EBOLA VIRUS DISEASE - WEST AFRICA (87): LIBERIA, SIERRA LEONE, MSF, DRUGS, VACCINE
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A ProMED-mail post
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ProMED-mail is a program of the
International Society for Infectious Diseases
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In this posting:
[1] Liberia
[2] Liberia, Sierra Leone
[3] Sierra Leone (Freetown)
[4] MSF report
[5] Drugs and vaccines: experimental
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[1] Liberia
Date: Fri 11 Jul 2014
Source: AllAfrica, The Inquirer (Monrovia) report [edited]
http://allafrica.com/stories/201407111565.html
Reports gathered in Monrovia say the Redemption Hospital located in New Kru Town [Monrovia] which caters to hundreds of people is practically abandoned by hospital employees for fear of contracting the deadly Ebola virus disease [EVD], which is alleged to have killed a nurse at the hospital recently. But the hospital's general administrator told this paper yesterday [10 Jul 2014] that the information being spread through the media that the hospital is closed is false, and that the health workers, doctors, and nurses are still committed to serving patients at all times.
Dr. Dominic Rennie, however, disclosed that more patients are refusing to go to the hospital and seek medical treatment because of the news about the EVD outbreak; admitting that last month [June 2014] one of the nurses fell prey to the deadly disease. Already, according to him, some people who blame the management of the hospital took away their patients and that only a few patients are seeking medical attention from the hospital, while the majority of the patients have refused to go for medical treatment.
Meanwhile, the president of the National Physician Assistant Association of Liberia, Jerry Kollie, said in a local radio program that members of the Association are prepared and willing to work, but that their fear too is the lack of protection. While it is true that people are not taking advantage of the medical centers to seek medical attention despite of the ongoing awareness, it is also noticed that health workers are refusing to attend to patients who are suspected of carrying the ebolavirus and our concern is drawn also to the wellbeing of the essential health workers.
We are all aware that EVD has no boundary like HIV and AIDS, and that EVD has no hands-on medication; therefore, in order to encounter and contain a patient who is down with such disease, the health workers must be sure that they too will not die saving lives. More people are said to have died from this disease already and many more people are being quarantined due to the 21-day observation period, even if the sickness is not Ebola but carries symptoms of EVD; this is troubling, and that is why the awareness must be broadened.
We urge those in authority to widen the awareness campaign through any and every means thought of because this disease is seriously affecting families and to date, statistics show that it is affecting mostly breadwinners of families, thus wiping out a generation of that family line because when a nurse or doctor who has gone to work dies from saving a life, that entire family's livelihood sits in limbo.
While stressing the need for greater awareness, we wish to commend all those including the government and people of the USA and the latest contribution from the Federal Republic of Nigeria for continuing to identify with this country in its fight against EVD. At the same time, we urge those receiving these donated items and funds to ensure proper accountability.
Again, we call on the government through the Ministry of Health and Social Welfare and its partners to amplify the awareness campaign and distribute protective equipment provided by international partners evenly as well as discover the best strategies that would strengthen the ongoing awareness campaign, thereby making it a reality to the Liberian custom.
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[2] Liberia, Sierra Leone
Date: Fri 11 Jul 2014
Source: International Business Times [edited]
http://www.ibtimes.co.uk/west-africa-eb ... ia-1456294
Hundreds of people are presently under surveillance in Liberia following the sudden outbreak of Ebola virus disease [EVD] in West Africa, increasing the monitoring costs in the country. In the last 2 days alone [10-11 Jul 2014], 4 fresh cases have been reported -- 2 each in Lofa and Montserrado, with no deaths being reported so far. "Before then, we were monitoring some 50 persons; but now under surveillance there are some 433 persons that need to be monitored, and monitoring these people costs a lot, while putting in place logistics in other counties that are not yet affected require a lot of funding," said Senator Peter Coleman, who is chairing the Senate's Committee on Health.
To deal with the latest outbreak, the lawmaker said Liberia's health ministry needs about USD 1.5 million from the government's budget. The Economic Community of West African States (ECOWAS) has also launched a solidarity fund to combat the spread.
The proposal has come alongside the World Health Organisation (WHO) report which points to a sharp rise in the number of cases affected by EVD reported in the western African countries of Guinea, Liberia and Sierra Leone. The outbreak is expected to worsen in the coming weeks, as the African countries are still working to find the exact extent of the spread of the virus while struggling to cope with managing the crisis.
In Sierra Leone, where there have been 337 confirmed cases, Anja Wolz, an emergency coordinator at the humanitarian aid organisation Medecins Sans Frontieres (MSF), said: "We're under massive time pressure: the longer it takes to find and follow up with people who have come in contact with sick people, the more difficult it will be to control the outbreak. We still have no idea how many villages are affected. I'm afraid we've only seen the tip of the iceberg."
[Byline: Vasudevan Sridharan]
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[3] Sierra Leone (Freetown)
Date: Sat 12 Jul 2014
Source: Bloomberg [edited]
http://www.bloomberg.com/news/2014-07-1 ... -rise.html
The worst outbreak of Ebola virus disease [EVD] moved to Sierra Leone's capital of Freetown, where an Egyptian was found with the city's 1st confirmed case of the disease.
The unidentified Egyptian national had traveled from Kenema, the largest city in the nation's Eastern Province, and checked into a clinic east of Freetown, Sidie Yahya Tunis, director of Information, Communication and Technology at the Ministry of Health and Sanitation, said by phone today [12 Jul 2014]. The person was moved back to the Ebola center in Kenema, he said. "EVD usually spreads to other places when suspected or confirmed cases in one community move to another, they abandon treatment centers to stay with relatives or they seek treatment outside the EVD centers," Tunis said.
There have been 99 EVD deaths in Sierra Leone out of 315 laboratory-confirmed cases, the ministry said in an e-mailed statement today. The ministry said yesterday [11 Jul 2014] that 92 people had died out of 305 cases. Cases of the hemorrhagic fever have killed more than 540 people in Guinea, Sierra Leone and Liberia in an outbreak that according to the World Health Organization may last another 3-4 months.
The toll is greater than the 280 people killed in 1976, when the virus was 1st identified near the Ebola River in what is now the Democratic Republic of Congo. The rapid spread of the virus is largely due to people moving across borders as well as cultural practices that are contrary to public health guidelines, such as people touching the body of a deceased relative before the funeral.
[Byline: Silas Gbandia]
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Communicated by:
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[4] MSF report
Date: Tue 8 Jul 2014
Source: Doctors Without Borders/Medicins San Frontieres (MSF) [edited]
http://www.doctorswithoutborders.org/ar ... est-africa
Struggling to Contain the Ebola Epidemic in West Africa
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MSF update, including current situation update, difficulties and necessary measures for control and the bat species (_Hypsignathus monstrosus_ and _Epomops franqueti_) thought to be the origin of the epidemic:
An Ebola virus disease [EVD] epidemic is currently plaguing Guinea, Liberia, and Sierra Leone on an unprecedented scale. Since March 2014, Doctors Without Borders/Medecins Sans Frontieres (MSF) has treated more than 250 confirmed cases of the deadly disease, for which there is no known cure [but with treatment, many survive].
MSF's Dr. Hilde de Clerck and MSF epidemiologist Dr. Michel Van Herp both have extensive experience in containing hemorrhagic fever outbreaks. They have helped respond to 6 Ebola outbreaks, notably in Democratic Republic of Congo, Uganda, and, most recently, Guinea. Here, they discuss the current outbreak and the challenges facing MSF teams as they fight to contain the spread of the disease.
Q. We are currently seeing a resurgence of the EVD epidemic in West Africa, in Guinea in particular. What is the current situation?
Hilde de Clerck: Just a few weeks ago, there were only 2 villages left in Guinea that MSF still had to monitor for "contact" people -- anyone who had been in contact with confirmed or suspected cases of EVD. As a result, we were quite hopeful that we were witnessing the end of the epidemic. But then, all at once, we received calls from 3 different sites in Guinea. Within 5 minutes, everything changed. It emerged that several cases had also appeared in villages in neighboring Sierra Leone that are very close to the Guinean border. For the people here, the border doesn't exist in the way that many might imagine a border would. Here, the border is porous, and people regularly cross back and forth. They have family on both sides and they frequently cross the border to travel to markets -- or to funerals.
In addition to the alert for those villages in Sierra Leone, there were also new alerts inside Guinea -- in Telimele, a mountainous region 200 km [about 125 miles] north of the capital, Conakry, and also in the capital itself.
All these new alerts together meant that in the Gueckedou region alone, one of the most affected areas in the south of Guinea, MSF went from monitoring only 2 villages to needing to monitor 40 villages and more than 500 "contact" people. When you carry out epidemiological analysis using records of the "contact" people you can see where cases are likely to appear. There are many villages affected. This has now become the largest epidemic we have ever faced, in terms of its duration and the numbers of cases.
Q. Why is the epidemic so difficult to control?
Michel Van Herp: Lack of knowledge amongst the population about EVD, the high mobility of people in this area of the world, and the wide geographic spread of cases all combine together to make it difficult to control this epidemic. It is the 1st time that Guinea, Sierra Leone, and Liberia have had to deal with the ebolavirus. People are afraid and find it difficult to believe that the disease even exists. Certain villagers close to Gueckedou in Guinea have even accused MSF of bringing the disease into their area. One villager asked us, "Our ancestors never spoke about this disease, so why would this have changed today?"
The communities here are not familiar with this disease, so we work with anthropologists as part of our outbreak response. These anthropologists work to help us better understand the populations here, and to facilitate our relationships with patients and communities. With a mortality rate as high as 90 percent [30-60 percent in this epidemic], when people hear of EVD, they immediately think of death. This generates intense levels of fear, and for some people here, EVD is perceived as something akin to magic. They believe that to say "Ebola" aloud is to make it appear, but the reverse also believed to be true -- denying that Ebola exists would mean that it won't be able to affect you. This fear and superstition is understandable if you think about how patients with cancer in western societies sometimes cope. For example, sometimes cancer patients refuse to accept their diagnosis in order to try to avoid the consequences of what that diagnosis means.
The high level of population mobility is another aggravating factor in the spread of the disease. People in these areas of West Africa are more mobile than those MSF has treated in previous Ebola outbreaks in Uganda or the Democratic Republic of the Congo. For instance, one patient we treated had traveled through 5 villages in a single week before coming to our treatment center. This means that he could have infected other people in each of those villages as he passed through.
Q. What impact could the lack of trust among the population have on the effectiveness of the resources deployed to slow down the spread of Ebola?
Hilde de Clerck: In Macenta, Guinea, one family lost 15 people to the ebolavirus. MSF was able to treat the head of the family and his wife, who both survived. As a result, we were confident that those 2 successfully treated parents would then have a lot of influence on the rest of the family about the critical need to seek treatment immediately if anyone experienced EVD-like symptoms. Yet, a few days later, a small boy from this same family fell ill. His aunt fled with him to another village and the child died a few days later. Often, convincing one member of the family is simply not enough. To control the chain of disease transmission it seems we have to earn the trust of nearly every individual in an affected family. This is a mammoth task, which is why greater involvement from the religious and political authorities in raising awareness about the disease is crucial.
Today, we face the hostility of the population in some areas. There are still 20 villages around Gueckedou that continue to deny access to medical teams, but we will continue dialogue with the local authorities to try to change this. Accurate information about the disease needs to be rapidly and widely spread across the affected countries. This is essential in order to combat the fear surrounding this disease, but also to increase awareness about several things: the need for people to come for treatment quickly; to not travel and put themselves in contact with other people if they suspect they might be infected; and the proper way to conduct the funerals of those who have died from the disease. Disseminating reliable information is only part of the battle to contain this outbreak. Patients and communities will also need to fully accept that information. Spreading knowledge and instilling trust among the population will be vital if we are to control the chain of virus transmission.
Q. Do we know the source of the epidemic?
Michel Van Herp: The epidemic seems to have originated in a village near Gueckedou in Guinea, from where the disease then spread out. It is a place where people do a significant amount of bat hunting. Just as many other families living in that area, the 1st family in the village to be infected with the disease admitted to having hunted 2 species of bat. These were _Hypsignathus monstrosus_ and _Epomops franqueti_, which both carry the ebolavirus. Bat colonies migrate across vast distances and we think that they 1st pass the virus amongst themselves, thereby passing it from the east to the west of Africa. The ebolavirus is then introduced into the population if they come into contact with infected animals.
The increase in virus transmission in Sierra Leone also seems to have had a connection to the social status of the source of infection -- to the social status of an "origin" case. In Sierra Leone the fact that a healer in the community was infected meant that the disease spread quickly. For funerals, deceased people are usually washed and then clothed, as is also customary in western societies. However, even after death, the Ebola virus remains present in the body of the deceased and any contact with that body can result in an infection. Given the importance of this healer in the social structure, several people were infected while attending the funeral.
This is in stark contrast to what happens if a child falls ill -- the sick child will normally only infect a few people. However, a mobile adult, with a big community role, will have contact with far more people, thus spreading the disease further. Thus, the social status or social role of an infected person in traditional society is another critical factor in virus transmission.
Q. What are the main challenges that still need to be addressed?
Hilde de Clerck: With the significant increase in new infection sites, MSF must now spread its teams across many more areas. MSF has experienced staff, but not an infinite supply -- there are a limited number, as we are also working in other emergencies around the world. MSF teams are working in many locations to help contain this outbreak, including: monitoring contacts, epidemiological surveys, health promotion, patient and community counseling, quarantine, medical care provision, running ambulances, disinfection of houses and burials. Other stakeholders help carry out parts of these tasks, but these teams are also small and do not always have the necessary experience.
There is now an urgent need for all actors to increase the number of human resources that can be made available to deal with this emergency -- especially experienced people. It's more about experience than medical sophistication in trying to contain this outbreak. While the work our teams are doing to help contain Ebola is not very sophisticated in medical terms, there are, however, very strict procedures that absolutely must be followed to avoid putting people in danger of infection. Ideally, to increase human resources on the ground, 2-person teams would be trained with one experienced person for a week or 2, or longer if possible.
Q. What difficulties do the MSF teams face in treating an emergency like this?
Hilde de Clerck: Apart from the enormous workload, it is extremely challenging both physically and emotionally for our staff. Outreach teams often travel long distances to reach affected communities. Many also know the affected families themselves and are witnesses to heartbreaking moments when people must be taken from their family or community into the treatment center. Teams working in the treatment centers must all wear full-body plastic protective gear, which is intensely uncomfortable and difficult to bear in such high temperatures. As there are many patients, we must be careful to avoid hyperthermia and dehydration.
Emotionally, this work is quite extreme. Many patients die, including children. Palliative care for this disease is tough, as patients are terrified. We comfort patients whenever possible. We are the last people to touch them, and many of them ask us to hold their hands. These moments are both difficult and emotionally intense. Even if it is an emergency, we try to be as humane and as gentle as we possibly can.
Q. Does an unprecedented epidemic call for unprecedented measures?
Michel Van Herp: The increase in the number of sites has stretched MSF to the limits of our available human resources. We now have 300 staff working to try to contain the outbreak. We need to keep our medical teams focused on medical care and the quarantining work, as MSF is one of the only stakeholders with the technical expertise to do so, especially in terms of quarantining patients. For this to be possible we absolutely need others to take over some of the other tasks we are also carrying out, so we can really prioritize the medical aspects. Thus, we need other actors that specialize in awareness raising and community "contact" monitoring to really increase their activities. A major challenge is monitoring cross-border contacts and coordinating the medical response.
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Communicated by:
ProMED-mail Rapporteur Mary Marshall
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[5] Drugs and vaccines: experimental
Date: Wed 9 Jul 2014
Source: City News, The Canadian Press report [edited]
http://www.citynews.ca/2014/07/09/ebola ... s-experts/
The largest Ebola virus disease outbreak in history is defying the containment efforts of affected countries and international response teams, leading to calls from some quarters to use experimental drugs or vaccines to try to stop the deadly virus. But a number of experts -- including the scientist who led the work on a Canadian-made ebolavirus vaccine -- say deploying untested tools in the current West African outbreak could be disastrous.
They say taking such a risky gamble could further erode local trust in the response teams, undermine their efforts and even endanger them. And if anyone were to have a bad reaction to one of the experimental therapies, it could jeopardize years of expensive and painstaking work spent developing tools with which to fight ebolaviruses and their cousin, the Marburg virus.
"I get emails basically every 2nd day from someone either asking, 'Is there something that you're planning?' or 'Shouldn't you?' And I know I'm not the only one getting those emails," says Dr. Heinz Feldmann, an ebolavirus expert who heads the laboratory of virology at the US National Institute of Allergy and Infectious Diseases' Rocky Mountain Laboratories in Hamilton, Montana, USA.
While most of these discussions are happening within scientific circles, the director of Britain's Wellcome Trust recently aired the issue publicly. Dr. Jeremy Farrar, an infectious diseases expert, has questioned why the therapies that are furthest along in the developmental pipeline aren't being used. He suggests if this outbreak were occurring in the developed world, there would be no debate. "Imagine if you take a region of Canada, America, Europe and you had 450 people dying of a viral hemorrhagic fever. It would just be unacceptable -- and it's unacceptable in West Africa," Farrar says. He notes the Canadian-made ebolavirus vaccine -- a project Feldmann led a decade ago when he worked at the National Microbiology Laboratory in Winnipeg (Canada) -- was released under emergency use provisions in 2009 when a German researcher pricked herself with a needle containing ebolavirus. She survived, but it was never clear if it was because of the vaccine or because she was not infected. "We moved heaven and earth to help a German lab technician. Why is it different because this is West Africa?" Farrar asks.
A small community of researchers, mostly based in Canada and the USA, has been working for years on vaccines and drugs to protect against or treat these viruses, which are among the deadliest known to humankind. The viruses are transmitted through contact with bodily fluids. People caring for the dying -- or preparing their bodies for burial -- are often infected. With little to offer medically, the main job of response teams is to break the chains of transmission by figuring out who is infected and isolating them. But these efforts are often met with distrust. Rumours emerge that the Western doctors are harvesting organs; people hide cases or flee -- extending the range of the epidemic. The World Health Organization says the current outbreak -- the 1st in West Africa -- has seen 844 cases in 3 countries, and 518 deaths.
[As of 8 Jul 2014, WHO reports the cumulative number of cases attributed to EVD in the 3 countries stands at 888, including 539 deaths -- see ProMED-mail post (86) below. - Mod.JW]
That's already virtually double the size of the next largest outbreak, in Uganda in 2000. And this outbreak isn't anywhere near over.
A number of vaccines are in various stages of development. Studies done in non-human primates suggest they could both prevent illness and improve survival chances [even] if given after infection. There are also a number of therapies in the works, including antibody combinations that look promising in animal testing. But the researchers have always been stymied by the challenges of getting regulatory approval for these interventions, which cannot follow the traditional pathways to licensure. Most drugs or vaccines can only make it to market once large scale studies show they are both safe and effective. But the only way the world will learn if Ebola and Marburg vaccines and drugs work is by using them in an outbreak -- a reality rife with ethical concerns and logistical problems.
In the current context, with response teams struggling to gain the co-operation of fearful locals, [any] word that experimental treatments were to be used could further exacerbate an already taxing situation, says Dr. Armand Sprecher, of Medecins Sans Frontiers (MSF/Doctors Without Borders). The organization warned recently that the outbreak was out of control and said it was stretched to its limits. "I would hate to cause more problems than we solve in the short run," Sprecher says. "Right now people are at their wits end just to deliver the care that we're able to provide."
Dr. David Heymann, a professor of infectious diseases at the London School of Hygiene and Tropical Medicine [also head of the Centre on Global Health Security at Chatham House, London; and chairman of Public Health England, UK], says after this outbreak is contained, the WHO, Ebola researchers, the countries they work in and the countries which are prone to these epidemics need to sit down and plan how they will deploy and test these therapies the next time. They need to have the study protocols ready to be signed.
"It would be unethical to roll it out now, in my opinion," says Heymann, a former assistant director general at the WHO and a member of the team that responded to the 1st Ebola virus disease outbreak in 1976. Feldmann agrees with Heymann's idea. Over the years he has been frustrated by the inability to get these needed tools approved. But he says he has been persuaded by friends working on the current response that using untested and unlicenced medical interventions now would be a mistake.
One was blunt about how badly awry such an effort could go. "He said, 'Anything injectable would be a disaster.' He thinks the rumour that we're just spreading the disease is going to be out there before we even start," Feldmann says. "I think as bad as it sounds -- and I really don't feel good about saying this -- I have the feeling they have to find a way to end this one without (experimental) therapy."
[Byline: Helen Branswell]
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[There is an ongoing debate about whether to use incompletely tested drugs or vaccines on the EVD affected population. The last post [5] above covers both sides of the question, concluding that because of the level of distrust of foreign intervention among the population, the attempt could be disastrous.
A photo of _Hypsignathus monstrosus_ is at
http://media-cache-ak0.pinimg.com/236x/ ... 0e2c77.jpg, and of _Epomops franqueti_ at
http://lascalaphe.free.fr/IMG/jpg/P1360527.jpg.
ProMED-mail Rapporteur Mary Marshall comments: "When I accessed this report [3] above at 15:30 PDT [on 12 Jul 2014], there were 28 comments, few if any helpful, most of them disgusting. Very sad if this is representative of the (mainly US?) readership." - Mod.JW
A HealthMap/ProMED-mail map can be accessed at:
http://healthmap.org/promed/p/54.]
