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Ebola virus
Colorized transmission electron micrograph (TEM) revealing some of the ultrastructural morphology displayed by an Ebola virus virion.
Photo credit: CDC

Ebola outbreak strains West Africa's health workers, systems

By Steven Ross Johnson
Posted: August 7, 2014 - 7:00 pm ET

The current outbreak of the deadly Ebola virus in West Africa has the potential of severely damaging the health infrastructure of countries hardest hit by the disease for years, experts agree, raising concerns about their ability to address future disease threats.

More than 1,700 suspected cases of Ebola have surfaced since the beginning of the outbreak in March through Aug. 4, resulting in more than 930 deaths, according to the latest figures from the World Health Organization.

Centers for Disease Control and Prevention Director Dr. Tom Frieden last week described the current epidemic as the worst and most complex outbreak of the illness ever recorded, estimating that it would take at least three to six months to contain its spread.

“It's the biggest and most complex (outbreak), and it's the first time it's been present in this region of the world, which means that response systems and community understanding of the disease is not what it should be,” said Frieden during a call with reporters July 31.

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The epicenter of the outbreak has been within the bordering nations of Guinea, Liberia and Sierra Leone, where 99% of cases and deaths have occurred. Another four suspected cases of Ebola have been found in Nigeria, where one person has died.

Many predict the outbreak could have long-term consequences for the region, possibly having a destabilizing effect both socially and economically for the hardest-hit countries. Particularly vulnerable are health systems within each country, which experts say are having to meet the challenges of the epidemic with infrastructures that were limited in resources and manpower prior to the outbreak.

“The challenge for us in the U.S. in trying to wrap our heads around this, is understanding what the healthcare facilities and healthcare infrastructure is in western Africa,” said Dr. Keegan Checkett, assistant professor of medicine at University of Chicago Medicine. “They have very, very little, and yet folks are tremendously committed and work incredibly hard and have high hopes—and so to have this come along and decimate all of the rebuilding efforts since the war ended, it's just a tragedy.”

Checkett has spent time in Liberia as part of a program called Healthcare Education and Relief Through Teaching, which sends U.S. doctors to developing countries to educate and assist local healthcare providers with developing their healthcare infrastructures.

Much of the healthcare infrastructure within the countries now hardest hit by the Ebola outbreak were devastated during more than a decade of armed conflicts that erupted throughout the region in the 1990s. Violence that occurred during civil wars in Sierra Leona and Liberia and spilled over into neighboring Guinea left all three nations in economic ruin.

On Wednesday, Reuters reported that the outbreak has “overwhelmed rudimentary healthcare systems” and prompted the deployment of troops in the border region of the three countries to quarantine those infected.

The outbreak has gotten much international attention because of public health concerns that the virus could spread to countries outside the region and continent through air travel. On July 31, the World Health Organization announced the launch of a $100 million response effort aimed at containing the spread of the virus.

The CDC has stated it plans to deploy 50 disease experts to the region over the next few weeks to help develop each country's healthcare infrastructure and educate the public on how to avoid contracting the virus.

But it remains to be seen whether such efforts will be sufficient in reducing the rate at which the virus seems to be spreading. According to the WHO, a total of 108 new cases of Ebola and 45 deaths were reported between Aug. 2 and Aug 4 alone.

“If you just look at the numbers, this outbreak is not slowing down,” said Dr. Nicole Iovine, associate hospital epidemiologist at UF Health Shands Hospital, Gainesville. “We don't have any evidence that the number of new infections is decreasing, so that would suggest that right now it's not under control.”

The challenges are twofold in terms of efforts to control the spread of the disease, Checkett said.

The first involves a lack of available trained healthcare workers in the region. More than 60 health workers have died from Ebola while attempting to treat infected patients. The highly contagious and deadly virus has reportedly forced several health facilities throughout Liberia to close because health staff has refused to work out of fear of contracting the disease. Many local health workers provided care without appropriate personal protective equipment, which consists of a heavy biohazard suit to protect against infection.

“In Liberia and in all of western Africa, trained healthcare workers are a precious resource and a limited resource,” Checkett said.

The current Ebola outbreak within this region of Africa represents another challenge in terms of the lack of available health workers trained in fighting this particular type of outbreak.

“One of the things that's occurring now is this hysteria that's increasing the outbreak,” said Dr. Babafemi Taiwo, a professor of infectious disease medicine at Northwestern University's Feinberg School of Medicine and director of research in Africa at the school's Center for Global Health. “Doctors and nurses who are not sufficiently educated on how this disease is spread or can be transmitted are becoming scared in such a way that it can compromise care.”

The disease is more commonly found in central parts of the continent. In places like Nigeria, the most populous country in Africa at 170 million, Ebola was never a major public health concern. But recently fears of a possible outbreak have been raised since late last month when Patrick Sawyer, a Liberian-American, flew from Liberia to Lagos, Nigeria's largest city, while sick with the virus. Six people were infected with Ebola as a result, including a nurse who died Aug. 5.

A dearth of trained personnel coupled with the prospect of the disease spreading to more-dense urban populations could overwhelm health systems in nations throughout the region, according to Taiwo.

“If Ebola was to show up in the U.S. now, there are very strong public health systems that can rapidly identify, isolate and contain infected persons,” Taiwo said. “But in Nigeria, it is possible for a patient to be undiagnosed and spread their infection to the next case and the next case, etc.”

Many health systems in West Africa also are struggling with a scarcity of resources that limit the kind of care that could offer patients a better chance of survival.

Ebola can have a death rate of up to 90% depending on certain conditions that include the strain of the virus, as well as the speed at which those infected start receiving treatment.

There is no cure, vaccine or effective treatment for Ebola. Doctors are left with few options outside of keeping the patient hydrated, managing their pain, and aggressively treating subsequent infections and conditions that may occur as a result of the virus, such as the uncontrollable bleeding from the eyes, ears and nose that tend to occur at the late stage of Ebola. Under the best of conditions, the patient's chances of survival are about 50%.

“The big thing that determines, to a large extent, whether someone lives or dies is whether or not they are able to get supportive care,” Iovine said.

In spite of the health challenges of containing the disease, Taiwo said there remained a possibility that countries could use the lessons learned from this outbreak to strengthen their capabilities to respond to future disease threats.

“There is an opportunity here to improve their healthcare systems,” Taiwo said. “The global attention to the deficiencies that exist now hopefully will spur additional initiatives to strengthen them.”

Follow Steven Ross Johnson on Twitter: @MHsjohnson

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