Monday, June 1, 2015

Less than Zero: Containing Epidemics in States with Poor Public Health Infrastructure

Ebola training with MSF
In 1972 Yugoslavia suffered the last outbreak of smallpox (variola major) in Europe. Under what has been described as 'draconian' measures, Tito imposed a three week quarantine and vaccinated (in most cases re-vaccinated) every member of the population. This brought one of the highest case fatality rates from smallpox to an abrupt end. Tito should well be credited with saving potentially thousands of lives and preventing the emergence of a pandemic. For more information see:

Today, enforced quarantine is not an option primarily due to democratic legal constructions and human rights law, however voluntary quarantine was in most instances successfully instituted in Guinea, Sierra Leone and Liberia but getting to zero requires more.

An expert panel has slammed WHO for what it considers numerous failures. The report can be accessed here: It's clear, not only from the Report, but from the recently noted new cases of Ebola in Liberia, that far more needs to be done particularly in nations which have poor public health infrastructures, are at war, are failed or failing states and or states in the process of recovering from war. Its simply not enough to rush in treat thousands of patients but leave while the epidemic is still on going and not at zero cases. Perhaps the hope was that if the case loads were reduced to a manageable level Ebola would burn out but this has not proven to be the case.

"MSF said over the past 8 weeks the number of new cases in the outbreak region has stagnated at around 30 new confirmed cases each week, "a number that would be considered a disaster under normal circumstances." "MSF's international president, Joanne Liu, MD, said in the statement that despite the focus on recent reports on how to improve future outbreak response, the current outbreak still isn't under control." On Ebola, we went from global indifference, to global fear, to global response, and now to global fatigue," she said. "We must finish the job." (See:

While the global health community rushed to West Africa many of the Ebola Treatment Units (ETU's) and Ebola Treatment Centers (ETC's) whilst helping Ebola patients, were also responsible for transmission,, due to lack of sensitive and rapid diagnostic technologies to triage outside the centers. Several of the current rapid Ebola tests will only be accurate by the time the viral load is so high its clear the patient has EBV or is dead. This lead to high numbers of patients with false negatives having to be retested and exposing more people to the virus. It is still the case with most rapid Ebola test kits developed by various commercial firms today.   Moreover the numbers of deaths from malaria ( and child birth complications increased dramatically. Nature published a paper entitled: Maternal Health: Ebola's Lasting Legacy ( The Lancet published a study assessing Malaria related deaths during the Ebola outbreak in Guinea (see: In addition to these issues, a highly politically charged environment must also be considered as impacting mortality rates across these fragile public health infrastructures.

Getting to zero will surely require more than rushing to the scene of such a public health emergency, setting up ETU's, pulling back critical staff when case loads slow, whilst spawning more deaths from other endemic diseases. A comprehensive approach must be put in place which addresses these serious gaps in public health protection. While several ETU's closed due to lack of patients, its imperative the global community remain in West Africa, not only to treat Ebola cases but those dying from Malaria and from preventable deaths in child birth. This approach will mean increasing staff, not decreasing them and establishing a long term support system for each country effected. We could be on the cusp of Ebola igniting again in West Africa and we must do everything to ensure each country gets to zero and is not increasingly and simultaneously, devastated by other preventable diseases. Underestimating Ebola or considering that we can live with a few cases is a very misguided public health policy and one we, in the international community, may all pay dearly for.

Containment will require investment in technologies to reduce transmission and enable accurate and swift diagnosis at the first instance. We should also consider triage outside Ebola centers and quarantine practices which are consistent with cultural values. While Medecines Sans Frontieres are to be absolutely applauded on their efforts in West Africa the international community must now continue to take responsibility for stabilizing and maintaining public health infrastructures if we are to get to zero cases.