Ebola, Forgotten but Not Gone

The Current Outbreak of the Ebola Virus Overshadowed by a New Pandemic

The nCoV-2019 virus outbreak is still ballooning, with well over 400,000 confirmed cases worldwide with no signs of slowing down [2]. To date, there have been 19,786 fatalities, a mortality rate that is notably higher than the rate observed in the 2018-9 influenza pandemic (>2.5%) and significantly higher than AH1N1 (~0.05%) [3,4].

As you might have hoped, the response has been incredibly rapid, faster than ever seen before, with a new human pathogen. Within weeks of identifying an outbreak of respiratory illness, the virus has been identified, sequenced, and cultured; rapid tests are available for diagnosis (albeit with continuing broadening and narrowing); at least two randomized controlled trials (RCTs) are being performed to analyze the effect of antiviral medications, one with a new drug; and the largest infection control effort in history is underway, including the quarantine of more than 50 million inhabitants in Hubei province, China [5].

Internationally, airlines have ceased operating in China; large-scale surveillance of suspected patients and their contacts is being performed around the clock, and naturally, the media response has been extensive. It would prove more difficult to find someone who didn’t know of the new coronavirus than someone unaware.

History

The history of Ebola and Ebola virus disease is different, both in impact and response. Ebola is vicious; out of 3,453 cases confirmed since the beginning of the current outbreak, 2264, or 66%, have died, similar to ratios from previous outbreaks and among the highest case fatality rates of any human pathogen [1].

First isolated in 1976 following separate ebola outbreaks in Sudan and what was then Zaire, there have been numerous outbreaks of Ebola since both small and large. However, scientific and media attention was limited for the first 20 years. An average of just nine yearly publications related to the Ebola virus were published between 1977-1994. In 1995, when a major Ebola outbreak occurred in DRC, interest began to be generated [6].

Coincidentally, the movie ‘Outbreak,’ released just two months before the first cases in the DRC, also increased public awareness of the Ebola virus. It was the 2014-6 epidemic, however, which displayed the epidemic potential of the disease, with nearly 30000 suspected cases and more than 11000 fatalities [7]. The declaration of a PHEIC and a global response followed, including the use of experimental antiviral treatment and vaccination. Nevertheless, it took two years before the epidemic terminated.

It may well be an inconvenient truth that the responsiveness to any outbreak will be based on the impact on Western society, chiefly the economy, rather than the severity of the illness and endangerment to human life and well-being. Notwithstanding the vast amount of funds the global economy generates for medical research and treatment products, a more consistent global approach to tackling both the outbreaks themselves and managing awareness and attention would give less developed countries a better platform to address the events in a timely manner, minimizing the risk of extreme outcomes.

Thankfully the current outbreak has been less explosive than that of 2014-6, which could explain, if not forgive, the correspondingly tepid response; while organizations such as Médecins Sans Frontières (MSF, Doctors Without Borders) have been on the front lines from the beginning, it took the WHO four reviews of its original negative decision before they announced a PHEIC.

Unfortunately, the situation has been complicated considerably by an ongoing conflict, which has escalated to actively target healthcare workers, including 386 attacks, with 77 injured and seven dead in 2019 [8]. Nevertheless, work has continued and has borne fruit, and new cases of Ebola have declined significantly during the current outbreak since the end of September 2019, with only one newly-confirmed case this past week, and hopefully, an end is close [1].

Outside of any political or economic reason, it is perhaps human nature to be attracted and fascinated by that which is new and shrouded in mystery and misinformation, and it is seemingly appropriate that the word “novel” (from Latin Novus, “new” or “fresh”) has been incorporated into the name of the virus which now makes the headlines.

All the same, the fact that a public health emergency is currently of less international import or concern does not make it any less important or pressing, especially to the locals and healthcare workers fighting the illness. Given the WHO saw fit to label it as such an emergency, it should also see fit to continue rendering assistance proportionate to that description until the emergency is completely over and the region free from further risk; otherwise, why have such labels at all?

Symptoms

Symptoms can manifest anywhere from 2 to 21 days after contact with the virus, with an average of 8 to 10 days. Primary signs and symptoms of Ebola often include some or several of the following:

• Fever
• Aches and pains, such as severe headaches and muscle pain
• Weakness and fatigue
• Sore throat
• Loss of appetite
• Gastrointestinal symptoms include abdominal pain, diarrhea, and vomiting
• Unexplained hemorrhaging, bleeding or bruising
• Red eyes
• Skin rash
• Hiccups

Diagnosis

Many common illnesses, including influenza (flu), malaria, or typhoid fever, can have the same symptoms. Diagnosing Ebola quickly after infection can be difficult. Early symptoms are not specific to Ebola virus infection and often are seen in patients with other, more common viruses. To determine whether Ebola is a possible diagnosis, there must be a combination of symptoms suggestive of Ebola virus disease AND a possible exposure to the virus within 21 days before the onset of symptoms. Exposure to the ebola virus may include contact with:

• blood or body fluids from a person sick with or who died from Ebola,
• objects contaminated with blood or body fluids of a person with the disease,
• infected fruit bats and nonhuman primates (apes or monkeys), or
• semen from a man who has recovered from Ebola virus disease.

If a person shows signs of disease and has had possible exposure, they need to be isolated, and public health authorities notified. Blood samples from the person should be collected and tested to confirm infection. Ebola virus can be detected in blood after the onset of symptoms. It may take up to three days after symptoms for the disease to reach appropriate viral load detectable levels. Polymerase chain reaction (PCR) is one of the most commonly used diagnostic methods because it can detect low levels of the Ebola virus.  Other methods can be used to confirm a patient’s exposure and infection status based on the detection of antibodies an Ebola infection produces.

Treatment of Ebola Virus Disease

The U.S. FDA currently approves two treatments to treat Ebola, specifically the species Zaire ebolavirus, in adults and children. They both make use of monoclonal antibodies (mAbs). These proteins produced in a lab mimic the body’s natural antibodies to stop a virus from spreading after it has infected a person. Whether or not other treatments are available to those with Ebola virus disease, basic interventions can significantly improve their chances of survival. This is especially true when provided early enough. These are referred to as supportive care treatments and include:

• Providing fluids and electrolytes
• Using medication to support blood pressure, reduce vomiting and manage fever or pain.
• Treating co-occurring infections

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