As of October 19, over 9,000 cases of Ebola had been reported, with close to 5,000 deaths, almost exclusively in West Africa. And while there have been success stories such as the elimination of Ebola infections from Nigeria and Senegal, the numbers of cases in vulnerable economies continues to grow.
While Ebola is unlikely to present a serious public health threat in countries with strong healthcare and infectious disease infrastructures, the long-term global health, social and economic impacts will be significant if strategic action isn’t taken. Earlier this week, I asked a group of infectious disease and risk experts at the University of Michigan School of Public Health about their top concerns and priorities moving forward. While their collective responses are by no means comprehensive (we didn’t discuss vaccine development for instance), they do provide a useful foundation for the path forward to combatting Ebola locally and globally.
OVERARCHING THEMES
There is no ‘secret sauce’ to managing infectious disease outbreaks. There is a wealth of experience in the US and globally on containing infectious disease outbreaks like the current Ebola outbreak. The limiting factors in containment and control are not lack of scientific and technical understanding, but an inability to apply existing knowledge in a timely and effective manner, and to coordinate and manage international responses effectively.
Sustained support for public health is critical. Future resilience requires greater and sustained funding in public health research and practice. Stop-start public heath funding that is driven by short-term responsiveness and long-term amnesia cannot ensure that expertise and capabilities will be in place as and when they are needed.
Intelligent risk and safety communication strategies are needed. Communication strategies are needed that draw on current expert understanding of effective risk communication. Communication should focus on changing the way people understand the virus to operate (their ‘mental models’) so that responses aren’t based on false and potentially damaging assumptions. It should also focus on teaching people about when and where they should be concerned, so that they have the ability to see where they should not be concerned.
Societal and economic factors cannot be ignored. Routes of infection spread are impacted significantly by social and economic factors, with economies characterized by dense populations, high mobility and poor health infrastructure being particularly vulnerable. Understanding and addressing the societal and economic drivers and impacts of infectious disease outbreaks such as the current Ebola outbreak, and taking an integrated approach to disease prevention and control, is essential to managing short and long-term impacts on society. It is essential to recognize that remote actions or inactions on an infectious disease such as Ebola have a direct impact on US society and the US economy, and as such should be viewed as a US issue.
PRIORITY RESEARCH NEEDS
Targeted research is needed. Targeted research is needed on the Ebola virus to develop a better understanding of modes of transmission; dose-response relationships; latency period between infection and ability of an infected person to transmit the virus; and disease histories within different populations. The resulting data is critical to developing validated models of spread, containment and control, and for developing evidence-based interventions.
State of knowledge reviews are required. Systematic reviews are needed urgently on the Ebola virus and related viruses to provide a synthesis of the current state of knowledge.
Surrogate viruses are needed for fast-tracking research. Research is needed to develop surrogate viruses that mimic the behavior of the Ebola virus, but do not present a similar risk to humans. These will allow research to be carried out in less biologically secure facilities, thus enabling more rapid research progress.
Prevention and containment research is a priority. Long term research and development investment in understanding and preventing Ebola infections and outbreaks is critical if future similar incidences are to be avoided. Specific investment is needed in public health, where the ability exists to synthesize expertise across disciplines to provide effective real-world solutions to infectious disease challenges.
Data should be made readily available to modelers. Make existing and emerging data more readily available to infectious disease modelers, including mobility data and contact tracing data. Improve quality of data on infection cases and contact tracing
Integrate modeling with research into virus behavior. Ensure that there are strong connections between lab research, field research and modeling communities.
Coordinate modeling efforts. Coordinate research and information flow between infectious disease modeling groups in the US, to expand significantly capacity to respond to emerging challenges.
REDUCING INFECTION TRANSMISSION
Use existing expertise well. Effective and timely application of long-standing knowledge in infectious disease containment is critical. We know how to handle highly infectious agents – there is no “secret sauce” to handling infectious diseases like Ebola. Instead, reduced risk will come through the rigorous and efficient application of known methodologies and procedures.
Strategically mobilize the most appropriate experts. Avoid mobilizing people without the necessary expertise to handle infectious disease outbreaks, while not engaging with experts with first hand knowledge of infectious disease control. Rather, mobilize experts who know what they are doing, and who can take appropriate action. Specifically, draw on the on-the-ground experience of State epidemiologists and State health departments in handling infectious disease outbreaks.
Develop coordinated, streamlined response protocols. Bureaucracy and political maneuvering in the face of an infectious disease outbreak like Ebola are killers in a literal sense.
Identify vulnerable economies and populations and proactively implement strategies to prevent infection spread. India is a particularly vulnerable economy, combining dense urban populations with a fragile healthcare infrastructure.
Train healthcare providers appropriately. Make sure the best information is available as clearly, concisely and accessibly as possible. Develop training modules for hospitals and other health care facilities throughout the US. Partner with other economies to develop location-specific modules, recognizing that this is a global issue.
Develop clear clean-up guidelines for hospitals and homes. Work with international partners to develop geographically-relevant clean-up resources. Ensure guidelines are practicable for the location they are used in.
Develop smart communication strategies. These should be focused on how the virus spreads, not on the risk of infection. Focus on changing people’s mental models about how the virus works and how it doesn’t. Teach people about when not to be concerned by being clear and up front about when to be concerned. This may seem counterintuitive in that it could lead people to be more worried, as it focuses attention on the real possibilities of the virus spreading. But in cases like the current Ebola outbreak, people are already at this point, and beyond it. By being more concrete about how Ebola infections can occur, surveillance of and attention to the most relevant issues is potentially boosted, while unhelpful attention to issues of little relevance is limited.
Develop and implement active surveillance strategies. Active surveillance is needed for travelers from affected countries and regions.
Implement field surveillance programs using smart phone/crowdsourcing technologies. These should be developed for and implemented across significantly impacted areas (this has been achieved in smaller settings in Africa)
Demystify the virus. Develop and implement clear and honest education and communication strategies, using formal and informal education routes, as well as social media and communicators/organizations with a high level of public trust.
Establish an international coordinating center to monitor and manage all responding agencies and NGOs in deeply affected areas. Ensure a high degree of competence and responsiveness in the coordinating center.
Develop infectious disease response playbooks. Develop concise, accessible and understandable manuals of lessons learned, together with baseline “plays” that draw on available knowledge, to help address future outbreaks.
IMPROVE THE COMFORT AND SAFETY OF DIRECT RESPONDERS
Develop better Personal Protective Equipment. Support research and development on the design of protective gear on two levels: a) enhancements to the comfort and usability of primary responder gear and gear that is appropriate to developed economies. b) protective gear solutions for remote locations and developing economies, including best practices for using available resources to ensure appropriate protection
Develop better breathing apparatus. Develop and deploy light-weight self-contained breathing apparatus for personal protective equipment
Make compliance easy. Address challenges of compliance with protective equipment – reduce the barriers to compliance through reducing the complexity of donning protective equipment and the comfort of wearing the equipment for prolonged periods.
CONTRIBUTORS
Matt Boulton, Professor of Epidemiology and Senior Associate Dean for Global Health, U-M School of Public Health
Joe Eisenberg, Professor of Epidemiology, U-M School of Public Health
Utibe Effiong, MPH MD and Researcher, U-M School of Public Health
Jim Koopman, Professor of Epidemiology, U-M School of Public Health
Andrew Maynard, Professor of Environmental Health Science and Chair of the Risk Science Center, U-M School of Public Health
Arnold Monto, Thomas Francis, Jr. Collegiate Professor of Public Health and Professor of Epidemiology, U-M School of Public Health
Eden Wells, Clinical Associate Professor of Epidemiology, U-M School of Public Health
Mark Wilson, Professor of Epidemiology, U-M School of Public Health
Brian Zikmund-Fisher, Associate Professor, Health Behavior & Health Education, U-M School of Public Health
The views represented here don’t necessarily represent the views of all contributors
Image: Ebola in Guinea. © EC/ECHO CC