Although the current Ebola virus disease (EVD) outbreak has gained notoriety in recent
weeks, especially after the first imported case was reported in the US, it is believed
to have started in December 2013 in the rural areas of Guinea.[1] By March 2014, the
outbreak had expanded beyond Guéckédou, Guinea where it was first reported.[1
2] Guéckédou is a rural town located near the border with Sierra Leone and Liberia,
countries where the disease would expand in the ensuing days.[1] In fact, by March
30 the World Health Organization (WHO) reported seven suspected cases in Liberia[3]
and by April 1st the death of two suspected cases in Sierra Leone.[2] The immediate
response after the reporting of the initial suspected and confirmed cases was, at
minimum, regrettable. Probably, there was a lack of sense of urgency since the previous
Ebola outbreaks, in Uganda, extinguished relatively quickly.[4
5
6] It would seem that the initial response to the outbreak at all levels (from local
and national authorities in the affected countries to WHO) was best characterized
by inertia with some authors describing the circumstances as a “leadership vacuum”
stemming from a crisis in global health leadership.[7] Despite some early signs that
the outbreak was getting out of control, no concerted international efforts were taken,
and it is arguable that even as of today our efforts seem to fall severely short from
our needs. In fact, the latest figures by WHO show a resurge in incidence with 144
new cases reported in the week ending February 8 after a period of at least 3 weeks
of decreasing trends.[8] It would seem that a halt has been reached to the important
improvement seen so far this year.[8] To date, there are a total of 22,894 reported
cases and 9,177 deaths in this outbreak.[8]
On August 8, 2014, WHO declared this outbreak as a “public health emergency of international
concern”, almost 5 months after receiving the initial report and almost 8 months after
the first probable case was infected.[9
10] It took 3 more months for the US to recognize Ebola as a global crisis,[11] only
after the first patient to have developed Ebola symptoms in US soil had unfortunately
passed away.[12] This patient started his journey from Liberia to the US on September
19; on September 26 he was brought to and discharged from an emergency room (ER) of
a hospital in Dallas, Texas despite having symptoms of EVD and was finally hospitalized
2 days later and passed away on October 8.[13] Since then, two nurses involved in
his care have developed[13] and have been cured of EVD. This case put in test readiness
of the steps needed for EVD containment which have previously been established: Isolate
and provide critical care for the patient, monitor the contacts for at least 21 days
(the estimated incubation period), disinfect, and sterilize. In theory, containing
an Ebola outbreak should not be complicated, especially in developed nations where
resources and infrastructure abound. However, it is our contention than in order to
control an Ebola outbreak we need far more than financial resources and infrastructure.
Let us consider the Ebola response in Spain where a nurse assistant was admitted to
hospital with EVD infection after caring for two Ebola-infected patients herself.
How is it possible that an indigenous Ebola transmission occurred in a developed nation,
let alone within a resourceful healthcare system? The answer to this question is complex;
however, some theories have been proposed. On the least favorable side, some healthcare
workers have voiced their concerns about the “improvisation” with which the first
infected Spaniards were transferred for treatment, lack of training, improper waste
management, and insufficient and inappropriate equipment.[12] On the other hand, the
infected nurse assistant said she might have contracted the disease because of improper
techniques during the process of removing her protective equipment.[12]
The United States has a solid healthcare infrastructure; however, let's look beyond
hospital beds and isolation units and let's identify challenges the country would
need to urgently address to prevent an EVD outbreak. One of the persisting problems
in the US healthcare system is insurance coverage. According to the Centers for Disease
Control and Prevention (CDC), 13.8% of adults (around 41 million people) still lacked
health insurance during the first quarter of 2014.[14] Lack of healthcare insurance
may prevent access to healthcare services and has been associated with higher mortality
rate in epidemic situations.[15] If an Ebola outbreak first strikes the uninsured
people, then we would face a very difficult scenario. It is likely that uninsured
people fall below poverty levels; for instance, almost a quarter of people living
in households with annual income less than $25,000 in the USA were uninsured in 2012.[16]
Poverty is usually associated with overcrowding; thus, enhancing the risk of transmission
among close contacts of an infected patient. There are other factors associated with
poverty that might negatively impact an evolving Ebola outbreak including low levels
of education, poor health literacy, concomitant diseases, lack of access to healthcare
services, poor housing conditions, and lack of transportation (forcing the use of
public transportation). Moreover, poverty disproportionately affects migrants and
minorities. In fact, lack of insurance is higher among non-citizens (43.4%) and is
also more frequent among Hispanic (29.1%), African American (19%), and Asian (15.1%)
minorities when compared to non-Hispanic whites (11.1%).[16] Some of these minorities
might have different cultural practices, which may enhance the risk for Ebola transmission.
For instance, caring of patients by relatives and even neighbors, which is likely
among cultures with strong family bonds, may become a factor that increases the number
of contacts.[17
18]
Additionally, an uninsured patient with symptoms would be likely to avoid visiting
a doctor until the symptoms force a visit to the ER, especially if the patient does
not know how to recognize EVD symptoms. By then, it may be too late and the patient
may have already been transmitting the infection. Once in the ER, the symptomatic
patient would likely be suffering from diarrhea and vomiting and would need to use
the same restrooms used by other people in the ER, increasing the risk of transmission.
In addition, an Ebola outbreak in the US not coupled with proper mass education could
result in public panic, leading to even more crowded ER units. Panic combined with
misinformation can lead to unfortunate consequences such as public anger manifested
against healthcare workers and facilities like it happened in Guinea earlier during
this outbreak. Another fact to consider is the concentration of healthcare services
in hospitals. In such an arrangement, it would be very difficult to establish triage
units or sentinel posts closer to the communities/vulnerable populations, which would
be an important step in controlling the epidemic advancement. Therefore, concentration
of both infected and uninfected persons in crowded hospital centers could occur. Finally,
budget cuts are important issues that have been reviewed in a recent article published
in JAMA.[13]
In summary, if we are to prevent an Ebola outbreak to ever occur in the Western World,
we would need to consider the additional following steps: Educate the population to
avoid overflowing of healthcare services, but at the same time to recognize early
symptoms properly; implement triage units or sentinel posts closer to the most vulnerable
populations (if and when needed); care for the uninsured; educate and train healthcare
workers; establish sterilizing units directly under the command of Health Departments;
and recruit and train staff and volunteers. We deem the prospects of an Ebola outbreak
to occur in the US and the Western World still very low; however, we believe it is
important to address the weaknesses in our healthcare systems to be better prepared
for such a challenge should it occur.