[00:00:01] Dr. Mark Kortepeter Well, Ebola has a lot of effects on the body that make it dangerous and lethal. So after it enters the body, it starts to replicate in what we call the gatekeeper cells. These would normally be first line of defense after the skin to try to wipe out the organism, but instead the organism replicates in them. And then it gets into the bloodstream and then one of the things it does, very unique, is it essentially wipes out your white blood cells, a type of white blood cell called the lymphocytes. Why is that so devastating? Well, these lymphocytes are key for mounting your immune response against the organism. So essentially, it renders you impaired in your ability to mount a response to the organism, so this allows for that massive amount of viral replication. We’re talking million, 10 million ml of blood reaching all major organs. It can have an impairment of your clotting function, and in severe cases, individuals can expel copious amounts of fluid, whether it’s vomiting or diarrhea, and this leads to very easy to spread to anybody close to them. And because they’re expelling a lot of fluid they become depleted in terms of their volume of their blood and fluid and it’s actually the fact that they can no longer maintain a blood pressure, which is what kills them.
[00:01:25] Narrator Welcome to Countermeasures, this season we are looking back at historic public health outbreaks and bioterrorism events. From the Black Plague to the 2001 anthrax attacks, we are looking across the span of time to uncover how we have responded to health threats, what we’ve learned, and what we still have to do. Ebola is a hemorrhagic fever, first identified in 1976 near the Ebola River, in what is now the Democratic Republic of Congo. Since then, the region has seen outbreak after outbreak. This is the 17th in the DRC alone. The strain currently spreading is called Bundibugyo, a genetic relative of the Zaire. They killed more than 11,000 people across West Africa between 2014 and 2016. There is no approved vaccine or treatment for the Bundibugyo strain. And case counts are already climbing faster than they did in the early months of the 2010s epidemic. To understand why this outbreak is different from the one most people remember in 2014 in West Africa, you first have to understand which strain we’re actually talking about.
[00:02:42] Dr. Michael Osterholm The Bundibugyo virus, which is one of the Ebola viruses that we know exist in the world today, actually causes illness in a very similar way as does the other viruses, particularly Ebola Zaire, which was responsible for the large outbreak in 2014 to 2016 in Western Africa, and as well as Ebola Sudan. This virus causes the damage that it does, first of all, by once it enters the body, it starts to deactivate all of the early warning systems in our immune response. So it actually has a way to shut them down, which then means a virus is allowed to proliferate even more. And then as it progresses over time, it actually begins to destroy blood vessels. What we call endothelial damage over the inside coating of the circulatory system now causes a great deal of inflammation. But as a result of this, we then see what we call a cytokine storm. A cytokine storm is where basically as tissues die and literally explode from the high viral loads. The immune system actually panics, and it begins launching an overwhelming chaotic counter attack known as a cytokine storm. That then basically only further exacerbates the problem we have in terms of the clinical side of it. And then we start getting organ breakdown, particularly in the liver, which is really an important organ in terms moderating and manufacturing blood clotting factors so that basically, we don’t see people bleeding out unnecessarily in a sense of the fact that they have these blood clotting factors now greatly reduced. And then the final cause of death is actually shock. Because of the fact that we have this leakage out of the circulatory system, individuals with Ebola can lose up to more than two gallons of fluid a day. And that’s a combination of blood-related activities and other body fluids. And that not only is this why patients die, but it’s also what makes them much more infectious as time goes on. So in those early stages of the illness that I talked about, actually, we don’t see a lot of transmission because the body fluids have not yet really begun to be present in a way that if someone touches the body, you, in fact, can potentially become exposed. It’s in these latter stages that that happens. So this virus does kill, likely, somewhat at a lesser level than we see with Ebola Zaire and Ebola Sudan. We’re hearing reports now out of the Central African countries of somewhere in the neighborhood of 25 to 30 percent case fatality rate, meaning that that percentage of people who get infected die.
[00:05:17] Narrator That’s Dr. Michael Osterholm, an epidemiologist, Regents Professor at the University of Minnesota School of Public Health, and Director of the Center for Infectious Disease Research and Policy at the University of Minnesota, who tracks Ebola vaccine development globally. Dr. Tom Carpino, Hock Fellow at the Duke Global Health Institute at Duke University explains further.
[00:05:41] Dr. Tom Carpino So the Bundibugyo virus is similar to the Zaire strain of Ebola in that they are hemorrhagic fevers. They are diseases that can cause severe body temperature and the hemorragic fever component. The case fatality rate for both of these strains is very high. The Bundibugyo is actually quite a bit lower in terms of case fatality rate and has the stereotype that it’s not as severe. But again, I think this does not mean we should not be taking it as seriously. We’ve already seen a dramatic rise in the number of infections. And to the extent that it actually seeming to be spreading quite a bit faster than we have in any of the past Ebola outbreaks in the past or epidemics in the past and because of that has the potential to cause a lot more, I would say, deaths than we’ve seen in prior epidemics. The virus for Bundibugyo as well as other filoviruses, and the Zaire Ebola strain, it can infect the body through any bodily surface. Usually we say if there’s like broken skin or any way [00:07:10]that it can [0.0s] basically get through our mucous membranes, also exchanging bodily fluids, basically even kissing through intercourse and a number of different ways, right? It can be spread through, you know, breastfeeding, for example, is another good way in any case. The virus is able to target immune cells and spread pretty rapidly through a person’s body. And there is an incubation period, meaning the person won’t have any symptoms, but the virus will be replicating within the body. And this happens for quite some time.
[00:07:50] Narrator It’s a lower fatality rate than the Zaire strain that devastated West Africa a decade ago. But as you’re about to hear, a lower number doesn’t mean a smaller problem.
[00:08:02] Dr. Mark Kortepeter Ebola spread from person to person through contact with blood or body fluids. And the reason this occurs is because Ebola patients could expel a lot of fluids from vomiting diarrhea, in some cases up to 10 liters of diarrhea per day. So that’s a lot body fluids, just imagine then, if someone vomits or has diarrhea in an open space, there’s a lotta splash. So people then are exposed potentially, they have contact with that fluid and they touch their own mucous membranes. Put their finger in their mouth or in their eyes, something like that. And so these fluids are teeming with virus and the more ill someone is, the more virus there is in the blood or body fluids. So if you’re caring for a patient or handling their specimens, this puts anybody doing those types of work at risk. So some of the myths though around Ebola is so sometimes people are worried, does this spread through the air? It does not spread through to the air, at least what we’ve seen from natural outbreaks. And one of the missed courses in Africa, sometimes there’s a lot of suspicion about how Ebola is being handled. And so family members may think they’re doing themselves a favor by hiding their patients at home due to fear from sending them into an Ebola treatment unit. But unfortunately, this actually increases their risk of getting infected as the patient gets more ill. And there’s also this myth about bleeding, and it’s fun and sexy to show pictures of people in movies with Ebola bleeding from every orifice. But really, a minority of people have significant bleeding, and it tends to cause oozing from IV sites or where the skin is broken. So it’s really usually not this massive amount of bleeding you might see in some horror movie.
[00:09:53] Narrator What actually moves this virus from person to person is far less cinematic and far harder to control once it starts.
[00:10:02] Dr. Mark Kortepeter A super spread event just occur, you know, just refers to when multiple individuals are exposed simultaneously to a certain pathogen. In the case of Ebola, super spreading events can occur when there’s large gatherings and large contact with individuals who are ill. Where this has happened most frequently is during funerals. So if you have someone who’s pretty high up in the village where the entire village wants to come and pay their respects, they during some funeral rites in parts of Africa, there’s a lot of direct contact with the dead body, which can still be teeming with organisms. So they can have, you know, sometimes they’ll drink from the same vessel as the dead body. They’ll have direct skin contact. They may, you know have contact as they’re preparing the body for the funeral. So this occurs, and it’s unrecognized. And suddenly then, after everybody’s been exposed, suddenly week or, you know, 10 days later, multiple people become ill. You may also have super spreader events when an unrecognized patient enters the healthcare system, you know, a clinic or a hospital, and the care providers don’t have the appropriate protective measures in place, so you can have multiple care providers or even other patients potentially exposed to that ill patient. And the third way this has happened in terms of a super spread event is that an unrecognized patient is given an injection. And this patient is ill, they’re given an injection, and this same containment and needle and syringe then is reused on multiple other patients subsequently without cleaning or sterilization. There have been outbreaks where Ebola, especially early on in Ebola, where this occurred and there’s just massive numbers of people then who became infected as a result of unsterilized needles and syringes.
[00:11:52] Narrator There is currently no approved vaccine for the Bundibugyo strain, so containing and measuring the outbreak comes down to one unglamorous task, finding every single person an infected patient may have come into contact with.
[00:12:07] Dr. Mark Kortepeter Contact tracing or running an outbreak investigation for Ebola is difficult and it requires a lot of time in the field. So the symbol for an epidemiologist is a shoe with a hole in it. And that really just signifies the fact that someone running down an outbreak in the field or especially an Ebola outbreak really has to get out into the community directly and talk with people to determine how they had contact with somebody who’s ill, who they’ve had contact. You know, is it contact in the household? Is it casual contact like in church or a community? Is it sexual contact? So you really need to get out into the community to understand how people have been exposed to try to find out where this all started. This can be very difficult in an environment where Ebola occurs. Most Ebola outbreaks occur in Sub-Saharan Africa. We have poor road conditions, potholes, mud, crossing rivers that don’t have bridges on them. There are language barriers, multiple different dialects in these countries where these disease occurs. In some cases, there may be local hostility to the healthcare workers. We’ve seen that historically, where these healthcare workers might be at risk of dealing with the community because there are a lot of suspicion around the disease and also around the fact that there are Ebola treatment units. And, you know, the view in the community is, well, their loved one goes into the Ebola treatment unit, and like Hotel California, they check in, but they don’t ever check out. So that leads to local hostility. And finally, some of these areas are fairly unstable in terms of the government and various different armed factions vying for control. And so the armed conflict also can play a role, which also adds to the difficulty of hunting down an Ebola outbreak.
[00:13:53] Dr. Tom Carpino For me, one of the clearest indicators that the epidemic is not under control is that folks have been identified with the virus with no clear epidemiological link to other people. And so that means that the contact tracing is not effective and more people are becoming infected than we know where they’re getting infected from is basically what it comes down to. And so, if we don’t know where people are getting it from, how can we prevent it from spreading even further? We have had a number of cases in Uganda. It doesn’t seem to have spread outside of the capital as of yet, but that doesn’t mean that it cannot. We have had, again, in the 2014 epidemic in the first few months. The virus spreading to multiple capital cities, and I think that when you have a lot of dense urban environments, it can allow things to go unchecked, I think, pretty quickly. It seems that because of the rurality at this point of a lot of the cases, it’s kind of self-limiting to a degree, but that doesn’t mean that it’s going to be, again, just stuck where it is like I could absolutely see this epidemic spreading much more widely than DRC and Uganda.
[00:15:27] Narrator To understand what losing control actually looks like, rewind to 2014 when Ebola stopped being a rural disease and became a global headline.
[00:15:37] Dr. Michael Osterholm In the earliest days of the 2014 Ebola Zaire outbreak, I actually wrote an op-ed in the Washington Post and said, wake up world. This virus is different now. It’s gonna spread. And it’s not different because the virus has changed, we’ve changed. And what I meant by that was we’re now living in very large, large cities, cities of 20 million people now, where the housing and the overall life experience is really a challenge in terms of closeness and contact. And so what we are seeing is the modern world of Ebola. In the past, it would occur in a rural village, in an isolated village, a long ways away from any major travel routes, etc. And we’d see 30, 40 cases appear that would be a result of somebody who was exposed to an infected animal in that village. And it surely was devastating for the village, but it didn’t really cause much of a public health impact issue, because it was so few people that were ultimately exposed. And by the very nature of how these villages were established, it meant there were only a limited number of people that could be exposed. That’s all changed. We now live in a modern world of travel. We see a lot of migration that goes from west to east in Africa. It follows different seasons of the year by what they’re doing in terms of agriculture. We’re seeing the issue right now in the mining camps, particularly in DRC and that area where people are coming from great distances to work there because that’s all they can do for work. They don’t have any other work. We actually have, you know, the horrible stories of physicians and health care providers that were in the villages, in the communities, even the large cities prior to this outbreak that actually had to leave the area of medicine because there was nobody to pay them. These clinics started to shut down. We actually know of physicians who are today spending their time mining for gold because they have no other means of income. And so that whole combination of lifestyle, of poverty, of the issue of living in these kind of close contact environments, together with the fact that we have the militia issues and the problems we see today with civil unrest. We also see a great reluctance occurring for many of the bodies to be handled safely, because they go against the traditional means of basically bringing a dead person to internment. And so when you add that all together, it is a whole lot of challenges, all wrapped into one to try to stop that virus, but it can be done.
[00:18:11] Narrator So has the world gotten any better at this since 2014?
[00:18:15] Dr. Michael Osterholm The bottlenecks that we see anytime with an Ebola outbreak, I don’t care whether it was 2014 or it’s 2026, are real because of the very fact that we have bottlenecks at the country level day in and day out for all of health. And so Ebola just gets dumped on top of that as another very serious challenge. The one thing, of course, that’s very important, you know, if I’m treating a malaria patient in a clinic, in a hospital, I’m not that concerned about obviously picking up malaria from them. Now with Ebola, I have to not only be mindful of what we’re doing for the patient, but what are we doing to protect the health care workers? Protective equipment is short of supply. It is really a critical element. Trying to do healthcare service in that kind of environment where you have very high temperatures and yet you’re covered in all of those protective equipment, that means you often can’t work for more than 20 or 30 minutes at a stretch without having to take a break because of exhaustion. All these kind of challenges have come together, but they’re not any different we saw than 2014. Now we have a better sense, I think, of what can happen. What I mean by that is, in 2014, at the very first days of the opening Ebola Zaire outbreak, if you had asked anybody in the Ebola world, are we going to see an outbreak with 30,000 cases? They would have said, well, not likely, but we haven’t seen one before. Now we know, oh yeah, you can have an outbreak, with 30,000 plus cases, more than 10,000 deaths. And you have to take that very seriously as a potential. And so I think today, you’re hearing the alarm system go up much, much, much earlier to the world saying, come on, you got to help here because this could turn out to be worse than it was in 2014, which at that time, no one imagined it and can get that bad. Now we can imagine it. Now we see what can really happen. And so this is a huge motivator or it should be for why we need to bring this to a halt because it could very well get a lot worse before it gets better.
[00:20:23] Narrator Every expert we spoke with came back to the same idea. None of this works without trust. And trust has to be local.
[00:20:32] Dr. Michael Osterholm For those who are old enough to remember a very famous US politician, Tip O’Neill, who several decades ago made it very clear that we should never forget all politics are local. And that message is true to every ounce of possible truth in terms of what happens with Ebola at the local level. I don’t care whether you’re talking about a city of two million or you’re talking about a community of two hundred thousand. In the end it’s going to be what happens locally. And so you cannot overstate the importance it is to have the connections with the local community and a variety of different individuals in that community, and remember we’re already dealing with so much civil unrest. How do you get people who are sworn enemies of each other to actually also cooperate and collaborate in trying to stop Ebola? Remember there’s a number of people that don’t believe this outbreak is real. They think that it’s something that’s been foisted upon them for any number of different political or economic reasons. So again, whatever happens is local. You know, old white guys like me do not have credibility in this area, and I understand why. It’s gotta come from the community. It’s got to be people people trust. And that people have a reason to believe you’re there not just because of Ebola but because you care about the entire community and you care about maternal health issues, you care about water supplies, you care about vaccines, you care about malaria prevention. Those are the people in the end that are going to have the most effect on us in trying to help reduce this epidemic.
[00:22:08] Narrator This is the 17th Ebola outbreak in the Democratic Republic of Congo since 1976. It began five months after the last one ended.
[00:22:17] Dr. Tom Carpino I think there is that overall idea that infectious diseases will continue to be a problem for global health security. And I think another key consideration is that we’re all living in complex systems that are dynamic, changing all of the time, and solutions that might afford to get a go aren’t necessarily going to work today. And we need to use all of the tools at our disposal in terms of new vaccine technologies, new therapeutic technologies, and AI for good in terms of developing, again, models that might help us better respond to emerging threats. And, I mean, artificial intelligence can be used in a lot of different ways, of course, but I think there’s definitely a role for that here as well. I think the last thing I’ll mention is that to the to the point about interconnected systems, we need to do a better job of understanding the critical nodes and leverage points and what can be done at those intersections. Like for example, we can think of airports as a really good example. If the world is an airport, there’s going to be, you know, inputs and outputs all of the time, and to make the biggest impact is potentially just shutting down the airport, right? You’re going to completely stop something from happening. So basically, I think what it comes down to is what are the interventions? What are the places potentially that could have the biggest impact?
[00:24:01] Narrator But it’s not all bad news.
[00:24:03] Dr. Tom Carpino I’m optimistic in the sense that I think that it has, if it didn’t at least improve outcomes directly, again, has led to a lot more conversations and people being at the table. The Global Health Security Conference this summer in Kuala Lumpur, a key takeaway from that conference for me was that part of the way to address these global health challenges is through trust and partnership building and communication. Without sharing information, without understanding what’s happening to our neighbor countries, you can’t best prepare to prevent infections back at home. I think that’s part of it. And I think the technology has advanced drastically over the past 12 years, right? We’ve had obviously the innovation in AI and the ability to model outbreaks a heck of a lot better using a lot more information, advanced sequencing exists now as well right next generation sequencing and because of that we can have a much stronger grasp on the potential trajectories of various infectious disease outbreaks like Ebola. And as a result, I think that with that greater information, we can better understand the potential scenarios that we can be facing.
[00:25:41] Narrator The questions this outbreak raises aren’t new, and they won’t be the last time we’re asking them. How fast can we recognize a threat? How can we honestly talk about it? How can we reach the communities where it’s happening? And how much are we willing to invest in preparedness before the next outbreak, because there will be one arise. Thank you for listening to Countermeasures. If you enjoy the show, please consider leaving us a rating or review. Thank you to our guests for taking the time to share their insights. If you found this episode insightful, please share it with colleagues and friends. And don’t forget to subscribe, so you don’t miss future conversations.