AfricaFocus Bulletin
January 21, 2015 (150121)
(Reposted from sources cited below)

Editor’s Note

Media coverage of the Ebola epidemic, which took a sharp downward
turn after a handful of patients in the United States recovered, has
faded even further into the background as the battle against the
epidemic has begun to succeed in the most-affected countries. But
those on the front lines warn that complacency could easily allow
the still-present virus to hold out and even expand. And although
there are clear lessons to be learned, there are also unanswered
questions, most notably about international will to implement the
imperative of sustainable health systems for the future.

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A 14-part report from the World Health Organization provides a rich
analysis of lessons learned and of measures needed for ending the
epidemic this year. But it also leaves many questions unanswered,
and some unasked. In particular, it does not address the fundamental
question of the failure of international agencies as well as
national governments to invest in sustainable health systems, a
factor that everyone agrees was a fundamental cause of vulnerability
(see “Sierra Leone: Losing Out” at
http://www.africafocus.org/docs15/sl1501.php).
And, while the UN and the United States have joined in calls for the
IMF to cancel debts of the most-affected countries, to assist in
their recovery, this proposal has not yet been acted on.

Among many valuable lessons covered in the WHO report is the
essential role of community involvement in changing behaviors to
block transmission channels for the virus (such as safe as well as
culturally appropriate burial practices). Another is the success of
several West African countries (Nigeria, Senegal, and Mali) in
implementing rapid response to the threat, with isolation,
treatment, and case tracking.

This AfricaFocus Bulletin contains excerpts from the last chapter of
the report, focused on what needs to be done in 2015. The full
report (http://www.who.int/csr/disease/ebola/en/) is essential
reading for anyone seeking a deeper analysis than in the sparse
ongoing news coverage. It includes chapters analyzing the evolution
of the epidemic in Liberia, Sierra Leone, and Guinea, as well as the
contrasting case of successful containment in the Democratic
Republic of the Congo.

Among the key questions posed but left unanswered by the WHO report
is the sharp differential in survival rates with treatment in
developed countries versus treatment in the most-affected countries.
As the report notes, this is a practical as well as an ethical
question, since people will not go to treatment centers unless they
have some hope of survival.

The ethics of this is clear, as stressed by Paul Farmer in a recent
op-ed in the Washington Post. Everyone deserves the same standard
care known to be effective in developed countries. Evidence from
several treatment centers in the affected countries shows this must
include intravenous as well as oral rehydration, as well as other
elements of “supportive care.” The unanswered question is whether
the implicit double standard will be abandoned, and adequate
resources allocated by the international community to implement
standard care both in the response in 2015 and in future epidemics.

Paul Farmer, “The secret to curing West Africa from Ebola is no
secret at all,” Washington Post, Jan 16, 2015
http://tinyurl.com/m4j6tk2
Survival rates from Ebola are high when people receive supportive
care that has been standard for cases of Ebola in rich countries and
foreign medical workers airlifted out. “What we need — what we’ve
always needed — to improve survival in West Africa is the capacity
to safely deliver excellent supportive care.”

Peter Piot in BBC article, Jan 21 “My concern is that when [the
Ebola outbreak] is over we will just forget about it. We need to be
better prepared and we need to invest in vaccines and treatment.
It’s like a fire brigade – you don’t start to set up a fire brigade
when some house is on fire.”
http://www.bbc.com/news/business-30907630

For a set of general talking points and previous AfricaFocus
Bulletins on health issues, visit
http://www.africafocus.org/intro-health.php

++++++++++++++++++++++end editor’s note+++++++++++++++++

Ebola response: What needs to happen in 2015

[Excerpts: full text available at
http://www.who.int/csr/disease/ebola/en/]

…

The four biggest lessons from 2014

First, countries with weak health systems and few basic public
health infrastructures in place cannot withstand sudden shocks,
whether these come from a changing climate or a runaway virus. Under
the weight of Ebola, health systems in Guinea, Liberia and Sierra
Leone collapsed. People stopped receiving — or stopped seeking —
health care for other diseases, like malaria, that cause more deaths
yearly than Ebola.

In turn, the severity of the disease, compounded by fear within and
beyond the affected countries, caused schools, markets, businesses,
airline and shipping routes, and borders to close. Tourism shut
down, further deepening the blow to struggling economies. What began
as a health crisis snowballed into a humanitarian, social, economic
and security crisis. In a world of radically increased
interdependence, the consequences were felt globally.

The evolution of the crisis underscored a point often made by WHO:
fair and inclusive health systems are a bedrock of social stability,
resilience and economic health. Failure to invest in these
fundamental infrastructures leaves countries with no backbone to
stand up under the weight of the shocks that this century is
delivering with unprecedented frequency.

Second, preparedness, including a high level of vigilance for
imported cases and a readiness to treat the first confirmed case as
a national emergency, made a night-and-day difference. Countries
like Nigeria, Senegal and Mali that had good surveillance and
laboratory support in place and took swift action were able to
defeat the virus before it gained a foothold.

Third, no single control intervention is, all by itself,
sufficiently powerful to bring an Ebola epidemic of this size and
complexity under control. All control measures must work together
seamlessly and in unison. If one measure is weak, others will
suffer.

Aggressive contact tracing will not stop transmission if contacts
are left in the community for several days while test results are
awaited. Good treatment may encourage more patients to seek medical
care, but will not stop community-wide transmission in the absence
of rapid case detection and safe burials. In turn, the powers of
rapid case detection and rapid diagnostic confirmation are
diminished in the absence of facilities for prompt isolation. As
long as transmission occurs in the community, medical staff
following strict protocols for infection prevention and control in
clinics will be only partially protected.

Finally, community engagement is the one factor that underlies the
success of all other control measures. It is the linchpin for
successful control. Contact tracing, early reporting of symptoms,
adherence to recommended protective measures, and safe burials are
critically dependent on a cooperative community. Having sufficient
facilities and staff in place is not enough. In several areas,
communities continued to hide patients in homes and bury bodies
secretly even when sufficient treatment beds and burial teams were
available. Experience also showed that quarantines will be violated
or dissolve into violence if affected communities are given no
incentives to comply.

An epidemic with two causes

The persistence of infections throughout 2014 had two causes. The
first was a lethal, tenacious and unforgiving virus. The second was
the fear and misunderstanding that fuelled high-risk behaviours. As
long as these high-risk beliefs and behaviours continue, the virus
will have an endless source of opportunities to exploit, blunting
the power of control measures and deepening its grip. Like the
populations in the three countries, the virus will remain constantly
on the move.

Getting to zero means fencing the virus into a shrinking number of
places where all transmission chains are known and aggressively
attacked until they break. It also means working within the existing
context of cultural beliefs and practices and not against them. As
culture always wins, it needs to be embraced, not aggravated, as WHO
aimed to do with its protocol on safe and dignified burials.

A more strategic emergency response

As the new year began, a revised response that builds on accumulated
experiences was mapped out by WHO. This new response plan adopts
what has been shown to work but also sets out new strategies
designed to seize all opportunities for getting the number of cases
down to zero.

Community resistance must be tackled by all outbreak responders with
the greatest urgency. Concrete guidance on ways of doing this is
likely to emerge from an analysis of Sierra Leone’s Western Area
Surge, which included several strategies for engaging communities
and responding to their concerns. As was learned during 2014,
community leaders, including religious leaders as well as tribal
chiefs, can play an especially persuasive role in reducing high-risk
behaviours.

Apart from low levels of community understanding and cooperation,
contact tracing is considered the weakest of all control measures.
Its poor performance likewise needs to be addressed with the
greatest urgency. For example, in Guinea, which has the most
reliable data, only around 30% of newly identified cases appear on
contact lists. In all three countries, the number of registered
contacts for confirmed cases is too low. In Sierra Leone, some lists
of contacts include family members only, and no one from the wider
community.

As the year evolved, outbreak responders learned the importance of
tailoring response strategies to match distinct needs at district
and sub-district levels. An understanding of transmission dynamics
at the local level usually reveals which control measures are
working effectively and which ones need improvement. Doing so
requires better district-level data and, above all, better
coordination. The outbreaks will not be contained by a host of
vertical programmes operating independently. Again, all control
measures must work seamlessly and in unison.

At year end, as cases flared up in new areas or moved from urban to
rural settings, a clear need emerged for rapid response teams and
for agile and flexible strategies that can change direction — and
location — quickly. In WHO’s assessment, all three countries now
have sufficient numbers of treatment beds and burial teams, but
these are not always located where they are most needed. As was also
learned during 2014, transporting patients over long distances for
treatment does not work, either for families and communities or in
terms of its impact on transmission.

As long as logistical problems persist, community confidence in the
response will remain low. People cannot be expected to do as they
are told if the effort leaves them visibly worse off — quarantined
without food, sleeping in the same room with a corpse for days —
instead of better off. These problems are compounded by poor road
systems and weak telecommunications in all three countries. In
Liberia, for example, health officials in rural areas are lucky if
they have an hour or two of internet connectivity per week. This
weakness defeats rapid communication of suspected cases, test
results and calls for help, thus ensuring that response efforts
continue to run behind a virus that seizes every opportunity to
infect more people.

A decentralized strategy — and an ethical imperative

As the response decentralizes to the subnational level, fully
functional emergency operations centres, with local government
health teams integrated and playing a leadership role, must be
established in each county, district and prefecture in the three
countries. These centres will drive the step-change in field
epidemiology capacity needed to achieve high-quality surveillance,
rapid and complete case-finding, and comprehensive contact tracing
— the fundamental requirements for getting to zero.

A decentralized response also demands urgent attention to well-known
gaps and failures in collecting, collating, managing and rapidly
sharing information on cases, laboratory results and contacts.
Understanding and tackling the drivers of transmission in each area
call for enhanced case investigation and analytical epidemiology.
Tools for collecting and sharing this information need to be
standardized and put into routine use by governments and their
partners.

Another major problem is the unacceptably large difference in case
fatality rates between people who receive care in affected countries
(71%) and foreign medical staff (26%) who were evacuated for
specialized treatment in well-resourced countries. Getting case
fatality down in affected countries is an ethical imperative.

Innovation needs to be encouraged, publicized, tested and funnelled
into control strategies whenever appropriate. Mali used medical
students with training in epidemiology to rapidly increase the
number of contact tracers. Guinea drew on its corps of young and
talented doctors to strengthen its outbreak response, with training
provided by WHO epidemiologists. These staff know the country and
its culture best. They will still be there long after foreign
medical teams leave.

In Sierra Leone, the government-run Hastings Ebola Treatment Centre,
a 123-bed facility entirely operated by local staff, has defied
statistics elsewhere in the country with its survival rates. Six out
of every 10 patients treated there make a full recovery. As noted by
an infection control specialist working on the wards, the only
patients that cannot be saved are those who wait too long to seek
care. After noting that Ebola virus disease has some similarities
with cholera, staff at the facility made intravenous administration
of replacement fluids a mainstay of the routine treatment protocol.

The pattern of transmission seen throughout 2014 makes a final
conclusion obvious: cross-border coordination is essential. Given
West Africa’s exceptionally mobile populations, no country can get
cases down to zero as long as transmission is ongoing in its
neighbours.

Prevent outbreaks in unaffected countries

With the increasing number of cases and infected prefectures in
Guinea, the risk of new importations to neighbouring countries is
also growing. In terms of preparedness, the most urgent need is for
active surveillance in the areas bordering Mali, Senegal, Guinea-
Bissau and Cote d’Ivoire, through the deployment of additional human
and material resources, and the introduction of standard performance
monitoring and reporting on a weekly basis.

Improvements in contact tracing and monitoring in the second phase
of the response provide an opportunity to substantially enhance the
efficacy of exit screening. Doing so further reduces the risk of new
Ebola exportations from affected areas. As contact tracing improves,
lists of active contacts could be systematically shared with border
and airport authorities to link this information with exit
screening.

Get health systems functioning again — on a more resilient footing

Much debate has focused on the importance of strengthening health
systems, which were weak before the outbreaks started and then
collapsed under their weight. In large parts of all three countries,
health services have disintegrated to the point that essential care
is either unavailable or not sought because of fear of Ebola
contagion.

As some have argued, cases will decrease fastest when a well-
functioning health system is in place. That argument also points to
the need to restore public confidence — which was never high — in
the public health system. Targeted drug-delivery campaigns that
aimed to treat and prevent malaria were well-received by the public
and are a step in the right direction, but much more needs to be
done.

Although virtually no good systems for civil registration and vital
statistics are still functioning in the three countries, indirect
evidence suggests that childhood deaths from malaria have eclipsed
Ebola deaths. Liberia, for example, had around 3500 malaria cases
each month prior to the outbreak, with around half of these cases,
mainly young children, dying. An immediate strengthening of health
systems could reduce these and many other deaths, while also
restoring confidence that health facilities can protect health and
heal disease.

Others argue that efforts must stay sharply focused on outbreak
containment. As this argument goes, response capacity is limited and
must not be distracted. This argument favours a step-wise approach
that initially concentrates on strengthening those health system
capacities, like surveillance and laboratory services, that can have
a direct impact on outbreak containment.

For its part, WHO sees a need to change past thinking about the way
health systems are structured. As the Ebola epidemic has shown,
capacities to detect emerging and epidemic-prone diseases early and
mount an adequate response need to be an integral part of a well-
functioning health system. Outbreak-related capacities should not be
regarded as a luxury or added as an afterthought. Otherwise, the
security of all health services is placed in jeopardy.

Step up research

Research aimed at introducing new medical products needs to continue
at its current accelerated pace. Executives in the R&D-based
pharmaceutical industry have expressed their view that all candidate
vaccines must be pursued “until they fail”. They have further agreed
that the world must never again be taken by surprise, left to
confront a lethal disease with no modern control tools in hand.

New tools will likely be needed to get to zero. For example,
vaccines to protect health care workers may make it easier to
increase the numbers of foreign and national medical staff. Better
therapies — and improved prospects of survival — may encourage
more patients to promptly seek medical care, greatly increasing
their prospects of survival.

…

Mine every success story

Operational research is needed to understand why some areas have
stopped or dramatically reduced transmission while others, including
some in the same vicinity and with similar population profiles,
remain hotspots of intense transmission.

Did the striking and robust declines in Lofa County, Liberia, and
Kailahun and Kenema districts in Sierra Leone occur because
devastated populations learned first-hand which behaviours carried a
high risk and changed them? Or can the declines be attributed to
simultaneous and seamless implementation of the full package of
control measures, as happened in Lofa country? Answers to these
questions will help refine control strategies.

Research is also needed to determine how areas that have achieved
zero transmission can be protected from re-reinfection. Some success
stories look real and robust, but these are only pockets of low or
zero transmission in a broad cloak of contamination.

At every opportunity, strategies devised for the emergency response
should be made to work to build basic health capacities as well.
Some success stories can serve as models.

Liberia demonstrated how quickly the quality of data and reporting
can improve, thus strongly supporting the strategic targeting of
control measures at district and sub-district levels.

Sierra Leone showed how laboratory services can be strengthened and
expanded, reducing waiting times for test results close to what is
seen in countries with advanced health systems while also supporting
the better clinical management of cases.

Each and every survivor is also a success story. In an effort to
fight the stigma that so often haunts these people, many treatment
centres hold celebratory ceremonies when survivors are released from
treatment. Each is given a certificate as proof that they pose no
risk to families or communities.

Get the incentives — and support — right

Both foreign and domestic medical staff have worked in the shadows
of death, placing their lives at risk to save the lives of others.
In many places, these staff also risked losing their standing in
communities, given the fear and stigma attached to anything or
anyone associated with Ebola.

These people deserve to be honoured and respected. They also deserve
to be paid on time and given safe places to work. Timely and
appropriate payment to national staff remains problematic. More
studies are currently under way to identify the circumstances under
which health care workers continue to get infected.

Special efforts are also needed to improve safety at private health
facilities, in pharmacies, and among traditional healers, as
evidence suggests the risk of transmission is highest in these
settings. The number of hospitals that remain closed or virtually
empty supports the conclusion that doctors and nurses are most
likely getting infected while treating patients in community
settings.

Incentives also need to be in place to ensure that foreign medical
teams stay in countries long enough to understand conditions,
including political and social as well as operational issues, and
pass on this knowledge to replacement staff. Towards the end of the
year, WHO ensured that its field coordinators stayed in countries
for several months.

The “post-Ebola syndrome”

Given the fear and stigma associated with Ebola, people who survive
the disease, especially women and orphaned children, need
psychosocial support and counselling services as well as material
support. They may need medical support as well. A number of symptoms
have been documented in what is increasingly recognized as a “post-
Ebola syndrome”.

Efforts are now under way to understand why these symptoms persist,
how they can best be managed, whether they are caused by the
disease, and whether they might be linked to treatment or the heavy
use of disinfectants. WHO staff have developed an assessment tool
that is being used to investigate these issues further.

Maintain unwavering commitment at national and international levels

Media coverage of the Ebola crisis peaked in August, when two
American missionaries and a British nurse became infected in West
Africa and were medically evacuated for treatment in their home
countries. Coverage increased dramatically in October, when the USA
and Spain confirmed their first locally transmitted cases.

…

Although the situation in Liberia at year end, especially in
Monrovia, looked promising, optimism must remain cautious. As
experiences in Guinea made clear, this is a virus that can go into
hiding for some weeks, only to return again with a vengeance. In
Liberia, as caseloads declined, evidence of complacency and “Ebola
fatigue” rapidly appeared in some populations even though
transmission continued.

The three countries will continue to need international support for
some time to come, whether in the form of direct support for
response measures or assistance in rebuilding their health services.
Countries and the international community must brace themselves for
the long-haul.

One overarching question hangs in the air. The virus has
demonstrated its tenacity time and time again. Will national and
international control efforts show an equally tenacious staying
power?

*****************************************************

AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues, with a
particular focus on U.S. and international policies. AfricaFocus
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