Category Archives: Ebola

Mobile suitcase laboratory: A tool for the rapid detection of emerging and endemic infectious disease

Ahmed Abd El Wahed who is based at Georg-August University, Goettingen, Germany shares his experiences with development and use of field diagnostics that can fit in a suitcase. This work received support from the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland. He explains the concept here …

Laboratory diagnosis mainly depends on nucleic acid detection by real-time polymerase chain reaction (PCR), which is available in central laboratories and has a turnaround time of more than two hours. Since real-time RT-PCR assays are not suitable for on-site screening, samples collected from local hospitals, treatment center or at the site of an outbreak have to be sent to laboratories over long distances for testing.

In developing countries, the necessary equipment for diagnosis is only available in few central laboratories, which are not accessible and of limited capacity to test large numbers of incoming samples. Moreover, transport conditions of samples are inadequate and therefore lead to unreliable results.

lab-in-a-suitcaseFor decentralizing of the molecular diagnostics, there is a need for a simple molecular point-of-need test. We have developed a mobile suitcase laboratory (62+49+30 cm) containing all reagents and equipment for the detection of the nucleic acid of infectious agents using the recombinase polymerase amplification (RPA) technology. The RPA assay run at a constant temperature (42°C) for a maximum of 15 minutes.

Moreover, all reagents are cold-chain independent and the mobile laboratory is operated by a solar power battery. The nucleic acid extraction is performed by a magnetic bead based method, in which a simple fast lysis protocol is applied. In case of highly infectious agents such as Ebola virus, the inactivation step was performed in a glovebox.

The suitcase lab is designed to detect almost 30 pathogens such as Dengue, Zika, Chikungunya, Ebola, Coronaviruses as well as Tuberculosis, Leptospira, Salmonella typhi and paratyphi, malaria, avian influenza, and Leishmania.

The suitcase lab featured in a presentation at the 65th Annual Meeting of the American Society of Tropical Medicine in Atlanta under the title of “Novel Extraction Protocol and Recombinase Polymerase Amplification Assay for Detection of Leishmania Donovani In 30 Minutes.” Authors/presenters included Dinesh Mondal, Prakash Ghosh, Md. Anik Ashfaq Khan, Faria Hossain, Susanne Böhlken-Fascher, Greg Matlashewski, Axel Kroeger, Piero Olliaro, and Ahmed Abd El Wahed.

Their work highlighted Leishmania donovani (LD), a protozoan parasite transmitted to humans by sand flies, which causes Visceral Leishmaniasis (VL). Currently, diagnosis is based on presence of anti-LD antibodies and clinical symptoms. Molecular diagnosis would require real-time PCR, which is not easy to implement at field settings.

In this study, we report on the development and testing of a novel extraction protocol in combination with recombinase polymerase amplification (RPA) assay for the detection of LD. The LD RPA assay detected equivalent to one LD genomic DNA. The RPA assay was performed at constant temperature (42°C) and the total assay runtime including the extraction procedure was 30 minutes.

The RPA assay also detected other Leishmania species (L. major, L. aethiopica and L. infantum), but did not identify nucleic acid of other pathogens. Forty-eight samples from VL, asymptomatic and post-kala-azar dermal leishmaniasis subjects were detected positive and 48 LD negative samples were negative by both LD RPA and real-time PCR assays, which indicates 100% agreement.

To allow the use of the assay at field settings, a mobile suitcase laboratory (56+45.5+26.5 cm) was developed and operated at the local hospital in Mymensingh, Bangladesh by using a solar-powered battery. DNA extraction was performed by a novel magnetic bead based method, in which a simple fast lysis protocol was applied.

Ebola and the Irony of Bush Meat

The deadly Ebola epidemic of 2013-15 in West Africa was suspected of having started when a child in a remote village of Guinea came in contact with infected bats. After that initial episode NONE of the thousands of subsequent cases were traced to zoonotic causes, and yet the health authorities and the media put high level focus on the need to avoid bush meat – whether bats, monkeys, antelope or others – as a prime way to avoid the disease.

dos-and-donts-ebola-poster-final-07jul14_amhNew evidence is emerging that in fact it the evolving relationship between the virus and humans that allowed the disease to spread so widely. within the animal kingdon, humans, not bush meat where the major spreaders of Ebola.

Now two conflicting reports have surfaced about efforts to curb the consumption of bush meat.  First, a research team based in Rivers State, Nigeria, one of the places where Ebola reached, conducted a study that tracked the average number of carcases recorded in each market before and after the Ebola virus spread in Nigeria in June 2014. They reported that …

“The markets were surveyed twice a month between March and September 2014. Our survey found a statistically significant fall in trade for all the main traded types of animals. These included antelopes, monkeys, genets, mongooses, rodents, porcupines, birds, crocodiles, turtles and snakes. In particular, the trade in monkeys and fruit bats almost disappeared. Trade in turtles, crocodiles and other cold-blooded species was less affected.”

The group concluded that bush meat, though culturally valued, was “not as important as previously thought for rural people in west Africa.”

83ebb85e-bc1e-11e3-_562888c-getty-imagesThe second report, published a few days later, was posted in the Nigerian newspaper, Vanguard, and echos earlier stories.  ”

“Some bush meat sellers in some major markets in Lagos have said the business is booming again barely two years after the country was declared Ebola Virus Disease free. Some of the bush meat sellers told newsmen on Saturday that they were fully back to their business.”

Behavior change is not a simple process, especially when it comes to culturally rooted practices. Had better hygiene practices been possible by health workers and the public, it is possible that Ebola would have remained isolated. We should worry more about guaranteeing health workers the skills and equipment needed for infection prevention that the sales of bush meat.

Poorly Managed Lassa Fever Outbreak in Nigeria

Dr. Obinna O E Oleribe, Chief Executive Officer, E&F Management Care Centre, Abuja Nigeria (Twitter: @OleribeO) shares with readers his view and experiences concerning the August 2015 – May 2016 Lassa Fever outbreak in Nigeria and sees its handling as a strong indicator of weak and failing National Health System.

111435-EPR-Nigeria-Lassa-Fever-Outbreak-20120322On February 6th, 2016, the Vanguard Newspaper reported the growing Lassa Fever outbreak that had killed over 101 persons out of 175 suspected and confirmed cases since August 2015 when the outbreak began in Nigeria. More recently, the World Health Organization (WHO) announced that it had been notified of 273 cases of Lassa fever, including 149 deaths in Nigeria between August 2015 and May 17, 2016. Of the 273, 165 cases and 89 deaths were confirmed through laboratory investigation from 23 states of Nigeria. These deaths include two health care workers out of 10 infected with Lassa fever virus. As at the time of the WHO report (May 17, 2016), eight states were still reporting Lassa fever cases (suspected, probable, and confirmed), deaths and following 248 contacts for the maximum 21-day incubation period.

First diagnosed in Nigeria in 1969, Lassa fever (LF) is an acute viral illness caused by Lassa virus, a zoonotic, rodent-borne (multimammate rat), single-stranded ribonucleic acid (RNA) virus from the Arenaviridae, virus family. Since it first isolation in 1969 from a missionary nurse working in Lassa town of Borno State in North-Eastern Nigeria, Lassa Fever has become almost endemic in not only Nigeria, but the West African sub-region as it has continued to be a major public health concern in Nigeria, Liberia, Sierra Leone and Guinea with over 70 million people at risk of the disease. Annually, there are over 3 million cases and about 67,000 deaths from Lassa Fever globally. High association with nosocomial outbreaks, healthcare workers are at increased risk of infection and death. Also, the disease is fast spreading beyond the shores of West Africa into Europe and America from viremic travelers.

A look at the WHO website revealed that Lassa Fever has gained the importance it demanded and was rightly cited on its first page as a disease of public health importance (disease outbreak news). Also, as it is further decreasing the already very limited human resources for health in Nigeria and the rest of West Africa, one would have thought that healthcare managers across the world would have given it the attention it needed.

Heres how Nigeria beat EbolaIn July 2014, Ebola was identified in Nigeria (Lagos State) after Patrick Sawyer imported the disease from Liberia (where there was already an ongoing epidemic). The Lagos State Government, the National Center for Disease Control (NCDC), the Nigerian Field Epidemiology and Laboratory Training Program (NFELTP) and Federal Ministry of Health (FMOH) with the support of well-meaning Nigerian volunteers and some international organizations rose to the occasion and within four months (July 20 – October 20, 2014) kicked Ebola out of Nigeria. They achieved this unbelievable feat through decisive actions, interdisciplinary collaboration, intensive case management, detailed contact tracing, and active port health services. Using isolation, quarantine and supportive management of the infected, case fatality rate was kept at 40% as eight out of the 20 infected individuals succumbed to the virus including several health workers. What was more interesting was the immediate response of government and all relevant stakeholders. The success recorded was to the amazement of the entire world, and completely against all epidemic projects and statistical reasoning.

However, few months later, there is another epidemic of another viral hemorrhagic fever. This time around, by a virus that is not as deadly or virulent as Ebola.  It has lasted for ten months, killed more people (over 1100% of those killed by Ebola), affected over 800% more cases and with higher case fatality rate of 54%. One, cannot but wonder why Nigeria is finding it difficult to mobilize the same strategies that ended Ebola in Nigeria in 2014 to end Lassa Fever? Or are the structures and personnel not available for this particular outbreak? Or is the will to stop the outbreak lacking among policy makers and healthcare managers?

I believe that there is a need to focus on developing sustainable public health systems that can be mobilized to manage outbreaks across nation; have ready and equipped field workers and foot soldiers who will track, isolate and manage suspected, probable and confirmed cased of any outbreak; and maintain strong surveillance systems able to identify and contain any new, emerging or re-emerging outbreaks.

Nigeria and her leaders should value the lives of the Nigerian people. The government should take health issues more seriously. The citizens of Nigeria need a government that cares. Healthcare workers have a right to live – and not die while working to save other people’s lives. Every hand should be on deck right now to end this outbreak – and as much as possible ensure a delay of its re-emergence.

The time to end Lassa Fever outbreak is NOW. Let us all work towards stopping it once and for all.

Documenting the Response to the Ebola Epidemic in Liberia through the Perspective of the Local Press

News QuaranteenJoin Kwame Sakyi and William R. Brieger of the he Johns Hopkins University at ASTMH Annual Meeting Afternoon Scientific Session #87 on Ebola on Tuesday at 1.45 pm to learn more about how the Liberian Press portrayed Ebola as seen in the Abstract below.

Mass media play an important role in documenting national responses to crises like Ebola. Reviewing media documentation helps a country better prepare for current and future public health challenges. Ebola articles first appeared in the Liberian press in March 2014. Our objectives were to determine the frequency of newspaper accounts and the major issues covered.

We conducted content analysis of Ebola coverage in three Liberian newspapers from March through December 2014. We reviewed electronic publications of three main newspapers by searching for the term “Ebola”.

Cases deaths articlesData collected for each article included date of publication, and topic. Data were compiled in Microsoft Excel. After reading the first 50 articles, we inductively generated codes to capture the news content and compiled these into a codebook. The codebook was constantly refined as additional articles were read. Codes were organized into major themes.

A total of 1,793 articles were published across the 3 newspapers over the 10-month period. The frequency of publications on Ebola ranged from 27 in March 2014, but increased to 95 April. Coverage dropped to only 15 in June, but began to rise sharply in August (227), reaching its peak in October (345).

Major ThemesNews reports frequency paralleled the incidence pattern of the disease. Major themes included the state of the epidemic, health care, psychosocial issues, international aid, political response, prevention, and local support. Overall political response to Ebola and the impact of Ebola on health workers received the most attention. In the early days common themes were border security and requests for aid.

At the peak key themes were health worker problems and political responses. A review of the national press during a crisis like Ebola provides a valuable overview of the response of the different players ranging from health services and NGOs to international partners and government. It reflects political will and conflicts and can help a central operations team better coordinate resources and responses of partners.

Malaria or Ebola … Ebola or Malaria

The similarity of initial signs signs and symptoms for Malaria and Ebola have been a cause for concern since the beginning of the deadly West African outbreak of Ebola over a year ago. A year later we find that the confusion persists.

DSCN7914 Island ETU MonroviaUS News and World Report in a story on the three new Ebola cases that have ‘mysteriously’ appeared in the suburbs of Monrovia, Liberia addressed the treatment received by the teenager whose infection with Ebola was not determined until after he died. “Authorities have traced about 175 people who had contact with the dead teen, who first became ill June 21 and went to a local health facility where he was treated for malaria and discharged.”

In contrast the Journal of the Royal Army Medical Corps has reported on the disturbing management of a sick nurse serving in Sierra Leone. “A 27-year old British nurse (was) admitted to the Kerry Town Ebola Treatment Unit, Sierra Leone, with symptoms fitting suspect-Ebola virus disease (EVD)
case criteria. A diagnosis of Plasmodium falciparum malaria and heat illness was ultimately made, both of which could have been prevented through employing simple measures not utilised in this case. The dual pathology of her presentation was atypical for either disease meaning EVD could not be immediately excluded. She remained isolated in the red zone (of an Ebola Treatment Center) until 72 hours from symptom onset.”

DSCN2552aIn both cases uninfected people are put at risk because of misdiagnoses. The health staff and community members in the Liberian example, the patient herself in Sierra Leone. In the Liberia situation it appears that health worker education is not complete if staff are not remaining on guard. Also as the number of specialized Ebola treatment units have closed, the triage process to identify and separate patients may have broken down.

The Sierra Leone example points out the need to maintain and enhance malaria prevention efforts to also prevent such mix-ups. Unfortunately public health efforts in the three affected countries to prevent malaria with insecticide treated nets were delayed, meaning the nurse’s experience may not be unique.

Once started, it appears that Ebola does not disappear completely. Another news report today looks into investigation of new suspected Ebola cases in the Democratic Republic of the Congo, where Ebola was first recognized in 1976. Misdiagnosis can be deadly.

Louisiana: High Rhetoric on Ebola, Low Concern for Public Health

The 63rd Annual Meeting of the American Society for Tropical Medicine and Hygiene begins in a couple days in New Orleans Louisiana. In preparation for this event the Governor of Louisiana through the Department of Health and Hospitals dis-invited any conference participant who has been to an Ebola-affected country (Liberia, Guinea, Sierra Leone) with the following information:

Lousiana StateNOTICE TO TRAVELERS: From a medical perspective, asymptomatic individuals are not at risk of exposing others; however, the State is committed to preventing any unnecessary exposure of Ebola to the general public. As part of that commitment, we have requested that any individuals that will be traveling to Louisiana following a trip to the West African countries of Guinea, Liberia, and Sierra Leone or have had contact with an EVD-infected individual remain in a self-quarantine for the 21 days following their relevant travel history. In Louisiana, we love to welcome visitors, but we must balance that hospitality with the protection of Louisiana residents and other visitors.

Not only does this decision, which bars many people who had no contact with patients or infected people, lack scientific backing, it is also unlikely to do much for health of Louisiana. These citizens actually need more that fearful proclamations to protect them. Louisiana needs to step up its public health efforts to show it really cares about its residents instead of political grandstanding.

America's Health RankingsAmerica’s Health Rankings from the United Health Foundation presents some interesting information on each US state – not just its ranking overall, but factors that contribute to this ranking. Overall, Louisiana ranked 48th in 2013. While there are 30 key indicators, ranks on individual vary with 24 being negative and 6 having a positive influence in the Louisiana’s overall 2013 rankings. Some problem areas are noted below:

  • Obesity 50th
  • Smoking 46th
  • High School Graduation 46th
  • Low Birth Weight 49th
  • Infant Mortality 48th
  • Infectious Disease 48th
  • Preventable Hospitalizations 48th

Of particular interest is public expenditure to address health problems. Here Louisiana ranks 19th at $87 per capita, below the national average. “After 4 years of increases, public health funding (in Louisiana) declined in the past year,” according to America’s Health rankings.

Nationally, “Public health funding ranges from more than $200 per person in Alaska and Hawaii to $37 per person in Nevada. The average funding in the United States is $92 per person, unchanged from last year’s edition (2012).” Louisiana, while not the lowest spender, could certainly do more to bring itself up in the rankings and help its people.

We would understand Louisiana’s concern if it had done more to correct these low rankings. The State’s neglect of its citizens is more of a threat to public health than a visiting conference attender who may have tried to improve public health in Africa.

What the Press Tells Us about the Early Days of Liberia’s Ebola Outbreak

The mass media are assumed to play an important role in the national response to a crisis, and Ebola should be no exception. The first cases of the disease in Liberia appeared in March 2014 after victims crossed the border from its point of origin In Guinea. A search for Ebola-related articles from the early period, March to May, was undertaken in The Liberian Observer.

DSCN7963While to date over 1,000 articles and references on Ebola were found in The Liberian Observer, most of the news coverage has appeared from August to October. In particular there were few articles in March, a surge in April and then a tapering off in May and June, before Ebola gained more prominence in print from July onwards.

Generally the early news articles in the Observer report events and opinions surrounding Ebola rather than serve as direct avenues for behavior change communication (BCC). Articles on politics, science, religion, economics, social commentary and even cartoons focused indirectly or directly on key events in the development of the national response.

DSCN7881Because of upcoming elections politicians used the outbreak to criticize each other’s response to the problem. In the early days the economic concerns focused primarily on reduced revenues across national borders in the region. Religious leaders either tried to rally support for control through prayer and fasting or blamed the epidemic on sin.

A couple opinion pieces in April acknowledged that BCC was going on through the radio. Special events such as sporting and athletics adopted an Ebola prevention theme, and several local NGOs pledged support for community outreach and awareness creation. Senators even had a retreat to learn more about the disease so they could educate their constituents.

DSCN7922 aOn March 23rd Marday L Peters wrote in the Observer, As Deadly Virus Threatens Liberia, Where is the Outcry?” At least from the communications point of view, the situation improved in April.

A.M. Johnson, The Health Correspondent for the Observer reported about Health Promoters Network, Liberia (HPNL) on April 3rd, quite early in the outbreak. HPNL in expressing its support for Ministry of Health and Social Welfare efforts “urged everyone within our borders to adhere to those preventive measures such as do not eat animals that are found dead in the bush, and avoid contacts with fruit bats, monkeys, chimpanzees, antelopes and porcupines. Limit as much as possible direct contact with body fluids of infected persons or dead persons. Wash your hands with soap and water as frequently as possible.” HPNL called on other Liberian NGOs to join the cause of educating the public.

On April 20th, S. Vaanii Passewe, II mentioned in a commentary that, “… the airwaves were laden with the news of an outbreak of the deadly Ebola outbreak… Subsequent warnings from the Ministry of Health notably said that the populace should report suspected cases, refrain from coming into body contact with suspected Ebola patients, avoid shaking hands, do not have casual sex with strangers, etc. These weird precautionary measures heightened fear.”

Some actionable information was provided in regular news articles in April. For example in an article on April 25th The Observer talked about “Ending Ebola in Liberia, A Collective Approach Needed,” readers were told about the symptoms, the potential spread through fruit bats and the fact that there was no specific cure, but supportive care is needed.

Further study of more mass media outlets concerning Liberia’s Ebola control efforts is needed. We know that although an early start to educate the public was undertaken, a relative dearth of coverage in the Observer might also indicate a reduction in enthusiasm by the press, NGOs and government to sustain Ebola communication and action. For whatever reason, the epidemic spiked. Fortunately efforts are now back on track, but there is a long road ahead.

Communication Challenges: Malaria or Ebola

The purpose of health education of behavior change communication (BCC) is to share ideas such that all sides of the communication process learn to act in ways that better control and prevent disease and promote health.  Both community members (clients) and health workers (providers) need to change behavior is their interaction to become a health promoting dialogue.

This dialogue becomes easier when all parties share some common perceptions about the issue at hand. Both health workers and community members can usually agree that malaria often presents with high body temperature. Also both usually agree that malaria can be disruptive of daily life and even be deadly.

But there are differences. While both may agree that there are different types of malaria, the health worker may mention different species of Plasmodium such as falciparum, ovale, vivax, malariae and now even knowlesi. The community member may think of yellow malaria, heavy malaria, aching malaria, and ordinary malaria. These differences may put acceptance of interventions to control malaria into jeopardy. Fortunately, current downward trends in malaria incidence imply that our communicants have more in common than not.

Cases 20140924Along comes Ebola Viral Disease in West Africa, which has killed around 3000 people in Guinea, Liberia, Sierra Leone and Nigeria at this writing.  The disease has never been seen on that side of the continent before. It is spreading more rapidly than it even did in its previous East and Central African outbreaks.  How does one communicate with people – both community members and health workers – about a disease they have never seen before?

The following encounter reported by BBC shows the initial confusion.

Not infrequently in the last few weeks I’ve encountered people complaining of a headache or a night of intense sweating. They slide off to the hospital and reappear a day or two later with a bag full of drugs, and they laugh it off. “Oh yeah, there are so many mosquitoes at this time of year,” they say. Better it be ‘normal’ malaria than death (Ebola).

The confusion results in harmful changes in treatment seeking behavior according to the The Pacific Northwest Conference of The United Methodist Church.

Misinformation and denial are keeping sick people from getting help. Some people are hiding from government officials and medical teams because they fear that if they go into quarantine, they will never see their loved ones again. Since the early symptoms of malaria and Ebola are similar, many malaria patients are not getting treatment. This crisis jeopardizes the progress toward improving access to health care generally.

In his blog, Larry Hollen summarizes the dilemma as follows: Both diseases disproportionately affect the poor and ill-informed Because Ebola and malaria have common early symptoms, such as fever, headache and vomiting, there may be confusion about the cause of illness among both those who are ill and health care providers.

Efforts to communicate the nature and dangers of Ebola have proceeded anyway. Posters, billboards, radio spots and even local volunteers with bullhorns, armed with information from the ministries of health or NGOs remind people that Ebola can kill and that people must report to a health facility for testing and care.

This top-down approach to communication often meets skepticism and suspicion. The messages also do not match reality when people find health centers closed due to loss of staff or health workers reluctant to see febrile patients fearing that they may have Ebola, not malaria. A health education dialogue cannot take place under such circumstances.

In fact suspicion is the order of the day. Sierra Leone and Liberia have emerged not long ago from brutal civil wars that not only destroyed must health and other infrastructure but killed much of their populations and alienated those who survived. Reinforcing this suspicion and distrust are militaristic approaches in both countries to contain the poor populations most affected.

False rumors are spreading that the international donors who are slowly rallying resources to fight the disease are actually the ones who may have created and started the spread of Ebola. It is unfortunately not surprising under such circumstances that a health education team going to a remote village in Guinea were killed.

Some positive approaches to Ebola communication have been documented including the use of trusted community health workers making door-to-door visits in Sierra Leone. More effort is needed to plan a more inclusive dialogue among all parties in order to halt the Ebola epidemic. Dialogue can start from the known – like the similarities with malaria – and move into the unknown. Drugs and vaccines will not be enough, if trust and good communication are lacking.