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CDC: Ebola could infect 1.4 million in West Africa by end of January if trends continue CDC: Ebola could infect 1.4 million in West Africa by end of January if trends continue
(about 4 hours later)
The number of Ebola cases in West Africa could reach 1.4 million by the end of January if trends continue without an immediate and massive scale-up in response, according to a new estimate by the Centers for Disease Control and Prevention. The Ebola epidemic in West Africa, already ghastly, could get worse by orders of magnitude, killing hundreds of thousands of people and embedding itself in the human population for years to come, according to two worst-case scenarios from scientists studying the historic outbreak.
The report released Tuesday is a tool the agency has developed to help with efforts to slow transmission of the epidemic and estimate the potential number of future cases. Researchers say the total number of cases is vastly underreported by a factor of 2.5 in Sierra Leone and Liberia, two of the three hardest-hit countries. Using this correction factor, researchers estimate that approximately 21,000 total cases will have occurred in Liberia and Sierra Leone by Sept. 30. Reported cases in those two countries are doubling approximately every 20 days, researchers said. The virus could potentially infect 1.4 million people by the end of January, according to a statistical extrapolation by the U.S. Centers for Disease Control and Prevention published Tuesday. That astonishing number came just hours after a report in the New England Journal of Medicine warned that the epidemic might never come fully under control, and that the virus could become endemic in the population, crippling civic life in the affected countries and remaining an ongoing threat to spread elsewhere.
“Extrapolating trends to January 20, 2015, without additional interventions or changes in community behavior,” such as much-improved safe burial practices, the researchers estimate that the number of Ebola cases in Liberia and Sierra Leone could be between approximately 550,000 to 1.4 million. These dire scenarios from highly respected medical sources were framed, however, by optimism from U.S. officials that a ramped-up response can and will contain the outbreak in the weeks and months ahead.
“The findings in this report underscore the substantial public health challenges posed by the predicted number of future Ebola cases,” the researchers wrote. “If conditions continue without scale-up of interventions, cases will continue to double approximately every 20 days, and the number of cases in West Africa will rapidly reach extraordinary levels.” CDC Director Tom Frieden cautioned that the estimates in the new report from his agency do not take into account the actions taken, or planned, since August by the U.S. and the international community. Help is on the way and it will make a difference, he said — but time is of the essence.
They also said their assumptions may not fully account for sick patients who are turned away from treatment centers that don’t have any spare beds. That suggests the number of underreported cases could be even higher. “A surge now can break the back of the epidemic, but delay is extremely costly,” Frieden said.
CDC Director Tom Frieden cautioned that the estimates in the report don’t take into account actions taken or planned since August by the United States and the international community. In a telephone briefing with reporters, he said he did not believe the worst-case scenario “would come to pass.” The situation on the ground in West Africa is bleak, with people dying of Ebola in the streets outside clinics with no available beds, and other victims remaining at home where they are infecting their care-givers. No Ebola outbreak has ever approached the scale of this one. The previous worst outbreak, in Central Africa, involved only 425 infections in Uganda from October 2000 to January 2001, and was brought under control by local responders aided by international organizations, according to the New England Journal of Medicine.
He added: “A surge now can break the back of the epidemic, but delay is extremely costly.” The World Health Organization has reported more than 5,800 cases including more than 2,800 deaths. The CDC assumed the actual number of cases is 2.5 times higher than what’s officially known.
He said the actions by the United States and other countries and organizations will slow the spread of the epidemic. The estimates in the report are based on data from August and don’t reflect the considerable increases in efforts to improve treatment and isolation. On graphs showing the rising number of infections and deaths, the lines continue to curve upward. Infections are doubling every 20 days in the coastal nations of Liberia and Sierra Leone, the CDC said. Each infected person is infecting roughly two additional people. The epidemic will begin to subside when that reproduction rate of 2.0 becomes lower than 1.0.
He said the tool developed by the CDC to make these projections provides the ability to help Ebola response planners make more informed decisions on the emergency response to help bring the outbreak under control – and what can happen if these resources are not brought to bear quickly. The CDC estimates that in Liberia and Sierra Leone, including unreported cases, there will be about 21,000 total infections by Sept. 30.
“It is still possible to reverse the epidemic, and we believe this can be done if a sufficient number of all patients are effectively isolated, either in Ebola Treatment Units or in other settings, such as community-based or home care,” he said. “Once a sufficient number of Ebola patients are isolated, cases will decline very rapidly – almost as rapidly as they rose.” “Extrapolating trends to January 20, 2015, without additional interventions or changes in community behavior (e.g., notable reductions in unsafe burial practices), the model also estimates that Liberia and Sierra Leone will have approximately 550,000 Ebola cases (1.4 million when corrected for underreporting),” the CDC wrote.
The latest findings come as the World Health Organization’s official count for the outbreak has surged past 5,800 people infected and 2,800 deaths. New projections by the WHO published by the New England Journal of Medicine on Tuesday, also acknowledge that “the true numbers of cases and deaths are certainly higher.” The WHO says the number of cases could quadruple to more than 20,000 by early November. The CDC report did not include any modeling for Guinea because the disease has struck “in three separate waves,” Frieden said, making it difficult to come up with a valid model to predict what can happen next. The biggest area of uncertainty centers on the heavily forested region where Guinea, Sierra Leone and Liberia intersect, which has been the epicenter of the outbreak.
The key to slowing or stopping spread of the deadly virus is getting sick patients into medical facilities or Ebola treatment units or in other settings where there is reduced risk of transmission. But many hospitals are closed, and treatment centers are so stretched that they must turn patients away. The disease may also spread beyond the countries currently affected. Jean Francois Aguilera, an epidemiologist for the International Organization for Migration, said in Monrovia on Tuesday that there is a high probability that the epidemic will spread to Ivory Coast, and some chance it will reach Mali. Typically the rainy season ends in mid-October, and people move more between countries when the weather improves. Senegal, which has seen one case so far, is also vulnerable, he said.
Projections for new Ebola cases: Read the CDC reportProjections for new Ebola cases: Read the CDC report
The CDC report offered a hypothetical scenario for slowing and eventually stopping the epidemic. In order for that to happen, about 70 percent of infected patients would need to be properly isolated and treated. Frieden said Guinea has available beds in its treatment centers, except for a heavily forested region that was the outbreak’s epicenter. In Sierra Leone, treatment centers are full, and patients are waiting outside, but not in large numbers. In Liberia, there are “significant numbers” of patients unable to get into treatment units, Frieden said. Aguilera said the potentially catastrophic estimates from the CDC seem plausible.
The report also attached specific numbers showing the high cost of delay. Every month-long delay in increasing the percentage of patients in treatment to 70 percent results in a tripling of the number of daily cases. “The reality, what I can see on the ground, is that we are late. We are running after the epidemic at the moment,” Aguilera said.
The United States recently launched a $750 million effort to establish treatment facilities in Liberia, and the United Nations Security Council voted unanimously last week to create an emergency medical mission to respond to the outbreak. In addition, the WHO is launching an effort to move infected people out of their homes and into small centers that would provide at least rudimentary levels of care, in hopes of increasing survival rates and slowing the transmission of the disease. “I’m sure we’ll slow down the epidemic,” he said when asked if there is reason for hope. “The international community is moving now, but too little, too late.”
Global health officials say the priority is Ebola treatment units, and those facilities are not arriving fast enough. It could be weeks, even months, before the 1,700 new treatment beds promised by Washington are operational. Paul Duprex, an associate professor of microbiology at Boston University, cautioned against doomsday thinking, such as wild speculation that the virus could have mutated to become transmissible through the air — something for which there is no credible evidence.
Gayle Smith, Special Assistant to the President and Senior Director for Development and Democracy, who was also on the call, said she could not provide more specifics on when those new treatment beds are likely to be operational.. “We need to be careful not to scare people with unrealistic numbers – it’s like this airborne suggestion – where’s the evidence, what’s the precedent, what are such scaremongering suggestions based on?” he said.
“I cannot give you an exact date,” she said. “What I will say is that DoD [Department of Defense] along with civilian agencies are working extremely hard on a fast basis to identify sites and getting construction up and running.” The new regional U.S. command based in Monrovia has been on the ground for a week, and officials are “very satisfied” with how fast they have been moving, she said. Frieden of the CDC said the tool developed by the CDC to make projections about future spread of the disease is an effort to help Ebola response planners make more informed decisions. This presents a what-if case — the nightmare scenario if no one does anything.
The report did not include any modeling for Guinea because of the way that country has experienced the outbreak so far, Frieden said. The disease has struck “in three separate waves,” he said, making it difficult to come up with a valid model to predict what can happen next. “The situation in Guinea is very much in the balance, and they do have the potential to control it — they’ve done it three times already.” The biggest area of uncertainty centers on the heavily forested region where Guinea, Sierra Leone and Liberia intersect, which has been the epicenter of the outbreak. “It is still possible to reverse the epidemic, and we believe this can be done if a sufficient number of all patients are effectively isolated, either in Ebola Treatment Units or in other settings, such as community-based or home care,” Frieden said. “Once a sufficient number of Ebola patients are isolated, cases will decline very rapidly – almost as rapidly as they rose.”
CDC researchers said findings in the report do not take into account several factors that could affect the forecast. Substantial changes in movement of people within countries or across borders could affect the arc of the epidemic. Researchers are also assuming the current epidemic has incubation periods and other characteristics similar to previous outbreaks. The correction factor — needed to adjust for underreporting of cases — could “change substantially over time,” the report said. Regional differences in underreporting of cases “might mean that using one correction factor across an entire country is inappropriate.” Paul Farmer, a Harvard professor of global health and co-founder of the nonprofit Partners In Health, visited Liberia in recent days and said in a telephone interview from Monrovia that, dire as the situation is, the epidemic is not unstoppable.
“It will be brought under control even as we apply these basic interventions. It’s going to work,” Farmer said.
The key to slowing or stopping spread of the deadly virus is getting sick patients into medical facilities or Ebola treatment units or in other settings where there is reduced risk of transmission. But many hospitals are closed, and treatment centers are so stretched that they must turn patients away.
The CDC report offered a hypothetical scenario for slowing and eventually stopping the epidemic. In order for that to happen, about 70 percent of infected patients would need to be properly isolated and treated. Frieden said Guinea has available beds in its treatment centers, except for in the heavily forested region. In Sierra Leone, treatment centers are full, and patients are waiting outside, but not in large numbers. In Liberia, there are “significant numbers” of patients unable to get into treatment units, Frieden said.
After Sierra Leone instituted a national three-day lockdown that ended Sunday, where nearly 30,000 health workers, volunteers and teachers aimed to visit every household in the country of six million people to educate residents and isolate the sick, officials confirmed 130 confirmed cases and are awaiting tests on 70 more.
The United States recently launched a $750 million effort that includes treatment facilities in Liberia, and the United Nations Security Council voted unanimously last week to create an emergency medical mission to respond to the outbreak. In addition, the WHO is launching an effort to move infected people out of their homes and into small centers that would provide at least rudimentary levels of care, in hopes of increasing survival rates and slowing the transmission of the disease.
Although the United States plans to build 17 treatment centers, each with 100-bed capacity, in Liberia, American personnel will not be staffing those facilities, officials have said. Instead, the U.S. plans to train volunteers and others from aid organizations or nonprofits. Some global health experts have said this could slow down the response because there aren’t enough volunteers stepping forward.
The virus is extraordinarily lethal, killing about half the people infected, though in some regions it has killed close to 70 percent. The virus is spread by bodily fluids; corpses are viral bombs and the traditional practice of washing the deceased for burial has been implicated in the explosion of the disease.
There is no evidence yet that this strain of the Ebola virus is significantly different than previous strains. Scientists say it is possible that it is slightly less lethal, or replicates slightly more slowly in the human host, and has allowed more sick people to survive the infection and move around with the virus.
“If you have a whole lot more survivors than you normally have, that’s a whole lot more people who are potentially shedding the virus than you would have in a normal Ebola outbreak,” said Tom Geisbert, professor of microbiology and immunology at the University of Texas Medical Branch at Galveston. But so far scientists have had limited ability to study this particular strain of the virus.
The most likely explanations for the scale of the outbreak involve geography, poverty and health care systems. West Africa has never had an Ebola outbreak. Few people recognized the disease when it first appeared late last year in Guinea near the borders with Sierra Leona and Liberia. hey are among the poorest countries on the planet and their health care system has been completely overwhelmed by the outbreak. The symptoms of Ebola — fever, vomiting, diarrhea — are similar to those of other diseases, such as malaria.
Staff writer Lenny Bernstein in Monrovia, Liberia contributed to this report.
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