Summary: Dean’s Symposium on Ebola Response, Bloomberg School of Public Health, Johns Hopkins University, 14 October 2014

Johns Hopkins University (hereafter JHU or JH) School of Public Health hosted an Ebola-related event on 14 October 2014.  The keynote was given by Michael Osterholm, the Director of Infectious Disease Research at the Center for Infectious Disease and Research (CIDRAP, University of Minnesota).

The following is a summary of the relevant presentations.

David Peters, Chair, International Health, JH School of Public Health:  The speaker focused on a community-based strategy to fight Ebola, working off the motto used by Assistant Minister of Health in Liberia, Tolbert Nyenswah: “Be Helpful, Stay Hopeful.”  Ebola is just one of many problems in West Africa, and collectively these problems have cultivated fear and distrust of officials and institutions.  The speaker showed graphics outlining three vicious cycles in the region that link health, economics, and political instability; as each of these problems matures, the cycle begins again and worsens.  The rationale for community-based strategies has been demonstrated in Lofa County, Liberia, where the rate-of-infection curve is leveling off.  Improved outreach, hygienic improvements, and innovation, combined with social mobilization and extra beds have coincided with lower number of reported cases in Monrovia.  This multi-faceted and broad approach is endorsed by the DRC Minister of Health, Felix Kabange.  DRC has offered to send 1,000 HCW to W. Africa to help integrate epidemiological practice with the preservation of human dignity during disease onset, delivery of medical care, recovery or death, and, after death, funeral proceedings.  The Congolese concept is a modular approach that involves a multi-disciplinary team to act quickly and combine community outreach, hospital treatment and delivery of adequate health services, safe and dignified burial services, and safe and reliable transport in support of these activities.  Each DRC team would consist of 33 people and involve a community outreach component to facilitate communication, psycho-social services, education, epidemiology, and WASH (water and sanitation for health) activities.  JHU’s is involved in this project because it is well-placed to negotiate with various actors and provide multi-disciplinary services.

Trish Perl, Professor of Medicine, JH School of Medicine:  Dr. Perl’s presentation was entitled, “Rethinking Care: Lessons from Current and Previous Ebola Outbreaks.”  Improving care will open more opportunities to engage communities.  A necessary step in this is to move away from isolating patients by scaling up simple medical care in West Africa and eventually treat patients with more aggressive methods, as we have seen in some of the previous 26 Ebola outbreaks, most notably in the isolation of the Kikwit outbreak in 1995, and Johannesburg in 1996, and the Uganda outbreak in 2000.  These past experiences have shown that education and effective infection control of the disease can make a crucial difference.  This has occurred via rapid identification, triage, hand hygiene, and provision of PPE and instruction about its use in controlled and observed settings.  There is no need to reinvent the wheel and adopt exotic measures; we can apply what we know works, but must do it in a proper and correct way.

Joshua Michaud, Kaiser Family Foundation and Professor JH Dept. of International Development: This presentation focused on the global response and financing to mitigate the effects of the Ebola outbreak.  Only a small part of the presentation was relevant to CORDS activities.  When we look back at past outbreaks, we see that most of the economic costs resulted from aversion behavior, namely the fear and distrust that arises when outbreaks occur.  During the SARS outbreak, 80-90% of economic costs resulted from aversion behavior.  So far, only about 15% of funds have been pledged (and a smaller amount actually delivered).  The UN estimates that $30.5 million is needed to prevent Ebola from spreading to other regions, and $45.8 million is needed for social mobilization and community engagement (this might be a good figure to quote in correspondence and reports).   International assistance has not addressed the IHR mandates regarding response to PHEICs, and as a result, individual countries have been left to build capacity on their own.  The current Ebola outbreak is a logical result of this neglect.  While the World Bank promotes the idea of implementing a special fund to aid the response to health emergencies, there is no reliable substitute to building minimum standards for identifying and control public health crises.

Joshua Epstein, Professor of Emergency Medicine, JH School of Medicine: This presentation focused on modeling methods, and gave the sobering prediction that Ebola will probably be endemic in Africa from this point forward.  Ebola will not vanish because of factors, such as evolution of the virus, persistence of animal reservoirs, and behavioral cycles of vigilance and complacency.  This last factor, vigilance and complacency, typically takes hold when vaccines are developed and administered, but, as we saw in Guinea in June 2014, people can become complacent when there are no reports of infection over a long period (I wonder if we are witnessing such complacency in Nigeria right now – I hope not).  Countries at highest risk for infection are those with high high urban population densities and low standards of public health.  As a possible way to effectively respond to the outbreak, he described the MORE strategy, which trains and employs Ebola survivors, utilizing their immunity to the disease.  Existing models support the effectiveness of the MORE approach, which would bring communitarian and financial benefits to the region.

Michael Osterholm, Director of Infectious Disease Research, CIDRAP (keynote address):  Dr. Osterholm’s keynote address was entitled, “Lean Forward with One Step Back,” and challenged listeners to re-think what we say we know about Ebola and employ risk communication approaches that focus less on certainty and more on the efforts being made to address the Ebola outbreak.  If we aren’t clear about what we don’t know, we run the risk of damaging credibility, and this hinders future communication.  We need to accept the unpredictability of the epidemic and the slow pace of progress.  The virus operates on virus time, and governments/institutions operate on bureaucratic time.  Ebola has effectively destroyed the health systems in three countries, and our response must address the reconstruction of whole health care systems.  Another problem is that the world generally doesn’t understand Ebola because they are not knowledgeable of the region where the outbreak is occurring.  The best information has come from anthropologists, who are currently worried about the movement of large groups of young people to the eastern parts of their countries for the annual harvest (even though the harvest isn’t taking place this year in most places in the region, there is concern that this is such ingrained cultural practice that the movement might happen anyway).  Movement of people in the region happens on back roads where monitoring is lacking, and this may affect further transmission.  A nightmare scenario is if the disease finds its way to a large urban center, such as Kinshasa, which has a larger slum population than the slums of all three Ebola-affected countries combined.  This is also a security issue because it would imperil the stability of countries throughout Africa and beyond.  Regarding development of a vaccine, CIDRAP and Wellcome Trust are working together on an initiative to facilitate implementation of a developed vaccine.  This initiative depends on full understanding of the challenges of controlling the disease, formalizing and organizing an international vaccine research agenda, and staying up to date on what is happening with the disease in the midst of an ever-changing situation.  Second to the disease itself, the certainty of experts about it is a threat to controlling it (Dr. Osterholm expounded on his belief that airborne transmission of Ebola is a possibility in the present, and our collective focus on contact transmission increases the risk of missing a major aspect of transmission).  Dr. Osterholm ended his presentation with a call to develop a plan that doesn’t focus on certainty, but on good science, real action, and the belief that we can control our destiny as it relates to the disease.  Also, we must be ready for surprises.