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CDC: Ebola Characterized by ‘Amplification in Health Care Settings’

When Peter Piot, the ‘Virus Detective Who Discovered Ebola‘, went to one of the first identified outbreaks in 1976 in the Democratic Republic of Congo, he reported that “it was clear that the outbreak was closely related to areas served by the local hospital”.

Piot says: “The team found that more women than men caught the disease and particularly women between 18 and 30 years old – it turned out that many of the women in this age group were pregnant and many had attended an antenatal clinic at the hospital.”

He goes on: “The team then discovered that the women who attended the antenatal clinic all received a routine injection. Each morning, just five syringes would be distributed, the needles would be reused and so the virus was spread between the patients.”

What he has to say about people getting ill after attending funerals is repeated in contemporary reports on ebola in West Africa, ad nauseam. But the comments about visits to the hospital, women attending antenatal care and reuse of syringes (and possibly other medical instruments) are no longer mentioned so much.

The CDC does write that ebola “has been characterized by amplification in health care settings and increased risk for health care workers (HCWs), who often do not have access to appropriate personal protective equipment“, but they are not as expansive as Piot about exactly what that means on the ground.

There was a whole rash of recent reports about women being more likely to be infected with ebola than men in the current outbreak and a rather narrow set of speculative explanations about why this might be so, one being that women are more likely to be involved in giving care than men.

While women may well more often be the ‘caregivers’, an article in the New England Journal of Medicine summarizes available data on every reported case. However, it finds that there is very little difference in the numbers of men and women infected, and even the number of men who die from ebola.

There are also far fewer children infected than adults, despite claims that ‘women and children’ are more likely to be infected than men.

As far as I can see, media speculation into why women may be more likely to be infected than men (because they may have been more likely in some instances) did not question the possibility that women are often more likely to access healthcare, especially when pregnant.

Piot makes this connection during the first investigated ebola epidemic and goes on to connect women’s elevated risk with the use of unsterile syringes, not just casual contact in healthcare facilities.

It is to be hoped that clinics are no longer issued with five syringes a day, though clear data about supplies of syringes and needles is hard to come by. But what about other infection control equipment and supplies; especially equipment and supplies in facilities that are experiencing extreme shortages?

What about facilities that are understaffed, where an adequate number of workers may be able to take certain precautions to protect themselves and their patients, but an inadequate number may only be able to think about their own safety, or not even that?

In the case of HIV there are many reasons why a woman might be more likely to be infected through unsafe healthcare. They are expected to attend antenatal care during pregnancy, give birth in a health facility, attend post-natal care, and perhaps several other reasons.

But since western countries, especially the US, have started taking an interest in ebola, they have reinforced efforts to round up people who look in the least bit like they have a fever and sticking them in an already overcrowded health facility, where conditions are appalling.

So if women were more likely to be infected with ebola earlier on in the current epidemic, and in some of the earlier outbreaks in other parts of Africa, perhaps the current approach is influencing the gender balance somewhat. One result possibly being that men are no longer less likely than women to go to a health facility (especially if they are given no option).

Piot says: “The closure of the hospital, the use of quarantine and making sure the community had all the necessary information eventually brought an end to the epidemic – but nearly 300 people died.” Most people were quarantined in their own homes, not in an overcrowded and filthy ward.

How things have changed. Far from trying to persuade people to stay in their homes and supporting family members to look after them, US soldiers are helping to send people to what could be the very epicenter of the epidemic.

There are now far more confirmed and suspected ebola cases than there is hospital capacity to care for them. So a strategy that aims to strengthen and make hospitals safer, in combination with strengthening communities to care for people at home might now be the only option left.

HIV in Namibia: What You Don’t Seek, You Won’t Find

There was no mention of HIV in Namibia’s 1992 Demographic and Health Survey and AIDS was only mentioned in passing. HIV prevalence had more than doubled since 1990, from 1.2% to 2.6%. But by 2000, when their second DHS was carried out, prevalence is estimated to have reached 14%, five times higher in less than a decade. So what areas of HIV had Namibia addressed during this time? The following table is from the 2000 DHS (p155, Table 11.1) :

Ways to avoid HIV/AIDS Women Men
Does not know AIDS or if it can be avoided 7.9 4.0
Believes no way to avoid 4.0 2.3
Does not know specific way 0.3 0.0
Abstain from sex 34.7 40.5
Use condoms 80.9 87.0
Have only one sexual partner 31.0 28.5
Avoid multiple partners 7.4 10.5
Avoid sex with prostitutes 1.0 3.3
Avoid sex with persons who have many partners 1.6 2.5
Avoid sex with homosexuals 0.2 0.3
Avoid blood transfusions 1.3 1.0
Avoid injections 0.8 0.6
Avoid sex with IV drug users 0.6 0.5
Avoid sharing razors/blades 2.2 2.6
Other including avoiding kissing/mosquito bites/traditional healer 1.8 1.6
Total 6,755 2,954

Aside from over 80% of people knowing about using condoms against HIV, which is good, knowledge about other ways of avoiding infection, even sexually transmitted HIV, ranges from poor to negligible. But the fact that less than 1% of people know that unsafe injections can transmit HIV is extremely worrying, considering risks from unsafe injections was well known at this time. More people are aware of the risk of transmission from razor blades than the risk of blood transfusions.

Even Jacques Pepin, who strenuously denies a significant role for unsafe healthcare in high HIV prevalence African countries, admits that 5% of HIV may have been transmitted via these routes globally in 2000, which means the contribution must have been far higher in countries with low safety standards and high HIV transmission rates, such as Namibia. Strangely, Pepin claims that safety in health facilities has improved so much in the ten years from 2000 to 2010 that “unsafe injections caused between 16,939 and 33,877 HIV infections” globally in 2010.

It is not very clear where Pepin got all his figures to carry out this estimate but there were an estimated 1.6m new HIV infections in sub-Saharan Africa in 2012 (compared to 2.6m in 2001). Does it seem credible that something in the region of 1.5% of all new infections globally (33,877 as a percentage of 2.3m new infections in UNAIDS’ 2013 Global Report), at the most, were transmitted through unsafe injections? It sounds like Pepin was trying to find a figure that concurs with UNAIDS’ Modes of Transmission Analyses, which have been claiming that the contribution of unsafe injections in African countries has been at that very low level since they started carrying out these analyses.

The Modes of Transmission model is so flawed that it overestimates heterosexual HIV transmission by several hundred percent, leaving the majority of transmissions unexplained. Therefore, their minute figure for transmission through reused syringes and other forms of unsafe healthcare could not possibly be correct, and seems to have been arrived at by overestimating heterosexual transmission and then claiming that only the remaining infections, a very small percentage, could be a result of unsafe healthcare.

Neither Pepin nor UNAIDS appear to have bothered investigating conditions in health facilities, possible outbreaks of healthcare transmitted HIV, infections among people who have never had sex, infections among people who only engage in ‘safe’ sex, infections in mothers who may have been infected by their infants and infections in infants whose mothers are HIV negative. If Pepin comes up with the same sort of figure as UNAIDS then his model is likely to be as flawed as theirs.

Namibia’s 2006-07 DHS finds that knowledge about ‘unsafe’ sex is high but this has had little impact on sexual behavior, nor on HIV transmission. So, no surprise there. The report blandly states that “HIV is transmitted among adults primarily through heterosexual contact between an infected partner and a non-infected partner” (which is what all DHS reports say, along with UNAIDS and other international institutions).

Report after report comes out on ‘knowledge, attitude and practices’ (KAP) from high prevalence country after country, and various well funded national and international institutions never seem to wonder if reducing HIV transmission is not merely about how much people know about sex, their attitudes towards sexual transmission and their sexual practices. For how long can this go on?

There’s a small amount of data in the 2006-07 DHS about whether people had medical injections and whether they remember if the person administering the injection saw the injecting equipment being taken out of a new packet, but there are no corresponding figures for HIV prevalence in relation to receipt of medical injections. It is concluded that most public and private facilities, at least 90%, practice safe injections, but that the lowest level of safe injections was found for women attending some types of private facility, at 49%; not so reassuring.

Figures for the next DHS (2013) are not yet available, but from the list of data being collected there doesn’t seem to be any new attention paid to non-sexual transmission of HIV, especially through injecting equipment reuse and other forms of unsafe healthcare. If you don’t investigate, you don’t need to deny finding the incriminating figures. This has worked for UNAIDS, but not for Namibia, or for any other country with serious HIV epidemics.

[For more about HIV from unsafe healthcare, visit our Healthcare Risks for HIV pages.]