Ebola epidemic

Ebola: Still outpaced, nurses strike, and why West Africa?

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Ebola crisis: ‘We are still being outpaced by epidemic,’ MSF head tells MPs

Via The GuardianEbola crisis: ‘We are still being outpaced by epidemic,’ MSF head tells MPs. Excerpt:

The Ebola epidemic is still outstripping efforts to contain it, according to doctors from Médecins Sans Frontières who have mounted most of the early response in west Africa. Speaking to MPs from the House of Commons international development committee, MSF’s head of UK programmes said the apparent decline in numbers in Liberia did not signal the end of the epidemic. “We are still being outpaced,” said André Heller-Perrache . ”There are far more actors on the ground but we are still being outpaced by it, with Sierra Leone being the most concerning case we have.” Dr Javid Abdelmoneim, a UK-based doctor in emergency medicine who has recently returned from Sierra Leone where he was a volunteer with MSF, said there was “too little of everything being done in terms of intervention”. He described how doctors in MSF’s treatment centre in Kailahun would don protective suits to meet an ambulance that could have been travelling across the country for 10 hours expecting dead bodies, which are highly infectious. “Usually there is a patient who is dead,” he said. “There was [in one ambulance] one dead woman and two who were alive but terrified. They have watched this poor woman die a wretched death and they are thinking, ‘I’m now going to die as well.’” Prof John Edmunds, from the London School of Hygiene and Tropical Medicine, who in September called the outbreak a potential doomsday scenario, said he would not say that the nightmare had been averted. “Things have improved dramatically in Liberia now – cases were doubling every two weeks. Now there is a turnaround and they are declining. “The number of cases in Liberia has flattened out. The increase has stopped and come down, but we haven’t got rid of Ebola. In Guinea and Sierra Leone the rate of increase hasn’t really changed much at all.”

Ebola in Sierra Leone: Health workers go on strike

Via BBC News: Ebola crisis: Sierra Leone health workers go on strike. Excerpt:

More than 400 health workers involved in treating Ebola patients have gone on strike at a clinic in Sierra Leone.

The staff, who include nurses, porters and cleaners, are protesting about the government’s failure to pay an agreed weekly $100 (£63) “hazard payment”.

The clinic, in Bandajuma near Bo, is the only Ebola treatment centre in southern Sierra Leone.

In Mali, a nurse and the patient he was treating earlier became the second and third people to die from Ebola there.

Nearly 5,000 people have been killed in the outbreak of Ebola in West Africa, mostly in Guinea, Liberia and Sierra Leone.

The World Health Organization (WHO) has declared the outbreak a global health emergency.

The Bandajuma clinic is run by medical charity MSF, which said it would be forced to close the facility if the strike continued.

MSF’s emergency co-ordinator in Sierra Leone, Ewald Stars, told the BBC that about 60 patients had been left unattended because of the strike at the clinic in Bandajuma.

Meanwhile, Reuters reports that in the US, National Nurses United are organizing strikes and rallies over inadequate protection for healthcare workers.

Ebola: Why West Africa?

Thanks to Greg Folkers for sending the link to this conditionally accepted paper in PLOS Neglected Tropical DiseasesWhat factors might have led to the emergence of Ebola in West Africa? The abstract:

An Ebola outbreak of unprecedented scope emerged in West Africa in December 2013 and presently continues unabated in the countries of Guinea, Sierra Leone, and Liberia. Ebola is not new to Africa and outbreaks have been confirmed as far back as 1976. The current West African Ebola outbreak is the largest ever recorded and differs dramatically from prior outbreaks in its duration, number of people affected, and geographic extent.

The emergence of this deadly disease in West Africa invites many questions, foremost among these: Why now and why in West Africa?

Here, we review the sociological, ecological, and environmental drivers that might have influenced the emergence of Ebola in this region of Africa and its spread throughout the region. Containment of the West African Ebola outbreak is the most pressing, immediate need.

A comprehensive assessment of the drivers of Ebola emergence and sustained human-to-human transmission is also needed in order to prepare other countries for importation or emergence of this disease.

Such assessment includes identification of country-level protocols and interagency policies for outbreak detection and rapid response, increased understanding of cultural and traditional risk factors within and between nations, delivery of culturally embedded public health education, and regional coordination and collaboration, particularly with governments and health ministries throughout Africa.

Public health education is also urgently needed in countries outside of Africa in order to ensure that risk is properly understood and public concerns do not escalate unnecessarily.

To prevent future outbreaks, coordinated, multiscale, early warning systems should be developed that make full use of these integrated assessments, partner with local communities in high-risk areas, and provide clearly defined response recommendations specific to the needs of each community.

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Science Magazine: How many Ebola cases are there really?

Every couple of days, the World Health Organization (WHO) issues a “situation update” on the Ebola epidemic, with new numbers of cases and deaths for each of the affected countries. These numbers―9216 and 4555 respectively, according to Friday’s update―are instantly reported and tweeted around the world. They’re also quickly translated into ever-more frightening graphics by people who follow the epidemic closely, such as virologist Ian Mackay of the University of Queenslandin Brisbane, Australia, and Maia Majumder, a Ph.D. student at the Massachusetts Institute of Technology in Cambridge who visualizes the data on her website and publishes projections on HealthMap, an online information system for outbreaks.

But it’s widely known that the real situation is much worse than the numbers show because many cases don’t make it into the official statistics. Underreporting occurs in every disease outbreak anywhere, but keeping track of Ebola in Guinea, Liberia, and Sierra Leone has been particularly difficult. And the epidemic unfolds, underreporting appears to be getting worse. (“It’s a mess,” Mackay says.)

So what do the WHO numbers really mean—and how can researchers estimate the actual number of victims? Here are answers to some key questions.

Does WHO acknowledge that the numbers are too low?

Absolutely. In August, it said that the reported numbers “vastly underestimate” the epidemic’s magnitude. WHO’s situation updates frequently point out gaps in the data. The 8 October update, for instance, noted that there had been a fall in cases in Liberia the previous 3 weeks, but this was “unlikely to be genuine,” the report said. “Rather, it reflects a deterioration in the ability of overwhelmed responders to record accurate epidemiological data. It is clear from field reports and first responders that [Ebola] cases are being under-reported from several key locations, and laboratory data that have not yet been integrated into official estimates indicate an increase in the number of new cases in Liberia.”

Where do the reported numbers come from, and why are they always too low?

Officially, the governments of Guinea, Sierra Leone, and Liberia transmit the numbers to WHO, which then passes them on to the world. But WHO is also closely involved in helping determine the numbers. The data come from several sources, says WHO epidemiologist Christopher Dye; the three main ones are clinics and treatment centers, laboratories doing Ebola tests, and burial teams.

Getting the numbers right is hard for many reasons. Many patients don’t seek medical care, for instance, because they don’t trust the medical system or because they live too far away. Of those who do, some die along the way, and some are turned away because treatment centers are overloaded. Of Ebola people who die at home, some are buried without ever coming to officials’ attention. It can also take time for recorded information to be passed on and entered into data reporting systems.

Testing is a big problem as well. The reports break down the numbers into suspected cases, based mostly on symptoms; probable cases, in which someone had symptoms and a link to a known Ebola case; and confirmed cases, in which a patient sample tested positive in the lab. In an ideal world, all suspected and probable cases would eventually be tested, but testing capacity is lacking. In WHO’s 15 October report, only 56% of the cases in the three countries was confirmed; in Liberia, where testing is huge problem, it was just 22%. (Friday’s report did not break down Liberia’s cases and said the data were “temporarily unavailable.”)

Dye says WHO and other groups are trying hard to improve the reporting on the ground. Among other things, they are trying to set up a system that would provide every patient with a unique identification number. Now, Dye says, patients who enter an Ebola clinic and then have a sample tested in the lab may enter the reports twice, because there is no way to know that the lab and the clinic were recording the same patient.

Are there ways to estimate the extent of the underreporting?

There are. For instance, In a technique called capture-recapture, epidemiologists visit one area or district and determine what percentage of the Ebola cases and deaths there has found its way into official records. “You throw out the net twice, and you compare,” says Martin Meltzer of the Centers for Disease Control and Prevention (CDC) in Atlanta, who is modeling the Ebola epidemic. (The term capture-recapture was borrowed from researchers who study the size of wildlife populations using two rounds of trapping.) But this method is logistically challenging and possibly dangerous, given the hostilities that some Ebola response teams have met, Meltzer says: “I’m not going to ask people to risk their lives to collect some data.”

For a paper published last month, Meltzer and his colleagues used a different technique. CDC has a computer model that, among other things, calculates how many hospital beds should be in use at any given time based on the cumulative number of cases at that moment. For 28 August, the time the paper was written, that number was 143 beds for Liberia; but people in the field told Meltzer that the actual number of beds in use was 320, a factor of 2.24 higher. (These numbers can be found in an annex to the paper.) “We had heard some other numbers that were higher, so we rounded that up to a correction factor of 2.5,” Meltzer says. But it’s a very rough approximation. Also, underreporting is likely to vary greatly from one place to another and over time, he says.

The CDC team’s widely reported worst case projection of 1.4 million cases by 20 Januarywas based on the correction factor of 2.5, and assuming control efforts didn’t improve. It included only Liberia and Sierra Leone; in Guinea, the reported numbers of cases have fluctuated too much to make a reasonable projection, Meltzer says, which could also could be partly due to underreporting.

What does WHO think is a reasonable correction factor?

WHO hasn’t published an estimate. “It’s a point that has been greatly discussed but there is a tremendous amount of uncertainty,” Dye says. For its internal planning purposes, however, WHO uses a correction factor of 2.0. When WHO’s Bruce Aylward said at a press conference last week that the agency is expecting to see between 5000 and 10,000 cases per week by early December, “the difference between the 5000 and the 10,000 is that factor of two,” Dye says. A correction factor of 2.0 would mean that the total number of cases has now crossed 18,000 and the number of deaths 9000.

If the numbers are that far off, should they be published at all?

Even if many cases are missed, the trends in the numbers are still very meaningful. They clearly show that the number of cases has roughly doubled every 3 to 4 weeks and that this trend is continuing. If underreporting  gets worse, however, it may be even more difficult to discern such trends.

Is there any good news in the recent numbers?

There is. The number of new cases in some areas at the epicenter of the outbreak—Kenema and Kailahun districts in Sierra Leone and Liberia’s Lofa County—has been dropping, and that’s not a result of underreporting, Dye says. “It has happened for a sufficiently large number of weeks now that we are confident that it’s a real reduction in incidence on the ground, probably related to control measures,” he says. “Our colleagues working on the ground believe it is, too.”

One important factor has been the increase in safe burials, Dye says. (The bodies of Ebola victims are very infectious.) People in the affected areas have resisted abandoning traditional burial practices that carry a high risk of infection, but in these three areas, local leaders, supported by WHO and others, have come to advocate a change. If that happens elsewhere, Dye says, “we expect to be able to cut out a substantial amount of infection in the community.”

*The Ebola Files: Given the current Ebola outbreak, unprecedented in terms of number of people killed and rapid geographic spread, Science and Science Translational Medicinehave made a collection of research and news articles on the viral disease freely available to researchers and the general public.

Ebola battling sadness, fear and disgust on the frontline

An MSF psychologist reveals the trauma of dealing with the Ebola outbreak for medics, cleaners and the families of the dead.
MDG : Ebola Treatment Center in Kailahun, Sierra Leone

MSF’s Ebola treatment centre in Kailahun, Sierra Leone. A pair of brothers, 11 and four, draw pictures with a psychologist. Their mother continues to receive treatment. Photograph: MSF

Ane Bjøru Fjeldsæter is a 31-year-old psychologist from Trondheim, Norway. For the past month, she has been working for Médecins sans Frontières (MSF) in Kailahun, Sierra Leone, helping to fight the largest ever outbreak of Ebola, which has killed more than 600 people in three countries. She provides support and counselling to patients and their families, as well as to the staff whose job it is to deal with the dead bodies.

I was expecting the Ebola epidemic to be quite gruesome and unlike anything I had seen before. But I really didn’t expect its magnitude – this outbreak is enormous. In Sierra Leone, it killed off a lot of health workers before MSF even arrived. Not surprisingly, medical staff were reluctant to work with us at first. They’d never come across Ebola before – but at least they had previous experience of people suffering and people dying. But for the non-medical staff, like the hygienists – our hospital cleaners – it’s been a new and disturbing experience, and a large part of my work involves helping them with counselling and support.

The hygienists have the hardest job of all because they are the ones dealing with the dead bodies. Since our Ebola centre opened two weeks ago, we’ve had 37 deaths: an average of two or three a day. A lot of the cleaners are young, unskilled workers. In an area with an unemployment rate of 95%, they jumped at this opportunity to get a job.

They are the ones who mop up the vomit, the stools and the blood. And when there’s a death, they are the ones who retrieve the body from the isolation ward, put it in the morgue and disinfect it. In the final stages of the disease, the viral load increases massively, which means the dead bodies are extremely contagious and very dangerous to deal with.

MDG : MSF Ebola Treatment Centre in Kailahun, Sierra LeoneDoctors try to feed a girl in the centre’s high-contamination-risk zone. Photograph: Sylvain Cherkaoui/Cosmos for MSFDealing with the dead bodies is disturbing: the hygienists experience feelings of sadness and fear, but also disgust. When Ebola patients die, there’s bleeding, vomiting and diarrhoea. The cleaners tell me they have flashbacks of the things they have seen and of things they have smelled. Even wearing a mask, you can’t shut out all the smells.

Traditionally, in Sierra Leone, dead bodies are taken care of by the tribal elders. A lot of the hygienists feel they are too young to be dealing with the dead, so worry they’re being disrespectful of their culture’s traditions. We make sure that on each shift there is always one man and one woman, so that when someone dies, there will always be someone of the same sex to tend to them.

The local staff experience huge stigma from the community. The son of one of our workers recently died from malaria. People in his village immediately said he had caused his son’s death because he was working with Ebola. It was very distressing for him.

The stigma makes it hard for the hygienists. We tell them: “You are heroes, you’re doing a very important service for your community – it’s absolutely vital that someone is doing this job.” But although we see them as heroes, that isn’t always how they are perceived by their families, their friends or their villages.

MDG : MSF Ebola Treatment Centre in Kailahun. Sierra LeoneA patient attempts to rehydrate himself under the watchful eye of a nurse. Photograph: Sylvain Cherkaoui/Cosmos for MSFWhen we discharge a patient who has survived Ebola, it makes an enormous difference to them. On Tuesday, three people who had been cured were discharged from the isolation ward, and all the cleaners were dancing, deliriously happy and taking photographs. They find ways to manage the stress: they take good care of each other; when someone is upset, they talk about it, and they are very open about voicing their concerns and difficulties.

Still, the local staff have had their lives turned upside down. But then throughout the entire district everything is upside down. Here in Kailahun, the banks are shut, the schools have been closed for more than a month, and the students are very upset that they are missing their exams. A lot of people are isolated by the fear that if they go near other people, they will get the disease. People are at a loss to understand what is happening to them.

Last week, a girl came out of the isolation ward. Her name was Bintu and she was almost two. Both her parents had tested positive for Ebola, but she tested negative, so we had to take her out of the ward because the risk of contamination was too high. That was a horrible day.

MDG : MSF psychologist Ane Bjøru Fjeldsæter at Ebola Treatment Centre in Kailahun, Sierra Leone Psychologist Ane Bjøru Fjeldsæter welcomes Tamba James, who has been tested negative for Ebola. Photograph: Sylvain Cherkaoui/Cosmos for MSFThe nurses told me she didn’t know how to speak. For the two days she’d been in the ward, she’d been so shocked that she hadn’t uttered a word. This can happen to children – it’s called elective mutism. When she came out, she was in shock: she didn’t make eye contact; she didn’t speak to anyone. We put her in a chair and she turned around, with her back to the world.

It must have been a terribly disturbing experience for a child: to see someone come into the ward in a spacesuit; to hear them speaking to her mother in words she didn’t understand; to see her mother start crying; and then to be handed over to the stranger in the spacesuit and carried off.

I sat with her for four hours, trying to talk to her in a calm and normal voice and singing her songs, to see if the shock would pass. By the end of the four hours she had turned around and was facing me. She made eye contact, she put her hand out for me to touch her, she tried to start a conversation with me. You could see that she was starting to warm up to me, and that she wasn’t in the same condition.

Bintu became an orphan that day. She is in the care of our child protection partner and they will locate other family members who can take care of her. She will need to be monitored for 21 days to see that she does not develop the disease herself.

Originally from The Guardian, July 17, 2014.