Tag Archives: Ebola

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.

More on Ebola:

Update on West Africa's #Ebola Outbreak: Getting worse

The news is bleak. I don’t have a lot of confidence in the reported numbers. At one time it was said that on a nice Saturday in the summer, four out of five cars driving around in downtown Boston were looking for a parking place. This is somewhat like the situation in Liberia and possibly other affected areas. There may be as many Ebola victims driving around in taxis looking for a clinic as there are in clinics. Or maybe a fewer. Or, maybe more. Maybe a lot more.

But, we have to work with the data we have. There are two charts based on the information provided by WHO for up through September 6th. I’ve projected each data set out 90 days. Since there is no abatement in frequency of new cases, and in fact the number continues to increase on average, and since WHO is claiming that the situation in the worst hit areas is pretty much out of control, a 90 day projection seems reasonable. In other words, there is no reason to think that the relative rate of new infections is going to change because of any outside intervention or internal change in the situation.

The first chart shows the number of new cases. This varies a great deal from report to report. Some of that variation over time is probably real, reflecting the internal complexities of disease spread. But I suspect it is mostly administrative. If a bunch of cases don’t get into one report, the get into the next report. This explains a nearly perfect alternation between increase and decrease between successive reports.

Screen Shot 2014-09-10 at 1.03.44 PM
The second chart shows the number of cases over time, accumulated. This Projected outwards, we can guess that by around the beginning of 2015, there will have been over 10,000 people who have been infected by Ebola in West Africa (including Nigeria and Senegal as well as the main area of the outbreak), and over 5,000 deaths. Since I know you are curious, if this is projected out over a year or so, the number of infected people goes to between 60,000 and 70,000. I have no idea if this is realistic.

Screen Shot 2014-09-10 at 1.02.24 PM

The situation is bad and getting worse.

#Ebola in West Africa: Update

WHO has put out very few updates in the last several days. The most current update is August 28th, and it pertains to information from August 26th and before. Based on that update, the total number of cases (confirmed, suspected, etc.) is ow 3069 with 1552 deaths. The number of new cases per day may be increasing, may be decreasing; hard to say at this point. Here’s the new cases per day since the second week of July:

Screen Shot 2014-09-02 at 11.08.33 AM

Senegal now has one case, a person who traveled there from Guinea. He had contact with a lot of people including health workers and family before it was figured he may have Ebola. There is no word from the Congo since I last wrote about it, at least from WHO.

I’m sure Murphy’s Law will apply and WHO will issue new information soon after this post goes up, so expect an update very soon.

DR Congo #Ebola Outbreak

We can now be pretty sure that the Ebola outbreak in the DR Congo is not an extension of the West African outbreak. The index case seems to have gotten the disease from a mammal she butchered, and the numerous other cases seem to stem from contact with her primary as health care workers and family members. I don’t think we have enough information yet to assess this outbreak vis-a-vis the genetics of the Ebola itself.

From WHO:

On 26 August 2014, the Ministry of Health, Democratic Republic of the Congo (DRC) notified the World Health Organization (WHO) of an outbreak of Ebola virus disease (EVD) in Equateur Province.

The index case was a pregnant woman from Ikanamongo Village who butchered a bush animal that had been killed and given to her by her husband. She became ill with symptoms of EVD and reported to a private clinic in Isaka Village. On 11 August 2014, she died of a then-unidentified haemorrhagic fever. Local customs and rituals associated with death meant that several health-care workers were exposed and presented with similar symptoms in the following week.

Between 28 July and 18 August 2014, a total of 24 suspected cases of haemorrhagic fever, including 13 deaths, have been identified. Human-to-human transmission has been established and includes the health-care personnel who were exposed to the deceased pregnant woman during surgery (one doctor and two nurses) in addition to the hygienist and a ward boy, all of whom developed symptoms and died. Other deaths have been recorded among the relatives who attended the index case, individuals who were in contact with the clinic staff, and those who handled the bodies of the deceased during funerals. The other 11 cases are currently being treated in isolation centres.

#Ebola: Second, possibly third outbreak, West African outbreak growing

The number of people known or suspected to be infected with Ebola in the West African outbreak is increasing, and the rate at which it is increasing is increasing. About 40 new cases are being reported per day on average, but the number of new cases has been going up by a few a day.

However, it is still unclear that these numbers represent what is actually happening on the ground. There is little confidence that the WHO has a good idea of who is currently stricken with the disease, and efforts to contain those who are have had mixed results.

A second outbreak is now occurring in the DR Congo (formerly Zaire). This is a second separate outbreak. So, it is NOT correct to say that Ebola has spread into the Congo. It didn’t. It emerged there independently.

What are the chances of that happening? I have long maintained that the conditions for Ebola spreading into human populations include factors that make the overall chance of that happening, for a large region, go up enough for multiple simultaneous epidemics to be more likely than chance might suggest. Perhaps I’ll discuss my reasoning for that another time. In any event, the DR Congo outbreak, about which we know very little so far, appears to be a different strain of Ebola, so this is not the Wester African Ebola spreading to Central Africa.

There are reports of a third outbreak of an unknown disease that might be Ebola also in the DR Congo. But that could be a lot of things. Including Ebola… so we shall see.

Also, there is one new case in Nigeria, after a period of several days with no new cases.

#Ebola UPDATE-Rate Of New Cases Rises, Note to Laurie Garrett, is there a case in South Africa?

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h2>New for August 16th

I will try to keep new information and updates in the same post for a while until I have a chance to do a comprehensive re-overview of everything.

The 16 August update from WHO indicates a large uptick in the daily number of cases. Over the two days of the most recent reporting period an average of 76 cases per day have been identified as confirmed, probable, or suspect, with a total of 76 deaths over that period of time.

Good news is that the situation in Nigeria doesn’t seem to be developing. There were no new cases over the this reporting period, and one death. The last new cases in Nigeria were reported on August 6th for the period between August 2 and august 4. So over ten days without a new case in Nigeria probably means that the “outbreak” is burned out.

Meanwhile, there is another suspected/possible case in another country. This has happened a number of times, where a suspected Ebola case is identified. Hong Kong, the Philippines, the US, etc. have had these, and of all of the cases none have been shown to be Ebola except possibly one, and that is in Saudi Arabia did not work out either, the Saudi case was not Ebola. The new possible case is in South Africa.

The updated graph showing the increase in daily cases is inserted below as before.

And now, a personal note to Laurie Garrett. Laurie wrote this post, and I wanted to comment on it but the commenting system there did not work for me. (Perhaps one has to be subscriber.)

Laurie,

I love you work. It was your book, based on your Thesis at the Kennedy School, that got me interested in tropical diseases. Well, that and at the same time going to the tropics, running a makeshift health clinic there, and getting some of the diseases. I often point people to your earlier writing on influenza to find out about the true pre-Wakefield anti-vax movement, to see how the US handling of Swine Flu made it very difficult if not impossible to have a sensible national vaccine program that was not byzantium (which is what we have now)

But I think your article on not being scared enough about Ebola has some problems. I agree that this outbreak has not been taken seriously. I nave noted in my own writing that WHO and CDC, even, are coddling the public about some of this. I also noted, which I don’t think you did, that Ebola “in Africa” is Ebola in America already. One of my neighbors died of Ebola, and one of his relatives in Liberia did as well, and some of my other neighbors lost relatives, I’ve heard. This is because Liberians and other Africans live in communities with one foot in Africa and one foot here. Those who died of Ebola did so in West Africa, but they are still neighbors who live here part time or African-based relatives of neighbors who live here full or part time.

So yes, for many reasons, be concerned.

Here’s where I don’t agree with you.

First, while the cures and vaccines are truly not deployed as you point out, you are more negative than necessary. In fact you are hyperskeptical. A common phrase in hyperskepticism is “there is not a shred of evidence of…” Well, there is not a shred of evidence that my four year old is upstairs eating a peanut butter and jelly sandwich instead of the nice dinner I made my family, but that does not mean it is anywhere near impossible. In fact, he’s probably eating a peanut butter and jelly sandwich, though I can produce not a shred of evidence from here in my basement that he is. There is in fact good scientific reasons to think that the cures that have been brought to the brink of testing are likely to work, and Ebola is not like Malaria (not even close) or even viral cousins such as Influenza when it comes to vaccine prospects. The prospects are good, if only someone would work on them.

Next problem: No, Saudi has not Ebola. No, there have not been a number of actual, non-panic-based cases of Ebola outside of the affected area other than my neighbor and those he infected, in Nigeria.

Next:No, Nigeria does not actually seem to be having an outbreak. No new cases in ten days is good news. It may be over there.

We’ll see about South Africa.

But yes, I do agree with you on two other points. First, all of the health care molecules have moved to one corner of the proverbial room suffocating other health care efforts in the affected countries. This is a big deal. Second, yes, it really is possible despite major media and major organizations insisting it is highly unlikely for this outbreak to seed an outbreak pretty much anywhere in the world. Not that likely. But I won’t say that there is not a shred of evidence that it could happen (citing that every single case outside the zone for which confirmation was completed has not worked out). I’ll just say that we have no freakin’ clue how likely it is, but it is not zero and the consequences would be dire.

So, I don’t want to tone-troll your article. You went for breathless, and you got to breathless, and that’s probably a good choice, you have the credibility to pull it off and people need to hear much of what you said. But no, Ebola is not leaking out of the zone now, and yes, there is better hope I think for the existing (as in on the table, not deployed or even tested) cures and vaccines (and by the way, the “ethical considerations” are a red herring, that is true for all drug development, but seems only mentioned frequently with respect to Ebola).

End of rant. Again, love your work.

Cheers,

Greg

<

h2>End of August 16th update

Probably.

Yesterday I made the optimistic statement that the number of new cases a day may be leveling off, as for two reporting periods in a row, representing five days, the new cases were about half of the previous reporting period, normalized to a per-day estimate.

Today’s report from WHO covers two days and indicates 128 more cases, so the number of new cases per day for the latest known period is actually higher than at any previous time during this outbreak. Pursuant to this I’ve replaced the pertinent graphic below. I was optimistic, but I also provided caveats. The caveats won.

Is the current Ebola Outbreak subsiding?

At some point, the Ebola Outbreak in West Africa has to slow down and stop. The disease is too hot to not burn itself out, and it has no human reservoir. Ebola accidentally broke into the human population earlier this year or late last year, probably once (see below), and despite the regular increase in daily reported cases over the last several weeks, the disease must at some point begin to level off.

The latest two updates from WHO indicate that the Ebola outbreak may be leveling off now, tough it is too early to be certain. The following graph shows the approximate number of new cases reported per day by WHO. This is calculated by taking the number of new cases in a report and dividing by the number of days covered by that report. A given estimate of daily new cases may be quite off for a number of reasons. First, even if there is a long term upward or downward trend, there is likely to be a lot of randomness in the data. Second, this is the number of cases reported in that time period, not the number of cases that manifest. It is likely that some cases manifest during the reporting period are not recorded yet, and cases manifest for the prior reporting period are included in the current reporting period. Over several reporting periods this would, obviously, even out, but a given number of days in a reporting period may be off by a day or so. So, these caveats mean that we should be very cautious in interpreting this graph.

NEWER GRAPH:
Ebola_2014_outbreak_cases_per_day_Aug_15Update

Note that what appears to have been a fairly steady increase in number of cases, with about the same number of ups as downs but with the ups adding to a higher sum, since late June, has been followed by two reporting periods with decreases in numbers of new cases. Note also, however, that in late May the number of new cases per day went up fairly quickly then dropped again before a new steady rise occurred. If we use a moving average of 3 data points, which would combine sets of 2-4 days each to obtain something close to a 10 day effective moving average, the upward trend is more evident than any recent downward trend:

Screen Shot 2014-08-12 at 2.44.43 PM

The next two WHO reports may clarify this trend.

Mortality Rate Is Decreasing

The mortality rate for this outbreak continues to decrease slightly, which is probably a result of increase effectiveness of the response to the outbreak, despite all the news stories about how things seem out of control.

EbolaOutbreak_2014_MortalityRate_Aug_11_update

The current mortality rate is dropping below 55% given confirmed, probable, and suspected cases and deaths. But the rate varies across different categories. The outbreak-long rate for all cases and all deaths is currently 55%, and looking only at confirmed cases and deaths, it is 56%. The mortality rate for all previous African Ebola outbreaks, taking total reported cases and total reported deaths, is 66%.

This is the largest outbreak ever, and then some

Currently there are over 1,800 confirmed, probable, or suspected cases reported in the West African outbreak, and 1176 confirmed cases. Using just the confirmed cases, to be conservative, the present outbreak is 277% larger than the next largest outbreak, which was in 2000 in the Gulu, Masindi, and Mbarara districts of Uganda, with 425 cases. The total number of confirmed cases for the present outbreak represents about 49% of all of the prior African Ebola outbreaks combined.

Patient Zero Identified?

Patient Zero, who we assume is the person to whom the disease jumped from its usual animal reservoir, directly or indirectly, may have been a toddler in Guinea. The two year old child died in December 2013, which is quite a bit before this outbreak came on everyone’s radar screen, and after which it was fairly low level for a while.

I’ve long maintained that a likely way for Ebola to get into other species is from ground dwelling mammals, such as chimps, gorillas, or forest antelopes and duikers, ingesting or mouthing the discarded wadges of fruit previously handled by Ebola-carrying fruit bats. From such non-human animals the Ebola would then enter human populations from people butchering bush meat. In this case though, I wonder if the toddler may have been a direct recipient, picking up and mouthing fruit-bat spit covered fragments of fruit found on the ground. A parent’s worse nightmare, apocalypse style, to be sure.

The Famous Untested Drug

There has been a bit of complaining about my use of the term “drug” or “cure” for ZMapp, a drug that was developed to fight Ebola but not used until just now. Some have said it is not a drug until it is tested and deployed, and until then, it is a possible cure and not a real cure.

This is wrong. A “possible cure” is when you take an existing compound or substance, apply it to a pathogen or an affected animal model, and get a hopeful result. This possible cure can then be further developed to make, most of the time, nothing because these things generally don’t work out. Or, to make a cure. Which can then be tested.

In the case of the treatment now given to three patients (two survived one died), the cure was developed for Ebola based on some pretty solid science and prior experience with similar type cures working for similar diseases, successfully, in the past. The cure was not in “hopeful” or “possible” phase, but rather in developed but untested phase. The WHO convened an emergency panel of experts, yesterday, which decided that the cure should be used in the field under certain circumstances. So now there is an untested but developed cure for Ebola being deployed in West Africa. The WHO discussion on this is here.

#Ebola Outbreak: Rate of new cases remains high, Nigeria may now have outbreak

It is probably safe to say that Nigeria now has an outbreak, as a handful of cases contracted in country seem to have been reported, though it is too early to be sure this will stick. Hopefully it won’t.

There is also one suspected case, a death, in Saudi Arabia, of someone who would have caught it in Liberia.

The number of new cases per unit time seems to have increased, or at least, stayed high as it has been for the last several days. The following chart based on WHO data shows the cumulative number of cases and deaths, including probable, suspected, and confirmed, as per WHO reports which come out at irregular intervals but generally every few days, though today’s report (August 6th). The mortality rate continues to hover between 50 and 60% (the drop at the end of that line is probably an artifact of the rate of new cases added and does not mean a drop in mortality rate, most likely)>

Ebola_2014_Outbreak_Aug_6_update

See this post for a more detailed look at the dat up through the previous report, where there is a discussion of some of the nuances.


More posts on Ebola:

<li><a href="http://scienceblogs.com/gregladen/2014/08/04/there-is-a-cure-for-ebola-we-have-it-we-just-dont-let-anyone-use-it/">There is a cure for Ebola, we have it, we just don’t let anyone use it.</a>

<li><a href="http://scienceblogs.com/gregladen/2014/08/04/ebola-outbreak-continues-probably-worsens-perhaps-spreads/">Ebola Outbreak Continues, Probably Worsens, Perhaps Spreads</a></li>
  • Ebola Perspective: Risks of spread to the US and elsewhere
  • <li><a href="http://scienceblogs.com/gregladen/2014/07/27/ebola-outbreak-in-west-africa-some-basic-information/">Ebola Outbreak in West Africa: Some basic information (Updated)</a></li>
    

    Ebola Outbreak Continues, Probably Worsens, Perhaps Spreads

    The WHO came out with a new report today with the latest figures on Ebola. These numbers take us to the end of July. There are two bits of bad news.

    First, the number of new cases is high, as high as any prior report (but keep in mind that these reports cover uneven time periods). There are 163 new cases and 61 new deaths, bringing the total number of confirmed cases and deaths to 1009 and 574, with the total number of confirmed, probable, and suspected to 1,603 cases and 887 deaths.

    Second, Nigeria is now in the mix. There was previously only one case in Nigeria, a Liberian man who contracted Ebola in Liberia and died in Nigeria. But now there are three probable new cases in Nigeria and one probable Death (none confirmed). According to WHO, of the Nigerian cases, “…one is a health-care worker and one is a Nigerian who travelled to Guinea — and a suspected case in a nurse.” I’m not sure if four cases (if confirmed) is an outbreak yet. If all the cases have quirky explanations having to do with other countries, than this not be anything new. But this could also be the beginning of the spread of the disease into Nigeria.

    Here’s a graphic of the cumulative number of caeses by country (not counting Nigeria) and the total so far. These are all cases (confirmed, probable, suspected). You will notice that Sierra Leone is contributing the largest number of cases, but Liberia is contributing the strongest uptick in what seems to be an increase in rate of new cases (more on that below).

    Ebola2014_Aug4_update_cases_by_country

    This graphic shows the number of cases over time and the number of deaths over time (totals). Note that the gap between the two is widening, suggesting a lowering of the mortality rate.

    Ebola_2014_total_cases_and_deaths_Aug4_update

    To try to get a better idea of mortality rate over time, here’s a graph of the an estimate mortality rate based on the total number of cases and the total number of deaths for each of the WHO reports (which come out every few days) over time. There is no sense in calculating a simple correlation coefficient or R-squared value for these data because each data point is based on the adjoining data point plus or minus (they are not independent) but one suspects a proper time series analysis would suggest a decrease.

    Ebola_2014_mortality_rate_over_time_per_report_August_4_update

    Keep in mind that as the number of cases or deaths shifts along the confirmed-probable-suspected axis, the morality rate can change quite a bit. One might expect that the least certain category would have the lowest mortality rate because one is more likely to incorrectly assign a patient to having the illness than one is to attribute a death to the disease. Here’s the behavior of mortality rate across the different categories of available data. Note that the rate for “new” is probably going to be biased downwards if the rate of new cases is going up (because the number of people who have not died yet, but will, is greater than if the rate is going down); that 37% figure, therefore, is nothing to get excited about. Also keep in mind that “Total” is a combination of the other three categories. Given the vagueness of some of the data, one could say that a good estimate of mortality is 55%, but a large number of cases have been added in the last several days, so it might be better to say that the mortality rate in this outbreak is at least 55%.

    Ebola_2014_Mortalit_Rate_Across_Categories_Aug_4_update

    It seems that the number of new cases is going up but this is hard to count. The WHO reports cover different time periods, and I’ll wager that even within that constraint the data are a bit funky given the on the ground situation. Over the large scale of time it is clear that the number of new cases is rising. This graph shows the number of new cases per month, but keep in mind that the dates of the various reports do not match the ends of the months cleanly so there is room for error her. These are all cases.

    Ebola_2014_New_Cases_Per_Month_Aug_4_Update

    Since the rate of infection can go up or down over a matter of days, or a least, more rapidly than would be reflected in a month by month accounting, here’s the same data by half-month:

    Ebola_2014_New_Cases_Per_Half_Month_Aug_4Update

    And, because that does not capture important detail here’s the data again by WHO report, keeping in mind that the length of time covered by each report varies.
    Ebola_2014_Rate_New_Cases_Per_Report_Aug_4_update

    Actual epidemiologists use much more sophisticated methods for analyzing this sort of data, but this should give you the idea that while the rate of new cases varies a lot from report to report, there is a general upward trend in the number of new cases.

    This Ebola outbreak is not going away soon, it seems.

    Other posts on Ebola:

    <li><a href="http://scienceblogs.com/gregladen/2014/08/04/there-is-a-cure-for-ebola-we-have-it-we-just-dont-let-anyone-use-it/">There is a cure for Ebola, we have it, we just don’t let anyone use it.</a>
    
    <li><a href="http://scienceblogs.com/gregladen/2014/08/04/ebola-outbreak-continues-probably-worsens-perhaps-spreads/">Ebola Outbreak Continues, Probably Worsens, Perhaps Spreads</a></li>
    
  • Ebola Perspective: Risks of spread to the US and elsewhere
  • <li><a href="http://scienceblogs.com/gregladen/2014/07/27/ebola-outbreak-in-west-africa-some-basic-information/">Ebola Outbreak in West Africa: Some basic information (Updated)</a></li>
    

    There is a cure for Ebola, we have it, we just don't let anyone use it.

    LATEST UPDATE HERE … new numbers just in from WHO, and they are bad.

    I had suspected this might be the case. Disease like Ebola are potentially easily cured using serum. Here’s the idea. Someone gets the disease and survives, and their body now produces products that give them an immunity. So, you take a bunch of their blood, clean it up as best you can, and inject the serum (the cleaned up blood, to oversimplify) with these immune products, in to a person with the disease. That stops the disease, at least some of the time. The early history of the discovery of many nasty viruses involves several stories like this, where a researcher or physician is infected, seemingly likely to die, and is given a serum and lives.

    The serum treatment is potentially very dangerous because it can include who knows what from the other person’s blood. But it is quite reasonable to suggest that we can make a product that is based on serum that is clean and effective. In this case, specific products were obtained from infected mice.

    And, apparently, there is such a thing, it is a secret, and it is reserved only for select individuals (because there probably isn’t much). Oh, and it is totally experimental and until now, never before tried on humans. From CNN:

    Three top secret, experimental vials stored at subzero temperatures were flown into Liberia last week in a last-ditch effort to save two American missionary workers who had contracted Ebola, according to a source familiar with details of the treatment.

    A representative from the National Institutes of Health contacted Samaritan’s Purse in Liberia and offered the experimental treatment, known as ZMapp, for the two patients, according to the source.

    According to company documents, four monkeys infected with Ebola survived after being given the therapy within 24 hours after infection. Two of four additional monkeys that started therapy within 48 hours after infection also survived. One monkey that was not treated died within five days of exposure to the virus.

    …In the monkeys, the experimental serum had been given within 48 hours of infection. Brantly didn’t receive it until he’d been sick for nine days.

    The medicine is a three-mouse monoclonal antibody, meaning that mice were exposed to fragments of the Ebola virus and then the antibodies generated within the mice’s blood were harvested to create the medicine. It works by preventing the virus from entering and infecting new cells.

    Brantly asked that Writebol be given the first dose because he was younger and he thought he had a better chance of fighting it, and she agreed. However, as the first vial was still thawing, Brantley’s condition took a sudden turn for the worse.

    Brantly began to deteriorate and developed labored breathing. He told his doctors, “I am going to die,” according to a source with firsthand knowledge of the situation.

    Knowing his dose was still frozen, Brantly asked if he could have Writebol’s now-thawed medication. It was brought to his room and administered through an IV. Within an hour of receiving the medication, Brantly’s condition was nearly reversed. His breathing improved; the rash over his trunk faded away. …

    Writebol also received a vial of the medication. Her response was not as remarkable, according to sources familiar with the treatment. However, doctors on Sunday administered Writebol a second dose of the medication, which resulted in significant improvement.

    This is an untested drug that is not available for general use. This has led to some argument of whether or not it can be called a “treatment” or a “cure” because it has not yet gone though the process of development, testing, and deployment. One could call it a “potential cure.” The key point, is, that it could be developed and implemented, and since the science of making an antibody basted treatment is well established, it is hard to understand why this has not happened. yet. I suggest that all it would take is deciding to spend the money and effort on developing it, rather than simply ignoring Ebola because it is not Malaria.

    If I was President Obama, I’d simply order the military to take this to the next step. The US Army has done as much research on Ebola as any other agency. It would be a simple matter to move a few budget items around and allow USAMRIID organize, using its own people and consultants, to move forward (because you know the present Congress is never going to authorize spending money on helping sick people in Africa, even though this is also very much about the United States.

    It is the right thing to do.

    Ebola Perspective: Risks of spread to the US and elsewhere

    LATEST UPDATE HERE

    It is true that this particular outbreak of Ebola has taken health officials somewhat by surprise. It is impossible to know, but I suspect that if you had asked a few ebola experts, a year ago, if there could be an epidemic that would spread across three or four countries, infect a couple thousand people, and last with no sign of letting up for a few months (that is the current situation, more or less), most would say no, probably not, though it is within the range of possibilities. Does the fact (assuming it is true) that this particular Ebola outbreak is unprecedented and kinda over the top even for an over the top disease like Ebola mean that there is something different about this Ebola or this outbreak? That is a question that may be on your mind.

    Another concern is the possibility that since this outbreak involves populations with more mobility including via aircraft than previous outbreaks that the Hollywood Scary Fiction scenario could happen. Here’s how that goes. Someone infected with Ebola, but not symptomatic, gets on a long plane flight, maybe with a few legs and layovers. They start to get sick on the first flight, and after changing planes twice and being very sick for the last leg, they get off the plane and collapse, are taken to a local hospital very far form the Ebola epidemic where no one is expecting Ebola, spend a little quality time in the waiting room, and are finally put in an in-patient unit in a room with two or three other people. Hundreds of people have been near this person. The patient threw up in the bathroom of each of the airplanes he was on, and later someone filled the sink in the same bathroom and used the water in the basin to wash his or her face. He drooled on his pillow while sleeping in his seat, and somehow the person next to him ended up with that pillow and slept on it for an hour. He threw up on some nurses and some orderlies had to clean up his diarrhea in the hospital a few times. And so on. By the end of all of this, a half dozen people are infected with Ebola, including a personal trainer, a grade school teacher, and four nurses. That’s just the first scene in the movie, long before the character played by Morgan Freeman is on the scene, and when the character played by Morgan Freeman shows up, you know things are getting serious.

    A variant of that concern is this: Two aid workers helping with the Ebola epidemic, Americans, catch Ebola and are very ill. It is decided to fly them back to the United States for treatment. This brings Ebola into the US, where it could spread to other people because, well, because Ebola! But is this a realistic concern or just a Hollywood studio’s wet dream?

    At this point in the epidemic we are seeing the usual bifurcation of reaction among the general public, sciency bloggers, and the press. On one had there is growing panic, people either being very scared, for real, or people or press outlets shopping fear on the market because it sells. On the other hand there is the stern corrective statement that all your fears are invalid, Ebola isn’t going to get out of hand, isn’t going to get to the US, there is nothing to worry about.

    At the same time there is a parallel and equally bifurcated rhetoric about the bigger picture, about dealing with Ebola as a public health problem. On one hand you have people asking for a vaccine, or some sort of cure, to address this thus far orphaned disease, because they are worried about it. On the other hand you have people noting that Malaria kills millions a year, and most years, Ebola kills no one, and when there is an outbreak, it only kills dozens or hundreds, except this last time which is still only many hundreds dead and the very low three figures sickened.

    Every one of the above mentioned concerns is valid and invalid at the same time, and every one of the reactions to the current Ebola crisis is both correct and incorrect at the same time. Let me explain.

    What is the meaning of the bigness and badness of the Ebola 2014 outbreak?

    There may be new things to learn about Ebola from this outbreak, but that won’t be until after the dust has settled and scientists have had a chance to look more closely at the data, and the virus, and everything else. But there does not seem to be anything new or unusual about the disease, and I don’t think there is any major difference in how the outbreak is being handled. But there are two differences from earlier outbreaks, one of which is certainly relevant to the large size of this event, the other perhaps important but as yet unclear.

    <li>Most, really all, prior outbreaks occurred in areas where the affected population was relatively thinly scattered on the landscape and the movement of people in and out of the area was minimal and slow. This outbreak is happening where there are much larger concentrations of population and a lot of movement of people.  This has simply upped the chance of transmission in close quarters (higher density) and made for opportunities for spread to previously unaffected settlements.</li>
    
    
    <li>There has been resistance to health workers coming into some villages.  This story is spreading around as though it was a major thing, that large areas were becoming dangerous or difficult for health workers to enter or work in.  We need to be cautious in drawing conclusions from the news.  It is very easy for westerners to slip into blaming the natives for their own difficulties and contrasting native ignorance with Great White Smartness.  There may well be areas where this is happening or important but until there is some actual unbiased carefully collected and evaluated information on this, please don't draw conclusions.  If you hear about something that looks like a great story, there is a good chance that it is a great story.  Emphasis on "story." </li>
    

    This particular Ebola outbreak is really like all the others, but jumbo size.

    Could sick aid workers being brought to the US spread the disease here?

    No.

    You can stand in a room with a person infected with Ebola ten feet across the room from you, and stand there for hours, without a mask, and you will not, can not, get Ebola. It simply isn’t transferred that way. Clean up Ebola vomit, Ebola diarrhea, physically move Ebola victims from bed to bed, give them a sponge bath, tend wounds or other injuries, insert and remove IV’s, handle the bodies of recently deceased Ebola victims, and especially, give traditional treatment to those bodies which, as is done in many cultures, which may involve cleaning and even internal cleaning or handling of organs, etc. etc., and you’ve got a reasonable chance of getting Ebola. Even then, the number of health care workers who actually get Ebola is probably very small. Tragic and horrible when it happens, but a few out of thousands most directly exposed and at risk for months is a small number.

    The people who are being transported to the US are isolated, in negative pressure facilities, and are being handled with kid gloves. Well, latex gloves, actually. They can not infect anybody but their immediate caretakers, and those individuals are very well protected.

    There is a risk of a different sort, though. While these particular patients are being handled with great care, there are healthy helpers, medical workers or others, who have been working with Ebola patients and seem to have not contracted the disease, who are occasionally wandering off to their respective homes and, I’m pretty sure, not being quarantined. I am not sure if all the people involved in helping in West Africa are being tested or properly watched. They may be, but there is some evidence that this is not the case. I’d like to learn more about that, and I hope we don’t learn anything the hard way.

    One US based doctor has returned to the United States and decided to quarantine himself. Alan Jamison will keep himself separate from society for 21 days since his last potential exposure to Ebola.

    If he is doing this on his own, there is the implication that doctors or others who were working with Ebola victims are being allowed two wander off and commune with the rest of us with the prospect that they are infected and eventually could spread the disease. However, I’m not sure that this is true. I don’t know that Dr. Jamison was not tested, I don’t know how much exposure he had and I don’t know what the procedure is for managing this potential problem. This is one guy who may be making hay where there is no grass. Worst case scenario, though, is that a health worker gets sick, the beginnings of Ebola like symptoms emerge, and the health worker gets treated. Nobody who has been working with Ebola patient is going to get a head ache, feel like throwing up, and say to themselves, “Hmm. I wonder if I’ve got allergies or something?”

    We should be worried about people wandering off, leaving the sites of the outbreak, generally. That’s clearly how this has spread to begin with. This applies to health workers and regular people. It applies to journalists in the field. We should not assume, but we can reasonably hope, that people are doing the right thing. But even when they don’t, remember, this is not measles, which is highly contagious.

    (Also, in case you didn’t know, Ebola is of course already in the United States. See this.)

    Can the scary hollywood scenario happen?

    Yes, of course it can. There is nothing in that scenario, taken on its own, that can’t happen. Bodily fluids get around. People are confined on aircraft, share a bathroom, and occasionally eat each other’s cookies by mistake. I don’t think there is any scientifically valid way to suggest that people who are symptomatic with Ebola are anything but a nightmare on a regular airplane flight, hanging around in airports, sharing cabs, et. When I hear international health experts saying that the chance of Ebola transmission on an airplane is pretty much non existent, I want to ask them: Ok, so, you’ll be entering and leaving the sick rooms of Ebola patients, maybe taking your kids along because it’s Follow Your Parents to Work Day, and maybe even have your kid sit next to the patient in bed and read them a story, without any protective gear at all. Right? No, absurd.

    However, the crazy scenario I gave you above, with the vomit and the pillow and the bathroom, requires a lot of things to go wrong in sequence, which is pretty unlikely. Also, the worst case scenario is that a few people end up with Ebola. It would be very hard for that to spread in the US. We’re too good on our health care, even when it seems we are not. On the other hand, if an air route with a symptomatic Ebola patient is sending people to any of many other places, with high population density, little education or information about things like Ebola (or even a belief that it is not a disease you get from other people) and no monitoring, I’d worry that smaller outbreaks could show up in other countries or other cities, in West Africa, elsewhere in Africa, or beyond. You can say that chances are it won’t happen. But it did happen. Ebola is in multiple countries spreading from multiple sites in West Africa.

    I’m pretty sure the people who deal with Ebola, though, try to not take chances. Rhetoric to the contrary is to avoid panic. Avoiding panic is good, and in fact, panic is unnecessary. Ebola is not that contagious. But somewhere between being concerned and avoiding panic by making it sound like Ebola refuses to pass from person to person on air planes, there is clearly something lost in translation.

    Who cares about Ebola, it is not Malaria!

    To me this is one of the most insidious problems we have and it doesn’t just apply to Ebola vs. Malaria. Let me give you an example from an entirely different area.

    How much money have spent on the science of subatomic physics, say, just in the US. And, what are the benefits? More importantly, what were the benefits that were specified at the outset of various research projects, and which of those have been realized?

    The answer to that second question is probably zero, zero. No benefits were specified, and thus, any gained don’t count. You are probably thinking, “No, wait, what about the knowledge, and all that stuff!?? That was surely specified in the grant proposals!” No doubt, but simply advancing knowledge is not a benefit. How do I know that? Malaria! Those physicists may have advanced our knowledge, and as a side effect invented the DVD and stuff, but nobody cured Malaria. Therefore it doesn’t count.

    Sounds like an incredibly stupid argument, doesn’t it?

    Now, side step over to Ebola. Is creating, say, a vaccine to address Ebola worth it? No! Why? Because Malaria! Malaria is way bigger, kills more people, is a truly serious public health problem, Ebola is rare. So if you’ve got some research money don’t spend it on Ebola, spend it on Malaria.

    That would be the smart thing to do!

    This is also an incredibly stupid argument, for a few reasons. The only reason you can compare Ebola and Malaria is because they are both diseases. They aren’t even the same kind of disease, they don’t have the same geographical spread (though it is overlapping). But they are diseases, so when we consider spending resources on research in one, it is natural to compare to the others. But they are also two different things. If I had a million dollars in the bank of my Malaria Vaccine Research Institute and gathered all the scientists together and said, “OK, folks, until we’ve spent this one million dollars, I want you all working on Ebola instead of Malaria, K?” they would look at me funny for a while and then call my wife to take me home. Ebola is a virus, Malaria is a cellular organism. They are very different things. The expertise and lab equipment would not be in my Institute. I might as well tell my scientists to spend a million dollars working on the next generation of high definition TV. That would be cool! And, suggesting that we compare the costs and benefits of that project to working on Malaria or Ebola would be dumb.

    One of the benefits of working on a vaccine for ANY virus is advancing knowledge of vaccines for viral disease generally, and we have a lot of work to do on vaccines for viral diseases. Perhaps work on Ebola would have some great side benefits. Indeed, money spent on a vaccine for Ebola would very likely produce … wait for it … a vaccine! Money spent working on a vaccine for Malaria has thus far failed to produce squat.

    A vaccine for Ebola is probably relatively easy to develop. Ebola is not a human disease. It comes from an animal reservoir. Ebola, if hit with a vaccine in human populations, can’t evolve resistance to that vaccine (or other treatment). Humans have little or no history of immune response to Ebola, and a very long (in essence, multi million year long) history of immune response to Malaria and its cousins. Developing an Ebola vaccine would be like putting up a childproof gate in your house, where the 2 year old is Ebola and the childproof gate is the Vaccine. Developing a vaccine for Malaria is like trying to stop a squadron of Navy Seals from penetrating a drive-in theater at a date and time of their choosing.

    This is why literally billions of dollars has been spent … billions, seriously … on developing a Malaria vaccine and there isn’t one. I would venture to say that if we looked at the part of the money spent on Malaria research in general (including vaccines) that covered just couriers and postage over the years, we’d have enough to fund a full on Ebola vaccine development program. Maybe not. Maybe you’d have to add in a few percent of the money spent on conferences (which are very important, I’m not saying they are not) by Malaria scientists. There is probably more money being spent right now on retirement payments to retired scientists who spent most of their time working on Malaria than needed to build an Ebola Research Center that could get a vaccine out there in a few years. Seriously. Please don’t compare Malaria to Ebola and use that to suggest that we should ignore Ebola. The crumbs that fall off the pieces of Malaria cake at the Malaria birthday party would be enough to handle Ebola. (Bonfire of the Vanities Reference.)

    But still, why should we bother with Ebola?

    Why bother with any disease? Why not figure out which one disease causes the most mortality or morbidity, and disallow any research on anything else? Then, when that is solved, move on to the next one. There are several reasons to not do this. First, it might not be possible to solve the big bad disease quickly, or ever, so the entire research program would spin its wheels forever. Second, the second and third and way down to the tenth or twentieth diseases are all real disease people really get and that really cause suffering. While the argument that spending excessively on a rare disease is a poor choice, spending a modest amount on a very addressable problem that is also small is exactly what we should be doing. Third, you can and should think of some of this as pure research. Pure research is where scientists seek out the answers to questions in a special category of question: Questions that scientists ask. No other criteria need apply. Scientist tend to ask questions that are at the edge of knowledge, or perhaps that are hanging around this or that water hole of ignorance. Scientists ask the questions they ask because they have two characteristics: There is something unknown, and there is something about that unknown thing that is knowable. With research. Usually.

    Now go back to Ebola again. Doesn’t somebody want to know about Ebola? Of course they do. Ebola is one of a family of viruses, the Filovirus family, that includes some pretty benign viruses and a handful of nasty ones (Ebola isn’t the only one). In the past there was a lot of research interest in the filovirus family for use as a biological weapon. Imagine making an Ebola like virus that spread though the air! You could really kick ass, militaristically speaking, with such a weapons. But, fortunately, we as a species have recently decided to not view biological weapons as legitimate. Research on biological weapons continued, of course, long after they were outlawed because we assumed we needed to “understand them” (make them and test them on rats) in case the other guys were making them, so we could deal with them. But I’m pretty sure most of that research has gone by the wayside as well. I would not be surprised, and I’m not much of a conspiracy theorist so I don’t want to emphasize this too much, if a lot of the work to make an Ebola vaccine was in a file drawer somewhere.

    Also, there is the simple stark reality of Ebola. If you are a typical American you may not care about Ebola because it is in a different country and won’t get here and there are other problems. But say you are like my neighbor here in Coon Rapids, Minnesota, Decontee. Decontee is Liberian. She is part of a large Liberian community here in the Twin Cities. Many Liberians are American Citizens with strong ties to Liberia. There is constant travel back and forth. I asked a Liberian guy I know where he gets his sombe (a wonderful traditional West and Central African dish) and he said “From my grandmother.” “Does she grow it?” “Yes. In Liberia. I get it when I go there.” The point is, there is a lot of back and forth. To be an American who is Liberian is to be a member of a community of people who is currently, at this very moment, threatened with Ebola. People in your community, in your family, can get Ebola. Decontee’s husband and her sister in law both got Ebola and died of it last week. Ebola is a problem that affects communities that are Diaspora that include our very neighbors and friends. It should not be an orphan disease.

    So wait, there was way too much nuance and possibly contradiction here, what am I supposed to think?

    I don’t want to tell you what to think.

    But in this case I’ll make a suggestion.

    Do not be worried about the health workers being brought back to the US. Indeed, at this point, openly worrying about this can do little more than make you look a bit dumb and a bit insensitive.

    Yes, worry about the possibility of Ebola getting “out” to pretty much anywhere, elsewhere in Africa, to the US, etc., because it can. But don’t worry too much. The chances are low. Forget about this “Oh, Ebola is not transmitted between people on airplanes” magical thinking. Of course it is. But Ebola is always hard to transmit, even on airplanes. In other words, be realistic.

    Forget about this comparison between Ebola and Malaria. When the Malaria people turn up a vaccine after spending billions of dollars of research money we can make a comparison. At the moment, Ebola is probably a vaccine-ready disease, and Malaria is not. You are comparing apples and oranges. No, worse than that. They’re both fruit. You are trying to compare, in a cost benefit analysis, the efficacy of spending money on a new car vs. working out whether or not it is worth clipping coupons when you go to the grocery store. Why are you doing that?

    But, if you are a member of a community like the various African communities in the US, then you do indeed have more of a concern. Not so much that travelers will bring Ebola to your doorstep, though that is a tiny bit more likely for you than for some others, maybe. But because your community is being directly affected because your community lives in two worlds, and one of those worlds is being invaded by a monster.