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How did the West Africa Ebola epidemic get out of control so fast?

August 31, 2014 at 5:51 PM EST
The spread of the most recent strain of the Ebola virus across parts of West Africa has highlighted not just the lethality of the disease but also the strains on the existing medical infrastructures there. For further insight, Stephen Morse, professor of epidemiology at the Mailman School of Public Health at Columbia University and Estrella Lasry, a tropical medical advisor at Doctors Without Borders, join Hari Sreenivasan.
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HARI SREENIVASAN: The spread of the most recent strain of the Ebola virus across parts of West Africa has highlighted not just the lethality of the disease but also the strains on the existing medical infrastructures there. For further insight, yesterday I spoke with Stephen Morse, professor of epidemiology at the Mailman School of Public Health at Columbia University and Estrella Lasry, tropical medical advisor at Doctors Without Borders.

HARI SREENIVASAN: First, why is this strain so much more lethal compared to others? I mean we’re talking 3,000 people infected, 1,500 dead.

STEPHEN MORSE: I don’t think it’s more lethal than other strains of Ebola Zaire. This is a highly lethal virus. I think the problem is that there are a large number of people getting infected and perhaps some of them are not getting care at the appropriate times. But I don’t think biologically it’s behaving much differently than the ones we already know about.

HARI SREENIVASAN: Is there a different social component on why this is spreading faster?

STEPHEN MORSE: I think that initially with the outbreak in Guinea, it was allowed to get out of control and there were just so many patients by then, it began to spread across the borders. And, so by time, the organizations like Médecins Sans Frontières, Doctors Without Borders, were able to start on it in the Spring. There were already so many cases of this, it was an uphill battle.

HARI SREENIVASAN: Why has the international kind of effort to try to combat this been so much slower than it seems that we’ve heard about in the past? Your organization is one of the last ones there and you have a number of people there, but you don’t see the same kind of push from lots of international aid agencies going in.

ESTRELLA LASRY: Well, usually the outbreaks aren’t as big as this one. So, we expected it to – we started working on the outbreak in March and we expected it to finish in two, three months, which is what we would usually see in an Ebola outbreak and in the Ebola outbreaks that we’ve been responding to in the past. Part of the problem with this outbreak is that it spread very quickly in an urban area, which meant that it was much more difficult to control in terms of the contact tracing and it was much more difficult to control in terms of how quickly it spread. So, it’s lasted much more than the previous outbreaks and it’s affected a lot more people and that’s why there is an absolute need for more organizations to get involved in the response.

HARI SREENIVASAN: You know, this is also highlighting kind of a disparity in kind of poor existing medical infrastructure. Some of these countries, entire countries, have less doctors than, say, a single hospital in a major Western city. And then there’s also a disparity between countries who’ve dealt with this virus before versus countries who have not.

STEPHEN MORSE: Yes, absolutely, and these countries, I think, are particularly stressed because they’ve had civil strife, they have trouble between the government and the local people – some distrust of government. So, you know, that is overlay over an already difficult and strained medical infrastructure. But even Nigeria, which is the very big country by comparison, has only 17,000 doctors.

HARI SREENIVASAN: How significant is the fear factor, the misinformation in spreading the disease, or chasing away caregivers?

ESTRELLA LASRY: It’s huge. It’s a big part of why the outbreak has been spreading so much. So, if the fear is causing people not to go to health facilities, to hide the disease, to hide people who have died in the villages. We’re not being granted access to some of the villages where we think there might be cases, so definitely it’s been playing a pivotal role in why the disease has been spreading in the way that it is spreading.

HARI SREENIVASAN: What’s the distrust? Why not let a doctor come into a village? What do you hear?

ESTRELLA LASRY: Well, first of all it’s very difficult, there’s been a lot of people who have died and a lot of people are taken into isolation wards. We’re dressed in the full personal protective equipment, the astronaut suits that you’ve been seeing on TV, and of course it adds to the fear, the fact that we’re bringing people into these wards. So, one of the things we try to do is ensure that family members do have access to see their relatives who are inside the ward, creating some kind of terraces where there’s a barrier, a physical barrier, between the family member and the patient. But it allows them to see their family member, it allows them to see that they are inside the ward, but they are being taken care of and we’re not hiding them.

HARI SREENIVASAN: You know, I even saw reports that kind of reverse causality, they say, you know everywhere these doctors go, more people are dying, so let’s keep the doctors out.

ESTRELLA LASRY: But it’s understandable that that kind of fear would be created in a population that does not know the disease and that is not used to this kind of response to a disease like that.

STEPHEN MORSE: In addition to perhaps a mistrust of authority and of course people coming from foreign countries to help, but since it has such a high mortality rate, normally the case fatality rate is fairly high and many people feel that there’s no point in going to the hospital anyway. And in some cases if infection control isn’t effective, in some hospitals other patients can get affected. There’s a historical basis for that. We can do much better now and Médecins Sans Frontières has demonstrated the improvements that are possible even with general care. But I think it needs educating the public about that.

HARI SREENIVASAN: So, really by the time they get to the hospital sometimes they’ve already infected thousands of others.

ESTRELLA LASRY: Yes, and the sooner someone who has been in contact with a patient, with a known case, actually says that they have been in contact, or the sooner that person is identified, the sooner they can be monitored. So, what’s happening is that for every case, for every confirmed patient, all of the contact, all of the physical contacts that they’ve had in the past 21 days are monitored on a daily basis. So, you can imagine how huge the response to that needs to be, especially with the amount of cases that we’re seeing. But not everybody is saying all of the contacts that they’ve had, or not everybody is willing to be followed for 21 days on a daily basis. So it’s also one of the challenges.

HARI SREENIVASAN: So, looking around the corner a little bit, we’ve had some promising results with ZMap and the tests that have been – how far away are we from anything close to what we could say is a vaccine that could be manufactured at scale that could actually reach this region?

STEPHEN MORSE: Scale is going to be a difficult problem, even with ZMap, they’re working very hard to try to scale it up just to experimental doses and it’s going to take a while. Some of the other drugs in the pipeline will take longer, because they need to be tested. As you know there’s a vaccine candidate going into early trials right now for safety testing essentially. But then the question is what’s the market for that vaccine. People who are going as healthcare workers, or lab technicians, or others who would be dealing directly with patients would be clearly able and willing to get the vaccine. But this is sporadic, we don’t know where the next Ebola outbreak is going to occur. So, you’re never quite sure whom to vaccinate until it actually happens.

HARI SREENIVASAN: Given that there are so few doctors and so many cases, what do you do to keep your own staff safe? I mean they’re working under incredible stress, under very long, difficult conditions, and people make mistakes when they’re on 18 hours a day, etc., etc., and these mistakes could cost them their lives.

ESTRELLA LASRY: We do several things. The first thing is to train people before they go to an outbreak. Once they’re in the outbreak, we make sure that they really understand the infection control, and if at any point they feel unsafe they can leave. But also once you go into the ward, we have a buddy system. So, you will never go into the ward alone. You dress with someone to make sure that there’s no skin, nothing is exposed. And then you go into the ward with at least one other person, so that in case you’re about to make a mistake, the other person can actually warn you. So, we try to keep everyone within a very, very strict set of rules, because there’s no place for mistakes.

HARI SREENIVASAN: Alright, Estrella Lasry, Stephen Morse, thanks so much.

ESTRELLA LASRY: Thank you.

STEPHEN MORSE: Thank you.