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Friday, October 24

Ebola and the Silent Epidemic of Contaminated Hypodermic Needles

Black Bag Doctors

How common is it in Africa for medical caregivers to reuse hypodermics that haven't been properly sterilized or sterilized not at all?  So common, researchers on the team that tracked down the first known person to have contracted the disease in the West African Ebola outbreak, a two-year old in Guinea, named a contaminated needle as one of their two guesses about how the toddler got infected with Ebola.(1)

The other guess revolved around the Bushmeat - Fruit Bat hypothesis of Ebola transmission among humans but the researchers had a problem with applying the hypothesis in this case. The most likely animal to human transmissions happen with hunters of the bats or people who handle the raw meat for cooking -- unlikely for a two-year old.      

The lead author of the study observed that if a contaminated jab was the culprit then obviously the Index Patient, as medical researchers term the first known person to contract a disease, wasn't the real Index Patient. The toddler is simply as far back as the team was able to trace the outbreak, the author explained to the New York Times.

Assuming for the sake of discussion the contaminated needle scenario, where would the toddler have been most likely to receive an injection?  Yes, a hospital or medical clinic. Or a Black Bag Doctor making rounds in the toddler's village.

Now what is a Black Bag Doctor?  I have the BBC's Man in West Africa, reporter Jonathan Paye-Layleh, to thank for turning up this Joker card in the deck:

It is a cruel twist that Liberia and Sierra Leone have been worst affected by the deadliest ever Ebola outbreak, as the two countries were still recovering from brutal civil wars that decimated their [public health] infrastructure in the 1990s when the disease hit.

The virus spread from Guinea, which borders both nations. It has been far more effective in containing the outbreak because it has more resources and a "more resilient" health system, [Sierra Leonean risk analyst Omaru Sisay] says.

"'Black bag doctors"

Similarly, Nigeria, one of Africa's wealthiest states, has contained the virus after it was brought to the country by a Liberian government worker travelling on a commercial airline.

Against this backdrop, many Liberians rely on what are locally known as "black bag doctors" who go from village to village to treat people, often with fake or outdated drugs, our correspondent says.

When people do not have money to pay the "black bag doctors", he adds, they give them some of their best livestock -- chickens or goats.

In Sierra Leone, state-employed health workers do private home visits, Mr Sisay says.

"They work on the side and treat patients at home. A maternity nurse may treat somebody who has high blood pressure; a dispenser somebody who has a respiratory illness."
Even with a fairly good health care system in the country I would think BBDs and moonlighting hospital workers also ply their trade in Guinea, at least in the more remote regions, which include the village where the toddler lived. Guinea's government, as part of its battle this year against the Ebola outbreak, might have put a lid on the use of contaminated needles at the institutional level -- state-run hospitals and medical clinics. But even if Guinea's government stopped the practice in state-run health care facilities that would have been this year; it says nothing about 2013 when the Ebola outbreak first occurred.

As to the likelihood the BBDs in Liberia and Sierra Leone use disposable jabs, based on my reading of a landmark three-part series in the San Francisco Chronicle (DEADLY NEEDLES: Fast Track to Global Disaster, published October 1998), for many years virtually all hypodermics in widespread use in Africa have been disposables. It's just that the disposables are reused until they wear out. 

As to sterilization of the disposables, again from my reading of the Chronicle piece I'd assume the most the BBDs do is rinse needles with distilled water then wipe them with alcohol. This wouldn't sterilize the hypodermic syringe and chamber.

Despite all the rhetoric going back many years (see the Chronicle report)
from African governments and global health organizations, nothing has changed substantially since 1976, when Belgian nuns in Zaire unwittingly infected several pregnant African women with Ebola virus through the use of contaminated hypodermics. 

As to the needle situation today in Zaire (now DR Congo), which saw an Ebola outbreak this year unrelated to the one in West Africa: the Citizendium encyclopedia article about Ebola mentions that in developing nations such as the Democratic Republic of the Congo, "patients may be requested to bring in their own needles, or else share." And often there isn't even water in the clinics for the doctors to wash their hands.   

Ebola Virus Transmission and Contaminated Needles

Regarding a direct link between post-1976 Ebola outbreaks and contaminated needles, the Illinois Department of Health website matter-of-factly states in its article about Ebola:

Outbreaks of this disease have appeared sporadically, in Central and Western Africa, since the first occurrence in 1976. During each of these outbreaks, a majority of cases occurred in hospital settings under the challenging conditions of the developing world.

These conditions, including a lack of adequate medical supplies and the frequent reusing of needles and syringes, played a major role in the spread of the disease. Outbreaks were more easily controlled when appropriate medical supplies and equipment were available and quarantine procedures were used.
[...]
In outbreaks of Ebola, person-to-person transmission frequently occurs among health care workers or family members who care for an ill person. The virus also has been spread through the reuse of hypodermic needles in the treatment of patients.

Reusing needles may be a common practice in developing countries, where the health care system is underfinanced. U.S. medical facilities do not reuse needles.
It's not only finances; government corruption and criminals are also in play. More factors are laid out in the Chronicle report. But whatever the reasons there's no "may be" about it; the practice is common in Africa, despite very grave dangers attached to reusing unsterilized hypodermic and IV needles. The dangers were well established by medical science at least as early as the 1950s.

(The dangers extend to contaminated blood transfusions and emergency blood supplies.)

The Chronicle report disabused me of the notion that the problem should have a simple solution. Why not, I wondered, simply boil the contraptions? Ebola can't survive more than five minutes in boiling water. Yes, the glass hypodermics can be boiled but the syringes in the disposable hypodermics bend in the sustained high heat.

And many doctors faced with long lines of people to inoculate and with only a few hypodermics on hand cut corners on the boiling time for the glass hypodermics -- one reason the disposables became widely distributed in the developing nations.   

On The Road to Hell With Good Intentions

Then why not invent hypodermics that are impossible to reuse?  It's been done. But to read the Chronicle report is to be plunged into a tangled tale of inventors, hypodermic syringe manufacturers, global health organizations, and governments -- a tale the authors, Reynolds Holding, William Carlsen, relentlessly unravel. They begin this way: 

CONFERENCE ROOM A
WORLD HEALTH ORGANIZATION, GENEVA

Dr.Ciro de Quadros, chief of the campaign that eradicated polio from the Western Hemisphere, could not believe the numbers. When the esteemed Brazilian and other world health leaders arrived in Switzerland last spring [1997], they expected to discuss the progress of the global vaccination program -- the most successful public health campaign in history.

Instead, they got a medical time bomb.

In de Quadros' hand was a chilling internal report: 10 million people a year were contracting lethal diseases such as hepatitis and AIDS through the reuse of contaminated syringes.

De Quadros rose to his feet and implored his colleagues to keep the findings confidential -- at least until the numbers could be reviewed once more.

"These figures are so incredible," he said, "that if they are released, they will make the front pages of newspapers around the world."

But an earlier internal WHO study had revealed an even more alarming figure: Every year as many as 1.8 million people infected by contaminated syringes, mostly children, would die -- about one every 20 seconds.

Medical researchers had warned for decades that hypodermic needles could be deadly. But the WHO reports made it painfully clear that world health officials had an international medical crisis on their hands -- and urgent action was needed.

"We want to avoid creating a panic," said WHO's Michael Zaffran, who helped prepare the still-unreleased infection numbers. "But maybe there is a need to create that panic to solve this problem."

This is a story, based on hundreds of interviews and thousands of documents, about a vast, virtually invisible epidemic, a crisis that could have been defused more than a decade ago.

It is about soaring disease rates in Egypt and plunging life expectancies in Brazil; children combing garbage dumps for syringes to sell in Kenya and India; and ignorance, poverty and corruption driving medical workers in Cambodia and Russia to reuse needles dozens -- sometimes hundreds -- of times.

It is about a promising generation of nonreusable syringes that got lost in a multibillion-dollar corporate battle over the global syringe market.

It is about how the world's leading syringe manufacturers first ignored the problem, then either delayed the new technology or did little to get it into the hands of health workers.

And it is about how top world health officials -- including several with de Quadros in Conference Room A -- downplayed the mounting death toll for years, fearing that publicizing it would jeopardize their immunization programs.

The story began more than half a century ago with the emergence of the hypodermic syringe: an instrument of almost mystical lifesaving power, yet one that can spread disease with deadly efficiency.
That's not talking about the use of unsterilized hypodermics during the Western colonial era on the African continent and everywhere else the colonizers set up shop. Cold comfort for the Africans would be that in the days before the dangers of unsterilized needles were understood, the colonialists also stuck contaminated jabs into themselves and their own people.

None of this speaks to the fact that hypodermics weren't only used to inject vaccines.  By the early part of the last century doctors and public health administrators had gone needle happy, as had militaries and factory and plantation owners -- and Christian missionaries.  Those Belgian nuns in Zaire infected pregnant women with Ebola when they injected them with a vitamin preparation.

And at the top of the list, antibiotics were injected throughout the world in staggering amounts. And all that with contaminated hypodermics, which very efficiently and rapidly spread deadly diseases.  

Not to get into the weeds but here I suppose I should mention the jolly hypothesis that unsterile injections didn't simply transmit the virus called HIV; they created it.        

No, unfortunately this isn't a tinfoil hat theory. For details see the "Unsterile Injections" section of Wikipedia's article on the history of HIV-AIDS.

Moreover, the biological mechanisms the researchers identified, by which billions of unsterile injections helped a garden-variety virus transform into a monster, wouldn't be limited to HIV if the hypothesis, first fielded by researchers in 2001, continues to hold up.     
 
I'm tempted to close at this point with "Have a nice day" then finalize my plans to rent a cave in the Himalayas.  But while this is no time for philosophizing I think it could fairly said the hypodermic needle crusade against killer diseases killed so many people it's a wonder there's anything left of the human race to tell the tale.

Fruit bats. My foot. All right Pundita that's enough. 

How to End Unsterile Injections in Africa -- Quickly?

And of course efficiently transmitting the Ebola virus through contaminated injections isn't like, say, shooting common cold germs or even HIV into an arm.  So here one might ask why governments and international agencies battling the current Ebola outbreak haven't sounded the alarm about the use of contaminated needles. And why haven't they announced strategies to combat the lethal practice at this most critical juncture in the battle against Ebola?

Shedding light on the answer means a return to Conference Room A. Peter Evans, then a senior technical officer of the World Health Organization, reminisced further for the benefit of the Chronicle about the Sackcloth and Ashes meeting in Geneva:

In four of the world's six regions -- primarily developing countries -- half of the billions of injections administered yearly were being given with unsterile needles and syringes.

The news was nearly as bad for the World Health Organization's prized immunization programs: One of every three vaccinations was potentially contaminated with lethal infections.

The figures devastated Evans and his colleagues. They had spent years teaching immunization workers safe injection practices and proper sterilization techniques. They had vaccinated millions of children in every corner of the globe.

Now they realized that they could have been exposing millions of children to some of the world's most deadly diseases.

And there was another major worry.

For several countries, demand for immunizations had collapsed over rumors that some vaccines were unsafe.

"There was a great fear," said Evans, "that any negative news about the safety of injections themselves could also seriously impact the immunization programs."
So much for Michael Zaffran's rumination that it might be necessary to panic the public. 

If the history is any guide I'd venture public health officials are afraid at this time that if they emphasize the issue of unsterile needles in Africa, this will discourage Africans and a great many others from taking vaccines -- including the Ebola vaccine when it becomes available.

That's not an unreasonable fear; however, some way must be found to convey to officials that it's working at cross purposes to spread Ebola and other deadly diseases with unsterile needles while at the same time trying to get all of Africa immunized against Ebola.

Yet again if history is the guide such effort would take considerable time given the ponderously slow way things move at international organizations.  A striking exception has been World Bank Group President Jim Yong Kim, M.D., a prickly man who's managed to make more enemies at the Bank in a shorter time than even Paul Wolfowitz. (As to how a medical doctor ended up running the Bank -- I don't know. I don't think anyone knows.)  Dr Kim called WHO Director General Margaret Chan on the carpet for the organization's crummy response to the Ebola outbreak, then cut miles of red tape within I guess 12 minutes flat to commit the Bank to $400 million to Ebola disease treatment and containment in West Africa (and he's just getting warmed up).

So, fast action is possible and in particular if well-heeled charitable organizations such as the Bill and Melinda Gates Foundation spring into executive action.  The question is how to quickly stop the unsterile injections, at least in Ebola-stricken regions, once the will and money are there to do it. 

Here's how I would do it. 

1.  Circumvent the entire bureaucratic machinery currently in charge of purchasing and distributing hypodermic needles in 'developing' countries.  (In 1998, when the Chronicle report was written, the bureaucracy was UNICEF.) Put a hastily formed American ngo in charge -- hastily to include cutting IRS red tape -- that is exclusively dedicated to a mission to stop the use of unsterile hypodermics.  Direct the mission initially to rural West African regions that have seen Ebola outbreaks.  

2.  If companies that currently make glass hypodermics are too small to handle large volume production, ask Walmart to donate an executive to getting a factory retooled "yesterday" to handle large orders.

3.  Load the ngo with retired military procurement and logistics experts, and put a high-ranking retired military logistics expert in charge. 

4.  Have the ngo first distribute glass hypodermics to African villages via the same distribution network that Médecins Sans Frontières (Doctors Without Borders) and other aid organizations such as Samaritan's Purse are using to get home care kits into families stricken by Ebola. And have the ngo work to quickly expand the network. This could be done with help from the U.S. government, which reportedly is providing (or plans to provide) home care kits to "hundreds of thousands of households, including 50,000 that the US Agency for International Development (USAID)" was supposed to deliver to Liberia in September.
   

5. Accompany the distribution with instructions on how to sterilize the glass hypodermics (e.g., at least 5 minutes of boiling) and the proper care of the needles when not in use. Have health workers explain to the village chiefs why it is absolutely critical they convey to people in the village that only boiled glass needles should be used for all and any injections.

6. Once the chief has explained the situation in his own way, have health workers teach designated residents of the villages how to use hypodermics so they can help with immunization shots, etc. If only a very limited number of glass hypodermics can be distributed to each village, the immunizations for a particular vaccine might have to stretch for several days rather than hours as the jabs are boiled after each use. Yet in this situation certainty is the only efficiency.

7. Once the glass needles have been distributed, ask an advertising agency to design a campaign to highlight the importance of using sterilized hypodermics. One candidate would be the agency that created the
"Don't Be a Lab Rat" media blitz this year for Colorado's government. The campaign, which was to persuade Colorado teenagers to stay away from marijuana, drew criticism. But it pounded home the message in colorful fashion. More importantly, it framed the warning in very simple, personal terms. That would be the ticket for getting across the hypodermic message, which should be spread by all means of public communication.


That's the general plan. Note it omits government attempts to pry disposable hypodermics away from BBDs or demonize them for not sterilizing the jabs. To return to the BBC report:
And when Ebola spread across the two nations, people refused to go to hospitals because they saw them "as the most dangerous place to be", Mr Sisay says. He was referring to the fact that hospitals were seen as the source of the disease. It has claimed the lives of many health workers - 61 in Sierra Leone, including its only virologist, Dr Umar Khan.

Many people also did not bother to go to hospital, as there is no cure for Ebola -- although supportive care such as rehydrating patients who have diarrhoea and vomiting can help recovery.
The Black Bag Doctors fill a need, no matter how poorly, when people have good reasons to fear a medical establishment. 

There is better way to deal with the BBDs.  When money talks nobody walks, and this also applies to chickens and goats when they're used for payment. Once the BBDs and private clinics see they're losing money because village cooperatives are sterilizing glass hypodermics and doing their own injections, you may trust they'll get hold of glass hypodermics and make a production of boiling their own jabs in front of the patient. 

And money shouts when it comes to disposable syringe manufacturers. Once they see their profits eroded by glass hypodermics, they'll work miracles to get truly unusable disposable needles into wide distribution in Africa. 

By truly unusable, I mean two little blades popping out in the hypodermic chamber as soon as the syringe is pushed and cutting the syringe in two.

Yes. The invention already exists, and it works. There is absolutely no way to reuse the jab. 

So it's not as if people would have to boil glass hypodermics forever.

Ebola's Hard Lessons

The bottom line for poorer countries is that they can't afford the kind of public health system that only a large tax base, oil wealth, or the ability to do big deficit spending can support.  Nor can countries without highly developed oversight and enforcement mechanisms ward off the kind of corruption that makes distribution of counterfeit medications and use of unsterile hypodermics routine. 

What governments in the poorer countries can do is look to their strengths.

I doubt it ever occurred to the people in Conference Room A that they weren't facing an either-or situation: either downplay the disaster or risk destroying the vaccination program.  There was a third alternative, although it wouldn't have been evident in 1994 because in that era the idea of participatory medicine was still considered the province of the lunatic fringe. 

But people's great fear of unsterile injections would have come from having no control over the hypodermics' safety.  The fear is rooted in the exclusionary model of medical practice, which has dominated for centuries -- ever since the arising of settled civilizations and the specialization of medical practice. 

In this model the patient is largely excluded from the medical treatment of his body. There is the medical practitioner and the practiced upon -- the latter being inanimate at the diagnosis stage beyond supplying answers to the practitioner's questions and pointing to show where it hurts, and limited in the treatment stage to following instructions. 

Yet in the West the exclusionary medical approach is going the way of the Model-T Ford. The sheer expense of maintaining the industry that rose up to service the approach has vaulted the idea of preventive medicine out of the fringe and into the mainstream. This has opened the door for people to participate more in maintaining their own health, even to the point of arranging their own lab tests.

This in turn is creating medical cooperatives that allow entire communities, even in the poorest neighborhoods, to share the responsibility for doctoring themselves, whether it's taking blood pressure, testing for blood sugar levels, and so on.     

And so by a long way around, the human race is now set on a course to return to the ancient tribal model of health care that predominated before the rise of civilizations, only this time with all the medical knowledge and technological advances the past centuries have evolved. 

Oddly enough, this puts rural Africans in an enviable position. Just as they were able to leap directly into the digital communication era without having to dismantle the landline era, the rudimentary exclusionary health care system in the villages, which African governments and the United Nations never cease to bemoan, means they can circumvent the past century of Western health care and go directly to the participatory model.

Odder still, the current Ebola outbreak is giving the participatory model of health care a big push forward in West African regions worst hit by the outbreak.

The exclusionary model was completely overwhelmed by the outbreak, which meant overflowing hospital wards and Africans who were suffering from grave illnesses other than Ebola shut out from medical attention.  And it meant they were hauling relatives and friends with Ebola symptoms from their villages to hospitals in cities and towns, thus spreading the outbreak into the urban landscape -- an unprecedented turn of events.

Finally some health officials grew a brain. Instead of bringing the villagers to the hospitals, give them the tools they needed to care for Ebola patients in their own villages.  Thus, the Ebola home care kits. And makeshift Ebola treatment clinics that UNICEF is rushing into communities. (See the article on home care kits.)

The desperation measures are seen by health officials as a great failure of the medical system but actually it's not rocket science to look after an Ebola patient, and it shouldn't cost a fortune unless a hospital is trying to scare up funds for a new building wing and infectious disease research department. 


Ebola is not airborne, whatever you might have heard to the contrary.  And the virus is so extremely fragile it can't last more than a few minutes once outside its host's bodily fluids unless it lands on a site in the North Pole or in frigid air-conditioning.  

(Does this mean wearers of hazmat suits should simply play a few hands of poker before removing their suits after tending an Ebola patient, as the way to avoid contaminating themselves when removing the complicated gear after tending an Ebola patient?  This might be the case although don't quote me because I wouldn't want to give the CDC and NIH fits.)

And just about any ordinary cleaning solution or alcohol disinfect the surrounds of an Ebola patient.

See the Washington Post's Can You Catch Ebola from an Infected Blanket? to learn why the virus is actually a wuss when left to its own devices unless it strikes in a cold climate, where it can last for several hours on a hard surface. But when last I checked West Africa isn't a cold climate. (Could you fox the little zombie even more by moving the patient into sunlight or the warmest room possible?  Pundita, that's enough.)  

Caring for Ebola patients is mostly knowledge -- knowledge the African villagers and even the professional health workers didn't have at first. (The same could be said for workers at a major hospital in Dallas that accepted an Ebola victim.)

They were sucker-punched by the outbreak in West Africa, which had never before seen Ebola. It took time to understand what the disease was and how it worked. But once you understand, there are a few simple ground rules for dealing with an Ebola patient or corpse without getting yourself killed in the process.

From this viewpoint it'd be smart to extend the idea of home kits and small community clinics to the entire process of warding off Ebola in Africa -- or any other disease, for that matter. Instead of going on a hospital construction spree, provide mobile clinics and more mobile labs. Instead of building expensive isolation wards, truck portable isolation units -- medical tents -- to the villages. Nowhere is it written the wards have to be hardwall construction. 


Death of the Statistical Person

It is hard to read the Chronicle report without feeling repulsed by officials who oversaw immunization programs they knew were killing many people. Yet they were men and women of their times, dedicated to saving the world from the scourge of deadly diseases.  And it's to be remembered that the World Health Organization was instrumental in wiping out the highly lethal airborne communicable smallpox disease.  Saving large numbers, however, can devolve into saving a mathematical creation, a faceless statistical entity. The faceless engender corruption and the most ruthless social remedies.  

Yet fueling the "shadow epidemic," as the Chronicle termed mass death by unsterile hypodermics, is an insidious idea that took hold more than a century ago.  You go to a clinic, there is a caregiver holding a needle, you roll up your sleeve, get an injection, and presto you are effortlessly protected from death by a deadly disease.

It's just that there is no such thing as effortless survival.


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1) Despite the technical hieroglyphs the findings read like a page-turner but for a good introduction see Adam Withnall's piece for the U.K. Independent, which discusses the preliminary paper, published in April in the New England Journal of Medicine. The final version was published in NEJM October 9.

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