Ebola is preventable

*Spreads from secretions, excretions of infected persons

*Case fatality rate of up to 90 percent - WHO

By Carol Aloysius

The Ebola virus now raging across four African countries has infected 2,100 persons and caused 1,145 deaths. It has dwarfed all previous outbreaks of the disease that frequently occurs in these countries. In Sierra Leone alone, which is the worst affected, 810 persons have died so far.

In certain African nations, the unexpected virulence of this year’s epidemic has led to unfounded fears and allegations that the disease simply does not exist and is just a part of western conspiracy. This has led to treatment centres being attacked as in the case of Liberia a few days ago, while in some states relatives have snatched their loved ones from Ebola centres to have them buried in their own village homes grounds. This has compounded the spread of the virus.

On the positive side, doctors now doing trial experiments with a drug approved by the WHO have said the results are positive though confirmation was not possible just now. If proved successful, this emergency drug is expected to be commercially available by early next year.

Due to the panic caused by the disease, many countries including Sri Lanka have taken steps to prevent its entry to the country, while raising more awareness among the public of this little known disease, its nature and how it spreads.

Registrar in Community Medicine for the Epidemiology Unit, Dr MADHAVA GUNESEKERA gives the Sunday Observer more insights into this highly infectious deadly disease, and what steps the Government Epidemiology Unit (GEU) has put in place in the event of an outbreak in Sri Lanka in the future, which he adds is a, “remote possibility”.

Excerpts...

Q. Ebola is on the increase. As this disease is relatively unknown globally and in Sri Lanka, how would you describe it to an uninformed public? Is it a virus disease? Or is it caused by bacteria?

A. It is a haemorrhagic fever (a fever that gives rise to bleeding manifestations) and caused by a virus.

The virus has five different strains and the severity of the disease changes according to the particular strain responsible for the disease.

Q. How did it originate? When was the first case of Ebola reported and where?

A. Ebola first appeared in 1976 in two simultaneous outbreaks, Sudan, and in Democratic Republic of Congo (called Zaire at that time). Outbreak in Congo occurred near the Ebola River, from which the disease takes its name.

Q. The highest number of Ebola virus patients are from West African countries such as Nigeria, Guinea, Sierra Leone and Liberia. Why are they more at risk than others?

A. Current outbreak of Ebola Virus is confined to West African countries at the moment. But earlier outbreaks have occurred in other countries such as Gabon, Uganda, and Democratic Republic of Congo etc. The disease exists in jungles of Africa as a Zoonotic Disease (a disease that occurs among animals) in these countries, and humans are infected accidentally when they come in to contact with infected animals

Q. How does Ebola Virus Disease (EVD), spread? Through the air, contaminated water, food, faeces or body fluids and secretions?

A. It spreads via secretions and excretions of an infected person (e.g. blood, vomits, urine, faeces, saliva, seminal fluids etc) and these should enter the body of an uninfected person through mucous membranes or broken skin.

People can also be exposed to Ebola virus through contact with objects, such as needles and bed linen that have been contaminated with infected secretions. Ebola is NOT a respiratory disease like the flu, so it is NOT transmitted through the air.

Ebola is not a food-borne illness (unless the animal is infected with Ebola virus and it is not properly cooked).

It is NOT a water-borne illness.

Q. Who are most at risk? Infants, children below five years, adolescents, elderly and why
A. No specific risk group has been identified. Anyone, any age can get it.

Q. Are females or males more vulnerable to the disease going by studies?
A. No predilection to a specific gender is evident.

Q. What about care givers, doctors and nursing staff treating them?
A. Care givers are more at risk, especially when they carry out invasive procedures such inserting cannulae, draw blood for investigations etc.

Q. Since most care givers are family members, does that mean that family members are the most at risk as they are also in close contact with the patient?
A. Yes

Q. Does that mean all family members who have close contact with the patient get infected by it?
A. As mentioned persons who have a close relationship (who look after the ill person, spouse) are more at risk. But not all get infected.

Q. Is it their high immunity levels, good nutrition and healthy habits that prevent some members of the same family caring for a EVD patient from contracting it?
A. We have no data available on this.

Q. Is poverty a contributory factor?
A. Even though poverty cannot be mentioned as a risk factor directly, it might contribute to the spread of the disease due to the lack of proper health care facilities.

Q. What about polluted unsanitary environments?
A. No

Q. Does having a non communicable disease like diabetes, hypertension and cardiac problems, compound the gravity of the disease in a patient? Can having an NCD make it easier for a person to get infected by EVD?
A. We have no data available on this yet.

Q. What are the most common symptoms?
A. Fever, intense weakness, muscle pain, headache and sore throat and they are followed by vomiting, diarrhoea, rash, and in some cases, both internal and external bleeding

Q. Any exceptions?
A. No asymptomatic cases have been reported except for Ebola Reston Species (current strain Ebola Zaire)

Q. How long does it take for the disease to manifest itself? What is the incubation period?
A. Usual incubation period (time from infection to the manifestation of disease) is 2-21 days

Q. Can a person affected by the disease be cured?
A. Yes

Q. Do you have any statistics (percentages will do) of cured patients globally?
A. Cure rate is between 10-75 percent and it depends on the strain of virus causing the disease. Current strain is supposed to be the most virulent strain.

Q. How were they cured?
A. Usually they are given ICU care and complications (liver and kidney problems) are treated. This supportive care is the only thing which is available at the moment.

Q. What is Supportive Therapy? What does this therapy involve in the case of such patients particularly?
A. Supportive therapy includes control of fever, maintaining fluid and acid base balance, treatment of liver and kidney failure, blood transfusions and treatment of concurrent infections etc.

Q. What is the treatment? Are there specific treatments?
A. No specific treatment is

Q. Is there a vaccine or drug to cure and prevent it? I understand there are trials going on right now and the WHO has said it was possible for a drug to be available next year. Your comments?
A. Experimental drugs are available and these were tested on some affected patients and some have recovered. But it is too soon for us to say that the drug is effective beyond doubt. As mentioned before, a certain proportion of patients recover on their own without any specific therapy (only with supportive care).

These drugs were used only in animals before and usually there are protocols which should be followed before these drugs can be used in people. It would take some time before these drugs made available freely.

Q. I understand the Health Ministry has recommended strict barrier nursing techniques to all nursing staff, doctors etc attending on Ebola patients if a patient is detected here. What are these barrier techniques?
A. Gowns, masks and goggles or face shield and closed shoes.

Q. Your Unit has also set in place some measures to screen arrivals from West Africa and other countries for possible Ebola virus. What exactly are these measures?
A. With the help of the Airport Health office at the Bandaranaike International Airport (BIA), Department of emigration and immigration and Airport and aviation Services (PVT) Ltd of Sri Lanka, a system was established to screen passengers arriving from countries affected by EVD at the moment. (More countries would be added to the list if the disease spreads to other countries in the future).

There are sign boards at the BIA requesting passengers arriving from affected countries to report to the Airport Health Desk voluntarily. If the passenger goes to the emigration desk directly, they would be referred back to the Airport Health Desk for screening.

A leaflet on Ebola (with signs and symptoms of the disease) is available at the BIA for ease of screening and patient education purposes.

Q. Who are manning these special counters for screening? Are they medical officers with a thorough knowledge of the symptoms of the disease?

A. Public Health Inspectors attached to the Airport Health Office at the BIA carry out screening and if they have any doubts, medical officers are called upon to examine the passenger and necessary action would be taken after the examination (screening is carried out 24 hours a day).

All the relevant staff officers were briefed about the illness and a letter containing necessary instructions was issued. In addition, training programs including practical demonstrations were conducted, for the staff officers.

Q. Do they have proper waste disposal systems at the BIA?
A. Yes, they have.

Q. How well informed are you ahead of the arrival of expatriates from West Africa? Does the airport send your Unit a list of new arrivals on a daily basis? Are the screening counters open 24 hours of the day every day?

A. A list of new arrivals from affected countries is sent from the Airport Health office daily to the Epidemiology Unit.

Medical Officers (MOH) of relevant areas are notified about the passengers and Public Health Inspectors visit the passengers to monitor their progress.

Q. Your chief epidemiologist has said your Dept. is ready to meet any emergency. What emergency plans do you have in place if a person is detected with the virus in Sri Lanka?
A. An Ambulance is kept ready at the BIA to transport any suspected cases of Ebola patients to the Infectious Disease Hospital - IDH if need arises.

Q. Does the IDH where they are taken to, have adequate lab facilities with properly trained personnel, nursing staff and medical persons to tackle this very complicated disease which has challenged even very experienced doctors abroad?

A. IDH is specialised hospital which is specifically geared for these types of diseases.

Laboratory facilities for the diagnosis of the disease is not available in Sri Lanka and it requires special laboratories with high level of Bio-safety (BSL-4 laboratories) and samples will have to be dispatched to such laboratories for the confirmation of the diagnosis.

Q. What about waste disposal- e.g. disposal of surgical gloves, masks, instruments like needles, syringes, even doctors and nurses uniforms, shoes, slippers, body fluids? Are they incinerated? Or put in bins for recycling? Your comments?
A. Some are disposable items and some can be reused after decontamination. Therefore, these two types of items are separated and further action is taken depending on the type of item.

It is not essential to incinerate the disposable items and burying of the item is quite adequate.

Q. Finally, I understand that trials are on for a drug to prevent and cure Ebola supported by the WHO and manufactured by the pharmaceutical giant GlaxoSmithKline. WHO medical chief is reported to have said it would be likely available by early next year? Is Sri Lanka also making arrangements to get this down once the drug is commercially released?

A. These drugs are still experimental drugs and not yet available.

Therefore it is too early say when the drug would be available.

The Government of Sri Lanka will take necessary steps to get down the drug to Sri Lanka after it is released, if there is a necessity.

Q. Since public panic is rising over a possibility of Ebola coming to Sri Lanka in the not too distant future, do you have a message to allay their fears? What are necessary precautions they must take?

A. Public need not panic. Even though the disease has a high fatality rate, the disease does not spread easily. One must be closely associated with an Ebola case to get the disease and as mentioned before, Ebola is not a respiratory disease like the flu, so it is not transmitted through the air and nor it is transmitted via food nor water. So probability of having EVD in Sri Lanka is quite remote.

Even if Sri Lanka gets the disease, the country has a strong health sector which is quite capable of handling such a disease.

Having good neighbours can cut heart attack risk

Living in a close-knit community and having good neighbours could have hidden health benefits and may even reduce people’s risk of suffering a heart attack, says a new research.

Researchers said that the social support and reduction in stress levels afforded by getting on well with the people in your community could be of benefit, particularly for elderly people more likely to suffer a health crisis.

Their findings, based on a four-year study of more than 5,000 Americans over 50, found that people who said they trusted and liked their neighbours, felt part of the community, and expected their neighbours would help them in a difficulty, were less likely to go on to have a heart attack..

Levels of social cohesion were rated one to seven based on people’s responses. Each one point on the scale represented a 17 percent lower risk of heart attack, the researchers said.

While some important factors such as genetic predisposition were not taken into account, the authors of the paper said that there were several potential explanations for their findings.

“Good neighbours will check in on each other. Older adults are more likely to have a reason to get out of bed in the morning, get dressed - even small things like this increases physical functioning and the benefits add up,” said Eric Kim, a doctoral student at Michigan who led the study.

“People with higher neighbourhood social cohesion might benefit from the support of neighbours, especially older adults, who might be getting support when they are sick, even just small things like providing transportation, picking up the mail or groceries. That would prevent worry and stress,” he said.

“More cohesive neighbourhoods might also be generating more positive emotions and life satisfaction, which has independently been linked with enhanced health, even after adjusting for things like stress and depression.”

The link between heart health and the place we live has been noted before, but usually in relation to factors such as deprivation, noise, air pollution, and the density of fast food outlets.

Responding to the new study, a senior cardiac nurse at the British Heart Foundation, said that many factors beyond just diet and exercise could increase our risk of heart disease.

The Independent

Death likely in patients with vitamin D deficiency

Low vitamin D levels linked to increased risks after noncardiac surgery

Patients with low blood levels of vitamin D are at increased risk of death and serious complications after non cardiac surgery, suggests a study.

“Vitamin D concentrations were associated with a composite of in-hospital death, serious infections, and serious cardiovascular events,” according to the new research by Dr Alparslan Turan and colleagues of the Cleveland Clinic.

They believe their results warrant further study to see if giving vitamin D supplementation before surgery can reduce the risk of these adverse outcomes.

The researchers analysed the relationship between vitamin D level and surgical outcomes in approximately 3,500 patients who underwent operations other than heart surgery between 2005 and 2011. Only patients who had available data on vitamin D levels around the time of surgery - from three months before to one month afterwards - were included in the study.

The concentration of vitamin D (specifically, 25-hydroxyvitamin D) in blood samples was analysed as a risk factor for death, cardiovascular events, or serious infections while in the hospital. The analysis included adjustment for other factors such as demographic characteristics, medical conditions, and type and duration of surgery.

Most patients did not meet the recommended 25-hydroxyvitamin D concentration of greater than 30 nanograms per millilitre (ng/mL). The median vitamin D level was 23.5 ng/mL - more than 60 percent of patients were in the range of vitamin D insufficiency (10 to 30 ng/mL). Nearly 20 percent had vitamin D deficiency (less than 10 ng/mL).

“Higher vitamin D concentrations were associated with decreased odds of in-hospital mortality/morbidity,” the researchers write. For each 5 ng/mL increase in 25-hydroxyvitamin D level, the combined risk of death, cardiovascular events, or serious infections decreased by seven percent.

Patients at the lowest level of 25-hydroxyvitamin D (less than 13 ng/mL) were at highest risk of death or serious complications.

Those with higher vitamin D levels (up to 44 ng/mL) had about half the risk as those in the lowest group.

- MNT