Washington, D.C., 10 November 2014 (PAHO/WHO) — The Director of the Department of Communicable Diseases and Health Analysis of the Pan American Health Organization/World Health Organization (PAHO/WHO), Dr. Marcos Espinal, said that preventing local transmission of Ebola is the main goal in preparing for the eventual arrival of cases of the disease in Latin America and the Caribbean.
According to Espinal, who is leading PAHO/WHO's support for preparedness and response in the region's countries, local transmission of Ebola can be prevented or interrupted if any imported cases are detected and isolated early, and if contacts of the infected person are identified and monitored. Link to interview.
Could Ebola reach Latin America and the Caribbean?
The truth is that we cannot rule out the possibility that a case of Ebola could reach our shores or our countries. The risk is there, and we have to prepare ourselves for this eventuality. Good preparation means planning ahead. We can't say what we do will be perfect, and we can't say that a case will never reach us. But if we minimize the risk of local transmission, we will be doing our job.
What should we do if a case of Ebola appears?
When we have these cases, it is important to isolate them rapidly and identify the contacts—the people who had contact with that person—because that is where the virus is going to be interrupted. This approach has been proven to work with outbreaks in Africa since 1976. The contacts should be observed for 21 days, and their temperature should be monitored to see whether or not they have become infected with the virus. If we don't identify contacts, that's how the disease spreads, with the virus possibly spreading to any of our countries.
What is PAHO doing to help countries get ready to respond to Ebola?
PAHO Director Carissa Etienne has been a strong leader in this area, emphasizing strong support for countries and calling for the engagement of everyone in the Organization in a corporate response that mobilizes all our resources. She has appointed a task force that meets every week to discuss strategies, consider new ideas, innovate, and review progress in the countries as they prepare to respond. The task force is composed of directors from PAHO's key technical and administrative areas. In addition, the Organization has created a web page devoted to Ebola that offers guidelines and standards not only on personal protection equipment but also on infection control and prevention, preparations the countries should be making, risk communication, and the management of dead bodies and burials. We have a series of documents that countries can use in developing their strategies, risk communication campaigns, and contingency plans for Ebola, which should be based on criteria specified in the International Health Regulations. We are also offering to send teams to the countries to meet with authorities in the ministries, provide training, and tie up loose ends so we will all be prepared.
What is the most important recommendation if an Ebola case appears?
The foremost recommendation is national leadership, including the involvement of the head of state, the minister of health, and ministers from other sectors such as finance, education, and tourism. It is essential to have a corporate, multisectoral approach to the disease. Educating the public is a joint undertaking; it goes beyond the ministry of health. Activating the rapid response mechanisms can often involve military and civil defense forces. Every country should have a task force that meets once a week, looks for gaps in preparedness, and identifies areas for improvement—for example, designation of isolation areas, purchase of personal protection equipment, or adjustments in the risk communication campaign for informing the public.
Why is there so much emphasis on communication?
We recommend good risk communication campaigns so that the public is informed in a transparent manner. One should not be afraid to say "we have a potential imported case of Ebola, we have isolated it, we are investigating and as soon as we have more information, we will inform the population." When the public sees authorities doing this, it builds confidence.
What can the Americas learn from the experience of controlling Ebola in Senegal and Nigeria?
Senegal and Nigeria handled their cases very well. They identified the contacts immediately and were able to interrupt the chain of transmission. WHO has declared that Senegal and Nigeria are now Ebola-free. This is important because these countries developed mass campaigns to identify contacts, then isolated and monitored them, and now they no longer have Ebola. They did not use sophisticated medicines or experimental drugs. They broke the chain of transmission, which is the main epidemiological objective in the management of outbreaks: to prevent local transmission. That is also the main objective in the Americas: to isolate the cases in order to prevent transmission or local spread to other people and other countries in our region.
Do health systems in the Americas have advantages compared with those in West Africa for coping with Ebola?
Our countries have stronger health systems than those in Africa. They have physical infrastructure. Our countries have a local clinic or a health post at every corner. In Africa, many people have to walk miles to get to the nearest health post. Not only do we have physical infrastructure, we also have human resources. They may lack training, but not all of them have to be trained. It is sufficient to have a team that is prepared to handle and treat the case.
Should all the hospitals in a country be prepared to handle Ebola cases?
Not all hospitals can or should handle Ebola cases. The recommendation is to have a dedicated center where the patient is isolated and there is a team of trained specialists on hand. It is important for each country to designate its isolation area. If the country has a federal system, authorities may have to decide whether one, two, or three areas should be designated, but the important thing is to have an area where the patients can be isolated and to transport them there rapidly. In very large countries, there should be a team standing by, and if a suspected case is identified in a given province, the team is rapidly mobilized to the province to give preliminary care and see that the patient is transferred to the isolation area by air or ambulance. Hospitals should give preliminary care when a suspected patient arrives and be ready to make the emergency phone call for an ambulance or helicopter to transfer the patient, then draw a sample, prepare the patient for transfer, and send the sample to an authorized laboratory in the United States or Canada that can handle and confirm the samples, which are an extreme biohazard.
Should all health personnel in a country be trained to handle Ebola cases?
There is no need to train all physicians in the management of Ebola. The information is important, and educating the public and physicians is vital, but we couldn't begin to train 10,000 people in the management of these cases. The situation doesn't call for mass training. What is important is to have a team that is trained to manage Ebola cases and to work with response teams in the country's interior to make sure that the person is isolated, that personal protection equipment is available, and that the team in the isolation area is protected. PAHO is offering to facilitate the purchase of this equipment by countries that wish to procure it through us.
What should be done in the event of a suspected case of Ebola in a country's health services?
If the patient has a good clinical history, the first thing to do is ask: "Have you had contact with people in any of the countries that are affected by Ebola?" "Have you had any contact with an Ebola patient?" "Were you in Liberia? Sierra Leone? At that point, if the signs and symptoms are sufficiently compatible with Ebola, the next step is to notify the authorities and the national rapid response team so that it can initiate action and make the assessment as quickly as possible. In the meantime, the patient should be isolated in a separate room pending transfer to the isolation unit. For example, there was a suspected case in Brazil. The patient was immediately transferred by air across state lines to the isolation unit in Rio de Janeiro. In the end, the person did not have Ebola, which can be confused with malaria, yellow fever, typhoid, and other conditions. It is important to stay calm and use prevention and infection control measures. If the patient comes to a rural clinic, hand washing is very important. We have to keep the person at the rural clinic until he or she can be transferred.
Who is at greatest risk of infection when a case is detected?
The group at greater risk is health workers. In Africa we have seen more than 400 health workers affected. This is why PAHO recommends procuring personal protection equipment for health workers. This is vital. Countries should act rapidly and place their orders through PAHO to make sure they have the equipment. With use of protective equipment, the risk declines enormously.
How can the risk of infection be minimized for health workers treating Ebola patients?
They need to be trained in how to put on and take off personal protection equipment. On our Ebola page on the PAHO website we provide infographics showing how to handle protection equipment. We are also offering virtual and physical training.
What is the treatment for Ebola?
The treatment is support, isolation, keeping patients' vital signs under control, and ensuring that the patient is adequately hydrated and monitored. We have seen in the Africa outbreak a survival rate of about 50%. There are experimental treatments that have been used, but none of them is proven. A treatment is coming, but it's going to take time. Two vaccines are already in the testing phase, and five more are about to enter the testing phase. It is expected that the first one will be ready sometime in 2015.
There is a lot of concern about Ebola. What should the public know about Ebola?
It's natural for people to be concerned and even afraid, given that there are still no approved medicines and no vaccines for the disease. But Ebola is not transmitted by air or mosquitoes, but rather by contact with the bodily fluids of someone who is already sick with the disease. During the incubation period there is no transmission. It is when a person comes in contact with the sweat, fluids, urine, or blood of a person who already has symptoms, and the healthy person also has breaks in their skin [updated WHO guidelines also emphasize the risk of transmission via eyes, nose and mouth].
Should international flights to the most affected countries in West Africa be banned?
Our position is not to ban flights. We recommend exit screening, that is, taking the temperature of people who are leaving the most affected countries, such as Sierra Leone, Guinea, and Liberia. Other countries have adopted measures as well. Each country is sovereign and decides what is best for its people. PAHO is following the situation and recommends implementing the guidelines issued by the Emergency Committee of the International Health Regulations, convened by WHO.
