Ebola Just 'A Plane Ride Away'

Jasenka Piljac Zegarac, PhD

Disclosures

July 15, 2019

Ebola is once again ravaging the vulnerable and less privileged parts of the world. The most recent outbreak of the virus was declared on August 1, 2018, in the very heart of Africa—the North Kivu and Ituri provinces of the Democratic Republic of Congo (DRC). As of June 27, 2019, a staggering 2297 Ebola cases (2203 confirmed and 94 probable) and 1553 deaths (1459 confirmed and 94 probable) have been recorded in the DRC.

Containing the Current Outbreak

Lessons learned in 2014 in Sierra Leone, Liberia, and Guinea can hardly be applied to a country torn apart by ongoing violent conflict and feuding political factions. Complicating the response and containment efforts further is the lack of trust in healthcare workers, who frequently come under attack by rebel forces.

Thus, it came as no surprise when, on June 10, the Ugandan Ministry of Health confirmed the cross-border spread of the virus and the first case of Ebola in Uganda.

Although the DRC and Uganda may seem half a world away, experts warn that Ebola in Africa is by no means an African problem. International travel and ongoing immigration from Africa to Europe, as well as the long incubation period of the Ebola virus (between 2 and 21 days),[1] make it a challenge to contain the spread of disease.

"With our increasingly connected world, infectious diseases are only an airplane ride away, making it possible for a person exposed to Ebola in rural Africa to be in a major metropolitan city within 36 hours," says Krutika Kuppalli, MD, affiliated assistant clinical professor in the Division of Infectious Diseases and Geographic Medicine at Stanford University School of Medicine and member of the Infectious Diseases Society of America (IDSA) Global Health Committee. "Ebola not only leads to considerable loss of life and burden on the healthcare system, but it can also have a profound socioeconomic impact. For example, the World Bank estimated that the three countries mainly affected by the 2014 West African outbreak lost $2.2 billion in gross domestic product. Although it may not be apparent, these losses have a downstream effect with worldwide implications."

Should We Worry About Ebola in the United States?

Experts largely agree that the risk is not very high at the moment.

"Ebola is not a very contagious disease," says Peter Jay Hotez, MD, dean of the National School of Tropical Medicine at Baylor College of Medicine. "The way we express that is the reproductive number, which is just under 2 in the case of Ebola[2]—this means that if an individual has Ebola, on average only 2 other individuals will get it if they're taking care of dying or recently deceased Ebola patients. That's in contrast to measles, which is one of the most highly contagious diseases with a reproductive number of 12-18, because the virus persists in the environment."

Kuppalli agrees that the chances of Ebola reappearing in the United States are currently not high but cautions that things could change very quickly. "Northeastern DRC has been plagued by years of violence, leading to mass displacement of Congolese fleeing the area," she says. "Owing to the mobile population, there is an increased risk of individuals who have been exposed to Ebola crossing the border into one of the surrounding countries. This is illustrated by the recent cases of Ebola that spread into Uganda earlier this month. How quickly the virus could spread is best demonstrated by a contact in the DRC who moved to Dubai this past week and is now being monitored there."

How Ready Are We?

With the situation brewing in central Africa, the questions routinely posed by staff in healthcare settings across America, "Have you traveled outside of the United States in the past 3 months?" and "Have you recently traveled to Africa?" suddenly seem to carry added weight. What if the answer to both is "yes" and the patient is presenting with Ebola-like symptoms? How are patients with positive travel screens handled, and do medical centers across the United States have clear guidance on how to provide care for them? Are we ready for Ebola 2.0?

Kuppalli believes that US health systems today are much better prepared to handle Ebola cases than they were in 2014. "The National Ebola Training and Education Center (NETEC) has done a wonderful job in preparedness and training of hospitals," she says. "Among other things, NETEC offers online course content, videos, and on-site readiness consultations to assist healthcare facilities as they build and sustain their capacity to effectively manage patients with Ebola and other special pathogens."

Healthcare staff practicing care of Ebola patients. Image from Shutterstock

Medical director of the Special Containment Unit at Texas Children's Hospital Amy Arrington, MD, says that the current outbreak is a little more worrisome now that Ebola has reached Uganda. "Regardless, we always have to be prepared, whether for Ebola or for any other special infection, such as avian flu, monkeypox, or any other hemorrhagic fever. It takes daily vigilance; travel screening; and staff that are prepared to take care of patients with special infections, such as Ebola."

Texas Children's Hospital is the first designated pediatric Ebola treatment center and is currently equipped with an eight-bed biocontainment unit, its own laboratory, designated autoclaves for trash, and a specialized team of volunteers—physicians, nurses, and laboratory specialists—who train every 3 months year-round. "Our staff train with personal protection equipment (PPE) and simulation exercises where they learn how to take care of patients with such diseases as Ebola," says Arrington.

Learning how to use PPE to safely transfer patients with Ebola is a major challenge, she adds. "I can't stress enough that it takes practice to learn how to become proficient at this. All hospitals should have established protocols on how to travel screen, identify, and isolate patients, and protect the staff. When patients are placed into special isolation, it is critical that staff know who they need to call and how they are going to transfer the patient. It's important to always have a phone tree with updated contacts, including the local Department of Health, and to make those friends before you need them."

Arrington says that their protocols are largely based on guidance from the Centers for Disease Control and Prevention (CDC) and protocols used by the University of Nebraska Medical Center, with modifications made for pediatric patients. The policy at Texas Children's is to immediately isolate those patients who have a positive travel screen and present with symptoms of a severe infectious illness. The specialized team is then activated to take over hands-on care.

Thus far, no pediatric cases of Ebola have been detected in the United States, but Ebola protocols can be applied in cases of other serious infectious diseases, such as severe acute respiratory syndrome, Middle East respiratory syndrome (MERS), or avian flu, Arrington says. Local smaller hospitals that don't have the infrastructure to care for patients with Ebola should be prepared to safely transfer them to one of the CDC-designated regional Ebola treatment centers, she adds. "The CDC and the Assistant Secretary For Preparedness and Response have developed a well-thought-out tiered approach and regional treatment network, not only for Ebola but other special pathogens as well, that allows hospitals to identify patients and safely transfer them to specialized centers on a geographic basis."

According to CDC's Interim Guidance for Preparing Ebola Treatment Centers, the decision to receive a patient with Ebola "should be informed by discussions with public health authorities and referring physicians, depending on the status of the patient." The CDC also recently updated infection prevention and control measures relevant to US healthcare facilities and personnel with information and links to the US Regional Treatment Network for Ebola and other special pathogens. The CDC continues to provide updated guidance on PPE and PPE donning (putting on) and doffing (removing) protocols.

The Ebola Vaccine

Merck's investigational Ebola vaccine V920, also known as rVSV-ZEBOV, though not yet approved by the US Food and Drug Administration, has proven to be a game changer in the DRC outbreak.

"This current outbreak could have been worse than the terrible one in Guinea, Liberia, and Sierra Leone in 2014 if it wasn't for the vaccine," says Hotez. "The vaccine has given us real hope that we could eventually contain this."

Kuppalli agrees that the vaccine has proven instrumental in managing the situation in the DRC. "According to information released by the World Health Organization (WHO), more than 90,000 individuals were vaccinated in the DRC and only 71 have gone on to develop infection," she says. "So, the vaccine has proven to be 97.5% effective. As of June 4, 2019, 130,000 people in the northeast DRC have been immunized."

She further notes that in case of an outbreak in the United States, the vaccine would probably be administered to individuals potentially exposed to the Ebola virus, which includes all those who have come into contact with the patient, as well as contacts of contacts.

Fear of Falling Through the Cracks

Arrington believes that travel screening is the weakest link in US-based Ebola prevention efforts. A person with Ebola could fall through the cracks because it is extremely difficult to screen every patient, given healthcare's many potential points of entry.

"What keeps me up at night is potentially missing a patient just by not being able to travel screen," she adds. "And it's not just Ebola. An outbreak of MERS is currently taking place on the Arabian Peninsula. The respiratory viruses that are the bigger threat than Ebola can easily be missed, because they present like the common cough and cold, pneumonia, or flu that we see every day."

Kuppalli agrees that early recognition of Ebola infection is a challenge that can seriously undermine prevention efforts. "Early in the disease course, Ebola tends to present with nonspecific symptoms similar to those of other infections, such as measles, malaria, influenza, or typhoid fever," she says. "It's important for practitioners in all healthcare settings to know about Ebola and ask patients pertinent travel screening questions. If someone has recently returned from the DRC or surrounding countries, healthcare providers should have heightened suspicion for Ebola."

The second biggest challenge, Arrington says, is being able to constantly maintain the necessary level of preparedness. "Ebola needs to remain a priority. We need to keep practicing and making sure that we have the necessary procedures and protocols in place."

A Plea for More Aid

The May 29 press release issued by the IDSA highlighted the concerns raised at the 72nd World Health Assembly in May, where representatives of the DRC and the WHO warned about the communication and planning problems that are hindering the response on the ground and called for $28 million in additional aid. Emphasizing the gravity of the current situation in the DRC, WHO Africa Regional Director Dr Matshidiso Moeti noted that the current outbreak in DRC is "one of the most complex health emergencies the world has faced."

In response to mounting international concern, the IDSA urged Congress to invest in appropriate and immediate responses to the current outbreak and to provide a minimum of $172.5 million for the US Agency for International Development's (USAID's) global health security efforts and $208.2 million in funding for the CDC's Center for Global Health Division for the coming year.

In fiscal year 2019, the US Congress appropriated $108.2 million to the CDC's global health security efforts, and the budget request for fiscal year 2020 included $90 million and $100 million for USAID and the CDC, respectively.[3]

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