Are we prepared for the Ebola outbreak?

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On 2 May, the Central government’s health watchdog named the Integrated Disease Surveillance Programme sent out an “Advisory to keep vigil for Ebola Virus Disease” to all state surveillance officers. On that day, more than three months ago, the West African nations of Guinea and Liberia reported 226 clinical cases of the Ebola virus disease (EVD), including 149 deaths. In the interim (up to 6 August), more than 1,700 had been infected in the four countries of Guinea, Liberia, Sierra Leone and Nigeria; a total of 932 had died in five nations, including three in Nigeria and one in Saudi Arabia.

The advisory was a confusing missive of risk-downgrading and misinformation. Among them was that Ebola — which is known to be among the most vicious and aggressive contagions yet encountered, with a death rate of 60-90 percent — has a “low risk of transmission in the early phase of symptomatic patients”; that “(e) ven if a person has a history of visit (SIC) to the affected area, the risk of developing the disease is very low”; that it calls for a “basic level of infection control”, which include everything from “hand hygiene, use of personal protective equipment…, prevention of needle stick and injuries from other sharp instruments, and a set of environmental controls”.

There is no evidence that the advisory had made a dent — until it was exhumed on 1 August and the Indian media was informed that it existed. In much the same manner as it has ignored the Ebola outbreak, the Indian media let this low-key government release slide by. On 6 August, Union Minister of Health and Family Welfare Dr Harsh Vardhan told both Houses of Parliament that the government had issued “advisories” to “State Disease Surveillance Units to be on alert for early detection and management of travel-related cases reported from the community”. He also said that “awareness would be created among the Indian community in these countries and among travellers to India from affected countries”. (see box Indian response, p. 30)

He didn’t tell Parliament that there had, in fact, been only one advisory, which was recently recycled; nor that it has, for the most part, lain completely ignored for a quarter of a year. Although, starting the beginning of August, the international airports at Chennai, Bengaluru and Kolkata reported that they had set up screening protocols for Ebola — which shows not a single obvious symptom even as it incubates in a human host for between two and 21 days, and then goes on to misleadingly mimic treatable flu-like traits before killing swiftly — in truth not a single airport in India is prepared for even one pre-symptomatic Ebola carrier from Africa or from any transit airport elsewhere that links infected regions in Africa and Indian airports. While there are no direct flights from West Africa to Indian cities, there are many to and from the Gulf that are used as a jump-point; and nearly 45,000 Nigerians obtain visas to India every year (2012).

The Airport Health Authority, a government body, is tasked with handling healthcare emergencies at the Indira Gandhi International Airport in New Delhi, which handles 37 million passengers annually (2013-14). As of 6 August, confirmed a senior official of the GMR Group, the airport had received no official communication from the Union health ministry on the matter of following any special protocol while dealing with passengers flying in from West Africa.

Meanwhile, in the absence of an announced protocol by the Indian consulate, many of the 3,000 Indians in Liberia are reported to be trying to find ways to leave without wiping out their bank balances. The decision by various airlines to stop flights to and from West Africa — including British Airways, Emirates, the Nigerian Arik Air, and the Togo-based ASKY Airlines (both pan-African) — has left them stranded. And those airlines that are still brave enough to continue operations have ramped up the price of their tickets so that a trip from Monrovia to India now costs upward of 1.75 lakh per head.

However, doctors and the western media tried to downplay the threat from Ebola, the outbreak beat down their initial optimism. The US’ premier Centers for Disease Control and Prevention moved from Fortress America fortitude to ramping up its Ebola alert to “Level 1 Activation” on 7 August. Level 1 Activation is for the most serious public health emergencies. The UK is quietly panicking as it goes on a screening spree following the tracking of one “possibly” infected woman — much of the European Union has quietly put in place airport screening mechanisms that include not only thermal-imaging scanners, but also quarantine units manned 24×7 by trained medics in full-barrier uniforms.

Despite its bravado, the US has established “quarantine stations” at all major airports, manned by the FBI and personnel from the US Customs and Border Protection. Detection mechanisms (and some quarantining facilities) — inadequate as they would be to deal with Ebola’s sneakiness — have been set up in Hong Kong, the Philippines and South Korea. The Philippines Department of Foreign Affairs raised Crisis Alert Level 2 (Restriction Phase) in Guinea (which has a Filipino population of 880), Liberia (632), and Sierra Leone (1,979). The South Korean government decided to send medical personnel and epidemiologists to Guinea (which has a Korean expat population of 45), Liberia (24) and Sierra Leone (88). Thailand has placed all its hospitals on alert. Hong Kong has primed all public hospitals to report on and test for Ebola, and placed 59 isolation units on standby. The US has passed out an advisory against travelling to West Africa, and Australia has cautioned against it. In Haiti, officials at Port-au-Prince and Cap-Haïtien airports and ports have been tasked with enforcing the monitoring system and quarantine.

There are more Non-Resident Indians in those three countries, but India’s response is remarkably laidback. There seems to be more official concern about the “7,000 Indian troops deployed in the African continent, but not in the affected countries”, who on “returning to India on leave or otherwise coming back would be suitably tracked and monitored for symptoms by the Armed Forces”. (Strangely, though, the health minister simultaneously told Parliament that Indians in Liberia include “about 300 personnel from the Indian Central Reserve Police Force, comprising largely women, as a part of the UN Peace-keeping operations”. Liberia is very definitely one of the affected countries.)

Meanwhile, Ebola-watchers believe that few governments — including India — are willing to speak the full and timely truth about an epidemic that could turn into the deadliest after the 1984 HIV rampage (which has become so embedded that it is now classified as a pandemic). An information underground has sprung up. The doomsayers — both religious and racist — are easily separated from the datahounds. Many of the latter were impelled by an early statement (which was never retracted) from the UN that the death statistics were higher than reported by “at least 50 percent”. Médecins Sans Frontières (MSF), which has 300 staff and more than 40 tonnes of supplies in the frontline, has also said that the figures were being seriously underreported, and that, conservatively speaking, it would take between three and six months for the current epidemic to abate.

Underground info has it that seven workers from a group of 15 returning from Sierra Leone have been quarantined in the Philippines with Ebola-like symptoms. In Brazil, a man with similar symptoms was driven straight from Guarulhos airport in Sao Paulo airport to the hospital Emilio Ribas. And a man has died of Ebola in Morocco. And this count is increasing by the day. Given the exponential spread of the Ebola virus — more than 600 percent since the Indian advisory — and the fact that it has, for the first time, killed in a megalopolis — the Nigerian capital, Lagos, which, with 21 million people, is the largest urban concentration in Africa — and has, again for the first time, jumped across an airspace — to Saudi Arabia — and possibly continents — to Brazil — the global alarm bells should have gone off deafeningly.

In India, the alarm seems to be particularly muted. Of the three airports currently under Ebola-watch, only Bengaluru’s Kempegowda International Airport has a separation zone for suspected Ebola carriers — but it is a glass cubicle and not hermetically sealed, as is the global norm. On 4 August, a report said that the city’s well-known Rajiv Gandhi Institute of Chest Diseases had kept aside six rooms and two halls for Ebola patients, in which 16 beds could be fitted. A report the very next day said that three wards with five beds each — 15 beds in total — had already been prepared for Ebola truck-ins from Kempegowda. Given that isolation units to treat Ebola patients are very high-tech and entirely leak-proof, this was alacrity that India is not accustomed to.

But what no airport in India has installed, as yet, are the basic Ebola identifiers: thermal-imaging systems that use infra-red to separate early-onset Ebola patients from ordinary travellers displaying the usual airport-related hypertension. These digital systems create a ‘heat picture’ of approaching human bodies, and a pointer automatically identifies the hottest area in the picture. Since most heat escapes the body from the head, which is usually the least covered part of the body, initial, casual diagnosis that allows for further tests is possible.

The problem in India is the cost of the thermal-imaging camera, which ranges from $4,000 ( 2.5 lakh) for the most basic to $17,000 ( 10.5 lakh) for one that would serve the purpose without demur. India would need at least 150 of them for its 29 existing international airports. The cost is, as government sees it, prohibitive.

India’s reluctance to extend itself is a consequence of the airport screening disaster during the H1N1 swine flu virus crisis of 2009. In all, 22 international airports in India had been identified for screening and isolation/critical-care facilities. Screening had begun on 30 April 2009 and was called off on 6 December 2009. It had involved 225 doctors and 172 paramedics, who had scanned almost 10 million passengers. Hardly any confirmed cases had a history of foreign travel. As government saw it, it had been an unsalvageable waste of crores of rupees.

Unfortunately, there is no assurance that it won’t be a similar waste this time round, too. But the risks of being overconfident, doing nothing and then being proved wrong are too great: the Ebola virus is a far deadlier nemesis than most the world has seen.

The word from some experts across the globe is that even airport screening is a palliative, a public mood-lifter, much as it was during the H1N1 crisis. Others believe that it is impossible to catch a ‘sleeper’ Ebola patient — one who is in the incubation, asymptomatic phase of 2-21 days (8-10 days for most sleepers) — with anything short of a blood test. (MSF has it that it takes five blood tests in all to definitively identify Ebola.) Individually, they are expensive; totalled together, they are exorbitant. They would put an enormous strain on anything short of a fully-developed nation with state-of-the-art medical facilities. The tests are:

• antibody-capture enzyme-linked immunosorbent assay (ELISA)
• antigen detection tests
• serum neutralisation test
• reverse transcriptase polymerase chain reaction (RT-PCR) assay
• electron microscopy
• virus isolation by cell culture

The fastest one of these tests — ELISA — can be done is eight hours. Essentially, this means that all suspected patients have to be isolated superfast — they might or might not be infected, but their profiling is unfairly broad — for longer than they can be accommodated in any airport facility. This calls not only for medical personnel at the airport sealed inside air- and fluid-proof personal protective equipment (PPE) — for up to four hours at a time, which is massively debilitating — but also for ready-to-move barrier nursing units for use in-transit to a nearby hospital. It sounds space age — and it is.

How does India fare on these stakes? Not good. The US — which has somehow managed to steal the Ebola epidemic limelight with its high-tech medevaccing from Liberia of two stricken doctors, its simultaneous withdrawal all 350 Peace Corps personnel from West Africa, and its patently illegal use of a vaccine untested on humans on the two doctors (which falls entirely outside Food and Drug Administration norms) — has four in-country facilities for testing Ebola, only one of which is part of the global EDPLN (Emerging and Dangerous Pathogens Laboratory Network). India — contrary to the Union health minister’s claim that the National Institute of Virology, Pune, and the National Centre for Disease Control, New Delhi, are capable — has none. At least, none that has ever tested Ebola.

And this absence of knowledge and sensitivity is probably why one of the first things that the Indian government did in response to the Ebola outbreak, on 7 August, more than five months after it exploded across West Africa, was announce a grant of $50,000 each to “some Ebola-affected countries, including Liberia”.


CONTAGIONS GET DEADLIER

How this Ebola epidemic is spiralling out of control and why it is becoming increasingly difficult to contain infectious outbreaks. By Tehelka Bureau

Already 900 dead. Four countries affected. Emergency declared in one of them, with troops quarantining citizens. Airline operations suspended, travel warnings increasing by the day. A $100 million fund for emergency response. The world is grappling with the untamed outbreak.

Ebola virus disease, formerly known as Ebola haemorrhagic fever, has daunting manifestations, particularly the unchecked internal and external bleeding that it causes in the later stages. But it is not half as dangerous as some other deadly afflictions. True, there is no vaccination yet. Yet, unlike rabies that invariably kills once manifested, Ebola gives patients about 30 percent chance of survival. In the current outbreak, 40 percent patients have gone on to recover.

Ebola is infectious. The virus enters the body and manipulates it, often beyond recovery. But it is not highly contagious. Unlike flu that moves through air, one needs to come in contact with the bodily fluids of an Ebola patient — blood, sweat, saliva or semen — to get infected. Outside an infected body, the virus can survive for some days in liquid. But chlorine disinfection, heat, direct sunlight, soaps and detergents destroy it.

Besides, when Ebola kills its victims, it kills them too quickly for its own good. It is only after the symptoms manifest that an Ebola patient becomes contagious. And then it is usually a matter of just 10 days. Whether the patients survive or die, they cannot spread the virus for too long.

Yet, Ebola is a huge medical challenge. Named after the Ebola river in Congo (formerly Zaire) where the first outbreak was recorded in 1976, the virus causes haemorrhagic fever and affects multiple organ systems, leading to internal and external bleeding. But the early symptoms are non-specific — rashes, fever, weakness, muscle pain, headaches, a sore throat — and are often mistaken as signs of malaria, typhoid or meningitis. It takes five different laboratory tests to definitely confirm Ebola.

An uncomplicated virus with a small genome, Ebola attacks silently. It subverts the immune system to multiply rapidly and takes over key organs. Then it makes blood clot inside blood vessels. As blood vessels choke up, the organs start leaking blood. As the clotting mechanism is kept busy inside blood vessels, internal and external bleeding is uncontrolled. The result is swift and often fatal.

In the absence of any specific cure for Ebola, the treatment involves hydrating the patient, maintaining oxygen levels and blood pressure, and administering drugs for any serious infection. An isolated ward is a must to contain an outbreak. At advanced epidemic stages, entire hospitals or neighbourhoods become controlled areas.

Preliminary tests suggest that the Zarine strain, the deadliest of the five Ebola subtypes, is responsible for the present outbreak. While the toll nears 900, including more than 60 doctors, the death rate remained below 60 percent because of early treatment in most cases.

The outbreak began in February in the forests of the west African country of Guinea. The epicentre shifted to neighbouring Sierra Leone in May — the virus was apparently brought in by a traditional healer — and in Liberia by June. Nigeria became the latest country to be affected, with three cases being reported as of 4 August, after the death of a US citizen who had contracted the virus in Liberia and moved from there in late-July. Two other US citizens who were infected during their stay in Liberia — a doctor and an aid worker — have since been flown home and are being treated in seclusion.

While the infections have been limited to Africa so far, the fear of transmission during air travel has led to airlines shutting down travel to Africa. Emirates has suspended flights to Guinea, while Nigeria’s largest airline, Arik Air, has stopped flights to Liberia and Sierra Leone. Nigeria has banned African airline Asky from its airspace and Ghana has banned flights from the Ebola-affected region.

Medical experts insist the chances of airline passengers contracting Ebola on a flight are pretty slim. So, why the scare? Because it only takes a droplet of blood or saliva to get infected. If even a microscopic amount of infected blood, say from a nasal bleed left on an armrest, or saliva sneezed out comes in contact with one’s hand or face, there is a fair chance the virus will enter through the nose, eyes, mouth or skin.

But it is not particularly the safety of passengers the world is worried about. The symptoms of Ebola can take as long as 21 days to manifest. During this period, there is no way to tell if one is infected and bar him or her from flying to another region or country. An infected person without symptoms cannot spread Ebola, but while fellow flyers will have nothing to fear in that period, the carrier is likely to spread it in a new location when the symptoms eventually manifest.

Yet for all its malignancy, Ebola did not mean to invade our world. Like HIV, West Nile or SARS, it is a relatively recent infectious disease that we borrowed from animals when we made close contact. There are some 320,000 viruses in mammals alone and we are only getting to know a few that give us trouble.

New pathogens jump from animals to humans in a process called zoonosis. It started since we began domesticating animals. Smallpox and diphtheria are classic examples. More recently, intensive pig farming in peninsular Malaysia led to the outbreak of Nipah fever in 1999, killing 105. Ducks and chicken in Southeast Asia caused the spillover of avian flu, H5N1. Contact between pigs and humans in Mexico landed us H1N1 and swine flu.

Ebola, in all likelihood, came to us from fruit bats. Gorillas and duikers (an antelope native to sub-Saharan Africa) often feed on the fruits partially eaten and discarded by bats. Research indicates that this chain of events allows indirect transmission from the natural host (through its saliva) to an animal reservoir. Humans contracted the virus from these animals, say, when someone handled a gorilla carcass or through improperly cooked bushmeat.

Since most cases occur in remote forested parts of Africa, the virus was contained in the past before the outbreak spiralled out of control. But this time, the outbreak has been termed “out of control” by Doctors without Borders. Unlike remote central Africa where the virus struck repeatedly in the past, the present epicentre in western Africa is urbanised. Even the capital cities of Guinea and Liberia have been exposed.

Like the rest of the developing world, urban Africa, too, is rapidly changing. A large section of the urban population of the affected countries — Guinea, Liberia and Sierra Leone and now Nigeria — travel more frequently and travel much farther than they did in the past century. It is one thing to track and contain all contacts within a radius of a few miles, quite another to trace, check and isolate potential patients on airport travel logs across the world.

Also, unlike central Africa, these are areas experiencing an Ebola outbreak for the first time and authorities and people alike are not used to the measures required to contain the virus. For instance, traditional funerals in Africa involve washing the body before it is buried, which can expose relatives to blood and other infectious bodily fluids. It remains a challenge for international health workers and local governments to interfere with such cultural beliefs that come in the way of infection control.

at the same time, the countries facing the present outbreak simply do not have the capacity to fight the virus on their own. Guinea, Liberia and Sierra Leone are some of the world’s least governed States with per capita incomes of $527, $454 and $809, respectively. Life expectancy in these countries is between 46-62 years and the governments spend $7-18 per capita on health.

But even if the global community is willing to help, it has been tough to channel support in these countries where governance is minimal, if not missing. The Guinean government could not quarantine the Ebola patient who was reportedly responsible for spreading the virus to the capital. The police had to fire tear gas to restrain mobs who wanted to raid morgues to give their relatives a traditional burial. Even the Red Cross had to temporarily abandon operations as aid workers came under attack from residents who accused the foreigners of bringing the virus to their homes.

The chaos is not surprising, given that Guinea, Liberia and Sierra Leone share an over-two-decade-long history of brutal civil wars that killed at least 400,000 people and displaced 500,000. These scarred populations cannot be expected to follow healthcare manuals unless a semblance of peace and order is restored through effective governance. Till then, mere financial and technical help may not be able to effectively contain the virus.

The urgency of the situation has also created room for a moral debate. Till date, there are no licensed drugs or vaccines for Ebola. The periodic, remote and until now small-scale nature of Ebola outbreaks meant that there was never a big enough market that pharma companies look for. This also meant little room for conducting trials in humans exposed to Ebola.

Yet, vaccines are being developed by a number of organisations — the vaccine research centre at the US National Institute of Allergy and Infectious Diseases for one — and many believe the present outbreak is the right opportunity for a trial. But the World Health Organisation has discouraged such ideas because “using an experimental vaccine on human beings in the middle of an outbreak in this case would not be ethical, feasible, or wise”.

With infection a flight away for most of the world, the debate is ‘civilisational’ as well. Ancient man lived in far isolated groups of not more than 200 individuals and no infection ever had a chance of jumping from one group to another or becoming an epidemic. A few millennia later, maybe we have become far too connected for our own good in this small world.

Today, the global community shares an increasingly common destiny and the deadly Ebola will test it as avian flu did. The outbreak will be considered over once 42 days — double the incubation period — pass without new cases. The world is counting.

letters@tehelka.com

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