Ebolavirus 2014 Outbreak
September 2014 Update #1
Paul Herscu, ND, MPH
Herscu Laboratory
In the context of teaching
about epidemics I began writing about the topic in the 1990s. Much of that work
can be found on our website www.hersculaboratoryflu.org. I have spoken about
Ebolavirus since the late 1990s, in comparison to influenza in its various
forms as well as laying out strategies to implement during epidemics. What
follows are my general thoughts and understanding of Ebolavirus, and how they
relate to practitioners of naturopathic medicine, complementary and alternative medicine (CAM),
homeopathy and other integrative medicine approaches, as of September, 2014. Practitioners
have remained mostly silent, yet many search for a framework to assist in
humanitarian aid at this time. I would like to elucidate information about the
Ebolavirus in general, and then move to specific thoughts about the Ebola 2014
Outbreak. The
first section might be read by anyone interested on the topic. The second part
is aimed at practitioners.
Filoviridae Family
The Ebolavirus is one of a
couple of genera that are taxonomically organized within the Filoviridae
Family. Aside from Ebolavirus, the other famous genus is Marburgvirus, along
with the lesser Cuevavirus. The highlight of this Family is that it causes
hemorrhagic fever and death in humans at a high rate.
Since 1997, but especially
after 9/11, the US government with CDC and other international agencies,
decided to catalogue more carefully and track biological agents that might be
employed in bioterrorism or had a high level of potential harm if epidemic
infection rates were reached. These were ‘Select Agents’, and on that list,
Ebolavirus was a Tier 1 agent, meaning it was classified as an emerging potential threat for a widespread
epidemic, with easy communicability, low infectious dose (even a few virions
are enough to cause illness), and potential weaponization of the infectious
agent.
The CDC had it right. If
you would like to see the list and further information, here are the links:
In the Filoviridae family,
viruses are single stranded and small, negative sense RNA. RNA viruses have RNA
as their genetic material and can be single or double stranded; Ebolavirus is
single stranded. The family name ‘Filoviridae‘ refers to the ‘filament’ appearance
of the virus. Single stranded RNA viruses are further separated into possessing
positive, negative and ambisense polarity. Positive sense viruses, known as
Group IV on the Baltimore Method are very similar to the host’s mRNA, and
therefore the human ribosome directly translates the genetic material as if it
were part of a human cell, making protein. Examples of positive sense RNA
viruses include SARS, West Nile Virus, Dengue virus, and Poliovirus, an
auspicious and challenging group of viruses by any estimation. The negative
sense viruses, such as Ebolavirus (Group V), are complementary to the host
cell’s mRNA. This viral genetic material must go through a change, it must be
transcribed into several positive sense RNA using a RNA-dependent RNA
polymerase in order to turn into a positive sense RNA. Then they act similar
enough to the above positive sense RNA virus. Examples of Negative sense RNA
viruses aside from Ebolavirus, are Marburgvirus, Rabies virus, and
Crimean-Congo hemorrhagic fever virus, also a very difficult group of viruses
for humans to interface with. Just to round out the dangerous viruses, there
are some single stranded RNA positive sense viruses that eventually need a DNA
phase to complete their cycle, called Retroviruses, that are also threatening.
HIV-1 and HIV-2, the viruses causing AIDS fit here. A list of viruses separated
by Baltimore’s virus classification method that groups viruses into families
based on their genome and replication method, can be found by clicking below:
As is common in viruses,
the virion attaches to the cell surface of the host cell, fuses with it,
releasing the viral nucleocapsid into the host cell cytosol. At this point the RNA-dependent RNA
polymerase transcribes the genetic code into positive stranded mRNA, which
eventually translates into proteins, eventually creating more virus, which bud
off the host cell only to start the process once more.
The virus is small with a
genome of around 19 kb in length,
with each virion looking like a long strand of hair, straight or curved like a
number 9 or a ‘u’ shape, which is around 80 nm wide and hundreds nm-14 μm
long.
Aside from the description
above, I should add that by use of genetic mutational clocks, we can tell that
the family has been around for tens of millions of years, meaning that it has a
long line of success to continue to build upon. RNA viruses have a very high
rate of mutation or change when compared to DNA viruses. On the one hand this
makes it hard to target the virus with vaccine, but on the other hand, not all
genetic material is equal. There are some portions that are highly important
for the virus to replicate; scientists are targeting those areas when looking
to control the disease.
Actually, the first virus
found in the family was Marburgvirus, described in 1967, named after the great
city of Marburg, Germany. Researchers were handling tissue from Ugandan grivets
(a monkey used to develop vaccines) and became sick, though the natural vector is
more commonly known to be bats. All told, in the original outbreak in Marburg,
31 people were exposed and fell ill; seven died from hemorrhagic fever. In the
wild, Angola and Uganda have taken the brunt of recurring outbreaks.
The high level of lethality
made it a natural pathogen to weaponize. And this happened in the former Soviet
Union, in today’s Sergiev Posad and at the State Research Center of Virology
and Biotechnology in Koltsovo. When people raise concerns about bioterrorism,
it is real and potentially exceedingly dangerous. All epidemics have been
small, either in nature or in the lab, as has been the case with Ebola Virus Disease
to date.
Which brings up the last
point, but the most important one, as of September, 2014. The virus passes by
direct contact with blood, bodily fluids, organs from a contaminated host or
from the corpses of those who have died from this virus. While this shows a
certain level of communicability, in that an individual need only come in
contact with a few virions before falling ill, we are incredibly fortunate in
that the virus is not passed by air as in aerosolized molecules, such as occurs
with influenza. This is why, in general, the Filoviridae outbreaks have been
short lived and except for those working with the tissues or viruses directly
in research labs, have occurred mostly in developing countries in Africa. Historically,
surrounded by poverty and in small villages, people got sick, they died, and
the outbreak was soon contained.
Ebola Virus Disease (EVD)
The Genus Ebolavirus,
identified in 1976, 9 years after Marburgvirus, follows all the biological
tendencies described above. At the moment there are only a handful of species
of Ebolavirus but this number is likely to grow as more research uncovers them.
There is an unusually fast mutation rate in Ebolavirus, as one person passes to
the next person being infected. Once someone has been exposed and becomes sick
from the Ebolavirus, we say they have ‘Ebola Virus Disease’, but some call it
simply ‘Ebola’, and others add ‘hemorrhagic fever’ to the name, though to be
technically accurate, ‘Ebola Virus Disease’, is the correct name. This current
epidemic is called ‘Ebola 2014 Outbreak’, though this name is likely to change
to ‘Ebola 2014 Epidemic,’ as we are past the outbreak phase. We also shorten the name to EVD. However, please be
aware that currently, in North America there is a separate viral epidemic
called either EVD68 or EV-D68, which is an enterovirus Species D, serotype 68,
causing the respiratory infections we hear much about.
Someone becomes infected with Ebolavirus by
having the virion enter through the mouth, broken skin or mucous membrane. The
virus then advances to a variety of cells, eventually spreading through the
lymph channels, liver and spleen. The virus takes over protein production,
releases pro-inflammatory cytokines, leading to vascular leakage, and clotting
problems. The virus also makes a protein that helps attach the virus to the
endothelial cells inside blood vessel walls, which eventually weakens the blood
vessels. Liver
cells die off, breaking down clotting processes, the adrenals and kidneys cell
die and blood pressure control is compromised. Organs begin to shut down.
The specifics around EVD are
as follows.
Incubation period is
anywhere from as short as 2 days, to a more typical 8-10 day period. However,
infections have been known to arise 3 weeks after exposure; if someone is not
symptomatic in 21 days, it is not likely that they will become symptomatic.
The symptoms
that arise with early EVD are typical to viral infections such as influenza.
Here we find complaints of chills, fever higher than 101.5F or 38.6C and significant
fatigue and tiredness, which commonly takes the patient to bed. There are skin
complaints such as flat or slightly raised rash on the face, trunk and arms.
After this initial
influenza like illness, on day 5-7, more GI and musculoskeletal symptoms
develop. Here we find muscle aches, joint pain and severe headache.
GI complaints, such as
loss of appetite, abdominal pains, nausea, vomiting, severe watery diarrhea
ensue.
Respiratory complaints,
such as sore throat, difficulty swallowing, shortness of breath and chest pain
are often present.
Up to this point, someone
may think they have a common, albeit severe, viral infection. It is after this
that the patient can either improve and have a long recovery period, or may
take a turn for the worse, usually after around a week or two of being ill.
This worsening is characterized by hematological complaints. In about half the
people infected, bleeding begins from an injury or spontaneously,
subcutaneously (purpura, ecchymoses, or bleeds from punctures), or from any
mucus membrane, such as GI tract, mouth, nose, vagina, eyes, but also
internally, with organ damage, especially in the liver and/or kidney.
Death may ensue around the
2-week mark.
Treatment is aimed at supportive care to
contain the symptoms and this by itself saves lives. Aside from that, we have
at least two major pathways that may offer solutions:
1. Antivirals.
It is likely that drugs used to treat other viruses will be tried to see if
there is any success, even drugs used for non RNA viruses. This makes sense in
that the virus may be stopped at various targets, such as at attachment or even
at the budding off stage or during any phases of replication. This means that
over the next few weeks and months you are likely to hear that this or that antiviral
has a certain amount of benefit for patients with EVD.
2. Plasma
products. Plasma products that mimic those of survivors of EVD will be
tried and will have different levels of success. This means everything from
plasma transfusions from survivors to fresh frozen plasma, to antibodies
manufactured in the lab. Plasma products may control both the inflammatory
response as well as vascular breakdown.
As mentioned above, one
positive attribute about the virus, up to now, is that it can only be passed by
direct contact with body fluids. No contact equals no transmission. Also in our
favor, as I had previously mentioned, is that the ill are so weak they tend to
isolate, not move around a lot. In fact, the vast majority of people who become
infected come to the ill person,
either to provide care or to perform funeral rites/burial practices with the
patient’s remains. But in this case unfortunately, the patient’s remains may
still infect those who come in contact with the body.
This particular outbreak
may have begun with a human being coming in contact with an infected host, such
as a primate or a bat, or in some other way in contact with fluids from those
species, along a short or longer chain of the ecology or predator/prey
relationship. Many primates, such as gorillas die of Ebolavirus. Humans may
have eaten bushmeat where that animal had eaten something that had the virus in
it. Recently it has been found that both pigs and dogs may be able to carry the
virus, a point I will return to in a moment. In general though, the disease is
so severe that, by nature, it should be self-limiting in humans. We are too
weak to move about, too secluded, and therefore die and the outbreak dies with
us. Before. Up to now.
I hope with the above, we
can come to the following conclusions, as to why this epidemic is spreading.
First, Africa is changing.
More people are leaving villages and congregating in more densely populated
areas, making likelihood of transmission greater. To date, no very large city
has gotten the epidemic yet, though if it does, the number of dead will climb
at an alarming rate.
Second, the countries where
the epidemic flourishes are poor. The poverty can be seen reflected in the
health care system where there is both a severe lack of infrastructure to
oversee an epidemic halting effort and where there are few to no physicians or
other health care workers to care for the sick properly or to disseminate
helpful information effectively.
Third,
lack of education in general, related to poverty and lack of education as to
what EVD is and more specifically how it is transmitted are all factors making
the epidemic worse. Traditional burial rites unchanged, perpetuate the
transmission of the disease. Most people suffering from EVD during this 2014
epidemic lack the knowledge of how the virus is transmitted and therefore
become infected from taking care of the ill or from preparing a body for
burial.
Adequate
and ongoing funding is needed for proper education and healthcare
infrastructure.
My worries & concerns
In no specific order, I
would like to tell you what I worry about most when thinking about this moment
in history.
At the moment, Ebolavirus
2014 has not infiltrated any large city, but if and when it does, the number of
people who will be impacted will skyrocket.
At the moment, leaving out
other vectors and reservoirs, Ebolavirus is transmitted human to human, only by
touching human tissue and fluid. However, if it mutates in such a way as to
allow aerosolizing methods of transmission, then this story will take a tragic
turn. We might see a potential 50% lethality but with very high levels of
transmission. For this to happen, a number of things need to take place. First
the virus must mutate and at the same time, not
mutate in its lethality, and simultaneously remain stable during transmission. It
is unlikely that these three things would occur at once, but it is potentially
possible.
Related, I worry about
someone weaponizing the virus. I believe government should play a bigger role
limiting exposure of anyone to the virus not just for their own health but
potentially for future devious purposes. It is akin to having loose radioactive
material lying around. I believe governments of the world need to be proactive
and forward thinking on this note.
The longer the epidemic
goes, the more mutations there are. Sooner or later it may become easier to
pass it to pigs and dogs, though it already does this to a small extent. There
are wild dogs all over Africa and if there becomes a version of the virus that
is passed easily between dogs and/or pigs, their proximity to humans could be a
source of infection. Again, this becomes more of a possibility the longer the
epidemic ensues.
Any discussion here must
address deep-seated poverty. In almost all respects, this epidemic is caused by
lack of political will to bear enough and rapid economic relief. Yes, the Ebolavirus
causes the disease, but that is only the start. For it to become an epidemic
you need a poor and uneducated population, which has neither the education or
resources to stop an epidemic.
There will either be
10,000-30,000 people killed from this epidemic or the number will be in the
millions. The difference is not the virus, but the delays our and other
governments have had in addressing needs of the public good. If you were to go
to the CDC website, you can find all the specifics of how the USA can deal with
Ebolavirus, how to make the diagnosis, how to transport the ill, how to take
care of the ill, how to handle samples, how to handle the dead, etc. In all
instances, if the virus does not change, we should be in good enough shape.
However, when you look at the list of tasks, what is striking is how impossible
it is to implement those tasks because of where the epidemic is taking place at
the moment. If we want to stop millions from dying, we have to act now, with
the appropriate, relevant level of funding and medical care. This epidemic
could kill only 10,000 people, but that number can pass within a month if we do
not bring the full plan to where it is needed now. See below for the CDC
references on Ebolavirus treatment recommendations if it were to reach the
shores of the USA:
The point I am making and
what is frustrating is that we know we know how to clean a hospital or a home
to get rid of the Ebolavirus, we know that after proper cleaning and
disinfecting, Ebolavirus will not be found in an area after a short time (one
day with proper cleaning). We know how to take care of human remains. We know
how to handle tissue, waste, fluids, and blood samples properly. We know how to
manage ill patients and those suspected of being ill with Ebolavirus, in terms
of keeping them from infecting others.
We know how to wash hands
and we know how to rehydrate the ill. While many people will die due to the
severity of this disease, many die needlessly from the effects that we may be
able to control, oral rehydration and IV hydration being on that short list.
Half of those infected do not die as of now. In short, we can detect those that
are ill, and keep them from infecting other people. In other words, 10,000
dead. A sad disheartening number, but a very different story than millions
dead. It is not science missing here, but the political will to spend enough money and resources quickly to do what needs to be done.
Most embarrassingly, and to
make my point here, when it is all said and done, and proper statistics are
applied what will be found is that the poor and uneducated were disproportionately
effected by death in this epidemic. In other words, it is less about the virus
and more about how as a society, we chose to address the infrastructure issues,
the allocation of resources in a timely fashion and the dispatching of medical
care where needed.
The role of those practicing in naturopathic,
homeopathic, CAM, and integrative medicine settings in general and during the time
of Ebola 2014 Outbreak, September, 2014
The highest level of any
physician should be to function at the primary
prevention level. In this instance, primary prevention means limiting the
number of people who are exposed to the virus so that the epidemic may end. The
majority of energy should be spent not on treatment, but in the prevention of
exposure to the virus. Prevention is the essential way we can see ourselves out
of this potential disaster, prevention as soon as possible. The natural
medicine community has a role to play.
The natural medicine
community, like any organization of individuals can and should bring its
political voice to bear urging politicians in charge of the purse strings to
adequately fund prevention protocols.
Like every other medical and
nonmedical organization, civic group or religious community, at the very least,
we can assist in the collection and distribution of products needed to decrease
exposure. Here I mean everything from surgical gloves and masks to gowns. I
also mean cleaning agents such as soap and pH changing products such as bleach.
Assisting with the removal of potentially exposed substances and surfaces will
also be needed. Please remember that these ‘simple’ acts will save millions of
lives.
Those trained in public
health measures can assist within the
current public health command. This means everything from assisting in
surveillance, finding both exposed and sick individuals, transporting exposed
and ill patients while limiting travel of those individuals and providing
quarantine assistance, helping with communication of status in a defined area,
and assisting in the safe removal and processing of the remains of the
deceased. Simply put, as is true in every large-scale emergency, either be part
of the larger command and control or try to stay out of the way. There is
always a great deal of confusion on the ground; we do not want to add to it.
This is also true for all other needed physicians and medical staff who are
best employed within the extant structure.
CAM practitioners can help
provide lower level medical support such as rehydration and palliative care.
And if during this time, one finds themselves in the situation that they are
either presented with an ill patient and/or presented with a person who was
exposed to the virus, then I believe that a CAM approach, such as a homeopathic
remedy, matching the symptoms of the individual can be given. I base this on
both basic humanitarian principles, as well as a form of precautionary
principle. You are not preventing any other treatment that may be tried, you
are protecting the society at large, the family of the ill person by
quarantine, and there, in that instance, there is nothing to lose. The medicine
and care is free to the patients. In all countries around the world, there are
compassionate and early use clauses for application of early investigational
therapies, for unapproved medicines under compassionate rules, even when the
therapy has a potential of harm, but this is especially so if the medicine is
safe, but not yet proven effective. For example in the USA, we have the
following from the FDA, though there are more:
“Availability
of Investigational Drugs for Compassionate Use,” and
“IDE Early/Expanded Access”
Indeed this is why so many antiviral
drugs are currently being tested.
Under these circumstances, to prevent,
ridicule, deride, or in other way diminish the likelihood of potential care to
be given is in fact limiting access to healthcare—recognized by most civil
society as a basic human right —and limiting access is contrary to the public good
as well as decency. Put simply, there is no proof that homeopathy or other CAM
approaches may help in this circumstance, but likewise there is no proof that
they will not help, and with
homeopathy, we have 200 years of proof that it does not hurt. In any other
situation, any reasonable, nonbiased scientist would try this. Indeed this is
the premise of the current treatments that have been tried recently during this
epidemic. So many antivirals are being tested as I write, on this basic
premise. For example, Zmapp, the experimental biopharmaceutical agent was used
on people before proper preclinical trials were concluded to show safety and
efficacy, and there we had real potential for harm. See below:
Anything short of allowing access is an
example of the ‘tomato effect’ seen in people acting unscientifically, and not
in keeping step with the rest of science at the moment as it relates to Ebola
Virus Epidemic 2014. In fact, I would say that in the circumstance I described
above, where the patient is receiving the best care possible, given the
resources available, it would be interesting for everyone to test out whether a
safe CAM approach like homeopathic medicine actually provides benefit. This
would be interesting for all; likewise, if the substance is completely useless,
this would be valuable information, too. Join me in this call for a rational
approach, unfettered by bias. Rational prudent thought should prevail.
The response of all CAM to the Ebola 2014 Epidemic
should be to help highlight and advocate for prevention, assist in
identification, stabilization and quarantining of exposed and ill individuals,
and support cleaning and disinfection processes, and provide CAM aid where and
when appropriate. There should be the push from every medical community to
their government to support relief efforts. If you are still asking what is the
best drug or herb or homeopathic remedy here, then your focus needs to change.
It is time to act. Individuals and groups should donate resources and material
as well as professional expertise.
If you would like to write
to your US Senator and Representative, to encourage support of immediate increase in funding to contain Ebolavirus epidemic, you can find
their contact information here by entering your zip code:
When you write to your
national lawmaker, be sure to include your name and address.
To donate funds, here is a
list of top rated charities, graded for how much of funds donated are used for
the intended cause (to fight Ebolavirus, for example) and what percent of their
funding is spent on raising more money:
If you are so moved to do
more and want to donate your time on the ground, training is available through
the CDC. For further information see:
Doctors without Borders
needs help in many areas, a listing is found here:
We encourage you to work
within your state and national associations to create policy and framework for
your members to understand Ebolavirus and make policy and contributions as
relevant.
In health,
Paul Herscu, ND, DHANP, MPH
