Sunday, October 12, 2014

My fears about ebola in the sub-continent

[Note that this is a first draft of my thoughts on this topic, I will make this more concise and pointed in a couple of days]

So, Here's what we know about Ebola in Western Africa so far (culled from various articles in the popular press I've been reading of late -- I'm not too keen on providing citations right now, might do it a bit later)

* The epidemic appears to have  initiated when an unfortunate 2 year old came in contact with an animal host of ebola (most likely an undercooked fruit bat - the consumption of which is quite common amongst the poor in West Africa)

* This occurred in Guinea - a region which does not have the experience that Congo / Sudan / Uganda / Zaire have in  controlling ebola.

* Because the symptoms of the disease are similar to other big diseases in the area (malaria / cholera / lassa), it slipped below the radar for a lot of time. It took almost 3 months to realize that the disease was actually Ebola. And the most virulent strain (Ebola Zaire).

* Prior ebola epidemics fizzled out quickly because they never found their way into a major metro area. However, this particular epidemic is different as it has entrenched itself in Conakry (Guinea), Freetown (SL) and Monrovia (Liberia) along with more rural areas in said countries.

* What is particularly saddening and alarming about Ebola is that it has no (generally available) cure. While it is quite hard to spread in general, anyone who cares for a patient of ebola is at extremely high risk of catching the disease - unless Hazmat suits are employed. So, doctors and nurses are at high risk; spouses and family are also at very, very high risk. (The human tragedy of wiping out all your near and dear ones is something which is extraordinarily distressing). Doctors are dropping like flies; A sizable number of liberia's 50 doctors have been put out of commission by ebola - some have died, some have fallen sick and are under care - and some just don't have the staff to run a clinic.

* The devastation and desperation in west africa is palpable; international airlines (except a couple) are not flying there due to the fear of spreading the virus. 3000 American troops have made it to Africa -- but they're not medical professionals. Doctors without borders appears to be the primary care provider in the area -- but they're suffering similar staggering losses too. (Though they are doing much better than liberians because they have the resort to western medicine if the contract ebola).

* This particular epidemic has a mortality rate of ~ 70% -- but the statistics are incredibly unreliable. The current number of formally reported cases is ~ 8000, but there is an unofficial expectation from CDC that the actual number is closer to 20,000. This thing has blown out of control.

* The disease has spread outside africa to the west as well (places which have flown health-workers out to be treated, or places which have migrants from west africa, such as dallas). Western doctors have proven fairly incompetent in dealing with aspects of this disease: diagnosing it (Dallas) or enforcing appropriate hazmat procedures (Spain). But what they have done well is treat the patients: Ebola survival rates in the west are way higher in the west. This is due to a combination of much better care - and more importantly, experimental drugs (ZMAPP and the like).

* ZMAPP appears to be a good cure for ebola - it has worked on 18 of 18 primates it was tested on; it has worked on most humans it was used on (though some have still died). The catch, of course, is that ZMAPP is available in severely restricted quantities. Thankfully the gates foundation has become involved in this (among other investors) and it is fairly rational to expect larger doses of ZMAPP in the near future.

* It also appears that a vaccine is in the works  - and might be available by the end of the  year. There appear to be multiple approaches towards the vaccine. At least one should work (we know that Ebola survivors appear resistant to the disease - so this tells us that there might be some cheese down the vaccination path)

* In the meanwhile, Ebola is growing exponentially in Liberia, Sierra Leone and Guinea. Not much has been heard from other nations in the area: Mali and Ivory coast are silent. (The hope is that this silence is genuine - and isn't masking a problem). These exponential growth rates are possibly going to touch 7 digits by January 2015 (per a projection by CDC).

* Ebola had spread to Nigeria for a bit too: but Nigeria appears to have been monitoring this situation very carefully. The virus did burn through a people there -- but it appears that the epidemic is under control in Nigeria. This is probably because the disease did not make it to one of the slums in Lagos (Nigeria's largest city with a Mumbai-esque 17M people).

And the following are my fears for India, informed by the occurring in Africa:

* Per a statement by Harsh Vardhan, India's minister for health, there are 45,000 Indians living in west africa (in the affected area).  Peter Piot (the discoverer of Ebola in 1976) also worries about Ebola in India: he calls it the ultimate nightmare scenario. He frets about asymptomatic carriers (e.g. Thomas Duncan) not being detected by temperature monitoring equipment in airports and making it to meet family - and infecting several people subsequently (after the incubation period for the virus, which can be as long as 3 weeks).

* Ebola in India would be almost as bad as it is in west africa. We have a tradition of family taking care of sick people; we have a tradition of doctors not wearing gloves while examining patients. We are filthy and our cities become unhygienic cesspools in the monsoons. The only thing we have in our favor is preparation and knowledge: but that isn't a given for doctors in smaller towns who might not be aware of the goings on.

* In my opinion, India's primary path against ebola should be a comprehensive flight ban / quarantine program -- don't even let the problem arise in the first place. This might mean short-changing our 45,000 Indians who currently live in west africa - but this is entirely excusable. But assuming that this alone shall suffice is dangerous, especially, when we notice that Africa is essentially exploding with this disease. A spark might fly towards India in a very convoluted route - maybe a liberian who things he/she is safe takes a road trip to Nigeria to fly to Europe and then India?

* India must be prepared to educate its doctors on what they should be looking for regarding Ebola.  They should be taught how to don and doff PPE (The latter is even more important than the former as the sad experience in Spain has shown us).

*India should set up an ebola task force where doctors are trained to handle ebola patients (this can be done by interning with the MSF / West African personnel in the hot zone). These doctors should tend to any cases that might arise in India - not anyone else. These doctors should be immunized as soon as the vaccines come out. This is to make sure that a sick patient does not expose any more than 1 other person to the disease (to make sure that this does not keep spreading).

* India should have military on high alert. Curfews should be enforced to make sure that Ebola stays contained.

* Hazmat gear should be procured for several doctors and nurses. Health workers should also have first dibs on treatment with ZMAPP. Military personnel should be utilized to teach doctors to don and off hazmat gear. Further, a trained military person must be involved in all sessions when doctors / nurses removed their gear.

My two cents: Ebola in India need not be an epic disaster if some precautions are taken. But I am concerned that the current government appears to only be focusing on prevention of the import of the disease to India. This worries me because this either appears to be poor risk management or poor communication on the government's part.

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