Our Hut Is Your Hut: Ebola: An Open Letter to PCVs and a Situational Summary

Hi All,

Last night we got home from a whirlwind 2 weeks in Dakar and Thies. We came home to a jungle of a garden, and kids and pets that we swear have grown noticeably in just 14 days. It feels so good to be home!

I owe you a “September in Review” post, which I’ll get to in the next couple of days, once we get unpacked and get the garden under control. In the mean time, I wanted to post a letter (written for other Senegal PCVs, but relevant for you all as well) and summary of the current Ebola situation (written for family and friends), composed in mid-September by rock star PCVs Sarah Mollenkopf, JanelleKibler, and Katie Wallner, for those of you wanting to learn more about what’s going on.

Jamm Rekk,

Kait

Hello PCVs,

We know that the presence of Ebola looming not all that far away across our southern border has ushered in a somewhat unique and uncertain time. Ebola is, after all, a scary disease. It is highly infectious among those that come in contact with it, it causes very violent symptoms such as bleeding, and it has claimed the lives of thousands of people in the most recent outbreak here in West Africa (2,288 according to WHO).

An ocean and many hundreds or thousands of miles away, this is especially terrifying for our loving parents. They are unable to see how miniscule the effect of the disease has been on the Senegalese population so far and they may be unsure or untrusting of the level of quality healthcare available in Senegal or the response of Peace Corps. This leaves them feeling helpless, powerless and stricken with anxiety of not knowing what the future beholds for the course of this epidemic; some may even be questioning their original support for their children to come on this crazy Peace Corps mission. Many parents have reached out to Peace Corps in Washington or to their Congressmen to express real – not unfounded but perhaps somewhat sensationalized – concerns and imploring them to act, even to evacuate us all immediately.

However, dramatized media and uninformed or idle minds have the tendency to hyperbolize the threat of this disease in our context. It is therefore our belief that some basic facts about the disease and the course of the disease might help shed some light on the reality of this situation and make us all feel more at ease. We urge you to share these with friends and family at home on your blogs, in emails or through Facebook. Engage them in a discussion about their concerns, about your concerns, and about any boundaries you may need to set for yourself; at what point will you no longer feel safe and what will you do about it.

The Peace Corps administration is in constant communication with the Senegalese Ministry of Health and other actors to monitor the situation and constantly re-evaluate the level of threat. They have assured us that our safety is a priority. Through the evacuation of volunteers in Guinea, Sierra Leone and Liberia they have demonstrated that they ARE willing to pull us all out if they believe that we are truly, potentially in harm’s way.

However, many volunteers here in Senegal are doing important work to which they have dedicated endless time and effort and have built meaningful relationships with counterparts, families and community members. I am sure that many of us would be devastated to be evacuated in the middle of our work if we did not believe that the threat of Ebola is real. It is, therefore, a balance. While our safety is unarguably paramount, we do not want decisions to be made prematurely that restrict our scope of work here in Senegal or pull us away from it entirely. We must, therefore, all participate in the conversation about these decisions.

Here are some facts and points of discussion to start a conversation with your friends and family. Feel free to copy and paste them directly, to put them in your own words, or to go a different way entirely if you feel it would be more effective for your audience.

Facts about Ebola:

- Background: Ebola is a virus from the Filoviridae family. There are 5 known species of the virus although only 4 are known to infect humans. It is a zoonotic disease (meaning that humans get it from animals) with the most likely animal host being bats. It was discovered in the Democratic Republic of the Congo in 1976 and has caused sporadic outbreaks since that time, mostly in remote villages near rainforests in Central and West Africa [4,5].

- Signs and Symptoms: Typical signs and symptoms include fever, headache, body aches, weakness, diarrhea, vomiting and lack of appetite. Less common signs and symptoms include a rash, red eyes, hiccups, cough sore throat, chest pain, and bleeding inside or outside the body [5].

- Transmission: The initial transmission of the virus from animal to human is not well understood but it is likely that humans are infected through direct contact. Transmission from human to human occurs through contact with the blood or secretions of infected person, or through contact with objects (like needles) that have been contaminated with infectious secretions [5].

- Infectivity: Once someone is exposed, symptoms will appear between 2 and 21 days (between 8 and 10 days is most common) [5]. People are infectious while they are symptomatic and will remain so far as long as their blood or secretions contain virus material. Men can still transmit the virus in their semen for up to 7 weeks after recovering [4]. The virus can also be transmitted through breast milk.

- Severity: The case fatality rate (the number of people die from the disease divided by the number of people who got sick with the disease) for this strain of the Ebola virus ranges from 31-90% [4,5].

- Diagnosis: Diagnosing the disease is very challenging as many of the symptoms are fairly non-specific and mimic other diseases (e.g. fever, headache, body aches, vomiting, etc.). Therefore, to make a diagnosis doctors usually try to rule out of diseases first (e.g. malaria, typhoid fever, meningitis, other viral hemorrhagic fevers, etc.) if they do not have reason to believe you may have been exposed. To make a definitive diagnosis, several lab tests are available to test for the presence of virus antigens or antibodies, or to isolate the virus through culture [5].

- Treatment: Currently there is no licensed curative treatment available so the only form of treatment is purely supportive. This includes balancing a patient’s fluids and electrolytes, maintaining a patient’s oxygen status and blood pressure, and treating patients for any complicating secondary infections [5]. There is an experimental treatment called ZMapp that has been widely discussed in the media because it has been made available in finite circumstances. However, it has never been tested in humans for safety or effectiveness and it is too early to know if it has been effective in the context of this outbreak. At this time, very few samples have ever been manufactured and all manufactured samples have been distributed at this time. It is therefore not available for general use or purchase [6].

- Prevention: The most important thing for prevention is to prevent direct contact with the blood or secretions of Ebola patients. This includes both patients who are living and those that have died. In a health-care setting it is important for healthcare workers to wear protective clothing (e.g. masks, gloves, gowns, goggles, etc.), utilize infection-control measures (e.g. complete sterilization of equipment, regular use of disinfectant, etc.) and isolate Ebola patients [5].

- Vaccine: There are currently no FDA approved vaccines for Ebola although the NIH has recently announced that they are expediting their work on launching a phase 1 clinical trial for two Ebola vaccines that have been developed by GlaxoSmithKline and the Public Health Agency of Canada. Initial human testing was set to begin in early to mid-September. In parallel, NIH has partnered with a British-based international consortium to test the NIAID/GSK vaccine candidate among healthy volunteers in the United Kingdom and in the West African countries of Gambia (after approval from the relevant authorities) and Mali. Additionally, NIH and the Thomas Jefferson University are collaborating to develop a candidate Ebola vaccine based on the established rabies vaccine [6].

Facts about this outbreak:

- Story: The current outbreak of Ebola virus began in early December, 2013 with the infection and subsequent death of a 2-year-old boy in southern Guinea, near the border with Sierra Leone. Seven days after he died, his mother died, followed by his 3-year-old sister 16 days after that. After that, his grandmother died, a nurse who had attended to the grandmother died, the village midwife died, the midwife’s sister died, and several people that attended the funeral of the midwife got sick and/or died [15]. From there it spread like wildfire. The estimated reproductive rate of disease (the number of people infected by each sick person) is around 1.8 [14].

- Impact so far:

o 4,269 people infected [9]

o 2,288 people dead in Guinea, Sierra Leone and Liberia [9]

o More people are believed to have died in these countries from secondary diseases like malaria and tuberculosis and from chronic illnesses and pregnancies with complications than from Ebola because the health care systems are so strained. Heavy rain adds to the risk of waterborne diseases like malaria. [16]

o Food security has become a problem. Quarantines keep workers from their jobs and have slowed the delivery of food to certain areas, according to the U.N. [16]

o BUT: In a glimmer of good news, the WHO said eight districts with previous Ebola cases (4 in Guinea, 3 in Sierra Leone and 1 in Liberia) had reported no new cases for three weeks [10].

- Countries involved:

o Guinea

o Sierra Leone

o Liberia

o Nigeria

o Senegal

o NOTE: DRC is not affected by this outbreak but there is a simultaneous outbreak of a separate strain of Ebola virus [12]

- Factors of spread:

o Spread through families, people caring for loved ones that are sick come into contact with infectious secretions [5]

o Burial ceremonies in which mourners have direct contact with the body [4]

o Healthcare centers lack of appropriate containment gear (e.g. gloves, gowns, glasses, etc.) [5]

o Lack of education

o Poor infrastructure [9]

§ Health facilities inadequate and overflowing, people forced to care for loved-ones at home

§ Crematorium overwhelmed, unable to keep up with number of bodies

§ Government finances stretched to limit

§ Widespread corruption

§ Liberia (hardest hit), just emerged from 14-year civil war in 2003

o Poor coordination among agencies [9]

- International response

o Doctors Without Borders has nearly 2000 staff members in 3 countries [11]

o 50 million dollars given by Gates Foundation to help fight outbreak and research vaccines [2]

o The World Bank has pledged a $230 million aid package, including $117 million in emergency response [11]

o Cuba to send 165 health workers to Sierra Leone in October [10]

o China dispatched a mobile laboratory team to Sierra Leone to help test for the virus. The team of 59 from the Chinese Center for Disease Control includes epidemiologists, clinicians and nurses. This team will join 115 Chinese medical staff already on the ground in Sierra Leone [16]

o US Government Response

§ CDC Role [7]:

· Activated Emergency Operations Center to help coordinate technical assistance and disease control activities

· 70+ staff members deployed in Guinea, Liberia, Nigeria and Sierra Leone to assist with surveillance, contact tracing, database management, health education

· Travel advisories issues for US citizens to avoid nonessential travel to affected nations

· Assistance with exit screening and communication efforts in West Africa to prevent sick travelers from getting on planes

· Education for US healthcare facilities about how to safely manage patients with suspected Ebola virus

§ USAID [16]

· Already committed more than $100 million to combat Ebola but last week announced they will spend $75 million to build treatment facilities and supply them with medical equipment. The treatment centers may house up to 1,700 additional beds.

· Will give 400,000 treatment kits with sanitizer and other protective items like gloves to families to help them protect their own safety as they care for sick relatives

§ Pentagon [16]

· Working to shift $500 million of not yet obligated funds to Ebola effort

· Will send troops; American military personnel could increase by 3,000 in the region

§ Other [16]

· Sending additional healthcare workers

· Creating a training facility to help prepare thousands more health care workers to handle sick patients. U.S. medics will train up to 500 health care workers per week to identify and care for people with Ebola.

· The President called on Congress to approve additional funding requested by his administration to carry out these efforts

o WHO Response [8]

§ Comprehensive databases on epidemic intelligence, verification status, laboratory investigation and operational information.

§ Tracking and recording outbreak history, critical decisions, important actions by WHO and partners and key documents.

§ Management of logistic support and specialized response equipment, materials and supplies.

§ Integrated database on the skills, experience and availability of international experts for response teams.

§ Profiling of technical institutions in the Global Outbreak Alert and Response Network concentrating on readiness and capacity to support international outbreak response.

§ Standardized information products for Member States, public health officials, media and the public.

§ Communications with the Global Outbreak Alert and Response Network to enhance operational readiness.

This outbreak in Senegal

- So far there has been a single confirmed case of Ebola in Senegal.

o Story: This was a 21-year-old male student who arrived from Guinea on August 20^th (before the border was closed). He arrived via 7-place through Kolda and stayed with relatives on the outskirts of Dakar. On August 23^rd he sought medical care for symptoms including fever and diarrhea and was treated for malaria. He continued to live with his relatives but his symptoms did not improve so he sought further medical attention was referred to a special infectious disease facility on August 26^th where he was hospitalized. On August 27^th Senegal received a report from Guinea that a person who had been in close contact with an Ebola patient had escaped surveillance [13]. This student received treatment in Dakar until he was declared to be cured on September 10^th [1]. Thirty-three people with whom he had contact in Dakar have been quarantined until the incubation period expires on September 20^th. All are being tested morning and night for fever but thus far all remain asymptomatic [17]. Sixty seven people who had contact with him have been traced so far and none have tested positive for the disease [10].

- There were two additional suspected cases of Ebola (in the regions of Matam and Ziguinchor) but both tested negative [1].

- Senegalese Response: The Senegalese government has reacted swiftly to the threat. The president of Senegal was quoted saying, “People should know that if it were not for this boy's state of health, he would be before the courts…You cannot be a carrier of sickness and take it to other countries.” The government has allocated 300 million CFA ($600,000) to a national crisis team spearheaded by the national minister of health, Awa Marie Coll Seck [17]. The Senegalese border with Guinea has been closed since August 21^st with no plans yet to open it again and all borders have been reinforced with extra surveillance [3]. Hand-washing stations have also been set up along the border with Mali. A humanitarian corridor has been opened to allow international agencies to be able to enter affected countries in the region and provide aid with the gateway being the Ouakam Military Airport in Dakar [18]. Furthermore, there has been a widespread socio-cultural response to the disease. In Dakar, many fearful residents have stopped their customary handshakes in greetings and avoid packed public transport to avoid contact. Many shun inhabitants of Parcelles Assaines, the neighborhood in Dakar where the student was residing with his family [17] and a few in the southern regions go so far as to shun Guineans in general, no longer frequenting their shops or allowing them on public transportation. Along the borders community members are also taking initiative to prevent Guineans from entering through porous border paths. Phone companies and television stations are sending out regular messages about signs and symptoms of Ebola and how to prevent it. And there are no more weekly markets in villages near the border with Guinea.

What Senegal has going for it

- Better infrastructure

o Not worn down by years of civil war

o More hospitals, more healthcare providers

- Preparation time

o Education campaigns began months ago to educate healthcare providers, gendarmerie, border control, general population

o Closed borders with Guinea

o Border surveillance with hand washing stations

Resources for more information:

- WHO Outbreak News (http://www.who.int/csr/don/archive/disease/ebola/en/)

- CDC Outbreak News (http://www.cdc.gov/vhf/ebola/outbreaks/guinea/index.html)

- Seneweb.com (great for local updates – in French)