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The Ebola efforts are struggling. Experts say these steps could help

W In the Ebola reaction team struggling to contain the outbreak in the Democratic Republic of Congo, the World Health Organization and its partners can make changes to their efforts and try to prevent the crisis from escalating further to a handful of experts examined by STAT .

The experts are cautious about criticizing WHO officials and others are desperately trying to stop the virus from spreading. Violence against Ebola reaction workers and a refusal to cooperate with control measures in some societies have made this outbreak, the second largest record, as opposed to something the Ebola respondents have seen in the past. Attacks on Ebola treatment centers have been repeated, and for many days reaction workers have not been able to move in hotspots.

At the same time, the experts believe that global health officials have opportunities to strengthen their efforts.


Here are three.

Good data is key

The basis of any Ebola response is epidemiology. Knowing where the virus is spreading and who is in the way is crucial to bringing an Ebola epidemic under control. But from the earliest days of this outbreak, it has been a problem.

"I don't think there is a good overview of what's happening. I don't think there's a good database," said Dr. Pierre Rollin, a veteran Ebola responder, retired earlier this year from the Centers for Disease Control and Prevention. "We just drive in the fog because we don't have good data."

Every previous Ebola outbreak was stopped using the same techniques: Find the cases and isolate them so they can't infect more people. Find out who they have been in contact with and monitor these people daily. If any of them get sick, isolate them and find their contacts. Bury the dead safely, so burial rituals do not end up infecting more people.

In this outbreak, the respondents received an extra tool: an experimental vaccine.

For this approach to work, the monitoring teams need to know in which social networks the Ebola virus spreads. In this outbreak, this has often not been the case. Significant numbers of the new cases were not previously on contact lists. Their health had not been monitored and they were not offered vaccine because no one knew they had been exposed.

The effect of these unidentified transmission chains appears to be growing as the outbreak expands. Since the beginning of May, only one third of the new cases were known contacts from an earlier case. Only about half of them had agreed to be monitored to see if they developed symptoms. Most had not agreed to be vaccinated.

Dr. Scott Dowell, Deputy Director of Monitoring and Epidemiology at the Bill and Melinda Gates Foundation, shares concerns about the growing number of unrecognized cases.

"I think there is very much a large pool of unknown transmission out there and unidentified patients" said dowell, who worked for decades for cdc and has worked a number of Ebola responses. "And it is uncertain how big that pool is. And also unsure of whether the current answer can come to the top of it, which is really worrying."

Rollin, who follows the exhaustion carefully, is concerned so few likely cases are added to outbreak totals. Likely cases are people who had Ebola-like symptoms and who had contact with people who were either known cases or who also had what looked like Ebola. Often these people who died and were buried without being tested for the disease, but for whom there is a high probability that they were infected.

Considering how many people refuse to cooperate with the Ebola reaction teams ̵

1; stay home when they are ill and fight for safe funeral teams trying to test equals – it must be a steady stream of probable cases, Rollin said. And yet they are rare. "So many cases are missing," he said.

Increase Lab Capacity

There are serious concerns that the existing laboratory capacity for testing samples from suspected Ebola cases can no longer keep up with the number of tests to be performed.

DRC's National Biomedical Research Institute – INRB – monitors testing. Rollin and others fear that current needs exceed their capacity, leading to delays in getting test results.

"The maze is overwhelmed," Rollin said.

If a laboratory cannot quickly process all of the tested tests, it is effectively shortening the number of new positive cases that can be found, Dowell said. It is not that they are not there; That is, the laboratory cannot determine them in time. It leads to slowdown by identifying the contacts in new cases and encouraging them to be vaccinated. People who need a vaccine can be vaccinated too late to prevent infection.

Delays in getting test results also prevent people from getting tested, says Dr. Axelle Ronsse, an emergency coordinator for the Belgian department of doctors without borders. The test results can sometimes take two or three days.

The Gates Foundation urges the Congolese Ministry of Health and the WHO to start using rapid test trials developed after the outbreak of West African Ebola in 2014-2016, saying that Dowell, who noted these tests, could increase the number of people who is tested.

There is a concern that the tests may lead to some false negatives – people who are actually infected but not test positive – Dowell admitted. But finding more infected people faster, though not all of them, should help, he said. The lab capacity problem also involves the sequencing of Ebola viruses, a technique that can be used to fill in information gaps in Transmission Chains when they, as with this outbreak, occur.

Recently confirmed cases cannot know where or how they were infected. However, by comparing their viral sequence to the sequences in other cases, it may be clear that the infection occurred when two independent persons were in a clinic the same day or that this patient was likely to infect this taxi driver.

INRB, the Congolese national laboratory, has been sequential viruses. But the information it finds is not always shared in time with the teams that conduct case monitoring. And the capacity is also a problem here. "As the number of daily positives has grown, sequencing has hardly kept up with the positives," Dowell said.

A report to the World Health Assembly from a group advising the WHO emergency program suggested insufficient use of the sequencing data says "timely analysis of genetic sequencing data is critical to fully characterize the onset of the outbreak [Ebola] for to inform diagnostic, vaccine and treatment methods. " It recommended "closer cooperation between INRB and WHO." [19659030] If Ebola treatment centers are seen as poisonous, you will find alternatives

In some societies, there is still profound restraint in going to Ebola treatment centers. Non-frontier physicians, pioneering the current system of Ebola treatment centers, have suggested diversifying care options can help.

ETC & # 39; as they are called, has become a place of stigma associated with death. In fact, people seeking care in treatment centers soon after the onset of symptoms have a higher chance of survival than those who scare the centers – but that reality has not been recognized in the affected communities.

Non-Borders doctors have suggested that some out-of-hospital hospitals be trained to treat Ebola patients safely – without posing a risk to their other patients – because the reality is that many people with Ebola symptoms turn to clinics or hospitals for ETC's.

Likewise, the group has urged the Ministry of Health to consider allowing some home care in Ebola patients, although it suggests that experimental Ebola drugs may be administered by a team of visiting health workers to some patients being cared for. home.

Ronsse said ETCs should remain the primary sites for the care of Ebola patients. But with so many patients refusing to go to them, one can find ways to minimize the risk these patients give to those health care workers who care for them in hospitals or family members in households to reduce transmission. Recently, WHO reported that 68% of people who died of Ebola in this outbreak died in society – at home or in a health care facility that was not a treatment center.

"It's something else we could do," Ronsse explained. "But we can not just home-based care or only treatment at the health center. We should have the three levels." Similarly, Ronsse said home care – which would involve training family members to take precautions and provide them with protective equipment and cleaners is not something that could be done on a large scale. "It's really for those people who wouldn't accept coming to the center," she said.

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