It’s better to assume ‘sick’ people have Ebola until proven otherwise, says U.S. agency

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In Nigeria
Sep 4th, 2014
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The Director of the United State’s disease control agency, Centre for Disease Control (CDC), Tom Frieden, toured Liberia, Sierra Leone and Guinea, the three countries worst affected by the Ebola outbreak. Here are some of his takeaways:

The impact of Ebola on shortage of food, other supplies as borders close and supplies can’t get in

 This is a big problem.  So, we have, for example, the African union willing to send doctors, nurses, health administrators and during the time I was there, they were stuck in another country because their flight had been canceled and couldn’t get in.  I was going to leave on one day, I ended up leaving a day earlier, rushing to the airport because the flight I was going to be on was canceled.  When I tried to get from Sierra Leone to Guinea, my flight was canceled.  I had to hop on a U.N. charter plane to get from one country to the next.  Getting supplies in, getting people to respond in, that’s a big challenge. I paradoxically, the more the world isolates and stops contact with these countries, the harder it will be for them to control the outbreaks.  The more cases there will be.  The less safe countries elsewhere will be.  Like it or not, we’re connected.  It’s in all of our interests to help these countries stop their outbreaks.  The U.S. government is leaning forward to do that.  The U.S. agency for international development has made nearly $20 million available since the start of the outbreak or reported start of the outbreak in March.  That includes everything from personal protective equipment to contracts for helping with safe health care and safe burials to stop the outbreak.  At CDC, we have more than 70 people on the ground today in the four countries dealing with Ebola.  We’re also sending teams to Senegal and the Ivory Coast to respond as well.  They’re doing everything from tracking the outbreak, to helping improve infection control to ensuring that people leaving the country are screened to see if they have fever.

What needs to be done?

 There’s been a lot of global collaboration.  The European Union is sending laboratories.  We met a Chinese delegation sending a laboratory.  The South Africans have opened a laboratory.  The Canadians have a laboratory have a lab up and running.  MSF has been doing a phenomenal job.  The challenge is that the number of cases is so large that the outbreak, the epidemic is so overwhelming what it requires is an overwhelming response.  Rapidly, effectively deploying resources to tamp it down where it’s spreading wildly.

 Better count of how many people have this virus

 Well, we know there are many undiagnosed cases.  We know many patients are having disease in places where they may not see a doctor, or they may not have a specimen drawn for Ebola.  And one thing that our staff has been doing it improving the tracking and reporting of cases so we can get a better handle on what’s happening.  I can’t say exactly how long the window is.  I can say for every single day we don’t increase our response further, it will get more difficult to control.  The peak will be higher.  It will last longer.  And we’re really addressing every government, every part of society within these three countries, individuals, religious leaders, political leaders, business leaders, among — throughout Africa, those who can help.  And for every government and every organisation to think about what you can do.

Too little, too late

 I think the challenge is pace. The Doctors Without Borders — Doctors

Without Borders director in one of the countries said to me everything we do is too little too late. He was referring MSF specifically. This is not for lack of trying. The virus is moving faster than anyone anticipated. That’s why we need to move fast.

Getting worse over the next few weeks

 I am not going to predict number. I will just say that we should everything we can to keep that number as low as possible. I do think there’s a risk to people travelling to countries when they get ill or becoming ill in other countries. The incubation period is 8 to 10 days average, and can be as long as 21 days. So, it is certainly possible we will see cases elsewhere. That’s why we are alerting clinicians throughout the U.S. to think of Ebola and people who have been travelling to countries that have been affected and to rapidly test for it.  We have helped laboratories around the U.S. become able to test for Ebola safely and accurately. That’s in place now so that testing can be done quickly. We don’t think Ebola would spread widely within the U.S. Routine health care infection control would probably prevent most transmission. We had five cases of other bleeding viruses in the U.S. over the past decade.  Four of a virus called Lassa, one of Marburg, very much like Ebola. Even though they were not identified in the hospital before they were diagnosed, even though people did not take special precautions there was not a single secondary spread from that. That doesn’t mean there couldn’t be a family member or health care worker who didn’t think Ebola, but we don’t think we will see a widespread transmission in the U.S. as it is being spread now.

Help from other places

 We certainly hope to get support with in-kind contributions from companies that can be making things to be used now, if those can be brought over and they are appropriate.  In terms of new medicines, new vaccines, we can certainly hope that they will be available, but we can’t count on it. In terms of the medicines, the supply of the first experimental medicine, ZMapp has been completely exhausted, and my understanding is making more of it is very difficult. First off, we don’t know whether or not it works. Second, if it does, we don’t have it.  We can’t rely on it. Vaccines have begun clinical trials. I think that’s very exciting. We hope they’ll work out and ensure they’re safe. We don’t have large quantities of them. If they are safe, we’ll have to figure out if they’re effective and figure out how to use them to help address the spread of Ebola. So we’re a long way from having these. But any new tool we have would be most welcomed. We shouldn’t forget, though, that things that we have today: standard medical care of hydration, monitoring of patients, of helping patients remain in good fluid balance that saves lives. That needs to happen as quickly as possible for as many patients as possible, not just for their sake, but because the more care they can receive in centers, the quicker they’ll go there, the less spread there will be in communities, the more likely they are to survive.

Human trials for  a vaccine

 We can hope that a vaccine works out and that medicines are proven safe, effective and available, but we can’t count on it. What we can count on is that the quicker we apply the proven means of finding patients, making sure that they stop spreading disease, providing care to them, finding their contacts, making health care safe and burial if necessary safe, the sooner we do that, the sooner cases will begin coming down.

Holding a child and later acquiring Ebola

 Nothing that we’ve seen so far suggests that Ebola is spreading differently in this outbreak. But it is in a very different circumstance. In this case, the young woman was holding her niece. The niece had nausea, vomiting, and diarrhea. She had a lot of body fluids, the sicker someone is, the more of the virus they have. When someone is not sick, they can’t spread it.  The sicker they get, the higher the viral load and the more infectious they are. If you have a little bit on your hands, then you wipe your eye or touch your mouth, you can get infected.  That’s presumably what happened in this case. The health education messaging for the countries that are affected is really pretty simple — don’t touch people who are sick or their body fluids and don’t touch people who have died or their body fluids.  Those two key messages need to be gotten out throughout the communities. It’s not easy to do. I spoke with the minister of health in one of the countries who had just gone to a remote rural area. They don’t have radio, they don’t have television or telephone coverage. There are a lot of misconceptions in the rural area that need to be addressed.

Has the world has sort of underestimated this outbreak?

 I’m focused on the future. I think what we need is a no-regrets policy. We need to do whatever we can now so we don’t look back a few months from now and say, gosh, we wish we had done more then. That’s what we have to focus on.

What do we know about whether or not this virus has mutated in a way that makes it easier, more transmissible?

  This is one of the things we’re looking into. In general, the Ebola virus has not changed a lot over the 40 plus years that we’ve known it. So that’s somewhat reassuring.  And that it’s not one of those viruses that changes frequently. But that doesn’t guarantee it won’t in the future. So one of the things our laboratory specialists will be doing with the advanced molecular detection initiative is to sequence viruses overtime from individual patients and over time in the outbreak to see if there are changes. That will take some time to do and we’ll have to track it to see if there are changes. But right now we don’t see any evidence that there is a change that would make it more transmissible.

Challenges of doctor/population ratio

 To turn this around is going to require lots of effort. It will require highly specialised people to work in the areas of Ebola treatment. The need is not just for doctors, but doctors, nurses, health administrators, emergency managers, people who can stay for long periods of time, three months or more who are used to working in very difficult environments.  But the bulk of the response will be from the people in these countries themselves. They’re willing, they need the resources to get the materials they need, they need the training to do what they need to do.  The exact numbers are hard to pin down, but fundamentally working with groups like Doctors Without Borders, MSF and the World Health Organization, we can help. It makes a huge difference to have international assistance to help train people from within each of the countries to do what they need to do to stop Ebola there.

High rates of Ebola infection in health care workers

For the Ebola treatment units, scrupulous infection control makes them quite safe. When I was inside the Ebola treatment unit run by MSF, I felt completely safe. You’re basically swaddled in protective gear. If you’re not risking a needle stick, the risk is essentially nil. The challenge is things like removing those — that equipment if it’s soiled and doing that very, very carefully. Doctors Without Borders and MSF is extraordinarily careful in doing that.  As I came out of the treatment unit, the person who was a local person, trained by MSF, was basically screaming at me, you know, hold your hand this way, do this, move this way and spraying me down with bleach at every step of the way to make sure I was safe. The biggest risk to health care workers has not been in the Ebola treatment units. It’s been in the general health care system because Ebola in these countries doesn’t look very different from a disease like malaria or typhoid or gastroenteritis. When it starts, it has very similar symptoms. So what we have emphasised is what’s called triage. Put anyone who might have Ebola in this group and people who don’t in this group. Use universal precautions for both. For those who might have Ebola, assume that they do until proven otherwise.


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