Steve Mirsky: Welcome to Scientific American's "Science Talk" posted on November 5th, 2014. I'm Steve Mirsky. And now our health and medicine correspondent, Dina Fine Maron, is in New Orleans at the annual conference of the American Society of Tropical Medicine and Hygiene. One of the conference speakers is Daniel Bausch, and Dina caught up with him to talk about Ebola earlier today. Dan Bausch is in the Department of Tropical Medicine and Section of Infectious Diseases at the Tulane University Health Sciences Center. He specializes in the research and control of emerging tropic viruses. He spent part of his career with the CDC's Special Pathogens branch, and he's spent a lot of time in sub-Saharan Africa, Latin America, and Asia combating pathogens such as Ebola and Lassa viruses, Hantavirus, and SARS coronavirus. He serves as a frequent consultant for the World Health Organization, the UN, and the National Institutes of Health. Here's Dina Fine Maron and Daniel Bausch.
Dina Fine Maron: You've been talking a lot about the Ebola big picture. Can you talk in brief about why we didn't see Ebola coming in west Africa?
Daniel Bausch: Prior to this outbreak the largest outbreak that we've ever had before was 425 cases in the northern area of Uganda in 2000 and 2001. So while that was a tragedy for the people who lived in that relatively remote region of Uganda, of course on the big picture this is something that doesn't really compare with the number of cases of HIV and TB and malaria and many other diseases on a daily basis. And so we really had in our minds that Ebola was that sort of disease that appears sporadically in remote regions of Africa, causes extreme tragedy for those populations, but not really something that we need to have on our radar in the bigger picture.
Dina Fine Maron: And we've been talking a lot about this week about next steps looking forward. What do you think we need to do to be prepared for the next Ebola-like threat?
Daniel Bausch: So there's two different levels. Taking Ebola first before we get to Ebola-like, so Ebola – I don't know what we can do to really stop this outbreak. We're trying our best. Obviously things are out of control. We need to make sure that it gets contained within the three countries that are presently the epidemic countries. We need to obviously block transmission and give the best care we can to people in those countries – not easy to do. We're scaling up as rapidly as we can. It's not easy to scale up; it's taking too much time. So we'll see. You know, we have to do our best. I kind of liken it to that sort of. You know, your – a family member has a – is very sick with a terrible disease. The chances perhaps of them pulling through may not be that high, but you're still going to give them the best treatment and have the best hope and do everything you can for them. And that's kind of what we're doing right now for those countries in west Africa.
But I think we need to look past that as well. If there's any silver lining in this, we need to make sure that some of the therapeutics and vaccines that have been on an experimental level so far, that we really use this opportunity to make sure we have tools, real-world, available tools for people, hopefully for this outbreak, but if not for this outbreak for the next outbreak, and make sure that we have something of worth that comes out of this. So that's a very important thing that I think we need to push on, a difficult thing to do, but nevertheless an opportunity to go there.
On the bigger picture, I think we're learning the lesson – and this is always the challenge in public health. Public health people say, "Well, we don't have any problem; there's no emergency, so why would we spend $10 million on preparation for one thing or another?" And of course then something happens and we've cut our funding in public health. And so we say, "Well, too bad we didn't have that," and an emergency does happen. Then you spend hundreds of millions of dollars trying to catch up, and of course at the cost of many lives.
So we need to kind of remember that. It's a lesson we've learned many times before; it's just kind of human nature. But nevertheless we need to make sure that funding for global health research for preparedness, that that funding is maintained. And I think a lot of that _______ of this outbreak and what we're seeing, there's been a lot of talk about who did what right and wrong in the last nine months. You know, did WHO respond? Did this group do one thing or another? And certainly mistakes were made; certainly we all could've done better. But I think really if we want to look historically in this, it's not so much what happened in the last nine months; it's what's happened in the last five years. And if we look at funding for WHO, funding for global health research, funding for many of the organizations that plan and respond and would be our preparedness arm, then we've taken a hit in those last five years and we're seeing the results.
Dina Fine Maron: And this week also there was separately an Institute of Medicine Ebola conference in DC that you were at, as well as here in Louisiana. One of the speakers on that panel from EPA, the Environmental Protection Agency, talked about how indeed it looks like patients – Ebola patients generate about, he said, 30 or 40 times the amount of medical waste that normal patients generate. Can you talk a little bit about how it's possible to handle that level of waste, both in west Africa and here in the United States?
Daniel Bausch: So much of that, of course, is the PPE or personal protective equipment that people need to wear in order to treat these patients. And so – and you can't stay in that very long. Almost all of it is disposable. So each time someone – a healthcare worker's going in to visit and treat the patient with Ebola, that person can stay in for maybe an hour and a half, two hours perhaps and then has to go through the doffing and decontamination procedure. And then all that gets thrown out, so there's a huge amount of waste, in addition to the, relative to that, the relatively small waste that comes from the patient himself or herself that consists of – these people are having eight to ten liters a day of diarrheal stools during the acute phases of the illness, and then all the other things that we know of in terms of needles and gloves and routine things. So you are generating a lot of waste.
And the situation is almost more complex for that in the United States than it is in Africa in many ways. In Africa that would get taken to a burn pit and put in that burn pit and then incinerated. We don't have a huge problem with environmental contamination in that way in terms of the virus. It's not particular stable in the environment, so in those burn pits we don't really have a big concern about it, you know, not completely getting burned or leaking into the groundwater and that sort of thing. That's not how people get infected with this virus. In the United States, of course, we are somewhat beholden to higher tech solutions, which in some ways are a little bit more problematic in terms of treating all that waste, and we need autoclaves or incinerators that can handle that sort of thing. It's not the actual inactivation that's particularly difficult; it's just the process of getting the waste from of course the frontline of care and interaction with the patients safely to the place where it can be incinerated or autoclaved.
Dina Fine Maron: And considering we still don't know how long Ebola can live on various surfaces, another topic of the Institute of Medicine conversation was about how we would do those study designs to answer those kinds of questions. It sounds like since we don't even have that baseline data, we don't know how to even begin those studies. What would you say is the next step there?
Daniel Bausch: We have some data, but it's not as much as we would like. And when people ask me that question and how long does Ebola last in the environment, I usually answer that it lasts hours to days, and it depends on the environmental conditions. And so if there's high heat, if it's really hot out, if there's a lot of light, then the virus will be inactivated relatively rapidly, and if it's relatively cool – and, you know, the studies that show it lasting weeks in the environment, most of those were essentially, you know, temperatures of refrigerators. That's not what the ambient temperature is in most places, especially most places where an Ebola outbreak is happening. But nevertheless we do need more studies to look at that.
One of the problems that we've seen is that our research agenda in the last ten years for diseases like Ebola and other things that we call select agents, some of these highly pathogenic diseases and viruses, has really focused very specifically on products. We've said, "Okay, we want vaccines, we want diagnostics, we want therapeutics," and these tools that of course are important and we do want those, but there's been much less emphasis on really just understanding the natural history of the disease, if you will. When is the virus shed and in what particular fluids in a patient who's infected with Ebola virus? How long does it last in the environment? You know, those studies have really not been our focus of funding, and so we're paying a little bit, you know, the price now of not having some of the just very basic, what seemed to be simple data that we'd like to have.
Dina Fine Maron: And there's been so much talk from the World Health Organization and CDC in the last two weeks about issuing new guidelines for PPE, personal protective equipment. What I guess changes really need to be made there to indeed make a more robust protection system?
Daniel Bausch: So there was a guidelines committee that was put together at WHO that met some weeks back; I actually chaired that committee. And so this got about 12 or so different experts from different organizations – MSF, CDC, NIOSH, WHO of course, various other places – together to discuss the PPE issue and figure out what's the right thing to wear. There's a lot of opinion; unfortunately there's very little data. And so we run into this situation where people say, "Well, I like to wear this and I think it's safest to use that," and someone else says, "Well, I think it's safest to use that and you need one thing or another." So we came through and I think issued the best guidelines that just came out a few days ago. They are – I think they're a useful tool for people, but we definitely need evidence base to inform that and to go further. And I don't anticipate that that will be the end of it, that now we have the PPE that you need. We say, "Okay, these are the best guidelines that we have, but we're going to need to work with this and try to again collect some evidence so this is more based on scientific data rather than on particular consensus opinion, albeit from experts."
Dina Fine Maron: And what can we learn so far from the successes in Nigeria and Senegal about apparently being Ebola-free now and the hints of success that are happening in Liberia?
Daniel Bausch: So I think Nigeria and Senegal, part of this – one shouldn't be naïve to think that it's related to the resources that a country has. And so this is happening, the large outbreak, in Guinea, Sierra Leone, Liberia – this is happening in some of the poorest countries in the world, countries that have been through years of civil unrest and civil war that's decimated the public health infrastructure, decimated the medical system. It's not by chance that this is happening there. This is happening because those countries were not prepared when a virus that's this dangerous and communicable in some phases of disease at least gets into a system that's completely unprepared for it.
And what I mean by that is just very simple things. First of all, you go to the hospital and you're sick, and things that we would of course take for granted – that in the hospital there's running water and soap and gloves and clean needs and things like that – are just not routinely available in Sierra Leone. And we've been struggling and trying to work with this for many years in Sierra Leone and Guinea and projects that I've been working with. So it starts there, and then we need to come in obviously with international response to try and help those countries out, but we've outstripped our resources just because of the scale of this. And now we're all behind and trying to catch up.
When on a few occasions cases have struck out to other neighboring countries, fortunately, certainly in the case of Senegal, also in Nigeria, they've gotten out to countries that have considerably more resources than Sierra Leone, Liberia, and Guinea. And so Nigeria is overall not a resource-poor country, nor is Senegal. These are places where there are resources. There's more public health infrastructure. And of course because of the importance of what was going on in their neighbors, in the epidemic countries, they were ready for it and they kind of got on the case pretty rapidly. So fortunately we dodged a bullet in those two countries and we don't think there's any more transmission of Ebola in Nigeria and Senegal.
As you know there has recently been a reported case into Mali. We're hoping that we'll have the same result there, that we won't have any awkward transmission – too soon to know really in Mali yet. And then again we really need to be vigilant in all those surrounding countries. That's really where we're most vulnerable. There's been a big focus on imported cases in the United States and a lot of fear about that, and I don't want to minimize – obviously that's important to those people and to our country, but still this is a west African problem principally and we need to act in west Africa to stop it.
Dina Fine Maron: We've heard just a tiny bit about the number of clinicians and health workers from other areas in Africa that have arrived to try to help in west Africa, from Kenya and elsewhere. How important are they in this response, and what sort of numbers are we talking about there?
Daniel Bausch: I don't know numbers overall. I mean, I think – so for example, I believe Cuba has put somewhere in the neighborhood of 400 healthcare workers available, I think a lesser number from most of the other countries, the United States of course trying to put the numbers up with training and get people into the field. So those numbers are increasing. A huge challenge really is the coordination of all those groups. And so, you know, most of them will deploy personnel to the field that have varied degrees of training, may or may not speak the language that is the language of the country or the language of the international group. English of course is what many of the people speak, or French, but if you don't speak one of those two languages there may be communication issues. And then, as I say, some of these people, probably a very small amount have worked with this sort of disease before; most have not. Many have not been in that sort of situation before or sometimes maybe not even in west Africa before. So the challenge of – even though we welcome the groups that are participating and we need the labor so that's definitely encouraged, but the challenge of coordinating all that and getting it into one coordinated response is a very large one.
Dina Fine Maron: Officially who is charged with that type of coordination? Is that a WHO role? Is MSF effectively taking on that role, or it's sort of a free-for-all in some ways?
Daniel Bausch: I don't think there's one group, maybe somewhere in between free-for-all and singularly focused, coordinated efforts. So there are various different groups that are doing this, so from the United States the Department of Defense and the Public Health Service are the implementers, if you will, of the Obama Plan. Certainly MSF is always a key player in this, WHO with guidance and training and different things that they provide, CDC to some degree as well. So it's varied groups, but that coordination even between those groups is still challenging, partly just because, as I mentioned earlier, the scale of this. You know, you can say you want to coordinate, but when you have – the communications are difficult in some of these areas, the roads are difficult, the flights now going into the country are not necessarily available in terms of the timing that you need. So there are just many, many logistical issues to try and get this set up.
You know, one of the things, for example, that – with the US government response in Liberia that they discovered right from the beginning was that the airstrip at the airport in Monrovia was not adequate actually for the planes that they needed to fly in supplies. And so even before you get to anything related to Ebola you need to repave the airstrip in order to get that in. And that sort of thing is not unusual and we can't underestimate the logistical impediments to implementing the program.
Dina Fine Maron: And the final question I wanted to ask you about is regarding the age distribution of Ebola patients and survival, something that Doctors Without Borders touched on a little bit when they were presenting last night. Can you speak to what we're seeing there?
Daniel Bausch: Yeah. So at the presentation last night here at the American Society of Tropical Medicine meetings Armand Sprecher touched on some of the data that they had that some of the younger kids, so children under five, the death rates were high for that group. Some of the – a publication actually that'll be coming out in the New England Journal today that myself with many other collaborators worked on, we showed that in Guinea it was actually an older group of people, over 40 or 45 I think it was who were the ones most at risk of death.
I think when we look at that there's a couple different things. First of all, we need to take it all with a grain of salt because there's a fair amount of case finding artifact, and what I mean by that is most of these data come from people who have come to isolation and treatment centers. And so that may not be just – it's certainly not everyone, and it might not be a randomly selected group. And so if we have – for example, you think about the data that Armand from MSF showed about the young kids having a higher death rate. There's still a considerable resistance about presenting and being recognized of having Ebola and coming to a treatment center in west Africa. So if you're thinking, you know, as a parent might that you don't want your kid to go there, right? So you keep your kid at home and hope that your kid gets better and give them some medications for malaria or Tylenol or whatever it may be. And if your kid does better, then they stay at home. If they're not particularly sick, you know, they don't really get that bad, and we know that there are – some people, of course, have very severe Ebola and get sick and die, and other people milder, at least, and survive. So if you're a parent maybe you're at home and as your kid gets sicker and sicker, there's a certain point, like we would all do, that they say, "Okay, now my child is so sick," and then you perceive that your child is at risk of dying, so they have no choice but now to go and present to the treatment center and come to recognition and have their kid admitted and diagnosed as Ebola. And if that happens, of course, that only the sickest kids where their parents are most worried about them bring their kid to the hospital, then that's a group that's gonna seem to be at particular risk. So that may be going on.
That said, if we look at the data from MSF and the data in the publication coming out today on young children and older people dying – and recognize that in this area of west Africa 45 is an older person, right? We still tend to think of that as relatively young. Nevertheless, if you think that the life expectancy in some areas of Guinea, Sierra Leone, Liberia, you know, is probably around 50, so someone who's 45 can be considered older. And we look at disease that cause a lot of fluid loss through diarrhea – so, for example, take cholera and who dies with cholera. It's really the very young and the very old, and those are people who just can't really tolerate the volume loss. And when you have eight or ten liters of diarrheal stool every day you're losing lots and lots and lots of fluids.
And of course if you're not in a position where we can replete, give those fluids back either through drinking water or oral rehydration solution ideally or through intravenous fluids, which many people are not due to our limited capacity to provide care in west Africa, the people who can't tolerate that are people who are older or younger or very young. A young child just can't lose that much fluid and still have enough to profuse – enough liquid in their veins, if you will, in their arteries to profuse all their organs, and so they develop multi organ system failure and die. And then same for older people, of course, the same situation where they're not as robust, if you will, as people who are in their 20s and 30s and can handle that and losing the fluids and not have complications of coronary artery disease and other things that go with that for an older person. So I think that may be what we're seeing in those groups, that these are the people just, again, like cholera, if you will, that just can't handle that degree of volume loss.
Dina Fine Maron: One addendum to that: the Doctors Without Borders data I think suggests it doesn't matter what day you show up for treatment in terms of the course of your Ebola disease and when you are presenting for care at a clinic. What can you say about that? Is that more about the level of care that we can offer or rehydration?
Daniel Bausch: I think – well, first of all even MSF would agree that those are preliminary data that we still need to dig deeper and kind of sort out and that there are many different things going on there. I think one of the things that may be going on that you alluded to is of course it only matters – you know, getting treatment earlier only matters if there's treatment, right? So if you come on day two, then some would say, "This is great, you're here on day two, you're here early, and now we can give the intravenous fluids if you need them and manage your electrolytes and make sure your potassium levels are adequate and those sorts of things." Then of course showing up early will be better. But if there's none of that available, if you have a situation where people can't give you those fluids, can't replete your potassium and different things that you need, then of course there's no association with coming early because it doesn't impact at all the course of disease. And so certainly in many of the facilities they can give those things, but right now in many we unfortunately cannot. And that's just – it's not the medicine that we want to be giving. It's not that we think it's okay to give people lesser treatment or anything like that. It's just the sheer capacity of this and trying to develop – you know, get enough beds to bring people in.
We do think now that, first of all, the bed capacity is – too slowly, at least in the beginning, but has been increasing with MSF and the US government and other groups from the UK and other countries that have been building wards and providing beds and labor. Somewhat ironically, as I think you mentioned earlier, that there seems to be a slight cresting right now of the number of cases in Liberia. Whether that really means that the cases are going down or whether that's just a small blip we'll have to see. It is true that in Liberia right now there's – all of a sudden over the last week or so, maybe ten days, that there are a lot of available beds, a problem that we didn't have before. And I hope that means that there's less cases; what it can also mean with less patients of course is now the existing capacity that we have can be the individual care for each person. You know, obviously it's intuitive. If you had 100 patients last week and now you're down to 40 patients, then the individual care you can provide those 40 with the same staff is better. So we might surmise that they could be getting more individual care and better care in the coming weeks.
Steve Mirsky: That's it for this episode. Get your science news at our Web site, www.ScientificAmerican.com. We have all of our Ebola coverage organized on a single Web page. Just Google "Scientific American and Ebola," and any of the first batch of articles that come up will take you to the main page, which is called, "Ebola: What You Need to Know." And follow us on Twitter, where you'll get a tweet whenever a new item hits the Web site. Our Twitter name is @sciam. For Scientific American "Science Talk" I'm Steve Mirsky. Thanks for clicking on us.
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