Getting an answer to the question in the title is crucial for people in countries with ongoing epidemics – to protect themselves they need to know the ways they are most likely to get Ebola. The answer is important for people in other African countries as well – to help them assess the probability the epidemic will reach their country, and to prepare for this possibility.
People outside Africa also need the answer. Politicians and bureaucrats who vote and manage aid funds can make better decisions with a clear account of whether and how what they are paying for is saving lives. Finally, although there is only an outside chance the virus has changed or will change to transmit more efficiently, that small possibility represents big risks to people around the world. We want to know what’s happening.
There are two steps for health aid managers to answer the question in the title. They must:
• Get the answer through surveillance.
• Report what they find to the general public.
As of September 2014, public health experts have not reported the relative contribution of various exposures in transmitting Ebola in the current outbreak. Their failure to do so may be due to missing the first step (ie, they don’t know) or the second (ie, they know but don’t say).
Contact tracing to find the source of infections
The public health response to West Africa’s Ebola epidemic includes a lot of effort to trace contacts of people with Ebola to identify new cases as soon as possible – as soon as they get symptoms. For example, at end-August, “WHO and its partners are on the ground establishing Ebola treatment centres and strengthening capacity for…contact tracing…” (WHO, Ebola virus disease update, 28 August, at: http://www.who.int/csr/don/archive/year/2014/en/).
However, I have found no reports of contact tracing to find where and how people with Ebola got their infections. How to do this is straightforward: Ask people with new Ebola infections if they had touched someone who was sick or if they had attended a funeral in the previous 21 days; touching someone sick or dead with Ebola is a recognized risk. Ask if they got injections, infusions, or any other skin-piercing procedure in the previous 21 days; such procedures are also recognized risks. Then trace contacts and visit and investigate reported health care settings.
If more than a few people with new infections report no contacts with other cases and no skin-piercing procedures, that is cause for concern and, more critically, further investigation. Such unexplained cases could be showing the virus is transmitting in unexpected ways.
John Potterat has been a practitioner and advocate of contract tracing and partner notification as a public health tool to understand and control the spread of infectious diseases. In a recent article on partner notification for HIV in Africa, written before the explosion of West Africa’s Ebola outbreak, Potterat presciently recommends the skills required to diagnose what has allowed that outbreak to grow: “Nurturing public health investigatory (and people and community rela¬tions) skills that one can acquire by conducting PN [partner notification] would be of great service anywhere that new communicable infections or public health emergencies are likely to emerge” (http://www.la-press.com/perspective-on-providing-partner-notification-services-for-hiv-in-sub–article-a4370-abstract).
Telling people what is happening
This second step to answer the question in the title is not automatic. Based on reports from previous Ebola outbreaks, patient-to-patient transmission in health care settings – eg, through injections with contaminated syringes and needles – contributes to expanding outbreaks. Considering the persistent expansion of the ongoing Ebola outbreak in West Africa, it is probable that patient-to-patient transmission plays an important part. If anyone has such information, they have not disclosed it.
In Africa, it has been common practice for ministries of health – encouraged by health aid managers – not to disclose evidence that patients have gotten blood-borne infections such as HIV from unsterile health care procedures. Not warning the public is excused by the assertion that warning might cause more harm than it would prevent: the infections prevented would be outweighed by disease and death due to patients avoiding health care.
Such body count calculations ignore doctors’ ethical obligations. The World Medical Association’s Declaration of Lisbon on the Rights of the Patient avers: “1d. Quality assurance should always be a part of health care… 9. Every person has the right to health education that will assist him/her in making informed choices about…the available health services…” (see: http://www.wma.net/en/30publications/10policies/l4/).
Furthermore, the assertion is based on a misleading mention of only two options – no health care vs. unsafe care. But there is a third option – safe care. Getting to the third option is not, primarily, a matter of money. It costs little or nothing to avoid unnecessary invasive procedures, shift to oral medication, boil instruments, or use plastic disposables. What is lacking is public awareness – lacking due to misinformation by ministries of health and health aid managers.
If ministry officials and/or health aid managers have evidence that people have gotten Ebola infections from health care procedures and settings during the current outbreak, will they tell the public?
Will concern to stop West Africa’s outbreak over-ride public health managers’ unwillingness to warn the public about risks in health care settings? Will the world public’s interest to know if the virus is changing over-ride health aid managers’ unwillingness to acknowledge the contribution of unsafe health care to the current outbreak?