Is the U.S. pursuing the right strategy against Ebola?

Just two months ago, patients were being turned away from Ebola treatment units in Liberia because there weren’t enough beds to cope with the spiraling caseload.

President Obama dispatched hundreds of troops to build and supply 17 new units, along with a 25-bed field hospital dedicated to treating infected healthcare workers. But before the first of the 100-bed units opened this month in Tubmanburg, there were signs that the epidemic was slowing down.

The number of new cases reported in Lofa County, where Liberia’s outbreak began, decreased from a peak of 153 in the week ending Aug. 16 to four new cases in the week ending Nov. 1, according to a report issued by the U.S. Centers for Disease Control and Prevention.

In Montserrado, Liberia’s most populous county, which accounts for half of the nation's Ebola cases, there has been a 73% decline in admissions to isolation wards, a 58% drop in blood samples testing positive for the virus and a 53% decline in the number of bodies collected for burial since mid-September, according to another report that appeared in an early version of the CDC’s Morbidity and Mortality Weekly Report on Friday.

Researchers caution, however, that new outbreaks continue to emerge in more remote parts of Liberia that could drive the numbers back up if they aren’t swiftly contained.

The country accounts for more than 6,800 of the 14,400 confirmed and suspected Ebola cases and more than 2,800 of the 5,100 deaths reported to the World Health Organization since March.

The latest twists are forcing the United States and its partners to reevaluate their response in West Africa, which has continued to lag behind the epidemic.

Rather than focus on building large treatment units, international aid groups such as Doctors Without Borders are urging donors to finance mobile teams that can quickly respond to new hot spots to isolate the sick, trace those who came into contact with them, disinfect contaminated areas and conduct safe burials.

Obama has asked Congress for $6 billion to expand the fight against Ebola in West Africa and at home.

The Los Angeles Times spoke with Rajiv Shah, the administrator of the U.S. Agency for International Development, to find out what the government is doing to get ahead of the virus. Here is an edited transcript of the conversation.

It’s been two months since the president announced that he was sending troops to West Africa as part of stepped-up efforts to fight Ebola. Have they had any effect?

If I could step back and just say, I fundamentally believe that we will not resolve the risk of Ebola in the United States until we tackle Ebola at its source in West Africa. To that end, the president has led an international effort that includes a number of other partners that have stepped up efforts in the last three months, two months in particular, and I think we’ve started to see that those efforts have made a very significant impact in beginning to stem the tide of this really disastrous disease.

In Liberia, for example, the USAID-coordinated effort has helped to already build and staff a number of new Ebola treatment units. We have helped to set up more than 50 burial teams that go out and get the bodies of the deceased, and safely and in a dignified way dispose of those bodies. And we have really worked throughout the country to communicate that Ebola is real, that people need to wash their hands, not touch each other and change their basic behavioral norms in order to protect themselves.

The result of that effort is that we’ve seen a reduction in the number of new cases per day from around 70 to around 20. And while there’s a lot of work to be done in the year ahead to really fundamentally tackle Ebola, there has without a question in Liberia been a significant reduction in transmission as a result of U.S. investments that are evidence-based and results-oriented.

There has been some concern that the decline in cases may also be a sign that the virus is moving into new places, and people are not bringing patients to treatment centers or contacting burials teams. Are you confident that this really is a decline in the spread of the virus?

There’s no question there’s been a real and significant decline in the transmission of the virus. It’s more pronounced in some districts and counties than others. You’re also right that there continue to be cases that are not identified, people that are not coming out and seeking care and isolation, and communities that are suffering from micro-epidemics that are faster moving, more rural and more difficult to reach.

We know that going forward we have to have a nimble, flexible, rapid response in communities that often are less aware of the virus, less eager to seek support, and where you can otherwise have clusters of new cases.

Which raises the question whether the U.S. is pursuing the right strategy at this point by focusing on building large treatment centers, particularly in Liberia where there are empty beds.

Empty beds are OK. You want to have capacity for when cases arise.

We will continually adapt the strategy based on evidence. And right now the focus is building these rapid-response capabilities that allow us to set up a 10- or 15-bed mini ETU (Ebola treatment unit) in a rural community that needs it right away, as opposed to fully staffing out very large treatment units that don’t necessarily need extra beds. The reality of the strategy that we have allows for flexibility, so that if an ETU should be at 30 beds and doesn’t need to be at 100 beds, we can run it at 30.

Are you talking about something that would be mobile?

Well, people are discussing what that means. To me they are largely static but established quickly. Remember, an ETU is not a physical hospital structure. It is a series of tents organized in a way that keeps people who are at risk of being positive separated from people who are not, with a very, very clear layout for infection control and management.

Part of their job would be treatment, but there would also be people who could be involved in safe burials, in community mobilization, contact tracing and all of the other things that need to happen in order to bring a flareup under control.

The International Medical Corps, which is based in Los Angeles, has been an important partner for building and staffing Ebola treatment units, and we’re working hand in glove with them to create this more mobile, rapid-response approach to case isolation in rural communities.

Do you have any of these mini ETUs up and running yet?

There are some that are up and running. Until recently, we’ve been calling them community care centers. Samaritan’s Purse is already helping to do this. UNICEF is already doing it, and IMC I think will start doing this. And I hope MSF (the French acronym for Doctors Without Borders) will also, since they are part of designing this approach.

Remember, this is an epidemic that we haven’t seen before, this scale, and the epidemiology will shift as we achieve success with our efforts. As the epidemiology shifts, we need to adapt our approach based on what’s working and what the data tells us.

Another big challenge has been personnel. What we’re hearing from aid groups is that they still feel there aren’t enough people responding in West Africa, particularly medical personnel. Why is that?

We are already supporting 1,000 medical personnel throughout the region. We recognize that that is going to have to continue and accelerate. We did see a decline in volunteers to our system, almost a 20% decline, after the New Jersey quarantine episode. It’s important to make sure that we’re treating these health workers like the heroes that they are and managing their return in a way that is driven by the science and the evidence as to what’s best.

We continue to work with our international partners and are trying to get doctors from Norway and epidemiologists from the African Union and scientists from India and medical personnel and construction engineers from China all involved in what needs to be an international response.

At the same time that we’ve seen a decline in new cases in Liberia, the number of cases has been picking up in Sierra Leone. There have also been flareups in parts of Guinea, and now a new chain of transmission has been identified in Mali. Is there enough aid going to those countries?

I think that’s exactly why the president has put forward a funding request to the Congress, so that we can continue to accelerate and intensify this response over the course of the next year.

It is going to take time to deal with a complex epidemic that, as we’ve seen before, can look like it’s dying down and then quickly explode again. So we’re not declaring success. We’re not at all suggesting the fight is over. In fact, what we’re doing is learning and adapting from data and evidence about what works and setting ourselves up so that we have the resources, partners and capabilities to lead the effort to tackle Ebola at its source through the coming year.

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