EDITORIAL COMMENTARY
Fighting Ebola and Advancing Knowledge on the Front Lines in a Capital City Emil P. Lesho Walter Reed Army Institute of Research, Silver Spring, Maryland
(See the Brief Report by Barry et al on pages 1821–4.)
Keywords.
Ebola; relief mission; humanitarian response; predictors.
—Theodore Roosevelt Critics might dismiss the report by Barry and colleagues from Guinea, in this issue of Clinical Infectious Diseases [1]. Nonspecific terminology, such as “difficulty breathing” and “hemorrhage,” dampen enthusiasm, as do the unknown time to presentation, duration of each symptom, lengths of stay, and treatment details. However, we need to keep in mind several things when appraising this work: (1) the setting, (2) the number of patients, (3) the usefulness of the findings, and (4) the wisdom of indigenous healthcare workers and collaborative engagement. Barry et al provide clinical predictors of death in patients with Ebola virus disease (EVD) from the world’s first EVD outbreak in Received 27 February 2015; accepted 3 March 2015; electronically published 13 March 2015. Correspondence: Emil P. Lesho, DO, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD 20910 ([email protected]). Clinical Infectious Diseases® 2015;60(12):1825–7 Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US. DOI: 10.1093/cid/civ204
a major metropolitan area, Conakry, the capital of Guinea [1]. This is commendable for several reasons, not the least of which was the environment. Second, opportunities for longitudinal observation of patients with EVD, however brief, in resource-constrained outbreak settings have been rare [2, 3]. Third, all of the fatalities were laboratory-confirmed EVD, making it one of the largest cohorts reported. Finally, their findings can inform rapid triage protocols in the event that an overwhelming outbreak occurs. SETTING: “UNIMAGINABLE” Caring for patients with EVD and conducting research presents enormous challenges in well-resourced settings, and in the ultraspecialized, high-level containment centers (HLCCs) with the full panoply of biosafety level 4–type features and sophisticated engineering controls [4, 5]. In unstable or severely resource-constrained environments, those difficulties were recently described as “unimaginable” [6]. Disposable needles and lancets, gloves and other protective equipment, refrigeration, electricity, and potable water are often unavailable [2, 6– 8]. A medical record (both individual and composite) or a study database is a blackboard or a marble-covered composition notebook. A relational database is 2 composition notebooks.
Previous Ebola outbreaks were confined to remote or rural areas. Conakry is an Atlantic port city on the tip of the Kaloum Peninsula, and is the logistical, financial, and cultural center of Guinea, containing approximately one-fourth of Guinea’s 2 million inhabitants. The United Nations lists Guinea as one of the poorest countries in the world. Much of the city’s healthcare infrastructure remains badly degraded from the history of civil war, political instability, limited human and financial resources, and organizational defects [9]. Serious security incidents—which hamper response efforts and increase the risk of transmission—are increasingly reported (an average of 10 per month over the last year) in several of Guinea’s districts, including Conakry [10]. Thirteen districts reported at least 1 such incident in early February, 2015, and 58 people were convicted for attacking government and nongovernmental healthcare workers, destroying public buildings, and making threats [10]. NUMBERS: SECOND LARGEST Those managing EVD patients in North America or Europe will most likely not care for more than a few patients, and will witness even fewer EVD-related deaths (Table 1) [11, 12]. In contrast, Barry et al attended to nearly 100 laboratory-confirmed cases and deaths. No doubt they took care
EDITORIAL COMMENTARY
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CID 2015:60 (15 June)
•
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Downloaded from http://cid.oxfordjournals.org/ at University of Connecticut on May 31, 2015
It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood.
Table 1. Ebola Statistics as of 20 February 2015 Statistic Total No. (laboratory confirmed) United States United Kingdom Guinea No. of EVD-designated centers in US network (No. of beds) No. of DOD-built ETUs transferred to USAID in West Africa No. of HLCCs in the United States
All Cases
Deaths
23 467 (14 186)
9471 (4781)
4 (4) 1 (1)
1 (1) 0 (0)
3131 (2741)
2067 (1689)
51 (72) 10 4
Metric tons of USAID-donated PPE, infrared thermometers, chlorine, plastic sheeting Sets of PPE provided by USAID to Liberia
400 1.4 million
Abbreviations: DOD, Department of Defense; ETU, Ebola treatment unit; EVD, Ebola virus disease; HLCC, high-level containment center; PPE, personal protective equipment; USAID, US Agency for International Development.
USEFULNESS: RAPID, LABORATORY-FREE TRIAGE DURING AN OVERWHELMING OUTBREAK More outbreaks will occur. In addition to being the largest and first urban outbreak, the 2014 outbreak will also be notable for creating a more permissive environment for maternofetal complications, malaria, and antimicrobial resistance [16, 17]. Some experts believe that the 2014 outbreak portends something worse [13, 16, 18]. Rapid, laboratory-free methods for triaging patients (based on symptoms),
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similar to that used by the military for mass casualty situations, could be vital if or when a more devastating outbreak occurs. Here Barry et al’s data can be helpful. For example, patients with difficulty breathing (Barry et al) [1] or tachypnea (Bwaka et al) [15] would triage to the “immediate” category. (This group requires attention within minutes to 2 hours on arrival to avoid death). Patients with severe myalgia would also triage to “immediate” based on Barry et al’s findings. However, based on Bwaka et al’s findings, myalgia would triage to “delayed,” because myalgia was statistically associated with survival in that study. The delayed group requires extensive care, but their general condition permits a delay in treatment without unduly endangering life. In the WHO report, patients with muscle pain, difficulty breathing, and unexplained hemorrhage were 1.24, 1.68, and 1.83 times as likely to die, respectively. (However, no statistical analyses are provided, so it is not known if those odds ratios are truly significant.) Finally, using Barry et al’s findings, a patient with bleeding (other than melanic gastrointestinal) would be triaged to the “expectant” category. (This group has injuries that overwhelm current medical resources at the expense of treating salvageable patients. These patients are not abandoned; rather separated from the view of other casualties, intermittently reassessed, and given comfort care.)
EDITORIAL COMMENTARY
In a crisis, external aid agents and healthcare providers sometimes tend to rush in with a “step aside” approach. Given the recent criticism about the perceived delay of the outside response to the 2014 outbreak, this tendency could escalate. However, this is suboptimal and often counterproductive [10, 19–21]. The challenge is how to promptly gain trust and provide beneficial and sustainable humanitarian assistance without undermining the legitimacy of the local healthcare teams or fostering resentment among ethnic groups or political factions [10, 19–21]. Arguably, it might be better “to proceed with unhurried haste,” an approach employed by alpinists to cover greater distances and heights in less time, while avoiding accidents and delays, using deliberate, measured, and sustained motion. Deliberately seek out and repeatedly engage local providers to collaboratively plan and execute medical humanitarian assistance. If possible, external agents should remain in the background [13, 19]. This increases transparency and gains community buy-in and trust. Indigenous providers know the cultural nuances or ramifications of certain actions, which, if not considered, result in misperceptions, misunderstandings, delays, and failure [7, 14, 15, 19, 20]. In fact, the difficulties of medical waste management were presciently described by local healthcare workers during a response to a Uganda outbreak in 2000 [14]. Fourteen years later, similar issues challenged clinicians and complicated the care of a patient in 2014 in one of the highly resourced HLCCs in the United States [22]. LOOKING FORWARD BY LOOKING BACK: COLLABORATIVE SYNERGY AND PRIOR KNOWLEDGE Perhaps synergy can be achieved by combining the wisdom and art of local providers
Downloaded from http://cid.oxfordjournals.org/ at University of Connecticut on May 31, 2015
of many more who did not meet inclusion criteria for this study. Except for a recent World Health Organization (WHO) report [13], I could not find a report with more confirmed EVD fatalities than that of Barry et al. The 2000 Uganda report is larger (195 confirmed fatalities), but that involved a different Ebola strain (Sudan ebolavirus) [14]. The 1995 Congo report ranks third, involving 63 [15]. Granted, the WHO report [13] is larger, but investigators did not distinguish between probable and confirmed EVD cases. This confounds attributable mortality given the coexistence of malaria, typhoid fever, bloody dysentery, meningococcal sepsis, and other viral hemorrhagic fevers, all of which can present with clinical manifestations similar to EVD [8].
UNHURRIED HASTE, COLLABORATIVE ENGAGEMENT, AND LOCAL WISDOM
2. 3.
4.
5.
6.
7.
8.
9.
10.
11.
Notes Acknowledgments. The author thanks David B. Goldman for review of the manuscript. Disclaimer. The views expressed herein are solely those of the author, not to be construed as official or representing those of the Walter Reed Army Institute of Research, the Department of the Army, or the Department of Defense. Potential conflict of interest. Author certifies no potential conflicts of interest. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
12.
13.
14.
References 1. Barry M, Touré A, Traoré FA, et al. Clinical predictors of mortality in patients with
15.
Ebola virus disease. Clin Infect Dis 2015; 60:1821–4. Feldmann H, Geisbert T. Ebola haemorrhagic fever. Lancet 2011; 377:849–62. Kortepeter MG, Bausch DG, Bray M. Basic clinical and laboratory features of filoviral hemorrhagic fever. J Infect Dis 2011; 204: S810–6. Kortepeter MG, Smith PW, Hewlett A, Cieslak TJ. Caring for patients with Ebola: a challenge in any care facility. Ann Intern Med 2015; 162:68–9. Tosh P, Sampthkumar P. What clinicians should know about the 2014 Ebola outbreak. Mayo Clin Proc 2014; 89:1710–7. Butler YS. Ebola virus: exposing the inadequacies of public health in Liberia. Mayo Clin Proc 2014; 89:1596–8. Lesho E, Okito E, Mann K, McCullough M, Hesse E. Collaborative medical engagement and needs assessment in the Democratic Republic of the Congo: a preliminary report from Muanda. Am J Trop Med Hyg 2014; 90:774–6. Muyembe-Tamfum JJ, Kipasa M, Kiyungu C, Colebunders R. Ebola outbreak in Kikwit, Democratic Republic of the Congo: discovery and control measures. J Infect Dis 1999; 179: S259–62. The United Nations Development Program. Assessing the socio-economic impacts of Ebola Virus Disease in Guinea, Liberia and Sierra Leone - The Road to Recovery. Available at: http://www.africa.undp.org/content/ dam/rba/docs/Reports/EVD%20Synthesis% 20Report%2023Dec2014.pdf. Accessed 20 March 2015. Farge E. Red Cross Ebola teams in Guinea attacked 10 times per month. Available at: http://www.reuters.com/article/2015/02/ 12/us-health-ebola-guinea-idUSKBN0LG1G O20150212. Accessed 27 February 2015. The White House, Office of the Press Secretary. Fact sheet: progress in our Ebola response at home and abroad. Available at: http://www.whitehouse.gov/the-press-office/ 2015/02/11/fact-sheet-progress-our-ebolaresponse-home-and-abroad. Accessed 27 February 2015. Armed Forces Health Surveillance Center, Division of Integrated Biosurveillance. Surveillance Summaries. Available at: https:// www.afhsc.mil/reports/DIB. Accessed 27 February 2015. World Health Organization Ebola Response Team. Ebola virus disease in West Africa— the first 9 months of the epidemic and forward projections. N Engl J Med 2014; 371: 1481–95. Okware SI, Omaswa FG, Zaramba S, et al. An outbreak of Ebola in Uganda. Trop Med Int Health 2002; 7:1068–75. Bwaka MA, Bonnet MJ, Calain P, et al. Ebola hemorrhagic fever in Kikwit, Democratic
16.
17.
18.
19.
20.
21. 22.
23.
24.
25.
26.
27.
28.
29.
Republic of the Congo: clinical observations in 103 patients. J Infect Dis 1999; 179:S1–7. Farrar J. Ideas, research, policy, practice, impact: 21st century. Special Plenary Session: resource-limited health care issues. In: IDWeek 2014, Philadelphia, PA, 8 October 2014. Lesho E. US Ebola case: an example of the misuse of antibiotics and a reminder for better stewardship. Mayo Clin Proc 2015; 90:161. Levin MM, Tapia M, Hill AV, Sow SO. How the current West African Ebola virus disease epidemic is altering views on the need for vaccines and is galvanizing a global effort to field-test leading candidate vaccines. J Infect Dis 2015; 211:504–7. Lesho EP, Jawad NK, Hameed HM. Towards a better approach to medical humanitarian assistance in Iraq and future counter insurgency operations. Mil Med 2011; 176:1–3. Lesho E. Prospective data, experience, and lessons learned at a surgically augmented brigade medical company (level II+) during the 2007 Iraq surge. Mil Med 2011; 176:763–8. Lesho E. Planning a medical relief mission. J Am Osteopath Assoc 1995; 95:37–44. Ribner B. Treating patients with Ebola virus infections in the U.S.: lessons learned. Special Plenary Session: resource-limited health care issues. In: IDWeek 2014, Philadelphia, PA, 8 October 2014. Hutchinson KL, Rollin PE. Cytokine and chemokine expression in humans infected with Sudan ebola virus. J Infect Dis 2007; 196:S357–63. Ockenhouse CF, Bernstein WB, Wang Z, Vahey MT. Functional genomic relationships in HIV-1 disease revealed by gene-expression profiling of primary human peripheral blood mononuclear cells. J Infect Dis 2005; 191: 2064–74. Ockenhouse CF, Hu WC, Kester KE, et al. Common and divergent immune response signaling pathways discovered in peripheral blood mononuclear cell gene expression patterns in presymptomatic and clinically apparent malaria. Infect Immun 2006; 74: 5561–73. Lesho E, Forestiero FJ, Hirata MH, et al. Transcriptional responses of host peripheral blood cells to tuberculosis infection. Tuberculosis 2011; 91:390–9. Kortepeter MG, Lawler JV, Honko A, et al. Real-time monitoring of cardiovascular function in rhesus macaques infected with Zaire ebolavirus. J Infect Dis 2011; 204:S1000–10. Nkoghe D, Kone ML, Yada A, Leroy E. A limited outbreak of Ebola haemorrhagic fever in Etoumbi, Republic of Congo, 2005. Trans R Soc Trop Med Hyg 2011; 105:466–72. Lesho E, Braun L, Coots N, Ozguc O, Ciobanu M, Fitzpatrick L. Disease prevalence among Moldovan orphans and other considerations for future humanitarian aid. Clin Pediat 2002; 41:235–7.
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with cutting-edge technology. For example, if serum from this and other EVD cohorts were banked in a repository, akin to the Department of Defense’s serum repository, it could be used in comparative genomic or proteomic studies of host response to generate outcome predictors, similar to what has been done for S. ebolavirus, human immunodeficiency virus, malaria, and tuberculosis [23–26]. Single molecule real-time sequencing could be applied to viral DNA samples for high-resolution outbreak investigations and forensic attribution. Implanted multisensory telemetry devices, permitting real-time monitoring of physiologic parameters, could alleviate the need for repeated contact or blood draws [27]. Wise alpinists know that summiting is only half of the problem; that greater challenges and dangers often accompany the descent. To mitigate those risks, they look ahead by looking back—for changing route and weather conditions; for an opposite, but crucial perspective; and for the lessonsofothers. Manyof the challenges facing today’s Ebola fighters (and other relief efforts), such as the importance of coordination, waste management, and community engagement, have been well described, some more than a decade ago [7, 8, 14, 15, 21, 28, 29]. The 2014 outbreak will likely remain a focal point for years to come.
Fighting Ebola and Advancing Knowledge on the Front Lines in a Capital City Emil P. Lesho Walter Reed Army Institute of Research, Silver Spring, Maryland
(See the Brief Report by Barry et al on pages 1821–4.)
Keywords.
Ebola; relief mission; humanitarian response; predictors.
—Theodore Roosevelt Critics might dismiss the report by Barry and colleagues from Guinea, in this issue of Clinical Infectious Diseases [1]. Nonspecific terminology, such as “difficulty breathing” and “hemorrhage,” dampen enthusiasm, as do the unknown time to presentation, duration of each symptom, lengths of stay, and treatment details. However, we need to keep in mind several things when appraising this work: (1) the setting, (2) the number of patients, (3) the usefulness of the findings, and (4) the wisdom of indigenous healthcare workers and collaborative engagement. Barry et al provide clinical predictors of death in patients with Ebola virus disease (EVD) from the world’s first EVD outbreak in Received 27 February 2015; accepted 3 March 2015; electronically published 13 March 2015. Correspondence: Emil P. Lesho, DO, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD 20910 ([email protected]). Clinical Infectious Diseases® 2015;60(12):1825–7 Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US. DOI: 10.1093/cid/civ204
a major metropolitan area, Conakry, the capital of Guinea [1]. This is commendable for several reasons, not the least of which was the environment. Second, opportunities for longitudinal observation of patients with EVD, however brief, in resource-constrained outbreak settings have been rare [2, 3]. Third, all of the fatalities were laboratory-confirmed EVD, making it one of the largest cohorts reported. Finally, their findings can inform rapid triage protocols in the event that an overwhelming outbreak occurs. SETTING: “UNIMAGINABLE” Caring for patients with EVD and conducting research presents enormous challenges in well-resourced settings, and in the ultraspecialized, high-level containment centers (HLCCs) with the full panoply of biosafety level 4–type features and sophisticated engineering controls [4, 5]. In unstable or severely resource-constrained environments, those difficulties were recently described as “unimaginable” [6]. Disposable needles and lancets, gloves and other protective equipment, refrigeration, electricity, and potable water are often unavailable [2, 6– 8]. A medical record (both individual and composite) or a study database is a blackboard or a marble-covered composition notebook. A relational database is 2 composition notebooks.
Previous Ebola outbreaks were confined to remote or rural areas. Conakry is an Atlantic port city on the tip of the Kaloum Peninsula, and is the logistical, financial, and cultural center of Guinea, containing approximately one-fourth of Guinea’s 2 million inhabitants. The United Nations lists Guinea as one of the poorest countries in the world. Much of the city’s healthcare infrastructure remains badly degraded from the history of civil war, political instability, limited human and financial resources, and organizational defects [9]. Serious security incidents—which hamper response efforts and increase the risk of transmission—are increasingly reported (an average of 10 per month over the last year) in several of Guinea’s districts, including Conakry [10]. Thirteen districts reported at least 1 such incident in early February, 2015, and 58 people were convicted for attacking government and nongovernmental healthcare workers, destroying public buildings, and making threats [10]. NUMBERS: SECOND LARGEST Those managing EVD patients in North America or Europe will most likely not care for more than a few patients, and will witness even fewer EVD-related deaths (Table 1) [11, 12]. In contrast, Barry et al attended to nearly 100 laboratory-confirmed cases and deaths. No doubt they took care
EDITORIAL COMMENTARY
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CID 2015:60 (15 June)
•
1825
Downloaded from http://cid.oxfordjournals.org/ at University of Connecticut on May 31, 2015
It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood.
Table 1. Ebola Statistics as of 20 February 2015 Statistic Total No. (laboratory confirmed) United States United Kingdom Guinea No. of EVD-designated centers in US network (No. of beds) No. of DOD-built ETUs transferred to USAID in West Africa No. of HLCCs in the United States
All Cases
Deaths
23 467 (14 186)
9471 (4781)
4 (4) 1 (1)
1 (1) 0 (0)
3131 (2741)
2067 (1689)
51 (72) 10 4
Metric tons of USAID-donated PPE, infrared thermometers, chlorine, plastic sheeting Sets of PPE provided by USAID to Liberia
400 1.4 million
Abbreviations: DOD, Department of Defense; ETU, Ebola treatment unit; EVD, Ebola virus disease; HLCC, high-level containment center; PPE, personal protective equipment; USAID, US Agency for International Development.
USEFULNESS: RAPID, LABORATORY-FREE TRIAGE DURING AN OVERWHELMING OUTBREAK More outbreaks will occur. In addition to being the largest and first urban outbreak, the 2014 outbreak will also be notable for creating a more permissive environment for maternofetal complications, malaria, and antimicrobial resistance [16, 17]. Some experts believe that the 2014 outbreak portends something worse [13, 16, 18]. Rapid, laboratory-free methods for triaging patients (based on symptoms),
1826
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similar to that used by the military for mass casualty situations, could be vital if or when a more devastating outbreak occurs. Here Barry et al’s data can be helpful. For example, patients with difficulty breathing (Barry et al) [1] or tachypnea (Bwaka et al) [15] would triage to the “immediate” category. (This group requires attention within minutes to 2 hours on arrival to avoid death). Patients with severe myalgia would also triage to “immediate” based on Barry et al’s findings. However, based on Bwaka et al’s findings, myalgia would triage to “delayed,” because myalgia was statistically associated with survival in that study. The delayed group requires extensive care, but their general condition permits a delay in treatment without unduly endangering life. In the WHO report, patients with muscle pain, difficulty breathing, and unexplained hemorrhage were 1.24, 1.68, and 1.83 times as likely to die, respectively. (However, no statistical analyses are provided, so it is not known if those odds ratios are truly significant.) Finally, using Barry et al’s findings, a patient with bleeding (other than melanic gastrointestinal) would be triaged to the “expectant” category. (This group has injuries that overwhelm current medical resources at the expense of treating salvageable patients. These patients are not abandoned; rather separated from the view of other casualties, intermittently reassessed, and given comfort care.)
EDITORIAL COMMENTARY
In a crisis, external aid agents and healthcare providers sometimes tend to rush in with a “step aside” approach. Given the recent criticism about the perceived delay of the outside response to the 2014 outbreak, this tendency could escalate. However, this is suboptimal and often counterproductive [10, 19–21]. The challenge is how to promptly gain trust and provide beneficial and sustainable humanitarian assistance without undermining the legitimacy of the local healthcare teams or fostering resentment among ethnic groups or political factions [10, 19–21]. Arguably, it might be better “to proceed with unhurried haste,” an approach employed by alpinists to cover greater distances and heights in less time, while avoiding accidents and delays, using deliberate, measured, and sustained motion. Deliberately seek out and repeatedly engage local providers to collaboratively plan and execute medical humanitarian assistance. If possible, external agents should remain in the background [13, 19]. This increases transparency and gains community buy-in and trust. Indigenous providers know the cultural nuances or ramifications of certain actions, which, if not considered, result in misperceptions, misunderstandings, delays, and failure [7, 14, 15, 19, 20]. In fact, the difficulties of medical waste management were presciently described by local healthcare workers during a response to a Uganda outbreak in 2000 [14]. Fourteen years later, similar issues challenged clinicians and complicated the care of a patient in 2014 in one of the highly resourced HLCCs in the United States [22]. LOOKING FORWARD BY LOOKING BACK: COLLABORATIVE SYNERGY AND PRIOR KNOWLEDGE Perhaps synergy can be achieved by combining the wisdom and art of local providers
Downloaded from http://cid.oxfordjournals.org/ at University of Connecticut on May 31, 2015
of many more who did not meet inclusion criteria for this study. Except for a recent World Health Organization (WHO) report [13], I could not find a report with more confirmed EVD fatalities than that of Barry et al. The 2000 Uganda report is larger (195 confirmed fatalities), but that involved a different Ebola strain (Sudan ebolavirus) [14]. The 1995 Congo report ranks third, involving 63 [15]. Granted, the WHO report [13] is larger, but investigators did not distinguish between probable and confirmed EVD cases. This confounds attributable mortality given the coexistence of malaria, typhoid fever, bloody dysentery, meningococcal sepsis, and other viral hemorrhagic fevers, all of which can present with clinical manifestations similar to EVD [8].
UNHURRIED HASTE, COLLABORATIVE ENGAGEMENT, AND LOCAL WISDOM
2. 3.
4.
5.
6.
7.
8.
9.
10.
11.
Notes Acknowledgments. The author thanks David B. Goldman for review of the manuscript. Disclaimer. The views expressed herein are solely those of the author, not to be construed as official or representing those of the Walter Reed Army Institute of Research, the Department of the Army, or the Department of Defense. Potential conflict of interest. Author certifies no potential conflicts of interest. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
12.
13.
14.
References 1. Barry M, Touré A, Traoré FA, et al. Clinical predictors of mortality in patients with
15.
Ebola virus disease. Clin Infect Dis 2015; 60:1821–4. Feldmann H, Geisbert T. Ebola haemorrhagic fever. Lancet 2011; 377:849–62. Kortepeter MG, Bausch DG, Bray M. Basic clinical and laboratory features of filoviral hemorrhagic fever. J Infect Dis 2011; 204: S810–6. Kortepeter MG, Smith PW, Hewlett A, Cieslak TJ. Caring for patients with Ebola: a challenge in any care facility. Ann Intern Med 2015; 162:68–9. Tosh P, Sampthkumar P. What clinicians should know about the 2014 Ebola outbreak. Mayo Clin Proc 2014; 89:1710–7. Butler YS. Ebola virus: exposing the inadequacies of public health in Liberia. Mayo Clin Proc 2014; 89:1596–8. Lesho E, Okito E, Mann K, McCullough M, Hesse E. Collaborative medical engagement and needs assessment in the Democratic Republic of the Congo: a preliminary report from Muanda. Am J Trop Med Hyg 2014; 90:774–6. Muyembe-Tamfum JJ, Kipasa M, Kiyungu C, Colebunders R. Ebola outbreak in Kikwit, Democratic Republic of the Congo: discovery and control measures. J Infect Dis 1999; 179: S259–62. The United Nations Development Program. Assessing the socio-economic impacts of Ebola Virus Disease in Guinea, Liberia and Sierra Leone - The Road to Recovery. Available at: http://www.africa.undp.org/content/ dam/rba/docs/Reports/EVD%20Synthesis% 20Report%2023Dec2014.pdf. Accessed 20 March 2015. Farge E. Red Cross Ebola teams in Guinea attacked 10 times per month. Available at: http://www.reuters.com/article/2015/02/ 12/us-health-ebola-guinea-idUSKBN0LG1G O20150212. Accessed 27 February 2015. The White House, Office of the Press Secretary. Fact sheet: progress in our Ebola response at home and abroad. Available at: http://www.whitehouse.gov/the-press-office/ 2015/02/11/fact-sheet-progress-our-ebolaresponse-home-and-abroad. Accessed 27 February 2015. Armed Forces Health Surveillance Center, Division of Integrated Biosurveillance. Surveillance Summaries. Available at: https:// www.afhsc.mil/reports/DIB. Accessed 27 February 2015. World Health Organization Ebola Response Team. Ebola virus disease in West Africa— the first 9 months of the epidemic and forward projections. N Engl J Med 2014; 371: 1481–95. Okware SI, Omaswa FG, Zaramba S, et al. An outbreak of Ebola in Uganda. Trop Med Int Health 2002; 7:1068–75. Bwaka MA, Bonnet MJ, Calain P, et al. Ebola hemorrhagic fever in Kikwit, Democratic
16.
17.
18.
19.
20.
21. 22.
23.
24.
25.
26.
27.
28.
29.
Republic of the Congo: clinical observations in 103 patients. J Infect Dis 1999; 179:S1–7. Farrar J. Ideas, research, policy, practice, impact: 21st century. Special Plenary Session: resource-limited health care issues. In: IDWeek 2014, Philadelphia, PA, 8 October 2014. Lesho E. US Ebola case: an example of the misuse of antibiotics and a reminder for better stewardship. Mayo Clin Proc 2015; 90:161. Levin MM, Tapia M, Hill AV, Sow SO. How the current West African Ebola virus disease epidemic is altering views on the need for vaccines and is galvanizing a global effort to field-test leading candidate vaccines. J Infect Dis 2015; 211:504–7. Lesho EP, Jawad NK, Hameed HM. Towards a better approach to medical humanitarian assistance in Iraq and future counter insurgency operations. Mil Med 2011; 176:1–3. Lesho E. Prospective data, experience, and lessons learned at a surgically augmented brigade medical company (level II+) during the 2007 Iraq surge. Mil Med 2011; 176:763–8. Lesho E. Planning a medical relief mission. J Am Osteopath Assoc 1995; 95:37–44. Ribner B. Treating patients with Ebola virus infections in the U.S.: lessons learned. Special Plenary Session: resource-limited health care issues. In: IDWeek 2014, Philadelphia, PA, 8 October 2014. Hutchinson KL, Rollin PE. Cytokine and chemokine expression in humans infected with Sudan ebola virus. J Infect Dis 2007; 196:S357–63. Ockenhouse CF, Bernstein WB, Wang Z, Vahey MT. Functional genomic relationships in HIV-1 disease revealed by gene-expression profiling of primary human peripheral blood mononuclear cells. J Infect Dis 2005; 191: 2064–74. Ockenhouse CF, Hu WC, Kester KE, et al. Common and divergent immune response signaling pathways discovered in peripheral blood mononuclear cell gene expression patterns in presymptomatic and clinically apparent malaria. Infect Immun 2006; 74: 5561–73. Lesho E, Forestiero FJ, Hirata MH, et al. Transcriptional responses of host peripheral blood cells to tuberculosis infection. Tuberculosis 2011; 91:390–9. Kortepeter MG, Lawler JV, Honko A, et al. Real-time monitoring of cardiovascular function in rhesus macaques infected with Zaire ebolavirus. J Infect Dis 2011; 204:S1000–10. Nkoghe D, Kone ML, Yada A, Leroy E. A limited outbreak of Ebola haemorrhagic fever in Etoumbi, Republic of Congo, 2005. Trans R Soc Trop Med Hyg 2011; 105:466–72. Lesho E, Braun L, Coots N, Ozguc O, Ciobanu M, Fitzpatrick L. Disease prevalence among Moldovan orphans and other considerations for future humanitarian aid. Clin Pediat 2002; 41:235–7.
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with cutting-edge technology. For example, if serum from this and other EVD cohorts were banked in a repository, akin to the Department of Defense’s serum repository, it could be used in comparative genomic or proteomic studies of host response to generate outcome predictors, similar to what has been done for S. ebolavirus, human immunodeficiency virus, malaria, and tuberculosis [23–26]. Single molecule real-time sequencing could be applied to viral DNA samples for high-resolution outbreak investigations and forensic attribution. Implanted multisensory telemetry devices, permitting real-time monitoring of physiologic parameters, could alleviate the need for repeated contact or blood draws [27]. Wise alpinists know that summiting is only half of the problem; that greater challenges and dangers often accompany the descent. To mitigate those risks, they look ahead by looking back—for changing route and weather conditions; for an opposite, but crucial perspective; and for the lessonsofothers. Manyof the challenges facing today’s Ebola fighters (and other relief efforts), such as the importance of coordination, waste management, and community engagement, have been well described, some more than a decade ago [7, 8, 14, 15, 21, 28, 29]. The 2014 outbreak will likely remain a focal point for years to come.
