Nobody's Coming to Save Us | Ebola Veterans on What's Coming and Who Failed

My prediction is going to be that we're going to be number one in terms of the scale and scope of this outbreak relative to other outbreaks in history. Because nothing surprised me, because this is exactly what I would expect to happen with an Ebola virus transmitting in a population under these circumstances where we're not able to provide supportive care. There's no funding for infrastructure. There's no community outreach because all of it's been defunded and the whole area is screwed up with conflict and all kinds of problems. Most importantly, the US has withdrawn from all of its obligations to global health and just completely left the entire region hanging, as well as the entire global community. This is exactly what I'd expect with an Ebola virus spreading under those circumstances.

The Ministry of Health in Uganda tweeted that they had no idea about the American treatment centers that were supposedly setting up in the region.

50 of them, no less.

It's kind of hard. Okay, to be fair, maybe only 1 or 2 in Kampala and the rest are in DRC, but still. Well, wouldn't you know?

Yeah. It's also just, what do they mean by those treatment centers? Because what they describe is not treatment.

Jess, you tracked Ebola data in the DRC from 2008 to 2019. The confirmed count of cases of Ebola right now is 51. The Imperial College modeling shows we may have 400 to 800 cases so far, maybe even over 1,000. How do you read the data gap here compared to what you saw in earlier outbreaks?

Yeah, so I think we are beholden to what diagnostic tools are available.

And in previous outbreaks, and most of the outbreaks that have happened historically have been among the—

within the Zaire strain of Ebola, we have better diagnostics, more readily available diagnostics for that one. This was a rare version of it. And right now it's happening in an under-resourced, underprepared area. So we're not dealing with the same kind of data collection or data reporting infrastructure.

So Christian, you said this looks like the North Kivu outbreak, but with much later detection. So say 2 to 3 months of undetected spread already. How confident are you in that estimate and what will genomics eventually tell us about when this outbreak actually started?

Yeah, so I think if we look at just the geographical area of this, it does look quite a bit like the North Kivu outbreak, but importantly, after a year of that ongoing Right, there is a cluster in the northern parts of the DRC right now, but cities like Goma, for example, and all places like that that are reporting cases, that was something that would happen within a year of the North Kivu outbreak, and we are there already. Right, so in terms of size, it does look quite a bit like that, but importantly, after a year of that outbreak having ongoing. Yeah, so the problem is during West African Ebola epidemic, where we did set up the diagnostics in Sierra Leone, for example, that then allowed them to do local diagnostics, there.

I'm a little— no, they're pretty Zaire-specific.

Yeah, so the problem is like during the West African Ebola epidemic, right, where we did set up the diagnostics in Sierra Leone, for example, that then allowed them to do local diagnostics there, is that back then it was conventional PCR machines, right? We did have the Zaire-specific assay back then, but then we had the pan-Ebola virus assay too. And the problem is that pan-Ebola, it just does not work very well because really the viruses, the wild species within the Ebola viruses, are really very diverse. So really locking into two parts of the genomes that are close together so you can do a good PCR, highly conserved, so you're going to have primers that, that cover the whole thing, and you have a lot of material, so it's highly expressed. This is near impossible to do with Ebola virus. So that's why you have the specific assays. But since the— over the last 10 years, we have moved towards machines that are all cartridge-based, like GeneExpert machine, for example. And that assay is just for Zaire Ebola virus, and it will not detect Bunyibugyo at all. It also won't detect Sudan. Those are separate assays. And the problem is that when you're locked into a platform in which it's all cartridge-based, it's all there, is that you can't just simply go and say, oh, let's just do a quick PCR test over here with new primers, because it takes a lot more updating on the manufacturers.

From a humanitarian perspective, or just stocking perspective, and resource-limited settings, if that— if the most likely species you're going to find are zaire and sudan in that region, nobody's going to stock Pundibugyo. Yeah, makes a lot of sense.

Yeah, but I've not even— I don't actually know that GeneXpert has a Pundibugyo-specific assay. I don't think so. I don't even think it exists. We're treating this as if it's a completely new situation, right? It's not. We have had Pundibugyo outbreaks before. We had Ebola outbreaks before. We have had multiple in this particular region at this particular time of year. Multiple times too, right? So we got to start from, look, we already know what works and what doesn't work. And when it comes to Ebola, the most important things are things like contact tracing and taking care of patients as they end up in ETUs, right? Those things work. They really work and they work well. Now we do have medical countermeasures for Zaire, for example, because that's the most common one. And we have approved ones. We both have approved monoclonals. We have approved vaccines that we can use in a Zaire outbreak. But Zaire and Bundibugyo in the glycoprotein, which is the target of the vaccine, right, they're 35% different at the amino acid level. That's very different, right? These are completely different viruses from that perspective. So the unfortunate fact is that something like a Zaire-specific vaccine is unlikely to make much of a difference. It's possible it could make a little bit of a difference, but probably not. The same is true for the monoclonals, right, that are approved for say a year. They just won't do the job.

Monoclonal supportive care is the same. I know. It's not this like you just throw the supportive care pill and then it takes care of the problem. That's not what it is. It is like a complicated equation between how does the healthcare worker do patient rate, a complicated equation about resources you have within the ETU itself. And also how late people are presenting to care. So in general, the earlier patients present to care, the better outcome they have with or without targeted therapies. When you look at Palm trial, Dr. Céline Gounder, this is a trial in 2017-2018 outbreak that looked at countermeasures that are targeted towards that year. Without a fail, looking at all the medical countermeasures, early presentation decreased mortality. And, and that's the same thing with supported care. If you come in early to care, you'll get better. So I'm not going to— I think Ebola responders have gone to fisticuffs fighting over IV fluids versus orals. And I kind of think that whatever you can do, man, like whatever you can do to get the fluids in, that's what you should do. Whatever you can do safely is what you should do. But generally what supportive care has traditionally looked like, it's so interesting. I, after my second or third deployment, I actually sat down and read the WHO bulletin from the 1970s from the care of that initial outbreak. And you might have done the same, Dr. Céline Gounder, when you came back. Or theirs. What do I choose? I always, I don't know if I'm gonna be able to share my screen, but I use this photo if I can as an illustrative thing for my students. This is a photo that I took, which was gloves that were cleaned by bleach and hung up on one of the ETUs, the community care, community worker ETUs that were being run in a really rural area in Sierra Leone. And the second time I was deployed, I was doing infection control spot checks in addition to running the ETU in Port Loko. And I turned to the community health worker who was just like amazing, taking care of all these folks in his village, right? And I said, amazing, you shouldn't really be reusing those. The more times you wash those in bleach, the chances are it's going to break down and you might get infected. And he turned to me and he smiled and he said, Doc, what do you want me to do? My choices are those gloves or no gloves. And I want to just point that reality out of how dire things can get.

The White House has said that they actually wanted Dr. Stafford transported to Germany because it was a shorter flight and that would expedite his care. Regardless of who's right in this particular situation, how much does a delay in care in Ebola for an Ebola patient, once you know they have Ebola, once they're symptomatic, how much does that delay matter? Are we talking about minutes, hours, days? Does that matter?

I think first off, it's ridiculous that we delayed him getting care. And I believe he was supposed to leave Monday and he didn't leave until Tuesday. So that's a full day that he did not get appropriate high-quality supportive care. Right. And we know that high-quality supportive care makes a huge difference in patients being able to survive. That's why people who have been hospitalized in Western countries have done very well. Right. So the longer you're waiting for a patient to get care, you're increasing the risk of them having all the complications, right? Electrolyte imbalances, having arrhythmias, having hypoglycemia because the virus level is going higher and higher. And so it's crazy that this poor man not only was not brought back to the United States, but also had a delay of getting higher level of care for at least a day. And real quick, I think the other concern that I've been having or talking about with other people is If this is what the US is going to do, how do you convince any American citizen to feel comfortable potentially deploying?

Right. Never.

If like, how can— and they're going to need people, right? It's going to— they're going to need people and they're going to need people who have expertise. But how, even if they send some CDC people over there, some of the CDC people could get exposed.

What—

just don't understand that at all.

Military. If we're saying this to American citizens, we could say that US military is also one of them. What are we going to do about them? I'm not worried about the citizens. What I'm worried about is the organizations. What happened during West Africa was that because a lot of these people have other jobs and their organizations are going to be like, nope, we're not taking that liability, nor will the NGOs or others deploying. If they don't think they can provide a self-insurance back, they're not going to take people and deploy them in that area either. So it's not just the individuals, it's actually freezes the entire response.

Well, and I think the other part of it that makes zero sense, right?

And maybe we'll get into this in a minute, but it always seems like it's just illogical. But when you hear it, you're like, yeah, this is absolutely logical. But it's always, I mean, just like politics is local, trust is local, and all of this is very, very local. And you need to know and really need to know all of these details. I mean, whether it's cremation was one issue in Liberia, that was a huge issue. Sierra Leone had been both a Muslim and a Christian country and different leaders, and you had to make sure you worked with everybody to make sure everything worked. But again and again, it just has to be locally led to make sure we have everything fit and work. Yeah.

Some of what I remember from West Africa, a couple things with the safe burial teams. One of the areas of pushback was actually the color of the body bags. And when they switched from black to white, that made people much more receptive.

Yeah.

You know, and it just has to do right with culture and religious beliefs and so on. They were also really frustrated that the safe burial teams were slow. And so the bodies would be like laying out there sometimes for more than, you know, a day or two. And the family found that really disrespectful, you know. And so there, there are often very logical reasons for what their concerns are.

If you're, if you truly believe that your mother will never reach eternal life, will always be in purgatory, will never have any rest, any peace. You will bury her knowing that you will be infected. Yes, 100%. And so it's always a long game and it always seems like it's just illogical, but when you hear it, you're like, yeah, this is absolutely logical. But if someone suddenly built a hospital from a foreign country, let's just say Martians, suddenly built a hospital on my street and started taking people in and doing things that I thought was weird, I mean, would I be—

Of course you would.

Oh, if they suddenly took a family member and buried them on Hart Island, that is a place in New York City where people are buried in nameless graves. That's considered a very sad story. I mean, yes, again and again, I'd be like, this is crazy. Of course I wouldn't like this.

I mean, the things that people have a hard time with, they shouldn't, because like we have religious customs and cultural practices here as well. And I don't see why it's any different whatsoever.

I mean, I remember someone once saying to me, uh, just know that no one will ever thank you. Um, and that sounds kind of heavy, but I think it's really important to know that you're doing things for the right reason.