The largest ever outbreak of Ebola virus disease (EVD), which began in December 2013, profoundly impacted not only the West African countries of Guinea, Sierra Leone, and Liberia, and to a lesser extent Nigeria, but also the rest of the world because some patients needed to be managed in high-resource countries. As of March 29, 2016, there were 28,616 confirmed, probable, and suspected cases of EVD reported in Guinea, Liberia, and Sierra Leone during the outbreak, with 11,310 deaths (case fatality rate of 39.5%). An unprecedented number of healthcare workers and professionals, including physicians, nurses, logistic and administrative personnel, housekeepers, epidemiologists, statisticians, psychologists, sociologists, and ethics experts in many countries, were directly or indirectly involved in the care of EVD patients.
Petrosillo, N. and ivljak, R. (2018), "Ebola Virus Disease: A Lesson in Science and Ethics", Ethics and Integrity in Health and Life Sciences Research (Advances in Research Ethics and Integrity, Vol. 4), Emerald Publishing Limited, pp. 33-44. https://doi.org/10.1108/S2398-601820180000004003Download as .RIS
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Ebola: A Personal Experience in Lagos, Nigeria
In August 2014, I was deployed as a World Health Organization (WHO) clinical consultant to the Ebola virus disease (EVD) response team in Lagos, Nigeria. News reports coming from West African countries experiencing dramatic increases in EVD cases were all over the front pages of newspapers, with distressing photos and stories. Moreover, a high percentage of EVD cases in Nigeria involved healthcare workers. To be honest, I was a bit worried. Before leaving my country, I was given several vaccines (yellow fever, hepatitis, meningitis etc.), which made me very nervous. Although keenly aware of the risks, I chose to help despite them.
My tasks were to provide technical advice on clinical care to the EVD Care Center at the Mainland Hospital in Yaba, a district of Lagos, to augment infection prevention and control practice training and provide technical advice for other activities by the Nigerian response team. Nigeria had experienced a successfully contained EVD outbreak, introduced by a Liberian-American lawyer incubating EVD, who travelled from Liberia to Lagos, denied previous exposure to EVD after he became sick and infected several healthcare workers who cared for him.
Since the first day in Lagos, I was aware that it would take a day or so to become oriented and to understand where I was. Lagos is a big city with 21 million inhabitants, many of whom are on the streets daily. Bush meat is everywhere and the traffic is terrible. Before leaving for Lagos, I was told not to walk alone and to be very careful when travelling on the roads. As soon as I arrived in Lagos, I understood the importance of following these safety precautions.
The isolation facility for suspected/confirmed EVD cases was in a compound for tuberculosis, which is endemic in Nigeria. We met the local healthcare workers in a large empty ward with several beds, which had previously been for pediatric tuberculosis patients, whose relatives looked after them there. I dare not imagine how respiratory precautions had been applied in that ward. Nevertheless, I realized that after the Ebola crisis passes, tuberculosis will still remain.
The isolation facility was located in the back of a compound with three wards, one connected to its own entrance gate that could accommodate 8–10 isolation beds, one inside with 14 beds for suspected EVD cases, and another with 14 beds for lab-confirmed EVD patients. I was replacing a WHO physician with extensive experience in EVD. Médecins Sans Frontières/Doctors Without Borders (MSF) volunteers had joined the response team a few days after his arrival, with an outbreak assessment and support team that included a team lead (clinician) with 2 years of EVD outbreak care experience, and a logistics person familiar with the usual water/sanitation issues. Logistics is crucial in the struggle against Ebola.
Thanks to the coordination of the MSF/WHO groups, provision of personal protective equipment (PPE) was guaranteed, and the logistics/water sanitation equipment in the facility ensured a safe work environment for clinicians, nurses and housekeepers. Nigerian participation in the healthcare of suspected/confirmed EVD patients was increasing; some Nigerian doctors and nurses were staffing the care center and others were being trained. Besides epidemiological, infection prevention and control, and clinical training, a scheduled observation shift and then three scheduled shadow shifts were expected. The trainees were all young, willing and friendly, but their presence was unpredictable. The work was intense and problems appeared everywhere. The medical team shared a large room, where they had no opportunity to rest or conduct focused meetings. There were people bustling around all day long. Sometimes it was preferable to hold briefings in the open-air garden in front of the isolation facility. Another problem was the shortage of local personnel to cover three shifts, which was partly overcome by the enthusiastic young staffers. The local healthcare workers were conscious of the extraordinary nature of the event in which they were participating.
My daily duties included attending a large meeting with representatives of the Nigerian Ministry of Health, local representatives, epidemiologists, logistics personnel etc., in a building that was a 40-minutes drive from the hospital. Then, we would drive to the EVD isolation facility through extremely heavy traffic on a road with few traffic lights. The day ended with another drive through traffic to an evening meeting, where all the teams (clinical, epidemiological, logistics etc.) reported on their activities (response team activities). Although the majority of the people attending this meeting were tired after the day’s work, everyone paid close attention to each update, including the overall number of suspected and confirmed cases, contacts to be traced or already traced, and rumors of likely cases. Strategic issues, including points of entry measures, contact tracing, logistics, media and social networks, were also discussed by national and international experts from WHO, MSF, the United Nations Children’s Fund (UNICEF), Centers for Disease Control and Prevention (CDC) etc.
The daily work was exhausting but not boring. Caring for suspected/confirmed EVD cases was exciting. The complex procedure for donning personal protection equipment, the heat, humidity and sweating, the constant disinfection with chlorine, the difficulty I experienced in approaching patients due to the protective suit that covered every part of my body, the poor diagnostic tools, and the dangerous and difficult procedure for doffing personal protective equipment all contributed to making the care of patients a challenge, and sometimes frustrating. Donning and doffing personal protective equipment were lengthy and painstaking activities. All the staff members were aware of the vital and life-saving importance of avoiding any contamination and infection from Ebola virus.
However, all our frustrations disappeared and were fully rewarded when a previously very sick patient improved and was discharged, such as a woman who, upon exiting from the dedicated passage of the isolation facility to the outside world, where her kids were waiting for her, cried “Thank God” and smiled at us in gratitude.
My personal experience was a life lesson. For the fight against EVD in Nigeria, ample financial and material resources, as well as well-trained and experienced international and national staff, were provided. Through efficient organization, with a strong coordinated commitment and international collaboration, the collective efforts of normal people acting with great humanity and self-sacrifice were successful. For Nigeria, the fight against EVD was a spectacular success story, which shows that Ebola can be contained.
Ebola virus disease (EVD), formerly known as Ebola hemorrhagic fever, is a severe and often fatal illness in humans. It is caused by the Ebola virus (EBOV), which is transmitted to people from wild animals and spreads among the human population through human-to-human transmission. The average EVD case fatality rate is around 50%, ranging from 25% to 90% in past outbreaks.
The 2014–2016 Ebola outbreak in West Africa was the largest and most complex since the virus was first discovered in 1976. There were more cases and deaths during that outbreak than from all others combined. It also spread among countries, starting in Guinea and then moving across land borders to Sierra Leone and Liberia. From the beginning of the epidemic until it ended in April 2016, a total of 28,616 confirmed, probable, and suspected EVD cases were reported with 11,310 deaths (case fatality rate of 39.5%). Besides Guinea, Liberia, and Sierra Leone, other countries were involved in the epidemic, including Nigeria (20 cases and 8 deaths), Mali (8 cases and 6 deaths), and Senegal (one case, no deaths) (https://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html). Moreover, only a few EVD cases were evacuated from West Africa to Western countries. A total of 26 cases, of which 4 were fatal (Center for Infectious Diseases Research and Policy (CIDRAP)), were treated in Europe (Kreuels et al., 2014; Mora-Rillo et al., 2015; Wolf et al., 2015) and North America (Liddell et al., 2015; Lyon et al., 2014) during the outbreak. The Ebola virus disease outbreak reminded the world of the dangers of disease transfer from animal reservoirs,that is, zoonosis. An unprecedented number of healthcare professionals, including physicians, nurses, logistics and administrative personnel, housekeepers, epidemiologists, statisticians, psychologists, sociologists, ethics experts, etc. from a variety of clinical settings in a number of countries were directly or indirectly involved in caring for EVD patients. Guidance documents on infection prevention and control practice and clinical care were provided by organizations with EVD experience (Centers for Disease Control & Prevention CDC, 2014; Médecins Sans Frontières MSF, 2014; World Health Organization WHO, 2014).
As important as guidance documents are, many lessons must be learned from the specific hands-on daily care of EVD patients in countries with limited healthcare facilities, which can help us avoid some of the risks inherent in the steep learning curve associated with delivering EVD care.
Critical Points in the Care of EVD Patients (Especially in Resource-limited Settings)
Ethically speaking, healthcare workers have a double obligation: to provide the best medical care in order to improve patient survival, with symptom relief and palliation as required, while at the same time they must also protect themselves and minimize further transmission to others, including their colleagues.
Anxiety, haste, and pressure, especially from politicians and the media, often blur the facts. The care of patients with EVD must be deliberate, vigilant, and guided by science. The basic procedures for how clinicians can safely approach a suspected/confirmed EVD patient, , which are based on decades of research and field observation, should be followed. Although much remains to be discovered, Ebola virus is only spread during the symptomatic phase of the illness, especially in the presence of diarrhea, vomiting, or bleeding, and we know the relevant epidemiological features, such as the incubation period, infected body fluids, and mechanisms of transmission. Understanding these principles helps eliminate the sense of mystery, reduces stress, and keeps responders focused on their work (Brett-Major et al., 2015).
Secondly, safe and effective care for EVD patients has been achieved in both resource-poor and well-resourced settings. The healthcare workers caring for a suspected/confirmed EVD patient should apply a targeted strategy for any of the clinical manifestations. Volume repletion and electrolyte management, attention to hypoperfusion-related complications, intravenous indwelling, hemodialysis in the event of acute renal insufficiency, and reanimation procedures, including mechanical ventilation, should be provided to patients when needed. Patient safety in the isolation environment and her/his psychological/mental status should be vigilantly managed. Differential diagnosis and the search for coinfections (malaria is endemic in many countries affected by Ebola) often require healthcare workers to perform blood-drawing and invasive procedures, although they risk contracting EVD from their patients unless rigorous contact and droplet and airborne safety precautions are scrupulously followed.
The highest mortality rate at the beginning of EVD epidemics may reflect the relatively low-level care EVD patients receive, owing to fear of viral transmission (healthcare workers’ fear of exposure and infection). Later on, when many invasive procedures (peripheral and central venous access, dialysis, and mechanical ventilation) were being performed safely in the proper settings, mortality dramatically decreased. “First do no harm” applies to the patient, the staff, and the community (Brett-Major et al., 2015).
Another important point is represented by the attention of clinicians and all the healthcare staff to the safety of the environment in healthcare facilities. Indeed, the environmental aspects of wards/units are typically not managed by clinicians. However, in EVD care, clinicians and all the healthcare staff have a critical stake in environmental safety. The routes taken by personnel and patients from low-risk to high-risk areas, water and sanitation, hygiene and waste management are not matters to be left to someone else. A safer environment means safety for patients, healthcare workers, and the community.
The safety of healthcare workers is also, and perhaps principally, related to the proper use of personal protective equipment. Careful and comprehensive training, repeated practice, mentoring by more experienced clinicians, and competency assessment must be in the context of on-site infection prevention and control and clinical procedures, in order to assure safe, sensible, functional, and reproducible practices. A designated controller of the doffing of personal protective equipment and co-supervision in high-risk areas using a buddy system can sharply reduce errors and the risk of contracting infection while caring for patients. Good teamwork among healthcare workers is of vital importance because the safety of each individual depends on the conscientiousness and professionalism of others.
Patient isolation increases the burden of care but also separates patients from their relatives, communities, and healthcare providers. Patient contact with doctors and nurses completely covered by personal protective equipment is very limited, especially because patients typically seek visual contact with doctors/nurses and try to read their facial expressions. This is quite impossible in high-isolation units, rendering the care environment an area where there is scant personal contact. Moreover, the community, which is so important in Africa, can experience the lack of communication with patients, relatives, caregivers, and the world outside the outbreak-affected as traumatic.
EVD is a severe, highly contagious and life-threatening infection. From the beginning of the epidemic, the main objective was to isolate the EVD patients in order to contain the spread of infection. Indeed, several cases were initially due to healthcare transmission, including hospital/outpatient care, home care, and funerary customs. In a retrospective analysis of EVD cases, exposure during traditional funerary rites was cited by 33%, although the proportion of cases reporting this kind of exposure decreased over time, when safe funerary practices and prompt hospitalization contributed to the containment of the epidemic (International Ebola Response Team et al., 2016). However, while bearing in mind that isolation measures/procedures should be strictly followed for suspected/confirmed cases, there is also the need to respect traditions and behaviors, and to communicate safely with healthcare workers, family, and friends. Information, education, and the opening of line-of-sight areas with low barriers where patients can talk with visitors across a safe distance, if possible via electronic communication devices, will generate positive feedback from everyone, relatives/friends and staff. When discussing burial with the families of deceased patients, allow for their viewing of the body and participating in a safe burial. This basic respect for patients and families helps to build and maintain positive relationships with communities, overcoming common misunderstandings and making activities in the EVD care center more transparent (Brett-Major et al., 2015).
Fear and Stigmatization of Healthcare Workers Who Come into Contact with EVD Patients
Management of EVD patients in high-isolation units is challenging and requires the balancing of staff and patient needs. When a healthcare worker is deployed in a resource-constrained and high-risk environment, psychological stress together with physical and emotional fatigue may affect her/his health and contribute to errors that can result in infection. For international staff, the post-deployment period may present additional but under-appreciated stressors. Returning to a higher-resourced healthcare setting leads to the inequity tension experienced by many people working in both economically disadvantaged and affluent countries. Colleagues, neighbors, and others at home may have considerable apprehension about interactions with returning healthcare workers, even though they may have little reason to suspect EVD or other illness. Moreover, whereas healthcare workers are usually well informed about the precautions necessary to prevent the spread of highly contagious diseases, family, neighbors, friends, or non-medical colleagues may erroneously fear that medical personnel might bring infection home from an epidemic overseas. In other words, there is the risk of stigmatization. Fears about Ebola transmission have also caused some government authorities in the United States to enforce the quarantine of volunteer healthcare workers who returned home from West Africa after participating in the treatment of EVD cases, despite CDC recommendations that they should only be actively monitored and not quarantined if they have no fever or symptoms of the disease (McCarthy, 2014).
During the EVD outbreak in Nigeria, there were media reports that patients suspected of having EVD (Ebegbulem, 2014) and healthcare workers who cared for them were feared. Patients suffering from malaria or fever were avoided, abandoned, or rejected by private hospitals in the erroneous belief that they could transmit EVD (Aborisad, 2014). In the Lagos Mainland Hospital, Yaba, where EVD patients were isolated and treated in Nigeria, some healthcare workers who volunteered to treat patients were viewed with suspicion and avoided by colleagues, family members, and the general public. Some were even advised by their families to resign from their roles and return home (Odebode, Adepegba, & Atoyebi, 2014; Ogoina, 2016).
At the beginning of the 2014–2016 Ebola outbreak in Africa, the deployment of international healthcare workers was slow, for three main reasons: lack of information about the situation and how they could help; fear of contracting Ebola; and their families’ reactions or resistance to their going (Turtle et al., 2015). Family concern was the main factor that deterred volunteers, followed by the perception of being essential in their current positions (Rexroth et al., 2015).
International Workers Repatriated from EVD-affected Countries: Clinical and Ethical Issues
As of June 24, 2015, a total of 65 individuals had been evacuated or repatriated worldwide from the EVD-affected countries. Of these, 38 individuals were evacuated or repatriated to the following European countries: Spain, Germany, France, United Kingdom, Switzerland, the Netherlands, Norway and Italy. The repatriation of international people who voluntarily worked in EVD-affected countries during the epidemic is a response to our social obligation to provide the best available care to aid workers who, in the name of solidarity, are willing to place their lives at risk in order to help others (Kass, 2014). “Whatever you did for one of these least brothers of mine, you did for me” (Matthew 25:40).
Repatriation also benefits the rest of the patients, both by increasing the probability that their caregivers will survive and by decreasing the risk of dissuading other professionals who might otherwise be considering the possibility of traveling to the area in order to help with their care (Donovan, 2014). However, some questions arose when infected workers were repatriated. In August 2014, a male Spanish missionary nurse was repatriated from Liberia in Spain in order to be treated for EVD, whereas some of his fellow missionaries who belonged to the same religious order and were also infected had to remain in Liberia because they lacked Spanish citizenship (Royo-Bordonada & García López, 2016). The Spanish missionary died a few days later in Madrid, while a female missionary, who had been denied transfer to Spain for treatment, was admitted to the Elwa Public Hospital, a barrack-like building where patients were crowded together without the necessary therapeutic or hygienic conditions, managed to survive the disease, and later walked out of the “death camp,” as it was called by the locals (Rego, 2014). The repatriation of volunteers and other workers raises the question of the disparate treatment afforded to international aid workers and to the African health workers on the front lines, who were the principal victims of infection (Rid & Emanuel, 2014).
On the one hand, there is no doubt that the duty of attending to workers who risk their lives falls to their respective countries of origin. Without this “rule,” many healthcare workers would be dissuaded from going to resource-constrained countries with an ongoing epidemic. However, the spread of an Ebola outbreak derives in great part from social injustices that do not afford individuals and societies the same level of medical assistance as provided in affluent countries.
Another controversial aspect of repatriation is the risk of introducing an infectious agent into a country that is free of the disease and has little experience in its management. In Spain and the United States, secondary transmissions of EVD to healthcare providers from repatriated patients have been reported, raising the issue of the lack of proper infection prevention and control measures (Ebegbulem, 2015; Parra, Salmeròn, & Velasco, 2014). On the other hand, two Italian healthcare workers with complicated cases of EVD were repatriated to Italy, one of whom received mechanical ventilation in the intensive care unit without any secondary transmission of the virus (Petrosillo et al., 2015).
Finally, yet importantly, the financial cost of repatriation is not negligible. Even if the cost on the ground can be highly variable, the cost of each repatriation is around one million euros (Romero, 2014). For Ebola preparedness during the epidemic, an activity-based cost method was used in the Netherlands, in which the cost of staff time spent in preparedness and response activities was calculated, based on a time-recording system and interviews with key professionals at the healthcare organizations involved. The Dutch healthcare system provided cost information on patient days of hospitalization, laboratory tests, personal protective equipment, as well as the additional cleaning and disinfection required. The estimated total costs averaged 12.6 million euros, ranging from 6.7 to 22.5 million euros. The main cost drivers were personal protective equipment expenditures and preparedness activities by personnel, especially those associated with ambulance services and hospitals. Out of the 13 possible cases that were clinically evaluated, only one confirmed case was admitted to hospital (Suijkerbuijk et al., 2018). The amount of money spent on repatriation appears disproportionate to that given by some European countries for funding prevention projects in EVD-outbreak-affected countries and their border areas (Royo-Bordonada & García López, 2016).
The recent EVD outbreak in West Africa was unprecedented in scale, larger than all the previous outbreaks combined, and unique in its multi-country spread. Several issues arose from this multi-scientific and multi-cultural experience. Ebola was the embodiment of humanity’s fear of what is not fully known and cannot be fought. Our experience has taught us that EVD care should be guided by science, while taking psychosocial and ethical considerations into account, particularly with respect to containing the spread of this highly contagious and life-threatening disease while trying to improve the quality of health care; respecting patients’ sensibilities, traditions and customs; minimizing the risks to healthcare workers while providing essential patient care, and determining the optimal solutions for protecting and treating infected local and international healthcare workers who increased their own risk of contracting EVD while saving others’ lives.
Health Care Worker (HCW) volunteers from developed countries know that they are exposing themselves to life-threatening risks in order to help patients and professionals in underdeveloped countries. In resource-constrained and high-risk environments they will inevitably experience psychological stress and physical/emotional fatigue. HCWs cannot be immune to fear of contagion in necessarily performing invasive procedures on Ebola patients. But traditional cultures and practices in resource-limited countries exacerbate concerns. Patients may falsely deny previous exposure to EVD and/or traditional funerary rites may lead friends and family to come into contact with the bodies of patients who had died of EVD.
Completely covering HCWs in high-isolation units with personal protective equipment enables them to treat highly contagious EVD patients. But stress and fatigue can contribute to errors and failing to practice optimal safety measures. International HCWs who contracted EVD while voluntarily working in EVD-affected countries were generally repatriated to their countries of origin. It does not mean the stressors were removed. Many died. Family, friends, and associates may be apprehensive about interacting with HCWs returning from treating EDV patients fearing contagion. Given the financial cost of repatriation, the money may have been better used to build facilities in the vicinity of the epidemic, which would have saved many more lives. What is clear is that without international help, the epidemic would have been far worse and more people would have died. Other EVD patients benefitted when caregivers survived and the likelihood that more international HCWs would volunteer to help combat the epidemic was increased. The lessons learned from the world’s largest Ebola outbreak must not be lost – these are summarized in Table 1.
|(1)||HCWs voluntarily traveled from developed countries to help EVD patients in underdeveloped countries||Without international help, the epidemic would have been far worse and more people would have died|
|(2)||HCWs selflessly exposed themselves to life-threatening risks in order to help others||Many of the HCWs who contracted EVD died|
|(3)||HCWs deployed to resource-constrained and high-risk environments experienced psychological stress and physical/emotional fatigue||Stress and fatigue may have contributed to errors and failure to practice optimal safety measures, resulting in the infection of HCWs|
|(4)||HCWs may discriminate against EVD patients, owing to fear of contagion||Patients may be avoided, abandoned or rejected by HCWs|
|(5)||HCWs performed invasive procedures (intravenous indwelling, hemodialysis, reanimation procedures, mechanical ventilation) on Ebola patients||HCWs were able to save lives but increased their own risk of contracting Ebola|
|(6)||Some patients falsely denied previous exposure to EVD||HCWs and others were placed at risk of infection, some of whom died|
|(7)||Traditional funerary rites required friends and family to come into contact with the bodies of patients who had died of EVD||Many persons were infected due to these practices until safety precautions were instituted|
|(8)||Completely covering HCWs in high-isolation units with personal protective equipment enabled them to treat highly contagious EVD patients||When HCWs’ faces were covered with personal protective equipment, their personal contact with patients was diminished|
|(9)||International HCWs who contracted EVD while voluntarily working in EVD-affected countries were generally repatriated to their countries of origin.||
|10.||The post-deployment period may present additional but under-appreciated stressors||Returning to a higher-resourced healthcare setting may lead to inequity tension|
|11.||Family members, neighbors, friends or non-medical colleagues may have considerable apprehension about interacting with HCWs returning from treating EDV patients, erroneously fearing contagion||Erroneous fear of contagion has caused returning HCWs to be stigmatized and rejected by family members, neighbors, friends, non-medical colleagues and the general public|
Notes: EVD – Ebola virus disease; HCWs – healthcare workers.
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- Introduction: Research Production in Life Sciences
- Promoting Equity and Preventing Exploitation in International Research: The Aims, Work, and Output of the TRUST Project
- Ebola Virus Disease: A Lesson in Science and Ethics
- Ethics Challenges in the Digital Era: Focus on Medical Research
- Big Data in Healthcare and the Life Sciences
- Shaping a Culture of Safety and Security in Research on Emerging Technologies: Time to Move beyond “Simple Compliance” Ethics
- Governing Gene Editing in the European Union: Legal and Ethical Considerations
- ARRIGE: Toward a Responsible Use of Genome Editing
- Dual Use in Neuroscientific and Neurotechnological Research: A Need for Ethical Address and Guidance
- Ethical Challenges of Informed Consent, Decision-Making Capacity, and Vulnerability in Clinical Dementia Research
- Diet Therapy Effective Treatment but Also Ethical and Moral Responsibility
- The Mismatch of Nutrition and “Medical Practice”: The Wayward Science of Nutrition in Human Health