Fifteen countries are at risk of Ebola outbreak, says WHO
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6305 (Published 17 October 2014) Cite this as: BMJ 2014;349:g6305
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The Ebola virus disease outbreak has caused unprecedented demands on health systems in West Africa which were already fragile, and are now at breaking point. The outbreak will only be brought under control with a massive input of money, infrastructure and people. Crucial among the personnel needed are healthcare workers. For example, Medecins Sans Frontieres (MSF), the most heavily involved charitable organisation currently has only 276 international staff on the ground in the three worst affected countries, Guinea, Liberia and Sierra Leone (1). This is far short of the thousands more that are needed (2). So far, in the UK 800 people have volunteered to go to West Africa. Although many more have considered the factors which hold people back from signing up have not been assessed. Informal discussions among colleagues, and monitoring of social media such as Twitter and Facebook, have suggested there may be a range of factors which influence health care workers decisions on going to West Africa. Some of these such as fear of becoming infected or personal home circumstance are not easily changed. But there are other factors, which potentially could be addressed if it was clear that they are important. These might include reassurance about the training to be given, clarity over payment and backfill of posts, or allaying uncertainties over repatriation for anyone who become unwell.
To gain a better understanding of the barriers which are preventing UK healthcare workers from volunteering to help control Ebola in West Africa, we have launched a simple brief online survey. We hope that this will identify any modifiable barriers which could be potentially addressed by policy makers, and those recruiting staff; this will facilitate more healthcare workers signing up to volunteer in West Africa, which should in turn help lead to a swifter end to the epidemic. Bringing the outbreak under control will not only benefit the people of West Africa, but will also help protect the UK from imported cases. We direct all UK healthcare workers to complete our survey, which can be found at https://www.surveymonkey.com/s/HPRUebola
Tom Solomon1,2
Lance Turtle1
Fiona McGill1
Claire Matata1
Rob Christley1
(1) Institute of Infection and Global Health, University of Liverpool, UK
(2) Walton Centre NHS Foundation Trust
1. Medecins Sans Frontieres. Ebola- MSF Staff on the Ground. Accessed at: http://www.doctorswithoutborders.org/our-work/medical-issues/ebola on 21.10.2014.
2. O'Carroll L. Hundreds of NHS medics volunteer to work in Sierra Leone as Ebola spreads. In The Guardian 17th October. Accessed at http://www.theguardian.com/world/2014/oct/17/nhs-medics-volunteer-sierra... on 21.10.2014.
Competing interests: No competing interests
Dear Editor,
The world is doing whatever best it can for the patients suffering from Ebola and to contain this epidemic. Volunteers are risking their own safety in doing so. Yesterday we had sent you some of our suggestions, and we hope that scientists will be sifting through all of those by now, as the BMJ really has a wide coverage and acceptance. Having worked in Africa for three years, and therefore know the customs and life style, and having occasionally seen and handled some very unusual skin conditions, I wish to submit some of my further suggestions if you’ll permit me, that may just be helpful and may come in handy.
While I have tried making them easily understandable through the figures that I am uploading, the important thing is to remember that it being a viral exanthema, it will have a defined course of its own, until tempered by some unidentified and unknown factors, and maybe some extraneous factors that have not been clearly identified as yet. I really don’t have any firsthand experience of managing Ebola, but my 31 years of clinical experience keeps telling that in the absence of definite anti-viral medicines, and with a relatively short course of illness, it will be prudent to avoid any medicines until absolutely necessary. Avoidance of aspirin (acetyl salicylic acid) that might be used for relief of aches and for bringing down fever must be avoided as it might increase the chance of hemorrhage, or may aggravate it. Off the counter drugs that might contain acetyl salicylic acid must be avoided as well. Another aspect that of the customary indulgence by certain people in tribal medicines must be avoided, as at times this can aggravate the condition and the prognosis.
Skin rash must be handled with caution and care. Aerosols would perhaps be a better option of delivering medicines over the skin, without making a direct contact. We had found that a mixture that contains calamine as a base, with a very little amount of boric acid, zinc oxide, camphor, glycerine, mixed in water works quite well for chicken pox and herpes zoster. It is soothing, and also relieves pruritus, and thereby prevents excoriation of skin that might occur due to scratching. This mixture we had named after our small and remote village (Betaa ka naglaa) as “BKN mixture”. It can be sprayed over the Ebola rash two to three times a day, and half an hour prior to that maybe a aerosol spray of dilute potassium permanganate solution would help, as it is seen to help in cases of herpes simplex and herpes zoster as well as in chicken pox. Direct contact should be avoided, and likewise douching, scrubbing or rubbing should also be avoided.
Although we know that Ebola is not an airborne disease, but until it is definitely proved that none of the different strains of Ebola are spread by airborne means, it may help if the patient wears a face mask that covers the mouth as well as the nose. We feel that panic as well as over-treatment should be avoided. While sitting far removed and far away from those suffering, this is perhaps the least that we can do from out here. Maybe something just clicks and benefits them. With this hope we are writing to you.
Best regards.
Competing interests: The views expressed are those of the authors, and do not reflect any official policy or position of any organization or association. Much of all this is part of our book that we are presently writing on Ebola.
Dear Editor,
Ebola virus disease (EVD) has in a way been spreading scare around the globe. Now with this news of the WHO placing 15 countries at countries at risk, maybe it will help these countries to brace themselves up, god forbid, for possible fresh cases of EVD, and a resultant flare up in the number of cases. This outbreak has already killed nearly 4500 people. But the best news is that some patients are getting saved, and that Nigeria and Senegal have been declared Ebola-free by the WHO.
We believe that whatever best can be done, is already being done by the world and the nations afflicted by EVD. Maybe if the policy makers, administrators, and scientists concentrate for a while on another aspect as well, in addition to all that is being done, maybe it might help contain the spread of this virus. We don’t have any proof or evidence to prove what we are opining out here, but we do believe that insects, arthropods, bugs and beetles, mites, etc, and any other animals that might be digging into a grave to consume the remains of the dead, should also come up on the watch.
Maybe there is a need for the body-bags and burial containers to be given that extra protection so that they can remain safe, undisturbed, by insects as well as other animals that might dig out the body. Cemeteries should otherwise be placed out of bounds, once a burial is over. Until proved otherwise, we need to be wary of insects in and around a grave, and for all animals known for digging out the dead and using it in its food chain.
Fruit bats consumption, as also the consumption of sick or animals that are found dead in the bush or in game parks must be stopped. Such carcasses must be burnt and disposed off swiftly, while taking all the necessary precautions. Spitting, vomiting, coughing, urinating or defecating in the open should be stopped. Simple things like hand washing, avoidance of eating raw and uncooked food, climbing trees to catch fruit bats and thus avoiding the fruit bats as also the insects that might be on the tree and may come to bite or get lodged in the body, must be avoided.
Finally, before going to attend a burial ceremony, it may be prudent to smear your body with an insect repellant like eg the DMP oil (Dimethyl phthalate) that is cheap and quite effective as well for repelling insects. We are uploading three figures and a write up, that might help understand our points in a better manner. Although we are not sure that these points given by us will be helpful completely, but this is our small contribution to the efforts that are already in place by the world.
Best regards.
Competing interests: The views expressed are those of the authors, and do not reflect any official policy or position of any organization or association. Much of all this is part of our book that we are presently writing on Ebola.
Re: Fifteen countries are at risk of Ebola outbreak, says WHO
While noting the need to be conservative when facing the challenge of infectious disease emergencies, we nevertheless are concerned about current pessimism regarding the future direction of Ebola virus disease (EVD) outbreak in West Africa stemming from projections in recent studies (e.g., (1-4)) that made use of Ebola data from June to early September, which might lead to an overreaction by public health policymakers, as it had indeed occurred during 2009 with pH1N1 outbreak.
To ascertain the current and future trends of the Ebola outbreak in West Africa, we utilize the well-known exponential smoothing forecast approach which in recent years has been commonly adopted to forecast time-series data (5-7). This forecasting approach assumes that more recent observations carrying more weight in determining forecasting results than observations in the more distant past, in order to capture recent trends of the outbreaks in Guinea, Liberia, and Sierra Leone.
Out-of-sample forecast experiment was performed using WHO Ebola cumulative confirmed/probable case data of July 12-October 19 for Guinea, June 30-October 18 for Liberia, and June 30-October 19 for Sierra Leone. We also fit the time series of cumulative combined total confirmed/probable case number of these three countries from July 12-September 28 for the exponential smoothing forecast, since September 28 was the last date of synchronized case reporting from these three countries. We use these time series data of up to September 21 for in-sample exponential smoothing fitting, while withholding data from September 23-October 18 for out-of-sample forecast experiment. The results in Figure 1 and Table 1 were generated using Time Series Forecasting System in SAS.
For in-sample estimation, the corresponding mean absolute percentage error (MAPE), commonly used as a summary measure of forecast accuracy (8) and provided in Table 1, indicates extremely good fit. The out-of-sample results indicate good fit (<5%) for Guinea and the combined total number, but a significant over-projection of the observed cumulative case numbers for Liberia and Sierra Leone after September 21. Since the strength of the exponential smoothing approach is that it assumes exponential growth while, more importantly, gives more weight to the more recent observations, it reveals a possible downturn in the number of new cases (i.e., the growth rate of cumulative case number) after September 21 when compared to earlier months from July to early September, most noticeably in Liberia and Sierra Leone. Comparing our results with an earlier modeling study, which suggested that as of August 2014, Sierra Leone and Guinea’s outbreaks are slowing whereas the Liberian outbreak continues to grow exponentially (9), it appears that exponential growth still continues, but perhaps at a slower pace than before.
During the 2003 SARS outbreak in Taiwan, we published a letter in the BMJ (10) in early June suggesting that the outbreak in Taiwan had already reached a downturn by May 14. Our assertion was later confirmed via a modeling study (11) several months after the outbreak ended in early July, which concluded that the turning point for SARS outbreak in Taiwan had indeed occurred on May 3.
Global strategy is urgently needed, although past modeling studies on SARS have showed that blanket border control probably will not prevent global spread, and might in some extreme cases even adversely worsen the severity of the outbreak in affected areas (12). The most pressing matter at the moment, for both humanitarian reason and prevention of global spread, is still how we can contain and prevent the virus to spread in these countries. We believe that the Ebola outbreak is similar to SARS in the sense that preventive measures such as diligent border screening and monitoring of travelers and strict adherence to safety protocol in healthcare facilities can effectively prevent sizable global spread, while contact tracing and quarantine once again will prove to be crucial for local containment in the affected areas.
Ying-Hen Hsieh1 and Cathy W.S. Chen2
1Department of Public Health, China Medical University, Taichung Taiwan 40402
2Department of Statistics, Feng Chia University, Taichung, Taiwan
1. CNN. CDC: Ebola cases could reach at least 550,000 by January. (http://edition.cnn.com/2014/09/23/world/africa/ebola-outbreak/index.html).
2. WHO Ebola Response Team. Ebola virus disease in West Africa - the first 9 months of the epidemic and forward projections. N Engl J Med 2014 Sep 22. [Epub ahead of print].
3. Towers S, Patterson-Lomba O, Castillo-Chavez C. Temporal Variations in the Effective Reproduction Number of the 2014 West Africa Ebola Outbreak. PLOS Currents Outbreaks. 2014; Edition 1.
4. Nishiura H, Chowell G. Early transmission dynamics of Ebola virus disease (EVD), West Africa, March to August 2014. Eurosurveillance 2014;19:1-6.
5. Makridakis S, Wheelwright S, Hyndman R. Forecasting: Methods and Applications, 3rd ed., Wiley: NY, 1998.
6. Hyndman RJ, Koehler AB, Ord JK. Snyder, R.D. Forecasting with exponential smoothing: the state space approach, Springer-Verlag: Berlin, 2008.
7. De Gooijer JG, Hyndman RJ. 25 years of time series forecasting. International Journal of Forecasting 2006;22(3):443-73.
8. Rayer S. Population forecast accuracy: does the choice of summary measure of error matter?. Population Research and Policy Review 2007: 26(2):163-84.
9. Fisman D, Khoo E, Tuite A. Early epidemic dynamics of the West African 2014 Ebola outbreak: estimates derived with a simple two-parameter model. PloS Currents Outbreaks 2014 (http://currents.plos.org/outbreaks/article/obk-14-0036-early-epidemic-dy...).
10. Hsieh YH, Chen CWS. Severe Acute Respiratory Syndrome: Numbers do not tell whole story. BMJ 2003;326:1395-6.
11. Hsieh YH, Lee JY, Chang HL. SARS epidemiology modeling. Emerging Infectious Diseases 2004;10(6):1165-7.
12. Hsieh YH, van den Driessche P, Wang L. Impact of travel between patches for spatial spread of disease. Bull. Math. Biology 2007;69(4):1355-75.
Competing interests: No competing interests.
Ying-Hen Hsieh
Department of Public Health, China Medical University, Taichung Taiwan 40402
Cathy W.S. Chen
Department of Statistics, Feng Chia University, Taichung, Taiwan
Competing interests: No competing interests