Ebola is endemic to the Congo but previously popped up in remote places where it could be rather easily snuffed out. Now it has reached a major city. Cross your fingers that it can be stopped.
It’s relatively easy to think of ways in which things could go wrong, especially when dealing with a deadly disease like Ebola. I’m not optimistic about the likely course of events in West Africa, as you might gather from previous posts. But in this post I want to make an honest effort to envision what success would look like, then work backwards to see how it might be possible to get there from here. What follows is fantasy, but with a serious purpose.
Victory Over Ebola!
It has been 42 days and there have been no new cases in any of the countries affected by the West African epidemic! The last patient has either recovered or, sadly, died. Temporary facilities have been disassembled or burned, and hospital buildings thoroughly disinfected. Everyone has been through a harrowing experience but generous aid and technical assistance from around the world should help the affected countries get back on their feet.
Animal reservoirs of Ebola still exist; it would be wonderful to extinguish the virus worldwide but it’s really hard to imagine that. Ongoing efforts will be needed to discourage contact with infected animals, such as bush meat and fruit that may have been partially eaten by infected bats. Vaccination may reduce the risk of future outbreaks, although it will be difficult to maintain universal immunity in still-poor countries, and a vaccine might not confer immunity against a new strain. So as long as Ebola exists in the wild there will continue to be occasional rural outbreaks. The world obviously must never again let Ebola get out of control!
The “Effective Reproduction Rate” (Re) [Discussed in The Ebola Chain Reaction] was held down below one, month after month. That is, each person who came down with Ebola infected on average less than one other susceptible person. This was true not only in the aggregate but also in each country and region and neighborhood. The number of patients being cared for peaked, then began a slow but consistent decline, as the number of new patients each day was fewer than the day before. American troops were drawn down, then withdrawn completely, as there was no more need for additional beds.
Winning the War
Gradually, Re was forced lower and lower, down below one and then well below. How was this accomplished? Some combination of these factors:
- There were enough Ebola isolation beds for everyone who came down with the disease, in all affected countries, and the public had so much confidence in the care in those facilities that just about everyone who came down with Ebola was admitted to one before other family members were infected. Treatment measures and drugs like ZMapp improved the survival rate somewhat; this reduced suffering and contributed to confidence but didn’t otherwise help bring the epidemic to a stop.
- An Ebola vaccine, though not available in sufficient quantities to immunize everyone, was strategically given to American soldiers, healthcare providers and others who were likely to be exposed. Except for President Ellen Johnson Sirleaf and her husband the vaccine was not given out based on money or position.
- Infection of healthcare providers was almost completely stopped by:
- Universal availability of infection control gear.
- Comprehensive training of staff at all healthcare facilities.
- Procedures to minimize exposure of unprotected staff during admission or when an admitted patient begins showing Ebola symptoms.
- The Ebola vaccine, when it became available.
- Traditional funeral and burial practices were suspended by general consent after a massive public information campaign.
- People stopped breaking quarantine and/or lying about their Ebola exposure [Discussed in my first post], due to a broad consensus supported by religious and other opinion leaders.
- Urban modes of transmission turned out not to be significant, or were greatly reduced by changes in behaviors and other measures.
It would be great if one could imagine the final stage taking place before a vaccine is available, since that won’t be until around the end of the year at the earliest. Please comment if you think I’m too pessimistic, but I just don’t see how you get Re down below one in Liberia and Sierra Leone without a vaccine. Guinea is different, since their problem in recent weeks has been rural flare-ups due to infected citizens returning there from the other two countries. If Guinea can keep snuffing out these outbreaks — using the classic techniques of isolation, contact-tracing and monitoring — it might be able to get its part of the epidemic under control before the vaccine arrives.
Boots on the Ground
President Obama announced his plan to send 3,000 U.S. troops to Monrovia on September 16, 2014. [CNN 9/16/14] The troops were outfitted and trained in record time and arrived in Monrovia on [wildly hopeful] October 16, 2014. At that time Monrovia needed [a wildly optimistic guess] 1,000 additional beds to accommodate all current Ebola sufferers. The troops set to work building facilities for 1,700 beds, which became ready for patients between [optimistically] November 1 and November 16. By then all the beds were needed, and new patients kept seeking treatment at an increasing rate since Re was still over one. The U.S. identified the problem early and built another 1,700 beds (and trained all necessary staff), also in record time. This time around they got ahead of the curve and Monrovia was finally able to offer isolated care to all Ebola sufferers.
This was the most difficult period of the epidemic, when cases were still growing exponentially, and civil order was progressively undermined. The arrival of Americans had a wonderful effect on the public mood, however. American know-how and money ensured the provision of reliable water, electricity, trash removal and in particular food supplies.While there were a few situations in which small mobs gathered around American installations it was never necessary for a U.S. serviceman to file a single shot, and nobody was injured.
Due to their excellent training and high discipline, only a handful of U.S. troops became infected with Ebola. Those who did fall ill were medevaced back to the U.S., where a combination of excellent care and their own fitness led to a much lower mortality rate than experienced in Africa. Political blow-back from these Ebola casualties was muted due to a national consensus that American needed to do whatever it could to help with the humanitarian crisis in Western Africa. Once the vaccine became available U.S. troops were protected against Ebola and this problem stopped.
Meanwhile, home care kits that had been sent to rural areas proved helpful in reducing Re somewhat, but the key to success in those areas was the addition of more beds, in this case provided and staffed by Médecins Sans Frontières.
The African Union played the same role in Sierra Leone as the U.S. did in Liberia, with the same happy effects. (This strains credulity. The U.S. may have to do the same thing in Sierra Leone itself, which will be exponentially harder the longer it is delayed.)
Guinea continued to experience flare-ups due to travelers from Liberia and Sierra Leone, but it was able to snuff each of them out, and prevent the disease from getting established in its cities.
And They Lived Happily Ever After
Is this a fairy tale or can it happen? There are a lot of ways in which it could fail. To mention just a few:
- Every day counts when you’re battling an exponentially-growing problem. Any delay in any part of the process risks the numbers growing beyond anyone’s ability to manage them. Liberia may already be beyond the point of no return, but we’ll never know if we don’t try.
- Sierra Leone is about as bad off as Liberia. Is someone else really going to step in there, or does the U.S. have to go there as well?
- Political support for the U.S. intervention is likely to be tepid at the outset and could turn sharply against the project after there are casualties. This could force an early withdrawal even if the program seems to be working.
- There could be a further breakdown of civic order that would make it impossible to get the situation under control.
- Mistrust and rumor, or arrogance and privilege, could sabotage the program.
The scenario certainly could fail, but it might just work. We must hope against hope that it will succeed.
Quarantine has always been a principal weapon against epidemics: isolate ailing people so they cannot spread illness. Quarantines come in various types, however, which have different effects:
- When an individual falls ill they need to be cared for in a facility that minimizes the risk that the virus will be spread to other susceptible people. This is the medical isolation that has been the key to defeating all past Ebola outbreaks. People who are suspected of having Ebola may also be kept isolated from others until their status becomes clear. I’ll call this a precautionary quarantine. A third situation is when a contact of an Ebola patient is cautioned to stay at home, or not to travel, during the 21-day incubation period. I’ll call this a monitoring quarantine.
- When an entire neighborhood or region is blocked off, the barrier is referred to by the French term, cordon sanitaire. This may be an urban neighborhood, such as the poor West Point district of Monrovia, or an entire region, such as the remote area at the intersection of Guinea, Liberia and Sierra Leone. Or it may be a de facto cordon sanitaire imposed by the closing of borders and the discontinuance of transport links.
- It is also possible to impose a curfew that limits when people can interact outside the home, in the hope that this will reduce transmission.
- Finally, Sierra Leone has announced a nationwidewide three-day lock-down, starting September 19, during which everyone will be required to stay home so as to allow a house to house inspection for hidden Ebola patients. [AFP 9/6/14]
Medical isolation is essential and effective, though in West Africa there have been many issues:
- Some rural “red” villages either doubted that Ebola is real or feared that the doctors brought it. They forced Médecins Sans Frontières/Doctors Without Borders (“MSF”) to withdraw, and in some cases physically blocked road access — a do-it-yourself (reverse) cordon sanitaire! [NYT 7/27/14] There was no choice but to let the epidemic burn itself out in those villages. I haven’t seen a report of what happened, but it will be illuminating to eventually find out.
- Urban neighborhoods have resisted siting of Ebola care facilities nearby. Residents of the poor West Point district of Monrovia attacked and ransacked a holding facility [NYT 8/19/14], which lead to the attempted cordon sanitaire around their entire neighborhood described below.
- People who fear letting ill family members go into Ebola care facilities often try to treat them at home, hiding them from authorities. This increases the risk of infection to home caregivers as well as other family members. Concern about this issue has led Sierra Leone to declare the country-wide lock down described below.
- There aren’t enough beds in Ebola care facilities, at least in Monrovia. Medical isolation fails if there’s nowhere for people to go. It’s not clear how it will be possible to get on top of this issue since the epidemic is growing exponentially and the construction of facilities — and especially provision of trained staff — is not.
Precautionary quarantines and monitoring quarantines are also essential elements of infection control. The main problem I’ve noticed there is the issue of people breaking quarantine and subsequently infecting some or many other people. The experience of Nigeria is horrific: the outbreak started with one man who broke quarantine in Liberia to fly to Lagos, but it was spread by a series of additional quarantine breakers, one after another. See my earlier post: Arrogance and Privilege Imperil Nigeria’s Attempt to Contain Ebola
On August 1, Guinea, Liberia and Sierra Leone announced a regional cordon sanitaire, to be enforced by their military forces, around the remote area where the outbreak began. The New York Times described it as an infection-control strategy that has not been employed for a century. [NYT 8/12/14] A few days later, however, a writer in the New Republic described as “heartless but effective” a similar cordon sanitaire used in 1995 to control an Ebola outbreak in Zaire. [New Republic 8/14/14] Reuters expressed the concern that the cordon could create abandoned “plague villages.” [Reuters 8/17/14] The World Food program has been struggling to provide adequate food supplies to 1.3 million people in limited access areas, including classic quarantines as well as cordons sanitaire. [WFP 9/2/14] There has been little mention of the regional cordon sanitaire in recent weeks, perhaps because the battle in the capital cities has taken center stage. The regional cordon may simply become a dead letter if Ebola continues to spread outside it.
On August 20, Liberia imposed urban cordons sanitaire on two poor and crowded neighborhoods of Monrovia: West Point and Dolo Town. Hundreds of young men in West Point rioted, throwing rocks at police, who used tear gas and live gunfire to disperse the crowd. [SaharaReporters 8/21/14] Several residents were injured, and a 15-year-old boy died. During the closure there were many stories of evasion, including a couple who bribed a soldier $10 to get out and a man who swam around the cordon each weekday to go to work in a government office. Ten days later the West Point cordon was lifted. [NYT 8/29/14] The West Point cordon would have to be called a failure. Meanwhile Dolo Town had accepted the restriction more calmly, although grumbling was reported three weeks later about continuing to be an “Ebola Jail Town.” [AFP 9/7/14]
Liberia also imposed a nationwide curfew on August 20, from 6 pm to 9 am. [AFP 8/20/14] There has been a report that nighttime armed burglaries have increased during the curfew. [The New Dawn Liberia 9/8/14] The value of the curfew is debatable. It depends on the importance of urban transmission modes, and how many potential transmission events are prevented by keeping people home at night.
A de facto cordon sanitaire around the entire region has been developing over the past couple of months through a series of border closings and flight suspensions, along with regulations barring entry to ships that had touched at ports in the affected countries. In the past week a plea has been made for flights to continue and for borders to be opened to screened transit. It will become increasingly difficult to get necessary materiel and personnel into the affected countries if transport restrictions aren’t eased.
Most recently, Sierra Leone has announced a three-day nationwide lockdown, starting Sept. 19, during which everyone is expected to stay in their homes, with exceptions only for essential travel. During this period a house-to-house inspection will be conducted to find patients that are being hidden from the authorities. A government spokesman is quoted as saying that, “We intend to ensure that the dreaded disease is checked.” [AFP 9/6/14] MSF has expressed concern that this sort of measure will do more harm than good: “It has been our experience that lockdowns and quarantines do not help control Ebola, as they end up driving people underground and jeopardizing the trust between people and health providers…” But the top U.N. official in Sierra Leone supported the idea. [NYT 9/6/14] My own view is that the idea is daring but a lot could go wrong:
- Households that are concealing an Ebola patient are likely to resist a thorough inspection, thus frustrating the purpose.
- Even if a household doesn’t harbor an Ebola patient, it may have some other secret that will lead it to resist inspection.
- People who are angry anyway will have three full days to sit at home and get angrier and angrier. This could burst out into violence.
- How will the inspectors distinguish people who just have malaria or colds from people who really do have Ebola?
- Will the inspectors all be wearing full protective gear, and will they be trained in procedures for putting them on and taking them off? The arrival of a moon-suited team would not be a warm and fuzzy experience, but if they aren’t protected the inspectors themselves could be the next wave of victims.
- If a lot of patients are found where will they go? I’m not sure about the situation in Sierra Leone, but in Monrovia there aren’t nearly enough beds in Ebola treatment facilities. [WSJ 9/7/14]
All that said, a desperate situation calls for desperate measures. I hope the lockdown works!
What can be done? This post will make some suggestions.
1. The first priority is to reduce the rate of transmission through known channels, which I discussed in detail in my previous post, The Ebola Chain Reaction.
Home Caregivers. Education is the first need: people need to know Ebola’s symptoms, then they need to know what to do if someone in their household starts to display them. This is an extremely hard problem. The early symptoms of Ebola — fever, vomiting and diarrhea — are indistinguishable from many other endemic diseases. Every person with a fever can’t be taken immediately to the hospital, and in the meantime the home caregiver is in no position to use any semblance of anti-infection protocol. In a crowded household people share the same spaces for eating, sleeping and every other aspect of life. Practical advice for home caregivers needs to be developed and communicated. That advice should include how a patient can be cared for in the home with reduced risk, when a patient should be taken to a clinic or hospital and how to decontaminate living spaces after a patient has left. But I don’t see how the risk of transmission to other members of a household can be much reduced, especially in poor, crowded housholds.
Healthcare Providers. Sooner or later — hopefully sooner — a symptomatic patient will be brought to a clinic or hospital. Again and again patients have infected multiple hospital staff members, and even forced the hospital to close for decontamination. As the numbers of patients increase this cannot be allowed to continue. Emergency rooms must be organized and staffed so that an Ebola patient can be identified and isolated without endangering staff or other patients. That’s easy to say but really hard to make true. Can we expect emergency room staff to wear bio-hazard suits? Can each patient be kept apart from other patients until they have been assessed? And again the problem arises of distinguishing early stage Ebola from other diseases. A quick, cheap and accurate test is needed to enable healthcare providers to distinguish who does or doesn’t present an Ebola risk. Airports are starting to use infrared detectors to cull out people who are running fevers, but it’s hard to imagine similar gear being deployed to all the relevant hospitals and clinics, and even if someone has a fever a hospital — unlike an airport — can’t just turn the patient away; but knowing who does and doesn’t have a fever might be helpful. And of course healthcare providers need the training and gear necessary to safely care for Ebola patients.
Traditional Funeral Practices. African funeral practices spread infection widely and must be suspended. This is a very difficult problem, since funerals are one of the ways people deal with the powerful emotion of grief. They will resist changes, and unless physically prevented are likely to model the behaviors they have seen and performed in the past. Culturally-specific strategies must be devised and implemented to encourage people to mourn Ebola victims in ways that do not place them at risk of infection.
These three transmission modes are quite capable of keeping the epidemic growing, with an Effective Reproduction Rate (Re) of more than one (as discussed in my last post). Pushing each of them down as low as possible is the first priority.
2. New modes of transmission are possible in the urban environment. Prior outbreaks have all been in rural areas, so there is no past experience with the additional ways Ebola can spread in a city, especially in crowded areas.
The first question is how important any new urban modes of transmission are, i.e. how much of a contribution they make to Re. If any urban mode of transmission is comparable to the known modes it needs to get similar priority, but if urban modes of transmission are more theoretical than real they can be deprioritized. The contact tracing process generates a tremendous amount of information about exactly what kinds of contacts did and did not lead to infection. Contact tracing information from all countries should be collected and analyzed, and conclusions should be shared amongst Ebola fighters. Communications to the public should generally be accurate, but in the public interest may not always be “the whole truth.” Significant modes of urban transmission that are so identified must be countered, if possible.
Even before data is available it makes sense to analyze urban life and make changes that seem logical and have the potential of being cost-effective.
- Replacing shaking hands with fist bumps is a step in the right direction, although elbow bumps or just bows would be even better. Air kisses between friends and colleagues (if that was ever an African thing) can be suspended for the duration.
- Situations where people are crowded into direct contact are part of urban life, but present an obvious risk. People can be cautioned to avoid crowds and steps can be taken to reduce crowding in taxis and buses. Update 9/8/14: This chilling item from the Wall Street Journal suggests that taxi drivers and surfaces in taxis could easily become contaminated by bleeding, etc. Ebola patients. [WSJ 9/7/14]
- While 60% alcohol hand sanitizer is better than nothing the CDC recommendation is to wash hands with soap and water whenever possible. Sanitizer could have an adverse effect if people use it instead of washing.
There is also a question of whether alcohol has much effect on the virus anyway.Update 10/7/14: Since Ebola has a lipid coat alcohol-based hand sanitizer should be effective against it. The CDC continues to recommend alcohol-based hand sanitizer (with at least 60% alcohol) when hand washing isn’t possible. [CDC 10/7/14] Bleach is standard for disinfection, but it’s not clear to me whether dipping ones hands in a shared bleach bucket, as is becoming common in some affected cities, is a net benefit.
- Some offices are taking people’s temperatures when they enter, and asking them to wear it as a badge. The risk of transmission in an office setting would seem to be very low in any case, but if this serves to raise awareness and control anxiety it may be worthwhile.
- Closing schools initially seems logical, but it imposes social costs and might turn out to be an overreaction. School children are somewhere doing something, probably with other children, when they aren’t in school. It might actually be better to open school, with provisions to minimize physical contact, and perhaps also with a process for taking each student’s temperature as they arrive and sending home anyone with a fever.
- Other situations in which people put their hands on one another deserve consideration. Massage parlors and sexual contact come to mind. And a panicky post worries about barber shops (not without reason).
Amongst all these possible risks and countermeasures, public communications should focus on the most important transmission modes and the most important countermeasures, based on the best available information at each point. On the other hand, worthless countermeasures, or countermeasures against trivial risks, may be ignored if they afford comfort and don’t unduly draw attention or resources away from more important issues, or lead to a dangerously false sense of security.
3. Superstition, rumors and mistrust must be countered and overcome. The West African Ebola fight has been plagued by these factors from the outset. In addition to the usual superstitions about causes and folk remedies the rumor spread that Ebola was brought by the healthcare personnel who were in fact trying to stop it. MSF had to withdraw from more than two dozen “red villages” because this hostility made them too dangerous. The poor and crowded West Point district of Monrovia attacked and ransacked a quarantine facility that had been sited there. In part this reflected “Ebola denial” which will disappear on its own as the epidemic makes itself felt more widely. But it also reflected mistrust and irrational fear that must be countered.
4. A pattern of quarantine breaking and lying must be broken. Again and again, especially among the privileged classes in Nigeria, people have broken quarantine and/or lied about prior contacts with Ebola cases, thereby putting dozens or hundreds of health care providers and other contacts at risk. (For details see my post, Arrogance and Privilege Imperil Nigeria’s Attempt to Contain Ebola) This reflects arrogance and a habit of getting their own way regardless of consequences to others. The immorality of this behavior — and its dire consequences — must be brought home to everyone, at every level of society. This is culturally-specific but one imagines that achieving this goal might involve use of media and involvement of religious and other thought leaders. It is hard to see how Nigeria — or indeed any society, including developed countries — can control Ebola if a pattern of quarantine breaking and lying like the one we have seen so far should persist.
5. Adequate healthcare facilities are essential to allow Ebola patients to be cared for outside the home, where they are much more likely to pass the virus along to others. The epidemic has consistently outstripped available facilities, and unless there is a marvelous international intervention this seems doomed to continue. Healthcare is also key to minimizing the death rate, which is important as a humanitarian matter even though it is only tangentially relevant to stopping the epidemic. Sadly, there is no possibility of replicating the level of care the two Americans received at Emory, which no doubt contributed to their recoveries. But any lessons learned in developed hospitals about how best to manage Ebola patients should be made available to African healthcare providers. Most important are any recommendations that it might be possible to implement in an overstressed and impoverished facility.
Updated 10/7/14: Here is a new idea that might make an important contribution, even though it’s really distasteful. Sierra Leone plans to build up to 1,000 “makeshift Ebola clinics” that would offer little, if any, treatment. [AP 10/2/14] These “clinics” would really be hospices which would let people die and be safely cremated or buried without infecting their families. It’s dreadful to think of abandoning people who could be saved with minimal care. But just at the moment this may be the least bad alternative, since if the patients die at home they will very likely infect their caretakers and some or all of the other members of their households. If enough of these facilities could be provided, and if people could be persuaded to use them, this could be a game changer.
6. Outsiders must send money, health care and infection control materials, healthcare workers and healthcare trainers. Happily — if far too late — the world finally seems to be waking up to the gravity of the situation, and to its own moral obligation to help, as well as its self-interest in stopping the epidemic before it affects even more countries. Individual readers can find a list of ways to help at the current Ebola Report post. Charity Navigator can help you assess the quality of charities that are fighting the epidemic. Doctors Without Borders USA, for example (the U.S. branch of Médecins Sans Frontières) gets the highest ratings for both use of funds and accountability/transparency.
7. Immunity is the ultimate weapon against disease, and in this case it may be the only way the epidemic can be stopped. Obviously, testing of a vaccine must be given top priority. People who have recovered from Ebola are also an important resource. It might be possible to recruit recovered Ebola patients to play roles in healthcare settings, such as hospital emergency rooms, or in other situations where their immunity could come in handy. Recovered patients may also offer a source of antibodies that could be purified as a serum to help current victims. Mutation is the ultimate weapon of disease, and this could undercut both a vaccine and survivor immunity, but as to this possibility we just have to hope for the best.