UN: After Dec there is no plan

[Vibrant62]

Re: UN: After Dec there is no plan.

Re: UN: After Dec there is no plan.

AD - this works if local communities can manage supplies of food, water PPE etc in each location, but centralised logistics and supply lines could be a problem.

However, if local communities are prepared to 'own' the issue, and cover this, it could work. The counter to this, is that in such poor countries where food supply is rapidly becoming an issue, I worry that things may already be at a point of 'every man for himself'.

I am not on the ground, so can only glean a sense of how things are from media reports.

It would be great to hear from anyone who lives in the region with their views, or from someone who has been deployed to work there, either commercially or for MSF or similar?

 

[AlaskaDenise]

Re: UN: After Dec there is no plan

I was thinking about poorer countries. Remember that this is what traditional rural Ugandans do when dealing with a "gemo". It worked for them. Here, we can remember Typhoid Mary's little house.

Was it the 1918 influenza or plague where communities isolated themselves and food was delivered by leaving it on the ground at the edge of town. Could we use helicopter food deliveries today (courtesy of the Swiss Army).

.

 

[Vibrant62]

Re: UN: After Dec there is no plan

Yes - the 'Gemo' is an interesting concept and suggests that Uganda at least may have had a run-in with ebola before, somewhere in their ancestral past, or something very similar.

AD - for those who were not party to our discussion, please could you repost the Gemo information here?

 

[Graupel]

Re: UN: After Dec there is no plan.

Re: UN: After Dec there is no plan.

Another similar alternative would be to designate one house as the quarantine area, removing non-infected or asymptomatic family members to a different house. When the outbreak is over, disinfected then burn down the house.

This plan could be implemented immediately.

.

Indeed, I think there needs to be serious discussion about plans like this. However, not sure how implementable it would be in any of the cities/towns?

 

[Laidback Al]

Re: UN: After Dec there is no plan.

Re: UN: After Dec there is no plan.

Another similar alternative would be to designate one house as the quarantine area, removing non-infected or asymptomatic family members to a different house. When the outbreak is over, disinfect, then burn down the house.

This approach assumes a quick resolution to the local outbreak. If the local outbreak lasted a long time, fomite transmission would not be an issue and there would be no need to burn down the house.

 

[AlaskaDenise]

Re: UN: After Dec there is no plan

Yes - the 'Gemo' is an interesting concept and suggests that Uganda at least may have had a run-in with ebola before, somewhere in their ancestral past, or something very similar.

AD - for those who were not party to our discussion, please could you repost the Gemo information here?

sure...

In David Quammen's new Ebola book, he described the traditional practices of the Acholi people, during a 2000 Ebola breakout in Gulu, Uganda. They believe in a gemo - a spirit that comes into the village and causes illness (past gemos were measles and smallpox). Once a gemo was declared, their culture dictates special behaviors:

- quarantine each patient in a house apart from other houses
- relying on survivors for patient care
- limiting movement of people between villages
- abstaining from sex
- not eating rotten or smoked meat
- suspending normal burial practices that entailed a "love touch"

Some think the cultural practices may have helped suppress the Gulu outbreak.


Dear UN: talk to the Acholi, tell them we have a new Gemo, then....listen.


.

 

[Sharky]

Re: UN: After Dec there is no plan.

Re: UN: After Dec there is no plan.

OK - so we have defined the problem.

What ideas do we have for solutions?

The problem goes much deeper than the UN's analysis implies. They have apparently ignored West African cultural issues, which are significant.

Here's my "10 point plan":

1. Recruit survivors as key members of front-line support. I realize their numbers are limited, but to the extent possible, they should be the ones doing house-to-house work, burying dead bodies, community education, triaging incoming patients, and so on. Using survivors for this work would eliminate the need for scary PPE, which is important when trying to engage locals.
2. Recruit survivors into donating blood for use in transfusion therapy. Yes, it's still experimental. Brantly obviously believes in it, and has donated over a gallon of his own blood.
3. Valuing the services of survivors could also help limit or reverse the stigmatization that's happening now.
4. Hospitals and other centralized care facilities can't be built fast enough, and they are probably also ripe areas for passing on the virus. The risk of catching something you may not already have increases the fear of locals to go there, even when they can. Instead of putting energy into building, adopt an aggressive in-place / in-home treatment program. The nurse who used trash bags for PPE showed that it's possible.
5. Emphasize the importance of fluid and electrolyte replacement. That may the single best thing people undergoing home treatment can do to increase their chance of survival.
6. Community education should include the basic basics, such as the germ theory of disease; Ebola is real; it's not caused by sorcery; it's transmitted by bodily fluids; and so on. Should be conducted by locals as much as possible, not foreigners, and especially not anyone wearing PPE.
7. Continue to tackle burial rights and customs. Solicit local help to figure out how to do this most effectively.
8. Regional isolation and quarantine. It's not perfect, but was used successfully with smallpox, including Variola minor, which had a CFR much less than Ebola; there's no reason to believe it wouldn't be effective here.
9. Airdrop relief supplies and/or have them delivered by survivors, not people in PPE.
10. Ban civilian air travel from affected countries. Stop issuing visas. Emergency and relief travel only.

 

[AlaskaDenise]

Re: UN: After Dec there is no plan

If locals are expected to forego their traditional burial practices, they might accept it better if there were a new custom (that white bag is so impersonal) attached to the improved burial custom. Something to take the place of the "love touch" - perhaps loved ones could attach pictures, notes, etc. onto the body bag - as a way of expressing their love for the victim. The locals must know of some artistic, special symbols that would be accepted.

.

 

[AlaskaDenise]

Re: UN: After Dec there is no plan

More research on a gemo turned up this expanded protocol:

Table 2. Acholi Protocol to Control Epidemics (gemo).

These methods are utilized only when the illness has been identified and categorized as a killer epidemic (gemo).

1. Quarantine/isolate (gengo) the patient in a house (ot) at least 100 meters away from all other houses. Nobody should be allowed to visit the patient.

2. A survivor of the epidemic feeds and cares for the patient. If no survivors are around an elderly woman or man will be the caregiver.

3. Houses with ill patients should be identified with two long poles of elephant grass (lum-lagada); one on each side of the door.

4. Villages/households (doggang) with ill patients should place two long poles with a pole across them to notify those approaching the village/household.

5. Everyone should limit their movements--stay in your household (doggang) and do not move between villages.

6. Do not eat any food from outsiders.

7. Pregnant women and children are especially prone to epidemics and should be especially careful to avoid the patient.

8. Increase harmony within the household; no harsh words or conflicts within the family.

9. Nobody should have sex.

10. Nobody should dance.

11. Do not eat rotten or smoked meat; only eat fresh cattle meat.

12. Once the patient gets better (no longer has symptoms) they should remain in isolation for one full lunar (dwe) cycle before moving freely in the village.

13. If the person dies the survivor/attendant buries the person and the person is buried at the edge of the village.

The Cultural Contexts of Ebola in Northern Uganda

.



.

 

[JJackson]

Re: UN: After Dec there is no plan.

Re: UN: After Dec there is no plan.

Here is a thought. ETU beds are going to outstrip supply for some while, whilst cases escalate. Home care is becoming essential BUT it risks whole family continued exposure, keeping the R0 above 1. There are also the issues of supply logistics so that families do not have to go out to collect food and water and other essentials - multiple locations in hard to reach territory will make this very, very difficult to keep supply lines open. If isolated families start starving families will flee, fearing forced isolation where they could starve (their perception), and/or they will flee fearing infection if housed in the same building as their infected relatives.

So - an idea...

Disaster relief NGOs have many thousands of tents and ancilliary requirements for the construction of tent cities when a major natural disaster strikes or for constuction of refugee camps.

Each tent is designed to provide housing for a family.

How about mobilising these NGOs to set up small isolation units per 10 villages or to service individuals who cannot get beds in an ETU (treatment Unit) from a population of say 10,000 or 20,000, which in turn can be seperated into 'probable cases'and close contacts for isolation? Probable cases can be isolated in a tent with a designated care giver who is provided with home PPE kits and training, pending a free bed in an ETU and/or after testing. Family members are housed in the isolation area (one tent per family), and seperated from the probable cases. If an individual develops ebola then they are moved to the probable section family tent with the original case. One family caregiver should be able to manage the two cases in terms of providing the basics etc.

It is then one drop point for logistics aid i.e food, water and other supplies, which can be delivered to the 'community' center and collected by caregivers, or families in isolation. Required kit (tents etc) should already be inexistence and would just require transport from the respective charities. The NGOs should already have systems in place for logistics management with a little adaptation, and additional staffing could come from those in isolation provided they pass a fever check, or if that is considered too risky, from the communities themselves. It is also one collection point for medics doing testing, body removal etc. Survivors could be employed here to assist.

Once a family in isolation has passed a 21 day point where NO member of their family has become sick, the entire family can return home to their village or town.

Do we think this could work? Problems?

They are already doing it - sort of.

In all three intense-transmission countries, a lack of available beds in ETUs forces many families to
care for patients at home. In the home setting, carers are unable to adequately protect themselves
from EVD exposure, and thus the risk of transmission wi thin the family and throughout the
community is greatly increased. As a remedial measure, Ebola Community Care Units
(ECUs)/Community Care Centres (CCCs) are now being introduced into communities. These facilities
will enable newly detected cases to be isolated, and thus reduce household transmission. ECUs/CCCs
are controlled environments within communities where patients with EVD can receive supportive
and palliative care in close proximity to their families.
Liberia and Sierra Leone are the first countries to implement ECUs/CCCs. Liberia has opened two
CCCs in Bong and Montserrado. In Sierra Leone, a total of 149 CCCs are planned within the next 10
weeks.

On 8 October, the Ebola Communication Network (ECN) was launched. ECN is an online collection of
Ebola resources for Ebola communication
3
developed by the Health Communication Capacity
Collaborative with inputs from UNICEF, the US Centers for Disease Control and Prevention, USAID,
IFRC, and WHO to strengthen the capacity of countries to implement s tate-of-the-art healthcommunication programs.
A working group of representatives of faith-based organizations was established to collaborate with
WHO, UNICEF and IFRC to ensure that religious and cultural practices are included as part of the
technical guidelines on safe and dignified burials.
A protocol on community engagement developed by WHO and UNICEF for the planning and roll-out
of ECUs/CCCs, has now been finalized. The protocol will ensure that affected communities are
listened to, consulted, and that they will drive the local-level response to reduce EVD transmission.

Both quotes come from yesterday's road map update

 

[Helderflower]

Re: UN: After Dec there is no plan.

Re: UN: After Dec there is no plan.

Disaster relief NGOs have many thousands of tents and ancilliary requirements for the construction of tent cities when a major natural disaster strikes or for constuction of refugee camps.

The BBC (South West) has just announced that UK disaster relief charity ShelterBox is standing ready to dispatch emergency shelter tents to Ebola-struck areas of West Africa.

Emergency shelter specialist ShelterBox is on standby to help the UK Government and international medical charities contain the Ebola outbreak in West Africa, which has already claimed over 4,000 lives.

At the moment the most pressing shelter need is for large scale medical tents to create field hospitals, but ShelterBox?s family tents have seen service over the years as recovery areas, such as after the Haiti earthquake in 2010 where there was a cholera outbreak.

http://www.shelterbox.org/news.php?id=1486

 

[Nika]

Re: UN: After Dec there is no plan

Any solution that comes from outside their community (as in 1000s of miles away by nonafrican people who they have never met, people who have never visited the region) isnt likely to be met with much success. Your time here is better spent conceptualizing how YOUR community will cope with it.

 

[Vibrant62]

Re: UN: After Dec there is no plan

Helderflower; JJackson

Good to see things like this happening.

As long as their community care centers allow for people to be seperated from each other so that they do not simply become infection centers, where people with e.g. malaria dont simply end up catching ebola from a real case - otherwise no-one will go there after a short period of time.

The tent idea at least allows for seperation of probable cases.

We will have to see the detail on the CCCs, but in the absence of a better solution, these have to be a good move.

 

[GardenSpider]

Re: UN: After Dec there is no plan

Any solution that comes from outside their community (as in 1000s of miles away by nonafrican people who they have never met, people who have never visited the region) isnt likely to be met with much success. Your time here is better spent conceptualizing how YOUR community will cope with it.

Excellent point Nika. The variables in West Africa- culture, history, education, poverty, beliefs- make it extremely difficult to problem solve from here for their diverse communities. What may work for the tribe in Uganda, can't necessarily be exported to a different people. Speaking as someone who has worked extensively in remote tribal villages, IMO, there is no artificially imposed solution that will work. MSF seems to have the greatest understanding of what is required given their years of experience in Africa. At present it seems the situation is unsolvable- exactly like trying to catch up with a speeding Porsche with a VW bug on the freeway- the distances keep growing.

Here at home, my family and I have decided to add Ebola to our emergency preparedness plans. We have such plans in place here in California for earthquake and now this seems prudent in the event Ebola does not burn out (plenty of human fuel), and there is no immediate vaccine available for all.

 

[Vibrant62]

Re: UN: After Dec there is no plan

Let me pose a question.

Banbury said that after 60 days we will be in a situation for which there is no plan.

If the outbreak remains out of control, then further international spread is inevitable, and we may end up with many more 'loci' of infection.

Can anyone find details of their regional, state, country or other plans for managing a domestic outbreak? Flu pandemic plans are not sufficient here - the dynamics of ebola are very, very different and there are many issues that are specific to ebola that may not have been considered in such plans.

For example, waste management; body handling; PPE; training; isolation requirements for contacts; contact tracing etc etc

Most of these would not figure in a flu pandemic plan.

The world may not have a global plan at the moment. Does anyone have a national one? Can you find one for your part of the world that could apply? Or do you know if such planning is underway, and if so, by whom?

 

[Nika]

Re: UN: After Dec there is no plan

Re planning for a global ebola pandemic... if you had asked that 12 months ago any planner would have dismissed the thought nearly immediately.

All planning training preparing is imperfect. We are human and time/money isnt infinite. Instead of dwelling on the lack of fully vetted practiced and immediately deployable ebola pandemic plans (many reporters love creating/milking this controversy as this is the easy lazy way of reporting for the circus) people have to (many are) moving forward with what we have.

Im very happy to see messaging coming out that regional ebola hospitals will be part of the solution.

Im pretty confident that any loci of onward transmission in the US will be neutralized. Watch the archived press conference from Cleveland yesterday. The mayor and other locals made it clear they had no technical understanding but that they were fully committed to doing what ever it takes to make their people safe. This wasnt a call to lock n load but an expression of community facing it together.

Even our worst urban environments are heavenly compared to the slums of Liberia.

 

[Ray]

Re: UN: After Dec there is no plan

And today the UN announces that they are out of money.

The new United Nations trust fund for Ebola has received a small fraction of the $1 billion that the world body says is needed to tackle the outbreak, and has only $100,000 left in its account, Secretary General Ban Ki-moon said Thursday.

Speaking to reporters, Mr. Ban urged governments and private donors to open their pocketbooks to contribute to the trust fund established in mid-September. It has received $20 million in cash, most of which it has spent.

?Our bank account has only $100,000 and this is a very serious problem,? Mr. Ban said.

The number of Ebola cases is expected to exceed 9,000 this week, with a total of 4,500 deaths, the World Health Organization said earlier in the day

?We need urgent global response,? Mr. Ban said.

The United Nations is separately rallying countries to contribute cash and in-kind contributions, from helicopters to protective gear, for the three most heavily affected countries in West Africa: Guinea, Liberia and Sierra Leone.




http://www.nytimes.com/2014/10/17/world/africa/ban-ki-moon-pleads-for-ebola-aid-donations.html

 

[Vibrant62]

Re: UN: After Dec there is no plan

Nika: Completely understandable that there are no historic plans. However, given recent events, dont countries/ states and regions now need one, if nothing else to learn from the Texas and Madrid events? Put in place waste disposal agreements that comply with local legistlations etc - in other words, sort out all the areas that have been troublesome. Do hopsitals hold stocks of necessary PPE? Are their safety stock levels up to scratch, or have they been run down on the most important items e.g. IV lines and saline. Most of the errors seen so far have come about because there has not been 'a plan'.

So long as Ebola does not alter in any fundamental way, yes, most countries could deal with it - but current operational plans should be being drawn up to set standards, decide training regimens for staff, designate hospitals, and plan for isolation centers in the event of a wider outbreak (100s of possible cases) which would overwhelm existing specialst beds (which is entirely possible is some countries/ regions) etc. How would countries like India, the Philipines, Indonesia etc cope? They are not as robust as say the US, but serious outbreaks there would increase the numbers of introductions to other countries, and greatly affect (in a bad way) the global economy.

Everyone accepts that ebola is adapting; it could increase in its transmissibility (without becoming airbourne) as it passages through thousands of human hosts, which would change things quite radically. Wouldn't it be sensible for such plans to be developed very rapidly, now? I would hope that such planning is already underway. The risks of such a development are sufficiently high and the impacts catastrophic - such that contingency planning should be underway.

We cannot afford hubris - public plans also provide reassurance and confidence to the populations affected. When we have them, we can hope they are never needed, and in the meantime we should do all we can to stop this outbreak (and any future ones) at source.

 

[Emily]

Re: UN: After Dec there is no plan

Excellent point Nika. The variables in West Africa- culture, history, education, poverty, beliefs- make it extremely difficult to problem solve from here for their diverse communities. What may work for the tribe in Uganda, can't necessarily be exported to a different people. Speaking as someone who has worked extensively in remote tribal villages, IMO, there is no artificially imposed solution that will work. MSF seems to have the greatest understanding of what is required given their years of experience in Africa. At present it seems the situation is unsolvable- exactly like trying to catch up with a speeding Porsche with a VW bug on the freeway- the distances keep growing.

Here at home, my family and I have decided to add Ebola to our emergency preparedness plans. We have such plans in place here in California for earthquake and now this seems prudent in the event Ebola does not burn out (plenty of human fuel), and there is no immediate vaccine available for all.

GardenSpider, I have the same concerns you do about the feasibility of this epidemic in Africa being contained at this point with only tracing and quarantine measures, yet we are told it can be by infectious disease specialists.

I hope they are right and we are wrong, but even if the epidemic can't be completely extinguished it may be that the epidemic can be limited until effective treatments can be found. Doctors practicing in Liberia seem to be less constrained than doctors here are as far as re-purposing drugs, so there is hope in that area.

Also regarding vaccines, there is no need to have a large supply for the world in order to stop an epidemic in one area, even that of a much more transmissible agent.

http://www.fhcrc.org/about/ne/news/2006/10/16/smallpox.html

Study finds mass vaccination unnecessary in the event of a large-scale bioterrorist smallpox attack in the United States
Prompt surveillance and containment of victims would effectively thwart an epidemic

SEATTLE - Oct. 16, 2006 " Mass vaccination would not be necessary in the event of a large-scale smallpox bioterrorist attack in the United States, according to a study led by researchers at Fred Hutchinson Cancer Research Center that appears online in the International Journal of Infectious Diseases.

Instead, the current U.S. government policy of post-release surveillance, prompt containment of victims and vaccination of hospital workers and close contacts would be sufficient to thwart an epidemic, according to lead author Ira M. Longini Jr., Ph.D., a world leader in using mathematical and statistical methods to study the natural course of infectious diseases...

Though the Ebola epidemic spans countries, I think due to transmission capabilities the epidemic is akin to a constellation of clusters that could be ended with ring vaccination and HCW vaccination if it is impossible to safely treat Ebola patients without risk outside of BSL-4 facilities. (Looks that way, doesn't it?)

I'm not at all worried about a widespread Ebola epidemic in this country and am making no preps for one as a private citizen.

 

[Vibrant62]

Re: UN: After Dec there is no plan

When there is a vaccine, ring vaccination would be an effective strategy in localised outbreak areas, but right now we only have two putative vaccines on the slate, with no guarantee that either will work, or if they do show benefit, to what extent they will work. e.g. flu vaccines are only 50% effective.

In the event that testing shows positive results, it will still take considerable time to produce them in any meaningful quantites ie volumes that could be used to arrest this outbreak. At the moment the GSK estimate is 20,000 doses sometime in the first part of next year. That would be a drop in the ocean based on current outbreak numbers and contacts, if we account for the undercount of WHO case numbers and we project forward.

Years of research have not delivered an HIV vaccine that works, so basing plans on a vaccine we dont yet have could be highly risky.