Wednesday, November 5, 2014

Ebolavirus 2014 Outbreak - #5

Ebolavirus 2014 Outbreak
October 31, 2014 Update #5
Paul Herscu, ND, DHANP, MPH
Herscu Laboratory


I would like to begin with the main points. First, it should become clearer that neither North America, nor Europe nor the majority of Africa will have an epidemic of EVD, so that chatter will stop. Second, it should shortly become obvious to everyone that the viral transmission has not become airborne, and that confusion will stop as well. And third, it’s becoming clearer that the reasons things got so bad in the first place have to do with poor health care infrastructure, rather than the virus itself. Sadly this widespread problem is deep and wide and will need our attention for years to come.

Many countries are negotiating around quarantine versus isolation versus quarantine in place versus revoking travel permits. This is true in Africa where many countries have forbidden travel into their countries for those arriving from impacted countries; Australia took the most extreme version similar to the advice I last posted, i.e., no one from an effected country allowed in unless they have completed a 21 day quarantine in the country of origin.  In the USA the military has taken a similar approach and in our civil society there has been much debate and evolution of rules. What is clear is that as the majority of ban of travel is in force around the world, travel on public transportation and in public areas is now forbidden in most every place, and given the timing of developing the infection and given the vigilance in place, I now consider this potential epidemic over for most of the world. 

Primarily, I think this is the case because everything we need, prevention wise, is now in place. Yes, it needs to be fixed or tweaked, and yes, there needs more active engagement between the developed nations and the impacted countries. But by and large what we know is that we can control and prevent the spread of EVD, which means less hysteria, less news, and well, as I told my friends that by the end of November, a month from today, most individuals will not be thinking much about Ebolavirus Disease, which is a sad statement. As this goes into the history books, what we will read about is that poor countries that do not have robust healthcare systems cannot tolerate epidemics easily. What is embarrassing is that the developed world took so long before we brought our resources to help curtail the spread of disease, primarily by prevention followed by active treatment. However, active, intense travel restrictions framed the prevention, which was the first major variable to limit spread. I know it is hard to believe this today, but by December 1st you will find it hard to recall why you were so nervous in the first place.

What do we need now for the best outcomes, and how does this endgame get played? Again, these are my suggestions and in no particular order.

My suggestion:

Quarantine. All countries around the world are contending with the issue of quarantine, and each has come up with slightly different answers. What is uniform is the following concept, which should make sense to everyone, no matter your opinion on quarantine. No person coming from an impacted country should be allowed to take public transportation for 21 days. Even if you do not believe in the concept of quarantine, by preventing public exposure, risk to the general public is greatly reduced.

Think of it this way. With Ebolavirus Disease we have a transmission rate just under 2, meaning that any one patient might pass it to, on average, 1-2 others. Compare this to influenza or measles where that number is much, much higher. If you stop public exposure, such as on planes, trains, and buses, then if a mistake is made it is made with the first person getting sick and then possibly passing it on to 1-2 others, who would all be quarantined properly. In other words, the system is now in place to stop an epidemic from occurring here. As the international quarantines continue to take place, the likely transmission of disease to other countries drops and the problem becomes localized, which is the major point of quarantine.

Local work. As mentioned in my last post, once the spread to other countries is stopped, resources can be diverted to impacted countries and can be applied to halt the spread locally and provide effective treatments. It looks like that focus is now beginning in earnest, which is excellent. So, as I mentioned before, here is what should happen. When you look at the map of the three countries of Sierra Leone, Liberia and Guinea, you will notice that Guinea is about twice the size of the combined area of Sierra Leone and Liberia. Nevertheless, there are fewer outbreak locations in Guinea, and fewer numbers reported there. See the map below:

(if this link does not open properly when clicked on, copy/paste URL into browser)

Note the thick gray lines which demarcate national borders. Note that the more blue an area is the more infected people there are; yellow circles represent patients in the past 21 days, the larger the circle, the more patients. What becomes easy to notice is that a majority of Guinea is free of EVD. I believe this is one of the keys. Isolate the areas that have the EVD active, keep the active areas separate from the non-active areas. And if you do that Guinea may well be the next nation to be announced EVD free. And if that were the case, then the amount of energy spent across this whole map would shrink by 50%, terrain wise. I think that is what will happen. Guinea will be announced EVD free some time by mid January. But the real key is to separate the regions where there is EVD from the area that it is absent. Really, we are talking about some version of the quarantine mentioned above and in the last post. The timing assumes a normal month. I am not sure how the holidays will impact this, but hopefully, at most, it will not set it back too many months. Most likely Guinea will be free of EVD within that timeframe, or at the worse case, if we continue our efforts, only a very few localized hotspots will still exist. In other words, much fewer to no yellow circles in Guinea.

Meanwhile in Liberia and Sierra Leone, with all the extra manpower, treatment beds, and public outreach, funding directed there could be that much more effective. Really by May of 2015, this epidemic could be over, except for a very few yellow circles on the map, if all goes well and there are no surprises. If that is what happens then what it shows to everyone, is that once the hysteria and politics are out of the way, we know enough about how to deal with this level of public health concern. Also, it highlights the desperate need we have to create and support effective enough health care systems in the developing world, and that, well, their problems can become very quickly our problems. Likewise, spending money and allocating resources to help their problems will have repercussions to help our problems. I am putting this down here on the record so that we can look back on it years from now. But for sure money spent to understand the Ebolavirus Disease will somehow benefit people who suffer from other diseases, such as Post Lyme Disease Syndrome, Chronic Fatigue Syndrome or Fibromyalgia, as well as autoimmune diseases. In short, it benefits the public good in the developed as well as the developing world when we realize that the public good is the public good, for all humanity.

My main fears as of now. Seeing as how we have now put systems in place to stop the spread of this disease, unless something unusual happens, the likelihood of mandatory vaccinations for everyone alive is off the table.

A local problem. The big fear I have now is that when we see that these systems are working and that no one or few in the USA is going to get EVD and no one or few in Europe is going to get EVD, it will become not just less important to you, but to the governments around the world. In other words, I worry that all the money and energy being pledged and spent in Africa will dry up, just as they have in Haiti. After the earthquake a few years ago a great deal was promised and pledged, but little was actually delivered, and was often spent inappropriately. But let me focus on just one part of that story. By accident, as I reported when it began, UN workers brought cholera to Haiti during the disaster relief. After there being no Cholera on record in Haiti for 100 years, there were 350,000 cases of cholera in Haiti in 2011, dropping to 100,000 in 2012 and 50,000 last year. Haiti still carries today about half of all the cholera cases in the world, and it has killed over 8,000 people. This is an excellent example of what happens when the world turns away from problems that are fixable. We can end cholera there in a short period of time, if we had the funds donated, and a more functional public health infrastructure and the people power to educate and treat the population. Again, this is not unknown science or waiting for some far-off cure. We can solve for it decisively if we cared to. I worry that EVD in the impacted countries may suffer the same fate if we stop caring.

(if this link does not open properly when clicked on, copy/paste URL into browser)

Interestingly, Haiti now bans travel into the country if you have been to the EVD impacted countries in the prior 28 days.

Related to the financial fears I described above, I also worry that diverted funds by local governments will make it too difficult for the local populations to keep controls on the ground. Many officials are acting appropriately and miraculously keeping the calm as they govern the medical treatment and prevention plans in the region. What is well known in the public health world is that plans often go awry on the ground, where the realities do not match up to the plan. Diversion of resources by some local officials is one such problem, which may slow progress. This is at times a very big problem, especially in developing countries that may not have a strong centralized government. Somehow, checks and balances on the local level have to be part of the solution.

So what I am I specifically worried about? I am worried that EVD will not go away completely because we diminish our interest and funding and medical support; it will be around, surfacing on and off more frequently than before this epidemic, and therefore will be seen to need a local vaccine program. In other words the healthcare systems will not be in place well enough to provide basic medical needs for the populations for other infections and other preventable diseases. 

Let’s use this horrible time as a springboard to bring their healthcare system into the 21st century. It is for the common good!

In health,
Paul Herscu, ND, DHANP, MPH