Les Roberts – “Day 23: The building next door is on fire!”

Les Roberts – Freetown, Sierra Leone – October 27th, 2014

Day 23: The building next door is on fire! But fire is dangerous, so anyone who enters will have to be quarantined in there for 21 days after the fire ends.

There is grim news to report from the vantage of Freetown. There is a deadly outbreak threatening worldwide safety: an outbreak of unadulterated insanity in the US. In our beloved State, the Governor, and his neighboring New Jersey Governor, has decided to enforce a three-week quarantine on any health workers returning from West Africa.

MSF has now had over 500 expatriates come to West Africa and return home. They have had several staff become infected, several of whom were evacuated to Europe, and I believe, none of whom are known to have infected anyone else. They have had an unknown number develop mild or asymptomatic cases. They have had at least one develop disease after going home. Their strategy for protecting the lands to which they repatriate is to have their staff monitor their temperatures twice daily and report-in to the MSF monitoring network daily for three weeks. The logic is that people can go about their daily lives with virtually no threat to those around them up to the point where an Ebola infection produces fever. Thus far, their record has been… perfect. That is, an R of zero! Of course, there will be cases in the future and this system will not be perfect if this outbreak keeps up. Of course, having CDC and health departments chase down hundreds of contacts is expensive and resource consuming. But since the outbreak began, thousands of people have returned to the US from this region and almost none has triggered contact following and significant public expenditure.

Stop and ponder, if Europe, or for that matter, the entire world followed the New York example. Almost certainly, this outbreak would blossom and spread and extend to Europe and wash across the US borders within the coming years. Global quarantine of the three affected nations would almost guarantee Ebola remaining prevalent here for a long, long time. Like measles or shigella or any of those other more transmittable and opportunistic diseases that blossom among the world’s poorest, travelers would be bringing the infection to our shores continuously as they do with measles and shigella. While less transmittable, Ebola has a noteworthy difference from measles – it is significantly more deadly. The best “high probability” approach we have to not being on hyper-alert for Ebola in the US for many years to come is to stomp this out now In West Africa. The US is doing its part here, as are the British and the Chinese and many other nations. But these nations would never find enough people and the right people to deal with this crisis if they established New York and New Jersey type quarantine rules.

I was just today in Romeni, a town under quarantine with military posted at each end of this one-road town of a few thousand in an attempt to keep infectious cases in the town. No one except health workers can go in and out. It was a little bizarre to see large numbers of adults hanging out in the middle of the day. Most chiefdoms now have a rule against allowing a stranger to sleep at your home: there is a $100 penalty for this act. These protected towns usually have young men guarding the edges against strangers coming into the town. While WHO does not endorse all of these quarantine approaches, in this setting, with this culture, I am not sure if these quarantine controls are a bad idea; there is no track record for evaluating this. (I am quite sure all of the quarantined towns that are not getting any food are a bad idea, but that is another discussion.) In contrast, we have a pretty good body of evidence that before infected individuals are febrile, they do not shed the virus and pose almost no risk to others. Keeping such people out of your state or off your subway probably produces no measurable benefit but creates a great barrier to allowing New York and New Jersey residents from being part of the solution.

There is a deadly outbreak threatening the globe. I fear we will not be safe from the scourge until a vaccine is developed that can prevent governors unencumbered by scientific evidence or logic from becoming infected with Presidential ambitions.

Les Roberts – “Day 18: The Departure of Hurricane Katrina”

Les Roberts – Freetown, Sierra Leone – October 22nd, 2014

Day 18: The Departure of Hurricane Katrina

There are few upsides to this Ebola outbreak. All of us in the WHO office are working very hard to do little things (e.g. get Standard Operating Procedures in place for prioritizing different kinds of lab samples or getting a facility inspected and deemed safe enough for the Cuban Medical Brigade to work there) and we all know the sum of those little things is not even close to adequate. But, the huge upside is that I work with some astonishing people. The world has sent it’s “A Team” here and it is really flattering to get to rub shoulders with them.

I remember “sliming fish” in salmon processing factories in Alaska during the summer in the 1980’s. I worked in four of them. These were big unheated metal factories with concrete floors. There were processing lines with distinct task stations and the first major station in each line was the person who cut the head off the fish. That person would typically set the work pace for the teams of 30-50 people farther down the processing line who did other chores like ripped out the gills, cut open the body cavity… There was one guy, a guy who had not gone to college and had a humble job the rest of the year, who could cut off 100 salmon heads per minute. There were two lines of people behind him who handed him fish, he had a guillotine-type device with a V-shaped blade, operated by a foot pedal, and he would chop off the head of each fish. This was Alaska, so he had removed the Federally mandated safety guard which allowed him to go faster. He would grab a (typically seven pound) fish fed to him by a line behind him on the right with his right hand, slide it across in front of his torso and chop off the head, and then keep sliding the fish to processing line in front of him on the left side, and at the same time he would have been moving a fish with his left hand chopping a head off and passing to the other line in front of him on the right. When he was in full blast, you could not see his hands they moved so quickly and the blade made a bang, bang, bang sound that was very 1984esque. He would perform his magic for three or four minutes until huge piles of fish were backed-up at the various processing stations and then just lean back for a while, cross his arms and gloat at the workload and work frenzy he had created. He was an astonishing worker who had this one tiny niche in which he was not just excellent, but superhuman. I have seen very few humans that struck me that way through the decades: Tiger Woods at his peak, Bill Foege, the former CDC Director. There has been a gal here these past weeks in Freetown who has left today, she is equally superhuman.

Katrina, whose husband claims she is the one for which the Hurricane was named, is an Australian virologist and epidemiologist. She came to do epi but there was a need for safety training and somehow she fell into that billet. She might not be my first pick for accompaniment on a lifeboat lost at sea: she is rather high energy. Think Katherine Hepburn meets Taz.   She has so much drive that when she does not get the support she expects from her supervisors in country, she starts cc:ing the WHO Assistant Director for Ebola in Geneva. She only has one engagement level, 200%. Don’t get me wrong, she is very polite and respectful. She is less than 100 pounds and unintimidating. But, this full throttle need to engage about something is operating whether it is 7AM or 11PM or any moment in between. But, man has she been an astonishing trainer!

She arrived in Sierra Leone just as a three-day training on how to stay safe in a Red Zone was developed and the developer’s time here was up. So in she stepped. The course has a day of lectures about ebola and general infection control principles. This worked well with her virologist training. When students would ask questions she did not know, she would study at night and answer the next day digging into the most esoteric aspects of virus physiology or urine collection techniques. And days two and three are all about PPE: a little about how to get it on, but a lot about how to get it off. Again, and again, and again. They walk around outside in the sun for 45 minutes in PPE. They pass through a mock ward in the PPE. They learn about the buddy system for quality control while removing PPE. And this could be boring but with Katrina these were three days of riveting self-confidence building. Adding to it the Chief Matron nurse gave Katrina a few of her best nurses, who took the course, watched the course, and then took over the course. Over six weeks she got four teams of trainers up and going and the course trained-up over 700, mostly nurses, in Ebola safety and PPE. As of last report, none of her first cohorts has become infected. The very first cohort almost all went to the largest ETU in the country here in Freetown where they have had a lot of staff infected over the months, so these were the highest risk trainees.

Being high energy certainly helped a lot in her success, but was not the largest part. The biggest part is that she just loves engaging with trainees. I suspect you have seen this, the really really great teachers, the Sharron Schwartz and Linda Cushman types, just exude love and happiness when engaging in the process of teaching. At the breaks, Katrina was constantly going around and visiting with the attendees and getting their stories. She was tired, but this is what energized her. The trainers made a special send-off meal for her for her last day. Katrina and many of these hard, tough senior nurses who have all lost co-workers, got all teary-eyed at the send-off. It was excruciating for them to not be able to hug good bye.

Wow, is it inspiring being around people like that!

Les

Freetown 2014 © Les Roberts

Katrina with Raj Shah: Every dignitary wants their picture taken with Katrina.

Freetown 2014 © Les Roberts

Putting it on is the easy part!

Freetown 2014 © Les Roberts

Did I mention that the British Home Secretary and the New Sierra Leone Ebola Czar wanted to see Katrina in action?

Freetown 2014 © Les Roberts

Katrina Roper in her element.

Les Roberts – “Day 13: Bias, bias everywhere, but not a chance to think.”

Les Roberts – Freetown, Sierra Leone – October 17th, 2014

Day 13: Bias, bias everywhere, but not a chance to think.

Great news.  I was meant to have dinner with the two top guys here from CDC but they had to cancel to have a conference call with Tom Frieden. What a great director, what an impossible position. But, that can be a discussion for someone else’s blog. What this really means is that I have a couple free hours for the first time in days and I can write to you.

I had a great chat recently with Craig Spencer (PFMH ’2013, one of Rachel Moresky’s international emergency medicine fellows) who is with MSF in Guinea. He said that a quick scan of their data suggests that the longer between the onset of symptoms and when one shows up in the clinic, the better the chances of survival. This is of course, the opposite of the message we want to get out. This is clearly a bias issue, probably survivor bias.

CDC thinks that the median time from the onset of symptoms to death in 6 days. In Sierra Leone, we think that on average people have symptoms for seven days before coming into a health care facility. Thus, in terms of Craig’s data, with no treatment at all, if someone is on day two of symptoms, there is probably a 70ish percent chance they will die. If they show up on day ten, there is probably only a 20ish percent chance they will die. Thus, of course the longer a patient has been symptomatic when they show up at your clinic, the better the chance they will survive. But, as I said before, the primary health benefit of a patient going for treatment is not that they will get medical care and survive. The primary benefit is that they will not infect a slew of other people as they become viremic and shed via every pore and liquid in their body. I can think of no other disease with the possible exception of rabies where the number one health reason for medical care is not related to the patient. Thus, if the message got out, “the later you come for treatment the more likely you are to survive,” this would completely undermine the control efforts.

Almost everyone understands that this survivor bias is going on. There is one hospital here in town that is very proud and loud about how they have a 70+% survival rate. It does not matter which one. They are an Ebola treatment facility and patients have to be laboratory confirmed positive to get referred to this hospital. Now, it takes three to four days in Freetown to get lab results back (and a LOT of people are working on this issue). Thus, given seven days from symptoms to clinic presentation plus the lab delay, patients have been symptomatic 10-11 days without dying upon arrival at this facility… Of course, they have a 70+% survival rate. I care much more about the fact that this facility has handled a couple hundred patients and none of their clinicians have been infected. To me, this is far more impressive and more important in terms of stopping the outbreak.

There are other big biases operating as well.  Before coming, I heard repeatedly (not just from the talking heads on the television but in my WHO briefing) that this outbreak seems to have a very low case fatality rate compared to past Ebola outbreaks, perhaps 46-48%.  I strongly suspect and the evidence is building that this is just an issue of low sensitivity surveillance; and the burial surveillance is worse than the case surveillance. (That is what the CDC meeting tonight was about. I think between CDC and WHO, we will have some quantitative insight into this before long.) Likewise, I keep hearing that in Sierra Leone, this is largely an urban outbreak. While Ebola has never been in cities before and this is huge and noteworthy unto itself, I strongly suspect that this is more an issue that surveillance is almost complete (especially for burials) in the urban centers compared to the rural areas. Now it is Government policy that bodies be swabbed for testing before burials and if a body is Ebola positive, it gets entered as a case and a death, improving the surveillance sensitivity of both surveillance measures.  Burial teams are providing nearly complete coverage in Freetown and are not available in many rural areas.

I would love to spend my time assessing these things but the fact is that if the surveillance system sensitivity is 30% or the urban fraction is exaggerated by a factor of two, the strategy for controlling the outbreak is the same. In Bo and Kenema, centers of the crisis last summer, the outbreak is on the decline. They now have enough beds for referrals. They have good contact tracing (maybe 90%????) and follow-up. The message has been sent out – come for treatment early. Most bodies get buried effectively by trained teams. Where it is not the case, groups spontaneously arose and developed their own no-touch approaches which use ropes with slip-knots to move corpses. We need to get that going everywhere as we have those efforts going well only in the Eastern areas. (Also, lab testing makes the clinics function better by getting the negatives out quickly, freeing beds, protecting the non-Ebola cases and allowing contact tracing to happen…)  Time spent on improving data quality is potentially time away from getting facilities up and running. So on we run.

Freetown 2014 © Les Roberts

Ebola walk: elbows against side, fingers interlocked, as part of PPE training at National Stadium.

I hate bias!  But I am just going to have to ignore its brazen manifestations for a while.

Cheers,

Les

Les Roberts – “Day 10: Leaving Columbia to be at peace with Columbia”

Les Roberts – Freetown, Sierra Leone – October 14th, 2014

Day 10: Leaving Columbia to be at peace with Columbia

I am constantly struggling with being an academic at a time when there is work to be done in the world. There have been maybe five occasions in my life (e.g. detected a measles outbreak that had killed 1,500 kids and saw my local partners stomp it out, showed that a vaccine was working fine in spite of all appearances to the contrary…) for which I am quite sure hundreds of deaths were averted because I was there at that moment. I have not had anything close to these experiences since coming to academia full-time eight years ago.

There is a lot that’s appealing and a lot that’s appalling about academia. Imagine two young people come to the University trying to make an Ebola vaccine as a next career chapter. One comes up with a cheap safe vaccine with 90% efficacy after 10 years using $100 M and with 100 publications about the Ebola vaccine. The other comes up with an equally effective, cheap and safe vaccine with only $1 M and 10 similar publications along the way. By virtually every other measure within society, the second efficient researcher would be called good and the first would be considered at least inefficient or maybe even a self-promoting parasitic slouch… But in academia, it is just the opposite! (There might be one or two other downsides).

But the appealing part is the students. It is the appealing part when they are in school but it is the really appealing part when they are launched into the field. I had dinner last night with Bronwyn Nichol (PFMH ’12). She is here with UNICEF working on social mobilization. It is frustrating and trying work as communications people are running the show and the health agenda often seems to have been overtaken. It was so great to see her and see how after just a couple years in Chad (with the Carter Center) and Jordan, she has become so well rounded in terms of understanding the alignment of management, programs and objectives. She is here via the Canadian Government and at the end of this gig, she will be able to have all her student loans paid off…Something on many of your minds, I suspect.

At dinner, we saw and spoke to one of my former Hopkins students who has been heading the CDC team in Kenema. The outbreak is largely under control up there now and this student, Muireann, has been one of the loudest voices articulating why this district has done so well. The night before, another former Hopkins student who works with the International Rescue Commitee (IRC) health unit was at Laura Miller’s house when I went there for dinner. (Thus, four former students and Susan Purdin in two nights!) Laura (PFMH ’11) has been here over three years and has faced some reluctance from her HQ to take on clinical roles. However, the IRC President, David Miliband, was out here last week and they now have embraced treatment (a figurative expression) wholeheartedly. In just the perfect process of partnering, IRC is going to pair its logistics and operational capacity with a local British group who has been working in the hospital here for a couple years and are going to start opening tent-based holding facilities next to health posts around the city. It is a different model than the one the UN is pushing for in rural areas but it makes complete sense for Freetown. That Laura has been here for years, knows everyone and is brilliant but modest makes her the perfect person to make this happen. I am sure that in the years ahead this Ebola chapter will be for her the satisfying experience that stopping those Congolese measles outbreaks was for me all those years ago.

Thus, ironically, taking a leave from Columbia to dash off and do something quite unrelated to what I teach and research has brought me more satisfaction and peace with my academic life than most anything else in the past eight years. The idea that the Program on Forced Migration and Health has sprinkled other Laura Millers out there – individuals who will hopefully never be quite so tested and who will have more subtle successes – is very comforting.

Les

Les Roberts – “Day 7: Brutal Triage”

Les Roberts – Freetown, Sierra Leone – October 11th, 2014

Day 7: Brutal Triage

The prediction landscape is looking bad. The official numbers reported are laboratory confirmed cases. Typically, we think people need seven to ten-ish days to become symptomatic. Typically people have symptoms for seven days before they get into a health facility. A month ago, it was one day, now it typically takes four days from when a patient is sampled to when the patient is told the result of their test (and lots get lost and mislabeled…). Thus, the numbers that you hear about new cases today reflect the transmission dynamics from over two weeks ago… and we thought the doubling time of the outbreak was 30 days, it seems to be less than that here. We knew the ~350 confirmed cases last week were an undercount… we now think there are seven to 900 in reality. The need for hospital beds is climbing more than the ability to get them up and running. There might be 200ish Ebola treatment beds now countrywide. There are perhaps 600 more in “holding areas.” We have schemes to get 500 or 600 Ebola treatment beds up and running over the next eight weeks. As Foreign Medical Team Coordinator, helping to get these beds up and supported is one of my primary tasks. If there are really 3000 cases this month, and 6000 next month… with all going perfectly on the treatment bed establishment side, we will have 30% of the beds we need next month, slightly worse than the situation now.

The Ministry of Health and WHO are trying to fill the void with Ebola Community Care Units (ECU’s). Tents with eight beds…. maybe two tents, a wet tent (vomit and diarrhea) and a dry tent and a big buffer zone around with a couple latrines and a burning pit and a water supply. They will be staffed by low level health workers or community volunteers, ideally survivors of Ebola who will have immunity. The idea is that at the first sign of symptoms, the family brings the feverish loved one in. Everyone will be treated with an antimalarial and an antibiotic. If they can be tested for Ebola, they will be. If not, they get monitored and if they develop three of the key symptoms they get referred to a proper hospital bed… which will be in short supply… or otherwise they move to the wet tent. They will be given ORS… maybe food… maybe they die, maybe they do not. This is very close to no treatment. But the goal is to get them out of their houses to where they will be less likely to infect others. The supervision will be scant. The work for those in the ECU’s will be very risky. Even MSF has had several staff infected now and they are hyper-vigilant and resource rich. But the logic is, for every health worker infected or ECU malaria patient who becomes infected with ebola while waiting in such a unit, two or three infections that would have happened if the person died at home will not occur.

We aspire that we will have ~150 of these going in 60 days… which involves a million dollars per unit, major logistic planning and supply chains, site preparation by the community, and well drilling… this will be a massive effort. But 2000 beds in ECU’s, 700 treatment beds… might be half of what we need by December. Thus, barring a dynamic change in the outbreak growth, in November, in December, most cases will likely die at home.

Thus, the CDC has been pushing kits and training messages to promote “safe home care.” The kits would have ORS (a lot…like 20 sachets) and gloves and masks and chlorine and an ORS mixing bottle. The kits’ design is yet to be finalized by the MOH and the international community. The main part of the kit will be messages to the family. Keep the person in a room alone, and no one shares their bathroom. Only have one person deal with them… don’t touch them… wear gloves… wash with chlorine as you exit their room. Again, like the ECU’s this is not about treating the ill as much as it is about minimizing infections. The logic flows like this:

Interim Ebola Approach

If you think about it a few steps removed from West Africa, this is freakin’ wild. We are primarily trying to facilitate people to die without infecting others. Very little of this logic beyond the ORS is about treatment. The last year PEPFAR was in full bloom, with all the administrative layers and consultants, it spent $10,000 per patient to have Africans on anti-retrovirals. The rights-based advocates were screaming about how it was only fair that Africans get what Westerners got. In July, there was an Onion headline “Experts: Ebola Vaccine At Least 50 White People Away.” http://www.theonion.com/articles/experts-ebola-vaccine-at-least-50-white-people-awa,36580/  It seemed kind of funny then… now that we are being so brutal in our public health triage it is much much less funny… maybe prophetic. We are about to assist thousands and thousands of people to die an excruciating death at home without even the most mild of pain relief. We are going to set up treatment facilities in hundreds of villages for one of the most deadly of diseases to be largely run by volunteers who will be lucky to get 3 days of training. Dozens, perhaps hundreds of them will die. And the most surreal aspect of this triage for me is that I completely think that this is the right thing to do given where we are and the limited ability to respond. As I think about you students reading this I struggle with the degree to which my endorsement of this multipronged approach is pragmatism or wisdom or loss of idealism.

Les

Les Roberts – “Man, this is one heavy gig!”

Les Roberts – Freetown, Sierra Leone – October 7th, 2014

I had a great lunch yesterday with Laura Miller (PFMH ’11) and Susan Purdin (former Program on Forced Migration and Health faculty who taught the Reproductive Health course for years).

What was so bizarre is that I could not hug them or shake their hand….no one does!  No one!   Last night I saw the British special Ebola Representative leave a meeting with the CDC lead here in country…. and they did not shake hands!  Everyone is washing their hands 20 or 30 times a day.   There are hand washing stations as you enter every hotel and government building and restaurant.   I have had my temperature taken 5 times today and 8 times yesterday.   Every hotel and office and controlled public facility has infra-red thermometers to scan your forehead before you enter.  Everyone…. poor and rich alike are hyper aware of this disease risk.

In order to control this outbreak there needs to be:

  • cases suspected….calling in….self-diagnosing
  • transport to a facility
  • triage or holding of suspected febrile cases (w/ testing, diagnosing, treatment)
  • contact tracing (which can lead back to step one)
  • and safe burials

 CDC is convinced safe burials are the highest priority.  WHO thinks treatment capacity is the greatest bottleneck / priority (because identification, triage, contact tracing all don’t work if you can’t refer cases and if the health system is not trusted).

I do not know who is right but I am sure both are needed…it is all freakin’ needed.   I have been made WHO’s Foreign Medical Team Coordinator which really means getting hospital beds up and running…with all the training and management and supply chains that goes with it.   Not what I expected to do…..but maybe the most important thing I can do.   Today we likely do not have ½ the beds in country that we need for the existing cases.  I expect that we can triple the treatment beds in the next two months while I am here….and all modeling, even best case scenarios suggest, we will be even further behind the patient bed demand than we are now.

Man, this is one heavy gig!

Les

Les says farewell

We are all very proud of Les Roberts, professor of the Program of Forced Migration and Health at Columbia, who left September 29th to work with the WHO in Sierra Leone on the Ebola response.  We’ll be posting his updates here, so please check back often!

Freetown 2014 ©Les Roberts

Hand-washing station at the entrance of Connaught Hospital, Freetown.

Please see below for an excerpt of his farewell email to his students.

—-

Friends,

I am sure that you all felt a little heartache as MSF and West African officials have pleaded for more help from the West during this ebola outbreak.  Both CDC and then WHO reached out to me requesting I go work on the outbreak and while at first I refused because of my teaching obligations, but my wife and consensus have reminded me that the teaching can be rearranged and postposed, but the outbreak intervention cannot.  I will be taking a 2 month leave of absence from Columbia University starting October 1st so I can work for WHO in Sierra Leone.

Thus, I am going to impose on your good nature and delay the start of my classes.

I am sorry if this disrupts your plans but I feel the need to be of some service at this moment when my limited skills will likely have something to contribute.  I look forward to seeing you in January.

Gratefully,

Les