Smart People On the Ground in West Africa

I recently returned from our annual Wilderness Medical Society (WMS) summer meeting, where I spent some quality time with some Mega-Smart people. This year we joined forces with the International Society for Travel Medicine (ISTM) in Jackson Hole, WY, hosting over 500 attendees for five high-value content days learning about everything from advances in Frostbite Management to The Border Crisis and the Ebola Outbreak. We heard from masters in both fields in a big forum, and then rubbed elbows with the experts over casual socializing. Aside from all the learning that goes on at these meetings, they take place in gorgeous bucket list places like Jackson Hole, Snowmass, Breckenridge and Park City:

The down from Castle, a 14-er outside of Aspen at a WMS meeting

The down from Castle, a 14-er outside of Aspen at a WMS meeting

Smart People

There’s a line from an old TV show called Sports Night “If you’re dumb, surround yourself with smart people. If you’re smart, surround yourself with smart people who disagree with you.” Without classifying myself into a category (stay tuned for a future post of a top-ten list of WildMedGirl-isms that’ll set the record straight), I’ll just say that I gravitate towards smart people or situations where I’ll have opportunities to hang out with smart people because A) It’s fun and interesting and B) I feel like I gain an ounce or two of brain power just by chatting with them.

One person I always look forward to seeing at the WMS meetings is a guy named Michael Callahan. I first met Callahan in 2007 at the Inaugural Northeast Wilderness Medicine Conference, held in Ithaca at Cornell, directed by my mentor from residency Dr. Jay Lemerey. At the meeting, Jay gathered his residents at dinner with Callahan and other faculty at the conference, and I remember being completely awestruck by their accomplishments and highly entertained by their stories. Callahan happened upon one of the inaugural WMS meetings back in the 80’s when he was an EMT/rock climber who crashed the conference. A couple of decades later, now Dr. Michael Callahan, an ID doc from Massachusetts General Hospital, finds himself responding to Mass Casualty Incidents and ID Outbreaks around the globe. Callahan is the father of two, an avid cyclist and houses a brain so full of data and thought-provoking ideas that you just want to chat with him for hours because you actually get smarter by talking to him. For EM Docs, it’s kind of like hanging out with toxicologists; we just can’t get enough. A few weeks ago in Jackson, in the midst of one of those marathon talks with Callahan, his phone explodes, and he comes back to the gang telling us he’ll be off to Liberia in two weeks.

That got me thinking in a personal way about the Ebola Outbreak. Callahan was going back. I wanted to get the word out about what was happening in West Africa and what needs to happen in West Africa to control the Outbreak, so Callahan collaborated with me on a Q & A which was published as breaking news in Wilderness Medicine a few weeks ago. Here’s the direct link to the edited version. The rest of this post is the unedited Ebola Update with Callahan, which includes the latest numbers from the World Health Organization.

West Africa – Ebola Virus Disease

Now in the sixth month of the Ebola Outbreak, the case incidence continues to accelerate. As of August 22, 2014, the WHO released these figures for the Ebola Viral Disease (EVD) outbreak that started in March of this year: 2,615 cases (confirmed, probable and suspected) including 1427 deaths. Between August 19th and 20th alone, there were 142 new cases and 77 deaths, all in the West African countries of Guinea, Liberia, Sierra Leone and Nigeria. Prior to 2014, the all-time absolute mortality number for the Ebola Virus, which was discovered in 1976, was 1,640.

Currently affecting the West African countries of Guinea, Liberia and Sierra Leone primarily, there have been 16 cases and five deaths in Nigeria linked to an undiagnosed patient traveling to Lagos from Liberia. With a 2% hit rate of Ebola cases in healthcare workers, carrying a 60% mortality rate, infection control is the number one priority in halting the epidemic. Personal Protective Equipment (PPE) for all healthcare personnel is clearly an essential part of containment, but proper donning and disrobing of PPE is a process where infection control can lapse. This is also the sort of infectious disease, spread by contact with blood or other secretions from infected patients, where a single misdiagnosed patient can easily spread the virus to multiple care providers in another country. According to the WHO as of August 25th, more than 240 healthcare workers (HCWs) developed EVD and more than 120 have died. And as of three days ago, Médecins Sans Frontières deployed a team of HCWs to the Democratic Republic of Congo in response to the confirmation of four cases of EVD in the DRC.

There is a secondary cause of morbidity and mortality during an epidemic such as the current Ebola Outbreak. Secondary morbidity and mortality result from complications of conditions and end-stage disease of chronic medical problems that go unaddressed during an epidemic, especially in healthcare systems that are resource-poor to begin with, such as those found in West Africa. Examples include routine but dangerous infections such as malaria, diarrheal disease and respiratory infections in children, Malignant Hypertension, and lack of Pre-Natal Care from simple UTIs in pregnancy to Pregnancy-Induced-Hypertension that can lead to Ecclampsia. The access to care problem is consumer and provider-driven. Patients are afraid to go to healthcare settings, concerned about exposure to Ebola, and clinics are over-run with sick patients who are suspected or confirmed cases.

Earlier this month at the annual Wilderness Medical Society (WMS) meeting held in conjunction with the International Society for Travel Medicine (ISTM) in Jackson Hole, WY, I had the opportunity to sit down with Dr. Michael Callahan, Infectious Disease Physician from the Massachusetts General Hospital and long-time WMS and ISTM member, where Dr. Callahan along with Dr. Chris Davis from the University of Colorado, gave a riveting presentation called “International Evacuation: Dead or Alive.” Michael has been a key player in Infection Control, and institution of Good Clinical Practices in several prior outbreaks and disasters including H7N9 and H5N1 outbreaks, the 2003 Marburg outbreak in Angola, the 2005 Christmas Tsunami in Indonesia and the 5 Ebola Outbreaks since 1999. He is part of The United States Government’s Medical Ambassador Program where US disaster experts provide boots to ground counsel to foreign government officers and physician leaders. Thank you Michael for taking a few questions as you prepare for your mission to West Africa.

Q: What are the top priorities for you as the Infection-Control expert upon arrival in Liberia?

A: The priority is to promptly and effectively limit further chances of health care associated transmission to family members, other patients and health care workers (HCW). Our efforts must be practical, inexpensive, sustainable, and adaptable. As such we leverage the expertise of local care providers most familiar with infection control, such as surgeons and TB treatments nurses, and we standardize personal protection equipment (PPE) through all levels of medical care.

In order to develop confidence in PPE and care precautions, we must remove any HCWs with recent, high risk exposures from direct patient-care responsibilities. The reason for doing so is to ensure that those that become ill are not attributed as a failure of PPE or disease prevention strategies. This is a key mistake we made in Liberia, where family members and HCW adopted PPE late, after infection, and therefore when they developed disease it was confused as a failure of our disease control protocols.

A second major investment is to break the cycle of transmission in the community. In rural West Africa, the primary care of ill patients is provided by family members. Familiarity with strategies for home-treatment of malaria, typhoid and bacterial respiratory infections, all of which can be performed without PPE can prove disastrous with Ebola and Marburg patients. For this reason, education using media, religion and at major employers can play a major role in getting the word out. One interesting development is our recent use of social media to get the word out. In the 2012 Ebola outbreak in Isiro, DRC, we used SMS (texting) to send and receive information on possible Ebola patients. Through the use of information incentives such as personal health recommendations, local Congolese would access the SMS information tree and report in on possible cases in their family, village or community. This development was a major factor in speeding contact tracing.

Other priority areas for initial engagement are to supplement laboratory testing using handheld, cartridge-based blood gas analyzers (e.g. ISTAT, Picollo, etc.), providing diagnostic capabilities to rule-out non-Ebola infections such as malaria, and developing high throughput PCR for rapid confirmation of Ebola infection in symptomatic patients.

Q: What can you identify as key differences between the current Ebola Outbreak and the 90’s epidemic in terms of rate of transmission and infection control?

A: The earlier outbreaks tended to be smaller, possibly because the outbreaks occurred in more rural regions. The development of Western Africa, the expansion of affluence and a large transnational worker community both within Africa and globally, together result in difficulties with case control. For example, in 1999 and 2003 outbreaks, patients remained within their communities and provinces. In the current outbreak, many more of those infected had the resources and skills required for transnational travel. On occasion this included deliberate attempts at avoiding disease detection.

One area in which differences between past and current outbreaks would be welcome is in our success at preventing community and hospital based transmission of Ebola and Marburg. While groups such as MSF and Merlin have made dramatic advances in education of PPE use-and reuse, this is still the weak link in nosocomial transmission. Fortunately, this issue has been more effectively highlighted in the current outbreak and this has resulted in an appropriate allocation of resources to PPE equipment, training and enforcement.

Q: What rapid screening techniques are useful for potential new Ebola patients? (5 & 5?)

A: Definitive diagnosis of Ebola and Marburg requires PCR, which in turn requires a protected testing suite, cold chain, a trained operator, and quality assurance systems to prevent errors in testing. At this time PCR is rarely available locally. In Guinea, samples were sent to Dakar, Cameroon or France and results were delayed many days. While PCR testing and reporting is becoming ever more available, reliable and fast, we still need alternative strategies for initial case identification and treatment. During the Isiro outbreak a team of Rescue Medicine physicians and laboratory personnel worked to develop a PCR-independent strategy for separating febrile patients with Ebola from those infected with other diseases such as malaria, typhoid, rickettsia and viral or bacterial URIs. The Filo Five-by-Five (E5X5) plan for ruling in Ebola cases was compared to conventional PCR and found to be between 88-92% Sensitive and 82-88% specific compared to rtPCR. The E5X5 uses 5 history and physical findings and 5 laboratory criteria to help identify suspect cases. The E5X5 is designed to be easily remembered by local care providers

E5X5 CRITERIA FOR RULING IN EBOLADetermination of probable Ebola Viral Disease requires a clinical score of 6 and a laboratory score of at least 6 to achieve a sensitivity of 90% +/-2 and a specificity of 85% +/- 3 compared to PCR
  1. History of close household contact with a confirmed Ebola patient (4)
  2. Febrile to T>101.5 (1)
  3. Pharyngitis without tonsillar pillar exudate (1)
  4. Headache (tends to be retro-orbital, monotonous, unremitting) (1)
  5. Myalgias (often confused with influenza or malaria) (1)
  1. Platelets <120k **(**late EVD finding) (2)
  2. AST >5x or > 90 and no other cause such as leptospirosis or viral hepatitis (2)
  3. Lactate > 3 following fluid resuscitation and clinical euvolemia (2)
  4. Coagulopathy as determined by Whole Blood Clotting Test + WBCT at 20 mins (5 cc) on non silica tube or PT>20 and INR>2.3 (1)
  5. Hemoglobinuria (not hematuria) (1)


Rescue Medicine anticipates that the growing clinical experience with EVD will lead to a revision of the E5X5 criteria, or that another system will be proposed that is even more accurate compared to PCR.

Q: How can the healthcare systems accommodate patients with everyday medical problems in the face of this epidemic and mitigate secondary morbidity and mortality?

A: The continuity of hospital operations is, as your question suggests, an overlooked aspect of mass casualty disease operations. Health impact studies that are now underway are looking at the enduring impact of Ebola on morbidity and mortality from other diseases. The consensus is more preventable deaths occur during and after Ebola outbreaks from other causes than from the virus itself.

The first priority to maintaining community health operations is to separate Ebola related activities such as diagnosis, triage, early isolation, laboratory monitoring, patient care and management of remains from all other hospital functions. Over the last few years deployment teams and local hospital networks have not prioritized physical separation of Ebola and other patients. In current operations we attempt to physically distance all EVD from the main hospital and casualty wards and prepare a separate triage and HCW team. These aggressive procedures have played a role in maintenance of non-EVD medical care activities at two major W. African hospitals. As inferred by these strategies, mingling of EVD care teams and conventional HCW cannot be permitted and family members cannot visit the patients in the EVD wards.

Q: For healthcare providers outside of the endemic region, what advice do you offer patients who are potential travelers, and returned travelers from abroad?

A: Travelers to this region are advised to update their vaccination and stand-by-therapies to reduce preventable risk of infection. Humanitarian relief teams operating under several disaster response authorities must also have up to date immunizations. Many disaster response organizations require their HCW sign an insect repellent and malarone adherence contract as both of these preventive measures reduce the incidence of febrile illness in tropical Africa. Other strategies to reduce febrile illness and to reduce the need to access local hospitals which might be treating EVD patients are to be particularly cautious with food and water, to avoid high risk activities that might result in trauma and to duplicate prescription medications and store in separate locations. Medical evacuation is an area of particular concern as the regulations by country are changing quickly and many for-profit MEDEVAC providers are themselves victimized by the shifting position of the African aircraft providers. For this reason, all travelers should carefully evaluate the capabilities of their MEDEVAC providers. Finally, all travelers should consider contingency plans should access to medical care or access to MEDEVAC be interrupted while traveling overseas.

Travelers returning from one of the 4 countries with EVD and those that might have come into contact with infected individuals en transit, should be referred to the closest qualified medical center in their home nation. Although health care facilities in Europe, Asia and the Americas have little direct experience with EVD, the principles for infection control, management of contaminated material and decontamination are not appreciably different from that of other infections transmitted by droplet or blood. In recent weeks a number of advisory panels convened to help identify best practices for caring for EVD patients have generated draft documents for primary care and hospital based care providers. These resources will continue to improve in quality and availability in the weeks ahead.

Regardless of whether you are a West African national, a humanitarian relief worker responding to this outbreak, or a traveler with concerns about Ebola, this outbreak is another example of the “Equal Opportunity Nature of Modern infectious Diseases” and a reminder that in today’s world the division of travel, tropical and global diseases is increasingly imprecise and misleading. Thank you for your interest.

I wish you the best of luck Michael, and sincerely thank you for your time and sharing your expertise with the members of the WMS and readers of Wild Medicine Girl and Wilderness Medicine Magazine.

Get Involved in the Response to the Ebola Outbreak:

Whether you’re looking to donate time (Healthcare workers able to deploy for a minumum of three weeks) or money, check out these organizations:

International Medical Corps

Doctors WIthout Borders / Medecins San Frontieres


2 thoughts on “Smart People On the Ground in West Africa

  1. Pingback: Out of Africa | Wild Medicine Girl

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