Nee-Kofi Mould-Millman, MDAssistant Professor, Dept of Emergency Medicine

Senior Investigator, Center for Global Health

• No conflicts of interest

• No financial disclosures

1) To understand pathogenesis and clinical syndrome of Ebola Virus Disease

2) To appreciate socio-cultural and healthcare systems factors contributing to transmission

3) To understand and assess various response strategies to the Ebola outbreak in West Africa

Photo Credit: Content Providers(s): CDC/Dr. Lyle Conrad - This media

comes from the Centers for Disease Control and Prevention's Public Health

Image Library (PHIL), with identification number #704

http://www.bbc.com/news/magazine-28262541

http://www.rocketswag.com/medicine/images/Where-Is-The-Ebola-River-Located.jpg

1590

• Evidenced by• Paucity of Ebola Virus Disease experts

• Lack of published literature on EVD

• Paucity of basic or clinical research on EVD

• No broader syndromic surveillance for EVD

1989 – 1997 1999 – 2003

• Post-Conflict Health Statistics (2012)*

• Population: 4,190,000

• Per capita income: $580

• Expenditure per capita: $102

• Physician-to-Population: 1:76,000

• WHO Goal is 1:1,000#

• Life expectancy at birth women/men: 60/63 yrs

• Infant mortality rate: 78/1,000 live births

* WHO: http://www.who.int/countries/lbr/en/# Kinfu Y, Dal Poz MR, Mercer H, Evans DB. The health worker shortage in Africa: are enough physicians and nurses being trained? Bull World Health Organ. 2009 Mar;87(3):225–30.

• Post-Conflict Health Statistics (2012)*

• Leading causes of mortality

• Malaria (17%)

• Lower respiratory tract infections (11%)

• Diarrheal diseases (11%)

• HIV/AIDS (5%)

• Tuberculosis (3%)

* WHO: http://www.who.int/countries/lbr/en/

• Consequences of civil war• Fragile socio-economic system

• Fragmented healthcare system

• Few healthcare providers

• Inadequate frontline healthcare

• Underdeveloped in-hospital emergency care

• Non-existent pre-hospital emergency care/transport

• No syndromic or contagious infection surveillance

• Pervasive skepticism and mistrust of authority

• Frontline healthcare workers flee & die

• Empty beds, empty waiting areas

• No delivery of acute or inpatient care

• Clinic and hospital closures

• Int’l NGOs flee Bong County and Liberia

• Ministry of Health in Bong County shuts down

• Healthcare system in Bong County crippled

• Inability to contain spread of Ebola Virus Disease

Mr. Patrick Sawyer

http://www.bbc.com/news/world-africa-29696011

Dr. Stella Adadevoh

• 13,567 cases

• 4,951 deaths

• 523 HCW cases

• 269 HCW deaths

http://apps.who.int/iris/bitstream/10665/137424/1/roadmapsitrep_31Oct2014_eng.pdf?ua=1

• 13,567 cases 15,351 cases (11%)

• 4,951 deaths 5,459 deaths (9%)

• 523 HCW cases 588 cases (11%)

• 269 HCW deaths

http://apps.who.int/iris/bitstream/10665/137424/1/roadmapsitrep_31Oct2014_eng.pdf?ua=1

http://apps.who.int/iris/bitstream/10665/137424/1/roadmapsitrep_31Oct2014_eng.pdf?ua=1

328 contacts being traced in Bamako

• CDC: • “½ million cases by Jan 2015” ???

• “Large potential for regional and global spread”

VULNERABILITY + INSULT = CRITICALFAILURE

CDC/Cynthia Goldsmith - Public Health Image Library, #10816 This media comes from the Centers for Disease Control and

Prevention's Public Health Image Library (PHIL), with identification number #1081…

Lipoprotein

Envelope

http://www.cdc.gov/vhf/ebola/hcp/survivability-ebola-medical-waste.html

1) Human infectivity

2) Hardy coat

• SYMPTOMS:• fever (87.1%),

• fatigue (76.4%),

• loss of appetite (64.5%),

• vomiting (67.6%),

• diarrhea (65.6%),

• headache (53.4%), and

• abdominal pain (44.3%)

* Malaria-like symptoms

N Engl J Med 2014; 371:1481-1495, October 16, 2014DOI: 10.1056/NEJMoa1411100

• EVD is an often fatal disease• Case fatality rate ~25-90% (36% in 2014)

• Jumps hosts from animal to human

• Handling of infected animals or carcasses

• Human-to-human transmission• Blood, secretions, body fluids, organs, etc

• Through broken skin or mucous membranes

N Engl J Med 2014; 371:1481-1495, October 16, 2014DOI: 10.1056/NEJMoa1411100

• Incubation period (infx to symptoms)• 2 to 21 days (mean 5 days)

• 61 days in semen

• Days in puddles, weeks in corpses

• ↑ Disease progression = ↑ Infectivity• No symptoms = non infectious

• Early disease = lower infectivity

• Late disease = higher infectivity

• Upon death = highest infectivity

N Engl J Med 2014; 371:1481-1495October 16, 2014DOI: 10.1056/NEJMoa1411100

• Hemorrhage• Only in 18%

• At IV sites & mucosa

• But predicts death

• At highest risk• Caretakers of sick

• Healthcare workers

• Those who handle deceased remains

N Engl J Med 2014; 371:1481-1495, October 16, 2014DOI: 10.1056/NEJMoa1411100

• Killing Ebola Virus by heating :• To 60°C (140°F) for 60 minutes,

• To 72-80°C (162° - 176°F) for 30 minutes, or

• Submersing the material in boiling water for five minutes.

Mitchell SW, McCormick JB. Physicochemical inactivation of Lassa, Ebola, and Marburg viruses. J Clin Microbiol 1984; 20(3):486-9.

VULNERABILITY + INSULT = CRITICALINJURY

• VULNERABILITY:• Social and cultural setting

• Limited healthcare workers

• Most at risk are healthcare workers

• Poor resources & infrastructure

• No syndromic surveillance

• No disaster or emergency preparedness

• INSULT:• Ebola is highly transmissible & infectious

• In crowded suburban and urban settings

• Failed efforts at initial containment

• Fear and panic among HCWs and NGOs

• CRITICAL INJURY:• Deaths of HCWs

• Absence of NGOs

• Stigmatization of hospitals

• Crippling of healthcare systems

Ebola disease exposes the vulnerability of fragile, unprepared, under-resourced African

health and emergency care systems!

• Mean time to symptom onset 5 days

• Quarantine and observation of suspected cases

• Ebola transmission can be interrupted

• Ebola case incidence can be reduced (in 2-3 wks)

• Simple personal protective equipment

• Enforce hand washing practices (soap)

• Sterilization with 1:10 bleach solutions

• Treatment of Ebola disease = basic resuscitative care

• Survivors of Ebola conferred immunity to Ebola

• Community education

• Safe burial practices

• Strengthen border surveillance

• Enforce local travel bans and restrictions

There is no 1 simple solution for a multi-faceted complex problem.

1) Improve syndromic surveillance #

2) Strengthen hospital preparedness

3) Create Ebola Treatment Units #

4) Improve access to diagnostic technology #

5) Improve health communication to public #

6) Improve contact tracing

7) Safe burial of the dead

8) Improve safe transportation of cases

# The Lancet, Volume 384, Issue 9940, Page 303, 26 July 2014

1) Improve syndromic surveillance

“Mobile technologies can offer early

warning systems, response to

outbreaks and communication

among doctors and local officials on

the scene and international health

authorities…” - Lancet.

The Lancet, Volume 384, Issue 9940, Page 303, 26 July 2014

2) Strengthen hospital preparedness

2) Strengthen hospital preparedness Infection prevention and control measures

Screening and isolation areas/protocolso Hands-off triage/screening (>1m)

Procuring personal protective equipment

Train special Ebola response teams

Implement pre-hospital transport & teams

3) Create Ebola Treatment Units (ETU)W.H.O.

Médecins Sans Frontièrs

Int’l Medical Corps

UN MEER

Cuban Doctors

3) Create Ebola Treatment Units Screening/triage areas

Observation/isolation areas

Treatment wards/units

3) Create Ebola Treatment Units

4) Improve access to diagnostic technologies Local ‘basic’ lab tests

Shared regional Ebola tests

5) Improve health communication to public

6) Improve contact tracing

http://www.cdc.gov/vhf/ebola/pdf/contact-tracing.pdf

7) Safe burials for the dead

8) Improve safe transportation of probable or confirmed cases

http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html

• World Health Organization (Nov 21)• Increase in # and location of cases

• Is there a handle on Ebola in West Africa???

http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html

• The Ebola outbreak has socio-cultural roots

• Exacerbated by unprepared, fragmented care systems

• Ebola has exposed fragile African healthcare systems

• Ebola can be contained with a planned approach

• Assistance from the international community is key

• Ebola has emphasized the importance of healthcare system preparedness and partnerships in global health

Questions?