Much Ado About #Ebola

What started out as a small outbreak in Guinea has grown to a blight which has started to cause global concern in more ways than one. But why has this outbreak been labeled “the worst in history”? There is still a lot to learn,  as world nations continue to combat the disease.

 

The scourge called Ebola……

Ebola [formerly known as Ebola hemorrhagic fever] is one of the world’s most virulent diseases.  The first Ebola virus was detected in 1976 in a small rural village in what is now the Democratic Republic of Congo [then known as Zaire]. The index case was a village headmaster who died after travelling around Ebola river. Since then, outbreaks have appeared sporadically in the DR Congo, Sudan, and Uganda.  The current outbreak is the largest and most complex Ebola outbreak ever documented.  The first case was reported in Guinea in March 2014.   The outbreak has spread to Sierra Leone, Liberia, Nigeria, and Senegal. The outbreak in Senegal and Nigeria are pretty much contained. The last reported case in Senegal was August 9, 2014 and the last in Nigeria was on September 8, 2014.

……and why it is so dangerous

Ebola is a biosafety level four pathogen and is also classified as one of the biological warfare category A agents along with smallpox and the plague.   Ebola, like other class A agents is easily disseminated or can be transmitted easily from person to person.   It has a high mortality rate and has the potential for major public health impact.   It can cause public panic and social disruption and will require special action for public health preparedness

How is Ebola Transmitted

Transmission is via human to human contact and can occur through direct contact with blood and other body fluids including saliva, mucus, vomits, feces, sweat, tears, spit, breast milk, urine, and semen.  Avoiding contact with these fluids is crucial.  Entry points usually include the nose, mouth, eyes, open wounds, cuts, and abrasions.  The virus has the potential to be transmitted sexually as the virus is found in the semen of men who have recovered from the disease for up to three months. In addition to this, dead infected persons can also infect others. Nearly two-thirds of the Ebola cases in Guinea are believed to be associated with established burial practices.   Those who succumb to the disease are now cremated and all their contaminated clothing incinerated.  Airborne transmission has not been documented, but the potential for aerosol spread remains. Infected persons can spray droplets following a cough, sneeze or even through talking.  Contact with objects that have been contaminated by the virus such as needles, syringes, fomites, blades, scalpels and other equipment remain a possibility.

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Ecological and genetic factors could interact to form new strains of the Ebola virus. Wild and domestic animals could be reservoirs of infection.  In fact, the initial infection is believed to have occurred after the virus was transmitted to a human via contact with an infected animal’s body fluid. Bats have been implicated as sources of transmission, and are considered hazardous in many ways.   They are widespread throughout most of the world, and are perhaps necessary in the role they play in pollinating flowers and dispersing fruit seeds. They also consume insects that could destroy crops.  They may appear in food markets in China, Thailand, Guam and even Australia.  On Pemba Island, off the coast of Tanzania, bats are roasted and are prepared for consumption in stir fry meals and soups. They have also been linked with dementia in Chamorro and Parkinson-like disease in Guam. Fruit bats in Gabon have tested positive for Marburg and Ebola virus.  Infected bats could feed on fruit, and their saliva left on the fruit, which people can pluck down and eat without following through on proper basic hygiene requirements such as washing, can lead to infection.

A cluster of cases can occur if cases are not isolated quickly and their contacts quarantined in a timely fashion for the maximum incubation period. The potential for wide spread Ebola disease is low considering that the disease is largely spread by direct contact. However, anyone who is in close contact with an infected person who already has symptoms of the disease is at risk of becoming infected.  Health care workers and family members are at the greatest risk of becoming infected.  In the countries with outbreaks this year, cumulative death rates in some of the countries were higher among health care workers than among the cases they cared for.

Cumulative number of cases and deaths, 2014

TableWHO- Regional Office outbreak summary accessed Sept 20 2014 [Adapted]

As of October 3, 2014   the World Health Organization (WHO) updated the number of cases to 7,492 and has reported 3439 deaths. However, WHO has said that these numbers may be vastly underestimated.

What are the Signs & Symptoms?

The incubation period can run from two days to twenty-one days, but most will have symptoms by the one week mark.  Symptoms include fever (usually > 101 degrees Fahrenheit), severe headache, muscle pain, weakness, diarrhea and vomiting as well as abdominal pain. These symptoms are also seen in cases of cholera and malaria. In addition, Ebola patients will have unexpected bleeding or bruising.

There is fear of the outbreak becoming a global phenomenon without adequate checks in place. On October 6, 2014, a nurse in Spain became the first person to contract Ebola outside of West Africa.The most recent case of  Ebola in the United States included a visitor from Liberia to the Southeastern city of Dallas, Texas. Eric Duncan, who caught the virus in Liberia and was being kept in isolation while receiving experimental drugs at Texas Health Presbyterian Hospital was pronounced dead on October 8, 2014.

Current challenges and the need for a more intensive response

The cost of this outbreak has been set at billions of US dollars. Livelihoods lost as a result of the outbreak cannot be quantified, and already weak health systems have only been stressed even more. There are not enough doctors and nurses to care for the large numbers in Liberia, yet these workers form a large group of individuals who have been sacrificed by this scourge.

The Ministries of Health and Social Welfare in most of the affected countries are however supported by The World Health Organization and other development partners, including religious groups: Médecins Sans Frontières, The Red Cross, and even other African countries. The President of Ghana made donations to Liberia, and the United States will be sending 3,000 military personnel to help contain the disease and will be delivering seventeen treatment centers with a hundred beds to Liberia. WHO has sent several well trained health workers from Uganda to train and assist the local population.

Public health diseases that are capable of outbreaks and are of national and international concern put great stress on the local health system.  It is therefore important to keep strengthening the capacity of these systems to effectively respond to the crisis. Local health workers everywhere, especially where the disease is ravaging have been largely fearful of engaging in the call to respond to the epidemic. Most do not have the appropriate protective clothing and necessary supplies to cope with the disease.

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According to the World Bank Group, this epidemic in West Africa has disrupted international travel, the closure of markets and in countries like Sierra Leone which rely heavily on subsistence farming and mining, the flight of foreign workers has crippled these industries. Forecast data shows that if the virus is not rapidly contained in Liberia, the country could see negative growth rates in 2015.

It is important to deal with the social structures that can interfere with effective control of the disease, especially in resource poor countries. The New York Times recently reported a story on the arrival of a shipping container packed with protective supplies needed to help Sierra Leone fight its current battle with Ebola which has been sitting on the docks for nearly two months.   In Liberia, shanty communities have to be quarantined at gun point and some residents do not believe that the virus exists.

And there is the issue of the stigma associated with Ebola. Suspected cases in resource poor countries may not seek treatment early to avoid being in contact with potential Ebola patients in case they do not have Ebola.  In countries like Nigeria where Ebola appears to be contained, it has shifted from being just a government problem to everybody’s problem, with businesses putting up hand washing stations; policemen are also seen wearing masks. There are stories of foreigners from the affected countries being shunned and discriminated against by virtue of their nationalities.

A lot of work has been done to keep country borders safe, but due to the nature of the virus, this action has its limitations. For example, screening for high temperature occurs at Nigeria’s Murtala Mohammed airport at three check-in points to ensure that no sick person gets onto the flights going out of the country.  While this ensures the safety of other passages, it may not stop incubating carriers from taking the disease abroad.

There is still a lot to learn about Ebola, and many are trying interesting and novel ways to treat the disease. Some believe that there is a possibility that the yellow fever vaccine can cross protect or reduce the severity of the disease in those already vaccinated.  A doctor in rural Liberia, Dr. Gorbee Logan resorted to the use of the HIV drug, Lamivudine to treat Ebola patients with what appears to be some success.  There is of course ZMapp, an experimental treatment that may be effective.

In an attempt to understand and contain Ebola, it is paramount that we are able to define what is real and what is sensational, as reflected in the media’s response to the outbreak. We must also remember that infected individuals are just that — human beings and not a disease.

Image: Getty 

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Frontline Research and Training in Reproductive and Family Health is a non-governmental organization with a goal to promote the reproductive health of individuals, families, communities and the general population. For more information, visit: Frontline Research and Training