In the large scheme of things having a global impact, it is believed that life on our planet is ruled by the interactions of the bacteria that drive nutrient and energy flow and the viruses that infect them. While these are the really big players we never really give them a thought even though their processes, the delicate dance of life and death have been going on for perhaps a billion years. Instead we are all focused on something coming out of West Africa we never even heard of until a few years ago. And that is just the problem; neither the disease nor our disease-fighting repertoire has the experience at this rather ugly tango in which we find ourselves involved. Ebola generally kills its human hosts too quickly to be a well-adjusted obligate parasite and we thought it could be relied upon to burn itself out. The later of which does not qualify for a disease control plan.
The World Health Organization has recently described the Ebola epidemic in West Africa as “the most severe acute health emergency seen in modern times”. A recent CDC analysis indicates that in Liberia and Sierra Leone infections could reach over 1.4 million cases by January 20th of next year. While taking into consideration under reporting, the CDC omitted Guinea which has been hard hit. If these cases are taken into consideration, many experts warn that numbers could be well over 4 million by that same date. And other predictions are dire:
-Numbers of Orphaned children has reached >4000 and is growing
-Infections could quickly surpass 10,000 a week
- Mortality rates have been adjusted up to 70%
-Regional economies will see ~50% economic decline ($ 33 billion)
-Economic spill over has already been seen in Africa and in global markets
For those that study viruses for a living, there is often a clinical objectivity and big picture vantage point that helps put an infection of this type into perspective. I was recently asked to put on that hat to help find a plan that could be put into place to save the most vulnerable of Ebola’s victims, the children. It was this process that I realized it was not about the petty bit player Ebola but survival, what it takes to knock the virus out and improve the chances of survival for those infected and affected. Several epidemic diseases of the past such as the bubonic plague and yellow fever have symptoms and human misery characteristics mimicked by Ebola. This causes terror and panic just like those diseases have done in the past. In 1665, one of the deadliest years of the bubonic plague epidemics, 80,000 people died in the city of London alone with over half children. But these are the epidemic diseases of the past. We controlled bubonic plague (Yersinia pestis bacteria) by focusing on rats and with yellow fever virus it was the mosquito. Estimates are that Cholera (Vibrio cholera bacteria) has killed more than a billion people during its run and still kills many without sanitary drinking water. Cholera flows like the oceans and is really a big player that we have to be constantly vigilant for and our focus must be to improve drinking water supplies around the world. Hand hygiene makes a clear dent at perhaps billions of cases of disease each year and millions of deaths.
What can it do against Ebola?
While a great deal has been learned from earlier Ebola outbreaks regarding how best to address the health emergency and community needs, the region’s health care systems have been caught behind the infection curve and the circumstances require a detailed look at how best to avoid an even bigger catastrophe. While we have a track record on all those other diseases mentioned and the big time players, we don’t yet fully understand just how contagious the Ebola virus really is. Until a few weeks ago we blamed the outbreak in Africa (now an epidemic) on poor healthcare infrastructure and sanitation. With the experience of just 2 infected persons in 2 modern healthcare facilities in Spain and Texas that idea needs to be completely re-appraised as well as everything else we know about this virus. The virus is obviously exploiting our every weakness and it is using all the other tricks in the virus playbook. Even the indication of fever cannot be relied upon as a fully effective diagnostic tool. Infectious dose seems to be quite low but we just don’t know yet and the virus can adjust by using other effective strategies for infection. Super massive shedding via multiple human soils, with sometimes long incubation times, asymptomatic infections, and the mimicking of common non-lethal everyday infections seems to have caught us by surprise.
Mathematical models have shown their usefulness in analyzing the spread and control of a wide variety of infectious diseases but can no longer be used to ascertain the eventual scale of this epidemic based on earlier Ebola outbreaks. The dire predictions above are largely due in good measure to our own hubris. This is something the Greeks knew over some 2000 years ago. With the 3 cases spread in modern sophisticated healthcare environments, personal protection equipment is now taking the blame. When this recent outbreak started, it was assumed it would simply burn itself out. We are fortunate that it is not aerosol spread (in the main that is) but in the flip-flop that is the closely related Influenza virus where this is the primary mode of transmission, there is also a hand contact component. It is for that reason, we shouldn’t take that or anything off the table as we are looking at a virus that because of all the characteristics listed above can cross-contaminate in a number of ways fairly easily. With massive shedding of virus it is a simple numbers game and hygiene failure or effectiveness hangs in the balance. From what we now know about the mechanics of infection, direct contact with mucus membrane is how the virus is transmitted. It is on this basis and through study of previous epidemic diseases that we can design and effectively implement prevention measures. Although this virus is extremely infectious, as an enveloped virus it is also very easily to kill with most antimicrobial formulations and more particularly with alcohol-based hand sanitisers. That said, it should also be mentioned that hand washing and hand sanitising represents one part only of all means to be implemented for preventing Ebola infections. US EPA recommendations with regard to effective disinfectants against Ebola call for formulations to have shown efficacy against non-enveloped viruses (as a surrogate guideline).
And here we’re not just talking about hand hygiene but every type of hygiene we know. From point of donning protective equipment to its doffing, the procedure needs to be by the book. And then there is the sanitizing of critical areas of the protective equipment even before being carefully removed. While a great number of factors are unfortunately stacked against us, and many will die as a result, we let the disease get out of control in West Africa because we treated it like a small “bush fire”. In the end, all infectious diseases come down to hygiene of one type or another and hubris free respect for the real underlying causes. Fortunately with multifaceted interventions including hand hygiene, we have the power to stop this epidemic in its tracks, as long as we can exert effective organized action. While it doesn’t seem like it now, Ebola is just a bit player, lets just hope that we can put it in its place as rapidly as possible and the micro-organisms that give us our oxygen don’t catch what we don’t have the tools to control.
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