The Race To Contain The Ebola Outbreak

MAUREEN CAVANAUGH: Our top story on Midday Edition, Ebola outbreak arrived in Liberia yesterday. In all, 3000 US soldiers will be training health workers, and setting up emergency health facilities in West Africa. The hardest hit countries, Liberia, Guinea and Sierra Leone are also taking measures to stop the spread of the disease. Sierra Leone has just lifted a three-day lockdown of citizens, in which health workers conducted a door-to-door education campaign. This biggest outbreak of Ebola shows no signs of stopping. It has claimed more than 2600 lives and officials fear there will be thousands more. I like to welcome my guests, Professor Erica Ollmann Saphire and Thomas Novotny. The last time we talked, the Ebola treatment ZMapp, developed by Mapp Pharmaceuticals here in San Diego, it has been used successfully on two Americans who contracted Ebola in West Africa. Since that time, however, the drug has had mixed success, is that right? ERICA OLLMANN SAPHIRE: It depends on the case history of the patient. The two Americans with the first. It was actually mobilized originally as intended for a Sierra Leone Doctor, and his medical team opted not to give it to him. That dose went to Nancy Writebol, that's why there was one available initially. After that, it went to a British nurse, Spanish priest, and three Liberian doctors. The priest and one of the doctors did not survive. The priest was seventy-five and he had been affected for weeks. He may have been out of the treatment window. Because the clinical trial has not been done yet, it is not clear what the treatment window is. That is one of the reasons this child is to be done. The Liberian Doctor we lost had complicated conditions like diabetes and hypertension that may have influenced his disease as well. MAUREEN CAVANAUGH: Is ZMapp still being used? ERICA OLLMANN SAPHIRE: Only a few human doses were available. It was still a research product. The human trial had not been scheduled till 2015. What was available has been used. Mapp Bio received additional funding to scale it up, and that effort will continue for the next eighteen months. The goal is to make those doses needed to do the human trials to establish efficacy, and what the treatment window is and what it should be. MAUREEN CAVANAUGH: Sierra Leone basically close down over the weekend to conduct a public health campaign to slow down the spread of Ebola. Remind us, how is the virus being spread? THOMAS NOVOTNY: It is through contact with infected bodily secretions, blood, anything that can transmit it. Also, medical equipment, things shared between patients, and direct contact between people. It is easy to transmit if there is contact between human beings. MAUREEN CAVANAUGH: Our health officials able to track the spread of the outbreak? Do they know what is coming? THOMAS NOVOTNY: I think that is one of the problems, why it has been so vigorously, the surveillance systems and the ability to count the cases and understand where they are in contact with people is really inhibited, partly by the cultural response of the people in these affected areas, and also because of the inadequacy of the public health system. The health systems in these three poor countries were pretty bad to begin with. This has devastated them even further. It is clear that the cases we have are underreported. It may be three times as many cases then are officially reported. MAUREEN CAVANAUGH: We keep hearing that Ebola cases are increasing exponentially. What does that mean? THOMAS NOVOTNY: Part of it is increased reporting and detection. It is also because of increased transmission. They do not have a good handle on the spread of the disease, and the confinement and the quarantine of patients have not been effective enough to stop it from being transmitted within households and hospitals. ERICA OLLMANN SAPHIRE: From epidemiology that has been done, we can see the exponential increase. The one man who flew on an airplane into Nigeria cost sixty-two cases in Nigeria. One infected person caused sixty-two cases. The virus was introduced into Sierra Leone by the funeral of one herbalists, a native healer. Thirteen women attended the body in the funeral, and became infected. That introduced the virus into Sierra Leone. The bodies and corpses themselves are also infectious, and that was part of the effort of the door-to-door campaign. MAUREEN CAVANAUGH: To try to find bodies that have been kept by families? THOMAS NOVOTNY: To identify cases, dead or alive. Part of the campaign was really for context tracing. MAUREEN CAVANAUGH: We have about 5000 documented cases. They may be underreported as you say. How many cases are anticipated if it is to spread this way? THOMAS NOVOTNY: There have been recent estimates generated by the CDC. But again, even generating estimates is comforted. They do not know the logistics of the spread as thoroughly as they wish. The estimates are at least 5000 cases before the epidemic is controlled. MAUREEN CAVANAUGH: And that is how long a time? THOMAS NOVOTNY: Probably the next 6 to 8 months, I think it is projected that long or longer. ERICA OLLMANN SAPHIRE: The original estimates from Guinea were that the number of cases where doubling every thirty-five days. That is about five weeks. Now the estimate is that it is doubling every three weeks. MAUREEN CAVANAUGH: As director of the Hemorrhagic Fever Consortium, is this one of the worst case scenarios you have been concerned about? ERICA OLLMANN SAPHIRE: Absolutely, that is why we formed the consortium. I do not know another field in science where everyone in the world working on one problem of antibody therapeutics has gotten into a single study, a sort of global Manhattan project. MAUREEN CAVANAUGH: As you say, one of the drug is being manufactured. They want to start human trials to find out where and on who it is most effective. Have there any other drugs that have been developed that are effective against Ebola? ERICA OLLMANN SAPHIRE: There are several candidate vaccines that work very well in animal models. They are going into healthy humans with no adverse effects. That is very helpful. Vaccines are the right answer for people who could become exposed. For example, healthcare workers can stop the spread if they are vaccinated. There are other small molecule therapeutics that are effective as well, and it may be that you could combine the small molecule drugs with antibody drugs. One of the advantages of antibodies the extended treatment window. Even latent infection, they were able to reverse the course of the disease. That is useful on a practical level, because it takes a while to identify cases and get them treatment. That extended treatment window has been an advantage. MAUREEN CAVANAUGH: So you're saying that research is going on in a dual phase, one towards vaccines that would stop people from getting people and another towards the treatment of people who have the disease? ERICA OLLMANN SAPHIRE: More or less yes, there are multiple parallel tracks. There is a little bit of back and fourth, because they can give a higher dose of vaccine immediately after exposure, and you can give antibodies before exposure. The best use of resources is probably to vaccinate before entry with antibodies. MAUREEN CAVANAUGH: What kind of timeframe all be looking at, when it comes to the vaccines as human trials have just begun on the vaccine, and human trials had to be undertaken on ZMapp. How long of a time frame is it, considering this emergency situation in West Africa? ERICA OLLMANN SAPHIRE: Certainly the urgency is keenly felt. That is why these things are being accelerated as much as possible. They would not be available to the degree that they are now, they would not be happening now if there was not an outbreak of urgency. From what I understand, healthy human trials are ongoing. They hope to see the vaccine and Africa by December 2014. We will see if we can get there, but certainly the urgency is keenly felt. MAUREEN CAVANAUGH: Before there is access to the vaccine, the public health intervention trying to stem the increase of this disease. US troops are being deployed in west Africa at the time. What are they going to be doing? THOMAS NOVOTNY: It takes time to do anything, actually. Several of the things they are going to be accomplishing involve logistics am I getting things there, whether it is personal detective equipment, but also they're going to be setting up a hospital that will be staffed by US Public health service physicians assisting with the lab facilities as well. It is important to also get diagnostics quickly to this situation, because being able to diagnose quickly with a suspected case will allow treatment to be more effective. That is something Doctor Saphire and I were discussing earlier. Right now, diagnostics actually take a few days to confirm the case. That is not helpful when it can be spread so easily. We hope that the labs will help move this along. We think research on diagnostics is important as well, and the supply of climate is critical. MAUREEN CAVANAUGH: What do you think about the level of national response to this crisis? THOMAS NOVOTNY: It has been slow and inadequate, I think. The WHO has been hamstrung with its own budgetary deficiencies, in the ability to move quickly in these outbreaks. With Obama's leadership, there has been motivation to get other countries on board that it has been very slow. It could have probably been affected a lot more quickly with a more rapid response. I think one has to look back on these things to learn from them. The WHO has a surveillance system supported by the CDC for morning reports on things like this, and they did sound the alarm, but I do not think there was sufficient recognition of the importance of this globally. It is not just a few countries that matter, it is the economic stability in Africa, the humanitarian component of this. But it is also thought of as a security risk, because of the instabilities that will result from this. MAUREEN CAVANAUGH: Professor Sapphire, obviously world health officials cannot be surprised that there is an Ebola outbreak in Africa. This is something they have been monitoring, right? ERICA OLLMANN SAPHIRE: Sure, there is an Ebola outbreak every year, in this decade. They are usually small, rural villages, and it is a very straightforward process to separate that village and get a small team to contain a small number of cases. There is an independent outbreak unrelated to the West African outbreak going on at the Democratic Republic of Congo. That is sixty cases, a typical Ebola outbreak. This one went out of control because it was not expected, in Western Africa. More importantly, it was not in a small remote village. It was in cities that are densely popular with the highly mobile population. We look at that and see the fear of how much more can" every time cases double, it will cost twice as many dollars and twice as many workers to contain it. The longer we take to do it, the more expensive and difficult it will be. THOMAS NOVOTNY: There was a case that with the Senegal, and it created an outbreak there. But Senegal has responded, and has taken fairly good care of containing the epidemic. It has not spread as fearfully as it might have in the other cities, and Nigeria. MAUREEN CAVANAUGH: And the country with most cases is Liberia. What about the fear a lot of people in the US have that the Ebola virus may spread here, that with more health workers going to West Africa, and coming over here? Is that potential? THOMAS NOVOTNY: There is potential, the more people we send there who could become exposed may have some impact. But we have a pretty good public health system. We have protocols in Place in hospitals so if there is expected cases, we have rigid protocols to handle these. We have the ability of equipment and isolation techniques that I think they respond to any influx of cases. ERICA OLLMANN SAPHIRE: Anybody who was sent there will be monitored when they come back. There will not be surprised cases. There is a lot of criticism about whether we should have brought those Americans back to Emory. We all know nothing bad happened. I think that people did not understand is the scientific advantage of getting the virus, the enemy, and our own territory so we can study it better. Think about World War II. Every time a German plane crash landed on to produce soil, the British intelligence officers were able to dissect the plane, understand its intelligence systems and its radar and gain a tremendous advantage in the war by gaining the enemy intelligence on their territory. Because the virus was here in a modern, and American hospital with a team of doctors and scientists and nurses, and all of the equipment you would want, they were able to make a lot of insights. They also discovered that the electrolyte balance was critical. We know how to do that. That is easy and cheap. It gives us a handle on how to treat cases better than over there. MAUREEN CAVANAUGH: My last question, as part of the nightmare scenario of Ebola coming here is the idea it could go airborne. What is the likelihood of that? ERICA OLLMANN SAPHIRE: Viruses do change, they do mutate. The likelihood of it becoming as rapidly airborne is something like measles is unlikely. If you look at HIV, it mutates rapidly. It has been circulating in the human population for decades. It has not gone airborne, it has not changed its route of transmission, it is still transmitted by bodily fluids. The cause for concern could be one, we do not know what the virus will do, but also, although it is hemorrhagic fever in humans and nonhuman primates, it is a respiratory virus in pigs. It spreads from take two pig through respiratory secretions and sneezes. And it spreads to laboratory primates housed separately, a couple of feet away. It can be aerosolized. But that speaks more to here are the questions and concerns we need to have when we handle these samples in a medical setting or the laboratory. Maybe we should monitor pig farms to make sure they are not exposing the ranchers or nearby monkeys. We do not expect the virus to change dramatically, but it is mutating at an alarming level. Those mutations are likely to make it do what it normally does more effectively. Maybe it will suppress the immune system more effectively, maybe it will transmit more rapidly, maybe it will change affinity for the cell, or how tightly it binds and pries itself in. ERICA OLLMANN SAPHIRE: Finally, the healthcare situation, things can be aerosolized through suctioning and other procedures. That is the airborne spread that is not normally a risk in the hospital setting. MAUREEN CAVANAUGH: Thank you both very much.