This article first appeared in Dallas Morning News
William H. Frist, the doctor and former Senate Majority Leader, has broken his self-imposed silence with a few words of perspective about the current Ebola outbreak.
In West Africa, the crisis could easily last into next spring. In the United States, it is much more containable. And while he says the virus is very “cagey,” scientists have a good understanding of how it is transmitted, know that this outbreak isn’t any different than any other Ebola outbreak and the odds that this virus has somehow mutated is “very, very unlikely.”
So what went wrong in Dallas? In some ways, it is also what went wrong in West Africa. Diagnostics are still too slow, meaning that samples were sent off to a lab somewhere and weren’t returned for a couple of days. There wasn’t a rapid enough response. And of course, the consequences years of underfunding global infectious diseases are also a factor in a virus that has been an issue on the African continent now reaching American soil.
Frist estimates that 23,000 people will die of the flu this year, and in America less than “10 will die of Ebola, hopefully just one.” And while every death is tragic, the reality is that protocols have to be strictly established and followed. “This is not contagious virus like flu,” he said.
Frist, in town to champion global investment for sensible family planning policies in underdeveloped countries, said the world response to HIV/AIDS showed the value of a global response. While the Ebola crisis in West Africa has lasted longer than he anticipated, he wants people to know that he is confident it will NOT spin out of control in the United States even though it might seem that public uncertainty is trumping established science.
Frankly, I think Frist is right in so many ways. A big part of infectious disease control is investing money in the right places, ideally at the source of the problem as early as possible, changing habits and having the right targeted response. “If we had invested one-tenth of what people think we have invested, we wouldn’t be in this position,” said Frist.
I know a key part of changing the trajectory of HIV/AIDS infections was the development and delivery of effective new drugs to patients. In the United States, those drugs saved lives. And, in Africa, drugs that reduced the transmission of HIV/AIDS from mother to child were integral in the battle. And that’s why Frist’s work is so important.
Frist, who is working with Hope Through Healing Hands in Nashville, wants to apply those principles to global family issues. We have all heard the stories of how a woman in an undeveloped country who delays childbirth has a greater chance to get an education and avoid a life in poverty. But there are other benefits — life itself. About 1 in 39 women in sub-Saharan Africa die of pregnancy complications. Simply spacing pregnancies at least three years apart dramatically increases over survival rates.
The overarching message is that the global health agenda must be just that — global. Generational poverty, infectious diseases and even infant/mother survival rates in Africa should concern us in the highly industrialize United States because the consequences can be just a plane ride away.
Language in the Global Health Arena for HIV/AIDS and Family Planning
Oct 10 2014
Jennifer Eaton DyerEating lunch outside the refectory of Vanderbilt Divinity School, back around the turn of the millennium, I remember stumbling across the stone etching of Schola Prophetarum, the School of the Prophets. I am sure all who have passed through the halls of the Divinity School may have reflected on their potential role as a prophet in our community, society, and our world. That is our legacy.
Oct 08 2014
Have you had a chance to meet Touch? This dog is changing lives and we're so excited to watch what he and Senator Frist are doing for our kids. If you haven't seen it already, watch this video now. This is such a special story:
Fox News | October 8, 2014
By Bill Frist
Wednesday morning brought sad news that Thomas Duncan, the Ebola-infected patient in Dallas, has passed away. It also brings heightened scrutiny of our nation’s strategic plan for dealing with Ebola in the U.S.
Ebola is undoubtedly a frightening disease. In West Africa -- without appropriate medical facilities and staff -- it is spreading at a truly alarming rate.
And now the disease is here. At home. A geographic spread that was nearly inevitable considering our global movement is sparking questions about what to do next. The CDC and other public health officials are walking a fine line: being realistic about a serious risk while belaying panic.
One individual must coordinate the efforts of key agencies and players to facilitate centralization of American resources to function synergistically and improve impact and speed.
It’s not an easy puzzle; global health issues never are. But the same steps we’ve been advocating for in Africa are applicable here.
First we have to understand this disease. Ebola is contagious, but far less so than small pox or HIV. It is transmissible only through direct contact with bodily fluids from an infected person: blood, vomit, urine, feces, saliva and other secretions. As we have seen with the effort in Dallas and the Ebola workers who were brought home, ability to contain and treat in U.S. medical facilities makes a widespread, uncontrollable outbreak extremely unlikely.
I am not minimizing the potential lethality of Ebola. But a response to Ebola needs to be tailored to the natural history of Ebola.
We know that containment is paramount, and isolation is the most important part of an Ebola strategy. But there is no way to isolate everyone in West Africa with a febrile illness given the variety of endemic viruses and infections to the area.
To really stop the spread of the disease—to get ahead of it—we need a rapid diagnostic test (RDT) that can be deployed on the ground, not in a laboratory. A test that facilitates appropriate quarantine of those with disease and release of those without. Not only will this allow us to focus resources, it will also help build trust and allay fears.
The same test could be used at home as well to quickly evaluate travelers and potentially prevent another case like the one in Dallas. Without an RDT, there will always be a window between when the patient becomes contagious, and when we can confirm a diagnosis. Precautionary quarantines and travel restrictions can help, but they will not replace accurate and timely diagnosis.
While we are waiting on a potential test, we must efficiently leverage the resources we have to offer.
Senators Rob Portman, R-Ohio and Lamar Alexander, R-Tenn., have urged President Obama to appoint a single administration official to coordinate the U.S. strategy to contain and combat Ebola. I agree that one individual must coordinate the efforts of key agencies and players to facilitate centralization of American resources to function synergistically and improve impact and speed.
The Centers for Disease Control (CDC), the Department of Homeland Security (DHS), Customs and Border Protection (CBP), and others will have crucial roles to play. They must present a united effort.
The death of the first patient diagnosed with Ebola on U.S. soil should not herald panic. But it is impetus to make sure we disseminate the most accurate information, that our response plan is coordinated and thoughtful, and that our nation’s best minds are focusing on a solution.
The importance of speed cannot be understated. Time is not on our side.
William "Bill" H. Frist, M.D. is an American physician, businessman, a former U.S. senator from Tennessee and the former Republican majority leader in the U.S. He is the chairman of global health non-profit Hope Through Healing Hands.
Oct 03 2014
By Milca Nunez, Frist Global Health LeaderNext Monday will be our fourth week in this field experience with Project HOPE in the Dominican Republic. We are almost halfway done, so I am anxious to learn as much as possible while I am here. I do not know if I will ever have another opportunity such as this one, where I get to travel, gain university credits and earn work experience. I am thankful for being here every day, although I feel nostalgic at times. But I decided to take on this challenge so I am determined to finish strong! Last week was a very busy week full of interesting and distressing things. I will elaborate further in the following lines.
Sen. Bill Frist
This articie was originally published at Forbes.com
The size and spread of this Ebola epidemic is simply unprecedented. The largest previous Ebola outbreak occurred in 1976 in Zaire: 318 confirmed cases and 280 deaths, but the current outbreak in West Africa has exceeded 4,400 cases with 2,300 deaths and growing. According to WHO estimates more than 20,000 more cases will occur before containment is achieved.
I, and many others, have written about the need for more resources and healthcare infrastructure. Hopefully the U.S. commitment of 1700 beds, training of 500 healthcare workers and 400,000 home treatment kits will offer much needed help and reduce the mortality rate from 50%.
But stemming the tide of this epidemic will not happen with only the commitment the President has made. Treating the sick is imperative, but as the number of cases grows exponentially, we have to take a closer look at why – we are failing at contact mapping and containment, and for three very good reasons.
First, there are cultural barriers to containment such as distrust of Western medicine, commitment to local burial practices, and a lingering disbelief that the virus exists. These barriers prevent containment procedures from being implemented and sanitary burials from being practiced.
Second, there is fear of the disease and what identification and isolation means. “Virus hunters,” public health workers skilled in contact mapping of exposures, are having a difficult time finding the sick because of the fear. People hide, change their address, and have even thrown rocks at aid workers. People do not want to be isolated and taken away from their families to wait out the incubation period and possibly die alone in makeshift clinic far from home.
Finally, we do not have a way of rapidly identifying the virus in the field. Current practice for fever in countries like West Africa is to rule out and treat the things that are more common, easily identified and more easily treated with the assumption that if the patient does not improve, a viral hemorrhagic fever is the diagnosis of exclusion. In West Africa, malaria or bacterial infections are the more likely more treatable diseases, so the practice is to rule out malaria and possibly use empiric antibiotics before assuming Ebola.
We have rapid detection tests (RDTs) for malaria that can and are being used in the field. The problem is the sensitivity and specificity are not adequate to definitively diagnose malaria. And even given this practice of diagnostic rule out, the truth remains that a negative test for malaria does not necessarily mean a positive test for Ebola and visa versa. We need diagnostics that are more definitive.
There are many types of tests for Ebola. Isolating the virus provides the most sensitive and specific diagnosis, but requires transport of biohazard material to a BSL-4 lab, of which there are few in the world. Alternatively there are reverse transcription polymerase chain reaction (RT-PCR) and quantitative PCR, which are both very sensitive and specific, but again require a lab. Newer tests include antigen and antibody identification using ELISA, and a nanoparticle microscopy system termed the Single Particle Interferometric Reflectance Imaging Sensor (SP-IRIS), which can digitally identify virons based on size. (ACS Nano. 2014 Jun 24;8(6):6047-55.)
There have been improvements in diagnostic ability in Sierra Leone that have improved care immensely, but all of these tests must be performed in a lab and that lab may not be local. It could take days to get results back. We need a test we can deploy rapidly in the field and have results in under an hour.
A very rapid test would be game-changing for Ebola. Let’s look at triage in a clinic. Everyone comes in the front door together and waits together. Most people have a fever, but they aren’t sure why. Most likely, it’s another endemic infection like malaria, typhoid or shigella. An RDT could quickly identify patients needing quarantine from those who do not. The benefit here is threefold: fast and early quarantine to separate patients at risk for infecting others making the rest of the hospital safer; replacing fear and anticipation with knowledge; and a more efficient use of quarantine resources because they are saved for people with known Ebola infections.
An RDT would also allow healthcare workers to confidently come to work knowing they are not infected. It would also prevent unnecessary quarantine of these most-needed personnel for the 21 day incubation period.
The same would hold true for exposed individuals. Given the lack of clinics and isolation units, public health workers are offering more home-based care. This requires isolation of people in their homes for up to three weeks. A RDT would allow appropriate use of those resources.
An RTD could also be used at borders and airports for health officials to safely allow or restrict access from a country with a known outbreak, enabling the delivery of much-needed supplies, workers, and resources safely.
Finally, when this outbreak is contained, having an RDT would help more quickly identify new outbreaks in the future, facilitating early containment and guiding the use of prophylactic drugs, like Zmab, if available.
I want to impress upon you this is not conjecture. The reasons above make logical sense, but experts can also use mathematical modeling studies to show the effect of adequate containment versus rapid detection. Containment is certainly effective and has worked during all outbreaks in the past, but diagnostics either on site, off site, for all febrile patients or even just healthcare works can make a significant impact on the size of an outbreak.
An RDT—a new test or an adaptation of what we have—would not only be a massive step towards controlling this outbreak, I think it is the only step that will ultimately prevent this tragic epidemic from becoming a pandemic.