Lessons From Ebola Outbreaks

Bed capacity and infection control

As I watch COVID-19 spread around the world, I’m reminded of the 2014-2016 West Africa Ebola virus outbreak. An emerging infectious disease outbreak that simultaneously affects several countries for the first time comes with unique challenges.

In June 2014, as the Ebola outbreak escalated, I deployed to Monrovia, Liberia. I worked at the Eternal Life Wining Africa (ELWA)-2 Ebola Treatment Unit (ETU), one of two ETUs in the entire country at that time. As patients poured in from all over, bed capacity soon became an issue at a national level.

Additionally, the Ministry of Health (MOH), responsible for the management of local response to epidemics, had limited capacity to respond as they had never experienced an Ebola outbreak. Similarly with COVID-19, many hospitals across the U.S. face not only shortages in beds, but also limited technical capacity to treat this novel disease.

Training in Infection Prevention and Control (IPC) during a crisis is critical to protect healthcare workers. When preparing for a surge of cases during a rapidly spreading infectious disease outbreak, hospitals should always put in place emergency preparedness plans focused on interventions to face a surge in bed capacity and emergency supplies. The U.S. healthcare system should prioritize clinical training in emergency preparedness, as well as strengthen Infection Prevention Control measures for infectious disease outbreaks.

Fear is natural

My two colleagues, Dr. Kent Brantly and Nancy Writebol, who were working at the ETU, became the first two Americans infected by Ebola. I was one of the physicians on the team that cared for them. I felt overwhelming fear, but had to reassure colleagues that all would be well.

A fellow healthcare provider came to me and asked, “What will happen to us? Will we also become infected?”

Other healthcare providers felt afraid that they too would become infected. The case fatality rate at that time was estimated at 90%. Fear is contagious, especially when responding to a disease outbreak with high mortality. Fear can either paralyze your actions, or give you courage. For those that are currently fighting COVID-19, know that fear is natural during a crisis. I was constantly reminded of the following quotation:

“Courage is not the absence of fear, but rather the judgment that something else is more important than fear. The timid presume it is lack of fear that allows the brave to act when the timid do not. But to take action when one is not afraid is easy. To refrain when afraid is also easy. To take action regardless of fear is brave.”

-Ambrose Hollingworth Redmoon,from “No Peaceful Warriors!”

 

Do no harm

As a clinician, how do you manage an outbreak of an emerging infectious disease when there is no scientifically approved treatment? In 2014, there was no proven treatment for Ebola. Supportive care was the only intervention approved by the World Health Organization (WHO), the Centers for Disease Control and Prevention and MSF. Soon, investigational therapies such as Zmapp, favipiravir, and others, became available. I administered the first investigational drug under compassionate use to my two colleagues with Ebola, a decision that wasn’t made lightly. Several agencies were consulted during and we decided that this was the ethical thing to do.  The WHO soon issued the following statement regarding the use of experimental drugs:

“It is ethical to offer unproven interventions with as yet unknown efficacy and adverse effects, as potential treatment or prevention.  Ethical criteria must guide the provision of such interventions. These include transparency about all aspects of care, informed consent, freedom of choice, confidentiality, respect for the person, preservation of dignity and involvement of the community.”

When we must make a decision regarding the use of an experimental therapy with limited scientific evidence available, we should heavily weigh the risks and benefits, and above all, do no harm. We must constantly review and remain updated with evolving scientific evidence in order to provide the best clinical care to our patients.

Caring for patients in Personal Protective Equipment (PPE)

“The good physician treats the disease; the great physician treats the patient who has the disease.”

– William Osler

It’s challenging to connect with patients when they can’t see us smile. Speaking though a mask muffles our voices. However, it’s still possible to get to know our patients when wearing cumbersome PPE. A patient with COVID-19 recently told me that though he couldn’t see me smiling, he could see the kindness in my eyes. We must ensure patient-centered care by learning as much as possible about our patients, including a good understanding of the community where they’re from.

Listening to community voices

Obtaining feedback from the community on public health interventions during an infectious disease outbreak is essential. In the 2018 Democratic Republic of Congo (DRC), my colleagues developed a standardized method of continuously obtaining feedback from the community to inform and improve the outbreak response. Communities were invited to visit ETUs, which many community members considered a “place of death,” in order to dispel fear and reframe the narrative of these sites of care. A social sciences structure set up an online recommendation tracking tool to monitor actions agreed upon from studies. It identified improvements in program effectiveness and monitored the impact of using evidence in response interventions. The effectiveness of public health measures increases when feedback from community members is incorporated, and when trusted community leaders are engaged in intervention development and implementation.

The above lessons learned from the Ebola outbreaks can help guide us as we face the current COVID-19 global pandemic.