Archive for December 2014

Evening Ebola Update, Tues, 12/30: Scottish nurse should not have left Heathrow/Bats could be cause of index case of EBOV/To give/not give life-saving measures in EBOV patients   Leave a comment

12/30/14

Dear Colleagues:

1.  The Telegraph reports that the Scottish nurse with EBOV c/o fever at Heathrow Airport, had her temperature taken 7 times over one hour by nurses using an ear thermometer with positive/negative results and was then permitted to board a plane for Glasglow.  The physician who sat next to her on the flight to Glasglow c/o that the screening at Heathrow was in disarray.  Later that same day the patient was transferred back to London to Royal Free Hospital.  See: http://www.telegraph.co.uk/news/uknews/scotland/11317882/Ebola-nurse-should-not-have-left-Heathrow-suggests-chief-medical-officer.html  The chief health officer admits the patient should never have been allowed to leave Heathrow.

2.  Science reports on an article in EMBO Molecular Medicine by Leendertz, et. al. re: bats in the rural village in Guinea where the current EBOV epidemic had its index case.  Apparently, there was a tree which was home to fruit bats which scattered all over the village when the tree burned down.  But Leendertz, et. al. were not able to find EBOV virus or antibodies in 100+ bats tested in the village area.  No real proof that bats were the intermediate host in this epidemic yet.  See: http://news.sciencemag.org/africa/2014/12/bat-filled-tree-may-have-been-ground-zero-ebola-epidemic

3.  Annals of Internal Medicine 30 December on-line has an special article on the ethics of giving life-saving therapies such as intubation to EBOV patients in developed countries by Halpern, et. al. from the University of Pennsylvania and Wharton School of Business.  The article gives four different patient scenarios and comments on whether life-saving measures should/should not be given.  In my opinion, the take-home message from Halpern, et. al. is: Explain your institution’s policy on life-saving measures to patients and family on admission; explain each EBOV patient is approached individually, and let them know that as a patient’s condition changes over time so will the decision to give or not give life-saving measures.  See the article at: https://col128.mail.live.com/mail/ViewOfficePreview.aspx?messageid=mgoqPqw12Q5BGXiRBgS6DalA2&folderid=flsent&attindex=0&cp=-1&attdepth=0&n=27647390

RGL, MD

Posted December 30, 2014 by levittrg in Ebola

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Evening Ebola Update, Mon, 12/29: NY Times summary of one year of EBOV/How WHO contained district EBOV outbreak/Scot HCW travels home with EBOV   Leave a comment

test12/29/14

Dear Colleagues:

l.  NY Times has an long Health Section article on ‘How EBOV Roared Back’ this past spring after the outbreak appeared to be contained.  The authors say the causes of the EBOV resurgence include: poor communication between WHO leaders in Africa and WHO HQ in Geneva; no experience with EBOV in West Africa; too few medical assets sent to West Africa last spring; remote location of the rural EBOV cases; cutback in WHO funding by UN; distrust of whites by West Africans; poor health care infrastructure in West Africa after their civil wars.  The NY TImes article spreads the ‘blame’ for the EBOV epidemic over many organizations and people.

2.  In reality, this EBOV epidemic ‘came out of the blue’ in a one year old baby from rural Guinea.  Babies are not the usual category of patients to become infected with EBOV so the outbreak spread rapidly until there was an epidemic.  See the NY Times article at: http://www.nytimes.com/2014/12/30/health/how-ebola-roared-back.html?hp&action=click&pgtype=Homepage&module=a-lede-package-region&region=top-news&WT.nav=top-news&_r=0

3.  WHO website reports how the Kailahun District, Sierra Leone, EBOV outbreak was contained rapidly in the past few weeks.  All the chiefs of the chiefdoms in Kailahun were actively engaged so that all chiefs joined the WHO fight.  Educators and contact tracers and burial teams were sent to Kailahun rapidly and in adequate numbers to contain the EBOV.  Everything went right; when turned away from villages or possible EBOV patients, the WHO team just returned the next day.
See the article at: http://who.int/features/2014/kailahun-beats-ebola/en/

4.  Reuters reports that the FDA just approved the Roche RT-PCR test for EBOV.  This test is a boon to HCW in West Africa because the test makes the diagnosis of EBOV in 3 hours, rather than one or more days.  See the announcement at: http://www.reuters.com/article/2014/12/29/us-health-ebola-roche-idUSKBN0K70TA20141229.  A faster EBOV test results in more rapid isolation and treatment of EBOV patients, which is key for reducing the reproductive rate, R.

5.  ABC News reports that a Scottish HCW in Sierra Leone flew British Airways home to Glasglow yesterday via Casablanca and London.  When he arrived he Glasglow, he developed fever and other symptoms of EBOV.  His EBOV test was positive; he will be transported and treated at Royal Free Hospital in London, which has a special isolation unit for EBOV patients.  See: http://abcnews.go.com/Health/scotland-confirms-case-ebola/story?id=27883071test   His contacts during the flight home and stopovers are all being traced and followed.

RGL, MD

Posted December 30, 2014 by levittrg in Ebola

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Afternoon Ebola Update, Sun, 12/28: Effect of EBOV epidemic on Malaria Tx and Deaths/Czar dodges AMC trainees to West Africa question/New term for 1976 Zaire EBOV strains   Leave a comment

12/28/14

Dear Colleagues:

l.  ABC News posted an AP story today on the Web reporting on the Malaria situation in West Africa now that we are in the worst of the Malaria season.  There were 15,000 deaths from Malaria in Guinea last year; 14,000 deaths occurred in children less than 5 y.o.   The planned Malaria prevention measures in Guinea, Liberia, and Sierra Leone will not happen in 2015 as a result of the diversion of medical assets to prevent and treat EBOV.  In Liberia the planned distribution of 2 million nets will not occur.  See this disturbing article at: http://abcnews.go.com/Health/wireStory/malaria-killing-thousands-ebola-west-africa-27860408.  (Remember the previous posting of an article which projected 180,000 maternal deaths from complications after childbirth in West Africa because non-EBOV treatment centers and hospitals are closed.)

2.  The U.S. EBOV ‘czar’ Ron Klain appeared on ‘Face the Nation’ TV show this morning.  He answered all the moderator’s questions in a positive manner.  Unfortunately, Mr. Klain ‘dodged’ the moderator’s question re” ‘roadblocks’ placed in the way of academic medical center trainees who wish to volunteer for service in West Africa for 3 or 6 months.  These trainees are just the people whom West Africa needs to bring EBOV cases to zero.  See a report of his interview at: http://www.foxnews.com/politics/2014/12/28/us-ebola-czar-pivot-point-reached-in-stopping-deadly-disease-but-more-domestic/

3.  American Society of Microbiology 20 November published on-line an article by Kuhn, et. al. from Fort Detrick, CDC, and USAMRIID, that re-identifies 1976 Zaire EBOV strains so that confusion over multiple terms for the same strain is eliminated:

‘Ebola virus (EBOV) was discovered in 1976 around Yambuku, Zaire. A lack of nomenclature standards resulted in a variety of designations for each isolate, leading to confusion in the literature and databases. We sequenced the genome of isolate E718/ME/Ecran and unified the various designations under Ebola virus/H.sapiens-tc/COD/1976/Yambuku-Ecran.’

‘Nucleotide sequence accession numbers.The GenBank accession no. of EBOV E718, now designated Ebola virus/H.sapiens-tc/COD/1976/Yambuku-Ecran, is KM655246.

See the article at:http://genomea.asm.org/content/2/6/e01178-14.full?sid=0022ac75-a6fd-41cf-8d84-49e0bc6f0b12

RGL, MD

Posted December 28, 2014 by levittrg in Ebola

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Evening Ebola Update, Sat, 12/27: EBOV epidemic Top Science Story 2014/Microarray for detection of EBOV antibodies in intermediate hosts/What factors are causing the Sierra Leone epidemic to continue   Leave a comment

12/27/14

Dear Colleagues:

l.  Science News 27 December reports on pages 14-15 the EBOV epidemic in West Africa as the Top Science Story of 2014.  The author, Nathan Seppa, writes that this epidemic happened when a contagious virus emerges in a population served by a broken medical system, and where cultural practices, public fears, and porous borders fuel the spread of the epidemic.  The epidemic also showed that our scientific understanding of EBOV was poor; researchers/clinicians had mostly only animal studies to go on to develop treatments and vaccines.  The WHO response was late and did not keep pace with the spread of the epidemic.  The author gives pertinent citations to his statements.  See the Science News article and citations (really the referred-to articles) at: https://www.sciencenews.org/node/189469?mode=pick&context=151

2.  Clinical and Vaccine Immunology 14 December has an article by Kamata, et. al. from USAMRIID about a protein microarray of EBOV (Zaire strain) glycoprotein (GP) and nucleoprotein (NP), and VP40 antigens which detected IgG antibodies to EBOV (Zaire) vaccination of rhesus monkeys.  So now there is a method to detect antibodies to EBOV (and Marburg virus) in domesticated and wild animals in West Africa which are intermediate hosts to EBOV and Marburg.  See the entire article at: http://cvi.asm.org/content/21/12/1605.full?sid=9b83f3f4-03aa-404d-a476-37a0de7e9af0

3.  NPR radio today interviewed Jeremy Farrar, Director of the Wellcome Trust.  Dr. Farrar said the Phase 2 trial of the GSK vaccine will start in January, and Phase 2 trials of two other vaccines will start in March.

4.  Al Jazeera 24 December has a report on the EBOV situation in Sierra Leone.  The report details how their broken medical system, cultural practices, and fear in Sierra Leone led to spread of EBOV in that country.  Read the specifics in: rehttp://cvi.asm.org/content/21/12/1605.full?sid=9b83f3f4-03aa-404d-a476-37a0de7e9af0port.  West Africa needs constant surveillance for EBOV outbreak and rapid response teams to stop an outbreak in its tracks.

RGL, MD

Posted December 28, 2014 by levittrg in Ebola

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Evening Ebola Update, Fri, 12/26: Strategies of EBOV drug vendors/’Community isolation’/Orphans   Leave a comment

12/26/14

Dear Colleagues:

l.  Investor’s Business Daily reports on the various strategies that EBOV drug makers have used to invest in viral drug manufacturing.  The key statement in this comprehensive report is:

“Maybe (Ebola will be) very profitable on a big scale for somebody, but it’s certainly not a chronic disease,” he told IBD. “As investors, we love cures, but there’s nothing like a chronic disease for revenues forever.”

See the entire IBD article at: http://www.nasdaq.com/article/viral-investing-ebola-drug-makers-varied-strategies-cm427500#ixzz3N3NZMfXo

2.  Nature 6 November published an article by Whitty of the U.K. Department of International Development and Farrar, Director of the Wellcome Trust, and others advocating the tough choice of  ‘community isolation’ in Sierra Leone to decrease the time to isolation of EBOV patients.  The goal is to isolate 70% of EBOV patients within 3 days of symptoms, which would decrease the number of persons infected by each newly infected EBOV patient to 1 or less (this number is called R or the reproduction rate).  ‘Community isolation’ would keep all patients with fever, diarrhea, vomiting, or other symptoms consistent with EBOV isolated in a tent or shelter near their village until the results of their EBOV tests were received.  The village would thereby be protected from EBOV transmission while EBOV tests were being processed; these tests can take several days for transport, processing, return of results to a remote village.  See the entire article at: http://www.nature.com/news/infectious-disease-tough-choices-to-reduce-ebola-transmission-1.16298

3.  Voice of America reports that the majority of the 10,000 orphans left with one parent or no parent after the EBOV epidemic have been ‘adopted’ by other family members or the community in which they live.  But some orphans are not ‘adopted’ and left to the WHO or UN or religious orders to care for.  Families do not want to ‘adopt’ these orphans because of the economic cost or the stigma/fear associated with their parents having died of EBOV.  See this article at: http://www.voanews.com/content/ebola-orphans-challenge-west-african-culture/2573837.html

RGL,MD

Posted December 27, 2014 by levittrg in Ebola

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Afternoon Ebola Update, Thurs, 12/25: Specifics on how anthropologists can help/ WHO response in Kono/Guide for interaction with West Africans   Leave a comment

12/25/14  Christmas Day

Dear Colleagues:

l.  Somatosphere, the science, medicine, anthropology website, has an article on building health infrastructure in West Africa by Alice Street, an anthropologist from University of Edinburgh.  The author makes the point that health infrastructure does not come ‘in a box’.  Infrastructure depends on people to be successful, so infrastructure has to be relational.  People have feelings, foibles, make mistakes, get tired, and sometimes just don’t care.  The author gives West African examples of how the best plans can go afoul: hired villagers won’t work if another village’s workers are also hired; too few ambulances are available to get patients to EBOV treatment centers; non-EBOV health centers are closed because febrile patients who visited centers are later diagnosed with EBOV; a love affair between workers causes them both to flee and no paychecks are distributed.  Read more about the ‘nitty-gritty’ of building infrastructure at: http://somatosphere.net/2014/12/rethinking-infrastructures.html

2. A NY Times report of mishandling of an EBOV sample at CDC (after previous mishandling of anthrax and flu specimens) is an example of the ‘nitty-gritty’ of building health infrastructure.  The CDC is a state-of-the-art health infrastructure, yet mistakes repeatedly occur because humans repeatedly make mistakes.  See: http://www.nytimes.com/2014/12/25/health/cdc-ebola-error-in-lab-may-have-exposed-technician-to-virus.html?ref=science&_r=0 for an account of the latest CDC human error.

3.  A recent article in The Lancet 18 December by Chandler, et. al. from the London School of Hygiene and Tropical Medicine, highlights how cultural anthropology can help HCW in EBOV-infected countries work productively with villagers.  Chandler, et. al. tell HCW that ‘just saying no’ to cultural practices does not work:

“From the perspective of afflicted people, however, the evidence that biomedicine is helping communities affected by Ebola can be hard to discern. Health facilities have been sources of Ebola transmission13 and many patients admitted to treatment centres do not survive. How can trust be established or collaboration developed if local people are expected to accept ideas and practices that do not accord with their own observations and experiences? In the context of a general willingness to adopt multiple modalities to achieve care and wellbeing, safer practices can be adopted without changing people’s core beliefs”  

See the entire article at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)62382-5/fulltext

4.  Chandler, et. al. article has a reference to the Ebola Response Anthropology Platform which lets HCW know how best to interact with West Africans and EBOV-infected communities to get positive results.  See the website at: http://www.ebola-anthropology.net/

5.  WHO reports that the Kono District in Sierra Leone, where the latest outbreak of EBOV is located, has 14 chiefdoms.  WHO and other big organizations have involved the chiefs of all these chiefdoms and set up procedures for preventing more EBOV.  300 contact tracers have been trained, and 45 people from the chiefdoms have been trained in EBOV prevention and treatment.  See: http://who.int/features/2014/ebola-response-kono/en/ for details on the WHO response in Kono.  Note how suspicious of the WHO measures the chiefs look in the photograph displayed.

Merry Christmas,
RGL, MD

Posted December 25, 2014 by levittrg in Ebola

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Evening Ebola Update, Wed, 12/24: NEJM urges AMC to let volunteers go to West Africa/Case mortality rate can drop to 23%/HHS should direct CDC to accept AMC volunteers as ‘EBOV fellows’   Leave a comment

12/24/14  Christmas Eve

Dear Colleagues:

NEJM Ebola Outbreak website has 3 new articles on the state of the EBOV epidemic on its one year anniversary in West Africa:

1.  A NEJM Editorial by Drazen, et. al., editors at the NEJM, notes that the EBOV case rate in West Africa has slowed and EBOV treatment centers have been built and are operational.  But more volunteers are needed, especially from U.S. academic medical centers (AMC).  The authors request that U.S. AMC remove ‘roadblocks’ (loss of health care insurance, loss of malpractice insurance, loss of salary, no temporary replacement staff for volunteer’s clinical assignments) so that qualified trainees who wish to volunteer in EBOV-infected countries may do so.  The Wellcome Trust in the U.K. has done so for AMC in the U.K.  See this Editorial at: http://www.nejm.org/doi/full/10.1056/NEJMe1415398?query=featured_ebola. 

2.  In my opinion, HHS should issue a directive that permits CDC to accept such AMC volunteers as 3-6 month ‘EBOV clinical fellows’ for training, deployment, and post-deployment isolation; CDC could then provide AMC volunteers with health care insurance, malpractice insurance, stipend, and travel expenses,  HHS has both the money and authority to do so.

3.  A NEJM Correspondence by Ansumana, et. al. reports on the clinical data from a series of 581 EBOV patients treated at an EBOV treatment center just outside of Freetown, Sierra Leone.  These EBOV patients were treated between September 20th and December 7th.  During that time period, the case fatality rate decreased from 48% to 31% to 23%.  The treatment protocol involved IV fluids, antibiotics, anti-malarials, pain and anti-vomiting meds, calorie replacement, electrolyte replacement, and vitamins/minerals.  See the specific treatment plan at: http://www.nejm.org/doi/suppl/10.1056/NEJMc1413685/suppl_file/nejmc1413685_appendix.pdf.

4.  Ansumana, et. al. state they do not know why their overall case mortality rate (31%) was so much lower than the reported case mortality rate (74%) at Kenema Hospital, Sierra Leone, in EBOV patients treated in May and June.  Perhaps the season change affected the virulence of EBOV or perhaps EBOV has mutated between June and September.  See the entire Ansumana, et. al. report at: http://www.nejm.org/doi/full/10.1056/NEJMc1413685?query=featured_ebola

5.  WHO Ebola Response Team reports in NEJM Correspondence on the West Africa EBOV epidemic after one year.  The incidence rate of EBOV is stable in Guinea and Sierra Leone and decreased in Liberia, according to the Team. New cases have shifted from the rural regions to the capital cities in all 3 countries.  Time to patient isolation has decreased, and percentage of safe burials has increased.  But the threat of EBOV spreading to other countries remains.  See the WHO Ebola Team report at: http://www.nejm.org/doi/full/10.1056/NEJMc1414992?query=featured_ebola

RGL, MD

Posted December 25, 2014 by levittrg in Ebola

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