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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.
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