State of the Globe: Ebola Outbreak in the Western World: Are We Really Ready?

Abstract

Although the current Ebola virus disease (EVD) outbreak has gained notoriety in recent weeks, especially after the first imported case was reported in the US, it is believed to have started in December 2013 in the rural areas of Guinea.[1] By March 2014, the outbreak had expanded beyond Guéckédou, Guinea where it was first reported.[1 2] Guéckédou is a rural town located near the border with Sierra Leone and Liberia, countries where the disease would expand in the ensuing days.[1] In fact, by March 30 the World Health Organization (WHO) reported seven suspected cases in Liberia[3] and by April 1st the death of two suspected cases in Sierra Leone.[2] The immediate response after the reporting of the initial suspected and confirmed cases was, at minimum, regrettable. Probably, there was a lack of sense of urgency since the previous Ebola outbreaks, in Uganda, extinguished relatively quickly.[4 5 6] It would seem that the initial response to the outbreak at all levels (from local and national authorities in the affected countries to WHO) was best characterized by inertia with some authors describing the circumstances as a “leadership vacuum” stemming from a crisis in global health leadership.[7] Despite some early signs that the outbreak was getting out of control, no concerted international efforts were taken, and it is arguable that even as of today our efforts seem to fall severely short from our needs. In fact, the latest figures by WHO show a resurge in incidence with 144 new cases reported in the week ending February 8 after a period of at least 3 weeks of decreasing trends.[8] It would seem that a halt has been reached to the important improvement seen so far this year.[8] To date, there are a total of 22,894 reported cases and 9,177 deaths in this outbreak.[8] On August 8, 2014, WHO declared this outbreak as a “public health emergency of international concern”, almost 5 months after receiving the initial report and almost 8 months after the first probable case was infected.[9 10] It took 3 more months for the US to recognize Ebola as a global crisis,[11] only after the first patient to have developed Ebola symptoms in US soil had unfortunately passed away.[12] This patient started his journey from Liberia to the US on September 19; on September 26 he was brought to and discharged from an emergency room (ER) of a hospital in Dallas, Texas despite having symptoms of EVD and was finally hospitalized 2 days later and passed away on October 8.[13] Since then, two nurses involved in his care have developed[13] and have been cured of EVD. This case put in test readiness of the steps needed for EVD containment which have previously been established: Isolate and provide critical care for the patient, monitor the contacts for at least 21 days (the estimated incubation period), disinfect, and sterilize. In theory, containing an Ebola outbreak should not be complicated, especially in developed nations where resources and infrastructure abound. However, it is our contention than in order to control an Ebola outbreak we need far more than financial resources and infrastructure. Let us consider the Ebola response in Spain where a nurse assistant was admitted to hospital with EVD infection after caring for two Ebola-infected patients herself. How is it possible that an indigenous Ebola transmission occurred in a developed nation, let alone within a resourceful healthcare system? The answer to this question is complex; however, some theories have been proposed. On the least favorable side, some healthcare workers have voiced their concerns about the “improvisation” with which the first infected Spaniards were transferred for treatment, lack of training, improper waste management, and insufficient and inappropriate equipment.[12] On the other hand, the infected nurse assistant said she might have contracted the disease because of improper techniques during the process of removing her protective equipment.[12] The United States has a solid healthcare infrastructure; however, let's look beyond hospital beds and isolation units and let's identify challenges the country would need to urgently address to prevent an EVD outbreak. One of the persisting problems in the US healthcare system is insurance coverage. According to the Centers for Disease Control and Prevention (CDC), 13.8% of adults (around 41 million people) still lacked health insurance during the first quarter of 2014.[14] Lack of healthcare insurance may prevent access to healthcare services and has been associated with higher mortality rate in epidemic situations.[15] If an Ebola outbreak first strikes the uninsured people, then we would face a very difficult scenario. It is likely that uninsured people fall below poverty levels; for instance, almost a quarter of people living in households with annual income less than $25,000 in the USA were uninsured in 2012.[16] Poverty is usually associated with overcrowding; thus, enhancing the risk of transmission among close contacts of an infected patient. There are other factors associated with poverty that might negatively impact an evolving Ebola outbreak including low levels of education, poor health literacy, concomitant diseases, lack of access to healthcare services, poor housing conditions, and lack of transportation (forcing the use of public transportation). Moreover, poverty disproportionately affects migrants and minorities. In fact, lack of insurance is higher among non-citizens (43.4%) and is also more frequent among Hispanic (29.1%), African American (19%), and Asian (15.1%) minorities when compared to non-Hispanic whites (11.1%).[16] Some of these minorities might have different cultural practices, which may enhance the risk for Ebola transmission. For instance, caring of patients by relatives and even neighbors, which is likely among cultures with strong family bonds, may become a factor that increases the number of contacts.[17 18] Additionally, an uninsured patient with symptoms would be likely to avoid visiting a doctor until the symptoms force a visit to the ER, especially if the patient does not know how to recognize EVD symptoms. By then, it may be too late and the patient may have already been transmitting the infection. Once in the ER, the symptomatic patient would likely be suffering from diarrhea and vomiting and would need to use the same restrooms used by other people in the ER, increasing the risk of transmission. In addition, an Ebola outbreak in the US not coupled with proper mass education could result in public panic, leading to even more crowded ER units. Panic combined with misinformation can lead to unfortunate consequences such as public anger manifested against healthcare workers and facilities like it happened in Guinea earlier during this outbreak. Another fact to consider is the concentration of healthcare services in hospitals. In such an arrangement, it would be very difficult to establish triage units or sentinel posts closer to the communities/vulnerable populations, which would be an important step in controlling the epidemic advancement. Therefore, concentration of both infected and uninfected persons in crowded hospital centers could occur. Finally, budget cuts are important issues that have been reviewed in a recent article published in JAMA.[13] In summary, if we are to prevent an Ebola outbreak to ever occur in the Western World, we would need to consider the additional following steps: Educate the population to avoid overflowing of healthcare services, but at the same time to recognize early symptoms properly; implement triage units or sentinel posts closer to the most vulnerable populations (if and when needed); care for the uninsured; educate and train healthcare workers; establish sterilizing units directly under the command of Health Departments; and recruit and train staff and volunteers. We deem the prospects of an Ebola outbreak to occur in the US and the Western World still very low; however, we believe it is important to address the weaknesses in our healthcare systems to be better prepared for such a challenge should it occur.