Sunday, August 3, 2014

Where have all the ebola patients gone?

The figures put out by the Sierra Leone Ministry of Health and Sanitation, MoHS require some explanation, and perhaps with the new task force in place and the new emergency plan announced by the President last week additional explanation will be forthcoming.  From the start of the outbreak the health ministry figures have been different from those coming from the WHO; this has been the case whether you look at the comfirmed, probable or suspect numbers, all of which WHO release. However, a further potentially more serious problem has emerged in recent weeks.

The MoHS started to release figures for survivors some weeks ago. Now if we look at the confirmed cases and subtract the confirmed deaths and the survivors this should give us a figure for confirmed cases who are still patients, ie they have neither died nor been certified to have survived. The numbers differ from WHO to MoHS and, naturally, from day to day; a few days ago the President on television reported 500 confirmed cases, 129 survivors and 167 dead. This is approximately in agreement with the WHO and MoHS figures, and it leads to a figure of 204 current patients (ie 500-129-167). Now MSF reports on its website that its Ebola facility in Kailahun has 65 beds. The Ebola treatment facility in Kailahun is nonfunctional following the infection and subsequent death of the leadership of the facility. These are the only specialist Ebola treatment centers that have been reported in Sierra Leone. So if we assume MSF's 65 beds are all occupied by Ebola patients (The Ministry of Health's July 23 Facebook page reported 65 patients at the two facilities) we still have 139 patients (not counting those confirmed positive in the last few days) that are not in a functional Ebola treatment center. Where are these patients? It seems beyond belief that they would be in a general hospital or clinic. When one Ebola patient showed up at a regular hospital in Freetown, panic ensued, and the hospital had to be closed and then disinfected. So where are the 139 Ebola patients? Is it possible they are somewhere out in the community? Is it possible no one knows where they are? Do some of them remain at the Kenema treatment center even though this is no longer functioning? Would the Ministry of Health please explain? What is happening to newly confirmed Ebola patients? Where are they being sent?

What is the procedure for handling and tracking suspected cases whose blood samples are sent for testing? It is a matter of public record that in some cases these patients have 'escaped' whilst awaiting their test results. Some might have 'escaped' or left hospital even after confirmation of their cases. We wonder what happened to the patients at Kenema after the collapse of services there. We have been told by the experts that the key to containing the outbreak is tracing all known contacts of Ebola patients. Now if we can't trace the patients themselves, it becomes impossible to trace their contacts! God help us all!

Which leads us to ask, what is the plan for the future? Where will new confirmed Ebola patients be sent? We understand a facility for them is being constructed at Lakka in the Western Area. This is very much in place and should probably be replicated in all the districts, to avoid the problems of moving Ebola patients out of district. As there is the possibility that sufficient health workers may not be available and willing to look after these patients, some plan could be considered by which immediate family members could be trained to care for Ebola patients. One thinks of a mother and infected child. Or a husband and wife. These are extremely difficult choices at a societal and individual level, but they are choices that have to be made. All the indications are that at this point in time we do not have sufficient specialist Ebola care available to handle the situation. We can not sufficiently protect the care givers, who themselves become infected and infect others. Telling patients with symptoms to report at a health facility is one thing, but from there, what happens to them? The vast majority of health facilities in the country are grossly unprepared to handle Ebola patients.

Dozens of unaccounted Ebola patients

If we accept the hard fact that we probably have dozens of Ebola patients whose whereabouts are now unknown, how do we move forward? Our Ministry of Health must come clean and institute thorough, rigorous documentation of all new cases. This is absolutely vital if we are to win this battle. The President announced the involvement of the police and military and they must be used where necessary to ensure that every Ebola suspect that comes to the attention of health authorities is tracked until final determination of his/her case.

This is no time for Sierra Leonean sloppiness.

This is no time for Sierra Leonean deception and cynicism.

Every single patient whose blood sample is sent for testing must be meticulously monitored until final determination of his/her case. The records must be scrupulously compiled. If our Ministry of Health is incapable of this then the international community should speedily step in and take over the job. This is potentially an  international disaster, so there should be no scruples about this. One unaccounted Ebola patient can ignite or reignite an epidemic.

The reporting of all deaths is another important measure announced by the President and involving the recordkeeping of the MoHS. The ministry has to date in this outbreak ignored all deaths from other than laboratory confirmed patients. This has led to an underestimation of the extent of the outbreak. Going forward, a good-faith, honest attempt must be made to include all deaths that are probably as a result of Ebola. This would give a much better picture of the progression of the disease and assist greatly in contact tracing and identifying areas for quarantining.