Emergency Response & the Ebola Outbreak
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Nikki Blackwell tells her story of the emergency response to the Ebola outbreak in Nzerekore, Guinea. She chronicles the enormous challenges of providing care to some of the most vulnerable people in the world, in one of the most under resourced and challenging environments. The Ebola virus was first isolated in 1976. Between then and 2013 there were twenty outbreaks of Ebola. However, the outbreaks, although vicious, were relatively small and in isolated areas. This outbreak was by far the most complex, with a mortality rate of up to 40%. The fruit bat is the natural host and reservoir of Ebola. They transmit it to other animals, and ultimately humans. Human to human transmission occurs from body fluids, mucous membranes, and sexual contacts. Nzerekore, Guinea has a terrible health service and infrastructure stemming from a long period of conflict. This is further exacerbated by the scarce number of doctors. Further, what compounded the problem even more was the delayed recognition and action from the international community. Eventually, Nikki and the Médecins Sans Frontières (MSF) had funding to launch a project, providing care to the region that was dealing with a devastating epidemic. What followed was an eye-opening experience for Nikki and her team. Nikki highlights the endless challenges she faced in delivery care in her role as Medical Director on the project. These include hot, dusty conditions with the constant stench of chlorine. Heavy, thick biohazard suits that take 30 minutes to get into and can only be worn for one hour due to the extreme nature of the dehydration and exhaustion they cause. Lastly Nikki describes the technical and emotional difficulties of providing care to this population of people with grave illness, constantly surrounded by death, all heightened by the real fear of the staff falling ill. Finally, Join Nikki as she tells her incredible tale of the Ebola outbreak in Nzerekore, Guinea as Medical Director for the MSF. For more like this, head to our podcast page. #CodaPodcast
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Emergency Response & the Ebola Outbreak
- 1. RESPONDING TO THE EBOLA EPIDEMIC IN GUINEA NIKKI BLACKWELL ALLLIANCE FOR INTERNATIONAL MEDICAL ACTION JUNE 2016
- 2. declaration
- 25. With homage and respect to all the people who lost their lives in the fight against Ebola
- 28. Why me, nature of living & working together… Conflict, natural catastrophe (obstetrics for both), epidemic, hunger crisis (not famine), mass population movement (idps, refugees) Haiti (chest trauma),iraq (post-op care, bronchs, mr organisms Pakistan – neonates, MDR (vancomycin, meropenem) Cholera haiti (measles,case management etc), ebola Niger/mali/burkina 67cm rule, muac as finishing note
Editor's Notes
- ALIMA – of which I am one of the founding directors Government in pataticular MOH of Guinea Funded by ECHO – emergency humanitarian arm of the European Union
- No conflict of interest Personal account of participating in the fight against the recent Ebola epidemic, not the A-Z of ebola virology nor a detailed analysis of that epidemic – my personal reflections Remind everyone before we start that in 2015 214 million malaria cases, 438 000 deaths…Versus Ebola 28 610 cases 11 308 known deaths (even if double…) Sure there are others in the audience who responded to this emergency – hands up please – very interested to hear your experiences
- VIROLOGY This RNA virus family Filoviridae includes three genera: Cuevavirus, Marburgvirus, and Ebolavirus. There are five species that have been identified: Zaire, Bundibugyo, Sudan, Reston and Taï Forest. The first three, Bundibugyo ebolavirus, Zaire ebolavirus, and Sudan ebolavirus have been associated with large outbreaks in Africa. The virus causing the 2013 West African outbreak belongs to the Zaire species. Fatality 18.5-90% depending on the centre the lowest being for sufferers treated in europe or the USA From 1976-2013 1500 deaths 20 known outbreaks (DRC, Sudan, Uganda, Gabon) –usually small and vicious in remote rural areas near to tropical rainforest of Central & East Africa, unlike 2013 (first cases notified in March 2014) outbreak which affected major urban centres as well as rural areas, also the largest and most complex yet Paul Farmer of Partners in Health, an NGO "What if the fatality rate isn’t the virulence of disease but the mediocrity of the medical delivery? »
- TRANSMISSION It is thought that fruit bats of the Pteropodidae family are natural Ebola virus hosts and act as a reservoir. Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals such as chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead or in the rainforest. Ebola then spreads through human-to-human transmission via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids. Health-care workers have frequently been infected while treating patients with suspected or confirmed EVD. This has occurred through close contact with patients when infection control precautions are not strictly practiced. (not because people are careless – without the means). Attack 20-32 times higher. CDC Oct 2015 x42 in Guinea Also carers of sick people at home Many HCW infected in their communities Burial ceremonies in which mourners have direct contact with the body of the deceased person can also play a role in the transmission of Ebola because levels of Ebola virus remain high after death. People remain infectious as long as their body fluids contains the virus. (used to say blood) SEXUAL TRANSMISSION SEMEN TESTING AFTER 3 months then monthly thereafter x2 negative a week apart -> recent flare up (due to sexual transmission) – now 12 months then testing
- Emile Although Ebola represents a major public health issue in sub-Saharan Africa, no cases had ever been reported in West Africa[note 2] and the early cases were diagnosed as other diseases more common to the area. Thus, the disease had several months to spread before it became recognized as Ebola.[55][57] Basic principles of epidemic management Community engagement is key to successfully controlling outbreaks Package of interventions *case management *surveillance and contact tracing *reliable laboratory service *contact tracing All worthless without social mobilisation
- March 25 – 4 SE districts of G Fière. 86 suspected cases and 59 deaths Plus suspect cases in Sierra Leone and Liberia Tragedy is that 4 months after PHEIC, everywhere could do ebola pcr within 24hrs, enough beds for all patients, >80% of registered contacts traced – imagine if that level of response had been present earlier in April…might never have got to the take off point of the exponential outbreak curve
- x21-32 542 in Guinea say CDC DEC 2015) times higher chance of contracting the disease Devastating effect on the ability of the health service to respond, hospital and health centres close 2 Samaritan’s purse workers in Liberia are medevaced after receiving the only 3 doses of Z MAPP in W Africa (from Sierra Leone – NOT used to treat Dr Omar Khan – now have it in our centre in NZK to treat the recent flare up in GF (sexual contact with survivor) Looking at results of the 27 patients in US & Europe insight into lethality of disease with full resource rich facilities…
- The most severely affected countries, Guinea, Liberia and Sierra Leonehave very weak health systems, lack human and infrastructural resources, and have only recently emerged from long periods of conflict and instability. Distrust of government officials after years of violent armed conflict, Needless to say there is widespread extreme poverty – meaningless to tell people to wash their hands with soap and water when they don’t have enough clean water to drink and can’t afford soap Very low literacy 1-2 doctors per 100 000 (brisbane 3.3 per 1 000, dublin 2.7) Liberia has >50 doctors (lots more than 2005, only 6) WHO DEC 2015 – TOP EMERGING PATHOGENS WITH NO EFFECTIVE Rx LIKELY TO CAUSE EPIDEMIC IN THE NEAR FUTURE The initial list of disease priorities needing urgent R&D attention comprises: Crimean Congo haemorrhagic fever, Ebola virus disease and Marburg, Lassa fever, MERS and SARS coronavirus diseases, Nipah and Rift Valley fever. The list will be reviewed annually or when new diseases emerge.
- People dressed in spacesuits walked down my street and started telling me what to do… Part of the world where germ theory of disease is not necessarily believed
- Like old fever and tb hospitals – way out of town Basic principles of epidemic management Community engagement is key to successfully controlling outbreaks Package of interventions *case management *surveillance and contact tracing *reliable laboratory service *contact tracing All worthless without social mobilisation
- RNA Viral envelope reasonably fragile – susceptible to chlorine (bleach) 0.05% bare hands and feet, clothes, including dead bodies Everything else in 0.5% solution
- Green zone – logistics, pharmacy, health education and contact tracing team, medical room – docs and nurses, patient files, handover, kitchen Explain who goes where
- Patient journey community to triage Overcoming reticence…
- Order of ward round suspect, probable, confirmed 2 metre gap fences -> patients could interact with families (important to demystify for family and community), also with staff
- Malaria, typhoid ,yellow fever, dengue, pneumonia Lassa…(2 patients died fulminant haemorrhagic fever EBV negative -> ?Lassa – 15% non malaria febrile illness = Lassa CDC late 1990s) Used to be called EHF now EVD
- Name on head Time on arm – 1 hour rule Drenched with sweat Diving suit Doffing – most dangerous time – exhausted, easy to make mistakes…do exactly what the hygienist says – protocolised order
- 2-21 day incubation period Shock and phases of the illness Usually 8-10 Not infectious when asymptomatic Resolving form, severe form (incl haemorrhagic – 26%, althougha bout half had oozing around ivc sites) Severe vomiting and diarrhoea (very like cholera) Distributive shock phase (gm neg sepsis – gut translocation) Neurological – confusion, seizures, coma, - viral meningoencephalitis, cerebral haemorrhage
- . Of those tested, the majority of patients with EVD had metabolic abnormalities that included hyponatremia, hypokalemia, hypocalcemia, and hypomagnesemia, and all the patients had hypoalbuminemia during their hospitalization (Table 2). Five patients (19%) had elevated creatinine levels at admission, and 11 patients (41%) had elevated creatinine levels at any time during hospitalization Leukopenia was prominent in the first week of illness,. Thrombocytopenia in nearly all Most patients had an elevated international normalized ratio during their hospitalization Aminotransferase levels peaked in the second week of illness; the median maximum aspartate aminotransferase level was more than three times the median maximum alanine aminotransferase level. Bilirubin levels, however, were only slightly elevated in most patients. Creatine kinase levels were markedly elevated in most patients tested, Serum lactate levels were elevated in most patients who were tested, with a median maximum value of 2.8 mmol per liter. Also research BIOFIRE Favipavir Now PREVAIL Back to Public Health principles – not really enough to treat the victims (finger in the dam) – prevention, curative treatments – ongoing research (for those who have run clinical trials in comfortable contexts…without even touching on the complex ethical issues)
- Logistics – keeping the show on the road Meals -> protein and kcal based for sick catabolic patient water
- Patient leaving
- Advised by community leaders about the best way to do this – 2M distance Prognosic indicators – age <5 & >40, peak Ct, creat>200, time from symptoms to care
- Living in NZK, staff health… Hope there wasn’t a power cut and that there was water for a shower…
- Medevac Really not such a big deal if your dealing with EVD all the time See why wet phase would be v difficult (and more dangerous) Claustrophobic for patient, very cold 2 diarrhoea – limit restaurants, one severe pneumonia, one severe malaria in a local person None of HCWs infected to date
- Post ebola sequelae Dec 2015 WHO 22000 orphans Discharge and sequelae 17 000 survivors in W. Africa Chronic joint pain Eye problems – uveitis – virtually no ophthalmologists in this part of W Africa Meningoencephalitis 10/12 after Rx and ‘recovery in UK health worker Immune privliged or sanctuary sites (eye, CSF, testes) after it`s gone from blood Most Ebola victims are dying of other disease –crumbled health system - already measles epidemic by March 2015 in GF, 2 cases of polio, cholera…, malaria,women too scared to go to health care facilities for childbirth (if they have re-opened), diarrhoea. Sleone May 2014- 2015 >30% increase in maternal death >25% increase in neonatal death
- What next time? Plexiglass corridors Webcam Picc lines -> adrenaline Hf O2
- Paul Farmer of Partners in Health, an NGO "What if the fatality rate isn’t the virulence of disease but the mediocrity of the medical delivery? » 2 patients who received NIV alone survived Of 7 who received MV, 5 required CRRT the 3 with CRRT too died 5 CRRT – 2 survivors All deaths 42 or older ?pathophysiology of pulmonary disease – multiple contributing factors – Vascular leak from endothelial infection (prime viral target) Cytokine dysregulation Direct damage to EBOV infected cells. Autopsy studies report evidence of replicating EBOV in alveolar macrophages and free EBOV in alveolar spaces Acute renal failure could be caused by hypovolemic shock and acute tubular necrosis; EBOV infection of renal endothelial, interstitial, and tubular cells; or other factors.24 The high creatine kinase levels observed in most of the 27 patients with EVD we evaluated suggest that the elevated aspartate aminotransferase levels in most patients with EVD could originate from both hepatic and muscle sources, with rhabdomyolysis and myoglobinuria also potentially contributing to renal injury. 22% of survivors (6) – 2NIV, 2MV, 2 MV & CRRT
- Paul farmer 4S Staff Stuff Space Systems You can’t have a health crisis turn into a human rights crisis
- BACKGROUND Ebola virus disease known (noticed) since 1976 – 2 simultaneous outbreaks, one in South Sudan and one in DRC near the Ebola river Notice 1994 Tai forest outbreak (Ivory Coast) – single case from an infected Chimpanzee (point out Liberia, Sierra Leone, Guinée Forestière) Paul Farmer of Partners in Health, an NGO "What if the fatality rate isn’t the virulence of disease but the mediocrity of the medical delivery? »