I work for Doctors Without Borders - ask me anything about Ebola.

Hey Doc.

For simple minds like me, in the bluntest terms: how fucked are we?

An outbreak that has been ongoing for over 6 months and has infected over 4000 people and killed over 2000 is not only having devastating consequences on the patients and their families, but is already leaving the health systems of Liberia, Sierra Leone and Guinea shattered, and in need of a complete reconstruction.

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The implications are huge. A deconstructed health system with half of the medical population decimated, a lack of trust in health facilities from the population, and apart from all of the Ebola cases and deaths, all of the non-Ebola cases and deaths that are not being managed, and that are probably in the 10s of thousands.

Difficult to know how far it can spread, since it depends largely on the response, but it is clear that the neighboring countries are at high risk.

Question: "Is Ebola a form of DIC because of the severe bleeding?" Answer: Some of the mechanisms are similar to DIC, as it affects the chain of coagulation, but Ebola also has effects on the immune system, making the response to fight against the virus more difficult for the infected patient.

Getting ready to wrap up.

Please remember that this outbreak is not only having consequences on the Ebola patients, but on the rest of the population mainly of Liberia, Sierra Leone and Guinea. The health systems of these 3 countries was already weak and it will now take years to reconstruct and to regain the population's trust. Once the outbreak is over and it's not in the headlines, people will forget how devastated these countries are. It is then that we will need to ensure continued support and awareness.

Thank you for all your questions and interest.

It's an AMA so what the hell:

Do you or anyone you know need a volunteer/staff with a Masters degree in Epidemiology? Ebola was what got me interested in science to begin with and I want to get into field epi.

Yes, MSF

Hi Estrella, thanks for taking the time to answer questions on Ebola today.

Here is a list of questions from our community on reddit, /r/doctorswithoutborders.

EDIT: We are also working with reddit to organise a fundraiser for MSF's Emergency Funding. We need help from our fellow redditors! If anyone is good at design then please get involved. We want to use a something created by the community for the community. Maybe a GTA inspired MSF T-Shirt or poster? We want to see all the cool shit redditors can come up with. Also reddit HQ is helping us with free promotion and sorting out the supply. This is a great opportunity to turn the collective interest in this issue into a tangible change on the ground. So please, please check out our thread and get creating!

/u/Spacetyrant:

Many of us are following this epidemic very closely -- and it is looking pretty dire. I have no infectious disease background whatsoever; I see the epidemic and the interconnected urban and rural environments it's attacking as an unpredictable complex system with a thousand ways to evade containment. To me this outbreak is starting to look like it may already be unstoppable in west Africa -- if not in all of sub-saharan Africa.

My question: Do you think it's still possible that a world response could conceivably be big enough, quick enough, and west Africa-savvy enough to have a chance to contain it within west Africa?

And, if so, how could that be done?

/u/Assfire:

Can Ebola be spread through the air (regardless of droplet size)? Can it be spread through the contamination of currency?

If someone with Ebola (symptomatic) touches a door knob and I touch that door knob 1 day later and than scratch my eye what is the probability that I contract the virus?

/u/chakalakasp:

What do you think the potential end game scenarios look like for the current EVD outbreak? Even if this is controlled, will it be endemic in West Africa? Can it be controlled (or is this an unknown?) Is this a global pandemic threat?

I have been privately communicating with several respected epidemiologists; what I've been hearing back has really concerned me. None of them want to have their name attached to their thoughts (for what I can assume are professional reasons), but their line of thinking at the moment is that the epidemic in West Africa is too late to contain and that only when the susceptible population decreases (via infection immunity or death) sufficiently will the virus slow down and peter out -- but that this would literally involve millions of cases. The analog used by one epidemiologist I have privately communicated with was the Black Death plague from 1346 to 1353 in Europe.

My second question, if you have time, revolves around CFR (or PFC, or however you want to slice it). In the PBS Frontline documentary, MSF was quoted as saying observed CFR in the clinics is in the 80% range (putting it in line with typical Ebola Zaire CFR). Is this true? Do the WHO figures of ~50% CFR for this epidemic mesh with your on the ground observations? Does the CFR data suffer from a lag effect, or is there some other reason for the discrepancy?

Thank you very much for your time. What you are doing is some of the bravest, most self sacrificing work imaginable.

/u/woody121

If EVD mutates into an airborne virus, what sort of protective gear might be useful for someone to have in their home?

Good luck in all you do, you lead a life so far from mine that I can only say thank you.

To woody121: Thank you! No reason why Ebola should mutate to an airborne virus. It survives in body fluids, but not on dry surfaces due to it's lipid membrane.

To chakalakasp: It's difficult to predict what the evolution of this outbreak will be like as it is very different in terms of spread and settings (more urban settings) than the outbreaks we've seen in the past. People still hide in the villages when they see the MSF ambulances arrive, and some of the ones who arrive at the treatment centers, cannot be admitted because we're so overwhelmed. We have started doing home-based treatment, but it's a difficult choice and we have to trust that the families will treat their relatives appropriately and not expose themselves to the disease. I'm not sure this can be compared to the black plague, but it is certain that without a larger and more substantial response to ensure containment, it will continue to spread in the area.

The CFR we're seeing is of around 60%, and for EBola Zaire we've seen CFR of 30-80%.

We definitely don't have all the information on cases and deaths

To Spacetyrant: I think it is possible if the response is quick and as large as the outbreak requires. We need to increase health promotion, awareness in the West African communities, the number of beds in Ebola Treatment Centers, and all of this requires a substantial increase in human resources.

What can someone who is not able to be hands on do to actually help in this epidemic?

What should be done that isn't being done by the western world?

A lot of people have been asking that. You can help create awareness, you can put pressure on your governments to act, you can donate to one of the organizations responding to the outbreak...

Is there an end in sight?

Not if the response is not substantially upscaled

Hi, thanks for answering questions. I have two: 1. What sort of response do you wish to see from the international community? What do you think of the int'l response so far? 2. Has MSF considered releasing any epidemiological or geo data? I haven't seen any estimates of incubation period, attack rate, time to death, etc for this outbreak. Having that information would be really helpful for logistics and outbreak response.

What we need to see are more people being deployed to do the hands-on work. Right now, we cannot provide all the appropriate treatment to our patients because of a lack of human resources. The international response has been slow and weak, even after Dr. Joanne Liu (president of MSF) plea at the UN briefing.
It is WHO who is releasing the epidemiological data as it is part of their mandate. We do some epidemiological surveillance, but are completely overwhelmed with the response itself and trying to contain the spread of the epidemic. Incubation period is 2-21 days, attack rate is difficult to know since there's a lot of information lacking and many cases and deaths we are missing. Time of death since the start of symptoms is extremely variable according to the previous state of the patients. But all that said, we are concentrating on containing this epidemic, so unfortunately don't have the time and resources to be able to answer all these questions using appropriate research methodology

Hey there Doc. Ok so in my microbiology class we have been studying Ebola on and off since the semester started. We came across this one article that talked about people who had survived Ebola and seemed to be doing well then it just comes back. What are your thoughts on the chance of a relapse with Ebola after surviving it?

We don't know of anyone who has relapsed.

Hello Dr. Lasry, I have read that the outbreak has killed many of the local health care workers in the areas where it has spread. With their education and training, how did they get infected with ebola? What could have prevented their infection in the first place?

yes, but this disease is relatively knew to the area and was unknown by the medical population as a potential risk, so measures of infection control for Ebola were not in place. Furthermore, the disease presented in a somewhat different way, with less hemorrhagic symptoms initially, and a lot of gastrointestinal symptoms, mimicking gastroenteritis for which less methods of infection control would be put in place. The health systems of these countries were already very weak, sometimes supplies are in shortage (even gloves), making infection control even more difficult.

The medical staff that contracted ebola and then were evacuated and received ZMapp got better. How closely are they being monitored to ensure ebola doesn't 'come back' in them? Is the ebola virus known to hang out in lymph nodes, dormant? Thanks

Not all of the people who have received ZMapp have survived, and we don't know, for those who did survive if it was an effect of the drug or if they would've survived anyway. Unfortunately too early to know.

The virus disappears from the blood and has been found for longer periods in semen and breast milk (up to about 3 months in semen), but not in lymph nodes.

I have two questions:

• The literature has very little on whether plasma transfer has been effective in protecting patients, or whether surviving Ebola confers long-term immunity. What are your thoughts?

• How can communications about this epidemic be more effective in generating support? What we're seeing IMO in the U.S. is ~90% of people ignoring the situation (just another overblown "crisis"/African issue) and ~10% of people in a full-out panic. What message can be used to create urgency without panic, and which is the best organization to get that message out? (It seems like the WHO has been unsuccessful and the CDC is hesitant to step up since it's not a U.S. issue...)

It seems that surviving Ebola does confer immunity although we don't know for how long. However, we don't know of any patients who have been infected twice.

Transfer of plasma from convalescent patients is actually being tested.

Awareness is definitely a way of generating support. The WHO has been slow to react but they are now speeding up, and the CDC has been at the outbreak almost since the beginning and has deployed more people on the ground than it ever has, as well as contributed to the awareness. The outbreak has been declared an international humanitarian emergency by the WHO.

I have heard that MSF's request for support from the US military in responding to the Ebola crisis is unprecedented. Have there historically been any requests by MSF for US military support in response to other crises? Also, what is your perception of the utility of the proposed 24-bed treatment facility for healthcare workers offered by the US government, in comparison to the overall need?

In non-conflict settings, MSF has at various times worked with the militaries of different countries that had logistical capabilities beneficial to the overall response--the 2005 earthquake in Kashmir and the 2010 earthquake in Haiti are examples--and we understand that militaries are at times equipped to provide logistical support on a scale few other organizations can match. That is the case today regarding the ebola crisis.

On the 25 bed Ebola Treatment Center, other than being insufficient, there is a need to isolate and treat the population. Of course it's important to manage healthworkers who get infected, but this should not be the focus of the response, albeit an important part of it.

Hello Dr. Lasry, I'm currently finishing up medical school this year and very interested in international health. I have three questions.

1. In what way can future healthcare professionals best get involved?

2. Regarding infection control; what do you see as the most fundamental barriers to effective exposure prevention? My understanding is that this virus is spread through contaminated body fluids, correct? Or does an animal vector remain a significant source of new infections?

3. How optimistic are you regarding the new monoclonal antibody infusion (ZMapp)?

Right now, create awareness. MSF accepts medical volunteers with a minimum of 2 years of experience. We cannot send people to the field who have not been exposed and developed some clinical expertise.

On infection control, awareness, barrier nursing and safe burials are the main ways to prevent the spread. It is now human-to human transmission that is causing the spread of the disease, although the start seems to have been from a human contact with a fruit bat.

About ZMapp we have to wait and see, difficult to make predictions at this stage.

What are your feelings as a health worker on the decision by the US government to only use $22 million to set-up a healthcare facility in Liberia solely for treating medical aid workers?

MSF's international president Joanne Liu said today in an op-ed in the Washington Post " So far, the Pentagon has pledged only one 25-bed unit for Liberia, to be used just for health workers. This is highly insufficient. In Monrovia alone, there is an immediate need for an additional 800 beds of isolation capacity. Other governments must step in in all three of the most affected countries."
Link: http://www.washingtonpost.com/opinions/a-concrete-response-to-the-ebola-outbreak-cannot-wait/2014/09/11/f7329414-386e-11e4-9c9f-ebb47272e40e_story.html

Most of the discussion originally was how difficult it was to infect others as it has to be through bodily fluids and that it would soon peter out. Why is this specific outbreak not stopping and actually growing in scope?

People are hiding and not coming to health facilities, and when they come, not all can be admitted as we are completely overwhelmed and there are not enough people responding on the ground.

Not all burials are being managed in a safe way, as sometimes the families bury their deceased before the burial teams can get there.

I read somewhere (almost definitely reddit) that western doctors were seen by some locals as causing the disease, as they were always in places of outbreaks. This, in turn, meant victims were less likely to seek medical help from westerners, like those working for MSF.

Is there any truth to this? If so, have you experienced this?

Yes, this is definitely one of the things happening in the outbreak context and it is not new or specific to this outbreak, since people automatically associate the medical staff or the medical cars with Ebola, and have difficulties understanding what came first, the disease or the Western doctors, as we are responding in all areas where the outbreak has spread to.

When do you think that the first cure for Ebola will be available? What formulation will it be based upon?

Would one sick person flying in from Nigeria be enough to start an epidemic in Europe for example?

The infection control facilities in Europe and the capacity of response, isolation and the number of health workers is so much higher that it is highly unlikely that the disease would spread in a similar way.

Hey doc! Thanks for all the information. So, ive been planning a trip to kenya with my fiance for december this year. what are my odds of having a safe trip?

Very high

What is the simplest, easiest, most effective thing someone can do to protect themselves from possible infection?

From what I have read it seems to be the same as for any virus. Wash your hands and cover your cough. I'm sure there's more, which is why I'm asking.

It depends on the setting, at this point, in the US, the best method is to include history of travel in the medical history to assess if there is a risk at all.

From the perspective of somebody who's on the ground, what do you need to help combat this outbreak properly?

More people on the ground and more Ebola Treatment Centers appropriately staffed.

We're going to continue for 10 more minutes. There will be other opportunities to take questions in the near future. Thanks for all your interest

Hello Dr., thank you for all your hard work. Am I to understand that Ebola has the same kind of stigma and it's countries of origin that aids had when it first arrived on the scene here in America?

Yes, it is similar, except it has a faster evolution than HIV/AIDS did at the start of the epidemic, and although some health facilities did contribute to the transmission through transfusions and poor aseptic practices, it is in a lesser magnitude than EBola, since HIV has different forms of contagion.

However, there is a larger stigma in the communities, who sometimes will shun patients (even cured patients) and their families. At the rate that the outbreak is spreading though, it seems like almost everyone has unfortunately had someone in their family/friends affected which may reduce the stigma in a paradoxical way.

We've got some questions on Twitter and FB that I will answer

Hi Doc.

If you catch Ebola and survive, are you then immune?

Thanks!

Yes, as far as we know

How can a private individual donate to help fight the outbreak?

You can donate to any of the organizations that are responding to the outbreak as an individual. Thank you

How many different strains of the ebola virus are there? or is it just one strain? Also if there are different strains of this virus which strain is the deadliest?

There are 5 different strains that we know of, Zaire and Bundibugyo are the 2 with the highest case fatality rate.

How do you regard to speed and response of other agencies, reacting to the ebola outbreak. For instance, I know one large NGO is only recruiting now to put staff on the ground for Ebola response in Liberia, sierra Leone etc...

Has it been a case of too little too late?

Late, but better late than never. There are still enormous needs to respond to the outbreak, and we need people now.

Hey doc, is it true that there's a vaccination for ebola but its just not being made because pharmaceutical giants see no profit in this?

There are 2 vaccines in the pipeline, and funding for this has been upscaled.

First off all great work and my respect. but i was wondering did the media blow this up or not ? i know that alot of people are infected and/or dead but i also heard that alot of african people ingnore docters adivce and peferom funeral rituals on the infected and touch the body´s thus it spreads like a wildfire. Should we be worried or is this not going to be the pandamic you see in the news ?

(sorry for any grammar mistakes)

The media did not blow this up, and unfortunately also started reporting heavily on it once the outbreak was already out of control, this is a humanitarian emergency.

It is true that some people are performing burials in unsafe ways, but it is difficult for a family who has lost a member to be absolutely strict and let the body alone until the burial teams arrive (this is sometimes taking more than one day due to the lack of personnel).

Good morning, thank you for taking questions.

I recently heard an MSF representative respond favorably to a hypothetical deployment of world armed forces biological and chemical warfare units to help quarantine and control Ebola spread in West Africa. I have a couple of related questions to this concept:

1) Would it be useful? Would these forces be able to contribute in a meaningful way, despite not being medical personnel?

2) Has the MSF considered a deployment like this? Do you know how you would handle soldiers like these, and how to use them without creating any backlash among locals?

3) Is an intervention like this an official goal/desire of the MSF, or simply one members off the cuff response?

4) Finally, can biowarfare techniques be used effectively for the long periods of time fighting off the entire outbreak would require?

Thank you, and please feel free to answer any subset of the questions, no need to reply to all.

What we are asking for is for the deployment of military medical expertise, trained in bioterrorism (because the methods of infection control are similar). They have the logistics and personnel to be quickly on the ground. This is an extraordinary situation that requires extraordinary measures.

https://www.doctorswithoutborders.org/news-stories/press-release/global-bio-disaster-response-urgently-needed-ebola-fight

Now I know the survival rate for Ebola in developing countries can be less than half, even as low as 10%... what would be one's chances if they caught Ebola in the West, and received quick access to the proper medical care?

Difficult to know, but the survival rate would be higher if we had more personnel on the ground able to manage these patients.

Along with its other forms of transmissions, can Ebola be contracted via sexual intercourse? If so, how easily is it transmitted in this manner?

It can be transmitted by sexual intercourse as the virus lives in all body fluids, but this is probably not the highest contributor to this outbreak.

Hi Estrella, Can you get ebola again if you survive it the first time? Thanks!

Not that we know of

Do you have a blog, sir? I mean, ma'am?

(/u/Not2_anoriginaluser)

No, I have a twitter account: EstrellaMSF

How do I know that Ebola is not just another pharmacy scam? Do not misunderstand me. I know that Ebola is a reality. But always existed, right?

Ebola is a reality, we are seeing it with our own eyes.

The virus was first identified in 1976 in Zaire (nor DRCongo), close to the Ebola river.

I understand all that, really. And of course that I'm worried. I have a close friend over there, and I pray everyday that he's okay.

How far are we to find a cure?

WE don't know how far away we are, but efforts are being made to speed up the process so we can use the new drugs and vaccines for this outbreak.