Ebolavirus
2014 Outbreak
October 13, 2014
Update #2
Paul Herscu,
ND, MPH
Herscu
Laboratory
It has been 2 weeks since I posted
September Ebolavirus 2014 Outbreak, comments and outlook; a great deal has
taken place since then. If you have not already read the original post, please
take time to read as this update elaborates upon that original post.
My central goal in presenting these
comments and outlooks is to create a framework that allows future information
to be properly analyzed and placed within a realistic context. In so doing, it
allows us to better predict future events. In short, having a structure enables
future findings, future investigations, and thereby future actions to more
appropriately match needs on the ground. We have had a case spread in the USA
and a case spread in Spain. However, by clearly understanding the situation, we
can limit anxiety for everyone, while we create a pathway for action. So, with
that in mind, let’s dive into where we are as of now, working off of my
original post, taking topic areas one at a time, and seeing how more or less we
are right on target.
Marburgvirus
I had begun by describing the virus
and the Filoviridae Family in
general mentioning the fact that Marburgvirus was the first such virus
described (I have placed the two paragraphs here in smaller type italicized
& in parentheses).
(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.
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.)
If we keep track of the news carefully
(which I do!), we see a small Marburgvirus outbreak has occurred during this
same time.
While not in the news, recall that
Marburgvirus is as lethal, as contagious, and in many ways quite similar to
Ebolavirus. So whatever you know about Ebolavirus, you should consider as
similar enough with Marburgvirus. And as mentioned, the main location of
outbreaks in Africa, is in Uganda, where this current episode is found.
I mention the location, as this is one
of the common places Marburgvirus occurs. In other words, healthcare workers
and government officials have dealt with this virus before. In a way, as far as
it could have gone with the resources at hand there was preparedness. The US,
with others, have previously spent time working with Ugandan health ministries
to prepare for Marburgvirus outbreaks, in helping identify and isolate
potential cases in order to stop a large outbreak from occurring.
As an example of preparedness and
diffusion of information techniques, Ugandan government officials have created
communication about the Marburgvirus incidence to make sure everyone knows
about it, even taking advantage of social media:
Further, that work has led to a quick
identification of the patient, which led to quick isolation in both Uganda,
where the patient lived and died, and then in Kenya, where the patient’s
embalmer is located.
In short, the world is never going to
know about the horrific epidemic that never came to be. Why? Not due to a
lesser virus, but because enough economic and political interest led to
adequate resources spent which stopped an epidemic from starting in the first
place. For me, these nonevents are the most dramatic of all, as they illustrate
that when we put our political will towards a solution, we can keep a problem
small with fewer lives and communities impacted and fewer lives lost. Again,
prevention should be the rule. I have more to say about this issue at a later
time but wanted to highlight that the structure that we described in the first
letter helps us understand this news. Onward.
Timing and pacing of Ebolavirus and Marburgvirus
As I wrote earlier, one ‘positive’
thing (in terms of limiting large scale transmission) of Ebolavirus and
Marburgvirus is that the illness is so severe that historically, people
infected would be so sick and so weak, they could not easily travel and
therefore the outbreak would die with that individual or with one of their
relatives, thereby limiting the outbreak. All that has changed with more
condensed living quarters, with more travel, with more people ‘coming to’ the
ill person one way or another. To put it another way, if we were so isolated
and poor and unable to travel and unable to leave, then as the days march on,
those infected become obvious. The 21-day longest possible transmission day
would come and go. Now, with travel and person to person contact that timeframe
is too long. We need to either quickly and completely isolate potentially
infected people, as described before, or figure out how to identify patients
earlier.
CCHF
I would like to describe another
illness to make this point. The above viruses are not the only viruses that
cause these sorts of illnesses. Another one is the Crimean–Congo hemorrhagic fever (CCHF). There is an excellent chance
that most of the people reading this have not heard of the illness, even though
about a third of the people who become acutely sick, die. And as importantly,
we know that one way to get this illness is by a tick bite, the Hyalomma
truncatum tick. (Interestingly, the full name includes Crimea because during one of
their “ethnic cleansing” that occurred in the Crimea during WWII, a couple of
hundred soldiers working agriculturally developed this disease. I am not going
to focus much on this illness at this time, even though the potential outbreak
area is very large, all the way from China to Europe, and impacts wild and
domestic animals as well as people. One good article on the topic was published
last year, Abstract link below.
And to my knowledge the last outbreak
of this was in Pakistan, as in the link below.
The reason I mention CCHF here is to
say that while they have more or less the same symptoms and lethality, the
timing is different as patients often will become sick earlier, which in a way
is worse for the individual, but better for others around them as it forces the
limitation of transmission as they are too sick, too soon, to spread the
illness.
Finally, to close this whole section,
I do not wish to cause undue alarm. And I do not actually want to take us all
through a lesson on all the viruses out there. Suffice it to say that there are
a host of viruses and bugs that can kill us in the worst of ways, here is a
link to that list:
The important point is that by and
large, we do not see galloping epidemics, but rather, limited outbreaks and or
isolated cases. Quarantine and isolation
of the sick, public health alongside personal hygiene create ‘fences within
fences’, which limit epidemics to outbreaks or isolated cases instead of
widespread disease. That, via education will have to remain the number one
focus of public health. One of the most missed aspects of the discussion thus
far is that the locations where Ebolavirus Outbreak 2014 has occurred do not
have a long history of dealing with Ebolavirus. So where Uganda does, Senegal does not, Liberia does not,
Sierra Leone does not. (Each of these
countries likely had sporadic cases but individuals were isolated and died and
therefore cases went unreported.) This is different from Uganda, which has seen
such illnesses and has a history of such reports. In this sense you can see the
difference between what happened in those countries, now leading to more than
4,000 officially dead, (though the number is probably closer to 10,000
unofficially, but that is for another time to discuss) and in Uganda with the
one person with Marburgvirus. A big difference in turmoil’s and tragedy, with
the most major difference being public health preparedness.
2014 Ebola Outbreak in Democratic Republic of the Congo
With that background, let me try to
make my point clearer. The Ebolavirus outbreak is not the only one that exists
right now. As described before, Ebolavirus exists in a variety of places
throughout Africa, though the most common outbreaks historically have been in
Uganda and the Democratic Republic of Congo (DRC). In fact, if we look to any
outbreak that killed more than 300 people it was only those two countries that
make the list. During this summer of 2014 there has been another outbreak of
Ebolavirus that you may not have heard of, this one in DRC. In the middle of
August one person died in the DRC of Ebolavirus, and by the end of August, 13
people were dead. By middle September a total of 35 people dead, by end of
September 41 total dead, and by October 2, less than two weeks ago, we had a
total of 42 people dead. This is where it gets tricky. This outbreak is called
the “2014 Ebola Outbreak in Democratic Republic of
the Congo”. It has nothing to do with, and is unrelated to, and believed to be
completely separate from the outbreak that you have heard of “2014 Ebola
Outbreak in Western Africa”. In other words no one in public health considers
these two outbreaks related. We are talking about 42 people dead in a country
of 75 million people, from the same virus, that in nearby countries has killed
thousands in a much less densely populated area, as in Liberia with 4 million
inhabitants, and Sierra Leone with 6 million, and Guinea 12 million. Yes, the
virulence of the virus may be different, but limiting transmission and heightened
surveillance have been the key to limiting impact.
In the next update I will focus on the
treatments being used.
I would like to add that I am saddened
by the fact the CAM community has still not come to a common voice, and has
remained mostly mute on the subject of this outbreak. I have described a very
sensible pathway in the first letter. Please talk to your organization’s
representatives and to your political representatives about putting more
resources both financial and in people power toward the public health efforts
essential in stemming this epidemic.
In health,
Paul Herscu,
ND, DHANP, MPH
