CDC: Ebola Characterized by 'Amplification in Health Care Settings'

When Peter Piot, the 'Virus Detective Who Discovered Ebola', went to one of the first identified outbreaks in 1976 in the Democratic Republic of Congo, he reported that "it was clear that the outbreak was closely related to areas served by the local hospital".

Piot says: "The team found that more women than men caught the disease and particularly women between 18 and 30 years old - it turned out that many of the women in this age group were pregnant and many had attended an antenatal clinic at the hospital."

He goes on: "The team then discovered that the women who attended the antenatal clinic all received a routine injection. Each morning, just five syringes would be distributed, the needles would be reused and so the virus was spread between the patients."

What he has to say about people getting ill after attending funerals is repeated in contemporary reports on ebola in West Africa, ad nauseam. But the comments about visits to the hospital, women attending antenatal care and reuse of syringes (and possibly other medical instruments) are no longer mentioned so much.

The CDC does write that ebola "has been characterized by amplification in health care settings and increased risk for health care workers (HCWs), who often do not have access to appropriate personal protective equipment", but they are not as expansive as Piot about exactly what that means on the ground.

There was a whole rash of recent reports about women being more likely to be infected with ebola than men in the current outbreak and a rather narrow set of speculative explanations about why this might be so, one being that women are more likely to be involved in giving care than men.

While women may well more often be the 'caregivers', an article in the New England Journal of Medicine summarizes available data on every reported case. However, it finds that there is very little difference in the numbers of men and women infected, and even the number of men who die from ebola.

There are also far fewer children infected than adults, despite claims that 'women and children' are more likely to be infected than men.

As far as I can see, media speculation into why women may be more likely to be infected than men (because they may have been more likely in some instances) did not question the possibility that women are often more likely to access healthcare, especially when pregnant.

Piot makes this connection during the first investigated ebola epidemic and goes on to connect women's elevated risk with the use of unsterile syringes, not just casual contact in healthcare facilities.

It is to be hoped that clinics are no longer issued with five syringes a day, though clear data about supplies of syringes and needles is hard to come by. But what about other infection control equipment and supplies; especially equipment and supplies in facilities that are experiencing extreme shortages?

What about facilities that are understaffed, where an adequate number of workers may be able to take certain precautions to protect themselves and their patients, but an inadequate number may only be able to think about their own safety, or not even that?

In the case of HIV there are many reasons why a woman might be more likely to be infected through unsafe healthcare. They are expected to attend antenatal care during pregnancy, give birth in a health facility, attend post-natal care, and perhaps several other reasons.

But since western countries, especially the US, have started taking an interest in ebola, they have reinforced efforts to round up people who look in the least bit like they have a fever and sticking them in an already overcrowded health facility, where conditions are appalling.

So if women were more likely to be infected with ebola earlier on in the current epidemic, and in some of the earlier outbreaks in other parts of Africa, perhaps the current approach is influencing the gender balance somewhat. One result possibly being that men are no longer less likely than women to go to a health facility (especially if they are given no option).

Piot says: "The closure of the hospital, the use of quarantine and making sure the community had all the necessary information eventually brought an end to the epidemic - but nearly 300 people died." Most people were quarantined in their own homes, not in an overcrowded and filthy ward.

How things have changed. Far from trying to persuade people to stay in their homes and supporting family members to look after them, US soldiers are helping to send people to what could be the very epicenter of the epidemic.

There are now far more confirmed and suspected ebola cases than there is hospital capacity to care for them. So a strategy that aims to strengthen and make hospitals safer, in combination with strengthening communities to care for people at home might now be the only option left.

The Dogmatic Sexualization of HIV

The main thrust of this blog has been to challenge the 'behavioral paradigm', the view that HIV is almost entirely transmitted by sexual behavior in African countries (The figure '90%' is often bandied about but there is no evidence for it). Therefore, any articles that either support or challenge the behavioral paradigm are of particular interest. As for the belief that the paradigm only holds for African countries, it is difficult to see that as anything other than racism.

A group of people led by Munyaradzi Mapingure have published a paper suggesting that the behavioral paradigm may need to be reconsidered in the light of their findings. They discuss sexual behavior data for Zimbabwe and Tanzania which clearly does not correlate with HIV prevalence. Zimbabwe has some of the highest HIV rates in the world while Tanzania has relatively low HIV prevalence. Yet levels of 'unsafe' sexual behavior are far higher in Tanzania than they are in Zimbabwe.

This lack of correlation between HIV and sexual behavior considered to be unsafe is not rare. There have been many instances of it over the years, in many countries. But few researchers have used the lack of correlation to question the behavioral paradigm. In 2003, a number of researchers published papers suggesting that HIV may not be as closely connected with sexual behavior as HIV prevention programming would lead one to believe. The HIV orthodoxy has yet to refute the body of evidence.

Mapingure and colleagues find that "women in Tanzania reported more risky sexual behaviour than women in Zimbabwe, which is opposite to what is reflected in the HIV prevalence. Prevalence of risky sexual behaviour characteristics, such as having had a casual sexual partner in the previous 12 months, having had more than one lifetime sexual partner, early sexual debut, being in a polygamous relationship and having siblings by different fathers, were all higher for Tanzania. Alcohol consumption, which increases the tendency to engage in risky sexual behaviour, was also more common in Tanzania than in Zimbabwe."

The authors conclude :"Clearly, sexual behaviour only cannot explain the observed differences in HIV prevalence between the two countries" and ask how this "paradox" can be explained. But there is no paradox. They even discuss other papers which make it quite clear that the behavioral paradigm was never in the least bit tenable. Every few years, detailed data on sexual and other behaviors in African countries are found not to correlate with HIV prevalence (check the Demographic and Health Surveys by country).

This paper suggests a few reasons why their results appear paradoxical but the authors seriously consider the possibility that non-sexual HIV transmission might be playing a part in Zimbabwe (which doesn't rule out the possibility of non-sexual transmission playing a part in Tanzania, also). They qualify this possibility by suggesting that such transmission would have been more likely in the 1980s, before the dangers of unsafe medical procedures were widely recognized.

HIV epidemics such as the ones in Zimbabwe, Swaziland, South Africa and others suggest that rates of transmission were probably still high well into the 1990s and perhaps the 2000s. The dangers of nosocomial transmission of HIV, transmission from unsafe medical procedures, may have been recognized a long time ago. But there is little evidence that this form of transmission was successfully eradicated in any sub-Saharan African country. It is more likely that relatively low HIV prevalence in Tanzania is a result of very low access to health services.

Conversely, higher access to health services in Zimbabwe could go a long way towards explaining the incredibly high rates of transmission seen there. And the rates really are incredible. Given the low transmission probability for sexual transmission of HIV per sex-act, Zimbabweans would need to do little else but have sex to explain national prevalence, which reached almost 30% at one time.

In an article commenting on the above paper, Mapingure says "early in the epidemic, syringes weren’t sterilized properly". WHO has recently accepted that as much as 14% of injections are unsafe. Disposable syringes are being reused, either because they are in short supply or because supplies are not reaching their target. Also, health workers are probably not fully trained in making their practices absolutely safe. Published Health Service Provision Assessments make it clear that many Kenyan and Tanzanian health facilities do not have the capacity to eliminate nosocomial infections.

He concludes “Most HIV prevention programmes are failing because they focus on sexual behaviour. We need to look at the whole sexualization of HIV.” This is not just a challenge to the behavioral paradigm. It is a challenge, a long overdue challenge, to the whole of the HIV orthodoxy. UNAIDS and those tasked with reducing the spread of HIV have failed miserably. To this day, they refuse to accept the possibility that non-sexual transmission of HIV is the only thing that can explain the huge differences in prevalence found between and within different countries.