Ebola - Generals [CDC?] are always fighting the last war (proverb)

[mac68DC]

So I have read a few times that the CDC and WHO know how to combat Ebola. They say they just need to apply the strategies that have worked in the past. Here is an example of such a statement.

---------------------------------------------------
CDC’s surge response to West African Ebola Outbreak
Press Release from Wednesday, August 6, 2014
http://www.cdc.gov/media/releases/2014/p0806-ebola.html

Excerpt: “The bottom line with Ebola is we know how to stop it: traditional public health. Find patients, isolate and care for them; find their contacts; educate people; and strictly follow infection control in hospitals. Do those things with meticulous care and Ebola goes away,”
---------------------------------------------------
WORLD HEALTH ORGANIZATION EBOLA RESPONSE
ROADMAP

http://apps.who.int/iris/bitstream/1...nseRoadmap.pdf
-----------------------------------------------------


Well, I have been breaking down the logistics based on the past outbreaks and the staff resources required seem astronomical (using staff man hours documented in the 1976 outbreak and then adj for urban environ). Right now I am just looking at the contact tracing demands for the projected 20,000 cases that they are planning for. A number which I have issues with, but that I will use as a target nonetheless.

I will post my worksheet numbers here after I play around with them some more.

The point is, its one thing to make bold statements like above about knowing how to solve this, its another to show the details on how the plan would actually be implemented. I just don't see it. I think they will need to start stepping out of the box.

Might need something like very large isolation camps (good luck securing that) because I just don't see the past strategies working with urban mobile populations.

I have not heard anything that gives me great confidence.

 

[mac68DC]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

"The Ebola outbreak in the West African nations of Guinea, Sierra Leone, Liberia and Nigeria has killed nearly 1,500 people. Just one contact left un-traced could go on to start a whole new line of Ebola transmission.
"It's like fighting a forest fire. If you leave behind even one burning ember, one case undetected, it could reignite the epidemic," Dr. Thomas Frieden, the director of the CDC, told reporters at a press conference earlier this summer.
"Contact tracing is a formidable challenge," said Dr. Margaret Chan, director-general of the World Health Organization. "In some areas, chains of transmission have moved underground. They are invisible. They are not being reported.""...

"...For example, in Sierra Leone, there are 2,000 contacts that need following, but the group Doctors without Borders says they've only been able to follow up with about 200 of them.
The group's teams in Sierra Leone and Liberia are "stretched to the breaking point" as the epidemic is "spiraling out of control," the group wrote in a press release..."

source : http://www.cnn.com/2014/08/25/health/ebola-contact-tracing/

 

[mac68DC]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

1976 Zaire outbreak contact tracing. (small rural village environment)

There were 10 contact tracing surveillance teams and 1 special purpose surveillance team to investigate possible routes for virus export.

Each contact tracing team consisted of 4 people: a team leader, 2 nurses and a chauffeur for the land rover.

Two doctors oversaw the 10 contact surveillance teams. These teams saw 5-10 cases a week.

Source: WHO
http://whqlibdoc.who.int/bulletin/1978/Vol56-No2/bulletin_1978_56(2)_271-293.pdf

Active surveillance disclosed that cases occurred in 55 of some 550 villages which were examined house-by-house.
Source: WHO
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2395567/

 

[sharon sanders]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

mac68DC - I moved this thread to the discussion forum since it appears you are developing a thought for comment. We typically post news only in the news forums and use the discussion forum for idea development.

Thanks!

 

[mac68DC]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

So my very (VERY) rough numbers are as follows.

For the projected 20,000 cases of Ebola, you will need (based on a minimum biweekly visit and using the sources posted in prev in this thread):

22,000+ vehicles with drivers
62,000+ nurses
2,500+ doctors

That's just for contact tracing and surveillance. Does not include anything else such as body pickup/disposal/ etc.

None of this matters because, the more I read about the process, the more I realized it would just not work. The situation is just too different - totally aside from the scale. The fact that the population is so much more mobile and the fact that a significant percentage of those infected don't want to be part of the process just nullifies any numbers. At least if the goal is 100% eradication.

I really only see this as a delaying strategy/tactic until a vaccine is developed.

That could be workable - but still seems like a huge undertaking.

 

[mac68DC]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

mac68DC - I moved this thread to the discussion forum since it appears you are developing a thought for comment. We typically post news only in the news forums and use the discussion forum for idea development.

Thanks!

I think this other post of mine also needs to be moved as well. Sorry about that.

http://www.flutrackers.com/forum/showthread.php?t=227066

 

[sharon sanders]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

I think your numbers are very realistic based on previously successful ebola control efforts.

What we have here is an outbreak that is out of control (as voiced by Friedan, WHO officials, MSF,..others).

It appears that if a country lacks basic public health infrastructure, ebola virus disease is difficult to stomp out if it develops beyond the initial cluster.

Will the 1/2 billion USD that the WHO has asked for bring in enough manpower and equipment to contain, control, and "cure" the current West Africa outbreak?

 

[sharon sanders]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

I think this other post of mine also needs to be moved as well. Sorry about that.

http://www.flutrackers.com/forum/showthread.php?t=227066

It is sorta a judgement call but I think your other thread is mostly pure fact. I think it is news reinforcement to drive the point that the ebola virus has been found in semen. People in outbreak areas need to take precautions against potential transmission during sex. It is a fact.

The topic of this thread is really a development thread for ideas on how to deal with an ebola outbreak that spans several countries. I look forward to everyone's input.

Thanks for great topics.

 

[mac68DC]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

WORLD HEALTH ORGANIZATION EBOLA RESPONSE
ROADMAP

http://apps.who.int/iris/bitstream/10665/131596/1/EbolaResponseRoadmap.pdf

Under Major Assumptions Section... "This Roadmap builds on nearly 40 years of experience gained in EVD control, and is rooted in the
fundamental strategies that have been proven effective in the context of previous outbreaks.
However, it incorporates new experience gained, particularly over the past 3 months, in urban and
widespread transmission settings. This experience is unique in the history of EVD and clearly
indicates that in such areas with very intense transmission, combined with fragile and very weak
health systems, the standard Ebola strategies must be complemented by new approaches. These
approaches must allow for the rapid scaling of control activities when the case load outstrips
currently available resources, and include a fundamental role for communities and their leaders in
strategy implementation.
...
This Roadmap assumes that in many areas of intense transmission the actual number of cases may
be 2-4 fold higher than that currently reported. It acknowledges that the aggregate case load of EVD
could exceed 20,000 over the course of this emergency. The Roadmap assumes that a rapid
escalation of the complementary strategies in intense transmission, resource-constrained areas will
allow the comprehensive application of more standard containment strategies within 3 months. This
plan recognizes that a number of currently unaffected countries could be exposed to EVD, but
assumes that the emergency application of the standard control strategies will stop any new
transmission within 8 weeks of the index case."


"Table 2 – Breakdown of costs for Objective 1
Cost item* Cost (USD '000)
Full Ebola intervention package
Ebola treatment centres 126,486
Referring /isolation centres and primary health care facilities 30,360
Laboratory diagnosis 19,570
Surveillance and contact tracing 34,223 <--- They are applying a good deal of resources to this. Compare this percentage-wise to the other expenditures.
Safe burials 6,133
Social mobilization and community engagement 12,114
Sub-national technical / logistical coordination 27,934
Complementary approaches for intense transmission areas 54,516
Short-term extraordinary measures to limit national spread 75,000 <----- I wonder how to parse this?
Support IHR measures to prevent international spread 2,670"

Now this part is very interesting.

"Total estimate...20,000 cases...The estimated costs for an Ebola treatment centre are based on average costs for a 50-bed
treatment facility, scalable up or down according to needs in a given area. The costs for a 50-bed
facility include an initial setup cost of $386,000 and monthly running costs of $881,000, resulting in a
total cost for six months of $5,672,000. It is estimated that at least 1,115 ETC beds will need to be
established to accommodate the case scenarios outlined in Table 4."

 

[mac68DC]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

maybe some clues here to the implementation. Basically leveraging the Communities themselves and providing them training.

Risky, but if done right you get an army of helpers who are intimate with the streets they manage. Actually this sounds really effective - as long as they maintain safety discipline.

This would bring down my estimates on nurses needed for contact tracing by huge amounts.

Is this in the road map?
-------------------------------

"Community health workers (CHWs) are community members who are given short-term training to provide basic health service. Often nominated and trusted by community members"


Commentary: The Role of CHWs in a Crisis Like Ebola:
http://www.mdghealthenvoy.org/commentary-the-role-of-chws-in-a-crisis-like-ebola/

Community health workers respond to Ebola outbreak in Sierra Leone:
http://www.unfpa.org/public/cache/offonce/home/news/pid/18101;jsessionid=B113BA39C54A21534E6AC2E981F3022F.jahia02

CHWS & THE 2014 EBOLA CRISIS: AN OPPORTUNITY FOR COMMUNITY-LEVEL CARE
http://1millionhealthworkers.org/2014/08/21/chws-the-2014-ebola-crisis-an-opportunity-for-community-level-care/


"The Role of CHWs in Controlling Ebola

Community health workers (CHWs) are community members who are given short-term training to provide basic health service. Often nominated and trusted by community members, CHWs are uniquely positioned to improve access to care, health-seeking behavior, and healthy behavior. The One Million Community Health Workers (1mCHW) Campaign believes that, in the context of Ebola crisis response, CHWs, if provided proper training and adequate safety equipment, can play a key role in containing transmission through the following activities:

...

2. Contact Tracing and Surveillance

IMG_0559Controlling an outbreak requires rigorous assessment and follow-up of exposed cases. This requires identifying all people who may have been exposed to a person with Ebola and checking for signs of illness everyday for 21 days – the maximum number of days of Ebola’s incubation period. Those who begin to develop Ebola symptoms should then be isolated to avoid further transmission, and then their contacts also traced and observed for 21 days. Given CHWs’ ability to provide basic health surveillance in their communities, they can play a key role in controlling the outbreak if done carefully with proper safety precautions and adequate supervision.

UNFPA has worked with the Government of Sierra Leone to conduct contact tracing to identify people linked to confirmed or probable Ebola cases using CHWs. CHWs were trained to identify household members with possible symptoms as well as people who may have been exposed. This data is sent to the District Surveillance Officer and the Government-manager District Ebola Task Force. Additionally, individuals who are identified by CHWs with symptoms of Ebola can be monitored closely. In Guinea, the CDC has trained CHWs to follow up on people who were exposed to Ebola for 3 weeks, checking on symptoms and reporting findings to a supervisor. Reported cases would then be tracked and sent to treatment centers with the hope of avoiding further transmission.

Given the need for interaction with possible exposed patients, this contact training method would require rigorous training on safety precautions, appropriate equipment, and supervision to not only reduce the risk to the CHW, but also the risk of spreading the virus to other households."

----

"Door to door

UNFPA, along with WHO and the Ministry of Health and Sanitation, have trained 300 health workers to serve as contact tracers.

The tracers go door-to-door to learn about people who might be affected, then follow up with each possible contact. Those exhibiting symptoms of Ebola, which include fever, diarrhoea and vomiting, are closely monitored.

The health workers are also trained to protect themselves from the virus.

The collected data is sent to the District Surveillance Officer and the Government-managed District Ebola Task Force.

The contact tracers are equipped with mobile phones provided through a partnership between UNFPA and the phone companies Africell and Airtel. Each company donated 150 phones that enable health workers to capture and store information in a database. The information is then relayed to the health ministry.

The mobile phone company Skytel also provided 30 mobile phones for contact tracing and surveillance."

 

[mac68DC]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

Emergency Plan of Action (EPoA)
Liberia: Ebola virus disease

http://adore.ifrc.org/Download.aspx?FileId=58454

"...One of the major gaps in the current
response is contact tracing within all locations...."

 

[Sharky]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

Nearly insurmountable logistics is one aspect of the problem.

Another concern is the current lack of cooperation from the infected or exposed locals. With people claiming that Ebola isn't real, or that it's caused by sorcery, and with people dumping dead bodies in the street (after obviously being exposed), not coming in for treatment and quarantine, raiding and looting care facilities, and so on -- it's hard to imagine any amount of money that could be thrown at the problem that would fix it.

I think it's likely the disease will need to burn out, as enough locals are exposed and those that survive develop immunity. After a while, population immunity should develop, and the disease should subside -- as long as new mutations of the virus don't appear for which previous immunity doesn't work.

The 20,000 number that's being thrown around seems very optimistic to me. Confirmed infection and deaths are still on an exponential growth curve, with 40% of cases reported in just the last 21 days. I saw a thread here on FT saying that there were 500 new cases in just the last week -- not including who knows how many unreported cases.

 

[Laidback Al]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

. . . I think it's likely the disease will need to burn out, as enough locals are exposed and those that survive develop immunity. After a while, population immunity should develop, and the disease should subside -- as long as new mutations of the virus don't appear for which previous immunity doesn't work. . . .

The current data on the Case Fatality Ratio or Rate (CFR) is unreliable. From past outbreaks, the CFR has been as high as .9 or 90%; nine of ten people die after infection. Waiting for this outbreak to "burn out" is not an a realistic option without grave social and economic consequences.

 

[Sharky]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

The current data on the Case Fatality Ratio or Rate (CFR) is unreliable. From past outbreaks, the CFR has been as high as .9 or 90%; nine of ten people die after infection. Waiting for this outbreak to "burn out" is not an a realistic option without grave social and economic consequences.

Yes, I agree the CFR numbers are fuzzy at best.

Although it's certainly worth whatever efforts can be made to avoid reaching the stage where the outbreak is resolved by population immunity alone, what I'm suggesting is that those efforts, no matter how large, may not completely stem the tide of this disease.

In that sense, I'm not thinking of "burn out" as an "option" -- a choice -- but rather as the reality of the situation.

And yes, I agree this implies grave social, economic and humanitarian consequences.

 

[Laidback Al]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

Sharky, agreed, burn out is never an acceptable solution. We can only hope that the international community can quickly implement a viable solution to this out-of-control outbreak. It will take an external multinational effort. Waiting is not the answer.

 

[JimO]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

What doesn't seem to be addressed is the role that survivors could play as community health workers. There is a growing number of people who are immune.

 

[Sharky]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

What doesn't seem to be addressed is the role that survivors could play as community health workers. There is a growing number of people who are immune.

Yes, survivors could help in several ways:

1. As front-line public health workers, doing contact tracing, triage screening, handling bodies, and other roles at high risk of exposure.
2. As spokespeople, to assure others both that Ebola is real, and that it's survivable.
3. As blood donors, to continue what should be ongoing trials of whether their immunity can be transferred to others, as indicated by some existing research.

I wouldn't say there's zero risk for survivors, though, in terms of re-infection. It's possible that the virus will mutate into a strain that they are not immune to. They should still use PPE, both for their own protection and to prevent accidental spread to others.

 

[Graupel]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

I think CHW are a critical part of the response, but there are several major barriers:

1) stigma against survivors
2) lack of any health systems to coordinate a CHW response
3) viral mutation as mentioned above
4) potential for major socio-political instability is rising rapidly
5) Contact tracing might be rapidly becoming a logistic impossibility- tracing will be hard enough, but then followup and referral might be simply impossible at the scale we're seeing?

That's not a very constructive or forward looking list, but it might be reality, especially with the new situations in Nigeria and Senegal.

 

[mac68DC]

Re: Ebola - Generals [CDC?] are always fighting the last war (proverb)

Pretty sure the Ebola train has left the station and everyone's ticket is punched.

While I have criticized the CDC and the WHO, that's easy to do while I am sitting safely at home. They were dealt a bad hand. The poor Doctors without Borders have been on the front lines since the start, and have taken a serious mauling.

All these organizations have had people who have sacrificed. Unfortunately, they were badly out flanked. The poor people on the front lines are sounding truly desperate. It must be horribly frustrating for them.

I absolutely can not envision any plan or action that will stop this epidemic.

Short of a very massive and immediate deployment, I can't even see slowing it down much in the countries now infected (other than Nigeria).

Time to start looking ahead, instead of being two steps behind.

I hope they have a competent and experienced international rapid deployment force on standby at all times. They need to handle the cases that are bound to pop up in other countries.

A very large deployment is needed ASAP for Nigeria. It's vital to get that situation under control. i know they only have a few official reported cases, but now is the time to get in there and get the infrastructure and community awareness up to speed.

I am not saying that the countries now affected should be abandoned. I Just want to see something get ahead of the train.

Nigeria is the key right now.