Bloodborne HIV: Don't Get Stuck!

With recent US and WHO statements and commitments, the health aid community is escalating the war on Ebola in West Africa. That’s good news. But I’m still worried. Escalation does not necessarily lead to success, especially if health aid managers escalate failed strategies. Two errors in the response to date have been:
• Not warning the public about risks to get Ebola during invasive health care. This error may well be the principle cause of the continuing increase in numbers of infections.
• Not respecting patients’ rights to choose where to be treated. This error breeds public distrust, undermining cooperation. A strategy to stop Ebola that does not rely on and respect the public is like trying to clean up a puddle with a hammer. The health aid community should switch to towels – to a softer approach.

Based on experience from past outbreaks, as soon as health aid managers fix these errors, we can expect a sharp fall in numbers of new infections, with the outbreak ending in a matter of weeks to months. To fix these errors, public health programs should:

1. Warn people that injections, infusions, and other skin-piercing procedures can spread Ebola, and to avoid such procedures as much as possible

An important observation from earlier outbreaks is that Ebola transmission in health care settings amplifies what is otherwise a self-limiting outbreak. Transmission during home-based care, even with some dangerous funerals, has not been enough to sustain an outbreak. Aside from what happens in the community, preventing any additional (“excess”) transmissions in health care settings has been enough to stop previous Ebola outbreaks.

Most transmissions in health care settings fall into two categories – transmissions from patients to health care workers, and patient-to-patient transmissions. In the current West African outbreak, health aid managers have addressed doctors’ and nurses’ risks to get Ebola from patients by providing protective gear such as gloves and aprons. However, health aid managers have been silent about patient-to-patient transmission, especially through reuse of unsterilized skin-piercing equipment for injections, infusions, and other procedures. This “oversight” may be the error that allows continuing “excess” transmissions in health care settings to amplify what would otherwise be a receding outbreak.

The urbanization of the current outbreak makes it especially important to warn the public to avoid invasive procedures with unreliably sterile instruments. In rural areas, where most Ebola outbreaks have been observed to date, options for invasive procedures are limited. But in towns and cities, where many who are infected with Ebola currently live, people can get injections, infusions, and other skin-piercing procedures from scores of enterprising healers in formal and informal sectors, including pharmacists, private clinics, quacks, etc.

How to stop “excess” patient-to-patient transmissions during invasive procedures? In theory, public health managers could assure that health care is safe by educating and supervising doctors and nurses. However, health care in the affected countries in West Africa was not safe for patients even before the current Ebola outbreak. With the outbreak further stressing the system and reducing available staff, health care is even less safe than in “normal” conditions. To stop transmission of Ebola during invasive procedures, there is no option except warning the public. That is also the only ethical option.

2. Demonstrate respect for the public by letting people choose where to be treated and by acknowledging risks in health care settings, including Ebola isolation wards

The World Medical Association’s Declaration of Lisbon on the Rights of the Patient (available at: http://www.wma.net/en/30publications/10policies/l4/) presents guidelines for doctors to respect patients. According to article 3: “The patient has the right to self-determination, to make free decisions regarding himself/herself… A mentally competent adult patient has the right to give or withhold consent to any diagnostic procedure or therapy…” such as, for example, entering an Ebola isolation ward vs. taking treatment at home.

Ebola response teams in West Africa have violated patients’ rights by coercing them to enter isolation wards. When health agencies allow Ebola suspects and even cases to choose treatment at home, it frees money and staff to give better treatment to remaining inpatients and to improve community outreach. Based on previous outbreaks, home treatment results on average in less than one new infection for each current case – which is all that is required to stop the epidemic.

Giving suspected cases and their families the option to treat at home will defuse tension between health care personnel and the general public. Healing this rift is essential to allow public health authorities to gain accurate information about the epidemic. People who are not afraid are more likely to talk.