Friday 8 August 2014

Ebola unsolved: WHO spells out the basics

The first time I took part in a World Health Organisation Working Party I was taken downstairs after the morning meeting for lunch in the luxurious canteen, where the food was much better and the view more alluring than in the medical school staff dining room back in London.

As we went back to start the afternoon session my host pointed pointed to a very large, two storey high convoluted and paint be-splattered painting by Jackson Pollock (or by a close cousin of that esteemed artist) which adorned the central lobby. I looked at it with little relish, at a loss as to what to say. “By common consent” my host remarked “this is the clearest depiction of the WHO organisational structure”.

The World Health Organisation, for only the third time in recent years, has issued a Public Health Emergency of International Concern (PHEIC) warning. I have my doubts about any committee process, but I have picked out the main points from the statement. The extraordinary thing is that it has been written almost as if it were a training manual for aspiring public health workers.

The current EVD outbreak began in Guinea in December 2013. This outbreak now involves transmission in Guinea, Liberia, Nigeria, and Sierra Leone. As of 4 August 2014, countries have reported 1 711 cases (1 070 confirmed, 436 probable, 205 suspect), including 932 deaths. This is currently the largest EVD outbreak ever recorded. In response to the outbreak, a number of unaffected countries have made a range of travel related advice or recommendations.

Several challenges were noted for the affected countries:

  • their health systems are fragile with significant deficits in human, financial and material resources, resulting in compromised ability to mount an adequate Ebola outbreak control response;
  • inexperience in dealing with Ebola outbreaks; misperceptions of the disease, including how the disease is transmitted, are common and continue to be a major challenge in some communities;
  • high mobility of populations and several instances of cross-border movement of travellers with infection;
  • several generations of transmission have occurred in the three capital cities of Conakry (Guinea); Monrovia (Liberia); and Freetown (Sierra Leone); and
  • a high number of infections have been identified among health-care workers, highlighting inadequate infection control practices in many facilities.

The statement then goes on to give States with Ebola transmission some practical advice, including that they should:

provide immediate access to emergency financing to initiate and sustain response operations; and ensure all necessary measures are taken to mobilize and remunerate (my emphasis) the necessary health care workforce; meet regularly with affected communities and to make site visits to treatment centres; establish an emergency operation centre to coordinate support across all partners, and across the information, security, finance and other relevant sectors, to ensure efficient and effective implementation and monitoring of comprehensive Ebola control measures. These measures must include infection prevention and control, community awareness, surveillance, accurate laboratory diagnostic testing, contact tracing and monitoring, case management, and communication of timely and accurate information among countries. For all infected and high risks areas, similar mechanisms should be established at the state/province and local levels to ensure close coordination across all levels.

States should ensure that there is a large-scale and sustained effort to fully engage the community – through local, religious and traditional leaders and healers – so communities play a central role in case identification, contact tracing and risk education; the population should be made fully aware of the benefits of early treatment.

It is essential that a strong supply pipeline be established to ensure that sufficient medical commodities, especially personal protective equipment, are available to those who appropriately need them, including health care workers, laboratory technicians, cleaning staff, burial personnel and others that may come in contact with infected persons or contaminated materials.

In areas of intense transmission (e.g. the cross border area of Sierra Leone, Guinea, Liberia), the provision of quality clinical care, and material and psychosocial support for the affected populations should be used as the primary basis for reducing the movement of people, but extraordinary supplemental measures such as quarantine should be used as considered necessary.

States should ensure health care workers receive: adequate security measures for their safety and protection; timely payment of salaries and, as appropriate, hazard pay; and appropriate education and training

States should ensure that: treatment centres and reliable diagnostic laboratories are situated as closely as possible to areas of transmission; that these facilities have adequate numbers of trained staff, and sufficient equipment and supplies relative to the caseload; that sufficient security is provided to ensure both the safety of staff and to minimize the risk of premature removal of patients from treatment centres; and that staff are regularly reminded and monitored to ensure compliance with Infection Prevention and Control.

States should conduct exit screening of all persons at international airports, seaports and major land crossings, for unexplained febrile illness consistent with potential Ebola infection. The exit screening should consist of, at a minimum, a questionnaire, a temperature measurement and, if there is a fever, an assessment of the risk that the fever is caused by EVD. Any person with an illness consistent with EVD should not be allowed to travel unless the travel is part of an appropriate medical evacuation.

There should be no international travel of Ebola contacts or cases, unless the travel is part of an appropriate medical evacuation. To minimize the risk of international spread of EVD:

  • Confirmed cases should immediately be isolated and treated in an Ebola Treatment Centre with no national or international travel until 2 Ebola-specific diagnostic tests conducted at least 48 hours apart are negative;
  • Contacts (which do not include properly protected health workers and laboratory staff who have had no unprotected exposure) should be monitored daily, with restricted national travel and no international travel until 21 days after exposure;
  • Probable and suspect cases should immediately be isolated and their travel should be restricted in accordance with their classification as either a confirmed case or contact.
  • States should ensure funerals and burials are conducted by well-trained personnel, with provision made for the presence of the family and cultural practices, and in accordance with national health regulations, to reduce the risk of Ebola infection.


There is even more detail in the document, but I think you get the drift of it. The World Health Organisation has to be polite and helpful, because that is part of their consensus building remit, but any halfway competent Parish Council in a remote European backwater would be offended to receive such a document, because it makes it clear that the afflicted countries have not been able to organise themselves to give their citizens basic health protection, nor have they managed to get through to them the elementary processes of disease control.

Coincidentally, I have just been reading the draft of an upcoming paper by Heiner Ridermann on the testing of Piaget’s stage of formal operations among a small sample of Germans and Nigerians. Despite the Nigerians being well educated there are very significant gaps of understanding on their part about practical health matters, and a very much higher belief in the efficacy of prayer. Replicating this result on a much larger and more representative sample will be interesting.

Press reports suggest that the official case numbers are a gross underestimate, that many health workers have abandoned their posts, that no attempts have been made to trace the contacts of confirmed cases, and that the bodies of Ebola victims are frequently left unburied. Currently, the Ebola virus seems to be doing very well, all 7 genes of it.

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