Tropical Health Matters

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.

US 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.”

In 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.

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:

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

Of particular interest is public expenditure to address health problems. Here Louisiana ranks 19^th 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.

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.

While 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.

Because 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.

On 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 20^th, 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.

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.

Along 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.