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West Africa: Ebola Response Scale-Up Urgent, Uncertain

AfricaFocus Bulletin
September 10, 2014 (140910)
(Reposted from sources cited below)

Editor's Note

"The best way to help Africa stem the tide of the current Ebola epidemic is by rapidly investing in and deploying basic infectious control measures like gowns, gloves, water, and sterilization tools, coupled with health worker and community health trainings in how to properly use them." - Adam C. Levine, Assistant Professor of Emergency Medicine, Brown Medical School

The momentum for scaling up the international response to the Ebola epidemic is increasing, after months of desperate appeals by West African countries and Doctors without Borders, the principal non-governmental organization involved in the response. As the World Health Organization (WHO) has reported an "exponential" growth rate in the epidemic, world leaders have begun to pledge to do more and the media is paying more attention. But both the pace of the scale-up and the shape of the response are still highly uncertain.

This AfricaFocus Bulletin contains excerpts from three recent articles: the WHO statement on exponential growth and the need to scale-up "three- or four-fold", a first-hand report from one of AllAfrica's correspondents in Liberia on community initiatives, and a background article by Dr. Adam Levine, quoted above.

While the complexities of dealing with the crisis are enormous, in fact the basic needs are ones that are known and could be met, if basic health systems were in place at both national and international levels. But they are not.

A roadmap for scaling up is now available from the WHO (http://tinyurl.com/phlza78). But, says epidemic scholar Laurie Garrett, the world still doesn't get it (http://tinyurl.com/l7wnk5u). While new resources are coming in, they are still a trickle, and the issue of coordination is enormous. The response is still hampered by panic and prejudice, both among countries and airlines shutting down transportation links and in public opinion in the countries which could provide resources.

While multifaceted international response is urgent, requiring the logistics capacity only available to military forces, the WHO stresses that "far greater community engagement is the cornerstone of a more effective response." Foreign workers are needed, and themselves need assurance of medical protection. But unless local communities see that they are being given priority, the effort cannot succeed.

On helping directly:

The lead non-governmental agency, stretched to its limit, is Doctors without Borders. See http://www.msf.org/diseases/ebola

"Give a Glove" - AllAfrica Foundation / HEARTT Foundation appeal http://allafrica.com/stories/201408221665.html / http://www.hearttfoundation.org/

On panic and stigmatism:

Analysis of travel bans by Amadou Mahtar Ba and Petition by African opinion leaders
http://allafrica.com/stories/201408310135.html / http://allafrica.com/stories/201408310074.html

"If You Live in Illinois, Do Not Panic About Ebola," Foreign Policy, Sep. 4, 2014 http://tinyurl.com/kyuo7yn

"The long and ugly tradition of treating Africa as a dirty, diseased place" Washington Post blog, Aug. 25, 2014 http://tinyurl.com/onwndsr

For talking points on health as a human right and previous AfricaFocus Bulletins on health, visit http://www.africafocus.org/intro-health.php

++++++++++++++++++++++end editor's note+++++++++++++++++

Liberia: Ebola Situation in Liberia - Non-Conventional Interventions Needed

World Health Organization (Geneva)

September 8, 2014

http://allafrica.com/stories/201409082406.html

During the past weeks, a WHO team of emergency experts worked together with President Ellen Johnson Sirleaf and members of her government to assess the Ebola situation in Liberia.

Transmission of the Ebola virus in Liberia is already intense and the number of new cases is increasing exponentially.

The investigative team worked alongside staff from the Ministry of Health, local health officials, and other key partners working in the country.

All agreed that the demands of the Ebola outbreak have completely outstripped the government's and partners' capacity to respond. Fourteen of Liberia's 15 counties have now reported confirmed cases.

Some 152 health care workers have been infected and 79 have died. When the outbreak began, Liberia had only 1 doctor to treat nearly 100,000 people in a total population of 4.4 million people. Every infection or death of a doctor or nurse depletes response capacity significantly.

Liberia, together with the other hard-hit countries, namely Guinea and Sierra Leone, is experiencing a phenomenon never before seen in any previous Ebola outbreak. As soon as a new Ebola treatment facility is opened, it immediately fills to overflowing with patients, pointing to a large but previously invisible caseload.

Of all Ebola-affected countries, Liberia has the highest cumulative number of reported cases and deaths, amounting, on 8 September, to nearly two thousand cases and more than one thousand deaths. The case-fatality rate, at 58%, is also among the highest.

Situation in Montserrado county

The WHO investigation concentrated on Montserrado county, which includes Liberia's capital, Monrovia. The county is home to more than one million people. The teeming West Point slum, which has no sanitation, little running water, and virtually no electrical supplies, is also located in Monrovia, and is adjacent to the city's major market district.

In Montserrado county, the team estimated that 1000 beds are urgently needed for the treatment of currently infected Ebola patients. At present only 240 beds are available, with an additional 260 beds either planned or in the process of being put in place. These estimates mean that only half of the urgent and immediate capacity needs could be met within the next few weeks and months.

The number of new cases is moving far faster than the capacity to manage them in Ebola-specific treatment centres.

For example, an Ebola treatment facility, hastily improvised by WHO for the Ministry of Health, was recently set up to manage 30 patients but had more than 70 patients as soon as it opened.

WHO estimates that 200 to 250 medical staff are needed to safely manage an Ebola treatment facility with 70 beds.

The investigation team viewed conditions in general-purpose health facilities as well as Ebola-specific transit and treatment facilities.

The John F Kennedy Medical Center in Monrovia, which was largely destroyed during Liberia's civil war, remains the country's only academic referral hospital. The hospital is plagued by electrical fires and floods, and several medical staff were infected there and died, depleting the hospital's limited workforce further.

The fact that early symptoms of Ebola virus disease mimic those of many other common infectious diseases increases the likelihood that Ebola patients will be treated in the same ward as patients suffering from other infections, putting cases and medical staff alike at very high risk of exposure.

In Monrovia, taxis filled with entire families, of whom some members are thought to be infected with the Ebola virus, crisscross the city, searching for a treatment bed. There are none. As WHO staff in Liberia confirm, no free beds for Ebola treatment exist anywhere in the country.

According to a WHO staff member who has been in Liberia for the past several weeks, motorbike-taxis and regular taxis are a hot source of potential Ebola virus transmission, as these vehicles are not disinfected at all, much less before new passengers are taken on board.

When patients are turned away at Ebola treatment centres, they have no choice but to return to their communities and homes, where they inevitably infect others, perpetuating constantly higher flare-ups in the number of cases.

Other urgent needs include finding shelters for orphans and helping recovered patients who have been rejected by their families or neighbours.

Last week, WHO sent one of its most experienced emergency managers to head the WHO office in Monrovia. Coordination among key partners is rapidly improving, aiming for a better match between resources and rapidly escalating needs.

Implications of the investigation

The investigation in Liberia yields 3 important conclusions that need to shape the Ebola response in high-transmission countries.

First, conventional Ebola control interventions are not having an adequate impact in Liberia, though they appear to be working elsewhere in areas of limited transmission, most notably in Nigeria, Senegal, and the Democratic Republic of Congo.

Second, far greater community engagement is the cornerstone of a more effective response. Where communities take charge, especially in rural areas, and put in place their own solutions and protective measures, Ebola transmission has slowed considerably.

Third, key development partners who are supporting the response in Liberia and elsewhere need to prepare to scale up their current efforts by three- to four-fold.

As WHO Director-General Dr Margaret Chan told agencies and officials last week in New York City and Washington, DC, development partners need to prepare for an "exponential increase" in Ebola cases in countries currently experiencing intense virus transmission.

Many thousands of new cases are expected in Liberia over the coming 3 weeks.

WHO and its Director-General will continue to advocate for more Ebola treatment beds in Liberia and elsewhere, and will hold the world accountable for responding to this dire emergency with its unprecedented dimensions of human suffering.


The Liberia Ebola Stories That Don't Get Told

[Excerpts. For full text see
http://allafrica.com/stories/201408181508.html]

Blog by Patience Handful Dalieh

[See also blog by AllAfrica's Boakai Fofana http://allafrica.com/stories/201408281352.html]

International news reports about Liberia leave the impression of overwhelming irrationality in response to the Ebola crisis. It's true that fear has provoked unfortunate incidents. But many Liberians are working hard and courageously - despite the lack of an international response that would supply the equipment and medical help to stem the virus.

Ebola hit close to home - hard - this month. Two members of my church - one a nun and the other a social worker who had been under 21-day quarantine and observation - both died.

My cousin Enid, an emergency nurse with the health ministry, was under surveillance as well, after coming into contact with an Ebola patient. She was assigned to Kakata, a densely populated trading town in Margibi County, where several health workers had already died and health facilities didn't have enough personal protective supplies. Our family was worried about her.

Now, she, too, has died. On her Facebook page a few weeks ago, she posted, "Ebola has hit Margibi again. More health workers are being affected this round 2 and some are even dying. Oh God have mercy." Our family and friends will remember that she caught the virus trying to save others. Rest In Peace, Enid.

But personal losses aren't stopping Liberians from trying to help ourselves and each other. Whatever you hear about the situation, you should know that people may be frightened, but most of us are working hard to stop the virus.

Ebola has become a household word. When the first case was reported in the northern Lofa area in late March, the chief medical officer, Dr. Bernice Dahn, warned that "the disease is reported to be spreading along the border" Liberia shares with Guinea and Sierra Leone.

Almost every Liberian citizen now knows what Ebola is. Many believe that the virus is real and are taking preventive measures, while others are in denial. But these people who are denying the existence of the Ebola virus in the country still follow the preventive measures, which baffles me.

"I don't understand some Liberians", said one of my friends, Derek Berlic. When I asked him why, he said, "Some people go around saying that the virus isn't real, but yet still they join us and wash their hands and use sanitizers as frequently as those of us that believe that the virus is real." He said it pleases him when he sees these individuals taking preventive measures, because it signals that somewhere in these people minds, they believe the virus is real, even if they don't want to admit it.

Most churches have joined the fight against Ebola by carrying on awareness campaigns, talking about it during sermons and placing buckets of water at entrances of the church buildings for members to wash their hands before entering for service. Both Christian and Muslim religious leaders have called on all Liberians to pray for the country - and, at the same time, to take their own preventive measures.

Supermarkets, shops and other business centers are following suit. The three mobile phone companies in Liberia have been using SMS to sensitive their subscribers by sending daily text messages about the virus. Across cities and towns, Liberians have organized themselves in various communities and are promoting awareness.

It seems that almost every Liberian has now become his or her 'brother's keeper' by carrying on sensitization in taxis, clubs, and market places - wherever they find themselves. On Facebook, many Liberians have made their profile pictures Ebola related and their statuses feature awareness messages on a daily basis. Liberian groups on Facebook discuss the situation.

Liberians in the diaspora have organized themselves into minigroups to send aid, such as gloves and other personal protective equipment, back home to fight this deadly disease. The Liberian ambassador in Washington DC, Jeremiah Sulunteh, announced that the embassy had established an account for those who want to donate.

The alarmingly high death rate from the Ebola virus among health workers has left citizens wondering how they will get medical care for many common illnesses, which can be deadly also, such as malaria. Bodies of suspected Ebola victims being left in the streets or in houses adds to the anxiety.

...

there are positive things every Liberian can do. So this is how I spent my weekend. With the organization Girls As Partners, I managed to reach out to ten different churches in the Gardnersville area of Monrovia, giving them buckets, chlorine and soap so their members could adhere to one of the Ebola preventive measures - washing hands. We also gave out leaflets containing facts about Ebola and its prevention.

...


Stop Worrying About Ebola (And Start Worrying About What it Means)

Adam C. Levine, Assistant Professor of Emergency Medicine, Brown Medical School

Huffington Post, August 13, 2014

[Excerpts. Full text available at http://tinyurl.com/lt3fnfw]]

Once again, Africa is in the international spotlight. As usual, the news isn't good.

The media seems to alternate between long stretches of ignoring Africa entirely, punctuated by short bursts of completely freaking out about the continent, usually due to a new outbreak of disease or terrorism that we fear may spread to our own shores. The recent Ebola outbreak in West Africa, which has infected almost 2,000 people over the past six months, is no exception.

Of course, we should care a great deal about the Ebola outbreak, but not for the reasons propagated by cable news and bloggers alike. We should care about Ebola not because of the threat it poses to us as Americans, but for what it says about the current state of the health care system in much of Africa and many other resource-limited settings around the globe.

Sadly, the media has instead coalesced around the following five myths, while ignoring the larger public health context and incredible health disparities present in our world.

Myth #1: Ebola is a universally fatal disease.

Ebola can certainly be fatal, but not universally so. In fact, the case fatality ratio for Ebola and its close cousin, Marburg virus, varies greatly depending on the setting. The first recorded outbreak of these diseases, which occurred in Germany and Yugoslavia in 1967, had a mortality rate of 23 percent - high by any standard, but far lower than the 53-88 percent mortality seen in subsequent outbreaks in sub-Saharan Africa over the next 40 years. (This first outbreak also occurred before anything was known about the disease and before the widespread availability of modern emergency departments and intensive care units in Europe.)

The risk of death for individuals infected with Ebola or Marburg in the United States or Europe today would almost certainly be far lower than that seen in any of the previous outbreaks. The two Americans recently infected in Liberia, for instance, are by all accounts improving, not because of any magic serum they received, but because of the close monitoring and care provided by their aid worker colleagues and their rapid evacuation to a modern hospital with intensive care facilities.

I have cared for patients and trained physicians in dozens of urban and rural hospitals across sub-Saharan Africa over the last decade. The mortality rate for nearly every disease I have ever managed, from pneumonia to heart attacks to cancer to motor vehicle accidents, is at least an order of magnitude higher in sub-Saharan Africa than for the exact same disease managed in an American hospital.

When it comes to your likelihood of dying from any disease in this world, Ebola included, geography matters.

Myth #2: There is no treatment for Ebola.

There are actually several effective treatments for Ebola that can help support individuals through the worst phases of the disease and increase their chance of survival. These treatments include early and careful resuscitation with intravenous fluids; blood products such as packed red blood cells, platelets, and concentrations of clotting factors to prevent bleeding; antibiotics to treat common bacterial co-infections; respiratory support with oxygen, or in severe cases, via a ventilator; and powerful vasoactive medications to counter the effects of shock. In addition, modern diagnostic equipment can help doctors and nurses continuously track vital signs in order to rapidly detect and manage new complications of the disease and stay one step ahead of the virus.

The incredible thing about these already proven treatments (as opposed to the experimental ones being discussed at length in the media) is that they can be used to fight not just Ebola but a myriad of other diseases across Africa. During the past six months that the Ebola outbreak has claimed the lives of nearly 1000 children and adults, approximately 298,000 children have died of severe pneumonia, 193,000 children have died of severe diarrhea, 288,000 children and adults have died of severe malaria, and 428,000 children and adults have died from injuries like car accidents, all in sub-Saharan Africa alone.

Better access to emergency and critical care services could help save patients with Ebola as well as those affected by these and many other far more common killers.

Myth #3: Ebola is the most contagious disease known and will spread rapidly across America if it is allowed to enter the country.

Ebola is not the most contagious disease known. It's not airborne and it's not even spread by aerosols (small droplets of spit that float through the air). This makes it less contagious than a host of other diseases, such as measles, chicken pox, tuberculosis, or even the seasonal flu. To the best of our knowledge, Ebola is spread only by close physical contact, especially with bodily fluids. ...

In a medical setting, all that is required to prevent the spread of Ebola from patient to health care worker to patient is the use of "contact precautions," which include gowns, gloves and regular hand-washing after every patient contact -- precautions that are standard in the intensive care units of all U.S. hospitals where patients with Ebola would be treated.

Contrast that to West Africa, where Ebola has been spreading rapidly due to a lack of basic public health measures in poorly equipped government hospitals and clinics. Many health centers and hospitals lack adequate supplies as basic as gloves and gowns, and many also lack the running water or alcohol-based solutions required for health care professionals to cleanse their hands in between patients. Unlike the United States, hospitals in Africa tend to have open wards with dozens of beds crowded into a single room and, in many cases I've seen, multiple patients sharing a single bed. It's not hard to see how Ebola can spread quickly in these types of crowded situations.

The best way to help Africa stem the tide of the current Ebola epidemic is by rapidly investing in and deploying basic infectious control measures like gowns, gloves, water, and sterilization tools, coupled with health worker and community health trainings in how to properly use them.

Myth #4: We need to start giving experimental Ebola drugs right away to as many Africans as possible to help stem the outbreak.

Any human being given an experimental treatment that has not yet been proven safe and effective in humans is, by definition, being experimented upon. Now, experimenting on humans, even those in poor countries, is not necessarily a bad thing. In fact, conducting research in resource-limited settings is a big part of my own job. However, every person enrolled in a medical research study, whether they are American or African, is entitled to the same basic international ethical protections, and people in poor countries actually deserve special protections.

For instance, while studies in the United States require approval from just one ethical review board, most studies in low-income countries require approval from two separate ethical review boards -- one international and one local. ... Finally, every patient enrolled in a study, whether they be in a treatment group or comparison group, must also receive the very best available proven treatments for the disease, which in the case of Ebola would include all of those outlined above. This would ensure that all patients in the study receive some benefit from the research, even if the experimental drugs turn out to be ineffective (or harmful).

...

Myth #5: Nothing can be done to help Africa -- it's just too poor.

The true tragedy of the Ebola outbreak is that most Africans lack access to the very same medications, equipment, and skilled physicians and nurses that have been available in the United States and Europe for several decades, and that could have prevented the current epidemic from raging out of control. Moreover, these very same measures could also be used to reduce mortality from the variety of other diseases currently killing thousands of times as many Africans each day as Ebola.

These lifesaving treatments are not out of reach for the continent. ... with enough political will and outside financial and technical support, African countries can achieve large scale improvements in their capacity to both prevent disease and manage even the most critical and emergent conditions -- not overnight perhaps, but in time to prevent the next big epidemic before it even begins.


AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

AfricaFocus Bulletin can be reached at africafocus@igc.org. Please write to this address to subscribe or unsubscribe to the bulletin, or to suggest material for inclusion. For more information about reposted material, please contact directly the original source mentioned. For a full archive and other resources, see http://www.africafocus.org


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