Ebola lessons reiterate need to recognize global health realities

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An article in a recent issue of the American Society for Laboratory Medicine Lab Culture Newsletter begins by placing the reader in a health facility “holding center” where residents of a city experiencing an Ebola outbreak, in Sierra Leone, in Guinea, or in Liberia, would be referred upon the onset of symptoms. In harrowing terms the article describes the hours and days that would follow in the “dry” waiting area — as opposed to the nearby “wet” area where patients whose symptoms include diarrhea and vomiting lie separated by a plastic fence — while waiting test results from the faraway, understaffed and overburdened laboratory where samples were sent. Only after days, of living, eating, sharing washing and toilet space with scores of other people with symptoms indicating Ebola, does the test result return to show that a patient — at least on arrival — did not have the deadly virus.

It is a powerful introduction and illustration to the need for point-of-care diagnostic tools — tests that can be used, and deliver fast, accurate results at the local health facilities to which patients go for evaluation and treatment. Research, and the World Health Organization, have responded, the article notes, with WHO approving in February a rapid test that can detect Ebola protein in 15 minutes. The article also notes, however, that the need for point-of-care tests that are “ASSURED” — Affordable, Sensitive, Specific, User-friendly, deliver Rapid results, Equipment-free, and Delivered to patients — has already long been illustrated by obstacles to diagnosing tuberculosis. Regulatory processes, funding, pricing, challenges in the field, it notes, continue to slow access to existing tools, as well as development of the tools that are needed.

Those challenges are just some of the global health issues that the Ebola crisis that began more than a year ago has vividly illustrated, while taking the lives of more than 4,000 people, with some 800 health workers among them. Others include barriers to care, treatment, and prevention that are as endemic as the illnesses they confront when a disconnect between one side of the world and the other slows responses. And all of those are reasons Dr. Craig Spencer’s perspective piece in the New England Journal of Medicine, Having and Fighting Ebola — Public Health Lessons from a Clinician Turned Patient, is as troubling as it is, highlighting the opportunities that politicians squandered in the wake of his illness. Rather than noting, as the event of his illness and others in the United States showed that “failing to stop the epidemic at its source threatens everyone,” as Spencer puts it, they put pointless quarantines for health worker volunteers returning to the U.S. into place, throwing up a fresh hurdle in an already egregiously delayed response. Fortunately, Spencer also notes, for politicians at least, the Ebola epidemic, and the demagoguery with which they responded, ended on Nov. 4 — election day in the United States, before they could do more harm.

In the meantime, health workers in the field plowed on in a more evidence-based path. Some at a Liberia treatment center came up with a simpler way to assess patients’ risks of Ebola than the currently used process of elimination, with a list of six questions, leading in their analysis to accurate predictions of whether a patient had Ebola — contact with a sick person, diarrhea, loss of appetite, muscle pains, difficulty swallowing, and absence of abdominal pain. The method, and their analysis is detailed in an Annals of Emergency Medicine article of which Dr. Adam Levine, who teaches emergency medicine at Brown University and volunteered in Liberia last fall, is the lead author. The authors found high prediction scores linked to higher rates of laboratory-confirmed disease. But they noted, that still leaves the need for a widely accessible, low cost point-of-care test.

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