Mono-Gram - Ebola and the Eastern Sierra

Tuesday, August 5, 2014

As the world is gripped by “Ebola fever”, what should our reaction be in the Eastern Sierra?

My personal view:

1. We all should remain aware – stay tuned for updates from public health and local media.
2. We all should be grateful for living where we do – first in a rural area, and then in the USA.
3. We should know our sophisticated healthcare system is prepared to handle any influx of cases.
4. Optional travel to the affected area should be absolutely avoided.
5. The epidemic is similar to our wildfires – it will go on for weeks, but it will eventually burn itself out, because it kills so quickly.
6. It will spread to other countries, due to better roads and the mobility of air travel.
7. It is likely that cases will show up in the USA, most likely in places that have large populations from West Africa, such as Minneapolis, Washington, D.C., and Columbus, Ohio.
8. Catching the virus requires close intimate contact with someone who currently has the infection. It is not spread through the air, food, or water.

In summary, there will be lots of headlines and fear about this epidemic in the days to come. I do not believe we will be impacted in the Eastern Sierra. However, we will stay informed and prepared.

Let’s count our blessings!

(Continue reading the following pages for more details if you find this fascinating like I do!)

The disease:

Previous Ebola outbreaks have seen fatality rates as high as 90%. The current epidemic, primarily across Gambia, Sierra Leone, and Liberia, has seen 887 deaths out of more than 1603 confirmed infections, which equals about a 55% mortality rate to date. These numbers are immediately outdated, and grossly underestimated.
Ebola virus is a member of the Filoviridae family. First isolated in 1976, 5 subtypes of Ebola virus are now recognized, of which 4 are pathogenic to humans. The Reston subtype infects only primates. The most deadly form is the Zaire subtype, with the natural reservoir for the virus believed to be the fruit bat. The virus has also been found in porcupines, primates, and wild antelope.

Ebola virus incubates in infected humans for 2-21 days, with the majority of patients becoming symptomatic after 8-9 days. Once infected, patients can experience severe symptoms within 1-2 days.

Symptoms of Ebola include:

• Sudden fever, often as high as 103º-105º F;
• Intense weakness, sore throat, and headache; and
• Profuse vomiting and diarrhea (occurs 1-2 days after the aforementioned symptoms).

More severe symptoms, such as the development of clotting problems, can develop in as soon as 24-48 hours, leading to bleeding from the nasal or oral cavities, along with hemorrhagic skin blisters. The development of renal failure, leading to multisystem organ failure along with disseminated intravascular coagulation (DIC), can then rapidly ensue over 3-5 days, along with significant volume loss.

Patients who develop a fulminant course often die within 8-9 days. Those who survive beyond 2 weeks have a better prognosis for survival.

One of the difficulties encountered in identifying Ebola virus is that in the early days of the disease, the symptoms may be similar to those of other types of infectious diseases, such as malaria, Lassa fever, typhoid, cholera, and even meningitis. Only after 3-5 days (or even later in the course of the disease) might the hemorrhagic blisters -- along with internal hemorrhage, the hallmark of the illness -- become evident.

Although Ebola is a highly contagious virus, it is not airborne and not spread by droplets, such as how measles and influenza are transmitted. You cannot acquire Ebola virus if another person coughs or sneezes close to you, and it is not spread by casual contact. Rather, it is acquired by direct contact with infected secretions such as vomit, diarrhea, and blood primarily. It may also be spread by direct contact with saliva, sweat, and tears. Other means of transmission include contact of secretions with a skin opening or healing wound, or if a person contacts secretions and touches his or her eyes, nose, or mouth.

It is important to remember that only patients who are symptomatic are contagious and can then transmit the virus to others through their secretions. Those who have contracted the disease are primarily healthcare workers caring for patients, as well as family members who have had close contact with infected patients. Another method of infection has involved family members who handle corpses at the time of burial, along with those who eat fruit bats, antelope, or other animals potentially infected with the virus.

Studies indicate that the virus is in much higher concentration in vomit, blood, and diarrhea compared with saliva, sweat, and tears, making disinfection of public areas such as restrooms imperative in order to contain the virus.

The actual risk to citizens living and working in the United States is quite low, and the public should be well aware that emergency departments (EDs) and critical care units in the United States are well equipped and prepared in the event that a patient with a recent travel history from West Africa, along with flu-like and gastrointestinal symptoms, presents to the hospital.

As the ED is often the proverbial "front door" to the hospital, universal precautions, along with a protocol to quarantine and isolate such patients, is now a top priority for all EDs. Such a plan requires healthcare providers to wear personal protective equipment, including eyewear or goggles, facemask, gloves, and a gown.

Effective decontamination methods for the virus include steam sterilization, chemical sterilization, incineration, and gaseous methods.

What about the effectiveness of airport screening? During the SARS outbreak in 2003, the WHO recommended screening passengers with questionnaires and thermal scanners, but few sick travelers were detected. Hong Kong screened 36 million passengers and detected 2 cases, and Australia screened 1.8 million people arriving, and 4 cases were detected by border screening, according to a 2005 study. Canada screened 4 million passengers and detected no cases, and Singapore screened 400 000 people entering the country and detected no cases.

The challenge for travel screening is that there is an 'incubation' period between someone being infected until they start showing symptoms. If infected people travel during that time, they are hard to spot based on symptoms. For diseases like influenza and SARS and Ebola, we have the additional problem that early symptoms can be difficult to distinguish from many other conditions, including malaria, which is widespread in all these countries.

In the past decade, five people have entered the US known to have a viral hemorrhagic fever like Ebola. It is reassuring that no one else contracted the disease.

At US airports, trained Customs and Border Patrol agents are working closely with the CDC to watch for sick passengers. Having just flown from London to LA last week, including standing in line with thousands of others for prolonged periods of time, I can appreciate both the difficult task, and understand the possibility of someone slipping through the system.

The African context

In the past, most outbreaks of Ebola in West Africa have been localized and well contained. What distinguishes this outbreak, which began in March 2014, is its severity and larger area of spread. It is already more than 3 times larger than any previous outbreak. When a traveler boarded a plane from Liberia to Lagos, Nigeria, last week -- apparently becoming ill in flight and dying 5 days after landing -- it became more concerning that the spread of any disease could be just a plane ride away. Most previous Ebola epidemics have been in remote villages. This one started in Guinea, and quickly spread to the capital city of Conakry via roads.

It is now being reported that 7 workers recently returned from Sierra Leona back home to the Philippines are being evaluated with possible signs of infection. This is the beginning of many reports – some of which will turn out to be confirmed, but many wildly false.

Watch the following video, especially if you are a healthcare worker:

https://www.youtube.com/watch?v=PZoBMuqNxn8&list=UUig0KhrB5NClMvX9QrbXcrw

With a Level 3 travel advisory in place at the recommendation of the Centers for Disease Control and Prevention (CDC), all nonessential travel to the region has been prohibited. Efforts to contain the spread of the virus have not been effective thus far, sparking an international effort involving the World Health Organization, CDC, and the United Nations. But it is not enough.

Additional need for healthcare professionals in rural areas, along with more modern equipment to help contain the virus, is essential. The United States has a thousand times more physicians per capita than these poor countries. When this Ebola epidemic eventually ends, the health budgets of these nations will have been bankrupted, and many of their most skilled and courageous physicians, nurses, hospital workers, and volunteers will have perished. Thus far, over 60 healthcare workers have died during this current epidemic. Healthcare workers and people preparing bodies for burial are vulnerable without proper personal protective gear.

There is now a huge distrust of healthcare workers, who don’t have a vaccine or a cure to offer, in spite of the fact that the public has seen 2 Americans “rescued” from West Africa and given a “miracle cure”. From Guinea: Eight youths, some armed with slingshots and machetes, stood warily alongside a rutted dirt road at an opening in the high reeds, the path to the village of Kolo Bengou. The deadly Ebola virus is believed to have infected several people in the village, and the youths were blocking the path to prevent health workers from entering.

“We don’t want any visitors,” said their leader, Faya Iroundouno, 17, president of Kolo Bengou’s youth league. “We don’t want any contact with anyone.” The others nodded in agreement and fiddled with their slingshots.

Singling out the international aid group Doctors Without Borders, Mr. Iroundouno continued, “Wherever those people have passed, the communities have been hit by illness.”

Health workers here say they are now battling two enemies: the unprecedented Ebola epidemic, which has killed more than 660 people in four countries since it was first detected in March, and fear, which has produced growing hostility toward outside help.

Governments are taking drastic measures, including banning public gatherings, closing schools, deploying armies to stop attacks on healthcare workers, and closing borders. Fear also threatens the creation of a vast cordon sanitaire – or barrier – around the 3 afflicted countries. All this will of course hurt these fragile economies, further imperiling the health of the people.

Sierra Leone, Guinea, and Liberia are three of the poorest, most remote nations on earth. All the countries affected have coastlines and Liberia is where many international shipping vessels are flagged. I imagine airline flights would be prohibitively expensive for most, though stowaways do occur. Fleeing in refugee boats or catching a ride on the big ships as deck hands seems a more likely vector or means of transit than flying and eluding authorities.

Nigeria, on the other hand, is not only the most populous, but also the richest. It has a large elite class that travels the world on business, for education, and to their second homes. Anecdote: “A businessman relative informs me that he has seen many Nigerian market women at Beijing airport who spend their lives flying from Lagos via Abu Dhabi to buy cheap goods in China and take them back home to sell. Enterprising Nigerian traders travel to every world market.” What we have feared has now happened – cases have been reported in Nigeria, which is a tipping point. If the virus starts to spread in a densely populated chaotic city such as Lagos, we would swiftly enter uncharted political and global health territory.

Consider the following: Nigerian physicians are on strike nationwide; hundreds of girls have been kidnapped from their schools and villages over the past six months by Boko Haram Islamist militants – and none have been successfully freed by the government. The government is weak, and is in the midst of national election campaigning. The nation is torn apart by religious tension, pitting the Muslim north against the Christian south. Islamists in the north have long distrusted Western medicine. They have opposed polio vaccine and have kidnapped and assaulted government health providers.  

The black market demand for monkey meat straight out of Africa could see the deadly ebolavirus hit the UK, experts have warned today [2 Aug2014]. Eating bush flesh is one of the main ways ebolavirus is transmitted to humans, and 7500 tonnes of illegal meat enter the UK every year. The exotic meats are eaten by some sectors of African immigrants in Britain as a luxury dish, and the trade has been defended on cultural grounds.

A BBC investigation previously discovered the markets at Ridley Road, London sold giant rats among other smuggled meats. It is known as a prime example of an area where black market meats are sold and is replicated all over the country. Dr Yunes Teinaz, a former environmental health official, warned the bushmeat is sold "all over the country" and is a "huge" health risk. This meat is sold everywhere. It's smuggled in vast quantities. "It's supplied all around Britain. It poses a potentially huge risk to public health, yet we are doing nothing to tackle it." The meat is often sold on the black market in the UK to people of African descent and to those who are already familiar with sellers. Speaking to the Daily Mail, one trader said: "Everybody knows where you can get it. Bush meat is like drugs; you can get it everywhere if you know the right people, but you won't see it openly on sale. It's word of mouth and under-the-counter deals."

Health workers struggle to separate myth from reality about EVD (Ebola virus disease) as residents say abandoning tradition is out of the question.

Medical teams struggling to curb EVD in west Africa have been discouraging bush meat consumption, believed to have caused the outbreak, but some rural communities dependent on the meat for protein are determined to continue their traditional hunting practices. While meat from wild animals such as fruit bats, rodents and forest antelopes has largely disappeared from market stalls in main towns such as Gueckedou in southern Guinea -- the epicentre of the disease and the capital Conakry, following campaigns to avoid contamination, it is still being eaten in remote villages despite the risks.

"Life is not easy here in the village. They [authorities and aid groups] want to ban our traditions that we have observed for generations. Animal husbandry is not widespread here because bushmeat is easily available. Banning bushmeat means a new way of life, which is unrealistic," said Saa Fela Leno, who lives in Nongoha village in Gueckedou.

Poor knowledge and superstition especially in rural communities, as well as cross-border movement, a poor public health infrastructure and other epidemiological causes have contributed to its spread.

Promoting hygienic practices to avoid contracting EVD is a protracted endeavor. Urging new norms for diet is far harder. Lubroth said: "It becomes very difficult to convey to an individual about a threat that cannot be seen, in this particular case a virus. One of the major aspects is to build trust with communities or villages. The sociology, the anthropology, the communication is so important, not like the veterinary or the wildlife or medical sciences," he told IRIN, explaining that epidemiological facts have to be translated in simple ways for ordinary people to understand, by using local allegories for instance. Yet promoters of health messages, such as Mariame Bayo in Guinea, have been threatened with death in villages where residents strongly oppose aid workers. "In Nongoha, we were told that if we don't leave, we would be cut into pieces and our flesh thrown into the water," she said.

Exposure to infected people as families care for sick relatives at home, touching bodies during burials or even hospital-acquired infections continue to account for the high death toll. However, rural communities still hunting for bushmeat risk further spillover of the virus from infected wild animals, according to the FAO. "We will die if we must, but abandoning our traditions is out of the question. It is true that we have lost many relatives. That's fate," said Gueckedou resident Mamadi Diawara. Guinea's communication minister, Alhousseine Makanera Kake, said bringing the outbreak under control is fraught with challenges. "Obstacles will remain until the outbreak is over. It goes without saying that we will not overcome this easily," he said.

It is still unclear why the Ebola virus crossed from its animal hosts this time in west Africa while communities have consumed bushmeat for generations without infection. "We do not know enough about EVD's natural cycle in the jungle. I'm sure it ticks away every year or every season, but it only makes it into the news when we have human mortality," said Lubroth. While warning against consuming bats or handling sick or dead animals, Lubroth said an outright ban on bush meat "will likely see it go underground, and that is actually worse. So we talk more about management than prohibition." Providing alternatives to bushmeat may solve only part of the problem. In the long run, better equipped and resourced public health systems remain crucial to curbing outbreaks.