Archive for March 2015

Evening Ebola Update, Mon, 3/30: Don’t blame Big Pharma for few vaccines/Africa needs ‘green water’/New whole genome EBOV vaccine works in monkeys/Novel pox report in NEJM is great   Leave a comment

3/30/15

Dear Colleagues:

l.  Nature 19 March has published a World View by Seth Berkley, CEO of GAVI, the Vaccine Alliance, re: the fact that only 20 vaccines have been developed for the >300 infectious diseases discovered in the second half of the 20th Century.  The author does not blame the drug industry for failing to develop an EBOV vaccine previously because such a vaccine would have been a ‘product without a market’ previous to 2014.  Instead, he says the world needs to recognize that vaccines benefit us all in today’s world of air travel.  ‘Instead (of drug industry), governments, public funders, and private donors sould be stepping up and investing’.  See his article at: http://www.nature.com/news/share-the-risks-of-ebola-vaccine-development-1.17134

2.  Nature 19 March contains a Comment on ‘Increasing water harvesting in Africa’ by Johan Rockstrom, et. al. from Stockholm University.  Africa’s population will double to 2.5 billion people by 2050.  Currently, 50% of Africans live in extreme poverty.  To produce enough food to feed Africa’s people now and in the future, the continent needs water to feed crops.  The water needs to be ‘green water’-moisture from rain held in the soil, and not ‘blue water’-runoff water from rain.  There just isn’t enough blue water in Africa to support crops.  The authors give several techniques to increase green water: terracing, mulches, canopy cover.  This article is a look into the future; read it at: http://www.nature.com/news/agriculture-increase-water-harvesting-in-africa-1.17116

3.  Science 26 March has an article by Marzi, et. al. from NIH reporting a replication-deficient EBOV virus vaccine which successfully induced protection against EBOV in non-human primates (macaques).  The altered EBOV virus cannot code for VP30.  The authors state this EBOV vaccine may have greater effectiveness in humans because it presents more than one EBOV gene or protein to the human immune system than the current EBOV vaccines in trials.  See the article at: http://www.sciencemag.org/content/early/2015/03/25/science.aaa4919.full

4.  PLoS Neglected Tropical Diseases has represented an article by Bausch, et. al. from the Tulane School of Public Health discussing why the current EBOV epidemic began in a village in Guinea.  The authors cite poverty which drove the Guineans into the tropical forest to seek food which was contaminated with EBOV, either bushmeat or cocoa pods, lack of health facilities to treat the EBOV infection, care-giving falling upon family members who subsequently became infected, and porous borders which spread the infection to Sierra Leone and Liberia.  See this article published originally in July, 2014, at: http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003056

5.  NIH 26 March reports that the cAd3-EBOZ vaccine (GSK) and the VSV-ZEBOV vaccine (NewLink Genetics) undergoing Phase 2 trials in Liberia are safe.  NIH thanks the Liberians for allowing the PREVAIL trials to be conducted in Liberia using Liberian subjects and controls.  See the article at: http://www.nih.gov/news/health/mar2015/niaid-26a.htm

6.  NIH 26 March report by Dr. Fauci says that the mutation rate of the EBOV virus in West Africa from March (Guinea) to June (Sierra Leone) to November (Mali) in 2014 was not greater than the mutation rates in previous outbreaks.  There is no reason to believe the EBOV virus in the current epidemic has become more virulent during 2014.  See Dr. Fauci’s statement at: http://www.nih.gov/news/health/mar2015/niaid-26.htm

7.  The science that shows the EBOV virus in Mali does not mutate more rapidly than in prior outbreaks is reported by Honen, et. al. from NIH in Science 26 March.  See the science at: http://www.sciencemag.org/content/early/2015/03/25/science.aaa5646

8.  NEJM 26 March has published a beautiful article by Vora, et. al. from Georgia and NIH on human infection by a novel zoonotic Orthopoxvirus in the Country of Georgia as a Brief Report.  The article is written so that those of us who have trouble understanding phylogenetic analysis of viruses can understand the detective work that took place in identifying this novel virus.  The illustrations are gorgeous and well-described.  I only wish the legend for Figure 3: Phylogenetic Analysis of the Novel Orthopoxvirus was more basic so I could understand Figure 3 better.  Importantly, the article points out that current diagnostic tests for other ‘pox’ can be positive with the novel virus, leading to misdiagnosis.  See the Brief Report at: http://www.nejm.org/doi/full/10.1056/NEJMoa1407647

RGL, MD

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Posted March 31, 2015 by levittrg in Ebola

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Evening Ebola Update, Sat, 3/21: Syrian TB, typhus/Gates says what to do next time/Animal model for EBOV/120,000 maternal deaths by October   Leave a comment

3/21/15

Dear Colleagues:

l.  ACAPS has issued a current report on the situation in Syria and the surrounding countries receiving refugees.  Within Syria 25,000 persons need hospital care for injuries each month, but only 1/2 of Syrian hospitals are fully functioning.  TB, typhus, and scabies are endemic in/out of Syria, and cholera is increasing.  Funding requests for Syria and the refugee camps out of Syria were less than 50% fulfilled in 2014.  See the full Syrian report at: http://acaps.org/img/documents/s-acaps-report-syria-4-years-on_13_march_2015.pdf

2.  Nature reports that maternal health in West Africa is suffering terribly as a result of EBOV epidemic.  Pregnant women are especially susceptible to EBOV; fetuses do not survive EBOV infection.  Because of the fluids associated with delivery, many midwives do not perform deliveries now.  The maternal deaths estimated by the U.N. for the first 9 months of 2015 are 120,000 deaths.  See two Nature reports at: http://www.nature.com/news/maternal-health-ebola-s-lasting-legacy-1.17036 and at: http://www.nature.com/news/fatal-fallout-1.17029

3.  Bill Gates has written a Perspective in the NEJM March 18 re: how to deal with the next epidemic.  He uses the experience of the current EBOV epidemic as the basis for his recommendations.  Gates is particularly upset with logistics of the current epidemic.  His recommendations for future epidemics are:

The world needs to build a warning and response system for outbreaks. This system should

• be coordinated by a global institution that is given enough authority and funding to be effective,

• enable fast decision making at a global level,

• expand investment in research and development and clarify regulatory pathways for developing new tools and approaches,

• improve early warning and detection systems, including scalable everyday systems that can be expanded during an epidemic,

• involve a reserve corps of trained personnel and volunteers,

• strengthen health systems in low- and middle-income countries, and

• incorporate preparedness exercises to identify the ways in which the response system needs to improve.”

Read Gates’ NEJM Perspective at: http://www.nejm.org/doi/full/10.1056/NEJMp1502918?query=TOC  The Atlantic also carried an article on Gates’ PerspectiveSee it at: http://www.theatlantic.com/health/archive/2015/03/bill-gates-speaks-out-on-ebola/388120/

4.  PLoS Neglected Tropical Diseases has posted an article by Peterson from University of Kansas re: good and bad news from the current EBOV epidemic.  The author notes that EBOV has moved from ‘neglected tropical disease’ to ’emerging infection’ because of the epidemic in West Africa.  Now research funds, on-site treatment facilities, and vaccine development have all rapidly become available to West Africa. The author states that the basis for surge in monies and people in EBOV is the fact that EBOV showed spread to affluent countries from the underdeveloped countries in West Africa.  Sadly, Peterson is probably right.  See his article at: http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003509

5.  ACAPS has issued a report on the effectiveness of quarantine in West Africa to curtail spread of EBOV.  The report says that self-quarantine is effective if food/water are supplied to villagers, if the reasons for quarantine are explained to the people affected, and if coercion is not used to enforce quarantine.  See the ACAPS report at: http://acaps.org/img/documents/t-acaps_thematic_note_ebola_west_africa_quarantine_sierra_leone_liberia_19_march_2015.odf

_2015.pdf

6.  Lancet 21 March has Correspondence from Dhillon from Brigham Hospital re: outsourcing some of WHO’s tasks so that the response to future epidemics is earlier and more complete.  WHO funding has been reduced in recent years because U.N. members have not fulfilled their voluntary contributions to WHO; now WHO depends on non-U.N. contributions for more than 1/2 of its budget.  From my review of the WHO organizational structure, I don’t believe outsourcing is the answer; adequate WHO funding so that adequate staffing of WHO can be maintained is the answer.  Dr. Chan addressed this issue with the Executive Board at its last meeting.  See the Lancet Correspondence at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60594-3/fulltext

7.  Lancet March, 2015, has an article by Faye, et. al. of the Pasteur Institute in Dakar, Senegal, re: chains of transmission of EBOV in Guinea.  The authors show how a single EBOV infected individual can start a chain of transmission after all existing EBOV cases are isolated or treated.  See the article at: http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(14)71075-8/abstract

8.  NY Times reports an EBOV case in Liberia two weeks after the last reported EBOV case.  This is an example of a single individual starting a transmission chain (see 7. above).  The infected woman did not come in contact with an infected EBOV patient or attend an unsafe burial.  She may have had sex with a previously EBOV infected male.  See the report at: http://www.nytimes.com/2015/03/21/world/africa/liberia-reports-first-ebola-case-in-weeks.html?ref=health&_r=0

9. WHO reports that mass vaccinations must take place in West Africa for pertussis, measles, and other diseases now.  The EBOV epidemic cut the rates of vaccination significantly.  See the WHO report at: http://who.int/mediacentre/news/releases/2015/vaccination-ebola-countries/en/

10.  Journal of Virology reports that Ludtke, et. al. from Bernard Nocht Institute in Hamburg have transplanted human stem cells into mice in such a way that these mice reproduce the clinical course of human EBOV infection when they are infected with EBOV.  Now there is a small animal model for EBOV infection in humans.  See: http://jvi.asm.org/content/89/8/4700.full?sid=bc66d3ab-71cd-4d92-aa6c-7060d9f5e01c

RGL, MD

Posted March 22, 2015 by levittrg in Uncategorized

Evening Ebola Update, Mon, 3/16: NIH case now critical; NEJM Video on PPE on/off; No commerical planes for U.S. contacts   Leave a comment

3/16/15

Dear Colleagues:

l.  NIH has issued an update on the Partners in Health HCW now hospitalized with EBOV at the NIH Center.  His/her condition has been downgraded from serious to critical.  I calculate this is Day 7 or 8 of his/her symptoms so this is the stage of highest viremia and most fluid loss with accompanying respiratory and renal problems.  See official NIH update (without much detail) at: http://www.nih.gov/news/health/mar2015/nih-16.htm

2.  NEJM has produced a video showing the proper method to doff and don a PPE.  The video may be viewed at: http://www.nejm.org/doi/full/10.1056/NEJMvcm1412105?emp=marcom&query=NEW

3.  Until the genome of the EBOV which infected the NIH case is determined to be unchanged from prior cases AND the genome still detectable by current RT-PCR tests, both standard and ‘quick’ versions, contacts of the current NIH case must be brought to the U.S. on private, ‘EBOV-proof’ aircraft.  No commercial aircraft should be used to transport contacts to the U.S. from West Africa until scientists have determined the genome of the current NIH EBOV case and the accuracy of RT-PCR tests for his/her EBOV genome.  Remember this patient had two negative EBOV tests before the test turned positive..

4.  Now that EBOV cases are decreasing in West Africa, some EBOV Treatment Centers are being ‘de-commissioned’.  This process must be approached with the same diligence and caution that contact tracing and isolation of EBOV patients has been done.  Many EBOV Treatment Centers will be re-purposed as non-EBOV health centers or schools. So decontamination is a critical part of the de-commissioning, and something that is new for everyone in research and in the field.

Postings to this blog will less frequent than daily as the EBOV epidemic continues to be overcome.  I appreciate everyone’s interest in making this blog a success.  Thank you.

RGL, MD

Posted March 16, 2015 by levittrg in Uncategorized