Tag: Ebola

A NYT investigative report finds that “there was a moment in the spring when the longest and deadliest Ebola outbreak in history might have been stopped”, but failures of communication among health officials in West Africa enabled it to spiral out of control:

A two-month investigation by The New York Times into this largely unexamined period discovered that the W.H.O. and the Guinean health ministry documented in March that a handful of people had recently died or been sick with Ebola-like symptoms across the border in Sierra Leone. But information about two of those possible infections never reached senior health officials and the team investigating suspected cases in Sierra Leone. As a result, it was not until late May, after more than two months of unchecked contagion, that Sierra Leone recorded its first confirmed cases. The chain of illnesses and deaths links those cases directly to the two cases that were never followed up in March.

Since then, West African authorities and international organizations have followed a steep learning curve, Alexandra Ossola writes, but containing the outbreak (which the WHO reports has now infected over 20,000 people) remains a daunting task:

The WHO and others have disseminated info​rmation about proper burials to dissuade families from conducting funeral practices that may cause further infection, and they have been pretty effective. But there are still too many risky burials; Sierra Leone, which still has the highest number of cases, did no​t meet its December 1 goal of safe burials for 70 percent of victims.

… There are signs that these countries are fighting Ebola more effectively, [CDC spokesperson Kristen] Nordlund said, but challenges remain. Health care workers are still struggling to contain Ebola’s spread in cities like Freetown, Sierra Leone. When people move across borders between countries with high infection rates, tracking down the people who may have come into contact with a patient becomes extremely challenging. Some hospitals still don’t have enough beds to safely treat infected patients, Nordlund said, and not all regions have sufficient number of medical personnel to do the necessary follow-up with those who may have been exposed.

Meanwhile, a group of scientists has put forth a theory as to how the outbreak made the jump from animals to its first human victim, a two-year-old boy from the remote Guinean village of Meliandou:

Reporting in the journal EMBO Molecular Medicine, scientists led by Fabian Leendertz at Berlin’s Robert Koch Institute delved into the circumstances surrounding this first fatality. The finger of suspicion points at insectivorous free-tailed bats — Mops condylurus in Latin — that lived in a hollow tree 50 metres (yards) from the boy’s home, they said. “The close proximity of a large colony of free-tailed bats… provided opportunity for infection. Children regularly caught and played with bats in this tree,” the team said after an exhaustive four-week probe carried out in April.

In other Ebola news, another returning health worker has carried the disease home with her, this time in the UK. Scottish nurse Pauline Cafferkey was diagnosed yesterday after returning from Sierra Leone, where she had been volunteering along with other NHS health workers:

Ms Cafferkey, who had been working with Save the Children in Sierra Leone, arrived in Glasgow on a British Airways flight on Sunday but was placed in an isolation unit at Gartnavel Hospital on Monday morning after becoming feverish. [Scotland’s First Minister Nicola] Sturgeon told journalists that as a precaution, Health Protection Scotland has traced and contacted, or left messages with, 63 of the 70 other passengers who were on the same flight from London to Glasgow as the patient.

The latest YouGov poll illustrates how quickly Americans have moved on from freaking out about the disease and the government’s response to it, indicating that media sensationalism and partisan politics infected far more Americans than Ebola ever will:

Republicans have exhibited the greatest change.  At the end of October, 67% of Republicans said the government wasn’t doing enough to contain the Ebola outbreak.  That percentage has dropped 28 points.  Just 39% of Republicans now say the government isn’t doing enough. There is also less interest in increasing government spending to deal with the outbreak.  Just one in four today would increase government spending on Ebola research, down from 36% at the end of October.

But perhaps the most striking example of public satisfaction with the government’s performance is the change in the way Americans evaluate the President’s performance.  For the first time in two months, more Americans approve of the way Barack Obama is handling this situation than disapprove.

Josh Marshall even suspects that Christie has quietly retired his draconian quarantine policy for health workers returning from West Africa, though he can’t seem to get a straight answer out of the state of New Jersey. There’s also some good news on the international front:

the World Health Organization reports that the number of Ebola cases has stopped increasing in Guinea and Liberia, though they are still on the rise in Sierra Leone, while Mali seems to be keeping its second minor outbreak under control.

But even if outbreaks have peaked, that doesn’t mean these countries’ troubles are over. Last week, Abby Haglage called attention to warning signs of an “Ebola famine” in Liberia:

[Last] Tuesday, Mercy Corps published (PDF) a shocking finding: 90 percent of Liberian households are reducing the amount of food they eat at each meal, and 85 percent are actually eating fewer meals than they were before the health crisis. In a country where food was already scarce, slimmed-down portions could be the difference between life and death. A vendor in Monrovia told Mercy Corps investigators that she and her eight children can no longer afford to eat 10 cups of rice a day. They’ve cut rations down to eight. Simultaneously on Tuesday, the UN Human Rights campaign released a statement warning that West Africa may be “on the brink of a major food crisis” due to Ebola.

A new World Bank report confirms just how much damage the epidemic has done to Liberians’ livelihoods:

To measure the economic impact of that devastation, the World Bank, Liberian Institute of Statistics and Geo-Information Services and the Gallup Organization conducted phone surveys and found that not only is a massive part of the country’s work force out of job, but food insecurity is worsening. Wage workers and the self-employed have taken the biggest hit, the report finds. Prior to the epidemic, more than 30% of working household breadwinners were self-employed, but now that rate is just above 10%. Many people lost jobs because their business or government offices closed.

The US government’s response to the Ebola crisis in West Africa has relied primarily on the Pentagon, whose resources and logistical capabilities would seem to make it a good choice to lead such an operation. Alex de Waal, however, argues that military-run relief projects are less efficient and more costly than civilian efforts led by humanitarian professionals:

When Air Force planes carry out airdrops of emergency relief, they are invariably much more expensive and less effective than their humanitarian counterparts. Army engineers have the equipment to construct flood defenses or temporary accommodation for people displaced by fire or water, but there is invariably much wastage and learning on the job (by definition, too late). Experienced relief professionals can list many of the downsides of bringing in the military:

they utilize vast amounts of oversized equipment, clogging up scarce airport facilities, docks and roads; their heavy machinery damages local infrastructure; they use more equipment and personnel in building their own bases and protecting themselves than in doing the job; their militarized attitudes offend local sensibilities and generate resentment; and they override the decision-making of people who actually know what they are doing.

In the days after the Haitian earthquake in January 2010, the U.S. Army was efficient at clearing debris, setting up an air traffic control system, and getting Haiti’s ports and airport functional. One third of the emergency spending in Haiti was costs incurred by the military. (The costing includes only additional or marginal costs for the deployment.) When the army moved into other relief activities, such as general health and relief programs, even those marginal costs were disproportionately high. Trained for battlefield injuries, army surgeons weren’t skilled at treating the crush injuries common in an earthquake zone. In West Africa today, militaries are providing an important air bridge, given that commercial airlines have stopped flying. But the United Nations could do the job more cheaply and efficiently—if it had the resources.

Eric Posner offers the above chart as evidence that the furore over Ebola is dying down. But risk-communication experts Jody Lanard and Peter Sandman fear that Americans underestimate the still-serious risk of the outbreak reaching pandemic proportions in the developing world:

The two of us are far less worried about sparks landing in Chicago or London than in Mumbai or Karachi. We wish Dallas had served as a teachable moment for what may be looming elsewhere in the world, instead of inspiring knee-jerk over-reassurance theater about our domestic ability to extinguish whatever Ebola sparks come our way. We are glad that Dallas at least led to improvements in CDC guidelines for personal protective equipment and contact tracing, and belatedly jump-started front-line medical and community planning and training. But it doesn’t seem to have sparked the broader concern that is so vitally needed.

Americans are having a failure of imagination – failing to imagine that the most serious Ebola threat to our country is not in Dallas, not in our country, not even on our borders. It is on the borders of other countries that lack our ability to extinguish sparks.

Maryn McKenna seconds that:

Being someone who has a professional specialty of covering epidemics (HIV, the anthrax attacks, SARS, H5N1, H1N1, lots of smaller outbreaks), I reluctantly have to conclude: Lanard and Sandman are not being alarmist here.

Imagine that Ebola cannot be contained; think back to the events of this weekend; and then imagine that reaction multiplied thousands of times. It isn’t a big leap to the suspicion, disruption and expense that will then be triggered in response to any travelers from the region. From there, it isn’t much of a further leap to closed borders, curbs on international movement, disruption in global trade, cuts in productivity, even civil unrest and the opportunities that unrest offers to extremist movements. None of that is far-fetched, if Ebola is not controlled.

Michele Barry reflects on the systemic failures that allowed the outbreak to spiral out of control. From her perspective, “the solution to this Ebola crisis is not drugs, mass quarantine, vaccines, or even airdrops of personal protective gear”:

The real reasons this outbreak has turned into an epidemic are weak health systems and lack of workforce; any real solution needs to address these structural issues. When one physician or nurse is caring for forty to fifty patients, mistakes happen. WHO’s legally binding International Health Regulations (2005) requires wealthier countries to mobilize financial and technical support to help contain an outbreak such as Ebola, for which the Director General has called an international public health emergency.

Yet workforce scale-up has been disturbingly slow. NGOs like Médicins Sans Frontières were not equipped to deal with Ebola, and have been overwhelmed by the outbreak. Workforce volunteers for these NGOs have been slow to mobilize and fearful US hospitals have set up barriers by insisting that their employees taking unpaid leave or vacation time and then return to mandatory 21-day quarantines, often without pay.

But the governor of New York, for his part, has pledged to compensate any lost pay. Perhaps the federal government should step in with actual financial incentives – cash money – to encourage health workers still on the fence to head to West Africa.

Paul Howard monitors the progress drug companies and government agencies are making:

If Uncle Sam doesn’t shell out the money to help develop and then buy an Ebola vaccine, no one else will. The Defense Threat Reduction Agency (DTRA), the only other major investor in countermeasures for early-stage research, wrapped promising drugs such as ZMAPP in red tape, and seemed more interested in publishing academic papers than in actually helping companies develop products. Not surprisingly, the government is not an effective pharmaceutical company.

Still, nothing focuses the mind of government bureaucrats like a global health crisis unfolding in real time on cable-news networks. The government and private companies are now fast-tracking vaccine-development programs. The National Institute of Allergy and Infectious Diseases at the National Institutes of Health is collaborating on developing Ebola vaccines with GlaxoSmithKline and NewLink Genetics. GSK hopes to get data from early-stage safety testing soon. If the vaccine passes, GSK intends to run a large trial with health-care workers in Ebola-affected countries by early 2015, if not sooner.

Dr. Jesse Goodman, the former chief scientist of the FDA, discusses the inherent challenges in developing a vaccine:

These are complex vaccines that involve a live virus and you always have to have very well-controlled production. Cost is one factor: I think it’s hard to predict, but these are not going to be inexpensive to produce. However, many public health experts have said that if we have a safe and effective vaccine, the cost mustn’t get in the way of it reaching communities.

With all experimental treatments, including vaccines, it’s really important not to make presumptions that they will work. It would really be a shame if we’re not able to learn what works and what doesn’t, for the next outbreak or if this one continues over an even longer period. A vaccine could be a really important tool, but if we don’t have solid studies that show that it works and is safe, I think it would be really problematic just to immunize huge numbers of people with a vaccine we don’t understand.

Meanwhile, Alexandra Sifferlin highlights a major research project at Emory University in pursuit of an effective treatment:

Scientists at Emory’s Children’s Center for Drug Discovery have extensively studied the development of drugs for HIV that stop the replication of the virus in the body. The center provided breakthroughs for HIV drug development and, more recently, the development of a drug for Hepatitis C. The viruses, though different, have similar replicating mechanisms (viral RNA replication), and now they think they can do it for Ebola.

The team, led by director Baek Kim, is fast-tracking a program to screen a library of over 10,000 chemical compounds that can treat viruses at the molecular level to see if one or more of them may show promise with Ebola. “We need to start screening many, many compounds,” says Kim, anywhere from 500 to 10,000 of them—each of which will be evaluated one by one. Emory chemist Raymond F. Schinazi, who discovered compounds used in multiple very successful anti-HIV drugs, will be working with five to 10 virologists, chemists and biochemists to get the job done.

While the federal government plays a leading role in keeping Ebola out of the US – to the extent that it’s possible – governors have the authority to come up with their own protocols for dealing with suspected patients who arrive in their states. Josh Voorhees sees a few problems with that:

Consider the rules that greet medical workers upon their arrival at one of five federally mandated points of entry. Land in New York City or Newark, and they face a mandatory 21-day quarantine, regardless of risk level. Arrive in Chicago, and they should be prepared for the same—unless, that is, they wore “protective clothing” while treating patients. Fly into Atlanta, and they can either agree to check in twice daily with health officials or be involuntarily quarantined at a “state-designated facility.” Touch down at Dulles International in Virginia, and they face the same active monitoring but without the threat of forced isolation. …

America’s governors, meanwhile, say they are just doing their jobs. “My first responsibility is to protect the public health and safety of the people of New Jersey,” [Chris] Christie told the Today show on Tuesday. That’s exactly the problem. The fact that a governor, almost by definition, focuses first and foremost on the short-term risk to his own state leaves him unable to consider the bigger picture.

In a speech yesterday, Obama implicitly scolded Christie and other governors who have opted for extraordinary measures such as mandatory quarantines for reacting to the epidemic “based on our fear”. Gregg Gonsalves harshly criticizes these governors, whom he says “have dealt a serious blow to the credibility of the CDC and the NIH as well”:

By instituting evidence-free policies, these politicians are effectively telling the American people, “You can’t trust the folks in Atlanta or Bethesda to take care of you, and you can’t believe their version of the facts; we know better.” It is a message that is not easily forgotten. The governors’ words and actions play into a general distrust of government and a sort of scientific denialism, where each person gets to decide what the facts are. It creates confusion about which institutions Americans should listen to, and whose advice they should follow, when it comes to public health. In ignoring the expertise and mandates of the CDC and the NIH, the governors are claiming, wrongly, that the public should look closer to home for correct guidance. The risks of this situation cannot be overstated.

In an editorial in the New England Journal of Medicine, seven doctors and public health experts underscore that mandatory quarantines are unnecessary given what we know about how Ebola is transmitted, and may in fact do more harm than good:

A cynic would say that all these “facts” [about the science of Ebola transmission] are derived from observation and that it pays to be 100% safe and to isolate anyone with a remote chance of carrying the virus. What harm can that approach do besides inconveniencing a few health care workers?

We strongly disagree. Hundreds of years of experience show that to stop an epidemic of this type requires controlling it at its source. Médecins sans Frontières, the World Health Organization, the U.S. Agency for International Development (USAID), and many other organizations say we need tens of thousands of additional volunteers to control the epidemic. We are far short of that goal, so the need for workers on the ground is great. These responsible, skilled health care workers who are risking their lives to help others are also helping by stemming the epidemic at its source. If we add barriers making it harder for volunteers to return to their community, we are hurting ourselves.

Would a 21-day, at-home quarantine with state reimbursement for lost work really inhibit health workers from volunteering in West Africa? These are people who are already intending to travel across the ocean to the most virulent hot zone on the planet – but a three-week paid vacation at home is a deal-breaker? If the threat of quarantine is enough to scare health workers away from volunteering, Amy Davidson argues, West Africa is screwed:

[Kaci] Hickox spent the night before she headed home to America watching a young girl die; that is hard enough. If the prospect of three weeks in a tent in a Jersey parking lot or, God forbid, reading the works of Andrew Cuomo discourages them, the argument goes, then the disease will spread out of control in Liberia, Sierra Leone, and Guinea, more people will flee those countries, and the United States will face a far greater risk than that posed by a doctor going to a bowling alley in Williamsburg. This is practical, but it raises another question: why, exactly, is the burden being put on already overwhelmed volunteers in the first place? Can’t we do more, and more directly? What does it say about the help available to West Africa if a little bullying by Chris Christie could make it all fall apart?

Clive Crook sensibly maintains that science alone can’t answer the policy question of how best to respond to the outbreak:

You don’t have to be a cynic, a slanted term, to argue for “better safe than sorry.” The calculus isn’t simple, either. The crucial thing, though, is that the doctors’ sensible conclusion doesn’t rest solely on the science. It requires a delicate judgment about many different risks and costs — the risk of extra U.S. cases in the short run, the risk of discouraging health workers from traveling to West Africa so that the disease keeps spreading there, the cost in civil liberty of restricting people’s movements, and so on. I agree with the doctors about where the balance lies, but the issue isn’t easy and, in any event, it isn’t just about the science of Ebola.