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Ebola cases in Germany test plans made long ago for other diseases

Back on March 26, just days after global health officials determined that a rash of deaths along the borders of Guinea, Sierra Leone and Liberia was the result of the deadly Zaire strain of the Ebola virus, the Klinikum St. Georg in Leipzig announced that it had a ward ready to deal with the disease.

Months later, on Oct. 14, a 56-year-old Sudanese United Nations health care official died in that unit. He’d contracted Ebola while working in Liberia, had arrived in a sealed container and was treated around the clock for a week by doctors and nurses in sealed outfits in that sealed ward.

Hospital and Leipzig city officials admit that while the ward was secure – helping to prevent the disease from spreading – there was very little they could do for the man himself.

Which is the story of Ebola and the West. There’s a lot teeth gnashing over how – away from the hot zone of West Africa, and with the vast wealth available to the medical communities of the United States and Europe – to deal best with the threat of a disease that’s killed half of those infected: 9,200 are known to have been infected, and 4,550 are known to have died.

World Health Organization officials are fearful that by December the number of those infected might be increasing by 5,000 to 10,000 a week and the lethality could be 70 percent.

The United Nations has said that keeping this outbreak from breaking out further will cost $1 billion. Treatment for a single patient in Germany is reported to have cost more than $2.5 million, including for a scanner and mobile X-ray device that had to be junked after the patient vomited on them.

European medical experts admit that no two of the 11 cases to date in Europe – 10 evacuees from the hot zone and a nurse who was infected in Spain while treating one of them – have been treated identically.

In Germany, St. Georg clinic director Dr. Bernhard Ruf said the challenge was to do everything possible to help the patient while making sure the staff stayed safe from the contagion.

“We don’t think you can deny any intensive medical care options to Ebola patients,” he said. “In the absence of an approved drug, treatment mainly consists in trying to control symptoms. The infection is often accompanied with organ failure, which needs to be treated symptomatically. Respirators and, if needs be, dialysis, are important measures to deal with these symptoms.”

In the United States, the director of the Centers for Disease Control and Prevention called the use of dialysis on an Ebola patient in Dallas a highly risky treatment. Ruf disagrees, acknowledging that there are risks but that they “can be controlled if you adhere to strict routines.”

He noted that it was difficult to know whether they’d learned a lesson.

“It was only one case,” he said, adding that medical officials across Europe involved in fighting Ebola compare notes frequently.

But Ruf said the outbreak highlighted the limitations of German preparedness.

“We set up the quarantine centers around Germany about 10 years ago, when the main worries were new influenza strains and SARS,” he said, referring to severe acute respiratory syndrome. “We did not envisage having to deal with Ebola cases. Treating Ebola presents challenges.”

The Leipzig clinic is part of a network of high-end hospitals around Germany that have a total of 50 beds in securely isolated wards ready to treat the disease. Ruf said that because of the intensive care required, however, Germany really could treat only about 10 Ebola patients at a time in those 50 beds.

Thus far three of the beds have been used. The case in Leipzig ended in death. A case in Hamburg ended in recovery; a Senegalese aid worker was released after five weeks of treatment. A case in Frankfurt looks hopeful; a Ugandan doctor who was infected while working in Sierra Leone is receiving treatment. German privacy laws have kept their identities secret.

The Hamburg case is intriguing. Media reports indicate that doctors there took a simple approach to Ebola treatment: fluids, pain medications and a high level of security to make sure the staff and population stayed safe. They avoided experimental drugs.

Germany, considered to be among the most well-prepared European nations to handle this crisis, hasn’t planned how to deal with Ebola should the disease spread through its population. Its treatment plan involves patients coming in limited numbers, and in controlled situations.

A World Health Organization report on the first cases of the current outbreak, however, illustrates just how quickly Ebola can overwhelm a region.

On Dec. 26 in the remote Guinean village of Meliandou, a 2-year-old boy became gravely ill. He had a fever, black bowel movements and vomiting.

The beginning of an epidemic

The current Ebola outbreak can trace its origins to a single remote village on the border Guinea, Sierra Leone and Liberia

West Afria map
  1. Dec. 26: Maliandou, Guinea A two-year-old boy, Emile, begins to show symptoms in a remote Guinean village.
  2. Dec. 28: Emile dies.
  3. Jan. 1: Emile's three-year-old sister, Philomena, begins to show symptoms.
  4. Jan. 4: Philomena dies.
  5. Jan. 6: Emile's pregnant mother, D. Sia, and a visiting family friend, Fanta, begin to show symptoms.
  6. Jan. 11: D. Sia dies after her pregnancy ends in a miscarriage. Two midwives who had helped with the miscarriage begin to show symptoms.
  7. Jan. 11: Kangama, Sierra Leone Fanta dies, after returning home to Sierra Leone, spreading the virus to a second country.
  8. Jan. 11: Gueckedou, Guinea Emile's grandmother, Koumba, becomes ill and is taken to a nearby hospital.
  9. Mid January: Both midwives die.
  10. Late January: Koumba is visited by her nephew, David, before she dies.
  11. Feb. 1: Conakry, Guinea David begins exhibiting symptoms after returning to Conakry, Guinea's capital and a city of 1.6 million residents.
  12. Feb. 5: David dies.
  13. March 23: The Institut Pasteur in Paris finally provides a diagnosis: the deadly Zaire strain of Ebola.
  14. Previously, Gabon, hundreds of miles away, was the furthest north the Zaire strain had been detected.
  15. 1994: Ivory Coast The last time Ebola was detected in West Africa.
Sources: World Health Organization, McClatchy Washington Bureau

The report points out that such symptoms are common to many diseases known in the region. Ebola was new to the area. In 1994, there had been a single case of Ebola in Ivory Coast, and the deadliest of Ebola strains, the Zaire, hadn’t been seen north of Gabon or the Democratic Republic of Congo, hundreds of miles away.

The village that became the center of this hot zone sits within miles of Sierra Leone and Liberia. The report notes that in the desperately poor region, the borders are porous, if guarded at all, and people seeking food or work routinely travel, creating what the report called “a dream situation for a highly contagious virus.”

Exactly how the virus, especially the Zaire strain, made it to this triangle of dense forest in three nations is unclear. The report makes an educated guess, based on timber and mining:

“The ecology in the densely forested area changed. Fruit bats, which are thought by most scientists to be the natural reservoir of the virus, moved closer to human settlements. Hunters, who depend on bush-meat for their food security and survival, almost certainly slaughtered infected wild animals – most likely monkeys, forest antelope or squirrels.”

Once there, the way Ebola spread is now known.

A WHO chart tracking the first deaths illustrates that. The 2-year-old boy, whom the report identifies only as Emile, showed symptoms on Dec. 26 and died Dec. 28. His sister, Philomena, 3, showed symptoms Jan. 1 and died four days later. Their pregnant mother, D. Sia, and a family friend who’d visited for the funerals, Fanta, showed symptoms on Jan. 6. D. Sia miscarried, and Fanta returned to her home in Sierra Leone. Both died Jan. 11, and the virus had spread to a second country.

Emile’s grandmother, Koumba, became ill that same day and was taken to a hospital in Gueckedou, Guinea. Just after her death, the two midwives who’d helped the family through the miscarriage showed symptoms. Within a week both were dead. Before Koumba died, she was visited by a nephew who then returned to his home in the Guinean capital, Conakry. He didn’t show any symptoms until Feb. 1, but he was dead by four days later, and the capital’s 1.6 million residents were now at risk.

It wasn’t until late March that officials were able to determine that the deadly disease was Ebola.

Dr. Pierre Formenty, the head Ebola expert for the WHO, traced the outbreak backward and said the “first cases yielded no strong or convincing hints . . . of just what the causative agent might be, especially in a country with so much background noise from multiple other killer diseases.”

Doctors in the region had been suspecting more common killers: cholera or malaria. They’d never seen Ebola before. When the diagnosis finally came on March 23, it came from the Institut Pasteur in Paris.

Doctors in Germany, the rest of Europe and the United States had been preparing for Ebola for about two decades.

In Hamburg, Berlin, Leipzig, Duesseldorf, Frankfurt, Stuttgart and Munich, they’ve built isolation wards for treating highly contagious diseases. The rooms are set up about the same everywhere. They’re in isolated wards with low-air-pressure rooms – so that in case of a breach, the air flow will be inward. The wards are hermetically sealed and approachable only through double-door systems, which include disinfectant showers.

The doors have magnetic locks and cannot be opened at the same time. Air and water are filtered before they leave the isolation ward, and all materials are decontaminated after use.

Dr. Ruf of Leipzig noted that staff preparation‏ includes everything from how to put on and take off protective gear to how to care for patients while in that gear. And, he said, it’s important that the training continues, even after this outbreak ends.

“We are aware that after Ebola is before the next epidemic,” he said. “We need to respond to these new challenges and possibly expand the capacity and the treatment options.”

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