By Jane Erikson
November 14 was an extraordinary day in global health. It was a Friday, the day the Centers for Disease Control and Prevention publishes its Morbidity and Mortality Weekly Report.
But on this Friday, the CDC published six MMWRs, all related to the Ebola virus epidemic. Four of the reports focused on the outbreak in Liberia, described as “the largest and longest Ebola epidemic in history.” The other two reports focused on Ebola importations in Dallas and Ohio.
It was also on that Friday that Tom Kenyon, MD, MPH, a 1984 alumnus of the UA pediatrics residency program, now director of the CDC Center for Global Health, gave an update on Ebola to faculty and students who packed the UA Medical Center’s DuVal Auditorium.
“This is unprecedented,” Dr. Kenyon said of the six MMWRs. “There is, I would say, guarded optimism that there is a slowing down of the epidemic in Liberia,” he said, “but we are far, far, far from it being over.”
Dr. Kenyon has been to West Africa twice since March when the Ebola outbreak, which is thought to have started in December 2013, was taking hold in Southern Guinea, along the border with Sierra Leone and Liberia. By July it was a full-blown epidemic, with deaths far outnumbering any of the previous 22 Ebola outbreaks, which never reached the scope of this one. By Nov. 30, cases in Guinea, Liberia and Sierra Leone totaled 17,111, with 6,055 deaths. Before this, the outbreak with the highest mortality was the first, in the Democratic Republic of Congo – then called Zaire – where 280 people died in 1976.
While Ebola outbreaks have all originated in Africa, the current outbreak is the first in West Africa – a remote and war-torn region with only limited public health services, and no means of detecting the virus, let alone responding to it, Dr. Kenyon said.
This outbreak also was the first to reach urban areas: the capital cities of Liberia, Guinea and Sierra Leone have all been affected. “Some would get sick in the forest areas, and then their families would bring them to the capital cities,” Dr. Kenyon said. “Urban Ebola is a new encounter that no one has ever faced before.”
The reports of a “slowing down” in some districts of Liberia came less than a month after the World Health Organization’s declaration that the West African country of Nigeria – about 1,000 miles east of Guinea, Sierra Leone and Liberia – was free of Ebola, after six weeks without any new cases.
Currently, there are no approved vaccines or medicine for Ebola. Progress made in slowing the epidemic is due solely, Dr. Kenyon said, to core public health interventions including prompt diagnosis and isolation, contact tracing, strong infection control and safe burials. Campaigns urging families not to bury their dead have successfully promoted safe burial. Now family members contact “burial teams” who have the necessary protective gear to handle dead bodies, in which the virus may still be infectious.
Monrovia, the capital city of Liberia, took the additional step of enacting a policy of cremating Ebola victims’ bodies.
And at the many Ebola Treatment Units constructed since March and staffed with trained medical professionals, patients are safely isolated from family and community members, breaking the cycle of transmission.
But Ebola has shut down primary care services, including immunizations and prenatal care. Dr. Kenyon recounted the story of a family who brought their relative who had had a stroke to one of the Ebola Treatment Units, because there was no other medical facility available. Doctors with Medecins Sans Frontieres (MSF), who staff the treatment units, had to turn the family away. They could not care for a stroke patient, and they could not expose the patient and his family to Ebola.
Dr. Kenyon expressed high praise for the work of MSF. The volunteer organization has responded so effectively to previous Ebola outbreaks that the CDC, since 2000, has charged MSF with overseeing clinical care. He also is grateful for the whole-of-U.S. government response to Ebola, including the involvement of the Department of Defense, which was called in to West Africa – another first – to help with logistics.
In the U.S., the CDC has created a Health Advisory Network to work with state health departments and hospitals and make them aware of updated guidelines, “because we’ve never had Ebola in the U.S. before, so we’ve had to adjust and change guidelines as is appropriate,” Dr. Kenyon said.
“Infectious diseases have no borders, and we have to be thinking globally,” he said. “When you have an epidemic in one part of the world, it’s just a plane ride away from another part of the world. That’s the reality of global health now. We’re so interconnected that these kinds of things are going to continue. Today it’s Ebola. In the future it will be something else.”
Dr. Kenyon’s ties to the UA also include serving as a volunteer faculty member with Family and Community Medicine’s global health summer course, “Global Health: Clinical and Community Care,” started in 1982 by Ronald Pust, MD, professor of family and community medicine and public health, and the College of Medicine’s director of global and border health.
Rajni Gunnala, a 2006 graduate of the College of Medicine's MD-MPH program, is a medical officer with the CDC Center for Global Health. She was working with the center’s successful polio eradication effort in Nigeria when she was called in August to work with the Ebola team in that country. She was second author on the update on Nigeria’s Ebola outbreak, published in the October 3 MMWR.
“I didn’t have any second thoughts about being involved with the Ebola response. This was an important outbreak response that needed more team support, and I was happy to help out,” Dr. Gunnala wrote in an email.
“I wasn’t providing direct clinical care to the patients but instead worked on the systems and data side of things. I had the chance to meet and work with many amazing, hard-working people while I was there, including hospital staff. The Ebola outbreak has been, and will need to continue to be, a huge global effort.”
Photo: Tom Kenyon, MD, MPH; Ron Pust, MD; Andy Theodorou, MD