Tag Archives: Ebola

Ebola and "the French Disease"

Jim Moore and I were both students in the PhD Program in Anthropology at Harvard a few years ago. He graduated about the time I entered the program. To give a rough historical touchstone, I remember the day he needed to get his thesis off to the Registrar, and there was a delay because it was taking longer than expected to deburst the pages fresh out of the printer. Anyway, Jim is Professor of Anthropology at UC San Diego, and has done a great deal of work with Old World Primates, the evolution of social systems, and related topics. A while back Jim wrote an important piece for American Scientist which was a summary of his intensive research on the complex origin of HIV in Africa. Jim and I got to talking the other day about that topic in relation to the current West African Ebola outbreak (though this really relates to Ebola across the region in West and Central Africa). I invited Jim to write a guest blog post on the topic, he did, and that post is below. The graphic above accompanies the post and is used with permission from Jim’s earlier American Scientist article.

Ebola and “the French Disease”

Jim Moore

The origin of AIDS

By comparing the degree of variation among samples of HIV 1 group M (the virus responsible for the pandemic), we can estimate how long it has been since the original variant existed; that gives us a time for the most recent common ancestor (TMRCA) of between 1908 and 1920 (depending on which recent analysis you like). For group O (which has not spread far), the TMRCA is a few years later, about 1920 to 1926. Put in the error estimates for these dates, and the range is about 1903 to 1948. Group N, with fewer than 20 patients known, is thought to have originated between 1948 – 1977 and the range for group P (2 patients) spans more than a century.

By comparing HIV 1 with different strains of SIVcpz and SIVgor (simian immunodeficiency virus of chimpanzees and gorillas), we find the closest match for group M comes from chimpanzee groups in SE Cameroon, just over the border from RP Congo (“Congo Brazzaville” to distinguish it from the Democratic Republic of Congo [DRC], ex-Zaire, ex-Belgian Congo). Group O appears to be derived from SIVgor, most likely someplace in southwest Cameroon. That discovery involved collecting thousands of samples of ape feces from all over Africa and screening them for SIV, a prodigious project overseen by Beatrice Hahn. And a recent paper in Science makes a good case that for HIV 1 group M, after initially becoming established in someone in northern RP Congo/SE Cameroon, the virus traveled down the Sangha River to Kinshasa (personally, I don’t think they can meaningfully separate Kinshasa and Brazzaville at this stage) around 1920, where it was maintained at a low prevalence until about 1960 when the pandemic began.

Do the same exercises for HIV 2, and the two epidemic groups (A & B) most likely originated around 1940 – 1945 (1924 to 1959) from SIVsm (sooty mangabey) someplace in or near Ivory Coast. Like HIV1 group M, the virus seems to have travelled from its point of origin (sooty mangabeys in the Tai Forest, Ivory Coast, have the closest SIV matches to both groups) to where they caught on and eventually became pandemic (Guinea-Bissau, where the war of independence seems to have facilitated the process).

Now here’s the thing: people in both areas have eaten primates, and so been exposed to SIVs, for millennia. And as a sexually transmitted disease, well, sex has been going on for even longer. Massively increased promiscuity in the context of commercial sex workers in rapidly urbanizing and poor populations? That’s more a twentieth century thing, starting early in the century but really taking off after World War Two and ongoing today. Furthermore, in around 1960 disposable plastic syringes became widely available and, in poor areas, were often reused and/or easily available to traditional healers and charlatans, making unsterile injections more common. And of course travel by trains, cars, and planes has increased through the 20th century (with an important caveat that in parts of Africa such as the DRC, many railroads and roads weren’t maintained after independence and fell apart post–1960s).

So exposure to SIV has been going on for millennia, and “the usual suspects” in terms of STD risk factors became important early in the 20th century but increased dramatically (and have remained high) since the late 1950s, and despite that the only strains of HIV that have “caught on” all date from around 1920 – 1945. What is missing?

The French Connection

Those places, those times: French Equatorial Africa and French West Africa. There are SIV-carrying primates in many parts of Africa, under various colonial powers at various times, but all four zoonotic HIV strains happened under the French. Bad luck?

Screen Shot 2014-10-27 at 11.13.54 AMIt is impossible to be sure, but I have argued that for HIV 1 the catalyst was the combination of two things. First comes the unbelievably brutal treatment of Africans in both French Equatorial Africa (FEA) and the Belgian Congo, resulting (among other things) in labor camps where men were overworked, malnourished, and provided with women as a matter of policy to keep the workers – well, “happy” is probably not the best word, but you get the idea. The second element was the effort to cure smallpox and sleeping sickness through aggressive diagnosis/treatment/inoculation campaigns using traveling “mobile clinics” that had inadequate equipment for the scale of the job they were doing. For example, one sleeping sickness expedition in 1916 into what is now Central African Republic diagnosed/treated more than 89,000 people with just 6 syringes (the number of needles isn’t recorded). Over more than a decade, these mobile clinics, pioneered by Dr. Eugene Jamot, reached – and injected – millions of people. The importance of sterile equipment was well understood, but the logistics (I speculate) would have been prohibitive. The campaigns represent a major humanitarian effort that saved many lives, but the combination of widespread use of unsterile needles and stress-induced immunosuppression could not have been better designed for adapting a virus to new hosts.

I do not know the relevant history of French West Africa (FWA) so am cautious about saying the same thing happened there with HIV 2. However, it is worth noting that in 1931 Jamot was held responsible for the accidental blinding of hundreds of people being treated by one of his subordinates (sleeping sickness was treated with an arsenic derivative, and the subordinate apparently tried out a higher dosage, with disastrous results). With a cloud over his reputation, Jamot shifted from FEA to – Ouagadougou, in FWA. There he took charge of the sleeping sickness campaign, again with mobile clinics and again treating thousands of people under difficult conditions over several years before his health deteriorated.

About 20 years between the origins of HIV 1 in FEA and HIV 2 in FWA, and about 15 years between the onset of Jamot’s work in FEA and his move to FWA. Very circumstantial, but it gives one pause.

Why belabor the French?

Eugene Jamot was a genuine hero, and while colonial support for the mobile clinics wasn’t all humanitarian (there were concerns about the loss of [forced] labor if too many died), I am sure the people involved were doing their best to help other people in need. It might seem mean-spirited to point the finger of AIDS at them.

Well, here is one reason. A recent article in Science by Faria et al. examined the history of HIV 1 group M, concluding that the virus arrived in Kinshasa in about 1920 where it barely kept up with population growth until about 1960, when it began rapidly spreading in the pandemic we see today. It is valuable and interesting work. The actual origin of the virus is not their focus, but they summarize it thusly:

After localized transmission, presumably resulting from the hunting of primates, the virus probably traveled via ferry along the Sangha River system to Kinshasa. During the period of German colonization of Cameroon (1884 – 1916), fluvial connections between southern Cameroon and Kinshasa were frequent due to the exploitation of rubber and ivory. (page 58)

German colonization? Well, yes; the Germans were in Cameroon up until 1916 (when French/Belgian forces that had traveled up the Sangha in 1914 finally drove them out; Jamot was a medical officer with the expeditionary force). But traffic on the Sangha River didn’t end in 1916, and most of it was between Brazzaville/Kinshasa and the French towns of Ouesso, Nola, and Carnot anyhow. Why specify the “period of German colonization”?? I do not KNOW, but I note that (1) there is no other mention of any colonial power in the Faria et al. article, and (2) of the 14 authors, 6 are affiliated with institutions in Belgium or France (the rest, UK and USA). It looks to me like there may have been a bit of whitewashing going on there, and using a scientific article to blow historical smoke in our eyes gets my dander up.

AIDS and Ebola

Here is a better reason for acknowledging the likelihood that AIDS got its start as an unanticipated consequence of underfunded, understaffed humanitarian efforts to deal with infectious diseases in equatorial/west Africa: history can repeat itself. To ignore ebola in West Africa is not an option, and half-measures have whole risks.


Further reading

The puzzling origins of AIDS (2004). Jim Moore. American Scientist 92: 540–547. pdf

The early spread and epidemic ignition of HIV–1 in human populations (2014).
Nuno R. Faria, Andrew Rambaut, Marc A. Suchard, Guy Baele, Trevor Bedford, Melissa J.Ward, Andrew J. Tatem, João D. Sousa, Nimalan Arinaminpathy, Jacques Pépin, David Posada, Martine Peeters, Oliver G. Pybus, and Philippe Lemey. Science 346: 56 – 61.

Some other material of mine on HIV origins


Further note: Readers of this blog will avoid confusion by noting that this Jim Moore is not the Aquatic Ape Jim Moore. Same name, different guy.

Ebola in the US Update

Of the seven Americans who have contracted Ebola, five overseas and two in Texas, all seven have survived. Comments from President Obama, focusing on how we have to be guided by the science:

“Here’s the bottom line. Patients can beat this disease. And we can beat this disease. But we have to stay vigilant. We have to work together at every level — federal, state and local. And we have to keep leading the global response, because the best way to stop this disease, the best way to keep Americans safe, is to stop it at its source — in West Africa.”

CDC Update page for the West African outbreak.

Ebola Update from Dr. Anthony Fauci, infectious disease chief at the National Institutes of Health (NIH).

More here from the Whitehouse.

Research Suggests Healthcare Workers Could Balk At Treating Ebola Patients

Given the current and developing situation in Dallas, where two health workers have become infected with Ebola while caring for a patient, it is reasonable to ask if health workers might decide to call in sick for a few months until this whole highly infectious often fatal disease thing blows over. Daniel Barnett, of the Department of Environmental Health Sciences at the Johns Hopkins Bloomberg School of Public Health, has looked into health workers’ unwillingness to report to work when there is a potential for infectious-disease transmission to themselves and their family members.

The health workers I know tend to run into burning buildings or jump into frozen lakes and such to rescue people, so I can’t see that happening. Apparently it has been an issue in Spain and in West Africa. I can’t explain Spain, but things are so dismal in West Africa that it is not at all unexpected. But what about in the US?

So far there doesn’t seem to be an issue according to Barnett’s research, but he cautions that continued willingness to work with Ebola patients here is not assured. In an earlier study, Barnett and colleagues found that one-third of workers at a large U.S. urban medical center would be unwilling to respond to a severe infectious disease outbreak.

“An individual’s personal perception of the importance of his or her work during the response phase and his or her sense of confidence in performing this role effectively, are among the most powerful determinants of willingness to respond,” notes Dr. Barnett. “Our research also suggests that familiarizing health responders with laws and policies designed to protect their wellbeing in an emergent infectious disease event is important for bolstering response willingness,” Barnett adds.

Barnet notes that for training to be effective it must provide clear guidance on infection control protocols and instill a clear understanding of outbreak response duties. I asked him about the domestic side of this, about training of health workers regarding in relation to thier behavior or decision making when they are off duty. This seems to have arisen as an issue with the second Ebola-infected worker in Dallas, who took an air flight after starting a fever (if reports are accurate) and before diagnosis as having the disease.

“Preparedness and response trainings on emergent infectious diseases need to cover not only work-related protocols,” he told me, “but also address behavioral elements outside of the healthcare setting in the interest of public health. To date, there’s essentially been no research or ‘environmental scan’ on the extent to which such trainings actually encompass behaviors and practices outside of the health care workplace. However, this type of training on precautionary measures outside the workplace is essential. It needs to be imbedded into trainings and harmonized across healthcare institutions to ensure consistency.”

Good Morning, America. There is another Ebola case. UPDATED

UPDATE: The first health worker to have been affected with Ebola in Texas may not be moved to Maryland.

From NBC:

Nina Pham, one of the two nurses who contracted Ebola in Dallas, is expected to be moved to a National Institutes of Health isolation unit in Bethesda, Maryland, a federal official with direct knowledge of the plans told NBC News on Thursday.

The transfer could happen later Thursday, but the official cautioned that plans were evolving. Pham, 26, was diagnosed with the virus on Sunday after treating Thomas Eric Duncan, who contracted Ebola in Liberia, flew to Dallas and later died.

The other nurse who contracted Ebola in Dallas, Amber Vinson, was flown on Wednesday to Emory University Hospital in Atlanta. The Emory and NIH units are two of the four facilities in the United States that are specially equipped to handle Ebola.

UPDATE: The second infected health worker will be transferred from Dallas to Emory.

This is a second health worker, who reported in with at fever on Tuesday. The worker is one of the 76 who had been self monitoring, who were thought to be most likely beyond the most likely period for infection.

(This might be a good time to point out that while the CDC uses 21 days, which is probably usually good, one study showed that a small percent of individuals might develop the disease after 21 days following exposure.

Yesterday, Tom Frieden, head of the CDC, noted “CDC Director on Ebola: ‘Even a Single Infection is Unacceptable'” Also, yesterday, Dallas nurses complained about the situation at the beginning of the treatment period for the Index patient who died there.

There was a briefing in Dallas.

During the briefing, it is confirmed that this new patient was involved in care for the Index patient.

We’re a great hospital, we always have been, we want to get this right, we fell really bad, we’re doing fine, etc. etc. (that was the hospital representative)

Teams have swooped in and started cleaning common areas near the new patient’s apartment, neighbors have been or are being interviewed.

The patient lived alone and with no pets. Inside cleaning and cleaning of the car will happen later today.

Question for hospital rep: Does a second case indicate systematic institutional problem. Answer: No. We know what we are doing and handling it and we are looking at everything.

Was this person a nurse? We won’t tell you that.

Question: When did this patient come forward and get a blood test in relation to yesterday’s press conference? Answer. Hipaa.

Question: There are three isolation rooms at the hospital. What will you do when you fill up? Answer: Working on that. Also, there are actually is more room than that, a little.

Question: Timeline? Answer, got confirmation about 1:00 AM. Then we started doing stuff, press release at 4:00.

Question: Allegations from the nurses?? Answer: I can’t comment. We have the proper protected gear.

Question (breathless): Are steps being taken to isolate the other workers? Answer. There are 75 hospital workers. They are asymptomatic, the are not contagious. Please try to avoid community panic with those questions (I paraphrase, he didn’t say that). When people get symptomatic they report in, like happened twice, the system is working.

By the way, the are not coming in to work.

Perspective:

On preparedness of the hospital. There is evidence that the Dallas hospital that treated Thomas Duncan was not prepared to handle an Ebola case, and initially, nurses were not well protected. It is also clear that the clean, crisp, rapid response we may have expected from the CDC was not there. However, it is probably the case that that hospital is now managing the two cases they have properly, and that the monitoring program for other contacts is good.

To me, this means that the repeated, near universal statement by the US health community that the US can handle Ebola was overstated. Let’s take a look at the overall problem. I previously divided the Ebola exposure problem into several phases. Here is an updated version of that:

1: An infected individual arrives in the US, becomes (or already is) symptomatic, and is not yet admitted to a hospital. At this point we rely on that person’s decisions to seek treatment. There can be several hours to several days of time of potential exposure, but even so, the person is ambulatory and less symptomatic, and probably is an infection risk but a low(ish) one.

2: The infected individual either becomes very sick and is brought to the hospital or self admits. At this point there is a risk of infection to other people at the hospital including other patients and hospital workers, as well as ambulance drivers, etc. During this second phase it is up to the hospital to quickly identify a possible Ebola case and isolate the patient, and start safe procedures for care. In the case of the Index patient in Dallas, this took several days (and the patient was sent back into Stage 1). This inadequacy conflicted with what the public was being told by experts. However, now that the very first actual case of Ebola emerging in the US happened, and those who were not expected to mess it up did mess it up, everyone is on their toes and the chances of a repeat of that are lower. The CDC has also developed an improved method of addressing this (their ready teams).

3: The infected individual is in an isolation unit and being cared for. At this point it is up to the hospital and the health workers to minimize the chance of infection of others, and those at risk are, theoretically, the health workers. In the case of the Index patient at Dallas, according to nurses who worked there, the risk of infection of health workers was not minimized fully at least initially, and it is even possible that risks beyond the care staff continued. Eventually, we assume this was fixed. But, the fact that two health workers have been infected does amply demonstrate that whatever was going on was not adequate, though at this point we don’t yet know in what way, or when, things were done improperly and we need to take the word of the same hospital and health system spokespeople that earlier assured us that things are fine. Since the system representatives have yet to fully acknowledge there were inadequate procedures or care, and describe that inadequacy openly, we really don’t know. I suspect they really have cleaned up their acts, because they are strongly motivated to, but we are starting to see the edges of an Orwellian response where information is being cleaned or withheld, sometimes under cover of HIPAA rules.

1: During the first three stages, exposure of others may happen, and those individuals need to be identified and managed. Individuals who do end up being infected during that period are now in Stage 1, but if there is an effective monitoring program, stage 1 is very short (hours?). Because the system is ready for secondary cases, stage 2 is minimized (or does not even exist), and the patient is now in Stage 3. In the case of Dallas, we can guess that the two patients who have cycled into Stage 1 (both health workers) are in Stage 3 and Stage 3 is being done properly.

At a later time, if there are too many additional cases, the revamped and updated Stage 3 response may break down again due to lack of isolation facilities. The authorities seem to be aware of this possibility.

We don’t have a lot of control over what happens during Stage 1 for newly arriving patients, though the system has demonstrated that it can handle Stage 1 for those of known risk who are in a monitoring pool. But for the system to be like various spokespeople claimed it was, a great deal of effort has to be put into training, procedure, and dispersal of equipment. Dallas demonstrates that for a hospital that should have been ready, this was not the case. But, the CDC response, of having ready teams (like we learned from movies and literature to be how the CDC operates, in fiction!) should make the transformation from inadequate response to adequate response more likely if there are other cases.

Many thousands of people in West Africa have gotten Ebola, about half have died. Our problems here in the US are tiny. But, everyone is concerned about the possibility of spread outside of West Africa. One consequence of the small leakage that may occur being handled poorly is a stricter response in the form of travel restrictions. This would have multiple negative consequences. The Dallas Index patient got past the system, but the international travel problem is being tightened up a little (we have no idea if that is adequate). If infections beyond Stage 1 continue to happen, as they have in the US and Spain, people will demand a closure of borders. And, perhaps, that is what should happen.

Timing of infections vis-a-vis the Index patient

Ebola is thought to manifest in as little as four days after exposure, with most cases showing up prior to 17 days after exposure, but as late as 25 days, using very liberal estimates of exposure time. The Dallas Index patient, Thomas Duncan, was cared for in the hospital staring on September 25th, and died on October 8. The most recent secondary infection was identified last night, so let’s round up and say that was 7 days after possible exposure. If we assume for the moment (we have no basis for this, this is a rough guess) that the first half of that care period was as suggested by nurses being handled inadequately, and the last half was managed well, to split the difference, perhaps the most likely period of exposure ended around the second of October. So, perhaps today is about two weeks post dating likely exposure. So, a roughly optimistic guess would be that the chances of another health worker ending up with Ebola is not small for the next three or four days. A fully pessimistic estimate is that we have ten or so days over which this could happen. Stay tuned.

Was the Texas Health Presbyterian Hospital Prepared for Ebola? Probably not.

This is breaking news as of Tuesday PM. According to the nurses at the hospital, no, not initially. Anonymous nurses have claimed via their union:

-Patient Zero was left for several hours in a place with up to seven other patients, not in isolation. When a senior nurse attempted to insist he be moved to an isolation unit she was met with “hostile” responses.
-Blood samples were transported through the hospital tube system instead of hand carried.
-Nurses were not entirely covered with protective wear. The gear they had left their necks exposed. To remedy this they were told to wrap tape or gauze (not sure) around their necks.
-People were going in and out of isolation areas without protective equipment.
-Medical waste was not properly handled, with hazardous waste piled nearly to the ceiling as there was no plan to dispose of it.

The hospital has not responded.

First person in US to catch Ebola: The Meaning of Ebola Patient Two (updated)

The first person ever to catch Ebola in the United States is now in isolation at Texas Health Presbyterian Hospital.

Don’t panic, even if you live in Dallas. But also, don’t fall into the hyperskeptical trap of assuming that because scientific authorities tell you everything is fine that concern is irrational. There are very rational reasons to be concerned. But you need to be smart about what to be concerned about.

A couple of weeks ago, as you know, a man came to Dallas with pre-symptomatic Ebola, and became symptomatic there. This was the first case of a person being diagnosed with Ebola in the US. The case was botched. The hospital sent home a man with pre-Ebola symptoms who had come from West Africa. He was later admitted after he got a bit sicker and tried a second time to get treatment. There were other ways in which the case was not handled too well, mainly from a public relations and messaging standpoint, but the CDC and the hospital involved seemed to be doing a good job and getting their acts together.

Now, the situation has developed in a rather disturbing way. A health worker that had been caring for Patient 0 has now been diagnosed with Ebola. This happened overnight. The patient was under self monitoring, had a mild fever, went to the hospital, was tested, and the reasonably reliable preliminary test indicated Ebola. A second much more reliable test is being done now but it is expected to be positive.

I just watched the news conference and from this I gathered the following important bits about the new patient.

<li>The patient was in the low risk pool.  Among Patient 0's contacts, there were higher risk and lower risk.  Higher risk individuals were being isolated and/or monitored very closely, lower risk individuals were self monitoring. This patient was self monitoring.</li>

<li>The person cared for Patient 0 during his treatment prior to his death at Texas Presbyterian; there was no contact during the initial botched visit. </li>

<li>The new Ebola patient used protective procedures (gown, mask, gloves) in that care.  The exact nature of the care beyond that is being kept secret at the moment owing to HIPAA rules.  (But see below to see how absurd the HIPAA rules are in this case.)</li>

<li>The new patient seems to have lived with a second person who is now also in isolation.</li>

Hazmat suit wearing teams arrived during the night at the apartment complex of the new patient, and decontaminated public areas such as the lobby of the apartment building, and the interior of the patient’s car. It is thought that there is a pet inside the person’s apartment, but teams, as of this writing have not entered the apartment. They plan to do that soon. Local police doorknocked everyone in the “immediate area” to explain to them that they should not panic, did a “reverse 911” call for the area, and are re-door knocking this morning. So, the identity of the patient will be known any moment now because you can’t really do all that without that happening. (Which, frankly isn’t too relevant. I’m not sure if HIPAA rules should protect health care workers in quite the same way as patients, though they may in fact do so.)

So, what is the meaning of this all?

First it means that when hundreds of administrators, police, government officials, hospital employees, health workers, etc. are tasked with the job in the US of making sure no one gets Ebola from a person who has Ebola, and also tasked with the care of that person, a) one person gets Ebola anyway, and b) the first patient dies.

I very quickly add that this is a TINY SAMPLE SIZE OF N=1 and I’m being a bit cynical here. But it is still true that all these resources failed to prevent what every one feared, and what the authorities said would not likely happen.

Second, note that this new patient did not get Ebola from Patient 0 prior to his first visit to the hospital, or after that first botched visit. Again, small sample size, but it points out something important. When we say that a human with Ebola can spread the disease only when they are symptomatic, that probably doesn’t even count the initial fever period. Infectiousness is probably correlated to the severity of the symptoms. The family members or heath workers who deal with the bodily fluids randomly coming out of a person who is dying of Ebola, bed ridden and very sick, are at the highest risk, even those in the lower risk pool like this new patient. (This is why the HIPAA rules need to be set aside. We actually need to know what this person’s role in the process was, what this person did exactly. That is important information that the public has a right to know. If this reveals the name of the worker by deduction, then so be it. The person’s name has already been effectively revealed by deduction form the activities at the person’s home.) But, importantly, once a person is really infectious, they are really, really, infectious. See my quick note below on spread of Ebola.

Third, note that the medical authorities have said all along that following proper procedures minimizes risk. Note that even when following proper procedures one person was infected anyway. Note that at this morning’s press conferences, the authorities have not changed their story. This is partly your fault, members of the public, because collectively you seem unable to understand that Ebola is both very dangerous and manageable. Your collective insistence that your fear being ramped up is somehow proof that Ebola has gone airborne is an example of that. If you collectively stop being unmitigated morons about this, then the authorities can stop being alarmingly Orwellian about it. Maybe.

Fourth, think about this. A huge effort is made to avert a possible Ebola outbreak. The effort fails in a couple of ways, but we get lucky, those failures don’t cause too many problems other than, possibly, the death of the patient because care was not timely and proper drugs were not administered. But as far as the concern over an outbreak goes, the early screw ups did not cause one. So, proper and resource intensive procedures are in place and everything is going as well as it can be. Then somebody gets ebola anyway. This explains West Africa. Here, in the US, we have 200 people for every Ebola patient. In West Africa, you might have 1 person for every 100 (possible) patients out there. Those numbers are made up, but you get the point. In order to limit Ebola in West Africa we’d have to do what we can do here, and that proves to be of limited utility. Prior outbreaks were stopped because of the high ratio of health workers AND the disease burning out by killing almost everyone in some families or small villages so spread was stopped. So now we have a better sense of what is going on there. Imagine that every person in the US isn’t just someone who heard about Ebola in some other city. Imagine, instead, that everybody in the US lives in an apartment building in which one or two other people in the building have Ebola. And there are no hospitals.

So, collectively, that is all good news and bad news. One more piece of good news: We are near the end of the period during which someone who may have been infected might show up.

On the spread of Ebola

I’ve written about how Ebola is spread before and about the unlikelihood of it “becoming airborne” (see links below). But I keep hearing, again and again, that this or that vague observation someone has made proves that it has already gone airborne. Well, I’ve got a bit more to add to that discussion to help people put it in perspective. The truth is, pretty much every one who is saying it is already airborne or that it is likely to go airborne or that eventually it is inevitable that it will go airborne is an airhead. Sorry for the strong language, but at this point it is simply true that with so much information out there about this being utterly wrong is not acceptable.

Consider Norovirus. It is roughly as infectious as Ebola. Two years ago, for example, we had an outbreak of it here in the Twin Cities. Someone at Huxley’s daycare had it. Then Huxley, then everyone else at his daycare, and everyone in our family, and everybody. Had it been fatal, the entire region would be dead. It is not airborne, but it is a disease that there is a good chance all the people crowing about Ebola needing to be airborne have had, have seen in action. Next time you feel the need to insist that Ebola is airborne remember the last time everybody in your family, one by one, got the “stomach virus” (as it is often called). It wasn’t airborne. You got it because germs form someones’ poop or vomit got into your mouth. Perhaps you should not have been licking people’s anuses or drinking their vomit with a straw during that time. Oh, you claim you did neither of these things? OK, fine, you weren’t doing that. But you still got kooties that came from vomit or poop. The way bodily fluids get around, and the opportunities for contact, are much greater with Ebola. With the stomach flu, most of the time most people can make their own way to the bathroom to have diarrhea and vomiting. With Ebola, the sicker patients are lying in bed doing this in a closed room. Everything gets kooties on it. Maybe they were soiling themselves and puking for a few hours in a “taxi” waiting to get into a hospital. Touch touches stuff that touches stuff and bits of Ebola rich feces or Ebola laced vomitus are now on your hands.

Even the flu is only barely spread airborne, but mainly through direct or indirect contact. Ebola is more infectious because it does better with indirect contact.

UPDATE: Major Media is reporting, based on a Sunday AM show interview, that there was a “breach” in protocol in Dallas. But the doctor interviewed did not say that. He said, essentially, that there must have been a breach but they do not know what happened. This is important for media to get right, and it is the media’s job to get these things right. If there was no breach in protocol, then the existing protocol allows for Ebola to cross the boundary. If there was in fact a breach, and we know what it was and can confirm it, that is a very different situation. To be clear: The fact that protocol was in place and used and Ebola got across does NOT mean that Ebola is being transmitted by air or in some other unknown way. It could mean that protocol was breached, but without specific evidence we don’t know that to be true, and we don’t know what went wrong. In between these two is the very high probability that standard protocol has a weakness or two that could be shored up. Personally, based on my own experience (not with Ebola) and based on some reports from the field, I would suggest this has to do with how gowns, masks, and esp. gloves are handled. You have to use the same kind of protocol to remove these things as when you are using these things. Perhaps care workers should be demasked, degloved, and degowned by a masked/gloved/gowned coworker who has just suited up in a space away from the patient. (I don’t think that is done now.)

More on Ebola:

NewLink Genetics, of Ames Iowa, Implicated in African Ebola Genocide?

According to those intimately involved in the response to the West African Ebola outbreak, NewLink Genetics owns the rights to a piece of the puzzle needed to quickly test and deploy one of two likely Ebola vaccines and they are holding up the entire process because they are not entirely sure they are going to get rich on it. Other suggest it is incompetence. NewLink seems to be claiming it is just a lot of paperwork. In the end, tough, none of these excuses is convincing. This is one of those cases that gives Big Pharm a bad reputation.

From as story in Science:

Stephan Becker is tired of waiting. The virologist at the University of Marburg in Germany is part of a consortium of scientists that is ready to do a safety trial of one of the candidate vaccines for Ebola. But the vaccine doses he’s supposed to test on 20 German volunteers are still in Canada. Negotiations with the U.S. company that holds the license for commercialization of the vaccine…have needlessly delayed the start of the trial… “It’s making me mad, that we are sitting here and could be doing something, but things are not moving forward,” Becker says.

… it’s inexplicable that one of the candidate vaccines, developed at the Public Health Agency of Canada (PHAC) in Winnipeg, has yet to go in the first volunteer’s arm, says virologist Heinz Feldmann, who helped develop the vaccine while at PHAC. “It’s a farce; these doses are lying around there while people are dying in Africa,” says Feldmann,…

At the center of the controversy is NewLink Genetics, a small company in Ames, Iowa, that bought a license to the vaccine’s commercialization from the Canadian government in 2010… Becker and others say the company has been dragging its feet the past 2 months because it is worried about losing control over the development of the vaccine. But Brian Wiley, vice president of business development at NewLink Genetics, says the company is doing all it can. “Our program has moved forward at an unprecedented pace,” he says. Even if it took another few months, “we would still be breaking a record in terms of getting this into patients.” Wiley says the holdup is “the administrative process”: agreeing on a protocol, getting collaborators to sign the right contracts, securing insurance in case something goes wrong.

Marie-Paule Kieny, a vaccine expert and WHO assistant director-general, disputes that NewLink is dragging its feet. “We have so far been able to resolve issues along the way, to get moving as fast as possible,” she says.

A stock of the Canadian-developed VSV vaccine is stored at PHAC in Winnipeg. The Canadian government owned 1500 doses, 800 to 1000 of which it has donated to WHO; the rest are owned by NewLink Genetics.

Scientists say WHO’s vials could have already been shipped to the research centers planning to do phase I trials. One such trial is scheduled at the Walter Reed Army Institute of Research in Silver Spring, Maryland; other studies, by a consortium that includes WHO and Becker, are on the drawing boards in Hamburg, Germany, in Geneva, and at sites in Kenya and Gabon. PHAC is ready to ship the doses “at a moment’s notice,” a representative says.

But for a clinical trial to start, regulators require information about how the vaccine was manufactured, and that resides with NewLink Genetics, which has been slow to release it, people familiar with the negotiations say. …

Part of the problem may be that NewLink is a small company, with about 100 employees, that has concentrated on immunotherapies to fight cancer in recent years. The Biomedical Advanced Research and Development Authority—a U.S. government agency tasked with speeding up the development of emergency drugs and vaccines—recently sent two staffers to Ames to help NewLink file documents needed by the U.S. Food and Drug Administration, a U.S. government representative says. “Our engagement of outside help has nothing to do with our competence, but with the urgency around this matter,” Wiley says.

Those who are taken ill and die of Ebola are the victims of a natural disaster, until paperwork, incompetence, greed, or some combination of those delays an international response by weeks time. After that, it is something else.

Can Dogs Transmit Ebola? And, should Excalibur be put down? they put down Excalibur.

UPDATE: They killed the dog.

UPDATE: I’m adding this here because it is my current post on Ebola. Thomas Eric Duncan, the person who became symptomatic with Ebola in Dallas, had died at the Texas Health Presbyterian Hospital (according to news alerts).

A nurse’s assistant in Spain caring for Spanish nationals returned with Ebola from West Africa contracted the disease, gaining the dubious distinction of being the first person to be infected with Ebola outside of that disease’s normal range in West Africa, Central Africa and western East Africa. There is speculation that she contracted the disease by contacting the outside surfaces of her own protective gear, which is exactly what I’ve speculated to be a likely cause of infection in health care workers. This is not certain, however.

Members of her family and others, including additional health care workers, are in quarantine. There is evidence that the hospital procedures were inadequate to keep a lid on Ebola in this context, and nurse’s unions and others are protesting and demanding change.

Meanwhile, the Spanish government has claimed that there is “scientific evidence” that dogs can transmit Ebola, so Excalibur, the nurse’s family dog, will be euthanized and incinerated. People have gone to the streets to safe the dog.

So, can dogs get, or transmit if they get it, Ebola? Short answer: Yes, and probably not. Here’s my thinking on this, and some information.

1) Pick a random species, or to make it easier, pick a random mammal, and test to see if it can transmit a disease known in humans. It is unlikely to be the case because diseases are to some degree adapted to exist in certain hosts, and host vary, well, by species. So it seems unlikely.

2) On the other hand, Ebola seems to be able to infect a very wide range of mammals. Ebola resides in multiple species of fruit bats (though maybe not uniformly or equally well). A range of mammals seen to be suitable intermediates between fruit bats and humans. The mammals known to be able to harbor Ebola are diverse. It isn’t like only primates can be infected. So, it seems quite possible.

3) On the third hand, I’ve never heard of dogs being addressed as an issue in the current crisis in West Africa or during prior outbreaks. One would think that if dogs were a concern this would have been mentioned by someone some time.

4) On the fourth hand, dogs in Central Africa are less likely to be house dogs, hanging around with the family on the couch, and more likely to be working dogs that spend all their time outdoors. A Spanish family pet may have hung around on the sick bed with an ill individual. I don’t know about dogs in West African cities. By the way, you have to go look to see what the story with dogs there is, and it may within that context. I’ve noticed that westerners tend to have a rather monolithic view of how humans “elsewhere” (especially the “third world”) relate to their dogs, based on a concept we hold of them, not based on actual knowledge. How dogs fit in with humans from place to place and time to time varies.

5) I’ve read a good amount of the peer reviewed literature on Ebola and I can not recall anything about dogs.

5) But … A quick check of Google Scholar did come up with one study. From the abstract:

During the 2001–2002 outbreak in Gabon, we observed that several dogs were highly exposed to Ebola virus by eating infected dead animals. To examine whether these animals became infected with Ebola virus, we sampled 439 dogs and screened them by Ebola virus–specific immunoglobulin (Ig) G assay, antigen detection, and viral polymerase chain reaction amplification. Seven (8.9%) of 79 samples from the 2 main towns, 15 (15.2%) of 14 the 99 samples from Mekambo, and 40 (25.2%) of 159 samples from villages in the Ebola virus–epidemic area had detectable Ebola virus–IgG, compared to only 2 (2%) of 102 samples from France. Among dogs from villages with both infected animal carcasses and human cases, seroprevalence was 31.8%. A significant positive direct association existed between seroprevalence and the distances to the Ebola virus–epidemic area. This study suggests that dogs can be infected by Ebola virus and that the putative infection is asymptomatic.

I’ve not looked further at the literature. This study suggests, unsurprisingly (see point 2 above) that dogs can harbor the virus. However, they don’t seem to be symptomatic. Therefore, spread from a dog seems unlikely. I would think the dog could be kenneled for a few weeks, rather than being put down.

Two Odd Examples of Pre Ebola "Ebola"

I used Google N-gram Viewer to inspect the occurrence of the word “Ebola” in the Google-indexed literature. A few instances of Ebola came up earlier than the disease being known, so I figured they were references to the place name in Zaire/Congo, after which the disease is named. And that was in fact the case. But, of handful of early instances I checked out, two were interesting.

The Ngram is above. Note that I have smoothing set to zero, which I recommend, and I’ve got the date set for early on in the use of the term so pre-disease uses are more visible.

The two interesting instances I wanted to show you are ..

1) An Okapi at the Paris Zoo named Ebola, allegedly the first captive born Okapi to survive in a zoo.

Screen Shot 2014-09-11 at 10.41.19 PM

The other is a bit stranger. Have a look:

Screen Shot 2014-09-11 at 10.44.16 PM

See the yellow highlight? This (and the Okapi picture) are screen grabs of what Google Books give you when you search for a word or term. Here, “China” in funny Gothic looking script was recognized by the scanner as “Ebola.” You can kind of see how that would happen. Not really. But it happened.

Two Ways Hollywood and Literature Have Confused The Ebola Problem

According to popular literature (some fiction, some not) and movies, Ebola can cause havoc, infecting thousands of people, killing over half of them, and threatening an entire nation if it were to become airborne. Turns out that’s not true. Ebola can do all those things without becoming airborne. In several nations.

The confusion caused by this misconception is further enhanced in a more subtle way. Since the Hollywood version of Ebola (or some other similar disease) indicates that it is dangerous because it becomes airborne, we see constant claims today on the Internet that Ebola must be airborne because it is out of control in West Africa. And, of course, we see claims that it is only a matter of time before it becomes airborne. But an examination of the disease from an evolutionary perspective suggests that this is extremely unlikely. It is almost as though people have to believe that Ebola will eventually become airborne (or already is) to take it seriously. It wont’ become airborne. You must still take it seriously.

So that is the first area of confusion, about what Ebola is and what it does and does not do.

To this confusion, by the way, we may add the already mentioned hyperbolic reaction to Ebola, often of a rather tin-hat variety and the equally incorrect hyperskepticism that has made claims like Ebola is not that big of a deal because it is not malaria. That is also demonstrably false.

The second area of confusion is what is normally done when something like Ebola shows up in the US, as it has in Dallas, Texas. The Hollywood and Literature version is that a big silver truck shows up at the site, people with protective gear jump out of the back, individuals are taken away to Level 4 containment facilities that are handily available nearby, the site is sterilized using high tech devices (or imploded or burned down with flame throwers?), and if there are a lot of possibly infected people, everybody is quickly rounded up and moved in large green trucks to a containment camp run by the Army, with Morgan Freeman in charge whom you think at first is a nice guy but turns out to be evil.

Well, some of that is sort of happening, but slowly and clumsily and with no has-mat suits and no containment camp. As I write this I’m watching the live briefing on Ebola in Dallas. We have just learned that pretty soon some guys are going to go over to the apartment where the family of the patient lives. They will do the laundry when they get there because there might be Ebola kooties on the sheets and pillows. The CDC went grocery shopping for them, and they are being told they can’t leave. So in a way this is a little like what Hollywood says would happen, but with much, much lower production value and pretty much as a post-hoc set of reactions rather than a clear plan always in place just in case.

We are also learning at the news conference that there is not a current plan for where to take a second or third Ebola case. No playbook in place. Having said that, the authorities are confident that they can handle the problem.

None of this is surprising. After all, fiction is fiction. That’s why they call it fiction. What is also not surprising, but disappointing, is the low level of thought behind the questions the press are asking, and the highly unprofessional approach taken by some reporters. Pro tip: Don’t ask only dumb questions, or questions that have already been answered, then be all mad and stuff when the press conference ends sooner than you thought it should.

More on Ebola:

Ebola in Dallas Texas: Is our response adequate?

First, let’s look at the situation in West Africa, because that is way more important than anything going on in the US right now. The WHO has said two things about this. First, if there is not a full intervention, there may be hundreds of thousands or even millions of cases of Ebola several months from now (cumulatively). Second, with full intervention they can stop this epidemic.

What is full intervention? They say that full intervention is the development and manufacture of an effective vaccine, and the deployment of that vaccine to a very large percentage of the affected population.

Putting this another way, the current response has been inadequate, and while it can be improved, it can’t be made adequate. Things are pretty bad, are going to get enormously worse, and there is little hope for any other outcome, unless full deployment of a vaccine that does not exist over the next six months is realistic.

Now let’s look at the US. Public health officials and public health experts have been saying the same thing for months. Don’t worry about an Ebola outbreak in the US. We can handle it. We know what we are doing, and we have the systems in place to take care of this. So just don’t worry.

I’m going to tell you now why this is probably both true and untrue.

It is probably true at the large scale. We are not going to have an outbreak of Ebola in the US that involves hundreds of people getting the disease. Probably not even dozens. But, it is not true that we have the capacity to fully handle Ebola coming to the US in the way most people assume this is meant. It is very possible for Ebola to some to the US and make a bunch of people sick with about half of them dying. How many is a bunch? Five, maybe eight, something along those lines, but possibly a few times, in a few places, adding to a couple of dozen. (Totally guessing here, feel free to make your own guess.) That may not happen at all, but given the current situation it is absolutely possible. However, it is not necessary. If our public health system was truly able to handle an Ebola intrusion, the only people who would have Ebola in the US would be those who arrive with it, and possibly a very small number of additional people, not a bunch. In other words, unless changes are made, the inadequacy of our system, said to be fully adequate, will allow several people in the US to become ill, some will die, over the next year.

Here is why.

First, consider the travel problem, which is probably the smallest part of this. When Patient X came to Dallas with no Ebola symptoms, he was almost certainly not a risk. But he did get on an aircraft with the disease, and took a long trip the US. If this event happens 100 times over the next several months, how many times will the patient become symptomatic on the plane, possibly exposing others? 10% of the time? 5%? 20%? Hard to say, but often enough that over the next several months hundreds of travelers and airline workers will be exposed, but, the chance of them contracting the disease is low. So, with the current expanding outbreak and current policies, a very small number of people may get Ebola in a system that claims to be totally able to handle it. That’s small change compared to what is going on in West Africa, and it is probably the least of our worries here in First World Land.

Second, we have the problem of reporting and identification. Patient X became symptomatic and then for something like a day did not seek medical help, during which time various individuals were potentially exposed. Again, since Ebola is not airborne, the chances of them getting the disease is low, but it is real. The problem is that when people get sick, there is almost always going to be a window of time from a few hours to a couple of days during which the most prepared health care system in the world has no control over what happens because the person does not show up at a hospital or clinic. There may be no way to avoid this, but the risks can be reduced. If the West African epidemic continues members of the communities that overlap between the US and West Africa will be at risk, albeit low risk, of exposure to those who travel back and forth on a regular basis. What needs to happen is that those communities take special care to address this issue internally. All it is going to take is one or two Americans catching the disease from a person living part time in West Africa to shut down air connections between the two regions. If we want to avoid this, there needs to be self-monitoring in the communities.

Third, we have the unconscionable thing that happened in Dallas. A patient who had been in Liberia showed up with Ebola like symptoms in a hospital and was sent home. Holy moly. Why did that happen? Well if you’ve been recently in the hospital for anything that required testing and such, you may already know. Hospitals and clinics, but especially emergency rooms, are run like those steak houses that became popular back in the 1980s. You arrive at the steak house, and a nice person with a big smile seats your group. Then a server comes over and takes drink orders. A second server brings the drinks. A third server comes by for your meal order. A fourth server brings the appetizers, and a fifth server brings your meal. Eventually somebody comes by with the check. (Remember those?)

In an emergency room, there will probably be a physician taking care of you but all the tests that are run are done by different individuals, if there is some kind of treatment you need, the person who cues you in on that (tells you how to take the pill or use the device they are going to give you) is different still. The person who checks you out is different still. What is the possibility that a concern you address to the physical will be responded to by that physician later during your visit? It depends on how fast the person who check you out and sends you home arrives on the scene. Maybe 50–50.

That is probably how Patient X was let go with Ebola. The system has too many places to break. How likely is that to happen again in other emergency rooms or clinics in the US? Not zero.

So, the bad news is that our system does not really put the lid on Patient Zeros that may show up in clinics or hospital, reliably. The system we have been assured would not allow an outbreak probably won’t allow an outbreak, but it may well allow dozens of people to be needlessly exposed, among whom some may contract the disease.

Now here’s the good news. It is said (though the information is spotty) that between 80–100 people who may have had even minimal contact with Patient X are being checked twice a day for fever, and a smaller number are being looked at more closely, even quarantined. The several schools attended by some kids Patient X had contact with are being sterilized. And so on. Frankly, this is more than necessary, but that’s irrelevant. If you only have a few tiny “hot zones” (in this case, one, and not that hot) an abundance of caution is not overkill. If over-cautious reactions eventually emerge whenever an Ebola patient shows up in the US, the larger scale outbreak will be avoided. But the handful of people initially at risk will not be safe by virtue of our system.

Perhaps that is unavoidable, but I think most people will look at the Dallas event and say that sending the patient home clearly should not have happened, and now every hospital and clinic in the country will be extra cautious. Like, remember that one time a surgeon accidentally amputated the wrong leg, and after that one time, it never happened ever again anywhere?

What, you don’t remember that? Hmm… me neither.

(Also, consider this: Imagine implementing the level of caution now being implemented in Dallas in the affected areas of West Africa? Can you imagine implementing this only half way, or a quarter of the effort? That would a) stop Ebola and b) be impossible. That is why the outbreak continues there. We have a lot to be thankful here in the US.)

Conclusion: The communities that have regular interaction with the affected countries are already in many cases somewhat organized as communities. These communities need to develop humane and thoughtful ways of making sure travelers are properly watched after. Everyone who works in any clinic or hospital has to double check what they are doing and not mess up again. The initial conditions that led to the current situation in Dallas are going to become more common over time.

And, remember, so far everything in Dallas is under control, but it will take 27 days to be sure (the incubation period is about 27 days, despite the “21 day” number you keep hearing). Also, while Ebola can manifest in an infected patient as quickly as two days after exposure, it is more typical to show up 8-10 days later. So the first week to 10 days of October is a fairly likely time, perhaps, to see a second case in Dallas, if there is in fact, further infection.

More on Ebola:

Ebola Will Not Become Airborne And Here Is Why

This discussion has been going on for some time, and a handful of recent events have prompted me to jump into it (beyond a simple comment or two). First, I saw a bunch of yammering among various biology teachers about this topic. Then Michael Osterholm wrote a well intentioned but seemingly deeply flawed opinion at the New York Times, then Dina Fine Maron wrote an excellent piece at Scientific American deconstructing Osterholm’s piece, then the latter two (and more) were summarized and expanded on in a post by Ann Reid at the NCSE.

Here, I will expand on this by applying first principles from evolutionary theory, organizing our thoughts in Tinbergenesque Terms.

There are four categories of reasons that Ebola won’t go airborne. I’m going farther out on a limb here than most others, who say things like “it is possible, but…” Imma say it just isn’t going to happen. Technically, over time, the Sus lineage of mammals (pigs) could give rise to a flying form, like what happened with some earlier lineage of mammal that gave rise to bats. So what I’m really saying is that Ebola will go airborne when pigs fly. Both are possible. But if that is what you really think of as “possible” instead of just “no, it won’t happen” than you may need to calibrate and stop buying those lottery tickets!

Here is why Ebola won’t go airborne.

First, diseases in general, including viruses, do change which species they infect sometimes, and they change in virulence and the exact effects on the host, but they really don’t change their mode of transmission. At the largest evolutionary scale there have been some novelties, obviously (or there would be no variation!). I am pretty sure many of the influenza viruses are not transmitted through the air, but the only ones we bother to name and study do, and are a subset of a larger group that transmits via water. I may have that wrong (going on old personal communications here) but if I am wrong that just crosses off Influenza as a virus that changed mode of transmission. Ebola is in a large group of viruses that are actually found in plants. Obviously, there was a change in transmission at the origin of Ebola. But really, this does not happen very often. If you can think of examples please tell me. (For a non virus example, Malaria is transmitted the same way all the time even if it changes (rarely) which species it affects or otherwise evolves like crazy to stay ahead of interventions.)

In short, we expect strong phylogenetic inertia in mode of transmission.

Second, there is no in place mechanism, probably. Ebola does not infect the tissues it would need to infect to make its way into a sneeze or cough. That would require a major change.

Third, developmentally, the first step in a virus’s life cycle is getting itself into a cell. Airborne viruses need to have a key that matches a lock on the outside of respiratory tissues. So Ebola not only lacks the means for getting out through a sneeze or cough, it also lacks the ability to do much if it did.

Fourth, it is not adaptive. Yes, a virus can mutate to do something stupid and maybe get a Darwin Award, but the chances are at least somewhat reduced. Ebola is very deadly in humans. Humans and the animal vectors that may stand between fruit bats (the likely wild host) and humans are not good hosts for Ebola. The chances of Ebola evolving to infect an unsuitable host are reduced.

Phylogenetically unlikely, mechanistically unlikely, ontogenetically unlikely, adaptively unlikely. Evolution is like baseball but slightly different. Four Tinbergen Strikes and you are out.

Now, the usual arguments in favor of Ebola doing the Hollywood thing rely on references to other viruses, like Influenza. Well, Influenza is way different from Ebola in its reproduction. It has a whole way of evolving that Ebola does not have. In fact, the differences is greater than, potentially (and rarely, but not never) the difference between evolution under sexual reproduction and evolution under simple replication. If two different Influenza strains infect the same cell, they can recombine (reassortment) to make an entirely novel never before seen Influenza. That is a very big deal and is thought to be the primary mechanism for the evolution of novel dangerous flu strains. Ebola does not do that. Ebola can’t do that.

Ebola does not do that. That thing Influenza does.

I said that twice. Now I’ll say it another way. Using Influenza evolution as a model for Ebola evolution is like using Primate Behavior as a model for Sea Slug Behavior. In other words, it does not fit.

Will Ebola go airborne? No.

ADDENDUM

I’m adding a bit more because some are still missing the point. This is an analogy that I think might be helpful

Cars fly, and airplanes drive around on the ground. Ebola can possibly be transmitted across space in a closed room from one person to another, and you can catch a flu by having someone with the flu bleed directly into your nose*.

But really, airplanes are vehicles designed to fly, they only drive around on the ground a little. They have wings, special engines, an overall shape and design that is adapted to flight. But really, cars only fly into the air now and then, and it is generally an accident.

An airborne virus replicates in high numbers in respiratory tissues, and causes the lysing (or some other process) of cells to allow itself out into mucous tissues. It is able to survive in mucous tissues, and then it is able to survive in aerosolized droplets. An aerosolized droplet is not a bit of bodily fluid cast into the air, it is not a drop of blood shed from a wound or bleeding eyeball, or a loogie. It is a bunch of liquid (mainly water) molecules coherent at a size sufficiently small that air currents are more important then gravity, so it becomes part of the atmosphere, and a virus may or may not be residing in it. Then, and airborne virus needs to have the external morphology that links up with a receptor site on respiratory cells in the individual subject to infection, and then, it reproduces mainly in that tissue.

Ebola is none of these things, except possibly one. Ebola is known to survive in mucous tissue for some time after it has left an infected individual. This is not the same as surviving in an aerosolized droplet, but it indicates the possibility. But to go back to the car-airplane analogy, that is a bit like saying that some cars fly farther when they leave the road during an accident.

The distinction is very important. Jane, commenter below, has oddly implied that I’m not taking Ebola seriously. I would like to point out that I may have been the only person to complain about and argue against the trope that Ebola is not so bad because it is not Malaria. I may also be one of the few bloggers writing about Ebola who has lived in Ebola country, doing health care work, and who has actually worked on the problem of the natural reservoir and contributed to it. I am also one of the few people writing now who has pointed out that even though most people with Ebola are in a few African countries, where this needs to be taken very seriously, that it is also true that those communities, in West Africa, are global. This is how my neighbor, Patrick, managed to die of Ebola. He was an American who also worked for the Liberian government, and was in Liberia taking care of his sister, who died of the disease. His wife and family are here, in my town. Ebola affects communities that are not separate from those who have the privilege of being able to muse about it. And here is where the distinction becomes multi-dimensional. All the talk about airborne transmission is not scientifically grounded, and it is a distraction. But saying that it will not become airborne is not saying that it is not a horrible disease that is highly infectious and has pandemic potential. This, the nuances of the epidemiology of Ebola, isn’t really that complex, but sadly, it is a bit too complex to be well managed by the press and others talking about it, in many cases.

And, the distinction is huge. Conflating the very small number of possible infections “across the room” (which are speculative but possible) in prior outbreaks (which, Jane, were not in East Africa) with an airborne mode of transmission is like working out transportation policy for the US but mixing up the part about how cars don’t fly and airplanes do. I really think Ebola is not going to become airborne. But if it was airborne, the whole ballgame would be very very different. That, however, does not mean that Ebola is not a very serious thing that needs to be addressed. Also, the utter failure to address this by the systems in place tells us that we as a society/species/collection of governments are unable to address a serious public health crisis even if we were under the impression that we were. Trading in misinformation and badly conceived ideas of what is happening or what could happen sets us back, it does not move us forward.

More on Ebola:


*Actually, this may not be true, to my knowledge no one has considered this, certainly not tried it!

UN Security Council Resolution on Ebola

Just a quick note. The UN Security Council has ad its first ever emergency meeting over a health issue, specifically the current West African Ebola outbreak. From a summary in Science, the Council …

… unanimously passed a resolution that declared the spread of the virus a “threat to international peace and security” and called on the world to send more health care workers and supplies to Liberia, Sierra Leone, and Guinea, and not to isolate those countries.

U.S. Ambassador to the United Nations Samantha Power, who chaired today’s meeting, noted that the resolution had 130 co-sponsors, more than any previous one in the history of the Security Council.

Has #Ebola Death Toll Surpassed Malaria in West Africa?

In the earlier days of the West African Ebola outbreak, it was not uncommon to hear people note that we should not panic about Ebola because, after all, far more people are killed from Malaria than Ebola. This is of course an irrelevant argument. That is like telling a person who has lost their family in a tragic airplane accident that it isn’t so bad because, after all, far more people die in car crashes than aircraft crashes. For example, on August 5th, James Bell write in the Guardian, in a piece called Concerned about Ebola? You’re worrying about the wrong disease:

Since the Ebola outbreak began in February, around 300,000 people have died from malaria, while tuberculosis has likely claimed over 600,000 lives. Ebola might have our attention, but it’s not even close to being the biggest problem in Africa right now. Even Lassa fever, which shares many of the terrifying symptoms of Ebola (including bleeding from the eyelids), kills many more than Ebola – and frequently finds its way to the US.

I’m not picking on James Bell here. A lot of people said things like this, and the facts are true, though as I said, there is almost always (actually, in exactly N-1 scenarios within a given domain of scenarios) an argument that goes like this, and it really isn’t particularly relevant unless one is tasked with dividing up a fixed set of resources that will be used for a fixed set of problems. Resources rarely come that way and problems are rarely solved that way. As I pointed out earlier, consider the thought experiment where you have $10,000,000 that you want to give to either developing an Ebola vaccine, or a Malaria vaccine. Since billions have been spent on developing a Malaria vaccine and there still isn’t one, your donation would be a drop in the bucket. Retrospectively, it would be equivalent to something like the combined costs of couriers and mail by researchers working on a Malaria vaccine over the last few decades. Or the cost of coffee and donuts in the break room. Or conference travel fees. Or something like that. The point is, a bunch of millions of dollars might actually produce an Ebola vaccine given the starting point we have now, or at least, move us a good deal in that direction.

But now, we can ask if Ebola in the countries that are heavily affected right now is still “minor” compared to Malaria.

This is a matter of numbers and the numbers are hard to come by. James Bell notes that between February and July, inclusively, there had been over 300,000 malaria deaths, I assume world wide. So the comparison is not really relevant; we should be looking at what is happening specifically in, for instance, Liberia, Guinea, and Sierra Leone (or the three combined perhaps). Comparing world wide figures to a regional outbreak is a bit like reducing the Malaria death rate by shifting from numbers from countries that have endemic Malaria to include the global population.

It is hard to know how many people die of malaria every year, and the quality of the data varies considerably from country to country. A fairly recent study (here’s a discussion of it) suggests that an older estimate of 600,000 deaths per year should be doubles to 1,200,000 deaths per years. Having worked and lived in a region with some of the worst malaria (measured numerous ways) for several years, I can easily accept a doubling of numbers. If we assume that 1.2 million is right, by the way, Bell’s number of 300,000 is actually conservative.

Using data from that malaria study and WHO’s Ebola data, we can make some comparisons. I’m including all the information so you can check my work.

Here we have data from Liberia, Guinea, and Sierra Leone. The population number and malaria deaths per year are both from the aforementioned study and pertain to 2012. Then I divided malaria deaths per year by 12 to get a monthly value. I’m more comfortable working in months than years because an Ebola outbreak is normally short lived, and the number of deaths changes dramatically from month to month.

Following this we have the total number of Ebola deaths per country (summed in the right hand column as are the above mentioned data) and the approximate number of months of the outbreak. Then, the total deaths divided by the number of months. This constitutes a low-ball estimate of deaths per month from Ebola for the given expanding outbreak. Here we can see that in the comparison between Malaria and Ebola, it is not clear that one is a greater threat than the other (142:92, 49:67, 145:144).

Then we have the August-only monthly number of deaths. Here we dee that Ebola is huge compared to Malaria. So, back when people were saying “Malaria is worse,” in late July and early August, Ebola was starting to prove them wrong.

The last two numbers are calculated for all three countries combined. Here we are going out on a limb, and it is better statistically to crawl out on a thicker limb than a thinner limb. I made some estimates here, and those numbers conform to what is being talked about by WHO and others. If Ebola continues to spread at its current rate the daily number of new cases could be between 150 and 300 by the beginning of January. I state these as low vs high estimates, but actually, they are both conservative. Multiplying this by 30 days in a month, and dividing by 2 to approximate the ca 50% mortality rate, we have conservative numbers for Ebola that leave Malaria in the dust. Even if the doubling of estimated Malaria death rates should be doubled again, Ebola will be a bigger factor than Malaria.

Liberia Guinea Sierra Leone Total
Population 3,954,977 10,068,721 5,696,471 19,720,169
Malaria Deaths Per Year 1706 586 1734 4,026
Malaria Deaths Per Month 142 49 145 336
Ebola Deaths Total 508 400 461 1,369
Months of outbreak 6 6 3
Monthly average Ebola deaths 92 67 144 303
August Ebola Deaths 644 148 224 1,016
Estimated Janurary Ebola Deaths (low) 4,500
Estimated Janurary Ebola Deaths (high) 9,000

So that is why we should stop saying that Ebola is not Malaria, so relax about Ebola.

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