Saturday, October 18, 2014

 

An Ebola 'Czar' Won’t Stop Ebola. But What Can He Do?

All right, we have an Ebola "czar" now.Realistically, what can we expect from him, and from the U.S. response to the outbreak?


So far, each new Ebola development in the United States- from the first two American aid workers flown here for treatment, to the infection of two Dallas nurses -- has set off its a new round of panic. And there were real shortcomings in Dallas -- substantive problems that allowed the disease to spread when it shouldn't have.

The response to domestic Ebola cases needs to get a whole lot better, and that was part of the White House's rationale for tapping Democratic lawyer Ron Klain to coordinate the effort. Naming an Ebola "czar" was also, in part, a public-relations effort to show action and reassure the public that the government is on top of the situation.

But two complicating factors are at work here: First, most Americans' Ebola fears are unfounded or exaggerated. Even with the very real shortcomings in the initial response, the risk of infection in the U.S. is incredibly low. At the same time, even if Klain, the CDC, and every American hospital do their jobs perfectly, there are limits to what they can accomplish.

So in the interest of both accountability and avoiding unnecessary panic, let's be realistic about what's inevitable, what's manageable, and what's truly a cause for alarm.

There will probably be more U.S. cases

Public health experts agree that Thomas Eric Duncan, the first person diagnosed with Ebola inside the U.S., probably won't be the last. They expect more infected people to reach American hospitals, with or without a travel ban from West Africa.

"We surely have to expect it could happen," said Michael Osterholm, a professor of public health at the University of Minnesota and an expert on infectious diseases.

Even Duncan's case wasn't a big surprise to the public health community -- as the Ebola outbreak spread through Africa, experts from the CDC and elsewhere said consistently that a U.S. case was probably inevitable. And even if the domestic response is perfect from now on, they're expecting to see more. In other words, another person with Ebola won't necessarily be a reason to panic or assume that the government is failing to protect us.

Some of those patients could die

Other than Duncan, every patient treated in the U.S. so far has lived. But no one knows exactly why. Remember, there is no treatment for Ebola. No cure, no vaccine, not even a proven therapy. Kent Brantly and Nancy Writebol, the first two aid workers treated in the U.S., received an experimental drug called ZMapp; but doctors who got the same drug in West Africa didn't make it. Some patients have responded well to massive doses of fluids, and others to blood transfusions from Ebola survivors, but developing a proven cure for Ebola will take years.

The big test: Controlling each new infection

Think of Duncan as a sort of nucleus. He got infected in West Africa, then came to the U.S. Here, he infected two people -- the nurses from the Dallas hospital. There will probably be more of those patients -- more people who get infected outside the U.S., but then make their way here, either intentionally or because they didn't realize they were sick.

The big test for the CDC, hospitals and state health departments is how well they can control the spread from each nucleus. That's the biggest criticism of how Duncan's case was handled at Texas Health Presbyterian Hospital in Dallas. His one initial infection has generated two new infections -- the same rate at which the virus is spreading in Liberia.

"The next time a patient comes in, we just can't have doctors and nurses coming out with Ebola," said Ashish Jha, a public health professor at Harvard.

Depending on the number of additional cases and where those patients show up, it might not be possible to ensure that not a single additional health care worker becomes infected. But that should be the goal, Jha said.

"Is it realistic to expect zero? I think we should be able to get pretty darn close to 0," he said.

Better hospital practices

The way to get there, experts said, is to handle new cases much differently than Duncan's. Whether you blame the CDC for unclear guidelines, or the hospital for breaking protocols, or a little of both, it's clear that Texas Health Presbyterian wasn't equipped to handle this the right way.

"I think the point about Dallas is, Presbyterian Hospital is the unfortunate hospital that got the first case," Osterholm said. "The rest of the country has learned a lot."

CDC Director Thomas Frieden initially said any U.S. hospital should be able to handle an Ebola patient, but now that strategy is shifting. Public health experts said every health care facility needs to be able to accurately identify Ebola, including taking a travel history for patients who show up with the early symptoms of Ebola, even though those symptoms are common.

Frieden said this week he would refocus on identifying one hospital in each state to prepare for and handle Ebola patients, and provide a CDC "SWAT team" to support those hospitals. Experts said that's a much better model, but that every health care worker still needs to know what to do for the first 24 to 36 hours.

"The patient's not going to show up at a center of excellence," Jha said.

Jha thinks having an Ebola "czar" can help with this part of the process, particularly by coordinating federal efforts with state health departments. Although the CDC is in the political spotlight now, he said he thinks the agency has done a "pretty reasonable job," but that state agencies have lagged.

The answer for the U.S. is in Africa

You probably don't need to be concerned about catching Ebola in the United States. But If you are, you need to be concerned about containing the virus in West Africa. We're going to see more Ebola cases inside the U.S., because the outbreak is still getting worse in Africa.

"If the epidemic in West Africa continues for months and months and months, we're going to be seeing Ebola cases in the U.S. for months and months and months," Jha said.

It might not fall under Klain's portfolio coordinating the domestic response, but putting more resources into Africa is the most important step the federal government can take. And the U.S. has stepped up -- President Obama has committed roughly $170 million to fight the outbreak in Liberia, Guinea and Sierra Leone, and has dispatched military personnel to the region to set up temporary hospitals. But the rest of the world hasn't offered nearly as much money, and more is still needed.

"Even if you say, 'I don't care about West Africa, I only care about Americans,' focus on shutting it down there. I is the only way to protect Americans," Jha said.

Panic doesn't help

There will be more Ebola patients in the U.S. -- each new one shouldn't necessarily be a call for alarm. Ebola is simply here now, and it will be until the West African outbreak is contained. Politicizing the tragedy and exaggerating the risks to Americans only make things worse, Jha said.

Jha also isn't especially worried about the virus spreading to Americans who are not health care workers. In Africa, it has primarily spread through funeral services, health care workers and family members caring for infected relatives in their homes. The risk of transmission outside a caregiving environment is extremely low.

He is especially frustrated by the continuing calls for a ban on travel from West Africa to the U.S., calling it a "distraction" that was understandable when it came from the "fringe" but a more serious problem now that it's coming from elected representatives. The CDC and NIH also oppose a travel ban, which they say could threaten the stability of the Liberian state.

The longer the virus ravages Africa, the greater the risk it will spread to even more countries. Controlling it in Africa is the only way to prevent a global pandemic the U.S. could not possibly wall itself off from, Jha said.

"You want to ban flights to West Africa: OK. You want to ban flights to India and China? You want to ban flights to Europe?" he said.


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