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Health

Nursing Properties Confront New Covid Outbreaks Amid Requires Employees Vaccination Mandates

In saying last Friday that it was monitoring outbreaks at nursing homes related to the Delta variant, the C.D.C. said some measures under review would include “testing, quarantine, visitation, use of PPE and source control.”

Underscoring the concern of regulators about unvaccinated workers, Colorado just implemented a new rule that unvaccinated staff members at nursing homes must be tested for the virus, using a rapid test, every time they come to work. California is now requiring health care workers in the state to be vaccinated or undergo frequent testing.

Feelings are raw among nursing home staff and operators.

“I don’t want to lose anyone else,” said Marita Smith, administrator at Saint Anne Nursing and Rehab Center in Seattle. Eight of 32 residents died of Covid early on in the pandemic, including four who were already on hospice. Ms. Smith says the losses help explain why all 52 staff members have been vaccinated.

“I question their reason for being in the business if they don’t get it,” Ms. Smith said. “You just don’t want to turn your back.”

Some nursing home staff members resisting vaccination argue that they can protect residents without being inoculated. “I go home, stay home as much as possible, do grocery pickup instead of shopping, do a lot of hand washing. I’m not exposing myself to other people,” said Jessica M., a director of nursing at a home in Grand Junction, Colo., who is unvaccinated.

She declined to give her last name because she wasn’t authorized to speak to the media. She added that she wanted to make sure “the side effects aren’t worse than protecting someone from Covid.”

But consumer advocates and others point to the difficulties nursing homes have long had in protecting residents from infection. A government report issued in May found that nursing homes averaged three Covid outbreaks from May 2020 through January 2021, with two-thirds reporting the outbreaks began with an infected staff member testing positive.

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Health

C.D.C. Warns of Superbug Fungus Outbreaks in 2 Cities

While C. auris has long been notoriously hard to treat, researchers for the first time identified five patients in Texas and Washington, D.C., whose infections did not respond to any of the three major classes of antifungal medication. So-called panresistance had been previously reported in three patients in New York who were being treated for C. auris, but health officials said the newly reported panresistant infections occurred in patients who had never received antifungal drugs, said Dr. Meghan Lyman, a medical officer at the C.D.C. who specializes in fungal diseases.

“The concerning thing is that the patients at risk are no longer the small population of people who have infections and are already being treated with these medications,” she said.

Infectious disease specialists say the coronavirus pandemic has probably accelerated the spread of the fungus. The shortages of personal protective equipment that hobbled health care workers during the early months of the pandemic, they say, increased opportunities for the fungus’s transmission, especially among the thousands of Covid-19 patients who ended up on invasive mechanical ventilation.

The chaos of recent months also did not help. “Infection control efforts at most heath care systems are stretched thin in the best of times, but with so many Covid patients, resources that might have gone to infection control were diverted elsewhere,” Dr. Clancy said.

For many health experts, the emergence of a panresistant C. auris is a sobering reminder about the threats posed by antimicrobial resistance, from superbugs like MRSA to antibiotic-resistant salmonella. Such infections sicken 2.8 million Americans a year and kill 35,000, according to the C.D.C.

Dr. Michael S. Phillips, chief epidemiologist at NYU/Langone Health, said health systems across the country were struggling to contain the spread of such pathogens. The problem, he said, was especially acute in big cities like New York, where seriously ill patients shuttle between nursing homes with lax infection control and top-notch medical centers that often draw patients from across a wider region.

“We need to do a better job at surveillance and infection control, especially in places where we put patients in group settings,” he said. “Candida auris is something we should be concerned about, but we can’t lose sight of the bigger picture because there are a lot of other drug-resistant bugs out there we should be worried about.”

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World News

Asia Grapples With Delta-Pushed Outbreaks

Indonesia has reported almost twice as many coronavirus cases as the US in the past few days. Malaysia’s per capita number of cases is roughly on par with Brazil and Iran. And the recent increases in Covid in Japan and South Korea have led to strict new restrictions on movement there from Monday.

Across the Asia-Pacific region, the Delta variant is causing new outbreaks in locations where transmission was previously kept relatively low but the rate of vaccination was too slow to contain recent outbreaks. One result is that everyday activities will be restricted again, just like in the fearful early days of the pandemic – even as the West returns to normal.

Indonesia, the fourth most populous country in the world, is a case in point. His government once hoped that its archipelagic geography and young population would save it from a debilitating eruption. But only about 13 percent of its 270 million people have received at least one dose of a Covid-19 vaccine, and Delta’s rise is marginalizing its healthcare system, forcing some patients to hunt for oxygen.

On July 3, the government closed mosques, schools, shopping centers and sports facilities on two of Indonesia’s largest islands for two weeks. But the daily average of new cases – more than 33,000 on Sunday – has continued to rise. Officials said Friday they would extend the same emergency rules to other islands.

Intensive care units in and around the capital Jakarta are at full capacity, doctors who have received the vaccine from the Chinese company Sinovac have fallen ill or died. The government has announced that it will give a third dose of the Moderna vaccine to around 1.5 million health workers starting this week.

In other Southeast Asian countries, too, the percentages of the population who even got a shot are in the single- or low-double-digit range. And as variant infections multiply, some are experiencing their worst outbreaks yet.

In Myanmar, where health workers went on strike to protest the military coup in February, cases are skyrocketing and schools were closed until July 23. People in several Malaysian cities are rubbing themselves under strict lockdowns as the country reports the highest per capita fall in the region. Vietnam is restricting freedom of movement in its two major cities and is trying to import vaccines. And at Thailand’s largest international airport, a terminal is being converted into a field hospital.

Richer countries in the region have more resources to fight the virus. But they too are vulnerable because they have made little progress in their vaccination campaigns. In Australia, Japan, New Zealand, and South Korea, less than one in three people has had an injection, according to a New York Times tracker.

New South Wales, Australia’s most populous state, reported the largest daily increase in cases this year on Sunday, as well as Australia’s first coronavirus-related death this year, a woman in her 90s. Sydney, the state capital, has already been on lockdown and authorities have warned it could be extended beyond July 17 when it expires.

South Korea reported 1,378 new cases on Saturday, the third day record in a row. The government plans to increase the restrictions in the capital Seoul and some neighboring regions to the highest level from Monday. Schools are closing, bars and nightclubs are closing, and no more than two people are allowed to meet in public after 6 p.m.

And in Japan, the fourth state of emergency will come into effect in Tokyo on Monday, less than two weeks before the start of the Summer Olympics. Restaurants, department stores and other businesses are being asked to close early, and the organizers of the Summer Games have announced that they will be banning viewers from most events in and around Tokyo. A ceremony marking the arrival of the Olympic torch in town was held in an almost empty park late last week.

On Saturday, Fukushima Prefecture said it would also exclude spectators from Olympic events due to the rising number of cases, reversing a position announced two days earlier by Olympic organizers.

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Health

New Covid outbreaks a high danger to financial restoration, OECD chief says

Covid-19 vaccinations without prior registration will be given at Sector 30 District Hospital in Noida, India on June 22, 2021.

Sunil Ghosh | Hindustan times | Getty Images

New outbreaks of Covid-19 remain one of the greatest risks to a global economic recovery, warned the Secretary-General of the OECD, calling on developed countries to support less developed countries with their vaccination programs.

“We have to do what we can to get as many people as possible around the world to vaccinate. There is a special responsibility for developed economies and it is not just about charity or charity, it is actually both a matter of self-interest “to keep our people safe … and to ensure that economic recovery is sustainable” said Mathias Cormann, Secretary General of the OECD, on Thursday.

“New outbreaks are still one of the biggest downside risks to the ongoing economic recovery,” he told CNBC’s Annette Weisbach.

“There is a race between vaccinating as many people as possible around the world, including and especially in developing countries, and the risk of new variants emerging and variants that may be resistant to the vaccines currently available,” he noted.

Read more: Covid-19 has destroyed 22 million jobs in advanced countries, according to the OECD

It is not only Cormann who fears that the continued spread of Covid-19, especially the latest highly transmissible Delta variant in younger and unvaccinated people, could destroy an economic recovery.

French Finance Minister Bruno Le Maire told CNBC on Tuesday that “the only thing that could jeopardize France’s economic recovery is a new wave of the pandemic”.

On Wednesday, the World Health Organization reiterated its call for wealthy nations to help poorer countries by sharing Covid vaccines, especially for health and care workers and the elderly.

Global minimum tax rate

The coronavirus pandemic may be the most pressing problem for global public health, but governments have now turned to other pressing matters, including international tax reform.

In June, treasury ministers from the most advanced economies known as the Group of Seven backed a US proposal requiring companies around the world to pay at least 15% income tax.

Last Thursday, US Treasury Secretary Janet Yellen announced that at least 130 nations had agreed to a global minimum tax on companies, part of a broader agreement to revise international tax rules.

Cormann said the deal was urgently needed, noting that “131 countries have reached an agreement on an internationally consistent path to fair taxation. Globalization and the digitization of our economies led to efficiency distortions and serious inequalities in our tax system and companies did not pay their fair share of taxes where they should. “

“We now have an agreement whereby the winners of globalization, including and especially the major digital multinationals, would pay their fair share of taxes or pay their fair share of taxes once (the deal) was in the markets in which they operate are implemented. “Their profits.”

He noted that all 131 countries have agreed that the global minimum corporate tax rate should be 15%, as have those in the group of 20 developed countries. “This underpins tax competition worldwide.”

Some low corporate tax countries like Ireland and Hungary have concerns about the deal, but Cormann said they were involved in the negotiation process: “Some countries seem to be starting from a different position,” he noted, “but 131 out of 139”. Counties (members of the G20 / OECD Inclusive Framework working together on tax reform) are on board and this is an important milestone. “

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Health

They Relied on Chinese language Vaccines. Now They’re Battling Outbreaks.

The reason for the surge in Mongolia, Mr. Batbayar said, is that the country reopened too quickly, and many people believed they were protected after only one dose.

“I think you could say Mongolians celebrated too early,” he said. “My advice is the celebrations should start after the full vaccinations, so this is the lesson learned. There was too much confidence.”

Some health officials and scientists are less confident.

Nikolai Petrovsky, a professor at the College of Medicine and Public Health at Flinders University in Australia, said that with all of the evidence, it would be reasonable to assume the Sinopharm vaccine had minimal effect on curbing transmission. A major risk with the Chinese inoculation is that vaccinated people may have few or no symptoms and still spread the virus to others, he said.

“I think that this complexity has been lost on most decision makers around the world.”

In Indonesia, where a new variant is spreading, more than 350 doctors and health care workers recently came down with Covid-19 despite being fully vaccinated with Sinovac, according to the risk mitigation team of the Indonesian Medical Association. Across the country, 61 doctors died between February and June 7. Ten of them had taken the Chinese-made vaccine, the association said.

The numbers were enough to make Kenneth Mak, Singapore’s director of medical services, question the use of Sinovac. “It’s not a problem associated with Pfizer,” Mr. Mak said at a news conference on Friday. “This is actually a problem associated with the Sinovac vaccine.”

Bahrain and the United Arab Emirates were the first two countries to approve the Sinopharm shot, even before late-stage clinical trial data was released. Since then, there have been extensive reports of vaccinated people falling ill in both countries. In a statement, the Bahraini government’s media office said the kingdom’s vaccine rollout had been “efficient and successful to date.”

Still, last month officials from Bahrain and the United Arab Emirates announced that they would offer a third booster shot. The choices: Pfizer or more Sinopharm.

Reporting was contributed by Khaliun Bayartsogt, Andrea Kannapell, Ben Hubbard, Asmaa al-Omar and Muktita Suhartono. Elsie Chen and Claire Fu contributed research.

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Health

Moody’s Analytics on Covid outbreaks in Asia, Fed fee hikes in 2023

Asian countries need to tame the current waves of the coronavirus outbreak to prepare their economies for future rate hikes by the US Federal Reserve, an economist said Monday.

Fed officials said last week that rate hikes could happen as early as 2023, diverging from earlier comments in March that said the US Federal Reserve doesn’t expect a hike until at least 2024.

Higher US rates would attract overseas investors, and central banks in other countries may have to raise their own rates in defense. Raising interest rates could help countries prevent too much capital from leaving their economies, but increasing interest rates too quickly increases the risk of an economic slowdown.

“The Asian countries need to get Covid under control so that once the Federal Reserve starts raising interest rates, the economies here have an advantage and can make the transition,” said Steve Cochrane, chief economist for Asia-Pacific at Moody’s Analytics CNBC’s “Squawk Box Asia”.

Cochrane predicted that the US Federal Reserve could hike rates by 25 basis points once per quarter starting in 2023. The so-called dot plot of the expectations of individual Fed members indicated two rate hikes this year.

Asian countries need to get a grip on Covid so that as soon as the Federal Reserve raises interest rates, the economies have an advantage here and can also handle the transition.

Steve Cochrane

Chief Economist APAC, Moody’s Analytics

Many economies in Asia, including Japan, Taiwan and Malaysia, have seen a renewed spike in Covid cases in recent months – which has forced authorities to impose stricter social distancing measures. The new waves of infection come as vaccination progress in the region lags behind that in the US and Europe.

The World Bank said in a report this month that economic output in two-thirds of East Asian and Pacific countries will remain below pre-pandemic levels through 2022. Factors dampening potential economic growth in these countries include widespread Covid outbreaks and a collapse in global tourism, the bank said.

Cochrane noted that Covid outbreaks across the region are “stilling” domestic demand and keeping inflation moderate.

The economist said several Asian countries, including China, South Korea and Singapore, are stepping up Covid vaccinations. “It looks good, but it has to go on,” he said.

But other countries, including Thailand, Indonesia and the Philippines, have not effectively controlled the outbreak and do not yet have strong immunization programs, Cochrane added.

– CNBC’s Jeff Cox contributed to this report.

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World News

Many States with Unhealthy Latest Outbreaks Present Instances and Hospitalization Drops

According to a database from the New York Times, many of the states that have seen the worst coronavirus outbreaks recently have seen significant decreases in both new cases and hospitalizations over the past two weeks.

For example, in Michigan, which has had one of the steepest declines in the country, the average number of daily cases fell 45 percent and hospital admissions fell 32 percent during that period as of Tuesday.

The average number of new cases in the past two weeks has decreased 30 percent in Minnesota, 38 percent in Pennsylvania, and 33 percent in Florida. In the same three states, hospital admissions are down 20 percent, 27 percent, and 11 percent.

Advances for states like Michigan, which recently began to recover from one of the worst sections of the pandemic, may suggest vaccinations are starting to curb the virus in the United States. Hospitalization dates can often lag behind case numbers for a number of reasons.

The director of the Centers for Disease Control and Prevention, Dr. Rochelle Walensky testified at a Senate hearing Tuesday that, although encouraged by the achievements against the pandemic, she urged Americans to remain vigilant about the threat from the virus around the world.

Ms. Walensky said a vaccine is the fastest way to end the pandemic.

“But even with this powerful tool, while we continue to have community transmission, we must adhere to public health measures that we know will prevent the spread of this virus, mask hygiene, hand hygiene and physical distancing “, she said.

Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, said in an interview that the vaccines had been a major contributor to improving case numbers and hospitalizations, but that the virus behaved in surprising ways There remained aspects that experts had to learn more about.

As an example of the unpredictable ups and downs of the virus, Dr. Osterholm pointed to Indiana, which borders Michigan and has lower vaccination rates, but has not seen the same increase in case numbers recently as its northern neighbor.

“I don’t see any national upswing. We won’t be like India. I think the vaccine concentration has certainly helped us immensely in getting that off the table, ”said Dr. Osterholm. “But I think at the state level, where we have significant populations that need vaccination, we could still see significant activity.”

After reaching an average high of 3.38 million doses per day in mid-April, the pace of US vaccinations had slowed. Almost every state now has a spate of vaccine doses that could be quickly distributed to teenagers once the Pfizer BionTech vaccine is approved for 12-15 year olds.

President Biden is pursuing a strategy that focuses on local reach and expanded vaccine access to meet his goal of at least partially vaccinating 70 percent of Americans by Independence Day.

“When it’s available, when it’s close by, when it’s convenient, people get vaccinated,” Biden said at the White House on Wednesday, highlighting initiatives like the availability of walk-ins and free Uber and Lyft trips to vaccination sites .

The vaccination relief could appeal to the 30 million or so Americans who say they’ll get the shot but have not yet done so for a myriad of reasons. Local officials and private companies are also offering a wide range of different incentives, such as free subway rides, beer, baseball tickets, and cash withdrawals, to make Americans reluctant to get vaccinated.

The changes in the virus’ trajectory in the United States are due to other regions of the world, particularly India and Southeast Asia, being hit hard. A number of variants are also spreading around the world, and scientists told a US Congressional panel on Wednesday that variants will pose an ongoing threat to the nation.

Dr. Tedros Adhanom Ghebreyesus, WHO director general, said Monday that the world is seeing a plateau in known cases, “but it’s an unacceptably high plateau, with more than 5.4 million cases and nearly 90,000 deaths in the past week.”

He continued, “Any decline is welcome, but we’ve been here before. Over the past year, many countries have seen a downward trend in cases and deaths, public health and society policies too quickly eased, and individuals have disappointed their vigilance only for these hard-won gains are being lost. “

Bryan Pietsch contributed to the reporting.

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Business

CDC Traces Covid-19 Outbreaks in Gyms, Urging Stricter Precautions

On Wednesday, public health officials urged athletes to wear masks and stay three feet apart while exercising as new research describes the rapid spread of coronavirus infections during intense exercise classes at gyms in Honolulu and Chicago.

Researchers at the Centers for Disease Control and Prevention advised fitness centers to take various measures to prevent outbreaks, including enforcing proper mask use and reminding the gym and staff to stay home if they have symptoms of illness or are tested positive for the virus.

Heavy breathing during vigorous physical activity in tight indoor spaces increases the chances of transmission, and fitness instructors giving exercise instructions to members may also have contributed to the spread, according to the CDC study. Exercising outdoors or taking virtual fitness classes could reduce the risk of infection, the authors said.

“It is very important that people who want to go to a gym and exercise are aware of the symptoms of Covid and are aware that if they feel something that looks and feels like a Covid-19 symptom, they will be staying at home as a precaution, ”said Richard A. Teran, a CDC epidemiologist in Chicago who was one of the authors of the Chicago case study released Wednesday.

At a Chicago gym, Dr. Teran and his colleagues 55 coronavirus infections among 81 people who participated in high-intensity personal fitness classes between August 24 and September 1.

Among them were 22 people who had attended class on the day they first had symptoms of the disease or the day after. Three went to an exercise class the day they tested positive or the day after. In total, 43 members of the gym who tested positive took classes when they were potentially contagious, researchers said.

The outbreak occurred even though the gym classes were limited to 25 percent of their usual size and there were only 10 to 15 people in attendance.

Members were required to wear masks when entering the gym. At this point, temperatures were measured and examined for symptoms. But they were allowed to remove their masks during training; Those who were infected were less likely to wear masks during class, the researchers found.

In Hawaii, public health investigators linked 21 infections in late June to a 37-year-old male fitness trainer in Honolulu who taught at various facilities and developed symptoms of Covid-19 – body aches, chills, headaches and coughs, according to a CDC released on Wednesday -Report.

On June 29, a few hours before his first symptoms, he was teaching a one-hour stationary bike class with 10 participants in which no one wore a mask. All of these participants tested positive in early July, including a 46-year-old man who worked as a fitness trainer at another facility. He became acutely ill and was hospitalized in an intensive care unit.

Updated

Apr. 27, 2021, 4:36 p.m. ET

Twelve hours before this instructor started experiencing symptoms, he held several small kickboxing sessions and a personal training session. Of 11 exposed people, 10 were infected at the beginning of July and tested positive. All 10 developed Covid symptoms and one was hospitalized in the intensive care unit.

On July 22nd, the City of Honolulu issued emergency warrants requiring facial covers in fitness centers, including while exercising. Previously, members of the gym could remove their face coverings while exercising.

Fitness centers and gyms have been hard hit since the pandemic broke out in March last year. They were among the first to close last spring, and now they look forward to welcoming customers back.

The International Health Racquet and Sportsclub Association, an industry group, recently reported that 15 percent of the country’s clubs and studios closed last fall and further closings and bankruptcies were expected. The association has encouraged people to return to the gym and adopted the slogan “Exercise is important!”.

Many clubs have implemented new safety protocols and taken steps to improve ventilation, improve air filtration systems, and maximize outdoor air circulation, said Alex Larcom, senior manager for health promotion and health policy for the association.

The outbreaks described in the CDC studies were caused by inconsistent mask use and other behavioral disorders, as well as possibly poorly ventilated buildings, she said.

“In Chicago you had members who went to class when they were symptomatic or Covid-positive,” Ms. Larcom said. This facility wasn’t originally designed as a fitness center, she added, and symptom screening appeared to have been poorly done.

“Across society, we rely on people who are sick or who think they are sick to get out of society,” she said. Those who went to the gym when they had symptoms “probably went to the grocery store, dined, and roamed the community too.”

The CDC researchers emphasized that a diverse approach to safety is required in fitness facilities, including good ventilation, consistent and correct use of the mask, persistent reminders to keep staff and customers at home when sick, and additional hand washing stations.

“Nothing is 100 percent certain,” said Ms. Larcom. “There is never a zero risk. But clubs are not the main driver behind the spread of Covid. “

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Health

White Home says Ebola outbreaks in Africa want swift motion

The two burgeoning Ebola outbreaks in the Democratic Republic of the Congo and Guinea require swift action “to avoid catastrophic consequences,” White House press secretary Jen Psaki said Tuesday.

It is the first official White House statement on the recurrence of Ebola in the two African countries. Psaki said President Joe Biden had been briefed on the situation in Central and West Africa.

“While the world is plagued by the ongoing COVID-19 pandemic, Ebola has re-emerged in both Central and West Africa at the same time. The world cannot afford to go the other way,” Psaki wrote in the statement. “We must do everything in our power to respond quickly, effectively and by reasonable means to stop these outbreaks before they turn into large-scale epidemics.”

The World Health Organization announced last week that it had confirmed new cases of Ebola in Butembo, a city in North Kivu Province in the Democratic Republic of the Congo. The city was an epicenter of the world’s second largest Ebola outbreak, which was declared over in June. WHO officials said Friday they would transport vaccines to the hard-to-reach city and try to contain the highly deadly disease before it spreads widely.

Regardless, Guinea officials confirmed the reappearance of Ebola in N’Zerekore in southern Guinea over the weekend. The West African nation declared an Ebola epidemic on Sunday after at least three people died and four more were infected with the disease. The neighboring countries of Sierra Leone and Liberia have put their citizens on alert.

In contrast to the highly infectious coronavirus, which can be transmitted by people without symptoms, it is believed that Ebola spreads mainly through people who are already visibly ill. The virus spreads through direct contact with the blood or body fluids of people who are sick or have died of the disease, according to the U.S. Centers for Disease Control and Prevention.

Ebola has an average death rate of 50% which, according to the WHO, can vary depending on the outbreak.

Psaki said US National Security Advisor Jake Sullivan spoke with ambassadors from Guinea, the Democratic Republic of the Congo, Sierra Leone and Liberia on Tuesday “to convey the United States’ readiness to work closely with these countries”.

“Mr. Sullivan highlighted President Biden’s commitment to lead the United States to strengthen health security and create better systems to prevent, detect and respond to health emergencies,” said Psaki. “Outbreaks require a quick and overwhelming response to avoid disastrous consequences.”

The recurrence of Ebola in Guinea and the Democratic Republic of the Congo has hit global health specialists particularly hard, as these countries have the two worst Ebola outbreaks in history. The outbreak in the Democratic Republic of the Congo, declared in June, lasted nearly two years. At the time of the end, there were a total of 3,481 cases and 2,299 deaths, according to WHO.

The infamous Ebola outbreak in West Africa began in Guinea in 2014 before spreading across land borders to Sierra Leone and Liberia, according to WHO. By the end of 2016, there were more than 28,000 cases, including over 11,000 deaths, according to the WHO.

“Since the 2014 Ebola epidemic in West Africa, the United States has sought to increase and prioritize health security support with partners under the global health security agenda and with strong support from Congress,” Psaki added Tuesday. “We cannot afford to take our foot off the gas – even in the fight against COVID, we must ensure the capacity and funding of health security worldwide.”

During the Ebola outbreak in West Africa, the US CDC confirmed 11 cases of Ebola in the US, mostly among medical professionals who had traveled to Africa to help with the response. Dr. Syra Madad, senior director of the system-wide program for specific pathogens at New York City Health + Hospitals, told CNBC on Tuesday that the city was working to ensure that its outbreak response protocols are up to date.

“Every time an epidemic is reported, at least in New York City – we know we are a travel center – we need to make sure our people are up to date on skills [personal protective equipment] and identify these patients, “she said in a telephone interview.” There’s a big mess just to make sure the concept of the operation plan is dusted off. “