Fighting Ebola – here and on the ground

The Ebola outbreak in West Africa in one of the biggest public health crises in recent years; affecting populations in Liberia, Guinea, Sierra Leone, Nigeria, and Mali. The World Health Organization (WHO) estimates that almost 7,000 deaths have occurred, though they believe the number to by higher, given the difficulty collecting the data.

The community at UBC’s School of Population and Public Health is actively contributing to the efforts to combat Ebola. Faculty members, students and researchers are providing advice and guidance at all levels. Some are helping develop preparedness plans and checklists in British Columbia, through their work at BC Centre for Disease Control and the provincial Ministry of Health. Some are offering clinical trial design advice. Others are assisting international organization, such as the WHO, as they build operational infection control plans for health care workers on the ground. Others are delivering hands-on, front line clinical care support in affected countries.

They are providing their expertise both here, and on the ground.

Providing high-level guidance
The outbreak has had devastating effects on workers involved in the response – not just those in the treatment units, but ambulance drivers, community outreach workers, and burial workers.

In Nigeria, 58 per cent of Ebola infections were occupational, and 86 per cent of deaths were from occupational infections. Additional risks such as psychological distress, stigma, violence, fatigue, heat stress, ergonomic problems, and chemical exposures, can further endanger the health of workers and inhibit the Ebola response.

It’s just this type of situation that Jerry Spiegel and Annalee Yassi had in mind when they created the Global Health Research Program (GHRP) in 2005.

The GHRP develops and evaluates appropriate technology to instill and nurture best practices among health care workers, particularly in the developing world. Their work was celebrated in 2013, when the GHRP was designated as a WHO Collaborating Centre in Occupational and Environmental Health.

The WHO asked its Collaborating Centres to contribute to the emergency response to the Ebola outbreak, and in late October, three GHRP team members – Annalee Yassi, Jerry Spiegel and Stephanie Parent – went to the WHO headquarters in Geneva to help strategize the Ebola response.

The GHRP has been focused on four main tasks:

• Developing WHO’s manual, Occupational Health and Safety in Epidemic Preparedness and Response to Ebola and Marburg Virus Disease. “We synthesized evidence and have outlined key messages on risk factors, health effects, and measures of control,” Yassi said. The manual will be released shortly and distributed widely.
• Adapting interactive animated educational tools for the Ebola response in the African context. For example, their Protect Patti tool will now teach healthcare workers how to put personal protective equipment (PPE), in order to minimize infection risk.
• Creating self-assessment checklists for deployed staff based on the WHO Ebola outbreak response handbook for health and safety in the field. These checklists are turned into a smartphone application that deployed staff can use in the field to assess their safety. “We have world-class expertise in surveillance tools and surveillance systems in low-income settings, and these systems are being adapted for the Ebola response in West Africa,” Yassi said.
• Designing a study to uncover the most important risk situations in the Ebola outbreak. “This study would be a case-control study, or a qualitative study with interviews with survivors of Ebola,” Yassi said. “Many barriers to such studies are currently being assessed, including recall bias, reporting bias, and the logistic difficulties in interviewing people in the field.”

 
Training, mentoring and developing guidelines
Dr. Srinivas Murthy, a first year SPPH MSc candidate and physician at BC Children’s Hospital, recently returned from Liberia, where he had been working as the WHO’s national lead for case management.

“I have training in both infectious diseases and critical care, and worked with WHO in the past, so I was invited to help,” said Dr. Murthy. “I was not doing direct patient care; my role was in clinical and case management. I provided training to health care workers, mentorship to local staff and developed guidelines and protocols.”

Being on the ground in one of the hardest hit African countries was daunting. “It was challenging, obviously. You do all the things that keep you at low risk but it is not easy when the disease is so prevalent,” said Murthy. “Still, people are acknowledging the risks, and gaining more experience.”

Murthy welcomes the manual that the GRHP is helping the WHO put in place. “We did as much training as we could without a formalized manual in place,” he said.

He also hopes that other resources become available – particularly human resources.

“What is most need to help? People. Money is nice and it is needed to get supplies in and pay salaries, but what is really needed is experience and skills. You need people to do the work and without that you really can’t solve this problem. Ebola is a unique disease, but it is also a disease that is manageable and this outbreak can be controlled with the appropriate number of resources.”

While he has been a resource in the past, Dr. Murthy will not be one again in the near term. He has a young family and “another extended sojourn is not feasible,” he admits.

Heading to the front lines
One of the people taking his place is Dr. Mike Rekart, a Clinical Professor in the School. Dr. Rekart will be working with Médecins Sans Frontières/Doctors Without Borders (MSF) in Sierra Leone.

Dr. Rekart will be overseeing a MSF Ebola case management centre – field hospital compounds where patients are brought in with possible Ebola.

“They are triaged and admitted or sent home,” Dr. Rekart says. “Most get admitted because it takes a few days for the blood tests to come back. If they are sick, they are given fluids and other basic care, such as malaria treatments, antibiotics for bacterial infections, and oxygen if needed. If they test positive for Ebola they are moved into the high level area.”

He will be working with MSF experts from around the world, as well as national health care workers, who will bear the brunt of the work. “There will be some differentiation based on expertise and language. The national staff is very skilled, and they have the language and cultural sensitivities to deal with situations where, for example, the centre fills up and patients need to be turned away.”

He admits sadly that, “patients will stay there until they are admitted or die. Even at MSF facilities the mortality rate is 50%. Then the body has to be taken out and buried by the burial teams. It has to be terrible.”

Rekart left December 1 to start his eight-week mission. He will spend three days in Amsterdam preparing, then head for the field. He will also have a three-week self-quarantine period when he returns.

“I do worry about infection. Even with the PPE and being careful I know that the risk is not zero. You have to try and avoid the panic. Doing this, I have the opportunity to use my skills. The chance to save a life is quite rare and that is why I am going.”

Adjunct Professor Paul Gully is also in Sierra Leone and is expected to return at the end of December.

Pushing a viewpoint
PhD candidate Steve Kanters is working far from the front lines, providing his own perspective on the need for adaptive clinical trials.

He has consulted with the Wellcome Trust and published a blog post in The Lancet, arguing that adaptive trials, which are stopped as soon as enough useful information is collected, can speed the decision-making process.

Kanters acknowledges that the WHO and MSF are moving ahead with trials using their own designs, but says that he will continue to send the message out via papers, editorials and blog posts.

“My arguments are more for trials on the next generation, the drugs that haven’t been tested yet, the experimental treatments. However, we are in a waiting phase, waiting for the next batch of TKM, of ZMMap. So we will have to wait and see.”