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Like sparks from a burning building, travelers are carrying Ebola around the world. What’s been happening? What will happen? What can we do?

The Ebola Diaspora

People travel for lots of reasons, some related to the epidemic, some not.

  • Now as always people will want to travel for business, tourism, or to spend time with family or friends. With Ebola increasingly out of control more and more of the people traveling from West Africa will turn out to be infected. I’ll address later in this post the idea of stopping travel altogether, but in short it wouldn’t work, except perhaps to delay the inevitable.
  • As life becomes more difficult in the affected countries people will have an additional reason to travel, seeking either a temporary respite or an extended or permanent refuge. If things get really bad this could change from a trickle to a panicky exodus.
  • People who have been exposed to Ebola, but are not yet symptomatic, may have a special incentive to travel to a country with a modern healthcare system. Such passengers also have a strong incentive to lie about their Ebola exposure, as the traveler from Liberia to Texas apparently did. [CNN 10/3/14] This could be a particular problem for developed Western countries, but also for more prosperous African countries such as Nigeria and South Africa.
  • Fever monitors in airports should prove to be an effective method of barring symptomatic patients from air travel. Update 10/6/14: It has been suggested that ibuprofen could be used to hide a person’s fever in order to get a symptomatic patient through airport screening. [Reuters 10/3/14]  I don’t know whether this is true, but if so it would be a weakness in the screening process.
  • Symptomatic patients may still slip across porous borders on the ground, but airport controls somewhat reduce the spread of Ebola and nearly eliminate the already-low risk to the airplane’s crew and passengers. Port authorities in the affected countries and their neighbors are attempting to do the same type of screening of ship’s crews. [AFP 9/29/14]

The bottom line is that people infected with Ebola will travel to other countries, on the ground and by air and by sea. Wherever they go they will fall ill, and potentially infect others, setting off local Ebola outbreaks. Everything will depend on the location and the response. Stable countries with capable healthcare systems and effective governments should be able to snuff out their Ebola outbreaks fairly easily, depending on the the level of noncompliance they encounter. Poor countries with crowded slums and limited healthcare may not be so lucky.

What’s Been Happening?

Apart from medical evacuations we know of just three cases in which someone infected with Ebola traveled outside of Guinea, Liberia and Sierra Leone.

Nigeria – Patrick Sawyer

Patrick Sawyer, a Liberian-American diplomat, traveled on July 20 from Monrovia to Lagos via Togo despite having severe Ebola symptoms, including vomiting repeatedly during his flights. He collapsed in the airport and was taken to a hospital where he died a few days later, but not before infecting half a dozen people who themselves went on to infect a dozen more. Nigeria identified and tracked 894 contacts of Sawyer and other infected people, of which 20 came down with Ebola and 8 died. [Washington Post 9/30/14] Details are in my earlier posts: Arrogance and Privilege Imperil Nigeria’s Attempt to Contain Ebola and How Contagious is Ebola?

This story involves multiple instances of noncompliance with quarantine orders and lying, as well as many cases in which hospital staff were unnecessarily infected. Nevertheless, Nigeria’s persistent contact tracing and isolation measures, and capable healthcare system, eventually brought the outbreak (apparently) to a close.

Senegal – A Guinean Student

A 21-year-old student named Mamadou Alimuo Diallo was under surveillance in Guinea because several relatives had fallen ill with Ebola. He nevertheless traveled by car to Dakar, Senegal, despite the fact that the border between Guinea and Senegal was supposed to be closed. He arrived in Dakar on August 20, and stayed in the large household of his uncle. He began feeling ill on the 23rd and went to a medical facility seeking treatment for fever, diarrhea and vomiting, but concealed his contact with Ebola patients, and was sent back to his uncle’s home. He was eventually admitted to a hospital for Ebola treatment on the 26th. [USNews 9/1/14]  Some 67 people with whom the student had been in contact were monitored, but none came down with the disease. The student recovered and returned to Guinea. [Modern Ghana 9/10/14]

Senegal apparently did a good job of contact tracing but really just got lucky, since this situation illustrated a lot of problems:

  • The student broke quarantine in Guinea.
  • The student was able to get into Senegal despite the fact that the border was supposedly closed.
  • The student lied about contact with Ebola patients on the 23rd, putting medical staff and family members at risk by going back to his uncle’s home.

It may be that Senegal’s medical facilities used better precautions than those in other countries, or it may be that the student was for some reason just not very infectious. But you couldn’t even call this an outbreak since there was no transmission of the virus in Senegal.

Dallas – Thomas E. Duncan

Thomas Duncan is a Liberian who traveled by plane from Monrovia to Dallas, Texas, arriving on Sept. 20. He lied on an exit form which asked whether he had had any contact with Ebola patients, since on Sept. 15 he had helped carry a stricken neighbor back into her apartment (after she had been turned away from a hospital). His temperature was taken at the Monrovia airport but was not elevated. [NYT 10/2/14]  On the 24th he developed symptoms and on the 26th went to the Texas Health Presbyterian Hospital Dallas. Although he told hospital staff that he had recently traveled from Liberia this information didn’t reach the diagnostic team and they sent him home. Update 10/4/14: The hospital has changed its story and admitted that in fact the entire diagnostic team had access to the fact that Duncan came from Liberia. [NYT 10/3/14] Reportedly, however, on his first hospital visit Duncan falsely denied having contact in Liberia with anyone who was ill. [AP 10/2/14]  On the 28th Duncan was taken to the hospital by ambulance and placed in isolation, with laboratory confirmation of Ebola on the 30th. [NYT 9/30/14]

The people at greatest risk were the four people in the apartment where he stayed in Dallas. They were initially told to stay at home, but were “noncompliant,” including sending at least one of their children to school! [Dallas Business Journal 10/2/14] Formal quarantine orders were then issued requiring them to stay home and not to receive visitors, and a police guard was posted. [Yahoo 10/3/14] Bureaucratic snags delayed cleaning of the contaminated apartment for several days after Duncan went into hospital. They subsequently have been moved to a lovely isolated home donated by a member of “a Dallas faith community.” [NYT 10/3/14]

A total of 12 to 18 people are believed to have had direct contact with Duncan, and they may in turn have had contact with around 100 other people. Those with direct contact are being monitored. This includes 5 school-age children. [Dallas Business Journal 10/1/14Updated 10/4/14: About 50 people are being monitored daily, of which 10 had direct contact with Duncan. [CDC 10/4/14]

Lots of mistakes have been made already, and it’s reasonable to guess that several people will pay for them with their lives:

  • Duncan shouldn’t have traveled or stayed with his relatives so soon after his contact with an Ebola patient, and he shouldn’t have lied about it on the exit form.
  • It’s incredibly stupid that the hospital sent Duncan home after he presented with a fever and told them he had come from Liberia.
    • Very possibly inadequate infection prevention procedures were taken while he was in the hospital, which presents a risk that healthcare workers were infected. Patrick Sawyer infected several doctors and nurses and the entire hospital had to be closed for a month-long decontamination! [Africa Independent Television 9/9/14]
    • This also of course increased the risk to the family where he was staying and any other people he contacted over the next couple of days.
  • It’s mind-boggling that students who had direct contact with Duncan might have been sent to school! And the other unstated “noncompliance” by the household where Duncan had been staying is worrisome.
    • Nigeria closed all schools in the entire country at the height of its Ebola outbreak to protect its children!  [BBC 8/27/14]
  • The delay in cleaning the apartment is inept but in point of fact those people are all so thoroughly exposed that it may not make a difference.

Since the mean incubation period is 11 days and Duncan’s symptoms started on Sept. 24 we can expect the first wave of infections in a few days, with hospital staff following a few days later. That’s if he’s as infectious as Patrick Sawyer; if instead he’s like the Senegal student nobody will be infected!

Mali – The Little Girl With a Nosebleed

Added 10/29/14. On October 19 a two-year-old girl was taken by her grandmother on public transport from a funeral in Guinea to Kayes in western Mali, including a two-hour stopover in Bamako, Mali’s capital and largest city. The child had developed a nosebleed in Guinea, so was symptomatic for the entire trip. The child was examined by a healthcare worker on Oct. 20, admitted to a hospital on Oct. 21, tested positive for Ebola on Oct. 23, and died the next day. Initially, some 43 close contacts were monitored, including 10 healthcare providers. [WHO 10/24/14]  This unfortunately has the potential for several to many infections, especially including the healthcare workers. The silver lining is the fact that the initial case was — eventually — identified, so her contacts could be traced. “If you have one case very early on and you catch it, you’re actually lucky,” says [Dr. Samba Sow from the National Center for Disease Control, CNAM, in Bamako] “If you don’t detect that first case you run the risk of people who are contagious staying in the community without being reported and that’s when you run the risk of an epidemic.” [VoA 10/29/14] At last report 82 contacts were being monitored. [Reuters 10/28/14]

Update 10/31/14: It now appears that the little girl traveled on buses and taxis or otherwise had contact with 141 people, of whom 57 have not yet been identified and found. [Reuters 10/31/14] This could be a disaster for Mali, or wherever those people were going. Or the day could be saved once again by the limited contagiousness of the Ebola virus.

What Will Happen?

Travelers infected with Ebola will continue to pop up from time to time, all over the world. The outcome in each case will depend on intelligence, resources, compliance with quarantines and luck.

  • One assumes that the resources available will enable developed countries to stop Ebola fairly quickly. The classic technique of isolation, contact tracing and monitoring has worked in dozens of rural outbreaks as well as in Nigeria, despite serious noncompliance. 
  • This should be true in Dallas, despite stupidity at the hospital and noncompliance by the family which have increased risk, and may cause unnecessary deaths.
  • The real problem is when Ebola pops up in a poor country with a weak healthcare system, especially in a crowded slum, and especially when there are endemic diseases like malaria that can cause similar symptoms. If Ebola gets established in such a situation it could become another Liberia.

Update 10/6/14: Northeastern University researcher Alessandro Vespignani has developed a computer model which predicted, as of Oct. 1, the likelihood of an infected person traveling to particular countries over the first three weeks of October. [Boston Globe 10/1/14] The ten countries with the highest probabilities are, in order: Ghana (46%), France, Senegal, U.S. (25%), Ivory Coast, U.K., Nigeria, Mali, Belgium and Morocco (about 10%). Of course the U.S. has already identified one such traveler, but it would seem that we still have about a one in four chance of encountering another by the end of the month. One question which isn’t clear from the article is whether the investigators took into account the possibility of a travel bias towards countries with good healthcare systems by people who are concerned about the possibility of having been exposed to the virus. The investigators are posting updating predictions at this link: Ebola – MoBS.

As noted above, the big concern is when one of these people arrives in a poor country with a weak healthcare system. The biggest worry is Ghana, followed by Senegal, Ivory Coast, Mali and Morocco. Nigeria is also high on the list but they showed considerable skill in quashing the Patrick Sawyer outbreak so may be somewhat less at risk (unless the virus gets loose in the ungovernable northern region). The slums of India or South America would also be quite vulnerable but the likelihood of travel there is much less.

What Can We Do?

There are just a few things we can — and must — do.

Limit Travel From Affected Countries?

There will no doubt be a move in America to bar travelers from the three affected countries (Guinea, Liberia and Sierra Leone). This has a superficial appeal, on the same reasoning as the cordon sanitaire around an epidemic ravaged city. (This is discussed in an earlier post: Ebola Quarantines) WHO takes the view, however, that travel bans are counter-productive. [AlJazeera 9/22/14] Not only do travel bans have detrimental economic consequences, but they can worsen the epidemic itself by hindering relief efforts. 
This article makes the case rather persuasively:

It’s also questionable how effective a travel ban would be. The Guinean student demonstrated how porous African land borders are, even when theoretically “closed.” Someone who really wanted to leave the affected countries could get out. Rich and privileged people may have multiple passports, that could be used to conceal their nationalities and/or their itineraries. And there would always have to be exceptions, of one sort or another. A ban might slow the process of seeding Ebola all around the world, but it wouldn’t altogether stop it. Update 10/6/14: The Northeastern University computer model mentioned above elegantly quantifies this. Even with an 80% reduction in flights from the affected countries the probability of an infected person arriving in a given country is only delayed by 3 to 4 weeks. [MoBS Lab 10/1/14]

Update 10/6/14: Despite the arguments against it, I see two possible reasons why a travel ban may nevertheless happen: (1) it may be forced on politicians by a panicky electorate, and/or (2) the numbers of infected travelers may become excessive, due either to a general exodus or medical tourism by people who suspect (or know) that they are infected.

The five-day Hajj (Muslim pilgrimage to Mecca) started on Oct. 2. Saudi Arabia denied visas to residents of the three West African countries, and asked travelers to fill out a medical screening form that details their travels for the previous three weeks. [BBC 10/2/14] Of course people may lie, but it certainly is to be hoped that this year’s Hajj at least will be Ebola-free.

Quarantine Arriving Travelers

Travelers from suspect countries could be quarantined for 21 days before being allowed into the country. This is a tried and true Medieval technique but it’s a really poor fit with our fast-paced globalized world. A non-starter.

Continue to Screen Travelers

Thomas Duncan’s temperature was taken at the Monrovia airport as part of the screening system put in place following the Patrick Sawyer debacle. This part of the process worked as intended, to keep symptomatic travelers off planes. He was asked all the right questions; though unfortunately he lied. This sort of screening is the best you can do, and it’s helpful, even though it can’t prevent pre-symptomatic people like Duncan from traveling.

It would be helpful to add arrival screening of people who have been in affected countries (or U.S. states!) but it’s difficult to identify those people and it would be a huge project to screen everyone on arrival.

Be Prepared

Healthcare providers all over the world must be alert to the possibility of Ebola. In this case Duncan didn’t lie about coming from Liberia (although there’s no indication he told anyone about his contact with an Ebola patient) but there was a lapse in communication within the hospital. This sort of mistake can be fatal! Both to healthcare providers and others who may be needlessly exposed when an Ebola patient is sent home.

Poor countries with weak healthcare systems must be especially vigilant to spot any unusual patterns of disease or death before Ebola has a chance to get intrenched.

There’s not much we can do as individuals, except perhaps to practice good general hygiene, including frequent hand washing. Oh, and if someone is visiting from West Africa feel free to ask whether they’ve had close contact with Ebola patients in the last three weeks…

End the Epidemic

The only definitive solution is to end the West African epidemic. In addition to compelling humanitarian reasons we need to wipe out Ebola everywhere (in humans, anyway) in order to feel fully safe in our own lives.

In April, early in the West African epidemic, the New York Times published an Op-Ed piece entitled “Ebola Virus: A Grim, African Reality.” It closed with this paragraph:

Ebola in Guinea is not the Next Big One, an incipient pandemic destined to circle the world, as some anxious observers might imagine. It’s a very grim and local misery, visited upon a small group of unfortunate West Africans, toward whom we should bow in sympathy and continue sending help. It’s not about our fears and dreads. It’s about them.

I felt then as I feel now: Ebola is not just an African problem, it’s a human problem.

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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:

  1. 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.
  2. 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.
  3. 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.
  4. 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!