Health security expert: Dermatologists first line of defense for Ebola

U.S. Public Health Service Rear Admiral Jordan W. Tappero, MD, MPH

Almost 29,000 cases of Ebola with more than 11,000 deaths were reported by the World Health Organization (WHO) in a 2016 report on the 2014-2016 West African Ebola epidemic. The numbers are grisly, but lessons were learned, especially the importance of global health security, said Sunday’s guest speaker, U.S. Public Health Service Rear Admiral Jordan W. Tappero, MD, MPH.

“In today’s increasingly interconnected global community, an infectious disease threat anywhere in the world is just a plane ride away,” Dr. Tappero said in an interview prior to his presentation. To prevent serious outbreaks from becoming regional epidemics or pandemics, he urged rapid detection and response to these threats at their source.

“Because cutaneous presentations are common with infectious diseases, dermatologists are an important disease detection asset. We need to ensure that there is good dermatologic support in the global community to quickly recognize disease threats like viral hemorrhagic fevers or emerging infections, such as Zika and Dengue viruses,” he said.

Because dermatologists are part of the front line of defense for global health security, they need to support global efforts to educate and train dermatologists.

“We need to have a network of people we can go to internationally as colleagues,” Dr. Tappero said. “The next public health threat could become a regional epidemic or a pandemic that could have cutaneous manifestations. We could be part of catching it early so it does not go big.”

Dr. Tappero recalled his involvement in combatting the deadly Ebola outbreak during his presentation, “The West African Ebola Epidemic and the Global Health Security Agenda.” He is the senior adviser for Global Health, Center for Global Health (CGH) at the U.S. Centers for Disease Control and Prevention (CDC). In 2014, Dr. Tappero deployed to Liberia, serving as CDC’s leader for Public Health and Medical Response to Ebola for West Africa.

In West Africa, several factors created a perfect storm for widespread transmission of Ebola virus disease that hit Guinea, Liberia, and Sierra Leone, he said. Residents are poor and went through civil wars in the 1990s and 2000s, so there was little in the way of public health infrastructure.

There was no awareness for the Ebola virus in West Africa because all previous outbreaks arose in East and Central Africa. Infectious disease experts suspect the Ebola virus was carried by African fruit bats to West Africa, leading to the most deadly of the 25 Ebola outbreaks in humans since the virus was discovered in 1976.

Experts also suspect the virus spread for months before it was detected and reported by WHO. Poor knowledge of the virus, high levels of illiteracy, and fear of the government after years of civil war fueled the problem among West African residents, Dr. Tappero said.

“The reason the outbreaks can be small or large is dependent on if there is surveillance,” he said. “Are community health workers trained to look for serious viral hemorrhagic fevers and report them? The harbinger of an Ebola or Marburg viral hemorrhagic fever outbreak is a cluster of deaths among health care workers who see really sick patients without realizing the cause is Ebola.”

When they first contract Ebola, the victims are not infectious until they develop onset of fever. Eventually, they develop worsening symptoms, such as vomiting and diarrhea, that expose others to the highly contagious virus through direct contact. Some patients develop hemorrhagic symptoms, including bleeding from the nose, ears, and mouth. The greatest danger of transmission is with the deceased because the corpse is “teeming with Ebola virus,” Dr. Tappero said.

With no approved Ebola virus vaccine, the best hope of controlling an Ebola outbreak is to establish a standalone facility where the victims can be isolated and receive care. This strategy increases the chances of survival from 10 percent to more than 50 percent. Victims are also asked to identify everyone they have been in contact with for the previous three weeks so they can be tracked for three weeks, which is the Ebola incubation period.

The 2014-2016 West African Ebola Epidemic was the most deadly Ebola outbreak and the first Ebola outbreak to result in widespread transmission in crowded urban settings.

“We had a crisis of major proportions,” Dr. Tappero said. “There was no place to go, and there was widespread contact with infected victims. At the beginning, we had too few isolation facilities and too few health care workers. We had difficulty tracking the contacts who were most likely to become infected. There were huge numbers of the dead in homes and not enough burial teams to pick them up and take them away, so everyone in the household and in the community was at risk.”

Eventually, molecular sequencing was used in the last six to 12 months of the outbreak to help identify sexual transmission clusters of Ebola — a mode of transmission that had not been seen in previous outbreaks.

Dr. Tappero closed his lecture by addressing the importance of international cooperation to improve global health.

“Addressing global health security is how we prevent events like this in the future. We need transparency with reporting, and improved public health infrastructure in all countries around the world, to prevent something like this from happening again,” he said.

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