Geopolitical and medical barriers to fighting the disease are shaping our viewpoints and approach to the epidemic
As the WHO declared this past week that Ebola was now a global threat, many felt that this was long overdue—and for good reason. For an epidemic that began insidiously back in March of this year–and now traced back to an index case in December of 2013–the importance of a coordinated global effort to fight this disease is more important than ever as the death toll continues to rise, and some organizations scale back their commitments in West Africa.
Recognizing that their workers may be at risk–not just from acquiring the disease but being able to provide adequate care to victims—one organization, HEARTT, according to a recent New York Times article, has started to re-evaluate their commitment in the region, returning at-risk health workers to the US.
Other well-known organizations such as Doctors without Borders, otherwise known as Medecins Sans Frontieres (MSF), have also begun to evaluate their commitments in the region as well. With over 700 workers, MSF has had an ongoing presence in the region throughout the epidemic.
With a recent news report of quarantined patients in a shelter in Monrovia, Liberia being overrun by protesters who subsequently carried away not only patients, but blood-soaked sheets and mattresses, the need for secure, organized and well equipped facilities is critical.
And, with recent reports of 17 Ebola patients currently unaccounted for after this raid on the facility in Monrovia, the need for enhanced security for those infected with the virus is essential to prevent ongoing spread of the disease in affected countries.
In response, the WHO has now urged screening for those exiting affected nations in West Africa at international airports, seaports, and land crossings in light of the Ebola patients who recently escaped from quarantine.
In one show of solidarity, Doctors Without Borders opened a new larger treatment center in Monrovia, Liberia’s capital on August 17, according to a recent report. The new treatment center is intended to hold 120 patients, but can be upgraded to hold up to 400 patients.
Too little too late?
Dr. Mathew Bank, a trauma surgeon and critical care specialist at North Shore University Hospital in Manhasset, New York who spent time working with MSF in Nigeria in 2007, believes that the situation in West Africa is getting worse by the day, and feels that the WHO’s effort to provide leadership should have come much sooner in the timeline.
“So far, 1,145 people have died of Ebola in West Africa,” Bank explained.” “Only last week, on August 8th, the WHO declared a Public Health Emergency, 4½ months after the first report of a rapidly evolving outbreak of Ebola in Guinea on March 22nd. In the interim, the majority of organized care for Ebola patients has come from non-governmental organizations (NGO’s).”
“Having experienced the limitations of a typical well-run NGO, I, for one, am hoping that the WHO and the Healthcare systems of the countries in the Developed World are able to provide a more organized response then they have shown so far,” Bank added.
“Resources such as negative pressure isolation rooms, ventilators, and reliable rapid laboratory testing for electrolytes are usually well past the limits of most NGO’s working in West Africa. The only organizations with enough medical expertise and funding to bring these types of resources into West Africa are governments from the Developed World and the World Health Organization (WHO),” Bank concluded.
Preferential Treatment for Americans?
The question of whether American volunteers who have contracted Ebola deserve special treatment has clearly become an important debate as the disease continues to spread throughout West Africa.
An opinion piece published online August 18 in the Annals of Internal Medicine by Dr. Nancy Kass, a Phoebe R. Berman Professor of Bioethics and Public Health at the Berman Institute of Bioethics and Johns Hopkins Bloomberg School of Public Health, argues that American missionary workers infected with Ebola virus while trying to help infected patients in West Africa do deserve special treatment. As the number of cases of Ebola continues to increase in four African countries, public interest and commentary has focused on the two infected Americans who were transported out of Liberia to Emory University Hospital in Atlanta, Georgia for highly specialized care.
Having already received an experimental monoclonal antibody treatment grown in tobacco plants, (ZMapp) many have questioned why the Americans were transported out of Liberia when others were not, and why they were given a drug that had never before been given to humans.
Kass believes that the Americans do deserve special treatment because of the very nature of their dedication and commitment to care for Ebola patients during this outbreak. Their act of caring for patients who are gravely ill with a disease with at least a 60 percent fatality rate represents incredible dedication beyond standard expectations of conduct.
Kass believes that it would be highly unethical not to guarantee them that they would be transported back to the US if they became infected with the Ebola virus, in an act of selflessness to humanity.
Kass further supports limiting the use of the highly experimental treatment to these two American patients, for a “very important reason.” The circumstances under which experimental medicines may be given are narrow and precise, and often worked out on an individual basis.
“I think it is perfectly acceptable and potentially even preferable if experimental medications are going to be used in Africa–to use them in an organized and structured way where data can and will be connected–but on a small scale initially,” explained Kass.
“It’s also important that we don’t make a leap from having tried it in two Americans and a Spanish priest to somehow thinking it’s useful or better than nothing,” she added.
“It may seem heartless to not use the drug on a large scale in those in need, but it is actually protectionist to not use it in large scale in a very positive sense of the word—instead, we should go slowly,” according to Kass. “We don’t know about safety—but what is at risk is harm to the public health community. There is also the potential for such efforts to backfire when public cooperation is so essential.”
Kass further believes that it would be unethical to exploit the poor and underprivileged to evaluate an experimental treatment during such an epidemic.
“If you start using experimental drugs that are potentially unsafe or potentially useless, particularly in Africa where there is just this long history of suspicion of their own health authorities, not to mention when Americans come in, there is a lot at stake that is really concerning,” said Kass.
“If something threatens the public’s willingness to cooperate with public health authorities, that’s big and has the potential to lead to re-emergence of epidemics (Polio) along with poor control of the ongoing Ebola epidemic,” added Kass.
Kass stresses that public health measures are actually more vital to controlling the current epidemic when compared with various medical therapies.
“The biggest help for controlling this epidemic is in public health measures—not in drugs,” she emphasized.
Kass stressed that educating the community in Africa, especially addressing mistrust of American as well as African public health authorities is vital to the success of any global public health outreach.
She explained that the dissemination of messaging in Africa is different than traditional public health approaches (TV, radio, billboards) in the US. Soccer games, street theatre, marketplace communications are common in Africa.
‘This is important because the stakes are a lot higher,” said Kass.
The bottom line is that global cooperation is a must going forward. Developing strong international bonds, reinforced with lines of communication and trust is vital.
“We have to strengthen local health systems- in terms of training and medications-which can hopefully lead to better trust and cooperation. Its important to leave the campsite cleaner than you found it,” said Kass.
Ebola Highly Unlikely To Spread in U.S.
Fear that Ebola could spread in the US has continued after two American missionaries continue treatment at Emory University Hospital in Atlanta, Ga. However, Dr. Carlos Del Rio, the Hubert Professor and Chair of the Department of Global Health at the Rollins School of Public Health and Professor of Medicine in the Division of Infectious Diseases at Emory University School of Medicine, explains in a commentary published online August 18 in the Annals of Internal Medicine that the chance of Ebola spreading in the US is highly unlikely.
Del Rio explains that–even if cases are imported into the US–the likelihood of further transmission beyond the index patient is highly improbable, as universal precautions are a proven and highly effective means to contain any potential spread of virus.
Ebola may be highly infectious, but is only acquired by direct contact with infected secretions, such as sweat, feces, blood or saliva. Most cases have developed among those providing direct care to patients such as health care professionals, or family members. It is also important to mention that deceased individuals are still infectious after death, so those involved with burial procedures, and handling the bodies are at risk, as well.
As the virus incubates 2-12 days, infected persons could potentially carry the virus anywhere in the world as a result of modern air travel.
Del Rio explains that clinics, hospitals, and emergency departments throughout the world should be ready to isolate any patient who has a recent history of travel to West Africa and concerning signs and symptoms of Ebola. These include sudden onset of fever, chills, malaise and muscle aches, followed by vomiting and diarrhea, and finally bleeding symptoms in more severe cases.
Del Rio further recommends the public review the WHO and CDC websites for up to date information on the epidemic.
And according to Del Rio, the epidemic is not close to being under control.
“This epidemic needs to be contained and needs to have a significant international effort to create the mechanisms to control it. We have to have infection control practices,” said Del Rio.
“It will require a more significant international effort which has not yet quite happened, although it’s beginning to happen. It is important to establish simple healthcare facilities that provide the type of care that’s necessary,” added Del Rio.
Trials to Study Ebola drugs?
Del Rio believes that special care must be taken to systematically evaluate drugs in patients with the Ebola virus.
“If you are going to test a drug, you need to have patients to test a drug, and the only time you have patients is during an outbreak,” explained Del Rio.
“So an outbreak opportunity seems to me like an ideal time to do a clinical trial and test the drug. You just need to be sure that the drug is tested in an ethical way,” added Del Rio.
But he recommended that we proceed with caution, stating “If these places don’t have adequate facilities, how will they do the research that we need?”
“The mortality of Ebola is said to be very high–high in places where that have no medical care. You wonder if we bring these patients with Ebola here, and place them in specialized ICUs such as we have in the US, the mortality will likely be very different.”
Del Rio makes reference to Dr. Anthony S. Fauci’s recent perspective in the New England Journal of Medicine, Ebola—Underscoring the Global disparities in Health Care Resources which argues that the global disparities in healthcare resources are at the heart of the current outbreak.
“This outbreak is occurring because of poor resources and facilities,” Del Rio emphasized. “We need to improve healthcare and healthcare facilities. We need to have a global concern about improving healthcare and healthcare facilities in those countries—as a global community, we cannot continue to ignore this because the reality is that there will be more outbreaks like this. Since these infected patients could come to our country, the way to protect us from future outbreaks is not by closing our borders, but by improving healthcare in these countries.”
Finally Del Rio believes that it is quite important to complete the upcoming NIH sponsored Ebola vaccine trials.
“In containing the outbreak, monoclonal antibodies will be really important, but the vaccine will be useful for prevention.”