It seems like Ebola is very far away, but public-health experts from North Carolina have been involved with trying to contain the disease.
By Rose Hoban
As the Ebola epidemic rages in West Africa, health and public-health professionals in North Carolina have been lending their expertise to arrest the spread of the disease both in Africa and at home.
At a standing-room-only event at the UNC Chapel Hill Gillings School of Global Public Health last week, providers described their efforts to contain the spread of the virus, which can kill as many as nine out of 10 people who acquire the disease.
UNC pulmonologist William Fischer spent several weeks this summer providing direct care to Ebola patients in Guinea. Speaking to the crowd via a Skype video link from Atlanta, he said the reason Ebola spreads so easily is because of mundane issues.
“When was the last time your son or daughter had diarrhea and you ran to your son or daughter with double gloves, a face mask, maybe a Tyvek suit?” Fischer asked. He said the major modes of transmission are providing care for friends and family.
“There’s a strong familial unit in this part of Africa that people are aggressive about caring for their loved ones. And Ebola has been found in almost every body fluid: semen, breast milk, sweat, diarrhea, blood. So there’s a constant opportunity to come in contact with this virus,” Fischer said. He explained that people acquire the virus when their mucous membranes, like those in the eyes or nose or mouth, are in contact with body fluids containing Ebola.
Originally called to be a consultant in Geneva by the World Health Organization, Fischer learned he would be diverted to the West African country of Guinea to provide direct care with a team from Doctors Without Borders.
He said he was terrified.
“But once I arrived at the hospital … and saw how things work, I became immediately comforted by two things: the presence of equipment to protect myself and, more importantly, the process of getting dressed and undressed,” Fischer said.
He described wearing “personal protective equipment” consisting of a surgical mask to cover the mouth and nose, a face mask to cover the eyes, a surgical gown to cover the rest of the body and several layers of gloves and rubber boots.
“The temperatures inside the [personal protective equipment] were measuring about 115 degrees,” Fischer said. “You’re exhausted. You’re emotionally exhausted at the number of people who have passed; you’re physically exhausted from dehydration and heat and fear.”
He described how Doctors Without Borders has strict rules about how to put on and take off the protective clothing. One staff member has the sole job of working with health care workers to get them in and out of their protective gear safely. That person gives instructions to the providers as they get undressed, spraying them down as they go.
“He didn’t care if it was my first time or the ten-thousandth time, you have to follow his instructions,” Fischer said. “I credit that process with me being able to do my job and be safe about it.”
Fischer also said that at some treatment centers, workers have been able to drive down mortality rates from Ebola to 40 or 50 percent, from a usual mortality rate of about 90 percent.
“It wasn’t with anything fancy; no new-fangled technology,” he said. “It was with hard-core critical-care medicine that includes aggressive fluid resuscitation.”
He said the cause of death from Ebola is similar to that of cholera: loss of fluids and changes in the patient’s blood chemistry that result from that fluid loss.
Teaching prevention
Ebola’s spread to Nigeria has been a recent, and disturbing, development in the progression of the West African epidemic, Fischer said.
“It’s the most populous country in Africa; it has tremendous natural resources. If Ebola gets into Lagos and takes hold in the population, the whole region is in trouble,” he said. “Nigeria is almost a powder keg of sorts.”
That’s why Jennifer MacFarquhar from the state Department of Health and Human Services spent several weeks in Nigeria in August instructing health care workers there on how to prevent the spread of disease.
Although MacFarquhar works at North Carolina’s DHHS, she is paid for by the CDC and is part of the agency’s Epidemic Intelligence Service. That means she can be called by the CDC on a few hours’ notice to deploy to an outbreak.
She made the point that different countries have varying degrees of public-health infrastructure. Nigeria, with its wealth and size, is better prepared to handle an outbreak than places such as Liberia or Guinea.
“People are greatly concerned about Ebola and they don’t want it in Nigeria,” said MacFarquhar, who worked out of Lagos, the former Nigerian capital, which, at 21 million people, is the largest city in Africa.
“Very quickly, they were able to pull resources together and develop a very good incident-management structure, where they were able to coordinate efforts to make sure that they got on top of the outbreak before it became widespread,” she said.
MacFarquhar said the country has a program similar to the CDC’s Epidemic Intelligence Service; public-health leaders pulled in all of their past and present workers from the Nigerian service.
“They were instrumental, especially in the contact tracing,” she said. “They were ruthless in their endeavors to go out and trace every person who potentially had contact with [Ebola cases].”
“We’re so lucky Nigeria has this base to call upon,” Fischer added. “Yet despite this aggressive base, there was still a failure to isolate the initial patient from Liberia. A number of health care workers became infected. Someone escaped contact tracing and was able to go to [another city].
“So despite even having all these resources, there’s still incredible potential to spread.”
North Carolina state epidemiologist Megan Davies reiterated the point that containing Ebola’s spread in Nigeria is essential.
“The risk to the U.S. is a destabilized West Africa, which we are already seeing,” she said.
Ebola coming to NC
Davies, who worked previously with the CDC’s Epidemic Intelligence Service, said she felt confident though that any case of Ebola that might make it to the U.S. would be quickly contained “because of our routine infection-control practices; because of our resources to deal with it.”
David Weber, an infection-control expert from UNC Health Care, said he believed that someone with Ebola would eventually end up in the U.S. He agreed there would never be an Africa-style outbreak.
“Because we know how to protect people in the hospital, it’s not anything special that we don’t do otherwise,” Weber said. “All the hospitals have plans they’ve worked on over the last several weeks.”
He said the public-health infrastructures in the U.S. and in North Carolina are strong, and reminded the audience that North Carolina successfully controlled cases of SARS in 2003. That disease was highly contagious, spread through airborne droplets.
“The idea that we’d see hundreds or thousands of cases in one of our cities is … highly unlikely,” Weber said.
Davies pointed out that already North Carolina has had to deal with people coming home from Liberia, where they possibly had been exposed to Ebola. Those workers were returning from the Liberian capitol, Monrovia, where they worked at a hospital with the missionary organization SIM USA. None of the workers had been exposed to Ebola directly through contact with patients. Most of the returning missionaries were family members of workers who were possibly exposed.
The CDC made the determination that family members were sufficiently low risk that they could return on public transport.
“We discussed at length [with the CDC] this perception of contagion,” Davies said. “We decided to simply monitor their symptoms and ask them to limit their movement voluntarily…. They were exhausted and needed time to recover.”
Davies consulted with Mecklenburg County’s health department to determine the monitoring that would work best. They decided that public-health nurses would check in with the missionaries by phone twice a day to monitor any symptoms.
All of the missionaries’ quarantine periods passed without anyone developing the disease. Two other missionary workers from North Carolina were admitted to Emory University Hospital in Atlanta to be treated for the disease. Both were successfully treated and eventually discharged from the hospital.
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