How About a Moonshot to End Ebola Virus Infections?
This inaugural blog is launched on July 20, 2019—the 50th anniversary of Neil Armstrong taking a “giant leap for mankind” on the moon. Like most folks who were alive that day, my memories of the occasion are vivid. Still gives me goosebumps. What a breathtaking technological achievement and what remarkable courage of the three astronauts aboard Apollo 11!
But on a markedly ominous note, this is only day two since the World Health Organization (WHO) declared the year-old epidemic of Ebola virus infection in the Democratic Republic of Congo (DRC) a “public health emergency of international concern” (PHEIC). Emergency declarations such as this are issued sparingly. Only four PHEICs have been made in the past: one for the Ebola epidemic in West Africa in 2014.
My guess is that many of you wonder, as do I, why with all our technological know-how (after all, we got men to the moon), can’t we defeat a tiny enemy like the Ebola virus? Plus we won the war against an even more destructive virus—variola virus, the cause of smallpox, which was declared eradicated by the WHO in 1980.
But upon reflection, I believe the technological breakthroughs related to eradicating Ebola, and the courage demonstrated by caregivers and researchers devoted to fighting Ebola are as staggering as those involved in getting Homo sapiens to the moon.
We’ve only known about Ebola virus disease (also referred to as Ebola hemorrhagic fever, or simply Ebola) since 1976 when two epidemics occurred simultaneously in Zaire (currently the DRC) and Sudan. The nature of the Ebolavirus species that cause the disease began to be characterized that same year when it was discovered by a team of scientists from the Center for Infectious Diseases and Prevention and Peter Piot, a Belgian microbiologist. (They named the virus after the Ebola River, which runs close to the village of Yambuku, in Zaire.) Since then, 21 outbreaks have occurred, mostly in countries in Equatorial Africa. This is the tenth outbreak in the DRC where the disease is endemic.
The epidemic that began in December 2013, however, was by far the largest and most frightening of all. For the first time, countries in West Africa—mainly Guinea, Liberia, and Sierra Leone—were hit. The strain of Ebola virus that was first isolated in Zaire (dubbed EBOV) was the culprit. How it found its way to West Africa is unknown, but some researchers suspect fruit bats as the carrier. A total of 28,616 cases and 11,300 deaths were reported (an additional 36 cases and 15 deaths occurred when the outbreak spread to other countries). A recent estimate of the cost of West Africa’s Ebola epidemic is an astounding $53 billion.
Much of what we know about the management of patients with Ebola virus infection and control of epidemics was learned in the first outbreaks in 1976. Early on, public health officials emphasized the critical importance of the safe handling of corpses and the value of quarantining infected people. Ebola virus is a highly contagious virus that is spread mainly through direct contact with skin or body fluids of an infected person. Thus, most cases occur among people who provide direct care to Ebola patients—usually family members and healthcare professionals. (About one quarter of cases occur among health care workers.) Traditional funerals in which family members prepare infected corpses for burial also transmit the virus to household members.
The illness caused by Ebola virus is horrific in many ways. It begins after a 4 to 9 day incubation period with the sudden onset of fever and chills, followed by flu-like symptoms (muscle pain, runny nose, and cough), gastrointestinal symptoms (diarrhea, nausea, vomiting, and abdominal pain), and in most severe cases, internal and external bleeding (from the eyes, ears, and mouth). In the terminal stage of illness (days 7 to 10), confusion sets in, and the victim lapses into a coma. Shock develops from dehydration (caused by diarrhea and vomiting) and bleeding. Mortality rates vary, but on average Ebola virus kills around 50% of its victims.
Given the gruesome nature of Ebola, it is no wonder that panic often accompanies its arrival in a community. In the West Africa epidemic, for example, members of afflicted families and villagers were terror stricken; health care providers were shaken; dead bodies laid in the streets, often for days. The havoc was reminiscent of the Great Plague of London 350 years earlier.
Several things are different about the current epidemic in the DRC. On the positive side, an effective vaccine that was developed during the West African epidemic is being used (donated by the pharmaceutical giant Merck). Also, much that was learned about proper infection control in healthcare facilities and the medical care of patients is being applied. Also encouraging is the use of investigatory drugs that looked promising in the West African epidemic. And importantly, unlike the sluggish response to the Ebola epidemic witnessed in West Africa, international agencies have rapidly scaled up the expertise and resources to combat the DRC epidemic.
So, why with all these positive developments did the WHO emergency panel feel it was time on July 18, 2019 to declare the epidemic in the DRC a PHEIC? This was the fourth time the committee had considered doing so. By this time, more than 2,500 people were sickened and nearly 1,700 had died, making this the second largest-ever Ebola outbreak. Several factors weighed into their decision: in recent weeks the disease reached Goma, a city of nearly two million; the virus had flared again in several spots where it had once been contained; and the epidemic had expanded in northeastern Congo near Rwanda and into Uganda.
But a unique aspect of the current DRC epidemic—one that is terribly worrisome—also influenced their decision. This is the first time that Ebola has emerged in a War Zone. Continued attacks on health workers, including the killing of two Congolese Ebola respondents in Beni, played a role not only in precipitating the decision about the seriousness of the epidemic but also is confounding efforts to control it.
The hope now is that the PHEIC declaration will yield additional international support and funding for clinical care, public health infrastructure, and research. But an additional, and overwhelming challenge in defeating Ebola is one of the biggest social determinants of health: poverty. Of the 77 million people living in the DRC, 80 percent live in extreme poverty. Thus, it’s not for a lack of technology or courage that a moonshot to end Ebola virus infection isn’t coming anytime soon. The underlying issue of poverty on the other hand, is a much bigger longshot.