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

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21 thoughts on “Les Roberts – “Day 7: Brutal Triage”

  1. Perhaps one or two houses in each village could be vacated and given up temporarily, to serve as Ebola clinics for triage, isolation and early supportive care, until more facilities are built. PSAs could advise villages to set this up on their own while waiting for limited health staff to arrive.

    Liked by 2 people

    • Some guesses: Those drugs are cheap and treat conditions that are much more likely than ebola and that present similar initial symptoms, and can also be deadly if untreated. It’s also important to get the false negatives out of the treatment centers as fast as possible to clear up space and to prevent them from becoming infected there.

      Like

    • I am merely making a guess here, but perhaps the administration of malaria drugs and antibiotics help to establish a sort of “reset” with respect to eliminating any possibility that some additional infection might be running concurrent to the Ebola outbreak. Perhaps by doing this, the question “why isn’t this patient responding expectedly?,” the response “maybe a secondary infection might be playing a role, like Malaria or other contagion.” Since the next logical move would be to eliminate those possibilities, I’m guessing. By “pre-treating” for Malaria, et al, the question is arguably moot before being asked.

      I could be completely wrong as I am not an MD, just the son and great-grandson of MDs.

      Cheers!

      Liked by 1 person

  2. In the US, the media is freaking out over the isolated American cases, despite the fact that the disease seems to be not very contagious (though extremely infectious) and will probably have different epidemiologic characteristics in a US setting versus a West African one (e.g., given differences in levels of infrastructure, manpower, and physical resources).

    Can you comment more on what the people of West Africa feel about the disease, if you have interacted with any and asked? How do they conceive of the disease? Do they understand its cause and the response needed? How will local culture/attitudes/beliefs play a role moving forward in the way the public health agencies plan and try to move forward? The media has given some minor coverage to these topics, but I wonder if you could give a more first-hand account…

    Good luck and come home safe.

    — Mark (a dual MD/MPH student who was in your Quantitative Foundations class last fall)

    Liked by 3 people

  3. Does anyone know, are there primary health care centers at the village or parish level? What’s happening at those facilities?

    And, Les, as usual, you are practical and poignant. I took your class at Hopkins and the last presentation on epidemiology of cholera deaths in refugee camp in the virunga mountains was obviously calling up horribly traumatic and painful memories. I continue to admire your willingness to put your heart out there alongside your head. Thank you for that.

    Liked by 5 people

  4. Hi everyone! Thank you so much for your comments and questions. Les has been sending in blog posts for us here at the office to post, but never expected it to be very interactive. Understandably, he’s extremely busy and won’t be able to reply to specific comments and questions at this time. But he’s appreciative that his post has received such a response, and if time allows in the future, he’ll be sure to reply. Thanks everyone!

    Liked by 5 people

  5. Thank you for this, Dr. Roberts.
    We talk about disease and compare them to each other by numbers, like the number of annual deaths, because that’s the main way we know how. Ebola is a case in the forefront of my mind that is really making me question how we frame death and disease. I understand that Cardiovascular Disease kills more by sheer quantity… but as I read more about the epidemiological, social, political, and racial dimensions of our conversation around Ebola, it’s becoming clearer that deaths incurred are simply not enough. It aches me to see the accusations, conspiracy theories, and misinformation being facilitated by our networked global society. Beyond deaths incurred, disease can create resounding shocks within the collective human psyche, forcing us to choose sides, concede our ethical ideals (rightly so, perhaps), but most importantly reveal who the heroes among us are.

    Liked by 5 people

  6. Les, thanks for this poignant and sobering piece. I am currently in Guinea (Gueckedou) and although the ETCs are now nearly full, with slow plans to erect a third by end November, we are not yet at the situation that Sierra Leone and Liberia find themselves in. But we will be soon if we don’t act fast. There is already chatter here of community care.
    And hello, Sarah Paige! (Les, like Sarah, I’m a former fellow attendee of your Hopkins course and a huge fan. We worked together briefly in 2004 in Afghanistan in 2004, where you made one of the best grilled cheese sandwiches I have ever eaten!)

    Liked by 3 people

  7. Thank you for this powerful blog which was shared with me by a graduate MSN/FNP student here in San Diego. I am sharing it more widely with all of our faculty and entire MSN study body as well. My husband who has a PhD in infectious disease from Karolinska and tumor biology has sent out 26 resumes offering to help and no responses so we help as we can from here with our prayers and fiscal donations. God bless you. You are not forgotten and many many of us have cared and for a long time. Gail Reiner, DNP, FNP-C/APU and UCSD

    Liked by 3 people

  8. I didn’t know what you were talking about for the first few paragraphs. It wasn’t until you used the word village that I knew you were referring to Africa.

    I say to as way of explaining that I had chills over my body as I read this.

    Liked by 2 people

  9. Pingback: Ebola-related rant | kirstyevidence

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