It's Christmas time...

Below is my attempt to try an make the BandAid30 lyrics a little more relevant and specific to the West African Ebola virus disease epidemic. 

I'm not musician, or poet - as you may tell - but I like these lyrics more...and they scan for me!

I've tried to build this while listening to my bought version of the latest BandAid song from iTunes or you can watch the video for the tune - just yell these lyrics over the top!!

It's Christmas time

Sometimes it hard not to be afraid

At Christmas time

We let in light and we banish shade

And in our world of plenty

We can spread a smile of joy

Throw your arms around the world 

At Christmas time

But say a prayer

Pray for less lucky ones

At Christmas time it’s hard

But while you're having fun

Remember a world outside your window

That it's a world less safe than here

Where a farewell kiss can kill you

And that death is much more near

And muddy roads all over

Cause delays that can spell doom

Well tonight we look around

To help you

Bring health and joy this Christmas

To West Africa

A song of hope when hope seems rare tonight (ooh)

Touch now to be spared

Cause that’s how virus is spread

How can you show you want to help at all?

Here's to you

Donate funds for everyone

Here's to them

And all their years to come

Show them that it's Christmas time for all

Come on world

Let’s show them we want to help

Rise up world

Let’s help build a safer place to

Heal the world

Let all know we care for you 

Heal the world

Let them know it’s Christmas time

Come on world

Let’s show them we want to help build

Rise up world

Let’s help build a stronger place to

Heal the world

Let all know we care for you 

Heal the world

Christmas 2014: give the gift of help...

I wrote a little guide back in August listing some places where one could donate if seeking to help out in the battle to contain Ebola virus and try and prevent more loss of life due to Ebola virus disease (EVD). 

With Christmas day nearly upon us, and many who read this blog likely to be doing something to celebrate it involving the giving of gifts to friends and loved ones, please think about donating to help the fight. 

You can easily add a donation, in the name of your friend or loved one, to help a range of organisations help save lives. I've re-posted my earlier list below in case you need some ideas. These donations can be made online-you can even get in a little Christmas craft and make a "voucher" tells the recipient what they did to help!

And the donation does not need to be limited to EVD of course! These organisations supply aid in many ways to those in all sorts of need. They also have a good record of getting that help to where it really needs to go. In some cases you can see that these guys spend most of your donation on tangible items and real aid - not on administration - a good thing to look out for. 

• Médecins Sans Frontières (MSF)They are meticulous, fastidious and well trained so they don't needlessly risk themselves. They are on the front lines everywhere. They have been all over this outbreak from early one. They warned us.
  http://www.msf.org/
• Direct ReliefThey can (and have) mobilize the personal protective equipment (PPE) and other material. They have contacts with others in industry. They are a nexus for getting this done.
  http://www.directrelief.org/
• International Federation of Red Cross and Red Crescent Societies.They are one the ground helping keep locals informed about Ebola virus
  http://www.ifrc.org/
• United Nations International Children's Emergency Fund (UNICEF)
  Always finding way to help children. There is a large orphaned population in West Africa due to EVD this year.
  http://www.supportunicef.org
• Ebola Response Fund, United Nations Foundation 
  The UN created this fund as way to allow individuals, corporations and civil society organizations to directly support UN entities in their efforts to respond to the Ebola virus disease outbreak.
  https://secure.globalproblems-globalsolutions.org/site/Donation2;jsessionid=5A0017918CF67B11BD1FA907C0DE8C70.app246a?9260.donation=form1&df_id=9260
• Africare
  Among other things, they are helping to outfit health care workers with PPE in West Africa
  http://www.africare.org/
• globalgiving
  Among other things, they help to educate and provide medical supplies to the countries under Ebola virus assault
  http://www.globalgiving.org/
• actionaid
  Spreading awareness about Ebola through village visits, music, explanation, drama...and some pretty cool dancing!
  http://www.actionaid.org/videos/ebola-door-door
• USAID
  Has a link to a range of agencies seeking funds to help stop the EVD epidemic
  http://www.usaid.gov/ebola
• Australia Red Cross: Ebola Outbreak 2014 Appeal
  Providing education, care and aid with burial
  http://www.redcross.org.au/ebola-outbreak-2014-appeal.aspx

Ebola double vision is clearing...

A quick follow up from my post in October entitled "Ebola double vision".

I've adjusted that graph and it adds another view of how the Ebola virus disease (EVD) epidemic is, in terms of overall case numbers, showing consistent signs of slowing. 

The time it takes for the case total to double (the doubling time) has stretched out from doubling every month or so, to taking about a month and a half to double.

But far from breathing a sigh of relief, the numbers in Guinea, which have never appeared consistently under control, and the still very high numbers in Sierra Leone, highlight that the epidemic is not yet leashed and the need remains for continued vigilance and more of the same hard and risky work being done by those in and around the region. In Liberia, the country that supplied the highest proportion of EVD cases leading up right up until this month, case numbers were down to just 75 in the previous week (reporting week #38). For context, that's still higher than the total of about 15 past outbreaks since 1976. And of course, this entire epidemic started from just 1 case. 100% of infected people need to be isolated and looked after (hydrated given pain relief and antibiotics among other things), 100% of burials need to be safe, and 100% of contacts need to be traced. That represents a huge task ahead of the stalwart healthcare, aid and many other support workers who have been facing Ebola virus every day for months and months.

The time between total case doublings.
For 4 doublings in a row it took a month or so, but the most
recent doubling took 44-days. 
Click on image to enlarge.

Ebola virus disease (EVD) and the human desire to see the worst...

Criticism is easier from up here!

There are those who just seem to enjoy hoping for the worst.

Yes, I'm othering "those people" - I'm invoking a "them" category because their outlook is just too alien for me to understand. I can respect and often understand other points of view, different beliefs and skin colours, clothing styles - all manner of things. But I just cannot understand those who seem to be filled with a macabre desire to see pain and suffering triumph over efforts to defeat it. 

Some of us are lucky enough to live in a free country and write our every little thought and feeling down to share with the world. I'm doing that now. Some use that privilege to say 'I told you so'. There is no room in the lives of some people for mistake, misstep or shades of grey. It's ones and zeroes, yes or no, all or nothing. The binary belief of those so self-assured in their personal opinions that they don't need to look around or experience for themselves any of those roles they criticize; they just know. They can just tell.

Are these personal-views-made-public all that destructive? Maddening though they may be, they probably don;t do a lot of damage, no. Nonetheless I thought it worth writing my own opinion about a related example in a recent opinion piece posted by the New York Post, addressing some aspects of that Ebola virus epidemic you may have heard about during 2014. It's the one causing>18,000 cases (and growing), >6,800 deaths, collapses of already minuscule health infrastructure, deaths of many key healthcare workers, potentially disastrous impacts on birthing, schooling and vaccination programs and bans on festive season gatherings.

The NYP article was entitled "The great Ebola lie — Outbreak hyped for funding & media attention". 

No hype there though. 

The author, Michael Fumento, seemed disappointed and a little angry about a few things. These included:

• that EVD deaths had not reached HIV's 35 million
  That's a really good thing in case you were wondering. This use of an HIV statistic is a bit off though; AIDS is not an acute disease but an acute public health emergency was what the WHO quote referenced. Sure-I'm just playing with words. Also worth remembering that EVD acutely kills >70% of those we know have been infected during the 2014 epidemic. A bit different from the course some pathogens chart. The particular choice of a citation for that WHO quote was also interesting. Firstly, the quote had been used some weeks earlier but secondly the next sentence from the original quote was not present in The Week's article source yet it adds even more context by stating that "Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over such a broad geographical area, for so long". Together, that does paint a kind of unique picture.

• that EVD did not attain a rate of 10,000 cases per week, starting in the first week of December.
  Also, really good.
  The models have been discussed around social media and in the scientific literature for a while. For example, articles most recently in Nature and in the PNAS discuss how predictive models provide much needed guidance for planning the scale of a satisfactory intervention and predicting as well as gauging the impact of those interventions...among other things. Oh, and that 10,000 cases number was not pulled out of thin air at a press conference, it and more dire predictions can be found in other models including those discussed in Science, the Lancet Infectious Diseases, here and here, the New England Journal of Medicine, PLoS Currents|Outbreaks here and here and the CDC's Morbidity and Mortality Weekly. And elsewhere, if one asks around.

• that 2014's EVD epidemic had already peaked by mid-October when the WHO held a media conference.
  But if you look at more recent data from WHO - their weekly numbers are plotted below - it's pretty clear nothing but Nigeria had peaked. Later data shows that cases were still adding up in Liberia and in fact still are raging in Sierra Leone. Cases in Guinea seem to wax and wane and export travelling cases to other countries fairly consistently. The US was happening and Mali yet to happen. 

Weekly Ebola virus disease (EVD) suspect+probable+confirmed cases by
WHO reporting week, and country.
Click on image to enlarge.

Most of the author's apparent anger seems directed at WHO but also other "big public health" including the Centers for Disease Control and Prevention. The main guts of the article reduce down to...

You’ve been lied to, folks. For months.

But "lie" is specific and well-defined word. Oxford defines a lie as... 

An intentionally false statement

So in the author's opinion, the WHO & the CDC and perhaps others, each conspired by making conscious decisions to lie to the world and promote hysteria in order to...ummm....be rewarded with "billions of dollars"? BigPublicHealths' endgame was really just to make a buck from all that extra funding (much/most of which still hasn't materialized) by hyping up history's biggest ever EVD epidemic.

Or is it more realistic to see it for what it actually was; a (delayed) effort to try and light a fire under a sluggish international community? 

Perhaps all those dollars were part of a costed (perhaps using models?) proposal for a suitable response to fully shut down the epidemic and remove Ebola virus humans in West Africa before everyone gives up? Could it really be that simple? Yup. It sure could. Because a response to an outbreak, even when not in a rich Western nation, is an expensive and big deal. In rich Western nations, it's a lot more expensive and, judging by the response to a couple of cases in the United States, a much bigger deal. So I'm really stumped about the focus for the angst; perhaps there is a deeper reason in the NYP article that I simply missed by being simple. Naah, that's not it.

It's already been said, but just to repeat the point; disease modelling uses the numbers we have to predict what the numbers will be. The numbers we have are already old and cannot tell us how bad things could get. Bodies in the street give us an innate sense of bad, but models put brackets around that in order for cheque signers to get a quantifiable understanding of just how bad things will be tomorrow, next week or next year. Models predict what could be if nothing happens to change the trends extrapolated from the numbers we have in hand. Modelers have no qualms about saying they produce predictions. Models can also do some other stuff like predict how things could improve if we provide help, teach, support, learn and change our habits. In Ebolaville, the models were one part of the support underpinning a new message of urgency  that, it was hoped, would stir a slumbering international awareness - jolt it to life - and elicit the kind of response that, at least partly, eventuated. 

Were we lied to by bigPublicHealth so they could get a huge payday? No, of course we weren't. But we were shown what could come to pass if no funding appeared. Keep in mind that "funding" also includes resources-in-kind such as:

• labs
• vehicles
• planes
• food
• antibiotics
• oral (nasogastric and intravenous) rehydration solution
• pain relief
• personal protective equipment
• awareness & advertising campaigns
• phones and better comms for reporting results
• bleach
• water
• treatment units
• healthcare workers 

And despite the assurances of the author of the NYP article, there are a few past epidemics that have been contained, not by simply disappearing, but because of the heroic efforts of many in public health and patient care roles all over the world....and often with lots of money. Some epidemics have been nipped in the bud before they could bloom beyond an outbreak, thanks to dedicated people...and money. 

Wouldn't it be great if our public health could be protected for free? Sorry. Never gonna happen. The truth about Ebola in 2014 is that we may well have avoided the loss of many of the thousands of souls gone too soon, if we had just got the messages, awareness and money flowing sooner. But we'll never know that for sure.

Anyway, this is my opinion piece.  

WHO Media Release: Sierra Leone reacts swiftly in the face of desperate need

I am reprinting in full, with permission, what I think is a really well written "story behind the numbers". These stories provide invaluable context around the various individual human and community tragedies that are constantly occurring during this epidemic. They also highlight the many difficulties faced by those trying to help people, track and contain spread and and collate all the numbers. Those numbers may be dispassionate in their quantification of aspects of the epidemic, but they are so important to guide timely aid to the right areas and at the right scale

Freetown – 10 December 2014 - Racing to fact check an ominous spike in Ebola cases from the remote diamond district of Kono in eastern Sierra Leone, bordering Guinea, a World Health Organization rapid response team found a worse-than-expected scene. WHO and the U.S. Center for Disease Control (CDC) joined forces with the Sierra Leone National Ebola Response Center (NERC) and Ministry of Health and Sanitation (MoHS) to sound the alarm and are now rallying all-comers in a massive build up to contain this burgeoning Ebola outbreak which ran the risk of continuing to grow and remaining hidden as world attention focuses on urban centers.

“Our team met heroic doctors and nurses at their wits end, exhausted burial teams and lab techs, all doing the best they could but they simply ran out of resources and were overrun with gravely ill people,” explains Dr Olu Olushayo, WHO National Coordinator, Ebola Epidemic Response. “In districts like Kono, with moderate transmission confined to limited villages and chiefdoms, the best chance of eliminating transmission is through aggressive and comprehensive case investigation and contact tracing,” he said. Scattered villages in 8 of the 15 chiefdoms are affected.

Reacting on intel from the Ministry of Health of Sierra Leone, WHO sent a seasoned field epidemiologist to Kono 10 days ago to tease out whether reported Ebola cases told the whole story. Cases go unreported for a variety of reasons and are exacerbated when overwhelmed and under-resourced frontline workers are unable to reach remote areas to get the truth from reluctant villagers. The surveillance officers had no vehicles. WHO and CDC quickly sent more investigators and rugged trucks.

They uncovered a grim scene. In 11 days, 2 teams buried 87 bodies, including a nurse, an ambulance driver, and a janitor drafted into removing bodies as they piled up at the only area hospital, ill-equipped to deal with the dangerous pathogen. In the 5 days before the team arrived, 25 people died in the hastily cordoned off section of the main hospital serving as a makeshift Ebola holding center.

As of 9 December 2014, this district of over 350 000 people officially has 119 reported cases. Upon hearing the WHO findings, Dr. Amara Jambai, MoHS Director of Disease Prevention and Control harkened a local saying to describe what remains yet to be discovered, "we are only seeing the ears of the hippo."

Help is arriving daily. The NERC and MoHS for the Government of Sierra Leone and UNMEER with WHO support are connecting ready-to-help partners with an all-out multi-agency response to critical needs on the ground. WHO field staff are sharing their expertise with surveillance investigators, community mobilizers, infection controllers, and coordinators. The doctors from Partners in Health and Wellbody Alliance who supported the overwhelmed holding center, are willing to stay on board to support care at the source in outlying health posts. The International Federation of the Red Cross will build a new Ebola Treatment Center on a tight timetable, while they disinfect the hospital with MoHS and create a temporary safe holding unit. The IFRC Kenema Ebola Treatment Center will take Kono patients until these solutions are in place. CDC has staff on the ground. UNMEER has lent it’s helicopters to the effort in support of the UN family (WHO, UNICEF, UNFPA, WFP, and others) engaged in building up capacity for staff and volunteers through training, materials and logistical support. International Rescue Committee is supporting infection prevention activities in the district. Funders such as DIFD and USAID are making much of the fast response possible. The race is on in this frontier fight against the virus, as Ebola responders dash to get ahead of the epidemic rather than chasing its tail.
 

Ebola testing: 48-72 hours for a negative to turn positive

Currently, some fraction of the people who present very early after they may have been infected by Ebola virus for testing, return a negative result. This is probably a rare event because the majority of cases arrive for care with Ebola virus disease (EVD) already well underway.

The latest Centers for Disease Control and Prevention (CDC) guidance in these instances is to wait (48 to) 72 hours and see if the patient remains ill, or becomes more unwell. If they do either of these, a second test is performed.[1] If the suspect case recovers from illness, no repeated testing is indicated. 

The test we rely on to confirm a clinically suspected EVD case is called a reverse transcriptase polymerase chain reaction (RT-PCR). RT-PCR is a technique designed to  seek out a tiny but very specific region of the Ebola virus's RNA genome, copy it into DNA then amplify those DNA copies a billion-fold by making more copies. Somewhere during that exponential amplification process, the technology of the day (currently fluorescence detection but formerly agarose gel detection, radiation and chemiluminescence) allows us to identify that the specific DNA we seek is appearing above an arbitrary threshold...we have a positive test result for Ebola virus. 

RT-PCR is a very sensitive technique. It was not that long ago - the 80s, not that long for some of us anyway - that clinicians and scientists were complaining that PCR methods were too sensitive. This was in large part because PCR was too successful at finding infectious agents where, and when, they had not been previously found. Change to dogma was in the wind. Fast forward to today and now we're lamenting that PCR isn't always sensitive enough. Very early on after acquiring what we later know to be a true infection, even exquisitely sensitive PCR methods can fail to detect those earliest of viruses while they are struggling to gain a foothold in our cells and replicate themselves to levels that outstrip our immune system's capacity to contain. Whether this is because the virus is hidden away in organs during its early replication or whether too few circulating viruses yet exist to surpass the necessary threshold of the RT-PCR assay's sensitivity at these early stages is unclear.

EVD patients who are not yet showing signs and symptoms of disease may present early for testing and care because they they are healthcare workers with a suspected or known exposure, or they may be the contact of a known EVD case or infected animal being tested early on to exclude infection. But as we have seen and read anecdotally, that first test can sometimes be negative; not due to inhibition of the RT-PCR (which can also happen, just not so much with today's purification methods) nor because they are truly uninfected, but simply because we're testing too early. These are examples of false negative results.

For the past few weeks I have been trying to find he evidence that underpins why the world chooses to use a 48-72 hour window in its guidelines. I've been asking a lot of people-and I thank those who replied. Tonight the very diligent and extremely tolerant folks at the World Health Organization got back to me with a quote from Dr Pierre Formenty, team leader Emerging and Dangerous Pathogens. A hard man to get hold of sometimes-as you might imagine. He said (lightly edited)...

There is at least one documented case during an outbreak in Africa; a contact with fever = a suspect case; he was negative at day 1 with RT-PCR (CDC Lab) and was found positive at day 3 (when retested).
So the 48-72 hours come from this incident. We want to be on the safe side and limit the number of false negative that are inevitable with any test.

And so there you have it. If anyone has anything further to add to this story, I'd be most happy put it here.

References...

1. http://www.cdc.gov/vhf/ebola/hcp/considerations-discharging-pui.html 

Influenza A(H7N9) virus: detection numbers and graphs...

This is a static page that houses my graphs of influenza A(H7N9) virus ("H7N9") numbers produced by the various Ministries of Health for the provinces and municipalities of China, Hong Kong's Centre for Health Protection (CHP) the World Health Organization and FluTrackers.

Please be aware that these numbers are in flux during the winter epidemic. They are a guide only.

There is also an accompanying map page which for now is located here.

Learn About Tableau

Reminders: 

• The graphs above, as with all on VDU, are made for general interest only. They are also freely available for anyone's use, just cite the page and me please. The data can be downloaded by clicking on the "Download" link at the bottom-right of each dashboard. It may be that I have misinterpreted the language in the reports (sometimes a little tricky to wade through) or miscalculated some totals based on the way data have been presented.
• In any outbreak, epidemic or pandemic caused by a know or emerging pathogen, the numbers presented publicly, and used in these graphs, are expected to represent only a fraction of all the cases that have and are occurring. This is just the nature of the imperfect biological'ness of these events.
• I am only able to plot what is publicly available-you could do this too. No secret associations or back-room deals provide me with these data.

The bad the worse and the over-interpreted...

EVD case numbers between WHO reports. 

The World Health Organization (WHO) Ebola virus disease (EVD)case numbers that came out on 29-Oct were pretty big (see graph on the left). As if there weren't already enough new cases and deaths every 2-5 days, now there is this bolus of 3,562 cases added to the total. And a net change in deaths of -2? What the heck?  

Let's see if we can add some context.

According to a number of past WHO reports, a lot of effort has been going in to trying to collect data more effectively including improving the linkage of lab results to cases, cases to deaths, lab data to deaths and probably a million other things. 

Dr Bruce Aylward
http://www.who.int/dg/adg/aylward/en/

In the previous Roadmap SitRep and Roadmap update, the Liberian numbers did not move - they even had the same date. That was new and it was concerning because it suggested that reporting had been stopped or collapsed entirely. However this new large download of cases is in some way good news because it suggests reporting is working and the systems and processes are coping - although undoubtedly still stressed - again. 

The thing to be aware of is that these are not cases that have all been detected or all occurred since the last report 5 days previously. According to Dr Bruce Aylward, WHO Assistant Director-General, Polio and Emergencies, during a preceding media conference (and my thanks Martin Enserink for asking the important question; underlining is mine)..

In terms of the jump in the number of cases, one of things that we've talked about in the past on this is that with the huge surge in cases in certain countries, particularly in September and October, people got behind on their data.

They ended up with huge piles of paper in terms of cases, etc, and we knew and I actually said to you the last time, we are going to see jumps in cases at certain times that are going to be associated more with new data coming in but it's actually on old cases.

And a couple of days there were about 2,000 additional cases in, if I remember correctly, it was actually the Liberia case report but most of these were old cases because remember they got swamped a couple of months ago with a lot of new cases and just got behind on their data, so a lot of that is about reconciling new data.

If we look at sort of a seven day rolling average number of cases which have been around 1,000, just under that, about 900, there hasn't been a big change in that in the recent weeks.

So the 3,562 cases come largely from the past as well as the present. It's not that the sky has fallen in the past 5 days. Which is good news. But of course, that puts us back to "just" 1,000 or so Ebola virus disease cases a week. In other words, in just 1 week there are more cases than in any individual outbreak since 1976. 

The cumulative EVD case curve at 29-Oct

However, this week has seen a few articles and comments noting that the number of new cases in parts of Liberia seem to have fallen slightly. 

This seems to be a real trend in that there are fewer burials and more empty treatment beds and fewer cases found when sought in the community. Why there are fewer is not precisely known and it is far to early to rely on this yet. But we do know that there are better numbers of safe burials, better education, more experience with the disease, more help and facilities and more PPE comapred to when this started. 

The three countries with intense transmission still require a lot of help from us though - that urgency must not let up. Remember that cases had dropped a lot back in May - and now look where we are.  

If you can't get there in person to offer specialist help, and most of us cannot, keep bringing the issue to the attention of your country's leaders, learn about the virus and the disease from trusted sources and help teach others and head off ignorant comments, and donate some (some more) money to those groups who can make a real difference on your behalf (I've listed some great options here). 

Fighting the fire at its source is still the best way to help save lives in Guinea, Sierra Leone and Liberia and to stop new outbreaks from occurring in other countries.

References..

1. WHO Ebola Roadmap SitRep#10
   http://apps.who.int/iris/bitstream/10665/137376/1/roadmapsitrep_29Oct2014_eng.pdf?ua=1
2. Virtual Press Conference transcript
   http://www.who.int/mediacentre/multimedia/vpc-29-october-2014.pdf?ua=1

Why Ebola virus is not human immunodeficiency virus (HIV)

I'm not an HIV expert and only an Ebola virus hobbyist but let's see if we can list some things that are similar and different about these two viruses.

Some ways that Ebola virus and HIV are similar...

1. Both are harder to catch than a cold. They do not spread through an airborne route.
2. Both have lipid envelopes - Ebola virus is about 904-
   1,100nm long x 80nm wide whereas HIV is about 120nm around
3. Both can be transmitted in blood, breast milk, and through sexual contact, being present in seminal fluid (HIV also in female genital secretions). For HIV the extent of the frequency of exposure and the viral load play during that exposure, play a role in the likelihood of infection; this is not well defined for Ebola virus.[1]

Some ways that Ebola virus and HIV differ...

1. HIV is an RNA virus that goes through a DNA phase which allows it to hide in our cells while Ebola virus is strictly an RNA virus
2. Ebola virus infects dendritic cells, monocytes, macrophages, endothelial cells, endocardium, kidney and liver cells but not peripheral lymphocytes while HIV primarily infects CD4+ lymphocytes and also dendritic cells
3. They differ in the mechanics underpinning the way that they replicate themselves
4. Ebola virus disease occurs very quickly whereas acquired immunodeficiency syndrome (AIDS) has a long latent period (although there is an earlier more acute disease)
5. At writing, no antiviral or vaccines exist on the market for Ebola virus or Ebola virus disease; a range of drugs exist to slow or suppress HIV
6. Ebola virus acutely kills cells, causes coagulation, organ damage and disrupts the immune response without lingering; HIV eventually becomes latent in the cells it infects, integrating with the genome
7. Ebola virus has 7 genes, HIV has 9 and overlapping reading frames.

References...

1. Principles of virology. Flint SJ, Enquist LW, Racaniello VR, Skalka AM.3rd Edition. Vol 2. Chap 6.

Mali makes it 6 countries in the West African Ebola virus disease epidemic

v2 251014

The 6th country in the West African outbreak to host a case of Ebola virus disease (EVD) in 2014, is Mali.

The case was a 2-year old girl who was symptomatic while still in Guinea.

She travelled with her grandmother >1,000km by public transport to Bamako (Capital city of Mali), setting out 19-Oct. WHO are treating the situation as an emergency; there were multiple opportunities for exposure. The case's mother may have died of EVD in Guinea and her grandmother may have travelled from Mali to Guinea to attend the funeral.

The case had contact with health services in Kayes, western Mali, on 20-Oct. She was referred and admitted to a paediatric ward of Fousseyni Daou Hospital 21-Oct with a fever of 39’C, cough, bleeding from nose and blood in her stool). Tests were negative for malaria but positive for typhoid fever. Pain relief was given but there was no improvement. 

Further tests confirmed EBOV 23-Oct at the SEREFO (Center for TB and AIDS Research) laboratory in Mali.

Samples are being sent to a WHO-approved laboratory for confirmation.

The girl has since died.[2]

The 2014 West African epidemic and Central African outbreak of EVD.
Click on image to enlarge. Feel free to use and share this map
(please attribute to this blog).
NB: Nigeria (19-Oct) and Senegal (17-Oct) were declared EVD free.

References..

1. http://www.who.int/mediacentre/news/ebola/24-october-2014/en/
2. http://www.bbc.co.uk/news/world-africa-29755443

Ebola double vision....

A quick post to crudely highlight that total (suspected+probable+laboratory confirmed) Ebola virus disease case numbers have been doubling approximately every month  since June (as far back as I went). 

Click on image to enlarge.

The reality is that the most recent reports from the World Health Organization (WHO) may be even less accurate than the underestimated numbers we have become used to during the epidemiological fog-of-war that surrounds any outbreak, epidemic or pandemic. 

Apart from the most recent update, WHO Situation Reports (SitReps) of late have made a point of highlighting that the numbers have been lower than what those in the field expect is real.

"It should be emphasized that the reported fall in the number of new cases in Liberia over the past three weeks is unlikely to be genuine. Rather, it reflects a deterioration in the ability of overwhelmed responders to record accurate epidemiological data. It is clear from field reports and first responders that EVD cases are being under-reported from several key locations, and laboratory data that have not yet been integrated into official estimates indicate an increase in the number of new cases in Liberia."

8-Oct-2014 WHO Ebola Response Roadmap SitRep

So, if you are a senior influencer or a decision-maker in your country and if that country, in which you are a citizen, has offered only limited, financial, or non-existent support to this unprecedented outbreak of infectious disease, I suggest the following: Stop disproportionately worrying about the few sporadic but simply controlled EVD cases that your already-straining healthcare budget has to look forward to. Stop worrying about how those budgets will cope with the unnecessary burden of your feel-good but near-pointless rollout of temperature monitoring resources at entry ports. Stop thinking that by blocking flights out of West Africa you will somehow protect your country and the rest of the world from exported cases.

Think about this instead: If you are not doing your damnedest to insist that your country has put people and equipment on the ground in Liberia, Sierra Leone or Guinea, then you do a disservice to humanity, and on your shoulders be the burden of the many deaths to come. 

We individual citizens can't do this. You and our governments can.

Complain about and hide behind who didn't react fast enough if you must, but do be very, very clear in your own mind that now, right this minute, if you are not acting, calling someone, pleading a humanitarian case, then it is you and those like you who are to blame for some of our global villages burning out of control. 

I don't care a damn if the currency for today's political action is "security" - you find a way to bring it back to being about humanity. 

We live in an interconnected world and some of those country's citizens are your constituents.

The global calls have gone out, the Resolution has been passed, the pleas have been made, the situation is clear to all. And you are failing. 

Get up and do something. Now.

References..

1. Ebola Virus Disease in West Africa — The First 9 Months of the Epidemic and Forward Projections.
   New England Journal of Medicine. 23-Sept. WHO Ebola Response Team
   http://www.nejm.org/doi/full/10.1056/NEJMoa1411100

Ebola index: Virology Down Under posts...

To make it a little easier for me to keep up, I thought an index of  my key posts - some of which address your most pressing concerns about Ebola virus, ebolaviruses and Ebola virus disease (EVD) - would be useful.

1. The tallies and graphs from the major countries that have hosted Ebola virus disease cases in West Africa. Updated as soon after the World Health Organization (WHO) releases their figures as I can manage.
   Ebola Virus Disease (EVD) 2014 West African outbreak..
   http://virologydownunder.blogspot.com.au/2014/07/ebola-virus-disease-evd-2014-west.html
2. The partner post to #1 but in maps and historical numbers.
   Ebolavirus disease (EVD) cases, clusters and outbreaks mapped out...
   http://virologydownunder.blogspot.com.au/2014/07/ebolavirus-disease-evd-cases-clusters.html
3. A summary of what we know about how the Ebola virus is transmitted between humans.
   Ebola virus may be spread by droplets, but not by an airborne route: what that means
   http://virologydownunder.blogspot.com.au/2014/08/ebola-virus-may-be-spread-by-droplets.html
4. The companion piece to #3 - highlights that we can force Ebola virus into an aerosols in non-human primates (not hiding this), and that pigs also seem to produce aerosols...but that this is not the same as natural human virus acquisition/disease which is due to direct contact between body fluids and mucous membranes/broken skin (includes physical touch and propelled).
   Ebola, pigs, primates and people
   http://virologydownunder.blogspot.com.au/2014/08/ebola-pigs-primates-and-people.html
5. Why this epidemic is extremely unlikely to produce a variant of Ebola virus that changes so much (accompanied by changes in the host), that it becomes an "airborne virus".
   The wind beneath my Ebola virus.... 
   http://virologydownunder.blogspot.com.au/2014/09/the-wind-beneath-my-ebola-virus.html
6. Some scientific literature to underscore the risks of acquiring Ebola virus from a very ill person's blood, sweat, spit and tears.
   Ebola: Blood, sweat and tears...
   http://virologydownunder.blogspot.com.au/2014/08/ebola-blood-sweat-and-tears.html
7. Some scientific literature and discussion to highlight the chronic risk of acquiring Ebola virus infection from the semen of a convalescent male.
   Ebola virus in semen is the real deal.... 
   http://virologydownunder.blogspot.com.au/2014/08/ebola-virus-in-semen-is-real-deal.html
8. A post about the many things that lead to healthcare worker (HCW) Ebola virus infections. This was in response to a CIDRAP article and to the increasing narrative that because of a high toll among HCWs, there must be something changed about this virus making it "easier to catch than what we have been told". Which has to date not been backed up laboratory science, epidemiology or the observations of those working in West Africa. 
   Ebola virus, HCWs infections and personal protective equipment..
   http://virologydownunder.blogspot.com.au/2014/09/ebola-virus-hcws-infections-and.html
9. A new graphic to even more simply explain the differences between an airborne transmission route and a short-distance wet droplet/cough route of transmitting viruses like Ebola virus.
   It's what falls out of the aerosol that matters....
   http://virologydownunder.blogspot.com.au/2014/10/its-what-falls-out-of-aerosol-that.html
10. A thought-provoking post about what to call the way in which viruses like Ebola virus may be transmitted since they are not truly airborne but may be coughed or vomited across short distances as big wet droplets. Airborne vs Propelled.
    What words would you use to separate influenza spread from Ebola virus disease spread?
    http://virologydownunder.blogspot.com.au/2014/10/what-words-would-you-use-to-separate.html
11. A short brief on the different variant, still from the Zaire ebolavirus species (same species as that ravaging West Africa), concurrently circulating in the Democratic Republic of Congo (DRC).
    The battle of Ebola gains a second front...the Democratic Republic of Congo (DRC; formerly Zaire)
    http://virologydownunder.blogspot.com.au/2014/08/the-battel-of-ebola-gains-second.html
12. Some of the many fake or non-Ebola virus disease images circulating on the interwebs. Help enlarge this or solve the unknowns, if you can.
    Fake/wrong Ebola virus disease images...
    http://virologydownunder.blogspot.com.au/2014/08/fake-ebola-virus-disease-images.html
13. How to use the perfect terms to discuss Ebola virus. How does Ebola virus differ from EBOV, differ from ebolaviruses, differ from Ebola virus disease? A primer on the lingo and how it compares to cars.
    Behind the naming of ebolaviruses...
    http://virologydownunder.com/behind-the-naming-of-an-ebolavirus/
14. How can you help? Donate money and help provide protective equipment for the heroic efforts of those willing to face down Ebola locally in West Africa or after driving/flying in.
    Protect the healthcare giver>>save lives>>stop Ebola virus disease
    http://virologydownunder.blogspot.com.au/2014/08/protect-healthcare-workerssave.html
15. Application of Prof David Fisman's predictive Ebola modelling.
    Updating a model of a modern Ebola epidemic...
    http://virologydownunder.blogspot.com.au/2014/09/updating-model-of-modern-ebola-epidemic.html
16. A term to better explain the crude ratio of people who have died in the midst of a chaotic epidemic.
    The proportion of fatal cases (PFC)...
    http://virologydownunder.blogspot.com.au/2014/09/the-proportion-of-fatal-cases-pfc.html
17. Some hints and tips on how to get the most from commonly used graphs on Virology Down Under.
    How to read a VDU graph...
    http://virologydownunder.blogspot.com.au/2014/08/how-to-read-vdu-graph.html
18. How to read my graph depicting Ebola virus case numbers between reports.
    Case number changes between Ebola virus disease reports...
    http://virologydownunder.blogspot.com.au/2014/09/case-number-changes-between-ebola-virus.html
19. An idea that could be used by Australia to more safely allow it to provide/encourage/permit the sending of human help, not just money, to West Africa.
    Australia's response to Ebola virus disease in West Africa: is too little enough?
    http://virologydownunder.blogspot.com.au/2014/10/australias-response-to-ebola-virus.html
20. A ranty reminder the outbreaks, epidemics and pandemics are chaotic things driven by chaotic humans. Numbers of cases never account for every case..because chaotic. Don't expect them too.
    The numbers are underestimates...
    http://virologydownunder.blogspot.com.au/2014/09/the-numbers-are-underestimates.html
21. A theory about the cumulative case and death graphs that suggests a possibly useful predictor of things beginning to run out of control.
    The control gap...
    http://virologydownunder.blogspot.com.au/2014/09/the-control-gap.html

What words would you use to separate influenza spread from Ebola virus disease spread?

I need your help.

I have spent umpteen hours on trying to make this message simple. None of that has been aided by the way that the CDC, the WHO and now the UN use the terms and words confusingly to convey messages to the public. The message is often delivered as if they were sitting around their meeting rooms talking to other health and science professionals. In my opinion, we all look to these guys for simple clear and consistent messages. Right now they need to do much better to convey complex concepts, simply, quickly and more often. Education helps prevent panic, mistakes and conspiracy theories (well-as much as anything can anyway).

So here is another attempt by me to get this wording into line with what the rest of world can make sense of. 

I could also really use your input to make this work - so leave a comment below, or Tweet me @MackayIM or email me or send me a carrier pigeon - with how to make this message simpler for you and your kids and your grandparents and that weird uncle you stay clear of at Christmas, to understand. 

Let's crowdsource a solution to this confusion, help out others and then see if the major public health bodies can come on board.

Propelled droplets versus a cloud of suspended.

This post and issue have been fuelled most recently by the Ebola virus disease (EVD) epidemic but is also fuelled by my experiences in talking to people about the MERS-CoV and influenza A(H7N9) virus outbreaks. They are respiratory viruses while ebolaviruses are not. Different viruses yes, but common concerns for people and to the issues around trying to understand overly technical terms when they are used differently in everyday life. 

Public health speaking is very public.

Public health issues are spoken about on a global stage, more now than ever. It is up to us to better define the right words and use them consistently. That has definitely not happened for "aerosol" and "airborne". 

We professionals can't just sit back and expect our stakeholders to come along with us for the ride - they will get confused when imagery conflicts with lingo and official statements, and when different public organizations disagree with each other or use tiny but significant differences in their language to communicate risks. 

People are not stupid and deserve more respect than they are currently getting from those who should know much, much better about how to work alongside the public (public health and all).  

So what is the problem here? 

Droplets would probably be an ideal word to differentiate from airborne - and it has been used to differentiate the level of precautions of personal protective equipment (PPE) to prevent infections - droplet precautions and airborne precautions - but the evil physicist types have ruined the use of that word for us by introducing droplet nuclei (the part of the aerosol that lingers in the air and can convey those viruses that survive in it, to a new person to infect them). Physicists like technicalities.

So the problem is trying to define a name for that other process that can simply and clearly describe infectious disease transmission of viruses & bacteria that are propelled from/by the sick person, across the gap between them and an uninfected person, measurably infecting the recipient. The name should make clear that it is a different process to the one that sees a person get sick by inhaling infectious viruses or bacteria held aloft by the air, in a cloud, made by a previously ill person, that has been hanging around for perhaps an hour or more. That one is an airborne route of transmission. 

Some people have berated me for talking technicalities and semantics in recent days while I try to better define this. Tough! Water off an influenza-host's back. Words have meaning and impact and useful words are needed. Especially when everyone is freaking out over a disease they have only read about in dramatized books or seen in Hollywood blockbusters. The two processes listed above are distinct and different for some viruses & bacteria. But it is biology and nothing is 100%, except death. 

Some infections, like those leading to influenza, could result from both processes. Some, like Ebola virus disease have never been observed in humans via one route (airborne), whereas there is a defined risk of them occurring by the other (direct contact between a range of virus-laden body fluids propelled onto a mucous membrane). Yes, coughing a tiny barely visible droplet onto someone else's mouth is direct contact between the wet fluids and the mucous membrane.

They two processes are battled differently. We protect ourselves from them differently. And names can tell us about the different levels of risk. But what is that other route to be called? 

I have an idea. First some perspective.

Ways to think of the differences.

A word cloud of ways to think of the
two different processes of spreading viruses
or bacteria that result in infection and disease
in humans.
v2 Thanks to Nina West for good analogy (Fog/Rain)

The idea.

How about we call the process of relatively short (up to about 3m) distance, coughed/sneezed/vomited wet droplet transfer of disease-causing doses of viruses or bacteria, "Propelled"?

Over to you, world.

Some greats from the comments below...

• "void the spray and live another day"
• Only touched by air, no need to care. Where it splatters, that's where it matters