A Global Health Emergency, JAMA Sept

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Opinion
VIEWPOINT
Lawrence O. Gostin, JD
O’Neill Institute for
National and Global
Health Law,
Georgetown University
Law Center,
Washington, DC.
Daniel Lucey, MD, MPH
Department of
Microbiology and
Immunology,
Georgetown University
Medical Center,
Washington, DC.
Alexandra Phelan,
LLM, BBiomedSc/LLB
O’Neill Institute for
National and Global
Health Law,
Georgetown University
Law Center,
Washington, DC.
Author Reading at
jama.com
Corresponding
Author: Lawrence O.
Gostin, JD,
Georgetown University
Law Center, O’Neill
Institute for National
and Global Health Law,
600 New Jersey Ave
NW, Washington, DC
20001 ([email protected]
.georgetown.edu).
The Ebola Epidemic
A Global Health Emergency
On August 8, the World Health Organization (WHO)
Director-General Margaret Chan declared the West Africa
Ebola crisis a “public health emergency of international
concern,”1 triggering powers under the 2005 International Health Regulations (IHR). The IHR requires countries to develop national preparedness capacities, including the duty to report internationally significant
events, conduct surveillance, and exercise public health
powers, while balancing human rights and international trade. Until last year, the director-general had
declared only one such emergency—influenza AH1N1 (in
2009). Earlier this year, she declared poliomyelitis a
public health emergency of international concern and
now again for Ebola, signaling perhaps a new era of potential WHO leadership in global health security.
The West African Ebola Epidemic
Ebola virus disease (EVD) has 3 species of human significance: Zaire, Sudan, and Bundibugyo. The West Africa
outbreak is from a new strain of the Zaire species,2 with
a reported case-fatality rate of 55%. Infection can cause
fever, vomiting, diarrhea, and generalized bleeding as
well as death.
FruitbatslikelycarryEbolavirus,withhumansinfected
by close contact with infected body fluids and “bushmeat”
of primates, forest antelope, wild pigs, and bats. Humanto-human transmission occurs only by close contact with
infectedbodyfluids.Importantly,noairbornetransmission
betweenhumanshasbeendemonstrated.EarlyEVDsymptoms are similar to those of malaria and typhoid fever—
as well as endemic hemorrhagic fevers such as Lassa—
rendering symptomatic differential diagnosis difficult.
Before the current outbreak began in December
2013, West Africa had no recorded Ebola deaths. Yet this
outbreak is the largest, with the crisis worsening. As of
August 8, WHO reported 1779 Ebola cases, with 961
deaths.3 Cases were first reported in Guinea on March
23, followed by Liberia, Sierra Leone, and Nigeria (due
to an infected airline passenger from Liberia). Of greatest concern is the potential urban spread, including capital cities. Previously Ebola was concentrated in rural
areas, where the public health response was sufficiently rapid to prevent spread to populated cities.
Vaccines and Treatment: Ethical Dilemmas
Since 1976 more than 15 Ebola outbreaks have erupted
in sub-Saharan Africa, yet therapeutic options remain undeveloped. There are no licensed vaccines or specific antiviral or immune-mediated treatments for ill patients or
for postexposure prophylaxis. The US National Institutes of Health is supporting the first phase 1 clinical trial
of a new prototype experimental vaccine expected to
begin in September 2014.
jama.com
jamanetwork/2014/jama/17sep2014/jvp140116
Fueling disquiet about global justice, 2 US aid workers
infected in Liberia were treated with an experimental
anti-Ebola antibody prior to being transported to Atlanta.4
This serum had been previously used only in nonhuman
primates.5 Even though the serum’s safety and efficacy remain unknown, it sparked an international controversy.
Should US workers receive a drug in extremely scarce supply when Africans are affected in far greater numbers?
Balanced against this sense of injustice is the ethical concern of administering an experimental drug to African patientsthathasnotundergoneanysafetytestinginhumans.
On August 11, WHO convened an expert committee
to assess the bioethical implications of withholding or providingearlyaccesstoexperimentaltreatments.6 Ifascarce
treatment offers benefits to patients, the ethical question
is who should have priority access? Society, for example,
owes a duty to health workers who place themselves at
heightened risk. Other ethical considerations could grant
priority to patients most likely to benefit, as well as targeting the drug to prevent spread in hospitals or the community.Moreover,whoshoulddecidewhetheranexperimental treatment should be administered? Liberian officials
apparently did not approve the use of an investigational
drug administered in their territory.7 National leaders also
wouldneedtobepartoffuturedecisionmakingprocesses
for allocating scarce vaccines and medications.
Public Health Countermeasures
Sierra Leone’s president captured the state of crisis: “The
very essence of our nation is at stake.”8 Without effective vaccines or treatments, West African governments
have declared public health emergencies, invoking extraordinary powers—a divisive trade-off between population health and human rights. The following classic public health measures are standard responses to EVD but
are supported by variable levels of evidence.
Isolation and Quarantine. Affected states have invoked
multiple forms of quarantine, ranging from stay-at-home
days for “reflection, education, and prayers” to guarded
home confinement. The military has been deployed for
house-to-house searches, traveler checkpoints, and cordon sanitaire (a guarded line preventing anyone from
leaving)—sometimes separating people and regions of the
country. Yet states have exhibited lax enforcement, with
the inability to police an evolving crisis. Given EVD’s incubation period, quarantine must last up to 21 days—a task
requiring intensive monitoring, enforcement, and delivery of essential services such as food and health care.
Social Distancing. Governments have invoked social distancing, such as school closures and bans on public gatherings, including sporting, shopping, and entertainment. In some areas, fear has produced an eerie quiet
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Opinion Viewpoint
in usually bustling neighborhoods, while in other areas social life has
continued unabated.
triggered temporary recommendations directed to affected states,
bordering states, and the international community.
Risk Communication and Burial. Public education has been incomplete, with governments occasionally impeding news coverage and
accurate risk communication.9 Ministries of health have ordered
mandatory reporting and required cremation of bodies. Yet traditional burial services often continue, with loved ones in close contact with the deceased, posing transmission risks.
Affected States. The WHO director-general asked states with active Ebola transmission to declare a national emergency, activate disaster management plans, and establish emergency operation centers. Emergency funding should build core capacities including
infection prevention and control. The director-general urged mobilization of health workers, with full remuneration, personal protective equipment, and worker safety assurances. Traditional leaders and healers should be fully engaged in risk communication.
Travel Restrictions. Porous borders place West Africa in jeopardy, but
airline travel could propel Ebola’s international spread, as occurred
in Nigeria. Nigeria is screening all arriving air passengers, while several air carriers temporarily suspended flights to the region. The US
Centers for Disease Control and Prevention (CDC) issued a level 3
travel warning to the region, reserved for the most serious threats.
Health Care Settings. Without trained staff, isolation units, personal protective equipment, and strict infection control, hospitals
have become “amplification points” for spread of EVD, placing health
workers at significant risk; approximately 140 African health care
workers have been infected, with 80 deaths.10 The high risk incurred by workers, often with inadequate salaries, has compounded a severe human resource shortage. There are numerous
ethical dilemmas, such as whether health professionals have a duty
to report to work without adequate personal protective equipment. The United States is considering medical evacuation of infected aid workers, while the CDC will send additional workers to the
region. Beyond health workers, patients fearing EVD have shunned
hospitals, remaining in the community without adequate treatment. Affected states rank lowest in global development, with fragile health systems and lacking the capacity and expertise to contain
the epidemic and treat those infected.
Global Governance
The West African Ebola crisis is unique given the virulence, intensive community and health facility transmission patterns, and weak
health systems. The WHO director-general’s declaration of a public
health emergency of international concern underscores the urgency of a coordinated international response and the imperative
of raising the capacity of low-income states. The WHO declaration
ARTICLE INFORMATION
Published Online: August 11, 2014.
doi:10.1001/jama.2014.11176.
Conflict of Interest Disclosures: The authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
Disclosure: Mr Gostin directs the WHO
Collaborating Center on Public Health Law and
Human Rights.
Land-Border States. Land-border states should conduct rigorous surveillance to quickly identify clusters of unexplained fevers or deaths,
with qualified laboratories, rapid-response teams for contact investigations, and case management.
The International Community. The director-general cautioned against
international travel or trade restrictions, except for EVD cases and
contacts. All states should implement risk communication and laboratory diagnostics and prepare for medical evacuations. International capacity building for low-income states was conspicuously absent in the recommendations, even though it is arguably the most
effective and humane way to contain the outbreak.
Years of civil unrest and weak development have left West Africa
with fragile health systems as it faces a crisis. Although the directorgeneral urged international solidarity, global governance once again
was weakened from a lack of capacity in developing countries. A sustainable solution to EVD, and other emerging threats, requires binding commitments for funding and technical assistance to build national preparedness capabilities, including surveillance, laboratories,
health systems, and rapid response.
2. Baize S, Pannetier D, Oestereich L, et al.
Emergence of Zaire Ebola virus disease in Guinea:
preliminary report. N Engl J Med. doi:10.1056
/NEJMoa1404505.
3. Ebola virus disease, West Africa: update 8
August 2014. http://www.afro.who.int/en/clusters
-a-programmes/dpc/epidemic-a-pandemic-alert
-and-response/outbreak-news/4241-ebola-virus
-disease-west-africa-8-august-2014.html. Accessed
August 11, 2014.
REFERENCES
4. Blinder A. Atlanta hospital admits second
American with Ebola. http://www.nytimes.com
/2014/08/06/us/nancy-writebol-kent-brantly
-ebola-atlanta.html?_r=0. August 5, 2014. Accessed
August 10, 2014.
1. WHO Statement on the Meeting of the
International Health Regulations Emergency
Committee Regarding the 2014 Ebola Outbreak in
West Africa. http://www.who.int/mediacentre
/news/statements/2014/ebola-20140808/en/.
August 8, 2014. Accessed August 10, 2014.
5. World Health Organization. Ebola virus disease
in Guinea. http://www.afro.who.int/en/clusters-a
-programmes/dpc/epidemic-a-pandemic-alert-and
-response/outbreak-news/4063-ebola
-hemorrhagic-fever-in-guinea.html. March 23,
2014. Accessed August 9, 2014.
Additional Contributions: We acknowledge the
contributions of John D. Kraemer, JD, MPH.
1096
All confirmed cases should be isolated and treated, while exposed
individuals should be monitored daily, with restricted travel within
the 21-day incubation period. However, to protect freedom of movement, the director-general did not recommend travel bans but advised exit screening at international airports, seaports, and landcrossings. Individuals with EVD-like illness should not be allowed to
travel except for medical evacuation.
6. WHO to convene ethical review of experimental
treatment for Ebola. http://www.who.int/en/.
August 6, 2014. Accessed August 9, 2014.
7. McWhirter C, Loftus P, Hinshaw D. Giving
Americans drug for Ebola virus prompts flak. http:
//m.us.wsj.com/articles/second-ebola-patient
-lands-in-u-s-1407256243. August 5, 2014.
Accessed August 10, 2014.
8. Nossiter A. Lax quarantine undercuts Ebola fight
in Africa. New York Times. August 5, 2014: A1.
9. Williams WCL. In the grip of Ebola. New York
Times. http://www.nytimes.com/2014/08/08
/opinion/in-the-grip-of-ebola.html?_r=0. August 7,
2014. Accessed August 10, 2014.
10. Hinshaw D, Akingbule G. Ebola virus inflicts
deadly toll on African health workers. http://online
.wsj.com/articles/nigerian-health
-minister-says-nurse-died-of-ebola-1407325187.
Updated August 7, 2014. Accessed August 10, 2014.
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