Based on the available medical intelligence, we recommend the following:
- The World Health Organization needs to be clearer regarding its communication of the case counts. There was a recent press report from WHO indicating "improvement" in the case counts in Liberia. This follows copious notation of information suppression, serious problems with local transparency in reporting, and security issues preventing accurate assessments. And then WHO clarified this statement to indicate they are conducting a ground truth investigation to evaluate precisely what is going on. The key question being investigated is "why is there notation of an apparent decline in new cases"?
- Closer scrutiny of the western bordering regions of Cote d'Ivoire is recommended, particularly with an eye on Montagne.
- We recommend acceleration of clinic construction / implementation in Nimba District, Liberia.
- MSF needs to publicly emphasize to their international aid workers their responsibility in terms of proactive communication with their home countries' local public health agencies. MSF is currently under fire for appearing to provide guidance to returning aid workers to the US that does not appear to be sensitive to local public health concerns here Stateside. A simple solution is to encourage proactive communication: all aid workers should, out of a desire to avoid aggressive reactive behavior (as noted in New Jersey), notify local public health officials prior to departure to West Africa, with a clear indication of their expected return. Upon their return, these aid workers should seek to proactively notify local public health of their arrival. This avoids the surprise factor that drives much of the reactionary, counter-productive behavior, where MSF officials are distracted from their main mission due to media requests for what are preventable public relations crises.
Based on the meeting last week in Geneva, WHO expects the Ebola epidemic to peak in the spring / summer of 2015. Meanwhile, we in this country apparently do not feel a restriction of the granting of travel Visas is a reasonable countermeasure to mitigate the probability of a "surprise translocation" to a US community. We continue to assess this guarantees more translocations to the US. The issues of failure to disclose among aid workers exacerbates this problem.
On The Issue of Quarantine
The crux of the discussion is why quarantine?
1. Because the balance of risk : benefit is such that it is prudent. This includes a consideration of
- [a] the probability of an undeclared and therefore unanticipated arrival of a traveler at potential risk;
- [b] the probability of that arriving traveler proactively declaring themselves to local public health and medical facility;
- [c] the probability that the medical center is truly prepared to receive a real case of Ebola;
- and [d] that local public health has adequate resources to perform an after-the-fact contact tracing operation.... among other factors.
2. The public's tolerance (based on perception) of risk. This is the oft-overlooked point, where failure to recognize the social / community factors can make or break successful mitigation of a crisis. It is clear the public has very low tolerance for a case of Ebola showing up here in the US, where public tolerance is far less in a "surprise translocation" scenario versus a well-prepped and anticipated aid worker transfer (e.g. Emory). So, a decision to enforce mandatory quarantine is not only related to the known science regarding infectivity. It strongly relates to a whole host of additional factors as well that includes the preparedness of the local medical infrastructure.... which is far worse in the context of an undeclared / "surprise" translocation.
It is the latter point that is the central issue: communities caught by surprise are associated with a trigger for crisis, either due to direct transmission of Ebola or due to sparking public anxiety. Both are preventable with proactive communication.
What should be considered mandatory and legally enforceable is the following:
- Proactive communication of travel plans and arrival by any Ebola aid worker to local public health authorities. This is the #1 cause of the problem, where our team has documented multiple instances of failure to proactively disclose risk exposure among African nationals (e.g. Senegal, Nigeria, Dallas, and Johannesburg in 1996) and among US aid workers. We want to be clear that we have observed multiple reports of multiple aid workers who have deliberately evade airport screening protocols, avoided proactive conversation with local public health, and when asked directly, avoided disclosure when directly asked by public health, law enforcement, or medical care providers. This failure to disclose has been directly related to catching communities by surprise, with a subsequent stoking of strong social negative social response. We are sorry to say this openly, but no, we cannot simply trust that arriving travelers (regardless of profession, perceived heroism, or nationality) will proactively or accurately disclose their risk exposure.
- Home quarantine with self-monitoring for 21 days after arrival. The recent San Francisco situation highlights an example of excellent communication with an aid worker. All aid workers should expect this when planning to provide aid in West Africa.
- Home (or otherwise) arrest if there is failed compliance with home quarantine. Ankle bracelets should be considered for monitoring purposes at this point. This is an unfortunate, but occasionally necessary measure that will send a message to future arrivals who may seek to evade these important measures to protect the community.
CDC Public Communications
- It is repeatedly clear to us that CDC does not have adequate feedback regarding how their public messaging is being received by multiple key social networks involved with response Stateside. This includes EMS, state and local public health officials, and healthcare providers (both nurses and physicians). We have now observed multiple occassions where CDC was compelled, in the context of a precipitated crisis, to respond to the public via media queries that are clearly distracting them from their core response mission in West Africa.
- The current issue we have identified is an apparent conflict in their messaging regarding "airborne transmission" of Ebola and their updated PPE guidance that includes a recommendation to use PAPR and N95 face masks. This is in apparent conflict with what is standard of practice for MSF in Africa, who are using standard surgical masks. Not only does this discrepancy continue to play into erosion of trust in CDC, but there are serious questions now raised about surge capacity- especially for PAPR. This was, in our estimation, an unfortunate communication that may prompt yet again an avoidable and preventable crisis for CDC to resolve.
- CDC has encouraged the public to use science to inform decisions regarding quarantine, yet science has not apparently guided their recommendation for healthcare provider PPE. Perhaps market manipulation has played a role. This then raises questions about the influence of industry on public anxiety, clarity in official guidance, and true preparedness.
- CDC should be fully aware of the tremendous disconnect between its guidance and the challenges local communities have in implementing that guidance. Additional problem areas pertain to the disposal of medical waste, sanitation concerns, EMS transport of patients, and transport of laboratory specimens, among other challenge areas. Awareness of these challenges may help refine their public messaging.
- Lastly, the behavior of both Democrat and Republican governors in the states of New York, New Jersey, Maine, and California should be a strong warning indicator to CDC of an erosion in public trust that must be taken seriously and addressed with definitive action by its leadership. The above recommendations should serve to assist in that endeavor.
In summary, it is clear to this team that the federal government has failed to exploit access to information that could have helped them avoid serious and unnecessary crises with its public. Crises that are an unnecessary distraction from its professed focus on response in West Africa.
Meanwhile, Ebola continues to spread in the face of an uncertain vaccination campaign to be implemented in the coming months.