Dear Colleagues, [*see note below]
There is much to like in Drs Huster's and Healey's recent article in BMJ acknowledging "a failed response and the need for a reset” (available at: https://blogs.bmj.com/bmj/2019/05/24/congos-ebola-epidemic-a-failed-resp... )! Responses successfully contained circa 20 outbreaks over 37 years from South Sudan in 1976 through 2013. But responses have not worked so well in West Africa during 2014-16 and now in eastern DRC. What’s different?
One thing that has crept into the response is a systematic recourse to force. People forced to do something may run away. That spreads ebola and undermines efforts to monitor contacts. Here’s a suggestion for reset: Stick to the principle that health care is a service, offered not forced. Specifically:
1. Don't force anyone with symptoms or even with confirmed ebola to go to a health facility.
2. If someone comes to a facility with symptoms suggesting ebola, offer to test them and offer to deliver test results to them a home if they would rather not stay at the facility; don't insist they get tested or wait at the facility for test results.
3. If someone tests positive, offer info and materials for home-based care and offer care at a facility; leave the choice to the patient and family. Assure people they can treat an ebola patient at home with oral rehydration. If some of the new treatments work better, if possible, offer treatment at home.
4. If someone dies with ebola or suspected ebola, offer to help with the burial, but don't insist.
What if people treat at home and manage burials? During the 1976 outbreak in DRC, the reproductive number (new infections/households with cases) fell through 5 generations of infections from 0.62 (38 new infections in 61 households with cases) to 0.20 (1 new infection in 5 households); see table 6 in: Ebola haemorrhagic fever in Zaire, 1976. In Sudan in 1976, 38 primary cases in the community infected 30 contacts for a reproductive number of 0.79 (= 30/38); p 254 in: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2395561/.
Isolating all cases in health facilities and controlling burials for cases who die may be best in theory and may be workable in some circumstances. But it is not necessary to end outbreaks. Forcing is new in the response to Africa’s ebola outbreaks and may be contributing to larger and longer outbreaks after years of short and small to modest outbreaks.
HIFA profile: David Gisselquist is an independent consultant in the United States and has a professional interest in nosocomial risks and transmission of HIV in Africa, agricultural development and agricultural inputs regulation, environment. Email address: david_gisselquist AT yahoo.com
[*Note from HIFA moderator (Neil PW): The above suggestions are not in line with current recommendations. Actual policy and practice should normally be based on international and national guidelines. That said, David highlights important issues around perceived or real coercion and community mistrust in the public health response. Many commentators, including MSF, are arguing for a more flexible approach, with decentralisation of care for selected patients in the community or a non-specialist hospital facility rather than in Ebola treatment centres. We look forward to hear from others.]