Friday, October 24, 2014

“It’s impossible to look into a glass ball and say we’re going to have this many or that many [cases], but we anticipate the number of cases occurring per week by that time [December] to be somewhere between 5,000 and 10,000 per week,” said World Health Organization (WHO) Assistant Director-General Dr. Bruce Aylward on October 14, 2014 in a press briefing. “You know, it could be higher, it could be lower but its gonna be somewhere in that ballpark.”

On September 23, the Centers for Disease Control and Prevention (CDC) reported that in a worst-case scenario, cases could reach 537,000 to 1.4 million through January 20, 2015. In a best-case scenario, cases could reach 11,000 to 27,000 cases through January 20.

As of October 19, 2014, the Ebola virus has infected   10,141 people and killed 4,922 people in seven countries (Guinea, Liberia, Nigeria, Senagal, Sierra Leone, Spain, and the United States). The disease is spreading exponentially with what the WHO calls “unprecedented dimensions of human suffering.”

If you were to ask public health officials a year ago whether an Ebola outbreak could turn into an epidemic, they would have confidently told you no because of the nature of the disease. Ebola hemorrhagic fever is a disease caused by one of five different Ebola viruses. While it is extremely lethal, it is not highly contagious because it is transmitted only through bodily fluids.

This West African Ebola outbreak is significantly different from previous Ebola outbreaks. While other outbreaks have swiftly died out, the West African outbreak has persisted. Why?

One reason why the 2014 outbreak has been more widespread than previous ones is that the West African countries were unprepared for the disease, having had no previous exposure to Ebola. Delayed national responses enabled the virus to quickly infiltrate populated cities.

The National Response

Serious public health awareness campaigns about Ebola did not begin early enough.

Dr. Anthony Mbonye, Uganda’s Director of Health Services, says, “They responded too slowly to make the community aware of the disease.”

Since Ebola was discovered in 1976, Uganda has successfully and quickly terminated four outbreaks. Its first Ebola outbreak was from 2000-2001. 224 people died. Uganda’s second outbreak was in May 2011. One person died. Its third outbreak was in June 2012. Four people died. Its fourth outbreak was from November 2012 to January 2013. Three people died.

Uganda has been so successful at combating Ebola because its citizens are very informed about the virus and the government has ensured appropriate medical facilities to treat patients. Health officials successfully curtailed this disease by designing interventions and public health messages appropriate for the local population.

“Unlike some West African communities or cultures, Uganda is very open in that they want to report cases and not hide them,” said Trevor Shoemaker, a virologist working at the Uganda Virus Research Institute in a joint project with the Centers for Disease Control and Prevention (CDC) in the US.

In Sierra Leone, civilians only realized the severity of the Ebola outbreak when the renowned Dr. Sheik Umar Khan died from the virus on July 29. His death made international headlines and “that’s when the political wheels started turning and the government started putting resources together to help,” says Ishmeal Alfred Charles, program manager for the

Catholic aid agency Caritas.

“Before his death there were persistent denials about the existence of the Ebola virus disease,” says Amara Bangura of BBC World Action.

In addition to prompting talk about viruses and health, this Ebola outbreak has raised questions on social justice and equity in West African countries.

Large-scale campaigning began in July after Dr. Khan’s death, approximately four months after the first Ebola case was made known and even after that, messages were geared toward mainstream media like television and radio. They reached the middle and upper echelons of society, disregarding the people living in very poor communities that don’t have access to the internet, TV, and radio.

The West African Ebola outbreak is also different from past Ebola outbreaks because of the affected countries’ existing social and political situations.

In a PBS interview, Stephen Morse, professor of epidemiology at the Mailman School of Public Health at Columbia University, says that these countries are “particularly stressed because they’ve had civil strife; they have trouble between the government and the local people — some distrust of government. So, you know, that is overlay over an already difficult and strained medical infrastructure.”

Fear of government and aid workers has resulted in “reverse causality.” Everywhere doctors go, more people are dying because patients hide rather than seek medical help.

The countries most affected by Ebola are ranked among the lowest in global development. The health infrastructure necessary to restrain an outbreak is not present in these low-income countries. They do not have sufficient facilities, equipment, supplies, training, communication systems, and health personnel.

The Ebola outbreak has exhausted medical personnel even more. In fact, the WHO estimates “a shortage of 7.2 million doctors, nurses, and midwives globally, with the countries most affected by Ebola among the worst off.”

The International Response

The international effort to combat the 2014 Ebola outbreak was not mobilized fast enough.

Lawrence O. Gostin, Director of the World Health Organization Collaborating Center for Public Health Law and Human Rights, calls it “fractured and delayed.”

The first host of the 2014 Ebola virus was a 2-year-old boy from Guinea who died in December 2013. By March 24, 2014, there were 86 suspected cases and 59 deaths in Guinea. The virus quickly spread to Liberia and Sierra Leone.

On July 24, the WHO upgraded the crisis to the highest level after two American aid workers (Nancy Writebol and Kent Brantly) and a Spanish Priest became infected.

However, it was not until August 8, 2014 — five months after Ebola spread outside of Africa — that the WHO declared the Ebola epidemic a Public Health Emergency of International Concern. Declaring a state of emergency required global coordination to terminate Ebola.

In an article published in The Lancet, a general medical journal, Gostin writes, “How could this Ebola outbreak have been averted and what could states and the international community do to prevent the next epidemic? The answer is not untested drugs, mass quarantines, or even humanitarian relief. If the real reasons the outbreak turned into a tragedy of these proportions are human resource shortages and fragile health systems, the solution is to fix these inherent structural deficiencies.”

By early September 2014, there were more than 1,800 confirmed deaths in Guinea, Liberia, and Sierra Leone.

Even after declaring a state of global emergency, the WHO had only written a 20-page road map with no agreement among major global health organizations and governments on how to respond.

On September 16, 2014, Obama called the Ebola a “security threat” and “security priority.” He announced an American response, which included the deployment of 3,000 American military personnel to Liberia and Senegal to help construct as many as seventeen Ebola treatment centers with 1,700 beds, as well as a joint command operation to coordinate international effort to combat the disease. Other donor countries are still scrambling to respond.

United States

The US, which is heralded for its medical facilities and top-notch doctors, has let cases of Ebola slip by.

On September 19, Thomas E. Duncan boarded a flight to Dallas, Texas from Liberia. After developing symptoms of Ebola, he sought care at Texas Health Presbyterian Hospital on September 25, but was sent home. On September 28, Duncan was admitted to the hospital again and put in isolation.

On September 30, the CDC confirmed that Duncan’s blood tested positive for Ebola. By that time, about 100 people could have been exposed to the virus, Texas health officials said.

Ebola’s arrival in the US has alarmed the nation, but CDC director Dr. Thomas R. Frieden says that there is a straightforward action plan: contact tracing. His team is focused on tracking down every person who has had contact with Duncan since his arrival to Dallas on September 20, and monitoring them for 21 days (the incubation period of Ebola) until the outbreak is declared dead.

On October 8, Duncan died.

Since Duncan’s death, two nurses at Texas Health Presbyterian Hospital who cared for Duncan, Nina Pham and Amber Joy Vinson, have tested positive for the Ebola.  Both are now cured. None of  Duncan’s American friends has contracted Ebola.

On October 17, a Doctors Without Borders physician, Craig Spencer, arrived at JFK International Airport after treating Ebola patients in Guinea. On October 23, Spencer was diagnosed with Ebola and put in isolation.

Since Spencer’s arrival in the US, he has been in physical contact with three people: his fiancée and two friends. They are now also being quarantined and monitored.

Spain

On October 6, 2014, the WHO was informed that nurse Teresa Romero tested positive for Ebola. Her case is the first case of human-to-human transmission of Ebola outside Africa. She became infected while treating Manuel Garcia Viejo, the  Spanish priest who was infected in Sierra Leone and evacuated to Madrid on September 22, 2014.

What happens now? 

Nicholas Kristof, an op-ed columnist at The New York Times, says, “The Ebola epidemic in West Africa is a tragedy. But, more than that, the response to it has been a gross failure.”

He continues, “We would never tolerate such shortsightedness in private behavior. If a roof leaks, we fix it before a home is ruined. If we buy a car, we add oil to keep the engine going. Yet in public policy — from education to global health — we routinely refuse to invest at the front end and have to pay far more at the back end.”

The rampant spread of the 2014 West African Ebola strain has made it clear to public health officials and political leaders how important immediate response to an outbreak is.

The Ebola outbreak began in December 2013 in Guinea. According to the CDC, in a worst-case scenario, cases could reach 1.4 million by January.

Bottom line — the current outbreak of Ebola virus is an international public health emergency and we need to respond like it is.

Dr. Francis Collins, the head of the National Institutes of Health (NIH), says an Ebola vaccine would likely have been found by now if not for budget cuts on research.

“NIH has been working on Ebola vaccines since 2001. It’s not like we suddenly woke up and thought, ‘Oh my gosh, we should have something ready here,’” Collins told The Huffington Post. “Frankly, if we had not gone through our 10-year slide in research support, we probably would have had a vaccine in time for this that would’ve gone through clinical trials and would have been ready.”

NIH has not received any additional money to find a treatment for Ebola; instead it has had to take dollars from other areas, such as research for a universal influenza vaccine, and redirect it to Ebola.

Proof is in the pudding. In Ebola’s case, proof is in the Firestone rubber plantation in Harbel, Liberia. When an employee’s wife arrived in Harbel with Ebola on March 30, 2014, Ed Garcia, the managing director of Firestone Liberia, responded immediately. He set up his own Ebola treatment center and placed the woman and her family in isolation. While she died soon after being quarantined, no one else at Firestone died or got infected.

Garcia and his team had no experience dealing with Ebola, but they had the advantage of a major corporation and mobilized their authority and resources. Forty-eight cases have been treated in the Firestone hospital and eighteen survived.

Whereas outside the plantation, Ebola is spreading faster than wildfire, Firestone has blocked the virus from spreading inside its territory.

Firestone shows us how Ebola can be contained with the money, resources, and cautionary measures taken.

Ebola is a very containable outbreak, but the world has let it get out of hand. Outside of the West Africa, there have patients with Ebola in the US, France, Britain, Spain, Germany, and Norway. As of October 2014, international efforts are being rushed — efforts that should have been present from the start. This outbreak raises concerns about global inequalities and global responsibility. When do nations feel the obligation to step up?

Senegal and Nigeria Become Ebola-Free… 

On October 17, 2014 WHO officially declared Senegal Ebola-free. On October 20, 2014, WHO officially declared Nigeria Ebola-free. An Ebola outbreak in a country is declared over once 42 days (double the maximum incubation period for Ebola) have passed and no new cases are detected. However, both countries’ surveillance systems remain alert, for they are still vulnerable to imported cases.

…As Mali Becomes the Sixth West African Country Exposed to Ebola

On October 23, 2014 Mali’s Health Minister said that a 2-year-old girl who recently traveled from Guinea with her grandmother tested positive. WHO is preparing to send a team of experts to Mali as soon as possible to help with clinical management, epidemiology, contact tracing, and social mobilization. This group will join three WHO workers who have been working on outbreak preparedness in Mali since October 19.

How Senegal and Nigeria became Ebola-free:

• Strong political leadership

•Early detection and response, aided  by a detailed plan and a quickly-activated National Crisis Committee

• Increased surveillance

•Rapid mobilization of resources from both domestic and international sources

•Nationwide public awareness campaigns

•Emphasis on multisectoral collaboration among relevant government ministries, backed by community engagement

• Direct money, food, and psychological support to patient contacts

• Support to help patient reintegrate into society use of scoial media