Tuesday, February 26

Congo Ebola: Medical facilities source of one-fifth recent infections

The tragic irony is that during the 2014 Ebola epidemic in West Africa many people refused to go to hospitals for treatment because they believed hospitals were the source of the disease. Many of these West Africans turned to 'black bag doctors' for treatment, which was going from the frying pan into the fire.   

Fast forward to today's epidemic: Why Does Ebola Keep Spreading In Congo? Here's A Major Clue; February 25, Nurith Aizeman for NPR (USA):


The surge of confirmed cases in Katwa and Butembo – 307 and rising — is now the largest flare-up during the course of this outbreak, which has infected nearly 900 people since August. And WHO officials estimate that in about one-fifth of these recent cases, the person contracted Ebola at a health care facility.
When Yao started visiting the clinics, it was pretty obvious how this was happening: Even government-run facilities such as large hospitals hadn't set up triage tents to separate possible Ebola patients from everyone else.
"This disease is not well-known in this part of the country. It is the first time," Yao explains, even though Ebola has broken out in other parts of the DRC on multiple occasions.
Even more problematic, says Yao, are the hundreds of unofficial private health facilities in this area. Some are large operations. In many other cases, says Yao, "it's just a house — a very old house."
And often a crowded one at that. "In one bed putting two children."
These facilities are also often short on supplies. "You can see people using several times the same gloves or the same equipment," including syringes, says Yao.
Along with modern medicine, many facilities also offer traditional cures. (Indeed, health officials commonly refer to such facilities as "tradi-moderns.") And this too creates opportunities for infection, says Yao.
That's because the traditional medicines are often diluted in water and put in a cup for the patient to drink. Then, he has noticed on his visits, the cup often isn't cleaned before it's passed on to the next patient.
In response to all these findings, Congo's government and the WHO are trying to reach out to every one of these health facilities in Katwa and Butembo. In conjunction with a range of nonprofit aid organizations, they are training the staff on infection control and providing them with necessary protective equipment.
But it's a daunting task. Just finding all the private clinics is difficult because there's no official list, says Yao. Officials know about only the ones reported by Ebola patients.
Dr. Cimanuka Germain of International Medical Corps, which is helping with the effort, says private clinics sometimes resist the help.
For instance, when he told the staff of one clinic that they should report suspected Ebola cases to a hotline instead of treating them, their response was: "This is not possible for us."
That facility treats about 65 patients a day, says Germain. They didn't want to lose business.
Then there's the facility where Germain spent days training nurses on how to set up and operate a triage tent. Two weeks ago he showed up for a surprise visit.
"One of them was there without wearing gloves," Germain says, sighing incredulously.
For Germain the takeaway was clear: "To change someone's behavior is not [a matter of] one day or two days — you need time."

As I discussed years ago on this blog, the issue with hypodermic syringes is huge because often they are not sterilized after each use. WHO was supposed to ban multiple-use syringes but success in that regard has been patchy in the poorest regions of the world, as the NPR report underscores.

And as the rest of the report makes clear, it's not only a matter of changing the behavior. Even with an understanding of the disease and good training for the staff, the clinic might not have access to the supplies they need or is unable to afford them.

Then there are the ongoing attacks. Reuters, February 25: Attackers Torch Ebola Treatment Center in Congo, Patients Evacuated:
KINSHASA (Reuters) - Attackers set fire to an Ebola treatment center run by Medecins Sans Frontieres (MSF) in eastern Democratic Republic of Congo late on Sunday, forcing staff to evacuate patients, the charity said.
There were no immediate details on the identity or motive of the people who torched the center in the district of Katwa, at the heart of the country’s worst outbreak of the deadly disease.
But the World Health Organization has said aid workers face mistrust in some areas, fueled by false rumors about treatments and preference for traditional medicine.
 The outbreak has killed 546 people since July, according to the Congolese health ministry.
Most of the cases since the start of the year have been in Katwa, which is close to the border with Uganda.
Three volunteers for the Congolese Red Cross were attacked as they helped with the burial of an Ebola victim in eastern Congo in October. Two months later, political protesters ransacked a nearby Ebola isolation center.
There is also the problem with keeping the experimental Ebola vaccine refrigerated in rural areas, where electricity can be spotty at best. Scientists have been working to develop a heat-resistant Ebola vaccine and with some encouraging success. See this February 25 report from Precision Vaccinations.

And there is the increasing problem, all over the world, of the 'urban-rural' interface. As humans and their livestock move ever closer to remote areas, then diseases once confined to jungles and forests more readily spread to humans and domesticated animals.  

So what's the prognosis?  The international aid community has been throwing everything they can at the outbreak including an experimental vaccine and doing so under difficult circumstances. 

The specter of a 'mutation' to an aerosolized form of Ebola hangs over all such outbreaks. The chances of the virus reassorting with one that's more easily transmitted are considered remote. But every day the outbreak spreads in areas with a lot of Mom&Pop pig and chicken farms (pigs being the perfect laboratory for viral reassortments) or markets that sell live livestock for slaughter and consumption (which even exist in U.S. cities along the Mexican-U.S. border) is another day the chances seem a little less remote.

Is an aerosolized Ebola virus the famous Doomsday Virus? I noted during the 2009 Swine Flu pandemic that viruses tend to weaken as they pass through more and more hosts (or reassort more and more.) So on paper, at least, the silver lining to human megapopulations is that they afford some protection against a true doomsday virus. 

However, quite a large number of people would be killed very quickly by an aerosolized Ebola virus and combatting it would be a body blow to globalized travel and trade. This would set off a major global financial crisis and could even crash several governments.

But the name of the survival game when up against a pandemic is the same as it's always been, ever since the rise of civilizations: Blockade. 

The counter-argument is that blockades on a large scale would crash civilization anyhow. But who's talking about large-scale?  Could your own neighborhood or apartment building set up a blockade just long enough for the pandemic to pass over?

And China's government demonstrated during the 2009 Swine Flu pandemic that it was possible for a government to create a modified borders blockade in combination with quarantine that could slow the inevitable exponential spread of a highly communicable lethal disease. And slow it just enough to race a vaccine into production and distribution among a key number of people. The 'secret' to the success of the plan was that most of the swine flu cases were headed toward China via the country's international airports.  

Surviving a doomsday virus would be doable -- not for everyone, but for enough to survive to keep civilization lurching along. 

It comes down to planning, robust civil-defense practices, and drill, drill, drill. That was how Rick Rescorla saved more than a thousand people from the attack on the World Trade Center on 9/11. He had drilled the employees in one firm on evacuation procedures until they could do it in their sleep -- and even then he hadn't stopped the drills.

[shrugging] It's up to you. It always is.


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