Archive for January 2015
l. PLoS Current Outbreaks 30 January posted an article by White, et. al. from the Norwegian Institute of Public Health, Oslo, reporting on the need for more operational EBOV treatment centers and more isolation of suspected EBOV patients and more EBOV HCW in Sierra Leone. See: http://currents.plos.org/outbreaks/article/projected-treatment-capacity-needs-in-sierra-leone/. I believe the authors overestimate the current needs re: EBOV in Sierra Leone: the authors used WHO data collection ending 8/13/14 before interventions were ramped up and included 2.5 unreported EBOV cases for each EBOV case reported. Under-reporting is greatly reduced since 8/14/15.
2. Foreign Policy Nov/Dec, 2014 contains an article entitled: ‘Global Thinkers of 2014’. Among the FP’s choices are several persons whom I believe will directly improve global health care in 2015, particularly zoonotic infectious diseases, and particularly health in Africa. These persons are:
1. Jennifer Lewis: Materials scientist at Harvard who has made ‘functional’ ink jets for 3D printers so that cellular tissue with blood supply can be printed, as well as light, strong, renewable surfaces for objects.
2. Emmanuelle Charpentier/Jennifer Doudna: Both independently invented gene-editing technique called ‘CRISPR’ which allows single base pair to be added to subtracted from a gene. The technique will eventually cure or prevent all disease based on gene abnormalities. Inventors also say CRISPR will cure infectious diseases, including HIV. Their companies are called Editas Medicine and CRISPR Therapeutics.
3. Elizabeth Holmes: Researcher who developed technique for miniscule amount of blood all that is needed for comprehensive blood panel and RT-PCR for viral, bacterial, and parasitic diseases. Her firm is called Theranos. This technique will shortly be ‘transported’ to Smart Phones which will do the finger prick and the processing of the blood within the Phone. This technique could end zoonotic epidemics and HIV in Africa.
4. Arye Kohavi: Israeli whose invention can ‘pull’ water out of moist air to produce potable water. One version can make 120 gallons of water per day. This invention could actually save the world. World Economic Forum in Davos this year listed water shortage and pandemics are the world’s two biggest risks. His company called Water-Gen.
To this list of 4 persons, I would add all of you: researching EBOV, treating EBOV patients, planning or doing vaccine trials, and planning/taking action to help West Africa recover from the EBOV epidemic when it is brought to ‘zero’, coordinating the response to this epidemic.
l. David Nabarro, M.D., the U.N.’s Special Envoy for Ebola, has issued a detailed plan for ‘bringing to zero’ the EBOV epidemic in Africa. The effort will cost an additional $1 Billion from January-June, 2015. That $1 Billion is a shortfall; efforts are underway to raise the money. The detailed plan for ‘zero’ EBOV cases with Introductions by Dr. Jim Kim and Dr. Nabarro is at: https://ebolaresponse.un.org/sites/default/files/ebolaoutlook.pdf
2. The Lancet reports 31 January that the allocated emergency funds for EBOV epidemic in the U.S. budget remained at $1.5 Billion despite the NIH budget reduction. See comments on how the $1.5 Billion will be spent and over what time period at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60138-6/fulltext
3. ACAPS has issued a Humanitarian Needs Assessment Guide on-line to guide NGO’s and others in assessing needs and delivering needs in the event of a humanitarian disaster. See the extensive guide at: http://www.acaps.org/img/documents/h-humanitarian-needs-assessment-the-good-enough-guide.pdf. Note that the section on ‘Field Visits’ (pages 68-72) does not include assessment of diseases in the field area prior to visit, communication with locals prior to visit, or input from anthropologists on local culture prior to visit. The current EBOV epidemic has taught everyone that all three items need to be done pre-field visit.
4. CDC MMWR today gives an update on the EBOV epidemic in West Africa as of 25 January. There are a total reported caseload of 22,000+ patients and total deaths of 8,800+. The week ending 24 January had 11 cases reported in Sierra Leone, < 1 case reported from Liberia, and 3 cases reported from Guinea each day. See the entire MMWR at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm64e0130a1.htm?s_cid=mm64e0130a1_e
5. PLoS Currents Outbreaks has an article by Webb, et. al. from Department of Mathematics at Vanderbilt University, Tennessee, showing by computer modelling that isolation of infected EBOV patients in West Africa by Day 3 of symptoms and contact tracing/isolation of 50% or more of contacts can stop the EBOV epidemic. See the article at: http://currents.plos.org/outbreaks/article/a-model-of-the-2014-ebola-epidemic-in-west-africa-with-contact-tracing-2/
l. SHEA Spotlight reports today that Dr. Jim Kim, President of the World Bank, is developing a ‘pandemic insurance policy’ with WHO, World Bank, academics, and insurance companies so that immediate resources – money, HCW, diagnostic equipment, isolation procedures, contact tracing teams – are available the moment an infectious agent capable of producing a pandemic is detected in a country. Presumeably, the insurance policy would require all of these immediate resources to be in country before the insurance policy was issued. See summaries of the Dr. Jim talk at Georgetown at NBC and BBC: http://www.nbcnews.com/storyline/ebola-virus-outbreak/prevent-another-ebola-insurance-plan-world-bank-head-says-n294811 and http://www.bbc.com/news/world-31013636. The verbatim speech has not yet been posted by the World Bank.
2. Popular Science 22 January has an article posted on-line re: why the EBOV epidemic has been less devastating than the CDC projection of 1.4 million cases by January, 2015. The CDC projection was based on data collected prior to September, 2014. It was only in September, 2014, that significant aid and personnel arrived in West Africa to reduce the EBOV caseload with contact tracing, isolation of suspected EBOV cases, safe burials and mourning practices, and EBOV treatment centers. The CDC projection also assumed that 1.5 EBOV cases went unreported for every EBOV case reported.
3. The Popular Science article says that the WHO projection of 20,000 EBOV cases by November, 2014, was more accurate than the CDC projection ( WHO still an overestimation) because the WHO study included data after September, 2014, and no unreported EBOV cases were included in the WHO calculation. See the Popular Science article at: http://www.popsci.com/why-ebola-epidemic-isnt-devastating-predicted-so-far
5. The Lancet Global Health February, 2015, has an article by O’Hare from the College of Medicine in Malawi and University of St. Andrews, U.K. explaining an economic reason why the EBOV epidemic has been so serious in Sierra Leone. The U.N. and African countries have agreed that the tax rate for African countries to meet their development needs should be 20% of GDP. But in Sierra Leone the collected tax rate is only 11% of GDP. O’Hare says this low tax collection is due to ‘illicit financial flight’ of capital. Multinational companies; e.g. mining companies, are given tax ‘incentives’ by SIerra Leone. These ‘incentives’ include the ability to move capital to their companies in other countries with a lower tax rate (this is called ‘profit shifting’). The result is loss of tax revenue for Sierra Leone. See: http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(14)70369-9/fulltext.
This week’s NEJM issue dated 29 January and its on-line companion issue posted today 28 January contain several EBOV related articles. My blog this evening is devoted to these articles and a touching Perspective on ‘weekend coverage’ at hospitals by a physician/journalist whose mother was hospitalized over a weekend:
1. By permission, NEJM editors have allowed posting of this week’s Interactive Medical Case: ‘A Liberian Health Care Worker with Fever’ for this blog’s readers. The Liberian HCW is followed as her diagnosis of EBOV is made, her treatment initiated, her critical period of illness analyzed, and her recovery supported. The diagnosis process and treatment are based on current data, and the discussions of each stage of her clinical course helpful. The illustration of the African patient naked in the Physical Exam section is both insensitive and without purpose in my opinion. No reason she couldn’t be dressed in an examining gown. See the Interactive Medical Case at: http://www.nejm.org/doi/full/10.1056/NEJMimc1414101?query=TOC
2. NEJM on-line 28 January has posted an article by Ramping, et. al. from an international consortium re: the safety and immunogenicity of chimpanzee adenovirus encoded with Ebola Zaire glycoprotein (GP) as a monovalent vaccine. The authors found the ChAd3 (or cAd3) both safe and immunogenic at doses given in 60 U.K. volunteers. The vaccine will now be Phase 3 tested in Africa. See the entire report at: http://www.nejm.org/doi/full/10.1056/NEJMoa1411627?query=featured_ebola
3. NEJM 29 January has a Perspective by Perri Klass, a Professor of Pediatrics and Journalism at NYU, who writes about her mother’s hospitalization over a weekend, including the results of ‘weekend staffing’ at the hospital. The Perspective is touching and a wake-up call to all of us who will someday be in her mother’s situation- hospitalized over a weekend waiting for Monday to see certain physicians or obtain certain tests or treatments. See the Perspective at: http://www.nejm.org/doi/full/10.1056/NEJMp1413363?query=TOC
1. NY Times reports that the WHO Executive Board endorsed yesterday a resolution containing Dr.Chan’s requests for ‘rapid response teams’ with full funding to respond to global health emergencies; a better mechanism to bring drugs and vaccines to market; and increased lab support in countries with global health emergencies. See the NY Times article at: http://www.nytimes.com/2015/01/26/world/who-members-endorse-resolution-to-improve-response-to-health-emergencies.html?ref=health. No details on where the funding for the ‘rapid response teams’ will come from.
2. Journal of Virology February, 2015, has posted on-line an article by Lauck, et. al. from the University of Wisconsin and Harvard University/The Broad Institute re: the association of the pegivirus GB-C infection with EBOV infection in West African patients. The presence of GB-C infection reduced the mortality of the EBOV infected patients, although the effect of increasing age was a confounding factor. The presence of GB-C in HIV patients has previously been shown to reduce the mortality of HIV infection. EBOV and GB-C infect myeloid and lymphatic immune cells respectively; the combination of both infections may mute the cytokine response to EBOV infection. See: http://jvi.asm.org/content/89/4/2425.full?sid=dc9d3913-ad5c-4c54-96fd-b42d6aa88d3f
l. Reuters has an article on what needs to change at WHO to make WHO more rapid and more effective in global health emergencies. The article quotes speakers at the WHO Executive Board’s Special Meeting on Ebola today who said that regional WHO directors made the EBOV epidemic political rather than a medical emergency and WHO responded too slowly with too little power to end the EBOV epidemic while it was an outbreak. See: http://www.reuters.com/article/2015/01/25/us-health-ebola-who-idUSKBN0KY0KA20150125
2. WHO website has posted Dr. Chan’s opening speech to the WHO Executive Board’s Special Meeting on Ebola today. The most important statements from Dr. Chan’s speech are: WHO has set up 27 laboratories in West Africa; deployed 60 Ebola health care teams in West Africa; established 66 Ebola Treatment Centers in West Africa; sent a total of 2000 HCW to West Africa. There are now WHO officials in all prefectures and districts of Liberia, Guinea, and Sierra Leone.
3. Dr. Chan states her most important goals now re: EBOV are: restoring and upgrading health care systems in West Africa so all countries are prepared to stop a subsequent outbreak of zoonotic infectious disease in its tracks; implement new ways to get medicines and drugs to market sooner; develop a ‘rapid response teams’ for WHO to immediately respond to global health emergencies; setting up a contingency fund to cover expenses of ‘rapid response teams’. See the entire Dr. Chan speech at: http://who.int/dg/speeches/2015/executive-board-ebola/en/
4. Many news sites on the world-wide web have reported that several Ebola vaccine Phase 3 trials will begin in West Africa within weeks. An article by Martin Enserink in Science 16 January on page 219-220 describes the methodology of these various trials. The debate over randomized controlled trials versus ‘compassionate use’ distribution of vaccine has been ‘solved’ by using different trial methodology in Liberia, Guinea, and Sierra Leone. Here is a modified chart from Enserink’s article:
1. Liberian trials: Led by: NIH; Participants: 30,000; Design: Randomized trial with control arm in general population. Vaccines: GSK, Merck.
2. Guinean trials: Led by: International consortium; Participants: 9000; Design: 1. Ring vaccination, 2. Observational study in EBOV HCW; Vaccines: To be determined.
3. Sierra Leone trials: Led by: CDC; Participants: 6000; Design: Stepped-wedge trial in EBOV HCW; Vaccines; To be determined.
See the Enserink artlice and chart at: http://www.sciencemag.org/content/347/6219/219.full
l. The Lancet 17 January has an Offline by editor Richard Horton addressing WHO weaknesses and possible solutions. This is Part 2 of the editor’s series on WHO. The author notes that Dr. Chan cannot ‘hire and fire’ her regional directors (appointed by member countries). Dr. Chan also does not have sufficient funds due to non-fulfillment of voluntary country contributions to perform all of WHO’s core functions. The author suggests a separate wholly funded agency within WHO to tackle global health emergencies. This agency would be directed by WHO and several diverse partners. See his entire Offline at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60034-4/fulltext
2. The Lancet 17 January has a World Report by Mohammadi containing detailed information on how clinical trials of 3 vaccines will be performed in West Africa the next 3 months. The author’s World Report directly answers the previously posted Lee, et. al. article: ‘Is the World Ready for an Ebola Vaccine?’ See Mohammadi’s detailed report at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60035-6/fulltext
3. CDC’s MMWR 23 January has one article re: how to monitor airplane passengers travelling on an airplane with a symptom-free EBOV patient and two articles on how to reduce EBOV infections within rural villages in Liberia and Sierra Leone. Regan, et. al. from the CDC report that it is only necessary to monitor passengers within a 3 foot radius of the symptom-free EBOV patient and the crew. The authors’ subject was one of Mr. Duncan’s nurses who later developed EBOV. See: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm64e0123a1.htm?s_cid=mm64e0123a1_e
4. The second report in MMWR 23 January re: the benefits of setting up EBOV treatment centers and/or community centers in villages in Liberia to isolate possible, probable, and confirmed EBOV patients as soon as EBOV symptoms develop. Washington, et. al. from the CDC compute that during one month of isolation in village EBOV treatment centers or community centers throughout Liberia (both at the periphery of villages) over 9,000 EBOV cases were prevented. See: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm64e0123a1.htm?s_cid=mm64e0123a1_e
5. The third report in MMWR 23 January by Crowe, et. al. of the CDC re: the benefits of establishing community surveillance workers in villages to ‘spot’ possible EBOV patients in villages based on a ‘trigger list’ of dangerous situations. These dangerous situations include: illness or death of HCW; illness or death of traveler to village; illness or death of person attending funeral within last 3 weeks; and other situations. The community surveillance workers notify the local health ministry official immediately; isolate the patient; give the isolated patient a packet of rehydration salts; give bleach pads to the family of the isolation patient to clean their home. See: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm64e0123a3.htm?s_cid=mm64e0123a3_e for the entire report and complete list of ‘triggers’.
6. Telegraph U.K. reports that the Scottish nurse with EBOV hospitalized at the Royal Free Hospital has been released after a full recovery. She was treated with convalescent blood from William Poole and an experimental anti-viral drug (? which one). Thank you Dr. Jacobs.