Ebola: from fever to fever and from victory to victory

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Article original submitted in Spanish to “Diario La Hora Esmeraldas” on Oct 22nd, 2014. Edited to be relevant for public in the US on Nov 4, 2014.

The world is keenly observing the development of a new chapter in the epic drama of the battle between human being and microorganisms with astonishment. Microorganisms are responsible for infectious diseases that have threatened, decimated and forced genetic adaptation of the species called to have dominion over the Earth. Indeed, we face a new threat in the form of a febrile disease carved out of the depths of the African jungle: Ebola. Ebola Virus Disease (EVD), as it is known today, is a disease caused by a long and thin filovirus that was first identified in areas surrounding the Ebola river in the tropical jungle of the Republic of Zaire, the old name of the Democratic Republic of Congo, in 1976.(1) Since then, the disease has sporadically erupted in outbreaks that have been relatively confined both in time and space, and for that reason they did not captivate the attention of international media. The only salient characteristic of this disease was the ferocity of its symptoms and high case fatality rate (usually between 30-90%, depending on species). (2) Such symptoms include the sudden onset of fever, malaise, diarrhea, and vomiting, which may develop into a hemorrhagic phase with high mortality rate.(1) It is precisely this high mortality, combined with ignorance about the disease among the general public, which make this a mysterious disease able to elicit panic in such distant geographical locations like Africa, where the epicenter of the current epidemic lies and the US. This short note tries to demystify the disease by briefly reviewing its medical, scientific and humanitarian aspects.

ebola

Firstly, the extent of the current epidemic is worth clarifying. It is the first time that an outbreak of Ebola has spread so quickly, has infected so many people (they had never before exceeded more than 500 affected individuals between confirmed and suspected cases) and has transcended the borders of many countries (besides Guinea, Sierra Leone and Liberia, the three countries of West Africa where the epidemic is concentrated, cases have been detected /treated in Nigeria, Senegal, Mali, United States, Spain and other European countries). Another unique feature is that it is the first time that an epidemic develops in West Africa, since so far previous outbreaks had occurred in Central and East Africa. (3)

Given the large number of infected persons and the high mortality associated with this disease, human suffering caused by this epidemic is indescribable. An epidemic that began in a remote rural community on the triple border between Ghana, Sierra Leone and Liberia, quickly spread, for the first time in history, to urban centers with greater population concentration and where the disease spread as a powder keg. (2) Families have been broken and the local culture greatly affected since health recommendations are not to have close contact with sick people, opposing long-standing African traditions. (4, 5) The population has also felt powerless due to lack of resources and insufficient government support, to the point of even attacking the health teams charged precisely with helping them. (6) In general, the current scenario in these regions of the world is worrying. International agencies seem to have responded slowly and so far cannot commit the minimum funds or personnel required to face this epidemic. Moreover, it is logical to wonder how is it possible that in more than 30 years since the discovery of the disease, there still are no significant advances either in the prevention or management of the disease. A simple answer is given in the blog of Dr. Juan Carlos Maldonado: it is not economically convenient for large pharmaceutical companies to invest millions of dollars in a disease that is rare and mainly affects people with limited economic resources who would not be able to purchase drugs (this is also true with other diseases affecting developing countries). It is a sad reality.

Doctoral students Miguel Reina Ortiz and Vinita Sharma

Doctoral students Miguel Reina Ortiz and Vinita Sharma

One could ask (certainly without losing sympathy for the great suffering of our fellow human beings): what is the real possibility that we will have to face a similar Ebola outbreak in the Americas? And, if it were to happen, are we ready? Answering any of these questions is a very difficult task; however, here are a couple of ideas. Firstly, there is frequent air travel between African countries and Europe/US. This would translate into a non-negligible probability that people originating from the affected countries will make it to US soil. However, we must understand that a person originating in those countries does not necessarily mean that they are carriers of the disease: discrimination and unnecessary segregation should not be acceptable in modern societies. Nonetheless, we have to be attentive at all levels, not only in airports, ports and land border crossing points, since we must remember that Ebola has an incubation period of 21 days (i.e., a person may enter the country without symptoms and develop them several days later, when is no longer at the airport, as happened recently in Dallas, Texas). (7) Another aspect to take into consideration is the likelihood of contamination, a regular person who does not work in healthcare, let alone caring for Ebola patient, and who has not been in close contact with an Ebola patient, would have very low risk of carrying the virus even if the person is an original of the affected countries and has recently enter the country. However, a healthcare professional who has been caring for Ebola patients has more likelihood to carry the virus even if the person is not a native from the affected countries and even if the person does not show symptoms upon arrival. Close monitoring should be kept for all “high-risk” people, although the real challenge, as evidenced by recent media coverage, is defining who is a high-risk person.

Ebola is not the first fever coming out of Africa threatening to decimate human populations, hence the title of this note “from fever to fever”. The fact that many febrile diseases have originated in Africa should not surprise us since human settlements found in Africa are amongst the most ancient ones; therefore it is reasonable to expect a finding like this. It is believed that many other febrile illnesses have originated or spread out of this vast continent including malaria,(8) dengue,(1) yellow fever, (9) and recent Chikungunya fever strains. (10) All of these diseases caused panic and decimated populations until they, either naturally or through the development of new technologies and deeper understanding of their mechanisms of transmission were controlled. Indeed, infectious diseases have gone from being the first cause of mortality to a less important position in developed countries while developing countries are making significant progress on their control. Ebola is new to the neighborhood, but if history can serve as any indication, it can also be controlled. For this reason, this note has the title ‘from fever in fever and from victory to victory”, since so far our encounters with infectious diseases have been repetitive, with new actors appearing from time to time, but we have also repetitively learned to understand them better and, in many cases, to control them. Our hope must be that the same series of events will happen with Ebola.

In summary, the authorities should maintain watchful eyes not only at checkpoints in borders and crossings to enter the country but also in the emergency rooms of all hospitals and units of both public and private health services. Similarly, protocols should be established to ensure timely diagnosis, transfer of patients, isolation, intensive care treatment, sterilization of surfaces and dwelling units, and public education. In order to achieve this, we must equip special units in the main cities of the country. Citizens, for our part, must remain calm and be constantly informed through official channels and report any suspected case immediately.

Written by Miguel Reina Ortiz, MD, MS, MPH, and Vinita Sharma, USF College of Public Health

References

  1. Guerrant RL, Walker DH, Weller PF. Tropical infectious diseases : principles, pathogens, and practice. Philadelphia]: Saunders Elsevier; 2011.
  2. Baize S, Pannetier D, Oestereich L, Rieger T, Koivogui L, Magassouba N, et al. Emergence of Zaire Ebola virus disease in Guinea. The New England journal of medicine. 2014;371(15):1418-25. Epub 2014/04/18.
  3. Chippaux JP. Outbreaks of Ebola virus disease in Africa: the beginnings of a tragic saga. The journal of venomous animals and toxins including tropical diseases. 2014;20(1):44. Epub 2014/10/17.
  4. Hewlett BS, Epelboin A, Hewlett BL, Formenty P. Medical anthropology and Ebola in Congo: cultural models and humanistic care. Bull Soc Pathol Exot. 2005;98(3):230-6. Epub 2005/11/05.
  5. Kunii O, Kita E, Shibuya K. [Epidemics and related cultural factors for Ebola hemorrhagic fever in Gabon]. [Nihon koshu eisei zasshi] Japanese journal of public health. 2001;48(10):853-9. Epub 2001/12/01.
  6. Canadian Broadcasting Corporation, CBC. (Apr 5, 2014). Ebola clinic in Guinea evacuated after attack. Canadian Broadcasting Corporation. Retrieved from http://www.cbc.ca/news/world/ebola-clinic-in-guinea-evacuated-after-attack-1.2599555.
  7. Gostin LO, Hodge JG, Jr., Burris S. Is the United States Prepared for Ebola? Jama. 2014. Epub 2014/10/18.
  8. Cox FE. History of human parasitology. Clinical microbiology reviews. 2002;15(4):595-612. Epub 2002/10/05.
  9. McNeill JR. Yellow Jack and Geopolitics: Environment, Epidemics, and the Struggles for Empire in the American Tropics, 1650-1825. OAH Magazine of History, 2004; 4:9-13.
  10. Lo Presti A, Ciccozzi M, Cella E, Lai A, Simonetti FR, Galli M, et al. Origin, evolution, and phylogeography of recent epidemic CHIKV strains. Infection, genetics and evolution : journal of molecular epidemiology and evolutionary genetics in infectious diseases. 2012;12(2):392-8. Epub 2012/01/17.

 

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