Back in familiar surroundings, my days are going to be less blog-worthy for a while, but I’ll write when something of interest happens. Yesterday was blog-worthy so here I am!
As a well resourced country Australia has the facility to respond in an influential way to emergencies of international importance. A current example is the West African Ebola outbreak. Disappointingly our government have taken a very parochial approach rather than offering leadership and increased capacity at the source of the outbreak, where the biggest impact at halting the epidemic can be ensured. This has brought the government under severe criticism from public health experts including Medecins sans Frontieres (MSF) who have been the leading aid organisation treating Ebola patients across West Africa since the outbreak began.
About a year ago a group of alumni from Australian National University’s Master of Applied Epidemiology recognised the gap in Australia’s ability to coordinate a national or international response to infectious disease emergencies. To address this gap, they formed a group named Australian Response Masters Network (Arm Network) and tapped into their professional networks to increase membership. Supported by University of NSW, Australian National University and the Burnet Institute, Arm Network exists to provide standby for emergencies in Australia or requests from bodies such as World Health Organisation, for assistance in international infectious disease emergencies.
Yesterday ARM Network ran a one day Ebola Infection Control training workshop at University of NSW’s School of Public Health. I was one of approximately fifty attendees from various walks of life including GPs, epidemiologists, virologists, paediatricians, infectious disease physicians, infection control nurses, public health nurses, aid organisation administrators and many others. Some of the group attended because of their involvement in implementing Australia’s domestic response in the event of Ebola cases being diagnosed here and others like myself were there because of plans to work with overseas aid organisations in affected areas.
The training included information on microbiology and clinical features of the virus, epidemiology, modes of transmission, principles of infection control, MSF’s response to the current outbreak, specimen collection and handling, experimental drugs, vaccine development, socio-cultural issues, health systems and much more. A range of presenters came, we had practical demonstrations of handwashing and how to “don” and “doff” the Personal Protective Equipment (also known as PPE, this refers to the paraphernalia such as hoods, masks, aprons, boots etc worn by Health Care Workers in known infectious areas of treatment centres or hospitals) and a panel discussion led by a group of Epidemiology students from West Africa.
One of the most interesting points, from a thoroughly interesting day, related to the issue around transmission of Ebola virus. It is thought that the virus originates from bush meat which is hunted, preserved, cooked and eaten throughout this area and includes such things as bats, antelope and monkeys. A certain type of fruit bat is the most likely reservoir. Once the virus enters a human host, a series of processes occur which not only lead to illness in the host, but also allow the sick host to transmit the virus to others. Since the virus was first identified in 1976, direct contact between humans has been considered the main transmission source of Ebola outbreaks in human populations. However yesterday we heard about the clinical complexity of infectious diseases which rarely have a unimodal transmission, meaning that there is usually a main route of transmission (eg direct contact, as with Ebola), but it’s always possible that other transmission routes may occasionally occur in certain, perhaps unusual, circumstances. An example might be respiratory transmission if a virus normally only transmissible by direct contact is aerosolised. For instance if Ebola-infected fluids were sprayed with a full force hose, this could potentially suspend virus particles in the air and give them the opportunity to be inhaled. Currently this is only a theory and it is not a known transmission route of Ebola virus. However, it has been the basis of some recent controversial debates in public health circles. It should also be noted that in a scenario such as this, virus particles would be diluted, therefore also reducing the possibility of transmission, which is a good case-in-point regarding the complexity of pathogen transmission.
Health care acquired infections are a significant cause of illness and death worldwide. Every year approximately 75,000 Americans die from infections acquired in hospital. This number must be much higher in third world countries where standards are lower, resources much more scarce and surveillance systems are non existent, such that WHO do not provide any estimate of numbers that I can find. The number of infections leading to illness and morbidity without death are even higher. Some of these infections occur in Health Care Workers who are at high risk due to the nature of the work they do, being exposed daily to patients with various illnesses. It is therefore amazing that in all of the Ebola outbreaks in Africa until this year, only a very small number of Health Care Workers contracted the disease despite their exposure to unwell patients. This has been thought to be a reflection of how difficult it is to contract the virus, which is mainly transmitted by direct contact with infected body fluids and requires an entry point such as mucous membranes or broken skin. A common statement heard in the media is that “unless a patient who is sick with Ebola bleeds or vomits on you, it is very difficult to contract the disease”. This statement is not untrue but it does omit the issue of “clinical complexity” in disease transmission, where on occasion other routes of transmission may occur.
The current Ebola outbreak has been exceptional in many ways. More people have contracted the virus in this outbreak (over 8,000 with exponential rises predicted), than in all previous known outbreaks put together. The case fatality rate is approximately 50%, largely due to the inability of health systems to respond appropriately. It is the largest and longest Ebola outbreak in history. It is the first time Ebola has occurred in more than one country simultaneously (with a case recently diagnosed in Mali, there are now six African countries which have been affected, as well as a number of western countries). It is the first time Ebola has affected urban areas and capital cities. It is also the first time that person-to-person transmission has occurred outside of Africa. As such, if we do not have selfless reasons to feel concerned about the inappropriate international response, we should surely develop selfish cause for concern?
WHO states that previously Health Care Workers became infected with Ebola before the disease was identified and that the numbers of workers falling ill fell dramatically once appropriate protective measures were implemented. They also say that the chains of transmission in previous outbreaks were far easier to break than in the current outbreak. This year to date more than 400 Health Care Workers have contracted Ebola virus and approximately half of these have died, including the leading viral haemorrhagic fever expert in Sierra Leone, Dr Sheikh Hummar Khan, whose death is a huge loss to the battle against Ebola. Infected Health Care Workers have mostly been local staff, but it also includes a handful of expatriates returning to their country of origin before becoming unwell, as well as two American nurses and a Spanish nurse who contracted the virus whilst nursing returned expatriate patients. Yesterday New York announced their first case of Ebola, in an MSF doctor returning home to Manhattan after spending time in Guinea. Thankfully for this tiny minority of victims, the chances of survival for someone being treated in a first world hospital are much higher than those being treated in Africa where health systems have effectively already collapsed. Contact tracing, the only effective way to break the chain of transmission, is also likely to be much more thorough in countries which are well resourced. This excellent seven minute video piece from the New York Times shows the state of health care in Monrovia, Liberia, where one epidemiological study has predicted up to 70,000 or more people may die of the disease by mid December. Clearly these circumstances are vastly different to the circumstances that patients in western countries find themselves in. http://www.youtube.com/watch?v=ZBbsnyqlihs (This video is less than 8 minutes long).
The number of Health Care Workers becoming infected in the current outbreak has been particularly contentious as assumptions have been made that PPE protocols must have been breached by the staff infected, for this to occur. However, the possibility that current guidelines are inadequate, or that the virus in these cases was transmitted outside of the person’s workplace are valid suggestions which were demonstrated yesterday in a very entertaining but somewhat disturbing timeline of events.
This leads me to the debate that has been raging about transmission of Ebola, how easy it is or is not to contract, what PPE should be recommended and whether assuming a breach in protocols without any evidence to suggest this, is an appropriate response. It’s perfectly understandable that the Director of the American Centers for Disease Control would want to call for calm in the escalating media storm but he has come under a lot of scrutiny and criticism, which is best demonstrated by the below footage of Tom Frieden being interviewed by Megyn Kelly. Kelly is not without her own hysterical leanings, such as her recent criticisms of the New York doctor who in fact did quarantine himself as soon as he knew he was unwell, and her calls for a travel ban from West Africa. Such measures are not only pretty much impossible to implement, but they are also known through experience (eg public reactions during the H1N1 pandemic in 2009) to have an opposite effect than intended – encouraging people to behave dishonestly and making the disease even harder to identify, which in turn increases transmission rates. I also disagree that Tom Frieden was lying because following the MSF protocols required of him at a Treatment Centre in Liberia does not mean he was dishonest about what he would feel safe doing. However, the way it played out on Fox News was more than a little unfortunate! It does also highlight the need for consistency where PPE recommendations are concerned and for an alteration of protocols when they appear to be failing.
http://www.youtube.com/watch?v=zKYwjXTN5nA (This video is less than one minute long).
The longer interview between Kelly and Frieden can be seen here, and is worth watching too. http://www.youtube.com/watch?v=Lz1I2UAlI8I (This video is less than 10 minutes long).
It’s a long and fascinating subject, but if I don’t stop now I can’t move onto my next topic, so I am stopping. Not before I share one more video though, for entertainment purposes, showing the difference between USA and UK media outlets in their coverage of the Ebola outbreak. http://www.youtube.com/watch?v=lAz-F1QnyCk (This video is less than 4 minutes long).
After my fascinating day in the classroom, I dashed home, got changed into my best evening dress and jumped in a cab to a big converted warehouse on the waterfront at Pyrmont, where Cambodian Children’s Fund were holding their 10th Anniversary Gala Dinner. Due to a combination of expense and other commitments I was unable to find anyone to go with me and so I put on my Brave Hat and turned up alone, encouraged by reassurances over the phone by the conference organiser. At a beautiful venue with views of the Harbour Bridge and the cityscape, I mingled with some lovely people with varying connections to CCF. I met teachers who have raised money through their small community, volunteers who have worked with CCF, not-for-profit workers involved in administration of funds, some family members of CCF’s founder Scott Neeson, and even some of the CCF children who attended the event to tell their stories. Lisa Wilkinson was MC for the night, items were raffled, charity packages sold, various people presented, drinks and gourmet food were served, the John Field Band played popular jazz music between presentations and a good time was generally had by all.
Overriding all of that, was the amazing experience of hearing first-hand from some of the children whose lives have been transformed by CCF. Video footage was screened of Scott Neeson at the Steung Meanchay garbage dump in Phnom Penh, approaching children scavenging for a living amongst the city’s waste and asking them if they would like to study at CCF. Two of the films were recorded nine years ago and each showed a young child ploughing through infinite piles of wet, smelly, dirty garbage, navigating around unloading garbage trucks, searching for anything worth recycling. The children, covered in dirt and dressed in rags, spoke to the camera in Khmer about their lives and experiences, describing deprivation of such magnitude that it is difficult to imagine. One young boy told of how he stopped to bury the bodies of babies when he encountered them amongst the rubbish. It was nothing short of horrific, and the footage of Neeson approaching them was brief, showing none of the ensuing events when clearly parents and families were approached and processes put into place to allow the child to put down their sack and enter a classroom for the first time in their life.
At the end of each of these heart-rending films, each child – now a young adult – stood in front of an audience of over 200 Australian adults in an environment nothing less than deluxe and spoke in fluent English, describing what had happened to them since this video footage was filmed. Dressed in smart clothes, well educated with ambitions and hopes for their futures which eclipse the filmed comments such as “I am destined to be poor”, they spoke of wanting to become a video editor, a doctor and a fashion designer. The fashion designer hopeful has already been offered a lucrative contract but has put her plans on hold while she works at CCF, providing social support to her elders and teaching English to children in her neighbourhood. Her desire to help her community reflects the community spirit, leadership and compassion that the children at CCF are also growing up with. Listening to her and the other young people speak, I doubt that there was a dry eye in the room.
The world’s garbage dumps, slums and ghettos must surely be filled with young potential such as this, who could never imagine the possibilities CCF has extended to these Cambodian children. They are living proof that a little coordinated humanity towards even the most destitute in our world can reconstruct futures and revolutionise societies. Work like this could have a momentous influence on communities across the globe and I doubt I am the only one who hopes that it does.