The Ebola Epidemic in West Africa Proceedings of a Workshop (2016) / Chapter Skim
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2 The Outbreak
2 The Outbreak
Pages 5-22
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From page 5... ...
It does kill monkeys, however, and it has been recently recovered from infected swine in Southeast Asia. LESSONS FROM PREVIOUS EBOLA OUTBREAKS David Heymann of Public Health England and Jean Jacques MuyembeTamfum of Kinshasa University in the DRC recounted their firsthand experience with several Ebola outbreaks, including the initial recognized emergence of Ebola-Zaire.
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Nevertheless, all Ebola outbreaks can be contained by applying the following basic principles, according to Heymann: • Patient identification, isolation and protection of health workers, and infection control. • Surveillance and contact tracing, as well as fever surveillance with rapid diagnosis and isolation.
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Bausch broadened this comparison to highlight multiple differences between the West African Ebola epidemic and all previous outbreaks (see Table 2-1)
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,' most of us would have not said that was a likelihood." CHALLENGES WITH EBOLA CONTROL Muyembe discussed several significant challenges that have arisen during efforts to control Ebola in Central Africa over the past 20 years. Most of these outbreaks occurred in remote locations; thus, logistics were difficult to organize, from transporting responders to the site, to conducting field activities, to pursuing contact follow-up, he noted.
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. Workshop participants discussed numerous factors that fueled the West African Ebola epidemic and which factors distinguished this episode from past outbreaks.
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Weaknesses in global and local public health governance and infrastructure also slowed action. This epidemic comprised many distinct outbreaks, with patterns of cases exhibiting wide variation among the three most affected countries, observed Bausch (see Figure 2-1)
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Several factors contributed to the swift control of the Nigerian outbreak, according to Tomori: the early detection of the index case (a traveler returning from Liberia who developed symptoms during his flight, and who collapsed upon arrival at Lagos airport) ; the fact that -- likely owing to a strike by public hospital workers -- he was admitted to a smaller private hospital; and, subsequent intense contact tracing efforts that resulted in the monitoring of nearly 900 people.
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provided aid to West Africa to help control an outbreak of cerebral spinal meningitis (CSM) .3 "They also left," he remarked, "and then we closed the door, and we lost the key." However, he observed, in 2014 there was a "glimmer of hope" in the response to Ebola outbreaks in the DRC and Nigeria: these outbreaks were extinguished through a combination of existing national 3 Cerebral spinal meningitis (CSM)
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Such support often benefits the giver more than the receiver, he said; for example, pathogen outbreaks offer foreign experts and health agencies opportunities for both scientific and operational research -- of which many workshop participants acknowledged having taken advantage. At the worst, these so-called partnerships leave scientists in resource-poor countries permanently dependent on outsiders, "reduced to mere sample collectors," he said, and unable to use the experience to control the next outbreak on their own.
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Public Health Challenges Nosocomial Transmission While previous Ebola outbreaks in Central Africa revealed the significant risks of nosocomial transmission, the West African epidemic was tragically notable for the number of health care workers who became infected: more than 850, of whom nearly 500 died, accounting for 3.4 percent of all reported cases, according to Bausch.4 In West Africa, the lack of access to personal protective equipment (PPE) or its appropriate use contributed to the high transmission among health care workers as described by Heymann and Sylvain Aldighieri of the Pan American Health Organization.
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Experience also showed that quarantines will be violated or dissolve into violence if affected communities are given no incentives to comply. Impact on Other Infectious Diseases The West African epidemic interrupted important ongoing public health activities, including immunization initiatives against several vaccine-preventable diseases (ECDC, 2015a; Edelstein et al., 2015)
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The apparently increasing frequency of Ebola outbreaks probably results from more sensitive outbreak detection, Bausch stated. Clinical Research As the West African epidemic unfolded, Heymann composed a "wish list" of research questions to be addressed in order to improve future clinical care for Ebola in such areas as maintaining electrolyte balance; the use of convalescent plasma for prophylaxis, as well as for treatment; point-of-care diagnostic testing; antiviral drug treatment; and the use of vaccines for outbreak control and disease prevention in health care workers.
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Looking Backward, Moving Forward Days after the 1-year anniversary of the announcement of the West African Ebola epidemic, and with its end plausibly in sight, Keiji Fukuda of the WHO observed that the global public health community had entered into "a period of very intense assessment and questioning." Now is the time to understand this event in detail, determine what can be done to prevent its recurrence, and consider how to achieve that goal, he stated. Role of the IHR Stepping back from the previously discussed factors that contributed to the unprecedented geographic spread, scale, and burden of Ebola in West Africa, both Fukuda and Heymann emphasized the importance of implementing sound global strategy to address threats to international health, as set forth in the IHR.
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The WHO and its organizational partners can facilitate access to funding, expertise, technology, materials, and other necessities for dealing with complex outbreaks, he said. "But it is equally clear that only countries can bring law, sovereignty, legitimacy, and then long-term sustainability to responding to these kinds of events, and this is critical to understand." Filling Information Gaps Workshop participants discussed the consequences of gaps in surveillance and diagnostics, as well as in information sharing through interprocess communication, hospital information systems, and laboratory information systems, during the West African epidemic.
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"I think it's coming, and of course even though it seems like a relatively trivial thing, it's hugely important in order to get some sort of systematic look at this disease and what works and what doesn't," he observed. In addition to medical records, Heymann noted that considerable genetic data on the Ebola virus was collected during the West African epidemic.
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However, the West African Ebola epidemic is but one of
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To meet this challenge, a balance must be struck between "just-in-time" responses to acute, precipitous outbreaks, and investments in basic public health infrastructure to support disease prevention, detection, and control wherever an outbreak might occur -- and which are shockingly lacking throughout much of the developing world, as several participants observed. Crises precipitate funding, but what can be done to increase support for basic public health capacity to mitigate outbreaks before they become crises?
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If it stings us for a period of time and it goes away, then we easily forget about it," he observed. This, he continued, is why people view cancer differently than infectious diseases: while on the one hand, nearly every person has been touched by cancer, Ebola is to most of the world an event "that happened over there." To really make strides against diseases like Ebola, we have to convince people that there is no "over there" for infectious pathogens in a globalized world, Fukuda stated.
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