25 August 2014

West Africa: With Better Ebola Response, 'Outbreak Would Be Over' - CDC's Tom Frieden

Photo: CDC/ Daniel J. DeNoon
Small boats crossing a remote border between Guinea and Liberia during the Ebola outbreak show how easily the virus can jump from one country to another.

interview

Washington, DC — As a fifth African country on Sunday announced Ebola deaths, Dr. Thomas Frieden, director of the U.S. Centers for Disease Control and Prevention (CDC), left for Liberia, Sierra Leone and Guinea, the hardest-hit countries. Friday afternoon he spoke by phone from his Atlanta, Georgia office with AllAfrica's Tami Hultman about the Ebola toll and what he expects from his visit.

At least a dozen suspected Ebola cases in the Democratic Republic of Congo (DRC), whose health minister Dr. Félix Kabange Numbi confirmed the two deaths, may not be related to the west African epidemic. But they underscore a point Frieden emphasized – that strengthening health systems is essential to prevent the global spread of emerging diseases. CDC was founded in 1946 to combat malaria in the United States and today is seen as a key protector of public health. Frieden became director in 2009 – the year Time magazine named him person of the year for his "bold" decision to roll out H1N1 influenza vaccine as soon as small amounts were available. "He's almost ideally situated by temperament and experience to be in a leadership role in this particular outbreak," Alfred Sommer, dean emeritus at the Bloomberg School of Public Health at Johns Hopkins University, told NBC news at the time. Frieden told AllAfrica that the crisis he and the global community face now is "unprecedented".

Here are excerpts from the conversation.

At a U.S. Congressional hearing on 7 August, you said CDC and your partners must "surge" to deliver resources. Can you be more specific about what that means?

The bottom line is that this is an unprecedented, overwhelming, crisis. It needs an unprecedented global response. You've seen the case numbers. They're horrific, and we know there are many more cases that haven't been diagnosed. We know that Ebola is not just killing people. It's also undermining the public health and healthcare systems, particularly in Liberia. That will result in more deaths from malaria, diarrhea, pneumonia, other things.

It's different in different places. The Guineans have made a lot more progress than the others. In Lagos [Nigeria], they were slow initially, but now have had an exemplary response. They have additional cases diagnosed in the past 24 hours [as of the afternoon of 22 August]. It shows just how hard it is to control this. You need a meticulous and comprehensive approach.

The second key bottom line about Ebola is that we know how to stop it. We can stop this. It really comes down to finding, responding, and preventing.First you find. You find patients, get a lab test done. Next, you respond: you isolate patients safely; you elicit the names of their contacts; you trace their contacts; and you speak with them every day for 21 days. If they get fever, you begin that process again.

There are two main ways that Ebola is spread. If we turn off these two taps – when we turn off these two taps – we will stop the outbreak. The first [way] is through health care – not primarily healthcare in Ebola treatment units but among people who come in with fever and end up having Ebola. That means we need to improve infection control throughout the entire healthcare system in the Ebola affected areas. The second is through burial practices. I know that this is a very sensitive topic, but unfortunately and tragically, many cases are being spread, in certain regions, by traditional practices involving burial and sending off the dead. At least until the outbreak is over for good, we need to work with communities, community leaders, and religious leaders to have safer ways of burying the dead. I'm sure that the dead person would not want one of their loved ones, or someone who is trying to pay respects to them, to die as a result of that process. That really highlights the importance of communication.

What we're doing there is extensive. We've got mobile labs deploying in the region. We're working with many international partners – South African, Canadian, German, French, the European Union…there's a lot of global partners. Even within the U.S. government, we've got both the defense department and CDC helping with testing and NIH [National Institutes of Health] helping with testing. It's really a coalition. We have epidemiologists – disease detectives. We have laboratory experts. We have analytics experts helping to understand what's happened. We have infection control experts. We have communications experts. We have emergency response experts – how to organize the work.

The two most urgent things to get right are how we organize the response. In an emergency like this, it's very difficult to make sure that our activities are strategic and effective. So we have an emergency response system that will facilitate control. The second is the need for more treatment beds, isolation treatment beds. Currently there are not nearly enough.

The gap is enormous. And it's very difficult to get the staff trained. There's a real challenge here.

Looking to the future, I'm confident that if we do have this global response, Ebola can be stopped. What we hope is that it will not only stop Ebola, but put in place the laboratories, people who are trained, emergency response capacity that will stop the next Ebola – or other health threat – before it spreads like this. I am 100% certain that if systems like this had been in place, the outbreak could be over already.

What do you say to hard pressed health systems now, in the middle of this crisis, about how to accomplish that, when resources are so strained?

One of the reasons I'm heading out there is to see for myself what we can do to support healthcare workers who are on the front lines. We need to make sure we get them infection control equipment. We need universal precautions. We need gloves. We need handwashing. If there's no water, we need alcohol-based or bleach-based hand sanitizer. In crowded facilities, people need to be wearing face shields.

These are big changes. It's hard enough to get doctors in the top hospitals in the United States to wash their hands regularly, when there's plenty of water around. We have to make it easy for healthcare workers to do it. We're going to have to emphasize that if we fail to do this, it's going to result in devastating problems.

I'm really looking forward to visiting. I'm a lot more comfortable on the front lines talking to patients than I am walking the halls of Congress. I want to see. I want to listen. I want to talk to my staff. I want to talk to healthcare workers. I want to talk to patients. I want to understand, because I've seen so often in my career, that what things look like on the ground is nothing like what people think they look like from afar. What I've been saying in the global coordination meetings is that the locus of planning and action has to be within these three key countries. So I want to listen to people there and see what we can possibly do at CDC and globally to control this faster.

At the end of January during concern about avian flu, in a blog post for CNN called 'How to prevent the next pandemic', you called for "rapid surveillance and containment" when emerging diseases appear. [http://globalpublicsquare.blogs.cnn.com/2014/01/31/how-to-prevent-the-next-pandemic/] You said "this combination of mass travel and an emerging virus such as this should underscore the connectedness of health security between countries." [By then, Ebola was already spreading quietly in the rural border region of Guinea and Liberia. In February, Guinea reported its first cases and enlisted Médecins Sans Frontières [Doctors Without Borders – MSF] to set up Ebola treatment centers. In March, Ebola reached Guinea's capital, Conakry and was confirmed in Liberia.] MSF and Samaritans Purse – two organizations on the front lines for months before the global health community took much notice – have been harsh in their assessments of international organizations. Samitarian's Purses's Ken Isaacs, in his Congressional testimony, said, "The international response to the disease has been a failure...  It was not until July 26th, when (two American healthcare providers) Kent Brantly and Nancy Writebol were confirmed positive, that the world sat up and paid attention."So that we can learn from the current disaster in west Africa, let me ask about the failure of rapid response and containment in this epidemic. It appears that the global response has been – and still is – completely inadequate.

That's certainly the case – that the response has not been adequate. If it had been, the outbreak would be over. We're delighted that at this point, we're being welcomed in to help. CDC is at the highest level of alert. We've only been at this level of alert three times in the past 10 years. We're working flat out 24/7. I have 400 staff working on this. We have nearly 70 on the ground, in the region. We have hundreds in Atlanta, backstopping and supporting and helping.

But we can't do it alone. No one entity can do it alone. I'm encouraged by the renewed commitment of the United Nations and World Health Organisation (WHO). I think MSF has been doing a phenomenal job. They're a wonderful group. I wish there were more groups like MSF who could come in and chip away at part of the need, because the need is so large.

You said on 4 August that the CDC was looking to deploy 50 staff to West Africa in the next few weeks. It sounds like you've exceeded that.

We said August 4th we'd do it in thirty days. We did it in fourteen days. So we really have handled this as the emergency it is. We're now up to nearly 70 staff. The situation on the ground, particularly in Liberia has been evolving so rapidly, we have not been able to keep up. We have not been able to keep up despite maximal effort.

Currently the biggest gap is treatment units. And every day that there aren't more treatment units up, there is a need for even more treatment units. It is an enormously challenging situation. The fact that Lagos, with an exemplary response, is continuing to have additional cases, just shows how meticulous the response needs to be. Guinea has made much more progress than the other two west African countries. We had a staffer there for three months, Dr. Pierre Volant, one of the world's experts in Ebola.

What he said was very clear. Stopping Ebola is about getting the details right. Lots and lots of details: infection control, burial, contact tracing, data management, laboratory testing. It's core public health activities, and it's that core public health system that these countries didn't have before these outbreaks – but we hope, ultimately, that every single country in Africa will have as the world recovers and learns from this.

But can you help us understand the impediments to jumping on this sooner? WHO was notified months ago about the epidemic. And it wasn't until late July that you started tweeting about Ebola. How was it missed? Were the countries not forthcoming enough? Were they putting obstacles in place – or did everybody somehow fail? I include AllAfrica in this criticism; although we've posted reporting on Ebola for months, we didn't give it sufficient prominence at the beginning. So I'm trying to understand how all of us who could have done more, earlier, somehow missed it and why that was?

I really think that goes back to the point of global health security. We've been saying for years that we need a global health security program. You kindly mentioned my comment in January, before the outbreak was known, which was exactly about this type of a problem. We need a public health safety net out there of the core systems to find, stop and prevent health threats. We can't predict where the next blind spot that's going to hit us is. That's why we need to address all of the blind spots. Whatever the weakest link in the chain is makes all of us vulnerable.

What will it take to get that? A public campaign, public pressure on the governments that have resources, as well as the governments that are most vulnerable to these emerging viruses? Does there need to be a coordinated civil society outcry? What do you think?

Well, one thing we've found over and over is that the business community appreciates the importance of stability and of not having events like this, which are horribly disruptivde to health, to the society, and to economics.I think having civil society demand that the public sector have a robust system to protect them from threats is certainly important. I hope that every upper income country assists. The U.S. is currently helping, and I hope we'll do more. Our number one priority in the CDC budget a year ago, which is pending in Congress, was an increase of $45 million for global health security – for exactly this type of activity. We need all of the OECD countries to do more. We need middle-income countries to take care of their own needs. We're happy to be partners with them and collaborate on that. For the lower-income countries, we need them to prioritize public health, because this is what happens if you don't.

The AllAfrica Foundation is launching a 'Give a Glove' campaign to call attention to the yawning gap between needs and available assistance and to enable people around the world to help.

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