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WWith Ebola-fighting teams struggling to contain the epidemic in the Democratic Republic of Congo, the World Health Organization and its partners can make changes to strengthen their efforts and prevent the crisis from erupting. it's getting worse, according to a handful of experts surveyed by STAT.
Experts fear criticizing WHO officials and others who are desperately trying to prevent the spread of the virus. The violence against Ebola workers and the refusal to cooperate with control measures in some communities have made this epidemic the second-largest ever, unlike anything Ebola practitioners have seen before. . Ebola treatment centers have been attacked several times and for many days, response service agents have been unable to move to crisis areas.
At the same time, experts believe that global health officials have an opportunity to strengthen their efforts.
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Here are three.
Good data is the key
Epidemiology is at the root of any response to Ebola. Knowing where the virus is spreading and who is on its way is critical to controlling an Ebola outbreak. But from the first days of this epidemic, it is a problem.
"I do not think there's a good record of what's going on. I do not think there is a good database, "said Dr. Pierre Rollin, an Ebola veteran who retired earlier this year from the Centers for Disease Control and Prevention. "We are driving in the fog because we do not have good data."
All previous Ebola outbreaks have been stopped using the same techniques: look for cases and isolate them so that they can not infect more people. Determine who they have contacts with and monitor these people daily. If any of them gets sick, isolate him and find his contacts. Bury the dead safely, so that funeral rituals do not contaminate more people.
In this epidemic, the stakeholders had an additional tool: an experimental vaccine.
For this approach to work, however, surveillance teams need to know in which social networks the Ebola virus is spreading. In this epidemic, this has often not been the case. A significant number of new cases were not previously on the contact lists. Their condition was not monitored and no vaccine was offered because no one knew they had been exposed.
The impact of these unidentified chains of transmission appears to increase as the epidemic develops. Since the beginning of May, only one-third of new cases were known contacts from a previous case. Only about half of these had agreed to be monitored to see if they were developing symptoms. Most did not agree to be vaccinated.
Dr. Scott Dowell, Assistant Director of Surveillance and Epidemiology at the Bill and Melinda Gates Foundation, shares concerns about the growing number of unrecognized cases.
"I think there is very likely a large unrecognized pool of transmission and unidentified patients," said Dowell, who has worked for decades for the CDC and worked on a number of responses to the Ebola virus. . "And the size of this pool is uncertain. And also uncertain for me to know if the current answer can go ahead, which is really disturbing. "
Rollin, who follows the outbreak closely, worries that so few probable cases add up to the totals of the outbreak. Probable cases are people who had Ebola-like symptoms and who had contact with people who were known or who also had Ebola-like symptoms. These are often people who are dead and buried without having been tested for the disease, but for whom there is a high probability of being infected.
Given the number of people who refuse to cooperate with Ebola teams – stay home when they're sick, fight safe burial teams trying to test corpses – there should be a constant flow of probable cases, Rollin said. And yet, they are rare. "So they miss a lot of cases," he said.
The capacity of the laboratory must be increased
There is concern that existing laboratory capacity to analyze samples of suspected cases of Ebola can no longer track the number of tests to be performed.
The National Institute of Biomedical Research of the DRC – INRB – supervises the tests. Rollin and others fear that current needs exceed its capacity, delaying the obtaining of test results.
"The lab is overwhelmed," Rollin said.
If a lab can not process all the tests quickly, it effectively limits the number of new positive cases that can be found, Dowell said. It's not that they are not there; it's because the lab can not locate them in time. This leads to slowdowns in identifying contacts of new cases and in their invitation to be vaccinated. People who need a vaccine may be vaccinated too late to prevent the infection.
Delays in obtaining test results also discourage people from getting tested, said Dr Axelle Ronsse, emergency coordinator at the Belgian branch of Doctors Without Borders. Test results can sometimes take two to three days.
The Gates Foundation urges the Congolese Ministry of Health and WHO to begin using rapid point-of-care tests developed after the Ebola epidemic in Africa. West of 2014-2016, said Dowell, who said that these tests could significantly increase the number of tests. people who are tested.
It is feared that the tests will lead to false negative results – people who are actually infected but not tested positive – admitted Dowell. But finding more people infected faster, if not all, should help, he said.
The laboratory capacity problem also extends to the sequencing of Ebola viruses, a technique that can be used to fill gaps in information on the chains of transmission when, as in the case of this epidemic, they occur. occur.
Newly confirmed cases may not know where and how they were infected. However, by comparing the sequence of their virus to that of the other cases, it can be clear that the infection occurred when two unrelated persons were in a clinic on the same day or it was patient has probably infected this taxi driver.
INRB, the Congolese national laboratory, is sequencing viruses. But the information he finds is not always shared in a timely manner with case monitoring teams. And the capacity is a problem here too. "As the number of daily positives has increased, sequencing has not nearly kept pace with these positives," Dowell said.
In his report to the World Health Assembly written by a group advising the WHO emergency program, there was mention of insufficient use of sequencing data, stating that "a timely analysis genetic sequencing data is essential to fully characterize [Ebola] epidemic to inform approaches to diagnosis, vaccination and treatment. "He recommended" closer collaboration between INRB and WHO ".
If Ebola treatment centers are considered toxic, find alternatives
In some communities, the reluctance to go to Ebola treatment centers remains deeply entrenched. Doctors Without Borders, which developed the current system of Ebola treatment centers, suggested that the diversification of care options could be helpful.
ETCs, as they are called, have become a place of stigma associated with death. In fact, people who seek care in treatment centers soon after the onset of symptoms are more likely to survive than those who avoid the centers – but this reality has not been recognized by the communities. affected.
Doctors Without Borders has proposed that some hospitals in the affected area be trained to treat Ebola patients safely – without posing a risk to their other patients – because, in fact, many people with Ebola symptoms are getting turn to clinics or hospitals rather than to treatment centers.
Similarly, the group urged the Ministry of Health to consider allowing some Ebola patients to be treated at home, even suggesting that experimental drugs against Ebola could be administered by a doctor. team of health professionals visiting some home-based care patients.
Ronsse said information centers should remain the main sites for Ebola patients. But with so many patients refusing to go looking for it, finding ways to minimize the risk that these patients present for health care workers who look after them in hospitals or their family members at home could help reduce the risk. transmission. The WHO recently reported that 68% of people who died of Ebola during this outbreak had died in the community – at home or in a health facility that was not a treatment center.
"It's something else we could do," Ronsse explained. "But we can not just do home care or treatments at the health center level. We should have the three levels. "
Similarly, Ronsse stated that home care – which would involve training family members to take precautions and give them protective equipment and cleaning equipment – is not something that could be done at a high level. ladder. "It's really for people who do not want to come to the center," she said.
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