Guinea EVD cases rise - but not like they have before...

Edited for clarity 24MAY2015 AEST

The uptick in cases this week from, in particular, Guinea interrupted what was looking promisingly like a continuous downward trend in cases all the way to zero - yes, that was too much to hope for.

However, it's worth keeping some context around this:

1. Everyone actually working in this space has forewarned us that getting to zero Ebola virus disease (EVD) cases was never going to be an easy journey.
2. The indicators have consistently shown more reluctance in Guinea to "kick out Ebola" than in Liberia or Sierra Leone. What caused that reluctance, I don't fully understand from my totally uninvolved chair a million  miles away.
   I know right? Surprising.
   Yes-I'd like a specific reason, all wrapped up and presented to me. I'm simplistic and selfish that way. Get that for me will you?? 'Cause I'm totes sure you haven't been trying your collective butts off all this time.
3. There were fewer new confirmed EVD cases this past week than in the tally for the week before or for other weeks - look back at January 2015, or October 2014 or June 2014, or any of a number of other dates when cases were accruing at a much faster rate than now (graph below).
   That is a silver lining. It's far from ideal, but it's not a return to the worst of it.

All along there has been something different about Guinea and that is now a clear sticking point in the final push to rid its people of Ebola virus|Makona. It never reported, as Sierra Leone did, days with averages of more than 100 cases. 

If we knew what was different about the people, communication, geography, weather, traditions, habits, thinking, ETUs, labs, government...or whatever..then we could perhaps better target the problem(s) and get to zero sooner. 

That will be core business for the next step to occur.

Click on graph to enlarge.

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A good week for viruses...not so great for humans...

Edited for clarity 25MAY2015

Middle East respiratory syndrome coronavirus (MERS-CoV) managed to get out for some sightseeing - travelling to South Korea this week - and Ebola virus|Makona was given a helping hand to spread to new people in Guinea and Sierra Leone with a small splurge of new confirmed cases.

MERS has now trickled into 24 countries world wide as shown in the European Centre for Disease Prevention and Control's (ECDC) epic 'travel-by-plane' map.

The original of this is created by the ECDC and is presented here.
Click on image to enlarge.

Meanwhile, a crude extrapolation from current Ebola virus disease (EVD) case numbers saw the predicted date when we might reach zero cases, move further into June. 

This could pull back again or it could move further away if the EVD clusters and sporadic cases continue to spread. We can't model that because it's entirely down to unpredictable human variables. We can list what those are, we can better prepare for them, we can educate about them and how to prevent them and we can acknowledge that they are real, but we cannot know when and in what mix they will come into play.

Extrapolation of the public data for confirmed Ebola virus disease cases from
WHO. The most recent week is boxed in red and bucked the trend of declining
 cases. To see how I made this please visit here.
Click on image to enlarge. 

The newest EVD cases remain mostly clustered around the Forecariah prefecture of western Guinea, on the north west border with Sierra Leone but also 5 new cases appeared in the north west of Guinea in Boke prefecture, which borders Guinea-Bissau. 

From the World Health Organization's Ebola virus disease Situation Report, 20MAY2015.
Click on image to enlarge.

Since the last EVD SitRep, two days of reporting have seen fewer cases than in the same two days of the week before. 

So there's that. 

Quickly reporting what is actually happening is invaluable for all sorts of reasons. Modelling and prediction allow us to get ahead of the virus. But having the data, and having them available publicly remains a challenge for every country and for every outbreak. 

Public health data are about the public's health. If it has been considered worth collecting and collating, why not communicate it too?

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MERS-CoV jumps a flight to South Korea...but from where?

It could be Qatar, Bahrain, the United Arab Emirates (UAE) or the Kingdom of Saudi Arabia (KSA). Any of these may have been the country of origin for the infected person who returned with a bunch of microscopic passengers, to the 24th country to host a case of Middle East respiratory syndrome coronavirus (MERS-CoV) infection - South Korea. 

The infected man then passed the spiky parasites on to his 63-year old wife and to a 76-year old man with whom he shared his hospital room. Close contact. From what we know of the MERS-CoV - it's a pretty ineffective transmitter among us humans types, preferring instead to give the hump to dromedaries.

Qatar seem less likely as it appears to have only been an airport transit point. If it's Bahrain, then we have 25 countries as Bahrain has not yet reported a MERS-CoV positive person. Both the people and the camels of the UAE and KSA are well known to this virus both in humans and camels. 

We await the clarity of the World Health Organization's analysis in a Disease Outbreak News (DON) article - although this might be a tough one to unravel.

Click on image to enlarge.

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Part 2: Exploring Healthcare Delivery at Indian Health Service, Navajo Nation (Gallup, NM)

My second and third weeks at IHS exposed me to different and innovative models of preventive health care delivery. Below, I�ve outlined the various programs that I learned about:

�    Navajo Area IHS HIV Program (HOPE): This program employs HIV Nurse specialists to assist the infectious disease physician with HIV clinic flow and to see patients independently for STD treatment, vaccinations, counseling and rapid HIV testing of partners. The HIV nurse also supervises the health technicians (pharmacists who help sort out medication distribution and adherence), and does field visits that involve home assessments, medication monitoring and community outreach for patients who are more challenging to care for. Over two days I attended a few field visits on the reservation and also participated in an outreach HIV education program at the local Gallup Adult Detention Center. This was my first time visiting patients on the reservation and it was eye-opening to see how spread out the homes were and how difficult it was to navigate the reservation as an outsider (because of the rain and mud roads and landmark-based directions). This gave me a greater appreciation for how difficult it must be for patients to seek medical care when they need it given that the reservation is so rural and relatively isolated. It was also interesting to see how the community on the reservation makes a living on their farms. Most homes had accompanying Hogans, which are traditionally used as a ceremonial space and have doors that all face east. For a few patients we visited, it was clear that they were using a combination of traditional Navajo healing/medicine man as well as antiretrovirals to treat their HIV. It was clear that the combination of these two forms of medicine sometimes posed a challenge to effective treatment of the virus. Because many of the community members lacked cell phone reception, it was sometimes hard to predict whether they would be home. The time that we were on the reservation was the beginning of the month, when people receive their paychecks and so we were told that many people on the reservation may be out in the town purchasing their month�s supply of goods. Nonetheless, we were able to visit a few homes when the patients were there and were able to review their medication adherence, provide counseling, and remind them of upcoming appointments. During our HIV awareness session at the Adult Detention Center, I was impressed by how engaged the group of 8 women were in learning about the primary, secondary and tertiary prevention of HIV and AIDS. Many were eager to get tested and share the information.

�    Navajo Community Outreach & Patient Engagement Program (COPE): This program works closely with community and tribal partners to promote healthy, prosperous and empowered Native communities. Their vision is to eliminate health disparities but providing robust community based outreach, strengthening local capacity and increasing access to healthy foods and promoting food sovereignty in tribal communities. One of the partnerships that COPE has developed is with Harvard Law School�s Food Policy Clinic, who had been working with the Navajo Division of Health over 2 years to develop Navajo Food Policy Toolkit. My visit overlapped with their visit to Navajo Nation, where they presented their work at a local Tribal Council meeting at the Sheep Spring Chapter House. During this meeting the Harvard Law School group presented their toolkit, which was a summary of all the food policy issues on the reservations. It was a large document that included sections on 1) Dine (traditional people) food ways 2) Structure of the Navajo Nation government 3) Role of state and federal government 4) Food production 5) Food processing, Distribution and Waste 6) Access to Healthy Food 7) Food assistance Programs and 8) School food and nutrition education. The tribal council was very welcoming and grateful to the group for putting together all of this research and they discussed ways to incorporate the information into local decision making. Some of the main issues they discussed were access to water, how to revitalize the agriculture practice and how to bring the processing of meat more locally onto the reservation. It was interesting to see how formally the tribal council was structured and how formally the proceedings took place.

�    Project ECHO (Extension for Community Health Outcomes): This organization provides a collaborative model of medical education and care management that aims to empowers clinicians everywhere to provide better care increasing virtual access to specialty treatment in rural and underserved areas. Currently, they run �clinics� between specialists at University of New Mexico and clinicians at IHS and elsewhere on complex conditions such as hepatitis C, rheumatoid arthritis, chronic pain, and behavioral health disorders. I was able to see Project ECHO from two viewpoints--one as the rural provider in Gallup, NM and one as the specialist at University of NM. I sat in on a �Hepatitis C Clinic� from Gallup where our Infectious Disease team discussed cases we saw and reviewed management via the teleconference. Separately, I sat in on a �Chronic Pain Clinic� at UNM where I heard cases about addiction and had a didactic lecture given by a neurosurgeon from UNM. I also sat in on a virtual workshop with prisoners around New Mexico conflict resolution. It was incredible to see how specialty care and education could be done in a way to empowers local physicians and it would be interesting to see how that model could be expanded elsewhere and applied to more specialities.

Over the course of the two weeks we spent our time outside of the clinic/hospital learning about the community. We did a homestay with one of the IHS doctors and her husband (who is a school teacher), which gave us the chance to see and hear about what it is like to live and work in Navajo Nation, first hand. Through our nightly chats with our homestay hosts, we learned about the challenges that their patients and students face in the community, including high rates of substance abuse and unemployment. However, we also learned a lot about the incredible Navajo culture, including language, food and traditions which the community is working to keep thriving. We attended local yoga classes (the doctor I stayed with teaches the class), we went on a couple of awesome hikes to Pyramid Rock and Inscription Rock at El Morro (where we saw evidence of past dwellers and travelers as far back as the 1400s-1800s), we learned about rescued wolves and stray animals at the Humane Society, and saw the local crafts at the weekend Flea Market and monthly Arts Crawl in Gallup town center. The physician community in Gallup was very tight knit--several healthcare providers were from academic institutions like Brigham and Women�s Hospital and UCSF as well as from US Public Health Commission Corps so it was inspiring to have the opportunity to hear about what brought them to IHS initially and see what has kept them doing meaningful work here for so many years. It was also great to learn about other programs, such as the HEAL Initiative that will continue to bring physicians to IHS to develop lasting relationships with the community. I hope to have the chance to return to Gallup again in the future!again in the future!

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Community Health Workers and Home Visits in Navajo Nation

�Next to the mountain. Literally right at the foot of the last mountain to your left.� That�s where she lived. Ms. G was a 60yo lady with diabetes, HIV, and a big heart. While here in Navajo Nation, I�ve had the opportunity to see amazing medicine in the clinic but also outside the clinic. In fact, when you think about it, most of what affects health doesn�t happen within the fours walls of a hospital or doctor�s office, but in a person�s home, among their family. As such, home visits can be a powerful lens for understanding how people live and how their environments contribute to their health in both positive and negative ways.

Yesterday, I was fortunate to travel with HIV community health workers to visit the homes of patients with HIV and make sure that they were being cared for and had their medications. For patient with HIV, adherence to anti-retroviral medications of 95% or greater is essential to rendering the HIV viral load undetectable. For many diseases, adherence of >70% is a victory, but for HIV high adherence means life or death. As such, ancillary support from social work, nursing, and family can be essential. 

After traveling for 1.5 hrs and missing her home multiple times (there are many mountains on the reservation), we arrived at Ms. G�s humble abode - a 2 bedroom converted trailer home. Ms. G profusely apologized for missing her appointment and not answering the phone, but because of the rain and the unpaved roads on the reservation, she was afraid she would get stuck in the wet clay and so was unable to get to her appointment. Regarding the phone, she did not have a landline, and her daughter needed her only cell phone.

In speaking with the CHW, I found that this scenario was not uncommon. ~80% of the roads and driveways on the reservation are unpaved, and only 60% have access to landlines with fewer having access to internet and cell reception. More disturbingly, 9% of households do not have access to clean drinking water and sanitation.

The infrastructure that I take for granted in Boston is feeble at best on the reservation, further exacerbating the poverty and poor health that plague this community. Sadly, the Navajo Nation suffers from unemployment reaching over 50% by some estimates with yearly income 1/3 of the general US and rates of intimate partner violence as high as 39%. In this setting, health and healthcare often take a back seat to food, nutrition, housing, and other goods.

Ms. G was ever the gracious host, offering my companions and I a drink and making us feel welcome in her home. On the kitchen table, I was impressed to see a strict food diary with blood glucose levels and a medication dispenser organized by her daughter. Of course, this victory was hard won and over the past 2 years, Ms. G had been hospitalized for complications related to diabetes and come close to death many times. The CHW was able to re-schedule her appointment using a cellphone, schedule labs that had been missed due to the rain, and provide her with a more organized medication dispenser.

As a medical doctor, I am trained to interpret numbers, look for signs and symptoms, examine the body, and come up with a diagnostic and treatment plan. All too often, the most important elements of a patient�s daily life (i.e. rain, poor infrastructure, no cell phone, domestic violence, economics hardships) are left out of the plan to the detriment of the patient and society�s health. In these cases, we physicians re-double our efforts to treat patients in the ways we know how, but never are we trained to think about the big picture, to think about how access to clean water or to telephones can make an outsized impact on health. It is here that the CHW and the home visit really shine and add impact to a medical team. 

In my next post, I�ll talk more in depth about innovative care delivery models in Navajo Nation.

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