Blood donation in post-Ebola West Africa

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Copyright: James Meiring. Winner HIFA Photography award 2016

What do wellington boots drying in the African sun have to do with blood donation in the post-Ebola era? Tell you later.

But first, as its World Blood Donor Day on June 14th, lets consider the differences between the blood transfusion services in a high income country like the UK with those in Nigeria or Sierra Leone? How has the Ebola epidemic impacted on these services?  

Blood transfusion services in the UK

I think we in the UK probably take our well-established national blood service(s) somewhat for granted and only really give it a second thought when either we need to call on its use or something drastic goes wrong.

Established in 1946, the Blood Transfusion Service (BTS) in England and Wales employs over 6000 people to collect & process the blood alone. All sorts of rules and practices surround the preparation and distribution and use of that blood. We are very fortunate that over 3% of people in the UK donate that blood (1% being the figure recommended as a minimum by the W.H.O. to meet a populations needs) but even then we get regular appeals for more blood and we still suffer shortages for particular blood groups and platelets.

But, have you ever asked yourself why we need continuing fresh donations of blood and who are the usual recipients of that blood?

In 2014, in England & Wales, the 3 major “consumers” of blood were:

  • 67%, to treat medical conditions including anaemia, cancer and blood disorders
  • 27%, in surgery, including cardiac surgery and emergency surgery
  • 6%,   to treat blood loss after childbirth

The most frequently transfused patient group is over 65 years of age.

100% of the blood donated is voluntary. This is important, as the W.H.O. has declared that the foundation of a safe blood supply is 100% voluntary donation. Blood obtained this way has lower rates of infections and so reduces chances of disease transmission via blood or blood products.

How does this compare with a blood transfusion service in West Africa ?

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Ebola – the not so new virus

   Ebola-poster

Ebola in West Africa has claimed more than 9300 lives in the last year.

Researchers have traced the origins of the epidemic to a two-year-old toddler, who died in December 2013 in Meliandou, a small village in south-eastern Guinea. The child was seen playing under a tree heavily infested with bats.

AT “Ebola: The 21st century plague?" [Royal Society of Medicine, London, UK. February 6, 2015], we heard from international experts handling the epidemic.  They examined the history of the disease, the lessons learnt from 2014 and what strategies are in place for preventing future outbreaks.  In doing so, we gained an explanation as to why a rural outbreak became a regional urban epidemic, and an understanding of the complexity of medical volunteering and running ebola treatment centres.

I have selected some keyfacts & insights from the talks, to give you a flavour of this one-off national symposium, an update from the frontline. This blog also appears on our monthly Global Health Knowledge Base, along with relevant ebola research and news.

Ebola virus has been with the world since at least 1976 – nearly 40 years
We are aware of 28 independent outbreaks of the ebola virus disease in that time, from 5 different strains named for each country of origin and all but one in Africa. What's different this time is that the death toll is so much higher.

Keyfact:  4 times as many deaths in one year as in the previous 40 years

Insight: Although ebola has been around for some time – and probably longer than we realise – the global community only became aware of it because a nun at a missionary clinic went down with a mystery disease caught from patients. Her blood sample sent to London in 1976 yielded a new virus – which was named "Ebola" after the river near to the outbreak village in Yambuko, DRC.  At the same time, 500 miles away in Sudan, a similar but separate outbreak occurred.

Ebola in West Africa largely confined to Guinea, Sierra Leone and Liberia
These have vast rural areas, with dense forest and wild life in close proximity to the local population, perfect for transmission of a virus from wildlife to people (zoonoses).

Keyfact: Right from 1976, wildlife transmission was suspected and the search for an animal reservoir began.   The index case for the 1976 Yambuko outbreak was a headmaster who had eaten monkey meat, the simulatenous Sudan outbreak was centred on a sugar factory infested by bats; a vet caught ebola from treating a sick chimpanzee colony in Cote D’Ivoire[1992]

Insight: In 1996,  a lab study finally showed that of various mammals, only bats could be infected and remain healthy (=reservoir)

 

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Teaching tools for Ebola & public health diseases

Ebola_toy
Credit:Wendie Norris

Band Aid is a tried and tested method of public engagement, bringing Ebola to public attention and giving us all something we can do to help rather than just scaring us. What is also needed here and in West Africa, is education.

For a novel method of education, I bring you Giant Microbes, which are sold as teaching tools. They are soft plush “cuddly” toys, anthropomorphised versions of microscopic images of microbes, and provide information on the microbe and the disease it causes in the attached label. Apparently they are currently sold out!

I own their version of Ebola virus (shown opposite is the actual toy sitting on my desk): its based on the shape of the virus seen in an electron microsopic image. My colleague owns a tuberculosis (TB) virus toy. Bought at a public health conference, the label for my Ebola toy is dated 2004 and describes the symptoms, the 50-90% mortality but also tells me that outbreaks are limited to a few hundred cases. The toy produced now, in 2014, will have a very different set of statistics to present.

The West African outbreak today stands at 14383 cases, with 5165 deaths in 6 countries.

Of those 6 African countries, Nigeria and Senegal have had their Ebola Virus Disease (EVD) outbreaks declared as officially over. [A national EVD outbreak is considered to be over when 42 days (double the 21-day incubation period of the Ebola virus) has elapsed since the last patient in isolation became laboratory negative for EVD].

Last week, my colleague had house-guests.  On seeing the TB “cuddly toy” at home, they asked where was the Ebola one (?) and she was gratified to say “its at work”!  Clearly information on Ebola has successfully entered UK public consciousness.

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Ebola: a “filthy little virus” says Bob Geldorf

Sierra_Leone_National_Ebola_Emergency_Operations_Center _CDC
Sierra Leone National Ebola Emergency Operations Center
Credit: Jennifer Brooks, CDC.


Following
the launch of Band Aid 30, "the Ebola song”, on X-factor [Sunday 16 November 2014], Bob Geldorf did the media rounds on the Monday morning including BBC 5live, to further drive home the message. People are dying from Ebola in West Africa because they are poor, living in countries without the health service infrastructure to stop it in its tracks, and “we are all just a plane ride away from it”.AS of that Monday, you can buy and download the song here via Amazon, Itunes and Google Play, or purchase the CD.

WE at CABI, devoted last month’s focus of the Global Health Knowledge Base e-newsletter to Ebola research.

With the charitable effort of Band Aid 30 ringing in our ears, I thought it timely to highlight another such effort, from researchers, specifically from the Wellcome Trust.

Wellcome Trust: Emergency Ebola initiative
 The Wellcome Trust (WT), the world's second largest private funder  of medical research after Bill & Melinda Gates Foundation,  are funding a multi-million pound emergency research package [Emergency Ebola Initiative] to investigate new approaches to treat, prevent and contain Ebola viral disease, during the current epidemic in West Africa. WT will also support research into the ethical challenges of testing experimental medicines during epidemics, and has a £40 million long-term investment in African science.

One of their anti-Ebola vaccines is being fast-tracked.

Further Reading

A new rapid sequencing method created for Lassa, was applied to Ebola virus, sequencing nearly 100 Ebola patient blood samples In Sierra Leone, within 10 days. The method is also cost-effective, and may help West African nations rapidly and effectively track outbreaks with limited resources. This article is one of the records on CABI's Global Health database.

 

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Accurate and timely communication is key to stopping transmission of Ebola

Ebola on TDB
Ebolavirus: coverpage for CABI's print journal Tropical Diseases Bulletin

Ebola brings out the worst and the best in mankind.

Global coverage of the Ebola outbreak in West Africa began with (the best) courageous foreign health care workers (HCWs) being flown home by their governments in a desperate attempt to save their lives, and rapidly moved on to the sheer panic amongst the local populations experiencing the outbreak: riots, health care workers and government officials abandoning their posts (the worst). Somewhere imbetween mention was made, usually by the foreign HCWS, of their local colleagues left behind who struggled on without resources and personal protection (the best).

Medicin Sans Frontiers highlighted the slow response of the international community.

Misinformation, public panic and stigma

Ebola haemorrhagic fever (caused by different ebola virus strains) has been around since 1976, with regular self-limiting outbreaks, usually in remote areas of one country. Index cases always involve some contact with animal reservoirs (bushmeat (wild animal meat), bats, rodents, monkeys), and its then spread by person-to-person transmission through contact with bodily secretions or with objects contaminated with secretions. It’s infamous for its high case-fatality rate and the ease with which it spreads among contacts of the diseased.

What makes this time different is the Zaire strain has now reached West Africa: there  it has spread from remote regions into highly populated urban areas, and it has crossed borders so that there are escalating outbreaks in 3 adjacent countries (Guinea, Sierra Leone and Liberia), with no end in sight. The epidemic (for that is what it is now), has resulted from sustained person-to-person transmission.

Cases have also been reported in Nigeria and Senegal but these countries seem to have contained the transmission of the virus. DR Congo  has an outbreak.   An up-to-date Ebola Healthmap can be found here.

Ignorance and fear, drivers of disease

Misinformation among health workers and the public fuelled panic and contributed to the spread of Ebola-zaire over the last 6 months.  HCWs abandoned their posts or were the source of rumours that created riots, government officials got out whilst they could. [The index case for Nigeria, was an official who left Liberia, who knowingly had had contact with an Ebola victim].

Fear has not just caused civil breakdown.  It is masking the magnitude of the outbreak, especially in Liberia and Sierra Leone. Families fear stigma so hide sick relatives or consider the hospitals as death sentences (breaking relatives out!) or indeed consider them the cause of the illness in the first place. Cases being cared for outside hospitals do not enter the statistics.   

Unlike the “Black Death” in medieval Europe, it’s not lack of real clinical knowledge that’s the problem but:

  1. Weak health systems, lacking skilled HCWs and resources
  2. Lack of knowledge amongst the general public
  3. Lack of community involvement & mistrust of government
  4. Misinformation among health workers, ministries of health and the public
  5. Lack of effective drugs and vaccines…supportive therapy only is current medical response.

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