Tuesday, October 14, 2014

Ebolavirus 2014 Outbreak - #2

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.

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.
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