Ebola Virus

[Doc Alan]

Ebola ( named after a river in Democratic Republic of Congo ) is only ONE of the " viral haemorrhagic fevers " which include dengue and yellow fever. The present outbreak has caused huge publicity because of its high fatality rate. About a thousand have died so far – several thousand since its discovery in 1976.


It’s rightly being taken seriously. A multimillion dollar international strategy to bring the outbreak under control ( successful with previous outbreaks ) has been launched by WHO ( World Health Organization ) and affected countries. WHO declares Ebola an international emergency.


The problems, now well known, are :-

• Transmitted to humans from wild animals and then human-human transmission ( through close contact ) ;

• No licensed specific treatment or vaccine;

• Stigma – local resistance and hostility based on ignorance.

• Lack of facilities and health workers ( themselves at risk, over 60 have died helping others ).

• Incubation period ( time from infection to symptoms ) is between 2 – 21 days. Many other diseases causing fever need to be ruled out ( including malaria, typhoid, and other viral causes of fever like dengue ).



Every infection gives Ebola a chance to better adapt to humans, but a future global pandemic is UNLIKELY :-

1. It can ONLY be spread by close contact.

2. It kills a large proportion of its victims, LIMITING its ability to spread.

3. It’s thought that " urbanisation " is a contributory factor in this outbreak – previously village outbreaks remained small, and victims ( sadly ) died without ever going to hospital.



The diagnosis can be proved in the laboratory by a variety of blood tests and/or viral culture. There are five different virus types. The most lethal ( Zaire ebolavirus ) is causing this outbreak.


There is a PHILIPPINES connection. One subtype, the Reston Ebolavirus, has caused severe outbreaks in macaque monkeys farmed in the Philippines and imported to the USA ( including Reston, Virginia ) for research. It may also infect pigs without causing symptoms. NO illness or death in humans has been reported to date.


Ebola has raised questions about whether medicines / vaccines that have never been tested on people should be used in this outbreak. " ZMapp " – a drug produced in genetically engineered tobacco plants - has apparently been given to two US health workers. WHO this week has convened an " ethical review of experimental drugs " – knowing there will be far too few in the near future to treat the general population.


" Innovative " medicine is to be encouraged generally, whether for severe infections, cancer or dementia - but ideally it needs :-


• Informed consent from the patient ( difficult with no evidence of effectiveness );

• Explanation of risks and benefits ( also difficult because not known );

• Record of the outcome ( success or not, only known once large scale trials have been carried out ).


The Ebola epidemic is small in absolute numbers – compared to measles ( over 120,000 deaths in 2012 ) and the millions affected by malaria and tuberculosis. But it is a test for the future of public health interventions in Africa.


The world is now waking up to antibiotic resistance and fears of bioterrorism. We must hope that this particularly nasty viral haemorrhagic fever is contained in Africa, brought under control, and the pharmaceutical industry can be encouraged to come up as soon as possible with effective vaccines and treatment.


http://www.who.int/mediacentre/factsheets/fs103/en/


http://www.thelancet.com/journals/la...322-2/fulltext


http://www.thelancet.com/journals/la...319-2/fulltext


http://jid.oxfordjournals.org/conten...pl_3/S757.full


http://businessmirror.com.ph/index.p...he-philippines


http://www.bbc.co.uk/news/health-28708632

[les_taxi]

Thanks for Info doc.

[Terpe]

Very interesting that

[Doc Alan]

Thanks Les and Terpe .

[Dedworth]

Another interesting and informative post Doc . Obviously a nasty virus but not quite as easy to catch as I thought.

The WHO have just okayed the use of untested drugs http://www.bbc.co.uk/news/health-28751623

From the BBC link I learnt a new word "ethicist - I wonder who the present day ethicists are and how they qualify as such

[raynaputi]

Thanks for this Doc.

[Doc Alan]

Thank you Dedworth, Mari, Rayna, and everyone else who has read this post .


• W.H.O. and their " ethicists " probably didn’t have much choice but to " okey the use of untested drugs " in this situation. Hopefully the ethicists understand that obtaining informed consent is NOT easy in the local population of countries affected by Ebola. There is resistance and mistrust - based not only on culture, but also their past experience of untested drugs proving ineffective or even dangerous.


• Drug companies themselves are wary. Pfizer had to make a multimillion dollar settlement in Nigeria about 20 years ago, when a new antibiotic for meningitis caused brain damage and death. Hostility from the local population has resulted in polio vaccination workers in Pakistan being killed. Even in the UK and Western Europe measles outbreaks still occur because parents have misguided mistrust of MMR vaccine.


• In fact the UK NHS Litigation Authority says claims of negligence against doctors for " innovative treatment " of serious conditions are very rare.


• There’s also the question of cost. The UK medicine " watchdog " - National Institute for Health and Care Excellence – " NICE " recently rejected a breast cancer drug which costs £ 90,000 for a course of treatment which might extend a patient’s life by 6 months. Branded drugs are relatively expensive ( but generics not always reliable ) in the Philippines. It has been said while it’s impossible to put a price on life’s precious moments, it ‘s not impossible to put a fair price on drugs !


• Until recent weeks it was said there was no specific treatment and no vaccines were available for Ebola. Realistically there still aren’t, at least on the scale required .


• To be fair, I understand " ZMapp " ( a combination of antibodies ) would be made available at no charge by the makers ( Mapp Pharmaceutical ). A few other drugs and serum may also become available – NONE yet proven by human trials. Until now, progress has been painfully slow, in part because the financial rewards have not been great.


• Until there ARE effective vaccines and drugs, good public health ( rapid diagnosis, isolation, and barrier nursing by properly equipped staff ) are the best hope for controlling this outbreak, and limiting its spread beyond West Africa.


• The latest Ebola outbreak is evolving, with over 1000 deaths so far. However, it’s worth noting that while a high death rate among patients ( over 50% this time ) is very bad news, it’s ALSO bad news for survival of the virus. The most " successful " viruses are those which are easily spread between human / animal " hosts " , infecting but not killing them, so the viruses themselves survive. Ebola does not spread through the air like cold and flu viruses – and there is no genetic evidence so far to show it mutating into more dangerous types.


• An international emergency, yes, but also reasons to be cheerful that it will NOT become a pandemic .

[Michael Parnham]

Cracking stuff again Alan!

[Arthur Little]

Yet ANOTHER interesting and informative thread, Alan ...

[Steve.r]

Interesting reports Alan, thanks

[Doc Alan]

Thank you Michael, Arthur, and Steve.r .

Without adding more links ( there are regular updates in news media ), in my opinion :-


• Unlikely to be a miracle cure or vaccine for Ebola any time soon.


• An infected person COULD board a plane and unknowingly carry Ebola virus to a country beyond West Africa, before symptoms appear. Usual incubation period up to a week.


• " High index of suspicion " essential to recognize the chance of Ebola virus infection if the travel history raises this possibility. Diagnosis on blood samples can be made a day before symptoms appear. Tight border controls, with early isolation, are vital. Contacts need to be traced, with safe handling of " biohazardous " materials and ( if required ) bodies.


• Virus not transmitted person-person through the air, or by " casual " contact.


• This all suggests the chance of an outbreak of Ebola virus infection is very low in high-resource countries, and low elsewhere.


• International assistance is already promised. What healthcare workers and the public already know hopefully should control this epidemic and avert panic through misinformation.

[Doc Alan]

Recent looting of a quarantine centre in Monrovia ( capital of Liberia ) – forcing it to close – highlights the problems in controlling this West African epidemic. There is ignorance about the virus, even disbelief that it exists, and reluctance to cooperate with health care workers ( who are feared to be carrying the virus ) .


In ways Ebola is similar to AIDS – diseases starting in animals of African jungles and taking hold in countries without decent health infrastructure, but on a FAR smaller scale. Lessons have been learned from AIDS - prevention is better than cure ( or treatment if incurable ), and certainly much cheaper.


Panic, fear, and disbelief are – up to a point – understandable. Vaccines and antibiotics have surely made infectious diseases less threatening ? But AIDS, SARS, MERS, bird flu and swine flu – plus antibiotic resistance - have made us think again.


Communicable ( infectious ) diseases now account for around a third of deaths, and non-communicable diseases ( cardiovascular; diabetes; cancers ) two thirds, worldwide. In the UK communicable diseases account for 10% ; the Philippines 40% ; but 60% or more in poor countries such as those affected by Ebola.


We don’t even know for sure how many people have been affected in this Ebola epidemic . But it’s thought more WILL, before control is achieved, hopefully in the next 6 months. We do know how few resources have – so far – been available in the countries involved.

According to World Health Organization, Guinea spends under £ 40 / person on health each year. Sierra Leone has 2 doctors/100,000. Compare this to UK ( over £ 2000 and 272 doctors ) or Philippines ( £ 85 and 115 doctors ). Unlike the UK, “ pay as you go “ / “ out of pocket “ healthcare is more often the rule than the exception.


At least the severity of this outbreak is recognised. There is international financial help. More health workers are available ( and sadly already around 150 infected / 80 deaths ). Long term investment is needed in providing more doctors, health infrastructure ( public health measures, clinics ) and education. Eventually new drugs / vaccines should become available.


Unfortunately the cost to the affected economies could exceed the medical bills . Lethal diseases that have no cure tend to cause over-reactions and confusion. There are already travel restrictions, and a few firms have removed foreign workers. This is understandable, but while most firms are taking a “ wait and see “ approach, let’s hope this epidemic will be contained sooner than later.


http://www.bbc.co.uk/news/world-africa-28827091



http://www.economist.com/news/intern...nd-world-fever

[Doc Alan]

The Ebola virus epidemic in west Africa has now infected up to 12,000, and killed more ( at least 2,400 ), than all the others combined, with regular updates including last week’s edition of " Horizon " .


• This is uncharted territory - but the epidemic appears right now to be out of control . Liberia’s existence as a country is claimed to be " seriously threatened ". World Health Organization thinks there may be 20,000 cases before this epidemic can be contained and controlled, perhaps within 6 – 9 months. Other diseases like malaria – with similar symptoms – of course continue to need treatment.


• Good news is that the Bill and Melinda Gates Foundation is to spend $50 million ( on top of $10 m already committed ) to support emergency responses . Of course this is a tenth of what is claimed by UN to be needed, and a tiny proportion of the Foundation’s money – but every little helps !



• New treatments and vaccines are now urgently being sought. Until now it was confined to poor African countries and largely containable with strict infection control. The possibility of international spread is a factor in this burst of activity. However, countries with good health services SHOULD be able to identify and isolate cases, preventing further spread.



• Already across Africa there is " economic contagion " – the whole continent is suffering the stigma of the disease, even though it’s largely affecting only three countries in west Africa . South Africa’s ailing economy, for example, can do without this, when it’s so far from the affected countries and has no known cases.



• The genetic code of the Ebola virus is RNA – like HIV and influenza. Increasing human-human transmission ( rather than its natural hosts, animals like fruit bats ) gives it the chance to become more " transmissible ". Every time it replicates, new mutations appear. If these reduced the human death rate, it could spread more easily – like common colds – but never be completely eliminated.



• The other good news is that there are several human trials of vaccines that have shown promise in animal tests . Usually a more cautious approach requires " Phase I " trials ( testing if a drug / vaccine is safe in healthy individuals ), followed by another series of trials over time. But these will be offered to health workers, and then others, in infected areas, sooner rather than later.


• One vaccine uses a chimpanzee " cold " virus to deliver Ebola genetic material, which triggers an immune response. Other viruses which readily infect cells could similarly be used to deliver Ebola viral proteins into cells and cause an immune response.



• Blood may also be given from Ebola " survivors " ( containing antibodies ) to existing patients – hopefully resulting in " passive immunity " ( as with other infections ).


• " ZMapp " is a cocktail of antibodies made by genetic engineering which appears to protect against Ebola ( 2 out of 4 infected people who have received it recovered ) – but supplies have run out for now. Existing drugs used for other conditions may also be tried - not the usual cautious, " evidence-based " approach, but justifiable if health care workers and patients are willing to try them.


• Resources of ALL kinds, from hospital beds to protective gear, and health care workers ( either local, or working for agencies such as Medecins San Frontieres ) are in short supply. But almost 40 years since discovery, the fight back against Ebola virus disease has at last become serious .




http://www.bbc.co.uk/iplayer/episode...rch-for-a-cure


http://www.bbc.co.uk/news/world-africa-28754546

[Dedworth]

I read the other day that Pooley the British nurse is OK and out of hospital

http://www.independent.co.uk/life-st...e-9722544.html

[Longweekend]

I read the other day that Pooley the British nurse is OK and out of hospital

http://www.independent.co.uk/life-st...e-9722544.html

Yes, and he wants to go back again after we sent an RAF plane out there to pick him up.....

[London_Manila]

It's only a matter of time until this virus hits the UK
Until then i would not want to use Airports like Dubai which has/have many connecting flights from Africa

The UK government seems to be doing nothing about the vast amount of flights arriving at Heathrow from Africa
Surely monitoring inbound passengers from this continent is a must

How many of our poor troops who have been sent out to Sierra Leone will end up catching this virus?

[Arthur Little]

It's only a matter of time until this virus hits the UK

... you are certainly one "cheery" chappie and no mistake!

[Michael Parnham]

... you are certainly one "cheery" chappie and no mistake!

I must admit Arthur, he has a point!

[Pete/London]

I think we must close off the countries at the source of the disease until it's under control.

At the moment it seems it's anyone's guess where it will spread to.

[Terpe]

I think we must close off the countries at the source of the disease until it's under control.

At the moment it seems it's anyone's guess where it will spread to.

Agree.

Much more effective than attempting to prevent the spread at arrival points.

[Terpe]

[Michael Parnham]

I think we must close off the countries at the source of the disease until it's under control.

At the moment it seems it's anyone's guess where it will spread to.

I agree also!

[andy222]

Agree.

Much more effective than attempting to prevent the spread at arrival points.

I don't know whether it's just my thinking or what. But why are we sending people out there to help only to let them back here with the risk that they could contract the virus and cause an epidemic here?

By the way, great post Doc.

[Doc Alan]

I have not recently added to this thread because of the regular developments and frequent updates available elsewhere ( http://www.bbc.co.uk/news/world-africa-28754546 ;

http://www.who.int/csr/disease/ebola/en/ ).



• The disease does highlight global disparities in healthcare resources. The chance that the virus will establish a foothold in high resource countries like the UK or United States remains very small. The UK has " tried and tested systems " in place for dealing with severe infectious diseases.


• The cost to the poor countries of West Africa affected by the epidemic is not only in terms of numbers affected and deaths ( 4000 of the latter, including 200 health workers, probably an underestimate ) but also economic ( see the BBC link ).



• It’s hard to keep vigilant, and mount an appropriate, measured, response without panic.


• Screening of airline passengers as they arrive from West Africa – directly or via some other country - is being implemented in the USA and seems likely to follow in the UK . This alone DOESN'T solve the problem :-


1. Immigration officers are not trained health professionals.


2. There are many causes of fever apart from ebola ( such as malaria, typhoid, cholera, hepatitis, dengue, and other viral haemorrhagic fevers ).



3. As the incubation period for ebola varies between 2 – 21 days, potential victims might not even have a fever on attempted entry - by whatever route - to a country such as the U K.


4. Definitive laboratory diagnosis takes time, apart from the expense ( a variety of blood tests for the virus, antibodies to it, looking for the virus by electron microscopy, or culture of the virus ).



• The Philippines has many ( possibly 3,500 ) OFWs, living and working in the areas of Guinea, Liberia, and Sierra Leone. There has been a travel ban to those affected areas in West Africa for over three months. The few OFWs who have returned are being " monitored " by the Department of Health ( DOH ). Rightly, the Philippines government has rejected WHO’s call to send health workers to West Africa. There is an “ Ebola summit “ today ( 9 September ) which intends to update and inform Filipinos and of course keep the country free of the virus
( http://www.philstar.com/headlines/20...ummit-thursday ).


• In addition to the huge amount of information available on ebola, it may be worthwhile reminding Forum members :-


1. It’s ONLY transmitted among humans by close and direct physical contact with infected bodily fluids – especially blood, faeces and vomit.


2. It can be transmitted " indirectly " – by contact with previously contaminated surfaces and objects. Appropriate cleaning and disinfection procedures reduce this already low chance.



3. It is NOT an airborne virus. ‘Flu, common colds, measles, and TB are more easily spread because they ARE airborne. We’ve known this by studying the virus over the four decades since its discovery. There is NO evidence that the ebola virus could mutate into a form that could be easily spread among humans through the air.


• This epidemic IS out of control in West Africa – but is still very unlikely to become a pandemic, even if isolated cases are almost inevitable in other continents.


• At last the international community has recognised ebola as a " public health emergency of international concern " . Sadly many more seem likely to be infected and die in West Africa before this epidemic is controlled. Effective vaccines and drugs are on the horizon to prevent and treat future outbreaks.


• There is – unsurprisingly - a good deal in the medical press on this topic. More recent ones include :-


http://download.thelancet.com/flatco...3614617918.pdf



http://www.thelancet.com/journals/la...697-4/fulltext

[KeithD]

Good to see the prepared western countries struggling to cope with one infection!

[London_Manila]

... you are certainly one "cheery" chappie and no mistake!

Preparing for the worst case scenario seems prudent at this stage

Travelers and relatives should be advised against any travel to the effected countries and neighbouring countries and Africa should be classed as off limits

I would think countries like Spain have proper procedures in place to deal with infectious diseases but that did not stop that poor nurse catching Ebola

Have doctors on standby at the immigration halls at all major airports in the UK
All persons returning from affected countries to be monitored daily until the incubation period has passed

I have seen a few African guys around Manila and if it hits the Philippines I for sure won't go there

[Doc Alan]

Updates continue to appear daily on BBC, World Health Organization / WHO and other websites.


The Philippines is in the Western Pacific Region of WHO, and there is a regional meeting in Manila to address various health issues including the Ebola outbreak.


While the points made at the meeting may seem obvious, they do summarize the current situation :-


• The world’s growing social and economic inequalities


• Rumours and panic spread faster than the virus


• The world is put at risk when a deadly virus hits the destitute


• Decades of neglected basic health systems and services can bring a fragile country to its knees


• There is a lack of research and development incentive as evidenced by the absence of an Ebola vaccine


• The world is ill-prepared to respond to a severe, sustained and threatening public health emergency.


I would not over-estimate my expertise in this topic . It seems that the Philippines government IS responding to the outbreak in order to prevent ( or at least control ) Ebola virus infection reaching the country. President Aquino recognises that the several million OFWs - with thousands of OFWs in West Africa – does “ make these kinds of outbreaks of paramount concern “.



Hopefully the West African epidemic will be controlled with the measures being implemented ; the infection rate will peak then decline ; the crisis will pass ; and cases in other countries including the UK and Philippines will be isolated. Effective vaccine(s) and drugs will become available .

The alternative is that cases will increase, travel restrictions will multiply, and the economy in Africa ( and elsewhere ) will suffer, a vicious circle .


What I do know is that it’s unlikely this virus will become airborne. It may well mutate, but only to a milder, more easily transmissible form, more “ successful “ than killing half its victims. Viruses do mutate but are not known for changing their actual mode of transmission.



http://www.wpro.who.int/mediacentre/...4/20141013/en/


http://globalnation.inquirer.net/112...ola-outside-ph


http://www.healthpromo.doh.gov.ph/do...virus-disease/

[KeithD]

I wonder what happens if we get a wider outbreak in the west. We keep getting told that we have these amazing rooms for dealing with such viruses, but an outbreak would soon fill them up, and then what?

[Pete/London]

I wonder what happens if we get a wider outbreak in the west. We keep getting told that we have these amazing rooms for dealing with such viruses, but an outbreak would soon fill them up, and then what?

I London they would be treated at the Royal Free Hospital in Belsize Park/ Hampstead. They would be cared for by Nurses and Junior Doctors, none of whom are able to afford to live in that area so travel to work on the underground and buses. Any failure to contain the virus would enable it to be spread around London very quickly,
We are all doomed !

It would be far better to isolate the countries at the source of the outbreak, not been done yet,
or build an isolation area miles from major cities and towns and when necessary, have staff there on 3 month shifts. Cant see anything else working.

[malolos]

I wonder what happens if we get a wider outbreak in the west. We keep getting told that we have these amazing rooms for dealing with such viruses, but an outbreak would soon fill them up, and then what?

There are enough old RAF AND Army camps where isolation units could be set up.