Les Roberts – Freetown, Sierra Leone – October 11th, 2014

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Day 7: Brutal Triage

The prediction landscape is looking bad. The official numbers reported are laboratory confirmed cases. Typically, we think people need seven to ten-ish days to become symptomatic. Typically people have symptoms for seven days before they get into a health facility. A month ago, it was one day, now it typically takes four days from when a patient is sampled to when the patient is told the result of their test (and lots get lost and mislabeled…). Thus, the numbers that you hear about new cases today reflect the transmission dynamics from over two weeks ago… and we thought the doubling time of the outbreak was 30 days, it seems to be less than that here. We knew the ~350 confirmed cases last week were an undercount… we now think there are seven to 900 in reality. The need for hospital beds is climbing more than the ability to get them up and running. There might be 200ish Ebola treatment beds now countrywide. There are perhaps 600 more in “holding areas.” We have schemes to get 500 or 600 Ebola treatment beds up and running over the next eight weeks. As Foreign Medical Team Coordinator, helping to get these beds up and supported is one of my primary tasks. If there are really 3000 cases this month, and 6000 next month… with all going perfectly on the treatment bed establishment side, we will have 30% of the beds we need next month, slightly worse than the situation now.

The Ministry of Health and WHO are trying to fill the void with Ebola Community Care Units (ECU’s). Tents with eight beds…. maybe two tents, a wet tent (vomit and diarrhea) and a dry tent and a big buffer zone around with a couple latrines and a burning pit and a water supply. They will be staffed by low level health workers or community volunteers, ideally survivors of Ebola who will have immunity. The idea is that at the first sign of symptoms, the family brings the feverish loved one in. Everyone will be treated with an antimalarial and an antibiotic. If they can be tested for Ebola, they will be. If not, they get monitored and if they develop three of the key symptoms they get referred to a proper hospital bed… which will be in short supply… or otherwise they move to the wet tent. They will be given ORS… maybe food… maybe they die, maybe they do not. This is very close to no treatment. But the goal is to get them out of their houses to where they will be less likely to infect others. The supervision will be scant. The work for those in the ECU’s will be very risky. Even MSF has had several staff infected now and they are hyper-vigilant and resource rich. But the logic is, for every health worker infected or ECU malaria patient who becomes infected with ebola while waiting in such a unit, two or three infections that would have happened if the person died at home will not occur.

We aspire that we will have ~150 of these going in 60 days… which involves a million dollars per unit, major logistic planning and supply chains, site preparation by the community, and well drilling… this will be a massive effort. But 2000 beds in ECU’s, 700 treatment beds… might be half of what we need by December. Thus, barring a dynamic change in the outbreak growth, in November, in December, most cases will likely die at home.

Thus, the CDC has been pushing kits and training messages to promote “safe home care.” The kits would have ORS (a lot…like 20 sachets) and gloves and masks and chlorine and an ORS mixing bottle. The kits’ design is yet to be finalized by the MOH and the international community. The main part of the kit will be messages to the family. Keep the person in a room alone, and no one shares their bathroom. Only have one person deal with them… don’t touch them… wear gloves… wash with chlorine as you exit their room. Again, like the ECU’s this is not about treating the ill as much as it is about minimizing infections. The logic flows like this:

If you think about it a few steps removed from West Africa, this is freakin’ wild. We are primarily trying to facilitate people to die without infecting others. Very little of this logic beyond the ORS is about treatment. The last year PEPFAR was in full bloom, with all the administrative layers and consultants, it spent $10,000 per patient to have Africans on anti-retrovirals. The rights-based advocates were screaming about how it was only fair that Africans get what Westerners got. In July, there was an Onion headline “Experts: Ebola Vaccine At Least 50 White People Away.” http://www.theonion.com/articles/experts-ebola-vaccine-at-least-50-white-people-awa,36580/ It seemed kind of funny then… now that we are being so brutal in our public health triage it is much much less funny… maybe prophetic. We are about to assist thousands and thousands of people to die an excruciating death at home without even the most mild of pain relief. We are going to set up treatment facilities in hundreds of villages for one of the most deadly of diseases to be largely run by volunteers who will be lucky to get 3 days of training. Dozens, perhaps hundreds of them will die. And the most surreal aspect of this triage for me is that I completely think that this is the right thing to do given where we are and the limited ability to respond. As I think about you students reading this I struggle with the degree to which my endorsement of this multipronged approach is pragmatism or wisdom or loss of idealism.

Les