By Raina MacIntyre
September 27 2014
The latest Ebola modelling paper from MMWR by Martin Meltzer et al(1) is a welcome change from the flood of descriptive papers which do nothing more than describe the massive failure of disease control efforts in West Africa. This study gives us a practical piece of information which can be used to inform disease control efforts: If 70% of cases are in Ebola treatment facilities, the epidemic can be controlled. If not, it will reach the dire predictions that have been made. The paper also illustrates the value of mathematical modeling in informing disease control efforts.
I have not to date heard a clearly articulated disease control strategy for Ebola in terms of objectives, aims or public health strategies. The Melzer paper provides a worthy aim – get 70% of Ebola patients into Ebola treatment centres (ETUs) to break epidemic transmission. I think this is a simple and achievable public health strategy to aim for. Current estimates of the proportion of EVD cases in treatment centres are 15-20% according to colleagues from SL and Liberia. I also understand many school buildings have been closed down, so there are available buildings which could be commandeered and used to care for Ebola patients. There are many recovered patients in SL, Liberia and Guinea who could be paid to care for Ebola patients in these makeshift ETU's. People have lost their jobs because hospitals and other industries have closed down, so recovered patients could be mobilised to care for Ebola patients.
This is what they did in the 1976 outbreak as beautifully described in NJEM recently.(2) In that outbreak, they used huts outside the village as ETUs, and used recovered patients to care for the sick and take food, drinks and supplies to them. Although the 1976 outbreak was in a village setting, such strategies can be applied in an urban setting.
Achieving 70% in ETUs in an urban setting is feasible, and not expensive. The details of the report from Dr Ada Igonoh, the Nigerian doctor who recovered from Ebola after treating Patrick Sawyer,(3) despite being harrowing, show how well organised the disease control effort was in Nigeria –an abandoned building was used initially to care for all Ebola patients. She and others were left there with minimal care, but given ORS, food and other supplies. When she recovered she had to have a chlorine bath and leave behind all her personal items such as mobile phone and iPad as an infection control precaution. Teams were also sent to decontaminate the home where she initially became unwell. Whilst the care itself was not ideal and many of her colleagues died, in a catastrophic situation such as that facing West Africa currently, lesser care for more people is better than higher care for a tiny minority. This is true from all perspectives including disease control and equity. The Nigerian model could be used in urban settings, and there are many abandoned buildings which could be used as treatment centres.
The other important point made in by responders from MSF is that people are dying of fluid and electrolyte depletion, and basic acute care is being ignored in favour of specialist interventions.(5) They say “…the skills needed to care for patients with Ebola are fundamental acute care skills, not the privileged domain of tropical medicine, infectious disease, or critical care.” (5) They say that bloods are being taken for Ebola PCR, but that serum electrolytes are not being tested. They make the point that simple tests and interventions can make a difference, but are not being used to save lives. For those who cannot receive care in ETUs, I hear the Sierra Leone government is now issuing care packs (containing gloves, masks, ORS and other supplies) for people who have to care for their sick in the home, which is an important strategy to support. Finally, as in any disaster, management and safe burial of dead bodies is a key strategy, which must be incorporated in a culturally sensitive manner into an integrated response. Local leadership efforts and knowledge must be respected and the partnerships between local health authorities and NGOs need to be supported.
In summary, I think we need a clearly articulated strategy with measurable, achievable goals to tackle the Ebola disaster. This could include:
1. Aim to get 70% of patients with Ebola into ETUs.
2. Create makeshift ETUs utilizing abandoned buildings following the example of Nigeria
3. Provide simple acute care to more patients in favour of high-resource interventions for fewer patients. Recovered patients can be paid and trained to assist with this.
4. Support provision of care packs for home treatment where patients cannot reach ETUs.
5. Coordinate culturally sensitive burial of bodies of the deceased.
6. Support local leadership efforts in partnership with NGOs
It’s time to stop describing the disaster and come up with an evidence-based action plan.
This piece was written after discussions with our Ebola public health research group at UNSW, which includes several UNSW students who are health professionals from affected countries in West Africa. You will hear more on this blog from West African health professionals on their views on how this can be achieved within their social and cultural context in a series titled "West African Voices on Ebola". West African readers who wish to contribute can do so by contacting me on email@example.com
Raina MacIntyre is Professor of Infectious Diseases Epidemiology at UNSW Australia. Full research profile: http://research.unsw.edu.au/people/professor-raina-macintyre
1. Meltzer MI, Atkins CY, Santibanez S, et al. Estimating the Future Number of Cases in the Ebola Epidemic — Liberia and Sierra Leone, 2014–2015. MMWR Supplements September 26, 2014 / 63(03);1-14
2. Breman, JG, Johnson, KM. Ebola Then and Now. Sept 10, 2014. NEJM.
3. Ada Igonoh. Through the valley of the shadow of death – Dr Ada Igonoh survived Ebola. This is her story. http://www.bellanaija.com/2014/09/15/must-read-through-the-valley-of-the-shadow-of-death-dr-ada-igonoh-survived-ebola-this-is-her-story/
4.Lamontagne, F, Clément, C, Fletcher, T et al. Doing Today's Work Superbly Well — Treating Ebola with Current Tools. NEJM. September 24, 2014DOI: 10.1056/NEJMp1411310