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  • Treatment of the Ebola contact.

    Posted by Michael Kennedy on October 3rd, 2014 (All posts by )

    The early information of the Ebola patients in Dallas seems to suggest that competence has not been high on the list of priorities. First, the patent seems to have known about his illness before he got on the plane to the US. He lied to the authorities in Liberia but that is not that unusual. All it takes is ibuprofen to evade the screening at the airport.

    Second the treatment of the relatives Has finally become humane after days of cruel treatment including quarantine in a contaminated apartment.

    The initial treatment was not a model of infectious disease protocol. Why he was sent home with a GI illness and a history of travel to Liberia is still not explained. My medical students are all told to take a history of travel with any GI illness symptom. It’s not clear who he saw but many ERs use Nurse practitioners or PAs to see ER patients.

    He is not doing well and he seems to be declining. We will see how he does but his relatives are still in serious trouble. We are still in trouble.

    The promised treatment program is still inadequate. Tomorrow will bring more bad news.

    A CDC official said the agency realized that many hospitals remain confused and unsure about how they are supposed to react when a suspected patient shows up. The agency sent additional guidance to health-care facilities around the country this week, just as it has numerous times in recent months, on everything from training personnel to spot the symptoms of Ebola to using protective gear.

    This is only the first case.

    UPDATE: More news from Bookworm.

    Ebola can transmit through people’s skin. It’s not enough to keep your hands away from your nose and mouth. If someone’s infected blood, vomit, fecal matter, semen, spit, or sweat just touches you, you can become infected. Even picking up a stained sheet can pass the infection. Additionally, scientists do not know how long the virus will survive on a surface once it’s become dehydrated. The current guess is that Ebola, unlike other viruses, can survive for quite a while away from its original host.

    Oh oh. This explains the infection of hospital workers in Nigeria from urine.

    The good news, if any, is this:

    If patients get Western medicine that treats the symptoms — drugs to reduce fever and to control vomiting and diarrhea, proper treatment if the body goes into shock, and blood transfusions — the mortality rate is “only” 25% — which is still high, but is significantly lower than the 70%-90% morality in Africa, where patients get little to no treatment.

    I will update this as news becomes available.

    UPDATE #2

    Now we have a possible case #2

    A patient with Ebola-like symptoms is being treated at Howard University Hospital in Washington, D.C., a hospital spokesperson confirmed late Friday morning.

    The patient had traveled to Nigeria recently.

    That person has been admitted to the hospital in stable condition, and is being isolated. The medical team is working with the CDC and other authorities to monitor the patient’s condition.

    “In an abundance of caution, we have activated the appropriate infection control protocols, including isolating the patient,” said hospital spokesperson Kerry-Ann Hamilton in a statement. “Our medical team continues to evaluate and monitor progress in close collaboration with the CDC and the Department of Health.”

    No final word yet. Then, of course, we have the NBC case.

    Thursday, news broke that a freelance NBC cameraman covering the outbreak in Monrovia, Liberia had tested positive for Ebola after experiencing symptoms of the disease.

    The cameraman, Ashoka Mukpo, had been working with chief medical correspondent Dr. Nancy Snyderman. NBC News is flying Mukpo and the entire team back to the U.S. so Mukpo can be treated and the team can be quarantined for 21 days.

     

    21 Responses to “Treatment of the Ebola contact.”

    1. MikeK Says:

      Doctors have a weird sense of humor sometimes. Still, gallows humor is still humor.

      UnitedHealthCares (UHC) of Dekalb County has informed hospital officials at Emory University that Ebola patient Dr. Kent Brantley does not meet inpatient criteria. UHC’s commission based claims reviewer, Sven Tweeny, CNA, has recommended 24 hours of observation care instead. “If we paid inpatient for every viral syndrome, we’d run out of money before New Year’s Eve.”

      Enjoy.

    2. dearieme Says:

      White Man’s Graveyard it used to be called, West Africa. Not without reason.

    3. MikeK Says:

      A good piece in the Wall Street Journal on what SHOULD be done.

      But the decisive risk to the U.S. will emerge in a few months. If the virus continues to spread in West Africa at its current pace, much larger global outbreaks will become likely.

      Should these outbreaks coincide with the cold-weather peak of the flu season—when symptoms of influenza can be confused for the early signs of Ebola—the health-care system’s ability to quarantine all the people with suspected Ebola infections, and test them in the required specially equipped labs, could be overwhelmed.

      And if Ebola does decisively break out of West Africa, we may be unable to control the spread of the disease solely by conventional public-health tools of infection controls, tracking and tracing sick contacts, and isolating the ill. If this happens, we may face a global pandemic early next year.,/i>

      The flu season issue is frightening.

      ZMapp showed remarkable efficacy in bolstering the immune system to directly attack the virus in monkey experiments and may also have helped several Ebola sufferers recover.

      There are also drugs targeting cancer called “kinase inhibitors” that show potency against the Ebola virus. One advantage of drugs working at the host level—on the person not the virus—is that theoretically the drugs can still work even if the virus mutates. This is in contrast to a vaccine that relies on targeting certain markers on the virus surface that can change as Ebola mutates.

      The drugs we have now, like reverse transcriptase inhibiters, which were the first drugs to act on HIV may be important if this starts to get out of hand.

      We can only wait and see.

    4. Subotai Bahadur Says:

      And if Ebola does decisively break out of West Africa, we may be unable to control the spread of the disease solely by conventional public-health tools of infection controls, tracking and tracing sick contacts, and isolating the ill.

      Right now we are unable to control the spread of the disease by conventional public-health tools, because we are not using them, apparently deliberately.

    5. ErisGuy Says:

      “It’s not clear who he saw”

      If I become sick, please do not take to a hospital with such poor records.

    6. ErisGuy Says:

      If 75% of the victims receiving treatment and supplies die, at what point should victims be denied treatment to preserve resources for victims of other illnesses who will live if they have access to doctors, nurses, hospitals, and medicines?

    7. ErisGuy Says:

      Are the power washers at the apartment complex the canaries in the coal mine? Their exposure would have been minimal. If they get sick….

      In 2-3 weeks, the future will reveal itself. Until then….

    8. MikeK Says:

      There is an interesting interview with a virologist who visited Liberia recently in Science Weekly.

      I actually think passing through the airport on my way out was the highest risk. They are bringing hundreds of people into a very confined space with a lot of direct contact, so if you get a patient into that environment, you are going to have exposures. It is a ridiculous situation. Also, they are checking your temperature three times before you get into the airport, but if you look at the people that do this kind of work, they don’t really know how to use the devices. They are writing down temperatures of 32°C, which everybody should know is impossible for a living person. All the checks they do are completely useless because they are done by people who are not well trained or overwhelmed by the number of passengers. It is just a disaster, and it needs to be fixed.

      So much for our willingness to allow travel from Liberia.

    9. Will Says:

      If I’m not mistaken, wasn’t it “the guy from the neighborhood” Bill Ayers that said something like 20 million white people would have to die, or something to that effect? I’m not implying that there’s any connection between this terrible problem and Ayers or his neighbor or anything of the sort. Just that it’s another in a string of terrible coincidences that has befouled an otherwise noble and diligent administration.

    10. Trent Telenko Says:

      The problem here in Dallas after Thomas Eric Duncan’s death is that Dallas County Judge Jenkins went into the apartment that Thomas Eric Duncan was staying in in his street cloths and no PPE before it was decontaaminated.

      Then he drove in his car to a public relations event with the elected and appointed heads of Dallas municiple and country government.

      If Judge Jenkins comes down with Ebola, Dallas local government is decapitated for three weeks or more, along with a fair portion of Dallas media.

      Worse, Jenkins has been out in public shaking hands and running for re-election in November!!!

      And the people he has been shaking hands with are not the white folks Bill Ayers said needed to die.

    11. Joe Wooten Says:

      Trent, that would leave a vacuum for the Texas Republican Party to fill, since Jenkins is a democritter. Since the conservative businessmen who used to run Dallas mostly behind the scenes have been ousted by the dhimmicrap party, Dallas has been getting worse.

      If it can be isolated fairly fast, I really don’t see a very big downside to that decapitation, other than quite a few folks dying a very nasty death.

      Some might think I’m just being nasty, but I am at the point where I consider this just returning the favor. Up here in Illinoisy I have already seen the typical crap of democrats pulling out campaign signs on private property, the very nasty racist whispering campaigns (against John Anthony), etc.

    12. Trent Telenko Says:

      There is a new suspected Ebola case in North Texas. The case showed up at a Frisco Tecas “Doc in a box” and they called 911.

      WFAA in Dallas has live feed showing the case being takn to Texas Health Presby in Dallas.

      The individual is on the CDC contact list for Thomas Eric Duncan.

      The contact is not family.

      CDC has a news conference set for 3pm CST.

    13. Trent Telenko Says:

      CNN just reported that the State of Texas confirmed to them that the Dallas County Sheriff’s deputy who is reporting Ebola symptoms was NOT one of the 48 close contacts being followed.

      However, He was one of the people who entered Duncan’s Department W/O PPE.

      That intake of air you just heard was the CDC and all levels of local Dallas government sucking their seat cushions into their collective bottoms.

    14. Trent Telenko Says:

      A Report from the Free Republic web site —

      http://www.freerepublic.com/focus/news/3212860/posts?page=97

      “The patient is the deputy sheriff tasked with entering his apartment originally.

      He is NOT on the list of 46 people to be monitored for symptoms.

      Since he wasn’t on the list, he did what anyone else would do – go to the walk-in clinic.

      He checked the box ‘yes’ on the question about coming into contact with a person that had ebola.

      Bystanders report him being doubled over in abdominal pain at the time.”

    15. MikeK Says:

      This is far from the end of this. Today, there is a case of suspected Ebola in Los Angeles. Taken off a plane at LAX by people in hazmat gear and taken to Centinella Hospital, a local place known for sports medicine, not communicable diseases. She/he was from Liberia. And the band plays on.

    16. Subotai Bahadur Says:

      From what I understand, the suspected Ebola cases in LA and NYC have been cleared.

      The head of the CDC gave a press conference this afternoon, where he announced the next round of fake protections that don’t protect. And in passing explicitly stated that the reason we do not stop commercial air passenger traffic from the infected countries was because it would cost too much for the protection. Successfully stopping the SARS epidemic some years ago cost the economy $40 billion, which they don’t want to do. I assume that means they value American lives at a very low level.

      The next round is questioning incoming passengers at 5 airports [eventually, and even then only 5] about risk factors, passing out fliers both in the infected countries and here that tells them what to deny [CDC is betting that EVERYONE WILL TELL THE TRUTH WHEN DOING SO BLOCKS THEM AND LYING GETS THEM INTO THE COUNTRY] when questioned, and taking their temperature with non-contact thermometers. That last is worthless as they already know how to beat it, the same way Duncan did; a handful of ibuprofen taken to kill any fever temporarily.

      But a key point is that, like the deputies in Dallas who were sent into the apartment with no PPE at all; he announced that the screeners in the airports will also not have any PPE. The reason is that if they were wearing it, it might worry people and make a bad impression.

      I know [having spent my career wearing a badge] that the Sheriff’s Office in Dallas has a bunch of deputies who are really not happy campers right now. How do you think the airport screeners are going to feel?

      Subotai Bahadur

    17. Trent Telenko Says:

      Subotai Bahadur,

      Nobody in the Federal government outside of the TSA thinks much of those inside TSA, and making them the 1st line of defense for Ebola is asking for a health care disaster. Not that we don’t have an on-going health care disaster — without Ebola and with Obamacare — already.

      The number of health care workers in the North Texas has effectively dropped by 10% due to events in Dallas and Frisco during the last week.

      I am hearing of Ebola being the tipping point for many baby-boomer doctors near retirement, and of their having put in retirement papers.

      Those older nurse and below baby-boomer health care workers (HCW) who are on part time have moved in some numbers to no-time and younger pregnant HCW are withdrawing completely from the system.

      I expect similar things are now happening with North Texas Emergency 1st Responders.

      The political elites cannot command the loyalty of the government 1st responders, HCW or the Military without sufficient PPE.

      And only the US Military has any durable PPE in real quantity…which these elites are sending to West Africa.

    18. Subotai Bahadur Says:

      Trent Trelenko,

      Thanks for the information. It fits.

      One good bit of news. There are reports that they have announced that SGT. Monning, the deputy who was exposed in Duncan’s apartment, does not have Ebola. He still has to be watched for a couple of weeks. And of course, you have to take the announcement with a grain of salt, considering the source.

    19. Trent Telenko Says:

      It is bleeding obvious to anyone paying attention.

      Local media in Dallas is stating a lot about “HCW not being afraid,” but it is utter horse manure.

      HCW here are just as afraid as HCW in Spain.

      See:

      Madrid hospital staff quit over Ebola fears

      Carlos III hospital treating virus-hit nurse Teresa Romero Ramos suffers staff shortage amid concerns over training and safety

      Ashifa Kassam in Madrid
      The Guardian, Friday 10 October 2014 05.31 EDT

      http://www.theguardian.com/world/2014/oct/10/madrid-hospital-staff-quit-ebola?

      Carlos III hospital in Madrid is scrambling to contract extra personnel as worries about lack of training and safety standards have left some staff refusing to attend to possible Ebola cases.

      Eight people are in quarantine, including four health workers who treated Teresa Romero Ramos, the Spanish nurse who contracted the virus after treating an Ebola patient repatriated from Sierra Leone.

      On Thursday, authorities said Romero Ramos was in a stable but critical condition. Her treatment has included injections with antibodies extracted from the blood of Ebola survivors.

      While no official numbers were available, Elvira González of the SAE nurses’ union said fear of Ebola had caused some staff to refuse to treat certain patients, while others had resigned their posts.

      Amid concerns over inadequate training and safety standards, one health worker told El País newspaper that many staff members were making excuses to avoid work. “They are saying they’ve got their period, that they’re getting dizzy, that they’re claustrophobic … People get anxious and they can’t work like that, being so nervous.”

      Others worry about being stigmatised. “Their children aren’t being invited to birthday parties and their friends are cancelling joint vacation plans,” Juan José Cano of Satse, a nursing union member, told El País. “They’ve become known as the Ebola nurses. And it’s not fair.”

      The hospital was not forcing staff to work at the Carlos III, González said. “There are questions as to whether the protective suits are adequate, if the protocols are adequate. A health professional could accuse the administration of a public health offence if they are forced to work in conditions that are not adequate.”

      The staff shortage has forced the hospital to seek help from unemployed health workers. One recent nursing graduate told El País she had delivered a CV to La Paz hospital in Madrid on Wednesday morning. Hours later, she received a call offering her work at the Carlos III the next day. Initially, “they didn’t say one word about Ebola”, the 25-year-old said. After discussing the job opportunity with her family, she turned down the work.

      Health authorities have done little to dispel claims by health workers’ that the response to Ebola in Madrid has been improvised. In August, when the first missionary with the virus was repatriated from Liberia, the Carlos III hospital was emptied to attend to him. When the second missionary arrived last month, it was decided that only the sixth floor would be cleared. Between appointments and surgeries, the hospital continued as normal.

      Initially, the same was done after Romero Ramos tested positive on Monday. But as the number of patients in quarantine grows, authorities have been forced to hastily find more space. In recent days, two more floors have been cleared, with patients either discharged or transferred to other hospitals in the city.
      _________________

    20. Trent Telenko Says:

      SB,

      I found this at the Free Republic Forum “Ebola Surveillance” thread

      —————————–
      Pixie’s Ebola Status report from PANDEMIC FLU INFORMATION FORUM

      http://www.singtomeohmuse.com/viewtopic.php?t=5725&postdays=0&postorder=asc&start=3300&sid=eacae20ff01181645fa59eeabb41ac43

      Quote:

      “The world’s response hasn’t kept pace with the spread of Ebola, Koroma said, and “a tragedy unforeseen in modern times” is threatening everyone.

      United Nations Secretary-General Ban Ki-Moon called for a 20-fold surge in international aid to fight Ebola.
      ….

      World Bank President Jim Yong Kim endorsed pledges Thursday from the United States and United Nations to guarantee medical evacuations for health care workers responding to the crisis, an effort to ensure that enough doctors and nurses are willing to risk their lives to help stop the disease.”

      It won’t be enough, very soon, to simply promise to evacuate volunteer medical workers.

      The exponential numbers are driving case loads into unmanageable territory.

      There’s a tipping point that will come around Thanksgiving (if one uses MSF’s case estimates) where the “infrastructure” that nations are now trying to get into place will become overwhelmed if the pace of response is not lightning fast, right now.

      So far, speed has been talked about in terms of weeks, then days. Now we’re really looking at setting the Thanksgiving countdown clock to hours.

      If an incredibly overwhelming response isn’t on the ground in just a few days, it is very likely that by Thanksgiving those workers who have been promised evacuation if they contract the virus will be instead being evacuated due to a complete social breakdown and the great danger it presents to the continuation of relief operations.

      By Thanksgiving, MSF and the remaining response teams may be forced to pull their workers out of the original affected outbreak areas.

      MSF and the other relief agencies may be tasked, at that point, to three or four other nations which, by that time, might be experiencing outbreaks of Ebola in an effort to try to stem the tide in those locations, where such a thing appears feasible.

      In Liberia, around Thanksgiving the U.S. military will be reexamining the operational situation and, having built the ETUs it said it would build, will probably begin quietly withdrawing its personnel. The U.S. military may be home by Christmas. The British, who are just now beginning to deploy their military forces, will no doubt attempt to complete their mission goals as soon as possible and then will likely reassess and withdraw also.

      The day that MSF and the U.S. military must announce that they are leaving will be a very bad day.

      What will happen to Liberia, Sierra Leone, and Guinea then? Well, then raw science will take over. Herd immunity is reached when around 40% of a population has either been infected or vaccinated. There won’t be a vaccine available in large quantities by the New Year’s. The public’s attention will turn to saving the newly affected nation states and to each exported case that turns up in their own backyards.

      So when Ban Ki-Moon says he needs a “20-fold surge,” he means he needs it tomorrow.

      The leaders of the world, along with their militaries and health resources, need to act, right now, as if a World War were breaking out, rather than a virus.

      They can respond, they do have the ability, but the orders have to go out now. Right now. Any time spent wasted on anything other than making public appeals for workers and moving with record breaking speed on logistics is tragically wasted time.

      Any government or public official spending time giving screen time to anything else — unless they are a local official who happens to have an Ebola patient in their local hospital — is misusing the few moments we have remaining to contain this outbreak.

      The immense amount of time that has been sunk into arguing the ideology of open borders will be seen later as having been a fruitless distraction from the reality that everything nonessential related to these countries needs to stop in an effort to focus on arresting the transmission of Ebola.

      Governments – stop whining. You need to either buy up the commercial air routes yourselves or set up regular access and egress flights to ferry essential personnel into and out of the hotspots via your militaries (the U.K. takes Tuesdays, the U.S. takes Thursdays, the Canadians take Saturdays..).

      It is not that complicated. Not if you all act like it’s Word War III. It may well be. It’s just that this time you won’t be fighting against ideologies or territory grabbers, you’ll be fighting against an invisible foe for which, perhaps, Will Smith movies can offer the best model of preparation and response.

      So, yes, a “20-fold surge,” now, right now, as the U.N. chief said. Absent that, the mathematics tell the tale.

      The surge will either be TO those countries, now, or the surge will be OUT of those countries come late November and early December.

      As we’ve seen throughout this experience, it’s important to get the prepositions right.

    21. Trent Telenko Says:

      This is a hard truth from Doctors Without Borders —

      ————
      Only the military can get the Ebola epidemic under control: MSF head

      BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g6151 (Published 10 October 2014) Cite this as: BMJ 2014;349:g6151
      http://www.bmj.com/content/349/bmj.g6151

      Médecins Sans Frontières (MSF), the humanitarian medical charity, has been on the front lines of the Ebola epidemic since it began. It has had a major role in the international effort to control the outbreak, caring for two thirds of the 8000 people in Guinea, Sierra Leone, and Liberia who have been infected. But in early September, after six months of battling Ebola in vain, and with the death toll mounting exponentially, MSF effectively admitted defeat and said that it would take major military mobilisation by wealthy countries with biohazard expertise, not just international aid, to stop the disease. The charity had doubled its staff, MSF’s president, Joanne Liu, told the UN members, but it still was overwhelmed.

      Liu, a Canadian paediatrician who has worked for MSF in war zones and natural disasters for the past 18 years, called upon UN members to dispatch their disaster response teams, backed by the full weight of your logistical capabilities. “Without this deployment, we will never get the epidemic under control,” she said.1

      Peter Piot, director of the London School of Tropical Medicine and Hygiene and the microbiologist who first identified the Ebola virus in 1976, also called in September for a “quasi military intervention.” He suggested that a major UN peacekeeping force should be deployed to Sierra Leone and Liberia, with huge donations of beds, ambulances, and trucks as well as an army of clinicians, doctors, and nurses.

      The message came as the numbers of deaths from Ebola began to spiral, particularly in Liberia. There have been over 3800 reported deaths in the region, according to the latest World Health Organization figures, 40% of which have been recorded since September.2 WHO has estimated that there could be 20 000 infections before the outbreak is brought under control, and the US Centers for Disease Control has predicted that, in a worst case scenario, as many as 1.4 million may be infected by the end of January.3 As the economies and health infrastructures of the three countries, home to over 22 million people, risk total collapse, the UN Security Council declared the outbreak was a threat to international peace and security.

      Limited response
      Yet a month after the first calls for military deployment, forces are only now starting to be mobilised in any numbers. The US, UK, Germany, and France have responded, although not exactly as Liu had hoped they would. The US has said it will send 4000 troops to build new isolation units and treatment facilities in Liberia, a country created by US citizens as a colony for former African American slaves. But President Obama has made it clear that US troops will not be staffing those units and coming into contact with Ebola patients. The UK has pledged to send 750 troops to establish new Ebola treatment centres in Sierra Leone, its former colony, and a training academy for those working in treatment centres. Around 5000 German troops have volunteered to work in west Africa but they have not yet been deployed, and the government has now admitted that it would not have the resources to fly any troops home for treatment should they become infected.

      So far no other countries have offered their armed forces, and President Obama warned in early October, if most countries choose to remain on the sidelines and watch the US do the bulk of the military work, the outbreak will continue to be a global threat.4

      Liu says she is exasperated at the slow, hands-off response. “Countries are approaching this with the mindset of going to war,” she says. “Zero risk. Zero casualties.”

      Liu describes the current military efforts as the equivalent, in public health terms, of airstrikes without boots on the ground. Pledges of equipment and logistical support are helpful—“The military are the only body that can be deployed in the numbers needed now and that can organise things fast.” But there is still a massive shortage of qualified and trained medical staff on the ground. “You need to send people not stuff and get hands on, not try to do this remotely,” Liu says, “Local doctors have been extremely brave, but we are running out of staff and that is why we are asking for a major workforce to deploy.”

      Since the 9/11 attack on New York’s twin towers, Western countries have developed military and civilian biohazard teams to protect their populations against a possible bioterrorist attack. Liu had hoped that these could be deployed to west Africa. “I think with the massive investment and knowing how much they are afraid of bioterrorism, they have some knowhow about highly contagious diseases.”

      MSF is not alone in thinking that what’s needed in west Africa is the same level of Western military involvement that there would be in the event of a major bioterrorist attack on home soil.

      The European Commission’s humanitarian arm (ECHO) has been pushing for military medical intervention, its health adviser, Jorge Castilla-Echenique, told Reuters in Dakar in September.5

      “The European Commission wants [US] Army and Seal protection teams to come here and produce an air bridge to keep the health workers and aid flowing. I’m talking about a MASH like operation,” said Castilla-Echenique, referring to US mobile army surgical hospitals that can serve as fully functional health facilities.

      “The problem with the military is that a treatment centre [50 beds] may cost €7m [£5.5m; $9m] over one year. But if it’s done by the US military, it’s going to cost €70m, because they are going to come with their own bubble so they won’t get sick,” he said.

      Health workers at risk
      It is not entirely clear how many healthcare workers, national or international, are currently working with Ebola patients in west Africa. MSF now has 2800 national staff and 200-300 international staff working across the three countries. Fourteen staff, including one international worker, have become ill, eight of whom have died. An assessment by the Office for the Coordination of Humanitarian Affairs, based on WHO’s prediction of 20 000 infections, calculates that 178 doctors and nurses would be needed. If the CDC’s predictions are right, the number would be many times higher.

      Despite a major international effort launched by WHO in July large numbers of health professionals are still working without proper protection or sanitation. Almost 200 healthcare workers are known to have died, including the leading experts in each country, and many of those remaining are now too afraid to go to work or have reportedly left the country.

      Troops are arriving just as a parallel global effort to accelerate the process for testing and approving experimental drugs and vaccines is getting under way. In November, clinical trials of several candidate treatments are planned to begin on Ebola patients in the region, with a view to obtaining results by December and producing the drugs for distribution early next year, should the trials prove successful. Potential vaccines are also being tested. Though she recognises that the availability of a vaccine in large quantities could be a “gamechanger,” Liu is concerned that the possibility that a new drug or vaccine could stop Ebola in its tracks may take the pressure off the global community to take more action to save lives in the meantime.

      “We cannot let this give people a reason not to deploy more resources to fight this on the ground,” she says. “Everyone is looking for excuses to not deploy because they are so scared.”

      While the details of those trials are still being ironed out—and we wait to find out whether the candidate vaccines and drugs will prove safe and effective—MSF warns that there are huge ethical decisions still to be made. Not least is the question of who should receive the vaccines if, as is almost certain to be the case, there are not initially enough to go round.

      “Right now everybody is reflecting on this. Who do we privilege if vaccines can be produced in time for this outbreak but there are not enough for everyone. Pregnant women? Those who’ve had contact with infected people? Health workers?”

      Although MSF is keen to be involved in efforts to develop treatments and vaccines for the disease, it does not believe that a vaccine is a solution to the current outbreak because no manufacturer would be able to produce enough for the entire populations of the three countries in one go.

      Tensions with WHO
      Besides providing medical help to those in need worldwide, MSF, which was founded by a group of French doctors to provide assistance to refugees during the 1967-70 Biafran war, has built itself as a prominent voice of absolute humanitarian ideals. Although it works closely around the world with the UN and with individual states, it is often one of WHO’s harshest critics. Liu, speaks of a “healthy tension” between MSF and the WHO, which she has accused of being woefully slow to react to the Ebola outbreak.

      MSF was ringing alarm bells in spring about the Ebola outbreak being out of control, but it took until August for WHO to recognise the scale of the threat and declare a “health emergency of international concern,” a legal mechanism that flips switches in the international community so that funding and expertise are mobilised faster and protection measures are put in place.

      “Every meeting where we’ve been trying to advise something, it’s been a challenge,” Liu says. “We had the feeling people didn’t understand what we were talking about. They were just looking at the figures. When you look at the figures in absolute [compared with other diseases that kill many more people] people say ‘why are we getting so excited?’ But Ebola has completely killed the infrastructure of these countries. It is attacking the state and the health structures. We cannot afford to let that continue.”

      “I am running out of words to convey the sense of urgency. The despair is so huge and the indifference so incredible.”

      Guinea, Sierra Leone and Liberia, three of the 12 least developed countries on earth,6 are countries many people outside Africa could not have placed on a map until the Ebola outbreak began.

      Liu recognises that the capacity of wealthy countries to care and respond to distant crises has been stretched like never before in recent months (MSF has never deployed as many staff in as many countries as in 2014). Crises in Syria, Iraq, Ukraine, and Gaza mean that when MSF urged countries to do more about Ebola, the message came back that “our plate is full.”

      But she says, lack of leadership not lack of money has been the real problem. What the Ebola crisis has shown is that the global system for coping with potential health emergencies has omitted to create a clear chain of command.

      “What is the international governance order? Who feels responsible?” she asks. “At the moment, no one feels responsible. “WHO considers itself to be a technical agency answering to member states. Somehow people left it to a private organisation to take the lead. There’s something wrong there.”

      In September, after the UN Security Council declared Ebola had become a global security threat, the United Nations created its first ever UN emergency health mission, the Mission for Ebola Emergency Response (UNMEER).7 The mission will be headed by British doctor David Nabarro, a former system coordinator for avian and human influenza for the UN. It aims to coordinate the international efforts to stop Ebola and has its headquarters in Ghana.

      Notes
      Cite this as: BMJ 2014;349:g6151