Understanding Ebola in West Africa Through Laurie Garrett's Lens on Kikwit

The WHO announced yesterday that the decline in Ebola cases which has been occurring has halted. This is ominous news as it highlights the very real fact that unless every Ebola case is run down, a new transmission chain can commence, reigniting the epidemic in West Africa. 

To understand why the West African Ebola epidemic is so recalcitrant to the public health measures that have been employed to stop all the prior instances of Ebola, it is instructive to examine prior outbreaks. After the 1st outbreak of the most virulent Zaire strain of the virus in 1976, the next biggest outbreak of this strain (present outbreak excluded) was in Kikwit (DRC) in 1995.  This--once considered large--300+ person 1995 Ebola outbreak has many lessons for today, as presented in a book published in late 2014 by Laurie Garrett. Ebola: Story of an Outbreak, extracted from Garrett's Betrayal of Trust: The Collapse of Global Public Health (with a new introduction focused on the West African outbreak), provides an in depth view of the Kikwit outbreak highlighting the struggles that physicians, many of whom are now everyday names in infectious diseases now (e.g. Ali Khan, Pierre Rollin, David Heymann), encountered in trying to extinguish this outbreak.

Many of the incidents described presage what occurred in West Africa: distrust of government authorities, belief in a mystical origin (which includes a special hippopotamus), graft, corruption, and intense press coverage. The lesson I found most instructive is that after the outbreak abated, within a couple of years, public health infrastructure and public health behaviors had again eroded to dangerously low levels. Such a devolution illustrates that resources infused from outside are effective in the short term, but are not sustainable without actual acceptance from the local population as a rapid regression to the mean takes place. For example, safe burial practices ceased, the etiology of Ebola was placed back in the supernatural realm, and an ambulance became a limo for a local government thug. This regression to the mean is occurring even more rapidly in West Africa where, while the disease still rages, lax public health practices by local populations have given rise to a shadow--and open--epidemic that continues to burn.

 As someone who was captivated by Garrett's The Coming Plague and who also enjoyed I Heard The Sirens Scream, I highly recommend this book as an important guidepost to understanding the challenges faced in West Africa.

How GMOs Could Have Prevented Nigerian Mystery Illness Cluster

Each time a cluster of illness occurs there is a process to determine its cause. One of the first thing that comes to mind with clusters, broadly speaking, is determining whether an infectious disease is present or something else. "Something else" will include a list of things, chief of which is a common exposure to some toxin. 

The recent cluster of illness (blurry vision, headache, alterations of conciousness) in Nigeria--which recently experienced several imported cases of Ebola--sparked concerns of Ebola, for obvious reasons. However, it appears that no infectious cause of illness is responsible for this event which has claimed the lives of 18.   

Currently there are two competing explanations: methanol contaminated gin and the WHO's preliminary hypothesis: pesticides. Both are good explanations because they fit the symptomatology of the cases and are biologically plausible. Final diagnosis should be able to confirmed with laboratory testing. 

The investigation of this event illustrates several aspects of public health investigations, the most important of which is the importance of surveillance. Without knowing what illnesses are occurring in an illness, it is impossible to detect unusual occurrences and place them in the context of what is the usual baseline mix of disease in an area. 

Another aspect of this case is the possible link with pesticides (which may not turn out be the case). Though I am a big fan of pesticides as I value human life and the conditions required for our flourishing--such as an abundant supply of food--pesticides can be dangerous if the quantity ingested exceeds a threshold. Because of these limitations, alternatives to pesticides are actively sought. One such alternative are GMO crops that are resistant to plant pathogens. One would think that such a pathbreaking advance in genetics and agriculture would be embraced, yet it is not.

Why are GMOs feared? It is not because of any evidence of their danger for there really isn't any as no one has died or been harmed from GMO-poisoning (an oxymoron). Yet for those who seek an alternative to pesticides, which cause up to 20,000 illnesses yearly in the US, GMOs are often considered off-limits because of the vocal anti-science, anti-reason, anti-GMO movement which often resorts to threats, violence, and property destruction in their nihilistic quest. 

Remember the corn we eat and the dogs we walk are all GMOs as artificial selection and breeding for specific traits are exactly the principles behind all genetic engineering. 

You would think that people that scream "safety" would actually care about safety and embrace GMOs, but it isn't safety that motivates them, it is hatred of the human minds that made GMOs possible.

Listeria: Another Reason Why You Should Not Drink Hot Dog Juice

The bacteria Listeria has a special place in my heart--not to imply that I don't love all bacteria in their own special way. Listeria is in the headlines again with the national recall of Blue Bell products being announced after 10 cases of listeriosis were reported in 4 states, 3 of which were fatal.

Though listeria has only a small slice (~1%) of the total food-borne illness burden, it does claim a substantial proportion (~20%) of food borne deaths granting it a special status. This is really a ubiquitous bacteria that is present in herd animals and the soil. It can contaminate soft cheeses, hot dogs, deli meats, cantaloupes and other products. The immunocompromised, pregnant, and newly born are at particular risk for severe infection.

What makes it so deadly is its ability to move from the GI tract to the blood and then to other organs. One place where it is particularly damaging is in the central nervous system. Listeria meningitis and encephalitis have particularly high mortality rates.

The best means to prevent listeria are safe food handling procedures (i.e. avoid hot dog "juice" exposure) and for those at particularly high risk to avoid eating foods that may be contaminated with listeria. There is also an innovative product (ListShield) containing viruses that attack listeria (bacteriophages) that can be sprayed directly onto food to kill the bacteria.

So why does listeria have a special place in my heart? It's not its actin "jets" (so cool) or tumbling motility (really endearing to watch). It is because as a operating room volunteer in the mid-1990s applying to medical school, I knew I wanted to be an infectious disease physician. When I was done volunteering, I would roam over to the infectious disease division and poke around looking for real life infectious disease physicians and researchers. One day, I stumbled upon a researcher (who has long since left my institution) who worked on listeria and he explained its microbiology and disease-causing attributes to me with such passion, I'll never forget the incident and the time he took to indulge my interest in infectious disease.

Viral Ecology Explained: A Review of David Quammen's Ebola

As I've written before one of the most fascinating aspects of infectious diseases to me is the fact that an infection is an intricate interplay between a host, a microorganism, the surrounding environment and, in many cases, a vector (e.g. an insect) or a reservoir species (e.g. bats). The concept viral ecology is often used to capture this interaction. 

Ebola is a paradigmatic disease that encompasses all of the above. With Ebola Virus Disease you have humans getting infected in specific geographic regions after some sort of contact with an as yet discovered reservoir species or an intermediate host such as an ape.  

David Quammen's Ebola: The Natural and Human History of a Deadly Virus, released last fall, is a great guide to the viral ecology of Ebola. The book is an expansion of an extracted portion of his 2012 tour de force Spillover.  

What Mr. Quammen does in this short book is masterfullyweave together the various threads of Ebola research that began in 1976 when its first outbreaks were recognized. Covering such topics such as the geography of Ebola outbreaks, the search for reservoir hosts, the impact on the gorilla population, and--my particular favorite aspect--why/when/where Ebola outbreaks occur. The book also contains a valuable epilogue that places the current West African Ebola epidemic in context--an essential requirement for understanding how this outbreak exploded to its current unprecedented stature.

Mr. Quammen is a gifted story teller and his treatment of infectious diseases is unrivaled. I am eagerly looking forward to reading and learning from his latest book The Chimp and the River, which is focused on arguably the most prolific infectious disease killer: HIV.

When Urgent Care Centers Meet Infectious Disease Emergencies

The rise of urgent care seems to be very rapid and has now opened up a third option in medicine to supplement physician's offices and hospital-based emergency departments. Such access is welcomed as it is convenient, free of the hassle of waiting rooms, and incurs less cost. Broadly speaking, I classify the nation's 9000 urgent care centers into two types: hospital-owned or hospital-independent. About three quarters of urgent care centers are not owned by hospitals and about half of the physicians who work in such center are specialists in Family Medicine. 

With 96% of cases not requiring the patient to be directed to an emergency department, it appears that a niche is being filled--especially for minor orthopedic ailments and wound care. However, in my biased infectious disease and disaster medicine worldview (as well as a board-certified emergency medicine physician and fellow of the American College of Emergency Physicians), I have a few concerns regarding urgent care centers that arise in a specific context.

No urgent care center is a substitute for an emergency department but there is, in my experience, a clear variation in operations between hospital and non-hospital affiliated centers. One specific concern that applies to non-hospital based urgent care centers is the degree of their integration into the public health communicable disease infrastructure in their locality. During outbreaks of important diseases widespread 2-way communication occurs between public health authorities and hospitals that urgent care centers--when not affiliated with a hospital--may never hear especially if staffed with locum physicians who may not even know which county they are practicing in, let alone the local epidemiology.

Recently, in a Pittsburgh suburb a non-hospital affiliated urgent care center not only gave a patient an erroneous diagnosis of measles--a public health emergency--but failed to order the appropriate confirmatory test, notify public health authorities, or perform any sort of infection control procedure. Thankfully the patient was clearly not a case of measles and no delayed contact-tracing had to performed, but that didn't prevent a social media panic from ensuing when the patient's father posted the false diagnosis, he had every reason to believe accurate, on Facebook. Were this an urgent care center affiliated with a hospital, numerous red flags would have tripped and hospital infection control would have been involved the moment the word "measles" was mentioned.

I wonder how many other infectious diseases of consequence may slip through the cracks in situations much like this (I'll save my rants on the poor antibiotic stewardship that occurs in urgent care centers for another time).

A solution to this shortcoming  is to embrace urgent care centers in health care emergency coalitions. Health care coalitions are largely hospital based but have increasingly began to involve entities from other realms of healthcare. Not only do such coalitions plan for infectious disease emergencies jointly, they adopt an integrated all-hazards approach that makes a community more resilient to a whole host of threats including weather emergencies and mass casualty accidents. As many hospital-independent urgent care centers are multi-state I estimate, and from research my colleagues and are conducting, not many are incorporated into hospital coalitions--a situation that is clearly suboptimal and, in a public health emergency, dangerous.