What Would Happen if Another Ebola Outbreak Happends Again
I year into the Ebola epidemic. Jan 2015
Several factors, including some that are unique to West Africa, helped the virus stay subconscious and elude containment measures.
WHO/S. Gborie
CHAPTER 3 - In Guinea, it took well-nigh iii months for health officials and their international partners to identify the Ebola virus as the causative agent. By that fourth dimension, the virus was firmly entrenched and spread was primed to explode.
By 23 March 2014, a few scattered cases had already been imported from Republic of guinea into Liberia and Sierra Leone, but these cases were not detected, investigated, or formally reported to WHO. The outbreaks in these 2 countries likewise smouldered for weeks, eventually condign visible every bit bondage of manual multiplied, spilled into upper-case letter cities, and became and so numerous they could no longer be traced.
Countries in equatorial Africa have experienced Ebola outbreaks for nearly four decades. Though they also have weak health systems, they know this disease well. All previous outbreaks, which remained largely confined to remote rural areas, were controlled, with support from WHO and other international partners, in periods ranging from three weeks to iii months. In those outbreaks, geography aided containment.
Clinicians in equatorial Africa have proficient reasons to suspect Ebola when a "mysterious" illness occurs, and this favours early detection. Laboratory capacity is in place. Staff know where to send patient samples for rapid and reliable diagnosis. Health systems are familiar with Ebola and much better prepared. For example, hospitals in Kinshasa, the capital of the Autonomous Republic of Congo, accept isolation wards, and staff are trained in procedures for infection prevention and control. Governments know the importance of treating a confirmed Ebola case as a national emergency.
An old disease in a new context
In contrast, W African countries, which had never experienced an Ebola outbreak, were poorly prepared for this unfamiliar and unexpected disease at every level, from early on detection of the offset cases to orchestrating an appropriate response. Clinicians had never managed cases. No laboratory had ever diagnosed a patient specimen. No regime had always witnessed the social and economic upheaval that tin accompany an outbreak of this disease. Populations could not understand what hit them or why.
Ebola was thus an one-time disease in a new context that favoured rapid and initially invisible spread. Equally a consequence of these and other factors, the Ebola virus has behaved differently in Westward Africa than in equatorial Africa, challenging a number of previous assumptions.
In past outbreaks, amplification of infections in health care facilities was the principal crusade of initial explosive spread. Transmission inside communities played a lesser role, with the notable exception of unsafe burials. In West Africa, entire villages take been abandoned later on community-broad spread killed or infected many residents and fear acquired others to flee.
Besides in by outbreaks, Ebola was largely confined to remote rural areas, with just a few scattered cases detected in cities. In West Africa, cities – including the capitals of all 3 countries – have been epicentres of intense virus transmission. The West African outbreaks demonstrated how swiftly the virus could move once it reached urban settings and densely populated slums.
In past outbreaks, the primary aim of rapid patient isolation was to interrupt chains of transmission. Today, with and then many people infected, the principal aim must as well include aggressive supportive care, specially rehydration and correction of electrolyte imbalances, which improves the chances of survival. Life-saving supportive care is difficult to provide in a typical West African wellness care setting but is improving equally more handling facilities are built past MSF, the United kingdom and Usa governments, WHO, and other partners.
Damaged public health infrastructures
Guinea, Republic of liberia, and Sierra Leone, which are among the poorest countries in the world, had only recently emerged from years of civil war and unrest that left basic health infrastructures severely damaged or destroyed and created a accomplice of young adults with little or no pedagogy.
Road systems, transportation services, and telecommunication are weak in all three countries, peculiarly in rural settings. These weaknesses greatly delayed the transportation of patients to treatment centres and of samples to laboratories, the advice of alerts, reports, and calls for help, and public information campaigns.
Loftier population mobility across porous borders
West Africa is characterized by a high degree of population movement beyond exceptionally porous borders. Recent studies estimate that population mobility in these countries is 7 times higher than elsewhere in the world. To a big extent, poverty drives this mobility as people travel daily looking for work or nutrient. Many extended Due west African families have relatives living in different countries.
Population mobility created two significant impediments to control. First, as noted early on, cross-border contact tracing is difficult. Populations readily cross porous borders just outbreak responders practise not. 2d, as the situation in one country began to amend, it attracted patients from neighbouring countries seeking unoccupied handling beds, thus reigniting transmission chains. In other words, every bit long as one country experienced intense manual other countries remained at hazard, no matter how strong their own response measures had been.
The traditional custom of returning, often over long distances, to a native village to dice and exist buried most ancestors is some other dimension of population movement that carries an especially high manual run a risk.
Severe shortage of health care workers
Prior to the outbreaks, the three countries had a ratio of only one to two doctors per nigh 100,000 populatoin. That meagre workforce has now been farther macerated by the unprecedented number of wellness care workers infected during the outbreaks. Virtually 700 were infected past year end and more than half of them had died.
Though the number of infected health care workers was highest at the beginning of the outbreaks, infections in doctors and nurses began to spike again in the last quarter of the year. The reasons for this fasten are currently being investigated.
In Liberia, some evidence suggests that, as cases began to decline and the risk was perceived to exist lower, stringent measures for personal protection lapsed. Protective measures in the customs, such as frequent hand hygiene and keeping a safe distance from others, visibly declined. In Sierra Leone, which at present has v times as many new cases per week when compared with Republic of liberia, exhaustion amongst staff may help explain the increase.
As experience has shown, when a urban center experiences intense and widespread transmission, equally happened first in Monrovia and then after in Freetown, the distinctions betwixt "hot" and "low-take a chance" zones get blurred. Infections in at least some health intendance workers, who rigorously followed safe procedures while caring for Ebola patients in a hospital or clinic, are known to take acquired their infection in the community.
As of mid-December, MSF had more than than 3,400 staff working in the affected countries. Of these staff, 27 became infected with Ebola and 13 of them died. Investigations past MSF found that the vast majority of these infections occurred in the community, and not in its treatment facilities, which accept an outstanding reputation for safe.
Cultural beliefs and behavioural practices
Loftier-gamble behaviours in the 3 countries have been like to what has been seen during previous Ebola outbreaks in equatorial Africa, with adherence to bequeathed funeral and burial rites singled out as fuelling big explosions of new cases. Medical anthropologists have, however, noted that funeral and burial practices in W Africa are exceptionally high-risk.
Data available in Baronial, equally reported past Guinea'south Ministry of Health, indicated that lx% of cases in that land could be linked to traditional burial and funeral practices. In November, WHO staff in Sierra Leone estimated that 80% of cases in that land were linked to these practices.
In Liberia and Sierra Leone, where burying rites are reinforced past a number of secret societies, some mourners bathe in or anoint others with rinse water from the washing of corpses. Understudies of socially prominent members of these secret societies have been known to sleep almost a highly infectious corpse for several nights, believing that doing so allows the transfer of powers.
Ebola has preyed on another deep-seated cultural trait: compassion. In Westward Africa, the virus spread through the networks that bind societies together in a culture that stresses compassionate care for the ill and ceremonial intendance for their bodies if they die. Some doctors are thought to take become infected when they rushed, unprotected, to assistance patients who collapsed in waiting rooms or on the grounds exterior a hospital.
Every bit several experts have noted, when technical interventions cross purposes with entrenched cultural practices, culture always wins. Control efforts must work within the civilization, not against it.
Reliance on traditional healers
Traditional medicine has a long history in Africa. Fifty-fifty prior to the outbreaks, poor access to authorities-run health facilities made care by traditional healers or self-medication through pharmacies the preferred health care option for many, especially the poor. Many surges in new cases have been traced to contact with a traditional healer or herbalist or attendance at their funerals.
After the outbreaks began, the high fatality rate encouraged the perception that hospitals were places of contagion and expiry, further reinforcing the lack of compliance with communication to seek early medical care. Moreover, many treatment facilities, subconscious behind high fences and sometimes draped with barbed wire, looked more like prisons than places for wellness care and healing.
Community resistance, strikes by health intendance workers
Control efforts in all three countries have been disrupted by customs resistance, which has multiple causes. Fright and misperceptions virtually an unfamiliar disease have been well documented past medical anthropologists, who accept too addressed the reasons why many refused to believe that Ebola was real.
People and their ancestors had been living in the same ecological environs for centuries, hunting the same wild animals in the same forest areas, and had never before seen a affliction like Ebola. Equally unfamiliar were the response measures, like disinfecting houses, setting up barriers and fever checks, and the invasion by foreigners dressed in what looked like spacesuits, who took people to hospitals or barricaded tent-like wards from which few returned.
A second source of customs resistance arose from the inability of ambulance and burial teams to respond quickly to calls for assistance, with bodies sometimes left in the community for as long equally 8 days. The communities will comply with official advice if it benefits them. They are far less likely to comply if the result, like uncollected bodies, causes visible harm.
Burials performed by military personnel accept been safe and efficient but non ever dignified, especially in a civilisation that observes bequeathed mourning rites and is accustomed to touching bodies of loved ones before they are cached in their finest clothes, in graves that are marked.
Strikes past hospital staff and burial teams take farther impeded control efforts. Near strikes occurred after staff were not paid for weeks or months, did not receive promised adventure pay, or were asked to piece of work under unsafe weather condition associated with the deaths of many colleagues.
Public health messages that fuelled hopelessness and despair
In the face up of early and persistent denial that Ebola was real, health messages issued to the public repeatedly emphasized that the disease was extremely serious and deadly, and had no vaccine, treatment, or cure. While intended to promote protective behaviours, these messages had the opposite effect.
If hospitals and "Western" medicine offered no treatments, therapies, or cures, families preferred to care for their loved ones at home. In their view, if expiry is almost inevitable, allow this happen every bit comfortably as possible at habitation, amid familiar and well-loved faces. Moreover, when patients were taken to treatment or transit centres, anxious families often received little information about the patient's condition, upshot, or even the identify of burial.
With time, and as unabridged households died of the illness, communities began to understand that keeping patients in homes carried a loftier take a chance for care-givers. Nonetheless, the astringent shortage of treatment beds, first in Monrovia and later in the western part of Sierra Leone, left families with few other options.
For unknown reasons that may include the stigma that surrounds this illness, the practice of hiding patients in homes continued in some areas, even after abundant treatment beds became available. The great stigma attached to Ebola explains why suspicious deaths are routinely tested for Ebola. Bodies that test negative can be cached in the traditional fashion, and families are freed from ostracism by the customs.
Spread by international air travel
The importation of Ebola into Lagos, Nigeria on 20 July and Dallas, Texas on 30 September marked the first times that the virus entered a new state via air travellers. These events theoretically placed every city with an international airport at take a chance of an imported case.
The imported cases, which provoked intense media coverage and public anxiety, brought domicile the reality that all countries are at some degree of adventure as long every bit intense virus transmission is occurring anywhere in the world – especially given the radically increased interdependence and interconnectedness that characterize this century.
Background noise from endemic infectious diseases
All previous Ebola outbreaks occurred in countries with a number of long-tenured infectious diseases that mimic the early symptoms of Ebola and aid keep the illness hidden. The initial symptoms of malaria, for example, are indistinguishable from those of Ebola. Cholera is also endemic in the area and caused a large outbreak in Guinea and Sierra Leone in 2012 that lasted most of that yr.
As a further complicating factor, the incidence of Lassa fever – which, like Ebola, is a viral haemorrhagic fever – is uniquely high in this W African region, with Sierra Leone recording the world's highest incidence of cases.
A virus with different clinical and epidemiological features
Recent virological analyses have adamant that the virus circulating in West Africa is genetically distinct from Zaire viruses seen in by outbreaks and in the 2014 outbreak in the Autonomous Republic of Congo. As scientists have noted, the virus in West Africa takes a different clinical course with different epidemiological consequences, although these differences practice not affect the infectious period, case fatality charge per unit, or modes of transmission.
As noted in a major study and commentary published in Science Magazine on 29 August, the virus' genome – its genetic "identity card" – is changing "adequately quickly" in fixed ways. As the authors of the report ended, "continued progression of this epidemic could afford an opportunity for viral adaptation, underscoring the need for rapid containment."
A burn in a peat bog
In past outbreaks of Ebola virus disease and the related Marburg haemorrhagic fever, cases were concentrated in a pocket-size number of geographical foci, which simplified logistical demands. Under such circumstances, the principal responders, WHO, MSF, and the U.s. CDC, could inundation affected areas with staff and materials, hunt the virus downwards, and uproot it within several weeks to three months.
The state of affairs in West Africa has been far more than challenging, with cases reported in all or most parts of the 3 countries, including their upper-case letter cities. The demands of addressing this wide geographical dispersion of cases outstripped international response chapters at well-nigh every level, ranging from worldwide supplies of personal protective equipment to the number of strange medical teams able to staff newly built handling centres.
During 2014, the outbreaks in West Africa behaved like a fire in a peat bog that flares up on the surface and is stamped out, but continues to smoulder underground, flaring upward again in the same place or somewhere else. Different other humanitarian crises, like an earthquake or a overflowing, which are static, the Ebola virus was constantly – and often invisibly – on the move.
The long elapsing of the outbreaks
The Ebola outbreak demonstrated the lack of international chapters to answer to a severe, sustained, and geographically dispersed public wellness crunch. Governments and their partners, including WHO, were overwhelmed by unprecedented demands driven past culture and geography as well equally logistical challenges. Together, these and other factors, including the behaviour of the virus, created a volatile state of affairs that evaded conventional control measures and constantly delivered surprises.
Faced with so much suffering so many unmet needs, many partners in the outbreak response courageously took on responsibilities that went across their traditional areas of work and expertise. Some, including MSF, the Us CDC, the International Federation of Ruby-red Cantankerous and Ruby Crescent Societies (IFRC), the World Nutrient Programme, and UNICEF built upon their well-established roles during health and humanitarian crises to aggrandize their areas of engagement.
MSF, which provided the majority of clinical care since the offset of the outbreaks, used its treatment centres to collaborate in clinical trials of experimental therapies and also provided funding. The Earth Food Programme extended its unparalleled logistical capacities to support response operations that went well across the delivery of food. Its helicopters were used to get rapid response teams to remote rural areas. Its engineering teams supported the rapid construction of treatment facilities by WHO and others and the immigration of ground for cemeteries.
Hundreds of CDC staff, including epidemiologists with extensive experience in outbreak containment, were deployed to support surveillance, contact tracing, data management, laboratory testing, and health instruction. UNICEF worked to promote child health and condom childbirth in improver to taking the lead on social mobilization.
IFRC used its vast network of volunteers to take on primary responsibility for safe and dignified burials. Equally WHO field staff observed, some operations encountered less community resistance when local staff were part of the response squad, as is often the instance with IFRC volunteers. All the same, given the cultural and religious sensitivities surrounding burials, the work of several teams was disrupted past violent community resistance, resulting in serious injuries to some team members.
The International Medical Corps, International Rescue Committee, and International Organization for Migration played major roles in staffing and managing handling facilities, in Liberia and Sierra Leone, designed to meet all isolation, intendance, rubber, and waste direction needs. Staff provided by the International Medical Corps included mental wellness and psychosocial specialists.
Doing unfamiliar piece of work
Many organizations and agencies took on technical piece of work normally handled by public health experts. UNFPA, for example, undertook contact tracing. The charity Save the Children assumed responsibility for managing a treatment heart built by the UK government in Kerry Town, Sierra Leone.
As the yr drew to a close, several charities were struggling to care for Ebola orphans, estimated by some to number more than 30,000 in the 3 countries. Poverty, the heavy stigma attached to this illness, and the speed with which information technology can devastate a hamlet fabricated it difficult to discover homes for orphaned children.
Manufacturers of essential supplies, like personal protective equipment, were too stretched to the limits of their production capacity, while WHO was left to ensure that donated supplies from existing stockpiles were of the correct quality to protect staff during an outbreak caused by an specially contagious and lethal virus. Unfortunately, when the outbreak started, no gear specifically designed to protect against Ebola virus infection existed, and this problem raised some uncertainties throughout the twelvemonth.
In a new function for WHO, the System supervised and funded the construction of handling centres, as requested by ministries of health, and developed floor plans for safe facilities constructed by others.
Despite all this support from multiple sources, chapters was insufficient for most of the twelvemonth or not available where it was needed most. The trouble of insufficient chapters was greatest for foreign medical teams needed to run treatment centres. Many WHO staff sent to the field to serve equally coordinators ended up donning protective gear and treating patients as well.
With response teams overwhelmed and resources stretched and so sparse, these commendable efforts to fill in the gaps raised some of import questions. Who is responsible for coordinating all these efforts? Who is responsible for ensuring that unfamiliar jobs taken on by some are properly done?
Source: https://www.who.int/news-room/spotlight/one-year-into-the-ebola-epidemic/factors-that-contributed-to-undetected-spread-of-the-ebola-virus-and-impeded-rapid-containment
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