Text: Chris Bateman. Article from the October 2014 issue of Noseweek Magazine.
We’re not ready for Ebola…if the way we’re handling TB is anything to go by.
South Africa’s record in its initial handling of the HIV/Aids pandemic – without antiretroviral drugs – and the burgeoning spread of extremely/extensively drug-resistant tuberculosis (XDR-TB) casts doubt on the country’s capacity to cope with Ebola.
The known daily TB death rate in South Africa is nearly 14 times the average daily Ebola death rate across the four affected West African countries since March. XDR-TB, which kills 90% of its victims, is out of control in South Africa – a sobering thought when contemplating how we are likely to deal with – or more likely not cope with – an Ebola outbreak.
The analogies were drawn by an expert in disease surveillance and laboratory systems, Dr Andrew Medina-Marino, on his return to South Africa from Ebola-ravaged Liberia. There, between early March and 3 September, the regional contagion had claimed more than 1,900 lives among 4,000 suspected infections – 2,200 confirmed. The current fatality rate of one of the world’s most feared diseases is nearly 50% of those infected.
Although no Ebola cases have been confirmed among the hundreds of blood samples sent from across the Southern African Development Community to South Africa’s National Institute for Communicable Diseases, the region is on high alert, with emergency plans for co-operation in detection, containment and awareness on fast-track, and with a travel ban from the affected countries in place. (See box.)
Because of South Africa’s distance from West Africa and the sudden onset and severe nature of Ebola, officials claim it is “highly unlikely” that cases will enter the country via land or sea. The highest-risk entry ports are Gauteng’s OR Tambo International Airport and nearby Lanseria Airport, from where all major medical air rescue company aircraft operate (two internationally). Travellers are being thermally screened at these airports and anyone with elevated temperatures, questioned. OR Tambo has a modern emergency isolation/ transfer medical centre.
A retrospective look at South Africa’s XDR-TB spread by leading drug-resistant TB expert Professor Keertan Dheda, at the annual national TB conference in Durban in June, adds a pinch of salt to reassurances by government spokesmen. Another problem is the absence of any regulation on communicable diseases six years after the draft provisions were first published.
Dheda, professor of medicine and head of pulmonology at the University of Cape Town, estimates that “several thousand” healthcare workers are currently infected with TB.
For perspective: while an estimated 10 people are dying of the dreaded Ebola every day, it has gone largely unnoticed that each day 140 South Africans are dying of all types of TB. Multiple Drug Resistant TB (MDR-TB) is out of control: the number of notified cases has increased from 7,350 in 2007 to 14,161 in 2012.
While the incubation period and mode of transmission differs – TB is air-borne whereas Ebola is spread via contact with bodily fluids and infected tissue – common denominators include the infection of first-line primary health care workers; a dysfunctional health system; low public awareness of basic infection control; and dismal, inappropriate education.
Dheda made an impassioned plea at the TB conference for a nationally coordinated strategy with uniquely tailored solutions including home-based or community care, plus multi-disciplinary teams in modern-day sanatoria” so that highly contagious “therapeutically destitute” TB patients are not discharged from hospital “back into a careless void”.
Medina-Marino says the dearth of local Ebola virus expertise and disease surveillance capacity is probably insufficient to deal with “anything more than a small, geographically-contained outbreak”.
As senior technical advisor: disease surveillance and laboratory systems, at the South African Medical Association (Sama’s) Foundation for Professional Development (FPD), he predicts that a scattered West-African-type Ebola outbreak in South Africa’s townships, for example, could quickly turn into a public health nightmare. The West African outbreak is the first in the world to have reached urban areas.
In South Africa, the government would have to lean heavily on the mainly US-funded National Institute for Communicable Diseases (NICD) to roll out epidemiological and outbreak- control programmes.
Medina-Marino returned from a month of voluntary work in Ebola-ravaged Liberia in August, having witnessed some of the effects of the rampant contagion. His views, particularly about dysfunctional health systems, were echoed in principle by Professor Sharon Fonn, of Wits University’s School of Public Health, who is also Co-director of the Consortium for Advanced Research Training in Africa (Carta).
A scattered West-African-type Ebola outbreak in our townships could quickly turn into a nightmare
Professor Lucille Blumberg, head of the NICD’s Surveillance and Outbreak Response Unit, warned that an Ebola outbreak would rapidly expose any deficiencies in a public health system, with poverty and fear aggravating contagion.
The Department of Health’s Dr Frew Benson, chief director of communicable diseases said that, with 150 health care workers dead among the more than 250 infected in the four outbreak countries, “the fear factor” had already played out in South Africa. Local nurses had refused to scrub up to perform a Caesarian section on a patient suspected of having Ebola even though she had been negatively-diagnosed. They had eventually done so, only under orders when told the patient was uninfected.
“You can imagine if we see more cases in South Africa, what the (care giver) impact would be,” he warned at an Ebola briefing.
Medina-Marino is a veteran of the US public health institute, Centers for Disease Control whose director Thomas Frieden warned on 2 September that “the window is closing” on containing the “global problem” of the West African epidemic. Medina-Marino, who was seconded to South Africa’s FPD three years ago, said there was “no question” that South Africa had among the world’s best laboratory diagnostic abilities and it was one of only three countries asked by the World Health Organisation (WHO) to send mobile diagnostic laboratories to West Africa.
As one of South Africa’s few doctors with high-level outbreak-response expertise, Medina-Marino, volunteered to work cheek-by-jowl with Medecins Sans Frontieres colleagues. MSF has 700 staff working across Guinea, Liberia, Sierra Leone and Nigeria.
Lindis Hurum, MSF’s emergency coordinator for the Liberian capital Monrovia, said the situation there was catastrophic, with most of the city’s hospitals closed and with decomposing, highly infectious bodies lying in the streets and in homes.
Dr Margaret Chan, WHO director general, declared the outbreak an international public health emergency, that was moving “faster than we can control it”.
The WHO has been severely criticised by the over-burdened MSF for its slow response (belatedly begun only after two deaths and seven confirmed cases in Lagos, Nigeria – the regional hub for international travel and business).
Chan called for a global coordinated effort to combat “the largest, most severe and most complex outbreak in the nearly four-decade history of this disease”.
MSF president Dr Joanne Liu said her organisation was “overwhelmed” and could now offer only palliative care. They needed 800 extra beds for MSF’s 160-bed Monrovian treatment centre. She said world health bodies “should be helping save lives in West Africa” rather than limiting their response to the potential arrival of infected patients.
Medina-Marino criticised South Africa’s record in dealing with disease outbreaks, saying the country had clumsily faced the “quite desperate” HIV pandemic (initially without antiretroviral drugs) and was failing to curtail a burgeoning XDR-TB pandemic – due only marginally to the lack of any proven drugs available for a large-scale XDR treatment roll-out.
South Africa’s response capacity and expertise remained focused on clinical care and treatment, she said. When it came to identifying appropriate infection-risk factors and contact- tracing, there was “still a lot of work to be done”. In her opinion, only the mainly US-funded NICD was properly prepared for an outbreak.
South Africa – regardless of what disease-control officials said – did not have the capacity for full-scale investigations, especially for an outbreak that was anywhere near the scale of that in West Africa. It could “probably handle between one and three isolated cases”.
“When things actually happen, the system breaks down very fast,” he said. “All the money in the world could not make up for delayed and uncoordinated responses.”
Professor Fonn said that internationally, curricula for medical students, nurses and doctors were inadequate and inappropriate. For example they were not being taught how to put on and remove protection gear without risking infection, and there was no system “for quick, effective communication between providers, should anything happen”. Community Ebola awareness training was non-existent, she said.
To avoid spreading panic, public messaging campaigns should be conducted before any outbreak “so that when it happens, you’re re-importing an old message.” One Ebola outbreak would cripple any less-than-robust health system, Fonn warned.
Blumberg said that once Ebola reached cities it became difficult to contain – the main enemies being poverty, fear and dysfunctional health systems. She said the NICD’s mobile laboratory in Liberia was “extremely busy” and every second sample was testing positive.
Benson said that 48 of South Africa’s 52 health districts had received Ebola prevention and awareness training. Defence forces throughout the SADC would be deployed to curtail movement should an outbreak occur, and Ebola-ready hospitals had been designated in every province, including one private hospital and two military hospitals.
Medina-Marino questioned just how properly equipped these hospitals were, with the paucity of institutional training.
Benson said basic health care worker protection training was being stepped up, immigration officials were receiving twice-weekly updates and training, and broader multi-sectoral awareness was being accelerated.
Asked what precautions should be taken by health care workers, Medina-Marino said that simply wearing gloves and asking patients whether they’d recently been in West Africa, or in contact with someone from there, would generally suffice.
He challenged Benson’s contention that people with Ebola were usually “very sick” and typically presented to a hospital because of the 2-21-day (non-infective) incubation period. In his experience, most people with Ebola symptoms first went to a primary or community health clinic (all 250 afflicted West African healthcare workers were infected in this way). Initially, doctors and nurses were “not necessarily thinking ‘this person has Ebola’ and interacted freely with patients, posing a major infection risk where it was least needed”.
Medina-Marino said there was no need to panic but warned there was “good reason” for the South African government to be better prepared.
The long tentacles of Ebola
When Korean Air announced it would halt its three flights a week to Nairobi due to fears about an Ebola pandemic in Liberia and Sierra Leone – both far-flung from South Korea, the airline was accused of overreacting.
The critics were wrong. When it comes to pandemics, it only takes a little global connectedness to trigger a cascade of infections. The outbreak of Ebola raging in West Africa – now labelled a Public Health Emergency of International Concern by the World Health Organisation – echoes a scenario mapped out by the New England Complex Systems Institute in 2006. In a computer simulation of pathogens and hosts, long-range routes of transmission – most prominently, international air routes – can allow the deadliest viral strains to outrun their own extinction, and in the process, to kill far more victims than they would otherwise have done.
In an evolutionary model that accounts for spatial distribution, a pathogen like the Ebola virus can cause its own demise by killing all the hosts in its immediate vicinity. If there is no one left alive to infect, a viral strain will die off. Successful pathogens leave their hosts alive long enough to spread infection. Typically, the most virulent mutations burn themselves out, and a stable balance is achieved between host and pathogen. But avenues of long-range dispersal break this pattern.
Ebola cannot spread through the air; it can only be transmitted through close contact with bodily fluids. Yet, in the age of global travel, patients in the dormant stage of infection can travel long distances before showing signs of illness, creating epicentres of secondary infection in geographically distant locations. Long-distance travel thus gives an unnatural advantage to the most virulent strains, allowing them access to new hosts even if they wipe themselves out on a local scale.
Related Content
