“If there’s anything that this outbreak has taught me, it’s that I’m often wrong,” says Dr. Daniel Bausch.
He’s talking about Ebola. He’s one of the world’s leading experts on the virus — an infectious disease specialist at Tulane University and a senior consultant to the World Health Organization.
And as he makes clear, he’s still got a lot to learn.
The virus came roaring back into headlines this past week. A Scottish nurse who survived Ebola is back in isolation in London, being “treated for Ebola,” according to the Royal Free Hospital. The hospital says the patient’s “condition has deteriorated and she is now critically ill.”
And two new research papers found that the virus can live in a male survivor’s semen for up to nine months, and that one man passed it to his sexual partner months after he was released from the Ebola ward.
“If you look back at the classic teaching about Ebola and survivors, it was that once you get better from this disease, even though it may take a while to recover, you made a full recovery and that kind of was the end of it,” says Bausch.
And now, with an estimated 17,000 survivors, researchers are discovering all kinds of twists and turns. The semen study is particularly puzzling to Ilhem Messaoudi.
“It’s an explosive virus. It replicates like crazy … and it destroys everything in its path,” says Messaoudi, a viral immunologist and professor of biomedical sciences at the University of California, Riverside, who is studying how the virus works in the human body. “So, how is it just hanging out in the testes for like nine months?”
There hasn’t been much research — in animals or humans — about what happens after survival. What we do know is mostly from past outbreaks of the virus, in particular, two studies looking at past survivors of the disease and comparing their health to Ebola-free friends and family.
Research on 19 survivors of a 1995 outbreak in Kikwit in the Democratic Republic of the Congo found that most had joint pain and vision problems after the virus. One lost sight. Studies from the 1970s and 1980s had, like recent research, found the virus persisting in the semen and eyes of survivors.
Researchers following 49 survivors of a 2007 Ebola outbreak in Uganda found that — even two years after the illness — they had eye problems like inflammation and blurred vision as well as joint pain, difficulty sleeping, difficulty swallowing and even hearing loss, memory loss and confusion.
A third study examining 105 survivors of the 2014-15 outbreak in Guinea found that about 90 percent had chronic joint pain and 98 percent had poor appetites or an aversion to food. They also reported difficulty with short-term memory, headaches, sleeplessness, insomnia, dizziness, abdominal pain, constipation, sexual dysfunction, and decreased libido and exercise tolerance.
Bausch says, aside from arthritis and eye inflammation, it’s still unclear which issues are directly related to the Ebola virus and which could be caused by the physical and emotional toll on the body. But something is going on.
“It’s clear that there is a post-Ebola syndrome,” he says.
Individual cases have opened a window into where the virus goes, and what it’s capable of — even after a survivor’s body has eliminated it from the bloodstream.
One well-reported example is Dr. Ian Crozier, who survived Ebola contracted in Sierra Leone, only to have one of his normally blue eyes turn green. Though the rest of his body, including his tears, was Ebola-free, his eye was teeming with the virus. The infection almost blinded him.
In a few other cases, Ebola hid out in the uterus. Most women who were pregnant when they got the virus miscarried. But, Bausch says, “a few women have survived with pregnancies intact.” When they went into labor, the babies were stillborn and often anatomically abnormal. For months, the recovered mothers had carried babies stricken with Ebola.
How could healthy survivors who tested negative for Ebola still harbor the virus? As Messaoudi explains, it’s because the immune system, which is capable of wiping out the virus in the bloodstream, doesn’t reach every nook and cranny of the body.
“The immune system is a little heavy-handed at times,” she says. Inflammation caused by the immune system’s activity could cause serious damage in places like the eyes, brain, placenta, fetus, testes, joint spaces and central nervous system. Messaoudi likens members of the immune system to the Navy SEALs. “They are trained killers,” she says, “so if you drop them in the wrong place and they misread their orders, it could lead to really big damage.”
So, for the most part, the immune system stays away from those sites, making them great spots for viruses to hide out. (That’s what other viruses do, like hepatitis B, and herpes viruses, including chicken pox, which hides in neurons for years and has the potential to re-emerge as shingles.)
But those viruses are different from Ebola, says Messaoudi. “Acute viruses like influenza, Ebola, yellow fever, West Nile [virus] — they infect, they replicate, and they’re cleared. That’s just how we’ve always thought of them. I’ve never heard of a yellow fever reservoir or a West Nile reservoir. Maybe they exist, and we just don’t know about it.”
Messaoudi says one of the most confusing things about the Ebola virus is its size. It’s a “no-frills virus” with a tiny genome, she says. Viruses that can hide in immune-privileged places and live for years usually have a lot more genes that allow them to quietly survive.
But Ebola is managing to scrape by in some corners of survivors’ bodies, and those places are, by nature, hard to get to. “It presents a huge challenge, because how do we get enough antivirals into these sites?” says Messaoudi. Getting to fluid in the spine requires a spinal tap. Patients with the virus inside their eye might need a fine needle to go straight into the space between the iris and the cornea. “So how do we eradicate those reservoirs?” she asks. “And why do some people end up developing these reservoirs and other people don’t?”
Bausch says these questions are important scientifically but not necessarily in terms of disease control. For example, there’s a small possibility that the arthritis that so many survivors report is from the virus itself, sitting inside joint spaces. But that would not pose a public health risk.
“Because how do you get infected from someone’s joint space? You don’t,” he says.
But there are some potentially worrisome sites where the virus holds on, like in semen.
As data on survivors trickles in, Bausch says, “There is a sense across WHO and U.N. systems that we need to have renewed efforts in terms of not only caring for survivors but recognizing that there are still transmission issues that may relate to survivors. And that’s a tough thing for people to take on, both in terms of the logistics, but also just emotionally.”
“The whole thought over the course of this outbreak and previous Ebola outbreaks is: You get down to zero cases, and then you count 42 days, and then you say it’s over,” he says.
Cases where Ebola lingers in the semen, eyes or even uterus of survivors push the outbreak’s finish line farther away.
“We’ve always known that it wasn’t completely over,” says Bausch. There’s always the possibility that whatever first seeded this outbreak, likely a fruit bat, is still out there. “So, we’ve always known that there was the potential for reintroduction from the wild. But I think more recently and with these data coming in, we’re understanding that there’s also this potential for reintroduction from persistent virus production in humans, most notably from sexual transmission” — even though experts still thinksexual transmission is rare.
Meanwhile, he says all the evidence points to survivors clearing their systems of Ebola virus over time. But, says Bausch, it’s probably not the day that they walk out of the Ebola treatment unit.
To see just how long the virus might linger, the U.S. National Institute of Allergy and Infectious Diseases and the Ministry of Health of Liberia have launched a five-year project to follow 1,500 survivors of the latest outbreak along with 6,000 of their close contacts. They’ll monitor health issues, organ and eye function, and possibly bodily fluid content. It will be the largest controlled study of Ebola survivors to date. ……………’
Ron Klain was White House Ebola response coordinator from October 2014 to February.
When President Obama and his fellow Group of Seven leaders meet in Germany beginning today, Ebola will be on the agenda. The leaders will talk about the need to wipe out the relatively small number of remaining cases in West Africa, as well as the need for aid to rebuild the ravaged nations of the region. Both steps are critical.
But neither will address what should be our No. 1 lesson from the Ebola crisis: the need for substantial measures to keep us safe from the pandemic on the horizon, a catastrophic event that is inevitable if we don’t move quickly to prevent it. As Bill Gates recently said, “If anything kills over 10 million people in the next few decades, it’s most likely to be a highly infectious virus, rather than a war.” So why, with the Ebola epidemic serving as a fresh warning, aren’t the G-7 leaders doing more to tackle this critical health and security issue?
As scary as Ebola was, the world’s success in taming it may have given us a false sense of security. Ebola was, in many ways, a deceptively simple test of the world’s epidemic response system. Ebola is hard to transmit and easy to detect. The epidemic broke out in three relatively small countries that contained no mega-city and sent only a limited number of travelers out of the region.
The next time, the world might face a far more dangerous threat. A pandemic flu could be spread easily and quickly, carried by individuals with no obvious symptoms. It could explode like a wildfire in a massive city and be carried overnight by thousands of travelers to the world’s major commerce centers.
To the extent there is discussion of improving the international response to epidemics, the focus has been on the need to reform the World Health Organization. Such reforms are badly needed, but even a fully effective WHO will not close the most gaping holes in the world’s epidemic response system. Even if the WHO did a better job of recognizing outbreaks that pose a risk of epidemic and alerting the world that action is needed, it does not have the substantial response function needed to combat such an epidemic. Recent discussions about creating a WHO response function — assuming that the agency could be trusted to manage it — rely largely on overburdened and underfunded nongovernmental organizations to staff a response. Thus, any new WHO response capacity will lack military-style mobile hospitals ready to be deployed; battalions of medical personnel with accompanying security support to isolate and treat the infectious and the ill; or a medical airlift capacity to move patients to places where they can get help.
Here is what should be on the G-7 agenda:
First, the G-7 nations — especially the United States, Britain, Germany and France — should agree to retain the capacities their militaries developed during the Ebola epidemic for infectious disease response and patient airlift. These capacities could easily dissipate now that the most acute phase of epidemic is over. In a future pandemic, the world may not have the four to six months it took to assemble these specialized units and capabilities, such as the tools to airlift infectious patients to treatment.
Second, the G-7 should combine these national military resources into a single international entity — what German Foreign Minister Frank-Walter Steinmeier has called a “white helmet battalion” — that could respond to an outbreak before it becomes a full-scale epidemic. This body should have the capacity to deploy rapidly anywhere in the world with medical field facilities, lab equipment, security and medical teams. The European Union has pledged to take up the question of creating an E.U.-flagged unit; what is really needed, however, is a broader effort that includes the United States (and perhaps other non-E.U. countries).
Third, the G-7 nations need to convene the relevant experts and authorities to develop a coherent approach to the fast approval and deployment of new vaccines and treatments that might be required to respond to a pandemic. In West Africa we saw a plethora of clinical tests separately led by the United States, Britain, France and China with no coordination. Moreover, fights about who would be liable if anyone was injured by these unproven vaccines and treatments went unresolved. GAVI, the global vaccine alliance, runs hugely successful immunization programs for proven vaccines, but it lacks a mechanism for handling unproven vaccines (or therapeutics), or for dealing with the intellectual property and liability issues involved when new medicines are introduced without a track record. The time to resolve such issues is before an epidemic is raging.
Finally, the G-7 nations need to step up their commitment to global health security, because in the long run, the only way to keep all of us safe from outbreaks is to have every nation’s health-care system sufficiently resourced to provide at least a preliminary response to an outbreak. President Obama’s leadership in this area has been exceptional, and — in a rare act of bipartisanship — Congress appropriated more than $800 million to support this effort during the Ebola crisis. But all of the G-7 nations need to dig deep to advance this program.
The last time the G-7 met, the Ebola epidemic had not yet captured global attention; now, a year later, it has faded from public consciousness. But unless the world wants to consign itself to an endless cycle of repeating what transpired in the year between these two meetings, it needs to take steps to combat the next pandemic before it is upon us.
WASHINGTON – Anvita Gupta is just 17, but the Scottsdale high school student already has an impressive list of accomplishments: She has worked with researchers in China, at Harvard and at the Research Science Institute.
On Monday, Anvita got to add to the list, meeting President Barack Obama at the fifth annual White Housescience fair. She was one of more than 100 students – and one of three from Arizona – invited to present their projects at the White House.
“It’s amazing. I have to think about what I want to do next to have it live up to this,” Anvita said after meeting with Obama.
Her research, writing an algorithm that makes it easier and quicker for computers to help develop disease-curing drugs, caught the eye of Obama, who singled her out during his speech.
“Anvita Gupta … used artificial intelligence and biochemistry to identify potential treatments for cancer, tuberculosis, Ebola,” Obama said to audience applause.
Obama said it’s important to recognize the work of young scientists like those honored Monday.
“We’ve got to celebrate the winners of our science fairs as much as we celebrate the winners of football or basketball or other athletic competitions,” Obama said. “Because young scientists, mathematicians, engineers, they’re critical to our future.”
Two students from Carl Hayden Community High School were also there, representing the school’s robotics team that was chronicled in the recent documentary, “Underwater Dreams.” Seniors Sergio Corral and Isela Martinez brought along the underwater robot their team designed and built, and showed it to the president.
“I don’t think I’m going to wash my right hand after that handshake,” Sergio said after shaking Obama’s hand.
“I never thought I would be meeting President Obama,” Sergio said. “I thank him a lot for pushing STEM education. It’s really the future and I think he understands that.”
At Monday’s event, Obama announced $240 million in private donations to help fund STEM – science, technology, engineering, math – education. Also on hand for the event were guests like Bill Nye the Science Guy, Google Executive Chairman Eric Schmidt and NASA astronaut Leland Melvin.
But the focus of the day was the students, and the theme of this year’s science fair was diversity.
“Science is for all of us,” Obama said. “Part of the problem is we don’t tell the stories enough of the incredible scientists and inventors along the way who are women, or people of color, and as a consequence, people don’t see themselves as potential scientists.”
All three Arizona students met Obama, who visited with 12 of the 35 teams who were displaying their work at the fair. After hearing Anvita, describe her work, Obama turned to a group of trailing reporters and said, “I don’t know what you all have been doing, but this is what she’s being doing.”
Encouraging girls to get involved in STEM is something that Anvita is passionate about. The BASIS Scottsdale senior started an after-school computer science group to teach middle school girls programming.
“It’s really great that women are getting this platform, so that we can inspire more young girls to believe in themselves and go forward in these STEM fields,” she said.