Editor’s note: This commentary is by Mark Pendergrast, who is the author of “Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service.” This piece first appeared in the Times Argus. He lives in Colchester and can be reached through his website, www.markpendergrast.com.
There is no question that Ebola is a terrifying disease. In 1976, in the first recognized human outbreak that originated in a small Catholic hospital in rural Yambuku, Zaire (now the Democratic Republic of Congo), its mortality rate was 88 percent. In other words, the virus killed nearly everyone it affected, and it sometimes did so in the most gruesome way, with some patients “bleeding out” because of the hemorrhagic fever. I later interviewed Joel Breman, the epidemic intelligence service officer from the CDC who investigated that original outbreak, who told me, “We were scared out of our wits. We didn’t know if we would get it.”
In the aftermath of that epidemic, which killed 280 people, Breman pondered a worst-case scenario. If Ebola ever adapts to humans, he thought, so that it gets into the respiratory tract and has efficient airborne transmission, it could lead to the extinction of the human race. Fortunately, however, field investigation at that time showed that the spread of Ebola resulted from contaminated injections or close contact with blood and body fluids of ill or dead persons.
As the death count in the 2014 Ebola epidemic in West Africa has crested 5,000, it is little wonder that the people in the worst-affected countries of Sierra Leone, Liberia and Guinea are subject to rumor, panic and discrimination. In the United States, where there have been seven imported cases, two health care workers who contracted it (and one death), there is far less reason to panic, yet unreasonable panic is what we have.
Even here in Vermont, a Rutland man named Peter Italia, who recently returned from West Africa, has been voluntarily quarantined (Gov. Shumlin has said he would order him locked up if it were not “voluntary”) for 21 days, at taxpayers’ expense, though he has no symptoms and no known contact with Ebola patients. Italia, who allegedly earned a medical degree in the Dominican Republic, may be nutty (he apparently believes in time travel), but the quarantine seems unnecessary. Instead, he should be monitored daily.
Let us review the facts we know about Ebola. It is not communicable until people have symptoms, which include fever, headache, fatigue, muscle pain, vomiting, diarrhea, stomach pain, and unexplained bruising or bleeding. Thus, it is reasonable to monitor people who have returned from West Africa to see if they develop any of these symptoms, but to restrict their movements otherwise is unnecessary and simply adds to the panic mentality and distracts from more purposeful activities. At least we let this man come home – Australia has just banned any travelers from the worst-affected countries.
Thankfully, Joel Breman’s imagined worst-case scenario has not come true, nor is it likely that this virus will mutate to make it more communicable. Ebola may have a high mortality rate – in West Africa it is now around 70 percent according to the World Health Organization, and apparently far less than that with good supportive patient care – but it is not easy to contract. Transmission requires close contact with the virus through infected bodily fluids or the clothing, bed sheets or other objects that might transmit the virus. That is why it is so important for health care workers to employ proper infection control and use protective barrier procedures.
The original epidemic was spread by unsterilized needles, poorly protected health workers, and funeral customs that involved touching the corpse. Now that we understand much more about Ebola, it should, logically, be relatively straightforward to break the chains of transmission, with proper precautions and community cooperation. Yet for various reasons — including a long-delayed recognition and response, a huge geographic area with multiple languages and cultures, low education level, poor health infrastructure, and distrust of Western medicine and hospitals — that has not yet occurred in Sierra Leone, Liberia or Guinea.
Ebola did not evolve in order to live in humans. It kills us too quickly, and it is too inefficient in spreading amongst us. With sufficient resources, Ebola should be brought under control in time.
When such a horrendous disease seems to spread and kill with impunity, it can appear implacable and unstoppable. In 1966, when the World Health Assembly voted to fund a campaign for worldwide smallpox eradication, the situation in West Africa was much the same, as smallpox, a disease that had killed humans since the time of the pharaohs, ran rampant. Yet the last case of smallpox in West Africa was diagnosed in 1970, and the disease was eradicated worldwide, other than for a lab accident, by 1977.
We could learn a great deal from the smallpox warriors who successfully rid the world of this terror. They did it through a method called surveillance-containment that is being applied with equal success to Ebola. First, find every case and track possible contacts. Then quarantine the patients and monitor their contacts to break the chains of transmission. For smallpox, that meant vaccinating everyone within a certain radius of confirmed cases while posting guards to keep active cases at home, in a hospital, or in some other community containment center.
Unlike smallpox, which afflicted only humans, we cannot eradicate Ebola. No one has identified its reservoir (the animal species that hosts the virus), though it appears likely that various African fruit bats serve as intermediate hosts. But it is a dead end in people. In other words, Ebola did not evolve in order to live in humans. It kills us too quickly, and it is too inefficient in spreading amongst us. With sufficient resources, Ebola should be brought under control in time.
An effective Ebola vaccine will perhaps be available in 2015. In the meantime, those with Ebola in West Africa need to be isolated and carefully treated. If they die, their bodies must be disposed of in a safe way. With the availability of cell phones, contact tracing and quick communication should be much easier than during smallpox eradication days. Indeed, Nigeria, the most populous country in Africa, has demonstrated that it can be done – it had 20 Ebola cases, seven of whom died, and has now been declared Ebola-free.
In a recent article, “Ebola Then and Now,” in the New England Journal of Medicine, Joel Breman and Karl Johnson, who also participated in the first Ebola outbreak investigation, wrote about how the original outbreak in 1976 was stopped. “We found that coordination of partners, transparency and clear designation of authority and responsibilities were essential,” as well as “adequate staff for rigorous identification, surveillance, and care of patients and primary contacts; strict isolation of patients; good clinical care; and rapid, culturally sensitive disposal of infectious cadavers.”
This is not rocket science, and the facts are readily available. This epidemic will end. How soon that occurs depends on the will, intelligence, and coordination of the world response and the cooperation of affected communities. The increasing numbers of new cases in West Africa indicates the world is still doing too little there, and too slowly.
But scaring the wits out of everyone, even in regions remote from the outbreak such as the United States, is not the way to accomplish the task. I have had conversations with friends and family about Ebola that illustrate the level of fear. One friend said she had been planning a visit to Texas but was now perhaps going to cancel it because an Ebola patient had died there. Another felt that all visitors to West Africa should be banned from re-entering the United States.
Garden-variety influenza – not even the pandemic kind – kills some 25,000 people in the United State annually, not to mention many more self-inflicted deaths due to tobacco and alcohol. Even though the flu vaccine has variable efficacy, it makes a lot more sense to seek that protection rather than to panic over Ebola in Vermont.