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Ebola — time for action

I trained in microbiology so I’ve watched the Ebola situation unfold with quiet dread.  When my favourite lecturer was asked what was worst of the worst infectious epidemics he could imagine, he responded that the sum of all fears would be a cross between Ebola and Newcastle’s disease. It would be a highly fatal hemorrhagic disease, combined with a highly contagious virus spread by birds. It’s time to talk of the dark dark possibility that one mutation could bring — the aerosolization of Ebola.

As long as this Filovirus stays in its current form, spread only through direct contact with an infected and obviously ill person, we have a chance to limit the spread. Quarantine is effective. If it goes airborne, the task becomes like preventing the flu, but without clinically tested vaccines, in a totally unprotected population, and with a 60% fatality rate. This is the nuclear option.

The Ebola virus has several different forms, and at least in animal studies, it has “gone airborne” before. Theoretically, it’s an odds game. The more times the virus is copied — the better the odds are that the right mutation will occur. To be brutally blunt, every infected person is another incubator, providing more copies, and more chances. For this reason, and for self interest alone, the West ought to be shifting into high gear to help Africans contain this. The humanitarian reasons go without saying. But our compassion for the ghastly suffering spreading through the slums and cities of West Africa could easily save thousands, and possibly many millions of lives, theoretically including our own.

On the plus side, we are not defenceless. There are good news stories and promising avenues. Several vaccines are being developed. Most immediately, the blood of survivors contains antibodies that can help victims. The West has grown monoclonal copies of some antibodies (ie. ZMapp) but they only grow as fast as the tobacco plants they’ve been genetically modified to grow in. Ken Brantly, one of the early US survivors who was given ZMapp is now giving his blood to another afflicted American aid worker. In Africa, a black market has already sprung up trading the blood of survivors. It’s risky and it will spread other diseases, but it is probably a rational response given the dire odds. The WHO is organizing a better cleaner method. It’s one of the few times I think a government — dare I say, even a UN solution — is something to foster and hope for. Go big-government. Except, surprise, the free market beat the government, and now some in the WHO are trying to stamp out the  “illicit trade”. (Do they even know the risk-benefit of these trades?) Shouldn’t they be advising consenting adults and carers on the safest way to do this, and the risks, and collecting statistics?

The numbers

On September 9th the World Health Organisation (WHO) said it had recorded 4,293 cases in five west African countries, of which at least 2,296 people had died. But even the WHO’s experts believe that is an underestimate as many people are suspected to be dying at home. By some estimates 12,000 people have been infected with Ebola so far.

At least 160 Liberian health-care workers have contracted the disease and half of them have died. Ebola is also spreading in Guinea, Sierra Leone and Nigeria, and a case has been reported in Senegal.

The Economist

Tragically, Liberia – which already ranks fourth-last in the world for numbers of doctors per population – has lost almost 20 doctors to Ebola. They only produce 10 doctors per year in a medical class. – ABC

“Not to put too fine a point on it: we have a closing window of perhaps weeks now before we will not be able to manage all the cases on the ground in the way that we normally would.” — Dr Ian Norton, chief of foreign medical teams with the World Health Organisation (WHO) – ABC

The good news

Even basic medical help can reduce death rates from 90% to under 50%:

Without medical care, the mortality rate of this Ebola outbreak is about 90 per cent. While it is a devastating disease, it is not universally fatal, even with minimal care.

But with better care, and certainly with the new Ebola treatment centres and with the right number of staff treating them, we can gradually escalate the level of care and have better outcomes.

For example, we have seen in Guinea for several months that with good supportive care we can bring the mortality rate down to 30 to 50 per cent at most.   — ABC

We will beat Ebola, but we need time

It’s a race between two rapidly rising curves. The exponential spread becomes ugly so fast. If we can delay the spread, we can conquer it.

As well as the antiserum and monoclonal antibodies, there are several vaccines in the making. Small safety trials have started already. But they are potentially several months away from being mass “field tested”  — even this speed breaks  normal ethical practice, but given the dire situation few are arguing.

The NIH/GSK vaccine is based on a benign virus which causes a cold in chimpanzees (an adenovirus). It is able to infect cells and deliver fragments of genetic material from two variations of Ebola (one of which is the Zaire strain responsible for the current outbreak). When Ebola proteins are expressed by infected cells, an immune response is triggered. A version using a single strain of Ebola is also being tested.

On September 7th, Nature Medicine reported that immediate and lasting immunity to Ebola could be stimulated in monkeys if a dual jab is used. The first jab primes the immune system with an adenovirus-based vaccine; the second boosts it with a modified vaccinia virus (the active component of the vaccine that eradicated smallpox). Johnson & Johnson, a big American health-care company, has accelerated laboratory testing of a combined vaccine, which could begin clinical trials next year.

Another candidate vaccine was developed many years ago by the Public Health Agency of Canada. It was recently licensed by NewLink Genetics of Ames, Iowa, which has approval to start phase 1 trials. This jab is based on a vesicular stomatitis virus (VSV), a livestock infection that resembles foot-and-mouth disease. VSV has been used previously to develop vaccines. The new vaccine, VSV-EBOV, is a live, replicating virus that infects cells and carries Ebola viral proteins into the host. Again, this stimulates an immune response. —The Economist

Antivirals are also in development. Fujifilm in Japan has offered to shop Favipravir as soon as WHO requests it.

The US CDC is tracking the spread.

We are spending millions to stop barbaric conflict in the Middle East — which well may be justified. But Ebola could be so much worse. We need the same kind of international effort, and every week delayed makes it harder.  We’re not at the panic and run stage, but we ought to be throwing major resources, both at research and to help the afflicted.

The human side of the current story is wrenching.

Monrovia: “…Jatu Zombo cradled her 5-year-old son, Foday, beneath a tarp set up to block the sun. A few feet away, her 10-year-old boy, Zen­nah, sat on a paint can. Both children were listless and visibly ill. They felt cold and had been vomiting. Their father had died four days earlier, and Zombo, 36, spent days calling for an ambulance that never came. Finally, her brother paid someone $20 in U.S. currency to bring them to JFK.

But the children could not get in. “No one has spoken to us,” said Zombo’s brother, Abraham Sesky. “So we are just sitting. We don’t know.” — Washington Post

The risk:

Virologists, such as Dr Ball at Nottingham, worry that increasing human-to-human transmission is giving Ebola the opportunity to become more transmissible. Each time the virus replicates, new mutations appear. It has accumulated and hung on to some mutations, like “cherries on a one-armed bandit”, he says. Nobody knows what would happen if Ebola hit the jackpot with a strain that is even better-adapted to humans.

Right now, food, medical supplies, health workers, training, and quarantine facilities are an investment the West would be crazy not to be freely giving, and fast. We must beat the curve.

News on ebola at MacLeans.ca

Entire country of Sierra Leone to be put on 3-day lockdown amid Ebola fears 

Experimental Ebola vaccines may be ready by the end of 2014

UPDATE: Liberia is asking the US for help to defeat Ebola the medical system reportedly breaking under the strain. Medical staff are in short supply in West Africa, and one nation is sending 165 to help… Guess which country is sending the largest group?

Cuba on Friday announced that it would deploy 165 medical personnel to Sierra Leone next month, the largest contingent of foreign doctors and nurses committed so far.

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