Thursday Ebola Linkage

2 October 2014, 1612 EDT

Well, this has been a very difficult period to watch as we see the unfolding tragedy of the Ebola outbreak in West Africa. We have seen dire warnings for the region, with a dramatic uptick in reported infections and some heartbreaking (and problematic) images from hospitals. There have been credible projections that left unchecked Ebola could have as many 1.4 million infections by early 2015 in Liberia and Sierra Leone, which would amount to more than 10% of the population of those two countries. With President Obama’s announcement of $500 million (perhaps up to $1 billion) and the deployment of 3000 soldiers, help may be arriving and more on the way, but it is unclear if this belated scale-up of attention and resources will arrive to stave off the worst in Liberia and Sierra Leone. Fortunately, the spread in neighboring Nigeria seems very well-contained.

We have also seen the first diagnosed Ebola patient outside the continent, in my own state of Texas, by a Liberian who travelled here and became symptomatic upon arrival. The situation appears to be under control but questions remain, as the patient was initially sent home after his first visit to the hospital. Here are some news and comments from around the web. I had some exchanges with WSJ and NYT reporters about airport fever monitoring as well as the ethics of the images the NYT had of suffering children on their pages. Read on for more.

The Situation in West Africa

Even as resources have been scaled up to fight Ebola, there seems to be a surge in infections of late in West Africa. While there were more than 6,000 confirmed cases at the end of September, that could be an undercount by a factor of 2-3. What’s more, there are projections that as case numbers expand, we could be talking about hundreds of thousands infected by year’s end, with a fatality rate in excess of 50%. That’s a more conservative estimate as the CDC estimated that 1.4 million people could be infected by January in just two countries Liberia and Sierra Leone if nothing is done. Some increased response has been set in motion but we are still talking about a very big epidemic.

The situation on the ground in some places is grim, but there is good news from Nigeria where a command center financed by the Gates Foundation helped set in motion tens of thousands of repeated health care visits to those few people who came in contact with the Liberian-American diplomat who transmitted the virus to Lagos:

Meanwhile, local health workers paid 18,500 face-to-face visits to repeatedly take the temperatures of nearly 900 people who had contact with them. The last confirmed case was detected on Aug. 31, and virtually all contacts have passed the 21-day incubation period without falling ill.

The New York Times had a series of very difficult articles (here, here) with photos of people dead, dying, or sick from the virus, including children, raising difficult ethical challenges of reporting an important story and respect for the sick and informed consent. Laura Seay and I had an exchange with Lydia Polgreen from the New York Times on Twitter.


The Response

Laurie Garrett has a new article in Foreign Policy bemoaning the lackadaisical response by some donors in response to the problem. Pledges outstrip actual delivery, the Europeans having delivered only $16 million of the $190 mn pledged and the Americans only a bit better at the time of writing:

A second chart of personnel and supplies delivered to the countries and of financial commitments illustrates a pace for the response to date. If we look at these numbers side by side, it becomes starkly clear that the world’s response effort is crawling compared with the exponential growth in viral spread.

It sounds like many of the clinics that the Americans are building with U.S. support are days and weeks away. A story on from September 30th noted:

The Pentagon said Monday that an additional 30 military personnel had arrived in the Liberian capital of Monrovia, bringing the total number of troops on the ground there to about 150 since Obama announced the military commitment two weeks ago…The first task will be to set up a 25-bed facility in Liberia that was expected to be running by mid-October for the treatment of health care workers believed to have contracted Ebola, Pentagon spokesmen said. None of the U.S. military personnel in West Africa will have direct contact with Ebola patients, the Pentagon said.

The New York Times put the military role more explicitly in another story:

The military is not filling the treatment centers with doctors and nurses, so the U.S.A.I.D. and the Liberian government are trying to figure out how to run them once they are completed.

International Transmission

Meanwhile, with reports of Ebola reaching the United States, there are renewed questions about the pre-screening measures to prevent sick travelers from boarding aircraft. Apparently, all passengers are being pre-screened with fever checks before they get on a plane. While the  Dallas traveler apparently was asymptomatic before boarding the plane, there is still some question about whether someone sick could get on the plane and transmit it to fellow passengers.

The CDC’s Tom Frieden was very certain the Dallas patient posed zero risk to fellow airline passengers:

There is zero risk of transmission on the flight. He was checked for fever before getting on the flight.

We know that Patrick Sawyer, the Liberian-American, who transmitted Ebola to Nigeria, was able to board a flight while he was symptomatic. He vomited on the plane but did not transmit to fellow passengers but apparently did to the people who helped him in to a diplomatic car. Hopefully, the fever screening that was enacted since Sawyer’s case will avoid future situations of actively symptomatic travelers, but I’ve heard mixed reports of how well those systems functions. It sounds like the equipment early on was not all that good.

I had a Twitter exchange with Drew Hinshaw, the Wall Street Journal reporter who has been covering the Ebola crisis, for his thoughts on how well that protection system is working. He didn’t think there was much risk for transmission on a plane, emphasizing the low likelihood other passengers would come into contact with passenger bodily fluids, though I worried that people might not make it to the toilet and require others to clean up for them.

Jeremy Youde alerted me to the European Centre for Disease Prevention and Control’s guidelines for how to deal with Ebola and travel. The upshot, you really have to come in close contact with the ill in the late stages of their disease and their bodily fluids. Here are some salient sections:

Simple physical contact with a sick person appeared to be neither necessary nor sufficient for contracting Ebola infection: one person who developed the disease was probably infected by contact with heavily contaminated fomites, and many persons who had simple physical contact with a sick person did not become infected. Transmission through heavily contaminated fomites is apparently possible (25). In summary, physical contact with body fluids seems necessary for transmission, especially in the early stages of disease (as is likely in passengers still able to travel on a plane), while in the later stages contact with heavily contaminated fomites might also be a risk for transmission.”

The Dallas Case and the Resilience of Western Health Systems

With the Dallas case, the U.S. health system is being tested. Experts are confident that the system is ready. People have been trained to deal with these situations, and we have protocols in place to do contact tracing for the people who came in contact with the patient, and we have proper procedures to isolate the sick person and care for them in the hospital.

Jeremy Youde summarizes some of these ideas in a new paper in World Politics Review:

CDC and the Department of Health and Human Services have been conducting regular briefings and trainings with health care workers and facilities around the country to alert them to Ebola’s symptoms and proper treatment protocols. If an airline passenger were to fall ill with Ebola while in flight, international airports in the United States have quarantine stations to isolate the infected, and CDC officials would conduct contact tracing to identify individuals who may have been in close contact with the sick person.

Still, he noted that many hospitals lack surge capacity to deal with emergencies:

A workshop hosted by the U.S. Institute of Medicine in 2009 showed that most health care facilities in the U.S. are already operating at close to their maximum capacities, meaning they could be overwhelmed by a widespread infectious disease outbreak.

Moreover, the fact that the Dallas patient was released the first time after he visited the hospital raises questions about how globally minded our medical staff. Did they not ask the patient his travel history or not know Liberia is in Africa and the epicenter for the epidemic? The NIH admitted that the hospital “fumbled” that part of the procedure:

A travel history was taken, but it wasn’t communicated to the people who were making the decision. … It was a mistake. They dropped the ball.

Let’s hope the optimistic assessment of the U.S. system’s resilience is right. I’m more confident that is true than I am about how successful the efforts will be in West Africa. Many people in West Africa will likely die, but I’m hopeful that hundreds of thousands of potential infections and deaths will be averted.