1584. What We're Afraid to Say about Ebola

By Michael T. Osterholm, The New York Times, September 11, 2014

The crowd in Nairobi. Kenya

MINNEAPOLIS — THE Ebola epidemic in West Africa has the potential to alter history as much as any plague has ever done.

There have been more than 4,300 cases and 2,300 deaths over the past six months. Last week, the World Health Organization warned that, by early October, there may be thousands of new cases per week in Liberia, Sierra Leone, Guinea and Nigeria. What is not getting said publicly, despite briefings and discussions in the inner circles of the world’s public health agencies, is that we are in totally uncharted waters and that Mother Nature is the only force in charge of the crisis at this time.

There are two possible future chapters to this story that should keep us up at night.

The first possibility is that the Ebola virus spreads from West Africa to megacities in other regions of the developing world. This outbreak is very different from the 19 that have occurred in Africa over the past 40 years. It is much easier to control Ebola infections in isolated villages. But there has been a 300 percent increase in Africa’s population over the last four decades, much of it in large city slums. What happens when an infected person yet to become ill travels by plane to Lagos, Nairobi, Kinshasa or Mogadishu — or even Karachi, Jakarta, Mexico City or Dhaka?

The second possibility is one that virologists are loath to discuss openly but are definitely considering in private: that an Ebola virus could mutate to become transmissible through the air. You can now get Ebola only through direct contact with bodily fluids. But viruses like Ebola are notoriously sloppy in replicating, meaning the virus entering one person may be genetically different from the virus entering the next. The current Ebola virus’s hyper-evolution is unprecedented; there has been more human-to-human transmission in the past four months than most likely occurred in the last 500 to 1,000 years. Each new infection represents trillions of throws of the genetic dice.

If certain mutations occurred, it would mean that just breathing would put one at risk of contracting Ebola. Infections could spread quickly to every part of the globe, as the H1N1 influenza virus did in 2009, after its birth in Mexico.

Why are public officials afraid to discuss this? They don’t want to be accused of screaming “Fire!” in a crowded theater — as I’m sure some will accuse me of doing. But the risk is real, and until we consider it, the world will not be prepared to do what is necessary to end the epidemic.

In 2012, a team of Canadian researchers proved that Ebola Zaire, the same virus that is causing the West Africa outbreak, could be transmitted by the respiratory route from pigs to monkeys, both of whose lungs are very similar to those of humans. Richard Preston’s 1994 best seller “The Hot Zone” chronicled a 1989 outbreak of a different strain, Ebola Reston virus, among monkeys at a quarantine station near Washington. The virus was transmitted through breathing, and the outbreak ended only when all the monkeys were euthanized. We must consider that such transmissions could happen between humans, if the virus mutates.

First, we need someone to take over the position of “command and control.” The United Nations is the only international organization that can direct the immense amount of medical, public health and humanitarian aid that must come from many different countries and nongovernmental groups to smother this epidemic. Thus far it has played at best a collaborating role, and with everyone in charge, no one is in charge.

A Security Council resolution could give the United Nations total responsibility for controlling the outbreak, while respecting West African nations’ sovereignty as much as possible. The United Nations could, for instance, secure aircraft and landing rights. Many private airlines are refusing to fly into the affected countries, making it very difficult to deploy critical supplies and personnel. The Group of 7 countries’ military air and ground support must be brought in to ensure supply chains for medical and infection-control products, as well as food and water for quarantined areas.

The United Nations should provide whatever number of beds are needed; the World Health Organization has recommended 1,500, but we may need thousands more. It should also coordinate the recruitment and training around the world of medical and nursing staff, in particular by bringing in local residents who have survived Ebola, and are no longer at risk of infection. Many countries are pledging medical resources, but donations will not result in an effective treatment system if no single group is responsible for coordinating them.

Finally, we have to remember that Ebola isn’t West Africa’s only problem. Tens of thousands die there each year from diseases like AIDS, malaria and tuberculosis. Liberia, Sierra Leone and Guinea have among the highest maternal mortality rates in the world. Because people are now too afraid of contracting Ebola to go to the hospital, very few are getting basic medical care. In addition, many health care workers have been infected with Ebola, and more than 120 have died. Liberia has only 250 doctors left, for a population of four million.

This is about humanitarianism and self-interest. If we wait for vaccines and new drugs to arrive to end the Ebola epidemic, instead of taking major action now, we risk the disease’s reaching from West Africa to our own backyards.

Michael T. Osterholm is the director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

1556. With Death Rate of 70%, Ebola Cases Are Expected to Reach 1.4 Million in Four Months

By Denise Grady, The New York Times, September 23, 2014

The body of an ebola victim is removed from her home in Monrovia, Liberia, last week. 

Yet another set of ominous projections about the Ebola epidemic in West Africa was released Tuesday, in a report from the Centers for Disease Control and Prevention that gave worst- and best-case estimates for Liberia and Sierra Leone based on computer modeling.

In the worst-case scenario, the two countries could have a total of 21,000 cases of Ebola by Sept. 30 and 1.4 million cases by Jan. 20 if the disease keeps spreading without effective methods to contain it. These figures take into account the fact that many cases go undetected, and estimate that there are actually 2.5 times as many as reported.

In the best-case model, the epidemic in both countries would be “almost ended” by Jan. 20, the report said. Success would require conducting safe funerals at which no one touches the bodies, and treating 70 percent of patients in settings that reduce the risk of transmission. The report said the proportion of patients now in such settings was about 18 percent in Liberia and 40 percent in Sierra Leone.

The caseload projections are based on data from August, but Dr. Thomas R. Frieden, the C.D.C. director, said the situation appeared to have improved since then because more aid had begun to reach the region.

“My gut feeling is, the actions we’re taking now are going to make that worst-case scenario not come to pass,” Dr. Frieden said in a telephone interview. “But it’s important to understand that it could happen.”

Outside experts said the modeling figures were in line with estimates by others in the field.

“It’s a nice job,” said Ira Longini, a professor of biostatistics at the University of Florida who has also done computer modeling of the epidemic. “It summarizes the extent of the problem and what has to happen to deal with it.”

Bryan Lewis, an epidemiologist at the Virginia Bioinformatics Institute at Virginia Tech, agreed that the estimates were reasonable, perhaps even a bit low compared with those generated by other models. He said that if some of the latest data from the World Health Organization is plugged into the C.D.C. model, “the very large numbers of estimated cases are, unfortunately, even larger.”

The current official case count is 5,843, including 2,803 deaths, according to the W.H.O.

The C.D.C. estimates omit Guinea, which has been hit hard, because the epidemic struck in waves that could not be modeled. 

The W.H.O. published its own revised estimates of the outbreak on Monday, predicting more than 20,000 cases by Nov. 2 if control does not improve. That figure is more conservative than the one from the C.D.C., but the W.H.O. report also noted that many cases were unreported and said that without effective help, the three most affected countries would soon be reporting thousands of cases and deaths per week. It said its projections were similar to those from the C.D.C.

The W.H.O. report also raised, for the first time, the possibility that the disease would not be stopped but could become endemic in West Africa, meaning that it could become a constant presence there.

President Obama’s promise last week to send 3,000 military personnel to Liberia and to build 17 hospitals there, each with 100 beds, was part of the solution, Dr. Frieden said. But it was not clear when those hospitals would be ready, or who would staff them.

Dr. Frieden said the Defense Department had already delivered parts of a 25-bed unit that would soon be set up to treat health workers who become infected, a safety measure he said was important to help encourage health professionals to volunteer. He said that more aid groups were also arriving in the region to set up treatment centers, and that a “surge” of help would “break the back of the epidemic.”

Dr. Jack Chow, a professor of global health at Carnegie Mellon University and a former W.H.O. official, said, “The surge only becomes realized when those beds are up and operating and the workers are delivering care.”

He added, “If even the medium case comes to pass, with, say, 700,000 cases by January, the epidemic will quickly overwhelm the capabilities that the U.S. plans to send.”

The W.H.O. reported that a new center had just opened in Monrovia, the Liberian capital, with 120 beds for treatment and 30 for triage. Patients were already lined up at the door.

The report from the C.D.C. acknowledged that case counts were rising faster than hospital beds could be provided. It said that in the meantime, different types of treatment would be used, based in homes or community centers, with relatives and others being given protective gear to help prevent the disease from spreading.

The United States government is also sending 400,000 kits containing gloves and disinfectant to Liberia to help families take care of patients at home.

At least one aid group in Liberia is already shifting its focus to teaching people about home care and providing materials to help because there are not enough hospital beds for the sick. Ken Isaacs, a vice president of the group, Samaritan’s Purse, said, “I believe inevitably this is going to move into people’s houses, and the notion of home-based care has to play a more prominent role.”

“Where are they going to go?” he said.

Though providing home-care kits may seem like a pragmatic approach, some public health authorities said they were no substitute for beds in isolation or containment wards.

But Dr. Frieden said that home care had been used to help stamp out smallpox in Africa in the 1960s. The caregivers were often people who had survived smallpox themselves and were immune to it. Some experts have suggested that Ebola survivors might also be employed to care for the sick.

Dr. D. A. Henderson, who led the W.H.O.’s smallpox eradication program, said that local people had been paid to help in the campaign.

“We recruited a lot of people to stand guard at huts with smallpox,” said Dr. Henderson, a professor at the Johns Hopkins Bloomberg School of Public Health and the University of Pittsburgh. “The important thing was to know they got paid.”

He added: “We gave money and food to families who had smallpox so they didn’t have to go out and beg, and they didn’t have to go to the market and potentially infect people. What can you do? If you don’t have food, you’ve got to leave the house and go out. Money can play a useful role.”

1548. Cuba to Commit Large Health Corps to Ebola Fight

By Kai Kupferschmidt, Science Insider, September 12, 2014

Cuban medical workers treating a cholera patient in Haiti

The Cuban government is sending 165 doctors and nurses to battle the Ebola outbreak in West Africa, the World Health Organization (WHO) announced this morning in Geneva, Switzerland, at a joint press conference with Cuba’s minister of public health, Roberto Morales Ojeda. The health care workers, 103 nurses and 62 doctors, are going to be deployed to Sierra Leone in the first week of October.

It is the biggest contribution of health care staff by any single country so far to help control the epidemic, noted WHO Director-General Margaret Chan. “This will make a significant difference in Sierra Leone,” Chan said.

To put the numbers in perspective: WHO has deployed about 500 foreign medical experts to the region. Because they rotate, at any one time about 170 of them are in the affected countries, Chan said.

Ebola has already sickened at least 4784 people and killed 2400 in the biggest outbreak on record, and its spread is still accelerating. Several governments have pledged support. For instance, the British government and the Wellcome Trust medical charity have announced they will spend £6.5 million to speed up research on Ebola vaccine candidates. Germany’s Ministry for Economic Cooperation and Development has announced it is increasing its contribution to WHO to fight Ebola from €1 million to €10 million. And the Bill & Melinda Gates Foundation has pledged $50 million to fight Ebola. But that does not address the main problem, experts say. “Money, materials are important, but those alone cannot stop Ebola transmission,” Chan said at the press conference. “The thing we need most of all is people.”

According to WHO, more than 200 health care workers are needed to run an isolation ward with 70 beds. While it is still unclear how many Ebola patients there are altogether, WHO estimates several hundred extra beds are needed in Liberia alone. At the moment there is not a single bed available in the whole country to treat Ebola patients, Chan said.

Several people on the ground in Liberia have confirmed that Ebola patients are being turned away at the treatment center in Monrovia to avoid staff being overwhelmed. “We need more actions. We need to surge at least two to four times in order to catch up with the outbreaks in these three countries,” Chan said. “I hope the announcement today will stimulate more countries to surge their support.”

*The Ebola Files: Given the current Ebola outbreak, unprecedented in terms of number of people killed and rapid geographic spread, Science and Science Translational Medicine have made a collection of research and news articles on the viral disease freely available to researchers and the general public.