political party in Sierra Leone. This move led to another major demonstration against the government in many parts of the country, but it was also put down by the army and Stevens' SSD force. Stevens is generally criticised for dictatorial methods and government corruption, but on a positive note, he kept the country stable and from collapsing into civil war. He created several government institutions that are still in use today. [ citation needed ] Stevens also reduced ethnic polarisation in government by incorporating members of various ethnic groups into his all-dominant APC government. Siaka Stevens retired from politics in November 1985 after being in power for eighteen years. The APC named a new presidential candidate to succeed Stevens at the party's last delegate conference, held in Freetown in November 1985. The candidate was Major General Joseph Saidu Momoh , head of the Sierra Leone Armed Forces and Stevens' own choice to succeed him. As head of the armed forces, General Momoh had been loyal to Stevens, who had appointed him to the position. Like Stevens, Momoh was also a member of the minority Limba ethnic group. As the sole candidate, Momoh was elected president without opposition and sworn in as Sierra Leone's second president on 28 November 1985 in Freetown. A one-party parliamentary election between APC members was held in May 1986. President Momoh appointed his former military colleague and key ally, Major General Mohamed Tarawalie to succeed him as the head of the Sierra Leone Military. General Tarawalie was also a strong loyalist and key Momoh supporter. President Momoh named James Bambay Kamara as the head of the Sierra Leone Police . Bambay Kamara was also a strong Momoh loyalist and supporter. Momoh broke from former President Siaka Stevens by integrating the powerful SSD into the Sierra Leone Police as a special paramilitary force . Under President Stevens, the SSD had been a powerful personal force used to maintain his hold on power, independent from the Sierra Leone Military and Sierra Leone Police Force. The Sierra Leone Police under Bambay Kamara's leadership was accused of physical violence, arrest, and intimidation against critics of President Momoh's government. President Momoh's strong links with the army and his verbal attacks on corruption earned him much-needed initial support among Sierra Leoneans. With the lack of new faces in the new APC cabinet under President Momoh and the return of many of the old faces from Stevens' government, criticisms soon arose that Momoh was simply perpetuating the rule of Stevens. The next few years under the Momoh administration were characterised by corruption, which Momoh defused by sacking several senior cabinet ministers. To formalise his war against corruption, President Momoh announced a " Code of Conduct for Political Leaders and Public Servants". After an alleged attempt to overthrow President Momoh in March 1987, more than 60 senior government officials were arrested, including Vice-President Francis Minah , who was removed from office, convicted of plotting the coup, and executed by hanging in 1989, along with five others.The brutal civil war significantly impacted Sierra Leone, with internal and external factors contributing to widespread violence. International interventions, notably by the United Kingdom and the United Nations, were crucial in restoring peace. In October 1990, owing to mounting pressure from both within and outside the country for political and economic reforms, president Momoh set up a constitutional review commission to assess the 1978 one-party constitution. Based on the commission's recommendations, a constitution re-establishing a multi-party system was approved by the exclusive APC Parliament by a 60% majority vote, becoming effective on 1 October 1991. There was great suspicion that President Momoh was not serious about his promise of political reform, as APC rule continued to be increasingly marked by abuses of power. The brutal civil war that was going on in neighbouring Liberia played a significant role in the outbreak of fighting in Sierra Leone. Charles Taylor – then leader of the National Patriotic Front of Liberia – reportedly helped form the Revolutionary United Front (RUF) under the command of former Sierra Leonean army corporal Foday Saybana Sankoh , an ethnic Temne from Tonkolili District in Northern Sierra Leone. Sankoh was a British trained former army corporal who had also undergone guerrilla training in Libya. Taylor's aim was for the RUF to attack the bases of Nigerian dominated peacekeeping troops in Sierra Leone who were opposed to his rebel movement in Liberia. On 29 April 1992, a group of young soldiers in the Sierra Leone Army, led by seven army officers—Lieutenant Sahr Sandy, Captain Valentine Strasser, Lieutenant Solomon "SAJ" Musa , Captain Komba Mondeh , Lieutenant Tom Nyuma , Captain Julius Maada Bio and Captain Komba Kambo —staged a military coup that sent president Momoh into exile in Guinea, and the young soldiers established the National Provisional Ruling Council (NPRC), with 25-year-old Captain Valentine Strasser as its chairman and Head of State of the country. The NPRC junta immediately suspended the constitution, banned all political parties, limited freedom of speech and freedom of the press and enacted a rule-by-decree policy, in which soldiers were granted unlimited powers of administrative detention without charge or trial, and challenges against such detentions in court were precluded. SAJ Musa, a childhood friend of Strasser, became the deputy chairman and deputy leader of the NPRC government. Strasser became the world's youngest Head of State when he seized power just three days after his 25th birthday. The NPRC junta established the National Supreme Council of State as the military highest command and final authority in all matters and was exclusively made up of the highest-ranking NPRC soldiers, including Strasser himself and the original soldiers who toppled President Momoh. One of the top-ranking soldiers in the NPRC junta, Lieutenant Sahr Sandy, a trusted ally of Strasser, was assassinated, allegedly by Major S.I.M. Turay, a key loyalist of ousted president Momoh. A heavily armed military manhunt was carried out across the country to find Lieutenant Sandy's killer. However, the main suspect, Major S.I.M. Turay, went into hiding and fled the country to Guinea, fearing for his life. Dozens of soldiers loyal to the ousted president Momoh were arrested, including Colonel Kahota M. Dumbuya and Major Yayah Turay. Lieutenant Sandy was given a state funeral and his funeral prayers service at the cathedral church in Freetown was attended by many high-ranking soldiers of the NPRC junta, including Strasser himself and NPRC deputy leader Sergeant Solomon Musa. The NPRC junta maintained relations with ECOWAS and strengthened support for Sierra Leone-based ECOMOG troops fighting in the Liberian war. On 28 December 1992, an alleged coup attempt against the NPRC government of Strasser, aimed at freeing the detained Colonel Yahya Kanu, Colonel Kahota M.S. Dumbuya and former inspector general of police Bambay Kamara, was foiled. Several Junior army officers led by Sergeant Mohamed Lamin Bangura were identified as being behind the coup plot. The coup plot led to the execution of seventeen soldiers by firing squad . Some of those executed include Colonel Kahota Dumbuya, Major Yayah Kanu and Sergeant Mohamed Lamin Bangura. Several prominent members of the Momoh government who had been in detention at the Pa Demba Road prison, including former inspector general of police Bambay Kamara, were also executed. On 5 July 1994 SAJ Musa, who was popular among the general population, particularly in Freetown, was arrested and sent into exile after he was accused of planning a coup to topple Strasser, an accusation SAJ Musa denied. Strasser replaced Musa as deputy NPRC chairman with Captain Bio, who was instantly promoted by Strasser to brigadier . The NPRC's efforts proved to be nearly as ineffective as the ousted Momoh administration in repelling the RUF rebels. More and more of the country fell into the hands of RUF fighters, and by 1994 they had gained control of much of the diamond-rich Eastern Province and were getting close to the capital Freetown. In response, the NPRC hired the services of South African -based private military contractor Executive Outcomes for several hundred mercenary fighters in order to strengthen the response to the advances of the RUF rebels. Within a month they had driven RUF fighters back to enclaves along Sierra Leone's borders and cleared the RUF from the Kono diamond-producing areas of Sierra Leone. With Strasser's two most senior NPRC allies and commanders Lieutenant Sahr Sandy and Lieutenant Solomon Musa no longer around to defend him, Strasser's leadership within the NPRC's Supreme Council of State became fragile. On 16 January 1996, after about four years in power, Strasser was arrested in a palace coup staged by his fellow NPRC soldiers led by Brigadier Bio at the Defence Headquarters in Freetown. Strasser was immediately flown into exile in a military helicopter to Conakry , Guinea . In his first public broadcast to the nation following the 1996 coup, Brigadier Bio stated that his support for returning Sierra Leone to a democratically elected civilian government and his commitment to ending the civil war were his motivations for the coup. Promises of a return to civilian rule were fulfilled by Bio. Prior to conducting the election, Sierra Leoneans and international stakeholders were involved in a major debate on whether the nation should focus on trying to end the long running civil war, or to conduct elections and hence returning governance back to a civilian-led administration with a multi-party system of parliament that would provide the foundation for long-lasting peace and national prosperity. Following the 1995 National Consultative Conference at the Bintumani Hotel in Freetown, dubbed "Bintumani I", which was a Strasser-led initiative, another National Consultative Conference at the same Bintumani Hotel in Freetown, dubbed "Bintumani II", was initiated by the Bio administration that involved both national and international stakeholders, in an effort to find a viable solution to the issues plaguing the country. " Peace before Elections vs Elections before Peace " became a key debate topic and this quickly became a point of national discussion. The discussions eventually concluded with key stakeholders, including Bio's administration and the UN, agreeing that while efforts in finding a peaceful solution to ending the war should continue, a general election should be held as soon as possible. Bio handed power over to Ahmad Tejan Kabbah of the SLPP, after the conclusion of elections in early 1996 which Kabbah won. President Kabbah took power with a great promise of ending the civil war. After taking over, President Kabbah immediately opened dialogue with the RUF and invited their leader Foday Sankoh for peace negotiations. On 25 May 1997, 17 soldiers in the Sierra Leone army led by Corporal Tamba Gborie, loyal to the detained Major Johnny Paul Koroma , launched a military coup which sent President Kabbah into exile in Guinea and they established the Armed Forces Revolutionary Council (AFRC). Corporal Gborie quickly went to the Sierra Leone Broadcasting Services headquarters in New England, Freetown to announce the coup to a shocked nation and to alert all soldiers across the country to report for guard duty. The soldiers immediately released Koroma from prison and installed him as their chairman and Head of State. Koroma suspended the constitution, banned demonstrations, shut down all private radio stations in the country and invited the RUF to join the new junta government, with its leader Foday Sankoh as the Vice-Chairman of the new AFRC-RUF coalition junta government. Within days, Freetown was overwhelmed by the presence of the RUF combatants who came to the city in thousands. The Kamajors, a group of traditional fighters mostly from the Mende ethnic group under the command of deputy Defence Minister Samuel Hinga Norman , remained loyal to President Kabbah and defended the Southern part of Sierra Leone from the soldiers. After nine months in office, the junta was overthrown by the Nigerian-led ECOMOG forces, and the democratically elected government of president Kabbah was reinstated in February 1998. On 19 October 1998, 24 soldiers in the Sierra Leone army—including Gborie, Brigadier Hassan Karim Conteh, Colonel Samuel Francis Koroma, Major Kula Samba and Colonel Abdul Karim Sesay—were executed by firing squad after they were convicted in a court martial in Freetown, some for orchestrating the 1997 coup that overthrew President Kabbah and others for failure to reverse the mutiny. In October 1999, the United Nations agreed to send peacekeepers to help restore order and disarm the rebels. The first of the 6,000-member force began arriving in December, and the UN Security Council voted in February 2000 to increase the force to 11,000, and later to 13,000. But in May, when nearly all Nigerian forces had left and UN forces were trying to disarm the RUF in eastern Sierra Leone, Sankoh 's forces clashed with the UN troops, and some 500 peacekeepers were taken hostage as the peace accord effectively collapsed. The hostage crisis resulted in more fighting between the RUF and the government as UN troops launched Operation Khukri to end the siege. The Operation was successful with Indian and British Special Forces being the main contingents. The situation in the country deteriorated to such an extent that British troops were deployed in Operation Palliser , originally simply to evacuate foreign nationals. However, the British exceeded their original mandate and took full military action to finally defeat the rebels and restore order. The British were the catalyst for the ceasefire that ended the civil war. Elements of the British Army , together with administrators and politicians, remained after withdrawal to help train the armed forces, improve the infrastructure of the country and administer financial and material aid. Tony Blair , the Prime Minister of Britain at the time of the British intervention, is regarded as a hero by the people of Sierra Leone, many of whom are keen for more British involvement. Between 1991 and 2001, about 50,000 people were killed in Sierra Leone's civil war. Hundreds of thousands of people were forced from their homes and many became refugees in Guinea and Liberia . In 2001, UN forces moved into rebel-held areas and began to disarm rebel soldiers. By January 2002, the war was declared over. In May 2002, Kabbah was re-elected president by a landslide. By 2004, the disarmament process was complete. Also in 2004, a UN-backed war crimes court began holding trials of senior leaders from both sides of the war. In December 2005, UN peacekeeping forces pulled out of Sierra Leone.Promises of a return to civilian rule were fulfilled by Bio. Prior to conducting the election, Sierra Leoneans and international stakeholders were involved in a major debate on whether the nation should focus on trying to end the long running civil war, or to conduct elections and hence returning governance back to a civilian-led administration with a multi-party system of parliament that would provide the foundation for long-lasting peace and national prosperity. Following the 1995 National Consultative Conference at the Bintumani Hotel in Freetown, dubbed "Bintumani I", which was a Strasser-led initiative, another National Consultative Conference at the same Bintumani Hotel in Freetown, dubbed "Bintumani II", was initiated by the Bio administration that involved both national and international stakeholders, in an effort to find a viable solution to the issues plaguing the country. " Peace before Elections vs Elections before Peace " became a key debate topic and this quickly became a point of national discussion. The discussions eventually concluded with key stakeholders, including Bio's administration and the UN, agreeing that while efforts in finding a peaceful solution to ending the war should continue, a general election should be held as soon as possible. Bio handed power over to Ahmad Tejan Kabbah of the SLPP, after the conclusion of elections in early 1996 which Kabbah won. President Kabbah took power with a great promise of ending the civil war. After taking over, President Kabbah immediately opened dialogue with the RUF and invited their leader Foday Sankoh for peace negotiations. On 25 May 1997, 17 soldiers in the Sierra Leone army led by Corporal Tamba Gborie, loyal to the detained Major Johnny Paul Koroma , launched a military coup which sent President Kabbah into exile in Guinea and they established the Armed Forces Revolutionary Council (AFRC). Corporal Gborie quickly went to the Sierra Leone Broadcasting Services headquarters in New England, Freetown to announce the coup to a shocked nation and to alert all soldiers across the country to report for guard duty. The soldiers immediately released Koroma from prison and installed him as their chairman and Head of State. Koroma suspended the constitution, banned demonstrations, shut down all private radio stations in the country and invited the RUF to join the new junta government, with its leader Foday Sankoh as the Vice-Chairman of the new AFRC-RUF coalition junta government. Within days, Freetown was overwhelmed by the presence of the RUF combatants who came to the city in thousands. The Kamajors, a group of traditional fighters mostly from the Mende ethnic group under the command of deputy Defence Minister Samuel Hinga Norman , remained loyal to President Kabbah and defended the Southern part of Sierra Leone from the soldiers. After nine months in office, the junta was overthrown by the Nigerian-led ECOMOG forces, and the democratically elected government of president Kabbah was reinstated in February 1998. On 19 October 1998, 24 soldiers in the Sierra Leone army—including Gborie, Brigadier Hassan Karim Conteh, Colonel Samuel Francis Koroma, Major Kula Samba and Colonel Abdul Karim Sesay—were executed by firing squad after they were convicted in a court martial in Freetown, some for orchestrating the 1997 coup that overthrew President Kabbah and others for failure to reverse the mutiny. In October 1999, the United Nations agreed to send peacekeepers to help restore order and disarm the rebels. The first of the 6,000-member force began arriving in December, and the UN Security Council voted in February 2000 to increase the force to 11,000, and later to 13,000. But in May, when nearly all Nigerian forces had left and UN forces were trying to disarm the RUF in eastern Sierra Leone, Sankoh 's forces clashed with the UN troops, and some 500 peacekeepers were taken hostage as the peace accord effectively collapsed. The hostage crisis resulted in more fighting between the RUF and the government as UN troops launched Operation Khukri to end the siege. The Operation was successful with Indian and British Special Forces being the main contingents. The situation in the country deteriorated to such an extent that British troops were deployed in Operation Palliser , originally simply to evacuate foreign nationals. However, the British exceeded their original mandate and took full military action to finally defeat the rebels and restore order. The British were the catalyst for the ceasefire that ended the civil war. Elements of the British Army , together with administrators and politicians, remained after withdrawal to help train the armed forces, improve the infrastructure of the country and administer financial and material aid. Tony Blair , the Prime Minister of Britain at the time of the British intervention, is regarded as a hero by the people of Sierra Leone, many of whom are keen for more British involvement. Between 1991 and 2001, about 50,000 people were killed in Sierra Leone's civil war. Hundreds of thousands of people were forced from their homes and many became refugees in Guinea and Liberia . In 2001, UN forces moved into rebel-held areas and began to disarm rebel soldiers. By January 2002, the war was declared over. In May 2002, Kabbah was re-elected president by a landslide. By 2004, the disarmament process was complete. Also in 2004, a UN-backed war crimes court began holding trials of senior leaders from both sides of the war. In December 2005, UN peacekeeping forces pulled out of Sierra Leone.The elections in 2007 and 2012 marked a return to multi-party democracy , with Ernest Bai Koroma 's election signaling a period of stability and recovery from the civil war. The Ebola epidemic in 2014 posed a significant health crisis, leading to a national state of emergency and highlighting the ongoing challenges faced by Sierra Leone in public health and governance. Sierra Leone is located on the southwest coast of West Africa , lying mostly between latitudes 7° and 10°N (a small area is south of 7°), and longitudes 10° and 14°W . The country is bordered by Guinea to the north and east, Liberia to the southeast, and the Atlantic Ocean to the west and southwest. Sierra Leone has a total area of 71,740 km 2 (27,699 sq mi) , divided into a land area of 71,620 km 2 (27,653 sq mi) and water of 120 km 2 (46 sq mi) . The country has four distinct geographical regions. In eastern Sierra Leone the plateau is interspersed with high mountains, where Mount Bintumani reaches 1,948 m (6,391 ft) , the highest point in the country. The upper part of the drainage basin of the Moa River is located in the south of this region. The centre of the country is a region of lowland plains , containing forests, bush and farmland , that occupies about 43% of Sierra Leone's land area. The northern section of this has been categorised by the World Wildlife Fund as part of the Guinean forest-savanna mosaic ecoregion , while the south is rain-forested plains and farmland. In the west, Sierra Leone has some 400 km (249 mi) of Atlantic coastline, giving it both bountiful marine resources and attractive tourist potential. The coast has areas of low-lying Guinean mangroves swamp. The national capital Freetown sits on a coastal peninsula , situated next to the Sierra Leone Harbour. The climate is tropical, with two seasons determining the agricultural cycle: the rainy season from May to November, and a dry season from December to May, which includes harmattan , when cool, dry winds blow in off the Sahara Desert and the night-time temperature can be as low as 16 °C (60.8 °F) . The average temperature is 26 °C (78.8 °F) and varies from around 26 to 36 °C (78.8 to 96.8 °F) during the year. Sierra Leone is home to four terrestrial ecoregions: Guinean montane forests , Western Guinean lowland forests , Guinean forest-savanna mosaic , and Guinean mangroves . Human activities claimed to be responsible or contributing to land degradation in Sierra Leone include unsustainable agricultural land use, poor soil and water management practices, deforestation, removal of natural vegetation, fuelwood consumption and to a lesser extent overgrazing and urbanisation. Deforestation , both for commercial timber and to make room for agriculture, is the major concern and represents an enormous loss of natural economic wealth to the nation. Mining and slash and burn for land conversion – such as cattle grazing – dramatically diminished forested land in Sierra Leone since the 1980s. It is listed among countries of concern for emissions, as having Low Forest Cover with High Rates of Deforestation (LFHD). There are concerns that heavy logging continues in the Tama-Tonkoli Forest Reserve in the north. Loggers have extended their operations to Nimini, Kono District, Eastern Province; Jui, Western Rural District, Western Area; Loma Mountains National Park, Koinadougu, Northern Province; and with plans to start operations in the Kambui Forest reserve in the Kenema District, Eastern Province. The country had a 2019 Forest Landscape Integrity Index mean score of 2.76/10, ranking it 154th globally out of 172 countries. Overfishing is also an issue in Sierra Leone. Habitat degradation for the African wild dog , Lycaon pictus , has been increased, such that this canid is deemed to have been extirpated in Sierra Leone. Until 2002, Sierra Leone lacked a forest management system because of the civil war that caused tens of thousands of deaths. Deforestation rates have increased 7.3% since the end of the civil war. On paper, 55 protected areas covered 4.5% of Sierra Leone as of 2003. The country has 2,090 known species of higher plants, 147 mammals , 626 birds, 67 reptiles , 35 amphibians , and 99 fish species. Unrestricted hunting during the war led to the decrease of many animal populations, including elephants, lions, and buffalo. Many of these animals can now only be found in sanctuaries. The tsetse fly, a malaria-carrying mosquito, is now dominant in the region and has led to an increase in the spread of the disease. Still, Sierra Leone's bird populations have been largely the same and includes native birds such as cuckoos, owls, and vultures. The Tiwai Island Wildlife Sanctuary and the Gola Forest Reserves are just two examples of the humanitarian efforts to preserve wildlife after the civil war. The Environmental Justice Foundation has documented how the number of illegal fishing vessels in Sierra Leone's waters has multiplied in recent years. The amount of illegal fishing has significantly depleted fish stocks, depriving local fishing communities of an important resource for survival. The situation is particularly serious as fishing provides the only source of income for many communities in a country still recovering from over a decade of civil war. In June 2005, the Royal Society for the Protection of Birds (RSPB) and BirdLife International agreed to support a conservation- sustainable development project in the Gola Forest in south eastern Sierra Leone, an important surviving fragment of rainforest in Sierra Leone.Sierra Leone is home to four terrestrial ecoregions: Guinean montane forests , Western Guinean lowland forests , Guinean forest-savanna mosaic , and Guinean mangroves . Human activities claimed to be responsible or contributing to land degradation in Sierra Leone include unsustainable agricultural land use, poor soil and water management practices, deforestation, removal of natural vegetation, fuelwood consumption and to a lesser extent overgrazing and urbanisation. Deforestation , both for commercial timber and to make room for agriculture, is the major concern and represents an enormous loss of natural economic wealth to the nation. Mining and slash and burn for land conversion – such as cattle grazing – dramatically diminished forested land in Sierra Leone since the 1980s. It is listed among countries of concern for emissions, as having Low Forest Cover with High Rates of Deforestation (LFHD). There are concerns that heavy logging continues in the Tama-Tonkoli Forest Reserve in the north. Loggers have extended their operations to Nimini, Kono District, Eastern Province; Jui, Western Rural District, Western Area; Loma Mountains National Park, Koinadougu, Northern Province; and with plans to start operations in the Kambui Forest reserve in the Kenema District, Eastern Province. The country had a 2019 Forest Landscape Integrity Index mean score of 2.76/10, ranking it 154th globally out of 172 countries. Overfishing is also an issue in Sierra Leone. Habitat degradation for the African wild dog , Lycaon pictus , has been increased, such that this canid is deemed to have been extirpated in Sierra Leone. Until 2002, Sierra Leone lacked a forest management system because of the civil war that caused tens of thousands of deaths. Deforestation rates have increased 7.3% since the end of the civil war. On paper, 55 protected areas covered 4.5% of Sierra Leone as of 2003. The country has 2,090 known species of higher plants, 147 mammals , 626 birds, 67 reptiles , 35 amphibians , and 99 fish species. Unrestricted hunting during the war led to the decrease of many animal populations, including elephants, lions, and buffalo. Many of these animals can now only be found in sanctuaries. The tsetse fly, a malaria-carrying mosquito, is now dominant in the region and has led to an increase in the spread of the disease. Still, Sierra Leone's bird populations have been largely the same and includes native birds such as cuckoos, owls, and vultures. The Tiwai Island Wildlife Sanctuary and the Gola Forest Reserves are just two examples of the humanitarian efforts to preserve wildlife after the civil war. The Environmental Justice Foundation has documented how the number of illegal fishing vessels in Sierra Leone's waters has multiplied in recent years. The amount of illegal fishing has significantly depleted fish stocks, depriving local fishing communities of an important resource for survival. The situation is particularly serious as fishing provides the only source of income for many communities in a country still recovering from over a decade of civil war. In June 2005, the Royal Society for the Protection of Birds (RSPB) and BirdLife International agreed to support a conservation- sustainable development project in the Gola Forest in south eastern Sierra Leone, an important surviving fragment of rainforest in Sierra Leone.Sierra Leone is a constitutional republic with a directly elected president and a unicameral legislature . The current system of the Government of Sierra Leone is based on the 1991 Sierra Leone Constitution . Sierra Leone has a dominant unitary central government and a weak local government . The executive branch of the Government of Sierra Leone, headed by the president of Sierra Leone has extensive powers and influence. The president is the most powerful government official in Sierra Leone. Within the confines of the 1991 Constitution, supreme legislative powers are vested in Parliament , which is the law-making body of the nation. Supreme executive authority rests in the president and members of his cabinet and judicial power with the judiciary of which the Chief Justice of Sierra Leone is the head. The president is the head of state , the head of government , and the commander-in-chief of the Sierra Leone Armed Forces . The president appoints and heads a cabinet of ministers, which must be approved by the Parliament. The president is elected by popular vote to a maximum of two five-year terms. The president is the highest and most influential position within the government of Sierra Leone. To be elected president of Sierra Leone, a candidate must gain at least 55% of the vote. If no candidate gets 55%, there is a second-round runoff between the top two candidates. The current president of Sierra Leone is former military junta leader Julius Maada Bio . Bio defeated Samura Kamara of the ruling All People's Congress (APC) in the country's tightly contested 2018 presidential election. Bio replaced outgoing President Ernest Bai Koroma after Bio was sworn into office on 4 April 2018 by Chief Justice Abdulai Cham . Bio is the leader of the Sierra Leone People's Party , the current ruling party in Sierra Leone. Next to the president is the vice-president , who is the second highest-ranking government official in the executive branch of the Sierra Leone Government. As designated by the Sierra Leone Constitution, the vice-president is to become the new president of Sierra Leone upon the death, resignation, or removal of the President. The Parliament of Sierra Leone is unicameral , with 146 seats. Each of the country's 14 districts is represented in parliament. 132 members are elected concurrently with the presidential elections; the other 16 seats are filled by paramount chiefs from the country's 16 administrative districts . The Sierra Leone parliament is led by the Speaker of Parliament, who is the overall leader of Parliament and is directly elected by sitting members of parliament. The current speaker of the Sierra Leone parliament is Abass Bundu , who was elected by members of parliament on 21 January 2014. The current members of the Parliament of Sierra Leone were elected in the 2012 Sierra Leone parliamentary election. The APC currently has 68 of the 132 elected parliamentary seats and the Sierra Leone People's Party (SLPP) has 49 of the elected 132 parliamentary seats. Sierra Leone's two most dominant parties , the APC and the SLPP, collectively won every elected seat in Parliament in the 2012 Sierra Leone parliamentary election. To be qualified as a Member of Parliament, the person must be a citizen of Sierra Leone, must be at least 21 years old, and must be able to speak, read, and write the English language with a degree of proficiency to enable him to actively take part in proceedings in Parliament; and must not have any criminal conviction. Since independence in 1961, Sierra Leone's politics has been dominated by two major political parties: the SLPP and the APC. Other minor political parties have also existed but with no significant support. The judicial power of Sierra Leone is vested in the judiciary , headed by the Chief Justice of Sierra Leone and comprising the Supreme Court of Sierra Leone, which is the highest court in the country, meaning that its rulings, therefore, cannot be appealed against. Other courts include the High Court of Justice, the Court of Appeal, the magistrate courts, and traditional courts in rural villages. The president appoints and parliament approves Justices for the three courts. The Judiciary has jurisdiction in all civil and criminal matters throughout the country. The current acting chief justice of Sierra Leone is Desmond Babatunde Edwards. The Sierra Leonean Ministry of Foreign Affairs and International Cooperation is responsible for foreign policy of Sierra Leone. Sierra Leone has diplomatic relations that include China, Russia, Libya, Iran, and Cuba. Sierra Leone has good relations with the West, including the United States, and has maintained historical ties with the United Kingdom and other former British colonies through its membership of the Commonwealth of Nations . The United Kingdom has played a major role in providing aid to the former colony, together with administrative help and military training since intervening to end the Civil War in 2000. Former President Siaka Stevens ' government had sought closer relations with other West African countries under the Economic Community of West African States (ECOWAS), a policy continued by the current government. Sierra Leone, along with Liberia , Ivory Coast and Guinea , form the Mano River Union (MRU). It is primarily designed to implement development projects and promote regional economic integration between the four countries. Sierra Leone is also a member of the United Nations and its specialised agencies, the African Union , the African Development Bank (AFDB), the Organisation of Islamic Cooperation (OIC), and the Non-Aligned Movement (NAM). Sierra Leone is a member of the International Criminal Court with a Bilateral Immunity Agreement of protection for the US military (as covered under Article 98). The Military of Sierra Leone, officially the Republic of Sierra Leone Armed Forces (RSLAF), are the unified armed forces of Sierra Leone responsible for the territorial security of Sierra Leone's border and defending the national interests of Sierra Leone within the framework of its international obligations. The armed forces were formed after independence in 1961, based on elements of the former British Royal West African Frontier Force present in the country. The Sierra Leone Armed Forces consist of around 15,500 personnel, comprising the largest Sierra Leone Army, the Sierra Leone Navy and the Sierra Leone Air Wing. The president of Sierra Leone is the Commander in Chief of the military and the Minister of Defence responsible for defence policy and the formulation of the armed forces. When Sierra Leone gained independence in 1961, the Royal Sierra Leone Military Force was created from the Sierra Leone Battalion of the West African Frontier Force. The military seized control in 1968, bringing the National Reformation Council into power. On 19 April 1971, when Sierra Leone became a republic, the Royal Sierra Leone Military Forces were renamed the Republic of Sierra Leone Military Force (RSLMF). The RSLMF remained a single-service organisation until 1979 when the Sierra Leone Navy was established. In 1995 Defence Headquarters was established, and the Sierra Leone Air Wing was formed. The RSLMF was renamed as the Armed Forces of the Republic of Sierra Leone (AFRSL). Law enforcement in Sierra Leone is primarily the responsibility of the Sierra Leone Police (SLP), which is accountable to the Minister of Internal Affairs (appointed by the president). Sierra Leone Police was established by the British colony in 1894; it is one of the oldest police forces in West Africa. It works to prevent crime, protect life and property, detect and prosecute offenders, maintain public order , ensure safety and security, and enhance access to justice. The Sierra Leone Police is headed by the Inspector General of Police , the professional head of the Sierra Leone Police force, who is appointed by the president of Sierra Leone . Each one of Sierra Leone's 14 districts is headed by a district police commissioner who is the professional head of their respective district. These Police Commissioners report directly to the Inspector General of Police at the Sierra Leone Police headquarters in Freetown. The current Inspector General of Police is William Fayia Sellu , who was appointed to the position by President president Julius Madda Bio on 27 July 2022 to replace Ambrose Sovula, who had been in the post since March 2020. Male same-sex sexual activity is illegal under Section 61 of the Offences against the Person Act 1861 , and imprisonment for life is possible. Excessive police brutality is also a frequent problem. Protesters have been killed by security forces, as have prison rioters (in one incident at Pademba Road Prison , 30 inmates and one correction officer were killed). Multiple allegations were made during the COVID-19 lockdown period of police attacking people trying to obtain basic necessities. Sierra Leone has been one of the signatories of the agreement to convene a convention for drafting a world constitution . As a result, in 1968, for the first time in human history, a World Constituent Assembly convened to draft and adopt the Constitution for the Federation of Earth . Milton Margai , then president of Sierra Leone , signed the agreement to convene a World Constituent Assembly. The Republic of Sierra Leone is composed of five regions: the Northern Province , North West Province , Southern Province , the Eastern Province , and the Western Area . Four provinces are further divided into 14 districts; the Western Area is divided into two districts. The provincial districts are divided into 186 chiefdoms, which have traditionally been led by paramount chiefs , recognised by the British administration in 1896 at the time of organising the Protectorate of Sierra Leone. The Paramount Chiefs are influential, particularly in villages and small rural towns. Each chiefdom has ruling families that were recognised at that time; the Tribal Authority, made up of local notables, elects the paramount chief from the ruling families. Typically, chiefs have the power to "raise taxes, control the judicial system, and allocate land, the most important resource in rural areas". Within the context of local governance, the districts are governed as localities . Each has a directly elected local district council to exercise authority and carry out functions at a local level. In total, there are 19 local councils: 13 district councils, one for each of the 12 districts and one for the Western Area Rural, and six municipalities also have elected local councils. The six municipalities include Freetown, which functions as the local government for the Western Area Urban District, and Bo , Bonthe , Kenema , Koidu , and Makeni . While the district councils are under the oversight of their respective provincial administrations, the municipalities are directly overseen by the Ministry of Local Government & Community Development and thus administratively independent of district and provincial administrations.The Parliament of Sierra Leone is unicameral , with 146 seats. Each of the country's 14 districts is represented in parliament. 132 members are elected concurrently with the presidential elections; the other 16 seats are filled by paramount chiefs from the country's 16 administrative districts . The Sierra Leone parliament is led by the Speaker of Parliament, who is the overall leader of Parliament and is directly elected by sitting members of parliament. The current speaker of the Sierra Leone parliament is Abass Bundu , who was elected by members of parliament on 21 January 2014. The current members of the Parliament of Sierra Leone were elected in the 2012 Sierra Leone parliamentary election. The APC currently has 68 of the 132 elected parliamentary seats and the Sierra Leone People's Party (SLPP) has 49 of the elected 132 parliamentary seats. Sierra Leone's two most dominant parties , the APC and the SLPP, collectively won every elected seat in Parliament in the 2012 Sierra Leone parliamentary election. To be qualified as a Member of Parliament, the person must be a citizen of Sierra Leone, must be at least 21 years old, and must be able to speak, read, and write the English language with a degree of proficiency to enable him to actively take part in proceedings in Parliament; and must not have any criminal conviction. Since independence in 1961, Sierra Leone's politics has been dominated by two major political parties: the SLPP and the APC. Other minor political parties have also existed but with no significant support. The judicial power of Sierra Leone is vested in the judiciary , headed by the Chief Justice of Sierra Leone and comprising the Supreme Court of Sierra Leone, which is the highest court in the country, meaning that its rulings, therefore, cannot be appealed against. Other courts include the High Court of Justice, the Court of Appeal, the magistrate courts, and traditional courts in rural villages. The president appoints and parliament approves Justices for the three courts. The Judiciary has jurisdiction in all civil and criminal matters throughout the country. The current acting chief justice of Sierra Leone is Desmond Babatunde Edwards.The Sierra Leonean Ministry of Foreign Affairs and International Cooperation is responsible for foreign policy of Sierra Leone. Sierra Leone has diplomatic relations that include China, Russia, Libya, Iran, and Cuba. Sierra Leone has good relations with the West, including the United States, and has maintained historical ties with the United Kingdom and other former British colonies through its membership of the Commonwealth of Nations . The United Kingdom has played a major role in providing aid to the former colony, together with administrative help and military training since intervening to end the Civil War in 2000. Former President Siaka Stevens ' government had sought closer relations with other West African countries under the Economic Community of West African States (ECOWAS), a policy continued by the current government. Sierra Leone, along with Liberia , Ivory Coast and Guinea , form the Mano River Union (MRU). It is primarily designed to implement development projects and promote regional economic integration between the four countries. Sierra Leone is also a member of the United Nations and its specialised agencies, the African Union , the African Development Bank (AFDB), the Organisation of Islamic Cooperation (OIC), and the Non-Aligned Movement (NAM). Sierra Leone is a member of the International Criminal Court with a Bilateral Immunity Agreement of protection for the US military (as covered under Article 98).The Military of Sierra Leone, officially the Republic of Sierra Leone Armed Forces (RSLAF), are the unified armed forces of Sierra Leone responsible for the territorial security of Sierra Leone's border and defending the national interests of Sierra Leone within the framework of its international obligations. The armed forces were formed after independence in 1961, based on elements of the former British Royal West African Frontier Force present in the country. The Sierra Leone Armed Forces consist of around 15,500 personnel, comprising the largest Sierra Leone Army, the Sierra Leone Navy and the Sierra Leone Air Wing. The president of Sierra Leone is the Commander in Chief of the military and the Minister of Defence responsible for defence policy and the formulation of the armed forces. When Sierra Leone gained independence in 1961, the Royal Sierra Leone Military Force was created from the Sierra Leone Battalion of the West African Frontier Force. The military seized control in 1968, bringing the National Reformation Council into power. On 19 April 1971, when Sierra Leone became a republic, the Royal Sierra Leone Military Forces were renamed the Republic of Sierra Leone Military Force (RSLMF). The RSLMF remained a single-service organisation until 1979 when the Sierra Leone Navy was established. In 1995 Defence Headquarters was established, and the Sierra Leone Air Wing was formed. The RSLMF was renamed as the Armed Forces of the Republic of Sierra Leone (AFRSL).Law enforcement in Sierra Leone is primarily the responsibility of the Sierra Leone Police (SLP), which is accountable to the Minister of Internal Affairs (appointed by the president). Sierra Leone Police was established by the British colony in 1894; it is one of the oldest police forces in West Africa. It works to prevent crime, protect life and property, detect and prosecute offenders, maintain public order , ensure safety and security, and enhance access to justice. The Sierra Leone Police is headed by the Inspector General of Police , the professional head of the Sierra Leone Police force, who is appointed by the president of Sierra Leone . Each one of Sierra Leone's 14 districts is headed by a district police commissioner who is the professional head of their respective district. These Police Commissioners report directly to the Inspector General of Police at the Sierra Leone Police headquarters in Freetown. The current Inspector General of Police is William Fayia Sellu , who was appointed to the position by President president Julius Madda Bio on 27 July 2022 to replace Ambrose Sovula, who had been in the post since March 2020. Male same-sex sexual activity is illegal under Section 61 of the Offences against the Person Act 1861 , and imprisonment for life is possible. Excessive police brutality is also a frequent problem. Protesters have been killed by security forces, as have prison rioters (in one incident at Pademba Road Prison , 30 inmates and one correction officer were killed). Multiple allegations were made during the COVID-19 lockdown period of police attacking people trying to obtain basic necessities. Sierra Leone has been one of the signatories of the agreement to convene a convention for drafting a world constitution . As a result, in 1968, for the first time in human history, a World Constituent Assembly convened to draft and adopt the Constitution for the Federation of Earth . Milton Margai , then president of Sierra Leone , signed the agreement to convene a World Constituent Assembly. The Republic of Sierra Leone is composed of five regions: the Northern Province , North West Province , Southern Province , the Eastern Province , and the Western Area . Four provinces are further divided into 14 districts; the Western Area is divided into two districts. The provincial districts are divided into 186 chiefdoms, which have traditionally been led by paramount chiefs , recognised by the British administration in 1896 at the time of organising the Protectorate of Sierra Leone. The Paramount Chiefs are influential, particularly in villages and small rural towns. Each chiefdom has ruling families that were recognised at that time; the Tribal Authority, made up of local notables, elects the paramount chief from the ruling families. Typically, chiefs have the power to "raise taxes, control the judicial system, and allocate land, the most important resource in rural areas". Within the context of local governance, the districts are governed as localities . Each has a directly elected local district council to exercise authority and carry out functions at a local level. In total, there are 19 local councils: 13 district councils, one for each of the 12 districts and one for the Western Area Rural, and six municipalities also have elected local councils. The six municipalities include Freetown, which functions as the local government for the Western Area Urban District, and Bo , Bonthe , Kenema , Koidu , and Makeni . While the district councils are under the oversight of their respective provincial administrations, the municipalities are directly overseen by the Ministry of Local Government & Community Development and thus administratively independent of district and provincial administrations.By the 1990s, economic activity was declining and economic infrastructure had become seriously degraded. Over the next decade, much of the formal economy was destroyed in the country's civil war. Since the end of hostilities in January 2002, massive infusions of outside assistance have helped Sierra Leone begin to recover. Much of the recovery will depend on the success of the government's efforts to limit corruption by officials, which many feel was the chief cause of the civil war. A key indicator of success will be the effectiveness of government management of its diamond sector. There is high unemployment, particularly among the youth and ex-combatants. Authorities have been slow to implement reforms in the civil service, and the pace of the privatisation programme is also slackening and donors have urged its advancement. The currency is the leone . The central bank is the Bank of Sierra Leone . Sierra Leone operates a floating exchange rate system, and foreign currencies can be exchanged at any of the commercial banks, recognised foreign exchange bureaux and most hotels. Credit card use is limited in Sierra Leone, though they may be used at some hotels and restaurants. There are a few internationally linked automated teller machines that accept Visa cards in Freetown operated by ProCredit Bank. Two-thirds of the population of Sierra Leone are directly involved in subsistence agriculture . Agriculture accounted for 58 per cent of gross domestic product (GDP) in 2007. Agriculture is the largest employer with 80 per cent of the population working in the sector. Rice is the most important staple crop in Sierra Leone with 85 per cent of farmers cultivating rice during the rainy season and an annual consumption of 76 kg per person. Rich in minerals, Sierra Leone has relied on mining, especially diamonds, for its economic base. The country is among the top ten diamond producing nations. Mineral exports remain the main currency earner. Sierra Leone is a major producer of gem-quality diamonds. Though rich in diamonds, it has historically struggled to manage their exploitation and export. Sierra Leone is known for its blood diamonds that were mined and sold to diamond conglomerates during the civil war , to buy the weapons that fuelled its atrocities. In the 1970s and early 1980s, economic growth rate slowed because of a decline in the mining sector and increasing corruption among government officials. Annual production of Sierra Leone's diamond estimates a range between US$250 million–$300 million. Some of that is smuggled , where it is possibly used for money laundering or financing illicit activities. Formal exports have dramatically improved since the civil war, with efforts to improve the management of them having some success. In October 2000, a UN-approved certification system for exporting diamonds from the country was put in place which led to a dramatic increase in legal exports. In 2001, the government created a mining community development fund ( DACDF ), which returns a portion of diamond export taxes to diamond mining communities. The fund was created to raise local communities' stakes in the legal diamond trade. Sierra Leone has one of the world's largest deposits of rutile , a titanium ore used as paint pigment and welding rod coatings. There are several systems of transport in Sierra Leone, which has a road, air and water infrastructure, including a network of highways and several airports. There are 11,300 kilometres (7,000 miles) of highways in Sierra Leone, of which 904 km (562 mi) are paved (about 8% of the roads). Sierra Leone's highways are linked to Conakry , Guinea, and Monrovia , Liberia. Sierra Leone has the largest natural harbour on the African continent, allowing international shipping through the Queen Elizabeth II Quay in the Cline Town area of eastern Freetown or through Government Wharf in central Freetown. There are 800 km (497 mi) of waterways in Sierra Leone, of which 600 km (373 mi) are navigable year-round. Major port cities are Bonthe , Freetown , Sherbro Island and Pepel . There are ten regional airports in Sierra Leone, and one international airport . The Freetown International Airport located in the coastal town of Lungi in Northern Sierra Leone is the primary airport for domestic and international travel to or from Sierra Leone. Passengers cross the river to Aberdeen Heliports in Freetown by hovercraft , ferry or a helicopter . Helicopters are also available from the airport to other major cities in the country. The airport has paved runways longer than 3,047 metres (9,997 feet) . The other airports have unpaved runways, and seven have runways from 914 to 1,523 metres (2,999 to 4,997 feet) long; the remaining two have shorter runways. Sierra Leone appears on the EU list of prohibited countries with regard to the certification of airlines. This means that no airline registered in Sierra Leone may operate services of any kind within the European Union. This is due to substandard safety standards. As of March 2023, the country's only international airport had regularly scheduled direct flights to Istanbul, Paris, Brussels and most major cities in West Africa. In September 2014 there were many Districts with travel restrictions including Kailahun, Kenema, Bombali, Tonkolili, and Port Loko because of Ebola . As of 2016, about 12% of the population of Sierra Leone had access to electricity. Of that 12%, 10% was in the capital Freetown, and the remaining 90% of the country used 2% of the nation's electricity. The majority of the population relies on biomass fuels for their daily survival, with firewood and coal used most prevalently. The burning of these sources has been reported to have adverse health effects on women and children. A 2012 study was done on the correlation between Acute Respiratory Infection (ARI), and burning biomass fuels in the home. The results were that 64% of children were diagnosed with ARI where firewood stoves were used, and 44% where charcoal stoves were used. The use of coal and firewood has also posed environmental concerns as they are both in conflict with the push for more sustainable sources of energy. As a result, the commercialisation of firewood and coal has been a point of contention with aid donors and government agencies such as the Ministry of Energy and Water Resources and the Forestry Division. There have been strong pushes for both solar and hydropower to become the dominant sources of energy in Sierra Leone because of the UN's Sustainable Development Goals , particularly goal number seven (affordable and clean energy). Sierra Leone's tropical climate, heavy annual rainfall, and abundance of rivers give it the potential to realistically pursue more solar and hydropower alternatives. In conjunction with the UK's Department for International Development (DFID), Sierra Leone has set the goal to provide solar power to all of its citizens by 2025. This overarching goal has been broken down into smaller goals as well. The first of these goals is to provide solar power to at least 50,000 homes in 2016, the second is 250,000 homes by 2017, and finally to provide power to 1,000,000 people by 2020. This initiative falls under the Energy Africa access campaign which seeks to provide electricity to 14 different African countries by 2030. Previous to this compact agreement, Sierra Leone's private sector for solar energy was weak, as it provided energy to less than 5% of the target population. Part of the reason for this was due to the import duties and taxes and the lack of quality control. To ensure that the Energy Africa goal is met, Sierra Leone has agreed to remove its import duties and Value Added Tax (VAT) on certified solar products. This change will attempt to encourage foreign investment while providing affordable, quality solar products to its citizens. It is estimated that there will be a 30% to 40% cost reduction on solar products with the lack of duties and taxes. As of 2012, Sierra Leone has 3 main hydroelectric plants. The first is the Guma plant which was decommissioned in 1982, the second is the Dodo Plant which is located in the Eastern Province, and finally the Bumbuna plant . There is also potential for several new hydroelectric plants to be opened on the Sewa River, Pampana River, Seli River, Moa River, and Little Scarcies. Amongst all these projects, both finished and potential, the Bumbuna dam still remains the largest of the hydroelectric projects in Sierra Leone. It is located near the Seli River and Freetown and was estimated to produce about 50 megawatts of electricity. There were plans to increase its capacity 400 megawatts by 2017 which would cost around $750 million. It has been projected that the Bumbuna dam could potentially reduce the amount of spending on foreign fuel and save the country at least $2 million a month. In the past this project received its funding of over $200 million from a combination of the World Bank , the African Development Bank , and the Italian company Salini Impregilo . Two-thirds of the population of Sierra Leone are directly involved in subsistence agriculture . Agriculture accounted for 58 per cent of gross domestic product (GDP) in 2007. Agriculture is the largest employer with 80 per cent of the population working in the sector. Rice is the most important staple crop in Sierra Leone with 85 per cent of farmers cultivating rice during the rainy season and an annual consumption of 76 kg per person. Rich in minerals, Sierra Leone has relied on mining, especially diamonds, for its economic base. The country is among the top ten diamond producing nations. Mineral exports remain the main currency earner. Sierra Leone is a major producer of gem-quality diamonds. Though rich in diamonds, it has historically struggled to manage their exploitation and export. Sierra Leone is known for its blood diamonds that were mined and sold to diamond conglomerates during the civil war , to buy the weapons that fuelled its atrocities. In the 1970s and early 1980s, economic growth rate slowed because of a decline in the mining sector and increasing corruption among government officials. Annual production of Sierra Leone's diamond estimates a range between US$250 million–$300 million. Some of that is smuggled , where it is possibly used for money laundering or financing illicit activities. Formal exports have dramatically improved since the civil war, with efforts to improve the management of them having some success. In October 2000, a UN-approved certification system for exporting diamonds from the country was put in place which led to a dramatic increase in legal exports. In 2001, the government created a mining community development fund ( DACDF ), which returns a portion of diamond export taxes to diamond mining communities. The fund was created to raise local communities' stakes in the legal diamond trade. Sierra Leone has one of the world's largest deposits of rutile , a titanium ore used as paint pigment and welding rod coatings.There are several systems of transport in Sierra Leone, which has a road, air and water infrastructure, including a network of highways and several airports. There are 11,300 kilometres (7,000 miles) of highways in Sierra Leone, of which 904 km (562 mi) are paved (about 8% of the roads). Sierra Leone's highways are linked to Conakry , Guinea, and Monrovia , Liberia. Sierra Leone has the largest natural harbour on the African continent, allowing international shipping through the Queen Elizabeth II Quay in the Cline Town area of eastern Freetown or through Government Wharf in central Freetown. There are 800 km (497 mi) of waterways in Sierra Leone, of which 600 km (373 mi) are navigable year-round. Major port cities are Bonthe , Freetown , Sherbro Island and Pepel . There are ten regional airports in Sierra Leone, and one international airport . The Freetown International Airport located in the coastal town of Lungi in Northern Sierra Leone is the primary airport for domestic and international travel to or from Sierra Leone. Passengers cross the river to Aberdeen Heliports in Freetown by hovercraft , ferry or a helicopter . Helicopters are also available from the airport to other major cities in the country. The airport has paved runways longer than 3,047 metres (9,997 feet) . The other airports have unpaved runways, and seven have runways from 914 to 1,523 metres (2,999 to 4,997 feet) long; the remaining two have shorter runways. Sierra Leone appears on the EU list of prohibited countries with regard to the certification of airlines. This means that no airline registered in Sierra Leone may operate services of any kind within the European Union. This is due to substandard safety standards. As of March 2023, the country's only international airport had regularly scheduled direct flights to Istanbul, Paris, Brussels and most major cities in West Africa. In September 2014 there were many Districts with travel restrictions including Kailahun, Kenema, Bombali, Tonkolili, and Port Loko because of Ebola . As of 2016, about 12% of the population of Sierra Leone had access to electricity. Of that 12%, 10% was in the capital Freetown, and the remaining 90% of the country used 2% of the nation's electricity. The majority of the population relies on biomass fuels for their daily survival, with firewood and coal used most prevalently. The burning of these sources has been reported to have adverse health effects on women and children. A 2012 study was done on the correlation between Acute Respiratory Infection (ARI), and burning biomass fuels in the home. The results were that 64% of children were diagnosed with ARI where firewood stoves were used, and 44% where charcoal stoves were used. The use of coal and firewood has also posed environmental concerns as they are both in conflict with the push for more sustainable sources of energy. As a result, the commercialisation of firewood and coal has been a point of contention with aid donors and government agencies such as the Ministry of Energy and Water Resources and the Forestry Division. There have been strong pushes for both solar and hydropower to become the dominant sources of energy in Sierra Leone because of the UN's Sustainable Development Goals , particularly goal number seven (affordable and clean energy). Sierra Leone's tropical climate, heavy annual rainfall, and abundance of rivers give it the potential to realistically pursue more solar and hydropower alternatives. In conjunction with the UK's Department for International Development (DFID), Sierra Leone has set the goal to provide solar power to all of its citizens by 2025. This overarching goal has been broken down into smaller goals as well. The first of these goals is to provide solar power to at least 50,000 homes in 2016, the second is 250,000 homes by 2017, and finally to provide power to 1,000,000 people by 2020. This initiative falls under the Energy Africa access campaign which seeks to provide electricity to 14 different African countries by 2030. Previous to this compact agreement, Sierra Leone's private sector for solar energy was weak, as it provided energy to less than 5% of the target population. Part of the reason for this was due to the import duties and taxes and the lack of quality control. To ensure that the Energy Africa goal is met, Sierra Leone has agreed to remove its import duties and Value Added Tax (VAT) on certified solar products. This change will attempt to encourage foreign investment while providing affordable, quality solar products to its citizens. It is estimated that there will be a 30% to 40% cost reduction on solar products with the lack of duties and taxes. As of 2012, Sierra Leone has 3 main hydroelectric plants. The first is the Guma plant which was decommissioned in 1982, the second is the Dodo Plant which is located in the Eastern Province, and finally the Bumbuna plant . There is also potential for several new hydroelectric plants to be opened on the Sewa River, Pampana River, Seli River, Moa River, and Little Scarcies. Amongst all these projects, both finished and potential, the Bumbuna dam still remains the largest of the hydroelectric projects in Sierra Leone. It is located near the Seli River and Freetown and was estimated to produce about 50 megawatts of electricity. There were plans to increase its capacity 400 megawatts by 2017 which would cost around $750 million. It has been projected that the Bumbuna dam could potentially reduce the amount of spending on foreign fuel and save the country at least $2 million a month. In the past this project received its funding of over $200 million from a combination of the World Bank , the African Development Bank , and the Italian company Salini Impregilo . As of 2016, about 12% of the population of Sierra Leone had access to electricity. Of that 12%, 10% was in the capital Freetown, and the remaining 90% of the country used 2% of the nation's electricity. The majority of the population relies on biomass fuels for their daily survival, with firewood and coal used most prevalently. The burning of these sources has been reported to have adverse health effects on women and children. A 2012 study was done on the correlation between Acute Respiratory Infection (ARI), and burning biomass fuels in the home. The results were that 64% of children were diagnosed with ARI where firewood stoves were used, and 44% where charcoal stoves were used. The use of coal and firewood has also posed environmental concerns as they are both in conflict with the push for more sustainable sources of energy. As a result, the commercialisation of firewood and coal has been a point of contention with aid donors and government agencies such as the Ministry of Energy and Water Resources and the Forestry Division. There have been strong pushes for both solar and hydropower to become the dominant sources of energy in Sierra Leone because of the UN's Sustainable Development Goals , particularly goal number seven (affordable and clean energy). Sierra Leone's tropical climate, heavy annual rainfall, and abundance of rivers give it the potential to realistically pursue more solar and hydropower alternatives. In conjunction with the UK's Department for International Development (DFID), Sierra Leone has set the goal to provide solar power to all of its citizens by 2025. This overarching goal has been broken down into smaller goals as well. The first of these goals is to provide solar power to at least 50,000 homes in 2016, the second is 250,000 homes by 2017, and finally to provide power to 1,000,000 people by 2020. This initiative falls under the Energy Africa access campaign which seeks to provide electricity to 14 different African countries by 2030. Previous to this compact agreement, Sierra Leone's private sector for solar energy was weak, as it provided energy to less than 5% of the target population. Part of the reason for this was due to the import duties and taxes and the lack of quality control. To ensure that the Energy Africa goal is met, Sierra Leone has agreed to remove its import duties and Value Added Tax (VAT) on certified solar products. This change will attempt to encourage foreign investment while providing affordable, quality solar products to its citizens. It is estimated that there will be a 30% to 40% cost reduction on solar products with the lack of duties and taxes. As of 2012, Sierra Leone has 3 main hydroelectric plants. The first is the Guma plant which was decommissioned in 1982, the second is the Dodo Plant which is located in the Eastern Province, and finally the Bumbuna plant . There is also potential for several new hydroelectric plants to be opened on the Sewa River, Pampana River, Seli River, Moa River, and Little Scarcies. Amongst all these projects, both finished and potential, the Bumbuna dam still remains the largest of the hydroelectric projects in Sierra Leone. It is located near the Seli River and Freetown and was estimated to produce about 50 megawatts of electricity. There were plans to increase its capacity 400 megawatts by 2017 which would cost around $750 million. It has been projected that the Bumbuna dam could potentially reduce the amount of spending on foreign fuel and save the country at least $2 million a month. In the past this project received its funding of over $200 million from a combination of the World Bank , the African Development Bank , and the Italian company Salini Impregilo . In 2019 Sierra Leone had a population of 7,813,215 and a growth rate of 2.216% a year. The country's population is mostly young, with an estimated 41.7% under 15, and rural, with an estimated 62% of people living outside the cities. As a result of migration to cities, the population is becoming more urban with an estimated rate of urbanisation growth of 2.9% a year. Population density varies greatly within Sierra Leone. The Western Area Urban District , including Freetown, the capital and largest city, has a population density of 1,224 persons per square km. The largest district geographically, Koinadugu , has a much lower density of 21.4 persons per square km. English is the official language , spoken at schools, government administration and in the media. Krio (derived from English and several indigenous African languages, and the language of the Sierra Leone Creole people ) is the most widely spoken language in virtually all parts of Sierra Leone. As the Krio language is spoken by 96% of the country's population, it unites all the different ethnic groups , especially in their trade and interaction with each other. Krio is the primary language of communication among Sierra Leoneans at home and abroad, and has also heavily influenced Sierra Leonean English . After the contribution made by the Bangladesh UN Peacekeeping Force in the Sierra Leone Civil War under the United Nations Mission in Sierra Leone , the government of Ahmad Tejan Kabbah declared Bengali an honorary official language in December 2002. According to the World Refugee Survey 2008 , published by the US Committee for Refugees and Immigrants, Sierra Leone had a population of 8,700 refugees and asylum seekers at the end of 2007. Nearly 20,000 Liberian refugees voluntarily returned to Liberia over the course of 2007. Of the refugees remaining in Sierra Leone, nearly all were Liberian. The populations quoted above for the five largest cities are from the 2004 census. The figure for Freetown is for the Western Urban Area (Greater Freetown). Other figures are estimates from the source cited. Different sources give different estimates. Some claim that Magburaka should be included in the above list, but there is considerable difference among sources. One source estimates the population at 14,915, whilst another puts it as high as 85,313. "Pandebu-Tokpombu" is presumably the extended town of Torgbonbu, which had a population of 10,716 in the 2004 census. "Gbendembu" had a larger population of 12,139 in that census. In the 2004 census, Waterloo had a population of 34,079. Sierra Leone is officially a secular state . Islam and Christianity are the two main religions in the country. The constitution of Sierra Leone provides for freedom of religion and the Sierra Leone Government generally protects it. The Sierra Leonean Government is constitutionally forbidden from establishing a state religion , though Muslim and Christian prayers are usually held in the country at the beginning of major political occasions, including presidential inaugurations and the official opening of the new session of Parliament. Surveys of the religious make up of Sierra Leone vary widely, though Muslims make up the majority of the population. Based on 2015 estimates of the population of Sierra Leone, 77% of the population are Muslims, 22% are Christians , and 1% practise African traditional religion . According to 2020 estimates by the Pew Research Center 78.5% of Sierra Leone's population are Muslims (mostly Sunni ), 20.4% are Christians (mostly Protestants ) and 1.1% belong to a traditional African religion or other beliefs. The Inter-Religious Council of Sierra Leone estimated that 77% of Sierra Leone's population are Muslims, 21% are Christians, and 2% are followers of traditional African religions. Most of Sierra Leone's ethnic groups are Muslim majority, including the country's two largest ethnic groups: the Mende and Temne. Sierra Leone is regarded as one of the most religiously tolerant countries in the world. Most of the major Muslim and Christian holidays are officially national holidays in the country, and religious conflict is rare. The country is home to the Sierra Leone Inter-Religious Council, which is made up of both Christian and Muslim religious leaders to promote peace and tolerance throughout the country. The Islamic holidays of Eid al-Fitr , Eid al-Adha and Maulid-un-Nabi (Birthday of the Islamic prophet Muhammad ) are observed as national holidays in Sierra Leone . The Christian holidays of Christmas , Boxing Day , Good Friday and Easter are also national holidays in Sierra Leone. In politics, the overwhelming majority of Sierra Leoneans vote for a candidate without regard of the candidate being a Muslim or a Christian. [ citation needed ] All of Sierra Leone's Heads of State have been Christians except Ahmad Tejan Kabbah, who was a Muslim. The overwhelming majority of Sierra Leonean Muslims are adherent to the Sunni tradition of Islam in practice. Most of the Mosques and Islamic schools across Sierra Leone are based on Sunni Islam. Ahmadiyya Muslims make up about 10% of the country's Muslim population. Sierra Leone has a vibrant Ahmaddiya Muslim population, especially in the southern city of Bo , which is home to a large Ahmadiyya Muslim population. There are five hundred Ahmadiyya Mosques across Sierra Leone. Shia Islam does not have a strong presence in Sierra Leone, and there are virtually no Shia Muslims in the country. Most Sierra Leonean Muslims of the Sunni and Ahmadiyya sect generally pray together in the same mosque . The vast majority of Sierra Leonean Muslims are adherent to the Maliki school of Sunni Islam. The Maliki school is by far the largest and most dominant Islamic school of jurisprudence across Sierra Leone. Many Ahmadiyya Muslims in Sierra Leone also follow the Maliki Jurisprudence. The Sierra Leone Islamic Supreme Council is the highest Islamic religious organisation in Sierra Leone and is made up of the country's Imams, Islamic scholars, and other Islamic clerics across the country. Sheikh Muhammad Taha Jalloh is the president of the Sierra Leone Supreme Islamic Council. The United Council of Imams is an influential Islamic religious body in Sierra Leone that is made up of all imams of mosques throughout Sierra Leone. The president of the United Council of Imam is Sheikh Alhaji Muhammad Habib Sheriff. The two largest mosques in Sierra Leone are the Freetown Central Mosque and the Ghadafi Central Mosque (built by former Libyan dictator Muammar Gaddafi ), both located in the capital Freetown . The large majority of Sierra Leonean Christians are Protestant, of which the largest groups are the Wesleyan – Methodists . Other Christian Protestant denominations with significant presence in the country include Presbyterians , Baptists , Seventh-day Adventists , Anglicans , Lutherans , and Pentecostals . The Council of Churches is the Christian religious organisation that is made up of Protestant churches across Sierra Leone. Recently there has been an increase of Pentecostal churches, especially in Freetown. In September 2017, a Sierra Leone-based Nigerian Pentecostal Christian pastor name Victor Ajisafe was arrested by the Sierra Leone Police and held in jail after he made controversial remarks against Islam and Sierra Leonean Muslims in particular at his church sermon in the capital Freetown. Ajisafe was apparently angry after a Zimbabwean Muslim cleric Mufti Menk had visited Sierra Leone and preached to large crowds. Many Christian organisations in Sierra Leone, including the Council of Churches, condemned Ajisafe's sermon against Islam and Muslims. Ajisafe's church was temporarily shut down by the Sierra Leone government and his church licence was temporarily suspended too. The incident brought religious tension in Sierra Leone, in a country known for its high level of religious tolerance, as many Sierra Leonean Muslims at home and abroad called for Ajisafe to be deported back to his home country of Nigeria . The pastor while in Sierra Leone police custody apologised to Sierra Leonean Muslims and to the government of Sierra Leone. After several days in jail, Ajisafe was released, his church licence was given back to him, and his church was later reopened under strict government conditions during several months of probation . Non-denominational Protestants form a significant minority of Sierra Leone's Christian population. Catholics are the largest group of non-Protestant Christians in Sierra Leone, forming about 8% of Sierra Leone's population and 26% of the Christian population in Sierra Leone. The Jehovah's Witnesses and the Church of Jesus Christ of Latter-day Saints are the two most prominent non-Trinitarian Christians in Sierra Leone, and they form a small but significant minority of the Christian population in Sierra Leone. A small community of Orthodox Christians resides in the capital Freetown. Sierra Leone is home to about sixteen ethnic groups , each with its own language. The largest and most influential are the Temne at about 35.5% and the Mende at about 33.2%. The Temne predominate in the Northern Sierra Leone and some areas around the capital of Sierra Leone . The Mende predominate in South -Eastern Sierra Leone (with the exception of Kono District ). The vast majority of Temne are Muslims at over 85%, with a significant Christian minority at about 10%. The Mende are also Muslim majority at about 70%, though with a large Christian minority at about 30%. Sierra Leone's national politics centres on the competition between the north-west, dominated by the Temne, and the south-east dominated by the Mende. The vast majority of the Mende support the Sierra Leone People's Party; while the majority of the Temne support the All People's Congress. The Mende, who are believed to be descendants of the Mane , [ citation needed ] originally occupied the Liberian hinterland. They began moving into Sierra Leone slowly and peacefully in the eighteenth century. The Temne are said to have migrated from Futa Jallon , which is in present-day Guinea . The third-largest ethnic group is the Limba at about 8.4% of the population. The Limba are native people of Sierra Leone. They have no tradition of origin, and it is believed that they have lived in Sierra Leone since before the European encounter. The Limba are primarily found in Northern Sierra Leone, particularly in Bombali , Kambia and Koinadugu District . The Limba are about 60% Christian and 40% Muslim. The Limba are close political allies of the neighbouring Temne. Since independence, the Limba have traditionally been influential in Sierra Leone's politics, along with the Mende. The vast majority of Limba support the All People's Congress (APC) political party. Sierra Leone's first and second presidents, Siaka Stevens and Joseph Saidu Momoh , respectively, were both ethnic Limba. Sierra Leone's former defense minister Alfred Paolo Conteh is an ethnic Limba. One of the biggest minority ethnic groups are the Fula at around 3.8% of the population. Descendants of seventeenth- and eighteenth-century Fula migrant settlers from the Fouta Djalon region of Guinea, they live primarily in the northeast and the western area of Sierra Leone. The Fula are virtually all Muslims at over 99%. The Fula are primarily traders , and many live in middle-class homes. [ citation needed ] Because of their trading, the Fulas are found in nearly all parts of the country. The other ethnic groups are the Mandingo (also known as Mandinka ). They are descendants of traders from Guinea who migrated to Sierra Leone during the late nineteenth to mid-twentieth centuries. The Mandinka are predominantly found in the east and the northern part of the country. They predominate in the large towns, most notably Karina , in Bombali District in the north; Kabala and Falaba in Koinadugu District in the north; and Yengema , Kono District in the east of the country. Like the Fula, the Mandinka are virtually all Muslims at over 99%. Sierra Leone's third president, Ahmad Tejan Kabbah, and Sierra Leone's first Vice-President, Sorie Ibrahim Koroma , were both ethnic Mandingo. Next in proportion are the Kono , who live primarily in Kono District in Eastern Sierra Leone. The Kono are descendants of migrants from Guinea; today their workers are known primarily as diamond miners. The majority of the Kono ethnic group are Christians, though with an influential Muslim minority. Sierra Leone's former Vice-President Alhaji Samuel Sam-Sumana is an ethnic Kono. The small but significant Creole or Krio people (descendants of freed African American, West Indian and Liberated African slaves who settled in Freetown between 1787 and about 1885) make up about 3% of the population. They primarily occupy the capital city of Freetown and its surrounding Western Area . Creole or Krio culture reflects the Western culture and ideals within which many of their ancestors originated – they also had close ties with British officials and colonial administration during years of development. The Creoles or Krio have traditionally dominated Sierra Leone's judiciary and Freetown's elected city council. One of the first ethnic groups to become educated according to Western traditions, they have traditionally been appointed to positions in the civil service, beginning during the colonial years. They continue to be influential in the civil service. The Creoles or Krios are virtually all Christians at about 99%. The Oku people are the descendants of liberated Muslim Yorubas from Southwest Nigeria , who were released from slave ships and resettled in Sierra Leone as Liberated Africans or came as settlers in the mid-19th century. The Oku people primarily reside in the communities of Fourah Bay, Fula Town, and Aberdeen in Freetown. The Oku are virtually all Muslims at about 99%. Other minority ethnic groups are the Kuranko , who are related to the Mandingo and are largely Muslims. The Kuranko are believed to have begun arriving in Sierra Leone from Guinea in about 1600 and settled in the north, particularly in Koinadugu District . The Kuranko are primarily farmers; leaders among them have traditionally held several senior positions in the Military. The current Governor of the Bank of Sierra Leone Kaifala Marah is an ethnic Kuranko. The Kuranko are largely Muslim majority. The Loko in the north are native people of Sierra Leone, believed to have lived in Sierra Leone since the time of European encounter. Like the neighbouring Temne, the Loko are Muslim majority. The Susu and their related Yalunka are traders; both groups are primarily found in the far north in Kambia and Koinadugu District close to the border with Guinea. The Susu and Yalunka kingdom was established in the early fifth seventh century [ clarification needed ] before the Mali empire, which was extended from Mali, Senegal, Guinea Bissau, Guinea Conakry to the northern part of Sierra Leone. They are the original owners of the Futa Djallon region covered by a vars land area both the Susu and Yalunka people are descendants of the Mande people. They are virtually all Muslims. The Yalunka also spelled Jallonke, Yalonga, Djallonké, Djallonka or Dialonké, are Mande people who have lived in the Djallon, a mountainous region in Sierra Leone, Mali, Senegal, Guinea Bissau, and Guinea Conakry West Africa over 520 years ago. The name Yalunka literally means "inhabitants of the Jallon (mountains)". Manga Sewa was born in Falaba, Solima chiefdom, in the Northern Province of British Sierra Leone to Yalunka parents. His father was a Yalunka paramount chief of Solima, a prosperous chieftaincy. Its capital, Falaba, was on the rich trading routes leading to the coast. Manga Sewa's father had several wives and dozens of children. are traders; both groups are primarily found in the far north in Kambia and Koinadugu District close to the border with Guinea. The Susu and Yalunka are both descendants of migrants from Guinea; they both are virtually all Muslims at over 99%. The Kissi live further inland in South-Eastern Sierra Leone. They predominate in the large town of Koindu and its surrounding areas in Kailahun District. The vast majority of Kissi are Christians. The much smaller Vai and Kru peoples are primarily found in Kailahun and Pujehun Districts near the border with Liberia. The Kru predominate in the Kroubay neighbourhood in the capital of Freetown. The Vai are largely Muslim majority at about 90%, while the Kru are virtually all Christians at over 99%. On the coast in Bonthe District in the south are the Sherbro . Native to Sierra Leone, they have occupied Sherbro Island since it was founded. The Sherbro are primarily fisherman and farmers , and they are predominantly found in Bonthe District. The Sherbro are virtually all Christians, and their paramount chiefs had a history of intermarriage with British colonists and traders. A small number of Sierra Leoneans are of partial or full Lebanese ancestry, descendants of traders who first came to the nation in the 19th century. They are locally known as Sierra Leonean-Lebanese. The Sierra Leonean-Lebanese community are primarily traders and they mostly live in middle-class households in the urban areas, primarily in Freetown, Bo , Kenema , Koidu Town and Makeni . Although women account for about 50 percent of the population in Sierra Leone, only 28 percent are household heads. As in the rest of the countries, education is a key factor in succeeding in aspects such as a well-paid job and covering the needs of a house. Rural areas are the most common to lack access to education having only male-headed four percent ahead of females with basic education and 1.2 percent more at the post-graduate level. In Sierra Leone, normally, men are automatically positioned as household heads; and their status does not change if their marital status changes over time. However, a female household does change depending on their marital status. A woman can be the head of the house only if she remains single for the rest of her life. But if a woman gets married, she will not be entitled to be the head of the house anymore. Females can take over the household head if they become widowed or divorced. In the labour field, it is expected that the household will financially provide for the needs of the family. However, females face gender discrimination making them the target of lower incomes and financial struggles. In numbers, females present a lower percentage (6.3) versus males (15.2) when it comes to being paid employees. Children who have been forced to be part of a war have experienced severe mental and emotional damage in Sierra Leone. However, the damage and way to deal with the effects of war depends on the gender of the kids. Both genders experienced and were involved in high levels of violence. Females, experiencing higher levels of rapes, presented greater signs of depression and anxiety. Males, on the other hand, presented higher levels of anxiety and hostility. Males also showed to be more vulnerable to depression after losing a caregiver. Women face discrimination when it comes to obtaining financial, social, and cultural help to start a business. It is difficult to avoid the economic paralysis in Sierra Leone given that more than half of the population in the country is women. Due to the lack of access to basic education, women are the least prepared when it comes to processing business licences, registering names or contracting. Not having the capital to start a new business is the biggest barrier for women. With the lack of technology, mostly in all Sierra Leone , it is hard to help a business to function. Education in Sierra Leone is legally required for all children for six years at primary level (Class P1-P6) and three years in junior secondary education, but a shortage of schools and teachers has made implementation impossible. Two thirds of the adult population of the country are illiterate. The Sierra Leone Civil War resulted in the destruction of 1,270 primary schools, and in 2001, 67% of all school-age children were out of school. The situation has improved considerably since then with primary school enrolment doubling between 2001 and 2005 and the reconstruction of many schools since the end of the war. Students at primary schools are usually 6 to 12 years old, and in secondary schools 13 to 18. Primary education is free and compulsory in government-sponsored public schools . The country has three universities: Fourah Bay College , founded in 1827 (the oldest university in West Africa), University of Makeni (established initially in September 2005 as The Fatima Institute, the college was granted university status in August 2009, and assumed the name University of Makeni, or UNIMAK), and Njala University , primarily located in Bo District . Njala University was established as the Njala Agricultural Experimental Station in 1910 and became a university in 2005. Teacher training colleges and religious seminaries are found in many parts of the country.Sierra Leone is officially a secular state . Islam and Christianity are the two main religions in the country. The constitution of Sierra Leone provides for freedom of religion and the Sierra Leone Government generally protects it. The Sierra Leonean Government is constitutionally forbidden from establishing a state religion , though Muslim and Christian prayers are usually held in the country at the beginning of major political occasions, including presidential inaugurations and the official opening of the new session of Parliament. Surveys of the religious make up of Sierra Leone vary widely, though Muslims make up the majority of the population. Based on 2015 estimates of the population of Sierra Leone, 77% of the population are Muslims, 22% are Christians , and 1% practise African traditional religion . According to 2020 estimates by the Pew Research Center 78.5% of Sierra Leone's population are Muslims (mostly Sunni ), 20.4% are Christians (mostly Protestants ) and 1.1% belong to a traditional African religion or other beliefs. The Inter-Religious Council of Sierra Leone estimated that 77% of Sierra Leone's population are Muslims, 21% are Christians, and 2% are followers of traditional African religions. Most of Sierra Leone's ethnic groups are Muslim majority, including the country's two largest ethnic groups: the Mende and Temne. Sierra Leone is regarded as one of the most religiously tolerant countries in the world. Most of the major Muslim and Christian holidays are officially national holidays in the country, and religious conflict is rare. The country is home to the Sierra Leone Inter-Religious Council, which is made up of both Christian and Muslim religious leaders to promote peace and tolerance throughout the country. The Islamic holidays of Eid al-Fitr , Eid al-Adha and Maulid-un-Nabi (Birthday of the Islamic prophet Muhammad ) are observed as national holidays in Sierra Leone . The Christian holidays of Christmas , Boxing Day , Good Friday and Easter are also national holidays in Sierra Leone. In politics, the overwhelming majority of Sierra Leoneans vote for a candidate without regard of the candidate being a Muslim or a Christian. [ citation needed ] All of Sierra Leone's Heads of State have been Christians except Ahmad Tejan Kabbah, who was a Muslim. The overwhelming majority of Sierra Leonean Muslims are adherent to the Sunni tradition of Islam in practice. Most of the Mosques and Islamic schools across Sierra Leone are based on Sunni Islam. Ahmadiyya Muslims make up about 10% of the country's Muslim population. Sierra Leone has a vibrant Ahmaddiya Muslim population, especially in the southern city of Bo , which is home to a large Ahmadiyya Muslim population. There are five hundred Ahmadiyya Mosques across Sierra Leone. Shia Islam does not have a strong presence in Sierra Leone, and there are virtually no Shia Muslims in the country. Most Sierra Leonean Muslims of the Sunni and Ahmadiyya sect generally pray together in the same mosque . The vast majority of Sierra Leonean Muslims are adherent to the Maliki school of Sunni Islam. The Maliki school is by far the largest and most dominant Islamic school of jurisprudence across Sierra Leone. Many Ahmadiyya Muslims in Sierra Leone also follow the Maliki Jurisprudence. The Sierra Leone Islamic Supreme Council is the highest Islamic religious organisation in Sierra Leone and is made up of the country's Imams, Islamic scholars, and other Islamic clerics across the country. Sheikh Muhammad Taha Jalloh is the president of the Sierra Leone Supreme Islamic Council. The United Council of Imams is an influential Islamic religious body in Sierra Leone that is made up of all imams of mosques throughout Sierra Leone. The president of the United Council of Imam is Sheikh Alhaji Muhammad Habib Sheriff. The two largest mosques in Sierra Leone are the Freetown Central Mosque and the Ghadafi Central Mosque (built by former Libyan dictator Muammar Gaddafi ), both located in the capital Freetown . The large majority of Sierra Leonean Christians are Protestant, of which the largest groups are the Wesleyan – Methodists . Other Christian Protestant denominations with significant presence in the country include Presbyterians , Baptists , Seventh-day Adventists , Anglicans , Lutherans , and Pentecostals . The Council of Churches is the Christian religious organisation that is made up of Protestant churches across Sierra Leone. Recently there has been an increase of Pentecostal churches, especially in Freetown. In September 2017, a Sierra Leone-based Nigerian Pentecostal Christian pastor name Victor Ajisafe was arrested by the Sierra Leone Police and held in jail after he made controversial remarks against Islam and Sierra Leonean Muslims in particular at his church sermon in the capital Freetown. Ajisafe was apparently angry after a Zimbabwean Muslim cleric Mufti Menk had visited Sierra Leone and preached to large crowds. Many Christian organisations in Sierra Leone, including the Council of Churches, condemned Ajisafe's sermon against Islam and Muslims. Ajisafe's church was temporarily shut down by the Sierra Leone government and his church licence was temporarily suspended too. The incident brought religious tension in Sierra Leone, in a country known for its high level of religious tolerance, as many Sierra Leonean Muslims at home and abroad called for Ajisafe to be deported back to his home country of Nigeria . The pastor while in Sierra Leone police custody apologised to Sierra Leonean Muslims and to the government of Sierra Leone. After several days in jail, Ajisafe was released, his church licence was given back to him, and his church was later reopened under strict government conditions during several months of probation . Non-denominational Protestants form a significant minority of Sierra Leone's Christian population. Catholics are the largest group of non-Protestant Christians in Sierra Leone, forming about 8% of Sierra Leone's population and 26% of the Christian population in Sierra Leone. The Jehovah's Witnesses and the Church of Jesus Christ of Latter-day Saints are the two most prominent non-Trinitarian Christians in Sierra Leone, and they form a small but significant minority of the Christian population in Sierra Leone. A small community of Orthodox Christians resides in the capital Freetown. Sierra Leone is home to about sixteen ethnic groups , each with its own language. The largest and most influential are the Temne at about 35.5% and the Mende at about 33.2%. The Temne predominate in the Northern Sierra Leone and some areas around the capital of Sierra Leone . The Mende predominate in South -Eastern Sierra Leone (with the exception of Kono District ). The vast majority of Temne are Muslims at over 85%, with a significant Christian minority at about 10%. The Mende are also Muslim majority at about 70%, though with a large Christian minority at about 30%. Sierra Leone's national politics centres on the competition between the north-west, dominated by the Temne, and the south-east dominated by the Mende. The vast majority of the Mende support the Sierra Leone People's Party; while the majority of the Temne support the All People's Congress. The Mende, who are believed to be descendants of the Mane , [ citation needed ] originally occupied the Liberian hinterland. They began moving into Sierra Leone slowly and peacefully in the eighteenth century. The Temne are said to have migrated from Futa Jallon , which is in present-day Guinea . The third-largest ethnic group is the Limba at about 8.4% of the population. The Limba are native people of Sierra Leone. They have no tradition of origin, and it is believed that they have lived in Sierra Leone since before the European encounter. The Limba are primarily found in Northern Sierra Leone, particularly in Bombali , Kambia and Koinadugu District . The Limba are about 60% Christian and 40% Muslim. The Limba are close political allies of the neighbouring Temne. Since independence, the Limba have traditionally been influential in Sierra Leone's politics, along with the Mende. The vast majority of Limba support the All People's Congress (APC) political party. Sierra Leone's first and second presidents, Siaka Stevens and Joseph Saidu Momoh , respectively, were both ethnic Limba. Sierra Leone's former defense minister Alfred Paolo Conteh is an ethnic Limba. One of the biggest minority ethnic groups are the Fula at around 3.8% of the population. Descendants of seventeenth- and eighteenth-century Fula migrant settlers from the Fouta Djalon region of Guinea, they live primarily in the northeast and the western area of Sierra Leone. The Fula are virtually all Muslims at over 99%. The Fula are primarily traders , and many live in middle-class homes. [ citation needed ] Because of their trading, the Fulas are found in nearly all parts of the country. The other ethnic groups are the Mandingo (also known as Mandinka ). They are descendants of traders from Guinea who migrated to Sierra Leone during the late nineteenth to mid-twentieth centuries. The Mandinka are predominantly found in the east and the northern part of the country. They predominate in the large towns, most notably Karina , in Bombali District in the north; Kabala and Falaba in Koinadugu District in the north; and Yengema , Kono District in the east of the country. Like the Fula, the Mandinka are virtually all Muslims at over 99%. Sierra Leone's third president, Ahmad Tejan Kabbah, and Sierra Leone's first Vice-President, Sorie Ibrahim Koroma , were both ethnic Mandingo. Next in proportion are the Kono , who live primarily in Kono District in Eastern Sierra Leone. The Kono are descendants of migrants from Guinea; today their workers are known primarily as diamond miners. The majority of the Kono ethnic group are Christians, though with an influential Muslim minority. Sierra Leone's former Vice-President Alhaji Samuel Sam-Sumana is an ethnic Kono. The small but significant Creole or Krio people (descendants of freed African American, West Indian and Liberated African slaves who settled in Freetown between 1787 and about 1885) make up about 3% of the population. They primarily occupy the capital city of Freetown and its surrounding Western Area . Creole or Krio culture reflects the Western culture and ideals within which many of their ancestors originated – they also had close ties with British officials and colonial administration during years of development. The Creoles or Krio have traditionally dominated Sierra Leone's judiciary and Freetown's elected city council. One of the first ethnic groups to become educated according to Western traditions, they have traditionally been appointed to positions in the civil service, beginning during the colonial years. They continue to be influential in the civil service. The Creoles or Krios are virtually all Christians at about 99%. The Oku people are the descendants of liberated Muslim Yorubas from Southwest Nigeria , who were released from slave ships and resettled in Sierra Leone as Liberated Africans or came as settlers in the mid-19th century. The Oku people primarily reside in the communities of Fourah Bay, Fula Town, and Aberdeen in Freetown. The Oku are virtually all Muslims at about 99%. Other minority ethnic groups are the Kuranko , who are related to the Mandingo and are largely Muslims. The Kuranko are believed to have begun arriving in Sierra Leone from Guinea in about 1600 and settled in the north, particularly in Koinadugu District . The Kuranko are primarily farmers; leaders among them have traditionally held several senior positions in the Military. The current Governor of the Bank of Sierra Leone Kaifala Marah is an ethnic Kuranko. The Kuranko are largely Muslim majority. The Loko in the north are native people of Sierra Leone, believed to have lived in Sierra Leone since the time of European encounter. Like the neighbouring Temne, the Loko are Muslim majority. The Susu and their related Yalunka are traders; both groups are primarily found in the far north in Kambia and Koinadugu District close to the border with Guinea. The Susu and Yalunka kingdom was established in the early fifth seventh century [ clarification needed ] before the Mali empire, which was extended from Mali, Senegal, Guinea Bissau, Guinea Conakry to the northern part of Sierra Leone. They are the original owners of the Futa Djallon region covered by a vars land area both the Susu and Yalunka people are descendants of the Mande people. They are virtually all Muslims. The Yalunka also spelled Jallonke, Yalonga, Djallonké, Djallonka or Dialonké, are Mande people who have lived in the Djallon, a mountainous region in Sierra Leone, Mali, Senegal, Guinea Bissau, and Guinea Conakry West Africa over 520 years ago. The name Yalunka literally means "inhabitants of the Jallon (mountains)". Manga Sewa was born in Falaba, Solima chiefdom, in the Northern Province of British Sierra Leone to Yalunka parents. His father was a Yalunka paramount chief of Solima, a prosperous chieftaincy. Its capital, Falaba, was on the rich trading routes leading to the coast. Manga Sewa's father had several wives and dozens of children. are traders; both groups are primarily found in the far north in Kambia and Koinadugu District close to the border with Guinea. The Susu and Yalunka are both descendants of migrants from Guinea; they both are virtually all Muslims at over 99%. The Kissi live further inland in South-Eastern Sierra Leone. They predominate in the large town of Koindu and its surrounding areas in Kailahun District. The vast majority of Kissi are Christians. The much smaller Vai and Kru peoples are primarily found in Kailahun and Pujehun Districts near the border with Liberia. The Kru predominate in the Kroubay neighbourhood in the capital of Freetown. The Vai are largely Muslim majority at about 90%, while the Kru are virtually all Christians at over 99%. On the coast in Bonthe District in the south are the Sherbro . Native to Sierra Leone, they have occupied Sherbro Island since it was founded. The Sherbro are primarily fisherman and farmers , and they are predominantly found in Bonthe District. The Sherbro are virtually all Christians, and their paramount chiefs had a history of intermarriage with British colonists and traders. A small number of Sierra Leoneans are of partial or full Lebanese ancestry, descendants of traders who first came to the nation in the 19th century. They are locally known as Sierra Leonean-Lebanese. The Sierra Leonean-Lebanese community are primarily traders and they mostly live in middle-class households in the urban areas, primarily in Freetown, Bo , Kenema , Koidu Town and Makeni .Although women account for about 50 percent of the population in Sierra Leone, only 28 percent are household heads. As in the rest of the countries, education is a key factor in succeeding in aspects such as a well-paid job and covering the needs of a house. Rural areas are the most common to lack access to education having only male-headed four percent ahead of females with basic education and 1.2 percent more at the post-graduate level. In Sierra Leone, normally, men are automatically positioned as household heads; and their status does not change if their marital status changes over time. However, a female household does change depending on their marital status. A woman can be the head of the house only if she remains single for the rest of her life. But if a woman gets married, she will not be entitled to be the head of the house anymore. Females can take over the household head if they become widowed or divorced. In the labour field, it is expected that the household will financially provide for the needs of the family. However, females face gender discrimination making them the target of lower incomes and financial struggles. In numbers, females present a lower percentage (6.3) versus males (15.2) when it comes to being paid employees. Children who have been forced to be part of a war have experienced severe mental and emotional damage in Sierra Leone. However, the damage and way to deal with the effects of war depends on the gender of the kids. Both genders experienced and were involved in high levels of violence. Females, experiencing higher levels of rapes, presented greater signs of depression and anxiety. Males, on the other hand, presented higher levels of anxiety and hostility. Males also showed to be more vulnerable to depression after losing a caregiver. Women face discrimination when it comes to obtaining financial, social, and cultural help to start a business. It is difficult to avoid the economic paralysis in Sierra Leone given that more than half of the population in the country is women. Due to the lack of access to basic education, women are the least prepared when it comes to processing business licences, registering names or contracting. Not having the capital to start a new business is the biggest barrier for women. With the lack of technology, mostly in all Sierra Leone , it is hard to help a business to function. Although women account for about 50 percent of the population in Sierra Leone, only 28 percent are household heads. As in the rest of the countries, education is a key factor in succeeding in aspects such as a well-paid job and covering the needs of a house. Rural areas are the most common to lack access to education having only male-headed four percent ahead of females with basic education and 1.2 percent more at the post-graduate level. In Sierra Leone, normally, men are automatically positioned as household heads; and their status does not change if their marital status changes over time. However, a female household does change depending on their marital status. A woman can be the head of the house only if she remains single for the rest of her life. But if a woman gets married, she will not be entitled to be the head of the house anymore. Females can take over the household head if they become widowed or divorced. In the labour field, it is expected that the household will financially provide for the needs of the family. However, females face gender discrimination making them the target of lower incomes and financial struggles. In numbers, females present a lower percentage (6.3) versus males (15.2) when it comes to being paid employees. Children who have been forced to be part of a war have experienced severe mental and emotional damage in Sierra Leone. However, the damage and way to deal with the effects of war depends on the gender of the kids. Both genders experienced and were involved in high levels of violence. Females, experiencing higher levels of rapes, presented greater signs of depression and anxiety. Males, on the other hand, presented higher levels of anxiety and hostility. Males also showed to be more vulnerable to depression after losing a caregiver. Women face discrimination when it comes to obtaining financial, social, and cultural help to start a business. It is difficult to avoid the economic paralysis in Sierra Leone given that more than half of the population in the country is women. Due to the lack of access to basic education, women are the least prepared when it comes to processing business licences, registering names or contracting. Not having the capital to start a new business is the biggest barrier for women. With the lack of technology, mostly in all Sierra Leone , it is hard to help a business to function. Education in Sierra Leone is legally required for all children for six years at primary level (Class P1-P6) and three years in junior secondary education, but a shortage of schools and teachers has made implementation impossible. Two thirds of the adult population of the country are illiterate. The Sierra Leone Civil War resulted in the destruction of 1,270 primary schools, and in 2001, 67% of all school-age children were out of school. The situation has improved considerably since then with primary school enrolment doubling between 2001 and 2005 and the reconstruction of many schools since the end of the war. Students at primary schools are usually 6 to 12 years old, and in secondary schools 13 to 18. Primary education is free and compulsory in government-sponsored public schools . The country has three universities: Fourah Bay College , founded in 1827 (the oldest university in West Africa), University of Makeni (established initially in September 2005 as The Fatima Institute, the college was granted university status in August 2009, and assumed the name University of Makeni, or UNIMAK), and Njala University , primarily located in Bo District . Njala University was established as the Njala Agricultural Experimental Station in 1910 and became a university in 2005. Teacher training colleges and religious seminaries are found in many parts of the country.The CIA estimated that the average life expectancy in Sierra Leone was 57.39 years. The prevalence of HIV/AIDS in the population is 1.6%, higher than the world average of 1% but lower than the average of 6.1% across Sub-Saharan Africa . Medical care is not readily accessible, with doctors and hospitals out of reach for many villagers. While free health care may be provided in some villages, the medical staff is poorly paid and sometimes charge for their services, taking advantage of the fact that the villagers are not aware of their right to free medical care. A dialysis machine, the first of its kind in the country, was donated by Israel. According to an Overseas Development Institute report, private health expenditure accounts for 85.7% of total spending on health. Having had no formal emergency medical services previously, the First Responder Coalition of Sierra Leone (FRCSL) was formed in June 2019 in Makeni to facilitate the development of emergency first responder programs nationwide. The founding members of the Coalition included the Sierra Leone Red Cross Society (the first chairing organisation), LFR International (proposed the formation), the University of Makeni , Agency for Rural Community Transformation , and the Holy Spirit Hospital . The establishment of the Coalition was concurrent with the declaration by the 72nd World Health Assembly that emergency care systems are essential to universal health coverage. Between June and July 2019, the FRCSL trained 1,000 community members from Makeni to be first responders and equipped each trainee with a first aid kit. Sierra Leone suffers from epidemic outbreaks of diseases, including yellow fever , cholera , Ebola , lassa fever and meningitis . Yellow fever and malaria are endemic to Sierra Leone. According to 2017 estimates, Sierra Leone has the third highest maternal mortality rate in the world. For every 100 liveborn children, one mother dies due to complications of giving birth. In the Multiple Indicator Cluster Survey (MICS) conducted by UNICEF in 2012, the prevalence of female genital mutilation in Sierra Leone was 94%. As of 2014 [ update ] , Sierra Leone was estimated as having the 11th highest infant mortality rate in the world. One of the consequences women in Sierra Leone face after a prolonged and obstructed labour that would have required a c-section is obstetric fistula . This condition often drives women into poverty and isolation. The AWC- Aberdeen Women's Centre in Freetown , the second busiest hospital in Sierra Leone, delivering up to 3000 babies each year. The centre provides free surgery for women suffering from this condition. The centre provides a variety of maternal and child health services and is supported by not-for-profit organisations such as Freedom from Fistula, The Aminata Maternal Foundation, [ better source needed ] and UNFPA. Mental healthcare in Sierra Leone is almost non-existent. Many sufferers try to cure themselves with the help of traditional healers. During the Civil War (1991–2002) , many soldiers took part in atrocities and many children were forced to fight. This left them traumatised, with an estimated 400,000 people (by 2009) being mentally ill. Thousands of former child soldiers have fallen into substance abuse as they try to blunt their memories. The water supply in Sierra Leone is characterised by limited access to safe drinking water. Despite efforts by the government and numerous non-governmental organisations, access has not much improved since the end of the Sierra Leone Civil War in 2002, stagnating at about 50% and even declining in rural areas. It is hoped that a new dam in Orugu, for which China committed financing in 2009, will alleviate water scarcity . According to a national survey carried out in 2006, 84% of the urban population and 32% of the rural population had access to an improved water source . Those with access in rural areas were served almost exclusively by protected wells. The 68% of the rural population without access to an improved water source relied on surface water (50%), unprotected wells (9%) and unprotected springs (9%). Only 20% of the urban population and 1% of the rural population had access to piped drinking water in their home. Compared to the 2000 survey access has increased in urban areas, but has declined in rural areas, possibly because facilities have broken down because of a lack of maintenance. With a new decentralisation policy, embodied in the Local Government Act of 2004, responsibility for water supply in areas outside the capital was passed from the central government to local councils. In Freetown, the Guma Valley Water Company remains in charge of the water supply. Ebola is prevalent in Africa where social and economic inequalities are common. The central African countries are the most prevalent of EVD, like the Democratic Republic of Congo, Sudan, Uganda, and Gabon. In 2014 there was an outbreak of the Ebola virus in West Africa. As of 19 October 2014, there had been 3,706 cases of Ebola in Sierra Leone, and 1,259 deaths, including that of the leading physician trying to control the outbreak, Sheik Umar Khan . In early August 2014 Guinea closed its borders to Sierra Leone to help contain the spreading of the virus, which originated in Guinea, as more new cases of the disease were being reported in Sierra Leone than in Guinea. Aside from the human cost, the outbreak was severely eroding the economy. By September 2014, with the closure of borders, the cancellation of airline flights, the evacuation of foreign workers and a collapse of cross-border trade, the national deficit of Sierra Leone and other affected countries was widening to the point where the IMF was considering expanding its financial support. Having had no formal emergency medical services previously, the First Responder Coalition of Sierra Leone (FRCSL) was formed in June 2019 in Makeni to facilitate the development of emergency first responder programs nationwide. The founding members of the Coalition included the Sierra Leone Red Cross Society (the first chairing organisation), LFR International (proposed the formation), the University of Makeni , Agency for Rural Community Transformation , and the Holy Spirit Hospital . The establishment of the Coalition was concurrent with the declaration by the 72nd World Health Assembly that emergency care systems are essential to universal health coverage. Between June and July 2019, the FRCSL trained 1,000 community members from Makeni to be first responders and equipped each trainee with a first aid kit. Sierra Leone suffers from epidemic outbreaks of diseases, including yellow fever , cholera , Ebola , lassa fever and meningitis . Yellow fever and malaria are endemic to Sierra Leone. According to 2017 estimates, Sierra Leone has the third highest maternal mortality rate in the world. For every 100 liveborn children, one mother dies due to complications of giving birth. In the Multiple Indicator Cluster Survey (MICS) conducted by UNICEF in 2012, the prevalence of female genital mutilation in Sierra Leone was 94%. As of 2014 [ update ] , Sierra Leone was estimated as having the 11th highest infant mortality rate in the world. One of the consequences women in Sierra Leone face after a prolonged and obstructed labour that would have required a c-section is obstetric fistula . This condition often drives women into poverty and isolation. The AWC- Aberdeen Women's Centre in Freetown , the second busiest hospital in Sierra Leone, delivering up to 3000 babies each year. The centre provides free surgery for women suffering from this condition. The centre provides a variety of maternal and child health services and is supported by not-for-profit organisations such as Freedom from Fistula, The Aminata Maternal Foundation, [ better source needed ] and UNFPA. Mental healthcare in Sierra Leone is almost non-existent. Many sufferers try to cure themselves with the help of traditional healers. During the Civil War (1991–2002) , many soldiers took part in atrocities and many children were forced to fight. This left them traumatised, with an estimated 400,000 people (by 2009) being mentally ill. Thousands of former child soldiers have fallen into substance abuse as they try to blunt their memories. The water supply in Sierra Leone is characterised by limited access to safe drinking water. Despite efforts by the government and numerous non-governmental organisations, access has not much improved since the end of the Sierra Leone Civil War in 2002, stagnating at about 50% and even declining in rural areas. It is hoped that a new dam in Orugu, for which China committed financing in 2009, will alleviate water scarcity . According to a national survey carried out in 2006, 84% of the urban population and 32% of the rural population had access to an improved water source . Those with access in rural areas were served almost exclusively by protected wells. The 68% of the rural population without access to an improved water source relied on surface water (50%), unprotected wells (9%) and unprotected springs (9%). Only 20% of the urban population and 1% of the rural population had access to piped drinking water in their home. Compared to the 2000 survey access has increased in urban areas, but has declined in rural areas, possibly because facilities have broken down because of a lack of maintenance. With a new decentralisation policy, embodied in the Local Government Act of 2004, responsibility for water supply in areas outside the capital was passed from the central government to local councils. In Freetown, the Guma Valley Water Company remains in charge of the water supply.Ebola is prevalent in Africa where social and economic inequalities are common. The central African countries are the most prevalent of EVD, like the Democratic Republic of Congo, Sudan, Uganda, and Gabon. In 2014 there was an outbreak of the Ebola virus in West Africa. As of 19 October 2014, there had been 3,706 cases of Ebola in Sierra Leone, and 1,259 deaths, including that of the leading physician trying to control the outbreak, Sheik Umar Khan . In early August 2014 Guinea closed its borders to Sierra Leone to help contain the spreading of the virus, which originated in Guinea, as more new cases of the disease were being reported in Sierra Leone than in Guinea. Aside from the human cost, the outbreak was severely eroding the economy. By September 2014, with the closure of borders, the cancellation of airline flights, the evacuation of foreign workers and a collapse of cross-border trade, the national deficit of Sierra Leone and other affected countries was widening to the point where the IMF was considering expanding its financial support. As of 2019, 30% of women and 14% of men were in a polygamous unions in Sierra Leone. "The percentage of women with one or more co-wives has decreased gradually over time, from 37% in 2008 and 35% in 2013 to 30% in 2019." Rice is the staple food of Sierra Leone and is consumed at virtually every meal daily. The rice is prepared in numerous ways, and topped with a variety of sauces made from some of Sierra Leone's favourite toppings, including potato leaves, cassava leaves, crain crain , okra soup, fried fish and groundnut stew. Along the streets of towns and cities across Sierra Leone, one can find foods consisting of fruit, vegetables and snacks such as fresh mangoes , oranges, pineapple, fried plantains , ginger beer , fried potato, fried cassava with pepper sauce; small bags of popcorn or peanuts, bread, roasted corn, or skewers of grilled meat or shrimp. Poyo is a popular Sierra Leonean drink. It is a sweet, lightly fermented palm wine , and is found in bars in towns and villages across the country. Poyo bars are areas of lively informal debate about politics, football , basketball, entertainment and other issues. Media in Sierra Leone began with the introduction of the first printing press in Africa at the start of the 19th century. A strong free journalistic tradition developed with the creation of several newspapers. In the 1860s, the country became a journalist hub for Africa, with professionals travelling to the country from across the continent. At the end of the 19th century, the industry went into decline, and when radio was introduced in the 1930s, it became the primary communication media in the country. The Sierra Leone Broadcasting Service (SLBS) was created by the colonial government in 1934 making it the earliest English language radio broadcaster service in West Africa. The service began broadcasting television in 1963, with coverage extended to all the districts in the country in 1978. In April 2010, the SLBS merged with the United Nations peacekeeping radio station in Sierra Leone to form the Sierra Leone Broadcasting Corporation , the government-owned current national broadcaster in Sierra Leone. The Sierra Leone constitution guarantees freedom of speech , and freedom of the press ; however, the government maintains strong control of media, and at times restricts these rights in practice. Some subjects are seen as taboo by society and members of the political elite; imprisonment and violence have been used by the political establishment against journalists. Under legislation enacted in 1980, all newspapers must register with the Ministry of Information and pay sizeable registration fees. The Criminal Libel Law, including Seditious Libel Law of 1965, is used to control what is published in the media. In 2006, President Ahmad Tejan Kabbah committed to reforming the laws governing the press and media to create a freer system for journalists to work in. As of 2013 [ update ] Sierra Leone is ranked 61st (up two slots from 63rd in 2012) out of 179 countries on Reporters Without Borders' Press Freedom Index . Print media is not widely read in Sierra Leone, especially outside Freetown and other major cities, partially due to the low levels of literacy in the country. In 2007 there were 15 daily newspapers in the country, as well as those published weekly. Among newspaper readership, young people are likely to read newspapers weekly and older people daily. The majority of newspapers are privately run and are often critical of the government. The standard of print journalism tends to be low owing to lack of training, and people trust the information published in newspapers less than that found on the radio. Radio is the most popular and most-trusted media in Sierra Leone, with 85% of people having access to a radio and 72% of people in the country listening to the radio daily. These levels do vary between areas of the country, with the Western Area having the highest levels and Kailahun the lowest. Stations mainly consist of local commercial stations with a limited broadcast range, combined with a few stations with national coverage – Capital Radio Sierra Leone being the largest of the commercial stations. The United Nations Mission in Sierra Leone (UNIOSIL) ran one of the most popular stations in the country, broadcasting programs in a range of languages. The UN mission was restructured in 2008 and it was decided that the UN Radio would be merged with SLBS to form the new Sierra Leone Broadcasting Corporation (SLBC). This merger eventually happened in 2011 after the necessary legislation was enacted. SLBC transmits radio on FM and has two television services, one of which is uplinked by satellite for international consumption. FM relays of the BBC World Service (in Freetown, Bo, Kenema and Makeni), Radio France Internationale (Freetown only) and Voice of America (Freetown only) are also broadcast. Outside the capital Freetown and other major cities, television is not watched by a great many people, although Bo, Kenema and Makeni are served by their own relays of the main SLBC service. There are three free terrestrial television stations in Sierra Leone, one run by the government SLBC and the other two are private stations in Freetown, Star TV which is run by the owner of the Standard-Times newspaper and AYV – Africa Young Voices. Several religious funded TV stations operate intermittently. Two other commercial TV operators (ABC and AIT) closed after they were not profitable. In 2007, a pay-per-view service was also introduced by GTV as part of a pan-African television service in addition to the nine-year-old sub-Saharan Digital satellite television service (DStv) originating from Multichoice Africa in South Africa. GTV subsequently went out of business, leaving DStv as the only provider of subscription satellite television in the country. Several organisations planned to operate digital terrestrial subscription TV services, with Multichoice's Go TV having built infrastructure ahead of getting a licence and ultimately failing to get a licence. ITV and SATCON are currently operational. Internet access in Sierra Leone has been sparse but is on the increase, especially since the introduction of 3G/4G cellular phone services across the country. There are several main internet service providers (ISPs) operating in the country. Freetown has internet cafés and other businesses offering internet access. Problems experienced with access to the Internet include an intermittent electricity supply and a slow connection speed in the country outside Freetown. The arts in Sierra Leone are a mixture of tradition and hybrid African and western styles. Association football is by far the most popular sport in Sierra Leone. Children, youth and adult are frequently seen playing street football across Sierra Leone. There are organised youth and adult football tournaments across the country, and there are various primary and secondary schools with football teams across Sierra Leone. The Sierra Leone national football team, popularly known as the Leone Stars , represents the country in international competitions. It has never qualified for the FIFA World Cup but participated in the 1994 and 1996 African Cup of Nations . When the national football team, the Leone Stars, have a match, Sierra Leoneans across the country come together united in support of the national team and people rush to their local radio and television stations to follow the live match. The country's national television network, The Sierra Leone Broadcasting Corporation (SLBC) broadcasts the national football team live match, along with many local radio stations across the country. When the Leone Stars win an important match, many youth across the county rush to the street to celebrate. Many of the Sierra Leone national team footballers play for teams based in Europe although virtually all of them started professional football in the Sierra Leone National Premier League . Many of the national team footballers are celebrities across Sierra Leone and they are often well known by the general population. Some of Sierra Leonean international footballers include Mohamed Kallon , Mohamed Bangura , Rodney Strasser , Kei Kamara , Ibrahim Teteh Bangura , Mustapha Dumbuya , Christian Caulker , Alhassan Bangura , Sheriff Suma , Osman Kakay , Mohamed Kamara , Umaru Bangura and Julius Gibrilla Woobay . The Sierra Leone National Premier League is the top professional football league in Sierra Leone and is controlled by the Sierra Leone Football Association . Fourteen clubs from across the country compete in the Sierra Leone Premier League. The two biggest and most successful football clubs are East End Lions and Mighty Blackpool . East End Lions and Mighty Blackpool have an intense rivalry and when they play each other the national stadium in Freetown is often sold out and supporters of both clubs often clash with each other before and after the game. There is a huge police presence inside and outside the national stadium during a match between the two great rivals to prevent a clash. Many Sierra Leonean youth follow the local football league. Many Sierra Leonean youth, children and adults follow the major football leagues in Europe, particularly the English Premier League , Italian Serie A , Spanish La Liga , German Bundesliga and French Ligue 1 . The Sierra Leone cricket team represents Sierra Leone in international cricket competitions and is among the best in West Africa. It became an affiliate member of the International Cricket Council in 2002. It made its international debut at the 2004 African Affiliates Championship, where it finished last of eight teams. But at the equivalent tournament in 2006, Division Three of the African region of the World Cricket League, it finished as runner-up to Mozambique , and just missed promotion to Division Two. In 2009, the Sierra Leone Under-19 team finished second in the African Under-19 Championship in Zambia, thus qualifying for the Under-19 World Cup qualifying tournament with nine other teams. However, the team was unable to obtain Canadian visas to play in the tournament, which was held in Toronto. Sierra Leone is the first African country to join the International Floorball Federation .As of 2019, 30% of women and 14% of men were in a polygamous unions in Sierra Leone. "The percentage of women with one or more co-wives has decreased gradually over time, from 37% in 2008 and 35% in 2013 to 30% in 2019." Rice is the staple food of Sierra Leone and is consumed at virtually every meal daily. The rice is prepared in numerous ways, and topped with a variety of sauces made from some of Sierra Leone's favourite toppings, including potato leaves, cassava leaves, crain crain , okra soup, fried fish and groundnut stew. Along the streets of towns and cities across Sierra Leone, one can find foods consisting of fruit, vegetables and snacks such as fresh mangoes , oranges, pineapple, fried plantains , ginger beer , fried potato, fried cassava with pepper sauce; small bags of popcorn or peanuts, bread, roasted corn, or skewers of grilled meat or shrimp. Poyo is a popular Sierra Leonean drink. It is a sweet, lightly fermented palm wine , and is found in bars in towns and villages across the country. Poyo bars are areas of lively informal debate about politics, football , basketball, entertainment and other issues.Media in Sierra Leone began with the introduction of the first printing press in Africa at the start of the 19th century. A strong free journalistic tradition developed with the creation of several newspapers. In the 1860s, the country became a journalist hub for Africa, with professionals travelling to the country from across the continent. At the end of the 19th century, the industry went into decline, and when radio was introduced in the 1930s, it became the primary communication media in the country. The Sierra Leone Broadcasting Service (SLBS) was created by the colonial government in 1934 making it the earliest English language radio broadcaster service in West Africa. The service began broadcasting television in 1963, with coverage extended to all the districts in the country in 1978. In April 2010, the SLBS merged with the United Nations peacekeeping radio station in Sierra Leone to form the Sierra Leone Broadcasting Corporation , the government-owned current national broadcaster in Sierra Leone. The Sierra Leone constitution guarantees freedom of speech , and freedom of the press ; however, the government maintains strong control of media, and at times restricts these rights in practice. Some subjects are seen as taboo by society and members of the political elite; imprisonment and violence have been used by the political establishment against journalists. Under legislation enacted in 1980, all newspapers must register with the Ministry of Information and pay sizeable registration fees. The Criminal Libel Law, including Seditious Libel Law of 1965, is used to control what is published in the media. In 2006, President Ahmad Tejan Kabbah committed to reforming the laws governing the press and media to create a freer system for journalists to work in. As of 2013 [ update ] Sierra Leone is ranked 61st (up two slots from 63rd in 2012) out of 179 countries on Reporters Without Borders' Press Freedom Index . Print media is not widely read in Sierra Leone, especially outside Freetown and other major cities, partially due to the low levels of literacy in the country. In 2007 there were 15 daily newspapers in the country, as well as those published weekly. Among newspaper readership, young people are likely to read newspapers weekly and older people daily. The majority of newspapers are privately run and are often critical of the government. The standard of print journalism tends to be low owing to lack of training, and people trust the information published in newspapers less than that found on the radio. Radio is the most popular and most-trusted media in Sierra Leone, with 85% of people having access to a radio and 72% of people in the country listening to the radio daily. These levels do vary between areas of the country, with the Western Area having the highest levels and Kailahun the lowest. Stations mainly consist of local commercial stations with a limited broadcast range, combined with a few stations with national coverage – Capital Radio Sierra Leone being the largest of the commercial stations. The United Nations Mission in Sierra Leone (UNIOSIL) ran one of the most popular stations in the country, broadcasting programs in a range of languages. The UN mission was restructured in 2008 and it was decided that the UN Radio would be merged with SLBS to form the new Sierra Leone Broadcasting Corporation (SLBC). This merger eventually happened in 2011 after the necessary legislation was enacted. SLBC transmits radio on FM and has two television services, one of which is uplinked by satellite for international consumption. FM relays of the BBC World Service (in Freetown, Bo, Kenema and Makeni), Radio France Internationale (Freetown only) and Voice of America (Freetown only) are also broadcast. Outside the capital Freetown and other major cities, television is not watched by a great many people, although Bo, Kenema and Makeni are served by their own relays of the main SLBC service. There are three free terrestrial television stations in Sierra Leone, one run by the government SLBC and the other two are private stations in Freetown, Star TV which is run by the owner of the Standard-Times newspaper and AYV – Africa Young Voices. Several religious funded TV stations operate intermittently. Two other commercial TV operators (ABC and AIT) closed after they were not profitable. In 2007, a pay-per-view service was also introduced by GTV as part of a pan-African television service in addition to the nine-year-old sub-Saharan Digital satellite television service (DStv) originating from Multichoice Africa in South Africa. GTV subsequently went out of business, leaving DStv as the only provider of subscription satellite television in the country. Several organisations planned to operate digital terrestrial subscription TV services, with Multichoice's Go TV having built infrastructure ahead of getting a licence and ultimately failing to get a licence. ITV and SATCON are currently operational. Internet access in Sierra Leone has been sparse but is on the increase, especially since the introduction of 3G/4G cellular phone services across the country. There are several main internet service providers (ISPs) operating in the country. Freetown has internet cafés and other businesses offering internet access. Problems experienced with access to the Internet include an intermittent electricity supply and a slow connection speed in the country outside Freetown.The arts in Sierra Leone are a mixture of tradition and hybrid African and western styles. Association football is by far the most popular sport in Sierra Leone. Children, youth and adult are frequently seen playing street football across Sierra Leone. There are organised youth and adult football tournaments across the country, and there are various primary and secondary schools with football teams across Sierra Leone. The Sierra Leone national football team, popularly known as the Leone Stars , represents the country in international competitions. It has never qualified for the FIFA World Cup but participated in the 1994 and 1996 African Cup of Nations . When the national football team, the Leone Stars, have a match, Sierra Leoneans across the country come together united in support of the national team and people rush to their local radio and television stations to follow the live match. The country's national television network, The Sierra Leone Broadcasting Corporation (SLBC) broadcasts the national football team live match, along with many local radio stations across the country. When the Leone Stars win an important match, many youth across the county rush to the street to celebrate. Many of the Sierra Leone national team footballers play for teams based in Europe although virtually all of them started professional football in the Sierra Leone National Premier League . Many of the national team footballers are celebrities across Sierra Leone and they are often well known by the general population. Some of Sierra Leonean international footballers include Mohamed Kallon , Mohamed Bangura , Rodney Strasser , Kei Kamara , Ibrahim Teteh Bangura , Mustapha Dumbuya , Christian Caulker , Alhassan Bangura , Sheriff Suma , Osman Kakay , Mohamed Kamara , Umaru Bangura and Julius Gibrilla Woobay . The Sierra Leone National Premier League is the top professional football league in Sierra Leone and is controlled by the Sierra Leone Football Association . Fourteen clubs from across the country compete in the Sierra Leone Premier League. The two biggest and most successful football clubs are East End Lions and Mighty Blackpool . East End Lions and Mighty Blackpool have an intense rivalry and when they play each other the national stadium in Freetown is often sold out and supporters of both clubs often clash with each other before and after the game. There is a huge police presence inside and outside the national stadium during a match between the two great rivals to prevent a clash. Many Sierra Leonean youth follow the local football league. Many Sierra Leonean youth, children and adults follow the major football leagues in Europe, particularly the English Premier League , Italian Serie A , Spanish La Liga , German Bundesliga and French Ligue 1 . The Sierra Leone cricket team represents Sierra Leone in international cricket competitions and is among the best in West Africa. It became an affiliate member of the International Cricket Council in 2002. It made its international debut at the 2004 African Affiliates Championship, where it finished last of eight teams. But at the equivalent tournament in 2006, Division Three of the African region of the World Cricket League, it finished as runner-up to Mozambique , and just missed promotion to Division Two. In 2009, the Sierra Leone Under-19 team finished second in the African Under-19 Championship in Zambia, thus qualifying for the Under-19 World Cup qualifying tournament with nine other teams. However, the team was unable to obtain Canadian visas to play in the tournament, which was held in Toronto. Sierra Leone is the first African country to join the International Floorball Federation .Sierra Leone's Freetown is a favourite destination for tourists. Although the sector was seriously affected during the Civil War, there has been a steady improvement in recent years. The city has a lot to offer to tourists. There is a vast expanse of beaches stretching along the Freetown Peninsula. The Lumley-Aberdeen beach stretches all the way from Cape Sierra Leone down to Lumley. There are also other popular beaches like the world renowned River Number 2 Beach, Laka Beach, Tokeh Beach, Bureh Beach, and Mama Beach. The Tacugama Chimpanzee Sanctuary, which is located within the peninsula's vast rainforest reserve, just a few kilometres from the centre of Freetown, has a collection of rare and endangered chimpanzees. Other popular destinations for tourists include the Freetown Cotton Tree, located in Central Freetown, a significant national monument and integral to the founding of the city; Bunce Island, which is a boat ride from the city, is home to the ruins of the slave fortress that was being used during the Transatlantic slave trade; the Sierra Leone Museum, which has a collection of both precolonial as well as colonial artifacts and other items of historical significance; the National Railway Museum; or take a journey around the city's coastline with the popular Sea Coach Express. The Aberdenn-Lumley area is a favourite destination for those venturing into the city's nightlife.

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Central chimpanzee

The central chimpanzee or the tschego ( Pan troglodytes troglodytes ) is a subspecies of chimpanzee . It can be found in Central Africa , mostly in Gabon , Cameroon , Republic of Congo and the Democratic Republic of Congo . Central chimpanzees are considered highly intelligent apes . They are also highly social living in large groups and follow a male dominant hierarchy. The activity budgets of this chimpanzee subspecies changes depending on if they were in the wild or sanctuaries. They have been observed using tools, this could be to open nuts or using twigs to gain access to ants and termites. Central chimpanzees have a key role in the ecology of rainforests; they play an important role as seed dispersers. Even though central chimpanzees and western lowland gorillas overlap the environment in which they live in they do not compete for food as their diets are different. According to the International Union for Conservation of Nature (IUCN), they classify the central chimpanzee as an endangered subspecies. Increasing human presence through deforestation and viruses pose great threats to them. Diseases in central chimpanzees pose risk to the population of them this include heart issues but also different types of viruses . Central chimpanzees are strong vector carrying . These viruses spread inter species to other species and sometimes to humans. These viruses include the Ebola virus . However, there are also human immunodeficiency viruses (HIV) at the origin which have links to central chimpanzees.Pan is derived from the Greek god of fields, groves, and wooded glens, Pan . Troglodytes is Greek for ' cave -dweller', and was coined by Johann Friedrich Blumenbach in his Handbuch der Naturgeschichte ( Handbook of Natural History ), published in 1779.The central chimpanzee mainly lives in Gabon , Cameroon , and Republic of the Congo , but also in the Central African Republic , Equatorial Guinea , the Cabinda exclave of Angola , southeast Nigeria , and possibly the coastal extension of the Democratic Republic of the Congo . Its range extends north to the Sanaga River in Cameroon, east to the Ubangi River that defines the border between the two Congos, and south to the Congo River , which defines a large part of the same border. Central chimpanzees are found predominantly in tropical moist forest and wet savanna woodlands, as well as the forest-savanna mosaics where these two biomes meet, from sea level to 3,000 metres (9,800 ft) . They tend to have larger ranges in the forest-savanna mosaics. The average range is 12.5 km 2 (4.8 sq mi) , but can vary from 5 km 2 (1.9 sq mi) to 400 km 2 (150 sq mi) . The central chimpanzee averages 59.7 kilograms (132 lb) in males and 45.8 kilograms (101 lb) in females. Standing they measure on average 96 cm (38 in) for males and 80 cm (31 in) for females. Central chimpanzees usually have a lifetime in captivity of 30 to 40 years, but some have been seen to live over 50 years. In the wild, the average lifetime decreases to 15 to 25 years. A physical characteristic that distinguishes the central chimpanzee from other subspecies is that it has less hair covering its face. This is most prevalent in female central chimpanzees. The arms are also longer than those of the other subspecies, and they also have longer fingers and short thumbs. All these characteristics help the central chimpanzee be better adapted at climbing trees. Central chimpanzees live in social groups of around 66 individuals, on average this tends to be more than the group size of western chimpanzee counterparts. It was found that chimpanzees split activity budget into four main categories. In chimpanzees there exists male dominance within these social groups. Often the strongest and most aggressive males will become the alphas of the group. This can be thought of like leaders of the group. This social hierarchy is well explained in a study done in 2018 by Jane Goodall institute. But in these groups of chimpanzees females also have leading roles as alpha female groups. Although it is not probable that an alpha female will outrank an alpha male. It was found that chimpanzees split activity budget into four main categories. The search for food, socialising, moving and resting. It was found that in the wild they spent 50% of their time in search of food. The rest of the time was then spent equally socialising, moving and resting. Studies which were done all over the African continent showed the same trend for all chimpanzee subspecies. The social groups will break up into smaller groups called parties which mostly consist of males. They will control a certain area, this could lead to inter species fights and killings. This was found to be one of the leading causes of death of chimpanzees in the Gombe stream research center. Central chimpanzees live in social groups of around 66 individuals, on average this tends to be more than the group size of western chimpanzee counterparts. It was found that chimpanzees split activity budget into four main categories. In chimpanzees there exists male dominance within these social groups. Often the strongest and most aggressive males will become the alphas of the group. This can be thought of like leaders of the group. This social hierarchy is well explained in a study done in 2018 by Jane Goodall institute. But in these groups of chimpanzees females also have leading roles as alpha female groups. Although it is not probable that an alpha female will outrank an alpha male. It was found that chimpanzees split activity budget into four main categories. The search for food, socialising, moving and resting. It was found that in the wild they spent 50% of their time in search of food. The rest of the time was then spent equally socialising, moving and resting. Studies which were done all over the African continent showed the same trend for all chimpanzee subspecies. The social groups will break up into smaller groups called parties which mostly consist of males. They will control a certain area, this could lead to inter species fights and killings. This was found to be one of the leading causes of death of chimpanzees in the Gombe stream research center. Central chimpanzees have a key role in the ecology and environmental role. In the forest central chimpanzees are seed dispersers . As since the majority of their diet consist of fruits , they are not able to digest the seeds, so when they defecate these seeds are dispersed on the forest floor . The central chimpanzees have been found to provide treatments to the seeds in the gut that aid the germination of seeds. These factors combined make them very effective seed dispersers and a circuital element to the ecological rainforest environment. Central chimpanzees are opportunistic frugivores . Compared to western lowland gorillas and Bornean orangutans who are generalized folivores and frugivores, central chimpanzees are specialised frugivores. Central chimpanzees diet consists mainly of fruits in their diets. During months were the fruit availability is low, central chimpanzees are able to keep a high fruit intake. The central chimpanzees tend to stay in the vegetation to get their food source. In a study, it mentions that central chimpanzees and western lowland gorillas high fruit consumption overlap in many parts of Central Africa. But in most cases, central chimpanzees consumed more fruits in their diets (60%), where western lowland gorillas also consumed more leaves . This is due to their digestive specificities. So they do not seem to have a direct competition for food between central chimpanzees and western lowland gorillas. It was also seen that central chimpanzees in the Montane forest of Kahuzi swallowed two different types of leaves of Commelinaceae for medical purposes. This was seen in 2.1% of the fecal matter of the central chimpanzees. It was proposed that this was done to control intestinal parasites. They are known to be occasional predators, which is the red colobus monkey . Although this is a rare occurrence this does occur in Central Africa. The population being in decline the occurrence of Central Africa is diminishing. Central chimpanzees are opportunistic frugivores . Compared to western lowland gorillas and Bornean orangutans who are generalized folivores and frugivores, central chimpanzees are specialised frugivores. Central chimpanzees diet consists mainly of fruits in their diets. During months were the fruit availability is low, central chimpanzees are able to keep a high fruit intake. The central chimpanzees tend to stay in the vegetation to get their food source. In a study, it mentions that central chimpanzees and western lowland gorillas high fruit consumption overlap in many parts of Central Africa. But in most cases, central chimpanzees consumed more fruits in their diets (60%), where western lowland gorillas also consumed more leaves . This is due to their digestive specificities. So they do not seem to have a direct competition for food between central chimpanzees and western lowland gorillas. It was also seen that central chimpanzees in the Montane forest of Kahuzi swallowed two different types of leaves of Commelinaceae for medical purposes. This was seen in 2.1% of the fecal matter of the central chimpanzees. It was proposed that this was done to control intestinal parasites. They are known to be occasional predators, which is the red colobus monkey . Although this is a rare occurrence this does occur in Central Africa. The population being in decline the occurrence of Central Africa is diminishing. The 2007 International Union for Conservation of Nature (IUCN) Red List of Threatened Species classifies the central chimpanzee as endangered . In 1988 they were considered " vulnerable ", but have been considered "endangered" since at least 1996. The World Wildlife Fund (WWF) estimates there are as many as 115,000 individuals alive, but that the number is more likely between 47,000 and 78,000 The central chimpanzee only has large, robust populations where large amounts of forest are left undisturbed; smaller, isolated populations also remain. According to the IUCN, decline in the central chimpanzee population is expected to continue for another 30 to 40 years. Major threats to central chimpanzee populations include Ebola virus disease , poaching for bushmeat , and habitat destruction . The IUCN attributes this to increasing human presence (agriculture, de-forestation, development) and political instability. Due to the close genetic relationship to gorillas , orangutans and humans , central chimpanzees are vulnerable to viruses that afflict humans, such as Ebola, the common cold , influenza , pneumonia , whooping cough , tuberculosis , measles , yellow fever , HIV and may contract other parasitological diseases such as schistosomiasis , filariasis , giardiasis , and salmonellosis . One of the major causes of central chimpanzee deaths is caused by heart disease. This sudden cardiac death is caused by fatal arrhythmia. This is when the heart has an unorganised, erratic firing of the impulse which impact the ventricles. But in central chimpanzees the post mortem analysis of this cause of death is complex to observe. The causes related to these spontaneous heart failures were observed in this study. They saw different reasons which lead to this disease the most prevalent ones were renal failure and trauma. Since the 1990s there have been multiple outbreaks of Ebola in great apes especially central chimpanzees all over the African continent, this has had a great effect on the population numbers. It had strong impacts on the central chimpanzees and western lowland gorillas. This virus spread to central chimpanzees but spread to western chimpanzee species. Ebola also spread to western lowland gorillas and even to humans. In 1994 an outbreak of Ebola was recorded in Nature. During the time of a couple weeks 25% of the central chimpanzee population disappeared in this rainforest, this amounted to 43 wild central chimpanzees that died. They were found in the Tai National Park. The spread of Ebola is commonly inter species especially between western lowland gorillas and central chimpanzees. Since the 1990s it is estimated that about one third of the population of western lowland gorillas and central chimpanzees have died. In another study done about the 1996 outbreak that happened in North Eastern Gabbon, showed that the population of central chimpanzees had a high risk of death if exposed to this virus. Out of the 37 central chimpanzees that were contaminated 27 were found dead. This threat from Ebola pandemics combined with conservation and habitat destruction pose a large issue to the central chimpanzee population. In 2004 an outbreak of Ebola of appeared in Central Africa. It had an enormous impact on the western lowland gorilla and therefore also had an impact on the central chimpanzee population. A study showed that the western lowland gorilla population in the area went from 380 individuals to 40. It is also noted in the study that the Ebola outbreak has caused a large decrease of the central chimpanzee population as well. This virus has drastic impact on the population of central chimpanzees. In 2011 an experiment began which would try to vaccinate the central chimpanzees, this experiment was performed on six central chimpanzees. Their experiment was to vaccinate central chimpanzees with a vaccine developed for humans. Their goal was to try to reduce the spread of Ebola within central chimpanzees. Through this experiment the central chimpanzees developed an immune response that was thought to have developed antibodies. This study was not conclusive. In 2015, the central chimpanzees were place on the endangered list so further experiments had to halted. Two types of human immunodeficiency virus (HIV) infect humans: HIV-1 and HIV-2. HIV-1 is the more virulent and easily transmitted, and is the source of the majority of HIV infections throughout the world; HIV-2 is largely confined to West Africa. Both types originated in West and Central Africa. HIV-1 has evolved from a simian immunodeficiency virus (SIVcpz) found in the central chimpanzee. Kinshasa , in the Democratic Republic of Congo, has the greatest genetic diversity of HIV-1 so far discovered, suggesting that the virus has been there longer than anywhere else. HIV-2 crossed species from a different strain of SIV, found in the sooty mangabey , monkeys in Guinea-Bissau . One of the major causes of central chimpanzee deaths is caused by heart disease. This sudden cardiac death is caused by fatal arrhythmia. This is when the heart has an unorganised, erratic firing of the impulse which impact the ventricles. But in central chimpanzees the post mortem analysis of this cause of death is complex to observe. The causes related to these spontaneous heart failures were observed in this study. They saw different reasons which lead to this disease the most prevalent ones were renal failure and trauma. Since the 1990s there have been multiple outbreaks of Ebola in great apes especially central chimpanzees all over the African continent, this has had a great effect on the population numbers. It had strong impacts on the central chimpanzees and western lowland gorillas. This virus spread to central chimpanzees but spread to western chimpanzee species. Ebola also spread to western lowland gorillas and even to humans. In 1994 an outbreak of Ebola was recorded in Nature. During the time of a couple weeks 25% of the central chimpanzee population disappeared in this rainforest, this amounted to 43 wild central chimpanzees that died. They were found in the Tai National Park. The spread of Ebola is commonly inter species especially between western lowland gorillas and central chimpanzees. Since the 1990s it is estimated that about one third of the population of western lowland gorillas and central chimpanzees have died. In another study done about the 1996 outbreak that happened in North Eastern Gabbon, showed that the population of central chimpanzees had a high risk of death if exposed to this virus. Out of the 37 central chimpanzees that were contaminated 27 were found dead. This threat from Ebola pandemics combined with conservation and habitat destruction pose a large issue to the central chimpanzee population. In 2004 an outbreak of Ebola of appeared in Central Africa. It had an enormous impact on the western lowland gorilla and therefore also had an impact on the central chimpanzee population. A study showed that the western lowland gorilla population in the area went from 380 individuals to 40. It is also noted in the study that the Ebola outbreak has caused a large decrease of the central chimpanzee population as well. This virus has drastic impact on the population of central chimpanzees. In 2011 an experiment began which would try to vaccinate the central chimpanzees, this experiment was performed on six central chimpanzees. Their experiment was to vaccinate central chimpanzees with a vaccine developed for humans. Their goal was to try to reduce the spread of Ebola within central chimpanzees. Through this experiment the central chimpanzees developed an immune response that was thought to have developed antibodies. This study was not conclusive. In 2015, the central chimpanzees were place on the endangered list so further experiments had to halted. In 2011 an experiment began which would try to vaccinate the central chimpanzees, this experiment was performed on six central chimpanzees. Their experiment was to vaccinate central chimpanzees with a vaccine developed for humans. Their goal was to try to reduce the spread of Ebola within central chimpanzees. Through this experiment the central chimpanzees developed an immune response that was thought to have developed antibodies. This study was not conclusive. In 2015, the central chimpanzees were place on the endangered list so further experiments had to halted. Two types of human immunodeficiency virus (HIV) infect humans: HIV-1 and HIV-2. HIV-1 is the more virulent and easily transmitted, and is the source of the majority of HIV infections throughout the world; HIV-2 is largely confined to West Africa. Both types originated in West and Central Africa. HIV-1 has evolved from a simian immunodeficiency virus (SIVcpz) found in the central chimpanzee. Kinshasa , in the Democratic Republic of Congo, has the greatest genetic diversity of HIV-1 so far discovered, suggesting that the virus has been there longer than anywhere else. HIV-2 crossed species from a different strain of SIV, found in the sooty mangabey , monkeys in Guinea-Bissau .

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Viral hemorrhagic fever

Viral hemorrhagic fevers ( VHFs ) are a diverse group of animal and human illnesses . VHFs may be caused by five distinct families of RNA viruses : the families Filoviridae , Flaviviridae , Rhabdoviridae , and several member families of the Bunyavirales order such as Arenaviridae , and Hantaviridae . All types of VHF are characterized by fever and bleeding disorders and all can progress to high fever, shock and death in many cases. Some of the VHF agents cause relatively mild illnesses, such as the Scandinavian nephropathia epidemica (a hantavirus ), while others, such as Ebola virus , can cause severe, life-threatening disease.Signs and symptoms of VHFs include (by definition) fever and bleeding: The severity of symptoms varies with the type of virus. The "VHF syndrome" (capillary leak, bleeding diathesis , and circulatory compromise leading to shock) appears in a majority of people with filoviral hemorrhagic fevers (e.g., Ebola and Marburg virus ), Crimean–Congo hemorrhagic fever (CCHF), and the South American hemorrhagic fevers caused by arenaviruses , but only in a small minority of patients with dengue or Rift Valley fever .Five families of RNA viruses have been recognised as being able to cause hemorrhagic fevers. [ citation needed ] The pathogen that caused the cocoliztli epidemics in Mexico of 1545 and 1576 is still unknown, and the 1545 epidemic may have been bacterial rather than viral. Different hemorrhagic fever viruses act on the body in different ways, resulting in different symptoms. In most VHFs, it is likely that several mechanisms contribute to symptoms, including liver damage, disseminated intravascular coagulation (DIC), and bone marrow dysfunction. In DIC, small blood clots form in blood vessels throughout the body, removing platelets necessary for clotting from the bloodstream and reducing clotting ability. DIC is thought to cause bleeding in Rift Valley, Marburg, and Ebola fevers. For filoviral hemorrhagic fevers, there are four general mechanisms of pathogenesis. The first mechanism is dissemination of virus due to suppressed responses by macrophages and dendritic cell (antigen presenting cells). The second mechanism is prevention of antigen specific immune response. The third mechanism is apoptosis of lymphocytes. The fourth mechanism is when infected macrophages interact with toxic cytokines , leading to diapedesis and coagulation deficiency. From the vascular perspective, the virus will infect vascular endothelial cells, leading to the reorganization of the VE-cadherin catenin complex (a protein important in cell adhesion). This reorganization creates intercellular gaps in endothelial cells. The gaps lead to increased endothelial permeability and allow blood to escape from the vascular circulatory system. [ citation needed ] The reasons for variation among patients infected with the same virus are unknown but stem from a complex system of virus-host interactions. Dengue fever becomes more virulent during a second infection by means of antibody-dependent enhancement . After the first infection, macrophages display antibodies on their cell membranes specific to the dengue virus. By attaching to these antibodies, dengue viruses from a second infection are better able to infect the macrophages, thus reducing the immune system's ability to fight off infection. [ citation needed ]Definitive diagnosis is usually made at a reference laboratory with advanced biocontainment capabilities. The findings of laboratory investigation vary somewhat between the viruses but in general, there is a decrease in the total white cell count (particularly the lymphocytes ), a decrease in the platelet count, an increase in the blood serum liver enzymes , and reduced blood clotting ability measured as an increase in both the prothrombin (PT) and activated partial thromboplastin times (PTT). The hematocrit may be elevated. The serum urea and creatine may be raised but this is dependent on the hydration status of the patient. The bleeding time tends to be prolonged. [ citation needed ]With the exception of yellow fever vaccine and Ebola vaccines , vaccines for VHF-associated viruses are generally not available. Post-exposure prophylactic (preventive) ribavirin may be effective for some bunyavirus and arenavirus infections. VHF isolation guidelines dictate that all VHF patients (with the exception of dengue patients) should be cared for using strict contact precautions, including hand hygiene, double gloves, gowns, shoe and leg coverings, and face shield or goggles. Lassa, CCHF, Ebola, and Marburg viruses may be particularly prone to nosocomial (hospital-based) spread. Airborne precautions should be utilized including, at a minimum, a fit-tested , HEPA filter-equipped respirator (such as an N95 mask ), a battery-powered, air-purifying respirator, or a positive pressure supplied air respirator to be worn by personnel coming within 1.8 meter (six feet) of a VHF patient. Groups of patients should be cohorted (sequestered) to a separate building or a ward with an isolated air-handling system. Environmental decontamination is typically accomplished with hypochlorite (e.g. bleach) or phenolic disinfectants . Medical management of VHF patients may require intensive supportive care. Antiviral therapy with intravenous ribavirin may be useful in Bunyaviridae and Arenaviridae infections (specifically Lassa fever, RVF, CCHF, and HFRS due to Old World Hantavirus infection) and can be used only under an experimental protocol as IND approved by the U.S. Food and Drug Administration (FDA). Interferon may be effective in Argentine or Bolivian hemorrhagic fevers (also available only as IND). [ citation needed ]The VHF viruses are spread in a variety of ways. Some may be transmitted to humans through a respiratory route. [ citation needed ] The virus is considered by military medical planners to have a potential for aerosol dissemination, weaponization, or likelihood for confusion with similar agents that might be weaponized.

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Filoviridae

Filoviridae ( / ˌ f aɪ l oʊ ˈ v ɪr ɪ d iː / ) is a family of single-stranded negative-sense RNA viruses in the order Mononegavirales . Two members of the family that are commonly known are Ebola virus and Marburg virus . Both viruses, and some of their lesser known relatives, cause severe disease in humans and nonhuman primates in the form of viral hemorrhagic fevers . All filoviruses are classified by the US as select agents , by the World Health Organization as Risk Group 4 Pathogens (requiring Biosafety Level 4-equivalent containment ), by the National Institutes of Health / National Institute of Allergy and Infectious Diseases as Category A Priority Pathogens, and by the Centers for Disease Control and Prevention as Category A Bioterrorism Agents , and are listed as Biological Agents for Export Control by the Australia Group . The family Filoviridae is a virological taxon that was defined in 1982 and emended in 1991, 1998, 2000, 2005, 2010 and 2011. The family currently includes the six virus genera Cuevavirus , Dianlovirus , Ebolavirus , Marburgvirus , Striavirus , and Thamnovirus and is included in the order Mononegavirales . The members of the family (i.e. the actual physical entities) are called filoviruses or filovirids. The name Filoviridae is derived from the Latin noun filum (alluding to the filamentous morphology of filovirions) and the taxonomic suffix -viridae (which denotes a virus family). According to the rules for taxon naming established by the International Committee on Taxonomy of Viruses (ICTV) , the name Filoviridae is always to be capitalized , italicized , never abbreviated, and to be preceded by the word "family". The names of its members (filoviruses or filovirids) are to be written in lower case, are not italicized, and used without articles . According to the rules for taxon naming established by the International Committee on Taxonomy of Viruses (ICTV) , the name Filoviridae is always to be capitalized , italicized , never abbreviated, and to be preceded by the word "family". The names of its members (filoviruses or filovirids) are to be written in lower case, are not italicized, and used without articles . The filovirus life cycle begins with virion attachment to specific cell-surface receptors , followed by fusion of the virion envelope with cellular membranes and the concomitant release of the virus nucleocapsid into the cytosol . The viral RNA-dependent RNA polymerase (RdRp, or RNA replicase) partially uncoats the nucleocapsid and transcribes the genes into positive-stranded mRNAs , which are then translated into structural and nonstructural proteins . Filovirus RdRps bind to a single promoter located at the 3' end of the genome. Transcription either terminates after a gene or continues to the next gene downstream. This means that genes close to the 3' end of the genome are transcribed in the greatest abundance, whereas those toward the 5' end are least likely to be transcribed. The gene order is therefore a simple but effective form of transcriptional regulation. The most abundant protein produced is the nucleoprotein , whose concentration in the cell determines when the RdRp switches from gene transcription to genome replication. Replication results in full-length, positive-stranded antigenomes that are in turn transcribed into negative-stranded virus progeny genome copies. Newly synthesized structural proteins and genomes self-assemble and accumulate near the inside of the cell membrane . Virions bud off from the cell, gaining their envelopes from the cellular membrane they bud from. The mature progeny particles then infect other cells to repeat the cycle. A virus that fulfills the criteria for being a member of the order Mononegavirales is a member of the family Filoviridae if: The mutation rates in these genomes have been estimated to be between 0.46 × 10 −4 and 8.21 × 10 −4 nucleotide substitutions/site/year. The most recent common ancestor of sequenced filovirus variants was estimated to be 1971 (1960–1976) for Ebola virus, 1970 (1948–1987) for Reston virus, and 1969 (1956–1976) for Sudan virus, with the most recent common ancestor among the four species included in the analysis (Ebola virus, Tai Forest virus, Sudan virus, and Reston virus) estimated at 1000–2100 years. The most recent common ancestor of the Marburg and Sudan species appears to have evolved 700 and 850 years before present respectively. Although mutational clocks placed the divergence time of extant filoviruses at ~10,000 years before the present, dating of orthologous endogenous elements (paleoviruses) in the genomes of hamsters and voles indicated that the extant genera of filovirids had a common ancestor at least as old as the Miocene (~16–23 million or so years ago). Filoviridae cladogram is the following: Orthoebolavirus bundibugyoense (BDBV) Orthoebolavirus taiense (TAFV) Orthoebolavirus zairense = Ebola virus (EBOV) Orthoebolavirus bombaliense (BOMV) Orthoebolavirus sudanense (SUDV) Orthoebolavirus restonense (RESTV) Cuevavirus lloviuense = Lloviu virus (LLOV) ? Dehong virus (DEHV) Orthomarburgvirus marburgense (Marburg virus & Ravn virus) Dianlovirus menglaense = Měnglà virus (MLAV) Tapjovirus bothropis = Tapajós virus (TAPV) Striavirus antennarii = Xīlǎng virus (XILV) Thamnovirus percae = Fiwi virus (FIWIV) Thamnovirus kanderense = Kander virus (KNDV) Thamnovirus thamnaconi = Huángjiāo virus (HUJV) Oblavirus percae = Oberland virus (OBLV)Filoviruses have a history that dates back several tens of million of years. Endogenous viral elements (EVEs) that appear to be derived from filovirus-like viruses have been identified in the genomes of bats , rodents , shrews , tenrecs , tarsiers , and marsupials . Although most filovirus-like EVEs appear to be pseudogenes , evolutionary analyses suggest that orthologs isolated from several species of the bat genus Myotis have been maintained by selection. There are presently very limited vaccines for known filovirus. An effective vaccine against EBOV, developed in Canada, was approved for use in 2019 in the US and Europe. Similarly, efforts to develop a vaccine against Marburg virus are under way. There has been a pressing concern that a very slight genetic mutation to a filovirus such as EBOV could result in a change in transmission system from direct body fluid transmission to airborne transmission, as was seen in Reston virus (another member of genus Ebolavirus) between infected macaques. A similar change in the current circulating strains of EBOV could greatly increase the infection and disease rates caused by EBOV. However, there is no record of any Ebola strain ever having made this transition in humans. The Department of Homeland Security 's National Biodefense Analysis and Countermeasures Center considers the risk of a mutated Ebola virus strain with aerosol transmission capability emerging in the future as a serious threat to national security and has collaborated with the Centers for Disease Control and Prevention (CDC) to design methods to detect EBOV aerosols.

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