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Jens Spahn MD works with Médicins Sans Frontiéres. INFECTION CONTROL Post-ebola syndrome is the next healthcare challenge Rapid medical tests in disaster areas Ebola leaves a health legacy Winners on the firing line Report: Anja Behringer For a ‘post mortem’ to know what could be improved for next time – and experts do not doubt that a ‘next time’ ebola outbreak will come. The first lesson learned: the WHO needs to be strengthened – more money, more power, more support. Second: in poor countries sustain- able healthcare structures should be established and targeted efforts are needed to raise awareness among the people about health risk. Third: the outbreak prompted the phar- maceutical industry to develop and distribute medication and vaccines at a previously unknown speed. However, apart from success for one particular vaccine, research efforts did not yield successful results. The survivors According to the WHO, 11,000 peo- ple died during this recent ebola epidemic in Western Africa. 17,000 Interview: MEDICA.de Infectious diseases are widespread in conflict areas, and without basic medical care on location, people cannot be appropriately treated. Laboratory tests are limited in the field. However, rapid diagnostic tests enable medical personnel to test patients for several infectious diseases, e.g. for the presence of malaria or HIV infection. Speaking of the Sudan and Afghanistan, Jens Hahn said it is hard to generalise about the work involved: ‘Every conflict area has its own structure that depends on the respective security situation. How freely can you move as a medical team? Can you actually perform the classic work of MSF? Can you drive to the site with your jeep and pro- vide primary healthcare to people, or does the security situation not allow it? In Afghanistan for exam- ple, treatment needs to focus on the centres. Here you can move freely only in the hospital or your living quarters. What diseases and injuries do you prepare for there? ‘That also strongly depends on the situation. In classic settings, like in South Sudan, these can be tropical diseases such as malaria, hepatitis or tuberculosis. A large number of war wounds is added in the increasing conflict areas with violent battles. Here you need to increasingly treat gunshot wounds. Infections that result from bullet or stab wounds, and other acts of violence. are also a part of our daily routine. ‘The battle involves classic infec- tious diseases such as transmissions of bacteria, viruses and parasites. But there are also many cases where people with bullet wounds cannot be medically treated until after a few weeks have gone by. ‘The severely infected wounds need to first receive first aid and then generally require subsequent surgery.’ Resources available on location ‘You also need to differentiate in this instance: when we need to drive a long way from our base camp to a village, we can only take a limited amount of material with us, mean- ing only those items that fit into two Jeeps, for example. ‘In terms of primary healthcare, malaria or respiratory diseases in children, for instance, can be treat- ed on a larger scale. Therapeutic foods for malnourished children and hygiene products, like soap, also have room in the Jeep. Many infec- tious diseases can occur because the simplest resources are not available on site. On site lab testing ‘Laboratory tests can only be done on a limited scale, especially in remote areas. A small test kit, for example, could make it possible to detect anaemia on location. Yet this test is rarely conducted because, typically, you can’t perform a blood transfusion in this kind of setting. By now, we commonly use rapid tests that can detect malaria within a few short minutes, for instance. You can envision this like a pregnancy test, only the test isn’t done with urine but with one drop of blood and an indicator. ‘The HIV rapid diagnostic test also plays a relatively big role in the field. These types of tests are not available for all diseases, however. From a medical point of view, it is rewarding to fall back on your manual skills and get away from just treating people with medical devices. Which rapid diagnostic test is used most frequently? ‘The malaria test; in the best-case scenario, we regularly visit differ- ent places after we’ve informed the community members in advance. Oftentimes, about 250 children are waiting for us in a malaria-infested area. ‘If a child exhibits an increased body temperature or other symp- toms, we perform a rapid diagnostic test. Since this is often the case for at least one-third of the people or more, you quickly need dozens of tests. Yet not all of them turn out positive. The children frequently also have other diseases.’ In conflict areas, are you person- ally more susceptible to infections and take special precautions? ‘That strongly depends on the area. During the Ebola epidemic, for example, where MSF could set up tents very quickly, you definitely had to protect yourself. We are dealing with a disease where drugs don’t provide any protection. This is why we are just as vulnerable as the people that live in this area. ‘I didn’t perceive the risk as much greater in Afghanistan than I did at home. Sure, TB is a major prob- lem there but this is a disease that primarily affects people with weak immune systems. Yes, there is an increased risk in some countries for certain diseases, such as malaria, for example. However, the risk to get sick yourself is not exorbitantly higher. ‘We need to pay more attention to hygiene. The local standards often don’t meet our own standards.   Source/author: MEDICA-tradefair.com/Kilian Spelleken patients, more than during any pre- vious outbreak, survived ebola virus disease (EVD) but are struggling with a range of sequelae, such as eye pain and decreased visual acu- ity, head and joint pain, hair loss, abdominal pain, loss of appetite, nausea, sleeping disorders or chron- ic fatigue. Neurological symptoms include short-term memory impair- ment and disorientation and women report menstrual abnormalities. The virus may persist in the eye, liquor (meningitis) and, nine months after the infection, even in semen. It is only due to the large num- ber of survivors that the sequelae become visible. Now, that the dis- ease itself has been contained, the post-ebola syndrome is the next healthcare challenge that needs to be mastered. What exactly causes the symp- toms is unclear – the virus itself, the massive immune response to it, or the use of aggressive disinfectants. Currently, data on the type, fre- quency and duration of symptoms are being collected and analysed. Maybe we are dealing with a chronic phase that follows the acute phase. Studies of survivors A study involving 49 patients who survived the 2007 Ugandan out- break pointed at a number of long- term sequelae that persisted as long as two years post infection. Whilst in Uganda a different sub-type of the ebola virus caused the infection, the symptoms are very similar to those reported by survivors in West Africa. In Liberia, researchers are collect- ing data on the long-term sequelae of the ebola infection. The team of the Partnership for Research on Ebola Virus in Liberia (Prevail) is trying to find out whether survi- vors develop immunity and whether, after the acute phase of the disease, they transmit the virus to sexual partners and other close contacts. Over a five-year period the Prevail team will regularly examine 1,500 survivors and 6,000 people in those survivors’ immediate vicinity and analyse blood, tears, sweat and semen. Another focus will be vision disorders that appear to be a typical sequela of an ebola infection. Lassa fever patients report similar seque- lae, as severe infections in general can weaken a patient over a long period of time. On the other hand, different symptoms can have very different causes. While all these physical issues need clinical care, the mental effects must not be neglected. The dis- ease itself, the loss of loved ones or social marginalisation upon dis- charge from the treatment centres – these are traumatic experiences, which leave scars. Moreover, tight family units were torn apart and many children are orphaned. For many survivors, ‘back to normal’ – to a day filled with hard physical labour – is impossible, in view of the many sequelae. Addressing the medical and psy- cho/social needs of EVD survivors is thus a major focus of the WHO action plan. First the good news: the most severe ebola outbreak ever has been contained. Last December, Guinea, where the first infection was reported in late 2013, was declared free of ebola cases. Liberia was considered free of ebola in mid-January after no new case had been reported for 42 days (the WHO criterion for ‘free of ebola’). Jens Hahn MD is an Internal Medicine and Intensive Care Specialist who works with the international, independent, medical humanitarian organisation Médecins Sans Frontières (MSF in English: Doctors Without Borders),. Here he describes his work in Afghanistan and South Sudan, and the use of rapid diagnostic tests in the field. The Ebola-virus may persist in the eye, liquor (meningitis) and even in semen. © jaddingt / Shutterstock.com Jens Hahn (Source: © privat) Photo: © Jens Hahn MSF doctors use Jeeps to reach people who otherwise would have no medical care 16 EUROPEAN HOSPITAL  Vol 25 Issue 2/16

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