Ebola Response: Slowed by a "Perfect Storm" of Setbacks

Via Medpage Today (09:09:2014)

WASHINGTON -- The world was taken by surprise by the West Africa Ebola outbreak and has been scrambling ever since to catch up, with many setbacks and only a few bright spots in the picture, international experts said at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC).

The Centre for Disease Control (CDC)'s initial response was based on years of experience with Ebola, according to Barbara Knust, DVM, of the agency's National Center for Emerging and Zoonotic Infectious Diseases.

In March, the agency dispatched 20 staff to do what the CDC has often done before -- help control an Ebola outbreak with such things as data management, contact tracing, and epidemiology, she told reporters.

It seemed to work, and in May the agency pulled its staff back, satisfied -- as was the World Health Organization (WHO) -- that the worst would soon be over.

But in the following months it became clear that a "perfect storm" of factors was at work, combining to push what had been a localized outbreak into a widespread and deadly epidemic, she said.

Those factors included a very mobile community that was sometimes angrily opposed to the outbreak control measures -- adequate infection control and safe burial practices, for instance -- that had always worked in the past.

The result was an outbreak that has grown so swiftly that "those measures still need to be put fully into effect," she said.

Currently, the CDC has some 90 people on the ground in the affected countries -- Guinea, Liberia, Sierra Leone, and Nigeria -- and is planning to send teams to nearby nations to help them get ready in case of further spread.

Knust was among three speakers added to the ICAAC program at the last minute to fill in the Ebola picture. The others were Aneesh Mehta, MD, of Emory University School of Medicine in Atlanta and Gary Kobinger, PhD, of Canada's National Microbiology Lab in Winnipeg, Manitoba.

Mehta was part of the 100-strong medical team that cared for two American medical missionaries who came down with the virus and were airlifted to Atlanta for treatment.

Both recovered and Mehta said he and colleagues gleaned some "clinical pearls" from their experience that might help future patients including those in West Africa.

Among them, he told MedPage Today, was the ability to swiftly correct specific electrolytes, to switch intravenous fluids quickly to match changing patient needs, and to give high-quality liquid nutrition to help repair the immune system.

"One of the things that we learned was the power of close monitoring and high-level nursing care," he added, something that both patients commented was absent in the African setting.

Although the caregivers initially had no idea what to expect, the two patients were very similar to other seriously ill people, Mehta said, and responded to similar interventions.

One advantage the American team had was daily on-site lab work which is not available to African doctors. But he said the American team also used point-of-care devices to monitor blood chemistry, which could also be used in the African setting.

The epidemic has now caused more than 3,700 cases and almost 1,850 deaths, according to WHO, and the treatment for Ebola is some form of the supportive care that Mehta discussed.

But several vaccines and therapeutics are in the pipeline and might be ready in time to have some impact on the epidemic, Kobinger said.

In particular, it's just possible that the two vaccines now entering phase I safety trials will pass that hurdle in time to be of some help.

But the process of getting such drugs into the clinic in a hurry is not an easy one, he said.

"It's easy to say let's do a clinical trial, but it's very complex, especially in the current situation where the focus is really on the outbreak response," he said.

On the other hand, if the vaccines are shown to be safe and effective, they could assist the public health response by persuading more healthcare workers to take part, Kobinger stated.

"If you could just protect them, you would have a tremendous impact on the response," he said, "because more people would go."

In the long run, the availability of drugs and vaccines might change the face of Ebola. "I'm hoping this will be the last large outbreak," he said.