Let’s Talk Ebola. Should WE Panic?

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With what has been happening, both in West Africa and here in the States, I thought that it would be important to discuss the disease and see if we as Americans should worry. I thought that we would start with some background information. The Ebola virus causes an acute, serious illness, which is often fatal if untreated. Ebola virus disease (EVD) first appeared in 1976 in 2 simultaneous outbreaks, one in Nzara, Sudan, and the other in Yambuku, Democratic Republic of Congo. The latter occurred in a village near the Ebola River, from which the disease takes its name.

So, where did the virus come from? It is thought that fruit bats of the Pteropodidae family are natural Ebola virus hosts. Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals such as chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead or in the rainforest.

Ebola then spreads through human-to-human transmission via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids.

The current outbreak in West Africa, (first cases notified in March 2014), is the largest and most complex Ebola outbreak since the Ebola virus was first discovered in 1976. There have been more cases and deaths in this outbreak than all others combined. It has also spread between countries starting in Guinea then spreading across land borders to Sierra Leone and Liberia, by air (1 traveller only) to Nigeria, and by land (1 traveller) to Senegal.

The most severely affected countries, Guinea, Sierra Leone and Liberia have very weak health systems, lacking human and infrastructural resources, having only recently emerged from long periods of conflict and instability. On August 8, the WHO Director-General declared this outbreak a Public Health Emergency of International Concern.

Health-care workers have frequently been infected while treating patients with suspected or confirmed EVD. This has occurred through close contact with patients when infection control precautions are not strictly practiced. We have in fact seen in the last few weeks/months the transport of infected healthcare workers to Emory Hospital in Atlanta as well as other hospitals in the States to utilize our specialized isolation units to treat them.

Burial ceremonies in which mourners have direct contact with the body of the deceased person can also play a role in the transmission of Ebola as well as the family members and friends of families caring for the ill patients.

People remain infectious as long as their blood and body fluids, including semen and breast milk, contain the virus. Men who have recovered from the disease can still transmit the virus through their semen for up to 7 weeks after recovery from illness.

The incubation period, that is, the time interval from infection with the virus to onset of symptoms is 2 to 21 days. It is believed from years of experience that humans are not infectious until they develop symptoms. First symptoms are the sudden onset of fever fatigue, muscle pain, headache and sore throat. This is followed by vomiting, diarrhea, rash, symptoms of impaired kidney and liver function, and in some cases, both internal and external bleeding (e.g. oozing from the gums, blood in the stools).

The diagnosis is difficult as we can see from the patient who developed Ebola in Texas. Often the patients appear to have flu-like symptoms. It also can be difficult to distinguish EVD from other infectious diseases such as malaria, typhoid fever and meningitis as well as an illness called Lassa fever. Confirmation that symptoms are caused by Ebola virus infection are made using the a number of investigative tests including antibody-capture enzyme-linked immunosorbent assay (ELISA), antigen-capture detection tests, serum neutralization test, reverse transcriptase polymerase chain reaction (RT-PCR) assay, electron microscopy, virus isolation by cell culture, which often take days to weeks for confirmation. Samples from patients are an extreme biohazard risk and the laboratory testing on non-inactivated samples has to be conducted under maximum biological containment conditions.

Treatment includes supportive care-rehydration with oral or intravenous fluids- and treatment of specific symptoms, hopefully to improve survival. There is as yet no proven treatment available for EVD. However, a range of potential treatments including blood products, that is a blood product from patients who recover from EVD and some immune therapies and drug therapies are currently being evaluated and a few doses, which were supposedly used on the few patients, brought to the States for treatment. No licensed vaccines are available yet, but 2 potential vaccines are undergoing human safety testing. The most exciting drugs for treatment of EVD are now going into Phase II in November to allow the broader use on humans. However, the time factor to get through Phase III will probably not be completed, to allow the use to all EVD patients until sometime in 2015.

What is most important today is the control and prevention of additional cases of EVD. Good outbreak control relies on applying a package of interventions, namely case management, surveillance and contact tracing, a good laboratory service, safe burials and social mobilization, all of which we have found to be difficult strategies in the poor villages in West Africa. Community engagement is key to successfully controlling outbreaks. Raising awareness of risk factors for Ebola infection and protective measures that individuals can take is an effective way to reduce human transmission. Risk reduction messaging should focus on several factors:

  • Reducing the risk of wildlife-to-human transmission from contact with infected fruit bats or monkeys/apes and the consumption of their raw meat. Animals should be handled with gloves and other appropriate protective clothing. Animal products (blood and meat) should be thoroughly cooked before consumption. This is probably where and why the first human infection started and progressed to the epidemic proportions now seen.
  • Reducing the risk of human-to-human transmission from direct or close contact with people with Ebola symptoms, particularly with their bodily fluids. Gloves and appropriate personal protective equipment should be worn when taking care of ill patients at home. Regular hand washing is required after visiting patients in hospital, as well as after taking care of patients at home.
  • Outbreak containment measures including prompt and safe burial of the dead, identifying people who may have been in contact with someone infected with Ebola, monitoring the health of contacts for 21 days, the importance of separating the healthy from the sick to prevent further spread, the importance of good hygiene and maintaining a clean environment.

Health-care workers should always take standard precautions when caring for patients, regardless of their presumed diagnosis. These precautions include basic hand hygiene, respiratory hygiene, the use of personal protective equipment (to block splashes or other contact with infected materials), safe injection practices and safe burial practices.

Health-care workers caring for patients with suspected or confirmed Ebola virus should apply extra infection control measures to prevent contact with the patient’s blood and body fluids and contaminated surfaces or materials such as clothing and bedding. When in close contact (within 1 meter) of patients with EBV, health-care workers should wear face protection (a face shield or a medical mask and goggles), a clean, non-sterile long-sleeved gown, and gloves (sterile gloves for some procedures). One of the problems that I saw in my forays into my volunteer missions was the use of previously used gloves, needles and bedclothes/sheets, etc. in the treatment of all sorts of patients.

Let us look at the statistics of the cumulative reported cases of Ebola/EVD. In the Washington Post today, the lead article, Out of Control, states that between March 23 and October 3 now total 6,491 and the total deaths are 3,439. That is approximately a 50% fatality rate, which is somewhat better than some of the predictions of 70% fatality rate seen in past epidemics.

Why are we seeing the tremendous increase in cases this year when in past years Ebola has been treated as a rare, exotic disease which emerges every few years only killing a few dozen victims in remote African villages. “West Africa was ill equipped for an Ebola disaster, because civil war and chronic poverty had undermined local health systems and there were few doctors and nurses. Health workers in the region had never experienced an Ebola outbreak and didn’t know what they were seeing in those first critical months.” (Washington Post, Out of Control, 10/5/14. It is predicted that this epidemic currently raging across West Africa may infect 20,000 by November and if efforts to slow the spread of EVD do not succeed the Centers for Disease Control and Prevention predict that Ebola could infect as many as 1.4 million Africans by January.

The world and the US have been slow to respond, but the President has pledged $750 million, equipment, staff and 3,000 troops to assist the buckling health care systems in the worst affected countries. The question was asked in many of the editorial pieces-Why did the Obama and the U.S. wait so long before they took Ebola seriously? Do we now think of this situation as a “National security threat”, acting out of fear and not compassion? Also, should we, the U.S. be the only country responding with such an outlay of money, equipment and troops? Other countries much closer to the epidemic don’t seem to be as concerned as we are. Or do they always expect the U.S. to always come to the aid of needed countries such as West Africa, the Philippines and Haiti?

You see, we are always comparing our healthcare system to those of the Europeans, Canadians, etc. and how we are so inferior to the other systems of health care delivery. If that is the case, why are we the U.S. providing the top of the line isolation chambers, physicians, physician extenders and vaccines? Our labs, NIH in conjunction with the Canadians are the ones producing vaccines that should “cure” Ebola, but at what expense and time factor?

Do we Americans have to fear spread through out the country? Do we also have to fear a mutation of the Ebola strain and worry about a change in the way it is spread-i.e. Now spread by air and contact, not fluids?

We should not worry as long as the physicians and nurses evaluating in coming patients with these flu-like symptoms properly evaluates each patient, including whether they have traveled and from where from West Africa. Unlike the ER doctors who saw the patient in Dallas and sent him home to expose others potentially to Ebola we have to be aware of potential exposure and established protocols.

Could this problem get worse in our country? Yes, absolutely! If we take this epidemic lightly and don’t practice medicine the way we were all trained.

Do we close down our borders to people flying in from the West African countries in anticipation of an “invasion”? That is probably “going over the edge” when considering appropriate measures. Although, if the epidemic gets any worse and we keep diagnosing more Ebola patients here in the U.S. it might be part of the plan to isolate and treat an increasing volume of patients.

More important, as in the ISIS/ISIL, Syrian/Iraqi situation, we need other countries to participate, economically, strategically and medically to the control and eradication of this horrendous health care problem. We can’t afford to solve all of the problems of the world and as we attempt to bring control to this epidemic we are sacrificing the reason of the ACA-to care for all of We Americans.

Wash you hands and get your flu shots!!!!

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