The Global Response to the Ebola Fever Epidemic: What Took So Long?

Mark J. Siedner of Harvard Medical School and John D. Kraemer of the O’Neill Institute for National and Global Health Law, Georgetown University, discuss the impact of the delayed global response to the Ebola epidemic.

On August 8, twenty weeks after the first suspected cases in what has become the worst hemorrhagic fever outbreak in history, the World Health Organization’s (WHO) Director-General declared the epidemic a public health emergency of international concern (PHEIC). The announcement, which signals that an epidemic constitutes a sufficient public health risk to member WHO States through the spread of disease, will ideally motivate financial and logistic support to the countries most affected. But after nearly 1,000 deaths, and for a disease where a relatively simple and coordinated public health response has extinguished prior epidemics, many are left wondering, “what took so long?”

An integral part of the WHO mission, mandated by the International Health Regulations (IHR), is to protect member states from international public health threats. The IHR were revised in 2005 after the SARS outbreak to improve responses to epidemics in an increasingly globalized world. Among the IHR’s central components is commitment from high-income countries to build capacity to prevent public health emergencies, and to provide assistance during active ones. The IHR task WHO with promptly identifying emergencies by declaring PHEICs to sound the proverbial alarm.

Timeline demonstrating course of Ebola epidemic including cumulative suspected cases, deaths, and notable events during the period (Source: CDC).

Timeline demonstrating course of Ebola epidemic including cumulative suspected cases, deaths, and notable events during the period (Source: CDC).

By most accounts, the criteria to declare a PHEIC were met months ago (Figure 1). The outbreak quickly made public health impact with its rapid pace and case fatality rates above 50% and by disproportionately affecting healthcare workers. It became an international epidemic five days after the first cases were reported when it spread from Guinea to Liberia. The epidemic is also unusual because it represents the first hemorrhagic fever epidemic in urban areas, where poverty and population density exacerbate disease spread. Only nine days after Guinea notified the WHO of the outbreak, Senegal closed its land borders with Guinea. By the end of May – 10 weeks before the PHEIC declaration – the epidemic raged on in Guinea, gained speed in Sierra Leone, and reemerged in Liberia.
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Ebola: Liberians Destined for Extinction

Liberian medical student Gondah Lekpeh gives us his perspective from the front lines of the Ebola outbreak.

On July 22 of this year, the Liberian Minister of Health informed us and the world that the Ebola hemorrhagic fever outbreak in our country is out of control. This disease is caused by the deadly Ebola virus, and the fate of infected individuals is death in 90% of cases.

The announcement followed more than a month of efforts by the Ministry of Health to contain and eradicate the virus. The Ministry is doing what it can, but with the weak health care system because of the lack of human and other resources, the Ebola outbreak has caused the system to break down. The disease continues to directly and indirectly take away lives. Indeed, our relatives, colleagues and friends are perishing daily and our survival as a people is unpredictable. Either through natural selection some will survive, or we will all be extinct. As I was writing this, a childhood schoolmate of mine, a nurse, just died this morning after contracting the disease at St. Catholic Hospital while treating a patient about two weeks ago.

Here in Liberia, the virus is spreading like wildfire, devouring the life of everyone along its path. Limited health resources, ignorance, stigmatization, denial, and cultural burial rites are fueling the spread of the disease. Ebola cases are reported in ten of the fifteen counties in our country. I do not have the space and time to elaborate on how ignorance, denial, stigmatization as well as cultural practices are spreading the virus. But regarding limited health resources, here is the tip of the iceberg. As part of control measures, everyone was advised to call the Ebola response unit for safe transfer of suspected cases and disposal of corpses from communities in and around Monrovia. There are two ambulances to transfer suspect cases to isolation center and two burial teams for Monrovia. These teams are overwhelmed and it takes about two to three days to respond to calls from communities. The relatives of suspected cases end up transporting the patient in a commercial vehicle, thereby contaminating themselves. The remains of suspected cases who died at homes spend days before the burial team can arrive. Moreover, there is only one treatment center in Monrovia. The isolation center is full to capacity and suspected cases are reportedly turned away. When will the spread and death of Ebola stop in the wake of limited resources? I do not know. But I know for sure that contact tracing is not possible and we are overstretched and exhausted.

Besides Ebola directly killing here, others are dying of treatable conditions due to closure of health facilities. Most health facilities in and around Monrovia have been closed for the past three weeks. This followed the failure of most health workers to show up on duty after the death of their colleagues. They fled due lack of equipment as simple as gloves to protect themselves. At the beginning of this week, some of these health facilities reopened. But activities currently at these hospitals are limited to training of staff on precaution measures. I do not know the fates of those with treatable conditions other than Ebola. Where the obstetric emergency cases are being managed? Where are the hundreds of children who usually present weekly at John F. Kennedy Medical Center under-five ER with diarrhea and severe dehydration and severe malaria complicated by anemia, hypoglycemia and seizure, seeking care? I do not know. But I know there are numerous corpses in homes in and around Monrovia which have overwhelmed the burial teams.

The Ebola virus is like a merciless rebel determined to annihilate his weak and feeble enemies (Liberians). Help! Help! We are drowning in the sea of Ebola.

About the author: Gondah Lekpeh is a fourth year medical student at A.M. Dogliotti College of Medicine in Monrovia, Liberia.

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Reflections on feces and its synonyms

As medical parasitologists we tend not to be too squeamish when discussing human feces. They represent one of the “five F’s” of parasitology – feces, fingers, flies, food, fomites – and indeed, most of the world’s poor living below the World Bank poverty level lives with intestinal worms and consequently parasitic helminth eggs in their feces.

Lester & Charlie Present

Image Credit: Lester & Charlie Present

Still, we were caught a bit off guard when one of the staff at PLOS Neglected Tropical Diseases telephoned to give us a heads up that we were about to publish “An In-Depth Analysis of a Piece of Shit: Distribution of Schistosoma mansoni and Hookworm Eggs in Human Stool” by Krauth et al.  The voice on the other line said the article had gone through extensive peer review as well as reviews by both Associate and Deputy Editors, and it was to go live in a couple of days.  They called because we should know that as the Editors-in-Chief we still had the prerogative to change the title.
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Introducing a New Look for the Journal Homepages

Today sees the launch of our re-vamped homepages for PLOS Medicine, PLOS Pathogens and PLOS Neglected Tropical Diseases. They’ve been designed to give easy access to all recently published work, and to better incorporate some of the beautiful images that accompany PLOS articles.

Take a look and see what you think:

www.plosmedicine.org

www.plospathogens.org

www.plosntds.org

 

2014-07-29 16_30_08-Medicine mock up

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World Hepatitis Day 2014 – Think Again

A former hepatitis virus researcher reminisces on the progress made and challenges remaining in the fight to eradicate chronic viral hepatitis.

WHD_2013_Campaign_poster

World Health Alliance World Hepatitis Day 2014 Campaign Poster

July 28, 2014.  “Hepatitis: Think Again.”  That is the motto for this year’s World Hepatitis Day, a program championed by the World Hepatitis Alliance to raise awareness, encourage prevention, and improve access to treatment for viral hepatitis.  The World Health Organization (WHO) endorsed the global recognition of this event in 2010.  Chronic viral hepatitis has been called a “silent killer” since often no symptoms are apparent until a life-threatening condition develops.

Hepatitis refers to liver inflammation, which is frequently caused by infection with a number of unrelated liver viruses termed hepatitis viruses A-E.  The hepatitis viruses A (HAV) and E (HEV) are generally self-limiting causes of food poisoning, while infection with the blood-borne hepatitis B (HBV) or C viruses (HCV) can lead to chronic hepatitis, which may cause long-term cirrhotic damage, end-stage liver disease, and hepatocellular carcinoma (HCC).  Hepatitis D (HDV) exacerbates HBV infections.  It is only observed in HBV-infected individuals, and not in isolation, since it requires the HBV coat protein to replicate.


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Visit PLOS at IUMS 2014 in Montréal

Palais des Congrès. Image Credit: Gavin Schaefer, Flickr

We are pleased to announce that PLOS Pathogens will be exhibiting at the International Union of Microbiological Societies (IUMS), July 27th – August 1st in Montréal.

IUMS unites 3 international congresses of bacteriology and applied microbiology, mycology and eukaryotic microbiology, and virology. The conference will also host a number of bridging sessions on cross-discipline topics such as emerging infectious diseases and zoonoses, vaccines and anti-microbials, and host-pathogen and host-cell interactions. As PLOS Pathogens reflects the full breadth of research in pathogenesis, facilitating discussion between researchers studying bacteria, fungi, parasites, prions, and viruses, this conference is an excellent fit.

Please stop by booth #212 in the exhibition hall, next to the central coffee kiosk, Monday-Thursday 9:00-17:00. There you can meet Laura Ray and Max Vidrine, Publications Manager and Senior Publication Assistant of PLOS Pathogens, and Erica Kritsberg, Marketing Manager of PLOS Pathogens, PLOS Medicine, and PLOS Neglected Tropical Diseases. We’d be more than happy to discuss Open Access and the PLOS corpus, and we’ll be giving away PLOS memorabilia (while supplies last). You can also follow us on Twitter, we’ll be tweeting from @plospathogens using the #IUMS2014 hashtag.
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Millennium Development Goal 6: Measuring Progress

One of the most dramatic international responses to the Millennium Development Goals launched by then United Nations Secretary Kofi Annan in 2000 has been the global public health community’s response to MDG 6 “To combat AIDS, malaria and other diseases” [1].  For HIV/AIDS it led to President George W. Bush’s launch in 2003 of the President’s Emergency Plan for AIDS Relief (PEPFAR) in order to get people in resource-poor countries on antiretroviral drugs, and also to the ambitious Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), and later to large scale neglected tropical disease programs launched by the United States Agency for International Development (USAID),  British Department for International Development (DFID), the World Bank and World Health Organization (WHO) for administering rapid impact packages of anthelminthic drugs, together with azithromycin, in order to target seven of the most common NTDs [1].

DALYs: number by diseases and 21 regions in 2010 (in thousands) Image Credit: Hotez et al.

I choose the word “dramatic” because of the sheer size and scope of these programs.  Since 2000, more than $70 billion of overseas development assistance has been spent for mass drug treatments and other allied health interventions, such as antimalarial bednets, health education, and other health system strengthening measures.

This week two large multi-authored studies were published on studies that aim to measure the global public health progress on MDG 6.

The first is a landmark study by the Global Burden of Disease 2013 researchers led by Dr. Christopher Murray and the Institute for Health Metrics and Evaluation at the University of Washington, Seattle, and supported by the Bill & Melinda Gates Foundation.  It provides an important snapshot in 2013 on where we stand with HIV/AIDS and malaria, as well as one additional “other disease,” namely tuberculosis.  The study analyzes a massive amount of data and I believe this Lancet publication will be a document that will be discussed for its public health and policy implications for a long-time to come.

Among its key findings are that through widespread use of antiretrovirals and other HIV/AIDS prevention measures, the number of new HIV/AIDS cases has decreased from 2.8 million new infections in 1997 to 1.8 million newly infected annually, with an almost two-thirds drop in the number of new pediatric AIDS cases.  The number of global deaths annually from HIV/AIDS has also started to fall from 1.7 million in 2005 to 1.3 million in 2013.  Similarly for malaria we have gone from 232 million new malaria cases in 2003 to 165 million in 2013, with a decrease from 1.2 million in 2005 to 855,000 deaths in 2013.  In contrast the gains in tuberculosis deaths have been more modest, but also muddled by the sharp rise in HIV-associated TB deaths.  Overall, I’m squarely in the Jeffrey Sachs camp on this one – overseas development assistance does indeed make a difference!

A second study published in PLOS Neglected Tropical Diseases does a deeper dive in the GBD Study 2010 with respect to neglected tropical diseases (NTDs).   Because integrated control of NTDs through mass drug administration and other measures did not begin until 2006 – and is only getting really ramped up in the last couple of years – it is too soon to say what the long term impacts will be on NTD control and elimination (and in terms of achieving London Declaration 2012 targets), but overall I am optimistic.  So far, the greatest declines (75 percent since 1990) have been for human African trypanosomiasis (HAT) – such that an elimination strategy may be feasible for Gambian HAT through case detection and treatment.    Another finding is the confirmation that many of the world’s NTDS occur in Asia and elsewhere outside of Africa.  At PLOS we have used the term “blue marble health” to address the high rates of diseases of poverty among the poor in wealthy countries.  In the coming months we hope to publish studies from the GBD Study 2013 on the NTDs and how they vary by region.

My additional takes on the findings from these two papers are as follows:  First, despite the gains through currently available interventions we are still going to need additional control tools before we consider eliminating the infections targeted by MDG 6.  I think a new generation of vaccines is going to be required.  Second, if we glance at the maps where HIV/AIDS and malaria are highest in Sub-Saharan Africa, they are in geographic regions where parasitic co-infections are also widespread, especially female genital schistosomiasis for HIV/AIDS and hookworm for malaria.  I believe that continued gains in the control of HIV/AIDS and malaria will require integrating parasite control into programs such as PEPFAR and GFATM.

The GBD Studies 2010 and 2013 are providing the essential bases for making evidence-based public health and policy decisions.  They will continue to inform us for a very long time!

  1. Hotez PJ (2013) Forgotten People Forgotten Diseases: The Neglected Tropical Diseases and their Impact on Global Health and Development Second Edition, ASM Press
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Evidently it’s Cholera Season

Just when the oppressive summer heat and humidity in South Asia seem no longer tolerable, especially to this Northern expatriate new to Bangladesh, the rains come, bringing relief in the form of cooler temperatures, fresh air, and sparkling trees and flowers.

What also comes with the monsoons is a reprieve from cholera.

Cholera is a form of acute watery diarrhoea, which spreads from person to person through food and water contaminated with the bacterium Vibrio cholerae. It is a miserable condition involving massive fluid loss and dehydration and left untreated can rapidly decline to death. Cholera is common in places with poor water and sanitation and sometimes causes large epidemics with thousands of people falling ill. Haiti’s cholera epidemic following the 2010 earthquake has killed more than 8000 people. The outbreak in South Sudan, currently affecting about 1500 people, is said to be worsening. In Bangladesh, where cholera is endemic, regular outbreaks are a fact of life and well-managed. Still, WHO estimates 3–5 million cases and up to 120,000 cholera deaths each year around the world.

At the public health research institution icddr,b (where I am an employee), our Dhaka Hospital sees about 300 people a day suffering from diarrheal diseases, but just before and after the monsoon this number can spike to as many as 1000 per day. Yes: 1000 patients per day, many with bodies ravaged by the dehydration and sometimes wasting that cholera can cause. Doubling the capacity of the hospital, beds known as ‘cholera cots’ occupy every available space and icddr,b erects massive tents to absorb the patient load. These tents can inhabit our entire parking lot.

TENT(Flood)14 AUG.07.12_Scaled

Image Credit: icddr,b


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PLOS launches Clinical Immunology Collection

Nathaniel Gore, Editorial Project Manager of PLOS Collections, on the launch of a new Clinical Immunology Collection

clinicalimmunology_allergies

Image Credit: NIAID/NIH, Wikimedia Commons / PLOS

Today PLOS launches a new Collection – the Clinical Immunology Collection. Following on from the successful redevelopment of the Synthetic Biology Collection, and responding to the commonly articulated request from our users that we provide more structured and efficient access to papers of interest in the PLOS corpus, the Clinical Immunology Collection is organized into several sub-disciplines, enabling researchers to easily locate the research they seek. To this end, the Clinical Immunology Collection launches today with sections on Allergies & Anaphylaxis and Tumor Immunology.

The Collection has been seeded with previously published PLOS content – from across the suite of PLOS journals – and will be expanded as new research and commentary is published by PLOS. Furthermore, the collection will see the addition of further Clinical Immunology subsections – including Immunodeficiency Syndromes, Autoimmune Conditions, Infectious Disease Immunology, Immunomodulatory Treatments and Transplant Immunology – and, later in the year, the addition of an Immunobiology Collection which will include sections on Cellular and Molecular Immunology, Evolutionary Immunology, Animal Models of the Human Immune System and Immune System Ontogeny.


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From One to One Million Article Views: Q&A with Author John Ioannidis

PLOS’s Erica Kritsberg interviews John Ioannidis about the success of his article “Why Most Published Research Findings Are False”, which reached one million views in April this year.

Iaonnidis

John Ioannidis

“Why Most Published Research Findings Are False”, the PLOS Medicine article by John Ioannidis, surpassed one million views late April 2014, the first PLOS article – research or other – to reach this milestone. First published Aug. 30, 2005, it has continued to influence thinking and inspire debate in the field and beyond.

To commemorate this achievement, Ioannidis, C. F. Rehnborg Professor in Disease Prevention, Professor of Medicine, of Health Research and Policy, and of Statistics at Stanford University (Stanford, CA, USA), spoke to us about the article’s background and impact to date.

What is the history behind the article? What compelled you to write about this topic?

JI: I had been thinking and working on the ideas behind this article for probably over a decade.  However, the first draft that integrated these ideas matured on the island of Sikinos (Greece) in early summer 2004. I remember working on it in a small balcony overlooking the cove of Alopronoia and telling Despina (my wife) all the time how excited I was about this work. I dare say it was some sort of very unique cognitive, but also aesthetic excitement.
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