dna exclusive: Ebola went undetected for 3 months; all have been slow in scaling up; says Dr Keiji Fukada

You have said that the response of the international community and the WHO to the Ebola outbreak has been late. Why has it been so? Was it difficult to detect the outbreak or was it difficult to mobilize resources?
The outbreak of Ebola went undetected in West Africa for as long as three months. The countries of Guinea, Liberia, Sierra Leone had been by years of conflict. It was easy for the virus to be transmitted as the cross border transportation was decent. Add to that the social customs and unsafe burial practices, the virus spread fast. Fundamentally, we were not prepared to tackle the outbreak which involved a complex high level of fear and uncertainty.  There are two reasons for this – first being the circumstances – that we were not adequately prepared to deal with something like this and second being the difficulty to scale up to necessary levels. Once it was known that there was an outbreak of an unknown disease in Guinea, and that it was Ebola, there were experts sent in from different organizations as well as WHO to the field. What everybody was slow in was ‘scaling up.’ When the number of cases started to increase very fast, it required a huge number of people to build ‘Ebola treatment units.’ Other people were needed to help train locals from the region so that they could conduct burials safely and to take care of patients. In this endeavour, international community including the WHO was slow in scaling up.

Why was the response so slow? Were we lacking in finances or were approvals to implement projects hard to come by?
It was hard for WHO, to go from deputing a few people to a lot of people in the field. To get a lot of people assembled on the field, took us more time than it should have. In terms of response from many organizations and countries, there was a very high level of concern about the infection itself.  It was perceived as dangerous. A lot of health workers got infected and the scare was that a health worker from the team were to get infected, they would carry infection back to their country. All of these things contributed to making it harder to respond quickly.

How much staff was affected in terms of dying or getting infected with the disease?
As of January this year, 700 staff members from WHO were deployed on the field in various capacities. Apart from them, 426 international experts were deployed as of 2014 in West Africa. The last we heard as of February second week is that 900 – 1000 of those deployed on field by all organizations including WHO, were affected and half of those have died. This is because health workers have more extensive contact with people who were infected. They stay in a very virus heavy environment and may get infected easily.

When countries were reluctant to come out and send in the people on the ground, what challenge did that pose to WHO?
At the beginning of the outbreak, we needed epidemiologists to help identify what was going on in terms of the outbreak. Also there was a need for providing better medical support to people. We eventually started to need communication experts to talk to local authorities and disseminate information in ways that locals could understand what the outbreak was all about and adopt safety measures. Later when we went into the outbreak, we needed to build facilities and level the ground to create the Ebola treatment units. Till date a strong need exists in West Africa for doctors and paramedics who can give medical care, communication experts who can conduct social mobilization and health workers to conduct contact tracing in the communities where infected patients have emerged, to find out more cases if any.

Is there a vaccination in place yet to tackle Ebola? If not, how is the progress on vaccine development?
We don’t have an approved vaccine right now or effectiveness data on the drugs available to tackle Ebola. The vaccine trials are going on though. The Phase I trials have been completed and Phase II trials for some of the vaccines are underway. These trials are being conducted to collect safety data. The large Phase III trials are going to be starting soon. We don’t have approved drugs as of now. We have some limited information about some experimental medicines like ZMapp and a couple of medicines working on the virus, but again there are not enough data to establish their effectiveness or efficacy. To pave the way forward, we need good trials to establish the effectiveness of the drugs as we have little comparative data about the people who were treated with drugs to those who did not receive the treatment.

Ebola by the local communities is being perceived as an attack from the west. They believe that the disease is a made up construct. Is the disbelief and non co-operation still rampant or has the mindset of the locals been changing?
We still know that there is ongoing transmission in some countries and that there is lack of engagement in some of the communities. These communities are hostile. It is very clear that there is lot of continued work that is still needed to stop the transmission of virus. Some communities are still not co-operative, and show violent behavior. What it frequently means is that there is a lack of trust in the people coming in to help. There is a lack of understanding that existing burial practices are unsafe. Also identification and hospitalization of symptomatic patients is still a huge challenge. For communities to accept these things they have to understand why it being done recommended. The challenge is to deliver the information to locals in the way they understand it the best. However, there are many communities in which there has been a huge change, which is why we are seeing burials being a comparatively lesser issue than in the past. Some communities have accepted that burial practices need to be changed to be safe, but not all communities are yet convinced.  These are the things that still need to be worked on.  We cannot take our eyes of the ball and intense continuation of the activity is necessary if we fully intend to get to zero cases.